John S. Parker

A phase III, multicenter, randomized, placebo-controlled clinical trial of topical aminocaproic acid (Caprogel) in the management of traumatic hyphema

OBJECTIVE To determine the safety and efficacy of topical aminocaproic acid (Caprogel) in the management of traumatic hyphema. DESIGN Multicenter, randomized, double-masked, placebo-controlled clinical trial. PARTICIPANTS A total of 51 patients participated in this trial (power = 36%, 2-tailed test). INTERVENTION Patients presenting with traumatic hyphema were randomly assigned to 5-day treatment with topical aminocaproic acid or a placebo gel. Patients were monitored daily with ocular examination and vital sign testing for the 5 days of treatment and at 24 and 48 hours after treatment. General physical examination and laboratory testing were performed at baseline and day 5. MAIN OUTCOME MEASURES The main efficacy variable was the rate of rebleeding. Secondary efficacy variables included time to hyphema clearance, intraocular pressure, time to secondary hemorrhage, and visual acuity. Safety variables included adverse events, vital signs, and laboratory measurements. RESULTS Rebleeding occurred in 30% of the placebo group (8 of 27; 95% confidence interval [CI] = 14-50%), versus 8% of the treatment group (2 of 24; 95% CI = 1-27%), for an estimated continuity-corrected difference in percentage of patients with bleeding of 17% (95% CI = -3-38%). Secondary efficacy variables were similar in the groups, except that there was a trend towards more visual improvement in the topical aminocaproic acid group (54%) than in the placebo group (30%) at the last measurement (P = 0.08). Adverse events were similar. CONCLUSIONS This study provides evidence that topical aminocaproic acid is safe and demonstrates trends towards reducing the rebleeding rate in the management of traumatic hyphema. However, because the study was terminated before complete enrollment, more definitive recommendations will require a larger trial.

Kawasaki's Syndrome in a Man With the Human Immunodeficiency Virus

PURPOSE/METHODS We examined a 25-year-old man who was positive for the human immunodeficiency virus (HIV) with Kawasakis syndrome. He responded dramatically to intravenous immunoglobulin. RESULTS/CONCLUSIONS Although Kawasakis syndrome is exceedingly rare in adults, it should be considered in any patient with fever, conjunctivitis, and other characteristic findings. The efficacy of treatment with intravenous immunoglobulin underscores the importance of prompt diagnosis.

In vivo molecular analysis of cytokines in a murine model of ocular onchocerciasis I. Up-regulation of IL-4 and IL-5 mRNAs and not IL-2 and IFNγ mRNAs in the cornea due to experimental interstitial keratitis

Sclerosing keratitis is the major cause of blindness due to onchocerciasis which results from chronic infection with the filarial parasite Onchocerca volvulus. Using a murine model of onchocercal sclerosing keratitis, we have demonstrated previously that predominantly (> 85%) CD3 + /CD4+ T-cells as well as the IL-2 receptor bearing cells infiltrate into the cornea in vivo during development and progress of the disease. The identification of CD4+ subsets TH1 and TH2 based on the cytokine secretion patterns of murine T-lymphocytes has been useful for understanding the immune basis of resistance and pathogenesis in murine models of several parasitic diseases. The present investigation was carried out to demonstrate whether the local immune response at the corneal lesion due to onchocercal interstitial keratitis correlated with such distinct patterns of cytokine production. For that purpose, mRNA was extracted separately from corneas obtained from the diseased eyes and the normal eyes of A/J mice with onchocercal interstitial keratitis, reverse transcribed and amplified by the polymerase chain reaction with four different cytokine specific primers. In corneas obtained from the eyes affected with onchocercal interstitial keratitis, mRNAs coding for IL-4 and IL-5 were up-regulated compared to the normal eyes having no lesions from the same animals. However, the levels of mRNAs for IL-2 and IFN gamma were found to be the same in the diseased and normal eyes. Taken together, these data suggest that IL-4 and IL-5 producing TH2-lymphocytes are active at the corneal lesion due to onchocercal interstitial keratitis.

Quantification of fluorescein-stained drusen associated with age-related macular degeneration.

Background: Previous studies of age-related macular degeneration have not quantified the number of drusen that accumulate fluorescein. Histopathologic studies have demonstrated druse subregions with different degrees of hydrophobicity, and these subregions might potentially exhibit different degrees of fluorescein uptake. Methods: We evaluated macular drusen from 35 age-related macular degeneration patients by measuring druse area in color digital images and fluorescein angiograms, using 2 morphometric methods. Results: Of 828 drusen evaluated, 405 had a corresponding fluorescein angiogram signal. About half of all drusen per eye (49.57%) stained in each participant. Among fluorescein-stained drusen, druse size measured in color images did not differ significantly from the sizes measured in corresponding fluorescein images (P = 0.8105), across the range of druse sizes. Conclusion: These findings indicate that our understanding of drusen subregion staining may not directly correlate to in vivo observations of macular drusen in age-related macular degeneration.

Descemet Membrane Endothelial Keratoplasty—A Review

Descemet membrane endothelial keratoplasty (DMEK) is the most recent step forward in the evolution of endothelial keratoplasty toward thinner grafts and more natural, anatomic corneal restoration. Offering unprecedented visual results and requiring no special or expensive equipment, DMEK has the potential to become the first line treatment for corneal endothelial disorders. The surgery’s perceived shortcomings (primarily technical difficulty) have mostly been addressed by new ‘no-touch’ procedures for both graft preparation and graft unfolding in the recipient eye. And as a result, DMEK has been gaining traction with ophthalmologists the world over. Now, in its most recent formulation, DMEK is ready for the typical corneal surgeon, in any clinical setting, and at low cost.

Descemet membrane endothelial keratoplasty in an eye with fuchs endothelial dystrophy and keratoconus

Purpose To report a case of Descemet membrane endothelial keratoplasty (DMEK) performed with phacoemulsification and intraocular lens implantation (triple procedure) for coexisting keratoconus (KC), Fuchs endothelial dystrophy (FED), and visually significant cataract. Case description One eye of one patient with moderate and stable KC, FED, and visually significant cataract was treated with combined DMEK and phacoemulsification with intraocular lens implantation (triple procedure). Visual acuity and corneal reflectivity/densitometry, thickness, and topographic measurements were recorded and compared to their preoperative values. At all postoperative time points, the endothelial graft was found to be completely attached. By 3 months postoperatively, the patients best spectacle corrected vision had improved from 20/50 (0.4) to 20/25 (0.8) where it remained stable. No intra- or postoperative complications were experienced. Conclusions DMEK may be an effective alternative to penetrating keratoplasty in eyes with coexisting stable KC and FED.

Boston Type 1 Keratoprosthesis: Visual Outcomes, Device Retention, and Complications

reported complications. We have reported on preparation of ultrathin (UT) endothelial grafts2,3 at the Veneto Eye Bank Foundation, Italy, and the long distance transport and delivery of grafts within an iGlide.4 One of the major advantages that we found using the iGlide was the design of the device. It consists of a cap/lid as an additional tool for preventing any movement of the donor tissue during shipment. We have observed that EndoGlide Ultrathin inserters do not have a cap, and this may therefore pose a risk of losing or moving the graft during long shipments with graft damage. The presence of a cap not only allows the graft to stay inside the glide during transportation but also allows it to be stained with trypan blue, if required, and washed with phosphate-buffered saline before transplantation without any changes, as the tissue stays firmly inside the glide unless pulled out during surgery. Incorrect folding of the preloaded graft can be avoided with the iGlide. In addition, the preloaded donor cornea lies on a thin contact lens preventing wrinkling of the thin donor layer in the iGlide. This avoids the possibility of graft wrinkling, which was reported as a second complication in this study. Because of the thickness and possibility of wrinkling, it becomes important to provide a firm base to the UT-DSAEK grafts using, for example, a contact lens. Furthermore, the size of the recipient bed and the donor disc was 8.0 mm in 32 cases and 7.5 mm in 3 cases as reported in this article. It is therefore of note that, after our previous report,5 we also receive requests for large donor posterior lamellar grafts (9.5 mm), and our laboratory and clinical experience shows that the iGlide also allows safe shipping and delivery of large UT-DSAEK grafts (data under consideration for publication). Although speculative, we have had anecdotal reports that storage of the tissue reduces the roughness of the stroma and may reduce adherence of the graft. For this reason, we would suggest that if stored prepared tissue is used, then venting incisions are important. We agree with the results of Palioura and Colby that preloaded donor tissue reduces surgical time and some of the risks associated with preparation of large UT-DSAEK, in the operating room (perforation, irregular cut, surgical delay). In addition, it is possible to provide standardized and validated tissue for transplant. Hence, we believe that the iGlide may be a useful solution to avoid many unnecessary manipulations and tissue wastage, and it is also a safe device for transportation and delivery of, both, smalland large-diameter UTDSAEK grafts.