Stromal Patch with fibrin glue as a novel surgical technique to seal peripheral Descemet's membrane perforations in deep anterior lamellar keratoplasty.

PURPOSE: The purpose of this article was to introduce a novel surgical technique for the management of peripheral Descemet's membrane perforation during deep anterior lamellar keratoplasty (DALK). METHODS: First, a thin stromal patch was prepared either from the anterior stromal lamella cut during DALK or from the anterior stroma of a Descemet's stripping automated endothelial keratoplasty button. The stromal patch was secured in a stromal pocket dissected deep in the trephination edge along the perforation site. Fibrin glue was applied to the stromal patch. Finally, the graft was sutured to the recipient bed. RESULTS: We used this technique in 3 cases with peripheral DM perforations during DALK. The first case was a persistent postoperative double anterior chamber who developed Urrets-Zavalia syndrome after air injection in an attempt to seal the perforation. In the second case, this technique was applied to seal an intraoperative DM perforation, without which the procedure would have been converted to penetrating keratoplasty. The third case had a persistent postoperative double chamber despite multiple air injections and fibrin glue application. The technique was effective in the management of all DM perforations with a resolution of double anterior chamber. CONCLUSION: This technique is safe and effective as an intraoperative method or a postoperative measure to seal peripheral DM perforations. We recommend this technique for repairing peripherally located DM perforations during DALK not amenable to simple measures like air injection or fibrin glue application.

Effect of adjunctive viscogonioplasty on drainage angle status in cataract surgery: a randomized clinical trial.

BACKGROUND: To compare the anatomic effects of phacoemulsification (Phaco) versus combined phacoemulsification and viscogonioplasty (Phaco-VGP) on drainage angle status in primary angle-closure glaucoma (PACG) using anterior segment optical coherence tomography (AS-OCT). DESIGN: Prospective, randomized clinical trial. PARTICIPANTS: Sixty-seven eyes of 57 patients with the diagnosis of PACG. METHOD: Patients were randomized to undergo Phaco alone (33 eyes) or Phaco-VGP (34 eyes). Patients were examined postoperatively on day 1, week 1 and week 6. Indentation gonioscopy and AS-OCT were performed preoperatively and at 6 weeks after surgery. MAIN OUTCOME MEASURES: Angle and anterior segment parameters by AS-OCT and amount of peripheral anterior synechiae (PAS) by gonioscopy. RESULTS: Sixty-five eyes of 55 patients completed the trial. The mean extent of PAS was significantly reduced from 127.7 to 95.0 degrees (P < 0.001) by Phaco alone, and from 174.0 to 77.3 degrees (P < 0.001) by Phaco-VGP. Phaco-VGP resulted in significantly greater reduction in PAS extent (P = 0.002). Angle-opening distance and trabecular-iris space-area measured by AS-OCT increased significantly after Phaco alone and Phaco-VGP (P < 0.001 for both). Although the change was higher in the Phaco-VGP group, this did not reach statistical significance. Anterior chamber depth (ACD) increased, and lens vault (LV) decreased after both procedures. The amount of change in ACD and LV was not significant between the two groups. CONCLUSION: Both Phaco alone and Phaco-VGP resulted in widening of the drainage angle, deepening of the anterior chamber and reduction of intraocular pressure (IOP) and PAS extent in PACG eyes. Phaco-VGP resulted in significantly more reduction of PAS. However, it seems that additional VGP has no significant effect on short-term IOP.

Bilateral electric cataracts: clinicopathologic report.

We report a case with bilateral intumescent electric cataracts, outcomes of cataract surgery with a new technique, and a histopathologic study of the anterior capsule followed by a review of the literature on electric cataracts. The patient had bilateral cataract extraction and posterior chamber intraocular lens implantation, achieving a visual acuity of 20/20. Hematoxylin and eosin staining of the anterior capsule revealed significant scar tissue formation consisting of fibroblast proliferation and hyaloid production over the basement membrane of the anterior capsule. Electric injuries can cause bilateral intumescent cataracts; the outcomes after cataract surgery are excellent provided the fundus and optic nerve examinations are normal. Scar formation over the anterior capsule may disturb lens nutrition, leading to cataract formation.

CYP1B1 mutation profile of Iranian primary congenital glaucoma patients and associated haplotypes.

The mutation spectrum of CYP1B1 among 104 primary congenital glaucoma patients of the genetically heterogeneous Iranian population was investigated by sequencing. We also determined intragenic single nucleotide polymorphism (SNP) haplotypes associated with the mutations and compared these with haplotypes of other populations. Finally, the frequency distribution of the haplotypes was compared among primary congenital glaucoma patients with and without CYP1B1 mutations and normal controls. Genotype classification of six high-frequency SNPs was performed using the PHASE 2.0 software. CYP1B1 mutations in the Iranian patients were very heterogeneous. Nineteen nonconservative mutations associated with disease, and 10 variations not associated with disease were identified. Ten mutations and three variations not associated with disease were novel. The 13 novel variations make a notable contribution to the approximately 70 known variations in the gene. CYP1B1 mutations were identified in 70% of the patients. The four most common mutations were G61E, R368H, R390H, and R469W, which together constituted 76.2% of the CYP1B1 mutated alleles found. Six unique core SNP haplotypes were identified, four of which were common to the patients with and without CYP1B1 mutations and controls studied. Three SNP blocks determined the haplotypes. Comparison of haplotypes with those of other populations suggests a common origin for many of the mutations.

Focal corneal decompensation after filtering surgery with mitomycin C.

PURPOSE: To report a case with focal corneal decompensation after filtering surgery with inadvertent inadequate irrigation of mitomycin C (MMC). METHODS: Case report and review of literature. RESULTS: A 25-year-old man first referred with the complaint of photophobia. His ocular examinations revealed diffuse keratic precipitates and many iris nodules in both eyes. The primary diagnosis was idiopathic bilateral granulomatous anterior uveitis. The intraocular pressure (IOP) gradually increased in the left eye and was not controlled with a prescription of topical antiglaucoma medications. As the disease progressed, the left eye underwent filtering surgery with MMC 0.02%. The postoperative period was uneventful, and the anterior chamber was deep after surgery. The IOP was controlled without medications; however; the inferior third of the cornea was edematous because of severe endothelial dysfunction. CONCLUSIONS: Inadequate irrigation of MMC during filtering surgery can cause focal corneal decompensation.

Comparison of the Corneal Power Measurements with the TMS4-Topographer, Pentacam HR, IOL Master, and Javal Keratometer.

PURPOSE: The aim was to compare the corneal curvature and power measured with a corneal topographer, Scheimpflug camera, optical biometer, and Javal keratometer. MATERIALS AND METHODS: A total of 76 myopic individuals who were candidates for photorefractive keratectomy were selected in a cross-sectional study. Manual keratometry (Javal Schiotz type; Haag-Streit AG, Koeniz, Switzerland), automated keratometry (IOL Master version 3.02, Carl Zeiss Meditec, Jena, Germany), topography (TMS4, Tomey, Erlangen, Germany), and Pentacam HR (Oculus, Wetzlar, Germany) were performed for all participants. The 95% limits of agreement (LOAs) were reported to evaluate the agreement between devices. RESULTS: The mean corneal power measurements were 44.3 ± 1.59, 44.25 ± 1.59, 43.68 ± 1.44, and 44.31 ± 1.61 D with a Javal keratometer, TMS4-topographer, the Pentacam and IOL Master respectively. Only the IOL Master showed no significant difference with Javal keratometer in measuring the corneal power (P = 0.965). The correlations of the Javal keratometer with TMS4-topography, Pentacam, and IOL Master was 0.991. 0.982, and 0.993 respectively. The 95% LOAs of the Javal keratometer with TMS4-topography, Pentacam, and IOL Master were - 0.361 to 0.49, -0.01 to 1.14, and - 0.36 to 0.36 D, respectively. CONCLUSION: Although the correlation of Pentacam, TMS4-topography, IOL Master, and Javal keratometer in measuring keratometry was high, only the IOL Master showed no significant difference with the Javal keratometer. The IOL Master had the best agreement with Javal keratometry.

Laser in situ keratomileusis and diode thermal keratoplasty for correction of hyperopia from +5.00 to +10.00 diopters.

PURPOSE: To evaluate the effects and safety of laser in situ keratomileusis (LASIK) and diode thermal keratoplasty (DTK) for correction of moderate to high hyperopia (+5.00 to +10.00 D). METHODS: This prospective study included 30 eyes of 15 patients who had LASIK-DTK bioptics. The median age of the patients was 50.5 years. LASIK was performed using a Nidek EC-5000 excimer laser system and DTK by a Prolaser DTK laser, 2 months after LASIK. Follow-up ranged from 9 to 12 months (mean, 10.5 mo). RESULTS: The mean preoperative spherical equivalent refraction was +8.25 +/- 0.25 D and mean postoperative was +1.00 +/- 0.50 D. The preoperative best spectacle-corrected visual acuity (BSCVA) was < or = 20/40 in 10 eyes and > or = 20/25 in 20 eyes. Postoperatively, BSCVA was < or = 20/40 in 8 eyes and > or = 20/25 in 22 eyes. No significant intra- or postoperative complications occurred. CONCLUSION: LASIK-DTK bioptics for correction of moderate to high hyperopia (+5.00 to +10.00 D) was safe and effective. In this method, two different ablative and non-ablative laser systems were used to compensate for regression, which is the most important concern in the correction of hyperopia.

Nattrassia mangiferae keratitis after laser in situ keratomileusis.

A 32-year-old man had photophobia and blurred vision 2 weeks after uneventful laser in situ keratomileusis to correct myopia. He was treated with steroids for suspected diffuse lamellar keratitis, antiherpetics, and antibiotic eyedrops, but the condition worsened and the patient developed further blurred vision, an inflamed eye, and pain. When referred to us, the patient had an extensive corneal ulcer with hypopyon and mycelia were reported in scrapings of the ulcer bed. Nattrassia mangiferae (Hendersonula toruloidea) was cultured from the specimen. The patient was treated with antifungal agents and 2 penetrating keratoplasties. At the last examination, the uncorrected visual acuity was 20/200.

Efficacy of intacs intrastromal corneal ring segment relative to depth of insertion evaluated with anterior segment optical coherence tomography.

AIM: To evaluate the effect of implantation depth of Intacs microthin prescription inserts (Addition Technology Inc, Fremont, California) on visual and topographic outcomes in patients with post- laser-assisted in situ keratomileusis (LASIK) ectasias. SETTINGS AND DESIGN: Retrospective, observational case series. MATERIALS AND METHODS: In this case series, 16 eyes of 12 patients were evaluated. All cases were post-LASIK ectasia that had undergone intrastromal corneal ring segment (ICRS) implantation. The planned insertion depth was 70% of stromal thickness using a manual dissector. At least 12 months postoperatively, all eyes underwent Visante (Carl Zeiss Meditec) AS-OCT to determine insertion depth. Cases were categorized into 3 groups based on the measured implantation depth: 40-59% thickness; 60-79% thickness; and ≥80% thickness. Visual, refractive and topographic outcomes were evaluated relative to implantation depth. RESULTS: The lowest improvement in the study parameters ocurred when the implantation depth was ≥80%. In this group, uncorrected visual acuity (UCVA) and best spectacle corrected VA (BSCVA) improved less than 0.5 lines. Manifest refractive spherical equivalent (MRSE) and mean keratometry (Km) change was less than 0.5 diopters (D). The greatest improvements were observed with implantation depth of 60-79% where UCVA and BSCVA increased by 4.5 and 2.5 lines respectively, and MRSE and Km changed by approximately 2.00 D. Less improvement was found when ICRS were implanted between 40-59% of stromal thickness. CONCLUSION: Implantation of ICRS greater than 80% of stromal thickness may have no effect on visual and topographic status.

Therapeutic possibilities of ceftazidime nanoparticles in devastating pseudomonas ophthalmic infections; keratitis and endophthalmitis.

As the number of contact-lens wearers rises worldwide, Pseudomonas aeruginosa (PA) keratitis is attracting more attention as a major public health issue. Corneal lesions of PA, being the most intimidating complication of contact-lens wearer, can progress rapidly in spite of local antibiotic treatment, and may result in perforation and the permanent loss of vision. One of the explanations proposed for the evasion of the pathogen from immune responses of the host as well as antibacterial treatment is the fact that invasive clinical isolates of PA have the unusual ability to invade and replicate within surface corneal epithelial cells. In this manner, PA is left with an intracellular sanctuary. Endophthalmitis, albeit rare, is another ophthalmic infection faced by the challenge of drug delivery that can be potentially catastrophic. The present hypothesis is that nanoparticles can carry anti-pseudomonas antibiotics (e.g. ceftazidime) through the membranes, into the "hidden zone" of the pathogen, hence being an effective and potent therapeutic approach against pseudomonas keratitis and endophthalmitis.

Effect of preemptive topical diclofenac on postoperative pain relief after photorefractive keratectomy.

PURPOSE: To assess the prophylactic effect of preoperative application of topical diclofenac on postoperative pain control in patients having photorefractive keratectomy (PRK). SETTING: Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran. DESIGN: Randomized masked clinical trial. METHODS: In this paired-eye study, patients having bilateral PRK received 1 drop of diclofenac 0.1% in 1 eye and 1 drop of placebo in the fellow eye 2 hours before PRK. Postoperatively, both arms of the trial (both eyes of each patient) received topical diclofenac every 6 hours for 2 days. One day and 2 days postoperatively, patients were asked to rate the perceived pain in each eye using an 11-point verbal numerical rating scale. A trained examiner noted the eye-specific responses. RESULTS: All 70 patients (140 eyes) completed the study and were included in the statistical analysis. Twenty-four hours after PRK, patients reported pain scores that were clinically and statistically significantly lower in the eyes pretreated with diclofenac than in the fellow eyes (0.97 versus 2.09) (P=.018). Pain scores at 2 days did not differ significantly (P=.877). CONCLUSION: Administration of a single drop of topical diclofenac 0.1% 2 hours before PRK seemed to increase the efficacy of postoperative pain management in a clinically and statistically significant manner. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Infliximab in a patient with refractory necrotizing scleritis associated with relapsing polychondritis.

PURPOSE: To describe a case of necrotizing scleritis associated with relapsing polychondritis (RP), which was treated with infliximab. METHOD: Observational case report. RESULTS: A 60-year-old woman presented with a red eye. She had a past medical history of nose deformity, hearing problem, and tinnitus. Ophthalmological examination disclosed necrotizing scleritis and peripheral ulcerative keratitis. RP was diagnosed. The disease progressed despite treatment with methotrexate and cyclophosphamide, but infliximab resulted in a stabilization of the disease. CONCLUSION: Infliximab could be a new weapon to treat refractory scleritis due to RP.

Prevalence of calibration errors in goldmann applanation tonometers.

PURPOSE: To determine the prevalence of calibration errors in Goldmann applanation tonometers at Farabi Eye Hospital. METHODS: This cross-sectional study was performed on all tonometers in use at Farabi Eye Hospital. All Haag-Streit Goldmann applanation tonometers were checked according to the manufacturer's method by two independent observers and by a third observer in case of mismatched results. Calibration errors were classified into 6 categories of ±0.5, ±1, ±1.5, ±2, ±2.5 and more than ±2.5 mmHg. RESULTS: Overall, 43 Goldmann tonometers were evaluated. There were 3 (7%), 10 (24.3%), 16 (38.3%), 24 (56.9%), 31 (72.1%) and 12 (27.9%) tonometers within calibration errors of ±0.5, ±1, ±1.5, ±2, ±2.5 and more than ±2.5 mmHg respectively. CONCLUSION: Goldmann tonometers were not within the manufacturer's recommended range (±0.5 mmHg) in 93%, and not within the acceptable range of ±2.5 mmHg in 28% of checked devices. Further study is needed to demonstrate the correlation between calibration errors and clinical errors.