Biomedical subjects
Publications and source records attributed to E J Cohen.
We report two histopathologically proven cases of epithelial downgrowth in which the secondary glaucoma was controlled by a double-plate Molteno tube shunt and useful vision restored with a penetrating keratoplasty. The combination of a tube shunt and penetrating keratoplasty may be indicated to maintain useful vision in advanced cases of epithelial downgrowth associated with secondary glaucoma.
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Twenty-nine suture removals from 20 eyes (21 patients) on which penetrating keratoplasty had been performed were analyzed in a nonrandomized consecutive study to evaluate the role of computer-assisted corneal topography in selective suture removal to reduce astigmatism. Topographic guidance for suture removal resulted in a net decrease in refractive and keratometric astigmatism in 21 of the 29 cases. The net reduction in astigmatism averaged 1.4, 0.9, and 1.0 diopters when measured by refraction, keratometry, and topography, respectively. The preliminary choice of sutures to be removed on the basis of refraction, keratometry, and inspection was changed in 20 of the 29 cases when information added by the topographic map was considered. Although many variables of suture removal remain unpredictable, computer-assisted corneal topography is a powerful means of describing corneal power after penetrating keratoplasty and is useful as a guide in selective suture removal for reduction of astigmatism.
The effects of gas-permeable contact lens wear on the density and morphologic characteristics of corneal endothelial cells were prospectively studied by wide-field specular microscopy in 18 eyes that had undergone keratoplasty at least 14 months previously. Daily-wear rigid gas-permeable lenses were fitted to allow as much movement and tear exchange as possible. There was no evidence of morphologic instability of the endothelial cells during the course of the study, with a mean duration of lens wear of 9.8 months. Although there is concern over adverse effects associated with polymethylmethacrylate contact lens wear, this study suggests that the endothelium of a corneal transplant tolerates rigid gas-permeable lens wear without adverse effect during a limited period of follow-up.
We retrospectively review our experience with four patients with Streptococcus pneumoniae scleritis. Two of the patients had been exposed to beta irradiation after pterygium removal 4 and 13 years previously. One patient had a 3-year history of chronic anterior nodular scleritis, and one patient had severe rheumatoid arthritis. All were treated with intensive i.v. and topical fortified antibiotics. In two of the cases, the infection was controlled and visual acuity returned to 20/30 and 20/60. In one patient, infectious scleritis progressed to endophthalmitis. This eye ultimately became phthisical and required enucleation because of chronic pain. In the remaining patient, infectious scleritis led to perforation, which required a corneal-scleral patch graft. This patient had a final visual acuity of counting fingers. An infectious etiology should be suspected in cases of necrotizing scleritis associated with a purulent discharge, and appropriate smears and cultures should be obtained. Infectious scleritis can be caused by streptococcal organisms. Appropriate topical and intravenous antibiotic treatment is effective in some cases.
Contact lenses were fit after traumatic corneal lacerations in 30 eyes (28 patients). Twenty-eight of the eyes (93%) were aphakic. Twenty-two of the 30 eyes (73%) wore the contact lens successfully (average follow-up 22 months). The visual acuity with the contact lens was 20/40 or better in 25 eyes (83%). In 13 eyes (43%) the final contact lens fit was a rigid gas permeable lens, with a daily wear soft contact lens as the final lens in 17 eyes (57%). The eight failures included four patients who were contact lens intolerant, two who had binocular diplopia, and two who lacked motivation. All but one of 12 (92%) small corneal lacerations (less than 3 mm) were successfully fit with contact lenses. Eleven out of the 13 (85%) central large lacerations, but none of the five large peripheral lacerations could be successfully fit with a contact lens. Three of the 30 eyes (10%) developed late retinal detachments. Contact lenses are successful in the majority of patients referred after corneal lacerations, but fitting these patients is challenging and time consuming.
We conducted a retrospective study of corneal ulcers that had been managed on the Cornea Service at Wills Eye Hospital in 1988 and 1989. Forty-four percent (51 of 116) of the ulcers were associated with contact lens use. Pseudomonas was the most often isolated organism (25 of 116, 22%) and was most frequently associated with cosmetic soft contact lenses (16 of 25, 64%). Ulcers associated with disposable contact lenses (five cases) were similar to those associated with conventional extended wear myopic lenses (15 cases). Pseudomonas was the predominant organism with both disposable (four of five, 80%) and conventional extended wear lenses (nine of 15, 60%). Staphylococcus aureus (19 cases) and Staphylococcus epidermidis (19 cases) were the next most frequently isolated organisms and usually occurred in ulcers not associated with contact lenses (29 of 38, 76%). Ulcers were treated 3.3 times more often in people using extended wear than in those using daily wear myopic lenses. Disposable contact lenses have not eliminated the problem of corneal ulcers associated with extended wear contact lenses.
Moraxella corneal ulcers are uncommon but may be complicated by marked inflammation and corneal perforation. In a series of eight cases treated over a period of 6 years, despite appropriate antibiotic therapy, descemetoceles and/or perforations developed in four cases, resulting in loss of the eye in two cases. In our series, the final visual acuity was count fingers or less in most patients (six of eight; 75%). Ulcers not only occurred in patients with systemic diseases, including alcoholism and malnutrition, but also in patients with various pre-existing ocular surface diseases. It is important to be aware of the potential of Moraxella ulcers to result in loss of vision and the eye.
Four patients with contact lens associated Acanthamoeba keratitis were treated at Wills Eye Hospital between 1987 and 1989. Two patients had used daily wear soft contact lenses and two had worn hard contact lenses. All four patients were treated with topical antibiotics (propamidine and neomycin), oral ketoconazole, and varying amounts of topical steroids. Two of these patients received topical clotrimazole. All four patients eventually required surgery for either control of their infection (three cases) or control of secondary disease (glaucoma and cataract). Medical therapy for Acanthamoeba keratitis remains problematic, and therefore prevention of this disease by avoidance of risk factors remains paramount.
We reviewed the records of 41 patients who underwent penetrating keratoplasty for a corneal opacity caused by trauma between Jan. 1, 1983, and Dec. 31, 1988. Most of the patients were young males whose average age was 35 years. Common tools accounted for many injuries (14 of 41, 34%). Sixteen injuries (39%) were work-related. Thirty-six patients (88%) had corneal scars from a perforating injury, four patients (10%) had corneal edema, and one patient (2%) required emergency penetrating keratoplasty for extensive tissue loss. Of the 39 patients with one year of follow-up, 31 (82%) maintained clear corneal grafts. Rejection occurred in nine of 39 patients (23%) and only three (33%) of the rejections resolved. Visual outcome was favorable with 20 patients (51%) attaining best-corrected postoperative visual acuity of 20/20 to 20/40, nine patients (23%) attaining visual acuity of 20/50 to 20/100, and ten patients (26%) attaining visual acuity of 20/200 or worse. Preoperative retinal disease (six of 39, 15%), astigmatic errors (five of 39, 13%), graft failures (four of 39, 10%), and postoperative glaucoma (12 of 39, 31%) adversely influenced the outcome. Although the prevalence of postoperative complications is relatively high, good visual results can be obtained in patients who undergo penetrating keratoplasty after ocular trauma.
We reviewed data on 150 repeat corneal transplants performed between 1983 and 1988 at Wills Eye Hospital. Minimal postoperative follow-up was six months. The most common diagnoses before regraft were pseudophakic bullous keratopathy (29 of 150), aphakic bullous keratopathy (28 of 150), Fuchs' dystrophy (21 of 150), failed graft (17 of 150), and keratoconus (14 of 150). Herpes simplex keratitis, interstitial keratitis, chemical burns, traumatic scars, and corneal dystrophies accounted for most of the remaining regrafts. Of the 150 regrafts, 39 (26%) failed during the study period. Almost half of the regraft failures occurred within six months, and over four fifths occurred within 18 months. Of the 111 eyes with clear grafts, final visual acuity data were available for 68 eyes (minimal follow-up, two years; mean, 3.3 years). A best-corrected visual acuity of 20/20 to 20/40 (22 of 68) or 20/50 to 20/100 (27 of 68) was achieved in most patients.
Contact lens (CL) fitting carries the risk of transmitting infectious agents, including adenovirus and Pseudomonas. Therefore, a number of precautions must be observed to ensure safety in the office. Paramount among these is hand washing, both immediately after contact with a patient's eyes and again between patients. Equally important is that all trial lenses and CLs removed from patients be disinfected before reuse. Low-water-content soft CLs can be heat disinfected; high-water-content CLs require chemical treatment. A combination of surfactant cleaning with a chlorhexidine-containing agent and hydrogen peroxide disinfection is preferred for rigid lenses to guarantee destruction of human immunodeficiency virus (HIV). The proper use of lens care solutions is also necessary to minimize the risk of their becoming contaminated with pathogenic organisms. Only commercially prepared solutions should be used, preferably in small-volume bottles that are frequently replaced. Preservative-free solutions should be discarded after 1 day's use, whereas preserved solutions may be used for up to 2 weeks. Sterile saline rather than tap water is recommended for rinsing rigid lenses. Finally, part of the clinician's responsibility in running a safe office is to educate patients about these hygienic practices.
The authors review four cases of Kaposi's sarcoma that were presented to the Foot Clinics of New York and affiliated North General Hospital during a 1-year period from the fall of 1987 to the fall of 1988. The authors conclude that it is sometimes difficult to diagnose Kaposi's sarcoma and to differentiate between the acquired immunodeficiency (AIDS) form and the classic form. Guidelines for diagnosis and a profile of the AIDS-related and non-AIDS-related Kaposi's sarcoma patient are discussed.
Anterior stromal puncture has recently been proposed as a new treatment for recalcitrant cases of recurrent corneal erosion. Concerns about the risks of corneal perforation and scarring, as well as doubts regarding its efficacy have prevented many patients from benefiting from this procedure. We introduce a new, inexpensive, commercially available instrument designed to standardize this technique, minimize scarring, and prevent corneal perforation. In a clinical trial involving 25 consecutive patients with recurrent erosions resistant to vigorous conservative treatment, the first 11 patients underwent stromal puncture in which a straight tuberculin needle was used; the following 14 were treated with a newly designed prototype needle. All patients in this series remained free of erosions after completion of stromal puncture, except for one woman with marked diffuse anterior basement membrane dystrophy, who went on to develop spontaneous bilateral erosions. Follow-up ranged from 2 months to 30 months (mean, 13 months). There were no complications of stromal puncture, and subjective and objective evaluations revealed no significant postoperative glare. Microscopic analysis of eye bank eyes subjected to anterior stromal puncture procedures demonstrated that the new prototype needle provided shallower penetration and thus less likelihood of perforation or excessive scarring than the straight needle. Also, postoperative discomfort and scarring appeared to be significantly less in patients treated with the prototype needle.
Familial and environmental factors may play a role in the development of conjunctival intraepithelial neoplasia (CIN). Nineteen patients with biopsy-proven CIN completed a questionnaire to evaluate possible predisposing factors. Nineteen age-matched and sex-matched controls completed questionnaires and received slit-lamp examinations. Factors associated with a relatively increased risk of developing CIN included exposure to petroleum products, heavy cigarette smoking, light hair and ocular pigmentation, and family origin in the British Isles, Austria or Switzerland. Non-office and nonprofessional workers were more likely to develop conjunctival intraepithelial neoplasia (p = .05), as were those who were not college graduates (p = .07).
Unlike Corynebacterium diphtheriae and Propionibacterium acnes, the pleomorphic gram-positive rods known as diphtheroids are generally regarded as nonpathogenic contaminants of the human external eye. We reviewed five years of microbiology records at Wills Eye Hospital and studied a series of eight cases of apparently infectious keratitis associated with heavy growth of diphtheroids on cultures of ulcer scrapings. All of these cases included indolent ulcers that occurred almost exclusively in elderly patients (mean age, 72 years; range, 11 to 92 years). All patients had preexisting ocular conditions that compromised the corneal surface such as exposed corneal sutures, eyelid surgery, aphakic extended wear contact lenses, viral keratitis, and diabetes mellitus. No other pathogens were isolated. All infections responded well to antibiotic therapy with all organisms sensitive to cefazolin and all but one sensitive to gentamicin.