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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 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.

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.

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.

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.

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.

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.

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.