Amilia Schrier

Regression of presumed primary conjunctival and corneal intraepithelial neoplasia with topical interferon alpha-2b.

Purpose. To evaluate topical interferon alpha-2b (IFN&agr;2b) as a lone therapy in the treatment of primary conjunctival and corneal intraepithelial neoplasia (CIN). Methods. Noncomparative, prospective, interventional case series. Seven patients from three institutions, treated between February and October 1999, with presumed primary CIN lesions (clinically diagnosed by corneal specialists) were given topical IFN&agr;2b drops (1 million units/mL) four to six times daily. Follow-up was performed biweekly until there was complete clinical resolution of the presumed CIN lesions. Patients were to continue topical IFN&agr;2b drops for 1 month after clinical resolution. Patient charts and clinical photographs were reviewed, and data were analyzed. Results. All seven eyes had complete resolution of the presumed CIN lesions after an average of 77.0 ± 59.2 days (range, 28–188 days). Average posttreatment follow up was 12.4 ± 2.5 months (range, 9–16 months). No patients were lost to follow-up. No recurrences have yet been seen. Side effects of treatment were limited to mild conjunctival hyperemia and follicular conjunctivitis in four (57.1%) eyes. In all cases, there was total resolution of conjunctival hyperemia and follicular changes within 1 month after cessation of the medication, without additional treatment. Conclusions. Topical IFN&agr;2b alone may be an effective treatment of primary CIN. It appears to be a safe alternative to radiation, intralesional IFN&agr;2b injection, and surgical excision with cryotherapy. Larger population studies with longer follow-up are recommended to better assess the risk of recurrence and other possible adverse effects.

Photoactivated riboflavin treatment of infectious keratitis using collagen cross-linking technology.

PURPOSEnTo evaluate riboflavin/ultraviolet-A (UVA) as an adjunct treatment for infectious keratitis.nnnMETHODSnThis prospective, dual-center, interventional case series included cases of infectious keratitis that were treated by instilling riboflavin 0.1% solution for 30 minutes to saturate the cornea, followed by exposure to 365-nm UVA light (3 mW/cm(2)) for 15 to 45 minutes, with continued instillation of riboflavin. Eyes continued on standard antibiotic treatment. The primary outcome measures were the times to resolution of the infiltrate and the epithelial defect.nnnRESULTSnForty patients aged 14 to 86 years were enrolled. Seven (18%) eyes had a previous keratoplasty. Bacterial species were identified in 24 eyes, fungal in 7, protozoan in 2, viral in 1, and no organism in 6. The maximum infiltrate diameter ranged from 1 to 12 mm and the epithelial defect diameter was 0 to 8 mm before treatment. In 6 cases (2 bacterial, 3 fungal, and 1 without growth), the keratitis did not resolve successfully and the eye received a penetrating keratoplasty (PK). In 1 eye with prior PK, the infection resolved following treatment, but a regraft was required to address perforation of the PK incision.nnnCONCLUSIONSnRiboflavin/UVA should be avoided in eyes with prior herpes simplex but otherwise posed no obvious safety risk in this series and appeared to be most effective when the infection depth was limited. The success rate was higher for bacterial infections than fungal infections. Randomized studies against antibiotics alone are needed to further evaluate efficacy.

In vitro antimicrobial efficacy of riboflavin and ultraviolet light on Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, and Pseudomonas aeruginosa.

PURPOSEnUltraviolet (UV) light and riboflavin has been developed as a collagen cross-linking treatment for corneal ectasia. This treatment has also been used to treat infectious corneal ulcers with apparent favorable results. In this experiment, the antibacterial action of riboflavin alone, UV light alone, and the combination of riboflavin and UV light was tested on Staphylococcus aureus, methicillin-resistant S aureus (MRSA), and Pseudomonas aeruginosa.nnnMETHODSnThirty agar plates with S aureus overlays were used. Ten plates were exposed to riboflavin (0.1% solution in dextran) alone, 10 plates were exposed to UV light (365 nm) alone, and 10 plates were exposed to a combination of riboflavin and UV light. Fifteen agar plates with MRSA and 15 plates with P aeruginosa were tested. Five plates of each group were exposed to riboflavin, 5 plates of each group were exposed to UV light alone, and 5 plates of each group were exposed to a combination of riboflavin and UV light. All plates were incubated for 24 hours and then analyzed.nnnRESULTSnAll plates exposed to riboflavin alone showed no bacterial death. All S aureus and MRSA plates exposed to UV light alone showed no bacterial growth. Three of five P aeruginosa plates exposed to UV light alone showed no bacterial death; two of five P aeruginosa plates exposed to UV light alone showed minimal inhibition. All plates exposed to the combination of riboflavin and UV light showed bacterial death.nnnCONCLUSIONSnRiboflavin in combination with UV light is an effective modality to eradicate the bacteria S aureus, MRSA, and P aeruginosa.

Lid imbrication syndrome : diagnosis with rose bengal staining

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

Can Intraocular Lenses Deliver Antibiotics Intracamerally

PURPOSEnTo determine the therapeutic concentrations of moxifloxacin achieved in an artificial anterior chamber by soaking the hydrophobic acrylic AcrySof™ SA60 (Alcon Inc.) intraocular lens (IOL) and the hydrophilic collamer Afinity™ CQ2015 (Staar Inc.) IOL in commercially available moxifloxacin 0.5% (Vigamox™; Alcon Inc.).nnnMETHODSnForty IOLs (20 Acrysof SA60 and 20 Afinity CQ2015) were soaked in 1u2009mL of commercially available moxifloxacin 0.5%: 10 of each IOL for 1u2009min, and another 10 of each IOL for 10u2009min. The IOLs were placed on absorbent pads for 10u2009s on each side to dry excess liquid, and then placed in vials of 10u2009mL balanced salt solution (BSS™) for 30u2009min. Five milliliters of the balanced salt solution was removed and analyzed by high-pressure liquid chromatography to determine antibiotic levels.nnnRESULTSnThe moxifloxacin levels achieved after soaking the hydrophobic SA60 lens were 0.238 and 0.342u2009μg/mL for 1 and 10-min soaks, respectively. The moxifloxacin levels achieved after soaking the hydrophilic CQ2015 lens were 0.283 and 0.717u2009μg/mL for 1 and 10-min soaks, respectively.nnnCONCLUSIONSnBoth lenses were capable of delivering clinically significant antibiotic levels after a 1-min soak. Moxifloxacin concentrations reached at both 1 and 10-min soak times exceed the MIC(90) of the most common pathogens responsible for postoperative endophthalmitis. The antibiotic-soaked IOL has potential to become a clinically significant technique in the prevention of postoperative endophthalmitis.

Antimicrobial activity of acrylic intraocular lenses soaked in fourth generation fluoroquinolones.

PURPOSEnThe aim of this study was to determine whether a commercially available brand of intraocular lenses (IOLs) soaked in moxifloxacin or gatifloxacin for 1 or 60 min have antimicrobial properties.nnnMETHODSnThe IOLs (N = 8-10/group) were soaked in saline, physiologic-strength moxifloxacin (1.8 microg/mL), or gatifloxacin (0.48 microg/mL) for 60 min or commercial-strength moxifloxacin (5 mg/mL) or gatifloxacin (3 mg/mL) for 1 or 60 min. Presoaked IOLs and gatifloxacin antibiotic disks were plated on agar with quality-controlled ATCC 25923 Staphylococcus aureus overlay. Bacterial kill zones were measured after 24 h.nnnRESULTSnIOLs soaked in physiologic-strength gatifloxacin or saline for 60 min produced no measurable bacterial kill zone, and the mean bacterial kill zone for IOLs soaked in physiologic-strength moxifloxacin was significantly greater (P = 0.011, 0 vs. 3.88 +/- 3.18 mm, respectively). Soaking the IOLs in commercial-strength moxifloxacin or gatifloxacin for 1 or 60 min produced significantly larger bacterial kill zones (P < 0.0001, mean: > or =33 mm for all groups). Soaking for 1 min produced a significantly larger mean bacterial kill zone by moxifloxacinthan gatifloxacin-treated IOLs (P = 0.002, 38.80 +/- 3.74 mm, 34.30 +/- 1.34 mm, respectively). The mean bacterial kill zone was significantly larger for IOLs soaked in commercial-strength moxifloxacin for 1 versus 60 min (P = 0.002, 38.80 +/- 3.74 mm, 33.56 +/- 1.42 mm, respectively). There was no significant difference in the mean bacterial kill zone between IOLs soaked for 1 or 60 min in commercial-strength gatifloxacin (34.30 +/- 1.34 mm, 33.67 +/- 0.50 mm, respectively).

Trypan Blue Capsulorhexis

Dear Editor: Despite the widespread use of Trypan Blue (D.O.R.C. International, Zuidland, the Netherlands) as an adjunct to stain the anterior capsule, evidence to support its use in nonmature cataracts is, nevertheless, largely anecdotal. In the Opththalmic Technology Assessment “Capsule staining as an adjunct to cataract surgery: A Report from the American Academy of Ophthalmology,” by Jacobs et al., the authors concluded that there is Level II (i.e., well-designed cohort and case-controlled studies) evidence that capsular dye staining may be helpful in surgeries for pediatric and white cataracts. However, for nonmature cataracts, the authors conclude that the overall surgical advantage has not yet been demonstrated. Moreover, Akman and Akova argued that a red reflex is sufficient for capsulorhexis, and that Trypan Blue, instead, complicates the procedure by reducing the color and contrast differences of the lens and stained capsule. To address the concerns of Jacob et al., and to test our hypothesis that Trypan Blue provides a surgical benefit, we present the first randomized, controlled, prospective, clinical study of the use of Trypan Blue as an adjunct in surgeries of nonmature cataracts with a good red reflex. The candidate eyes included the first 20 cataract extraction cases of each of our 7 senior residents: 10 which were performed with Trypan Blue and 10 without Trypan Blue. The sequence for the use of the dye was predetermined by a random number generator for each resident. Among these initial 140 cases, 117 cases (from 112 patients) met our inclusion criteria: planned primary phacoemulsification cataract surgery, best-corrected visual acuity 20/70 to 20/200, pupillary dilation 6 mm or larger, moderate to good red reflex, and a cataract consisting of at least 2 nuclear sclerosis. Of these cases, 67 cases received Trypan Blue while 50 cases served as controls. For the eyes assigned to receive Trypan Blue, 0.1 ml of VisionBlue (0.06% Trypan Blue ophthalmic solution) was injected directly on top of the anterior lens capsule and under an air bubble prior to performing capsulorhexis. After 5 seconds of staining, the anterior chamber was irrigated using balanced saline solution through the paracentesis. Thereafter, Viscoat (Alcon Laboratories, Fort Worth, TX) was used to fill the anterior chamber. In the control group, no air bubble or dye was used, and only Viscoat was injected into the anterior chamber. In both groups, the resident surgeon used a cystotome, followed by utrata forceps, to create a capsulorhexis (Figure 1; available at http:// aaojournal.org). Attending surgeons were instructed to only intervene if the capsulorhexis advanced beyond the pupil edge and was