Recurrence of Ocular Surface Squamous Neoplasia Treated With Excisional Biopsy and Cryotherapy.

PURPOSE: To evaluate the recurrence rate of ocular surface squamous neoplasias (OSSN) after excision and cryotherapy in an academic cornea practice and to determine factors associated with recurrence. DESIGN: Retrospective interventional case series. METHODS: All cases of OSSN from 1998 through 2013 that were treated with excisional biopsy and adjunctive cryotherapy were retrospectively reviewed. Clinical characteristics upon presentation including size of lesion, location, and atypical features were noted. All recurrences of OSSN after excision and cryotherapy were noted and categorized in relation to clinical characteristics, pathologic grade, and margin involvement. RESULTS: Forty-three cases of OSSN from 42 patients were analyzed with a median follow-up of 29 months. A total of 32.6% of subjects had dysplasia and 67.4% had squamous cell carcinoma (SCC). A total of 83.7% of subjects had both corneal and conjunctival involvement while 16.3% had conjunctival involvement only. Overall, 3 recurrences were observed, all of which had margin involvement; nonetheless, the majority of incompletely excised OSSN (25/28) showed no recurrence. The recurrence rate at 6 months was 2.3%. Recurrence at 1 year, 2 years, and 5 years remained stable at 7.1%. CONCLUSIONS: Excision with cryotherapy is an effective treatment for the majority of OSSN cases, even among cases with pathologic evidence of tumor at the margin, with an overall recurrence rate of 7.1% at 1 year, 2 years, and 5 years.

Clinical characteristics of Acanthamoeba keratitis infections in 28 states, 2008 to 2011.

PURPOSE: The aim was to describe a geographically and clinically diverse sample of cases of Acanthamoeba keratitis (AK) and establish the risk factors for poor outcomes among patients with this disease. METHODS: We conducted a retrospective, population-based case series of 116 patients with AK identified through a national surveillance network. Data were collected via a medical record review by diagnosing ophthalmologists and by phone interviews with patients. Exact logistic regression modeling was used to determine risk factors for poor visual outcomes. RESULTS: Among patients with data available on contact lens use, it was found that 93.3% wore contact lenses. The median time from symptom onset to care seeking was 2 days, whereas the median time from symptom onset to diagnosis was 27 days. Keratoplasty was performed in 27 of 81 patients with available outcome data and was more likely in patients >40 years old [odds ratio (OR) 5.25, 95% confidence interval (CI) 1.49-21.92]. When adjusted for age, the risk factors for keratoplasty included the presence of a ring infiltrate (OR 40.00, 95% CI 3.58-447.0) or any sign of stromal invasion (OR 10.48, 95% CI 2.56-55.09). One-third of patients with available data on best-corrected visual acuity had a best-corrected visual acuity <20/200, with the presence of a ring infiltrate as the only significant predictor of this outcome when adjusted for age (aOR 3.45, 95% CI 1.01-12.31). CONCLUSIONS: AK remains challenging to diagnose. Consequently, patients with advanced disease are more likely to have poor outcomes, particularly if they are older. The increasing awareness of AK among general eye care providers may shorten referral times and potentially improve outcomes.

Descemet stripping endothelial keratoplasty for the treatment of combined fuchs corneal endothelial dystrophy and keratoconus.

PURPOSE: To report the first case series of patients with Fuchs corneal endothelial dystrophy (FCD) and keratoconus (KCN) who underwent Descemet stripping endothelial keratoplasty (DSEK). METHODS: This is a retrospective case series of 6 eyes of 4 patients with combined FCD and KCN who underwent DSEK at 3 different centers. Clinical information collected included corneal topography measurements, central corneal thickness, and endothelial cell count. Visual outcomes and change in keratometric measurements were evaluated. RESULTS: The follow-up for patients ranged from 10 to 72 months. The best-corrected visual acuity was 20/40 or better in all 6 eyes. The mean keratometric measurements decreased in all cases (range of 0.5-5.8 diopters); however, topography still demonstrated an inferior steepening in each case. CONCLUSIONS: Patients with FCD and KCN have been previously reported as being managed with penetrating keratoplasty. We present 6 eyes of 4 patients who were managed with DSEK for the FCD. Topographically, the characteristic inferior steepening of KCN did not change; however, all patients with DSEK had flatter postoperative keratometric measurements with improved visual acuity. If a DSEK is performed for FCD before apical corneal scarring from KCN, a good visual outcome may be achieved.

Immunologic graft rejection in descemet's stripping endothelial keratoplasty and penetrating keratoplasty for endothelial disease.

OBJECTIVE: To evaluate and compare the cumulative incidence and risk factors for first-episode immunologic graft rejection in Descemet's stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PK) and to identify potential risk factors for rejection. DESIGN: Retrospective chart review. PARTICIPANTS: All patients who underwent PK or DSAEK for endothelial disease at the Department of Ophthalmology, North Shore LIJ, between January 2004 and June 2010. METHODS: One hundred sixty-nine PK cases and 122 DSAEK cases were reviewed. All patients had a minimum of 3 months of follow-up, with median follow-up of 36 months in the PK group and 29 months in the DSAEK group. MAIN OUTCOME MEASURES: Cumulative incidence of first-episode immunologic graft rejection in PK and DSAEK cohorts. Risk factors for graft rejection were reviewed. RESULTS: Cumulative incidence of rejection was not significantly different between the DSAEK and PK cohorts (P<0.1324). However, among patients without glaucoma, the risk of rejection in PK was higher than that in DSAEK (hazard ratio [HR], 5.56). Prior incisional glaucoma surgery imparted a 3.15 times greater risk of rejection regardless of transplant type. Phakic patients were more likely to experience rejection than patients with a posterior chamber intraocular lens (HR, 3.23; P<0.0266), but not more likely than those with an anterior chamber intraocular lens or who were aphakic. Graft failure occurred within 6 months in 31% of PK rejections and none of the DSAEK rejections. CONCLUSIONS: Descemet's stripping automated endothelial keratoplasty and PK did not show a statistically significant difference in the incidence of rejection; however, among nonglaucomatous eyes, there were significantly fewer rejections in those that underwent DSAEK.

Textural interface opacity after descemet stripping automated endothelial keratoplasty: a report of 30 cases and possible etiology.

PURPOSE: Descemet stripping automated endothelial keratoplasty (DSAEK) has its own set of complications including interface abnormalities. This case series presents the largest number of patients who developed textural interface opacity (TIO) at the graft-host interface after DSAEK. METHODS: This is a retrospective multicenter case series of 30 patients from 7 institutions with the finding of TIO. Clinical information collected included donor preparation details, recipient information, and surgical technique. Clinical outcomes included best-corrected visual acuity and status of TIO appearance at the last follow-up visit. Slit-lamp photographs were analyzed and compared. RESULTS: The majority of the patients (73%) had a best-corrected visual acuity of 20/40 or better. Four of the donor tissues were prepared with a microkeratome blade with the same lot number. Six patients had a central interface space between host and donor stromal surfaces--presumed interface fluid but potentially viscoelastic. A slight majority (57%) of patients had improvement in the severity of TIO, with 20% noted to have a complete resolution of TIO (mean follow-up of 11.9 months). Two clinical types of TIO were seen: an elongated type and a punctate type. CONCLUSIONS: Most patients with TIO after DSAEK obtain good visual outcomes. TIO spontaneously improves or even resolves during follow-up without intervention. The etiology of this condition is unknown, but we propose 2 different mechanisms. The elongated type could be secondary to an irregular cut of the donor with the microkeratome blade. The punctate type may be secondary to retained viscoelastic.

Spontaneous reattachment of Descemet stripping automated endothelial keratoplasty lenticles: a case series of 12 patients.

PURPOSE: To review 12 cases of postoperative detachment and spontaneous reattachment of Descemet stripping automated endothelial keratoplasty (DSAEK) lenticles. DESIGN: Retrospective, observational case series. METHODS: This was a review of patients undergoing DSAEK at 7 institutions. Patients who had a significant detachment of their DSAEK lenticle during the postoperative period were identified and divided into 2 groups. Significant detachment was defined as either complete central interface fluid with bare peripheral attachment (group 1) or a free-floating lenticle in the anterior chamber (group 2). Patients who subsequently had a spontaneous reattachment of the lenticle were identified, with data regarding surgical technique and intraoperative and postoperative complications collected for analysis. RESULTS: Our cohort consisted of 12 eyes of 12 patients who met the definition of significant postoperative detachment with subsequent spontaneous reattachment. Four patients had complete central detachment with peripheral attachment (group 1), whereas 8 patients had a free-floating lenticle (group 2). Ten of the 12 patients had a successful outcome as defined as an attached and clear DSAEK lenticle. In our study, reattachment was seen as early as 5 days and as late as 7 months after surgery, with reattachment in 9 of 12 patients by day 25. CONCLUSIONS: Spontaneous reattachment of detached DSAEK lenticles may occur during the postoperative period. The decision of when to bring the patient back for a rebubble ultimately must be made on a case-by-case basis.

Visually significant and nonsignificant complications arising from Descemet stripping automated endothelial keratoplasty.

PURPOSE: To examine the complications encountered after Descemet stripping automated endothelial keratoplasty (DSAEK) at one institution. DESIGN: Retrospective case review. METHODS: The first 126 consecutive DSAEKs done at the New York Eye and Ear Infirmary from March 1, 2006 to March 1, 2008 were reviewed. A total of 126 eyes of 113 patients underwent DSAEK. All cases were included regardless of outcome. All complications intraoperatively and postoperatively were recorded. RESULTS: Graft detachment was the most common complication, occurring in 22 eyes (17.5%); 17 of these (77%) were successfully repositioned. Idiopathic graft failure occurred in 15 eyes (6%). Other visually significant complications included graft rejection (2 eyes), choroidal effusion (2 eyes), epithelial ingrowth (2 eyes), endophthalmitis (1 eye), pupillary block (1 eye), and suture abscess (1 eye). Twenty-four eyes had non-visually significant complications including decentered lenticles, interface fibers, partial peripheral detachments, retained Descemet membrane, and eccentric trephination. CONCLUSIONS: While DSAEK is a viable alternative to penetrating keratoplasty, serious complications may still occur postoperatively. While certain rare complications like endophthalmitis, epithelial ingrowth, and suture abscess may affect vision, more common complications such as decentered lenticles and partial peripheral detachments are less likely to affect visual outcome.

The use of postoperative slit-lamp optical coherence tomography to predict primary failure in descemet stripping automated endothelial keratoplasty.

PURPOSE: To determine if central donor lenticle thickness as measured by slit-lamp optical coherence tomography (SL OCT; Heidelberg Engineering, Heidelberg, Germany) is predictive of primary donor failure in patients undergoing Descemet stripping automated endothelial keratoplasty (DSAEK). DESIGN: Retrospective cross-sectional study. METHODS: Eighty-four patients who underwent DSAEK surgery by 2 surgeons (D.C.R. and J.A.S.) were enrolled. At each postoperative visit (postoperative day 1, week 1, month 1, and month 2), an SL OCT scan was obtained. Statistical differences in SL OCT measurements of successful and failed DSAEK procedures were measured using the Student t test. A successful DSAEK surgery was defined as having an anatomically attached, clear recipient corneal stroma and donor lenticle compatible with good vision 2 months after surgery. A failed DSAEK surgery was defined as an attached donor lenticle with SL evidence of corneal edema and thickening visible at 2 months or more. RESULTS: Ninety-three eyes of 84 consecutive patients who underwent DSAEK surgery also underwent postoperative SL OCT. After 2 months of follow-up, 82 (88%) procedures were successful and 11 (12%) procedures were failures. The average donor lenticle thickness in successful DSAEK eyes was 314 +/- 128 microm on postoperative day 1 as compared with failed DSAEK eyes, which averaged 532 +/- 259 microm (P = .0013). This was independent regardless of whether the lenticle was attached on the first postoperative visit. Seventy-nine (98%) successful DSAEK eyes had a lenticle thickness of < or = 350 microm at the 1-week visit. All of the failed DSAEK eyes (11 eyes) had a lenticle thickness > or = 350 microm at the 1-week postoperative visit. Statistically significant differences in SL OCT thickness measurements were seen between successful and failed DSAEK cases at all examinations after postoperative week 1. CONCLUSIONS: Corneal thickness measurements made with SL OCT are an important predictor of DSAEK failure in both attached and detached lenticles within the first week of surgery. DSAEK lenticle thickness of 350 microm or less at 1 week had a predictability of success of more than 98%.

Atypical MRI features of intraorbital metastatic melanoma.

A 78-year-old man with a history of melanoma presented with a 2-week history of diplopia, pain, and intermittent blurriness in his right eye. Imaging showed a multicystic mass within the right lateral rectus muscle that was biopsy-proven metastatic melanoma. To our knowledge, this is the first case report of orbital metastasis from melanoma presenting as a multicystic mass intrinsic to the extraocular muscle with layering fluid-fluid levels.

Clinical significance of central corneal thickness in the management of glaucoma.

OBJECTIVE: To evaluate the effect of central corneal thickness determination on the clinical management of patients with glaucoma and glaucoma suspect. METHODS: A cross-sectional retrospective study was performed on 188 consecutive patients. Mean ultrasound pachymetry measurements of central corneal thickness and corresponding Goldmann applanation tonometry measurements were obtained. Intraocular pressures (IOPs) were corrected using linear and mathematical (Orssengo-Pye) algorithms. Measurement-significant outcomes were defined as an IOP adjustment of 1.5 mm Hg or greater and outcomes-significant results as an IOP adjustment of 3.0 mm Hg or greater. Changes in therapy such as the use of eyedrops and addition or cancellation of laser therapy or surgery were then noted for those individuals with measurement- or outcomes-significant changes. RESULTS: Using the linear correction scale, 105 (55.9%) of 188 patients had at least a measurement-significant adjustment in their IOP measurements: 67 (35.6%) had adjustments between 1.5 and 3.0 mm Hg, while 38 (20.2%) had an outcomes-significant IOP adjustment (> or =3.0 mm Hg). Among the 188 patients, 16 (8.5%) had a change in eyedrop therapy, 4 (2.1%) had a change regarding laser therapy, and 6 (3.2%) had a change in the decision regarding glaucoma surgery. Using the exponential correction (Orssengo-Pye) scale, similar percentages were obtained. CONCLUSION: Pachymetry-measured central corneal thickness has a significant effect on the clinical management of patients with glaucoma and glaucoma suspect.