Long-term outcome of autologous fascia lata grafting with conjunctival flap overlay in horses with ulcerative keratitis and keratomalacia.

OBJECTIVES: To describe the technique, postoperative complications, and outcome after autologous fascia lata grafting with conjunctival flap overlay in horses with ulcerative keratitis and keratomalacia. STUDY DESIGN: Retrospective case series. ANIMALS: Eleven horses with ulcerative keratitis and keratomalacia. METHODS: Horses included had undergone fascia lata grafting with conjunctival flap overlay due to impending or recent corneal perforation. Preceding therapy, lesion characteristics, postoperative complications, and short- and long-term outcomes were recorded. RESULTS: Postoperative complications included complete (1/11) or partial (2/11) dehiscence of the conjunctival flap and fascia lata graft, postoperative pneumonia (1/11), intermittent hypercreatinemia (2/11) and mild uveitis after trimming of the conjunctival flap (9/10). The donor sites healed without complications (11/11). A satisfactory short-term outcome (at cessation of medical therapy) was achieved in all horses (11/11). Long-term follow-up (median 29 months, range 7-127 months) was available for 10/11 horses. A comfortable eye with functional vision was achieved in 9/10 horses with long-term follow-up, including 3/4 horses with prior corneal perforation and 1/11 horses in which the fascia lata graft completely dehisced 15 days after surgery. Enucleation was required in a single horse (1/10) after phthisis bulbi developed 7 months postoperatively. CONCLUSION: Fascia lata grafting with conjunctival flap overlay appears to be a viable solution for globe preservation in horses with ulcerative keratitis and keratomalacia. Long-term ocular comfort with functional visual outcomes can be achieved in most cases with limited concerns for donor site morbidity while bypassing acquisition, storage or lesion-size limitations related to other biomaterials.

Corneal Perforation Repair Using a Novel Lyophilized Amniotic Membrane Graft Technique: Plug and Patch.

BACKGROUND The use of amniotic membranes for corneal perforations using different surgical techniques has been widely described in the literature. This case report is a novel variation in the technique that can be useful for incorporating in clinical practice when the need arises. CASE REPORT A 36-year-old male patient presented to our clinic with a corneal ulcer in his left eye caused by herpetic keratitis, treated with a topical non-steroidal anti-inflammatory (indomethacin 0.1% solution). Examination revealed a paracentral 2-mm wide corneal perforation on the site of the corneal ulcer. The patient was admitted to the hospital. He was treated with intravenous piperacillin-ofloxacine, and an emergency surgical intervention using a lyophilized amniotic membrane was performed using a "plug and patch" technique. Postoperatively, the patient received 48 h of intravenous antibiotics and was discharged on topical antibiotic/corticosteroid eyedrops along with a 10-day course of oral antibiotics (ofloxacin) and antiviral therapy (valaciclovir). Three months after surgery, the anterior chamber was formed, the corneal defect was closed, and visual acuity improved. One year after initial presentation, anterior segment optical coherence tomography showed a large scarred but healed cornea. CONCLUSIONS We report the successful use of combination of a single round-shaped rolled amniotic membrane with a multilayered amniotic membrane transplantation for the treatment of a 2-mm-wide perforated corneal ulcer. This technique allowed for preservation of the globe integrity without the need for a keratoplasty, stopped further tissue loss, and was associated with a rapid visual recovery.

Corneal Perforation as a Rare and Late Manifestation of Choroidal Melanoma.

PURPOSE: To report a case of corneal perforation as a rare and late manifestation of choroidal melanoma and to highlight the major histopathological findings of this unusual combined clinical presentation. METHODS: A 74-year-old male patient presented to our department due to corneal perforation of the right eye with the absence of light perception for 6 months. The intraocular pressure was hard on palpation. Because of the protracted finding and reduced visual prognosis, primary enucleation was performed. RESULTS: The histopathological examination revealed choroidal melanoma with epithelioid and spindle cell components at the posterior pole, which was positive for Melan-A, Human Melanoma Black 45 (HMB45), BAP1, and SOX10. The anterior segment showed complete anterior chamber hemorrhage and blood remnants in the trabecular meshwork. The cornea displayed diffuse blood staining with hemosiderin and hemosiderin-loaded macrophages and keratocytes. No inflammatory cells were present near the corneal perforation, which had a width of 3 mm. Intraocular heterotopic ossification was indicative of a long-standing condition. Postoperative cancer staging was normal. CONCLUSION: Corneal perforation should be considered as a very rare and late manifestation of advanced choroidal melanoma and may result from interaction between intraocular hemorrhage, elevated IOP, and its secondary signs such as corneal blood staining.

Congenital corneal staphyloma in 8q21.11 microdeletion syndrome.

BACKGROUND: Although 8q21.11 microdeletion syndrome (8q21.11 DS) has been reported in association with congenital corneal opacities, reports of the clinicopathological features and management are scarce. METHODS: We reviewed medical records including ophthalmic evaluations, imaging, operative reports, and pathology reports of two unrelated patients referred to the Ophthalmology Clinic of UPMC Children's Hospital of Pittsburgh with a cytogenetic diagnosis of 8q21.11 DS. RESULTS: Ophthalmological evaluation of both children revealed bilateral enlarged, staphylomatous, and cloudy corneas with neovascularization. These findings were consistent with the diagnosis of congenital corneal staphyloma (CCS). In one patient, anterior segment optical coherence tomography and high-frequency ultrasound revealed materials consistent with lens remnants embedded in the cornea; this was confirmed by histopathology. In the second patient, lens was found to be adherent to the cornea during surgery. One eye underwent enucleation for corneal perforation secondary to elevated intraocular pressure. In the other eyes, treatment consisted of penetrating keratoplasty combined with vitrectomy. Ahmed tube was subsequently placed to control intraocular pressure. CONCLUSION: 8q21.11 microdeletion syndrome can be associated with bilateral CCS, likely related to a combination of anterior segment developmental anomalies and elevated intraocular pressure. Tectonic penetrating keratoplasty is necessary to prevent corneal perforation, together with a strict control of the intraocular pressure.

Dramatic Improvement of Severe Cicatricial Ectropion after Discontinuing Long-Term Erlotinib Therapy in a Patient with Lung Cancer

There is no consensus on the choice of systemic and ophthalmic treatment for patients who develop ocular toxicity with erlotinib in the few cases reported previously. Various ocular complications related to erlotinib have been reported, with one of the most serious being corneal perforation. Our patient was at risk of potential corneal perforation because of severe cicatricial ectropion and diffuse punctate corneal epitheliopathy. Therefore, erlotinib treatment was temporarily discontinued with the approval of the oncology department and the patient was closely followed. She was prescribed steroid eye ointment, single-use preservative-free artificial tears, and eye lubricant gel to protect the ocular surface. On day 4 of treatment, the patient's findings were significantly improved. After 1 week, the cicatricial ectropion had dramatically improved and the patient's complaints were completely resolved. To our knowledge, there is no case report of a patient with both ocular toxicity after long-term use that shows dramatic improvement with drug cessation, and severe cicatricial ectropion affecting the entire lower eyelid. Here, we described a patient who used erlotinib for 3 years due to non-small cell lung cancer and developed severe cicatricial ectropion which improved dramatically within one week of temporarily discontinuing erlotinib and discussed the possible reasons. Although ocular complications with erlotinib are usually encountered early in treatment, it should be kept in mind that erlotinib-related ocular complications may also arise with long-term use.

Ocular Cicatricial Pemphigoid: Camouflaged as Persistent Conjunctivitis.

Ocular cicatricial pemphigoid (OCP) is a rare autoimmune disease with heterogenous clinical manifestations. The classical lesion involves ocular conjunctiva that leads to progressive scarring and fibrosis which ultimately results in visual loss. We report a case of a young male, who had chronic conjunctivitis which remained un-responsive to conventional treatment and results in significant morbidity. Later, it was diagnosed as ocular cicatricial pemphigoid involving eyes, nasal cavity, larynx as well as skin. Patient received immuo-suppressive therapy, which helped in arresting the disease process.

Corneal Higher-Order Aberrations in Eyes With Corneal Scar After Traumatic Perforation.

OBJECTIVES: To evaluate corneal higher-order aberrations (HOAs) in eyes with corneal scar after traumatic perforation and their correlation with visual acuity. METHODS: This retrospective consecutive case study included 40 eyes of 40 consecutive patients (mean age, 39.2±21.6 years), treated for traumatic corneal perforation at Tokyo Dental College, and 18 normal control eyes. Higher-order aberrations of anterior and posterior corneal surfaces and total cornea were analyzed by swept-source optical coherence tomography. Correlations between corneal HOAs and visual acuity were analyzed. RESULTS: Higher-order aberrations within 4-mm diameter were significantly larger in eyes with corneal perforation (anterior surface, 0.51±0.54 µm; posterior surface, 0.20±0.14; and total cornea, 0.52±0.50) as compared to normal controls (0.10±0.02, 0.02±0.01, and 0.09±0.02, respectively; all P<0.001). Higher-order aberrations within 6-mm diameter were significantly larger in eyes with corneal perforation (anterior surface, 1.15±1.31; posterior surface, 0.31±0.23; and total cornea, 1.09±1.28) as compared to normal controls (0.21±0.06, 0.06±0.01, and 0.19±0.06, respectively; all P<0.001). The most common topography pattern observed was the minimal change pattern (37.5%), followed by asymmetric pattern (30.0%). Visual acuity significantly correlated with corneal HOAs (anterior surface: R=0.646, P<0.001; posterior surface: R=0.400, P=0.033; and total cornea: R=0.614, P<0.001). CONCLUSIONS: Corneal scar after traumatic perforations not only induces corneal opacity, but also increases corneal HOAs, which indicates a direct effect on visual acuity.

Corneal perforation in undiagnosed Sjögren's syndrome following topical NSAID and steroid drops post routine cataract extraction.

A 74-year-old man presented with a progressive decrease in visual acuity and foreign body sensation in his right eye 8 days post uncomplicated phacoemulsification cataract surgery and intraocular lens insertion. The patient had been placed on a perioperative cataract regimen which consisted of G. Maxitrol (dexamethasone, polymyxin B sulfate, neomycin sulfate) four times a day and G. Yellox twice daily (bromfenac, a non-steroidal anti-inflammatory) for 2 weeks. On examination, he had a corneal ulcer and stromal thinning in his right eye which progressed to a full thickness perforation 12 hours later. The patient required a full thickness tectonic corneal transplant. Direct questioning revealed that this patient had both dry mouth and eyes. Serology revealed that the patient was positive for rheumatoid factor and for anti-Ro and anti-La antibodies. A parotid gland biopsy revealed significant lymphocytic infiltrate consistent with Sjögren's syndrome.

Non-traumatic corneal perforations: aetiology, treatment and outcomes.

PURPOSE: To report aetiology, characteristics, treatment and main outcomes of non-traumatic corneal perforations in a single referral centre. METHODS: A retrospective review of clinical records of patients diagnosed with non-traumatic corneal perforation. The analysed data included demographic characteristics, medical history, initial and final corrected distance visual acuity (CDVA), perforation aetiology, size, location, initial therapy, surgical treatment, ocular integrity and complications. A comparison between non-infectious and infectious groups was performed. Different variables were analysed through a multiple logistic regression analysis for the probability to have at least one more procedure. RESULTS: We included 127 eyes of 116 patients with a mean age of 50 years and a mean follow-up of 11 months. The initial CDVA was 3.00 logarithm of the minimum angle of resolution (logMAR) and the final CDVA was 2.30 logMAR (p>0.5). Regarding treatment, of the 49 eyes with an initial cyanoacrylate patch, 35 eyes (71.4%) had at least one more procedure performed (p>0.001). In comparison, of the 49 eyes with an initial tectonic penetrating keratoplasty (PK), 33 (67.3%) eyes remained stable while 16 (32.7%) eyes needed one or more interventions (p=0.004). In a multiple logistic regression analysis, an initial cyanoacrylate patch represented a probability of 4.7 times to require a subsequent procedure in comparison with an initial PK. Overall, globe integrity was achieved in 96.1% of the cases. CONCLUSIONS: Corneal perforations represent an important cause of ocular morbidity. The use of a cyanoacrylate patch is useful as an initial therapy in corneal perforations; however, procedures such as PK are often necessary to achieve anatomical success, especially in non-infectious aetiologies.

Fonsecaea pedrosoi as a rare cause of acute conjunctival ulceration.

Conjunctival ulceration accompanied with secretion and pain was observed in a 30-year-old male, 3 days after a perforating corneal trauma. Cultures of conjunctival ulcer samples grew Fonsecaea pedrosoi, a major causative agent of chromoblastomycosis that is typically transmitted during trauma. The conjunctival ulcer was successfully treated with amphotericin B, itraconazole, and fluconazole. This case report summarizes the diagnosis and treatment of a conjunctival ulcer due to F. pedrosoi, which is a rare complication of contaminated ocular trauma. To the best of our knowledge, this is the first reported case of F. pedrosoi causing acute conjunctival ulceration in the literature.

Fonsecaea pedrosoi as a rare cause of acute conjunctival ulceration / Fonsecaea pedrosoi como agente raramente associado à úlcera conjuntival aguda

ABSTRACT Conjunctival ulceration accompanied with secretion and pain was observed in a 30-year-old male, 3 days after a perforating corneal trauma. Cultures of conjunctival ulcer samples grew Fonsecaea pedrosoi, a major causative agent of chromoblastomycosis that is typically transmitted during trauma. The conjunctival ulcer was successfully treated with amphotericin B, itraconazole, and fluconazole. This case report summarizes the diagnosis and treatment of a conjunctival ulcer due to F. pedrosoi, which is a rare complication of contaminated ocular trauma. To the best of our knowledge, this is the first reported case of F. pedrosoi causing acute conjunctival ulceration in the literature.

RESUMO O quadro clínico de uma úlcera conjuntival acompanhada de secreção e dor foi observado em homem de 30 anos de idade, 3 dias após um trauma perfurante da córnea. As culturas de uma amostra retirada da úlcera conjuntival foi positiva para Fonsecaea pedrosoi, uma cromoblastomicose, geralmente transmitido após traumatismos. O caso foi tratado com sucesso com a anfotericina B, itraconazol e fluconazol. Este relato de caso reporta o diagnóstico e tratamento de uma úlcera conjuntival causada por F. pedrosoi, que raramente é visto nos olhos expostos a traumatismos contaminados. Até onde sabemos, este é o primeiro caso relatado na literatura de F. pedrosoi causando úlcera conjuntival aguda.

[E-PTFE Membrane for the Management of Perforated Corneal Ulcer]. / E-PTFE Membran für die Behandlung von perforiertem Hornhautulkus.

Purpose: To present the surgical management of perforated corneal ulcer using PRECLUDE® Pericardial Membrane, composed of expanded polytetrafluoroethylene (e-PTFE; GORE-TEX®), as an alternative surgical procedure in patients at high risk of graft rejections and to evaluate side effects for a prolonged period. Patients and Methods: The study included all patients who were admitted to our department and underwent surgical repair of perforated corneal ulcer with the e-PTFE membrane between 2010 and 2015. In total, 8 patients (8 eyes) were enrolled. Medical records of all patients were retrospectively reviewed. The operation was performed under peribulbar anaesthesia. Non-absorbable, microporous, watertight 0.1 mm thick e-PTFE membrane was used to close the corneal ulcer. The membrane was cut to overlap the defect adequately and to achieve the desired tissue attachment without preparing the conjunctiva or superficial trephination of the cornea. The membrane was fixed to the healthy cornea with several non-absorbable sutures (Prolene® 10.0), in order to achieve the proper stress without wrinkling. Results: Five of 8 patients were treated for systemic immunological diseases. Sjögren's syndrome was diagnosed in 2 patients, granulomatosis with polyangiitis in one, vasculitis with a history of previous sclerokeratitis in one and systemic lupus erythematosus in one. In 2 patients, corneal perforation was observed as a complication of corneal infection and in one patient as a late complication of a severe chemical burn. Corneal perforations were successfully covered with e-PTFE membrane in all patients. E-PTFE membrane was well tolerated in all patients and the eye was always preserved. After 3 to 4 months, the membrane was removed in 7 patients. The underlying cornea was thin, firm, stable and vascularised. In one patient with Sjögren's syndrome, the e-PTFE membrane is still in place. Conclusion: Surgical management of perforated corneal ulcer using E-PTFE membrane may be the method of choice for eye preservation or for delayed corneal transplantation. Our results confirmed that the procedure is safe and effective, especially in high risk patients. After removing the membrane, penetrating keratoplasty can be performed as a definitive treatment in all eyes where an improvement in visual acuity is expected.

Cuando todo lo demás falla: queratoplastia tectónica con córnea silico-disecada en paciente con alto riesgo de perforación corneal / When all else fails: Tectonic keratoplasty with silica gel re-dried cornea in a patient with high risk of corneal perforation

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Secondary corneal amyloidosis after perforating corneal trauma: A series of 5 cases and review of the literature.

We retrospectively reviewed the clinical and surgical histories of 5 patients with traumatic secondary corneal amyloidosis, a relatively rare sequela of nonsurgical and surgical perforating corneal trauma. Four had history of nonsurgical trauma, and 1 had surgical trauma to the cornea. Three specimens were obtained by penetrating keratoplasties and 2 by excision of the cornea during evisceration of the ocular contents. All the corneal specimens showed full-thickness scars of a prior perforating wound with congophilic amyloid deposits that exhibited apple-green birefringence under polarized light and dichroism. All cases had variable degrees of predominantly chronic nongranulomatous inflammation. Ultrastructural examination in 1 patient disclosed 8-nm diameter fibrils in disarray, consistent with amyloid. Amyloid P immunostaining was positive in all 3 patients tested for this protein.

Perforación corneal como primera manifestación de síndorme de Sjören secundario a artritis reumatoide / Corneal melts as the initial manifestation of sjögren syndrome secondary to rheumatoid arthritis

La artritis reumatoide es una enfermedad sistémica inflamatoria crónica frecuente, de etiología desconocida. El síndrome de Sjögren puede ir asociado a dicha patología. El curso clínico de la artritis reumatoide a nivel ocular es muy variable y el diagnóstico temprano es determinante para prevenir graves complicaciones. Presentamos el caso de una mujer de 64 años de edad que acudió al Servicio de Urgencias por presentar ojo rojo bilateral con fotofobia, lagrimeo continuo, dolor y disminución de la agudeza visual. En la exploración se objetivó importante adelgazamiento del estroma corneal en OD y perforación corneal OI, que requirió recubrimiento tectónico con membrana amniótica. Los análisis serológicos mostraron los siguientes resultados: Factor Reumatoide+, ANA+, ENA Anti-Ro/SSA+, ENA Anti-La/SSB+. La paciente fue diagnosticada de Artritis Reumatoide y Síndrome de Sjögren secundario. Desde entonces, sigue un tratamiento sistémico con corticoides y azatioprina. Aproximadamente, el 25% de los pacientes desarrollan enfermedad oftalmológica, esencialmente queratoconjuntivitis seca (25%), epiescleritis, escleritis y queratitis. Estas manifestaciones son en general poco severas, pero hay un pequeño porcentaje de pacientes, como el caso que aquí presentamos, que sufren una inflamación ocular grave y que sin tratamiento inmunosupresor precozmente instaurado, pueden desarrollar úlceras corneales estériles, centrales o periféricas, que les puede llevar incluso a la perforación y destrucción del globo (AU)

Rheumatoid arthritis(RA) is a common chronic inflammatory autoinmune disease, with unknown etiology. Approximately 11-31% of RA patients have secondary Sjögren´s syndrome. Ophthalmologic manifestations of these diseases can cause corneal scarring, ulceration, infection, and even perforation; thus, although the prognosis is good for most patients with Sjögren syndrome and ophthalmologic features, individuals with complications have much guarded prognosis. We report the case of a 65 years old woman with photophobia, pain, tearing and blurred vision in both eyes. Slit lamp exam showed an important corneal melting right eye, and corneal perforation left eye, which required amniotic membrane transplantation. The diagnosis was: Rheumatoid Arthritis and secondary Sjögren´s Syndrome. Azathioprine treatment was started in combination with oral steroids. Approximately 25% of patients have ocular involvement, and keratoconjunctivitis sicca is the most frequent ocular complication. Although the prognosis is good in most cases, an early diagnosis is necessary to avoid several complications (AU)