Search

Purpose: To report the indications, outcomes, and complications of therapeutic penetrating keratoplasty (Th PK) in patients with corneal perforation and/or nonhealing corneal ulceration., Methods: A retrospective review was conducted of 51 eyes of 51 patients undergoing Th PK between January 1, 2006 and April 15, 2016. Data collected included patient demographics, visual acuity (VA), size of the corneal infiltrate and epithelial defect, degree of corneal thinning/perforation, microbiological results, surgical details, and postoperative complications., Results: The average age at presentation was 56.0 years (range 6-92 years), and most of the patients were females (n=31, 60.8%). Th PK was performed for corneal perforation in 28 eyes (54.9% of cases), nonhealing corneal ulcer in 16 eyes (31.4% of cases), and imminent risk of corneal perforation in 7 eyes (13.7% of cases). Infection was the most common reason for performing a Th PK and was present in 92.3% (47/51) of all cases. Of the infectious cases, the most common etiologies were bacterial (44.7%, 21/47) and fungal (31.9%, 15/47). The most common identifiable risk factor for undergoing a Th PK was a history of contact lens wear, which was seen in 32.7% of patients. Initial anatomic success was achieved in all patients after performing Th PK. Most patients (33/51; 64.7%) had clear grafts at their last follow-up examination. There was an improvement in VA in 70.2% (33/47, where data were available) of the patients at the final postoperative visit compared with the preoperative visit. Average best postoperative VA (1.14±0.88 logarithm of the minimum angle of resolution [LogMAR]; 20/276) was significantly better than the presenting (1.98±0.68 LogMAR; 20/1910) and preoperative (2.18±0.55 LogMAR; 20/3,027) visual acuities (P<0.0001). The most common complication after Th PK was cataract, which was present in 81.8% (27/33) of phakic eyes in which lens status could be assessed, followed by graft failure (47.1%; 24/51), and secondary glaucoma (45.1%; 23/51). Five eyes developed infection in the therapeutic graft, four eyes had persistent corneal epithelial defect at their last follow-up visit, and two eyes underwent evisceration., Conclusions: Therapeutic penetrating keratoplasty achieves anatomic success and it is a useful procedure for restoring a stable cornea in cases in which infection fails to heal or when the cornea perforates. Furthermore, Th PK achieves corneal clarity and improves vision in most patients.

Objective: To survey ophthalmologists about current practice patterns regarding the evaluation of dry eye patients and referrals for a Sjogren syndrome (SS) workup., Methods: An online survey was sent to ophthalmologists affiliated with the Scheie Eye Institute or Wills Eye Hospital using REDCap in August 2015. Descriptive statistics were used to summarize the data., Results: Four hundred seventy-four survey invitations were sent out and 101 (21%) ophthalmologists completed the survey. The common traditional dry eye test performed was corneal fluorescein staining (62%) and the most common newer dry eye test performed was tear osmolarity (18%). Half of respondents (51%) refer fewer than 5% of their dry eye patients for SS workups, with 18% reporting that they never refer any patients. The most common reasons for referrals included positive review of systems (60%), severe dry eye symptoms (51%) or ocular signs (47%), or dry eye that is refractory to treatment (42%). The majority (83%) felt that there is a need for an evidence-based standardized screening tool for dry eye patients to decide who should be referred for evaluation for SS., Conclusions: Ophthalmologists continue to prefer the use of traditional dry eye tests in practice, with the most common test being corneal fluorescein staining. There is an underreferral of dry eye patients for SS workups, which is contributing to the continued underdiagnosis of the disease. Most respondents felt that there was a need for an evidence-based standardized screening tool to decide which dry eye patients should be referred for SS evaluations.

Objective: To assess the effect of excimer laser phototherapeutic keratectomy (PTK) with intraoperative mitomycin-C (MMC) on the quality of vision in patients with Salzmann nodular degeneration (SND)., Methods: Thirteen eyes of 12 patients were enrolled in the study between December 2010 and March 2012. Uncorrected and best-corrected Snellen distance visual acuities were measured at every visit. Contrast sensitivity and manifest refraction were measured preoperatively, at 1 month and at 3 months. Corneal topography, Galilei dual Scheimpflug imaging, VISX WaveScan, and ultrasound central corneal pachymetry were measured preoperatively and at 3 months after PTK procedure., Results: Contrast sensitivity was statistically significantly better both at 1 month (P<0.01) and 3 months (P<0.01). Postoperatively, there was 46% increase in eyes with measurable corneal topography, 69% increase in Galilei dual Scheimpflug imaging, and a 77% increase in WaveScan measurements. The third-order (P<0.01) and total corneal higher-order aberrations (HOAs) (P=0.01) were significantly lower postoperatively compared with the preoperative corneal aberrations measured on Galilei dual Scheimpflug imaging., Conclusions: Significant improvement in contrast sensitivity and corneal HOAs was seen after PTK for SND. Phototherapeutic keratectomy with MMC can be considered as an effective procedure in the improvement of the quality of vision in patients with SND.

Objective: To evaluate the indications and outcomes of sutureless amniotic membrane transplant (AMT; ProKera) in the management of ocular surface disorders., Methods: Chart review of patients who had ProKera (Bio-Tissue, Inc.) implantation for ocular surface disorders between June 2008 and May 2012 at 3 ophthalmology practices in Philadelphia, PA. The parameters evaluated included age, sex, indication for AMT, any other combined procedure, duration of retention of amniotic membrane, the effect of amniotic membrane on ocular surface healing, follow-up time, and complications., Results: There were 35 eyes of 33 patients with a mean age of 68.2±19.5 years (range: 17-99 years). There were 25 male patients, and median follow-up was 110 days (mean: 164.6 days; range: 30-960 days). The indication for insertion of ProKera was nonhealing corneal ulcers of infective origin (group 1) in 9 eyes (25.7%), neurotrophic keratopathy (group 2) in 11 eyes (31.4%), chemical injury (group 3) in 5 eyes (14.3%), and other indications (group 4) in 10 eyes (28.6%). Complete or partial success was seen in a total of 44%, 64%, 80%, and 70% eyes in groups 1 to 4, respectively. Discomfort with the device was seen in 6 (17.1%) of 35 eyes, and recurrence of primary pathologic condition occurred in 5 (14.3%) of 35 eyes., Conclusion: ProKera treatment is easy to use and reasonably well tolerated, with moderate success in corneal ulcers and encouraging results in acute moderate chemical injury. Recurrence of primary pathologic condition is seen particularly associated with neurotrophic keratitis and dry eye syndrome.

Objective: To report the therapeutic practice patterns of silicone hydrogel (SiH) bandage soft contact lenses (BSCL) and the resultant rate of microbial keratitis (MK)., Methods: A retrospective case series of patients treated with therapeutic BSCLs for ocular surface disease from January 2006 to January 2009 in a tertiary care cornea practice. All patients had a history of ocular surface disease., Results: Seventy-four patients were treated with a therapeutic SiH BSCL (102 intervals of use) for complicated ocular surface disease. Two patients developed infectious corneal infiltrates (2/102, 2.0%) [corrected]. Two of 3 MK episodes were in patients with limbal stem-cell deficiency (2/102, 2.0%)., Conclusions: Therapeutic SiH BSCLs were safely used in most patients. However, results suggest that prophylactic antibiotic use did not eliminate the risk for MK with SiH BSCL use in patients with chronic ocular surface disease.

Purpose: This study was designed to determine the demographics of patients aged 50 years or more with a diagnosis of keratoconus, who were seen on the Cornea Service at Wills Eye Hospital., Methods: A retrospective chart review of all patients with the diagnosis of keratoconus was undertaken to identify demographics characteristics between January 1, 2005 and December 31, 2005., Results: A total of 697 patients were identified. Two hundred seventy-nine (40.0%) patients were age 50 years or more. The age ranged from 50 to 93 years (average 60.2 +/- 8.2 years). Keratoconus was diagnosed as a bilateral disease in 266 (95.3%) and as a unilateral disease in 13 patients (4.7%). In 186 patients (66.6% of the total), the average age at the time of diagnosis was 31.7 +/- 10.9 years (range from 13 to 70 years). Of the 279 patients, 167 had surgery (59.8%). In the group of 112 patients that did not have surgery, 25 (9.0%) were treated with glasses in both eyes, 85 (30.5%) with contact lenses in both eyes, and 2 (0.7%) with glasses in one eye and contact lenses in the other eye. The average time of follow-up was 13.6 +/- 10.5 years (range from 0.1 to 38.7 years)., Conclusions: In a corneal referral practice, the number of patients older than 50 years with keratoconus is higher than previously reported in the literature. We believe that this is because our practice has a strong interest in both contact lenses and corneal surgery with the ability to follow up patients on a long-term basis.

Objectives: To assess the impact of the different types of contact lenses (CLs) on quality of life (QoL) in patients with keratoconus based on self-reported results from The Contact Lens Impact on Quality of Life (CLIQ) Questionnaire., Methods: Consecutive keratoconus patients who wore CLs (rigid gas permeable [RGP], hybrid or soft toric) at least in one eye were asked to complete the CLIQ questionnaire on the Cornea Service, Wills Eye Institute., Results: A total of 71 patients with a mean age of 42.6 +/- 13.1 year were included in the study. One eye of each patient was included in the study. Of these, 40 eyes used rigid gas-permeable lenses, 20 eyes used hybrid lenses and 11 eyes used soft toric lenses. The mean CLIQperson measure was 45.5 +/- 8.2 in RGP group, 45.4 +/- 7.5 in hybrid group and 48.4 +/- 10.5 in soft toric group. There was no significant difference among the three groups in self-reported results from the CLIQ questionnaire (P = 0.8)., Conclusions: Subjects with keratoconus who wear RGP, hybrid or soft toric CLs, reported similar contact lens impact on their QoL.

Purpose: To identify current indications and trends in indications for penetrating keratoplasty (PKP) and associated procedures., Methods: Retrospective chart review of all patients who underwent PKP at Wills Eye Institute from January 1, 2001, to December 31, 2005., Results: A total of 1,162 cases were performed in this 5-year period. Leading indications for PKP were pseudophakic corneal edema (PCE) in 330 (28.4%) cases, followed by regraft in 250 (22.0%), keratoconus in 186 (16%), and Fuchs' endothelial dystrophy in 126 (10.8%) cases. Of the 330 cases of PCE, 232 (70.3%) were associated with posterior chamber intraocular lenses (PCIOLs) and 96 (29.1%) with anterior chamber lenses. In 330 eyes with PCE, the lens was not exchanged in 246 (74.5%) cases and was exchanged in 76 (23%) cases. Seventy of the exchanged lenses were anterior chamber intraocular lenses (ACIOLs) and six lenses were PCIOLs. In cases of ACIOL exchanges, 10 were for scleral sutured IOLs, 18 for PCIOLS, and 42 for another ACIOL., Conclusions: Pseudophakic corneal edema remains the leading indication for PKP at our institution followed by regraft, continuing a trend noted in our previous studies. Although the percentage of cases of PCE associated with PCIOLS increased, fewer lenses were exchanged, perhaps reflecting increased confidence in biocompatibility of newer IOLs. The decrease in overall number of corneal transplants in these 5 years continues a trend noted in our previous study and mirrors the national decline in PKP.

Purpose: To assess the risk and incidence of rejection in patients who underwent bilateral penetrating keratoplasty (PK) and had at least one rejection episode., Methods: The records of patients undergoing PK between January 1994 and December 2003 were retrospectively reviewed. Inclusion criteria were bilateral PKs and at least one rejection within 18 months of either PK. Exclusion criteria were PK performed elsewhere, multiple grafts in the same eye, and fewer than 18 months between PKs in the two eyes., Results: Eighty-three patients had bilateral PKs (56 women and 27 men) at least 18 months apart and had a rejection episode within 18 months of at least one surgery. Their mean age was 57.1 +/- 17.7 years. The mean follow-up after the first and second PKs were 9.6 +/- 5.4 and 4.1 +/- 3.7 years, respectively. Kaplan-Meier survival analysis showed that PK in the second eye did not impose an increased risk of rejection in the first eye. There was no significant difference in the frequency of rejections between the two eyes during the first 18 months after the second PK. The first eye was significantly more likely to have a rejection during the first 18 months after the first PK than during the first 18 months after the second PK (P=0.01)., Conclusions: Having a PK in the second eye does not impose a significantly increased risk of rejection for the first eye when PKs are performed at least 18 months apart. There is an indefinite risk for rejection. Lifelong regular follow-up and immediate evaluation for new symptoms are essential.

Purpose: To evaluate the visual and topographic outcomes in patients with keratoconus who have undergone cataract surgery and to analyze different methods of keratometry and formulas for intraocular lens (IOL) calculation in patients with keratoconus., Methods: In a retrospective case series, 12 eyes (nine patients) with keratoconus underwent phacoemulsification with IOL implantation. The IOL power was determined by using standard and corneal topography-derived keratometry in three formulas: SRK, SRKII, and SRKT. Three months after surgery, best-corrected visual acuity (BCVA), visual improvement, simulated keratometry, and contact lens fit were assessed. Retrospectively, the difference between spherical equivalent and desired refraction was evaluated for the ideal IOL power. The difference between the ideal IOL power and the calculated IOL power from the three formulas was determined to evaluate the best formula for these patients., Results: The mean age was 55 years (range, 38-76 years). All eyes had improved BCVA (mean of four lines). Of the five eyes with mild keratoconus, three were switched from rigid gas-permeable lens wear before surgery to soft toric contact lenses (n = 2) or spectacles (n = 1). Patients with moderate and severe keratoconus (7 of 12) still required rigid gas-permeable lenses after surgery. In mild keratoconus, there was no difference between standard and topography-derived keratometry. The most accurate IOL power was found by using SRKII., Conclusions: Cataract surgery can improve BCVA in all severities of keratoconus without significant corneal change. IOL calculation is more predictable in mild keratoconus than in moderate and severe disease.