John E. Sutphin

Mitomycin C treatment for conjunctival-corneal intraepithelial neoplasia: a multicenter experience.

OBJECTIVE The purpose of the study is to evaluate the efficacy and risks of topical mitomycin C (MMC) for conjunctival-corneal intraepithelial neoplasia (CCIN). DESIGN The study design was a clinical case series of CCIN. PARTICIPANTS Seventeen patients, 16 with biopsy-confirmed CCIN and 1 with invasive squamous cell carcinoma (SCC), were included in the study. INTERVENTION Patients received topical drops of MMC 0.02% to 0.04% four times daily from 7 to 28 days. Retreatment was done in cases of lesion recurrence. MAIN OUTCOME MEASURES The size of the CCIN before and after the treatment and ocular complications post-MMC application were evaluated. RESULTS Ten patients remained disease-free after one course of MMC application. In one case, residual CCIN remained very small without regrowth. In the one patient with invasive SCC and in five patients with CCIN, regrowth occurred within 6 months of the first treatment. After retreatment, invasive SCC and CCIN in an additional two patients were eradicated. In two cases, although the size of the lesions decreased after two and three applications of MMC, regrowth occurred, and the CCIN returned to its original size. In the final case, limited recurrence has occurred and no retreatment has been done. The complications of MMC use included mild-to-moderate conjunctival hyperemia and mild allergy, which resolved after discontinuation of the treatment. Severe pain manifested when treatment was longer than 14 days. CONCLUSIONS Application of topical MMC is an efficient treatment for most but not all cases of CCIN.

Outbreak of Keratitis Presumed to Be Caused by Acanthamoeba

PURPOSE A sharp increase of Acanthamoeba keratitis from two cases per year to 30 cases per year at our institution prompted this study to determine whether there was a change in the clinical characteristics, basic epidemiology, and outcome of this disease. METHODS We reviewed all cases of Acanthamoeba keratitis diagnosed at the University of Iowa Hospitals and Clinics from mid-1993 through 1994. RESULTS We screened 217 patients with keratitis by tandem scanning confocal microscopy and suspected Acanthamoeba in 51 patients. Diagnosis was confirmed by cytology in 43 patients (48 eyes). There were no positive cultures. Patients examined within four weeks of onset of symptoms were younger (mean age, 32.6 +/- 15.4 years) and wore contact lenses (11 of 18 patients), and infrequently herpes simplex keratitis (four of 18 patients) was diagnosed. Patients examined after four weeks were older (mean age, 54.0 +/- 19.5 years), infrequently wore contact lenses (six of 25 patients), and often had herpes simplex keratitis (12 of 25 patients). CONCLUSIONS Corneal examination with tandem scanning confocal microscopy was associated with a marked increase in the detection of Acanthamoeba, strongly suggesting that the disease is more prevalent than suspected. Acanthamoeba may account for many cases of clinically presumed herpes simplex keratitis, the leading cause of corneal blindness in the United States. Acanthamoeba should be considered in the differential diagnosis of any unexplained keratitis, even those of short duration.

Ic3d Classification of Corneal Dystrophies—edition 2

Purpose: To update the 2008 International Classification of Corneal Dystrophies (IC3D) incorporating new clinical, histopathologic, and genetic information. Methods: The IC3D reviewed worldwide peer-reviewed articles for new information on corneal dystrophies published between 2008 and 2014. Using this information, corneal dystrophy templates and anatomic classification were updated. New clinical, histopathologic, and confocal photographs were added. Results: On the basis of revisiting the cellular origin of corneal dystrophy, a modified anatomic classification is proposed consisting of (1) epithelial and subepithelial dystrophies, (2) epithelial–stromal TGFBI dystrophies, (3) stromal dystrophies, and (4) endothelial dystrophies. Most of the dystrophy templates are updated. The entity “Epithelial recurrent erosion dystrophies” actually includes a number of potentially distinct epithelial dystrophies (Franceschetti corneal dystrophy, Dystrophia Smolandiensis, and Dystrophia Helsinglandica) but must be differentiated from dystrophies such as TGFBI-induced dystrophies, which are also often associated with recurrent epithelial erosions. The chromosome locus of Thiel-Behnke corneal dystrophy is only located on 5q31. The entity previously designated as a variant of Thiel-Behnke corneal dystrophy on chromosome 10q24 may represent a novel corneal dystrophy. Congenital hereditary endothelial dystrophy (CHED, formerly CHED2) is most likely only an autosomal recessive disorder. The so-called autosomal dominant inherited CHED (formerly CHED1) is insufficiently distinct to continue to be considered a unique corneal dystrophy. On review of almost all of the published cases, the description appeared most similar to a type of posterior polymorphous corneal dystrophy linked to the same chromosome 20 locus (PPCD1). Confocal microscopy also has emerged as a helpful tool to reveal in vivo features of several corneal dystrophies that previously required histopathologic examination to definitively diagnose. Conclusions: This revision of the IC3D classification includes an updated anatomic classification of corneal dystrophies more accurately classifying TGFBI dystrophies that affect multiple layers rather than are confined to one corneal layer. Typical histopathologic and confocal images have been added to the corneal dystrophy templates.

Diagnosis of Acanthamoeba keratitis in vivo with confocal microscopy

We present eight cases of Acanthamoeba keratitis. In each case, the Acanthamoeba organisms were visualized in the epithelium and anterior stroma using tandem scanning confocal microscopy. The organisms were highly reflective, ovoid, and were 10–25 μm in diameter. The Acanthamoeba organisms in the human corneas were identical in size and shape to Acanthamoeba organisms on an agar plate visualized with the same confocal microscope. Confocal microscopy is a useful method for identifying. Acanthamoeba organisms in vivo within the corneal epithelium and anterior stroma.

Long-term results of eyes with penetrating keratoplasty and glaucoma drainage tube implant.

PURPOSE To present long-term results of eyes with penetrating keratoplasty (PK) and glaucoma tube implant. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS We retrospectively reviewed medical records of all patients who underwent both PK and glaucoma tube implant (Baerveldt or Ahmed) at the University of Iowa between July of 1988 and December of 1997 (55 eyes). METHODS Success of the tube implant or PK was evaluated using Kaplan-Meier survival analysis. Association of relevant clinical factors with glaucoma or corneal graft outcome was evaluated using log-rank test or Cox proportional hazard regression analysis. The factors evaluated were glaucoma and cornea diagnoses; prior, simultaneous, and subsequent surgeries; type of tube implant; relative timing of surgeries; and postsurgical complications. MAIN OUTCOME MEASURES Glaucoma outcome was assessed by postoperative intraocular pressure (IOP), number of medications, and need for further glaucoma surgery. Corneal outcome was assessed by graft rejection, failure, and Snellen visual acuity. Surgical procedures before and during the study period, and their complications were evaluated. RESULTS The mean preoperative intraocular pressure was 29.8 mmHg with an average of 2.9 medications. At last postoperative follow-up, the mean IOP decreased to 14.3 mmHg with 0.7 medication. The tube implant successfully controlled glaucoma in 45 eyes (82%) at 3 years. More severe postsurgical complications were associated with greater glaucoma failure. Graft rejection occurred in 17 eyes, and 7 of these progressed to failure. Nonimmunologic graft failure occurred in an additional 17 eyes (31%). The remaining 31 eyes (56%) had a clear graft. The corneal grafts remained clear in 70% and 55% of eyes at 2 and 3 years, respectively. Corneal graft failure was associated with glaucoma and cornea diagnoses groups, type of tube implant, and relative timing of the two surgeries. Complications occurred in 23 eyes (42%), and 10 of these were serious. CONCLUSIONS A drainage tube implant can successfully control glaucoma in a majority (82%) of keratoplasty eyes at 3 years. However, the success of corneal grafts is low (55%) at 3 years. Postsurgical complications are not uncommon and are associated with poor glaucoma outcome. Other clinical factors are associated with poor graft outcome.

Model for ocular tear film function

Blepharitis patients have a number of disturbances in their tear film associated with meibomian gland dysfunction that affect evaporation and tear osmolarity. We tested a series of 156 consecutive patients, with a presumed diagnosis of blepharitis, dry eye, or allergic disease, and a series of 72 normals. We compared their tear film characteristics using tear osmolarity, tear volume, tear production (fluorophotometric and Schirmer test), tear turnover (decay constant), tear evaporation, and meibomian gland function evaluated by gland drop-out, expressed lipid viscosity, and volume. Of the 156 patients tested, we found 37 had only dry eye, 10 had only allergic disease, 73 had meibomian gland dysfunction and dry eye, and 36 had only meibomian gland dysfunction. We created a model of the relative influence some of these factors had on each other using their correlation coefficients. The highest correlations for osmolarity were Schirmer test (-0.44), lipid volume low (-0.44), lipid viscosity high (0.39), gland drop-out (0.39), and tear evaporation (0.36). With regression analysis we accounted for 47% of the total variation in osmolarity, but only 17% of the variation in tear evaporation. We also present our classification system for blepharitis and dry eye patients based on our measurable physiologic parameters.

Eye bank survey of surgeons using precut donor tissue for descemet stripping automated endothelial keratoplasty.

PURPOSE To assess surgeon satisfaction with precut corneal tissue from 1 eye bank for Descemet stripping automated endothelial keratoplasty (DSAEK). Surgical techniques and predictors of procedural success were also examined. METHODS A 19-question survey was completed by 53 surgeons around the United States for 197 DSAEK cases using prepared corneal allograft tissue from the Iowa Lions Eye Bank. Surgeries were performed between April 1 and December 31, 2006; surveys were completed retrospectively within a few weeks of surgery. RESULTS Tissue was found to be acceptable in 98% of DSAEK cases reported. Difficulties with precut tissue (eg, lack of anterior cap adherence to the posterior lamella, not visible or decentered central dot, anterior edge undermining) were reported in approximately 10% of cases. A rebubbling procedure was performed in 23% of cases for donor dislocations. The donor lenticule adhered, with resulting corneal deturgescence, in 86% of cases. Surgeons declared a successful procedure in 92% of cases. Of the 14 unsuccessful cases, donor tissue quality was the underlying etiology in only 1 case. Procedural success rates were related to surgeon experience (P = 0.002), lenticule adherence after only 1 anterior chamber air bubble (P = 0.005), no small perforations to release fluid (P = 0.005), and the presence of corneal deturgescence (P = 0.002). CONCLUSIONS The use of precut tissue for DSAEK is not associated with increased risk of complications related to tissue preparation. With standardization of precutting donor tissue, safety of DSAEK surgery may be improved while increasing surgeon efficiency.Background:Syphilis outbreaks among men who have sex with men (MSM) in the United States have raised concerns about increased HIV transmission in this population. We sought to estimate HIV incidence among men diagnosed with primary or secondary (P&S) syphilis in sexually transmitted disease (STD) clinics in Atlanta, San Francisco, and Los Angeles. Methods:We analyzed deidentified sociodemographic information from routine syphilis surveillance databases and matching remnant sera from consecutive male patients with P&S syphilis who were tested for syphilis at 3 public health laboratories during January 2004 through January 2006. Deidentified sera positive for Treponema pallidum by particle agglutination were screened for HIV-1 antibodies by enzyme immunoassay (EIA). Specimens that were confirmed HIV-positive by Western blot analysis were then tested for recent HIV infection using the less sensitive (LS) HIV-1 Vironostika EIA and BED HIV-specific IgG/total IgG assay. Results:Of 357 men with P&S syphilis (98 in Atlanta, 151 in San Francisco, and 108 in Los Angeles), 32% had primary syphilis and 85% were MSM (12% no MSM risk and 3% no information). The median age was 36 years; 40% were white, 31% black, 20% Hispanic, and 8% other. Among men with P&S syphilis, 160 (45%) were HIV-positive, of whom 8 were classified as having acquired recent HIV infection by the LS-Vironostika EIA (all confirmed by BED) and had no history of antiretroviral use or HIV-positive results >6 months earlier. Seven of the 8 men with recent HIV infection were MSM. The estimated HIV incidence was 9.5% per year (95% confidence interval [CI]: 2.9 to 16.0) among all men and 10.5% per year (95% CI: 2.7 to 18.3) among MSM. Conclusions:We found high HIV incidence among a high-risk population of US men diagnosed with P&S syphilis in STD clinics in Atlanta, San Francisco, and Los Angeles. Intensive integrated HIV/STD prevention programs are needed for this population.

Comparison of the femtosecond laser (IntraLase) versus manual microkeratome (Moria ALTK) in dissection of the donor in endothelial keratoplasty: initial study in eye bank eyes.

Purpose: To determine the safety and efficacy of a femtosecond laser (IntraLase) and manual microkeratome (Moria ALTK) in creating precut endothelial keratoplasty donor tissue. Methods: Sixteen corneoscleral buttons from 8 donors were evaluated within 2 days of the death of the donor. The mean donor age was 72 years, and mean death-to-preservation time was 11 hours. Eight eyes underwent deep lamellar keratectomy by using the femtosecond laser (IntraLase: firing rate, 30 kHz; lamellar cut energy, 7.4 μJ; side cut energy, 5.5 μJ; spot size, 10 μm; diameter, 9.0 mm; depth, 400 μm; spiral pattern), whereas the other 8 eyes were cut by using the Moria ALTK microkeratome (350-μm head). Ultrasonic pachymetry and endothelial cell density (ECD) were performed before and after keratectomy. The residual stromal bed was examined with electron microscopy to determine the smoothness of the surface. Cell viability was assessed by using a transferase dUTP nick end labeling (TUNEL) assay. Results: The mean preoperative pachymetry was similar in the microkeratome group and femtosecond laser group (P = 0.239). The microkeratome group obtained a consistently deeper keratectomy of 446 ± 25 versus 400 ± 41 μm in the laser group (P = 0.023). Similarly, the residual stromal bed was thinner in the microkeratome group (115 ± 28.5 vs. 177 ± 42 μm; P = 0.005). There was no statistically significant difference in the ECD between the 2 groups preoperatively or at 48 hours after keratectomy. Compared with the preoperative state, there was a 1% and 4% reduction of ECD in the microkeratome and femtosecond laser groups, respectively. Scanning electron microscopy of the stromal surface consistently showed a smoother contour in the manual microkeratome group. TUNEL assays indicate no significant endothelial cell loss in either the microkeratome group or the femtosecond laser group. Conclusions: The femtosecond laser (30 kHz) and the manual microkeratome are equally effective in creating precut endothelial keratoplasty donor tissue, with no detrimental effect on endothelial cell density. The microkeratome creates a smoother stromal surface and thinner endothelial discs. The femtosecond laser lamellar dissection depth is less deep, and the stromal surface is less smooth. This particular feature of femtosecond laser keratectomy may improve disc adherence, which continues to be a problem in endothelial keratoplasty. A prospective, randomized study is needed to evaluate postoperative vision and disc adherence by using both technologies in endothelial keratoplasty.

DIAGNOSIS OF ASPERGILLUS KERATITIS IN VIVO WITH CONFOCAL MICROSCOPY

Confocal microscopy provides a new, noninvasive way of imaging the human cornea in vivo. One of its most important clinical uses is the diagnosis and management of infectious keratitis. The authors used tandem scanning confocal microscopy to image the corneas in two culture-proven cases of Aspergillus keratitis. Fungal hyphae were imaged as high-contrast filaments 6 microns in diameter from 60 to 400 microns in length. Confocal microscopy may be a fast and safe diagnostic tool in determining the presence of fungal hyphae in vivo within the human cornea.

Preliminary Results of Photorefractive Keratectomy in Active-duty United States Navy Personnel

PURPOSE To evaluate the safety, efficacy, and quality of vision after photorefractive keratectomy (PRK) in active-duty military personnel. METHODS Photorefractive keratectomy (6.0-mm ablation zone) was performed on 30 navy/marine personnel(-2.00 to -5.50 diopters [D]; mean, -3.35 D). Glare disability was assessed with a patient questionnaire and measurements of intraocular light scatter and near contrast acuity with glare. RESULTS At 1 year, all 30 patients had 20/20 or better uncorrected visual acuity with no loss of best-corrected vision. By cycloplegic refraction, 53% (16/30) of patients were within +/- 0.50 D of emmetropia and 87% (26/30) were within +/- 1.00 D. The refraction (mean +/- standard deviation) was +0.45 +/- 0.56 D (range, -1.00 to 1.63 D). Four patients (13%) had an overcorrection of more than 1 D. Glare testing in the early (1 month) postoperative period demonstrated increased intraocular light scatter (P<0.01) and reduced contrast acuity (with and without glare, (P<0.01). These glare measurements statistically returned to preoperative levels by 3 months (undilated) and 12 months (dilated) postoperatively. Two patients reported moderate to severe visual symptoms (glare, halo, night vision) worsened by PRK. One patient had a decrease in the quality of night vision severe enough to decline treatment in the fellow eye. Intraocular light scatter was increased significantly (>2S D) in this patient after the procedure. CONCLUSIONS Photorefractive keratectomy reduced myopia and improved the uncorrected vision acuity of all patients in this study. Refinement of the ablation algorithm is needed to decrease the incidence of hyperopia. Glare disability appears to be a transient event after PRK. However, a prolonged reduction in the quality of vision at night was observed in one patient and requires further study.