Transplantation of autologous cultivated oral mucosal epithelial sheets for limbal stem cell deficiency at Siriraj Hospital: a case series.

BACKGROUND: The loss of limbal stem cells owing to either corneal burn or inflammation leads to the repopulation of opaque skin over the raw surface of the cornea. It has been proposed that reconstitution of oral mucosal stem cells over this raw surface will mimic the limbal stem cells and restore vision. The efficacy and safety of applying a sheet of cultivated oral mucosal cells as an autologous graft for corneal replacement were evaluated. CASE PRESENTATION: The study was conducted during 2014-2015 and involved a total of six patients, of whom three had suffered a chemical burn and three had Stevens-Johnson Syndrome (SJS). Oral mucosal tissue was dissected from each patient, seeded onto irradiated J2 fibroblast feeder cells for 14 days, and analyzed for quality and safety 1 day before being transplanted onto the cornea of the affected eyes. After transplantation, topical antibiotic and anti-inflammatory eye drops were instilled four times daily, and the patients wore contact lenses. Subjects were clinically followed for visual acuities and adverse effects at 2, 4, and 6 weeks, 3 and 6 months, and 1 year post-transplantation. Data were presented descriptively. Visual acuities in patients improved at 2 weeks post-surgery. However, two patients with SJS had corneal ulcer at 2 weeks postoperatively. At the 1-year postoperative examination, the eyes of two patients were in good condition with decreased vascularization and epithelial defect. CONCLUSIONS: Cultivated oral mucosal epithelial sheet transplantation in limbal stem cell deficiency had a favorable efficacy. In this study, patients with chemical burn had more clinical benefit than those with SJS. Trial registration ClinicalTrials.gov: NCT02415218. Registered retrospectively 4 Apr 2015 ( https://clinicaltrials.gov/ct2/show/NCT02415218 ).

Keratoconus in Patients with Macular Stromal Dystrophy.

OBJECTIVE: To show the association between keratoconus and macular dystrophy. MATERIAL AND METHOD: All patients with macular dystrophy and associated clinical findings leading to a diagnosis of keratoconus by corneal topography were retrospectively reviewed during a 10-year period. Uncorrected and best-corrected visual acuity, automated refraction, manifest refraction, corneal thickness, and corneal curvature by corneal topography were evaluated RESULTS: Three patients with macular dystrophy exhibiting decreased vision, multifocal white dense deposits, and haze surrounding the deposits in the corneal stroma were evaluated. All had a steep corneal curvature of >47 diopters and a thin cornea consistent with keratoconus. Penetrating keratoplasty was performed in one patient with severely decreased vision. Macular dystrophy was diagnosed based on an Alcian blue-stained pathological specimen. CONCLUSION: Keratoconus may develop as a result of changes associated with macular dystrophy. Therefore, patients with severely decreased vision should be evaluated for keratoconus to ensure proper management.

Clinical features of Acanthamoeba keratitis in contact lens wearers and non-wearers.

Clinical presentations of patients with Acanthamoeba keratitis (AK) attending the Faculty of Medicine Siriraj Hospital during 1996-2006 were reviewed. The studied parameters included history of ocular trauma, use of contact lenses, associated eye diseases, systemic diseases, visual acuity, symptoms, signs, treatment, visual outcomes, and sequelae. Data were analyzed by comparing non-contact lens (nCL) and contact lens (CL) wearers with eachother. Twenty-two patients (24 affected eyes) (68.2% female) had AK, 9 (37.5%) were nCL and 15 (62.5%) were CL. Both groups had similar basic characteristics; however the nCL group was significantly older (48.3 +/- 14.5 vs 30.6 +/- 15.3 years old, p=0.006), and tended to have a longer duration of symptoms with more severe clinical findings, but this was not statistically significant. Eleven had severe ciliary injection (nCL 55.5%, CL 40.0%), 3 had satellite lesions (nCL 22.2%, CL 6.7%), 2 had radial keratoneuritis in the CL group (13.3%), 1 ring infillrate in the nCL group (11.1%) and 1 pseudodendrite in the CL group (6.7%). The mean duration of follow-up was 8.2 +/- 7.9 (ranging 0.3-29) months. Therapeutic measures included anti-Acanthamoeba medications (5/9 for nCL, 8/15 for CL), penetrating keratoplasty due to uncontrolled infections (1/9 for nCL, 2/15 for CL) and corneal perforation (1/9 for nCL), and enucleation due to endophthalmitis (1/9 for CL). At the last follow-up visit, the CL [corrected] group had slightly better visual acuity (55.5% vs 66.7%). In conclusion, AK among patients who do not use contact lenses may have a delayed diagnosis, resulted in more severe ocular manifestations and poorer prognosis. Physicians should be aware of Acanthamoeba infection as a cause of keratitis in any patient, not just contact lens wearers. Long periods of follow-up are recommended to observe for recurrent episodes and proper management of AK patients.

Risk factors for contact lens related microbial keratitis: a case-control study.

OBJECTIVE: To evaluate the risk factors that may contribute to microbial keratitis in contact lens wearers. MATERIAL AND METHOD: This prospective case-control study included 52 patients with contact lens related keratitis treated between 1 December 2006 and 15 October 2007 at the Faculty of Medicine, Siriraj Hospital. Controls were sixty-three contact lens users attending with disorders unrelated to contact lens wear All subjects with informed consent were interviewed about demographic data, types of contact lens and contact lens solutions, contact lens use past the recommended replacement date, overnight wear, and lens hygiene. Odds ratio (OR, estimates of relative risks) and 95% confidence interval (CI) were calculated through multivariable logistic regression analysis. RESULTS: The use of contact lens past the replacement date caused the highest risk of developing microbial keratitis (OR = 9.1; CI 1.8-45.4, p = 0.005). Overnight wear of lenses (OR = 2.9, CI 1.3-6.2, p = 0.012) and poor lens hygiene (OR = 2.3, CI 1.0-5.1, p = 0.007) significantly increased the risk of microbial keratitis, respectively. None of the other risk factors showed a significant association. CONCLUSION: The significant risk factors for contact lens related microbial keratitis in the present study were the use of contact lens past the replacement date, overnight wear, and poor lens hygiene. Thus, the appropriate advice of contact lens care and usage may reduce the risk of microbial keratitis in contact lens wearers.

Refractive outcomes of femtosecond LASIK for myopic correction at Siriraj Hospital, Thailand.

OBJECTIVE: To evaluate refractive outcomes of myopic femtosecond LASIK at Siriraj Hospital, Thailand. MATERIAL AND METHOD: A retrospective study of patients who underwent femtosecond LASIK at SiLASIK center Siriraj hospital, Mahidol University, Thailand,from April 2009 to April 2010 was conducted. All patients had completely normal preoperative eye examination. All LASIK procedures were performed using Intralase femtosecond laser (Abbott Medical Optics Inc (AMO)) and VISX star S4 excimer laser (AMO). Postoperative follow-up included visual acuity (ETDRS chart) and manifest refraction at 1 day, 1 week, 1 month and 3 months. The flap thickness was evaluated at 3 months using Visante optical coherence tomography (OCT Carl Zeiss Meditec). RESULTS: One hundred and twenty eight eyes of 64 patients were included in the study. Mean preoperative manifest refraction spherical equivalent (MRSE) was -5.47 +/- 2.28 diopters (range, -1.88 to -12.63 diopters). At 3 months post-operation, the MRSE was -0.26 +/- 0.39 diopters (range, + 0.25 to -2.00 diopters) and 95.31% were within + 1.00 diopter of intended correction. There was 98% of eyes achieved uncorrected distance visual acuity (UDVA) 20/40 or better and 73% achieved UD VA 20/20 or better There was 31% of eyes gained one line and 15% lost 1 line of corrected distance visual acuity (CDVA). The mean error of flap thickness (difference between actual and intended central flap thickness) was + 0.23 +/- 1.77 microm for 120 microm flap setting and + 0.22 +/- 0.97 microm for 110 microm flap setting. The flap morphology was planar configuration. CONCLUSION: Myopic femtosecond LASIK at Siriraj Hospital provided satisfactory refractive outcomes and high accuracy of the flap thickness.

Efficacy of amniotic membrane patching for acute chemical and thermal ocular burns.

OBJECTIVE: To study the efficacy of amniotic membrane patching (AMP) for acute chemical and thermal ocular burns and compare the results with a control group. MATERIAL AND METHOD: Fifteen patients (21 eyes) with acute ocular burn severity grading of II to IV were retrospectively reviewed. Thirteen eyes were treated with preserved AMP while eight eyes were treated with conventional treatment. Outcomes and complications were evaluated and compared between eyes in the AMP group and the control group with the same severity of burn. RESULTS: In the AMP group, the mean age was 36.9 +/- 11.7 years (range, 20-58). The mean follow-up time was 8.0 +/- 6.8 months (range, 1-20). Complete epithelialization was achieved in 69.2% (9/13 eyes) in total, 100% (5/5 eyes), 100% (3/3 eyes) and 20% (1/5 eyes) in grade II, III and IV respectively. Mean epithelial healing time in the AMP group was 10.4 +/- 5.8 days (range, 4-20). Comparison of grade 2 and 3 burns showed that the AMP group in which patching was performed within 5 days resulted in faster epithelial healing, less corneal haze and limbal deficiency than in the group in which patching was performed after 5 days, and the control group (mean epithelial defect 7.0 +/- 2.0, 19.5 +/- 0.7, 9.9 +/- 10.8 days respectively). CONCLUSION: Adjunctive treatment of ocular burns with AMP promoted rapid epithelial healing and reduced corneal complication. Surgery performed in the early stage tended to yield a better outcome.

Tonometry after laser in situ keratomileusis treatment: a preliminary study in Thai patients.

OBJECTIVE: To evaluate the change in intraocular pressure (IOP) measurement by Goldmann applanation tonometer after Laser in Situ Keratomileusis (LASIK) for myopia and myopic astigmatism, and to assess the correlation between the changes of lOP reading and the reduction of central corneal thickness (CCT) after LASIK in Thai patients. STUDY DESIGN: Prospective correlational study. MATERIAL AND METHOD: LASIK was performed on 65 eyes of 33 patients for correction of myopia and myopic astigmatism. IOP was measured by Goldmann applanation tonometer before and 3 months after LASIK. The correlation between the change in IOP reading and the change in central corneal thickness were evaluated. RESULTS: IOP reading was significantly reduced by mean of 2.9 +/- 2.5 mmHg (p = 0.0001). The authors used Pearson analysis to study the correlation between the change in IOP and the reduction of CCT. In subgroup analysis the patients were divided by degree of myopia: group 1, myopia less than -3 diopters (D) (n = 14); group 2, myopia -3 to -6 D (n = 31); group 3, myopia greater than -6 D (n = 20)). The result showed more correlation in higher myopia group (Pearson; r = 0.158 in group 3, r = -0.098 in group 2 and r = -0.102 in group 1). CONCLUSION: Goldmann applanation tonometry underestimates the IOP in thin cornea. Variability in CCT is a potent confounder of this tonometry technique. Therefore, it has important implications for considering CCT measurement incorporated with Goldmann applanation tonometry for glaucoma diagnosis especially in myopic patients who undergo LASIK surgery.

Topical 0.002% mitomycin C for the treatment of conjunctival-corneal intraepithelial neoplasia and squamous cell carcinoma.

PURPOSE: To demonstrate the efficacy of topical 0.002% mitomycin C (MMC) as an adjunctive and alternative treatment in primary and recurrent conjunctival-corneal intraepithelial neoplasia (CCIN) and squamous cell carcinoma (SCC). METHODS: The medical records of 7 patients with histopathologically confirmed CCIN and conjunctival SCC were retrospectively reviewed. All cases were treated with topical 0.002% MMC 4 times daily. The tumor size pre- and post-treatment, clinical response, and ocular complications were evaluated. RESULTS: The mean age of the patients was 56 +/- 13.4 years. The most common presenting symptom was foreign body sensation (57.1%) with a mean duration of 2.3 +/- 3.8 months. Six patients had pathologically proven CCIN (85.7%) and 1 had SCC (14.3%). Before MMC treatment, 6 eyes (85.7%) had recurrences after surgical excision. The tumor-free period ranged from 2 to 19 months. Two patients had multiple recurrences. MMC 0.002% 4 times daily was applied for a period of 5.4 +/- 4.4 weeks (range, 2-14). All had complete tumor regression as observed clinically and confirmed by impression cytology. Side effects of MMC therapy included ocular irritation, mild conjunctival hyperemia, and punctate keratopathy. There were no serious complications detected. The mean follow-up time was 30.7 +/- 15 months (range, 2-52) with no evidence of clinical recurrence in any case. CONCLUSIONS: Topical 0.002% MMC showed a favorable outcome as an adjunctive and alternative treatment of CCIN and SCC with regression of primary and recurrent tumors.

Comparison of topical lomefloxacin 0.3 per cent versus topical ciprofloxacin 0.3 per cent for the treatment of presumed bacterial corneal ulcers.

PURPOSE: To compare the efficacy and safety of topical lomefloxacin 0.3 per cent with topical ciprofloxacin 0.3 per cent for treating mildly severe suspected bacterial corneal ulcers. METHOD: This prospective, randomized, double-masked controlled clinical trial was conducted on 41 patients (41 eyes) with suspected bacterial corneal ulcers who were randomized into 2 groups: 23 patients were in the lomefloxacin group and 18 patients in the ciprofloxacin group. All of these corneal ulcers were scraped for gram's stain, KOH preparation and microbiologic cultures before starting treatment. The clinical success rate, the time to cure, the rates of treatment failures, ocular signs and symptoms and the adverse effects of the study medication were evaluated. RESULTS: Topical lomefloxacin is equivalent clinically and statistically to topical ciprofloxacin. No statistically significant treatment differences were found between lomefloxacin (100%) and ciprofloxacin (100%) in terms of success rate. Similarly, no differences were noted in the time to cure (p > 0.05), the treatment failure, or the resolution of the clinical signs and symptoms (p > 0.05). The adverse effects of lomefloxacin were superficial punctate keratitis (26.1%) and irritation (8.7%), whereas those of ciprofloxacin were superficial punctate keratitis (22.2%), white precipitate (11.1%) and irritation (11.1%). However, no statistically significant differences of these adverse effects were found between the two groups (p > 0.05). CONCLUSION: Lomefloxacin ophthalmic solution (0.3%) is equivalent clinically and statistically to ciprofloxacin ophthalmic solution (0.3%) for the treatment of mildly severe presumed bacterial corneal ulcers without statistically significant differences in the adverse effects and discomfort.

Application of Preserved Human Amniotic Membrane for Corneal Surface Reconstruction.

Objective: To evaluate the efficacy of preserved human amniotic membrane transplantation for reconstruction of the corneal surface diseases.Methods: Preserved human amniotic membrane transplantations were performed in 84 eyes of 78 patients for corneal surface reconstruction. The indications were limbal stem cell deficiency from Steven-Johnson syndrome, chemical burn and herpes keratitis (27 eyes), bullous keratopathy (26 eyes), persistent epithelial defect and dellen (17 eyes), band keratopathy (11 eyes), preparing for prosthesis (1 eye), corneal ulcer (1 eye) and acute chemical burn (1 eye).Results: Success was noted in 83.3% (70/84) eyes, partial success in 13.1% (11/84) eyes, and failure in 3.6% (3/84) eyes for an average follow-up of 10.5 months (3 - 29 months). No patient developed major immediate post-operative complications.Conclusion: Amniotic membrane transplantation can reduce inflammation, promote corneal epithelial healing, and decrease irritation in corneal surface problems.