Clinical evidence for hepatitis B transmission resulting from corneal transplantation.

PURPOSE: Two cases of hepatitis B virus (HBV) infection after penetrating keratoplasty are presented. METHODS: An extensive clinical and serologic investigation of these two transplant recipients was performed. In addition, the medical histories, autopsy reports, and specimens of blood from the two deceased corneal tissue donors were retrieved and studied. RESULTS: Serum from both donors was positive for hepatitis B surface antigen; the clinical history and serologic testing of both recipients strongly suggest that the HBV infection in each case was acquired from donor corneal tissue. CONCLUSION: To our knowledge, these are the first documented cases of HBV infection after corneal transplantation. Eye banks should continue to screen donors for HBV.

Pseudophakic corneal edema. An 11-year study of its development, incidence, and treatment.

This paper studies the appearance and development of pseudophakic corneal edema (PCE) in a series of 840 patients referred for keratoplasty for corneal edema. There were no cases of PCE in 100 eyes with corneal edema studied between 1960 and 1970. In 200 cases of corneal edema studied between 1978 and 1980, there were 30 eyes with PCE (15%). The disease has gradually increased to 56% of all cases of corneal edema seen in 1986. A tendency of PCE to decrease has been noted in the last 2 years. The high incidence of PCE in recent years, which is the main reason for keratoplasty today, seems to be related to the use of closed loop anterior chamber lenses. Fuchs' dystrophy, which formed the bulk of cases of corneal edema, may be present in many cases of PCE. results of keratoplasty with intraocular lens (IOL) removal or exchange provided better than 80% good results in a group of 230 cases followed from 1 to 7 years with visual improvement better than 20/100 in over 50% of cases. The removal of an intraocular lens causing progressive visual symptoms is advised even at the risk of causing corneal edema.

Ultrastructural changes in the posterior layers of the cornea in Schnyder's crystalline dystrophy.

A case of central crystalline dystrophy of Schnyder is presented in which ultrastructural studies were performed on the corneal specimen after penetrating keratoplasty. Electron microscopic changes were documented not only in the anterior but in the posterior stroma and in the corneal endothelium. In the posterior stroma and at the interface between the stroma and Descemet's membrane, numerous ovoid, electron-lucent spaces were present that most likely represented foci of lipid deposition. In addition, rare, focal areas of endothelial cell degeneration were observed that produced minute discontinuities in the endothelial cell covering of Descemet's membrane. Changes in the posterior layers of the cornea in Schnyder's crystalline dystrophy may contribute to the comparatively poorer surgical results obtained with lamellar rather than full-thickness grafts in these cases.

Results of keratoplasty for aphakic or pseudophakic corneal edema with intraocular lens implantation or exchange.

This paper reports the results of 99 penetrating keratoplasties for aphakic and pseudophakic corneal edema using a single-piece, semielastic anterior chamber lens. There were 24 patients with aphakic corneal edema and 75 with pseudophakic corneal edema. Most cases had history compatible with macular disease. A Cilco-Kelman multiflex anterior chamber lens was used in all cases. All intraocular lenses were removed from pseudophakic eyes (38 iris supported lenses and 37 anterior chamber lenses). Preoperative glaucoma was present in over 20% of all cases. Grafted eyes were followed from 1 to 5 years. There were 24 clear grafts in aphakic eyes (87%) and 72 in pseudophakic eyes (96%). Visual improvement occurred in 30% of aphakic eyes and in 10% of pseudophakic eyes. In 50% of both groups, vision improved to better than 20/100. The study shows that the use of this type of anterior chamber lens did not affect the outcome of corneal grafts, and that there were no differences in graft results between the two groups. Visual acuity results were related to retinal changes.

Aspergillus panophthalmitis complicating treatment of pterygium.

A 58-year-old woman lost her left eye due to Aspergillus panophthalmitis four months after excision of a pterygium. The patient had received postoperative beta radiation and developed a scleral ulcer in the area of treatment from which no organisms could be cultured on two occasions. Because of the difficulty of diagnosing superficial mycotic infections of the eye, and because the treatment of so-called radiation scleritis may worsen fungal infections, ophthalmologists need to be aware of the potential infectious complications associated with the treatment of pterygia.

Glaucoma in keratoplasty.

This paper reports intraocular pressure findings in 676 eyes that received penetrating keratoplasties. There were four groups: 1. keratoconus without preoperative glaucoma (75 cases); 2. Fuchs' dystrophy and cataract (triple procedure) without glaucoma (260 cases); 3. aphakic eyes with or without intraocular lenses (204 cases); and 4. pseudophakic eyes with or without intraocular lens removal (137 cases). The last two groups had a significant number of glaucoma cases. All were controlled before surgery. There were no early or late glaucoma cases in the first group. A few cases with triple procedures had mild early intraocular pressure elevation. Thirty percent of aphakic eyes and 52% of pseudophakic eyes had early glaucoma. Twenty percent and 25% of these two groups had persistent glaucoma. Preoperative glaucoma eyes were included in these long-standing glaucoma cases.

Graft rejection and glaucoma.

Four patients (three women and one man, 30 to 63 years old) developed increased intraocular pressure during graft rejection reactions. The increased intraocular pressure returned to normal in one case after successful treatment of the immune reaction but a second patient required antiglaucoma medication for a short period. Two patients with previous intraocular inflammation or anterior segment changes developed severe glaucoma and required long-term antiglaucoma medication. One patient was a corticosteroid-responder and eventually required filtering surgery.

Fluorescein angiography of soft contact lens induced vascularization in penetrating keratoplasty.

Soft contact lenses after penetrating keratoplasty have become more popular as improved materials with high water content and high oxygen permeability have become available. However, aphakic patients who have undergone penetrating keratoplasty seem to be at high risk for development of graft vascularization when extended wear soft lenses are used for optical correction. This report, to our knowledge, is the first to use corneal fluorescein angiography to study contact lens induced vascularization. Corneal fluorescein angiography, in two cases, showed that vascularization was often more extensive than clinically apparent. Further, these "new" vessels, in both cases, were shown to be "leaky." This great degree of leak contributed to graft edema in both and possibly, in one case, to graft rejection. These findings suggest that care in fitting and careful follow-up is necessary in any graft patient fit with an extended wear lens and that delicate or problem patients may be better aided with other forms of optical correction. Further, this report shows the value of corneal fluorescein angiography as a useful tool in the study of vascularization of the cornea from any cause.

The effect of a new intraocular irrigating solution containing dextran on rabbit corneal endothelium.

This study investigated the effect of a balanced salt solution for intraocular irrigation containing 2% dextran 40. The effect of this solution was compared to that of a normal saline solution (0.9%) and balanced salt solution (Alcon). Following incubation of rabbit corneas for up to 72 h at 4 degrees C, the incubated corneas were studied by staining with Nitroblue Tetrazolium and by scanning electron microscopy. Insignificant changes occurred during the first 24 h of incubation. However, corneas stored in the dextran containing solution showed slightly smaller endothelial cells with tight junctions after 72 h. Endothelial cells showed progressive membrane rupture and eventual disappearance when incubated in normal saline for over 24 h at 4 degrees C.

Keratoplasty and intraocular lenses.

This paper describes the surgical results in 163 patients in whom intraocular lenses (IOL) had been implanted, exchanged, or removed during penetrating keratoplasty (PKP). They were divided into the following groups: PKP, cataract extraction, and IOL implant; PKP in aphakia and IOL implant; PKP and IOL exchange; PKP and IOL removal. In all groups clear transplants were obtained in over 92% of the cases, with best optical and visual results obtained in cases of Fuchs' dystrophy with cataract extraction and IOL implant (98% clear grafts and vision better than 20/40 in most cases). There were no significant differences in graft transparency and in the magnitude of visual acuity improvement between cases of pseudophakic edema with IOL replaced or removed at the time of surgery, and cases of aphakic edema with secondary IOL implant. Good surgical results are attributed to the use of young donor tissue with short time of storage, microsurgical techniques, and the use of sodium hyaluronate (Healon) for the protection of graft endothelium.

Cell-mediated immunity in herpetic keratitis measured by leukocyte migration inhibition.

Leukocyte migration inhibition factor (LMIF) assays have been used as a measure of cell-mediated immune responses. Direct assays of this factor were determined in 30 patients with recurrent herpes simplex stromal keratitis during the quiescent stage of the disease and in 10 of these patients during the acute stage as well. The migration of leukocytes incubated in the presence of HSV antigens was compared to that without viral antigens for the migration index (MI). Only 1 out of 30 patients had a positive response during the quiescent stage, while among the 10 patients with the active disease, four had a positive response.