Publications by authors named "Joel Sugar"

55 Publications

Herpetic Eye Disease Study: A Controlled Trial of Topical Corticosteroids for Herpes Simplex Stromal Keratitis.

Ophthalmology 2020 04;127(4S):S5-S18

Purpose: To evaluate the efficacy of topical corticosteroids in treating herpes simplex stromal keratitis.

Methods: The authors performed a randomized, double-masked, placebo-con- trolled, multicenter clinical trial of 106 patients with active herpes simplex stromal keratitis who had not received any corticosteroids for at least 10 days before study enrollment. Patients were assigned to the placebo group (n = 49) or the steroid group (topical prednisolone phosphate; n = 57); both regimens were tapered over 10 weeks. Both groups received topical trifluridine. Visual acuity assessment and slit-lamp biomicroscopy were performed weekly for 10 weeks, every other week for an additional 6 weeks or until removal from the trial, and at 6 months after randomization.

Results: The time to treatment failure (defined by specific criteria as persistent or progressive stromal keratouveitis or an adverse event) was significantly longer in the steroid group compared with the placebo group. Compared with placebo, corticosteroid therapy reduced the risk of persistent or progressive stromal keratouveitis by 68%. The time from randomization to resolution of stromal keratitis and uveitis was significantly shorter in the steroid group compared with the placebo group even though both groups included patients who were removed from the study and treated with topical corticosteroids according to best medical judgment. Nineteen (33%) of the steroid-treated patients and 11 (22%) of the placebo-treated patients completed the 10 weeks of protocol therapy and had stable, noninflamed corneas after 16 weeks. At 6 months after randomization, no clinically or statistically significant differences in visual outcome or recurrent herpetic eye disease were identified between the steroid and placebo groups.

Conclusions: The topical corticosteroid regimen used in this study was significantly better than placebo in reducing persistence or progression of stromal inflammation and in shortening the duration of herpes simplex stromal keratitis. Postponing steroids during careful observation for a few weeks delayed resolution of stromal keratitis but had no detrimental effect as assessed by visual outcome at 6 months.
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http://dx.doi.org/10.1016/j.ophtha.2020.01.037DOI Listing
April 2020

Management of Congenital Aniridia-Associated Keratopathy: Long-Term Outcomes from a Tertiary Referral Center.

Am J Ophthalmol 2020 02 12;210:8-18. Epub 2019 Nov 12.

Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, Illinois, USA. Electronic address:

Purpose: To report the outcomes of medical and surgical management for congenital aniridia-associated keratopathy (AAK) over a long-term follow-up period.

Design: Retrospective, comparative case series.

Methods: Medical records of patients diagnosed with congenital aniridia were retrospectively reviewed. Age, sex, ethnicity, follow-up time, AAK stage, noncorneal abnormalities, ocular surgeries, and complications were recorded. The visual acuity equivalent (VAE), approximate Early Treatment Diabetic Retinopathy Study (appETDRS) letter score, was calculated using recorded Snellen visual acuities.

Results: A total of 92 eyes of 47 patients (31 females) with mean age of 48.0 ± 18.0 years and mean follow-up of 78.6 ± 42.2 months were included. At the initial visit, 12 eyes (13%) were classified as Stage I AAK, 33 eyes (35.9%) were Stage II, 25 eyes (27.2%) were Stage III, 17 eyes (18.5%) were Stage IV, and 5 eyes (5.4%) were Stage V. Limbal stem cell transplantation (LSCT) and Boston keratoprosthesis (KPro) were frequently performed in eyes with Stages III-V. These advanced corneal surgeries significantly improved the median (95% confidence interval [CI]) of calculated appETDRS scores from 2 (0-20) to 26 (15-41) (Snellen values, 20/20,000 to 20/300; P = 0.0004). Patients with earlier Stages (I-II) of AAK were managed medically and had stable visual acuity through their final visits (appETDRS score of 26 [20-35] to 35 [26-35]; Snellen, 20/300 to 20/200; P > 0.05). The appETDRS VAE was significantly improved from 20 (0-35) to 30 (20-55), Snellen, 20/400 to 20/250, following LSCT (P = 0.021) and from 2 (0-20) to 2 (0-41) after KPro; Snellen, 20/20,000 VAE but with improved 95% CI after follow-up (P = 0.019).

Conclusions: With proper characterization and staging of AAK, individualized medical and advanced surgical interventions preserves and improves visual acuity.
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http://dx.doi.org/10.1016/j.ajo.2019.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6964251PMC
February 2020

Consultation Section: Cataract. October consultation #2.

Authors:
Joel Sugar

J Cataract Refract Surg 2019 10;45(10):1518

Chicago, Illinois, USA.

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http://dx.doi.org/10.1016/j.jcrs.2019.08.017DOI Listing
October 2019

Is This the Future of Eye Banking?

Cornea 2018 07;37(7):811-812

Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago Eye and Ear Infirmary, Chicago, IL.

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http://dx.doi.org/10.1097/ICO.0000000000001616DOI Listing
July 2018

Recognition of Fungal Keratitis in Boston Type I Keratoprosthesis: Importance of Awareness and Novel Identification of Exophiala phaeomuriformis.

Cornea 2018 May;37(5):655-657

Department of Ophthalmology, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL.

Purpose: To present a case of Exophiala phaeomuriformis fungal keratitis to demonstrate the heightened concern for fungal infection in patients with a keratoprosthesis and to highlight the rare involvement of Exophiala phaeomuriformis.

Methods: Case report.

Results: Exophiala phaeomuriformis was identified in a susceptible patient 7 years after Boston type I keratoprosthesis (KPro) implantation.

Conclusions: Although fungal infiltration after KPro placement does not represent a novel clinical infection, identification of the rare Exophiala species in a patient with a KPro has not been reported and provides an opportunity for reflection on fungal identification, prophylaxis, and prevention in this vulnerable patient population.
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http://dx.doi.org/10.1097/ICO.0000000000001541DOI Listing
May 2018

Consultation Section: Cornea. October consultation #2.

Authors:
Joel Sugar

J Cataract Refract Surg 2017 10;43(10):1358-1359

Chicago, Illinois, USA.

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http://dx.doi.org/10.1016/j.jcrs.2017.10.005DOI Listing
October 2017

October consultation #2.

Authors:
Joel Sugar

J Cataract Refract Surg 2016 10;42(10):1535-1536

Chicago, Illinois, USA.

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http://dx.doi.org/10.1016/j.jcrs.2016.09.005DOI Listing
October 2016

Keratoconus and Other Corneal Diseases: Pharmacologic Cross-Linking and Future Therapy.

Handb Exp Pharmacol 2017;242:137-161

University of Illinois at Chicago, Chicago, IL, 60612, USA.

The ability to cross-link collagen fibers and use this technique to strengthen the cornea has become of great interest to ophthalmologists in the last decade. For progressive diseases such as keratoconus, collagen cross-linking confers the possibility of halting progression and stabilizing the cornea, a benefit that is not observed with any other current treatment. Collagen cross-linking uses riboflavin combined with ultraviolet A light to induce the formation of bonds between collagen fibrils that strengthen the cornea. This chapter will discuss the theory, technique, indications, and complications of corneal cross-linking. Much of what will be discussed is in areas of active research that will likely be further clarified as more experience is gained with this procedure.
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http://dx.doi.org/10.1007/164_2016_23DOI Listing
April 2019

Epithelial Ingrowth Following Endothelial Keratoplasty.

Cornea 2016 Apr;35(4):465-70

*Private Practice, Mumbai, India; †Wills Eye Hospital, Philadelphia, PA; ‡Michigan Cornea Consultants, Southfield, MI; §Department of Ophthalmology, Upstate Medical University, Syracuse, NY; ¶Department of Ophthalmology, University of Illinois at Chicago (UIC); ‖Department of Ophthalmology, Rush Medical College, Chicago, IL; and **Department of Ophthalmology, Northwestern University, Feinberg School of Medicine, Chicago, IL.

Purpose: To present a large case series of epithelial ingrowth or implantation following endothelial keratoplasty (EK) with the purpose of identifying the common causes as well as the various clinical presentations. We aim to determine the typical clinical course and the most effective treatment for this rare but serious complication.

Methods: This is a retrospective study of 13 patients who developed epithelial ingrowth or implantation post-EK. Slit lamp photographs were independently examined along with other diagnostic imaging and histopathology to confirm the diagnosis. Patient medical records including operative reports were reviewed to determine the number of surgeries that occurred before EK and details of surgical technique, for example, whether venting incisions were performed. Records from follow-up visits were reviewed to determine the natural progression and management of these cases. The literature was reviewed and a meta-analysis was performed.

Results: The patients were divided into 5 groups according to the type of epithelial presentation. Eight patients had involvement within the interface away from the visual axis. One patient had ingrowth in the interface within the visual axis, 2 had retrocorneal involvement, and 1 had anterior chamber involvement. One had both retrocorneal and anterior chamber involvement. Venting incisions were performed in 8 patients, but only 1 had ingrowth related to the venting incision. Nine patients were observed without evidence of significant progression. Four patients had surgical treatment to remove the epithelium.

Conclusions: Epithelial ingrowth or implantation occurs most commonly within the interface away from the visual axis and typically does not progress. The presentation of a homogeneous gray-white interface opacity is characteristic. Ingrowth can result from venting incisions, but rarely does. Other causes are eccentric trephination or loose donor or host epithelium being dragged into the eye at the time of surgery.
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http://dx.doi.org/10.1097/ICO.0000000000000775DOI Listing
April 2016

Clostridium perfringens endophthalmitis after penetrating keratoplasty with contaminated corneal allografts: a case series.

Cornea 2015 Jan;34(1):23-7

*Department of Ophthalmology and Visual Sciences, University of Illinois Eye and Ear Infirmary, Chicago, IL; †Department of Ophthalmology, Rush University Medical Center, Chicago, IL; ‡Chicago Eye Institute, Chicago, IL; and §Midwest Eye-Banks, Ann Arbor, MI.

Purpose: To report the postoperative clinical course of 3 patients who underwent corneal transplantation with corneal allografts contaminated with Clostridium perfringens and to evaluate the risk factors for anaerobic contamination in 2 donors.

Methods: Patient records and adverse reaction reports from a single eye bank related to cases of posttransplant C. perfringens endophthalmitis were reviewed. Records regarding the mated corneas, donor autopsy reports, and other pertinent data were also reviewed.

Results: Three adverse reactions associated with transplantation of corneal allografts contaminated with C. perfringens were reported. Two cases were from mated corneas. Both patients developed fulminant endophthalmitis after undergoing uncomplicated penetrating keratoplasty and required subsequent enucleation. Another isolated case (with no adverse reaction in the mate cornea) developed hypopyon postoperatively that resolved with intravitreal and topical antibiotics. Possible risk factors for anaerobic tissue contamination in the donors included illicit drug use in the first donor and exposure to sewage at the time of death in the second donor.

Conclusions: Clostridial endophthalmitis is an aggressive rapidly progressive infection with potentially poor visual outcomes that can be transmitted from infected corneal allografts. Further investigation is needed to clarify the role of anaerobic donor rim cultures and the donor risk factors associated with recovering corneal allograft tissue contaminated with C. perfringens.
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http://dx.doi.org/10.1097/ICO.0000000000000303DOI Listing
January 2015

October consultation #6.

Authors:
Joel Sugar

J Cataract Refract Surg 2014 Oct;40(10):1750-1; discussion 1751

Chicago, Illinois, USA.

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http://dx.doi.org/10.1016/j.jcrs.2014.08.009DOI Listing
October 2014

The effect of donor age on penetrating keratoplasty for endothelial disease: graft survival after 10 years in the Cornea Donor Study.

Ophthalmology 2013 Dec;120(12):2419-2427

Jaeb Center for Health Research, Tampa, Florida.

Objective: To determine whether the 10-year success rate of penetrating keratoplasty for corneal endothelial disorders is associated with donor age.

Design: Multicenter, prospective, double-masked clinical trial.

Participants: A total of 1090 participants undergoing penetrating keratoplasty at 80 sites for Fuchs' dystrophy (62%), pseudophakic/aphakic corneal edema (34%), or another corneal endothelial disorder (4%) and followed for up to 12 years.

Methods: Forty-three eye banks provided corneas from donors aged 12 to 75 years, using a randomized approach to assign donor corneas to study participants without respect to recipient factors. Surgery and postoperative care were performed according to the surgeons' usual routines.

Main Outcome Measures: Graft failure defined as a regraft or, in the absence of a regraft, a cloudy cornea that was sufficiently opaque to compromise vision for 3 consecutive months.

Results: In the primary analysis, the 10-year success rate was 77% for 707 corneas from donors aged 12 to 65 years compared with 71% for 383 donors aged 66 to 75 years (difference, +6%; 95% confidence interval, -1 to +12; P = 0.11). When analyzed as a continuous variable, higher donor age was associated with lower graft success beyond the first 5 years (P<0.001). Exploring this association further, we observed that the 10-year success rate was relatively constant for donors aged 34 to 71 years (75%). The success rate was higher for 80 donors aged 12 to 33 years (96%) and lower for 130 donors aged 72 to 75 years (62%). The relative decrease in the success rate with donor ages 72 to 75 years was not observed until after year 6.

Conclusions: Although the primary analysis did not show a significant difference in 10-year success rates comparing donor ages 12 to 65 years and 66 to 75 years, there was evidence of a donor age effect at the extremes of the age range. Because we observed a fairly constant 10-year success rate for donors aged 34 to 71 years, which account for approximately 75% of corneas in the United States available for transplant, the Cornea Donor Study results indicate that donor age is not an important factor in most penetrating keratoplasties for endothelial disease.
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http://dx.doi.org/10.1016/j.ophtha.2013.08.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3885822PMC
December 2013

Increased expression of secreted frizzled-related protein-1 and microtubule-associated protein light chain 3 in keratoconus.

Cornea 2013 May;32(5):702-7

Departments of Ophthalmology and Pathology, Loyola University Health System, Maywood, IL 60153, USA.

Purpose: To study the expression of secreted frizzled-related protein-1 (SFRP-1) and microtubule-associated protein light chain 3 (LC3), an autophagy marker, in keratoconus.

Methods: Under an institutional review board-approved protocol, de-identified and/or surgically discarded normal donor (n = 10) and keratoconus corneas (n = 10) were obtained. The corneal samples were fixed in formalin and embedded in paraffin. Immunohistochemical staining using SFRP-1 and LC3 antibodies was performed.

Results: The majority of expression of SFRP-1 was seen in the epithelium; however, in 3 tissues that showed high expression, staining was also present in the stroma and endothelium. Like SFRP-1, the LC3 expression in keratoconus tissues occurred at 3 different levels: low, medium, and high. Collectively these data suggest that there are differences in the expression levels of SFRP-1 and LC3 in keratoconus tissue compared with the normal tissue. Low expressivity of SFRP-1 seemed to correspond to low expressivity of LC3, whereas medium to high expressivity of SFRP-1 corresponded to medium to high expressivity of LC3.

Conclusions: Increased expression of SFRP-1 and LC3 was observed in keratoconus corneas. Keratocyte autophagy seen with keratoconus may play a role in the pathogenesis of keratoconus.
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http://dx.doi.org/10.1097/ICO.0b013e318282987aDOI Listing
May 2013

Relationship Between Fuchs Endothelial Corneal Dystrophy Severity and Glaucoma and/or Ocular Hypertension.

Arch Ophthalmol 2012 Nov;130(11):1384-8

OBJECTIVE To investigate whether Fuchs endothelial corneal dystrophy (FECD) severity is associated with glaucoma and/or ocular hypertension (G/OHTN). METHODS A subset of eyes (n = 1610) from the FECD Genetics Multi-Center Study were examined to estimate the association between FECD severity (grades 0-6 based on guttae confluence) and G/OHTN. Logistic regression models that accounted for the correlation between eyes and adjusted for age, sex, central corneal thickness, intraocular pressure, presence of diabetes, and time of day of the initial evaluation were fit. RESULTS A total of 107 eyes (6.6%) had G/OHTN based on the study definition. The prevalence of G/OHTN in the control group was 6.0%. The prevalence was lower in index cases with an FECD grade of 1 through 3 and family members with a grade of 0 or 1 through 3 (0.0% and 2.1%, respectively) but higher in index cases and family members with a grade of 4 through 6 (11.2% and 8.5%, respectively). Adjusting for covariates, eyes with a grade of 4 through 6 were more likely to have concurrent G/OHTN than eyes with no FECD (index cases vs controls: odds ratio [OR] = 2.10, P = .04; affected vs unaffected family members: OR = 7.06, P = .07). Age (OR = 1.06 per 1-year increase, P < .001) and intraocular pressure (OR = 1.15 per 1-mm Hg increase, P < .001) were also associated with an increased prevalence of G/OHTN. Sex, diabetes, time of day of evaluation, and central corneal thickness were not associated with the prevalence of G/OHTN (P ≥ .15). CONCLUSIONS Glaucoma and/or ocular hypertension occurs more often in eyes with severe FECD compared with unaffected eyes. Therefore, it may be beneficial to monitor for the development of glaucoma in these patients.
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http://dx.doi.org/10.1001/archophthalmol.2012.1969DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3954552PMC
November 2012

What causes keratoconus?

Cornea 2012 Jun;31(6):716-9

Department of Ophthalmology, University of Illinois at Chicago, Chicago, IL, USA.

Purpose: The etiology of keratoconus has been the subject of numerous studies. Here, we review the body of literature that attempts to determine what causes keratoconus.

Methods: A review of the published literature was performed to evaluate the possible causes of keratoconus and how the different etiologies may play a role in the development of this disease.

Results: Peer-reviewed published papers and recent abstracts concerning the different etiologies of keratoconus were reviewed and discussed. Biochemical, genetic, and environmental factors are reviewed. The role of eye rubbing and atopic disease are explored.

Conclusions: We agree with the hypothesis that there is a genetic predisposition that requires a "second hit" or environmental event to elicit progressive disease in keratoconus. Eye rubbing may serve as the "second hit" in some predisposed individuals. Inflammatory mediator studies question if keratoconus is really a noninflammatory thinning disorder of the cornea.
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http://dx.doi.org/10.1097/ICO.0b013e31823f8c72DOI Listing
June 2012

Boston type I keratoprosthesis for visual rehabilitation in a patient with gelatinous drop-like corneal dystrophy.

Cornea 2012 Jul;31(7):844-5

University of Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, Chicago, IL, USA.

Purpose: To report the use of a Boston type I keratoprosthesis as a primary penetrating procedure to treat gelatinous drop-like corneal dystrophy (GDLD), with presentation of pathologic findings and discussion of other surgical options.

Case Report: A 49-year-old woman with GDLD in both eyes and history of recurrent corneal opacification following multiple superficial keratectomies is presented. Best corrected visual acuity (BCVA) was counting fingers in both eyes. A Boston type I keratoprosthesis was implanted in her left eye after optical iridectomy, extracapsular cataract extraction, and anterior vitrectomy.

Results: The surgery was uneventful and one month after surgery, best corrected vision improved to 20/20 and has been maintained for a period of more than 14 months. No post-operative complications were observed. Histopathology of the corneal specimen is presented.

Conclusions: GDLD is a rare disorder of amyloid deposition. Recurrence of this condition following surgery is extremely common. Boston type I keratoprosthesis is an effective procedure for restoring vision in affected patients.
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http://dx.doi.org/10.1097/ICO.0b013e31822fff1aDOI Listing
July 2012

Modalities to decrease stromal herpes simplex keratitis reactivation rates.

Arch Ophthalmol 2010 Nov;128(11):1497; author reply 1497-8

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http://dx.doi.org/10.1001/archophthalmol.2010.259DOI Listing
November 2010

Copper deposition in a variant of multiple myeloma: pathologic changes in the cornea and the lens capsule.

Cornea 2011 Mar;30(3):360-3

Department of Ophthalmology, Summa Health System, Akron, OH 44304, USA.

Purpose: To report the pathologic changes in the cornea and the lens capsule resulting from copper deposition in a variant of multiple myeloma.

Methods: Case report.

Results: Light microscopy of the cornea revealed endothelial cell attenuation with diffuse copper deposition in the central Descemet membrane, which showed thinning, whereas copper banding was seen in the midperipheral and peripheral cornea where the Descemet membrane was normal in thickness. Copper deposition was confirmed by x-ray microanalysis. The anterior lens capsule showed subepithelial copper deposits. Thickening, multilayering, and splitting of the lens capsule were also noted.

Conclusions: We report the pattern of deposition of copper in the Descemet membrane of the cornea and the anterior lens capsule in multiple myeloma, associated with hypercupremia. Descemet membrane thinning and regional differences in copper deposition were noted. Also, thickening and splitting of the lens capsule are a novel observation.
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http://dx.doi.org/10.1097/ICO.0b013e3181ee67fdDOI Listing
March 2011

Outcome of descemet stripping automated endothelial keratoplasty in patients with an anterior chamber intraocular lens.

Cornea 2010 Nov;29(11):1273-7

Department of Ophthalmology and Visual Sciences, University of Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL 60612, USA.

Purpose: To evaluate the outcome of Descemet stripping automated endothelial keratoplasty (DSAEK) in patients with a retained anterior chamber intraocular lens (ACIOL).

Methods: A retrospective review of 11 patients with corneal decompensation and ACIOL who underwent DSAEK was performed. All patients except 1 had open-loop style ACIOLs, and in all cases, there was adequate anterior chamber depth. At the time of surgery, 6 patients had a temporary suture to secure their graft, 2 of which were retained from the insertion method, and the other 4 were placed additionally. Postoperatively, the rate of donor detachment, graft clarity, corneal pachymetry, and visual acuity were noted.

Results: There was only 1 graft dislocation postoperatively, which was reattached successfully by air injection. There was 1 primary graft failure (without dislocation) among the 11 patients during the mean follow-up of 12 months (range: 6-25 months); at last follow-up, the visual acuity had improved in all the other 10 patients.

Conclusions: This series demonstrates that DSAEK can be performed successfully in patients with existing ACIOLs. These early outcomes suggest that DSAEK alone may be considered as an alternative to a lens exchange with DSAEK in patients with adequate anterior chamber depth.
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http://dx.doi.org/10.1097/ICO.0b013e3181d00a5eDOI Listing
November 2010

Effects of Sp1 overexpression on cultured human corneal stromal cells.

Genes Cells 2009 Oct 16;14(10):1133-9. Epub 2009 Sep 16.

Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago College of Medicine, Chicago, IL, USA.

Sp1, a transcription factor, is upregulated in keratoconus, a cornea-thinning disease. Keratoconus corneas have also been shown to contain increased levels of degradative enzymes such as cathepsin B and decreased proteinase inhibitors such as alpha1-proteinase inhibitor (alpha1-PI). We transfected cultured human corneal stromal cells to overexpress Sp1. The resulting effects on cathepsin B and alpha1-PI levels as well as the cellular proliferative and apoptotic activities were examined by Western blotting and cytochemical staining. It was found that the Sp1 transfected cells contained a greater amount of cathepsin B than did mock transfected controls. The activity of cathepsin B was also increased. By contrast, the protein level of alpha1-PI was lowered in corneal stromal cells upon Sp1 overexpression. The Sp1-induced alterations thus mimicked closely those observed in keratoconus, supporting the notion that Sp1 upregulation may be a key factor contributing directly to the disease development. Furthermore, the apoptotic activity was unaffected in Sp1 transfectants but the proliferation was inhibited, consistent with the idea that Sp1 may play a role in differentiation of corneal cells.
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http://dx.doi.org/10.1111/j.1365-2443.2009.01340.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813039PMC
October 2009

Early results of Descemet-stripping and automated endothelial keratoplasty (DSAEK) in patients with glaucoma drainage devices.

Cornea 2009 Oct;28(9):959-62

Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA.

Purpose: To evaluate the outcome of Descemet-stripping and automated endothelial keratoplasty (DSAEK) in patients with glaucoma tube shunts in the anterior chamber.

Methods: Retrospective review of 4 patients with a history of tube shunt placement that experienced corneal decompensation and subsequently underwent DSAEK at 1 institution. Details of the surgical procedures as well as postoperative features including graft attachment, visual acuity, intraocular pressure (IOP), graft clarity, and central corneal thickness were recorded.

Results: There were no graft detachments postoperatively. In all but 1 case, the corneal edema resolved with a corresponding decrease in corneal thickness. In 1 case, where there was excessive donor tissue manipulation intraoperatively, the edema failed to resolve. This patient underwent a repeat DSAEK with subsequent graft attachment and resolution of the corneal edema. In all 4 patients, the tube shunt was revised at the time of DSAEK. The tube was not tied or plugged in any of the patients. Except for 1 patient with fibrin reaction, there were no IOP spikes postoperatively. At the 6-month follow-up, the visual acuity had improved in all patients and the IOP had not changed significantly from preoperative levels.

Conclusion: This small series suggests that DSAEK is a viable and effective option in patients with existing tube shunts. The presence of a tube did not affect the rate of graft dislocation; however, it appeared to increased the rate of complications postoperatively. These early outcomes support the use of DSAEK as an alternative to penetrating keratoplasty in this patient population.
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http://dx.doi.org/10.1097/ICO.0b013e31819c4e2cDOI Listing
October 2009

Donor risk factors for graft failure in the cornea donor study.

Cornea 2009 Oct;28(9):981-5

University of Illinois at Chicago, Chicago, IL, USA.

Purpose: The purpose of this study was to assess the relationship between donor factors and 5-year corneal graft survival in the Cornea Donor Study.

Methods: Donor corneas met criteria established by the Eye Bank Association of America, had an endothelial cell density of 2300 to 3300/mm, and were determined to be of good to excellent quality by the eye banks. Donor corneas were assigned using a random approach and surgeons were masked to information about the donor cornea including donor age. Surgery and postoperative care were performed according to the surgeons' usual routines and subjects were followed for 5 years. Donor and donor cornea factors were evaluated for their association with graft failure, which was defined as a regraft or a cloudy cornea that was sufficiently opaque to compromise vision for a minimum of 3 consecutive months.

Results: Graft failure was not significantly associated with the type of tissue retrieval (enucleation versus in situ), processing factors, timing of use of the cornea, or characteristics of the donor or the donor cornea. Adjusting for donor age did not affect the results.

Conclusion: Donor and donor cornea characteristics do not impact graft survival rates for corneas comparable in quality to those used in this study.
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http://dx.doi.org/10.1097/ICO.0b013e3181a0a3e6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3124710PMC
October 2009

Histopathologic and immunohistochemical studies of keratoglobus.

Arch Ophthalmol 2009 Aug;127(8):1029-35

Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, USA.

Objective: To examine histopathologic and immunohistochemical features of human corneal buttons from patients who developed keratoglobus.

Methods: Nine corneal buttons were obtained during penetrating keratoplasty from patients with keratoglobus. Histologic features were examined using hematoxylin-eosin-stained sections. Immunohistochemical staining for alpha1-proteinase inhibitor, Sp1, and matrix metalloproteinases 1, 2, and 3 was performed, with 2 normal and 2 corneal sections with keratoconus as controls.

Results: Hematoxylin-eosin staining revealed diffuse stromal thinning and focal disruptions in Bowman's layer in all keratoglobus specimens. Similar abnormal immunostaining results for alpha1-proteinase inhibitor and Sp1 were detected in keratoglobus and keratoconus at their respective active disease sites. Immunostaining for matrix metalloproteinases 1, 2, and 3 was significantly more intense in corneas with keratoglobus than in normal controls. Matrix metalloproteinase staining intensity was especially prominent in areas where the underlying Bowman's layer was disrupted.

Conclusions: Histological features in our keratoglobus specimens are consistent with previous reports. The similarities in immunohistochemical labeling between keratoglobus and keratoconus suggest that these entities may share common mechanisms that are involved in stromal thinning.
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http://dx.doi.org/10.1001/archophthalmol.2009.184DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2821018PMC
August 2009

Clinical and histopathologic features of failed descemet stripping automated endothelial keratoplasty grafts.

Cornea 2009 Jun;28(5):530-5

Department of Ophthalmology, University of Illinois at Chicago, Chicago, IL, USA.

Purpose: To study the histopathologic features of Descemet stripping automated endothelial keratoplasty (DSAEK) grafts removed after graft failure and to correlate with relevant clinical features.

Methods: Retrospective study of 8 cases in 7 patients who experienced DSAEK graft failure during the surgeons' learning phase. Perioperative clinical findings were correlated with pathologic findings of the explanted graft specimens. Imaging software was used to measure the central and peripheral thickness of each graft.

Results: Graft failure occurred in association with graft detachment or excessive surgical manipulation. In 4 cases, the donor tissue detached, including 2 cases with routes for bubble escape. In 3 cases, the graft remained attached but failed to clear. The mean preoperative DSAEK button thickness was 205 +/- 61.8 microm. Average death to preservation time was 8 hours 47 minutes, and average preservation to surgery time was 2 days 22 hours. By light microscopy, explanted donor tissue showed varying degrees of keratocyte degeneration and marked endothelial cell loss. Two specimens with bubble escape had less endothelial loss, and 1 specimen showed epithelial ingrowth at the interface. Repeat keratoplasty (5 DSAEK, 2 penetrating keratoplasty) was successful in 6 of 7 cases.

Conclusions: This series correlates factors that may play a role in DSAEK failure with histopathologic features of explanted DSAEK lenticules. Marked endothelial loss was common in cases with surgical trauma but was less in cases with bubble escape. One specimen showed an epithelial membrane on the stromal interface. Outcomes of repeat DSAEK in these patients seem promising.
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http://dx.doi.org/10.1097/ICO.0b013e31818d3b1cDOI Listing
June 2009

Slitlamp biomicroscopy and photographic image analysis of herpes simplex virus stromal keratitis.

Arch Ophthalmol 2009 Feb;127(2):161-6

Sid W. Richardson Ocular Microbiology Laboratory, Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, 6565 Fannin St, Houston, TX 77030, USA.

Objective: To validate photographic bioimaging for evaluating the severity of herpes simplex virus keratitis.

Methods: Stromal keratitis of patients in the Herpetic Eye Disease Study was clinically measured with a slitbeam micrometer and then photographed at trial entry. Calibrated images of 169 eyes were analyzed for the size, location, and density of stromal keratitis and endotheliitis, with shape factor as a function of area and perimeter. Validity was assessed by comparing clinical and computerized measurements and by correlating the keratitis area with visual acuity. Logistic regression explored characteristics associated with larger or denser corneal inflammation.

Results: Stromal keratitis had a median area of 22.4 mm(2) (interquartile range, 12.8-31.6 mm(2)) with a median shape factor of 0.69 (interquartile range, 0.56-0.79); 126 eyes (75%) had their midpoint within 2 mm of the cornea's geometric center. Photoanalytical area estimates of herpetic stromal keratitis correlated closely with clinical measurements (correlation coefficient, 0.83). Eyes with larger stromal keratitis had worse vision (correlation coefficient, 0.32) and were more likely to have iritis (P = .01). Necrotizing stromal keratitis was significantly whiter (P = .02).

Conclusions: Image analysis validly assesses the disciform geometry of herpetic stromal keratitis and confirms that increased severity is associated with uveitis and reduced vision.
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http://dx.doi.org/10.1001/archophthalmol.2008.577DOI Listing
February 2009

Keratectasia after laser in situ keratomileusis: a histopathologic and immunohistochemical study.

Arch Ophthalmol 2008 Dec;126(12):1655-63

Department of Ophthalmology, University of Illinois at Chicago, Chicago, IL, USA.

Objective: To examine histopathologic and immunohistochemical features of human corneal buttons from patients who developed keratectasia after laser in situ keratomileusis (LASIK).

Methods: Five corneal buttons were obtained during penetrating keratoplasty from patients who developed keratectasia after LASIK. Histologic features were examined by hematoxylin-eosin staining using paraffin-embedded sections and by transmission electron microscopy. Immunostaining for alpha(1)-proteinase inhibitor, Sp1, and matrix metalloproteinases 1, 2, and 3 was performed with 2 healthy corneas and 2 corneas with keratoconus as controls.

Results: Central stromal thinning was observed after hematoxylin-eosin staining in all corneas with keratectasia. No histologic features specific to keratoconus, including Bowman layer disruption, were identified in the corneas with keratectasia. By transmission electron microscopy, collagen fibril thinning and decreased interfibril distance were observed in the stromal bed. Immunostaining intensity and/or pattern for alpha(1)-proteinase inhibitor and Sp1 in the corneas with keratectasia was comparable to that of healthy corneas and differed from that in the corneas with keratoconus. No significant staining with anti-matrix metalloproteinases 1, 2, and 3 antibodies was observed in either the corneas with keratectasia or the healthy corneas.

Conclusions: Histologic findings suggest that post-LASIK keratectasia results in collagen fibril thinning and decreased interfibril distance within the residual stromal bed. Discrepant results between keratectasia and keratoconus suggest that the pathogenesis of the 2 conditions differ.
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http://dx.doi.org/10.1001/archophthalmol.2008.544DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2649738PMC
December 2008

The relative value of confocal microscopy and superficial corneal scrapings in the diagnosis of Acanthamoeba keratitis.

Cornea 2008 Aug;27(7):764-72

Department of Ophthalmology, University of Illinois at Chicago, Chicago, IL 60612, USA.

Purpose: To compare the relative diagnostic value of confocal microscopy and superficial corneal cultures in the diagnosis of Acanthamoeba keratitis by using clinical and microbiologic definitions of disease.

Methods: Results of confocal microscopy, superficial corneal smear, and superficial corneal culture were analyzed for validity against 2 different microbiologic and a clinical composite standard for Acanthamoeba keratitis.

Results: In patients with both clinical characteristics and objective evidence of Acanthamoeba keratitis, confocal microscopy exhibited a sensitivity of 90.6% (95% confidence interval [CI]: 79.3%-96.9%) and a specificity of 100% (95% CI: 95.0%-100%). In patients with either positive culture or smear evidence of Acanthamoeba keratitis, confocal microscopy showed a sensitivity of 90.9% (95% CI: 78.3%-97.5%) and specificity of 90.1% (95% CI: 81.5%-95.6%). In strictly culture-positive patients, confocal microscopy showed a sensitivity of 92.9% (95% CI: 76.5%-99.1%) and a specificity of 77.3% (95% CI: 67.7%-85.2%). Of the 53 patients with Acanthamoeba keratitis, confocal microscopy was positive in 48 patients, whereas corneal smears and cultures were positive in 30 of 41 and 23 of 42 patients, respectively. Sensitivity of Acanthamoeba culture was 52.8% (95% CI: 38.6%-66.7%) in patients with a clinical diagnosis of Acanthamoeba keratitis. Simultaneous testing of smear and superficial corneal scraping resulted in a sensitivity of 83.0% (95% CI: 70.2%-91.9%), independent of the results of confocal microscopy.

Conclusions: As confocal microscopy comes into wider clinical use, it remains in need of clinical and pathologic correlation. When performed and interpreted by an experienced operator, confocal microscopy is both sensitive and specific in the diagnosis of Acanthamoeba keratitis. Contemporaneous corneal scrapings are independently sensitive in the detection of Acanthamoeba keratitis, and a combination of both diagnostic modalities offers the highest likelihood of rapidly and accurately diagnosing Acanthamoeba keratitis in patients with atypical keratitis.
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http://dx.doi.org/10.1097/ICO.0b013e31816f27bfDOI Listing
August 2008

Prognostic factors affecting visual outcome in Acanthamoeba keratitis.

Ophthalmology 2008 Nov 24;115(11):1998-2003. Epub 2008 Jun 24.

University of Illinois at Chicago, Department of Ophthalmology, Chicago, Illinois, USA.

Objective: To identify clinical and demographic factors associated with a worse visual outcome in Acanthamoeba keratitis (AK).

Design: Retrospective, case control study.

Participants: A total of 72 eyes of 65 patients with AK who were diagnosed at the University of Illinois Eye and Ear Infirmary between May of 2003 and May of 2007 with treatment complete by October of 2007. The first affected eye was analyzed in bilateral disease.

Methods: Patient demographic, clinical characteristics, treatment methods, and final visual outcome data were collected through medical record reviews for all patients diagnosed with AK. Cases were defined as patients with AK with a visual outcome worse than 20/25 or those requiring penetrating keratoplasty (PKP). Controls were defined as patients with AK with a visual outcome of 20/25 or better. Logistic regression was used to estimate the odds ratio (OR) identifying prognostic factors associated with a worse visual outcome.

Main Outcome Measures: Final visual outcome worse than 20/25.

Results: AK was confirmed through microbiologic evidence in 48 of 65 eyes (73.8%) or with confocal microscopy in 62 of 65 eyes (95.4%). Final visual acuity data were available in 61 of 65 eyes (93.8%); of these 61 eyes, 40 (65.6%) achieved a final visual acuity of 20/25 or better. In multivariable analysis, deep stromal involvement or the presence of a ring infiltrate at presentation was independently associated with worse visual outcomes (OR, 10.27; 95% confidence interval [CI], 2.91-36.17). Symptom duration before diagnosis was statistically predictive of disease stage at presentation (OR, 4.43; 95% CI, 0.99-19.83; multivariable analysis) but not final visual outcome (OR, 2.55; 95% CI, 0.83-7.88; univariate analysis). PKP was performed in 11 of 12 eyes with active disease.

Conclusions: Corneal disease staging at presentation with slit-lamp examination was highly predictive of worse outcomes, allowing the identification of patients who might benefit from more aggressive medical or surgical intervention. Unlike in previous reports, patient-reported duration of symptoms before treatment was not reliable in predicting the final visual result in our series.
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http://dx.doi.org/10.1016/j.ophtha.2008.04.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3816554PMC
November 2008