Neurotrophic keratopathy: An updated understanding

PURPOSE

To propose an updated definition and staging system for neurotrophic keratopathy (NK) and provide consensus on diagnosis and treatment.

METHODS

A study group was convened to review the data pertinent to NK using a modified nominal group process. They proposed an updated definition for NK and a new 6-step staging system (Neurotrophic Keratopathy Study Group [NKSG] Classification) that can be used in conjunction with the different treatment options available currently or in the future.

RESULTS

NK is defined as the dysfunction of corneal innervation that results in dysregulation of corneal and/or cellular function. It is characterized by loss of corneal sensation and neuronal homeostasis, leading to eventual corneal epithelial breakdown and ultimately keratolysis if untreated. The NKSG classification emphasizes verifying corneal sensation early and distinguishes different epithelial and stromal aspects of NK with the following stages: stage 1 (altered sensation without keratopathy), stage 2 (epitheliopathy/punctate epithelial keratopathy [PEK] without stromal haze), stage 3 (persistent/recurrent epithelial defects without stromal haze), stage 4 (epitheliopathy/PEK or persistent/recurrent epithelial defects with stromal haze), stage 5 (persistent/recurrent epithelial defect with corneal ulceration), and stage 6 (corneal perforation). Treatment consists of a variety of modalities (both indirect and direct).

CONCLUSIONS

This updated definition and staging system will provide clinicians with the necessary information to diagnose and treat NK at an early stage before it becomes a sight-threatening disorder. It also provides a framework for evaluating current and future treatment options at distinct stages of the disease.

The corneal endothelium: clinical review of endothelial cell health and function

The endothelial cell is a critical structure within the cornea and is responsible for maintaining corneal clarity through its pump function. Endothelial cells are lost over time naturally but can be injured medically, surgically, or as a part of various dystrophies. Monitoring of endothelial cells can be performed clinically or more formally with specular microscopy. In cases of significant compromise, endothelial cells can be transplanted by various endothelial keratoplasty techniques. The future pipeline is bright for possible endothelial cell regeneration and rehabilitation. This article reviews these topics in depth to provide a comprehensive look at the structure and function of the endothelial cell, etiologies of endothelial cell damage, detailed review of iatrogenic causes of endothelial cell loss, and management strategies.

Donor, Recipient, and Operative Factors Associated With Increased Endothelial Cell Loss in the Cornea Preservation Time Study

Importance

Determining factors associated with endothelial cell loss after Descemet stripping automated endothelial keratoplasty (DSAEK) could improve long-term graft survival.

Objective

To evaluate the associations of donor, recipient, and operative factors with endothelial cell density (ECD) 3 years after DSAEK in the Cornea Preservation Time Study.

Design, Setting, and Participants

This cohort study was a secondary analysis of data collected in a multicenter, double-masked, randomized clinical trial. Forty US clinical sites with 70 surgeons participated, with donor corneas provided by 23 US eye banks. Individuals undergoing DSAEK for Fuchs dystrophy or pseudophakic/aphakic corneal edema were included.

Interventions

The DSAEK procedure, with random assignment of a donor cornea with a preservation time of 0 to 7 days or 8 to 14 days.

Main Outcomes and Measures

Endothelial cell density at 3 years as determined by a reading center from eye bank and clinical specular or confocal central endothelial images.

Results

The study included 1090 participants (median age, 70 years) with 1330 affected eyes (240 bilateral cases [22.0%]), who underwent DSAEK for Fuchs dystrophy (1255 eyes [94.4%]) or pseudophakic/aphakic corneal edema (PACE) (75 eyes [5.6%]). Of these, 801 eyes (60.2%) belonged to women and 1207 (90.8%) to white individuals. A total of 749 participants (913 eyes; 164 [21.9%] bilateral cases) had functioning grafts with acceptable endothelial images preoperatively and at 3 years postoperatively and were included in this analysis. Factors associated with a lower ECD at 3 years (estimated effect with 99% CI) in the final multivariable model included donors with diabetes (-103 [-196 to -9] cells/mm2), lower screening ECD (-234 [-331 to -137] per 500 cells/mm2), recipient diagnosis of PACE (-257 [-483 to -31] in cells/mm2), and operative complications (-324 [-516 to -133] in cells/mm2). Endothelial cell loss (ECL) from a preoperative measurement to a 3-year postoperative measurement was 47% (99% CI, 42%-52%) for participants receiving tissue from donors with diabetes vs 43% (99% CI, 39%-48%) without diabetes; it was 53% (99% CI, 44%-62%) for participants diagnosed with PACE vs 44% (99% CI, 39%-49%) for those diagnosed with Fuchs dystrophy, and 55% (99% CI, 48%-63%) in participants who experienced operative complications vs 44% (99% CI, 39%-48%) in those who did not. No other donor, recipient, or operative factors were significantly associated with 3-year ECD.

Conclusions and Relevance

Donor diabetes, lower screening ECD, a PACE diagnosis in the recipient, and operative complications were associated with lower ECD at 3 years after DSAEK surgery and may be associated with long-term graft success. While causation cannot be inferred, further studies on the association of donor diabetes and PACE in recipients with lower 3-year ECD warrant further study.

Ciliary body metastasis from renal cell carcinoma successfully treated with intravitreal bevacizumab

Purpose

To report an innovative new treatment option for ciliary body tumor metastasis from renal cell carcinoma treated with intravitreal bevacizumab.

Observations

A 70-year-old Caucasian man presented with a ciliary body tumor as a result from metastasis from renal cell carcinoma. It was preferable to treat the ciliary body tumor in the least invasive manner possible based on the patient's health, systemic metastasis, and the invasiveness of local resection. The tumor was treated with intravitreal bevacizumab for attempted tumor regression. Complete tumor resolution occurred following three injections.

Conclusions and importance

There is no consensus on treatment for ciliary body metastases from renal cell carcinoma. Based on the successful result of our patient, intravitreal bevacizumab could be an acceptable treatment option for this type of intraocular tumor. It affords a relatively non-invasive method of tumor regression without undergoing major intraocular surgery.

Descemet Membrane Endothelial Keratoplasty: Safety and Outcomes: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature on the safety and outcomes of Descemet membrane endothelial keratoplasty (DMEK) for the surgical treatment of corneal endothelial dysfunction.

METHODS

Literature searches were last conducted in the PubMed and the Cochrane Library databases most recently in May 2017. The searches, which were limited to English-language abstracts, yielded 1085 articles. The panel reviewed the abstracts, and 47 were determined to be relevant to this assessment.

RESULTS

After DMEK surgery, the mean best-corrected visual acuity (BCVA) ranged from 20/21 to 20/31, with follow-up ranging from 5.7 to 68 months. At 6 months, 37.6% to 85% of eyes achieved BCVA of 20/25 or better and 17% to 67% achieved BCVA of 20/20 or better. Mean endothelial cell (EC) loss was 33% (range, 25%-47%) at 6 months. Overall change in spherical equivalent was +0.43 diopters (D; range, -1.17 to +1.2 D), with minimal induced astigmatism of +0.03 D (range, -0.03 to +1.11 D). The most common complication was partial graft detachment requiring air injection (mean, 28.8%; range, 0.2%-76%). Intraocular pressure elevation was the second most common complication (range, 0%-22%) after DMEK, followed by primary graft failure (mean, 1.7%; range, 0%-12.5%), secondary graft failure (mean, 2.2%; range, 0%-6.3%), and immune rejection (mean, 1.9%; range, 0%-5.9%). Overall graft survival rates after DMEK ranged from 92% to 100% at last follow-up. Best-corrected visual acuity after Descemet's stripping endothelial keratoplasty (DSEK) ranged from 20/34 to 20/66 at 9 months. The most common complications after DSEK were graft detachment (mean, 14%; range, 0%-82%), endothelial rejection (mean, 10%; range, 0%-45%), and primary graft failure (mean, 5%; range, 0%-29%). Mean EC loss after DSEK was 37% at 6 months.

CONCLUSIONS

The evidence reviewed supports DMEK as a safe and effective treatment for endothelial failure. With respect to visual recovery time, visual outcomes, and rejection rates, DMEK seems to be superior to DSEK and to induce less refractive error with similar surgical risks and EC loss compared with DSEK. The rate of air injection and repeat keratoplasty were similar in DMEK and DSEK after the learning curve for DMEK.

Safety and Efficacy of Lacrimal Drainage System Plugs for Dry Eye Syndrome: A Report by the American Academy of Ophthalmology

OBJECTIVE

To review the published literature assessing the efficacy and safety of lacrimal drainage system plug insertion for dry eye in adults.

METHODS

Literature searches of the PubMed and Cochrane Library databases were last conducted on March 9, 2015, without date restrictions and were limited to English language abstracts. The searches retrieved 309 unique citations. The primary authors reviewed the titles and abstracts. Inclusion criteria specified reports that provided original data on plugs for the treatment of dry eyes in at least 25 patients. Fifty-three studies of potential relevance were assigned to full-text review. The 27 studies that met the inclusion criteria underwent data abstraction by the panels. Abstracted data included study characteristics, patient characteristics, plug type, insertion technique, treatment response, and safety information. All studies were observational and rated by a methodologist as level II or III evidence.

RESULTS

The plugs included punctal, intracanalicular, and dissolving types. Fifteen studies reported metrics of improvement in dry eye symptoms, ocular-surface status, artificial tear use, contact lens comfort, and tear break-up time. Twenty-five studies included safety data. Plug placement resulted in ≥50% improvement of symptoms, improvement in ocular-surface health, reduction in artificial tear use, and improved contact lens comfort in patients with dry eye. Serious complications from plugs were infrequent. Plug loss was the most commonly reported problem with punctal plugs, occurring on average in 40% of patients. Overall, among all plug types, approximately 9% of patients experienced epiphora and 10% required removal because of irritation from the plugs. Canaliculitis was the most commonly reported problem for intracanalicular plugs and occurred in approximately 8% of patients. Other complications were reported in less than 4% of patients on average and included tearing, discomfort, pyogenic granuloma, and dacryocystitis.

CONCLUSIONS

On the basis of level II and III evidence in these studies, plugs improve the signs and symptoms of moderate dry eye that are not improved with topical lubrication, and they are well tolerated. There are no level I studies that describe the efficacy or safety of lacrimal drainage system plugs.

Boston Keratoprosthesis: Outcomes and Complications: A Report by the American Academy of Ophthalmology

OBJECTIVE

To review the published literature on safety and outcomes of the Boston type I keratoprosthesis (BI-KPro) for the surgical treatment of corneal opacification not amenable to human cadaveric corneal transplantation.

METHODS

Searches of peer-reviewed literature were conducted in PubMed and the Cochrane Library in December 2012, July 2013, and January 2014 without date restrictions. The searches were limited to studies published in English and yielded 587 citations. The abstracts of these articles were reviewed, 48 articles were selected for possible clinical relevance, and 22 were determined to be relevant for the assessment objectives. Nine studies were rated as level II evidence and 13 studies were rated as level III evidence. Excluded were level III evidence, case reports, review articles, letters, editorials, and case series with fewer than 25 eyes.

RESULTS

In 9 articles, a best-corrected Snellen visual acuity (BCSVA) of 20/200 or better occurred in 45% to 89% of eyes. Five articles described a BCSVA of 20/50 or better in 43% to 69% of eyes, and 4 articles found a BCSVA of 20/40 or better in 11% to 39% of eyes. Retention rates of the BI-KPro ranged from 65% to 100%. Reasons for loss of vision after BI-KPro implantation most commonly included corneal melts resulting from exposure keratopathy, endophthalmitis, and infectious keratitis or corneal ulceration. The 2 most common complications after surgery were retroprosthetic membrane formation (range, 1.0%-65.0%; mean ± standard deviation [SD], 30.0±19.0%) and elevated intraocular pressure (range, 2.4%-64.0%; mean ± SD, 27.5±18.1%). The 2 most common posterior segment complications were endophthalmitis (range, 0%-12.5%; mean ± SD, 4.6±4.6%) and vitritis (range, 0%-14.5%; mean ± SD, 5.6±4.7%).

CONCLUSIONS

The reviewed articles on BI-KPro use suggest that the device improves vision in cases of severe corneal opacification that were not amenable to corneal transplantation using human cadaveric keratoplasty techniques. A number of severe anterior and posterior segment complications can develop as follow-up continues, making ongoing close observation paramount for patients undergoing this surgery. These complications include infection, device extrusion, and permanent vision loss.

Mammography test sets: reading location and prior images do not affect group performance

AIM

To examine how the location where reading takes place and the availability of prior images can affect performance in breast test-set reading.

MATERIALS AND METHODS

Under optimized viewing conditions, 10 expert screen readers each interpreted a reader-specific set of images containing 200 mammographic cases. Readers, randomly divided into two groups read images under one of two pairs of conditions: clinical read with prior images and laboratory read with prior images; laboratory read with prior images and laboratory read without prior images. Region-of-interest (ROI) figure-of-merit (FOM) was analysed using JAFROC software. Breast side-specific sensitivity and specificity were tested using Wilcoxon matched-pairs signed rank tests. Agreement between pairs of readings was measured using Kendall's coefficient of concordance.

RESULTS

Group performances between test-set readings demonstrated similar ROI FOMs, sensitivity and specificity median values, and acceptable levels of agreement between pairs of readings were shown (W = 0.75-0.79, p < 0.001) for both pairs of reading conditions. On an individual reader level, two readers demonstrated significant decreases (p < 0.05) in ROI FOMs when prior images were unavailable. Reading location had an inconsistent impact on individual performance.

CONCLUSION

Reading location and availability of prior images did not significantly alter group performance.

Visual outcome after Descemet's stripping automated endothelial keratoplasty in an 8-month-old with congenital hereditary endothelial dystrophy

Descemet's stripping automated endothelial keratoplasty (DSAEK) has rapidly become the standard of care for endothelial dysfunction of the cornea in adults. There are few reports of DSAEK in children and infants, mainly because most pediatric corneal opacities are full-thickness and therefore not amenable to lamellar procedures but also because of the unique difficulties of performing this procedure in the youngest patients. We report the case of an 8-month-old girl who underwent DSAEK for congenital hereditary endothelial dystrophy. At 24 months' follow-up, her visual acuity was 20/40 in the operated eye. To our knowledge, this is the first report of an objective visual outcome in a child with DSAEK performed in infancy.

[Recovery from parkinsonism with N-acetylcysteine-differentiated neurons]

The upregulation of dopaminergic neuronal differentiation is necessary for stem cell therapy in Parkinson's disease (PD). In this study, neuronal differentiation efficiency increased by more than 2 times in P19 embryonic stem cells (ESCs) induced by N-acetylcysteine (NAC) and retinoic acid (RA) as compared to RA alone, with suppressed glial differentiation. The majority of NAC-treated stem cells grafted into brains of PD mice differentiated into dopaminergic neurons and persisted well for 6 weeks. Parkinsonism was also greatly improved after grafting NAC-treated cells in comparison to cells treated with only RA. Our results strongly suggest that NAC treatment may be an effective strategy for generating stem cells fated to become dopaminergic neurons for PD clinical therapy.

Relationship Between Fuchs Endothelial Corneal Dystrophy Severity and Glaucoma and/or Ocular Hypertension

OBJECTIVE To investigate whether Fuchs endothelial corneal dystrophy (FECD) severity is associated with glaucoma and/or ocular hypertension (G/OHTN). METHODS A subset of eyes (n = 1610) from the FECD Genetics Multi-Center Study were examined to estimate the association between FECD severity (grades 0-6 based on guttae confluence) and G/OHTN. Logistic regression models that accounted for the correlation between eyes and adjusted for age, sex, central corneal thickness, intraocular pressure, presence of diabetes, and time of day of the initial evaluation were fit. RESULTS A total of 107 eyes (6.6%) had G/OHTN based on the study definition. The prevalence of G/OHTN in the control group was 6.0%. The prevalence was lower in index cases with an FECD grade of 1 through 3 and family members with a grade of 0 or 1 through 3 (0.0% and 2.1%, respectively) but higher in index cases and family members with a grade of 4 through 6 (11.2% and 8.5%, respectively). Adjusting for covariates, eyes with a grade of 4 through 6 were more likely to have concurrent G/OHTN than eyes with no FECD (index cases vs controls: odds ratio [OR] = 2.10, P = .04; affected vs unaffected family members: OR = 7.06, P = .07). Age (OR = 1.06 per 1-year increase, P &lt; .001) and intraocular pressure (OR = 1.15 per 1-mm Hg increase, P &lt; .001) were also associated with an increased prevalence of G/OHTN. Sex, diabetes, time of day of evaluation, and central corneal thickness were not associated with the prevalence of G/OHTN (P ≥ .15). CONCLUSIONS Glaucoma and/or ocular hypertension occurs more often in eyes with severe FECD compared with unaffected eyes. Therefore, it may be beneficial to monitor for the development of glaucoma in these patients.

Cystic benign melanosis of the conjunctiva

PURPOSE

To report the clinical and histologic features of cystic benign melanosis.

METHODS

This case series reports on the clinical and histopathologic features of 3 patients with enlarging, cystic, brown, pigmented, conjunctival lesions.

RESULTS

Slit-lamp examination showed cystic melanotic lesions of bulbar conjunctiva. Histopathologic examination of the biopsy specimens showed epithelial lined cysts in the substantia propria, goblet cells, and secondary pigmentation of basilar keratinocytes.

CONCLUSIONS

Cystic benign melanosis, a unique conjunctival lesion, should be differentiated from cystic nevus and primary acquired melanosis.

N-acetylcysteine enhances neuronal differentiation of P19 embryonic stem cells via Akt and N-cadherin activation

We examined whether N-acetylcysteine (NAC) enhanced embryonic body (EB) formation and neuronal differentiation in terms of EB formation, neuronal marker (microtubule-associated protein 2; MAP-2) expression, and neuron maturation using P19 embryonic stem cells. The size and numbers of EBs were greatly increased, together with the up-regulated N-cadherin expression. Also, MAP-2 expression and neurite outgrowth were much increased with activation of serine/threonine protein kinase (Akt) and blocked by addition of an Akt inhibitor (LY294002). Our results suggested that NAC increased EB formation by up-regulating the N-cadherin expression. Furthermore, NAC-enhanced neuronal differentiation was mediated by activation of Akt.

Interface fungal keratitis after endothelial keratoplasty: a clinicopathological report

The authors report two cases of interface fungal keratitis following Descemet's stripping automated endothelial keratoplasty (DSAEK). Two patients developed culture-proven interface keratitis with Candida albicans and Candida glabrata following DSAEK. Both patients presented with white interface opacities at approximately 1 month after uncomplicated DSAEK. Adjunct confocal microscopy identified fungal elements prior to surgical therapy. A penetrating keratoplasty was performed in both cases after failed medical therapy with fungal elements confirmed by corneal histopathology. Interface fungal keratitis must be recognized as a potential complication of endothelial keratoplasty. Surgeons should consider corneal donor rim cultures on all endothelial keratopathy cases and confocal microscopy on cases with new interface opacities in the early postoperative period. These measures may lead to early identification and treatment of fungal interface infections.

Malaysian and Thai smokers' beliefs about the harmfulness of 'light' and menthol cigarettes

OBJECTIVE

This study explored the extent to which Malaysian and Thai smokers believe "light" and menthol cigarettes are less harmful than "regular" cigarettes and the correlates of these beliefs.

METHODS

The study used data from wave 1 of the International Tobacco Control Southeast Asia Survey. 2006 adult smokers (95.3% male) from Malaysia and 2000 adult smokers (94.5% male) from Thailand were interviewed face to face in 2005.

RESULTS

29% of Malaysian respondents reported currently smoking light cigarettes and 14% menthols, with 19% agreeing that lights are less harmful and 16% agreeing that menthols are less harmful. 38% of Thai respondents reported currently smoking light cigarettes and 19% menthols, with 46% agreeing that lights are less harmful and 35% agreeing that menthols are less harmful. Malaysian smokers reporting current use of light or menthol cigarettes were more likely to believe that they are less harmful. Reported use of lights did not relate to beliefs for Thai respondents. The belief that light and/or menthol cigarettes are less harmful was strongly related to the belief that they have smoother smoke.

CONCLUSIONS

The experience of smoother smoke is likely to produce some level of belief in reduced harm, regardless of how brands are labelled and whether or not Federal Trade Commission FTC/International Organisation for Standardisation tar, nicotine and carbon monoxide yield figures are used.

Clinicopathologic findings in failed descemet stripping automated endothelial keratoplasty

OBJECTIVE

To evaluate the clinical features of and histologic findings from failed Descemet stripping automated endothelial keratoplasty (DSAEK).

METHODS

This retrospective observational case series evaluated 47 consecutive corneal specimens from 42 patients who underwent either penetrating keratoplasty or repeated DSAEK for failed DSAEK. Clinical information was obtained for the cases. Sections of the specimens were examined using light microscopy. Immunohistochemical staining was performed for cytokeratins AE1/AE3 and for the myogenic marker smooth-muscle actin when indicated. Transmission electron microscopic examination was performed in some cases.

RESULTS

Graft survival ranged from 0.5 to 34 months. Histologic examination showed that 94% of the specimens (44 of 47) had endothelial cell loss. Residual host Descemet membrane (19%; 9 of 47), fibrocellular tissue (19%; 9 of 47), epithelial implantation (15%; 7 of 47), and fungal infection (4%; 2 of 47) were also identified. Immunohistochemical stains were positive for AE1/AE3 in the epithelial implantations and for smooth-muscle actin in cells in the fibrocellular proliferations.

CONCLUSIONS

The principal cause of failed DSAEK is endothelial cell loss. Residual host Descemet membrane, fibrocellular tissue at the edge of the lenticule, and epithelial implantation are common histologic findings. Fungal infection may occur in the setting of DSAEK.

Critical elements and lessons learnt from the implementation of an RFID-enabled healthcare management system in a medical organization

Healthcare services are complex and life-critical. One mistake in any procedure may lead to irremediable consequences; numerous researchers, thus, introduce information and communication technology to improve quality of services and enhance patient safety by reducing the medical errors. Radio frequency identification (RFID) is considered as one of the emerging tool assist in meeting the challenges of the present situation. In recent years, RFID has been applied in medical organizations for the purpose of managing and tracking medical equipment, monitoring and identifying patients, ensuring that the right medication is given to the right patient, and preventing the use of counterfeit medicine. However, most of the existing literature focuses on demonstrating how RFID can benefit the healthcare industry, whereas little attention has been given to the management issues involved in constructing an RFID project in medical organizations. In this paper, an exploratory case study is conducted in a medical organization to illustrate the development framework and critical issues that should be taken into consideration in the preparation, implementation and maintenance stage of constructing such a project. All the experiences and results discussed in this paper offer valuable and useful insights to steer those who would like to start their journey using RFID in medical organizations.

The rainbow: from ancient Greece to modern optics

We provide a historical perspective on the rainbow, with a review of early research and observations regarding the rainbow's origin and a discussion of some of the major contributors to our current understanding of what the rainbow represents. An overview of the various types of rainbows is undertaken. We conclude with a discussion of the rainbow's link to refraction, light, the visual system, and perception.

Descemet's stripping endothelial keratoplasty: safety and outcomes: a report by the American Academy of Ophthalmology

OBJECTIVE

To review the published literature on safety and outcomes of Descemet's stripping endothelial keratoplasty (DSEK) for the surgical treatment of endothelial diseases of the cornea.

DESIGN

Peer-reviewed literature searches were conducted in PubMed and the Cochrane Library with the most recent search in February 2009. The searches yielded 2118 citations in English-language journals. The abstracts of these articles were reviewed and 131 articles were selected for possible clinical relevance, of which 34 were determined to be relevant to the assessment objectives.

RESULTS

The most common complications from DSEK among reviewed reports included posterior graft dislocations (mean, 14%; range, 0%-82%), followed by endothelial graft rejection (mean, 10%; range, 0%-45%), primary graft failure (mean, 5%; range, 0%-29%), and iatrogenic glaucoma (mean, 3%; range, 0%-15%). Average endothelial cell loss as measured by specular microscopy ranged from 25% to 54%, with an average cell loss of 37% at 6 months, and from 24% to 61%, with an average cell loss of 42% at 12 months. The average best-corrected Snellen visual acuity (mean, 9 months; range, 3-21 months) ranged from 20/34 to 20/66. A review of postoperative refractive results found induced hyperopia ranging from 0.7 to 1.5 diopters (D; mean, 1.1 D), with minimal induced astigmatism ranging from -0.4 to 0.6 D and a mean refractive shift of 0.11 D. A review of graft survival found that clear grafts at 1 year ranged from 55% to 100% (mean, 94%).

CONCLUSIONS

The evidence reviewed is supportive of DSEK being a safe and effective treatment for endothelial diseases of the cornea. In terms of surgical risks, complication rates, graft survival (clarity), visual acuity, and endothelial cell loss, DSEK appears similar to penetrating keratoplasty (PK). It seems to be superior to PK in terms of earlier visual recovery, refractive stability, postoperative refractive outcomes, wound and suture-related complications, and intraoperative and late suprachoroidal hemorrhage risk. The most common complications of DSEK do not appear to be detrimental to the ultimate vision recovery in most cases. Long-term endothelial cell survival and the risk of late endothelial rejection are beyond the scope of this assessment.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Metastatic esophageal adenocarcinoma presenting in the iris

PURPOSE

To report a case of metastatic esophageal adenocarcinoma presenting as an acute primary iris tumor of unknown origin.

DESIGN

Interventional, clinicopathologic case report.

METHODS

A 47-year-old healthy man sought treatment for a three-week history of a progressively enlarging red spot on the left iris. Presentation, local and systemic evaluation, and treatment are described.

RESULTS

Iris biopsy revealed the lesion represented metastasis, and a systemic evaluation later revealed the primary source as esophageal adenocarcinoma. The patient began systemic chemotherapy.

CONCLUSIONS

Metastatic iris lesions can have atypical presentations. Tissue biopsy, tumor antigens, and a thorough systemic evaluation are crucial in identification of primary tumors in cases of unknown metastatic origin.

Synthesis of LiYF4, BaYF5, and NaLaF4 optical nanocrystals

This paper reports the synthesis of high quality LiYF4, BaYF5, and NaLaF4 nanocrystals by high-temperature co-decomposition of precursors in organic solvents. Their bulk counterparts have long been used as efficient luminescent hosts for various applications including lasers, upconversion fluorescence, and quantum cutters. The particles were characterized using TEM, XRD, dynamic light scattering (DLS), and fluorescence spectrometry. Trifluoroacetic acid (CF3COOH) and the reaction temperature were crucial for the formation of NaLaF4 and LiYF4 nanoparticles. NaLaF4 was not formed without using CF3COOH, only LaF3 and NaF mixture was formed. NaLaF4 nanoparticles were obtained only when CF3COOH was added in the reaction solution and the temperature was > or =330 degrees C. For the synthesis of LiYF4,, in the absence of CF3COOH in the reaction, a mixture of YOF and LiYF4 nanoparticles was formed. Pure LiYF4 particles were obtained only until CF3COOH was added in the reaction at 340 degrees C or above. The nanoparticles were easily dispersed in organic solvents include hexane, toluene, and chloroform and formed transparent colloidal solutions. The ease of doping of these as-synthesized host nanoparticles for designed optical properties was assessed. The LiYF4, BaYF5, and NaLaF4 nanoparticles, co-doped with 20% Ytterbium (Yb) and 2% Erbium (Er), showed bright upconversion fluorescence upon 980 nm NIR excitation, confirming the high quality of as-synthesized nanoparticles. These nanoparticles are potential candidates for nano-optical devices, thin films, telecommunication, and bio-probes.

Use of EBSD to identify phases in interdendrite region of a cast Zn-Al-based alloy (ZA27)

Electron backscattered Kikuchi diffraction methodology was used to identify phases in the interdendrite region of an alloy ZA27. Two Zn-rich hexagonal close-packed structure phases eta and epsilon phases were distinguished using predetermined lattice parameters of the phases. In relation to studies of scanning electron microscopy and X-ray diffraction, electron backscattered diffraction results revealed that the Al-rich precipitates of the alpha phase were from decomposition of the eta'(T), and the four-phase transformation: alpha+epsilon--> T'+eta, had occurred in the epsilon phase after ageing at 150 degrees C for 8 h.

Excimer laser exacerbation of Avellino corneal dystrophy

We review the clinical, histopathological, and ultrastructural findings and DNA phenotyping of a patient with Avellino corneal dystrophy exacerbated by laser in situ keratomileusis. The findings are reported and interpreted in the context of a literature review. The case highlights the possible difficulty of recognizing subtle dystrophic findings, as well as the importance of avoiding refractive surgical intervention in patients with Avellino corneal dystrophy to avoid exacerbation of dystrophic deposits in the cornea and subsequent reduction in vision.

Superficial hypertrophic dendriform epitheliopathy: a follow-up series

PURPOSE

To report the interval courses of previously reported cases of superficial hypertrophic dendriform epitheliopathy (SHDE) and to describe 3 new cases of this uncommon entity following penetrating keratoplasty.

METHOD

Retrospective chart review.

RESULTS

We report follow-up on 3 previously described cases of SHDE, including discussion of cases and their clinical course. All 3 patients had persistent surface abnormalities complicating graft success resulting in poor visual outcomes. Three new cases of SHDE are discussed with a summary of the ocular findings and treatment. All patients underwent multiple penetrating keratoplasties for recurrent graft failures resulting from chronic postkeratoplasty surface keratopathy.

CONCLUSIONS

SHDE is a rare complication of penetrating keratoplasty that can lead to delayed healing, chronic derangement of the corneal surface, corneal scarring, and an increased risk of graft rejection. Understanding and recognizing this entity is crucial for maximizing graft outcomes. Further investigation of the pathogenesis is necessary for complete understanding and management of the disorder.

Surgical monovision and monovision reversal in LASIK

PURPOSE

This study was designed to assess the success of surgical monovision in presbyopic patients.

METHODS

A university refractive surgery center retrospective chart review of 82 patients who elected to undergo surgical monovision with laser in situ keratomileusis (LASIK) between January 2000 and January 2003 was conducted. Specific factors included for analysis included preoperative and postoperative defocus spherical equivalent, whether the patient underwent enhancements, whether the patient underwent a preoperative monovision trial with contact lens, and whether the patient underwent monovision reversal.

RESULTS

Eighty-two patients who underwent LASIK for monovision were analyzed. Mean preoperative spherical equivalent in the distance-corrected eye was -4.07 (standard deviation (SD), 2.49); for the eye corrected for near vision, mean preoperative spherical equivalent was -4.10 (SD, 2.56). Postoperative spherical equivalent in the distance eyes was -0.01 (SD, 0.38) and in the near eyes -1.24 (SD, 0.91). There were 6 enhancements in the near eyes (7%) and 17 enhancements in the distance vision eyes (21%). This difference was statistically significant (P = 0.007). Thirty patients underwent a contact lens trial of monovision before LASIK, and none of those patients elected monovision reversal. There were 52 patients who did not undergo a contact lens monovision trial before LASIK monovision, and 2 of these patients underwent monovision reversal. Monovision success in this population was 97.6%.

CONCLUSION

Surgical monovision can help presbyopic patients achieve their goal of reduced dependence on spectacles. A trial of monovision contact lenses or spectacles may be important in helping surgeons select patients for successful surgical monovision.

Corneal Perforation During Laser Blepharoplasty

A 61-year-old woman presented with photophobia, pain, epiphora, and decreased vision as a result of two iatrogenic corneal perforations sustained during carbon dioxide laser blepharoplasty. The management and course of the case are outlined. Laser blepharoplasty complications are reviewed. This case highlights the potential occurrence of corneal penetration with laser blepharoplasty. Meticulous awareness of the laser effects on periocular tissue must be kept in mind at all times during laser blepharoplasty to avoid unnecessary intraocular side effects and undesirable postoperative outcomes.

Dendritic Keratopathy in Ocular Rosacea

PURPOSE

To report a case of dendritic keratopathy secondary to ocular rosacea in a 62-year-old man.

METHOD

Case report.

RESULTS

We discuss the ophthalmologic findings, management, and course in a patient with an unusual dendritic corneal lesion resistant to medical therapy. Other causes of dendritic lesions on the cornea were ruled out after investigation. The patient experienced symptomatic and objective improvement in the lesion with treatment of ocular rosacea.

CONCLUSION

This case represents an interesting presentation of rosacea with dendritic keratopathy associated with typical skin lesions.

Ocular Complications of Hypovitaminosis A after Bariatric Surgery

PURPOSE

To report the ocular complications of xerophthalmia, nyctalopia, and visual deterioration to legal blindness as a result of inadequate vitamin A supplementation after malabsorptive bariatric surgery.

DESIGN

Observational case report and literature review.

PARTICIPANT

A 39-year-old woman with xerophthalmia and nyctalopia occurring 3 years after gastric bypass surgery.

RESULTS

We report a patient with a rare finding of xerophthalmia and visual deterioration after gastric bypass surgery as a result of vitamin A deficiency. The patient was referred for decreased vision associated with chronic dry eyes, bilateral diffuse punctate keratitis, and corneal scarring of unknown cause after several ophthalmologic examinations. The medical history, ophthalmic findings, and clinical course are discussed.

CONCLUSIONS

Gastric bypass procedures can cause vitamin A deficiency leading to serious ocular complications, including xerophthalmia, nyctalopia, and ultimate blindness. The increasing incidence of obesity and gastric bypass procedures warrants patient and physician education regarding strict adherence to vitamin supplementation. Education is imperative to avoid detrimental ophthalmic complications resulting from hypovitaminosis A and to prevent a potential epidemic of iatrogenic xerophthalmia and blindness.

Diagnostic abilities of three CAD methods for assessing microcalcifications in mammograms and an aspect of equivocal cases decisions by radiologists

Radiologists use an "Overall impression" rating to assess a suspicious region on a mammogram. The value ranges from 1 to 5. They will definitely send a patient for biopsy if the rating is 4 or 5. They will send the patient for core biopsy when a rating of 3 (indeterminate) is given. We have developed three methods to aid diagnosis of cases with microcalcifications. The first two methods, namely, Bayesian and multiple logistic regression (with a special "cutting score" technique), utilise six parameter ratings which minimise subjectivity in characterising the microcalcifications. The third method uses three parameters (age of patient, uniformity of size of microcalcification and their distribution) in a multiple stepwise regression. For both training set and test set, all three methods are as good as the two radiologists in terms of percentages of correct classification. Therefore, all three proposed methods potentially can be used as second readers.

LASIK after epikeratophakia

PURPOSE

To present a case of successful laser in situ keratomileusis (LASIK) performed on a patient with residual hyperopic astigmatism and symptomatic anisometropia after previous epikeratoplasty (epikeratophakia).

METHODS

LASIK was used successfully to treat hyperopic astigmatism after regression of epikeratophakia performed 16 years earlier.

RESULTS

Visual acuity improved to 20/30 without correction, and best-corrected visual acuity was 20/25 at the 3-month postoperative visit.

CONCLUSIONS

LASIK can be used successfully as an alternative treatment to correct residual refractive error after epikeratoplasty.

Aniridia and Brachmann-de Lange syndrome: a review of ocular surface and anterior segment findings

PURPOSE

To review the ocular surface and anterior segment findings in Brachmann-de Lange syndrome and describe a new case involving aniridia and congenital glaucoma.

METHODS

A newborn presented 2 days after birth with bilateral cloudy corneas, photophobia, and epiphora. We provide a 5-year descriptive history and clinical course with review of the literature on Brachmann-de Lange syndrome.

RESULTS

Multiple ocular surgeries were performed for ocular sequelae from aniridia and congenital glaucoma including Ahmed valve placement and penetrating keratoplasties in both eyes. At 5.5 years of age, the child had a clear graft OD and amblyopia from graft failure OS following recurrent graft infections. A review of Brachmann-de Lange syndrome found 43 patients with ocular surface and anterior segment findings. The most common findings included conjunctivitis, blepharitis, microcornea, and corectopia. Aniridia and congenital glaucoma were not previously reported with Brachmann-de Lange syndrome.

CONCLUSIONS

Ocular surface and anterior segment abnormalities must be considered when examining patients with Brachmann-de Lange syndrome. Ocular findings may include vision-threatening anomalies, as in our case with aniridia and congenital glaucoma. To our knowledge, these findings are previously unreported in Brachmann-de Lange syndrome.

Effects of environmental endocrine disruptors on the sex differentiation in Korean rockfish, Sebastes schlegeli

The effects of estradiol-17beta, methyltestosterone, tributyltin, bisphenol A and 2,4-dinitrophenol on sex differentiation were investigated in the Korean rockfish, Sebastes schlegeli. The 51 day-old fry with undifferentiated gonads were fed with food containing the chemicals at 0.05, 0.5, 5, 50 and 100 micro/g diet for 29 days. Sex ratio and gonadal abnormality after the chemical treatment were determined by histological examination of gonads. In control group, the sex ratio of fry was 1:1.3 (female:male), and more males than females appeared. The sex of fry fed with estradiol-17beta at 5, 50 and 100 micro/g diet was all females. Feminization of the fry was induced by exogenic estradiol-17beta. In the methyltestosterone group, sex ratio of fry was 1:10.2 in 0.05 micro/g diet, 1:2.4 in 0.5 micro/g diet, 1:3.1 in 5 micro/g diet, 1:1.2 in 50 micro/g diet and 1:2.3 in 100 micro/g diet. Masculinization of the fry was induced by methyltestosterone at the lowest concentration. Furthermore, intersex of the fry was observed. The number of intersex fry was 23.3, 25.0 and 35.3 at 0.5, 5 and 50 micro/g diet of methyltestosterone, respectively. Sex ratio of bisphenol A group showed no difference with that of the control. The sex of fry fed with 2,4-dinitrophenol at 5, 50 and 100 micro/g diet was all females. 2,4-dinitrophenol should be considered as a new member of endocrine disruptors. In tributyltin group, the sex ratio of fry at 100 micro/g diet of tributyltin was 5.4:1. Tributyltin induced the feminization of the fry at the highest dose. Tributyltin showed an estrogenic effect in the Korean rockfish in contrast to an androgenic effect in gastropods.

Antibiotic selective pressure for the maintenance of antibiotic resistant genes in coliform bacteria isolated from the aquatic environment

Coliform bacteria isolated from the aquatic environment were investigated for antibiotic susceptibility and detailed structures of class 1 integrons. A high proportion of isolates were found to be resistant to sulfamethoxazole, aminoglycosides, and beta-lactams. The 750 (53.6%) isolates were resistant to one or more of the antibiotics tested out of 1,400 coliform bacteria. Based on the MIC of antibiotics and antibiogram, 150 isolates were selected and further studied for class 1 integrons. The intI1 gene was found in 36 (24.0%) of the 150 isolates. Twelve isolates carried the gene cassettes responsible for antibiotic resistance, while no gene cassettes were found in 24 isolates. Seven different genes, dfrA5, dfrA7, dfrA12, dfrA17, aaA2, aaA5, and aad(3'), were detected in gene cassettes. The dfrA and aad genes located on class 1 integrons were responsible for resistance to trimethoprim and aminoglycosides. The remaining 24 coliform bacteria had the incomplete or non-functional class 1 integrons. These results indicated that antibiotic selective pressures may play an important role to maintain gene cassettes of class 1 integrons and in the absence of sustained antibiotic pressures, such as the aquatic environment, coliform bacteria may carry empty or non-functional class 1 integrons.

Biodegradation of gaseous benzene with microbial consortium in a biofilter

The objective of this study was to investigate the biodegradation of gaseous benzene in a biofilter inoculated with benzene-oxidizing microorganisms. The biofilter performance was monitored in terms of benzene removal efficiency and carbon dioxide production. The biofilter was capable of achieving as much as 96% benzene removal efficiency at a residence time of 2 min and an inlet concentration of 220 ppm. During operation with an inlet benzene of 220 ppm, the maximum elimination capacity of the biofilter was 483 g of C6H6 m(-3) day(-1). Under the same conditions, carbon dioxide with a concentration of up to 726 ppm was produced. It was found that carbon dioxide wasproduced at a rate of 608 mg day(-1), which corresponded to a volume of 0.35 l day(-1). Observable features of the microorganisms, meaning microbial activity occurrence in the biofilter, were investigated with the microscopy analysis.

Differential inhibition and inactivation of human CYP1 enzymes by trans-resveratrol: evidence for mechanism-based inactivation of CYP1A2

trans-Resveratrol (3,5,4'-trihydroxy-trans-stilbene) has been reported to confer chemoprotection against 7,12-dimethylbenz[a]anthracene (DMBA)-induced carcinogenicity in a murine model. A potential mechanism for this effect by trans-resveratrol is inhibition of DMBA-bioactivating cytochrome P450 (CYP) enzymes such as CYP1B1, CYP1A1, and CYP1A2. In the present study, we examined in detail the in vitro inhibitory effects of trans-resveratrol on these three human CYP enzymes. trans-Resveratrol decreased 7-ethoxyresorufin O-dealkylation activity catalyzed by human recombinant CYP1B1, CYP1A1, and CYP1A2 in a concentration-dependent manner and by a mixed type of inhibition. This direct inhibition was enzyme-selective, as judged by the differences in the apparent K(i) values (0.8 +/- 0.1 microM, 1.2 +/- 0.1 microM, and 15.5 +/- 1.1 microM for CYP1B1, CYP1A1, and CYP1A2, respectively). Preincubating recombinant CYP1A2 or human liver microsomes with trans-resveratrol and NADPH prior to the initiation of substrate oxidation resulted in a time- and concentration-dependent decrease in catalytic activity. The inactivation of liver microsomal CYP1A2 by trans-resveratrol required NADPH, was not reversible by dialysis, and was not affected by the trapping agents glutathione, N-acetylcysteine, catalase, or superoxide dismutase, but was attenuated by a CYP1A2 substrate, imipramine. Analysis of a panel of individual human liver microsomes showed intersample differences in the response to the in vitro inactivation by trans-resveratrol. In contrast to CYP1A2, CYP1B1 was not subject to inactivation by this compound and the reduction in CYP1A1 activity was time- but not concentration-dependent. In summary, trans-resveratrol differentially inhibited human CYP1 enzymes and this occurred by two distinct mechanisms: direct inhibition (mainly CYP1B1 and CYP1A1) and mechanism-based inactivation (CYP1A2).

Estrogen attenuates cell death induced by carboxy-terminal fragment of amyloid precursor protein in PC12 through a receptor-dependent pathway

In the present study, we investigated effects of estrogen on cell death induced by carboxy-terminal fragment of amyloid precursor protein (CT), a candidate causative substance in the pathogenesis of Alzheimer's disease. 17 beta-Estradiol attenuated CT-induced cell death in PC12 cells, whereas 17 alpha-estradiol, nonestrogenic stereoisomer, did not exert any significant protective effect on CT-induced cell death. These results suggest that protective effects of estrogen may be mediated by estrogen receptor (ER) in PC12 cells. To confirm the results, we determined the effects of tamoxifen, an estrogen receptor antagonist. Tamoxifen blocked the protective effects of 17 beta-estradiol, although it did not affect those of 17 alpha-estradiol. Overall, it might be thought that the protective effect of estradiol on CT-induced cell death is achieved by hormonal properties mediated through the estrogen receptor rather than the structural properties as a reducing agent.

C-terminal fragment of amyloid precursor protein induces astrocytosis

One of the pathophysiological features of Alzheimer's disease is astrocytosis around senile plaques. Reactive astrocytes may produce proinflammatory mediators, nitric oxide, and subsequent reactive oxygen intermediates such as peroxynitrites. In the present study, we investigated the possible role of the C-terminal fragment of amyloid precursor protein (CT-APP), which is another constituent of amyloid senile plaque and an abnormal product of APP metabolism, as an inducer of astrocytosis. We report that 100 nM recombinant C-terminal 105 amino acid fragment (CT105) of APP induced astrocytosis morphologically and immunologically. CT105 exposure resulted in activation of mitogen-activated protein kinase (MAPK) pathways as well as transcription factor NF-kappaB. Pretreatment with PD098059 and/or SB203580 decreased nitric oxide (NO) production and nuclear factor-kappa B (NF-kappaB) activation. But inhibitors of NF-kappaB activation did not affect MAPKs activation whereas they abolished NO production and attenuated astrocytosis. Furthermore, conditioned media derived from CT105-treated astrocytes enhanced neurotoxicity and pretreatment with NO and peroxynitrite scavengers attenuated its toxicity. These suggest that CT-APP may participate in Alzheimer's pathogenesis through MAPKs- and NF-kappaB-dependent astrocytosis and iNOS induction.

The protective role of HSP90 against 3-hydroxykynurenine-induced neuronal apoptosis

3-hydroxykynurenine (3HK), an endogenous metabolite of tryptophan in the kynurenine pathway, is a potential neurotoxin in several neurodegenerative disorders. Stabilizing protein structure, heat shock proteins (HSPs) have diverse roles as molecular chaperones to mediate stress tolerance. In the present study, we investigated the possible protective role of HSPs against 3HK induced neuronal cell death. Here we report that 3HK induced in a dose- and time-dependent manner neuronal cell death in neuroblastoma SK-N-SH cells. The cell death showed characteristic apoptotic features such as cell shrinkage, plasma membrane blebbing, chromatin condensation, and nuclear condensation and fragmentation. Furthermore, SK-N-SN cells were protected from 3HK induced cytotoxicity by prior elevation of HSPs expression. Our results show that the protective effect was abolished by HSP90 anti-sense oligonucleotides while not by HSP27 and HSP70 anti-sense oligonucleotides. Also, our result shows that HSP90 effectively inhibits caspases activities leading to the apoptosis. These results suggest that 3HK induces apoptosis in neuroblastoma SK-N-SN cells and that HSP90 is major contributing protein component of protection against 3HK induced apoptosis.