A case of infectious crystalline keratopathy after corneal cross-linking.

PURPOSE: To present a case of infectious crystalline keratopathy after corneal cross-linking in a child with delayed wound healing, and its successful management with antibiotic and anti-fungal eye drops. OBSERVATIONS: A 14-year-old male presented for a second opinion with a non-staining crystalline keratopathy after corneal crosslinking for progressive keratoconus. He reportedly rubbed his eyes vigorously in the post-operative course and had a slowly healing epithelial defect. He was treated with several antibiotic drops and was put on high dose topical difluprednate drops post-procedure for persistent corneal haze. His infection continued to progress until steroids were stopped and he was treated with topical voriconazole. While cultures were negative, the patient's visual acuity and corneal lesions improved significantly after starting voriconazole therapy and stopping steroid drops, pointing to a diagnosis of infectious crystalline keratopathy. CONCLUSIONS AND IMPORTANCE: This is one of the first case reports to describe a primary infectious crystalline keratopathy after a corneal cross-linking procedure, and the first to describe this phenomenon in a child with delayed corneal re-epithelialization. Though corneal cross-linking is a relatively safe procedure, atypical infections like crystalline keratopathy can occur in these patients in the setting of topical steroid use. Atypical organisms such as fungi should always be on the differential, especially for patients with recalcitrant infection in the setting of immunosuppression.

Relief of symptomatic pseudo-polycoria due to iris biopsy using a daily contact lens.

PURPOSE: To report a case of pseudo-polycoria from iris biopsy managed by a daily disposable prosthetic colored hydrogel lens. OBSERVATIONS: A 55-year-old- Caucasian female presented with complaints of photophobia in her right eye, that was exacerbated when going from a dark to light environment. Her past ocular history included a diagnosis by another outside physician of presumed multifocal iris melanoma in the right eye, followed by an iris biopsy performed one month later. Upon presentation to our clinic two months later, best corrected visual acuity was 20/20- in the right eye and 20/25 in the left eye. Slit lamp exam of the right eye revealed iris abnormalities, full-thickness biopsy defects at 2, 3 and 6 o'clock and a 0.8 × 0.7mm area of iris hyperpigmentation at 8 o'clock (Fig A,B,C, and D). The patient was provided with three non-surgical options to manage her symptoms: a commercially available soft daily replacement printed prosthetic hydrogel lens, a commercially available soft monthly replacement silicone printed prosthetic hydrogel lens, or a custom soft yearly replacement prosthetic hydrogel lens with dark inlay. The soft daily printed prosthetic hydrogel lens was chosen because of its ease in hygiene regimen and did not limit peripheral vision as the yearly dark inlay lens would. RESULTS: The patient now wears Alcon Dailies® Color, Base curvature 8.6, Diameter 13.8, color mystic green in the right eye and her symptoms of photophobia have been resolved (Figure F). CONCLUSION: There are limited options to manage photophobia in patients with polycoria or pseudo-polycoria. Surgical intervention is dictated by how many quadrants of iris are involved and therefore how symptomatic a patient may be. A less invasive alternative to surgical intervention is the use of a contact lens. In this case, traditional hand painted or printed yearly or monthly replacement hydrogel contact lenses were not used. Instead, a daily disposable hydrogel was successfully fit, highlighting that there is often a simple solution to a seemingly complicated issue.

Epithelial Inclusion Cyst of the Bulbar Conjunctiva Secondary to Scleral Lens Impingement Managed With a MicroVault.

Acquired epithelial inclusion conjunctival bulbar cyst is a reported complication of scleral contact lens impingement commonly corrected with a diameter change or notch of the scleral contact lens. This case discusses an acquired epithelial inclusion conjunctival bulbar cyst due to microtrauma caused by prolonged scleral contact lens wear and corrected with a MicroVault.

A novel collaboration: Multifocal RGPs and low vision aids increase quality of life in visually impaired.

OBJECTIVES: By presenting 2 cases, this study aimed to discuss the utility of multifocal rigid gas permeable contact lenses in the low vision patient population, and their ability to decrease reliance on low vision aids and to increase quality of life. METHODS: A retrospective case series of 2 patients receiving care from two specialty practice locations was performed. Both patients were visually impaired presbyopic myopes, and sought care from both contact lens and low vision specialties in order to improve visual function and enhance their ability to perform activities of daily living. They were each fit with multifocal gas permeable contact lenses to be used in conjunction with low vision devices. The Visual Functioning Questionnaire - 25 was administered to both patients in order to quantify improvement to quality of life with the new contact lenses. RESULTS: Both patients were successfully fit with multifocal gas permeable contact lenses and reported decreased reliance on low vision aids as well as significant improvement in quality of life when wearing the contact lenses. CONCLUSION: The use of multifocal rigid gas permeable contact lenses in the low vision patient population may be an effective tool to make visually impaired patients, particularly presbyopic degenerative myopes, less reliant on low vision aids, thereby improving their quality of life.

Dupilumab-associated blepharoconjunctivitis.

PURPOSE: To report a case of dupilumab-associated blepharoconjunctivitis. OBSERVATIONS: A 48 year-old Caucasian male presented with bilateral blepharitis, multiple chalazia, dry eye disease and significant papillary conjunctivitis. The past medical history included fourteen years of severe atopic dermatitis. After failed attempts to treat atopic dermatitis with topical corticosteroids, the patient enrolled into a four-year clinical trial of biweekly dupilumab injections. Four to six weeks after initiation of dupilumab, the patient reported blurred vision, ocular irritation and redness. Slit lamp examination demonstrated bilateral meibomian gland dysfunction, edematous eyelids with multiple chalazia and significant papillary conjunctivitis. Meibography by Lipiscan revealed significant truncation, atrophy and bifurcation of meibomian glands bilaterally. The patient's multiple chalazia were excised and eyelid hygiene was closely followed. Cliradex wipes and Avenova were added to the patient's regime and one session of Lipiflow treatment was administered. The patient continued this eyelid hygiene regimen along with neomycin/polymyxin B/dexamethasone ophthalmic ointment after each dupilumab infusion. CONCLUSIONS AND IMPORTANCE: Five weeks after Lipiflow treatment with concomitant use of Cliradex and Avenova, visual acuity and ocular discomfort improved. Current treatment includes Cliradex eyelid wipes along with neomycin/polymyxin B/dexamethasone ophthalmic ointment for a week after each dupilumab infusion. Topical steroids and antibiotics with eyelid hygiene are effective ways to treat atopic dermatitis patients exhibiting dupilumab's ocular side effects. Lipiflow therapy may also help in treatment.

Case Report: Management of Corneal Clouding from Lecithin: Cholesterol Acyltransferase Deficiency.

SIGNIFICANCE: Given that there are few reported cases of lecithin:cholesterol acyltransferase (LCAT) deficiency, recognition of the condition with proper management is notable. Long-term follow-up and contact lens fitting after penetrating keratoplasty provide best possible outcomes. PURPOSE: The purpose of this study was to report a case of LCAT deficiency successfully treated with penetrating keratoplasty and longer-term follow-up with contact lens fitting. CASE REPORT: A 43-year-old white woman of Italian descent presented with corneal clouding and trouble with night vision. The patient had a history of LCAT deficiency, irritable bowel syndrome, gastroesophageal reflux disease, osteoporosis, and hemolytic anemia. Slit-lamp examination demonstrated corneal haze throughout the corneal layers. The corneas had normal pachymetry. Given the opacity of each cornea (right greater than left) and decreased night vision, penetrating keratoplasty was performed on the right eye. At post-operative month 16, the corneal graft remained clear. The patient was able to achieve a best-corrected visual acuity of 20/30+ with a scleral lens. CONCLUSIONS: Penetrating keratoplasty may be necessary to provide better quality of vision in LCAT deficiency patients, specifically to enhance one's contrast sensitivity, despite relatively good Snellen visual acuity.

Modeling the resting state of oxalate oxidase and oxalate decarboxylase enzymes.

In view of the biological and commercial interest in models for Oxalate Decarboxylases (OxDC) and Oxalate Oxidases (OxOx), we have synthesized and characterized three new Mn (II) complexes ( 1- 3) employing N3O-donor amino-carboxylate ligands (TCMA, 1,4,7-triazacyclononane- N-acetic acid; K (i) Pr 2TCMA, potassium 1,4-diisopropyl-1,4,7-triazacyclononane- N-acetate; and KBPZG, potassium N,N-bis(3,5-dimethylpyrazolyl methyl)glycinate). These complexes were characterized by several techniques including X-ray crystallographic analysis, X-band electron paramagnetic resonance (EPR), electrospray ionization mass spectrometry (ESI-MS), and cyclic voltammetry. The crystal structures of 1 and 3 revealed that both form infinite polymeric chains of Mn (II) complexes linked by the pendant carboxylate arms of the TCMA (-) and the BPZG (-) ligands in a syn-antipattern. Complex 2 crystallizes as a mononuclear Mn (II) cation, six-coordinate in a distorted octahedral geometry. Although complexes 1 and 3 crystallize as polymeric chains, all compounds present the same N3O-donor set atoms around the metal center as observed in the crystallographically characterized OxDC and OxOx. Moreover, complex 2 also contains two water molecules coordinated to the Mn center as observed in the active site of OxDC and OxOx. ESI-MS spectrometry, combined with EPR, were useful techniques to establish that complexes 1- 3 are present as mononuclear Mn (II) species in solution. Finally, complexes 1- 3 are able to model the resting state active sites, with special attention focused on complex 2 which provides the first exact first coordination sphere ligand structural model for the resting states of both OxDC and OxOx.

Clinical nurse specialist participation on a collaborative research project. Barriers and benefits.

Clinical nurse specialists are expected to contribute to the development of new nursing knowledge through research activities. Competing demands require constant juggling of time and priorities, and activities, such as research, often do not receive the attention they deserve. Research requires specific skills and knowledge and significant time expenditure. Collaborative research is an appropriate way for the clinical nurse specialist to both contribute to research and improve his or her research skills. This article discusses two pediatric critical care clinical nurse specialists' participation in a collaborative research team led by university faculty. The study was designed to reduce family uncertainty and stress and to increase staff nurse competency in providing family care. The ability of the clinical nurse specialists to contribute to the research team was enhanced by knowledge of the research process, good communication skills, and clinical expertise in the specific population of interest. Challenges for the clinical nurse specialists included limited experience in conducting clinical research and balancing clinical and research priorities. Both clinical nurse specialists and the university faculty benefited from this collaboration. The clinical nurse specialist, with expertise in a clinical specialty, is able to bridge the gap between the academic and clinical sites, making clinical research more likely. At the same time, working with expert researchers allows the clinical nurse specialist to increase his or her research skills.