Peter Hersh

Sports-related Ocular Trauma

A prospective evaluation of all patients presenting with a sports-related ocular injury during a 1-year (4-season) period was conducted. Of the 202 patients evaluated, 28 (13.8%) required hospitalization and 11 (5.6%) required intraocular surgery. Twenty-six patients (12.8%) sustained permanent ocular sequelae including seven (3.5%) who suffered visual loss. Basketball accounted for 28.7%, baseball/softball 19.8%, and racquetball 11.4% of all injuries. At the time of injury, 5.1% of patients had worn protective eye wear, whereas on follow-up only 31% had used eye protection. These results indicate that sports trauma remains a significant cause of ocular morbidity.

Complications of subconjunctival 5-fluorouracil following glaucoma filtering surgery

The antimetabolite 5-fluorouracil (5-FU) has been used to inhibit fibroblastic growth to increase the success rate in glaucoma filtration surgery. Subconjunctival 5-FU can have adverse side effects. This paper describes two cases in detail of the ocular side effects of 5-FU. The first case is representative of the ocular surface problems. The second case deals with bleb leaks. Relative contraindications to 5-FU treatment are pre-existing ocular surface problems, early postoperative bleb leaks and fornix-based conjunctival flaps in filtering procedures. New drug delivery methods are presently being investigated to help decrease the adverse side effects and increase the efficacy of 5-FU.

Secondary hemorrhage in traumatic hyphema

We analyzed the records of 132 patients hospitalized between July 1986 and February 1989 for management of traumatic hyphema. The incidence of secondary hemorrhage was compared between patients treated with or without systemic administration of aminocaproic acid in addition to an otherwise identical protocol. Results among patients who were examined within one day of injury disclosed a 4.8% secondary hemorrhage rate in aminocaproic acid-treated patients (three of 63 patients) compared with a 5.4% rate in the patients not treated with aminocaproic acid (three of 56 patients, P = .31). All six patients sustaining secondary hemorrhage recovered visual acuities of 20/40 or better, with five of six patients achieving 20/20 visual acuities. A separate group of 13 patients who were examined more than one day after injury were found to have a secondary hemorrhage rate of 38.5% (five of 13 patients). Macular injury, not secondary hemorrhage, was most often responsible among those patients suffering permanent visual loss. In this study of a predominantly white population, patients had a relatively low incidence of secondary hemorrhage and did not demonstrate detectable benefit from aminocaproic acid administration. Because of the recognized side effects and cost of treatment, further analysis to determine which patients will benefit from treatment with aminocaproic acid is indicated.

Intraocular Pressure Increase Associated With Epsilon-Aminocaproic Acid Therapy for Traumatic Hyphema

We treated five patients receiving epsilon-aminocaproic acid who demonstrated sudden and accelerated clot dissolution with accompanying increases in intraocular pressure 24 to 96 hours after discontinuing treatment. All of these patients required additional ocular hypotensive medications and one patient required anterior chamber washout for persistently increased intraocular pressure. These findings suggest that certain patients with hyphema may be at risk for significant intraocular pressure increases following cessation of epsilon-aminocaproic acid therapy.

The Use of Glaucoma Shell Tamponade in Leaking Filtration Blebs

Our experience with the use of glaucoma shell tamponade for bleb leaks in six patients is described. All patients had posterior lip sclerectomies, with leaking blebs diagnosed intraoperatively (2 patients), early (2 patients) and late (2 patients) following surgery. The glaucoma shell works by applying a high resistance to excessive aqueous humor run-off through the leaking wound, and promotes conjunctival epithelial closure by approximating the wound edges. In all six cases the use of the glaucoma shell tamponade was fully effective. The leaks were sealed off and diffuse functioning filtering blebs were maintained, with very low intraocular pressure. We recommend the use of the glaucoma shell tamponade as the treatment of choice for bleb leaks prior to considering surgical repair.

Penetrating Keratoplasty and Anterior Segment Reconstruction for Severe Ocular Trauma

The principles for management of acute ocular trauma are also applicable to the subsequent reconstruction of the anterior segment. As with the primary repair of ocular trauma, meticulous anatomical restoration during reconstructive surgery minimizes secondary complications and enhances the visual prognosis. Anterior segment reconstruction may then involve procedures such as stripping of corneal pannus, removal of lens and vitreous remnants, iris and angle reconstruction, intraocular lens implantation, and penetrating keratoplasty. A total of 39 consecutive cases of severe ocular trauma, which had undergone penetrating keratoplasty and anterior segment reconstruction, were evaluated for visual outcome, graft survival, and secondary complications. Post-operatively, 49% of eyes achieved > 20/100 as compared with 10% before surgery, and 72% improved by at least two Snellen lines. In all, 31 (80%) initial keratoplasties remained clear, as did all 4 subsequently regrafted corneas, for an overall keratoplasty success rate of 90%. Elevated intraocular pressure occurred postoperatively in 18 eyes (46%), and among these, 10 of 13 eyes (77%) had preoperative glaucoma, whereas 8 of 26 (31%) did not (P < 0.015). Peripheral anterior synechiae could be anatomically corrected at surgery in 80% of cases (24 of 30 eyes). Thus, despite major trauma and a high prevalence of glaucoma, both the visual and the anatomical improvements were highly satisfactory and without severe complications.

U.S. Multicenter Clinical Trial of Corneal Collagen Crosslinking for Treatment of Corneal Ectasia after Refractive Surgery

PURPOSEnTo evaluate the safety and efficacy of corneal collagen crosslinking (CXL) for the treatment of corneal ectasia after laser refractive surgery.nnnDESIGNnProspective, randomized, multicenter, controlled clinical trial.nnnPARTICIPANTSnOne hundred seventy-nine subjects with corneal ectasia after previous refractive surgery.nnnMETHODSnThe treatment group underwent standard CXL, and the sham control group received riboflavin alone without removal of the epithelium.nnnMAIN OUTCOME MEASURESnThe primary efficacy criterion was the change over 1 year of topography-derived maximum keratometry (K), comparing treatment with control groups. Secondary outcomes evaluated were corrected distance visual acuity (CDVA), uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent, endothelial cell count, and adverse events.nnnRESULTSnIn the crosslinking treatment group, the maximum K value decreased by 0.7 diopters (D) from baseline to 1 year, whereas there was continued progression in the control group (1.3 D difference between treatment and control, P < 0.0001). In the treatment group, the maximum K value decreased by 2.0 D or more in 14 eyes (18%) and increased by 2.0 D or more in 3 eyes (4%). The CDVA improved by an average of 5.0 logarithm of the minimum angle of resolution (logMAR) letters. Twenty-three eyes (32%) gained and 3 eyes (4%) lost 10 or more logMAR letters. The UDVA improved 4.5 logMAR letters. Corneal haze was the most frequently reported crosslinking-related adverse finding.nnnCONCLUSIONSnCorneal collagen crosslinking was effective in improving the maximum K value, CDVA, and UDVA in eyes with corneal ectasia 1 year after treatment, with an excellent safety profile. CXL is the first approved procedure to diminish progression of this ectatic corneal process.

Penetrating keratoplasty for severe complications of radial keratotomy.

Severe sight-threatening complications were seen in five eyes of three patients following improperly performed radial keratotomy. All patients exhibited neovascularization of the incision sites, severe stromal scarring or ulceration involving the visual axis, loss of the anterior chamber, and iridocorneal adhesions. These complications necessitated multiple and complex surgical interventions, including penetrating keratoplasty and anterior segment reconstruction. Final visual acuity was decreased to light perception in four eyes while one eye achieved 6/60 vision following repeated penetrating keratoplasty. The success and safety of radial keratotomy rely on careful case selection, appropriate instrumentation, specialized training, and the ability to perform complex secondary procedures to correct surgical complications.