The efficacy of corneal debridement in the treatment of microsporidial keratoconjunctivitis: a prospective randomized clinical trial

PURPOSE

To evaluate the efficacy of corneal debridement in the treatment of clinically diagnosed cases of microsporidial keratoconjunctivitis.

DESIGN

Prospective, double-masked randomized clinical trial.

METHODS

Patients with clinical features such as multifocal, coarse, raised, punctate, round to oval epithelial lesions in the cornea in slit-lamp examination with mild to moderate conjunctival congestion, suggestive of microsporidial superficial keratoconjunctivitis, were included in the prospective study. All patients were randomized into 2 groups. Group 1 patients underwent debridement with the help of a sterile #15 blade on a Bard-Parker handle, whereas only conjunctival swabs were taken from Group 2 patients. All patients were treated with ocular lubricants.

RESULTS

One hundred and twenty patients with clinical features suggestive of microsporidial superficial keratoconjunctivitis were included in the study. The mean age was 34.3 ± 13.6 years (Group 1) and 35.8 ± 16.2 years (Group 2) (P = .59). The mean duration of symptoms was 6.8 ± 3.9 days (Group 1) and 7.2 ± 4.6 days (Group 2) (P = .61). Baseline characteristics showed no difference between the 2 groups. The primary outcome was the time from the presentation to complete resolution (ie, absence of corneal lesions) of the clinical signs and symptoms. The secondary outcomes were final visual acuity and residual corneal side effects and/or scarring, if any. The mean resolution time of the corneal lesions was 5.7 ± 4.0 days (Group 1) and 5.9 ± 3.9 days (Group 2) (P = .83). There was no significant difference in final visual outcome in the 2 groups. No serious side effects were observed.

CONCLUSION

Debridement does not have any significant advantage in terms of resolution of the corneal lesions and final visual outcome in cases of microsporidial keratoconjunctivitis.

Liquid nitrogen cryotherapy of superior limbic keratoconjunctivitis

PURPOSE

To evaluate the effects of liquid nitrogen cryotherapy on superior limbic keratoconjunctivitis (SLK).

DESIGN

Interventional case series.

METHODS

In this clinical practice case series, the effects of liquid nitrogen cryotherapy on SLK were observed. Liquid nitrogen cryotherapy was performed using a Brymill E tip spray (0.013-inch aperture) with a double freeze-thaw technique. All subjects were outpatients who had local anesthesia with a single drop of topical proparacaine. The main outcome measure was the resolution of the disease process after treatment.

RESULTS

Four female patients (average age, 64 +/- 13 years) and seven eyes with SLK were treated with liquid nitrogen cryotherapy. Resolution of signs and symptoms occurred within two weeks. Disease recurred in two patients and three of seven eyes, although repeat cryotherapy eradicated SLK in all cases. The repeat cryotherapy was performed at three months postoperatively. There were no adverse ocular events.

CONCLUSIONS

Liquid nitrogen cryotherapy appears to be an effective alternative treatment for SLK as all subjects studied achieved long-term cures. Repeat cryotherapy may be necessary in some instances and may be performed three months after the first treatment.

Conjunctival resection combined with tenon layer excision and the involvement of mast cells in superior limbic keratoconjunctivitis

PURPOSE

To evaluate the effectiveness of conjunctival resection combined with Tenon layer excision in treating superior limbic keratoconjunctivitis (SLK) and the involvement of mast cells in SLK.

DESIGN

Retrospective, interventional case series.

METHODS

Forty eyes of 30 SLK patients who were unresponsive to medical treatment received superior bulbar conjunctival resection, and another 20 patients who underwent cataract and retinal surgery served as a control group. The conjunctiva specimens from study and control patients were examined by hematoxylin and eosin staining and immunohistochemistry using antibodies against mast cell tryptase.

RESULTS

In all operated eyes, the clinical symptoms and signs, including irritation and redness and superior bulbar conjunctival hyperemia and superior tarsal conjunctival papillary hypertrophy, subsided significantly three months after the operation. Only three eyes had recurrence from the margin of conjunctival resection, and this was relieved after reoperation. Keratinized conjunctival epithelium, loss of goblet cells, and increased mast cell numbers (P<.05) were found in the SLK group.

CONCLUSIONS

Our cases demonstrate that superior bulbar conjunctival resection combined with Tenon layer excision is an effective treatment for SLK. The pathologic findings suggest that mast cells may play a role in the pathogenesis of SLK.

Development of Superior Limbic Keratoconjunctivitis After Upper Eyelid Blepharoplasty Surgery

PURPOSE

To describe a unique presentation of superior limbic keratoconjunctivitis (SLK) that occurred after upper eyelid blepharoplasty and to review the literature regarding the current theories of SLK pathogenesis and its treatment.

METHODS

A 48-year-old woman presented with a 2-year history of irritation and foreign body sensation in both eyes that began immediately after bilateral upper eyelid blepharoplasty. Her symptoms were unresponsive to therapy with lubricating eyedrops and ointments, cyclosporine 0.05% drops, and silver nitrate cauterization. The patient subsequently underwent surgical resection of the superior bulbar conjunctiva in both eyes.

RESULTS

Complete resolution of SLK symptoms.

CONCLUSIONS

The pathogenesis of SLK has been associated with mechanical injury to the superior limbus and superior bulbar conjunctiva. The development of SLK after upper eyelid blepharoplasty in our patient supports this theory and should be considered a possible adverse consequence of blepharoplasty.

Amniotic membrane transplantation for the reconstruction of the ocular surface in three cases

This paper describes the use of amniotic membrane in the reconstructive surgical repair of generalized keratomalacia, ankyloblepharon, and after fibrous histiocytoma removal in two dogs and a cat. Case 1 was an 11-year-old female Yorkshire terrier with severe bullous keratomalacia in the left eye (OS). A frozen canine amniotic membrane graft and a third eyelid flap were applied. At day 80 postoperatively, only a mild scar and corneal vascularization were present. Case 2 was a 4-year-old female Siamese cat with symblepharon of both eyes after rhinotracheitis. Resection of the conjunctiva and frozen canine amniotic membrane transplant were performed. One month later, there was a little corneal scarring and corneal vascularization. Case 3 was a 6-year-old female terrier with a scleral and corneal mass at the 11-12 o'clock position (OS). Resection of the mass and amniotic membrane transplantation were performed. The mass was a fibrous histiocytoma localized to the sclera and cornea. This eye healed with mild conjunctivalization and no pigmentation. Amniotic membrane transplantation can be used as a method of reconstruction of the ocular surface with good repair of the cornea and minimal scarring in small animals.

Reconstruction of the ocular surface by transplantation of a serum-free derived cultivated conjunctival epithelial equivalent

PURPOSE

The purpose of this study was to investigate the use of a serum-free derived cultivated conjunctival epithelial sheet for ocular surface transplantation and reconstruction.

METHODS

Seven subjects with various ocular surface disorders were selected for the procedure: one patient had an extensive conjunctival nevus, three patients had pterygium, two patients had persistent leaking trabeculectomy blebs, and one patient had bilateral superior limbic keratoconjunctivitis. Conjunctival epithelial cells were harvested from the forniceal conjunctiva of patients 2 weeks before the definitive surgery. Cultivation of conjunctival epithelial cells on human amniotic membrane (HAM) was carried out under serum-free conditions. At the time of transplantation, the area of diseased conjunctiva was excised and the cultured conjunctival epithelium-HAM composite was transplanted onto the surgical defect. Patients were followed up with serial slit-lamp examinations, fluorescein staining, and photographic documentation.

RESULTS

A confluent stratified conjunctival epithelial sheet was formed on the HAM within 12 to 14 days. Transplanted grafts remained well-epithelialized after surgery. A successful outcome, defined as resolution of the disease, maintenance of conjunctival epithelialization, maintenance of graft integrity, and absence of significant complications, was obtained in all seven patients. A good functional and cosmetic result was achieved in all eyes. The mean follow-up period was 11.6 months (range, 6-18 months).

CONCLUSIONS

Transplantation of a serum-free derived autologous cultivated conjunctival epithelial sheet on HAM was successfully performed in seven patients with ocular surface disorders. This may provide a novel method for conjunctival replacement in conditions where the normal conjunctiva is damaged or deficient.

Use of free conjunctival grafts in horses: ten cases

OBJECTIVE

To assess the effectiveness of free conjunctival grafts in the treatment of horses with a range of keratopathies.

DESIGN

A retrospective clinical study of ten client-owned horses treated at Murdoch University Veterinary Hospital from May 1996 to September 2001.

PROCEDURE

The suitability of patients for the surgical procedure was assessed using a slit lamp biomicroscope and by direct and indirect ophthalmoscopy. Surgery was performed with the aid of an operating microscope, under general anaesthesia. A subpalpebral ocular lavage catheter was used for administration of topical atropine and antibiotics postoperatively.

RESULTS

In all ten horses the affected globe was saved. In nine of the horses vision in the eye was satisfactory 6 months after surgery, and in one horse the eye was blind. Complications included further corneal ulceration or eyelid abscessation and some loss of sutures, although these did not preclude a successful outcome.

CONCLUSION

Free conjunctival grafts were successful in treating a range of keratopathies in the horse, and the technique offers a number of advantages over other forms of surgical intervention.

Bilateral Keratoconjunctivitis Associated with Lichen Planus

PURPOSE

To describe a case of bilateral keratoconjunctivitis in a patient with lichen planus.

METHODS

Case report and review of the English literature.

RESULTS

To our knowledge, this is the fourth reported case of keratoconjunctivitis associated with lichen planus. A 33-year-old Navajo man with lichen planus had recurrent and progressive keratoconjunctivitis that failed to improve on multiple topical medications. Tapered oral prednisone, 2% topical cyclosporin, and amniotic membrane transplantation pacified the acute exacerbation.

CONCLUSIONS

Our patient with lichen planus developed an ocular surface disease with cicatricial conjunctivitis, keratouveitis, keratoconjunctivitis sicca, punctate epithelial erosions, and persistent epithelial defects leading to noninfectious or infectious corneal ulceration. Amniotic membrane transplantation may play an adjunctive role in refractory cases of lichen planus-related keratoconjunctivitis. Topical cyclosporin may stabilize the ocular surface when combined with systemic immunosuppression in severe cases.

New surgical treatment for superior limbic keratoconjunctivitis and its association with conjunctivochalasis

PURPOSE

To introduce a new surgical procedure for treating superior limbic keratoconjunctivitis (SLK) and to suggest the association of SLK with conjunctivochalasis.

DESIGN

Interventional case series.

METHODS

Six eyes of five patients with long-standing severe ocular irritation unresponsive to treatment with topical steroid and artificial tears were operated on using our new procedure. This technique consists of four steps as follows: (1) Rose bengal (RB) staining is used to localize the abnormal conjunctival area; (2) an arc-like conjunctival incision is placed from the 2 to the 10 o'clock position adjacent and distal to the RB-stained area; (3) the conjunctiva is resected to form a crescent using the arc-like incision as the base; the size of the resection is determined by conjunctival redundancy after removal of the subconjunctival connective tissue; and (4) the crescent conjunctival opening is closed with interrupted sutures. In two eyes, the new surgical procedure was performed together with surgery for inferior bulbar conjunctivochalasis.

RESULTS

In all operated eyes, RB staining had disappeared by the end of the second postoperative week; recovery from symptoms and loss of inflammation were recorded by 1 month after treatment. In the case with the longest follow-up (14 months), there was cytologic evidence of goblet cell recovery at 3 months after the operation. In another, there was normalization of the nucleo/cytoplasmic ratio of conjunctival cells without the appearance of goblet cells.

CONCLUSIONS

Our treatment very effectively resolved symptoms associated with SLK, even in eyes unresponsive to conventional therapy with eye drops. Considering that we did not address the diseased part of the conjunctiva but rather the adjacent conjunctival redundancy, we propose that superior bulbar conjunctivochalasis is involved in the pathogenesis of SLK.

[Amniotic membrane transplantation in severe corneal epithelial diseases. Preliminary results]

PURPOSE

To evaluate amniotic membrane transplantation (AMT) in severe corneal epithelial diseases.

METHODS

Amniotic membrane transplantation was performed in 14 eyes of 14 patients from four groups: A, five severe ocular burns; B, four cases of cicatricial keratoconjunctivitis; C, three persistent epithelial defects after penetrating keratoplasty; D, two cases of pseudophakic bullous keratopathy. Five patients underwent AMT alone; two patients underwent AMT combined with limbal transplantation; the other three patients had limbal transplantation performed before AMT. Eight patients required combined penetrating keratoplasty. Patients with corneal stable reepithelialization, no corneal neovascularization, and no recurrence of the initial pathology were considered successful.

RESULTS

The mean follow-up was 7+/-3 months. All but three patients underwent corneal reepithelialization within 6 weeks of AMT, with a mean healing time of 31+/-23 days. The success rate was 75% at 6 months (Kaplan-Meier method). Three of four procedures in group B failed. In eight patients, visual acuity improved, in one it worsened, and in the last five patients it remained unchanged. Visual acuity increased by an average of 7+/-9 lines.

CONCLUSION

AMT is a useful technique for ocular surface reconstruction, especially in association with limbal transplantation. It could also improve the prognosis of penetrating keratoplasty in patients with severe corneal conditions.

Cataract surgery combined with ocular surface reconstruction in patients with severe cicatricial keratoconjunctivitis

PURPOSE

To present the technique and outcome of cataract surgery combined with ocular surface reconstruction in patients with severe cicatricial keratoconjunctivitis.

SETTING

Department of Ophthalmology, Tokyo Dental College, Chiba, Japan.

METHODS

Phacoemulsification with transplantation of a limbal allograft and an amniotic membrane was performed in 4 eyes of 3 patients with cataract and end-stage cicatricial keratoconjunctivitis. The surgical technique and the improvements in visual acuity were reviewed. The follow-up ranged from 13 to 27 months.

RESULTS

Phacoemulsification and intraocular lens implantation were performed in all cases without intraoperative complications. In 3 of the 4 eyes, the best corrected visual acuity improved from hand motions to 20/100, hand motions to 20/30, and counting fingers to 20/50. The visual acuity recovered to 20/60 postoperatively in 1 eye in which the preoperative visual acuity was light perception; at 1 year, the visual acuity decreased to hand motions because of recurrent fibrous tissue over the cornea.

CONCLUSION

Small-incision phacoemulsification was performed safely in combination with ocular surface reconstruction in patients with cataract and end-stage cicatricial keratoconjunctivitis.

Amniotic membrane in the surgical management of acute toxic epidermal necrolysis

OBJECTIVE

To report a new surgical technique to manage severe acute toxic epidermal necrolysis.

DESIGN

Two interventional case reports.

PARTICIPANTS

Two patients. Case 1: A 6-year-old boy had severe toxic epidermal necrolysis develop after being treated with trimethoprim and sulfamethoxazole for chronic otitis media. Both eyes and eyelids were affected. He underwent bilateral lysis of symblepharon and all adhesions and bilateral amniotic membrane transplantation to the entire ocular surface except the cornea. Loss of eyelid skin required transplantation of amniotic membrane to all four eyelids and strips of amniotic membrane at the eyelid margins. Case 2: An 8-year-old girl with severe toxic epidermal necrolysis associated with mycoplasma pneumonia had bilateral, diffuse keratoconjunctivitis, diffuse corneal epithelial defects, and bilateral symblepharon. Amniotic membrane transplantation was performed bilaterally, using a symblepharon ring in the left eye.

INTERVENTION

Amniotic membrane transplantation.

MAIN OUTCOME MEASURES

Preservation of normal ocular and eyelid surfaces and prevention of blindness.

RESULTS

Case 1: Thirty-six months after bilateral ocular surgery, there is no symblepharon, good ocular surface wetting, and an uncorrected bilateral vision of 20/20. Case 2: Amniotic membrane transplantation protected both ocular surfaces and prevented conjunctival contracture without adhesion of the eyelids to the ocular surface. The central vision was preserved. There was minimal peripheral corneal vascularization and mild conjunctival scarring of the tarsal conjunctival surface 34 months postoperatively.

CONCLUSIONS

These are the first cases of acute toxic epidermal necrolysis treated with amniotic membrane transplantation and the first use of the procedure on external eyelid surfaces with good healing of the eyelids. This new treatment for acute toxic epidermal necrolysis preserves normal ocular and eyelid surfaces and may prevent blindness.

[Amniotic membrane transplantation with or without limbal allografts in corneal surface reconstruction in limbal deficiency]

PURPOSE

We examined whether amniotic membrane transplantation (AMT) is useful in preparing the perilimbal stroma to enhance the success of allograft limbal transplantation (ALT).

METHODS

Forty-seven eyes of 42 consecutive patients with cytologically proven limbal deficiency (LD) were included in this prospective study. Based on the severity of LD, group A (mild) with 18 eyes received AMT alone, group B (moderate) with 13 eyes received AMT and ALT, and group C (severe) with 16 eyes received AMT, ALT and penetrating keratoplasty. All except for group A received continuous systemic cyclosporin A.

RESULTS

Except for the two eyes with atopy, all amniotic membrane-covered surfaces showed rapid epithelialization in 2-4 weeks, reduced inflammation, vascularization and scarring, and became smooth. For the mean follow-up period of 23 months, 38 eyes (82.6%) showed visual improvement, consisting of > or = 6 lines (15 eyes), 4-5 lines (10 eyes), 1-3 lines (13 eyes). Visual improvement was noted in 16/18 eyes (88.9%) in group A, in 10/13 eyes (77%) in group B, and in 12/16 eyes (75%) in group C. In group C corneal graft rejection occurred in 12 of 16 eyes (75%). In group B and C, early reversible limbal allograft rejection was noted in 3 of 29 eyes (10.3%) and a recurrent limbal deficiency was observed in 8 of 29 eyes (27.6%).

CONCLUSION

For partial LD with superficial involvement, AMT alone is sufficient and hence superior to ALT because of no need for using cyclosporin A. For total LD, additional ALT is needed and AMT helps reconstruct the perilimbal stroma with reduced inflammation and vascularization, which collectively may enhance ALT success.

[Phototherapeutic keratectomy (PTK) after epidemic keratoconjunctivitis]

BACKGROUND

Persistent and recurrent nummuli after epidemic keratokonjunktivitis (EKC) often lead to reduced visual acuity and increased glare. In spite of long-term topical steroid therapy nummuli often recur. We tried to treat persistent nummuli with phototherapeutic keratectomy (PTK).

PATIENTS

PTK with an excimer laser (193 nm) was performed in 13 eyes of 9 patients with nummuli. The nummuli were observed over 3-72 months (mean: 36 months). Preoperatively, the visual acuity was 0.1-0.9 (mean: 0.39 +/- 0.22) and the brightness acuity test (BAT) was 0.05-0.5 (mean: 0.25 +/- 0.15). Prior to PTK all eyes had been treated with local steroids several times for recurrent nummuli.

RESULTS

During the follow-up from 15 to 56 months (mean: 33 +/- 11.5 ms), 11 eyes had an increase in visual acuity: 0.3-1.0 (mean: 0.63 +/- 0.26). The reduction of glare was especially beneficial for the patients: 0.3-0.9 (mean: 0.55 +/- 0.21). One patient had a recurrence of nummuli in both eyes 6 weeks after PTK. The subjective-induced spheric refractive change was -2.5 D to +2.0 D. The astigmatic error changed between -2.0 D to +1.5 D.

CONCLUSION

PTK seems to be an effective method of treating persistent, recurrent nummuli after EKC. The low rate of recurrence of nummuli after PTK is remarkable.

Photorefractive keratectomy for myopia in the setting of adenoviral subepithelial infiltrates

PURPOSE

To report a patient with persistent subepithelial corneal opacities 18 months after adenoviral keratoconjunctivitis who underwent photorefractive keratectomy for the correction of myopia.

METHODS

Case report, review of medical literature, and slit-lamp photography.

RESULTS

The patient underwent photorefractive keratectomy in each eye, 1 week apart, with ablation of central corneal opacities and resultant best-corrected visual acuity of BE, 20/20. Symptomatic subepithelial stromal infiltrates recurred in the peripheral but not the central cornea of each eye 3 months after laser treatment.

CONCLUSIONS

Photorefractive keratectomy was successful in the correction of myopia and prevented the recurrence of adenoviral subepithelial corneal infiltrates within the laser-treated central cornea.

Lacrimal punctal occlusion for the treatment of superior limbic keratoconjunctivitis

PURPOSE

To test the hypothesis that superior limbic keratoconjunctivitis is caused by insufficient tear supply to the superior keratoconjunctiva.

METHODS

We used cautery and sutures to permanently occlude the lacrimal puncta of 11 patients (22 eyes) with superior limbic keratoconjunctivitis for whom topical treatment was ineffective.

RESULTS

All 11 patients (22 eyes) responded favorably to lacrimal punctal occlusion. After lacrimal punctal occlusion, rose bengal and fluorescein staining (both on a scale of 0 [no staining] to 9 [complete staining]) were reduced (mean +/- SD, 2.7 +/- 1.6 to 1.1 +/- 1.8 and 1.4 +/- 1.2 to 0.4 +/- 0.8, respectively). Impression cytology disclosed improvement of squamous metaplasia in the superior conjunctiva as well as increased goblet cells in nine of 13 eyes (69%) examined. Subjective symptoms improved in all 22 eyes (100%).

CONCLUSIONS

Improvement of local tear deficiency to the superior limbic portion by punctal occlusion was an effective treatment in this small series. Superior limbic keratoconjunctivitis might be caused by the insufficient local tear supply.

Surgical reconstruction of the ocular surface in advanced ocular cicatricial pemphigoid and Stevens-Johnson syndrome

PURPOSE

Ocular cicatricial pemphigoid and Stevens-Johnson syndrome often cause ocular damage and blindness not amenable to surgical correction. We present a new surgical technique for reconstructing affected eyes.

METHODS

Fourteen eyes of 11 patients with cicatricial keratoconjunctivitis (seven patients with cicatricial pemphigoid and four with Stevens-Johnson syndrome; average age +/- S.D., 55.5 +/- 25.4 years) were treated with a combination of allograft limbal transplantation, amniotic membrane transplantation, and tarsorrhaphy, followed every 15 minutes by artificial tears derived from the patient's blood serum. Eight eyes required concomitant penetrating or lamellar keratoplasty because of corneal opacity.

RESULTS

With a mean follow-up of 143 days (range, 10 to 608 days), we achieved successful ocular surface reconstruction in 12 eyes, with minimal recurrence of symblepharon. Failure occurred in two eyes (one each in 9- and 10-year-old boys) that developed corneal infiltration and vascularization.

CONCLUSIONS

A combination of allograft limbal transplantation, amniotic membrane transplantation, and tarsorrhaphy, followed by the use of serum-derived tears, can reconstruct the ocular surface in most cases. Although in this study the follow-up period was short and relatively few patients were studied, this approach appears to offer an alternative to keratoprosthesis for treating severe cicatricial keratoconjunctivitis with dry eye.

Superior limbic keratoconjunctivitis in identical twins

The first two cases of superior limbic keratoconjunctivitis occurring in identical twins are reported. In both cases the symptoms began 16 years ago and have never permanently responded to numerous topical medications or to bilateral resection of the superior bulbar conjunctiva.

Cryosurgery for treatment of recurrent proliferative keratoconjunctivitis in five dogs

Cryosurgery was used for treatment of recurrent proliferative keratoconjunctivitis in 5 dogs that had been treated with combined medical and surgical procedures without success. Four dogs recovered completely after one application of cryosurgery. The fifth dog did not respond to cryosurgery until after oral administration of corticosteroids was stopped, indicating a possible immune-mediated mechanism of action of cryosurgery on proliferative keratoconjunctivitis.

[Listeria monocytogenes kerato-uveitis]

An 86-year-old patient with corneal gutae and diabetes presented with a Listeria monocytogenes serpent ulcer on her right eye. Smears taken from the ulcer revealed Listeria monocytogenes serotype 4b. Despite specific antibiotic therapy including cephalosporins and systemic administration of amikacin, as well as topical gentamycin drops, the eye had to be enucleated on the 16th day after hospitalization. Massive fibrinous reaction and extreme pain causing the patient to reject alimentation were the clinical signs at this time. The anterior chamber aspirate taken perioperatively was sterile.

Treatment of superior limbic keratoconjunctivitis by thermocauterization of the superior bulbar conjunctiva

Superior limbic keratoconjunctivitis (SLK) is a chronic and recurrent inflammatory disease of the superior tarsal, bulbar and limbal conjunctiva that often responds to topical treatment with silver nitrate. As an alternative treatment in 11 patients (13 eyes), we applied thermal cautery to the inflamed superior bulbar conjunctiva following subconjunctival injection of 2% xylocaine. The overall positive response rate to thermocautery was 73% (8 patients). Of the positive responders, 63% (5 patients) had been considered silver nitrate treatment failures. Keratitis sicca was additionally noted in 55% of the patients studied. Impression cytology of involved superior bulbar conjunctiva was nearly devoid of goblet cells during the acute stage of the disorder. Following successful cauterization, goblet cells returned. Thus, thermocauterization of the superior bulbar conjunctiva appears to be a safe and effective mode of therapy for SLK.

Conjunctival resection for superior limbic keratoconjunctivitis

Ten patients with superior limbic keratoconjunctivitis were examined. Eight patients were female and 9 had bilateral disease. Five of the 10 patients had a history of thyroid disease. Two of the patients had filaments and four had a significantly decreased tear production. A conjunctival resection was carried out in all of the patients. Postoperatively, eight of these patients were either asymptomatic or much improved. Two patients with decreased tear production showed no improvement. Preoperatively, a normal Schirmer's test is helpful in predicting the success of conjunctival resection.

Cryosurgery in the management of vernal keratoconjunctivitis

Forty-eight eyes of patients with bulbar vernal conjunctivitis and eight eyes of patients with severe tarsal vernal conjunctivitis were treated with cryopexy. A pointed probe with tip temperature of -35 degrees C was used for the bulbar application, while a round-ended probe with tip temperature of -70 degrees C was used for tarsal application after excision of large cobblestones. Immediate results were highly impressive, while observation over 36 months in some of the patients showed long-term relief or very marked reduction in frequency of exacerbations. Cryotherapy avoids the long-term use of topical corticosteroids in vernal conjunctivitis and is preferable in our largely illiterate population. This study shows that the method is effective and safe.

Cryosurgery in palpebral vernal catarrh

In nine labeled as resistant palpebral vernal catarrh (keratoconjunctivitis), the upper eyelids were treated by cryosurgery. Eight patients (16 eyelids) showed dramatic and encouraging symptomatic and anatomic results. Cryosurgery has been shown to be an effective, simple, and inexpensive treatment of palpebral vernal catarrh.

Immunological aspects of superior limbic keratoconjunctivitis

Three patients with superior limbic keratoconjunctivitis (SLK) were treated by conjunctival resection. The results of immunological studies and histological examination of the excised tissue were unremarkable; none of seven criteria of antibody dependence were met. We found no specific immune defects in three patients with superior limbic keratoconjunctivitis.

Sterile corneal ulcers after cataract surgery in keratoconjunctivitis sicca

Mild keratoconjunctivitis sicca can become dramatically worse after cataract extraction and result in corneal thinning and perforation. Anticipation of this problem can prevent it, but lack of recognition may result in permanent central scarring from ulceration, which responds slowly to treatment.

Conjunctival resection treatment and ultrastructural histopathology of superior limbic keratoconjunctivitis

Four patients with symptomatic superior limbic keratoconjunctivitis underwent resection of the superior bulbar conjunctiva. One of these patients also underwent a tarsal conjunctival resection in the other eye. Three of the patients had previously been treated by various regimens without resolution; the fourth had had no prior treatment. All four patients had immediate and continued relief of the ocular symptoms after the superior bulbar conjunctiva was excised. The patient who underwent tarsal conjunctival resection experienced only short-term relief. We studied the conjunctival tissue by light and transmission electron microscopy. Both techniques revealed abnormalities related to the bulbar conjunctival surface with keratinization of the epithelium, acanthosis, degeneration of the nuclei, and intracellular accumulation of glycogen. Inflammatory cells were minimally present. The tarsal conjunctiva appeared essentially normal.