Laurence Sullivan

Controlled study of the use of autologous serum in dry eye patients.

Purpose. To determine the efficacy and safety of topical autologous serum as a treatment of dry eye patients. Methods. A 2-month, prospective, single-masked, placebo-controlled study was conducted in patients with bilateral severe dry eye. One eye was randomized to receive the patients own serum as a tear substitute, and the fellow eye received unpreserved normal saline solution as a placebo. Subjective symptoms and clinical parameters of dry eye including conjunctival impression cytology were assessed at baseline and 1 week, 1 month, and 2 months after treatment. Results. Twelve dry eye patients were enrolled. Both subjective symptoms (discomfort, foreign-body sensation, dryness, and photophobia), objective signs (fluorescein and rose bengal staining and conjunctival impression cytology) improved significantly in treated eyes compared with baseline. Control eyes also had improvement in symptoms, signs, and rose bengal staining compared with baseline. Neither Schirmer test results nor tear break-up time improved in either group. The means score of all parameters were improved in both groups, and the results of conjunctival impression cytology were better in treated eyes; however, these results are not significantly different. There were no serious adverse effects observed in this study. Conclusions. There was a trend toward improvement in symptoms and signs of dry eye including cytologic changes after application of autologous serum in severe dry eye patients. However, this trend was not statistically significant. A larger scale study is warranted.

Management of alkali burns : an 11-year retrospective review.

OBJECTIVE To review the spectrum of patients with alkali burns admitted over an 11-year period and to assess the clinical outcomes after the introduction of a standard alkali burn treatment protocol. DESIGN Retrospective nonrandomized comparative study. PATIENTS AND INTERVENTIONS A total of 121 patient records with alkali burns (n = 177 eyes) admitted to a tertiary hospital between 1987 and 1998 were reviewed. Eyes treated with a standard alkali burn treatment protocol, which included intensive topical steroids, ascorbate, citrate, and antibiotics, were compared with eyes treated by conservative management with antibiotics, and a short course of steroids. MAIN OUTCOME MEASURES Time to corneal reepithelialization, final best-corrected visual acuity, and time to visual recovery, length of hospital stay, and complications were analyzed. RESULTS The standard protocol tended to delay corneal reepithelialization by one day (P: = not significant) in eyes with grade 1 burns (n = 76) and by 2 days (P: = 0.04) in grade 2 burns (n = 52), with no difference in final visual outcome. There were 37 eyes with grade 3 burns. Those treated with the standard protocol showed a trend toward more rapid corneal reepithelialization. Twenty-seven of 29 (93%) eyes with grade 3 injuries achieved a final best-corrected visual acuity of 20/40 or better compared with 3 of 6 (50%) eyes not treated according to the standard protocol (P: = 0.02). Eyes with grade 4 burns (n = 12), whether treated with the standard protocol or not, required 10 to 12 weeks for corneal reepithelialization. There was no statistically significant difference in final visual acuity. CONCLUSIONS On the basis of our findings, a number of recommendations can be made for the management of alkali injuries. Patients with a grade 1 or 2 injury do not require routine admission and do not benefit from the use of intensive treatment with ascorbate and citrate. A trend toward more rapid healing and a better final visual outcome were apparent in grade 3 burns, but our standard protocol made no difference in grade 4 burns.

Microbial keratitis associated with extended wear of silicone hydrogel contact lenses

Traditional hydrogel soft contact lenses (SCL) have limited oxygen permeability.1, 2 Recently introduced silicone hydrogel SCL have much higher oxygen transmissibility (Dk/t O2), allowing near normal oxygen supply to the cornea during extended lid closure, and are hoped by some to address most of the problems related to corneal hypoxia encountered with previous extended wear soft contact lenses.1, 3 They have therefore been approved for up to 30 days of continuous wear in both Europe and Australia. Four cases of microbial keratitis in patients who were using silicone hydrogel SCL (either CibaVision Focus Night and Day lenses (Lotrafilicon A, fluorosiloxane hydrogel) or Bausch & Lomb PureVision lenses (Balafilcon A, silicone hydrogel)) on an extended wear basis are presented. The minimum amount of continuous wear was 24 hours. All cases were treated either in private or at the corneal clinic of the Royal Victorian Eye and Ear Hospital from December 2000 to February 2001. All the patients underwent a complete ophthalmic examination by a corneal specialist. Microbiological specimens were taken from all patients via cornea scrapings and were submitted for Gram and Blankophor staining, and bacterial and fungal cultures via direct inoculation onto sheep blood agar, chocolate agar, and Sabouraud agar. Bacterial sensitivities of cultured organisms were also obtained. Where possible, the contact lenses themselves were also sent for microbial cultures. Each case is described in brief, and a summary presented in Table 1. View this table: Table 1 Summary of case details This 22 year old man presented with a 2 day history of left ocular injection, pain, photophobia, and blurred vision. He was wearing CibaVision Focus Night and Day SCL continuously for 10 days at a time, discarding the lenses after a month of use. He had swum in the sea while wearing the same lenses 2 weeks before, after which …

A comparison of different depth ablations in the treatment of painful bullous keratopathy with phototherapeutic keratectomy.

AIM To study the efficacy of phototherapeutic keratectomy (PTK) for pain relief for patients with painful bullous keratopathy and poor visual potential. METHODS Patients with painful bullous keratopathy and poor visual potential were treated with superficial PTK (8–25 μm), intermediate (50–100 μm) or deep PTK (25% stromal thickness) using the Nidek EC5000 excimer laser after manual epithelial debridement. Follow up ranged from 1 to 24 months (mean 6.5 months). Outcome measures included symptomatic relief and need for further treatment. RESULTS In the superficial PTK group five of eight (62%) patients improved symptomatically after treatment. The three (38%) who did not improve went on to have penetrating keratoplasty for pain relief. In the intermediate depth group only two of five (40%) patients had symptom alleviation. The three others (60%) required further procedures. 20 of 24 (83%) patients treated with deep PTK had significant or total alleviation of symptoms. Of these, one developed acute anterior uveitis 9 months after PTK and two required botulinum ptosis for persistent corneal epithelial defects, one of whom had three consecutive episodes of microbial keratitis. Three of 24 suffered occasional discomfort and one patient required a penetrating keratoplasty for continued pain. CONCLUSION PTK can be a useful therapeutic measure in painful bullous keratopathy with poor visual potential. Deep PTK appears to be more successful in pain management than superficial treatment.

Efficacy and Safety of 0.3% Carbomer Gel Compared to Placebo in Patients with Moderate-to-Severe Dry Eye Syndrome

PURPOSE Carbomer gel is a water-soluble polymeric resin that has been reported to maintain the tear film in contact with the eye for an extended period. The efficacy and safety of this new artificial tear were assessed. METHODS A multicenter, single-masked, randomized, placebo-controlled study was carried out on 123 patients with moderate-to-severe dry eyes. The placebo was a mannitol solution with benzalkonium chloride 0.008% as preservative. Patients were observed over an 8-week period, and subjective and objective changes analyzed, compared to a baseline of no therapy, after 1 to 7 days washout period from previous medication. RESULTS All primary subjective symptoms decreased significantly in the carbomer gel-treated group compared to the placebo group (i.e., dryness, discomfort, and foreign body sensation). The carbomer gel also significantly improved the rose bengal staining score relative to placebo. When data for the primary subjective efficacy variables were stratified for disease severity, there was a statistically significant improvement from baseline by day 10 for severely affected patients and from day 42 for patients with moderate disease. Secondary subjective symptoms that improved significantly in the tear gel group compared to placebo were photophobia, erythema, tear breakup time, blurry-filmy, dry-sandy sensation, and physician impression. However, no significant improvements in the secondary subjective symptoms of tearing, itching, scaling, conjuctival discharge, palpebral conjunctival redness, bulbar conjuctival redness, conjunctival luster, relief of discomfort, ease of use, and overall acceptability were found in either group over the baseline score. In addition, neither carbomer gel nor placebo improved the baseline fluorescein staining score or the Schirmer test score. Two patients suffered local allergic reactions to the carbomer gel or its preservative, which settled on withdrawal of the medication. CONCLUSIONS Carbomer gel was more efficacious than was placebo in improving a number of subjective and objective symptoms of moderate-to-severe dry eye syndrome. The results of this study indicate that carbomer gel was a safe as was the placebo.

Pterygium-induced corneal astigmatism.

A significant degree of corneal astigmatism can be induced by the encroachment of a pterygium onto a cornea. The pterygium generally causes with‐the‐rule corneal astigmatism that is hemimeridional on the side of the pterygium. There is a significant correlation between the extension of the pterygium onto the cornea and the amount of induced astigmatism. However, there is a poor correlation between pterygium‐induced astigmatism measured topographically and that measured by manifest refraction. Successful pterygium surgery will reduce pterygium‐induced refractive astigmatism and improve visual acuity. This paper outlines the management of a patient with an advanced pterygium, in whom a large degree of corneal astigmatism was induced by the encroachment of a pterygium onto the cornea. Subsequent excision of the pterygium brought about a reversal of the pterygium‐induced corneal astigmatism.

Comparison of residual stromal bed and flap thickness in primary and repeat laser in situ keratomileusis in myopic patients

PURPOSE: To compare the change in residual stromal thickness and flap thickness between primary laser in situ keratomileusis (LASIK) and repeat LASIK in myopic patients. SETTING: Melbourne Excimer Laser Group, East Melbourne, Australia. METHODS: This retrospective nonrandomized comparative trial comprised 46 eyes of 34 patients who had repeat LASIK. The thickness of the residual stromal bed was calculated by subtracting the calculated stromal ablation from pachymetry of the stromal bed after cutting the flap in primary treatment and directly measuring during retreatment. The thickness of the LASIK flap in primary and repeat LASIK was calculated by subtracting the central pachymetry of the stromal bed after creating the flap from pachymetry before cutting and lifting the flap, respectively. The main outcome measures were comparison of the residual stromal bed and flap thickness between the primary treatment and the retreatment. RESULTS: The mean thickness of the calculated residual stromal bed after primary treatment was 329.8 μm ± 40.8 (SD), and the mean measured residual stromal bed at retreatment was 317.3 ± 42.8 μm. The mean difference in residual stromal bed thickness was 12.5 ± 13.0 μm (P<.001). Sixteen eyes (34.7%) had a decrease in bed thickness between 11 μm and 20 μm. The mean flap thickness during primary LASIK and repeat LASIK was 145.2 ± 17.1 μm and 169 ± 18.3 μm, respectively. The mean interval between primary treatment and retreatment was 7.4 ± 4.1 months. The mean change in flap thickness was 23.8 ± 15.2 μm (P<.001). Fifteen eyes (32%) had an increase in flap thickness between 11 μm and 20 μm. There was a negative correlation between refractive error before primary treatment and the difference in flap thickness. No correlation was found between the difference in flap thickness and the interval between the primary treatment and the repeat treatment. CONCLUSIONS: Intraoperative pachymetry of the stromal bed during retreatment is strongly recommended as the residual stromal bed and flap thickness changes between primary and retreatment. There is a tendency for the measured stromal bed at retreatment to be thinner than the calculated stromal bed and for the flap to be thicker than previously measured.

Treatment of infectious keratitis with riboflavin and ultraviolet-A irradiation

UNLABELLED We report 4 eyes with infectious keratitis treated with riboflavin/ultraviolet-A irradiation (corneal collagen crosslinking [CXL]) in addition to medical treatment. In 2 eyes with bilateral keratitis, the fellow eye was treated with medical treatment alone. The other 2 eyes had refractory keratitis. The results suggest that CXL may be more worthwhile in cases refractory to conventional medical treatment. FINANCIAL DISCLOSURE No author has a financial or proprietary interest in any material or method mentioned.

Mechanical methods in refractive corneal surgery.

The past year has seen considerable advances and debate with regard to several new and some established mechanical means of refractive surgery. Lamellar in situ keratomileusis is gaining increased interest, especially for the treatment of moderate and high myopia, although considerable questions still exist with regard to its safety, predictability, and the possibility of loss of lines of best corrected visual acuity. Mini-radial kera-totomy may be of benefit in reducing the risk of traumatic rupture of radial keratotomy incisions, and a refinement of the nomograms for astigmatic keratotomy in the treatment of congenital astigmatism has been proposed. Another report on the use of hexagonal keratotomy for the treatment of hyperopia again raised concerns of its predictability. A blind eye study of intrastromal corneal rings has provided some reassurance with regard to its safety but has also raised doubts over its predictability. Meanwhile, several more reports of the use of both anterior and posterior chamber phakic intraocular lenses for the treatment of myopia have been presented.

Congenital orbital teratoma

We present a case of mature congenital orbital teratoma managed with lid-sparing exenteration and dermis fat graft. This is a case report on the management of congenital orbital teratoma. A full-term baby was born in Fiji with prolapsed right globe which was surrounded by a nonpulsatile, cystic mass. Clinical and imaging features were consistent with congenital orbital teratoma. Due to limited surgical expertise, the patient was transferred to Adelaide, Australia for further management. The patient underwent a lid-sparing exenteration with frozen section control of the apical margin. A dermis fat graft from the groin was placed beneath the lid skin to provide volume. Histopathology revealed mature tissues from each of the three germ cell layers which confirmed the diagnosis of mature teratoma. We describe the successful use of demis fat graft in socket reconstruction following lid-sparing exenteration for congenital orbital teratoma.