Tissue adhesives: new perspectives in corneal perforations

In corneal perforations associated with extensive progressive corneal disease, a technique using tissue adhesive closure of the perforation site and reformation of the anterior chamber before penetrating keratoplasty or conjunctival flap mobilization has been described. Over the past year, six eyes have been successfully treated in this manner. This method allows reformation of the eye under local anesthesia as an emergency procedure without incarceration or injury of the intraocular contents and without pain to the patient. The definitive surgical procedure can then be performed safely under retrobulbar anesthesia.

The theory and computation of optical modifications to the cornea in refractive keratoplasty

The optical theory of keratophakia employing implant lenticules with a refractive index different from that of the cornea is presented. This generalized theory also embraces keratophakia employing donated stromal lenticules and keratomileusis, with equal accuracy. The method of solution of the formulas is indicated. The effects of the various parameters upon the radius of curvature to be applied to the cornea are illustrated and discussed.

[The artificial epithelium in chronic corneal diseases and to avoid emergency keratoplasty (author's transl)]

Report on the treatment of 41 patients in the last 10 years. In chronic corneal diseases epikeratoprosthesis is possible when every other therapy failed. With growing experience functional results are better and complications seldom. Since several years we use glued-on contact lenses in acute ulcers too in order to avoid emergency keratoplasty. When suitable donor material is missing or if plastic surgery of the eye lids is necessary the artificial epithelium prevents ulcer perforation as a mechanical collagenase inhibitor. The anterior chamber can be reinstalled in perforated ulcers by sealing with cyanoacrylate glue and covering with artificial epithelium. A corticosteroid therapy of the iritis becomes possible to avoid the frequent complication of anterior synechia in later keratoplasty. By reducing the steroid dosis vascularisation of the ulcer is reached and a corneal grafting can be evaded sometimes if the prognosis of keratoplasty is poor or the central cornea is clear such as in ulcers near the limbus.

Anterior vitrectomy for complications of cataract extraction

Our results of anterior vitrectomy in 12 patients with vitreo-corneal touch following cataract extraction, and in three patients with ghost-cell glaucoma due to vitreous hemorrhage were reported. The Machemer vitreous infusion suction cutter was used for pars plana and trans-corneal approaches. Anterior vitrectomy was effective in treating both disorders.

Keratoplasty in aphakic eyes with corneal edema. Results in 100 cases with 10-year followup

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Vitreous touch after phacoemulsification

Three cases with touch of an intact anterior vitreous face to the cornea following phacoemulsification had moderate corneal edema. In each patient, a different method successfully removed the touch of the anterior vitreous face to the corneal endothelium with subsequent prompt clearing of the corneal edema. Although uncommon, an intact anterior vetreous face against the corneal endothelium is possible when a wide opening has been made in the posterior capsule and the underlying vitreous face remains intact. In one case the recognition of anterior vitreous face contact to the cornea was delayed by the severity of the corneal edema. Of the 3 methods of treatment used, the pars plana anterior vitrectomy approach seemed the most effective and the medical approach with 4% cocaine seemed to be the least predictable.

[Lamellar keratoplasty, ipsilateral rotation-autokeratoplasty and contralateral autokeratoplasty (author's transl)]

During the years 1967--1977, there were performed about 500 mostly perforating keratoplasties. Among these there were special groups: 50 lamellar keratoplasties (43 central, 7 marginal), 5 perforating ipsilateral rotation-autokeratoplasties 2 perforating contralateral autokeratoplasties. The results encourage to use these special keratoplasties more often instead of the usual perforating keratoplasty.

[Electronically controlled motor-trephine for keratoplasty under the microscope (author's transl)]

An electric driven Motor-Trephine for Kerato-plasty is presented. By electronic control the rotation speed of the trephine can be adjusted between 0 and 1000 RPM and shown by a digital indicator. The trephine improves the microscopical view of the operationsfield during the trephination. The trephine is produced by Hans Geuder Ltd.

[Keratotorus. Aetiology with regard to heredity (author's transl)]

We describe the biggest group of toric deformation of the cornea reported up to now. We point out in particular two ribs whose parents are blood-related. Hence we obtained the first evidence for an inheritance (autosomal recessive) of this corneal anomaly. The term Keratotorus is recommended as the best definition for this toric corneal deformation. Although there are similarities with other anomalies of curvature of the cornea, the clinical picture of keratotorus can be seen also in the future as a nosological entity.

Destructive ophthalmic procedures, a comparison between a developed and a developing country

The causes for enucleation, evisceration, and exenteration were compared between Malawi and Israel. Differences in etiology, age, and sex were found due to the medical facilities, standard of living, and cultural background of each country.

Role of corneal surgery in destructive corneal disease

Surgery plays an integral role in the management of destructive corneal disease. There are many techniques for structural reinforcement of marginal corneal destruction. Therapeutic penetrating keratoplasty for severe cases of central corneal destruction can be an effective method of removing the bulk of diseased tissue, and securing histopathological confirmation of the diagnosis.

Systemic immunosuppression in marginal keratolysis

Experience in the investigation and treatment of eleven patients with the peripheral corneal melting syndrome is described. It is considered that short-term treatment with non-corticosteroid immunosuppressive regimes should be tried in patients with severe progressive disease which may not respond to other methods of treatment.

[On keratoplasty indicated in progressive infection of the cornea (author's transl)]

A report is given about 9 patients with acute inflammatory process of the cornea. In all cases a penetrating keratoplasty was performed. This procedure is indicated in progressive infections of the cornea, mostly caused by bacteria. Some aspects of this proceeding are discussed.

Current surgical management of the vitreous wick syndrome

We successfully treated three consecutive cases of the vitreous wick syndrome by combining repair of the fistula with closed vitrectomy to remove vitreous gel from the anterior chamber and from the internal aspect of the fistula. In two cases, the fistula seemed to be formed by the tract of an externally tied corneoscleral suture. In two cases the external opening of the fistula was large, and we covered it by a partial-thickness, anteriorly hinged scleral flap. One patient developed an epithelial ingrowth, which was successfully treated by transscleral and transcorneal cryotherapy combined with the use of an intraocular gas bubble to provide a thermal insulating effect to enhance the cryotherapy.

Keratoplasty for bullous keratopathy with intraocular lens

The presence of a pseudophakos does not appear to introduce any greater hazard when keratoplasty is required because of corneal edema. This, together with the histories obtained from patients requiring such keratoplasty, strongly suggests that the insult to the corneal endothelium takes place at the time of placement of the intraocular lens in the great majority of cases. Of possible further significance is the fact that five of the sixteen patients who underwent keratoplasty had had secondary procedures to stabilize or to reposition the lens following the original lens implantation. The increased trauma inherent in the intraocular lens operation has been pointed out by many authorities. The fact that twelve of the sixteen patients requiring keratoplasty had been operated by experienced, nationally known intraocular lens surgeons further emphasizes this. The immediate problem appears to be the development and refinement of surgical techniques to avoid some of the complications which have been described. The prognosis for keratoplasty in cases of bullous keratopathy with an intraocular lens has been found to be at least as good as in cases without an intraocular lens.

Familial band--shaped keratopathy and spheroidal degeneration. Clinical and electron microscopic study

Presumptive primary band-shaped keratopathy was described in a 35-year-old man and his 62-year-old paternal uncle. Lamellar keratoplasty was performed in one eye in each of these patients. The light and electron microscopic studies were carried out on both corneal specimens. Histologic stains for calcium were negative. Noncalcific band-shaped keratopathy was confirmed by electron microscopic findings too. Electron-dense globular deposits were found in the region of Bowman's membrane and superficial stroma. These may be characterized as a secondary form of spheroidal degeneration.

[Considerations on surgery of the iris (author's transl)]

Surgery of the iris is of essential importance in anterior segment surgery. In angle closure glaucoma a peripheral iridectomy performed early enough, when the trabeculum is not yet altered, is curative. In simple glaucoma if a filtering operation is performed, the iridectomy is fundamental in order to have a good communication between the posterior chamber and the filtering bleb and to avoid iris incarceration into the filtering wound. In cataract surgery iridectomy is mandatory, especially in intracapsular extraction. In penetrating corneal grafts a patent iridotomy or iridectomy, or several, is a safety factor avoiding the consequences of pupillary block, anterior synechiae and irreducible mydriasis. Another important problem is the surgery of the iris for optical purposes. Other indications which are not discussed in this paper are trauma of the anterior segment of the eye, the removal of benign or malignant tumors, epithelial cysts etc.

[Perforating keratoplasty: preconditions, indications, complications, follow-up treatment (author's transl)]

The results of a penetrating keratoplasty depends not only on certain morphological-biochemical and immunological factors, but also on an adequate surgical technique. The indications for perforating corneal grafting have constantly extended during the past 20 years and are classified according to the chances of success and to the emergency of grafting; some unusual indications are mentioned. Complications are rarely observed, but may occur during or after the surgery. Postoperative care is discussed.

Anterior chamber scroll and corneal edema

This case represents the successful removal of a transparent anterior chamber scroll and the subsequent resolution of corneal edema overlying the tissue. It emphasizes the clinical observation that a small area of endothelial touch can be associated with a disproportionately large area of overlying corneal edema, and may indeed be the cause of it.

Management of persistent filtering cicatrix following cataract extraction

We used a safe and simple surgical technique in the management of persistent filtering cicatrices after cataract extraction. The edematous, friable filtering cicatrix was excised entirely and a healthy fornix-based conjunctival flap was sutured over the fistula. Invariably, the fistula was very small, usually only large enough to admit a 27-gauge needle. Of the 27 eyes treated with this technique, there were two failures, but no other complications.

[Keratoplasty in childhood (author's transl)]

Report on 36 keratoplasties (30 eyes) in children up to 15 years of age. An efficient postoperative care was of critical importance for the final outcome. The specific problems are discussed. Regarding the fact that generally children are only operated on in case of heavy corneal disease which brings about a higher risk of graft failure our results may be judged as "fair": 63% of the transplants were optically clear; 43% exhibited good and 30% fair functional results. The best results were achieved with keratoplasties in corneal dystrophies (keratoconus included). Another group with good results was that with herpetic corneal disease, whereas transplants after heavy perforating injuries mostly failed. A beter postoperative medical collaboration and consultation is needed to improve final results. This is especially true for correcting operative measures (loosening sutures) and for therapy and prophylaxis of graft reactions.

Sclerocornea associated with the Smith-Lemli-Opitz syndrome

A 2,000-g infant boy had many features of the Smith-Lemli-Opitz syndrome (prenatal growth deficiency and developmental retardation, microcephaly with unusual facies, hypospadias, and feeding difficulties) as well as sclerocornea. The association of this rare eye finding with this rare congenital syndrome is unique. Successful penetrating keratoplasty was performed in one eye at 8 months of age.

The role of cryosurgery in external ocular and periocular disease

This preliminary report suggests that cryosurgery has a definite place in the management of certain external periocular and ocular problems. Cryosurgery for basal or squamous cell carcinoma of the lid is easily performed, gives excellent cosmetic results, and has a low recurrence rate. It is not recommended for lesions involving the fornices, or sclerotic and morphea-type basal cell carcinomas. Tumor recurrences following radiation, surgery, or cryosurgery can still be retreated with cryosurgery. To date, there is no evidence that cryosurgery at temperatures above -40 C causes damage to the lacrimal outflow system. Cryosurgery is of value in the management of trichiasis, reactive lymphoid hyperplasia, spider hemangioma, molluscum contagiosum, and conjunctival dysplasia. Cryotherapy for management of intraepithelial epithelioma and squamous cell carcinoma of the conjunctiva and cornea is still under investigation. Cryosurgery will, in our opinion, become the treatment of choice for basal and squamous cell carcinomas of the eyelids. The 96% cure rate with one treatment for these lesions reported here is artificially high since the follow-up period is too short. However, retreatment with cryosurgery is a simple ten-minute outpatient procedure which is certainly not the case with recurrences after other forms of therapy.

Intraocular lens implantation combined with penetrating keratoplasty

A restrospective analysis was conducted of 27 cases of penetrating keratoplasty associated with intraocular lens implantation. Although not statistically significant, the results indicated an 80% success rate when penetrating keratoplasty, cataract extraction and intraocular lens implantation were combined in a single operation. Secondary implantation of intraocular lenses in cases of previous keratoplasty were unsuccessful in all three cases.

Astigmatism in cataract surgery

We report on our investigation into astigmatism in 40 eyes following a corneal cataract incision closed with a continuous 10/0 nylon monofilament suture (Ethilon). Immediately after surgery there was astigmatism caused by the nylon suture (suture-induced astigmatism), its severity depending on the tightness of the suture. It ranged from 1 to 10-5 dioptres, the mean value 4-09 dioptres with a standard deviation of +/-2-5. Removing the nylon suture eliminated this astigmatism and within a few weeks the corneal astigmatism correction in 48% of eyes returned to the preoperative level. In 80% of eyes the difference between the final postoperative corneal astigmatism (4 months after removing the continuous suture) and the preoperative astigmatism was 0-75 dioptres or less and the maximum change was 1-5 dioptres. In 40% of eyes the axis of the cylinder changed from a horizontal to an oblique axis but did not change from a with- to against-the-rule axis. The degree of astigmatism remained constant while the suture was in place and in 50% of eyes was equal to or less than 3 dioptres. The mean of the spherical equivalents was 11-31 dioptres with a standard deviation of +/-1-25. A spectacle correction 14 days after operation prescribed either as the mean spherical equivalent (11-50 dioptres) or according to the patient's refraction will give satisfactory vision until the suture is removed 4 months after operation. The degree of astigmatism following a corneal section and continuous nylon suture compares very favourably with astigmatism following other suturing techniques for cataract.

Keratoplasty and intraocular lenses: follow-up study

In an effort of explore new approaches with the possibility of improving on existing methods of managing problem cases with combined corneal disease and cataracts, 35 patients were treated by keratoplasty, cataract extraction, and intraocular lens implantation in various combinations or by cataract extraction and lens implantation without keratoplasty over the past two years. Twenty-four of twenty-six grafts have remained clear over a 3- to 21-month period of observation. The two failures have been successfully regrafted. Eleven patients received a penetrating keratoplasty, cataract extraction and intraocular lens with ten remaining clear. Eight patients with corneal disease and aphakia received a penetrating graft and intraocular lens with all grafts remaining clear. Seven patients with a clear graft received a subsequent cataract extraction and lens implantation with six remaining clear. Nine patients with endothelial dystrophy and cataracts were not affected by cataract extraction and lens implantation. The relatively high success rate, rapid visual rehabilitation, and reduction in the incidence of vitreous loss, vitrectomy, and delayed vitreous complications via the methods employed have, to date, proven encouraging. Caution is advised until data from a larger case series and long-term follow-up become available. Short-term success is directly related to technique. To achieve immediate success, the need for considerable experience in keratoplasty and lens implantation can not be overemphasized.

Descemet membrane detachment

Four eyes of three patients had extensive postoperative Descemet membrane (DM) detachment. Blood was present just anterior to the DM in three of the four eyes and later converted to and persisted as pigment. Haziness of the cornea at the level of the DM could be seen with reattachment. Detachments of the DM are classified as planar when there is 1 mm or less separation of the DM from its overlying stroma in all areas. Nonplanar DM detachments exceed 1 mm of separation. Planar detachments have a much better prognosis than nonplanar detachments do, with or without descemetopexy. Repair of DM detachments, when necessary, should include air injection, with the lease possible instrumentation of the DM.

Keratoprosthesis: a 12-year follow-up

A retrospective study of our total experience with implantation of four types of keratoprosthesis in 125 cases was reviewed. Diagnoses in the cases treated included chemical burns, derangement of the anterior segment from disease or injury, aphakic bullous keratopathy, ocular pemphigoid, Stevens-Johnson syndrome, anterior cleavage syndrome, Mooren ulcer, and blast injuries. The visual results in some cases have been gratifying and in others heartrending. Thirty percent of the patients attained 20/15 to 20/40 visual acuity, but at the end of 12 years, only 13% still had this visual acuity. Twenty-four percent attained 20/50 to 20/200 visual acuity, but this figure fell to 17% at the end of 12 years. Loss of initial good visual acuity was due to the numerous complications which required close observation and repeated surgery to control. The number of complications has been reduced by the use of a keratoprosthesis with a Dacron skirt and of the addition the Cardona nut and bolt to the shaft. The surgical technique has been improved by the use of a scleral expander, elimination of a scleral graft, and the use of the Tenon graft. The indications for the keratoprosthesis have changed over the years. Many alkali burns and practically all aphakic bullous keratopathy have been eliminated from the indications. Keratoprosthesis should be reserved for desperate cases. The technique of implantation is not complicated and initial results are usually good. The multiple complications, however, make it necessary for these cases to be followed by a surgeon who is familiar with the management of complications.

Ultrasonic fragmentation for vitrectomy and associated surgical procedures

Ultrasonic fragmentation (USF) can be used to fragment various tissues such as the lens, the vitreous, the iris, and the ciliary body, so that they may be aspirated through a 23-gauge canula. Since the technique was first described in 1973, it has been used in 148 eyes in a variety of conditions with encouraging results. In aphakic bullous keratopathy, the corneas and vision improved in 78% of the cases. Pupillary block was relieved in 100% of cases. Cystoid macular edema improved in 63%. Vitreous opacification from other than hemorrhage cleared in all cases, and vision improved in 71%. Massive vitreous hemorrhage was cleared in 86%, and vision improved in 58%. In massive vitreous hemorrhage and retinal detachment, the vitreous was cleared and the retina reattached in 80% of cases. In massive vitreous contraction, the vitreous was removed in all cases and the retina reattached in all (100%) of cases. In massive vitreous membranes and retinal detachment, the membranes were successfully removed in 100% and the retina reattached in 82%. Lens remnants in the vitreous were removed in 100% of cases. Secondary membranes were removed successfully in 100% of cases. Vitreous presentation in the anterior chamber, caused by a ruptured posterior capsule during extracapsular extraction or actual vitreous loss during intracapsular extraction, was treated successfully in 100% of cases. One case of medullo-epithelioma of the ciliary body was removed but recurred twice after ultrasonic fragmentation. Complications occurred in seven of 148 cases (4.8%) and consisted of five cases of retinal detachment (probably because of lens material reaction) and two cases of epithelial downgrowth in cases where the wound was not closed with sutures. Ultrasonic fragmentation appears to be a fairly simple procedure, performed with a machine with no moving parts, through two 1-mm incisions and using two 0.6-mm cannulas, with a minimum of complications and encouraging results. It should be tried before more radical procedures are recommended. A good anatomic result was obtained in 129 of the 148 consecutive cases (88%). The technique is described and the results reported.

Pars plana vitrectomy. Vitrectomy technique in anterior segment surgery

Instrumentation and techniques developed primarily for vitreoretinal surgery were used to treat 20 eyes with an occluded or inadequate pupillary space and 5 aphakic eyes with complications caused by formed vitreous in the anterior chamber. A pars plana approach was used in 19 eyes and a limbus approach was used in 6 eyes. In every eye an adequate pupillary space was provided and all formed vitreous was removed from the anterior segment. No intraoperative complications occurred. This new approach to selected cases of anterior segment surgery offers several advantages over conventional techniques. A larger number of cases and longer period of follow-up are necessary to further define the specific indications and limitations of this technique.

[Urgent keratoplasty for a corneal infection by actinomyces (author's transl)]

A 41-year-old man suffering from an actinomyces infection of the cornea of his right eye, was treated unsuccessfully with antibiotics especially intensive local and systematic therapy with penicillin, paracentesis of the anterior chamber with penicillin irrigation, and cautery of the corneal ulcer were fruitless. Finally, the corneal infection was cured by an urgent perforating keratoplasty.