Michael S. Insler

Comparison of Ciprofloxacin Ophthalmic Solution 0.3% to Fortified Tobramycin-Cefazolin in Treating Bacterial Corneal Ulcers

PURPOSE The purpose of the study is to compare the clinical efficacy and safety of ciprofloxacin ophthalmic solution 0.3% (Ciloxan) with a standard therapy regimen (fortified tobramycin, 1.3%-cefazolin, 5.0%) for treating bacterial corneal ulcers. METHODS This randomized, parallel group, double-masked, multicenter study was conducted in 324 patients at 28 centers in the United States, Europe, and India. Patients were randomized into 2 treatment groups: 160 to ciprofloxacin and 164 to fortified tobramycin-cefazolin. Positive microbiologic cultures were obtained in 188 (58%) of 324 patients. Of these, 176 patients met protocol criteria and were evaluated for treatment efficacy: 82 in the ciprofloxacin group and 94 in the standard therapy group. The dosing schedule for both treatment groups was 1 to 2 drops of the first study medication (ciprofloxacin or fortified tobramycin) every 30 minutes for 6 hours, then hourly for the remainder of day 1; 1 to 2 drops every hour on days 2 and 3; 1 to 2 drops every 2 hours on days 4 and 5, followed by 1 to 2 drops every 4 hours on days 6 to 14. The second medication (ciprofloxacin or cefazolin) was instilled 5 to 15 minutes after the first drug, following the same dosing frequency. Physicians judgment of clinical success, cure rate, changes in ocular sings, and symptoms and the rate of treatment failures were the primary efficacy criteria. RESULTS Topical ciprofloxacin monotherapy is equivalent clinically and statistically to the standard therapy regimen of fortified antibiotics. No statistically significant treatment differences were found between ciprofloxacin (91.5%) and standard therapy (86.2%) in terms of overall clinical efficacy (P = 0.34). Similarly, no differences were noted in resolution of the clinical signs and symptoms (P > 0.08) or the time to cure (P = 0.55). The incidence of treatment failures was less in the ciprofloxacin group (8.5%) compared with the standard therapy group (13.8%). Significantly fewer patients treated with ciprofloxacin reported discomfort than did patients treated with the standard therapy regimen (P = 0.01). CONCLUSION Ciprofloxacin ophthalmic solution 0.3% monotherapy is equivalent clinically and statistically to standard therapy (fortified tobramycin-cefazolin) for the treatment of bacterial corneal ulcers and produces significantly less discomfort.

Transplantation of cultured human neonatal corneal endothelium

Human neonatal corneal endothelial cells were successfully maintained in tissue culture, morphologically resembling adult corneal endothelium. Eyebank donor corneas were obtained, denuded of their native endothelium and seeded with a suspension of the cultivated neonatal endothelial cells. After 48 hours, the eye-bank tissue was then transplanted into the eyes of Rhesus monkeys. Over a five month period, five of eight transplants cleared, with a mean central corneal thickness of 0.480 mm and endothelial cell densities ranging from 560 to 1650 cells/mm2. All control eyes without donor endothelium remained cloudy. In the experimental group three eyes initially thinned but subsequently became edematous. Further studies are needed to improve the seeding procedure and to assess the long-term viability of transplanted endothelium.

Penetrating Keratoplasty With Trabeculectomy

Seven patients who had a mean preoperative intraocular pressure of 40 mm Hg (range, 34 to 52 mm Hg) underwent combined keratoplasty and trabeculectomy. This resulted in an average postoperative intraocular pressure of 23.7 mm Hg. Five of seven eyes had well controlled intraocular pressures throughout the postoperative period (mean follow-up, 16.1 months). This approach can achieve a satisfactory result while avoiding some of the complications of other forms of glaucoma therapy.

CONTAMINATION OF DONOR CORNEA BY GENTAMICIN-RESISTANT ORGANISMS

Cultures of the donor corneoscleral rims in 70 consecutive penetrating keratoplasties showed microbial contamination in 14 cases. All positive cultures were tested by standard microdilution broth method for sensitivities to gentamicin, an antibiotic routinely used in McCarey-Kaufman transport medium. Seven of 15 organisms demonstrated resistance to gentamicin at concentrations above 100 micrograms/ml. These results indicated the selection of more antibiotic-resistant microorganisms in antibiotic-supplemented medium and the need for appropriate antibiotic prophylaxis at the time of surgery.

Visual results in repeat penetrating keratoplasty

In a study of visual prognosis after repeat penetrating keratoplasty, we found that 18 of 29 eyes required only one regraft and 11 required multiple repeat penetrating keratoplasties. After an average follow-up of 15.7 months, six of the 18 eyes with only one regraft had achieved visual acuities of 20/100 or better. After an average follow-up of 27.5 months, only one of 11 eyes with multiple regrafts achieved a best corrected visual acuity of 20/100 or better.

Pseudomonas Keratitis and Folliculitis From Whirlpool Exposure

A local outbreak of pseudomonal folliculitis from whirlpool exposure occurred in 12 persons. A corneal ulcer developed in one patient within 48 hours of using the whirlpool. Treatment with fortified gentamicin resolved the corneal infiltrate and vision returned to normal. A second patient, who had not showered immediately after leaving the whirlpool, was left with areas of skin hyperpigmentation and scarring despite treatment with ultraviolet rays and tetracycline. Although the skin rash may be self-limited, the potential for visual loss from pseudomonal keratitis emphasizes the need for proper disinfection of swimming and whirlpool water.

Corneal ulceration following cataract surgery in patients with rheumatoid arthritis

A sterile corneal ulcer was observed in four cataract patients (two with intraocular lenses) during the early postoperative period. All patients had a history of rheumatoid arthritis and were on systemic antiinflammatory agents. The two patients treated medically exhibited a short recovery phase with complete healing over several days and no recurrence. Aggressive treatment of the dry eye syndrome with artificial tears, bandage lenses, punctal occlusion, tarsorrhaphy, and antibiotics resulted in immediate improvement. In this report, variabilities in corneal ulceration are stressed while emphasis is given to the role of dry eyes and exposure as the principal common factor. A discussion of risk factors, presentation, treatment, pathogenesis, and prevention is provided.

Primary Surgical Repair of Severe Peripheral Marginal Ectasia in Terrien's Marginal Degeneration

We have developed a safe, successful, and simple procedure for repairing the severe peripheral marginal ectasia in Terriens marginal degeneration. The area of ectasia is incised along its thinnest paralimbal dimension down to Descemets membrane. Ectatic stroma along both sides of the incision is then undermined until normal-thickness stroma is reached. After excision of excess ectatic stroma, if necessary, the normal-thickness stroma is then sutured together, primarily with 9-0 Prolene. The sutures are left in place permanently, and the remaining refractive error is corrected with spectacles or contact lenses. This technique substantially improved visual acuity in three of four patients and decreased corneal astigmatism in all four. Although one eye required resuturing, there were no complications in any case.

Candida albicans endophthalmitis after penetrating keratoplasty.

We examined two patients who received contaminated corneas from the same organ donor during penetrating keratoplasty. Both developed Candida albicans endophthalmitis, which responded to surgical and antifungal therapy. On follow-up examination one patient had a visual acuity of hand motions, a pupillary membrane, and a macular scar. The other had a visual acuity of 20/100 and a clear graft.

Effects of extracapsular cataract extraction with posterior chamber lens implantation on the development of neovascular glaucoma in diabetics

ABSTRACT We retrospectively reviewed four cases of extracapsular cataract extraction with implantation of a posterior chamber intraocular lens into diabetics. All four developed postoperative iris rubeosis and neovascular glaucoma; three of the cases had a poor visual outcome. The implant surgeon must show discretion in deciding to implant an intraocular lens in diabetics whether or not they are noninsulin dependent and well controlled, understanding the serious complications that may result from progression of diabetic retinopathy and rubeosis iridis.