Reconstruction of filtering blebs with free conjunctival autografts.

BACKGROUND: Situations arise in which the surgical repair or revision of filtering blebs is either technically impossible or inadequate, and total reconstruction becomes necessary. This is most frequently encountered in eyes that have undergone multiple procedures, resulting in significant bulbar conjunctival scarring and episcleral fibrosis. METHODS: To preserve the pre-existing filtration site, the authors successfully treated five such patients in whom conjunctival scarring adjacent to and surrounding the blebs precluded local revision, by transplanting free conjunctival autografts. Two patients required grafting from the fellow eye. Specific modifications from previously reported conjunctival flap techniques were used to enhance graft healing and continued filtration. RESULTS: Satisfactory intraocular pressure control was maintained in all patients receiving minimal to no anti-glaucomatous medications with an average follow-up of 42.6 months (range, 7-90 months). No patient had a significant decrease in visual acuity or surgical complications. CONCLUSION: Free conjunctival autografting techniques are a useful adjunct in the surgical revision of leaking, failed, or migrating filtration blebs.

Donor failure after corneal transplantation surgery.

Donor failure refers to graft edema present within the first 24 h after penetrating keratoplasty that persists in spite of maximal medical therapy. We reviewed the case histories of 1,351 penetrating keratoplasties. Of these, 17 (1.2%) were considered donor failures. Five cases were histopathologically consistent with Fuchs' dystrophy. Seven cases demonstrated mechanical stripping of the endothelium. Five cases, all from the same eye bank, revealed an absence of posterior stromal keratocytes. Storage medium at the eye bank of origin was found to have an alkaline pH. Careful preoperative evaluation of donor corneas is emphasized, but if an apparent "epidemic" of donor failure occurs, a thorough investigation of the eye bank methodology should be initiated.

Superficial epithelial keratectomy in the treatment of epithelial basement membrane dystrophy.

Thirty eyes with symptomatic epithelial basement membrane dystrophy that were unresponsive to current standard modalities of therapy were treated with a total superficial epithelial keratectomy. Follow-up ranged from two months to 89 months (average, 37 mo). One hundred percent of patients were relieved of their preoperative symptoms, and only 3% have shown any evidence of recurrence of their dystrophic process.

Superficial epithelial keratectomy in the treatment of epithelial basement membrane dystrophy.

Thirty-three eyes with symptomatic epithelial basement dystrophy, unresponsive to current standard modalities of therapy, were treated with a total superficial epithelial keratectomy. Follow-up was from 2 months to 7 years 5 months with an average of 47 months. All patients were relieved of their preoperative symptoms and only 3% have shown any evidence of recurrence of their dystrophic process.

Conjunctival flaps in the treatment of refractory pseudomonas corneal abscess.

Pseudomonas corneal abscess can result in a rapid downhill clinical course despite institution of appropriate medical measures. In this situation the clinician is faced with surgical intervention. A series of patients treated and stabilized through conjunctival flap therapy are presented. The role of conjunctival flap therapy in halting the progression of this entity is described.

Results of penetrating keratoplasty in the iridocorneal endothelial syndrome.

Five patients (four men and one woman ranging in age from 30 to 41 years) with the iridocorneal endothelial syndrome (four with Chandler's syndrome and one with essential iris atrophy) underwent penetrating keratoplasty for complaints relating to diminished visual acuity or pain. After follow-up periods ranging from one year to four years and seven months (average, 2.7 years), postoperative visual acuities ranged from 20/15 to 20/30. No evidence of recurrence of the corneal abnormalities observed before grafting was apparent in the donor corneas at the last examinations. Two patients who required medical treatment for intraocular pressure control preoperatively also required adjuvant therapy postoperatively. These results suggested that penetrating keratoplasty is a relatively safe and effective procedure for patients with diminished vision or other complaints related to corneal abnormalities in the iridocorneal endothelial syndrome. It does not, however, restore to normal the iris and angle structures affected adversely by the progression of the corneal endotheliopathy and therefore other measures may be required to control intraocular pressure.

The FDA report on intraocular lenses.

Clinical studies of intraocular lenses (IOLs) as investigational devices have been regulated in the United States by the Food and Drug Administration (FDA) since February 9, 1978. As of August 1982, data have been collected on more than one million IOLs implanted. During the last 12 months of the study, 409,000 IOLs were implanted. Visual acuity of 20/40 or better at one year after surgery was present in 85% of over 45,000 cases reviewed. Increasing patient age, surgical problems, postoperative complications, and adverse reactions were factors that reduced the visual acuity. The current trend in the USA is for implantation of the posterior chamber and anterior chamber IOLs.

Graft reactions after unilateral and bilateral keratoplasty for keratoconus.

Penetrating keratoplasty was performed on 134 eyes with keratoconus (102 patients) Including 32 bilateral cases. The incidence of homograft rejection in the first eye of bilateral cases before surgery was performed on the second eve was identical to the incidence in unilateral cases (16%). The incidence of graft rejection was somewhat higher (25%) in the second eye of bilateral surgery, but this difference in rates of rejection was not statistically significant. Surgery on the second eye affected adversely the successful graft on the first even in only one case and this was resolved with medical therapy.

Round and oval cones in keratoconus.

In advanced keratoconus, there are two cone types. The more common round or nipple shaped cone is limited in diameter but may reach any degree of conicity. The cone center lies mostly in the lower nasal quadrant. The oval or sagging cone, is often larger and lies more commonly in the inferotemporal quadrant close to the periphery. The oval cone is usually associated with more episodes of corneal hydrops, scarring and difficulty in fitting contact lenses. Histopathologic review of 23 cases (10 round, 13 oval), revealed that the oval group had more breaks in Bowman's membrane, 10.1 versus 5.0, (P smaller than 0.01), and a tendency toward greater pannus formation with more ruptures in Descemet's membrane. We hope this clinicopathologic correlation may allow a more logical approach to patient care based on recognizing two different cone types in advanced keratoconus.

Interim FDA report on intraocular lenses.

Intraocular lenses have been regulated by the Food and Drug Administration since February 9, 1978. Data reported through August 9, 1979 reveal 177,503 lenses of four different classes have been implanted. The anterior chamber intraocular lens appears to have a higher incidence of certain postoperative complications compared with both control operations and implantation of lenses in the other three classes. The anterior chamber intraocular lens appears to be associated with a lower level of visual acuity compared with both control cases and the other three lens classes during the first six months following implantation. Some complications occurred less frequently following implantation of intraocular lenses than in control cases.

Combined keratoplasty, cataract extraction and intraocular lens implantation.

In summary, corneal surgery with or without simultaneous cataract extraction and intraocular lens implantation, or in the presence of an intraocular lens, is justified in view of possible good, clear grafts (80% of our cases) and vision better than 20/50 (60% of our cases).

Anterior chamber after intrascleral filtering surgery.

Intrascleral filtering surgery was performed in 58 eyes and the anterior chamber (AC) depth was estimated postoperatively by recording the equivalent number of corneal thicknesses (CT) of central AC depth (lens-cornea distance). Lens-cornea touch occurred in 3 of 28 eyes with chronic simple glaucoma and was highly correlated with cataract formation. Lens-cornea touch did not develop in any of 11 eyes with other types of phakic glaucoma. Lens-cornea touch did not occur in any eye if the postoperative AC depth was ever 2 CT or greater and all three instances of lens-cornea touch occurred on or by the fifth postoperative day. Nineteen aphakic eyes were operated and all had normal AC depth from the first postoperative day. The data do not support the common belief that filtering procedures done beneath a scleral flap result in faster AC depth reformation than filtering procedures not done beneath a scleral flap.

Thermokeratoplasty in the treatment of persistent corneal hydrops.

Thermokeratoplasty (TKP) was used to treat six cases of chronic corneal hydrops previously refractory to traditional therapy. In all instances TKP resulted in a clearing of the hydrops within three weeks. In four cases the resultnat comfort and clarity precluded the necessity for transplantation, while in the remaining two cases subsequent penetrating keratoplasty was successfully performed. Thermokeratoplasty is advocated in chronic hydrops refractive to standard therapy, in acute hydrops to accelerate recovery, in recurrent hydrops to assist in healing of breaks in Descemet membrane, thus preventing recurrences, in cases with extensive hydrops to deturgesce the peripheral cornea prior to transplantation, and as definitive therapy in cases where transplantation is contraindicated.