Systemic Allergic Response in the Setting of a Metallic Intraorbital Foreign Body With Intraoperative Magnet-Assisted Retrieval.

A 12-year-old boy with a past medical history of nickel allergy was referred to our service after sustaining an air rifle injury with a retained BB in his left inferior orbit. On examination, he had a palpable orbital mass and systemic urticaria. Plain films demonstrated a spherical metallic foreign body adjacent to the left inferior orbital rim. Given his worsening systemic reaction despite oral antihistamine therapy, decision was made to remove the foreign body. In the operating room, the Allergan Magna Finder-a prepackaged, sterile device normally used for retrieval of a port used in tissue expansion surgery-was placed over the inferior conjunctiva of the lower eyelid. With the magnet holding gentle anterior traction on the foreign body, it was easily dissected and removed. The patient tolerated the procedure well, and had rapid resolution of his systemic allergic response following removal of the BB.

Local Recurrence and Ocular Adnexal Complications Following Electronic Surface Brachytherapy for Basal Cell Carcinoma of the Lower Eyelid.

IMPORTANCE: Various treatment options exist for nonmelanoma skin cancer (NMSC), including topical agents, surgery, or definitive or adjuvant radiation therapy. Recently, electronic surface brachytherapy (ESB) has been described as a noninvasive option for NMSC. We report a case of local recurrence of basal cell carcinoma (BCC) and ocular complications following ESB to the lower eyelid. OBSERVATIONS: A man in his 60s presented with a recurrent BCC within the radiation field 10 months after undergoing ESB for a biopsy-proven BCC. In addition to the recurrence, he had contracture of the conjunctiva in the socket of his previously enucleated eye, as well as lower eyelid ectropion, resulting in displacement and loss of retention of his ocular prosthesis. CONCLUSIONS AND RELEVANCE: Electronic surface brachytherapy should be used with caution, particularly in the periocular region because the late effects of hypofractionated radiation may cause ocular and orbital complications. To our knowledge, this is the first reported case of ocular complications with this modality. This case highlights a local recurrence following use of this new treatment modality, suggesting further investigation is warranted to determine the safety and efficacy of ESB.

Cryopyrin-associated periodic syndromes and the eye.

AIM: To describe the ophthalmologic findings in two patients with Muckle-Wells Syndrome, a phenotype of the Cryopyrin Associated Periodic Syndromes (CAPS) spectrum. There is currently sparse ophthalmic literature regarding the ocular manifestations of CAPS. We hope to increase awareness of this spectrum of diseases and the importance of proper treatment amongst eye care professionals. METHODS: Interventional Case Series. RESULTS: Patient 1 experienced resolution of aseptic meningitis, papilledema, and anterior uveitis following treatment with anikinra. Patient 2 experienced resolution of panuveitis following treatment with anikinra. CONCLUSIONS: The severe ocular manifestations of the most severe CAPS phenotype, Chronic Infantile Neurological Cutaneous and Articular Syndrome/Neonatal Onset Multisystem Inflammatory Disease Syndrome (CINCA/NOMID) have been previously described. There is increasing evidence that patients may experience similar ocular disease with the milder phenotype of Muckle-Wells Sydnrome. There is also increasing evidence that appropriate therapy can have a profound effect on patient prognosis.

Choroidal neovascularization following implantation of verisyse™ iris-supported phakic intraocular lens in a pregnant myopic patient.

Both choroidal neovascularization during pregnancy, and choroidal neovascularization following implantation of phakic intraocular lenses have been reported in the literature. To our knowledge, this is the first case reported of a gravid woman developing choroidal neovascularization in an eye with a phakic intraocular lens. A 31-year-old woman became aware of her pregnancy three weeks after placement of the Verisyse™ iris-supported phakic intraocular lens. She was at 15 weeks gestation when she developed a Fuch's spot consistent with choroidal neovascularization. By eight months gestation, her symptoms nearly resolved. While the development of choroidal neovascularization in this patient may appear incidental, women of childbearing age considering phakic intraocular lenses warrant additional discussion on the possible increased likelihood of choroidal neovascularization.

Topical-intracameral anesthesia without preoperative mydriatic agents for Descemet-stripping automated endothelial keratoplasty and phacoemulsification cataract surgery with intraocular lens implantation.

UNLABELLED: We describe a technique for a new triple procedure comprising phacoemulsification and intraocular lens (IOL) implantation followed immediately by Descemet-stripping automated endothelial keratoplasty (DSAEK). It is performed under topical anesthesia, with dilation accomplished using methylparaben-free lidocaine 1% with no added epinephrine. In a case series of 32 patients, adequate dilation was achieved and no patient reported significant intraoperative discomfort. No operative or postoperative complications were encountered, and visual rehabilitation was quick and satisfactory. Topical anesthesia eliminated the risks associated with retrobulbar and peribulbar blocks, as well as the risks associated with general anesthesia. Intracameral dilation with preservative-free lidocaine 1% provided adequate and short-lived dilation, alleviating the need for intraoperative pharmacologic constriction when transitioning from IOL implantation to DSAEK. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Visual outcomes after wavefront-guided photorefractive keratectomy and wavefront-guided laser in situ keratomileusis: Prospective comparison.

PURPOSE: To compare visual outcomes between wavefront-guided photorefractive keratectomy (PRK) and wavefront-guided laser in situ keratomileusis (LASIK). SETTING: Academic center, Salt Lake City, Utah, USA. METHODS: In this randomized prospective study, myopic eyes were treated with wavefront-guided PRK and or wavefront-guided LASIK using a Visx Star S4 CustomVue platform with iris registration. Primary outcome measures were uncorrected (UDVA) and corrected (CDVA) distance visual acuities and manifest refraction. Secondary outcome measures were higher-order aberrations (HOAs) and contrast sensitivity. RESULTS: The PRK group comprised 101 eyes and the LASIK group, 102 eyes. At 6 months, the mean UDVA was -0.03 logMAR +/- 0.10 [SD] (20/19) and 0.07 +/- 0.09 logMAR (20/24), respectively (P = .544). In both groups, 75% eyes achieved a UDVA of 20/20 or better (P = .923); 77% of eyes in the PRK group and 88% in the LASIK group were within +/-0.50 diopter of emmetropia (P = .760). There was no statistically significant difference between groups in contrast sensitivity at 3, 6, 12, or 18 cycles per degree. The mean postoperative HOA root mean square was 0.45 +/- 0.13 mum in the PRK group and 0.59 +/- 0.22 mum in the LASIK group (P = .012), representing an increase factor of 1.22 and 1.74, respectively. CONCLUSIONS: Wavefront-guided PRK and wavefront-guided LASIK had similar efficacy, predictability, safety, and contrast sensitivity; however, wavefront-guided PRK induced statistically fewer HOAs than wavefront-guided LASIK at 6 months. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Nepafenac-associated bilateral corneal melt after photorefractive keratectomy.

PURPOSE: We are reporting a case of bilateral corneal melt after photorefractive keratectomy requiring bilateral corneal transplantations. RESULTS: A 35-year-old man underwent uncomplicated photorefractive keratectomy and was treated postoperatively with topical nepafenac, one drop in both eyes every 2 hours. Three days into this course of treatment, the patient developed bilateral irritation and the dose was decreased to one drop every 4 hours. The next day, he developed stromal melting in both eyes. Although nepafenac was discontinued at this point, the ulcerative keratolysis progressed in both eyes requiring penetrating keratoplasty. CONCLUSIONS: We report a case of sterile ulceration after photorefractive keratectomy surgery, which we believe was caused by frequent postoperative dosing of nepafenac.

Is tisseel a viable option in posterior lamellar keratoplasty?

PURPOSE: It is well known that Tisseel Fibrin Sealant provides an excellent tissue adhesive. However, its thick and viscuous nature makes it nearly impossible to apply it in a uniform and thin layer. We propose applying the sealant phase as a dry powder and polymerizing it in-vivo by exposing it to thrombin solution after a graft has been placed. METHODS: For each experiment two rabbit corneal buttons were affixed to each other using either Tisseel or thrombin plus dry fibrinogen component, the tensile strength of the bond was then tested in the tension box. Balanced salt solution was used as an aqueous substitute. RESULTS: Tisseel was demonstrated to create significant adhesive tensile force (expressed as N/m) between corneal buttons (P < 10). Using only the dry fibrinogen component followed by injection of the thrombin solution directly into the balanced salt solution did not significantly alter the strength of the bond (P = 0.18). CONCLUSION: The use of the dry fibrinogen component followed by injection of thrombin solution into the balanced salt solution, without the accompanying fibrinolysis inhibitor, is equally effective in adhesive strength when compared to complete Tisseel. This technique may be used in lamellar corneal surgery, although there would be potential difficulties with its application in the in vivo setting.

Dermatologic conditions seen in end-stage renal disease.

The skin changes reported in patients with end-stage renal disease (ESRD) are diverse and manifold. In this article we focus on a collection of specific cutaneous entities seen most frequently in the setting of ESRD, each presenting with distinctive and unique morphology. These include perforating disorders, porphyria cutanea tarda, pseudoporphyria, calcinosis cutis, calciphylaxis, and nephrogenic systemic fibrosis. The clinical features, histopathology, pathophysiology, differential diagnosis, and management of each entity are reviewed.