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Purpose Descemet stripping endothelial keratoplasty (DSEK), currently the most common procedure for managing corneal endothelial dysfunction, may be repeated following DSEK failure from a variety of causes. This multicenter study reports the risk factors and outcomes of repeat DSEK. Methods This was an institutional review board-approved multicenter retrospective chart review of patients who underwent repeat DSEK. Twelve surgeons from 5 Midwest academic centers and 3 private practice groups participated. The Eversight Eye Bank provided clinical indication and donor graft data. We also assessed the role of the learning curve by comparing cohorts from the first and second 5-year periods. Results A total of 121 eyes from 121 patients who underwent repeat DSEK were identified. The average age of the patients was 70 ± 12 years. The most common indication for repeat DSEK was late endothelial graft failure without rejection (58%, N = 63). Average preoperative and 12-month postoperative repeat DSEK corrected distance visual acuities were 20/694 and 20/89, respectively. Visual acuity outcomes, endothelial cell density, and cell loss did not significantly vary between the 2 cohorts. Initial graft rebubble rates for the first and second cohorts were 51% and 25%. The presence of glaucoma, prior glaucoma surgery, or a history of penetrating (full thickness) keratoplasty did not significantly affect visual outcomes. The median, mean, and range of intraocular pressures before repeat DSEK were 15.0, 15.7, and 6 to 37 mm Hg, respectively. Patients with higher intraocular pressures before repeat DSEK had improved postoperative corrected distance visual acuities. Conclusions Repeating DSEK improves vision following failed or decompensated DSEK surgery. Higher preoperative repeat DSEK IOPs were associated with improved visual outcomes, and initial graft rebubble rates, which decreased over time, were likely due to surgeon experience.

Purpose To report the postoperative clinical course of 3 patients who underwent corneal transplantation with corneal allografts contaminated with Clostridium perfringens and to evaluate the risk factors for anaerobic contamination in 2 donors. Methods Patient records and adverse reaction reports from a single eye bank related to cases of posttransplant C. perfringens endophthalmitis were reviewed. Records regarding the mated corneas, donor autopsy reports, and other pertinent data were also reviewed. Results Three adverse reactions associated with transplantation of corneal allografts contaminated with C. perfringens were reported. Two cases were from mated corneas. Both patients developed fulminant endophthalmitis after undergoing uncomplicated penetrating keratoplasty and required subsequent enucleation. Another isolated case (with no adverse reaction in the mate cornea) developed hypopyon postoperatively that resolved with intravitreal and topical antibiotics. Possible risk factors for anaerobic tissue contamination in the donors included illicit drug use in the first donor and exposure to sewage at the time of death in the second donor. Conclusions Clostridial endophthalmitis is an aggressive rapidly progressive infection with potentially poor visual outcomes that can be transmitted from infected corneal allografts. Further investigation is needed to clarify the role of anaerobic donor rim cultures and the donor risk factors associated with recovering corneal allograft tissue contaminated with C. perfringens.

Laser in situ keratomileusis (LASIK) is the most commonly performed refractive surgical procedure for the correction of ametropia. The advantages of LASIK include rapid visual rehabilitation, decreased stromal scarring, less irregular astigmatism, minimal regression, less postoperative pain, and the ability to treat a greater range of refractive disorders. Unlike surface-ablation procedures, LASIK preserves the integrity of Bowman’s membrane and the overlying epithelium, thus decreasing the risk for microbial keratitis. However, microbial keratitis following LASIK has become an increasingly recognized, sight-threatening complication of refractive surgery. The incidence of infectious keratitis following LASIK is difficult to estimate and can vary widely depending on the source of the information. One large retrospective study investigating the complications associated with LASIK found an incidence of 2 infections in 1062 eyes; a similar study found an incidence of 1 infection in 1019 eyes. A more recent case series of LASIK-associated infections encountered at a single institution reports an estimated incidence between 1:1000 and 1:5000. Based on a comprehensive review and analysis of the literature on infections following LASIK, Chang et al. state that the incidence of infection after LASIK can vary widely (0% to 1.5%). In a survey by the American Society of Cataract and Refractive Surgery (ASCRS), the incidence reported by LASIK surgeons who had experienced an infectious keratitis was 1 in 2919 cases performed during the year 2001. In this study of 116 cases, 76 presented the first week after surgery, 7 during the second week, 17 between the second week and the fourth week, and 16 after 1 month. The most common organisms cultured were atypical mycobacteria (33 of 116 cases, 28%) and staphylococci (23 of 116 cases, 20%) species. In 47 of the 116 cases, infectious keratitis was

Purpose To analyze the results of resident-performed laser in situ keratomileusis (LASIK). Setting Rush University Medical Center, Department of Ophthalmology, Chicago, Illinois, USA. Methods This retrospective study comprised 44 consecutive eyes of 22 patients who had LASIK performed from August 2000 through February 2002. Based on preoperative spherical equivalent, the eyes were divided into a low myopia group (A) (−1.0 to −6.0 diopter [D]) and a higher myopia group (B) (> −6.01 D). Preoperative and postoperative spherical equivalent (SE), best corrected visual acuity (BCVA), and uncorrected visual acuity (UCVA) were measured and analyzed within each group. Patients had at least 2 follow-up visits, with the second visit occurring between 1 and 9 months postoperatively. Results Preoperatively, the mean SE in Group A was −3.93 D ± 1.53 (SD) and in Group B, −8.49 ± 1.70 D. At the final visit, the SE in Group A decreased to −0.29 ± 0.55 D and in Group B, −1.09 ± 0.87 D. The UCVA in Group A at the final visit was 20/20 or better in 43% of eyes and 20/40 or better in 100% of eyes. In Group B, the UCVA was 20/20 or better in 31% of eyes and 20/40 or better in 75% of eyes. In all eyes, the BCVA improved by 1 line in 16% or remained the same in 84%. No eyes lost any lines of BCVA. The SE taken at the last visit was within ±0.5 D in 69% of all eyes and within ±1.0 D in 82% of all eyes. The incidence of patients needing retreatment in resident-performed LASIK surgery was 3 of 44 (6.8%). Conclusions Laser in situ keratomileusis performed by residents is a safe and effective procedure for correction of refractive error. Postoperative UCVA, refractive error, retreatment rate, and loss of BCVA were consistent with published results from nonresident surgeons. These results also exceeded the U.S. Food and Drug Administration requirements for LASIK surgery.

* BACKGROUND: The purpose of the microkeratome in laser assisted in situ keratomileusis (LASIK) is to create a corneal flap of desired thickness, thus exposing the stroma. The accuracy and repeatability of intended flap thickness with the current microkeratome system has not been documented. The purpose of this study was to determine the precision and consistency of creating a corneal flap thickness of 160µm with the Moria LSK-One microkeratome (distributed by Microtech, Inc., Doylestown, PA). * PATIENTS AND METHODS: The records of 93 eyes from 67 patients who underwent LASIK were reviewed. The central corneal thickness was measured at baseline. The microkeratome using a "130" footplate was used to create an intended flap 160pm thick, and the corneal thickness was then remeasured. * RESULTS: The mean flap thickness for both eyes combined was 1 59pm (S.D. = 28). There was no significant correlation between pre-flap corneal thickness or average K and the corneal flap thickness. * CONCLUSION: This study provides evidence that the Moria LSK-One microkeratome creates reproducible LASIK flaps consistently near the intended 160µm corneal flap thickness. This knowledge enables the surgeon to make a corneal flap with great confidence in the thickness of the excision. In addition, this study provides a clinical, in vivo model for testing corneal flap thickness. [Ophthalmic Surg Lasers 1999;30:350-353.]

Ocular adnexal mucosal-associated lymphoid tissue lymphomas (MALTomas) are rare, and there are no phase III trials to guide treatment. Primary radiation therapy has been the typical management. This retrospective series reports the experience of a single institution and adds to the current literature.Our electronic medical record system and available paper charts were used to identify patients with MALTomas of the lacrimal gland or sac, conjunctiva, and orbital structures, including extraocular muscles. In order to determine pathology, staging, treatment information, local and distant control, salvage treatments, and late toxicity, records were reviewed.Sixteen patients with ocular adnexal MALTomas had local radiation between 1992 and 2011 for primary or recurrent disease. Fifty percent of patients had lymphoma in the conjunctiva, 25% had lymphoma in the lacrimal sac/gland, and 25% of patients had lymphoma in the posterior orbit. Stage IAE disease occurred in 75% of patients, 6% had stage IIAE disease, and 19% of patients had a positive bone marrow biopsy. One patient received chemotherapy as part of initial therapy. The median radiation dose was 30 Gy (25.5-36 Gy) delivered with electrons (31%) or photons (69%). After a mean follow-up of 62.8 months, 2 patients had residual/progressive disease, 2 had contralateral recurrence, and 1 patient had a distant failure, for local control of 87.5% and overall disease control of 68.75%. Recurrence/progression occurred at a median of 35.45 months. Two patients with residual/progressive disease and 1 patient with a contralateral recurrence were followed, successfully salvaged, and have no evidence of disease. Fourteen patients are still alive, and there were no disease-related/toxicity deaths. Seven patients developed cataracts in the treated eye, 2 patients had radiation retinopathy, 2 had permanent dry eye syndrome, and 1 patient had severe keratopathy requiring enucleation. Six patients (3.75%) had worsening visual acuity of unclear etiology.Primary radiation therapy for ocular adnexal MALTomas with a median dose of 30 Gy led to excellent local control. Patients who did recur were successfully salvaged. Radiation was generally well tolerated, with expected cataractogenesis, given the dose required to achieve local control (with only 1 patient developing severe keratopathy after receiving the highest dose in this series).

To outline current options for managing astigmatism during cataract surgery and update readers on new techniques for improving the final refractive outcome in these patients.Recent studies continue to show the effectiveness of peripheral corneal relaxing incisions (PCRIs) for correcting astigmatism in combination with monofocal, multifocal, and toric intraocular lens (IOL) implants. The options in toric IOLs are expanding. Intraoperative aberrometry is a new tool that can improve the accuracy of PCRIs and toric IOLs.PCRIs and toric IOLs are currently the two main options for astigmatism management during cataract surgery. Refractive outcomes are improved by new techniques, which refine the effectiveness and accuracy of these two options.

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

To investigate the incidence, culture results, treatment, and visual outcomes of infectious keratitis after laser in situ keratomileusis (LASIK) worldwide, the Cornea Clinical Committee of the American Society of Cataract and Refractive Surgery (ASCRS) contacted 8600 United States and international ASCRS members by e-mail and asked them to respond to a questionnaire about post-LASIK infectious keratitis. One hundred sixteen infections were reported by 56 LASIK surgeons who had performed an estimated 338 550 procedures. Seventy-six cases presented in the first week after surgery, 7 during the second week, 17 between the second and fourth weeks, and 16 after 1 month. Forty-seven cases were not diagnosed on initial presentation. The most common organisms cultured were atypical mycobacteria and staphylococci. Empiric therapy is not recommended as most of the organisms are opportunistic and not responsive to conventional therapy. Flap elevation and culturing should be performed when post-LASIK infectious keratitis is suspected.

PURPOSE: To report an effective treatment for recurrent squamous papillomas of the conjunctiva with excision and application of mitomycin C. METHOD: Case report. RESULTS: A 5-year-old African-American girl with recurrent squamous papillomas of the right bulbar and palpebral conjunctiva was treated with multiple therapies, including excision, cryotherapy, and conjunctival injection of alpha-interferon; all therapies were followed by recurrence. After treatment with excision followed by intraoperative application of mitomycin C to the involved conjunctiva, the patient had no recurrence in a 30-month period. CONCLUSIONS: Excision with application of mitomycin C was successful in managing a case of squamous papillomatosis that was resistant to traditional therapy.

The authors describe a technique to facilitate the centration of the donor lenticule during Descemet’s stripping and automated endothelial keratoplasty. The donor corneal lenticule is unfolded and grossly centered in the anterior chamber using a barbed 30-gauge needle on a 3-cc air syringe or a reverse Sinsky hook. Fine adjustments to center the lenticule can be achieved by applying external pressure to the cornea with a laser in-situ keratomileusis flap roller. This simple technique provides a mechanism for simultaneously removing interface fluid and allows the surgeon to center the donor corneal lenticule without further risk of direct mechanical trauma to the donor endothelium.

e18502 Background: Ocular adnexal mucosal associated lymphoid tissue lymphomas (MALTomas) are rare with no phase III trials to guide treatment. Typical management has been primary radiation therapy. This retrospective series aims to report the experience of a single institution and add to the current literature. Methods: Using our electronic medical record systems and available paper charts, we identified patients with MALTomas of the lacrimal gland or sac, conjunctiva, and posterior orbital structures. Records were reviewed to determine pathology, staging, treatment information, local and distant control, salvage treatments, and late toxicity. Results: Sixteen patients with ocular adnexal MALTomas had local radiation between 1992 and 2011 for primary or recurrent disease. 50% had lymphoma in the conjunctiva, 25% in the lacrimal sac/gland, and 25% in the posterior orbit. 75% had stage IAE disease, 6% had stage IIAE, and 19% had a positive bone marrow biopsy. One patient received chemotherapy as part of his initial therapy. The median radiation dose was 30 Gy (25.5-36 Gy) delivered with electrons (31%) or photons (69%). After a median follow-up of 34.78 months, two patients had residual/progressive disease, two had contralateral recurrence, and 1 had a distant failure, for local control of 87.5% and overall disease control of 68.75%. Recurrence/progression occurred at a median of 35.45 months. Two patients with residual/progressive disease and one with a contralateral recurrence were followed, successfully salvaged, and are NED. Fourteen patients are still alive and there were no disease-related/toxicity deaths. Seven patients developed cataracts in the treated eye, 2 had radiation retinopathy, 2 had permanent dry eye syndrome, and 1 had severe keratopathy requiring enucleation. Six patients (3.75%) had worsening visual acuity of unclear etiology. Conclusions: Primary radiation therapy for ocular adnexal MALTomas with a median dose of 30 Gy led to excellent local control. Those patients who did recur were successfully salvaged. Radiation was generally well-tolerated with expected cataractogenesis given the dose required to achieve local control with only one patient developing severe keratopathy after receiving the highest dose in this series.

Overcorrection is a significant complication following radial keratotomy (RK). This study using human cadaver eyes demonstrates that the use of interrupted sutures placed across radial incisions coincident with a 7-mm optical zone mark can induce a wide range of central corneal steepening and can therefore correct varying amounts of hyperopia following RK. A case presentation confirms the effectiveness of using interrupted sutures to steepen the cornea following RK, but it also shows that significant regression of the effect must be considered at the time of suture placement. Since placement of interrupted corneal sutures is a routine procedure, it is a very convenient technique for treating overcorrection following RK.

Infectious keratitis may be unsuspected preoperatively in patients undergoing penetrating keratoplasty. We have diagnosed five cases of previously unknown corneal infection discovered only after post-keratoplasty histopathologic examination using specific stains. These cases of preoperatively unsuspected infectious keratitis illustrate examples where histopathologic examination using specialized stains may alert the physician to the need for appropriate postoperative antimicrobial therapy. Furthermore, these cases illustrate the ability of soft contact lenses to mask symptoms of infectious keratitis. Additionally, the clinical appearance of advanced bullous keratopathy may mask signs of infectious keratitis.

The mechanism by which surgical procedures correct astigmatism are incompletely understood and, therefore, the results are often unpredictable. In this study, a Terry keratometer was used to analyze the effect of each component part of a 3-, 4-, and 5-mm trapezoidal astigmatic keratotomy. Semiradial incisions along the horizontal meridian produced corneal flattening along the horizontal meridian twice that of the vertical meridian, therefore inducing positive cylinder astigmatism at 90 degrees. A single pair of tangential incisions placed 5 mm apart, when added to the semiradial incisions, accounted for 100%, 87%, and 78% of the maximal effect from the 3-, 4-, and 5-mm completed trapezoidal astigmatic keratotomies, respectively. This study suggests that maximal correction of astigmatism may be attained with a single set of tangential incisions placed 5 mm apart between two sets of semiradial incisions.

• Bandage soft contact lenses are an effective therapy for patients with a variety of corneal diseases. These patients often require accurate measurement of the intraocular pressure, necessitating movement or removal of the contact lens for slit-lamp Goldmann applanation tonometry. Intraocular pressure was measured in 21 normal, healthy volunteers, using a pneumatonometer (Alcon). A therapeutic soft contact lens (Plano T) was then placed on the eye and the pneumatonometer was used to remeasure the intraocular pressure through the contact lens. The average intraocular pressure without the contact lens was not statistically different from the intraocular pressure with the contact lens. These data suggest that pneumatonometry is an effective way to assess the intraocular pressure in patients wearing bandage contact lenses, thus eliminating the need to manipulate the lens solely for the purpose of intraocular pressure determination.

Acanthamoeba keratitis has frequently been associated with contact lens use. In this study, contaminated hydrogel contact lenses of patients were subjected to disinfection by thermal hydrogen peroxide and chemical (quaternary ammonium) systems. New hydrogel contact lenses contaminated by incubation on Acanthamoeba polyphaga plates were similarly subjected to the disinfection systems described above. Thermal disinfection was universally effective in eradicating acanthamoeba, whereas hydrogen peroxide and quaternary ammonium disinfection were ineffective. Scanning electron microscope photomicrographs suggest that acanthamoeba may adhere to surfaces of hydrogel contact lenses. These findings have significant implications for soft contact lens users.

To the Editor. —The testing of visual acuity in a young child or an illiterate patient is often a difficult task. Poor attention and comprehension of the examination may compromise the accuracy or validity of the results. The HOTV acuity testing system (Good-Lite Co, Forest Park, Ill) is a widely used method for testing visual acuity in these patients. However, the testing is complicated by difficulty in directing the patient's attention to the letter of interest. We have devised a technique for handlight retroillumination of the standard HOTV visual acuity chart to simplify the examination procedure. The patient is seated in the examination chair holding the HOTV's standard letter board. The patient is instructed in the technique of recognition of matched letters for the examiner's HOTV chart to the patient's board. The examiner faces the patient from a distance of 10 ft and holds up the HOTV acuity chart. Using