Abstract P2-14-01: Metastatic trial search: Advocacy groups collaborate to engage metastatic breast cancer patients in clinical trials

Background: Less than 5% of adult cancer patients participate in trials, delaying the arrival of new therapies to the clinic. This is concerning for metastatic breast cancer patients, for whom there is no curative treatment. To facilitate metastatic patients' access to trials, BreastCancerTrials.org (BCT) partnered with five breast cancer advocacy groups to design and develop Metastatic Trial Search (MTS), a trial matching service based on BCT technology and embedded on their websites.

Approach: BCT's partners include Breastcancer.org, Living Beyond Breast Cancer, Metastatic Breast Cancer Network, Triple Step Toward the Cure, and Young Survival Coalition. MTS was seamlessly integrated on each partner's website. To find trials, users submit data about their gender, age, location, menopausal status, cancer subtype, and sites with evidence of disease and in return receive a list of matching trials in BCT's patient-friendly format. MTS launched October 1, 2015.

Results: Our evaluation included analysis of web traffic, an online user survey, two user focus groups, and partner interviews. MTS traffic between Oct. 2015 and May 2016 resulted in over 10,000 page views; peaks of activity correlated with social media posts. The user survey, conducted between Oct. 2015 and Jan. 2016, had 102 participants; 88% learned about MTS from our advocacy partners, mostly through email (52%) or social media (21%). Most participants (60%) cited learning about new breast cancer research as an important benefit of MTS. Sixty-three percent of users were looking for treatment trials, 16% contacted a research site and 12% spoke to their doctors about trials that they found on MTS. Among all respondents, 7% enrolled in a trial and 29% were still considering enrollment. Sixty percent of MTS users were satisfied with their experience, 33% were neutral, and 6% were dissatisfied; 65% would recommend MTS to a friend. To improve MTS, users ranked adding filters to narrow search results as the most pressing need. Providing a trial alert service was ranked second. Over 80% agreed with the statement: “MTS met an unmet need.” The focus groups were made up of 14 survey respondents who volunteered to participate. Discussants spoke highly about MTS' ease-of-use and its advocacy group endorsement. They also appreciated how MTS helped them learn about different ways to participate in research and provided information to share with their oncologists. According to many participants, one of the most important benefits of MTS was that it helped them “be prepared” if they needed to change treatment.

Our advocacy partners were very satisfied with their involvement and all stated that “collaboration and sharing” were the most important outcomes. In addition, they viewed the consistency of seeing MTS on each of their sites as a benefit for patients looking to advocacy groups for trusted information.

Conclusion: Our experience with MTS shows that advocacy groups working together can create an important channel for engaging patients in learning about metastatic breast cancer trials. Next steps will be to expand our advocacy network, make it easier for users to narrow search results, and offer ways for patients to learn about newly opened clinical trials.

Citation Format: Cohen EJ, Colen SL, Dahlke DV, Esser M, Flowers L, Guglielmino JE, Jenkins M, Knackmuhs G, Lusen R, Mertz SA, Esserman LJ. Metastatic trial search: Advocacy groups collaborate to engage metastatic breast cancer patients in clinical trials [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-14-01.

Effect of Direction and Tension of Kinesio Taping Application on Sensorimotor Coordination

The present study investigates whether different directions and tensions of Kinesio(®) Tex tape (KT) application differently influence the precision of sensorimotor synchronization, defined as the ability to coordinate actions with predictable external events. 10 healthy participants performed sets of repetitive wrist flexion-extensions synchronized to a series of paced audio stimuli with an inter-onset interval (IOI) of 500 and 400 ms. KT was applied over the wrist and finger extensor muscles. 2 facilitatory (light and moderate tension) and one inhibitory KT applications were used in different sessions. Standard deviation of the asynchrony (SDasy) and percentage difference of SDasy were calculated and compared across KT and the no-KT control cases. Direction and tension of KT application did not differently influence the ability to coordinate rhythmic movements to an auditory stimulus. However, compared with the no-KT control case, SDasy decreased significantly in all KT cases in both 500- and 400-ms IOI. Independent of direction/tension, the effect of KT on improving sensorimotor synchronization is likely associated with variations in the nature of the neuro-anatomical constraints determining the control of voluntary movement. KT is then proposed to be tested on sensorimotor disorders associated with intense repetitive exercise to check for regaining effective motor control.

Abstract P5-07-01: BreastCancerTrials.org: Early Evaluation of a Nationwide Clinical Trial Matching Service

Background: In 1999, UCSF researchers and patient advocates began a collaboration to design BreastCancerTrials.org (BCT.org), a web-based clinical trial matching service. In May 2005, the UCSF Center of Excellence for Breast Cancer Care (COE) and NCI launched BCT.org as a 2-year pilot with the participation of 13 Bay Area research sites. The pilot showed that breast cancer patients were willing to use an online clinical trial matching service, that they were able to enter their detailed health history onto web-based forms, and that the system's underlying caMATCH technology led to valid matches. In a companion study to evaluate the accuracy of patient-entered data, UCSF researchers found a 93% match rate between the data UCSF patients entered in BCT.org and their corresponding clinic charts. As a result, the COE partnered with a non-profit corporation (Quantum Leap Healthcare Collaborative or QLHC) to launch a nationwide version of BCT.org in October 2008. Development: The COE and QLHC team upgraded BCT.org to include personalized questionnaires for different breast conditions; the ability to use BCT.org anonymously; and the development of more clearly presented trial information. To improve the quality of matching, the team developed TrialCODE, a caMATCH-compatible tool for coding and validating a wide range of eligibility criteria. In July 2009, BCT.org added a Trial Alert Service to inform users when newly listed trials match their history, and SecureCONNECT, a messaging platform that enables users to share their online health history with research sites. COE researchers defined metrics and configured Google Analytics to monitor user traffic and support quality improvement.

Results: As of June 2010, the BCT.org trial registry had 331 coded trials, including 213 for treatment, 63 for psychosocial/support, and 55 distributed among diagnosis/screening, prevention, and other categories. The treatment trials were evenly divided between early and advanced disease and included additional trials for individuals with DCIS. In the 18 months between Jan. 2009 and June 2010, BCT.org received 25,206 visits with traffic increasing by 36% in the first 6 months of 2010 compared to the same period in 2009. Since its launch in July 2009, the Trial Alert Service (TAS) enrolled over 1,400 subscribers. As a result, the number of returning users increased from 1,335 to 4,007 in the 6-month period leading up to its launch, compared to the 6-month period after launch. Fifty research sites have registered to use SecureCONNECT and, with patient consent, can securely view BCT. org patient health histories. During the 18 month evaluation period, 3,563 BCT.org users started a health history with 2,206 (62%) completing it and matching to trials; among the users who matched to trials, 920 users (42%) clicked through to view a list of participating research sites. Conclusion: Thousands of patients have adopted BCT.org and use it to monitor trial opportunities. The registry of breast cancer trials is diverse and growing. The COE and QLHC are working to increase participation in SecureCONNECT and evaluate its impact on the efficiency of trial screening and enrollment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-07-01.

Therapeutic decision in anterior scleritis: our experience at a tertiary care eye center

PURPOSE

To determine the characteristics of patients with anterior scleritis at a tertiary care eye center and determine which factors in these patients were associated with the need for systemic immunosuppressive therapy.

PATIENTS AND METHODS

Retrospective study. Fifty patients with anterior scleritis presenting to the Cornea Service at Wills Eye Hospital from August 1996 to August 2001 were reviewed and divided into two groups. The control group included 35 patients who responded to oral non-steroid anti-inflammatory drugs (NSAIDs) and/or systemic steroids. The study group consisted of 15 patients who required additional treatment with systemic immunosuppressive agents. The influence of demographics, type of scleritis, bilateral disease, and ocular complications were analyzed. The presence of a systemic autoimmune disease, the best corrected visual acuity (BCVA), medications, and complications related to treatment were recorded. The statistical significance was evaluated by Student's t test for independence samples and Fisher's exact test; P<0.05 was considered significant.

RESULTS

After a mean follow-up of 19.3 +/- 24.9 months, an associated systemic autoimmune disease was present in 17 patients (34%). Scleritis was the first manifestation of the systemic disease in 10 out of 17 patients (59%). Patients who required immunosuppressive treatment had more frequent ocular complications (80% versus 26%, P=0.0004) than did patients who responded to oral NSAIDs and/or steroids.

CONCLUSIONS

Scleritis may be the sign of presentation of a systemic autoimmune disease. The presence of ocular complications, in particular corneal involvement, may be associated with the need for systemic immunosuppressive therapy.

Clear corneal wound infection after phacoemulsification

OBJECTIVE

To evaluate clear corneal wound infections after phacoemulsification.

MATERIALS AND METHODS

The medical records of 7 patients with clear corneal wound infections after phacoemulsification were reviewed retrospectively. Data that were reviewed included patient age, sex, onset of symptoms and signs after surgery, possible risk factors for infection, concomitant ocular disease, use of perioperative prophylactic antibiotics and steroids, culture and antibiotic sensitivity results, treatment regimen, and outcome.

RESULTS

The median onset of signs and symptoms after surgery was 10 days (range, 4-60 days). Corneal cultures yielded methicillin-resistant Staphylococcus aureus in 2 cases, Streptococcus pneumoniae in 1 case, and Staphylococcus epidermidis in 1 case. Cultures yielded no microorganisms for 1 patient. Corneal cultures were not obtained in 2 patients. In 3 of the 4 culture-positive cases, the isolated microorganisms were resistant to the perioperative prophylactic antibiotics (fluoroquinolones and tobramycin) that were used. No possible risk factors were noted except use of topical steroids 4 times a day without antibiotic coverage for iritis before referral in one of our patients. Six of these 7 wound infections healed with topical antibiotic therapy. One of the patients required lamellar keratectomy and conjunctival flap for complete healing. In 4 of the 7 cases, best-corrected visual acuity at the last follow-up visit was better than 20/40.

CONCLUSIONS

Clear corneal wound infection after phacoemulsification is a serious complication of cataract surgery. Infections are caused by gram-positive organisms sensitive to bacitracin and the combination of trimethoprim-sulfamethoxazole but often resistant to aminoglycosides and/or fluoroquinolones.

Tarsorrhaphy: clinical experience from a cornea practice

PURPOSE

To evaluate indications, success rate, and complications of tarsorrhaphy in a cohort of cornea and external disease patients.

METHODS

In this study, charts of patients who underwent tarsorrhaphies from January 1, 1995, to September 30, 2000, were retrospectively evaluated. Information reviewed included patient age and sex, indication for tarsorrhaphy, duration of signs and symptoms before tarsorrhaphy, time to epithelial healing after tarsorrhaphy, type of tarsorrhaphy (temporary/permanent), complications, timing of tarsorrhaphy removal, recurrence of signs and symptoms after complete or partial opening of the tarsorrhaphy, number of tarsorrhaphies needed to be replaced or extended, and duration of follow up.

RESULTS

Seventy-seven patients were included in this study. Indications for a tarsorrhaphy were persistent epithelial defects or other ocular surface problems associated with neurotrophic ulcers, penetrating keratoplasty (PK), postinfection, exposure keratopathy, surgery other than PK, dry eye syndrome, radiation keratopathy, ocular cicatricial pemphigoid, Stevens-Johnson syndrome, entropion, and application of tissue adhesive. The epithelial defects in 70 (90.9%) of the 77 eyes completely resolved. Overall, the mean duration of signs and symptoms before tarsorrhaphy was 89.8 +/- 27.8 days, and time-to-healing after tarsorrhaphy was 18.0 +/- 2.0 days. The difference between the duration of the signs and symptoms before tarsorrhaphy and time-to-healing after tarsorrhaphy was statistically significant ( p = 0.01). Of the 77 tarsorrhaphies, 24 (31.2%) were temporary and 53 (68.8%) were permanent. Complications after tarsorrhaphy included trichiasis, adhesion between upper and lower lids after tarsorrhaphy lysis, premature opening of the temporary tarsorrhaphy, pyogenic granuloma, and keloid formation of the eyelid.

CONCLUSION

Tarsorrhaphy is a very effective and safe procedure in the management of nonhealing epithelial defects and other surface problems, with a 90.9% success rate and only minor complications.

Chalazion as a cause of decreased vision after LASIK

PURPOSE

To describe a post-LASIK patient with decreased vision and a chalazion of the upper eyelid.

METHODS

A 46-year-old man was referred with decreased vision of 1 month's duration. He underwent bilateral uncomplicated LASIK for myopic astigmatism 1.5 years and bilateral enhancements 1 year previously. He had 20/20 uncorrected vision in both eyes after those procedures. He developed a chalazion of his right central upper eyelid 1 month prior with simultaneous blurring of vision. On our examination, his uncorrected visual acuity was 20/60 in the right eye. Complete eye examination including refraction, computerized corneal topography, and pachymetry were done.

RESULTS

With a manifest refraction of +1.25 +0.50x80, the visual acuity in the right eye improved to 20/20. Computerized corneal topography revealed circular central corneal flattening in both eyes, much greater in the right eye than the left eye. The location of the chalazion with the right eye closed corresponded to the area of central corneal flattening. The central power from the corneal topography was 39.4 D OD and 40.8 D OS. He was diagnosed as having acquired hyperopia associated with chalazion-induced central corneal flattening of the right eye. Chalazion-induced hyperopic change on topography disappeared, and his uncorrected vision improved to 20/20 in the left eye as the chalazion resolved completely.

CONCLUSION

In post-LASIK patients with decreased vision and topography changes late after surgery, periocular masses should be considered in the differential diagnosis. Decreased corneal thickness and rigidity after LASIK might be a predisposing factor to external compression-induced curvature changes.

Accidental self-removal of a flap--a rare complication of laser in situ keratomileusis surgery

PURPOSE

To report a rare complication in which the patient accidentally removed the laser in situ keratomileusis corneal flap.

METHODS

Interventional case report. A 35-year-old woman underwent uncomplicated laser in situ keratomileusis surgery. Ten days after surgery, she inserted a soft contact lens into the right eye to improve her vision. She tried to remove the contact lens, but had pain and bleeding. She was referred 10 days later with a diagnosis of loss of flap.

RESULTS

On examination, she had a best-corrected visual acuity of 20/70 in the right eye. The right eye examination revealed no corneal flap, mild corneal edema, and significant haze. A central epithelial defect was found.

CONCLUSION

Accidental corneal flap removal can rarely follow laser in situ keratomileusis surgery. This complication provides insight into the weak adhesion of the flap onto the stromal bed after laser in situ keratomileusis surgery and, hence, the inherent risk of traumatic flap dislocation or amputation, which needs to be explained to the patient.

Unilateral corneal lattice dystrophy

PURPOSE

To report three cases of seemingly unilateral dystrophy indistinguishable from type I classic lattice corneal dystrophy.

METHODS

Case study of three patients. Three patients, a 31-year-old man, a 44-year-old woman, and a 41-year-old man had multiple lattice lesions in one eye and an apparently healthy fellow eye. Two of these patients underwent penetrating keratoplasty because of poor vision.

RESULTS

Histopathologic examination of the excised corneal button of patient 2 showed amyloid deposits consistent with lattice. In the third patient, lattice lesions were noted in the other eye nearly 13 years after he was first examined.

CONCLUSIONS

Lattice corneal dystrophy is rarely unilateral. Lattice, even in unilateral cases, may cause significant vision loss to warrant penetrating keratoplasty. Lattice lesions may develop in the fellow eye many years later. This possibility should be explained to all patients with apparently unilateral lattice corneal dystrophy.

Use of SoftPerm contact lenses when rigid gas permeable lenses fail

PURPOSE

We evaluated the performance of the SoftPerm contact lens (Wesley Jessen) in patients with irregular astigmatism, usually due to keratoconus or after penetrating keratoplasty (PK), who were unable to befitwith, or intolerant of, rigid gas permeable (RGP) contact lenses.

METHODS

A retrospective study of patients fit with SoftPerm lenses in the Cornea Department at Wills Eye Hospital between March 1985 and March 2000 was performed.

RESULTS

Thirty-five cases were reviewed, with follow-up available in 33 cases. Most of the eyes had irregular astigmatism secondary to keratoconus (22/35,62.9%) or PK (10/35,28.6%) and had failed a trial of RGP lenses. The mean logMAR visual acuity with SoftPerm lenses was 0.13+/-0.18 (range -0.12 to 0.6). In 25 cases in which comparison with glasses or RGP lenses was possible, SoftPerm lenses provided better visual acuity than glasses in 17/25 cases (68%) with a mean difference of -0.24 (P = 0.001, paired t-test); visual acuity with SoftPerm lenses was better than RGP visual acuity in 13/25 cases (52%), with a mean difference of -0.06 (P = 0.07, paired t-test). Complications included broken lenses (16/33,48.5%), giant papillary conjunctivitis (GPC) (9/33, 27.3%), and peripheral corneal neovascularization (9/33, 27.3%). The GPC and peripheral corneal neovascularization were often delayed in presentation. The major subjective complaint was discomfort (13/33, 39.4%). At the last follow-up, the SoftPerm lens was still in use in 22/33 cases (66.7%). Discomfort was the most common reason for discontinuation. The mean duration of lens wear was 52.5+/-31.7 months, range 3 to 110 months.

CONCLUSIONS

The SoftPerm lens can provide satisfactory visual correction in many cases of irregular astigmatism with RGP failure. However, problems such as frequent breakage, GPC, peripheral corneal neovascularization, and discomfort necessitate close follow-up.

The effect of state legislation on eye donation

PURPOSE

Pennsylvania Act 102 implemented in March 1995 required all acute care hospitals in Pennsylvania to routinely refer all deaths to the Organ Procurement Organization for determination of suitability for organ/tissue donation. This study analyzed the effect of the law on eye donation.

METHODS

Retrospective analysis of the total number of referrals and the actual number of eye donations from 62 hospitals in Pennsylvania to the Lions Eye Bank of Delaware Valley was performed for the years 1993 to 1998. Information gathered included donor's age, gender, race, cause of death, referring institution, and result of referral.

RESULTS

From 1993 to 1998, the total numbers of referrals were 988, 1,647, 8,101, 21,123, 21,783, and 22,987, and the numbers of donors were 570, 574, 660, 644, 594, and 568, respectively. The increase in the number of donors after implementation of the law was not commensurate with the number of referrals. This was caused by a disproportionate increase in the number of referrals older than 70 years of age (from a mean of 33% to 52%), which exceeded the donor age limit of 69 years, and also to a lower family consent rate (from a mean of 48% to 24%).

CONCLUSIONS

Well-designed state legislation with proper implementation greatly increased hospital referrals for eye donation. However, there was only a small increase in the number of eye donors because many of the referrals were beyond the acceptable upper age limit for eye donation. A small increase in the donor age limit would increase the number of eye donations without having to expand the potential donor pool. Education of the public may help to improve the family consent rate.

Binocular vision recovery in bilateral keratoplasty

PURPOSE

To determine the benefit of bilateral penetrating keratoplasty with regard to binocular vision.

METHODS

We compared patients who underwent corneal transplantation bilaterally with patients who had successful corneal transplantation in one eye and corneal disease in the other eye. Specifically, changes in fusion, stereopsis, and binocular vision function were analyzed. A questionnaire regarding performance of daily tasks was given.

RESULTS

Patients with bilateral keratoplasty performed better in all the analyzed functions. Fusion was achieved by 81.25% in the unilateral group versus 100% in the bilateral group (p = 0.15). Stereopsis was present more in the bilateral group (100% vs. 62.5%, p = 0.008) and the quantity of stereopsis was significantly better in the bilateral group (121 seconds of arc vs. 1,284 seconds of arc, p = 0.014). 88.8% of the patients subjectively improved in daily activities after second eye surgery.

CONCLUSION

There are objective and subjective improvements after bilateral penetrating keratoplasty.

Trends in contact lens-related corneal ulcers

PURPOSE

To identify changes in number of contact lens-related corneal ulcers per year and the type of contact lenses involved.

METHODS

Charts of 299 patients with corneal ulcers seen at the Cornea Service of Wills Eye Hospital from January 1, 1996, to June 30, 1999, were retrospectively reviewed. A corneal ulcer was defined as an infiltrate that was treated at least hourly with topical fortified antibiotics or fluoroquinolones.

RESULTS

Of these 299 cases, 37 (12.4%) were related to contact lens use. Contact lens-related ulcers accounted for 10.7% of all corneal ulcers in 1996, 15.3% in 1997, 8.6% in 1998, and 18.2% in the first 6 months of 1999. The contact lenses most commonly associated with ulcers were conventional soft daily-wear contact lenses (33%). There were similar numbers of ulcers associated with extended wear (n = 16) and daily wear (n = 17) of soft contact lenses. In addition, the number of cases associated with conventional (n = 17) and disposable/frequent replacement (n = 16) lenses were similar. Corneal cultures were performed in 15 (40.5%) cases and were positive in 8. There has been a significant decrease in the number of contact lens-related ulcers treated at our institution compared with previous years (1988-1999, p < 0.01).

CONCLUSIONS

The number of contact lens-related corneal ulcers in the past 4 years was significantly fewer than previous years at our institution. A similar number of ulcers were associated with conventional and disposable/frequent replacement lenses despite the commercial preponderance of the latter type of lenses.

Human immunodeficiency virus p24 antigen testing in cornea donors

PURPOSE

Testing for the p24 antigen of the human immunodeficiency virus (HIV) may detect early HIV infection in the seronegative window; however, falsely reactive results may occur in cadaver specimens. Although neither the Food and Drug Administration (FDA) nor the Eye Bank Association of America requires p24 testing of cornea donors, many tissue banks using other organs from cornea donors do perform this assay, and the FDA requires that eye banks reject corneal tissue if a reactive p24 assay is reported. We investigated the impact of p24 testing on eye banking and corneal transplantation.

METHODS

Two clinical cases and records from the Lions Eye Bank of Delaware Valley (LEBDV) were reviewed retrospectively.

RESULTS

Two corneas from the LEBDV were transplanted before the reporting of p24 reactivity by other tissue banks. In one case, because of the young age of the recipient, the surgeon elected to replace the cornea with new tissue hours after the original transplant, and later polymerase chain reaction (PCR) testing was negative. In the other case, there was not enough specimen to perform Western blot or PCR confirmatory testing. The patient was followed with periodic serologic testing for HIV and has remained seronegative. To avoid such problems in the future, the LEBDV initiated testing of all donors with p24 and other nonrequired screening tests. Over a 2-month period, 22 corneas (from 11 donors) were discarded because of these tests: 4 donors had reactive p24 tests, 6 were reactive for antibody to hepatitis B core antigen, and 1 had a reactive syphilis test.

CONCLUSIONS

Results from p24 assays by other tissue banks may cause difficult clinical situations when the results are received after transplantation of the tissue, but the use of the p24 assay in the screening of cornea donors may result in excessive waste of donor tissue. Further guidance is needed regarding the management of positive results from this and other nonrequired screening tests.

Infectious crystalline keratopathy in an immunosuppressed patient

PURPOSE

To report a case of infectious crystalline keratopathy (ICK) in a patient with systemic malignancy on immunosuppressive chemotherapy. The patient wore frequent replacement contact lenses on an extended wear basis.

METHODS

A 51-year-old female with carcinoma of the breast and systemic metastases was referred for a corneal ulcer. She received intravenous docetaxel, trastuzumab, and systemic dexamethasone. She wore frequent replacement Acuvue lenses on an extended wear basis. Her visual acuity was 20/200 in the right eye and 20/400 in the left eye. The right eye examination revealed diffuse superficial punctate keratopathy. In the left eye, there was a 3.8 x 4.5 mm corneal infiltrate with projecting crystalline processes. Corneal scrapings were performed for smears and cultures. Treatment with topical fortified cefazolin and fortified tobramycin every hour around the clock was initiated.

RESULTS

Culture of the corneal scrapings grew Streptococcus anginosus and Staphylococcus aureus. There was a good response to medical therapy. When last seen after 4 weeks of treatment, the infiltrate measured about 1 mm and the visual acuity was 20/40 with pinhole.

CONCLUSIONS

Systemic immunosuppression may be a predisposing factor for the development of ICK. This case suggests that debilitated patients may be at risk for unusual infections and should be discouraged from overnight wear of contact lenses.

Penetrating keratoplasty in iridocorneal endothelial syndrome

PURPOSE

To evaluate the clinical outcome of penetrating keratoplasty (PK) in iridocorneal endothelial (ICE) syndrome.

METHODS

Clinical charts of patients who underwent penetrating keratoplasty for ICE syndrome between 1985 and 1999 were reviewed retrospectively. Glaucoma control, best corrected visual acuity pre- and post-PK, graft clarity, graft rejection episodes, improvement in pain, and additional procedures were analyzed.

RESULTS

Fourteen cases were reviewed with an average follow-up of 58 months after PK. Initial grafts failed in seven patients (50%), in six cases because of rejection, and one owing to endothelial failure without signs of rejection. Repeat PKs were performed in six patients. At final follow-up, 12 grafts were clear. Glaucoma was controlled pre- and post-PK (average intraocular pressure, 16 mmHg for both eyes). Pre-PK, eight patients were using glaucoma medicines and nine had had glaucoma surgery. At the end of the follow-up, seven patients were using glaucoma medicines; six patients required glaucoma surgery after their initial PK. At the final follow-up visit, visual acuity in three patients (21%) was 20/40 or better, it ranged from 20/50 to 20/100 in four patients (29%) and 20/200 to 20/400 in five patients (36%), and in two patients with failed grafts (14%) it was counting fingers or worse.

CONCLUSION

Clear grafts were achieved in 12 cases, although six patients (43%) underwent repeat PKs. All patients had glaucoma, which was controlled before and after PK by medical treatment and surgical procedures. Favorable outcomes can be achieved in patients with ICE syndrome but may require multiple corneal and glaucoma procedures.

The role of glaucoma therapy in the need for repeat penetrating keratoplasty

PURPOSE

To evaluate the effects of medical and surgical therapy for glaucoma in patients requiring repeat penetrating keratoplasty (PK) for endothelial failure.

METHODS

Retrospective review of the charts of all patients undergoing repeat PK at the Cornea Service at Wills Eye Hospital between January 1, 1989 and December 31, 1995. Study end-points were time to first rejection episode, number of rejection episodes, time to endothelial failure, and time to regraft.

RESULTS

During the study period, 156 patients underwent repeat PK for irreversible endothelial failure. Ninety-four (60.3%) patients had a concomitant diagnosis of glaucoma. Of these 94, 27 (28.7%) underwent glaucoma surgery. The surgically treated group had a significantly higher percentage of patients with at least one rejection episode (55.6%) than those without glaucoma (32.8%; p = 0.04). Similarly, a significant difference existed in the percentage of both medically and surgically treated glaucoma patients having at least one rejection episode (50%) when compared with patients without glaucoma (32.8%; p = 0.04). Rejection episodes occurred sooner in the glaucoma patients than in the nonglaucoma group (18 months vs. 32 months; p = 0.01), irrespective of glaucoma therapy. Grafts in glaucoma patients failed 12 months earlier than those in patients without glaucoma.

CONCLUSION

In a selected group of patients who required repeat PK for endothelial graft failure, a majority of patients were found to have a history of glaucoma. Among regraft patients, surgical therapy for glaucoma was found to increase the risk of rejection episodes when compared to patients without glaucoma. The patients with glaucoma were found to be at increased risk for early rejection and failure compared to patients without glaucoma.

Fungal keratitis in a soft contact lens wearer

PURPOSE

To describe a case of fungal keratitis in a soft contact lens wearer.

METHODS AND RESULTS

A 57 year old female, compliant, frequent replacement soft contact lens wearer, with a possible prior history of herpes simplex keratitis, presented with pain and injection of her left eye of four weeks duration. Gram stain of a corneal ulcer of the left eye revealed fungal organisms and cultures grew Fusarium solani. The infiltrate responded to topical and systemic antifungal agents, but a corneal perforation developed which required a therapeutic penetrating keratoplasty.

CONCLUSIONS

Fungal infections are a cause of corneal ulcers in contact lens wearers. Despite the use of topical and systemic antifungal agents, fungal ulcers frequently require surgical intervention.

Spectrum of fungal keratitis at Wills Eye Hospital, Philadelphia, Pennsylvania

PURPOSE

To report the spectrum of fungal keratitis at Wills Eye Hospital, Philadelphia.

METHODS

We reviewed the records of 24 cases of culture-positive fungal keratitis treated from January 1991 to March 1999 at Wills Eye Hospital. Risk factors, fungal identification, antifungal treatment, and outcomes were evaluated.

RESULTS

The study included 24 eyes (24 patients). Fourteen patients (58.3%) were female. The mean age was 59 years (range, 19-86 years). Predisposing factors included chronic ocular surface disease (41.7%), contact lens wear (29.2%), atopic disease (16.7%), topical steroid use (16.7%), and ocular trauma (8.3%). Early identification of fungal elements was achieved by staining of corneal scrapings in 18 cases (75%). Half of the cases (12 eyes) had corneal infections caused by yeast, and the other half by filamentous fungi. Candida albicans was the most commonly isolated organism (45.8%), followed by Fusarium sp (25%). Natamycin and amphotericin B were the topical antifungals most frequently used, while systemic treatment commonly used included fluconazole, ketoconazole, or itraconazole. Six patients (25%) had penetrating keratoplasty during the acute stage of infection. After a mean follow-up of nine months, 13 eyes (54.1%) had the best corrected visual acuity 20/100 or better.

CONCLUSIONS

In contrast to other studies from the northern United States, we found Fusarium sp the most commonly isolated filamentous fungus. In our series, C. albicans was the most frequent cause of fungal keratitis, and a past history of ocular trauma was uncommon.

Nontraumatic corneal perforation

PURPOSE

To study the predisposing conditions, treatments, and visual outcomes of nontraumatic corneal perforations.

METHODS

A retrospective chart review was conducted of all nontraumatic corneal perforations seen between January 1992 and December 1998, with > or = 3 months of follow-up, at the Cornea Service Wills Eye Hospital.

RESULTS

A total of 40 nontraumatic corneal perforations was analyzed. Sixty-two percent of the cases were female. At presentation, 35 of 40 eyes (87.5%) had best corrected visual acuity of 20/200 or worse. The most common diseases associated with perforations were keratoconjunctivitis sicca (12 eyes, 30%), bacterial keratitis (6 eyes, 15%), exposure keratopathy (5 eyes, 12.5%), and herpes simplex virus (HSV) keratitis (4 eyes, 10%). Visual acuity improved > or = 2 Snellen lines in 3 of 8 eyes (37.5%) treated with penetrating keratoplasty, 5 of 14 eyes (35.7%) treated with tissue adhesive, and 1 of 12 eyes (8.3%) given medical treatment. After allowing for the different levels of presenting vision, treatment modality was not significantly related to final visual outcome.

CONCLUSION

Keratoconjunctivitis sicca is the most common underlying disease associated with nontraumatic corneal perforation. Corneal perforations were managed successfully using tissue adhesive, medical therapy, or penetrating keratoplasty. Treatment depended on the characteristics of the perforation and on the visual potential of the eye.

Surgical management of ocular surface squamous neoplasms: the experience from a cornea center

PURPOSE

To report the surgical outcomes of treatment for ocular surface squamous neoplasms.

METHODS

Retrospective review of squamous neoplasms of the ocular surface managed at a cornea center over a 15-year period. Surgical treatment was divided into two methods. The procedure was identical within each group. One group of patients was treated with simple excision of the lesion. The second group of patients was treated with excision followed by focal cryotherapy to the involved limbus and/or conjunctival margin. Follow-up is reported.

RESULTS

A total of 28 lesions were reviewed. Included were 20 primary tumors and 8 recurrent tumors referred following initial treatment at other centers. Histopathologic diagnoses included 1 actinic keratosis, 7 dysplasias, 18 carcinomas in situ, and 2 invasive squamous cell carcinomas. The rate of recurrence for primary tumors was 28.5% with simple excision and 7.7% for excision combined with cryotherapy (p = 0.27). The rate of recurrence for recurrent tumors was higher: 16.6% for tumors treated with excision and cryotherapy and 50% (one in two) for lesions treated with simple excision (p = 0.46).

CONCLUSION

Simple excision of ocular surface squamous neoplasms appears to result in a higher recurrence rate when compared to excision with adjunctive cryotherapy. Judicious cryotherapy to the involved limbus and conjunctival margins results in recurrence rates comparable with other, more extensive cryotherapy procedures. This technique of cryotherapy has very few adverse effects on the eye.

Phototherapeutic keratectomy for Schnyder's crystalline corneal dystrophy

PURPOSE

To describe the treatment of Schnyder's crystalline dystrophy (SCD) with excimer laser phototherapeutic keratectomy (PTK).

METHODS

Chart review of three patients (four eyes) with SCD treated with PTK between March 1992 and December 1998. Pre- and posttreatment visual acuity, subjective glare, photophobia, manifest refraction, ultrasound pachymetry, hyperopic shift, and biomicroscopic findings were studied. Brightness acuity testing (BAT) was evaluated in two eyes.

RESULTS

Four eyes were treated during the study period. The average best corrected visual acuity (BCVA) improved from 20/175 to 20/40 under bright conditions. All patients reported subjective improvement in glare and photophobia. No visually significant recurrence was observed during the follow-up period which ranged from seven months to three years. The mean spherical equivalent refractive shift was +3.28 diopter (D). One patient developed irregular astigmatism from an eccentric ablation. No vision threatening complications were observed.

CONCLUSION

PTK can be effective at improving visual symptoms in patients with SCD. It can be a useful therapeutic alternative to lamellar or penetrating keratoplasty in these patients.

Indications for and outcomes of repeat penetrating keratoplasty, 1989-1995

OBJECTIVE

To evaluate the indications for and outcomes of repeat penetrating keratoplasty over a 7-year period and compare them to a similar study over the prior 6-year period at the same institution.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Two hundred twenty-three consecutive repeat corneal transplants performed by one of five corneal surgeons between 1989 and 1995 were studied.

MAIN OUTCOME MEASURES

Reasons for primary and regraft failure, indications for the initial corneal graft, graft clarity, and best-corrected visual acuity were measured on each patient.

RESULTS

Between 1989 and 1995, 16% (271 of 1689) of transplants performed by our cornea group were regrafts compared with 9% (165 of 1860) in the period from 1983 to 1988 (P < 0.01). The most common indications for penetrating keratoplasty before regraft were pseudophakic bullous keratopathy (27%, 61 of 223), failed graft (20%, 44 of 223), Fuchs' dystrophy (11%, 24 of 223), aphakic bullous keratopathy (9%, 21 of 223), keratoconus (8%, 17 of 223), and herpes simplex keratitis (6%, 14 of 223). Compared with the prior study period of 1983 to 1988, an increase was revealed in the incidence of failed graft (11% to 20%, P = 0.03), and a decrease was revealed in the incidence of aphakic bullous keratopathy (19% to 9%, P = 0.01). Of the 223 regrafts, 55 (25%) failed during the study period (range, 1 month to 7.5 years; mean 2.1 years). Eleven percent (6 of 55) of regraft failures occurred within 6 months, and 55% (30 of 55) failed within 18 months. Of the 150 regrafts with 2 years follow-up (mean, 3.9 years), 111 (74%) had clear grafts. A best-corrected visual acuity of 20/20 to 20/40 was achieved in 41% (46 of 111), 20/50 to 20/100 in 32% (36 of 111), 20/200 to 20/400 in 21% (23 of 111), and counting fingers to no light perception in 5% (6 of 111).

CONCLUSIONS

Failed grafts are increasing as an indication for penetrating keratoplasty. Graft clarity and visual acuity results continue to be very good, supporting the use of repeat corneal transplantation.

Penetrating keratoplasty for varicella-zoster virus keratopathy

PURPOSE

To examine and report the results of penetrating keratoplasty performed in patients with varicella-zoster virus keratopathy.

METHODS

The authors retrospectively reviewed the records of 15 patients who had penetrating keratoplasty for varicella-zoster virus keratopathy from January 1989 through December 1998 on the Cornea Service at Wills Eye Hospital.

RESULTS

Twelve patients had a preoperative diagnosis of herpes zoster ophthalmicus, and three, of varicella. Four eyes had lateral tarsorrhaphies performed in conjunction with penetrating keratoplasty. Three eyes had endothelial rejection episodes that responded well to treatment with topical steroids. One eye had a regraft 1 month after primary failure, and this second graft also failed because of recurrent neurotrophic keratopathy. Three eyes that had repeated penetrating keratoplasty for graft failure had clear grafts at the last examination. At an average follow-up time of 50 months, 13 (86.7%) grafts remained clear, and the best corrected visual acuity was 20/100 or better in eight (53.3%) eyes. Five patients had decreased visual acuity because of retinal diseases.

CONCLUSION

Although varicella-zoster virus keratopathy is an uncommon indication for penetrating keratoplasty, effective visual rehabilitation can be achieved in these patients. Careful postoperative management, frequent lubrication, and lateral tarsorrhaphies to protect the corneal surface are major factors in the successful outcome of these cases.

Corneal ulcers and the use of topical fluoroquinolones

PURPOSE

To determine whether the widespread use of topical fluoroquinolones has changed the spectrum of ulcerative keratitis, and to determine how it has affected practice patterns in the treatment of corneal ulcers.

METHODS

We retrospectively reviewed the charts of 48 consecutive patients with infectious corneal ulcers from 7/1/91 to 12/31/91 and 47 consecutive patients from 7/1/94 to 12/31/94. Patients were treated with intensive topical antibiotics (either standard fortified antibiotics or topical fluoroquinolones) at a frequency of at least every hour while awake. Some patients were admitted to the hospital, and some underwent scraping for smears and cultures.

RESULTS

Ulcers which were seen in 1994 appear to have been more severe than those seen in 1991 as judged by the presence of more ulcers associated with hypopyons, (P< 0.05) but not with regard to the size of the infiltrate or epithelial defect. More ulcers in 1994 were treated on an outpatient basis (P< 0.02) and fewer ulcers were scraped and cultured than in 1991 (P< 0.001). Culture results from the 1991 and 1994 groups were similar. The most frequently isolated organisms were coagulase-negative Staphylococcus, Pseudomonas, Staphylococcus aureus, and Streptococcus spp.

CONCLUSION

The spectrum of ulcerative keratitis at a tertiary referral center may be showing a trend towards more severe ulcers, but the causative agents responsible for the infection are unchanged.

Recurrence of corneal dystrophy after excimer laser phototherapeutic keratectomy

BACKGROUND

Excimer laser phototherapeutic keratectomy (PTK) can be useful to treat anterior corneal dystrophies both before and after penetrating keratoplasty.

OBJECTIVE

To evaluate the recurrence of corneal dystrophies after excimer laser PTK.

DESIGN

Retrospective case series.

PARTICIPANTS

Fifty excimer laser PTK procedures were performed in 43 eyes of 33 patients with corneal dystrophies. Preoperative diagnoses included Reis-Bücklers dystrophy (13 eyes), granular dystrophy (11 eyes), anterior basement membrane (ABM) dystrophy (11 eyes), lattice dystrophy (7 eyes), and Schnyder crystalline dystrophy (1 eye).

INTERVENTION

Two excimer lasers (VISX 20/20 model B and VISX Star) were used to perform all PTKs.

MAIN OUTCOME MEASURES

After PTK, patients were followed on a regular basis with measurement of best-corrected visual acuity and biomicroscopic examination. Evidence of recurrent dystrophy was noted according to specific criteria.

RESULTS

Follow-up range was from 1.1 to 71.2 months (mean, 19.5 months). Clinically significant recurrent dystrophy occurred in 17 eyes. The ABM dystrophy recurred in the form of recurrent corneal erosions in 5 (42%) of the 12 eyes within 6 to 9 months of PTK. Four of these five eyes had mild erosions, which were treated successfully with topical medications while one eye required an additional PTK for an erosion outside the initial treatment area. Eight (47%) of 17 eyes with Reis-Bücklers dystrophy developed clinically significant recurrence an average of 21.6 months after PTK. Three (23%) of 13 eyes with granular dystrophy were found to have a significant recurrence a mean of 40.3 months after PTK. Only one (14%) of seven eyes with lattice dystrophy developed a significant recurrence at 6 months after PTK. Six eyes with significant recurrence after PTK were retreated successfully with additional PTK. Three eyes later developed recurrence of granular and Reis-Bücklers dystrophy after the second PTK. The probability of recurrence of these dystrophies after PTK was calculated using the Kaplan-Meier survival analysis.

CONCLUSION

Phototherapeutic keratectomy can restore and preserve useful visual function for a significant period of time in patients with anterior corneal dystrophies. Even though corneal dystrophies are likely to recur eventually after PTK, successful retreatment with PTK is possible.

Risk factors in microbial keratitis leading to penetrating keratoplasty

OBJECTIVE

To determine the characteristics of infectious corneal ulcers at the time of presentation to the cornea specialist associated with a favorable response to medical therapy versus a poor outcome manifested by the need for penetrating keratoplasty for therapy or visual rehabilitation.

DESIGN

Retrospective, case-control study.

PARTICIPANTS

A total of 162 patient records were reviewed, including the study group of 30 patients and the control group of 132 patients.

INTERVENTION

A retrospective review of all cases of microbial keratitis presenting to the Cornea Service between January 1, 1989 and December 31, 1995 was conducted. The cases were divided into two groups. The study group consisted of patients with microbial keratitis who failed medical therapy and required penetrating keratoplasty. The control group included patients with infectious ulcers who responded to medical therapy alone.

MAIN OUTCOME MEASURES

The influence of demographics, medical and ocular history, delay in presentation to the primary ophthalmologist or the corneal specialist, topical medications, and contact lens usage were compared. Visual acuity and ulcer characteristics were recorded. The statistical significance was evaluated by the chi-square test for independence and multiple logistic regression.

RESULTS

Older age (P=0.001), delay in referral to the corneal specialist (P<0.03), and treatment with topical steroids prior to presentation (P<0.0001) were statistically significant factors associated with the need for penetrating keratoplasty. Steroid use and the delay in referral were correlated. A past history of ocular surgery (P=0.01), poor visual acuity at presentation (P<0.001), and ulcer characteristics, including central location (P<0.0001), large size (P<0.0001), presence of perforation or descemetocele (P<0.0001), limbal involvement (P<0.0001), and hypopyon (P=0.05), were all associated with the need for penetrating keratoplasty.

CONCLUSIONS

Older age, delay in referral to the corneal specialist, topical steroid treatment, past ocular surgery, poor vision at presentation, large size, and central location of the ulcer are risk factors for poor outcome of microbial keratitis, as indicated by the need for penetrating keratoplasty.

Oral acyclovir after penetrating keratoplasty for herpes simplex keratitis

OBJECTIVE

To determine the efficacy of systemic acyclovir in decreasing complications and improving the outcome of penetrating keratoplasty for herpes simplex virus (HSV) keratitis.

METHODS

Retrospective study of 53 primary penetrating keratoplasties for HSV keratitis at an eye hospital from January 1, 1989, through December 31, 1996. Medical records were analyzed for history of HSV keratitis, preoperative neovascularization, and disease activity. Postoperative use of acyclovir, recurrence of HSV keratitis, rejection, uveitis or edema, and graft failure were evaluated.

RESULTS

Twenty-four patients (mean +/- SD follow-up, 44.7 +/- 32.6 months) received no acyclovir and were compared with 20 patients, (mean +/- SD follow-up, 28.8 +/- 16.7 months), who received 400 mg acyclovir twice a day for at least 1 year. No patient in the acyclovir group had a recurrence of dendritic keratitis in the first year compared with 5 (21%) of the patients who did not receive acyclovir (P = .03). No patient had graft failure in the acyclovir group compared with 4 (17%) in the group without acyclovir after 1 year of follow-up (P = .06).

CONCLUSION

Postoperative systemic acyclovir therapy after penetrating keratoplasty for HSV keratitis is associated with a reduced rate of recurrent HSV dendritic keratitis and possible graft failure at 1 year of follow-up.

Evaluation of triggers for corneal graft rejection

BACKGROUND AND OBJECTIVE

To evaluate potential triggering factors contributing to corneal graft rejection.

PATIENTS AND METHODS

A prospective, case control study was conducted over a five month period. All patients presenting with new onset corneal graft rejection were enrolled into the study group. Two patients with clear grafts who presented shortly after each enrolled study group patient served as controls. Groups were matched for age, preoperative diagnosis, and number of previous keratoplasties. Participating patients and examining ophthalmologists filled out questionnaires regarding infectious, environmental and immunologic exposures.

RESULTS

66 patients were enrolled into the study, of which 22 had new rejection episodes. The most prevalent diagnoses were keratoconus (36.6%) and herpes simplex keratitis (22.7%). Anterior chamber reaction (77.3%) and keratic precipitates (68.2%) were the most common signs of graft rejection. A history of prior rejection episodes was significantly more frequent in the study group population (p < 0.001). Factors such as sun exposure, stress, smoking and travel were more prevalent in the rejection group but not statistically significant. The history of recent vaccinations and allergic reactions were equally prevalent in both groups.

CONCLUSIONS

The new onset of corneal graft rejection was highly associated with a prior history of graft rejection episodes (p < 0.001). Other analyzed factors were not significant triggering factors for rejection in this small series.

Ultrasound biomicroscopy as a tool for detecting and localizing occult foreign bodies after ocular trauma

OBJECTIVE

To show the utility of ultrasound biomicroscopy (UBM) in imaging small ocular foreign bodies of the anterior segment.

DESIGN

Retrospective case series.

PARTICIPANTS

Twelve eyes of 12 consecutive patients evaluated in the emergency department or referred to specialty services at 1 institution between August 1994 and November 1997 were examined.

INTERVENTION

Ocular ultrasound biomicroscopy was performed.

MAIN OUTCOME MEASURES

Detection and localization of an ocular foreign body were measured.

RESULTS

An intraocular or superficial foreign body was detected by UBM in 9 (75%) of 12 eyes. The foreign body was classified as corneal in two eyes, subconjunctival in two, intrascleral in three, and intraocular in two eyes. The foreign body was not visible by ophthalmic physical examination in seven of the nine eyes with a confirmed ocular foreign body. In the remaining two eyes, UBM was used to determine the depth of a visible foreign body. In three of the eyes with a confirmed foreign body, computed tomography and/or contact B-scan ultrasonography was obtained and failed to show a foreign body. Six of the foreign bodies were nonmetallic.

CONCLUSIONS

Clinical detection of ocular foreign bodies after trauma can be hindered by small size, haziness of the optical media, poor patient cooperation, or hidden location. Ultrasound biomicroscopy is a valuable adjunct in the evaluation of suspected ocular foreign bodies, especially in cases involving small, nonmetallic objects.

Acute hydrops in the corneal ectasias: associated factors and outcomes

PURPOSE

To identify factors associated with the development of hydrops and affecting its clinical outcome.

METHODS

Chart review of all patients with acute hydrops seen by a referral cornea service during a 2.5-year period between June 1996 and December 1998.

RESULTS

Twenty-one patients (22 eyes) with acute hydrops were seen. Nineteen patients had keratoconus, 2 had pellucid marginal degeneration, and 1 had keratoglobus. Twenty-one of 22 (95%) eyes had seasonal allergies and 20 of 22 (91%) eyes had allergy-associated eye-rubbing behavior. Six of 22 (27%) had a diagnosis of Down's syndrome. Six patients were able to identify a traumatic inciting event: vigorous eye rubbing in 4 and traumatic contact lens insertion in 2. The affected area ranged from 7% to 100% of the corneal surface area and was related to disease duration and final visual acuity. Proximity of the area of edema to the corneal limbus ranged from 0 to 2.3 mm and was also related to prognosis. Three serious complications were observed: a leak, an infectious keratitis, and an infectious keratitis and coincidental neovascular glaucoma. Various medical therapies did not differ significantly in their effect on outcome, and ultimately 4 (18%) of 22 patients underwent penetrating keratoplasty. Best-corrected visual acuity was equal to or better than prehydrops visual acuity in 5 of the 6 patients in whom prehydrops visual acuity was known, without corneal transplantation.

CONCLUSIONS

Allergy and eye-rubbing appear to be important risk factors in the development of hydrops. Visual results are acceptable in some patients without surgery. Close observation allows for the early detection and treatment of complications such as perforation and infection.

Microbial keratitis resulting in loss of the eye

BACKGROUND AND OBJECTIVES

The purpose of this study was to determine the clinical characteristics of infected corneal ulcers resulting in loss of the eye.

PATIENTS AND METHODS

The authors conducted a retrospective study of all cases requiring evisceration or enucleation due to microbial keratitis at Wills Eye Hospital between January 1, 1989, and December 31, 1995. Medical records were reviewed to determine the past medical and ophthalmic history, duration of symptoms and treatment prior to referral, and the size of the ulcer at time of presentation. Treatment, culture results, and clinical course were also analyzed.

RESULTS

During the study period, 1.8% (17 of 965) of the patients with corneal ulcers admitted to Wills Eye Hospital underwent evisceration or enucleation for microbial keratitis. The median age of the patients was 67 years (+/- 20.1 years). A majority of the patients (82%, 14 of 17) had a history of preexisting ocular disease resulting in poor visual acuity. The median duration of symptoms prior to presentation to Wills Eye Hospital was 11.4 days (+/- 13.9 days). The average size of the corneal infiltrate was 40.8 mm2 (+/- 38.7 mm2). The most common pathogens were Pseudomonas (7 cases) and Streptococcus (3 cases). Patients required evisceration (14 cases) or enucleation (3 cases) due to uncontrolled infection.

CONCLUSIONS

Microbial keratitis resulting in loss of the eye occurred typically in patients who were elderly with preexisting poor visual acuity, who presented with severe infections due to virulent organisms or delayed treatment.

Ultrasound biomicroscopy and histopathology of sclerocornea

PURPOSE

We present a clinicopathologic case report of sclerocornea with the intent of showing the usefulness of ultrasound biomicroscopy (UBM) and the correlation of histopathologic findings.

METHODS

An infant with congenital bilateral sclerocornea was seen for an evaluation under anesthesia. Dense opacification of both corneas prevented adequate examination of both anterior and posterior segments of the eye. UBM was performed preoperatively with subsequent corneal transplantation of the left eye. The corneal button was submitted for histopathologic examination.

RESULTS

Preoperative UBM proved helpful in assessing the status of the cornea as well as the anterior chamber and its structures. Findings on histopathologic examination correlated well with the results on UBM and confirmed the diagnosis of sclerocornea.

CONCLUSION

We recommend the use of UBM in assessing opacified corneas to assist in obtaining a diagnosis, to highlight potential associated structural anomalies, and to help guide decisions regarding surgical management.

The accuracy of finger tension for estimating intraocular pressure after penetrating keratoplasty

BACKGROUND AND OBJECTIVE

Intraocular pressure (IOP) estimation by Goldmann tonometry is inaccurate in the immediate postoperative period after penetrating keratoplasty. For this reason, many corneal surgeons use a finger tension (FT) IOP estimation technique in the early post-keratoplasty period. The authors performed a prospective clinical study to evaluate the accuracy of this traditional technique.

PATIENTS AND METHODS

FT estimates were performed by three experienced corneal surgeons on 68 patients on the first and second days after penetrating keratoplasty. These estimates were compared with MacKay-Marg (MM) tonometry readings for these patients.

RESULTS

The mean confident FT from the pooled data of the three surgeons exceeded the MM reading by 5.0 mm Hg (22.6 vs. 17.6). The mean FT exceeded the MM reading by only 3.9 mm Hg for the most accurate surgeon. Some observers were significantly more accurate than others, however, lid edema and tenderness of the globe markedly diminished the FT accuracy of all of the observers at significance levels of P < .001 and P < .01, respectively. Among all of the FT estimates, in only one patient (2%) did the FT underestimate the MM reading by more than 10 mm Hg.

CONCLUSION

The authors' results suggest that for some patients, and for some surgeons, the FT or digital method of IOP estimation remains useful for detecting elevated IOP early after corneal transplantation if the proper technique is used and substantial lid edema and patient discomfort are absent.

The role of ultrasound biomicroscopy in ocular trauma

PURPOSE

To demonstrate the usefulness of ultrasound biomicroscopy (UBM) in detecting and localizing small ocular foreign bodies.

METHODS

This is a retrospective study of the records of 555 consecutive patients evaluated by UBM by the Visual Physiology Unit of the Wills Eye Hospital from August 1994 to November 1997.

RESULTS

In 9 patients, a foreign body was identified. In 6 patients, the history suggested the presence of a foreign body, but one could not be detected by clinical examination. In 2 patients, the referring physicians requested UBM to determine whether or how deep a known foreign body had penetrated the globe. In 1 patient, the foreign body was not suspected clinically. In regard to other diagnostic techniques, CT failed to identify the foreign body in 1 patient. In another, contact B-scan ultrasonography failed. In a third, both CT and contact B-scan ultrasonography failed. The foreign body was intracorneal in 2 eyes, subconjunctival in 2, intrascleral in 3, and intraocular in 2. Six were nonmetallic. Two were metallic. In one case, the foreign body was lost and its composition is unknown. In 5 cases, the UBM findings altered the patient's management.

CONCLUSIONS

UBM is a valuable adjunct in the evaluation of small, anteriorly located foreign body that may not be detectable by other methods. UBM may be especially useful for finding nonmetallic foreign bodies.

Conjunctival necrosis following the administration of subconjunctival corticosteroid

This report describes an unusual reaction to injected subconjunctival corticosteroid. The authors examined a patient with large areas of conjunctival necrosis at the site of a previous subconjunctival corticosteroid injection. A Gram's strain and culture of the affected conjunctival area and the bottled corticosteroid suspension were negative. Necrosis of the conjunctiva is a heretofore unreported adverse reaction to a subconjunctival corticosteroid injection. These lesions probably represent a localized toxic reaction rather than a sequela of infection.

Indications for penetrating keratoplasty and associated procedures, 1989-1995

PURPOSE

To identify changing trends in indications for penetrating keratoplasty and associated surgical procedures.

METHODS

Review of charts from all patients who underwent penetrating keratoplasty at Wills Eye Hospital from January 1, 1989 through December 31, 1995.

RESULTS

A total of 2,442 corneal transplants were performed in 2,186 patients. The leading indication for penetrating keratoplasty was pseudophakic corneal edema, accounting for 634 cases (26.0%); 54.7% of them were associated with anterior chamber intraocular lenses, 36.4% with posterior chamber intraocular lenses, and 3.1% with iris-fixated intraocular lenses. Regraft (17.8%), Fuchs' dystrophy (15.7%), and keratoconus (13.2%) followed pseudophakic corneal edema in frequency. Cataract extraction, with or without intraocular lens implantation, was combined with penetrating keratoplasty in 439 cases of 1,264 phakic eyes (34.7%). Intraocular lens exchange was performed in 285 of the 634 cases of pseudophakic corneal edema (44.9%).

CONCLUSION

Pseudophakic corneal edema was the leading indication for penetrating keratoplasty, with an increasing number of cases associated with posterior chamber intraocular lenses during the study period (p = 0.001). The number of regrafts steadily increased between 1989 and 1995 (p = 0.001), being the second most common indication for corneal transplantation since 1992.

Chalazion-induced hyperopia as a cause of decreased vision

This article presents three cases of decreased vision due to acquired hyperopia, which were caused by a chalazion of the upper eyelid. Through manifest refraction and computerized corneal topographic analysis, acquired hyperopia associated with central corneal flattening was revealed. These findings were responsible for the blurred vision that was reversed by chalazion resolution or removal. Although not usually considered a risk factor for refractive disorders other than astigmatism, chalazia of the upper eyelid can present as a decrease in vision associated with reversible central corneal flattening and acquired hyperopia.