Enhanced loading dose of teicoplanin for three days is required to achieve a target trough concentration of 20 µg/mL in patients receiving continuous venovenous haemodiafiltration with a low flow rate.

INTRODUCTION: Because of its lower risk of renal toxicity than vancomycin, teicoplanin is the preferred treatment for methicillin-resistant Staphylococcus aureus infection in patients undergoing continuous venovenous haemodiafiltration (CVVHDF) in whom renal function is expected to recover. The dosing regimen for achieving a trough concentration (Cmin) of ≥20 µg/mL remains unclear in patients on CVVHDF using the low flow rate adopted in Japan. METHODS: The study was conducted in patients undergoing CVVHDF with a flow rate of <20 mg/kg/h who were treated with teicoplanin. We adopted three loading dose regimens for the initial 3 days: the conventional regimen, a high-dose regimen (four doses of 10 mg/kg), and an enhanced regimen (four doses of 12 mg/kg). The initial Cmin was obtained at 72 h after the first dose. RESULTS: Overall, 60 patients were eligible for study inclusion. The proportion of patients achieving the Cmin target was significantly higher for the enhanced regimen than for the high-dose regimen (52.9% versus 8.3%, p = 0.003). In multivariate analysis, the enhanced regimen (odds ratio [OR] = 39.93, 95% confidence interval [CI] = 5.03-317.17) and hypoalbuminaemia (OR = 0.04, 95% CI = 0.01-0.44) were independent predictors of the achievement of Cmin ≥ 20 µg/mL. CONCLUSIONS: An enhanced teicoplanin regimen was proposed to treat complicated or invasive infections by methicillin-resistant Staphylococcus aureus in patients receiving CVVHDF even with a low flow rate.

Infectious keratitis after corneal crosslinking for keratoconus caused by levofloxacin-resistant microorganisms.

INTRODUCTION: We present seven cases of infectious keratitis after corneal crosslinking (CXL) to attenuate keratoconus progression. METHODS: Of 524 consecutive patients who underwent CXL, 7 cases (4 males and 3 females; 21.5 ± 7.1 years) developed postoperative infectious keratitis were retrospectively reviewed. CXL was performed using the Dresden protocol or an accelerated protocol involving epithelial removal. RESULTS: All cases appeared normal on the day after surgery, but subsequently developed eye pain, blurred vision, corneal infiltration, inflammation of the anterior chamber, and ciliary injection on day 2 or 3. Methicillin-resistant Staphylococcus aureus was cultured from two eyes, methicillin-sensitive Staphylococcus aureus from two eyes, and Streptococcus pneumoniae from one eye. All detected bacteria were resistant to levofloxacin (LVFX). Five of the seven cases, especially four of the five severe cases with hypopyon, had a history of atopic dermatitis. All cases were observed after 2015. CONCLUSIONS: Infectious keratitis after CXL caused by microbes resistant to LVFX is increasing. In addition to careful postoperative observation of the cornea, preoperative evaluation of bacteria within the conjunctival sac evident on nasal swab cultures may be useful to identify potentially problematic microbes and inform the selection of appropriate antibiotics.

Passive exercise of the lower limbs and trunk alleviates decreased intestinal motility in patients in the intensive care unit after cardiovascular surgery.

[Purpose] The purpose of this study was to clarify the effects of passive exercise of the lower limbs and trunk (PELT) in ICU patients after cardiovascular surgery with decreased bowel motility. [Subjects and Methods] Ten ICU patients with clinically-apparent decreased bowel motility during the period of April to July 2016 were enrolled this study. Bowel sounds (BS) for 5 minutes at rest and 5 minutes after PELT were recorded through an electronic stethoscope. A frequency analysis was performed and the BS before and after PELT were compared. In addition, the percent change in BS before and after PELT was determined, and the relationship between the percent change in BS and individual parameters (invasiveness of surgery, inflammation, nutrition, renal function) was examined. [Results] Average BS (integral value) for 5 minutes before and after PELT were 63.1 ± 41.3 mVsec and 115.0 ± 57.8 mVsec, respectively; therefore, BS was significantly increased by PELT. When compared to patients at rest, a significant increase was found 0-4 minutes after PELT. None of the individual parameters was significantly correlated with the percent change. [Conclusion] PELT can increase the bowel motility of ICU patients with decreased bowel motility.

Growth of Floc Structure and Subsequence Compaction into Smaller Granules through Breakup and Rearrangement of Aluminum Flocs in a Constant Laminar Shear Flow.

We have constructed an outer-cylinder-rotating Couette device for high-speed shear flow in laminar flow conditions and visualized the structure formation and subsequent rearrangement of PACl (flocculant made of aluminum hydroxide gel) and kaolinite flocs by visible light imaging. In a previous report, we analyzed the case of relatively low shear rate (G-value = 29 1/s) and confirmed that the flocculation process could be separated into two stages: a floc growth stage and a breakup/rearrangement stage. Once the large bulky flocs that reached the maximum size appeared, they rearranged and densified through structural fracture and rearrangement. In this report, this process was further investigated by conducting experiments under two different high shear rates (58 and 78 1/s) at which breakup and rearrangement became more pronounced, and three different aluminum kaolinite ratios (ALT ratios) that were over and under the optimum dosage (neutralization point by Zeta potential). Visualization results confirmed that, during the growth stage, the flocculation rate could be approximated by a scaling relationship between floc size and elapsed time, which depended on the ALT ratio. After reaching the maximum size, the floc rapidly became compact and dense following adsorption of the gel, incorporating fine fragments from erosion breakup. The over and under dosages created a lot of fragments of erosion breakup, but less so in the optimum dosage. In the optimum ALT ratio, fragments did not remain because they were incorporated into the flocs and densified, and the floc size was thought to be maintained. The floc circularity distribution peaked at around 0.6 and 1, suggesting that the flocs were spherical in shape due to erosion breakup.

A Novel Riboflavin Formulation for Corneal Delivery Without Damaging Epithelial Cells.

Purpose: This study aimed to evaluate the trans-epithelial permeability enhancement and cell damage caused by a novel riboflavin composition for corneal delivery. Methods: We developed a trans-epithelial formulation of riboflavin for corneal delivery using 1,2-dioleoyl-3-dimethylammonium-propane (DODAP) and isostearic acid (ISA). The permeation enhancement was evaluated using an in vitro corneal epithelial cell culture system by measuring the amount of transferred riboflavin with high-performance liquid chromatography. Riboflavin permeation of MedioCROSS TE, a commercially available riboflavin formulation containing benzalkonium chloride, was also evaluated and compared to that of the DODAP/ISA formulation by changing the riboflavin concentration. The trans-epithelial electrical resistance (TEER) was measured after exposure to the samples in an in vitro corneal epithelial cell culture system to assess cytotoxicity. Results: The DODAP/ISA formulation demonstrated greater permeation when used together than when each component was used individually. The permeation enhancement effect of the DODAP/ISA formulation was almost the same as that of MedioCROSS TE. However, when a 10-fold higher riboflavin concentration was used in the DODAP/ISA formulation, the permeation enhancement effect surpassed that of MedioCROSS TE. After 24 hours of exposure, the TEER of the DODAP/ISA formulation was higher than that of MedioCROSS TE, indicating that the DODAP/ISA formulation was less cytotoxic than MedioCROSS TE. Conclusions: This study indicated that the DODAP/ISA formulation could serve as a less cytotoxic alternative to MedioCROSS TE. Further studies are required to determine the clinical efficacy and safety of the DODAP/ISA formulation in vivo. Translational Relevance: This study may provide alternative procedures for corneal collagen crosslinking with less of a cytotoxic effect on corneal epithelial cells.

Long-term results of femtosecond laser-assisted sutureless anterior lamellar keratoplasty.

PURPOSE: To evaluate the long-term results of femtosecond laser-assisted anterior lamellar keratoplasty (FALK) for anterior corneal pathologies. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Thirteen consecutive patients who underwent FALK for anterior corneal pathologies. INTERVENTION: Femtosecond laser-assisted sutureless anterior lamellar keratoplasty. MAIN OUTCOME MEASURES: Best spectacle-corrected visual acuity (BSCVA), manifest refraction, need for adjunctive surgery, and complications. RESULTS: Follow-up ranged from 12 to 69 months (mean = 31 months). The BSCVA was significantly improved over preoperative values at the 12-, 18-, 24-, and 36-month visits. A BSCVA greater than 20/30 was achieved in 54% of patients at the 12-month visit when all 13 patients were available for follow-up, in 50% and 33% of patients at the 18- and 24-month visits, respectively, when 12 patients were available, and in 60% and 50% of patients at the 36- and 48-month visits when 5 and 2 patients were available, respectively. The BSCVA of the eye that completed the 60- and 70-month visits was 20/50. Patients achieved a mean gain of 5 lines of BSCVA at the 6-, 12-, 18-, and 24-month visits, 4 lines at the 36-month visit, 5 lines at the 48-month visit, and 6 lines at the 60- and 72-month visits. Two patients lost a mean of 1.5 lines of BSCVA because surface haze developed after photorefractive keratectomy (PRK) and granular dystrophy recurred in the graft. At a mean of 5 weeks postoperatively, 83.3% of patients achieved BSCVA within 2 lines of that recorded at the 24-month visit. At the 12-month visit, mean spherical equivalent and refractive astigmatism were -0.4 diopters (D) and 2.2 D, respectively, with no significant shift from preoperative values or values recorded in different follow-up visits. Adjunctive surgeries included phototherapeutic keratectomy, PRK, cataract extraction, and epithelial ingrowth debridement. Complications included residual corneal pathology, mild interface haze, anisometropia, recurrence of pathology, haze after adjunctive PRK, dry eye, epithelial ingrowth, and suspicious ectasia. CONCLUSIONS: Femtosecond laser-assisted sutureless anterior lamellar keratoplasty improves the BSCVA of patients with anterior corneal pathologies with rapid visual rehabilitation and no significant induced astigmatism. Our preliminary results indicate that FALK results remained stable throughout the follow-up period.

Transient peripheral edema following displaced corneal graft after descemet stripping automated endothelial keratoplasty (DSAEK): case presentation.

BACKGROUND: Descemet's Stripping with Automated Endothelial Keratoplasty (DSAEK) is constantly gaining popularity in the management of endothelial dysfunctions such as bullous keratopathy or Fuchs' dystrophy. CASE PRESENTATION: A 36 year-old man with Fuchs' dystrophy underwent combined phacoemulsification and DSAEK of the right eye. Immediately postoperatively, corneal graft displacement and peripheral corneal edema which remained stable during the first postoperative month were evident on slit lamp examination. Three months after the procedure the peripheral edema had completely resolved and the patients' subjective symptoms were improved. CONCLUSIONS: The purpose of this case presentation is to demonstrate that corneal graft displacement after DSAEK can lead to peripheral corneal edema that can resolve without further intervention such as graft repositioning or replacement.

[Efficacy of cryoprecipitate transfusion for coagulopathy after cardiopulmonary bypass in thoracic aortic surgery].

BACKGROUND: Excessive bleeding after cardiopulmonary bypass remains a major complication for cardiac surgery. The principal causes of hemostatic bleeding are related to inadequate surgical hemostasis or diluted coagulopathy. We investigated the efficacy of cryoprecipitate (Cryo) transfusion in thoracic aortic surgery with cardiopulmonary bypass. METHODS: We divided 30 patients undergoing thoracic aortic surgery into two groups retrospectively. Fifteen patients transfused with cryoprecipitate and fresh frozen plasma (FFP) were defined as Group Cryo, and the other 15 patients transfused with FFP only were defined as Group FFP We compared the amount of blood products administered and the blood loss during the perioperative period between the two groups with P <0.05 to be significant. RESULTS: There were no significant differences in the clinical background between the two groups. There were significant differences in the volume of blood loss (Group Cryo 544 +/- 233 ml, Group FFP 888 +/- 339 ml), requirements of FFP (Group Cryo 0.6 +/- 1.7 unit, Group FFP 4.3 +/- 6.0 unit) in ICU. CONCLUSIONS: Cryoprecipitate transfusion is an effective treatment for coagulopathy caused by dilution of coagulation factors after cardiopulmonary bypass.

Evaluation of the Physiological Corneal Intrastromal Riboflavin Concentration and the Corneal Elastic Modulus After Violet Light Irradiation.

Purpose: KeraVio is a corneal crosslinking treatment modality that utilizes violet light (VL)-emitting glasses and topical epithelium-on riboflavin administration. We focus on the new KeraVio protocol without riboflavin. This study aims to quantify the physiological intrastromal concentrations of riboflavin in corneas without riboflavin decreases and evaluate the biomechanics of corneas after VL irradiation. Methods: Twelve human donor corneas were included in this study and randomly categorized into four groups. The corneas underwent four imbibition techniques (physiological riboflavin without drops, epithelial [epi]-on with 0.05% flavin adenine dinucleotide [FAD], epi-off with FAD, and 0.1% riboflavin epi-off). Corneas in the FAD epi-on, FAD epi-off, and riboflavin epi-off groups were instilled with the respective solution every 2 minutes for 30 minutes. An ex vivo experiment was conducted with 24 porcine corneas arranged into three treatment groups and one control group. Corneas in the KeraVio with FAD epi-on group were treated with VL irradiation at 0.31 mW/cm2 for 4.8 hours (5.4 J/cm2) and simultaneously received FAD drops every 30 minutes during the VL irradiation. Corneas in the group with KeraVio without FAD epi-on were only treated with VL irradiation (5.4 J/cm2). Results: We identified the original physiological riboflavin of human corneal stroma at a concentration of 0.31 ± 0.03 µg/g, but its value was approximately 39-fold smaller than that in the 0.1% riboflavin epi-off group. The group with KeraVio without FAD and the standard corneal crosslinking group showed a significant increase in biomechanical stability compared with the controls, whereas the elastic modulus in the treated groups was equivalent. Conclusions: We preliminarily identified physiological riboflavin in human corneas without adding riboflavin drops. The VL exposure may strengthen the corneal biomechanics without requiring the use of additional riboflavin drops. Translational Relevance: We preliminarily identified physiological riboflavin in the human cornea without adding riboflavin drops. VL irradiation without riboflavin drops may increase the corneal stiffness using physiological riboflavin.

Use of ultra-high-resolution optical coherence tomography to detect in vivo characteristics of Descemet's membrane in Fuchs' dystrophy.

PURPOSE: To demonstrate the capability of ultra-high-resolution (UHR) anterior segment optical coherence tomography (OCT) to image Descemet's membrane (DM) and measure its thickness in vivo. (2) To evaluate the use of DM characteristics and thickness in the diagnosis of Fuchs' dystrophy. DESIGN: Case-control study. PARTICIPANTS: Twenty eyes of 12 Fuchs' dystrophy patients, 20 eyes of 13 young normal, and 20 eyes of 15 elderly normal subjects. METHODS: Subjects were imaged using novel, custom-built UHR-OCT. Images were used to describe the characteristics of DM. Custom-made software was used to measure DM thickness and central corneal thickness (CCT). Specimens of DM obtained from Fuchs' dystrophy patients who underwent endothelial keratoplasty (EK) were histopathologically examined. Regression analyses were used to assess the correlation of DM thickness measured by UHR-OCT in vivo and by light microscopy and to determine the intergroup correlations between age, CCT, and DM thickness. MAIN OUTCOME MEASURES: We assessed DM characteristics and thickness, CCT, and age. RESULTS: Using UHR-OCT, the DM seemed in normal young subjects as a single, opaque, smooth line and in normal elderly subjects as a band of 2 smooth opaque lines with a translucent space in between. In Fuchs' dystrophy, DM appeared as a thickened band of 2 opaque lines; the anterior line was smooth whereas the posterior line had a wavy and irregular appearance with areas of localized thickenings. The DM thickness measured in vivo by UHR-OCT correlated significantly with that measured by light microscopy in 5 Fuchs' dystrophy eyes that underwent EK. The average central thicknesses of DM in normal young, in normal elderly and in Fuchs' dystrophy eyes were 10+/-3, 16+/-2, and 34+/-11 microm, respectively (P<0.001). There was a significant correlation between age and DM thickness only in normal groups. In Fuchs' dystrophy patients, there was a significant correlation between CCT and DM thickness that was not significant for normal groups. CONCLUSIONS: Ultra-high-resolution OCT is an innovative technique for the in vivo imaging of DM. Determining DM characteristics and thickness by UHR-OCT could be a new approach for the diagnosis of Fuchs' dystrophy.

Intraoperative use of three-dimensional spectral-domain optical coherence tomography.

BACKGROUND AND OBJECTIVE: To develop a prototype three-dimensional anterior segment spectral-domain optical coherence tomography (SD-OCT) device and demonstrate the feasibility of its use in the operating room. PATIENTS AND METHODS: Single-institution interventional case series including six consecutive patients undergoing Descemet's stripping automated endothelial keratoplasty (DSAEK). The prototype anterior segment SD-OCT was used intraoperatively to search for the presence of interface fluid between the host cornea and the DSAEK graft. RESULTS: Anterior segment SD-OCT was successfully used intraoperatively during DSAEK. After the initial placement of the graft, no fluid was clinically apparent; however, interface fluid was identified by anterior segment SD-OCT in two of the six cases. After additional aspiration, all patients were fluid-free on follow-up anterior segment SD-OCT scanning. CONCLUSION: Intraoperative anterior segment SD-OCT was used successfully to find interface fluid that was clinically undetectable under the microscope. As such, all patients were able to leave the operating room with a fully attached graft.

Experimental model for analyzing cutting resistance by various knives for cataract surgery.

BACKGROUND: The trend in current cataract surgery towards clear corneal incision and sutureless procedures makes us realize the importance of wound construction. For optimal surgical outcomes, we need good surgical instruments. In this study, we employed a resistance recording system to analyze the characteristics of seven commercially available disposable cataract knives and to find clues for the future development of 'good' cataract knives. METHODS: The cutting resistance was recorded during perpendicular penetrations of porcine scleral tissues by cataract knives. This data was processed and analysed mathematically with MATLAB software (The MathWorks, Inc, Natick, MA, USA) to see the resistance wave shapes and their derivatives to show the products' differing characteristics. RESULTS: The wave shapes demonstrated product-dependent characteristics. The average maximum penetration resistance varied from 86.4 to 233 mN. The first order time derivatives also showed distinctive wave shapes. CONCLUSION: We used an experimental model to analyze one aspect of a knife's character. This model can help give clues for future developments, although this is the initial step.

Complications of LASIK flaps made by the IntraLase 15- and 30-kHz femtosecond lasers.

PURPOSE: To describe complications associated with femtosecond laser-assisted flap creation in LASIK surgery. The management and visual outcomes of femtosecond laser complications related to flap creation in LASIK patients are also described. METHODS: All eyes that underwent LASIK with the IntraLase femtosecond laser from September 2003 to June 2006 at a university-based refractive center were included in this retrospective, noncomparative, interventional case series and IntraLase-related LASIK complications are described. All flaps were made with the 15- and 30-kHz IntraLase femtosecond laser. RESULTS: Included in the study were 4772 eyes, of which 44 (0.92%) eyes had direct or indirect complications due to flap creation. Thirty-two eyes had indirect complications (diffuse lamellar keratitis [DLK] and transient light sensitivity)--20 (0.42%) eyes developed DLK (stage 1 to 2) and 12 (0.25%) eyes had transient light sensitivity syndrome. Twelve (0.25%) eyes had direct femtosecond laser flap-related complications--8 (0.17%) eyes had premature breakthrough of gas through the epithelium within the flap margins, 3 (0.06%) eyes had incomplete flaps due to suction loss, and 1 (0.02%) eye had irregular flap due to previous corneal scar. CONCLUSIONS: Less than 1% of eyes had direct or indirect complications due to femtosecond laser flap creation. Laser in situ keratomileusis complications specifically related to the IntraLase femtosecond laser did not cause loss of best spectacle-corrected visual acuity in any eyes.

Femtosecond-assisted astigmatic keratotomy for post-keratoplasty irregular astigmatism.

We describe the technique of femtosecond-assisted astigmatic keratotomy (AK) in a post-keratoplasty patient with irregular, nonorthogonal astigmatism. Using the keratoplasty software, an anterior arcuate side cut (400 mum thick, 6.5 mm diameter) was created using the femtosecond laser in a 68-year-old woman with irregular astigmatism 28 years after penetrating keratoplasty for keratoconus. No intraoperative or postoperative adverse events were seen during the follow-up period. Six months after the procedure, the uncorrected visual acuity improved from 20/60 to 20/50 and the best spectacle-corrected visual acuity, from 20/50 to 20/32. The mean manifest astigmatic correction decreased from 4.00 diopters (D) to 0.50 D; corneal topography showed a significant improvement in irregular astigmatism. The technique of femtosecond-assisted AK is simple and efficient for managing irregular and nonorthogonal astigmatism in post-keratoplasty patients and may overcome the limitations of earlier techniques.

Second femtosecond laser pass for incomplete laser in situ keratomileusis flaps caused by suction loss.

PURPOSE: To examine the technique of second-pass femtosecond laser to correct an incomplete flap during laser in situ keratomileusis. SETTING: Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida, USA. METHODS: Twenty porcine eyes were assigned to 1 of 4 groups. In the first 2 groups, a flap was created with a femtosecond laser with a centrally black-painted applanator at a 200 microm depth; a second flap was created at a 400 microm depth with the normal applanator. These groups differed by waiting or not waiting for the opaque bubble layer (OBL) to clear. In the third and fourth groups, the eyes were separated into those with and without OBL; however, the same depth was used for the second pass, which was performed after intentional suction loss. After these treatments, the corneas were examined using anterior segment optical coherence tomography (AS-OCT) and the surgical microscope. RESULTS: In the first group (did not wait for OBL to clear), the peripheral shallow cut and the central deep line were observed in the AS-OCT images, with corresponding findings under the surgical microscope. In the second group (waited for OBL to disappear), there were 2 parallel lines on the AS-OCT images; the lines corresponded to dual flaps. In the third and fourth same-depth-cut tests, lines and irregularities were seen on the bed and the back of the flap. CONCLUSION: A second femtosecond laser pass for incomplete flaps, especially when the OBL has cleared, may result in an uneven lamellar cut.

Flap amputation with phototherapeutic keratectomy (PTK) and adjuvant mitomycin C for severe post-LASIK epithelial ingrowth.

PURPOSE: To report a patient with severe post-laser in situ keratomileusis (LASIK) epithelial ingrowth and keratolysis treated with flap amputation and phototherapeutic keratectomy (PTK) with adjuvant intraoperative mitomycin C (MMC). METHODS: Case report. RESULTS: A 55-year-old woman was referred to our department due to severe post-LASIK epithelial ingrowth with corneal melting 2 years after primary LASIK. The patient had had two previous attempts for epithelial ingrowth treatment (flap lift and epithelial ingrowth manual removal) that were unsuccessful. Slit lamp biomicroscopy and anterior segment optical coherence tomography showed extensive epithelial ingrowth and keratolysis (thinning of the LASIK flap) while the patient had photophobia and could not tolerate contact lenses. Flap amputation with subsequent PTK (in order to smooth out the corneal irregularities caused by the keratolysis and/or variations in flap thickness) and adjuvant intraoperative MMC application for 2 minutes was performed. There were no intra- or postoperative adverse events seen during the follow-up period. Six months after the procedure, uncorrected visual acuity improved to 20/40 compared with 20/50 preoperatively, while best spectacle-corrected visual acuity improved from 20/40 to 20/32. The topographic astigmatism was decreased from 3.24 diopters (D) to 1.00 D. CONCLUSIONS: Flap amputation with PTK and adjuvant intraoperative MMC is an option for the management of severe post-LASIK epithelial ingrowth with keratolysis.

Femtosecond laser-assisted sutureless anterior lamellar keratoplasty.

PURPOSE: To report the technique and small case series results of femtosecond laser-assisted sutureless anterior lamellar keratoplasty (FALK) for anterior corneal pathology. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Twelve consecutive eyes from 12 patients with anterior corneal scarring. INTERVENTION: Femtosecond laser-assisted sutureless anterior lamellar keratoplasty. MAIN OUTCOME MEASURES: Measured parameters included femtosecond laser settings, technique, uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), and complications. RESULTS: Mean follow-up was 12.7 months (range, 6-24). No intraoperative complications were found. Uncorrected visual acuity (VA) improved in 7 eyes (58.3%) compared with preoperative VA. The mean difference between preoperative and postoperative UCVAs was a gain of 2.5 lines (range, unchanged-7 lines). Best-corrected VA was unchanged or improved in all eyes compared with preoperative levels. The mean difference between preoperative and postoperative BCVAs was a gain of 3.8 lines (range, unchanged-8 lines). In 2 eyes, adjuvant surgical procedures were performed (one treated with phototherapeutic keratectomy and the other with photorefractive keratectomy). Six patients (50%) developed dry eye after FALK, which improved during the follow-up period. No graft rejection, infection, or epithelial ingrowth was found in this series of patients. CONCLUSIONS: Femtosecond laser-assisted sutureless anterior lamellar keratoplasty could improve UCVA and BCVA in patients with anterior corneal pathology.

Subconjunctival gas bubble Formation during LASIK flap creation using femtosecond laser.

PURPOSE: To report a patient who developed subconjunctival gas bubble formation during creation of a LASIK corneal flap with the IntraLase femtosecond laser. METHODS: Case report of a 19-year-old-man with compound myopic astigmatism and a normal preoperative evaluation who underwent bilateral simultaneous LASIK. RESULTS: The IntraLase FS15 was used to create an 8.8-mm diameter superior flap. Laser settings were 110-microm depth, 1.70-mJ bed and side-cut energy, 12-microm spot separation, 10-microm line separation, 70 degrees side-cut angle, 240-microm pocket start width, and 200-microm pocket start depth. The procedure was uneventful in the right eye whereas subconjunctival air bubbles were observed along the corneal limbus in the left eye (no bubbles were seen in the peripheral cornea). The patient was examined 30 minutes later, and the subconjunctival bubbles could still be observed. By the next day, the bubbles had disappeared completely. Postoperative uncorrected visual acuity was 20/20 in both eyes. CONCLUSIONS: Subconjuctival bubbles can be found after LASIK flap creation with a femtosecond laser.

Epithelial breakthrough during IntraLase flap creation for laser in situ keratomileusis.

We report the clinical manifestations and outcomes in 4 patients who experienced premature gas-bubble leakage during raster lamellar dissection during IntraLase femtosecond laser corneal flap creation. Three patients experienced a full-thickness epithelial breakthrough and the fourth, a flap tear. The patient who experienced the flap tear was unable to have laser in situ keratomileusis successfully. The flap complications did not result in a decreased best corrected visual acuity in any patient but may have resulted in epithelial ingrowth in one and a corneal scar and microstriae in another. Potential predisposing factors for epithelial breakthrough, the incidence of epithelial breakthrough, and methods for avoiding and salvaging traumatic corneal flaps are discussed.

Tacrolimus ointment 0.03% in the eye for treatment of giant papillary conjunctivitis.

PURPOSE: To report a case of refractory giant papillary conjunctivitis (GPC) treated by using topical tacrolimus 0.03% ointment. METHODS: A 16-year-old white boy with a history of GPC was referred to our department for severe GPC with eye itching, tearing, photophobia, discharge, and blepharospasm. The patient had received previous treatments with antihistamines, mast cell stabilizers, topical corticosteroid ointments, and surgical resection-cryopexy of GPC that were ineffective. RESULTS: Topical tacrolimus 0.03% ointment (Protopic; 0.5 cm) was applied into the lower fornix twice a day. An improvement of the patient's symptoms was observed during the first 5 days of therapy, and the GPC was resolved within 15 days. After 1 month of continued topical tacrolimus ointment treatment, there was no evidence of GPC. Topical tacrolimus was tapered during the next 2 months. Six months after treatment, there were no GPC findings, and no side effects were reported. CONCLUSIONS: Topical tacrolimus 0.03% ointment for severe GPC, refractory to conventional therapy, appears to be an effective alternative treatment.