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Purpose The purpose of this report was to describe 4 cases of acute corneal transplant rejection occurring in association with coronavirus disease 2019 (COVID-19) mRNA vaccination. Methods Four patients with prior keratoplasty developed presumed immunologic rejection after the mRNA-1273 vaccination for coronavirus 2 (SARS-CoV-2). Case 1 had received Descemet membrane endothelial keratoplasty 6 months ago and presented with endothelial graft rejection 3 weeks after the first vaccine dose. Case 2 had undergone penetrating keratoplasty 3 years previously and presented with acute endothelial rejection 9 days after the second vaccine dose. Case 3 had prior Descemet stripping automated endothelial keratoplasty (DSAEK) and began experiencing symptoms of endothelial graft rejection 2 weeks after the second vaccine dose. Case 4 presented with endothelial rejection of the penetrating keratoplasty graft 2 weeks after the second vaccine dose. Results Frequent topical corticosteroids alone were initiated in all 4 cases. In case 1, the endothelial rejection line appeared fainter with improvement in visual acuity and corneal edema 5 weeks after diagnosis. Case 2 experienced complete resolution of corneal stromal edema and rejection line 6 weeks after diagnosis. Cases 3 and 4 have both experienced initial improvement with steroid treatment as well. Conclusions These cases suggest acute corneal endothelial rejection may occur soon after either dose of the COVID-19 mRNA vaccine. Prompt initiation of aggressive topical steroid therapy may result in complete resolution of clinical signs and symptoms. Further studies are needed to elucidate the causal mechanism of corneal graft rejection after COVID-19 vaccination.

Purpose: To report the first case of an atypical infectious keratitis caused by Streptococcus vestibularis after ICRS implantation. Case report: A 65-year-old man underwent intracorneal ring segments (ICRS) implantation for the treatment of a pellucid marginal corneal degeneration (PMCD) in his both eyes (OU). Three weeks after the surgery of the right eye (OD), the patient presented with pain, redness, and vision loss in his OD. BCVA was 20/100 Snellen equivalent in the OD. Slit-lamp examination revealed punctate whitish infiltrates along the ring segment with associated corneal stromal edema in the OD. Corneal scrapings were obtained for gram satins and bacterial and fungal cultures, and topical treatment with hourly ciprofloxacin was started. Two days later, corneal stromal edema worsened with involvement of the ring channel. Thus, the ring segment was removed and sent for cultures, and the ring channel was irrigated with vancomycin. Culture from ring segment came back positive for Streptococcus vestibularis, so topical targeted antiobiotherapy with vancomycin and erythromycin was applied. At 3 weeks of follow-up, BCVA was of 20/40 Snellen equivalent in the OD and a subtle corneal leucoma in the OD was observed in the slit-lamp examination. Conclusion: Although infectious keratitis is a rare and serious disorder associated with ICRS implantation, its early recognition and management is essential in order to avoid sight-threatening complications. Thus, a prompt obtainment of corneal curettage samples and removal of ring segment becomes decisive to initiate a targeted antiobiotherapy.

Homocystinuria is a metabolic disorder caused by a deficiency of cystathionine beta-synthase with autosomal recessive inheritance. Clinically it is characterized by lens subluxation, skeletal abnormalities, and thromboembolic accidents. We present a 6-year-old boy who was a known case of homocystinuria. The patient had a previous history of thrombotic cerebrovascular infarction at the age of 3. He had mild and vague pain in the left eye two weeks before presentation without being exposed to trauma. Ophthalmic examination revealed the dislocation of the crystalline lens into the anterior chamber with diffuse corneal stromal edema in the affected eye. The patient was treated with topical atropine and betamethasone eye drops, but due to the corneo-lenticular contact and corneal edema, he underwent lens extraction and placement of iris-fixated intraocular lens after 48 hours. Corneal edema exhibited improvement at follow-up visits. Early age onset and unilateral complete lens dislocation to the anterior chamber in the absence of a history of trauma is a less common presentation of homocystinuria. In patients with systemic diseases including homocystinuria that cause zonulysis, lens dislocation is usually symmetric and bilateral. Nevertheless, in unilateral cases especially in those who did not have any history of trauma, evaluation for systemic diseases like homocystinuria is necessary for early diagnosis and prevention from other systemic involvements.

Purpose To describe cases in which netarsudil ophthalmic solution 0.02% precipitated reversible, reticular cystic epithelial edema. Methods A retrospective case review at the Brooklyn Veteran's Association Hospital of patients with corneal stromal edema that were treated with netarsudil and subsequently developed cystic epithelial edema. Results Four male patients with a mean age of 72 ± 8.0 years developed a reticular, honeycomb-like pattern of epithelial edema located in the interpalpebral and inferior cornea. In 3 of 4 patients, epithelial edema arose within 1 month compared with 2 months in 1 patient. New epithelial cysts did not correlate with worsening central corneal thickness and best spectacle-corrected visual acuity in every patient, which was likely due to the location of the cysts. Two of 4 patients developed increased central corneal thickness with worsening best spectacle-corrected visual acuity. In comparison, 1 patient had improvement in both parameters, whereas 1 patient had no significant change. In all cases, there was resolution of the epithelial cysts after discontinuation of netarsudil. Conclusions Although rho-kinase inhibitors have been suggested to improve endothelial function, we have documented worsening epithelial cysts in a subset of patients with pre-existing corneal edema. These effects of netarsudil were transient and resolved after discontinuing treatment within 2 weeks in most patients. We hypothesize that the incidence of this adverse finding is more common than previously believed. Nevertheless, large-scale studies are needed to accurately report on the incidence and clinical significance of this novel finding.

A 43-year-old man developed acute corneal hydrops after laser in situ keratomileusis (LASIK). A persistently fluid-filled interface between the corneal flap and stroma (without flap dehiscence or wound leakage) did not respond to the conservative treatment. To avoid keratoplasty, the subflap fluid was drained by an air injection into the anterior chamber; the surgery also included suturing of the corneal flap and stroma. The corrected distance visual acuity improved rapidly after resolution of the fluid-filled interface and corneal stromal edema, and no leakage was observed. Thus, a minimally invasive surgery to drain the subflap fluid by an air injection was effective for treating a persistently fluid-filled interface in a case of acute corneal hydrops after LASIK.

Purpose: To report a case of neurotrophic keratopathy associated with nasopharyngeal carcinoma. Case Report: A 59-year-old man who had been diagnosed with a nasopharyngeal carcinoma was referred to the authors because of visual disturbance and pain in his right eye. Slit-lamp examination revealed a corneal epithelial defect and corneal stromal edema surrounding the epithelial defect area in his right eye. Magnetic resonance imaging showed a mass in his cavernous sinus, which was identified as nasopharyngeal carcinoma (NPC). We diagnosed neurotrophic keratopathy associated with NPC and initiated treatment with preservative-free artificial tears, antibiotic eye drops, fibronectin, a therapeutic contact lens, and amniotic membrane transplantation. However, the persistent corneal epithelial defect was unresponsive to these treatments. Conclusion: Neurotrophic keratopathy secondary to NPC is thought to be rare. We presented a case of neurotrophic keratopathy associated with cavernous sinus metastasis of an NPC. The development of new and more effective treatments for this refractory disease is anticipated.

Pseudophakic bullous keratopathy is characterized by corneal stromal edema with epithelial and subepithelial bullae due to cell loss and endothelial decompensation through trauma during cataract surgery. Patients present decreased vision, tearing, and pain caused by ruptured epithelial bullae. Cataract affects approximately 20 million people worldwide, and this complication can occur in 1 to 2% of the cataract surgeries. This study reviewed the bullous keratopathy etiopathogenesis and the clinical and surgical treatment available for this corneal disease.

Purpose: To introduce a case of corneal endothelial toxicity caused by Asclepias curassavica (Milkweed) in Korea. Observations: A 37-year-old Asian man presented with decreased vision and redness in the right eye, which developed after contact with Asclepias curassavica. At presentation, best-corrected visual acuity (BCVA) was 20/60 in the right eye. Slit lamp examination demonstrated severe corneal stromal edema with Descemet's folds and conjunctival hyperemia. We prescribed topical prednisolone acetate 1% eye drops (8 times a day), cyclosporine 0.1% (once a day) and oral prednisolone (30 mg a day for 3 days). One day later, the BCVA improved to20/40 and marked improvement in corneal edema was observed. At 5 days, BCVA was 20/22 and anterior segment examination showed minimal corneal edema with resolution of Descemet's folds. At 2 weeks, BCVA was 20/20 in the right eye and corneal edema completely resolved. Conlcusions and importance: This case suggests that high index of suspicion for toxicity from Asclepias species is necessary when encountered with patients who present with corneal edema after exposure to these plants. Aggressive anti-inflammatory treatment might be helpful for early recovery, at least for young patients. Keywords: Asclepias, Corneal edema, Corneal endothelial dysfunction, Inflammation, Millkweed

Meibomian gland dysfunction is the most frequent cause of evaporative dry eye, yet its underlying pathophysiology is unknown. To gain insight into this pathophysiology, we characterized the time-dependent tear film and ocular surface changes occurring in X-linked anhidrotic-hypohidrotic ectodermal dysplasia mice (Tabby), which lack the meibomian gland. These mice sequentially developed corneal epithelial defects, central corneal stromal edema, neovascularization, and pannus 8 to 16 weeks after birth. Aqueous tear secretion was normal, whereas tear break-up time and ex vivo tear evaporation times were all shortened. Corneal epithelial microvilli were less numerous, conjunctival goblet cell density was unaffected, and MUC5AC and MUC5B gene expression was increased. Markers of squamous metaplasia (cytokeratin 10 and small proline-rich protein 1B) were noticed in the corneal epithelium of Tabby mice as early as the fourth week. Taken together, the Tabby mouse is a relevant meibomian gland dysfunction-related dry eye model that may lead to a better understanding of how meibomian glands are related to ocular surface health. This model may also help with discovering novel drug options for treating evaporative dry eye.

A 21-year old female presented to the emergency department with an abnormal appearance of her left eye after trivial trauma the previous day. A protruding, opaque appearing area was noted on the left cornea. The patient underwent visual acuity testing, fluorescein staining with slit lamp examination revealing a conical corneal protrusion with corneal stromal edema suggestive of corneal hydrops. Corneal hydrops is a rare complication of keratoconus and various corneal ectasias where aqueous humor can leak into the corneal stroma causing edema and protruding pockets of fluid. Treatment is based on treating the underlying keratoconus or corneal ectasia in addition to cycloplegics, topical corticosteroids, topical antibiotics, and topical hypertonic saline.

Purpose: To evaluate the outcomes of implantation of an iris-claw intraocular lens (IC-IOL) in retropupillary position in aphakic patients. Methods: We conducted a prospective interventional study, including 36 aphakic eyes with inadequate capsular support. The postoperative examination included best-corrected visual acuity (BCVA), intraocular pressure (IOP) measurement, central corneal thickness (CCT), and anterior segment examination with emphasis on the anterior chamber reaction and shape of pupil. Follow-up was done for 3 months. Results: Thirty-six eyes of 34 patients, including 22 right eyes and 14 left eyes were included. Indications for surgery were complicated cataract surgery in 38.9% (n = 14), aphakia in 27.8% (n = 10), pseudophakic bullous keratopathy in 16.7% (n = 6), dislocated posterior chamber IOL (PCIOL) in 11.1% (n = 4), IC drop in 2.8% (n = 1), and subluxated PCIOL in 2.8% (n = 1). Postoperatively, the visual acuity improved by at least two lines in 32 (88.9%) and worsened in four (11.1%) eyes at the end of three months. Mean postoperative IOP at the end of the third month was 12.42 mmHg (standard deviation [SD] 2.57; range 11.55–13.29 mmHg). The mean postoperative CCT at the end of the third month was 542.42 microns (SD 13.77; range 537.76–547.07 microns). Sixteen eyes (44.4%) had horizontally oval pupil, eleven eyes (30.6%) had round pupil, and nine eyes (25%) had irregular pupil. Twenty-three eyes (63.9%) presented with significant anterior chamber reaction and seven eyes (19.4%) had corneal stromal edema on postoperative day 1. Conclusion: Our study demonstrated that retropupillary IC-IOL implantation in eyes without adequate capsular support is an effective and safe procedure with a good visual outcome and fewer complications.

Purpose. To report a case of a Descemet membrane’s (DM) detachment after radial keratotomy (RK).Methods. A patient (male) underwent RK (16 cuts) 20 years before referring to the Eye Center of Humanitas (Milan) for a progressive visual loss. The slit-lamp examination showed severe corneal stromal edema and a large DM detachment in the lower half of the cornea. Anterior segment optical coherence tomography (AS-OCT) and endothelial cells count confirmed DM detachment and endothelial cells damage. Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) was planned and topical hypertonic therapy was prescribed before the surgery.Results. Eight months later, the patient mentioned a spontaneous increase in visual acuity; the slit-lamp examination and the AS-OCT displayed a recovery of corneal transparency with a resolution of DM detachment.Conclusions. This is the first report of spontaneous DM detachment with severe corneal edema after RK. We suggest that hypertonic therapy may reduce DM detachment and restore corneal transparency.

A 31-year-old man presented to our clinic for an ocular trauma to his left eye. His best-corrected visual acuity was 20/200 OS (left eye). Anterior segment examination showed an epithelial defect, which implies a direct injury to the cornea. A marked focal stromal edema accompanied by Descemet’s membrane folds were located at 10 o’clock in the paraxial area, about 4 mm apart from the corneal center. Anterior segment optical coherence tomography (AS-OCT) revealed marked corneal swelling of the lesion. Five days later, the patient’s best-corrected visual acuity improved to 20/50 OS. The stromal edema resolved showing no signs of epithelial defect, although small opacity remained. AS-OCT revealed complete resolution of corneal swelling. Despite the resolution of corneal edema, however, specular microscopy showed substantially decreased endothelial cell density in the lesion compared to the fellow eye. Here we report a case of traumatic corneal stromal edema discovered by AS-OCT.

PURPOSE To report a case of delayed spontaneous Descemet membrane (DM) tear after big-bubble Deep Anterior Lamellar Keratoplasty (DALK). METHODS Uneventful big-bubble DALK was performed on a 29-year-old patient with advanced keratoconus. No injury to DM was noted intraoperatively and in the first postoperative week. On examination after 1 month, the patient presented with tear and partial detachment of Descemet membrane (DMD). RESULTS Circumscribed eccentric stromal edema, but not DMD, partially resolved after a 3-month observational period. CONCLUSIONS A tear to DM and consecutive DMD may occur spontaneously after big-bubble DALK. Sutural traction and regressing corneal stromal edema may be etiologic factors.

We report a challenging case of recurrent flat anterior chamber without hypotony after trabeculectomy in a 54-year-old Black male with a remote history of steroid-treated polymyositis, cataract surgery, and uncontrolled open angle glaucoma. The patient presented with a flat chamber on postoperative day 11, but had a normal fundus exam and intraocular pressure (IOP). Flat chamber persisted despite treatment with cycloplegics, steroids, and a Healon injection into the anterior chamber. A transverse B-scan of the peripheral fundus revealed a shallow annular peripheral choroidal detachment. The suprachoroidal fluid was drained. The patient presented 3 days later with a recurrent flat chamber and an annular peripheral choroidal effusion. The fluid was removed and reinforcement of the scleral flap was performed with the resolution of the flat anterior chamber. A large corneal epithelial defect developed after the second drainage. The oral prednisone was tapered quickly and the topical steroid was decreased. One week later, his vision decreased to count fingers with severe corneal stromal edema and Descemet's membrane folds that improved to 20/50 within 24 h of resumption of the oral steroid and frequent topical steroid. The patient's visual acuity improved to 20/20 following a slow withdrawal of the oral and topical steroid. Eight months after surgery, the IOP was 15 mm Hg without glaucoma medication. The detection of a shallow anterior choroidal detachment by transverse B-scan is critical to making the correct diagnosis. Severe cornea edema can occur if the steroid is withdrawn too quickly. Thus, steroids should be tapered cautiously in steroid-dependent patients.

Introduction. The objective was to evaluate the efficacy of active pedicle epithelial flap transposition combined with amniotic membrane transplantation (AMT) in treating nonhealing corneal ulcers.Material and Methods. Eleven patients (11 eyes) with nonhealing corneal ulcer who underwent the combined surgery were included. Postoperatively, ulcer healing time was detected by corneal fluorescein staining. Visual acuity, intraocular pressure, surgical complications, and recurrence were recorded. Corneal status was inspected by the laser scanning confocal microscopy and anterior segment optical coherence tomography (AS-OCT).Results. The primary diseases were herpes simplex keratitis (8 eyes), corneal graft ulcer (2 eyes), and Stevens-Johnson syndrome (1 eye). All epithelial flaps were intact following surgery, without shedding or displacement. Mean ulcer healing time was10.8±3.1days, with a healing rate of 91%. Vision significantly improved from 1.70 to 0.82 log MAR (P=0.001). A significant decrease in inflammatory cell infiltration and corneal stromal edema was revealed 2 months postoperatively by confocal microscopy and AS-OCT. Corneal ulcer recurred in 1 eye. None of the patients developed major complications.Conclusion. Active pedicle epithelial flap transposition combined with AMT is a simple and effective treatment for nonhealing corneal ulcers.

Reliable measurements of the intraocular pressure (IOP) are necessary for glaucoma patients. The measuring procedure, anatomical changes of the eye or extraocular influences can lead to errors during applanation tonometry. The IOP is overestimated if measured through the wrong eyepiece of the slit lamp, if a force is interfering with the tonometer arm during the measurement, if the lid comes into contact with the tonometer tip, if blepharospasm occurs, if there is lid retraction or if a Valsalva maneuver is present. An underestimation of the IOP occurs if staining with fluorescein is absent or insufficient, if the illumination is not bright enough, if a corneal stromal edema is present, after LASIK, during accommodation, during repeated measures within a few minutes or during systemic blood pressure drop. Discrepancies of the IOP in both directions can appear if the calibration of the tonometer is irregular, if abnormal central corneal thickness or astigmatism is present. For correct measurements calibrations are advised once or twice a year.

Item does not contain fulltext A 48-year-old myopic patient with bilateral anterior chamber depth of 3.1 mm and endothelial cell density (ECD) of 2525 cells/mm(2) and 2638 cells/mm(2) preoperatively had bilateral implantation of an Artisan iris-fixated phakic intraocular lens (pIOL). Five years postoperatively, unilateral corneal stromal edema was seen in a circumscribed area overlying the temporal ridge of the pIOL in the right eye; the ECD was 1631 cells/mm(2) and the pachymetry, 586 microm. Explantation of the pIOL was refused by the patient. Seven years postoperatively, the ECD was 413 cells/mm(2) in the right eye and corneal decompensation occurred. The progressive unilateral endothelial loss was explained by excessive rubbing of the eyes because of chronic itching and an anterior shift of the pIOL over the 7 years as demonstrated by anterior optical coherence tomography.

Microbial keratitis caused by more than one microorganism is rare. It may occur as a coinfection or as a secondary infection superimposed with an existent microorganism.[1] Both infectious and immune mechanisms are implicated in microbial keratitis. Herein, we report an unusual clinical case of viral and fungal mixed infection. Written informed consent was obtained from the patient. A 31-year-old man complained of red left eye for 10 days; accompanied with eye pain, photophobia, and blurred vision for 7 days and exacerbated in the next 2 days. At the beginning, he visited a hospital in Beijing. Corneal smear and the scrapings culture results were negative. Then he was treated as a patient with viral keratitis. He used topical ganciclovir eye gel, interferon, levofloxacin, pranoprofen eye drops, deproteinized calf blood extract eye gel, and oral famciclovir tablets. Ocular manifestation was alleviated obviously according to the patient's description and medical record. At 3 days before, he visited our hospital, the patient suffered from heavy cold and recovered after he took over-the-counter cold medications. Unfortunately, he felt severe eye pain and photophobia for 2 days before he was referred to our hospital. He had neither trauma history nor wore contact lenses previously. The visual acuity of his right eye was 20/20. No significant abnormality was detected in the right eye. While the visual acuity of the left eye was counting finger in front of the eye and could not be corrected. The clinical manifestation was showed in the Figure 1a. Figure 1 (a) Gray infiltrate with irregular edges involved approximately 5 mm diameter of the cornea. Endothelial plaque, satellite lesions, and hypopyon appeared. (b) Corneal infiltrate and satellite lesions were confluent. (c) Corneal epithelium erosion and ... After the patient was admitted, a repeat corneal smear was performed, and the scrapings were sent for bacterial (aerobes/anaerobes), fungal, and Acanthamoeba cultures and tested for antibiotic sensitivity. Fungal hyphae and epithelium were found in corneal smear [Figure ​[Figure1g1g and ​and1h].1h]. However, cultures were negative. The patient was diagnosed with fungal keratitis and viral keratitis based on previous medical history, clinical manifestations, and corneal smear results. The procedure of treatment was divided into four stages. Rapid remission stage lasted approximately 1 week [Figure 1b]. Combined antifungal, antiviral, and anti-inflammatory therapy was administered, including 5% natamycin eye drops (q1h), ganciclovir eye gel (tid), pranoprofen eye drops (qid), tropicamide (a cycloplegic compound) eye drops (tid), and oral acyclovir tablets (400 mg, qid). Hypopyon disappeared 1 day after treatment, but fungi were persistent in corneal scrapings 4 days after treatment. Chronic lag stage lasted more than 2 weeks. The patient complained about eye pain at night. Severe mixed conjunctival congestion appeared. Corneal epithelium erosion enlarged, accompanied with sustained stromal edema and aqueous flares [Figure 1c]. The stromal infiltrate improved very slowly. We considered that the toxin released when the hyphae was broken and the toxicity related to topical eye drops, particularly 5% natamycin, may injure the ocular surface. Thus, we gradually reduced the dosage of natamycin from q2h to qid. Pranoprofen and tropicamide eye drops was terminated because of ocular surface defect side effects. Antiviral therapy was same. Ocular surface protections was added, such as artificial tears without preservatives, dextran 70 eye drops (qid), deproteinized calf blood extract eye gel (bid), and sodium chloride conjunctival sac wash (bid). Corneal scrapings did not contain fungi 16 days after the patient was admitted. Healing stage lasted approximately 1 week. Conjunctival congestion was still severe. Corneal epithelium defect and infiltrate were healing very slowly, accompanied with mild anterior chamber inflammation [Figure 1d]. The topical treatment of 5% natamycin and ganciclovir was completely withdrawn at the end of this stage. Reparation stage lasted 2 weeks. Corneal stromal edema and inflammation still existed. We carefully observed lesion development for 7 days without recrudescence even withdrew antifungal agent [Figure 1e]. Then topical corticosteroid 0.1% fluometholone eye drops (tid), tobramycin, and dexamethasone ointment (qon) was administered. Oral acyclovir tablets tapered slowly. Conjunctival congestion was alleviated. Corneal infiltrate gradually vanished. The anterior chamber was quiet. When the patient was discharged, the visual acuity of the left eye increased to 20/40 [Figure 1f]. The fungus is a kind of conditional pathogenic microorganism. In a normal conjunctival sac, the positive rate of fungal culture ranges from 2.9%[2] to 27.4%.[3] Fungal keratitis is the combined result of pathogen and host factors, such as long-term use of broad-spectrum antibiotics, dysbacteriosis in the conjunctival sac, or application of corticosteroids, leading to local hypoimmunity or corneal trauma cases. In general, patients exhibit ocular trauma history, particularly from contact with plants or wood. In the present case, the patient was a young, healthy office staff without trauma or systemic disease except colds. The corneal smear was negative for microorganism at his first consultation. Corneal ulceration was diagnosed and treated as viral keratitis. The diagnosis was based on empiric with the clinical manifestation and effective diagnostic treatments. After the patient was referred to our hospital, fungal hyphae were detected. A typical clinical manifestation of mycotic keratitis caused by filamentary fungi showed. It is extremely rare that fungi and virus affected cornea at the same time. Polymerase chain reaction is a sensitive diagnostic method to detect viruses. Unfortunately, we could not get viral sample laboratory test in etiologic diagnose. Considering the medical history and antiviral diagnostic treatment was effective on the 1st week after onset, we believed that viral keratitis existed and fungal keratitis might be a secondary infection caused by previous infection. Although the mechanism of mixed infection was hard to determine, we speculated the existed corneal ulcer might be the potential causes of subsequent fungal infection. Meanwhile, the antivirals and antibiotics application aggravated conjunctival sac dysbacteriosis. Immediate treatment using antifungal with antiviral medicines was necessary. However, the early rapid remission stage turned to the chronic lag stage after many eye drops were used. Why did the severe mixed conjunctival hyperemia, corneal edema, and anterior chamber inflammation persist? At first, we considered eye drops-related irritation. After, we reduced the administration frequency and provided ocular surface protections, the corneal epithelium started to heal, but stromal edema and inflammation persisted for 1 month. Then topical immunopathologic mechanism was considered. Stromal keratitis is immunoinflammatory in nature, and local immunosuppression with topical steroids, along with antiviral coverage, should be involved.[4] However, topical steroids not only reduce immune inflammation, but potentially provide conditions suitable for the growth of exogenous fungi and ocular commensals. We carefully observed the lesion development without natamycin and then administered topical corticosteroid. The proper use of corticosteroids for the treatment of fungal corneal infections has been continuously debated.[5] The topical steroid is not prohibited, but should be applied with extremely care. Ophthalmologists should be aware of the uncommon manifestations of keratitis and adjust treatment depending on a patient's condition. Financial support and sponsorship This study was supported by a grant from Tianjin Medical University Eye Institute science foundation (No. 15YKYJS003). Conflicts of interest There are no conflicts of interest.

Aim To demonstrate the changes in ultrastructure and histopathology of the cornea in acute corneal alkaline burns after femtosecond laser-assisted deep lamellar keratoplasty. Methods The New Zealand white rabbits treated with alkaline corneal burn were randomized into two groups, Group A (16 eyes) with femtosecond laser-assisted deep lamellar keratoplasty 24h after burn and Group B (16 eyes) without keratoplasty as controls. All eyes were evaluated with transmission electron microscopy (TEM) at 1, 2, 3, and 4wk follow-up, then all corneas were tested by hematoxylin and eosin staining histology. Results The corneal grafts in Group A were transparent, while those in Group B showed corneal stromal edema and loosely arranged collagen fibers. One week after treatment, TEM revealed the intercellular desmosomes in the epithelial layers and intact non-dissolving nuclei in Group A. At week 4, the center of the corneas in Group A was transparent with regularly arranged collagen fibers and fibroblasts in the stroma. In Group B, squamous cells were observed on the corneal surface and some epithelial cells were detached. Conclusion Femtosecond laser-assisted deep lamellar keratoplasty can suppress inflammatory responses, prevent toxic substance-induced injury to the corneal endothelium and inner tissues with quicker recovery and better visual outcomes.

Purpose: To report a case of bilateral corneal edema in a patient with a history of cocaine abuse and bipolar-depression treated with amantadine for 6 months, and to review the literature on amantadine corneal toxicity. Methods: The clinical record of a patient with amantadine corneal toxicity and the existing literature on this subject were extensively reviewed for prevalence, clinical presentation, pathogenesis and therapy. Results: A 27 year-old male who suffered from depression and cocaine abuse presented with sudden visual loss (20/150 OD and 20/200 OS) caused by bilateral corneal stromal edema without ocular inflammation. Corneal edema was related to amantadine therapy (200 mg per day) for 6 months. Visual acuity improved to 20/20 OU and corneal edema resolved after one month of cessation of therapy. Corneal endothelial cell density after 3 months of discontinuation of amantadine therapy was 636 ± 359 cells/mm² in the right eye and 1,176 ± 238 cells/mm² in the left eye. There was also increased pleomorphism (45.3% 6A cells OD, 56.4% 6A cells OS) and polymegatism (coefficient of variation, 39.04 ± 6.38 OD and 34.76 ± 2.68 OS). Conclusions: Amantadine therapy has become popularized for the treatment of many neurologic and behavioral disorders at all ages. It has been associated with reversible corneal edema but may cause irreversible endothelial cell damage after prolonged administration. This report summarizes the information currently available in the literature regarding amantadine corneal toxicity.

This is a case report of a symptomatic non‑clearing, vascularized, disciform, corneal stromal edema with a feeder vessel that has remained refractory to medical therapy of antiviral, steroid, and antibiotics, for a period of three weeks, but showed a rapid improvement in visual acuity of 0.1 Log mar within five days of feeder vessel cauterization, together with improvement of two psychometric scales in corneal cloudiness on a scale range of 0 to 3, clinical evidence of resolution of corneal edema, and subjective resolution of the patient’s symptoms. Cauterization was done under magnification with a ball cautery point warmed in a spirit lamp following topical anesthesia. This intervention may become handy in difficult non‑clearing corneal edema and prevent blinding consequences, in a low‑resource facility, in selected applicable cases.Keywords: Cauterization, corneal edema, disciform corneal edema, embolization, feeder vessel, pannus, viral keratitis

PURPOSE Corneal endotheliitis causes endothelial decompensation and is associated with significant visual impairment. The goal of this article is to report a case of corneal endotheliitis associated with coxsackievirus A24 infection after cataract surgery in a patient who had no previous symptoms indicative of conjunctivitis. METHODS A 55-year-old man was admitted for cataract surgery when acute hemorrhagic conjunctivitis was prevalent. Because he did not show any signs of suspected conjunctivitis, the cataract surgery was performed. No intraoperative complications occurred, and he was discharged 1 day after the surgery. Three days later, he visited our clinic with complaints of ocular pain and decreased vision in the left eye. Slit-lamp examination showed corneal stromal edema and mild inflammatory reaction in the anterior chamber. On postoperative day 7, anterior chamber irrigation and viral culture from the aqueous humor sample were performed. RESULTS Coxsackievirus A24 was detected in the viral culture. Electron photomicroscopic examination with immunohistochemical staining confirmed the presence of viral antigen. CONCLUSIONS This is the first report of corneal endotheliitis caused by coxsackievirus A24 confirmed by viral antigen detection in the aqueous humor of an affected eye.

Corticosteroids seem to affect the functions of corneal endothelial cells directly in addition to their anti-inflammatory effect.A 69-year-old man presented with blurred vision in his left eye and decreased visual acuity in both eyes. He had received anterior-posterior radial keratotomy for myopia in both eyes 40 years earlier.Both eyes showed mild corneal stromal edema in the pupil area. We diagnosed the condition as corneal edema secondary to cell loss and dysfunction of corneal endothelium after surgery. One month later, the stromal edema was further advanced in the left eye. Corneal thickness had increased from the initial value of 619 microm to 631 microm, and corrected visual acuity had decreased from 0.5 to 0.06. There were no signs suggesting inflammatory reaction. The left eye was then treated with topical corticosteroid eyedrops and subconjunctival corticosteroid injection. Two months later, corneal thickness had decreased to 546 microm and visual acuity had improved to 0.5.This case shows that topical corticosteroids may be effective in treating corneal edema by producing an anti-inflammatory effect and possibly activating the endothelium.

Purpose: To assess acute corneal decompensation after silicone oil removal in some aphakic eyes with clear corneas whose anterior chambers were completely filled with silicone oil for a considerable period of time. Methods: Eight eyes of 8 patients who underwent vitrectomy and intraocular silicone oil injection were studied. All the eyes were aphakic and anterior chambers were completely filled with silicone oil. In all eyes, corneas were clear and no corneal finding indicating keratopathy was detected by slit-lamp microscopy before silicone oil removal. The mean silicone oil removal time was 4 months (range 2–7 months). A specular microscope was used for the evaluation of corneal endothelial changes and corneal pachometry was performed to observe corneal changes before and after the silicone oil removal in 5 eyes besides slit-lamp microscopy. The follow up period after silicone oil removal was 2–12 months (mean 6 months).Results: In all eyes severe corneal stromal edema and clouding was detected in the first day following silicone oil removal. Increased corneal thickness was seen in all eyes. Decreased (at or below critical levels) corneal cell density was detected by specular microscopy before and after silicone oil removal. No significant improvement was observed during the follow up period. Conclusion: Eyes whose anterior chambers completely filled with silicone oil could be evaluated as clear corneas by slit lamp microscopy despite severe endothelial damage. We recommend that eyes with silicone oil in the anterior chambers should be monitored by a combination of slit-lamp microscopic examination and specular microscopy to determine the relative corneal endothelial tolerance to the silicone oil and endothelial damage. Early removal of the silicone oil can be considered when the retinal adhesion allows.

BACKGROUND Toxic epidermal necrolysis (TEN) can lead to ocular surface scarring associated with pain, dry eye symptoms, and decreased visual acuity that often are difficult to treat. HISTORY AND SIGNS A 34-year-old woman was referred to our department two-years after TEN induced by lamotrigin (lamictal(R)). She was complaining of severe visual acuity loss, pain, and dry eye symptoms. Visual acuity was reduced to light perception in the right eye (RE) and to 0.2 in left eye (LE). Basal Schirmer test was 2 mm in RE and 3 mm in LE. With or without therapeutic contact lenses, the patient was experiencing severe discomfort requiring tear supplementation up to 50 - 80 times/day in both eyes. THERAPY AND OUTCOME A free autologous mucosal graft (3.5 x 2.0 cm) was transplanted from the lower lip into the upper RE fornix. Six months after surgery, with therapeutic contact lenses, the need for tear supplementation was markedly reduced to 3 - 4 times/day in RE while it remained unchanged in LE. In RE, slit-lamp examination revealed decreases in the corneal stromal edema and in the diameter of neo-vessels associated with an improvement of visual acuity (counting fingers at 30 cm). Basal Schirmer test values were unchanged. It has to be mentioned that the improvement observed after surgery was markedly dependent on wearing a therapeutic contact lens. CONCLUSIONS Free autologous buccal graft transplantation (with its presumably accessory salivary glands) in association with the use of a therapeutic contact lens can be an efficient approach to treat ocular complication following drug-induced TEN (Lyell's syndrome).

To report the case of a patient with unilateral corneal endotheliitis in which both cytomegalovirus (CMV) and human herpesvirus-6 (HHV6) DNA was identified in the aqueous humor. A 67-year-old man with corneal endotheliitis OD was referred to us for decreased visual acuity. Local corneal stromal edema, pigmented keratic precipitates, a coin-shaped lesion and minimal anterior chamber reaction were observed by slit-lamp biomicroscopy. Cells with owl’s eye appearance in the endothelial cell layer were observed by in vivo laser confocal microscopy. The patient had rheumatoid arthritis, which was treated by oral prednisolone and intravenous abatacept. Polymerase chain reaction analysis of aqueous humor samples detected both CMV and HHV6 DNA, but not other HHVs. Treatment with topical ganciclovir and systemic valganciclovir resulted in a clear cornea. A patient with corneal endotheliitis had both CMV and HHV6 DNA identified in the aqueous humor. Although both viruses were identified in this case, clinical manifestations resembled CMV corneal endotheliitis, and it was unclear whether HHV6 could affect the clinical course. Systemic abatacept and corticosteroid therapy might play a positive role in cases with both CMV and HHV6 DNA in this corneal endotheliitis.

Caso clínico: Varón de 62 años de edad con trasplante renal y tratamiento inmunosupresor que acude por disminución de la visión (20/100) en ojo izquierdo, edema corneal y presión intraocular de 46mmHg. Un mes después aparece queratitis dendrítica marginal inferior. El raspado corneal y la proteína C reactiva demuestran la presencia de un virus del herpes simple (HVS). Discusión: La epiteliopatía corneal autoinmunitaria o endotelitis idiopática corneal se caracteriza por edema corneal y precipitados queráticos. Se cree que el HVS podría ser secretado desde el trabeculum, inervado por el nervio trigémino, apoyado clínicamente por la progresión del edema estromal desde la periferia. Case report: A 62-year-old man with previous renal transplant and immunosuppressive treatment presented with decreased visual acuity (20/100) in his left eye, corneal oedema and intraocular pressure of 46mmHg. One month later an inferior marginal dendritic keratitis appeared. Corneal scraping and real-time polymerase chain reaction showed herpes simplex virus (HSV). Discussion: The autoimmune corneal endotheliopathy or acute idiopathic corneal endotheliitis is characterised by corneal stromal oedema and keratic precipitates. HSV might be secreted from the trabeculum, innervated by the trigeminal nerve. This hypothesis is supported by the clinical observation that the corneal stromal oedema usually starts from the periphery.

Three of four siblings born to parents with a history of heavy alcohol abuse had bilateral diffusely cloudy corneas at birth. These three siblings, who had mild systemic features of fetal alcohol syndrome, underwent corneal transplantations, and their specimens were examined by light and electron microscopy. Histologically, the alterations in Bowman's layer ranged from thickening to total loss. There were varying degrees of corneal stromal edema. The unique pathologic feature in the corneas was the anomaly of the anterior banded zone of Descemet's membrane, which was either absent, poorly formed, or thinned in the central and peripheral cornea. The corneal endothelium was attenuated or multilayered. The diffuse clouding and the range of histologic abnormalities in the corneas might be related to the maternal alcohol abuse.

Rhabdophis tigrinus is a common colubrid snake that can be found in an extensive geographical region in East Asia. It consists of two subspecies: R.t. tigrinus (yamakagashi) and R.t. formosanus (Taiwan tiger keelback). R. tigrinus possesses two different sets of poisonous glands: the Duvernoy's glands in the maxilla, and the nuchal glands in the dorsal skin of the neck. We report the first case in current English literature of toxin ophthalmia caused by the nuchal gland secretion of R.t. formosanus. The patient was a 40-year-old man whose right eye was sprayed by the nuchal gland fluid of R.t. formosanus. He presented with symptoms of foreign body sensation, progressive burning pain, and blurred vision. Ophthalmologic examination revealed diffuse superficial punctate keratitis, corneal stromal edema with Descemet folds, and conjunctival congestion. The patient responded well to topical treatment with a corticosteroid, antihistamine, and antibiotic, and had a favorable clinical course and outcome.

Purpose To report a series of severe corneal changes following intravitreal injection of bevacizumab (Avastin) for age-related macular degeneration. Design Retrospective noncomparative case series. Methods The authors retrospectively reviewed the corneal changes that developed after the procedure in 1200 (460 patients) intravitreal injections of bevacizumab. Results Five significant corneal changes (1.1%) occurred in these patients within the 1st postinjection week. The severe corneal changes included corneal infiltrative keratitis (n = 2) and corneal stromal edema and descemet folds (n = 3). The findings depended on clinical examination and biomicroscopic and confocal evaluation. In terms of causality assessment, no rechallenge was possible. The appropriate treatment was applied and recovery was achieved in all patients during the follow-up period. Conclusions Intravitreal injection of bevacizumab may cause corneal changes. The safety and effects of bevacizumab on the cornea should be evaluated in detail.

Purpose Human corneas with or without stromal edema were examined by second harmonic generation (SHG) imaging microscopy to characterize stromal collagen organization. Methods Tissue buttons from 31 corneas with stromal edema and 8 normal corneas were fixed, and 3-mm(2) blocks were cut and stained with phalloidin, to visualize the cytoskeleton. The blocks were examined by SHG imaging with a laser confocal microscope and a mode-locked titanium:sapphire femtosecond laser. Samples were scanned to a depth of 150 microm from the surface of Bowman's layer, and SHG forward- and backscatter signals were collected. Phalloidin staining was detected by conventional laser confocal microscopy. The three-dimensional structure of the anterior segment of the cornea was reconstructed from stacked SHG images. Results Three-dimensional reconstruction of SHG signals showed adherence of interwoven collagen lamellae in the anterior stroma to Bowman's layer in both normal and edematous corneas. Abnormal SHG signals at the level of Bowman's layer were observed in edematous corneas; three-dimensional images revealed that these signals were actually localized above Bowman's layer and were indicative of subepithelial fibrosis. Phalloidin staining showed transdifferentiation of stromal cells into fibroblastic cells in edematous corneas. The incidence of subepithelial fibrosis or of fibroblastic cells increased beginning 12 months after the onset of clinical stromal edema. Conclusions SHG imaging of the anterior segment of edematous corneas revealed a normal appearance of interwoven collagen lamellae in the anterior stroma. The development of subepithelial fibrosis beginning 12 months after the onset of edema suggests that stromal edema may be a progressive disease.

PURPOSE. Klf4, one of the highly expressed transcription factors in the mouse cornea, plays an important role in maturation and maintenance of the ocular surface. In this study, the structure and proteoglycan composition of the Klf4 conditional null (Klf4CN) corneal stroma was investigated, to further characterize the previously reported Klf4CN stromal edema. METHODS. Collagen fibril spacing and diameter were calculated from scattering intensity profiles from small angle synchrotron x-ray scattering patterns obtained across the cornea along a vertical meridian at 0.5-mm intervals. Collagen fibril organization and proteoglycans were visualized by electron microscopy (EM), with or without the cationic dye cuprolinic blue. Proteoglycans and glycosaminoglycans were further analyzed by fluorophore-assisted carbohydrate electrophoresis (FACE) and immunoblot analysis. Q-RT-PCR was used to measure the transcript levels. RESULTS. In the central cornea, the average collagen interfibrillar Bragg spacing increased from 44.5 nm (SD ±1.8) in wild-type to 66.5 nm (SD ±2.3) in Klf4CN, as measured by x-ray scattering and confirmed by EM. Mean collagen fibril diameter increased from 32 nm (SD ±0.4) in wild-type to 42.3 nm (SD ±4.8) in Klf4CN corneal stroma. Downregulation of proteoglycans detected by EM in the Klf4CN stroma was confirmed by FACE and immunoblot analysis. Q-RT-PCR showed that, whereas the Klf4CN corneal proteoglycan transcript levels remained unchanged, matrix metalloproteinase (MMP) transcript levels were significantly upregulated. CONCLUSIONS. The Klf4CN corneal stromal edema is characterized by increased collagen interfibrillar spacing and increased diameter of individual fibrils. The stroma also exhibits reduced interfibrillar proteoglycans throughout, which is possibly caused by increased expression of MMPs.

A ceratopatia bolhosa caracteriza-se pelo edema corneano estromal acompanhado de bolhas epiteliais e subepiteliais devido à perda de células e/ou alterações da junção endotelial. Nos casos mais avançados, ocorre espessamento do estroma e presença de fibrose subepitelial e vascularização corneana. Apresenta baixa de acuidade visual devido à diminuição da transparência da córnea e pode estar acompanhada de sensação de corpo estranho, lacrimejamento e dor devido as alterações epiteliais como a presença de bolhas íntegras ou rotas. Ceratite bolhosa é uma das principais causas de transplante de córnea em diferentes regiões e países. A principal etiologia é a perda de células endoteliais, principalmente após cirurgia de catarata e na distrofia endotelial de Fuchs. Sabe-se que atualmente há cerca de 20 milhões de pessoas com catarata no mundo, e esta complicação pode afetar 1 a 2% das cirurgias de catarata. Este texto faz uma revisão sobre a etiopatogênese da ceratopatia bolhosa e sobre os tratamentos clínicos e cirúrgicos disponíveis para a doença.

Purpose To describe a patient with cone dystrophy who presented with acute hydrops and perforation, leading to the diagnosis of keratoconus. Methods Case report and literature review. Results A 21 -year-old male patient with a history of cone dystrophy presented with a flat anterior chamber, diffuse corneal stromal edema with an intrastromal cleft, and ruptured Descemet membrane, findings consistent with acute hydrops with corneal perforation. After bandage contact lens placement and instillation of a cycloplegic agent, the anterior chamber reformed within 24 hours. Over the next week, conservative management with a bandage lens, pressure patching, topical fluoroquinolone antibiotic, and topical cycloplegic led to the reformation and maintenance of anterior chamber stability. Corneal topography of the unaffected eye showed global corneal thinning and steep sim K readings suspicious for early keratoconus. Conclusions Although the association between keratoconus and cone dystrophy is extremely rare, our patient's vision-threatening complication of acute hydrops with corneal perforation highlights the importance of corneal evaluation including topography in cone dystrophy. Conservative management was successful in the restoration of anatomic integrity in this situation.

Purpose To investigate clinical manifestations and response to antiviral therapy of 8 patients with cytomegalovirus (CMV)-induced corneal endotheliitis who were diagnosed and treated at 2 university hospitals in Japan. Design Retrospective, consecutive, multicenter case series. Participants Eight eyes of 8 patients diagnosed with active CMV corneal endotheliitis at Kyoto Prefectural University of Medicine and Ehime University School of Medicine. The diagnosis was made based on the detection by polymerase chain reaction assay of CMV, but not herpes simplex virus (HSV) and varicella zoster virus (VZV) DNA, in the aqueous humor from the affected eye. Methods Retrospective review of the clinical manifestations and responses to antiviral treatment. Main Outcome Measures Patient profiles, including duration of corneal endotheliitis, systemic disease, intraocular pressure, and clinical manifestation of anterior and posterior segments. The clinical response to systemic and topical antiviral treatment was evaluated by slit-lamp examination. Corneal endothelial density was examined by specular microscopy. Results The average observation period after CMV detection was 10.4 months (range, 2–24 months). None of the patients had systemic immunodeficiency. Corneal manifestations included linear keratic precipitates associated with multiple coin-shaped lesions and local corneal stromal edema. Of the 8 patients, 4 had undergone penetrating corneal transplantation. Systemic ganciclovir therapy was used in 7 patients, and in 1 patient, valacyclovir was administered, with the corneal endotheliitis responding quickly to the early administration of galovir. At the final examination, 6 eyes had a clear cornea, but 2 eyes had bullous keratopathy. Conclusions Besides HSV and VZV, CMV must be considered as an etiologic agent in patients with corneal endotheliitis. Cytomegalovirus corneal endotheliitis may be a newly identified clinical entity of reactivated CMV in the anterior chamber of individuals free of accompanying systemic symptoms.

Purpose. To report bilateral corneal endotheliitis caused by a vesicular virus (family Rhabdoviridae). Methods. Case report of a 49-year-old man with a complaint of sudden onset of decreased vision in both eyes had diffuse corneal stromal edema with extensive folds in Descemet's membrane and was diagnosed as having bilateral viral endotheliitis. Virologic investigations were performed using aqueous humor from the right eye. Results. An ether- and chloroform-sensitive cytopathic agent was isolated in Vero and BHK-21 cell lines from the aqueous humor. It was identified as a vesicular virus belonging to the family Rhabdoviridae by electron microscopy. Neutralizing antibody was demonstrated at a titer greater than 1 in 4,096 dilutions in the convalescent serum. Neurologic complications included loss of hearing and postinfectious polyradiculopathy affecting both lower limbs. Best-corrected visual acuity was 20/120 OD and 20/20 OS. Six months later, he developed glaucoma in the right eye. Trabeculectomy with intraoperative application of 5-fluorouracil was performed. Conclusion. This is the first report of bilateral endotheliitis caused by a vesicular virus and confirmed by virus isolation from the aqueous humor of the affected eye.

THE NEW ENGLAND JOURNAL OF MEDICINE Treatment of Severe Ocular-Surface Disorders With Corneal Epithelial Stem-Cell Transplantation Kazuo Tsubota, MD; Yoshiyuki Satake, MD; Minako Kaido, MD; Naoshi Shinozaki, MS; Shigeto Shimmura, MD; Hiroko Bissen-Miyajima, MD; Jun Shimazaki, MD Background Conditions that destroy the limbal area of the peripheral cornea, such as the Stevens-Johnson syndrome, ocular pemphigoid, and chemical and thermal injuries, can deplete stem cells of the corneal epithelium. The result is scarring and opacification of the normally clear cornea. Standard corneal transplantation cannot treat this form of functional blindness. Methods We performed and evaluated 70 transplantations of corneal epithelial stem cells from cadaveric eyes into 43 eyes of 39 patients with severe ocular-surface disorders and limbal dysfunction. Medical treatment had failed in all patients. The patients had a mean preoperative visual acuity of 0.004 (only being able to count the number of fingers presented by the examiner) in the affected eyes, which satisfies the criteria for legal blindness in most countries. In 28 eyes, we also performed standard corneal transplantation. Stem-cell transplantations were performed as many as four times on 1 eye if the initial results were not satisfactory; 19 eyes had multiple transplantations. Patients were followed for at least one year after transplantation. Results A mean of 1163 days after stem-cell transplantation, 22 of the 43 eyes (51 percent) had corneal epithelialization; of the 22 eyes, 7 eyes had corneal stromal edema and 15 eyes had clear corneas. Mean visual acuity improved from 0.004 to 0.02 (vision sufficient to distinguish the largest symbol on the visual-acuity chart from a distance of 1 m) (P Conclusions Transplantation of corneal epithelial stem cells can restore useful vision in some patients with severe ocular-surface disorders. N Engl J Med. 1999;340:1697-1703

A 28-year-old female with a history of contact lens wear presented with a 1 week history of pain and photophobia in her left eye. In vivo confocal microscopy (IVCM) and corneal scrape confirmed the diagnosis of Acanthamoeba keratitis (AK) which was treated with intensive topical propamidine isethionate (0.1%) and chlorhexidine (0.02%) with tapering dosage over 11 months. Five years after complete resolution of AK and cessation of all contact lens wear, the subject presented to her optometrist with a history of ocular discomfort and mild photophobia. Without further investigation she was prescribed topical corticosteroids. Three weeks later she presented with pain and reduced vision in the left eye. Slit-lamp examination revealed focal, inferior corneal stromal edema. IVCM confirmed widespread Acanthamoeba cysts. Treatment with topical polyhexamethylene biguanide (PHMB) 0.02% and propamidine isethionate 0.1% resulted in resolution of the AK. Despite an initially mild AK, this subject presumably retained viable Acanthamoeba cysts in her cornea 5 years after the initial episode. This report highlights the importance of caution when using corticosteroids in patients with a previous history of AK, even in the relatively distant past. Patients with AK should be warned regarding the risks of recurrence following presumed resolution.

PURPOSE: To report a case with corneal endotheliitis and idiopathic sudden sensorineural hearing loss, in which herpes simplex virus type 1 DNA was demonstrated in the trabeculum and the aqueous humor by polymerase chain reaction. DESIGN: Interventional case report. METHODS: A 60-year-old man presented with corneal stromal edema in the right eye and sudden bilateral sensorineural hearing loss. The trabeculum excised during trabeculectomy and the aqueous humor were examined for the presence of herpes simplex virus type 1 DNA by polymerase chain reaction. RESULTS: Polymerase chain reaction demonstrated herpes simplex virus type 1 DNA in the aqueous humor and the trabeculum. CONCLUSION: Herpes simplex virus type 1 may cause corneal endotheliitis and idiopathic sudden sensorineural hearing loss simultaneously.

Purpose: Corneal bee sting is a relatively rare injury. The authors report the significant endothelial changes despite complete resolution of corneal injury after a corneal bee sting. Case summary: Two males, ages 55 and 30, presented to our clinic for unilateral decreased visual acuity and eyeball pain after bee sting injuries. At the first visit, localized corneal stromal edema and epithelial defect were detected. One week after medical treatments, both patients achieved restoration of vision and resolution of corneal injury. In one patient, specular microscopy of the traumatized eye at one and five months showed a significant decrease in endothelial densities as compared with the contralateral eye. Conclusions: Corneal bee sting may cause significant endothelial changes despite complete resolution of clinical symptoms and injury. Specular microscopy should be considered in future intraocular surgeries.

Purpose: To report a case of intraocular foreign body of a vitreous cutter tip fragment. Case summary: A 60-year-old women was referred by her ophthalmologist with a two-day history of visual disturbance in her right eye. She had undergone pars plana vitrectomy, barrier laser and C3F8 gas injection due to pseudophakic rhegmatogenous retinal detachment in our retinal service center four months previously. Slit-lamp biomicroscopy of her right eye showed cornea stromal edema with Descemet membrane folding. Gonioscopic examination revealed a metallic foreign body in the direction of the 6-o ’clock anterior chamber angle. Anterior chamber irrigation with successful removal of the metallic foreign body using intraocular foreign body forceps was performed. The removed intraocular foreign body was a vitrectomy cutter tip fragment 20 gauge in size and 3 mm in length. After surgery, the corneal stromal edema disappeared and her visual acuity in the right eye recovered. Conclusions: Intraoperative breakage of vitreous cutter tips can occur and cause toxic ocular tissue reaction. Care should be taken against vitreous cutter tip breakage during vitrectomy. J Korean Ophthalmol Soc 2010;51(1):141-144

A 56-year-old man developed idiopathic corneal endotheliopathy. The lesion consisted of severe stromal edema at the lower half of the cornea along with a number of associated keratic precipitates and steadily progressed to the upper half of the cornea. By polymerase chain reaction, herpes simplex virus DNA was demonstrated in the aqueous humor of this patient. Corneal stromal edema was resolved in response to treatment with topically applied and systemic acyclovir. Herpes simplex virus DNA was repeatedly demonstrated in the aqueous humor when the endothelial lesion recurred later. This evidence strongly indicates that this unique endothelial disorder is of viral origin.

PURPOSE: To report an eye with corneal endotheliitis and increased intraocular pressure in which the trabeculum demonstrated immunoreactivity for herpes simplex virus. METHOD: Case report. A 62-year-old man presented with increased intraocular pressure, keratic precipitates, and corneal stromal edema in his left eye. The tissue excised during trabeculectomy was immunohistochemically examined for herpetic viruses. RESULT: Immunoreactivity for herpes simplex virus was identified in the trabeculum. CONCLUSION: Herpes simplex virus may cause trabeculitis and increased intraocular pressure in patients with corneal endotheliitis.

A 44-year-old man with bilateral keratoconus was referred for Intacs implantation (Addition Technology, Inc.) because of progressive discomfort and contact lens intolerance in the left eye. The procedure was performed under topical anesthesia. The tunnel was created with the IntraLase laser using the following settings: channel depth of 400 mm (70% of the peripheral corneal pachymetric values), entry incision length of 1.5 mm and width of 1.0 mm, channel inner diameter of 6.8 mm and outer diameter of 7.6 mm. One week postoperatively, the patient began to show signs of focal corneal edema around the Intacs segments (Figure 1). Despite an intensive course of topical steroids and suture removal, the corneal edema did not improve. Intraocular pressure was 10 mm Hg bilaterally. At 1 month, slitlamp examination revealed worsening of the initial focal edema surrounding the Intacs segments. At 2 months, there was no improvement in the corneal stromal edema. A decision to explant the Intacs was made. The procedure was uneventful, and the Intacs segment cultures were negative. The corneal edema gradually resolved over the following month. There are several possible/postulated mechanisms for this post-Intacs complication. Although pathologic changes in keratoconus have been shown to involve the anterior layers of the cornea primarily, alterations in the size and shape of the endothelial cells have also been reported. It has been demonstrated that the endothelium of keratoconic corneas show striking abnormalities, with increases in polymegathism and pleomorphism. 1 Furthermore, it has been postulated that the use of certain types of tight-fitting contact lenses can cause hypoxic strain to an already dysfunctional endothelium, permanently worsening stromal edema. 2 In combination with the previous observations, the endothelial distress caused by laser ablation during tunnel creation with the femtosecond laser could temporarily increase endothelial permeability and exacerbate a previously impaired endothelium. In our case, segment explantation led to resolution of the corneal stromal edema. It seems the presence of Intacs segments in combination with abnormal endothelial function is a crucial factor in the development of this complication.

Purpose To determine whether annular keratotomy can relieve pain associated with bullous keratopathy. Methods Three patients with painful bullous keratopathy and poor visual potential underwent partial-thickness (0.30 to 0.42 mm) trephination of the cornea under local anesthesia. Results All patients reported an absence of pain and foreign body sensation during an average follow-up interval of six months. The surgical procedure was uncomplicated; however, two eyes developed increased central corneal stromal edema. Conclusions Annular keratotomy appears to be a relatively safe and simple surgical procedure that may be useful in managing pain in eyes with painful cornea edema and poor visual potential.

Seven patients presenting with acute corneal stromal edema without prior surgery, trauma, ocular disease or known exposure to noxious agents are reported. One patient had a severe iridocyclitis; two others subsequently developed herpetic keratouveitis. Four cases, however, were unassociated with other known ocular disease. All four of these patients exhibited keratic precipitates and displayed minimal or no flare and cells in the anterior chamber, although the latter was largely obscured by the corneal edema. In each of these four instances, the inflammation and corneal edema resolved following topical corticosteroid therapy. In two of the four cases, both children, antibody to Herpes simplex virus could not be identified. We suggest that, in patients without known prior corneal disease or trauma, acute diffuse corneal stroma edema may stem from severe iridocyclitis or a primary endotheliitis due either to herpetic infection, the recently described presumed autoimmune corneal endotheliopathy, or a condition which we herein designate acute idiopathic corneal endotheliitis.

Corneal edema occurring in the congenital rubella syndrome can result from coexistent glaucoma or develop in the absence of an elevated intraocular pressure. We examined a 36-week-old female infant with documented congenital rubella syndrome who had bilateral corneal stromal edema without attendant congenital glaucoma. Histopathologic examination of the cornea revealed absent Descemet's membrane, deep interstitial keratitis, stromal corneal swelling, and deranged, focally absent endothelial cells. A viral infiltration of endothelium is postulated as the mechanism of the corneal edema and keratitis.

Background Surgeons may be unaware of the ability of plant toxins to cause corneal damage. Therefore, corneal damage following intraocular surgery due to plant toxins may be misdiagnosed as postoperative infection. Case presentation A 74-year-old man presented with hyperemia and reduced visual acuity in both eyes 6 weeks after uneventful cataract surgery. We observed extensive hyperemia and corneal stromal edema with Descemet’s folds in both eyes. After obtaining a detailed patient history, we diagnosed plant toxin-induced corneal edema due to Asclepias physocarpa, which can induce corneal edema by inhibiting the Na+/K+ ATPase activity of the corneal endothelium. Antimicrobial and steroid eye drops and an oral steroid were prescribed accordingly. Symptons began to improve on day 3 and had almost completely resolved by day 6. At 1 month, the patient had fully recovered without any sequelae. Conclusion The correct diagnosis was possible in the present case as symptoms were bilateral and the patient was able to report his potential exposure to plant toxins. However, if the symptoms had been unilateral and the patient had been unaware of these toxins, he may have undergone unnecessary surgical interventions to treat non-existent postoperative endophthalmitis.