Nicolas Toledano

Peripheral melt of flap after laser in situ keratomileusis

BACKGROUND Laser in situ keratomileusis (LASIK) is an effective procedure to correct myopia. It may have complications related to the flap, such as epithelial ingrowth and stromal melt. METHODS We report on a patient who developed extensive epithelial ingrowth and partial keratolysis of the flap following LASIK. This complication was treated by lifting the flap and removing the epithelium from within the interface. RESULTS Progressive keratolysis (stromal melt) can result in irregular astigmatism and loss of vision as well as photophobia and ciliary injection. The pathogenesis is not completely understood although the epithelial ingrowth in the interface is always present, and epithelial-stromal interaction with production of proteases may be involved. CONCLUSION Epithelial ingrowth may develop in the lamellar interface after LASIK and be associated with melting of the edge of the flap. This undesirable complication can be successfully managed with early surgical removal of the epithelium and proper attachment of the flap.

Severe keratomycosis secondary to Scedosporium apiospermum

Purpose. To report an unusual case of severe keratomycosis caused by Scedosporium apiospermum without any known previous ocular injury, that resulted in a corneal perforation, which was treated with an emergency penetrating tectonic keratoplasty and later with phacoemulsification and astigmatic keratotomy to restore good visual function. Methods. A 45-year-old woman with a history of multiple sclerosis presented with a severe and refractory corneal abscess in her right eye without any known prior injury. Corneal scrapings were obtained and stained for microscopic evaluation. The samples were sent for aerobic and anaerobic bacterial and fungal cultures. Results. Microbiologic examination of the corneal scraping showed Scedosporium apiospermum micelle. The fungal culture was sensitive to miconazole, itraconazole and voriconazole. Partial clinical improvement was achieved with hourly topical natamycin, amphotericin B, and systemic itraconazole application, although in vitro sensitivity tests showed resistance to the topical antifungal agents used. A corneal paracentral perforation occurred despite aggressive treatment. An emergency eccentric penetrating keratoplasty was performed with satisfactory results. Subsequent phacoemulsification and astigmatic keratotomy restored a good visual function. Conclusion. A fungal etiology should be suspected in a progressive and refractory corneal abscess. This report highlights the utility of microbiologic investigation to perform an early and accurate diagnosis. Aggressive medical treatment and even therapeutic penetrating keratoplasty to remove infected tissue could result in the maintenance of useful visual function. In view of the poor prognosis of this specific fungus, a closer observation and early keratoplasty might be required to preserve the ocular globe.

Management and Treatment of Central Steep Islands after Excimer Laser Photorefractive Keratectomy

BACKGROUND Permanent central steep islands are an undesirable phenomenon that cause distorted images and a significant reduction in visual acuity. We describe treatment of central steep islands with repeat excimer laser photoablation in the central cornea. METHODS Three patients with preoperative refractions of -7.50 -2.50 x 170 degrees D (right eye), -8.00 -2.25 x 10 degrees D (right eye) and -6.00 -1.50 x 90 degrees (right eye) developed central steep islands which persisted more than 12 months. All patients lost more than two lines of spectacle-corrected visual acuity and complained of visual disturbances. We retreated the central steep islands with a VISX 20/20 excimer laser PRK ablation that matched the size of the central island measured on videokeratography. RESULTS Symptomatic glare and distortion were significantly reduced and the central steep islands were resolved. Several weeks after reablation, spectacle-corrected visual acuity improved to the preoperative level. CONCLUSION Central steep island, an infrequent complication of excimer laser photorefractive keratectomy, can be safely removed with a repeat laser ablation that matches the central circular steep area.

Influence of topical Cyclosporine A and dissolvent on corneal epithelium permeability of fluorescein

The corneal stroma is the major barrier to penetration for the lipophilic Cyclosporine A (CsA) molecule and prevents the use of the common ophthalmic solvents. At present, corn oil, castor oil and olive oil are the three most commonly used vehicles. The aim of this study was to determine the effect that topically applied CsA dissolved in different oils has on corneal epithelial permeability measured by fluorophotometry. Forty healthy volunteers, with absence of ocular or systemic disease and not receiving topical or systemic drugs were enrolled. Measurements were taken before and 45 min after the instillation of 40 microliters of a 2% aqueous solution of sodium fluorescein without preservatives. Basal corneal permeability and the permeability 24 h after the instillation of 2% CsA-olive oil, olive oil alone, 2% CsA-castor oil, castor oil alone, 2% CsA-corn oil and corn oil alone, were calculated. To prepare the topical 2% CsA, a Sandimmun oral solution (Sandoz, Basel, Switzerland) was employed under sterile conditions. We found that epithelial permeability 24 h after the instillation of any CsA formulations or solvents increased more than 6.62 times (p < 0.001). No differences in corneal permeability values were found between any of the CsA formulations and the vehicles. We conclude that oils used to dissolve CsA are mainly responsible for the increased corneal epithelial permeability. No differences were found in the effects of the tested solvents on corneal epithelial permeability.

Frosted branch angiitis and late peripheral retinochoroidal scar in a patient with acquired toxoplasmosis.

Purpose To report a case of acute frosted branch angiitis associated with acquired toxoplasmosis in which a late peripheral chorioretinal scar developed. Method Case report. Results A 32-year-old man without systemic symptoms presented with sudden visual loss in his left eye. Examination demonstrated frosted branch angiitis without necrotizing chorioretinitis. Serologic tests showed elevated Toxoplasma gondii-specific immunoglobulin M antibody titers. Antitoxoplasmic therapy and oral steroids healed the ocular inflammation. In a follow-up visit one year later, a peripheral chorioretinal scar was noted. Conclusions Acute frosted branch angiitis without focal necrotizing chorioretinitis can be a manifestation of acquired toxoplasmosis. This could be an important, and sometimes forgotten, sign of the disease.

Blood-aqueous barrier permeability determination in HLA B27-positive acute anterior uveitis patients

The blood-aqueous barrier (BAB) permeability was studied by fluorophotometry in 17 healthy control subjects and in 27 eyes from 27 patients with HLA-B27-positive acute anterior uveitis (HLA-B27 AAU). Twenty of these patients had an associated spondyloarthropathy. BAB permeability was studied during the ocular inflammatory crisis and in the disease-free periods in the same patients. Anterior chamber fluorophotometric scans were performed before and 30 minutes after the intravenous injection of 14 mg/kg of sodium fluorescein. The diffusion coefficient (Kd) was obtained from the ratio between the fluorescein concentration in the anterior chamber and the NPBF. Data were analyzed using the Students t test and analysis of variance. A statistically significant difference (P < 0.001) was found between the Kd of active HLA-B27 AAU (61.4±16.8×10−4 min−1) and the Kd of inactive HLA-B27 AAU (4.8±1.6×10−4 min−1). No statistically significant differences were found between the Kd of inactive HLA-B27 AAU and the Kd of the control subjects (4.3±1.0×10−4min−1). We also failed to detect significant differences between patients with and without spondyloarthropathy either during the acute attack or during the disease-free period. On the basis of these results we conclude that the permeability of the BAB remains intact in inactive HLA-B27-positive AAU. The parallel fluorophotometric behaviour of HLA-B27-positive AAU with spondyloarthropathy and without spondyloarthropathy suggests that both share a common pathogenetic mechanism.

Bilateral anterior uveitis as a presenting manifestation of sarcoidosis and syphilis

We report an unusual case of bilateral acute anterior uveitis in an asymptomatic patient in which ophthalmic examination and laboratory tests showed the diagnosis of syphilis and sarcoidosis. A previously healthy 34 year old Hispanic woman with a 2 week history of blurred vision was referred for evaluation. The patient had no systemic complaints. On examination her best corrected visual acuity was 20/30 in the right eye and 20/40 in the left. Slit lamp examination showed bilateral findings of moderate (2+) anterior chamber cells and non-granulomatous keratic precipitates (Fig 1). Fundus examination did not show any signs of vascular, retinal, or choroidal disease and a diagnosis of bilateral acute anterior uveitis was made. Treatment with topical prednisolone acetate and cyclopentolate drops resulted in mild …

P 123 Effect of different oils used to dissolved cyclosporine a on corneal epithelial permeability

Purnose The incorporation of polymers into artificial tears both increases the thickness of the precorneal tear film and decreases the rate of drainaae of the for8nulations. On the basis of these effects, we hypothesized that a time study of the artificial increase in tear volume induced by such formulations could be a useful method of assessing their precorneal residence time. Methods New Zealand albino rrlbbits were used. The tear volume was measured under general anesthesia by determining the dilution ratio of a topically applied 1% fluorescein solution. The formulations studied were proprietary preparations of 1.4% PVA (Liquifilm, Allergan), 1% MC (Nlethylcellulose 1%. MSD-Chibret), 0.2% Carbomer 940 (Lacrinorm, Laboratoire CHAUVIN) and a 0.52% aqueous solution of HEC (Hydroxyethylcellulose). One drop (25~1) of the test formulation was instilled into one eye at different times before the determination of tear volume. A control group received a polymer-free aqueous solution. &&@ All the polymer formulations induced an increase in the tear volume as compared with the polymer-free solution. After administration of PVA, MC, HEC and Carbomer 940 preparations, the tear volume remained significantly increased for 5 min., 20 min., 20 min. and 60 min. respectively. Conclusions The precorneal residence times of these polymer formulations have been demonstrated to be shorter in humans than those observed in this study in rabbits. However. there is a similar rank order in the two species. Thus, the determination of the tear volume in rabbits providtzs a useful method for preliminary screening of new polymer artificial tears.

Effect of Bendazac Lysine on lens and retina in diabetics

The possible beneficial effects on the lens and retina which Bendazac Lysine may have in the treatment of adult diabetic patients were investigated. Twenty patients, ranging in age from 54.80 ± 5.86 years old, were studied. The average duration of the diabetes was 11.32 ± 4.10 years. Thirteen patients had background retinopathy. The metabolic controls carried out during the study were satisfactory (HbA1<11%). Bendazac Lysine (500 mg three times a day) was administered for 6 months. Blood-retinal barrier permeability (VPR and VPRt) and lens transmittance (t) were evaluated prior to and 6 months after treatment by fluorophotometry. No statistically significant differences between the pre- and post-treatment values of the retina permeability were observed, however, there was a statistically significant improvement (p<0.05) (initial value: t= 0.813 ± 0.040 and final value: t=0.823 ± 0.037) in the lens transmittance. The authors conclude that Bendazac Lysine has a beneficial effect on the lens in the diabetic adult although no improvement in the permeability of the blood-retinal barrier has been observed.