Robert M. Knape

Intravitreal bevacizumab treatment of bilateral peripapillary choroidal neovascularization from optic nerve head drusen

Choroidal neovascular membranes are a rare cause of decreased vision in children with optic nerve head drusen. We present a case of bilateral choroidal neovascular membranes associated with optic nerve head drusen in a 5-year-old boy who was successfully treated with a combination of focal laser photocoagulation and intravitreal bevacizumab.

Five-year outcomes of eyes with glaucoma drainage device and penetrating keratoplasty.

PurposeTo investigate intraocular pressure (IOP) control and corneal graft survival rates in eyes with glaucoma drainage device (GDD) implantation and penetrating keratoplasty (PK) and 5 years of follow-up data. DesignRetrospective review. MethodsWe performed a review of records of all patients who underwent both GDD placement and PK at our institution between January 1, 1988 and December 31, 2003. Twenty-eight eyes of 27 patients were studied. Glaucoma outcome was assessed by postoperative IOP, number of glaucoma medications, and need for further glaucoma surgery. Corneal grafts were assessed for clarity. ResultsAll eyes had GDD placement in the anterior chamber. The mean pre-GDD IOP was 28.8±10.3 mm Hg on a mean of 2.6±0.8 glaucoma medications. At 5-year follow-up, the mean IOP was 13.0±5.9 mm Hg on a mean of 0.9±1.0 glaucoma medications. GDD implantation successfully controlled glaucoma in 96%, 86%, 79%, 75%, and 71% of eyes at 1, 2, 3, 4, and 5 years, respectively. Grafts remained clear in 96%, 82%, 75%, 57%, and 54% of eyes at 1, 2, 3, 4, and 5 years, respectively. Failure of glaucoma outcome or graft survival was associated with prior intraocular surgeries. ConclusionsOur data suggests that GDD placement can provide glaucoma control in a high percentage (71%) of eyes with PK even at 5 years. Furthermore, the success of PK in eyes with GDD remains reasonable (54%) at 5 years. IOP control and graft survival rates are comparable with earlier published studies with shorter follow-up or tube placement in the vitreous cavity.

Anterior chamber blood reflux during trabeculectomy in an eye with previous trabectome surgery.

INTRODUCTION The Trabectome is a novel surgical device used in the treatment of open angle glaucoma that removes trabecular meshwork tissue to improve aqueous access to drainage channels. Little is known about the long-term consequences of permanently unroofing Schlemm canal. Eyes that have had previous surgery in the iridocorneal angle, specifically permanent removal of trabecular meshwork tissue, may have an increased propensity for blood reflux. CASE PRESENTATION We present a case of a patient who had intraoperative blood reflux onto peripheral iris during trabeculectomy 11 months after Trabectome surgery. DISCUSSION Intraoperative blood reflux and resultant hyphema is strongly correlated with Trabectome surgery, but the literature does not reveal any cases of late postoperative blood reflux. In our patient, the absence of overlying angle structures, including the roof of Schlemm canal, may have allowed blood to reflux into the angle and onto peripheral iris during a sudden decrease in intraocular pressure in trabeculectomy surgery. Further studies to assess the consequences of permanent trabecular meshwork tissue removal may be warranted.

Trainee glaucoma surgery: experience with trabeculectomy and glaucoma drainage devices.

BACKGROUND AND OBJECTIVE To examine outcomes of trabeculectomy with mitomycin C and glaucoma drainage device placement for uncontrolled glaucoma when performed by resident surgeons. PATIENTS AND METHODS This study included any patient who underwent a trabeculectomy with mitomycin C (n = 93) or a glaucoma drainage device (n = 60) by a resident surgeon between 2001 and 2006. Outcome measures at 3, 6, and 12 months included failure of treatment, number of follow-up appointments, complications, number of medications, and need for further surgery. RESULTS One year postoperatively, intraocular pressure averaged 12.1 ± 5.1 mm Hg in the trabeculectomy group and 13.0 ± 5.1 mm Hg in the glaucoma drainage device group (P = .31). Complications occurred in 30% of eyes with trabeculectomy and 10% of eyes with a glaucoma drainage device. CONCLUSION During the first postoperative year, glaucoma drainage device surgery may have fewer complications and less morbidity than a trabeculectomy with mitomycin C when these surgeries are performed by resident surgeons. Final intraocular pressures were similar between the two groups.

Optic Nerve Findings in CHILD Syndrome

Congenital hemidysplasia with ichthyosiform erythroderma and limb defects (CHILD) syndrome is a rare disorder characterized by birth defects of several organ systems, including the skin, viscera, musculoskeletal system, and central nervous system. The authors present the first report of CHILD syndrome with ocular manifestations in a patient with progressive bilateral optic nerve atrophy.

Morning Glory Disc Anomaly and Optic Nerve Coloboma

The morning glory disc anomaly (MGDA) is a congenital optic nerve disorder characterized by an enlarged, excavated disc surrounded by an annulus of chorioretinal pigmentary deposition. First distinguished as a unique optic nerve disorder by Kindler in 1970, the term morning glory syndrome was applied for its ophthalmoscopic resemblance to the morning glory flower. MGDA is usually unilateral and is twice as common in females as males. Systemic findings with MGDA include sphenoid basal encephalocele and ipsilateral neurovascular dysgenesis. Optic nerve colobomas are most frequently noted at the optic disc. Colobomas of the optic disc appear as a white, sharply demarcated excavation within an enlarged disc. The defect is decentered inferiorly, reflecting the position of the embryonic fissure relative to the primitive epithelial papilla. The inferior neuroretinal rim is often thin or absent, and the defect may extend inferiorly to the adjacent choroid or retina. Colobomas with prelaminar involvement are rare and associated with microphthalmos and orbital cysts. While MDGA is considered by some to be within a spectrum of excavated optic disc anomalies, many neuro-ophthalmologists today consider MGDA distinct from similar appearing optic nerve anomalies, including optic nerve colobomas. The etiology of the 2 disorders and the possibility of an overlap in pathogenesis remains controversial. To date, there have been no reports of combined MGDA and optic nerve coloboma. Cennamo et al reported a case of coexistence of MGDA with lens colobomas but no colobomas noted elsewhere. We report a child with ipsilateral MGDA and optic nerve coloboma.

Pseudodendritic fungal epithelial keratitis in an extended wear contact lens user.

Purpose: Pseudodendritic keratitis in a contact lens wearer is generally associated with acanthamoeba keratitis. We report a case of isolated pseudodendritic fungal epithelial keratitis that occurred in an extended wear contact lens user. Methods: A 48-year-old woman was evaluated in our clinic for a 36-hour history of left eye pain. She wore extended wear soft contact lenses and frequently rinsed her eyes with tap water. Her left cornea had a paracentral 3-mm area of epithelium with raised ridges in a pseudodendritic pattern. The underlying corneal stroma was normal. A therapeutic and diagnostic corneal scraping of the lesion was performed and sent for Gomori methenamine silver (GMS) staining. The clinical concern was for epithelial acanthamoeba keratitis. Results: The GMS staining revealed septate fungal hyphae within sheets of corneal epithelium. The patient was started on frequent alternating natamycin (5%) and amphotericin B (0.15%) antifungal eyedrops and exhibited a rapid clinical response. Her keratitis completely resolved, and her vision returned to her baseline of 20/25. Corneal fungal cultures showed no growth. Conclusions: Our case is an extremely unusual presentation of fungal keratitis, which rarely presents as a pseudodendritic epithelial keratitis. There are two previous similar case reports initially misdiagnosed as acanthamoeba keratitis. Clinicians should be aware that isolated fungal epithelial keratitis can present as a distinct entity and should be considered in the differential diagnosis of pseudodendritic keratitis. The GMS staining is an excellent diagnostic test in a patient presenting with pseudodendritic keratitis because it allows rapid diagnosis of acanthamoeba and fungal infections.

Antimetabolite application technique in trabeculectomy surgery.

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