Emmett F. Carpel

Topical diclofenac in the treatment of ocular pain after excimer photorefractive keratectomy

BACKGROUND Following excimer laser photorefractive keratectomy, patients experience significant ocular pain until corneal reepithelialization. Despite the use of cold compresses, bandage soft contact lenses, cycloplegics, narcotics, and topical corticosteroids, the pain has not been adequately controlled in many patients. METHODS A randomized, double-masked, parallel-group study of diclofenac sodium 0.1% ophthalmic solution and its placebo vehicle was evaluated. Patients undergoing excimer myopic photorefractive keratectomy on their second eye were admitted overnight. Postoperative procedures included two drops of diclofenac or placebo immediately after surgery and then qid until reepithelialization, topical tobramycin (qid), 0.1% fluorometholone (q2h), cycloplegics, and a disposable soft contact lens. Thirty-two patients (diclofenac = 16, placebo = 16) were evaluated from +30 minutes to +96 hours by several types of questionnaires. RESULTS Most patients who received placebo experienced pain, starting within 1 hour, peaking at 4 to 6 hours and lasting 36 to 48 hours. The diclofenac-treated patients rarely experienced the early peak in pain, had less pain overall until 72 hours postoperatively, and experienced significantly less photophobia and burning/stinging. Significantly fewer patients on diclofenac required oral narcotics. Three patients (diclofenac = 2, placebo = 1) developed corneal infiltrates, the etiology of which is not known. In a separate study we conducted, there was no difference in epithelial healing times between the diclofenac-treated eyes and those not receiving the drug. CONCLUSIONS Diclofenac appears to significantly reduce the ocular pain following excimer photorefractive keratectomy.

The Normal Cup-Disk Ratio

We determined the cup-disk ratios of 580 individuals, ranging in age from 4 to 91 years, with a Hruby lens; we also determined the cup-disk ratios of 289 of the 580 with a direct ophthalmoscope. All had applanation pressures of 18 mm Hg or less. There was no linear relationship (covariation) between cup-disk ratio and refractive error or intraocular pressure, but there was a tendency toward increasing cup-disk ratio with increasing age. The mean cup-disk ratio in the group examined with the Hruby lens was 0.38 and that in the group examined with the direct ophthalmoscope was 0.25. With either method almost all eyes had cup-disk ratios of 0.7 or less. In 9% of the eyes the cup was ovoid. In only 10% of these cases was the vertical cup-disk ratio greater than the horizontal cup-disk ratio, and in only one case was this difference 0.2 or more. The Hruby lens method consistently gave a slightly larger cup-disk ratio than the direct ophthalmoscope did. However, there was seldom a disparity of more than 0.2. The Hruby lens or biomicroscopic lens should be used to determine the fullest extent of the contour of the cup. Any cup-disk ratio of 0.7 or more, any vertical cup-disk ratio larger than the horizontal cup-disk ratio, and any disparity between the direct ophthalmoscope estimation and Hruby lens estimation of more than 0.2 should be viewed with suspicion.

Results One Year After Using the 193-nm Excimer Laser for Photorefractive Keratectomy in Mild to Moderate Myopia

As part of a clinical trial, photorefractive keratectomy using the VISX 2015 193-nm excimer laser was performed on 91 healthy eyes of 91 patients. Preoperative refractive errors (spherical equivalent) ranged from -1.00 to -7.50 diopters (mean, -4.16 +/- 1.41 diopters). No patient had more than 1 diopter of refractive astigmatism. Six months postoperatively, the average residual refractive error was +0.09 +/- 0.63 diopters (range, -2.13 to +1.63 diopters). Correction within 1 diopter of that attempted was attained in 85 eyes (93%). Uncorrected visual acuity of 20/40 or better was attained in 86 eyes (95%) and was 20/25 or better in 67 eyes (74%). At one year, follow-up information was available on 85 eyes of 85 patients. The average residual refractive error was -0.15 +/- 0.65 diopters (range, -2.50 to +1.63 diopters). Correction within 1 diopter of that attempted was attained in 85 eyes (93%). Uncorrected visual acuity was 20/40 or better in 83 eyes (98%) and was 20/25 or better in 68 eyes (80%). One patient lost three lines of best-corrected visual acuity because of corneal haze, dropping from 20/15 to 20/30, whereas all other patients returned to best-corrected visual acuity within one line of their preoperative best-corrected visual acuity. Photorefractive keratectomy with the 193-nm excimer laser appears to be a useful treatment modality for the reduction of mild to moderate myopia.

Posterior amorphous corneal dystrophy.

A family of ten individuals aged 18 months to 75 years had biomicroscopic findings consisting of large, amorphous, sheet-like opacifications of the posterior stroma and Descemets membrane, and alterations of the endothelium. A uniform thinning of the cornea was present. These findings do not conform to previously described corneal dystrophies. The condition appears minimally progressive and the three-generation pedigree indicated an autosomal-dominant inheritance pattern.

Surgical Drape Support

This modified surgical drape support is affixed to the patients nose and face with self-adhesive pads or sterile surgical tape. The disposable support is flexible and keeps the surgical drape away from the nasal and oral passageways, facilitating observation of the patient by operating room personnel and relieving the patients anxiety and the breathing problems that often occur during ophthalmic procedures.

Epithelial Folds Following Slippage of LASIK Flap

We present a case of a slipped corneal flap after laser-assisted in-situ keratomileusis, LASIK. A 22-year-old, female with myopia and a refractive error of -5.50 D sph OU had an uneventful LASIK performed on her left eye with a Chiron Automated Corneal Shaper (ACS) and a VISX-Star Excimer laser using a nasal hinged flap. On the first postoperative day, slit lamp examination revealed 4.0 mm slippage of the corneal flap. The flap was rolled and folded on itself within the inferior cul-de-sac. With the aid of the operating microscope, the flap was repositioned on the stromal bed. Immediately following the repositioning, many folds were still visible despite centering the flap on the stromal bed and performing stretching maneuvers. Detailed examination showed the folds to be of edematous epithelial origin. The underlying stromal bed was flat. Within days following repositioning, the folds had disappeared and the flap assumed the typical postoperative LASIK appearance. The final uncorrected visual acuity returned to 20/20.

Intraocular Molluscum Contagiosum After a Corneoscleral Laceration

PURPOSE To report molluscum contagiosum as a cause of severe posttraumatic intraocular inflammation. METHODS A 9-year-old girl developed severe intraocular inflammation in the right eye after a corneoscleral laceration. She underwent vitrectomy, and bacterial and fungal cultures of intraocular fluids were negative. A pedunculated white-tan mass removed from her right optic nerve head was sent for histologic evaluation. RESULT Histologic examination of the tissue showed stratified keratinizing squamous epithelium with intracytoplasmic inclusions consistent with molluscum contagiosum. CONCLUSIONS It is likely that infected epithelial cells were implanted at the time of injury. Vitrectomy as debridement was curative.

A new surgical drape support.

A lightweight, malleable surgical drape support attaches to the patients forehead by sterile tape strips and rests comfortably over the patients nose. It keeps the surgical drape from occluding the nasal and oral airway of the patient, allowing for comfort as well as observation during an ophthalmic surgical procedure performed under local anesthesia. It is sterilizeable and compact and thus does not impede the surgeon or assistant during microsurgical procedures.

Circumferential nodulocystic keratopathy

An apparently unique type of corneal nodular keratopathy is presented. The keratopathy was characterized by large, circumferentially bilaterally located, cystic nodules just inside the limbus. No epithelial cell or collagenous degeneration nor evidence of chronic inflammatory process was found on histopathologic examination of a biopsy of a nodule. Proteinaceous material was present between the epithelial cell basement membrane and collagenous stroma. There was no antecedent history of keratitis or uveitis. The patient was known to have inflammatory bowel disease (regional ileitis) and rheumatoid arthritis with ankylosing spondylitis. However, the corneal lesions could not definitely be associated with any of these disorders. This case does not correspond with any previously described corneal disorders. We have termed it circumferential nodulocystic keratopathy, which best describes its clinical and histologic features.An apparently unique type of corneal nodular keratopathy is presented. The keratopathy was characterized by large, circumferentially bilaterally located, cystic nodules just inside the limbus. No epithelial cell or collagenous degeneration nor evidence of chronic inflammatory process was found on histopathologic examination of a biopsy of a nodule. Proteinaceous material was present between the epithelial cell basement membrane and collagenous stroma. There was no antecedent history of keratitis or uveitis. The patient was known to have inflammatory bowel disease (regional ileitis) and rheumatoid arthritis with ankylosing spondylitis. However, the corneal lesions could not definitely be associated with any of these disorders. This case does not correspond with any previously described corneal disorders. We have termed it circumferential nodulocystic keratopathy, which best describes its clinical and histologic features.