Escleroqueratoplastia terapéutica sectorial de grosor completo en queratitis fúngica recurrente / Therapeutic sectorial full-thickness sclero-keratoplasty for recurrent fungal keratitis

OBJETIVO: Comunicar el manejo de una queratitis fúngica recurrente severa, que requirió repetidas queratoplastias penetrantes. A pesar de los múltiples tratamientos antifúngicos tópicos, intraoculares y sistémicos, una infiltración micótica superotemporal repetidamente penetraba y descompensaba al trasplante corneal. Los cultivos preoperatorios y operatorios aislaron al mismo organismo, Fusarium spp. DISCUSIÓN: La infección corneal que se expande a la esclera o a las estructuras del ángulo interno es la causa más frecuente de recurrencia en la queratitis fúngica después del trasplante de córnea. En estos casos, la escleroqueratoplastia sectorial de grosor completo del sitio sospechoso de recurrencia, asociada a una queratoplastia penetrante central, debería ser una técnica quirúrgica a considerar ya que permite una eliminación definitiva de la infección con excelentes resultados de agudeza visual final. Ninguna complicación postoperatoria ha sido registrada en este caso

OBJECTIVE: To report the management of a severe and recurrent fungal keratitis that required repeated penetrating keratoplasties. Despite multiple topical, intraocular and systemic antifungal treatments, superotemporal hyphal infiltration repeatedly penetrated the corneal transplant causing continuous recurrences. Cultures collected before and during surgery isolated the same organism, Fusarium spp. CONCLUSION: Corneal infection extending to the sclera and internal angle structures is the main cause of recurrence of fungal keratitis after corneal transplantation. Sectorial full-thickness sclero-keratoplasty combined with a central penetrating keratoplasty should be a surgical technique to be considered in cases where these locations are suspected to be the source of recurrence. It enables a definitive elimination of the infection, with excellent final visual acuities. No postoperative complications were reported in this case

Therapeutic sectorial full-thickness sclero-keratoplasty for recurrent fungal keratitis.

OBJECTIVE: To report the management of a severe and recurrent fungal keratitis that required repeated penetrating keratoplasties. Despite multiple topical, intraocular and systemic antifungal treatments, superotemporal hyphal infiltration repeatedly penetrated the corneal transplant causing continuous recurrences. Cultures collected before and during surgery isolated the same organism, Fusarium spp. CONCLUSION: Corneal infection extending to the sclera and internal angle structures is the main cause of recurrence of fungal keratitis after corneal transplantation. Sectorial full-thickness sclero-keratoplasty combined with a central penetrating keratoplasty should be a surgical technique to be considered in cases where these locations are suspected to be the source of recurrence. It enables a definitive elimination of the infection, with excellent final visual acuities. No postoperative complications were reported in this case.

Superficial keratectomy and amniotic membrane patch in the treatment of corneal plaque of vernal keratoconjunctivitis.

PURPOSE: To report the importance of early surgical treatment of corneal ulcers associated with vernal keratoconjunctivitis (VKC) which may potentially produce severe lesions and permanent visual sequelae. METHODS: The authors present the case of a child with corneal ulcer in plaque who did not respond to medical treatment and had a good response to surgical treatment. RESULTS: A superficial keratectomy with an amniotic membrane patch was performed. A rapid postoperative epithelialization with a final good visual acuity was achieved. CONCLUSIONS: Although amniotic membrane grafts following keratectomy have been described as a successful treatment in deep ulcers, in cases with slight stromal thinning, the amniotic membrane patch may be enough to achieve epithelialization. This procedure avoids the presence of the remains of membrane under the epithelium, which may affect postoperative corneal transparency.

Pathological findings in the lens capsules and intraocular lens in chronic pseudophakic endophthalmitis: an electron microscopy study.

PURPOSE: The aim of this study was to describe the pathological findings in lens capsules and intraocular lens (IOL) studied by scanning and/or transmission electron microscopy (SEM and TEM, respectively) in a series of four eyes with chronic pseudophakic endophthalmitis (CPE). PATIENTS AND METHODS: We performed a retrospective study of four patients presenting CPE in whom surgical treatment with pars plana vitrectomy, capsulectomy with extraction of the IOL, and intravitreous antibiotic therapy was thereafter performed. The extracted IOL and the capsular remains were studied by SEM and/or TEM and microbiologic analysis of aqueous humour and vitreous aspirate was also carried out in all the cases. RESULTS: The presence of microorganisms was observed in the material analysed in all the cases studied. The use of TEM identified bacterial contamination by Staphylococcus spp and mixed contamination with microorganisms presenting a bacillar morphology suggestive of infection by Propionibacterium acnes in addition to the presence of cocci in the capsular remains. In another two cases, SEM localized colonies of Staphylococcus spp on the surface of the IOL in one case and mixed bacterial colonization with cocci plus filamentous bacteria in the other. The presence of macrophages associated with bacteria was observed in the capsular remains. CONCLUSIONS: Microorganisms were found in the IOL or the capsular material in the four cases studied, thereby explaining the refractoriness and severity of infection. The possible presence of polymicrobial infections, especially in the cases with filamentous bacteria, also explains the recurrence of infection.

Amniotic membrane transplantation for ocular surface pathology: long-term results.

Amniotic membrane transplantation has been used for >90 years for cutaneous and mucous lesions for regeneration of tissues. In recent years its effectiveness has been demonstrated in the treatment of diseases of the ocular surface. We present our experience with 53 amniotic membrane transplantations for different ocular pathologies with two different forms of implantation. The 53 cases were divided into three groups according to pathology and type of implant. Group 1 included 24 eyes with amniotic membrane grafts after resection of extensive conjunctival lesions. Group 2 included 19 eyes with amniotic membrane grafts for corneal pathology, and group 3 consisted of 10 eyes with amniotic membrane patches for corneal epithelial defects without ulceration. No intra- or postoperative complications were observed during an average follow-up period of 32 months (24-48 months). Group 1 demonstrated rapid healing of the lesions with minimal scarring in all cases. In group 2 a favorable response was observed in 16 of 19 cases. In group 3 complete healing was achieved in only 3 of 10 cases, and the time for which the graft remained was related to the success of the treatment. The primary intention was to achieve prolonged fixation of the implant. Finally, amniotic membrane transplantation is a safe and effective technique for the treatment of different pathologies of the ocular surface. After the resection of extensive conjunctival lesions it is currently the preferred treatment. In corneal pathology, it represents an additional therapeutic alternative when conservative medical treatments fail.

[Topical treatment with mitomycin C in considerably raised conjunctival intraepithelial neoplasia]. / Tratamiento tópico con mitomicina C en la neoplasia intraepitelial córneo-conjuntival de gran espesor.

CASE REPORT: We present a case of recurrent conjunctival intraepithelial neoplasia, treated previously on two occasions with excisional biopsy. Although the lesion was considerably raised, topical treatment with mitomycin-C 0.04% was applied, achieving the complete regression of the tumor. DISCUSSION: Topical mitomycin-C acts at the ocular surface. However, successive treatment cycles can achieve complete regression, even in considerably thick tumors.

Tratamiento tópico con mitomicina c en la neoplasia intraepitelial córneo-conjuntival de gran espesor / Topical treatment with mitomycin c in considerably raised conjunctival intraepithelial neoplasia

Caso clínico: Presentamos un caso de neoplasia intraepitelial córneo-conjuntival recidivante, tratado previamente mediante resección en dos ocasiones. A pesar de la gran elevación de la lesión se instauró tratamiento tópico con mitomicina C 0,04 por ciento consiguiéndose la regresión completa del tumor. Discusión: Aunque la mitomicina C tópica actúa en la superficie de las lesiones, el tratamiento con sucesivos ciclos puede conseguir la completa regresión de tumores de gran grosor (AU)

Ocular involvement in a case of systemic indeterminate cell histiocytosis: a case report.

PURPOSE: To describe ocular involvement in a case of systemic indeterminate cell histiocytosis, a rare disease characterized by the proliferation of indistinct histiocytes. These histiocytes resemble Langerhans cells but lack Birbeck granules. The disease usually occurs in adults, with no predisposition for either sex. The clinical features include multiple asymptomatic nodules and cutaneous papules. There are no previous reported cases in the literature regarding ocular indeterminate cell histiocytosis and its treatment. METHODS: A patient with skin papules and hyperpigmentation associated with systemic involvement and corneal infiltration was diagnosed with systemic indeterminate cell histiocytosis after a skin biopsy. Immunohistochemical examination showed specific surface proteins of indeterminate cells, and electron microscopy showed Langerhans-like cells without typical Birbeck granules. Progressive and severe photophobia and corneal thickening made bilateral corneal transplant necessary. RESULTS: Visual acuity remained stable because of the use of systemic immunosuppressors, which decrease the recurrence of infiltration after a corneal transplant. CONCLUSION: Indeterminate cell histiocytosis is a rare disease and there is no previous description of ocular involvement. Infiltrating lesions must be treated with corneal transplant and systemic cyclosporin if they decrease visual acuity.

Adjustable refractive surgery: 6-mm Artisan lens plus laser in situ keratomileusis for the correction of high myopia.

PURPOSE: To evaluate efficacy, predictability, stability and safety of adjustable refractive surgery (ARS) by combining a phakic intraocular lens (IOL) (Artisan lens 6-mm optical zone [OZ]) and laser in situ keratomileusis (LASIK) (6.5 mm OZ) for the correction of myopia greater than -15.00 diopters (D). DESIGN: Noncomparative interventional case series. PARTICIPANTS: Twenty-six eyes of 18 patients with a preoperative spherical equivalent between -16.00 and -23.00 D. METHODS: First surgery: An 8.5/9.5-mm flap was created and a 6-mm optic iris claw phakic IOL of -15.00 D was inserted in the anterior chamber through a posterior corneal incision. The second surgery was performed once refraction and topography were stable, between 3 and 5 months later. Second surgery: LASIK enhancement (6.5-9.2 OZ); the flap was relifted, and the residual refractive error was corrected. MAIN OUTCOME MEASURES: The main parameters in this study were uncorrected visual acuity, best-corrected visual acuity (BCVA), refraction, contrast sensitivity, endothelial cell count (ECC), and subjective response. RESULTS: Twenty-eight months after both surgeries, 80.70% of the eyes were within 0.50 D of emmetropia and 100% within 1.0 D. Twenty-six percent of the eyes gained 3 or more lines from their preoperative BCVA, and 42% gained 2 or more lines. There was no visual loss in any eye from 6 weeks to 24 months after LASIK enhancement (second surgery) and refraction, and visual acuities remained stable. Two subjects (11%) had some subjective disturbances at night. There was a 0.61% mean loss of ECC during the first 12 months and a 0.60% loss during the next 16 months. No serious complications were observed. CONCLUSIONS: ARS with the combination of a 6-mm optic, 15 D Artisan lens, and LASIK appears to be a safe and highly predictable method for the correction of myopia greater than -15.00 D. It is the best approach with the technology currently available.

Limbal-conjunctival autograft transplantation for the treatment of recurrent pterygium.

OBJECTIVE: Different investigators have recently emphasized the importance of the limbus and its stem cells in the pathogenesis of the pterygium. In this article we examine the usefulness of limbal-conjunctival autograft transplantation for the treatment of advanced recurrent pterygium. DESIGN: Prospective noncomparative case series. PARTICIPANTS: Seven patients with advanced recurrent pterygium. All had previously been treated a minimum of two times by simple excision (two of them with intraoperative mitomycin C). INTERVENTION: Limbal-conjunctival autograft transplantation after pterygium excision was performed in all cases. MAIN OUTCOME MEASURES: Pterygium recurrences and complications with a minimal follow-up period of 14 months. RESULTS: There were no recurrences of pterygial growth beyond the limbal edge. In addition, no significant complications were noted. Only one case of limited pseudopterygium in the donor site and one case of graft retraction were recorded. No further surgical interventions were needed in any case. CONCLUSIONS: Limbal-conjunctival autograft transplantation is a promising technique for the treatment of advanced recurrent pterygium.

Combined surgery to correct high myopia: iris claw phakic intraocular lens and laser in situ keratomileusis.

PURPOSE: To evaluate the results of combined surgery, implantation of an Artisan phakic iris claw intraocular lens (IOL) followed by laser in situ keratomileusis (LASIK) to correct high myopia. METHODS: A prospective study of 6 patients (8 eyes) with high myopia who had Artisan phakic IOL implantation followed by LASIK was undertaken. The IOL was a standard -15.00-D, 6-mm diameter optical zone. Residual refractive error was corrected by LASIK. Mean follow-up was 16 +/- 4 months (range, 12 to 20 mo). RESULTS: After the second procedure (LASIK), uncorrected visual acuity ranged from 0.4 to 0.63 (mean, 0.5 +/- 0.07) at 1 month and from 0.6 to 0.7 (mean, 0.62 +/- 0.04) at 12 months. Spectacle-corrected visual acuity improved 2 or more lines in 62.5% (5 eyes) from preoperative values. Mean postoperative spherical equivalent refraction was -0.68 +/- 0.23 at 1 month and -0.35 +/- 0.22 at 12 months after LASIK. All eyes were within +/-1.00 D of emmetropia following the LASIK portion of the two-stage procedure and 5 eyes were within +/-0.50 D. We had no major complications. No significant endothelial damage occurred. CONCLUSIONS: The accurate refractive outcome, absence of major complications, stability of results, and most important, improvement in quality of vision (defined as no change in vision when illumination conditions varied, eg, at night) experienced by these highly myopic patients are reasons to continue using and improving this combined technique.

LASIK for the correction of residual refractive errors from previous surgical procedures.

BACKGROUND AND OBJECTIVE: To evaluate laser assisted in situ keratomileusis (LASIK) efficacy in correcting residual refractive errors after corneal or intraocular surgery (penetrating keratoplasty, radial keratotomy, photorefractive keratectomy, phacoemulsification with intraocular lens (IOL) implantation, penetrating ocular trauma and phakic IOL implantation). MATERIAL AND METHODS: We performed LASIK in 87 eyes of 62 patients previously operated by means of other surgical techniques to completely correct the residual refractive error. We report the mean refractive error (in terms of spherical equivalent refraction), uncorrected visual acuity (UCVA) and spectacle corrected visual acuity (SCVA) before and after the surgical procedure. We also analyze safety and stability, in these results with a minimum of 12 months follow-up. RESULTS: Mean preoperative spherical equivalent was -5.25 +/- 2.1 diopters (D). Postoperatively, mean spherical equivalent was -0.70 +/- 0.65 D, 76% of eyes were between plano and -1.00 D and 99% were between plano and -2.25 D. At 12 months follow-up the change in the refractive result was equal or less than 0.5 D in 94% of eyes. Preoperatively SCVA was 1.0 or better in 24.13% of cases, and 0.5 or better in 89.65%. Postoperative SCVA was 1.0 or better in 26.43% and 0.5 or better in 95%. Preoperative UCVA was 0.1 in 2 eyes, 0.05 in 4 eyes and count fingers in the rest of the cases. Postoperative UCVA was 1.0 or better in 1.1% and 0.5 or better in 70.1%. We had an extremely low complication rate in this particular group of patients. CONCLUSIONS: LASIK can be successfully used to correct residual refractive errors after other surgical procedures.

Application of the amniotic membrane in ocular surface pathology.

The amnion is a fine semi-transparent membrane that has been used in clinical practice to encourage epithelization in burns, in skin ulcers, or as a skin graft. Application in ocular surface disorders first took place in 1940. We carried out the membrane amniotic implantation on 11 patients with different pathologies: three cases of limbal stem cell deficiency (caustication with failure of prior keratoplasty, congenital aniridia and post-radiotherapy keratopathy), one case with persistent neurotrophic corneal ulcer after prior keratoplasty, four cases with epithelial defect of long evolution, one case of extensive Salzmann's degeneration of the cornea, and two cases after the resection of conjunctival tumour. The follow-up period varied between 2 and 6.5 months (mean = 4 months). Amniotic membrane was obtained by elective Caesarean, and it was preserved at -80 degrees C. In all transplanted patients the reabsorption of the amniotic membrane took place between the third and the fifth week. In the cases of resection of conjunctival tumour the epithelialization was completed between the first and the second post-operative week, with minimal residual scarring. In the other cases, with affliction of the corneal epithelium, the complete epithelialization, together with a marked reduction in the inflammatory response, occurred in all except 2 cases. In conclusion, the implantation of preserved human amniotic membrane can favour the recovery of a normal ocular surface in different pathologies, both in corneal and conjunctival lesions.

Clear lens extraction to correct high myopia.

PURPOSE: To assess the refractive outcome and postoperative complications in a single surgeon series of clear lens extraction for high myopia. SETTING: Ophthalmology Department, Cornea and Refractive Surgery Unit, Vall d'Hebrón Hospital, Autónoma University of Barcelona, Spain. METHODS: Forty-six clear lens extraction procedures performed in 37 patients from November 1992 to January 1994 by one surgeon were retrospectively analyzed. Capsule tear and vitreous loss, endothelial cell loss, preoperative and postoperative best corrected visual acuity and cycloplegic refraction, and retinal detachment occurrence were looked at. RESULTS: Capsule tear with vitreous loss occurred in one eye (2.17%). Mean endothelial cell loss was 2.6% during the first postoperative year. Best corrected visual acuity was 6/12 or better in 69.4% of eyes preoperatively and in 88.5% postoperatively. Mean cycloplegic refraction was -16.05 diopters (D) preoperatively; the residual cycloplegic refraction was within 1.00 D in 48.4% of eyes and within 2.00 D in 92.5% postoperatively. CONCLUSION: Because of its high predictability, stability, and low morbidity, we believe clear lens extraction is a reasonable refractive surgery option for middle-aged patients with myopia.