Evaluation of a novel treatment, selenium disulfide, in killing Demodex folliculorum in vitro

OBJECTIVE

To evaluate the effectiveness of varying concentrations of selenium sulfide, an active ingredient in antidandruff shampoo, in killing Demodex folliculorum.

METHODS

Sixty-five eyelashes with live Demodex from 29 patients seen at the Nassau University Medical Center (17 patients) and Ophthalmic Consultants of Long Island (12 patients) were observed under light microscopy for 90 minutes in 0.1%, 0.5%, 1.0%, and 4% selenium sulfide with either carboxymethyl cellulose (CMC) solution or petroleum jelly ointment (Vaseline, Unilever, London) as excipients. Positive and negative controls also were evaluated as separate solutions of CMC, petroleum jelly, basic saline solution, 50% tea tree oil, and 100% tea tree oil. The number of Demodex deaths and time of death were recorded.

RESULTS

Demodex deaths in the selenium sulfide reagents were observed in the 4% selenium sulfide solution with CMC (36.4% kill rate, 4 of 11 Demodex, average time of death 17.5 minutes, p = 0.038) and 4% selenium sulfide with petroleum jelly ointment (12.5% kill rate, 1 of 8 Demodex, time of death 75 minutes, p = 0.351). No Demodex deaths were witnessed in the other selenium sulfide treatment groups. All Demodex died in the 50% and 100% tea tree oil positive control group.

CONCLUSIONS

Selenium sulfide has shown efficacy in killing Demodex at a 4% concentration with the CMC solution and mild activity with 4% petroleum jelly. More research on selenium sulfide solutions at higher concentrations is indicated.

Randomized Prospective Evaluation of Microblepharoexfoliation BlephEx as Adjunctive Therapy in the Treatment of Chalazia

PURPOSE

Chalazia are benign eyelid lesions caused by the obstruction and inflammatory reaction of the meibomian glands. Demodex mites are one potential cause of chalazia leading to mechanical obstruction of the meibomian gland. In this prospective randomized study, we examine a novel approach to treating chalazia with the use of microblepharoexfoliation (MBE), an in-office lid hygiene technique that exfoliates the eyelid margins.

METHODS

Fifty patients with clinical evidence of acute chalazion were enrolled in this study. Subjects were randomly assigned to a MBE plus lid hygiene group (23 patients, mean age 66.6 ± 16.6 years) or a lid hygiene alone group (27 patients, mean age 62.1 ± 14.4). The MBE plus lid hygiene group received MBE treatment and were evaluated 1 month after the baseline visit. The main outcome measured was the resolution of the chalazion at the 1-month follow-up visit.

RESULTS

The lid hygiene plus MBE treatment group demonstrated a statistically significant resolution of the chalazion compared with the lid hygiene group alone ( P = 0.007; chi-square test). Among the MBE plus hygiene group, 87% of the patients had resolution of their chalazion as opposed to the lid hygiene alone group, which had 44% resolution.

CONCLUSIONS

This is the first prospective, randomized clinical trial that demonstrated efficacy of MBE as a noninvasive adjunctive treatment method for chalazion resolution.

Nocardia keratitis mimicking superior limbic keratoconjunctivitis and herpes simplex virus

Purpose

Nocardia keratitis is a rare type of infectious keratitis and may mimic other corneal diseases and lead to delay in diagnosis. This case illustrates how Nocardia often escapes accurate diagnosis due to its insidious onset, variable clinical manifestations, and unusual characteristics on cultures.

Observation

The patient presented with an epithelial defect and superior pannus and scarring, which was misdiagnosed as superior limbic keratoconjunctivitis (SLK) and herpes simplex virus (HSV) keratitis. Repeat corneal scraping cultures, smears, and conjunctival biopsy were necessary to elucidate the diagnosis. It can be effectively treated with the intravenous preparation of trimethoprim-sulfamethoxazole 80 mg/mL (brand name SEPTRA) used topically as eye drops.

Conclusion

The diagnosis of Nocardia keratitis relies on a high clinical suspicion and a prompt corneal scraping with culture. Due to its potential for rapid resolution with early therapy, it is important to isolate Nocardia early in its disease course.

Importance

Topical amikacin had been the standard of care for Nocardia keratitis for many years. However, recently there is increasing resistance of Nocardia to amikacin. SEPTRA offers an alternative therapy. Nocardia keratitis mimics other infectious and inflammatory etiologies so rapid diagnosis and treatment is critical in the prevention of long-term complications.

Influence of bacterial burden on meibomian gland dysfunction and ocular surface disease

Purpose

Bacterial burden on the eyelid margin and within meibomian glands was evaluated for influence on specific ocular surface disease (OSD) markers across the meibomian gland dysfunction (MGD) spectrum.

Methods

In this prospective, observational, single-center study, 40 patients were divided into 4 equal groups of 10 that encompassed increasingly worse MGD/OSD categories. All patients answered the standard Ocular Surface Disease Index questionnaire, and underwent tear osmolarity testing (TOT), Schirmer 1, matrix metalloproteinase 9 (MMP-9) testing, meibography, and lissamine green staining. Cultures of eyelid margins and meibomian gland secretions were directly plated on blood, chocolate, and Sabouraud agar; smears were sent for gram and Papinicolau evaluation.

Results

Mean patient age was 55.25±17.22 years; there were 10 males and 30 females. TOT and MMP-9 testing were similar across groups. Culture positivity was 62.5% for right eyes, 70% for left eyes, and was not statistically different across groups (for both eyelid margin and meibomian glands). The majority of cultures were positive for coagulase-negative staphylococcus (CNS).

Conclusion

This study is in concordance with others, citing the predominance of CNS within the biofilm of both “normal” and clinically significant MGD/OSD patients. Our study exemplifies that symptoms of OSD do not necessarily correlate with degree of clinical exam findings, nor culture positivity. These results argue that bacterial burden should be reconsidered as a direct risk factor and treatment target for MGD/OSD patients.

Differential Bacterial Colonization and Biofilm Formation on Punctal Occluders

Dry eye is a common condition that is treated primarily by topical lubricants, immunomodulation, and a variety of punctal and canalicular plugs (occluders). Biofilm formation has been reported as an ongoing problem with the clinical use of occluders. In order to explore the role of biofilm formation on occluders, we tested the bacteria strain, Staphylococcus aureus, with three different types of occluders, DeltaR, OdysseyR, and AlphamedR. Scanning electron microscopy (SEM) of these occluders revealed a variation in surface appearance, with OdysseyR being the smoothest (but with grooves), followed by DeltaR, and AlphamedR. Exposing each type of occluder to dynamically grown bacterial cultures of S. aureus, a ~3 fold statistically significant difference in bacteria colonization between the OdysseyR and AlphamedR occluder and a ~2 fold higher trend between OdysseyR and DeltaR were detected. These quantitative results were also verified with SEM, showing extensive S. aureus colonization and biofilm formation on the surface of the OdysseyR occluder. The results also indicate that bacterial colonization readily occurs on all three types of occluders. The occluder with the smoothest but grooved surface (OdysseyR), displayed increased biofilm formation when compared to those with rougher surfaces.

Late-Onset Microsporidial Keratitis in Femtosecond Astigmatic Keratotomy After Laser-Assisted Phacoemulsification

PURPOSE

To present a case of microsporidial keratitis in a femtosecond laser-created astigmatic keratotomy (AK) incision.

METHODS

Case report.

RESULTS

A 65-year-old Middle Eastern man presented 2 months after uncomplicated femtosecond laser-assisted cataract surgery (FLACS) and AK with mildly decreased vision and corneal edema in the operative eye. Shortly after treatment with topical corticosteroids, a fulminant corneal infiltrate manifested along the temporal arcuate incision. Multiple corneal scrapings sent for laboratory analysis were inconclusive. Two weeks after the initial presentation, a deep tissue sample was obtained using a 27-gauge cannula passed within the arcuate incision. The gram stain was directly observed, revealing intracellular microsporidial spores. The patient was treated with oral albendazole 400 mg once daily over 2 weeks and topical voriconazole 1% and fumagillin 3 mg/mL eye drops over 10 weeks. During this course, visual function steadily recovered as the infiltrate coalesced and ocular inflammation subsided.

CONCLUSIONS

This is the first reported case of microsporidial keratitis presenting as a late-onset infection after femtosecond laser-assisted AK.

Conjunctival Capillary Hemangioma

Conjunctival hemangioma over the age of 60 is rare, with few cases reported in the literature. We present a unique case of a conjunctival capillary hemangioma, adding to the sparse literature of this uncommon vascular tumor. Here, we present an interesting case of spontaneous development of this tumor at age 68, without associated systemic disease process or cutaneous manifestations.

Lifitegrast for the treatment of dry eye disease in adults

INTRODUCTION

Dry eye disease (DED) is a common ocular disorder that can have a substantial burden on quality of life and daily activities. Lifitegrast ophthalmic solution 5.0% is the first medication approved in the US for the treatment of the signs and symptoms of DED. The aim of this article is to summarize the preclinical and clinical data on lifitegrast and discuss how lifitegrast may fit into the current treatment landscape for DED. Areas covered: A literature search of published preclinical and clinical data was conducted to review the chemistry, pharmacodynamics, pharmacokinetics, and clinical efficacy/safety of lifitegrast. The impact that lifitegrast may have on DED treatment practices is also discussed. Expert opinion: The introduction of lifitegrast provides a potentially important additional option for eye care professionals treating DED. In clinical trials conducted in adults with DED, lifitegrast ophthalmic solution 5.0% improved both signs and symptoms of DED. Of note, in 2 phase 3 trials, symptom improvements were observed as early as 2 weeks, which may be explained by lifitegrast's unique mechanism of action of blocking a specific signaling pathway in inflammation. Future research should include evaluation of whether lifitegrast can be used in combination with other DED treatments.

DEBS - a unification theory for dry eye and blepharitis

For many years, blepharitis and dry eye disease have been thought to be two distinct diseases, and evaporative dry eye distinct from aqueous insufficiency. In this treatise, we propose a new way of looking at dry eye, both evaporative and insufficiency, as the natural sequelae of decades of chronic blepharitis. Dry eye is simply the late form and late manifestation of one disease, blepharitis. We suggest the use of a new term in describing this one chronic disease, namely dry eye blepharitis syndrome (DEBS). Bacteria colonize the lid margin within a structure known as a biofilm. The biofilm allows for population densities that initiate quorum-sensing gene activation. These newly activated gene products consist of inflammatory virulence factors, such as exotoxins, cytolytic toxins, and super-antigens, which are then present for the rest of the patient’s life. The biofilm never goes away; it only thickens with age, producing increasing quantities of bacterial virulence factors, and thus, increasing inflammation. These virulence factors are likely the culprits that first cause follicular inflammation, then meibomian gland dysfunction, aqueous insufficiency, and finally, after many decades, lid destruction. We suggest that there are four stages of DEBS which correlate with the clinical manifestations of folliculitis, meibomitis, lacrimalitis, and finally lid structure damage evidenced by entropion, ectropion, and floppy eyelid syndrome. When one fully understands the structure and location of the glands within the lid, it becomes easy to understand this staged disease process. The longer a gland can resist the relentless encroachment of the invading biofilm, the longer it can maintain normal function. The stages depend purely on anatomy and years of biofilm presence. Dry eye now becomes a very easy disease to understand. We feel that dry eye should be treated and prevented by early and routine biofilm removal through electromechanical lid margin debridement.

A multicenter randomized controlled fellow eye trial of pulse-dosed difluprednate 0.05% versus prednisolone acetate 1% in cataract surgery

PURPOSE

To compare the effects of 2 corticosteroids on corneal thickness and visual acuity after cataract surgery.

DESIGN

Multicenter, randomized, contralateral-eye, double-masked trial.

METHODS

Fifty-two patients (104 eyes) underwent bilateral phacoemulsification. The first eye randomly received difluprednate 0.05% or prednisolone acetate 1%; the fellow eye received the alternative. Before surgery, 7 doses were administered over 2 hours; 3 additional doses were given after surgery, before discharge. For the remainder of the day, corticosteroids were administered every 2 hours, then 4 times daily during week 1 and twice daily during week 2. Corneal pachymetry, visual acuity, and corneal edema were evaluated before surgery and at days 1, 15, and 30 after surgery. Endothelial cell counts were evaluated before surgery and at 30 days after surgery. Retinal thickness was evaluated before surgery and at 15 and 30 days after surgery.

RESULTS

Corneal thickness at day 1 was 33 μm less in difluprednate-treated eyes (P = .026). More eyes were without corneal edema in the difluprednate group than in the prednisolone group at day 1 (62% vs 38%, respectively; P = .019). Uncorrected and best-corrected visual acuity at day 1 were significantly better with difluprednate than prednisolone by 0.093 logMAR lines (P = .041) and 0.134 logMAR lines (P < .001), respectively. Endothelial cell density was 195.52 cells/mm(2) higher in difluprednate-treated eyes at day 30 (P < .001). Retinal thickness at day 15 was 7.74 μm less in difluprednate-treated eyes (P = .011).

CONCLUSIONS

In this high-dose pulsed-therapy regimen, difluprednate reduced inflammation more effectively than prednisolone acetate, resulting in more rapid return of vision. Difluprednate was superior at protecting the cornea and reducing macular thickening after cataract surgery.

Recurrent corneal ulceration in presence of synthetic microfibrils

Recurrence of microbial keratitis in the presence of protozoal infection is very rare and infrequently reported unless predisposing factors are present. The association of recurrent microbial keratitis and synthetic microfibrils has never previously been reported to our knowledge. This single interventional case study describes the clinical course and treatment of a contact lens wearer who was treated for Acanthamoeba keratitis with superinfection from bacterial organisms in the presence of synthetic microfibrils. The presence of synthetic fibrils on a corneal ulcer base may act as a nidus for pathological organisms and interfere with normal corneal healing. This may result in infection recurrence and the growth of resistant opportunistic organisms.

Correlating patient-reported response to hydroxypropyl cellulose ophthalmic insert (LACRISERT®) therapy with clinical outcomes: tools for predicting response

BACKGROUND/AIMS

To determine whether patient-reported improvement in symptoms of dry eye syndrome, activities of daily living, and other quality-of-life measures after treatment with hydroxypropyl cellulose ophthalmic inserts correlates significantly with physician assessment of clinical outcomes.

METHODS

Patient registry of those treated for 1 month with inserts as monotherapy or in combination with existing treatments for moderate-to-severe dry eye syndrome. A total of 520 participants were enrolled. Of those, 418 patients completed the study. Results of this registry were evaluated and correlations were calculated to determine whether patient-reported symptoms, quality of life, and changes in disease severity based on the Ocular Surface Disease Index, and activities of daily living outcomes are predictive of physician assessment of clinical signs, symptoms, and adherence to therapy.

RESULTS

Most patients reported overall improvement in their condition. Patient-reported improvements in the symptoms of dry eye syndrome and activities of daily living were significant predictors of physician assessment of compliance with insert therapy, improvement in symptoms and clinical signs, effectiveness of therapy, and acceptance of use as adjunctive therapy.

CONCLUSIONS

Patient-reported symptoms and activities of daily living are predictors of patient compliance and treatment success with the use of inserts, as reported by treating physicians. The benefits were additive to the standard of care that was continued during the course of the study. These predictors, along with clinical diagnostic tests, can be used by eye care professionals to assess the efficacy of treatment for moderate-to-severe dry eye syndrome quickly and reliably.

Hydroxypropyl cellulose ophthalmic inserts (lacrisert) reduce the signs and symptoms of dry eye syndrome and improve patient quality of life

PURPOSE

A multicenter, 2-visit, open-label, 4-week study was conducted to determine the acceptability of hydroxypropyl cellulose ophthalmic inserts in adult patients with a history of dry eye syndrome (DES).

METHODS

At visit 1, patients (N = 520) were evaluated, screened by slit-lamp biomicroscopy, and completed the Ocular Surface Disease Index (OSDI), a validated measure of quality of life. Patients were trained in the proper placement and use of hydroxypropyl cellulose ophthalmic inserts and were contacted by telephone on day 3 of the study. At week 4, patients were given a clinical evaluation and completed a second questionnaire. Answers determined changes in symptoms and quality of life. Adverse events were monitored throughout the study.

RESULTS

Four hundred eighteen patients completed the study and reported significant improvements in discomfort, burning, dryness, grittiness, stinging, and light sensitivity (P = .05) after 4 weeks use of hydroxypropyl cellulose ophthalmic inserts. Significant improvements in clinical signs (keratitis, conjunctival staining, and tear volume) were reported. Contact lens wearers reported significant improvements similar to nonwearers, with a strong trend toward improvement in light sensitivity. Mean OSDI total scores, measuring quality of life, significantly improved by 21.3% (from 41.8 +/- 22.38 to 32.9 +/- 21.97, P < or = .0215). The most commonly reported adverse event leading to discontinuation was blurred vision, observed in 8.7% of patients (n = 45). Compliance during the study was good; 41.5% of subjects were fully compliant. Of the 58.5% of subjects who missed doses, the majority (69.4%) missed only one to five.

CONCLUSIONS

Hydroxypropyl cellulose ophthalmic inserts significantly reduced symptoms and clinical signs of moderate to severe DES. They also significantly improved DES in patients wearing contact lenses. Patients experienced a statistically significant improvement in quality of life, as measured by the OSDI, of 21.3%.

Failed descemet-stripping automated endothelial keratoplasty grafts: a clinicopathologic analysis

PURPOSE

To describe the clinicopathologic findings in failed Descemet-stripping automated endothelial keratoplasty (DSAEK) grafts.

DESIGN

Retrospective, interventional case series.

METHODS

SETTING

New York Eye and Ear Infirmary.

STUDY POPULATION

Twenty-one patients with 22 failed DSAEK grafts treated between March 1, 2006 and February 1, 2008.

INTERVENTION

Repeat DSAEK or penetrating keratoplasty were performed in the eyes with failed grafts. All failed grafts were examined histopathologically.

MAIN OUTCOME MEASURES

Histopathologic parameters studied in failed DSAEK grafts included endothelial cell count, interface characteristics, retrocorneal membrane formation, inflammation, and immunoreactivity for herpes simplex virus type 1 (HSV-1) antigen.

RESULTS

DSAEK failure was strongly associated with postoperative lenticle dislocation. Graft failure was primary in 19 DSAEKs and secondary to rejection, eccentric trephination with epithelial ingrowth, or bacterial infection in the remaining 3. All failed grafts demonstrated endothelial hypocellularity and stromal edema. Additional findings included stromal inflammation (68%), interface fibrosis (50%), retrocorneal membrane (36%), unplanned retention of Descemet membrane (14%), immunoreactivity for HSV-1 (14%), paucicellular stroma (14%), and uneven trephination with epithelial ingrowth (5%).

CONCLUSIONS

Most DSAEK failures are secondary to endothelial cell loss. Other contributing factors include interface fibrosis, retrocorneal membrane formation, retained host Descemet membrane, uneven trephination, epithelial ingrowth, graft rejection, and infection.

Evaluation of topical cyclosporine for the treatment of dry eye disease

OBJECTIVE

To evaluate the use of topical cyclosporine, 0.05% (Restasis; Allergan Inc, Irvine, California), for the treatment of mild, moderate, and severe dry eye disease unresponsive to artificial tears therapy.

METHODS

This was a prospective clinical study. One hundred fifty-eight consecutive patients with dry eye disease unresponsive to artificial tears therapy were divided into 3 groups of disease severity: mild, moderate, and severe. Patients were evaluated using the Ocular Surface Disease Index for symptomatic improvement, tear breakup time, fluorescein staining, lissamine green staining, and Schirmer testing. Patients were observed for 3 to 16 months. The main outcome measure was improvement in disease.

RESULTS

Forty-six of 62 patients with mild dry eye disease (74.1%), 50 of 69 with moderate disease (72.4%), and 18 of 27 with severe disease (66.7%) showed improvement, with 72.1% improving overall.

CONCLUSIONS

Topical cyclosporine shows beneficial effects in all categories of dry eye disease. Symptomatic improvement was greatest in the mild group and the best results in improvement of disease signs were in patients with severe dry eye disease.

Dry eye disease: pathophysiology, classification, and diagnosis

Dry eye disease (DED) is a multifactorial disorder of the tear film and ocular surface that results in eye discomfort, visual disturbance, and often ocular surface damage. Although recent research has made progress in elucidating DED pathophysiology, currently there are no uniform diagnostic criteria. This article discusses the normal anatomy and physiology of the lacrimal functional unit and the tear film; the pathophysiology of DED; DED etiology, classification, and risk factors; and DED diagnosis, including symptom assessment and the roles of selected diagnostic tests.

High-frequency ultrasound of extranodal limbal Rosai-Dorfman disease: affecting the conjunctiva, sclera, and cornea

PURPOSE

To correlate the clinical, high-frequency ultrasound, and pathology characteristics of an epibulbar Rosai-Dorfman tumor.

METHODS

We report a case of a steroid-resistant yellow perilimbal epibulbar tumor referred for ophthalmic oncology evaluation. It was documented by slit-lamp photography and evaluated by high-frequency ultrasound. A hematology-oncology evaluation and excisional biopsy were performed.

RESULTS

Ophthalmic examination revealed a solitary yellow perilimbal epibulbar tumor. High-frequency ultrasound imaging revealed low internal reflectivity and partial-thickness scleral and corneal invasion with no extension into the anterior segment. Primary excision was performed. Although histopathology revealed large atypical histiocytes, immunochemistry found them to be both S-100 positive and CD1a negative (diagnostic of Rosai-Dorfman disease). Hematology-oncology evaluation revealed no systemic disease or links to human herpesvirus. Local control required cryotherapy and sub-Tenon steroid injection.

CONCLUSIONS

Epibulbar Rosai-Dorfman tumors can invade the sclera and are often treated by surgical excision. High-frequency ultrasound imaging should be used to determine the presence or extent of invasion before surgery.

Methicillin-resistant Staphylococcus aureus infectious keratitis following refractive surgery

PURPOSE

To elucidate risk factors, clinical course, visual outcomes, and treatment of culture-proven methicillin-resistant Staphylococcus aureus (MRSA) infectious keratitis following refractive surgery.

DESIGN

Interventional case series.

METHODS

Multicenter chart review of 13 cases of MRSA keratitis following refractive surgery and literature review.

RESULTS

Thirteen eyes of 12 patients, nine of whom were either healthcare workers or exposed to a hospital surgical setting, developed MRSA keratitis following refractive surgery. All patients presented with a decrease in visual acuity and complaints of pain or irritation in the affected eye. Common signs on slit-lamp biomicroscopy were corneal epithelial defects, focal infiltrates with surrounding edema, conjunctival injection, purulent discharge, and hypopyon. All patients were diagnosed with infectious keratitis on presentation and treated with two antibiotics. All eyes were culture-positive for MRSA.

CONCLUSIONS

According to a computerized MEDLINE literature search, this is the first case series of MRSA infectious keratitis following refractive surgery, the first reports of MRSA keratitis after refractive surgery in patients with no known exposure to a healthcare facility, the first report of MRSA keratitis after a laser in situ keratomileusis (LASIK) enhancement, and the first reports of MRSA keratitis after prophylaxis with fourth-generation fluoroquinolones. MRSA keratitis is a serious and increasing complication following refractive surgery. Patients with exposure to a healthcare environment should be considered at additional risk for developing MRSA keratitis. However, in addition, surgeons should now be vigilant for community-acquired MRSA. Prompt identification with culturing and appropriate treatment of MRSA keratitis after refractive surgery is important to improve visual rehabilitation.

Long-term Resolution of Chronic Dry Eye Symptoms and Signs after Topical Cyclosporine Treatment

PURPOSE

To report the resolution of symptoms and signs of chronic dry eye for at least 1 year after completion of a minimum 6-month course of topical 0.05% cyclosporine in a subgroup of patients from 2 practices.

DESIGN

Retrospective case series.

PARTICIPANTS

Eight patients who had had chronic dry eye disease for 3 to 20 years were treated with topical cyclosporine for 6 to 72 months, and then remained free of symptoms or signs of disease for at least 1 year (range, 16-29 months; mean, 21 months) after stopping treatment.

INTERVENTION

Treatment with topical 0.05% cyclosporine with or without topical corticosteroids twice a day along with nonpreserved artificial tears. Tests performed were patient history, slit-lamp examination, rose bengal and fluorescein staining of the ocular surface, tear breakup time, and Schirmer's test with anesthesia.

MAIN OUTCOME MEASURES

Resolution of all symptoms and signs of dry eye disease after a minimum 6-month course of topical 0.05% cyclosporine.

RESULTS

Eight patients, including approximately 4% of the total patients with chronic dry eye treated with 0.05% cyclosporine in one author's practice, were free of signs or symptoms of dry eye disease a minimum of 1 year after completing a 6- to 72-month course of therapy. There were no parameters noted that distinguished these patients from others who required maintenance topical cyclosporine or who did not appear to respond to topical cyclosporine.

CONCLUSIONS

Topical cyclosporine treatment appears to be associated with a cure of symptoms and signs in a subgroup of chronic dry eye patients. In such patients, presumably there is effective elimination of inflammatory processes underlying chronic dry eye disease. Such patients should be monitored long term because a return of disease may be noted. These results suggest that topical cyclosporine treatment halts progression of chronic dry eye in some patients.

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.

An update on the use of ophthalmic ketorolac tromethamine 0.4%

Ketorolac tromethamine 0.4% ophthalmic solution, a recent reformulation of the original ketorolac tromethamine 0.5% solution, is indicated for the reduction of ocular pain and burning/stinging following cataract and refractive surgery. Studies have demonstrated that ketorolac tromethamine 0.4% has equivalent efficacy to ketorolac tromethamine 0.5% in reducing postsurgical inflammation and controlling pain. Several studies have demonstrated that, as well as reducing pain and ocular inflammation, ketorolac tromethamine 0.4% effectively treats cystoid macular oedema, inhibits miosis and may prevent cystoid macular oedema when used both pre- and postoperatively. Ketorolac tromethamine 0.4% is a versatile agent and is effective when used as either monotherapy or as an adjunct therapy to steroids.

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.

Efficacy of Commercially Available Topical Cyclosporine A 0.05% in the Treatment of Meibomian Gland Dysfunction

OBJECTIVE

To investigate the efficacy of topical cyclosporine A 0.05% (tCsA) (Restasis, Allergan Pharmaceuticals) in the treatment of meibomian gland dysfunction (posterior blepharitis).

METHODS

Thirty-three patients with symptomatic meibomian gland dysfunction were randomized in a prospective study to either tCsA or placebo (Refresh Plus preservative-free artificial tears), 2 times daily for 3 months. They were evaluated at baseline and at 1, 2, and 3 months for subjective symptoms and objective signs including meibomian gland inclusions, lid margin vascular injection, tarsal telangiectasis, fluorescein staining, tear breakup time, and Schirmer scores.

RESULTS

Twenty-six patients completed the study. All patients were tested for ocular symptoms, lid margin vascularity, tarsal telangiectasis, meibomian gland inclusions, tear breakup time, and fluorescein staining. At the 3-month visit, the tCsA group showed a greater improvement in ocular symptoms than the placebo group, but this difference was not statistically significant. At the 3-month visit, several objective examination findings were statistically significantly (P < 0.05) improved in the tCsA group compared with the placebo group. These differences included lid margin vascular injection, tarsal telangiectasis, and fluorescein staining. The most significant finding (P = 0.001) was the greater decrease in the number of meibomian gland inclusions in the tCsA group compared with the placebo group.

CONCLUSIONS

Topical CsA may be helpful in the treatment of meibomian gland dysfunction (posterior blepharitis). Topical CsA did not induce an improvement in the symptoms, but it did decrease the number of meibomian gland inclusions in patients with meibomian gland dysfunction.

A Comparison of Gatifloxacin to Ciprofloxacin in the Prophylaxis of Streptococcus pneumoniae in Rabbits in a LASIK Model

PURPOSE

To investigate the efficacy of the fourth-generation fluoroquinolone, gatifloxacin 0.3%, compared to ciprofloxacin 0.3%, in preventing Streptococcus pneumoniae keratitis in a rabbit laser in situ keratomileusis (LASIK) model.

METHODS

Twelve albino rabbits had bilateral lamellar flaps created. Group A (eight eyes) was given gatifloxacin 0.3%; group B (eight eyes) was given ciprofloxacin 0.3%; and group C (eight eyes) served as the controls. Groups A and B received one drop of antibiotic 20 minutes before the creation of the lamellar flap, at the conclusion of flap formation, and four times per day for 3 days. All corneas were inoculated with 0.1 mL of 4 x 10 organisms/mL of S. pneumoniae immediately after flap formation. On day 3, all corneas were examined and cultured.

RESULTS

Group A (gatifloxacin) had no infiltrates and three areas of 1-mm central corneal haze. On day 3, one of eight corneas had a positive culture. Group B (ciprofloxacin) had seven infiltrates, including one perforation, and six of eight corneas had positive cultures. Group C (control) had eight corneal infiltrates, and all eight corneas had positive cultures. The data show a statistically significant difference between gatifloxacin and ciprofloxacin and gatifloxacin and control for mean infiltrate size and mean culture scores.

CONCLUSIONS

The fourth-generation fluoroquinolone, topical gatifloxacin 0.3%, is superior to topical ciprofloxacin 0.3% for prophylaxis against a clinical isolate of S. pneumoniae in a rabbit LASIK model.

Modified Intracorneal Ring Segment Implantations (INTACS) for the Management of Moderate to Advanced Keratoconus

PURPOSE

To evaluate the safety and efficacy of modified intracorneal ring segment implantation (INTACS) in the management of moderate and advanced keratoconus (KCN).

METHODS

A modified procedure of intracorneal ring segment (INTACS) implantation was performed in eyes with moderate to advanced keratoconus that were intolerant to contact lens or spectacle correction. The main outcome measures were uncorrected visual acuity (UCVA), best spectacle corrected visual acuity (BSCVA), refraction, and keratometry. The preoperative values were compared with the values 6 and 12 months postoperatively.

RESULTS

Implantation was performed on 20 eyes of 15 patients; 9 were female and 6 were male. The mean age was 30.2 years (SD +/- 5.44; range, 23-40). At the 6-month follow-up, UCVA improved from 20/154 (SD +/- 0.11) preoperatively to 20/28 (SD +/- 0.21) postoperatively (P < 0.05); BCSVA improved from 20/37 (SD +/- 0.21) preoperatively to 20/22 (SD +/- 0.13) postoperatively (P < 0.05). Spherical refractive error improved from -3.38 D (SD +/- 3.12) to -1.15 D (SD +/- 1.84); cylindrical refractive error improved from -3.75 (SD +/- 2.04) preoperatively to -1.21 (SD +/- 0.84) postoperatively (P < 0.05); average keratometry decreased from 49.50 D (SD +/- 1.64) preoperatively to 46.35 D (SD +/- 1.50) postoperatively. The changes remained stable to the 12-month follow-up. There was 1 case of anterior chamber perforation. There were 6 eyes that had ring exposure secondary to corneal thinning over the implants 3-6 months postoperatively, and a dense corneal infiltrate developed in 1 patient at 7 months postoperatively.

CONCLUSIONS

The procedure appears to be effective in improving UCVA and BSCVA of patients with clinical keratoconus. In our small study group, however, there were significant (6/20) postoperative problems with regards to thinning and ring exposure.

Post-LASIK corneal flap displacement following penetrating keratoplasty for bullous keratopathy

OBJECTIVE

To report 3 patients who experienced late flap dislocation after laser in situ keratomileusis (LASIK) in eyes that had undergone prior penetrating keratoplasty (PKP) for bullous keratopathy.

METHODS

Retrospective chart review of 2 referral corneal and refractive surgery practices, case reports, and literature review.

RESULTS

Three patients (mean age 58.3 years, 2 male, 1 female), all status post-corneal transplant for bullous keratopathy, had residual myopic astigmatism and underwent LASIK for correction of their significant anisometropia. Flap dislocation occurred at a mean of 7 days (range 3 to 14 days) following the LASIK procedure. All patients had peripheral corneal edema in their recipient bed. All 3 patients required an additional surgical procedure for visual rehabilitation.

CONCLUSION

Flap displacement may occur following LASIK in patients who have undergone PKP for bullous keratopathy. The endothelial pump function, which is vital to maintaining flap adherence, may be compromised in these patients. We suggest that patients with a history of PKP and endothelial compromise who undergo LASIK wear protective shields for a longer than normal period and be followed closely to reduce the risk of flap slippage.

Gaze-induced Desçemet's folds secondary to a primary pterygium

PURPOSE

To report a case of gaze-induced Desçemet's folds secondary to a primary pterygium.

METHODS

Interventional case report, chart review, and literature review.

RESULTS

Slitlamp examination of a 49-year-old man showed Desçemet's folds in the left eye on extreme right gaze secondary to the restrictive effect of a primary pterygium. The folds correlated with increasing astigmatism documented on corneal topography and restricted ocular motility and diplopia on attempted adduction.

CONCLUSIONS

To the authors' knowledge, this is the first reported case of folds induced in Desçemet's membrane secondary to the tethering effect of a primary pterygium.

Childhood Onset of Pterygia in Twins

PURPOSE

To report a case of childhood onset of pterygia in twins.

METHODS

Twelve-year-old male twins had nasal lesions on the left eye of twin A and on the right eye of twin B. Both lesions were excised with superior conjunctival autograft.

RESULTS

Histopathologic examination showed the lesions to be pterygia. Other pedigrees of familial pterygia have been described. However, to the authors' knowledge, this young age at onset has not been documented with histopathology in twins.

CONCLUSIONS

This case report documents the youngest age at onset of pterygia in twins, with histologic confirmation. It suggests a genetic or developmental cause for pterygium formation.

The impact of topical cyclosporine A emulsion 0.05% on the outcomes of patients with keratoconjunctivitis sicca

OBJECTIVE

To assess patients' experiences with topical cyclosporine A (tCSA) 0.05% ophthalmic emulsion (Restasis) to treat keratoconjunctivitis sicca (KCS) in a real-world setting.

METHODS

A total of 4504 ophthalmologists, optometrists and primary care physicians from throughout the United States participated in the study. Individual physicians identified patients from their practice who were appropriate candidates for treatment with tCSA and provided them with free sample medication and study materials. Patients voluntarily enrolled in the program by following the instructions provided in the study materials. Data for this study were obtained from patient surveys that included questions related to patients' experiences using topical cyclosporine A 0.05% ophthalmic emulsion (tCSA). Using automated surveys at baseline, 30-days and 60-days post-medication initiation, patients rated symptom severity, symptom impact on daily activities, and use of artificial tears pre- and post-treatment with study medication. Participants also reported on the rapidity of symptom relief and satisfaction with tCSA.

RESULTS

A total of 5884 patients completed the study. The vast majority (84%) was female; average age was 63 years. Patients who completed the study (n = 5884) achieved significant reductions (p < 0.001) of 30% in symptom severity and 31%-36% in activity impairments relative to baseline. A positive association (p < 0.001) was observed between number of years with dry eye and the average ratings for symptom severity and impact on everyday activities. Onset of relief was noted within 1 week by 32% of patients and within 3 weeks by 73%. More than 60% reported decreased use of artificial tears at both 30 days and 60 days post-treatment initiation.

CONCLUSIONS

Results suggest that in a real-world setting tCSA is an effective treatment for patients suffering from KCS. Onset of relief may be more rapid than in previously published reports.

Slitlamp biomicroscopy of the tear film of patients using topical Restasis and Refresh Endura

We describe a technique in which slitlamp biomicroscopy is performed to evaluate eyes in patients using a topical dry-eye agent; ie, topical cyclosporine A ophthalmic emulsion 0.05% (Restasis) or glycerin 1%-polysorbate 80 1% (Refresh Endura). Both are delivered in an oil-emulsion formulation. We also describe a previously unreported physical finding in the tear film of these patients. The examination technique can help confirm patient compliance and the tear-film stability of the 2 agents.

Penetration of topically applied gatifloxacin 0.3%, moxifloxacin 0.5%, and ciprofloxacin 0.3% into the aqueous humor

PURPOSE

To investigate the aqueous penetration of 3 commercially available ophthalmic fluoroquinolones.

DESIGN

Prospective, double-masked, clinical study.

PARTICIPANTS

Fifty-two eyes of 52 patients.

INTERVENTION

Fifty-two patients undergoing cataract surgery were given preoperative topical gatifloxacin 0.3% (Zymar), moxifloxacin 0.5% (Vigamox), or ciprofloxacin 0.3% (Ciloxan). The patients were instructed to use their antibiotic drops 4 times a day for 3 days before surgery. On the day of surgery, patients were given their assigned antibiotic every 15 minutes for 3 doses, 1 hour before their procedure. At the time of surgery, 0.1 ml of aqueous fluid was aspirated from the anterior chamber with an air cannula needle attached to a tuberculin syringe. The aspirate was immediately stored at -70 degrees C.

MAIN OUTCOME MEASURE

Fluoroquinolone concentrations were determined by reverse-phase high-pressure liquid chromatography assay technique with ultraviolet detection at a wavelength of 275 nm.

RESULTS

Mean aqueous concentration of gatifloxacin in 16 eyes was 0.63 microg/ml (standard deviation [SD], 0.30), moxifloxacin in 14 eyes was 1.31 microg/ml (SD, 0.46), and the mean concentration of ciprofloxacin in 22 eyes was 0.15 microg/ml (SD, 0.11).

CONCLUSIONS

Both moxifloxacin (P<0.001) and gatifloxacin (P<0.005) penetrated the aqueous humor at significantly higher levels than ciprofloxacin. Moxifloxacin penetrated into the aqueous humor at significantly higher levels than gatifloxacin (P<0.05). The anterior chamber levels of moxifloxacin and gatifloxacin may be due to the difference in antibiotic concentration.

Topical 0.05% cyclosporin in the treatment of dry eye

Dry eye disease is a common and often underdiagnosed condition that affects > 10% of the adult population, > 65 years of age in the US. This condition has been classified into two separate, but overlapping, categories--aqueous deficiency and evaporative loss. Diagnosis is confused by the lack of a single diagnostic test. Fluorescein break-up time is one of the best screening tests and is augmented by Lissamine green supravital staining. New concepts of pathogenesis have shown that dry eye disease appears to be caused by inflammation mediated by T-cell lymphocytes. This finding led to the study and FDA-approval of topical 0.05% cyclosporin A (Restasis) for the treatment of dry eye disease. 0.05% Cyclosporin A offers the first therapeutic treatment for patients with moderate-to-severe dry eye disease due to aqueous deficiency.

A comparison of the fourth-generation fluoroquinolones gatifloxacin 0.3% and moxifloxacin 0.5% in terms of ocular tolerability

PURPOSE

To compare the ocular tolerability of the commercially available ophthalmic solutions of the fourth-generation fluoroquinolones, gatifloxacin 0.3% (Zymar, Allergan, Inc., Irvine, CA) with benzalkonium chloride (BAK) and moxifloxacin 0.5% (Vigamox) without BAK.

METHODS

A baseline evaluation was conducted on 30 healthy volunteers for conjunctival hyperemia, conjunctival vascularity, pupil size, and anterior chamber (AC) cell and flare. Pupils were measured under scotopic conditions with a Colvard pupillometer. Conjunctival hyperemia and vascularity, and AC reaction were measured on a Likert-like scale of 0-3. Subjects then received drops in both eyes from masked bottles of gatifloxacin ophthalmic solution 0.3% with BAK (in one eye determined randomly) and moxifloxacin ophthalmic solution 0.5% without BAK (in the contralateral eye) in a double-masked fashion. Subjects graded pain and ocular irritation in each eye on a scale of 1-10 after 5 min with their eyes closed. The examination was then repeated.

RESULTS

The average age of this study population was 34.4 years. The groups of eyes receiving moxifloxacin 0.5% demonstrated an increase in mean conjunctival hyperemia (0.21 [range: 0-1] at baseline to 1.52 [range: 0-3] at 5 min.) that was significantly greater (p = 0.0005) compared with that of the group receiving gatifloxacin 0.3% (0.22 [range: 0-1] at baseline to 0.45 [range: 0-2] at 5 min). The group receiving moxifloxacin 0.5% showed an increase in conjunctival vascularity (0.55 [range: 0-1] at baseline to 1.61 [range: 0.5-3] at 5 min.) that was significantly greater (p = 0.0005) compared with that of the group receiving gatifloxacin 0.3% (0.52 [range: 0-1] at baseline to 0.68 [range: 0-2] at 5 min.). Significantly less pain (1.2 vs. 3.2, p = 0.001) and irritation (0.64 vs. 3.42, p = 0.001) occurred with gatifloxacin 0.3% than with moxifloxacin 0.5%. Pupil size was significantly reduced (5.65 mm-5.05 mm) in eyes receiving moxifloxacin 0.5% (p = 0.004) and no significant change occurred in pupil size (5.60 mm-5.65 mm) in eyes that received gatifloxacin 0.3% (p = 0.878). No AC reaction was noted with either medication.

CONCLUSIONS

The group of eyes receiving gatifloxacin 0.3% with BAK demonstrated greater ocular tolerability in comparison to the group receiving moxifloxacin 0.5% without BAK. Moxifloxacin-induced pupillary miosis may be due to prostaglandin release in the anterior chamber. A limitation of this study is the relatively young age of the study population.

NIR laser tissue welding of in vitro porcine cornea and sclera tissue

BACKGROUND AND OBJECTIVE

The objective of this study was to test the hypothesis that an near infrared (NIR) laser system (1,455 nm) in combination with a motorized translational stage to control the position and speed of the laser beam and a shutter to control the laser exposure to the tissue being welded could be used to successfully weld ocular tissues.

STUDY DESIGN/MATERIALS AND METHODS

Seventy-five porcine corneas and 23 porcine scleral tissues were welded in vitro in this study. The welded tissues were examined using histopathology and tensile strength analysis. Eight different welding conditions were analyzed for porcine cornea and one for sclera tissues. The tensile strength of the welded groups was compared to a sutured cornea control group.

RESULTS

The NIR laser welding system provides strong, full thickness welds and does not require the use of extrinsic dyes, chromophores, or solders. Mean weld strengths of 0.15-0.45 kg/cm(2) were obtained for the cornea and 1.01 kg/cm(2) for sclera welds. The native H(2)O in the ocular tissue serves as an absorber of the 1,455 nm radiation and helps to induce the welds.

CONCLUSIONS

We conclude that an NIR laser system using an optimal laser radiation wavelength of 1,455 nm can effectively weld cornea and sclera tissue and that this laser tissue welding (LTW) methodology typically causes minimal disruption of tissue, and thus, avoids opacities and irregularities in the tissue which may result in decreased visual acuity. The optimization of a laser welding system that leads to a strong full thickness tissue bond without tissue destruction, an instant seal that promotes wound healing, and the absence of a continued presence of a foreign substance like a suture, is of considerable importance to the ophthalmology medical community. This need is especially apparent with respect to corneal transplantation and fixing the position of corneal flaps in Laser-Assisted In Situ Keratomileusis (LASIK), a laser procedure used to permanently change the shape of the cornea.

Prevention of Recurrent Reis-B??cklers Dystrophy Following Excimer Laser Phototherapeutic Keratectomy With Topical Mitomycin C

PURPOSE

To report a case of excimer laser phototherapeutic keratectomy (PTK) for Reis-Bücklers dystrophy with a single intraoperative application of adjunctive topical 0.02% mitomycin C (MMC).

METHODS

Interventional case report and review of the literature.

RESULTS

A 73-year-old woman with visually significant Reis-Bücklers dystrophy underwent PTK of her right eye with 0.02% adjunctive MMC for visual rehabilitation. Before treatment, best corrected visual acuity (BCVA) was 20/400. The left eye had previously undergone PTK on 2 occasions without MMC, and the dystrophy had recurred following each treatment. One year after the procedure, her MMC-treated cornea remains clear with no recurrence of Reis-Bücklers dystrophy.

CONCLUSIONS

The use of topical MMC in conjunction with PTK may be a safe and effective treatment of Reis-Bücklers dystrophy and may be helpful in preventing recurrence of the disease.

Candida parapsilosis keratitis following treatment of epithelial ingrowth after laser in situ keratomileusis

PURPOSE

To present a case of Candida parapsilosis following laser in situ keratomileusis (LASIK).

METHODS

Retrospective chart review.

RESULTS

A case report of a 51-year-old woman who underwent bilateral LASIK is presented. Two weeks after the procedure, the patient presented with epithelial ingrowth OD. The ingrowth was treated with flap lifting and scraping, followed by postoperative antibiotics. Four weeks later, the patient presented with numerous interface infiltrates. Smears were positive for yeast forms and cultures grew Candida parapsilosis. Administration of topical and systemic antifungal therapy resulted in clearing of the infection with partial visual recovery.

CONCLUSIONS

To our knowledge, this represents the first reported case of a post-LASIK Candida parapsilosis keratitis. A high degree of suspicion coupled with rapid and appropriate treatment can result in visual recovery.

Dry eye diagnosis and management in 2004

PURPOSE OF REVIEW

To document the changes in treatment paradigm for the management of dry eye. Restasis is 0.05% cyclosporine A and is the first immunomodulatory agent approved for treatment of dry eye.

RECENT FINDINGS

Mounting evidence supports the inflammatory mechanism as explanation for the occurrence of dry eye disease. Immunomodulation has been shown to be effective in treating patients with moderate to severe dry eye disease caused by keratoconjunctivitis sicca. This addresses one of the two main forms of dry eye. There is a new report that immunomodulation using topical 0.05% cyclosporine A (Restasis) may also have a positive effect on meibomian gland dysfunction, the other main form of dry eye.

SUMMARY

Dry eye disease is defined as an abnormality of tear film resulting in changes in the ocular surface. These changes may be seen on ocular examination with the use of fluorescein and supravital staining techniques. Classification of dry eye disease shows two main types: aqueous deficiency and evaporative loss. There is hope that both of these types of dry eye will respond to immunomodulation therapy. Restasis shows promise as the first of these agents to be approved as therapy to treat moderate to severe dry eye disease.