A Detailed Analysis of Individuals Having Graft Failure After Corneal Transplantation

PURPOSE

To describe demographic and clinical characteristics of patients with graft failure after keratoplasty, determine the cause of graft failure and outcomes.

METHODS

The charts of patients between 2008-2013 in the Cornea Service at Wills Eye Hospital with a history of a corneal transplant before the end of 2012 were retrospectively reviewed. Included were patients who had graft failure after corneal transplantation and had at least one year of follow-up after transplantation. Penetrating keratoplasty (PK) and Descemet's stripping endothelial keratoplasty (DSEK) patients were analyzed separately.

RESULTS

A total of 186 eyes of 170 patients with graft failure after a PK (156) or DSEK (30) procedures were identified. The baseline characteristics included 100 female and 70 male patients with an age between 0 and 90 years (median 63 years). At the time of surgery, 38% had three or more systemic diseases and 68% were using three or more systemic medicines. Mean follow up time for PK was nearly four times of DSEK. Only 2 DSEK eyes (7%) underwent a 3rd DSEK graft, while 47 (30%) PK eyes underwent a 3rd PK and 15 (10%) PK eyes underwent more than three PK procedures.

CONCLUSIONS

Most DSEK failures occurred in 1st year, while graft failure in PKs is scattered over years. Failure in DSEK is mostly due to graft or surgical risk factors but in PK mostly due to factors in the host. DSEK does not appear to be as affected by the patients' demographic and clinical characteristics as much as PK.

The results of Muller Muscle Conjunctival Resection versus Levator Advancement for mild to moderate ptosis

Purpose: To compare the surgical outcomes of Muller muscle conjunctival resection (MMCR) and levator advancement (LA) in patients with mild to moderate blepharoptosis. Methods: A retrospective review of patients who underwent surgery for mild to moderate ptosis between 2015 and 2020 was performed. The degree of ptosis was graded based on the amount of upper eyelid drooping: mild ≤ 2 mm and moderate < 4 mm. Surgical success was defined as post-operative marginal reflex distance 1 (MRD1) ≥ 4.0 and ≤ 5.0 mm, and a satisfactory eyelid contour. Results: A total of 82 eyes of 65 patients underwent ptosis repair surgeries. MMCR was performed in 48 eyes and LA in 34 eyes. Under-correction was detected in 8.3% and 11.8% of the patients in MMCR group and LA group respectively. There was no patient with over-correction in the MMCR group postoperatively, 3 patients in the LA group had over-correction (0% vs. 8.8% respectively). The success rate in our study was found to be 91.7% in the MMCR group and 72.2% in the LA group. Conclusions: The MMCR and LA procedures are effective approaches in treating patients with mild to moderate eyelid ptosis in our population. Each procedure had its superiority in selected groups of patients. However, the complication rate and duration of surgery were found to be lower in MMCR group. Abbreviations: LA = Levator Advancement, LF = Levator Function, MMCR = Muller Muscle Conjunctival Resection, MRD 1 = Marginal Reflex Distance.

Long-term results of cataract surgery in patients with anterior uveitis

PURPOSE

This study was aimed to assess the long-term results of phacoemulsification and posterior chamber intraocular lens implantation in patients with anterior uveitis.

METHODS

Patients with complicated cataract secondary to anterior uveitis who underwent phacoemulsification and posterior chamber intraocular lens implantation were included in this study. Long-term results and all complications were evaluated throughout the postoperative 4 years.

RESULTS

A total of 55 eyes of 48 patients were identified in this study. Cases with anterior uveitis were categorised into four aetiologic groups. Of the 55 eyes, 22 (19 patients) had idiopathic anterior uveitis, 10 (9 patients) had viral anterior uveitis, 10 (9 patients) had Fuchs' anterior uveitis and 13 (11 patients) had anterior uveitis associated with collagen vascular diseases. Preoperative macular oedema was more frequent (63.6%) in the idiopathic group than in the other groups (p < 0.001). The success rates of the best corrected visual acuity of 20/40 or better ranged from 80.0 to 100.0% in the groups. While postoperative increased intraocular pressure rate was statistically significantly higher in the Fuchs' group (p = 0.047), there was no statistically significant difference in other complication rates between the groups.

CONCLUSIONS

The long-term outcomes of phacoemulsification with intraocular lens implantation in patients with uveitic cataract were satisfactory with excellent visual acuity and relatively low complication rates.

The Association between Diabetes and Herpes Simplex Eye Disease

PURPOSE

To evaluate the association between diabetes mellitus (DM) and presence and severity of Herpes simplex eye disease (HSED).

METHODS

We conducted two sub-studies. We included the patients seen on the Cornea Service of the Wills Eye Hospital from January 2008 to August 2012. Study 1 included 541 patients with HSED and 3226 controls. Study 2 involved 40 diabetic and 120 non-diabetic ocular surface HSED patients. Severity of ocular surface HSED was graded as mild, moderate, or severe, based on best-corrected visual acuity (BCVA). Patients were excluded if they had fewer than two office visits or had non-Herpes simplex-related vision-threatening conditions. Diabetes was graded as: diet group (DM controlled with diet), oral group (DM controlled with oral medications), and insulin group (DM control required insulin).

RESULTS

Five of 541 (0.93%) HSED patients had type 1 DM, similar to 19/3246 (0.59%) controls (p = 0.375); 48 of 541 (8.88%) HSED patients had type 2 DM, similar to 287/3246 (8.84%) controls (p = 0.981). Using multinomial logistic regression analyses, the probability/risk of being in the severe ocular surface HSED group as opposed to the mild ocular surface HSED group were not statistically significantly different between DM patients and those without DM (p = 0.120; OR, 1.900; 95% CI, 0.846-4.266).

CONCLUSIONS

There may not be a positive association between type 2 DM and HSED.

Surgical Management of Double-Head Pterygium Using a Modified Split-Conjunctival Autograft Technique

AIM

To describe a modified split-conjuctival autograft technique for double-head pterygium and evaluate the postoperative outcomes.

METHODS

A retrospective analysis of all patients who underwent split-conjunctival autograft surgery for double-head pterygium from November 2012 to March 2014. Conjunctival autograft was split vertically, in order to obtain limbal sides of cojunctival autograft for both sides. No adjunctive agent was used. Records of included patients were reviewed and outcomes and recurrence rates were noted.

RESULTS

Eight cases of double-head pterygia were noted in 158 total cases of pterygia evaluated (5%). The baseline characteristics included 2 female and 6 male with an age between 26 and 71 (average 42.63) years. All eyes had 12-month follow-ups in average (6-21 months). No intraoperative or postoperative complications were noted. No recurrence was observed.

CONCLUSION

A modified, vertical-split conjunctival autograft without any adjunctive agents is a successful and safe technique in management of double-head pterygium.

A case of retrobulbar optic neuritis caused by duloxetine

Psychotropic medications may cause many ocular adverse effects including toxic optic neuropathy. We present a unique case of a 44-year-old woman using duloxetine who presented with unilateral visual loss due to retrobulbar neuritis. Physicians and patients should be alerted to this potential side effect. To the best of our knowledge, this is the first case of developing retrobulbar neuritis related to duloxetine usage.

Treatment of tularemia during pregnancy

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An atypical case of tularemia presented with pseudoptosis

We report an unusual case of tularemia involving pseudoptosis associated with deterioration of the lymphatic drainage system extending from the upper eyelid to the preauricular lymph nodes. A 16-week pregnant patient was admitted with an absess on the neck, preauricular lymphadenopathy, and pseudoptosis on the left side. The micro-agglutination test was positive for Francisella tularensis antibody at a titer of 1/200. The absess was surgically drained and oral cefuroxime was given for 6 weeks. Two weeks after drainage, the pseudoptosis improved due to the recovery of lymphatic drainage system of the eyelid and remission of the absess on the neck. Our case report contributes to the medical literature on tularemia during pregnancy and informs healthcare professionals on the management of the infection in such cases.

Demographic patterns and treatment outcomes of patients with recurrent corneal erosions related to trauma and epithelial and bowman layer disorders

PURPOSE

To evaluate demographics and outcomes of patients with recurrent corneal erosions related to trauma and epithelial and Bowman layer disorders.

DESIGN

Retrospective case series.

METHODS

setting: Wills Eye Institute, Philadelphia, Pennsylvania. study population: Two hundred seventy-two eyes (230 patients) presenting between 2008 and 2011 with recurrent corneal erosions related to trauma and epithelial and Bowman layer disorders. procedure: Conservative management, diamond burr polishing, excimer laser phototherapeutic keratectomy (PTK), and epithelial debridement alone. main outcome measure: Recurrence of erosions, more than 6 weeks after commencing treatment.

RESULTS

Mean age was 46.5 ± 14.6 (2-85) years. Female subjects accounted for 53% of patients and 18.3% had bilateral involvement. Etiology included epithelial basement membrane dystrophy in 52.9% (144/272) and trauma in 25.7% (70/272). One hundred sixty-six eyes with more than a single visit were initially managed conservatively, 68 of 166 (40.9%) had diamond burr polishing, 7 of 166 (4.2%) had PTK, and 4 of 166 (2.4%) had epithelial debridement alone. Many eyes had >6 weeks follow-up: 120 of 166 (72.3%) after conservative management, 54 of 68 (79.4%) after diamond burr polishing, 7 of 7 (100%) after PTK, and 4 of 4 (100%) after epithelial debridement. Percentage of eyes with recurrence was 56.7% (68/120) after conservative management, 14.8% (8/54) after diamond burr polishing, and 28.6% (2/7) after PTK. Rate of recurrence (eye-years) was 0.74, 0.19, and 0.23 with conservative management, diamond burr polishing, and PTK, respectively. Mild haze was seen in 22.2% of eyes (12 eyes) after diamond burr polishing and 28.6% (2 eyes) after PTK.

CONCLUSION

Recurrent corneal erosions are most commonly associated with epithelial basement membrane dystrophy. Patients are generally initially managed conservatively, with recurrence in more than half of eyes. Diamond burr polishing is the most common surgical intervention and is effective in a majority of eyes.

Indications and outcomes of corneal transplantation in geriatric patients

PURPOSE

To identify the most common corneal transplant procedures, indications, coexisting ocular diseases, and outcomes in elderly patients, and to compare younger geriatric patients with super-geriatric patients.

DESIGN

Retrospective case series.

METHODS

Data of all patients 65 years old and older who underwent corneal transplantation at Wills Eye Institute from April 2007 to January 2013, and were followed up for at least 1 year, were collected. Two hundred seventy-one eyes of 253 patients were divided into 2 groups according to the age of the patient.

RESULTS

Group I (65-79 years old) included 181 eyes and Group II (80 years and older) included 90 eyes. The most common indication was Fuchs endothelial dystrophy, with 78 eyes (43%) in Group I and 34 eyes (38%) in Group II. In Group I, 93 Descemet stripping endothelial keratoplasty (DSEK) (51%), 84 penetrating keratoplasty (PK) (46%), and 4 keratoprosthesis procedures(2%) were performed; in Group II, 37 DSEK (41%), 51 PK (57%), and 2 keratoprosthesis procedures (2%) were performed. Graft survival rate at last visit was 90% for Group I and 88% for Group II. Rejection occurred in 18 Group I eyes (10%) and 7 Group II eyes (8%) (P = .562).

CONCLUSION

Endothelial abnormalities were more common indications and keratoconus was a less common indication for surgery in the elderly. Fuchs dystrophy was the leading indication for surgery in both super-geriatric and younger geriatric patients. Graft survival rate was slightly higher in the younger geriatric age group but was not statistically significant. In the elderly, there is an increased prevalence of both glaucoma and retinal diseases that can affect the visual outcomes after corneal transplantation.

Unilateral acute dacryocystitis associated with oculoglandular tularemia: a case report

PURPOSE

To describe an unusual case of oculoglandular tularemia associated with unilateral acute dacryocystitis and purulent conjunctivitis with 18 weeks pregnancy.

METHODS

It is difficult to culture francisella tularensis on media so serological tests such as micro-agglutination methods are used to diagnose the infection. PCR test results were weak positive. The serum sample was analyzed for the presence of f. tularensis antibody, which was determined positive with a titer of 1/160.

RESULTS

Oral amoksicilin-clavulonic acid treatment was applied to the patient because of the side-effects of other antibiotics on the fetus. Dacryocystitis was surgically drained but relapsed a few weeks later, so it was drained again and a ciprofloksasin-impregnated sponge was placed into the tissue defect that occured after drainage. No relapses were seen after recovery of dacryocystitis.

CONCLUSIONS

Oculoglandular tularemia is not only suspected in cases who complain of fever, cervical lymphadenopathy and purulent conjunctivitis, it should also be suspected in cases who are admitted to the hospital with acute dacryocystitis, which is a rare component of oculoglandular syndrome.

Management of cataracts and oculo-cutaneous malignancy in xeroderma pigmentosum

This case report describes the management of a 17-year-old woman with xeroderma pigmentosum (XP) with bilateral mature cataract, conjunctival squamous cell carcinoma in the left eye (OS) and a cutaneous squamous cell carcinoma on her nose. To our knowledge, this is the first reported XP case with a cataract developing in the last couple of years without any ocular trauma, any history of inadequate diet or of previous corticosteroid use. We believe that cataracts can be related to improper working of the DNA repair mechanism of the lens epithelial cells in XP patients.

The surgical treatment of congenital tarsal kink syndrome associated with corneal ulcer

The authors present a case of unilateral eyelid congenital tarsal kink associated with corneal ulcer. The tarsal kink was corrected by a horizontal tarsal incision, performed half the thickness of the tarsus along its entire horizontal extent. Terminal levator aponeurosis fibers were reattached to the tarsal incision line to create sufficient everting force for correction of the entropion. The tarsal kink disappeared and eyelid positions remained stable during a follow-up period of 2 years.