Herpes zoster peripheral ulcerative keratitis in patients with the acquired immunodeficiency syndrome.

The purpose of this study was to describe the clinical characteristics and course of peripheral ulcerative keratitis (PUK) secondary to herpes varicella-zoster virus in patients with the acquired immunodeficiency syndrome (AIDS). Three AIDS patients with ocular herpes zoster infection (mean age at onset, 33.0 years; range, 30-42) developed PUK. The three patients had skin involvement, and two of them had bilateral keratouveitis. All were treated with high-dose oral acyclovir (4 g/day) with or without topical antiviral therapy. Two of the patients responded well to oral acyclovir, but one of them stopped the treatment, and bilateral progressive outer retinal necrosis and lethal encephalitis developed. The third patient had a recurrent episode of inflammation with PUK, extensive stromal scarring, and deep neovascularization. AIDS patients with herpes varicella-zoster virus infection may have severe and protracted corneal manifestations, including PUK. The correct diagnosis and aggressive early long-term systemic antiviral treatment must be instituted to control inflammation, ulcer progression, and complications.

Intrastromal corneal ring: 12-month sighted myopic eyes.

BACKGROUND: To evaluate the efficacy, predictability, and stability of the refractive effect produced by the Intrastromal Corneal Ring (ICR), the authors completed a 12-month study on 10 myopic eyes. METHODS: Ten patients with preoperative refractive errors ranging from -2.63 diopters (D) to -4.25 D (mean, -3.30 D) participated in the study. The attempted correction was -2.50 D for a 7.0-mm diameter, 0.3-mm thick ICR. One eye of each patient received an ICR. RESULTS: The average change in spherical equivalent at 12 months was -2.25 D (SD 0.54 D; range, -1.62 to -3.25 D). All patients maintained a spectacle-corrected visual acuity of 20/20 or better during the 12-month study period, with the exception of patient no. 6 who saw 20/30 at the 6-month examination. Her spectacle-corrected visual acuity returned to 20/20 a few days after the ICR was explanted and remained stable throughout the study. Uncorrected visual acuity had improved to 20/40 or better in all patients on postoperative day 1 and remained in this range for the 9 eyes (90%) during the 12 months of follow up. At postoperative month 12, 9 of 9 eyes (100%) had an uncorrected visual acuity of 20/40 or better with 3 of 9 eyes (33%) seeing 20/20 or better. The remaining patient, no. 6, experienced a tear in Descemet's membrane during the procedure and required explantation of the ring after 6 months due to induced astigmatism and deterioration of uncorrected visual acuity. Two patients developed infiltrates that resolved with the use of antibiotics. The most common postoperative ocular findings were peripheral corneal haze in all eyes that diminished over time, minute lamellar channel deposits (7 of 10 eyes, 70%), deep stromal neovascularization (5 of 10 eyes, 50%), and pannus (5 of 10 eyes, 50%). CONCLUSION: This preliminary study shows that implantation of an intrastromal corneal ring of this dimension (0.3-mm thick) can reduce approximately 1.50 to 3.00 D of myopia and maintain spectacle-corrected visual acuity.

The value of combined serum angiotensin-converting enzyme and gallium scan in diagnosing ocular sarcoidosis.

PURPOSE: To evaluate the role of combined serum angiotensin-converting enzyme (ACE) activity and whole-body gallium (67GA) scanning in diagnosing sarcoidosis in patients with features consistent with ocular sarcoidosis but with normal or equivocal chest radiographs. METHODS: Serum ACE levels and whole-body 67GA scans were obtained as part of the initial workup in 22 patients with active ocular inflammation and ultimately biopsy-proven sarcoidosis (sarcoid uveitis group). A second group consisting of 70 patients with active uveitis in whom sarcoidosis also was considered a diagnostic possibility also was studied. All 70 patients ultimately had a definitive diagnosis other than sarcoidosis (nonsarcoid uveitis). All patients in this group also had a serum ACE and whole-body 67GA scan performed as part of their initial investigations. RESULTS: All patients in the sarcoid uveitis group had either an elevated ACE level or an abnormal scan. In 16 of the 22 patients, results of both tests were abnormal. In no patient in the nonsarcoid uveitis group were results of both tests abnormal. The sensitivity of an elevated ACE in diagnosing sarcoidosis was 73% and the specificity was 83%. Using the combination of a positive 67GA scan and an elevated ACE, the specificity for diagnosis was 100% and the sensitivity was 73%. CONCLUSIONS: The combination of serum ACE level and whole-body 67GA scan increases the diagnostic specificity without affecting sensitivity in patients with clinically suspicious ocular sarcoidosis who have normal or equivocal chest radiographs.

Analysis of the acute ophthalmic manifestations of the erythema multiforme/Stevens-Johnson syndrome/toxic epidermal necrolysis disease spectrum.

PURPOSE: To evaluate the epidemiology, possible etiologic factors, complications encountered, and treatment administered to a group of patients with ocular involvement in the erythema multiforme/Stevens-Johnson syndrome/toxic epidermal necrolysis disease spectrum who were seen at two large tertiary referral centers over a 34-year period. METHODS: Hospital records from 1960 to 1994 at the Massachusetts General Hospital and Shriners Hospital for Crippled Children were reviewed for patients with erythema multiforme, Stevens-Johnson syndrome, or toxic epidermal necrolysis. Only patients fulfilling specific clinical diagnostic criteria and those who received a diagnosis by a dermatologist were included in the review. RESULTS: A total of 366 patients with erythema multiforme, Stevens-Johnson syndrome, or toxic epidermal necrolysis were identified. Drugs were the most commonly identified etiologic factor in all three conditions: sulfonamides were the most frequently identified agents. Eighty-nine patients (24%) had ocular manifestations at the time of their acute hospital stay. Ocular involvement was seen in 9% of patients with erythema multiforme, in 69% with Stevens-Johnson syndrome, and in 50% with toxic epidermal necrolysis. The ocular problems were more severe in patients with both Stevens-Johnson syndrome and toxic epidermal necrolysis. There was no significant difference between the number of patients who were treated with systemic steroids and those who were not (P = 0.42). CONCLUSIONS: The erythema multiforme/Stevens-Johnson syndrome/toxic epidermal necrolysis disease spectrum remains an important cause of severe visual loss in a significant number of patients. Systemic steroids used during the acute phase of the disease appear to have no effect on the development of ocular manifestations. Studies on the acute immunopathogenic mechanisms occurring in these disease are warranted if more effective therapies are to be found.

Increasing the diagnostic yield of conjunctival biopsy in patients with suspected ocular cicatricial pemphigoid.

BACKGROUND: Ocular cicatricial pemphigoid is a chronic, progressive, autoimmune disease that scars mucous membranes and may lead to blindness. It is of critical importance to be able to make the diagnosis as early as possible to allow early treatment. Conjunctival biopsy facilitates the early diagnosis of this condition. MATERIALS AND METHODS: Conjunctival biopsy results of 166 consecutive patients seen over a 7-year period, in whom the diagnosis of ocular cicatricial pemphigoid was considered, were reviewed. RESULTS: One hundred twenty-one patients ultimately received a diagnosis of ocular cicatricial pemphigoid. Immunofluorescence studies demonstrated characteristic deposition of immunoreactants at the epithelial basement membrane zone in 63 patients (sensitivity = 52%). When immunofluorescent-negative or inconclusive biopsies were processed further using an immunoperoxidase technique an additional 37 diagnoses were made. This represented an increase in sensitivity from 52% with immunofluorescence only to 83% with the addition of the immunoperoxidase technique. CONCLUSION: The routine use of the immunoperoxidase technique in immunofluorescent-negative biopsies, allied with appropriate harvesting and handling of biopsied conjunctiva, should significantly increase the diagnostic yield in patients with clinically suspect ocular cicatricial pemphigoid.

Disease relapse in patients with ocular manifestations of Wegener granulomatosis.

PURPOSE: To evaluate possible factors associated with disease relapse in patients with ocular manifestations of Wegener granulomatosis. METHODS: Eight patients with ocular manifestations of Wegener granulomatosis were longitudinally followed for a mean period of 34 months. Serial antineutrophil cytoplasmic antibody (ANCA) levels were determined on all patients. RESULTS: All eight patients had either scleritis alone or scleritis combined with peripheral ulcerative keratitis. Clinical disease remission was achieved in all patients using immunosuppressive chemotherapy. Five patients had subsequent relapse after treatment withdrawal. The serum ANCA level had failed to revert to normal during remission in four of the five patients who had had relapses. The ANCA levels for all three patients who remained in remission without therapy converted to normal. There was no significant difference in the initial serum ANCA level (P = 0.35) or the mean cumulative cyclophosphamide dose (P = 0.13) between those who had a relapse and those who did not. CONCLUSION: Failure of ANCA titers to revert to normal levels may be associated with the potential for relapse in patients with ocular manifestations of Wegener granulomatosis.

Recurrence rate of herpetic uveitis in patients on long-term oral acyclovir.

We examined the recurrence rate of herpetic uveitis (HU) in 13 patients (group A) treated prophylactically with long-term systemic acyclovir (600-800 mg/day) and compared it with that of 7 patients with no prophylactic therapy (group B). HU was diagnosed on the basis of a history of dendritic or disciform keratitis accompanied by iridocyclitis and iris atrophy. The study population consisted of 12 men and 8 women with a mean age at onset of uveitis of 52.9 years (range 19-78 years). All patients were followed for at least 8 months. The mean follow-up time of patients on long-term oral acyclovir was 26.0 months. In this group, only one patient experienced a single recurrent episode of uveitis while on 600-800 mg/day of acyclovir therapy; two additional patients had recurrence of HU within 16.2 months after the acyclovir dose was tapered below 600 mg/day. In striking contrast, 16 recurrences occurred in the 7 patients of group B (p < 0.05). Of these, the initial recurrence occurred within an average of 4.3 months following cessation of therapy. There was a significant difference (p < 0.05) in the mean recurrence-free interval between patients in group A (24.6 months) and those in group B (3.4 months). Herpetic uveitis is a serious ocular disease in which recurrence of inflammation results in severe ocular complications. The long-term use of oral acyclovir may be of benefit in the prevention of recurrences, and hence may reduce the blinding complications of this disease. Efforts at completing a randomized, placebo-controlled trial on this matter by the Herpes Epithelial Disease Study Group were unsuccessful due to insufficient patient recruitment.

Trabeculectomy with mitomycin C in glaucoma associated with uveitis.

Twenty-four trabeculectomies performed in 24 patients for control of uveitic glaucoma were retrospectively evaluated to analyze the effect of intraoperative application of mitomycin C (MMC) on the short-term outcome of trabeculectomy for glaucoma associated with uveitis. Success rates, postoperative levels of intraocular pressure (IOP), and complications were studied. After a mean follow up of 9.87 months (range, 3 to 27 months), 18 eyes (75%) achieved an IOP of 21 mm Hg or less without antiglaucoma medications. The same IOP level with one antiglaucoma medication was achieved in four eyes (16.6%). Statistical analysis demonstrated a significant reduction in IOP postoperatively during the period studied (P = .0001). Complications observed included exacerbation of the uveitis (12.5%), choroidal detachment (12.5%), hypotony (8.3%), postoperative shallow anterior chamber (4.2%), wound leak (4.2%), hyphema (4.2%), and macular edema (4.2%). The results of this retrospective and uncontrolled study suggest that intraoperative application of MMC may be a good option for enhancement of short-term trabeculectomy success rates in cases of uveitic glaucoma.

Intrastromal corneal ring--one-year results of first implants in humans: a preliminary nonfunctional eye study.

BACKGROUND: The Intrastromal Corneal Ring (ICR) is a new investigational medical device designed to alter corneal curvature without surgical intervention in the central cornea. The ring is inserted between the layers of the stroma in the cornea's periphery at two-thirds depth through an approximately 2-millimeter incision. METHODS: To investigate the safety and refractive effect of implanting an ICR of a given thickness (0.30 mm) and outer diameter (7.70 mm) into human corneas, an ICR was implanted into one nonfunctional eye of each of three patients during the period of March to May, 1991. One predesignated ICR was successfully explanted 5 months after implantation to evaluate the feasibility of ICR removal and to observe the effect of ring removal on corneal curvature. Patients were followed for 1 year after the initial implant procedure. RESULTS: The three implant procedures and postoperative courses proceeded without any significant complications. Approximately 2.00 D of central corneal flattening was achieved in all eyes. No adverse reactions or other medically-significant complications were observed over a 1-year follow-up period. The patient who underwent ICR removal experienced no perioperative complications, and the patient's cornea has remained stable with a return to its preoperative curvature. CONCLUSION: Although this study is preliminary and limited in scope, we have demonstrated that the ICR can be tolerated safely in the human cornea and results in a flattening of the corneal curvature that is stable for up to a year after insertion. The successful removal of the ICR begins to establish reversibility of the procedure and induced refractive effect.

Diverticulo de Meckel como causa de abdomen agudo cirurgico. / Meckel's diverticulum causing surgical acute abdomen

O diverticulo de Meckel como causa de abdomen agudo cirurgico e relativamente infrequente e devido a isso, o diagnostico no pre-operatorio quase nunca e realizado.Os autores fazem um analise de oito pacientes operados no Servico de Emergencia do Hospital de Base do Distrito Federal. Em cinco casos a complicacao encontrada foi obstrucao intestinal por brida que partia do diverticulo, em dois casos ocorreu perfuracao do diverticulo sendo demonstrado histologicamente mucosa gastrica heterotopica e o paciente restante teve volvo do diverticulo com necrose, hemorragia e perfuracao do mesmo