The characteristics of Posner-Schlossman syndrome: A comparison in the surgical outcome between cytomegalovirus-positive and cytomegalovirus-negative patients

This retrospective observational study aims to report the clinical characteristics and surgical results in eyes with Posner-Schlossman syndrome (PSS), and compare these outcomes between cytomegalovirus (CMV)-positive and -negative eyes.We reviewed the medical records of 21 consecutive immunocompetent patients clinically diagnosed with PSS between the years 2010 and 2018. Aqueous humor was collected from all the affected eyes to detect if CMV was present, and polymerase chain reaction (PCR) was performed using the herpesvirus family primers.The average period between the initial PSS attack and aqueous humor sampling at our institute was 9.3 years. Out of the 21 patients, 62% were CMV-positive. Regardless of CMV status, the mean intraocular pressure (IOP), mean deviation (MD), and central corneal endothelium cell (CEC) density, at the initial examination at our institute were already significantly worse in the affected eyes than in the unaffected eyes (all P values < .05). The average visual acuity (VA) was only significantly worse in the CMV-positive group (P = .02). Out of all the patients, those that were CMV-positive had undergone more glaucoma surgeries (P = .056). Fourteen patients underwent either a trabeculectomy (TRAB) or a trabeculotomy (LOT), and their IOP significantly reduced following surgery (P < .001). In 85.7% of those that had surgery, their IOP was successfully lowered to less than 20 mm Hg.Long-lasting PSS causes a decrease in VA, MD, and the CEC density. A prompt diagnosis is required, and an appropriate treatment plan should be formulated. In those patients with PSS that develop uncontrolled glaucoma, both TRAB and LOT may be effective in controlling IOP.

Long-term outcomes of penetrating keratoplasty for corneal complications of herpes zoster ophthalmicus

BACKGROUND/AIM

To review the long-term outcomes of penetrating keratoplasty (PKP) for corneal complications of herpes zoster ophthalmicus (HZO).

METHODS

We reviewed the medical records of 53 eyes of 53 patients who underwent PKP due to corneal complications of HZO at the Kellogg Eye Center.

RESULTS

The mean age of patients at the time of PKP was 68.0±16.4 years, with a follow-up of 4.0±3.8 years and quiescent period of 6.5±5.3 years from active HZO to PKP. Preoperatively, 25 (47.2%) eyes were completely anaesthetic, while 16 (30.2%) had deep corneal neovascularisation in four quadrants. Comorbid ocular disease, including cataract, glaucoma and macular disease, was present in 25 (47.2%) eyes. Twenty patients (37.8%) received acyclovir for the entire postoperative period. There were no recurrences of zoster keratitis in any eye. The most common complications were difficulty healing the ocular surface (12/53, 22.6%) and glaucoma (14/53, 26.4%). Thirty per cent of the eyes required one or more additional postoperative procedures, most commonly tarsorrhaphy (10/53, 18.9%) and amniotic membrane graft (6/53, 11.3%). At 1, 2-4 and ≥5 years, 94%, 82% and 70% grafts remained clear, respectively. Visual acuity improved at 1 year postoperatively (p<0.0001), but this improvement was not sustained. There was no significant benefit of long-term acyclovir on visual acuity (p=0.2132) or graft survival (p=0.241).

CONCLUSIONS

Even in eyes with significant preoperative risk factors, PKP for the corneal complications of HZO can achieve favourable tectonic and visual results. Although most grafts remained clear, long-term visual potential may be limited by comorbid ocular diseases. Prophylactic postoperative oral acyclovir did not improve outcomes.

[Limbal transplantation: multicenter retrospective case series analysis]

PURPOSE

To report the results of limbal transplantation (LT) in patients with limbal stem cell deficiency (LSCD) in the context of ocular surface diseases.

MATERIALS AND METHODS

A multicenter (5 centers) retrospective case series analysis of patients who underwent LT between 1996 and 2004 was performed. Data were collected by the same researcher using a customized database. Success was defined by the absence of a persistent corneal epithelial defect, on-going inflammation or recurrence of a pterygium.

RESULTS

Data from 72 LT performed in 61 patients (65 eyes) with a mean follow-up of 20.8 months (SD 23.5; range, 3-115) were analyzed. There were 33 males and 28 females with a mean age of 55.8 years (SD: 15.6; range, 20-89). Fifty-eight (80.6%) LT were autografts (40 pterygia, 12 alkali burns, 3 iatrogenic cases, 2 viral infections, 1 neoplasia case) and 14 (19.4%) were allografts from cadaveric donors (7 immune-based disorders, 6 alkali burns, 1 iatrogenic case); all patients receiving allografts also received systemic immunosuppression. Of the total number of LT, 48 (66.7%) were successful. This proportion increased to 81.0% (47/58) when autografts were used. However, only 7.1% (1/14) of all allografts were successful. The success rate was higher (80.0%) when performed for a pterygium and lower when done for immune-based inflammation (14.3%).

CONCLUSION

Autograft tissue for LT is always preferable to allografts to surgically treat LSCD, as clinical success is significantly higher, and systemic immunosuppression is avoided. As expected, immune-based disorders are the most difficult cases to treat. LT has been shown to be an excellent option for recurrent pterygium, although prospective studies need to be performed to further corroborate these results.

[Relationship between rubella virus and Fuchs heterochromic uveitis; 2 patients]

Two otherwise healthy men, aged 26 and 29 years, were diagnosed with Fuchs heterochromic uveitis (FHU) on the basis of the presence of iris heterochromia or iris atrophy, stellate corneal precipitates, and/or cataract. Microbiological investigation of aqueous humour demonstrated intraocular antibody production against rubella virus, but not against Toxoplasma gondii, herpes simplex virus or varicella zoster virus. Microbial nucleic acid detection was negative for all pathogens. Some time later, both patients underwent cataract surgery, which improved their vision considerably. FHU is a chronic, generally unilateral iridocyclitis, accompanied by the above-mentioned ophthalmologic manifestations in the absence of systemic disease. Little is known about the pathogenesis ofFHU, but recent publications have provided evidence for the possible involvement of the rubella virus.

Molluscum contagiosum in a patient with no risk factors

PURPOSE

To report a case of molluscum contagiosum in a patient with no risk factors.

METHODS

A 38-year-old patient with a tumor located in the lower eyelid that appeared 5 months previously was seen in the authors' hospital. The lesion had grown slowly and appeared as a crateriform mass with elevated edges. It was surgically excised and the histopathology study confirmed the diagnosis of molluscum contagiosum. Risk factors were absent.

RESULTS

The histopathologic study confirms the presence of eosinophilic inclusion bodies in the keratinocytes cytoplasm.

CONCLUSIONS

External evaluation of the lower lid lesion did not show the morphologic configuration of a molluscum contagiosum. A virus can be suspected if attention is paid to the margin of the eyelid and the patient's age.

Penetrating Keratoplasty for Perforated Corneal Ulcers

PURPOSE

This study was designed to study an alternative technique of lamellar separation of corneal layers for therapeutic keratoplasty in place of an en bloc removal of host corneal button in eyes with perforated corneal ulcers with pseudocornea.

METHODS

Twelve eyes with perforated corneal ulcers with pseudocornea in which therapeutic keratoplasty was planned were included in the study. A new technique was used in which the host corneal tissue was removed in layers by lamellar dissection started peripherally and proceeding centripetally with care taken to prevent perforation at the site of iris incarceration. After injection of viscoelastic into the anterior chamber with a 26-gauge needle entered tangentially, the deeper layer of the cornea was then gently dissected and peeled away from the iris tissue, with care not to avulse the fragile iris and the overlying fibrotic membrane. Adjunctive procedures were performed, and the donor tissue was secured over the host bed.

RESULTS

A complete separation of the iris tissue from corneal button and the fibrous membrane was achieved in 9 eyes. In 3 eyes, iris was partly trimmed along with the fibrous membrane, because the membrane was totally adherent to the iris tissue. Eight patients required pupilloplasty. Apart from minimal bleeding, no other complication was encountered. At the end of 3 months, 9 of 12 grafts remained clear.

CONCLUSIONS

Debulking and layer-by-layer removal of host corneal tissue is effective in preservation of iris while performing therapeutic keratoplasty in eyes with perforated corneal ulcers with pseudocornea.

Autologous cultivated conjunctival transplantation for recurrent viral papillomata

PURPOSE

To describe the use of an autologous serum-free derived cultivated conjunctival epithelial equivalent in the treatment of extensive recurrent viral papillomata.

DESIGN

Interventional case report.

METHODS

A 10-year-old child with extensive recurrent viral papillomata involving the superior and inferior tarsal, forniceal, and bulbar conjunctiva underwent surgical excision of all diseased areas and double freeze-thaw cryotherapy. Autologous serum-free cultivated conjunctival equivalents were used to reconstruct the ocular surface and conjunctival fornices.

RESULTS

Almost complete epithelialization was achieved within 5 days postoperatively. A good cosmetic and functional result was obtained, and no recurrences or cicatricial complications developed during 12-month follow-up.

CONCLUSION

Transplantation of autologous cultivated conjunctiva was effectively used in the reconstruction of the ocular surface after extensive excision of recurrent viral papillomata. This modality of treatment may be useful in the treatment of ocular surface disorders in which extensive conjunctival and fornix reconstruction is required.

Multiple bilateral eyelid molluscum contagiosum lesions associated with TNFalpha-antibody and methotrexate therapy

PURPOSE

To demonstrate a patient developing multiple bilateral eyelid molluscum contagiosum lesions after initiation of TNFalpha-antibody therapy for rheumatoid arthritis.

DESIGN

Single interventional case report.

METHODS

Clinical, histopathologic, and immunologic-serological findings are presented.

RESULTS

A 67-year-old patient with a 5-year history of rheumatoid arthritis had been treated with prednisone and methotrexate for the last 5 years. After initiation of additional TNFalpha-antibody treatment, complaints from rheumatoid arthritis subsided, but multiple bilateral molluscum contagiosum lesions of upper and lower eyelids occurred despite normal or only slightly reduced CD(4) (420-178/ microl) and CD(8) counts (143-58/microl). Histopathologic evaluation of the excised warts confirmed the clinical diagnosis. Under continued therapy, the warts have been recurring for 12 months.

CONCLUSION

TNFalpha-antibody treatment for rheumatoid arthritis may compromise the host response to molluscum contagiosum, especially if methotrexate is given additionally. Patients should be informed about this potential complication.

Herpes simplex virus type 2 as a cause of acute retinal necrosis syndrome in young patients

PURPOSE

To determine the causative virus in acute retinal necrosis (ARN) syndrome in a series of patients by calculation of modified Witmer coefficients.

DESIGN

Noncomparative case series.

PARTICIPANTS

Ten patients with ARN syndrome from four medical centers.

METHODS

Aqueous samples, vitreous samples, or both were collected prospectively during surgery from patients with a clinical diagnosis of ARN syndrome. Serologic measures of intraocular and serum antibodies to potentially causative viruses were measured by enzyme-linked immunosorbent assay.

MAIN OUTCOME MEASURES

Modified Witmer coefficients (immunoglobulin G and immunoglobulin A) for herpes simplex virus types 1 (HSV-1) and 2 (HSV-2), varicella zoster virus (VZV), and cytomegalovirus (CMV), as well as adenovirus type 2, were calculated from aqueous or vitreous samples, or both.

RESULTS

Intraocular antibody measurements were strongly suggestive of a single diagnosis in 9 of 10 patients tested. Modified Witmer coefficients demonstrated intraocular antibody production to HSV in five patients and antibodies to VZV in four patients, and the measurement was inconclusive in one patient. No patients were positive for adenovirus or CMV. Strain-specific antibody titers demonstrated that all HSV-positive patients were reactive only to HSV-2. Herpes simplex virus type 2 was found predominantly in younger patients with ARN syndrome (mean age, 21.2 +/- 10 years; range, 17-39 years), whereas VZV was more commonly seen in older patients (mean age, 40.8 +/- 12.2 years; range, 29-58 years; P = 0.033). Immunoglobulin A testing confirmed immunoglobulin G testing in all patients examined.

CONCLUSIONS

Although VZV is thought to be the most common cause of ARN syndrome, HSV-2 is an important cause of ARN syndrome, particularly in younger patients. Because infection with HSV-2 has important medical ramifications, these results suggest that determination of a causal agent should be considered in some cases of ARN syndrome.

Photorefractive keratectomy for myopia in the setting of adenoviral subepithelial infiltrates

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Epibulbar molluscum contagiosum

PURPOSE

To report a case of epibulbar conjunctival nodules from molluscum contagiosum in a patient with atopic dermatitis.

METHODS

A 39-year-old man with atopic dermatitis who was treated with oral prednisone was initially examined with ocular itching, foreign body sensation, and conjunctival injection of the right eye and was found to have three discrete conjunctival nodules. Excision of the nodules led to complete resolution of the signs and symptoms.

RESULT

Histopathologic examination of the conjunctival specimen disclosed molluscum contagiosum.

CONCLUSION

Patients with defective or suppressed cell-mediated immunity are at increased risk of unusual ocular involvement with molluscum contagiosum.

The conjunctival wart: report of a case and review of treatment options

Human papillomavirus, a papovavirus, is the causative agent of all warts. There are at least 63 subtypes of this virus, certain ones of which are more likely to cause warts in particular locations or to be associated with malignancies. Over the last 6 years, HPV-6, HPV-11, and HPV-16 have been detected in both benign and malignant lesions of the conjunctiva. We report a patient with a large viral papilloma of the palpebral conjunctiva of the right lower eyelid. This case demonstrates that even very large viral papillomas can be treated successfully.

[Thirty year experience in cryotherapy of viral ulcerations of cornea]

After the discussion of the advantages of the low temperature application in viral ulcerations of cornea, the results of the cryotherapy in 1200 patients are presented. The average period of treatment of the viral ulcerations, with no involvement of corneal stroma, was 2.9 days, whereas with the involvement 9.2 days. The recurrent viral ulceration was observed in 6.2% of the patients but the re-application of the cryotherapy always resulted in recovery.