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Purpose To report the outcome of unilateral small incision lenticule extraction (SMILE) in a patient with granular corneal dystrophy type 2 (GCD2). Methods Slit-lamp photography and Fourier domain optical coherence tomography were used to document the clinical course and appearance of the corneas in a patient with genetically determined GCD2 who underwent unilateral SMILE in the right eye. Results Slit-lamp examination of a 23-year-old woman revealed 2 faint opacities at the surgical interface approximately 2 months after the SMILE procedure had been performed on her right eye. Nine and 3 typical GCD2 deposits located immediately beneath the Bowman layer were observed in the right and left corneas, respectively. Over time, the deposits at the interface increased in size, density, and number in the right eye. Fourier domain optical coherence tomography performed 33 months after the SMILE procedure revealed deposits at the SMILE interface that were distinct from those located immediately beneath the Bowman layer. The severity of disease exacerbation was less in this patient than what is typically observed in others who have undergone laser-assisted in situ keratomileusis or photorefractive keratectomy. Conclusions SMILE is contraindicated in patients with GCD2, as are other corneal refractive surgical procedures. This case highlights the importance of genetic testing before the performance of refractive corneal procedures-especially for patients with corneal opacities on preoperative slit-lamp examination or a family history of corneal disease compatible with that of a corneal dystrophy.

To evaluate the effect on donor rim cultures and postoperative infections of doubling the povidone-iodine exposure time during corneal tissue recovery before its use in keratoplasty.Consecutive donor cornea recoveries were evaluated for positive donor corneal rim cultures and postoperative infections before and after a protocol change of doubling the exposure time of povidone-iodine during donor preparation.In 631 consecutive cornea donor recoveries, 18 (2.9%) had positive fungal rim cultures and 41 (6.5%) had positive bacterial rim cultures. Three (0.48%) developed postoperative fungal infections, and no bacterial infections occurred. After doubling the povidone-iodine exposure time during the recovery process, 725 consecutive corneas were reviewed. Four (0.6%) had positive fungal rim cultures, and 29 (4.0%) had positive bacterial rim cultures. No postoperative fungal or bacterial infections occurred. No noticeable increase in epithelial toxicity developed between the 2 groups.Increasing the povidone-iodine exposure time during the donor cornea recovery process decreased the rate of positive donor corneal rim fungal cultures (P = 0.001), positive donor corneal rim bacterial cultures (P = 0.04), and postoperative fungal infections (P = 0.06).

Purpose To analyze current practice patterns in the prevention and treatment of corneal graft rejection for both penetrating keratoplasty (PK) and endothelial keratoplasty (EK) and to compare these patterns with previously reported practices. Methods In 2011, an electronic survey was sent to 670 members of the Cornea Society worldwide addressing the routine postoperative management of corneal transplants at different time points, treatment of various manifestations of corneal graft rejection, and preferred surgical techniques. Results A total of 204 of 670 surveys (30%) were returned and evaluated. All respondents used topical corticosteroids for routine postoperative management and treatment of endothelial graft rejection. Prednisolone was the topical steroid of choice in all clinical scenarios, similar to previous surveys from 1989 to 2004. Use of subconjunctival and systemic steroids increased for many scenarios of probable and definite graft rejection. Routine use of prednisolone decreased by approximately 10% from previous surveys, whereas difluprednate was used in 13% of high-risk eyes during the first 6 months. Dexamethasone, fluorometholone, and loteprednol use remained stable. Adjunctive topical cyclosporine use increased significantly for PK and EK. EK was the preferred technique for endothelial dysfunction, whereas PK and deep anterior lamellar keratoplasty were both used for keratoconus and anterior scars. Most respondents (75%) felt that graft rejection occurs more frequently after PK than after EK. Conclusions Prednisolone remains the treatment of choice for management and treatment of graft rejection; however, since the introduction of difluprednate, its use has declined slightly since the introduction of difluprednate. Despite perceived differences in rejection rates, there were no differences in prophylactic steroid treatment for PK and EK.

Purpose To assess the relationship between donor and recipient factors and corneal allograft rejection in eyes that underwent penetrating keratoplasty in the Cornea Donor Study. Methods Overall, 1090 subjects undergoing corneal transplantation for a moderate risk condition (principally Fuchs dystrophy or pseudophakic corneal edema) were followed for up to 5 years. Associations of baseline recipient and donor factors with the occurrence of a probable or definite rejection event were assessed in univariate and multivariate proportional hazards models. Results Eyes with pseudophakic or aphakic corneal edema (n = 369) were more likely to experience a rejection event than eyes with Fuchs dystrophy (n = 676) [34% ± 6% vs. 22% ± 4%; hazard ratio = 1.56; 95% confidence interval (CI), 1.21-2.03]. Among eyes with Fuchs dystrophy, a higher probability of a rejection event was observed in phakic posttransplant eyes compared with those that underwent cataract extraction with or without intraocular lens implantation during penetrating keratoplasty (29% vs. 19%; hazard ratio = 0.54; 95% CI, 0.36-0.82). Female recipients had a higher probability of a rejection event than male recipients (29% vs. 21%; hazard ratio = 1.42; 95% CI, 1.08-1.87) after controlling for the effect of preoperative diagnosis and lens status. Donor age and donor recipient ABO compatibility were not associated with rejection. Conclusions There was a substantially higher graft rejection rate in eyes with pseudophakic or aphakic corneal edema compared to that in eyes with Fuchs dystrophy. Female recipients were more likely to have a rejection event than male recipients. Graft rejection was not associated with donor age.

Purpose To investigate the relative abilities of different haplotypes of the Fusarium solani (FSSC)-Fusarium oxysporum (FOSC) complexes to attach to and invade hydrogel contact lenses. Methods Silicone hydrogel and traditional hydroxyethylmethacrylate soft contact lenses were exposed to conidia [10 ml in phosphate-buffered saline (PBS)] of different haplotypes of fusaria associated with the Fusarium keratitis outbreak of 2004-2006. Select lenses and fungi were examined under conditions of organic enrichment. The lenses were incubated with shaking at ambient temperatures, then examined microscopically for the presence of penetration pegs (PPs). Results Attachment to and penetration of balafilcon A lenses in PBS within 96 hours were observed with representative isolates of FSSC 1-a, 1-b, and 2-d. Densities and coiled morphology of the PPs were similar. Eight of 8 FOSC failed to attach and form PP in PBS without prior sorption of organics by the lens. Generally, FSSC 1 isolates showed more rapid development of PP. Representatives of all haplotypes, including FSSC 2-c (ATCC 36031, a standard challenge strain), showed at least sparse attachment and penetration of the balafilcon A lens and, to a lesser degree, the lotrafilcon A lens. The development of PP in etafilcon A and galyfilcon A lenses required extended incubations (>21 days) relative to balafilcon A lenses. Conclusions Attachment to and penetration of unworn hydrogel soft contact lenses by Fusarium varied with the strain and lens type rather than with the clinical, environmental, or geographic source of the isolates. Without organic enrichment of the lenses, penetration was more rapid and extensive by representatives of FSSC 1. Penetration was slow and less extensive under these conditions with FOSC and FSSC 2-c and 3. Organic enrichment of the lenses typically favored development of PP by the FOSC. Attachment and penetration of lenses occurred sooner and to a greater extent with surface-treated silicone hydrogel lenses than with the hydroxyethylmethacrylate lens.

Purpose The purpose of this study was to report the confocal microscopic, characteristics of epithelial downgrowth and the clinical utility of serial confocal examinations in the management of epithelial downgrowth. Methods Retrospective case review of 3 eyes from 3 patients that developed epithelial downgrowth after ocular surgery with penetrating ocular trauma and literature review. Results Two cases developed epithelial downgrowth and a retrocorneal membrane after both penetrating ocular trauma and multiple intraocular surgeries. A third case developed epithelial downgrowth presenting as a membranous growth noted on the endothelial surface after multiple intraocular surgeries. In all cases, confocal microscopy revealed round, hyperreflective nuclei characteristic of epithelial cells at the level of the endothelium, and in 2 cases, the diagnosis was confirmed by histopathologic evaluation. In cases 2 and 3, confocal microscopic analysis proved useful in following epithelial regression after 5-fluorouracil injection, and in case 3, confocal microscopy proved to be potentially more sensitive in identifying residual epithelial downgrowth than routine light microscopy. Conclusions Confocal microscopy can definitively diagnose epithelial downgrowth occurring after previous ocular surgery or ocular trauma and may prove useful for following downgrowth after intervention.

To evaluate the clinical implementation of guidelines for the treatment of dysfunctional tear syndrome (DTS) developed by the International Task Force (ITF) of dry eye disease experts.Nine physicians implemented the ITF guidelines for 3 months. Newly diagnosed patients with DTS rated their ocular symptoms and were clinically examined. Using the guidelines, physicians determined the DTS severity level (0-4, where 4 is most severe) and made their therapeutic choices.Of 183 patients enrolled (mean age, 65.1 years; range, 25-91 years), 67% presented without lid margin disease, and 68% had no apparent ocular surface inflammation. Symptoms were significantly more severe in patients with altered tear distribution or evident inflammation (P0.05). Most patients diagnosed at severity level 1 did not have lid margin disease (56/61, 92%), and inflammation was not apparent (53/58, 91%); 43% of severity level 1 patients (27/63) were treated at level 2 (therapeutic choices include unpreserved tears or topical cyclosporine). Most patients presenting with inflammation were diagnosed at severity level 2 (74%, 32/43). More than 9 in 10 severity level 2 patients were treated at level 2 (100/106; 94%). Physicians reported that 96% of their treatment recommendations were consistent with management they would have recommended if they had not consulted the ITF guidelines. They spent an average of 4.5 minutes per patient applying the guidelines.Implementation of the ITF guidelines was simple and not time consuming. Many practitioners chose to treat patients diagnosed at severity level 1 with treatments at level 2 that include unpreserved tears and topical cyclosporine.

To report a series of cases with asymmetric keratoconus attributed to eye rubbing, discuss its pathogenesis, and review the literature.Case reports and literature review.A careful history obtained from 5 patients with asymmetric keratoconus revealed habitual eye rubbing of the more severely affected eye.Trauma, such as occurs with habitual eye rubbing, plays a role in the pathogenesis of keratoconus.

Objective: To report the reactivation of presumed adenoviral keratitis after laser in situ keratomileusis (LASIK). Methods: Case report and literature review. Results: The patient underwent uneventful LASIK more than 5 years after an episode of adenoviral keratitis that left subepithelial corneal scarring. Three months after LASIK, new subepithelial infiltrates appeared in the right eye. These lesions resolved without sequelae during treatment with topical steroids. The patient's uncorrected and best-corrected visual acuity returned to her postoperative baseline. Conclusion: LASIK may cause delayed exacerbation of subepithelial infiltrates caused by adenoviral keratitis. However, good visual outcomes can be achieved with recognition of this reactivation and treatment with topical corticosteroids.

To report a case of Avellino corneal dystrophy that increased in severity 1 year after uncomplicated laser in situ keratomileusis (LASIK) for myopia.Avellino dystrophy was confirmed by polymerase chain reaction sequencing of DNA from the patient and her parents.Best spectacle-corrected visual acuity decreased from 20/20 to 20/30 12 to 20 months after LASIK owing to opacities that appeared centrally in the corneal stroma and the LASIK flap and remaining posterior stroma interface.LASIK is contraindicated in patients with Avellino corneal dystrophy because vision may be reduced by corneal opacities that appear in the interface of the flap and remaining posterior stroma postoperatively.

PURPOSE: To report the histopathologic findings of the iridocorneal endothelial (ICE) syndrome and posterior polymorphous membranous dystrophy (PPMD) in 3 patients who underwent Descemet stripping automated endothelial keratoplasty (DSAEK), and to correlate these findings with the clinical diagnosis. METHODS: Three patients with clinical findings compatible with either ICE syndrome (1 patient) or PPMD (2 patients) underwent DSAEK. The DSAEK specimens were processed for light microscopy, immunhistochemical staining for cytokeratins AE1/3 and MAK6, and electron microscopy. RESULTS: Examination of the DSAEK specimens showed multilayered endothelial cells and thickened Descemet membrane in all cases. Immunohistochemical staining for cytokeratins was positive in the endothelium in all cases. Ultrastructural examination showed a thickened Descemet membrane and wide-spaced collagen in Descemet membrane in 1 case of PPMD but not in 2 cases of ICE syndrome, including 1 case that carried the clinical diagnosis of PPMD. In 2 cases, the histopathologic evaluation of the DSAEK specimen confirmed the clinical diagnosis; however, in 1 case the pathological diagnosis was ICE syndrome, while the clinical diagnosis was PPMD. CONCLUSIONS: ICE syndrome and PPMD can be diagnosed and differentiated from one another by histopathologic evaluation of corneal specimens obtained at the time of DSAEK. We recommend submitting the corneal tissue obtained during DSAEK for pathological examination when the etiology of corneal edema is unclear.

PURPOSE To evaluate the effect of mitomycin C (MMC) on the exacerbation of corneal opacity that occurs in patients with granular corneal dystrophy type II (GCD II) after refractive corneal surface ablation. METHODS Ten eyes of patients with GCD II who underwent refractive corneal surface ablation with MMC were compared with 10 eyes that were not treated with MMC. Best spectacle-corrected visual acuity, the degree of corneal opacity, and contrast sensitivity were evaluated at least 3 years after surgery. Corneal opacities were quantified using Pentacam densitometry maps. RESULTS No measured between-group value showed a statistically significant difference. CONCLUSION Simultaneous application of MMC does not prevent exacerbation of GCD II after refractive corneal surface ablation.

Purpose To determine the relative susceptibility of worn and unworn hydrogel contact lenses to penetration by hyphae of the Fusarium solani-Fusarium oxysporum species complex. Methods Hydrogel contact lenses (lotrafilcon A, balafilcon A, senofilcon A, galyfilcon A, and etafilcon A) were removed from their original packages and placed directly on the eyes of 24 experienced contact lens wearers for 8-9 hours. Lenses were removed, each placed in 3.0 mL sterile phosphate buffered saline (PBS), and inoculated with 10 conidia of fusaria. Similar sets of unworn lenses were soaked in Sabouraud's dextrose broth for 2 hours prior to exposure to fusaria conidia in PBS. The entire surface of lenses was examined with microscopy for 14 days for the development of coiled hyphae in the lens matrix (ie, penetration pegs [PP]). Results A total of 21 of 54 worn hydrogel lenses representing 4 types of silicone hydrogel and one type of hydroxyethylmethacrylate lens were penetrated by the fusaria. Compared to unworn lenses, 9 of the 21 PP-positive worn lenses showed earlier and more extensive penetration than seen with the unworn lenses. Several worn lenses compared to their unworn counterparts showed negligible or delayed penetration. Conclusions Worn hydrogel contact lenses without a history of exposure to disinfection solutions compared to unworn lenses of similar status may show enhanced or decreased susceptibilities to penetration by Fusarium. This suggests that tear characteristics are an additional factor in the invasive contamination of hydrogel contact lenses by Fusarium.

PURPOSE To describe an invasive spindle cell carcinoma of the conjunctiva managed by full-thickness eye wall resection. METHODS A 51-year-old man developed a conjunctival mass that was excised and proved to be a spindle cell carcinoma. A tumor recurrence 20 months later was evaluated by ultrasound biomicroscopy (UBM) and managed by full-thickness eye wall resection and scleral graft. RESULTS UBM depicted an epibulbar mass with deep invasion through the limbus to Descemet membrane. The tumor was removed by full-thickness eye wall resection and scleral graft. CONCLUSIONS Deep scleral invasion of conjunctival spindle cell carcinoma can sometimes be managed by local resection rather than irradiation or enucleation.

To analyze factors implicating the association of ReNu with MoistureLoc (ReNu ML) multipurpose contact lens solution (MPS) with the increased incidence of Fusarium keratitis.Used contact lens cases with and without contact lenses and MPS containers were collected from patients with confirmed or possible Fusarium keratitis. Direct microscopy including transparent adhesive tape preparations and swab cultures were used to determine fungal colonization. Survival and growth of selected isolates of Fusarium spp. in drying MPS on plastic surfaces were determined by microscopy and recoverable colony counts on enriched agar.Discrete regions of fungal colonization, including occasional microcycle conidiation and chlamydospore formation, were observed on the surfaces of contact lens cases and, less often, on solution containers that had been used by patients with Fusarium keratitis associated with the use of ReNu ML. Isolates provisionally grouped with the F. solani-F. oxysporum complex were inhibited by fresh MPS in original solution containers and contact lens cases, but survived in stressed (drying) films of MPS, particularly ReNu ML. These in vitro test results were similar to the direct in situ observations of the materials from patients.Selective, rapid growth and survival of cells of the F. solani-F. oxysporum complex on plastic surfaces, particularly of contact lens cases with stressed ReNu ML films, may explain, in part, the recent Fusarium keratitis outbreak.

Purpose To evaluate the corneal deposits of Avellino corneal dystrophy (ACD) in patients with corneal neovascularization from pterygium or phthisis bulbi as a way of understanding the pathogenesis of ACD. Methods Five patients with ACD with pterygium, 10 patients with ACD (age >50 years) without pterygium, 1 patient with ACD with phthisis bulbi with corneal neovascularization, and 1 patient with ACD with phthisis bulbi without corneal neovascularization were examined. The corneal deposits of all patients were assessed by slit-lamp examination and reviewed with biomicroscopic photographs. The distance between the limbus and the nearest corneal opacities was measured. Results In eyes with vascularized nasal pterygia, there was a granule-free zone adjacent to the advancing edge of the pterygium so that the distance between the nasal limbus and the most nasally located granule exceeds that of the distance between the limbus and the closest granule elsewhere on the cornea. In patients with ACD with phthisis bulbi, no granular deposits were observed in the cornea with neovascularization, but there were deposits in the cornea without neovascularization. Conclusion Corneal neovascularization prevents the deposition of corneal opacities in patients with ACD.

Purpose: To report the first case of Avellino corneal dystrophy exacerbation after LASIK in a white or North American patient. Methods: Case report and literature review. Results: A 25-year-old white female developed progressive corneal opacities after LASIK. Preoperative examination had revealed only subtle white corneal opacities in each eye. The patient's mother had similar corneal opacities. DNA analysis of the patient revealed a heterozygous mutation at the R124H location in the BIGH3 gene. Conclusions: LASIK can exacerbate Avellino corneal dystrophy and should be avoided in patients with this condition. A careful history and genetic analysis can identify affected patients and those at risk.

Purpose: To report the incidence and outcomes of diffuse lamellar keratitis (DLK) after LASIK and to analyze potential causative factors. Methods: Retrospective review of 15,119 cases (11,232 primary procedures and 3887 enhancements) from 7168 patients undergoing LASIK from May 1995 through October 2002, comparing preoperative data and postoperative outcomes for each case developing DLK to patients in the study population and a control series of eyes that did not develop DLK. Results: We identified 61 eyes (0.40%) that developed DLK after LASIK. Three study groups were identified based on sterilization protocols used: (1) steam autoclave without reservoir (8348 cases), (2) cassette autoclave with reservoir (6771 cases), (3) steam autoclave without reservoir and new instrument cleaner (1758 cases). Significantly more eyes developed DLK with Protocol 2 (47 cases, 0.94%) than with Protocol 1(11 cases; 0.1%; P < 0.0001) or Protocol 3 (3 cases, 0.2%; P < 0.0005). There was no significant difference in the incidence of DLK in Protocol 1 versus Protocol 3. DLK was significantly more common after primary procedures than with enhancement procedures only under Protocol 2. No individual developed DLK after more than 1 procedure. Treatment protocols included frequent topical steroids only (24 cases, 39.3%), frequent topical steroids and oral steroids (19 cases, 31.2%), or topical and oral steroids combined with lifting and irrigating beneath the flap (18 cases, 29.5%). Final refractions and visual acuities were not significantly different in eyes that developed DLK and those that did not. Conclusions: DLK is a nonspecific inflammatory response to multiple stimuli that cannot be attributed solely to individual variation in the inflammatory response, the microkeratome, or material deposited by the microkeratome. Sterilizers with reservoirs may cause some cases of DLK. With appropriate diagnosis and treatment, DLK should resolve without sequelae, yielding visual outcomes comparable to cases with uneventful postoperative courses.

Objective: To describe the changes in corneal thickness determined by ultrasonic pachymetry during follow-up of herpes simplex virus disciform corneal edema. Methods: Thirty-five patients with herpetic keratitis underwentslit-lamp biomicroscopy and ultrasonic pachymetry. Measurements during follow-up and at clinical resolution of corneal inflammation were compared with the initial corneal thickness. Results: Corneal thickness of disciform stromal keratitis decreased 15% (95% confidence interval 10% to 20%) during follow-up, and 65% (95% confidence interval 43% to 88%) of this decrease occurred during the first 2 weeks. Increased central corneal thickness measured by pachymetry was associated with biomicroscopic detection of corneal edema (P = 0.03). Conclusions: Corneal pachymetry supplements clinical assessment of herpetic disciform edema.

Purpose. To report successful visual rehabilitation following severe bilateral alkali injury using piggyback hyperoxygen-transmissible (hyper O 2 ) contact lenses. Methods. Case report and literature review. Results. More than 15 years after a severe bilateral alkali injury, multiple surgical procedures including repeat bilateral penetrating keratoplasty, severe tear deficiency, and chronic ocular surface disruption, the patient achieved 20/30 best-corrected vision through the simultaneous use of a hyper O 2 rigid gas permeable contact lens over a hyper O 2 soft contact lens in his right eye. The patient has tolerated this piggyback combination without any adverse reactions or complications, and his corneal graft remains clear and healthy. Conclusion. Visual rehabilitation for conditions that compromise the ocular surface can be accomplished by utilizing newer soft and rigid contact lens materials that facilitate oxygen transmission, thereby promoting epithelial healing and improving safety in extended wear situations. These newer materials may potentially reduce complications previously associated with extended wear therapeutic lenses.

Three hundred fourteen members of the Castroviejo Society were surveyed to determine current practices in the prevention and treatment of corneal graft rejection. One hundred thirty-seven responses were received and tabulated for routine postoperative prophylactic immunosuppression as well as treatment of epithelial rejection, endothelial rejection (three patterns), subepithelial infiltrates, acutely and progressively opacifying grafts without inflammation, and photophobia. All respondents applied topical steroids in the postoperative period, while about half also administered steroids subconjunctivally. For the treatment of obvious endothelial rejection, 100% of respondents used topical steroids, 57% used subconjunctival steroids, and 37% used systemic steroids. Prednisolone acetate, 1%, was the preferred topical preparation for all conditions (55-68% of respondents). Individual responses to the questionnaire showed a surprisingly wide variation in treatment preferences.

PurposeTo review the epidemiology, biology, systemic and ocular features, and treatment options for varicella zoster disease, including postherpetic neuralgia.MethodsLiterature search and review of author's experience with patients with varicella and herpes zoster ophthalmicus.ResultsIn recent years

The Collaborative Corneal Transplantation Studies (CCTS) were designed to evaluate the effect of donor-recipient histocompatibility matching and cross-matching on the survival of corneal transplants in high-risk patients. We now report on the role of symptoms in the detection of corneal allograft reactions in the CCTS and on the relationship between symptom reporting and graft survival. The 456 patients transplanted in the CCTS were followed for a minimum of 2 years or until graft failure. The follow-up protocol included 11 scheduled examinations in the first year, four examinations during the second year, and examinations every 6 months thereafter. Interim examinations were performed in response to patient-reported symptoms. At every examination, patients were asked specifically if they had redness, sensitivity to light, loss of vision, or pain (RSVP). Of the 456 patients transplanted, 62% had at least one graft reaction. Patients diagnosed with reactions at scheduled visits in the first postoperative year were 2.5 times more likely to report symptoms than those without reactions. Reports of red eye and vision loss were strongly associated with allograft reaction. However, these symptoms were neither highly sensitive nor specific for reaction (sensitivity = 46%, specificity = 70% at 6 months). The severity of reaction influenced the reporting of symptoms: 69% of patients with severe reactions reported symptoms versus 48% of patients with mild reactions (p < 0.001). The only patient characteristic associated with reliable symptom reporting was age, with younger patients with reactions being more likely to report symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)