Nattaporn Tesavibul

Single and multilayer amniotic membrane transplantation for persistent corneal epithelial defect with and without stromal thinning and perforation

AIMS To evaluate the efficacy of amniotic membrane transplantation (AMT) in persistent corneal epithelial defect with or without stromal thinning and corneal perforation. METHODS 28 patients (28 eyes) with persistent corneal epithelial defect unresponsive to medical treatment were given preserved human amniotic membrane transplants. The patients were divided into three groups: group A, persistent corneal epithelial defect 10 eyes; group B, epithelial defect with stromal thinning 13 eyes; and group C, corneal perforation five eyes. AMT was performed using one layer in group A and multilayers in group B and C. The causes of persistent epithelial defect were neurotrophic keratopathy (24 eyes), limbal deficiency (six eyes), exposure keratopathy (four eyes), and Moorens ulcer (one eye). RESULTS Success was noted in 82.1% (23/28 eyes) in all groups, with 80% (8/10 eyes), 84.6% (11/13 eyes), and 80% (4/5 eyes) in groups A, B, and C respectively, with a mean follow up of 10.9 months (1–30 months). The mean epithelialisation time after AMT was 2.1 weeks. The healing times of groups B and C are also significantly shorter than group A (p=0.017 and 0.018, respectively). Corneal stromal thickness was significantly increased in all cases in groups B and C (p=0.006). Those with corneal perforation in group C were completely healed by multilayer AMT. There was no difference in the epithelialisation time between successful cases treated by a single operation (17 eyes) or repeated operation (six eyes). Vision improved in 18.9% (8/28 eyes) and worsened as a result of cataract formation in 2.3% (1/28 eyes). Failure was noted in 17.9% (5/28 eyes), because of corneal infection (two eyes), neurotrophic keratopathy with and without limbal deficiency (two eyes), and intractable corneal perforation (one eye). No patient developed major immediate postoperative complications or graft rejection. CONCLUSION Amniotic membrane can successfully treat refractory corneal epithelial defect by promoting epithelial healing and thus prevent corneal perforation. It can be used as a treatment for corneal perforation by restoring corneal stromal thickness so that emergency penetrating keratoplasty can be avoided.

Topical 0.002% Mitomycin C for the Treatment of Conjunctival-corneal Intraepithelial Neoplasia and Squamous Cell Carcinoma

PURPOSE To demonstrate the efficacy of topical 0.002% mitomycin C (MMC) as an adjunctive and alternative treatment in primary and recurrent conjunctival-corneal intraepithelial neoplasia (CCIN) and squamous cell carcinoma (SCC). METHODS The medical records of 7 patients with histopathologically confirmed CCIN and conjunctival SCC were retrospectively reviewed. All cases were treated with topical 0.002% MMC 4 times daily. The tumor size pre- and post-treatment, clinical response, and ocular complications were evaluated. RESULTS The mean age of the patients was 56 +/- 13.4 years. The most common presenting symptom was foreign body sensation (57.1%) with a mean duration of 2.3 +/- 3.8 months. Six patients had pathologically proven CCIN (85.7%) and 1 had SCC (14.3%). Before MMC treatment, 6 eyes (85.7%) had recurrences after surgical excision. The tumor-free period ranged from 2 to 19 months. Two patients had multiple recurrences. MMC 0.002% 4 times daily was applied for a period of 5.4 +/- 4.4 weeks (range, 2-14). All had complete tumor regression as observed clinically and confirmed by impression cytology. Side effects of MMC therapy included ocular irritation, mild conjunctival hyperemia, and punctate keratopathy. There were no serious complications detected. The mean follow-up time was 30.7 +/- 15 months (range, 2-52) with no evidence of clinical recurrence in any case. CONCLUSIONS Topical 0.002% MMC showed a favorable outcome as an adjunctive and alternative treatment of CCIN and SCC with regression of primary and recurrent tumors.

Performance profile of sodium hyaluronate in patients with lipid tear deficiency: randomised, double‐blind, controlled, exploratory study

Aim: To assess the short-term efficacy of hypotonic 0.18% sodium hyaluronate in patients with evaporative tear-sufficient dry eye due to lipid tear deficiency (LTD). Methods: This was a randomised, double-blind, controlled, exploratory study. A total of 10 patients with dry eye due to LTD were treated as follows: one drop of hypotonic 0.18% sodium hyaluronate in one eye and one drop of isotonic 0.3% hydroxypropyl-methylcellulose (HPMC)/0.1% dextran in the other eye. Non-invasive tear film break-up time (NIBUT) evaluated by using a tear scope with grid pattern and subjective ocular symptoms of dry eye were assessed at 15, 30, 60 and 90 min after instillation. Results: Both sodium hyaluronate and HPMC/dextran caused a significant (p<0.05) improvement in NIBUT and symptoms. Mean (SD) NIBUT in the sodium hyaluronate group was 3.2 (1.0), 6.4 (2.8), 5.5 (1.9), 5.3 (1.3) and 3.9 (1.7) s at 0, 15, 30, 60 and 90 min, respectively, compared with 3.6 (1.9), 5.5 (3.2), 5.0 (1.5), 4.4 (2.2) and 3.5 (1.2) s in the HPMC/dextran group. However, increase in NIBUT was significantly (p<0.05) greater and longer in the sodium hyaluronate group than in the HPMC/dextran group. Conclusion: Treatment with sodium hyaluronate and HPMC/dextran eye drops is useful for treating patients with dry eye due to LTD. However, sodium hyaluronate caused a significantly (p<0.05) greater increase in NIBUT values than HPMC/dextran in such patients.

A randomized double-masked study of 0.05% cyclosporine ophthalmic emulsion in the treatment of meibomian gland dysfunction.

Purpose: To compare the efficacy of topical cyclosporine [0.05% cyclosporine A (CsA)] and preservative-free artificial tears in the treatment of meibomian gland dysfunction (MGD). Methods: A 3-month prospective, randomized, double-masked, parallel-group controlled trial enrolled 70 patients with symptomatic MGD and unstable tear film [tear breakup time (TBUT) <8 seconds]. Patients were randomized to topical CsA (0.05%; group A) and 0.5% carboxymethylcellulose (control; group B) instilled twice daily for 3 months. Ocular Surface Disease Index (OSDI), lid margin inflammation, meibomian gland expression, conjunctival injection, corneal and interpalpebral dye staining, noninvasive tear breakup time (NIBUT) using the Tearscope Plus and invasive fluorescein tear breakup time (FBUT), and Schirmer I test were performed. Results: At the 3-month evaluation, mean OSDI, NIBUT and FBUT, lid margin inflammation, meibomian gland expressibility, and tarsal injection showed significant improvement from baseline in group A (P < 0.01, P < 0.01, P < 0.001, P < 0.05, and P < 0.001, respectively). In group B, only the OSDI improved significantly from baseline at 3 months (P = 0.003). TBUTs (NIBUT and FBUT) were significantly longer in group A at all visits, and the mean change of TBUTs from baseline was also significantly greater in group A at 3 months (P < 0.001). Conclusions: Topical CsA 0.05% twice daily may be helpful in the treatment of MGD mainly by improving tear film stability.

Efficacy of cultivated corneal epithelial stem cells for ocular surface reconstruction

Purpose To investigate the clinical outcomes of cultivated corneal limbal epithelial transplantation (CLET) using human amniotic membrane for corneal limbal stem-cell deficiency. Methods Prospective, noncomparative case series. Eighteen patients (19 eyes) with severe ocular surface diseases were chosen to undergo CLET using human amniotic membrane. Twelve eyes received auto-CLET, and seven eyes received allo-CLET. Clinical outcomes of corneal surface epithelialization, conjunctivalization, inflammation, visual acuity, graft status, and complications were observed. Results Corneal epithelium cultivated on amniotic membrane (two to four layers) was positive for molecular markers p63, ABCG2, CK3, and CK12. The mean patient age was 44.7 ± 15.2 years. A successful clinical outcome, defined as corneal epithelialization without central conjunctivalization or severe inflammation, was obtained in 14 (73.7%) of 19 eyes (mean follow-up 26.1 ± 13.5 months; range 6–47). A histopathologic success, defined as absence of goblet cells at the central cornea, was achieved in 12 (63.2%) eyes. Clinical failures occurred in five (26.3%) of 19 eyes, and histopathologic failures occurred in seven (36.8%) of 19 eyes. Survival analysis at 1 year showed that the clinical success rate was 77.9% and the pathological success rate was 72.3%. Fourteen of 19 (73.7%) eyes had visual acuity improvements after CLET. Six cases underwent penetrating keratoplasty; five of these grafts remained clear after 20.4 ± 6.9 months (range, 12–31) of follow-up. Complications included infectious keratitis (three cases) and recurrent symblepharon (one case). All complicated cases had lid abnormalities. Factors affecting the final clinical outcomes were lid abnormalities, abnormal corneal stromal beds, and complications. Conclusion CLET can successfully restore ocular surface damage in most cases with corneal limbal stem cell deficiency.

Preserved Amniotic Membrane Transplantation for Conjunctival Surface Reconstruction

AbstractObjective. To study the efficacy of preserved human amniotic membrane in the reconstruction of conjunctival defect created during surgical removal of conjunctival lesions or symblepharon lysis. Methods. Preserved human amniotic membrane transplantation was performed in 93 eyes of 85 patients for reconstruction of various conjunctival surface problems. The indications for surgery were (1) pterygium excision (54 eyes), (2) conjunctival tumors excision (23 eyes), lysis of symblepharon (13 eyes), and covering a scleral graft (three eyes). Results. Success was noted in 69.9% (65/93) eyes, partially success in 22.6% (21/93) eyes, and failure in 7.5% (7/93) eyes with a mean follow-up of 8.9 months (1–28 months). In pterygium, conjunctival tumor, symblepharon, and scleral graft group, the success rate in each group was 70.3%, 78.3%, 53.8%, and 66.7% respectively. No serious immediate post-operative complications or graft rejection occurred. Conclusion. Amniotic membrane transplantation can be considered an alternative treatment for difficult ocular surface problems, and is effective in promoting epithelial healing, and reducing inflammation and scarring.

Clinical Manifestations of Cytomegalovirus-Associated Posterior Uveitis and Panuveitis in Patients Without Human Immunodeficiency Virus Infection

IMPORTANCE Little attention has been paid to clinical features of cytomegalovirus (CMV) infections in individuals without human immunodeficiency virus (HIV). OBJECTIVE To describe the clinical manifestations and comorbidities of patients without HIV infection who have CMV-associated posterior uveitis or panuveitis. DESIGN AND SETTING Retrospective observational case series in an academic research setting. PARTICIPANTS The medical records were reviewed of 18 patients (22 affected eyes) diagnosed as having posterior uveitis or panuveitis who had aqueous positive for CMV by polymerase chain reaction techniques. MAIN OUTCOME MEASURES Demographic data, clinical manifestations, and associated systemic diseases were recorded. RESULTS Ocular features included focal hemorrhagic retinitis (n = 13) and peripheral retinal necrosis (n = 7). Two eyes had no focal retinal lesions but manifested vasculitis and vitritis. All patients exhibited vitreous inflammation. Inflammatory reactions in anterior segments developed in 14 of 22 eyes (64%). Retinal vasculitis was observed in 16 of 22 eyes (73%) and included mostly arteries (in 13 of 16 eyes [81%]). Eleven of 18 patients were taking immunosuppressive medications (5 for hematologic malignant diseases, 4 for systemic autoimmune diseases, and 2 following organ transplants). One additional patient was diagnosed as having non-Hodgkin lymphoma 3 months after the onset of CMV-associated panuveitis, and another patient had primary immunodeficiency disorder. Of the remaining 5 patients, 2 had diabetes mellitus, and 3 had no associated systemic diseases and exhibited no evidence of immune deficiency. CONCLUSIONS AND RELEVANCE Cytomegalovirus-associated infections of posterior eye segments can develop in patients without HIV infection who have compromised immune function of variable severity but may occur also in individuals who have no evidence of immune insufficiency. Cytomegalovirus infections located in posterior eye segments in patients without HIV infection caused intraocular inflammatory reaction in all cases and demonstrated more variable clinical presentation than classic CMV retinitis observed in patients with HIV infection.

Efficacy of Cyclosporine 0.05% Eye Drops in Stevens Johnson Syndrome with Chronic Dry Eye

OBJECTIVE To evaluate the efficacy of cyclosporine 0.05% (CsA) eye drops in patients with Stevens Johnson syndrome (SJS) who had chronic dry eye. DESIGN Prospective noncomparative interventional case series. METHODS Thirty cases of SJS patients who developed dry eye defined by symptoms and signs, including the Schirmer I test, the fluorescein clearance test (FCT), and corneal staining (fluorescein and Rose Bengal staining) were treated with CsA 0.05% eye drops twice daily for 6 months. Dry eye symptoms, eye injection, tear break up time (TBUT), and corneal staining were evaluated before and after the treatment at 0, 2, 4, and 6 months. The Shirmer I test and FCT were evaluated at 0 and 6 months. RESULTS Seventeen patients (56.67%) completed the study. Eight patients (26.67%) withdrew from the study as a result of intolerable side effects of CsA, which included pain, redness, and eyelid swelling. Five cases were lost in follow up. All 17 cases demonstrated significant improvement in dry eye symptoms, conjunctival injection, corneal staining, Schirmer I test, and FCT (P<0.05). CONCLUSIONS CsA 0.05% eye drops might be beneficial in the treatment of chronic dry eye associated with SJS.

Frosted branch angiitis as a result of immune recovery uveitis in a patient with cytomegalovirus retinitis

BackgroundSince the introduction of Highly Active Antiretroviral Therapy (HAART), AIDs related morbidity and mortality have declined. However, the advent of HAART brought the new problem of immune recovery inflammatory syndrome. Cytomegalovirus retinitis remains the most common cause of visual loss in AIDs patients. Some patients with cytomegalovirus retinitis who experienced immune recovery as a consequence of HAART develop worsening of visual symptoms from immune recovery uveitis (IRU).FindingsWe report a case of cytomegalovirus retinitis and AIDs who developed an unusual presentation of IRU after the initiation of HAART. A 40-year-old woman presented with a history of blurry vision in the right eye. She was diagnosed with human immunodeficiency virus infection and cytomegalovirus retinitis, treated with intravitreal injections of ganciclovir. The retinitis improved. One week after HAART initiation, she developed IRU, characterized by increased intraocular inflammation, extensive frosted branch angiitis and cystoid macular edema. The CD4+ T lymphocyte count increased from 53 to 107 cells/mm3. Systemic prednisolone with continuation of HAART and intravitreal injections of ganciclovir were given with significant improvement.ConclusionAtypical presentation of IRU, characterized by extensive frosted branch angiitis and increased intraocular inflammation may occur in immunocompromised patients with cytomegalovirus retinitis who experienced immune recovery. The time from HAART initiation to develop IRU may vary from days to months. This case demonstrated a very rapidly developed IRU which should be recognized and appropriately managed to avoid permanent damage of the eye.

Crystallization after intravitreal ganciclovir injection.

Purpose: To report crystal formation as a complication of intravitreal ganciclovir injection. Patients and methods: A 73-year-old female patient with unilateral cytomegalovirus retinitis was treated with intravitreous ganciclovir (4 mg/0.04 mL). Results: After the intravitreal injection, sudden crystallization was observed in the vitreous humor. The patient experienced marked reduction in visual acuity and increased intraocular pressure. Despite aqueous paracenthesis and pars plana vitrectomy, optic atrophy was observed and her visual acuity remained unimproved after 12 months. Conclusion: Crystal formation can occur as a complication of intravitreal ganciclovir injection. Associated retinal and optic nerve damage was found which results in permanent visual morbidity.