Mycobacterium keratitis after laser in situ keratomileusis.

PURPOSE: The authors report two cases of Mycobacterium keratitis following LASIK. METHODS: The case reports are based on a retrospective review of clinical history and associated findings. RESULTS: Two patients developed infectious keratitis after undergoing laser in situ keratomileusis (LASIK). In case #1, the infection developed after manipulation of the lamellar flap to remove epithelium from the stromal bed. In case #2, prior radial keratotomy may have been a contributing factor to development of the infection. Corneal infiltrates appeared as focal, white, stromal deposits. Cultures isolated Mycobacterium fortuitum from case #1 and Mycobacterium chelonae from case #2. Topical fortified amikacin, clarithromycin, tobramycin, and ciprofloxacin eventually controlled the infection. Topical prednisolone acetate and bandage contact lenses were necessary to control inflammation and pain. Infiltrates were slow to resolve until focal necrosis eroded through the flaps leading to rapid clearing of the infiltrates; however, scarring of the cornea developed at the site of necrosis. Visual recovery was good in the first case but limited in the second. CONCLUSIONS: Mycobacterium keratitis complicating LASIK may be difficult to eradicate until the sequestered stromal infiltrate drains. Rapid recognition of the causative organism and aggressive medical and surgical management of the infection may improve the outcome.

Persistent Torulopsis magnoliae endophthalmitis following cataract extraction.

Postoperative fungal endophthalmitis typically manifests as an indolent uveitis, weeks to months after surgery. In our patient, Torulopsis magnoliae endophthalmitis appeared as an acute, purulent postoperative endophthalmitis on the third day following extracapsular cataract extraction with implantation of a posterior chamber intraocular lens (IOL). The patient required three separate vitrectomy operations with instillation of intravitreal Amphotericin B; the last operation also included complete removal of the posterior capsule and IOL. This case, which is to our knowledge the first reported case of T. magnoliae endophthalmitis, is unusual in that it manifested as an acute, fulminant infection in the early postoperative period and was recalcitrant to standard endophthalmitis therapy.

Management of corneal astigmatism after cataract surgery.

High degrees of surgically induced astigmatism following cataract surgery may limit the desired visual rehabilitation. The induced astigmatism is a reflection of the cataract incision, its closure, and subsequent wound healing. Excessively tight sutures induce central corneal steepening. Wound dehiscence and wound gap cause a flattening of the central cornea along this axis. Wound compression steepens the central curvature. The management of induced astigmatism is directed to the underlying problem. Suture cutting and removal will reduce suture compression of the wound. Repair of wound dehiscence and wound gap will reestablish wound integrity. Incisional keratotomy will compensate the corneal steepening induced by limbal wound compression. The reduction of astigmatism aids visual function by realizing the visual potential of the operated eye.

The use of Molteno implant and anterior chamber tube shunt to encircling band for the treatment of glaucoma in keratoplasty patients.

This retrospective study reviews the results of 35 keratoplasty patients with complex corneal and glaucoma disease, who received Molteno-type (n = 25) or anterior chamber tube shunt to encircling band (ACTSEB)-type (n = 10) implant for the treatment of difficult glaucomas. The implant was placed before the keratoplasty in 14 eyes, during the keratoplasty procedure in 6 eyes, and subsequent to the corneal surgery in 15 eyes. Mean follow-up for the keratoplasty was 25.46 months (range, 6-58 months) and 24.74 months (range, 7-42 months) for the seton procedure. Graft rejection occurred in 12 (34%) of 35 eyes and was progressive in 9 eyes. Nonimmunologic failure was seen in 9 (26%) of 35 eyes. Grafts were repeated in ten eyes with eight of these (80%) remaining clear at a mean of 14.4 months. Considering the results of the repeat grafts, 25 (71%) of 35 eyes achieved clear transplants. Overall, 46% of patients had final visual acuities of 20/100 or better and 69% had final visual acuities of 20/400 or better. The mean preoperative intraocular pressure (IOP) of 34.54 mmHg (range, 14-68 mmHg; standard deviation [SD], 11.51) was lowered to a mean of 14.65 mmHg (range, 6-30 mmHg; SD, 4.49). In the final analysis, 30 (86%) of 35 eyes were judged successful from a glaucoma standpoint. We conclude that the Molteno- and ACTSEB-type implants are viable treatment alternatives in this difficult glaucoma group.

Accuracy and reproducibility of KeraScanner analysis in PERK corneal topography. PERK Study Group.

The measurement of the corneal radius of curvature centrally and in the corneal periphery is exceedingly difficult because of variables in photography and data acquisition. We present a technique of Automated image scanning of corneal photographs which provides a more accurate and reproducible analysis of the paracentral corneal contour. We analyzed the sources of error of corneal topography measurement. CorneaScope photographs of calibration balls were generated by each Prospective Evaluation of Radial Keratotomy (PERK) Surgical Center. The 90% confidence intervals for individual ring-radial positions on the 8.00 and 10.00 mm balls were 7.91 to 8.09 mm and 9.89 to 10.11 mm respectively. Our isopter method of analysis for clinical comparison averages all eight radii of curvature for each CorneaScopef ring. This isopter technique reduces the corresponding 90% confidence intervals to 7.96 to 8.03 and 9.95 to 10.06 mm. The measurement variability of a 10 mm calibration ball decreased in the following order: calibration ball positioning, scanner personnel, photograph movement between scans, and nonrepositioned scanning. Photographs of calibration balls demonstrate +/- 4 microns of measurement resolution and patient corneal photographs may be evaluated to +/- 40 microns. This automated scanning system provides consistent data when digitizing keratographs.

Temporary keratoprosthesis for combined penetrating keratoplasty, pars plana vitrectomy, and repair of retinal detachment.

The Landers-Foulks temporary keratoprosthesis was used to combine penetrating keratoplasty, pars plana vitrectomy, and scleral buckling in the management of 13 eyes with opaque cornea and posterior segment abnormalities. In seven cases, trauma precipitated the ocular disease. Complications of cataract surgery resulted in anterior and posterior segment pathology in six cases. The corneal graft was initially clear in all cases. However, corneal edema complicated phthisis bulbi in four cases and followed homograft reaction in two cases. Eight eyes with retinal detachment (RD) preoperatively were successfully reattached. In five eyes, the retina redetached as these eyes became phthisical. Visual function improved in six cases. In general, eyes with a history of trauma had a much poorer outcome than did eyes with anterior and posterior segment problems related to previous cataract surgery.

Corneal ulcer due to Listeria monocytogenes.

We present a patient with a corneal ulcer due to Listeria monocytogenes, which has not previously been considered to be a feature of human listeriosis. The ulcer responded to topical and subconjunctival gentamicin and cephaloridine. Subsequent management was complicated by the development of a fibrinous pupillary membrane leading to pupillary block requiring iridotomy and later vitrectomy with trabeculectomy. Listeria monocytogenes may be confused with diphtheroid contaminants seen in corneal ulcer scrapings and is probably underreported as a cause for microbial keratitis.

Snailtracks of the corneal endothelium.

An unusual pattern of corneal endothelial cell alterations has been observed at the slitlamp in eyes following intraocular surgery. Because of their appearance, we have called these changes "snailtracks". We have commonly seen these snailtracks following extracapsular cataract extraction. Similar changes have been noted in cadaver corneas stored in McCarey-Kaufman (M-K) medium. This study presents information which suggests that these changes represent corneal endothelial cell damage.

Phaco-Ersatz: cataract surgery designed to preserve accommodation.

Phaco-Ersatz represents a new approach to cataract surgery and the correction of aphakia. The procedure involves the removal of the cataractous cortex and nucleus while preserving the lens capsule and its zonular attachments. The empty lens capsule is then refilled with biocompatible and optically suitable clear gel. A physiologic lens is recreated in situ. Experimental work with human cadaver eyes and rabbit and cat eyes in vivo demonstrates this surgical feasibility. A review of the literature reveals contradicting theories regarding the physical laws and lens properties governing accommodation. The accommodative potential of the ersatz lens has not been tested, but it may be speculated that this recreated lens may, in fact, possess some accommodative properties. Experimental investigations in this area represent the logical extension of intraocular lens implant development.

A retrospective review of endophthalmitis due to coagulase-negative staphylococci.

We retrospectively reviewed 28 cases of postoperative endophthalmitis due to coagulase-negative staphylococci. There was an average delay between surgery and the acute presentation of 7 X 2 days (SD 3 X 3). All patients were treated with intraocular antibiotics (IOAB) or therapeutic vitrectomy with IOAB. In six of the 28 cases the organisms were resistant to gentamicin as measured by the Kirby-Bauer technique; none was resistant to cephalosporins. Isolates that had been stored by lyophilisation were reconstituted and tested by serial dilution; none was resistant to gentamicin, though two were borderline. The final visual acuity was 6/18 or better in 72% of the eyes.

Lasiodiplodia theobromae panophthalmitis.

Lasiodiplodia theobromae is a rare ocular pathogen. We report a case of panophthalmitis caused by this fungus. The patient was a healthy 62-year-old janitor with no history of ocular trauma in whom keratitis developed. Cultures of corneal scrapings identified the fungus. Despite treatment with appropriate antimycotics the keratitis progressed to infectious scleritis and then spontaneous perforation of the globe, which necessitated enucleation. The ultrasonographic, microbiologic and histologic findings are discussed and the results of in-vitro sensitivity testing presented.

Acanthamoeba keratitis associated with soft contact lenses.

Three patients (a 13-year-old girl, a 25-year-old man, and a 22-year-old woman) who used daily-wear soft contact lenses, sterilized with saline made from distilled water and salt tablets, developed Acanthamoeba keratitis. Acanthamoeba was cultured from the contact lens solution of one patient. This patient, in whom the diagnosis was made by corneal biopsy early in the clinical course, was successfully treated with topical neomycin-polymyxin, miconazole, and propamidine isethionate. The other two patients underwent penetrating keratoplasty. One of these patients, who received a graft early in the clinical course, developed a recurrence of disease in the graft, whereas the other, who received the graft 18 months after the initial symptoms, has maintained a clear corneal transplant with useful vision.

Late onset endophthalmitis associated with filtering blebs.

Thirty-six cases of late onset endophthalmitis in patients with filtering blebs are presented. Onset of endophthalmitis ranged from 4 months to 60 years after bleb formation. Possible contributing factors could be identified only in a minority of patients. Aqueous, vitreous or both were cultured in all cases. Eighty-three percent of eyes were culture positive. Streptococci were the most frequent causative organisms, isolated from 57% of culture positive eyes. Twenty-three percent of eyes grew Hemophilus influenzae. Only two cases were caused by staphylococci. In general, the visual outcome was poor, probably primarily due to the virulence of the infecting organisms. Endophthalmitis remains a risk even many years after creation of a filtering bleb. The microbiologic spectrum in this clinical setting is considerably different from that of recent postoperative endophthalmitis. Based on the bacteriology and clinical course of the patients presented, recommendations for management are discussed.

Results of the prospective evaluation of radial keratotomy (PERK) study one year after surgery.

The Prospective Evaluation of Radial Keratotomy (PERK) study is a nine-center, self-controlled clinical trial of a standardized technique of radial keratotomy in 435 patients who had physiologic myopia with a preoperative refraction between -2.00 and -8.00 diopters. The surgical technique consisted of eight incisions using a diamond micrometer knife with blade length determined by intraoperative ultrasonic pachymetry and the diameter of central clear zone determined by preoperative refraction. At one year after surgery, myopia was reduced in all eyes; 60% were within +/- 1.00 diopter of emmetropia; 30% were undercorrected and 10% were overcorrected by more than 1.00 diopter (range of refraction, -4.25 to +3.38 D). Uncorrected visual acuity was 20/40 or better in 78% of eyes. The operation was most effective in eyes with a refraction between -2.00 and -4.25 diopters. Thirteen percent of patients lost one or two Snellen lines of best corrected visual acuity. However, all but three eyes could be corrected to 20/20. Ten percent of patients increased astigmatism more than 1.00 diopter. Disabling glare was not detected with a clinical glare tester, but three patients reduced their driving at night because of glare. Between six months and one year, the refraction changed by greater than 0.50 diopters in 19% of eyes.

Psychosocial characteristics of candidates for the prospective evaluation of radial keratotomy (PERK) study.

The National Eye Institute Prospective Evaluation of Radial Keratotomy (PERK) Study is a multicenter clinical trial for the evaluation of radial keratotomy. This article describes the questionnaire data collected on PERK patients and compares them with a similar group of myopic persons studied during the Rand Health Insurance Experiment (heretofore referred to as the Rand study). The PERK patients are young, white myopes who dislike being dependent on corrective lenses but perceive themselves to be more visually impaired than do comparable Rand study myopes. Most female subjects and a plurality of the male subjects have tried contact lenses and quit wearing them mainly because use of the lenses was inconvenient or bothersome. There is no evidence that patients are psychologically or socially deviant. Both male and female subjects expressed a fear of being without vision and cited impatience with the lenses as their major motivation for wanting surgery.

Corneal endothelial cell loss, cystoid macular edema, and iris-supported intraocular lenses.

Endothelial cell loss, persistent cystoid macular edema and a chronic low-grade uveitis may complicate intracapsular cataract extraction combined with iris supported intraocular lenses. Clinical examination of 19 eyes of 17 patients, at 1.1 to 5 years after cataract surgery, and correlation with wide field specular microscopy and fluorescein angiography, documents this problem. The mean central corneal endothelial cell count was 497 cells/mm2 (standard deviation, 119). In ten cases, focal edema was localized to the corneal periphery. Cystoid macular edema was present in all but one case. Intermittent cornea/implant touch or low-grade intraocular inflammation, possibly from iris/implant contact, may explain the natural history of the endothelial cell loss and cystoid macular edema. Monitoring endothelial cell counts and macular function in patients with iris-supported implants may afford the early recognition of this problem. In such cases, early implant removal may alter the natural history and preserve corneal and macular function.

Vacuum Fixation Ring for radial keratotomy.

The Vacuum Fixation Ring helps stabilize the eye during radial keratotomy. It elevates the intraocular pressure, making the cornea rigid, and improves the control for deep reproducible incisions. The instrument is designed for use with topical anesthesia and a variety of diamond or steel knives.

Gentamicin-resistant Pseudomonas aeruginosa corneal ulcers.

Six cases are described of Pseudomonas aeruginosa ulcerative keratitis in which antibiotic sensitivity studies demonstrate organism resistance to gentamicin sulfate but sensitivity to other aminoglycosides such as tobramycin and amikacin. In four cases, community-acquired infections represent the source of these ulcers. This paper documents the emergence of aminoglycoside resistance among Pseudomonas aeruginosa keratitis within the general community.

Chronic conjunctivitis associated with 'floppy eyelids'.

The floppy eyelid syndrome represents a chronic conjunctivitis characterized by a triad of (1) a loose upper lid that readily everts on elevating the lid, (2) a soft rubbery tarsus that can be folded on itself, and (3) a diffuse papillary conjunctivitis. Seven cases of this condition are reported, all involving men, and four involving obese patients.

Posterior corneal pigmentation in melanosis oculi.

A 5-year-old girl was seen with findings consistent with melanosis oculi and notably decreased vision secondary to dense corneal pigmentation. A penetrating keratoplasty was performed without complications. Light microscopy disclosed dense pigment granules layered in deep stroma just anterior to Descemet's membrane. Electron microscopy revealed these to be melanocytes, without evidence of phagocytic activity. The corneal pigmentation may have resulted from a misdirection of melanocytes in embryogenesis. To our knowledge, the finding of visually notable corneal pigmentation has not been previously reported in association with the syndrome of melanosis oculi.