Quality of vision after excimer laser phototherapeutic keratectomy with intraoperative mitomycin-C for Salzmann nodular degeneration.

OBJECTIVE: To assess the effect of excimer laser phototherapeutic keratectomy (PTK) with intraoperative mitomycin-C (MMC) on the quality of vision in patients with Salzmann nodular degeneration (SND). METHODS: Thirteen eyes of 12 patients were enrolled in the study between December 2010 and March 2012. Uncorrected and best-corrected Snellen distance visual acuities were measured at every visit. Contrast sensitivity and manifest refraction were measured preoperatively, at 1 month and at 3 months. Corneal topography, Galilei dual Scheimpflug imaging, VISX WaveScan, and ultrasound central corneal pachymetry were measured preoperatively and at 3 months after PTK procedure. RESULTS: Contrast sensitivity was statistically significantly better both at 1 month (P<0.01) and 3 months (P<0.01). Postoperatively, there was 46% increase in eyes with measurable corneal topography, 69% increase in Galilei dual Scheimpflug imaging, and a 77% increase in WaveScan measurements. The third-order (P<0.01) and total corneal higher-order aberrations (HOAs) (P=0.01) were significantly lower postoperatively compared with the preoperative corneal aberrations measured on Galilei dual Scheimpflug imaging. CONCLUSIONS: Significant improvement in contrast sensitivity and corneal HOAs was seen after PTK for SND. Phototherapeutic keratectomy with MMC can be considered as an effective procedure in the improvement of the quality of vision in patients with SND.

Nontuberculous mycobacterial infection after clear corneal phacoemulsification cataract surgery: a report of 13 cases.

PURPOSE: To review the patient profile, clinical presentation, management, and outcomes of nontuberculous mycobacterial (NTM) infection after clear corneal phacoemulsification. METHODS: Review of consecutive cases diagnosed with NTM infection after phacoemulsification from 2004 to 2009. Demographic data, clinical characteristics, diagnosis, treatment, and outcomes were analyzed. RESULTS: Thirteen eyes of 13 patients with mean age of 61.1 years, consisting of 7 men and 6 women were included. Twelve of 13 eyes (92%) underwent uncomplicated clear cornea phacoemulsification with posterior lens implant. Mean interval from surgery to onset of symptoms was 6.3 weeks, and time to referral ranged from 2 days to 9 months. Ten eyes (77%) presented with stromal wound abscess, whereas 3 (23%) appeared as iridocyclitis with posterior capsule plaques. Five eyes were clustered while the rest were isolated cases. All cases were culture positive for NTM. Two cases were treated medically, 3 had removal of lens implant and capsule, and 8 had penetrating keratoplasty with or without removal of lens implant, iridectomy, and/or pars plana vitrectomy. After a mean follow-up of almost 22 months, best-corrected visual acuity of 20/40 or better was achieved in half of the cases (54%). One case of recurrence was noted. CONCLUSIONS: NTM infection should be suspected in patients presenting with corneal stromal wound abscess or iridocyclitis with posterior capsular plaques 6 to 7 weeks after phacoemulsification. Early diagnosis and treatment can lead to good outcomes, and management should include a combination of medical and surgical therapies.

Indications, visual outcome, and ectasia in clear corneal transplants 20 years old or more.

PURPOSE: To report the indications, visual outcome, and development of ectasia in clear corneal transplants at least 20 years or more after penetrating keratoplasty (PK). METHODS: A computer search of all post-PK patients in the electronic medical records of the Cornea Service was done. Only patients with clear primary grafts aged 20 years or more were included. Main outcome measures noted were indications for surgery, final visual outcome, and postoperative complications. A subset of patients who developed ectasia clinically was also analyzed. RESULTS: One hundred forty-nine eyes of 109 patients were identified. The most common indication was keratoconus (76.5%). After average follow-up of 27 years, the mean postoperative best-corrected visual acuity was 0.29 ± 0.38 logarithm of the minimum angle of resolution (Snellen equivalent 20/39). Postoperative complications included rejection (29.5%), cataract formation (26.2%), and steroid-induced elevated intraocular pressure (15.4%). Peripheral thinning and ectasia diagnosed by slit lamp were noted in 59 eyes (39.6%), most of which were mild (54.2%), inferiorly located (66.1%), and involved the graft-host junction (81.4%). Most of the grafts that developed ectasia had a preoperative diagnosis of keratoconus (91.5%). Mean postoperative visual acuity of ectatic grafts with rigid gas permeable contact lens and/or glasses was 0.24 ± 0.25 logarithm of the minimum angle of resolution (Snellen equivalent 20/34). CONCLUSION: PK grafts can remain clear for 20 years or more and have excellent visual outcome. Most of the 20-year-old grafts in our study were in patients with keratoconus. Rejection and graft-host ectasia are problems to be encountered in long-surviving grafts. Ectatic grafts can still attain good vision with properly fitted contact lenses and glasses.

Treatment of mucous membrane pemphigoid with mycophenolate mofetil.

PURPOSE: To evaluate the clinical outcomes of mycophenolate mofetil (MMF) treatment of mucous membrane pemphigoid (MMP). METHODS: This is a retrospective analysis of consecutive patients with clinical MMP seen in the Ocular Surface Disease Clinic at the Wills Eye Institute, between January 1, 2004, and December 31, 2010, treated with MMF. The main outcomes measured were control of inflammation and discontinuation of MMF. RESULTS: A total of 23 MMP patients taking MMF were identified. The median age of the MMF-treated patients was 77.0 years. Eleven of the 23 patients (47.8%) had biopsy-proven MMP. All patients were at least Foster grading system stage 2, with most stage 3 or 4. Eight patients (34.8%) failed previous treatments with dapsone, methotrexate, prednisone, azathioprine, cyclophosphamide, or 6-mercaptopurine. The average duration of MMF treatment was 23.32 ± 33.17 months (range 1-124.83 months, median 7.4 months). Of the 23 patients with MMP, control of inflammation was achieved with MMF within 3 months for 56.5% [95% confidence interval (CI) 54.5-59.6], within 6 months for 69.6% (95% CI 65.2-76.6), and within 12 months for 82.6% (95% CI 75.3-92.4) of the patients. Nineteen patients (82.4%) achieved control of inflammation, with 16 of the 19 (84.2%) achieving control of inflammation with MMF as monotherapy. Fifteen patients were treated with MMF as initial therapy. Twenty-one percent of patients (5 of 23) were taken off MMF for failure of inflammatory control (4) or an allergic reaction (1). CONCLUSIONS: Treatment of MMP with MMF in this uncontrolled case series resulted in control of inflammation in the majority of patients with minimal side effects. Our data support consideration of MMF as an initial treatment option for active ocular MMP.

Corneal changes in ectrodactyly-ectodermal dysplasia-cleft lip and palate syndrome: case series and literature review.

The aim of this study is to describe the corneal changes in three unrelated patients with ectrodactyly-ectodermal dysplasia-cleft lip and palate (EEC) syndrome and review the literature on the possible etiology and clinical presentation of similar cases. Case 1 is an 18-year-old female with cleft lip and palate, syndactyly, and bilateral corneal pannus superiorly and inferiorly. She was initially diagnosed and treated as herpes simplex virus keratitis. Case 2 is a 3-year-old female born with cleft lip and palate, absent radial digits in both hands, and bilateral lacrimal stenosis. She developed progressive stromal scarring and neovascularization in both eyes. Her cornea perforated after developing infectious ulceration. Case 3 is a 49-year-old male with cleft palate, claw-hand deformities, absent meibomian glands and lacrimal duct, right ankyloblepharon, and a superior wedge-shaped opacity in the left cornea. The clinical findings demonstrated the different spectrum of keratopathy seen in patients with EEC. All patients were treated medically and without any surgical intervention. Limbal stem cell deficiency (LSCD) is presumed to be the cause in all three cases. Corneal changes in EEC can have variable presentation. LSCD seems to be the etiology of such keratopathy. Recurrent infection from lacrimal drainage obstruction and tear film instability are other risk factors for disease severity and progression.

Descemet membrane detachment among siblings: role of anatomic and familial predisposition.

PURPOSE: To describe 2 siblings with Descemet membrane detachment (DMD) after intraocular surgery and discuss the potential role of anatomic and familial predisposition. METHOD: Case reports. RESULTS: A 64-year-old woman had bilateral DMDs after trabeculectomy in her right eye and during combined cataract extraction and trabeculectomy in her left eye. Both were successfully treated with intracameral sulfur hexafluoride gas injections. Her older sister also developed DMD in her left eye that was noted after uncomplicated cataract surgery. Slit-lamp examination of her unoperated eye revealed irregular Descemet membrane with thickening and a wavy configuration, suggesting an intrinsic corneal abnormality. No endothelial guttae or polymorphous changes were noted. Intracameral sulfur hexafluoride gas injection was attempted to reattach the Descemet membrane but was unsuccessful. The patient then underwent Descemet stripping endothelial keratoplasty with excellent postoperative results. CONCLUSIONS: Predisposition to DMD among relatives may be linked to hereditary morphological abnormalities present in their corneas.

Photorefractive keratectomy using a 213 nm wavelength solid-state laser in eyes with previous conductive keratoplasty to treat presbyopia: Early results.

PURPOSE: To evaluate the efficacy and safety of photorefractive keratectomy (PRK) using a 213 nm wavelength solid-state laser to treat regression in eyes that had previous conductive keratoplasty (CK) for presbyopia. SETTING: Outpatient refractive surgery center, Manila, Philippines. DESIGN: Prospective consecutive case series. METHODS: Consecutive eyes that had previous CK for presbyopia were treated with PRK using a 213 nm wavelength solid-state laser (Pulzar Z1). Uncorrected near (UNVA) and distance (UDVA) visual acuities (monocular and binocular), corrected distance visual acuity (CDVA), refraction, keratometry, and slitlamp evidence of corneal haze and other complications were evaluated for up to 6 months after surgery. RESULTS: The study evaluated 20 eyes (20 patients). Six months after PRK, 47% of eyes had monocular UNVA of Jaeger (J) 3 or better and 27% had a binocular UDVA of 0.10 logMAR (20/25 Snellen equivalent) or better with a concurrent UNVA of J3 or better. Seventy-three percent of eyes were within ±1.00 diopter of the attempted refraction. No eye lost 2 or more lines of CDVA or developed significant corneal haze. CONCLUSION: Photorefractive keratectomy after CK using a 213 nm wavelength solid-state laser produced functional visual acuity in presbyopic patients in the short term (6 months).

Frosted-branch angiitis

OBJECTIVE: To report a case of frosted-branch angiitis. METHOD: This is a case report of frosted-branch angiitis seen at the University of the Philippines-Philippine General Hospital. RESULTS: A 42 year-old male presented with progressive blurring of vision of the left eye. Indirect funduscopy showed dilated retinal veins with perivascular sheathing, giving the appearance of frosted-branches of a tree. CONCLUSION: Frosted-branch angiitis is a rare form of retinal vasculitis with various etiologies. Despite the severe retinal appearance, the prognosis is usually good, with rapid recovery of visual acuity after prompt steroid treatment.