Mycobacterium chelonae keratitis:Resolution after debridement and presoaked collagen shields

We report a case of Mycobacterium chelonae keratitis following corneal injury by a foreign body. Diagnosis was made by Ziehl-Neelsen staining and Lowenstein-Jensen culture of corneal scrapings. On the basis of the in vitro susceptibility testing, the patient was treated with topical fortified amikacin. Given the lack of response to this therapy, we decided to carry out a debridement of the infiltrative areas to eliminate infected tissue, and to use an amikacin-soaked collagen shield supplemented every 4 h with topical fortified amikacin to promote healing of the debrided area and to potentiate the effects of the antibiotic therapy. After this treatment, clinical resolution was observed and a further acid-fast stain and culture for mycobacterium were negative. Debridement of the infiltrative areas could be used in cases of mycobacterium keratitis when early diagnosis is made and before the corneal infection has become widespread.

A new model of posterior capsule opacification in rodents

PURPOSE. To describe a new model of posterior capsule opacification (PCO) in rodents METHODS. An extracapsular lens extraction (ECLE), by continuous curvilinear capsulorrhexis and hydrodissection, was performed in 42 consecutive Brown Norway rats. Animals were killed at 0, 6, and 24 hours and 3, 7, and 14 days after surgery. Eyes were enucleated and processed for light microscopy and immunohistochemistry. RESULTS. In 34 (81%) of the animals the operated eye appeared well healed before death, with a clear cornea and a well-formed anterior chamber. In eight (19%) there was no view of anterior segment structures because of hyphema, fibrin, or corneal opacification. PCO was clinically evident 3 days after ECLE and was present in all animals at 2 weeks. Immediately after ECLE, lens epithelial cells (LECs) were present in the inner surface of the anterior capsule and lens bow. Twenty-four hours after surgery, LECs started to migrate toward the center of the posterior capsule. At 3 days, multilayered LECs, some spindle shaped, were present throughout the lens capsule. Capsular wrinkling was apparent. Lens fibers and Soemmering's ring were observed in all animals 14 days after surgery, indicating some degree of cellular differentiation. Activated macrophages were present in greater numbers at 3 and 14 days after surgery (P <0.05), when proliferation and migration of LECs appeared to be greatest, and lens fiber differentiation was evident, respectively. CONCLUSIONS. In rodents PCO occurs after ECLE and is associated with low-grade inflammation, mostly of mononuclear macrophages. Although no intraocular lens implantation was performed, this model appears to be valuable for studying the sequence of events that leads to PCO after cataract surgery and the extracellular matrix cues that promote lens fiber differentiation.

Long-term graft survival in patients with flexible open-loop anterior- chamber intraocular lenses

Purpose. To evaluate the long-term graft survival and complications of flexible, open-loop anterior-chamber intraocular lenses in patients with penetrating keratoplasty for pseudophakic or aphakic bullous keratopathy. Methods. We reviewed charts of all consecutive patients who underwent penetrating keratoplasty for pseudophakic or aphakic bullous keratopathy combined with implantation of a flexible, open-loop, anterior-chamber intraocular lens at our institution between 1983 and 1988. One-hundred one eyes of 99 patients were evaluated. Graft-survival rates were calculated by using the Kaplan-Meier actuarial method. Results. Mean follow-up was 49.8 months (range. 1-144). The probability of graft survival at 1, 2, 4, 6, and 8 years was 93, 87, 78, 65, and 65%, respectively. A total of 25 (24.8%) grafts failed. Progressive corneal edema without signs of rejection was the most common finding in patients with failed grafts (10 eyes, 40%). The most frequent complication observed was newly diagnosed or worsening of preexisting glaucoma (46 eyes, 45.5%). Conclusions. Our long-term results support flexible, open-loop anterior-chamber intraocular lenses as a reasonable option, at the time of penetrating keratoplasty, in patients with pseudophakic and aphakic bullous keratopathy.

Indications for penetrating keratoplasty and associated procedures, 1989-1995

Purpose. To identify changing trends in indications for penetrating keratoplasty and associated surgical procedures. Methods. Review of charts from all patients who underwent penetrating keratoplasty at Wills Eye Hospital from January 1, 1989 through December 31, 1995. Results. A total of 2,442 corneal transplants were performed in 2,186 patients. The leading indication for penetrating keratoplasty was pseudophakic corneal edema, accounting for 634 cases (26.0%); 54.7% of them were associated with anterior chamber intraocular lenses, 36.4% with posterior chamber intraocular lenses, and 3.1% with iris-fixated intraocular lenses. Regraft (17.8%), Fuchs' dystrophy (15.7%), and keratoconus (13.2%) followed pseudophakic corneal edema in frequency. Cataract extraction, with or without intraocular lens implantation, was combined with penetrating keratoplasty in 439 cases of 1,264 phakic eyes (34.7%). Intraocular lens exchange was performed in 285 of the 634 cases of pseudophakic cornea edema (44.9%). Conclusion. Pseudophakic corneal edema was the leading indication for penetrating keratoplasty, with an increasing number of cases associated with posterior chamber intraocular lenses during the study period (p = 0.001). The number of regrafts steadily increased between 1989 and 1995 (p = 0.001), being the second most common indication for corneal transplantation since 1992.

Diabetic-like loss of corneal sensitivity in the 50% galactose fed rat is ameliorated with topical administration of an aldose reductase inhibitor

Purpose: To investigate the temporal course of corneal sensitivity loss & the role of aldose reductase inhibitors (ARI) in an animal model of diabetic ocular complications. Methods: Weanling male S-D rats were randomly grouped to received ad libitum water & diet consisting of Purina (#5001) w/ either: 50% starch (CON,n=15) or 50% D-galactose (GAL,n=30). Half the galactosemic rats (ARI,n=15) received topical 0.25% CT-112 (3x daily, 20µl, Senju Pharmaceutical Co., Japan). Control & remaining half of the galactosemic animals received equivalent doses of saline eyedrops. Rats were restrained w/o medication during sensitivity measurements conducted w/ a Cochet-Bonnet Aesthesiometer mounted on a micromanipulator. The end of the filament (0.012mm dia.), which applied a mean pressure of 0.96 g/mm perpendicular to the corneal surface at center, was in the plane of focus of a slit-lamp biomicroscope. Measurements were conducted by two investigators which were masked to the treatment group. The average blink-responses from 10 consecutive stimuli to each cornea were expressed as a percent. Results: Mean (±SD) baseline corneal sensitivity in all groups were similar (CON 73%±11, GAL 71%±15, ARI 74%±16). Corneal sensitivity in the galactosemic rat was decreased (p

Transcameral suture to prevent tube-corneal touch after glaucoma drainage device implantation: a new surgical technique

PURPOSE: To report a new technique to correct tube position in anterior chamber after glaucoma drainage device implantation.

PATIENT AND METHODS: A patient who underwent a glaucoma drainage device implantation was noted to have the tube touching the corneal endothelium. A 10/0 polypropylene suture with double-armed 3-inch long straight needle was placed transcamerally from limbus to limbus, in the superior part of the eye, passing the needle in front of the tube.

RESULTS: The position of the tube in the anterior chamber was corrected with optimal distance from corneal endothelium and iris surface. The position remained satisfactory after 20 months of follow-up.

CONCLUSIONS: The placement of a transcameral suture offers a safe, quick, and minimal invasive intervention for the correction of the position of a glaucoma drainage device tube in the anterior chamber.

Non-Acanthamoeba amebic keratitis

Purpose. To describe the clinical presentation and outcome of two cases with presumed non-Acanthamoeba amebic keratitis. Methods. Case reports. Results. Both patients presented with typical symptoms and signs of Acanthamoeba keratitis. The patients' soft contact lenses, lens cases, open solutions, and conjunctival samples were cultured. Diagnosis of non- Acanthamoeba amebic keratitis was based on the presence of keratitis and amebic growth from patients' contact lenses of the affected eyes. Amebic culture from the contralateral contact lens was negative. Vahlkampfia cysts were identified in case 1, and Naegleria cysts in case 2. Topical treatment with polyhexamethylene biguanide and propamidine resolved the keratitis in case 1. Case 2 was lost to follow-up. Conclusion. Non-Acanthamoeba amebic keratitis was diagnosed in two patients based on the clinical presentation (resembling Acanthamoeba keratitis), culture of the contact lens, and response to antiamebic treatment (in one case). Keratitis associated with Naegleria contamination of contact lenses has not been previously reported.

Limbal stem cell deficiency:Concept, aetiology, clinical presentation, diagnosis and management

Defects in renewal and repair of ocular surface as a result of limbal stem cell deficiency are now known to cause varying ocular, surface morbidity including persistent photophobia, repeated and persistent surface breakdown and overt conjunctivalisation of the cornea. Ocular conditions with abnormalities of ocular surface repair include pterygium, limbal tumours, aniridia, severe scarring following burns, cicatricial pemphigoid and Stevens-Johnson Syndrome, sequelae of mustard gas exposure and Herpes simplex epithelial disease, radiation keratopathy, contact lens induced keratopathy, neuroparalytic keratitis and drug toxicity. Restoring ocular health in these eyes has traditionally been frustrating. An understanding of these intricate cell renewal and maintenance processes has spurred the evolution in recent years of new treatment methods for several blinding diseases of the anterior segment; many more exciting modalities are in the offing. However, there is inadequate awareness among ophthalmologists about the current principles of management of ocular surface disorders. The purpose of this article is to help elucidate the important principles and current treatment methods relevant to ocular surface disorders.

Malignant glaucoma after diode laser cyclophotocoagulation

PURPOSE: To report a case of malignant glaucoma after diode laser cyclophotocoagulation. METHOD: Case report. RESULTS: A 45-year-old man with uncontrolled secondary glaucoma in his right eye after corneoscleral graft and cataract extraction underwent diode laser cyclophotocoagulation. The right eye was aphakic, with an intact posterior capsule. Two weeks later, the patient presented with blurred vision, edematous cornea, and flat anterior chamber. The posterior capsule was touching the endothelium. Intraocular pressure was 20 mm Hg. Repeated Nd:YAG laser capsulotomy was effective in reversing the malignant glaucoma attack, and the anterior chamber deepened. CONCLUSION: Malignant glaucoma can occur after diode laser cyclophotocoagulation.

The quality of reporting of diagnostic accuracy studies published in ophthalmic journals

Aim: To evaluate the quality of reporting of all diagnostic studies published in five major ophthalmic journals in the year 2002 using the Standards for Reporting of Diagnostic Accuracy (STARD) initiative parameters. Methods: Manual searching was used to identify diagnostic studies published in 2002 in five leading ophthalmic journals, the American Journal of Ophthalmology (AJO), Archives of Ophthalmology (Archives), British Journal of Ophthalmology (BJO), Investigative Ophthalmology and Visual Science (IOVS), and Ophthalmology. The STARD checklist of 25 items and flow chart was used to evaluate the quality of each publication. Results: A total of 16 publications were included (AJO = 5, Archives = 1, BJO = 2, IOVS = 2, and Ophthalmology = 6). More than half of the studies (n = 9) were related to glaucoma diagnosis. Other specialties included retina (n = 4) cornea (n = 2), and neuro-ophthalmology (n = 1). The most common description of diagnostic accuracy was sensitivity and specificity values, published in 13 articles. The number of fully reported items in evaluated studies ranged from eight to 19. Seven studies reported more than 50% of the STARD items. Conclusions: The current standards of reporting of diagnostic accuracy tests are highly variable. The STARD initiative may be a useful tool for appraising the strengths and weaknesses of diagnostic accuracy studies.

Allo-limbal transplantation in patients with limbal stem cell deficiency

Aim - To report the outcome of a series of patients with stem cell deficiency who underwent allo-limbal transplantation and to describe a technique for this procedure. Methods - Six consecutive patients underwent allo-limbal stem cell transplantation. The primary diagnosis included alkali burn (n = 2), trachoma (n = 1), chronic rosacea blepharitis and keratoconjunctivitis (n = 1), aniridia (n = 1), and Stevens-Johnson syndrome (n = 1). The limbal rim consisted of peripheral cornea and perilimbal sclera, FK-506 was used postoperatively for immunosuppression. Results - The length of follow up ranged from 3 to 24 months (mean follow up 11.8 (SD 9.3) months). The outcome was considered satisfactory in five of six cases. The corneal surface was completely epithelialised within 2 weeks, and there was a substantial improvement in vision and symptoms. One patient had recurrent epithelial defects related to eyelid abnormalities. No side effects associated with systemic immunosuppression were noted. Conclusion - Allo-limbal transplantation, with systemic immunosuppression with FK-506 is useful in reconstruction of the ocular surface with improvement in vision in patients with severe stem cell deficiency.

Corneal toxicity and inflammation secondary to retained perfluorodecalin

PURPOSE: To describe a case with bullous keratopathy and anterior segment inflammation associated with heavy liquids. DESIGN: Observational case report. METHODS: Review of clinical and histopathologic changes. RESULTS: A 65-year-old patient underwent a pars plana vitrectomy for a rhegmatogenous retinal detachment. Perfluorodecalin was used as a temporary retinal tamponade. After surgery, bubbles of heavy liquid were noted in the anterior chamber. Fifteen months later, severe corneal edema developed, associated with corneal vascularization and keratic precipitates. Removal of heavy liquid through a paracentesis was attempted but the cornea remained edematous, and a penetrating keratoplasty was performed. In the histopathologic examination inflammatory changes from retention of perfluorodecalin were observed. There was a decompensated cornea with florid bullous keratopathy, inflammatory infiltration with vascularization, and deposition of perfluorodecalin within keratocytes and perivascular macrophages. CONCLUSION: Presence of heavy liquids in the anterior chamber may be associated with an intense inflammatory response and corneal decompensation. © 2005 by Elsevier Inc. All rights reserved.

Pseudo-endothelial dystrophy associated with emulsified silicone oil

Purpose. To describe endothelial changes associated with emulsified silicone oil. Methods. Report of a case. Results. A 77-year-old man had multiple and diffuse clear vesicles on the endothelium of his left eye (LE). The cornea was clear and thin. He had undergone pars plana vitrectomy and intraocular silicone oil injection 5 years before presentation. Specular microscopy revealed numerous small bubbles of emulsified silicone oil and a mild degree of endothelial damage. Conclusion. Emulsified silicone oil can adhere to the endothelium and induce an apparent droplet-like endotheliopathy.

Amniotic membrane transplantation for ocular surface reconstruction

Aims - To evaluate the efficacy of amniotic membrane transplantation (AMT) for ocular surface reconstruction. Methods - 10 consecutive patients who underwent AMT were included. The indications were: group A, cases with persistent epithelial defect after corneal abscess (n = 1), radiation (n = 1), or chemical burn (n = 3); group B, cases with epithelial defect and severe stromal thinning and impending or recent perforation, due to chemical burn (two patients, three eyes) or corneal abscess (n = 2); group C, to promote corneal epithelium healing and prevent scarring after symblepharon surgery with extensive corneo-conjunctival adhesion (n = 1). Under sterile conditions amniotic membrane was prepared from a fresh placenta of a seronegative pregnant woman and stored at -70°C. This technique involved the use of amniotic membrane to cover the entire cornea and perilimbal area in groups A and B, and the epithelial defect only in group C. Results - The cornea healed satisfactorily in four of five patients in group A, but the epithelial defect recurred in one of these patients. After AMT three patients underwent limbal transplantation and one penetrating keratoplasty and cataract extraction. In group B amniotic membrane transplantation was not helpful, and all cases underwent an urgent tectonic corneal graft. Surgery successfully released the symblepharon, promoted epithelialisation and prevented adhesions in the case of group C. Conclusion - AMT was effective to promote corneal healing in patients with persistent epithelial defect, and appeared to be helpful after surgery to release corneo-conjunctival adhesion. Most surgery for further surface rehabilitation. Amniotic membrane used as a patch was not effective to prevent tectonic corneal graft in cases with severe stromal thinning and impending or recent perforation.