Repository Corticotropin Injection as an Alternative Treatment for Refractory Ocular Mucous Membrane Pemphigoid.

PURPOSE: The purpose of this study was to report the clinical course and outcome of patients with refractory ocular mucous membrane pemphigoid (MMP) treated by repository corticotropin injection (RCI). METHODS: Patients with biopsy-proven ocular MMP treated with RCI from 3 tertiary medical centers were evaluated. Medical records between January 2013 and January 2021 were reviewed and deidentified to retrieve relevant disease-related data. Primary outcome measures included conjunctival inflammatory activity, change in Foster clinical conjunctival scarring staging after RCI treatment, and the development of ocular and systemic complications. RESULTS: Included were 15 patients (10 women and 5 men; 36-95 yrs of age) with a mean follow-up of 4.5 years. Most of the patients (80%) had Foster stage 3 at presentation, and all patients had active MMP. Each patient had failed to respond to at least 1 immunomodulatory drug during the follow-up, and 9 (60%) patients had treatment failure of at least 2 other agents before the use of RCI. The mean duration of RCI treatment was 21 months (range, 3-54 mo). Foster stage did not change in any of the 15 patients at the last follow-up. Nine patients continued RCI therapy at the last follow-up, and in all of them, the disease activity of MMP was well controlled. No serious adverse events because of RCI were documented during the follow-up in any treated patient. CONCLUSIONS: RCI may serve as an alternative or an adjunctive treatment in patients with severe and refractory ocular MMP. Treatment with RCI seems to be safe and well-tolerated.

Compositional Analysis of Extracellular Aggregates in the Eyes of Patients With Exfoliation Syndrome and Exfoliation Glaucoma.

Purpose: Exfoliation syndrome (XFS) is a condition characterized by the production of insoluble fibrillar aggregates (exfoliation material; XFM) in the eye and elsewhere. Many patients with XFS progress to exfoliation glaucoma (XFG), a significant cause of global blindness. We used quantitative mass spectrometry to analyze the composition of XFM in lens capsule specimens and in aqueous humor (AH) samples from patients with XFS, patients with XFG and unaffected individuals. Methods: Pieces of lens capsule and samples of AH were obtained with consent from patients undergoing cataract surgery. Tryptic digests of capsule or AH were analyzed by high-performance liquid chromatography-mass spectrometry and relative differences between samples were quantified using the tandem mass tag technique. The distribution of XFM on the capsular surface was visualized by SEM and super-resolution light microscopy. Results: A small set of proteins was consistently upregulated in capsule samples from patients with XFS and patients with XFG, including microfibril components fibrillin-1, latent transforming growth factor-ß-binding protein-2 and latent transforming growth factor-ß-binding protein-3. Lysyl oxidase-like 1, a cross-linking enzyme associated with XFS in genetic studies, was an abundant XFM constituent. Ligands of the transforming growth factor-ß superfamily were prominent, including LEFTY2, a protein best known for its role in establishing the embryonic body axis. Elevated levels of LEFTY2 were also detected in AH from patients with XFG, a finding confirmed subsequently by ELISA. Conclusions: This analysis verified the presence of suspected XFM proteins and identified novel components. Quantitative comparisons between patient samples revealed a consistent XFM proteome characterized by strong expression of fibrillin-1, lysyl oxidase-like-1, and LEFTY2. Elevated levels of LEFTY2 in the AH of patients with XFG may serve as a biomarker for the disease.

Corneal perforation in ocular graft-versus-host disease.

PURPOSE: Corneal perforation is a rare, vision-threatening complication of ocular graft-versus-host disease (GVHD) and is not well understood. Our objective was to examine the clinical disease course and histopathologic correlation in patients who progressed to this outcome. METHODS: This study is a retrospective case series from four academic centers in the United States. All patients received a hematopoietic stem cell transplant (HSCT) prior to developing ocular GVHD. Variables of interest included patient demographics, time interval between HSCT and ocular events, visual acuity throughout clinical course, corticosteroid and infection prophylaxis regimens at time of corneal perforation, medical/surgical interventions, and histopathology. RESULTS: Fourteen eyes from 14 patients were analyzed. Most patients were male (86%) and Caucasian (86%), and average age at time of hematopoietic stem cell transplant was 47 years. The mean interval between hematopoietic stem cell transplant and diagnosis of ocular graft-versus-host disease was 9.5 months, and between hematopoietic stem cell transplant and corneal perforation was 37 months. Initial best-corrected visual acuity was 20/40 or better in 9 eyes, and all eyes had moderate or poor visual outcomes despite aggressive management, including corneal gluing in all patients followed by keratoplasty in 8 patients. The mean follow-up after perforation was 34 months (range 2-140 months). Oral prednisone was used prior to perforation in 11 patients (79%). On histopathology, representative specimens in the acute phase demonstrated ulcerative keratitis with perforation but minimal inflammatory cells and no microorganisms, consistent with sterile corneal "melt" in the setting of immunosuppression; and in the healed phase, filling in of the perforation site with fibrous scar. CONCLUSIONS: In these patients, an extended time interval was identified between the diagnosis of ocular graft-versus-host disease and corneal perforation. This represents a critical window to potentially prevent this devastating outcome. Further study is required to identify those patients at greatest risk as well as to optimize prevention strategies.

Acanthamoeba Keratitis, Pathology, Diagnosis and Treatment.

Acanthamoeba keratitis is an unusual corneal infection that is recently increasing in frequency and is often contracted by contact lens wearers, someone who experienced recent eye trauma, or someone exposed to contaminated waters. Acanthamoeba survive in air, soil, dust, and water. Therefore, eye trauma and poor contact lens hygiene practices lead to the entrapment of debris and thus infection. Acanthamoeba keratitis results in severe eye pain, inflammation, and defects of the epithelium and stroma that can potentially result in vision loss if not diagnosed early and treated promptly. The disease can be diagnosed using corneal scrape/biopsy, polymerase chain reactions, impression cytology, or in vivo confocal microscopy. Once diagnosed, it is usually treated with an antimicrobial combination therapy of biguanide and aromatic diadine eye drops for several months. Advanced stages of the disease result in vision loss and the need for corneal transplants. Avoiding the risk factors and diagnosing the disease early are the most effective ways to combat Acanthamoeba keratitis.

A surgical skills assessment rubric for pterygium surgery.

PURPOSE: To introduce an assessment tool (rubric) for evaluating ophthalmology residents' competency in pterygium surgery. METHODS: A panel of experienced international surgeons collaborated and developed the rubric. After describing various stages of the procedure, the Dreyfus scale of skill acquisition was used for scoring each stage. After finalizing the rubric, two surgeons independently evaluated 20 masked pterygium surgery videos of 10 residents and scored the videos according to the rubric. The agreement between the scores of them was examined with the intra-class correlation coefficient test. RESULTS: This rubric divides pterygium surgery into 13 different stages and covers the two most common techniques of pterygium surgery; conjunctival autograft and amniotic membrane transplant. The rubric showed face and content validity. Overall, an intraclass correlation coefficient of 0.90 (95% confidence interval 0.76-0.96, P < 0.001) was achieved between the two surgeons. The residents scored significantly higher on surgeries performed later in their rotation compared to the earlier surgeries (4.32 ± 0.35 vs 3.96 ± 0.31, P = 0.006). Certain stages of pterygium surgery were more strongly correlated with the residents' past pterygium surgical experience. CONCLUSION: This study introduces an international rubric for assessing competency in pterygium surgery. In addition to face and content validity, this rubric shows high inter-rater reliability. This may be a useful tool for teaching and measuring competency in pterygium surgery.

Identification of a Sjögren's syndrome susceptibility locus at OAS1 that influences isoform switching, protein expression, and responsiveness to type I interferons.

Sjögren's syndrome (SS) is a common, autoimmune exocrinopathy distinguished by keratoconjunctivitis sicca and xerostomia. Patients frequently develop serious complications including lymphoma, pulmonary dysfunction, neuropathy, vasculitis, and debilitating fatigue. Dysregulation of type I interferon (IFN) pathway is a prominent feature of SS and is correlated with increased autoantibody titers and disease severity. To identify genetic determinants of IFN pathway dysregulation in SS, we performed cis-expression quantitative trait locus (eQTL) analyses focusing on differentially expressed type I IFN-inducible transcripts identified through a transcriptome profiling study. Multiple cis-eQTLs were associated with transcript levels of 2'-5'-oligoadenylate synthetase 1 (OAS1) peaking at rs10774671 (PeQTL = 6.05 × 10-14). Association of rs10774671 with SS susceptibility was identified and confirmed through meta-analysis of two independent cohorts (Pmeta = 2.59 × 10-9; odds ratio = 0.75; 95% confidence interval = 0.66-0.86). The risk allele of rs10774671 shifts splicing of OAS1 from production of the p46 isoform to multiple alternative transcripts, including p42, p48, and p44. We found that the isoforms were differentially expressed within each genotype in controls and patients with and without autoantibodies. Furthermore, our results showed that the three alternatively spliced isoforms lacked translational response to type I IFN stimulation. The p48 and p44 isoforms also had impaired protein expression governed by the 3' end of the transcripts. The SS risk allele of rs10774671 has been shown by others to be associated with reduced OAS1 enzymatic activity and ability to clear viral infections, as well as reduced responsiveness to IFN treatment. Our results establish OAS1 as a risk locus for SS and support a potential role for defective viral clearance due to altered IFN response as a genetic pathophysiological basis of this complex autoimmune disease.

Infections after refractive surgery.

PURPOSE OF REVIEW: The purpose of the review is to provide a summary of the recent literature concerning infections after refractive surgery pertinent to each procedure category. RECENT FINDINGS: New data from a large retrospective study suggest that the incidence of post-laser assisted in-situ keratomileusis infectious keratitis is declining. Additionally, recent case studies have reported viral, fungal, and Acanthamoeba pathogens. Corneal collagen cross-linking is emerging as an alternative therapeutic option for early stage post-LASIK infectious keratitis. Postoperative bandage contact lens used in patients undergoing surface ablation procedures may confer a higher risk of infection because of greater colonization rates in those individuals, such as healthcare providers, with relatively high risk of exposure to potential pathogens. In the setting of post-penetrating keratoplasty astigmatism, femtosecond laser astigmatic keratotomy procedures pose a risk of infectious keratitis and even endophthalmitis. Lastly, recent case reports of endophthalmitis after refractive lens procedures highlight the importance of postoperative monitoring for this sight threatening, albeit rare, complication. SUMMARY: The risks and management of infections after surgical refractive procedures vary widely depending on the specific technique employed. As technology and treatment options continue to evolve with further research, we anticipate continued success in the management of postoperative infections after refractive surgery.

Brief Report: Patients With Primary Sjögren's Syndrome Who Are Positive for Autoantibodies to Tripartite Motif-Containing Protein 38 Show Greater Disease Severity.

OBJECTIVE: Autoantibodies reactive with Ro52 (tripartite motif-containing protein 21 [TRIM21]) are detected in 70% of patients with primary Sjögren's syndrome (SS). TRIM21 belongs to a 34-member C-IV family of TRIM proteins. Although autoantibodies against other TRIM proteins within the C-IV family have been detected in the sera of patients with primary SS, their clinical relevance remains unclear. This study was undertaken to investigate the frequency of anti-TRIM38 in patients with primary SS and evaluate its association with various clinical measures of the disease. METHODS: Serum samples from patients with primary SS (n = 235) and controls (n = 50) were analyzed for reactivity with in vitro-transcribed and -translated (35) S-methionine-labeled TRIM38 protein. The associations of anti-TRIM38 with various laboratory and clinical measures of primary SS were evaluated. Reactivity of anti-TRIM38 with different structural domains of TRIM38 was analyzed. Affinity-purified anti-TRIM38 antibodies were used to immunoprecipitate TRIM21. RESULTS: TRIM38-reactive autoantibodies were detected in the sera of 24 of the 235 patients with primary SS and 2 of the 50 controls. Anti-TRIM38 positivity was significantly associated with the presence of anti-Ro60, anti-Ro52, anti-La, rheumatoid factor, and hypergammaglobulinemia. Clinically, anti-TRIM38 was associated with significantly higher ocular surface staining scores, lower Schirmer's test scores, and minor labial salivary gland biopsy focus scores of ≥3.0. Anti-TRIM38 antibodies mainly recognized the cortactin-binding protein 2 (CortBP-2; amino acids 128-238) and the B30.2/SPRY (amino acids 268-465) domains on TRIM38. Affinity-purified antibodies to TRIM38-CortBP-2 and TRIM38-B30.2/SPRY domains reacted with TRIM21. CONCLUSION: Our data demonstrate that anti-TRIM38 specificity arising in a subset of patients with primary SS is associated with increased severity of the disease.

Impact of Corneal Endothelial Dysfunctions on Intraocular Oxygen Levels in Human Eyes.

PURPOSE: We studied the implications of corneal endothelial dysfunctions on oxidative stress in the anterior segment via in vivo measurements of oxygen partial pressure (pO2) in the anterior chamber (AC) of human eyes. METHODS: We recruited 51 patients undergoing cataract surgery and/or endothelial keratoplasty (EK). Endothelial cell density (ECD; n = 33) and central corneal thickness (CCT; n = 41) were measured on patients with relatively clear corneas. Before surgery, an oxygen sensor was introduced into the AC via a peripheral corneal paracentesis. In all patients, seven measurements of pO2 were obtained by positioning the flexible tip near the endothelium at the central cornea, at four cardinal subendothelial locations near the midperipheral cornea, and in the mid-AC and AC angle. In patients with pseudophakia or eyes undergoing cataract surgery, pO2 also was measured near the lens surface and in the posterior chamber. RESULTS: Consistent with our previous reports, a steep oxygen gradient was noted in the anterior segment of normal controls (n = 24). In patients with endothelial dysfunctions (n = 27), there was a significant increase of pO2 at all five subendothelial locations without a significant increase of pO2 in the AC angle. By regression analyses, subendothelial pO2 correlated inversely with ECD and positively with CCT in patients with endothelial dysfunctions. CONCLUSIONS: This study demonstrates an even steeper intraocular oxygen gradient in eyes with corneal endothelial dysfunctions. It suggests that the reduced oxygen consumption in corneal endothelial cells may increase oxidative stress in the AC and the existence of an alternative aqueous inflow pathway that maintains a relatively low and constant pO2 at the AC angle.

Intraoperative management of posterior capsular rupture.

PURPOSE OF REVIEW: Posterior capsular rupture (PCR) and vitreous loss are inevitable complications encountered in cataract surgery across all levels of surgical experience and in spite of technological advances to improve safety. Thus, cataract surgeons must always be prepared to practice safe and effective intraoperative management strategies for capsular rupture. RECENT FINDINGS: Novel approaches for lens fragment removal, vitrectomy, and lens implantation have expanded the available options for cataract surgery in the setting of an open posterior capsule. Intraoperative PCR management strategies should prioritize safety and strive to minimize vitreous traction, stabilize anterior chamber volume, maintain capsular and zonular integrity, and protect the corneal endothelium and other anterior segment structures. SUMMARY: With appropriate management of PCR and vitreous, surgeons may still deliver safe and satisfactory visual outcomes for modern cataract surgery.

Unique TGFBI protein in lattice corneal dystrophy.

PURPOSE: Specific components of transforming growth factor-beta-induced protein (TGFBIp) responsible for amyloid deposits in lattice corneal dystrophy (LCD) have not been delineated. LCD has been associated with various TGFBIp mutations such as R124C, L518P, and L527R. Using recombinant TGFBIp, this study was undertaken to identify TGFBIp components potentially contributing to the protein deposits in LCD. METHODS: Recombinant wild-type (WT) TGFBIp and four mutants (R124C, R124H, L518P, and L527R) were generated in HEK293FT cells. WT and mutant TGFBIp were collected from crude cell lysates or purified from culture media. Immunoblot analyses were performed with four different anti-TGFBIp antibodies raised against various regions of TGFBIp. RESULTS: Consistent with the authors' previous findings, purified recombinant proteins are more prone to polymerize than crude cell lysates. As expected, all monomers and polymers of TGFBIp WT and mutants were detected by these antibodies. However, the authors noted WT and TGFBIp mutants showed differential reactivities with these antibodies. A 47-kDa band was detected in purified 2-tag proteins of L518P by all four antibodies. A unique 43-kDa band was detected in both 1-tag cell lysates and purified proteins of R124C by the authors' custom-made antibody (KE50) and a commercial anti-TGFBIp. CONCLUSIONS: Based on its universal reactivity with various antibodies, the authors surmise that the 47-kDa protein is a ubiquitous TGFBIp fragment derived from the N-terminus of the L518P mutant. The fact that the 43-kDa protein fragment was present primarily in R124C and R124H but not in WT implicates its potential role in the protein deposits of LCD.

Granular and lattice deposits in corneal dystrophy caused by R124C mutation of TGFBIp.

PURPOSE: Both granular and lattice deposits are present in Avellino corneal dystrophy (ACD), primarily associated with the R124H mutation of transforming growth factor-ß-induced (TGFBIp). We investigated the presence of these deposits in other TGFBI mutations and the use of Thioflavin-T (ThT), a fluorescent amyloid stain for characterizing corneal amyloid deposits. METHODS: Surgical corneal specimens of 3 unrelated patients clinically diagnosed with ACD were studied. Corneal sections from normal individuals and patients with prior lattice corneal dystrophy (LCD) were used as controls. Histochemical studies were performed with Congo red and Masson trichrome stains, and fluorescent imaging with scanning laser confocal microscopy was performed for ThT and anti-TGFBIp antibody staining. RESULTS: Clinical and histopathological findings supported the diagnoses of ACD in these 3 cases in whom granular deposits stained with Masson trichrome and lattice deposits stained with ThT and Congo red showed birefringence and dichroism as expected. However, genotyping revealed a heterozygous R124C mutation in each case. In addition to classical stromal deposits, unique subepithelial TGFBIp aggregates, which stain with neither ThT nor trichrome, were observed. In control LCD sections, stromal deposits were stained with ThT but not with trichrome, confirming lack of granular deposits. CONCLUSIONS: Our results demonstrate that both granular and lattice corneal deposits can be associated with R124C mutation in addition to the more common R124H mutation. An additional feature of nonhyaline, nonamyloid, TGFBIp subepithelial deposits might substantiate the categorization of such cases as a variant form of ACD. This study further validates ThT staining for detection of amyloid TGFBIp deposits.

Genotype of lattice corneal dystrophy (R124C mutation in TGFBI) in a patient presenting with features of avellino corneal dystrophy.

PURPOSE: To present a patient with a genotype usually associated with lattice corneal dystrophy but with clinical and histopathologic features of advanced Avellino corneal dystrophy. METHODS: Penetrating keratoplasty was performed with subsequent histopathologic analysis. For genetic testing, a 5-mL blood sample was taken after informed consent. Genetic sequencing was performed by the John and Marcia Carver Laboratory of the University of Iowa. The mutation was identified by direct sequencing through the positions of the coding sequences of the TGFBI gene that have been previously reported to have genetic variations (exons 4 and 11-14). RESULTS: Corneal examination revealed bilateral lattice and multiple confluent subepithelial and anterior stromal granular opacities. Histopathologic examination showed amyloid deposits by Congo red stain and hyaline deposits by Masson trichrome stain, consistent with a diagnosis of Avellino dystrophy. Automated DNA sequencing revealed a heterozygous Arg124Cys (R124C) mutation in the coding sequence of the TGFBI gene on chromosome 5q31. Recurrent granular deposits developed in the corneal graft 14 months after surgery. CONCLUSIONS: Our case presented with clinical and histopathologic findings consistent with a diagnosis of Avellino dystrophy and exhibited a genotype with R124C mutation. Avellino dystrophy has not previously been reported to be associated with the R124C mutation, which is usually associated with lattice corneal dystrophy. This also raises the issue as to whether classification of the corneal stromal dystrophies should be based primarily on phenotype/histopathology or on genotyping.

Pathogenesis and outcome of Paecilomyces keratitis.

PURPOSE: To examine the clinical pathology and management of Paecilomyces lilacinus keratitis. DESIGN: Observational case series, literature review, and laboratory study. METHODS: Characteristics and outcome of 17 patients with laboratory-confirmed Paecilomyces keratitis treated at 2 referral centers were combined with 25 previously reported cases. Experimental models were developed by topically inoculating a human corneal isolate of P. lilacinus onto murine eyes and onto human donor corneas. RESULTS: Of 42 reported eyes with Paecilomyces keratitis, 13 (31%) were associated with chronic keratopathy or previous ocular surgery, 11 (26%) followed corneal trauma, and 10 (24%) occurred in soft contact lens wearers. Medical cure occurred in 13 (31%), including 9 of 31 eyes (29%) treated with natamycin or amphotericin B. Penetrating keratoplasty or other surgery was performed in 29 (69%). In vitro testing of P. lilacinus indicated resistance to natamycin and amphotericin B but susceptibility to ketoconazole and voriconazole. Experimental inoculation after superficial scarification established moderately severe corneal paecilomycosis by hyphae and conidia in immunosuppressed mice and in explanted donor corneas. CONCLUSIONS: P. lilacinus is an emerging fungal pathogen that infects corneal tissue by filamentous invasion with occasional intrastromal sporulation. P. lilacinus keratitis does not reliably respond to natamycin or amphotericin B and has often required therapeutic keratoplasty, but topical azole antifungal agents such as voriconazole appear promising.

Identification of an amyloidogenic region on keratoepithelin via synthetic peptides.

Mutations of keratoepithelin (KE) gene in human chromosome 5q31 have been linked with corneal epithelial or stromal dystrophies characterized by the abnormal deposits of amyloid fibrils and/or non-amyloid aggregations in corneal tissue. We report herein that synthetic peptide containing amino acid (a.a.) residues of 515-532 of native KE protein can readily form beta-sheet-containing amyloid fibrils in vitro. Amyloid fibrils formed in various conditions from short synthetic peptides (containing a.a. 515-532 and 515-525, respectively) were characterized by thioflavin T (ThT) fluorescence assay, Congo red staining, electron microscopy (EM) and circular dichroism (CD). Triple-N-methylation of the synthetic peptides prevented the beta-sheet polymerization and related amyloid fibril formation. Comparison study with ThT fluorescence further demonstrated that synthetic peptides containing corneal dystrophy-related mutations within this region formed amyloid fibrils to various extents. Our results suggest that each individual dystrophy-related mutation by itself does not necessarily potentiate amyloid fibril formation of KE. Roles of these intrinsically amyloidogenic foci in abnormal KE aggregations and amyloid deposits of stromal corneal dystrophies await further investigation.

Cytokeratin 12 in human ocular surface epithelia is the antigen reactive with a commercial anti-Galpha q antibody.

PURPOSE: In our initial attempt to identify differentiation markers for ocular surface epithelia, we observed a unique staining pattern by a commercial anti-Galphaq antibody. We further isolate and characterize the protein reactive with this anti-Galphaq antibody in human ocular surface epithelia. METHODS: Human donor corneoscleral buttons were sectioned and stained with a battery of commercial antibodies against Galpha proteins. Western blot analysis of cell lysates of corneal epithelial cells and HEK 293 cells transfected with Galphaq cDNA was used to determine the identity of the protein reactive with the anti-Galphaq antibody (E-17). Comparisons were made with another anti-Galphaq antibody (G4415) and an anti-cytokeratin 12C (J7) antibody. The isolated proteins reactive with E17 and J7 were then analyzed with two dimensional isoelectric focusing. Polypeptide sequences were identified using matrix assisted laser desorption/ionization time of flight mass spectrometry (MALDI-TOF MS) after in-gel protein digestion. RESULTS: The E-17 anti-Galphaq antibody preferentially stained the entire corneal epithelia and the suprabasal layers of the limbus with complete absence of staining in the basal limbus and conjunctiva. Western blot analysis of corneal epithelial cells showed that E-17 antibody identified a protein with a molecular weight of 55 kDa. However, the antibody did not react with the purported antigen, Galphaq protein (42 kDa) produced by Galphaq cDNA. Another anti-Galphaq antibody (G4415) did not react with the 55 kDa protein but did react with the 42 kDa Galphaq protein. Further comparison of the E-17 antibody with the J7 antibody revealed that both recognized the 55 kDa band in one and two dimensional analysis. MALDI-TOF MS analysis confirmed that the 55 kDa protein of interest was actually cytokeratin 12 (CK12), rather than Galphaq protein. CONCLUSIONS: The commercial E-17 anti-Galphaq antibody did not react with Galphaq protein, its purported antigen. Instead, it recognized a 55 kDa protein, which was characterized to be cytokeratin 12 by isoelectric focusing and peptide fingerprinting with mass spectrometry. Based on its reactivity with CK12, this commercial E-17 can be used as a differentiation marker to study ocular surface epithelia.

Treatment of recurrent corneal and conjunctival intraepithelial neoplasia with topical interferon alfa 2b.

OBJECTIVE: To evaluate topical interferon alfa 2b (IFNalpha2b) as a single therapeutic agent in the treatment of presumed recurrent corneal and conjunctival intraepithelial neoplasia. DESIGN: Noncomparative, retrospective case series. PARTICIPANTS: Seven consecutive patients with recurrent corneal and conjunctival intraepithelial neoplasia diagnosed at the University of Minnesota from July 2000 to November 2003 were studied retrospectively. All patients had a history of histologically proven primary corneal and conjunctival intraepithelial neoplasia and were treated by surgery, cryotherapy, radiation, and/or topical mitomycin C before recurrence. INTERVENTION: Patients with a clinical diagnosis of recurrent corneal and conjunctival intraepithelial neoplasia were treated with recombinant topical IFNalpha2b drops (1 million IU/ml) 4 times daily until lesion resolution was noted. MAIN OUTCOME MEASURES: A review of medical records was performed to assess the duration of and response to treatment with topical IFNalpha2b, defined by clinical resolution of corneal and conjunctival intraepithelial neoplasia. RESULTS: The average age of the 7 patients at the initiation of topical IFNalpha2b treatment for presumed recurrent corneal and conjunctival intraepithelial neoplasia was 68.7 years (range, 54-88). Six of 7 patients had successful treatment of recurrent corneal and conjunctival intraepithelial neoplasia lesions with topical IFNalpha2b treatment. The average length of IFNalpha2b treatment to resolution of recurrent corneal and conjunctival intraepithelial neoplasia was 14.5 weeks (range, 5-24). After treatment with topical IFNalpha2b for recurrent corneal and conjunctival intraepithelial neoplasia, 2 patients had another recurrence of corneal and conjunctival intraepithelial neoplasia, noted at 1 year and 2 months, respectively. The average post-treatment follow-up was 11.7 months (range, 8-17) after the resolution of recurrent corneal and conjunctival intraepithelial neoplasia. No side effects of treatment were noted in any patient. CONCLUSIONS: Topical IFNalpha2b as a single therapeutic agent is an effective treatment of presumed recurrent corneal and conjunctival intraepithelial neoplasia. It offers the benefits of topical therapy and avoids the risks of surgical or other interventions-specifically, ocular surface toxicity, cicatricial conjunctival changes, and limbal stem cell deficiency. Larger controlled studies with longer follow-up periods are recommended to confirm the long-term efficacy and safety of this topical treatment.

Impression cytology in the diagnosis of acanthamoeba keratitis with surface involvement.

PURPOSE: To evaluate the use of impression cytology in the diagnosis of Acanthamoeba keratitis with surface involvement. DESIGN: Observational case series. METHODS: Three patients with culture-proven superficial Acanthamoeba keratitis were studied. Patients' medical records were reviewed for clinical information, treatment procedures and disease course. Impression cytology specimens taken from the cornea of those patients were processed and observed by bright field microscopy. The main outcome measure was the cytopathological examination and identification of amoebic organisms. RESULTS: In each of these three patients, impression cytology specimens revealed the amoeba cysts. Some specimens also showed pleomorphic trophozoites with typical amoeba nuclei. CONCLUSION: Corneal impression cytology successfully detected the cysts and trophozoites of Acanthamoeba from patients with superficial amoeba keratitis. This indicates that impression cytology can be a useful technique to facilitate early diagnosis of Acanthamoeba keratitis with surface involvement.

Detection by impression cytologic analysis of conjunctival intraepithelial invasion from eyelid sebaceous cell carcinoma.

OBJECTIVE: To demonstrate that conjunctival impression cytologic analysis can detect conjunctival intraepithelial invasion from sebaceous cell carcinoma of the eyelid. DESIGN: Observational case series with cytopathologic correlation. PARTICIPANTS: Four patients with unilateral blepharoconjunctivitis and biopsy-proven sebaceous cell carcinoma. METHODS: Impression cytologic analysis specimens were taken from the suspicious area of the bulbar conjunctiva of each patient. Staining of the specimens was performed with a modified Papanicolaou stain. MAIN OUTCOME MEASURE: Observation of the abnormal tumor cells in the collected specimens by bright field microscope. RESULTS: The technique of impression cytologic analysis allowed collection and identification of abnormal tumor cells with characteristic cytoplasmic vacuoles. CONCLUSIONS: Conjunctival impression cytologic analysis successfully detected the ocular surface sebaceous carcinoma cells from the eyelid. However, full-thickness biopsies are necessary to confirm the diagnosis. Judicious use of impression cytologic analysis may facilitate the detection and diagnosis of this invasive tumor.