Klaus-Peter Steuhl

Amniotic membrane grafts for nontraumatic corneal perforations, descemetoceles, and deep ulcers☆

PURPOSE To describe the clinical outcome of amniotic membrane transplantation (AMT) for nontraumatic corneal perforations, descemetoceles, and deep ulcers. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Thirty-four eyes of 33 consecutive patients operated on for nontraumatic corneal perforations or descemetoceles at four academic departments of ophthalmology. Associated autoimmune disorders included rheumatoid arthritis (n = 6), Stevens-Johnson syndrome (n = 3), ocular cicatricial pemphigoid (n = 2), systemic lupus erythematosus (n = 1), and one eye with Moorens ulcer, as well as neurotrophic, or exposure keratopathy (n = 10), postinfectious nonhealing ulcers (n = 6), and postsurgery (n = 5). INTERVENTION Three or four layers of amniotic membrane (AM) were applied over the ulcer bed and anchored with 10-0 nylon interrupted or running sutures. A large AM piece was used as a patch to cover the entire corneal surface. MAIN OUTCOME MEASURES Formation of anterior chamber depth, epithelialization of the AM grafts, and stability of the corneal stromal thickness. RESULTS The mean follow-up period was 8.1 +/- 5.7 (ranging from 2-23) months. A successful result was observed in 28 of 34 eyes (82.3%). Of the successful cases, 23 eyes needed one AMT procedure, whereas 5 eyes needed two procedures to achieve a successful result. In five eyes, a subsequent definitive surgical procedure such as penetrating keratoplasty or lid surgery was needed. Failure was observed in six eyes with rheumatoid arthritis, neurotrophic keratopathy, or graft melting. CONCLUSIONS AMT is an effective method for managing nontraumatic corneal perforations and descemetoceles. It can serve as either a permanent therapy or as a temporizing measure until the inflammation has subsided and a definitive reconstructive procedure can be performed. This treatment option is also beneficial in those countries where corneal tissue availability is limited.

GS-101 Antisense Oligonucleotide Eye Drops Inhibit Corneal Neovascularization Interim Results of a Randomized Phase II Trial

PURPOSE Pathologic corneal neovascularization not only reduces corneal transparency and visual acuity, but also is one of the most significant preoperative and postoperative risk factors for graft rejection after corneal transplantation. The aim of this study was to test tolerability and efficacy of gene signal (GS)-101 eye drops, an antisense oligonucleotide against insulin receptor substrate-1, versus placebo on inhibition of progressive corneal neovascularization. DESIGN Randomized, double-blind, multicenter, phase II clinical study. PARTICIPANTS AND CONTROLS Interim analysis on 40 patients with progressive corneal neovascularization resulting from various underlying diseases being nonresponsive to conventional therapy. INTERVENTIONS Four groups of 10 patients were treated for 3 months in this dose-finding study comparing 3 doses of GS-101 (eye drops twice daily; 43, 86, and 172 microg/day total) with placebo (10 patients per group). MAIN OUTCOME MEASURES The primary end point was the area covered by pathologic corneal blood vessels, which was measured morphometrically on digitized slit-lamp pictures using image analysis techniques. RESULTS GS-101 eye drops were well tolerated. All serious and 95% of all other adverse events were categorized by the investigators as unrelated. In 3 patients, there was a potentially related side effect of ocular surface discomfort. At a dose of 86 microg/day (43 microg/drop), GS-101 eye drops produced a significant inhibition and regression of corneal neovascularization (-2.04+/-1.57% of total corneal area; P = 0.0047), whereas the low dose tended to stabilize it (0.07+/-2.94%; P = 0.2088) compared with placebo (0.89+/-2.15%), where corneal neovascularization progressed in all patients. There was no apparent benefit to the higher dose (1.60+/-7.63%). CONCLUSIONS The interim results of this phase II study suggest that GS-101 eye drops at an optimal dose of 86 microg/day are an effective and noninvasive approach specifically to inhibit and regress active corneal angiogenesis, a major risk factor for corneal graft transplantation and graft rejection. Safety concerns were not detected. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Prognostic value of clinical and histopathological parameters in conjunctival melanomas: a retrospective study

Aim: To determine prognostic factors for recurrence of disease and tumour related mortality in patients with conjunctival melanoma. Methods: A retrospective analysis of clinical and histopathological data of 69 patients with histologically verified conjunctival melanoma. Results: As univariate analysis showed, significant risk factors for the development of recurrence were: irregular pigmentation (RR = 2.0, p = 0.0007), incomplete surgical excision (RR = 3.5, p = 0.008), tumour invasion deeper than in substantia propria (RR = 3.9, p = 0.008), and presence of epithelioid tumour cells (RR = 2.9, p = 0.05). For tumour related mortality a significantly increased risk was found for tumour location in palpebral conjunctiva, caruncle, plica, or fornices (RR = 5.9, p = 0.001), for tumour infiltration deeper than the substantia propria (RR = 5.5, p = 0.001), for incomplete surgical excision (RR = 4.4, p = 0.05), and for nodular or mixed (nodular and superficial) growth pattern of the tumours (RR = 1.2, p = 0.002). The use of an adjuvant therapy for the surgical excision of the melanomas had no statistically significant influence upon the development of recurrent disease nor upon the tumour related mortality. Conclusion: These data present similar clinical and histopathological risk factors for patients with conjunctival melanoma as reported previously. The present study also addresses the failure of retrospective studies on conjunctival melanoma to prove the efficacy of a supplementary therapy to surgical excision.

TERT promoter mutations in ocular melanoma distinguish between conjunctival and uveal tumours

Background:Recently, activating mutations in the TERT promoter were identified in cutaneous melanoma. We tested a cohort of ocular melanoma samples for similar mutations.Methods:The TERT promoter region was analysed by Sanger sequencing in 47 uveal (ciliary body or choroidal) melanomas and 38 conjunctival melanomas.Results:Mutations of the TERT promoter were not identified in uveal melanomas, but were detected in 12 (32%) conjunctival melanomas. Mutations had a UV signature and were identical to those found in cutaneous melanoma.Conclusion:Mutations of TERT promoter with UV signatures are frequent in conjunctival melanomas and favour a pathogenetic kinship with cutaneous melanomas. Absence of these mutations in uveal melanomas emphasises their genetic distinction from cutaneous and conjunctival melanomas.

Matrix metalloproteinases (MMP-2 and 9) and tissue inhibitors of matrix metalloproteinases (TIMP-1 and 2) during the course of experimental necrotizing herpetic keratitis

To determine the distribution and activities of metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) during the course of experimental herpes simplex virus (HSV) type-1 keratitis, BALB/c mice were corneally infected with 10(5) plaque-forming units (PFU) of HSV-1 (KOS strain) and then observed for the clinical signs of keratitis. Corneas were harvested at days 0, 2, 7 and 14 post-infection (p.i.). MMP-2, MMP-9, MMP-8, TIMP-1 and TIMP-2 were detected by immunohistochemistry and the Western blot technique. The enzymatic activities were analyzed by zymography. Epithelial HSV keratitis was present at day 2 after corneal infection and healed by day 5 p.i. While the expression and activity of MMP-2, MMP-8 and MMP-9 increased in the corneas at day 2 p.i., it was reduced at day 7 p.i. TIMP-1 and -2 were expressed in the corneas before and seven days after infection. Necrotizing stromal keratitis with corneal ulceration and dense polymorphonuclear leukocyte (PMN) infiltration was present at day 14 p.i. This correlated with increased expression of MMP-2, MMP-8 and MMP-9 in the corneas. MMP-8, MMP-9 and MMP-2 staining was particularly intense in the proximity of the ulcers and in areas of PMN infiltration. At day 14 p.i., MMP-2, -8 and -9 activities were upregulated, and TIMP-2 was expressed. These data suggest that MMPs produced by resident corneal cells and PMNs may possibly play a role in early epithelial keratitis and in the ulcerative process in the late phase after corneal HSV-1 infection. The ratio of MMPs to TIMPs may be important for the course of necrotizing HSV keratitis. TIMPs might participate in the repair process.

Anti-CD20 monoclonal antibody therapy in relapsed MALT lymphoma of the conjunctiva

Abstract:  Low‐grade non‐Hodgkins lymphomas of the conjunctiva may be cured by radiotherapy, but complications are frequent and relapses may occur. Other treatment modalities including resection, cryotherapy, injection of interferon‐α or systemic chemotherapy have been used with varying success. We treated two patients with relapsed extranodal marginal zone lymphoma (ENMZL) of mucosa‐associated lymphoid tissue (MALT) of the conjunctiva with the anti‐CD20 monoclonal antibody rituximab (375 mg/m2 intravenously once weekly for 4 wk) which has previously been shown to be effective in a variety of other B‐cell non‐Hodgkins lymphomas. Treatment was well tolerated and resulted in one partial and one complete remission. With a follow‐up of 32 or 30 months, respectively, further recurrences have not been observed. Rituximab is a highly effective and well‐tolerated treatment of conjunctival MALT lymphoma, which may not only be of value in relapse, but also in cases of contraindication to radiotherapy.

CD4+ T-cell type 1 and type 2 cytokines in the HSV-1 infected cornea.

Abstract · Purpose: It has been previously shown that CD4+ T-lymphocytes are critical mediators in HSV-1 stromal keratitis (HSK). CD4+ T cell subpopulations (type 1, type 2) can be defined by their capabilities of producing different sets of cytokines. This study was performed to determine the role of type 1 and type 2 cytokines in murine HSK. · Methods: BALB/c mice (n=20) were inoculated with 105 PFU of HSV-1 (KOS strain) and were followed clinically. At various time points post-infection (p.i.), the conjunctival and corneal tissues were analyzed histologically (n=2 each time point), and immunohistochemically (n=5 each time point) for the presence of interleukin-1α (IL-1α), type 1 cytokines (IL-2, interferon-γ) and a type 2 cytokine (IL-4). The expression of cytokine mRNA was tested in eye samples by reverse transcription-polymerase chain reaction (RT-PCR). · Results: Stromal keratitis clinically progressed after day 9. In 15% of the mice, disease regressed until day 14 p.i. Polymorphonuclear neutrophils, lymphocytes and other mononuclear cells infiltrated the conjunctiva by day 2 and rapidly expanded to the central cornea between days 7 and 14. IL-1α, IFN-γ and IL-2 mRNA were found in the eyes at days 1 and 2 p.i. IL-1α protein was detected in the conjunctiva, limbus and corneal epithelium at day 2. The IL-1α staining intensities increased with disease progression. This was paralleled by IL-2 and IFN-γ staining intensities. In contrast, IL-4 mRNA and protein were detected at days 7 through 14 after HSV-1 infection; compared to IL-2 and IFN-γ, IL-4 staining intensities were lower. · Conclusions. The findings suggest that the lymphocytic infiltrate during the development of HSV-1 keratitis is predominantly composed of type 1 cells expressing IL-2 and IFN-γ. Type 2 cytokines participate in the late stage of inflammation and might be useful to improve the course of the disease.

Original articleGS-101 Antisense Oligonucleotide Eye Drops Inhibit Corneal Neovascularization: Interim Results of a Randomized Phase II Trial

PURPOSE Pathologic corneal neovascularization not only reduces corneal transparency and visual acuity, but also is one of the most significant preoperative and postoperative risk factors for graft rejection after corneal transplantation. The aim of this study was to test tolerability and efficacy of gene signal (GS)-101 eye drops, an antisense oligonucleotide against insulin receptor substrate-1, versus placebo on inhibition of progressive corneal neovascularization. DESIGN Randomized, double-blind, multicenter, phase II clinical study. PARTICIPANTS AND CONTROLS Interim analysis on 40 patients with progressive corneal neovascularization resulting from various underlying diseases being nonresponsive to conventional therapy. INTERVENTIONS Four groups of 10 patients were treated for 3 months in this dose-finding study comparing 3 doses of GS-101 (eye drops twice daily; 43, 86, and 172 microg/day total) with placebo (10 patients per group). MAIN OUTCOME MEASURES The primary end point was the area covered by pathologic corneal blood vessels, which was measured morphometrically on digitized slit-lamp pictures using image analysis techniques. RESULTS GS-101 eye drops were well tolerated. All serious and 95% of all other adverse events were categorized by the investigators as unrelated. In 3 patients, there was a potentially related side effect of ocular surface discomfort. At a dose of 86 microg/day (43 microg/drop), GS-101 eye drops produced a significant inhibition and regression of corneal neovascularization (-2.04+/-1.57% of total corneal area; P = 0.0047), whereas the low dose tended to stabilize it (0.07+/-2.94%; P = 0.2088) compared with placebo (0.89+/-2.15%), where corneal neovascularization progressed in all patients. There was no apparent benefit to the higher dose (1.60+/-7.63%). CONCLUSIONS The interim results of this phase II study suggest that GS-101 eye drops at an optimal dose of 86 microg/day are an effective and noninvasive approach specifically to inhibit and regress active corneal angiogenesis, a major risk factor for corneal graft transplantation and graft rejection. Safety concerns were not detected. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Merkel cell carcinoma of the eyelid: histological and immunohistochemical features with special respect to differential diagnosis

Abstract · Background: Merkel cell carcinomas (MCC) not infrequently involve the periorbital region and the eyelids. Clinically, they are relatively characteristic but often unsuspected. Histologically, MCC are often misdiagnosed as lymphoma, melanoma, or metastatic small cell carcinoma of the lung (SCCL). · Methods: We present clinical, histological, and immunohistochemical data on six eyelid cases (all females; age 63–102 years; one with concomitant CLL) from our files of 77 MCC with special respect to differential diagnosis. For comparison, 22 SCCL were analyzed. Immunohistochemistry was done with antibodies against pan-cytokeratin (pan-CK), cytokeratin-20 (CK-20), neurofilament protein (NF), neuron-specific enolase (NSE), chromogranin (CHR), and S100 protein (S100). · Results: Morphologically, five of six MCC were prototypic, one was of the small cell variant. Immunohistochemically, dot-like positivities for pan-CK and CK-20 were seen in all six MCC, and for NF in five tumors. None of the 22 SCCL stained positively for CK-20 or NF but 21/22 cases were positive for pan-CK. Only 1/21 SCCL showed dot-like patterns for pan-CK; 20/21 reacted diffusely. All MCC and 13/22 SCCL displayed CHR-positive cells. All MCC and all SCCL were positive for NSE and negative for S100. · Conclusions: Dot-like positivities for CK-20 or NF are important to prove MCC and to exclude SCCL in clinically and morphologically doubtful cases. Dot-like positivities for pan-CK favor MCC, but do not always exclude SCCL. NSE and CHR are of no value for the differential diagnosis of MCC and SCCL. Melanoma and lymphoma are ruled out by negativity for S100 and pan-CK, respectively.

Treatment of HSV-1 stromal keratitis with topical cyclosporin A: a pilot study

Abstract · Background: In stromal keratitis induced by herpes simplex virus (HSV) the host’s immune response contributes to corneal scarring and neovascularization. The purpose of this study was to analyze the efficacy of topically applied cyclosporin A (CsA) in patients with HSV keratitis. · Methods: The authors performed a prospective pilot study in patients with HSV stromal keratitis (n=18). Eyes were treated with CsA eyedrops and acyclovir ointment. The drugs were tapered off gradually. Visual acuity, slit-lamp appearance, intraocular pressure and corneal sensitivity were evaluated monthly (follow-up 5.2±0.28 months, mean±SEM. · Results: Keratitis resolved with CsA treatment in 10 of 14 patients with non-necrotizing keratitis and in 2 of 4 with necrotizing keratitis. As CsA was used topically, the corticosteroids could be withdrawn in all patients with non-necrotizing keratitis and in 1 of 3 with necrotizing keratitis. Under CsA therapy, persistent or progressive inflammation was noted in 6 of the 18 patients. These 6 patients with keratitis improved only with combined CsA/corticosteroids. Corneal ulcers healed in 4 patients with topical CsA, and corneal neovascularization improved in a further 8. Except for toxic epitheliopathy, no further CsA complications were noted. · Conclusions: The findings in this pilot study suggest that HSV stromal keratitis can be treated successfully with CsA eyedrops, especially in non-necrotizing disease. CsA may be particularly helpful in the presence of steroid glaucoma, herpetic corneal ulcers, and to taper off topical corticosteroids. Additional use of acyclovir may aid in suppressing the recurrence of epithelial HSV keratitis. A randomized study should be performed to evaluate the role of topical CsA in more detail.