Jerome C. Ramos-Esteban

Incidence of rainbow glare after laser in situ keratomileusis flap creation with a 60 kHz femtosecond laser

PURPOSE: To report the incidence of and factors associated with rainbow glare after laser in situ keratomileusis (LASIK) flap creation with a 60 kHz femtosecond laser. SETTING: Department of Refractive Surgery, Cleveland Clinic Cole Eye Institute, Cleveland, Ohio, USA. METHODS: Consecutive patients having LASIK by the same surgeon were questioned during postoperative examinations or by telephone about postoperative rainbow glare (radiating colors around a white light at night). Femtosecond laser (IntraLase) settings included pulse frequency 60 kHz, flap thickness 90 to 110 μm, and spot/line separation 8 μm. Raster energy was 0.8 μJ (75% of eyes) and 1.0 to 1.1 μJ (25%). Excimer laser ablation was performed with the LADAR 4000 or 6000 platform using custom or conventional treatments. RESULTS: Of 260 consecutive patients, 256 (98.5%) were successfully contacted. Fifteen patients (28 eyes) reported postoperative rainbow glare (5.8%), described as 4 to 12 bands of color around a white light, with 6 bands most common. The symptom did not correlate with refractive error, age, or sex but was more frequent at 1.0 μJ or 1.1 μJ raster energy (11.6%) than at 0.8 μJ (4.1%). The incidence followed a bimodal distribution, with the first grouping due to inadequate alignment and higher energy just after laser installation and the second just before a later maintenance service call. CONCLUSION: Rainbow glare is a mild optical side effect of femtosecond LASIK. In this study, higher raster energy levels and length of time between service calls were associated with the occurrence of rainbow glare.

Posttraumatic Stenotrophomonas maltophilia infectious scleritis.

Purpose: To describe the history, clinical presentation, and successful surgical and antibiotic management of a case of posttraumatic infectious scleritis secondary to Stenotrophomonas maltophilia. Methods: A 51-year-old white man presented with worsening light sensitivity, localized conjunctival hyperemia, and a painful scleral nodule in his right eye that developed over a period of 1 month after minor ocular trauma. The patient was treated by his referring ophthalmologist for “episcleritis” with fluorometholone 0.1%, 1 drop 4 times a day, since injury onset without clinical improvement. Evaluation consisted of slit-lamp examination, ultrasound biomicroscopy, and surgical exploration with tissue cultures and histology. Results: Ultrasound biomicroscopy of the right eye revealed the presence of a dome-shaped mass overlying an area of partial-thickness scleral laceration in the inferotemporal quadrant. The scleral nodule was surgically excised, and the scleral laceration was repaired with one 8-0 nylon suture. Culture results revealed infection by S. maltophilia, which was resistant to gentamicin, tobramycin, and trimethoprim-sulfamethoxazole. The patient experienced immediate pain relief after surgery, and treatment was continued with both topical ciprofloxacin 0.3% and prednisolone acetate 1% for 1 month with full recovery. Conclusions: S. maltophilia should be considered in the differential diagnosis of posttraumatic infectious scleritis. Submission of appropriate surgical specimens for microbiologic analysis and adequate antibiotic therapy may prevent the development of endophthalmitis in cases of suspected posttraumatic infectious scleritis.

Conjunctival lichen planus simulating ocular surface squamous neoplasia.

Purpose: To describe the history and clinical presentation of a case of conjunctival lichen planus simulating ocular surface squamous neoplasia (OSSN). Methods: A 32-year-old Hispanic man presented with a 6-month history of worsening foreign body sensation, localized conjunctival hyperemia, and a progressively enlarging “bump” located in the temporal aspect of his right eye. The patient denied any prior ocular trauma or surgery to the affected eye. Evaluation consisted of slit lamp examination and surgical excision of the mass with histopathologic studies. Results: Slit lamp examination revealed the presence of a 6 × 5 × 1 mm elevated conjunctival fleshy mass that extended into the corneal limbus in the right eye. The lesion exhibited intrinsic pigmentation and vascularization as well as the presence of a dilated feeder vessel. Based on clinical findings, a diagnosis of OSSN was suspected. An excisional biopsy was performed with cryotherapy application to the surgical margins. Histopathologic study of the lesion revealed hyperkeratosis, parakeratosis, irregular acanthosis, and a band-like infiltrate of predominantly lymphocytes hugging the epithelium, consistent with the diagnosis of lichen planus. Conclusion: Ocular lichen can present as a focal conjunctival lesion. Excisional biopsy allowed us to make the diagnosis of this rare entity, which presented as a simulating lesion with clinical features consistent with ocular surface squamous neoplasia.

Treatment of multidrug-resistant Flavobacterium indologenes keratitis with trimethoprim-sulfamethoxazole.

Purpose: To describe the history, clinical presentation, and successful medical management of a case of multidrug-resistant Flavobacterium indologenes keratitis. Methods: An 83-year-old pseudophakic female presented with a 2-day history of decreased visual acuity, light sensitivity and dull ocular pain in her right eye. Two weeks before presentation, the patient had been treated for a red eye with combination topical loteprednol etabonate (0.5%) and tobramycin (0.3%) eye drops. Corneal scrappings were performed by the referring ophthalmologist, and hourly administration of gatifloxacin 0.3% eye drops was started. Evaluation consisted of slit lamp examination, organism identification, and antibiotic sensitivity testing. Results: Examination of the right eye revealed a central 5-mm × 2-mm anterior stromal infiltrate with an overlying epithelial defect. Gatifloxacin 0.3% eye drops were stopped, and hourly topical fortified vancomycin (50 mg/mL) and ceftazidime (50 mg/mL) eye drops were instituted. Oxidase-positive gram-negative bacilli were identified in the thioglycollate broth on day 3, and therefore, vancomycin was discontinued and hourly ciprofloxacin 0.3% eye drops were added to the regimen. The cultures ultimately grew F. indologenes, which was highly resistant to all antibiotics tested except for trimethoprim-sulfamethoxazole. Accordingly, ciprofloxacin 0.3% and ceftazidime were discontinued. The patient was started on hourly topical trimethoprim (16 mg/mL)/sulfamethoxazole (80 mg/mL) eye drops, resulting in clinical control of the infection over a period of 1 month. Conclusions: Flavobacterium indologenes keratitis can be resistant to treatment with many medications, and antibiotic susceptibility profile testing in these cases may provide crucial information to help eradicate the infection.