- Email: [email protected]
Microkeratome-induced reduction of astigmatism after penetrating keratoplasty
sacrificed, the trigeminal ganglia removed and placed onto A549 cells to determine the herpes simplex virus type-1 latency rates. The data were analyzed using log-likelihood ratio analysis. The results showed that both surface excimer laser ablation (17 of 26 eyes, 65%) and laser-assisted in situ keratomileusis (9 of 20 eyes, 45%) produced significantly more herpes simplex virus type-1 positive eyes than did the no treatment group (7 of 26 eyes, 27%) (P ⬍ 0.002). Similarly, both surface excimer laser ablation (45 of 260 days, 17%) and laser-assisted in situ keratomileusis (26 of 200 days, 13%) induced significantly more total herpes simplex virus type-1 shedding days than did the no treatment group (9 of 260 days, 3.5%) (P ⬍ 0.000001). No significant differences existed between laser-assisted in situ keratomileusis and surface excimer laser ablation groups for either outcome variable. All three groups demonstrated 100% trigeminal ganglia latency (P ⫽ not significant). Using virological outcome measures, the current study provides the first experimental proof that laser-assisted in situ keratomileusis, as well as surface excimer laser ablation, can trigger the reactivation of latent herpes simplex virus type-1 and induce ocular shedding of live virus. Our study provides an explanation for the clinical occurrence of herpes simplex keratitis in a patient after laser-assisted in situ keratomileusis.3 REFERENCES
1. Yashar AG. Market conditions now favorable for refractive surgery. Ophthalmology Times 2000;25(6):60 – 61. 2. Dhaliwal DK, Barnhorst DA, Romanowski EG, Rehkopf PG, Gordon YJ. Excimer laser keratectomy efficiently reactivates latent HSV-1 in the experimental rabbit ocular model. Am J Ophthalmol 1998;125:488 – 492. 3. Davidorf JM. Herpes simplex keratitis after LASIK. J Refractive Surg 1998;14:667.
Microkeratome-Induced Reduction of Astigmatism After Penetrating Keratoplasty Tanuj Dada, MD, Rasik B. Vajpayee, MBBS, MS, Vishal Gupta, MD, Namrata Sharma, MD, and Vijay K. Dada, MBBS, MS PURPOSE:
To report the reduction in postpenetrating keratoplasty astigmatism with the use of the microkera-
Accepted for publication Sep 29, 2000. From the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. Inquiries to Rasik B. Vajpayee, MBBS, MS, Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 110029, India; fax: 91-11-6852919; e-mail: [email protected]
VOL. 131, NO. 4
tome to create a lamellar corneal flap as the first stage in a two-step laser in situ keratomileusis. METHODS: The hansatome microkeratome was used to create a lamellar corneal flap in a 24-year-old man with a net corneal astigmatism of 7.3 diopters, 2 years after penetrating keratoplasty. No laser ablation was performed. RESULTS: The net corneal astigmatism reduced to 3.9 diopters at 1 month and 2.3 diopters at 3 months of follow-up, without any laser ablation. CONCLUSION: Laser in situ keratomileusis may be performed as a two-stage procedure, because the lamellar corneal flap alone may reduce postpenetrating keratoplasty astigmatism. (Am J Ophthalmol 2001;131: 507–508. © 2001 by Elsevier Science Inc. All rights reserved.)
L
ASER IN SITU KERATOMILEUSIS IS A USEFUL MODALITY
in the management of high spherical and cylindrical errors after penetrating keratoplasty.1– 4 This report highlights the reduction in the astigmatic error induced by the cut of the microkeratome during a planned two-stage laser in situ keratomileusis. ● CASE:
Laser in situ keratomileusis was planned as a two-stage procedure in a 24-year-old man, 2 years after he had undergone penetrating keratoplasty in the right eye. The best-corrected visual acuity was 20/30, with a refractive error of ⫺2.0 Dsph/⫺7 Dcyl at 15 degrees in the right eye. Biomicroscopic examination revealed a clear graft measuring 8 ⫻ 8 mm, a well-healed scar along the graft host junction, with no evidence of anterior or posterior wound gape, corneal thinning/ectasia, or vascularization. Sutures had been removed between 6 months and 1 year after the surgery. The Orbscan (Bausch and Lomb, Salt Lake City, Utah) corneal topography revealed a keratometry reading of 58.5 at 156 degrees/51.3 at 66 degrees, with an astigmatism of 7.3 diopters. The hansatome microkeratome (Bausch and Lomb, Salt Lake City, Utah) was used to create a lamellar corneal flap with a diameter of 8.5 mm and a depth of 180 m. The follow-up visits were scheduled at 24 hours, 1 week, 1 month, and 3 months after the surgery. The corneal topography readings were recorded (Table 1). The mean astigmatism reduced from 7.3 diopters to 3.7 diopters at 1 week, 3.9 diopters at 1 month, and was 2.3 diopters at the end of 3 months. The refractive error was ⫺3.0 DSph/⫺2.0 Cyl at 5 degrees, and the best-corrected visual acuity was 20/30 at the end of 3 months. The corneal topography and the refraction remained stable at the final follow-up at 6 months. Compound myopic astigmatism is a common complication of penetrating keratoplasty and leads to a poor visual outcome.5 Most investigators have performed laser in situ keratomileusis after penetrating keratoplasty as a single-
BRIEF REPORTS
507
PURPOSE: To report fungal infection complicating Acanthamoeba keratitis. METHODS: Case report. A 45-year-old woman with contact lens–related bilateral Acanthamoeba keratitis developed corneal ulcer, corneal perforation, and mature cataract in the left eye, which was managed by penetrating keratoplasty, lensectomy, and vitrectomy. RESULTS: Histopathologic examination of the keratoplasty specimen from the left eye revealed extensive lamellar stromal necrosis with the coexistence of both empty cysts and branching hyphae. Cultures from the keratoplasty specimen grew Scedosporium apiospermum. CONCLUSION: Keratomycosis caused by S. apiospermum may complicate protracted Acanthamoeba keratitis. (Am J Ophthalmol 2001;131:508 –509. © 2001 by Elsevier Science Inc. All rights reserved.)
TABLE 1. Corneal Topography Changes After Microkeratome Cut Follow-up
Central Corneal Topography
Net Astigmatism
Preoperative 1 month 3 months
51.3 @ 66, 58.5 @ 156 52.2 @ 13, 56.1 @ 103 53.8 @ 14, 56.1 @ 104
7.3 diopters 3.9 diopters 2.3 diopters
stage surgery by making a corneal flap with a microkeratome and then performing laser ablation.1– 4. Our case highlights the fact that the lamellar cut made by the microkeratome can modify the existing refractive error, independent of laser ablation. In addition, a refractive shift may continue to occur up to 3 months after the creation of the corneal flap. Therefore, it may be beneficial to perform laser ablation after 3 months or after the refraction has stabilized after the microkeratome cut. High astigmatic error after penetrating keratoplasty is usually caused by irregular scarring and asymmetric contractile forces emanating from the host graft junction. The creation of a lamellar corneal flap with the microkeratome results in a circumferential release of these contractile forces with a resultant reduction in the surgically induced astigmatism. We therefore recommend that laser in situ keratomileusis may be performed as a two-stage procedure to correct high postoperative surgical astigmatism after penetrating keratoplasty. The lamellar corneal flap should be cut in the first stage, and the laser ablation should be done by relifting the flap after achieving a stable corneal topography and refraction.
I
presented with pain, decreased visual acuity, and photophobia in both eyes. She wore extended-wear soft contact lenses. Examination showed bilateral corneal ulcers with infiltrates. Visual acuity was reduced to hand motion in the left eye and counting fingers in the right eye. After initial treatment with cyclosporin A and prednisolone acetate for presumed herpes simplex virus, Acanthamoeba was identified in the contact lens solutions. Multiple corneal scrapings and biopsies were negative. In both eyes, she was treated with topical brolene, ketorolac, neomycin, and cyclogyl. Contact lens use was discontinued. In August 1997, persistent bilateral corneal ulceration prompted bilateral corneal re-biopsy and scrapings at the Jules Stein Eye Institute (UCLA School of Medicine, Los Angeles, California) that revealed Acanthamoeba in the left eye. For both eyes, treatment was continued with brolene, biguanide, neomycin, and clotrimazole. In June 1998, the patient developed a perforated corneal ulcer and a mature cataract in the left eye. A penetrating keratoplasty, lensectomy, and vitrectomy were performed in the left eye. A portion of the keratoplasty specimen was processed for bacterial, fungal, and Acanthamoeba cultures. Gross examination of the remaining keratoplasty specimen revealed severe ulceration and a dense, white stromal infiltrate. Microscopic examination of the specimen revealed lamellar necrosis and double walled cystic structures, most of which were empty (Figure 1). In addition, hyphal structures with bulbous tips and 90 degree angle branching were evident in the stroma and penetrated the
REFERENCES
1. Spadea L, Mosca L, Balestrazzi E. Effectiveness of LASIK to correct refractive error after penetrating keratoplasty. Ophthalmic Surg Lasers 2000;31:111–120. 2. Arenas E, Maglione A. LASIK for astigmatism and myopia after penetrating keratoplasty. J Refract Surg 1997;113:27–32. 3. Parisi A, Salchow DJ, Zirm ME, Stieldolf C. LASIK after automated lamellar keratoplasty and penetrating keratoplasty. J Cataract Refract Surg 1997;23:1114 –1118. 4. Donnenfeld ED, Kornstein HS, Amin A, et al. LASIK for correction of myopia and astigmatism after penetrating keratoplasty. Ophthalmology 1999;106:1966 –1975. 5. Perlman EM. An analysis and interpretation of refractive errors after penetrating keratoplasty. Ophthalmology 1981;88: 39 –45.
Accepted for publication Sep 29, 2000. From the Jules Stein Eye Institute, Department of Ophthalmology (N.A.F., B.J.M., B.J.G.), and the Department of Pathology and Laboratory Medicine (N.A.F., B.J.G.), UCLA School of Medicine, Los Angeles, California. Supported by an unrestricted grant from Research to Prevent Blindness, New York, New York. Inquiries to Ben J. Glasgow, MD, Jules Stein Eye Institute, 100 Stein Plaza, UCLA, Room B-269, Los Angeles, CA 90095-7000; fax: (310) 794-2144; e-mail: [email protected]
Acanthamoeba Keratitis Associated with Fungal Keratitis Nicholas A. Froumis, Bartly J. Mondino, MD, and Ben J. Glasgow, MD 508
AMERICAN JOURNAL
N MAY 1997, A 45-YEAR-OLD WOMAN LIVING IN ITALY
OF
OPHTHALMOLOGY
APRIL 2001
1. Yashar AG. Market conditions now favorable for refractive surgery. Ophthalmology Times 2000;25(6):60 – 61. 2. Dhaliwal DK, Barnhorst DA, Romanowski EG, Rehkopf PG, Gordon YJ. Excimer laser keratectomy efficiently reactivates latent HSV-1 in the experimental rabbit ocular model. Am J Ophthalmol 1998;125:488 – 492. 3. Davidorf JM. Herpes simplex keratitis after LASIK. J Refractive Surg 1998;14:667.
Microkeratome-Induced Reduction of Astigmatism After Penetrating Keratoplasty Tanuj Dada, MD, Rasik B. Vajpayee, MBBS, MS, Vishal Gupta, MD, Namrata Sharma, MD, and Vijay K. Dada, MBBS, MS PURPOSE:
To report the reduction in postpenetrating keratoplasty astigmatism with the use of the microkera-
Accepted for publication Sep 29, 2000. From the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. Inquiries to Rasik B. Vajpayee, MBBS, MS, Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 110029, India; fax: 91-11-6852919; e-mail: [email protected]
VOL. 131, NO. 4
tome to create a lamellar corneal flap as the first stage in a two-step laser in situ keratomileusis. METHODS: The hansatome microkeratome was used to create a lamellar corneal flap in a 24-year-old man with a net corneal astigmatism of 7.3 diopters, 2 years after penetrating keratoplasty. No laser ablation was performed. RESULTS: The net corneal astigmatism reduced to 3.9 diopters at 1 month and 2.3 diopters at 3 months of follow-up, without any laser ablation. CONCLUSION: Laser in situ keratomileusis may be performed as a two-stage procedure, because the lamellar corneal flap alone may reduce postpenetrating keratoplasty astigmatism. (Am J Ophthalmol 2001;131: 507–508. © 2001 by Elsevier Science Inc. All rights reserved.)
L
ASER IN SITU KERATOMILEUSIS IS A USEFUL MODALITY
in the management of high spherical and cylindrical errors after penetrating keratoplasty.1– 4 This report highlights the reduction in the astigmatic error induced by the cut of the microkeratome during a planned two-stage laser in situ keratomileusis. ● CASE:
Laser in situ keratomileusis was planned as a two-stage procedure in a 24-year-old man, 2 years after he had undergone penetrating keratoplasty in the right eye. The best-corrected visual acuity was 20/30, with a refractive error of ⫺2.0 Dsph/⫺7 Dcyl at 15 degrees in the right eye. Biomicroscopic examination revealed a clear graft measuring 8 ⫻ 8 mm, a well-healed scar along the graft host junction, with no evidence of anterior or posterior wound gape, corneal thinning/ectasia, or vascularization. Sutures had been removed between 6 months and 1 year after the surgery. The Orbscan (Bausch and Lomb, Salt Lake City, Utah) corneal topography revealed a keratometry reading of 58.5 at 156 degrees/51.3 at 66 degrees, with an astigmatism of 7.3 diopters. The hansatome microkeratome (Bausch and Lomb, Salt Lake City, Utah) was used to create a lamellar corneal flap with a diameter of 8.5 mm and a depth of 180 m. The follow-up visits were scheduled at 24 hours, 1 week, 1 month, and 3 months after the surgery. The corneal topography readings were recorded (Table 1). The mean astigmatism reduced from 7.3 diopters to 3.7 diopters at 1 week, 3.9 diopters at 1 month, and was 2.3 diopters at the end of 3 months. The refractive error was ⫺3.0 DSph/⫺2.0 Cyl at 5 degrees, and the best-corrected visual acuity was 20/30 at the end of 3 months. The corneal topography and the refraction remained stable at the final follow-up at 6 months. Compound myopic astigmatism is a common complication of penetrating keratoplasty and leads to a poor visual outcome.5 Most investigators have performed laser in situ keratomileusis after penetrating keratoplasty as a single-
BRIEF REPORTS
507
PURPOSE: To report fungal infection complicating Acanthamoeba keratitis. METHODS: Case report. A 45-year-old woman with contact lens–related bilateral Acanthamoeba keratitis developed corneal ulcer, corneal perforation, and mature cataract in the left eye, which was managed by penetrating keratoplasty, lensectomy, and vitrectomy. RESULTS: Histopathologic examination of the keratoplasty specimen from the left eye revealed extensive lamellar stromal necrosis with the coexistence of both empty cysts and branching hyphae. Cultures from the keratoplasty specimen grew Scedosporium apiospermum. CONCLUSION: Keratomycosis caused by S. apiospermum may complicate protracted Acanthamoeba keratitis. (Am J Ophthalmol 2001;131:508 –509. © 2001 by Elsevier Science Inc. All rights reserved.)
TABLE 1. Corneal Topography Changes After Microkeratome Cut Follow-up
Central Corneal Topography
Net Astigmatism
Preoperative 1 month 3 months
51.3 @ 66, 58.5 @ 156 52.2 @ 13, 56.1 @ 103 53.8 @ 14, 56.1 @ 104
7.3 diopters 3.9 diopters 2.3 diopters
stage surgery by making a corneal flap with a microkeratome and then performing laser ablation.1– 4. Our case highlights the fact that the lamellar cut made by the microkeratome can modify the existing refractive error, independent of laser ablation. In addition, a refractive shift may continue to occur up to 3 months after the creation of the corneal flap. Therefore, it may be beneficial to perform laser ablation after 3 months or after the refraction has stabilized after the microkeratome cut. High astigmatic error after penetrating keratoplasty is usually caused by irregular scarring and asymmetric contractile forces emanating from the host graft junction. The creation of a lamellar corneal flap with the microkeratome results in a circumferential release of these contractile forces with a resultant reduction in the surgically induced astigmatism. We therefore recommend that laser in situ keratomileusis may be performed as a two-stage procedure to correct high postoperative surgical astigmatism after penetrating keratoplasty. The lamellar corneal flap should be cut in the first stage, and the laser ablation should be done by relifting the flap after achieving a stable corneal topography and refraction.
I
presented with pain, decreased visual acuity, and photophobia in both eyes. She wore extended-wear soft contact lenses. Examination showed bilateral corneal ulcers with infiltrates. Visual acuity was reduced to hand motion in the left eye and counting fingers in the right eye. After initial treatment with cyclosporin A and prednisolone acetate for presumed herpes simplex virus, Acanthamoeba was identified in the contact lens solutions. Multiple corneal scrapings and biopsies were negative. In both eyes, she was treated with topical brolene, ketorolac, neomycin, and cyclogyl. Contact lens use was discontinued. In August 1997, persistent bilateral corneal ulceration prompted bilateral corneal re-biopsy and scrapings at the Jules Stein Eye Institute (UCLA School of Medicine, Los Angeles, California) that revealed Acanthamoeba in the left eye. For both eyes, treatment was continued with brolene, biguanide, neomycin, and clotrimazole. In June 1998, the patient developed a perforated corneal ulcer and a mature cataract in the left eye. A penetrating keratoplasty, lensectomy, and vitrectomy were performed in the left eye. A portion of the keratoplasty specimen was processed for bacterial, fungal, and Acanthamoeba cultures. Gross examination of the remaining keratoplasty specimen revealed severe ulceration and a dense, white stromal infiltrate. Microscopic examination of the specimen revealed lamellar necrosis and double walled cystic structures, most of which were empty (Figure 1). In addition, hyphal structures with bulbous tips and 90 degree angle branching were evident in the stroma and penetrated the
REFERENCES
1. Spadea L, Mosca L, Balestrazzi E. Effectiveness of LASIK to correct refractive error after penetrating keratoplasty. Ophthalmic Surg Lasers 2000;31:111–120. 2. Arenas E, Maglione A. LASIK for astigmatism and myopia after penetrating keratoplasty. J Refract Surg 1997;113:27–32. 3. Parisi A, Salchow DJ, Zirm ME, Stieldolf C. LASIK after automated lamellar keratoplasty and penetrating keratoplasty. J Cataract Refract Surg 1997;23:1114 –1118. 4. Donnenfeld ED, Kornstein HS, Amin A, et al. LASIK for correction of myopia and astigmatism after penetrating keratoplasty. Ophthalmology 1999;106:1966 –1975. 5. Perlman EM. An analysis and interpretation of refractive errors after penetrating keratoplasty. Ophthalmology 1981;88: 39 –45.
Accepted for publication Sep 29, 2000. From the Jules Stein Eye Institute, Department of Ophthalmology (N.A.F., B.J.M., B.J.G.), and the Department of Pathology and Laboratory Medicine (N.A.F., B.J.G.), UCLA School of Medicine, Los Angeles, California. Supported by an unrestricted grant from Research to Prevent Blindness, New York, New York. Inquiries to Ben J. Glasgow, MD, Jules Stein Eye Institute, 100 Stein Plaza, UCLA, Room B-269, Los Angeles, CA 90095-7000; fax: (310) 794-2144; e-mail: [email protected]
Acanthamoeba Keratitis Associated with Fungal Keratitis Nicholas A. Froumis, Bartly J. Mondino, MD, and Ben J. Glasgow, MD 508
AMERICAN JOURNAL
N MAY 1997, A 45-YEAR-OLD WOMAN LIVING IN ITALY
OF
OPHTHALMOLOGY
APRIL 2001