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Epithelial transplantation for the management of severe ocular surface disease
• Surveillance and control of epidemic keratoconjunctivitis. Gottsch JD.* Trans Am Ophthamol Soc 1996;94:539-587.
T
HE AUTHOR STUDIED WHETHER IMPLEMENTING A
formal set of infection-control policy and proced ures (ICPPs) could reduce the number of outbreaks of epidemic keratoconjunctivitis (EKC) and the number of nosocomially infected patients at the Wilmer Eye Institute. A retrospective and prospective study of the incidence of EKC and the number of affected patients was performed for the years 1984 through 1991. Infection-control measures were formulated in 1992, with regulations implemented for patient control and management, hand washing, instrument disinfection, medication distribution, and employee furloughs. Two levels of ICPPs were established on the basis of nonepidemic or epidemic conditions. After imple mentation, a prospective 4-year study (1992 through 1995), and statistical analyses were performed to determine whether the number of outbreaks of EKC and affected patients significantly decreased. The number of epidemics and affected patients was signifi cantly less when the years before and after implemen tation of ICPPs were compared by chi-square analysis (P < .01 and P < .01, respectively). The author suggested that a baseline of infection-control mea sures should be practiced daily by physicians and staff, and measures should be taken to identify patients and staff at risk for spreading disease.—Thomas J. Liesegang *Wilmer Institute Maumenee 317, 600 N Broadway, Baltimore, MD 21287-9235.
• Transvitreal endocyclophotocoagulation. Haller JA.* Trans Am Ophthamol Soc 1996;94:589-676.
T
HE AUTHOR CHARACTERIZED THE PROCEDURE OF
transvitreal endocyclophotocoagulation in ani mal eyes, examined the effect in human eyes histopathologically, and evaluated the clinical safety and efficacy in a large series of patients with long-term follow-up. Histopathologic examination of rabbit eyes demonstrated acute changes of ciliary process de struction, proteinaceous exudate, stromal edema, VOL.123, No. 4
nuclear pyknosis, pigment dispersion, vascular con gestion with hemorrhage, and fibrous or fibrovascular scar development. Enucleated human eyes disclosed total ablation of the ciliary processes with fibrosis and pigment clumping in areas of treatment. In a clinical series of 73 patients (mean age, 57.7 years; mean follow-up, 28.6 months), the mean preoperative in traocular pressure (IOP) was 38 mm Hg and the mean postoperative IOP was 16. At 1 year, 48 of 55 (87.3%) were successfully controlled and at last follow-up, 50 of 73 (68%) were successfully con trolled. Complications developed in nine eyes (12%), including IOP ^ 6 mm Hg in six eyes, a peripheral choroidal effusion in four (5.5%), fibrinous anterior chamber reaction in three (4.1%), phthisis in two (2.7%), and choroidal hemorrhages in one. Thirtyfive eyes had penetrating keratoplasty performed be fore or at the same time as endolaser. Graft rejection occurred in 11 of 35 (31%). Endolaser to the ciliary body was especially successful in glaucomatous eyes after keratoplasty, although corneal graft prognosis is limited in these cases. The technique has particular value in eyes that require other surgical intervention at the time of glaucoma treatment.—Thomas J. Liesegang "Johns Hopkins Hospital, Maumenee 719, 600 N Wolfe St, Baltimore, MD 21287-9277.
• Epithelial transplantation for the management of severe ocular surface disease. Holland EJ.* Trans Am Ophthamol Soc 1996; 94:677-743.
E
PITHELIAL TRANSPLANTATION FOR OCULAR SUR-
face disease was classified by the author as one of the following procedures: conjunctival autograft, conjunctival allograft, conjunctival limbal autograft, ca daveric conjunctival limbal allograft, living related conjunctival limbal allograft, or keratolimbal allo graft. Eighteen of 25 eyes (72%) with a keratolimbal allograft procedure developed a stable ocular surface. Fifteen eyes (60%) demonstrated a significant im provement in visual acuity. Persistent epithelial de fects and symblephara were successfully managed with this procedure. Six of 13 (46%) subsequent keratoplasties were successful. Patients with limbal
ABSTRACTS
577
deficiency due to Stevens-Johnson syndrome and patients with preoperative conjunctival keratinization had a significantly worse outcome. The author offered his indications for epithelial transplantation as fol lows: For patients with unilateral cicatrizing conjunc tival disease, the first option recommended was a conjunctival autograft. For patients with unilateral limbal deficiency, conjunctival limbal autograft was the procedure of choice. For patients with bilateral disease, living related conjunctival limbal allograft was recommended first. If this procedure was not available, he suggested consideration of keratolimbal allograft. Keratolimbal allograft was a useful tech nique in the management of severe ocular surface disease caused by limbal deficiency.—Thomas J. Liesegang *U Minn Department of Ophthalmology, Box 493, 420 Delaware St SE, Minneapolis, MN 55455-0501.
• Histological changes and wound healing response following noncontact holmium: YAG laser thermal keratoplasty. Koch DD.* Trans Am Ophthamol Soc 1996;94:745-802.
T
HE AUTHOR EVALUATED THE ACUTE HISTOPATHO-
logic changes and the induced wound-healing response in rabbit and human corneal tissue follow ing noncontact holmium:YAG laser thermal kerato plasty (LTK). Laser thermal kerotoplasty was per formed on three human corneas 1 day prior to penetrating keratoplasty, using 10 pulses and a range of radiant energies. Rabbit corneas were treated with 10-pulse and 5-pulse LTK and followed for up to 3 months; tissues were studied with light and transmis sion electron microscopy and immunohistochemistry. The amount of human acute tissue injury increased with increasing pulses of radiant energy. In human corneas, changes in the irradiated zones included epithelial cell injury and death, loss of fine filamen tous structure in the Bowman layer, disruption of stromal lamellae, and keratocyte injury and death. In the rabbit corneas, similar acute changes were noted. Compared to 10-pulse treatments, 5-pulse treatments produced less acute tissue injury and had more rapid restoration of normal stromal architecture. The au
578
thor felt that noncontact LTK produced acute epithe lial and stromal tissue changes and in rabbit corneas stimulated a brisk wound-healing response that could contribute to postoperative regression of induced refractive correction.—Thomas J. Liesegang *Cullen Eye Institute, 6501 Fannin NC-200, Houston, TX 77030.
• Visual impairment, visual functioning, and qual ity of life assessments in patients with glaucoma. Parrish RK.* Trans Am Ophthamol Soc 1996;94: 919-1028.
T
HE AUTHOR STUDIED THE RELATION BETWEEN VISU-
al impairment, visual functioning, and the global quality of life in 147 consecutive patients with glaucoma. Visual impairment was defined by the American Medical Association Guides to the Evalua tion of Permanent Impairment; visual functioning was measured with the VF-14 and the Field Test Version of the National Eye Institute-Visual Func tioning Questionnaire (NEI-VFQ); the global quality of life was assessed with the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). None of the SF-36 domains demonstrated more than a weak correlation with visual impairment. The VF-14 scores were moderately correlated with visual impairment. Of the 12 NEI-VFQ scales, distance activities and vision-specific dependencies were moderately corre lated with visual acuity impairment and with visual field impairment; vision-specific social functioning, near activities, vision-specific role difficulties, general vision, vision-specific mental health, color vision, and driving were modestly correlated; visual pain was weakly correlated, and two other scales were not significantly correlated. The author concluded that the SF-36 was unlikely to be useful in determining visual impairment in patients with glaucoma. Based on the moderate correlation between visual field impairment and the VF-14 score, this questionnaire may be generalizable to patients with glaucoma. Several of the NEI-VFQ scales correlated with visual field impairment scores in patients with a wide range of glaucomatous damage.—Thomas J. Liesegang *Bascom Palmer Eye Institute, P. O. Box 016880, Miami, FL 33101.
AMERICAN JOURNAL OF OPHTHALMOLOGY
APRIL
1997
T
HE AUTHOR STUDIED WHETHER IMPLEMENTING A
formal set of infection-control policy and proced ures (ICPPs) could reduce the number of outbreaks of epidemic keratoconjunctivitis (EKC) and the number of nosocomially infected patients at the Wilmer Eye Institute. A retrospective and prospective study of the incidence of EKC and the number of affected patients was performed for the years 1984 through 1991. Infection-control measures were formulated in 1992, with regulations implemented for patient control and management, hand washing, instrument disinfection, medication distribution, and employee furloughs. Two levels of ICPPs were established on the basis of nonepidemic or epidemic conditions. After imple mentation, a prospective 4-year study (1992 through 1995), and statistical analyses were performed to determine whether the number of outbreaks of EKC and affected patients significantly decreased. The number of epidemics and affected patients was signifi cantly less when the years before and after implemen tation of ICPPs were compared by chi-square analysis (P < .01 and P < .01, respectively). The author suggested that a baseline of infection-control mea sures should be practiced daily by physicians and staff, and measures should be taken to identify patients and staff at risk for spreading disease.—Thomas J. Liesegang *Wilmer Institute Maumenee 317, 600 N Broadway, Baltimore, MD 21287-9235.
• Transvitreal endocyclophotocoagulation. Haller JA.* Trans Am Ophthamol Soc 1996;94:589-676.
T
HE AUTHOR CHARACTERIZED THE PROCEDURE OF
transvitreal endocyclophotocoagulation in ani mal eyes, examined the effect in human eyes histopathologically, and evaluated the clinical safety and efficacy in a large series of patients with long-term follow-up. Histopathologic examination of rabbit eyes demonstrated acute changes of ciliary process de struction, proteinaceous exudate, stromal edema, VOL.123, No. 4
nuclear pyknosis, pigment dispersion, vascular con gestion with hemorrhage, and fibrous or fibrovascular scar development. Enucleated human eyes disclosed total ablation of the ciliary processes with fibrosis and pigment clumping in areas of treatment. In a clinical series of 73 patients (mean age, 57.7 years; mean follow-up, 28.6 months), the mean preoperative in traocular pressure (IOP) was 38 mm Hg and the mean postoperative IOP was 16. At 1 year, 48 of 55 (87.3%) were successfully controlled and at last follow-up, 50 of 73 (68%) were successfully con trolled. Complications developed in nine eyes (12%), including IOP ^ 6 mm Hg in six eyes, a peripheral choroidal effusion in four (5.5%), fibrinous anterior chamber reaction in three (4.1%), phthisis in two (2.7%), and choroidal hemorrhages in one. Thirtyfive eyes had penetrating keratoplasty performed be fore or at the same time as endolaser. Graft rejection occurred in 11 of 35 (31%). Endolaser to the ciliary body was especially successful in glaucomatous eyes after keratoplasty, although corneal graft prognosis is limited in these cases. The technique has particular value in eyes that require other surgical intervention at the time of glaucoma treatment.—Thomas J. Liesegang "Johns Hopkins Hospital, Maumenee 719, 600 N Wolfe St, Baltimore, MD 21287-9277.
• Epithelial transplantation for the management of severe ocular surface disease. Holland EJ.* Trans Am Ophthamol Soc 1996; 94:677-743.
E
PITHELIAL TRANSPLANTATION FOR OCULAR SUR-
face disease was classified by the author as one of the following procedures: conjunctival autograft, conjunctival allograft, conjunctival limbal autograft, ca daveric conjunctival limbal allograft, living related conjunctival limbal allograft, or keratolimbal allo graft. Eighteen of 25 eyes (72%) with a keratolimbal allograft procedure developed a stable ocular surface. Fifteen eyes (60%) demonstrated a significant im provement in visual acuity. Persistent epithelial de fects and symblephara were successfully managed with this procedure. Six of 13 (46%) subsequent keratoplasties were successful. Patients with limbal
ABSTRACTS
577
deficiency due to Stevens-Johnson syndrome and patients with preoperative conjunctival keratinization had a significantly worse outcome. The author offered his indications for epithelial transplantation as fol lows: For patients with unilateral cicatrizing conjunc tival disease, the first option recommended was a conjunctival autograft. For patients with unilateral limbal deficiency, conjunctival limbal autograft was the procedure of choice. For patients with bilateral disease, living related conjunctival limbal allograft was recommended first. If this procedure was not available, he suggested consideration of keratolimbal allograft. Keratolimbal allograft was a useful tech nique in the management of severe ocular surface disease caused by limbal deficiency.—Thomas J. Liesegang *U Minn Department of Ophthalmology, Box 493, 420 Delaware St SE, Minneapolis, MN 55455-0501.
• Histological changes and wound healing response following noncontact holmium: YAG laser thermal keratoplasty. Koch DD.* Trans Am Ophthamol Soc 1996;94:745-802.
T
HE AUTHOR EVALUATED THE ACUTE HISTOPATHO-
logic changes and the induced wound-healing response in rabbit and human corneal tissue follow ing noncontact holmium:YAG laser thermal kerato plasty (LTK). Laser thermal kerotoplasty was per formed on three human corneas 1 day prior to penetrating keratoplasty, using 10 pulses and a range of radiant energies. Rabbit corneas were treated with 10-pulse and 5-pulse LTK and followed for up to 3 months; tissues were studied with light and transmis sion electron microscopy and immunohistochemistry. The amount of human acute tissue injury increased with increasing pulses of radiant energy. In human corneas, changes in the irradiated zones included epithelial cell injury and death, loss of fine filamen tous structure in the Bowman layer, disruption of stromal lamellae, and keratocyte injury and death. In the rabbit corneas, similar acute changes were noted. Compared to 10-pulse treatments, 5-pulse treatments produced less acute tissue injury and had more rapid restoration of normal stromal architecture. The au
578
thor felt that noncontact LTK produced acute epithe lial and stromal tissue changes and in rabbit corneas stimulated a brisk wound-healing response that could contribute to postoperative regression of induced refractive correction.—Thomas J. Liesegang *Cullen Eye Institute, 6501 Fannin NC-200, Houston, TX 77030.
• Visual impairment, visual functioning, and qual ity of life assessments in patients with glaucoma. Parrish RK.* Trans Am Ophthamol Soc 1996;94: 919-1028.
T
HE AUTHOR STUDIED THE RELATION BETWEEN VISU-
al impairment, visual functioning, and the global quality of life in 147 consecutive patients with glaucoma. Visual impairment was defined by the American Medical Association Guides to the Evalua tion of Permanent Impairment; visual functioning was measured with the VF-14 and the Field Test Version of the National Eye Institute-Visual Func tioning Questionnaire (NEI-VFQ); the global quality of life was assessed with the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). None of the SF-36 domains demonstrated more than a weak correlation with visual impairment. The VF-14 scores were moderately correlated with visual impairment. Of the 12 NEI-VFQ scales, distance activities and vision-specific dependencies were moderately corre lated with visual acuity impairment and with visual field impairment; vision-specific social functioning, near activities, vision-specific role difficulties, general vision, vision-specific mental health, color vision, and driving were modestly correlated; visual pain was weakly correlated, and two other scales were not significantly correlated. The author concluded that the SF-36 was unlikely to be useful in determining visual impairment in patients with glaucoma. Based on the moderate correlation between visual field impairment and the VF-14 score, this questionnaire may be generalizable to patients with glaucoma. Several of the NEI-VFQ scales correlated with visual field impairment scores in patients with a wide range of glaucomatous damage.—Thomas J. Liesegang *Bascom Palmer Eye Institute, P. O. Box 016880, Miami, FL 33101.
AMERICAN JOURNAL OF OPHTHALMOLOGY
APRIL
1997