Perilimbal Bulbar Conjunctival Pigmentation in Vernal Conjunctivitis

OBJECTIVES

To prospectively evaluate the occurrence of perilimbal conjunctival pigmentation in patients with vernal conjunctivitis and normal controls; to document the location, extent, density, and color of such pigmentation; and to correlate these changes with disease severity.

METHODS

Prospective, noninterventional case-control study. Demographic data, disease symptoms and duration, clinical signs of disease severity and extent, and characteristics of the perilimbal pigmentation were recorded.

RESULTS

Twenty-five patients with vernal conjunctivitis and 30 controls were studied. The mean age of the patients (21 M, 4 F) and controls (18 M, 12 F) was 7.5 +/- 3.7 years and 10.3 +/- 3.1 years, respectively. Perilimbal pigmentation was seen in all patients with vernal conjunctivitis and in none of the controls. The palpebral conjunctival changes and patient symptoms correlated with the severity of the disease in patients with vernal conjunctivitis. However, the extent of perilimbal pigmentation did not correlate with the symptoms and signs of vernal conjunctivitis or the density of palisadal pigment.

CONCLUSIONS

Perilimbal bulbar conjunctival pigmentation appears to be a consistent finding in patients with vernal conjunctivitis that is both specific and sensitive. It is also present in eyes with inactive disease and hence is a useful clinical sign that aids diagnosis in patients with mild or quiescent disease. Further studies are required to establish the histopathologic correlation of this finding and its etiopathogenesis. It is also important to establish whether this finding occurs with the same frequency in eyes of whites, as this study was performed in a cohort of Asian patients who have greater limbal pigmentation and a higher incidence of limbal changes in vernal conjunctivitis.

Limbal stem cell transplantation

The past two decades have witnessed remarkable progress in limbal stem cell transplantation. In addition to harvesting stem cells from a cadaver or a live related donor, it is now possible to cultivate limbal stem cells in vitro and then transplant them onto the recipient bed. A clear understanding of the basic disease pathology and a correct assessment of the extent of stem cell deficiency are essential. A holistic approach towards management of limbal stem cell deficiency is needed. This also includes management of the underlying systemic disease, ocular adnexal pathology and dry eye. Conjunctival limbal autografts from the healthy contralateral eye are performed for unilateral cases. In bilateral cases, tissue may be harvested from a cadaver or a living related donor; prolonged immunosuppression is needed to avoid allograft rejection in such cases. This review describes the surgical techniques, postoperative treatment regimes (including immunosuppression for allografts), the complications and their management. The short and long-term outcomes of the various modalities reported in the literature are also described.

Ophthalmic photography using a digital camera

PURPOSE

To report the application of a digital camera for ophthalmic photography in routine clinical use.

METHODS

A digital camera (Nikon Coolpix 995) was used both for external macrophotography of the eye and ocular adnexa, and slitlamp photography of the anterior segment of the eye.

RESULTS

We were able to take external macrophotographs under high magnification of the eye and ocular adnexa. Slitlamp photography could be performed under diffuse, slit beam, and retroillumination. The structures of the angle, the optic disc and surrounding retina could be photographed using appropriate lenses. The attachment to the operating microscope allowed intraoperative photography. It could also be attached to the laboratory microscope to capture images of various histopathology and microbiology slides.

CONCLUSIONS

A digital camera is a versatile instrument for ophthalmic photography. It is easy to use in routine clinical practice and provides good quality photographs.

Interface keratitis due to Mycobacterium fortuitum following laser in situ keratomileusis

A case of unilateral interface keratitis due to Mycobacterium fortuitum following simultaneous bilateral LASIK procedure for low myopia is reported. Excimer phototherapeutic keratectomy was performed to the stromal bed to reduce the infective load. Intensive topical therapy with topical amikacin and ciprofloxacin resulted in resolution of the keratitis.

Combined phacoemulsification, pars plana vitrectomy, and foldable intraocular lens implantation

We describe a technique for combined cataract and vitreoretinal surgery using sutureless sclerocorneal and sclerotomy incisions and a foldable intraocular lens. This technique, with its variations for cases with and without gas-fluid exchange, was successfully performed in 40 consecutive cases over a 5-month period. No significant complications related to the surgical procedures were encountered. The rationale and advantages of this technique are discussed.

Keratectasia in 2 cases with pellucid marginal corneal degeneration after laser in situ keratomileusis

We report 2 patients who experienced progressive blurring of vision following myopic laser in situ keratomileusis (LASIK) in 1 eye (Case 1) and bilaterally (Case 2). High against-the-rule astigmatism, associated with perilimbal thinning inferiorly, was seen on refraction in all eyes. Regional corneal pachymetry confirmed the peripheral corneal thinning inferiorly. Corneal topography revealed the typical features of pellucid marginal corneal degeneration (PMCD) in the untreated eye of Case 1. Advanced changes were noted in the fellow eye. The corneal topography findings in Case 2 were similar to those seen in PMCD. Patients with early PMCD may present to the refractive surgeon with a stable refraction, normal corrected visual acuity, and adequate central corneal thickness. Corneal topography data along with regional corneal pachymetry must be interpreted carefully to detect these cases. Laser in situ keratomileusis can lead to a rapid progression of PMCD.

Penetrating keratoplasty as a globe-saving procedure in fragile cornea

PURPOSE

To report a case of fragile cornea associated with osteogenesis imperfecta type I in which primary penetrating keratoplasty was done as a tectonic procedure.

METHODS

A 6-year-old boy with osteogenesis imperfecta type I presented with a corneal laceration in his right eye following minor trauma. Since wound repair was not possible due to tissue loss, he underwent a primary penetrating keratoplasty.

RESULTS

Postoperatively, the eye healed well without any wound leak. The boy had uneventful suture removal 10 weeks following surgery.

CONCLUSION

Primary penetrating keratoplasty is a viable option to restore ocular integrity in fragile corneas following trauma when tissue loss precludes simple repair.

Tuberculous granuloma managed by full thickness eye wall resection

PURPOSE

To report the use of eye wall resection in the management of tuberculous granuloma.

DESIGN

Interventional case report.

METHODS

In a 26-year-old man with biopsy-proven tuberculous granuloma of the left eye, total eye wall resection and donor scleral grafting was performed for management of tuberculous granuloma involving the sclera, part of the cornea, the iris, the chamber angle, and the ciliary body. Adjuvant therapy included oral antitubercular medication.

RESULTS

The treatment of the infection was successful. The scleral graft healed well, and the crystalline lens was preserved.

CONCLUSIONS

Total eye wall resection, a technique described in the management of uveal tumors, can be adopted to manage selected cases of tuberculous granuloma of the eye.

Complications of laser-in-situ-keratomileusis

Laser-in-situ-keratomileusis (LASIK) has become a popular technique of refractive surgery because of lower postoperative discomfort, early visual rehabilitation and decreased postoperative haze. Compared to photorefractive keratectomy (PRK), LASIK involves an additional procedure of creating a corneal flap. This may result in complications related to the flap, interface and underlying stromal bed. The common flap-related complications include thin flap, button holing, free caps, flap dislocation and flap striae. The interface complications of diffuse lamellar keratitis, epithelial ingrowth and microbial keratitis are potentially sight threatening. Compared to PRK, there is less inflammation and faster healing after LASIK, but there is a longer period of sensory denervation leading to the complication of dry eyes. The refractive complications include undercorrection, regression, irregular astigmatism, decentration and visual aberrations. Honest and unbiased reporting is important to understand the aetiology and redefine the management.

Bilateral corneal fibrosis in homocystinuria: case report and transmission electron microscopic findings

PURPOSE

To report the unusual occurrence of bilateral, superficial, corneal fibrosis with pannus formation in a young woman with homocystinuria, and to describe the light and transmission electron microscopic findings of these deposits.

METHODS

Excision of the corneal lesion and amniotic membrane transplantation was performed in both eyes. The excised material was studied using light and transmission electron microscopy.

RESULTS

Whitish, elevated, irregular masses with superficial vascularization in the peripheral cornea were noted in both eyes. Histopathologic evaluation of the excised corneal tissue revealed variable epithelial thickness with melanin pigment in the basal layer. A fibrovascular pannus, fibrosis and disruption of the Bowman's layer, and fibrosis of anterior stroma were evident. Transmission electron microscopy revealed numerous empty intracytoplasmic vacuoles in the corneal epithelial cells and intracytoplasmic inclusions containing fibrillogranular material in the cytoplasm of keratocytes.

CONCLUSION

We report the unusual association of corneal fibrosis and scarring in a young woman with homocystinuria. The deposits revealed the presence of membrane-bound inclusions containing fibrillogranular material in the corneal epithelium and keratocytes. Although the etiology of these deposits is not clear, the condition improved following excision of these lesions and amniotic membrane transplantation.

Bilateral macular hemorrhage caused by azathioprine-induced aplastic anemia in a corneal graft recipient

PURPOSE

To report the occurrence of bilateral macular hemorrhage following the use of azathioprine for immunosuppression in a corneal transplant recipient.

METHODS

The patient underwent therapeutic penetrating keratoplasty for progressive fungal keratitis in his left eye. Although the infection did not recur, the graft failed with vascularization of the cornea in three quadrants. He underwent repeat penetrating keratoplasty 2 years later and was treated with azathioprine (100 mg daily) to enhance graft survival. Four months after instituting azathioprine therapy, he developed aplastic anemia and macular hemorrhage in both eyes.

RESULTS

Fluorescein angiography revealed a preretinal location of the macular hemorrhage. After cessation of azathioprine therapy and treatment with blood component replacement, hematological parameters improved and the macular hemorrhage cleared with good visual recovery during the next 2 months.

CONCLUSION

This report highlights the serious ocular and systemic complications that can occur following the use of systemic immunosuppressants after ophthalmic surgery.

Timing of fornix reconstruction for postoperative conjunctival prolapse

BACKGROUND AND OBJECTIVE

To describe fornix reconstruction for conjunctival prolapse occurring after ocular surgery.

MATERIALS AND METHODS

Two patients with persistent conjunctival prolapse of variable duration following ocular surgery underwent fornix reconstruction using the method described by Barrett. The two patients underwent different surgical methods. In the second patient, no attempt was made to include the malar periosteum.

RESULTS

Case 1 with longer duration of prolapse needed further surgery to excise residual prolapsing conjunctiva that had hyperplastic squamous epithelium. Case 2 in which fornix reconstruction was done 2 months after prolapse showed a good result after only one surgical operation.

CONCLUSION

Forniceal reconstruction is recommended for persistent postoperative conjunctival prolapse. Early surgery appears to have better results.

Corneal topography and Schirmer testing in eyes with the Hudson-Stahli line

PURPOSE

To evaluate corneal topographic features and tear secretion in eyes with the Hudson-Stahli line.

METHODS

Keratometry, computerized videokeratography and Schirmer testing were performed in 50 cases with bilateral Hudson-Stahli line, and 55 controls without the Hudson-Stahli line. Similar tests were performed in 21 subjects with unilateral Hudson-Stahli line.

RESULTS

Corneal topographic features and keratometry in the horizontal meridian were similar in cases and controls, and in fellow eyes of subjects with unilateral Hudson-Stahli line. Keratometry in the vertical meridian in cases (43.01 +/- 2.01) was significantly lesser than in controls (43.94 +/- 1.77) (P = 0.01). This value was not different in fellow eyes of patients with unilateral Hudson-Stahli line. Schirmer testing revealed significantly greater tear secretion in cases (16.72 +/- 4.99 mm) compared to controls (12.57 +/- 3.62 mm) (P < 0.01). In subjects with unilateral Hudson-Stahli line, mean Schirmer values in the eye with the line (17.52 +/- 6.86 mm) were significantly greater than in eyes without (13.67 +/- 4.64 mm) (P = 0.04).

CONCLUSION

Formation of the Hudson-Stahli line may be dependent on the presence of normal tear secretion in the eye.

Combined intravenous pulse methylprednisolone and oral cyclosporine A in the treatment of corneal graft rejection: 5-year experience

PURPOSE

To report the mid-term results of a treatment strategy using topical steroids, intravenous pulse methyl prednisolone and oral cyclosporine A (CSA) for the treatment of acute corneal graft rejection.

METHODS

Noncomparative, interventional case series. Treatment of corneal graft rejection included 1% prednisolone eye drops, intravenous infusion of 500 mg methyl prednisolone, and oral CSA in two regimens--standard dose was 15 mg/kg/day for 2 days, 7.5 mg/kg/day for 2 days, then adjusted to maintain trough blood levels of 100-200 microg/l; low dose was 2 mg/kg/day with no loading dose.

RESULTS

Outcome in 34 eyes of 34 patients (21 M;13 F) aged 60 +/- 17.7 years (range 9-83 years), who presented after an average duration of 6.6 +/- 6.3 days (range 0-30 days) following acute corneal graft rejection, are reported. Twenty-five patients received standard dose CSA while nine patients received the low dose regimen. Mean duration of treatment before reversal of graft rejection was 13.6 +/- 12.1 days (range 3-54 days). Treatment was successful in reversing the graft rejection in 32/34 (94%) eyes. Irreversible graft failure occurred in one eye in each group. During a mean follow-up period of 19.2 +/- 16.7 months (range 1-55 months), further episodes of graft rejection were seen in 1/32 (3%) eyes. Complications due to treatment included: duodenal ulcer in one patient that responded to medical treatment, and transient elevation in serum creatinine levels in three patients, which returned to normal after decrease in dosage or cessation of oral CSA.

CONCLUSION

Our 5-year experience with the use of oral CSA in the treatment of acute corneal graft rejection has shown this treatment approach to be safe and effective in reversing the rejection process. This approach may also protect the graft from subsequent episodes of allograft rejection. A randomised controlled trial to further delineate the role of CSA in reversing acute graft rejection seems warranted.

Bilateral peripheral corneal infiltrates after simultaneous myopic laser in situ keratomileusis

We describe a patient with multiple superior corneal infiltrates in both eyes, separated from the limbus by an intervening clear zone, that appeared 1 day after uneventful laser in situ keratomileusis. The overlying epithelium was intact, and the flap and interface were uninvolved. Based on these features, a clinical diagnosis of sterile corneal infiltrates was made and the eyes were treated with topical antibiotics and steroids. The infiltrates resolved during the ensuing weeks without corneal scarring. Good visual acuity was maintained. Recognition of this benign complication is important because aggressive corneal scrapings are not required. The infiltrates appear to be immunogenic in origin, although the exact etiopathogenesis is not clear.

Isolation of a vesicular virus belonging to the family rhabdoviridae from the aqueous humor of a patient with bilateral corneal endotheliitis

PURPOSE

To report bilateral corneal endotheliitis caused by a vesicular virus (family Rhabdoviridae).

METHODS

Case report of a 49-year-old man with a complaint of sudden onset of decreased vision in both eyes had diffuse corneal stromal edema with extensive folds in Descemet's membrane and was diagnosed as having bilateral viral endotheliitis. Virologic investigations were performed using aqueous humor from the right eye.

RESULTS

An ether- and chloroform-sensitive cytopathic agent was isolated in Vero and BHK-21 cell lines from the aqueous humor. It was identified as a vesicular virus belonging to the family Rhabdoviridae by electron microscopy. Neutralizing antibody was demonstrated at a titer greater than 1 in 4,096 dilutions in the convalescent serum. Neurologic complications included loss of hearing and postinfectious polyradiculopathy affecting both lower limbs. Best-corrected visual acuity was 20/120 OD and 20/20 OS. Six months later, he developed glaucoma in the right eye. Trabeculectomy with intraoperative application of 5-fluorouracil was performed.

CONCLUSION

This is the first report of bilateral endotheliitis caused by a vesicular virus and confirmed by virus isolation from the aqueous humor of the affected eye.

Topical chloramphenicol for eye infections

Topical chloramphenicol has been widely used in the treatment and prevention of superficial eye infections due to its broad spectrum of activity and low cost. The use of this drug has decreased considerably in the United States since the first case of aplastic anaemia associated with topical chloramphenicol was reported in the 1960s. This medication, however, is still widely used in many other countries. This paper evaluates the evidence for and against the use of topical chloramphenicol in ocular diseases.