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Seven patients with documented Acanthamoebakeratitis were treated with prolonged and intensive triple antiamoebic therapy consisting of topical neomycin-polymyxin B-gramicidin, propamidine isethionate 0.1%, and miconazole nitrate 1%. Additionally, five patients were treated with topical corticosteroids. Six of seven patients were cured of Acanthamoebakeratitis with medical therapy alone, one patient required therapeutic penetrating keratoplasty to eradicate the infection. Two patients underwent penetrating keratoplasty to improve their vision after medical therapy. Our series differs from previous reports in that triple antiamoebic therapy was used in all seven patients and was successful in both early and advanced cases of Acanthamoebakeratitis. Prolonged and intensive topical therapy with these three antiamoebic drugs may be an effective mode of therapy for Acanthamoebakeratitis.

The clinical appearance of endothelial rejection following penetrating keratoplasty was studied in three human cases. On the posterior surface of each graft was an endothelial rejection line formed by keratitic precipitates. In two cases, the rejection process was reversed with corticosteroids, while in one case, the endothelial rejection line progressed across the back of the graft, destroying the transplanted endothelium.This latter graft became available for study five weeks after the onset of rejection. Routine histologic and scanning electron microscopic examination of this specimen showed nearly complete destruction of endothelial cells and early retrocorneal membrane formation.The presence of an endothelial rejection line proved a common helpful sign in the diagnosis of early graft rejection.

TO THE EDITOR. —Punctal occlusion has proved to be a valuable adjunct in the treatment of moderate to severe dry-eye syndrome. Recently, silicon plugs have become available for reversible occlusion of the lacrimal punctum and canaliculus.1 Although this device has proved beneficial to many cases in our experience, its use is not without some potential hazard, as the following two case reports will indicate. REPORT OF CASES. —Case 1.—A 29-year-old woman suffered from moderate dry-eye syndrome that caused irritation, particularly of the right eye. Since she was helped by temporary occlusion of her canaliculi with collagen inserts, we elected to perform punctal occlusion using a punctal plug for her lower right punctum. The lower lid was grasped with forceps in the recommended manner and the punctum was dilated with the punctal dilator supplied by the manufacturer. An attempt was then made to insert the plug, but, because of the

TO THE EDITOR. —The report by Pogrebniak and Sugar1 in the November 1988 issue of the Archives pointed out the potential corneal toxicity from hydrogen peroxide soaked tonometer tips. Fortunately, that case showed clearing of the cornea within 2 days. I recently encountered a more severe corneal burn from a tonometer tip that had been cleaned with a 3% solution of hydrogen peroxide. In this case, hydrogen peroxide had been applied to the tonometer tip 30 minutes before using it on a patient. Because of the fear of viral transmission, the peroxide had not been irrigated. The tip was moist at the time the pressure was taken. The patient noted blurred vision and pain following the examination.By the next day, the patient had a perfect "O-shaped" opacity in the anterior stroma that was identical in size to the tip of the applanation tonometer. The opacity was displaced slightly