Roy S. Rubinfeld

Anterior Stromal Puncture for Recurrent Erosion: Further Experience and New Instrumentation

Anterior stromal puncture has recently been proposed as a new treatment for recalcitrant cases of recurrent corneal erosion. Concerns about the risks of corneal perforation and scarring, as well as doubts regarding its efficacy have prevented many patients from benefiting from this procedure. We introduce a new, inexpensive, commercially available instrument designed to standardize this technique, minimize scarring, and prevent corneal perforation. In a clinical trial involving 25 consecutive patients with recurrent erosions resistant to vigorous conservative treatment, the first 11 patients underwent stromal puncture in which a straight tuberculin needle was used; the following 14 were treated with a newly designed prototype needle. All patients in this series remained free of erosions after completion of stromal puncture, except for one woman with marked diffuse anterior basement membrane dystrophy, who went on to develop spontaneous bilateral erosions. Follow-up ranged from 2 months to 30 months (mean, 13 months). There were no complications of stromal puncture, and subjective and objective evaluations revealed no significant postoperative glare. Microscopic analysis of eye bank eyes subjected to anterior stromal puncture procedures demonstrated that the new prototype needle provided shallower penetration and thus less likelihood of perforation or excessive scarring than the straight needle. Also, postoperative discomfort and scarring appeared to be significantly less in patients treated with the prototype needle.

THE ANTIBACTERIAL ACTIVITY OF TOPICAL ANESTHETICS

PURPOSE Topical anesthetics are commonly used prior to obtaining bacterial cultures in ulcerative keratitis. We performed an in vitro study designed to test both the bacteriostatic and bactericidal effects of commercially available preserved topical anesthetic agents. METHODS Proparacaine, tetracaine, cocaine, and sterile water solutions were applied to filter paper disks, which were then placed on Mueller-Hinton agar plates that had previously been inoculated with known quantities of Pseudomonas aeruginosa and Staphylococcus aureus. After 24 h of incubation, zones of inhibition were measured and recorded. RESULTS Proparacaine strongly inhibited the growth of S. aureus at all concentrations (0.5%, 0.25%, 0.125%) and inhibited growth of P. aeruginosa at 0.5% and 0.25% but not at 0.125% concentration. Tetracaine also inhibited S. aureus at 0.5% and inhibited P. aeruginosa at 0.5% and 0.25% concentrations. Cocaine exhibited no inhibition of S. aureus and exhibited mild inhibition of P. aeruginosa growth only at the 4% concentration. CONCLUSIONS The in vitro antibacterial effect of topical anesthetics suggests one possible reason why bacterial culture yields in clinical ulcerative keratitis are suboptimal. We propose that clinicians consider the use of a 1% or 2% cocaine solution instead of standard commercial topical anesthetics in the management of individual cases of ulcerative keratitis and in future clinical bacterial keratitis studies.

Early onset acute orbital involvement in childhood acute lymphoblastic leukemia

A 5-year-old girl with acute lymphoblastic leukemia undergoing induction chemotherapy experienced acute proptosis while agranulocytotic and febrile. Orbital biopsy showed leukemic infiltration, and complete resolution was achieved with local irradiation and chemotherapy. Early onset orbital involvement is highly unusual in acute lymphoblastic leukemia. In the setting of agranulocytosis and fever, rapidly enlarging intraorbital masses require urgent ophthalmologic attention. Immediate biopsy is indicated to distinguish between several treatable conditions including opportunistic infection, hemorrhage, and neoplastic infiltration.

Keratoconus After Penetrating Keratoplasty

Signs of keratoconus, including Munsons sign, apical thinning, and Vogts striae, developed in a 41-year-old woman 6 years after successful penetrating keratoplasty. Screening donor corneas for ectatic diseases may prevent such occurrences.

Cytomorphology of a mixed pigmented/nonpigmented pleomorphic adenoma of the ciliary body : A diagnostic pitfall in the evaluation of intraocular tumors

Intraoperative cytology is an alternative and sometimes preferred method to frozen section in the rapid evaluation of surgical biopsies. This report describes the cytological, histological, and immunohistochemical features of a case of mixed pigmented/non‐pigmented pleomorphic adenoma of the ciliary body with clinical and morphological features reminiscent of malignant melanoma. The characteristic cyto‐histomorphology of this unusual tumor and its distinguishing features from malignant melanoma are discussed. Diagn Cytopathol 1996;14:259–262.

Pneumococcal keratitis, bacteremia, and septic arthritis in an asplenic patient.

We report the case of a 66-year-old black woman who presented with concomitant acute infectious keratitis, bacteremia, and septic arthritis caused by Streptococcus pneumonia. The septic arthritis resolved rapidly with surgical drainage and intravenous antibiotics, but despite aggressive topical and intravenous antibiotic therapy for the infectious keratitis, the cornea perforated, the patient developed endophthalmitis, and the eye eventually was eviscerated. To the best of our knowledge this is the first reported case of this nature. This patient had undergone splenectomy > 50 years prior to developing these infections. Although the risk of serious infection in clinically significant bacteremia is greatest in the perioperative period after splenectomy, these patients are at increased risk of such events for a lifetime. Because encapsulated bacteria, especially Pneumococcus, pose the greatest risk of sepsis and infection in asplenic patients, pneumococcal vaccination of penicillin prophylaxis must always be considered in these patients. A careful and complete medical history and systemic evaluation remain a crucial element of the evaluation and management of serious infectious keratitis.

UVA-light and riboflavin-mediated corneal collagen cross-linking.

Keratoconus and other corneal conditions associated with progressive stromal thinning including keratectasia after laser-assisted in situ keratomileusis (LASIK) and pellucid marginal degeneration represent therapeutic challenges. Until recently, available therapies including contact lenses, epikeratoplasty, intrastromal corneal rings, and corneal transplantation targeted, in principle, the abnormal shape of the cornea by mechanical means. The underlying molecular pathogenic mechanisms of corneal ectasia were not addressed with any of these therapies until the introduction of corneal collagen cross-linking to clinical practice in 1999.1 This breakthrough clinical application was the result of multiple laboratory observations and discoveries made over preceding decades. Early experiments of Cannon and Foster2 showed that degraded normal collagen or synthesis of abnormal collagen might play a role in the pathogenesis of keratoconus. This concept was later confirmed by subsequent clinical and experimental studies. Keratoconus was characterized by progressive stromal thinning and ectasia3 as a result of increased expression of lysosomal and proteolytic enzymes4–7 and decreased concentration of protease inhibitors,5,8 which result in corneal thinning and altered configuration of corneal collagen lamellae.9,10