Transactions. Section on Ophthalmology. American Academy of Ophthalmology and Otolaryngology最新文献

A retrospective study of our total experience with implantation of four types of keratoprosthesis in 125 cases was reviewed. Diagnoses in the cases treated included chemical burns, derangement of the anterior segment from disease or injury, aphakic bullous keratopathy, ocular pemphigoid, Stevens-Johnson syndrome, anterior cleavage syndrome, Mooren ulcer, and blast injuries. The visual results in some cases have been gratifying and in others heartrending. Thirty percent of the patients attained 20/15 to 20/40 visual acuity, but at the end of 12 years, only 13% still had this visual acuity. Twenty-four percent attained 20/50 to 20/200 visual acuity, but this figure fell to 17% at the end of 12 years. Loss of initial good visual acuity was due to the numerous complications which required close observation and repeated surgery to control. The number of complications has been reduced by the use of a keratoprosthesis with a Dacron skirt and of the addition the Cardona nut and bolt to the shaft. The surgical technique has been improved by the use of a scleral expander, elimination of a scleral graft, and the use of the Tenon graft. The indications for the keratoprosthesis have changed over the years. Many alkali burns and practically all aphakic bullous keratopathy have been eliminated from the indications. Keratoprosthesis should be reserved for desperate cases. The technique of implantation is not complicated and initial results are usually good. The multiple complications, however, make it necessary for these cases to be followed by a surgeon who is familiar with the management of complications.

The most common causes of acquired corneal scarring before age 6 are herpes simplex keratitis, penetrating injuries, and congenital dystrophies. We performed 18 keratoplasties in 16 eyes of 15 patients under the age of 12 years, achieving clear grafts in 14 eyes (87%). We also performed 11 grafts in nine eyes of eight patients with congenital, central corneal opacities, achieving only one clear graft and four instances of phthisis bulbi or enucleation for buphthalmos. We do not recommend penetrating keratoplasty in patients with unilateral, congenital corneal opacities. However, those with bilateral cloudy corneas should have an attempt at kertoplasty as early in life as possible. The social and psychologic condition of the family often makes the difference between success and failure.

A pathologic and experimental study of the etiology and morphology of the ridge, visible gonioscopically in the region of the internal lips of the cataract incision during and after the cataract operation, is described. The ridge observed clinically cannot be reproduced in human eye-banks eyes but can be reproduced in vivo in the eye of the owl monkey. Histopathology and ultramicroscopic studies of these experimental eyes, together with evidence derived from histopathologic slides of postmortem human eyes, suggest that the ridge is probably the result of immediate edematous swelling of the deeper layers of the corneal stroma after the incision transects corneal endothelium and the Descemet membrane. While internal wound lip malapposition may be a contributing factor to formation of the ridge, it is probably not an essential component. The ridge is not caused by the incision-closing sutures for it is already present prior to suturing of the wound. The role in ridge formation of mechanical stress alterations produced immediately by the incision is considered but is not known.

Three patients who developed epithelial invasion of the anterior chamber were treated by radical anterior segment surgery. Two adults had typical epithelial downgrowth of the anterior chamber, while the third patient, an 8-year-old child, developed large serous cysts following evacuation of a traumatic hyphema. In all three patients, the invading epithelium involved the iris, cornea, and angle, while the two adults had epithelium on the vitreous face as well. The operation consisted of an en bloc excision of cornea and sclera with contiguous iris, ciliary body, and vitreous when necessary. A free-hand corneoscleral graft was fashioned and sewn into the bed using interrupted 9-0 nylon sutures on the scleral side and continuous 10-0 nylon sutures on the corneal side. The patients all developed transitory glaucoma in the early post-operative period. The glaucoma was controlled with acetazolamide. A mild anterior uveitis usually was present for several months and was suppressed with topical applications of corticosteroids. Histopathologic study of the excised tissue showed complete removal of the epithelium.

The Troutman microsurgical keratometer has been shown to be useful in monitoring intraoperative procedures, and it has been demonstrated in the case of cataract and keratoplasty to have a significant influence on the control of operatively induced astigmatism. It is applicable to any surgical procedure which has the potential of altering permanently and unpredictably the corneal curvatures. Intraoperative keratometry has clearly demonstrated some inadequacies of our current cataract and keratoplasty techniques. It is now being used to guide our efforts toward a more rational control of the vexing problem of astigmatism.

An unselected sample of 142 pregnant women had a single cervical culture for C trachomatis at 36 to 40 weeks' gestation. Of these women, 18 (12.7%) had positive cultures, and their infants were followed in postoperative fashion. Of these 18 infants, eight (44%) developed ophthalmia neonatorum. A combination of cultures and conjunctival smears for Giemsa staining and fluorescent-antibody examination for infected cells confirmed the diagnosis in 70% of the infants with conjunctivitis. However, 12 of 18 infants has serum antibodies against genital strain chlamydial antigens at 1 year of age, indicating that a majority of the infants were infected. Four of the infants had superior micropannus at 1 year of age; however, none of the infants had active conjunctivitis nor corneal or conjunctival scars.