Michael S. Loughnan

Squamous cell carcinoma of the conjunctiva: a series of 26 cases

Aim: To retrospectively study 26 patients with squamous cell carcinoma (SCC) of the ocular surface to determine pathological and clinical characteristics of tumour associated with outcome. Methods: Patients with conjunctival SCC from St Vincents Hospital and the private ophthalmology practices of the authors were reviewed. Results: Patents were usually male (77%), elderly (69% > 60 years of age), with most lesions (81%) occurring at the limbus. Seven patients (27%) suffered recurrent ocular surface squamous neoplasia (OSSN) within 4–15 months and two of these patients (8%) died of metastatic disease. Intraocular invasion was noted in three patients (11%), while corneal and/or scleral invasion was found in eight (30%). Orbital invasion was noted in four patients (15%). Six required orbital exenteration. Preoperative impression cytology of five patients with minimally invasive disease showed OSSN in four (80%). In situ carcinoma could not be differentiated from minimally invasive disease using impression cytology. Preoperative diagnosis of SCC was made in 35% of cases. Clinical accuracy was higher for larger lesions (>10 mm) and those with hyperkeratosis. Conclusions: Conjunctival SCC occurs in sun damaged ocular surface, usually at the limbus in elderly men. Recurrence of OSSN is common with significantly increased risk for older patients, lesions of large diameter, high proliferation index (Ki-67 score), and positive surgical margins. Orbital exenteration may be required for control of local disease and death from metastatic disease occurs in a small percentage of patients.

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.

Late Recurrences and the Necessity for Long-term Follow-up in Corneal and Conjunctival Intraepithelial Neoplasia

PURPOSE The purpose of the study was to elucidate the natural history of corneal-conjunctival intraepithelial neoplasia (CIN) and suggest treatment and follow-up guidelines. METHODS The records of all histologically proven cases of CIN at the Royal Victorian Eye and Ear Hospital between 1979 and 1994 were reviewed. RESULTS Seventy-nine eyes of 76 patients had a pathologic diagnosis of CIN and were observed for up to 15 years. The lesion recurred in 31 eyes (39%) overall. There was no statistical difference shown in the likelihood of recurrence based on histologic classification. Complete excision was attempted in each case. In 18 eyes, dysplastic cells were evident at the excision margin. Ten (56%) of these tumors recurred, compared to a 33% recurrence rate in completely excised lesions. The time to the first recurrence ranged from 33.0 days to 11.5 years between the first and second surgeries, with 11 lesions recurring after more than 4 years. Incompletely excised lesions reappeared more rapidly (average, 2.5 years) than did those with clear surgical margins (average, 3.8 years). Seven cases progressed to invasive squamous cell carcinoma and four cases led to blindness or removal of the eye. CONCLUSIONS This study suggests that excision margin at the time of surgery is the most important factor in predicting recurrence. The slow growth of the recurrent lesions combined with the ever-present malignant potential leads the authors to suggest that all patients with a history of CIN warrant annual follow-up for the remainder of their lives.

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.

Prevalence of Orbscan II corneal abnormalities in relatives of patients with keratoconus.

Background:  To determine the prevalence of Orbscan II‐derived keratoconus traits in relations of individuals with keratoconus and a control group and to apply these to a pedigree analysis.

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.

Bilateral epibulbar xanthomas--a case report.

Purpose: To report bilateral epibulbar xanthomatous lesions in an adult with a normal serum lipid profile and no cutaneous or systemic features of a histiocytic disease. Methods: Clinicopathologic report. Results: A 44-year-old man presented with gradually enlarging yellow epibulbar masses in both eyes. The lesions had recurred after excisions performed 2 years previously. Systemic evaluation was normal. Excisional biopsies were performed, and histological examination revealed numerous foamy histiocytes with scattered Touton giant cells and lymphocytes. No recurrence was observed after 1 year of follow-up. Conclusion: Xanthomatous epibulbar lesions are exceedingly rare and may occur as an isolated finding. Evaluation should be directed toward detecting underlying non-Langerhans cell histiocytic diseases and disorders of lipid metabolism. Recurrent lesions may be successfully treated by surgical excision.

Importance of corneal saturation time with riboflavin prior to collagen cross-linking.

Collagen cross-linking (CXL) has revolutionized keratoconus management. Studies describe 5-min, 15-min and 30-min riboflavin saturation times prior to ultraviolet A (UVA) irradiation. The aim of our study is to compare riboflavin saturation times. We retrospectively reviewed the records of 60 patients who underwent CXL for progressive keratoconus across three private practices in Melbourne, Australia. The CXL was performed at the same centre for all patients, and the treatment protocol was identical in both groups except for duration of riboflavin saturation: group 1 (30 eyes) had 15min, while group 2 (30 eyes) had 30min. After epithelium debridement, riboflavin 0.1% (Ribolink, Opto Global, Adelaide, Australia) was instilled on the cornea at regular intervals prior to and during UVA irradiation (3mW/cm for 30min; X-Link, Opto Global). Corneal thickness was maintained above 400μm. Corneal topography (Pentacam, Oculus; or Orbscan II, Bausch & Lomb, Melbourne, Australia) was performed before and after CXL to measure the maximum simulated keratometry value of the steepest axis (Ksteep) and maximum corneal power (Kmax) at baseline, 1 and 2years. Each patient was imaged using the same machine before and after CXL. Results are reported as mean± standard deviation. Student’s t-test was used to determine the significance of the difference. Chi-square test was used to determine the significance in the numbers of eyes progressing ≥1.0 diopter (D) in either measurement. No difference in age (24.0±7.3 vs. 22.8±6.1years; P=0.50) or mean duration of follow-up (2.2±0.7 vs. 2.4 ±0.4years; P=0.50) existed between 15and 30-min groups, respectively. At baseline, mean Kmax (55.08±5.33 vs. 56.62±5.03, respectively) and Ksteep (49.74±3.88 vs. 50.57±3.91, respectively) were similar (P>0.05). After 12months, the change in Ksteep from baseline was +0.18±1.78D (P=0.9) for the 15-min group and 0.31±0.70D (P=0.8) for the 30-min group. The change in Kmax was +0.07±1.94D (P=0.6) and +0.24±1.37 (P=0.7), respectively. After 2years, eyes in the 15-min group steepened by a mean of +0.54±1.78D, while the 30-min group flattened by 0.21±0.74D (P=0.06; Fig. 1). After 1year,