Michael E. Sulewski

Delayed-onset fungal keratitis after endophthalmitis

PURPOSE This study aimed to present two patients with delayed-onset, endogenous fungal keratitis after treatment for fungal endophthalmitis after cataract surgery. METHODS The authors retrospectively reviewed the clinical course of two patients in whom deep stromal fungal keratitis developed 2 weeks and 3 months, respectively, after apparent successful aggressive therapy for fungal endophthalmitis. Before the onset of the keratitis, both patients underwent vitrectomies with intraocular injection of 7.5 to 10.0 mcg amphotericin B, as well as treatment with systemic fluconazole and topical antifungal therapy. In case 1, a pre-existing prosthetic intraocular lens and lens capsular bag were removed at the time of vitrectomy, whereas in case 2, the intraocular lens was left in place and a posterior capsulectomy was performed. RESULTS The keratitis worsened in both patients, despite intensive systemic and topical antifungal therapy. Both patients underwent therapeutic penetrating keratoplasties. In case 1, this resulted in successful resolution of the infection and no recurrences 3 months after the transplant. The corneal transplant was complicated by an expulsive choroidal hemorrhage in the other patient. Fusarium solani was cultured from the initial vitrectomy specimen in patient 1, and although it was not cultured from the keratitis, septate hyphal elements were present on histopathologic examination. The causative organism in case 2 was Acremonium kiliense, which was cultured from both the original vitrectomy specimen and the deep corneal stromal infiltrate. CONCLUSIONS Fungal organisms may not be eradicated completely from eyes with endophthalmitis despite aggressive therapy and apparent initial successful treatment. These patients need to be monitored for prolonged periods, and treatment should be reinitiated at the earliest sign of recrudescence of infection.

Chronic Localized Conjunctival Chemosis

Conjunctival chemosis is a commonly encountered clinical finding stemming from the presence of excess fluid in the conjunctiva. It is typically self-limiting or reversible if the underlying condition is treated. The authors present a series of seven cases of chronic localized conjunctival chemosis. Each patient had a localized area of dependent conjunctival edema for >or= 6 months. Evaluation of each patient included clinical examination, laboratory studies, and neuroimaging to attempt to elucidate the pathogenesis of the chemosis. Conjunctival biopsy was performed in six of the seven patients. In all of the patients studied, clinical examination uncovered no definitive signs of local inflammation. Laboratory evaluation was normal, and neuroimaging failed to confirm obstruction of venous or lymphatic drainage. Conjunctival biopsies showed chronic tissue inflammation or lymphangiectasia. The diagnosis of chronic localized conjunctival chemosis (CLCC) can be made if localized conjunctival edema persists for 6 months. Evaluation of biopsy specimens supports the theory that CLCC may result from scarring and structural alteration of conjunctival lymphatics, which appears to irreversibly affect the distribution of fluid in the conjunctiva.

Efficacy of media enriched with nonlactate-generating substrate for organ preservation: in vitro and clinical studies using the cornea model.

BACKGROUND Using a rabbit cornea model, our recent study demonstrated that Chen Medium (CM), an isotonic media enriched with nonlactate-generating high-energy substrates, is very effective for organ preservation. In the present study, the efficacy of CM is further evaluated with human corneas METHODS The effectiveness of CM and Optisol for preserving the endothelial integrity of human corneas in vitro was evaluated by scanning electron microscopy. Clinical efficacy was evaluated in a total of 83 patients: 10 patients with keratoconus grafted randomly with either CM- or Optisol-stored cornea of the same donor, and 73 patients with various conditions grafted with CM-stored corneas. After surgery, visual acuity and quality of the graft were monitored for up to 4.6 years. RESULTS The scanning electron microscopic study revealed that after 11-day storage at 4 degrees C, the CM-stored cornea had only marginal disruptive changes, 9.4+/-1.1%, in endothelial cells, as opposed to 42.4+/-4.6% of the Optisol-stored cornea. All 78 CM-stored corneas, including 67 with 12.2- to 17.7-hr death-to-storage time, 3-7.6 days of storage time, and initial marginal quality before storage, were successfully transplanted. These grafts were thin and clear, with an excellent epithelial integrity and without significant changes in endothelial cell density. Five Optisol-stored corneas were also successfully grafted; one of them, however, was edematous for about 4 weeks, and all the grafts were slightly thicker with substantial endothelial cell loss. CONCLUSION Using a cornea model, present and recent studies show that CM is very effective for preserving tissue viability and endothelial integrity. Previous study revealed that CM-stored tissues maintained high levels of ATP and metabolic function, with suppression of lactate formation and accumulation. Thus, these findings support the concept that preservation of tissue viability is closely associated with the ability of the tissues to retain metabolic activity, to generate ATP efficiently, and to prevent acidosis effectively during storage.

Risk Factors Associated with Progression to Blindness from Primary Open-Angle Glaucoma in an African-American Population

ABSTRACT Purpose: To determine the risk factors associated with progression to blindness from primary open-angle glaucoma (POAG) in an African-American population. Methods: This study examined 2119 patients enrolled in the Primary Open-Angle African-American Glaucoma Genetics (POAAGG) study. A total of 59 eyes were identified as legally blind as a result of POAG (cases) and were age-and sex-matched to 59 non-blind eyes with glaucoma (controls). Chart reviews were performed to record known and suspected risk factors. Results: Cases were diagnosed with POAG at an earlier age than controls (p = 0.005). Of the 59 eyes of cases, 16 eyes (27.1%) presented with blindness at diagnosis. Cases had worse visual acuity (VA) at diagnosis (p < 0.0001), with VA worse than 20/40 conferring a 27 times higher risk of progression to blindness (p = 0.0005). Blind eyes also demonstrated more visual field defects (p = 0.01), higher pre-treatment intraocular pressure (IOP; p < 0.0001), and higher cup-to-disc ratio (p = 0.006) at diagnosis. IOP was less controlled in cases, and those with IOP ≥21 mmHg at more than 20% of follow-up visits were 73 times more likely to become blind (p < 0.0001). Cases missed a greater number of appointments per year (p = 0.003) and had non-adherence issues noted in their charts more often than controls (p = 0.03). However, other compliance data did not significantly differ between groups. Conclusion: Access to care, initial VA worse than 20/40, and poor control of IOP were the major risk factors associated with blindness from POAG. Future studies should examine earlier, more effective approaches to glaucoma screening as well as the role of genetics in these significantly younger patients who progress to blindness.

Elevated intraocular pressure-induced interlamellar stromal keratitis occurring 9 years after laser in situ keratomileusis.

Elevated intraocular pressure-induced interlamellar stromal keratitis (PISK) is an entity of interface haze usually occurring weeks to months after laser in situ keratomileusis (LASIK) that is associated with elevated intraocular pressures and worsening with steroid treatment. There is evidence that this interface haze is the result of abnormal fluid dynamics that occur in the cornea after LASIK. We present a case of pressure-induced interlamellar stromal keratitis occurring 9 years after LASIK in the setting of anterior uveitis. This case emphasizes the importance of considering such diagnoses as pressure-induced interlamellar stromal keratitis in the differential diagnosis when presented with a patient with corneal haze and a history of LASIK.

Uses of the Sheets Lens Glide in Contemporary Cataract Surgery

operations were successful in that diurnal variation did not occur in these two cases. However, the large perforations were not really acceptable cosmetically and microperforations were required. At that time, Surgidev Corporation had been licensed by me to develop the technology of manufacturing polysulfone corneal inlays, and they solved the technological problem of creating the micro perforations, but at additional cost to the manufacturing process. Furthermore, to get polysulfone corneal inlays with or without microperforations past the United States Food and Drug Administration would have required prolonged and expensive studies, which Surgidev Corporation was not prepared to undertake. The bottom line, as far as I am concerned, is that polysulfone corneal inlays do work and can be tolerated for many years, up to 15 so far, but they need to be equipped with microperforations surrounding a central nonperforated 3.0 mm diameter zone.

A significant drug-drug interaction detected through corneal examination: resolution of cornea verticillata while using amiodarone.

Purpose: To describe a patient with resolution of cornea verticillata while still using amiodarone as a result of a drug interaction lowering serum levels of amiodarone. Methods: An 83-year-old retired physician with long-standing cornea verticillata was noted to have complete resolution of cornea verticillata on a routine follow-up eye examination. The patient reported complete compliance with using amiodarone daily, with no recent changes in dosage or formulation. Despite this, he reported a recent increase in the frequency of palpitations. He had recently started rifampin for treatment of tuberculosis. Results: Serum amiodarone and desethylamiodarone levels were obtained and found to be below therapeutic range. After rifampin was discontinued, serum amiodarone and desethylamiodarone levels increased to a therapeutic range and cornea verticillata returned after 4 months. Conclusions: In patients currently using amiodarone, clearing of cornea verticillata should alert the ophthalmologists to the possibility of decreased serum amiodarone levels.

Diagnosis and Management of Ocular Involvement in Sjögren’s Syndrome

Evaluation of a patient with dry eye symptoms and possible Sjogren’s syndrome (SS) requires a complete review of systems and a thorough ocular surface examination that includes staining of the conjunctiva. SS patients may have a variety of clinical presentations, and it is important to have a low threshold for referring dry eye patients to a rheumatologist for a SS workup. A stepwise approach to the management of ocular surface disease is advised starting with topical anti-inflammatory therapy, autologous serum tears, and scleral lenses for the more advanced cases. For SS patients undergoing surgery, aggressive ocular surface treatment preoperatively and careful postoperative monitoring is the key to ensuring a successful outcome. In advanced cases of SS with corneal melting or perforation, aggressive local therapy, treatment of the underlying systemic disease with early immunosuppressive therapy, and close collaboration with a rheumatologist are critical to controlling the disease.

Progressive Restrictive Strabismus in an Adult Woman

A woman in her 60s presented to the ophthalmology clinic with 10 months of blurred vision in her left eye. More recently, she noted that her left eye “drifts out at times.” She also reported drooping of the left upper eyelid and binocular, variable horizontal or vertical diplopia at distance. She also complained of itchy eyes but denied any pain or headaches. Her medical history includes breast cancer, diagnosed in 2000 and treated with lumpectomy and radiotherapy. A mammogram, completed 4 months before her ophthalmology visit, was reported as stable. On presentation, her visual acuity was 20/20 OD and 20/40 OS. She had slightly decreased color vision (8/10 Ishihara plates) of the left eye and there was no relative afferent pupillary defect. Confrontation visual fields were full. External examination revealed mild left proptosis and severely limited adduction of the left eye. Both optic nerves appeared normal on retinal examination. Magnetic resonance imaging of the brain (Figure 1) showed a 2.3-cm intraconal mass inseparable from the left lateral rectus muscle. The mass medially deviated the left optic nerve and conformed to the shape of the orbital globe with mild bony remodeling of the lateral orbital wall.