Keratoconus: why and when do we turn to surgical therapy?
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Cornea↗
Biomedical subjects
Mark J Mannis
Publications and source records attributed to Mark J Mannis.
Clinical profile and early surgical complications in the Cornea Donor Study.
PURPOSE: The Cornea Donor Study was designed to investigate the safety and efficacy of older donor corneal tissue compared with younger donor tissue in recipient eyes at moderate risk to the graft from progressive endothelial failure. Baseline patient data, including indications for transplant, intraoperative complication rates, and early postoperative complication rates are described herein. METHODS: This study was a multicenter prospective, double-masked, controlled clinical trial. RESULTS: Fuchs dystrophy was the most common indication for corneal transplantation (61%). Intraoperative complications occurred in 33 (3%) patients. A persistent epithelial defect was the most commonly reported postoperative complication, occurring in 92 patients (8%). CONCLUSION: Intraoperative and postoperative complication rates were low. There was no apparent association between donor or recipient age and either intraoperative or early postoperative complication rates.
Adult↗
Superficial hypertrophic dendriform epitheliopathy: a follow-up series.
PURPOSE: To report the interval courses of previously reported cases of superficial hypertrophic dendriform epitheliopathy (SHDE) and to describe 3 new cases of this uncommon entity following penetrating keratoplasty. METHOD: Retrospective chart review. RESULTS: We report follow-up on 3 previously described cases of SHDE, including discussion of cases and their clinical course. All 3 patients had persistent surface abnormalities complicating graft success resulting in poor visual outcomes. Three new cases of SHDE are discussed with a summary of the ocular findings and treatment. All patients underwent multiple penetrating keratoplasties for recurrent graft failures resulting from chronic postkeratoplasty surface keratopathy. CONCLUSIONS: SHDE is a rare complication of penetrating keratoplasty that can lead to delayed healing, chronic derangement of the corneal surface, corneal scarring, and an increased risk of graft rejection. Understanding and recognizing this entity is crucial for maximizing graft outcomes. Further investigation of the pathogenesis is necessary for complete understanding and management of the disorder.
Adult↗
Surgical monovision and monovision reversal in LASIK.
PURPOSE: This study was designed to assess the success of surgical monovision in presbyopic patients. METHODS: A university refractive surgery center retrospective chart review of 82 patients who elected to undergo surgical monovision with laser in situ keratomileusis (LASIK) between January 2000 and January 2003 was conducted. Specific factors included for analysis included preoperative and postoperative defocus spherical equivalent, whether the patient underwent enhancements, whether the patient underwent a preoperative monovision trial with contact lens, and whether the patient underwent monovision reversal. RESULTS: Eighty-two patients who underwent LASIK for monovision were analyzed. Mean preoperative spherical equivalent in the distance-corrected eye was -4.07 (standard deviation (SD), 2.49); for the eye corrected for near vision, mean preoperative spherical equivalent was -4.10 (SD, 2.56). Postoperative spherical equivalent in the distance eyes was -0.01 (SD, 0.38) and in the near eyes -1.24 (SD, 0.91). There were 6 enhancements in the near eyes (7%) and 17 enhancements in the distance vision eyes (21%). This difference was statistically significant (P = 0.007). Thirty patients underwent a contact lens trial of monovision before LASIK, and none of those patients elected monovision reversal. There were 52 patients who did not undergo a contact lens monovision trial before LASIK monovision, and 2 of these patients underwent monovision reversal. Monovision success in this population was 97.6%. CONCLUSION: Surgical monovision can help presbyopic patients achieve their goal of reduced dependence on spectacles. A trial of monovision contact lenses or spectacles may be important in helping surgeons select patients for successful surgical monovision.
Adult↗
An evaluation of image quality and accuracy of eye bank measurement of donor cornea endothelial cell density in the Specular Microscopy Ancillary Study.
PURPOSE: The Specular Microscopy Ancillary Study was designed to examine donor corneal endothelial specular image quality, compare the central endothelial cell density determined by eye banks with the endothelial cell density determined by a central specular microscopy reading center, and evaluate donor factors that may have an impact on specular image quality and endothelial cell density accuracy. DESIGN: Nonrandomized comparative trial. PARTICIPANTS: Endothelial specular images of donor corneas assigned in the Cornea Donor Study. METHODS: Certified readers assessed donor image quality (analyzable from fair to excellent vs. unanalyzable) and determined the central endothelial cell density. Independent adjudication was performed if there was a difference in the quality of grading or if the endothelial cell density varied by > or =5.0% between readers. Average reading center-determined endothelial cell density was compared with the endothelial cell density determined by each eye bank. MAIN OUTCOME MEASURES: Evaluation of image quality and accuracy of endothelial cell density. RESULTS: Of 688 donor endothelial images submitted by 23 eye banks, 663 (96%) were analyzable (excellent, 40 [6%]; good, 302 [44%]; fair, 321 [47%]), and 25 (4%) were unanalyzable by reading center standards. In situ retrieval and greater epithelial exposure correlated with a higher image quality grading. The eye bank-determined endothelial cell density of 434 of the 663 (65%) analyzable images were within 10% of the endothelial cell density determined by the reading center, whereas 185 (28%) were more than 10% higher and 44 (7%) were more than 10% lower. Greater variation in endothelial cell density between the eye banks and the reading center was observed with shorter time of death to preservation, presence of an epithelial defect, folds in Descemet's membrane, lower image quality, and the use of fixed-frame or center method endothelial cell density analysis. CONCLUSIONS: Overall, donor endothelial specular image quality and accuracy of endothelial cell density determination were good. However, the data suggest that factors that may affect image quality and contribute to variation in interpretation of the endothelial cell density should be addressed, because the donor endothelial cell density is an important parameter for assessing long-term corneal graft survival.
Cell Count↗
Nomogram-based intraocular lens power adjustment after myopic photorefractive keratectomy and LASIK: a new approach.
PURPOSE: (1) To evaluate the accuracy of nomogram-based adjustment of intraocular lens (IOL) power to achieve a desired refractive target after cataract surgery in postmyopic LASIK and photorefractive keratectomy (PRK) eyes and (2) to compare the accuracy of the nomogram-based method with the clinical history method. DESIGN: Multicenter, retrospective, interventional, noncomparative case series. SUBJECTS: Fourteen patients (19 eyes) after myopic LASIK or PRK with visually significant cataracts. INTERVENTION: All eyes underwent cataract extraction and posterior chamber intraocular lens implantation. In each case, IOL power was determined with standard keratometry and biometry. Power adjustment was made by use of a theoretical nomogram followed by implantation. MAIN OUTCOME MEASURES: (1) Final refraction and spherical equivalent after cataract surgery and (2) deviation of the final spherical equivalent from the refractive target. RESULTS: After cataract extraction, by use of nomogram adjustment, 63.2% of eyes were within 0.5 D of the intended spherical equivalent, 84.2% were within 1.0 diopter of the intended spherical equivalent, and 100% were within 1.5 D of the intended spherical equivalent. The clinical history method was accurate in predicting the correct IOL power in 37.5% of cases, regardless of whether spectacle or corneal plane refraction was used. CONCLUSIONS: (1) Given the change in spherical equivalent induced by myopic LASIK/PRK, IOL power can be adjusted accurately to avoid undercorrection without the need for the prerefractive surgery corneal power. (2) The nomogram-based method was more accurate than the clinical history method.
Adult↗
The Pan-American Association of Ophthalmology: an opportunity for the Americas.
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Americas↗
Ocular rosacea.
Rosacea is a common skin disease that frequently involves the eye. Although the pathogenesis of the disease remains undefined, recent findings suggest that an altered inflammatory response plays an important role in both cutaneous and ocular rosacea. Ocular manifestations include lid and ocular surface alterations. Chronic inflammation can lead to corneal vascularization, which may compromise vision. Treatment of ocular rosacea is aimed at preventing irritation of the ocular surface (e.g., lubricants, lid hygiene) and controlling inflammation with topical and systemic anti-inflammatory drugs. Systemic tetracyclines are the mainstay of treatment. These drugs act multifactorially by decreasing bacterial flora and the expression of matrix metalloproteinases, altering meibum secretion, inhibiting the production of bacterial lipases, and providing an immunomodulatory effect.
Journal Article↗
Personality in keratoconus in a sample of patients derived from the internet.
PURPOSE: Keratoconus is a corneal disease that manifests itself in young adulthood and decreases vision. Anecdotally, keratoconus patients are commonly described as having unusual personality characteristics; however, previous researchers have not been able to define a unique keratoconus personality profile. We sought to better define the personality of patients with keratoconus. METHODS: The Millon Behavioral Health Inventory (MBHI) is a psychological instrument designed for use with physically ill patients to assess factors relevant to their medical care. The MBHI may aid in the evaluation of keratoconus patients and provide information relevant to the doctor-patient relationship. Patients with keratoconus were recruited through the World Wide Web. Surveys were conducted by mail, with all responses returned anonymously. One hundred fifty-three keratoconus patients were compared with the MBHI age-matched norms, generated from medical and nonmedical samples of adults. Subgroups of keratoconus patients were compared based on their self-reported rating of the daily burden of keratoconus. RESULTS: Keratoconus patients scored significantly lower (chi, P <0.05) compared with the normative population on the respectful coping style scale, and their scores were not significantly associated with a history of penetrating keratoplasty or their rating of the effect of keratoconus on their lives. This suggests that keratoconus patients are less respectful of practitioners, uncooperative, and noncompliant with treatment plans. Practitioners may look unfavorably on patients who exhibit these characteristics. This would also explain why the clinical perception of keratoconus patients persists, but other personality inventories have not defined a distinct keratoconus profile. CONCLUSIONS: These data from the MBHI, showing that keratoconus patients score lower on the respectful coping style scale, may explain eye care practitioners' perceptions about these patients' personality characteristics.
Adolescent↗
Intraocular lens calculation in a patient with previous penetrating keratoplasty and LASIK.
PURPOSE: To report a case of a patient who underwent cataract extraction with intraocular lens (IOL) implantation after previous penetrating keratoplasty (PK) followed by laser in situ keratomileusis (LASIK). METHODS: Case report and literature review of cataract surgery after PK and LASIK. Cataract surgery was successfully performed in a patient with previous PK and LASIK. This paper outlines our method of calculating the correct power IOL for implant. RESULTS: The patient's 1-month postoperative uncorrected visual acuity was 20/70 and best spectacle-corrected visual acuity was 20/30+ with -0.75 +0.50 x 180. CONCLUSIONS: We report the case of a patient with cataract extraction with IOL implantation after PK and LASIK as well as a description of the method used to calculate IOL power after PK and LASIK. While the IOL selection can be difficult, using the appropriate nomogram can result in good visual outcomes.
Algorithms↗
Baseline donor characteristics in the Cornea Donor Study.
PURPOSE: The Cornea Donor Study (CDS) is an ongoing study that is being conducted to determine whether donor age is related to long-term corneal graft survival. Characteristics of the donor population have been evaluated with respect to donor age, endothelial cell density, and death to preservation interval. METHODS: Within the context of a prospective, double-masked, controlled trial, 1101 donor corneas were assigned without regard to donor age. RESULTS: Slit-lamp characteristics of the donor corneas showed little variation with donor age, except for the presence of corneal arcus. As death to preservation time decreased, fewer epithelial abnormalities and a lower frequency of stromal edema and Descemet folds were observed. There was little change in the mean of the endothelial cell density with donor age beyond age 60, despite variation. CONCLUSION: With respect to donor age, there was little difference in either the slit-lamp characteristics or endothelial cell density of the donor corneas. Fewer epithelial abnormalities were observed with shorter death to preservation time.
Adolescent↗
Infectious keratitis after astigmatic keratotomy in penetrating keratoplasty: review of three cases.
PURPOSE: To present 3 cases in 2 patients of infectious keratitis of the astigmatic keratotomy (AK) site in patients who had previous penetrating keratoplasty. METHODS: History, clinical examination, chart review, cultures, and laboratory results were obtained from 2 patients with infectious keratitis within the donor stroma of their graft after an AK was performed. RESULTS: One patient had an early infiltrate of the AK site that was culture negative. This cleared with fortified antibiotics, and the patient had a final visual acuity of 20/30-2. The second patient developed 2 late infections, the first with coagulase negative Staphylococcus and the second infection with Pseudomonas aeruginosa. Both of these infections cleared with fortified antibiotics, and the final visual acuity was 20/25. Neither patient developed a rejection episode from the infections, and both grafts survived. CONCLUSIONS: We report a series of 3 cases of infectious keratitis in 2 patients after AKs in corneal grafts. This, to the best of our knowledge, has not been previously reported. Patients who suffer infectious keratitis after AK in corneal grafts may have good visual outcomes if managed with appropriate antibiotic regimens and closely followed.
Astigmatism↗
Dendritic keratopathy in ocular rosacea.
PURPOSE: To report a case of dendritic keratopathy secondary to ocular rosacea in a 62-year-old man. METHOD: Case report. RESULTS: We discuss the ophthalmologic findings, management, and course in a patient with an unusual dendritic corneal lesion resistant to medical therapy. Other causes of dendritic lesions on the cornea were ruled out after investigation. The patient experienced symptomatic and objective improvement in the lesion with treatment of ocular rosacea. CONCLUSION: This case represents an interesting presentation of rosacea with dendritic keratopathy associated with typical skin lesions.
Androstadienes↗
The long-term results of keratoplasty in eyes with a glaucoma drainage device.
PURPOSE: To study the outcome of penetrating keratoplasty (PK) in eyes with a glaucoma drainage device (GDD). DESIGN: Retrospective case-controlled study. METHODS: We reviewed all patients who underwent PK from December 1986 to September 2002 at the University of California, Davis (n = 1,974). We identified 33 patients (40 grafts) who were treated with a GDD and followed up for 6 months or more after PK. Graft survival and glaucoma control were compared with grafts in patients without glaucoma (n = 40) and patients with medically controlled glaucoma (n = 17). Kaplan-Meier survival analysis, log rank test, repeated-measures analysis of variance (ANOVA), Fisher exact test, and chi(2) were used in group comparisons. Multivariate analysis was performed using the Cox proportional hazards model. RESULTS: The percentages of clear grafts in the glaucoma drainage device group were 58.5% and 25.8% at 1 and 2 years, respectively. At these time points, glaucoma was controlled in 74.0% and 63.1% of the eyes, respectively. Both medically controlled glaucoma patients and nonglaucomatous patients had higher graft survival percentages at comparable time points. The presence of a GDD was an important factor influencing graft survival (Hazard ratio = 6.8). CONCLUSION: A GDD implant is an independent risk factor for graft failure. Although these devices are effective in controlling intraocular pressure (IOP) in the majority of eyes in the presence of PK, corneal graft clarity is often compromised.
Adolescent↗
Report of the American Board of Ophthalmology task force on the competencies.
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Accreditation↗
Intraocular lens power calculation after corneal refractive surgery.
PURPOSE OF REVIEW: Keratorefractive procedures designed to decrease refractive errors have gained enormous popularity among ophthalmologists and patients. As the post-refractive surgery patient population ages, visually significant cataracts will develop. With advances in techniques for cataract extraction and intraocular lens implantation, cataract surgery has evolved into a refractive surgical procedure as well as an operation to improve best corrected visual acuity. This raises expectations in terms of desired postoperative refractive status and uncorrected visual acuity. Although performing modern cataract surgery in post-refractive surgery eyes is technically no more complicated than operating on virgin eyes, the calculation of intraocular lens power for a desired refractive target can be challenging and complicated. This has become increasingly apparent as case reports of "refractive surprises" after cataract surgery appear in the literature more frequently. RECENT FINDINGS: This paper reviews the current clinical experience with intraocular lens power determination after cataract surgery in post-keratorefractive patients, provides an overview of possible sources of error in intraocular lens power calculation in these patients, and analyzes methods to minimize intraocular lens power errors. SUMMARY: The clinical and routine methods of intraocular lens power determination after keratorefractive surgery need to be modified to improve accuracy. Our knowledge of this subject is still evolving. Given the enormous impact of this problem on clinical practice, awareness of the shortcomings and suggested methods to improve accuracy can be valuable to clinicians.
Cataract↗
Corneal refractive power after myopic LASIK.
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Cornea↗
Analysis of intraocular lens power calculation in post-radial keratotomy eyes.
PURPOSE: To determine whether refractive complications can be prevented by applying the currently most accurate method of intraocular lens (IOL) power calculation in the post-radial keratotomy (RK) patient. SETTING: Department of Ophthalmology, University of California, Davis, Sacramento, and American Eye Institute, Cedars Sinai Medical Center, Los Angeles, California, USA. METHODS: Twenty-four eyes having cataract surgery after RK were studied retrospectively for the final postcataract refraction and for the target refraction used in selecting the IOL. Nine of the eyes were further studied for the keratometry (K) values obtained with different methods and for the theoretical postoperative refraction with an IOL aiming for plano or -1.50 diopters (D) based on the known flatter calculated K, axial length, power of the implanted IOL, and refraction after cataract surgery. RESULTS: Implantation of an IOL aiming for plano in the 24 post-RK eyes would have resulted in a hyperopic refraction in 83.4% cases. The choice of an IOL targeted at myopia reduced the frequency of hyperopia to 42.0% (24 cases). Selection of an IOL calculated with a flatter calculated K and aiming for plano decreased the frequency of hyperopia to 44.4%; however, aiming for -1.50 D still resulted in hyperopia in 44.4% of eyes (9 cases). CONCLUSIONS: Unintentional hyperopia can be significantly decreased but not eliminated as a complication of post-RK cataract surgery. The accuracy of the IOL power determination can be improved if myopia is targeted as the postcataract surgery refractive error and the flatter calculated K is used in the IOL determination.
Humans↗