Carol L. Karp

Intraocular lens implantation in the absence of capsular support: a report by the American Academy of Ophthalmology.

OBJECTIVE This review was conducted to determine the safety and efficacy of open-loop anterior chamber, scleral-sutured posterior chamber, and iris-sutured posterior chamber intraocular lenses (IOLs) in eyes with inadequate capsular support for posterior chamber implantation in the capsular bag or ciliary sulcus. It also attempted to determine whether there is a preferred IOL or fixation site of choice in eyes with inadequate capsular support. METHODS A literature search conducted for the years 1980 to 2001 yielded 189 citations related to IOL implantation in the absence of capsular support. An update search, conducted in March 2002, yielded an additional 28 articles. The Anterior Segment Panel members reviewed these abstracts and selected 148 articles of possible clinical relevance for review. Of these, 89 were considered sufficiently clinically relevant for the panel methodologist to review and rate according to the strength of evidence. A level I rating was assigned to properly conducted, well-designed, randomized clinical trials; a level II rating was assigned to well-designed cohort and case-control studies; and a level III rating was assigned to case series. Articles comparing the safety and efficacy of the IOL type and fixation site were further evaluated for the quality of the statistical methods used in the study. Studies with a rating of A or B were considered acceptable, C was borderline, and D and F were considered unacceptable as medical evidence. RESULTS Forty-three articles with data concerning outcome of IOL insertion in eyes with inadequate capsular support had an evidence rating of level III or higher and were used in the final review of the safety and efficacy of one or more lens types and/or fixation sites. Seven articles had data about more than one lens type. Six had a statistical method rating of C or higher and were used to evaluate differences in visual outcomes and complication rates between lens types and fixation sites. CONCLUSIONS The literature supports the safe and effective use of open-loop anterior chamber, scleral-sutured posterior chamber, and iris-sutured posterior chamber IOLs for the correction of aphakia in eyes without adequate capsular support for placement of a posterior chamber lens in the capsular bag or ciliary sulcus. At this time, there is insufficient evidence to demonstrate the superiority of one lens type or fixation site. Precise determination of small differences in visual outcome or complication rates will require a large prospective, randomized clinical trial.

Treatment of conjunctival and corneal intraepithelial neoplasia with topical interferon α-2b

Abstract Objective To evaluate the role of topical interferon alfa-2b (IFNα2b) in the treatment of conjunctival and corneal intraepithelial neoplasia (CIN). Design Noncomparative case series. Participants Five patients with histologically proven CIN or recurrences of proven CIN were studied prospectively. Intervention After histologic confirmation, patients were given topical recombinant IFNα2b (INTRON A, Schering Plough, Kenilworth, NJ) 1 million IU/ml four times a day. Patients were continued on interferon until complete resolution of the tumor had occurred. Main outcome measures Patients were followed clinically and photographically for evidence of tumor resolution. Results All patients had complete resolution of the CIN lesion on IFNα2b. The mean time to clinical resolution was 11.6 weeks (range, 4–22 weeks). The mean follow-up was 17.6 months (range, 7–28 months). One patient had a clinical recurrence of his corneal CIN 1 year after tumor resolution. This patient was retreated, resulting in clinical resolution within 6 weeks, and has been tumor free for 8 months of follow-up.

Perilesional and topical interferon alfa-2b for conjunctival and corneal neoplasia.

OBJECTIVE To evaluate the role of combined subconjunctival and topical interferon alfa-2b (IFN alpha 2b) in the treatment of conjunctival and corneal intraepithelial neoplasia (CIN). DESIGN Noncomparative case series. PARTICIPANTS Six patients with histologically proven CIN or recurrences of histologically proven CIN were studied prospectively. INTERVENTION Patients were given a single subconjunctival/perilesional injection of recombinant IFN alpha 2b (Schering Plough, Kenilworth, NJ) 3 million international units (IU) in 0.5 ml and then started receiving topical interferon drops (1 million U/ml) four times a day. Patients were followed weekly until complete resolution of the tumor. After 1 week, patients with minimal response while receiving topical therapy were retreated with perilesional injections three times a week until resolution. Patients received topical interferon drops for a month after clinical resolution of the lesion. MAIN OUTCOME MEASURES Patients were followed clinically and photographically for evidence of tumor resolution. RESULTS The authors present a series of six patients who were treated successfully with a combination of subconjunctival/perilesional and topical IFN alpha 2b. All six patients had complete clinical resolution of the CIN lesion within 6 weeks of initiation of treatment. In the time of follow-up (average, 7.2 months; range, 2-11 months), there have been no treatment failures or recurrences. CONCLUSION IFN alpha 2b may be a viable medical alternative to surgical excision for primary or recurrent CIN.

Infectious keratitis after LASIK

PURPOSE To report the clinical course, management, and outcomes of culture-proven infectious keratitis in 15 eyes of 13 subjects after LASIK. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Fifteen eyes of 13 subjects who underwent LASIK and developed culture-positive keratitis. INTERVENTION Infectious keratitis was encountered in the operative eyes between 1 day and 450 days. Cultures were obtained, and topical antibiotic therapy was administered in all cases. Some cases required flap lifting, irrigation, and soaking of the bed with antibiotics, flap amputation, or further surgical intervention. MAIN OUTCOME MEASURES Time periods from onset to diagnosis, from clinical diagnosis to clinical resolution, final acuities, microbiologic profiles, and medical and surgical interventions were reviewed. RESULTS Onset of symptoms of infection varied, depending on the infectious organism. Bacterial organisms tended to present earlier, whereas mycobacterial and fungal organisms had a later mean onset of presentation. Furthermore, the atypical organisms such as mycobacteria, fungus, and acanthamoeba also had a more delayed diagnosis, resulting in a prolonged disease course. CONCLUSIONS Infectious keratitis after LASIK is a potentially vision-threatening complication. Onset of symptoms varies depending on causative agents. Furthermore, atypical organisms in the interface or beneath the flap can pose both diagnostic and therapeutic dilemmas. Location in the interface can make it more difficult to culture the organisms and prevent adequate penetration of topical antibiotics.

Femtosecond Laser-Assisted Sutureless Anterior Lamellar Keratoplasty

PURPOSE To report the technique and small case series results of femtosecond laser-assisted sutureless anterior lamellar keratoplasty (FALK) for anterior corneal pathology. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Twelve consecutive eyes from 12 patients with anterior corneal scarring. INTERVENTION Femtosecond laser-assisted sutureless anterior lamellar keratoplasty. MAIN OUTCOME MEASURES Measured parameters included femtosecond laser settings, technique, uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), and complications. RESULTS Mean follow-up was 12.7 months (range, 6-24). No intraoperative complications were found. Uncorrected visual acuity (VA) improved in 7 eyes (58.3%) compared with preoperative VA. The mean difference between preoperative and postoperative UCVAs was a gain of 2.5 lines (range, unchanged-7 lines). Best-corrected VA was unchanged or improved in all eyes compared with preoperative levels. The mean difference between preoperative and postoperative BCVAs was a gain of 3.8 lines (range, unchanged-8 lines). In 2 eyes, adjuvant surgical procedures were performed (one treated with phototherapeutic keratectomy and the other with photorefractive keratectomy). Six patients (50%) developed dry eye after FALK, which improved during the follow-up period. No graft rejection, infection, or epithelial ingrowth was found in this series of patients. CONCLUSIONS Femtosecond laser-assisted sutureless anterior lamellar keratoplasty could improve UCVA and BCVA in patients with anterior corneal pathology.

Subconjunctival/Perilesional Recombinant Interferon α2b for Ocular Surface Squamous Neoplasia: A 10-Year Review

PURPOSE To evaluate the biologic effect of subconjunctival recombinant interferon α2b (IFNα2b) for the treatment of ocular surface squamous neoplasia (OSSN). DESIGN Retrospective study. PARTICIPANTS Patients with primary or recurrent OSSN treated with subconjunctival injections of recombinant IFNα2b were studied retrospectively. INTERVENTION Patients were given perilesional subconjunctival injections of 3 million international units in 0.5 ml of IFNα2b (Intron; Schering-Plough, Kenilworth, NJ) until tumor resolution. MAIN OUTCOME MEASURES Patients were followed up clinically and photographically for evidence of tumor resolution and were monitored for evidence of tumor recurrence. RESULTS The authors present a series of 15 eyes (14 patients) that were treated with perilesional, subconjunctival, recombinant IFNα2b. Clinical resolution of the tumor occurred in 13 of 15 eyes. The median time to resolution was 1.4 months (range, 0.6-5.7). In the time of follow-up after lesion resolution (median, 55 months), only 1 of the 15 eyes in the study exhibited disease recurrence, and this occurred 4 months after clinical resolution. CONCLUSIONS Perilesional subconjunctival recombinant IFNα2b may be a viable medical alternative for the treatment of OSSN. Future studies will be needed to evaluate the ideal treatment regimen of IFNα2b.

AMNIOTIC MEMBRANE TRANSPLANTATION FOR BULLOUS KERATOPATHY IN EYES WITH POOR VISUAL POTENTIAL

Purpose: To evaluate the long‐term outcomes of epithelial debridement and amniotic membrane transplantation (AMT) for pain and discomfort relief in patients with symptomatic bullous keratopathy and poor visual potential. Setting: Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miami, Florida, USA. Methods: This retrospective study included 18 eyes (18 patients) with bullous keratopathy presenting with intractable pain or discomfort and poor visual potential. After epithelial debridement, all eyes had AMT with the basement membrane side up. During a mean follow‐up of 25.1 months ± 9.6 (SD) (range 12 to 45 months), pain relief, epithelial healing, and visual changes were analyzed. Results: Pain relief was obtained in 88% of patients. Sixty‐six percent of eyes had complete resolution of ocular discomfort starting soon after the first postoperative day. One eye had evisceration for persistent pain 10 months postoperatively. Corneal epithelial healing was complete in all except 1 eye. Remaining complaints included foreign‐body sensation (5%), tearing (11%), and photophobia (5%). Conclusions: Amniotic membrane transplantation was a safe, effective, and long‐lasting treatment modality for intractable pain associated with chronic bullous keratopathy in eyes with poor visual potential. It can be an alternative to conjunctival flaps for the long‐term management of patients with bullous keratopathy in whom corneal transplantation is not indicated. A comparison of the efficacy of AMT with that of other surgical procedures must be performed.

Mycobacterium interface keratitis after laser in situ keratomileusis

PURPOSE To report the clinical course, management, and outcome of infectious interface keratitis caused by mycobacterium species after laser in situ keratomileusis (LASIK). DESIGN A small noncomparative interventional case series. PARTICIPANTS Five eyes in four patients who underwent LASIK in different locations around the world and had culture-positive mycobacterium keratitis develop. INTERVENTION The LASIK flap was lifted or amputated, samples were submitted for Ziehl-Neelsen acid-fast stain and Lowenstein-Jensens agar cultures for diagnosis; topical treatment with fortified clarithromycin and amikacin was administered until clinical resolution. MAIN OUTCOME MEASURES Time periods from onset to diagnosis and from diagnosis to clinical resolution, and the final visual acuity. RESULTS Onset of symptoms of infection occurred after a mean of 20 days (range, 11 days-6 weeks) after LASIK or an enhancement procedure. Definitive diagnosis was obtained after a mean period of 4.5 weeks (range, 12 days-8 weeks) from onset. Keratitis resolved within 8.4 weeks (range, 1-18 weeks) of treatment with fortified clarithromycin and amikacin. Corticosteroids were found to worsen and prolong the course of disease. In four of five eyes the LASIK flap was amputated. CONCLUSIONS Mycobacterial keratitis is a potentially vision-threatening complication after LASIK, characterized by a long latent period, delayed diagnosis, and a protracted course even under intensive specific antibiotic therapy. Inclusion of specific culture media and staining protocols for mycobacteria, along with aggressive treatment on diagnosis, including lifting or amputating the LASIK flap, culturing, topical fortified clarithromycin and amikacin, while avoiding corticosteroids, may significantly improve resolution of the infection and potentially improve the visual outcome.

Ultra-high resolution optical coherence tomography for differentiation of ocular surface squamous neoplasia and pterygia.

OBJECTIVE To assess the use of an ultra-high-resolution (UHR) optical coherence tomography (OCT) as an adjuvant diagnostic tool in distinguishing ocular surface squamous neoplasia (OSSN) and pterygia. DESIGN Prospective case series. PARTICIPANTS Thirty-four eyes of 34 patients with conjunctival lesions clinically suspicious for OSSN or pterygia. METHODS All patients were photographed and then imaged with a custom-built UHR OCT device. Subsequently, each patient underwent excisional or incisional biopsy with histopathologic diagnosis. MAIN OUTCOME MEASURES Comparison of preoperative UHR OCT images and the corresponding histopathologic specimen; comparison of epithelial thickness between the 2 groups as measured by UHR OCT. RESULTS Preoperative UHR OCT images of OSSN demonstrated similarities to the histopathologic specimens. Both optical and pathologic specimens showed a thickened layer of epithelium, often with an abrupt transition from normal to neoplastic tissue. Likewise, preoperative UHR OCT images of patients with pterygia were well correlated with the histopathologic specimens. As opposed to OSSN, both UHR OCT and pathologic images of pterygia demonstrated a normal thin epithelium, with underlying thickening of the subepithelial mucosal layers. Differences in the measured epithelial thickness on UHR OCT between OSSN and pterygia were statistically significant, with an average epithelial thickness of 346 μm (standard deviation [SD], 167) in OSSN patients and 101 μm (SD, 22) in pterygium patients (P<0.001). By receiver operating characteristic curve, the sensitivity and specificity of UHR OCT for differentiating between OSSN and pterygia was found to be 94% and 100%, respectively, using a cutoff value of 142 μm. CONCLUSIONS Ultra-high-resolution OCT may show promise as a noninvasive diagnostic tool to evaluate ocular surface lesions. In addition to a statistically significant difference in epithelial thickness, a significant degree of morphologic correlation with the histopathologic results demonstrates its potential in evaluating ocular surface squamous neoplasia and pterygia.

Topical interferon alpha 2b eye-drops for treatment of ocular surface squamous neoplasia: a dose comparison study

Background/aims To compare the effectiveness and side-effect profile of two doses of interferon alpha2b (IFNα2b) eye-drops (1 million international units (IU)/ml versus 3 million IU/ml) in the treatment of ocular surface squamous neoplasia (OSSN). Methods Retrospective case series. Results Thirty-five eyes were identified over an 11-year period (1996–2007). Twenty-one eyes (19 patients) with conjunctival intraepithelial neoplasia (CIN) were treated with 1 million IU/ml of topical IFN-α2b; 12 eyes (nine patients) with CIN were treated with 3 million IU/ml. Two patients with squamous cell carcinoma (SCC) were treated with topical interferon, one with 1 million IU/ml and one with 3 million IU/ml. Baseline demographic information was not statistically different between the two groups. In patients with CIN, topical therapy eliminated disease in 81% of eyes in the 1 million IU/ml group versus 92%, in the 3 million IU/ml group, p=0.41. The median time to OSSN resolution was 2.8 months in the 1 million IU/ml group and 1.9 months in the 3 million IU/ml group, p=0.55. Neither eye with SCC responded to interferon therapy. Topical therapy was well tolerated. After a median follow-up of 24 months, three recurrences were seen in eyes successfully treated with topical therapy. Conclusion In our study, there were no significant differences between the 1 million IU/ml group and the 3 million IU/ml group for the treatment of CIN.