Punctal occlusion in the management of chronic Stevens-Johnson syndrome

Simple surgical punctal occlusion with high frequency radiowave electrosurgery

BACKGROUND

To introduce and evaluate the efficacy of a simple punctal occlusion technique for dry eye patients.

METHODS

Medical records of 79 eyes from 40 patients refractory to common dry eye conservative treatment who underwent multiple high-frequency radio-wave electro-punctal occlusion were retrospectively reviewed. Pre- and post-procedural ocular surface indices (Schirmer test, tear break-up time (TBUT), and corneal staining grade (Oxford scheme)) and subjective symptom scores (including frequency of artificial tear use, interval between procedures, and total repeat time) were analyzed.

RESULTS

Average Schirmer test result was significantly (P < 0.05) improved from 4.10 ± 1.39 mm to 8.14 ± 3.13 mm at 6 weeks after the procedure (n = 79). A total of 32 eyes from 16 patients underwent repeated procedure with a mean interval of 8.00 ± 4.86 months, while 24 patients had a single procedure. Twenty-five of 30 patients showed improvement for subjective symptom scores. No complications related to the procedure were observed.

CONCLUSIONS

A simple, less-invasive punctal occlusion technique using a fine-needle tip with high-frequency radio-wave could significantly relieve subjective symptoms and improve ocular surface indices of patients with aqueous deficient dry eye without causing a major complication. This procedure may play a considerable role in treating dry eye refractory to common practices.

Visual function and quality of life in patients with Stevens-Johnson syndrome who received acute protocol-based ocular care

Purpose: To report visual function and quality of life (VF/QOL) using the National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) and the ocular surface disease index (OSDI) in patients in the chronic phase of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). Methods: The NEI-VFQ-25 questionnaire was administered to 15 patients who received protocol-based care in the form of topical medications with or without amniotic membrane transplantation (AMT) for acute SJS/TEN. The scores obtained were compared with scores from a healthy population. The associations between the NEI-VFQ-25 and dry eye symptoms as measured by OSDI questionnaire were also studied. Results: Patients were surveyed at a mean of 4.47 ± 2.22 years after acute SJS/TEN. Eleven patients received AMT in the acute phase. The median best corrected visual acuity at the time of administration of the questionnaire was 20/20. The mean composite NEI-VFQ-25 score was 86.48 ± 12. Patients who received protocol-based treatment in the acute phase of SJS/TEN had comparable NEI-VFQ-25 scores with healthy subjects on all subscales except ocular pain (p = 0.027) and mental health (p = 0.014), which were significantly reduced. The NEI-VFQ-25 composite scores significantly correlated with OSDI (R = -0.75, p = 0.001). Conclusion: A protocol-based management strategy composed of early ophthalmic evaluation, grading based on severity, the use of topical corticosteroids and AMT in the acute phase of SJS/TEN in patients with ocular complications helped preserve the VF/QOL. This study highlights the impact of appropriate management of the ocular complications in the acute phase of SJS/TEN.

Acute and Chronic Management of Ocular Disease in Stevens Johnson Syndrome/Toxic Epidermal Necrolysis in the USA

Stevens Johnson syndrome and toxic epidermal necrolysis are on a spectrum of a severe, immune-mediated, mucocutaneous disease. Ocular involvement occurs in the vast majority of cases and severe involvement can lead to corneal blindness. Treatment in the acute phase is imperative in mitigating the severity of chronic disease. Advances in acute treatment such as amniotic membrane transplantation have shown to significantly reduce the severity of chronic disease. However, AMT is not a panacea and severe chronic ocular disease can and does still occur even with aggressive acute treatment. Management of chronic disease is equally critical as timely intervention can prevent worsening of disease and preserve vision. This mini-review describes the acute and chronic findings in SJS/TEN and discusses medical and surgical management strategies.

Surgical Management of Limbal Stem Cell Deficiency

Treatment of limbal stem cell deficiency is challenging. Multiple options can be adopted according to the underlying cause and the patient and physician preferences. Stem cell transplant is a common treatment modality and several techniques have been described with outcomes varying by the laterality of the condition. Keratoprosthesis is a preferred option for bilateral conditions. Indications for type 1 and type 2 keratoprosthesis differ and the past 2 decades have seen a revolution in the field of keratoprosthesis with encouraging and improved outcomes. Management also includes preventive measures and measures to optimize/stabilize the ocular surface that would go a long way in reducing the deterioration of the ocular surface. The aim of this review is to provide an overview of the currently available techniques and to present a comprehensive algorithm to assist in decision making for unilateral and bilateral limbal stem cell deficiency.

Advances in the diagnosis and treatment of dry eye

The core mechanism of dry eye is the tear film instability. Tear film-oriented diagnosis (TFOD) is a concept to clarify the cause of tear film instability by tear film, and tear film-oriented treatment (TFOT) is a concept to treat dry eye disease by replacing the lacking components of the tear film layer based on the TFOD. In TFOD, the fluorescein breakup pattern of the tear film is important, and the subtype of dry eye can be judged to some extent from the breakup patterns. Current noninvasive devices related to the dynamic analysis of the tear film and visual acuity enabled the diagnosis of dry eye, subtype analysis, and the extent of severity. In Asian countries, secretagogues represent the main treatment in TFOT. Since meibomian gland dysfunction is a factor that greatly affects the tear breakup time, its treatment is also essential in the dry eye treatment strategy. A newly discovered dry eye subtype is the short breakup time-type (BUT) of dry eye. The only abnormal finding in this disease is the short BUT, suggesting a relationship with ocular neuropathic pain and eye strain. Recently, data from many studies have accumulated which show that dry eye is a life-style disease. In addition to the treatment of dry eyes, it is becoming possible to prevent the onset by intervening with the daily habits, diet, exercise and sleep, etc. It has been pointed out that oxidative stress is also involved in the pathology of dry eye, and intervention is being carried out by improving diet and taking supplements. Future research will be needed to link clinical findings to the molecular biological findings in the tear film.

[Punctal and canalicular plugs: Indications, efficacy and safety (French translation of the article)]

Lacrimal occlusion with punctal or canalicular plugs have been used to treat dry eye disease for more than 40 years. Indeed, punctal plugs constitute a safe and effective tool to retain the natural tear film and prolong the effect of tear substitutes. A wide variety of plugs is available, differing in their design, location (punctal versus canalicular) and their resorbability. There indications have increasingly broadened, and they are now one of the treatment options for numerous ocular surface diseases. Current research focuses on using punctal plugs for extended delivery of drugs to the ocular surface. This review addresses physiology of lacrimal drainage, available models of punctal plugs, their indications, practical details of prescribing and placing punctal and canalicular plugs, and possible complications.

Punctal and canalicular plugs: Indications, efficacy and safety

Lacrimal occlusion with punctal or canalicular plugs have been used to treat dry eye disease for more than 40 years. Indeed, punctal plugs constitute a safe and effective tool to retain the natural tear film and prolong the effect of tear substitutes. A wide variety of plugs is available, differing in their design, location (punctal versus canalicular) and their resorbability. There indications have increasingly broadened, and they are now one of the treatment options for numerous ocular surface diseases. Current research focuses on using punctal plugs for extended delivery of drugs to the ocular surface. This review addresses physiology of lacrimal drainage, available models of punctal plugs, their indications, practical details of prescribing and placing punctal and canalicular plugs, and possible complications.

Acute and Chronic Ophthalmic Involvement in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis - A Comprehensive Review and Guide to Therapy. II. Ophthalmic Disease

Our purpose is to comprehensively review the state of the art with regard to Stevens- Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to improving the management of associated ocular surface complications. SJS and TEN are two ends of a spectrum of immune-mediated disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. Part I of this review focused on the systemic aspects of SJS/TEN and was published in the January 2016 issue of this journal. The purpose of Part II is to summarize the ocular manifestations and their management through all phases of SJS/TEN, from acute to chronic. We hope this effort will assist ophthalmologists in their management of SJS/TEN, so that patients with this complex and debilitating disease receive the best possible care and experience the most optimal outcomes in their vision and quality of life.

Stevens-Johnson syndrome: The role of an ophthalmologist

Stevens-Johnson syndrome (SJS) is an acute blistering disease of the skin and mucous membranes. Acute SJS leads to the acute inflammation of the ocular surface and chronic conjunctivitis. If not properly treated, it causes chronic cicatricial conjunctivitis and cicatricial lid margin abnormalities. Persistent inflammation and ulceration of the ocular surface with cicatricial complications of the lids leads to chronic ocular sequelae, ocular surface damage, and corneal scarring. The destruction of the glands that secrete the tear film leads to a severe form of dry eye that makes the management of chronic SJS difficult. The option that is routinely used for corneal visual rehabilitation, keratoplasty, is best avoided in such cases. We describe the management strategies that are most effective during the acute and chronic stages of SJS. Although treatments for acute SJS involve immunosuppressive and immunomodulatory therapies, amniotic membrane transplantation is also useful. The options for visual rehabilitation in patients with chronic SJS are undergoing radical change. We describe the existing literature regarding the management of SJS and highlight recent advances in the management of this disorder.

New Method for Removing Thermosensitive Acrylic Punctal Plugs From Lacrimal Puncta

PURPOSE

This study explored a new method for removing thermosensitive acrylic punctal plugs from lacrimal puncta.

METHODS

A total of 14 dry eye patients (14 eyes), who required the removal of thermosensitive acrylic punctal plugs from the lacrimal puncta because of serious complications, were recruited. Among the 14 patients, lacrimal punctal granuloma formation occurred in 3 patients, tearing occurred in 6 patients, canaliculitis occurred in 3 patients, and chronic inflammation of the ocular surface occurred in 2 patients. The plugs were removed using a new method. Briefly, after local anesthesia was administered, a small lid clamp was used to flip the eyelid outward. After the application of the lid clamp, the plug could be removed without the use of any additional tools if the lacrimal punctum was large enough. If the lacrimal punctum was not large enough, microforceps were used to expand the lacrimal punctum before the application of the lid clamp. If the plug still could not be removed after the expansion of the lacrimal punctum, we moved the small lid clamp from the distal side of the lacrimal ductule to the lacrimal punctum.

RESULTS

Using this method, the plug was successfully removed in all of the patients.

CONCLUSIONS

This is a simple and effective method for removing thermosensitive acrylic punctal plugs from lacrimal puncta.

CLINICAL TRIAL REGISTRATION-URL

: http://www.clinicaltrials.gov. Unique identifier: ChiCTR-IPR-14005476.

Long-Term Outcome of Treatment with Topical Corticosteroids for Severe Dry Eye Associated with Sjögren's Syndrome

This retrospective study was performed to analyze the long-term outcome of topical corticosteroid treatment for severe dry eye associated with Sjögren's syndrome (SS). Patients who had severe dry eye associated with SS were topically treated with loteprednol etabonate 0.5% (group A, n=66) or fluorometholone 0.1% (group B, n=67) twice daily and were followed up for 2 years. Visual acuity (VA), intraocular pressure (IOP), Schirmer test, tear film breakup time (BUT), keratoepitheliopathy, and symptom scores were measured at baseline and 6, 12, 18, and 24 months after treatment. VA and IOP were not changed significantly during follow-up in either group. Schirmer test results, keratoepitheliopathy, and symptom scores at 6, 12, 18, and 24 months (p<0.05) and tear film BUT at 12, 18, and 24 months (p<0.05) significantly improved after treatment compared with baseline in both groups. No significant differences between the groups were found in any parameter during follow-up. At 24 months, the number of patients with IOP elevation of more than 2 mmHg compared with baseline was 4 in group A (6.1%) and 9 in group B (13.4%). The mean IOP in these patients was lower in group A than in group B (15.00±0.82 mmHg versus 16.50±1.12 mmHg; p=0.04). Long-term application of low-dose topical corticosteroids is effective for controlling signs and symptoms of chronic, severe dry eye associated with SS. Loteprednol etabonate 0.5% may have a lower risk for IOP elevation than fluorometholone 0.1%.

Evaluation of a thermosensitive atelocollagen punctal plug treatment for dry eye disease

PURPOSE

To evaluate the efficacy of a thermosensitive atelocollagen punctal plug in the treatment of dry eye disease.

DESIGN

Prospective observational case series.

METHODS

The thermosensitive atelocollagen punctal plug was warmed at 37 C, 39 C, 41 C, and 43 C to evaluate the appropriate temperature and time for solidification. Dry eye patients were divided into 2 groups according to the preparation method of the atelocollagen punctal plug. In the conventional implantation group, atelocollagen gel was kept at room temperature for 15 minutes before implantation (27 eyes of 14 patients). In the preheating group, atelocollagen was warmed at 41 C for 8 minutes before implantation (23 eyes of 13 dry eye patients). Strip meniscometry, vital stainings, tear film break-up time (BUT), and symptom scores were evaluated before and 1 month after plug implantation.

RESULTS

In vitro experiments revealed that heating at 41 C for 8 minutes was sufficient to solidify the gel. The mean fluorescein score in the conventional implantation group significantly improved after treatment (before, 3.5 ± 2.3 points; after, 2.5 ± 0.9 points, P < .05). In the preheating group, the mean fluorescein score (before, 3.7 ± 1.7 points; after, 1.5 ± 1.2 points), strip meniscometry (before, 0.6 ± 0.7 mm; after, 1.1 ± 0.3 mm), BUT (before, 3.2 ± 0.7 seconds; after, 4.8 ± 1.0 seconds), and visual analog scale scores (before, 6.6 ± 1.5 points; after, 4.1 ± 0.9 points) significantly improved after treatment (P < .05).

CONCLUSION

The thermosensitive atelocollagen punctal plug was effective for dry eye treatment. The preheating method was found to be useful to strengthen the efficacy of the thermosensitive atelocollagen punctal plug.

The relation between visual performance and clinical ocular manifestations in Stevens-Johnson syndrome

PURPOSE

To investigate the relation between visual function, clinical findings, and visual symptoms in Stevens-Johnson syndrome (SJS) and to compare the results with Sjögren syndrome (SS) patients and normal subjects.

DESIGN

Cross-sectional comparative study.

METHODS

One hundred fifteen eyes of 59 consecutive patients with SJS and toxic epidermal necrolysis (TEN), 208 eyes of 104 healthy normal subjects, and 132 eyes of 66 SS patients were investigated in this multicenter study. All study subjects underwent tear function and ocular surface examinations, Landolt and functional visual acuity examinations, and the Japanese version of the NEI VFQ-25 (National Eye Institute Visual Function Questionnaire).

RESULTS

The mean ocular surface grading scores were significantly higher and the mean score of all 12 NEI VFQ subscales was significantly lower in the SJS patients compared to the SS patients and the normal subjects (P < .05). The conventional and functional logarithm of minimal angle of resolution (logMAR) visual acuities in SJS patients with minimal corneal complications were significantly higher and the mean total composite NEI VFQ scores were lower compared to SS patients. The conventional and functional logMAR visual acuities and the mean ocular surface grading scores in SJS with aqueous deficiency were significantly higher and the mean total composite NEI VFQ scores were lower compared to SS patients. Strong correlations between best-corrected logMAR functional visual acuities and either ocular surface grading scores or the composite NEI VFQ-25 scores were observed.

CONCLUSIONS

The functional visual acuity examination reflects the severity of clinical ocular surface findings and vision-related quality of life more than the standard conventional visual acuity in SJS.

Surgical management of lacrimal punctal cauterization in chronic GVHD-related dry eye with recurrent punctal plug extrusion

We investigated the efficacy of lacrimal punctal occlusion surgery with a cautery device in patients with chronic GVHD (cGVHD)-related dry eye, with recanalization of puncta and recurrent punctal plug extrusion. A total of 23 puncta from 14 eyes of 10 patients with chronic GVHD (cGVHD)-related dry eye underwent punctual thermal cauterization with a high-temperature disposable cautery device. All patients were refractory to conventional treatment, including artificial tear eye drops, autologous serum eye drops and vitamin A eye drops, and had a history of recanalization and recurrent punctal plug extrusion. The effect of lacrimal punctal cauterization by thermal cautery device was evaluated by changes in subjective symptom scores, corrected distance visual acuity, Schirmer's test values, fluorescein staining scores, rose bengal staining scores, and tear-film break-up time before and 3 months after the surgery. Subjective symptom scores, Schirmer's test values, fluorescein and rose bengal scores, and tear-film break-up time improved significantly 3 months after the surgery. Recanalization of puncta was not observed in all the cases (0 of 14 eyes, 0%). Lacrimal punctal cauterization was effective with no recanalization and significant improvements in subjective symptoms and the ocular surface environment in cGVHD-related dry eye patients who had been refractory to conventional treatments.

Oral azithromycin for treatment of posterior blepharitis

PURPOSE

To evaluate the effects of oral azithromycin in patients with posterior blepharitis.

METHODS

Twenty-six eyes of 13 patients with posterior blepharitis diagnosed by a qualified ophthalmologist were enrolled in this study. Patients were instructed to use oral azithromycin 500 mg per day for 3 days in 3 cycles with 7-day intervals. Subjective clinical outcomes were graded and scored 1 day before and 30 days after the end of the treatment (53 days after initiating the treatment) based on severity scores of: (1) eyelid debris; (2) eyelid telangiectasia; (3) swelling of the eyelid margin; (4) redness of the eyelid margin; and (5) ocular mucus secretion. For the assessment of global efficacy, patients were asked by the investigator to rate the subjective symptoms (eyelid itching, ocular itching, eyelid hyperemia, ocular hyperemia, ocular mucus secretion, photophobia, foreign body sensation, and dry eye sensation) on a scale of 0 (no symptoms) to 5 (severe symptoms). Break-up time, Schirmer I test, corneal fluorescein staining score, and rose bengal staining score were also performed in all patients.

RESULTS

All clinical outcomes scoring showed statistically significant improvement after oral azithromycin, except for eyelid swelling. Average subjective symptom grading improved statistically after treatment with oral azithromycin, except for eyelid hyperemia, photophobia, and foreign body sensation. Average tear film break-up time values showed statistically significant improvement after the treatment with oral azithromycin. No statistically significant improvement was observed on average values of Schirmer I test, corneal fluorescein staining score, and rose bengal staining score.

CONCLUSIONS

The combination of multiple clinical parameters shown in this study supports the clinical efficacy of pulsed oral azithromycin therapy for the management of posterior blepharitis.

The challenge of dry eye diagnosis

The currently available methods for the diagnosis of dry eye are still far from being perfect for a variety of reasons. This review attempts to highlight the advantages and disadvantages of both traditional tests (such as Schirmer’s test, break-up time and ocular surface staining) and innovative noninvasive procedures, including tear meniscus height measurement, corneal topography, functional visual acuity, tear interferometry, tear evaporimetry and tear osmolarity assessment.

Interleukin-17 in various ocular surface inflammatory diseases

Recently, the association of Th-17 cells or IL-17 with ocular inflammatory diseases such as uveitis, scleritis and dry eye syndrome was discovered. We assessed whether interleukin (IL)-17 was present in the tears of various ocular surface inflammatory diseases and the tear IL-17 concentrations were clinically correlated with various ocular surface inflammatory diseases. We measured concentrations of IL-17 in tears of normal subjects (n = 28) and patients (n = 141) with meibomian gland dysfunction (MGD), dry eye syndrome (DES), Sjögren syndrome (SS), Stevens-Johnson syndrome (SJS), graft-versus-host disease (GVHD), filamentary keratitis, and autoimmune keratitis associated with rheumatoid arthritis or systemic lupus erythematosus. Clinical epitheliopathy scores were based on the surface area of corneal and conjunctival fluorescein staining. The mean concentrations of IL-17 in tears of patients with filamentary keratitis, GVHD, autoimmune keratitis, SS, DES, MGD, SJS were significantly higher in order than that in normal subjects. Tear IL-17 concentration was significantly correlated with clinical epitheilopathy scores in the patients with systemic inflammatory disease, while tear IL-17 was not correlated with clinical severity of the cornea and conjunctiva in the dry eye patients without any systemic inflammatory disease. Tear IL-17 is likely to correlate clinically with corneal disease severity only in the patients with systemic inflammatory disease.

Surgical punctal occlusion with a high heat-energy releasing cautery device for severe dry eye with recurrent punctal plug extrusion

PURPOSE

To report the rate of recanalization and the efficacy of punctal occlusion surgery with a high heat-energy-releasing cautery device in patients with severe dry eye disease and recurrent punctal plug extrusion.

DESIGN

Prospective, interventional case series.

METHODS

Seventy puncta from 44 eyes of 28 dry eye patients underwent punctal occlusion with thermal cautery. All patients had a history of recurrent punctal plug extrusion. A high heat-energy-releasing thermal cautery device (Optemp II V; Alcon Japan) was used for punctal occlusion surgery. Symptom scores, best-corrected visual acuity, fluorescein staining score, rose bengal staining score, tear film break-up time, and Schirmer test values were compared before and 3 months after the surgery. Rate of punctal recanalization also was examined.

RESULTS

Three months after surgical cauterization, symptom score decreased from 3.9 ± 0.23 to 0.56 ± 0.84 (P < .0001). Logarithm of the minimal angle of resolution best-corrected visual acuity improved from 0.11 ± 0.30 to 0.013 ± 0.22 (P = .003). Fluorescein staining score, rose bengal staining score, tear film break-up time, and the Schirmer test value also improved significantly after the surgery. Only 1 of 70 puncta recanalized after thermal cauterization (1.4%).

CONCLUSIONS

Punctal occlusion with the high heat-energy-releasing cautery device not only was associated with a low recanalization rate, but also with improvements in ocular surface wetness and better visual acuity.

[Mucous membrane pemphigoid with ocular involvement. Part II: therapy]

Treatment of mucous membrane pemphigoid (MMP) aims at reduction of conjunctival inflammation by means of systemic immunosuppression. In addition, cicatricial progression and management of the resulting ocular surface disease requires topical conservative or surgical measures. The former includes systemic immunosuppression with steroids and other immunosuppressive agents: dapsone in mild to moderate disease and cyclophosphamide in severe cases have been established in two randomized trials. Other agents such as methotrexate, azathioprine, mycophenolate mofetil or monoclonal antibodies including daclizumab or rituximab were found to be effective in uncontrolled small studies. Surgery is primarily focused on eyelid problems such as entropium and trichiasis. Ocular surface disease and secondary complications, e.g. cataract formation and glaucoma, may need surgical treatment. Any surgery is associated with the risk of a relapse of inflammation and should be postponed until inflammation is controlled by systemic therapy. Management of MMP patients requires close collaboration of a specialized ophthalmologist with specialists from dermatology and internal medicine.

Bilateral conjunctival retention cysts in the aftermath of Stevens-Johnson syndrome

In this case report, we describe the rare occurrence of bilateral conjunctival retention cysts in a child with Stevens-Johnson syndrome. The case was managed conservatively as there were no functional or cosmetic problems.

Topical bevacizumab and ocular surface neovascularization in patients with stevens-johnson syndrome

PURPOSE

To evaluate the efficacy and safety of topical bevacizumab on ocular surface neovascularization among patients with Stevens-Johnson syndrome.

METHODS

This was a retrospective, interventional case report. Three eyes of 2 patients were examined. Bevacizumab (25 mg/mL) eyedrops were applied 4 times daily for a period of 3 months. Main outcome measures were improvement of symptoms, visual acuity, degree of ocular surface neovascularization, corneal opacification, conjunctival injection, and occurrence of adverse events.

RESULTS

Both patients completed the 3-month observation period and reported that it significantly improved ocular comfort. At the end of the study period, visual acuity improved in all 3 eyes; all eyes were observed to have decreased ocular surface neovascularization, corneal opacification, and conjunctival injection. No serious adverse events were reported.

CONCLUSIONS

Topical bevacizumab is well tolerated and may be effective in improving comfort and inducing regression of ocular surface neovascularization, conjunctival injection, and corneal opacification in patients with ocular surface disease caused by Stevens-Johnson syndrome. Further controlled and long-term studies are needed to fully evaluate the long-term effects of this novel treatment.

Concept of functional visual acuity and its applications

Functional visual acuity (FVA) has been suggested to reflect an individual's performance in relation to certain daily activities involving visual tasks. The concept of FVA has been thought applicable to the detection of masked impairment of visual function in patients with dry eye who complain of decreased visual acuity despite normal conventional visual acuity. A stable tear-film layer over the surface of the cornea is essential for a smooth ocular surface and the formation of clear visual images. In dry eye, the ocular surface tends to dry out when normal blinking is suppressed during gazing, and patients with dry eye may have problems maintaining clear vision while gazing. The FVA measurement system is a device to measure changes in continuous visual acuity over time. Visual maintenance ratio (VMR) is the ratio between FVA and baseline visual acuity. FVA and VMR are indices for the assessment of functional vision. FVA has been thought applicable to the detection of changes in functional vision in relation to the tear film over the ocular surface. It may also be useful for the assessment of subjective visual complaints in diseases that do not involve dry eye.

The natural history of Stevens Johnson syndrome: patterns of chronic ocular disease and the role of systemic immunosuppressive therapy

OBJECTIVE

To characterize patterns of chronic ocular disease in patients with Stevens-Johnson syndrome (SJS) and its variant toxic epidermal necrolysis (TEN), and to describe their response to treatment.

METHODS

Retrospective case series. A review of hospital records of 30 patients (60 eyes) with ocular manifestations of SJS or TEN was carried out. The principal outcome measure was to identify and classify the patterns of chronic ocular disease in SJS and TEN. The secondary outcome measure was the response to treatment.

RESULTS

Patterns of chronic ocular disease observed after the acute episode included: mild/moderate SJS, severe SJS, ocular surface failure (SJS-OSF), recurrent episodic inflammation (SJS-RI), scleritis (SJS-S) and progressive conjunctival cicatrisation resembling mucous membrane pemphigoid (SJS-MMP). The median follow-up was 5 years (range 0-29). 19 patients (29 eyes (48%)) developed SJS-OSF, SJS-RI, SJS-S or SJS-MMP during follow-up. SJS-OSF was present in 12 patients (18 eyes (30%)). In 5 patients (eight eyes) this developed 1 year after the acute illness, without any further inflammatory episodes; it was associated with SJS-RI in 1 patient (2 eyes), with SJS-RI and SJS-S in 1 patient (1 eye), with SJS-S in 1 patient (1 eye) and with SJS-MMP in 4 patients (6 eyes). Episodes of SJS-RI occurred in 4 patients (7 eyes (12%)). The median time from acute disease to the first episode of SJS-RI was 8.5 years (range 5-63). SJS-S developed in 2 patients (4 eyes (7%)), of which 2 eyes subsequently developed SJS-OSF. SJS-MMP developed in 5 patients (10 eyes (16.6%)). The median duration from the acute stage to the diagnosis of SJS-MMP was 2 years (range 1-14). Immunosuppressive therapy successfully controlled inflammation in 10/10 patients with SJS-MMP, SJS-RI or SJS-S.

CONCLUSION

Ocular disease in SJS/TEN is not limited solely to the sequelae of the acute phase illness. Patients and physicians need to know that ocular disease progression, due to surface failure and/or acute inflammatory conditions, may occur at variable periods following the acute disease episode. Recognition of this, and prompt access to specialist services, may optimise management of these uncommon patterns of disease in SJS.

Science and Strategy for Preventing and Managing Corneal Ulceration

ABSTRACT Corneal ulcers can cause significant loss of vision from scarring and astigmatism, but rapid management can limit the destruction and improve outcomes. Infectious ulcers usually resolve with antimicrobial treatment. Noninfectious ulcers, however, present a diagnostic and therapeutic challenge. They can often be resolved by eliminating toxic medications and providing surface support with lubrication and collagenase inhibitors, but resistant ulcers may need more aggressive therapy with bandage contact lenses, tarsorrhaphy, or autologous serum. Ulcers impending perforation require urgent surgical management (e.g., tissue glue, conjunctival flaps, or keratoplasty). Topical steroids are useful when the ulceration is secondary to inflammatory mediators, but they are contraindicated in corneal melts with minimal inflammation, such as those associated with Sjogren syndrome. Systemic immunomodulation is required in addition to topical therapy in the presence of autoimmune disease. Understanding of the pathological processes that occur in different types of corneal ulcers is essential to formulation of a logical and effective treatment plan. Newer, more targeted treatment modalities may offer treatment options that have greater efficacy and fewer adverse effects.

Aspergillus fumigatus colonization of punctal plugs

PURPOSE

Punctal plugs are used in patients with dry eye syndrome to preserve the tears. In this report, I present two cases of Aspergillus fumigatus colonization of punctal plugs.

DESIGN

Observational series of two cases.

METHODS

Approval was obtained from the institutional review board. Two men aged 29 and 31 years developed black spots inside the hole of punctal plug, which looked like eyeliner deposits. The deposits inside the hole of the plug in each patient were removed and cultured.

RESULTS

Cultures of the two punctal plugs black deposits grew A fumigatus. Bacterial cultures were negative.

CONCLUSIONS

Colonization of the punctal plug hole with A fumigatus was observed in two cases. It is recommended that punctal plugs be removed in patients undergoing refractive or intraocular procedures or in patients who are receiving topical corticosteroids. Current punctal plugs should be redesigned to avoid the presence of an inserter hole.

Functional visual acuity in Stevens-Johnson syndrome

PURPOSE

To evaluate the correlation of functional visual acuity (FVA) measurement with ocular surface findings in patients with Stevens-Johnson syndrome (SJS).

DESIGN

Prospective comparative study.

METHODS

Sixty-nine eyes of 38 patients with chronic SJS assessed at the Tokyo Dental College, Tokyo Medical Center, and the Kyoto Prefectural University of Medicine, Department of Ophthalmology, Kyoto, Japan, were studied. Twenty eyes of 10 normal subjects and 40 eyes of 20 patients with Sjögren syndrome (SS) were also studied. Conventional Landolt visual acuity (VA) and FVA examinations and slit-lamp examinations were performed. FVA was measured continuously by the FVA measurement system during a 30-second blink-free period in one eye. The visual maintenance ratio (VMR) was calculated as follows: VMR = [(2.7 - FVA)/(2.7 - baseline VA)], where logarithm of minimal angle of resolution values of FVA were entered into the formula and 2.7 represented the lowest visual acuity in this series. Slit-lamp examinations, Schirmer test, and fluorescein vital stainings were also performed in all subjects.

RESULTS

VMR was markedly lower in patients with SJS compared with patients with SS and controls. FVA values showed a relation with the presence of corneal opacity and vascularization.

CONCLUSIONS

The FVA measurement system is not only a useful tool in the evaluation of dynamic VA changes, but also reflects the ocular surface clinical findings in SJS.

Corneal grafting and aggressive medication for corneal defects in graft-versus-host disease following bone marrow transplantation

PURPOSE

To evaluate the clinical outcomes of corneal grafting for severe dry eye complications in bone marrow transplant recipients.

METHODS

Eleven eyes of nine patients with severe corneal complications of chronic graft-versus-host disease were treated from 2000 to 2005. The subjects underwent penetrating keratoplasty (n=9 eyes; seven for perforation and two for leucoma) or deep anterior lamellar keratoplasty (n=2 eyes) for deep postinflammatory stromal scarring without endothelial abnormalities. Patients were observed for graft survival, visual acuity, and postoperative complications.

RESULTS

During the follow-up period (mean=21.6 months), nine grafts (82%) remained clear or almost entirely clear and gained more than two logarithmic units of best-corrected visual acuity. Two regrafts were necessary as the primary grafts became cloudy after 9 and 11 months. Persistent epithelial defects occurred in seven eyes (64%), cataract in six (55%), ocular hypertension in five (45%), corneal calcareous degeneration in two (18%), loss of clarity in two (18%), and sterile ulceration in one (9%).

CONCLUSION

Corneal grafting was effective for restoring corneal clarity and improving visual function in this series of patients. Although the complication ratio was high and some patients required regrafting, there was a clinical improvement in the majority of patients.

Optical Aberrations and Visual Disturbances Associated with Dry Eye

Optical aberrations and visual disturbances are associated with dry eye, although visual impairment is often not detected by conventional visual acuity testing. The newly developed functional visual acuity (FVA) device allows continuous dynamic evaluation of distance visual acuity and assessment of the effect of natural tear film status on dynamic visual function. Similarly, to detect corneal surface irregularities during sustained eye opening in dry eye subjects, a new tear stability analysis system (TSAS) has been developed. Both FVA and TSAS measurement systems seem to be effective tools in the assessment of dynamic visual acuity changes in dry eye and normal subjects. Both methods were also found to be helpful in the evaluation of the outcome of management of dry eye disease. FVA testing has been suggested to be an important indication of an individual's performance in relation to certain daily activities, such as driving, reading and working at a video display terminal. This review provides illustrations of results obtained from FVA and TSAS systems.

Quantification of Tear Interference Image

PURPOSE

To review the literature on lipid supplementation therapy for dry eye and on image analysis using tear interference images from the specific tear lipid layer interference camera DR-1.

METHODS

Systematic literature review of lipid supplementation therapy for lipid tear deficiency dry eye, kinetic analysis of tear interference images using DR-1 camera, and computer-synthesized interference color chart for DR-1 camera.

CONCLUSION

To establish lipid supplementation therapy, a quantification system of tear lipid layer is required. Tear lipid thickness could be quantified using a computer-synthesized interference color chart system.

Punctal Plugs in the Management of Dry Eyes

Punctal plugs appear to be a relatively safe, effective, and reversible method of preserving aqueous and artificial tears on the ocular surface to reduce the signs and symptoms of dry eye. An absorbable plug may be used temporarily to assess the effectiveness of this therapy prior to insertion of a longterm nonabsorbable plug (Freeman-type, Herrick Lacrimal Plug, or SmartPlug) or cautery. Indications and contraindications for use of punctal plugs are discussed, as are features of various plugs, techniques of insertion and removal, complications, and outcomes.