Parveen K. Nagra

WOUND DEHISCENCE AFTER PENETRATING KERATOPLASTY

To assess the patient characteristics, risk factors, and outcomes of penetrating keratoplasty wound dehiscence. Methods: Retrospective chart review of 30 eyes of 29 patients with corneal grafts who underwent repair of penetrating keratoplasty wound dehiscence from January 1, 1998 to December 31, 2003, followed on the Cornea Service at Wills Eye Hospital. Results: The mean time from penetrating keratoplasty to wound dehiscence was 7.5 years (range 1 week to 31 years). The mean age at time of wound dehiscence was 66 years (range 28-98 years). One eye developed wound dehiscence following suture removal, whereas the remaining 29 eyes sustained trauma-induced dehiscences. Falls were the most common mechanism of trauma, especially in the elderly population. There was a wide range of visual outcomes in the 21 patients followed for 1 year, with 4 patients maintaining best corrected visual acuity between 20/20 and 20/40 and 5 patients with light perception vision at 1 year. There were no cases of endophthalmitis. Conclusions: Patients with corneal transplants have a life-long risk for wound dehiscence. This complication may be reduced by the regular use of eye protection in all corneal transplantation patients.

Cataract extraction following penetrating keratoplasty.

Objective: To assess the safety of cataract extraction following penetrating keratoplasty for corneal graft survival and to evaluate visual and refractive outcomes in corneal graft patients undergoing cataract extraction. Methods: Retrospective chart review of 29 eyes of 24 patients with corneal grafts who underwent cataract extraction from January 1, 1993 to December 31, 2002, followed on the Cornea Service at Wills Eye Hospital. Results: The mean time from penetrating keratoplasty to cataract extraction was 8.4 years (range 2 months to 36 years). Following cataract extraction, the corneal grafts remained clear in all but 1 eye (3%), during an average follow-up time of 44.5 months (range 3–118 months). All of the remaining patients benefited from improved visual acuity, with 15 of 28 patients having a postoperative best-corrected visual acuity of 20/30 or better. Patients also benefited from decreased absolute spherical refractive error, with a preoperative mean value of 6.6 ± 3.4 D compared with 2.4 ± 1.6 D postoperatively, while cylindrical refractive error remained relatively stable at 3.2 ± 2.9 D preoperatively and 2.8 ± 2.4 postoperatively. The patient who developed graft failure had 3 episodes of preoperative endothelial rejection and a clear corneal graft at the time of cataract surgery. Conclusions: Cataract surgery following penetrating keratoplasty is a safe and effective procedure, with a low but definite risk of corneal graft failure. In patients with clear grafts and visually significant cataracts, cataract extraction alone is preferred over repeat penetrating keratoplasty and cataract extraction.

Seasonal, geographic, and antimicrobial resistance patterns in microbial keratitis: 4-year experience in eastern Pennsylvania.

Purpose: The aim of this study was to review the demographics, causative organisms, seasonal and geographic variation, and antimicrobial resistance patterns of microbial keratitis at our institution over a 4-year period. Methods: Electronic medical records of all patients with microbial keratitis who underwent corneal culturing at a single institution in eastern Pennsylvania between January 1, 2009 and December 31, 2012 were reviewed. Results: A total of 311 patients representing 323 instances of infectious keratitis were analyzed. The most frequently implicated organisms in contact lens-related infections were Pseudomonas aeruginosa for bacteria and Fusarium species for fungus, compared with Staphylococcus aureus and Candida species in non–contact lens-associated bacterial infections. Bacterial keratitis occurred most frequently in spring and least frequently in winter (P = 0.024). Patients who live in large fringe metro (suburban) areas accounted for the highest proportion of infectious keratitis cases. P. aeruginosa and methicillin-sensitive S. aureus isolates were highly susceptible to fluoroquinolones, whereas 32% of coagulase-negative staphylococcus isolates tested were resistant to moxifloxacin and gatifloxacin, and all methicillin-resistant S. aureus organisms tested were resistant to these 2 fluoroquinolones. No organisms tested were resistant to tobramycin, gentamicin, or vancomycin. No fungal infections tested were resistant to voriconazole. Conclusions: Most infectious keratitis occurred in nonwinter months and in patients from suburban counties. Although fluoroquinolones were effective against the most common bacteria, staphylococcal species exhibited a high rate of resistance, representing a therapeutic challenge given the increasing use of fluoroquinolones as first-line monotherapy. No organisms tested were resistant to tobramycin, gentamicin, vancomycin, or voriconazole.

Lipemia retinalis associated with branch retinal vein occlusion.

PURPOSE To report a patient with a branch retinal vein occlusion associated with lipemia retinalis. DESIGN Observational case report. METHODS A 58-year-old woman presented with decreased vision and was found to have a branch retinal vein occlusion with massive lipid exudation in the setting of lipemia retinalis. Laboratory testing demonstrated an abnormal lipid profile with a markedly elevated triglyceride level. The setting was a retina service in a major referral center. RESULTS Management of the hypertriglyceridemia with medication, exercise, and dietary modification resolved the lipemia retinalis and was associated with improvement in visual function. CONCLUSIONS Although usually not visually significant, lipemia retinalis may be associated with vascular pathology, such as a branch retinal vein occlusion with marked exudative response and decreased visual acuity. Because of potential systemic and ocular complications of lipemia retinalis, these patients should be referred for management of their lipid disorder.

Long-term outcomes of penetrating keratoplasty and Descemet stripping endothelial keratoplasty for Fuchs endothelial dystrophy: fellow eye comparison.

Purpose: To compare the visual outcomes and complications after Descemet stripping endothelial keratoplasty (DSEK) and penetrating keratoplasty (PK) in the same set of patients. Methods: Fifteen patients underwent PK in 1 eye and DSEK in the fellow eye for Fuchs endothelial dystrophy at the Wills Eye Institute from 1993 to 2011. Results: Mean postoperative best-corrected visual acuity in the PK and DSEK groups (0.39 ± 0.39 and 0.23 ± 0.12 logarithm of the minimum angle of resolution, respectively) was statistically significantly better than mean preoperative best-corrected visual acuity (0.83 ± 0.36 and 0.76 ± 0.34 logarithm of the minimum angle of resolution, respectively) (P < 0.025 and P < 0.001, respectively). Mean manifest refraction cylinder was higher in the PK eyes than in the DSEK eyes at 1 year [3.58 ± 1.82 and 1.23 ± 1.63 diopter (D), respectively] and at 2 years of follow-up (3.57 ± 1.81 and 1.05 ± 1.18 D, respectively) (P < 0.001) but was not statistically different at the last visit (3.18 ± 2.67 and 1.5 ± 1.66 D, respectively) (P = 0.052). Mean postoperative follow-up was 101.9 ± 39.5 and 29.9 ± 19.9 months after PK and DSEK, respectively. Most common complications after PK were high astigmatism in 15 eyes, monocular diplopia in 7 eyes, posterior capsule opacity in 6 eyes, and secondary glaucoma and graft rejection episodes in 5 eyes each. After DSEK, secondary glaucoma in 3 eyes and graft rejection in 2 eyes were the most common complications. Conclusions: Final visual outcomes were not statistically different between the 2 procedures, but DSEK had early visual stabilization and PK had a more complicated course, with more astigmatism, rejections, suture-related infections, and graft failures.

Comparative evaluation of dual Scheimpflug imaging parameters in keratoconus, early keratoconus, and normal eyes

Purpose To determine the efficacy of various parameters measured by dual Scheimpflug imaging technology in differentiating eyes with keratoconus or early keratoconus from normal eyes. Setting Cornea Service, Wills Eye Institute, Philadelphia, Pennsylvania, USA. Design Comparative case series. Methods A retrospective evaluation was performed of the parameters provided by the Galilei dual Scheimpflug analyzer in keratoconus, early keratoconus, and normal eyes. Logistic regression and receiver operating characteristic curve analysis were used to compare the mean values and to calculate the sensitivity and specificity of these parameters. Results Many parameters were statistically significantly different between keratoconus and normal eyes compared with early keratoconus eyes (P < .05). Total cornea power‐steep and posterior curvature‐steep keratometry had the highest area under the curve (AUC) score (0.99) for differentiating keratoconus eyes from normal eyes. All anterior curvature parameters were statistically significant in differentiating keratoconus eyes from normal eyes, whereas only the anterior curvature‐steep was statistically significant in differentiating early keratoconus eyes from normal eyes. The central pachymetry and thinnest pachymetry were statistically significant in differentiating keratoconus and early keratoconus eyes from normal eyes. Third‐order root mean square (RMS) and total RMS had the highest AUC scores (0.83 and 0.82, respectively) for differentiating early keratoconus eyes from normal eyes. Conclusion Total corneal power, anterior curvature, posterior curvature, pachymetry, and corneal aberration data generated from the dual Scheimpflug analyzer showed promising results in differentiating keratoconus and early keratoconus eyes from normal eyes. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

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.

Corneal collagen cross-linking: ectasia and beyond.

Purpose of review Corneal collagen cross-linking has recently emerged as a novel approach for management of ectasia. This article reviews the literature published in the past 3 years about the expanding spectrum of cross-linking as a therapeutic modality and its complications. Recent findings Recent studies have confirmed the beneficial effects of cross-linking in stabilization and to a lesser extent, regression of keratoconus and postrefractive surgery ectasia. Other applications include cross-linking as a combined procedure with intracorneal ring segments, and photorefractive keratectomy for ectasia, corneal edema, and infectious keratitis. Animal studies of chemical cross-linking of sclera as a potential treatment for progressive myopia have also been performed. Various modifications of the technique to increase the safety profile of cross-linking have been reported, including the use of hypoosmolar riboflavin, transepithelial cross-linking, customized epithelial debridement, and higher fluence shorter duration ultraviolet A light exposure. Reported complications include keratitis, corneal haze, endothelial cell loss and failure of treatment. Summary Cross-linking has been shown to be an effective modality for corneal ectasia, the regression being less in patients with postrefractive ectasia than keratoconus. In a few studies, it has been found to be effective in symptomatic improvement of bullous keratopathy, and infectious keratitis but further studies are required. Cross-linking with epithelial debridement is found to be most effective but various modifications are being investigated for an improved, and better safety outcome.

Corneal changes in ectrodactyly–ectodermal dysplasia–cleft lip and palate syndrome: case series and literature review

The aim of this study is to describe the corneal changes in three unrelated patients with ectrodactyly–ectodermal dysplasia–cleft lip and palate (EEC) syndrome and review the literature on the possible etiology and clinical presentation of similar cases. Case 1 is an 18-year-old female with cleft lip and palate, syndactyly, and bilateral corneal pannus superiorly and inferiorly. She was initially diagnosed and treated as herpes simplex virus keratitis. Case 2 is a 3-year-old female born with cleft lip and palate, absent radial digits in both hands, and bilateral lacrimal stenosis. She developed progressive stromal scarring and neovascularization in both eyes. Her cornea perforated after developing infectious ulceration. Case 3 is a 49-year-old male with cleft palate, claw-hand deformities, absent meibomian glands and lacrimal duct, right ankyloblepharon, and a superior wedge-shaped opacity in the left cornea. The clinical findings demonstrated the different spectrum of keratopathy seen in patients with EEC. All patients were treated medically and without any surgical intervention. Limbal stem cell deficiency (LSCD) is presumed to be the cause in all three cases. Corneal changes in EEC can have variable presentation. LSCD seems to be the etiology of such keratopathy. Recurrent infection from lacrimal drainage obstruction and tear film instability are other risk factors for disease severity and progression.

Dry eye syndrome in aromatase inhibitor users.

Aromatase inhibitors are frequently used as an adjuvant therapy in the treatment of breast cancer. We observed that several patients taking aromatase inhibitors presented with severe dry eye symptoms, and we investigated whether there is a relationship between aromatase inhibitors and dry eyes in these patients.