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Objective Comparison of conventional Penetrating Keratoplasty (PKP), posterior mushroom PKP and Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) regarding overall graft survival of primary corneal transplants for Fuchs´ endothelial dystrophy (FED), best spectacle-corrected visual acuity (BSCVA) and astigmatism. Methods Single centre study using prospectively collected data from the national database for follow-up of corneal transplants. Main outcome parameters: 10 years graft survival, astigmatism at 24 months, pre- and post-operative BSCVA. Results In total, 721 cases were included: PKP, n = 171; posterior mushroom PKP, n = 91; and DSAEK, n = 459. There was no significant difference in graft survival between PKP, posterior mushroom PKP and the DSAEK technique (log-rank test, P = 0.12). The overall post-operative BSCVA improvement in all treatment groups was significant (paired t-test, P

Item does not contain fulltext Importance: Myopia (ie, nearsightedness) is becoming the most common eye disorder to cause blindness in younger persons in many parts of the world. Visual impairment due to myopia is associated with structural changes of the retina and the globe because of elongation of the eye axis. How axial length-a sum of the anterior chamber depth, lens thickness, and vitreous chamber depth-and myopia relate to the development of visual impairment over time is unknown. Objectives: To evaluate the association between axial length, spherical equivalent, and the risk of visual impairment and to make projections of visual impairment for regions with high prevalence rates. Design, Setting, and Participants: This cross-sectional study uses population-based data from the Rotterdam Study I (1990 to 1993), II (2000 to 2002), and III (2006 to 2008) and the Erasmus Rucphen Family Study (2002 to 2005) as well as case-control data from the Myopia Study (2010 to 2012) from the Netherlands. In total, 15404 individuals with data on spherical equivalent and 9074 individuals with data on axial length were included in the study; right eyes were used for analyses. Data were analyzed from September 2014 to May 2016. Main Outcomes and Measures: Visual impairment and blindness (defined according to the World Health Organization criteria as a visual acuity less than 0.3) and predicted rates of visual impairment specifically for persons with myopia. Results: Of the 15693 individuals included in this study, the mean (SD) age was 61.3 (11.4) years, and 8961 (57.1%) were female. Axial length ranged from 15.3 to 37.8 mm; 819 individuals had an axial length of 26 mm or greater. Spherical equivalent ranged from -25 to +14 diopters; 796 persons had high myopia (ie, a spherical equivalent of -6 diopters or less). The prevalence of visual impairment varied from 1.0% to 4.1% in the population-based studies, was 5.4% in the Myopia Study, and was 0.3% in controls. The prevalence of visual impairment rose with increasing axial length and spherical equivalent, with a cumulative incidence (SE) of visual impairment of 3.8% (1.3) for participants aged 75 years with an axial length of 24 to less than 26 mm and greater than 90% (8.1) with an axial length of 30 mm or greater. The cumulative risk (SE) of visual impairment was 5.7% (1.3) for participants aged 60 years and 39% (4.9) for those aged 75 years with a spherical equivalent of -6 diopters or less. Projections of these data suggest that visual impairment will increase 7- to 13-fold by 2055 in high-risk areas. Conclusions and Relevance: This study demonstrated that visual impairment is associated with axial length and spherical equivalent and may be unavoidable at the most extreme values in this population. Developing strategies to prevent the development of myopia and its complications could help to avoid an increase of visual impairment in the working-age population.

To investigate the clinical presentation, isolated organism, treatment, and morbidity of contact lens–associated microbial keratitis needing hospitalization. This retrospective study included all consecutive patients with contact lens–associated microbial keratitis hospitalized in the Rotterdam Eye Hospital from January 1, 2005, to December 31, 2009. All data regarding epidemiological characteristics, clinical presentation, isolated organism, and treatment were collected from medical records. There were 109 cases (108 patients) of contact lens–associated microbial keratitis hospitalized during the study period. Mean age was 33.3 ± 15.4 (SD) years. Pseudomonas aeruginosa was the most frequently isolated microorganism (68.8 %), with minor resistance to gentamicin (2.7 %) and ofloxacin (1.3 %). At time of presentation, best corrected visual acuity (BCVA) was very poor, with the largest proportion of patients (65.1 %) seeing worse than 0.05 Snellen. After intensive treatment, the visual outcome improved considerably, with the largest proportion (67.0 %) achieving a BCVA ≥ 0.7 Snellen. Low BCVA at admission was significantly associated with a worse final BCVA. A total of 22 patients (20.2 %) required corneal transplantation (three emergency cases). Larger size of stromal infiltrate was significantly associated with the need for corneal transplantation. Microbial keratitis is a serious complication of contact lens wear, with approximately one out of five hospitalized cases requiring corneal transplantation. Ofloxacin, or a combination of gentamicin and cephazolin, still appear to be excellent first-choice therapies in the Netherlands, as little resistance has developed to these antibiotics.

PURPOSE: To assess age-related risk factors (RFs), microbiologic profile, and prognosis of infectious keratitis and create guidelines for prevention and treatment. METHODS: Retrospective review of patients with infectious keratitis admitted to 2 Dutch tertiary referral centers from January 2002 to December 2004. RESULTS: Forty-nine patients were admitted to the Academic Medical Center (Amsterdam) and 107 to the Rotterdam Eye Hospital. Mean age was 56.6 +/- 24.4 (SD) years; 49.4% were >or=60 years of age. The most common RFs among the elderly were systemic illness (36.4%), ocular surgery (33.8%), topical steroids (26%), blepharitis (20.8%), and herpetic eye disease (28.6%). This was significantly different from the most common RFs among younger patients (contact lens wear, 62.7%; chi2, P = 0.000). Gram-negative infections predominated (52.3%) and were more prevalent among younger patients (chi2, P = 0.000). Gram-positive infections prevailed among the elderly. Untreated patients had higher culture positive rates (68.7%) than patients treated with antibiotics before culturing (41.3%; chi2, P = 0.001). Elderly patients had a higher risk of perforations than younger patients (27.6% vs. 9.9%), a worse prognosis (mean VA, 6/30 vs. 6/10), and more often needed surgery (57.1% vs. 23.4%; P < 0.005 in all cases). CONCLUSIONS: Infectious keratitis is a more severe disease in elderly than in younger patients with more complications and a worse prognosis. Elderly patients have multiple and more diverse risk factors, making prevention difficult. Prevention should aim at minimizing topical steroid use and controlling blepharitis, ocular surface disease, and herpetic eye disease. Initial antibiotic treatment should include sufficient coverage of Gram-positive pathogens

Objective: To determine the prophylactic effect of oral acyclovir on the recurrence rate of herpetic eye disease after penetrating keratoplasty. Design: A randomized, double-masked, placebo-controlled multicenter trial. Participants: Sixty-eight consecutive patients (68 eyes) with corneal opacities due to herpetic eye disease who underwent penetrating keratoplasty. Intervention: Oral acyclovir 400 mg twice daily or placebo tablets for 6 months. Main Outcome Measures: The recurrence rate of herpetic eye disease-related events and rejection episodes, proven by viral cell culture or polymerase chain reaction. Results: During the 2-year follow-up period, there were 3 culture-proven herpetic eye disease recurrences in the acyclovir group and 9 in the placebo group. Lifetime survival analysis of the probability of remaining free from recurrence revealed a significantly reduced risk of recurrent herpetic disease in the acyclovir-treated group. Conclusion: This study suggests that oral acyclovir effectively prevents herpes-related recurrences after penetrating keratoplasty in herpetic eye disease.

Contains fulltext : 80692.pdf (Publisher’s version ) (Closed access) PURPOSE: To investigate the long-term effect of oral acyclovir administered during the first 6 months after penetrating keratoplasty (PK) for herpetic eye disease (HED). METHODS: A 5-year follow-up was undertaken for a patient population from a placebo-controlled, randomized trial on acyclovir prophylaxis after keratoplasty. In this former study the effectiveness of oral acyclovir prophylaxis was significant during the first 2 years after keratoplasty. Prospective data such as graft survival, graft clarity, vascularization, infective events, and rejection episodes were obtained from the national keratoplasty follow-up registry. Additional clinical data were derived from the medical charts. RESULTS: For 47 of the original 63 enrolled patients, the 5-year follow-up was completed. Comparing the acyclovir group with the placebo group, we found that with regard to the cumulative clinically evident recurrences, there was a statistically significant lower monthly event rate in the acyclovir group (P = 0.037). There were no statistically significant differences in visual acuity or in the use of oral aciclovir between the two treatment groups. The incidences of graft failure, vascularization, and medication or surgery for glaucoma were too low to analyze differences between the two groups. CONCLUSION: The results of our study suggest that oral acyclovir prescribed during the first 6 months after PK for HED protects against clinically evident HED recurrences during the first 5 years following PK.

Some extreme corneal irregularities cannot be treated adequately with corneal contact lenses. For such cases a rigid semi-scleral lens can be prescribed. We evaluated the use of a highly gas permeable rigid semi scleral lens in patients with diseased corneas for whom conventional contact lens strategies had failed. Twenty two patients (29 eyes) were successfully fitted with individually manufactured semiscleral lenses. Corneal hypoxia, which has previously limited the use of polymethylmethacrylate (PMMA) scleral contact lenses, did not occur. The semi scleral lenses were well tolerated. Two cases were selected to illustrate the fitting of these lenses.

Background: After penetrating keratoplasty for reasons unrelated to herpes simplex virus (HSV) keratitis, any nonspecific epithelial defect may still be caused by HSV. The purpose of this study is to determine the incidence of newly acquired herpetic keratitis and to assess contributing factors. Methods: The authors retrospectively studied the results of 2398 penetrating keratoplasties performed between 1980 and 1995. Three typical case histories are discussed. Results: Of 2112 patients in whom the primary diagnosis was not related to HSV keratitis, 18 presented with epithelial herpetic keratitis in their corneal graft. The incidence of newly acquired herpetic keratitis after penetrating keratoplasty was 1.2 per 1000 person-years. In most cases, the infection occurred in the first 2 years after the transplantation. Most often, well-known reactivating stimuli could have caused the HSV infection. Conclusions: Herpes simplex virus keratitis may develop after penetrating keratoplasty even without a clinical history of HSV in the host. Thus, HSV should be considered in the differential diagnosis of a postpenetrating keratoplasty epithelial defect. The high incidence of this infection in the first 2 years after such surgery suggests a causal relation between corneal transplantation and the HSV infection.

Due to economical reasons some ophthalmologists are using an irrigating solution made by the hospital pharmacy instead of the commercially available solutions. These irrigating solutions come in bottles which are identical to the ones used for other solutions. During the last three years bottles were accidentally mixed up five times. Consequently, bottles containing solutions such as chlorhexidine, cetrimide, chlorhexidine/cetrimide and cialit solutions were used during cataract surgery. This resulted in immediate corneal edema which, in its turn resulted in a bullous keratopathy. Four patients underwent a penetrating keratoplasty. In one patient the cornea was covered with a conjunctival flap. Light microscopy of the corneas included epithelial edema, loss of keratocytes, and a disrupted and sometimes absent endothelial cell layer.

To review retrospectively the charts of all 190 patients who underwent penetrating keratoplasty for keratoconus in one hospital during a 5-year period (1995-2000), with special attention paid to contact lens fitting.The frequency of postoperative contact lens use, the time to fit lenses after grafting, tolerance and visual acuity, and postoperative risks for the graft were studied.The authors successfully fitted large-diameter (12 mm) tricurve rigid gas-permeable contact lenses for 90 (47%) of 190 penetrating keratoplasty patients with good tolerance. There were nine dropouts, and 91 eyes were corrected in another way. Fitting contact lenses after grafting usually started after 8.5 months (range, 1-60 months). The average tolerance was 9.2 hours a day (range, 2-12 hours), and best-corrected visual acuity was 20/25 (range, 20/16-20/200). The average follow-up was at least half a year. The average age of the patient at the first lens fitting was 36.2 years (range, 14-75 years). There was no increased risk in graft rejection.Twelve-millimeter rigid gas-permeable contact lens wear was successful in 47% of patients who underwent penetrating keratoplasty for keratoconus. It does not interfere with the use of chronic postoperative topical medication, nor does it increase the risk of corneal graft rejection. It is necessary to recommend likely use of contact lenses to patients who have undergone grafting surgery.

The purpose of this study is to evaluate corneal astigmatism and suture-related complications for transplants sutured with nylon and transplants sutured with Mersilene in primary corneal transplants for Fuchs endothelial dystrophy.A retrospective, observational, and comparative study between transplants sutured with either nylon 10-0 or 11-0 (n = 108) or Mersilene 11-0 (n = 58) was done. One hundred sixty-six eyes of 140 patients who received a primary penetrating keratoplasty for Fuchs endothelial dystrophy between 1995 and 2001 at the Rotterdam Eye Hospital in Netherlands were included.Overall, transplant survival did not differ between groups (log-rank test; P = 0.24). During the first 2 years after transplantation, significantly lower astigmatism was seen in transplants sutured with nylon (P = 0.03). Transplants sutured with Mersilene had a significantly higher risk of surgical intervention to correct astigmatism or wound dehiscence after transplantation (hazard ratio, 2.83; 95% confidence interval, 1.34-6.01). Time to first infiltrate, metaplasia (marked scarring along the sutures), or cheesewiring was significantly less in the Mersilene group (P0.01). There was a tendency toward a higher risk of complications associated with loose or broken sutures in the nylon group (hazard ratio, 2.00; 95% confidence interval, 0.57-6.98), which was more pronounced after 2 years.During the first years after corneal transplant surgery, Mersilene sutures are associated with a higher risk of complications and more interventions to correct suture-related problems. However, after 2 years, the grafts seem to be able to retain Mersilene sutures with less risk of suture-related complications as compared with grafts with retained nylon sutures. These favorable long-term effects of Mersilene sutures may outweigh its short-term disadvantage in patients with Fuchs endothelial dystrophy.

Background: The hereditary Reis–Buckler dystrophy is one of the anterior localised corneal dystrophies with superficial reticulated opacities, sometimes in combination with recurrent attacks of corneal erosion. Phototherapeutic keratectomy (PTK) is now the first method to consider for managing this disease when intervention is required. Methods: We treated six eyes of four related patients with Reis–Buckler dystrophy, who had a demonstrable reduction in visual acuity due to corneal opacities within their virgin corneas (three eyes), penetrating (one eye) or lamellar (two eyes) grafts. We present the results of change in visual acuity and best corrected spherical spectacle and contact lens refraction at 1 year following surgery. In one case, we had to fit a rigid contact lens to correct the hyperopic shift which caused anisometropia. Results: The mean spherical refractive change 1 year after PTK surgery was 0.33 ± S.D., 1.8 D. A hyperopic shift was observed in four eyes. Visual acuity remained stable in all patients 1 year after surgery. The central corneal area remained clear, and mean best spectacle corrected visual acuity improved from +0.8 log MAR before PTK to +0.15 log MAR after 1 year. There was no siginficant change ( P> 0.8) between the mean 1 year best spectacle corrected visual acuity (+0.125 log MAR ± S.D. 0.15) and the best contact lens corrected visual acuity (+0.108 log MAR ± S.D. 0.16). After fitting a contact lens in one patient to correct anisometropia, the hyperopic shift did not change significantly during 12 months of follow-up. It was not necessary to adjust the lens parameters. One patient required cataract surgery. Conclusion: PTK corneal surgery is the treatment of first choice when intervention is required in patients with Reis–Buckler dystrophy because it is safe and much less invasive than lamellar or penetrating keratoplasty. Contact lens fitting following PTK has not changed corneal shape. © 2002 British Contact Lens Association. Published by Elsevier Science Ltd. All rights reserved.

Purpose To study the incidence of suture-related complications following penetrating keratoplasty (PK) and their effect on the success of corneal grafting. Methods The records of 332 patients receiving 361 grafts in 1993 and 1994 were reviewed, and suture-related complications were recorded. These complications were divided into five groups: suture erosions, infiltrates at the suture sites, infectious keratitis, loose sutures with imminent wound dehiscence, and wound dehiscence after suture removal. Results Occurrence rates were suture erosions, 10.8%; infiltrates, 9.4%; infectious keratitis related to sutures, 3.3%; loose sutures with imminent wound separation in need of surgical repair, 8.3%; and wound dehiscence following suture removal, 2.4%. Conclusions Suture-related complications frequently occur after PK. Infectious keratitis and wound separations needing surgical repair may lead to loss of best-corrected visual acuity due to scarring, induced allograft reactions, and/or increased astigmatism. Recommendations for post-PK suture management are proposed.

To describe a new surgical technique for deep, anterior lamellar keratoplasty using a viscoelastic for dissection of Descemet's membrane (DM) from the posterior stroma.Through a paracentesis, aqueous was exchanged by air to visualize the posterior corneal surface-i.e., the air-to-endothelium interface. Using the interface as a reference plane, a 30 gauge needle was inserted into the cornea to just anterior to DM. Viscoelastic was injected to separate DM from the posterior stroma, and a recipient, anterior lamella was excised. A full-thickness donor button was sutured into the recipient bed, after stripping its DM.In 25 eye bank eyes, the procedure could be completed in 20 eyes; in 5 eyes, DM ruptured during visco-dissection. With light microscopy, dissection depth was located at the level of DM. In two patient eyes the procedure could be completed. In a third patient eye DM ruptured during visco-dissection, and the procedure was converted into a penetrating keratoplasty.Using visco-dissection, a lamellar keratoplasty can be performed quickly, with the donor-to-recipient interface just above the recipient DM, i.e., with a nearly perfect anatomical replacement of all corneal stroma. There is substantial risk of rupture or microperforation of DM during surgery.

New surgical techniques in lamellar keratoplasty, including phototherapeutic keratectomy, automated lamellar keratectomy, plano-epikeratoplasty, deep anterior lamellar keratoplasty, combined amniotic membrane and limbal transplantation, large-diameter corneoscleral lamellar keratoplasty, and posterior lamellar keratoplasty, have recently become available. These procedures broaden the array of treatments for corneal disorders and may be used as alternatives to penetrating keratoplasty.

The incidence of contact-lens-associated microbial keratitis is uncertain and its related morbidity in the general population of contact-lens wearers is not known. We examined these issues in a prospective epidemiological study.We surveyed all practising ophthalmologists in the Netherlands to identify all new cases of microbial keratitis reported during a 3-month period in 1996. Follow-up telephone calls were made to examine ocular morbidity. We undertook annual nationwide telephone surveys between 1994 and 1997 to estimate the prevalence of contact-lens wear.Of 440 ophthalmologists contacted, 379 provided information. There were 92 cases of microbial keratitis; 17 used daily-wear rigid gas-permeable lenses, 63 daily-wear soft lenses, and 12 extended-wear soft lenses. The estimated annualised incidence of microbial keratitis was 1.1 per 10,000 (95% CI 0.6-1.7) users of daily-wear rigid gas-permeable lenses, 3.5 per 10,000 (2.7-4.5) users of daily-wear soft lenses, and 20.0 per 10,000 (10.3-35.0) users of extended-wear soft lenses (p0.00001 for comparison between all groups), Five of the 92 patients achieved a final visual acuity of 20/70 or less. Pseudomonas and Serratia spp were the organisms most commonly isolated. Pseudomonas keratitis accounted for the largest mean diameter of corneal ulcers, the highest mean number of days in hospital, the greatest number of mean outpatients visits, and the poorest visual acuity outcome.The incidence of microbial keratitis among users of extended-wear soft contact lenses in the Netherlands is similar to that reported in the USA during 1989. Awareness of risk factors and improvement in contact-lens materials have not led to a decrease in incidence. Overnight wear should be strongly discouraged.

PURPOSE: To report the long-term sequelae of a case of bilateral chemical keratitis caused by airbag deployment. METHODS: Case report and review of the literature. RESULTS: A 21-year-old woman presented with bilateral reduced vision, photophobia, and tearing after a car accident. Examination revealed some facial burns and severe chemical injury to the cornea and conjunctiva. Immediate irrigation with physiologic saline solution and subsequent treatment with topical antibiotics, corticosteroids, and vitamin C resulted in full restoration of vision but could not prevent permanent corneal damage. CONCLUSIONS: Severe alkali injury of the cornea generally has a good prognosis but can lead to permanent damage and persistent complaints of dry eye. Language: en

Aims—A total of 97 triple procedures performed over a6y ear period werestudied retrospectively to determine the best approach to calculate intraocular lens power. Methods—The cases were divided into two diagnostic categories. Results—After 1 year best corrected visual acuity was 20/40 or better in 37.5% of the cases of the ‘modified group’. This group consists of patients with the diagnosis Fuchs’ dystrophy, non-guttate endothelial dystrophy, and Reis‐Buckler dystrophy. Analysis of visual acuity was made using logMAR. A final postoperative refraction within 2 dioptres of predicted refraction was achieved in 76.5% of patients in the modified group. Conclusion—In future, in the absence of a keratometry, a keratometry value of 7.49 mm will be used for calculation of the power of the implant as analysed in this study. (Br J Ophthalmol 1997;81:774‐777) When a patient requires both penetrating keratoplasty and cataract extraction the two procedures can be performed in combination or separately, with or without an intraocular lens implant. Combined cataract extraction and penetrating keratoplasty has been reported by Katzin and Meltzer in 1966. 1

To test the efficacy and safety of recombinant human epidermal growth factor (hEGF) on corneal re-epithelialisation following penetrating keratoplasty.A prospective, randomised, placebo controlled study was carried out in which patients were matched for diagnosis and received either hEGF ophthalmic solution (30 micrograms/ml or 100 micrograms/ml) or placebo in a double masked fashion. Matched pairs of patients received donor corneas from the same donor and were operated by the same surgeon on the same day. At the end of surgery all donor epithelium was removed mechanically. Patients were examined twice daily and fluorescein stained photographs were taken until the epithelium had closed. The area of the defect was measured by planimetry of the fluorescein stained defect on the photographs.There were no significant differences in re-epithelialisation of the donor cornea between the placebo group and the group treated with 30 micrograms/ml hEGF. Time until complete closure was slightly longer with 100 micrograms/ml hEGF compared with 30 micrograms/ml hEGF and with placebo. Mean healing rate of the epithelial defect with 100 micrograms/ml hEGF was significantly slower than in the other groups.No significant acceleration of corneal re-epithelialisation was demonstrated with the use of recombinant hEGF after penetrating keratoplasty in humans.

Objectives To describe the refractive results of cataract surgery after photorefractive keratectomy (PRK) for patients with myopia, and to find a more accurate method to predict intraocular lens (IOL) power in these cases. Design Nonrandomized, retrospective clinical study. Patients and Methods Nine patients (15 eyes) who underwent cataract surgery after prior PRK to correct myopia were identified. The medical records of both the laser and cataract surgery centers were reviewed. Main Outcome Measures Eight different keratometric values (K values; measured or calculated) were entered into 3 different IOL calculation formulas: SRK/T, Holladay 1, and Hoffer Q. The actual biometry and IOL parameters were used to predict postoperative refraction, which was compared with the actual refractive outcome. Also, the relative underestimation of the refractive change in corneal dioptric power by keratometry after PRK was calculated. Results In 7 of 15 eyes, IOL exchange or piggybacking was performed because of hyperopia. Retrospectively, the most accurate K value for IOL calculation was found to be the pre-PRK K value corrected by the spectacle plane change in refraction. Use of the Hoffer Q formula would have avoided postoperative hyperopia in more cases than the other formulas. The mean underestimation of the change in corneal power after PRK varied from 42% to 74%, depending on the method of calculation. Conclusion The predictability of IOL calculation for cataract surgery after PRK can be improved by using a corrected, refraction-derived K value instead of the measured, preoperative K value.

Ulcerative colitis (Crohn's disease) is a chronic relapsing inflammatory bowel disease of unknown etiology. The most common ocular complications include conjunctivitis and uveitis, particularly iritis. Herein, we describe a patient who had a decrease in visual acuity due to an increasing astigmatism. This was accompanied with a peripheral limbal thinning of the cornea and faint confluent corneal changes. No systemic activity was present during the period that the patient was monitored. Changes of astigmatism were followed up with videokeratography. This apparatus monitors changes in clinical course accurately and makes comparison possible between separate visits.