Visualization of the trabeculo-Descemet membrane in deep sclerectomy after Nd:YAG goniopuncture: an in vivo confocal microscopy study.

OBJECTIVES: To evaluate the morphologic characteristics of the trabeculo-Descemet membrane (TDM) by in vivo confocal microscopy (IVCM) after deep sclerectomy with collagen implant and to correlate the findings with the intraocular pressure (IOP)-lowering effect of goniopuncture. METHODS: Twenty eyes of 19 patients were evaluated in a prospective, observational case series. Examination using IVCM and measurement of IOP were performed 15 minutes before and 15 minutes after Nd:YAG goniopuncture. RESULTS: Two groups could be distinguished on the basis of morphologic characteristics of the TDM before goniopuncture. In group 1 (13 eyes), the TDM was characterized by the presence of an area of epithelial cells in the deep stromal level. After goniopuncture, an opening at the TDM with dispersed epithelial cells was visible. In group 2 (7 eyes), fibrotic tissue overlying the TDM was observed in all cases, and no openings were visible after goniopuncture. Group 1 had a statistically significant decrease in mean (SD) IOP after goniopuncture (21.6 [4.8] mm Hg before and 13.5 [4.6] mm Hg after, P = .008); there was no significant change in group 2 (19.2 [4.3] mm Hg before and 20.8 [7.5] mm Hg after, P = .30). There was a strong correlation between the presence of fibrous tissue and percentage of IOP lowering after goniopuncture (ρ = -0.89, P < .001). CONCLUSIONS: The presence of fibrotic tissue covering the TDM is associated with failure of goniopuncture. Use of IVCM may be valuable in predicting the efficacy of goniopuncture in patients with elevated IOP after deep sclerectomy with collagen implant.

New strategy to study corneal endothelial cell transplantation: the chick cornea model.

PURPOSE: To set up a culture assay of chick corneal endothelial cells (CECs) for transplantation into host corneas. METHODS: Histology sections were performed at 6, 9, 12, 15, and 18 embryonic days of development of the chick embryo. Visualization of the gross morphology of CECs and of epithelium, stroma, and Descemet membrane was performed. Transplantation of CECs at 18 embryonic days of development into explanted, denuded from endothelial cell, host corneas of the same stage was attempted. RESULTS: The results from the histological sections clearly indicate that after embryonic day 12, the endothelial cells are well differentiated and the proliferation is complete. Transplanted CECs were able to migrate and integrate into the denuded host corneas. CONCLUSIONS: This study demonstrated its feasibility using an easy accessible model of chick cornea. With this technique, sufficient CECs may be obtained for biochemical and functional investigations using only nonhatched chickens that are easily accessible and easy to manipulate.

Pediatric ocular rosacea.

A case of severe pediatric ocular rosacea was effectively treated after 2.5 years of misdiagnosis. A high index of suspicion should be maintained in children with ocular surface disease, with or without dermatologic rosacea, to correctly diagnose ocular rosacea and avoid morbidity and complications.

Retinal vessel analyzer measurements of the effect of panretinal photocoagulation on the retinal arteriolar diameter in diabetic retinopathy.

PURPOSE: The purpose of this study was to investigate the effect of panretinal photocoagulation (PRP) on the retinal arteriolar diameter in patients with diabetic retinopathy using a retinal vessel analyzer. METHODS: Ten eyes of 6 consecutive patients with type II diabetes and severe nonproliferative or proliferative diabetic retinopathy were studied prospectively. Measurements of the retinal arteriolar diameter were performed before the first photocoagulation session and after the end of the PRP treatment. RESULTS: Retinal arteriolar diameter before PRP was 131 +/- 15 arbitrary units and decreased to 112 +/- 14 arbitrary units after PRP (P = 0.012). There was a significant vasoconstriction of 13.8% +/- 8.3% following PRP. Mean visual acuity before and after PRP was 0.31 +/- 0.36 logarithm of the minimal angle of resolution and 0.28 +/- 0.30 logarithm of the minimal angle of resolution, respectively (P = 0.68). There was no significant change in mean arterial pressure before and after PRP (P = 0.89). There was no correlation between the visual acuity change or the number of laser burns and the percentage change in the retinal arteriolar diameter (P > 0.1). CONCLUSION: Panretinal photocoagulation has a vasoconstrictive effect on retinal arterioles in patients with severe nonproliferative or proliferative diabetic retinopathy. These results are consistent with an autoregulatory response of the retinal circulation to increased inner retinal oxygen tension after PRP. The retinal vessel analyzer is a fast, accurate, noninvasive, online measuring system for the study of the retinal vascular response to PRP in patients with diabetic retinopathy.

Peripheral autoimmune neuropathy assessed using corneal in vivo confocal microscopy.

BACKGROUND: Corneal nerves can be examined using in vivo confocal microscopy (IVCM). This new technique permits sequential observation of the corneal subbasal nerve plexus and detects early signs of diabetic peripheral neuropathy. OBJECTIVE: To describe a patient with autoimmune peripheral neuropathy followed up using corneal IVCM. DESIGN: Case report. SETTING: Clinic of neurology, Geneva, Switzerland. Patient A 56-year-old man with peripheral neuropathy diagnosed as anti-myelin-associated glycoprotein neuropathy. His symptoms initially worsened despite the administration of intravenous immunoglobulins and plasma exchange. Evolution was eventually favorable after rituximab and corticosteroids were given. At 1-year follow-up, clinical recovery was almost complete, and the patient was stable according to the results of clinical and electrophysiologic assessments. Main Outcome Measure Corneal nerve measurement by IVCM. RESULTS: Examination of corneal nerves using IVCM at 2 different times during the patient's clinical evolution (peak disease and recovery phase) demonstrated histologic signs that correlated with the results of clinical and electrophysiologic assessments. CONCLUSION: This observation supports the hypothesis that corneal IVCM could also be helpful for the early detection or follow-up of autoimmune peripheral neuropathy.

Clinical course of epidemic keratoconjunctivitis: evaluation by in vivo confocal microscopy.

PURPOSE: To describe, by in vivo confocal microscopy, the structural changes occurring during the course of adenovirus epidemic keratoconjunctivitis (EKC), from the onset of the disease up to 24 weeks of follow-up. METHODS: Eight patients (age, 8-57 years) with clinical evidence of EKC were examined and photographed in vivo with a Heidelberg Retina Tomograph II, Rostock Cornea Module. RESULTS: At 1 week, confocal microscopy revealed clusters of hyperreflective cells in the basal epithelial cell layer. In these sites, we observed subepithelial accumulations of dendritic cells, located mainly at the level of the Bowman layer. Underneath in the anterior stroma, we detected clusters of highly reflective, irregularly shaped cells. At 2 weeks, all patients presented follicular conjunctivitis, focal keratitis, and subepithelial infiltrates. At this point, confocal microscopy revealed persistent clusters of hyperreflective basal epithelial cells intermingled with roundish cells that probably represent leukocytes. Underneath, dendritic cells had formed an intricate network and, in the anterior stroma, we detected a hyperreflective cellular plaque that corresponded to the subepithelial infiltrate. At 24 weeks after onset of the symptoms, density and dimension of dendritic cell clusters were decreased, but we now detected stromal hyperreflectivity in the midstroma. CONCLUSIONS: In vivo confocal microscopic examination of subepithelial infiltrates appearing during EKC suggests that the innate immune system, as represented by the dendritic cells, is highly active early on. Nonetheless, the inflammatory component in both epithelium and stroma is massive and, in deeper stromal layers, long standing.

Bacterial keratitis after nonpenetrating glaucoma surgery.

A 68-year-old woman had uneventful deep sclerectomy with a collagen implant in the left eye that was complicated by infectious keratitis 2 weeks later. Corneal scraping revealed the presence of Staphylococcus aureus. The patient responded to topical antibiotic treatment, and the corneal infiltration resolved, leaving a corneal scar. Bacterial keratitis may occur after nonpenetrating glaucoma surgery and should be included in the list of early postoperative complications.

Outcomes of coaxial microincision cataract surgery versus conventional coaxial cataract surgery.

PURPOSE: To compare the outcomes of coaxial microincision cataract surgery (MICS) with those of conventional coaxial cataract surgery. SETTING: University Eye Clinic, Geneva, Switzerland. METHODS: In a prospective study, 50 eyes of 50 patients with nuclear or corticonuclear cataract (grades 2 to 4 on the Lens Opacities Classification System III) were randomly selected to have cataract extraction through a temporal clear corneal incision using 1 of 2 techniques: coaxial MICS (25 eyes) or conventional coaxial cataract surgery (25 eyes). Coaxial MICS was performed through a 1.6 mm incision and conventional coaxial cataract surgery, through a 2.8 mm incision. In all cases, a flexible hydrophobic acrylic intraocular lens (Lentis L-303, WaveLight GmbH) was implanted. Intraoperative parameters were ultrasound time, surgical time, and total volume of balanced salt solution used. The best corrected visual acuity, corneal thickness, and endothelial cell count were evaluated preoperatively and postoperatively. RESULTS: There were no relevant clinical differences between groups or perioperative complications in either group. The only statistically significant differences between the 2 groups were ultrasound time (P = .0002) and surgical time (P = .005). CONCLUSIONS: Coaxial microincision cataract surgery was a safe and effective technique. Although ultrasound and surgical time were significantly higher with coaxial MICS than with conventional coaxial cataract surgery, the postoperative results in the 2 techniques were comparable.

Comparison of adapted Vryghem macular function test and Lotmar-light interferometer in predicting visual acuity after cataract surgery.

PURPOSE: To assess the accuracy of a newly described macular function test (Vryghem macular function test) adapted to our examination equipment and to compare it to the Lotmar-light interferometer for the preoperative evaluation of cataract patients at the University Eye Clinic, Geneva, Switzerland. METHODS: This prospective study included 71 consecutive patients (72 eyes) who were undergoing uneventful cataract surgery. Testing with the Lotmar-light interferometer and an adapted form of Vryghem macular function test (AVMFT) using a Birkhauser reading chart, a hyperaddition of +8 D and halogen illumination were performed to assess macular function and to predict postoperative visual acuity (VA). The duration of each test and the density and location of lens opacities were also noted. Best-corrected postoperative VA was compared to the predicted values of each test. RESULTS: The positive predictive value was 94.2% for AVMFT compared to 92.2% for the Lotmar-light interferometer. The negative predictive value was 50% for AVMFT compared to 42.9% for the Lotmar-light interferometer. The sensitivity was 83.1% for AVMFT and 79.7% for the Lotmar-light interferometer. The specificity was 76.9% for AVMFT and 69.2% for the Lotmar-light interferometer. The correlation coefficient for AVMFT and preoperative Lotmar results (both in LogMAR) with postoperative best-corrected VA (poBCVA; LogMAR) were similar (0.74 and 0.77 respectively). CONCLUSION: The results of this study suggest that AVMFT is as reliable as the Lotmar-light interferometer in predicting postoperative VA after uneventful cataract surgery. The correlation coefficients with postoperative VA were 0.74 and 0.77, respectively. Both tests showed a high positive (94.2% and 92.2%, respectively) but a low negative (50.0% and 42.9%, respectively) predictive value.

Functional study in NSE-Hu-Bcl-2 transgenic mice: a model for retinal diseases starting in Müller cells.

In NSE-Hu-Bcl-2 transgenic mice, line 71, retina undergoes early postnatal degeneration linked to the prior death of Müller cells. The purpose of this study was to complete the characterization of this retinal dysfunction by using electroretinographic (ERG) recordings in both scotopic and photopic conditions. Here, we showed that both rod and cone systems were profoundly affected in NSE-Hu-Bcl-2 transgenic mice as soon as 15 postnatal days in accordance with histological study performed previously.

In vivo confocal microscopy in hydroxychloroquine-induced keratopathy.

BACKGROUND: Vortex keratopathy, arising as a side effect of several medications, is characterized by golden-brown deposits in the cornea. METHODS: A 41-year-old woman treated for sarcoidosis with hydroxychloroquine therapy and suffering from vortex keratopathy was examined by in vivo confocal microscopy. Scans of both corneas were performed. RESULTS: By slit lamp examination, the left but not the right eye showed a golden-brown deposit throughout the cornea. In vivo confocal microscopy revealed the presence of highly reflective, dot-like intracellular inclusions concentrated in the basal epithelial layer. They were also detected within the anterior and posterior stroma, but not within the endothelium. In regions of the anterior stroma, devoid of inclusions, hyperreflective ramified keratocytes were observed, forming an extended interconnecting network. CONCLUSION: In addition to the granular deposits, in vivo confocal microscopy revealed hyperreflective, possibly phagocytic keratocytes.

Outbreak of endophthalmitis after cataract surgery: the importance of the quality of the surgical wound.

Postoperative endophthalmitis is a rare but potentially devastating condition. We investigated an outbreak of 8 cases of endophthalmitis in patients who underwent phakectomy performed by a single surgeon from January through September 2004. The outbreak was traced to damaged surgical blades, and it highlights the importance of the quality of the surgical wound.

Bilateral corneal perforation in familial amyloidotic polyneuropathy.

PURPOSE: We report the progression of bilateral central perforating ulceration in the cornea of a patient with familial amyloidotic polyneuropathy (FAP), also known as hereditary Portuguese amyloidosis, who received two corneal grafts in an interval of 6 years. The pathology of the original host and the grafted cornea is described. METHODS: Overall histology and immunolocalization of transthyretin, amyloid beta (Abeta), and epithelial and inflammatory markers were performed. RESULTS: Corneal sensitivity and tear film were reduced. The grafted but not the original tissue contained amyloid deposits with transthyretin immunoreactivity. Epithelial and stromal thinning was accentuated in the graft, with epithelial dysplasia, hyperproliferation, and parakeratosis. Abundance of basement membrane material in hyperproliferative regions suggested recurrent attempts of wound healing. Activated keratocytes, ingrowth of vessels, infiltrated inflammatory, and immune cells reflect both acute and chronic inflammation. CONCLUSION: Amyloid deposits may progressively reduce corneal sensitivity and damage epithelium and stroma. Corneal neuropathy, together with impaired tear film, may entail the pathology of dry eyes as a bystander effect, contributing to exacerbation of epithelial injury, deregulated proliferation, and parakeratosis. Once established, both acute and chronic inflammation may sustain progression of the corneal pathology.

Effect of isometric exercise on choroidal blood flow in type I diabetic patients.

BACKGROUND: In healthy subjects, choroidal blood flow is regulated when the mean ocular perfusion pressure increases. Since capillary vascular beds are altered in diabetic patients, the regulation of choroidal blood flow could be affected by this pathology. PATIENTS AND METHODS: 10 type I diabetic patients without retinopathy (DNR group) and 7 type I diabetic patients with retinopathy (DR group) participated in the study. In NDR and DR groups, choroidal blood flow was measured while patients raised their mean arterial blood pressure by squatting. The results were compared to those of a previous study in normals. Pupillometry was performed at rest on the two diabetic groups and on seven normals during a modification of illumination (white/black screen transition). RESULTS: In the NDR and DR groups, mean ocular perfusion pressure raised by 61 and 50 % during squatting, respectively. Consecutively, choroidal blood flow did not change in NDR as in normals, but increased linearly in DR patients. The white/black screen transition produced an increase of the pupil diameter of 52 and 49 % in normals and NDR patients, respectively, while it increased by only 16 % in the DR patients. CONCLUSIONS: As already shown in healthy subjects, choroidal blood flow is regulated in NDR patients when the ocular perfusion pressure increases. In DR patients, the absence of this control could be due to a failure of the autonomic nervous system, as suggested by pupillometry results.