Compression sutures in the management of corneal transplant wound infections

PURPOSE

To report the usefulness of compression sutures in the management of three cases of bacterial wound infections in corneal transplants.

METHODS

Interventional case series.

RESULTS

All three cases of wound dehiscence and perforation resulting from bacterial wound infections were successfully treated with placement of compression sutures with concurrent topical antibiotic treatment.

CONCLUSION

The placement of compression sutures is a successful surgical technique to reestablish corneal transplant wound integrity compromised by infection.

Human immunodeficiency virus-positive patients with posterior intracorneal precipitates

PURPOSE

To describe an unusual and possibly new keratopathy in human immunodeficiency virus (HIV)-positive patients.

DESIGN

Retrospective observational case series.

PARTICIPANTS

: Six HIV-positive patients at four centers.

METHODS

A complete medical history was obtained and a thorough ophthalmic examination was performed on each of the patients.

RESULTS

Each patient had bilaterally symmetrical keratopathy consisting of variably pigmented round and reticular posterior intracorneal precipitates at the level of Descemet's membrane. The precipitates were diffuse, but larger and more prominent near the limbus and finer toward the central cornea. None of the eyes were inflamed, and all had normal vision. No patient had uveitis on presentation or any history of cytomegalovirus retinitis.

CONCLUSION

These patients have a unique posterior keratopathy, which requires further investigation.

Phacoemulsification cataract extraction and posterior chamber lens implantation in patients with uveitis

PURPOSE

This study reports outcomes of phacoemulsification cataract extraction and posterior chamber intraocular lens implantation within the capsular bag in patients with uveitis.

METHODS

We retrospectively reviewed the charts of 32 patients (39 eyes) with uveitis who underwent phacoemulsification cataract extraction and posterior chamber intraocular lens implantation by two surgeons at The Cleveland Clinic Foundation from January 1990 to June 1998. Patients with less than 3 months of follow-up were excluded.

RESULTS

Diagnoses of uveitis included idiopathic (15 eyes), sarcoidosis (10 eyes), pars planitis (four eyes), CMV retinitis (two eyes), Fuchs heterochromic iridocyclitis (two eyes), syphilis (two eyes), and one eye each of tuberculosis, Crohn's disease, HLA-B27 associated, and acute retinal necrosis. Average follow-up was 20 months (range, 3 to 63 months). Best-corrected visual acuity improved in 37 eyes (95%). Average improvement was 4 +/- 3 Snellen acuity lines (range, 1 to 10 lines). Thirty-four eyes (87%) attained final visual acuity better than or equal to 20/40. Visual loss occurred in one eye (3%) with CMV retinitis. No improvement in visual acuity was seen in one eye (3%) that developed a retinal pigment epithelial detachment. Posterior capsule opacification occurred in 24 eyes (62%), 12 of which required Nd:YAG capsulotomy (31%). Other postoperative complications included recurrence of uveitis (41%), cystoid macular edema (33%), epiretinal membrane formation (15%), and posterior synechiae (8%).

CONCLUSIONS

Phacoemulsification cataract extraction with posterior chamber intraocular lens implantation is safe in patients with uveitis. The incidences of recurrence of uveitis, cystoid macular edema, epiretinal membrane, and posterior synechiae were lower than those reported previously for extracapsular cataract extraction.

Corticosteroid therapy for optic disc neovascularization secondary to chronic uveitis

PURPOSE

To report successful corticosteroid treatment of optic disc neovascularization associated with uveitis.

METHODS

Retrospective review of medical records.

RESULTS

Nine patients were identified with chronic uveitis and optic disc neovascularization without clinical or angiographic evidence of retinal ischemia. Ages ranged from 14 to 37 years (median age, 27). All patients were treated with either oral and/or subtenon's corticosteroids. Partial regression of the neovascularization was observed in all patients within 2 to 6 weeks (median, 5 weeks) after initiating treatment. Eight of nine patients had complete resolution of disc neovascularization at a median of 3 months (range, 2 to 42 months) after initiation of treatment and a median follow-up of 24 months (range, 7 to 144 months). Recurrence of disc neovascularization occurred in two patients, but it regressed again after further corticosteroid therapy.

CONCLUSIONS

Optic disc neovascularization may occur in patients with chronic uveitis in the absence of retinal ischemia. This neovascularization can be successfully treated with corticosteroids.

Oral erythromycin treatment for childhood blepharokeratitis

Blepharokeratitis is a chronic external ocular and adnexal inflammatory condition marked by erythematous and edematous lid margins, lid margin crusting and scaling, meibomian gland inflammation and inspissation, and conjunctival hyperemia. The associated keratitis usually involves the inferior cornea and is characterized by punctate epithelial keratopathy and marginal stromal infiltrates. The inflammation sometimes leads to corneal thinning, scarring, and vascularization. The standard therapy for adult blepharokeratitis includes lid hygiene, topical cortico-steroid preparations, and topical antibiotics. Oral tetracycline and its analogues, doxycycline and minocycline, are used in adults to treat associated meibomian gland dysfunction. Whereas blepharitis is common in children, blepharokeratitis is rare and is often associated with severe ocular and psychosocial morbidity. Treatment of youths may be problematic because of poor compliance with lid hygiene and therapy that includes drops and ointment.(1) Furthermore, the use of tetracycline and its analogues is contraindicated in children aged less than 8 years because it may cause dental enamel abnormalities. Isolated case reports have suggested that erythromycin may be a reasonable alternative to tetracycline in childhood blepharokeratitis.(2,3) We report on the successful treatment of this condition with oral erythromycin in 5 children.

Surgically-induced Astigmatism After Laser in situ Keratomileusis for Spherical Myopia

PURPOSE

To characterize the surgically-induced-astigmatism (SIA) associated with spherical LASIK.

METHODS

Refractive outcomes in 70 eyes that underwent primary myopic LASIK with purely spherical ablation were analyzed. The Summit Apex Plus excimer laser was used. The Bausch & Lomb Hansatome with the 180-microm plate was used to produce superiorly hinged flaps. The relationship between refractive astigmatism and corneal topographic astigmatism was analyzed using linear regression and vector analysis.

RESULTS

There was a statistically significant negative correlation (slope = -0.21) between refractive surgically-induced astigmatism and preoperative topographic cylinder. A 0.24-D with-the-rule shift was also found. Surgically-induced astigmatism was not correlated with the magnitude of laser ablation.

CONCLUSION

The lamellar keratotomy portion of LASIK reduces pre-existing corneal astigmatism and produces a relative steepening of the hinge meridian.

Blepharoptosis surgery complicated by late suture migration

PURPOSE

To report late suture migration as a complication of blepharoptosis surgery.

METHOD

Case reports.

RESULTS

After upper eyelid blepharoptosis repair, two eyes of two patients developed unusual foreign body reactions and ulceration in the conjunctiva caused by migration of nonabsorbable suture from the levator aponeurosis to the upper conjunctival fornix. The foreign body caused eyelid edema, papillary changes in the upper tarsal conjunctiva, recurrent blepharoptosis, and a foreign body sensation that started more than 3 months after the surgery and persisted until the suture was removed. The sutures, hidden in edematous conjunctiva of the superior fornix, eluded detection.

CONCLUSIONS

Foreign body reaction secondary to suture migration is an uncommon complication of blepharoptosis repair.

Propionibacterium acnes as a cause of visually significant corneal ulcers

PURPOSE

To report Propionibacterium acnes as a cause of vision-threatening infectious keratitis and to discuss culture isolation and antibiotic treatment.

METHODS

Retrospective case series presentation collected from three academic medical centers.

RESULTS

Six cases of P. acnes infectious keratitis are presented, all of which were associated with a compromised corneal barrier or environment. All cases were culture-positive on thioglycolate broth; none became positive before 7 days of growth. No other organisms were isolated from any culture, and the growth of P. acnes occurred in some cases despite negative gram stains.

CONCLUSION

P. acnes can produce vision-debilitating keratitis when the cornea is compromised. Growth in culture should be monitored for at least 10 days to ensure isolation of this fastidious organism. P. acnes may respond to several different antibiotics that have gram-positive coverage, but it should be treated with vancomycin to enhance clearance of the organism.

Cicatrizing conjunctivitis associated with paraneoplastic lichen planus

PURPOSE

To report two cases of cicatrizing conjunctivitis associated with paraneoplastic lichen planus.

METHODS

Case reports.

RESULTS

Two patients were examined because of redness and discomfort in both eyes. A 63-year-old woman with follicular, small-cleaved cell lymphoma had cicatrizing conjunctivitis, stomatitis, vulvitis, and skin lesions. A 25-year-old man with malignant thymoma had cicatrizing conjunctivitis, erosive stomatitis, and penile papules. Histopathologic studies of conjunctiva and skin biopsy specimens in the first patient and labial biopsy specimens in the second revealed lichen planus.

CONCLUSION

Paraneoplastic lichen planus is a possible cause of cicatrizing conjunctivitis associated with inflammatory skin and mucous membrane disease.

Keratocyte apoptosis associated with keratoconus

Keratoconus is an ectatic corneal dystrophy associated with stromal thinning and disruption of Bowman's layer. The purpose of this study was to explore a possible association between keratocyte apoptosis and keratoconus. Keratocyte apoptosis was evaluated in corneas of patients with keratoconus, corneas of patients with stromal dystrophies, and normal donor corneas using the transferase-mediated dUTP-digoxigenin nick and labeling (TUNEL) assay. Keratocyte apoptosis was also studied in keratoconus and normal corneas using transmission electron microscopy. TUNEL-stained keratocytes were detected in 60% of corneas with keratoconus, but only 35% of corneas with stromal dystrophies (P =0.03). The number of TUNEL-positive keratocytes detected in the keratoconus, stromal dystrophy, and normal corneas was 7+/-1 (mean+/-standard error, range 0-20), 2+/-0. 8 (range 0-9), and 0+/-0 (range 0-0) TUNEL-positive cells per section, respectively. The differences between the keratoconus and the stromal dystrophy (P =0.0097) or the normal cornea (P =0.01) groups were statistically significant. The difference between the stromal dystrophy and normal cornea groups was not statistically significant (P =0.45). The stromal dystrophy group was included to account for surgery-associated keratocyte apoptosis. No TUNEL-stained keratocytes were detected in normal corneas. Cell morphologic changes consistent with apoptosis were detected by transmission electron microscopy (TEM) in keratocytes of keratoconus corneas, but not in keratocytes in normal corneas. Chronic keratocyte apoptosis associated with ongoing epithelial injury may link risk factors associated with keratoconus such as chronic eye rubbing, contact lens wear, or atopic eye disease. Similarly, increases that have been detected in several different degradative enzymes in keratoconus corneas could be associated with chronic keratocyte apoptosis and less than perfect control of release of intracellular contents.

Treatment strategies and visual acuity outcomes in chronic postoperative Propionibacterium acnes endophthalmitis

PURPOSE

To report the treatment strategies and visual acuity outcomes of chronic postoperative endophthalmitis caused by Propionibacterium acnes.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

All patients presenting 8 or more weeks after cataract surgery with intraocular inflammation caused by culture-proven P. acnes infection and treated at two institutions from 1974 through 1996 were included.

METHODS

Patients underwent three different initial treatment strategies. The study did not have a defined treatment protocol, but all patients received intraocular antibiotics. Patients were not randomly assigned to the various treatment strategies.

MAIN OUTCOME MEASURES

Final visual acuity and effectiveness of various treatment procedures either as initial or follow-up therapy were assessed.

RESULTS

Using the 3 initial strategies, 36 patients were treated: (1) intraocular antibiotic injection alone (IOAB; n = 12); (2) pars plana vitrectomy and IOAB injection (PPV; n = 10); and (3) PPV with subtotal capsulectomy and IOAB injection (PPV-PC; n = 14). The number of patients with recurrent or persistent inflammation after one of the three initial treatment strategies were as follows: (1) IOAB alone, 12 (100%); (2) PPV, 5 (50%); and (3) PPV-PC, 2 (14%). None of the patients that underwent subsequent PPV, total capsular bag removal, IOAB injection, and either intraocular lens (IOL) exchange or removal had persistent or recurrent intraocular inflammation. Overall, final visual acuity was 20/40 or better in 18 patients (50%), and a total of 28 patients (78%) retained 20/400 or better vision. The mean follow-up after the last treatment was 2.9 years.

CONCLUSIONS

In this series of chronic P. acnes endophthalmitis, initial treatment with IOAB injection alone or vitrectomy without capsulectomy was associated with high rates of recurrent or persistent intraocular inflammation. Pars plana vitrectomy, partial capsulectomy, and IOAB injection without IOL exchange was usually successful on long-term follow-up. In patients with recurrent intraocular inflammation, pars plana vitrectomy, total capsular bag removal, IOAB injection, and IOL exchange or removal was a uniformly successful strategy. In contrast to other types of postoperative endophthalmitis, IOL exchange can be considered in these patients after total capsular bag removal.

Posterior segment inflammation in HLA-B27+ acute anterior uveitis: clinical characteristics

PURPOSE

To examine clinical characteristics of patients who have posterior segment manifestations in HLA-B27-associated acute anterior uveitis.

METHODS

Medical records of 114 HLA-B27-positive patients with acute anterior uveitis were reviewed in a retrospective fashion. Criteria for inclusion were the presence of acute anterior uveitis, a positive HLA-B27 antigen, and one of the following findings: vitreous cells >/=+2; cystoid macular edema; papillitis; vasculitis; or pars plana exudates. Twenty-four patients met the inclusion criteria.

RESULTS

Posterior segment manifestations were found in 24 (21.05%) of 114 patients with HLA-B27+ acute anterior uveitis. Eighteen patients had diffuse vitritis (75%), seven had cystoid macular edema (29.1%), and two had papillitis (8.3%). Three patients had more than one finding. The prevalence of associated systemic disease (15 of 24 patients, 62.5%) and hypopyon (6 of 24 patients, 25%) in patients with posterior segment involvement was significantly higher than in the group of patients without posterior segment involvement (systemic disease, 33 of 90, 36.7%, p=0.04, exact chi-quare test; hypopyon, 4 of 90, 4.4%, p=0.006, exact chi-square test). The mean visual acuity at the last visit was 20/30 (range 20/20-20/100). Immunosuppressive therapy (other than corticosteroids) and surgical intervention were not required in the treatment of patients with posterior segment manifestations. CONCLUSION<?Pub Caret>: HLA-B27+ anterior uveitis is associated with posterior segment manifestations. Patients with posterior segment involvement have a significantly higher incidence of associated systemic diseases and hypopyon.

Haemophilus influenzae associated scleritis

AIMS

To describe the clinical course and treatment of Haemophilus influenzae associated scleritis.

METHODS

Retrospective case series.

RESULTS

Three patients developed scleritis associated with ocular H influenzae infection. Past medical history, review of systems, and laboratory testing for underlying collagen vascular disorders were negative in two patients. One patient had arthritis associated with an antinuclear antibody titre of 1:160 and a Westergren erythrocyte sedimentation rate of 83 mm in the first hour. Each patient had ocular surgery more than 6 months before developing scleritis. Two had cataract extraction and one had strabismus surgery. Nodular abscesses associated with areas of scleral necrosis were present in each case. Culture of these abscesses revealed H influenzae in all patients. Treatments included topical, subconjunctival, and systemic antibiotics. Scleral inflammation resolved and visual acuity improved in each case.

CONCLUSION

H influenzae infection may be associated with scleritis. Accurate diagnosis and treatment may preserve ocular integrity and good visual acuity.

Epithelial removal with the excimer laser (laser-scrape) in photorefractive keratectomy retreatment

OBJECTIVES

To retrospectively evaluate refractive and topographic outcomes after excimer laser photorefractive keratectomy (PRK) retreatment using the laser-scrape technique for epithelial removal.

DESIGN

Retrospective clinical study.

PARTICIPANTS

Thirty eyes of patients who had PRK retreatment for undercorrection after primary PRK were examined.

INTERVENTION

The PRK retreatment was performed using a laser-scrape technique in which the excimer laser was used to remove the majority of the epithelium overlying the anterior stromal surface before additional PRK ablation.

MAIN OUTCOME MEASURES

Uncorrected visual acuity, best-corrected visual acuity (BCVA), surface regularity index (SRI), and surface asymmetry index were measured.

RESULTS

Primary PRK was performed for myopia of -5.1 +/- 1.7 diopters (range, -1.1 to -7.5 diopters). Mean spherical equivalent (SE) was -1.3 +/- 0.4 diopters (range, -0.6 to -2.0 diopters) before retreatment. Mean SE 6 months after retreatment decreased to +0.1 +/- 0.4 diopter (range, +1.25 to -0.75 diopters; P < 0.0001). Four eyes (15%) were more than +0.5 diopter overcorrected at 6 months. Ninety-six percent of eyes achieved mean SE within +/- 1 diopter and 77% within +/- 0.5 diopter of emmetropia after retreatment. Visual acuity improved significantly 6 months after reablation (P < 0.0001) with 100% 20/40 or better and 73% 20/25 or better without correction. Final BCVA also improved compared with before retreatment (P = 0.02). Twelve eyes gained 1 line of BCVA and no eye lost more than 1 line of BCVA. The SRI before retreatment was 0.6 +/- 0.3 (range, 0.0-0.9) and remained the same 0.6 +/- 0.2 (range, 0.1-1.0; P = 0.8), 6 months after retreatment.

CONCLUSION

Excimer laser PRK retreatment using the laser-scrape technique for epithelial removal is an accurate and safe procedure for treating undercorrection of eyes after PRK for low-to-moderate myopia.

Photorefractive keratectomy using the summit SVS Apex laser with or without astigmatic keratotomy

PURPOSE

The purpose of this study was to evaluate the results of myopic photorefractive keratectomy (PRK) with or without astigmatic keratotomy (AK) for different levels of intended correction by using the SVS Apex laser.

METHODS

This is a retrospective cohort study of 226 eyes that had PRK for myopia ranging from -1.0 to -7.6 diopters and 6 months of follow-up. In addition, 64 of these eyes had AK for naturally occurring or laser-induced astigmatism. Uncorrected visual acuity, spectacle-corrected visual acuity, and corneal topography with quantitative descriptors of surface regularity (SRI) and surface asymmetry (SAI) were used to monitor the results of PRK with or without AK.

RESULTS

At 6 months, 95.6% eyes had an uncorrected visual acuity of 20/40 or better, 90% eyes were within +/-1.0 diopter of emmetropia, and 3.1% eyes lost two lines of best-corrected vision. No eyes lost more than two lines of best-corrected vision. Mean refractive astigmatism was reduced, but mean SAI and SRI were increased, 6 months after PRK. Uncorrected vision, best-corrected vision, and predictability decreased, whereas SAI and SRI increased, with increasing attempted correction.

CONCLUSION

PRK, with or without AK, effectively reduced myopia in all eyes by 6 months after surgery. Predictability tended to decrease with increasing attempted correction, even for eyes with relatively low to moderate myopia. PRK may induce surface asymmetry and irregularity at 6 months, and these alterations tend to be greater as the attempted correction increases.

Long-term follow-up of extracapsular cataract extraction and posterior chamber intraocular lens implantation in patients with uveitis

OBJECTIVE

The objective of the study was to determine the long-term outcome of patients with uveitis who underwent extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (PCIOL) implantation.

DESIGN

Retrospective review.

PARTICIPANTS

Twenty-eight patients (36 eyes).

INTERVENTION

Extracapsular cataract extraction and PCIOL implantation.

MAIN OUTCOME MEASURES

Level of best-corrected Snellen visual acuity, change in visual acuity, length of follow-up, long-term findings, and complications.

RESULTS

In long-term follow-up (mean, 81.4 months), 94% of eyes had visual acuity improvement compared with preoperative levels. Average change in visual acuity for all eyes was an improvement of 6.4 Snellen lines; 75% of eyes were 20/40 or better. The prevalences of cystoid macular edema (CME), epiretinal membrane (ERM), and posterior capsule opacification (PCO) were 56%, 56%, and 58%, respectively.

CONCLUSIONS

Patients with uveitis who are treated with ECCE with PCIOL implantation can have successful visual results in long-term follow-up despite the prevalence of PCO or macular abnormalities such as CME and ERM.

Chest computed tomography and mediastinoscopy in the diagnosis of sarcoidosis-associated uveitis

PURPOSE

To report the usefulness of chest computed tomography and mediastinoscopy in diagnosing sarcoidosis in elderly patients with uveitis.

METHODS

Case reports. Two Caucasian women, aged 73 and 70 years, underwent evaluations for uveitis, which included chest computed tomography and mediastinoscopy.

RESULTS

A chest computed tomographic scan of each woman disclosed mediastinal lymphadenopathy and warranted mediastinal lymph node biopsy by mediastinoscopy. In both patients, histopathologic and microbiologic studies demonstrated sterile noncaseating granulomas consistent with the diagnosis of sarcoidosis.

CONCLUSIONS

The diagnosis of sarcoid-associated uveitis in the elderly may be facilitated by chest computed tomography, which may be more sensitive than conventional chest roentgenography. Laboratory studies of biopsied mediastinal nodes obtained by mediastinoscopy can confirm the diagnosis.

Mitomycin C treatment for conjunctival-corneal intraepithelial neoplasia: a multicenter experience

OBJECTIVE

The purpose of the study is to evaluate the efficacy and risks of topical mitomycin C (MMC) for conjunctival-corneal intraepithelial neoplasia (CCIN).

DESIGN

The study design was a clinical case series of CCIN.

PARTICIPANTS

Seventeen patients, 16 with biopsy-confirmed CCIN and 1 with invasive squamous cell carcinoma (SCC), were included in the study.

INTERVENTION

Patients received topical drops of MMC 0.02% to 0.04% four times daily from 7 to 28 days. Retreatment was done in cases of lesion recurrence.

MAIN OUTCOME MEASURES

The size of the CCIN before and after the treatment and ocular complications post-MMC application were evaluated.

RESULTS

Ten patients remained disease-free after one course of MMC application. In one case, residual CCIN remained very small without regrowth. In the one patient with invasive SCC and in five patients with CCIN, regrowth occurred within 6 months of the first treatment. After retreatment, invasive SCC and CCIN in an additional two patients were eradicated. In two cases, although the size of the lesions decreased after two and three applications of MMC, regrowth occurred, and the CCIN returned to its original size. In the final case, limited recurrence has occurred and no retreatment has been done. The complications of MMC use included mild-to-moderate conjunctival hyperemia and mild allergy, which resolved after discontinuation of the treatment. Severe pain manifested when treatment was longer than 14 days.

CONCLUSIONS

Application of topical MMC is an efficient treatment for most but not all cases of CCIN.

Small-diameter, round, eccentric penetrating keratoplasties and corneal topographic correlation

PURPOSE

The purpose of the study is to report the outcome and postoperative topographic analysis of seven patients who underwent small-diameter, round, eccentric penetrating keratoplasty.

METHODS

Seven patients underwent small-diameter, round, eccentric penetrating keratoplasty for a variety of corneal disorders (cataract wound necrosis and dehiscence or fistula, three patients; penetrating keratoplasty wound infection, two patients; corneal rheumatoid melt and perforation, one patient; localized fungal keratitis, one patient). Full-thickness corneal transplants ranged in size from 3.0 to 5.5 mm. The graft wound and sutures spared the visual axis in all cases. Patients were observed for 7 to 42 months (mean, 21 months). All patients had postoperative topographic analysis. One of these also had preoperative analysis.

RESULTS

All grafts tectonically were effective in treating the intended condition. Best-corrected visual acuity was 20/30 or better in the four patients without pre-existing corneal transplants or dry eyes; 20/60 and 5/200 in the patients with previous central penetrating keratoplasties; and 20/40 in the patient with rheumatoid melt. There was no clinically significant regular or irregular astigmatism induced centrally by the eccentric graft in the four patients where visual acuity was 20/30 or better. Irregular astigmatism was noted in the other three patients.

CONCLUSION

Small-diameter, eccentric penetrating keratoplasties may be used successfully to treat various peripheral corneal disorders. In some cases, this can be performed without inducing high or irregular astigmatism or both centrally.

Spontaneous collapse of primary acquired iris stromal cysts

PURPOSE

To describe the spontaneous collapse of primary acquired iris stromal cysts.

METHODS

We reviewed the medical records, clinical findings, and ultrasonography of two patients who had been followed up for primary acquired iris stromal cysts.

RESULTS

During follow-up, both patients experienced spontaneous collapse of their cysts, which resulted in membrane formation on the peripheral corneal endothelium, localized peripheral anterior synechiae, ectropion uveae, and slightly peaked pupil.

CONCLUSION

Primary acquired iris stromal cysts may undergo spontaneous collapse, resulting in clinical findings similar to other anterior segment disorders.

The efficacy of topical metronidazole in the treatment of ocular rosacea

PURPOSE

The purpose of the study is to investigate the efficacy of metronidazole topical gel in the treatment of ocular rosacea.

METHODS

Ten patients with ocular rosacea were treated prospectively with lid hygiene and topical metronidazole applied to the lid margin in one eye and lid hygiene alone in the fellow eye. The treatment period was 12 weeks. A masked observer graded the ocular findings at the initial visit and at the conclusion of the treatment period. Pretreatment scores were compared with post-treatment scores with respect to ocular surface, eyelid margin, and combined eyelid plus ocular surface.

RESULTS

Eight of ten treated eyes improved, whereas only five of ten control eyes improved. There was a statistically significant improvement in the eyelid score in both the treated and control groups (P = 0.003, P = 0.025, respectively), but no significant improvement in the ocular surface score in either group. When the pretreatment and post-treatment eyelid and ocular surface scores were combined, there was a significant improvement in the treated eyes but not in the control eyes (P = 0.022, P = 0.10, respectively). No adverse effects of the metronidazole treatment were encountered in this study.

CONCLUSION

Metronidazole topical gel may be a safe and effective means of treating rosacea blepharitis.

Bacterial contamination of anaerobic vitreous cultures: using techniques employed for endophthalmitis

PURPOSE

To investigate the occurrence of contaminated cultures of vitreous specimens from non-infected eyes obtained using anaerobic techniques employed for endophthalmitis.

METHODS

Vitreous specimens were obtained using meticulous sterile techniques employed for endophthalmitis from seventeen patients undergoing pars plana vitrectomy for non-infective indications: vitreous hemorrhage (12 eyes), retinal detachment (3), Coat's disease (1), and congenital dislocated lens(1). Vitreous specimens were inoculated in the operating room onto an anaerobic blood agar plate and into thioglycolate broth. Bacterial growth occurring before 10 days was considered positive.

RESULTS

Three organisms were isolated from three separate eyes. One colony of Staphylococcus species was isolated on an anaerobic blood agar plate on day 3. A single colony of Propionibacterium acnes grew on an anaerobic blood agar plate on day 6. Alpha-hemolytic streptococci grew from thioglycolate broth on day 10.

CONCLUSIONS

Growth as detected in this study might represent contaminating rather than an infecting organism in an eye suspected of having endophthalmitis.

Microsporidial keratoconjunctivitis caused by Septata intestinalis in a patient with acquired immunodeficiency syndrome

PURPOSE

To examine and treat a patient with acquired immunodeficiency syndrome (AIDS) who had mildly hyperemic conjunctiva and epithelial keratopathy in both eyes.

METHODS

The patient underwent conjunctival biopsy. The specimen was examined by transmission electron microscopy.

RESULTS

Septata intestinalis was demonstrated to be the cause of keratoconjunctivitis in the patient. The keratoconjunctivitis resolved after three weeks of therapy with topical fumagillin. No organisms were seen on repeat conjunctival biopsy.

CONCLUSIONS

Microsporidial keratoconjunctivitis in patients with AIDS can be caused by S. intestinalis. This condition appears to respond to topical fumagillin.

American Uveitis Society Meeting October 30, 1995 Marriott Marquis Hotel, Atlanta, GA, USA

1 Retinal vascular occlusion and scleroderma. Tessler H, Flores-Guevara J, Goldstein D, Chicago, IL, USA. 2 MHC Class II antigen expression in ciliary body in spontaneous and experimental uveitis. Kalsow C, Zhavoronkova M, Dwyer A, Rochester, NY & Scottsville, NY, USA. 3 IL-10 in the vitreous of patients with intraocular lymphoma. Whitcup S, Solomon D, Nussenblatt R, Chan C-C, Bethesda, MD, USA 4 Iris juvenile xanthogranuloma studied by immunohistochemistry. Shields J, Shields C, Eagle R, DePotter P, Collins M, Philadelphia, PA, USA. 5 Outcomes analysis in with JRA-associated uveitis. Dana M-R, Merayo-Lloves J, Foster C, Boston MA, USA. 6 Persistent glaucoma secondary to periocular steroids. Akduman L, Conway M, Burchfield J, Kolker A, Black D, DelPriore L, Kaplan H, St. Louis, MO, USA 7 The use of itraconazole in ocular histoplasmosis Callanan D, Fish G, Dallas, TX, USA 8 Succesful treatment of macular hole secondary to sympathetic ophthalmia. Cano J, Diaz M, Navea A, Ruiz C, Castilla M. Barcelona, Spain. 9 HLA-DR2+ intermediate uveitis. Pulido J, Tang W, Han D, Mieler W. Milwaukee, WI, USA. 10 Vein occlusion in AIDS misdiagnosed as CMV retinitis. Park K, Marx J, Rao N. Los Angeles, CA, USA. 11 HIV-associated foveal hemorrhage. Crews K, Zimmerman P, Lohner S. Salt Lake City, UT, USA. 12 Cytomegalovirus papillitis in patients with AIDS. Patel S, Rutzen A, Marx J, Thach A, Chong L, Rao N, Los Angeles, CA, USA. 13 Recurrence rate of CMV retinitis following the ganciclovir implant and pars plans vitrectomy and silicone oil. Marx J, Thach A, Rao N, Chong L. Los Angeles, CA, USA.

Corneal anesthetic abuse and Candida keratitis

PURPOSE

Topical corneal anesthetic abuse is a self-inflicted injury, causing profound corneal morbidity. Superimposed infection is an important complicating factor. The authors report four patients with confirmed topical anesthetic abuse of the cornea, in whom Candida keratitis developed.

METHODS

A retrospective review of the medical records of four patients with confirmed topical corneal anesthetic abuse and fungal keratitis.

RESULTS

A 21-year-old woman, two 28-year-old women, and a 35-year-old man were included in the study. All these patients sustained a corneal injury, prompting the chronic use of topical anesthetics (0.5% proparacaine hydrochloride in 3 patients, and 0.5% tetracaine hydrochloride and 0.4% benoxinate hydrochloride in the other). Corneal findings included epithelial defects in all patients, focal infiltrate in one patient, and ring-shaped stromal infiltrate in three patients. Topical anesthetic was discontinued, all patients initially were treated empirically with antibacterial agents, and three patients received topical corticosteroids. Subsequent corneal cultures grew Candida spp, Candida albicans specifically in three patients, and local and systemic antifungal therapy was started. Corneas in two patients re-epithelialized; a conjunctival flap was performed on another patient with a descemetocele; and the remaining patient was lost to follow-up, although repeat fungal cultures yielded no growth.

CONCLUSIONS

Corneal superinfection with Candida may occur during topical anesthetic abuse. Therapy includes discontinuation of the anesthetic and institution of antifungal therapy.

Clinical features and associated systemic diseases of HLA-B27 uveitis

PURPOSE

To delineate the clinical features, course, complications, and associated systemic diseases in patients with HLA-B27-associated uveitis.

METHODS

We reviewed the records of 148 patients with HLA-B27-associated uveitis from two large uveitis practices.

RESULTS

There were 127 (86%) white and 21 (14%) nonwhite patients, and a male-to-female ratio of 1.5:1. The median age at onset of uveitis was 32 years; eight patients (5%) had their first attack after age 55 years. Acute anterior uveitis was noted in 129 patients (87%), and nonacute inflammation was noted in 19 (13%). Ocular involvement was categorized as unilateral or unilateral alternating in 138 patients (93%), but ten patients (7%) had bilateral, concurrent disease. The median duration of an attack was six weeks, and the median number of recurrences for patients with more than 12 months of follow-up was three. Cataracts were associated with posterior synechiae (P = .03), increased intraocular pressure (P = .003), and cystoid macular edema (P = .04). An HLA-B27-associated systemic disorder was present in 83 patients (58%), 30 of whom were women, and it was diagnosed in 43 of the 83 patients as a result of the ophthalmologic consultation. Thirty-four (30%) of 112 patients had a family history of a spondyloarthropathy.

CONCLUSIONS

Although HLA-B27-associated uveitis is usually described as a disease of young white men, women and nonwhites may also be affected. A subgroup of patients have severe disease and consequently more complications. Most patients have an associated systemic disease, including women, who appear to have more atypical spondyloarthropathies. The systemic diseases were frequently undiagnosed before the onset of the ocular disease and before the uveitis consultation.

Disappearance of crystals in Schnyder's crystalline corneal dystrophy after epithelial erosion

PURPOSE

A 40-year-old woman with Schnyder's crystalline corneal dystrophy had two episodes of epithelial erosion.

METHODS

We reviewed the patient's medical record and photographic file.

RESULTS

In the areas underlying the epithelial erosion, the crystalline opacities disappeared. The crystals recurred in the subsequent five years but were not as dense.

CONCLUSIONS

Crystals in the subepithelial or Bowman's layer may lead to epithelial destabilization and corneal epithelial erosion. Disappearance of the crystalline opacities may occur after disruption of the epithelium.

Relationship between corneal edema and topography

We found that corneal edema can occur without significant concomitant changes in central and peripheral corneal topography. We examined the relationship between corneal edema and corneal topography in 10 subjects with normal ocular examinations. Baseline pachymetry and topographic measurements for both eyes of each patient were obtained. The right eye of each subject was exposed to an anoxic environment for 2 hours using a nitrogen chamber goggle. The left eye served as control. Optical pachymetry and computerized corneal topographic measurements were taken for both eyes immediately after removal of the nitrogen chamber goggle. All corneas exposed to the nitrogen chamber were thickened in all areas after removal of goggles. Average percent thickening per area was: 16.4% centrally, 6.3% nasally, 6.0% temporally, 6.3% superiorly, and 9.2% inferiorly. Corneas exposed to the nitrogen chamber demonstrated no significant topographic changes, except in the nasal area where the corneal power lessened. Furthermore, there was no significant correlation between corneal thickening in any area measured and changes in corneal topography. Control corneas did not thicken or demonstrate significant topographic changes.

Minimum bactericidal concentrations of Propionibacterium acnes isolates from cases of chronic endophthalmitis

Six isolates of Propionibacterium acnes recovered from cases of chronic infectious endophthalmitis following extracapsular cataract extraction were tested for antibiotic susceptibility. All isolates were susceptible to penicillin, cefazolin, and vancomycin with a macrobroth dilution method. Minimum bactericidal concentrations testing at 72 h revealed that six of six isolates were killed by < or = 1.0 micrograms of vancomycin/ml, one of six isolates by < or = 1.0 micrograms of penicillin/ml, and zero of six isolates by < or = 1.0 micrograms cefazolin/ml.

Contact lens type, material, and deposits and giant papillary conjunctivitis

Giant papillary conjunctivitis (GPC) is a condition commonly encountered in clinical practice. Much research has taken place aimed at more clearly understanding the pathogenesis of GPC. We review the current literature and discuss the association between GPC and contact lens type, material, and deposits.

American uveitis society meeting october 31, 1994 san francisco, california

1 Ophthalmic manifestations of presumed rifabutin-related uveitis. Arevalo JF, Freeman WR, La Jolla, CA, USA. 2 Diagnosis of toxoplasmosis acute anterior uveitis by PCR. Cano J, Diaz M, Navee A, Maldonado M, Barcelona, Spain. 3 Neuroretinits in patients with AIDS. Berger B, Austin TX, USA. 4 Presumed varicella zoster retinitis in a pediatric patient with AIDS. El Baba F, Nachman S, Stony Brook, NY, USA. 5 ARN with hypopyon caused by EVB and herpes type VI viruses. Cano J, Diaz M, Navea A, Maldonado MJ, Barcelona, Spain. 6 CD8(+) T-lymphocytes and ocular infections in HIV(+) patients. Lowder CY, Butler CP, Dodds EM, Recillas-Gispert C, Cleveland, OH, USA. 7 Intravitreal foscanet for persistent CMV. Lieberman RM, Orellana J, New York, NY, USA. 8 Perfluorocarbon liquid versus air-fluid exchange during surgical repair of retinal detachment caused by cytomegalovirus retinitis in patients with AIDS. Sery T, Gomes J, Sando R, Dua H, Donoso L, Vrabec T, Philadelphia, PA, USA. 9 Endogenous ophthalmitis simulating retinoblastoma: a report of six cases. Shields J, Shields C, Eagle R, Barrett J, DePotter P, Philadelphia, PA, USA. 10 Ocular lymphoma resembling chronic postoperative endophthalmitis. Fox G, Chan CC, Whitcup SM, Nussenblatt R, Bethesda, MD, USA. 11 A phase II trial of combination chemotherapy for primary central nervous system lymphoma. Whitcup SM, Stark-Vanes V, Nussenblatt RB, Heiss H, Witte R, Bethesda, MD, USA. 12 Cancer-induced autoimmune retinopathy. Thirkill C, Sacramento, CA, USA. 13 Leukocytoclastic vasculitis. Tessler H. Chicago, IL, USA. 14 Bilateral choroidal neovascular membranes after Candida albicans chorioretinitis. Dodds E, Townsend-Pico W, Lowder CY, Lewis H, Cleveland, OH, USA. 15 An unusual complications of Toxoplasma retinochoroiditis. Gormley PD, Flaxel CJ, Pavesio CE, Conrad DK, Lightman S, London, UK. 16 Surgical removal of a choroidal neovascular membrane in sympahtetic ophthalmia. Conrad DK, McCluskey PJ, Schwartz S, Gregor Z. Lightman S, London, UK. 17 Peripheral laser scatter ablation in pars planitia. Park SE, Mieler WF, Pulido JS, Milwaukee, WI, USA.

Growth curve for Propionibacterium acnes

We established growth curves for Propionibacterium acnes isolates recovered from eyes with chronic postoperative endophthalmitis. The growth curve plotted the average of the duplicate bacterial concentration against time. The generation time for P. acnes calculated from the growth curves was approximately 5.1 hours. The growth of P. acnes is slower than other anaerobic bacteria. This may account for its delayed appearance in culture of ocular specimens. It may also explain treatment failure if the concentration of an antibiotic injected into the vitreous does not remain at an effective level during the critical replicative phase of the organism.

An unusual ocular manifestation of discoid lupus erythematosus

BACKGROUND

Discoid lupus erythematosus is a chronic skin disease characterized by well-demarcated papules and plaques. Mucous membrane changes are common; however, conjunctival involvement is unusual. We report a case of unilateral, chronic, isolated discoid lupus erythematosus of the conjunctiva.

OBSERVATIONS

A 32-year-old man presented for evaluation of chronic conjunctivitis of the right eye that had persisted for 9 years. A biopsy of the bulbar conjunctiva revealed a mixed mononuclear cellular infiltrate distributed along the epithelial basement membrane zone and around the stromal blood vessels. Immunohistopathologic examination revealed a diffuse, granular pattern of fluorescence corresponding to immunoglobulins and complement components along the epithelial basement membrane zone and in the walls of the stromal blood vessels. Electron microscopy demonstrated changes in the epithelial basal lamina consistent with discoid lupus erythematosus, including areas that were multilayered. Immunoelectron microscopy identified sub-basal lamina deposits of immunoglobulin G.

CONCLUSIONS

Discoid lupus erythematosus should be a suspected cause of chronic conjunctival inflammation; the diagnosis is substantiated by immunopathologic and ultrastructural studies.

Systemic diseases associated with intermediate uveitis

BACKGROUND

Intermediate uveitis is characterized by vitreal inflammation with associated inflammation of the vitreous base and peripheral anterior retina and choroid. It may be found as an isolated and idiopathic condition or in association with systemic disorders such as multiple sclerosis and sarcoidosis.

OBJECTIVE

To identify the clinical features of intermediate uveitis and assess its association with systemic diseases.

METHODS

Retrospective study of 83 patients presenting with intermediate uveitis between 1970 and 1991.

RESULTS

Evidence of systemic disorders was found in 26 of 83 patients (31.3%). Of these 26 patients, 10 had presumed sarcoidosis, 6 had multiple sclerosis, 2 had isolated optic neuritis, 2 had inflammatory bowel disease, 4 had isolated thyroid abnormalities, and 2 had histories suggestive of Epstein-Barr virus infection. Associated ocular findings included cystoid macular edema, peripheral retinal perivascular sheathing, cataracts, posterior vitreous detachment, fine keratic precipitates, preretinal macular fibrosis, retinal tears, retinal detachment, and optic disc edema.

CONCLUSIONS

Patients with intermediate uveitis may have associated systemic diseases and should have careful follow-up with regular systemic evaluation.

Combined extracapsular cataract extraction, posterior chamber intraocular lens implantation, and pars plana vitrectomy

The surgical management of coexisting cataract and vitreoretinal disease has been controversial, particularly for eyes with a history of proliferative diabetic retinopathy (PDR) or chronic uveitis. We retrospectively studied the results of combined extracapsular cataract extraction (ECCE), posterior chamber intraocular lens (PC-IOL) implantation, and pars plana vitrectomy in 20 eyes of 16 patients. The indications for combined vitrectomy included dense, nonclearing vitreous hemorrhage attributed to PDR in 10 eyes, age-related macular degeneration in 2, and trauma in 1. The remaining 7 eyes had pars plana vitrectomy to remove inflammatory vitreous cell and debris associated with chronic uveitis. Follow up ranged from 4 to 32 months (average, 17.4 months). Visual acuity improved in 19 eyes (95%)--to 20/100 or better in 12 (60%). The improvement ranged from 1 to 13 Snellen lines (average, 4.9 lines). Postoperative visual acuity improvement averaged 7.5 Snellen lines for eyes with chronic uveitis, 7.0 lines for those with age-related macular degeneration, and 3.3 lines for those with a history of PDR. Postoperative visual acuity was less than 20/100 in 8 eyes (40%). In most cases, these latter results were attributed to macular changes associated with the underlying ocular disease. Our results confirm previous studies that have shown that combined ECCE/PC-IOL implantation and pars plana vitrectomy is a well-tolerated surgical procedure for diabetics, which can provide clear anterior and posterior segment media. In addition, our results suggest that this combined procedure can be useful in restoring vision in certain eyes with uveitis in the short-term postoperative period.

Enterococcal infectious crystalline keratopathy

Two patients developed infectious crystalline keratopathy (ICK) 9 and 11 months after penetrating keratoplasty. In both cases, cultures yielded enterococcus sensitive to vancomycin. The first patient developed diffuse loss of corneal and conjunctival epithelia after 24 h of treatment with vancomycin eyedrops, whereas the second patient did not respond after 14 days of topical vancomycin therapy. Both patients eventually required penetrating keratoplasty. Enterococcus is a ubiquitous bacterium resistant to many antibiotics that should be suspected of causing ICK.

Bacterial endophthalmitis following cataract surgery in an eye with a preexisting Molteno implant

We describe a patient with a preexisting, functioning Molteno implant in whom acute endophthalmitis developed following cataract extraction. The condition was treated successfully without removing the implant.

Visual outcome in acute retinal necrosis

Acute retinal necrosis (ARN) is generally a progressive retinitis, often complicated by retinal detachment and a poor visual outcome. A series of 12 consecutive patients (13 eyes) with ARN is reported. All patients were examined early, with a limited extent of disease (in 77% of the eyes, less than 25% of retina involved). Patients were treated with high-dose intravenous acyclovir (10 mg/kg every 8 hours) and laser photocoagulation. During a follow-up period of 3 to 21 months, only 1 patient developed a rhegmatogenous retinal detachment resulting in visual loss. No patients developed bilateral disease once intravenous antiviral therapy was begun. Final visual acuity was 20/40 or better in 6 eyes (46%), and 20/400 or better in 12 eyes (92%). Two patients were examined within 6 weeks of extracapsular cataract extraction with intraocular lens implantation. In the majority of the cases, clinical findings were limited to several quadrants of the peripheral retina. Eyes with limited disease, if aggressively treated, have a relatively good visual prognosis.

Conjunctival involvement in paraneoplastic pemphigus

Paraneoplastic pemphigus is a recently described autoimmune inflammatory mucocutaneous disease associated with an underlying neoplasm. Although histopathologic and direct immunofluorescence findings of involved skin and mucous membranes are consistent with pemphigus vulgaris, indirect immunofluorescence and immunoprecipitation study results are unique. We treated two patients with non-Hodgkin's lymphoma and paraneoplastic pemphigus. Both patients had bilateral bulbar conjunctival hyperemia and diffuse papillary tarsal conjunctival reactions. One patient had sloughing of conjunctival epithelium and the other had tarsal conjunctival cicatrization and forniceal shortening. Histopathologic findings of conjunctivae obtained from both patients were consistent with pemphigus vulgaris. Diffuse deposition of IgG and C3 in the intercellular substance of the conjunctival epithelium was demonstrated by direct immunofluorescence. Indirect immunofluorescence testing disclosed binding of autoantibodies to rodent bladder and intestinal epithelium. Immunoprecipitation disclosed antibodies reactive to Desmoplakin I (250 kd), bullous pemphigoid (230 kd), Desmoplakin II (210 kd) and 190-kd proteins. Ophthalmologists and pathologists should be aware of the conjunctival changes in paraneoplastic pemphigus.

Low-dose methotrexate therapy for ocular inflammatory disease

BACKGROUND

Methotrexate is a second-line anti-inflammatory agent used in the treatment of rheumatic diseases. At low doses (12.5 mg/week), it is associated with few serious side effects.

METHODS

Twenty-two patients (5 men, 17 women) with chronic noninfectious ocular inflammatory disease, who had not responded to or who had become intolerant of corticosteroid or alternate cytotoxic agents, were treated weekly with oral low-dose, pulse methotrexate. Treated diseases included chronic uveitis-vitreitis (9), scleritis (4), inflammatory pseudotumor (3), orbital myositis (3), and retinal vasculitis (3).

RESULTS

Follow-up ranged from 2 to 39 months (mean, 11 months). Response time ranged from 3 to 9 weeks (mean, 5 weeks) after implementation of methotrexate therapy. Sixteen of 22 patients had reduction of inflammatory activity. Fourteen of these 16 patients were able to taper or discontinue corticosteroid therapy. Five patients had complete remission of their disease; six patients did not respond to methotrexate.

CONCLUSION

Treatment with low-dose methotrexate appears to be effective therapy for steroid-resistant ocular inflammatory disease.

Extracapsular cataract extraction and posterior chamber intraocular lens implantation in uveitis patients

PURPOSE

Intraocular lens implantation in uveitis patients has been a controversial issue. The purpose of this study is to evaluate the visual and surgical outcomes of extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (PC IOL) implantation in a diverse group of uveitis patients.

PATIENTS AND METHODS

The results of 39 cases of ECCE and PC IOL implantation in 30 patients with uveitis were retrospectively analyzed. Five patients (six eyes) had pars plana vitrectomies combined with ECCE and PC IOL implantation. Patient age ranged from 26 to 71 years (average, 53.0 years). Specific uveitic syndromes were determined for 22 patients (73.3%). The postoperative follow-up period ranged from 6 to 43 months (average, 20.3 months).

RESULTS

Visual acuity improved postoperatively in 38 eyes (97.4%), and this improvement ranged from 1 to 11 Snellen lines (average, 7.5 Snellen lines). Visual acuity improved postoperatively to 20/40 or better in 32 eyes (82%). Seven eyes had visual acuity worse than 20/40, which was attributed to posterior segment abnormalities after ECCE and PC IOL implantation. Uveitis recurred in 20 eyes (51.3%), and postoperative cystoid macular edema (CME) was observed in 18 eyes (46.2%). In all cases, the recurrent uveitis and CME improved or resolved with corticosteroid therapy.

CONCLUSION

These results suggest selected uveitis patients can have improved vision without unacceptable risk for 1 to 3 years after ECCE and PC IOL implantation.

Immunobullous diseases with ocular involvement

Collaborative efforts of the dermatologist and ophthalmologist and other physicians with interest and experience in the management of the autoimmune bullous diseases optimize patient care by avoiding potentially harmful delay in diagnosis or implementation of therapy. At our institution, ophthalmologic and dermatologic follow-up visits for patients with bullous disorders involving the eyes are arranged for the same day so that ophthalmic examination and monitoring and adjustment of medication by the dermatologist can be effected. During initiation of treatment, visits are monthly. Later, when patients are stabilized, intervals may be extended to 3 to 6 months. More frequent visits are arranged as needed with the ophthalmologist to manage infectious complications or problems requiring surgical management and with the dermatologist to manage extraocular disease and adverse reactions to medication and to triage concurrent illnesses.

Glaucoma filtering surgery with postoperative 5-fluorouracil in patients with intraocular inflammatory disease

Twenty-one eyes of 18 patients with uncontrolled glaucoma and intraocular inflammatory disease had glaucoma filtering surgery with postoperative subconjunctival 5-fluorouracil (5-FU). Follow-up for eyes in which intraocular pressure was controlled ranged from 6 to 53 months (mean, 34 months; median, 35 months). Fifteen of 21 eyes (71%) had controlled intraocular pressure (21 mmHg or less). Control was achieved in 9 of 10 (90%) phakic eyes and in 6 of 11 (55%) aphakic or pseudophakic eyes with or without glaucoma medication. Four of six filter failures had a second filtering procedure with 5-FU, and of these four procedures, three were successful. Cataract progression occurred in 9 of 10 phakic eyes, leading to cataract surgery in 7 eyes. Other complications included corneal epithelial defects in 13 eyes, bleb leaks in 3 eyes, choroidal effusions in 13 eyes, 1 choroidal hemorrhage, 1 serous retinal detachment and macular retinal pigment epithelial disturbance associated with hypotony and choroidal effusion. Filtering surgery with postoperative subconjunctival 5-FU can successfully control intraocular pressure in eyes with ocular inflammatory disease.

Corneal microsporidioses: characterization and identification

Two ocular infectious disorders attributed to Microsporidia have been observed. They differ in that one infection involves the corneal stroma leading to corneal ulceration and suppurative keratitis whereas the other infection involves the conjunctival and corneal epithelium. The corneal stromal infection is caused by a binucleated oval spore that is Nosema-like in character. The conjunctival and corneal epithelial infection occurs in HIV-sero-positive individuals and is caused by a spore containing a single nucleus that is a member of the genus Encephalitozoon. Characteristics of these genera and the above-mentioned infections are presented.

Subepithelial infiltrates in Acanthamoeba keratitis

Six patients had Acanthamoeba keratitis that manifested an unusual type of subepithelial corneal infiltrate late in the course of the disease. These infiltrates occurred in the anterior corneal stroma, often in a location removed from the site of infection. In four of these patients the infiltrates occurred with no other clinical signs of inflammation. Two patients had mild foreign-body sensation that resolved despite the persistence of the subepithelial infiltrates. The infiltrates resolved with topical corticosteroid therapy in three patients; however, in two of these three patients the infiltrates recurred when corticosteroid therapy was tapered or discontinued. The subepithelial infiltrates appeared and behaved similarly to those associated with viral and chlamydial corneal infections. An immunologic mechanism may be responsible for these unusual delayed-in-onset infiltrates.

Presumed Pneumocystis carinii choroiditis. Unifocal presentation, regression with intravenous pentamidine, and choroiditis recurrence

Pneumocystis carinii choroiditis is a well-documented but rare infection that has been described as a bilateral, multifocal process. Treatment efficacy has not been well established. In this report, three cases of presumed P. carinii choroiditis that developed during aerosolized pentamidine therapy for the prophylaxis of P. carinii pneumonia are described. All patients had unilateral choroiditis, and two patients were first observed to have unifocal choroiditis. In all patients, choroidal lesions decreased in size with intravenous pentamidine treatment. Choroiditis exacerbated in the two unifocal cases after the frequency of maintenance intravenous pentamidine therapy was decreased. P. carinii choroiditis may appear as a unifocal, unilateral lesion that may represent an earlier stage of infection than previously described. Intravenous pentamidine therapy appears to control P. carinii choroiditis but may need to be continued to prevent exacerbation. Patients receiving prophylactic aerosolized pentamidine therapy are not protected against extrapulmonary disease, and presumed P. carinii choroiditis may serve as a marker for disseminated infection.