Modified phototherapeutic keratectomy technique for the treatment of elevated corneal opacities.

A simple modification to the existing phototherapeutic keratectomy techniques to treat elevated corneal opacities is described for a case of severe bilateral macular dystrophy. After epithelial removal, a single drop of carboxymethylcellulose sodium 1.0% was applied centrally on the cornea. A spatula drawn smoothly stretched the drop in all directions without breaking its surface tension until the tip of the highest corneal elevation was seen. Large-diameter phototherapeutic keratectomy for 30-micron ablation was applied. This process was repeated several times, with decreasing amounts of tissue ablation as needed. Postoperative slit-lamp biomicroscopy revealed a smooth corneal surface with no elevated corneal opacities. The patient reported significant improvement with tearing and photophobia. This simple modification from painting to stretching the masking agent, thus transforming it to an ablatable mask, allowed for an effective and practical treatment of elevated corneal opacities. Carboxymethylcellulose sodium 1.0% is nontoxic, biocompatible, and requires no incubation or solidification time.

Unilateral Malignant Glaucoma Postbilateral Implantable Collamer Lens: Effect of Miotics.

An implantable collamer lens® (ICL) V4c model (STAAR Surgical, Monrovia, CA, USA) was placed in the eye of a 31-year-old male patient with high myopia followed by the development of malignant glaucoma. After failing medical treatment for 5 days, a noncomplicated pars plana vitrectomy and anterior hyaloidectomy succeeded in breaking the aqueous misdirection. Sixteen months later, intraoperative miotics were purposefully withheld from the ICL surgery in the fellow eye and malignant glaucoma did not develop. Even though the patient's visual acuity postoperatively was 20/20, OU, a single small atrophic iris patch in the affected eye resulted in slightly more halos and glare in mesopic conditions as compared to the fellow eye. Earlier surgical intervention may have prevented iris ischemia and iridocorneal touch with its subsequent iris atrophy and resulted in an even more favorable visual outcome. Withholding intraoperative miotics during ICL surgery appeared to be beneficial in this case.

Corneal light shield as a delivery system for standardized application of mitomycin C in excimer surface ablation.

PURPOSE: To develop a simple, reproducible method of applying intraoperative mitomycin C (MMC) in excimer surface ablation surgery. METHODS: A two-part protocol was developed to study several properties of corneal light shields. Part A tested the amount of MMC (0.2 mg/mL) absorbed, expansion dimension attained, and amount released to filter paper. Part B examined in vitro release of MMC to a photorefractive keratectomy (PRK)-treated enucleated pig eye. RESULTS: Mean MMC absorbed by corneal light shields was 63.7 +/- 5.0 mg (range: 57.4 to 72.8 mg); coefficient of variability was 7.8%. Expansion diameter and thickness were constant at 9.0 mm and 1.1 mm, respectively. Mean solution released to filter paper was 55.4 +/- 3.9 mg (range: 51.3 to 63.5 mg); coefficient of variability was 7.1%. Mean solution transferred to the PRK-treated pig eye was 2.3 +/- 0.7 mg (range: 1.1 to 3.5 mg); coefficient of variability was 33%. CONCLUSIONS: Mitomycin C contact surface area, amount absorbed, and amount released by each corneal light shield were reproducible. Uniform dimensions theoretically provide uniform distribution of MMC. This method may allow standardization of intraoperative MMC application in excimer surface ablation.

Central island formation after cataract surgery in a laser in situ keratomileusis eye: New etiology.

We report a case of central corneal steepness formation after cataract surgery in a post-laser in situ keratomileusis (LASIK) eye. A 51-year-old woman with traumatic cataract and a history of myopic LASIK surgery had uneventful phacoemulsification cataract surgery. Postoperatively, the corneal topography difference map showed a central island formation of 2.1 diopters (D) compared with the preoperative level, which correlated with a clinical myopic shift of 2.00 D from the targeted emmetropia. At 4 months, most of the central island had resolved spontaneously. At 15 months, topography returned to preoperative levels. We speculate that wound hydration in the flap interface during surgery resulted in a pond-like fluid accumulation in the center of the cornea, resulting in a myopic refractive shift. We report this case because of the high probability that this phenomenon could be confounded by an erroneous intraocular lens (IOL) calculation and the potential for a serious iatrogenic complication from a premature IOL exchange or touch-up procedure.

Recalcitrant post-LASIK Mycobacterium chelonae keratitis eradicated after the use of fourth-generation fluoroquinolone.

OBJECTIVE: To report a patient with Mycobacterium chelonae keratitis after LASIK and discuss therapeutic measures. DESIGN: Interventional case report and literature review. INTERVENTION: A healthy, 25-year-old man presented 6 weeks after LASIK with infectious keratitis in the left eye. Scrapings were obtained from the central stromal bed after lifting the flap and inoculated on culture media. MAIN OUTCOME MEASURES: Response to medical treatment. RESULTS: Mycobacterium chelonae was identified from stromal bed scrapings. The protracted course of the infection necessitated surgical debridement and flap amputation with slow and suboptimal response to prolonged (14 weeks) treatment with topical amikacin 3.3%, clarithromycin 1%, and levofloxacin 0.5%. The substitution of levofloxacin 0.5% with gatifloxacin 0.3% resulted in closure of the epithelial defect within 1 week and resolution of the infiltrates in 3 weeks. The combined regimen of gatifloxacin 0.3%, amikacin 3.3%, and clarithromycin 1% was continued for a total of 4 months. The patient remains infection free 1 year after stopping all antibiotics. CONCLUSION: Treatment of post-LASIK nontuberculous mycobacteria remains a challenge. Institution of combination therapy including fortified amikacin, clarithromycin 1%, and a fourth-generation fluoroquinolone appeared to be beneficial in this patient.

LASIK for high myopic astigmatism resulting from perforating ocular injury.

PURPOSE: To present a case of successful treatment of high myopic astigmatism after a perforating injury with significant corneal laceration and pupil ectopia using excimer LASIK. METHODS: A 30-year-old man presented for treatment of high myopic astigmatism in his right eye resulting from perforating ocular trauma, which occurred 8 years prior to presentation. The corneoscleral wound repair was performed with posterior chamber intraocular lens implantation. Uncorrected visual acuity (UCVA) in the right eye was counting fingers at 1 m, best corrected to 20/30 with -7.00 + 5.00 x 110. Visual acuity in the left eye was 20/20 with -1.5 D. The patient was unable to tolerate spectacles and contact lenses because of asthenopia and high astigmatism, respectively. As an alternative, LASIK with the Allegretto Wave excimer laser was performed. RESULTS: Three months postoperatively, UCVA was 20/25 in the right eye and 20/15 in the left eye. CONCLUSIONS: This case indicates that LASIK can be a useful surgical method for correcting high myopic astigmatism resulting from ocular trauma with significant corneoscleral laceration.