Corneal endothelial morphologic features in toxic anterior segment syndrome.

PURPOSE: To investigate the clinical and laboratory findings of toxic anterior segment syndrome (TASS) following cataract surgery with intraocular lens (IOL) implantation, with emphasis on the morphologic features of the corneal endothelium. METHODS: A single-center retrospective observational case-control design was used. The sample consisted of 15 patients (mean age 60.3 +/- 11.2 years) with a diagnosis of TASS following unilateral cataract surgery with IOL implantation. In all cases, cataract surgery with IOL implantation had already been performed in the fellow pseudophakic eye without complications. Data on the corneal endothelial morphologic features in both eyes were collected from the files as follows: endothelial cell density, coefficient of variation of cell size, and percentage of hexagonal cells. Values in the eyes with TASS (study group) were compared with the fellow eyes (control group). Between-group differences were analyzed with Student's t test at a significance level of 5%. RESULTS: The eyes with TASS were characterized by a significantly lower endothelial cell density than the control eyes (2302 +/- 220 cells/mm vs. 2853 +/- 145 cells/mm), higher mean cell area (coefficient of variation; 38 +/- 1.4 vs. 24 +/- 2.5), and lower mean percentage of hexagonal cells (22 +/- 1.5% vs. 48 +/- 3.2%; P < 0.01 for all). Common presenting symptoms and signs were blurred vision (60%), anterior segment inflammation (100%), and cell deposition (20%). CONCLUSIONS: TASS following cataract surgery with intraocular lens implantation is associated with a low corneal endothelial cell density.

Endothelial cell loss during pterygium surgery: importance of timing of mitomycin C application.

PURPOSE: To determine if the timing of mitomycin C (MMC) application during pterygium surgery affects endothelial cell loss. METHODS: A retrospective, nonrandomized, case-series design was used. The study group included 40 patients who underwent pterygium surgery with the bare sclera technique. MMC 0.02% was applied intraoperatively for 5 minutes, either before (16 patients) or after (24 patients) excision of the head of the pterygium. Endothelial images were acquired at the center of the cornea with a specular microscope before surgery and at 3 intervals during follow-up (average of 3 measurements each). Differences in cell loss from baseline were analyzed by paired t test. RESULTS: In the group in which MMC was applied post excision, mean preoperative endothelial cell count was 2254 +/- 128 cells per square millimeter. Mean postoperative values were 1775 +/- 63 cells per square millimeter at 1 week (percentage cell loss, 21.25% +/- 2.8%), 1707 +/- 41 cells per square millimeter at 1 month (24.26% +/- 1.8%), and 1780 +/- 72 cells per square millimeter at 3 months (21.05% +/- 3.2%). The difference in cell count from the preoperative value was significant at all time points (P < 0.02). In the group in which MMC was applied before excision, mean preoperative endothelial cell count was 2352 +/- 118 cells per square millimeter, and mean postoperative values were 2345 +/- 120 cell per square millimeter at 1 week, 2260 +/- 162 cells per square millimeter at 1 month, and 2230 +/- 144 cells per square millimeter at 3 months. No endothelial cell loss was documented in this group. CONCLUSION: The endothelial cell loss associated with the use of MMC during pterygium surgery might be avoided by applying MMC before excision of the pterygium head, so that it does not come into contact with the corneal surface.

Bilateral primary pterygia: an occupational disease?

The authors report on a case of bilateral pterygia that the Israeli Social Security Service acknowledged to be an occupational disease. The question of whether certain occupations are risk factors for pterygia has important medico-legal implications. The authors sought to shed more light on this issue through a case report of bilateral simultaneous pterygia in an Israeli tennis instructor and through a literature review. Results indicate that most studies show a strong relation between pterygia formation and outdoor work with exposure to UV rays. Also, the patient refused to use protective eyewear during his long outdoor working hours and, by doing so, exposed his eyes to excessive sunlight, which led to occupational disease.

Long-term topical cyclosporin A therapy in Thygeson's superficial punctate keratitis: a case report.

PURPOSE: To describe a patient with Thygeson's superficial punctate keratitis successfully treated with long-term cyclosporin A. CASE PRESENTATION: A 15-year-old boy presented with long-term ocular symptoms of foreign body sensation, burning, irritation, tearing, and transient photophobia. One year's treatment with steroidal agents had led to only partial improvement. Clinical and laboratory evaluation yielded a diagnosis of Thygeson's superficial punctate keratitis. Treatment with 0.5% topical cyclosporin A for the last 4.5 years has been associated with symptom resolution and corneal clearing, without side effects. CONCLUSION: Topical cyclosporin A seems to effective and safe for the treatment of Thygeson's superficial punctuate keratitis and should be considered in selective cases when topical steroids fail or in there is a high risk of complications from long-term steroid treatment. Considering the chronicity of Thygeson's superficial punctate keratitis, further prospective studies of long-term cyclosporine A treatment are needed.

Effect of mitomycin C in pterygium surgery on corneal endothelium.

PURPOSE: To evaluate changes in endothelial cell count after pterygium surgery with 5-minute application of mitomycin C (MMC) 0.02%. METHODS: The study participants included 24 consecutive patients (17 men and 7 women) who underwent pterygium surgery with MMC at a major tertiary center between September and October 2005. The bare sclera technique was used in all cases. After excision of the head and neck of the pterygium, a surgical sponge soaked with MMC 0.02% was placed on the exposed sclera for 5 minutes, with the conjunctival layer draped over the sponge. Thereafter, the sclera was irrigated with balanced salt solution, and surgery was completed. Endothelial images were acquired at the center of the cornea with a specular microscope (average of 3 measurements) before surgery and at 1 week, 1 month, and 3 months after surgery. RESULTS: Mean preoperative endothelial cell count was 2254 +/- 128 cells/mm. The percentage of postoperative cell loss was 21.25% +/- 2.8% at 1 week, 24.26% +/- 1.8% at 1 month, and 21.05% +/- 3.2% at 3 months. The difference in cell count from the preoperative value was significant at all time points (P < 0.02). There were no adverse drug effects and no serious operative complications. CONCLUSIONS: A 5-minute application of MMC 0.02% to the bare sclera during pterygium surgery has an immediate and significant effect on endothelial cell density, which remains stable for up to 90 days. Furthermore, longer-term studies are needed of different concentrations and durations of the drug and of procedures wherein MMC is applied before excision of the pterygium head.

Effect of dexamethasone eyedrops on blood glucose profile.

PURPOSE: To evaluate the effect of dexamethasone eyedrops on blood glucose. METHODS: Two hundred eighty-five patients who underwent cataract surgery were prospectively randomized to receive treatment with topical dexamethasone or diclofenac for 1 month. A capillary blood sample was collected before surgery, immediately after, 1 week later, and 1 month later. RESULTS: A significant increase in blood glucose levels was noted only in the diabetic dexamethasone group, from 170 +/- 55.5 (mg/dl) before surgery to 229 +/- 76.8 (mg/dl) 1 month later (p = 0.05, 95% confidence interval of -13 to -83.2). The latter level was significantly higher than the 1-month level in the diabetic patients treated with diclofenac drops (198.4 +/- 66.5 mg/dl, p = 0.038). CONCLUSIONS: Postoperative dexamethasone eyedrops have a greater effect on the blood glucose profile of diabetic patients than on nondiabetic patients. Clinicians should be alerted to this risk and may initiate appropriate follow-up in this patient subgroup.

Fibrin glue versus vicryl sutures for primary conjunctival closure in pterygium surgery: long-term results.

PURPOSE: To compare the long-term results of conjunctival closure with fibrin adhesive or Vicryl sutures in pterygium surgery. METHODS: The study was performed in 81 patients (81 eyes) with primary nasal pterygium. Surgery in all patients consisted of the bare sclera technique combined with intraoperative administration of mitomycin C 0.02%. Patients were randomized to undergo conjunctival closure with a fibrin adhesive (Quixil) (n = 42) or Vicryl sutures (n = 39). Clinical assessment was performed on postoperative days 1, 3, 10, and 21 and thereafter at 3, 6, and 12 months. All patients completed a questionnaire at each follow-up visit grading pain, discomfort, and satisfaction with the procedure. The groups were compared for operative time, ocular signs and symptoms, overall satisfaction, and recurrence rate. RESULTS: Average operative time was 16 min in the fibrin-glue group and 28 minutes in the Vicryl-suture group (p < 0.05). Significantly less pain and discomfort were noted in the subjects treated with glue than in controls (p < 0.05). Satisfaction was significantly higher in the study group (p < 0.04). There were no complications during follow-up period in the glue-treated patients; one patient in the suture group had a medically treatable corneal dellen. At the end of follow-up, recurrent pterygium developed in five (11.9%) eyes of the fibrin-glue group and in three (7.7%) eyes of the Vicryl-suture group (p < 0.05). CONCLUSIONS: The use of fibrin glue in pterygium surgery significantly reduces operative time and patient pain compared with suturing. However, it may be associated with a higher recurrence rate.

Pterygium surgery: fibrin glue versus Vicryl sutures for conjunctival closure.

PURPOSE: To compare the short-term results of conjunctival closure in pterygium surgery using fibrin adhesive versus Vicryl sutures with respect to operative time, postoperative ocular signs and symptoms, and overall patient satisfaction. METHODS: A comparative prospective randomized clinical trial was performed in 65 patients (65 eyes) with primary nasal pterygium. Surgery in all patients consisted of the bare sclera technique combined with intraoperative mitomycin C. Patients were randomized to undergo conjunctival closure with a fibrin tissue adhesive (Quixil; n = 39) or 8-0 Vicryl absorbable interrupted sutures (n = 26). Clinical assessment was performed on days 1, 3, 10, and 21 after surgery. Patients completed a questionnaire at each follow-up visit, grading pain, discomfort, and satisfaction with the procedure. The groups were compared for operative time, ocular signs and symptoms, and overall satisfaction. RESULTS: Average operative time was 16 minutes (range, 14-16 minutes) in the fibrin glue group and 20 minutes (range, 20-29 minutes) in the Vicryl suture group (P < 0.05). Significantly less pain, photophobia, foreign body sensation, irritation, epiphora, itching, local hyperemia, conjunctival chemosis, and dry eye were noted in the subjects treated with glue than in controls (P < 0.05). There were no complications during the 3-week follow-up period in the glue-treated patients. One of the patients in the suture group had a medically treatable corneal delle. CONCLUSION: The use of fibrin glue in pterygium surgery significantly reduces operative time and patient symptoms, pain, and discomfort. A longer follow-up is needed to evaluate the influence of fibrin glue on rate of recurrence and long-term complications.

[Goblet cell distribution and epithelial cell morphology in pterygium].

BACKGROUND: Studies conducted to date on the distribution density of goblet cells and epithelial cell morphology in pterygium have yielded contradictory findings. OBJECTIVE: To evaluate the density of goblet cells in pterygium and possible correlation between clinical and demographic features and goblet cell distribution. METHODS: The methodology involved retrospective case series. The study sample included 45 consecutive patients undergoing bare sclera operation. Biopsy specimens were examined under light microscopy. The goblet cells were counted in four fields under X480 magnification and determined by the density range. Demographic features were evaluated for every patient. The relationships between elastosis, inflammation, congestion of blood vessels and the density range in goblet cell count were determined. RESULTS: Distribution density of goblet cells was found to be homogenous among cases. In 16 cases (35%) the count showed more than 120 cells in a field, while in 13 cases (30%) the authors calculated under 15 cells in a field. In 27 cases (60%) there was a high rate of elastosis. In only 3 cases (6.6%) the authors found mild dysplasia of the epithelium. There was a low rate of congestion of blood vessels in only 5 cases (11%). In all cases inflammation was found. There was no significant correlation found with all demographic parameters evaluated. CONCLUSION: There is a high rate of difference in the distribution and density of goblet cells in pterygia, without any correlation with demographic and clinical features listed. There is a variable elastosis rate, significant congestion of blood vessels and a low rate of dysplasia. All cases presented with chronic inflammatory reaction.

Fibrin glue as a suture substitute: histological evaluation of trabeculectomy in rabbit eyes.

PURPOSE: To describe the outcome of the use of fibrin adhesive (Quixil) in penetrating trabeculectomy in a rabbit model. METHODS: Fibrin adhesive was used experimentally to attach the conjunctiva and the scleral flap in two groups of 17 New Zealand albino adult rabbits (34 eyes). In the first experiment (20 eyes), the fibrin adhesive was used to reattach the tissue after conjunctival peritomy and scleral flap only in 14 eyes (experiment I). In 6 eyes (controls), the conjunctiva was attached with nylon sutures. In the second experiment (14 eyes), the fibrin adhesive was used after conjunctival peritomy, scleral flap, and penetrating trabeculectomy in 8 eyes (experiment II). In a control group of 6 eyes, nylon sutures were used to attach the scleral flap and the conjunctiva after penetrating trabeculectomy. Biomicroscopy and histopathological examinations were performed on postoperative days 1, 3, 7, 14, 21, and 30. Intraocular pressure was measured before and after surgery in the second experiment. Main outcome measures are histological presence of adhesive in the tissue, degree of capillary congestion, inflammatory reaction, collagen density [scar formation] and clinical (IOP measurements before and after surgery, conjunctival chemosis, anterior chamber reaction, presence of filtering bleb and wound leakage). RESULTS: In experiments I and II, the adhesive was well identified histologically in the tissue as an amorphic eosinophilic substance for up to day 3 and nearly disappeared by day 7. An acute inflammatory reaction was noted for up to 14 days, which converted to chronic inflammation with collagen deposits and scar formation by day 30. Similar inflammatory reaction was observed in the control group. The adhesive had no adverse effects on ocular tissue compared with sutures. One eye in experiment II demonstrated wound dehiscence. Intraocular pressure dropped from 17.35 mmHg preoperatively to 8.28 mmHg on postoperative day 1 in experiment II, and from 17.2 mmHg to 11.5 mmHg in the controls. No significant change in intraocular pressure was noted in experiment I. CONCLUSIONS: The fibrin adhesive had no adverse effects on ocular tissue compared with sutures. It might serve as an effective substitute for conjunctival and scleral wound closure in trabeculectomy surgery.

Estimation of prevalence and incidence rates and causes of blindness in Israel, 1998-2003.

BACKGROUND: The prevalence and incidence of blindness in Israel appear to be comparable to other western countries. Comparisons are difficult because of different definitions of blindness, and the uniqueness of the Israeli Registry of the Blind. OBJECTIVE: To characterize the population who were registered as Blind in Israel in the years 1998-2003 and estimate the prevalence and incidence of blindness by age and causes of blindness. METHODS: A retrospective review of the annual report of the national Registry of the Blind in Israel between 1998 and 2003 identified 21,585 blind persons who received a certificate for blindness. Blind persons are identified by ophthalmologists throughout Israel and referred to the Registry of the Blind if they have a visual acuity of 3/60 or worse, or a visual field loss of <20 degrees in their better eye. This report includes prevalence data on 21,585 persons enrolled in this review still alive and living in Israel in 2003. We estimated the prevalence rate of blindness nationwide and the incidence rate for each cause of blindness for every year. RESULTS: The main leading causes of blindness in Israel in 1998 were (in percent of the total number of newly registered patients): age-related macular degeneration (20.1%), glaucoma (13.8%), myopic maculopathy (12%), cataract (10.4%), diabetic retinopathy and maculopathy (10.1%), and optic atrophy (7.9%), and in 2003, 28%, 11.8%, 7.4%, 6.5%, 14.4% and 6.5% respectively. CONCLUSIONS: The results indicate that the incidence of age-related macular degeneration, diabetic retinopathy and maculopathy in Israel is increasing, while that of glaucoma, myopic maculopthy, optic atrophy and cataract is decreasing.

Preoperative injection of mitomycin C in combined pterygium and cataract surgery.

PURPOSE: To evaluate the safety and efficacy of a preoperative injection of mitomycin C (MMC) in combined pterygium and cataract surgery. METHODS: This was a prospective, nonrandomized, interventional trial. Thirty-nine patients with cataract and pterygium enrolled in a prospective, nonrandomized trial. All patients underwent combined pterygium and cataract surgery. Twenty-seven received a single 0.1-mL injection of 0.15 mg/mL MMC into the pterygium head 4 weeks before surgery and 12 did not. Patients were followed for 12 to 23 months postoperatively. Recurrence of pterygium, side effects, and complications of MMC were recorded. RESULTS: Recurrent pterygium developed in none of the patients treated with MMC preoperatively and in 5 of the nontreated patients. Two patients in the pretreated group had allergic conjunctivitis immediately after MMC injection. No other local eye complications or adverse systemic reactions were recorded. CONCLUSIONS: Preoperative injection of MMC into the head of the pterygium 4 weeks prior to combined pterygium and cataract surgery resulted in no recurrence and no serious complications up to 12 to 23 months of follow-up postoperatively. This procedure may be recommended to save time and cost and to prevent the possible side effects of MMC when administered topically at the time of cataract surgery. Further follow-up and additional studies will be needed to determine the long-term safety and efficacy.

Effect of pterygium surgery on corneal topography: a prospective study.

OBJECTIVE: To evaluate the effect of pterygium surgery on the corneal topography and visual acuity and to correlate the results with patients' features. METHODS: A prospective, nonrandomized, self-controlled trial. Computerized videokeratography was performed in 54 patients (55 eyes) with primary pterygium before and after pterygium excision using bare sclera technique combined with intraoperative mitomycin C. The following topographic parameters were noted: corneal astigmatism at the central 3 mm; total mean refractive power of the whole cornea; surface regularity index (SRI); and surface asymmetry index (SAI). Best corrected visual acuity of the operated eyes was also examined. Differences between pre- and postoperative values were evaluated statistically with paired two-tailed t test and two-tailed Pearson correlation. RESULTS: The respective values (mean +/- SD) before and after treatment of the study parameters were as follows: simulated keratometric astigmatism at 3 mm, 3.12 +/- 2.43 and 2.51 +/- 2.50 (P = 0.05); mean SRI, 0.99 +/- 0.65 and 0.90 +/- 0.65 (NS); mean SAI, 1.37 +/- 1.69 and 1.23 +/- 1.49 (NS). Best corrected visual acuity was 20/40 preoperatively and 20/25 postoperatively (P < 0.01). Both pre- and postoperative astigmatism correlated with pterygium size. CONCLUSIONS: Pterygium surgery significantly reduces refractive astigmatism and improves SRI, SAI, and best corrected visual acuity.

Pterygium surgery with mitomycin C: how much sclera should be left bare?

PURPOSE: To evaluate the effect of covering the sclera with conjunctiva during surgical treatment of pterygium on the rate of postoperative complications, cosmetic outcome, and risk of recurrence. METHODS: A comparative, prospective clinical design was used. The study population consisted of 371 consecutive patients with unilateral primary advanced pterygium. All underwent bare sclera technique for pterygium excision. At completion of surgery, topical mitomycin C 0.02% was applied for 5 minutes. In the first 189 patients (group A), the conjunctiva was sutured to the sclera 2 mm from the limbus. The next 146 patients (group B), the conjunctiva was sutured at the limbus, covering the whole scleral postexcision defect. In the last 36 patients (group C), the conjunctiva remained unsutured to the sclera. The patients were followed for complications, cosmetic outcome, and recurrence for 26 months. RESULTS: After 26 months, 12 patients in group A (6.35%), 10 in group B (6.85%), and 9 in group C (25%) had recurrent pterygium. There were no cases of acute drug toxicity or scleral melting. Treatable delen were noted in 2 patients in group A (1.05%), 2 (1.36%) in group B, and 9 (25%) in group C. The cosmetic appearance was much better in group A than in groups B and C. CONCLUSIONS: Leaving the whole sclera uncovered in pterygium surgery places patients at high risk of complications and recurrence. There is no difference in complications and recurrence between covering the whole sclera with conjunctiva and leaving 2 mm bare, although the latter yields a more esthetic outcome.

Outcome of double-headed pterygium surgery.

PURPOSE: To evaluate the postoperative outcome and recurrence rate of bare sclera technique combined with intraoperative application of mitomycin C (MMC) 0.02% for 5 minutes in the treatment of primary and recurrent double-head pterygia. METHODS: A prospective, noncomparative interventional case series of 13 eyes in 13 patients with primary (n = 10) or recurrent double-head pterygia in one eye operated on by one surgeon (R.A.). They all had bare sclera excision combined with intraoperative application of MMC 0.02% for 5 minutes. All patients were followed postoperatively for recurrence of the lesion, aesthetic outcome, and incidence of eye complications. RESULTS: Mean follow-up was 36.3 +/- 3.8 months for the patients with primary and 28.4 +/- 2.7 months for the patients with recurrent double-head pterygia. There was only one recurrence in one of the three eyes in the group with recurrent pterygia (33.33%). The only significant complication observed was a pyogenic granuloma in two of the recurrent and one of the primary cases. CONCLUSIONS: The bare sclera technique combined with intraoperative MMC 0.02% for 5 minutes is an effective and safe procedure for double-head pterygia. This method can serve as a useful alternative to amniotic membrane transplantation in countries where the latter is not available and in patients in whom conjunctival autograft is not feasible.

[Causes of blindness in the year 2000 in Israel].

This study of the causes of blindness in Israel in the year 2000 is based on the National Registry of the Blind in Israel. Patients are considered blind if they have a visual acuity of 1/60 or worse, in their better eye, or visual field loss of > 20 degree, in their better eye. At the end of 1998, 15,937 were registered as blind, 2.7/1000 of the total population and in the year 2000 2.9/1000. The leading causes of blindness in Israel in 1998 were glaucoma, macular degeneration and diabetes mellitus. In the year 2000 the leading causes of blindness are: macular degeneration, glaucoma and diabetes mellitus. Macular degeneration is found to be more prevalent in the year 2000 because of high life expectancy of the total population. Glaucoma is found to be less prevalent then in 1998. This can be attributed to early diagnosis and better treatment of the disease. Early detection of glaucoma and good response to treatment is essential for prevention of blindness in such cases.

Intraoperative mitomycin C 0.02% for pterygium: effect of duration of application on recurrence rate.

PURPOSE: To compare the effect of a 3- and 5-minute intraoperative application of topical mitomycin C 0.02% on the recurrence of pterygium. METHODS: A comparative, prospective clinical design was used. The study population consisted of 134 consecutive patients with unilateral primary advanced pterygium (growth of 3 mm or more horizontally from the limbus). All underwent excision of the lesion, leaving the sclera bare. At completion of surgery, topical mitomycin C 0.02% was applied for 3 minutes in the first 60 patients (group A) and for 5 minutes in the remaining 74 patients (group B). The patients were followed for 26 months by slit-lamp biomicroscopic examination of the anterior segment. Recurrent pterygium was defined as the postoperative appearance of a fibrovascular tissue crossing the limbus. RESULTS: After 12 months of follow-up, pterygium recurred in 20 patients (33.3%) in group A and in two patients (2.7%) in group B. After 15 months, the recurrence rates were 36.6% and 5.4%, respectively, and remained unchanged at 26 months. There were no cases of drug toxicity in either group. CONCLUSIONS: Five-minute intraoperative application of a single dose of 0.02% mitomycin C is safe and more effective than a 3-minute application in recurrence of pterygium.

Effect of coffee consumption on intraocular pressure.

BACKGROUND: Many ophthalmologists instruct patients with glaucoma to avoid coffee, although data supporting this practice are insufficient. OBJECTIVE: To estimate the effect of drinking coffee on intraocular pressure (IOP). METHODS: In this crossover study, the effect of the consumption of regular (180 mg caffeine in 200 mL beverage) and decaffeinated coffee (3.6 mg caffeine in 200 mL beverage) was compared in patients with normotensive glaucoma (n = 6) or ocular hypertension (n = 22). IOP was monitored in both groups at 30, 60, and 90 minutes after coffee ingestion. RESULTS: In patients with normotensive glaucoma who drank regular coffee, the mean +/- SD changes in IOP at 30, 60, and 90 minutes were 0.9 +/- 0.5, 3.6 +/- 1.1, and 2.3 +/- 0.66 mm Hg, respectively; in those who drank decaffeinated coffee, they were 0.75 +/- 0.36, 0.70 +/- 0.4, and 0.4 +/- 0.6 mm Hg, respectively. The corresponding values in patients with ocular hypertension were as follows: after regular coffee, 1.1 +/- 0.7, 3.4 +/- 1.0, and 3.0 +/- 2.7 mm Hg; and after decaffeinated coffee, 0.6 +/- 0.4, 0.9 +/- 0.2, and 0.5 +/- 0.5 mm Hg. The difference in the change in IOP from baseline after ingestion of regular versus decaffeinated coffee was statistically significant in each group at 60 and 90 minutes. Subjects who drank regular coffee demonstrated a greater elevation in IOP; this elevation may be clinically significant. CONCLUSIONS: Intake of caffeinated beverage (>/=180 mg caffeine) may not be recommended for patients with normotensive glaucoma or ocular hypertension.