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 microm 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< or =.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< or =.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.

Hyperopic Photorefractive Keratectomy With Adjunctive Topical Mitomycin C for Refractive Error After Penetrating Keratoplasty for Keratoconus

OBJECTIVE

To present a case of photorefractive keratectomy (PRK) with adjunctive topical mitomycin C (MMC) in an anisometropic hyperopic patient after penetrating keratoplasty (PKP) for keratoconus.

METHODS

Interventional case report, chart review, and literature review.

RESULTS

A 43-year-old man with a refraction of +7.00 -4.75 x 125 in the right eye underwent PRK 10 months after PKP for keratoconus. The patient had sutures removed for 3 months and was intolerant of contact lenses. After photoablation, 0.02% MMC was applied to the corneal stromal bed. The patient was followed up daily until the epithelium closed and at 1 week, 1 month, 3 months, and 6 months postoperatively.

CONCLUSIONS

To our knowledge, this represents the first reported case of the use of MMC to prevent postoperative haze after PRK for PKP in an eye with keratoconus. MMC (0.02%) applied topically to the cornea immediately after PRK is safe and effective to treat a hyperopic refractive error after PKP and prevent postoperative corneal haze formation without the risks of performing a lamellar flap into an ectatic corneal bed.

Photorefractive Keratectomy with Mitomycin C for the Management of a LASIK Flap Complication Following a Penetrating Keratoplasty

OBJECTIVE

To evaluate the safety and efficacy of photorefractive keratectomy (PRK) with mitomycin C (MMC) following a buttonhole secondary to attempted laser in situ keratomileusis (LASIK) in an eye that had undergone a prior penetrating keratoplasty (PKP).

METHODS

Case report and review of the literature. A 26-year-old man underwent PRK with MMC following a buttonhole flap complication after LASIK in an eye that had undergone a PKP for keratoconus.

RESULTS

Three months following the procedure, the patient demonstrated a clear cornea and a best-corrected visual acuity of 20/20.

CONCLUSION

To our knowledge, this is the first case report of buttonhole during LASIK following a PKP and the use of PRK to treat a LASIK flap complication following a successful PKP. In addition, this is the first case report of prophylactic use of MMC to prevent corneal haze with PRK following PKP. A buttonhole is a rare complication following LASIK for residual refractive error following PKP, which can be successfully managed with PRK and prophylactic MMC.

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.

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 microm (range, 507 to 741 microm). Mean postoperative pachymetry was 461.3 microm (range, 370 to 564 microm). 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.

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.

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 65 degrees C 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.

The Effects of LASIK on the Ocular Surface

Laser in situ keratomileusis (LASIK) can affect corneal sensation, aqueous tear production, wound healing, and the incidence of corneal erosions. Virtually all patients experience dry eye at least transiently after LASIK. Because intact corneal sensation drives tear production, denervation associated with the LASIK procedure is the most significant cause of post-LASIK dry eye. To prevent symptomatic postoperative dry eye, it is crucial to identify and treat pre-existing dry eye before surgery. This review addresses the pathophysiology and management of dry eye, as well as the relationship between LASIK and corneal erosions, and suggests intra- and post-operative management techniques to minimize complications and maximize the stability of the ocular surface. Contraindications to LASIK and alternative refractive surgical procedures are discussed.

Medications for dry eye syndrome: a drug-therapy review

Early interventions were palliative, attempting to replace water lost from the tear film. Today, therapy is directed at the underlying inflammation, a recognized component of dry eye syndrome, and at the resulting progressive changes to the ocular surface. This approach offers promise of lasting relief to patients with moderate to severe symptoms.

Issues in the use of preservative-free topicals

In a perfect world, patients would use medications as prescribed. In reality, patients may cut corners, especially if they may save money by doing so. Clinicians and pharmacists must acknowledge this tendency, yet at the same time protect patients from using contaminated ophthalmologic agents and strive to achieve optimal clinical outcomes.

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.

Chryseobacterium meningosepticum keratitis

PURPOSE

To describe a case of a corneal ulcer caused by Chryseobacterium meningosepticum in an eye without significant comorbidities.

DESIGN

Interventional case report.

METHODS

Retrospective case review.

RESULTS

A 48-year-old man presented with a corneal ulcer in his right eye and was treated with ofloxacin and fortified bacitracin ophthalmic solution. Cultures grew C. meningosepticum, and the infection resolved. Two previous case reports in the literature have described ocular infections with this bacterium, both in postoperative patients with significant ocular comorbidities.

CONCLUSIONS

This is the first report of ocular infection with C. meningosepticum in an eye with no significant comorbidities.

Topical cyclosporine A 0.5% as a possible new treatment for superior limbic keratoconjunctivitis

PURPOSE

To report the early success of the use of topical cyclosporine A 0.5% drops to treat Theodore's superior limbic keratoconjunctivitis (SLK).

DESIGN

A retrospective noncomparative case series.

PARTICIPANTS

Five patients diagnosed with SLK.

INTERVENTION

All five patients were treated with topical cyclosporine A 0.5% drops as primary or adjunctive therapy after treatment failure in some of prednisolone acetate 1% drops and topical silver nitrate 0.5% application. Topical cyclosporine A 0.5% drops were used four times a day in both eyes.

MAIN OUTCOME MEASURES

Resolution of symptoms (foreign body sensation and irritation) and signs (rose bengal staining, tarsal papillary reaction, and injection).

RESULTS

All five patients had long-term (6 months to 3 years) improvement of irritation and foreign body sensation, as well as improvement of injection and filamentary keratitis. Aside from burning on instillation, there were no complications related to this therapy.

CONCLUSIONS

Topical cyclosporine A 0.5% is helpful as primary or adjunctive therapy for SLK. It may also be used as a maintenance drug to prevent recurrence. Further study may delineate the specific role and treatment parameters for the use of topical cyclosporine A 0.5% in the treatment of SLK.

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(R)).

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.

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.

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 degrees C to 34 degrees 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.

The effect of hinge position on corneal sensation and dry eye after LASIK

PURPOSE

To investigate the effect of hinge position on corneal sensation and dry eye syndrome after laser in situ keratomileusis (LASIK).

DESIGN

Prospective, randomized, self-controlled trial.

PARTICIPANTS

Fifty-two patients >/=18 years of age undergoing bilateral LASIK.

INTERVENTION

Patients underwent bilateral LASIK with the superior-hinge Hansatome microkeratome in one eye and the nasal-hinge Amadeus microkeratome in the other eye. In all eyes, the flaps were 160 micro m thick, with a diameter of 9.5 mm.

MAIN OUTCOME MEASURES

Masked Cochet-Bonnet esthesiometry was performed centrally before surgery and at 1 week, 1 month, 3 months, and 6 months after surgery. Dry eye was evaluated at the same time intervals with lissamine green corneal and conjunctival staining, Schirmer testing with anesthesia, and tear-film breakup time. Subjective evaluation of dry eye sensation was performed at 3 and 6 months after surgery.

RESULTS

Corneal sensation was reduced in eyes with either superior- or nasal-hinge corneal flaps at 1 week, 1 month, and 3 months after surgery (P < 0.001). Compared with preoperative values, a significant reduction in corneal sensation remained at 6 months in corneas with superior-hinge flaps (P < 0.001) but not in corneas with nasal-hinge flaps (P = 0.263). Mean corneal sensation was greater in corneas with a nasal-hinge flap compared with corneas with a superior-hinge flap at all postoperative visits (P < 0.001). The loss of sensation was greatest at 1 week and showed improvement at each subsequent time interval up to 6 months. Overall, dry eye signs and symptoms were greatest during the immediate postoperative period and improved at all subsequent time intervals. Dry eye signs and symptoms were generally greatest in the eyes with a superior-hinge flap and milder in eyes with a nasal-hinge flap.

CONCLUSIONS

The long posterior corneal nerves, which innervate the cornea, enter the eye at 3- and 9-o'clock. A superior-hinge flap transects both arms of the neuroplexus, whereas a nasal hinge transects only the temporal arm. LASIK results in a significant reduction in corneal sensation. Corneal sensation and dry eye signs and symptoms decreased immediately after LASIK and improved at all time periods between 1 week and 6 months in eyes with both a nasal-hinge flap and a superior-hinge flap. However, the loss of corneal sensation and presence of dry eye syndrome were greater in eyes with a superior-hinge flap than in eyes with a nasal-hinge flap.

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.

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.

High-frequency ultrasonographic evaluation of conjunctival intraepithelial neoplasia and squamous cell carcinoma

OBJECTIVE

To evaluate the high-frequency B-scan ultrasonographic characteristics of squamous conjunctival neoplasia (conjunctival intraepithelial neoplasia and squamous cell carcinoma).

METHODS

Each of 11 patients was examined with 20- and/or 50-MHz ultrasonography in a retrospective consecutive case series.

MAIN OUTCOME MEASURES

Ultrasonographic findings with clinical and histopathologic correlations.

RESULTS

Eleven eyes of 11 patients (8 men) were affected. Disease involved the right eye in 6 (55%) of the patients and the left eye in 5 (45%) of the patients; it was multifocal in 5 (45%) of the eyes. All tumors extended to, or primarily involved, the limbal conjunctiva. One patient developed superficial spread overlying a functioning partial-thickness filtering bleb, 1 developed intraocular extension, 1 developed scleral invasion, and 3 developed orbital involvement before treatment. Results of ultrasonographic examinations showed that the superficial aspect of the smaller limbal tumors appeared as fusiform thickening of the conjunctiva. In all patients, the tumor surface was highly reflective in contrast to the characteristically low reflectivity seen within the tumor stroma. Intraocular tumor extension was variably reflective, but evidenced by blunting of the anterior chamber angle and thickening of the uvea. Orbital extension was viewed as low reflective tumor extension into the relatively hyperechoic orbital tissues.

CONCLUSIONS

High-frequency ultrasonography may be used to assess the extent of squamous conjunctival neoplasia. While the 50-MHz system offered better resolution, 20-MHz ultrasonography allowed for a wider and deeper field of view. High-frequency ultrasonography was useful in determining tumor thickness, shape, and internal reflectivity, and especially in revealing tumor extension into the sclera, eye, and orbit.

Antiinflammatory effect of preoperative ketorolac in phacoemulsification

We report the antiinflammatory effect and efficacy of preoperative treatment with ketorolac in a patient with rheumatoid arthritis having phacoemulsification. This 70-year-old woman was on a maintenance dose of systemic methylprednisolone at the time of uneventful phacoemulsification in the left eye. She developed a sterile hypopyon on the first postoperative day and was treated aggressively with topical and systemic therapy, resulting in a gradual resolution of the inflammatory response. The patient subsequently had phacoemulsification in the right eye. The only significant difference in the preoperative management this time was that the patient received topical ofloxacin and ketorolac 4 days before surgery. The postoperative inflammatory response was much more controlled. The patient was continued on ketorolac and prednisolone acetate, resulting in the usual postoperative inflammatory response.

Herpes simplex reactivation following laser in situ keratomileusis and subsequent corneal perforation

PURPOSE

To present a case of corneal perforation secondary to herpes simplex reactivation after laser in situ keratomileusis (LASIK) and its subsequent management. METHODSL A case report of a 69-year-old man who underwent LASIK after penetrating keratoplasty for herpes simplex keratitis (HSK) is presented.

RESULTS

The patient is a 69-year-old man who had a penetrating keratoplasty of the right eye 6 years prior for corneal scarring secondary to HSK. A spectacle refraction of -13.25 + 6.00 x 45 yielded 20/60 visual acuity in his grafted eye. LASIK was performed, and the patient's visual acuity without correction on postoperative day 1 was 20/60. Ten days after LASIK, the patient developed thinning of the cornea at the temporal edge of the flap, which perforated the following day. The perforation site was glued with cyanoacrylate adhesive and covered with a soft contact lens. After 7 months, a 4-mm lamellar keratoplasty and conjunctivoplasty was performed. Nine months after surgery, the patient's visual acuity without correction is 20/50 and the graft remains intact.

CONCLUSION

Herpes simplex keratitis may be a contraindication for LASIK in postkeratoplasty patients. Bandage contact lenses and cyanoacrylate adhesive can be used successfully to manage the rare complication of corneal perforation after LASIK.

Topical cyclosporin A in the management of therapeutic keratoplasty for mycotic keratitis

PURPOSE

To investigate the efficacy of topical cyclosporine A 0.5% as a substitute for corticosteroids in the management of therapeutic keratoplasties for mycotic keratitis.

METHODS

Prospective, nonrandomized interventional case series. Three patients with culture-proven mycotic keratitis underwent therapeutic keratoplasties. All were treated with topical cyclosporine A 0.5% postoperatively as a primary or an adjunctive therapy for prevention of allograft rejection. The patients were followed up from 15 to 42 months for maintenance of graft clarity and best-corrected visual acuity.

RESULTS

Two of three patients maintained clear grafts while using topical cyclosporine A 0.5% twice daily with best-corrected visual acuity of 20/40 and 20/50. One patient developed an opacified graft secondary to preexisting ocular surface disease.

CONCLUSIONS

Topical cyclosporine A 0.5% may be a useful adjunct in the management of therapeutic keratoplasties for mycotic keratitis.

Air bag-induced corneal flap folds after laser in situ keratomileusis

PURPOSE

We describe a case of air bag-induced ocular trauma resulting in folds in the corneal flap 3 weeks after laser in situ keratomileusis.

METHODS

Case report. Three weeks after laser in situ keratomileusis, a 20-year-old man was involved in a motor vehicle accident and sustained blunt trauma to the right eye, which caused corneal flap folds, corneal edema, anterior chamber cellular reaction, and Berlin retinal edema.

RESULTS

Six weeks after laser in situ keratomileusis, persistent flap folds necessitated re-operation with lifting of the flap and repositioning. One week after the procedure, the visual acuity improved to 20/20-2, and the folds had cleared.

CONCLUSION

Trauma after laser in situ keratomileusis may produce folds in the corneal flap. With persistence of these folds, management by lifting and repositioning the corneal flap may be necessary to permit recovery of visual acuity.