H. Bruce Ostler

The Floppy Eyelid Syndrome

We examined 11 overweight men, ranging in age from 34 to 56 years, who had the floppy eyelid syndrome, a disorder of unknown origin manifested by an easily everted, floppy upper eyelid and papillary conjunctivitis of the upper palpebral conjunctiva. The upper eyelid everts during sleep, resulting in irritation, papillary conjunctivitis, and conjunctival keratinization. Effective treatment consists of preventing the upper eyelid from everting while the patient is sleeping.

Herpetic Eye Disease Study: A Controlled Trial of Oral Acyclovir for Herpes Simplex Stromal Keratitis

PURPOSE To evaluate the efficacy of oral acyclovir in treating stromal keratitis caused by herpes simplex virus (HSV) in patients receiving concomitant topical corticosteroids and trifluridine. METHODS The authors performed a randomized, double-masked, placebo-controlled, multicenter trial in 104 patients with HSV stromal keratitis without accompanying HSV epithelial keratitis. Sample size was chosen so that a 5%, one-tailed test would have an 80% chance of detecting a doubling of the median time to treatment failure. Patients were randomized to receive a 10-week course of either oral acyclovir (400 mg 5 times daily, n = 51) or placebo (n = 53). All patients also received a standard regimen of topical prednisolone phosphate and trifluridine. Ophthalmologic examinations were performed weekly during the 10-week treatment period, every 2 weeks for an additional 6 weeks, and at 6 months after entry into the trial. RESULTS The median time to treatment failure (defined as worsening or no improvement of stromal keratitis or an adverse event) was 84 days (95% confidence interval, 69-93 days) for the acyclovir group and 62 days (95% confidence interval, 57-90 days) for the placebo group. By 16 weeks, 38 patients (75%) in the acyclovir group and 39 patients (74%) in the placebo group had failed treatment. Also by that time, the keratitis had resolved with trial medications, and there was no subsequent worsening in nine patients (18%) in the acyclovir group and ten (19%) in the placebo group. None of these results were significantly different between the two groups. However, visual acuity improved over 6 months in significantly more patients in the acyclovir group than in the placebo group. CONCLUSION There was no statistically or clinically significant beneficial effect of oral acyclovir in treating HSV stromal keratitis in patients receiving concomitant topical corticosteroids and trifluridine with regard to time to treatment failure, proportion of patients who failed treatment, proportion of patients whose keratitis resolved, time to resolution, or 6-month best-corrected visual acuity. Visual acuity improved over 6 months in more patients in the acyclovir group than in the placebo group.

The ocular manifestations of herpes zoster, varicella, infectious mononucleosis, and cytomegalovirus disease

Herpes zoster, caused by varicella-zoster (V-Z) virus which also causes varicella (chickenpox), is usually a benign self-limited disease. However, when the ophthalmic division of the trigeminal nerve is affected, the ocular disease (ophthalmic zoster), although also usually mild and self-limited, may have severe complications (corneal scarring, glaucoma, iris atrophy, posterior synechiae, scleritis, motor disturbances, optic neuritis, retinitis, anterior segment necrosis, and phthisis bulbi and servere postherpetic neuralgia). Varicella affects the eye rarely (except for the typical lid lesions), but associated conjunctival and corneal lesions, iridocyclitis, glaucoma, chorioretinitis, and optic nerve lesions have been described. Infectious mononucleosis may involve the eye either by direct involvement or from a remote focus such as the central nervous system. Ocular manifestations of cytomegalovirus disease is usually limited to the choroid and retina unless involvement of the developing embryo occurs prior to the development of the eye.

HUMAN INFECTION WITH THE AGENT OF FELINE PNEUMONITIS

Abstract A Bedsonia sp. isolated from conjunctival scrapings of a man with acute follicular keratoconjunctivitis differed from the TRIC agents in its resistance to sulphonamides and in producing an iodine-negative inclusion. The patient owned a cat with a recent history of rhinitis and conjunctivitis—manifestations consistent with feline pneumonitis. A bedsonial agent isolated from this cat and from another cat in the same household had the same characteristics as the agent recovered from the patient. The isolate from the patient produced a typical, acute, inclusion-positive conjunctivitis in experimentally infected cats.

Treatment of Ocular Disease in Eczema Herpeticum

Individuals with atopic dermatitis are particularly susceptible to herpes simplex viral infection and may develop dissemination (eczema herpeticum). Additionally, they may develop severe and bilateral herpetic ocular disease. The keratitis is commonly complicated by stromal scarring and slow epithelial healing despite topical antiviral therapy. We treated three patients who had herpetic keratoconjunctivitis associated with eczema herpeticum. In all three cases the keratitis resolved promptly (48 to 72 hours) without residual scarring after treatment with systemic acyclovir and topical trifluridine. The combined use of systemic acyclovir and topical trifluridine may be of similar value in treating all cases of atopic herpetic keratitis.

Thygeson's Superficial Punctate Keratitis

Thygesons superficial keratitis is a chronic disease of the cornea characterized by focal epithelial lesions. We studied 45 cases of Thygesons superficial punctate keratitis. Twenty-eight were male and 17 were female patients. The disease had been active in our patients from one month to 24 years. The clinical findings, course, outcome, and response to therapy were studied. Viral cultures and microscopic studies were performed on the corneal epithelial scrapings from ten cases. The average course of the disease was prolonged in patients who received topical steroid therapy. Subepithelial opacities were seen more frequently in patients who had received treatment with idoxuridine (IDU).

Herpes simplex: The primary infection

A primary infection with herpes simplex virus (HSV) occurs at some time in the life of almost every member of the population, especially among those living in crowded, unsanitary conditions. In many cases the lesions are subclinical, and in most cases they are self-limited even when clinical. In a few patients, such as the newborn infant, the patient with concomitant eczema, or the patient with reduced immunity, the primary infection may become severe, generalized, and life-threatening. Type 1 HSV has a predilection for a number of sites, including the oral cavity, the eye, and the skin; and type 2 HSV has a predilection for the genital area and for the newborn.

Glucocorticoid therapy in ocular herpes simplex

ibstract. In the absence of controlled clinical studies comparing stromal herpes simplex keratitis managed with and without glucocorticoids, the controversy surrounding this subject continues. In this pair of articles, Dr. Ostler emphasizes the danger of glucocorticoid suppression of host immune defenses which inhibit herpes simples replication, while Drs. Pavan-Langston and Abelson emphasize the danger of allowing stromal and endothelial inflammation to produce permanent structural alteration. Dr. George Waring presents a summary statement, suggesting therapeutic guidelines based on these two articles. (Sun Ophthalmol 23:35-48, 1978)

Noninfectious Ring-Shaped Keratitis Associated with Pseudomonas Aeruginosa

Ring-shaped keratitis appeared in the left eye of a 37-year-old woman who had worn soft contact lenses for more than five years. The corneal ring began to appear within seven days of a central corneal abrasion. Gram staining of the patients contact lens cleaning solution showed many gram-negative rods, and microbiologic investigations of the patients soft contact lens and contact lens case disclosed Pseudomonas aeruginosa. There was no clinical or laboratory evidence of an infectious process. Prompt treatment with polymyxin B-bacitracin ointment and prednisolone acetate 1% eyedrops led to resolution of the opacity and a return to the patients normal visual acuity. The P. aeruginosa endotoxin may have been transferred through the epithelial break into the superficial corneal stroma, leading to ring formation via endotoxin-initiated, properdin-mediated, antibody-independent complement activation.

Oculogenital transmission of type 2 herpes simplex virus in adults

Type 2 (genital) herpes simplex virus (HSV-2) was isolated from three patients (two adults and an 11-year-old girl) with acute ocular infections. Two of these patients had acute blepharoconjunctivitis and one had acute keratoconjunctivitis. Genital herpes infections had preceded the eye infections in the two adults. This was not the case in the 11-year-old, but she had been in close contact with her sister who had apparently had the genital disease. The study strongly suggests transmission of HSV-2 from the genital site to the eye.