Rapid keratitis and perforation after corneal collagen cross-linking.

PURPOSE: To describe a case of rapid keratitis and corneal perforation after epithelium off collagen cross-linking. OBSERVATIONS: We report a case of a 17-year-old male who underwent collagen cross-linking with the protocol and device approved by the United States Food and Drug Administration (FDA) that developed a corneal infiltrate 3 days after the procedure. He later developed corneal thinning and perforation on day 5 requiring the use of cyanoacrylate glue and a Kontur lens. Despite initial improvement in the infiltrate with fortified antibiotics he later had leakage of aqueous around the glue and a flat chamber requiring an emergent penetrating keratoplasty on postoperative day 16. CONCLUSION AND IMPORTANCE: While collagen cross-linking has been very effective for treating keratoconus and is being recommended more frequently since FDA approval in the United States, severe complications such as corneal perforation requiring early transplant can still occur.

Clinical Outcomes and Intraocular Pressure Control After Scleral-glued Intraocular Lens Insertion in Eyes With Pseudoexfoliation.

PURPOSE: To analyze clinical outcomes and intraocular pressure control following scleral-glued intraocular lens (IOL) fixation in eyes with pseudoexfoliation (PXF). METHODS: A retrospective chart review and outcome analysis was performed on a series of eyes undergoing glue-assisted, scleral-fixated (scleral-glued) IOL insertion in the setting of PXF and poor or absent capsular support. RESULTS: In total, 28 eyes were included in the study. The indications for scleral-glued IOL fixation included late endocapsular IOL dislocation (21/28, 75%), exchange for iris-fixated IOL due to complication (4/28, 14%), subluxed crystalline lens (2/28, 7%), and aphakia after complicated cataract surgery (1/28, 4%). In total, 15/28 (54%) eyes had diagnosed preexisting glaucoma at the time of scleral-glued surgery. The most common postoperative complication was ocular hypertension requiring escalation of medical management, which occurred in 8/28 (29%) eyes. At final follow-up, corrected distance visual acuity was equivalent to or improved from preoperative measurements in 25/28 (89%) eyes. CONCLUSIONS: The scleral-glued surgery is a good option for fixating an IOL in eyes with PXF and poor zonular integrity or absent capsular support. Special attention should be placed on intraocular pressure control following surgery, which can be less predictable in PXF eyes with or without preexisting glaucoma.

Ipsilateral Ophthalmic and Cerebral Infarctions After Cosmetic Polylactic Acid Injection Into the Forehead.

A 55-year-old woman developed no light perception vision in her right eye 5 days after an injection of polylactic acid cosmetic filler into her right forehead. Diffuse corneal edema and anterior chamber inflammation prohibited any view to the posterior segment to identify the cause of her profound vision loss. MRI of the orbits with diffusion-weighted imaging showed hyperintensity of the right optic nerve with signal reduction on apparent diffusion coefficient mapping, consistent with ischemia. Our patient also was found to have acute infarctions in the distribution of the right anterior cerebral artery on MRI of the brain despite having no permanent focal neurologic deficits aside from vision loss.

The Use of Ozurdex (Dexamethasone Intravitreal Implant) During Anterior Segment Surgery in Patients with Chronic Recurrent Uveitis.

PURPOSE: To describe the outcomes of concurrent Ozurdex implantation during anterior segment surgery in patients with chronic recurrent uveitis. METHODS: Retrospective chart review. Data recorded from preoperative and 1-, 3-, and 6-month postoperative visits included visual acuity, intraocular pressure (IOP), medications, and clinical examination findings of inflammation. RESULTS: Twelve patients (12 eyes) with chronic, recurrent noninfectious uveitis undergoing cataract extraction (n=9) or intraocular lens (IOL) explantation (n=3) were included. Mean duration of follow-up after Ozurdex implantation was 12.9 months. There was a significant reduction (n=10, P=0.02) in the average number of inflammation recurrences 6 months before surgery compared to 6 months after surgery with Ozurdex in affected eyes. IOP remained stable in the postoperative period. One patient undergoing anterior chamber IOL (ACIOL) explantation experienced migration of Ozurdex into the anterior chamber resulting in corneal edema that resolved after 1 month. CONCLUSIONS: Ozurdex safely and effectively controlled postoperative inflammation in eyes with chronic recurrent uveitis when concurrently implanted during anterior segment surgery in our patients. Caution should be exercised in cases of IOL explantation, as Ozurdex use is now contraindicated in eyes with posterior capsule rupture and ACIOLs.

Topical Cyclosporine A 1% for the Treatment of Chronic Follicular Conjunctivitis.

OBJECTIVE: To evaluate the use of topical cyclosporine A (CSA) 1% in the treatment of chronic follicular conjunctivitis (CFC). METHODS: Retrospective chart review from 2001 to 2012 identified 12 patients (22 eyes) with CFC (mean ± standard deviation [SD] age, 50.2 ± 15.4 years; 75% female; 92% white) treated with CSA. Main outcome measures included inflammation grade, visual acuity, concurrent corticosteroid (CS) therapy, effect on CS taper, and adverse effects. RESULTS: Mean ± SD follow-up time was 11.7 ± 9.7 months. Mean ± SD time from diagnosis to CSA treatment initiation was 2.4 ± 3.2 months. Mean ± SD duration of CSA treatment was 5.8 ± 2.8 months. Four patients (33%) complained of irritation (n = 2), redness (n = 1), itching (n = 1), and burning (n = 1) but none discontinued treatment. Concurrent CSs were tapered off in all patients after a mean ± SD of 5.0 ± 2.5 weeks. Mean ± SD initial vision was 0.078 ± 0.093 logMAR, whereas vision at final examination was 0.056 ± 0.081 logMAR (P = 0.02). Mean ± SD initial inflammation grade of 1.9 ± 1.0 was significantly reduced to final grade of 0.7 ± 0.9 (P = 0.0002). Mean ± SD time to initial inflammation control in 9 patients (75%) was 33.2 ± 24.5 days. Two patients (17%) switched to oral CSA because of lack of inflammation control. CONCLUSIONS: Topical CSA 1% is an effective and well-tolerated therapy that decreased chronic inflammation and tapered topical CS in patients with CFC. The use of CSA in such patients warrants further investigation.

Pediatric orbital hemangiopericytoma associated with trisomy 15.

We report a case of an orbital hemangiopericytoma (HPC) in a female infant diagnosed at 7 weeks of age. Cytogenetic analysis of the tumor revealed trisomy 15. To the authors' knowledge, this is only the second reported case of this chromosomal aberration being associated with HPC, both cases occurring in infants.

Topical cyclosporine a 1% for the treatment of chronic ocular surface inflammation.

OBJECTIVE: To evaluate the use of topical cyclosporine A (CsA) 1% emulsion in the treatment of chronic ocular surface inflammation (OSI). METHODS: We conducted a retrospective chart review of patients with various forms of OSI treated with topical CsA 1% from 2001 to 2012. RESULTS: Twenty-nine patients (52 eyes) with various forms of OSI, including epidemic keratoconjunctivitis (n=14), chronic follicular conjunctivitis (n=12), Thygeson superficial punctate keratopathy (n=2), and vernal keratoconjunctivitis (n=1), were included. Twenty-seven patients had inflammation refractory to prior therapies. Twenty-four patients received concurrent medications with CsA 1%. Twenty-three of 24 patients on concurrent corticosteroids (CS) were able to taper their use while receiving CsA 1%. Thirteen patients experienced ocular discomfort with CsA 1%; one patient discontinued therapy all together as a result of these side effects; another switched to CsA 0.5% with improvement of adverse symptoms. Inflammation was controlled in 22 (92%) of the 24 patients who received CsA 1% for at least 2 months in duration. CONCLUSION: Topical CsA 1% helps to control inflammation and spares CS use in patients with chronic OSI.

Treatment of chronic, noninfectious, nonnecrotizing scleritis with tumor necrosis factor alpha inhibitors.

PURPOSE: To evaluate the use of TNF-alpha inhibitors for non-infectious, non-necrotizing scleritis. METHODS: We conducted a retrospective chart review of patients with non-infectious, non-necrotizing scleritis treated at our institutions from 2002 to 2012. RESULTS: Seventeen patients (26 eyes) were included. Ten patients were started on infliximab and seven on adalimumab; five patients were treated with both TNF-alpha inhibitors on separate occasions. All patients had an associated autoimmune disease. Control of active inflammation for at least 2 months was achieved in 15 (88%) of 17 patients. Seven out of eight patients successfully tapered concurrent corticosteroid use. Only one patient discontinued TNF-alpha inhibitor use due to an allergic reaction. CONCLUSIONS: TNF-alpha inhibitors appear to have a role in managing non-infectious, non-necrotizing scleritis refractory to initial therapy, mainly by reducing inflammation and decreasing concurrent CS use.

Characteristics, outcomes, and prognostic indicators of fall-related open globe injuries.

PURPOSE: To describe characteristics and outcomes of fall-related open globe (OG) injuries. METHODS: A total of 602 patients (603 eyes) presenting with OG injuries were included. Among them, 85 wounds (85 patients) were fall-related, which were compared with the nonfall-related OG injuries (control group). RESULTS: The mean patient age in the fall group was 65.8 years, which was higher than the control population (35.8 years; P < 0.001). Most of the fall-related injuries occurred in women (58.8%). The most common zone injured in both groups was Zone I (38.8% and 46% in the fall and control group, respectively). Compared with the control group, patients with fall-related OG injuries had a worse visual acuity on admission and at final visit (P < 0.001). The authors performed regression analysis to characterize factors associated with developing no light perception and need for enucleation. Injuries involving Zone III and presenting vision of no light perception were associated with a higher rate of no light perception. Similarly, patients presenting with no light perception were more likely to undergo enucleation, eventually. CONCLUSION: Fall-related OG injuries can lead to severe ocular morbidity especially in the elderly patients. They carry a worse visual prognosis compared with other injuries, which emphasizes on the importance of protective measures in this population.

Cyclo-oxygenase inhibitors in the treatment of chronic non-infectious, non-necrotizing scleritis and episcleritis.

PURPOSE: To evaluate the use of selective vs. non-selective cyclo-oxygenase inhibitors (COXIs) for the treatment of chronic non-infectious, non-necrotizing scleritis and episcleritis. METHODS: Sixty-nine patients with scleritis and episcleritis treated for ≥2 months with COXIs were included. Outcome measures were rates of inflammation control, corticosteroid sparing, and COXI discontinuation, as well as side effects. RESULTS: Initial inflammation control was achieved in 78-81% of scleritis patients and 73-80% episcleritis patients on COXIs (p > .05). Rates of steroid sparing after 4-24 months of consecutive treatment were similar. Gastrointestinal side effects were observed in 1 (2.7%) patient on selective vs. 3 (9.4%) patients on non-selective COXIs (p = .33). Overall discontinuation rate was 6/37 (16%) for selective vs. 7/32 (22%) for non-selective COXIs (p = .76). CONCLUSIONS: Selective vs. non-selective COXIs were equally efficacious for the treatment of chronic non-infectious, non-necrotizing scleritis and episcleritis. Prospective studies to elucidate potential differences in side effect profiles may be warranted.

Mycophenolate mofetil in the treatment of chronic non-infectious, non-necrotizing scleritis.

PURPOSE: To determine the effectiveness and corticosteroid (CS) sparing capabilities of mycophenolate mofetil (MMF) in the treatment of chronic non-infectious, non-necrotizing scleritis. METHODS: A retrospective chart review of patients treated for scleritis at the Institute of Ophthalmology and Visual Science at New Jersey Medical School was performed. Only those patients taking MMF for greater than or equal to six consecutive months were included. Main outcome measures were rate of inflammation control, CS, and MMF discontinuation, as well as visual acuity and side effects. RESULTS: Twenty-two patients (32 eyes) were included in the study. Mean ± SD age was 53.5 ± 13.3 years. Twenty (91%) patients had previously failed some form of immunomodulatory therapy. After 6, 12, 18, and 24 months of consecutive MMF treatment, 91-100% of patients achieved inflammation control. Mean time to resolution of inflammation was 2.8 months, while mean duration of inflammation control was 14.8 months. CS sparing was achieved in 100% of patients at each time point, with mean starting CS dose decreased by 91% at final visit. Vision was stable or improved in 24 (75%) eyes. Fourteen (64%) patients reported side effects including leucopenia (n = 7), gastrointestinal upset (n = 4), abnormal liver function tests (n = 3), and abnormal renal function tests (n = 2). None required hospitalization or medical treatment. Four (18%) patients discontinued MMF due to side effects (n = 3) and treatment ineffectiveness (n = 1). CONCLUSION: MMF is an effective and well-tolerated therapy that can successfully reduce inflammation and decrease CS use in the treatment of chronic non-infectious, non-necrotizing scleritis.