Five-year outcomes of eyes with glaucoma drainage device and penetrating keratoplasty.

PURPOSE: To investigate intraocular pressure (IOP) control and corneal graft survival rates in eyes with glaucoma drainage device (GDD) implantation and penetrating keratoplasty (PK) and 5 years of follow-up data. DESIGN: Retrospective review. METHODS: We performed a review of records of all patients who underwent both GDD placement and PK at our institution between January 1, 1988 and December 31, 2003. Twenty-eight eyes of 27 patients were studied. Glaucoma outcome was assessed by postoperative IOP, number of glaucoma medications, and need for further glaucoma surgery. Corneal grafts were assessed for clarity. RESULTS: All eyes had GDD placement in the anterior chamber. The mean pre-GDD IOP was 28.8 ± 10.3 mm Hg on a mean of 2.6 ± 0.8 glaucoma medications. At 5-year follow-up, the mean IOP was 13.0 ± 5.9 mm Hg on a mean of 0.9 ± 1.0 glaucoma medications. GDD implantation successfully controlled glaucoma in 96%, 86%, 79%, 75%, and 71% of eyes at 1, 2, 3, 4, and 5 years, respectively. Grafts remained clear in 96%, 82%, 75%, 57%, and 54% of eyes at 1, 2, 3, 4, and 5 years, respectively. Failure of glaucoma outcome or graft survival was associated with prior intraocular surgeries. CONCLUSIONS: Our data suggests that GDD placement can provide glaucoma control in a high percentage (71%) of eyes with PK even at 5 years. Furthermore, the success of PK in eyes with GDD remains reasonable (54%) at 5 years. IOP control and graft survival rates are comparable with earlier published studies with shorter follow-up or tube placement in the vitreous cavity.

Pseudodendritic fungal epithelial keratitis in an extended wear contact lens user.

PURPOSE: Pseudodendritic keratitis in a contact lens wearer is generally associated with acanthamoeba keratitis. We report a case of isolated pseudodendritic fungal epithelial keratitis that occurred in an extended wear contact lens user. METHODS: A 48-year-old woman was evaluated in our clinic for a 36-hour history of left eye pain. She wore extended wear soft contact lenses and frequently rinsed her eyes with tap water. Her left cornea had a paracentral 3-mm area of epithelium with raised ridges in a pseudodendritic pattern. The underlying corneal stroma was normal. A therapeutic and diagnostic corneal scraping of the lesion was performed and sent for Gomori methenamine silver (GMS) staining. The clinical concern was for epithelial acanthamoeba keratitis. RESULTS: The GMS staining revealed septate fungal hyphae within sheets of corneal epithelium. The patient was started on frequent alternating natamycin (5%) and amphotericin B (0.15%) antifungal eyedrops and exhibited a rapid clinical response. Her keratitis completely resolved, and her vision returned to her baseline of 20/25. Corneal fungal cultures showed no growth. CONCLUSIONS: Our case is an extremely unusual presentation of fungal keratitis, which rarely presents as a pseudodendritic epithelial keratitis. There are two previous similar case reports initially misdiagnosed as acanthamoeba keratitis. Clinicians should be aware that isolated fungal epithelial keratitis can present as a distinct entity and should be considered in the differential diagnosis of pseudodendritic keratitis. The GMS staining is an excellent diagnostic test in a patient presenting with pseudodendritic keratitis because it allows rapid diagnosis of acanthamoeba and fungal infections.

Fungal keratitis and contact lenses: an old enemy unrecognized or a new nemesis on the block?

PURPOSE: To review studies of fungal keratitis related to contact lenses and determine whether the recent insurgence is a new phenomenon or an exacerbation of an ongoing trend. METHODS: A review of the recent literature on contact lens-related fungal ulcers and a comparison to older studies. RESULTS: The incidence of fungal keratitis associated with contact lenses increased from 5% in the 1980s to between 10% and 25% in the 1990s and was noted to be 44% in Florida at the turn of the century. The most recent study from Florida showed that the incidence had increased from 29% in the late 1990s to 52% in the early 2000s, even before the Fusarium keratitis epidemic in 2004 and 2005. This increase mainly represented an increase in the number related to nontherapeutic contact lenses. CONCLUSIONS: Contact lens-related fungal keratitis was relatively rare 20 years ago. However, the incidence has progressively increased since then. Contact lens-related fungal ulcers had become more common even before the recent Fusarium keratitis epidemic. This change may be related to changing contact lens care habits and younger patients being fitted with contact lenses.

Fitting contact lenses for visual rehabilitation after penetrating keratoplasty.

PURPOSE: To determine the optical indications for contact lens wear after corneal transplantation. The type of lenses used, fitting philosophy, visual outcomes, and complications were examined. METHODS: A 4-year retrospective chart review was performed and identified 35 eyes in 30 patients wearing contact lenses for visual rehabilitation after penetrating keratoplasty. RESULTS: The optical indications for contact lens fitting after penetrating keratoplasty were multifactorial and included irregular astigmatism (62.9%), spherical anisometropia (57.1%), and astigmatic anisometropia (54.3%). The average time from surgery to initial contact lens fitting was 18.2 months. Spherical rigid gas-permeable lenses were the most common type of lens used. The mean best-corrected visual acuity improved from less than 20/40 with spectacles alone to better than 20/30 when using a contact lens. Punctal occlusion and lubrication helped to improve contact lens tolerance. Complications associated with contact lens use tended to be minor and responded generally well to conservative treatment measures. CONCLUSION: Contact lenses can improve visual function in patients with irregular astigmatism and anisometropia after penetrating keratoplasty.

Recurrent scleral abscess after uncomplicated cataract extraction.

PURPOSE: To report the unusual occurrence of a recurrent scleral abscess after uncomplicated cataract extraction. METHODS: Case report of a 77-year-old healthy woman. RESULTS: Multiple cultures and antibiotic treatments failed to resolve presenting symptoms. Gram stain, Gomori methenamine silver (GMS) stain, and all cultures were negative. After drainage of the abscess, the patient's symptoms cleared briefly, then returned 6 months later showing a positive GMS stain consistent with Candida. The patient was treated with amphotericin, natamycin, and fluconazole at this time, and a return in visual acuity occurred along with a resolution of symptoms. No re-occurrence has been noted with 2.5 years of follow-up. CONCLUSIONS: Cataract extraction, although generally a safe procedure, can still result in unusual complications such as scleral abscesses. Excellent outcomes are possible once the infections are identified and treated.

Present status of contact lens-induced corneal infections.

This article addresses the spectrum of corneal infections associated with contact lens wear. The status of bacterial, fungal, and Acanthamoeba keratitis is discussed as well as diagnosis and treatment for these infections.

Primary antiphospholipid syndrome presenting with a branch retinal artery occlusion in a 15-year-old boy.

Acute vascular events are rare in the pediatric population, but there is an association with the presence of antiphospholipid antibodies. When there is no other underlying medical disorder, this is referred to as primary antiphospholipid syndrome. We present a case of a 15-year-old boy who developed an acute superior branch retinal artery occlusion. Complete evaluation revealed significant elevations in antiphospholipid antibodies. To our knowledge, there are no cases in children of primary antiphospholipid syndrome presenting with this clinical manifestation.

Preseptal cellulitis caused by trichophyton (ringworm).

A 10-year-old boy with a past medical history significant for chicken pox at 7 years of age was referred to our eye center by an outside ophthalmologist for a 15-day history of worsening right-sided preseptal cellulitis. The patient reported photophobia, pruritus, and pain in the eyelid region. There appeared to be vesicular lesions on the eyelids. Empiric therapy with oral antibacterial and antiviral medications failed to resolve the preseptal cellulitis. Lid cultures revealed coagulase negative Staphylococcus, Streptococcal viridans, and a Trichophyton species of fungus. The infection was successfully treated with two courses of oral itraconazole. This is the first case of preseptal cellulitis caused by this dermatophyte that we could find in the literature.