Clinical outcomes and functional visual performance: comparison of the ReSTOR apodised diffractive intraocular lens to a monofocal control

AIMS

To compare clinical outcomes of patients bilaterally implanted with SN60D3 intraocular lenses (IOLs) with outcomes of bilateral monofocal controls, and to determine the validity of implanting an apodised diffractive lens in a healthy patient population.

METHODS

Six unmasked US investigators prospectively enrolled 72 patients aged </=70 years with bilateral cataracts in otherwise healthy eyes. Patients underwent routine cataract extraction via phacoemulsification with SN60D3 implantation. Visual outcomes were assessed 1 week, 1 month and 6 months postoperatively. Patients completed two subjective surveys. As controls, 51 patients who were 6 months postoperative to bilateral implantation of AcrySof monofocal IOLs also were assessed.

RESULTS

Corrected and uncorrected distance visual acuity was similar across groups. For uncorrected near and intermediate visual acuity, statistically significant differences were found favouring the SN60D3 group (p<0.0001). Contrast sensitivity was significantly better in monofocal patients at 6 cpd and 18 cpd under various lighting conditions. The Functional Evaluation and the Questionnaire demonstrated that SN60D3 patients achieved significantly higher levels of functional vision and spectacle freedom (p<0.0001).

CONCLUSION

Despite mildly decreased contrast sensitivity when compared with a monofocal IOL, the SN60D3 provided high patient satisfaction, excellent functional vision, and high rates of spectacle freedom.

Air bag-induced corneal flap folds after laser in situ keratomileusis

PURPOSE

We describe a case of air bag-induced ocular trauma resulting in folds in the corneal flap 3 weeks after laser in situ keratomileusis.

METHODS

Case report. Three weeks after laser in situ keratomileusis, a 20-year-old man was involved in a motor vehicle accident and sustained blunt trauma to the right eye, which caused corneal flap folds, corneal edema, anterior chamber cellular reaction, and Berlin retinal edema.

RESULTS

Six weeks after laser in situ keratomileusis, persistent flap folds necessitated re-operation with lifting of the flap and repositioning. One week after the procedure, the visual acuity improved to 20/20-2, and the folds had cleared.

CONCLUSION

Trauma after laser in situ keratomileusis may produce folds in the corneal flap. With persistence of these folds, management by lifting and repositioning the corneal flap may be necessary to permit recovery of visual acuity.

Phototherapeutic keratectomy for anterior scarring in an epikeratophakia lenticule

PURPOSE

To present a case of anterior scarring in an epikeratophakia lenticule and its partially successful treatment with the excimer laser.

METHODS

Excimer laser phototherapeutic keratectomy (PTK) was used to reduce corneal scarring in an epikeratophakia lenticule.

RESULTS

Visual acuity improved after two sessions of PTK.

CONCLUSIONS

PTK is an alternative to epikeratophakia lenticule removal.

Laser in situ keratomileusis for correction of myopia and astigmatism after penetrating keratoplasty

PURPOSE

To determine the safety and effectiveness of laser in situ keratomileusis (LASIK) for visual rehabilitation of residual myopia and astigmatism after penetrating keratoplasty.

DESIGN

Prospective, noncomparative case series.

PARTICIPANTS

LASIK was performed on 23 eyes of 22 patients unable to wear glasses or contact lenses after penetrating keratoplasty due to anisometropia, high astigmatism, and/or contact lens-intolerance.

METHODS

All patients underwent LASIK for visual rehabilitation after penetrating keratoplasty. Uncorrected visual acuity and best spectacle-corrected visual acuity, degree of anisometropia, and corneal transplant integrity were recorded before surgery, as well as at 1 month, 3 months, 6 months, and 12 months after LASIK surgery.

RESULTS

The mean spherical equivalent before surgery was -7.58+/-4.42 diopters (D), which was reduced to -1.09+/-2.01 D, -0.79+/-1.84 D, -0.77+/-1.25 D, and -1.57+/-1.20 D, respectively, at 1, 3, 6, and 12 months after LASIK. The mean cylinder before surgery was 3.64+/-1.72 D, which was reduced to 1.98+/-1.15 D, 1.64+/-1.14 D, 1.48+/-0.92 D, and 1.29+/-1.04 D, respectively, at 1, 3, 6, and 12 months after LASIK. Spherical equivalent anisometropia was reduced from a mean of 6.88+/-4.4 D to 1.42+/-1.05 D at the final examination. Best-corrected visual acuity remained the same or improved in 21 of 23 eyes and decreased by 1 and 3 lines in 2 patients. There were no surgical flap or corneal transplant complications.

CONCLUSIONS

LASIK is a viable treatment alternative for myopia and astigmatism after penetrating keratoplasty in patients who are contact lens-intolerant. LASIK is more effective in treating myopia than astigmatism after penetrating keratoplasty.

Subconjunctival mitomycin C for the treatment of ocular cicatricial pemphigoid

PURPOSE

The authors performed a prospective evaluation of the efficacy of treating ocular cicatricial pemphigoid (OCP) with subconjunctival mitomycin C.

DESIGN

Unmasked, prospective, internally controlled case series.

METHODS

Patients were eligible for treatment with subconjunctival mitomycin C under three criteria: (1) significant complications of systemic immunosuppressant therapy; (2) markedly asymmetric conjunctival disease; and (3) end-stage OCP. All patients received monocular subconjunctival injections of 0.25 ml of 0.2 mg/ml mitomycin C to both the superior and inferior bulbar conjunctivae in the eye with the more severe disease.

RESULTS

Nine eyes of nine patients (mean age, 74 years) were treated with subconjunctival mitomycin C to the more-involved eye and were followed for a mean of 23.5 months (range, 12-40 months). Eight of nine patients showed quiescence of their OCP in the treated eye based on serial evaluation of conjunctival cicatrization and grading of conjunctival erythema. Five of the nine untreated eyes showed progression of the conjunctival disease. One patient required concomitant systemic immunosuppressive therapy after subconjunctival mitomycin C. Two patients underwent successful visual rehabilitative surgery in the mitomycin C-treated eye.

CONCLUSION

The use of subconjunctival mitomycin C may be effective in preventing progression of conjunctival cicatrization and erythema in patients with OCP. No complications of mitomycin C treatment were noted. Long-term follow-up and further investigation into the efficacy of subconjunctival mitomycin C in the management of OCP is warranted.

Topical Cyclosporine A in the management of postkeratoplasty glaucoma and corticosteroid-induced ocular hypertension (CIOH) and the penetration of topical 0.5% cyclosporine A into the cornea and anterior chamber

PURPOSE

To evaluate the effect on intraocular pressure (IOP) of substituting topical Cyclosporine A 0.5% for topical corticosteroids in patients with postkeratoplasty glaucoma and corticosteroid-induced ocular hypertension (CIOH). We also sought to determine the penetration of topical 0.5% Cyclosporine A into the cornea and anterior chamber.

METHODS

Topical Cyclosporine A 0.5% was prospectively substituted for topical corticosteroids in 47 patients (52 eyes) with postkeratoplasty glaucoma and CIOH in order to eliminate the IOP-elevating effect of topical corticosteroids, while maintaining protection against allograft rejection. Ten patients received 0.5% topical Cyclosporine before keratoplasty. Their corneal tissue and aqueous samples were evaluated by high pressure liquid chromatography for Cyclosporine levels.

RESULTS

Forty-eight of 52 eyes (92.3%) demonstrated a reduction of IOP at first followup (mean: -7.9 mmHg; range: -19 to +2). Mean followup was 10.3 months, ranging from 1 to 37 months. At last follow-up, mean IOP was -8.2 mm Hg. There were six allograft rejections, five of which were reversed with the reintroduction of topical corticosteroids. Graft clarity was maintained in 46 of 52 eyes (88%). The mean cornea Cyclosporine concentration was 3679 ng/gm (range: 1980 to 5520 ng/ gm) and aqueous humor mean concentration was 6.05 ng/mL (range: 0.4 to 15.5 ng/mL).

CONCLUSIONS

Topical Cyclosporine A 0.5% may be substituted for topical corticosteroids to aid in the management of postkeratoplasty glaucoma and CIOH. However, the use of Cyclosporine in place of corticosteroids may be associated with an increased risk of immune rejections. The corneal penetration of topical Cyclosporine is excellent while the penetration into the anterior chamber is poor.

Conjunctival flaps

PURPOSE

The authors reviewed their experience with total conjunctival flaps (TCF) and partial conjunctival flaps (PCF) for the past 5 years in 61 patients.

METHODS

Forty-eight patients had TCF and 13 had PCF. Diagnoses for surgery included severe bullous keratopathy for chronic graft failure (not candidates for keratoplasty) (19), herpes zoster ophthalmicus (7), chronic ulcerative keratitis (14), neurotrophic keratitis (2), and herpes simplex keratitis (9).

RESULTS

There were seven complications. Four flap retractions occurred in the TCF group, requiring resuturing in two. Three complications occurred in the PCF group. One patient had two flap retractions and recurrent ulceration, requiring tarsorrhaphy. One patient with PCF suffered a perforation after flap retraction, necessitating penetrating keratoplasty.

CONCLUSION

The authors believe conjunctival flaps are underused and should be considered seriously for bullous keratopathy, neurotrophic keratitis, recalcitrant keratitis, and persistent nonhealing epithelial defects.

Clinical features of bleb disorder of the cornea

BACKGROUND

Bleb disorder of the cornea is a rare corneal epithelial disorder that has previously been described in asymptomatic patients or those with recurrent nontraumatic corneal erosions.

METHODS

We report two cases of bleb disorder, each presenting with blurred vision from irregular astigmatism secondary to the bleb changes. We also report on the detection of bleb disorder in siblings.

RESULTS

Both patients underwent surgical debridement of the epithelium with resolution of symptoms on epithelial resurfacing.

CONCLUSION

The diagnostic clues, inheritance pattern, differential diagnosis, and treatment options of bleb disorder of the cornea are discussed.

Retained Aspergillus-contaminated contact lens inducing conjunctival mass and keratoconjunctivitis in an immunocompetent patient

PURPOSE

A 66-year-old woman presented with a 1-month history of prominent mucoid discharge and foreign body sensation in her left eye.

METHODS

Ocular evaluation revealed a moderately severe superficial punctate keratitis involving the temporal half of the left cornea. The superior tarsal conjunctiva showed marked papillary reaction with an area of indentation temporally. A mass was present in the superior temporal aspect of the fornix, clinically resembling a pyogenic granuloma. At the posterior aspect of this mass and covered by mucoid material, was a soft contact lens.

RESULTS

Upon removal of the lens, without any additional therapy, the patient became asymptomatic and totally resolved her keratitis and mass lesion. Cultural identification of the soft contact lens was positive for Aspergillus fumigatus.

CONCLUSIONS

We hypothesize that the mucoid discharge and mass lesion represented a mechanism similar to allergic fungal sinusitis.

Suction cup/contact lens complications following penetrating keratoplasty

PURPOSE

Rigid gas permeable (RGP) contact lenses facilitate visual rehabilitation in cases of high or irregular corneal astigmatism following penetrating keratoplasty. A variety of plunger-like suction cup devices are available to assist in the removal of these lenses.

METHODS

We report three patients with serious complications associated with the use of a suction cup device for contact lens removal following penetrating keratoplasty.

RESULTS

Two patients suffered corneal wound dehiscence following contact lens removal; one contact lens was removed by the patient's spouse and the other was removed by a trained technician. A third patient triggered a graft rejection, and ultimately, graft failure, after a vigorous attempt at lens removal.

CONCLUSIONS

Forces generated by suction cup devices during removal of RGP contact lenses are sufficient to cause significant trauma. Contact lenses with an apical clearance fit may augment these forces, with the potential for complications following penetrating keratoplasty.

Timolol gel versus acetazolamide in the prophylaxis of ocular hypertension after phacoemulsification

PURPOSE

To compare postoperative intraocular pressure (IOP) after administration of acetazolamide and timolol following phacoemulsification and intraocular lens implantation.

SETTING

Ophthalmic Consultants of Long Island, Rockville Centre, New York, USA.

METHODS

Sixty patients were included in a prospective, randomized, masked trial. The patients received either two doses of oral, sustained-release acetazolamide (Diamox Sequels) or a single dose of topical timolol 0.5% gel (Timoptic XE). Intraocular pressure was measured by Goldmann applanation tonometry preoperatively and 1 day postoperatively.

RESULTS

Mean preoperative IOP was 16.4 mm Hg. One day postoperatively, it was 19.5 mm Hg in the oral acetazolamide group and 15.9 mm Hg in the timolol gel group. One patient in the acetazolamide group developed significant adverse reactions.

CONCLUSION

Prophylactic use of topical timolol 0.5% gel for viscoelastic-induced ocular hypertension after cataract extraction appears to offer better IOP control than oral acetazolamide and has potentially fewer adverse systemic effects.

Topical cyclosporin A in the management of postkeratoplasty glaucoma

PURPOSE

To evaluate the effect of substituting topical cyclosporin A 0.5% for topical corticosteroids in patients with postkeratoplasty glaucoma.

METHODS

Topical cyclosporin A 0.5% was prospectively substituted for topical corticosteroids to treat 25 patients with postkeratoplasty glaucoma.

RESULTS

Twenty-one (84%) of 25 patients showed a reduction in intraocular pressure (IOP) (range, 1-22 mm Hg; mean, 8.7 mm Hg). Follow-up ranged from 3 to 12 months (mean, 5.8). Graft clarity was maintained in all patients, with one allograft rejection episode. Thirteen patients were able to discontinue one or more glaucoma medication(s).

CONCLUSION

Topical cyclosporin A 0.5% may be substituted for topical corticosteroids to aid in the management of postkeratoplasty patients with glaucoma. However, the resultant decrease in IOP may be associated with an increased risk for immune rejections.

Intracorneal, aqueous humor, and vitreous humor penetration of topical and oral ofloxacin

OBJECTIVES

To investigate the intracorneal, aqueous, and vitreous penetration of ofloxacin, and to assess the concentration of the drug after topical administration alone and after combined topical and oral administration.

METHODS

Twenty consecutive patients undergoing penetrating keratoplasty with vitrectomy for bullous keratopathy received 2 drops of 0.3% ofloxacin every 30 minutes starting 4 hours before surgery. Group A (10 patients) received topical therapy alone. Group B (10 patients) received an additional 3 doses of oral ofloxacin, 400 mg, every 12 hours starting 26 hours before surgery. Aqueous humor, vitreous humor, and corneal specimens were analyzed for ofloxacin levels.

RESULTS

For group A, the mean intracorneal ofloxacin level was 4.51 micrograms/mL (range, 0.58-8.77 micrograms/mL; 10 specimens), the mean aqueous humor level was 1.34 micrograms/mL (range, 0.07-4.98 micrograms/mL; 8 specimens), and the mean vitreous humor level was 0.37 micrograms/mL (range, 0.05-0.90 micrograms/mL; 8 specimens). For group B, the mean intracorneal ofloxacin level was 8.59 micrograms/mL (range, 1.18-23.24 micrograms/mL; 10 specimens), the mean aqueous humor level was 2.77 micrograms/mL (range, 0.25-5.80 micrograms/mL; 10 specimens), and the mean vitreous humor level was 2.55 micrograms/mL (range, 0.28-4.97 micrograms/mL; 9 specimens).

CONCLUSIONS

Topically applied ofloxacin achieves therapeutic levels in the cornea and aqueous. Mean levels achievable are well above the 90% minimal inhibitory concentration (MIC90) for the majority of bacteria responsible for endophthalmitis and corneal ulceration. The addition of oral ofloxacin to topical therapy increased vitreous penetration 7-fold in this assay trial.

Comparison of corneal sensation following photorefractive keratectomy and laser in situ keratomileusis

PURPOSE

To evaluate the effect of photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) on corneal sensation.

SETTING

Eye Institute, Medical School of the University of Crete, Heraklion, Greece, and Orasis, Hellenic Eye Center of Athens, Greece.

METHODS

In a masked study, corneal sensation was measured with the Cochet-Bonnet aesthesiometer in 40 consecutive patients 6 to 12 months following PRK and LASIK (60 mm constitutes normal reading and < 40 mm, abnormal).

RESULTS

After 6 to 12 months, the mean corneal sensation following PRK was 39.2 mm (range 30 to 55 mm) (mean 9.5 months) and after LASIK, 53.6 mm (range 40 to 60 mm) (mean 9.3 months). The mean correction attempted for PRK was 7.05 diopters (D) (range 2.5 to 12.0 D) and for LASIK, 11.71 D (range 6.0 to 20.0 D).

CONCLUSION

In this group of patients, with correction of primarily severe myopia, corneal sensation was significantly greater after LASIK than after PRK.

Comparison of topical timolol gel to oral acetazolamide in the prophylaxis of viscoelastic-induced ocular hypertension after penetrating keratoplasty

PURPOSE

Viscoelastic-induced ocular hypertension following penetrating keratoplasty (PK) may result in endothelial cell loss and optic nerve damage.

METHODS

In a prospective, randomized, masked trial, two doses of oral sustained-release acetazolamide were compared to a single dose of topical 0.5% timolol gel after 40 PKs.

RESULTS

The mean preoperative intraocular pressure (IOP) was 17.4 mm Hg for the oral acetazolamide group and 16.7 mm Hg for the timolol gel group. The mean IOP on the first postoperative day was 17.9 mm Hg with oral acetazolamide and 12.9 mm Hg with timolol gel. One patient developed significant adverse reactions with oral acetazolamide; there were no adverse reactions with timolol gel.

CONCLUSION

Prophylactic use of timolol gel for viscoelastic-induced ocular hypertension after PK appears to offer better IOP control than oral acetazolamide, with potentially fewer adverse systemic effects.

Ocular deviation following excimer laser photorefractive keratectomy

We present a case of ocular deviation and diplopia that developed 9 months after monocular excimer laser photorefractive keratectomy. In this case, decompensation occurred because of a breakdown of fusion at distance. We suggest a cover test to assess the presence of significant phorias in all candidates for refractive surgery procedures.

Infectious keratitis with corneal perforation associated with corneal hydrops and contact lens wear in keratoconus

BACKGROUND

Corneal perforation is an uncommon complication associated with keratoconus. The first cases of infectious keratitis and corneal perforation associated with corneal hydrops and contact lens wear are reported in two keratoconus patients.

METHODS

A retrospective chart review and histopathological examination were carried out.

RESULTS

Both patients progressed to corneal perforation and emergency penetrating keratoplasty. One patient cultured Fusarium and the second patient Serratia marcesens. Both patients wore contact lenses against medical advice.

CONCLUSIONS

The tear in Descement's membrane, stromal oedema, and epithelial bedewing associated with corneal hydrops results in loss of the epithelial-endothelial barrier of the cornea, creating a conduit for infectious organisms through the cornea. Acute hydrops associated with epithelial keratitis, stromal swelling, and a Descement's membrane tear may be a significant risk factor for infectious keratitis and corneal perforation. Contact lenses should not be worn during an active corneal hydrops owing to the increased risk for severe infectious keratitis and corneal perforation.

Visually debilitating pterygium: surgical and contact lens treatment

PURPOSE

We present the management of a patient with large pterygia complicated by irregular astigmatism and corneal opacities. Visual rehabilitation required both surgical excision and contact lens fitting.

METHODS

We examined a 30-year-old man with hand motion vision from a large pterygium overgrowing his right cornea. Histopathology was consistent with pterygium. During the first few postoperative weeks, his uncorrected visual acuity improved to 20/60, and manifest refraction yielded no further improvement. In the subsequent months, there were increasing anterior stromal corneal opacities, and the refraction became hyperopic to a variable degree.

RESULTS

Best corrected visual acuity was 20/70-20/100. Axial length was 22.64 +/- 0.07 mm. Computerized corneal topography 6 months postoperative was similar to the preoperative topography and revealed irregular and asymmetric astigmatism, with marked variation of the central corneal dioptric power. Slit lamp biomicroscopy suggested that the corneal opacities were responsible for the patient's decreased acuity; however, contact lens fitting provided 20/30 vision with a rigid gas permeable contact lens.

CONCLUSIONS

The improved vision with contact lens therapy strongly suggested that the irregular and asymmetric astigmatism were more visually significant than the corneal opacities.

Decreased corneal sensation as an initial feature of Acanthamoeba keratitis

BACKGROUND

Herpes simplex keratitis is the most common misdiagnosis in patients with Acanthamoeba keratitis, which is increasing in frequency and is associated with daily wear soft contact lenses. Both entities usually present as unilateral keratitis. The manifestations of superficial Acanthamoeba keratitis (i.e., unilaterality, dendriform appearance, positive response to antivirals, and decreased corneal sensation) increase the opportunity for misdiagnosis as herpes simplex keratitis. The authors have encountered six patients with Acanthamoeba keratitis in whom the correct diagnosis was delayed from 2 weeks to 3 months.

METHODS

All six patients underwent testing with the Cochet-Bonnet esthesiometer and extensive pharmacologic treatment for herpes simplex keratitis. Corneal scrapings were taken between 2 and 6 weeks after the initial examination.

RESULTS

In all six patients, corneal sensation was decreased significantly. Drug therapy was ineffective. Cultures were positive for Acanthamoeba. Five of six patients underwent penetrating keratoplasty.

CONCLUSIONS

Decreased corneal sensation has contributed to the misdiagnosis of Acanthamoeba as herpes simplex keratitis. Misdiagnosis results in delayed treatment and worse outcome. The authors found that significantly decreased corneal sensation is a frequent finding in early Acanthamoeba keratitis. Therefore, physicians should consider Acanthamoeba keratitis as an alternative diagnosis in patients with presumed herpes simplex keratitis with decreased corneal sensation.

Psoriatic corneal abscess

PURPOSE/METHODS

We examined a patient with psoriasis and stromal infiltrate that was treated with topical corticosteroids.

RESULTS/CONCLUSIONS

The patient gradually improved and the stromal infiltrate diminished. The cause of psoriasis and its ocular manifestations remains unknown. A corneal abscess without epithelial infiltration that responds to topical corticosteroid therapy may represent a specific ocular manifestation of psoriasis.

The National Basketball Association eye injury study

OBJECTIVE

To investigate the epidemiology of eye injuries sustained by professional basketball players in the National Basketball Association (NBA).

METHODS

A prospective study involving all NBA athletes who sustained eye injuries between February 1, 1992, and June 20, 1993, was conducted. Twenty-seven NBA team athletic trainers, physicians, and ophthalmologists were provided data forms to complete for any player examined for an eye injury. Practice and game exposures during the preseason, regular season, playoffs, and championships were included.

RESULTS

Of the 1092 injuries sustained by NBA players during the 17-month period, 59 (5.4%) involved the eye and adnexa. Eighteen (30.5%) of the injuries occurred while the player was in the act of rebounding, and 16 (27.1%) while the player was on offense. The most common diagnoses included 30 abrasions or lacerations to the eyelid (50.9%), 17 contusions (edema and/or ecchymosis) to the eyelid or periorbital region (28.8%), and seven corneal abrasions (11.9%). There were three orbital fractures (5.1%). Most injuries were caused by fingers (35.6%) or elbows (28.8%). Nine players (15.3%) missed subsequent games because of their injury. Fifty-seven players (96.6%) were not wearing protective eyewear at the time of injury.

CONCLUSIONS

The incidence of eye injuries in NBA players during the 17-month period was 1.44 per 1000 game exposures. Frequent physical contact in professional basketball players leaves them at great risk for sustaining eye injuries. To prevent these injuries, protective eyewear is recommended.

Controlled evaluation of a bandage contact lens and a topical nonsteroidal anti-inflammatory drug in treating traumatic corneal abrasions

BACKGROUND

Treating traumatic corneal abrasions is a common problem for the ophthalmologist. Traditional management has been the use of a pressure patch. Three different therapeutic modalities were evaluated for their efficacy in treating traumatic corneal abrasions.

METHODS

Forty-seven consecutive patients with traumatic corneal abrasions were randomized prospectively in a single-masked, controlled clinical trial which compared the efficacy of (1) pressure patching, (2) a bandage contact lens, and (3) a bandage contact lens with a topical nonsteroidal anti-inflammatory drug (0.5% ketorolac tromethamine).

RESULTS

There was no significant difference in the healing time of the three groups. However, psychometric analysis showed a significant decrease in pain in the group that received a bandage contact lens with a topical nonsteroidal anti-inflammatory drug. There was a significant difference in the ability to return to normal activities in both contact lens groups compared with the pressure-patch group. There was no significant difference among the three groups with respect to photophobia, redness, ocular irritation, headache, or tearing.

CONCLUSION

Use of a bandage contact lens significantly shortens the time required for a patient to return to normal activities. Moreover, addition of a nonsteroidal anti-inflammatory drug to a treatment regimen significantly decreases the pain associated with traumatic corneal abrasions. Use of a bandage contact lens with a topical nonsteroidal anti-inflammatory may prove to be an effective adjunct in treating traumatic corneal abrasions.

A novel antibiofilm technology for contact lens solutions

PURPOSE

Nonsteroidal anti-inflammatory drugs, including sodium salicylate, inhibit extracellular bacterial biofilm production. The authors studied the effect of the addition of sodium salicylate on bacterial adherence and biofilm formation on contact lenses and cases and commonly used medical polymers.

METHODS

The study was done in vitro with bacterial adherence and biofilm measured on lenses and cases that were exposed to saline contaminated with Staphylococcus epidermidis and Pseudomonas aeruginosa with and without 1 and 3 mm sodium salicylate. Bacterial adherence to contact lenses was quantitated by a vortex assay and by scanning electron microscopy. Biofilm formation on contact lens cases and other polymers was measured by an optical density assay and a radiolabeling assay.

RESULTS

Inhibition of biofilm formation was demonstrated on plastic contact lens cases in a dose-related manner with 1 and 3 mm sodium salicylate. A dose-related decrease in bacterial adherence also was noted. Assays with contact lenses also demonstrated less adherence in the presence of sodium salicylate. Electron micrographs of the contact lens showed less biofilm, most noticeable with 3 mm salicylate. Other studies demonstrated decreased adherence of S. epidermidis to polyethylene and polystyrene. Sodium salicylate also decreased biofilm on plastic tissue culture wells, but sorbic acid paradoxically increased deposition.

CONCLUSION

The authors found that the addition of low-dose sodium salicylate to saline decreased the adherence of S. epidermidis and P. aeruginosa to contact lenses and lens cases. Biofilm production also was decreased on the lens cases and on medical polymers used to make plastic cases. These studies suggest that sodium salicylate deserves additional study to determine its use in contact lens solutions.

Corneal Perforation in a Premature Infant

BACKGROUND

Few cases of corneal perforation in a premature infant have been described in the literature.

METHODS

Identical twins were born at 30-weeks gestation. One twin developed a corneal epithelial defect, infiltration, and perforation with extrusion of intraocular contents, requiring an emergency penetrating keratoplasty. The second twin developed a progressive corneal opacity, requiring a lamellar keratectomy.

RESULTS

After penetrating keratoplasty, the patient developed absolute glaucoma with buphthalmos, leading to enucleation. The twin's lamellar keratectomy specimen proved to be a dermoid.

CONCLUSIONS

One must be aware of the danger of the development of spontaneous corneal perforation with extrusion of intraocular contents in premature infants presenting at birth with an epithelial defect.

Penetration of topically applied ciprofloxacin, norfloxacin, and ofloxacin into the aqueous humor

PURPOSE

To determine the intraocular penetration of topically applied fluoroquinolone antibiotics into aqueous humor.

METHODS

Thirty-two patients undergoing cataract extraction received either 0.3% ciprofloxacin, 0.3% norfloxacin, or 0.3% ofloxacin topical drops. The patients were given two drops 90 minutes preoperatively and two drops 30 minutes preoperatively. At the time of surgery, 0.1 ml aqueous fluid was aspirated from the anterior chamber and immediately stored at -70 degrees C.

RESULTS

Concentrations of ciprofloxacin, norfloxacin, and ofloxacin were determined using a broth dilution bioassay. Morganella morganii with a known minimal inhibitory concentration was used to assay ciprofloxacin and norfloxacin levels. Salmonella enteritidis with a known minimal inhibitory concentration was used to assay ofloxacin levels. Topically applied ciprofloxacin achieved a mean aqueous level of 0.072 microgram/ml (range, 0.02-0.153 microgram/ml). One sample was below the sensitivity of the bioassay. Topical norfloxacin achieved a mean aqueous level of 0.0570 microgram/ml (range, 0.046-0.10 microgram/ml). Seven samples did not reach the sensitivity of the bioassay. Topical ofloxacin achieved a mean level in the aqueous humor of 0.338 microgram/ml (range, 0.078-0.625 microgram/ml). There was no statistically significant difference in intraocular aqueous humor levels of ciprofloxacin versus norfloxacin (P > 0.05). Topical ofloxacin achieved aqueous humor levels significantly higher than either ciprofloxacin or norfloxacin (P < 0.004).

CONCLUSION

Of the currently available topical fluoroquinolone antibiotics, ofloxacin achieves the highest aqueous humor concentrations.

Lid imbrication syndrome. Diagnosis with rose bengal staining

BACKGROUND

Lid imbrication syndrome is an abnormality of lid apposition in which the upper lid overlies the lower lid. Patients often complain of irritation, tearing, and foreign body sensation. The condition may be difficult to diagnose.

METHOD

Twenty-one patients with suspected lid imbrication syndrome were compared with 21 age-matched controls. All patients were given 0.5% topical rose bengal.

RESULTS

The diagnosis of lid imbrication syndrome was confirmed by the presence of rose bengal staining of the tarsal conjunctiva of the upper lid margin. The amount of rose bengal staining correlated with the severity of lid imbrication. Eighteen of 21 patients had received a diagnosis previously of dry eye syndrome. Four patients had persistent epithelial defects.

CONCLUSIONS

Rose bengal staining of the superior lid margin tarsal conjunctiva offers an extremely reliable aid for diagnosing lid imbrication syndrome. The condition commonly presents as a dry eye or persistent epithelial defect. Treatment ranges from viscous tear substitutes to horizontal lid shortening of the upper lid.

Progressive Schnyder's corneal dystrophy

BACKGROUND

Schnyder's crystalline dystrophy is a central anterior bilateral corneal dystrophy characterized by the deposition of crystals composed of cholesterol and other lipids. This condition classically is described as nonprogressive after childhood, but a series of recent studies following patients over time has challenged this teaching.

PATIENTS

The authors present a family pedigree including a patient first reported in 1954 and followed for 25 years with dramatic progression of the corneal condition in a dense, discoid pattern of crystals. Best-corrected visual acuity decreased from 20/30 to 20/80 in both eyes. This patient now has three children, all with typical corneal involvement.

RESULTS

Ocular pathologic examination performed on corneal biopsies submitted for light and electron microscopy demonstrated cholesterol deposition consistent with a diagnosis of Schnyder's.

CONCLUSION

Schnyder's corneal dystrophy may progress significantly over time. The characterization of this condition as stationary may need to be reconsidered.

Effect of doxycycline hyclate on corneal epithelial wound healing in the rabbit alkali-burn model. Preliminary observations

We examined the effects of doxycycline hyclate on epithelial healing in vivo in the rabbit alkali-burn model. Twelve 2-3-kg Dutch belted rabbits were divided into three groups and received standard bilateral alkali burns (1 N sodium hydroxide for 30 s in an 11-mm circular plastic well). In group 1, two rabbits (four eyes) served as untreated controls. In group 2, five rabbits (10 eyes) received doxycycline hyclate (1.5 mg/kg) orally daily for 14 days. In group 3, five rabbits (10 eyes) received doxycycline hyclate (5 mg/kg) orally daily for 14 days. The epithelial defects were drawn and photographed on alternate days, after fluorescein staining. At conclusion, extracts of the corneas were evaluated for collagenase activity. At 14 days, the mean percentage of epithelial defects results in groups 1-3 were 50.0, 50.7, and 7.1%, respectively. Using the Wilcoxon rank sum test (two tailed), the differences were found to be statistically significant (p = 0.0015). Preliminary data indicated that oral doxycycline administration also decreased the collagenase activity in corneas obtained from these animals. Our preliminary findings indicated that systematically administered doxycycline hyclate, 5 mg/kg/day, promotes corneal reepithelialization in the rabbit alkali-burn model, a result, perhaps, of the drug's ability to inhibit excessive collagenase activity.

Intraepithelial corneal immunoglobulin crystals in IgG-kappa multiple myeloma

A 52-year-old man was first examined because of bilateral superficial punctate keratitis. Slit-lamp examination disclosed numerous intraepithelial minute opacities in both corneas. A corneal biopsy revealed intraepithelial rhomboidal or rectangular crystals that immunohistochemically stained only for IgG-kappa. Serum immunoelectrophoresis demonstrated an IgG-kappa monoclonal gammopathy. Over the ensuing 6 years, the clinical appearance of the crystals changed from small dot-like opacities to polychromatic crystals. At this time, bone marrow examination established the diagnosis of multiple myeloma. Ophthalmologists should be aware of this entity and carefully monitor these patients; the corneal lesions may be the initial manifestation of an asymptomatic monoclonal gammopathy preceding the development of multiple myeloma.

Sterile endophthalmitis after sutureless cataract surgery

BACKGROUND

Sutureless cataract surgery has recently increased in popularity because of the rapid visual rehabilitation and the inherent reduction of surgically induced astigmatism.

METHODS

This procedure is dependent on a lamellar, multiplaned incision. As with new surgical techniques, associated complications become evident with time. Recently, there have been several cases of infectious endophthalmitis after this procedure. The authors report on nine cases of sterile endophthalmitis. In all nine cases, surgery was performed with refrigerated balanced salt solution (BSS) and 100 mg of cefazolin and/or 20 mg of methylprednisolone sodium succinate, given subconjunctivally, at its completion.

RESULTS

All nine cases occurred in a period of time during which 68 cases were performed using refrigerated BSS for irrigation. These nine cases came from two different surgeons using basically the same surgical technique. After the investigation of these complications, the refrigerated BSS was discontinued, and there have been no episodes of sterile endophthalmitis in the last 650 cases.

CONCLUSION

It appears that refrigerated BSS should be avoided if periocular injections are going to be used. It may be that the cold BSS fails to allow sufficient tissue swelling to seal the surgical incision, allowing for subconjunctival injections to seep into the wound, and leading to a sterile endophthalmitis.

Soemmering's ring support for posterior chamber intraocular lens implantation during penetrating keratoplasty. Changing trends in bullous keratopathy

BACKGROUND

Changing trends in cataract extractions have resulted in a new category of bullous keratopathy: corneal decompensation after complicated extracapsular cataract extraction. These cases of bullous keratopathy are associated with rupture of the posterior capsule, vitreous loss, and significant intraocular inflammation at the time of the original complicated extracapsular cataract extraction.

METHODS

The authors reviewed 14 consecutive cases of penetrating keratoplasty for bullous keratopathy in which posterior chamber intraocular lens implantation was supported by remnants of the posterior capsule and/or Soemmering's ring without suture fixation. All 14 patients had a history of complicated extracapsular cataract extraction with capsule rupture and vitreous loss.

RESULTS

All 14 patients had clear, compact grafts without migration of the intraocular lens with a mean follow-up of 12.1 months. Vision improved in 93% of cases, and there was no significant worsening of glaucoma.

CONCLUSIONS

Pseudophakic bullous keratopathy after traumatic extracapsular cataract extraction with an anterior chamber intraocular lens and aphakic bullous keratopathy after traumatic extracapsular cataract extraction are two relatively new clinical entities that present new intraocular lens management options. Bullous keratopathy after complicated extracapsular cataract extraction should be recognized as a distinct clinical entity. Intraocular lens implantation into the ciliary sulcus with Soemmering's ring and peripheral capsular support provide the advantages of a posterior chamber intraocular lens without the risk of iris or scleral sutures. The authors predict that bullous keratopathy associated with traumatic extracapsular cataract extraction will become one of the more common indications for penetrating keratoplasty.

Glued-on, rigid gas-permeable contact lens for severe radiation-induced keratitis

A 68-year-old woman with severe radiation-induced keratoconjunctivitis sicca became progressively unresponsive to conventional medical treatment. Her left eye deteriorated rapidly and required total tarsorrhaphy. In an attempt to stabilize the right eye and preserve some functional vision, we glued a high-Dk rigid, gas-permeable contact lens with tissue-grade cyanoacrylate adhesive to Bowman's membrane. This glued-on contact lens induced rapid and dramatic improvement of the patient's comfort and sight. Recent developments in high-permeability, rigid, contact-lens materials now make artificial replacement of the epithelium a potentially useful treatment for severe ocular surface disease when conventional treatment has failed.

Contact lens-related deep stromal intracorneal hemorrhage

Deep corneal neovascularization is a recently described complication of contact lens wear. Visual loss associated with deep corneal neovascularization has been associated with stromal lipid leakage. Deep intracorneal hemorrhage is rare and has been documented infrequently with the use of contact lenses. The authors present five cases of deep stromal hemorrhage associated with contact lens-related deep corneal neovascularization. These patients had no other discernible cause for their vascularization and subsequent hemorrhage. One patient required a penetrating keratoplasty for visual rehabilitation. Contact lenses of all types may cause neovascularization. The deep stromal neovascularization develops insidiously and may progress in the absence of acute symptoms. The presence of deep stromal neovascularization must be watched carefully and managed as a potentially vision-threatening complication of contact lens use.

Keratoconus associated with floppy eyelid syndrome

Floppy eyelid syndrome is a recently described entity, which characteristically involves overweight individuals. The characteristic findings are an upper lid that may be readily everted, tarsal laxity, and diffuse papillary conjunctival changes. The cause of floppy eyelid syndrome is believed to be a mechanical disorder due to the eversion of the lids while sleeping. The cause of keratoconus remains uncertain. There are strong proponents to a mechanical etiology for this disease. The authors report five cases of floppy eyelid syndrome with concomitant keratoconus. One patient with bilateral keratoconus had bilateral symmetric floppy eyelid syndrome. The other four patients had asymmetric keratoconus and floppy eyelid syndrome. In all four patients, the keratoconus was significantly worse in the eye with the more severe case of floppy eyelid syndrome. In addition, these four patients all gave a history of sleeping with their head facing predominantly on the side with the floppy eyelid syndrome and keratoconus. Two patients with keratoconus and floppy eyelid syndrome were able to undergo successful contact lens rehabilitation of their keratoconus after treatment of the floppy eyelid syndrome.

Cyanoacrylate temporary tarsorrhaphy in the management of corneal epithelial defects

Cyanoacrylate tarsorrhaphy is an easily administered, painless technique for the temporary management of corneal epithelial defects. We have used the technique in 17 patients to treat persistent epithelial defects and exposure keratitis, as well as following epikeratophakia, allowing the tarsorrhaphy to remain in place for 1 to 15 days (mean, 5.7 days). Eleven of the 17 patients required only one application of cyanoacrylate; five had additional cyanoacrylate applied at the time of the original tarsorrhaphy to produce more extensive lid closure; and one required additional cyanoacrylate on day 3 to produce more extensive lid apposition.

Symblepharon formation in epidemic keratoconjunctivitis

Two case reports are presented in which patients with epidemic keratoconjunctivitis (EKC) develop symblepharon during the course of their infection. This report is the initial documentation of symblepharon formation in EKC and the first reported episode of conjunctival membrane formation in association with adenovirus type 2.

Massive suprachoroidal hemorrhage in penetrating keratoplasty

We studied the frequency of massive suprachoroidal hemorrhage during and after penetrating keratoplasty. Nine cases of intraoperative or immediately postoperative massive suprachoroidal hemorrhage were identified in 830 consecutive patients (1.08%) undergoing penetrating keratoplasties at the Manhattan Eye, Ear, and Throat Hospital over a 2 1/2-year period. Six of the nine patients had atherosclerotic disease or hypertension, six of nine patients had glaucoma, and eight of nine patients had undergone previous intraocular surgery. Surgery was performed under general anesthesia in 714 patients, and four of these patients (0.56%) suffered hemorrhages. Five of 116 (4.3%) local anesthesia patients experienced expulsive choroidal hemorrhage. The increased resistance to venous outflow associated with retrobulbar anesthetic injection may significantly contribute to the risk of massive suprachoroidal hemorrhage.

Massive suprachoroidal hemorrhage in penetrating keratoplasty

We studied the frequency of massive suprachoroidal hemorrhage during and after penetrating keratoplasty. Nine cases of intraoperative or immediately postoperative massive suprachoroidal hemorrhage were identified in 830 consecutive patients (1.08%) undergoing penetrating keratoplasties at the Manhattan Eye, Ear, and Throat Hospital over a 2 1/2-year period. Six of the nine patients had atherosclerotic disease or hypertension, six of nine patients had glaucoma, and eight of nine patients had undergone previous intraocular surgery. Surgery was performed under general anesthesia in 714 patients, and four of these patients (0.56%) suffered hemorrhages. Five of 116 (4.3%) local anesthesia patients experienced expulsive choroidal hemorrhage. The increased resistance to venous outflow associated with retrobulbar anesthetic injection may significantly contribute to the risk of massive suprachoroidal hemorrhage.