Granulomatous uveitis and congenital cataract: a rare association.

INTRODUCTION: The association of a granulomatous uveitis and congenital cataract and is rarely observed in newborn children. We describe the history of two patients presenting simultaneously with these two features in the absence of a TORCH infection. PATIENTS AND METHODS: The first patient, a boy born in 1997, presented to our hospital two days after birth with multiples Koeppe's and Busacca's nodules and bilateral cataract. The second patient, a boy born in 2006, was referred two weeks after birth. He presented with a severe unilateral granulomatous uveitis, multiples iris nodules, a high intraocular pressure of 45 mmHg and a congenital cataract. THERAPY AND OUTCOME: Lens extraction produced a rapid resolution of uveitis in these two patients. TORCH infection was ruled out in both children by history, extensive serologies performed simultaneously in mother and child or PCR of ocular fluids. CONCLUSIONS: A congenital cataract associated with a granulomatous uveitis is an extremely rare association. The removal of the lens resulted in complete resolution of the inflammation: a phacogenic mechanism could be at the origin of ocular inflammation in both cases.

Combined meropenem and linezolid as a systemic treatment for postoperative endophthalmitis.

PURPOSE: The aim of this study was to evaluate the antibiotic treatment of postoperative endophthalmitis with combined systemic meropenem and linezolid. METHODS: A retrospective analysis of endophthalmitis treated with systemic meropenem and linezolid compared to conventional systemic antibiotics by evaluation of outcome and adverse effects was carried out. RESULTS: 26 patients with unilateral postoperative endophthalmitis with a systemic combination regimen of meropenem (2 g TID, mean duration of treatment 5.5 days) and linezolid (600 mg BID, mean duration of treatment 8.9 days) (group 1, mean follow-up time 140 days) were included in this study and compared to 45 postoperative endophthalmitis patients treated with conventional systemic antibiotics (group 2; mean follow-up time 320 days). In group 1, 69.2 % of eyes additionally received intravitreal amikacin and vancomycin (vs. 24.4 % in group 2; p < 0.001), in 92.3 % pars plana vitrectomy was performed (vs. 68.9 % in group 2, p = 0.047). Mean best corrected visual acuity improved from a baseline of 1.76 logMar for group 1 and 1.83 logMar for group 2 to 0.91 logMar (p = 0.0001) and 0.90 logMar (p < 0.0001), respectively, at the end of the follow-up, revealing no significant differences between the two groups at any time point (p > 0.05). Ocular complications were observed in 34.6 % of eyes in group 1 (vs. 37.8 % in group 2; p > 0.05). Adverse drug effects occurred significantly more frequently in group 1 (26.9 % vs. 4.4 % p = 0.02). CONCLUSION: In spite of the reported better penetration through the blood-ocular barrier and the broader antibacterial spectrum of meropenem and linezolid, no benefit in outcome was found in the present study. In contrast, adverse effects and costs of the combination regimen were significantly higher.

Prospective, randomized clinical evaluation of Optisol vs organ culture corneal storage media.

OBJECTIVE: To compare the outcome of penetrating keratoplasty with the use of corneas stored either in Optisol (Chiron Ophthalmics, Irvine, Calif) or in organ culture. METHODS: Penetrating keratoplasty was performed on 12 pairs of patients matched by age and diagnosis. Each pair of procedures was done on the same day by the same surgeon using the same technique. Twelve pairs of corneas were used. One cornea of each pair had been stored in organ culture at 36 degrees C and one in Optisol at 4 degrees C. Mean (+/-SD) storage time was 6+/-3 days. Mean endothelial cell density before storage was 2617/mm(2) for the corneas in organ culture and 2624/mm(2) for the corneas in Optisol. Examinations were performed at 1, 4, 12, and 24 months. RESULTS: One reversible rejection occurred in the Optisol group. At 1 month the mean endothelial cell density was 2327+/-341/mm(2) for the organ culture group and 2240+/-504/mm(2) for the Optisol group. At 12 months the difference was more pronounced (2225+/-410 and 2103+/-466/mm(2), respectively), although statistically not significant. Corneal thickness also did not show any statistically significant difference. CONCLUSION: Penetrating keratoplasty performed with corneas stored for a maximum of 11 days in either Optisol or organ culture show similar outcomes in the first 2 postoperative years. Arch Ophthalmol. 2000;118:757-760

In vivo confocal microscopy after photorefractive keratectomy in humans. A prospective, long-term study.

OBJECTIVE: To assess corneal morphological characteristics in vivo after photorefractive keratectomy (PRK) in humans. METHODS: Eighteen eyes were examined before and after PRK by means of in vivo confocal microscopy. Epithelial, stromal, and endothelial morphological characteristics were recorded. Minimum follow-up was 12 months. RESULTS: Immediately after PRK, the anterior stroma showed marked intercellular edema. At 1 month, fine linear structures were noted in the anterior stroma and midstroma, and a thin hyperreflective scar was present. The linear structures and the scar tissue were more marked at 4 months but were still present up to 26 months. Anterior stromal keratocyte density increased significantly 1 and 4 months after PRK, whereas midstromal and posterior keratocytes and endothelial cell densities did not change. Basal epithelial nerves were recognizable as early as 1 month after PRK. Contact lens-related microdots in the stroma remained unaffected. CONCLUSIONS: The stromal linear structures represent a finding that is detectable only by confocal microscopy at high magnification, is not related to previous contact lens wear, and is still visible 26 months after PRK. The extension of these structures as far as the midstroma indicates that the permanent corneal changes caused by PRK affect deeper stromal layers than the immediate subepithelial region.

11-0 mersilene as running suture for penetrating keratoplasty.

We evaluated astigmatic results and complications of the combined suturing technique in penetrating keratoplasty by using 11-0 Mersilene as a running suture. Twenty-seven grafts were studied for a follow-up that ranged between ten and 46 months (mean, 27.2 months). During the study, complications included three graft failures, one instance of inadvertent breakage of the running suture, one instance of one suture bite cutting through the recipient cornea, and suture microabscesses in two eyes. Keratometric astigmatism was 2.5 +/- 2.1 diopters at six months, was 2.4 +/- 2.3 diopters at 12 months, and was 2.5 +/- 2.0 diopters at 24 months. Our data indicate that 11-0 Mersilene is suitable for the running suture in corneal transplants in the combined technique. Spontaneous suture dissolution did not occur throughout the follow-up period. The use of a less biodegradable suture enables the maintenance of low levels of astigmatism for longer periods when compared with a previous study that used 11-0 nylon suture.

Running nylon suture dissolution after penetrating keratoplasty.

We attempted to evaluate whether the low degrees of astigmatism achieved early in the postkeratoplasty period with the combined interrupted/running suturing technique were maintained for long periods of time. For 13 to 70 months (mean, 30.2 months), we monitored a group of patients (25 eyes) who had previously undergone the combined interrupted/running suturing technique (12 interrupted 10-0 nylon sutures and one running 11-0 nylon suture). Nine running sutures broke spontaneously, causing a significant increase of the keratometric astigmatism of the entire population from 1.7 +/- 1.6 to 3.4 +/- 2.6 diopters (mean +/- standard deviation). The mean vector-corrected change in astigmatism after suture breakage was 4.9 +/- 2.6 diopters. Surgical procedures to reduce astigmatism were required in many of the eyes in which the 11-0 running nylon suture broke. Our results suggested that 11-0 nylon is not an ideal material for the running suture because its high rate of spontaneous disruption leads to undesired, statistically significant increases in postkeratoplasty astigmatism. Further, our results indicated that the selective suture technique can maintain low degrees of astigmatism only if the sutures remain intact. Studies of the effect of keratoplasty suturing techniques on astigmatism should probably include a follow-up that is sufficiently long to indicate its long-term value to the patient.

Morphology of the stromal surface and endothelium using two different microkeratomes.

PURPOSE: To compare stromal surface and endothelial morphology after keratectomies and after laser in situ keratomileusis (LASIK), using two different microkeratomes. METHODS: Keratectomies (160-microm and 400-microm) were performed on 82 enucleated porcine eyes using the Chiron Automated Corneal Shaper (52 eyes) and the Microtech Turbokeratome (30 eyes). LASIK procedures of -9.00 D, -27.00 D, and -36.00 D were performed with a Schwind excimer laser. The corneas were immediately fixed in glutaraldehyde or stained with alizarin red and trypan. Scanning electron microscopy was then performed. RESULTS: All keratectomies performed with the Chiron microkeratome displayed a relatively smooth surface. The quality of the keratectomies with the manually advanced Microtech microkeratome was variable, with a high incidence (4 of 9) of incomplete cuts and irregular surfaces. In the eyes in which the stromal laser ablation was performed, a thin layer of condensed stroma (pseudomembrane formation) was seen. Vital staining did not indicate endothelial damage. CONCLUSIONS: The surface morphology was unacceptable for one of the microkeratomes tested. Keratectomies of 160 to 400 microm and LASIK up to -36.00 D did not acutely alter endothelial morphology in porcine eyes.

Transplantation of congenitally opaque corneas.

AIMS: To assess retrospectively the prognosis and complications of corneal grafting for congenital opacities. METHODS: Fifty eight eyes of infants and young children with congenital corneal opacities were studied retrospectively. Preoperative diagnoses included sclerocornea (27 eyes), Peters' anomaly (17 eyes), partial sclerocornea (12 eyes), and congenital glaucoma (two eyes). Penetrating keratoplasty was performed between 5 days and 65 months of age with a mean follow up of 40 (SD 29) months. RESULTS: The overall success (including regrafts) was 70% in eyes with sclerocornea, 83% for partial sclerocornea, and 100% for Peters' anomaly. However, 23 eyes had to be regrafted between 2 weeks and 110 months postoperatively. The probability of maintaining a clear graft, calculated by survival analysis, was 75% (SE 6%) at 1 year and 58% (7%) at 2 years for the entire group. Complications included cataract development (12 eyes), secondary glaucoma (14 eyes), epithelial defects (six eyes), band keratopathy (five eyes), retinal detachment (three eyes), wound leakage (two eyes), retrocorneal membrane (one eye), and microbial keratitis (two eyes). CONCLUSIONS: It is concluded that corneal grafting for congenital opacities in infants has an excellent potential for long term survival and should be performed as early as possible for unilateral as well as bilateral involvement. The postoperative course is complex and often requires regrafting.

Corneal grafting of donor tissue preserved for longer than 4 weeks in organ-culture medium.

In vitro viability of the endothelium of corneas stored in organ-culture medium is longer than in other storage techniques. This article reports on the clinical results of 20 penetrating keratoplasties performed using corneas stored for > 4 weeks in organ culture. Seventeen of the procedures were elective and three were emergencies. Mean preservation time was 35.6 +/- 7 days (mean +/- SD) and mean follow-up was 16.2 months. During preservation, an endothelial cell loss of 10% was noted. Seventeen grafts remained transparent, and three failed between 3 and 24 months postoperatively. Mean endothelial cell density was 2,153 +/- 372/mm2 at 4 months and 1,854 +/- 390/mm2 at 12 months. Central pachymetry was 548 +/- 53 microns at 4 months and 528 +/- 57 microns at 12 months after surgery. Corneas stored for up to 48 days in organ culture can be used in elective as well as in emergency procedures.

In vivo confocal microscopy of fleck dystrophy.

PURPOSE: To use in vivo confocal microscopy to evaluate corneas with fleck dystrophy. METHODS: Both eyes of three patients with corneal fleck dystrophy were examined with a scanning slit confocal microscope. Corneal epithelium, stroma, and endothelium were evaluated, as well as the basal epithelial and stromal nerves. RESULTS: The epithelium did not show any anomalies, but the basal nerves showed hyperreflective inclusions. Throughout the entire stroma, hyperreflective dots of various shapes were seen. These consisted mostly of spherical matter with a diameter of 3-5 microm and were sometimes enclosed in cyst-like structures. The majority of the stromal cells and stromal nerves appeared normal. The endothelial cell layer was unaffected. CONCLUSION: In vivo confocal microscopy demonstrates previously unreported inclusions in the basal nerves of fleck dystrophy corneas. In addition to this new finding, the study confirms earlier histopathologic reports, demonstrating accumulation of pathologic material in the stromal cells.

Treatment of postkeratitis fusarium endophthalmitis with amphotericin B lipid complex.

PURPOSE: The authors report the first case of Fusarium solani keratitis that progressed to fungal endophthalmitis and was successfully treated with amphotericin B lipid complex (ABLC). METHOD: The case of a 34-year-old immunocompetent woman who developed a contact lens-related F. solani keratitis requiring emergency penetrating keratoplasty (PKP) was analyzed. The immunocompetent patient developed fungal endophthalmitis (anterior chamber tap positive for F. solani three months after PKP) and was eventually treated with ABLC. RESULTS: Systemic amphotericin B (total, 0.42 g) and ketoconazole in addition to topical natamycin and amphotericin did not prove to be effective in eradicating the mycosis in the anterior chamber. Under ABLC treatment (total, 8.79 g), the anterior chamber inflammation resolved completely. No recurrence was observed during an 11-month follow-up after treatment was discontinued. CONCLUSION: ABLC proved to be effective in treating F. solani endophthalmitis. It is an important addition to the ophthalmic armamentarium, and appeared to be a better therapeutic agent than standard amphotericin B in this patient.

[Surgical correction of refractive errors]. / Chirurgische Korrektur der Fehlsichtigkeit.

This article reviews operation techniques and indications for the surgical correction of ametropia. The author also explains and lists the anomalies of refraction. The limitations of the methods as well as open questions for the future are discussed.

Comparison of oral antiviral therapy with valacyclovir or acyclovir after penetrating keratoplasty for herpetic keratitis.

AIMS: To compare the outcome of prophylactic oral valacyclovir (VAL) or oral acyclovir treatment (ACV) in patients having undergone penetrating keratoplasty for herpetic keratitis (HK). METHODS: All patients having received a penetrating keratoplasty for HK and being treated postoperatively with either oral VAL or oral ACV (inclusion period from 12/97 to 3/06 and 5/92 to 9/96, respectively) were retrospectively evaluated. Records were analysed for postoperative reactivation of recurrent HK, graft rejection, endothelial cell loss, central corneal thickness and visual acuity after a follow-up of up to 5 years. RESULTS: Twenty patients received VAL and were compared with 19 patients being treated with ACV. Two patients developed clinical signs of recurrent herpetic disease in the VAL group compared with three patients in the ACV group. Two patients from both groups each developed an irreversible graft failure. Best corrected visual acuity improved in both treatment groups from baseline (logMAR) -1.97 (VAL), -1.47 (ACV) to -0.85, -0.72, respectively, at the 1-year follow-up and slightly deteriorated after 5 years in the ACV group (-0.71 VAL vs -1.14 ACV). CONCLUSION: Prophylactic oral VAL treatment is at least as effective as ACV in preventing recurrence in patients who underwent corneal transplantation for HK. The tolerability of the two drugs is similar, but the dosing for VAL might be more comfortable for patients.

Contact lens-associated fusarium keratitis in Switzerland.

BACKGROUND: Fusarium has been an exceptionally rare cause of infectious keratitis. A recent outbreak of Fusarium keratitis in contact lens wearers in North America and Asia has been associated with the multipurpose disinfection solution ReNu with MoistureLoc (Bausch&Lomb). We report a series of Fusarium keratitis in Swiss contact lens wearers. PATIENTS AND METHODS: A multicentre retrospective case review of patients with corneal ulceration and a positive microbiological identification of Fusarium species was undertaken. RESULTS: Between September 2005 and August 2007, six cases of Fusarium keratitis were identified. Patients were 39 to 63 years of age. All patients were using disposable soft contact lenses for at least two years. Four patients used daily wear disposable lenses. Two patients were wearing 1-monthly disposable lenses and used ReNu with MoistureLoc solution. Due to multiresistant Fusarium, enucleation was required in two cases and an emergency keratoplasty was performed in three cases. An optical keratoplasty was undertaken in one case that developed corneal scarring. Final visual acuity in patients with preserved eyes ranged from light perception to 8 / 20. CONCLUSIONS: Exposure to ReNu with MoistureLoc is not the only risk factor for Fusarium keratitis. In addition to antifungal therapy, an early keratoplasty with excision of the infected tissue seems mandatory to improve prognosis.