Morris E. Hartstein

Can we measure corneal biomechanical changes after collagen cross-linking in eyes with keratoconus?--a pilot study.

Purpose: To assess changes in biomechanical properties of human cornea after treatment of keratoconus with UV-A-riboflavin corneal collagen cross-linking (CXL). Design: Single-center, prospective, interventional study. Methods: Ten eyes of 10 patients aged 26.5 ± 5.7 (mean ± SD) years with progressive keratoconus were treated with UV-A-riboflavin CXL and assessed with the Ocular Response Analyzer (ORA) that measured corneal hysteresis (CH), corneal resistance factor (CRF), Goldmann-correlated intraocular pressure (IOPg), and corneal compensated intraocular pressure (IOPcc). Intraocular pressure was also measured by Goldmann applanation tonometry (GAT-IOP). Patients were assessed with ORA preoperatively, at week 1, months 1, 3, and 6 after treatment. Postoperative measurements at each visit were compared with preoperative values. Results: CH and CRF were transiently elevated after cross-linking treatment, with the difference not statistically significant (P > 0.3). IOPcc and IOPg were statistically significantly higher at 1 week and 1 month but not subsequently (P < 0.04). GAT-IOP was statistically significantly higher at 1 week and at 1 and 3 months (P < 0.01). Conclusions: There were no significant differences in corneal biomechanical properties, as measured with the ORA parameters CH and CRF, after CXL in keratoconus. IOPcc, IOPg, and GAT-IOP values were transiently elevated after CXL treatment in our study. Whether this reflects a measurement artifact resulting from corneal changes or true elevation of intraocular pressure is unclear.

Conservative management of necrotizing fasciitis of the eyelids.

OBJECTIVE To describe the management of patients with necrotizing fasciitis of the eyelids. DESIGN Retrospective, noncomparative interventional case series. PARTICIPANTS Seven patients with necrotizing fasciitis limited to the eyelids. METHODS Retrospective review of the charts and photographs of seven patients with necrotizing fasciitis limited to the eyelids. MAIN OUTCOME MEASURES Eyelid function and appearance, mortality, and morbidity. RESULTS Seven of seven patients had good eyelid function and adequate appearance without reconstruction after healing. No deaths occurred. CONCLUSIONS Eyelid necrosis due to necrotizing fasciitis can be a devastating condition. The morbidity and mortality of selected cases are reduced with prompt and appropriate antimicrobial therapy and nonaggressive debridement of necrotic tissue after autodemarcation of the necrotic zone.

Orbital solitary fibrous tumor: radiographic and histopathologic correlations.

OBJECTIVE To correlate the clinicopathologic and radiographic features characteristic of orbital solitary fibrous tumor (SFT). METHODS The diagnostic features and clinical outcome of seven adults with orbital SFT are retrospectively outlined. Orbital imaging was performed by ultrasonography, computed tomography, or magnetic resonance imaging. Some cases were imaged by multiple modalities. Histopathologic examination of each tumor specimen included standard light and immunohistochemical stains. RESULTS Heterogeneous internal composition was better appreciated on magnetic resonance imaging than on computed tomography. All cases undergoing magnetic resonance imaging showed T1 isointensity and T2 hypointensity relative to gray matter. Strong, generalized immunohistochemical reactivity to vimentin and CD34 validated the diagnosis of SFT and differentiated the specimens from other spindle cell neoplasms. After complete tumor resection, our patients remain tumor free with postoperative intervals of 15 to 45 months. CONCLUSIONS Solitary fibrous tumor has now been reported in 26 orbits. No physical finding is pathognomonic, but several imaging traits are highly characteristic. Intralesional image heterogeneity and a predominantly low T2 signal intensity are distinctive of SFT. Complete tumor resection and immunohistologic specimen evaluation are emphasized. Clinicians should consider the diagnosis of SFT when confronted with an adult patient having an orbital soft tissue mass demonstrating the distinctive magnetic resonance imaging findings.

The Effects of Sleep Deprivation on Oculomotor Responses

Purpose: Fatigue due to sleep deprivation is one of the main causes of accidents. An objective and efficient method for determining whether the person is tired could provide a valuable tool in accident prevention. In this study, we evaluated whether oculomotor responses related to pupillary light reflex and saccadic velocity can identify subjects with sleep deprivation and whether these objective values correlate with subjective feeling of sleepiness. Methods: Thirteen normal subjects (5 male, 8 female) participated in a 4-day study. During the first two days following a full night’s (8 hr in bed) sleep, they underwent baseline automated oculomotor testing using the FIT-2500-Fatigue-Analyzer. Following a third full night’s sleep, participants were then sleep-deprived for 28 hr. Ten measurements of automated oculomotor tests were performed during the sleep deprivation period. Visually-guided saccadic velocity (SV), initial pupil diameter (PD), pupillary constriction latency (CL), and amplitude of pupil constriction (CA) were assessed using the FIT-2500-Fatigue-Analyzer. The FIT-index, which expresses the deviation of the ocular parameters from the baseline measurements, was calculated. Correlation of oculomotor parameters with the subjective Stanford Sleepiness Scale (SSS) was performed. Results: We found that oculomotor measures showed a significant increase in CL (298.6 to 308.4 msec, P < 0.05) and calculated FIT index (3.4 to 16.8, P < 0.05) and a significant decrease in SV (64.8 to 59.6 deg/sec) during sleep deprivation. The SSS was found to significantly increase over the sleep deprivation period (2.05 to 5.05, P < 0.05) and was significantly correlated with the FIT-index (r > 0.66, P < 0.02). Conclusion: Evaluation of oculomotor responses, particularly CL and SV together with the FIT-index, might have practical applications for the assessment of an individual’s state of alertness or fatigue. Correlation of the FIT-index to the SSS provides evidence for the potential usefulness of oculomotor function measurements in the detection of subjective sleepiness.

The smooth surface tunnel porous polyethylene enucleation implant.

BACKGROUND AND OBJECTIVE To describe early clinical results with the porous polyethylene smooth surface tunnel (SST) enucleation implant. PATIENTS AND METHODS Uncontrolled, prospective interventional case series of patients undergoing enucleation with placement of the SST implant. This implant consists of a porous polyethylene sphere with a smooth anterior surface containing pre-drilled tunnels to facilitate direct suturing of the rectus muscles to the implant without use of an implant wrap. Postoperatively, socket healing was assessed, and prosthesis and socket motility were evaluated by the surgeon using an ordinal scale (0 = no motility to 4 = excellent motility). RESULTS Thirty patients received the SST implant, with a mean follow-up of more than 23 months. Two cases of exposure occurred and were managed surgically without the need for explantation. Mean socket motility was 3.1 on a 0 to 4 ordinal scale, with mean prosthesis motility of 2.8. CONCLUSION The SST implant provides satisfactory socket motility and is generally well tolerated in the anophthalmic socket without the need for wrapping material.

Topical anesthetic abuse keratitis secondary to floppy eyelid syndrome.

Purpose: To report the diagnosis and management of a patient with chronic ophthalmic topical anesthetic abuse and floppy eyelid syndrome. Methods: We describe the case of a 47-year-old man suffering from persistent bilateral ocular irritation and chronic corneal erosions. Results: The patient was hospitalized in our ophthalmology department and underwent thorough ophthalmic, systemic, and psychiatric evaluation. Chronic topical anesthetic abuse was discovered. Removal of abused drops and copious lubricating treatment lead to partial improvement further permitting diagnosis of floppy eyelid syndrome. Definitive surgical treatment by horizontal eyelid tightening combined with continuous lubrication resulted in remission of symptoms. Conclusions: Uncommon conditions may coexist in 1 patient. In this case, floppy eyelid syndrome resulted in topical anesthetic abuse. Ophthalmologists should keep both these conditions in mind when treating patients with otherwise unexplained chronic persistent corneal erosions.

How to Avoid Blepharoplasty Complications

Complications unfortunately are part of blepharoplasty surgery. The goal of this article is to help guide the surgeon through the thought process of the preoperative evaluation, surgical planning, and actual surgery to avoid complications. With better understanding of the goals of blepharoplasty and the areas for potential problems, we hope to reduce the possibility of developing complications.

Comparison of corneal endothelial cell density estimated with 2 noncontact specular microscopes.

Purpose To assess the repeatability of endothelial cell density (ECD) measurements by the EM-935 endothelial microscope and their agreement with those of the Konan-Noncon Robo SP 6000 (Noncon Robo) specular microscope. Methods We assessed the agreement between automated and semiautomated methods of analysis of the EM-935 and the Noncon Robo by measuring ECD in 40 eyes of 20 healthy subjects and calculating the 95% limits of agreement (LoA) and plotting Bland-Altman graphs. We then evaluated the repeatability of both the methods of the EM-935 by calculating the intraclass correlation coefficients (ICC) and coefficient of variation (CV). Results The mean ECD of the 40 eyes was 2531±244 cells/mm2 for Noncon Robo and 2483±159 cells/mm2 for EM-935-Automated. The difference between these 2 methods was not statistically significant. The mean ECD for EM-935-semiautomated was 2635±190 cells/mm2 and was statistically significantly higher than the 2 other methods (p<0.001). The 95% LoA were −435 to 339 cells/mm2 for the Noncon Robo and EM-935-Automated, −230 to 438 cells/mm2 for the Noncon Robo and EM-935-semiautomated, and −347 to 43 cells/mm2 for the EM-935-Automated and EM-935-semiautomated. Repeatability was better for EM-935-semiautomated method compared with automated method as expressed by ICC (95% CI) of 0.80 (0.52–0.95) vs 0.50 (0.09–0.84) and coefficient of variation of 2.43% vs 2.85%, respectively. Conclusions The EM-935 specular microscope showed better repeatability for the semiautomated mode compared with the automated mode. Although measurement agreement with the Noncon Robo was somewhat better for the semiautomated mode, agreement was only moderate for both methods. This leads us to recommend that these instruments should not be used interchangeably.

Biological glue in pterygium surgery with a rotational flap or sliding flaps.

Purpose: To compare 2 surgical approaches to conjunctival flap placement during pterygium surgery using a biologic adhesive: single rotational flap and double sliding flaps. Methods: Thirty-three consecutive patients (34 eyes) with primary pterygium were assigned prospectively and randomly to receive pterygium surgery with either 1 rotational flap (group A, 19 eyes) or double sliding flaps (group B, 15 eyes) by using a biologic adhesive to secure the flaps. The patients were followed for 24 weeks. Results: In group A, 1 (5.3%) flap was lost because of ischemia, whereas all the others remained in position and became fully integrated. In group B, 4 (26%) flaps did not retain their primary position. In 2 (13%) eyes, the superior and inferior flaps partially dehisced, resulting in a 2- to 3-mm gap; in 1 (6.5%) eye, the inferior flap dehisced completely and retracted to the lower fornix; and in 1 (6.5%) eye, both flaps completely dehisced and retracted, leaving an area of bare sclera. Conclusions: The use of tissue adhesive is a promising technique in pterygium surgery. In this study, gluing 1 rotational flap resulted in excellent postoperative results, but it seemed less suitable for use with double sliding flaps.

Evaluation of the Tearing Patient

Patients with insuffi cient lacrimal drainage may present to the ophthalmologist with a complaint of tearing. This tearing may be unilateral or bilateral, intermittent or constant, isolated or associated with other ocular symptoms. Tearing may cause blurred vision, problems with contact lens wear, or annoyance with tears fl owing down the cheek. Patients may also complain of a buildup of mucopurulent material in the medial canthus, leading to mattering of the eyes. To correctly identify and treat the cause of tearing, it is helpful to fi rst differentiate between hyperlacrimation (tear overproduction) and epiphora (decreased tear outfl ow). Hyperlacrimation may be attributable to a variety of causes and must be ruled out before addressing any potential outfl ow problems. Causes of hyperlacrimation, listed in Table 6.1, include the general categories of supranuclear and infranuclear etiologies, refl ex lacrimation, and direct lacrimal gland stimulation. Epiphora may be caused by problems at any point along the lacrimal outfl ow apparatus: punctum, canaliculus, lacrimal sac, lacrimal pump, nasolacrimal duct, and the valve of Hasner at the nasal opening of the nasolacrimal duct. Specifi c problems involving these areas are listed in Table 6.2.