Timothy Chou

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.

Ganciclovir ophthalmic gel 0.15% for the treatment of acute herpetic keratitis: background, effectiveness, tolerability, safety, and future applications

Eye disease due to herpes simplex virus (HSV) is a leading cause of ocular morbidity and the number one infectious cause of unilateral corneal blindness in the developed parts of the globe. Recurrent keratitis can result in progressive corneal scarring, thinning, and vascularization. Antiviral agents employed against HSV have primarily been nucleoside analogs. Early generation drugs included idoxuridine, iododesoxycytidine, vidarabine, and trifluridine. While effective, they tended to have low bioavailability and measurable local cellular toxicity due to their nonselective mode of action. Acyclovir 0.3% ointment is a more selective agent, and had become a first-line topical drug for acute HSV keratitis in Europe and other places outside of the US. Ganciclovir 0.15% gel is the most recently approved topical treatment for herpes keratitis. Compared to acyclovir 0.3% ointment, ganciclovir 0.15% gel has been shown to be better tolerated and no less effective in several Phase II and III trials. Additionally, topical ganciclovir does not cause adverse systemic side effects and is therapeutic at lower concentrations. Based on safety, efficacy, and tolerability, ganciclovir 0.15% gel should now be considered a front-line topical drug in the treatment of dendritic herpes simplex epithelial keratitis. Topics of future investigation regarding other potential uses for ganciclovir gel may include the prophylaxis of recurrent HSV epithelial keratitis, treatment of other forms of ocular disease caused by herpesviruses and adenovirus, and ganciclovir gel as an adjunct to antitumor therapy.

Pyogenic granuloma formation following placement of the Medennium SmartPLUG punctum plug.

Purpose: To report a complication, not previously described, of the Medennium SmartPLUG, which is a new punctal plug with a novel design. Methods: Two case reports are detailed, including clinical and pathologic photographs. Results: Case 1 is a 58-year-old woman with Sjögren syndrome. Nearly 2 years following placement of a SmartPLUG in her right lower canaliculus, the patient presented with an erythematous, papillomatous growth overlying her punctum. Biopsy demonstrated pyogenic granuloma. Case 2 is a 62-year-old woman with dry eye. Exactly 2 years after a SmartPLUG was place in her right lower canaliculus, she also developed a pyogenic granuloma. After irrigation to remove the plug, the growth decreased in size. Conclusion: Pyogenic granuloma can develop as a late complication of the Medennium SmartPLUG punctum plug.

Penetrating Ocular Trauma From Airsoft Gun

Comment. In this population-based cohort of children diagnosed as having periocular infantile hemangioma during a 40-year period, amblyopia with or without strabismus occurred in approximately 1 in 5 children. To our knowledge, this study is the first population-based report on periocular infantile hemangiomas in the United States. The rate of amblyopia of 19% in this population is significantly lower than the rates in prior studies, which range from 43% to 76%. As stated by Robb, it is likely that previous studies overreported the rate of amblyopia as it is often only the more severe cases that are referred to ophthalmic specialists. Given that only half of the periocular hemangiomas diagnosed at our institution were evaluated by an ophthalmologist, a recalculated rate that includes only those children seen by an ophthalmologist would yield an amblyopia rate of 37%, illustrating the artificial increase that occurs from reports arising solely from departments of ophthalmology. Because this study uses a population-based patient cohort, a 19% rate of amblyopia is likely to be a more accurate representation of the general population. However, assessing vision by the fixation method, the form of visual measurement used during this 40-year study, has been reported to overestimate the presence of amblyopia. This study is also limited by the small sample size, which, coupled with the predominantly white race of the study patients, may limit the generalizability of these findings to all children with periocular hemangioma. Schwartz et al have reported that the size and location of the hemangioma (upper eyelid) are the most likely factors to be associated with the development of amblyopia. We similarly found that the majority (88%) of the patients with amblyopia had upper eyelid lesions. However, the majority of the 43-patient cohort (86%) had upper eyelid lesions, negating any direct association between upper eyelid lesions and the development of amblyopia. However, the association with size was confirmed in this study in which the hemangiomas among patients with amblyopia were nearly 3 times larger than those in patients without amblyopia. Owing to the small sample size, though, this finding was not statistically significant. Amblyopia occurred in approximately 1 in 5 children with periocular hemangioma in this populationbased cohort. Although the medical records were incomplete, lesion size appeared to be the most significant risk factor for amblyopia development.

Clinical course and management of postoperative methicillin-resistant Staphylococcus aureus keratitis in immunocompromised patients: two case reports

We describe the clinical course and successful treatment of two cases of methicillin- resistant Staphylococcus aureus (MRSA) keratitis. In case 1, MRSA keratitis occurred 5 days after cataract extraction, associated with endophthalmitis; in case 2, diagnosis was made 19 months after penetrating keratoplasty. Treatment in both cases consisted of topical fortified vancomycin and fortified bacitracin. A third topical antibiotic, polymyxin B-trimethoprim, was added to the therapeutic regimen in case 2, one month into the treatment. Oral doxycycline was prescribed to reduce collagenase activity and treat blepharitis. Mupirocin nasal ointment and skin antiseptics were used to decrease and eliminate potential MRSA colonization. Topical prednisolone acetate 1% was applied conservatively to mitigate inflammation in both cases. In case 2, topical cyclosporine A was also used for similar purposes. Keratitis may have worsened while on these immune-modulating drops, especially in case 2, and eradication of infection may have been slowed. Eventually both patients achieved full resolution of infection. Duration of keratitis was 3 and 1.5 months, respectively. Polyantimicrobial therapy is effective in eradicating MRSA-related postoperative keratitis. Topical fortified vancomycin and fortified bacitracin were used in both cases, with a third topical antibiotic, polymyxin B-trimethoprim, also required in case 2. Oral doxycycline, nasal mupirocin, and antiseptic soap may be useful adjuncts in management. Treatment time to achieve full resolution may be prolonged relative to other types of bacterial keratitis. Alterations in immune status may have lengthened the time of treatment. Our two patients were immune compromised and were also susceptible to endophthalmitis. It is possible that topical immune-modulating drops such as prednisolone acetate may potentiate MRSA infection, and if used, should be only done so with great caution.

Improved refractive outcomes of postgraduate year 4 cataract surgery after implementing a stepwise biometry lecture series reinforced by self-assessment at a teaching program

Purpose To determine whether a structured biometry course improves refractive outcomes of resident phacoemulsification. Setting Northeast Veterans Administration Hospital, Northport, New York, USA. Design Retrospective case study. Methods Phacoemulsification surgeries performed by residents before and after a biometry curriculum were reviewed. The inclusion criterion was phacoemulsification performed by residents. Patients with fewer than 3 months of follow‐up were excluded. The main outcome measure—the mean absolute difference between the target and final refraction—was compared using a linear mixed model. Results Phacoemulsification surgeries performed by 4 residents before (n = 223) and by 4 residents after (n = 242) a biometry curriculum was implemented were reviewed. All measured preoperative factors were similar in both groups, including age, visual acuity, axial length, steep and flat keratometry values, astigmatism, anterior chamber depth, and lens thickness. Before the biometry course was instituted, 10% of patients had a mean absolute difference of less than 0.25 diopter (D); the percentage was 35% afterward. The mean absolute difference was less than 0.50 D in 40% before the curriculum was initiated and 70% after. The mean absolute difference was less than 1.00 D in 75% before the curriculum was initiated versus 94% after (all P < .05). The corrected distance visual acuities were similar in both groups, with 83% and 80%, respectively, having an acuity of at least 20/25 (P > .05). Conclusion Residents’ refractive predictions significantly improved after a formal biometry curriculum, showing that improvements in resident surgical outcomes are possible with structured curriculums reinforcing outcome measures. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

Early-onset methicillin-resistant Staphylococcus aureus keratitis and late-onset infectious keratitis in astigmatic keratotomy incision following femtosecond laser–assisted cataract surgery

UNLABELLED A 79-year-old woman had uneventful femtosecond laser-assisted cataract surgery including paired laser astigmatic keratotomies (AKs) in the right eye. Three weeks postoperatively, a corneal infiltrate developed in the superotemporal AK incision. Cultures grew methicillin-resistant Staphylococcus aureus. The infection was treated with topical fortified vancomycin and tobramycin; full resolution required several months of therapy. Five months after cataract surgery, the patient presented with a second stromal infiltrate, also in the superotemporal AK incision. Despite negative cultures, the infiltrate resolved quickly on a short course of broad-spectrum fortified antibiotics. At 6 months, the corrected distance visual acuity was 20/30. This case demonstrates that infectious keratitis can occur following uneventful femtosecond laser-assisted AK performed concurrently with cataract surgery. We reviewed the literature on infectious keratitis following refractive keratotomy and femtosecond laser-assisted procedures. Several recommendations to prevent these infections are proposed. FINANCIAL DISCLOSURE No author has a financial or proprietary interest in any material or method mentioned.