Treatment outcome and risk factors for visual loss in Cytomegalovirus endotheliitis.

BACKGROUND: To determine treatment outcome and risk factors for visual loss in Cytomegalovirus (CMV) endotheliitis. METHODS: Retrospective case-note review of all CMV positive endotheliitis patients seen at the Singapore National Eye Center, for demographics, visual acuity (VA), extent of corneal edema, anterior chamber (AC) activity, ocular history, glaucomatous optic neuropathy (GON), and ganciclovir therapy. Outcome measures were VA, corneal edema, and AC activity. RESULTS: Median age at diagnosis of the 19 patients (21 eyes) was 57 years. Median duration of follow up was 37 months. Sixteen eyes received systemic ganciclovir, and four eyes received ganciclovir gel. The AC inflammation resolved in 19 eyes. The corneal edema resolved in eight eyes, but persisted in 12 eyes. One patient resolved spontaneously. Pre-treatment corneal edema exceeding 75%, older age, GON, and previous corneal graft were risk factors for persistent corneal edema post treatment (P = < 0.001, 0.001, 0.02 and 0.02 respectively, Fisher's exact test), and VA worse than 6/60. CONCLUSIONS: Anterior chamber inflammation resolves with ganciclovir therapy, but severe pre-treatment corneal edema, older age, previous corneal graft, and GON are associated with a poor visual outcome.

Viral anterior uveitis.

PURPOSE OF REVIEW: With improvements in molecular diagnostics tests, viruses are increasingly being found to be associated with what was previously described as idiopathic anterior uveitis. This review presents the clinical features of viral anterior uveitis. RECENT FINDINGS: Herpes simplex virus/varicella zoster virus (HSV/VZV) are important causes of anterior uveitis, but other viruses including cytomegalovirus (CMV) and rubella are also found in a significant number of cases. The various viral anterior uveitides have similar features and should be suspected in eyes with diffuse, fine, stellate keratic precipitates, iris atrophy or ocular hypertension. Acyclovir remains the mainstay of therapy in HSV/VZV infections. CMV responds to ganciclovir, but the relapse rate is high and prolonged therapy may be required. Cataract and glaucoma are the main complications of viral anterior uveitis requiring appropriate management. SUMMARY: There is considerable overlap between clinical manifestations of the different viral anterior uveitides as well noninfectious hypertensive anterior uveitis syndromes. Hence, corticosteroids should be used with caution in these eyes if virus diagnostic tests are not available.

A survey of contact lens complications in Singapore.

OBJECTIVES: To describe the type of complications related to contact lens wear seen in a hospital setting in Singapore. METHODS: Data were collated over a 2-year period from April 1999 to March 2001, from all public hospitals in Singapore. A standardized clinical record form was completed by the attending doctor when a patient presented for contact lens-related complications. RESULTS: Nine hundred and fifty-three contact lens-related complications were recorded. The mean age of presentation was 26.4 years. Women made up the majority n=491 (68%). Most patients were Chinese (555, 77%). Six hundred and seventy-six (93.7%) patients were soft contact lens wearers. Most patients, 585 patients (85.2%) wore their lenses on a daily basis. Two hundred and forty-four cases (25.6%) of infective keratitis were seen, with 55 patients requiring hospital admission for management of the infection. Soft disposable contact lens wear was associated with the majority of the infective keratitis (178, 73%). Epithelial keratitis occurred in 229 patients (24.0%) with punctuate epithelial erosions being the commonest presentation in 139 (14.6%). Allergic conjunctivitis occurred in 179 (18.8%) of the cases with giant papillary conjunctivitis accounting for 147 (15.4%) of them. Dry eyes (77, 8.1%), sterile infiltrates (71, 7.5%) and neovascularization of the cornea (75, 7.9%) were the next commonest complications seen. Corneal edema, solution- and lens-related complications occurred in small numbers, accounting for less than 5% of the complications reported. CONCLUSION: Infective keratitis secondary to soft lens wear was the most common complication, followed by epithelial keratitis and allergic conjunctivitis seen in public hospitals in Singapore.

Clinical features of cytomegalovirus anterior uveitis in immunocompetent patients.

PURPOSE: To describe the clinical presentation of cytomegalovirus (CMV) anterior uveitis in human immunodeficiency virus (HIV)-negative patients. DESIGN: Retrospective, interventional case series. METHODS: HIV-negative patients with anterior uveitis associated with elevated intraocular pressure (hypertensive anterior uveitis) seen at the Singapore National Eye Centre had their aqueous analyzed for viral deoxyribonucleic acid by polymerase chain reaction, and their records were reviewed for demographic data, ocular findings, laboratory results, and treatment. RESULTS: Aqueous was obtained from 105 of 106 eligible eyes. Twenty-four eyes demonstrated positive results for CMV (22.8%). Eighteen eyes had Posner-Schlossman syndrome (PSS; 75%) at presentation, five eyesba had Fuchs heterochromic iridocyclitis (FHI; 20.8%), and one eye had a presumed herpetic anterior uveitis. Twelve of the 24 eyes were treated with ganciclovir. Of the 12 who completed treatment, all responded clinically, and their aqueous demonstrated negative results for CMV on repeat testing. However, nine had recurrences within eight months of stopping treatment and required further courses of ganciclovir. The 81 CMV-negative eyes included 30 with PSS, 11 with FHI, 27 with uveitic glaucomas of unknown cause, and 13 with presumed herpetic anterior uveitis. CONCLUSIONS: CMV anterior uveitis is not uncommon in our immunocompetent patients and it may present as a recurrent acute or chronic inflammation, resembling PSS, herpetic anterior uveitis, or FHI.

Immunosuppressive therapy for ocular diseases.

PURPOSE OF REVIEW: To identify advances in immunosuppressive therapy of ocular diseases since 2007. RECENT FINDINGS: The biologics in current use include antitumour necrosis factor-alpha agents (infliximab, etanercept and adalimumab), cytokine receptor antibodies (daclizumab) and interferon-alpha2a. They are effective and comparatively well tolerated options in the treatment of refractory uveitis in both adults and children in the short term, except for etanercept. Daclizumab had a favourable outcome in treating birdshot chorioretinopathy but not in Behcet's disease. The uncertainty of their long-term results, their high costs as well as the necessity for repeated intravenous infusions in the case of infliximab limit their widespread use. Mycophenolate mofetil is another efficacious, fairly well tolerated and less costly immunosuppressant. It has the additional advantage of an oral formulation. T cell inhibitors, cyclosporine and tacrolimus, were found to be useful steroid-sparing drugs in allergic eye disease and dry eyes. A number of studies on less invasive sustained ocular drug delivery systems, including episcleral implants, nanospheres, and cyclodextrin particles, were conducted on animals with encouraging results. SUMMARY: The armamentarium of immunosuppressive agents is constantly expanding and augurs well for the safe and effective treatment of ocular inflammation.

National survey of ophthalmologists in Singapore for the assessment and management of asymptomatic angle closure.

PURPOSE: Approximately 10% of Chinese people older than 50 years in Singapore have asymptomatic narrow angles [also termed primary angle closure suspects (PACS)]. The aim of this study was to determine the attitudes and practices of ophthalmologists in Singapore regarding the management of these patients. METHODS: A nation wide questionnaire-based survey was conducted on all registered, practicing ophthalmologists in Singapore by electronic mail and post. An ophthalmologist was defined as a doctor who had completed at least 3 years of specialist training in ophthalmology and had passed the Master's Degree in Ophthalmology or equivalent examinations. The survey asked the ophthalmologists about the methods and criteria used for the diagnosis of angle closure. It also inquired about the management of PACS and opinions on the effectiveness of prophylactic laser peripheral iridotomy (LPI) in preventing both acute and chronic angle closure. RESULTS: A total of 126 out of 158 ophthalmologists responded (79.7% response rate). Of the respondents, 84.9% would advise prophylactic LPI for asymptomatic PACS; 84.9% believed that prophylactic LPI would prevent acute angle closure but only 44% thought that it could prevent the development of glaucomatous optic nerve damage. The preferred method of prophylactic LPI was sequential argon-YAG LPI. In assessing patients for angle closure, 85.4% used gonioscopy, 92.9% assessed anterior chamber depth, and 17.5% performed provocative tests. CONCLUSIONS: Ophthalmologists in Singapore vary in the method of assessment of patients with angle closure. Most believe that prophylactic LPI should be performed for asymptomatic PACS.

Corneal endotheliitis associated with evidence of cytomegalovirus infection.

OBJECTIVE: To describe the clinical presentation of cytomegalovirus (CMV) corneal endotheliitis in human immunodeficiency virus (HIV)-negative patients. DESIGN: Retrospective interventional case series. PARTICIPANTS: Twelve consecutive patients with corneal endotheliitis diagnosed between 2002 and 2005. METHODS: Aqueous of eyes with corneal endotheliitis was analyzed for viral DNA by polymerase chain reaction (PCR), and patient records were reviewed for demographic data, medical and ocular history, best-corrected Snellen visual acuity, intraocular pressure (IOP), anterior and posterior segment findings, laboratory workup, diagnosis, and treatment. MAIN OUTCOME MEASURE: Presence of CMV DNA. RESULTS: Corneal endotheliitis was seen in 12 eyes of 10 patients during the study period. There were 8 men and 2 women, and all were Chinese. Their mean age was 49 years (range, 25-61 years). The corneal involvement ranged from small areas of focal endotheliitis to diffuse bullous keratopathy. The keratic precipitates had a variable appearance. There was only mild anterior chamber inflammation with no posterior synechiae. Two thirds of eyes had diffuse iris atrophy. All the eyes had elevated IOP. Eleven of the 12 eyes were positive for CMV DNA. None of the patients were positive for HIV. All patients had received local or systemic immunosuppression, or both, before corneal endotheliitis developed. Ten eyes of 8 patients were treated with systemic antiviral therapy. After treatment, the endotheliitis resolved completely in 7 eyes, and 3 eyes had significant improvement in corneal translucency. The IOP was normal, with no medications in all but 1 eye. Repeat PCR analysis in all the treated eyes was negative for CMV DNA. CONCLUSIONS: Cytomegalovirus infection is an important cause of corneal endotheliitis in our patients, and appropriate antiviral therapy may prevent more ocular damage.

Prevalence of dengue maculopathy in patients hospitalized for dengue fever.

OBJECTIVE: Dengue fever causes numerous systemic manifestations, including maculopathy, with loss of vision. This study sought to determine the prevalence of dengue maculopathy in patients hospitalized with dengue fever. DESIGN: Cross-sectional observational study in which consecutive patients hospitalized with dengue fever during a dengue epidemic were enrolled over a 3-week period. PARTICIPANTS: Patients hospitalized in 2 general hospitals in Singapore with dengue fever. TESTING: Patients completed a standardized questionnaire and underwent tests for near and distance visual acuity (VA), Amsler grid testing, dilated retinal examination, serum complements C3 and C4, and urinary microalbumin. MAIN OUTCOME MEASURES: Dengue maculopathy found on retinal examination. RESULTS: One hundred ninety-seven patients were enrolled, of whom 119 (60.4%) were male and 78 (39.6%) female. The patients ranged between 12 and 67 years old (mean, 32.65). One hundred sixty of 197 patients had positive dengue immunoglobulin M serology. Dengue maculopathy was detected in 27 eyes of 16 of the seropositive patients, giving a prevalence of 10% (95% confidence interval, 6.03%-15.40%). None of the patients who were dengue immunoglobulin M negative had dengue maculopathy. Dengue maculopathy eyes were more likely to have distance acuity worse than logarithm of the minimal angle of resolution 0.15 (Snellen 6/9 or worse) (P = 0.005) and abnormalities on Amsler grid testing (P = 0.001), with a greater proportion of these patients having visual complaints (P = 0.002) and lower mean complement C3 levels (P = 0.008) as compared with patients without maculopathy. Logistic regression analysis showed Amsler grid abnormalities to be the most consistent factor associated with dengue-related maculopathy (P<0.001), with a hazard ratio of 8.669; sensitivity, 29.6%; and specificity, 95.4%. CONCLUSION: The prevalence of dengue maculopathy among patients hospitalized for dengue fever is 10% in our series. Amsler grid abnormalities, reduced distance VA, and the presence of visual symptoms are associated with dengue maculopathy. Low complement C3 levels in these patients suggest that this is an immune-mediated disease.

The role of enhanced depth imaging optical coherence tomography in chronic Vogt-Koyanagi-Harada disease.

AIMS: To determine the role of enhanced depth imaging optical coherence tomography (EDI-OCT) in chronic Vogt-Koyanagi-Harada (VKH) disease. METHODS: Records of all consecutive patients with VKH seen at the Singapore National Eye Centre were retrospectively reviewed for concurrent EDI-OCT and indocyanine green angiograms (ICGAs) obtained six or more months after disease onset, demographics and duration of disease. The ICGAs were scored based on the following signs: early choroidal stromal vessel hyperfluorescence and leakage, hypofluorescent dark dots, fuzzy vascular pattern of large stromal vessels and disc hyperfluorescence, and correlated with the subfoveal choroidal thickness (SFCT) measured using EDI-OCT. Only images of one eye were analysed. RESULTS: 105 pairs of EDI-OCT and ICGA of 52 patients were included. Mean age was 51.7 years. Half of the patients (26) were male and the majority were Chinese (39 patients, 75.0%). Mean duration of disease was 106.3 months. There were 79 ICGA active episodes. Mean SFCT was thinner when ICGA was quiet (mean=187.31 µ), than when the ICGA was active (mean=272.38 µ, p=0.002). There was a positive correlation of the SFCT with the ICGA score but a negative correlation with age and duration of disease. Multivariate analysis showed that age, duration of disease and ICGA were the main factors affecting SFCT. CONCLUSIONS: The positive correlation of SFCT measurements with ICGA score suggests that it may be used to monitor disease activity in chronic VKH in addition to ICGA, possibly reducing the number of ICGAs required.

Comparison of Enhanced Depth Imaging and Swept Source Optical Coherence Tomography in Assessment of Choroidal Thickness in Vogt-Koyanagi-Harada Disease.

PURPOSE: To compare enhanced depth imaging (EDI-OCT) and swept source optical coherence tomography (SS-OCT) in assessment of Vogt-Koyanagi-Harada (VKH) disease. METHODS: All consecutive VKH patients seen at Singapore National Eye Centre during 2012-2013 were imaged using both modalities. Subfoveal choroidal thickness (SFCT) was measured by one masked trained observer. RESULTS: A total of 137 pairs of scans were obtained from 48 patients. SFCT was more likely to be measurable on SS-OCT than EDI-OCT (112, 81.8%; 84, 61.3%; p<0.001 Fisher's Exact test). There was good inter-OCT correlation of SFCT when both scans were measureable (mean of the difference in SFCT ± 2 standard deviations (SD) of -14.5 ± 21.0 µm). CONCLUSIONS: SS-OCT images are superior to EDI-OCT but the SFCT measurements are comparable when both are readable.

Management of Severely Subluxated Cataracts Using Femtosecond Laser-Assisted Cataract Surgery.

PURPOSE: To assess the role of femtosecond laser technology in the management of severely subluxated cataracts. DESIGN: Retrospective, interventional case series. METHODS: All eyes with subluxated cataract seen between July 2012 and June 2015 were assessed for suitability for femtosecond laser-assisted cataract surgery, with the use of capsular tension devices. Participants with subluxated cataracts of at least 6 clock hours of zonular weakness were included in the study. Data collected included patient demographics, preoperative and postoperative best-corrected visual acuity (BCVA), nuclear density, extent of zonular weakness, completeness of capsulotomy, and complications. Poor visual outcome was defined as BCVA of worse than 20/40. Main outcome measure was the retention of the capsular bag. RESULTS: Of the 72 eyes with subluxated cataracts undergoing surgery during the study period, 47 eyes of 47 patients were eligible for analysis. Mean age of the patients was 60.7 years (standard deviation [SD] 13.2 years). The majority were male (32, 68.1%) and Chinese (38, 80.8%). The mean duration of follow-up was 8 months (SD 5.6 months). The main identifiable cause of lens subluxation was trauma (11 eyes). Almost two thirds (30 eyes) had more than 9 clock hours of zonular weakness. Seventy percent of cataracts (33) were nuclear sclerosis grade 3 and above. The capsular bag was preserved in 43 eyes (91.5%). The intraocular lens was stable and centered at the last follow-up in all these 43 eyes. An anterior capsule tear occurred in 6 eyes, all of which had cataracts of nuclear sclerosis grade 3 and above, with posterior extension occurring in 3 eyes. Primary posterior capsule rupture occurred in 1 eye. At 1 month 37 eyes (80.4%) had a BCVA of 20/40 or better. There was significant improvement in BCVA at 1 month (mean of 0.92 logMAR units [SD 0.88] to 0.22 [SD 0.38] [P < .001, paired samples t test]), which was maintained at 1 year. CONCLUSIONS: Selected cases of severely subluxated cataracts may be managed using femtosecond laser technology to perform the capsulotomy and nuclear fragmentation, with successful preservation of the capsular bag in 90% of eligible cases, especially in eyes with soft cataracts.

The Pattern of Uveitis among Chinese, Malays, and Indians in Singapore.

PURPOSE: To describe the pattern of uveitis among Chinese, Malays, and Indians at a tertiary referral institution in Singapore. METHODS: Charts between January 1997 and December 2010 were retrospectively reviewed. Charts between January 2014 and December 2014 were prospectively reviewed. RESULTS: A total of 1249 and 148 charts were retrospectively and prospectively reviewed, respectively. The top causes of anterior uveitis (AU) were HLA-B27, idiopathic, and CMV AU. The top known causes of intermediate uveitis were tuberculosis, primary intraocular lymphoma, and sarcoidosis. The top causes of posterior uveitis were CMV retinitis, toxoplasmosis, and dengue maculopathy. The top causes of panuveitis were VKH, idiopathic panuveitis, tuberculosis, and Behçet disease. HLA-B27 and CMV AU were more frequent among Chinese (21% vs 9% (non-Chinese); p<0.001; 10% vs 5% (non-Chinese); p<0.001, respectively). Tuberculous uveitis was more frequent among Malays and Indians (12% (non-Chinese) vs 5% (Chinese), p<0.001). CONCLUSIONS: Different uveitis patterns were encountered among patients of different races.

Analysis of competency in phacoemulsification trainees using the cumulative sum analysis.

PURPOSE: To determine the number of cases required to achieve competency in phacoemulsification in terms of the posterior capsule rupture rate. SETTING: Singapore National Eye Centre, Singapore. DESIGN: Retrospective cohort study. METHODS: The posterior capsule rupture rate of the first 300 phacoemulsification cases performed by each trainee in the Singapore National Eye Centre (2004 to 2012) was charted using cumulative sum graphs. Competency was primarily defined as a posterior capsule rupture rate of 2% or lower and secondarily as 5% or lower. RESULTS: Twenty trainees fulfilled the inclusion criteria. Four trainees (20%) and 19 trainees (95%) achieved a posterior capsule rupture rate of 2% and 5%, respectively. At least 41 cases were required to achieve a 5% posterior capsule rupture rate (mean 106, median 83). CONCLUSIONS: There was considerable variation in the trainees' abilities. Only 20% of the trainees achieved a posterior capsule rupture rate of 2% or lower and required at least 212 cases.

Surgical management of late dislocated lens capsular bag with intraocular lens and endocapsular tension ring.

A case of late spontaneous dislocation of the lens capsular bag (CB) with foldable acrylic intraocular lens (IOL) and endocapsular tension ring (CTR) and its surgical management is reported in a 52-year-old man. The dislocation occurred 2 years 3 months after phacoemulsification cataract surgery in which a CTR was used for zonular instability. A 3-port pars plana vitrectomy was performed. Because it was not possible to grasp the IOL-CTR-CB complex, perfluorocarbon liquid was used to attempt to float it up. This was unsuccessful, so a scleral indenter was used to apply external pressure on the sclera to tilt the IOL-CTR-CB complex into a position where it could be grasped with a forceps and removed through a corneal section. A scleral-fixated IOL was placed, and the patient achieved a best corrected visual acuity of 6/9. The procedure was safe and effective without intraocular complications.

Orbital metastatic tumour as initial manifestation of asymptomatic gastric adenocarcinoma.

INTRODUCTION: Metastatic orbital tumour from gastric cancer is rare. Patients with metastatic disease may present initially to the ophthalmologist with symptoms from metastases instead of from the primary cancer. CLINICAL PICTURE: We report a case, with clinicopathological correlation, of metastatic gastric adenocarcinoma presenting first in the orbit with diplopia. Computed tomography and magnetic resonance imaging of the orbit showed a well-defined enhancing right intraconal tumour. TREATMENT AND RESULTS: Excisional biopsy was performed and histopathology confirmed a metastatic adenocarcinoma. Focused gastrointestinal screening revealed an otherwise asymptomatic Stage IV gastric adenocarcinoma. Chemotherapy was initiated with good tumour response. CONCLUSION: Early biopsy of unusual orbital tumours is critical as orbital metastases may be the initial manifestation of an asymptomatic primary. Histopathological diagnosis can aid localisation of the primary tumour and allow prompt treatment to be instituted.

Genome-wide association study identifies five new susceptibility loci for primary angle closure glaucoma.

Primary angle closure glaucoma (PACG) is a major cause of blindness worldwide. We conducted a genome-wide association study (GWAS) followed by replication in a combined total of 10,503 PACG cases and 29,567 controls drawn from 24 countries across Asia, Australia, Europe, North America, and South America. We observed significant evidence of disease association at five new genetic loci upon meta-analysis of all patient collections. These loci are at EPDR1 rs3816415 (odds ratio (OR) = 1.24, P = 5.94 × 10(-15)), CHAT rs1258267 (OR = 1.22, P = 2.85 × 10(-16)), GLIS3 rs736893 (OR = 1.18, P = 1.43 × 10(-14)), FERMT2 rs7494379 (OR = 1.14, P = 3.43 × 10(-11)), and DPM2-FAM102A rs3739821 (OR = 1.15, P = 8.32 × 10(-12)). We also confirmed significant association at three previously described loci (P < 5 × 10(-8) for each sentinel SNP at PLEKHA7, COL11A1, and PCMTD1-ST18), providing new insights into the biology of PACG.

The outcomes of indocyanine green angiography monitored immunotherapy in Vogt-Koyanagi-Harada disease.

AIMS: To compare outcomes of indocyanine green angiography (ICGA) versus clinically monitored immunotherapy in Vogt-Koyanagi-Harada (VKH) disease. METHODS: Consecutive patients of Singapore National Eye Centre with VKH receiving high-dose corticosteroids within 4 weeks of onset of symptoms had therapy titrated to clinical signs of activity (controls) or ICGA findings (ICGA). Charts were reviewed for demographics, interval to treatment, duration of therapy and number of systemic immunosuppressants required. Outcome measures were best corrected acuity, disease activity, presence of sunset glow (SSG) fundus and peripapillary atrophy (PPA) at 2 years. RESULTS: 52 patients were included (38 controls, 14 ICGA). Duration of treatment was shorter in the control group (17 vs 42 months, p<0.001) and they required fewer systemic immunosuppressants than the ICGA group (16% vs 96%, p<0.001). The majority (49 eyes, 96.1%) had 6/12 or better vision and were clinically quiet (43 eyes, 84.3%) in both groups. SSG fundus and PPA were similar in both groups. Treatment within 2 weeks of onset was the main factor affecting their occurrence on multivariate analysis (OR 0.18, 95% CI 0.03 to 0.9, p=0.047; OR 0.08, 95% CI 0.01 to 0.51, p=0.007, respectively). CONCLUSIONS: ICGA-guided immunotherapy did not result in significantly better outcomes with respect to visual acuity and disease activity in VKH eyes treated within 1 month of onset.

Cytomegalovirus-positive corneal stromal edema with keratic precipitates after penetrating keratoplasty: a case-control study.

PURPOSE: To identify differences between cytomegalovirus (CMV)-positive and CMV-negative eyes presenting as suspected endothelial graft rejection after penetrating keratoplasty (PK). METHODS: A retrospective consecutive case-control series. Aqueous humor samples of all eyes with corneal stromal edema and keratic precipitates (KPs) after PK, seen at the Singapore National Eye Centre from 2007 to 2010, were analyzed for CMV DNA by polymerase chain reaction. Their charts were reviewed for demographic data, medical and ocular history, best-corrected visual acuity, intraocular pressure, anterior segment clinical findings, and therapy. RESULTS: Of 11 eligible eyes (11 patients), 7 were CMV positive. All eyes were negative for herpes simplex virus and varicella zoster virus. The 2 groups were similar in age, gender, and previous ocular surgery. The main differences were the presence of extensive heavily pigmented KPs, Descemet membrane folds, and the absence of vascularization of the donor in CMV-positive eyes (100% vs. 0%, P = 0.003, Fisher exact test). All the CMV-positive eyes were treated with ganciclovir (5 systemic, 2 topical), and the control eyes received immunosuppression. However, all the grafts failed. Best-corrected visual acuity at the last visit was worse than 20/400 in all except 1 control eye, which had a follow-up of 30 months. CONCLUSIONS: There is a high prevalence of CMV infection in eyes that develop corneal stromal edema with KPs after PK. Heavy endothelial pigmentation, Descemet membrane folds, and the absence of donor vascularization may aid in the diagnosis of CMV in the event that aqueous analysis is not possible.

Immune ring formation associated with cytomegalovirus endotheliitis.

PURPOSE: To describe immune ring (IR) formation as a manifestation of cytomegalovirus (CMV) endotheliitis. DESIGN: Retrospective observational case series. METHODS: Review of all consecutive CMV anterior uveitis and endotheliitis patients seen at the Singapore National Eye Centre for the occurrence of an IR. CMV infection was diagnosed by polymerase chain reaction analysis of the aqueous. RESULTS: None of the 72 eyes with CMV anterior uveitis had an IR formation. Four episodes of IR formation were seen in 3 eyes (14.3%) of 21 cases of CMV-positive endotheliitis. All were unilateral and all 3 patients were human immunodeficiency virus negative middle-aged Chinese males. The IR developed 2 to 7 months after occurrence of the endotheliitis and the aqueous was positive for CMV during 2 of the episodes of IR formation. In 2 eyes, the IR occurred at the completion of a course of systemic ganciclovir when the aqueous was negative for CMV. The immune rings resolved with combination therapy of topical prednisolone acetate 0.12% and ganciclovir. Patient 1 had a recurrence of the IR 4 months after stopping treatment but again resolved following treatment with ganciclovir and topical corticosteroids. CONCLUSION: Corneal immune rings can occur as a result of CMV infection. Hence CMV infection may have to be considered in such cases.

Management of traumatic severely subluxated cataracts.

PURPOSE: To determine outcome of cataract surgery in severely subluxated traumatic cataracts. DESIGN: Noncomparative case series. METHODS: Retrospective review of cataract surgery in all consecutive eyes with at least 6 clock hours of zonulysis, for patient demographics, presenting best-corrected visual acuity (BCVA) and postoperative BCVA at various time points, extent of zonulysis, and type and timing of insertion of capsular tension device. Main outcome measures were retention of the capsular bag and BCVA at last visit. Secondary outcome measures included IOL stability and centration, and perioperative complications. RESULTS: There were 41 eyes (41 patients). Mean age at time of surgery was 57 years and the mean duration of follow-up was 21.4 months. The capsular bag was preserved with aid of a Cionni modified capsular tension ring (CTR) in 36 eyes (87.8%) and a combination of a capsular tension segment (CTS) and CTR in 2 eyes. In 3 eyes with total zonulysis, the bag could not be preserved despite the use of a CTS in 2 eyes. Preoperatively only 9 of the 41 eyes (22.0%) had a BCVA of 20/40 or better, as compared to 38 eyes at the last visit (92.7%, P < .001, χ(2) test). Posterior capsule rupture occurred in 3 eyes, 2 of which occurred during fixation of the CTR. CONCLUSIONS: The capsular bag can be successfully preserved even in severely subluxated traumatic cataracts with the aid of fixated capsular tension devices.