Richard S. Koplin

Delayed-onset multifocal polymicrobial keratitis after laser in situ keratomileusis

We report a case of mixed Aspergillus fumigatus and coagulase-negative Staphylococcus stromal keratitis in a 43-year-old man who developed discomfort and swelling in his right eye 20 days after uneventful bilateral laser in situ keratomileusis (LASIK). Clinical examination revealed 2 distinct corneal infiltrates beneath the LASIK flap. Corneal scrapings were taken for microscopic examination and culture. Both infiltrates initially improved on topical antibiotic therapy, but over the next 18 days, 1 infiltrate worsened and repeat cultures were performed, which demonstrated A fumigatus. Natamycin 5% and amphotericin 0.1% were started and continued for 8 weeks with resolution of the infiltrate and return of the best corrected visual acuity. Delayed-onset multifocal keratitis is a rare complication of LASIK. Fungal entities should be considered in the differential diagnosis.

Serious ocular complications of cosmetic iris implants in 14 eyes.

PURPOSE: To report the presentation and subsequent management of a series of patients presenting with cosmetic iris implants. SETTING: New York Eye and Ear Infirmary, New York, New York, USA. DESIGN: Case series. METHODS: In this evaluation of patients with NewColorIris cosmetic iris implants, data collected included patient demographics, visual acuity, intraocular pressure (IOP), endothelial cell count, and slitlamp examination findings at presentation. Medical and surgical interventions and the postoperative course were recorded. RESULTS: Fourteen eyes of 7 patients (ages 22 to 60; 71% men) were identified. Nine eyes (64%) presented with decreased visual acuity, 7 (50%) had elevated IOP, 5 (36%) had corneal edema, and 5 (36%) had anterior uveitis. All 14 eyes had explantation of the iris prosthesis (range 4 to 33 months after placement). The minimum follow‐up after implant removal in all eyes was 2 months (range 2 to 28 months). Intraoperative complications included suprachoroidal hemorrhage during explantation in 1 eye. Postoperative complications included corneal edema (8 eyes), cataract (9 eyes), and increased IOP/glaucoma (7 eyes). Secondary surgeries included Descemet‐stripping automated endothelial keratoplasty (5 eyes), cataract extraction with intraocular lens placement (7 eyes), trabeculectomy (3 eyes), glaucoma drainage implant placement (3 eyes), and penetrating keratoplasty (1 eye). CONCLUSIONS: The cosmetic iris implants may result in severe ocular morbidity. Complications in our series included uveitis, glaucoma, corneal edema, and decreased visual acuity. Although explantation helped stabilize symptoms, additional medical and surgical intervention to control IOP and corneal decompensation was required in many cases. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Descemet stripping automated endothelial keratoplasty after failed penetrating keratoplasty.

Purpose: To report the rate of graft dislocation, surgical anatomic success, and postsurgical complications associated with Descemet stripping automated endothelial keratoplasty (DSAEK) after previous primary failed penetrating keratoplasty (PK). Methods: Institutional review board–approved, single-center, retrospective chart review study of 30 eyes of 30 patients with prior failed PK who underwent DSAEK with a minimum of 3 months follow-up. Primary outcomes measured included rates of anatomic success and failure, postoperative complications, lenticle size, visual acuity, intraocular pressure change, and a report of external factors that may affect success. Results: Thirty eyes of 30 patients were identified. The primary dislocation rate was 16.7%. Five primary DSAEKs detached; 1 was successfully rebubbled in the office, 2 had repeat successful DSAEKs, and 2 failed on a second attempt and had a subsequent PK. Despite successful anatomic attachment, 1 eye had primary graft failure, 3 that cleared initially failed within 6 months, and 1 that successfully cleared had subsequent graft rejection resulting in failure at 6 months. The 2 eyes requiring PK were excluded from the visual outcomes analysis, leaving 28 eyes with successfully attached lenticles. At 3 months postoperatively, of the 28 eyes, 19 showed an improvement in visual acuity, 6 had no change in vision from preoperative data, and 1 had worsening of vision (anatomic attachment but endothelial failure). Two of the 28 eyes had no data at that time point. Conclusions: DSAEK eyes after failed PK demonstrated improved vision with a low complication rate in a majority of patients. The graft dislocation rate and postoperative complications rates are comparable with the primary DSAEK dislocation rates in our own published series and in the literature.

The prevalence and pathogenicity of Propionibacterium acnes keratitis.

Purpose: To study the prevalence, pathogenicity, and virulence of Propionibacterium acnes keratitis. Methods: All cases of infectious keratitis submitted to the microbiologic laboratory of the New York Eye and Ear Infirmary between January 1, 2003, and April 6, 2006, were reviewed. Those cases in which P. acnes was recovered from culture were collected, and the medical records studied in depth. Results: Of 1555 cultures submitted to the microbiology laboratory, 1329 (85.5%) were positive for growth. One hundred twenty four (9.3%) of the 1329 cases yielded P. acnes in at least 1 culture medium. Seventy eight (62.9%) of 124 cases had not been pretreated with antibiotics before culture, and 66.7% of the nonpretreated ulcers were monomicrobial (P. acnes only). Fifty one (65.4%) of 78 cases of the nonpretreated corneal ulcers presented with a cellular reaction in anterior chamber, 12 (15.4%) with a hypopyon (6 were monomicrobial), 21 (26.9%) had stromal thinning (12 of which were monomicrobial), and 2 (2.6%) progressed to perforation (both polymicrobial). Corneal ulcers associated with P. acnes tended to be small (66.7%) and were widely distributed: central (n = 17, 21.8%), paracentral (n = 44, 56.4%), and peripheral (n = 17, 21.8%). The most common risk factors were contact lens wear and previous history of ocular surgery. Three of the 78 nonpretreated patients were unresponsive to medical treatment and required surgery for keratitis. Conclusion: This study provides evidence that P. acnes is a frequent cause of bacterial keratitis and may cause significant morbidity.

Chronic postoperative endophthalmitis from Staphylococcus aureus

ABSTRACT We recently treated a patient with chronic postoperative endophthahnitis caused by Staphylococcus aureus, which usually presents with a fulminant clinical course. Because of the chronic course, the initial treatment was high dose steroids followed by lensectomy and vitrectoiny. However, this was not effective, and intravitreal antibiotics and steroids were ultimately required. We now recommend that in patients with chronic postoperative inflammation unresponsive to high dose steroids, intraocular cultures followed by injection of intraocular antibiotics be considered.

Surgical Technique For Managing A Subluxed Posterior Chamber Lens Implant

To the Editor: The introduction and maturation of extracapsular surgical techniques in association with posterior chamber lens implantation has, by all accounts, decreased the incidence of intraocular lens (IOL) subluxation in cataract-implant surgery.1-6 The majority of subluxations appear to be related to unrecognized zonulysis7 or capsular tears at surgery and poor fixation of the lens haptics within the capsular bag or ciliary sulcus. 8 Malpositions of posterior chamber implants may also be associated with stiffJ-Ioop lenses9 and forces related to asymmetrical capsular fibrosis. Inferior subluxation of posterior cham ber implants is usually associated with inferior capsular tears or zonulysis (so called sunset syndromeIO); however, malpositioned lenses when associated with capsular fixation may be variably displaced in any direction. Techniques for stabilizing or repositioning IOLs include various suture fixation techniques to the iris and scleral lip. 4, 7,8,11,12,13,14 We report the repair of an unusual case of IOL subluxation influenced by a significant capsular tear and fibrosis within the remaining area of capsular fixation.

Endophthalmitis after descemet stripping endothelial keratoplasty with concave-oriented dislocation on slit-lamp optical coherence topography.

Purpose: To present the first reported case of Descemet membrane stripping endothelial keratoplasty (DSEK)-associated endophthalmitis with concave dislocation on slit-lamp optical coherence topography (SL-OCT). Methods: An 86-year-old man underwent DSEK for corneal decompensation secondary to prior surgery. On all postoperative visits, a slit-lamp examination and SL-OCT were performed. Results: On the first postoperative day, the lenticle was dislocated in a concave configuration as imaged with the SL-OCT. On the second postoperative day, the patient had eye pain, nausea, and increased intraocular pressure. On SL-OCT imaging, the concave configuration and fibrin stranding were imaged. With intraocular pressure lowering, the patients pain subsided, and he was scheduled for a lenticle refloat the following day. The next day, endophthalmitis was diagnosed secondary to exuberant purulent inflammation. At surgery, the lenticle was removed, cultures were obtained, and pars plana vitrectomy and intravitreal injections were administered. Intraoperative cultures were positive for heavy growth of Streptococcus pneumoniae. Conclusions: Endophthalmitis is a potential complication for any intraocular procedure including DSEK. SL-OCT imaging postoperatively may reveal concave lenticle configuration and subtle anterior chamber fibrin stranding may be early sign of endophthalmitis.

In situ nuclear disassembly: efficient phacoemulsification without nuclear rotation using lateral sweep sculpting and in situ cracking techniques.

We describe an in situ nuclear disassembly technique using a simplified form of sculpting and cracking, enhanced by phacoemulsification technology with a Kelman-style tip. The technique does not require mobilization or rotation of the nucleus within the capsular bag, and hydrodissection is optional. The technique requires a Kelman-style curved tip and Kuglen hook and takes advantage of the versatility of the curved phacoemulsification needle for sculpting and cracking. Since in situ nuclear disassembly requires no rotation of the nucleus for extraction, it is useful in cases in which zonules are compromised or the surgeon suspects posterior lenticonus and the potential for loss of integrity of the posterior capsule.

Removal of epithelial ingrowth via central perforating wound tract 6 years post LASIK.

Background: The purpose was to report a case of a novel approach for the removal of central interface epithelial ingrowth caused by a perforating corneal injury 6 years after laser-assisted in situ keratomileusis (LASIK). Methods: Access to a large central area of epithelial ingrowth under a LASIK flap was achieved through the wound tract from a perforating corneal injury. Suturing of the central LASIK flap in a similar manner commonly carried out peripherally was then performed to prevent recurrent epithelial ingrowth. Results: The offending epithelial ingrowth was removed with no recurrence over a 1-year follow-up. Conclusions: This is, to our knowledge, the first reported case of central epithelial ingrowth removal from a LASIK interface by a perforating injury wound tract.

Facilitating cortical aspiration after insertion of a capsular tension ring

&NA; We describe a simple, effective technique to prevent the cortical entrapment that can occur after a capsular tension ring (CTR) is implanted during phacoemulsification. Before the epinucleus has been removed, the blunt tip of an ophthalmic viscosurgical device (OVD) cannula is burrowed centrally in the cortical/epinuclear plate and OVD is injected as the cannula is advanced. The cannula is turned superiorly and dissection continued to the lens equator. The cleavage plane is extended for approximately 2 clock hours in the direction of the intended CTR insertion. The CTR is then inserted below the cortical/epinuclear plate. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.