Acute angle closure after implantable contact lens insertion unresponsive to surgical peripheral iridectomy.

We present a case of acute angle closure that occurred after insertion of an implantable contact lens (ICL). The apparent papillary-block angle closure did not resolve after 2 patent iridotomies and a surgical iridectomy, but did respond to pupil dilation (not constriction). Ultrasound biomicroscopy revealed abnormally large and irregular ciliary processes that may have contributed to the unusual behavior of the ICL-iris complex. The condition resolved after the ICL was replaced by one with a smaller haptic diameter. Routine ultrasound biomicroscopic assessment of the ciliary body anatomy preoperatively and ICL haptic positioning postoperatively may identify risk factors that could predispose ICL patients to acute angle closure.

Acanthamoeba sclerokeratitis: treatment with systemic immunosuppression.

OBJECTIVE: This study describes the clinical features, management, and outcome of 19 patients who had severe Acanthamoeba sclerokeratitis (ASK) unresponsive to conventional management, requiring systemic immunosuppression to control disease. DESIGN: Retrospective, non-comparative, interventional case series. PARTICIPANTS: Records of all patients with Acanthamoeba keratitis treated at Moorfields Eye Hospital between 1989 and 2000 were reviewed. From more than 200 patients, 19 who developed ASK treated with systemic immunosuppression were identified. MAIN OUTCOME MEASURES: Visual acuity, level of pain, and degree of inflammation were recorded after immunosuppressive treatment. RESULTS: ASK requiring immunosuppression occurred in 20 eyes of 19 patients (11 males and 8 females). The mean age (mean +/- standard deviation) at onset was 38.6 +/- 13.2 years. On presentation, best-corrected visual acuity was counting fingers or worse in 11 eyes (55%), 6/18 to 6/60 in 5 eyes (25%), and 6/12 or better in 4 eyes (20%). The mean time between onset of initial symptoms of Acanthamoeba keratitis and commencement of systemic immunosuppression was 4.8 +/- 3.5 months. The mean duration of immunosuppression required to control inflammation was 7.2 +/- 3.9 months. Severe scleritic pain remained uncontrolled in two patients and resulted in enucleation. Best-corrected visual acuity at final follow-up was counting fingers or worse in eight eyes (40%), 6/18 to 6/60 in six eyes (30%), and 20/40 or better in six eyes (30%). The mean follow-up period after resolution of inflammation was 24.3 +/- 20.9 months (range, 0.2-59.7 months). CONCLUSIONS: ASK is an uncommon complication of Acanthamoeba keratitis. The scleritis associated with this infection seems to be an immune-mediated response. After topical amebicidal treatment, systemic immunosuppression may be required to control the pain and tissue destruction associated with ASK.