Letters to the Editor hydroxyapatite orbital implants is low, and that the minor complications encountered are readily medically or surgically managed.We do suggest, however, that secondary implant surgery is more complex and technically demanding, resulting in a difference in outcome relative to primary implant surgery.In addition, many patients undergoing secondary procedures already have significant anophthalmic eyelid and orbital deficiencies.An acceptable surgical outcome in this patient population may be considered a suboptimal result in a primary procedure.For all the aforementioned reasons, the results and complications of these two distinct surgical procedures should be compared separately.

Purpose: To assess four commonly available visual function tests to detect visually disabling or vision-threatening eye conditions among new patients of a large, urban, public, general ophthalmology clinic,Methods: Three hundred seventeen patients were tested for contrast sensitivity, Amsler grid abnormalities, and visual acuity at near and at distance, A complete eye evaluation found the prevalence of serious eye diseases, allowing determination of the sensitivity (Sn), specificity (Sp), likelihood ratio (LR), and other characteristics of each test,Results: Of 317 patients, most were Hispanic (77%), women (60%), and middle-aged (44 +/- 17 years). Normal findings were reported in 18%; refractive error in 43%; cataracts in 16%; glaucoma in 7.3%; and macular degeneration in 4.1%. Near visual acuity of 20/40 or worse (Sn = 0.75; Sp = 0.74; LR = 2.8); and distance visual acuity testing of 20/30 or worse (Sn = 0.74; Sp = 0.73; LR = 2.7) correlated significantly with ocular disease, whereas contrast sensitivity testing (Sn = 0.62; Sp = 0.41; LR = 1.1) and Amsler grid test (Sn = 0.19; Sp = 0.92; LR = 2.4) did not. Test performance decreased when refractive errors were excluded and among those younger than 40 years of age relative to those 40 years of age or older.Conclusion: Of the four screening tests studied, distance and near threshold visual acuities as defined above were judged to have the best correlations of an abnormal result with ocular disease, both including or excluding refractive error, Different combinations of tests did not result in more accurate detection of ocular disease. More efficient screening tools for detecting ocular disease need to be developed.

PURPOSE: To determine the rate of recurrence and complications after bare sclera excision of primary pterygia followed by low-dose mitomycin C (0.2 mg/ml twice daily for five days), placebo (balanced saline solution), or conjunctival autograft.METHODS: We performed a prospective, double-masked clinical trial of 64 patients (60 Hispanic) randomly assigned to a treatment group. Twenty-four patients received mitomycin C, 23 conjunctival autograft, and 17 placebo. Recurrence was defined as fibrovascular tissue over the corneoscleral limbus onto clear cornea in the area of previous pterygium excision.RESULTS: The recurrence rate after mitomycin C and conjunctival autograft was 38% and 39% of eyes, respectively, after mean follow-up (in recurrence-free patients) of 12.3 and 13.5 months, respectively. The recurrence rate after placebo treatment was significantly higher (P = .002), 88%, after mean follow-up (in recurrence-free patients) of 9.3 months. Increasing age was associated with significantly fewer recurrences (P = .006) after controlling for pterygium type (atrophic, noninflamed, or inflamed) and treatment group. The mean time to recurrence varied from 3.7 to 4.8 months; only 6% of recurrences were noted after the sixth postoperative month, Major complications included symblepharon (two), loose autograft (one), and pyogenic granuloma (two). No group had significantly more complications.CONCLUSIONS: Conjunctival autograft and low-dose topical mitomycin C are equally effective as adjunctive treatment after excision of primary pterygia in this young, southern California, predominantly Hispanic population. Both methods have significantly lower rates of recurrence than bare sclera excision alone, and neither is associated with severe complications after one year of followup. Increasing patient age is associated with significantly less risk of recurrence.

ABSTRACT BACKGROUND: The holmium:YAG laser shrinks stromal collagen and changes corneal refractive power, reportedly without recurrent or persistent epithelial defects, stromal necrosis, or damage to the epithelium and endothelium observed with some other thermokeratoplasty techniques. METHODS: We studied the safety of the holmium:YAG laser using various patterns and energy densities after treating 12 poorly sighted eyes, two immediately prior to corneal transplantation and 10 followed for a mean period of 90 days (range, 60 to 180 days). Visual acuity, intraocular pressure and inflammation, central corneal endothelial cell density and thickness, and intraocular structures of the eye were indices evaluated regularly. Patients were also assessed for specific symptoms during the post-operative period. RESULTS: There were no problems with epithelial healing and no stromal necrosis or evidence of endothelial damage; no significant differences were noted in any of the endothelial cell indices examined. A mean change in corneal curvature of 1.10 diopter (D) was achieved, but varying amounts of regression of this effect was noted. CONCLUSIONS: Holmium:YAG laser thermal keratoplasty appears to be safe over a follow up of up to 180 days. Corneal refractive changes on the order of 1.05 D can be achieved using the parameters employed in this study. Whether or not larger, persistent corneal refractive change can be achieved with a holmium:YAG laser remains to be determined. [J Refract Surg. 1995,11:358-365.]

PURPOSE: We studied events leading to the development of posttraumatic endophthalmitis by examining the significance of 15 factors on micro bial contamination of injured eyes.METHODS: A prospective study was done of 30 ruptured globes in patients admitted to an urban medical center. Cultures were taken from the conjunctiva before and after preoperative disinfection and from the anterior chamber at the beginning and end of wound repair. Twenty-five of 30 patients received a three-day regimen of intravenous antibiotics that were begun before surgery.RESULTS: Anterior chamber samples grew microorganisms in ten (33%) of 30 eyes, with positive cultures recovered from specimens taken at the beginning of wound repair in eight eyes and at the end of wound repair in six eyes, Contamination with indigenous flora may have occurred at the time of injury in one eye and during repair in another eye. Microbes recovered included Staphylococcus, Corynebacterium, and Aspergillus species. No patient developed endophthalmitis. Of the 15 factors studied, only intravenous antibiotics significantly decreased the incidence of positive anterior chamber cultures in eyes treated before wound repair compared with eyes not receiving such therapy (P =.002).CONCLUSIONS: Despite the frequency of an terior chamber microbial contamination during injury or repair of the wound, with our treat ment protocol and the presence of physiologic mechanisms to reduce intraocular microbes, no eyes developed clinical endophthalmitis. With our limited sample size only intravenous antibiotic therapy was found significantly to reduce anterior chamber microorganisms at the rime of surgical repair, supporting their prophylactic use against the development of posttraumatic endophthalmitis.

The efficacy of corneal transplantation in infants with corneal opacity secondary to congenital glaucoma has not been established. We retrospectively reviewed our results of nine penetrating keratoplasties performed on eight eyes of six infants who had multiple risk factors for poor prognosis: age < 2 years at the time of grafting; uncontrolled glaucoma in four eyes; concurrent lensectomy, retinal, or glaucoma surgery in five eyes; aphakia in five eyes; and an acute perforation in one eye. Six of the nine grafts (67%) remained clear during a mean follow-up of 24 months (30 months in eyes with clear grafts). Development of ambulatory vision or better occurred in six of eight (75%) eyes after corneal transplantation and treatment of refractive errors and amblyopia. Graft failure occurred in three eyes-two from corneal decompensation, and one from homograft rejection. Complications included one total retinal detachment, one case of Streptococcus pneumoniae keratitis, and three cases that lost intraocular pressure control, requiring further glaucoma surgery. We conclude that useful vision can be achieved after penetrating keratoplasty even in some high-risk infants with congenital glaucoma.