Factors associated with intraoperative floppy iris syndrome.

PURPOSE: To identify factors associated with intraoperative floppy iris syndrome (IFIS) in patients undergoing routine phacoemulsification. DESIGN: Comparative case series. PARTICIPANTS: Analysis of 899 eyes of 660 patients undergoing routine cataract surgery. METHODS: All routine cases of cataract extraction with posterior chamber intraocular lens implantation between September 1, 2005, and August 31, 2006, were documented. Pertinent patient information, including age, gender, race, medical history, and current medication use (including tamsulosin [Flomax, Boehringer-Ingelheim, Ingelheim, Germany], other alpha(1)-antagonists, angiotensin antagonists, anticholinergics, cholinergic agonists, muscle relaxants, nitric oxide donors, and saw palmetto), were collected at the time of surgery. A telephone survey was used to determine previous use of tamsulosin, other alpha(1)-antagonists, and saw palmetto. Cases were identified intraoperatively as IFIS or non-IFIS following the triad of criteria developed by Chang and Campbell. MAIN OUTCOME MEASURES: Presence of IFIS associated with medication use and medical history. RESULTS: Analysis showed IFIS in 27 patients (4.1%) representing 33 eyes (3.7%). Tamsulosin use (P<0.001) and history of alpha(1)-antagonist use other than tamsulosin (P = 0.01) were shown to strongly correlate with IFIS in our study. Hypertension was noted to be a significant variable via multivariable generalized estimating equations analysis (P = 0.04) with a prevalence of 75.8% in patients with IFIS versus 56.4% in patients without IFIS. Saw palmetto showed a slight, but statistically insignificant, trend that current use or history of use may be associated with IFIS. There were no cases of posterior capsular rupture or vitreous loss. CONCLUSIONS: Exposure to tamsulosin highly correlates with IFIS. Use of other alpha(1)-antagonists is also associated with IFIS. Several patients in our series were identified to have IFIS with no history of alpha(1)-antagonist use, indicating that other etiologic factors, or a combination of factors, can also elicit this response. Multivariable regression analysis shows no proven relationship between IFIS and individual use of angiotensin antagonists, anticholinergics, cholinergic agonists, muscle relaxants, nitric oxide donors, or saw palmetto, and diabetes or congestive heart failure.

Comparison of the Infiniti vision and the series 20,000 Legacy systems.

PURPOSE: To compare the efficiency of the Infiniti vision system and the Series 20,000 Legacy system phacoemulsification units during routine cataract extraction. METHODS: Thirty-nine eyes of 39 patients were randomized to have their cataract removed using either the Infiniti or the Legacy system, both using the Neosonix handpiece. System settings were standardized. Ultrasound time, amount of balanced salt solution (BSS) used intraoperatively, and postoperative visual acuity at postoperative days 1, 7 and 30 were evaluated. RESULTS: Preoperatively, best corrected visual acuity was significantly worse in the Infiniti group compared to the Legacy group (0.38 +/- 0.23 and 0.21 +/- 0.16, respectively; p = 0.012). The mean phacoemulsification time was 39.6 +/- 22.9 s (range 6.0-102.0) for the Legacy group and 18.3 +/-19.1 s (range 1.0-80.0) for the Infiniti group (p = 0.001). The mean amounts of intraoperative BSS used were 117 +/- 37.7 ml (range 70-195) in the Legacy group and 85.3 +/- 38.9 ml (range 40-200) in the Infiniti group (p = 0.005). No differences in postoperative visual acuity were found. CONCLUSION: The ability to use higher flow rates and vacuum settings with the Infiniti vision system allowed for cataract removal with less phacoemulsification time than when using the Legacy system.

Cataract associated with type-1 diabetes mellitus in the pediatric population.

PURPOSE: To report 14 cases (28 eyes) of cataract associated with type-1 diabetes mellitus in young children and adolescents. METHODS: Retrospective review of the medical records of 14 patients from seven institutions. All patients under the age of 18 years who met the inclusion criteria of type-1 diabetes mellitus and cataract were included. RESULTS: Mean age at the time of diabetes diagnosis was 9.8 years (range, 0.5-14 years), and mean age at cataract diagnosis was 11.7 years (range, 5-16 years). Two patients presented with cataracts one month before the diagnosis of diabetes; seven after the diagnosis of diabetes; and in five patients the cataract was found at the time the diabetes was diagnosed by the pediatrician. Nineteen out of 23 operated eyes had a best corrected post operative visual acuity of 20/40 or better. Two patients (4 eyes) developed diabetic retinopathy postoperatively. CONCLUSIONS: Although cataract formation in type-1 diabetes is rare, it is treatable and potentially sight-saving in young children and adolescents.

Surgical techniques and adjuvants for the management of primary and recurrent pterygia.

The removal and rate of recurrence of pterygium have been discussed for years. The disorder is highly associated with environmental factors, and recurrence rates can be unacceptably high and cannot be successfully predicted. New techniques and graft preparations and postoperative management strategies are helping to reduce the recurrence rates and provide an ocular surface that is near ideal for future cataract or refractive surgery. This review discusses the advantages and disadvantages of various treatment strategies.

Immunoglobulin gene implicated in murine herpes stromal keratitis is not associated with the human disease.

PURPOSE: Susceptibility to herpes stromal keratitis (HSK) is strongly influenced by genetic factors, as shown by multiple rodent models using human herpes simplex virus. A single gene, encoding the immunoglobulin G (IgG) 2a heavy chain protein, confers susceptibility or resistance through a mechanism involving molecular mimicry in one mouse model. However, other rodent studies have produced contradictory results. This study tested the hypothesis that the GM23 gene (the human IgG2a homolog) influences susceptibility to HSK in humans. METHODS: The study population consisted of all consenting patients diagnosed with HSK (25 whites, 2 African Americans) at the Medical University of South Carolina Storm Eye Institute Clinic in Charleston, SC, between August 2000 and June 2004. Healthy controls (23 white adults with no history of HSK) were recruited from the same local population. Genomic DNA from subjects was genotyped at the GM23 locus, which has been implicated as an HSK resistance gene in animal models, by polymerase chain reaction-restriction fragment length polymorphism (RFLP) analysis. RESULTS: No difference in GM23 genotype frequency was observed between patients with HSK and controls. CONCLUSION: Susceptibility to HSK in whites is not predicted by GM23 genotype.

Ocular manifestations after primary varicella infection.

PURPOSE: To report a case of ocular manifestations after a primary varicella infection. METHODS: Review of the literature and a case report of a 10-year-old male patient with history of blurry vision and an enlarged pupil 2 months after a varicella infection. Examination revealed uveitis, interstitial keratitis, and internal ophthalmoplegia. RESULTS: The uveitis resolved with topical steroids; the interstitial keratitis resolved with a faint scar, and the internal ophthalmoplegia persisted. CONCLUSION: This case report describes a patient with uncommon ocular manifestations after primary varicella.

Bronchogenic squamous cell carcinoma presenting as cicatrizing conjunctivitis.

PURPOSE: To report a case of cicatrizing conjunctivitis as the initial manifestation of a bronchogenic squamous cell carcinoma. METHODS: Case report of a 57-year-old patient with bilateral history of ocular pain, redness, and discharge, with no apparent predisposing factors. Examination revealed chemosis, pseudomembrane, and symblepharon formation, and multiple ulcerated pustular and vesicular periocular and perioral lesions literature review. RESULTS: Skin biopsy was compatible with bullous pemphigoid. Two months later he developed respiratory symptoms, and a squamous cell carcinoma was diagnosed. CONCLUSIONS: This case demonstrates cicatrizing conjunctivitis as a possible paraneoplastic syndrome associated with squamous cell lung carcinoma.

Randomized, double-masked clinical trial evaluating corneal endothelial cell loss after cataract extraction and intraocular lens implantation: Fluid-based system versus ultrasound phacoemulsification.

PURPOSE: To assess the endothelial cell loss after cataract extraction using a fluid-based system and compare it with conventional ultrasound. METHODS: A total of 46 eyes of 23 patients with up to 3+ bilateral cataract were included. The first eye was randomized to either fluid-based system or conventional ultrasound, and the fellow eye received the alternate system. Visual acuity and ultrasound pachymetry were measured preoperatively and at 1 day, 1 week, and 1 and 3 months postoperatively. Specular microscopy was performed preoperatively and 3 months after the surgery. Data was analyzed using the paired t test and Wilcoxon signed rank test. A P value less than 0.05 was considered statistically significant. RESULTS: Postoperatively, no significant differences were found among the groups. However, there was a significant difference (P < 0.01, analysis of variance with Tukey as posttest) in corneal pachymetry at day 1 after the surgery compared with baseline in both groups. There was a 6.3% and 7.9% loss of endothelial cells in the fluid-based system and ultrasound group, respectively. CONCLUSION: Visual acuity, pachymetry, and endothelial cell loss after cataract extraction and intraocular lens implantation using a fluid-based system is similar to conventional ultrasound.

Evaluation of 0.4% ketorolac tromethamine ophthalmic solution versus 0.5% ketorolac tromethamine ophthalmic solution after phacoemulsification and intraocular lens implantation.

PURPOSE: The aim of this study was to compare the effectiveness and patient tolerance of 0.4% ketorolac tromethamine ophthalmic solution and 0.5% ketorolac tromethamine ophthalmic solution after routine phacoemulsification and lens implantation. SETTING: The setting for this study was the Storm Eye Institute and Magill Research Center for Vision Correction, Medical University of South Carolina (Charleston, SC). METHODS: This work was a prospective, double-masked study that included 40 eyes of 40 patients randomly assigned to receive topical treatment with 0.4% ketorolac or 0.5% ketorolac, starting 15 min prior to routine phacoemulsification and foldable posterior chamber intraocular lens implantation. Following the procedure, patients were instructed to use the assigned treatment agent 4 times a day after surgery for 1 week and twice a day for 3 weeks, when drops were discontinued. Slit-lamp examination, intraocular pressure (IOP), laser cell and flare measurements, and subjective patient tolerance were evaluated postoperatively at 1, 7, and 30 d. Comparisons between the 2 groups were made at each visit, as well as comparisons to baseline. A P=value less than .05 was considered statistically significant. RESULTS: At day 1, a higher percentage of patients (70% vs. 40%) reported symptoms (mainly foreign body sensation and stinging/burning) in the 0.5% ketorolac group, compared to the 0.4% ketorolac group. No significant differences were found between the 2 groups over time regarding best-corrected visual acuity (BCVA), IOP, slit-lamp assessment of cells, and cell and flare measured using the laser cell/flare meter. CONCLUSIONS: Treatment with 0.4% ketorolac tromethamine ophthalmic solution is as effective as 0.5% ketorolac tromethamine ophthalmic solution in reducing inflammation after routine cataract surgery. Patients reported less discomfort using 0.4% ketorolac.

Prevention of Staphylococcus aureus endophthalmitis with topical gatifloxacin in a rabbit prophylaxis model.

PURPOSE: The aim of this study was to investigate the prophylactic use of 0.3% gatifloxacin drops to prevent endophthalmitis in a rabbit model. METHODS: Forty (40) New Zealand white rabbits were randomly placed into group A (20 rabbits) where they received 1 drop of 0.3% gatifloxacin in their right eye every 15 min (0, 15, 30, and 45 min), or group B (20 rabbits) where they received 1 drop of balanced salt solution (BSS) in their right eye every 15 min (0, 15, 30, and 45 min). Following this treatment regimen, the anterior chamber of each rabbit was injected with 0.025 mL of saline containing 5 x 10(5) colonyforming units of a clinical isolate of Staphylococcus aureus (vancomycin-sensitive). After the inoculum injection, the treatment regimen continued: group A (1 drop of 0.3% gatifloxacin) or group B (1 drop of BSS) immediately postinjection, 6, 12, 18, and 24 h, at which time the animals were examined in a masked fashion, photographed, anesthetized, euthanized, and the aqueous and vitreous humors collected to determine the number of viable bacteria. RESULTS: The median clinical scores for the gatifloxacin group were significantly lower than the control group (P < 0.05). Bacterial recovery of S. aureus was significantly higher in the control group in both the aqueous and vitreous humor (P < 0.05). CONCLUSIONS: Gatifloxacin-treated eyes demonstrated significantly less inflammation, infection, and culture-positive endophthalmitis (P < 0.05), compared to the control animals. It is important to further investigate the clinical implications from this prophylatic study.

Refractive Surgery Survey 2004.

To determine the refractive surgery (RS) preferences of ophthalmologists worldwide, questionnaires were sent to 8897 members of the American Society of Cataract and Refractive Surgery. A total of 1053 questionnaires were returned by the deadline. The practice distribution included 29.5% cataract surgeons, 48.8% comprehensive ophthalmologists, 11.6% RS specialists, 5.1% cornea and external disease specialists, 1.9% glaucoma specialists, 1.1% retina specialists, and <1.0% oculoplastics/pediatrics/researchers/retired. Results were compared with those in the 2003 survey and demonstrate that refractive surgery continues to develop and change.

Effect of hinge location on corneal sensation and dry eye after laser in situ keratomileusis for myopia.

PURPOSE: To evaluate the effects of a superior or nasal hinge location on corneal sensation and dry eye after laser in situ keratomileusis (LASIK). SETTING: Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: This prospective randomized masked study included 47 patients having bilateral myopic LASIK surgery. The first eye was randomly assigned to have a nasal or superior hinge flap; the fellow eye had the alternate location. Visual acuity, contrast sensitivity, corneal sensation, basic secretion test, tear film breakup time, conjunctival and corneal staining, and a subjective questionnaire were evaluated preoperatively and postoperatively at 1 week and 1, 3, and 6 months. The Wilcoxon signed rank test and paired t test were used for comparison. RESULTS: Dry eye occurred with the same frequency in both groups. However, eyes with the nasal hinge had significantly better nasal sensation than those with the superior hinge (P<.05) at 1 month. CONCLUSION: Better nasal corneal sensation was found at 1 month in the nasal hinge group but there was no difference in any other parameters measured.

Cryptococcus albidus keratitis after corneal transplantation.

PURPOSE: To report suspected donor-to-host transmission of Cryptococcus albidus after penetrating keratoplasty. METHODS: Review of the literature and a case report of a 69-year-old woman who underwent penetrating keratoplasty for Fuchs corneal dystrophy and developed persistent corneal infiltrates 7 months postoperatively are presented. RESULTS: Cryptococcus albidus was cultured from the original donor tissue at the time of the repeat keratoplasty. CONCLUSION: This case demonstrates an unusual case of cryptococcal keratitis after keratoplasty suspected to be a donor-to-host transmission.

Photodynamic therapy with verteporfin in a rabbit model of corneal neovascularization.

PURPOSE: To determine the efficacy of photodynamic therapy (PDT) with verteporfin (Visudyne; Novartis AG, Basel, Switzerland) for treatment of corneal neovascularization in a rabbit eye model. METHODS: Corneal neovascularization was induced in Dutch belted rabbits by placing an intrastromal silk suture near the limbus. Verteporfin was administered by intravenous injection at a dose of 1.5 mg/kg, and the pharmacokinetics of verteporfin distribution in the anterior segment or PDT-induced (laser energy levels 17, 50, and 150 J/cm(2)) regression of corneal blood vessels were then determined. To assess PDT-induced toxicity of the anterior segment, corneal and iris/ciliary body histology, and IOP were evaluated after PDT. RESULTS: Verteporfin accumulation in vascularized regions of the cornea and the iris/ciliary body tissue were time dependent and maximum levels achieved at 60 minutes after injection. In rabbits, PDT of corneal vessels using laser energy of 17 or 50 J/cm(2) resulted in 30% to 50% regression of corneal neovascularization; however, in these animals, a rapid regrowth of new blood vessels occurred between 3 and 5 days. In the rabbits receiving PDT using laser energies of 150 J/cm(2), the mean vessel regression was 56%. During the nine days of the laser therapy follow-up period, no vessel regrowth was observed in these rabbits. Histologic examination of the anterior segment after PDT (150 J/cm(2)) showed localized degeneration of the corneal blood vessels without observable change in other anterior segment structures. CONCLUSIONS: These results provide evidence that PDT can produce significant regression of neovascular corneal vessels with no observable toxicity to the anterior segments. However, the optimal laser energy necessary to induce long-term regression (150 J/cm(2)) was three times that used to treat choroidal neovascularization.

Relationship between cycloplegic and wavefront-derived refraction.

PURPOSE: To compare cycloplegic refractions to preoperative wavefront-derived refractions from three Hartmann-Shack-based wavefront devices. METHODS: Ninety-nine eyes of 55 subjects were evaluated preoperatively using the LADARWave, WaveScan, and Zywave aberrometers. With cycloplegic refraction as the standard, the spherical equivalent refraction, sphere, and cylinder were compared to the wavefront-derived refractions using the three wavefront devices. RESULTS: The LADARWave unit showed the highest correlation between wavefront-derived sphere and mean spherical equivalent refraction values relative to cycloplegic refraction, followed by Zywave and WaveScan. The WaveScan unit exhibited higher variability than the LADARWave or Zywave. Although Alcon Laboratories (LADARWave) and Bausch & Lomb Surgical (Zywave) recommend dilation, VISX specifically recommends against dilation in their WaveScan unit. All devices showed high cylinder error vectors when the cycloplegic cylinder was greater than 1.00 D. CONCLUSION: Although wavefront-derived refractions appeared to correlate well to cycloplegic refractions, further research is required to reduce variability and improve the calculation of cylinder terms.

Rapid diagnosis and treatment of mycobacterial keratitis after laser in situ keratomileusis.

We report the results of laser in situ keratomileusis (LASIK) in a 51-year-old woman with subsequent mycobacterial keratitis diagnosed by staining with acid-fast and fluorochrome methods, a technique known to have good sensitivity and specificity for mycobacteria. A rapid diagnosis was made without waiting for cultures, and treatment was instituted, including tapering of topical steroids and appropriate antibiotic therapy. The result was preservation of the LASIK flap and a favorable visual outcome at 6 months.

Residual cleaner after normal cleaning of laser in situ keratomileusis instruments.

PURPOSE: To determine whether residual cleaner could be detected in the rinse solution of surgical instruments after a standard cleaning protocol. SETTING: Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: The wavelength for maximum absorbance of 5 cleaners (Endozime) [The Ruhof Corp.], Enzol/Cidezyme [Advanced Sterilization Products], and Klenzyme [Steris Co.] enzymatic detergents; Palmolive Ultra dishwashing liquid [Colgate-Palmolive Co.]; and Universal concentrated surgical instrument cleaner and lubricant [B. Graczyk, Inc.]) was determined. Identically designed stainless-steel and titanium instruments were cleaned using a standardized protocol. Water temperatures of 25 degrees C (room temperature) or 40 degrees C (warm temperature) were used to rinse the instruments. The amount of residual cleaner in each rinse solution and remaining on each instrument at the completion of the cleaning procedure as a percentage of the total cleaner was determined. RESULTS: Residues of all cleaners were detected using a standard protocol involving rinse solutions at 25 degrees C. Increasing the temperature of the rinse solutions significantly reduced the cleaner residues (P<.05, Friedman repeated-measures analysis of variance on ranks test and Student-Newman-Keuls test) regardless of the instrument material. No significant difference was detected in the residual cleaners on stainless-steel and titanium instruments. CONCLUSIONS: Lower levels of cleaner residue were found on surgical instruments after a standard cleaning protocol using warm rinse water. Because cleaner residue has been reported to cause inflammation (eg, diffuse lamellar keratitis) after laser in situ keratomileusis (LASIK), it is advisable to use cleaners and cleaning protocols that result in acceptable cleaning without detectable levels of cleaner residue to avoid potentially harmful effects to the cornea after LASIK.

Comparison of ketorolac tromethamine 0.5% and loteprednol etabonate 0.5% for inflammation after phacoemulsification: prospective randomized double-masked study.

PURPOSE: To compare the efficacy of a topical nonsteroidal antiinflammatory agent (ketorolac tromethamine ophthalmic solution 0.5%) and a topical steroid (loteprednol etabonate ophthalmic suspension 0.5%) in controlling inflammation after cataract surgery. SETTING: Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: Sixty patients were prospectively and randomly assigned to receive topical treatment with ketorolac tromethamine ophthalmic solution 0.5% or loteprednol etabonate ophthalmic suspension 0.5% starting the day after routine phacoemulsification for cataract extraction. Both patient and investigator were masked to treatment. All patients had uneventful small-incision phacoemulsification with placement of a foldable posterior chamber intraocular lens (IOL). Patients used 1 of the 2 antiinflammatory agents 4 times a day starting 24 hours after surgery. Signs and symptoms of inflammation as documented by external slitlamp examination, intraocular pressure (IOP), and Kowa cell and flare measurements were evaluated on postoperative days 1, 4, 7, and 30. RESULTS: There was no statistically significant difference in any measurement of postoperative inflammation between the 2 groups. There was no difference in objective or subjective cell and flare measurements or in IOP between groups. No patient in either group was removed from the study for lack of treatment efficiency. CONCLUSIONS: Ketorolac tromethamine ophthalmic solution 0.5% was as effective as loteprednol etabonate ophthalmic suspension 0.5% in reducing inflammation after routine phacoemulsification and IOL implantation. These results suggest that ketorolac tromethamine 0.5% is a safe and effective antiinflammatory alternative to steroids after cataract extraction.

Endothelial decompensation after laser in situ keratomileusis.

We report the results of laser in situ keratomileusis (LASIK) in a 58-year-old woman with a history of corneal guttata in the right eye and mild Fuchs' dystrophy in the left eye. Preoperative pachymetry was 586 microm and 656 microm, respectively. The surgical treatment was +1.50 diopters (D) in the right eye and +3.25 D in the left eye. Surgery was performed using a VISX S2 Star laser and a Hansatome microkeratome with a 9.5 mm ring. Postoperatively, edema in the right eye resolved and pachymetry returned to 585 microm, but the left cornea decompensated despite maximum medical therapy and had a final pachymetry of 779 microm. The patient was referred to our cornea service for penetrating keratoplasty, which was performed 14 months after the LASIK treatment.

Corneal flap complications in refractive surgery: Part 1: development of an experimental animal model.

PURPOSE: To report the outcome, learning curve, and complication rates of an experimental animal model for corneal flaps in refractive surgery. SETTING: Magill Research Center for Vision Correction, Storm Eye Institute, Charleston, South Carolina, USA. METHODS: Corneal flaps with a nasal or a temporal hinge were created in 190 eyes of 95 Dutch Belted rabbits using the Automated Corneal Shaper microkeratome (Bausch & Lomb Surgical). Diffuse lamellar keratitis (DLK) was induced by inoculating the corneal interfaces with 1 of 7 substances. Postoperatively, the eyes were examined with a slitlamp. Special emphasis was placed on corneal flap complications and the relationship between slipped flaps and hinge position and/or inoculation agent. RESULTS: A good corneal flap was achieved in 174 eyes (92%). The eyes with a nasal hinge had a lower incidence of slipped flaps (14%) than eyes with a temporal hinge (37%) (P =.02). CONCLUSION: With the animal model described, corneal flaps were created in a precise and reproducible way in more than 90% of eyes. Nasal hinged flaps showed less postoperative displacements than temporal hinged flaps and are adequate for further study.