Pellucid marginal corneal degeneration 12 years after penetrating keratoplasty for keratoconus

Historically the divisions between the mental health and substance abuse fields have been so deep that attempts to provide coordinated treatment across service sectors for people with dual diagnoses of psychiatric disorder and substance use disorder have failed. The authors describe a program in Maine designed to develop collaboratives, or communities of providers, who work together to offer coordinated mental health and substance abuse treatment and support. Surveys of provider agencies in one collaborative conducted one year and two years after the collaborative was established showed an increase in interagency referrals, joint assessments of clients, and jointly sponsored training and client services.     

Corneal neovascularization after penetrating keratoplasty

The purpose of this study was to delineate the patient and surgical factors that contribute to the development of corneal neovascularization (CNV) after penetrating keratoplasty (PK). Thirty-six eyes of 36 patients with no antecedent CNV were enrolled in the study. Grafts were sutured to the host with 16 10-0 nylon sutures with the knots buried alternately in either the host or donor corneal stroma. Multiple perioperative factors were recorded for each patient, and at each postoperative visit systematic corneal drawings were used to follow the development of neovascularization. The stroma adjacent to each suture of each graft was given a neovascularization score based on the extent of vessel growth toward the wound interface. Univariate and multivariate analyses were performed, including generalized estimating equations logistic regression where each eye is considered a cluster of observations. Thirty-four patients without preoperative CNV or inflammation were followed prospectively for 6-9 (mean, 7) months after PK. Fourteen eyes (41%) developed some degree of CNV. Indication for keratoplasty, age, gender, phakic status, and size of donor button were not risk factors for CNV development. The most significant risk factor identified for any degree of CNV was placement of the suture knot in the host stroma (p = 0.00007), with the overall relative risk of CNV associated with these knots over 2 (95% confidence interval, 1.1-4.2). Furthermore, the mean recipient size in eyes with postoperative CNV was larger than eyes that did not develop neovascularization (p = 0.015), and active blepharitis was associated with a fivefold increase in the risk of developing CNV to the wound edge (p = 0.008). Embedding suture knots in the host stroma, active blepharitis, and a large recipient bed are significantly associated with postkeratoplasty CNV.     

Retrephination keratoplasty for high astigmatism after penetrating keratoplasty

PURPOSE: We report preliminary results of a new procedure for correcting high astigmatism after penetrating keratoplasty. METHODS: The procedure entails full-thickness trephination along the original donor-recipient junction with careful suturing in a combined interrupted and running fashion. Four eyes of four patients with severe astigmatism and myopia after penetrating keratoplasty underwent the procedure. RESULTS: High preoperative cylinder ranging from 4.50 to 16.00 D (mean 9.00 D) was reduced to 0.50 to 3.50 D (mean 1.90 D) at the last examination (between 3 to 6 months). Spherical equivalent myopia ranging from -2.00 to -10.25 D (mean -4.90 D) was essentially unchanged at plano to -9.00 D (-4.70 D) at the last examination. Overall, there was a mean refractive cylinder reduction of 7.10 D (79%). CONCLUSION: Retrephination after penetrating keratoplasty appears to be an acceptable alternative for correcting high astigmatism, and had only a small effect on the level of myopia.     

The prognosis of penetrating keratoplasty based upon corneal morphology

In this paper, the author has attempted to express the prognosis for successful penetrating keratoplasty based upon a morphological classification of corneal disease. Four groups have been designated with their basic prognosis ranging from excellent to poor. The importance of appraising the diseased cornea in the area of its optimal recipient zone has been stressed. Ancillary factors adversely affecting the estimated final prognosis of keratoplasty have been considered, with emphasis upon the importance of glaucoma, lid function, tear film, ocular inflammation and patient compliance. Not only is it important for the surgeon to appraise the chance of successful surgery, but it is essential for the patient to be informed in advance regarding the probability for successful surgery and the need to comply with sometimes demanding requirements of postoperative care.     

Cyclocryotherapy for refractory glaucoma after penetrating keratoplasty

Twenty-eight patients (28 eyes) with secondary glaucoma following penetrating keratoplasty and failed to respond to anti-glaucoma drugs and routine filtering procedures were performed with cyclocryotherapy by nitrogen monoxide. All patients were followed up for more than one year. The results showed intraocular pressure was well controlled in 89% of the eyes, graft remained clear in 85%, and visual functions are preserved in 82% of the patients. Our study suggests that precisely controlled temperature, time, and extent of cryotherapy, and post-operative anti-rejection agents be the key factor to success. Over-treatment, which may lead to atrophy of the eye, must be avoided. It should not be given up flowing under-treatment in the initial procedure.     

Laser in situ keratomileusis after automated lamellar keratoplasty and penetrating keratoplasty

We present three patients who had laser in situ keratomileusis (LASIK) after corneal surgery as follow: 15 months after automated lamellar keratoplasty (ALK) for hyperopia, 6 months after ALK for hyperopia, and 2 years after penetrating keratoplasty (PKP). Although the first case was uneventful, intraoperative complications arose in the second case because the connection of the ALK-related flap to its stromal bed was insufficient. In the third case, the refractive error caused by PKP was corrected as shown by corneal topography and visual acuity measurement. In conclusion, LASIK after PKP can be considered a precise and safe procedure if 2 to 3 years pass between the procedures. An interval of 6 months between ALK and LASIK was too short, whereas 15 months after ALK for hyperopia, LASIK was performed without problems and delivered a good result.     

The influence of glaucoma history on graft survival after penetrating keratoplasty

BACKGROUND: It was the purpose of this retrospective study to evaluate the effect of a preoperative history of glaucoma on graft survival after penetrating keratoplasty. PATIENTS AND METHODS: Six hundred and forty-six penetrating keratoplasties with generally good prognosis were analyzed retrospectively. Indications for surgery were corneal dystrophy, degeneration and scarring. Only first keratoplasties in corneas without severe vascularization or acute inflammation were included. Surface disorders, a history of herpes or Acanthamoeba keratitis were further exclusion criteria. Keratoplasties were performed only if glaucoma seemed to be controlled preoperatively. Graft survival ratios were calculated according to Kaplan and Meier, and statistical significance was evaluated by means of the log-rank test. RESULTS: With a glaucoma history the estimated 3-year graft survival rate was 71%, in contrast to 89% without such a history. This difference was statistically significant (P < 0.001). There was no difference between the groups with respect to immune reactions. With a glaucoma history, postoperative episodes of glaucoma decompensation were responsible for half of the graft failures. CONCLUSIONS: A preoperative history of glaucoma affects graft prognosis negatively, presumably through a negative influence of postoperatively elevated intraocular pressure on a vulnerable graft endothelium, and not by an increase in immune reactions. Therefore, keratoplasties in eyes with glaucoma are high-risk procedures and glaucoma has to be monitored more efficiently pre- and postoperatively.     

Neodymium:YAG laser optical opening for retained Descemet''s membrane after penetrating keratoplasty

Although the extent of suprathreshold damage to murine lung that results from exposure to pulsed ultrasound increases with time, the threshold level for lung hemorrhage is relatively insensitive to total exposure time. Adult mice were exposed for 20 s and 3 min to 2.3-MHz ultrasound (10-microseconds pulses, 100-Hz pulse repetition frequency) at peak positive pressures ranging up to 3 MPa. Threshold pressures for the two exposure times, 1.6 MPa and 1.4 MPa, respectively, are the same within the statistical significance of the measurements.     

Positive donor rim culture in penetrating keratoplasty

A 3-year retrospective study on the risk factors of positive donor rim cultures in penetrating keratoplasty was performed. One thousand and ninety-seven consecutive donor rim cultures were reviewed from the period between June 1990 and October 1993 to determine the rate of culture positivity. The sex, age, diabetes status, use of respirator at time of death, cause of death, harvesting technique, storage time, and corneal storage medium utilized for the donors with positive donor rim culture were compared to those for 100 randomly selected culture negative donor controls. Logistic analysis was performed to eliminate confounding effects. Forty-six of the 1,097 (4.19%) donor rim cultures were positive. We found an association between the in situ technique for donor harvesting and culture negativity (p = 0.03). None of the other donor characteristics was associated with culture positivity. None of the 46 recipients who received the positive culture corneas developed endophthalmitis. In situ cornea harvesting promotes less contamination than enucleation and enriched gentamicin and streptomycin storage medium may further decrease donor rim culture positivity.     

Astigmatism after penetrating keratoplasty. Videokeratoscopic analysis on a series of 60 grafts

Lactoferrin was previously shown to inhibit the adhesion of A. actinomycetemcomitans, P. intermedia and P. nigrescens to human cells. Lactoferrin was also shown to competitively inhibit the binding of these bacteria to the basement membrane protein laminin. The present study aimed to determine the type of interactions inhibited by lactoferrin. Lactoferrin binds to fibroblast monolayers and Matrigel, a reconstituted basement membrane, through ionic interactions. The adhesion of A. actinomycetemcomitans to these substrata was mainly dependent on the ionic strength of the environment. P. intermedia and P. nigrescens also adhere to fibroblasts mainly by ionic interactions, while their adhesion to Matrigel seems to be mediated by specific mechanisms. Lectin-type interactions were not found to be involved in the binding of these bacteria to the substrata. Treatment of either A. actinomycetemcomitans or fibroblasts with lactoferrin decreased the adhesion in a dose-dependent manner, while lactoferrin treatment of Matrigel alone had no adhesion-counteracting effect. Adhesion of P. intermedia and P. nigrescens to Matrigel was not significantly affected by the ionic strength, but the presence of lactoferrin inhibited the adhesion. Lactoferrin bound to Matrigel, P. intermedia and P. nigrescens was rapidly released, while lactoferrin bound to A. actinomycetemcomitans and fibroblasts was retained. These findings indicate that lactoferrin-dependent inhibition of the adhesion of A. actinomycetemcomitans, P. intermedia and P. nigrescens to fibroblasts and Matrigel can involve binding of lactoferrin to both the bacteria and substrata. The decreased adhesion may be due to blocking of both specific adhesin-ligand as well as non-specific charge-dependent interactions.     

Peripheral radial incisions to treat inferior contact lens edge lift after penetrating keratoplasty for keratoconus

A patient with marked corneal astigmatism and inferior contact edge lift after penetrating keratoplasty for keratoconus had corneal relaxing incisions (CRIs) on the donor button and radial incisions on the host cornea. Results were evaluated by computerized videokeratography and by refitting the contact lens. Two pairs of CRIs decreased astigmatism from 11.00 to 4.25 diopters but did not alleviate the contact lens edge lift, which was caused by excessive steepness in the keratoconic host cornea. After 6 radial incisions were made to flatten the inferior host cornea, the peripheral cornea flattened and the patient was successfully refitted with a contact lens.     

Granular-lattice (Avellino) corneal dystrophy

Smooth muscle differentiation in the ovary is rare, and its histopathologic spectrum, including ovarian smooth muscle metaplasia (SMM), has not been well described. The clinicopathologic findings in 48 ovaries with SMM from 40 women are reported. The average age of women with ovarian SMM was 55.6 years (range, 34 to 86 years). Foci of SMM were semiquantitatively characterized as 1+ in 46% (1 to 3 foci), 2+ in 37% (4 to 6 foci), and 3+ in 17% (> 6 foci). SMM was bilateral in 8 (23%) of the 35 patients who had bilateral oophorectomies. SMM was intimately associated with another ovarian process in 28 (58%) cases, including ovarian cysts (11), endometriosis (3), granulosa cell tumors (3), extensive stromal luteinization (1), ovarian fibroma (1), adhesions (1), and folliculogenesis (8). Ovaries with 2+ to 3+ SMM were associated with another ovarian lesion significantly more often than those with 1+ SMM (p < 0.01). Most women with ovarian SMM (86%) also had uterine leiomyomas. Significant endometrial pathology was present in 13 (37%) of 35 simultaneously removed uteri. In conclusion, SMM occurs most often in perimenopausal or postmenopausal women, most of whom also have uterine leiomyomas. Ovarian SMM is usually confined to a few microscopic fields, is bilateral in < 25% of patients, and is often associated with other ovarian lesions.     

Epithelial downgrowth following penetrating keratoplasty with a running adjustable suture

A 78-year-old female patient who had a third penetrating keratoplasty for aphakic bullous keratopathy and iris fixation of a posterior chamber intraocular lens using a single, 10-0 nylon running suture technique developed a suture track leak postoperatively. Attempts to ease the tension on the suture track reduced the astigmatism and stopped the leak temporarily. Eighteen months after the procedure, epithelial downgrowth was noted on the corneal graft on both sides of the leak site and intraocular pressure was elevated. A fourth penetrating keratoplasty combined with a trabeculectomy was performed. To our knowledge, this is the first report of epithelial downgrowth associated with suture adjustment following the single, continuous suture technique.