Irving M. Raber

Indications for Penetrating Keratoplasty and Associated Procedures, 2001–2005

Purpose. To identify current indications and trends in indications for penetrating keratoplasty (PKP) and associated procedures. Methods. Retrospective chart review of all patients who underwent PKP at Wills Eye Institute from January 1, 2001, to December 31, 2005. Results. A total of 1,162 cases were performed in this 5-year period. Leading indications for PKP were pseudophakic corneal edema (PCE) in 330 (28.4%) cases, followed by regraft in 250 (22.0%), keratoconus in 186 (16%), and Fuchs’ endothelial dystrophy in 126 (10.8%) cases. Of the 330 cases of PCE, 232 (70.3%) were associated with posterior chamber intraocular lenses (PCIOLs) and 96 (29.1%) with anterior chamber lenses. In 330 eyes with PCE, the lens was not exchanged in 246 (74.5%) cases and was exchanged in 76 (23%) cases. Seventy of the exchanged lenses were anterior chamber intraocular lenses (ACIOLs) and six lenses were PCIOLs. In cases of ACIOL exchanges, 10 were for scleral sutured IOLs, 18 for PCIOLS, and 42 for another ACIOL. Conclusions. Pseudophakic corneal edema remains the leading indication for PKP at our institution followed by regraft, continuing a trend noted in our previous studies. Although the percentage of cases of PCE associated with PCIOLS increased, fewer lenses were exchanged, perhaps reflecting increased confidence in biocompatibility of newer IOLs. The decrease in overall number of corneal transplants in these 5 years continues a trend noted in our previous study and mirrors the national decline in PKP.

Results of alloplastic tube shunt procedures before, during, or after penetrating keratoplasty.

The association of glaucoma and penetrating keratoplasty presents a difficult management problem, particularly when medical therapy and conventional glaucoma surgery have failed. We have found alloplastic tube shunt surgery to be an effective method for intraocular pressure control in glaucomatous eyes subjected to penetrating keratoplasty. We report 46 patients who underwent alloplastic tube shunt implantation before (13 patients, group A), in combination with (17 patients, group B), or after (16 patients, group C) penetrating keratoplasty. All groups had significantly lowered intraocular pressure postoperatively. The most common complication was graft failure, in 31% of patients in group A, 29% in group B, and 44% in group C. Other postoperative complications and results including visual outcome are reviewed. Because the management of advanced glaucoma in patients undergoing keratoplasty is difficult, alloplastic tube shunt implantation should be considered.

Pseudomonas Corneoscleral Ulcers

We studied four cases of Pseudomonas corneal ulcers that extended into the sclera despite intensive antibiotic treatment. All four cases required eventual enucleation or evisceration. In addition to the expected limbal perforations and acute endophthalmitis, histopathologic examinations showed scleral necrosis with underlying inflammation in the supraciliary space in three of the four cases. Once Pseudomonas corneal infection has extended into the sclera, we have found that medical treatment is not effective.

Baseline Factors Related to Endothelial Cell Loss Following Penetrating Keratoplasty

OBJECTIVE To identify baseline (donor, recipient, and operative) factors that affect endothelial cell loss following penetrating keratoplasty for a moderate-risk condition (principally Fuchs dystrophy or pseudophakic or aphakic corneal edema). METHODS In a subset (n = 567) of Cornea Donor Study participants, preoperative and postoperative endothelial cell densities (ECDs) were determined by a central reading center. Multivariate regression analyses were performed to examine which baseline factors correlated with ECD over time. RESULTS Larger grafts (P < .001), younger donor age (P < .001), and female donor (P = .004) were significantly associated with higher ECD during follow-up. Median endothelial cell loss at 5 years was 68% for grafts larger than 8.0 to 9.0 mm in diameter, 75% for grafts 7.0 mm to smaller than 8.0 mm in diameter, and 74% for grafts 8.0 mm in diameter. Grafts from female donors experienced a 67% cell loss compared with a 72% cell loss among grafts from male donors. Method of tissue retrieval, donor cause of death, history of diabetes, and time from death to preservation or to surgery were not significantly associated with changes in ECD over time. CONCLUSIONS Following penetrating keratoplasty for endothelial dysfunction conditions, larger donor graft size, younger donor age, and female donor were associated with higher ECD over 5 years. These data warrant exploring the possibility that similar associations may exist following endothelial keratoplasty. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00006411.

Phototherapeutic keratectomy for Schnyder's crystalline corneal dystrophy.

Purpose. To describe the treatment of Schnyders crystalline dystrophy (SCD) with excimer laser phototherapeutic keratectomy (PTK). Methods. Chart review of three patients (four eyes) with SCD treated with PTK between March 1992 and December 1998. Pre-and posttreatment visual acuity, subjective glare, photophobia, manifest refraction, ultrasound pachymetry, hyperopic shift, and biomicroscopic findings were studied. Brightness acuity testing (BAT) was evaluated in two eyes. Results. Four eyes were treated during the study period. The average best corrected visual acuity (BCVA) improved from 20/175 to 20/40 under bright conditions. All patients reported subjective improvement in glare and photophobia. No visually significant recurrence was observed during the follow-up period which ranged from seven months to three years. The mean spherical equivalent refractive shift was +3.28 diopter (D). One patient developed irregular astigmatism from an eccentric ablation. No vision threatening complications were observed. Conclusion. PTK can be effective at improving visual symptoms in patients with SCD. It can be a useful therapeutic alternative to lamellar or penetrating keratoplasty in these patients.

Repair of Descemet's membrane detachment with intracameral injection of 20% sulfur hexafluoride gas

Detachment of Descemets membrane is a rare complication of cataract surgery that can cause permanent corneal decompensation. We report five patients with Descemets membrane detachments who were successfully treated with intracameral injection of 20% sulfur hexafluoride gas with resultant resolution of their corneal edema.

Cicatrizing conjunctivitis as a predominant manifestation of linear IgA bullous dermatosis

Linear IgA bullous dermatosis is an uncommon mucocutaneous autoimmune disorder that is distinct from dermatitis herpetiformis and bullous pemphigoid. Two patients who had significant conjunctival involvement but minimal skin disease are described. Irreversible conjunctival scarring indistinguishable from ocular pemphigoid developed in both patients.

Sutureless amniotic membrane ProKera for ocular surface disorders: short-term results.

Objective: To evaluate the indications and outcomes of sutureless amniotic membrane transplant (AMT; ProKera) in the management of ocular surface disorders. Methods: Chart review of patients who had ProKera (Bio-Tissue, Inc.) implantation for ocular surface disorders between June 2008 and May 2012 at 3 ophthalmology practices in Philadelphia, PA. The parameters evaluated included age, sex, indication for AMT, any other combined procedure, duration of retention of amniotic membrane, the effect of amniotic membrane on ocular surface healing, follow-up time, and complications. Results: There were 35 eyes of 33 patients with a mean age of 68.2±19.5 years (range: 17–99 years). There were 25 male patients, and median follow-up was 110 days (mean: 164.6 days; range: 30–960 days). The indication for insertion of ProKera was nonhealing corneal ulcers of infective origin (group 1) in 9 eyes (25.7%), neurotrophic keratopathy (group 2) in 11 eyes (31.4%), chemical injury (group 3) in 5 eyes (14.3%), and other indications (group 4) in 10 eyes (28.6%). Complete or partial success was seen in a total of 44%, 64%, 80%, and 70% eyes in groups 1 to 4, respectively. Discomfort with the device was seen in 6 (17.1%) of 35 eyes, and recurrence of primary pathologic condition occurred in 5 (14.3%) of 35 eyes. Conclusion: ProKera treatment is easy to use and reasonably well tolerated, with moderate success in corneal ulcers and encouraging results in acute moderate chemical injury. Recurrence of primary pathologic condition is seen particularly associated with neurotrophic keratitis and dry eye syndrome.

Posterior polymorphous dystrophy associated with nonkeratoconic steep corneal curvatures.

Purpose: To report a case series of eyes with posterior polymorphous corneal dystrophy and steep nonkeratoconic corneas. Methods: Retrospective, descriptive, nonrandomized case series. Results: Thirty-five eyes of 18 patients (14 cases from 6 families and 4 isolated cases) with diffuse posterior polymorphous corneal dystrophy had mean topographic simulated keratometry readings of 52.21 diopters (D), with a range of 46.47 D to 59.86 D and an SD of 3.69 D, with no slit-lamp or topographic findings suggestive of keratoconus. Conclusions: The patients in this series demonstrate diffuse posterior polymorphous corneal dystrophy and nonkeratoconic steep corneas.

Peripheral hypertrophic subepithelial corneal degeneration.

Purpose To describe the clinical features, clinical course, and response to therapy of an atypical peripheral corneal opacification. Methods Retrospective case series review. Results Six patients are described with similar findings of bilateral, fairly symmetric, peripheral, hypertrophic, subepithelial corneal opacification. All patients were female and had no concurrent systemic conditions. All six patients complained of ocular irritation. Three patients complained of blurred vision, and one patient had monocular diplopia. In three patients followed up for more than 30 months, the corneal opacification remained stable in one patient and enlarged in the other two patients. The other three patients were examined once or twice, so the evaluation of disease progression was precluded. Two patients were treated surgically with superficial keratectomy followed by 2-minute intraoperative application of 0.02% mitomycin-C. Pathologic examination of bilateral keratectomy specimens from one patient showed subepithelial fibrosis without inflammation. Conclusions The clinical findings are reminiscent but atypical of Salzmann nodular degeneration.