Larry F. Rich

Recurrent Erosion: Treatment by Anterior Stromal Puncture

The majority of patients with recurrent corneal erosion respond to conventional forms of therapy such as topical lubricants, patching, debridement, or bandage soft contact lenses. However, there remain a small number who do not. For the small number of patients who do not respond to this type of treatment, this report describes a procedure: multiple anterior stromal punctures are created that presumably stimulate more secure epithelial adhesion to the underlying stroma. Of 21 eyes in 18 patients treated in this manner, three eyes required retreatment of adjacent areas; otherwise, there were no recurrences in follow-up periods ranging from 5 months to 12 years. This procedure is a simple and effective method for safe office treatment of patients with recalcitrant recurrent erosion.

The Effects of Hard and Soft Contact Lenses on the Corneal Endothelium

We examined the morphologic characteristics of the corneal endothelium in three groups of contact lens wearers: those who had used daily-wear soft contact lenses for an average of 6.3 years, long-term (greater than 20 years) users of hard contact lenses, and former users of hard contact lenses who had worn them for an average of 9.6 years but who had discontinued them for an average of 4.3 years. When compared to age-matched controls, all groups had similar endothelial cell densities but demonstrated significant increases in variation of cellular size (polymegethism) and shape (pleomorphism). We found that daily-wear soft contact lenses can cause endothelial polymegethism and pleomorphism similar to those caused by hard contact lenses and that the endothelial changes induced by hard contact lenses are more profound with greater duration of wear and are apparently not completely reversible.

Steroid-induced glaucoma after laser in situ keratomileusis associated with interface fluid

PURPOSE To report the ocular manifestations and clinical course of eyes developing interface fluid after laser in situ keratomileusis (LASIK) surgery from a steroid-induced rise in intraocular pressure. DESIGN Retrospective, noncomparative interventional case series. PARTICIPANTS/INTERVENTION We examined six eyes of four patients who had diffuse lamellar keratitis develop after uneventful myopic LASIK surgery and were treated with topical corticosteroids. PRINCIPAL OUTCOME MEASURE: Slit-lamp findings, intraocular pressure measurements, and visual field loss. RESULTS All eyes had a pocket of fluid develop in the lamellar interface between the flap and the stromal bed associated with a corticosteroid-induced rise in intraocular pressure. However, because of the interface fluid, intraocular pressure was normal or low by central corneal Goldmann applanation tonometry in all eyes. The elevated intraocular pressure was diagnosed by peripheral measurement in several cases after months of elevated pressure. All six eyes had visual field defects develop. Three eyes of two patients had severe glaucomatous optic neuropathy and decreased visual acuity develop as a result of undiagnosed steroid-induced elevated intraocular pressure. CONCLUSIONS A steroid-induced rise in intraocular pressure after LASIK can cause transudation of aqueous fluid across the endothelium that collects in the flap interface. The interface fluid leads to inaccurately low central applanation tonometry measurements that obscure the diagnosis of steroid-induced glaucoma. Serious visual loss may result.

Sterile interface keratitis associated with micropannus hemorrhage after laser in situ keratomileusis

Numerous etiologies have been suspected to lead to sterile interface keratitis after laser in situ keratomileusis. This tan interface haze with a rippled appearance has been called Sands of the Sahara. We present 2 cases in which red blood cells entered the interface after a small hemorrhage from peripheral corneal vascularization during the microkeratome pass. Although this bleeding was controlled and all visible blood cells were removed at surgery, both patients developed the appearance of a focal interface keratitis on the first postoperative day.

Laser-assisted in situ keratomileusis complications in diabetes mellitus

Purpose. To report the incidence of complications and the refractive results in patients with diabetes mellitus treated with laser-assisted in situ keratomileusis (LASIK). Methods. A retrospective review of the charts, focusing on 6-month postoperative data, was performed on 30 eyes from patients with diabetes and 150 age- and gender-matched control eyes operated on during the same period. The incidence of complications and postoperative refractive results were compared. The data analyzed include UCVA, spherical equivalent, astigmatism power, astigmatism axis, and vector astigmatism change. Results. Diabetic eyes treated with LASIK had an overall complication rate of 47% compared with the control population complication incidence of 6.9% (p < 0.01). The most frequent complications occurring in the diabetic population are punctate epithelial erosions and persistent epithelial defects. Spherical correction change was −4.64 diopters (D) for diabetic eyes and −4.98 D for control eyes (p = 0.49). Mean spherical equivalent change was −4.69 D for diabetic eyes and −4.75 D for control eyes (p = 0.9). Mean change in uncorrected visual acuity (LogMAR) was 1.5 for diabetic eyes and 1.65 for control eyes (p = 0.18). Mean astigmatism magnitude change was 0.31 in diabetic eyes and 0.57 in control eyes (p = 0.12). Mean vector corrected astigmatism change was 0.97 for diabetic eyes and 1.12 for control eyes (p = 0.31). Mean vector-corrected astigmatism axis for patients with diabetes was 18.17 for diabetic eyes and 6.20 for control eyes (p = 0.30). Conclusion. Patients with diabetes who undergo LASIK are at a significantly higher risk of developing postoperative epithelial complications. In addition, this study revealed poorer refractive results in the eyes of patients with diabetes treated with LASIK.

Diurnal Variation in Vision After Radial Keratotomy

We tested eight patients who had undergone radial keratotomy with regard to refraction, keratometry, corneal thickness, and intraocular pressure one to two weeks after surgery. Patients were examined immediately after eye-lid opening at 7:30 A.M. and again at 4:00 P.M. The contralateral eye was used as a control. The treated eye was 1.48 +/- 0.24 diopters (mean +/- S.E.M.) more hyperopic at the morning examination compared to the afternoon visit, whereas the control eye had an insignificant shift (0.16 +/- 0.06 diopters). The treated eye was significantly flatter (1.37 +/- 0.19 diopters) in the morning than in the afternoon when compared to the control eyes, which were only 0.11 +/- 0.09 diopter flatter. The intraocular pressure changed insignificantly in both the treated and control eyes (-0.5 +/- 0.53 mm Hg and -0.5 +/- 0.84 mm Hg, respectively). The mean morning corneal thickness was significantly greater (5.7%) than the afternoon thickness when compared to the controls (1.7% morning increase in thickness). These data suggest that diurnal variation in corneal thickness after radial keratotomy plays a role in diurnal variation of vision in the early postoperative period.

Sterile Interface Keratitis After Laser in situ Keratomileusis: Three Episodes in One Patient With Concomitant Contact Dermatitis of the Eyelids

PURPOSE To illustrate a case in which sterile interface keratitis after laser in situ keratomileusis (LASIK) occurred concomitantly with an allergic contact dermatitis of the eyelids. METHODS Retrospective case review. RESULTS Resolution of the interface keratitis and dermatitis occurred following an intense course of topical corticosteroids and brief course of oral corticosteroids. Despite an attempt to eliminate potential causes, the same patient developed interface keratitis in the fellow eye following both the initial LASIK and an enhancement, in which no microkeratome was used. Intense treatment with both topical and oral corticosteroids led to a final uncorrected visual acuity of 20/20 in the right eye and 20/25+2 in the left eye. CONCLUSION The etiology and mechanism of sterile interface keratitis after LASIK are unknown, but are probably multifactorial. The concomitant contact dermatitis reaction may indicate a common immune mechanism.

Evaluation of prior photorefractive keratectomy in donor tissue.

PURPOSE To describe a case in which an eye donor had prior bilateral photorefractive keratectomies and to elucidate possible methods of evaluation and screening of donor tissue. METHODS Case report. A 62-year-old eye donor was reported to have received radial keratotomy before his death. Further investigation by the eye bank showed a history of photorefractive keratectomy (PRK), not radial keratotomy. The corneas were therefore not used for transplantation, and the eyes were evaluated by slit-lamp examination, photography, corneal topography, and histology. RESULTS Slit-lamp and photographic examination did not indicate the presence of PRK ablations. Corneal topography mapping with the TMS-1 was relatively ambiguous for identifying PRK flattening, while multiple data formatting of the cornea with the Orbscan resulted in the strongest suggestion of prior PRK. Histologic analysis showed central corneal thinning and loss of Bowmans membrane consistent with PRK. CONCLUSIONS In the absence of a positive donor history for PRK, current methods of screening donor tissue for prior PRK often are insufficient to exclude these corneas from use in transplantation. More refined placido imagery corneal topography or newer technologies such as the Orbscan may allow more sensitive and specific methods of donor tissue screening.

The effect of radial keratotomy on the corneal endothelium

Morphometric analysis of the corneal endothelium was performed on 11 eyes of patients who underwent anterior radial keratotomy with the contralateral eye serving as the controls. We analyzed cell density, variation in cell size (polymegethism), and cell shape (pleomorphism) by computer analysis of central and midperipheral specular micrograms one year after surgery. The central endothelial density decreased from 2,503 to 2,419 cells/mm2 (3.3% decrease). The coefficient of variation in cell size (polymegethism) was 0.290 preoperatively and 0.309 postoperatively centrally. Central hexagonality was reduced centrally from 61.4% preoperatively to 56.8% in the operated on eye. These differences were not statistically significant (P greater than .05). In a separate subgroup of six patients, midperipheral specular microscopy under and between incisions disclosed a similar pattern of mild cell density decrease and morphometric remodeling one year after surgery. No morphometric characteristic was significantly different from the central control values (P greater than .05), suggesting that the corneal endothelial monolayer had stabilized one year after radial keratotomy.

Treatment of interface keratitis with oral corticosteroids.

Purpose: To describe the results of treating interface keratitis using a combination of intensive topical and oral corticosteroids. Setting: Casey Eye Institute, Portland, Oregon, USA. Methods: Thirteen eyes treated for grade 2 to 3 interface keratitis using an oral corticosteroid (prednisone 60 to 80 mg) as well as an hourly topical corticosteroid were retrospectively reviewed. The best corrected visual acuity (BCVA) was used as an objective guide of whether to treat with intense topical and oral corticosteroids, flap irrigation, or both. Predisposing factors such as intraoperative epithelial defects or a history of severe allergies or atopy were also looked for. Results: All 13 eyes responded favorably to the combination of intensive topical and oral corticosteroids and had a BCVA of 20/20 after the keratitis resolved. In 6 eyes (46%), the patients had a history of severe seasonal allergies. One day postoperatively, 3 eyes (23%) had an epithelial defect and 2 eyes (15%), lint particles or debris embedded in the interface. With oral corticosteroid use, 3 patients (23%) noted mild stomach irritation and 2 (15%) noted nervousness. All 5 side effects resolved without sequelae. No patient developed a serious side effect. Conclusion: A short, intense course of an oral corticosteroid was an effective treatment in patients with grade 2 or higher interface keratitis when combined with a topical corticosteroid administered hourly. The BCVA is a helpful objective measure of the severity of interface keratitis and can be used to guide the clinician in the therapeutic strategy.