Partial dislocation of laser in situ keratomileusis flap by air bag injury.

PURPOSE: A patient developed significant corneal complications from air bag deployment, 17 months after laser in situ keratomileusis (LASIK). METHODS: Case report, slit-lamp microscopy, and review of the medical literature. RESULTS: A 37-year-old woman underwent bilateral LASIK with resultant 20/20 uncorrected visual acuity. Seventeen months later, she sustained facial and ocular injuries from air bag deployment during a motor vehicle accident. Examination revealed bilateral corneal abrasions, partial dislocation of the right corneal LASIK flap, and a hyphema in the right eye. The LASIK flap was realigned, but recovery was complicated by a slowly healing epithelial defect and flap edema. One month following the injury, epithelial ingrowth beneath the LASIK flap was noted. Surgical elevation of the flap and removal of the epithelial ingrowth was performed. Eight months later, epithelial ingrowth was absent and the visual acuity was 20/40. Residual irregular astigmatism necessitated rigid gas permeable contact lens fitting to achieve 20/20 visual acuity. CONCLUSIONS: Air bags may cause significant ocular trauma. The wound healing response of LASIK allows corneal flap separation from its stromal bed for an indeterminate time after surgery. Discussion of the possible risk of corneal trauma as part of informed consent prior to LASIK may be appropriate.

Postoperative Rhizopus scleritis in a diabetic man.

A 50-year-old diabetic man developed necrotizing scleritis with adjacent keratitis 4 weeks after uncomplicated cataract extraction and intraocular lens implantation through a scleral tunnel incision. Cultures of the necrotic sclera grew Rizopus species. Severe destruction of the globe ensued despite topical, subconjunctival, and intravenous amphotericin B, in combination with hyperbaric oxygen therapy. Histopathological examination of the enucleated globe was consistent with Rhizopus infection. One year later, the patient was well without signs of recurrence.

Topical anesthetic abuse ring keratitis: report of four cases.

PURPOSE: We present the clinicopathologic correlations of two case and two other clinical cases of topical anesthetic abuse keratopathy that were originally diagnosed as Acanthamoeba keratitis because of ring keratitis presentation and characteristic history. METHODS: Four patients who were referred to us with suspected Acanthamoeba keratitis are included. Each was initially treated for amoebic keratitis, by using established protocols, and only later was the true origin (topical anesthetic abuse) uncovered. The clinical and surgical histories, pathologic analysis of the corneal specimens, and follow-up of < or = 4 years are included. RESULTS: Our four cases show another cause for ring infiltration of the cornea. Two cases resulted in corneal transplantation and multiple other medical or surgical treatments in an attempt to restore vision but had poor outcomes of finger-counting vision. Two other cases responded to intensive medical treatments with return of useful vision. Evaluation of the surgical specimens revealed a previously unpublished finding of near total cell death within the corneal stroma. CONCLUSION: Topical anesthetic abuse resulting in sight-threatening keratitis may be seen as a masquerade syndrome in many cases. Because of the often poor outcome, we must be aware of this entity, prevent abuse, and be vigilant in our prohibition of topical anesthetic for any therapeutic use.

Acanthamoeba infection after radial keratotomy.

PURPOSE: To describe a case of Acanthamoeba infection of the cornea after radial and astigmatic keratotomy. METHODS: A 29-year-old man developed ulcerative keratitis in the right eye 6 weeks after uncomplicated radial and astigmatic keratotomy. RESULTS: Three sets of corneal cultures for bacteria and fungi were negative. Culture on non-nutrient agar grew Acanthamoeba organisms. Clinical improvement occurred after topical antiamebic therapy was instituted. CONCLUSIONS: Incisional keratotomy may predispose the cornea to delayed-onset infectious keratitis. Acanthamoeba should be considered as a possible cause of infection and should be cultured for in refractory cases.

The combined (Genesis) technique of radial keratotomy. A prospective, multicenter study. Refractive Keratoplasty Study Group.

PURPOSE: A prospective, multicenter, clinical study to evaluate a standardized surgical (Genesis) protocol which includes combined-technique radial incisions in patients seeking reduction of their physiologic myopia. The combined incisions were designed to incorporate the safety of the centrifugal incision technique with the efficacy of the centripetal incision technique. METHODS: A total of 375 eyes undergoing radial keratotomy procedures performed in six different clinical centers were analyzed. All procedures were performed in accordance with the Genesis nomograms. The Genesis protocol called for using preoperative screening pachymetry to guide central clear zone size selection, incising the thinnest corneal quadrant first, suturing corneal perforations, and discouraged more than one enhancement procedure, when indicated. Globe fixation technique served as a study variable. RESULTS: Mean follow-up was 6.2 months (range, 1.5-12 months). Mean residual cycloplegic refraction was -0.48 +/- 0.61 diopters (D) (range, -2.50 to +1.50 D); 92% of eyes were within 1 D of the planned goal of -0.50 D and 85% were within 1 D of emmetropia; 14% were myopic; and 1% was hyperopic by more than 1 D. Uncorrected visual acuity was 20/40 or better in 95% of eyes; the remaining 5% retaining myopic refractive errors. A single procedure was performed in 73% of eyes, and 99% received less than two enhancements. Of eyes with no enhancements, 97% had uncorrected visual acuity of 20/40 or better. One study eye (0.3%) had a two-line loss of spectacle visual acuity. There were no invasions of the central clear zone. Globe fixation was a significant predictor for enhancement incidence (P < 0.001) but not for perforation incidence (P = 0.06). Incision sequence was predictive for perforation incidence (P < 0.0002). CONCLUSION: The combined-technique of radial keratotomy, coupled with the Genesis surgical protocol, affords centrifugal incision safety with centripetal incision efficacy. The Genesis nomograms, with a built in refractive outcome goal of -0.50 D provide an acceptable degree of accuracy and predictability while guarding against hyperopic overcorrection.

Bilateral transient keratoendotheliitis associated with systemic lupus erythematosus.

Numerous ocular manifestations have been attributed to systemic lupus erythematosus (SLE) and other collagen vascular diseases. Only one report has been published discussing an entity of transient corneal edema associated with SLE, which was attributed to keratoendotheliitis. We report the case of a 45-year-old woman with long-standing SLE and severe central nervous system involvement in whom bilateral transient corneal edema developed that was responsive to topical and systemic corticosteroid treatment over a four-week period. We believe this case may also represent an inflammatory keratoendotheliitis associated with SLE.

Combined treatment of Acanthamoeba keratitis with propamidine, neomycin, and polyhexamethylene biguanide.

We developed an intensive treatment regimen of topical neomycin, propamidine, and polyhexamethylene biguanide that was tapered to a maintenance level over a 14- to 28-day period as toxicity developed. Since July 1991, we used this treatment on six eyes of five patients in whom Acanthamoeba keratitis was diagnosed clinically. All patients had positive cultures for microorganisms from their corneas or contact lens cases or had pathognomonic findings of pseudodendritic subepithelial infiltrates and radial keratone-uritis. After therapy, all patients improved within two to four weeks, with regression or resolution of neuritis and infiltrates, healing of epithelial defects, and lessening of pain. By three to four months, visual acuity had returned to 20/20 in all eyes. We believe the addition of polyhexamethylene biguanide to our treatment regimen in Acanthamoeba keratitis dramatically aided and hastened the clinical improvement in five consecutive patients and may, with early diagnosis, increase the number of medical cures.