Seth A. Biser

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.

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.

Bilateral methicillin-resistant staphylococcus aureus keratitis in a medical resident following an uneventful bilateral photorefractive keratectomy.

Purpose. To present a case of bilateral methicillin-resistant Staphylococcus aureus (MRSA) keratitis after photorefractive keratectomy (PRK). Methods. Retrospective chart review. Results. A 26-year-old female internal medicine resident underwent an uneventful bilateral PRK. After the procedure, the patient was fit with a bandage contact lens and was prescribed tobramycin 0.3%, fluorometholone 0.1%, and diclofenac sodium 0.1% four times per day. Postoperatively, corneal ulcers were noted in each eye, and the patient was referred for a consultation. Gram stain showed gram-positive cocci. The patient immediately started using vancomycin, 35 mg/mL every half hour, and ofloxacin 0.3% every hour around the clock. Forty-eight hours later, corneal and lid cultures were positive for MRSA. Three months after the infection, there was approximately 40% corneal thinning in the right eye and 10% thinning in the area of the corneal ulceration of the left eye. The patient is awaiting corneal transplantation of the right eye. Conclusions. To our knowledge, this represents the first reported case of bilateral MRSA keratitis after PRK. Methicillin-resistant S. aureus is a potentially serious infectious agent after PRK and may be associated with exposure to a hospital setting. For patients who have had extensive exposure to a hospital environment and are undergoing ocular surgery, we recommend prophylaxis against MRSA. To treat a possible MRSA keratitis, we suggest starting a fourth-generation topical fluoroquinolone every 30 minutes, alternating it with vancomycin 50 mg/mL every 30 minutes, and discontinuing steroid use. A high degree of suspicion coupled with rapid and appropriate treatment may result in improved visual recovery.

Conservative treatment of meibomian gland dysfunction.

Purpose. To evaluate the effectiveness of lid hygiene and preservative-free artificial tears for the treatment of meibomian gland dysfunction (MGD) during a 6-week period. Methods. Suitable patients with MGD were educated about their disease and instructed to begin a regimen of lid hygiene, which included the application of a heated saline solution and the use of nonpreserved artificial tears. Baseline measurements obtained at the time of enrollment included basic tear secretion test, tear breakup time, a questionnaire grading MGD symptoms (i.e., burning, irritation, itching, sharp pains, foreign body sensation, and hazy vision), and lid margin slitlamp photographs. All measurements except for basic tear secretion were repeated at the 6-week follow-up visit. Photographs were unlabeled, and two cornea specialists graded them in a masked fashion for the presence of lid erythema, irregularity, thickness, meibomian gland capping, and telangiectasis. Results. Thirty-seven patients with a clinical diagnosis of MGD were enrolled, and 26 patients (70%) completed the study. Initial measurement of basic tear secretion averaged 17 mm and was more than 10 mm in 81% of eyes. The tear breakup time was prolonged by an average of 3.4 seconds; in 30% of cases, it was normalized to 10 seconds or more. Symptoms improved in 88% of cases; among those, symptoms were graded mild or less in 83%, and none in 39%. Photographs before and after treatment were not significantly different. Conclusions. In this noncontrolled case–cohort study of selected patients with MGD, lid hygiene and preservative-free artificial tears significantly improved tear breakup time and relieved symptoms of the condition.

Flap folds after femtosecond LASIK.

Purpose To report a case of bilateral flap folds after a laser-assisted in situ keratomileusis (LASIK) procedure in which the flap was created by the femtosecond laser. Methods Retrospective chart review. Results A 43-year-old white woman underwent bilateral simultaneous LASIK. The corneal flap was created with the femtosecond laser. Postoperatively, the patient noted significantly decreased visual acuity, glare, and haloes. She was diagnosed with corneal flap striae, which were treated unsuccessfully with a lifting and stretching procedure, but responded to subsequent bilateral flap suturing. Conclusions Despite the increased accuracy in flap creation with the femtosecond laser, large flap folds may develop.

Arthrographis keratitis mimicking acanthamoeba keratitis.

Objective: To describe a case of keratomycosis caused by Arthrographis kalrae, mimicking Acanthamoeba keratitis. Methods: Case report. Results: A 23-year-old female contact lens wearer developed dendritic keratitis in her amblyopic eye (OD). Baseline vision was 20/50. Treatment with trifluridine 1% resulted in resolution of the dendrite, but an area of stromal haze developed, spreading to a discontinuous ring shape, and the vision dropped to 20/200. Photophobia was intense, and pain was out of proportion to the examination. Cultures were sent, and empiric treatment of Acanthamoeba was begun, without subsequent improvement. After 4 weeks, cultures were positive for a fungal species. Amphotericin 0.5% drops were begun, with moderately rapid resolution of the active keratitis. At last follow-up, best-corrected vision was 20/100. Review of the culture showed the organism to be Arthrographis kalrae. Conclusion: Arthrographis kalrae has been reported only once before as an ocular pathogen. As in the previously reported case of Arthrographis, our patient’s presentation was strongly suggestive of Acanthamoeba keratitis.

Slitlamp stretching of the corneal flap after laser in situ keratomileusis to reduce corneal striae

Purpose: To examine the efficacy of treating immediate postoperative corneal striae and poor flap alignment by stretching the corneal flap at the slitlamp with a cotton‐tip applicator and compare the results using this technique with those using the conventional technique of refloating the flap with balanced salt solution (BSS®). Setting: TLC Laser Eye Center, Garden City, New York, USA. Methods: Charts of 7154 eyes having laser in situ keratomileusis (LASIK) were reviewed retrospectively. During the 11 months prior to January 1, 2000, 3516 eyes had LASIK. Patients with flap striae or a malpositioned flap at the immediate slitlamp evaluation were treated by refloating the flap (Group A). During the 11 months subsequent to January 1, 2000, 3638 eyes had LASIK. Patients with flap striae or a malpositioned flap at the immediate slitlamp evaluation were treated by flap stretching with a cotton‐tip applicator (Group B). The number of eyes that required retreatment for flap striae was analyzed. Results: Twenty‐nine eyes in Group A (0.82%) required retreatment for visually significant flap striae after day 1, and 11 eyes in Group B (0.30%) required retreatment. A loss of best corrected visual acuity occurred in 3 Group A eyes and 2 Group B eyes. Conclusions: During the immediate postoperative period, stretching the flap with a cotton‐tip applicator was a simple, safe, and effective technique for reducing visually significant flap striae. Unlike refloating the flap with BSS, flap stretching at the slitlamp does not require additional anesthesia, exposure time, or dehydration of the ocular surface.

Hyperthermic treatment of post-LASIK corneal striae

Purpose: To investigate the effect of hyperthermia for the treatment of long‐standing corneal flap striae after laser in situ keratomileusis (LASIK). Setting: TLC Laser Eye Center, Garden City, New York, USA. Methods: Patients with visually significant flap striae at least 3 weeks post‐LASIK were offered hyperthermic treatment. The central 6.0 mm of epithelium was removed from affected corneas, and the flaps were elevated. A striae removal spatula was heated to 65oC in sterile water, and both sides of the flaps were mechanically massaged with the spatula for 5 to 10 minutes until the striae were visually reduced. Results: Thirty‐six eyes of 34 patients were treated with hyperthermia to remove corneal striae. All patients had a clinical reduction in striae. The mean pretreatment best corrected visual acuity (BCVA) was 20/44, improving to 20/25 on follow‐up (mean follow‐up 16.4 months). Patients subjectively noted reduced haze and glare and no loss of BCVA. There were no serious flap complications. Conclusion: Hyperthermic treatment is a safe, effective treatment option for corneal striae after LASIK.

Laser in situ keratomileusis after penetrating keratoplasty

Dramatic improvements in microsurgical techniques have resulted in the emergence of penetrating keratoplasty (PKP) as a more common and successful procedure, with over 40,000 surgeries performed annually. Unfortunately, postoperative visual rehabilitation remains challenging. Most patients will not tolerate more than 3 D of anisometropia, due to image size disparity or astigmatism of greater than 1.5 to 3 D. Refractive unpredictability following PKP is extremely common, due to the inherent imprecision of the operation, with most series documenting mean cylinders of 4 to 5 D and significant anisometropia. The residual refractive error may be due to surgical technique, wound healing variables, and donor tissue and is then often further complicated by implantation of an intraocular lens. Refractive anisometropia and high postoperative astigmatism can compromise the patient’s return to normal binocular function. Anisometropia in the undercorrected eye may result in headache, photophobia, burning, tearing, diplopia, and blurred vision. Binder reported in a series of patients following corneal transplant and cataract extraction that only 21 of 43 eyes achieved refractive errors within 2 D of emmetropia. Davis and coworkers evaluated patients having combined cataract extraction with PKP. Only 75% of patients fell between –4.00 and +2.00, when emmetropia was the goal. Flowers and colleagues evaluated intraocular lens power calculation in combined corneal transplant and cataract extraction and reported that only 39% of patients had a refractive error within 2 D of emmetropia. The range of ametropia was from –9.75 to 12.88 D, with 65% of the patients having myopic errors. Many of these patients’ eyes that cannot be rehabilitated with spectacle correction can be aided by contact lenses. Contact lenses are vital to the rehabilitation of postkeratoplasty eyes. Ten to 30% of patients who

Lamellar keratectomy using an automated microkeratome.

Purpose: To evaluate the effectiveness of treating anterior corneal pathology by performing a superficial lamellar keratectomy with an automated microkeratome. Methods: Retrospective chart review of 10 eyes (8 patients) seen in a subspecialty referral practice for anterior segment disease. With the use of an automated microkeratome, a lamellar flap was created, which was then surgically excised. Results: Ten eyes of eight patients were followed for a mean of 5.4 months (range, 4 to 10 months). Subjective visual acuity and/or sensation of ocular irritation improved in 10 of 10 eyes. Mean improvement in Snellen best-corrected visual acuity was 1.8 lines (range, −1 to +3 lines). One patient lost 1 line of Snellen acuity due to progression of a posterior subcapsular cataract. Mean change in spherical equivalent was +0.5 diopters (range, −1.60 to +4.25 diopters), and mean improvement in corneal clarity (1 to 4 scale) was 1.8. Mean preoperative pachymetry was 589.0 μm (range, 507 to 741 μm). Mean postoperative pachymetry was 461.3 μm (range, 370 to 564 μm). Recurrence of pathology (band keratopathy and Salzmann’s nodular degeneration) occurred in two patients. In one patient, immunohistochemical staining of corneal tissue from the lamellar dissection confirmed the diagnosis of herpes simplex virus type 1 stromal keratitis, improving the course of postoperative care. Conclusion: Lamellar keratectomy with the use of an automated microkeratome is a safe and effective method for removing superficial anterior corneal opacities. For selected cases, it offers specific advantages over other surgical modalities. In particular, this procedure may induce far less hyperopic shift than would the equivalent amount of tissue removal by performing excimer laser phototherapeutic keratectomy.