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Purpose To compare the incidence of visually significant postoperative cystoid macular edema (CME) in pseudophakic eyes after Descemet membrane endothelial keratoplasty (DMEK) performed after recent versus remote cataract surgery. Methods A retrospective chart review was performed of all consecutive eyes that underwent DMEK without concurrent cataract surgery at the University of Iowa between October 2012 and December 2014. The DMEK procedures were classified as staged if performed between 2 weeks and 6 months after cataract surgery and solitary if performed more than 6 months after cataract surgery. Possible confounders, including a history of diabetes in the recipient, were tracked. Macular optical coherence tomography was performed to detect CME 1 month after DMEK if the best-corrected visual acuity was ≤20/30 with a clear cornea with no other reason for visual compromise. Results A total of 173 eyes from 140 patients were included in the statistical analysis. Staged DMEK was performed in 88 eyes (50.8%) and solitary DMEK in 85 eyes (49.2%). The incidence of CME was 8.0% (7 of 88 eyes) in the staged DMEK group and 7.1% (6 of 85 eyes) in the solitary DMEK group (P = 0.823). The incidence of CME did not differ significantly between the staged and solitary DMEK groups regardless of the recipient diabetic status. All cases of CME resolved within 6 months on topical therapy. Conclusions The incidence of postoperative CME after DMEK is similar in the setting of recent or remote cataract surgery.

To evaluate the outcome of the Boston type 1 keratoprosthesis (KPro-1) in eyes with iridocorneal endothelial syndromes and failed keratoplasties.A retrospective review was performed of every eye with a history of iridocorneal endothelial syndrome and a failed corneal transplant that was treated with a KPro-1 at a tertiary eye care center between January 1, 2008, and July 1, 2014. The main outcome measures were visual outcome, prosthesis retention, and postoperative complications.Four eyes met the inclusion criteria. Two eyes had essential iris atrophy and 2 eyes had Chandler syndrome. All 4 eyes had failed corneal transplants and successful glaucoma drainage devices. The mean patient age at the time of KPro-1 surgery was 68.3 years (range, 60-80 years). The mean postoperative follow-up duration was 47 months (range, 27-69 months). Preoperatively, the best-corrected visual acuity (BCVA) was worse than 20/200 in all 4 eyes, including 2 eyes that had hand motions vision. After KPro-1, all 4 eyes initially obtained a BCVA of ≥20/70. At the most recent examination, the BCVA was still ≥20/100 in 3 eyes. The KPro-1 device was retained in all 4 eyes. Postoperative complications included glaucoma progression (1 eye), a retroprosthetic membrane (1 eye), and sterile vitritis (1 eye).The Boston KPro-1 may offer a better prognosis than repeat traditional keratoplasty in reestablishing corneal clarity in eyes with iridocorneal endothelial syndromes. Despite anatomic success, visual rehabilitation may be compromised by preexisting glaucomatous optic neuropathy and its postoperative progression.

Purpose To compare corneal graft survival using tissue from diabetic and nondiabetic donors in patients undergoing initial Descemet stripping automated endothelial keratoplasty (DSAEK) or penetrating keratoplasty (PKP). Methods A retrospective chart review of pseudophakic eyes that underwent DSAEK or PKP was performed. The primary outcome measure was graft failure. Cox proportional hazard regression and Kaplan-Meier survival analyses were used to compare diabetic versus nondiabetic donor tissue for all keratoplasty cases. Results A total of 183 eyes (136 DSAEK, 47 PKP) were included in the statistical analysis. Among 24 procedures performed using diabetic donor tissue, there were 4 cases (16.7%) of graft failure (3 DSAEK, 1 PKP), and among 159 procedures performed using nondiabetic donor tissue, there were 18 cases (11.3%) of graft failure (12 DSAEK, 6 PKP). Cox proportional hazard ratio of graft failure for all cases comparing diabetic with nondiabetic donor tissue was 1.69, but this difference was not statistically significant (95% confidence interval, 0.56-5.06; P = 0.348). There were no significant differences in Kaplan-Meier curves comparing diabetic with nondiabetic donor tissue for all cases (P = 0.380). Statistical analysis of graft failure by donor diabetes status within each procedure type was not possible because of the small number of graft failure events involving diabetic tissue. Conclusions We found similar rates of graft failure in all keratoplasty cases when comparing tissue from diabetic and nondiabetic donors, but further investigation is needed to determine whether diabetic donor tissue results in different graft failure rates after DSAEK compared with PKP.

The aim of this study was to evaluate preparation outcomes of tissue prepared for Descemet membrane endothelial keratoplasty (DMEK) from diabetic and nondiabetic donors.In this nonrandomized, consecutive case series, DMEK grafts were prepared from diabetic and nondiabetic donors by experienced technicians in 2 eye banks using slightly different, modified submerged manual preparation techniques to achieve "prestripped" graft tissue. Graft preparation results were analyzed retrospectively. The main outcome measure was the rate of unsuccessful (failed) DMEK graft preparations, defined as tears through the graft area that prevent tissue use.A total of 359 corneas prepared from 290 donors (114 diabetic and 245 nondiabetic) were included in the statistical analysis of graft preparation failure. There were no significant differences between diabetic and nondiabetic donor tissue characteristics with respect to donor age, death to preservation time, death to preparation time, endothelial cell density, percent hexagonality, or coefficient of variation. DMEK tissue preparation was unsuccessful in 19 (5.3%) cases. There was a significant difference in the site-adjusted rate of DMEK preparation failure between diabetic [15.3%; 95% confidence interval (CI), 9.0-25.0] and nondiabetic donors (1.9%; 95% CI, 0.8-4.8), and the corresponding site-adjusted odds ratio of DMEK graft preparation failure in diabetic donor tissue versus nondiabetic donor tissue was 9.20 (95% CI, 2.89-29.32; P = 0.001).Diabetes may be a risk factor for unsuccessful preparation of donor tissue for DMEK. We recommend caution in the use of diabetic tissue for DMEK graft preparation. Further study is needed to identify what subset of diabetic donors is at risk for unsuccessful DMEK graft preparation.

To evaluate the outcome of the Boston type 1 keratoprosthesis (Kpro-1) in eyes with failed interventions for chemical and thermal injury.A retrospective review was performed of every eye with chemical or thermal injury that was treated with a Kpro-1 at a tertiary eye care center between January 1, 2008 and July 1, 2013. The main outcome measures were visual outcome, prosthesis retention, and postoperative complications.Nine eyes met the inclusion criteria, including 7 eyes with alkali burns, 1 eye with an acid burn, and 1 eye with a thermal burn. After a mean follow-up of 40.7 months (range, 29-60 months), the median best-corrected visual acuity was 20/60 (range, 20/15 to no light perception). One eye was ≥20/20, 3 eyes were ≥20/40, and 6 eyes were ≥20/70. The initial Kpro-1 prosthesis was retained in 7 (77.7%) eyes and successfully replaced in the other 2 eyes. One or more serious complications occurred in 6 (66.7%) eyes. These included 2 cases of sterile corneal ulceration with prosthesis extrusion, 2 cases of microbial keratitis (1 bacterial and 1 fungal), 2 cases of bacterial endophthalmitis, and 2 cases of retinal detachments. These complications contributed to visual outcomes of hand motions in 2 eyes and no light perception in 1 eye.The Boston Kpro-1 is associated with highly satisfactory visual outcomes and prosthesis retention in most cases of severe chemical or thermal injury. Serious complications are common and may compromise the final outcome.

Purpose The aim of this study was to evaluate and compare the outcomes of Boston keratoprosthesis type 1 (Kpro-1) in eyes with herpes simplex virus (HSV) and herpes zoster virus (HZV) keratopathy. Methods A retrospective review was performed of the medical records of every patient treated with a Boston Kpro-1 at the University of Iowa Hospitals and Clinics between January 1, 2008 and July 1, 2012. Eyes with visual loss due to HSV or HZV keratopathy were included in the statistical analysis. The main outcome measures were graft retention, postoperative complications, and visual outcome. Results Nine eyes met the inclusion criteria, including 5 eyes in the HSV group and 4 eyes in the HZV group. The graft retention rate was 100% in the HSV group after a mean follow-up of 48.4 months, compared with 25% in the HZV group after 50.5 months (P = 0.048). There were 3 cases of microbial keratitis, including 2 eyes that also developed endophthalmitis, in the HZV group, compared with no cases in the HSV group (P = 0.048). There was significantly better best-corrected visual acuity at the most recent examination in the HSV group than in the HZV group (P = 0.019). All 5 HSV eyes had improved best-corrected visual acuity compared with preoperative acuity, whereas only 1 HZV eye experienced a similar result (P = 0.048). Conclusions Kpro-1 is associated with an excellent prognosis for graft retention, acceptably low prevalence of sight-threatening complications, and highly satisfactory visual improvement in eyes with HSV keratopathy, but not in eyes with HZV keratopathy.

Purpose To evaluate the outcomes of medical and surgical management of fungal keratitis at a tertiary care eye center. Methods A retrospective review was performed of the medical records of all patients with a diagnosis of microbiologically or histopathologically confirmed fungal keratitis at the University of Iowa Hospitals and Clinics from July 1, 2001, through June 30, 2011. The main outcome measure was a microbiological cure with either medical therapy alone or medical therapy combined with therapeutic keratoplasty (TKP). The secondary outcome measures were graft survival of the TKPs and subsequent optical keratoplasties (OKPs) and visual outcome. Results Seventy-three eyes met the inclusion criteria. A microbiological cure was achieved in 72 eyes (98.6%). Forty-one eyes (56.2%) were treated with medical therapy alone, and 32 (43.8%) eyes required 1 TKP (29 eyes) or 2 TKPs (3 eyes). Among the 32 eyes treated with TKP, 17 (53.1%) maintained a clear graft. Among 15 eyes with failed grafts, 12 eyes ultimately achieved clear grafts after a total of 19 OKP procedures. Among 41 eyes treated with medical therapy alone, all 3 eyes treated with OKP remained clear. The final median best-corrected visual acuity was 20/30 in the medical therapy group and 20/40 in the TKP group. Conclusions A high microbiological cure rate can be achieved in eyes with fungal keratitis; however, TKP is often needed to achieve this objective. A good final visual outcome can be achieved in most cases, but multiple keratoplasty procedures may be required.

To evaluate the efficacy, refractive predictability and stability, and complications of photorefractive keratectomy (PRK) with adjunctive mitomycin C (MMC) in patients with postkeratoplasty anisometropia.A retrospective review was carried out of all cases of PRK performed for postkeratoplasty anisometropia with the VISX Star S4 excimer laser with MMC between January 1, 2004, and December 31, 2008. The main outcome measures were best spectacle-corrected distance visual acuity (CDVA) and patient tolerance of full spectacle refractive correction. Secondary outcome measures were uncorrected distance visual acuity (UDVA), refractive accuracy and stability, and complications.Twenty cases met the inclusion criteria. At 6 months, the spectacle CDVA had improved from a preoperative mean of 20/50 to 20/30 (P = 0.01). Ten eyes (50%) gained 2 or more lines of CDVA. Eighteen eyes (90%) had a CDVA of 20/40 or better. All 20 patients (100%) were subjectively satisfied with full binocular spectacle correction. There was an improvement in UDVA from a preoperative mean of 20/282 to 20/52 (P0.001). Thirteen patients (65%) had an UDVA of 20/40 or better. There was a reduction in the mean refractive spherical equivalent from -5.2 to -0.9 diopters (D), in myopia from -7.6 to -1.8 D, and in astigmatism from 4.9 to 2.0 D. No significant change in visual acuity or refractive error occurred between 3 and 12 months. No sight-threatening complications occurred. One eye (5%) lost 2 lines of CDVA.PRK with adjunctive MMC is an effective method of reducing postkeratoplasty anisometropia and providing satisfactory spectacle rehabilitation.

PURPOSE To determine the visual outcomes, device retention, and complications after Boston type 1 keratoprosthesis (KPro-1) device implantation. METHODS Comprehensive review of every case of KPro-1 implantation at a tertiary eye care center. RESULTS The initial KPro-1 procedure, performed in 75 eyes without a previous keratoprosthesis, was included in the analysis. During the first 6 postoperative months, improvement occurred in the mean preoperative best-corrected visual acuity of 20/1265 to a mean best-obtained postoperative visual acuity of 20/97 (P < 0.001). After a mean follow-up period of 41.4 months (range, 0.8-82.8 months), the final mean best-corrected visual acuity was 20/428. Improved vision was recorded in 43 eyes (57.3%), ambulatory vision (≥20/400) in 47 eyes (62.7%), intermediate functional vision (≥20/80) in 23 eyes (30.7%), and full functional vision (≥20/40) in 11 eyes (14.7%). The initial device was retained in 64 eyes (85.3%), with a Kaplan-Meier retention probability of 96% at 6 months and 82% at 5 years. One or more sight-threatening complications occurred in 51 eyes (68%). These included device extrusion in 11 eyes (14.7%), ulcerative keratitis in 12 eyes (16%), endophthalmitis in 7 eyes (9.3%), sterile vitritis in 3 eyes (4%), retroprosthetic membranes in 25 eyes (33.3%), maculopathy in 26 eyes (34.7%), retinal detachment in 9 eyes (12%), and progressive optic neuropathy in 7 eyes (9.3%). CONCLUSIONS Boston KPro-1 implantation is associated with satisfactory visual outcomes and excellent device retention in a majority of cases. However, serious postoperative complications are common and may compromise the final visual result.

Purpose To determine the prevalence and risk factors for escalation of glaucoma therapy after deep lamellar endothelial keratoplasty (DLEK). Methods Retrospective review of every case of DLEK performed at a tertiary care facility between December 1, 2003 and January 31, 2006. Results Eighty eyes met the inclusion criteria. Escalation of glaucoma therapy occurred in 13 eyes (16.3%) during a mean follow-up period of 27.1 months. Ten eyes required additional topical medical therapy, and 3 eyes required surgical intervention. Glaucoma therapy escalation was significantly associated with preexisting glaucoma (42.9% vs. 10.6%; P = 0.008). Conclusion Escalation of glaucoma therapy is not uncommon after DLEK, especially in eyes with preexisting glaucoma.

PURPOSE To evaluate the outcome of primary adult optical penetrating keratoplasty (PKP) in a Saudi Arabian population. PATIENTS AND METHODS A retrospective review was performed of the medical records of every Saudi Arabian patient 12 years of age or older who underwent PKP for keratoconus, corneal edema, stromal scarring, or stromal dystrophy at King Khaled Eye Specialist Hospital between January 1, 1997, and December 31, 2001, and for whom a minimum of 3 months of follow-up was available. RESULTS Of 910 eyes that met the inclusion criteria, there were 464 eyes with keratoconus, 188 eyes with corneal edema, 175 eyes with stromal scarring, and 83 eyes with stromal dystrophy. The 5-year survival probability was 96.1% for keratoconus, 71.1% for stromal scarring, 85.9% for stromal dystrophy, and 40.3% for corneal edema. The most significant risk factor affecting graft survival was surgical indication (P < 0.001). Among eyes with corneal edema, increasing donor age (P = 0.004) and the occurrence of one or more complications (P < 0.001) were significantly associated with an increased risk of graft failure. Overall, improvement in vision occurred in 750 (82.4%) eyes, remained the same in 97 (10.7%) eyes, and worsened in 63 (6.9%) eyes. CONCLUSION In the Saudi Arabian population, the prognosis for graft survival and improved visual acuity is excellent for eyes with keratoconus and stromal dystrophy, good for stromal scarring, and poor for eyes with corneal edema.

To report 2 cases of donor-to-host transmission of Candida albicans interface keratitis after Descemet stripping automated endothelial keratoplasty (DSAEK).We performed clinical and microbiologic examinations on 2 patients who underwent DSAEK for pseudophakic corneal edema.Two patients underwent uneventful DSAEK surgery using corneal tissue from the same donor. The donor corneoscleral rims were cultured at the time of surgery and both rims subsequently grew C. albicans and Candida glabrata. Approximately 5 weeks after surgery, infiltrates were noted in the DSAEK interface in both of these patients. Despite treatment with antifungal therapy, the Candida keratitis was unable to be controlled medically and required surgical intervention in each case, after which there was no recurrence of infection.Candida interface keratitis can occur after DSAEK. These 2 cases emphasize the importance of donor corneoscleral rim cultures, especially with the increase in lamellar and endothelial keratoplasty, which can make such interface infections more difficult to diagnose and treat. Patients with fungal positive donor corneal rim cultures should be prophylactically treated with antifungal therapy.

PURPOSE To evaluate the prevalence of postoperative complications and their impact on graft survival after primary adult optical penetrating keratoplasty (PKP). METHODS A retrospective review was done of consecutive cases of PKP performed between January 1, 1997, and December 31, 2001, for keratoconus, corneal edema, stromal scarring, and stromal dystrophy. RESULTS The inclusion criteria were met by 910 eyes, including 464 with keratoconus, 188 with corneal edema, 175 with stromal scarring, and 83 with stromal dystrophy. One or more complications occurred in 362 eyes (39.8%). The most common complication was endothelial rejection (17.3%), followed by glaucoma worsening (15.5%), bacterial keratitis (5.8%), persistent epithelial defects (3.4%), and wound dehiscence (1.6%). There were significant differences among the surgical groups in overall prevalence of complications (P < 0.001) and with the prevalence of endothelial rejection (P = 0.01), glaucoma worsening (P < 0.001), bacterial keratitis (P = 0.04), and persistent epithelial defects (P = 0.02). Complication-associated graft failure varied significantly among the surgical groups (P = 0.02). CONCLUSION The prevalence of post-PKP complications and their impact on graft survival vary significantly among surgical indications for primary adult optical PKP.

Purpose The purpose of this study was to evaluate graft survival, postoperative complications, and visual outcome after penetrating keratoplasty (PKP) for keratoconus (KC) in eyes with or without a history of vernal keratoconjunctivitis (VKC). Methods A retrospective review was conducted on all cases of PKP performed at King Khaled Eye Specialist Hospital between January 1, 1997, and December 31, 2001, for KC. Results Four hundred sixty-four eyes were included in the study, including 80 (17.2%) eyes with VKC and 384 (82.8%) without VKC. Five-year graft survival was 97.3% and 95.5% in eyes with or without VKC, respectively. There were no statistically significant differences in Kaplan-Meier graft survival between the 2 groups at any time interval. There were no statistically significant differences in the percentage of eyes experiencing postoperative complications in eyes with or without VKC (27.5% vs 31.8%, respectively; P = 0.50). However, late-onset persistent epithelial defects were significantly more likely to occur in eyes with VKC (6.3% vs 1.8%; P = 0.04). There were no significant differences in the prevalence of endothelial rejection, bacterial keratitis, glaucoma, wound dehiscence, early-onset persistent epithelial defects, or secondary cataract. The median final best-corrected visual acuity was 20/30 in both groups. The percentage of eyes with a final best-corrected visual acuity of 20/40 or better was 76.2% in eyes with VKC and 71.9% in eyes without VKC (P = 0.49). Conclusions Graft survival, postoperative complications, and visual outcome are comparable after PKP for KC in eyes with or without VKC.

PURPOSE To compare central corneal endothelium cell density and morphology in eyes with keratoconus and unilateral resolved hydrops with the unaffected fellow eye. METHODS Bilateral confocal microscopy was performed 3 months after resolution of acute unilateral hydrops in patients with keratoconus who presented to the King Khaled Eye Specialist Hospital between February 1, 2004, and November 31, 2005. RESULTS Twenty-six patients (19 men and 7 women) with a mean age of 22 years (range, 11-36 years) were enrolled in the study. A history of ocular allergy or rigid gas-permeable hard contact lens wear was present in 14 and 12 patients, respectively. The mean interval to resolution of hydrops was 12 weeks (range, 9-14 weeks), after which neovascularization was present in 8 eyes. The mean endothelial cell density in affected and unaffected eyes was virtually identical (2759 vs. 2788 cells/mm2, respectively; P = 0.82), although 5 (19.2%) affected eyes did have endothelial cell density that was >15% less than that of the unaffected fellow eye. Compared with unaffected eyes, there was a mean increase polymegathism in affected eyes from 33% to 35% and a mean decrease in hexagonality from 60% to 55%, but these differences were not statistically significant (P = 0.11 and 0.06, respectively). CONCLUSIONS Decreased endothelial cell density is uncommon after resolution of acute hydrops, although morphologic changes may be present in a majority of cases.

To describe the clinical course of a patient requiring ophthalmic care for entropion and fungal keratitis in the setting of undiagnosed enophthalmos after previous ventriculoperitoneal shunting consistent with silent brain syndrome.Case report.A 33-year-old man who had a history of ventriculoperitoneal shunting for an encephalocele during infancy presented because of ocular irritation and entropion, which was presumed to be entirely due to a chemical injury he had sustained 2 years before. He underwent 2 upper eyelid entropion repairs and developed fungal aspergilloma keratitis in the postoperative period. He underwent 2 penetrating keratoplasties and a limbal stem cell transplant but had complications with reinfection of the graft, eventually leading to a prephthisical painful eye. During enucleation, an aspergilloma was found within an enlarged superior fornix. Computed tomographic scan revealed severe enophthalmos with air between the lids and the globe, which was consistent with silent brain syndrome.In patients with silent brain syndrome, the lack of apposition between the eyelids and the globe results in entropion, trichiasis, lagophthalmos, and ocular irritation. This can complicate entropion repair and the severity of infectious keratitis. We also propose that the enlarged fornices seen in silent brain syndrome can also serve as a reservoir for infection, similar to the pathogenesis seen in the giant fornix syndrome.

Purpose The aim of this study was to evaluate the outcome of pretreatment of Acanthamoeba keratitis with intravenous pentamidine (IVP) before therapeutic keratoplasty (TKP). Methods A retrospective chart review was performed of the medical records of every patient treated with IVP before TKP for Acanthamoeba keratitis at a single, tertiary care eye center between January 1, 2002, and December 31, 2012. The main outcome measures were microbiological cure, graft survival, and visual outcome. Results Eight eyes of 7 patients met the inclusion criteria. Preoperatively, all 8 eyes had failed traditional antiamoebic therapy, including 5 eyes with recurrent infections after previous TKP. The patients were treated with IVP (190-400 mg/d) for a median of 14 days (range, 7-26 days). After 8 TKP, a microbiological cure was achieved, and a clear graft was maintained in 5 (62.5%) eyes during a mean follow-up interval of 31.2 months (range, 1.0-95.7 months). Repeat TKP in 3 eyes with recurrent Acanthamoeba keratitis resulted in 2 additional microbiological cures and 1 more clear graft. The final best-corrected visual acuity was ≥20/40 in 5 (62.5%) eyes and worse than 20/200 in 3 eyes. Overall, the final vision was improved in 6 (75.0%) eyes, remained the same in 1 (12.5%) eye, and was worse in 1 (12.5%) eye. Conclusions The adjunctive use of IVP before TKP may assist with the achievement of microbiological cure, clear graft, and good visual outcome in a majority of eyes with Acanthamoeba keratitis.

PURPOSE The aim of this study was to assess and compare the association of glaucoma therapy with graft survival after performing penetrating keratoplasty (PKP) and Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS A retrospective chart review was performed of cases: primary PKP from January 1, 2003, to December 31, 2005, or primary DSAEK from January 1, 2006, to December 31, 2008. Eyes with a surgical indication of pseudophakic corneal edema were included in the statistical analysis. Eyes were stratified by glaucoma treatment into those with (1) no glaucoma treatment, (2) medical therapy only, or (3) surgical intervention. The main outcome measure was graft survival. RESULTS Fifty-seven PKP-operated and 156 DSAEK-operated eyes met the inclusion criteria. After PKP and DSAEK, respectively, the 5-year Kaplan-Meier graft survival was 94.7% and 93.8% in eyes with no glaucoma treatment (P > 0.99), 93.8% and 96.3% in eyes with medical therapy only (P > 0.99), and 56.8% and 50% in eyes with surgical intervention (P > 0.99). After both procedures were performed, graft survival was significantly worse in eyes with surgical intervention compared with that in eyes with no glaucoma treatment (P < 0.0001) or in eyes with medical therapy alone (P < 0.0001). CONCLUSIONS PKP and DSAEK have comparable graft survival in eyes without glaucoma management and in those with comparable glaucoma management.

PURPOSE To report a case of bilateral herpes simplex keratitis with unilateral secondary bacterial keratitis resulting in corneal perforation in a patient with pityriasis rubra pilaris. METHODS Case report. RESULTS A 77-year-old female with pityriasis rubra pilaris was referred for a perforated corneal ulcer of the left eye. Cultures were positive in both eyes for Herpes simplex and in the left eye for Pseudomonas fluorescens and Staphylococcus aureus A microbiological cure was obtained with a combination of tectonic keratoplasty, fortified topical antibiotics, and systemic acyclovir. CONCLUSIONS Pityriasis rubra pilaris is a rare, inflammatory dermatologic disease that may predispose patients to bilateral Herpes simplex keratitis, secondary bacterial superinfection, and a tendency toward rapid stromal ulceration with risk of perforation.

PURPOSE To report the outcomes of Boston keratoprosthesis (K-pro) type I implantation for congenital aniridia. METHODS A retrospective review of the medical records of every patient with congenital aniridia who underwent Boston K-pro type I implantation at the University of Iowa Hospitals and Clinics from January 1, 2009, through December 31, 2011 was performed. The main outcome measures were visual acuity, graft retention, and postoperative complications. RESULTS A total of 7 eyes (7 patients) met the inclusion criteria. The mean patient age was 52 years (range, 12-85 years). The preoperative visual acuity was 20/1600 in 6 eyes (85.7%) and hand motions in 1 eye (14.3%). After a median follow-up period of 18 months (range, 3-30 months), the median final best spectacle-corrected visual acuity was 20/200 (range, 20/100 to light perception). This included 2 eyes (28.6%) that were 20/100 and 5 eyes (71.4%) that were better than 20/300. Compared with the preoperative best spectacle-corrected visual acuity, the final vision was improved in 6 eyes (85.7%) and worse in 1 eye (14.3%). The K-pro graft was retained in all 7 eyes (100%). The most common complication was the formation of a retroprosthetic membrane in 3 eyes (42.9%), none of which required either a YAG capsulotomy or a vitrectomy. One eye (14.3%) developed a wound dehiscence that required surgical repair. CONCLUSIONS The Boston K-pro type I is a good option for the visual rehabilitation of eyes with congenital aniridia.

PURPOSE To determine if the lamellar cut of donor tissue for endothelial keratoplasty (EK) by an eye bank facility is associated with a change in the prevalence of positive bacterial or fungal donor rim cultures after corneal transplantation. METHODS A retrospective review was conducted of bacterial and fungal cultures of donor rims used for corneal transplantation at a tertiary eye care center from January 1, 2003, to December 31, 2008, with tissue provided by a single eye bank. The cases were divided into 2 groups. Group 1 ("no-cut") included keratoplasty procedures in which a lamellar cut was not performed. Group 2 ("precut") included EK procedures in which a 4-hour period of prewarming of tissue followed by a lamellar cut was performed in the eye bank before tissue delivery to the operating surgeon. RESULTS There were 351 donor rim cultures in group 1 and 278 in group 2. Bacterial cultures were positive in 30 donor rims (8.5%) in group 1 and 13 (4.7%) in group 2 (P = 0.058). Positive bacterial cultures were not associated with any postoperative infections. Fungal cultures were positive in 8 donor rims (2.3%) in group 1 and 7 (2.5%) in group 2 (P = 1.0). Positive fungal cultures were associated with 2 cases (13.3%) of postoperative fungal infections. CONCLUSIONS Corneal donor tissue can be precut for EK by trained eye bank personnel without an increased risk of bacterial or fungal contamination.

PURPOSE To report a family with aggressive, early-onset pterygium. METHODS We examined all living relatives (with one exception) of a Saudi Arabian family and found three members with pterygium (onset occurred when the patients were at early 20s, 6, and 4 years of age). RESULTS Multiple attempts at surgical removal, even in conjunction with application of topical mitomycin C and use of conjunctival autograft, failed to prevent recurrent pterygium, which advanced across the visual axis and produced profound visual disability in the three cases. CONCLUSION Contrary to previously published reports of familial pterygium, two of the three cases had childhood age at onset and all three had an aggressive clinical course after the onset of recurrent pterygium after surgical resection; genetic identification may be beneficial.

To report the rate of graft dislocation in patients who underwent Descemet stripping automated endothelial keratoplasty (DSAEK) after a previous penetrating keratoplasty (PKP).Institutional review board-approved, multicenter, retrospective chart review. Inclusion criteria included: prior failed PKP and subsequent DSAEK. The primary outcomes measured in this study were the presence of a graft dislocation, rate of rebubble, and graft attachment. Additional variables included: presence of a prior glaucoma drainage device, graft-to-host size disparity, number of sutures remaining in PKP, and stripping of the Descemet membrane at the time of DSAEK surgery.Ninety patients (97 eyes) were included in the study. In 31% (30 of 97), the endothelial graft dislocated after surgery. All 30 cases required a rebubble except 1, which reattached spontaneously. Ninety-eight percent (95 of 97) of all grafts remained attached for the duration of the follow-up period. Only 2 eyes (2.2%) required repeat graft. Endothelial grafts dislocated in 67% of patients with glaucoma draining devices. The dislocation rate for grafts larger than the host was 12 of 49 (24%), equal to the host was 3 of 17 (18%), and smaller than the host was 8 of 19 (42%). Dislocations occurred in 5 of 21 (24%) of grafts with sutures remaining and 22 of 76 (29%) of those with all sutures out. Five of 12 (42%) cases of grafts performed without stripping the Descemet had dislocations.The graft dislocation rate in DSAEK procedures after PKP is comparable to that after primary DSAEK cases. Donor grafts that are smaller than the host PKP and the presence of prior glaucoma drainage devices are risk factors for higher rates of graft dislocation.

To determine the prevalence and risk factors for the development of visually significant cataracts after phakic Descemet stripping automated endothelial keratoplasty (DSAEK) and the impact of this complication on the final outcome.A retrospective case review was conducted of 12 consecutive eyes with corneal decompensation secondary to Fuchs endothelial dystrophy that had been treated with DSAEK without concomitant removal of the crystalline lens from January 1, 2005 to July 1, 2007 at the University of Iowa Hospitals and Clinics. Eyes in which a minimum follow-up period of 12 months was available were included in the statistical analysis.Of the 10 eyes that met the inclusion criteria, visually significant cataracts occurred in 4 eyes (40%) in the first postoperative year and required surgical intervention. A significant difference in the mean anterior chamber depth was detected between eyes that developed cataracts and those that did not (P = 0.005). In 3 eyes, cataract development was associated with a preoperative anterior chamber depth of less than 2.80 mm. All 3 of these eyes developed pupillary block with markedly elevated intraocular pressure during the first 24 postoperative hours. After 24 months, the 6 eyes that did not develop cataracts had a mean best spectacle-corrected visual acuity of 20/24. Among the 4 eyes that required cataract surgery, the mean best spectacle-corrected visual acuity was 20/35. One eye had developed endothelial graft failure and required repeat DSAEK.The development of cataracts is common after phakic DSAEK and may be associated with considerable ocular morbidity.

PURPOSE To compare the outcome of bifold forceps and cartridge injector suture pull-through insertion techniques for Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS A retrospective review was conducted of the medical records of all patients treated with DSAEK at the University of Iowa Hospitals and Clinics from January 1, 2005 to July 1, 2007. The main outcome measures (endothelial cell loss, graft survival, and visual acuity) were evaluated postoperatively at 1, 3, 6, 12, and 24 months. RESULTS Of 179 DSAEK procedures carried out during the study period, the bifold forceps insertion technique was used in 143 cases and the cartridge injector suture pull-through insertion technique was performed in 36 cases. The mean follow-up was 17.4 ± 9.5 months and 19.1 ± 11.0 months for the 2 groups, respectively. No significant differences were detected in postoperative complications, endothelial cell loss, visual acuity, or graft survival between the 2 groups. At 12 months postoperatively, the forceps and pull-through insertion groups had a mean endothelial cell loss of 42.5% ± 23.0% and 51.4% ± 26.1%, respectively. After 1 postoperative year, the mean logarithm of the minimum angle of resolution vision values were 0.171 ± 0.015 (Snellen equivalent = 20/30) in the forceps group and 0.253 ± 0.039 (Snellen equivalent = 20/36) in the pull-through group. At the most recent examination, 136 (95.1%) forceps insertion and 35 (97.2%) pull-through insertion grafts were clear. CONCLUSIONS Bifold forceps and suture pull-through insertion techniques are associated with similar surgical outcomes after DSAEK.

To analyze the outcome of excisional biopsy of ocular surface (conjunctival and corneal) squamous cell intraepithelial (in situ) neoplasia with and without the adjunctive use of intraoperative and postoperative mitomycin C.A retrospective case review was conducted on 34 consecutive patients with histopathologically proven ocular surface squamous cell intraepithelial neoplasia who were treated from January 1, 1980, to December 31, 2008, at University of Iowa Hospitals and Clinics. Eyes in which a minimum follow-up period of 3 months was available were included in the statistical analysis.Of 34 eyes, 32 met the inclusion criteria. Adjunctive therapy was provided with mitomycin C in 17 eyes, including 13 that had only postoperative treatment and 4 that had only intraoperative treatment. The adjunctive use of mitomycin C was associated with a significantly reduced prevalence of recurrence (5.9% vs. 66.7%; P = 0.0005). When the surgical margins were positive, the use of adjunctive mitomycin C was associated with a reduced prevalence of tumor recurrence (12.5% vs. 55.6%), but this difference was not statistically significant (P = 0.13). When surgical margins were negative, the adjunctive use of mitomycin C was significantly associated with a reduced prevalence of recurrence (0% vs. 83.3%; P = 0.002).The adjunctive use of mitomycin C is significantly associated with a reduction in the prevalence of postoperative recurrences of ocular surface squamous cell intraepithelial neoplasia and should be considered as an adjunctive therapy even when surgical margins are negative.

PURPOSE: To evaluate graft survival and visual outcome after penetrating keratoplasty (PKP) for trachomatous corneal scarring. METHODS: A retrospective review was conducted on all cases of PKP performed at King Khaled Eye Specialist Hospital between January 1, 1997, and December 31, 2001, for trachomatous corneal scarring. RESULTS: This study included 127 eyes. The mean age at the time of surgery was 64.7 years (range, 40-90 years). The mean follow-up was 1266 days (range, 91-3423 days). At the most recent visit, 102 (80.2%) grafts were clear, and 25 (19.7%) had failed. Kaplan-Meier graft survival was 98.3% at 1 year, 85.9% at 2 years, 83.2% at 3 years, 80.2% at 4 years, and 76.6% at 5 years. Major postoperative complications included worsening of glaucoma (27.6%), endothelial rejection (17.3%), and bacterial keratitis (8.7%). Visual acuity improved in 107 (84.3%) eyes, remained the same in 12 (9.5%) eyes, and worsened in 8 (6.3%) eyes. Final visual acuity of 20/160 or better was obtained in 67 (56.7%) eyes. CONCLUSIONS: Treating trachomatous corneal scarring with PKP can be associated with a good prognosis for graft survival and improved vision in carefully selected cases with mild or well-controlled ocular surface disease and absent or previously surgically corrected eyelid abnormalities.

Purpose To describe the confocal microscopic findings in subepithelial infiltrates associated with epidemic keratoconjunctivitis (EKC). Methods Observational case report. Results A 14-year-old Saudi girl with keratoconus developed subepithelial infiltrates (SEIs) after the onset of bilateral EKC. Confocal microscopy of the left cornea 8 weeks after the onset of EKC showed many highly reflective dendritic cells at the level of basal epithelium, epithelial basement membrane zone, and anterior stroma, as well as many highly reflective fusiform and round cells within the anterior stroma, with deceasing density in progressively deeper layers of the stroma. These findings were not present on confocal microscopy that had been performed 2 weeks before the onset of EKC. Conclusion Confocal microscopic examination of SEIs after EKC provides evidence of an inflammatory response localized to the basal epithelium and anterior stroma of the central cornea.

Purpose: To characterize the clinical characteristics and surgical outcomes for Salzmann's nodular corneal degeneration (SNCD). Methods: In this retrospective, noncomparative, observational case series, all patients codedwith a diagnosis of SNCD between January 1, 1996, and April 30, 2002 were included. Cases whose clinical description did not match the classic description of this disorder were excluded. Clinical characteristics, surgical procedures, and qualitative outcomes were recorded. Results: Among 103 patients diagnosed with SNCD, 93 (152 eyes) met inclusion criteria. Eighty-three patients (89.2%) were women (P < 0.00001), and 59 patients (63.4%) had bilateral disease. A normal age distribution was noted, with a mean age of 54.3 years (median, 53 years; standard deviation = 16.9). Meibomian gland dysfunction was noted in 51 patients (54.8%), contact lens wear in 31 patients (33.3%), peripheral vascularization in 29 patients (31.2%), pterygium in 15 patients (16.1%), keratoconjunctivitis sicca in 9 patients (9.7%), and exposure keratitis in 4 patients (4.3%). Forty-nine eyes (32.2%) of 37 patients (39.8%) required a total of 62 surgical procedures. Impaired vision led to 53 (85.5%) of these procedures and resulted in improved vision in 42 (79.2%) of these cases. Seven eyes (4.6%) underwent surgical intervention for subjective discomfort or contact lens intolerance, and all had improved symptoms at last follow-up. Conclusions: SNCD appears to be a disorder that occurs predominantly in middle-aged women and may be associated with chronic ocular surface inflammation and/or irritation. It is important to diagnose properly because of the good prognosis with medical and surgical therapy.

OBJECTIVE To demonstrate the potential value of obtaining routine fungal cultures of donor rims at the time of corneal transplantation and instituting prophylactic therapy in culture-positive cases, even in the absence of clinical evidence of established microbial keratitis or endophthalmitis. METHODS Interventional case report and literature review. RESULTS A 69-year-old Saudi man underwent penetrating keratoplasty with donor tissue that was culture-positive for Candida glabrata. The postoperative course was complicated by slight override of the graft associated with an associated epithelial defect, but there was no evidence of microbial keratitis or significant anterior chamber inflammation. Following repair of the graft override on postoperative day 42, the epithelial defect healed. The subsequent clinical course was unremarkable until postoperative day 146, when a deep stromal infiltrate was present at the graft-host junction, associated with a dense endothelial plaque. Cultures of the anterior chamber were positive for Candida glabrata. Treatment with topical and intracameral amphotericin B and systemic fluconazole, along with topical corticosteroids and intracameral t-PA, was successful in eradicating the corneal infiltrate and resolving intraocular inflammation. Four months after treatment was initiated, there was no evidence of recurrent fungal keratitis or endophthalmitis. CONCLUSION This case provides support for the practice of obtaining routine fungal cultures of donor rims at the time of corneal transplantation and for the implementation of prophylactic antifungal therapy in culture-positive cases.

PURPOSE To evaluate the outcome of corneal transplants performed with donor corneas that had been stored for prolonged (>168 hours) periods of time in Optisol-GS storage media. METHODS A retrospective review was performed of the medical records of every patient who underwent corneal transplantation between January 1, 1999 and December 31, 1999 utilizing donor tissue that had been in Optisol-GS storage medium for more than 168 hours. RESULTS Two hundred thirty-four corneal transplants met the inclusion criteria. The mean duration of follow-up was 33.7 +/- 14.7 months (range 2 to 56 months). The mean Optisol-GS storage time was 237.1 +/- 41.6 hours (range 168 to 348 hours). The overall graft survival rate was 78.6%, ranging from a high of 100% for keratoconus to a low of 42.9% for therapeutic grafts. The likelihood of graft survival, of achieving a visual outcome of 20/40 or better, or of suffering a visual outcome of 20/200 or worse, was not statistically significantly affected by progressively longer periods of donor storage time for the entire study population or for any recipient diagnosis. There were no cases of primary graft failure or early (

Purpose: To demonstrate the development of presumed immune-mediated stromal rejection after deep anterior lamellar keratoplasty and its reversal after initiation of intensive topical corticosteroid therapy. Methods: Observational case report carried out with the approval of the hospital institutional review board. Results: Stromal edema and peripheral vascularization developed 16 months after deep anterior lamellar keratoplasty for keratoconus in a 13-year-old girl. After 2 weeks of intensive topical corticosteroids, complete reversal of stromal edema and regression of peripheral vascularization occurred, with full recovery of visual function. Conclusion: The clinical appearance and response to therapy in this case support the diagnosis of immune-mediated stromal rejection. Ophthalmologists should be aware that sight-threatening stromal rejection may occur in lamellar corneal grafts.

To identify changing indications for keratoplasty over the last 20 years at a tertiary care eye hospital in a country with rapidly evolving ophthalmic care services.A retrospective review was performed of the eye bank records of every patient who received a lamellar or penetrating keratoplasty at the King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia, between January 1, 1983 and December 31, 2002. For each case, the primary surgical indication was identified.A total of 8318 corneal transplants were performed during this 20-year period. In the first 5 years of the study, the leading indications for corneal transplantation were corneal scarring (52.0%), aphakic/pseudophakic bullous keratopathy (13.5%), corneal degeneration (10.0%), and keratoconus (7.6%). During the last 5 years of the study, the leading indications for corneal transplantation were keratoconus (40.2%), corneal scarring (19.8%), failed corneal transplant (11.3%), and corneal ulceration (10.2%). There was a dramatic increase in the number of transplants performed for keratoconus (441%) and failed corneal transplants (285%) as well as a dramatic decrease in the number of transplants performed for corneal degeneration (-88%) and scarring (-60%) between the first and last 5 years of the study period.Major changes in the indications for corneal transplantation were related to the introduction and expansion of modern ophthalmic services at a time of rapid socioeconomic development and population growth.

PURPOSE To determine the prognosis of penetrating keratoplasty in eyes with keratoconus and vernal keratoconjunctivitis. METHODS The medical records of all patients with keratoconus and vernal keratoconjunctivitis who underwent penetrating keratoplasty at King Khaled Eye Specialist Hospital from January 1, 1986 to December 31, 1996 and for whom at least 24 months' follow-up is available were analyzed retrospectively. RESULTS Of 85 (61 males, 24 females) patients, 90 eyes met the inclusion criteria. The mean follow-up was 44.7 (range, 26-144) months. At the most recent follow-up visit, 83 (92.2%) grafts were clear. The mean best corrected visual acuity was 20/40. Graft rejection episodes occurred in 12 (13.3%) eyes, with irreversible graft failure occurring in 4 (4.4%) eyes. Bacterial keratitis occurred in 6 (7.7%) eyes, 2 (2.2%) of which developed irreversible graft failure. Herpes simplex keratitis resulted in irreversible graft failure in 1 (1.1%) eye. CONCLUSION Penetrating keratoplasty in eyes with keratoconus and vernal keratoconjunctivitis has an excellent visual outcome and a low complication rate.

To report a case of corneal infection with Chrysosporium parvum, a filamentous fungus usually associated with pulmonary infections.A 43-year-old Saudi man had a corneal stromal infiltrate and perforation of his left eye. He was treated with a therapeutic penetrating keratoplasty and topical and systemic antifungal therapy. Corneal scrapings, microbiologic evaluation, and histopathologic examination of the surgical specimen were performed to establish the diagnosis. After the development of recurrent stromal keratitis at the graft-host junction, similar diagnostic and therapeutic maneuvers were performed.Corneal scrapings and histopathologic examination were positive for numerous septate hyphae with endospores, consistent with a diagnosis of filamentous keratomycosis. Microbiologic isolation confirmed the diagnosis of Chrysosporium parvum. Similar diagnostic maneuvers for recurrent keratitis produced identical results.To our knowledge, this is the first case of Chrysosporium parvum keratomycosis.

To document an association between Terrien's marginal degeneration and posterior polymorphous dystrophy.A 23-year-old Saudi man presented with decreased vision, peripheral corneal thinning with vascularization and scarring, and abnormalities of the posterior stroma and Descemet's membrane.Clinical examination, corneal topography, and specular microscopy were consistent with a diagnosis of Terrien's marginal degeneration and posterior polymorphous dystrophy.We report the first case, to our knowledge, of the simultaneous occurrence of Terrien's marginal degeneration with posterior polymorphous dystrophy.

By analysis of outpatient records at the Massachusetts Eye and Ear Infirmary, the clinical course of 10 consecutive patients who underwent epikeratoplasty for keratoconus was reviewed to determine their clinical and functional status 5 years after surgery. Eight of 10 patients (80%) had clear, intact lenticules at 12 months. During a mean follow-up of 67 months (range = 35-101 months), each maintained long-term stability of best corrected vision, refractive astigmatism, and keratometric astigmatism. The mean uncorrected visual acuity improved from 20/660 to 20/134, whereas the mean spectacle corrected acuity improved from 20/260 to 20/30. All but one patient had a spectacle acuity equal to hard contact lens acuity. However, no patients were corrected to 20/20 at the end of the follow-up period. Refractive and keratometric astigmatism stabilized by 12 months (mean = 3.62 and 3.05 D, respectively), and decreased slightly during the longer period of follow-up (mean = 2.94 and 2.17 D, respectively). Epikeratoplasty is a useful method of visual rehabilitation in highly selected cases of keratoconus in which there is no central opacity, preoperative hard contact lens acuity is worse than 20/40, the average keratometry is60 D, contact lens intolerance is present, and in which the patient will tolerate some degree of reduced contrast sensitivity and20/20 high contrast acuity.

By analysis of outpatient records at the Massachusetts Eye and Ear Infirmary, the clinical course of 10 consecutive patients who underwent epikeratoplasty for keratoconus was reviewed to determine their clinical and functional status 5 years after surgery. Eight of 10 patients (80%) had clear, intact lenticules at 12 months. During a mean follow-up of 67 months (range = 35-101 months), each maintained long-term stability of best corrected vision, refractive astigmatism, and keratometric astigmatism. The mean uncorrected visual acuity improved from 20/660 to 20/134, whereas the mean spectacle corrected acuity improved from 20/260 to 20/30. All but one patient had a spectacle acuity equal to hard contact lens acuity. However, no patients were corrected to 20/20 at the end of the follow-up period. Refractive and keratometric astigmatism stabilized by 12 months (mean = 3.62 and 3.05 D, respectively), and decreased slightly during the longer period of follow-up (mean = 2.94 and 2.17 D, respectively). Epikeratoplasty is a useful method of visual rehabilitation in highly selected cases of keratoconus in which there is no central opacity, preoperative hard contact lens acuity is worse than 20/40, the average keratometry is < 60 D, contact lens intolerance is present, and in which the patient will tolerate some degree of reduced contrast sensitivity and < 20/20 high contrast acuity.