Susceptibility of Acanthamoeba to soft contact lens disinfection systems.

Members of the genus Acanthamoeba are increasingly recognized as agents of indolent, chronic, infectious keratitis. Recently, Acanthamoeba corneal infection has been reported in some persons who wear soft contact lenses. In this study, three "heat" and three "cold" soft contact lens disinfection systems were tested according to the manufacturers' instructions against Acanthamoeba castellanii and Acanthamoeba polyphaga in separate trials, and with appropriate controls. Suspensions of Acanthamoeba cysts or trophozoites of each species were tested individually. Each of the three heat disinfection units killed all acanthamoebae in one cycle in all trials. A chlorhexidine 0.005%/thimerosal 0.001% solution killed A. castellanii trophozoites and cysts, but those of A. polyphaga survived. Trophozoites and cysts of both species survived an alkyl triethanol ammonium chloride 0.013%/thimerosal 0.002% solution and a hydrogen peroxide 3% preparation. Heat disinfection overall appears to be more effective in killing Acanthamoeba trophozoites and cysts as compared to cold disinfection methods.

Pseudophakic bullous keratopathy with Intermedics model 024 (Hessburg) anterior chamber intraocular lenses.

We report the development of pseudophakic bullous keratopathy in 18 eyes following implantation of Pharmacia Intermedics Ophthalmics model 024 (Hessburg) anterior chamber intraocular lenses. Eight of these intraocular lenses were implanted during uncomplicated intracapsular cataract extractions. Mean onset of corneal edema was 21.4 months after lens implantation. Patients with this type of lens already implanted in their eyes require close follow-up for complications.

Cromolyn treatment of giant papillary conjunctivitis.

Five patients with symptomatic giant papillary conjunctivitis were treated with topical cromolyn sodium eyedrops. All patients responded favorably with relief of symptoms. Four of the patients who were subsequently examined while receiving cromolyn therapy had less prominent giant papillae on the upper tarsal conjunctivae. Thus far, the treatment of giant papillary conjunctivitis has been poorly defined and is not always practical. Topical cromolyn eyedrops seem to be helpful in the treatment of this disorder.

Cutaneous malignant melanoma metastatic to the vitreous.

A 38-year-old man previously had a cutaneous malignant melanoma excised from his right shoulder. He presented to our clinic with neovascular glaucoma, corneal edema, large pigmented keratic precipitates, anterior chamber reaction, and pigmented aggregates in the vitreous of his left eye. There were no other ocular findings. Subsequent enucleation was performed and the globe was studied histopathologically. Special stains and electron microscopy showed the presence of both macrophages and malignant melanin-producing cells within the vitreous. The diagnosis of cutaneous malignant melanoma metastatic to the vitreous was made based on these findings. This is a rarely reported clinical entity, for which a high index of suspicion should be maintained.

Herpes zoster ophthalmicus and acquired immune deficiency syndrome.

Acquired immune deficiency syndrome (AIDS) is a recently recognized disease characterized by abnormalities in cell-mediated immunity that predispose affected persons to severe opportunistic infections and unusual malignant neoplasms. We describe four cases of herpes zoster ophthalmicus in four previously healthy homosexual men. Two had signs and symptoms consistent with AIDS, and two had signs and symptoms of a lymphadenopathic syndrome associated with AIDS. We suggest that underlying AIDS be considered in young, healthy persons with herpes zoster ophthalmicus and no known cause of immunosuppression.

Susceptibility of Acanthamoeba to cryotherapeutic method.

Acanthamoeba keratitis is becoming an increasingly well-known clinical entity. The Acanthamoeba species in their encysted state are resistant to antimicrobial agents, resulting in corneal infections that are refractory to medical therapy. Corneal cryotherapy has been used to treat Acanthamoeba keratitis with varying and equivocal success. We subjected trophozoites and cysts of two species of Acanthamoeba recovered from corneal infections to trials of in vitro freeze-thaw-refreeze cryotherapeutic methods. The trophozoites of both species were killed in all trials. However, the cysts of both species survived all trials. Cryotherapy may not be an effective means to eliminate Acanthamoeba cysts from the cornea.

Ocular involvement in the respiratory vasculitides.

The respiratory vasculitides are idiopathic inflammatory syndromes, characteristically involving the pulmonary vasculature as well as that of several other organ systems. The inflammatory response in these diseases is uniformly granulomatous. There are three distinct, recognized respiratory vasculitides: Wegener's granulomatosis, Churg-Strauss syndrome (allergic granulomatosis and angiitis), and lymphomatoid granulomatosis. Each of these entities may have ophthalmic manifestations, and ocular involvement may, in fact, be the presenting sign. The systemic and ocular manifestations, as well as the differential diagnosis and management of each of these entities are discussed.

Corneal microsporidiosis in a patient with AIDS.

Microsporidia are obligate intracellular protozoan parasites that are becoming increasingly recognized as opportunistic pathogens in patients with AIDS. They have been associated with enteritis, hepatitis, and peritonitis and recently keratoconjunctivitis. Gram stain demonstrates the presence of these organisms on light microscopic sections. The specific diagnostic features that distinguish microsporidia from other small nonspore-forming organisms are best demonstrated by electron microscopy, which is also used to characterize the members of Microsporea. In this study, salient histopathologic features of microsporidia in corneal epithelium obtained from an HIV-seropositive individual who developed AIDS are illustrated and discussed.

Minimum bactericidal concentrations of Propionibacterium acnes isolates from cases of chronic endophthalmitis.

Six isolates of Propionibacterium acnes recovered from cases of chronic infectious endophthalmitis following extracapsular cataract extraction were tested for antibiotic susceptibility. All isolates were susceptible to penicillin, cefazolin, and vancomycin with a macrobroth dilution method. Minimum bactericidal concentrations testing at 72 h revealed that six of six isolates were killed by < or = 1.0 micrograms of vancomycin/ml, one of six isolates by < or = 1.0 micrograms of penicillin/ml, and zero of six isolates by < or = 1.0 micrograms cefazolin/ml.

Recurrence of the clinical signs of lattice corneal dystrophy (type I) in corneal transplants.

Lattice corneal dystrophy (type I) is characterized by branching stromal lattice figures, white subepithelial opacities, and anterior stromal haze. Corneal transplantation is often required to restore the vision of patients with lattice corneal dystrophy. Our retrospective study of 61 penetrating keratoplasties in 39 patients with lattice corneal dystrophy found clinical signs of lattice corneal dystrophy in 29 transplants (48%) after periods ranging from three to 26 years. Subepithelial opacities or anterior stromal haze or both were the most common signs of recurrence. Lattice figures appeared in only one graft. Regrafting was necessary to restore vision in eight cases (15%) in which primary corneal transplantation had been performed for this condition.

Disappearance of crystals in Schnyder's crystalline corneal dystrophy after epithelial erosion.

PURPOSE: A 40-year-old woman with Schnyder's crystalline corneal dystrophy had two episodes of epithelial erosion. METHODS: We reviewed the patient's medical record and photographic file. RESULTS: In the areas underlying the epithelial erosion, the crystalline opacities disappeared. The crystals recurred in the subsequent five years but were not as dense. CONCLUSIONS: Crystals in the subepithelial or Bowman's layer may lead to epithelial destabilization and corneal epithelial erosion. Disappearance of the crystalline opacities may occur after disruption of the epithelium.

Blepharoptosis surgery complicated by late suture migration.

PURPOSE: To report late suture migration as a complication of blepharoptosis surgery. METHOD: Case reports. RESULTS: After upper eyelid blepharoptosis repair, two eyes of two patients developed unusual foreign body reactions and ulceration in the conjunctiva caused by migration of nonabsorbable suture from the levator aponeurosis to the upper conjunctival fornix. The foreign body caused eyelid edema, papillary changes in the upper tarsal conjunctiva, recurrent blepharoptosis, and a foreign body sensation that started more than 3 months after the surgery and persisted until the suture was removed. The sutures, hidden in edematous conjunctiva of the superior fornix, eluded detection. CONCLUSIONS: Foreign body reaction secondary to suture migration is an uncommon complication of blepharoptosis repair.

Spontaneous collapse of primary acquired iris stromal cysts.

PURPOSE: To describe the spontaneous collapse of primary acquired iris stromal cysts. METHODS: We reviewed the medical records, clinical findings, and ultrasonography of two patients who had been followed up for primary acquired iris stromal cysts. RESULTS: During follow-up, both patients experienced spontaneous collapse of their cysts, which resulted in membrane formation on the peripheral corneal endothelium, localized peripheral anterior synechiae, ectropion uveae, and slightly peaked pupil. CONCLUSION: Primary acquired iris stromal cysts may undergo spontaneous collapse, resulting in clinical findings similar to other anterior segment disorders.

Trantas dots and limbal inflammation associated with soft contact lens wear.

A 30-year-old man developed vernal-like limbal changes associated with soft contact lens wear including Trantas dots, limbal nodules, and diffuse limbitis. These findings add to the contention that the conjunctival changes found in giant papillary conjunctivitis and vernal conjunctivitis share a common immunopathogenesis.

An immunopathologic study of giant papillary conjunctivitis associated with an ocular prosthesis.

A 21-year-old woman, whose left eye had been enucleated when she was 2 years old, developed giant papillary conjunctivitis and experienced ocular discomfort and increased tearing when she wore her prosthesis. Cultures grew normal flora, and topical antibiotics failed to relieve her symptoms. Immunopathologic studies of a conjunctival biopsy specimen disclosed plasma cells of all five classes of immunoglobulins in the substantia propria and many IgE-containing cells. Russell bodies found in some of the plasma cells were of the IgM and IgG types. The patient was treated with a 2% solution of cromolyn sodium, applied four times a day. Within one month, her symptoms had resolved, there was less conjunctival congestion, and the papillae were much less prominent. Our findings suggested that there may be a heterogenous humoral response in giant papillary conjunctivitis along with a strong immediate (Type I) hypersensitivity component.

Phacoemulsification cataract extraction and posterior chamber lens implantation in patients with uveitis.

PURPOSE: This study reports outcomes of phacoemulsification cataract extraction and posterior chamber intraocular lens implantation within the capsular bag in patients with uveitis. METHODS: We retrospectively reviewed the charts of 32 patients (39 eyes) with uveitis who underwent phacoemulsification cataract extraction and posterior chamber intraocular lens implantation by two surgeons at The Cleveland Clinic Foundation from January 1990 to June 1998. Patients with less than 3 months of follow-up were excluded. RESULTS: Diagnoses of uveitis included idiopathic (15 eyes), sarcoidosis (10 eyes), pars planitis (four eyes), CMV retinitis (two eyes), Fuchs heterochromic iridocyclitis (two eyes), syphilis (two eyes), and one eye each of tuberculosis, Crohn's disease, HLA-B27 associated, and acute retinal necrosis. Average follow-up was 20 months (range, 3 to 63 months). Best-corrected visual acuity improved in 37 eyes (95%). Average improvement was 4 +/- 3 Snellen acuity lines (range, 1 to 10 lines). Thirty-four eyes (87%) attained final visual acuity better than or equal to 20/40. Visual loss occurred in one eye (3%) with CMV retinitis. No improvement in visual acuity was seen in one eye (3%) that developed a retinal pigment epithelial detachment. Posterior capsule opacification occurred in 24 eyes (62%), 12 of which required Nd:YAG capsulotomy (31%). Other postoperative complications included recurrence of uveitis (41%), cystoid macular edema (33%), epiretinal membrane formation (15%), and posterior synechiae (8%). CONCLUSIONS: Phacoemulsification cataract extraction with posterior chamber intraocular lens implantation is safe in patients with uveitis. The incidences of recurrence of uveitis, cystoid macular edema, epiretinal membrane, and posterior synechiae were lower than those reported previously for extracapsular cataract extraction.

Cicatrizing conjunctivitis associated with paraneoplastic lichen planus.

PURPOSE: To report two cases of cicatrizing conjunctivitis associated with paraneoplastic lichen planus. METHODS: Case reports. RESULTS: Two patients were examined because of redness and discomfort in both eyes. A 63-year-old woman with follicular, small-cleaved cell lymphoma had cicatrizing conjunctivitis, stomatitis, vulvitis, and skin lesions. A 25-year-old man with malignant thymoma had cicatrizing conjunctivitis, erosive stomatitis, and penile papules. Histopathologic studies of conjunctiva and skin biopsy specimens in the first patient and labial biopsy specimens in the second revealed lichen planus. CONCLUSION: Paraneoplastic lichen planus is a possible cause of cicatrizing conjunctivitis associated with inflammatory skin and mucous membrane disease.

Conjunctival involvement in paraneoplastic pemphigus.

Paraneoplastic pemphigus is a recently described autoimmune inflammatory mucocutaneous disease associated with an underlying neoplasm. Although histopathologic and direct immunofluorescence findings of involved skin and mucous membranes are consistent with pemphigus vulgaris, indirect immunofluorescence and immunoprecipitation study results are unique. We treated two patients with non-Hodgkin's lymphoma and paraneoplastic pemphigus. Both patients had bilateral bulbar conjunctival hyperemia and diffuse papillary tarsal conjunctival reactions. One patient had sloughing of conjunctival epithelium and the other had tarsal conjunctival cicatrization and forniceal shortening. Histopathologic findings of conjunctivae obtained from both patients were consistent with pemphigus vulgaris. Diffuse deposition of IgG and C3 in the intercellular substance of the conjunctival epithelium was demonstrated by direct immunofluorescence. Indirect immunofluorescence testing disclosed binding of autoantibodies to rodent bladder and intestinal epithelium. Immunoprecipitation disclosed antibodies reactive to Desmoplakin I (250 kd), bullous pemphigoid (230 kd), Desmoplakin II (210 kd) and 190-kd proteins. Ophthalmologists and pathologists should be aware of the conjunctival changes in paraneoplastic pemphigus.

Chest computed tomography and mediastinoscopy in the diagnosis of sarcoidosis-associated uveitis.

PURPOSE: To report the usefulness of chest computed tomography and mediastinoscopy in diagnosing sarcoidosis in elderly patients with uveitis. METHODS: Case reports. Two Caucasian women, aged 73 and 70 years, underwent evaluations for uveitis, which included chest computed tomography and mediastinoscopy. RESULTS: A chest computed tomographic scan of each woman disclosed mediastinal lymphadenopathy and warranted mediastinal lymph node biopsy by mediastinoscopy. In both patients, histopathologic and microbiologic studies demonstrated sterile noncaseating granulomas consistent with the diagnosis of sarcoidosis. CONCLUSIONS: The diagnosis of sarcoid-associated uveitis in the elderly may be facilitated by chest computed tomography, which may be more sensitive than conventional chest roentgenography. Laboratory studies of biopsied mediastinal nodes obtained by mediastinoscopy can confirm the diagnosis.

Infectious crystalline keratopathy.

In three patients (three men, 44, 67, and 83 years old) an unusual keratopathy characterized by white, branching, crystalline stromal opacities produced lesions that were insidious, that increased in size slowly, and that were clinically and histopathologically associated with little corneal inflammation. Intraocular inflammation eventually became evident in two of the patients. The keratopathy developed while the patients were using topical corticosteroids. In two cases, histopathologic studies disclosed accumulations of gram-positive cocci in the corneal stroma; a viridans streptococcus agent was isolated on culture. In one case, the viridans streptococcus was determined to be a dextran producer, which may have contributed to the pathogenesis of the keratopathy. Despite aggressive treatment with a variety of drugs, epithelial healing, and resolution of the corneal infiltrate, residual scarring persisted in two cases and neovascularization and graft edema in one case each.