Air bag-induced corneal flap folds after laser in situ keratomileusis.

PURPOSE: We describe a case of air bag-induced ocular trauma resulting in folds in the corneal flap 3 weeks after laser in situ keratomileusis. METHODS: Case report. Three weeks after laser in situ keratomileusis, a 20-year-old man was involved in a motor vehicle accident and sustained blunt trauma to the right eye, which caused corneal flap folds, corneal edema, anterior chamber cellular reaction, and Berlin retinal edema. RESULTS: Six weeks after laser in situ keratomileusis, persistent flap folds necessitated re-operation with lifting of the flap and repositioning. One week after the procedure, the visual acuity improved to 20/20-2, and the folds had cleared. CONCLUSION: Trauma after laser in situ keratomileusis may produce folds in the corneal flap. With persistence of these folds, management by lifting and repositioning the corneal flap may be necessary to permit recovery of visual acuity.

Laser in situ keratomileusis for correction of myopia and astigmatism after penetrating keratoplasty.

PURPOSE: To determine the safety and effectiveness of laser in situ keratomileusis (LASIK) for visual rehabilitation of residual myopia and astigmatism after penetrating keratoplasty. DESIGN: Prospective, noncomparative case series. PARTICIPANTS: LASIK was performed on 23 eyes of 22 patients unable to wear glasses or contact lenses after penetrating keratoplasty due to anisometropia, high astigmatism, and/or contact lens-intolerance. METHODS: All patients underwent LASIK for visual rehabilitation after penetrating keratoplasty. Uncorrected visual acuity and best spectacle-corrected visual acuity, degree of anisometropia, and corneal transplant integrity were recorded before surgery, as well as at 1 month, 3 months, 6 months, and 12 months after LASIK surgery. RESULTS: The mean spherical equivalent before surgery was -7.58+/-4.42 diopters (D), which was reduced to -1.09+/-2.01 D, -0.79+/-1.84 D, -0.77+/-1.25 D, and -1.57+/-1.20 D, respectively, at 1, 3, 6, and 12 months after LASIK. The mean cylinder before surgery was 3.64+/-1.72 D, which was reduced to 1.98+/-1.15 D, 1.64+/-1.14 D, 1.48+/-0.92 D, and 1.29+/-1.04 D, respectively, at 1, 3, 6, and 12 months after LASIK. Spherical equivalent anisometropia was reduced from a mean of 6.88+/-4.4 D to 1.42+/-1.05 D at the final examination. Best-corrected visual acuity remained the same or improved in 21 of 23 eyes and decreased by 1 and 3 lines in 2 patients. There were no surgical flap or corneal transplant complications. CONCLUSIONS: LASIK is a viable treatment alternative for myopia and astigmatism after penetrating keratoplasty in patients who are contact lens-intolerant. LASIK is more effective in treating myopia than astigmatism after penetrating keratoplasty.

Subconjunctival mitomycin C for the treatment of ocular cicatricial pemphigoid.

PURPOSE: The authors performed a prospective evaluation of the efficacy of treating ocular cicatricial pemphigoid (OCP) with subconjunctival mitomycin C. DESIGN: Unmasked, prospective, internally controlled case series. METHODS: Patients were eligible for treatment with subconjunctival mitomycin C under three criteria: (1) significant complications of systemic immunosuppressant therapy; (2) markedly asymmetric conjunctival disease; and (3) end-stage OCP. All patients received monocular subconjunctival injections of 0.25 ml of 0.2 mg/ml mitomycin C to both the superior and inferior bulbar conjunctivae in the eye with the more severe disease. RESULTS: Nine eyes of nine patients (mean age, 74 years) were treated with subconjunctival mitomycin C to the more-involved eye and were followed for a mean of 23.5 months (range, 12-40 months). Eight of nine patients showed quiescence of their OCP in the treated eye based on serial evaluation of conjunctival cicatrization and grading of conjunctival erythema. Five of the nine untreated eyes showed progression of the conjunctival disease. One patient required concomitant systemic immunosuppressive therapy after subconjunctival mitomycin C. Two patients underwent successful visual rehabilitative surgery in the mitomycin C-treated eye. CONCLUSION: The use of subconjunctival mitomycin C may be effective in preventing progression of conjunctival cicatrization and erythema in patients with OCP. No complications of mitomycin C treatment were noted. Long-term follow-up and further investigation into the efficacy of subconjunctival mitomycin C in the management of OCP is warranted.

A caruncular dermoid with contiguous eyelid involvement: embryologic implications.

An 11-year-old girl with a mass arising from the caruncle and the upper eyelid was examined for spontaneous epibulbar bleeding. Excision of the lesion involved reconstruction of the proximal nasolacrimal system, lid margin, and conjunctiva. The histopathologic diagnosis was consistent with a dermoid of the caruncle. This case is notable not only for a dermoid accompanied by epibulbar bleeding but for its caruncular origin and attachment to the upper eyelid. This case suggests that the caruncle and the upper eyelid arise from similar embryologic structures.

Topical Cyclosporine A in the management of postkeratoplasty glaucoma and corticosteroid-induced ocular hypertension (CIOH) and the penetration of topical 0.5% cyclosporine A into the cornea and anterior chamber.

PURPOSE: To evaluate the effect on intraocular pressure (IOP) of substituting topical Cyclosporine A 0.5% for topical corticosteroids in patients with postkeratoplasty glaucoma and corticosteroid-induced ocular hypertension (CIOH). We also sought to determine the penetration of topical 0.5% Cyclosporine A into the cornea and anterior chamber. METHODS: Topical Cyclosporine A 0.5% was prospectively substituted for topical corticosteroids in 47 patients (52 eyes) with postkeratoplasty glaucoma and CIOH in order to eliminate the IOP-elevating effect of topical corticosteroids, while maintaining protection against allograft rejection. Ten patients received 0.5% topical Cyclosporine before keratoplasty. Their corneal tissue and aqueous samples were evaluated by high pressure liquid chromatography for Cyclosporine levels. RESULTS: Forty-eight of 52 eyes (92.3%) demonstrated a reduction of IOP at first followup (mean: -7.9 mmHg; range: -19 to +2). Mean followup was 10.3 months, ranging from 1 to 37 months. At last follow-up, mean IOP was -8.2 mm Hg. There were six allograft rejections, five of which were reversed with the reintroduction of topical corticosteroids. Graft clarity was maintained in 46 of 52 eyes (88%). The mean cornea Cyclosporine concentration was 3679 ng/gm (range: 1980 to 5520 ng/ gm) and aqueous humor mean concentration was 6.05 ng/mL (range: 0.4 to 15.5 ng/mL). CONCLUSIONS: Topical Cyclosporine A 0.5% may be substituted for topical corticosteroids to aid in the management of postkeratoplasty glaucoma and CIOH. However, the use of Cyclosporine in place of corticosteroids may be associated with an increased risk of immune rejections. The corneal penetration of topical Cyclosporine is excellent while the penetration into the anterior chamber is poor.

Conjunctival flaps.

PURPOSE: The authors reviewed their experience with total conjunctival flaps (TCF) and partial conjunctival flaps (PCF) for the past 5 years in 61 patients. METHODS: Forty-eight patients had TCF and 13 had PCF. Diagnoses for surgery included severe bullous keratopathy for chronic graft failure (not candidates for keratoplasty) (19), herpes zoster ophthalmicus (7), chronic ulcerative keratitis (14), neurotrophic keratitis (2), and herpes simplex keratitis (9). RESULTS: There were seven complications. Four flap retractions occurred in the TCF group, requiring resuturing in two. Three complications occurred in the PCF group. One patient had two flap retractions and recurrent ulceration, requiring tarsorrhaphy. One patient with PCF suffered a perforation after flap retraction, necessitating penetrating keratoplasty. CONCLUSION: The authors believe conjunctival flaps are underused and should be considered seriously for bullous keratopathy, neurotrophic keratitis, recalcitrant keratitis, and persistent nonhealing epithelial defects.

Clinical features of bleb disorder of the cornea.

BACKGROUND: Bleb disorder of the cornea is a rare corneal epithelial disorder that has previously been described in asymptomatic patients or those with recurrent nontraumatic corneal erosions. METHODS: We report two cases of bleb disorder, each presenting with blurred vision from irregular astigmatism secondary to the bleb changes. We also report on the detection of bleb disorder in siblings. RESULTS: Both patients underwent surgical debridement of the epithelium with resolution of symptoms on epithelial resurfacing. CONCLUSION: The diagnostic clues, inheritance pattern, differential diagnosis, and treatment options of bleb disorder of the cornea are discussed.

Retained Aspergillus-contaminated contact lens inducing conjunctival mass and keratoconjunctivitis in an immunocompetent patient.

PURPOSE: A 66-year-old woman presented with a 1-month history of prominent mucoid discharge and foreign body sensation in her left eye. METHODS: Ocular evaluation revealed a moderately severe superficial punctate keratitis involving the temporal half of the left cornea. The superior tarsal conjunctiva showed marked papillary reaction with an area of indentation temporally. A mass was present in the superior temporal aspect of the fornix, clinically resembling a pyogenic granuloma. At the posterior aspect of this mass and covered by mucoid material, was a soft contact lens. RESULTS: Upon removal of the lens, without any additional therapy, the patient became asymptomatic and totally resolved her keratitis and mass lesion. Cultural identification of the soft contact lens was positive for Aspergillus fumigatus. CONCLUSIONS: We hypothesize that the mucoid discharge and mass lesion represented a mechanism similar to allergic fungal sinusitis.

Suction cup/contact lens complications following penetrating keratoplasty.

PURPOSE: Rigid gas permeable (RGP) contact lenses facilitate visual rehabilitation in cases of high or irregular corneal astigmatism following penetrating keratoplasty. A variety of plunger-like suction cup devices are available to assist in the removal of these lenses. METHODS: We report three patients with serious complications associated with the use of a suction cup device for contact lens removal following penetrating keratoplasty. RESULTS: Two patients suffered corneal wound dehiscence following contact lens removal; one contact lens was removed by the patient's spouse and the other was removed by a trained technician. A third patient triggered a graft rejection, and ultimately, graft failure, after a vigorous attempt at lens removal. CONCLUSIONS: Forces generated by suction cup devices during removal of RGP contact lenses are sufficient to cause significant trauma. Contact lenses with an apical clearance fit may augment these forces, with the potential for complications following penetrating keratoplasty.

Timolol gel versus acetazolamide in the prophylaxis of ocular hypertension after phacoemulsification.

PURPOSE: To compare postoperative intraocular pressure (IOP) after administration of acetazolamide and timolol following phacoemulsification and intraocular lens implantation. SETTING: Ophthalmic Consultants of Long Island, Rockville Centre, New York, USA. METHODS: Sixty patients were included in a prospective, randomized, masked trial. The patients received either two doses of oral, sustained-release acetazolamide (Diamox Sequels) or a single dose of topical timolol 0.5% gel (Timoptic XE). Intraocular pressure was measured by Goldmann applanation tonometry preoperatively and 1 day postoperatively. RESULTS: Mean preoperative IOP was 16.4 mm Hg. One day postoperatively, it was 19.5 mm Hg in the oral acetazolamide group and 15.9 mm Hg in the timolol gel group. One patient in the acetazolamide group developed significant adverse reactions. CONCLUSION: Prophylactic use of topical timolol 0.5% gel for viscoelastic-induced ocular hypertension after cataract extraction appears to offer better IOP control than oral acetazolamide and has potentially fewer adverse systemic effects.

Topical cyclosporin A in the management of postkeratoplasty glaucoma.

PURPOSE: To evaluate the effect of substituting topical cyclosporin A 0.5% for topical corticosteroids in patients with postkeratoplasty glaucoma. METHODS: Topical cyclosporin A 0.5% was prospectively substituted for topical corticosteroids to treat 25 patients with postkeratoplasty glaucoma. RESULTS: Twenty-one (84%) of 25 patients showed a reduction in intraocular pressure (IOP) (range, 1-22 mm Hg; mean, 8.7 mm Hg). Follow-up ranged from 3 to 12 months (mean, 5.8). Graft clarity was maintained in all patients, with one allograft rejection episode. Thirteen patients were able to discontinue one or more glaucoma medication(s). CONCLUSION: Topical cyclosporin A 0.5% may be substituted for topical corticosteroids to aid in the management of postkeratoplasty patients with glaucoma. However, the resultant decrease in IOP may be associated with an increased risk for immune rejections.

Intracorneal, aqueous humor, and vitreous humor penetration of topical and oral ofloxacin.

OBJECTIVES: To investigate the intracorneal, aqueous, and vitreous penetration of ofloxacin, and to assess the concentration of the drug after topical administration alone and after combined topical and oral administration. METHODS: Twenty consecutive patients undergoing penetrating keratoplasty with vitrectomy for bullous keratopathy received 2 drops of 0.3% ofloxacin every 30 minutes starting 4 hours before surgery. Group A (10 patients) received topical therapy alone. Group B (10 patients) received an additional 3 doses of oral ofloxacin, 400 mg, every 12 hours starting 26 hours before surgery. Aqueous humor, vitreous humor, and corneal specimens were analyzed for ofloxacin levels. RESULTS: For group A, the mean intracorneal ofloxacin level was 4.51 micrograms/mL (range, 0.58-8.77 micrograms/mL; 10 specimens), the mean aqueous humor level was 1.34 micrograms/mL (range, 0.07-4.98 micrograms/mL; 8 specimens), and the mean vitreous humor level was 0.37 micrograms/mL (range, 0.05-0.90 micrograms/mL; 8 specimens). For group B, the mean intracorneal ofloxacin level was 8.59 micrograms/mL (range, 1.18-23.24 micrograms/mL; 10 specimens), the mean aqueous humor level was 2.77 micrograms/mL (range, 0.25-5.80 micrograms/mL; 10 specimens), and the mean vitreous humor level was 2.55 micrograms/mL (range, 0.28-4.97 micrograms/mL; 9 specimens). CONCLUSIONS: Topically applied ofloxacin achieves therapeutic levels in the cornea and aqueous. Mean levels achievable are well above the 90% minimal inhibitory concentration (MIC90) for the majority of bacteria responsible for endophthalmitis and corneal ulceration. The addition of oral ofloxacin to topical therapy increased vitreous penetration 7-fold in this assay trial.

Comparison of corneal sensation following photorefractive keratectomy and laser in situ keratomileusis.

PURPOSE: To evaluate the effect of photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) on corneal sensation. SETTING: Eye Institute, Medical School of the University of Crete, Heraklion, Greece, and Orasis, Hellenic Eye Center of Athens, Greece. METHODS: In a masked study, corneal sensation was measured with the Cochet-Bonnet aesthesiometer in 40 consecutive patients 6 to 12 months following PRK and LASIK (60 mm constitutes normal reading and < 40 mm, abnormal). RESULTS: After 6 to 12 months, the mean corneal sensation following PRK was 39.2 mm (range 30 to 55 mm) (mean 9.5 months) and after LASIK, 53.6 mm (range 40 to 60 mm) (mean 9.3 months). The mean correction attempted for PRK was 7.05 diopters (D) (range 2.5 to 12.0 D) and for LASIK, 11.71 D (range 6.0 to 20.0 D). CONCLUSION: In this group of patients, with correction of primarily severe myopia, corneal sensation was significantly greater after LASIK than after PRK.

Comparison of topical timolol gel to oral acetazolamide in the prophylaxis of viscoelastic-induced ocular hypertension after penetrating keratoplasty.

PURPOSE: Viscoelastic-induced ocular hypertension following penetrating keratoplasty (PK) may result in endothelial cell loss and optic nerve damage. METHODS: In a prospective, randomized, masked trial, two doses of oral sustained-release acetazolamide were compared to a single dose of topical 0.5% timolol gel after 40 PKs. RESULTS: The mean preoperative intraocular pressure (IOP) was 17.4 mm Hg for the oral acetazolamide group and 16.7 mm Hg for the timolol gel group. The mean IOP on the first postoperative day was 17.9 mm Hg with oral acetazolamide and 12.9 mm Hg with timolol gel. One patient developed significant adverse reactions with oral acetazolamide; there were no adverse reactions with timolol gel. CONCLUSION: Prophylactic use of timolol gel for viscoelastic-induced ocular hypertension after PK appears to offer better IOP control than oral acetazolamide, with potentially fewer adverse systemic effects.

Forceps and vacuum injuries to the cornea: histopathologic features of twelve cases and review of the literature.

Histopathologic and ultrastructural features were examined from 11 cases of corneal injury from obstetrical forceps and one case from vacuum extraction. Four major types of histopathologic features were observed. Type I (n = 4) included large tears of Descemet's membrane with a fragment of Descemet's membrane extending into the anterior chamber at one end of the tear and scroll formation at the other end. Type II (n = 6) consisted of scrolls of Descemet's membrane at each margin of the original break. Type III (n = 2) included those with small breaks in Descemet's membrane and healing by fibrosis at and posterior to the original tear. Type IV (n = 1) contained a small break in Descemet's membrane with minimal fibrosis. Transmission electron microscopy revealed Descemet's scrolls and retrocorneal fibrous tissue. Scanning electron microscopy revealed folds in Descemet's membrane and attenuation or absence of endothelium. Spindle- and stellate-shaped cells and pigment granules were present in the area of the tear in most cases. A review of the literature is presented.

Infectious keratitis with corneal perforation associated with corneal hydrops and contact lens wear in keratoconus.

BACKGROUND: Corneal perforation is an uncommon complication associated with keratoconus. The first cases of infectious keratitis and corneal perforation associated with corneal hydrops and contact lens wear are reported in two keratoconus patients. METHODS: A retrospective chart review and histopathological examination were carried out. RESULTS: Both patients progressed to corneal perforation and emergency penetrating keratoplasty. One patient cultured Fusarium and the second patient Serratia marcesens. Both patients wore contact lenses against medical advice. CONCLUSIONS: The tear in Descement's membrane, stromal oedema, and epithelial bedewing associated with corneal hydrops results in loss of the epithelial-endothelial barrier of the cornea, creating a conduit for infectious organisms through the cornea. Acute hydrops associated with epithelial keratitis, stromal swelling, and a Descement's membrane tear may be a significant risk factor for infectious keratitis and corneal perforation. Contact lenses should not be worn during an active corneal hydrops owing to the increased risk for severe infectious keratitis and corneal perforation.

Visually debilitating pterygium: surgical and contact lens treatment.

PURPOSE: We present the management of a patient with large pterygia complicated by irregular astigmatism and corneal opacities. Visual rehabilitation required both surgical excision and contact lens fitting. METHODS: We examined a 30-year-old man with hand motion vision from a large pterygium overgrowing his right cornea. Histopathology was consistent with pterygium. During the first few postoperative weeks, his uncorrected visual acuity improved to 20/60, and manifest refraction yielded no further improvement. In the subsequent months, there were increasing anterior stromal corneal opacities, and the refraction became hyperopic to a variable degree. RESULTS: Best corrected visual acuity was 20/70-20/100. Axial length was 22.64 +/- 0.07 mm. Computerized corneal topography 6 months postoperative was similar to the preoperative topography and revealed irregular and asymmetric astigmatism, with marked variation of the central corneal dioptric power. Slit lamp biomicroscopy suggested that the corneal opacities were responsible for the patient's decreased acuity; however, contact lens fitting provided 20/30 vision with a rigid gas permeable contact lens. CONCLUSIONS: The improved vision with contact lens therapy strongly suggested that the irregular and asymmetric astigmatism were more visually significant than the corneal opacities.

Decreased corneal sensation as an initial feature of Acanthamoeba keratitis.

BACKGROUND: Herpes simplex keratitis is the most common misdiagnosis in patients with Acanthamoeba keratitis, which is increasing in frequency and is associated with daily wear soft contact lenses. Both entities usually present as unilateral keratitis. The manifestations of superficial Acanthamoeba keratitis (i.e., unilaterality, dendriform appearance, positive response to antivirals, and decreased corneal sensation) increase the opportunity for misdiagnosis as herpes simplex keratitis. The authors have encountered six patients with Acanthamoeba keratitis in whom the correct diagnosis was delayed from 2 weeks to 3 months. METHODS: All six patients underwent testing with the Cochet-Bonnet esthesiometer and extensive pharmacologic treatment for herpes simplex keratitis. Corneal scrapings were taken between 2 and 6 weeks after the initial examination. RESULTS: In all six patients, corneal sensation was decreased significantly. Drug therapy was ineffective. Cultures were positive for Acanthamoeba. Five of six patients underwent penetrating keratoplasty. CONCLUSIONS: Decreased corneal sensation has contributed to the misdiagnosis of Acanthamoeba as herpes simplex keratitis. Misdiagnosis results in delayed treatment and worse outcome. The authors found that significantly decreased corneal sensation is a frequent finding in early Acanthamoeba keratitis. Therefore, physicians should consider Acanthamoeba keratitis as an alternative diagnosis in patients with presumed herpes simplex keratitis with decreased corneal sensation.

Juvenile xanthogranuloma of the corneoscleral limbus.

Juvenile xanthogranuloma is a rare and usually benign skin disease of unknown cause that occurs in infants and young children. We studied a case of juvenile xanthogranuloma of the corneoscleral limbus in a 17-year-old black boy, who presented with a 5-month history of a lump in the right eye. The lesion extended from the superior limbus, fanning out as it proceeded posteriorly for 6 mm with a width of 9 mm and a height of 2 to 3 mm. This yellow-orange mass was vascular and firmly fixed to the underlying tissue. The lesion was diagnosed as a dermoid and observed for 7 months without documented growth before an uneventful excisional biopsy was performed. The pathologic diagnosis showed the characteristic picture of juvenile xanthogranuloma with numerous Touton giant cells. Lipid stains provided further confirmation.