Scleral Contact Lens to Preserve a Corneal Graft in Chronic Lagophthalmos

Facial burns involving the periorbital region may lead to cicatricial ectropion and lagophthalmos, causing severe exposure keratopathy and eventually blindness if uncorrected. In these patients, it is critical to provide aesthetic and functional surgical correction to protect the ocular surface from chronic desiccation in addition to visual rehabilitation. Conventional methods may not be sufficient to provide visual rehabilitation in complex cases. Scleral lenses can be a multipurpose alternative for these patients. Herein, we present the challenging case of a patient who developed cicatricial lagophthalmos and exposure keratopathy after facial transplantation due to gasoline burns and received a scleral contact lens for visual rehabilitation.

Implications of neuropathy and management of the corneal surface in a patient with Stuve-Wiedemann syndrome

Purpose: To describe the ophthalmological management of a girl diagnosed with Stuve Wiedemann syndrome (SWS). Clinical and in vivo confocal microscopy (IVCM) are described. Methods: Case report of a 6-year-old girl, who presented with neurotrophic keratitis and was treated with intense lubrication including heterologous serum and tear plugs. Results: In the following months, the evolution of the neurotrophic keratitis was good, but a hypertrophic corneal leukoma persisted with mild neovascularization in the left eye. Conclusion: Close ophthalmological follow-up in patients with SWS is needed, given that most of the time they do not present symptoms due to the characteristic neuropathy of their lesions. Abbreviations: SWS = Stuve-Wiedemann syndrome, IVCM = in vivo confocal microscopy, CNTF = ciliary neurotrophic factor, BCVA = best corrected visual acuity, LIFR = Leukemia Inhibitory Factor Receptor, IGF1 = Insulin-like growth factor-1.

Tape-splint tarsorrhaphy technique to manage exposure keratopathy in a patient refusing surgical intervention

This case report describes the benefits of a unique tape-splinting technique to serve as a nonsurgical tarsorrhaphy in the management of exposure keratopathy in a patient who refuses surgical intervention.

Online Questionnaire-Based Study on the Knowledge, Attitude, and Practices of Non-Ophthalmic Physicians-in-Training Regarding Exposure Keratopathy Among Patients Admitted in a Tertiary Referral Hospital

Objective

This study aimed to determine the knowledge, attitude, and practices of non-ophthalmic physicians-in-training regarding recognition and prevention of exposure keratopathy among patients admitted in a tertiary referral hospital.

Methods

This study was a single-center cross-sectional study. An anonymous self-administered online questionnaire was distributed among non-ophthalmic physicians-in-training at the Philippine General Hospital (PGH) using convenience and snowball sampling.

Results

A total of 77 responses were recorded with a response rate of 37%. The majority of the respondents uniformly reported the absence of an established eye care protocol or policy being implemented for different subsets of patients at risk for developing exposure keratopathy. Ninety-six percent (96%) was aware of exposure keratopathy. The most urgent reason for referral to the ophthalmology service was the presence of whitish of opacity at 46.8%, while the least urgent reason was the presence of eye redness at 36.4%. Only 43% of the patients with incomplete eyelid closure was referred to the ophthalmology service. The most frequently used modality of prophylactic eye protection treatment was eyelid taping (84.4%) followed by lubricants (drops and gels, 79.1%). The most common reason for not referring was the absence of an established protocol on the appropriate indication for referral to the ophthalmology service.

Conclusion

This study showed that the majority of non-ophthalmic physicians-in-training had adequate knowledge and favorable attitude regarding recognition and prevention of exposure keratopathy among patient admitted at the PGH; however, the absence or the unavailability of an eye care protocol among patients with inadequate eyelid closure in our institution on the prevention of exposure keratopathy and its early treatment and appropriate indications for ophthalmology referral resulted in non-uniformity and varied practice patterns on its management.

Corneal manifestations and treatment among patients with COVID-19-associated rhino-orbito-cerebral mucormycosis

Purpose

TO report the corneal manifestations in patients with COVID-19-associated rhino-orbito-cerebral mucormycosis (ROCM).

Methods

This study was a retrospective, observational, and record-based analysis of patients of ROCM with corneal involvement.

Results

A total of 220 patients were diagnosed with ROCM over a period of 3 months. Thirty-two patients had developed corneal manifestations. The mean age at diagnosis was 52.84 ± 12.8 years. The associated risk factors were systemic mucormycosis, uncontrolled diabetes, recent COVID-19 infection, and injudicious use of systemic steroids. Twenty-nine patients were known diabetics, 32 had recent COVID-19 infection, and 13 gave a history of injudicious use of steroids. The right eye (RE) was affected in nine patients, the left eye (LE) in 20 patients, and both eyes in three patients. Nine patients had a round-oval corneal ulcer. One patient each had a perforated corneal ulcer with uveal prolapse, sealed perforated corneal ulcer, spontaneously healed limbal perforation, diffuse corneal haze with hyphemia, panophthalmitis, diffuse corneal stromal abscess, limbal ischemia, anterior uveitis with posterior synechiae, inferior corneal facet, and filamentary keratitis. Three patients each had a corneal melt and inferior conjunctival xerosis with chemosis. Orbital exenteration was performed in six patients. Five patients with corneal ulcers healed. Topical eye drops of amphotericin (0.5 mg/ml) cycloplegic, antiglaucoma medications, and lubricant eye drops were started along with systemic antifungals.

Conclusion

Central corneal ulcer was the most common manifestation of mucormycosis. A concentration as low as 0.5 mg/ml of amphotericin eye drops was effective in the treatment.

Diagnostic and therapeutic challenges in non-specific orbital inflammation - a case report

Objective: The aim of this report is to present the diagnostic and therapeutic approach in a case of non-specific orbital inflammation complicated with sight-threatening exposure keratopathy. Case presentation: An 81-year-old female patient presented to our Ophthalmology Department for left, painful, unilateral exophthalmia and decreased vision in the same eye. The clinical examination revealed left proptosis, inferior dystopia, upper lid edema, erythema and moderate retraction, ocular motility restriction, chemosis and corneal epithelial defect. The keratopathy complicated in evolution with hypopyon. The patient received treatment for the exposure keratopathy and, after every specific cause of unilateral exophthalmia was ruled out using imagistic and laboratory examinations, systemic corticosteroid treatment was initiated. Although the response to treatment was prompt, it was incomplete because of the long-standing evolution. Discussions: In this case, the diagnosis was difficult because a malignant breast tumor was encountered and an orbital biopsy was impossible to be performed. The presence of exposure keratopathy complicated with hypopyon imposed the exclusion of an infectious process and delayed the initiation of the corticosteroid therapy. Conclusions: The diagnosis and treatment of this disease represent a challenge given the need to rule out all the local and systemic conditions that may present with exophthalmia.

Perioperative Care of the Patient with Eye Pathologies Undergoing Nonocular Surgery

The authors reviewed perioperative ocular complications and implications of ocular diseases during nonocular surgeries. Exposure keratopathy, the most common perioperative eye injury, is preventable. Ischemic optic neuropathy, the leading cause of perioperative blindness, has well-defined risk factors. The incidence of ischemic optic neuropathy after spine fusion, but not cardiac surgery, has been decreasing. Central retinal artery occlusion during spine fusion surgery can be prevented by protecting eyes from compression. Perioperative acute angle closure glaucoma is a vision-threatening emergency that can be successfully treated by rapid reduction of elevated intraocular pressure. Differential diagnoses of visual dysfunction in the perioperative period and treatments are detailed. Although glaucoma is increasingly prevalent and often questions arise concerning perioperative anesthetic management, evidence-based recommendations to guide safe anesthesia care in patients with glaucoma are currently lacking. Patients with low vision present challenges to the anesthesia provider that are becoming more common as the population ages.

Pillar tarsoconjunctival flap: An alternative approach for the management of refractory corneal ulcer

PURPOSE

To report the effectiveness of the surgical procedure of the tarsoconjunctival flap (FTC) in patients with severe ocular surface impairment refractory to previous conventional treatments.

METHODS

A retrospective, noncomparative, consecutive case series.

RESULTS

Pillar tarsoconjunctival flap (PTCF) was performed in eight eyes of eight patients. Three patients had neurotrophic corneal ulcer (NCU), three had exposure keratopathy and two had corneal melting. Seven of them had satisfactory postoperative results, showing total corneal re-epithelialization that lasted throughout the postoperative follow-up (mean 10.33 ± 2.65 months [SD], range 6 to 12 months). Mean time for the re-epithelization was 11.28 ± 8.97 days [SD] (range 4 to 30 days).

CONCLUSION

This study suggest PTCF is a valid alternative to tarsorrhaphy in cases of persistent epithelial defect (PED) or NCU resistant to conventional treatments. Notwithstanding, prospective comparative trials comparing PTFC with conventional and/or novel therapies in PED or NCU are needed to corroborate these findings.

Modified Gundersen Flap Using Inferior Palpebral-Bulbar Conjunctiva

PURPOSE

The purpose of this article was to describe a modification to the traditional Gundersen flap technique that expands eligible eyes to include those with severe conjunctival scarring and to report results from a clinical case.

METHODS

A 68-year-old woman with a history of herpes simplex keratitis, multiple failed penetrating keratoplasties, lagophthalmos, persistent epithelial defect, and low visual potential in the left eye presented for the evaluation of a Gundersen flap. Severe superior bulbar conjunctival scarring precluded a traditional approach. A modified Gundersen flap technique using a contiguous flap of inferior palpebral-bulbar conjunctiva extending from the inferior tarsal border to the limbus was devised and performed.

RESULTS

The modified Gundersen flap technique successfully stabilized the ocular surface, obviating the need for a cosmetically disfiguring permanent tarsorrhaphy or an evisceration.

CONCLUSIONS

This modified Gundersen flap technique expands the indications to eyes with severe conjunctival scarring and can be offered in eyes with previous trabeculectomies, glaucoma drainage implants, and scleral buckles, which were previously excluded from the globe-preserving option.

Exposure Keratopathy: An Idiopathic Lagophthalmos Case Report

Exposure keratopathy refers to corneal damage that results primarily from prolonged exposure of the ocular surface to the outside environment. Herein, we describe a case of exposure keratopathy with bilateral idiopathic lagophthalmos and discuss factors pertaining to prompt diagnosis and treatment.

A 21-year-old woman presented with bilateral nocturnal lagophthalmos, blurred vision, and whitish spots in both eyes. She had no remarkable history of medication use, trauma, surgery, cranial nerve abnormality, critical illness, or other ocular problems. Examination revealed bilateral lagophthalmos, good Bell’s phenomenon, bilateral inferior corneal scars, and vision loss. Laboratory results were normal; there was an absence of proptosis, and no epithelial defects were apparent. Based on these findings, she was diagnosed with exposure keratopathy resulting from idiopathic bilateral lagophthalmos and treated with lubricants. 

This was a rare case of exposure keratopathy with bilateral lagophthalmos of idiopathic origin, and a challenging one, which prompted the researchers to formulate an appropriate treatment plan.

Incidence and related factors of surface eye disorders in traumatic intensive care unit patients in Iran

BACKGROUND

Intensive care unit (ICU) patients are exposed to several surface eye disorders ranged from minor complications like corneal dryness to more serious ones such as corneal perforation and blindness. This study is then to assess the incidence of the ocular complications and related factors.

MATERIALS AND METHODS

During a prospective cross sectional study in a general adult ICU, ocular complications of the patients were assessed by an ophthalmologist. Data were analyzed using descriptive analysis. A P-value of ≤0.05 was considered significant.

RESULTS

Out of 155 patients, 130 cases (260 eyes) were covered during the study period, 2016-2017. The most common complications among the patients included dry eye and corneal abrasion (25.8%) followed by conjunctivitis (25%). The mean time of occurrence for dryness and corneal abrasion was 4±2.93 days after admission to the ICU. Lower Glasgow coma scale (GCS) and longer hospital stay were significantly associated with ocular complications in the ICU (P<0.05).

CONCLUSION

Eye surface complications are commonplace in critically ill patients admitted in the ICU. Dry eye, corneal abrasion, and conjunctivitis have been revealed as the most prevalent complications in this study. Lower GCS and longer stay in the ICU predisposed the cases to these complications. Efficient eye care protocol and training the ICU staff are both recommended to reduce complication rates as such.

Ocular surface characteristics and colonization in a burn center: A prospective cohort study

We aimed to evaluate the characteristics and colonization by pathogenic microorganisms of the ocular surface in patients in a burn center and to determine their association with sedation, mechanical ventilation, and periocular burn. We prospectively evaluated 40 patients during an eight-month period. Five evaluations where performed, at baseline and weekly on four more occasions or until hospital discharge or death. On each visit, we assessed periocular burn, lid position, Bell's phenomenon, Schirmer's test, presence of chemosis, conjunctival hyperemia, and exposure keratopathy; conjunctival fornix swabs were taken for microbiology culture. Also, we documented the level of sedation, mechanical ventilation status, and systemic and ocular treatment. Absent Bell's phenomenon and chemosis were significantly different at baseline in patients under mechanical ventilation, sedation, and in those with periocular burn. The cumulative incidence of exposure keratopathy was 22.5% and the cumulative incidence of ocular surface colonization by pathogenic microorganisms was 32.5%. Both outcomes were associated with mechanical ventilation and periocular burn. The most frequent pathogenic microorganisms in the ocular surface were Candida parapsilosis, Acinetobacter baumanii, and Pseudomonas aeuroginosa. We did not observe any case of persistent epithelial defect, infectious keratitis, corneal perforation or corneal opacity in this cohort. Results from our study may benefit future patients by allowing better risk stratification and treatment strategies for the ocular surface care in burn units.

Predicting Factors Influencing Visual Function of the Eye in Patients with Unresolved Facial Nerve Palsy after Upper Eyelid Gold Weight Loading

Implantation of gold weights into the upper eyelid is a proven method of treating lagophthalmos and exposure keratopathy in patients with unresolved facial nerve palsy. The aim of this study was to evaluate the factors affecting visual acuity and corneal complications in patients after upper eyelid gold weight lid loading. Material and methods: This prospective consecutive clinical study was conducted in years 2012–2018. In total, 59 people (40 women, 19 men aged 55.5 ± 17.4 years) meeting the inclusion criteria were treated with gold weights. The ordered multinomial logit model was used to analyze the factors affecting best-corrected visual acuity (BCVA) and degree of exposure keratopathy after surgery. The influence of the following variables was analyzed: patient age, etiology and duration of the facial nerve palsy, history of the previous eyelid surgery, degree of lagophthalmos in mm, presence of Bell’s phenomenon, and corneal sensation, Schirmer test results. Results: Implantation of gold weights into the upper eyelid effectively reduced lagophthalmos and exposure keratopathy in the study group (p < 0.001). BCVA was maintained or better in 95% of patients after surgery. Patient age, presence of the Bell’s phenomenon, and corneal sensation significantly affected the final BCVA (p < 0.1). The presence of Bell’s phenomenon and corneal sensation had a positive effect on the degree of keratopathy after surgery (p < 0.1). In turn, patient age and history of tarsorrhaphy were significant negative prognostic factors of exposure keratopathy and BCVA after surgery (p < 0.05). Etiology and duration of facial nerve palsy, degree of corneal exposure in mm, and results of the Schirmer test did not have a significant impact on the outcome after surgery (p > 0.1). Conclusions: The results of our study may help to answer the question of how to direct ophthalmologists and other specialists who refer to ophthalmologists for management advice in patients with facial nerve palsy. Elderly patients with a history of tarsorrhaphy who present with poor Bell’s phenomenon and/or a lack of corneal sensation should be the first candidates for immediate correction of lagophthalmos.

Schirmer Tear Test Value and Corneal Lesions' Incidence during General Anesthesia for Non-Ophthalmic Surgery in Non-Brachycephalic Dogs: A Pilot Study Comparing Three Different Lubricant Eye Drop Formulations

Aim of this blinded, prospective, randomized clinical study was to compare three different lubricant eye drops (LED) in healthy adult dogs undergoing general anaesthesia (GA) for non-ophthalmic surgery. Tear production rate was monitored by means of Schirmer tear test-1 (STT-1), and incidence of post-operative corneal abrasions/ulcerations was detected by corneal staining. A complete ophthalmic examination was performed before premedication, at extubation time and 24 h after GA in twenty-five non-brachycephalic dogs (fifty eyes) undergoing elective orthopaedic or spinal surgery procedures. Dogs were randomly allocated to one of three groups receiving as prophylactic LED either carmellose sodium (GC), or 1% hyaluronic acid (GH), or 0.25% hyaluronic acid (GL). In each eye STT-1 was repeated every hour during GA, before instilling one drop of the assigned LED. In all groups STT-1 values drastically decreased during GA, while 24 h later nine eyes (18%) had STT-1 values lower than 15 mm/minute. All of the three formulations tested were fully effective in preventing corneal ulceration (0% in all groups), while 10% of eyes reported superficial de-epithelialization. Fluorescein staining demonstrated that hourly prophylactic LED application prevented exposure keratopathy during general anesthesia in 90% of the eyes in non-brachycephalic dogs.

Levator recession and minimal lateral tarsorrhaphy for the management of lagophthalmos and corneal exposure in facial palsy

PURPOSE

Recession of levator muscle can potentially decrease the severity of corneal exposure by reducing margin-reflex distance 1. The purpose of this study is evaluation of effects of levator recession on lagophthalmos in facial palsy.

MATERIALS AND METHODS

In a non-comparative case series of consecutive patients with exposure keratopathy due to facial paralysis between 2012 and 2017, levator recession was performed through lid crease incision. Small-size (⩽3 mm) lateral tarsorrhaphy was performed on a case-by-case basis for those with moderate-to-severe keratopathy. Preoperative and postoperative measurements of margin-reflex distance 1 and lagophthalmos were compared using paired t-test.

RESULTS

Thirty-four patients (14 men and 20 women) were enrolled with an average age of 52.3 years. Mean follow-up was 13.3 months (range, 6-36 months). The most common etiology of facial paralysis was Bell's palsy (22 cases), followed by motor vehicle accident (8), parotid surgery (3), and brain tumor surgery (1). No additional procedure was performed for eight patients, while lateral tarsorrhaphy was performed in 26 cases. Mean margin-reflex distance 1 decreased from 5.0 ± 0.4 mm to 4.0 ± 0.5 mm (p < 0.001) and mean lagophthalmos decreased from 3.3 ± 0.9 mm to 1.8 ± 0.9 mm (p < 0.001). Subgroups of patients with additional lateral tarsorrhaphy and without tarsorrhaphy experienced the same amount of reduction in margin-reflex distance 1 and lagophthalmos.

CONCLUSION

Recession of levator muscle was effective in reduction of margin-reflex distance 1 and lagophthalmos in facial palsy patients. This procedure can be added to the surgical armamentarium for management of patients with facial palsy and lagophthalmos.

The role of autophagy in the pathogenesis of exposure keratitis

Incomplete tear film spreading and eyelid closure can cause defective renewal of the ocular surface and air exposure-induced epithelial keratopathy (EK). In this study, we characterized the role of autophagy in mediating the ocular surface changes leading to EK. Human corneal epithelial cells (HCECs) and C57BL/6 mice were employed as EK models, respectively. Transmission electron microscopy (TEM) evaluated changes in HCECs after air exposure. Each of these models was treated with either an autophagy inhibitor [chloroquine (CQ) or 3-methyladenine (3-MA)] or activator [Rapamycin (Rapa)]. Immunohistochemistry assessed autophagy-related proteins, LC3 and p62 expression levels. Western blotting confirmed the expression levels of the autophagy-related proteins [Beclin1 and mammalian target of rapamycin (mTOR)], the endoplasmic reticulum (ER) stress-related proteins (PERK, eIF2α and CHOP) and the PI3K/Akt/mTOR signalling pathway-related proteins. Real-time quantitative PCR (qRT-PCR) determined IL-1β, IL-6 and MMP9 gene expression levels. The TUNEL assay detected apoptotic cells. TEM identified autophagic vacuoles in both EK models. Increased LC3 puncta formation and decreased p62 immunofluorescent staining and Western blotting confirmed autophagy induction. CQ treatment increased TUNEL positive staining in HCECs, while Rapa had an opposite effect. Similarly, CQ injection enhanced air exposure-induced apoptosis and inflammation in the mouse corneal epithelium, which was inhibited by Rapa treatment. Furthermore, the phosphorylation status of PERK and eIF2α and CHOP expression increased in both EK models indicating that ER stress-induced autophagy promoted cell survival. Taken together, air exposure-induced autophagy is indispensable for the maintenance of corneal epithelial physiology and cell survival.

Periorbital lesions in severely burned patients

PURPOSE

This study aimed to characterize the injuries involving periorbital region in our severely burned patients.

METHOD

A 2 years retrospective study was conducted with a total of 210 severe burns admissions. Periorbital burn injuries (all produced in association with facial injuries) were encountered in 126 patients, representing the study group that was further analyzed for multiple parameters: demographics, mechanism of injury, TBSA (total body surface area), burn depth, inhalation injury, need for intubation and mechanical ventilation. The presence and severity of ocular injuries were also evaluated.

RESULTS

Analyzing our study group (n=126), we observed the presence of multiple negative prognosis factors: elderly patients, extensive burns, deep burns affecting functional areas, unfavorable mechanism (electric, chemical or explosions), inhalation injuries, need for intubation and mechanical ventilation, leading to severe morbidity and high mortality level. Ocular injuries were encountered in 37 patients (30 primary and 7 secondary lesions). The predominance of primary ocular lesions is explained trough high severity burns encountered in our patients with high mortality and lack of long-term clinical observations.

CONCLUSION

The clinical outcome for periorbital burn injuries depends on patient characteristics, etiology, burn extension and depth, associated lesions, infectious risk and the quality of the treatment applied. Presence of ocular injuries in various severity degrees impose an adequate evaluation and specialized treatment, being associated with important morbidity. In severely burned patients, it is mandatory to apply preventive measures to avoid ocular complications. If exposure keratopathy is detected, prompt ophthalmologic treatment is essential to avoid functional impairment including loss of vision. Abbreviations: TBSA = total body surface area, MSOF = multisystem organ failure, OCS = orbital compartment syndrome, AION = anterior ischemic optic neuropathy.

Knowledge and practice patterns of Intensive Care Unit nurses towards eye care in Chhattisgarh state

Purpose

The aim of the study was to present the level of knowledge and practice patterns regarding exposure keratopathy in mechanically ventilated patients among Intensive Care Unit (ICU) nurses in Chhattisgarh state.

Methods

A previously validated semi-structured questionnaire was administered in the ICU of six multispecialty hospitals in Chhattisgarh in 2014-2015. Demography included age, gender, level of education, and months of working in ICU. Most of the questions dealt with frequency of eyelid closure assessment, frequency of cleaning of eyes with saline gauze, using a protocol-based approach for eye care, and documentation of ophthalmic complications. Common barriers to delivery of eye care such as shortage of time and too much writing tasks were also inquired.

Results

Our study included 120 nurses. They worked for mean 22.9 ± 17.8 months in ICU. Knowledge about high risk of exposure keratopathy in ventilated patient was present in 93% (78%; 95% confidence interval [CI]) nurses. Only six nurses (5%) followed a strict protocol for eye care, 52 nurses (43%) checked for eyelid closure in the ventilated patients, and 58 (48%) cleaned the eyes frequently. Those who were aware of exposure keratopathy checked eyelid closure (73% vs. 48%) and cleaned eyes with saline gauze more frequently (24% vs. 4%). Nurses in cardiac ICU were significantly lesser aware of exposure complications compared to medical ICU nurses (40% reduction in awareness, 95% CI = 0.37-0.98, P = 0.04).

Conclusion

Although there is high awareness, practice patterns of ICU nurses were less than desired. Educational initiatives should focus on weaknesses in knowledge and practice noted to improve eye care of patients in ICU.

The utilization of an ocular wound chamber on corneal epithelial wounds

Purpose

Currently available ocular moisture chambers are not adequate to manage the treatment of periocular burns, corneal injuries, and infection. The purpose of these studies was to demonstrate that a flexible, semi-transparent ocular wound chamber device adapted from technology currently used on dermal wounds is safe for use on corneal epithelial injuries.

Materials and methods

A depilatory cream (Nair™, 30 seconds) was utilized to remove the excess hair surrounding the left eyes of anesthetized Institute Armand Frappier (IAF) hairless, female guinea pigs (Crl:HA-Hrhr). A 4 mm corneal epithelium defect was created using a corneal rust ring remover (Algerbrush^®II). Epithelial defects were either left untreated or the eyes were fitted with an ocular wound chamber and 0.5 mL of hydroxypropyl methylcellulose (HPMC) gel (GenTeal^®) or HPMC liquid (GenTeal^®) was injected into each chamber (N=5 per group). At 0, 24, 48, and 72 hours fluorescein and optical coherence tomography imaging was collected and the intraocular pressure (IOP) was measured. H&E staining was performed on corneal and eyelid skin samples and evaluated by a veterinary pathologist.

Results

Corneal epithelial wounds demonstrated 100% closure rates when left untreated or treated with an ocular wound chamber containing HPMC gel at 72 hours while wounds treated with an ocular wound chamber containing HPMC liquid were 98% healed. No significant differences were found in corneal thickness and wound healing, IOP, or eyelid skin pathology in any treatment group when compared to controls.

Conclusions

This study indicates that adapted wound chamber technology can be safely used on sterile, corneal epithelial wounds without adverse effects on periocular or ocular tissue when filled with a liquid or gel.

The Magnetic Levator Prosthesis for Temporary Management of Severe Blepharoptosis: Initial Safety and Efficacy

Purpose

We further optimized and evaluated the safety of the magnetic levator prosthesis (MLP) for temporary management of severe blepharoptosis, and compared efficacy and comfort against the ptosis crutch.

Methods

The interpalpebral fissure (IPF) of participants (n = 12) with ptosis was measured during attempted eyelid opening, volitional closing, and spontaneous closing with no device, ptosis crutch, or the MLP. A 10-point scale documented comfort. Additionally, a 20 minute and then 1 week trial of the MLP was offered. Safety measures were skin erythema rating, change in visual acuity, and change in corneal staining.

Results

The MLP and crutch opened the eye (IPF 11.2 and 9.3 mm), but the MLP allowed better volitional closure (IPF 1.0 vs. 4.9 mm, P = 0.009), but was no better in allowing spontaneous blink (IPF 7.5 vs. 7.7 mm, P = 0.722). Both devices were equally comfortable (both median 8/10 comfort, P = 0.46). With extended use, opening with the MLP showed IPF 9.24 mm at 20 minutes and 9.46 mm at 1 week, and volitional closure was IPF 0.95 and 0.52 mm, respectively. Closure on spontaneous blink improved with extended wear to IPF 5.14 and 5.18 mm, respectively (P = 0.002). Two participants exhibited moderate skin erythema and one had increased corneal staining without change in acuity.

Conclusions

The MLP is safe and feasible for temporary correction of severe ptosis.

Translational Relevance

First group data in patients showing successful reanimation of the eyelid with magnetic force.

The Impact of Normal Saline on the Incidence of Exposure Keratopathy in Patients Hospitalized in Intensive Care Units

Background

Patients in the intensive care unit (ICU) have impaired ocular protective mechanisms that lead to an increased risk of ocular surface diseases including exposure keratopathy (EK). This study was designed to evaluate the effect of normal saline (NS) on the incidence and severity of EK in critically ill patients.

Materials and Methods

This single-blind randomized controlled trial was conducted on 50 patients admitted to ICUs. The participants were selected through purposive sampling. One eye of each patient, randomly was allocated to intervention group (standard care with NS) and the other eye to control group (standard care). In each patient, one eye (control group) randomly received standard care and the other eye (intervention group) received NS every 6 h in addition to standard care. The presence and severity of keratopathy was assessed daily until day 7 of hospitalization using fluorescein and an ophthalmoscope with cobalt blue filter. Chi-square test was used for statistical analysis in SPSS software.

Results

Before the study ( first day) there were no statistically significant differences in the incidence and severity of EK between groups. Although, the incidence and severity of EK after the study (7^th day) was higher in the intervention group compared to the control group, their differences were not statistically significant. Although, the incidence and severity of EK, from the 1^st day until the 7^th, increased within both groups, this increase was statistically significant only in the intervention (NS) group.

Conclusions

The use of NS as eye care in patients hospitalized in ICUs can increase the incidence and severity of EK and is not recommended.

[Severe bilateral pseudomonas sclerokeratitis in comatose patient (clinical case)]

The article presents a clinical case of severe bilateral pseudomonas sclerokeratitis in a patient with occlusion hydrocephalus and intracranial hypertension, who was in a coma and on a ventilator for 20 days. At first examination (7 days after the onset of purulent keratitis, during which the process had been rapidly progressing), the clinical picture included lagophthalmos, severe purulent corneal ulcer, bilateral purulent scleromalacia, perforated cornea in the left eye. On the same day, in order to maintain eye integrity, urgent reconstructive penetrating sclerokeratoplasty with subsequent sclerocorneal coating was performed in both eyes right in the intensive care unit. Parts of the melted iris and ciliary body pars plana that were left in place were abundantly washed with BSS and moxifloxacin solutions - 150 µg/ml. Postoperative care included forced instillations of antibiotics and antiseptics. Two years after the first surgery, 2 more full-thickness corneal transplantations were performed in the patient's right eye aiming at restoration of its optical system. Thus, immediate sclerokeratoplasty with anterior segment irrigation and intraocular administration of highly diluted antibiotics appeared to be the only chance to save the vision in one eye. The fellow eye, where perforation occurred as a result of severe purulent sclerokeratitis and purulent iridocyclitis, despite all measures taken, lost its sight. After three surgeries (penetrating sclerokeratoplasty and two re-PK), visual acuity in the only seeing (right) eye was 0.1, which can be considered a satisfactory result.

Nurses can play an active role in the early diagnosis of exposure keratopathy in intensive care patients

AIM

This study was conducted in order to determine nurses' ability to diagnose exposure keratopathy reliably in the early stage in intensive care patients.

METHODS

This methodological and descriptive study was carried out between 2011 and 2012 in the Neurology and Anesthesiology and Reanimation Intensive Care Units of a teaching hospital in western Turkey. The sample consisted of 4354 ocular assessments in 156 corneas of 78 patients. A patient identification form and a fluorescein test patient tracking chart were used in the data collection. The corneas of the patients were checked by a fluorescein dye test by the same nurse and ophthalmologist.

RESULTS

The mean age of the patients was 59 ± 15.5 years and 47.4% of them were female. The consistency between the nurse and the ophthalmologist was almost perfect in terms of determining the presence of exposure keratopathy, characteristics, and the grade of corneal staining. Exposure keratopathy was detected at a rate of 2% by the ophthalmologist. A significant relationship was found between the presence of lagophthalmos and the development of exposure keratopathy. A positive correlation was found between the grade of corneal staining and the degree of the eyelid position of the patients and the duration of mechanical ventilation therapy.

CONCLUSION

After eye care and assessment training, intensive care nurses can play an effective role in detecting early-stage exposure keratopathy in intensive care patients.

Making a Difference in Eye Care of the Critically Ill Patients

Ocular surface disorders are frequently encountered in patients under sedation and paralyzed patients in intensive care units (ICUs). In the ICUs, treatment is usually focused on the management of organ failures, and eye care becomes a side issue. As a result, ophthalmological complications do occur (incidence ranges from 3.6% to 60%) and are frequently overlooked in this setting. To identify the best available evidence in providing the best eye care to prevent exposure keratopathy, a literature review was performed. The databases of PUBMED, COCHRAN, and EMBASE library were searched. We only looked at higher quality articles. Among various eye care measures that have been advocated to prevent exposure keratopathy, the most effective is the application of polyethylene covers. Early diagnosis and effective treatment will help prevent microbial keratitis and visual loss.

Ophthalmic management of the facial palsy patient

The management of the ocular sequelae of facial palsy should be individualized for each patient. The patient's age, ocular motility, tear production, and corneal sensation are considered when developing a treatment plan. Individuals with transient weakness often require only therapy with topical lubricants. Permanent or chronic facial paralysis is usually associated with lagophthalmos, ectropion, and exposure keratitis. Both "static" and "dynamic" procedures can be performed to improve these conditions. Combined eyelid surgery and suspension of the midface often provides the best result. However, patients with permanent facial palsy usually suffer chronic ocular symptoms, requiring long-term follow-up and continued topical therapy.

Prevention of exposure keratopathy in intensive care unit

AIM

To compare the efficacy for preventing exposure keratopathy of three forms of eye care (artificial tear, moist chamber and polyethylene covers) for intensive care patients.

METHODS

Eighty-four patients in Intensive Care Unit (ICU) were randomized to three treatment groups, including artificial tears group, moist chambers group and polyethylene film group. Patients of artificial tear group received two drops of carboxymethylcellulose drops to each eye every 2 hours. The moist chambers and the polyethylene were changed every 12 hours or as needed if they became unclean or torn. The corneal fluorescein stains were performed daily.

RESULTS

No of 28 patients (0%) in the polyethylene group and one of the 27 patients (3.70%) in the moist chamber group had exposure keratopathy, compared to 8 of the 29 patients (27.59%) in the artificial tear group. There were statistical significance between the artificial tear group and the moist chamber group (P=0.02), and the artificial tear group and the polyethylene group (P=0.003). The time on eye care every day of the artificial tear group, the moist chamber group and the polyethylene group was 26.69±2.39 minutes, 35.33±2.63 minutes and 7.48±0.87 minutes, respectively. The eye care of the polyethylene group were statistically more time-save than that of the artificial tear group (P<0.001) and the moist chamber group (P<0.001).

CONCLUSION

Polyethylene covers are more effective and more time-saving in reducing the incidence of corneal damage in intensive care patients.