David G. Heidemann

Transsclerally Sutured Intraocular Lenses in Penetrating Keratoplasty

We reviewed the charts of 114 consecutive patients who underwent penetrating keratoplasty with transscleral fixation of a posterior chamber intraocular lens. Two patients died within three months of follow-up and were excluded from the study. In the remaining 112 patients, follow-up ranged from four to 47 months (mean, 17.2 months). Postoperative visual acuity improved in 95 patients (85%), remained the same in 13 patients (11.5%), and worsened in four patients (3.5%). In 71 patients with at least one year of follow-up, best-corrected visual acuity was 20/40 or better in 17 patients (24%), 20/50 to 20/80 in 25 patients (35%), 20/100 to 20/400 in 17 patients (24%), and counting fingers or worse in 12 patients (17%). Problems with lens decentration, tilt, dislocation, or scleral suture-related infections were minimal. Glaucoma and cystoid macular edema were the most common causes of decreased visual acuity. Four patients (3.6%) developed intraoperative choroidal detachments. Three patients (2.7%) developed rhegmatogenous retinal detachments early in the postoperative course.

Treatment of chronic nonhealing neurotrophic corneal epithelial defects with thymosin β4

Neurotrophic corneal defects are difficult to heal and all too often lead to scarring and vision loss. Medical management is often of limited success. We describe the results of nine patients (ages 37–84) with chronic nonhealing neurotrophic corneal epithelial defects who were treated with thymosin beta 4 (Tβ4) sterile eye drops for 28 or 49 days with a follow‐up period of 30 days. Those with geographic defects (six patients) showed dramatic healing without clinically significant neovascularization. Stromal thinning was observed in one patient. Three patients with punctate epithelial defects did not have a demonstrable change in their clinical findings. Reduced ocular irritation was reported by all patients soon after treatment initiation. Results from these compassionate use cases indicate that Tβ4 may provide a novel, topical approach to wound healing in chronic nonhealing neurotrophic corneal ulcers.

Treatment of chronic nonhealing neurotrophic corneal epithelial defects with thymosin beta 4.

Neurotrophic keratopathy is a degenerative disease of the corneal epithelium and stroma that results from impaired corneal innervation. Reduced corneal sensitivity is responsible for producing recurring or chronic epithelial defects that may lead to subsequent ulceration and/or perforation. It is most frequently associated with topical medications, long-standing diabetes mellitus, herpes zoster ophthalmicus (HZO), herpes simplex keratitis, neurologic disease, or localized trauma. Conventional treatments include prophylactic topical antibiotic drops or ointment, frequent nonpreserved ocular lubricants, patching, and bandage contact lenses. In recalcitrant cases, oral doxycycline, autologous serum, and the surgical application of an amniotic membrane, tarsorrhaphy, or a conjunctival flap are used alone or in combination. Successful modulation healing in these patients is erratic at best and vexing for both the patient and ophthalmologist. The potent wound healing and anti-inflammatory effects of thymosin beta 4, a naturally occurring, 43–amino acid, G-actin– sequestering molecule, has been demonstrated in numerous animal and cellular models of corneal injury. We sought to evaluate thymosin beta 4 in a human disorder that did not have an infectious component or one in which stem cell dysfunction or conjunctival disruption was extensive. A preliminary unpublished evaluation of thymosin beta 4 in diabetic corneal defects was encouraging. Here we describe the treatment results of 4 patients with chronic neurotrophic corneal epithelial defects who were treated under a Food and Drug Administration investigational new drug compassionate use protocol (approved by the Wayne State University Human Investigation Committee) with a sterile, single-dose, nonpreserved, ophthalmic formulation of thymosin beta 4 eye drops supplied by RegeneRx Biopharmaceuticals, Inc (Rockville, Maryland).

Necrotizing Keratitis Caused by Capnocytophaga ochracea

We studied three cases of Capnocytophaga keratitis that demonstrated stromal necrosis and a ring infiltrate. In all cases, the keratitis occurred in a previously diseased or traumatized cornea. One patient was treated with chronic antiamoebic therapy for presumed Acanthamoeba keratitis. Two cases resulted in corneal perforation. Laboratory isolation was difficult because of slow, fastidious growth. Capnocytophaga is not uniformly sensitive to commonly used topical antibiotics such as the cephalosporins and aminoglycosides, but may respond to treatment with topical clindamycin.

Infectious keratitis after photorefractive keratectomy in a comanaged setting

A 48-year-old man had simultaneous bilateral photorefractive keratectomy (PRK). The surgeon who performed the PRK did not see the patient in follow-up, and there was confusion regarding the comanaging doctor. Therefore, the patient was not examined immediately postoperatively. Several days later, he was hospitalized for an unrelated, painful orthopedic problem and heavily sedated. Seven days after the PRK, an ophthalmologist was consulted for ocular irritation and discharge. Examination showed bilateral, purulent conjunctivitis and severe infectious keratitis in the left eye. The patient was treated with periocular and topical antibiotics. Corneal cultures yielded Staphylococcus aureus. The keratitis resolved slowly, leaving the patient with hand motion visual acuity. A corneal transplant and cataract extraction was performed 15 months later, resulting in a best corrected visual acuity of 20/400 because of glaucomatous optic nerve damage. Severe infectious keratitis may occur after PRK. Poor communication between the surgeon, comanaging doctor, and patient may result in treatment delay.

Early- versus late-onset infectious keratitis after radial and astigmatic keratotomy: Clinical spectrum in a referral practice

PURPOSE To compare the clinical characteristics of early- versus late-onset keratitis after radial keratotomy (RK) and astigmatic keratotomy (AK). SETTING Referral subspecialty practice. METHODS This retrospective review comprised 19 patients with infectious keratitis after RK and AK. Early- versus late-onset groups were analyzed for predisposing conditions; infiltrate location, size, and depth; microbiologic data; and final visual outcome. RESULTS Ten patients in the early-onset group developed keratitis within a mean of 7.4 days after surgery (range 3 to 14 days). Nine patients in the late-onset group developed keratitis a mean of 5.4 years after surgery (range 1.5 to 15.0 years). Staphylococcus aureus was the predominant organism in the early-onset group and Pseudomonas aeruginosa in the late-onset group. In the early-onset group, most infiltrates occurred in the paracentral aspect of the RK incision and extended to the middle or posterior stroma. In the late-onset group, most infiltrates occurred in the peripheral portion of the RK incision and were localized to the superficial stroma. A hypopyon was present in 7 of 10 ulcers in the early group and in 1 of 9 in the late group. Two patients in the early group developed endophthalmitis. Most patients in the late-onset group had incisional pseudocysts; 2 had other risk factors for keratitis. Final visual acuity was 20/40 or better in 7 of 10 patients in the early group and in 8 of 9 patients in the late group. CONCLUSIONS Early-onset corneal ulcers after incisional refractive keratotomy were usually paracentral and deep, whereas late-onset ulcers were usually peripheral and superficial. Despite the predominance of Staphylococcus and Pseudomonas in the early- and late-onset groups, respectively, a variety of organisms may be responsible for infections in keratotomy incisions.

Acanthamoeba keratitis associated with disposable contact lenses.

Two patients developed Acanthamoeba keratitis associated with the use of disposable extended-wear hydrogel contact lenses. Both patients removed, irrigated, and reinserted the contact lenses without disinfecting them. One patient wore the lenses on a daily basis, rinsed the lenses in tap water, stored them overnight, and discarded them weekly. Both infections were treated successfully. In a third patient, Acanthamoeba species was cultured from two pairs of disposable lenses that had been stored in cases rinsed with well water. Potential benefits from disposable contact lens wear are negated when patients do not comply with a continuous wearing schedule.