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.

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.

Outcome of primary adult optical penetrating keratoplasty with imported donor corneas.

PURPOSE: To evaluate the outcome of primary adult optical penetrating keratoplasty (PKP) performed with internationally acquired donor tissue. PATIENTS AND METHODS: A retrospective review was performed of the medical records of every patient 12 years of age or older who underwent PKP for keratoconus, corneal edema, stromal scarring, or stromal dystrophy at King Khaled Eye Specialist Hospital in the Kingdom of Saudi Arabia between January 1, 1997 and December 31, 2001, and for whom a minimum of 3 months' follow-up was available. RESULTS: Of 885 eyes that met the inclusion criteria, there were 453 eyes with keratoconus, 180 eyes with corneal edema, 171 eyes with stromal scarring, and 81 eyes with stromal dystrophy. For the entire group, the probability of graft survival was 96.9% at 1 year, 86.0% at 3 years, and 80.3% at 5 years. The 5-year probability of graft survival was 96.2% for keratoconus, 39.4% for corneal edema, 71.1% for stromal scarring, and 85.2% for stromal dystrophy. Increasing donor age was significantly associated with an increased risk of graft failure on multivariate Cox proportional hazard regression analysis (P = 0.005). Endothelial cell density, death-to-preservation time, and preservation-to-surgery time were not significantly associated with an increased risk of graft failure. CONCLUSIONS: In our patient population, excellent graft survival was achieved utilizing internationally acquired donor tissue for eyes with keratoconus, stromal dystrophy, and stromal scarring, but not for those with corneal edema.

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.

Changing trends in the clinical course and outcome of bacterial keratitis at King Khaled Eye Specialist Hospital.

OBJECTIVE: To evaluate changes in the predisposing factors and causative organisms, clinical course, and outcome of bacterial keratitis at King Khaled Eye Specialist Hospital (KKESH) between 1995 and 2005. METHODS: Retrospective review of 78 and 103 cases of culture-positive bacterial keratitis admitted to KKESH in 1995 and 2005. Main outcome measures Microbiological cure, visual outcome. RESULTS: There was little change in the predisposing factors for bacterial keratitis, initial clinical severity, or the microbiological profile between 1995 and 2005. While similar topical fortified antibiotic therapy regimens were used in both 1995 and 2005, there was a significant increase in the use of topical corticosteroids in 2005 (P < 0.001), either alone or in combination with medroxyprogesterone 1% and doxycycline. There were significant improvements in the percentage of eyes achieving microbiological cure with medical therapy alone (76.0 vs. 92.2%, P = 0.002) or in combination with surgical intervention (92.4 vs. 100.0%; P = 0.005). The percentage of eyes requiring enucleation or evisceration due to treatment failure declined significantly from 7.6 to 0% (P = 0.006). There was a significant improvement in the percentage of eyes achieving a final visual acuity > or =20/40 (10.1 vs. 29.1%, P = 0.001). CONCLUSIONS: Significantly better clinical outcomes were achieved in 2005 compared to 1995. Increased emphasis on management of inflammation in conjunction with the infectious process may have contributed to the improved outcomes.

Penetrating keratoplasty for trachomatous corneal scarring.

PURPOSE: To evaluate graft survival and visual outcome after penetrating keratoplasty (PKP) for trachomatous corneal scarring. METHODS: A retrospective review was conducted on all cases of PKP performed at King Khaled Eye Specialist Hospital between January 1, 1997, and December 31, 2001, for trachomatous corneal scarring. RESULTS: This study included 127 eyes. The mean age at the time of surgery was 64.7 years (range, 40-90 years). The mean follow-up was 1266 days (range, 91-3423 days). At the most recent visit, 102 (80.2%) grafts were clear, and 25 (19.7%) had failed. Kaplan-Meier graft survival was 98.3% at 1 year, 85.9% at 2 years, 83.2% at 3 years, 80.2% at 4 years, and 76.6% at 5 years. Major postoperative complications included worsening of glaucoma (27.6%), endothelial rejection (17.3%), and bacterial keratitis (8.7%). Visual acuity improved in 107 (84.3%) eyes, remained the same in 12 (9.5%) eyes, and worsened in 8 (6.3%) eyes. Final visual acuity of 20/160 or better was obtained in 67 (56.7%) eyes. CONCLUSIONS: Treating trachomatous corneal scarring with PKP can be associated with a good prognosis for graft survival and improved vision in carefully selected cases with mild or well-controlled ocular surface disease and absent or previously surgically corrected eyelid abnormalities.

Ring corneal infiltrate and progressive ring thinning following primary varicella infection.

Unilateral stromal keratitis is a known rare sequela of primary varicella infection. The authors describe a unique case of immunological (Wessely) ring formation and progressive ring thinning following primary varicella infection in a 6-year-old girl.

Feeder-free differentiation of cells exhibiting characteristics of corneal endothelium from human induced pluripotent stem cells.

The purpose of this study was to devise a strategy for the derivation of corneal endothelial cells (CEnCs) from adult fibroblast-derived induced pluripotent stem cells (iPSCs). IPSCs were generated from an adult human with normal ocular history via expression of OCT4, SOX2, KLF4 and c-MYC Neural crest cells (NCCs) were differentiated from iPSCs via addition of CHIR99021 and SB4315542. NCCs were driven toward a CEnC fate via addition of B27, PDGF-BB and DKK-2 to CEnC media. Differentiation of NCCs and CEnCs was evaluated via rt-PCR, morphological and immunocytochemical analysis. At 17 days post-NCC induction, there were notable changes in cell morphology and upregulation of the neural crest lineage transcripts PAX3, SOX9, TFAP2A, SOX10 and p75NTR and the proteins p75/NGFR and SOX10. Exposure of NCCs to B27, PDGF-BB and DKK-2 induced a shift in morphology from a spindle-shaped neural phenotype to a tightly-packed hexagonal appearance and increased expression of the transcripts ATP1A1, COL8A1, COL8A2, AQP1 and CDH2 and the proteins ZO-1, N-Cad, AQP-1 and Na+/K+ATPase. Replacement of NCC media with CEnC media on day 3, 5 or 8 reduced the differentiation time needed to yield CEnCs. IPSC-derived CEnCs could be used for evaluation of cornea endothelial disease pathophysiology and for testing of novel therapeutics.

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.

Escalation of glaucoma therapy after penetrating keratoplasty.

PURPOSE: To determine the prevalence and risk factors for escalation of glaucoma therapy after penetrating keratoplasty (PK) and its impact on graft survival and visual outcome. DESIGN: Retrospective case series. PARTICIPANTS: Seven hundred fifteen consecutive eyes of 678 patients undergoing PK. METHODS: Retrospective review of every case of PK performed at King Khaled Eye Specialist Hospital between January 1, 2001 and December 31, 2002. MAIN OUTCOME MEASURES: Escalation of glaucoma therapy, graft survival, and visual outcome. RESULTS: Escalation of glaucoma therapy occurred in 89 (12.4%) eyes of 715 PK procedures during a mean follow-up of 32.2 months. Medical escalation accounted for 73 (82.0%) cases, whereas surgical escalation occurred in 16 (18.0%) eyes. The following were significantly associated with an increased risk of escalation of glaucoma therapy: surgical indication for PK (P<0.001), increasing patient age (P<0.001), preexisting glaucoma (P<0.001), recipient trephination < 7.0 mm (P = 0.02), and pseudophakia or aphakia (P<0.001). Eyes with escalation of glaucoma therapy had significant reduction in graft survival compared with eyes in which this did not occur (52.8% vs. 82.9%, P<0.001). Escalation of glaucoma therapy was associated with a significant reduction in the percentage of eyes achieving visual acuity of 20/40 or better (9.0% vs. 42.1%, P<0.001) and a significant increase in those obtaining 20/200 or worse (70.8% vs. 26.7%, P<0.001). CONCLUSIONS: Escalation of glaucoma therapy is a serious sequela of PK that is significantly associated with an increased risk of graft failure and poor visual outcome.

Corneal transplant survival after onset of severe endothelial rejection.

PURPOSE: To evaluate corneal graft survival after onset of severe endothelial rejection after penetrating keratoplasty (PK). DESIGN: Retrospective case series. PARTICIPANTS: One hundred fifty-six patients (161 PKs) treated at a single center. METHODS: Retrospective review of the medical records of every case of severe endothelial rejection admitted to the King Khaled Eye Specialist Hospital (KKESH) between January 1, 1998 and December 31, 2002. Patients for whom PK had been performed at KKESH between June 1, 1983 and December 31, 2002 and in whom at least 3 months of follow-up was available were included in the statistical analysis. MAIN OUTCOME MEASURE: Graft survival. RESULTS: One hundred fifty-seven PKs (152 patients) met the inclusion criteria and were included in the statistical analysis. Four PKs (4 patients) were excluded from the statistical analysis due to inadequate follow-up. The rejection episode was reversed during the first 3 months in 90 grafts (57.3%). By Kaplan-Meier analysis, graft survivals were 42.6% at 1 year and 36.1% at 3 years. The surgical indication for PK significantly correlated with likelihood of reversibility (P<0.001) and long-term graft survival (P<0.001). Risk factors associated with an increased risk of postrejection graft failure included increasing donor age (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.04-1.24; P = 0.004), increasing patient age (OR, 1.23; 95% CI, 1.11-1.35; P<0.001), and history of rejection episodes (P = 0.002). CONCLUSION: Endothelial rejection is a serious complication of PK, with a high risk of graft failure.

Bacterial keratitis after penetrating keratoplasty: incidence, microbiological profile, graft survival, and visual outcome.

PURPOSE: To determine the incidence, microbiological profile, graft survival, and factors influencing graft survival after the development of bacterial keratitis after penetrating keratoplasty (PK). DESIGN: Retrospective case series. PARTICIPANTS: One hundred two patients (102 eyes) treated at a single center during a 5-year period. METHODS: Retrospective review of the medical records of every patient treated for culture-positive keratitis between January 1, 1998 and December 31, 2002 who previously had undergone penetrating keratoplasty at the King Khaled Eye Specialist Hospital. MAIN OUTCOME MEASURES: Graft survival and visual outcome. RESULTS: There were 2103 PKs performed and 102 (4.9%) cases of culture-positive keratitis during the study period. There were 168 bacterial isolates, of which 140 (83.3%) were gram positive, 28 (16.7%) were gram negative, and 1 (0.6%) was acid fast. Only 38 (37.3%) grafts remained clear after a mean follow-up of 985 days (range, 82-2284). The best graft survival was in eyes with PK for keratoconus (83.7%), whereas the poorest grat survival was for previously failed grafts (5.6%). By Kaplan-Meier analysis, there was an immediate steep decline in graft survival to 54.9%, followed by a slow decline to 47.2% by 1 year and 35.8% after 4 years. Factors associated with an increased risk of graft failure were the surgical indication for PK (P<0.001), increasing patient age (P = 0.004), smaller donor (P = 0.001) and recipient (P = 0.0003) graft size, history of previous microbial keratitis (P = 0.02) or endothelial rejection episodes (P = 0.02), and coexisting glaucoma (P = 0.001). The visual outcome was > or =20/40 in only 8 (8.2%) eyes and better than 20/200 in only 21 (21.6%) eyes. CONCLUSION: The development of bacterial keratitis after PK is a serious complication that is associated with a high incidence of graft failure and poor visual outcome.

Bacterial keratitis after primary pediatric penetrating keratoplasty.

PURPOSE: To determine the prevalence, microbiological profile, and prognosis for bacterial keratitis after primary pediatric penetrating keratoplasty (PKP). DESIGN: Retrospective case series. METHODS: Retrospective review of all cases of primary PKP performed in children 12 years of age or younger at the King Khaled Eye Specialist Hospital between January 1, 1990 and December 31, 2005 and inclusion of all postoperative cases of culture-positive, bacterial keratitis. RESULTS: Culture-positive bacterial keratitis developed in 35 (17.3%) of 202 primary keratoplasties. Gram-positive organisms were cultured in 91.4% of infected eyes and accounted for 77.6% of isolates. Streptococcus pneumoniae was the most common organism. No eyes achieved a final visual acuity of 20/40 or better, while 65.7% had hand motions or worse. CONCLUSIONS: Bacterial keratitis after pediatric keratoplasty is a serious complication that is associated with a high risk of graft failure and poor visual outcome.

Laser in situ keratomileusis versus surface ablation: visual outcomes and complications.

PURPOSE: To compare the visual outcomes and complications of laser in situ keratomileusis (LASIK) with those of surface treatment by laser-assisted subepithelial keratectomy (LASEK), photorefractive keratectomy with mechanical epithelial removal (M-PRK), and transepithelial photorefractive keratectomy (T-PRK). SETTING: Tertiary care eye center. METHODS: This retrospective review comprised all cases of LASIK, LASEK, M-PRK, and T-PRK performed at King Khaled Eye Specialist Hospital between July 1, 2004, and June 30, 2005. Separate statistical analyses were performed for eyes with low to moderate myopia (spherical equivalent [SE] less than -6.00 diopters [D]) and high myopia (SE -6.00 to -11.25 D). RESULTS: Of 696 eyes that met the inclusion criteria, 464 had LASIK, 104 had LASEK, 69 had M-PRK, and 59 had T-PRK. Eyes with low to moderate myopia had a statistically significantly smaller mean difference between logMAR final postoperative uncorrected visual acuity (UCVA) and preoperative best spectacle-corrected visual acuity (BSCVA) after T-PRK and M-PRK than after LASIK or LASEK. A higher percentage of eyes with high myopia had a final UCVA within +/-2 lines of the preoperative BSCVA with T-PRK than with LASIK, LASEK, or M-PRK. There were more major non-flap-related complications after LASEK than after LASIK, M-PRK, or T-PRK. CONCLUSIONS: In eyes with low to moderate myopia, T-PRK and M-PRK provided slightly better visual outcomes than LASIK or LASEK. In eyes with high myopia, T-PRK provided better visual outcomes than LASIK, LASEK, and M-PRK. Laser in situ keratomileusis was associated with the most major postoperative complications.

Primary pediatric keratoplasty: indications, graft survival, and visual outcome.

BACKGROUND: Penetrating keratoplasty in children has been documented to have a higher rate of graft failure and a worse visual prognosis than adult keratoplasty. METHODS: We undertook a retrospective review of all cases of primary penetrating keratoplasty performed in children 12 years of age or younger at the King Khaled Eye Specialist Hospital between January 1, 1990, and December 31, 2003. RESULTS: One hundred sixty-five primary penetrating keratoplasties were performed in 134 children during the study interval. The surgical indications were congenital opacities in 130 eyes (78.8%), acquired, traumatic opacities in 18 eyes (10.9%), and acquired, nontraumatic opacities in 17 eyes (10.3%). Among congenital opacities, 35 cases were caused by congenital hereditary endothelial dystrophy (CHED). The median follow-up for 73 grafts (44.2%) that remained clear was 50 months (range, 12-50 months), whereas the median follow-up for 92 grafts (55.8%) that failed was 6 months (range, 1-54 months). Kaplan-Meier graft survival was significantly higher at all postoperative intervals in eyes with CHED than for other surgical indications (p < 0.001). Eyes with CHED were significantly more likely to achieve ambulatory vision or vision >20/200 than eyes with other indications (p < 0.001). CONCLUSIONS: Pediatric keratoplasty was associated with an excellent prognosis for graft survival in eyes with CHED and a fair prognosis for graft survival in eyes with non-CHED congenital opacities and acquired opacities. The best visual prognosis was obtained in eyes with CHED and the worst prognosis was for non-CHED congenital opacities.

Capsule staining as an adjunct to cataract surgery: a report from the American Academy of Ophthalmology.

OBJECTIVE: This document evaluates currently available data in the published literature to answer the question of whether the use of dye such as indocyanine green or trypan blue to stain the lens capsule to improve visualization is safe and effective as an adjunct to cataract surgery. METHODS: Literature searches conducted in March 2003 and May 2004 retrieved 139 citations. The panel members reviewed the abstracts and selected 47 of possible clinical relevance for review. An additional 14 articles were identified for evaluation. Of the 61 articles reviewed, the panel members selected 36 for the panel methodologist to review and rate according to the strength of the evidence. A level I rating was assigned to properly conducted, well-designed, randomized clinical trials; a level II rating was assigned to well-designed cohort and case-control studies; and a level III rating was assigned to case series and case reports. RESULTS: There is level III evidence that indocyanine green, trypan blue, and fluorescein are each effective in staining the lens capsule and that indocyanine green and trypan blue provide better ease of use and visualization of the capsule than fluoroscein. There is level II evidence that staining the capsule is helpful in completing capsulorrhexis and that it is helpful for pediatric patients under age 5 years and in cases of white cataract. The overall surgical advantage of a completed continuous curvilinear capsulorrhexis using dye has not been demonstrated, but this may be related to the outcome measures chosen rather than a failure to confer advantage. There are substantial data indicating that trypan blue 0.1% is not toxic to the cornea. There are limited data suggesting that indocyanine green 0.125% to 0.5% is not toxic to anterior segment structures. CONCLUSIONS: There are data confirming that dye is safe and effective as an adjunct for capsule visualization in cataract surgery. It is reasonable to use dye when inadequate capsule visualization may compromise the outcome in cataract surgery. More studies are needed to confirm a lack of toxicity of indocyanine green and trypan blue, particularly in the event of posterior segment or longer duration exposure.