Incidence and Outcomes of Positive Donor Corneoscleral Rim Fungal Cultures after Keratoplasty.

PURPOSE: To determine the incidence of positive corneoscleral donor rim fungal cultures after keratoplasty and to report clinical outcomes of grafts with culture-positive donor rims. DESIGN: Retrospective cohort study. PARTICIPANTS: Consecutive donor corneas and keratoplasty recipients at a single tertiary referral center over 20 years. METHODS: Patient charts were reviewed to determine the incidence of positive donor rim fungal cultures and clinical outcomes of all grafts using contaminated tissue. MAIN OUTCOME MEASURES: The primary outcome measures were positive donor rim fungal culture results and the development of postkeratoplasty fungal infection using corresponding corneal tissue. The secondary outcome measure was the impact of postoperative prophylaxis on donor tissue-associated infections. RESULTS: A total of 3414 keratoplasty cases were included in the statistical analysis. Seventy-one cases (2.1%) were associated with a fungal culture-positive donor rim. Candida species were cultured in 40 cases (56.3%). There was a higher incidence of positive rim cultures over the last 5 years of the analytic period compared with the first 15 years (P = 0.018). Fungal keratitis developed in 4 cases (5.6%), and all patients required further surgical intervention to achieve cure. There were no cases of fungal endophthalmitis. Empiric antimycotic prophylaxis initiated at the time of positive culture result reduced the incidence of keratitis from 15.8% in untreated cases to 1.9% in treated cases (P = 0.056). CONCLUSIONS: Positive donor rim fungal cultures are uncommon, but carry an unacceptably high risk of postoperative fungal infection. This risk may be reduced with prophylactic antimycotic therapy when culture-positive donor rims are identified.

Boston type 1 keratoprosthesis for failed keratoplasty.

The purpose of this study was to evaluate the outcomes of the Boston type 1 keratoprosthesis (Kpro-1) in eyes with failed keratoplasty. A retrospective review was performed of every patient treated with a Kpro-1 at a tertiary eye care center between January 1, 2008 and July 1, 2013. Eyes with a failed keratoplasty originally performed for corneal edema, trauma, or keratoconus were included in the statistical analysis. The main outcome measures were visual outcome, prosthesis retention, and postoperative complications. Twenty-four eyes met the inclusion criteria, including 13 eyes with corneal edema, 8 eyes with trauma, and 3 eyes with keratoconus. After a mean follow-up period of 28.9 months (range 7-63 months), the median best corrected visual acuity (BCVA) was 20/125. The BCVA was ≥ 20/40 in 4 (16.7 %) eyes, ≥ 20/70 in 9 (37.5 %) eyes, and ≥ 20/200 in 14 (58.3 %) eyes. Overall, the postoperative BCVA improved in 17 (70.9 %) eyes, was unchanged in 3 (12.5 %) eyes, and was worse in 4 (16.7 %) eyes. The initial Kpro-1 was retained in 22 (91.7 %) eyes, and was successfully repeated in the other 2 eyes. One or more serious prosthesis- or sight-threatening complications occurred in 8 (33.3 %) eyes. These included 1 case of wound dehiscence leading to prosthesis extrusion, 1 case of fungal keratitis leading to prosthesis extrusion, 4 cases of endophthalmitis, and 5 retinal detachments. The Boston Kpro-1 is associated with an excellent prognosis for prosthesis retention and satisfactory visual improvement in eyes with previous failed keratoplasty.

Eyelid procedures in patients who have undergone Boston keratoprosthesis surgery.

PURPOSE: Artificial corneas or keratoprostheses such as the Boston keratoprosthesis (KPro) are being used more frequently to provide a clear corneal window in patients with severe corneal disease. A significant percentage of patients who undergo Boston KPro implantation require subsequent eyelid surgery. However, few articles in peer-reviewed literature evaluate the indication and outcome of eyelid procedures after Boston KPro implantation. This study examines the frequency, nature, and outcomes of oculoplastic procedures in patients with Boston KPro implantation. METHODS: A retrospective chart review was conducted of all KPro-1 procedures performed at the University of Illinois at Chicago between December 2006 and September 2010 and all KPro-1 and KPro-2 procedures performed at the University of Iowa between December 2008 and October 2010. RESULTS: One hundred and twenty eyes underwent Boston KPro-1 procedures, and 2 eyes underwent Boston KPro-2 procedures. Twenty-one (17.2%) of the 122 eyes required subsequent eyelid alterations. Chemical burn was the most common preoperative corneal diagnosis (8 of 21; 38.1%). A variety of oculoplastic procedures were performed; the most common procedure was a permanent lateral tarsorrhaphy. Seventeen (81.0%) of 21 KPro eyes that underwent oculoplastic procedures maintained the KPro at an average of 12.4 months of follow up. CONCLUSIONS: A significant number of patients with Boston KPros require subsequent eyelid surgery. With limited existing literature and increasing popularity for using Boston KPros to treat severe corneal disease, it is essential for oculoplastic and corneal surgeons to understand the need for eyelid alterations in these patients and the surgical intricacies surrounding these cases.

Comparison of outcomes of penetrating keratoplasty versus Descemet's stripping automated endothelial keratoplasty for penetrating keratoplasty graft failure due to corneal edema.

To evaluate the outcomes of repeat corneal transplantation, either penetrating keratoplasty (PKP) or Descemet's stripping automated endothelial keratoplasty (DSAEK), for penetrating keratoplasty grafts which failed due to corneal edema. The charts of 24 eyes with failed PKP grafts, due to corneal edema, which underwent a repeat corneal transplant (PKP in 17 eyes [Group 1] and DSAEK in seven eyes [Group 2]) between 2003 and 2007 were retrospectively reviewed. There was no statistically significant difference in the median postoperative visual acuity between the two groups at 1, 2, or 3 years. In Group 1, two (18%) eyes had a final visual acuity ≥ 20/40, in contrast to four (80%) eyes in Group 2, which was statistically significant (P = 0.038). Seven (41%) of the Group 1 eyes developed postoperative complications compared to only one (14%) eye in Group 2. Eleven (65%) of the Group 1 eyes and five (71%) of Group 2 eyes had clear grafts on the last examination. There was no statistically significant difference in the graft survival rate for Group 1 versus Group 2 at 3 years (57.9% vs 68.6%, P = 0.507). There was a trend towards better postoperative visual acuity, a lower postoperative complication rate, and a higher graft survival rate in eyes that underwent DSAEK rather than repeat PKP for graft failure secondary to corneal edema. Given this small, retrospective study, future studies comparing repeat PKP with DSAEK are warranted to determine which procedure allows for improved outcomes.

Glaucoma therapy escalation in eyes with pseudophakic corneal edema after penetrating keratoplasty and Descemet's stripping automated endothelial keratoplasty.

The purpose of this study was to determine and compare the prevalence of glaucoma therapy escalation (GTE) after penetrating keratoplasty (PKP) and Descemet's stripping automated endothelial keratoplasty (DSAEK) in eyes with a surgical indication of pseudophakic corneal edema. A retrospective review was conducted of the medical records of all patients who underwent PKP or DSAEK to treat pseudophakic corneal edema at a tertiary eye care center from January 1 2003 to December 31, 2006. Eyes that were treated with PKP from January 1, 2003 to December 31, 2004 and with DSAEK from January 1, 2005 to December 31, 2006 were included in the statistical analysis. Inclusion criteria included satisfactory preoperative control of intraocular pressure (IOP) and follow-up of at least 12 months. The main outcome measure was GTE, which was defined as a sustained requirement for escalation of topical medical therapy or the need to provide surgical intervention to maintain a satisfactory postoperative IOP. Among 54 eyes that met the inclusion criteria, GTE occurred in 7 (35.0%) of 20 eyes after PKP and in 14 (41.2%) of 34 eyes after DSAEK (P = 0.78) during a mean follow-up period of 27.6 and 28.6 months, respectively. Surgical escalation occurred in 2 (10.0%) eyes after PKP and 2 (5.9%) eyes after DSAEK (P = 0.62), and was associated with late-onset endothelial graft failure in all four eyes. Glaucoma therapy escalation is relatively common and occurs with comparable frequency in eyes with pseudophakic corneal edema after PKP and DSAEK.

Initial resident refractive surgical experience: outcomes of PRK and LASIK for myopia.

PURPOSE: To evaluate and compare the outcome of initial resident surgical experience with photorefractive keratectomy (PRK) and LASIK. METHODS: Retrospective review of all cases performed with the VISX Star S4 platform (Abbott Medical Optics) between July 1, 2003 and June 30, 2007. Inclusion criteria were spherical equivalent of -0.50 to -10.00 diopters (D), refractive astigmatic error of ≤3.00 D, intention to provide full distance correction, and minimum 3-month postoperative follow-up after initial ablation or retreatment (if performed). RESULTS: A total of 153 cases performed by 20 different residents met the inclusion criteria; 38 eyes underwent PRK and 115 eyes had LASIK. After initial treatment, mean Snellen uncorrected distance visual acuity (UDVA) after PRK was 20/17.3 and after LASIK was 20/19.5. Photorefractive keratectomy was associated with a significantly better approximation between preoperative corrected distance visual acuity (CDVA) and postoperative UDVA (ΔlogMAR 0.009 vs 0.091; P=.004) and a greater percentage of eyes that achieved UDVA of 20/20 or better (94.7% vs 78.3%; P=.02) or 20/30 or better (100% vs 87.8%; P=.02). There was a higher prevalence of retreatment in eyes that underwent LASIK (7.0% vs 0%; P=.20). One (0.9%) eye lost 2 lines of CDVA after LASIK. CONCLUSIONS: Supervised refractive surgery residents can achieve excellent visual outcomes in patients operated during their initial refractive experience. Photorefractive keratectomy was associated with better visual outcome than LASIK.

Cataract surgery in the patient that cannot lie flat.

PURPOSE OF REVIEW: At times a patient requiring cataract surgery cannot be positioned flat rendering the case challenging. In addition, sometimes the medical condition that limits the patient's ability to lie supine also carries an increased risk of being placed under general anesthesia making topical anesthesia a safer option. The surgeon must often use ingenuity in positioning in order to carry out a successful surgery. This review will highlight different techniques employed for cataract surgery in a patient that cannot lie supine. RECENT FINDINGS: There is a small amount of published literature describing techniques of cataract surgery in the patient who cannot lie supine. We hope to highlight the various techniques that have been described in the literature. SUMMARY: Cataract surgery can become more complex when the patient cannot be positioned with their head flat on the operating table. With creative alterations to normal positioning, successful phacoemulsification can be executed.

Penetrating keratoplasty versus deep anterior lamellar keratoplasty for the treatment of keratoconus.

PURPOSE: To compare the outcome of penetrating keratoplasty (PKP) and deep anterior lamellar keratoplasty (DALK) in the surgical management of keratoconus (KC). PATIENT AND METHODS: A retrospective review was conducted of the medical records of all patients treated with PKP or DALK for KC at University of Iowa Hospitals and Clinics from January 1, 2000, to December 31, 2006. The main outcome measures were visual outcome, graft survival, and complications. Cases with a minimum follow-up of 6 months were included in the statistical analysis. RESULTS: Of 41 eyes that met the inclusion criteria, 30 eyes were treated with PKP and 11 eyes were treated with DALK. The mean follow-up was almost identical for eyes treated with PKP or DALK (21.9 vs. 22.5 months, respectively). At the most recent examination, the mean best spectacle-corrected visual acuity (BSCVA) was 20/28 for the PKP group and 20/29 for the DALK group (P = 0.77). The percentage of eyes that achieved BSCVA of 20/25 or better was higher in the PKP group than in the DALK group (77.3 vs. 45.5%, respectively), but this difference was not statistically significant (P = 0.72). Endothelial rejection occurred in 4 (13.3%) eyes after PKP. Visually significant interface haze occurred in the early postoperative course in 2 (18.2%) eyes after DALK. No cases of late-onset endothelial failure were found in either group. CONCLUSION: Treatment of KC with PKP or DALK is associated with similar visual outcomes, graft survival, and prevalence of sight-threatening complications.

Keratoplasty for treatment of Acanthamoeba keratitis.

PURPOSE: To evaluate and compare the outcomes of therapeutic keratoplasty (TKP) and optical keratoplasty (OKP) in the management of medically unresponsive Acanthamoeba keratitis and post-keratitis scarring, respectively. DESIGN: Retrospective, nonrandomized, comparative, interventional case series. PARTICIPANTS: Thirty patients with Acanthamoeba keratitis treated at a single center. METHODS: Retrospective review of all cases of penetrating keratoplasty (PKP) or lamellar keratoplasty (LKP) performed for Acanthamoeba keratitis at a single center between January 1, 1980, and December 31, 2007. Inclusion criteria included histopathologic confirmation of Acanthamoeba organisms in the surgical specimen and at least 6 months of postoperative follow-up. MAIN OUTCOME MEASURES: Postoperative complications, microbiological cure, graft survival, and visual acuity. RESULTS: Thirty-one eyes of 30 patients met the inclusion criteria. This included 22 eyes (22 patients) that were initially treated with TKP (20 PKP/2 LKP) and 9 eyes (8 patients) treated with OKP (8 OKP/1 LKP). Of the 22 eyes treated with TKP, multiple keratoplasties (range, 2-6) were performed in 12 eyes (55%), whereas repeat keratoplasty was performed in only 1 eye (11%) treated with OKP (P = 0.004). Recurrent Acanthamoeba keratitis, glaucoma, early and late persistent epithelial defects, and endophthalmitis were more likely to occur after TKP than after OKP. A microbiological cure was achieved in all surgical cases. Among eyes treated with TKP, this required 1 keratoplasty in 14 eyes, 2 keratoplasties in 6 eyes, and 3 keratoplasties in 2 eyes. After the initial keratoplasty, Kaplan-Meier survivals after TKP were 45.5%, 45.5%, and 37.5% at 1 year, 5 years, and 10 years, respectively, compared with 100%, 100%, and 66.7%, respectively, after OKP (P = 0.004). The median visual acuity was 20/40 after TKP and 20/25 after OKP. Eyes treated with TKP were less likely to obtain visual acuity of 20/40 or better and more likely to have vision of 20/200 or worse. CONCLUSIONS: Therapeutic keratoplasty can successfully treat medically unresponsive cases of Acanthamoeba keratitis, although multiple grafts may be required and the visual prognosis is guarded. Optical keratoplasty performed after resolution of active keratitis is associated with an excellent prognosis for both graft survival and visual outcome. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

DMEK outcomes using nondiabetic grafts for recipients with diabetes mellitus.

PURPOSE: To compare Descemet membrane endothelial keratoplasty (DMEK) outcomes using nondiabetic grafts in diabetic and nondiabetic recipients. METHODS: All eyes that underwent DMEK between February 2013 and October 2016 (follow-up ≥3 months, without prior keratoplasty) were included. Recipients were divided into diabetic (insulin dependent [IDDM] or noninsulin dependent [NIDDM]) and nondiabetic groups. Main outcome measures included postoperative visual acuity, rebubble procedure rates, and graft failure rates. RESULTS: Of 334 eyes (243 subjects) included for analysis, 63 eyes (18.8%) were from diabetic recipients. At each timepoint, best-corrected visual acuity trended lower for IDDM recipients compared to NIDDM and nondiabetic recipients. There were no statistically significant differences in rebubble rates of diabetic compared to nondiabetic recipients (20.6% vs. 12.9%, p = 0.17), or IDDM compared to nondiabetic recipients (27.3% vs. 12.9%, p = 0.08; hazard ratio 2.26). Overall, 13 grafts (3.9%) failed (mean follow-up, 565 days; range, 90-1293 days). Graft failures did not differ between diabetic and nondiabetic recipients (4.0% vs. 4.9%, p = 0.15) regardless of subgroup (p = 0.36). CONCLUSIONS: DMEK provides excellent outcomes for patients with and without diabetes. DMEK outcomes were excellent with improvements in visual acuity and low rates of graft failure. Our findings were unable to determine differences between rebubble procedure rates but do emphasize the need for further research using stratified groups based on diabetes severity.

Glaucoma-associated corneal endothelial cell damage: A review.

The corneal endothelium is critical in maintaining a healthy and clear cornea. Corneal endothelial cells have a significant reserve function, but preservation of these cells is paramount as they have limited regenerative capacity. Glaucoma is a prevalent disease, and damage to the corneal endothelium may be caused by the disease process itself as well as by its treatment. The mechanisms involved in glaucoma-associated damage to the corneal endothelium need further investigation. Understanding how glaucoma and glaucoma surgery impact the endothelium is important for protecting corneal clarity and visual acuity in all glaucoma patients, including those undergoing corneal transplant. We will discuss a range of identified factors that may impact corneal endothelial cell health in glaucoma, including intraocular pressure, glaucoma medications, surgical glaucoma management, mechanical forces, and alterations in the aqueous environment.

Factors Associated With Graft Rejection in the Cornea Preservation Time Study.

PURPOSE: To identify factors related to graft rejection following Descemet stripping automated endothelial keratoplasty (DSAEK) in the Cornea Preservation Time Study (CPTS). DESIGN: Cohort study within a multicenter randomized clinical trial. METHODS: A total of 1330 eyes of 1090 subjects undergoing DSAEK were randomized to receive a donor cornea with preservation time (PT) of 0-7 days (n = 675) or 8-14 days (n = 655) and followed for 3 years. Central endothelial cell density (ECD) was determined by a central image analysis reading center. Multivariable Cox models adjusted for PT, recipient diagnosis, and surgeon effect were used to identify factors associated with rejection. RESULTS: Cumulative probability of definite graft rejection was 3.6% (99% confidence interval 2.5%-5.3%). Younger recipient age was associated with graft rejection (P < .001; hazard ratio: 0.53 [0.33, 0.83] per decade). PT, donor-recipient sex mismatch, recipient diagnosis, recipient race, graft size, discontinuation of topical corticosteroids and immune-modulators, prior immunizations within 3 months, and prior glaucoma surgery were not associated with rejection (P > .01). Among clear grafts with an ECD measurement at baseline and 3 years (n = 913), endothelial cell loss (ECL) was greater in eyes that experienced a rejection episode (n = 27) than in those that did not (n = 886) (48% vs 38%, P = .03). Twelve of 44 eyes (27%) with definite graft rejection subsequently failed, comprising 15% of the 79 failures in the CPTS. CONCLUSIONS: Graft rejection is uncommon after DSAEK and more likely with younger age, in a study cohort mostly > 50 years old. Rejection increases ECL, but it is not a leading cause of DSAEK failure.

Microbial Keratitis and Endophthalmitis After the Boston Type 1 Keratoprosthesis.

PURPOSE: To determine the incidence, ocular surface disease associations, microbiological profile, and clinical course of postoperative infections after implantation of the Boston type 1 keratoprosthesis (KPro-1). METHODS: A retrospective chart review was conducted of all cases of the KPro-1 performed at a tertiary eye care center between January 1, 2008, and December 31, 2014. RESULTS: Seventy-five KPro-1 procedures were included in the analysis. Postoperative infections occurred in 13 eyes (17.3%) with an incidence of 0.064 cases per eye-year. The Kaplan-Meier probability of an infection-free graft was 0.96, 0.90, 0.88, 0.87, and 0.86 at years 1 through 5, respectively. The rate of infections was greater in eyes with ocular surface disease (26.3% vs. 8.1%, P = 0.06), especially in those with a history of chemical or thermal injury or herpes zoster keratopathy (P = 0.001). There were 8 cases (10.7%) of microbial keratitis due to either fungi (5 cases) or bacteria (3 cases). There were 7 cases (9.3%) of endophthalmitis due to bacteria (5 cases) or intraocular extension of fungal keratitis (2 cases). The incidence of microbial keratitis and endophthalmitis was 0.034 and 0.03 cases per eye-year, respectively. Therapeutic management of the infected eyes required graft and device removal in 7 eyes (53.8%). After completion of microbiologic treatment, 7 eyes (53.8%) had lost more than 2 lines of the best-corrected preinfection visual acuity, including 5 eyes with endophthalmitis that had hand motion vision or worse. CONCLUSIONS: Postoperative infections are a serious issue that compromises device retention and visual outcomes after keratoprosthesis implantation.

West Nile Virus Infection in Human and Mouse Cornea Tissue.

The purpose of this study was to determine the in vitro and ex vivo susceptibility of human corneal cells to West Nile virus (WNV) infection and evaluate the ability of the virus to disseminate to the corneas of infected mice. Human corneal epithelial cells were challenged with WNV, incubated for 1-6 days, and tested for evidence of WNV infection. Viral RNA and antigen were detected at every time point, and the virus reached a peak titer of 2.5 × 107 plaque-forming units (pfu)/mL at 3 days postinoculation (PI). Corneas procured from donors were incubated in culture dishes containing WNV for 1-5 days and tested for evidence of WNV. Viral RNA and antigen were detected, and the virus reached a mean peak titer of 4.9 × 104 pfu/mL at 5 days PI. Mice were inoculated intraperitoneally with WNV, and their eyes were harvested at 2, 5, and 8 days PI and tested for evidence of WNV. Viral RNA was detected in corneas of four of nine systemically infected mice as early as 2 days PI. We conclude that human corneal cells support WNV replication in vitro and ex vivo, and WNV may disseminate into the corneas of experimentally infected mice. These findings indicate that corneal transmission cannot be ruled out as a novel mode of human-to-human WNV transmission and additional experiments should be conducted to assess this risk further.

Incidence of Cystoid Macular Edema After Descemet Membrane Endothelial Keratoplasty as a Staged and Solitary Procedure.

PURPOSE: To compare the incidence of visually significant postoperative cystoid macular edema (CME) in pseudophakic eyes after Descemet membrane endothelial keratoplasty (DMEK) performed after recent versus remote cataract surgery. METHODS: A retrospective chart review was performed of all consecutive eyes that underwent DMEK without concurrent cataract surgery at the University of Iowa between October 2012 and December 2014. The DMEK procedures were classified as staged if performed between 2 weeks and 6 months after cataract surgery and solitary if performed more than 6 months after cataract surgery. Possible confounders, including a history of diabetes in the recipient, were tracked. Macular optical coherence tomography was performed to detect CME 1 month after DMEK if the best-corrected visual acuity was ≤20/30 with a clear cornea with no other reason for visual compromise. RESULTS: A total of 173 eyes from 140 patients were included in the statistical analysis. Staged DMEK was performed in 88 eyes (50.8%) and solitary DMEK in 85 eyes (49.2%). The incidence of CME was 8.0% (7 of 88 eyes) in the staged DMEK group and 7.1% (6 of 85 eyes) in the solitary DMEK group (P = 0.823). The incidence of CME did not differ significantly between the staged and solitary DMEK groups regardless of the recipient diabetic status. All cases of CME resolved within 6 months on topical therapy. CONCLUSIONS: The incidence of postoperative CME after DMEK is similar in the setting of recent or remote cataract surgery.

Boston Type 1 Keratoprosthesis: Visual Outcomes, Device Retention, and Complications.

PURPOSE: To determine the visual outcomes, device retention, and complications after Boston type 1 keratoprosthesis (KPro-1) device implantation. METHODS: Comprehensive review of every case of KPro-1 implantation at a tertiary eye care center. RESULTS: The initial KPro-1 procedure, performed in 75 eyes without a previous keratoprosthesis, was included in the analysis. During the first 6 postoperative months, improvement occurred in the mean preoperative best-corrected visual acuity of 20/1265 to a mean best-obtained postoperative visual acuity of 20/97 (P < 0.001). After a mean follow-up period of 41.4 months (range, 0.8-82.8 months), the final mean best-corrected visual acuity was 20/428. Improved vision was recorded in 43 eyes (57.3%), ambulatory vision (≥20/400) in 47 eyes (62.7%), intermediate functional vision (≥20/80) in 23 eyes (30.7%), and full functional vision (≥20/40) in 11 eyes (14.7%). The initial device was retained in 64 eyes (85.3%), with a Kaplan-Meier retention probability of 96% at 6 months and 82% at 5 years. One or more sight-threatening complications occurred in 51 eyes (68%). These included device extrusion in 11 eyes (14.7%), ulcerative keratitis in 12 eyes (16%), endophthalmitis in 7 eyes (9.3%), sterile vitritis in 3 eyes (4%), retroprosthetic membranes in 25 eyes (33.3%), maculopathy in 26 eyes (34.7%), retinal detachment in 9 eyes (12%), and progressive optic neuropathy in 7 eyes (9.3%). CONCLUSIONS: Boston KPro-1 implantation is associated with satisfactory visual outcomes and excellent device retention in a majority of cases. However, serious postoperative complications are common and may compromise the final visual result.

Boston type 1 keratoprosthesis for primary congenital glaucoma.

BACKGROUND/AIMS: To evaluate the Boston type 1 keratoprosthesis (KPro-1) in treatment of eyes with primary congenital glaucoma. METHODS: A retrospective review was performed of every eye with congenital glaucoma that was treated with a KPro-1 at a tertiary eye care centre between 1 January 2008 and 1 July 2014. The main outcome measures were visual outcome, prosthesis retention and postoperative complications. RESULTS: Six eyes of six patients met the inclusion criteria. This included two paediatric patients, aged 6 months and 6 years, and four adults who were 27-33 years of age. Preoperatively, the best corrected visual acuity (BCVA) was worse than 20/400 in every eye. Three eyes had hand motions and one eye had light perception vision. After a mean follow-up period of 31 months (range 16-51 months), three eyes (50.0%) had a BCVA that was ≥20/400. Overall, the BCVA improved in four eyes (66.7%), and remained the same in two eyes (33.3%). The device was retained in six eyes (83.3%). One or more complications occurred in five eyes (83.3%) and included sterile corneal ulceration (three eyes), retroprosthetic membrane formation (three eyes), progressive glaucomatous optic neuropathy (two eyes), device extrusion (one eye) and an epiretinal membrane (one eye). CONCLUSIONS: The Boston KPro-1 has an excellent prognosis for retention in eyes with congenital glaucoma. The visual prognosis remains guarded due to the high prevalence of pre-existing ocular comorbidity and the common occurrence of sight-threatening postoperative complications.

Boston Type 1 Keratoprosthesis for Iridocorneal Endothelial Syndromes.

PURPOSE: To evaluate the outcome of the Boston type 1 keratoprosthesis (KPro-1) in eyes with iridocorneal endothelial syndromes and failed keratoplasties. METHODS: A retrospective review was performed of every eye with a history of iridocorneal endothelial syndrome and a failed corneal transplant that was treated with a KPro-1 at a tertiary eye care center between January 1, 2008, and July 1, 2014. The main outcome measures were visual outcome, prosthesis retention, and postoperative complications. RESULTS: Four eyes met the inclusion criteria. Two eyes had essential iris atrophy and 2 eyes had Chandler syndrome. All 4 eyes had failed corneal transplants and successful glaucoma drainage devices. The mean patient age at the time of KPro-1 surgery was 68.3 years (range, 60-80 years). The mean postoperative follow-up duration was 47 months (range, 27-69 months). Preoperatively, the best-corrected visual acuity (BCVA) was worse than 20/200 in all 4 eyes, including 2 eyes that had hand motions vision. After KPro-1, all 4 eyes initially obtained a BCVA of ≥20/70. At the most recent examination, the BCVA was still ≥20/100 in 3 eyes. The KPro-1 device was retained in all 4 eyes. Postoperative complications included glaucoma progression (1 eye), a retroprosthetic membrane (1 eye), and sterile vitritis (1 eye). CONCLUSIONS: The Boston KPro-1 may offer a better prognosis than repeat traditional keratoplasty in reestablishing corneal clarity in eyes with iridocorneal endothelial syndromes. Despite anatomic success, visual rehabilitation may be compromised by preexisting glaucomatous optic neuropathy and its postoperative progression.

Treatment of acanthamoeba keratitis with intravenous pentamidine before therapeutic keratoplasty.

PURPOSE: The aim of this study was to evaluate the outcome of pretreatment of Acanthamoeba keratitis with intravenous pentamidine (IVP) before therapeutic keratoplasty (TKP). METHODS: A retrospective chart review was performed of the medical records of every patient treated with IVP before TKP for Acanthamoeba keratitis at a single, tertiary care eye center between January 1, 2002, and December 31, 2012. The main outcome measures were microbiological cure, graft survival, and visual outcome. RESULTS: Eight eyes of 7 patients met the inclusion criteria. Preoperatively, all 8 eyes had failed traditional antiamoebic therapy, including 5 eyes with recurrent infections after previous TKP. The patients were treated with IVP (190-400 mg/d) for a median of 14 days (range, 7-26 days). After 8 TKP, a microbiological cure was achieved, and a clear graft was maintained in 5 (62.5%) eyes during a mean follow-up interval of 31.2 months (range, 1.0-95.7 months). Repeat TKP in 3 eyes with recurrent Acanthamoeba keratitis resulted in 2 additional microbiological cures and 1 more clear graft. The final best-corrected visual acuity was ≥20/40 in 5 (62.5%) eyes and worse than 20/200 in 3 eyes. Overall, the final vision was improved in 6 (75.0%) eyes, remained the same in 1 (12.5%) eye, and was worse in 1 (12.5%) eye. CONCLUSIONS: The adjunctive use of IVP before TKP may assist with the achievement of microbiological cure, clear graft, and good visual outcome in a majority of eyes with Acanthamoeba keratitis.