Jerry G. Ford

Central Visual Field Changes Associated with Acquired Pits of the Optic Nerve

PURPOSE To investigate the histopathologic causes for the most prominent clinical observations of the iris of patients with pseudoexfoliation syndrome (PXS), particularly poor mydriasis but also atrophy of the iris pigment epithelium with anterior chamber melanin dispersion, stromal atrophy, and vascular changes. METHODS Thirty-three iris specimens from patients with PXS with and without glaucoma were investigated by transmission electron microscopy with special regard to sphincter and dilator muscle tissues. RESULTS Pseudoexfoliation fibers were observed consistently in association with fibroblasts and melanocytes in the iris stroma, endothelial cells and pericytes of vessels, both anterior and posterior pigment epithelial cells, and muscle cells of sphincter and dilator muscles. The various cell types showed uniformly surface cell membrane excavations with PXS fibers, indicating local PXS production. Focal disintegration of the pigment epithelial layers was associated with unusual PXS material aggregations along the apical aspects of epithelial cells. Compared with age-matched control specimens, the muscle cells showed, in addition to PXS production, remarkable degenerative and atrophic changes in PXS eyes. CONCLUSION The authors suggest that abnormal extracellular matrix production and/or vascular abnormalities leading to tissue hypoxia cause degenerative tissue changes and that atrophy of muscle cells might potentiate the reduction of dilating properties of the iris.

5-Fluorouracil for the treatment of intraepithelial neoplasia of the conjunctiva and cornea

OBJECTIVE To evaluate the efficacy of pulse dosing of topical 5-fluorouracil (5-FU) in the treatment of conjunctival and corneal intraepithelial neoplasia. DESIGN Prospective, noncomparative case series. PARTICIPANTS Seven patients with histologic evidence of intraepithelial neoplasia were identified by conjunctival biopsy or tumor excision. METHODS Seven patients with a minimum of 7 months of follow-up were treated with pulsed dosing of 1% 5-FU. Topical 1% 5-FU was administered four times daily for 2 to 4 days for each cycle. The number of initial treatment cycles was two to six, with the time between cycles being 30 to 45 days. MAIN OUTCOME MEASURES The presence or absence of clinically evident intraepithelial neoplasia was evaluated after each treatment interval. Patients were also monitored for adverse reactions to the use of topical 5-FU. RESULTS Four patients remain disease free with a mean follow-up of 18.5 months (range, 7-36 months) with no additional treatment after the initial treatment cycles (mean, 3.75 cycles; range, 2-5 cycles). Three patients had recurrence of disease after the initial treatment cycles. Two patients were treated with additional cycles for recurrent disease (six cycles in one patient and five cycles in the other patient) and are free of disease at 20 and 21 months after treatment, respectively. One patient had persistent disease despite treatment with topical 5-FU and was treated with topical mitomycin C with resolution of the disease without recurrence for 16.5 months. No adverse reactions to pulse dose treatment with topical 5-FU were noted. CONCLUSIONS Pulsed dosing with 1% topical 5-FU for the treatment of conjunctival and corneal intraepithelial neoplasia, alone or as an adjunct to excision of bulky disease, is a well-tolerated and effective method of treatment.

Topical 5-Fluorouracil in Treating Epithelial Neoplasia of the Conjunctiva and Cornea

PURPOSES To evaluate the efficacy of topical 5-fluorouracil (5-FU) in treating conjunctival and corneal epithelial neoplasia. METHODS Three patients underwent surgical excision of bulky disease followed by topical 1% 5-FU in artificial tear base for 2 to 3 weeks or until epithelial separation occurred. An additional three patients underwent treatment with topical 1% 5-FU alone. RESULTS Minimum follow-up was 6 months. In one patient with conjunctival in situ carcinoma and no detectable normal conjunctiva, who had normal findings on conjunctival histologic examination after application of topical 5-FU, a focus of invasive disease requiring orbital exenteration. One patient had a favorable response to 5-FU therapy but required a repeat excision for control of bulky disease. Four patients have remained disease-free for 10, 13, 18, and 30 months after topical 5-FU therapy. CONCLUSION With its potential selective toxicity on dysplastic epithelium, topical 5-FU shows promise as an adjunctive treatment for managing conjunctival and corneal epithelial neoplasia.

BILATERAL MONOCULAR DIPLOPIA ASSOCIATED WITH LID POSITION DURING NEAR WORK

Purpose To describe a common pattern of topographic changes and clinical signs of six patients presenting with a complaint of monocular diplopia after reading and to investigate the cause of this topographic disturbance. Methods Patient population: Subject group of six patients with monocular diplopia complaints after reading and 20 patients without such complaints. Examinations performed before and after a reading period of 30 min: videokeratoscopic examination, red reflex examination, position of the lids in primary gaze and in reading position. Data analysis: inspection of keratoscopic rings, qualitative analysis of topography maps, comparison of SAI and SRI of control and subject groups before and after reading, comparison of lid position of control and subject group. Results Half of the subject group and none of the control group developed subtle ring distortions of keratoscopic rings. SAI and SRI values increased significantly in the subject group compared with the control group (p = 0.02 and p < 0.001, respectively) corresponding to the development of a focal distortion in the entrance pupil of the videokeratoscopic image. Each subject developed a horizontal band on red reflex located at the superior, middle, or inferior aspect of the pupil after near work. Two controls developed faint bands in the red reflex outside the entrance pupil. The interpalpebral fissure in down gaze was narrower in the subject group compared with the control group (p = 0.001). Conclusions Some individuals may develop monocular diplopia after reading. We hypothesize that during near work these corneal topographic alterations occur primarily related to the position of the lids and tear film interaction with the corneal surface.

Retrospective analysis of a novel method of transscleral suture fixation for posterior-chamber intraocular lens implantation in the absence of capsular support.

Purpose To determine the safety and efficacy of an alternative method for transscleral fixation of a secondary posterior-chamber intraocular lens (pcIOL) during penetrating keratoplasty. Methods Eighty-nine eyes that underwent secondary pcIOL implantation by using a modified transscleral suture-fixation technique during penetrating keratoplasty were retrospectively evaluated. The surgical technique used suture fixation to the surface of the sclera 5 mm posterior to the limbus, with the knot buried beneath Tenons capsule and conjunctiva. Patient records were reviewed for postoperative complications, including suture erosion, pcIOL subluxation, vitreous hemorrhage, and retinal detachment. Mean follow-up was 24.4 months, with a range of 4–68 months. Results All eyes had successful fixation of their pcIOL immediately after surgery. Three (3.3%) eyes had graft failure. Six (6.7%) of 89 eyes showed evidence of suture erosion or partial exposure. Postoperative suture breakage occurred in two (2.2%) eyes. Posterior-segment complications included retinal detachment in one (1.1%) eye, vitreous hemorrhage in one (1.1%) eye, and limited choroidal hemorrhage in two (2.2%) eyes. Median visual acuity at 1-year follow-up was 20/70 (range, 20/25 to light perception). Conclusion This transscleral fixation technique provides a straightforward alternative to previously described techniques. Suture erosion, IOL dislocation, and posterior-segment complications occurred at relatively low rates compared with other pcIOL implantation techniques.

Orbital cellulitis, subperiosteal abscess, sinusitis, and septicemia caused by Arcanobacterium haemolyticum

PURPOSE/METHODS A 16-year-old boy had orbital cellulitis, subperiosteal abscess, sinusitis, and septicemia. Arcanobacterium haemolyticum was identified as the causative organism. RESULTS/CONCLUSIONS This organism is a cause of orbital cellulitis and may require aggresive therapy in order to achieve a therapeutic response.

Successful medical treatment of a case of Paecilomyces lilacinus keratitis.

Purpose: To report a successful medical treatment of a case of keratitis caused by Paecilomyces lilacinus. Methods: A 68-year-old woman developed an infection of the left cornea after minor trauma. The causative organism was found to be a particularly virulent organism, P. lilacinus. The patient was initially treated with natamycin topically and itraconazole orally, but the organism was resistant and failed to respond. She was then switched to topical voriconazole and oral terbinafine. Results: The patient was successfully treated with these medications without surgical intervention, an unusual outcome for this organism. Conclusions: If one encounters a case of fungal keratitis that fails to respond to the more commonly used agents, one should suspect a resistant organism such as Paecilomyces and should switch to voriconazole and/or terbinafine both topically and orally.

Progressive outer retinal necrosis secondary to varicella zoster virus in acquired immune deficiency syndrome.

Background A syndrome consisting of rapidly progressive outer retinitis in patients with suppressed immune systems has been described. The etiologic agent appears to be a member of the herpes virus family. Methods A 41-year-old man with acquired immune deficiency syndrome (AIDS) developed bilateral outer retinitis and choroiditis, which progressed despite antiviral treatment. A transscleral eye wall biopsy specimen and whole globe were submitted for microbiologic and histologic study. Results Polymerase chain reaction of a transscleral eye wall biopsy specimen and of the enucleated specimen determined the etiologic agent to be varicella zoster virus (VZV). Histologic studies demonstrated intranuclear inclusions consistent with viral particles in choroidal cells. Conclusion Our study revealed intranuclear inclusions in choroidal cells, a previously undocumented finding in progressive outer retinal necrosis. Polymerase chain reaction was very useful in identifying the causative agent.

Wound healing following anterior keratectomy and lamellar keratoplasty in the pig

PURPOSE To examine corneal wound healing in an animal model of two types of mechanical lamellar keratectomy. METHODS One eye from each of 28 pigs was studied. Using a motorized keratome, corneas were subjected to an anterior lamellar keratectomy with removal of anterior stroma and epithelium, or to automated lamellar keratoplasty (ALK) with reapposition of a corneal flap. The exposed stromal surfaces were labeled intraoperatively with a fluorescent dye (DTAF) to assess deposition of stromal components during subsequent wound healing. Examination before surgery and enucleation included measurement of corneal curvature and intraocular pressure, and assessment of corneal haze. Eyes were prepared for histological examination, fluorescence microscopy, and for fibronectin immunohistochemistry. RESULTS Both keratectomy procedures produced flattening of corneas by up to 3.80 diopters, 28 days after surgery. Corneal haze was more pronounced in eyes from which epithelium was removed (anterior lamellar keratectomy group). The increased haze in this group was associated histologically with appearance of many reactive keratocytes and inflammatory cells, deposition of new stromal material, and more widespread appearance of fibronectin immunoreactivity. In the lamellar keratoplasty group, only the edges of the corneal wound showed significant reactivity, and included keratocyte activation and epithelial ingrowth. CONCLUSIONS The pig provides a useful model for studies of refractive surgical techniques using procedures and instruments designed for use in humans. Mechanized keratectomy procedures that minimize disruption of the epithelium and Bowmans layer produce a less reactive corneal wound than procedures in which an expanse of epithelium and anterior stroma are removed.

Dopamine and intraocular pressure in critically ill patients.

BackgroundA recently released dopamine-1 receptor agonist, fenoldopam, increases intraocular pressure (IOP) in both healthy volunteers and patients with chronic ocular hypertension. Dopamine, a potent agonist at both dopamine-1 and -2 receptors, is frequently infused in critically ill patients for its inotropic, renal vasodilatory, and natriuretic effects. The authors hypothesized that low doses of dopamine would significantly increase IOP. MethodsPatients in the intensive care unit who were currently receiving dopamine infusions of less than 5 &mgr;g · kg−1 · min−1 were studied. After local ocular anesthesia was obtained, baseline IOP was measured in each eye with a hand-held tonometer. IOP was then determined after dopamine was discontinued. ResultsTwenty-three patients received a mean dopamine infusion of 2.6 ± 0.2 &mgr;g · kg−1 · min−1. Twelve of the 23 patients were receiving mechanical ventilation during the study. Mean IOPs in nonventilated patients (n = 11) off dopamine were 13.1 ± 0.9 mmHg (left eye) and 12.6 ± 0.9 mmHg (right eye). Mean IOPs for the same patients receiving dopamine were significantly higher at 16.1 ± 0.9 mmHg (left eye) and 15.9 ± 1.1 mmHg (right eye). Mean IOPs in intubated patients (n = 12) off dopamine were 12.3 ± 0.7 mmHg (left eye) and 12.5 ± 1.2 mmHg (right eye). Mean IOPs for the same patients while receiving dopamine were significantly higher in intubated patients at 17.8 ± 1.3 mmHg (left eye) and 17.3 ± 1.3 mmHg (right eye). The average mean elevation in IOP in patients while receiving dopamine was significantly higher in intubated patients as compared with nonintubated patients (5.2 ± 0.9 mmHg vs. 3.1 ± 0.6 mmHg). ConclusionsCommonly used doses of dopamine are associated with increased IOP in critically ill patients. Although normal patients should be able to tolerate this elevation safely for several weeks, there may be a potential risk in patients with preexisting glaucomatous nerve damage or ocular hypertension, especially if they are sedated and mechanically ventilated.