Bennie H. Jeng

Autologous serum 50% eyedrops in the treatment of persistent corneal epithelial defects.

Purpose: To evaluate the success rate of treating persistent corneal epithelial defects using 50% autologous serum eyedrops. Methods: We reviewed the medical records of all patients seen at our institution from September 2004 to May 2007 who had persistent corneal epithelial defects that were nonresponsive to conventional medical treatment and that were treated with 50% autologous serum eyedrops. We also correlated the defect duration prior to initiation of serum therapy with rate of epithelial healing. Results: A total of 25 eyes of 25 patients failed conventional medical therapy for treatment of a persistent corneal epithelial defect and were treated with 50% autologous serum eyedrops every 2 hours while awake. All corneas were neurotrophic, with the etiologies being herpetic (11 eyes), postkeratoplasty (8 eyes), postkeratorefractive surgery (1 eyes), diabetic (1 eye), post-chemical burn (1 eye), and unknown (3 eyes). The median duration of the epithelial defects prior to initiation of autologous serum eyedrops was 13.9 weeks (range 0.29-52 weeks). After institution of autologous serum therapy, 23 of the 25 eyes healed in a mean time of 22.4 days. Seventeen eyes (68.0%) healed within 4 weeks (mean 1.7 weeks) of starting therapy with 50% autologous serum eyedrops. The number of days required for healing was associated with the length of time the defect was open prior to initiation of serum drops (r = 0.68, P < 0.001). Conclusions: The use of 50% autologous serum eyedrops appears to be an efficacious medical treatment modality for persistent corneal epithelial defects that are recalcitrant to conventional medical therapy.

Acute conjunctivitis: truth and misconceptions

ABSTRACT Objective: Acute conjunctivitis is an extremely common condition and can be associated with significant morbidity and economic burden. Despite this, considerable controversy exists pertaining to the prevalence, diagnosis, management, and treatment of the condition. A panel of ophthalmology experts was assembled to review and discuss the current evidence based literature as it pertains to each of these persistent controversies. Methods and scope: An acute conjunctivitis round table symposium was convened at the American Academy of Ophthalmology meeting in Atlanta, November 2008. The expert panelists consisted of four academic ophthalmologists in the field of cornea and external disease, whose discussion was informed by an English language literature survey carried out on the PubMed database for the period of January 1972 to October 2008. A narrative summary was generated from the literature review and direct transcription of this event, from which this Review article was developed. Findings and conclusions: Considerable light has been shed on acute microbial conjunctivitis and especially those cases caused by adenovirus. Many of the myths that have perpetuated for years have been debunked by emerging evidence. The advent and the implementation of better diagnostic tools and anti-viral medications will help clinicians to improve their diagnostic accuracy, improve management and treatment decisions, and ultimately benefit patients while saving overall healthcare costs.

Clinical experience with Acanthamoeba keratitis at the Cole Eye Institute, 1999-2008.

Purpose: To review the clinical presentations, risk factors, medical and surgical management, and outcomes of patients with Acanthamoeba keratitis (AK). Methods: Retrospective review of laboratory and medical records of all patients suspected of having AK from January 1999 through May 2008 at Cole Eye Institute. Results: Twenty-nine eyes of 26 patients were identified as having either culture- or tissue-proven AK or presumed AK based on clinical examination and complete response to full course of treatment. The most common risk factors identified for AK were history of contact lens wear (89.7%) and exposure to contaminated water (27.6%). Clinical presentations included early AK (superficial disease) in 37.9% of eyes or late AK (deep stromal disease with or without epithelial disease) in 62.1% of eyes. All early AK cases had best-corrected visual acuity of 20/30 or better at last follow-up, whereas only 55.6% of late AK cases achieved 20/30 or better. Eight eyes underwent penetrating keratoplasty. One patient demonstrated viable-appearing cysts in the corneal button, despite 15 months of maximum medical treatment and 5 months off all medical treatments. Over the nearly 10-year period, there was no significant increase in the number of cases seen each year. Conclusions: The most common risk factor for AK continues to be contact lens wear. AK requires prolonged and intense treatment, although good final visual acuity can be achieved. Potentially viable Acanthamoeba cysts can still persist in a noninflamed cornea after extensive medical therapy, supporting the practice that corneal transplantation after presumably resolved cases of AK should be followed with vigilance to detect the earliest signs of recurrent disease.

Nitric oxide generated by corneas in corneal storage media

Purpose. The purpose of the study was to quantify nitric oxide release by human corneal buttons in storage media over time. Methods. Group 1 consisted of six chambers of Optisol GS corneal storage media, each containing a viable human corneal button with an attached scleral rim (unsuitable for transplantation), sampled at 1-day intervals for at least 17 days (range, 17–28 days). Group 2 consisted of 34 chambers of Optisol GS media, each used to store a corneal button for penetrating keratoplasty, sampled immediately after each surgery. An unused vial of Optisol GS storage medium was sampled daily for 17 days to serve as a background medium control. The total amount of nitrite and nitrate in each sample was determined by a spectrophotometric method based on the Griess reaction. Results. Data from the daily sampling in group 1 showed that nitrite and nitrate concentrations in storage media containing human corneas increase from a baseline level (beginning at the time the corneas are placed in the media) to an equilibrium concentration of 2.77 &mgr;M in a mean time of 6.15 days. Seventy-six percent of the data points from group 2 fell within the 80% predictive interval derived from group 1. No nitrite or nitrate was detected in background medium control samples. Conclusion. The progressive increase in nitrite and nitrate in corneal storage media over time suggests that nitric oxide is continuously released by corneas during storage before transplantation. Given the toxic free radical properties of nitric oxide, corneas in storage media may be subjected to the cumulative toxic effects of nitric oxide.

Development of superior limbic keratoconjunctivitis after upper eyelid blepharoplasty surgery: Support for the mechanical theory of its pathogenesis

Purpose: To describe a unique presentation of superior limbic keratoconjunctivitis (SLK) that occurred after upper eyelid blepharoplasty and to review the literature regarding the current theories of SLK pathogenesis and its treatment. Methods: A 48-year-old woman presented with a 2-year history of irritation and foreign body sensation in both eyes that began immediately after bilateral upper eyelid blepharoplasty. Her symptoms were unresponsive to therapy with lubricating eyedrops and ointments, cyclosporine 0.05% drops, and silver nitrate cauterization. The patient subsequently underwent surgical resection of the superior bulbar conjunctiva in both eyes. Results: Complete resolution of SLK symptoms. Conclusions: The pathogenesis of SLK has been associated with mechanical injury to the superior limbus and superior bulbar conjunctiva. The development of SLK after upper eyelid blepharoplasty in our patient supports this theory and should be considered a possible adverse consequence of blepharoplasty.

Recurrence rates of herpes simplex virus keratitis in contact lens and non-contact lens wearers.

Objective: To evaluate the recurrence rates of herpes simplex virus (HSV) keratitis in contact lens wearers compared with non-contact lens wearers. Methods: Retrospective cohort study. Charts of patients diagnosed with HSV keratitis seen at the Cleveland Clinic between January 2001 and December 2004 were reviewed. Results: One hundred seventeen patients were included in this study: 21 contact lens wearers and 96 non-contact lens wearers. Contact lens wearers were found to have a higher median recurrence rate (0.4 episodes/year) compared with non-contact lens wearers (0.2 episodes/year) (P=0.02). A multivariate regression evaluating factors predictive of the number of recurrences found that contact lens use remained a significant predictive variable (P=0.02) when accounting for patient demographic and disease factors and variable follow-up time. Conclusions: Patients with a history of HSV keratitis should be counseled about the potential increased risk of recurrence that may be associated with contact lens wear.

Incidence, occurrence rate, and characteristics of suture-related corneal infections after penetrating keratoplasty

Purpose: To report the incidence, occurrence rate, and characteristics of suture-related infections after penetrating keratoplasty (PK). Methods: Patients who underwent PK at our institution between January 1, 2002, and July 1, 2006, were cross-referenced with patients diagnosed with corneal infections between January 1, 2002, and July 1, 2007. All patient charts were reviewed retrospectively for occurrence of suture-related infections, duration of follow-up, and clinical characteristics. Results: Of the 487 PKs performed in 412 patients, 22 eyes of 22 patients developed postoperative corneal infections. Of these, 5 eyes were identified as having suture-related graft infections, yielding an occurrence rate of 1.0%. The average follow-up was 3.46 years per PK, yielding an incidence of 2.96 infections per 1000 PK-years. The mean interval from surgery to infection was 8 months (range: 3-23 months). All culprit sutures were in the interpalpebral zone. No patients were using topical antibiotics at the time of infection, and all patients were using topical corticosteroid drops. Cultured organisms included Staphylococcus aureus (3 cases), coagulase-negative Staphylcoccus (1 case), and S. viridans (1 case). In 2 patients with isolated corneal involvement, topical moxifloxacin was initiated, and the patients responded favorably. In 3 patients with corneal infection and an associated hypopyon or endophthalmitis, vitreous biopsy, intravitreal injections of antibiotics, and fortified topical antibiotics were used. One patient required a repeat PK as a result of the infection. Two eyes eventually became phthisical. Conclusions: The rate of suture-related infections after PK may be lower than previously reported. In our patients, suture-related infections all occurred within the first 2 years after surgery, and some of them resulted in significant morbidity, underscoring the importance of patient identification of symptoms and early clinical recognition.

Epithelial debridement for the treatment of epithelial basement membrane abnormalities coincident with endothelial disorders.

Purpose: To determine if treatment directed at the epithelial basement membrane abnormalities in eyes with endothelial disorder can improve visual acuity and surface irregularity. Methods: Retrospective interventional case series of 4 eyes of 3 patients with epithelial basement membrane abnormalities and endothelial disorder coincident with Fuchs endothelial corneal dystrophy or iridocorneal endothelial syndrome that had initial treatment directed only at the epithelial basement membrane disorder. Results: In 2 of the 4 eyes undergoing epithelial basement membrane debridement, visual acuity improved by 3 Snellen lines. In the other 2 eyes, the intervention improved visual acuity by 2 lines in 1 eye and no lines in the other, but the procedure allowed for accurate keratometry readings to be obtained for intraocular lens calculations before cataract surgery. Conclusions: Epithelial basement membrane abnormalities can occur in eyes with endothelial disorder. Treatment of the epithelial basement membrane disorder in these eyes can sometimes improve the regularity of the ocular surface and visual acuity.

Reduction of hyperopia and astigmatism after superficial keratectomy of peripheral hypertrophic subepithelial corneal degeneration.

Purpose. To report the development of progressive hyperopia and astigmatism resulting from peripheral hypertrophic subepithelial degeneration which was treated with superficial keratectomy of the lesion. Methods. Case report. Results. A patient with peripheral hypertrophic subepithelial degeneration of both corneas was followed up for a 6-year period. During this time, the patient experienced a slowly progressive increase in hyperopia and astigmatism in both eyes. In the left eye, extension of the degeneration paracentrally resulted in significant hyperopia and astigmatism and a best spectacle-corrected visual acuity of 20/70. Superficial keratectomy was performed and resulted in a dramatic reversal of the hyperopic and astigmatic shift and a best spectacle-corrected visual acuity of 20/30+2. Conclusions. Peripheral hypertrophic subepithelial corneal degeneration can result in progressive flattening of the central corneal topography in the involved meridians. This flattening can induce a significant hyperopic and astigmatic shift in refraction. This refractive change can be reversed with superficial keratectomy to remove the degeneration.

Compression sutures in the management of corneal transplant wound infections.

Purpose. To report the usefulness of compression sutures in the management of three cases of bacterial wound infections in corneal transplants. Methods. Interventional case series. Results. All three cases of wound dehiscence and perforation resulting from bacterial wound infections were successfully treated with placement of compression sutures with concurrent topical antibiotic treatment. Conclusion. The placement of compression sutures is a successful surgical technique to reestablish corneal transplant wound integrity compromised by infection.