Keratoconus in Patients with Macular Stromal Dystrophy.

OBJECTIVE: To show the association between keratoconus and macular dystrophy. MATERIAL AND METHOD: All patients with macular dystrophy and associated clinical findings leading to a diagnosis of keratoconus by corneal topography were retrospectively reviewed during a 10-year period. Uncorrected and best-corrected visual acuity, automated refraction, manifest refraction, corneal thickness, and corneal curvature by corneal topography were evaluated RESULTS: Three patients with macular dystrophy exhibiting decreased vision, multifocal white dense deposits, and haze surrounding the deposits in the corneal stroma were evaluated. All had a steep corneal curvature of >47 diopters and a thin cornea consistent with keratoconus. Penetrating keratoplasty was performed in one patient with severely decreased vision. Macular dystrophy was diagnosed based on an Alcian blue-stained pathological specimen. CONCLUSION: Keratoconus may develop as a result of changes associated with macular dystrophy. Therefore, patients with severely decreased vision should be evaluated for keratoconus to ensure proper management.

Comparison of Nested PCR and Culture Identification of Pythium insidiosum in Patients with Pythium Keratitis.

Background: Delayed diagnosis can lead to the development of endophthalmitis and blindness, which is difficult to manage because of the lack of an effective antimicrobial agent. Objective: Comparing the nested polymerase chain reaction (PCR) technique with the standard diagnostic culture method for Pythium insidiosum. Material and Method: Eighty-three patients with suspected fungal keratitis were enrolled in this observational, crosssectional study from the Faculty of Medicine Siriraj Hospital between February 2011 and February 2014. Patient symptoms, associated diseases, duration of ulcers, precipitating causes, best-corrected visual acuity, intraocular pressure, and other clinical findings were recorded. Corneal scrapings were taken for Gram staining, bacterial and fungal cultures, staining with potassium hydroxide preparation, and DNA extraction for nested PCR. The sensitivity, specificity, accuracy, and agreement of the nested PCR analysis and culture diagnosis of P. insidiosum were compared. Results: Five patients had a positive result for nested PCR amplification of P. insidiosum, while only one of these was also positive for culture growth of Pythium. Nested PCR sensitivity was 50% (95% confidence interval [95% CI] 1.3-98.7), specificity 94.7% (95% CI 86.9-98.5), and accuracy 93.5% (95% CI 85.7-97.2) with a fair agreement (kappa 0.258, p = 0.011). Conclusion: Therefore, nested PCR may be an appropriate test for P. insidiosum in diagnosing Pythium keratitis with high accuracy, despite small amounts of corneal specimen.

Evaluation of nested pcr technique for detection of Pythium insidiosum in pathological specimens from patients with suspected fungal keratitis.

Diagnosis of Pythium keratitis is problematic due to the difficulty in obtaining a culture report resulting in unnecessarily prolonged usage of antimicrobial medication due to misdiagnosis. This study evaluated and compared nested PCR technique with culture and immunoperoxidase staining assays of Pythium insidiosum in paraffin-embedded corneal tissues from patients with suspected fungal keratitis. Six of 51 pathological reports compatible with fungal infection and 6 of 48 culture-proven fungal keratitis were identified as Pythium. Twenty-seven specimens were PCR-positive for Pythium insidiosum. In comparison with fungal culture for P. insidiosum, PCR had 83% sensitivity and 77% specificity with fair agreement (Kappa score of 0.227, p = 0.001). The mean age of PCR-positive is younger than PCR-negative group and there is a female preponderance in Pythium-infected group (p = 0.002 and p = 0.004, respectively). Nineteen specimens had positive results using immunoperoxidase staining assay with fair agreement to culture method (Kappa 0.340, p < 0.001), and 83% sensitivity, 85% specificity and 85% accuracy (95% CI: 76.7-90.7). PCR-based technique compared with culture and/or immunoperoxidase staining assay had 91.7% sensitivity, 81.8% specificity and 83% accuracy (95% CI: 74.5-89.1) with moderate agreement (Kappa 0.477, p < 0.001). Thus nested PCR detection of P. insidiosum should be employed in preliminary diagnosis of Pythium keratitis in order to initiate proper management.

Use of cyclosporine A and tacrolimus in treatment of vernal keratoconjunctivitis.

Vernal keratoconjunctivitis is a sight-threatening inflammatory disease of conjunctiva and cornea. It is frequently observed in young children with the onset usually occurring in the first decade of life. Mild cases of VKC tend to remit with nonspecific and supportive therapy. In contrast, severe cases are usually more protracted with remission/relapse occurring for a prolonged period of time. Although VKC is classified as an allergic eye condition, the role of allergens as an inciting factor is not clear. Pathogenesis of VKC involves roles for IgE, cytokines, chemokines, and inflammatory cells (T and B lymphocytes, mast cells, basophils, neutrophils, and eosinophils) with the release of their granular proteins, proliferation of fibroblasts, and laying down exuberant amounts of collagen fibers in the conjunctival tissue. In severe VKC cases-often of tarsal VKC-diagnostic giant papilla are classically observed on the upper tarsal plate, giving the classic 'cobble-stone' appearance. Corneal ulcer can occur from the effect of eosinophilic granular proteins on corneal epithelium and by physical trauma by intense eye rubbing. Topical corticosteroids, often required for controlling symptoms and signs in severe VKC, can lead to serious ocular complications. Immunomodulators that have been investigated for VKC treatment include topical ocular preparations of cyclosporine A and tacrolimus. Severe VKC responds promptly to topical cyclosporine A and tacrolimus, mostly within 1 month of therapy. Prolonged use of cyclosporine A and tacrolimus in VKC is safe and is tolerated by most patients without significant side effects. Recent investigations on the use of these two agents in VKC are the main purpose of this review. The use of cyclosporine A and tacrolimus are a major breakthrough in treatment for severe VKC, a debilitating allergic eye disease in children.

Clinical features of Acanthamoeba keratitis in contact lens wearers and non-wearers.

Clinical presentations of patients with Acanthamoeba keratitis (AK) attending the Faculty of Medicine Siriraj Hospital during 1996-2006 were reviewed. The studied parameters included history of ocular trauma, use of contact lenses, associated eye diseases, systemic diseases, visual acuity, symptoms, signs, treatment, visual outcomes, and sequelae. Data were analyzed by comparing non-contact lens (nCL) and contact lens (CL) wearers with eachother. Twenty-two patients (24 affected eyes) (68.2% female) had AK, 9 (37.5%) were nCL and 15 (62.5%) were CL. Both groups had similar basic characteristics; however the nCL group was significantly older (48.3 +/- 14.5 vs 30.6 +/- 15.3 years old, p=0.006), and tended to have a longer duration of symptoms with more severe clinical findings, but this was not statistically significant. Eleven had severe ciliary injection (nCL 55.5%, CL 40.0%), 3 had satellite lesions (nCL 22.2%, CL 6.7%), 2 had radial keratoneuritis in the CL group (13.3%), 1 ring infillrate in the nCL group (11.1%) and 1 pseudodendrite in the CL group (6.7%). The mean duration of follow-up was 8.2 +/- 7.9 (ranging 0.3-29) months. Therapeutic measures included anti-Acanthamoeba medications (5/9 for nCL, 8/15 for CL), penetrating keratoplasty due to uncontrolled infections (1/9 for nCL, 2/15 for CL) and corneal perforation (1/9 for nCL), and enucleation due to endophthalmitis (1/9 for CL). At the last follow-up visit, the CL [corrected] group had slightly better visual acuity (55.5% vs 66.7%). In conclusion, AK among patients who do not use contact lenses may have a delayed diagnosis, resulted in more severe ocular manifestations and poorer prognosis. Physicians should be aware of Acanthamoeba infection as a cause of keratitis in any patient, not just contact lens wearers. Long periods of follow-up are recommended to observe for recurrent episodes and proper management of AK patients.

A double-masked comparison of 0.1% tacrolimus ointment and 2% cyclosporine eye drops in the treatment of vernal keratoconjunctivitis in children.

OBJECTIVE: To compare the efficacy of 0.1% tacrolimus (FK-506) ophthalmic ointment with 2% cyclosporine eye drops in the treatment of vernal keratoconjunctivitis (VKC). DESIGN: Prospective double-masked randomized comparative trial. PARTICIPANTS: Twenty-four VKC patients were enrolled into the study. Their mean age was 9.61 +/- 2.55 years. Twelve patients were allocated into the FK-506 group and the other twelve into the cyclosporine group. Their baseline characteristics were similar between groups. METHODS: After a 2 week run-in period, patients were randomized into 2 groups in a double-masked, parallel fashion. Group A received 0.1% FK-506 eye ointment twice daily with placebo eye drops four times daily for 8 weeks. Group B received 2% cyclosporine eye drops with placebo ointment for the same duration. All patients received an open-treatment with 0.1% FK-506 eye ointment for another 4 weeks. Subjective ocular symptoms and side effects were recorded by patients once daily, during the entire period. Objective ocular signs were evaluated and scored at each follow up visit. MAIN OUTCOME MEASURE: Improvement of total subjective symptom scores per day (TSSS) within group and between groups at various time points. RESULTS: For within group comparison, there was a significant decrease in TSSS, compared to their baselines, at weeks 4 and 8, in both treatment groups. However, no statistical difference in TSSS was noted between groups at any time point. Total ocular sign scores (TOSS) in the FK-506 group decreased significantly at weeks 4 and 8 compared to baseline. Although there was a decrease of TOSS in the cyclosporine group, the difference did not reach statistical significance. Side effect scores reduced significantly in both groups at week 4 compared to their respective baselines (p = 0.034 in the FK506 group and p = 0.003 in the cyclosporine group). There was no significant difference in the comparison between groups on TOSS and side effect scores at any time point of the study. During the open FK-506 period, patients in cyclosporine group showed further reduction of both TSSS and TOSS. However, these changes were not statistically significant (p > 0.05). CONCLUSION: 0.1% FK-506 eye ointment and 2% cyclosporine were both effective in treatment of VKC. 0.1% FK-506 could become another viable therapeutic option for VKC.

Risk factors for contact lens related microbial keratitis: a case-control study.

OBJECTIVE: To evaluate the risk factors that may contribute to microbial keratitis in contact lens wearers. MATERIAL AND METHOD: This prospective case-control study included 52 patients with contact lens related keratitis treated between 1 December 2006 and 15 October 2007 at the Faculty of Medicine, Siriraj Hospital. Controls were sixty-three contact lens users attending with disorders unrelated to contact lens wear All subjects with informed consent were interviewed about demographic data, types of contact lens and contact lens solutions, contact lens use past the recommended replacement date, overnight wear, and lens hygiene. Odds ratio (OR, estimates of relative risks) and 95% confidence interval (CI) were calculated through multivariable logistic regression analysis. RESULTS: The use of contact lens past the replacement date caused the highest risk of developing microbial keratitis (OR = 9.1; CI 1.8-45.4, p = 0.005). Overnight wear of lenses (OR = 2.9, CI 1.3-6.2, p = 0.012) and poor lens hygiene (OR = 2.3, CI 1.0-5.1, p = 0.007) significantly increased the risk of microbial keratitis, respectively. None of the other risk factors showed a significant association. CONCLUSION: The significant risk factors for contact lens related microbial keratitis in the present study were the use of contact lens past the replacement date, overnight wear, and poor lens hygiene. Thus, the appropriate advice of contact lens care and usage may reduce the risk of microbial keratitis in contact lens wearers.

Prevalence of dry eye syndrome and Sjogren's syndrome in patients with rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis has manifestations in various organs including ophthalmic involvement. The present study evaluates prevalence of dry eye and secondary Sjogren's syndrome using salivary scintigraphy which has not been used in previous reports. OBJECTIVE: To evaluate the prevalence of secondary Sjogren's syndrome in patients with rheumatoid arthritis, including clinical characteristics and dry eye, compared with non-Sjogren's syndrome. DESIGN: Descriptive cross sectional study MATERIAL AND METHOD: Sixty-one patients with rheumatoid arthritis were recruited at Siriraj Hospital during March 2009-September 2010 and filled in the questionnaires about dry eye for Ocular Surface Disease Index (OSDI) with a history taking of associated diseases, medications, duration of symptoms of dry eyes and dry mouth. The Schirmer I test without anesthesia, tear break-up time, rose bengal staining score, severity of keratitis and salivary scintigraphy were measured and analyzed. RESULTS: Prevalence of secondary Sjogren's syndrome and dry eye were 22.2% (95% CI 15.4 to 30.9) and 46.7% (95% CI 38.0 to 55.6), respectively. Dry eye interpreted from OSDI, Schirmer 1 test, tear break-up time and rose bengal staining was 16.4%, 46.7%, 82% and 3.3% respectively. Fifty-two percent of patients had a history of dry eye and dry mouth with mean duration 27.4 and 29.8 months, respectively. Superficial punctate keratitis and abnormal salivary scintigraphy were found in 58.2% and 77.8%. Duration of rheumatoid arthritis, erythrocyte sedimentation rate were not correlated with secondary Sjogren's syndrome. Dry eye from OSDI with secondary Sjogren's syndrome (33.3%) compared with non-Sjogren's syndrome (9.5%) was significant difference (p = 0.008). Adjusted odds ratio for secondary Sjogren's syndrome in OSDIL score > 25 was 13.8 (95% CI 2.6 to 73.8, p = 0.002) compared to OSDI score < 25. CONCLUSION: Awareness and detection of dry eye syndrome and secondary Sjogren's syndrome in rheumatoid arthritis was crucial for evaluation of their severity and proper management.

Refractive outcomes of femtosecond LASIK for myopic correction at Siriraj Hospital, Thailand.

OBJECTIVE: To evaluate refractive outcomes of myopic femtosecond LASIK at Siriraj Hospital, Thailand. MATERIAL AND METHOD: A retrospective study of patients who underwent femtosecond LASIK at SiLASIK center Siriraj hospital, Mahidol University, Thailand,from April 2009 to April 2010 was conducted. All patients had completely normal preoperative eye examination. All LASIK procedures were performed using Intralase femtosecond laser (Abbott Medical Optics Inc (AMO)) and VISX star S4 excimer laser (AMO). Postoperative follow-up included visual acuity (ETDRS chart) and manifest refraction at 1 day, 1 week, 1 month and 3 months. The flap thickness was evaluated at 3 months using Visante optical coherence tomography (OCT Carl Zeiss Meditec). RESULTS: One hundred and twenty eight eyes of 64 patients were included in the study. Mean preoperative manifest refraction spherical equivalent (MRSE) was -5.47 +/- 2.28 diopters (range, -1.88 to -12.63 diopters). At 3 months post-operation, the MRSE was -0.26 +/- 0.39 diopters (range, + 0.25 to -2.00 diopters) and 95.31% were within + 1.00 diopter of intended correction. There was 98% of eyes achieved uncorrected distance visual acuity (UDVA) 20/40 or better and 73% achieved UD VA 20/20 or better There was 31% of eyes gained one line and 15% lost 1 line of corrected distance visual acuity (CDVA). The mean error of flap thickness (difference between actual and intended central flap thickness) was + 0.23 +/- 1.77 microm for 120 microm flap setting and + 0.22 +/- 0.97 microm for 110 microm flap setting. The flap morphology was planar configuration. CONCLUSION: Myopic femtosecond LASIK at Siriraj Hospital provided satisfactory refractive outcomes and high accuracy of the flap thickness.

Transplantation of autologous cultivated oral mucosal epithelial sheets for limbal stem cell deficiency at Siriraj Hospital: a case series.

BACKGROUND: The loss of limbal stem cells owing to either corneal burn or inflammation leads to the repopulation of opaque skin over the raw surface of the cornea. It has been proposed that reconstitution of oral mucosal stem cells over this raw surface will mimic the limbal stem cells and restore vision. The efficacy and safety of applying a sheet of cultivated oral mucosal cells as an autologous graft for corneal replacement were evaluated. CASE PRESENTATION: The study was conducted during 2014-2015 and involved a total of six patients, of whom three had suffered a chemical burn and three had Stevens-Johnson Syndrome (SJS). Oral mucosal tissue was dissected from each patient, seeded onto irradiated J2 fibroblast feeder cells for 14 days, and analyzed for quality and safety 1 day before being transplanted onto the cornea of the affected eyes. After transplantation, topical antibiotic and anti-inflammatory eye drops were instilled four times daily, and the patients wore contact lenses. Subjects were clinically followed for visual acuities and adverse effects at 2, 4, and 6 weeks, 3 and 6 months, and 1 year post-transplantation. Data were presented descriptively. Visual acuities in patients improved at 2 weeks post-surgery. However, two patients with SJS had corneal ulcer at 2 weeks postoperatively. At the 1-year postoperative examination, the eyes of two patients were in good condition with decreased vascularization and epithelial defect. CONCLUSIONS: Cultivated oral mucosal epithelial sheet transplantation in limbal stem cell deficiency had a favorable efficacy. In this study, patients with chemical burn had more clinical benefit than those with SJS. Trial registration ClinicalTrials.gov: NCT02415218. Registered retrospectively 4 Apr 2015 ( https://clinicaltrials.gov/ct2/show/NCT02415218 ).

Efficacy of contact lens solutions against Thai clinical isolates of Acanthamoeba.

Three clinical isolates of Acanthamoeba (A. castellanii, A. polyphaga, and A. mauritaniensis) were used to evaluate the cysticidal activity of four different contact lens multi-purpose solutions (Complete Protec, ReNu MultiPlus, Solocare Aqua, and Opti-free Aldox). Enumeration of amoebic was carried out with the control and test samples at 0, 2, 4, 6, 8, 10, and 24 hours after being added to the solutions using the most probable number (MPN) technique. A contact lens solution which achieved a 3-log reduction of Acanthamoeba during the manufacturer's minimum recommended disinfection time (MMRDT) was considered an effective solution. The studied contact lens solutions demonstrated decreasing number of amoebic with increasing exposure times, but were not effective against Acanthamoeba cysts during the MMRDT. Solocare Aqua gave the greatest reduction in A. castellanii (0.70-log reduction) and A. mauritaniensis (0.33-log reduction) by 4 hours. Only Solocare Aqua caused a 3-log reduction in A. castellanii (3.02-log reduction) by 24 hours. Opti-free Aldox showed the greatest cysticidal activity against A. polyphaga (0.32-log reduction) by 6 hours, and gave the greatest reduction in A. mauritaniensis by 8, 10, and 24 hours.

Sjögren-like syndrome after bone marrow transplantation.

OBJECTIVE: To study the incidence of dry eye in Sjögren-like syndrome, graft-versus-host disease (GVHD) in hematological patients undergoing bone marrow transplantation (BMT). MATERIAL AND METHOD: Prospective, cross-sectional study in twenty-six patients that were planned for BMT (group I). Twenty-nine patients undergoing BMT before study were classified as group II no GVHD (9), and group III with GVHD (20). Thirty-two normal subjects were controls. All subjects were examined by slit lamp biomicroscopy and had their tear samples analyzed about tear osmolarity. They were also evaluated for aqueous tear production by phenol red thread test, Schirmer test without anesthesia, tear film stability by tear break-up time (TBUT), and rose bengal staining 2 weeks before BMT (for group I) as well as 6 weeks, 3 months, and 6 months after BMT. The patients with GVHD were followed up 1 month later. Main outcome measures were amount of tear production, tear film stability, and dry eye symptoms. RESULTS: Average aqueous tear production in group III was less than control and group II (p < 0.001). Mean TBUT in group III was faster than control (p < 0.001) and group I before BMT (p = 0.001). Mean score of rose bengal staining in group III was more than control and group I before BMT (p < 0.001). Keratoconjunctivitis sicca and red eye developed in 27.5%, and 20% of group III, with incidence of dry eye by Schirmer test without anesthesia (67.5%). This compares with group II having incidence of dry eye of 16.7%. However, 42.3% of group I before BMT had dry eye compared with 9.4% in the controls (p < 0.001). CONCLUSION: Trend of dry eye in patients with BMT and GVHD were higher than no-GVHD group. Doctors should be aware of ocular symptoms and signs of dry eye in patients with BMT and follow-up for proper management.

Topical 0.002% mitomycin C for the treatment of conjunctival-corneal intraepithelial neoplasia and squamous cell carcinoma.

PURPOSE: To demonstrate the efficacy of topical 0.002% mitomycin C (MMC) as an adjunctive and alternative treatment in primary and recurrent conjunctival-corneal intraepithelial neoplasia (CCIN) and squamous cell carcinoma (SCC). METHODS: The medical records of 7 patients with histopathologically confirmed CCIN and conjunctival SCC were retrospectively reviewed. All cases were treated with topical 0.002% MMC 4 times daily. The tumor size pre- and post-treatment, clinical response, and ocular complications were evaluated. RESULTS: The mean age of the patients was 56 +/- 13.4 years. The most common presenting symptom was foreign body sensation (57.1%) with a mean duration of 2.3 +/- 3.8 months. Six patients had pathologically proven CCIN (85.7%) and 1 had SCC (14.3%). Before MMC treatment, 6 eyes (85.7%) had recurrences after surgical excision. The tumor-free period ranged from 2 to 19 months. Two patients had multiple recurrences. MMC 0.002% 4 times daily was applied for a period of 5.4 +/- 4.4 weeks (range, 2-14). All had complete tumor regression as observed clinically and confirmed by impression cytology. Side effects of MMC therapy included ocular irritation, mild conjunctival hyperemia, and punctate keratopathy. There were no serious complications detected. The mean follow-up time was 30.7 +/- 15 months (range, 2-52) with no evidence of clinical recurrence in any case. CONCLUSIONS: Topical 0.002% MMC showed a favorable outcome as an adjunctive and alternative treatment of CCIN and SCC with regression of primary and recurrent tumors.

Tonometry after laser in situ keratomileusis treatment: a preliminary study in Thai patients.

OBJECTIVE: To evaluate the change in intraocular pressure (IOP) measurement by Goldmann applanation tonometer after Laser in Situ Keratomileusis (LASIK) for myopia and myopic astigmatism, and to assess the correlation between the changes of lOP reading and the reduction of central corneal thickness (CCT) after LASIK in Thai patients. STUDY DESIGN: Prospective correlational study. MATERIAL AND METHOD: LASIK was performed on 65 eyes of 33 patients for correction of myopia and myopic astigmatism. IOP was measured by Goldmann applanation tonometer before and 3 months after LASIK. The correlation between the change in IOP reading and the change in central corneal thickness were evaluated. RESULTS: IOP reading was significantly reduced by mean of 2.9 +/- 2.5 mmHg (p = 0.0001). The authors used Pearson analysis to study the correlation between the change in IOP and the reduction of CCT. In subgroup analysis the patients were divided by degree of myopia: group 1, myopia less than -3 diopters (D) (n = 14); group 2, myopia -3 to -6 D (n = 31); group 3, myopia greater than -6 D (n = 20)). The result showed more correlation in higher myopia group (Pearson; r = 0.158 in group 3, r = -0.098 in group 2 and r = -0.102 in group 1). CONCLUSION: Goldmann applanation tonometry underestimates the IOP in thin cornea. Variability in CCT is a potent confounder of this tonometry technique. Therefore, it has important implications for considering CCT measurement incorporated with Goldmann applanation tonometry for glaucoma diagnosis especially in myopic patients who undergo LASIK surgery.

Application of Preserved Human Amniotic Membrane for Corneal Surface Reconstruction.

Objective: To evaluate the efficacy of preserved human amniotic membrane transplantation for reconstruction of the corneal surface diseases.Methods: Preserved human amniotic membrane transplantations were performed in 84 eyes of 78 patients for corneal surface reconstruction. The indications were limbal stem cell deficiency from Steven-Johnson syndrome, chemical burn and herpes keratitis (27 eyes), bullous keratopathy (26 eyes), persistent epithelial defect and dellen (17 eyes), band keratopathy (11 eyes), preparing for prosthesis (1 eye), corneal ulcer (1 eye) and acute chemical burn (1 eye).Results: Success was noted in 83.3% (70/84) eyes, partial success in 13.1% (11/84) eyes, and failure in 3.6% (3/84) eyes for an average follow-up of 10.5 months (3 - 29 months). No patient developed major immediate post-operative complications.Conclusion: Amniotic membrane transplantation can reduce inflammation, promote corneal epithelial healing, and decrease irritation in corneal surface problems.

Vernal keratoconjunctivitis in Thailand.

A prospective, cross-sectional and randomized cross-over study was conducted to study the clinical features and treatment outcome among Thai patients with vernal keratoconjunctivitis (VKC). History-taking and eye examinations were performed. Mild cases of VKC were given topical antihistamine four times daily. Moderate and severe cases of VKC were treated with topical lodoxamide four times a day. Severe cases of VKC were given topical corticosteroids. Moderate and severe cases of VKC, which were refractory to treatment with either corticosteroids or a mast cell stabilizer had topical cyclosporine 0.5% instilled four times daily. Five patients were exposed to two different treatment regimens in sequence. As main outcome measures, itching, foreign body sensation, photophobia, conjunctival injection, papillae and chemosis were evaluated weekly. The patients with the palpebral type of VKC had daily symptoms, which were more severe and triggered by house-dust with a significant difference among the groups. Limbal VKC was associated with allergic rhinitis more commonly than palpebral VKC. Positive results of skin prick testing to acacia, careless weed, mold, Johnson grass and cow's milk were significantly more common in patients with palpebral VKC. The most common symptoms and signs were found in the mixed type of VKC. Purulent discharge, pannus and lid erythema were found in the palpebral type. Levocabastine hydrochloride was sufficient for mild cases of limbal VKC; lodoxamide for the limbal and mixed types. Prednisolone acetate was the drug of choice in severe cases of any type but only for a short period of time. The success rate of topical cyclosporine in the palpebral type was lower than in the limbal type due to an intolerable burning sensation. Topical cyclosporine used in 4 patients with limbal and palpebral type had a success rate of 100% which was greater than in the lodoxamide group (66.7%, 0%). Compared with topical corticosteroid-treated eyes in one patient, the success rate in topical cyclosporine-treated eyes was not success. Grading the severity of each type of VKC is crucial to obtain good response of any medication and compliance. Topical cyclosporine 0.5% can be an alternative drug to relieve symptoms and signs of VKC in order to avoid steroid-induced glaucoma.

Development of a health-related quality of life questionnaire for Thai patients with rhinoconjunctivitis.

The objective of this study was to develop a disease-specific questionnaire for patients with rhinoconjunctivitis. All patients were recruited at the Out-Patient Clinic at Siriraj Hospital. Related topics were gathered from several sources, and a list of 63 items was produced. In phase I, the first version of the questionnaire was completed by 363 patients. Forty-eight items were identified by clinical impact analysis during the item removal process, two more questions were then added, giving a total of 50. Two hundred and forty-three patients completed the second version questionnaire in phase II. The average time taken to complete the questionnaire was 6.38 minutes. The item removal process in phase II was achieved by a multi-step process. There were 36 items in the third version questionnaire which consisted of six dimensions and two independent items as follows: symptoms (17 items), physical functioning (3 items), role limitations (3 items), sleep (3 items), social functioning (3 items), emotions (5 items), general health (1 item), and absenteeism (1 item). The scores of each item ranged from 1 to 5; a lower score indicating a better quality of life. Data from the selected 36 items was extracted to test the validity and reliability of the final version. The floor and ceiling effects of the scores for each dimension were low. Multitrait multi-item analysis was conducted to examine construct validity. The scaling success of convergent and divergent validity was 100% and 94%, respectively. Internal consistency determined by Cronbach's alpha coefficient, was satisfactory (0.79-0.87). The study indicates that the questionnaire is suitable for use in clinical settings. While the test results are encouraging, further work needs to be done on the test-retest reliability and on responsiveness.

Topical cyclosporine 0.5 per cent and preservative-free ketorolac tromethamine 0.5 per cent in vernal keratoconjunctivitis.

A prospective, randomized cross-over study was conducted in patients with vernal keratoconjunctivitis, successfully treated with cyclosporine, to evaluate the efficacy of cyclosporine 0.5 per cent compared with preservative-free ketorolac tromethamine 0.5 per cent. Patients received topical cyclosporine in both eyes along with an assessment of the severity of their conjunctivitis. In cyclosporine-treated patients, medication was discontinued 1 week before evaluation, then the medication was started for I month, and washed out 1 week before the other drug was started. Symptoms of itching, foreign body sensation, tearing, photophobia, discharge, burning, conjunctival injection, chemosis, giant papilla, keratopathy and intraocular pressure were evaluated weekly. There was a statistically significant decrease in all symptoms of cyclosporine-treated eyes at day 7, 14 and 30 and all signs at day 21 and 30. In ketorolac-treated eyes, there was a significant difference in itching, foreign body sensation, photophobia, tearing, mucous discharge, all symptoms, chemosis, giant papillae and conjunctival injection at day 7, and overall symptoms at day 14. Compared to cyclosporine-treated eyes at day 7, kotorolac-treated eyes had significantly fewer symptoms. Topical cyclosporine 0.5 per cent reduces symptoms and signs slower than preservative-free ketorolac tromethamine 0.5 per cent.

Comparison of topical lomefloxacin 0.3 per cent versus topical ciprofloxacin 0.3 per cent for the treatment of presumed bacterial corneal ulcers.

PURPOSE: To compare the efficacy and safety of topical lomefloxacin 0.3 per cent with topical ciprofloxacin 0.3 per cent for treating mildly severe suspected bacterial corneal ulcers. METHOD: This prospective, randomized, double-masked controlled clinical trial was conducted on 41 patients (41 eyes) with suspected bacterial corneal ulcers who were randomized into 2 groups: 23 patients were in the lomefloxacin group and 18 patients in the ciprofloxacin group. All of these corneal ulcers were scraped for gram's stain, KOH preparation and microbiologic cultures before starting treatment. The clinical success rate, the time to cure, the rates of treatment failures, ocular signs and symptoms and the adverse effects of the study medication were evaluated. RESULTS: Topical lomefloxacin is equivalent clinically and statistically to topical ciprofloxacin. No statistically significant treatment differences were found between lomefloxacin (100%) and ciprofloxacin (100%) in terms of success rate. Similarly, no differences were noted in the time to cure (p > 0.05), the treatment failure, or the resolution of the clinical signs and symptoms (p > 0.05). The adverse effects of lomefloxacin were superficial punctate keratitis (26.1%) and irritation (8.7%), whereas those of ciprofloxacin were superficial punctate keratitis (22.2%), white precipitate (11.1%) and irritation (11.1%). However, no statistically significant differences of these adverse effects were found between the two groups (p > 0.05). CONCLUSION: Lomefloxacin ophthalmic solution (0.3%) is equivalent clinically and statistically to ciprofloxacin ophthalmic solution (0.3%) for the treatment of mildly severe presumed bacterial corneal ulcers without statistically significant differences in the adverse effects and discomfort.

Comparison of topical prednisolone acetate, ketorolac tromethamine and fluorometholone acetate in reducing inflammation after phacoemulsification.

AIMS: To compare the efficacy and ocular adverse effects of topical prednisolone acetate, ketorolac tromethamine, and fluorometholone acetate in reducing inflammation after phacoemulsification. METHOD: One hundred and twenty eyes were enrolled in a prospective, investigator-masked, randomized controlled trial. Each drug was prescribed 4 times a day for 28 days. The following data were recorded weekly: visual acuity, intraocular pressure, slit lamp biomicroscopy, grading of cells and flare in the anterior chamber, and ocular symptoms. RESULTS: The number of eyes with a minimal amount of cells in the anterior chamber in the ketorolac group was less than the prednisolone group on day 7 (11:20, p = 0.008) and day 14 (23:31, p = 0.015), and than fluorometholone group on day 7 (11:21, p = 0.011). Intraocular pressure in the prednisolone group was higher than the ketorolac group on day 21 (14.6:12.2 mmHg, p = 0.016). One eye in the prednisolone group had intraocular pressure of 32 mmHg. Burning sensation was reported frequently in the ketorolac group. CONCLUSION: All 3 drugs were effective in reducing post-operative inflammation. The efficacy of prednisolone acetate and fluorometholone acetate was comparable. Ketorolac tromethamine showed less efficacy than corticosteroids, however, it did not induce ocular hypertension.