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Background: Hereditary benign intraepithelial dyskeratosis (HBID) is a rare autosomal dominant disorder with incomplete penetrance. It is characterized by bilateral limbal conjunctival plaques combined with similar changes in the oral mucosa., Patient: An 11-year-old African-American patient presented with bilateral chronic conjunctivitis, nasal and temporal limbal conjunctival plaques, and plaques of the oral mucosa, all of which resisted therapy. The onset of the symptoms was in early childhood. Conjunctival smears, allergy tests, blood samples and the internal examination were inconclusive. Histologically, the ocular lesions showed acanthosis, parakeratosis, hyperkeratosis and dyskeratosis. An infiltrate of chronic inflammatory cells was present beneath the intact epithelial basement membrane., Conclusions: The clinical and histological findings are characteristic of HBID. Symptoms usually start in early childhood and show a waxing and waning course. HBID was first seen among Haliwa Indians in North Carolina. In the meantime HBID has been described in other parts of the US and also in Europe. As these patients were not related to any of the Haliwa Indians, they are considered new mutations. Malignant changes of the conjunctival or oral lesions have not been reported.

Objective: This study aimed to determine whether there is a true difference in predictability between single-zone and multizone laser in situ keratomileusis (LASIK) for the correction of low myopia or whether any difference in predictability is because of a need for separate clinical nomograms for the two treatments., Design: A prospective, randomized, clinical trial., Participants: Fourteen surgeons and 190 eyes of 95 patients with myopia who desired surgical correction of myopia ranging from -2.00 to -7.00 diopters (D) participated., Intervention: Fellow eyes of patients with myopia undergoing bilateral simultaneous LASIK were randomized to single-zone and multizone ablation. Astigmatism was not corrected at the time of LASIK., Main Outcome Measures: Predictability, postoperative videokeratography, and contrast sensitivity were assessed at 3 months after surgery., Results: At 3 months, r2 values relating laser setting to change in spherical equivalent refraction were 0.78 for single-zone and 0.76 for multizone ablation; mean outcome with respect to intended was -0.84 D (0.65 standard deviation [SD]) for single-zone and -0.62 D (0.78 SD) for multizone eyes (P = 0.035). There was no relationship between single-zone and multizone ablation and the likelihood of asymmetric postoperative videokeratography (P = 0.83). The only difference in contrast sensitivity was a significantly greater decrease in log contrast for multizone eyes at 12 cyc/deg under undilated conditions., Conclusions: There is no true difference in predictability between single-zone and multizone LASIK for the correction of low myopia. Separate clinical nomograms for single-zone and multizone LASIK should eliminate the difference in predictability that was observed in this clinical trial.

Purpose: To assess the effects of laser in situ keratomileusis (LASIK) on the corneal endothelium., Methods: In a prospective study, the corneal endothelium of 98 eyes of 65 consecutive patients (mean age, 41 years; range, 22 to 66 years) was photographed before, 2 weeks after, and 12 weeks after LASIK for the correction of 2.75 to 14.5 diopters of myopia. Theoretical ablation depths were 200 to 330 microm below the corneal surface. Cell density, coefficient of variation, and percent of hexagonal cells were determined using 150 to 200 cells from each image. Eighty-eight eyes (91%) of 59 patients had a history of contact lens wear., Results: The mean+/-SD preoperative endothelial cell density was 2,549+/-365 cells per mm2, and the mean coefficient of variation was 0.35+/-0.06. There was no statistically significant change in the mean endothelial cell density or mean coefficient of variation of cell size at the 2-week (2,561+/-360 cells per mm2 and 0.35+/-0.06) or 12-week (2,541+/-364 cells per mm2 and 0.35+/-0.05) postoperative examinations. The percent of hexagonal cells was not significantly changed 2 weeks postoperatively; however, 12 weeks postoperatively (P=.0413, two-tailed t test), the percent of hexagonal cells was decreased by 1%., Conclusions: Corneal endothelial cell density and morphology were unchanged 2 and 12 weeks after LASIK for the correction of up to 14.5 diopters of myopia. In this LASIK study, the correction of up to 14.5 diopters of myopia appears to cause no clinically significant effect on corneal endothelial cell density or morphology.

Purpose: To study the histology and pattern of keratocyte repopulation of surgically removed human epikeratoplasty lenticules., Methods: Removed epikeratoplasty lenticules and penetrating keratoplasty buttons that contained epikeratoplasty lenticules were evaluated for duration of epikeratoplasty, histologic and ultrastructural features, and average number of keratocytes per high-power microscopic field. The keratocyte density was compared with age-matched controls., Results: Fifteen epikeratoplasty specimens from eight penetrating keratoplasties and seven removed lenticules were reviewed. The indications for keratoplasty were myopia, keratoconus, and aphakia. The lenticules were in place for 7-120 months, and the keratocyte count ranged from 14 to 40 per high-power field. Keratocyte density increased to 30-40 per high-power field, similar to age-matched controls, at approximately 48 months postoperatively, similar to the density of the controls. Keratocytes appeared to have migrated from the periphery to the center of the lenticules., Conclusions: Normal keratocyte density in epikeratoplasty lenticules is reached by approximately 48 months after surgery.

Objectives: To study the effects of radial keratotomy (RK) and photorefractive keratectomy (PRK) on contrast sensitivity and glare disability using 4 different devices, and to correlate subjective complaints with obj ective scores of visual performance., Methods: Preoperative contrast sensitivity for 30 eyes undergoing RK and 30 eyes undergoing PRK was compared with contrast sensitivity at 1, 3, and 6 months postoperatively using the CSV 1000, MCT (Multivision Contrast Tester) 8000, and Pelli-Robson chart. The BAT (Brightness Acuity Tester) and MCT 8000 were used to test for daytime and nighttime glare disability, respectively. At 3 and 6 months postoperatively, a questionnaire was administered to assess visual performance subjectively., Results: Contrast sensitivity decreased after RK and PRK up to the sixth postoperative month, while glare disability was significantly increased at 1 month after PRK as determined by the MCT 8000 and the BAT, and at the third and sixth months after RK using the MCT 8000. Compared with RK, PRK significantly decreased contrast sensitivity as measured with the MCT 8000 at all spatial frequencies 1 month postoperatively. No significant difference in visual performance between patients undergoing RK and PRK was observed with the CSV 1000, the Pelli-Robson chart, or the BAT up to 6 months postoperatively. No consistent difference was found between glare disability scores of patients undergoing RK and PRK when measured with the MCT 8000. Subjective reports of problems with night driving and blurring correlated only with glare disability scores of the MCT 8000 3 months after RK., Conclusions: Both RK and PRK reduce contrast sensitivity and cause glare disability; however, the relative effect is highly dependent on the time postoperative testing is performed and the instrument used for testing. Contrast sensitivity and glare disability, as measured by the instruments used in this study, do not accurately reflect patients' subjective assessment of visual performance in daily life.

Objective: The purpose of the study is to determine safety and efficacy outcomes of excimer laser photorefractive keratectomy (PRK) for the treatment of mild-to-moderate myopia., Design: A prospective, multicenter, phase III clinical trial., Participants: A total of 701 eyes of 701 patients were entered in the study; 612 eyes were examined at 2 years after surgery., Intervention: Intervention was photorefractive keratectomy using the Summit ExciMed UV200LA excimer laser (Summit Technology, Inc., Waltham, MA). The treatment zone diameter used was 4.5 mm in 251 eyes (35.8%) and 5 mm in 450 eyes (64.2%). Attempted corrections ranged from 1.50 to 6.00 diopters (D)., Main Outcome Measures: Predictability and stability of refraction, uncorrected and spectacle-corrected visual acuity, refractive and keratometric astigmatism, corneal haze, contrast sensitivity, subjective reported problems of glare and halo, and patient satisfaction were the parameters measured., Results: At 2 years, 407 (66.5%) eyes achieved 20/20 or better uncorrected visual acuity and 564 (92.5%) eyes achieved 20/40 or better visual acuity. Three hundred thirty-six (54.9%) eyes were within 0.5 D and 476 (77.8%) eyes were within 1.0 D of attempted correction. Stability of refraction improved with time; 86.8% of eyes were stable within 1.0 D from 6 to 12 months, 94% were stable from 12 to 18 months, and 96.3% were stable from 18 to 24 months. There was no evidence of progressive or late myopic or hyperopic refractive shifts. One hundred fourteen (18.6%) eyes gained 2 or more lines of spectacle-corrected visual acuity, whereas 42 (6.9%) eyes lost 2 or more lines; however, of the latter, 32 (76.2%) had spectacle-corrected visual acuity of 20/25 or better and 39 (92.9%) eyes had 20/40 or better. Four hundred forty-two (72.2%) corneas were clear, 138 (22.5%) showed trace haze, 20 (3.3%) mild haze, 9 (1.5%) moderate haze, and 3 (0.5%) marked haze. On patient questionnaires, 87 (29.7%) patients reported worsening of glare from preoperative baseline; 133 (50.1%) reported worsening of halo symptoms from baseline., Conclusions: Photorefractive keratectomy appears effective for myopic corrections of -1.50 to -6.00 D. Uncorrected visual acuity is maximized in most eyes by 3 months, although some patients require between 6 months and 1 year to attain their best postoperative uncorrected visual acuity and some may require from 1 to 2 years for stabilization of refraction. Refraction stabilizes progressively without evidence of late myopic or hyperopic refractive shifts. Optical sequelae of glare and halo occur in some patients treated with a 4.5- or 5-mm treatment zone.

Objective: The purpose of the study is to determine whether there is a higher incidence of complications in adult patients receiving corneas from pediatric donors compared to those receiving corneas from adult donors., Design: The design is a follow-up of two matched cohorts., Participants: The outcome of penetrating keratoplasty in 29 adult patients (age 20 years of age and older) receiving pediatric donor corneas (range, 0-5 years) was compared to that of 29 control patients matched for recipient age and diagnosis who received adult donor corneas (range, 40-70 years)., Intervention: Chart review was performed., Main Outcome Measures: Graft rejection, postoperative keratometry, postoperative refractive cylinder, postoperative intraocular pressure, and graft failure due to rejection were measured., Results: One or more allograft reactions occurred in 11 (37.9%) of 29 patients who received pediatric donor corneas compared to 2 (6.9%) of 29 patients who received adult donor corneas (P = 0.005, chi-square). There were a total of 20 rejection episodes in patients receiving pediatric donor corneas compared to a total of 5 rejection episodes in patients receiving adult donor corneas. The average postoperative keratometry was 46.1 diopters for the pediatric donor group and 44.0 diopters for the adult donor group (P = 0.03). There was no statistically significant difference in average refractive cylinder (P = 1.0), intraocular pressure (P = 0.26), or the incidence of graft failure due to rejection (P = 1.0) between the two groups. The average follow-up time for clear grafts was 58.3 months in the pediatric donor group and 59.9 months in the adult donor group., Conclusions: The incidence of allograft reactions and the postoperative corneal curvature is greater in adult eyes undergoing penetrating keratoplasty with young donor corneas compared to those undergoing penetrating keratoplasty with older donor corneas. There was no difference in the incidence of graft failure due to rejection between the two groups.

Purpose: To study the effect of topical mitomycin C on conjunctival squamous neoplasia., Methods: Three patients with recurrent conjunctival epithelial neoplasia were treated with topical mitomycin C 0.04%., Results: Six to 9 months after treatment, no patient had clinical evidence of tumor recurrence. Conjunctival biopsy in two patients and cytology in one patient showed no evidence of tumor 1 to 4 months after treatment. One patient required short-term treatment for corneal edema and epithelial toxicity., Conclusion: Topical mitomycin C caused tumor regression without recurrence for 6 to 9 months after treatment.

Purpose: To clarify the role of topical corticosteroids in the management of Acanthamoeba keratitis., Methods: The records of 38 patients diagnosed with Acanthamoeba keratitis at three institutions were retrospectively reviewed., Results: After medical therapy alone, patients diagnosed within 1 month of symptom onset had an increased likelihood of being cured (p = 0.02) and attaining visual acuity of 20/60 or better (p < 0.01). Fourteen (73.7%) of 19 patients treated with topical corticosteroids at any time were cured after antiamoebal therapy alone, whereas five (26.3%) patients required penetrating keratoplasty for either persistent infection (n = 3) or perforation (n = 2). The mean antiamoebal therapy duration, excluding duration after keratoplasty if applicable, was 38.5 weeks. Thirteen (76.5%) of 17 patients treated with antiamoebal therapy without topical corticosteroids were medically cured, whereas four (23.5%) required penetrating keratoplasty for either persistent infection (n = 2) or perforation (n = 2). The mean antiamoebal therapy duration was 20 weeks. Although the mean antiamoebal therapy duration in the steroid-treated group was significantly longer than that in the non-steroid-treated group (p = 0.02), outcome after medical therapy between the groups was not significantly different., Conclusions: Topical corticosteroids were not associated with a higher rate of medical treatment failure in patients with Acanthamoeba keratitis. Rather, poor outcome was significantly related to diagnostic delays. Therefore prudent use of corticosteroids in selected patients with severe pain not responsive to analgesics or severe corneal or anterior chamber inflammation appears justified.

Purpose: To study the safety and efficacy of simultaneous bilateral laser in-situ keratomileusis (LASIK) METHODS: Data were obtained from 254 consecutive patients that were randomized to simultaneous or sequential bilateral LASIK., Results: 146 patients were enrolled in the simultaneous group and 108 patients were enrolled in the sequential group. Mean follow-up was 10 months (range 6-18). There was no significant difference in intraoperative complication rate (p = 0.34), loss of two or more lines of spectacle corrected visual acuity (p = 0.9), or percentage of eyes within +/- 0.50 D of intended (p = 0.63) between simultaneous and sequential groups., Conclusions: The risk of performing bilateral simultaneous LASIK is not significantly different from that of sequential treatments.

Aims: Possible risk factors were evaluated for herpes simplex virus (HSV) epithelial keratitis in patients with stromal keratouveitis., Methods: The study population included 260 patients who had active stromal keratitis and/or iridocyclitis without epithelial disease and who were enrolled in one of three clinical trials of the Herpetic Eye Disease Study. Study treatment involved a 10 week course of topical placebo, topical prednisolone phosphate, or topical prednisolone phosphate with oral acyclovir. All groups received topical trifluridine four times daily for 3 weeks then twice daily for another 7 weeks. Patients were examined for HSV epithelial keratitis for 16 weeks., Results: Dendritic or geographic epithelial keratitis occurred in 12 (4.6%) study patients. Adverse effects attributable to trifluridine prophylaxis were acute allergic blepharoconjunctivitis in 10 (3.8%) study patients and corneal epithelial erosions in 11 (4.2%) study patients. No significant difference in the occurrence of HSV epithelial keratitis was found among the study treatment groups: one (2.0%) of 49 topical placebo treated patients, nine (6.5%) of 138 patients treated with topical corticosteroids without acyclovir, and two (2.7%) of 73 patients treated with topical corticosteroids and oral acyclovir. Univariate exponential models suggested that patients with a history of previous HSV epithelial keratitis and non-white patients were more likely to develop HSV epithelial keratitis during treatment of stromal keratouveitis., Conclusion: Individuals with prior HSV epithelial keratitis and certain ethnic groups may have a higher rate of recurrent epithelial keratitis during the acute treatment of HSV stromal keratouveitis.

Purpose: The authors prospectively investigated the effect of excimer laser photorefractive keratectomy (PRK) for myopia on the corneal endothelium., Methods: Quantitative computer-assisted morphometric analysis of central and peripheral corneal endothelial cells was performed on 142 myopic eyes before and at 3 months, 1 year, and 2 years after PRK. The mean age of the subjects was 37 years (range, 21-66 years). Ninety-one (64%) of them had a history of contact lens wear. Mean attempted correction was -3.9 diopters (range, -1.6 to -6.0 diopters)., Results: The mean preoperative endothelial cell density was 2660 cells/mm2 centrally and 2776 cells/mm2 peripherally. There was no change in central endothelial cell density at any of the postoperative examinations. The peripheral cell density decreased 4.1% (P = 0.003) at 3 months and 6.2% (P = 0.0001) at 1 year. However, the peripheral cell density was not significantly different from the preoperative value at 2 years. The peripheral coefficient of variation of cell size was 7.8% lower 2 years postoperatively than it was preoperatively, and this improvement was attributable to cessation of contact lens wear after PRK. The decrease in peripheral endothelial cell density at 1 year correlated with the amount of attempted correction, but there was no correlation between attempted correction and the change in central or peripheral endothelial cell density 2 years postoperatively., Conclusion: For the correction of up to 6.0 D of myopia, PRK causes no detectable changes in central corneal endothelial cell density, but it does cause a transient, modest loss of peripheral corneal endothelial cells at 1 year. Variations in endothelial cell shape caused by contact lens wear resolve after PRK.

Purpose: We studied the occurrence of late scarring after photorefractive keratectomy and its response to topical corticosteroids and debridement during the course of follow-up of 950 eyes that had photorefractive keratectomy with excimer laser., Methods: Five eyes of four patients developed localized corneal scars, decreased visual acuity, and increased myopia after five to 33 months of good visual acuity, with trace haze. In two eyes, scars were removed by debridement alone. In these two eyes, recurrent scars were treated by debridement, followed by aggressive treatment with topical corticosteroids. Two other eyes were treated with topical corticosteroids alone. The fifth eye, which developed a scar after debridement to correct a subjective visual distortion after photorefractive keratectomy, was treated with debridement followed by aggressive topical corticosteroids., Results: Treatment with topical corticosteroids alone in two eyes improved uncorrected visual acuity slightly and decreased myopia, although the scars remained unchanged. Debridement without aggressive topical corticosteroid use resulted in rapid return of the scars and a decrease in visual acuity. Subsequent debridement after aggressive topical corticosteroid treatment resulted in resolution of scars and no recurrence after discontinuation of corticosteroids in one case. In another case, the scar recurred eight months after discontinuation of topical corticosteroids. In Case 4, the scar has not recurred as the topical corticosteroid dosage has been reduced., Conclusions: Patients who undergo photorefractive keratectomy should be counseled concerning the risk of late scarring, reexamined frequently after photorefractive keratectomy, and treated with topical corticosteroids after corneal trauma. Long-term treatment with topical corticosteroids may be required to prevent the recurrence of scars after debridement.

Purpose: We studied a case of corneal ulceration in utero from lower eyelid entropion., Methods: A 3-week-old male infant was referred for examination of a left corneal ulcer that was present at birth and unresponsive to antibiotics., Results: Examination disclosed a lower eyelid entropion that was treated surgically by a nonincisional method, leaving a central leukoma after re-epithelialization., Conclusion: Congenital lower eyelid entropion should be included in the differential diagnosis of congenital corneal opacities.

Objectives: To describe a national eye banking registry and to assess the effects of donor age, cause of donor death, time from death to procurement, storage time, and distance between the points of recovery and transplantation on the reported occurrence of primary corneal graft failure., Design: We performed a retrospective case-control study to estimate the odds ratios of five donor factors for cases of primary graft failure voluntarily reported to a national registry using controls from selected eye banks. We also performed a nested case-control cohort study to compare cases of primary graft failure that occurred in both corneas from the same donor with those of nonmated corneas in which primary graft failure was reported to assess odds ratios for the same donor factors., Patients: One hundred forty-seven patients developed primary graft failure in penetrating keratoplasty transplantations performed between January 1, 1991, and December 31, 1993. These cases were reported to the Adverse Reaction Registry of the Eye Bank Association of America, Washington, DC. Controls included 7240 donor corneas distributed by nine eye banks during 1992., Results: Of the 147 donor corneas that developed primary graft failure, 17 (12%) were obtained from donors who were aged 70 years and older, 39 (27%) came from donors who died of trauma, 13 (9%) had a cadaver time longer than 12 hours, 10 (7%) had a storage time longer than 7 days, and 38 (26%) were distributed outside the eye bank's region. Compared with controls, these donor corneas were more likely to have a storage time longer than 7 days (odds ratio, 2.4; 95% confidence limits, 1.2 and 4.6) and to come from donors aged 70 years and older (odds ratio, 2.4; 95% confidence limits, 1.4 and 4.0). The 22 corneas (15%) in which primary graft failure occurred in both recipients from the same donor were 8.5 times (95% confidence limits, 1.1 and 51.5) more likely to be preserved beyond 1 week than were nonmated corneas with primary failure but were not from significantly older donors. Logistic regression analysis showed that the association between prolonged storage time and primary graft failure in mated corneas remained significant even when the analysis was controlled for other donor factors., Conclusions: No clearly defined donor or eye banking factor accounted for most cases of primary graft failure, although prolonged corneal storage and advanced donor age may increase its risk. Ophthalmologists are urged to report to their eye bank all cases of primary graft failure and other adverse events that might be attributable to donor eye tissue.

Background: We utilized videokeratography to determine the frequency of keratoconus suspects in a refractive surgery population, and compared the results of refractive keratotomy in these patients to those of patients with normal corneal topography., Methods: The records of 67 consecutive patients (120 eyes) undergoing refractive keratotomy were reviewed retrospectively. Quantitative measurements of relative inferior corneal steepening (inferior-superior value, I-S value) were obtained from preoperative videokeratography., Results: Three of 120 eyes (3 of 67 patients, 4.5%) were identified as keratoconus suspects based on I-S (inferior-superior) values greater than +1.74 (range, +1.76 to +2.00), which represented two standard deviations (+/- 0.66) above the mean (+0.42). All three of these eyes achieved postoperative uncorrected visual acuity of 20/30 or better. Of those eyes with normal preoperative topography (I-S value +1.74 or less), 90 of 112 (80%) achieved postoperative uncorrected visual acuity of 20/30 or better, and 105 of 112 (94%) achieved 20/40 or better., Conclusions: Although long-term follow up is needed to confirm stability of refractive surgery outcome, it appears that keratoconus suspects can obtain acceptable results with refractive keratotomy. Studies on larger patient populations using videokeratography are needed to better define keratoconus, keratoconus suspects, and normal variants of corneal topography and to determine how eyes with abnormal topography respond to refractive keratotomy.

The management of keratoconus with contact lenses may be complicated by punctate epithelial keratopathy, epithelial breakdown, and nodular, raised subepithelial scars. We report four consecutive cases of contact lens intolerance due to pain in patients with keratoconus and raised, nodular scars. Excimer laser phototherapeutic keratectomy (PTK) was used to treat all patients. Follow-up ranged from 7 to 14 months (mean: 10 months). All patients resumed rigid gas permeable (RGP) contact lens wear 2 to 4 weeks after surgery. Visual acuities ranged from 20/40 to 20/70 before surgery and improved to 20/25 or better in all patients postoperatively. PTK flattened the central cornea by an average of 5.43 D (range: 1.13-10.19 D); and refractive cylinder was reduced an average of 4.00 D (range: 3.25-5.25 D). We conclude that PTK may delay or avoid penetrating keratoplasty in selected patients with keratoconus who are contact lens intolerant due to nodular subepithelial scars.

The Collaborative Corneal Transplantation Studies (CCTS) were designed to evaluate the effect of donor-recipient histocompatibility matching and cross-matching on the survival of corneal transplants in high-risk patients. We now report on the role of symptoms in the detection of corneal allograft reactions in the CCTS and on the relationship between symptom reporting and graft survival. The 456 patients transplanted in the CCTS were followed for a minimum of 2 years or until graft failure. The follow-up protocol included 11 scheduled examinations in the first year, four examinations during the second year, and examinations every 6 months thereafter. Interim examinations were performed in response to patient-reported symptoms. At every examination, patients were asked specifically if they had redness, sensitivity to light, loss of vision, or pain (RSVP). Of the 456 patients transplanted, 62% had at least one graft reaction. Patients diagnosed with reactions at scheduled visits in the first postoperative year were 2.5 times more likely to report symptoms than those without reactions. Reports of red eye and vision loss were strongly associated with allograft reaction. However, these symptoms were neither highly sensitive nor specific for reaction (sensitivity = 46%, specificity = 70% at 6 months). The severity of reaction influenced the reporting of symptoms: 69% of patients with severe reactions reported symptoms versus 48% of patients with mild reactions (p < 0.001). The only patient characteristic associated with reliable symptom reporting was age, with younger patients with reactions being more likely to report symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

We report six-month results of the Summit Technology Myopic Keratomileusis Phase I multicenter study. Fifty-seven eyes of 57 patients had keratomileusis to correct high myopia. A microkeratome was used for the primary keratectomy and the excimer laser was used to ablate the stroma of the resected lenticle (cap) or the stromal bed (in situ). At six months, 31 of the 47 eyes available for follow-up (65.9%) had uncorrected visual acuity of 20/40 or better; 16 (34.0%) had uncorrected acuity of 20/25 or better. Thirty-seven eyes (78.7%) maintained the same (+/- one Snellen line) best corrected visual acuity as before surgery; seven (14.9%) lost two lines and three (6.4%) lost more than two lines. In addition to the six-month multicenter study results, we report two year results in a subset of 28 eyes (22 from the multicenter study and six fellow eyes). At six months, 17 of the 24 eyes available for follow-up (70.9%) had uncorrected visual acuity of 20/40 or better and nine (37.5%) had uncorrected acuity of 20/25 or better, including eyes that had worse than 20/80 best corrected visual acuity preoperatively. At 24 months, five of the seven eyes available for follow-up (71.4%) had uncorrected acuity of 20/25 or better. Only one patient lost two lines of best corrected vision at six months and no patient lost more than two lines; at 24 months, all patients maintained (+/- one line) best corrected vision.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: To compare the outcome of anterior chamber (AC) intraocular lens (IOL) implantation with the outcome of posterior chamber (PC) IOL implantation at the time of penetrating keratoplasty in the absence of capsular support., Design: Retrospective study of 122 eyes that underwent secondary IOL implantation without capsular support at the time of penetrating keratoplasty. Ninety eyes received an AC IOL and 32 received a PC IOL sutured to the iris or the ciliary sulcus., Results: Survival analysis showed the probability of a clear graft to be 86% for eyes with an AC IOL and 90% for eyes with a PC IOL at 1 year. Intraocular pressure rose by 5 mm Hg or more in 30% of eyes with AC IOLs and 5% of eyes with PC IOLs. Visual acuity was better than 20/200 in 48% of eyes with AC IOLs and 68% of eyes with PC IOLs., Conclusion: This study demonstrated a trend for a better outcome with PC IOLs than AC IOLs for secondary implantation at time of penetrating keratoplasty in the absence of capsular support.

Purpose: To evaluate comprehensively the magnitude of suspected risk factors for corneal graft failure from any cause, failure from rejection, and immunologic reaction in patients at high risk for graft failure after corneal transplantation., Methods: The records of the 457 participants in the Collaborative Corneal Transplantation Studies were reviewed. All participants had at least two quadrants of stromal vascularization and/or a history or previous graft rejection. Patients were followed for 2 to 5 years. Characteristics of the patient, study eye, donor, donor-recipient histocompatibility, and surgical procedure were examined for their association with the graft outcomes of failure from any cause, rejection failure, and immunologic reaction. Multivariate survival analysis techniques were used to estimate rates of graft outcome events and to estimate the magnitude of risk factors., Results: Many apparent risk factors did not maintain their association with graft outcomes after adjustment for other risk factors. Young recipient age, the number of previous grafts, history of previous anterior segment surgery, preoperative glaucoma, quadrants of anterior synechiae, quadrants of stromal vessels, a primary diagnosis of chemical burn, and blood group ABO incompatibility were among the strongest risk factors identified for graft failure. Donor and corneal preservation characteristics had little influence on graft outcome., Conclusions: Risk of graft failure varies substantially, even within a high-risk population. The number of risk factors present should be considered by the patient and surgeon when contemplating transplantation and planning follow-up.

Objective: To report a possible adverse effect of topical steroid-phosphate preparations and to identify factors that may contribute to the development of this effect., Design: The medical records of five patients who developed calcium deposition in the cornea were reviewed and analyzed for possible contributing factors., Patients: Five cases of calcium deposition in the cornea associated with the use of topical steroid-phosphate preparations are described. Scrapings from the cornea and/or specimens obtained at keratoplasty were available in all cases. These cases had the following characteristics in common: use of steroid-phosphate preparations (n = 5); multiple topical drops (n = 5); penetrating keratoplasty (n = 3); presence of epithelial defects (n = 4); history of herpetic stromal keratitis (n = 3) [corrected]; and history of iritis (n = 3). A hypothesis explaining calcium deposition in association with steroid-phosphate preparations is presented., Conclusions: We recommend withdrawal of steroid-phosphate preparations in patients who develop band keratopathy.

We examined 15 eyes of ten patients with complications of hexagonal keratotomy, which included glare, photophobia, polyopia, fluctuation in vision, overcorrection, irregular astigmatism, corneal edema, corneal perforation, bacterial keratitis, cataract, and endophthalmitis. Wound healing abnormalities and anterior displacement of the central cornea adjacent to the incisions were common. Eight eyes lost best-corrected visual acuity of two or more Snellen lines. Three eyes required penetrating keratoplasty for visual rehabilitation. Histologic analysis of two of these corneas disclosed variations in wound depth and abnormalities of wound configuration, including considerable wound gaping. Hexagonal keratotomy appears to be an unpredictable, unsafe surgical procedure with a high complication rate, and it should be abandoned until well-controlled experimental trials establish its safety and efficacy.

The susceptibility of Herpes simplex virus (HSV) to acyclovir (ACV), 5-trifluorothymidine (TFT) and vidarabine (Ara-A) in HSV-infected embryo fibroblasts from BALB/c and C57BL/6 mice as well as Vero cells were measured. Ara-A and TFT (at its highest concentration) were more effective in Vero cells and BALB/c mouse embryo fibroblasts (MEF) than in C57BL/6 MEF. In contrast, ACV was more effective in C57BL/6 MEF than BALB/c MEF and Vero cells. These data suggest that genetically determined differences in the ability of host cells to support the replication of HSV influence the activity of antiviral drugs.

Objective: To determine whether ultrasonic measurements of corneal thickness are of prognostic value after high-risk penetrating keratoplasty., Design: A prospective, multicenter, randomized trial., Patients: Four hundred fifty patients at high risk for graft failure because of previous immunologic graft failure or because of two or more quadrants of stromal vascularization. Patients underwent surgery and were treated according to a specific protocol and observed at frequent intervals., Intervention: At each postoperative visit, ultrasonic measurement of central corneal thickness was performed and the corneal status was determined by biomicroscopic examination., Main Outcome Measure: Graft failure owing to immunologic or nonimmunologic causes., Results: Corneal thickness stabilized by 3 months at a median thickness of 0.54 mm. The range of corneal thicknesses in patients with corneal grafts judged to be clear was large. In 49% of eyes, development of an allograft reaction episode was accompanied by an increase in corneal thickness of at least 10%; the greater the increase in thickness, the more likely the graft would fail. Clear grafts with central thicknesses of 0.59 mm or greater at 1, 3, or 6 months had a much greater risk of failure than those with thicknesses of less than 0.59 mm., Conclusion: Corneal thickness measurements after high-risk penetrating keratoplasty are of prognostic value.

We analyzed 1,010 consecutive penetrating keratoplasties to determine the incidence of postoperative endophthalmitis, the frequency of positive donor rim cultures, and whether a correlation between these two factors exists. There were three cases of bacterial endophthalmitis, all caused by streptococci, and one case of Candida albicans endophthalmitis. In all cases except one case of streptococcal endophthalmitis, the same organism was cultured from the donor rim. We cultured 138 organisms from 128 of 932 donor rims (14%). A remarkable percentage of gram-positive organisms were resistant to gentamicin, the only antibiotic contained in corneal storage media. On the basis of our data and previously published data, we believe that donor material is frequently the source of microorganisms in endophthalmitis after penetrating keratoplasty.

Purpose: The purpose of this study was to determine whether herpes simplex virus (HSV) transcripts are present in the corneas of patients with chronic herpetic stromal keratitis., Methods: Corneal buttons from patients with a history of stromal keratitis, but no ongoing active disease, together with positive and negative control tissues, were analyzed by in situ hybridization using single-stranded RNA probes for all three classes of viral lytic cycle transcripts as well as for the latency-associated transcripts (LATs). Tissues also were screened for presence of HSV genomic DNA using the polymerase chain reaction (PCR)., Results: HSV DNA was detected in 7 of 13 quiescent corneas by PCR, but no viral transcripts were detected in any of these corneas by in situ hybridization., Conclusions: At the level of detection afforded by in situ hybridization, HSV persistent in scarred human corneas after stromal keratitis appears to be transcriptionally dormant. This contrasts with the situation in neurons of latently infected sensory ganglia, in which LATs are present at high levels.

Background/purpose: Selective removal of interrupted sutures and adjustment of a running suture can minimize astigmatism after penetrating keratoplasty, but the long-term effects of early suture manipulations remain largely unknown. The authors tested the hypothesis that the cornea becomes "fixed" more than 1 year after keratoplasty so that desirable refractive results will remain when all sutures are eventually removed., Methods: The authors reviewed retrospectively the changes in astigmatism that occurred when all remaining sutures were removed from 162 eyes 1 to 6 years after penetrating keratoplasty. Single-running sutures were used in 130 eyes, double-running sutures in 20 eyes, and a combination of interrupted and running sutures in 12 eyes., Results: Removal of single-running sutures caused an average decrease in astigmatism of 0.52 diopters (D) from 6.10 +/- 4.41 D to 5.57 +/- 3.14 D. However, the astigmatism in 62% of eyes changed 2 or more D (range, 11.94 to -17.87 D), and the range changed more than 20 degrees in 55% of eyes. The average vectorial change was 6.5 +/- 4.3 D (range, 0.59 to 19.8 D). There was no decrease in the amount of astigmatic change with increasing time between surgery and suture removal. Graft size and diagnosis had no effect on the amount of astigmatic change. Astigmatic errors became stable, with less than 1 D of change between successive examinations within 6 months after suture removal. Similar results were obtained for eyes with double-running and interrupted-running sutures., Conclusions: Corneal astigmatism may change unpredictably and by large amounts when all remaining sutures are removed 1 to 6 years after penetrating keratoplasty.

Viruses that affect the cornea produce changes that range from benign, self-limited conjunctivitis to sight-threatening scarring and vascularization of the cornea. In this article, the forms of viral keratitis most commonly encountered by the clinician are reviewed. The epidemiology, clinical presentation, and treatment of infection by Herpes simplex virus, varicella zoster virus, and the adenoviruses are discussed. Also included are other viral infections of the cornea.

The eye is an important site for infectious disease because an incorrect diagnosis can cause loss of vision or loss of life. An approach to accurate diagnosis, intervention, and therapy is outlined.

We have previously recovered herpes simplex virus type 1 (HSV) from the corneas of latently infected mice by cultivation in vitro. It could be argued, however, that these data do not definitively distinguish between persistent and latent corneal infection. We have now used RNA hybridization in situ to resolve this question by determining the expression of HSV genes in the corneas of BALB/c mice during latent infection. Two to four months after topical corneal inoculation with HSV, when no active ocular disease or infectious virus was present, corneas were removed and digested with collagenase. Dissociated cells pooled from two corneas were hybridized with 3H- or 35S-labeled 2.6-kb single-stranded RNA probes to detect sense and antisense ICP-0 transcripts. Twenty-five percent of the pools hybridized with the probe for antisense ICP-0 (latency-associated transcript, LAT), while only 3% hybridized with the probe for ICP-0 (p less than 0.03). Of the cells in positive pools, 0.6-7.0% showed a positive hybridization signal for LAT. No infectious virus was found by culture of supernatants from the probed pools or control latently infected corneas. These data provide further evidence that HSV can establish a true latent infection in the mouse cornea.

Three hundred fourteen members of the Castroviejo Society were surveyed to determine current practices in the prevention and treatment of corneal graft rejection. One hundred thirty-seven responses were received and tabulated for routine postoperative prophylactic immunosuppression as well as treatment of epithelial rejection, endothelial rejection (three patterns), subepithelial infiltrates, acutely and progressively opacifying grafts without inflammation, and photophobia. All respondents applied topical steroids in the postoperative period, while about half also administered steroids subconjunctivally. For the treatment of obvious endothelial rejection, 100% of respondents used topical steroids, 57% used subconjunctival steroids, and 37% used systemic steroids. Prednisolone acetate, 1%, was the preferred topical preparation for all conditions (55-68% of respondents). Individual responses to the questionnaire showed a surprisingly wide variation in treatment preferences.

We describe penetrating keratoplasty for corneal scarring in a patient with congenital sensory neuropathy and repeated self-mutilation. This patient underwent a successful penetrating keratoplasty but suffered a series of postoperative complications necessitating three repeat grafts. Some of these complications were attributable to decreased corneal sensation while others were caused by self-mutilation. Since his last penetrating keratoplasty 4 years ago, this patient has had functional visual acuity.

The authors reviewed in a retrospective manner 47 penetrating keratoplasties performed on 23 eyes of 21 patients with rheumatoid arthritis. The indications for the first penetrating keratoplasty were corneal melt in 19 eyes (83%), infectious keratitis in 2 eyes (9%), and corneal scarring after ulceration in 2 eyes (9%). Twelve of the 23 eyes required 24 repeat penetrating keratoplasties. Seventeen of the 23 eyes (74%) had clear grafts at the last follow-up visit, a median of 13.7 months after the last penetrating keratoplasty. The final best corrected visual acuity was greater than or equal to 20/60 in 4 eyes (17%), 20/70 to 20/100 in 1 eye (4%), 20/200 to 20/400 in 7 eyes (30%), counting fingers in 4 eyes (17%), hand motions in 2 eyes (9%), and light perception in 4 eyes (17%). One eye (4%) was enucleated. Anatomic success (absence of phthisis bulbi, enucleation, or conjunctival flap) was achieved in 20 eyes (87%). The survival probability for the 21 patients was only 48% 5 years after the first penetrating keratoplasty. The authors conclude that penetrating keratoplasty is often anatomically successful in patients with rheumatoid arthritis; however, the prognosis is poor for both vision and survival of the patient.

Four herpes simplex type 1 virus (HSV) isolates were selected from patients with mild ocular disease and four from patients with severe ocular disease on the basis of the number of epithelial recurrences, presence or absence of stromal disease, visual acuity, and the need for corneal transplantation. The scarified right corneas of 20 BALB/c mice were inoculated with each low-passage HSV isolate (1.0 x 10(7) plaque-forming units/ml) and examined three times per week for 2 weeks for the presence and severity of epithelial and stromal disease. The eight individual virus isolates differed with respect to the incidence of dendritic disease (P less than 0.001), the severity of dendritic disease (P less than 0.001), the incidence of stromal disease (P = 0.002), and the severity of stromal disease (P = 0.001) they produced in the mouse. The severity of disease was compared for the two groups of viruses: (1) those that had caused mild disease in their human hosts and (2) those that had caused severe disease. There were no statistically significant differences in the severity or incidence (44 versus 43 animals, respectively) of dendritic disease or stromal disease (27 of 80 animals in each group) between the two groups. These data suggest that the naive BALB/c mouse model of acute HSV keratitis after topical ocular inoculation does not reflect clinically significant differences in the severity of human HSV keratitis that might be caused by variations in the virus genome.

Gentamicin sulfate is frequently included in the initial treatment of suspected bacterial keratitis. We present the gentamicin susceptibility test results for coagulase-negative staphylococci and Staphylococcus aureus isolated from corneal ulcers in nine patients. All were resistant to gentamicin by standard disk diffusion techniques. The minimum inhibitory concentrations were very high, some exceeding the concentration normally achieved by frequent topical application of antibiotics. Clinicians should be aware that strains of staphylococci extremely resistant to gentamicin may cause keratitis. An antibiotic with broad activity against Gram-positive organisms, such as a cephalosporin or vancomycin, should be included as part of the initial therapy for corneal ulcers that might be caused by staphylococci.

We analyzed clinical data on 22,739 contact lens wearers who were studied and whose lenses were approved under 48 manufacturer-sponsored studies for the Food and Drug Administration between 1980 and 1988. The incidence of corneal ulcers was low in the cosmetic (nontherapeutic) daily-wear soft and rigid gas-permeable lens wearers (1/1,923 and 1/1,471 patient-years, respectively). Corneal ulcers and severe adverse reactions occurred two to four times more frequently in extended-wear cosmetic soft and rigid gas-permeable lens wearers than in cosmetic daily-wear lens wearers. Aphakic extended-wear soft lens users were nine times more likely to develop a corneal ulcer when compared to the soft daily-wear cosmetic group. Corneal abrasions and keratitis accounted for 81 of 159 severe adverse reactions, whereas corneal ulcers accounted for 28 of 159 adverse reactions. The data indicate that overnight extended wear of contact lenses is associated with a greater risk of serious, sight-threatening complications than daily wear.

A 64-year-old woman with bilateral corneal and conjunctival crystal deposition was evaluated. A biopsy of her conjunctiva showed intracytoplasmic inclusions of immunoglobulin crystals in fibrocytes, macrophages, and endothelial cells. Serum protein electrophoresis showed elevated kappa and IgA light and heavy chains which corresponded with immunoperoxidase staining results of the conjunctival biopsy. Conjunctival and corneal crystal deposition may be indicative of paraproteinemia, and histopathologic examination of a conjunctival biopsy may be useful in diagnosing this condition.

Mitogen-stimulated lymphocytes induce a highly reproducible form of corneal neovascularization (CNV) in inbred mice. To determine if supernatants derived from stimulated lymphocytes and their constituent mediators were also angiogenic, we injected conditioned medium (CM) from mitogen-stimulated lymphocytes, control non-conditioned medium, recombinant interleukin-2 (rIL-2), or control bovine serum albumin (BSA), a component of rIL-2, into the corneas of syngeneic A/J mice. Control, nonconditioned medium was not angiogenic. While the other injections all induced some CNV, the CM and rIL-2 both induced a significantly greater area of CNV than BSA (p less than 0.05). The area of CNV induced by the CM was greater than that induced by IL-2 (p = 0.03). These data show that IL-2, which stimulates vascular endothelial cells in vitro and is elaborated during corneal immune reactions in vivo, is one of the potential mediators of immunologically mediated CNV.

A 59-year-old man who had previously undergone a trabeculectomy in his right eye was examined because of an enlarging pigmented lesion of the inferior portion of the iris. A fine-needle aspiration biopsy of aqueous fluid revealed spindle cells and epithelioid malignant melanoma cells. The eye was enucleated, and subsequent histopathologic examination demonstrated a mixed spindle cell and epithelioid cell melanoma of the inferior portion of the iris with seeding of melanoma cells into the conjunctival filtering bleb via the trabeculectomy site. This case illustrates the usefulness of fine-needle aspiration biopsy in the evaluation of pigmented iris lesions and illustrates that iris melanoma can seed through a trabeculectomy site.

Thirty consecutive patients scheduled for cataract surgery were randomized to external compression with the Honan intraocular pressure (IOP) reducer or digital pressure. The average increase in IOP after retrobulbar injection of 4 ml of anesthetic was 6.20 mm Hg. This increase was followed by a rapid decline in IOP within the first 2 1/2 minutes, averaging 1.20 mm Hg +/- 0.70 below baseline level for the Honan group and 1.00 mm Hg +/- 0.96 below baseline level for the digital group. From 5 to 10 minutes after injection there was a more gradual decline in IOP that averaged 0.35 mm Hg/min in the Honan group and 0.36 mm Hg/min in the digital group. After 10 minutes of external compression the IOP was 5.73 mm Hg +/- 0.96 below baseline level in the Honan group and 4.67 mm Hg +/- 0.64 below baseline level in the digital group. No statistical difference between the IOP measurements of the two groups was observed at 2 1/2 minutes at 5 minutes, or at 10 minutes.

A 26-year-old male drug abuser developed amaurosis fugax followed by retinal vasculitis in the right eye after nasal inhalation of methamphetamine. He gradually recovered, but required prolonged systemic corticosteroid therapy. We believe that the amaurosis fugax was due to drug-induced vasospasm and that the retinal vasculitis was a drug-induced hypersensitivity vasculitis.