Management and treatment of central steep islands after excimer laser photorefractive keratectomy.

BACKGROUND: Permanent central steep islands are an undesirable phenomenon that cause distorted images and a significant reduction in visual acuity. We describe treatment of central steep islands with repeat excimer laser photoablation in the central cornea. METHODS: Three patients with preoperative refractions of -7.50 -2.50 x 170 degrees D (right eye), -8.00 -2.25 x 10 degrees D (right eye) and -6.00 -1.50 x 90 degrees (right eye) developed central steep islands which persisted more than 12 months. All patients lost more than two lines of spectacle-corrected visual acuity and complained of visual disturbances. We retreated the central steep islands with a VISX 20/20 excimer laser PRK ablation that matched the size of the central island measured on videokeratography. RESULTS: Symptomatic glare and distortion were significantly reduced and the central steep islands were resolved. Several weeks after reablation, spectacle-corrected visual acuity improved to the preoperative level. CONCLUSION: Central steep island, an infrequent complication of excimer laser photorefractive keratectomy, can be safely removed with a repeat laser ablation that matches the central circular steep area.

Endothelial damage with cataract surgery techniques.

PURPOSE: To evaluate intraoperative endothelial damage after planned extracapsular cataract extraction (ECCE) with difference capsulotomy techniques and phacoemulsification. SETTING: San Carlos University Hospital, Castroviejo Institute, Madrid, Spain. METHODS: In this prospective, randomized study, 60 patients with senile cataract scheduled for cataract surgery were divided into three groups of 20 each: Group 1 had phacoemulsification; Group 2, planned ECCE with continuous curvilinear capsulorhexis; and Group 3, ECCE with letter-box capsulotomy. Preoperatively and 3 months postoperatively, endothelial cell density, percentage of hexagonality, and the cell size variation coefficient were determined by contact specular microscopy; endothelial permeability was examined by anterior segment fluorophotometry and central corneal thickness, by ultrasonic pachymetry. Results were analyzed using the two-tailed Student's t-test and analysis of variance. RESULTS: In all three groups, endothelial permeability and cell loss increased significantly from the preoperative values, but there were not significant differences among the postoperative values. Mean cell loss was 11.8% in Group 1, 12.8% in Group 2, and 10.1% in Group 3. There were no differences between the preoperative and postoperative morphometric indexes. Postoperative pachymetric measurements were not significant. CONCLUSIONS: Endothelial response was not statistically significantly different among the surgical techniques, although endothelial damage was lower in Group 3, which could indicate a protective effect of the anterior capsule during cataract extraction. Endothelial barrier function remained disturbed despite the apparent morphological stabilization.

Deposits of topical norfloxacin in the treatment of bacterial keratitis.

PURPOSE: Fluoroquinolone solutions are widely used in therapy of bacterial keratitis. These drugs are safe, and their ocular side effects are mild and not serious in nature. The most frequent untoward effect associated with ciprofloxacin therapy has been a white crystalline deposit. This deposit has not been reported after using the other commercially available quinolones, ofloxacin and norfloxacin. METHODS: We present three cases of norfloxacin deposits after treatment of bacterial keratitis. RESULTS: In the three cases, the norfloxacin was substituted for another antibiotic effective against the bacteria, and the precipitate spontaneously resolved in all cases within a few days with no untoward ocular effect. CONCLUSION: Crystalline corneal deposits can develop during topical norfloxacin therapy. The exact factors contributing to the formation are unknown, although the differences in the tear pH/solubility could be involved. Clinicians should be aware of this ocular side effect.

Immunologic and clinical evaluation of postsurgical necrotizing sclerocorneal ulceration.

PURPOSE: To perform a clinical, laboratory and pathologic evaluation in patients who had developed a postsurgical necrotizing sclerocorneal ulceration to detect a serious associated autoimmune disorder and to treat the ocular disease early. METHODS: Nine patients with postsurgical necrotizing sclerocorneal ulceration after uneventful cataract extraction were studied by means of immunohistochemical techniques on conjunctival resections, immunologic serologic studies, and rheumatologic evaluation. Nine healthy subjects who underwent uneventful cataract surgery were used as controls. RESULTS: The pathologic studies showed a local immunoglobulin M (IgM) and IgG deposition, increased human leukocyte antigen (HLA-DR) expression, and a significant T-helper cell participation in conjunctival biopsies in the most severe ulcerations, which were detected in four patients with underlying autoimmune systemic disorder (rheumatoid arthritis, 45%) and only a macrophagic infiltration in the mildest ulcers in patients (55%) without immune disorders. Serologic features included high titers of rheumatoid factor in the four (45%) patients with rheumatoid arthritis, nonspecific serologic immune alteration in three (33%) patients, and were unremarkable in two (22%) patients. The medical and immunologic evaluations were negative in the control cases. Topically administered cyclosporin A healed the ocular disease. CONCLUSION: A surgically induced local autoimmune reaction could occur in the incision area in patients with systemic vasculitic disease. There was no underlying systemic disorder in the mildest ulcers, and these ulcers could be due to a defect in the surgical technique. Our results suggest the need for a detailed systemic evaluation in patients with severe postsurgical necrotizing ulceration. Early diagnosis and aggressive medical treatment of the ocular disorder improves the visual outcome.

HLA-B27--associated uveitis presenting with diffuse vitritis.

A 26-year-old man complained of a sudden decrease in vision in the left eye. He had a past medical history of pauciarticular juvenile rheumatoid arthritis with a positive HLA-B27 haplotype and negative antinuclear antibodies and later development of ankylosing spondylitis. His ocular history was unremarkable. An ophthalmic examination revealed a predominant diffuse vitritis (3+) in the left eye. The uveitis improved after treatment with topical and systemic steroids. Following an extensive clinical and laboratory evaluation, a final diagnosis of HLA-B27-associated uveitis was made. Although uncommon, diffuse vitritis can occur in the setting of this uveitis and may be a predominant symptom.

Analysis of the blood-retinal barrier: its relation to clinical and metabolic factors and progression to retinopathy in juvenile diabetics. A 4-year follow-up study.

BACKGROUND: The study was carried out to evaluate the correlation between blood-retinal barrier (BRB) permeability and the development of diabetic retinopathy (DR) and to assess the metabolic and clinical factors related to DR over a 4-year period by means of vitreous fluorophotometry (VF). METHODS: Thirty-five type I diabetics with no retinopathy, age 7-21 years (mean 14.32 +/- 2.1 years) were enrolled in this longitudinal study. Two visits included standard ophthalmological examination, fluorescein angiography and VF were performed, on entry into the study and 4 years later. The following risk factors in DR were analyzed: age, duration of diabetes, blood pressure, cholesterol, triglycerides, fasting blood glucose levels, glycosylated hemoglobin (HbA1c), insulin dose/kg body weight (IDBW), fructosamine and albuminuria. To estimate the BRB permeability we adopted the vitreous penetration ratio transmittance (VPRt) value. RESULTS: At 4-year follow-up the mean VPRt had significantly increased. During that time 13 patients developed DR and their final mean VPRt was significantly higher than that in non-DR patients. Additionally, the initial mean VPRt was higher but not significantly so, in patients that later developed DR than in non-DR subjects. A constant linear correlation was found between VPRt and duration of diabetes, HbA1c and microalbuminuria. CONCLUSION: VF is a quantitative method that could measure and predict the breakdown of the BRB before angiographic retinopathy in type I diabetics. The major clinical and metabolic factors related to alterations in the BRB are duration of diabetes, HbA1c and microalbuminuria.