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Purpose: To investigate therapeutic ocular surface medium (TOSM), a potential physiological tear replacement therapy, for moderate to severe dry eye., Methods: Forty-six patients with symptoms of moderate to severe dry eye despite maximal standard therapy were enrolled in a prospective pilot study of TOSM over 1 month (n = 10) and a randomized, double-masked, controlled trial of TOSM versus saline (placebo) over 2 months (n = 36). The primary outcome measure was conjunctival rose bengal staining., Results: An improvement in conjunctival rose bengal staining by ≥3 points occurred in 7 of 10 patients receiving TOSM in the pilot study (P = 0.017) and in 8 of 18 patients (44%) in the randomized trial (P = 0.982). In the pilot study, subjective dry eye symptoms significantly improved (P = 0.005). TOSM significantly improved the blepharitis score (P = 0.002) and conjunctival impression cytology (P = 0.028) in the randomized controlled trial. There were no serious or irreversible side effects with TOSM., Conclusions: TOSM is a physiological tear replacement for dry eye that, unlike autologous serum, can be easily manufactured, could be widely available, and may also be beneficial for blepharitis.

Purpose: Many corneal surgeons are making the transition from penetrating keratoplasty to endothelial keratoplasty techniques such as Descemet's stripping endothelial keratoplasty and Descemet's stripping automated endothelial keratoplasty in the routine treatment of corneal endothelial failure. Donor dislocation is the commonest complication of these newer techniques. We set out to determine whether preoperative lens/iris diaphragm integrity might influence the rate of donor dislocation and whether donor endothelial failure was more common after surgical intervention for donor dislocation., Design: A retrospective multisurgeon comparative case series from a large teaching and referral center., Participants: Ninety-three eyes of 85 patients: consecutive cases of Descemet's stripping endothelial keratoplasty (n = 77) or Descemet's stripping automated endothelial keratoplasty (n = 16) performed between March 2004 and January 2007., Methods: A retrospective review of case notes., Main Outcome Measures: The number of eyes with an open communication between the anterior and posterior chambers (an iridectomy or lens capsular defect not covered by a posterior chamber intraocular lens), the number of eyes requiring surgical intervention to correct donor dislocation, and the number of eyes with donor endothelial failure within the follow-up period., Results: Complete data sets were available for analysis in 89 eyes. The median follow-up interval at the time of the audit was 7 months (range 1-34 months). Donor dislocation was significantly more common (P = 0.017) in eyes with an open communication between the anterior and posterior chambers, occurring in 11 of 25 cases (44%) versus 12 of 64 cases (19%) with an intact iris/lens diaphragm. Early endothelial failure was significantly more common (P = 0.011) in cases requiring additional surgical intervention for donor dislocation, occurring in 6 of 21 cases (29%) after successful surgical reattachment of a dislocated donor disc versus 4 of 67 cases (6%) in which no additional intervention was required., Conclusions: Donor dislocation after endothelial keratoplasty is more common in cases with an open communication between the anterior and posterior chambers. The risk of donor endothelial failure is increased in cases of donor dislocation. Trainee surgeons and surgeons in making the transition from penetrating keratoplasty should initially select cases with an intact lens/iris diaphragm.

Purpose: To review cases of culture-positive fungal keratitis seen at Moorfields Eye Hospital over a 13-year period to January 2007., Methods: Isolates were identified retrospectively from laboratory reports. The clinical records were reviewed. The fungal type, risk factors for infection, in vitro sensitivity, and clinical outcome were recorded., Results: There were 66 isolates from 65 patients (men, 53.8%). Forty (60.6%) of the isolates were subspecies of Candida. The average interval from the onset of keratitis to confirmation of fungal infection was 3.4 weeks (median, 1.0 week; range, 0-16 weeks). Prior ocular surface disease (OSD) or a penetrating keratoplasty (PK) was present in 38 (97.4%) patients with Candida infection, and 29 (74.4%) patients with Candida infection were using topical steroid at the time of diagnosis. The principal risk factors for filamentary fungal infection were trauma (8 cases, 30.8%) or cosmetic contact lens wear (8 cases, 30.8%), with OSD or a prior PK each present in 5 (19.2%) cases. The difference in the proportions of risk factors between the 2 fungal groups was statistically significant (P < 0.000). The visual outcome was similar between groups, and at final review, 27 (41.5%) eyes had a visual acuity of < or = 1/60 and 3 (4.6%) eyes were eviscerated. In vitro sensitivity testing showed full or part sensitivity in 100% of 55 isolates tested against econazole, 87.9% of 58 isolates tested against amphotericin, 75% of 40 isolates tested against itraconazole, and 100% of 20 isolates tested against voriconazole., Conclusions: Candida was the principal isolate, usually from eyes with OSD or a prior PK treated with topical steroids.

Purpose: To study the outcomes of AlphaCor implantation., Methods: : The AlphaCor artificial cornea is indicated for corneal blindness not treatable by donor grafting. Prospective preoperative and follow-up data were collected. Data were evaluated using SPSS for statistical analysis of outcomes, trends, and associations., Results: This report includes data returned through February 28, 2006, for all 322 devices implanted, with mean follow-up in situ of 15.5 months and a maximum of 7.4 years. The probability of AlphaCor retention at 6 months and 1 and 2 years for protocol cases was 92%, 80%, and 62%, respectively, and off-label cases were at higher risk (P = 0.010), as were cases not prescribed medroxyprogesterone (MPG; P = 0.001). Currently, the most common complications were stromal melting, fibrous reclosure of the posterior lamellar opening, and white intraoptic deposits, with incidences in 2005 of 11.4%, 5.1%, and 2.6%, respectively. MPG seems to protect against melts, and eyes with a history of herpetic keratitis were not at increased risk. A history of glaucoma or the presence of tubes did not affect device retention. Complications culminated in loss of an eye in 1.3%. Mean preoperative visual acuity (VA) was hand movements. The VA achieved postoperatively (light perception to 20/20) was affected by previous pathology and postoperative course, with a mean improvement of 2 lines., Conclusion: AlphaCor provides a treatment option where a donor tissue graft would not succeed in severe corneal conditions, while being reversible to a donor graft in the event of complications for anatomic integrity. Surgical technique and adjunctive therapies are evolving with experience. Continued data collection is important for a fuller understanding of AlphaCor's role.

Infectious crystalline keratopathy (ICK) is an uncommon, indolent corneal infection in which the slow clinical course contrasts with the rapid laboratory growth and microbiological sensitivities of the infecting organism. This prospective study aimed to determine whether biofilm production was the cause of this disparity. A case of failed medical management of ICK in a patient with Stevens-Johnson syndrome is presented. A penetrating keratoplasty yielded corneal tissue that was freshly fixed for electron microscopy using 0.05% ruthenium red and 2.5% gluteraldehyde. Candida albicans was grown from 3/3 broths, and fungi with morphology consistent with Candida were seen on histological examination. Electron microscopy revealed microorganisms morphologically typical of Candida surrounded by a polysaccharide-rich glycocalyx consistent with a biofilm. We concluded that Candida albicans is capable of producing a biofilm and is a known cause of ICK. This case is supportive evidence that biofilm production is associated with cases of ICK and may explain the chronic, pauciinflammatory features of ICK and its relative resistance to antibiotic treatment.

Silicone rubber contact lenses (SRCLs) are infrequently used because of the risk of developing unpredictable lens tightening, their poor availability, and their expense. However, their high oxygen transmissibility and nonabsorption of water make them valuable as therapeutic lenses. SRCLs are routinely used in our management of severely dry eyes, decompensated or vascularised corneas, and conditions where the corneal shape is flat or irregular. The records of 48 consecutive patients fitted with SRCLs between January 1989 and June 1990 were studied. The clinical history, indications, complications, success, and duration of SRCL wear were analysed. Therapeutic goals, which included epithelial healing, sealing of corneal perforations, and improved comfort and vision, were achieved in 53 of 62 eyes. The best corrected acuity was attained using SRCLs in 58 of 62 eyes. Failure of lens wear was due to lens tightening (four eyes), spoilation (two), discomfort, fornix shortening, handling problems, and decentration (one each). Infective keratitis complicated one case, but SRCL wear was resumed after successful treatment. With adequate follow-up, SRCLs have a low complication rate and are well tolerated even in severely compromised eyes, for which conventional lenses may be contraindicated. Their continued use as therapeutic lenses is advocated in carefully selected cases.