Angus K. K. Wong

Intraoperative mitomycin C to prevent recurrence of pterygium after excision: A 30-month follow-up study

OBJECTIVE The purpose of the study was to examine the efficacy of intraoperative mitomycin C (MMC) in preventing recurrence of pterygium after excision and the postoperative complications encountered. DESIGN The study design was a prospective, randomized, clinical trial. PARTICIPANTS A total of 180 primary and recurrent pterygia were recruited for the study. They were randomized into five groups: A, control with no MMC; B, 0.02% MMC for 5 minutes; C, 0.04% MMC for 5 minutes; D, 0.02% MMC for 3 minutes; and E, 0.04% MMC for 3 minutes. INTERVENTION All patients received pterygium excision with or without the above four modes of intraoperative MMC application. MAIN OUTCOME MEASURES Recurrence of pterygium and postoperative complications such as superficial scleral melting were measured. RESULTS At a mean follow-up of 30 (groups A-C) and 20 months (groups D and E), the respective recurrence rates in groups A through E were 75%, 8.3%, 8.6%, 42.9%, and 22.9%. There were two cases of postoperative superficial scleral melting in group C. Otherwise, no major postoperative complications were encountered. CONCLUSIONS The midterm results of a single intraoperative application of MMC at the concentration of 0.02% for 5 minutes are encouraging. Its application as an adjunctive therapy for the surgical treatment of pterygium appeared to be safe and effective. However, because of the possibility of serious late complications, the authors suggest that this procedure be reserved for patients who have high probability of recurrence after excision of pterygium.

A randomised trial comparing 0.02% mitomycin C and limbal conjunctival autograft after excision of primary pterygium

Background: Mitomycin C (MMC) and limbal conjunctival autograft (LCAU) are two known useful adjuvants in the prevention of pterygial recurrence. This study was conducted to compare the outcome of these two treatments. Methods: Prospective study on consecutive cases of primary pterygium (February 2001 to March 2002) randomised into two adjuvant groups: (1) intraoperative 0.02% MMC for 5 minutes or (2) LCAU. Patients were followed for recurrence (defined as fibrovascular tissue invading the cornea >1.5mm) and complications for a period of one year. Results: 115 eyes in 114 patients who completed the study were randomised to receive MMC (n = 63) and LCAU (n = 52). There were 10 recurrences (15.9%) in the MMC group and only one recurrence (1.9%) in the LCAU group. There was a statistically significant difference in the recurrence rate between the two groups (p = 0.04). There were a total of three conjunctival cysts, three symblephara, one granuloma, and one dellen. No other visually significant complications were encountered in either group. Conclusion: Although LCAU resulted in better one year success rates, it is technically more difficult and inapplicable in cases with previous limbal disturbance. Simple excision followed by MMC or LCAU are both safe and acceptable adjuvants for pterygium excision. Choice of adjuvant should be carefully made based on assessment of recurrence risk, local practices, and surgeon’s expertise.

Orthokeratology Lens-related pseudomonas aeruginosa Infectious Keratitis

Purpose. To report a case of orthokeratology lens-related Pseudomonas corneal ulcer in an adult. Methods. Case report. Results. A 37-year-old man presented with a 1-day history of painful red eye. He was a soft contact lens wearer before he started on nocturnal orthokeratology lens wear of 8 to 10 hours per night 9 months ago. Corneal scraping sent for culture revealed a heavy growth of Pseudomonas aeruginosa. The patient was treated with intensive topical fortified tobramycin and ceftazidime drops. The ulcer healed with a residual paraxial corneal scar. Although his best-corrected visual acuity (BCVA) recovered from finger counting (8/200) at presentation to 20/30, he suffered visual loss from a premorbid BSCVA of 20/15. His contrast sensitivity (Vector Vision CSV 1000 test) performance was also worse than his fellow eye. Conclusion. Nocturnal orthokeratology lens wear may be associated with an increased risk of infection.

Phacoemulsification, primary posterior capsulorhexis, and capsular intraocular lens implantation for uveitic cataract

Purpose: To evaluate the safety and efficacy of phacoemulsification, primary posterior capsulorhexis (PCCC), and primary intraocular lens (IOL) implantation for uveitic cataracts. Setting: Institutional practice. Methods: Fifteen consecutive eyes of 13 patients with various causes of uveitis received anterior capsulorhexis, phacoemulsification, PCCC, and in‐the‐bag implantation of a heparin‐surface‐modified IOL for visually disabling cataract. The safety and efficacy of the combined operation were studied prospectively. Results: At a mean follow‐up of 16.9 months (range 8 to 30 months), all eyes had a clear central visual area. Fourteen of 15 eyes (93.3%) had good visual improvement after surgery. Eight eyes (53%) achieved a best corrected visual acuity (BCVA) of 20/30 or better and 6 (40%), 20/20 or better. Seventy‐three percent of eyes attained a BCVA of 20/80 or better. The mean improvement in visual acuity was 5.2 Snellen lines (range 0 to 11 lines). No cases of uveitis flare‐up or other major complications related to the cataract surgery occurred. Conclusions: The study’s preliminary results are encouraging and indicate that phacoemulsification, PCCC, and IOL implantation can be considered in patients with visually disabling uveitic cataract.

Combined intravenous pulse methylprednisolone and oral cyclosporine A in the treatment of corneal graft rejection: 5-year experience.

Purpose To report the mid-term results of a treatment strategy using topical steroids, intravenous pulse methyl prednisolone and oral cyclosporine A (CSA) for the treatment of acute corneal graft rejection.Methods Noncomparative, interventional case series. Treatment of corneal graft rejection included 1% prednisolone eye drops, intravenous infusion of 500 mg methyl prednisolone, and oral CSA in two regimens—standard dose was 15 mg/kg/day for 2 days, 7.5 mg/kg/day for 2 days, then adjusted to maintain trough blood levels of 100–200 μg/l; low dose was 2 mg/kg/day with no loading dose.Results Outcome in 34 eyes of 34 patients (21 M;13 F) aged 60 ± 17.7 years (range 9–83 years), who presented after an average duration of 6.6 ± 6.3 days (range 0–30 days) following acute corneal graft rejection, are reported. Twenty-five patients received standard dose CSA while nine patients received the low dose regimen. Mean duration of treatment before reversal of graft rejection was 13.6 ± 12.1 days (range 3–54 days). Treatment was successful in reversing the graft rejection in 32/34 (94%) eyes. Irreversible graft failure occurred in one eye in each group. During a mean follow-up period of 19.2 ± 16.7 months (range 1–55 months), further episodes of graft rejection were seen in 1/32 (3%) eyes. Complications due to treatment included: duodenal ulcer in one patient that responded to medical treatment, and transient elevation in serum creatinine levels in three patients, which returned to normal after decrease in dosage or cessation of oral CSA.Conclusion Our 5-year experience with the use of oral CSA in the treatment of acute corneal graft rejection has shown this treatment approach to be safe and effective in reversing the rejection process. This approach may also protect the graft from subsequent episodes of allograft rejection. A randomised controlled trial to further delineate the role of CSA in reversing acute graft rejection seems warranted.

The use of combined intravenous pulse methylprednisolone and oral cyclosporin A in the treatment of corneal graft rejection: A preliminary study

Purpose Oral cyclosporin A used in addition to high-dose intravenous pulse methylprednisolone has been shown to have an adjunctive effect in reversing the rejection of liver and renal transplants. The aim of this prospective study was to evaluate the benefits and risks of this combined drug therapy in acute corneal graft rejection.Methods Eleven patients with acute corneal graft rejection received the combined regimen of a single pulse of intravenous methylprednisolone (500 mg) and a low dose of oral cyclosporin A (to maintain a trough blood level of 100-200 µg/1).Results At a mean follow-up of 16.5 months (range 8-22 months) from the presentation of the graft rejection, reversal of graft rejection was achieved in 10 of 11 cases (90.9%). No recurrence of graft rejection was encountered during the study period. One patient developed a duodenal ulcer, which healed after medical treatment. No other complications were encountered.Conclusions The high efficacy and low risk of the combined regimen demonstrated in this preliminary study call for a larger-scale prospective double-masked study to confirm the value of this treatment protocol.

Confocal microscopy of posterior polymorphous endothelial dystrophy

Purpose: To report the in vivo confocal microscopic findings of posterior polymorphous endothelial dystrophy (PPED). Methods: Four patients with PPED from 2 unrelated families and 2 asymptomatic children of an index patient were included in this observational case series. The eyes of the 6 subjects were examined by confocal light microscopy. Results: Confocal microscopy demonstrated craters, streaks, and cracks over the corneal endothelium surface. Pleomorphism and polymegathism were present in eyes with PPED. Guttae and clusters of abnormal endothelial cells were also identified in corneas of these PPED patients. These findings were absent in eyes without clinical manifestations of PPED. Conclusions: In vivo confocal microscopy is potentially useful for excluding suspected cases of subclinical PPED. Abnormalities in the Descemet membrane and endothelium were observed.

In vivo confocal microscopy of Thygeson's superficial punctate keratitis

A 56‐year‐old Chinese man diagnosed with Thygesons keratitis by clinical biomicroscopy was examined using a tandem scanning confocal microscope. Among normal superficial epithelial cells, clumps of markedly enlarged epithelial cells were identified. Multiple highly reflective filamentary structures were observed in the deeper layers. Most of these lesions were linear; some demonstrated curled ends and others demonstrated branching lesions with ‘sprouts’. No inflammatory cells were evident in the areas of corneal stroma sampled. In vivo confocal microscopy may be helpful in the diagnosis of Thygesons superficial keratitis. To the best of our knowledge, we report the first in vivo confocal images of focal desquamation of epithelium and intraepithelial hyper‐reflective linear lesions in English literature.

Cognitive and functional impairments in ischemic stroke patients with concurrent small vessel and large artery disease

BACKGROUND AND PURPOSE Concurrent small vessel, intracranial and extracranial large artery disease (SLAD) is common in Asian but its impact on cognitive and functional outcomes is unclear. We aimed to evaluate the clinical, cognitive and functional outcomes in ischemic stroke patients with SLAD. METHODS Chinese ischemic stroke patients with diffuse white matter lesions (WMLs) were recruited as part of the VITATOPS Trial. They were studied with MRI and MRA of brain. Various neuropsychiatric batteries were used to assess the cognitive functions. RESULTS Totally 97 patients with acute ischemic stroke and diffuse WMLs were included, of whom 44 (45%) had SLAD. Patients with SLAD had lower Mini Mental State Examination (MMSE) when compared with the patients without SLAD. They had more behavioral symptoms and caused more stress in caregivers as assessed by the Neuropsychiatric Inventory (NPI). Multivariate regression analysis showed SLAD contributed significantly to MMSE, NPI Patient (NPI P) and NPI Care Giver (NPI CG). Among 44 patients with SLAD, 30 (68%) had severe cognitive impairment. They were older and less educated. They had more diabetes and poorer performance in neuropsychiatric tests including Mattis Dementia Rating Scale Initiation/Perseveration subset (MDRS I/P) and Clinical Dementia Rating (CDR). They also had poorer functional outcomes as assessed by Barthel Index (BI) and Instrumental activities of daily living (IADL). CONCLUSIONS This was the first MRA-based study to take into consideration the clinical, cognitive and functional outcomes in ischemic stroke patients with SLAD. Patients with SLAD had poorer cognitive and functional outcomes when compared to patients without SLAD.

The use of combined intravenous pulse methylprednisolone and low-dose oral cyclosporin A in the treatment of corneal graft rejection: Addendum to previous report

The use of combined intravenous pulse methylprednisolone and low-dose oral cyclosporin A in the treatment of corneal graft rejection: Addendum to previous report