Jonathan H. Tzu

Clinical features and prognosis of Boston type I keratoprosthesis-associated corneal melt.

Purpose: To describe the clinical features and outcomes of corneal melt associated with Boston type I keratoprosthesis (KPro) implantation. Methods: Medical records of patients who experienced corneal melt following KPro implantation were reviewed retrospectively. Results: Sixty-six adult patients had KPro implantation from January 2004 to November 2010. Six patients had an underlying inflammatory ocular surface disorder. Four experienced corneal melt (6.1%) 5–42 months after the initial surgery. One patient was diagnosed with Sjögren’s syndrome as a result of diagnostic workup following melt. Three patients were treated with systemic immunomodulatory therapy; two experienced fungal keratitis and subsequent endophthalmitis. KPro had to be explanted and replaced with donor cornea in all cases. Conclusions: KPro-associated corneal melt is uncommon and appears to occur in patients with preexisting inflammatory disorders, which might not have been previously diagnosed. Timely explantation of KPro and replacement with donor cornea may prevent a poor outcome.

Lamellar Keratoplasty Using Gamma-Irradiated Corneal Lenticules

PURPOSE To report the clinical outcomes of lamellar keratoplasty using sterile, gamma-irradiated corneal tissues (VisionGraft) for partial-thickness corneal defects. DESIGN Interventional case series. METHODS The medical records of 10 patients with partial-thickness corneal defects who were operated at The Wilmer Eye Institute between April 2009 and December 2009 were retrospectively reviewed. Indications for surgery included corneal melt with microperforation (n = 6), keratoprosthesis-associated corneal melt (n = 2), and noninflammatory limbal lesions (n = 2). The grafts were fashioned from full- or partial-thickness tissues using disposable trephines, based on the depth, shape, and size of the defect in the recipient bed, and were secured with multiple interrupted 10/0 nylon sutures. Rate of epithelialization and clarity of the grafts at the last visit were assessed retrospectively. RESULTS All but 1 graft became epithelialized between postoperative 1st and 13th days. Corneal inflammation progressed in the 1 patient with Boston type 1 keratoprosthesis-associated corneal melt, probably attributable to the progression of underlying Sjögren syndrome, despite initiation of systemic immunomodulatory treatment, and required replacement of the device. The donor tissues remained clear in all the other cases over a period of 7 to 15 months. No immune rejection, infection, significant opacification, or neovascularization of the donor tissues were noted during a follow-up period. CONCLUSIONS VisionGraft may be considered in lieu of fresh donor corneas for lamellar corneal patch grafts because of its availability, easy handling, and lack of immunogenicity.

Chronic Hypotony Associated With the Boston Type 1 Keratoprosthesis

PURPOSE To report the occurrence of chronic hypotony as a complication following Boston type 1 keratoprosthesis (KPro) implantation and to determine associated risk factors. DESIGN Retrospective case series. METHODS The medical records of all patients undergoing KPro implantation between January 2004 and November 2010 at the Wilmer Eye Institute were reviewed. Patients who developed chronic hypotony following Boston type 1 KPro implantation not attributable to anatomic problems (eg, retinal detachment, overfiltering glaucoma tube shunts, tissue necrosis with aqueous leak) or other causes were identified. Demographics and preoperative, intraoperative, and postoperative clinical findings were analyzed. Light microscopic examination of an enucleated globe as well as fibrous retroprosthetic membranes excised at the time of vitrectomy from another patient was performed. RESULTS Sixty-eight eyes received KPro implantation over the study period. Six eyes experienced chronic hypotony, with a median time of 18.5 months between KPro implantation and the onset of hypotony. The incidence of chronic hypotony in this series was calculated to be 3.7% at 1 year (95% CI = 0.9%-14.0%) and 13.3% at 2 years (95% CI = 5.5%-30.0%). Of the 6 eyes that developed chronic hypotony, 5 had a previous history of glaucoma or ocular hypertension, but only 3 had a glaucoma drainage implant. All eyes progressing to chronic hypotony were noted to have a retroprosthetic membrane prior to the onset of hypotony. Cox regression modeling demonstrated an increased risk of chronic hypotony in eyes with retroprosthetic membranes (P < .01) but no increase in risk for older patients (P > .1), eyes with glaucoma drainage implants (P > .5), or a previous history of multiple donor corneal transplants (P > .5). CONCLUSION Chronic hypotony can be a significant complication of KPro implantation and should be assessed carefully in eyes with retroprosthetic membranes. Further study of an association between hypotony and retroprosthetic membrane formation may be useful to gain insight into the mechanism of this complication and potential prevention or treatment options.

Clinical Course of Vitreomacular Traction Managed Initially by Observation.

BACKGROUND AND OBJECTIVE To investigate the clinical course and outcomes of patients with vitreomacular traction (VMT) managed initially by observation. PATIENTS AND METHODS This noncomparative case series included patients with a diagnosis of VMT based on clinical symptoms and findings on spectral-domain optical coherence tomography (SD-OCT) between 2005 and 2014. VMT was documented using a standardized grading system based on the degree of distortion of the foveal contour. Data were collected at five retina clinics using standardized collection forms. Visual acuity, changes in SD-OCT findings, and timing of the release of VMT as seen on SD-OCT were recorded. RESULTS The study included 230 eyes of 185 patients. Mean age was 72.5 years, and mean follow-up was 32 months. At baseline, VMT grading was grade 1 in 92 eyes (40%), grade 2 in 118 eyes (51.3%), and grade 3 in 20 eyes (8.7%). By last follow-up, spontaneous release of VMT occurred in 73 eyes (31.7%). Spontaneous release of VMT occurred at a mean of 18 months (median: 10.9 months) after initial visit. Mean logMAR best corrected visual acuity (BCVA) was 0.28 (20/55) (range: 20/20 to 20/400) at baseline and 0.25 (20/51) (range: 20/20 to 20/400) at last follow-up. Pars plana vitrectomy was performed in 10 eyes (4.1%) for macular hole (six eyes) and increased VMT (four eyes); BCVA was at least 20/40 in eight of the 10 eyes at last follow-up. CONCLUSION Patients with VMT generally had a favorable clinical course when managed initially by observation. Spontaneous release of VMT occurred in approximately one-third of patients. At last follow-up, pars plana vitrectomy was performed in fewer than 5% of patients.

Refractive Outcomes of Combined Cataract and Glaucoma Surgery

Purpose:This study was designed to evaluate the refractive outcomes of combined cataract extraction and glaucoma surgery. Design:Retrospective case series. Methods:A retrospective chart review of patients undergoing simultaneous cataract extraction with trabeculectomy or glaucoma drainage device surgery was performed. The main outcome measure evaluated was whether or not spherical equivalent of −1.00 to +0.50 D was achieved at 3 to 6 months postoperatively. Secondary outcomes included: reduction in intraocular pressure, amount of cylinder induced by combined surgery, and individual patient characteristics that may have affected refractive outcome. Outcomes were compared with an age-matched and sex-matched control group of patients who had uncomplicated cataract surgery during the same time period. Results:Forty-three eyes of 36 patients underwent combined cataract extraction and glaucoma surgery. A refractive outcome of spherical equivalent between −1.00 and +0.50 D was achieved in 32 of 43 eyes (74%) at 3 to 6 months after surgery. Logistic regression analysis found a 1.14 increased risk of the refraction being outside this defined refractive range in older compared with younger patients (by year, 95% CI, 1.04-1.27). Type of lens implant used, type of glaucoma surgery, and preoperative best-corrected visual acuity did not significantly affect refractive outcome. In a subset of 22 eyes with available preoperative keratometry measures, a mean 1.31 D (SD=0.86; range, 0.26 to 3.76) of corneal astigmatism was induced by combined surgery. In comparison, a matched control group who had cataract surgery alone achieved target refractive outcome in 34 of 40 eyes (85%, P=0.001) and had a trend for less induced cylinder (0.99, SD=0.72, P=0.11). Conclusions:Favorable refractive outcomes were achieved in the majority of patients despite the potential alteration of preoperative measurements and introduction of error into lens selection when using a combined approach. There does not seem to be a difference in the refractive outcome with regard to the type of glaucoma surgery performed. Control patients who had cataract surgery alone had a higher percentage of achieving target refractive goal and less induced cylinder.

Reversal in Gender Valuations of Cataract Surgery After the Implementation of Free Screening and Low-Priced High-Quality Surgery in a Rural Population of Southern China

Purpose: To assess the impact of community outreach and the availability of low-cost surgeries [500 Renminbi (RMB) or 65 United States dollars (US

Willingness to pay for potential enhancements to a low-cost cataract surgical package in rural southern China.

) per surgery] on the willingness to pay for cataract surgery among male and female rural-dwelling Chinese. Methods: Cross-sectional willingness-to-pay surveys were conducted at the initiation of a cataract outreach programme in June 2001 and then again in July 2006. Respondents underwent visual acuity testing and provided socio-demographic data. Results: In 2001 and 2006, 325 and 303 subjects, respectively, were interviewed. On average the 2006 sample subjects were of similar age, more likely to be female (p < 0.01), illiterate (p < 0.01), and less likely to come from a household with annual income of less than US

Clinical manifestations of optic pit maculopathy as demonstrated by spectral domain optical coherence tomography

789 (62% vs. 87%, p < 0.01). Familiarity with cataract surgery increased from 21.2% to 44.4% over the 5 years for male subjects (p < 0.01) and 15.8%–44.4% among females (p < 0.01). The proportion of respondents willing to pay at least 500 RMB for surgery increased from 67% to 88% (p < 0.01) among male subjects and from 50% to 91% (p < 0.01) among females. Conclusions: Five years of access to free cataract testing and low-cost surgery programmes appears to have improved the familiarity with cataract surgery and increased the willingness to pay at least 500 RMB (US

Optic nerve sheath fenestration for the treatment of papilledema secondary to cerebral venous thrombosis

65) for it in this rural population. Elderly women are now as likely as men to be willing to pay at least 500 RMB, reversing gender differences present 5 years ago.

Dry eye specific quality of life in veterans using glaucoma drops

Purpose:  To assess determinants of patients’ willingness to pay (WTP) for potential components of a multi‐tiered cataract surgical package offered by a non‐governmental organization (NGO) in rural China.