Which intraocular lens would ophthalmologists choose for themselves?

PURPOSE: Contemporary cataract surgery is increasingly customizable with the advent of presbyopia-correcting intraocular lenses (IOLs) and the femtosecond laser. The purpose of this study was to determine the types of IOLs ophthalmologists choose for themselves and whether demographic characteristics, surgical experience, and attitudes of ophthalmologists might influence their decision-making. Additional goals included evaluating the use of femtosecond laser use in cataract surgery and investigating surgeon IOL preferences for their patients. METHODS: We distributed a 29-question Survey Monkey survey to senior ophthalmology residents and practicing ophthalmologists and received 347 responses during a 1-month period. We analyzed 328 surveys using chi-square tests and Fisher's exact tests. RESULTS: Main outcome measures included surgeons' personal preferences for choice of IOL, femtosecond laser-assisted cataract surgery, and IOL preference for patients. In the setting of no astigmatism, 61.3% of respondents would choose a monofocal IOL set for either distance or monovision for their own surgery. For corneal astigmatism >1.25 D, 60.3% of respondents would choose a toric monofocal lens and only 6.9% would want a femtosecond laser or manual LRI for their own surgery. Of the respondents, 34.6% perform femtosecond laser-assisted cataract surgery, but only 15.3% would want femtosecond cataract surgery performed on themselves. Also, 67.7% implant presbyopia-correcting IOLs (diffractive echelette, multifocal, or accommodative). When correcting for patients' corneal astigmatism >1.25 D, 65.7% of respondents preferred a toric monofocal IOL. CONCLUSION: Ophthalmologists value quality of vision and are risk averse. Overall, a surgeons' personal preference for their own surgery is correlated with past surgical experience with patients.

Partial Scleral Rupture Presenting 4 Years After Laser in Situ Keratomileusis.

PURPOSE: To report a case of partial scleral rupture after laser in situ keratomileusis (LASIK) surgery. METHODS: This is a retrospective case report describing a late complication of LASIK surgery. RESULTS: A 32-year-old white woman with a history of LASIK surgery performed with a mechanical microkeratome 4 years previously presented for evaluation of partial bilateral scleral ruptures. An arcuate filtering bleb along the contour of the cornea was found on the right eye with associated hypotony and corneal astigmatism. There were no signs or symptoms of prior inflammation, and rheumatologic workup was negative. Imaging revealed scleral microbreaks in the absence of adjacent thinning. CONCLUSIONS: The pattern and location of thinning without findings consistent with inflammatory disease suggest that the partial bilateral scleral rupture was because of mechanical damage at the time of LASIK, possibly compounded by the hormonal changes of pregnancy.

Epithelial Ingrowth Following Endothelial Keratoplasty.

PURPOSE: To present a large case series of epithelial ingrowth or implantation following endothelial keratoplasty (EK) with the purpose of identifying the common causes as well as the various clinical presentations. We aim to determine the typical clinical course and the most effective treatment for this rare but serious complication. METHODS: This is a retrospective study of 13 patients who developed epithelial ingrowth or implantation post-EK. Slit lamp photographs were independently examined along with other diagnostic imaging and histopathology to confirm the diagnosis. Patient medical records including operative reports were reviewed to determine the number of surgeries that occurred before EK and details of surgical technique, for example, whether venting incisions were performed. Records from follow-up visits were reviewed to determine the natural progression and management of these cases. The literature was reviewed and a meta-analysis was performed. RESULTS: The patients were divided into 5 groups according to the type of epithelial presentation. Eight patients had involvement within the interface away from the visual axis. One patient had ingrowth in the interface within the visual axis, 2 had retrocorneal involvement, and 1 had anterior chamber involvement. One had both retrocorneal and anterior chamber involvement. Venting incisions were performed in 8 patients, but only 1 had ingrowth related to the venting incision. Nine patients were observed without evidence of significant progression. Four patients had surgical treatment to remove the epithelium. CONCLUSIONS: Epithelial ingrowth or implantation occurs most commonly within the interface away from the visual axis and typically does not progress. The presentation of a homogeneous gray-white interface opacity is characteristic. Ingrowth can result from venting incisions, but rarely does. Other causes are eccentric trephination or loose donor or host epithelium being dragged into the eye at the time of surgery.

Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern(®) Guidelines.

UNLABELLED: COMPREHENSIVE ADULT MEDICAL EYE EVALUATION® PREFERRED PRACTICE PATTERN® GUIDELINES: Evidence-based update of the Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern® (PPP) guidelines, discussing the rationale and components of an ophthalmic evaluation for adult patients with and without risk factors.

Factors associated with corneal graft survival in the cornea donor study.

IMPORTANCE: The Cornea Donor Study (CDS) showed that donor age is not a factor in survival of most penetrating keratoplasties for endothelial disease. Secondary analyses confirm the importance of surgical indication and presence of glaucoma in outcomes at 10 years. OBJECTIVE: To assess the relationship between donor and recipient factors and corneal graft survival in the CDS. DESIGN, SETTING, AND PARTICIPANTS: Multicenter prospective, double-masked, controlled clinical trial conducted at 80 clinical sites. One hundred five surgeons enrolled 1090 participants undergoing corneal transplant for a moderate-risk condition, principally Fuchs dystrophy or pseudophakic or aphakic corneal edema (PACE). Forty-three eye banks provided corneas. INTERVENTIONS: Corneas from donors younger than 66 years and donors 66 years or older were assigned, masked to donor age. Surgery and postoperative care were performed according to the surgeons' usual routines. Participants were followed up for as long as 12 years. MAIN OUTCOMES AND MEASURES: Graft failure, defined as a regrafting procedure or a cloudy cornea for 3 consecutive months. RESULTS: The 10-year cumulative probability of graft failure was higher in participants with PACE than in those with Fuchs dystrophy (37% vs 20%; hazard ratio [HR], 2.1 [99% CI, 1.4-3.0]; P < .001) and in participants with a history of glaucoma before penetrating keratoplasty, particularly with prior glaucoma surgery (58% with prior glaucoma surgery and use of medications to lower intraocular pressure at the time of surgery vs 22% with no history of glaucoma surgery or medication use; HR, 4.1 [99% CI, 2.2-7.5]; P < .001). We found trends toward increased graft failure in recipients who were 70 years or older compared with those younger than 60 years (29% vs 19%; HR, 1.2 [99% CI, 0.7-2.1]; P = .04) or were African American (HR, 1.5; P = .11) or who had a history of smoking (35% vs 24%; HR, 1.6 [99% CI, 0.9-2.8]; P = .02). Lower endothelial cell density (ECD) and higher corneal thickness (CT) at 6 months (6% vs 41% for ECD ≥2700 vs <1700 cells/mm2 [P < .001]; 14% vs 36% for CT <500 vs ≥600 µm [P = .001]), 1 year (4% vs 39% for ECD ≥2700 vs <1700 cells/mm2 [P < .001]; 18% vs 28% for CT <500 vs ≥600 µm [P = .04]), and 5 years (2% vs 29% for ECD ≥1500 vs <500 cells/mm2 [P < .001]; 7% vs 34% for CT <550 vs ≥650 µm [P < .001]) were associated with subsequent graft failure. CONCLUSIONS AND RELEVANCE: Most penetrating corneal grafts for Fuchs dystrophy or PACE remain clear at 10 years. The risk for failure is greater for graft recipients with PACE and those with a history of glaucoma. Measurements of ECD and CT during the course of postkeratoplasty follow-up are associated with a risk for failure. However, even with very low ECD and high CT at 5 years, most corneas remain clear at 10 years.

Achromobacter xylosoxidans keratitis masquerading as recurrent erosion after LASIK.

PURPOSE: To describe the clinical stages and management of Achromobacter xylosoxidans keratitis with post-LASIK epithelial ingrowth in two patients. METHODS: Retrospective chart review. RESULTS: Both patients had been treated with topical antibiotics and corticosteroids for several weeks prior to presentation. Examination at presentation revealed significant areas of epithelial ingrowth without signs of acute inflammation, prompting an erroneous initial diagnosis of recurrent corneal erosion. A corneal infiltrate was eventually observed and A. xylosoxidans was cultured from both patients. Clinical resolution occurred with treatment consisting of topical fortified antibiotics. In one patient, the flap was lifted to obtain cultures and irrigate the stromal bed with fortified antibiotics. CONCLUSIONS: Post-LASIK epithelial ingrowth may have served as a risk factor for A. xylosoxidans infection. Classic signs of infectious keratitis were absent, delaying the diagnosis. Three clinical stages described herein may assist the clinician with diagnosis and customized management obviating the need for penetrating keratoplasty.

Effect of donor and recipient factors on corneal graft rejection.

PURPOSE: To assess the relationship between donor and recipient factors and corneal allograft rejection in eyes that underwent penetrating keratoplasty in the Cornea Donor Study. METHODS: Overall, 1090 subjects undergoing corneal transplantation for a moderate risk condition (principally Fuchs dystrophy or pseudophakic corneal edema) were followed for up to 5 years. Associations of baseline recipient and donor factors with the occurrence of a probable or definite rejection event were assessed in univariate and multivariate proportional hazards models. RESULTS: Eyes with pseudophakic or aphakic corneal edema (n = 369) were more likely to experience a rejection event than eyes with Fuchs dystrophy (n = 676) [34% ± 6% vs. 22% ± 4%; hazard ratio = 1.56; 95% confidence interval (CI), 1.21-2.03]. Among eyes with Fuchs dystrophy, a higher probability of a rejection event was observed in phakic posttransplant eyes compared with those that underwent cataract extraction with or without intraocular lens implantation during penetrating keratoplasty (29% vs. 19%; hazard ratio = 0.54; 95% CI, 0.36-0.82). Female recipients had a higher probability of a rejection event than male recipients (29% vs. 21%; hazard ratio = 1.42; 95% CI, 1.08-1.87) after controlling for the effect of preoperative diagnosis and lens status. Donor age and donor recipient ABO compatibility were not associated with rejection. CONCLUSIONS: There was a substantially higher graft rejection rate in eyes with pseudophakic or aphakic corneal edema compared to that in eyes with Fuchs dystrophy. Female recipients were more likely to have a rejection event than male recipients. Graft rejection was not associated with donor age.

Fungal keratitis with intracameral extension following penetrating keratoplasty.

PURPOSE: To report the clinical findings and management of a case of fungal keratitis with extension into the anterior chamber following penetrating keratoplasty. METHODS: Interventional case report. RESULTS: A 45-year-old man developed a white, cottonball-like mass in the anterior chamber 3 months after penetrating keraplasty for keratoconus. Cytology evaluation was performed following excisional biopsy of the intracameral portion of the lesion. The presence of filamentous fungus was confirmed. The patient was treated with oral, topical, and intracameral voriconazole with complete resolution of the infection 9 months after initial presentation. CONCLUSION: This case illustrates the unusual presentation of fungal keratitis with intracameral extension and demonstrates effective management with preservation of the corneal graft and restoration of visual function.

Polymicrobial keratitis: Acanthamoeba and infectious crystalline keratopathy.

PURPOSE: To report the early presentation, cause, and successful medical management of combined Acanthamoeba keratitis (AK) and infectious crystalline keratopathy (ICK). DESIGN: Interventional case series. METHODS: Retrospective review of 111 AK patients diagnosed and managed at the University of Illinois Eye and Ear Infirmary between June 1, 2003 and November 30, 2008 for an additional diagnosis of infectious keratitis. RESULTS: Of 5 AK patients with microbiologic evidence of an additional bacterial keratitis during their active AK treatment, concomitant ICK developed in 3 patients. All patients were examined within 3 weeks of their AK diagnosis and were found to have characteristic signs and symptoms consistent with ICK. Bacterial culture results at the time of AK diagnosis were negative in 2 patients, but subsequent culture results were positive for Streptococcus oralis. Initial culture results demonstrated light growth of methicillin-sensitive Staphylococcus aureus in the remaining patient, who had received partial antibiotic treatment. Topical corticosteroids were used before diagnosis in 2 patients and were in use in only 1 patient after AK diagnosis. All infections resolved with medical therapy alone. One patient later required penetrating keratoplasty for visual rehabilitation. CONCLUSIONS: In patients with AK, ICK can develop early and without either the use of corticosteroids or a preexisting epithelial defect, inconsistent with previously suggested mechanisms and major risk factors for secondary infection. Combined AK and ICK may exhibit increased pathogenicity with the onset of severe, often new, pain and acceleration of localized tissue loss and resultant scarring. Although early recognition and aggressive medical treatment were successful in resolving the combined infections in our cases, Acanthamoeba coinfection, and perhaps endosymbiosis, should be considered in the evaluation and clinical management of AK, especially in those cases progressing atypically. Further research is needed to understand the precise mechanism of the introduction of coinfectious pathogens and their role in the pathogenicity of AK.

Suture reaction masquerading as a conjunctival malignancy.

CASE REPORT: We report a case of conjunctival inflammation secondary to a retained suture masquerading as a neoplastic lesion. Excisional biopsy was performed in the right eye on a superior bulbar conjunctival lesion that appeared to be a conjunctival malignancy. A past history of ptosis surgery was obtained. Careful repeated examination with anesthesia, applying traction to the forniceal conjunctiva, revealed an occult polypropylene suture. Despite clinical features typical of malignancy, histologic examination revealed only chronic inflammatory cells. COMMENTS: Patients with suspicious conjunctival lesions and a history of ptosis surgery should be carefully explored for retained suture fragments. Examination with anesthesia may be needed to find an occult suture.

Pupil response to tropicamide following laser in situ keratomileusis.

PURPOSE: To investigate the effect of corneal thinning after laser in situ keratomileusis (LASIK) on the corneal penetration of topical eye medication. SETTING: Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA. METHODS: Laser in situ keratomileusis surgery was performed in 19 eyes of 10 patients enrolled in this prospective study. Measurements were made before surgery and 3 months postoperatively. After instillation of tropicamide 1%, the change in pupil size over time was measured with a Colvard pupillometer. Central corneal thickness (CCT) was measured with ultrasonic pachymetry before and 3 months after LASIK. The corneal epithelial condition was also examined by fluorescein dye staining. RESULTS: The mean CCT decreased significantly from 564 microm +/- 33 (SD) before LASIK surgery to 514 +/- 48 microm 3 months postoperatively (P<.0001). Pupil diameter 10, 15, and 20 minutes after tropicamide 1% instillation was significantly larger 3 months after surgery than preoperatively (P=.0083, P=.0043, and P=.0144, respectively). The mean time to reach a pupil diameter of 6.0 mm decreased significantly from 14.4 +/- 4.3 minutes in preoperative eyes to 11.5 +/- 2.3 minutes in postoperative eyes (P=.0281). Mild punctate corneal epithelial staining (fewer than 5 spots) were observed in 4 eyes at the 3-month postoperative examination. CONCLUSIONS: Pupil dilation after tropicamide 1% instillation was significantly faster after LASIK surgery. Corneal thinning that resulted from LASIK enhanced corneal penetration of tropicamide 1%.

Baseline donor characteristics in the Cornea Donor Study.

PURPOSE: The Cornea Donor Study (CDS) is an ongoing study that is being conducted to determine whether donor age is related to long-term corneal graft survival. Characteristics of the donor population have been evaluated with respect to donor age, endothelial cell density, and death to preservation interval. METHODS: Within the context of a prospective, double-masked, controlled trial, 1101 donor corneas were assigned without regard to donor age. RESULTS: Slit-lamp characteristics of the donor corneas showed little variation with donor age, except for the presence of corneal arcus. As death to preservation time decreased, fewer epithelial abnormalities and a lower frequency of stromal edema and Descemet folds were observed. There was little change in the mean of the endothelial cell density with donor age beyond age 60, despite variation. CONCLUSION: With respect to donor age, there was little difference in either the slit-lamp characteristics or endothelial cell density of the donor corneas. Fewer epithelial abnormalities were observed with shorter death to preservation time.

Predictive formula for calculating the probability of LASIK enhancement.

PURPOSE: To develop a formula to predict a patient's need for laser in situ keratomileusis (LASIK) enhancement. SETTING: Northwestern Laser Vision Center, Department of Ophthalmology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA. METHODS: In this retrospective study, charts of patients who received LASIK with the Visx Star excimer laser for myopia and myopic astigmatism were reviewed. Laser in situ keratomileusis enhancement was performed in 130 of 720 eyes. Variables such as age, keratometry, spherical power, power and axis of astigmatism, and surgeon factor were compared in patients who required retreatment and those who did not. Multivariate logistic regression analysis was used to determine a formula for the probability of enhancement surgery. RESULTS: Age (P<.0001), preoperative cycloplegic sphere (P<.0001), and surgeon (P<.0001) were the statistically significant factors for predicting retreatment. The predictive formula derived from these factors had a sensitivity of 79%, a specificity of 61%, and positive and negative predictive values of 31% and 93%, respectively. CONCLUSIONS: Older age, higher preoperative cycloplegic sphere, and surgeon significantly influenced a patient's likelihood for LASIK retreatment. A formula based on these predisposing factors helps to more accurately predict the need for retreatment.