James W. Karesh

Factors Associated with Glaucoma after Penetrating Keratoplasty

We conducted a retrospective analysis of 80 eyes that underwent penetrating keratoplasties to determine the factors associated with early (less than three months) and late (more than three months) postoperative increases in intraocular pressure. The patients ranged in age from 14 to 91 years (mean age, 58.5 years). The 56 patients with aphakic eyes had a mean age of 64 years and the 24 patients whose eyes had lenses had a mean age of 48 years. In the 17 eyes with preoperative glaucoma, the intraocular pressure was controlled with medication (mean intraocular pressure, 17.6 mm Hg; range, 10 to 21 mm Hg). The follow-up periods ranged from 12 to 26 months (mean, 22 months). Of the 80 eyes, 25 had early increases in intraocular pressure and 23 had late increases. Twenty eyes showed increases during both periods. Of the 17 eyes with preoperative glaucoma, 14 had early increases and 15 had late increases (P less than .001). Of the 57 aphakic eyes, 24 had early increases (P less than .001) and 21 had late increases (P less than .025). Other factors (whether vitrectomy was done, suture technique, and graft size) were not statistically significant.

Complications of exposed monofilament sutures.

Exposed monofilament suture ends caused a variety of symptoms and signs in 18 patients. These included foreign-body sensation, pain, contact lens intolerance, giant papillary conjunctivitis, tarsal ulceration, conjunctival granuloma, corneal infiltrate, and corneal vascularization. These changes followed cataract surgery, corneal transplantation, and pars plana vitrectomy. Diagnoses in these cases were made by careful slit-lamp examination and by eversion of the upper eyelid. In every case, removal of the sutures or trimming the suture ends resulted in the immediate relief of all symptoms with complete resolution of all signs within two months.

Polytetrafluoroethylene as an Interpositional Graft Material for the Correction of Lower Eyelid Retraction

Polytetrafluoroethylene (PTFE), a nonantigenic, autoclavable, inert, woven synthetic graft material was used to correct ten lower eyelids with retraction secondary to either thyroid disease (7 eyelids) or surgically repaired maxillofacial trauma (3 eyelids). The material was well tolerated for postoperative periods ranging from 10 to 26 months. In two eyelids, a portion of the PTFE was removed to treat eyelid thickening and an infected meibomian gland. Results of histopathologic examination of the graft showed minimal inflammation and capillary and connective ingrowth into the graft matrix as well as a dense fibrous capsule around the graft. In selected cases, PTFE may be an acceptable substitute for other graft materials used in oculoplastic surgery.

Staging and therapy of orbital lymphomas

Ten patients with non‐Hodgkins lymphoma primarily affecting the orbital region were evaluated at Michael Reese Hospital and Medical Center, Chicago, between 1976 and 1983. Diagnoses were based on the histopathologic classification systems of the Working Formulation of the Non‐Hodgkins Lymphomas and Rappoport. Sequential staging procedures performed at the time of diagnosis included liver‐spleen scans, Technecium‐99 bone scans, gallium 67 scans, computerized axial tomograms of the orbit and abdomen, bone marrow examination and cerebral spinal fluid analyses. Adverse prognostic factors included the following: orbital bone erosions, Stage IV disease, and large cell or mixed cell, diffuse histologic features. The type of histopathologic findings combined with the results of sequential staging procedures is useful in identifying those patients who would benefit most from systemic chemotherapy.

Prospective Clinical, Study of Radial Keratotomy

A prospective clinical study of radial keratotomy was conducted at the University of Maryland. Results of surgery on 33 eyes of 19 patients with a minimum follow-up of seven months and a mean of 13.8 months are reported. There were eight patients (15 eyes) who needed adequate unaided visual acuity for occupational purposes. Preoperative visual acuity was 20/400 in 79% of eyes. Postoperative visual acuity was 20/50 or better in 48% of cases. However, in patients with preoperative refractive errors of 5 diopters or less, postoperative visual acuity was 20/50 or better in 84% of cases. Average decrease in myopia was 2.5 diopters. Decrease in myopia following radial keratotomy did not correlate with corneal curvature or whether 8 or 16 incision technique was used. However, there was a very significant (P = 0.001) difference in postoperative visual acuity of patients with refractive error of 5 diopters or less, as compared to those with greater than 5 diopters of myopia. Complications included corneal scarring, vascularization, and glare. No microperforation or endothelial cell loss was observed.

Dacryocystifis Associated with Malignant Lymphoma of the Lacrimal Sac

BACKGROUNDnTumors of the lacrimal sac are unusual, and lymphomas of the lacrimal sac are quite rare. Four patients with a history of well-differentiated, small cell lymphoma or chronic lymphocytic leukemia presented with either acute or chronic dacryocystitis and epiphora due to lymphomatous infiltration of the lacrimal sac.nnnMETHODSnAll four patients underwent dacryocystorhinostomy with lacrimal sac biopsy. All tissues underwent complete histopathologic evaluation including immunohistochemical studies for cell surface markers and, in addition, were compared with previous biopsies performed for the initial diagnosis of lymphoma.nnnFINDINGSnAll biopsies demonstrated small cell well-differentiated lymphoma on histologic and immunofluorescent examination. No patient demonstrated orbital involvement on computed tomography. One patient had previously diagnosed chronic lymphocytic leukemia and one patient demonstrated diffuse lymph node involvement on postoperative systemic evaluation. All four patients underwent additional chemotherapy. No recurrence of dacryocystitis or epiphora occurred.nnnCONCLUSIONnFour patients presented with dacryocystitis secondary to lacrimal sac lymphoma. Lymphomatous lacrimal sac infiltration is an unusual cause of dacryocystitis. Biopsy of the lacrimal sac plays a diagnostically important role in dacryocystorhinostomy even in the absence of obvious tumorous involvement of the lacrimal sac mucosa.

Conjunctiva-Muller's muscle excision to correct anophthalmic ptosis

We treated 35 eyelids with ptosis and anophthalmos by resecting conjunctiva and Müllers muscle. Before surgical intervention all patients were evaluated by an experienced ocularist who, if necessary, modified or refit the prosthesis. All eyelids had a positive response to 10% phenylephrine hydrochloride. Preoperatively, the margin reflex distance-one (MRD-1) of the ptotic eyelids ranged from -2.0 to +3.5 mm. The amount of conjunctiva-Müllers muscle excision ranged from 7.25 to 9.25 mm. Following surgery, the average change in MRD-1 was 3.33 mm. Thirty-one eyelids (88.6%) achieved a post-operative level within 1 mm of the opposite eyelid. There were two overcorrections and two undercorrections. Postoperatively, no patients had any compromise of the superior fornix, socket dryness, or inability to retain their prosthesis. Resection of conjunctiva and Müllers muscle is a simple and effective method to treat ptosis associated with anophthalmos.

Pleomorphic Adenocarcinoma of Ciliary Epithelium Simulating an Epibulbar Tumor

A 72-year-old woman had epibulbar nodules and a blind eye following trauma in childhood. Histologic examination disclosed a pleomorphic adenocarcinoma of ciliary epithelium with invasion of the epibulbar region, retina, retinal pigment epithelium, and optic nerve. The diagnosis was confirmed by histochemical stains and electron microscopy. The pigmented and nonpigmented neoplastic cells of the ciliary epithelium had a patchy basement membrane around the cell membrane and produced hyaluronic acid in the stroma.

Orbital Cellulitis Caused by Eikenella corrodens

Eikenella corrodens is a gram-negative, facultative anaerobic bacillus with specific culture and growth requirements and unusual antibacterial susceptibilities. It has only recently been recognized as a human pathogen. Ocular and adnexal infections with this organism are rare especially in children. We treated two children with orbital cellulitis caused by E. corrodens. One was an 8-year-old boy; the other was an 11-year-old girl. Orbital cellulitis in both patients occurred after an upper respiratory tract infection. Sinusitis and a subperiosteal abscess were present in both patients. Eikenella corrodens and Streptococcus viridans were isolated from the boy; E. corrodens was the sole isolate in the girl. Intravenous ampicillin, prolonged hospitalization, and surgical drainage of the orbit were required to control the infection in both patients. Eikenella corrodens must be considered in the differential diagnosis of orbital cellulitis in children, and ophthalmologists must become familiar with the characteristics of this peculiar organism.

Periocular granuloma annulare

A 2-year-old boy presented with a 3-month history of nontender masses involving the right superotemporal orbit and scalp. Over the three-week period before presentation he also developed nodules on his wrist, abdomen, and buttocks. The remainder of the ocular and general physical exam was unremarkable. A biopsy of the right orbital mass demonstrated stellate areas of collagen necrosis surrounded by pallisading epithelioid histiocytes and scattered multinucleated giant cells. Special stains for connective tissue mucin were positive in the areas of necrosis. The diagnosis reached pathologically and clinically were that of pseudorheumatoid nodules and granuloma annulare syndrome respectively. These two diagnostic terms have been used independently in the ophthalmologic and dermatologic literature, despite the identical histologic and clinical behaviors seen by both medical groups. A unified nomenclature system of pseudorheumatoid nodule for the histopathology of an individual lesion and granuloma annulare for the syndrome is suggested.