Surgical techniques and adjuvants for the management of primary and recurrent pterygia.

The removal and rate of recurrence of pterygium have been discussed for years. The disorder is highly associated with environmental factors, and recurrence rates can be unacceptably high and cannot be successfully predicted. New techniques and graft preparations and postoperative management strategies are helping to reduce the recurrence rates and provide an ocular surface that is near ideal for future cataract or refractive surgery. This review discusses the advantages and disadvantages of various treatment strategies.

Phototherapeutic keratectomy for the treatment of subepithelial fibrosis and anterior corneal scarring after descemet stripping automated endothelial keratoplasty.

PURPOSE: To describe the use of phototherapeutic keratectomy (PTK) and transepithelial photorefractive keratectomy (PRK) for the treatment of subepithelial fibrosis and anterior corneal scarring after Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: The settings included the Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, FL, and Carolina Cataract and Laser Center, Ladson, SC. Two patients with Fuchs endothelial dystrophy were noted to have anterior corneal opacities and corneal decompensation before DSAEK. Although both patients demonstrated improvement in corneal edema after DSAEK, they were left with residual anterior corneal opacities that were visually significant. The opacities were treated with excimer laser photoablation. RESULTS: Both patients demonstrated an improvement in best-corrected visual acuity after elimination of the anterior corneal opacity using PTK or transepithelial PRK. CONCLUSIONS: Excimer laser ablation is an effective option for the treatment of residual subepithelial fibrosis and anterior corneal scarring after DSAEK. When appropriate, use of PTK or PRK can also eliminate residual refractive error.

Early outcomes of descemet stripping automated endothelial keratoplasty in pseudophakic eyes with anterior chamber intraocular lenses.

PURPOSE: To evaluate complications and clinical outcomes of Descemet stripping automated endothelial keratoplasty in eyes with preexisting anterior chamber intraocular lenses. DESIGN: Retrospective review. METHODS: Thirty-one patients who underwent Descemet stripping automated endothelial keratoplasty and who had a preexisting anterior chamber intraocular lens were identified from May 2006 through March 2009. Patient follow-up ranged from a minimum of 1 month up to 30 months. Preoperative and postoperative best spectacle-corrected visual acuity, manifest refraction, comorbid conditions, and complications were recorded. Endothelial cell loss, graft dislocation, graft failure rates were calculated. RESULTS: The mean age at surgery was 78 ± 9 years (range, 53 to 91 years). All eyes had pseudophakic bullous keratopathy, except 1 patient who had a failed penetrating keratoplasty graft. Excluding those patients with severely limited visual potential because of noncorneal pathologic features, the mean best spectacle-corrected visual acuity improved significantly from 20/200 to 20/400 before surgery to 20/63 at 3 months (P < .0001), 20/60 at 6 months (P = .0006), 20/50 at 12 to 15 months (n = 10; P = .004), and 20/40 between 23 and 30 months (n = 8; median, 25 months; P = .007). The preoperative mean spherical equivalent was -0.3 ± 1.8 diopters compared with -0.15 ± 1.5 diopters after surgery (P = .78). The graft dislocation rate was 13%, and the graft failure rate was 16%. For those patients with endothelial cell density data available, the average endothelial cell loss was 48% at a mean of 14 months. CONCLUSIONS: Although Descemet stripping automated endothelial keratoplasty surgery in patients with an anterior chamber intraocular lens remains a controversial topic, the visual and anatomic outcomes from this limited study support this approach as a surgical option in selected cases.

Factors associated with intraoperative floppy iris syndrome.

PURPOSE: To identify factors associated with intraoperative floppy iris syndrome (IFIS) in patients undergoing routine phacoemulsification. DESIGN: Comparative case series. PARTICIPANTS: Analysis of 899 eyes of 660 patients undergoing routine cataract surgery. METHODS: All routine cases of cataract extraction with posterior chamber intraocular lens implantation between September 1, 2005, and August 31, 2006, were documented. Pertinent patient information, including age, gender, race, medical history, and current medication use (including tamsulosin [Flomax, Boehringer-Ingelheim, Ingelheim, Germany], other alpha(1)-antagonists, angiotensin antagonists, anticholinergics, cholinergic agonists, muscle relaxants, nitric oxide donors, and saw palmetto), were collected at the time of surgery. A telephone survey was used to determine previous use of tamsulosin, other alpha(1)-antagonists, and saw palmetto. Cases were identified intraoperatively as IFIS or non-IFIS following the triad of criteria developed by Chang and Campbell. MAIN OUTCOME MEASURES: Presence of IFIS associated with medication use and medical history. RESULTS: Analysis showed IFIS in 27 patients (4.1%) representing 33 eyes (3.7%). Tamsulosin use (P<0.001) and history of alpha(1)-antagonist use other than tamsulosin (P = 0.01) were shown to strongly correlate with IFIS in our study. Hypertension was noted to be a significant variable via multivariable generalized estimating equations analysis (P = 0.04) with a prevalence of 75.8% in patients with IFIS versus 56.4% in patients without IFIS. Saw palmetto showed a slight, but statistically insignificant, trend that current use or history of use may be associated with IFIS. There were no cases of posterior capsular rupture or vitreous loss. CONCLUSIONS: Exposure to tamsulosin highly correlates with IFIS. Use of other alpha(1)-antagonists is also associated with IFIS. Several patients in our series were identified to have IFIS with no history of alpha(1)-antagonist use, indicating that other etiologic factors, or a combination of factors, can also elicit this response. Multivariable regression analysis shows no proven relationship between IFIS and individual use of angiotensin antagonists, anticholinergics, cholinergic agonists, muscle relaxants, nitric oxide donors, or saw palmetto, and diabetes or congestive heart failure.

Comparison of the Infiniti vision and the series 20,000 Legacy systems.

PURPOSE: To compare the efficiency of the Infiniti vision system and the Series 20,000 Legacy system phacoemulsification units during routine cataract extraction. METHODS: Thirty-nine eyes of 39 patients were randomized to have their cataract removed using either the Infiniti or the Legacy system, both using the Neosonix handpiece. System settings were standardized. Ultrasound time, amount of balanced salt solution (BSS) used intraoperatively, and postoperative visual acuity at postoperative days 1, 7 and 30 were evaluated. RESULTS: Preoperatively, best corrected visual acuity was significantly worse in the Infiniti group compared to the Legacy group (0.38 +/- 0.23 and 0.21 +/- 0.16, respectively; p = 0.012). The mean phacoemulsification time was 39.6 +/- 22.9 s (range 6.0-102.0) for the Legacy group and 18.3 +/-19.1 s (range 1.0-80.0) for the Infiniti group (p = 0.001). The mean amounts of intraoperative BSS used were 117 +/- 37.7 ml (range 70-195) in the Legacy group and 85.3 +/- 38.9 ml (range 40-200) in the Infiniti group (p = 0.005). No differences in postoperative visual acuity were found. CONCLUSION: The ability to use higher flow rates and vacuum settings with the Infiniti vision system allowed for cataract removal with less phacoemulsification time than when using the Legacy system.

Cataract associated with type-1 diabetes mellitus in the pediatric population.

PURPOSE: To report 14 cases (28 eyes) of cataract associated with type-1 diabetes mellitus in young children and adolescents. METHODS: Retrospective review of the medical records of 14 patients from seven institutions. All patients under the age of 18 years who met the inclusion criteria of type-1 diabetes mellitus and cataract were included. RESULTS: Mean age at the time of diabetes diagnosis was 9.8 years (range, 0.5-14 years), and mean age at cataract diagnosis was 11.7 years (range, 5-16 years). Two patients presented with cataracts one month before the diagnosis of diabetes; seven after the diagnosis of diabetes; and in five patients the cataract was found at the time the diabetes was diagnosed by the pediatrician. Nineteen out of 23 operated eyes had a best corrected post operative visual acuity of 20/40 or better. Two patients (4 eyes) developed diabetic retinopathy postoperatively. CONCLUSIONS: Although cataract formation in type-1 diabetes is rare, it is treatable and potentially sight-saving in young children and adolescents.

High-order aberrations and preoperative associated factors.

PURPOSE: The purpose of this study was to determine which preoperative factors are associated with the presence of high-order aberrations. METHODS: A total of 93 eyes of 52 subjects were evaluated preoperatively between 1 January and 31 March 2003, using a Hartmann-Shack-based aberrometer. Age, gender, cycloplegic refraction, pupil size, keratometry readings, anterior chamber depth, white-to-white tests, intraocular pressure and basic secretion tests were evaluated. RESULTS: Factors associated with high-order aberrations included age > or = 40 years (mean 4.39 +/- 2.95 microm; p = 0.03, Mann-Whitney test), higher keratometry values (44.96 +/- 1.57 D) (r = 0.447, p < 0.001, Spearman's correlation coefficient), higher degrees of myopia (> or = - 6.1 D) (p < 0.001, Kruskall-Wallis test) and increasing pupil size (p < 0.001, anova). Other factors including anterior chamber depth, white-to-white results, intraocular pressure and basic secretion test results did not correlate with the presence of high-order aberrations preoperatively. CONCLUSIONS: Ocular wavefront aberrations varied greatly from subject to subject. Treatment should be customized for each laser based on patient characteristics in order to ensure the optimal treatment profile for the aberration.

A review of the use of ketorolac tromethamine 0.4% in the treatment of post-surgical inflammation following cataract and refractive surgery.

The non-steroidal anti-inflammatory drug (NSAID) ketorolac tromethamine 0.4% ophthalmic solution, a recent reformulation containing 20% less active ingredient that the original formulation, is indicated for the reduction of ocular pain and burning/stinging following corneal refractive surgery. Clinical studies have shown ketorolac tromethamine 0.4% to be as effective as ketorolac tromethamine 0.5% to control inflammation after cataract surgery including prevention of cystoid macular edema (CME). Its efficacy to inhibit miosis during cataract surgery as well as its role in the treatment of dry eye has been reported. The purpose of this paper is to review the use of ketorolac tromethamine 0.4% in the treatment of post-surgical inflammation following cataract and refractive surgery.

Randomized, double-masked clinical trial evaluating corneal endothelial cell loss after cataract extraction and intraocular lens implantation: Fluid-based system versus ultrasound phacoemulsification.

PURPOSE: To assess the endothelial cell loss after cataract extraction using a fluid-based system and compare it with conventional ultrasound. METHODS: A total of 46 eyes of 23 patients with up to 3+ bilateral cataract were included. The first eye was randomized to either fluid-based system or conventional ultrasound, and the fellow eye received the alternate system. Visual acuity and ultrasound pachymetry were measured preoperatively and at 1 day, 1 week, and 1 and 3 months postoperatively. Specular microscopy was performed preoperatively and 3 months after the surgery. Data was analyzed using the paired t test and Wilcoxon signed rank test. A P value less than 0.05 was considered statistically significant. RESULTS: Postoperatively, no significant differences were found among the groups. However, there was a significant difference (P < 0.01, analysis of variance with Tukey as posttest) in corneal pachymetry at day 1 after the surgery compared with baseline in both groups. There was a 6.3% and 7.9% loss of endothelial cells in the fluid-based system and ultrasound group, respectively. CONCLUSION: Visual acuity, pachymetry, and endothelial cell loss after cataract extraction and intraocular lens implantation using a fluid-based system is similar to conventional ultrasound.

Immunoglobulin gene implicated in murine herpes stromal keratitis is not associated with the human disease.

PURPOSE: Susceptibility to herpes stromal keratitis (HSK) is strongly influenced by genetic factors, as shown by multiple rodent models using human herpes simplex virus. A single gene, encoding the immunoglobulin G (IgG) 2a heavy chain protein, confers susceptibility or resistance through a mechanism involving molecular mimicry in one mouse model. However, other rodent studies have produced contradictory results. This study tested the hypothesis that the GM23 gene (the human IgG2a homolog) influences susceptibility to HSK in humans. METHODS: The study population consisted of all consenting patients diagnosed with HSK (25 whites, 2 African Americans) at the Medical University of South Carolina Storm Eye Institute Clinic in Charleston, SC, between August 2000 and June 2004. Healthy controls (23 white adults with no history of HSK) were recruited from the same local population. Genomic DNA from subjects was genotyped at the GM23 locus, which has been implicated as an HSK resistance gene in animal models, by polymerase chain reaction-restriction fragment length polymorphism (RFLP) analysis. RESULTS: No difference in GM23 genotype frequency was observed between patients with HSK and controls. CONCLUSION: Susceptibility to HSK in whites is not predicted by GM23 genotype.

Ocular manifestations after primary varicella infection.

PURPOSE: To report a case of ocular manifestations after a primary varicella infection. METHODS: Review of the literature and a case report of a 10-year-old male patient with history of blurry vision and an enlarged pupil 2 months after a varicella infection. Examination revealed uveitis, interstitial keratitis, and internal ophthalmoplegia. RESULTS: The uveitis resolved with topical steroids; the interstitial keratitis resolved with a faint scar, and the internal ophthalmoplegia persisted. CONCLUSION: This case report describes a patient with uncommon ocular manifestations after primary varicella.

Evaluation of 0.4% ketorolac tromethamine ophthalmic solution versus 0.5% ketorolac tromethamine ophthalmic solution after phacoemulsification and intraocular lens implantation.

PURPOSE: The aim of this study was to compare the effectiveness and patient tolerance of 0.4% ketorolac tromethamine ophthalmic solution and 0.5% ketorolac tromethamine ophthalmic solution after routine phacoemulsification and lens implantation. SETTING: The setting for this study was the Storm Eye Institute and Magill Research Center for Vision Correction, Medical University of South Carolina (Charleston, SC). METHODS: This work was a prospective, double-masked study that included 40 eyes of 40 patients randomly assigned to receive topical treatment with 0.4% ketorolac or 0.5% ketorolac, starting 15 min prior to routine phacoemulsification and foldable posterior chamber intraocular lens implantation. Following the procedure, patients were instructed to use the assigned treatment agent 4 times a day after surgery for 1 week and twice a day for 3 weeks, when drops were discontinued. Slit-lamp examination, intraocular pressure (IOP), laser cell and flare measurements, and subjective patient tolerance were evaluated postoperatively at 1, 7, and 30 d. Comparisons between the 2 groups were made at each visit, as well as comparisons to baseline. A P=value less than .05 was considered statistically significant. RESULTS: At day 1, a higher percentage of patients (70% vs. 40%) reported symptoms (mainly foreign body sensation and stinging/burning) in the 0.5% ketorolac group, compared to the 0.4% ketorolac group. No significant differences were found between the 2 groups over time regarding best-corrected visual acuity (BCVA), IOP, slit-lamp assessment of cells, and cell and flare measured using the laser cell/flare meter. CONCLUSIONS: Treatment with 0.4% ketorolac tromethamine ophthalmic solution is as effective as 0.5% ketorolac tromethamine ophthalmic solution in reducing inflammation after routine cataract surgery. Patients reported less discomfort using 0.4% ketorolac.

Bronchogenic squamous cell carcinoma presenting as cicatrizing conjunctivitis.

PURPOSE: To report a case of cicatrizing conjunctivitis as the initial manifestation of a bronchogenic squamous cell carcinoma. METHODS: Case report of a 57-year-old patient with bilateral history of ocular pain, redness, and discharge, with no apparent predisposing factors. Examination revealed chemosis, pseudomembrane, and symblepharon formation, and multiple ulcerated pustular and vesicular periocular and perioral lesions literature review. RESULTS: Skin biopsy was compatible with bullous pemphigoid. Two months later he developed respiratory symptoms, and a squamous cell carcinoma was diagnosed. CONCLUSIONS: This case demonstrates cicatrizing conjunctivitis as a possible paraneoplastic syndrome associated with squamous cell lung carcinoma.

Prevention of Staphylococcus aureus endophthalmitis with topical gatifloxacin in a rabbit prophylaxis model.

PURPOSE: The aim of this study was to investigate the prophylactic use of 0.3% gatifloxacin drops to prevent endophthalmitis in a rabbit model. METHODS: Forty (40) New Zealand white rabbits were randomly placed into group A (20 rabbits) where they received 1 drop of 0.3% gatifloxacin in their right eye every 15 min (0, 15, 30, and 45 min), or group B (20 rabbits) where they received 1 drop of balanced salt solution (BSS) in their right eye every 15 min (0, 15, 30, and 45 min). Following this treatment regimen, the anterior chamber of each rabbit was injected with 0.025 mL of saline containing 5 x 10(5) colonyforming units of a clinical isolate of Staphylococcus aureus (vancomycin-sensitive). After the inoculum injection, the treatment regimen continued: group A (1 drop of 0.3% gatifloxacin) or group B (1 drop of BSS) immediately postinjection, 6, 12, 18, and 24 h, at which time the animals were examined in a masked fashion, photographed, anesthetized, euthanized, and the aqueous and vitreous humors collected to determine the number of viable bacteria. RESULTS: The median clinical scores for the gatifloxacin group were significantly lower than the control group (P < 0.05). Bacterial recovery of S. aureus was significantly higher in the control group in both the aqueous and vitreous humor (P < 0.05). CONCLUSIONS: Gatifloxacin-treated eyes demonstrated significantly less inflammation, infection, and culture-positive endophthalmitis (P < 0.05), compared to the control animals. It is important to further investigate the clinical implications from this prophylatic study.

Effect of hinge location on corneal sensation and dry eye after laser in situ keratomileusis for myopia.

PURPOSE: To evaluate the effects of a superior or nasal hinge location on corneal sensation and dry eye after laser in situ keratomileusis (LASIK). SETTING: Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: This prospective randomized masked study included 47 patients having bilateral myopic LASIK surgery. The first eye was randomly assigned to have a nasal or superior hinge flap; the fellow eye had the alternate location. Visual acuity, contrast sensitivity, corneal sensation, basic secretion test, tear film breakup time, conjunctival and corneal staining, and a subjective questionnaire were evaluated preoperatively and postoperatively at 1 week and 1, 3, and 6 months. The Wilcoxon signed rank test and paired t test were used for comparison. RESULTS: Dry eye occurred with the same frequency in both groups. However, eyes with the nasal hinge had significantly better nasal sensation than those with the superior hinge (P<.05) at 1 month. CONCLUSION: Better nasal corneal sensation was found at 1 month in the nasal hinge group but there was no difference in any other parameters measured.

Cryptococcus albidus keratitis after corneal transplantation.

PURPOSE: To report suspected donor-to-host transmission of Cryptococcus albidus after penetrating keratoplasty. METHODS: Review of the literature and a case report of a 69-year-old woman who underwent penetrating keratoplasty for Fuchs corneal dystrophy and developed persistent corneal infiltrates 7 months postoperatively are presented. RESULTS: Cryptococcus albidus was cultured from the original donor tissue at the time of the repeat keratoplasty. CONCLUSION: This case demonstrates an unusual case of cryptococcal keratitis after keratoplasty suspected to be a donor-to-host transmission.

Refractive Surgery Survey 2004.

To determine the refractive surgery (RS) preferences of ophthalmologists worldwide, questionnaires were sent to 8897 members of the American Society of Cataract and Refractive Surgery. A total of 1053 questionnaires were returned by the deadline. The practice distribution included 29.5% cataract surgeons, 48.8% comprehensive ophthalmologists, 11.6% RS specialists, 5.1% cornea and external disease specialists, 1.9% glaucoma specialists, 1.1% retina specialists, and <1.0% oculoplastics/pediatrics/researchers/retired. Results were compared with those in the 2003 survey and demonstrate that refractive surgery continues to develop and change.

Herpes zoster ophthalmicus: presenting as giant-cell arteritis.

A 74-year-old woman was referred to the authors' clinic with a 1-week suspicion of giant-cell arteritis. Uncomplicated, bilateral temporal artery biopsies were performed 3 days after admission for therapy. Four hours after the procedure she developed vesicular lesions of the face compatible with herpes zoster ophthalmicus. The temporal artery biopsy revealed perineural lymphocytic aggregation. Both giant-cell arteritis and herpes zoster ophthalmicus form part of the differential diagnosis in elderly patients with headache. In such cases, clues from a temporal artery biopsy may aid in diagnosis of herpes zoster. In addition, the patient in this case developed the rash 10 days after onset of symptoms, which is rare as the average time from onset of symptoms to rash in zoster is 3-5 days.

Corneal endothelial cell damage after lens extraction using the fluid-based system compared to ultrasound phacoemulsification in human cadaver eyes.

PURPOSE: To compare the endothelial cell damage after lens removal using a fluid-based system to conventional ultrasound. METHODS: Twenty human cadaver eyes were randomized to undergo phacoemulsification using either a fluid-based system or conventional ultrasound. After surgery, each corneoscleral button was removed, stained and damaged endothelial cells per square millimeter were assessed using light microscopy. RESULTS: Fluid-based system mean damaged endothelial cells/mm was 60.2 +/- 24.1 compared with 60.4 +/- 42.6 when using conventional ultrasound (P = 0.248). CONCLUSION: The fluid-based system is as safe for the corneal endothelium as conventional ultrasound during cataract removal in human cadaver eyes.

Comparison of wavefront sensing devices.

Wavefront measurement is an emerging technology that can evaluate low-order and high-order aberrations. This review compiles the different wavefront sensing devices and compares the most popular Hartmann-Shack aberrometers.