Bruce Allan

Peripheral sterile corneal infiltrates and melting after collagen crosslinking for keratoconus

Corneal collagen crosslinking (CCC)with riboflavin/ ultraviolet-A (UV-A) is a new therapeutic technique designed to strengthen the cornea and arrest progressive corneal ectasia. Few complications have been reported following this therapy. We report the case of a 40-year-old patient who had CCC for progressive keratectasia secondary to keratoconus. The patient had no medical history of systemic illness or ocular inflammatory disorders. Corneal collagen crosslinking was performed under topical anesthesia (proxymethacaine 0.5% without preservative). The central 8.0 mm of epithelium was mechanically debrided without trephination using a hockey stick blade. Riboflavin 0.1% in 20% dextran drops (Medio-Cross, IROC AG) were applied every 3 minutes for 30-minute exposure to UVA (365 nm, 3 mW/cm) using a dedicated UVA source (UV-X, IROC AG). Riboflavin 0.1% drops were applied every 5 minutes throughout the UV exposure period. A bandage contact lens was placed at the end of surgery. Postoperatively, chloramphenicol 0.3% 4 times daily, dexamethasone 0.1% drops 2 hourly (preservativefree), and cyclopentolate 1% drops twice daily were prescribed. Five days postoperatively, 3 peripheral areas of marginal infiltration without overlying epithelial ulceration were observed (Figure 1, A). The central epithelial defect had healed. A diagnosis of noninfective keratitis was made, and the patient was started on twice hourly preservative-free levofloxacin and dexamethasone 0.1%. Markers for rheumatoid factor, antineutrophilic cytoplasmic antibodies, immune complexes, erythrocyte sedimentation rate, and C-reactive protein were all negative. One week later, much of the marginal infiltration had disappeared leaving areas of peripheral stromal thinning, estimated at 40% to 50% of the total corneal thickness at the maximal point. A linear superior area of superficial infiltration remained (Figure 1, B). Topical steroids were increased to hourly prednisolone acetate 1%, and topical antibiotic agents were reduced to 4 times daily. In the subsequent weeks, there was complete resolution of infiltrates but with residual marginal thinning (maximum 30%) (Figure 1, B). The best corrected visual acuity had returned to 6/18 at the last examination, 2 months after the crosslinking procedure.

New clinical pathways for keratoconus

Pre-2000, the clinical management of keratoconus centred on rigid contact lens fitting when spectacle corrected acuity was no longer adequate, and transplantation where contact lens wear failed. Over the last decade, outcome data have accumulated for new interventions including corneal collagen crosslinking, intracorneal ring implantation, topographic phototherapeutic keratectomy, and phakic intraocular lens implantation. We review the current evidence base for these interventions and their place in new management pathways for keratoconus under two key headings: corneal shape stabilisation and visual rehabilitation.

Conventional routine clinical review may not be necessary after uncomplicated phacoemulsification

AIM To determine the clinical intervention rate during routine review after uncomplicated phacoemulsification. METHODS A review of case notes in 651 consecutive cases of uncomplicated phacoemulsification from 1994 (⩽5.5 mm self sealing wound) was performed. The intervention rate at scheduled routine review visits and at unscheduled visits to the eye casualty service in the first 120 postoperative days was recorded. Interventions were defined as departures from predetermined postoperative care protocols. RESULTS Clinical interventions were reported in 2.8% (95% confidence interval 1.5 to 4.1%) of (n=1652) routine follow up visits. Many of these interventions were avoidable or trivial; 90% of patients had no postoperative intervention at any visit. 7.3% of patients made unscheduled visits to the emergency service. The intervention rate in this group was 50% (35.9 to 64.1%). CONCLUSIONS The intervention rate in routine clinical review after uncomplicated modern cataract surgery is low. Alternatives to conventional postoperative review, including shared care with non-ophthalmologists and improved perioperative patient education with an open channel for self referral, should be evaluated.

Randomized Trial of Multifocal Intraocular Lenses versus Monovision after Bilateral Cataract Surgery

OBJECTIVE To compare spectacle independence in patients randomized to receive bilateral multifocal intraocular lenses (IOLs) or monofocal IOLs with the powers adjusted to produce monovision. DESIGN Randomized, multicenter clinical trial. PARTICIPANTS A total of 212 patients with bilateral, visually significant cataract. METHODS Before bilateral sequential cataract surgery, patients were randomized (allocation ratio 1:1) to receive bilateral Tecnis ZM900 diffractive multifocal lenses (Abbott Medical Optics, Santa Ana, CA) or Akreos AO monofocal lenses (Bausch & Lomb, Rochester, NY) with the powers adjusted to target -1.25 diopters (D) monovision. Outcomes were assessed 4 months after the second eye underwent operation. MAIN OUTCOME MEASURES The primary outcome was spectacle independence. Secondary outcomes included questionnaires (VF-11R, dysphotopsia symptoms, and satisfaction) and visual function measures (near, intermediate, and distance logarithm of minimum angle of resolution [logMAR] visual acuity, stereoacuity, contrast sensitivity, and forward light scatter). RESULTS A total of 212 patients were randomized, and 187 patients (88%) returned for assessment 4 months after surgery. Uniocular distance refractions in the monovision arm showed a mean spherical equivalent of +0.075 D in the distance eye and -0.923 in the near eye. In the multifocal arm, the mean distance spherical equivalents were -0.279 D and -0.174 D in the right and left eyes, respectively. A total of 24 of 93 patients (25.8%) in the monovision arm and 67 of 94 patients (71.3%) in the multifocal arm reported never wearing glasses (P<0.001, Fisher exact test). The adjusted odds ratio of being spectacle free was 7.51 (95% confidence interval, 3.89-14.47). Binocular uncorrected acuities did not differ significantly for distance (0.058 logMAR for monovision vs. 0.076 for multifocal, P = 0.3774) but were significantly worse in the multifocal arm for intermediate acuity (0.149 vs. 0.221, P = 0.0001) and in the monovision arm for near acuity (0.013 vs. -0.025, P = 0.037). In the first postoperative year, 6 patients (5.7%) in the multifocal arm underwent IOL exchange (4 had a bilateral and 2 had a unilateral exchange). No patients in the monovision arm underwent IOL exchange. CONCLUSIONS Patients randomized to bilateral implantation with the diffractive multifocal Tecnis ZM900 were more likely to report being spectacle independent but also more likely to undergo IOL exchange than those randomized to receive monofocal implants (Akreos AO) with the powers adjusted to give low monovision.

Quality of life in high myopia: implantable Collamer lens implantation versus contact lens wear.

PURPOSE To compare vision-related quality of life in implantable Collamer lens (ICL) recipients and successful contact lens (CL) wearers not seeking refractive surgery. DESIGN A comparative cross-sectional study of consecutive cases. PARTICIPANTS Forty-one consecutive cases of bilateral ICL implantation in Moorfields Eye Hospital, London, and a control group of 41 CL wearers with a similar starting level of myopia attending consecutively at 1 of 2 community optometric practices in the London area. INTERVENTION Quality of Life Impact of Refractive Correction questionnaire administration in a semistructured interview. MAIN OUTCOME MEASURE Quality of Life Impact of Refractive Correction score. RESULTS Quality of Life Impact of Refractive Correction scores were significantly higher (P<0.001) in ICL recipients (53.67+/-4.50) than in CL wearers (44.42+/-5.07). Age (mean+/-standard deviation [SD], 37.7+/-7 vs. 37.5+/-7.3), gender distribution (% female, 90% vs. 74%; P = 0.295), and preoperative (ICL recipients) or uncorrected (CL wearers) refractive error (mean refractive spherical equivalent+/-SD, 11.0+/-2.7 vs. 11.3+/-3.5) were similar in ICL recipients and CL wearers, respectively. Postoperative uncorrected visual acuities in ICL recipients (0.04 [20/20]+/-0.18) and CL-corrected visual acuities in control patients (0.01 [20/20]+/-0.14) measured in the better eye in each group also were similar (P = 0.53). CONCLUSIONS Implantable Collamer lens implantation may offer significant quality-of-life advantages over CL wear for patients with high myopia. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Successful management of Aspergillus scleritis by medical and surgical treatment

Background Inflammatory scleral disease is frequently associated with autoimmune disorders and only occasionally caused directly by an infective agent. Fungal infections primarily involving the sclera are rare, and the outcome is generally poor. Here we report three patients with post-operative Aspergillus scleritis who were successfully managed by medical therapy and surgical intervention.Patients Scleral infection with Aspergillus sp. was diagnosed 6 and 5 months after cataract extraction in a 76-year-old diabetic and an 82-year-old woman respectively, and in a 54-year-old man 3 months after trabeculectomy. Swabs and/or scrapings had not been conclusive and the diagnosis of Aspergillus infection was established in all cases only after scleral biopsy.Results The infection was eliminated in all cases. This was achieved in one eye by treatment with oral itraconazole in combination with systemic and topical amphotericin B. The two patients with fungal scleritis after cataract extraction required in addition to the medical therapy (oral itraconazole, topical econazole and amphotericin B) scleral excisions and patch grafts to control infection.Conclusion Fungal scleritis may remain undiagnosed for months. A scleral biopsy may be necessary to establish this diagnosis. Prolonged systemic antifungal therapy alone may not eradicate fungal infection. Surgical excision improves the outcome of fungal scleritis.

Pterygium excision with conjunctival autografting

EDITOR,-I would like to thank E A Bouzas and G Mastorakos for their interest in our paper. In the September issue of the Archives of Ophthalmology they described three out of 60 patients with Cushings syndrome who developed a central serous retinopathy during the course oftheir illness and quoted other circumstantial evidence that steroids may have a role in the aetiology of central serous retinopathy. However, in view of the vast number of patients who are on steroids for one reason or another this risk must be extremely low and a proper epidemiological study is required. Our paper pointed out that central serous retinopathy is in fact rare in systemic lupus erythematosus (although large numbers of patients are treated with steroids) and, furthermore, our patients were unusual in that although they developed the typical angiographic features of central serous retinopathy they both failed to get visual improvement with resolution of the retinopathy. In our view, the association between central serous retinopathy and steroid therapy is an interesting point which remains unproved. D J SPALTON St Thomass Hospital, Lambeth Palace Road, LondonSEI 7EH

Organ culture storage of pre-prepared corneal donor material for Descemet's membrane endothelial keratoplasty

Purpose To evaluate the effect of media composition and storage method on pre-prepared Descemets membrane endothelial keratoplasty (DMEK) grafts. Methods 50 corneas were used. Endothelial wound healing and proliferation in different media were assessed using a standard injury model. DMEK grafts were stored using three methods: peeling with free scroll storage; partial peeling with storage on the stroma and fluid bubble separation with storage on the stroma. Endothelial cell (EC) phenotype and the extent of endothelial overgrowth were examined. Global cell viability was assessed for storage methods that maintained a normal cell phenotype. Results 1 mm wounds healed within 4 days. Enhanced media did not increase EC proliferation but may have increased EC migration into the wounded area. Grafts that had been trephined showed evidence of EC overgrowth, whereas preservation of a physical barrier in the bubble group prevented this. In grafts stored in enhanced media or reapposed to the stroma after trephination, endothelial migration occurred sooner and cells underwent endothelial-mesenchymal transformation. Ongoing cell loss, with new patterns of cell death, was observed after returning grafts to storage. Grafts stored as free scrolls retained more viable ECs than grafts prepared with the fluid bubble method (74.2± 3% vs 60.3±6%, p=0.04 (n=8). Conclusion Free scroll storage is superior to liquid bubble and partial peeling techniques. Free scrolls only showed overgrowth of ECs after 4 days in organ culture, indicating a viable time window for the clinical use of pre-prepared DMEK donor material using this method. Methods for tissue preparation and storage media developed for whole corneas should not be used in pre-prepared DMEK grafts without prior evaluation.

Use of a single peripheral triangular mark to ensure correct graft orientation in Descemet membrane endothelial keratoplasty.

rine have been reported over the past 6 decades. Fraunfelder and Scafidi reviewed the complications after topical phenylephrine. Fifteen of 32 entailed cardiac arrest, and 11 of those were fatal. Others have pointed out the occurrence of severe pulmonary hypertension, systemic hypertension, and rupture of intracranial aneurysms. Perhaps only a small subset of patients is at risk. Preexisting cardiac arrhythmiamaypredispose to induction of ventricular fibrillation. The patient’s cardiovascular status and history must be known before deciding to use phenylephrine in or on the eye. Cataract surgeons around the world use various concentrations of intracameral phenylephrine, some much lower concentrations than the concentration we used in our patient. This may be safer relative to the total dose of phenylephrine exposure; however, the efficacy of the various concentrations is not clear. In 2003, Lundberg and Behndig compared pupil dilation using intracameral phenylephrine (15 mg/mL) alone with dilation using topical mydriatics (cyclopentolate 1.0% and phenylephrine 10.0%). They found that the intracameral mydriatic alone produced a significant pupil dilation of 6.7 mm G 1.0 (SD), which was sustained throughout the procedure. However, this dilation was statistically less than the dilation with topical mydriatics, which was 7.7 G 1.0 mm but had shorter sustainability. In 2010, the same group showed that phenylephrine given intracamerally resulted in the same mydriatic effect in concentrations between 0.15 mg/mL and 5.00 mg/mL but had a significantly greater effect in higher concentrations of 15 mg/mL and 30 mg/mL. Topical mydriatics have lower bioavailability and higher systemic absorption. In patients with cardiovascular risk factors, it may be plausible to use only intracameral phenylephrine for dilation or topical cyclopentolate 1.0% and intracameral phenylephrine, reducing the systemic absorption and side effects of the drug. Whether this would be effective in reducing the risk for IFIS in patients on a antagonists is unknown as no studies have performed a direct comparison. Prudence dictates that one consider the total dose of phenylephrine used, preferring 2.5% drops to 10.0%. Bilateral application doubles the dose. Surgeons might prefer to use iris hooks or a Malyugin ring rather than extra phenylephrine. We recommend cardiovascular monitoring of patients with risk factors and the ready availability of anesthetists experienced in cardiopulmonary resuscitation. Intermittent verbal communicationwith thepatient and use of topical anesthesia (enabling the surgeon to see whether the patient loses voluntary fixation) can aid immediate recognition of the onset of ventricular fibrillation. This caution applies to pupil dilation for both cataract surgery and photography.

Meta-analysis of randomized controlled trials comparing excimer laser and phakic intraocular lenses for myopia between 6.0 and 20.0 diopters.

Purpose Meta-analysis of randomized controlled trials (RCTs) comparing excimer laser refractive surgery and phakic intraocular lenses (pIOLs) for the correction of myopia between 6.0 and 20.0 diopters (D). pIOLs are an alternative surgical option to excimer laser for these patients. The evidence base comparing these 2 methods has never been assessed systematically. Methods Cochrane Eyes and Vision Group, International. We performed a comprehensive literature search using the Cochrane Collaboration methodology to identify RCTs. A meta-analysis on the results of RCTs was performed. We analyzed data for efficacy outcomes, accuracy outcomes, safety outcomes, adverse effects, and quality-of-life measures. Results This review included 3 RCTs with a total of 228 eyes. The range of myopia was 6.0 to 20.0 D with up to 4.0 D of astigmatism. The pIOL group was less likely to lose 2 or more lines of best spectacle–corrected visual acuity at 12 months (odds ratio, 0.35; 95% confidence interval, 0.19–0.66, P = 0.001). PIOL surgery scored more highly on patient satisfaction/preference questionnaires. Conclusions The results of this systematic review show that pIOLs are safer within 1 year of follow-up compared with excimer laser surgical correction for myopia between 6 and 20 D. There is weaker evidence for superior visual quality in pIOL recipients. Further RCTs adequately powered for subgroup analysis with long-term follow-up are necessary to establish the ideal myopic range for excimer laser and pIOL treatments.