Intraocular Lens Implantation in the Absence of Zonular Support: An Outcomes and Safety Update: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature on the visual acuity results and complications of different surgical techniques for intraocular lens (IOL) implantation in the absence of zonular support. METHODS: Peer-reviewed literature searches were conducted last in PubMed and the Cochrane Library in July 2019. The searches yielded 734 citations of articles published in English. The panel reviewed the abstracts of these mostly retrospective case series studies, and 45 were determined to be relevant to the assessment objectives. Three articles were rated as level II evidence, and 42 articles were rated as level III evidence. RESULTS: Eight different types of IOL fixation techniques with at least 6-month follow-up were evaluated: anterior chamber IOL (ACIOL), iris-claw IOL, retropupillary iris-claw IOL, 10-0 polypropylene iris-sutured posterior chamber IOL (PCIOL), 10-0 polypropylene scleral-sutured PCIOL, 8-0 polypropylene scleral-sutured PCIOL, CV-8 polytetrafluoroethylene, and intrascleral haptic fixation (ISHF). Eight articles reported data comparing 2 techniques. The 45 studies had insufficient statistical power to compare the techniques conclusively. A qualitative analysis of similar types showed that trends in visual acuity outcomes were not inferior to those of ACIOL implantation, but the severity of preoperative pathologic features was not controlled for. Compared with ACIOL, complications of cystoid macular edema were higher in 10-0 polypropylene iris-sutured PCIOL and 8-0 polypropylene scleral-sutured PCIOL. Non-anterior chamber IOL techniques were less likely to report chronic uveitis. Chronic glaucoma was highest in the 8-0 polypropylene scleral-sutured PCIOL group. Although retinal detachment was infrequent overall, it was twice as common in both iris- and scleral-sutured PCIOLs (except CV-8 polytetrafluoroethylene suture) compared with nonsutured methods: ACIOL, iris-clipped IOL, and ISHF PCIOL. CONCLUSIONS: The evidence reviewed shows no superiority of any single IOL implantation technique in the absence of zonular support. The various techniques seem to have equivalent visual acuity outcomes and safety profiles. Each technique has its own profile of inherent risk of postoperative complications. Surgeons must educate patients on the importance of close, long-term follow-up as a result of the uncertain nature of these techniques. Large prospective studies are needed to confirm the long-term complication profiles of these various IOL implantation techniques.

Autologous Serum-Based Eye Drops for Treatment of Ocular Surface Disease: A Report by the American Academy of Ophthalmology.

PURPOSE: To describe the safety and effectiveness of using autologous serum-based eye drops for the treatment of severe dry eye and persistent corneal epithelial defect. METHODS: Literature searches of the PubMed and Cochrane Library databases were conducted most recently in March 2019. The searches identified 281 citations, which were reviewed in abstract form. Of these, 48 were selected for a full-text review, and 13 met the inclusion criteria and were assigned a quality-of-evidence rating by the panel methodologist. Eight of these studies were rated level II and 5 were rated level III; there were no level I studies. RESULTS: This analysis included 10 studies of the use of autologous serum-based eye drops for severe dry eye disease and 4 studies of persistent epithelial defect. Several studies showed good effectiveness, with some improvement in symptoms, signs, or both. Eight of the studies reported improved symptoms for severe dry eye disease, and all noted improvement in at least 1 clinical sign. For persistent epithelial defects, all of the studies showed improvement, with 3 of the 4 demonstrating an improvement rate of more than 90%. Adverse events were rare. CONCLUSIONS: Although autologous serum-based tears may be effective in the treatment of severe dry eye and persistent epithelial defect, conclusions are limited owing to the absence of controlled trials.

Therapeutic penetrating keratoplasty for acanthamoeba keratitis: a review of cases, complications and predictive factors.

PURPOSE: To review 12 acanthamoeba keratitis (AK) patients who required a therapeutic penetrating keratoplasty (TPK) and determine whether there are factors at the presenting visit that can predict the need for TPK. MATERIALS AND METHODS: This was a retrospective case series. All diagnosed AK patients between January, 2009 and February, 2016 at Wills Eye Hospital, Philadelphia, PA, USA, were enrolled. Information regarding demographics, disease manifestation, management and complications was collected. Potential predictors for TPK were obtained by comparing TPK cases with those who were treated medically. RESULTS: Sixty-three eyes from 63 patients were diagnosed with AK. Twelve eyes (19%) required TPK during the course of treatment, and 51 eyes (81%) were treated medically. Reasons for performing TPK included medically non-responsive ulcer in seven eyes (58%), perforated ulcer in three eyes (25%) and significant corneal thinning in two eyes (17%). The most common post-TPK complications included graft failure (75%), cataract (50%) and uncontrolled glaucoma required glaucoma surgery (17%). Reactivation of AK was seen in one (8%) patient. Anti-amoebic treatment beginning after 25 days from the start of AK symptoms [odds ratio (OR) = 7.63; confidence interval (CI) = 1.01-55.33; p = 0.041] and poorer presenting vision (OR = 5.42; CI = 1.91-15.36; p = 0.002) were independent predictors of the need for TPK in multivariate analysis. CONCLUSION: TPK is a procedure with significant postoperative complications but is required by some patients with AK. Eyes with higher risk for needing TPK can be identified earlier and thus provided more intensive treatment and closer follow-up care.

Descemet Membrane Endothelial Keratoplasty: Safety and Outcomes: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature on the safety and outcomes of Descemet membrane endothelial keratoplasty (DMEK) for the surgical treatment of corneal endothelial dysfunction. METHODS: Literature searches were last conducted in the PubMed and the Cochrane Library databases most recently in May 2017. The searches, which were limited to English-language abstracts, yielded 1085 articles. The panel reviewed the abstracts, and 47 were determined to be relevant to this assessment. RESULTS: After DMEK surgery, the mean best-corrected visual acuity (BCVA) ranged from 20/21 to 20/31, with follow-up ranging from 5.7 to 68 months. At 6 months, 37.6% to 85% of eyes achieved BCVA of 20/25 or better and 17% to 67% achieved BCVA of 20/20 or better. Mean endothelial cell (EC) loss was 33% (range, 25%-47%) at 6 months. Overall change in spherical equivalent was +0.43 diopters (D; range, -1.17 to +1.2 D), with minimal induced astigmatism of +0.03 D (range, -0.03 to +1.11 D). The most common complication was partial graft detachment requiring air injection (mean, 28.8%; range, 0.2%-76%). Intraocular pressure elevation was the second most common complication (range, 0%-22%) after DMEK, followed by primary graft failure (mean, 1.7%; range, 0%-12.5%), secondary graft failure (mean, 2.2%; range, 0%-6.3%), and immune rejection (mean, 1.9%; range, 0%-5.9%). Overall graft survival rates after DMEK ranged from 92% to 100% at last follow-up. Best-corrected visual acuity after Descemet's stripping endothelial keratoplasty (DSEK) ranged from 20/34 to 20/66 at 9 months. The most common complications after DSEK were graft detachment (mean, 14%; range, 0%-82%), endothelial rejection (mean, 10%; range, 0%-45%), and primary graft failure (mean, 5%; range, 0%-29%). Mean EC loss after DSEK was 37% at 6 months. CONCLUSIONS: The evidence reviewed supports DMEK as a safe and effective treatment for endothelial failure. With respect to visual recovery time, visual outcomes, and rejection rates, DMEK seems to be superior to DSEK and to induce less refractive error with similar surgical risks and EC loss compared with DSEK. The rate of air injection and repeat keratoplasty were similar in DMEK and DSEK after the learning curve for DMEK.

Management of herpes simplex virus epithelial keratitis.

PURPOSE OF REVIEW: To review recent advancements in the management of herpes simplex virus (HSV) epithelial keratitis. RECENT FINDINGS: Trifluridine eye drop, acyclovir (ACV) ointment, ganciclovir gel, and oral ACV are still the main therapeutic agents. Cryopreserved amniotic membrane has been recently used as an adjuvant treatment. Resistance to ACV has become a concerning issue. The animal models of HSV vaccine are able to reduce HSV keratitis. New antivirals are under development. SUMMARY: Current cases of HSV epithelial keratitis are manageable with available medications, but new advancements are required to decrease disease burden in the future. HSV vaccine can be revolutionary.

"Therapeutic Penetrating Keratoplasty: A Retrospective Review".

PURPOSE: To report the indications, outcomes, and complications of therapeutic penetrating keratoplasty (Th PK) in patients with corneal perforation and/or nonhealing corneal ulceration. METHODS: A retrospective review was conducted of 51 eyes of 51 patients undergoing Th PK between January 1, 2006 and April 15, 2016. Data collected included patient demographics, visual acuity (VA), size of the corneal infiltrate and epithelial defect, degree of corneal thinning/perforation, microbiological results, surgical details, and postoperative complications. RESULTS: The average age at presentation was 56.0 years (range 6-92 years), and most of the patients were females (n=31, 60.8%). Th PK was performed for corneal perforation in 28 eyes (54.9% of cases), nonhealing corneal ulcer in 16 eyes (31.4% of cases), and imminent risk of corneal perforation in 7 eyes (13.7% of cases). Infection was the most common reason for performing a Th PK and was present in 92.3% (47/51) of all cases. Of the infectious cases, the most common etiologies were bacterial (44.7%, 21/47) and fungal (31.9%, 15/47). The most common identifiable risk factor for undergoing a Th PK was a history of contact lens wear, which was seen in 32.7% of patients. Initial anatomic success was achieved in all patients after performing Th PK. Most patients (33/51; 64.7%) had clear grafts at their last follow-up examination. There was an improvement in VA in 70.2% (33/47, where data were available) of the patients at the final postoperative visit compared with the preoperative visit. Average best postoperative VA (1.14±0.88 logarithm of the minimum angle of resolution [LogMAR]; 20/276) was significantly better than the presenting (1.98±0.68 LogMAR; 20/1910) and preoperative (2.18±0.55 LogMAR; 20/3,027) visual acuities (P<0.0001). The most common complication after Th PK was cataract, which was present in 81.8% (27/33) of phakic eyes in which lens status could be assessed, followed by graft failure (47.1%; 24/51), and secondary glaucoma (45.1%; 23/51). Five eyes developed infection in the therapeutic graft, four eyes had persistent corneal epithelial defect at their last follow-up visit, and two eyes underwent evisceration. CONCLUSIONS: Therapeutic penetrating keratoplasty achieves anatomic success and it is a useful procedure for restoring a stable cornea in cases in which infection fails to heal or when the cornea perforates. Furthermore, Th PK achieves corneal clarity and improves vision in most patients.

Survey of Ophthalmologists Regarding Practice Patterns for Dry Eye and Sjogren Syndrome.

OBJECTIVE: To survey ophthalmologists about current practice patterns regarding the evaluation of dry eye patients and referrals for a Sjogren syndrome (SS) workup. METHODS: An online survey was sent to ophthalmologists affiliated with the Scheie Eye Institute or Wills Eye Hospital using REDCap in August 2015. Descriptive statistics were used to summarize the data. RESULTS: Four hundred seventy-four survey invitations were sent out and 101 (21%) ophthalmologists completed the survey. The common traditional dry eye test performed was corneal fluorescein staining (62%) and the most common newer dry eye test performed was tear osmolarity (18%). Half of respondents (51%) refer fewer than 5% of their dry eye patients for SS workups, with 18% reporting that they never refer any patients. The most common reasons for referrals included positive review of systems (60%), severe dry eye symptoms (51%) or ocular signs (47%), or dry eye that is refractory to treatment (42%). The majority (83%) felt that there is a need for an evidence-based standardized screening tool for dry eye patients to decide who should be referred for evaluation for SS. CONCLUSIONS: Ophthalmologists continue to prefer the use of traditional dry eye tests in practice, with the most common test being corneal fluorescein staining. There is an underreferral of dry eye patients for SS workups, which is contributing to the continued underdiagnosis of the disease. Most respondents felt that there was a need for an evidence-based standardized screening tool to decide which dry eye patients should be referred for SS evaluations.

Emerging trends in contact lens-related infections.

PURPOSE OF REVIEW: This article reviews the literature on past and recent trends in contact lens-related microbial keratitis from bacterial, fungal, and Acanthamoeba infections. RECENT FINDINGS: Contact lens wear is the most important risk factor for microbial keratitis. Despite increased use of daily disposable contact lens wear, the incidence of bacterial ulcers related to contact lens wear remains high. Overnight contact lens wear is the leading risk factor in contact lens-related bacterial infections. There may be a trend towards increasing antibiotic resistance of Gram-positive bacteria to fourth-generation fluoroquinolones. The incidence of Acanthamoeba and fungal infections, despite resolution of two outbreaks involving multipurpose solutions, are also on the rise. SUMMARY: Contact lens-related microbial keratitis is rising and may be associated with more severe, vision threatening, infections.

Blepharokeratoconjunctivitis in children.

PURPOSE OF REVIEW: This article reviews the current literature on pediatric blepharokeratoconjunctivitis (BKC) to enhance the understanding on the incidence, clinical course, and treatment options. RECENT FINDINGS: Pediatric BKC is a disorder with a wide spectrum of clinical manifestations. Therapies target both the infectious and inflammatory components of this disorder. SUMMARY: Pediatric BKC is a disorder with a wide spectrum of clinical manifestations and severity, which is often overlooked or misdiagnosed.

Quality of vision after excimer laser phototherapeutic keratectomy with intraoperative mitomycin-C for Salzmann nodular degeneration.

OBJECTIVE: To assess the effect of excimer laser phototherapeutic keratectomy (PTK) with intraoperative mitomycin-C (MMC) on the quality of vision in patients with Salzmann nodular degeneration (SND). METHODS: Thirteen eyes of 12 patients were enrolled in the study between December 2010 and March 2012. Uncorrected and best-corrected Snellen distance visual acuities were measured at every visit. Contrast sensitivity and manifest refraction were measured preoperatively, at 1 month and at 3 months. Corneal topography, Galilei dual Scheimpflug imaging, VISX WaveScan, and ultrasound central corneal pachymetry were measured preoperatively and at 3 months after PTK procedure. RESULTS: Contrast sensitivity was statistically significantly better both at 1 month (P<0.01) and 3 months (P<0.01). Postoperatively, there was 46% increase in eyes with measurable corneal topography, 69% increase in Galilei dual Scheimpflug imaging, and a 77% increase in WaveScan measurements. The third-order (P<0.01) and total corneal higher-order aberrations (HOAs) (P=0.01) were significantly lower postoperatively compared with the preoperative corneal aberrations measured on Galilei dual Scheimpflug imaging. CONCLUSIONS: Significant improvement in contrast sensitivity and corneal HOAs was seen after PTK for SND. Phototherapeutic keratectomy with MMC can be considered as an effective procedure in the improvement of the quality of vision in patients with SND.

A Detailed Analysis of Individuals Having Graft Failure After Corneal Transplantation.

PURPOSE: To describe demographic and clinical characteristics of patients with graft failure after keratoplasty, determine the cause of graft failure and outcomes. METHODS: The charts of patients between 2008-2013 in the Cornea Service at Wills Eye Hospital with a history of a corneal transplant before the end of 2012 were retrospectively reviewed. Included were patients who had graft failure after corneal transplantation and had at least one year of follow-up after transplantation. Penetrating keratoplasty (PK) and Descemet's stripping endothelial keratoplasty (DSEK) patients were analyzed separately. RESULTS: A total of 186 eyes of 170 patients with graft failure after a PK (156) or DSEK (30) procedures were identified. The baseline characteristics included 100 female and 70 male patients with an age between 0 and 90 years (median 63 years). At the time of surgery, 38% had three or more systemic diseases and 68% were using three or more systemic medicines. Mean follow up time for PK was nearly four times of DSEK. Only 2 DSEK eyes (7%) underwent a 3rd DSEK graft, while 47 (30%) PK eyes underwent a 3rd PK and 15 (10%) PK eyes underwent more than three PK procedures. CONCLUSIONS: Most DSEK failures occurred in 1st year, while graft failure in PKs is scattered over years. Failure in DSEK is mostly due to graft or surgical risk factors but in PK mostly due to factors in the host. DSEK does not appear to be as affected by the patients' demographic and clinical characteristics as much as PK.

Definition and Diagnostic Criteria for Pediatric Blepharokeratoconjunctivitis.

Importance: Pediatric blepharokeratoconjunctivitis (PBKC) is a chronic, sight-threatening inflammatory ocular surface disease. Due to the lack of unified terminology and diagnostic criteria, nonspecific symptoms and signs, and the challenge of differentiation from similar ocular surface disorders, PBKC may be frequently unrecognized or diagnosed late. Objective: To establish a consensus on the nomenclature, definition, and diagnostic criteria of PBKC. Design, Setting, and Participants: This quality improvement study used expert panel and agreement applying the non-RAND modified Delphi method and open discussions to identify unified nomenclature, definition, and definitive diagnostic criteria for PBKC. The study was conducted between September 1, 2021, and August 14, 2022. Consensus activities were carried out through electronic surveys via email and online virtual meetings. Results: Of 16 expert international panelists (pediatric ophthalmologists or cornea and external diseases specialists) chosen by specific inclusion criteria, including their contribution to scientific leadership and research in PBKC, 14 (87.5%) participated in the consensus. The name proposed was "pediatric blepharokeratoconjunctivitis," and the agreed-on definition was "Pediatric blepharokeratoconjunctivitis is a frequently underdiagnosed, sight-threatening, chronic, and recurrent inflammatory eyelid margin disease associated with ocular surface involvement affecting children and adolescents. Its clinical spectrum includes chronic blepharitis, meibomitis, conjunctivitis, and corneal involvement ranging from superficial punctate keratitis to corneal infiltrates with vascularization and scarring." The diagnostic criteria included 1 or more suggestive symptoms accompanied by clinical signs from 3 anatomical regions: the eyelid margin, conjunctiva, and cornea. For PBKC suspect, the same criteria were included except for corneal involvement. Conclusions and Relevance: The agreements on the name, definition, and proposed diagnostic criteria of PBKC may help ophthalmologists avoid diagnostic confusion and recognize the disease early to establish adequate therapy and avoid sight-threatening complications. The diagnostic criteria rely on published evidence, analysis of simulated clinical cases, and the expert panel's clinical experience, requiring further validation with real patient data analysis.

Dry eye syndrome in aromatase inhibitor users.

BACKGROUND: Aromatase inhibitors are frequently used as an adjuvant therapy in the treatment of breast cancer. We observed that several patients taking aromatase inhibitors presented with severe dry eye symptoms, and we investigated whether there is a relationship between aromatase inhibitors and dry eyes in these patients. DESIGN: Retrospective chart review. PARTICIPANTS: Forty-one women. METHODS: A computerized search of health records was performed to identify patients using anastrazole, letrozole and exemestane seen by the Cornea Service from August 2008 to March 2011. The results were compared with age-matched controls. MAIN OUTCOME MEASURES: Ocular surface changes among aromatase inhibitors users. RESULTS: Of the 41 women, 39 were Caucasians. Thirty-nine patients had breast cancer (95%), one patient had ovarian cancer (2.5%) and one had an unknown primary cancer. Mean age was 68 ± 11.3 years (range 47-95). Most common presenting symptoms were blurred vision in 28 (68%) patients, irritation/foreign body sensation in 12 (29%) patients, redness in 9 (22%) patients, tearing in 6 (22%) patients and photosensitivity in 2 (5%) patients. Mean Schirmer's test measurement was 11 ± 5.8 mm (range 0.5-20 mm). Blepharitis was noted in 68 of 82 eyes (73%), decreased or poor tear function in 24 eyes (29%), conjunctival injection in 18 eyes (22%) and superficial punctate keratitis in 12 eyes (29%). Among an age-matched population (45-95 years), dry eye syndrome was found in only 9.5% of patients. CONCLUSIONS: Because the prevalence of ocular surface disease signs and symptoms appears to be higher in study group than control patients, aromatase inhibitors might be a contributing factor to the dry eye symptoms.

Episodes of microbial keratitis with therapeutic silicone hydrogel bandage soft contact lenses.

OBJECTIVE: To report the therapeutic practice patterns of silicone hydrogel (SiH) bandage soft contact lenses (BSCL) and the resultant rate of microbial keratitis (MK). METHODS: A retrospective case series of patients treated with therapeutic BSCLs for ocular surface disease from January 2006 to January 2009 in a tertiary care cornea practice. All patients had a history of ocular surface disease. RESULTS: Seventy-four patients were treated with a therapeutic SiH BSCL (102 intervals of use) for complicated ocular surface disease. Two patients developed infectious corneal infiltrates (2/102, 2.0%) [corrected]. Two of 3 MK episodes were in patients with limbal stem-cell deficiency (2/102, 2.0%). CONCLUSIONS: Therapeutic SiH BSCLs were safely used in most patients. However, results suggest that prophylactic antibiotic use did not eliminate the risk for MK with SiH BSCL use in patients with chronic ocular surface disease.

Sutureless amniotic membrane ProKera for ocular surface disorders: short-term results.

OBJECTIVE: To evaluate the indications and outcomes of sutureless amniotic membrane transplant (AMT; ProKera) in the management of ocular surface disorders. METHODS: Chart review of patients who had ProKera (Bio-Tissue, Inc.) implantation for ocular surface disorders between June 2008 and May 2012 at 3 ophthalmology practices in Philadelphia, PA. The parameters evaluated included age, sex, indication for AMT, any other combined procedure, duration of retention of amniotic membrane, the effect of amniotic membrane on ocular surface healing, follow-up time, and complications. RESULTS: There were 35 eyes of 33 patients with a mean age of 68.2±19.5 years (range: 17-99 years). There were 25 male patients, and median follow-up was 110 days (mean: 164.6 days; range: 30-960 days). The indication for insertion of ProKera was nonhealing corneal ulcers of infective origin (group 1) in 9 eyes (25.7%), neurotrophic keratopathy (group 2) in 11 eyes (31.4%), chemical injury (group 3) in 5 eyes (14.3%), and other indications (group 4) in 10 eyes (28.6%). Complete or partial success was seen in a total of 44%, 64%, 80%, and 70% eyes in groups 1 to 4, respectively. Discomfort with the device was seen in 6 (17.1%) of 35 eyes, and recurrence of primary pathologic condition occurred in 5 (14.3%) of 35 eyes. CONCLUSION: ProKera treatment is easy to use and reasonably well tolerated, with moderate success in corneal ulcers and encouraging results in acute moderate chemical injury. Recurrence of primary pathologic condition is seen particularly associated with neurotrophic keratitis and dry eye syndrome.

Prior Contralateral Penetrating Keratoplasty Is a Risk Factor for Second Eye Graft Rejection.

AIMS: To determine whether prior penetrating keratoplasty (PK) in the contralateral eye increases risk of second eye PK graft rejection. METHODS: Cohort study of 593 consecutive PKs in transplant-naïve eyes (500 unilateral cases, 93 second eyes). Outcomes were compared between PKs performed in eyes with versus without a history of prior contralateral eye PK. Risks of rejection and failure were estimated using Cox proportional hazards models. RESULTS: Mean age was 53.7 ± 23.3 years; average follow-up was 4.00 ± 2.87 years. Rejection occurred in 211 (35.6%) grafts. The incidence of rejection was 34.0% in unilateral cases and 44.1% in second eyes with PK in the contralateral eye. Prior contralateral PK was a significant risk factor for graft rejection (HR = 1.42, 95% CI 1.01-2.01, p = .045). CONCLUSION: Contralateral PK is associated with increased risk of second eye graft rejection. Loss of ocular immune privilege is a possible mechanism.

Development of a Nomogram to Predict Graft Survival After Descemet Stripping Endothelial Keratoplasty.

BACKGROUND/PURPOSE: The purpose of this study was to analyze Descemet stripping endothelial keratoplasty (DSEK) outcomes and develop a nomogram to compute the probability of 3- and 5-year DSEK graft survival based on risk factors. STUDY DESIGN/METHODS: The medical records of 794 DSEK procedures between January 1, 2008, and August 1, 2019, were retrospectively reviewed to identify 37 variables. We also evaluated for the presence of corneal graft failure, defined as irreversible and visually significant graft edema, haze, or scarring. Variables were assessed by multivariable Cox models, and a nomogram was created to predict the probability of 3- and 5-year graft survival. RESULTS: Graft failure occurred in 80 transplants (10.1%). The strongest risk factors for graft failure included graft detachment [hazard ratio (HR) = 4.46; P < 0.001], prior glaucoma surgery (HR = 3.14; P = 0.001), and glaucoma (HR = 2.23; P = 0.018). A preoperative diagnosis of Fuchs dystrophy was associated with a decreased risk of graft failure (HR = 0.47; P = 0.005) compared with secondary corneal edema. Our nomogram has a concordance index of 0.75 (95% confidence interval, 0.69 to 0.81), which indicates that it may predict the probability of graft survival at 3 and 5 years with reasonable accuracy. We also analyzed graft rejection, which occurred in 39 cases (4.9%). The single risk factor found to be significantly associated with graft rejection was prior glaucoma surgery (HR = 2.87; P = 0.008). CONCLUSIONS: Our nomogram may accurately predict DSEK graft survival after 3 and 5 years based on 4 variables. This nomogram will empower surgeons to share useful data with patients and improve collective clinical decision-making.

Graft Outcomes After Temporary Keratoprosthesis in Combined Penetrating Keratoplasty and Vitreoretinal Surgery.

PURPOSE: Corneal pathology can obstruct the visualization required for surgical management of coexisting posterior segment diseases, and use of a temporary keratoprosthesis (TKP) permits combined penetrating keratoplasty (PK) and vitreoretinal surgery. We evaluated graft outcomes after TKP for combined PK and vitreoretinal surgery and analyzed risk factors for graft failure. METHODS: We reviewed the electronic medical records for patients who underwent TKP for PK combined with vitreoretinal surgery at Wills Eye Hospital between May 2007 and April 2021. Overall, 28 variables were analyzed. The main outcome measure was corneal graft failure, defined as irreversible graft edema or opacification. RESULTS: A total of 46 eyes of 46 patients underwent combined surgery and were included in the study. The mean age at surgery was 55.7 ± 18.6 years (range 19-86 years), and the mean follow-up was 31.8 ± 30.5 months (range 1.6-114.0 months). Multivariable analysis revealed 2 factors significantly associated with graft failure: history of trauma (hazard ratio = 5.38; 95% confidence interval, 1.53-18.91; P = 0.009) and intraocular silicone oil after transplant (hazard ratio = 5.67; confidence interval 1.66-19.44; P = 0.006). Corneal graft failure occurred in 60.9% of all cases over the course of follow-up, but the absence of both variables yielded a 33.3% failure rate. CONCLUSIONS: Although outcomes vary, previous ocular trauma and the presence of intraocular silicone oil are risk factors for failure that may facilitate patient selection and improve counseling about long-term graft potential after TKP for combined PK and vitreoretinal surgery.

Determinants of Clinical Outcomes After Infectious Scleritis.

PURPOSE: The aims of this study were to describe the clinical course of microbial infectious scleritis and identify factors associated with poor visual outcomes. METHODS: Data from 26 eyes of 26 patients with culture-proven bacterial or fungal scleritis presenting at a single tertiary center from January 1, 2007, to July 1, 2021, were reviewed. Thirty-six variables were analyzed for associations with poor vision [best-corrected visual acuity (BCVA) <20/200] or loss of vision (no light perception vision or requirement for enucleation or evisceration) at final visit. RESULTS: The mean age at initial presentation was 67.1 ± 14.0 (range: 34-92) years with a mean follow-up of 2.1 ± 2.2 (0.05-8.45) years. The mean presenting logarithm of minimal angle of resolution (logMAR) BCVA was 1.3 ± 1.0 (∼20/400) and mean final logMAR BCVA was 1.6 ± 1.2 (∼20/800). Fourteen eyes (53.8%) exhibited poor vision and 7 (26.9%) had loss of vision at final follow-up. History of necrotizing scleritis and poor presenting vision were associated with poor final vision (OR = 19.1; P = 0.017 and OR = 7.5; P = 0.047, respectively), whereas fungal scleritis was associated with loss of vision (odds ratio [OR] = 30.3, P = 0.013). Subconjunctival antimicrobial treatment was inversely associated with loss of vision (OR = 0.06, P = 0.023). There was no difference in vision between medical and combined medical-surgical management, although infection resolution time was shorter for combined intervention (16.8 ± 10.6 vs. 53.7 ± 33.8 days; P = 0.005). CONCLUSIONS: Infectious scleritis is often successfully treated, but loss of vision or eye removal is common. Poor baseline vision, history of necrotizing scleritis, and fungal etiology were prognostic for worse clinical outcomes. Surgical intervention was associated with quicker resolution compared with medical treatment alone.