Ira G. Wong

Epidemiology of ulcerative keratitis in Northern California

OBJECTIVE To determine the incidence and associated risk factors for ulcerative keratitis in northern California. METHODS In this large-population, retrospective, cohort study, all medical records with diagnosis coding for corneal ulcers during a consecutive 12-month period were reviewed. Incidence rates were calculated using a dynamic population model. Multivariate relative risk regression was conducted to evaluate potential risk factors for ulcerative keratitis. RESULTS Within the target population of 1 093 210 patients, 302 developed ulcerative keratitis. The incidence of ulcerative keratitis was 27.6 per 100 000 person-years (95% confidence interval, 24.6-30.9). The incidence of corneal ulceration in contact lens wearers was 130.4 per 100 000 person-years (95% confidence interval, 111.3-151.7), with an adjusted relative risk of 9.31 (7.42-11.7; P < .001) compared with non-contact lens wearers, who had an incidence of ulcerative keratitis of 14.0 per 100 000 person-years (11.7-16.6). Seven of 2944 people known to be infected with human immunodeficiency virus developed ulcerative keratitis, with 5 being contact lens wearers. The incidence of ulcerative keratitis in human immunodeficiency virus-positive patients was 238.1 per 100 000 person-years (95% confidence interval, 95.7-490.5), with an odds ratio of 9.31 (7.42-11.7; P < .001) compared with human immunodeficiency virus-negative patients, who had an incidence of ulcerative keratitis of 27.1 per 100 000 person-years (24.1-30.3). CONCLUSIONS The incidence of ulcerative keratitis in this population is higher than previously reported. This may be owing to the increasing prevalence of contact lens wear.

Supratarsal Injection of Corticosteroid in the Treatment of Refractory Vernal Keratoconjunctivitis

PURPOSE We studied supratarsal injection of corticosteroid as a new therapeutic modality for treating severe vernal keratoconjunctivitis to determine its efficacy in treating patients refractory to all conventional therapy. METHODS Twelve patients with vernal keratoconjunctivitis resistant to all established therapy were prospectively studied by randomly assigning them to receive supratarsal injection of either short- or intermediate-acting corticosteroid. Relief of symptoms and resolution of clinical signs were evaluated. Patients were followed up to four years to identify side effects. RESULTS All patients experienced dramatic symptomatic relief within one to five days, regardless of the type of corticosteroid injected. Marked decrease in cobblestone papillae was noted in 14.9 days (mean) after short-acting corticosteroid injection and 12.8 days after intermediate-acting corticosteroid injection (P = .65). Shield ulcers and limbal involvement resolved in one to three weeks, independent of the corticosteroid used (P = .90). No complications were observed with supratarsal injection of short-acting corticosteroid. One patient developed persistent increase of intraocular pressure after injection of intermediate-acting corticosteroid. CONCLUSIONS The dramatic symptomatic and clinical improvement suggests that supratarsal injection of corticosteroid may be a valuable therapeutic approach to treating refractory vernal keratoconjunctivitis. Short-acting and intermediate-acting corticosteroids were equally efficacious. Because of the lack of intraocular pressure increase observed with short-acting corticosteroid, we favor its use in supratarsal injection.

Cytomegalovirus-associated acute retinal necrosis syndrome.

PURPOSE To describe a case of acute retinal necrosis syndrome in which a polymerase chain reaction-based assay provided evidence for cytomegalovirus as the causative agent of the syndrome. METHODS Polymerase chain reaction-based assays were used to analyze a vitreous aspirate from a 70-year-old man with acute retinal necrosis syndrome. The specimen was tested for cytomegalovirus, varicella-zoster virus, and herpes simplex virus type 1 and type 2. RESULTS The polymerase chain reaction assay for cytomegalovirus was positive, and polymerase chain reaction assays for varicella-zoster virus and herpes simplex virus type 1 and type 2 were negative. CONCLUSION Cytomegalovirus may be a causative agent of acute retinal necrosis syndrome.

Metipranolol-associated Granulomatous Iritis

PURPOSE Topical metipranolol therapy for primary open-angle glaucoma has been associated with anterior granulomatous uveitis in the United Kingdom. We studied granulomatous uveitis reactions to topical metipranolol 0.3% therapy for primary open-angle glaucoma in two patients in the United States. METHODS Two patients, aged 71 and 81 years, were given topical metipranolol 0.3% therapy for primary open-angle glaucoma. RESULTS Both developed granulomatous uveitis. The iritis was associated with an increase in intraocular pressure in both patients and resolved on discontinuation of the drug. One patient was inadvertently rechallenged with metipranolol, and the iritis recurred. CONCLUSIONS Topical metipranolol 0.3% therapy may be associated with the development of granulomatous uveitis and a paradoxical increase in intraocular pressure.

Microsporidial keratoconjunctivitis in a patient without human immunodeficiency virus infection.

PURPOSE To describe a case of microsporidial keratoconjunctivitis in a patient without human immunodeficiency virus (HIV) infection. METHODS Case report. An epithelial corneal scraping from a woman with chronic bilateral keratoconjunctivitis was evaluated by Giemsa stain. RESULTS Giemsa stain of an epithelial corneal scraping disclosed intracellular and extracellular spores characteristic of microsporidia. An HIV enzyme-linked immunosorbent assay (ELISA) test was negative. The signs and symptoms of the bilateral keratoconjunctivitis resolved after treatment with albendazole. CONCLUSION Microsporidia may cause a chronic epithelial keratoconjunctivitis in the absence of HIV infection.

Assessment of methylsulfonylmethane as a permeability enhancer for regional EDTA chelation therapy

Pharmacologic chelators do not effectively penetrate cell membranes and blood–brain barrier. This study assesses methylsulfonylmethane (MSM) as a permeability enhancer and an excipient to facilitate EDTA transport across biologic membranes, and to make possible localized, regional chelation. Topical application of MSM with C14EDTA onto the rat cornea led to uptake of the C14EDTA in all tested ocular tissues. Without MSM, EDTA did not penetrate the eye. The ability of MSM to deliver EDTA into an eye provides an opportunity for regional chelation therapy. Additionally, these studies suggest that MSM could also be an adjuvant for delivering ciprofloxacin and other chemical compounds to specific, local tissue sites.

Incidence and prevalence of episcleritis and scleritis in Northern California.

Purpose: To evaluate the incidence and prevalence of episcleritis and scleritis in a large well-defined population in Northern California. Methods: Secondary analysis was performed on data from the Northern California Epidemiology of Uveitis Study. The patient database of a large regional health maintenance organization was searched for all patients who potentially experienced ocular inflammatory disease during the 12-month study period. Medical records were reviewed for all potential patients to confirm ocular inflammatory disease and specific diagnosis, establish the time of onset, and collect additional data. Age- and sex-stratified quarterly study population data were used to calculate incidence rates and prevalence ratios. Results: After reviewing 2011 possible cases, 297 new-onset cases of episcleritis, 39 prior-onset cases of episcleritis, 25 new-onset cases of scleritis, and 8 prior-onset cases of scleritis were confirmed. For episcleritis, the overall incidence was 41.0 per 100,000 person-years and an annual prevalence ratio of 52.6 per 100,000. The overall incidence of scleritis was 3.4 per 100,000 person-years and an annual prevalence ratio of 5.2 per 100,000 persons. For both episcleritis and scleritis, there was a statistically significant increase in eye disease in older patients (P = 0.05 and <0.001, respectively) and for women in comparison with men (P = 0.001 and <0.001, respectively). Patients with scleritis were older than those with episcleritis (P = 0.017). Conclusions: This study found that patients with scleritis were older than those with episcleritis and that women had higher rates of both episcleritis and scleritis compared with what men had.

Topical Metal Chelation Therapy Ameliorates Oxidation-Induced Toxicity in Diabetic Cataract

Oxidative stress plays a critical role in cataractogenesis, the leading cause of blindness worldwide. Since transition metals generate reactive oxygen species (ROS) formation, metal chelation therapy has been proposed for treatment of cataracts. However, the effectiveness of most chelators is limited by low tissue penetrability. This study is the first to demonstrate that the topically applied divalent metal chelator ethylenediamine tetraacetic acid (EDTA) combined with the carrier and permeability enhancer methyl sulfonyl methane (MSM) ameliorates both oxidation-induced lens opacification and the associated toxic accumulation of protein-4-hydroxynonenal (HNE) adducts. Both in vitro (rat lens culture) and in vivo (diabetic rats), EDTA–MSM (1) significantly reduced lens opacification by about 40–50%, (2) significantly diminished lens epithelial cell proliferation and fiber cell swelling in early stages of cataract formation in vivo, and (3) notably decreased the levels of protein–HNE adducts. These findings have important implications specifically for the treatment of cataract and generally for other diseases in which oxidative stress plays a key pathogenic role.

Vitreitis and Waldenström’s macroglobulinemia

PURPOSE To describe vitreitis in a patient with Waldenströms macroglobulinemia. METHODS Case report and review of pertinent literature. RESULTS A 90-year-old man developed vitreitis 10 years after a systemic diagnosis of a lymphoproliferative disorder. Numerous small, normal-appearing lymphocytes were seen on pathologic examination of the vitreous. He developed worsening lymphadenopathy and was diagnosed with Waldenströms macroglobulinemia after systemic review. CONCLUSION Chronic lymphoproliferative diseases such as Waldenstroms macroglobulinemia may cause vitreitis.

A novel technique for harvesting keratolimbal allografts from corneoscleral buttons

PURPOSE To describe a method for obtaining partial-thickness keratolimbal allografts from corneoscleral buttons to be used in corneal limbal stem cell transplantation. DESIGN Description of device design and technique for use. METHODS Cyanoacrylate tissue adhesive, placed on the posterior side of a trephinated corneoscleral rim, is used to secure the allograft to a disposable acrylic sphere that is attached to a cylindrical base. RESULTS After fixation of the corneoscleral rim to the acrylic sphere, keratolimbal allograft harvesting is performed as a continuous strip dissection with a 65 Beaver blade. This technique minimizes trauma to the epithelial stem cells, provides excellent stability of the corneoscleral rim during harvesting, and preserves the central corneal button. CONCLUSIONS This method for obtaining keratolimbal allografts effectively provides tissue stabilization during harvesting, minimizing epithelial stem cell trauma and eliminating the need for whole donor globes.