Steven B. Koenig

Visual acuity, refractive error, and endothelial cell density six months after Descemet stripping and automated endothelial keratoplasty (DSAEK).

Purpose: To evaluate visual acuity, refractive outcomes, and endothelial cell density 6 months after Descemet stripping and automated endothelial keratoplasty (DSAEK). Methods: We performed an institutional review board-approved prospective study of a surgical case series of 34 patients at 2 institutions undergoing DSAEK for Fuchs endothelial dystrophy, pseudophakic bullous keratopathy, or aphakic bullous keratopathy with or without simultaneous phacoemulsification and intraocular lens implantation. Clinical outcomes, including best spectacle-corrected visual acuity (BSCVA), spherical equivalent refraction, and refractive astigmatism and topographic or keratometric astigmatism, were assessed at the 6-month postoperative examination and compared with preoperative values with paired Student t tests. The change in endothelial cell density from the eye bank examination to 6 months after transplantation was similarly evaluated. Results: BSCVA averaged 20/99 preoperatively and 20/42 postoperatively (P < 0.0001). After DSAEK, 30 (88.2%) of 34 patients showed improved BSCVA, and 21 (61.8%) of the 34 patients achieved a BSCVA of 20/40 or better. For patients not undergoing simultaneous phacoemulsification and intraocular lens implantation, a hyperopic shift in refraction of 1.19 ± 1.32 D was noted. Refractive astigmatism, topographic astigmatism, and keratometry showed no statistically significant change. Endothelial cell density of donor corneas averaged 2826 ± 370 cells/mm2, whereas the mean postoperative density was 1396 ± 440 cells/mm2. This finding corresponded to an average loss of 1426 cells/mm2 (50% loss; P = 0.0001). The first half of cases experienced an average cell loss of 1674 cells/mm2 (59% loss) compared with 1181 (41% loss) in the second half of cases (P = 0.005). Three (9%) of 34 grafts experienced iatrogenic graft failure and required reoperation with new donor tissue. Also, 9 (27%) of 34 grafts experienced dislocation in the early postoperative period and required repositioning. Conclusions: In this prospective study of DSAEK for bullous keratopathy and Fuchs endothelial corneal dystrophy, improvement of visual acuity was achieved with only a mild tendency toward hyperopic shift and without significant induced astigmatism. Endothelial cell loss was significant, however, and may be related to surgical experience.

Herpetic Eye Disease Study: A Controlled Trial of Oral Acyclovir for Herpes Simplex Stromal Keratitis

PURPOSE To evaluate the efficacy of oral acyclovir in treating stromal keratitis caused by herpes simplex virus (HSV) in patients receiving concomitant topical corticosteroids and trifluridine. METHODS The authors performed a randomized, double-masked, placebo-controlled, multicenter trial in 104 patients with HSV stromal keratitis without accompanying HSV epithelial keratitis. Sample size was chosen so that a 5%, one-tailed test would have an 80% chance of detecting a doubling of the median time to treatment failure. Patients were randomized to receive a 10-week course of either oral acyclovir (400 mg 5 times daily, n = 51) or placebo (n = 53). All patients also received a standard regimen of topical prednisolone phosphate and trifluridine. Ophthalmologic examinations were performed weekly during the 10-week treatment period, every 2 weeks for an additional 6 weeks, and at 6 months after entry into the trial. RESULTS The median time to treatment failure (defined as worsening or no improvement of stromal keratitis or an adverse event) was 84 days (95% confidence interval, 69-93 days) for the acyclovir group and 62 days (95% confidence interval, 57-90 days) for the placebo group. By 16 weeks, 38 patients (75%) in the acyclovir group and 39 patients (74%) in the placebo group had failed treatment. Also by that time, the keratitis had resolved with trial medications, and there was no subsequent worsening in nine patients (18%) in the acyclovir group and ten (19%) in the placebo group. None of these results were significantly different between the two groups. However, visual acuity improved over 6 months in significantly more patients in the acyclovir group than in the placebo group. CONCLUSION There was no statistically or clinically significant beneficial effect of oral acyclovir in treating HSV stromal keratitis in patients receiving concomitant topical corticosteroids and trifluridine with regard to time to treatment failure, proportion of patients who failed treatment, proportion of patients whose keratitis resolved, time to resolution, or 6-month best-corrected visual acuity. Visual acuity improved over 6 months in more patients in the acyclovir group than in the placebo group.

Descemet stripping and automated endothelial keratoplasty (DSAEK) in eyes with failed penetrating keratoplasty.

Purpose: To report our results of using Descemet stripping and automated endothelial keratoplasty (DSAEK) in eyes with failed penetrating keratoplasty (PK). Methods: An institutional review board-approved, prospective, surgical case series of 7 eyes of 7 consecutive patients undergoing DSAEK for graft failure after 1 or more PKs at 1 academic eye center. Results: The mean follow-up period was 13.3 months (range, 9-18 months). One eye suffered recurrent donor graft dislocation and elected to undergo repeat PK instead of repeat DSAEK. Of the remaining 6 patients, the average preoperative visual acuity (VA) was 20/851 compared with a best-corrected visual acuity (BCVA) of 20/65 postoperatively (P = 0.008). After DSAEK, 6 (100%) eyes showed improved BCVA, and 4 of 6 eyes (67%) achieved a BCVA of 20/40 or better. All 6 grafts remained clear at the last follow-up visit. Two eyes showed graft dislocation on the first postoperative day and underwent repositioning of the lenticule with good results. Two other eyes were diagnosed with primary iatrogenic graft failure within 1 week of DSAEK and underwent repeat DSAEK with new donor tissue with good results. One eye experienced acute graft rejection that was successfully treated with topical steroids. Conclusions: This pilot series of DSAEK in eyes with graft failure from previous PK shows favorable VA and graft clarity outcomes. The complications observed were similar to those observed for DSAEK for Fuchs dystrophy and pseudophakic bullous keratopathy and include graft dislocation, iatrogenic graft failure, and homograft rejection.

Epikeratophakia—The Surgical Correction of Aphakia: Update 1981

Epikeratophakia grafts used to rehabilitate vision in adult monocular aphakic patients intolerate of contact lens correction or not candidates for IOLs were studied prospectively. Thirty-two patients who entered this study between its inception in February 1980 through February 1981 were followed for at least eight months. Patients with normal visual potential before surgery had average visual acuities with spectacle overcorrection of 20/50 at four months, 20/40 at eight months, and 20/30 at one year. Few long-term complications were seen. Empirical modification of the lathing process has decreased the undercorrection from the 5.5 diopters seen in the early patients to the 1.0 diopter seen in the more recent patients. Problems with predictability are related to the behavior of preserved corneal tissue during the lathing and the healing of these lamellar grafts. This procedure is intended for aphakic patients of whom IOL and contact lens correction is not possible.

Pseudophakia for traumatic cataracts in children.

Purpose: The purpose of this prospective study is to evaluate the postoperative visual acuity, refractive error, intraocular pressure, and status of the posterior capsule in children with traumatic cataracts who undergo extracapsular cataract extraction and insertion of a posterior chamber lens. Methods: Extracapsular cataract extraction and primary endocapsular fixation of a posterior chamber lens implant were performed in eight children (age range, 4–17 years) with unilateral traumatic cataracts. Results: There were no intraoperative complications, and seven of eight eyes achieved 20/40 or greater spectacle visual acuity during an average follow-up interval of 10 months (range, 5–20 months). The average postoperative spherical equivalent refractive error was +0.33 diopter (D) (range, −2.25 to +2.12 D); the average postoperative anisometropia was approximately 1 D (range, 0–2.25 D). In one patient, a coagulase-negative staphylococcal endophthalmitis developed 10 days after surgery. In three eyes that had opacified posterior capsules, YAG laser capsulotomy was performed. Conclusions: These preliminary results suggest that intraocular lens (IOL) implantation may be a safe and effective method of optical correction for children with traumatic cataracts.

Endophthalmitis After Penetrating Keratoplasty

Of 445 eyes (305 of which were aphakic) that underwent penetrating keratoplasty, 11 developed endophthalmitis, three immediately after surgery, two after subsequent secondary surgery, and six after late ulceration of the transplanted cornea. The diagnosis was based clinically on the loss of the red reflex and vitreous opacification, and was confirmed by culture of vitreous aspirate. All patients who developed endophthalmitis were aphakic and had received corticosteroids at the time of infection; most had undergone previous ocular surgery. These patients differed from those previously described with this condition because neither the donor tissue nor the storage medium was the source of infection. Treatment included intracameral, systemic, and topical administration of antibiotics. When the endophthalmitis originated from a corneal ulcer in a graft, the infected tissue was replaced with a new transplant. Despite treatment, the final visual outcomes were not good. One eye had a final visual acuity of 20/200 and one eye had a final visual acuity of 20/400. Three eyes had light perception and six eyes had no light perception. One eye was eventually enucleated.

On-lay lamellar keratoplasty for the treatment of keratoconus.

On-lay lamellar keratoplasty was performed in 29 patients who had keratoconus. Twelve patients (greater than 1 year follow-up) showed an average decrease in keratometry of 9.13 +/- 2.02 (mean +/- SE) D; 6 patients (6-11 months follow-up) showed an average of 10.15 +/- 2.88 D. Visual acuity continued to improve for about one year after surgery. Six patients with best visual acuities of 20/20 before surgery showed an average visual acuity of 20/29 +/- 11 (mean +/- SD) 4 months after surgery; 4 with more than a year of follow-up achieved an average of 20/26 +/- 9. Four patients with 20/40 preoperatively achieved an average of 20/63 +/- 33 four months after surgery; 3 with more than a year of follow-up showed an average of 20/38 +/- 13. All patients with successful grafts can now tolerate contact lenses for daily wear.

Candida keratitis after descemet stripping and automated endothelial keratoplasty.

Purpose: To report the donor-to-host transmission of Candida albicans after Descemet stripping and automated endothelial keratoplasty (DSAEK). Methods: An 80-year-old woman with pseudophakic bullous keratopathy developed an infiltrate in the donor corneal lenticule after DSAEK. Results: Donor corneoscleral rim cultures grew C. albicans. Gram stain of the removed corneal lenticule demonstrated budding yeast and pseudohyphae, and cultures yielded C. albicans. Despite topical and systemic antifungal therapy and therapeutic penetrating keratoplasty, the patient developed a blind painful eye and underwent enucleation. Conclusions: This case report indicates that fungal keratitis may occur from donor-to-host transmission after DSAEK. The location of the infected tissue poses diagnostic and therapeutic challenges for the surgeon.

Corneal Sensitivity after Epikeratophakia

Corneal sensitivity was tested in 60 eyes of 30 patients who underwent unilateral epikeratophakia for the correction of aphakia (20 patients) or keratoconus (10 patients). Postoperative recovery time ranged from 2 months to 21 months (mean: 10 months). Our results indicate a relative hypesthesia of the epikeratophakia lenticule when compared with the peripheral host cornea and contralateral control cornea. However, corneal sensitivity tested in 11 patients with more than 1 year follow-up was increased compared with the sensitivity of 19 patients whose postoperative recovery was less than 1 year. Histopathologic findings in two lenticules from a nonhuman primate demonstrated sparse epithelial axon terminals. Host corneal nerves appear to innervate the lenticules by intraepithelial extension and by penetration of the superficial keratectomy scar.

Optic Glioma Masquerading As Spasmus Nutans

An eight-month-old child who presented with signs of spasmus nutans subsequently developed obstructive hydrocephalus, bilateral optic atrophy, and loss of vision due to a juvenile pilocytic astrocytoma involving the optic nerves, chiasm, and anterior third ventricle. It appears that gliomas arising from this region may produce signs that imitate spasmus nutans.