John W. Reed

Topical 5-Fluorouracil in Treating Epithelial Neoplasia of the Conjunctiva and Cornea

PURPOSES To evaluate the efficacy of topical 5-fluorouracil (5-FU) in treating conjunctival and corneal epithelial neoplasia. METHODS Three patients underwent surgical excision of bulky disease followed by topical 1% 5-FU in artificial tear base for 2 to 3 weeks or until epithelial separation occurred. An additional three patients underwent treatment with topical 1% 5-FU alone. RESULTS Minimum follow-up was 6 months. In one patient with conjunctival in situ carcinoma and no detectable normal conjunctiva, who had normal findings on conjunctival histologic examination after application of topical 5-FU, a focus of invasive disease requiring orbital exenteration. One patient had a favorable response to 5-FU therapy but required a repeat excision for control of bulky disease. Four patients have remained disease-free for 10, 13, 18, and 30 months after topical 5-FU therapy. CONCLUSION With its potential selective toxicity on dysplastic epithelium, topical 5-FU shows promise as an adjunctive treatment for managing conjunctival and corneal epithelial neoplasia.

Cataract formation and cataract extraction after penetrating keratoplasty.

PURPOSE This retrospective study was done to identify risk factors for cataract formation and cataract extraction after penetrating keratoplasty to determine whether a combined procedure (simultaneous cataract extraction with keratoplasty) or penetrating keratoplasty alone should be performed. METHODS Variables from 342 phakic eyes having undergone penetrating keratoplasties were studied with univariate and multivariate analyses, including diagnosis, race, sex, age, preoperative lens opacities, preoperative vision, and length of follow-up. RESULTS For cataract formation, age was the only independent risk factor found by multivariate analysis (P = 0.0001). For cataract extraction after penetrating keratoplasty, independent risk factors included age, sex, diagnosis, and preoperative lens opacities (P < or = 0.03). For example, the probability of a 65-year-old patient with Fuchs dystrophy requiring a cataract extraction within 5 years of keratoplasty is 81%. CONCLUSION The likelihood of cataract formation and cataract extraction subsequent to penetrating keratoplasty increases greatly after 50 years of age, regardless of the diagnosis leading to the need for keratoplasty. The need for cataract extraction also is increased for female patients, for patients with Fuchs dystrophy, and for those with early preoperative lens opacity.

BILATERAL MONOCULAR DIPLOPIA ASSOCIATED WITH LID POSITION DURING NEAR WORK

Purpose To describe a common pattern of topographic changes and clinical signs of six patients presenting with a complaint of monocular diplopia after reading and to investigate the cause of this topographic disturbance. Methods Patient population: Subject group of six patients with monocular diplopia complaints after reading and 20 patients without such complaints. Examinations performed before and after a reading period of 30 min: videokeratoscopic examination, red reflex examination, position of the lids in primary gaze and in reading position. Data analysis: inspection of keratoscopic rings, qualitative analysis of topography maps, comparison of SAI and SRI of control and subject groups before and after reading, comparison of lid position of control and subject group. Results Half of the subject group and none of the control group developed subtle ring distortions of keratoscopic rings. SAI and SRI values increased significantly in the subject group compared with the control group (p = 0.02 and p < 0.001, respectively) corresponding to the development of a focal distortion in the entrance pupil of the videokeratoscopic image. Each subject developed a horizontal band on red reflex located at the superior, middle, or inferior aspect of the pupil after near work. Two controls developed faint bands in the red reflex outside the entrance pupil. The interpalpebral fissure in down gaze was narrower in the subject group compared with the control group (p = 0.001). Conclusions Some individuals may develop monocular diplopia after reading. We hypothesize that during near work these corneal topographic alterations occur primarily related to the position of the lids and tear film interaction with the corneal surface.

Corneal tattooing to reduce glare in cases of traumatic iris loss.

The traumatic loss of iris is often associated with symptoms of glare, which can be debilitating. This symptom may be benefitted by wearing a contact lens with a clear, central optical zone and opacification of the remainder. The patient who is contact lens-intolerant may be helped by tattooing of all of the cornea except the central visual axis. Four patients who had traumatic iris loss and who were treated by this technique reported reduced glare as well as improvement in the cosmetic appearance of the eye. Although corneal tattooing is an ancient procedure, it continues to be of benefit for selected patients.

Retrospective analysis of a novel method of transscleral suture fixation for posterior-chamber intraocular lens implantation in the absence of capsular support.

Purpose To determine the safety and efficacy of an alternative method for transscleral fixation of a secondary posterior-chamber intraocular lens (pcIOL) during penetrating keratoplasty. Methods Eighty-nine eyes that underwent secondary pcIOL implantation by using a modified transscleral suture-fixation technique during penetrating keratoplasty were retrospectively evaluated. The surgical technique used suture fixation to the surface of the sclera 5 mm posterior to the limbus, with the knot buried beneath Tenons capsule and conjunctiva. Patient records were reviewed for postoperative complications, including suture erosion, pcIOL subluxation, vitreous hemorrhage, and retinal detachment. Mean follow-up was 24.4 months, with a range of 4–68 months. Results All eyes had successful fixation of their pcIOL immediately after surgery. Three (3.3%) eyes had graft failure. Six (6.7%) of 89 eyes showed evidence of suture erosion or partial exposure. Postoperative suture breakage occurred in two (2.2%) eyes. Posterior-segment complications included retinal detachment in one (1.1%) eye, vitreous hemorrhage in one (1.1%) eye, and limited choroidal hemorrhage in two (2.2%) eyes. Median visual acuity at 1-year follow-up was 20/70 (range, 20/25 to light perception). Conclusion This transscleral fixation technique provides a straightforward alternative to previously described techniques. Suture erosion, IOL dislocation, and posterior-segment complications occurred at relatively low rates compared with other pcIOL implantation techniques.

Penetrating Keratoplasty for Herpes Zoster Keratopathy

We reviewed retrospectively the records of 12 patients with herpes zoster keratopathy who had undergone penetrating keratoplasty. Preoperatively, seven patients (58%) had noninflamed eyes with visually significant corneal scarring or edema. Five patients (42%) had progressive neurotrophic corneal ulceration, and four of those had corneal perforation. Tarsorrhaphies were placed in ten patients and appeared to be beneficial in preventing postoperative breakdown of the corneal surface. At an average follow-up time of 36 months, ten of the 12 grafts (83%) remained clear, with nine patients (75%) having a visual acuity of 20/80 or better.

Clinical and Pathologic Findings of Aphakic Peripheral Corneal Edema: Brown-mclean Syndrome

Twenty-two patients (36 eyes) are reported with Brown- McLean syndrome, which consists of peripheral corneal edema associated with peripheral endothelial pigment deposits, usually after intracapsular cataract extraction. This group, the largest reported to date, had a spectrum of corneal alterations, those at the more severe end of the spectrum being both progressive and symptomatic. Some patients required medical and surgical treatment, including keratoplasty. Four corneas (two obtained surgically, two postmortem) were examined by light and electron microscopy (EM). Centrally, the corneas were relatively normal, but peripherally there were disintegrated endothelial cells with an abnormal posterior collagenous layer of Descemets membrane. Scanning EM showed a somewhat distinct junction between the normal central endothelium and the diseased peripheral endothelium.