Michael H. Goldstein

Mycobacterium chelonae keratitis after laser in situ keratomileusis successfully treated with medical therapy and flap removal.

PURPOSE To report a case of Mycobacterium chelonae keratitis after laser in situ keratomileusis successfully treated with medical therapy and flap removal. METHODS Case report. A 36-year-old white woman in good health developed a paracentral keratitis in her right eye 1 month after bilateral laser in situ keratomileusis. Initial treatment included topical steroids and then intensive Ocuflox (ofloxacin ophthalmic solution; Allergan, Inc, Irvine, California) without success. Cultures were negative. The keratitis worsened, and she was referred to our institution. Interface infiltration was noted, and the flap was lifted to obtain adequate laboratory studies. Cultures were positive for M chelonae. RESULTS The keratitis was treated with intensive topical amikacin sulfate 1%, topical clarithromycin 1%, and Ciloxan (ciprofloxacin HCL; Alcon Laboratories, Inc, Fort Worth, Texas) with minimal improvement in her clinical condition. She developed a toxic reaction to amikacin 1%. In order to improve antibiotic penetration, the hazy, ulcerated corneal flap was removed. The keratitis then resolved with intensive topical clarithromycin 1% and Ocuflox over 5 weeks. The patient now has visual acuity without correction of 20/50, despite superficial corneal haze. CONCLUSION M chelonae is a rare and insidious cause of infection after laser in situ keratomileusis. Diagnosis can be difficult and is often delayed. Aggressive medical management, with flap removal, if needed, may lead to resolution of infection.

Comparison of mitomycin C trabeculectomy, glaucoma drainage device implantation, and laser neodymium : YAG cyclophotocoagulation in the management of intractable glaucoma after penetrating keratoplasty

PURPOSE This study aimed to compare the surgical outcomes of mitomycin C trabeculectomy glaucoma drainage device (GDD) surgery and laser neodymium:YAG (Nd:YAG) cyclophotocoagulation (CPC) in the management of intractable glaucoma after penetrating keratoplasty (PKP) in a retrospective study. DESIGN Interventional case series. PARTICIPANTS/METHODS The medical charts of consecutive patients who had pre-existing glaucoma or who developed glaucoma after PKP and underwent a surgical procedure to control the glaucoma at the University Eye Associates of Boston University Medical Center, New England Eye Center, and Massachusetts Eye and Ear Infirmary between January 1991 and July 1995 were reviewed. Follow-up ranged from 6 months to 4 years after the glaucoma procedure. A total of 38 patients were included consisting of 17 patients who underwent mitomycin C, 10 patients who underwent GDD surgery, and 11 patients who had CPC. INTERVENTION Mitomycin C trabeculectomy, GDDs, or Nd:YAG CPC to control glaucoma after PKP was performed, MAIN OUTCOME MEASURES Graft status, postoperative intraocular pressure (IOP), and visual acuity were the main outcome measures. RESULTS There were no differences among the three groups with respect to the follow-up time after the corneal graft operation (P = 0.15) or after the glaucoma operation (P = 0.98). At the final follow-up, the average decrease in the IOP was 17 mmHg (P < 0.001) after mitomycin C, 15 mmHg (P = 0.003) after GDD surgery, and 14.4 mmHg (P = 0.001) after CPC. There were no differences in the proportion of patients who developed postoperative IOP above 20 mmHg (P = 0.50) and in the proportion who developed hypotony (P = 0.10) among the three groups. Two grafts failed after mitomycin C and one failed after CPC. Among the three procedures, there were no differences in the proportion of patients who experienced either an improvement (P = 0.14) or a decrease (P = 0.22) in the visual acuity by more than one line after the glaucoma procedure. One patient each in the GDD group and the CPC group lost light perception after the procedure. The risk of graft failure was almost three times higher for each additional PKP (odds ratio = 2.80, P = 0.02). CONCLUSIONS No differences were found among the three glaucoma procedures with respect to controlling IOP and graft failure. There was a trend for patients treated with CPC to have a higher incidence of graft failure, glaucoma failure, hypotony, and visual loss by more than one line, although this was not statistically significant. The number of PKPs was associated with graft failure, independent of the surgical procedure.

Clinical Guidelines for Management of Dry Eye Associated with Sjögren Disease

PURPOSE To provide a consensus clinical guideline for management of dry eye disease associated with Sjögren disease by evaluating published treatments and recommending management options. DESIGN Consensus panel evaluation of reported treatments for dry eye disease. METHODS Using the 2007 Report of the International Workshop on Dry Eye (DEWS) as a starting point, a panel of eye care providers and consultants evaluated peer-reviewed publications and developed recommendations for evaluation and management of dry eye disease associated with Sjögren disease. Publications were graded according to the American Academy of Ophthalmology Preferred Practice Pattern guidelines for level of evidence. Strength of recommendation was according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. RESULTS The recommendations of the panel are briefly summarized herein. Evaluation should include symptoms of both discomfort and visual disturbance as well as determination of the relative contribution of aqueous production deficiency and evaporative loss of tear volume. Objective parameters of tear film stability, tear osmolarity, degree of lid margin disease, and ocular surface damage should be used to stage severity of dry eye disease to assist in selecting appropriate treatment options. Patient education with regard to the nature of the problem, aggravating factors, and goals of treatment is critical to successful management. Tear supplementation and stabilization, control of inflammation of the lacrimal glands and ocular surface, and possible stimulation of tear production are treatment options that are used according to the character and severity of dry eye disease. SUMMARY Management guidelines for dry eye associated with Sjögrens disease are presented.

Growth factor, cytokine and protease interactions during corneal wound healing.

Healing of corneal injuries is an exceptionally complex process involving the integrated actions of multiple growth factors, cytokines, and proteases produced by epithelial cells, stromal keratocytes, inflammatory cells, and lacrimal gland cells. Following corneal injury, basal epithelial cells migrate and proliferate in response to chemotactic cytokines and mitogenic growth factors, including epidermal growth factor and keratinocyte growth factor. Simultaneously, keratocytes adjacent to the injured area undergo apoptosis under the Fas/Fas ligand system, while more distant keratocytes transform into activated fibroblasts and migrate into the wound, where they begin synthesizing new extracellular matrix components that form the scar tissue under the dominant influence of the TGFb/ CTGF system. Epithelial cells and activated stromal fibroblasts also secrete growth factors and cytokines that have paracrine and autocrine functions. Corneal repair proceeds for the next several weeks to months, during which time the gene expression profile slowly returns to the pre-injury pattern and the provisional scar matrix slowly remodels by actions of matrix metalloproteinases. While minor epithelial injuries heal by regeneration of normal architecture, large stromal injuries heal by repair with irregular scar tissue that impairs the optical properties of the cornea.Also, if the integrated regulation of the wound healing process is interrupted at any point, the wound fails to heal properly and a corneal ulcer develops. Better understanding of the cellular and molecular changes that occur during repair of corneal wounds will provide the opportunity to design agents that selectively modulate key phases of corneal wound healing, resulting in scars that more closely resemble normal corneal architecture.

Immunohistochemical localization of EGF, TGF-alpha, TGF-beta, and their receptors in rat corneas during healing of excimer laser ablation.

Purpose: Members of the epidermal growth factor (EGF) and transforming growth factor beta (TGF-β) families of growth factors and receptors are known to regulate key aspects of corneal wound healing, including epithelial migration and scar formation. To further understand their roles, mRNA levels were measured and proteins were immunolocalized in rat corneas at multiple time points during healing of excimer laser ablation injury. Methods: Excimer laser photoablation was performed to a depth of 50 μm on rat corneas. Levels of mRNAs for EGF, TGF-α, TGF-β isoforms 1, 2, and 3, and their receptors (EGF-R and TGFβ-IIR) were measured by quantitative RT-PCR on days 0, 1.5, 7, 21, 42, and 91 after ablation. Immunohistochemical localization of the growth factors and their receptors was performed on days 0, 7, and 21 in corneal sections. Results: Levels of EGF mRNA remained stable in rat corneas after ablation (68 ± 12 copies/cell, mean ± SD), whereas levels of TGF-α mRNA progressively increased sixfold to a maximum at day 42 (300 copies/cell) then slightly decreased on day 91. Levels of EGF-R mRNA rapidly increased 60-fold on day 7 compared with day 0 (571 vs. 9 copies/cell) then decreased sixfold above baseline at day 91. Levels of TGF-β1 mRNA remained stable (36 ± 10 copies/cell), whereas levels of TGF-β2 and TGF-β3 mRNAs peaked on day 21 (300-fold and 25-fold increase) and remained elevated through day 91. Levels of TGFβ-IIR mRNA showed a similar pattern. Immunostaining of all the growth factors and receptors was primarily in basal layers of epithelial cells in uninjured cornea and during healing. Intensity of immunostaining for TGF-β1, TGFβ-IR, and TGFβ-IIR increased appreciably in the basal epithelial layers after ablation. Conclusions: Levels of mRNAs for several key members of the EGF and TGF-β systems increase during corneal wound healing. In addition, the proteins are primarily localized in basal layers of epithelial cells, which suggest these cells are active in synthesizing autocrine and paracrine growth factors that modulate corneal wound healing.

Fungal keratitis after laser in situ keratomileusis: a case report.

Purpose. To report a case of fungal keratitis resulting after laser in situ keratomileusis (LASIK). Methods. A 38-year-old white man in good health developed a corneal infiltrate with laboratory confirmation of fungal keratitis after LASIK. Corneal scrapings were taken. Silver stain was positive for hyphae. Culture was positive for Curvularia sp. The patient was started on intensive natamycin 5% and amphotericin 0.15% topical therapy. Results. The patients keratitis was successfully treated with intensive antifungal therapy. Conclusions. Infectious keratitis is a rare but a serious potential complication after LASIK. To our knowledge, no previous case of fungal keratitis after LASIK has been reported. This case emphasizes the importance of surveillance for infection after LASIK.

Assessment of transient changes in corneal hydration using confocal Raman spectroscopy

Purpose. The degree of corneal hydration has been linked to excimer laser corneal ablation rates. Enhanced precision with excimer laser refractive surgery may result from a better understanding of the transient changes in corneal hydration. To better understand the dynamic nature of corneal hydration, bovine corneas were investigated under different surface treatments. Methods. Confocal micro-Raman spectroscopy was used to quantify corneal hydration. Water and acetone solutions were used to establish a quantitative response of the relative OH/CH Raman bands, which are consistent with the water and collagen protein bands in cornea, respectively. Intact bovine corneas were manually debrided (designated MD group) or lamellar flaps were created to expose stromal tissue (designated lamellar keratectomy or LK group). Raman spectra were recorded every 30 seconds for 6 minutes while the prepared cornea surfaces were exposed to quiescent air or to a forced nitrogen gas flow across the surface. Results. The OH and CH Raman bands yielded a linear response while the percentage of acetone was varied from 0% to 100%. For the bovine cornea under forced flow drying, the OH/CH Raman band ratio was found to decrease by 41% from the initial value for both the MD and LK treatment groups. These decreases were significantly more (p = 0.0051 and 0.054, respectively) than the 26% decrease in the OH/CH band ratio measured for the control corneas. In quiescent air, the control and MD groups exhibited a 7% and 6% decrease in the OH/CH ratio, respectively, while the LK treatment group revealed a 19% decrease in the OH/CH ratio. Conclusions. The bovine eye experiments demonstrate that significant changes in corneal hydration are realized under different drying conditions and treatment methodologies. This study elucidates the nature of transient changes in corneal hydration in a bovine model and suggests the need for further study of the role of such variations in surgical outcome for excimer laser corneal refractive procedures.

Ocular manifestations of electrical injury: a case report and review of the literature.

PURPOSE To report a case of electrical shock resulting in multiple ocular manifestations, including anisocoria, acute bilateral iritis, bilateral cataracts, and macular cyst formation, and to provide a review of the literature on electrically induced ocular injuries. METHODS Case report and review of the literature. RESULTS The case presented demonstrates a sequential occurrence of anisocoria, bilateral cataract formation, iritis, and macular cyst formation, with resolution following medical and surgical treatment. CONCLUSIONS Electrically induced injuries can have many ocular manifestations that may occur simultaneously or sequentially, occasionally occurring later than the inciting event. The most common ocular finding is cataract formation.

Preseptal cellulitis caused by trichophyton (ringworm).

A 10-year-old boy with a past medical history significant for chicken pox at 7 years of age was referred to our eye center by an outside ophthalmologist for a 15-day history of worsening right-sided preseptal cellulitis. The patient reported photophobia, pruritus, and pain in the eyelid region. There appeared to be vesicular lesions on the eyelids. Empiric therapy with oral antibacterial and antiviral medications failed to resolve the preseptal cellulitis. Lid cultures revealed coagulase negative Staphylococcus, Streptococcal viridans, and a Trichophyton species of fungus. The infection was successfully treated with two courses of oral itraconazole. This is the first case of preseptal cellulitis caused by this dermatophyte that we could find in the literature.

Sports injuries: an ounce of prevention and a pound of cure.

Objectives: To evaluate and review the literature regarding sports-related eye injuries and prevention through appropriate protective eyewear. Methods: The literature was reviewed regarding sports-related eye injuries and prevention of these injuries. Results: The review of the literature suggests that ocular sports injuries can occur with all sports and affects all ages. These injuries may affect professional athletes and amateur athletes around the world. There are between 40,000 and 600,000 documented sports-related ocular injuries in the United States every year. More than 90% of these ocular injuries from sports are preventable. Conclusions: Most of sports-related eye injuries are preventable. Increased recognition of the risks of eye injury playing sports may lead to improved protection and a decreased morbidity from eye injuries. To help prevent sports-related eye injuries, education of athletes, parents, coaches, trainers, referees, and health care practitioners is critical.