Eye patching after cataract surgery is associated with an increased risk of short-term corneal oedema.

PURPOSE: To evaluate the effect of postoperative eye patching after routine cataract surgery on corneal oedema and visual acuity on the first postoperative day. SETTING: One public healthcare centre. DESIGN AND METHODS: This randomized controlled trial included patients undergoing uneventful cataract surgery in one medical centre. Patients were randomized into two groups: the surgical eye was patched with a single dose of a local steroid and antibiotic for 24 hr in the first group, and a plastic shield was used in the second with local steroid and antibiotic drops. The eyes were examined preoperatively and on the first postoperative day. Examination included the following: best-corrected visual acuity (BCVA), full slit lamp examination, intraocular pressure (IOP), anterior chamber depth (ACD) and central corneal thickness (CCT) using the IOL Master 700 (Zeiss, Germany). Cumulative dissipated energy (CDE) and operation time were recorded for all cases. RESULTS: One hundred eyes of 100 patients were included in the study. The postoperative increase in CCT 24 hr after surgery was 138 and 70 µm in the patched group as compared to the non-patched group, respectively (p = 0.001). Best-corrected visual acuity (BCVA) on the first postoperative day was 0.5 ± 0.45 LogMAR and 0.3 ± 0.3 LogMAR in the patched and non-patched group, respectively (p = 0.01). There was no difference in CDE (11.33 ± 9.2 and 10.22 ± 7.3; p = 0.94) between the two groups. CONCLUSIONS: Eye patching after routine cataract surgery is associated with an increase in corneal oedema and slower visual recovery on the first postoperative day.

Corneal Decompensation in Uveitis Patients: Incidence, Etiology, and Outcome.

Purpose: To identify the prevalence, etiology, management and visual outcomes of treatment in uveitis-related corneal decompensation.Patients and methods: This is a retrospective study of patients with corneal decompensation identified from a large cohort with uveitis in a tertiary referral clinic setting.Results: Between March 1991 and May 2018, 4132 new patients with uveitis were seen in Manchester Uveitis Clinic. Of these, 25 patients (0.6%) were identified with corneal decompensation of which 9 (0.2%) were affected bilaterally (total 34 eyes). The mean interval between uveitis diagnosis and decompensation was 23 months (range 0-117 m). Ten patients (41%) had associated glaucoma. Seventeen eyes (50%) had undergone intraocular surgery prior to decompensation. For eyes with no history of raised intraocular pressure or intraocular surgery, keratouveitis (presumed autoimmune or tuberculous) was the most common cause of corneal decompensation. Fourteen eyes (41%) required corneal graft and of these, five required repeat grafting.Conclusions: Corneal decompensation in eyes with uveitis is a rare but significant complication. Direct endothelial inflammation may alone cause decompensation, but in most eyes with uveitis, prior raised intraocular pressure or intraocular surgery are required to precipitate the cornea into decompensation. Outcomes of corneal transplantation in this group may be disappointing.

Application of Vitamin E + Coenzyme Q Therapy During FAKO + IOL Implantation.

INTRODUCTION: Cataract surgery is a widely used procedure around the world. After cataract surgery, one of the important points is that oxidative stress may cause postoperative corneal edema and vision loss. AIM: In this study, we aim to reduce the oxidative stress and related conditions that may develop during intraoperative and postoperative FAKO + IOL implantation. MATERIAL AND METHODS: Total amount of 32 patients with cataract were included to the study. The patients were classified as two groups randomly and the same surgical procedure was applied to the patients in both groups, except using visudrop. Group I was defined as a control group and routine FAKO + IOL implantation surgery was performed. In Group II, after the sideport was opened at the beginning of the operation, 0.5 cc visudrop (coenzyme q + vitamin E + hypermellosis) was given to the anterior camara. After the operation, 0.5 cc visudrop was also given to the anterior camara. Postoperative examination findings were compared statistically. RESULTS: In Group II, postoperative 1st day and postoperative 7th day visual acuities were significantly higher than in Group I. In Group II, postoperative 1st day and postoperative 7th day visual acuity increments were significantly higher than in Group I. In Group I, postoperative 1st day and 7th day pachymetry value increments were significantly higher than in Group II. CONCLUSION: Using visudrop during the FAKO + IOL implantation may be an effective method for postoperative corneal edema and vision.

Correlation between age and corneal edema in pediatric patients with Peters anomaly.

PURPOSE: To evaluate corneal edema in different-aged pediatric patients with Peters anomaly and to correlate in vivo with ex vivo histopathologic findings. METHODS: A retrospective cross-sectional study was performed. The medical records of patients diagnosed with Peters anomaly who underwent examination under anesthesia (EUA) between 2011 and 2015 were reviewed. Eyes in which central corneal thickness (CCT) measurements were taken were included. The thickest point in the CCT pachymetric map was used to objectively quantify corneal edema. Correlation between CCT and age was calculated. Additionally, a retrospective review of histopathologic studies of excised corneal buttons from pediatric eyes with Peters anomaly between 2011 and 2015 was performed. RESULTS: Eighteen eyes of 12 children were included. Mean age was 14 ± 15 months, and mean CCT was 842 ± 304 µm. A significant inverse correlation was noted between the CCT and the age of the patients, with lower CCT values in older children (r = 0.6; P = 0.01). Seven excised corneal buttons that underwent penetrating keratoplasty were reviewed. All corneal buttons showed absence of Descemet membrane and localized absence of endothelium. However, three specimens showed presence of corneal endothelium in areas of absent or attenuated Descemet membrane. CONCLUSIONS: In Peters anomaly, the CCT decreases with age, possibly due to a decrease in corneal edema. Histopathologic studies show cases of endothelial expansion in areas of absent or attenuated Descemet membrane. This may contribute to improved endothelial function and decreased edema with age.

[Manual small incision cataract surgery: Experience of a regional eye care service in Togo]. / La chirurgie de la cataracte à petite incision manuelle : experience d'un service régional de soins oculaires au Togo.

In order to fight against blindness in the central region of Togo, a project was implemented in a partnership between the Ministry of Health and an international Non-Governmental Organization: the Swiss Red Cross. Cataract surgery underwent an annual audit of the research-action type, in order to improve the functional results of patients. One of the recommendations of these audits was the introduction of manual small incision surgery in place of the classic extracapsular technique. This study had for its objective to evaluate the functional results and follow-up of patients undergoing the new technique compared with quality standards of cataract surgery according to the World Health Organization. This study was carried out by retrospective analysis of records and operative reports of patients over twenty years of age undergoing manual small incision cataract surgery from June 2012 to June 2015. Out of a total of 1292 patients undergoing cataract surgery in the five districts covered by the project during the same period, 1003 patients met the inclusion criteria (77.63 %). Among the 1003 cases, 504 (50.25 %) were male, while 499 (49.75 %) were female. The overall mean age was 62 years. The cataract was total in 84.65 % of cases and partial in 15.35 % of cases where visual acuities were quantifiable. Postoperative complications were dominated by corneal edema (22 %). On the first postoperative day, the good results (visual acuity≥3/10), the average results (visual acuity between 3/10 and 1/10) and the poor results (visual acuity<1/10) were respectively 41.2 %, 50.60 % and 8.2 % without optical correction, changing to 64.40 %, 28.90 % and 6.70 % after optical correction. Between the first and third week, 855 patients (85 %) were seen again. The good, average and poor results were respectively 61.90 %, 35.70 % and 2.40 % without correction, going to 85.30 %, 12.70 % and 2 % after optical correction. Among the 85.30 % good results, 53 % had a visual acuity≥5/10. Residual ametropias are the main cause of poor functional results and the introduction of biometry can contribute to their improvement. Cataract surgery through a well-controlled manual small incision is a promising alternative to the technique of choice, phacoemulsification, which is not yet widely accessible in our low-income countries.

Population-based Incidence of Intraocular Lens Exchange in Olmsted County, Minnesota.

PURPOSE: To determine the population-based incidence of pseudophakic intraocular lens exchange in Olmsted County, Minnesota. DESIGN: Retrospective review of a population-based cohort. METHODS: Patients undergoing pseudophakic intraocular lens exchange in Olmsted County, Minnesota, between January 1, 1986 and December 31, 2016 were identified from the Rochester Epidemiology Project medical record linkage system. Indications and outcomes were determined, and the incidence rate was calculated as cases per 1 000 000 person-years. Poisson regression analysis was used to assess changes in incidence over time, and the cumulative probability of needing a lens exchange was estimated by Kaplan-Meier analysis. RESULTS: Eighty cases of intraocular lens exchange were identified, yielding an overall age- and sex-adjusted incidence rate of 28.4 per million (confidence interval [CI], 22.1-34.7), which increased over the study period (P = .04). The 30-year cumulative probability of intraocular lens exchange among patients undergoing cataract surgery was 1.5% (CI, 0.6%-2.4%), increasing at a relatively constant rate. Dislocated lenses accounted for 72.5% of lens exchanges. Unplanned refractive outcome of primary cataract surgery and uveitis-glaucoma-hyphema syndrome from squared-edged haptics emerged as newer indications for intraocular lens exchange. CONCLUSIONS: The population-based incidence of pseudophakic intraocular lens exchange has increased over the last 30 years, and can be explained by the increase in incidence rate of cataract surgery over the same period. Surgeons should be aware of emerging indications of intraocular lens exchange, which reflect changes in lens design and increasing expectations of refractive outcomes.

Amantadine Use as a Risk Factor for Corneal Edema: A Nationwide Cohort Study in Taiwan.

PURPOSE: To evaluate the association between amantadine use and corneal toxicity in a nationwide population. DESIGN: Retrospective cohort study of nationwide population-based administrative database. METHODS: This study analyzed data in the Taiwan Longitudinal Insurance Database for a group of 8195 patients diagnosed with Parkinson disease during a 15-year period (January 1, 1996 to December 31, 2010). A control group of 8195 patients without Parkinson disease was randomly matched with the Parkinson group by age, sex, and comorbidity index. The Kaplan-Meier method was used to calculate the cumulative incidence of corneal edema. Incident rate ratios and Cox proportional hazard regressions were estimated to compare the risk of corneal edema. The same methods were then used to compare the risk between patients with and without amantadine treatment. RESULTS: The incidence of corneal edema in the Parkinson group (123 patients; 1.50%) was significantly higher than that in the control group (82 patients; 1.0%) (P = .004). The incidence ratio for corneal edema in the Parkinson group vs the controls was 5.77. When the Parkinson group was further subgrouped by use and non-use of amantadine, the hazard ratio for corneal edema was 1.79 times higher in the amantadine subgroup. Analyses of the amantadine subgroup by cumulative dose revealed that the 30-day hazard ratio for corneal edema was 2.05 higher in patients given moderate doses (2000-4000 mg) of amantadine and 2.84 times higher in the subgroup of patients given high doses (>4000 mg). CONCLUSIONS: Amantadine increases the risk of corneal edema in a dose-dependent manner.

Transient Corneal Edema After Phacoemulsification.

OBJECTIVE: To determine the association between pre-operative and intra-operative factors leading to transient corneal edema after phacoemulsification. STUDY DESIGN: Cohort study. PLACE AND DURATION OF STUDY: Department of Ophthalmology, Shifa Foundation Community Health Centre, Islamabad, from October 2011 to September 2012. METHODOLOGY: Patients undergoing phacoemulsification and Intraocular Lens (IOL) implantation were enrolled in the study using consecutive non-probability sampling. Pre-operative risk factors including peripheral corneal degenerations, the type and density of cataract were documented. Surgical risk factors included the incision site, the type of intraocular lens, the phacotechnique and the phacopower time. Postoperatively the patients were assessed for corneal clarity and the degree of striate keratopathy. Statistical analysis was done using SPSS version 17. RESULTS: There were 43% male and 57% female patients (n = 182). Mean age was 58.92 ± 13.00 years (median and mode-60 years). Factors which increased the risk of transient corneal edema after phacoemulsification included hypertension (p = 0.022), dense nuclear cataracts (p=0.006), divide and conquer technique (p = 0.008), duration of phacopower use (p < 0.001) and peripheral corneal degenerations (p < 0.001). CONCLUSION: Patients with peripheral corneal degenerations and dense nuclear cataracts had significantly higher rates of postoperative corneal edema. Use of phaco-chop technique and less phaco-power time helps in decreasing corneal edema.

Long-term trends and outcomes of anterior vitrectomy in Western Australia.

PURPOSE: To describe trends, risk factors and outcomes of anterior vitrectomy during cataract and intraocular lens (IOL) surgery. METHODS: All patients 16 years and older undergoing cataract and IOL surgery in Western Australia (WA) from January 1980 to December 2001 (n = 115 815) were included. Hospital administrative data were used to identify all cataract and IOL procedures and subsequent admissions for retinal detachment, IOL dislocation, endophthalmitis and pseudophakic corneal oedema. Data were validated with chart review and analysed to identify trends and risk factors for anterior vitrectomy and the risk of subsequent complications. RESULTS: In total, 1390 (1.2%) anterior vitrectomies were performed. The rate increased with change in surgical technique. Significant risk factors for anterior vitrectomy were age <50 years (OR 1.31), male sex (OR 1.23), IOL procedure (OR 11.45) and operations in public hospitals (OR 1.99) or rural/remote (OR 1.40) areas. Anterior vitrectomy was strongly associated with increased risk of retinal detachment (RD) (RR 18.5), endophthalmitis (RR 3.6), IOL dislocation (RR 21.1) and pseudophakic corneal oedema (RR 17.3). Retinal detachments and IOL dislocations occur earlier after anterior vitrectomy. CONCLUSION: Anterior vitrectomy rates have remained stable since the introduction of phacoemulsification. Anterior vitrectomy is a major risk factor for serious complications compared with uncomplicated surgery, particularly RD and IOL dislocation. We identified an increasing trend in anterior vitrectomy being performed during extracapsular and IOL surgery.

Acute corneal hydrops in keratoconus - new perspectives.

PURPOSE: To summarize the current concepts and recent literature regarding the epidemiology, pathogenesis, imaging modalities, and treatment of acute hydrops in keratoconus. DESIGN: Perspective. METHODS: Review and synthesis of selected literature, with interpretation and perspective. RESULTS: Acute corneal hydrops is an incompletely understood complication of keratoconus, characterized by marked corneal edema caused by a break in Descemet membrane, allowing aqueous to enter the corneal stroma and epithelium. Although usually self-limiting, with clinical signs of edema typically resolving after 3 months, it often leaves a vision-impairing scar, necessitating and expediting the need for corneal transplantation. Studies have identified risk factors for developing acute hydrops. Modern imaging modalities such as ultrasound biomicroscopy, anterior segment optical coherence tomography, and in vivo confocal microscopy have enlightened us to the microstructural changes that take place during acute hydrops, the factors that influence its duration, and sequelae. Newer treatment regimens have seen a reduction in the duration of corneal edema during acute hydrops, and have improved the survival of corneal grafts after transplantation for resolved hydrops. CONCLUSIONS: Effective management of acute corneal hydrops in keratoconus is based on recognizing and addressing the risk factors, treating the acute event effectively and promptly to reduce the duration of edema and its complications, and, ultimately, successful corneal transplantation with acceptable long-term graft survival rates. Improved in vivo imaging of the cornea during acute hydrops has led to an enhanced understanding of the pathogenesis and ultrastructural changes of the condition, and in turn has resulted in improved management of the disease.

Evolving indications for and trends in keratoplasty in British Columbia, Canada, from 2002 to 2011: a 10-year review.

PURPOSE: The aim of this study was to report the evolving indications for keratoplasty and the shift in the type of keratoplasty performed in British Columbia, Canada, over a 10-year period from 2002 to 2011. METHODS: This was a retrospective database review of all the records of corneal transplant tissues at the Eye Bank of British Columbia, Canada, from January 2002 to December 2011. The patient demographics, indications, and types of transplant performed were analyzed. RESULTS: A total of 4843 corneal transplants were performed in 3742 patients (1968 male and 1774 female) from January 2002 to December 2011. The number of keratoplasties performed ranged from 420 in 2008 to 578 in 2011. The top 4 indications over the 10-year period were Fuchs endothelial dystrophy (FED; 18.9%), aphakic/pseudophakic bullous keratopathy (17.4%), regraft (17.1%), and keratoconus (15.5%). Penetrating keratoplasty (PKP) accounted for 86.5% (4191 transplants) of all keratoplasties performed. Since the introduction of Descemet stripping automated endothelial keratoplasty (DSAEK) in 2007, there was a significant increase in the number of DSAEKs (P < 0.0001) performed and a statistical decline in the number of PKPs (P < 0.0001) performed. Despite only 30 deep anterior lamellar keratoplasties being performed, an increasing trend was observed after 2008 (P = 0.0087). A decreasing trend in PKPs and an increasing trend in DSAEKs were observed for surgeries performed for FED, aphakic/pseudophakic bullous keratopathy, and regraft. CONCLUSIONS: FED has become the top indication for performing a keratoplasty over the 10-year period. There was a shift from PKP to DSAEK performed for endothelial failure. Although the number of deep anterior lamellar keratoplasty surgeries was small, there was a significant increasing trend.

Pseudophakic/aphakic corneal edema--morphometric predisposing factors analysis based on the fellow eye examination.

PURPOSE: To find morphometric factors predisposing to the development of corneal decompensation following cataract surgery. MATERIAL AND METHODS: Study group consisted of 50 patients after keratoplasty performed as pseudophakic/aphakic corneal edema (PCE/ACE) treatment. Control group formed 50 patients after cataract removal without signs of corneal decompensation. Specific subgroups were analyzed too. The morphometric data of the fellow eye anterior chamber were obtained with Visante OCTTM. RESULTS: Anterior chamber depth and anterior chamber angle width were significantly smaller in study group (p < 0.00001, U-test). With excluded preoperative risk factors: Fuchs dystrophy, acute angle closure glaucoma attack history the significant differences were also observed (p < 0.01). In Fuchs' dystrophy and intraoperative complication subgroups comparison these two anterior chamber parameters were smaller too (p < 0.001). Anterior chamber width was also smaller in study group with p = 0.001. Central corneal thickness was higher in study group with p = 0.013. After exclusion of patients with Fuchs' dystrophy there was no difference in comparison (p = 0.34). The difference in total axial length comparison was insignificant (p = 0.18). Relative anterior microphthalmos was diagnosed in 31 patients of study group (62%) and in 17 of control (34%). CONCLUSIONS: Small anterior chamber dimensions and higher central corneal thickness due to Fuchs' dystrophy are factors influencing the risk of PCE/ACE development.

Effects of intracameral administration of α-chymotrypsin on intracapsular lens extraction and postoperative outcome in clinically normal dogs.

OBJECTIVE: To assess the intraoperative and postoperative clinical effects and histologic effects of intracameral administration of α-chymotrypsin in clinically normal dogs undergoing standard intracapsular lens extraction (ICLE). ANIMALS: 6 young adult male dogs without evidence of systemic or ocular disease. PROCEDURES: All dogs underwent bilateral ICLE 7 minutes following injection of 75 U of α-chymotrypsin or an identical volume (0.5 mL) of a commercially available balanced saline solution (BSS) into the posterior chamber of the eye. Ease of lens extraction was subjectively assessed and intraoperative intraocular hemorrhage and fibrin accumulation scored. For 27 days after surgery, ocular hyperemia and discharge, chemosis, corneal edema, hyphema, and aqueous flare were scored, and intraocular pressure (IOP) was measured. Thirty days after surgery, histologic evidence of anterior synechia, collapse of and inflammation within the iridocorneal angle, and iritis were scored. RESULTS: In 5 of 6 dogs, the surgeon was able to correctly identify the eye treated with α-chymotrypsin on the basis of ease of lens extraction. Mean intraoperative intraocular hemorrhage and fibrin scores for BSS-treated eyes were significantly higher than for α-chymotrypsin-treated eyes. Postoperatively, there were no significant differences between treatments for any clinical variables, including IOP Histologic scores were not significantly different between treatments for any variable. Vision was lost as a result of glaucoma in 1 α-chymotrypsin-treated eye and 1 BSS-treated eye. CONCLUSIONS AND CLINICAL RELEVANCE: Intracameral administration of 75 U of α-chymotrypsin 7 minutes before ICLE facilitated lensectomy without apparent adverse effects in clinically normal dogs.

Indications for penetrating keratoplasty and associated procedures, 2001-2005.

PURPOSE: To identify current indications and trends in indications for penetrating keratoplasty (PKP) and associated procedures. METHODS: Retrospective chart review of all patients who underwent PKP at Wills Eye Institute from January 1, 2001, to December 31, 2005. RESULTS: A total of 1,162 cases were performed in this 5-year period. Leading indications for PKP were pseudophakic corneal edema (PCE) in 330 (28.4%) cases, followed by regraft in 250 (22.0%), keratoconus in 186 (16%), and Fuchs' endothelial dystrophy in 126 (10.8%) cases. Of the 330 cases of PCE, 232 (70.3%) were associated with posterior chamber intraocular lenses (PCIOLs) and 96 (29.1%) with anterior chamber lenses. In 330 eyes with PCE, the lens was not exchanged in 246 (74.5%) cases and was exchanged in 76 (23%) cases. Seventy of the exchanged lenses were anterior chamber intraocular lenses (ACIOLs) and six lenses were PCIOLs. In cases of ACIOL exchanges, 10 were for scleral sutured IOLs, 18 for PCIOLS, and 42 for another ACIOL. CONCLUSIONS: Pseudophakic corneal edema remains the leading indication for PKP at our institution followed by regraft, continuing a trend noted in our previous studies. Although the percentage of cases of PCE associated with PCIOLS increased, fewer lenses were exchanged, perhaps reflecting increased confidence in biocompatibility of newer IOLs. The decrease in overall number of corneal transplants in these 5 years continues a trend noted in our previous study and mirrors the national decline in PKP.

Outbreak of toxic anterior segment syndrome associated with glutaraldehyde after cataract surgery.

PURPOSE: To present clinical findings of a cluster of cases of toxic anterior segment syndrome (TASS) after uneventful phacoemulsification cataract surgery. SETTING: Department of Ophthalmology, Akdeniz University, Antalya, Turkey. METHODS: Six eyes of 6 patients developed TASS after uneventful phacoemulsification cataract surgery with implantation of a 3-piece acrylic IOL performed by 2 ophthalmologists on the same day. Clinical findings included corneal edema, Descemet's membrane folds, anterior chamber reaction, fibrin formation, and irregular, dilated, and unreactive pupils. RESULTS: Glutaraldehyde 2% solution was used inadvertently by the operating room staff who cleaned and sterilized reusable ocular instruments before autoclaving. None of the affected corneas improved. Additional surgical procedures were required and included penetrating keratoplasty, trabeculectomy, and glaucoma tube implantation. CONCLUSIONS: Glutaraldehyde in concentrations generally used for cold sterilization is highly toxic to the corneal endothelium. The operating room staff involved in sterilizing instruments should be well educated about and careful to follow the protocols to properly clean and sterilize reusable ocular instruments.

Forty years of changing indications in penetrating keratoplasty in Israel.

PURPOSE: To examine the leading indications for keratoplasty and identify the changing trends in the past 40 years in Israel. METHODS: Pathology reports of all penetrating keratoplasties (PKPs) performed at Hadassah-Hebrew University Hospital from 1961 to 2000 were reviewed. We evaluated the indications for keratoplasty in each decade between the years 1961 and 2000. RESULTS: During the 40-year period, a total of 1681 PKPs were performed. Keratoconus (n = 478, 28.4%) was the most common indication, followed by graft failure (n = 226, 13.4%), pseudophakic corneal edema (PCE) (n = 142, 8.4%), herpetic infections (n = 125, 7.4%), nonherpetic infections (n = 114, 6.8%), scarring (n = 113, 6.7%), and trauma (n = 110, 6.5%). The 7 groups account for approximately 77.5% of all keratoplasties performed. Ocular infections were the most common indications before 1970 and have been declining ever since. Keratoconus became the leading indication in the past 30 years. In the past decade, of 663 keratoplasties, keratoconus was the most common indication (56, 38.6%) followed by graft failures/rejections and PCE (the second most common indication between the years 1981 and 1990). CONCLUSIONS: Keratoconus was the leading indication for keratoplasty in our series. There was a decreasing trend in PK for ocular herpetic infections during the decades. The rate of PCE decreased while failed graft became the second most common indication for PKP during the past decade.

Corneal edema after cataract surgery: incidence and etiology.

Corneal edema from inadequate endothelial pump function is one of the most common complications of cataract surgery. Various causes for this endothelial dysfunction can be divided into four categories including (a). mechanical injury, (b). inflammation/infection, (c). chemical injury, and (d). concurrent eye disease. This review serves as a basis for the diagnosis and treatment of this complication.

An epidemic of corneal destruction caused by plasma gas sterilization. The Toxic Cell Destruction Syndrome Investigative Team.

BACKGROUND: Toxic endothelial cell destruction (TECD) syndrome after intraocular ophthalmic surgery is rare and can result from exposure to a variety of toxins. During January 8 to 14, 1998, 6 patients developed TECD with corneal edema associated with unreactive or dilated pupils at Hospital A. METHODS: A case patient was any Hospital A patient with TECD within 24 hours after surgery during January 5 to 14, 1998 (epidemic period). A control was any hospital A ophthalmic surgery patient without TECD during the epidemic period. The medical records of hospital A ophthalmology surgery patients during the pre-epidemic (ie, September 1, 1997-January 4, 1998) and epidemic periods were reviewed. Inductively coupled plasma atomic emission spectrometry was used to detect trace inorganic elements on sterilized surgical instruments. Cannulated surgical instruments and laboratory rinsates were perfused directly to the corneal endothelium of isolated rabbit and human corneas. Corneal endothelial ultrastructure and swelling were assessed. RESULTS: The rate of TECD at hospital A was higher during the epidemic than pre-epidemic period (6/12 vs 0/118, P<.001). The only change during the periods was the introduction, on November 5, 1997, of a new sterilization method, AbTox Plazlyte, for sterilization of ophthalmic surgery instruments. Findings from spectrometry revealed that copper and zinc residues were higher in instruments sterilized with Plazlyte than in those sterilized with ethylene oxide (median copper value, 7.64 mg/L vs 0.14 mg/L, respectively, P =.02; median zinc value, 5.90 mg/L vs 1.35 mg/L, respectively, P =.2). Corneal endothelial perfusion of Plazlyte sterilized-instrument rinsates or laboratory solution with copper and zinc produced irreversible damage, similar to toxic corneal endothelial destruction, to rabbit and human corneas. CONCLUSION: A new sterilization method degraded brass to copper and zinc on cannulated surgical instruments resulting in TECD of the cornea. Arch Ophthalmol. 2000;118:1167-1176