Keratoconus after penetrating keratoplasty

Signs of keratoconus, including Munson's sign, apical thinning, and Vogt's striae, developed in a 41-year-old woman 6 years after successful penetrating keratoplasty. Screening donor corneas for ectatic diseases may prevent such occurrences.     

Aqueous hyposecretion after penetrating keratoplasty

Following penetrating keratoplasty, aqueous hyposecretion results in marked thickening of the cornea identical to that seen when the donor endothelium is unsatisfactory. The lack of secretion is accompanied by hypotony, and the persistence of fluorescein in the anterior chamber can be measured by fluorophotometry or observed clinically 24 hours after the instillation of topical fluorescein. An eye with aqueous hyposecretion will usually recover in seven to ten days, and additional surgery is not only unnecessary, but harmful to an already damaged eye. However, poor donor tissue can often be replaced promptly and successfully with repeated penetrating keratoplasty. Therefore, clinical differentiation of these conditions is important in management decisions.     

再次穿透性角膜移植原因临床分析

目的分析行再次穿透性角膜移植（repeatpenetratingkeratoplasty,RPK）患者的原发病以及再次角膜移植的直接原因。方法调查1999年1月1日～2008年12月31日在青岛眼科医院和山东省眼科医院接受穿透性角膜移植的患者资料,对其中行RPK患者的资料进行回顾性分析,分析RPK患者的原发病和RPK的直接原因以及高危受者RPK的直接原因。结果10年间共有2922例患者（3455只眼）接受了穿透性角膜移植手术,其中接受RPK共206例患者（215只眼）。RPK受者中男性148例,女性58例,平均年龄（39．2±17．6）岁。原发病依次为单纯疱疹病毒性角膜炎（19％）、化脓性角膜炎（18％）、角膜裂伤（14％）、角膜烧伤（13％）、大泡性角膜病变（11％）、角膜变性或营养不良（9％）、角膜白斑（7％）、圆锥角膜（6％）、植片混浊（2％）、其他（1％）。RPK的直接原因依次为角膜移植片慢性失功（45％）、移植角膜排斥反应（27％）、角膜移植片溃疡（18％）、原发病复发（7％）、其他（3％）。其中高危受者RPK的前两位原因分别为移植角膜排斥反应（46％）和角膜移植片慢性失功（31％）;非高危受者RPK的前两位原因分别为角膜移植片慢性失功（60％）和角膜移植片溃疡（17％）。结论RPK受者原发病以感染性疾病为主;排斥反应和角膜移植片慢性失功造成的角膜移植片混浊分别是高危和非高危受者接受RPK的主要原因。     

Tissue plasminogen activator and penetrating keratoplasty

We report a patient who developed severe intraocular fibrin formation following penetrating keratoplasty and vitrectomy surgery. The fibrin response worsened despite aggressive treatment with topical steroids. On the second postoperative day, 25 micrograms of intracameral tissue plasminogen activator was administered, resulting in rapid resolution of the fibrin response. The graft remained clear. We believe tissue plasminogen activator may be useful in selected cases of severe, recalcitrant postkeratoplasy fibrin formation.     

Dematiaceous fungal keratitis following penetrating keratoplasty

A keratitis with an unusual, sessile, filamentary mass extending into the anterior chamber developed in a patient three weeks after penetrating keratoplasty. The causative organism was identified as Exophilia (Wangiella) dermatitidis, a dematiaceous fungus. The infection was cured with a combination of medical and surgical therapy. Inoculation of the isolate into rabbit corneas produced a similar keratitis from which the same organism was cultured. Miconazole levels measured in corneal tissue removed at surgery were approximately 25 times greater than the minimum inhibitory concentration for the fungal isolate.     

Intraocular lens implantation after penetrating keratoplasty

Thirty-three postkeratoplasty eyes underwent extracapsular cataract extraction with posterior chamber lens implantation or secondary anterior chamber lens implantation 3 to 128 months following corneal transplantation. The mean follow-up after the secondary lens implantation was 24 months (range 2 to 70 months). Seven of the 33 corneas became cloudy 1 to 8 months after lens implantation. Prior to graft failure, 71% of the eyes achieved refractive errors within 2 diopters of emmetropia and 19 of 33 eyes (57%) achieved uncorrected visual acuities of 20/100 or better. In spite of surgical attempts to reduce preexisting astigmatism, the mean post-implant keratometry astigmatism was unchanged after secondary surgery. Compared with a concurrent series of triple procedures, the advantage of providing patients with refractive errors closer to emmetropia by performing surgery after a corneal transplant is outweighed by the increased risks to the graft, the increased costs and medical risks of two operations, the risk of increased astigmatism, and the delay in visual acuity recovery from the time of keratoplasty until obtaining a final refraction after secondary surgery.     

Cephalosporium endophthalmitis following penetrating keratoplasty.

A 69-year-old male with chronic herpes simplex keratitis underwent penetrating keratoplasty, using cryopreserved tissue. Seven weeks postoperatively the patient developed cephalosporium endophthalmitis. Intensive medical and surgical therapy was unsuccessful and the eye had to be enucleated within three weeks. Cephalosporium species are isolated more often in intraocular infection than from corneal ulceration. Although favorable response to Amphotericin-B and Primaricin has been reported, the final outcome has been unfavorable in most of these cases.     

Visual correction following penetrating keratoplasty.

Postoperative visual correction following penetrating keratoplasty usually includes spectacles, but for some patients optimal vision may be obtained using contact lenses. We studied 126 eyes of 101 patients undergoing penetrating keratoplasty to determine the frequency of postoperative contact-lens use, its clinical associations, its effect on the risk of corneal graft rejection, and its potential effects on topical medications. A total of 20 patients (16%) wore contact lenses postoperatively for maximal optical correction. Among eyes with good macular potential, 17 of 63 (27%) wore contact lenses. Contact-lens wear did not preclude the use of chronic postoperative topical medications, nor did it increase the risk of corneal graft rejection. We conclude that contact lenses may be useful for optimizing vision after penetrating keratoplasty, especially when macular potential is good.     

Complications of penetrating keratoplasty: graft infections

Microbial infection of a corneal transplant is a complication that is a bane to all corneal surgeons, the sequelae of which can be devastating. Identified risk factors include exposed, loose, or broken sutures; persistent epithelial defects or severe punctate keratopathy; soft contact lens wear including therapeutic lenses; graft hypoesthesia; kerato-conjunctivitis sicca; previous herpetic eye disease; graft failure; ocular adnexa and lid abnormalities; and ongoing external and corneal infections. Management includes preventive measures, microbiologic diagnostic procedures, and antibiotic therapy. Infectious crystalline keratopathy is a unique corneal infection that predominantly occurs in corneal transplants. It is characterized by the slowly progressive development of needle-like opacities in the corneal stroma and is most commonly caused by streptococcal species. Another group of infections that occur in grafts is recurrence of an infectious process for which the patient was originally grafted. Two notable pathogens in this group include Acanthamoeba and herpes simplex.     

Pediatric penetrating keratoplasty: indications and outcomes

Purpose

This report evaluates patient characteristics, indications, and outcomes of pediatric keratoplasty, and identifies variables that help to predict poor surgical outcomes.

Methods

We undertook a retrospective review of all cases in our department of primary penetrating keratoplasty performed in children 14 years of age or younger between January 2003 and December 2009.

Results

Sixteen primary penetrating keratoplasties were performed during the study interval. Mean age was 11.2 years (3 to 14 years) and the gender ratio was 2. The mean duration of follow-up was 16 months (2 to 36 months).The surgical indications were acquired traumatic opacities in 6 cases, keratoconus in 5 cases, corneal perforation secondary to infectious keratitis in 3 cases, hereditary corneal dystrophy in 1 case, and acquired non-traumatic opacities secondary to congenital glaucoma in one case. The initial visual acuity was less than 1/20 in 68% of cases and the mean final visual acuity after 1 year was 2/10. The graft was clear in 52% of cases after 1 year of follow-up. Postoperative complications were graft failure (24%), ocular inflammation (5%), and ocular trauma (19%).

Conclusion

Penetrating keratoplasty in children has been documented to have a higher rate of graft failure and a worse visual prognosis than adult keratoplasty. Poor prognosis outcomes were especially caused by noncooperation of parents and postoperative ocular trauma.     

Basic principles of anatomy for optimal surgical treatment of prostate cancer

The treatment of prostate cancer (PCa) with nerve sparing radical prostatectomy (NSRP) has experienced a substantial improvement in recent years due to new insights in anatomy of the prostate and of the adjacent structures. Knowledge of this specific anatomy is mandatory during RP in order to avoid injuries to functional tissue. Above all, these tissues are the neurovascular bundle (NVB) and the urethral sphincter. We therefore reviewed the available literature on prostatic anatomy and summarized it in this article. A search of the PubMed database was performed using the keywords radical prostatectomy, anatomy, neurovascular bundle, fascia, pelvis and sphincter. Relevant articles were reviewed, analyzed and summarized. This article gives an insight in the anatomy of the NVB, the urethral sphincter and the fascias surrounding the prostate. The NVB might be hampered near the seminal vesicles, at the lateral surface of the prostate and in the area of the prostato-urethral junction. The urethral sphincter might be hampered during dissection of the dorsal vein complex and during dissection of the urethra at the prostatic apex. Finally, the anatomy of the fascias surrounding the prostate is complex and can inter-individually vary substantially, which adds to the technical difficulties of NSRP. With this article we provide an overview on the complex anatomy of the prostate and the adjacent tissues. Respecting and considering these anatomic principles during NSRP should result in good postoperative functional outcome, as well as in good outcome in cancer control.     

Comparison of epikeratoplasty and penetrating keratoplasty for keratoconus

We report the results obtained in two groups of 30 eyes surgically treated for keratoconus. The eyes in the first group underwent epikeratoplasty, and those in the second group, penetrating keratoplasty. All eyes had sutures removed and a follow-up period ranging from 3 to 6 years. In the epikeratoplasty group, mean postoperative uncorrected visual acuity was 20/52 +/- 0.25; spectacle corrected, 20/23 +/- 0.18; and contact lens corrected, 20/21 +/- 0.17. In the penetrating keratoplasty group, mean postoperative uncorrected visual acuity was 20/63 +/- 0.23; spectacle corrected, 20/22 +/- 0.11; and contact lens corrected, 20/20.5 +/- 0.07. In the epikeratoplasty group, astigmatism (2.18 +/- 1.48) and astigmatism reduction (-4.16 +/- 2.98) were comparable to the penetrating keratoplasty group (astigmatism; 3.16 +/- 1.43 and astigmatism reduction; -4.2 +/- 2.56). Among the advantages offered by epikeratoplasty were both the absence of immunologic complications and reduction of operative risk. Penetrating keratoplasty provided patients with higher reduction of the myopic defect and earlier improvement in both visual acuity and contrast sensitivity.