Photodynamic therapy in retinal angiomatous proliferation stage I.

PURPOSE: To report a case of photodynamic therapy (PDT) treatment in an 85-year-old patient with retinal angiomatous proliferation (RAP) stage I. METHODS: According to Treatment of Age-Related Macular Degeneration with Photodynamic Therapy and Verteporfin in Photodynamic Therapy study guidelines, two sessions of PDT with verteporfin were performed, which was activated by a diode laser light at 690 nm. RESULTS: The left eye was treated with PDT because of RAP stage I. Even in the early stage of RAP, PDT treatment did not alter the natural course of the disease. In particular, the lesion evolved towards stage III, being initially in stage I, with the final result of development of retinal pigment epithelial (RPE) tear after the second session of PDT treatment. CONCLUSIONS; Even in the early stage of RAP, PDT treatment did not alter the natural course of the disease, with the final result of RPE tear after the second session of PDT treatment.

Effect of Fas and Fas ligand deficiency in resistance of C57BL/6 mice to HSV-1 keratitis and chorioretinitis.

PURPOSE: To investigate the effect of Fas and Fas ligand (FasL) deficiency on the development of herpes stromal keratitis and on the von Szily model of herpes retinitis in C57BL/6 mice, which are ordinarily resistant to development of both of these herpetic diseases. METHODS: Anterior chamber inoculation of the right eye of each mouse with various titers of HSV-1 (KOS strain) was performed. Both eyes of each mouse were enucleated on postinoculation day 15 and processed for histopathologic examination. HSV-1 was inoculated into one cornea of other mice, and the severity of stromal keratitis was scored. RESULTS: Contralateral destructive chorioretinitis developed in susceptible Balb/cByj mice (19/23); ipsilateral chorioretinitis did not occur (0/23). Stromal keratitis developed in susceptible C.AL-20 mice (15/16). None of the C57BL/6 (0/10 for keratitis or 0/20 for retinitis) developed inflammation. Neither did B6.SMN.C3H.gld (FasL deficient; 0/12 or 0/28) or B6.MRL.lpr (Fas deficient; 0/11 or 0/34) mice (keratitis or contralateral chorioretinitis). Minimal scattering of inflammatory cells in the contralateral retina but not destructive chorioretinitis was observed in two C57BL/6, three B6.SMN.C3H.gld, and five B6.MRL.lpr mice. Few inflammatory cells were also found in the ipsilateral vitreous and vitreoretinal interface (but not destructive chorioretinitis) of all C57BL/6, two gld, and three lpr mice. CONCLUSIONS: Immune dysregulation secondary to deficiency in Fas or FasL system does not influence the resistance of the C57BL/6 mice to develop herpes simplex keratitis or destructive herpes simplex chorioretinitis.

Topical 2.0% dorzolamide vs oral acetazolamide for prevention of intraocular pressure rise after neodymium:YAG laser posterior capsulotomy.

OBJECTIVE: To compare the efficacy and safety of topical 2.0% dorzolamide hydrochloride with oral acetazolamide in preventing intraocular pressure (IOP) rise following neodymium:YAG (Nd:YAG) laser posterior capsulotomy. DESIGN: A prospective, randomized, double-masked, placebo-controlled study. PATIENTS: Two hundred ten patients undergoing Nd:YAG laser posterior capsulotomy. INTERVENTION: Pretreatment with dorzolamide, acetazolamide, or placebo. Dorzolamide administration as a single drop (1 drop approximately 20 microL) 1 hour before capsulotomy. Acetazolamide administration as a single dose of 125 mg orally 1 hour before capsulotomy. RESULTS: At first and third hour postoperatively, IOPs and IOP changes from baseline were significantly (P<.001) higher in the placebo group than in the dorzolamide or acetazolamide group. At the same time, IOPs and IOP changes from baseline were similar (P>.50) in the dorzolamide and acetazolamide groups. No patient treated with dorzolamide or acetazolamide experienced an IOP higher than 30 mm Hg after capsulotomy, but 15.7% of patients receiving placebo had an IOP above this level (P<.001). Of patients receiving placebo, 5.7% experienced IOP higher than 35 mm Hg. No serious side effects were recorded in any of the studied patients. CONCLUSION: Topical 2.0% dorzolamide and oral acetazolamide, given prophylactically as a single administration 1 hour before Nd:YAG laser posterior capsulotomy, have comparable high efficacy and safety in preventing IOP elevation following this procedure.

Amniotic membrane inlay and overlay grafting for corneal epithelial defects and stromal ulcers.

OBJECTIVES: To determine the effect of amniotic membrane transplantation (AMT) on persistent corneal epithelial defects (PEDs) and to compare the efficacy between inlay and overlay techniques. METHODS: Thirty patients (30 eyes) underwent AMT for PED. The use of AMT was restricted to patients in whom all previous measures, including bandage contact lens and tarsorrhaphy, had failed. The amniotic membrane was placed on the surface of the cornea in overlay (group A) or inlay (group B) fashion. RESULTS: The PED healed after the first AMT in 21 eyes (70%) within an average of 25.5 days after surgery and recurred in 6 eyes (29%). Among the 22 eyes treated with an overlay AMT (group A), the PED healed after the first AMT in 14 eyes (64%) within an average of 24.5 days and recurred in 4 eyes (29%). Among the 8 eyes treated with an inlay AMT (group B), the PED healed within an average of 27.4 days after AMT, which did not statistically significantly differ from group A (P = .72). The PED healed after the first AMT in 7 eyes (88%) and recurred in 2 (29%) of 7 eyes. CONCLUSIONS: The AMT can be helpful in the treatment of PED in which all other conventional management has failed. However, the success rate in our study was not as high as that previously reported, and our results showed a high incidence of recurrences of epithelial defects. We did not find any difference between overlay and inlay techniques in terms of healing time and recurrence rate.

Ocular features associated with anticardiolipin antibodies: a descriptive study.

PURPOSE: To evaluate ocular features in patients presenting with inflammation in the presence of anticardiolipin antibodies. METHODS: A descriptive study of 13 patients presenting with idiopathic ocular inflammation involving anterior and posterior segment was performed. Patients were followed for a mean follow-up of 22 months (range, 1 to 125). A comprehensive report of ocular involvement, including visual symptoms, visual acuity, clinical characteristics, funduscopic and fluorangiographic features, was reported. Systemic associated symptoms were analyzed. Laboratory investigations included anticardiolipin antibody titers and isotypes, presence of other autoantibodies, and markers of immune system activation. RESULTS: The most common ocular symptom at presentation was blurred vision (eight patients) followed by redness and pain(three patients) and visual loss(two patients). Anterior segment abnormalities, including iritis (eight patients) scleritis (two patients) and filamentary keratitis (one patient), were present in 76% of patients, whereas the most represented feature of posterior involvement was retinal vasculitis (60%) followed by vitritis (38%), retinal detachment (15%), posterior scleritis (7%), and central retinal artery occlusion (7%). All patients had abnormal titers of anticardiolipin antibodies, predominantly IgG isotype; six had markers of immune system activation. CONCLUSIONS: Although posterior pole disease is more commonly associated with anticardiolipin antibodies, the anterior segment can also be involved with a wide spectrum of features. Scleritis has never been previously described as associated with anticardiolipin antibodies. Systemic symptoms are frequently present in association with ocular disease.

Epstein-Barr virus dacryoadenitis resulting in keratoconjunctivitis sicca in a child.

PURPOSE: To describe a case of severe dry eye syndrome in a child. METHODS: Observational case report. The authors describe a 10-year-old male with severe dry eyes who was profoundly disabled by pain and photophobia despite aggressive conventional therapy. Lacrimal gland histology was consistent with the primary Sjögren syndrome, and serologic and immunohistologic evidence supported the hypothesis of Epstein-Barr virus causality. RESULTS: Treatment with systemic acyclovir and cyclosporin A resulted in dramatic and rapid reversal of the profound sicca syndrome and enabled the patient to resume his normal activities. CONCLUSION: Epstein-Barr virus dacryoadenitis should be considered in the differential diagnosis of keratoconjunctivitis sicca in children. Epstein-Barr virus can cause keratoconjunctivitis sicca, which can be treated successfully with acyclovir therapy in addition to suppression of the inflammatory response.

Chronic cicatrizing conjunctivitis in a patient with ocular cicatricial pemphigoid and fatal Wegener granulomatosis.

PURPOSE: To describe a case of chronic cicatrizing conjunctivitis in a patient with ocular cicatricial pemphigoid and Wegener granulomatosis. METHODS: Observational case report. A retrospective study. RESULTS: An 80-year-old man presented with chronic cicatrizing conjunctivitis, peripheral corneal thinning, and Wegener granulomatosis, which were diagnosed by his referring physician based on clinical (recurrent epistaxis, sinus congestion) and histopathologic features of nasal mucosa (granulomatous inflammation, vasculitis). A conjunctival biopsy performed by us disclosed features of active Wegener granulomatosis and ocular cicatricial pemphigoid, which indicate lack of control of both diseases with methotrexate treatment. The patient died of pulmonary complications from Wegener granulomatosis 1 week after our evaluation. CONCLUSION: Ocular cicatricial pemphigoid and Wegener granulomatosis are both potentially fatal autoimmune diseases. Ocular involvement in Wegener granulomatosis indicates poor control of the underlying systemic condition and is a marker for active vasculitis, which indicates the need for treatment with cyclophosphamide.

Gas-permeable scleral contact lens therapy in ocular surface disease.

PURPOSE: To describe the therapeutic benefits of nonfenestrated gas-permeable scleral contact lenses in the management of patients with ocular surface disease. METHODS: The charts of 49 consecutive patients (76 eyes) with ocular surface disease whose management included the use of gas-permeable scleral contact lenses were reviewed. We also developed a questionnaire to assess the impact of lens wear on subjective aspects of activities of daily living. RESULTS: The mean age of the 49 patients was 44.6 years (range, 3 to 87 years); 31 patients were female and 18 were male. The most common indication for fitting of the lenses was Stevens-Johnson syndrome (54 [71%] of the 76 eyes). Other indications included ocular cicatricial pemphigoid, exposure keratitis, toxic epidermal necrolysis, postherpetic keratitis, congenital deficiency of meibomian glands, superior limbal keratoconjunctivitis, Sjögren syndrome, and inflammatory corneal degeneration. The mean follow-up was 33.6 months (range, 2 to 144 months). Improvement in best-corrected visual acuity (defined as a gain of 2 or more Snellen lines) was observed in 40 (53%) of the eyes. In eight (53%) of the 15 eyes with active corneal epithelial defects at the time of lens fitting, the defects healed, whereas in the remaining seven eyes the corneal epithelial defects remained unchanged. Forty-five (92%) of the 49 patients reported improvement in their quality of life as a result of reduction of photophobia and discomfort. The mean wearing time of the gas-permeable scleral contact lenses was 13.7 hours per day (range, 4 to 18 hours). Many patients had preparatory surgical procedures before lens fitting (for example, punctal occlusion or mucous membrane grafting), and some had visual rehabilitation surgical procedures (for example, keratoplasty and/or cataract surgery) after lens fitting. CONCLUSIONS: Gas-permeable scleral contact lens wear provides an additional effective strategy in the surface management and visual rehabilitation of patients with severe ocular surface disease.

Intraocular lens removal from [corrected] patients with uveitis.

PURPOSE: To report a series of patients with uveitis and cataract who had undergone cataract extraction with posterior chamber intraocular lens implantation and who subsequently had the intraocular lens removed because of progressive intraocular damage from inflammation. METHODS: Review of the records of 19 patients after removal of a posterior chamber intraocular lens. The decision to perform surgery was based on standard criteria after evaluation at a single uveitis referral center. RESULTS: The complications leading to intraocular lens removal were perilental membrane (eight eyes), chronic low-grade inflammation not responding to anti-inflammatory treatment (eight eyes), and cyclitic membrane resulting in hypotony and maculopathy (three eyes). After intraocular lens removal the inflammation subsided and the visual acuity improved or stabilized in 14 of the 19 eyes. The causes of further reduction in the visual acuity of the other five patients were macular edema (two patients), maculopathy resulting from hypotony (one patient), retinal detachment (one patient), and vitreous hemorrhage (one patient). CONCLUSIONS: Intraocular lens implantation can form part of a reasonable plan for visual rehabilitation of patients with uveitic cataract, but inclusion of an intraocular lens in the plan is not always in the overall long-term best interest of the patient. Intraocular lens removal may salvage useful vision for patients who continue to exhibit complications secondary to uveitis after cataract extraction and intraocular lens implantation, provided the intraocular lens is removed before irreparable damage has been done to macula or optic nerve.

Topical versus sub-Tenon's anesthesia without sedation in cataract surgery.

PURPOSE: To compare pain control using topical anesthesia with that using sub-Tenon's anesthesia for clear corneal phacoemulsification cataract surgery and foldable intraocular lens (IOL) implantation. SETTING: Departments of Ophthalmology, General Hospital Asklepeion Voulas and General Hospital of Athens, University of Athens, Athens, Greece. METHODS: One hundred consecutive patients scheduled for bilateral cataract surgery 1 to 2 months apart were prospectively randomized to receive topical anesthesia (100 eyes) or sub-Tenon's anesthesia (100 eyes). The randomization was stratified so that one half of first-eye surgeries and one half of second-eye surgeries were assigned to each anesthesia group, with each patient receiving each type of anesthesia once. All patients had clear corneal phacoemulsification with foldable IOL implantation. Patients were asked to rate their pain level on a 10-point scale for 4 periods: during the administration of the anesthetic agent, during surgery, immediately after surgery, and 24 hours postoperatively. The surgeon recorded his subjective assessment of ease of surgery and surgical complications using a standardized template. RESULTS: Eighty-one percent of patients who received topical anesthesia and 8% of patients who received sub-Tenon's anesthesia reported no pain during delivery of the anesthetic agent. The mean pain score was 0.19 +/- 0.39 (SD) in the topical group and 1.35 +/- 0.63 in the sub-Tenon's group. The difference between groups was statistically significant (P <.001). Seventy-two percent of patients in the topical anesthesia group and 86% in the sub-Tenon's anesthesia group reported no pain or slight discomfort during surgery (mean score 1.13 +/- 1.57 and 0.57 +/- 1.28, respectively) (P <.001). Ninety percent of topical anesthesia patients and 100% of sub-Tenon's anesthesia patients reported no pain or slight discomfort 30 minutes postoperatively (mean score 0.80 +/- 0.93 and 0.12 +/- 036, respectively) (P <.001). All patients in the topical anesthesia group and 77% in the sub-Tenon's group reported no pain 24 hours postoperatively (mean pain 0.00 +/- 0.00 and 0.23 +/- 0.40, respectively) (P <.001). Complications including prolonged akinesia of the globe, chemosis, and conjunctival hemorrhage occurred significantly more frequently in the sub-Tenon's than in the topical group (P <.001). CONCLUSIONS: Patients having cataract surgery under topical anesthesia had more intraoperative and postoperative discomfort than patients receiving sub-Tenon's anesthesia. However, patients having topical anesthesia reported less pain during its administration and had fewer complications. Both anesthesia methods provided high levels of pain control without additional sedation.

Peripheral ulcerative keratitis after Salmonella gastroenteritis.

PURPOSE: To describe a case of bilateral peripheral ulcerative keratitis after Salmonella gastroenteritis. METHODS: Case report with description of treatment and outcome. RESULTS: The peripheral ulcerative keratitis gradually resolved in both eyes after appropriate systemic antibiotic therapy and local ocular care. CONCLUSION: Peripheral ulcerative keratitis can result as a consequence of infectious gastroenteritis.

A case of atypical Cogan's syndrome with uncommon corneal findings.

PURPOSE: We report a case of atypical bilateral interstitial keratitis associated with Cogan's syndrome. METHODS: A 28-year-old man presented with a 2-year history of recurrent bilateral keratitis. Bilateral hearing loss preceded the ocular symptoms by 2 years. The patient also complained of skin nodules, headache, back pain, and arthritis. Corneal finding were consistent with superior stromal keratitis with stromal neovascularization and lipid deposition in the stroma. The patient's audiogram revealed cochlear pathology compatible with Cogan's syndrome (sensorineural deafness). RESULTS: The patient was treated with topical steroids but eventually required corneal transplantation in the right eye as a consequence of progressive loss of vision secondary to progressive lipid keratopathy. Visual acuity at the patient's most recent follow-up evaluation was 20/40. CONCLUSION: This case represents an unusual type of interstitial keratitis associated with Cogan's disease. The absence of ocular symptoms at the time of initial ear involvement and the atypical presentation of the keratitis were responsible for the delay in diagnosis in this patient, resulting in hearing impairment.

Krill protease effects on wound healing after corneal alkali burn.

PURPOSE: To study the effect of a novel protease in the development and progression of corneal ulceration secondary to alkali burning. METHODS: By using a 4N alkali burn model of corneal ulceration in rabbits, the effects and efficacy of topical application of a novel protease (PHM-101) capable of degrading metalloproteinases was studied for 28 days of treatment and 7 days off treatment for its effect on corneal ulceration and recurrent erosion. RESULTS: At day 28, both the protease- and placebo-treated groups had different numbers of eyes showing reepithelialization (nine (45%) of 20 and six (33%) of 18, respectively]. By day 35 the protease-treated group had significantly fewer recurrent epithelial defects [two (13%) of 15 vs. eight (61%) of 13; p = 0.02]. Similarly, at day 35 the protease-treated group showed significantly less corneal ulceration [two (13%) of 15 vs. six (46%) of 13; p = 0.02], and those ulcers were of a lesser severity (three units vs. 17.76 units). No difference was found in the degree of stromal edema or neovascularization, nor was there any difference in histopathologic characteristics of inflammatory cell infiltration and corneal scarring. CONCLUSION: We conclude that this novel protease is efficient in reducing recurrent corneal epithelial defects and stromal ulceration after alkali burning.

Long-term immunosuppressive treatment of serpiginous choroiditis.

OBJECTIVE: To determine the efficacy of immunosuppressive treatment in serpiginous choroiditis. DESIGN: The clinical courses were reviewed of six consecutive patients (12 eyes) with vision-threatening, steroid-dependent/resistant serpiginous choroiditis treated with a combination of immunosuppressive agents including azathioprine, cyclosporine, and cyclophosphamide. All patients underwent treatment for at least 12 months. RESULTS: The follow-up period ranged from 17 to 105 months (mean 57, median 43). All patients were able to taper oral steroids. Five patients discontinued all immunosuppressive medications after a treatment period of 12 to 69 months (mean 39 months). Immunosuppressive treatment was continued in one patient at a "low" maintenance dose. Ten eyes had improved visual acuities, while vision remained impaired in two due to macular scars. Recurrence was noted in two patients when an attempt was made to decrease the dose of immunosuppressive medication. Two patients experienced side effects which were reversed by decreasing the dose of the medications. CONCLUSION: Long-term immunosuppressive treatment appears to prolong remission and preserve vision in patients with serpiginous choroiditis.

Pars plana vitrectomy in patients with intermediate uveitis.

OBJECTIVE: To describe the effect of pars plana vitrectomy in patients with intermediate uveitis. METHODS: Retrospective analysis of the clinical course and visual outcome following pars plana vitrectomy in patients with intermediate uveitis. RESULTS: Thirty-two patients (43 eyes) were included in the study. Pars plana vitrectomy was combined with cataract surgery in 22 of 43 eyes. The intermediate uveitis was associated with sarcoidosis in 16 eyes and multiple sclerosis in five eyes, and was idiopathic in 22 eyes. The mean (+/-SD) follow-up was 45.6 (+/-38) months (range: 6-146 months). In 19 of 43 eyes (44.1%), there was improvement in the course of uveitis, allowing the discontinuation of immunosuppressive treatment in seven patients. Cystoid macular edema resolved in 12 of 37 eyes (32.4%). Forty of 43 eyes achieved a better or retained their initial visual acuity. The remaining three eyes deteriorated by two or more lines in the Snellen chart due to the progression of cataract, chronic cystoid macular edema, and glaucomatous optic atrophy, respectively. CONCLUSIONS: The results of this study suggest that pars plana vitrectomy may have a beneficial effect on the course of uveitis and the associated complications of cystoid macular edema, thereby reducing the need for long-term immunosuppression. Pars plana vitrectomy combined with simultaneous cataract surgery can improve the visual outcome in these patients.

Treatment of calcific band keratopathy by Nd:YAG laser.

A new technique is presented for the treatment of secondary calcific band keratopathy. The Nd:YAG laser was used for the disruption and removal of corneal calcium deposits. This technique was used in seven cases with satisfying results.

Fibrin reaction after extracapsular cataract extraction: a statistical evaluation.

As part of a retrospective study, 1056 eyes of 940 patients who had undergone extracapsular cataract surgery and posterior chamber IOL implantation were studied using statistical methods (chi-squared test). We studied the presence of fibrin reaction in three subgroups: diabetics without retinopathy (102 eyes), previously operated for primary open angle glaucoma "POAG" (78 eyes) and exfoliation syndrome without glaucoma (43 eyes). The results were compared for these three groups and for a group of normal individuals. The incidence of fibrin reaction was 13.7% in the diabetics, 44.8% in the group of previously operated POAG and 27.9% in the group of exfoliation syndrome without glaucoma. All the groups studied had this complication much more often than the controls (p < 0.0001). The incidence among previously operated eyes for POAG was higher than in diabetic eyes without retinopathy (p < 0.0005) and in exfoliation syndrome without glaucoma eyes (0.05 < p < 0.1). Fibrin reaction was more common in exfoliation syndrome without glaucoma than in diabetic eyes without retinopathy (p < 0.05).

Twelve years' continuous wear of the same therapeutic soft contact lens: a case report.

PURPOSE: To describe a case of a patient who had worn the same therapeutic soft contact lens (TSCL) continuously for twelve years, since he had failed to attend normal follow-up visits. METHODS: Microbiological histological and scanning electron microscopic (SEM) studies of conjunctiva, cornea and TSCL were done. RESULTS: Cultures were negative. Corneal histology revealed mild stromal edema and mild epithelial parakeratosis. Corneal SEM was remarkable for the preservation to some extent of normal corneal epithelial specialization with microtricae and microvillae. SEM of the TSCL showed a ruffed multi-layer surface with several cracks including different types of cells. CONCLUSIONS: The patient showed surprising tolerance to the continuous wear of the same contact lens for 12 years.

Diffuse retinal pigment epitheliopathy: treatment with laser photocoagulation.

PURPOSE: To evaluate the effectiveness of laser treatment in eyes with diffuse retinal pigment epitheliopathy (DRPE). METHODS: The authors retrospectively reviewed the medical records of 56 consecutive patients (78 eyes) with DRPE. All eyes were treated with digital fluorescein angiography guided argon green laser photocoagulation, direct on the focal retinal pigment epithelium (RPE) leaks and in a grid pattern to the RPE decompensation areas. A processed digital red-free fundus image including all the important traces on it was used as a guide to the laser treatment. The follow-up period ranged from 6 months to 7 years. RESULTS: At the end of the follow-up time, 70 (89.7%) eyes showed anatomic improvement with complete or partial resolution of the macular exudative lesions. Visual acuity of less than 20/40 was noted in 60 eyes (76.9%) preoperatively compared with 46 eyes (59.0%) finally (p=0.0252). The visual acuity was improved in 19 eyes (24.4%), stabilized in 51 (65.4%), and reduced in only 8 eyes (10.2%). CONCLUSIONS: In this series of patients with DRPE, the results of laser treatment were uniformly satisfactory producing a gradual resolution of the macular exudative lesions and an improvement or stabilization of the visual acuity.

The role of cytokines in experimental herpes simplex keratitis.

Experimental corneal infection with herpes simplex virus 1 (HSV-1) resulted in 11-21 days in herpes simplex keratitis (HSK) in C.A1-20 but not C.B-17 strain of BALB/c Igh-1-disparate mice. Formation of mRNAs of various pro-inflammatory cytokines was analyzed in corneas and draining lymph nodes (LNs) of HSK-susceptible C.A1-20 and HSK-resistant C.B-17 mice following HSV-1 corneal inoculation by reverse transcription-polymerase chain reaction (RT-PCR) and Southern blot analysis. Transcripts for interleukin (IL)-2 and interferon (IFN)-gamma were expressed in LNs of susceptible but not resistant mice. The level of IL-6 expression in the cornea correlated with the severity of keratitis in susceptible mice, being evident at days 4 and 14 after virus inoculation and thus showing a biphasic response. Resistant mice did not develop HSK and did not express IL-6. The IL-1beta and IL-4 gene transcription began early (day 7) in the corneas of resistant mice and then ceased, while in the corneas of susceptible mice, it began later (day 11). Taken together, these results indicate that IL-1beta, IL-4, IL-6, and IL-7 participate in the local inflammatory response in HSK.