Penetrating keratoplasty: outcomes from a corneal unit compared to national data.

AIMS: To determine long term graft survival rates and visual results for different indications for penetrating keratoplasty from a single institution over 10 years and compare these to national outcome data. METHODS: Retrospective chart analysis. 784 records were available for review of 1096 consecutive penetrating keratoplasty procedures performed between 1990 and 1999 (72%). Outcomes of graft survival, visual acuity, and astigmatism were analysed and compared to national outcome data supplied by the UK Transplant Service. RESULTS: At 5 year follow up, overall graft survival was 66%. This was subdivided into 98% for keratoconus, 86% for viral keratitis, 85% for Fuchs' dystrophy, 84% for pseudophakic bullous keratopathy, 55% for regrafts, and 57% for other diagnoses. There was a significantly higher graft survival rate for all diagnostic subgroups except Fuchs' dystrophy at 3 years of follow up compared to the national average. Best corrected visual acuity at 5 years was 6/18 or better in 53% of cases. The mean keratometric astigmatism was 3.4 dioptres. CONCLUSION: Penetrating keratoplasty is a safe and effective treatment for selected corneal disorders. Penetrating keratoplasty for viral keratitis may achieve good results with long term antiviral treatment. Patients may achieve better outcomes if their surgery is performed at specialist centres.

Penetrating keratoplasty: indications over a 10 year period.

AIMS: To determine the indications for penetrating keratoplasty (PK) at the Corneoplastic Unit and Eye Bank, UK, a tertiary referral centre, over a 10 year period. METHODS: Records of all patients who underwent PK at our institution between 1990 and 1999 were reviewed retrospectively. Of the 1096 procedures performed in this period, 784 records were available for evaluation (72%). RESULTS: Regrafting was the most common indication, accounting for 40.9% of all cases. Keratoconus was the second most common indication (15%), followed by Fuchs' endothelial dystrophy (9.3%), pseudophakic bullous keratopathy (7.6%), and viral keratitis (5.9%), which included both herpes simplex and herpes zoster and showed a statistically significant decreasing trend using regression analysis (p<0.005). Among the regraft subgroup, viral keratitis accounted for 21.2% as the underlying primary diagnosis. The most common cause for graft failure in the regraft subgroup was endothelial failure (41.8%). CONCLUSION: Regrafting is the leading indication for PK; viral disease-although declining-is the leading primary diagnosis.

Penetrating keratoplasty in infants.

PURPOSE: To analyze graft survival and visual outcome after penetrating keratoplasty in infants with congenital corneal opacity. METHODS: We retrospectively reviewed the records of 11 patients with congenital corneal opacity who underwent penetrating keratoplasty as infants. Six patients had a diagnosis of Peter's anomaly, 1 of congenital hereditary endothelial dystrophy, 1 of posterior polymorphous dystrophy, and 2 of sclerocornea, and in the other patient, the cause of the opacity was unknown. RESULTS: In total, 26 penetrating keratoplasties were performed on 16 eyes of 11 infants. All patients initially underwent surgery before the age of 13 months. Five patients underwent bilateral penetrating keratoplasty, and 10 of the transplants were repeat operations on eyes that had already had at least one previously failed graft. The age of the infants at the time of first penetrating keratoplasty ranged from 2 to 56 weeks (median, 13 weeks). The graft survival time for all transplants ranged from 3 to 137 months (median, 16 months). Overall first graft survival at 12 months was 61% (95% CI, 33%-81%), with 10 of 16 eyes retaining a clear corneal graft. Peter's anomaly, lensectomy, and repeat penetrating keratoplasty were factors most highly associated with poor graft survival and a low final visual acuity. CONCLUSION: Early penetrating keratoplasty for congenital corneal opacity may prevent deprivation amblyopia. Although this procedure carries a high risk of failure, particularly in those patients with Peter's anomaly, careful case selection, optical correction, and management of postoperative amblyopia may result in a successful visual outcome.

Living related conjunctival limbal allograft for the treatment of stem cell deficiency.

PURPOSE: To evaluate the outcomes of living related conjunctival limbal allograft transplantation for the treatment of stem cell deficiency. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Nine living related donors, eight recipients (10 eyes) with Stevens-Johnson syndrome (3 eyes), ectodermal dysplasia (3 eyes), chemical injury (2 eyes), ocular cicatricial pemphigoid (1 eye), and atopic keratoconjunctivitis (n = 1). INTERVENTION: Four clock hours of limbal conjunctival tissue from the best matched human leukocyte antigen (HLA) relative donor were transplanted to the recipient eye superiorly and inferiorly after conjunctival peritomy and removal of conjunctival pannus. Systemic cyclosporine was administered to all recipients. MAIN OUTCOME MEASURES: Restoration of corneal epithelium, reduction of vascularity and conjunctivalization, improved comfort, improved corneal clarity, and visual improvement. RESULTS: Mean follow-up period was 26.2 months. Two highly inflamed eyes failed to initially epithelialize. The remainder all survived with restoration of corneal epithelium and reduction of vascularization. Corneal opacification was reduced (four of eight eyes) and visual improvement was achieved in seven eyes. All five eyes with pain had an improvement in symptoms. Allograft rejection occurred in two eyes (25%), and both were treated successfully. Both eyes had two class I HLA mismatches, and both had an underlying diagnosis of Stevens-Johnson syndrome. One eye developed a recurrent epithelial defect and perforated, requiring a penetrating keratoplasty that remained clear with an intact epithelial surface. The two initial failures also perforated and required penetrating keratoplasties that failed. None of the donor eyes had any complications. CONCLUSIONS: Restoration of the ocular surface by HLA-matched conjunctival limbal allograft transplantation can be accomplished in selected recipients. Systemic cyclosporine, even at low doses, is useful in ensuring long-term survival.

Clinical and pathologic findings in human keratolimbal allograft rejection.

OBJECTIVE: To characterize the clinical and pathologic features of cadaveric keratolimbal allograft (KLAL) rejection. DESIGN: The study design is descriptive. PARTICIPANTS: Four patients (five eyes) with KLAL rejection are reported. INTERVENTION: All patients were subjected to slit-lamp biomicroscopy, treatment of rejection, and ultimately required repeat KLAL surgery. In three patients (four eyes), specimens obtained at the time of repeat surgery were subjected to immunohistochemical staining against the following immune and surface human antigens: CD4, CD8, CD19, CD3, DR, CK19, CK3, and vimentin. RESULTS: Signs of allograft rejection included intense sectoral injection, diffuse or perilimbal conjunctival injection, edema, and infiltration of the KLAL grafts, leading to punctate epithelial erosions, epithelial defects, and surface keratinization. Rejected specimens revealed T-lymphocyte infiltration (CD4:CD8, 2:1) with strong HLA-DR (MHC class II) expression. The epithelium stain results were positive for cytokeratin 19 and weakly positive to absent for cytokeratin 3. The epithelial stain results were weakly positive for vimentin in only one specimen. CONCLUSIONS: KLAL rejection is a newly recognized entity. Pathologic findings of rejected specimens indicate that this is a T-cell mediated rejection phenomenon. The pattern of cytokeratin staining provided little evidence that the epithelium covering KLALs had a corneal phenotype. The scarcity of vimentin-positive epithelial cells suggests that the stem-cell/transient-cell pool was probably depleted. Early recognition of clinical rejection is important, as treatment with immunosuppressive therapy may reverse the process.

Photorefractive keratectomy for hyperopia: six months results in 45 eyes.

OBJECTIVE: To evaluate the safety and efficacy of photorefractive and photoastigmatic keratectomy for hyperopia. METHODS: The Chiron Keracor 116 excimer laser (Chiron Technolas, Munich, Germany) was used to create a peripheral annular ablation profile for the correction of hyperopia and a prior cylindrical ablation in the negative axis for correction of the astigmatic component in 45 consecutive eyes with up to +6.50 diopters (D). All patients were followed for a minimum of 6 months. RESULTS: At 6 months, mean subjective refraction was +0.12 D (standard deviation, 0.70), with 87% within 1 D of emmetropia. Ninety-three percent achieved uncorrected visual acuity of 20/40 or better. Three eyes (6.7%) lost 2 lines of best spectacle-corrected visual acuity and six eyes (13.3%) gained 2 lines or more. CONCLUSIONS: Photorefractive and photoastigmatic keratectomy effectively and predictably reduced hyperopia, improving uncorrected visual acuity in all patients at 6 months. Longer follow-up is required to be certain that refractive changes are stable.

The role of topical corticosteroids in the management of Acanthamoeba keratitis.

PURPOSE: To clarify the role of topical corticosteroids in the management of Acanthamoeba keratitis. METHODS: The records of 38 patients diagnosed with Acanthamoeba keratitis at three institutions were retrospectively reviewed. RESULTS: After medical therapy alone, patients diagnosed within 1 month of symptom onset had an increased likelihood of being cured (p = 0.02) and attaining visual acuity of 20/60 or better (p < 0.01). Fourteen (73.7%) of 19 patients treated with topical corticosteroids at any time were cured after antiamoebal therapy alone, whereas five (26.3%) patients required penetrating keratoplasty for either persistent infection (n = 3) or perforation (n = 2). The mean antiamoebal therapy duration, excluding duration after keratoplasty if applicable, was 38.5 weeks. Thirteen (76.5%) of 17 patients treated with antiamoebal therapy without topical corticosteroids were medically cured, whereas four (23.5%) required penetrating keratoplasty for either persistent infection (n = 2) or perforation (n = 2). The mean antiamoebal therapy duration was 20 weeks. Although the mean antiamoebal therapy duration in the steroid-treated group was significantly longer than that in the non-steroid-treated group (p = 0.02), outcome after medical therapy between the groups was not significantly different. CONCLUSIONS: Topical corticosteroids were not associated with a higher rate of medical treatment failure in patients with Acanthamoeba keratitis. Rather, poor outcome was significantly related to diagnostic delays. Therefore prudent use of corticosteroids in selected patients with severe pain not responsive to analgesics or severe corneal or anterior chamber inflammation appears justified.

Posterior amorphous corneal dystrophy. A new pedigree with phenotypic variation.

BACKGROUND: Posterior amorphous corneal dystrophy is a rare condition characterized by bilateral sheet-like opacification of the posterior stroma in association with corneal flattening and thinning. It has been reported in only four families, all from the United States. The authors report on a fifth family, the first from Britain, with nine affected individuals. METHODS: Slit-lamp photography, refraction, keratometry, pachometry, corneal topography, and specular microscopy were used to assess the family members. RESULTS: Two distinct forms of the disease were identified. All patients with the centroperipheral form were hypermetropic and had keratometry readings below 41.00 diopters and a central corneal thicknesses less than 0.50 mm. Those with the less severe peripheral form were less hypermetropic, some slightly myopic, and had keratometry readings above 41.00 diopters, but the central corneal thicknesses was similar to those with the centroperipheral form. No abnormalities of the endothelium were detected, and visual acuity was only mildly affected. The condition appears to be nonprogressive. CONCLUSION: Though the centroperipheral form of posterior amorphous corneal dystrophy is more likely to lead to presentation, most patients are asymptomatic. This dystrophy can be very subtle in its appearance and easily overlooked. This led the authors to suspect that the prevalence of this condition is higher than the few reports in the ophthalmic literature suggest.

Avellino corneal dystrophy. Clinical manifestations and natural history.

PURPOSE: The pathologic features of a variant of granular corneal dystrophy has been described in which the presence of lattice changes in addition to characteristic granular lesions has been documented. The authors investigated the mode of inheritance, natural history, and clinical manifestations of this dystrophy. METHODS: A family with this condition was investigated, and a pedigree was established. Family members underwent ophthalmic examination, and ophthalmic history was obtained. In addition, pathologic examination of corneal tissue from affected patients was performed. RESULTS: Similar to the four previously described cases, this family also traced its origins to Avellino, Italy. This autosomal dominant condition affected 27 of 92 family members, ranging in age from 5 to 77 years. Granular deposits were the earliest and most common manifestations. Lattice lesions were present in some patients with granular lesions. Older patients had anterior stromal haze between deposits, which impaired visual acuity. Recurrent granular deposits were noted in donor corneal tissue after penetrating keratoplasty for this condition. Pathologic examination of corneal tissue from affected patients confirmed the presence of hyaline material seen in granular dystrophy as well as fusiform deposits of amyloid, similar to those seen in lattice dystrophy type I. CONCLUSION: This study establishes the natural history and clinical manifestations of this condition.

Penetrating keratoplasty and transscleral fixation of posterior chamber lens.

We reviewed the outcome in 115 patients who underwent penetrating keratoplasty and transscleral fixation of a posterior chamber lens. One patient died soon after surgical procedures, and nine patients were lost to follow-up, leaving a cohort of 105 patients. Mean follow-up time was 26.8 months (range, six to 43 months). Visual acuity of 20/40 or better was found in 29 patients (27.6%) and 20/50 to 20/200 in 37 patients (35.2%). Reasons for poor visual outcome included cystoid macular edema in ten patients (9.5%), age-related macular degeneration in six patients (5.7%), and retinal detachment in four patients (3.8%). None of the patients developed lens decentration. There were no instances of hyphema and only one patient had a perioperative limited suprachoroidal hemorrhage. New-onset increase in intraocular pressure developed in 20 of 66 patients (30.3%). Analysis of the 39 patients with preoperative increase in intraocular pressure that required medical treatment demonstrated an improvement in 13 patients (33.3%), worsening in 12 patients (30.8%), and unchanged status in 14 patients (35.9%). The exposed haptic suture was covered by using one of the following three alternative methods: a conjunctival flap, a scleral flap, or a corneal tissue button. Exposure of the haptic suture through the conjunctiva was a complication in 21 patients (20%). Of these 16 (76.1%) occurred in the group with a conjunctival covering, five (23.8%) occurred in the group with a scleral flap, and none occurred in the corneal tissue button group. This study demonstrated that transscleral fixation of a posterior chamber lens is a viable option in the treatment of patients undergoing penetrating keratoplasty and intraocular lens implantation with absent capsular support.