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Purpose: To compare corneal characteristics of eyes with high myopia with those of eyes with no spherical ametropia using Orbscan and ultrasonic pachymetry., Methods: Orbscan and ultrasonic pachymetry values were prospectively recorded in a study group of 105 patients with high myopia (i.e., axial length greater than 26mm in both eyes) and in a control group of 105 patients with no spherical ametropia (absolute value of spherical equivalent less than 1.25D regardless of cylinder value). Astigmatism data were expressed by rectangular coordinates in a dioptric plane. Axis was decomposed in 2 components (WTR/ATR and oblique) which were analyzed by Cos2axis and Sin2axis trigonometric functions. Enantiomorphism (mirror-image symmetry) between fellow eyes was quantified by a Euclidean distance for the location of the thinnest point and by the difference (in absolute value) between 180° and the sum of both axes for astigmatism., Results: In the study group, the mean axial length and subjective spherical equivalent were, respectively, 27.82±2.14mm (26.00 to 34.06) and -9.00±3.46D (-4.71 to -19.82). The mean corneal astigmatism was +0.92D×91.3° in the study group and +0.65D×89.3° in the control group. The mean corneal cylinder was higher in the study group (1.44D versus 0.91D; P<0.001) whereas axis showed no significant differences between both groups. The mean maximal keratometry was steeper in the study group (44.53D versus 44.13D; P=0.03) whereas the mean keratometry and minimal keratometry displayed no significant differences between both groups. No significant differences in central corneal thickness (540.2μm versus 546.9μm; P=0.10), peripheral corneal thickness, corneal diameter, corneal irregularity, asphericity, and irregular astigmatism were found between both groups. There were no significant differences in enantiomorphism parameters between both groups. In the study group, correlation with axial length was significant only for spherical equivalent (r=-0.86; P<0.001) and corneal cylinder (r=0.16; P=0.04)., Conclusion: High myopia exhibits corneal characteristics similar to corneas of eyes with no spherical ametropia, except for toricity. While the posterior segment elongates, development of high myopia appears not to affect corneal characteristics. Corneal toricity may be associated with evolution toward high myopia by perturbing mechanisms of emmetropization., (Copyright © 2014. Published by Elsevier Masson SAS.)

Purpose: To analyze the relationships between refractive parameters as well as the relationship between fellow eyes in a normal population., Methods: Both subjective refraction and auto-refractometry data of 500 patients were prospectively recorded. Refraction data were analyzed on three rectangular coordinates in a dioptric space. WTR/ATR ratio of axis was quantified by the Cos2axis function. Enantiomorphism (mirror-image symmetry) between fellow eye axes was quantified by the absolute value of the difference between 180° and the sum of both axes., Results: Mean refraction and mean cylinder were -1.74D (+0.28D × 91.5°) and 0.81 ± 0.89D respectively. The spherical component had no significant influence on refractive astigmatism (r(s)≤ 0.07, P ≥ 0.07) except for high spherical ametropia. Eyes with spherical equivalent greater than 4D (in absolute value) demonstrated higher cylinder (1.15D vs 0.84D, P<0.001). Cylinder influenced the WTR/ATR ratio (r(s)=-0.25, P<0.001) and the enantiomorphism (r(s)=0.36, P<0.001). Age also influenced the WTR/ATR ratio (r(s)=0.27, P<0.001) and the enantiomorphism (r(s)=0.14, P<0.001). Axes were more likely WTR and enantiomorphic when the cylinder was high and the subject young. Oblique axes were less enantiomorphic (35.5° vs 20.6°, P<0.001) and were associated with lower cylinder (0.56D vs 0.98D, P<0.001). Correlation between fellow eyes was significant for cylinder (r(s)=0.66, P<0.001) and for spherical equivalent (r(s)=0.96, P<0.001). Gender had no significant influence on refraction (P>0.12) except for spherical equivalent (relative hyperopia of +0.17D, P=0.04 in females)., Conclusion: The spherical component of the refraction appears to be independent of the refractive astigmatism except for high spherical ametropia. Cylinder influences somewhat the WTR/ATR ratio of axis and the enantiomorphism. Relationships between refractive parameters are weak in comparison to the fellow eye relationships., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

We report a case of a 67-year-old woman with no significant past ocular history, who was referred for management of an unresponsive microbial keratitis resulting from trauma with a piece of clothing fabric 1 month previously in Portugal and worsening despite topical fortified antibiotics. On examination, visual acuity was limited to "light perception". Slit lamp examination revealed an 11×11mm full-thickness corneal infiltrate. Confocal images showed branching hyphae suggestive of a fungal infection. Fungal cultures of corneal scrapings revealed growth of Cylindrocarpon lichenicola, a saprophytic, filamentous fungus, which is an unusual cause of keratitis. Despite aggressive antifungal therapy with voriconazole and amphotericin B, she required penetrating keratoplasty for impending corneal perforation. Follow-up was uneventful, with no recurrence at 1 year. Fungal infections must be suspected in all corneal ulcers of traumatic etiology. Specific cultures and confocal microscopy must be performed early, so as to enable early treatment modification., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Polar notations (sphere, cylinder, and axis) of refraction perfectly characterize a single refraction but are not suitable for statistical analysis or graphic representation. While the spherical component of refraction can be easily analyzed by the spherical equivalent, statistical analysis of astigmatism requires non-polar expressions of refraction. Indeed, the cylinder and axis of astigmatism are not independent data. In addition, axis is a directional data including a non-trigonometric cycle. Refraction can be written in a non-polar notation by three rectangular coordinates (x, y, z), which can also represent the spherocylinder by one point in a dioptric space. These three coordinates constitute three independent (orthogonal) variables that correspond to a sphere-equivalent component and a pair of Jackson cross-cylinder components, oriented at 0°/90° (WTR/ATR astigmatism) and 45°/135° (oblique astigmatism). Statistical analysis and graphical representation become less complicated when using rectangular coordinates of refraction. Rectangular coordinates of the mean refraction are obtained by average rectangular coordinates. Similarly, rectangular coordinates of refraction change are obtained by a single subtraction of rectangular coordinates between the final and initial refractions. After statistical analysis, the rectangular coordinates obtained can be converted into a polar form for a more easily understood result. Finally, non-polar notations including rectangular coordinates are useful for statistical and graphical analysis, which would be difficult with only conventional polar notations of refraction., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Refraction can be expressed by four polar notations which correspond to four different combinations of spherical or cylindrical lenses. Conventional expressions of refraction (plus and minus cylinder notation) are described by sphere, cylinder, and axis. In the plus cylinder notation, the axis visualizes the most powerful meridian. The axis usually corresponds to the bow tie axis in curvature maps. Plus cylinder notation is also valuable for all relaxing procedures (i.e., selective suture ablation, arcuate keratotomy, etc.). In the cross-cylinder notation, two orthogonal cylinders can describe (without the sphere component) the actual refraction of both the principal meridians. This notation must be made before performing the vertex calculation. Using an association of a Jackson cross-cylinder and a spherical equivalent, refraction can be broken down into two pure components: astigmatism and sphere. All polar notations of refraction may perfectly characterize a single refraction but are not suitable for statistical analysis, which requires nonpolar expression. After doubling the axis, a rectangular projection breaks down the Jackson cross-cylinder, which has a polar axis, into two Jackson cross-cylinders on the 0 degrees /90 degrees and 45 degrees /135 degrees axis. This procedure results in the loss of the directional nature of the data. Refraction can be written in a nonpolar notation by three rectangular coordinates (x,y,z), which can also represent the spherocylinder by one point in a dioptric space. These three independent (orthogonal) variables have a concrete optical significance: a spherical component, a direct/inverse (WTR/ATR) component, and an oblique component of the astigmatism. Finally, nonpolar notations are useful for statistical analysis and graphical representation of refraction., (Copyright (c) 2009 Elsevier Masson SAS. All rights reserved.)

Introduction: To evaluate the accuracy of ocular response analyzer (ORA) parameters (corneal hysteresis (CH), corneal resistance factor (CRF), and ocular tension (IOPcc and IOPg)) and the correlation with corneal biometry measured with the Orbscan topographer., Material: and methods: The Ocular Response Analyzer is a new instrument that measures ocular rigidity/elasticity (CH and CRF) and intraocular pressure (IOPcc), which is assumed to be independent of corneal pachymetry. We compared the results of the ORA in 100 eyes with normal slit lamp examination, except ametropia, with the results from corneal measurements obtained with the Orbscan., Results: A high correlation and a low difference between the right and left eyes show the accuracy of measurements (rS=0.84, p<0.001 and 8.52%). The mean CH and CRF were 10.25+/-1.6 mmHg (range, 6.5-14.4) and 10.25+/-1.85 mmHg (range, 4.9-14.2), respectively with a Gaussian distribution in normal eyes. The relationship between CH and CRF was significant with corneal pachymetry but not with IOPcc (corneal corrected). CH and CRF were related, although to a lesser extent, with corneal diameter and astigmatism power, but not to keratometry, sex, age, or spherical equivalent., Conclusion: The mean and the distribution of biomechanical factors are similar to the values found in the literature but the relationship to pachymetry seems to be stronger (pachymetry and corneal diameter) than what has been reported in previous publications. The new IOP corrected for the cornea is independent of pachymetry but is not significantly different from Goldmann IOP or IOP measured with a standard noncontact tonometer.

Purpose: We compared pupil size measurements obtained with the Orbscan and autorefractometer to the Colvard Infrared pupillometer in order to determine their respective clinical advantages., Material and Methods: We prospectively measured the pupil diameter in 94 eyes of 47 normal patients using the Colvard device, the Nikon NKR 8000 autorefractometer, and the Orbscan device. For each device, two successive measurements were taken to determine its reproducibility. We also studied the relationship with the contralateral eye (i.e., difference and correlation). The measurements obtained with the different devices in different light intensities were compared and studied using regression analysis., Results: Pupil diameter measured using the Orbscan had the highest reproducibility (mean difference between the two successive measurements: 3.8% or 0.15mm) and showed the smallest difference between the two eyes (5.0% or 0.19mm) and the strongest correlation with the contralateral eye (r=0.93; p<0.001). Scotopic Colvard measurements and autorefractometer measurements with low light settings were not significantly different (5.86mm versus 5.86mm; p=0.48). Autorefractometer measurements with low light settings showed the strongest correlation with the scotopic Colvard measurements (r=0.84; p<0.001). The Orbscan measurements were less correlated with the scotopic or photopic Colvard measurements (r=0.73; p<0.001 and r=0.51; p=0.003, respectively). For the Colvard pupillometer, the correlation between photopic measurements and scotopic measurements was also poor (r=0.51; p<0.001)., Conclusion: Pupil size measurements with the autorefractometer may be advantageous before refractive surgery. Measuring pupil size in photopic conditions, as with the Orbscan, cannot screen people with large pupils in mesopic conditions.

Purpose: To analyze the lens biometry obtained by Orbscan and A-scan ultrasound in normal eyes., Material: and methods: The lens thickness obtained by A-scan ultrasound and the anterior curvature of the crystalline lens obtained by Orbscan were prospectively recorded in 280 normal eyes (including eyes with ametropia) of 140 patients (10-95 years of age). The correlation of lens biometry with the contralateral measure, patient age and sex, subjective refraction, and other ocular biometric parameters (anterior chamber depth, iridocorneal angle, corneal diameter, central pachymetry, pupil, corneal radii of curvature, and posterior segment length) was assessed., Results: The lens anterior curvature showed no significant correlation in particular with the subjective spherical equivalent; however, the quality of this measure was poor: the reproducibility of the lens anterior curvature was low (the average difference between two successive Orbscan measurements was 14.4%). The correlation with the contralateral eye was poor (rs=0.55; p<0.001 versus rs=0.97; p<0.001 for lens thickness). Lens thickness showed the strongest correlation with the patient's age (rs=0.82; p<0.001); it increased by 0.26 mm per decade. Lens thickness correlated with anterior chamber depth (rs=-0.72; p<0.001) and iridocorneal angle (rs=-0.65; p<0.001). The last two parameters also correlated with age (rs=-0.68; p<0.001 and rs=-0.62; p<0.001, respectively). Anterior chamber depth and iridocorneal angle decreased by -0.21 mm and -1.7 degrees , respectively, per decade., Conclusion: Lens thickness is mainly influenced by age and correlates with the anterior chamber depth and the iridocorneal angle. The influence of aging on anterior segment biometry essentially consists in an increase in lens volume.

Purpose: To study the safety and efficacy of adjuvant combination therapy using 5-fluorouracil and heparin for prevention of proliferative vitreoretinopathy (PVR) during vitrectomy for retinal detachment surgery., Methods: Two consecutive groups of 30 eyes with a rhegmatogenous retinal detachment (grade C1 or more) were prospectively compared. In the study group, 5-FU and heparin were administrated in the intraoperative infusion. Clinical safety and the efficacy were regularly studied over 1 year., Results: In the 5-FU heparin therapy group, keratitis was more frequently observed the 1st day after surgery (p = 0.005), but not after 1 week (p = 0.54). However, conjunctival hyperemia was more severe after 1 and 7 days (p = 0.04). In both groups, no differences were found concerning intraocular pressure, postoperative hemorrhage or inflammatory reaction (flare) of the anterior chamber and the aspect of the eyelids (p > or = 0.14). The number of reoperations resulting from PVR, after 1 month and 1 year, was not significantly different between the two groups (p > or = 0.3). The reattachment rate and visual acuity (BSCVA) were not statistically different after 1 year (p > or = 0.12)., Conclusion: Adjuvant combination therapy using 5-FU and heparin seems to be safe. However, its efficacy needs to be demonstrated by larger studies including eyes presenting a lower grade of PVR (grade B).

Orbscan is a recent optical device that combines the Placido disk of the videokeratoscope and a scanning slit. The scanning slit measures the elevation of both the corneal surface (anterior and posterior) and the anterior iris-lens surface. Biometric measures of the anterior segment such as corneal thickness, anterior chamber depth, corneal diameter, and iridocorneal angle are obtained using spatial coordinates of various ocular surfaces. Orbscan is not only a corneal topograph but a versatile device capable of measuring the biometry of the anterior segment of the eye.

Purpose: To evaluate the tolerance and efficiency of the Mydriasert(R) ophthalmic insert on pupil dilation., Method: Two pharmaceutical forms of a combination of tropicamide and phenylephrine (HCl) were compared on both eyes of 80 patients. For each patient, one Mydriasert insert (Ioltech) was placed in the lower conjunctival sac of the eye. Dilation of the control eye was obtained using 0.5% tropicamide eye drops and 10% phenylephrine eye drops (Novartis Ophthalmics), which were instilled with three frequency regimens (5, 10 or 15 min). The pupil diameter was regularly measured until the maximal mydriasis had occurred., Results: Both subjective and objective tolerance of the insert was excellent. The size of the maximal mydriasis obtained when using the insert was significantly greater than that obtained when using the eye drops, regardless of the frequency of the instillation (p < 0.04). The difference in maximal pupil diameter ranged from +0.16 mm to +0.38 mm. Mydriasis kinetics was slower with the insert. The time necessary to obtain a maximal mydriasis was 47.3 min when the insert was used, whereas it was in the range of 31.4 to 38.5 minutes with the eye drops (p < 0.001). As far as pupil diameter is concerned, the superiority of the insert compared to the eye drops became observable only about 45 min after the insert had been placed in the eye. The relative efficacy of the insert compared to the eye drops did not correlate with patient features (p > or = 0.06)., Conclusion: Despite the small quantity of drug delivered by the insert, Mydriasert allows a much greater mydriasis compared to that usually obtained when the eye drops were used. However, a longer time lapse is necessary for this to occur.

Proliferative vitreoretinopathy (PVR) is the major cause of retinal detachment surgery failure. Many adjuvants were studied in vitro and on animals, some were studied on humans. Daunomycin seems to reduce PVR recidivism. 5-FU and steroids are nontoxic but their efficacy is not clear. Heparin reduced postoperative inflammation and seems to reduce PVR recidivism when associated with 5-FU. Associating heparin and steroids seems to reduce PVR in some groups of patients (aphakic, anterior PVR). Colchicine and retinoic acid per os are ineffective, silicone oil is effective as an internal tamponade but not as an adjuvant of PVR. Currently, no molecule has proven efficacy as an adjunctive treatment of PVR.

Objective: To study the damage to the anterior segment of the eye during mellitus diabetes., Methods: We prospectively studied the anterior segment of the eye in 200 diabetic patients and 200 patients with no history of diabetes (control group). Parameters included the corneal curvature radius, corneal thickness, central corneal sensitivity (Cochet Bonnet esthesiometer), pupil diameter before and after dilation using tropicamide and phenylephrine eye drops, delay for maximal pupil dilation, lens transparency, and intraocular pressure. The damage to the anterior segment was compared in both groups and was correlated with the parameters of diabetes (type, duration, and equilibration), retinopathy grade, and peripheral neuropathy., Results: Corneal geometry (i.e., curvature radius and thickness) and intraocular pressure did not correlate with diabetes. Cataract was significantly influenced by diabetes (p<0.001). The duration needed to obtain pharmacological maximal mydriasis significantly correlated with iris color (rs=0.47, p<0.001), patient age (rs=0.28, p<0.001) and diabetes (rs=0.25, p<0.001). Dilation was significantly longer in the diabetic patient than in those of the control group (36.5 min vs 30.7 min, p<0.001). Corneal sensitivity significantly correlated with age (rs=0.48, p<0.001) and diabetes (rs=0.53, p<0.001). Corneal sensitivity was decreased in the diabetic group (5.42 vs 5.94, p<0.001) and it correlated with retinopathy grade (rs=0.47, p<0.001) and with peripheral neuropathy (rs=0.15, p<0.001). Sensitivity and specificity of hypoesthesia in detecting peripheral neuropathy were 67.4% and 49.4%, respectively. Among the parameters of diabetes, duration of progression showed the strongest correlation with damage to anterior segment (rs > or = 0.25, p<0.001)., Conclusion: Diabetes influences lens transparency, pharmacological pupil dilatation and corneal sensitivity. In spite of the unspecific character of the damage and the subjectivity of the measurement, corneal sensitivity is an interesting parameter to take into consideration among diabetic patients.

Purpose: To study the relationship between keratoconus and axial myopia., Methods: We prospectively studied refraction and ocular biometry in 100 consecutive keratoconus eyes, and 100 emmetropic eyes. Biometric data (including posterior segment length) were obtained by A-scan ultrasound, Orbscan, and ultrasonic pachymetry. Biometric measurements were compared in both groups., Results: Anterior chamber depth, posterior segment length and axial length were significantly different between the two groups (p<0.001). Axial length was significantly greater in the keratoconus group than in the emmetropic group (23.97 mm versus 23.21 mm, p<0.001). Posterior segment length was significantly greater in the keratoconus group than in the emmetropic group (16.54 mm versus 15.99 mm, p<0.001). In the keratoconus group, the posterior segment length and the subjective spherical equivalent were significantly correlated (rs=-0.45, p<0.001)., Conclusion: The increase in posterior segment length in the keratoconus group and the correlation between posterior segment length and spherical equivalent in the keratoconus group suggest a statistical relationship between keratoconus and axial myopia.

Purpose: To study acute-angle-closure glaucoma (AACG) biometry using Orbscan and echography., Material and Methods: We prospectively studied 200 normal eyes of 100 patients (including eyes with ametropia), 50 eyes of 25 patients before peripherial YAG laser iridotomy, 25 phakic eyes of 25 patients with a history of acute-angle-closure glaucoma (AACG) in the fellow eye. Both plane and polynomial modes of reconstruction of the iridocorneal angle measurement were analyzed. Biometric measurements of the three groups were compared. Biometric measurements (i.e., iridocorneal angle, anterior chamber depth, axial length, and lens thickness) and subjective spherical equivalent were correlated with the etiological classification., Results: Age, sex, iridocorneal angle, anterior chamber depth, lens thickness, axial length and subjective spherical equivalent were significantly different in the three groups (p<0.002). The polynomial iridocorneal angle measurement was 43.4 degrees in the normal group, 36.5 degrees in the iridotomy group, and 28.4 degrees in the AACG group (p<0.001). Iridocorneal angle measurement correlated with the other biometric measurements (rs>0.51; p<0.001) and with the etiological classification (rs< or =0.68; p<0.001). The anterior chamber depth measurement obtained by Orbscan or echography was the best parameter for predicting ACCG (rs=0.77; p<0.001)., Conclusion: The anterior chamber depth and polynimial iridocorneal angle obtained using the Orbscan device appears to be useful in predicting acute-angle-closure glaucoma.

Purpose: To report the results of limbal transplantation in patients with severe ocular burns and limbal stem cell deficiency., Patients and Methods: This series includes six autografts (unilateral ocular burns) and five allografts (bilateral ocular burns) performed in ten eyes of ten males with an average age of 43 years. The origin of the ocular burn was chemical in eight cases and thermal in the remaining two cases. The average time between the initial trauma and limbal transplantation was 79 months. The average size of limbal grafts was 190 degrees (range: 80-20 degrees for autografts and 120-360 degrees for allografts). Patients with allografts received oral cyclosporine in three cases, topical cyclosporine in one case, and intravenous methylprednisolone in one case. Eight patients underwent penetrating keratoplasty an average of 11 months after limbal transplantation (range: 5-24 months)., Results: The average follow-up time was 36 months (range: 7-77 months). The overall success rate of limbal transplantation (ocular surface improvement) was 73% (8/11). The success rate of penetrating keratoplasty was 63% (5/8). The average initial visual acuity was 0.4/10 and the average final visual acuity was 1.6/10. Visual acuity improved by two lines or more in seven cases., Discussion: Limbal transplantation is a useful surgical technique in patients with severe ocular burns. However, results remain insufficient and new techniques such as limbal stem cell culture and transplantation are needed to improve the visual prognosis of these patients.

Purpose: To determine the incidence and factors influencing glaucoma following penetrating keratoplasty., Material and Method: We prospectively studied 440 consecutive patients undergoing penetrating keratoplasty over a period of 5 years, with an average follow-up of 2 years. High intraocular pressure was defined as IOP over 20 mmHg measured by Goldmann applanation for at least 1 week or if a patient required topical treatment for at least 1 week. Before surgery, 18.7% of the patients presented with glaucoma or high intraocular pressure; 44.9% received a graft for a bullous keratopathy condition, 25.6% had keratoconus, 31.5% received an anterior chamber lens, and 48.5% were phakic., Results: After surgery, 42.2% of the patients had ocular pressure at 20 mmHg or more and required treatment for high ocular pressure. The increase in intraocular pressure appeared after an average delay of 3.3 +/- 4.7 months. The frequency of the increase in intraocular pressure was 54.3% for the bullous keratopathy patients, 26.6% for the keratoconus patients (p<0.001). At the end of the second year, the graft survival was 82.1% in absence of glaucoma, whereas it was 71.5% in cases of glaucoma after keratoplasty. Between all parameters that we studied, high intraocular pressure before surgery, etiology, the status, and receiver age over 60 years were the main factors influencing high intraocular pressure after keratoplasty. Intraocular pressure was correlated with the decrease in endothelial cell density and was at the origin of graft failure. Intraocular pressure correlated with the Best Spectacle Corrected Visual Acuity (BSCVA) by its effect on endothelial cell density and optic nerve destruction., Conclusion: The increase in intraocular pressure is a real and serious complication of keratoplasty. Its physiopathology is very complex. Better knowledge of risk factors can be useful in controlling it.

The decimal visual acuity chart is not easy to use for statistical analysis and requires a transformation into LogMAR units (decimal logarithm of the Minimum Angle Resolution). In contrast to the decimal chart, the logarithmic chart has an arithmetic progression and a constant interval between lines. The LogMAR chart makes statistical analysis of visual acuity easy. Change in visual acuity is calculated directly by subtracting LogMAR data, while the average visual acuity is obtained with the arithmetic mean value of the LogMAR data. The mean acuity expressed in LogMAR units can be transformed into a decimal chart for a more comprehensive result. To calculate the average visual acuity directly from the decimal data, the geometric mean value must be used instead of the arithmetic mean value.

Rejection is the leading cause of corneal graft failure, induced by loss of the so-called eye immune privilege. Prevention of graft rejection with immunosuppressive therapy is then necessary. Topical corticosteroids are currently the gold standard, and steroids are the only treatment for acute rejection episodes. Steroids are nonspecific immunosuppressive agents, and they can induce glaucoma, cataract, infections, and epithelial defects. Cyclosporin has a specific effect, because it inhibits interleukin-2 transcription and, consequently, the specific activation of T lymphocytes. When cyclosporin is given orally, it effectively prevents graft rejection in high-risk recipients, but it may induce severe side effects (i.e., systemic hypertension, kidney deficiency, and malignant tumor induction). When cyclosporin is given topically, it can effectively replace steroids in case of dexamethasone-induced glaucoma and graft infection, but it can also induce serious corneal epithelial defects. Cyclosporin is not a treatment for acute rejection episodes. Mycophenolate mofetil and FK 506 are promising drugs, but currently they cannot be used routinely to prevent corneal graft rejection.

Purpose: To analyze long-term refractive and videokeratoscopic changes after penetrating keratoplasty., Patients and Methods: Forty eyes of 40 patients (26 keratoconus) with a clear corneal graft and no other ocular disease were examined after all sutures were removed, respectively at 22.0+/-7.3 months and 50.5+/-13.6 months after keratoplasty. All of the eyes were examined using videokeratography (EyeSys 2000) and ultrasonic pachymetry. Changes in subjective refraction, best spectacle-corrected visual acuity (LogMAR units), topography, and central corneal thickness between both exams were recorded., Results: Visual acuity increased by an average of 0.41 lines +/-0.24 (p<0.001) between both exams, whereas no significant change in refractive astigmatism and videokeratoscopy (i.e., power, pattern, and indices) was observed. Central corneal thickness significantly increased from 545+/-36 micro m to 574+/-40 micro m (p<0.001). Change in best spectacle-corrected visual acuity significantly correlated with delay between the exams (r(s)=+0.34, p=0.03), whereas change in refractive astigmatism, topographic indices, and topographic patterns did not significantly correlate with delay., Conclusion: After penetrating keratoplasty, visual acuity improves long after surgery, whereas refraction and corneal surface regularity show no significant modification. This improvement in visual acuity, not explained by current techniques, may be due to an increase in graft transparency.

Purpose: To compare the predictability, efficacy, and safety of two methods of Lasik correction of compound myopic astigmatism: positive cylinder ablation versus negative cylinder ablation., Methods: Twenty nine eyes of 19 patients were retrospectively analyzed. They had undergone Hansatome or ALK-e flap keratectomy, and a Technolas Keracor 217c laser ablation. Group 1 (14 eyes) was corrected with the positive cylinder program, group 2 (15 eyes) with the negative cylinder program. Spherical equivalent (SE), cylinder, vector analysis, and best corrected and uncorrected visual acuities (BCVA, UVA) were compared in the two groups. Minimum follow-up was 6 months., Results: The preoperative mean SEs for groups 1 and 2 were, respectively, - 7.09+/-3.36 D and - 8.05+/-2.27 D (NS). Mean cylinders were 1.73+/-0.88 (group 1) and +/-0.74 (group 2) D. Visual acuities were not statistically different in the two groups. Postoperative mean SEs were, respectively, - 0.57+/-1.58 D and - 0.68+/-0.88 D. Mean cylinder was, respectively, 0.57 +/- 0.54 D and 0.7 +/- 0.46 D in groups 1 and 2. Astigmatism induced by surgery, calculated by vector analyses was, respectively, 1.36 +/- 0.66 D and 1.54 +/- 0.56 D. Percentages of UVA above 20/25 were, respectively, 50% and 35%. None of those differences was statistically significant. One eye lost one line of BCVA., Conclusion: The positive cylinder ablation method makes a larger optical zone of ablation possible with the same central deepness of ablation. We found that the predictability, efficacy, and safety of this technique compares well with the negative cylinder ablation in compound myopic astigmatism.

Purpose: To study the correlation between subjective refraction and biometry obtained by Orbscan and echography in normal eyes. To compare biometric parameters with the subjective spherical equivalent., Material and Methods: Subjective refraction, biometric parameters using Orbscan, and echography were recorded in 190 normal eyes (including eyes with ametropia) of 95 patients. Biometric parameters (i.e., corneal diameter, anterior chamber depth, central pachymetry, iridocorneal angle, corneal and lens radii of curvature, and axial length of the eye) were compared in different refractive groups and were correlated with the subjective refraction., Results: Corneal biometric parameters did not correlate with the subjective spherical equivalent and showed no differences between the refractive groups except for the central pachymetry. In the high myopic group (<-6D), the central cornea was significantly thinner (531 micro m versus 549 micro m, p=0.016). The correlation between corneal radius and axial length was strong in emmetropic eyes (r(s)=0.63, p<0.001) and poor but significant in ametropic eyes (r(s)=0.28, p=0.002). Axial length, anterior chamber depth, and iridocorneal angle showed significant differences between the refractive groups (p<0.001) and correlated with the subjective spherical equivalent (r(s[[/INF=0.44, p<0.001). Subjective spherical equivalent showed the strongest correlation with the axial length (rs)=0.82, p<0.001). Subjective spherical equivalent, central corneal thickness, axial length, anterior chamber depth, and anterior corneal radius showed a strong correlation between both eyes (rs[[/INF=0.94, p<0.001)., Conclusion: Biometric characteristics of the eye (excluding cornea characteristics) vary with subjective spherical equivalent. Axial length presents the strongest correlation with the subjective spherical equivalent and correlates with the other ocular biometric parameters. Axial length plays a major role in the ocular biometry and refraction.

Purpose: To report the spectrum of fungal keratitis at the Centre Hospitalier National d'Ophtalmologie XV-XX, Paris., Methods: We reviewed 19 cases of fungal keratitis from January 1993 to January 2001. We evaluated the different risk factors, fungal identification, topical and systemic antifungal therapy, surgical treatment and outcome., Results: Nineteen patients were included, 7 women and 12 men, with visual acuity ranging from 9/10 to no perception of light. The mean age was 56.2 years. Patients were hospitalized for an average stay of 16.3 days and all received a diagnostic and therapeutic scraping and 16 received a local antifungal treatment. The most common risk factors were topical steroid treatment (42.1%), corneal graft (31.6%), trauma or foreign body (31.6%). The mean delay between the first signs and fungal keratitis diagnosis was 14 days. Yeast as Candida parapsilosis and albicans were the most frequently isolated fungi (58%), followed by Aspergillus sp. (21%) and Fusarium sp. (21%). The most commonly used topical treatment was amphotericin B, and itraconazole was used as systemic treatment. Five patients had evisceration, 6 had penetrating keratoplasty and 5 retained leukoma., Conclusion: Candida was the most frequently isolated fungi and topical steroid treatment the main risk factor. The prognosis is relatively poor (26% of lost vision) because of a delay in diagnosis and other previous ocular pathology or surgery.

Purpose: To evaluate amniotic membrane transplantation (AMT) in severe corneal epithelial diseases., Methods: Amniotic membrane transplantation was performed in 14 eyes of 14 patients from four groups: A, five severe ocular burns; B, four cases of cicatricial keratoconjunctivitis; C, three persistent epithelial defects after penetrating keratoplasty; D, two cases of pseudophakic bullous keratopathy. Five patients underwent AMT alone; two patients underwent AMT combined with limbal transplantation; the other three patients had limbal transplantation performed before AMT. Eight patients required combined penetrating keratoplasty. Patients with corneal stable reepithelialization, no corneal neovascularization, and no recurrence of the initial pathology were considered successful., Results: The mean follow-up was 7+/-3 months. All but three patients underwent corneal reepithelialization within 6 weeks of AMT, with a mean healing time of 31+/-23 days. The success rate was 75% at 6 months (Kaplan-Meier method). Three of four procedures in group B failed. In eight patients, visual acuity improved, in one it worsened, and in the last five patients it remained unchanged. Visual acuity increased by an average of 7+/-9 lines., Conclusion: AMT is a useful technique for ocular surface reconstruction, especially in association with limbal transplantation. It could also improve the prognosis of penetrating keratoplasty in patients with severe corneal conditions.

Purpose: To evaluate the accuracy and reproducibility of iridocorneal angle measurement obtained with a slit-lamp method (Orbscan)., Methods: The iridocorneal angle was measured in 100 normal eyes of 50 patients using the Orbscan II device. Angles were measured in eight meridians using both the "plane" and "polynomial" modes. For each eye, two exams were taken successively and the reproducibility was calculated by analyzing the difference between both measurements. Angle value was correlated with subjective spherical equivalent and other biometric measurements obtained by Orbscan (i.e., anterior chamber depth, axial length, corneal diameter)., Results: Reproducibility of the angle measurement was significantly better with the plane mode than with the polynomial mode (5.4%+/-4.7 versus 7.2%+/-6.2; p<0.001). Reproducibility significantly varied with localization (p<0.001). Significant differences were found between reconstruction modes (49.3 degrees +/-4.6 degrees for plane mode versus 42.8 degrees +/-6.7 degrees for the polynomial mode; p<0.001) and according to localization (p=0.02). Correlation with the other biometric measurements was higher for the plane mode than for the polynomial mode. Angle measurement with the plane mode showed significant correlation with subjective spherical equivalent (r(s)=-0.59; p<0.001), the anterior chamber depth measurement (r(s)=-0.74; p<0.001), the axial length measurement (r(s)=-0.34; p<0.002), and the corneal diameter measurement (r(s)=-0.34; p<0.002)., Conclusion: The iridocorneal angle measure obtained with the plane mode showed high reproducibility and it significantly correlated with clinical parameters. It appears to be useful for clinical application.

We describe the case of a 66-year-old woman who had previously undergone facial peeling and developed severe bilateral corneal burn due to direct contact Exopeel((R)) with her eyes. Despite medical treatment and an amniotic membrane graft, deep stromal opacity persisted in one eye.

Purpose: To compare the accuracy and reproducibility of the orbscan pachymetry and ultrasonic pachymetry in the normal eye and in the penetrating keratoplasty eye., Methods: Pachymetric measurements were assessed in 50 eyes of 25 normal patients and 50 eyes of 48 patients who had undergone penetrating keratoplasty using both Orbscan II and ultrasonic pachymetry (Tomey SP-2000). For each eye, 2 successive measures were recorded with both instruments. For both devices, the default setting was used. Orbscan pachymetry maps were divided into 5 groups using a modification of Liu's classification., Results: Orbscan pachymetry strongly correlated with ultrasonic pachymetry (rs = 0.91; p < 0.001). Ultrasonic pachymetry values and Orbscan pachymetry values showed no significant differences in the normal group (respectively, 557 microns +/- 36 and 555 microns +/- 34; p > 0.05). Ultrasonic pachymetry values and orbscan pachymetry values were significantly different in the penetrating keratoplasty group (respectively, 571 microns +/- 52 and 550 microns +/- 54; p < 0.001). The best value for the acoustic factor for Orbscan pachymetry in the penetrating keratoplasty group was 0.89. Ultrasonic pachymetry reproducibility and Orbscan pachymetry reproducibility were not significantly different (0.86% +/- 0.61 v. 0.67% +/- 0.63; p = 0.13 in the normal group; 1.22% +/- 0.81 v. 1.23% +/- 1.13; p = 0.92, in the penetrating keratoplasty group). Both pachymetry methods showed less reproducibility in the penetrating keratoplasty group than in the normal group (p < 0.02). Thinnest point localization was significantly different in both groups (p < 0.001). In 66% of the normal group, the thinnest point of the cornea was located in inferotemporal quadrant. This point was located at an average of 0.63 +/- 0.25 mm from the visual axis in the normal group and 1.60 +/- 0.81 mm in the penetrating keratoplasty group (p < 0.001). Whereas "Centered round" (40%) and "centered oval" (34%) were the most common patterns in the normal group, "decentered oval" (40%) and "irregular" (30%) were more frequent in the penetrating keratoplasty group (p < 0.001)., Conclusion: Orbscan pachymetry strongly correlated with ultrasonic pachymetry. Reproducibility of both methods is excellent and not significantly different. Thinnest point localization and pachymetric map classification are significantly different in normal eyes and in penetrating keratoplasty eyes.

Purpose: To study the refractive and topographic modifications induced by penetrating keratoplasty suture removal., Methods: We prospectively studied 80 corneas from 80 patients who had undergone penetrating keratoplasty. All of the eyes were examined before and after all sutures were removed, respectively at 10.9 5.1 months and 21.5 9.6 months after keratoplasty. Subjective refraction, best spectacle-corrected visual acuity (LogMAR units), keratometry, and corneal topography using the EyeSys 2000((R)) device (axial tangential and refractive power) were recorded. Topographies were classified according to the pattern (Bogan classification) and the asphericity shape (prolate and oblate)., Results: Best spectacle-corrected visual acuity (Log MAR units) increased significantly after suture removal (1.1 1.9 lines, plt; 0.001). Suture removal decreased the subjective cylinder (5.01 D 2.06 with suture, 4.11 2.08 without suture; p=0.009). The change in subjective cylinder correlated with the change in topographic pattern(s)=0.67 p<0.001). Conversely to the "bow tie" patterns, the other topographic patterns were more frequent after suture removal. The change in visual acuity was essentially explained by the change in subjective cylinder(s)=0.40 p=0.002). The average central corneal power decreased significantly after suture removal by 0.83 to 1.81 D (p<0.001), whereas the subjective spherical equivalent increased (hyperopization) (-4.07D 3.73 with suture, -3.48 3.40 without suture; p=0.02). The change in central corneal power significantly correlated with the change in subjective spherical equivalent (r(s)()>0.30 plt; 0.001). The corneal power of the mid-periphery did not significantly change after suture removal. Suture removal significantly modified the asphericity shape distribution. (majority of prolate shape with suture, majority of oblate shape without suture, p<0.001)., Conclusion: Keratoplasty sutures induce a central bulge in the corneal graft. Suture removal induces a decrease in the subjective cylinder and it increases the subjective spherical equivalent (hyperopization) through a decrease in the central corneal power. Suture removal modifies the corneal topographic pattern and shape. Visual acuity improvement after suture removal is mainly explained by the decrease in subjective astigmatism.

Purpose: To evaluate the accuracy and reproducibility of the biometric measurements obtained with the Orbscan((R)) device in normal eyes., Methods: Anterior chamber depth, axial length, and corneal diameter were studied in 50 normal eyes of 25 patients using the Orbscan((R)) device and A-Scan ultrasonography. For each eye, two exams were done successively and reproducibility was calculated by analyzing the difference between both measurements., Results: The reproducibility of anterior chamber depth and corneal diameter measurements obtained by Orbscan((R)) was high (respectively 0.721.25% and 0.831.40%). The anterior chamber depth measurements by Orbscan((R)) and A-Scan ultrasonography were strongly correlated (rs=0.92;p<0.001). The axial length measurement obtained with the Orbscan((R)) device was less reproducible (3.554.11%). For the axial length, the Orbscan((R)) measurements and A-Scan ultrasonography measurement was poorly correlated. (rs=0.64; p<0.001)., Conclusion: The anterior chamber depth measurement obtained with the Orbscan((R)) device showed high reproducibility and it was strongly correlated with the measurement obtained by A-Scan ultrasonography. Axial length measurement obtained with the Orbscan((R)) device was less reproducible and poorly correlated with the A-Scan ultrasonography measurement. It was not relevant for clinical application.

Idiopathic polypoidal choroidal vasculopathy (IPCV) has recently been recognized as a distinct cause of recurrent subretinal hemorrhages and exudates as well as multiple hemorrhagic retinal pigment epithelium detachments in the macula. IPCV is usually considered to have a good visual prognosis. We report the case of a 44-year-old woman with particularly severe bilateral macular and peripheral IPCV. The patient was followed for 13 years and had final visual acuity of counting fingers in the right eye and 20/400 in the left eye. Patients with IPCV with macular choroidal neovascularization tend to have a poor visual prognosis. This case of IPCV should alert the physician to be particularly attentive to the follow-up of these patients.

We report four cases of Urrets-Zavalia Syndrome (fixed dilated pupil with iris atrophy) observed after penetrating keratoplasty. The precise etiology of the syndrome is uncertain and different mechanisms are reviewed. Care should be taken to avoid the use of mydriatic eye drops after penetrating keratoplasty.

Purpose: To study the correlation between subjective refraction and corneal topography. To compare the topographic analysis of surgically induced astigmatism (cataract and penetrating keratoplasty) with that of idiopathic astigmatism., Methods: Subjective astigmatism, subjective spherical equivalent, best spectacle-corrected visual acuity (LogMAR units), and videokeratoscopy using the EyeSys 2000((R)) device (axial, tangential, and refractive power) were recorded in 100 eyes with idiopathic astigmatism, 100 eyes after cataract surgery, and 100 eyes after penetrating keratoplasty. Topographies were classified according to pattern (Bogan classification) and asphericity (shape factor: prolate or oblate)., Results: The asphericity shape distribution was significantly different between the 3 groups (p<0.001). The shape of idiopathic astigmatism was almost always prolate (90%) whereas the oblate shape was more frequent in the penetrating keratoplasty group (75%). There was no significant difference in topographic pattern distribution between the 3 groups (p=0.11). The asymmetric bow tie pattern was the most common topographic pattern. Topography pattern classification was significantly correlated with the subjective astigmatic cylinder. (r(s)=0.60, p<0.001). Unlike the round and oval patterns, the bow tie pattern was associated with the high subjective cylinder. Correlation between the subjective cylinder, the refractive power cylinder, and the axial power cylinder was strong (r(s)=0.92 p<0.001), but it was weak for the tangential power cylinder (r(s)=0.72 p<0.001). The correlation between the subjective spherical equivalent and central cornea power was poor (r(s)<0.37, p<0.001). Subjective astigmatic cylinder showed the strongest correlation with best spectacle-corrected visual acuity (r(s)=0.70, p<0.001), whereas the predicted corneal acuity, corneal uniformity index, asphericity, and refractive power symmetry index were poorly correlated with it (r(s)<0.54, p<0.001)., Conclusion: Despite the difference in the asphericity shape, the topographic pattern was similar in the 3 groups. The pattern type was significantly correlated with the subjective astigmatic cylinder. Topographic indices failed to predict visual acuity, while the subjective cylinder showed a strong correlation with visual acuity.

We report a case of herpetic perforated peripheral corneal ulcer in a patient with cutaneous porphyria and hepatitis C. The patient underwent peripheral lamellar keratoplasty. Antiherpetic antibodies were found at a significantly higher level in the aqueous humor than in the serum. Outcome was favorable with antiviral treatment. We discuss the causal role of the hepatitis C virus, porphyria and herpes simplex.

We report a case of acute angle-closure glaucoma in a patient treated with bronchodilator nebulization. An 82-year-old man with chronic obstructive bronchopathy was treated for acute respiratory decompensation with salbutamol and ipratropium bromide aerosols. Twenty-four hours after beginning the treatment, the patient developed acute angle-closure glaucoma which resolved rapidly with appropriate treatment. The case emphasizes the importance of precautionary measures (waterproof glasses and inhalation masks). In addition patients with a high risk of angle-closure glaucoma should be detected prior to prescribing bronchodilating aerosols.

Purpose: To compare the accuracy and reproducibility of the Eye Sys videokeratoscope algorithms for analyzing idiopathic and surgery-induced astigmatism analysis., Methods: Refractive astigmatism, videokeratoscopy (axial, tangential and refractive power), autorefractometry, autokeratometry, and keratometry were recorded in 20 patients with idiopathic astigmatism, 40 patients who had undergone cataract surgery and 40 patients who had undergone penetrating keratoplasty. For each eye, 2 successive videokeratoscopy were recorded., Results: Both cylinder and axis provided by the tangential algorithm are significantly less reproducible than the cylinder and axis provided by the axial and refractive algorithms (P < 0.001). Cylinders provided by the axial and refractive algorithms showed a stronger correlation with subjective cylinder (rs > 0.89; p < 0.001) than the cylinder provided by the tangential algorithm (rs = 0.66; p < 0.001). Both keratometric axis and autokeratometric axis showed the strongest correlation with subjective axis (rs > 0.92; p < 0.001). The accuracy and reproducibility were higher for the topographic "bow tie" patterns than for the other topographic patterns., Conclusion: The axial and refractive algorithms of the Eye Sys videokeratoscope are more accurate and reproducible than the tangential algorithm for analyzing idiopathic or surgery-induced astigmatism.

Purpose: To investigate the effect of sodium hyaluronate on reepithelialization time after penetrating keratoplaty., Methods: We prospectly studied 56 consecutive penetrating keratoplasties. One group of patients (n = 22) received dexamethasone ointment at the end of surgery. The second group (n = 34) received sodium hyaluronate and topical dexamethasone. Postoperative reepithelialization time and graft central thickness were recorded., Results: There was no statistical difference between both groups for epithelialization (4.6 + 3.2 days in the hyaluronate group and 4.4 + 2.3 days in the dexamathasone group) and for graft thickness at day one (710 + 85 microns for the former group and 713 + 84 microns for the latter group) and at day of reepithelialization (663 + 80 microns for the former group and 703 + 99 microns for the latter group). The epithelium aspect was different at the first postoperative day between both groups., Conclusion: The use of sodium hyaluronate at the end of penetrating keratoplasty improves the graft epithelium aspect at the first postoperative day, but it does not influence reepithelialization time. Further studies are needed to investigate the mechanism of sodium hyaluronate effect on corneal epithelium.

Infectious crystalline keratopathy is an exceptional but serious complication of penetrating keratoplasty. Streptococcus viridans and a steroid treatment are very often found. The treatment is always lengthy and difficult. The high number of bacteria and the steroid treatment, necessary to prevent rejection, worsen the infection. We report a case of Streptococcus crystalline keratopathy that evolved, despite the treatment, simultaneously toward abscess and acute rejection. Topical cyclosporin treatment was used to maintain an immunosuppression without worsening the infection.

Purpose: To evaluate the clinical results of the triple procedure performed using phacoemulsification., Methods: We prospectively studied 23 consecutive triple procedures carried out during a 3-year period. The average follow-up was 18 months. The main indications for grafting were Fuchs' endothelial dystrophy (30%) and infectious keratitis (26%)., Results: A capsulorrhexis was performed in 70% of the cases whereas a "can opener" was performed in the remaining 30%. A divide and conquer phacoemulsification method was used in 43% of the cases. Hydrodissection was used for lens removing in 27% of the cases. The posterior lens capsule was inadvertently broken and a flexible anterior chamber lens was inserted in one case. Twenty-two posterior chamber lenses were inserted in the capsular bag (16) or in the sulcus (6). The estimated 1-year graft survival was 76.8% overall, and 92.9% when high-risk recipients were excluded. Causes of graft failure were immune rejection (n = 4), persistent epithelial defect (n = 1) and uncontrolled glaucoma (n = 1). The average endothelial density during the second year was 1,401 cell/mm2. Average corrected visual acuity was 20/45 at 12 months. Average astigmatism was 3.9 D. No retinal complication was observed., Conclusions: In-the-bag placement of posterior chamber lens is a safe and useful technique during the triple procedure. Phacoemulsification may be useful when the nucleus is hard and voluminous.

Purpose: To study the factors which induce post keratoplasty astigmatism. To assess the reliability of different methods in the astigmatism measurement and to study the visual acuity predicting factors., Methods: We retrospectively studied the corneal topography in 60 eyes with penetrating keratoplasty after suture removal, using the CAS* (Eye Sys). The diagnosis was keratoconus in 65% of the cases and bullous keratopathy in 15% of the cases. The graft was secured with a single running suture in 38.3% of the cases, interrupted sutures in 23.3% of the cases, or a combination of both running and interrupted sutures in remaining 28.3%., Results: The suture method, diagnosis and surgeon did not influence subjective refraction nor visual acuity. The topographic pattern correlated with subjective cylinder (rs = 0.52 p = 0.02). The refractive power cylinder ("Holladay diagnostic summary") correlated well with subjective cylinder (rs = 0.81 p < 0.001) and visual acuity (rs = -0.63; p < 0.001). The Javal keratometry remains the best method to measure astigmatism axis (rs = 0.58; p < 0.001)., Conclusions: The Holladay diagnostic summary (refractive power) is a useful tool for evaluating qualitative outcome of corneal transplantation.