Renée Solomon

Efficacy of commercially available topical cyclosporine A 0.05% in the treatment of meibomian gland dysfunction

Objective: To investigate the efficacy of topical cyclosporine A 0.05% (tCsA) (Restasis®, Allergan Pharmaceuticals) in the treatment of meibomian gland dysfunction (posterior blepharitis). Methods: Thirty-three patients with symptomatic meibomian gland dysfunction were randomized in a prospective study to either tCsA or placebo (Refresh Plus® preservative-free artificial tears), 2 times daily for 3 months. They were evaluated at baseline and at 1, 2, and 3 months for subjective symptoms and objective signs including meibomian gland inclusions, lid margin vascular injection, tarsal telangiectasis, fluorescein staining, tear breakup time, and Schirmer scores. Results: Twenty-six patients completed the study. All patients were tested for ocular symptoms, lid margin vascularity, tarsal telangiectasis, meibomian gland inclusions, tear breakup time, and fluorescein staining. At the 3-month visit, the tCsA group showed a greater improvement in ocular symptoms than the placebo group, but this difference was not statistically significant. At the 3-month visit, several objective examination findings were statistically significantly (P < 0.05) improved in the tCsA group compared with the placebo group. These differences included lid margin vascular injection, tarsal telangiectasis, and fluorescein staining. The most significant finding (P = 0.001) was the greater decrease in the number of meibomian gland inclusions in the tCsA group compared with the placebo group. Conclusions: Topical CsA may be helpful in the treatment of meibomian gland dysfunction (posterior blepharitis). Topical CsA did not induce an improvement in the symptoms, but it did decrease the number of meibomian gland inclusions in patients with meibomian gland dysfunction.

Infectious keratitis after laser in situ keratomileusis: Results of an ASCRS survey

&NA; To investigate the incidence, culture results, treatment, and visual outcomes of infectious keratitis after laser in situ keratomileusis (LASIK) worldwide, the Cornea Clinical Committee of the American Society of Cataract and Refractive Surgery (ASCRS) contacted 8600 United States and international ASCRS members by e‐mail and asked them to respond to a questionnaire about post‐LASIK infectious keratitis. One hundred sixteen infections were reported by 56 LASIK surgeons who had performed an estimated 338 550 procedures. Seventy‐six cases presented in the first week after surgery, 7 during the second week, 17 between the second and fourth weeks, and 16 after 1 month. Forty‐seven cases were not diagnosed on initial presentation. The most common organisms cultured were atypical mycobacteria and staphylococci. Empiric therapy is not recommended as most of the organisms are opportunistic and not responsive to conventional therapy. Flap elevation and culturing should be performed when post‐LASIK infectious keratitis is suspected.

Preoperative ketorolac tromethamine 0.4% in phacoemulsification outcomes: Pharmacokinetic-response curve

PURPOSE: To assess the clinical benefit, relative efficacy, and pharmacokinetic‐response curve of preoperative and postoperative ketorolac tromethamine 0.4% (Acular LS) to improve outcomes during and after cataract surgery. SETTING: Private clinical practice. METHODS: One hundred patients were randomized in a double‐masked fashion to 4 groups of 25 to receive ketorolac for 3 days, 1 day, or 1 hour or a placebo before phacoemulsification. All treatment groups received ketorolac 0.4% for 3 weeks postoperatively; the placebo group received vehicle. Outcomes measures were preservation of preoperative mydriasis, phacoemulsification time and energy, operative time, corneal clarity, endothelial cell counts, postoperative inflammation, intraoperative and postoperative discomfort, complications, and incidence of clinically significant cystoid macular edema (CME). RESULTS: Maintenance of pupil size with 3‐day ketorolac dosing was significantly better than with 1‐day dosing (P<.01), which was significantly better than with 1‐hour or placebo dosing (P<.01). Both 3‐day and 1‐day dosing were superior to 1‐hour or placebo dosing. No patient receiving ketorolac 0.4% for 1 or 3 days developed CME compared with 12% of patients in the control (placebo) group and 4% in the 1‐hour group. Three‐day and 1‐day dosing of ketorolac reduced surgical time, phacoemulsification time and energy, and endothelial cell loss and improved visual acuity in the immediate postoperative period compared with 1‐hour predosing and the placebo (P<.05). CONCLUSION: The preoperative use of ketorolac tromethamine 0.4% for 3 days followed by 1‐day of predosing provided optimum efficacy and superior outcomes relative to 1‐hour pretreatment and a placebo.

Evaluation of Topical Cyclosporine for the Treatment of Dry Eye Disease

OBJECTIVE To evaluate the use of topical cyclosporine, 0.05% (Restasis; Allergan Inc, Irvine, California), for the treatment of mild, moderate, and severe dry eye disease unresponsive to artificial tears therapy. METHODS This was a prospective clinical study. One hundred fifty-eight consecutive patients with dry eye disease unresponsive to artificial tears therapy were divided into 3 groups of disease severity: mild, moderate, and severe. Patients were evaluated using the Ocular Surface Disease Index for symptomatic improvement, tear breakup time, fluorescein staining, lissamine green staining, and Schirmer testing. Patients were observed for 3 to 16 months. The main outcome measure was improvement in disease. RESULTS Forty-six of 62 patients with mild dry eye disease (74.1%), 50 of 69 with moderate disease (72.4%), and 18 of 27 with severe disease (66.7%) showed improvement, with 72.1% improving overall. CONCLUSIONS Topical cyclosporine shows beneficial effects in all categories of dry eye disease. Symptomatic improvement was greatest in the mild group and the best results in improvement of disease signs were in patients with severe dry eye disease.

Infectious keratitis after photorefractive keratectomy

PURPOSE To elucidate risk factors, microbial culture results, and visual outcomes for infectious keratitis after photorefractive keratectomy (PRK). DESIGN Multicenter, retrospective chart review, case report, and literature review. METHODS The records of 12 patients with infectious keratitis after PRK were reviewed. MAIN OUTCOME MEASURES Causative organism, response to medical treatment, and visual outcome. RESULTS Infectious keratitis developed in 13 eyes of 12 patients after PRK. Organisms cultured were Staphylococcus aureus (n = 5), including a bilateral case of methicillin-resistant Staphylococcus aureus; Staphylococcus epidermidis (n = 4); Streptococcus pneumoniae (n = 3); and Streptococcus viridans (n = 1). Four patients manipulated their contact lenses, and 2 patients were exposed to nosocomial organisms while working in a hospital environment. Prophylactic antibiotics used were tobramycin (nine cases), polymyxin B-trimethoprim (three cases), and ciprofloxacin (one case). Final best spectacle-corrected visual acuity ranged from 20/20 to 20/100. CONCLUSIONS Infectious corneal ulceration is a serious potential complication of PRK. Gram-positive organisms are the most common pathogens. Antibiotic prophylaxis should be broad spectrum and should include gram-positive coverage.

Subconjunctival mitomycin C as adjunctive therapy before pterygium excision

PURPOSE To evaluate the safety and efficacy of subconjunctival mitomycin C as adjunctive therapy before pterygium surgery. DESIGN Prospective noncomparative case series. PARTICIPANTS Thirty-six eyes of 36 patients. INTERVENTION Thirty-six eyes of 36 patients prospectively received 0.1 ml of 0.15 mg/ml mitomycin C subconjunctivally injected into the head of the pterygium 1 month before bare sclera surgical excision. MAIN OUTCOME MEASURE Recurrence of pterygia. RESULTS The pterygia resolved in 34 (94%) of 36 eyes, with a recurrence rate of 6% over a mean follow-up of 24.4 months. No wound-healing complication developed in any patient. CONCLUSIONS Subconjunctival mitomycin C is an effective treatment before pterygium excision. Subconjunctival injection allows exact titration of mitomycin C delivery to the activated fibroblasts and minimizes epithelial toxicity.

Efficacy and wound-temperature gradient of WhiteStar phacoemulsification through a 1.2 mm incision

Purpose: To evaluate the efficacy and wound‐temperature gradients of WhiteStar micropulse technology using bimanual phacoemulsification without an irrigation sleeve through a 1.2 mm incision. Setting: Island Eye Surgicenter, Carle Place, New York, USA. Methods: Ten patients had bimanual phacoemulsification using micropulse technology without an irrigation sleeve through a 1.2 mm clear corneal incision. A thermocouple consisting of a 30‐gauge copper wire was inserted into clear cornea directly adjacent to the wound to digitally record temperature gradients at the wound. Endothelial cell counts were evaluated preoperatively and postoperatively in all patients. Results: All 10 patients maintained corneal clarity with no sign of thermal damage to the wound. The maximum corneal wound temperatures during phacoemulsification ranged from 24°C to 34°C, well below the temperature of collagen shrinkage. The endothelial cell loss at 3 months was 7%. Conclusions: Because of the decreased thermal effect with WhiteStar technology, an irrigation sleeve over the phacoemulsification needle is superfluous. As a result, bimanual phacoemulsification can be safely performed through a 1.2 mm incision.

Effect of hinge width on corneal sensation and dry eye after laser in situ keratomileusis

Purpose: To investigate the effect of hinge width on corneal sensation and dry‐eye syndrome after laser in situ keratomileusis (LASIK). Setting: TLC Laser Eye Center, Garden City, New York, USA. Methods: Fifty‐four patients at least 18 years of age had bilateral LASIK with a narrow nasal hinge microkeratome flap in 1 eye and a wider nasal hinge microkeratome flap in the other eye. In all eyes, the flaps were 160 &mgr;m in thickness with a diameter of 9.5 mm. Masked Cochet‐Bonnet esthesiometry was performed in the central cornea preoperatively and at 1 week and 1, 3, and 6 months. Dry eye was evaluated at the same intervals by lissamine green corneal and conjunctival staining, Schirmer test with anesthesia, and tear‐film breakup time. Results: Corneal sensation was significantly reduced from preoperative levels through 6 months in the narrow‐hinge group and through 3 months in the wider‐hinge group (P≤.002). The mean corneal sensation was greater in corneas with a wider hinge flap than in those with a narrow hinge flap at all postoperative examinations; the difference was significant at 1 and 3 months (P≤.002). The loss of sensation was greatest at 1 week and improved at all subsequent examinations. Overall, dry‐eye signs and symptoms were greatest immediately postoperatively and improved at subsequent intervals. Conclusions: Corneal sensation and dry‐eye signs and symptoms improved at all intervals between 1 week and 6 months. The loss of corneal sensation and presence of dry‐eye syndrome were greater in eyes with a narrow hinge flap than in eyes with a wider hinge flap.

A comparison of the fourth-generation fluoroquinolones gatifloxacin 0.3% and moxifloxacin 0.5% in terms of ocular tolerability

SUMMARY Purpose: To compare the ocular tolerability of the commercially available ophthalmic solutions of the fourth-generation fluoroquinolones, gatifloxacin 0.3% (Zymart, Allergan, Inc., Irvine, CA) with benzalkonium chloride (BAK) and moxifloxacin 0.5% (Vigamoxt) without BAK. Methods: A baseline evaluation was conducted on 30 healthy volunteers for conjunctival hyperemia, conjunctival vascularity, pupil size, and anterior chamber (AC) cell and flare. Pupils were measured under scotopic conditions with a Colvard pupillometer. Conjunctival hyperemia and vascularity, and AC reaction were measured on a Likert-like scale of 0-3. Subjects then received drops in both eyes from masked bottles of gatifloxacin ophthalmic solution 0.3% with BAK (in one eye determined randomly) and moxifloxacin ophthalmic solution 0.5% without BAK (in the contralateral eye) in a double-masked fashion. Subjects graded pain and ocular irritation in each eye on a scale of 1-10 after 5min with their eyes closed. The examination was then repeated. Results: The average age of this study population was 34.4years. The groups of eyes receiving moxifloxacin 0.5% demonstrated an increase in mean conjunctival hyperemia (0.21 [range: 0-1] at baseline to 1.52 [range: 0-3] at 5min.) that was significantly greater (p = 0.0005) compared with that of the group receiving gatifloxacin 0.3% (0.22 [range: 0-1] at baseline to 0.45 [range: 0-2] at 5min). The group receiving moxifloxacin 0.5% showed an increase in conjunctival vascularity (0.55 [range: 0-1] at baseline to 1.61 [range: 0.5-3] at 5 min.) that was significantly greater (p = 0.0005) compared with that of the group receiving gatifloxacin 0.3% (0.52 [range: 0-1] at baseline to 0.68 [range: 0-2] at 5 min.). Significantly less pain (1.2 vs. 3.2, p = 0.001) and irritation (0.64 vs. 3.42, p = 0.001) occurred with gatifloxacin 0.3% than with moxifloxacin 0.5%. Pupil size was significantly reduced (5.65mm-5.05mm) in eyes receiving moxifloxacin 0.5% (p = 0.004) and no significant change occurred in pupil size (5.60mm-5.65mm) in eyes that received gatifloxacin 0.3% (p = 0.878). No AC reaction was noted with either medication. Conclusions: The group of eyes receiving gatifloxacin 0.3% with BAK demonstrated greater ocular tolerability in comparison to the group receiving moxifloxacin 0.5% without BAK. Moxifloxacin-induced pupillary miosis may be due to prostaglandin release in the anterior chamber. A limitation of this study is the relatively young age of the study population.

Microbial keratitis trends following refractive surgery: Results of the ASCRS infectious keratitis survey and comparisons with prior ASCRS surveys of infectious keratitis following keratorefractive procedures

&NA; In 2008, the American Society of Cataract and Refractive Surgery (ASCRS) surveyed its 9121 United States and international members to evaluate the changing trends and incidence, culture results, treatment, and visual outcomes of infectious keratitis following keratorefractive procedures worldwide. This paper presents and analyzes the results with comparisons to the data in surveys conducted in 2001 and 2004. Nineteen infections were reported by 14 surgeons who had performed an estimated 20 941 keratorefractive procedures, an incidence of 1 infection in every 1102 procedures. Sixteen cases presented in the first postoperative week, 1 case during the second week, 1 case between the second and fourth weeks, and 1 case at 1 month or later. The 16 cases that presented in the first week were diagnosed at initial presentation. The most common organism cultured was methicillin‐resistant Staphylococcus aureus (MRSA). Microbial keratitis following refractive surgery is an increasingly recognized sight‐threatening complication. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found after the text.