[Corneal melting after ocular surgery in patients with auto-immune disorders]. / Immuunstromale corneale ulceratie na een oogoperatie bij patiënten met collageen-vasculaire auto-immuunaandoeningen.

Two women aged 78 and 74 years respectively, both with dry eyes due to underlying auto-immune disorders, presented after uncomplicated cataract surgery with immunostromal corneal ulceration. Intensive topical lubrication combined with systemic immunosuppressants were necessary to control the corneal melt. Dry eyes are a frequently-encountered problem among patients with rheumatoid disorders and increase the risk of corneal melting. Auto-immune related corneal melting can occur spontaneously or after ocular surgery, it threatens visual acuity and ocular integrity and may be associated with systemic vasculitis. When treating patients with rheumatoid disorders, the presence of dry eyes and the accompanying risk of serious complications need to be ascertained. In patients at risk, pre-operative preventive measures to suppress any underlying systemic disorders and improve the ocular environment are necessary. When corneal melting is diagnosed, aggressive topical therapy combined with systemic immunosuppressants is indicated.

The use of soft bandage contact lenses in the management of primary (localised non-familial) conjunctival amyloidosis: a case report.

We present a case of primary (localised non-familial) conjunctival amyloidosis, which is an uncommon condition, characterised by amyloid deposition within the substantia propria of the conjunctiva. Soft bandage contact lenses were fitted in order to protect the cornea from the mechanical abrasion of the irregular surface of the palpebral conjunctiva. We used non-ionic high water content (70%) soft bandage lenses from Filcon 4A with a Dk of 40. The lenses were well tolerated and gave significant relief of the symptoms.

Suture-related complications following keratoplasty: a 5-year retrospective study.

PURPOSE: To study the incidence of suture-related complications following penetrating keratoplasty (PK) and their effect on the success of corneal grafting. METHODS: The records of 332 patients receiving 361 grafts in 1993 and 1994 were reviewed, and suture-related complications were recorded. These complications were divided into five groups: suture erosions, infiltrates at the suture sites, infectious keratitis, loose sutures with imminent wound dehiscence, and wound dehiscence after suture removal. RESULTS: Occurrence rates were suture erosions, 10.8%; infiltrates, 9.4%; infectious keratitis related to sutures, 3.3%; loose sutures with imminent wound separation in need of surgical repair, 8.3%; and wound dehiscence following suture removal, 2.4%. CONCLUSIONS: Suture-related complications frequently occur after PK. Infectious keratitis and wound separations needing surgical repair may lead to loss of best-corrected visual acuity due to scarring, induced allograft reactions, and/or increased astigmatism. Recommendations for post-PK suture management are proposed.

A quick surgical technique for deep, anterior lamellar keratoplasty using visco-dissection.

PURPOSE: To describe a new surgical technique for deep, anterior lamellar keratoplasty using a viscoelastic for dissection of Descemet's membrane (DM) from the posterior stroma. METHODS: Through a paracentesis, aqueous was exchanged by air to visualize the posterior corneal surface-i.e., the air-to-endothelium interface. Using the interface as a reference plane, a 30 gauge needle was inserted into the cornea to just anterior to DM. Viscoelastic was injected to separate DM from the posterior stroma, and a recipient, anterior lamella was excised. A full-thickness donor button was sutured into the recipient bed, after stripping its DM. RESULTS: In 25 eye bank eyes, the procedure could be completed in 20 eyes; in 5 eyes, DM ruptured during visco-dissection. With light microscopy, dissection depth was located at the level of DM. In two patient eyes the procedure could be completed. In a third patient eye DM ruptured during visco-dissection, and the procedure was converted into a penetrating keratoplasty. CONCLUSION: Using visco-dissection, a lamellar keratoplasty can be performed quickly, with the donor-to-recipient interface just above the recipient DM, i.e., with a nearly perfect anatomical replacement of all corneal stroma. There is substantial risk of rupture or microperforation of DM during surgery.

Incidence of contact-lens-associated microbial keratitis and its related morbidity.

BACKGROUND: The incidence of contact-lens-associated microbial keratitis is uncertain and its related morbidity in the general population of contact-lens wearers is not known. We examined these issues in a prospective epidemiological study. METHODS: We surveyed all practising ophthalmologists in the Netherlands to identify all new cases of microbial keratitis reported during a 3-month period in 1996. Follow-up telephone calls were made to examine ocular morbidity. We undertook annual nationwide telephone surveys between 1994 and 1997 to estimate the prevalence of contact-lens wear. FINDINGS: Of 440 ophthalmologists contacted, 379 provided information. There were 92 cases of microbial keratitis; 17 used daily-wear rigid gas-permeable lenses, 63 daily-wear soft lenses, and 12 extended-wear soft lenses. The estimated annualised incidence of microbial keratitis was 1.1 per 10,000 (95% CI 0.6-1.7) users of daily-wear rigid gas-permeable lenses, 3.5 per 10,000 (2.7-4.5) users of daily-wear soft lenses, and 20.0 per 10,000 (10.3-35.0) users of extended-wear soft lenses (p<0.00001 for comparison between all groups), Five of the 92 patients achieved a final visual acuity of 20/70 or less. Pseudomonas and Serratia spp were the organisms most commonly isolated. Pseudomonas keratitis accounted for the largest mean diameter of corneal ulcers, the highest mean number of days in hospital, the greatest number of mean outpatients visits, and the poorest visual acuity outcome. INTERPRETATION: The incidence of microbial keratitis among users of extended-wear soft contact lenses in the Netherlands is similar to that reported in the USA during 1989. Awareness of risk factors and improvement in contact-lens materials have not led to a decrease in incidence. Overnight wear should be strongly discouraged.

The future of lamellar keratoplasty.

New surgical techniques in lamellar keratoplasty, including phototherapeutic keratectomy, automated lamellar keratectomy, plano-epikeratoplasty, deep anterior lamellar keratoplasty, combined amniotic membrane and limbal transplantation, large-diameter corneoscleral lamellar keratoplasty, and posterior lamellar keratoplasty, have recently become available. These procedures broaden the array of treatments for corneal disorders and may be used as alternatives to penetrating keratoplasty.

A new rigid gas-permeable semi-scleral contact lens for treatment of corneal surface disorders.

Some extreme corneal irregularities cannot be treated adequately with corneal contact lenses. For such cases a rigid semi-scleral lens can be prescribed. We evaluated the use of a highly gas permeable rigid semi scleral lens in patients with diseased corneas for whom conventional contact lens strategies had failed. Twenty two patients (29 eyes) were successfully fitted with individually manufactured semiscleral lenses. Corneal hypoxia, which has previously limited the use of polymethylmethacrylate (PMMA) scleral contact lenses, did not occur. The semi scleral lenses were well tolerated. Two cases were selected to illustrate the fitting of these lenses.

Influence of topical human epidermal growth factor on postkeratoplasty re-epithelialisation.

AIM: To test the efficacy and safety of recombinant human epidermal growth factor (hEGF) on corneal re-epithelialisation following penetrating keratoplasty. METHODS: A prospective, randomised, placebo controlled study was carried out in which patients were matched for diagnosis and received either hEGF ophthalmic solution (30 micrograms/ml or 100 micrograms/ml) or placebo in a double masked fashion. Matched pairs of patients received donor corneas from the same donor and were operated by the same surgeon on the same day. At the end of surgery all donor epithelium was removed mechanically. Patients were examined twice daily and fluorescein stained photographs were taken until the epithelium had closed. The area of the defect was measured by planimetry of the fluorescein stained defect on the photographs. RESULTS: There were no significant differences in re-epithelialisation of the donor cornea between the placebo group and the group treated with 30 micrograms/ml hEGF. Time until complete closure was slightly longer with 100 micrograms/ml hEGF compared with 30 micrograms/ml hEGF and with placebo. Mean healing rate of the epithelial defect with 100 micrograms/ml hEGF was significantly slower than in the other groups. CONCLUSION: No significant acceleration of corneal re-epithelialisation was demonstrated with the use of recombinant hEGF after penetrating keratoplasty in humans.

Newly acquired herpes simplex virus keratitis after penetrating keratoplasty.

BACKGROUND: After penetrating keratoplasty for reasons unrelated to herpes simplex virus (HSV) keratitis, any nonspecific epithelial defect may still be caused by HSV. The purpose of this study is to determine the incidence of newly acquired herpetic keratitis and to assess contributing factors. METHODS: The authors retrospectively studied the results of 2398 penetrating keratoplasties performed between 1980 and 1995. Three typical case histories are discussed. RESULTS: Of 2112 patients in whom the primary diagnosis was not related to HSV keratitis, 18 presented with epithelial herpetic keratitis in their corneal graft. The incidence of newly acquired herpetic keratitis after penetrating keratoplasty was 1.2 per 1000 person-years. In most cases, the infection occurred in the first 2 years after the transplantation. Most often, well-known reactivating stimuli could have caused the HSV infection. CONCLUSIONS: Herpes simplex virus keratitis may develop after penetrating keratoplasty even without a clinical history of HSV in the host. Thus, HSV should be considered in the differential diagnosis of a postpenetrating keratoplasty epithelial defect. The high incidence of this infection in the first 2 years after such surgery suggests a causal relation between corneal transplantation and the HSV infection.

Crohn's colitis and the cornea.

Ulcerative colitis (Crohn's disease) is a chronic relapsing inflammatory bowel disease of unknown etiology. The most common ocular complications include conjunctivitis and uveitis, particularly iritis. Herein, we describe a patient who had a decrease in visual acuity due to an increasing astigmatism. This was accompanied with a peripheral limbal thinning of the cornea and faint confluent corneal changes. No systemic activity was present during the period that the patient was monitored. Changes of astigmatism were followed up with videokeratography. This apparatus monitors changes in clinical course accurately and makes comparison possible between separate visits.

Triple procedure; analysis of outcome, refraction, and intraocular lens power calculation.

AIMS: A total of 97 triple procedures performed over a 6 year period were studied retrospectively to determine the best approach to calculate intraocular lens power. METHODS: The cases were divided into two diagnostic categories. RESULTS: After 1 year best corrected visual acuity was 20/40 or better in 37.5% of the cases of the 'modified group'. This group consists of patients with the diagnosis Fuchs' dystrophy, non-guttate endothelial dystrophy, and Reis-Buckler dystrophy. Analysis of visual acuity was made using logMAR. A final postoperative refraction within 2 dioptres of predicted refraction was achieved in 76.5% of patients in the modified group. CONCLUSION: In future, in the absence of a keratometry, a keratometry value of 7.49 mm will be used for calculation of the power of the implant as analysed in this study.

Toxic keratopathy due to the accidental use of chlorhexidine, cetrimide and cialit.

Due to economical reasons some ophthalmologists are using an irrigating solution made by the hospital pharmacy instead of the commercially available solutions. These irrigating solutions come in bottles which are identical to the ones used for other solutions. During the last three years bottles were accidentally mixed up five times. Consequently, bottles containing solutions such as chlorhexidine, cetrimide, chlorhexidine/centrimide and cialit solutions were used during cataract surgery. This resulted in immediate corneal edema which, in its turn resulted in a bullous keratopathy. Four patients underwent a penetrating keratoplasty. In one patient the cornea was covered with a conjunctival flap. Light microscopy of the corneas included epithelial edema, loss of keratocytes, and a disrupted and sometimes absent endothelial cell layer.

Iris claw lens: anterior and posterior iris surface fixation in the absence of capsular support during penetrating keratoplasty.

BACKGROUND: Intraocular lens implantation in eyes with pseudophakic or aphakic corneal edema and insufficient posterior capsular support presents a surgical challenge. The iris claw lens has the advantage that it can be fixated to the iris without sutures because the peripheral iris is incarcerated between the claws. METHODS: We present the results of a study with implantation of an iris claw lens in combination with penetrating keratoplasty in 19 eyes of 19 patients with pseudophakic or aphakic corneal edema which lacked posterior capsular support. The lens was fixated on the anterior iris surface (12 eyes) or posterior iris surface (seven eyes). RESULTS: Mean follow-up time was 11.8 months (7 to 21 months). All grafts remained clear. One patient was lost for follow up after 3 months. Visual acuity improved in 83% of the patients. Twenty-eight percent of the patients had a visual acuity of > or = 20/40. Complications such as pigment dispersion, glaucoma, peripheral synechiae, and lens decentration were rare. CONCLUSIONS: We feel iris claw lens implantation combined with penetrating keratoplasty is a safe alternative to achieve pseudophakia in eyes with corneal edema and inadequate posterior capsular support.

Extreme temporary thinning after keratoplasty of organ-cultured corneas.

Many investigators have measured corneal thickness after keratoplasty using organ culture and storage mediums. Values for corneal thickness were found to stabilize 6-12 months postoperatively, reaching normal values. We followed 59 corneal transplant recipients whose donor tissue was obtained from organ culture (average preservation time 13 days) for > 1 year retrospectively. The overall graft survival was 95.3%. The graft was thick in the early postoperative period. It subsequently became thinner, reaching the lowest level 5-9 months postoperatively (mean 0.48 mm, SD 0.04). After this period the corneas gradually became thicker and reached the normal corneal thickness. The extreme thinning of transplanted corneas in the first postoperative year has not been described before. We found a negative correlation between conservation time and thickness 5-9 months postoperatively. We postulate that organ culture may have a high impact on keratocyte function.

Pupillary membrane after cataract extraction with posterior chamber lens in glaucoma patients.

Deposition of a fibrin-like material leading to a membrane in the pupillary opening is described in glaucoma patients following extracapsular cataract extraction and intraocular lens implantation. The fibrinoid reaction was observed in 4 out of 57 eyes (7%), all operated on within two years by the same surgeon (CTL). The fibrinoid reaction appeared 2 to 15 days postoperatively in glaucoma patients on whom iridoplasty or synechiolysis had been performed during surgery. It seems advisable to give such patients long-acting subconjunctival steroids at the end of the operation.