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This article reviews the ocular findings in patients with a myriad of autoimmune syndromes. This review will provide guidance and heighten awareness for the allergist or eye care provider to pay heed to the manifestations and treatments of autoimmune syndromes.Autoimmune syndromes can present with varied manifestations on the ocular surface known to potentially cause significant visual morbidity. In particular, sterile corneal ulcers are the most devastating and common finding in uncontrolled autoimmune disease. Ophthalmic manifestations of autoimmune syndromes have been reported individually; however, herein we present a comprehensive review of typical and atypical syndromes that may present with sterile corneal ulceration.Autoimmune inflammatory syndromes are known to be associated with ocular surface inflammatory processes ranging from bothersome dry eye syndromes to vision-threatening sterile corneal ulceration. It is important to pay heed to the clinical presentation of common and uncommon presentations of the syndromes in the eye. We propose best practice for management of ocular surface disease in these clinical entities.

Purpose To report 3 patients with corneal decompensation and anterior uveitis within 24 hours of cataract surgery from a single ambulatory surgery center using intracameral lidocaine HCl 1% and phenylephrine 2.5% inadvertently preserved with 10% benzalkonium chloride. Methods This case series describes 3 patients who underwent traditional cataract extraction with a significant decrease in visual acuity in the immediate postoperative period resulting in secondary surgical intervention for corneal decompensation in 2 patients. Results All 3 patients experienced a dramatic decrease in visual acuity on the day of surgery, ranging from 20/400 to light perception. They were treated with topical steroids and sodium chloride, with stabilization of vision at 20/60 in 1 patient. The remaining 2 patients did not recover with medical management. One underwent Descemet stripping automated endothelial keratoplasty with placement of the corneal graft on top of Descemet membrane, which could not be removed secondary to extensive fibrosis. The third patient underwent penetrating keratoplasty secondary to deep corneal scarring. Conclusions This is the first case series of toxic anterior segment syndrome occurring secondary to the use of benzalkonium chloride-preserved intracameral lidocaine and phenylephrine. Clinicians should remain alert to this phenomenon, and should refrain from using intracameral preservatives during cataract surgery.

Purpose of review The present review provides an overview on the potential of different systemic and topical treatments in chronic forms of ocular allergy and dry eye disorder (DED). The impact on anterior surface of ocular inflammatory disorder encompasses an array of conditions, which are frequently underreported. This can contribute to underdiagnoses and ineffective management from healthcare providers such as an allergist and/or ophthalmologist who routinely provide care for these common disorders. Owing to the current limited therapeutic options, healthcare providers are routinely seeking alternative treatments that could facilitate effective management of the conditions. Recent findings Recent advances in immunopathophysiology of ocular surface disorders has provided new potential targets and therapeutic strategies for the treatment of DED and ocular allergy that may include various immunobiological modulators. These modulators have focused on regulating the Th1 and Th2 immune-mediated inflammatory pathways that inhibit various cytokines (e.g. IL-1, IL-4, IL-5, IL-9, IL-13) antibodies (e.g. IgE), and other surface markers of various cell lines (e.g. activated T-lymphocytes, lymphocyte function-associated antigen-1). Summary Recent findings about the pathophysiology of DED and ocular allergy have led to the greater understanding of the molecular and cellular mechanisms of ocular surface diseases leading to the potential novel targets for immunomodulation of anterior surface ocular disorders. New topical glucocorticoids, leukotriene receptor antagonists, IL-1 antagonists, IL-5, IL-4/IL-13 antagonists, integrin antagonists, and quinolone derivatives appear to be encouraging.

Purpose: To investigate microbiologic trends and role of biofilm on periorbital biomaterials surgically explanted for recalcitrant infection. Methods: A search of the Bascom Palmer Eye Institute, University of Miami Miller School of Medicine microbiology laboratory electronic database was conducted from 1980 to 2010. Culture results were analyzed from submitted periorbital biomaterials explanted for nonresolving infections or exposure. Random select samples cultured during the study were sent for electron microscopy. Results: Twenty-one explanted biomaterials were identified from 18 patients. Five orbital plate implants included 2 made of nylon, 1 of porous polyethylene, 1 of silicone, and 1 metallic. Of 4 anophthalmic socket sphere implants, 2 were silicone, 1 was porous polyethylene, and 1 was poly-2-hydroxyethyl methacrylate. Lacrimal intubation devices included 10 silicone stents and 2 pyrex glass Jones tubes. All biomaterials were culture positive with 40 total isolates identified. The most common organisms overall were Mycobacterium chelonae (N = 9), Staphylococcus aureus (N = 8), and Pseudomonas aeruginosa (N = 3). One hundred percent of orbital spheres had Gram-positive organisms, 90% of lacrimal silicone stents grew atypical mycobacterium, and 60% of orbital plates were culture positive for yeast species. Mixed organism growth was documented on 58% of the specimens. Ten of 12 implants (83%) examined with electron microscopy exhibited organisms encased in glycocalyx, suggestive of biofilm. Conclusions: A diverse array of microorganisms can colonize biomaterials implanted within the orbit and lacrimal drainage system. The authors’ study showed that the majority of infected periocular and orbital alloplastic implants display biofilm when studied with electron microscopy (83%). The cultured organism type depended on the implant location and composition. Most infected silicone lacrimal stents grew atypical mycobacterium, whereas infected orbital fracture repair plates demonstrated yeast species. Biofilms are known to be antibiotic resistant, explaining the need to explant most infected alloplastic implants. Further research concerning treatment of biofilms may prevent explantation and improve surgical outcomes. (Ophthal Plast Reconstr Surg 2013;29:376–381) T he expanding availability of implantable biomaterials has increased the use of synthetic material in oculofacial surgery. Biomaterials, such as acrylic, nylon, glass, silicone, hydroxyapatite, and porous polyethylene, provide the surgeon with an expanding armamentarium of surgical tools for treating orbital and periocular disease. They also may provide microorganisms with an immune-privileged, abiotic surface for growth. Recalcitrant infections associated with implants have been described in almost every part of the body where they have been used. The presence of biofilms on implants in ophthalmology has been documented on corneal sutures, punctal plugs, lacrimal intubation devices, scleral buckles, and intraocular lenses. 1–7

Current treatment options for allergic rhinoconjunctivitis include topical antihistamines, vasoconstrictors, mast cell stabilizers, intranasal corticosteroids (INCS), and nonsteroidal anti-inflammatory drugs that are generally used as a supplement to oral or intranasal therapies, necessitating the use of multiple treatments for the different symptoms of allergic rhinitis (AR). To assess the efficacy of INCS for ocular symptoms (OS) of AR. A search was performed of clinical trials (n = 32) from 1973 to 2009 of English articles (Medline, Embase, and PubMed) using "intranasal corticosteroid," "allergic rhinitis," "ocular symptoms," "allergic conjunctivitis," and "rhinoconjunctivitis" as key words. Quality assessment for the 32 eligible studies was performed using the Jadad score. Statistical analysis for continuous data was done by weighted mean difference or standardized mean difference. Thirty-two trials were included and separated into three different groups. The overall weighted mean was obtained from the Jadad score and came out to 9.29 (95% CI, 8.7-9.88). For meta-analysis for total OS scores and individual symptoms (10 parallel studies) the weighted mean was 10.17 (95% CI, 9.34-11). In the parallel studies, meta-analysis of individual symptoms (nine studies) gave a weighted mean of 10.09 (95% CI, 9.55-10.63). For eye symptoms but no individual symptoms (13 studies), the weighted mean was 8.56 (95% CI, 7.66-9.46). To date, clinical studies conducted statistically showed the efficacy of INCS on the OS of AR as evidenced by the meta-analysis results for the studies reporting total OSs.

Corticosteroids are an effective short-term treatment option for seasonal allergic conjunctivitis (SAC). Their use has been limited due to their side effects and has led to the development of modified 'soft', 'smart' ophthalmic corticosteroid formulations that retain their anti-inflammatory mechanism of action with an improved safety profile.Similar to the development of the prodrug concept for the nose and lung that led to the development of ciclesonide, a chloromethyl-ester group substitution at the carbon-20 (C-20) position of the traditional corticosteroid has led to the development of a family of potential ophthalmic corticosteroids including loteprednol etabonate that has demonstrated similar efficacy to the C-20 ketone corticosteroids in the treatment of the signs and symptoms of ocular allergies, but less likely to induce elevations in intraocular pressure (IOP) or the formation of cataracts. The C-20 ester corticosteroid, loteprednol etabonate has been designed to be rapidly converted to an inactive, nontoxic metabolite, thus minimizing adverse effects, and loteprednol etabonate (0.2%) is currently the only ophthalmic corticosteroid specifically developed for and approved by the Food and Drug Administration for treatment of SAC.The development of modified or soft, smart corticosteroids such as loteprednol etabonate provides an avenue for expanding the treatment of the inflammation associated with signs and symptoms in patients with chronic forms or severe acute exacerbations of allergic conjunctivitis. Modified corticosteroids are an effective and well tolerated option for the short-term treatment of the inflammation and signs and symptoms associated with SAC.

The term complementary/alternative medicine (CAM) refers to those therapeutic and diagnostic approaches different from conventional allopathic medicine. CAM may encompass homeopathy, acupuncture, phytotherapy, antioxidant therapy, and numerous holistic or behavioral techniques. Allergists and physicians of all disciplines are confronted with patients using CAM treatments, making it imperative that they become familiar with the scientific literature surrounding them. Given the high prevalence of allergic diseases and associated costs of CAM treatments, proof of CAM therapies is needed to establish appropriate guidelines for their use. Efficacy of CAM modalities should be established with randomized, double-blind, placebo-controlled trials, including adverse-effects monitoring. Of all the CAM therapies examined to treat allergic rhinitis, some herbal therapies and antioxidants demonstrate a trend toward some clinical efficacy. Researchers have yet to determine how to integrate these CAM modalities into the general treatment paradigm of allergic rhinitis.

PURPOSE To investigate the pathogens and biofilms responsible for clinically significant infection of silicone stents implanted within the lacrimal system. METHODS Retrospective review of culture results and patient demographics for all silicone lacrimal stents removed early for clinically significant infection and sent to the Bascom Palmer Microbiology Laboratory through the end of year 2010. As a control, routinely removed, clinically noninfected stents from the same institution were prospectively sent for culture over a 6-month period. Four clinically infected and 6 clinically noninfected stents showing mucus within the lumen at removal were sent for scanning electron microscopy. Images were randomized and graded by a microbiologist for the presence of organisms, matrix deposits, organisms within matrix, and overall impression of significant biofilm formation. RESULTS Nineteen stents were included in the study; 100% of clinically infected (n = 10) and noninfected (n = 9) stents were culture positive. Culture positivity for nontuberculous mycobacterium was found in 90% of infected stents and none of the noninfected stents (p < 0.001). Of infected stents, 50% grew Gram-positive organisms compared with 89% of noninfected stents (p = 0.07). Fifty percent of infected versus 67% of noninfected stents were culture positive for Gram-negative organisms (p = 0.46). Electron microscopy of stents revealed organisms consistent with culture results (size, shape) in planktonic and biofilm form. Masked observer image grading revealed a statistically significant higher amount of organism and biofilm on infected versus noninfected specimen. CONCLUSION Nontuberculous mycobacteria comprise the primary pathogens responsible for clinically significant infection of silicone stents in the lacrimal system in South Florida. Robust biofilm production by this organism likely plays a role in pathogenesis. Further research into biofilm-related lacrimal implant infection may aid in the development of useful prevention and treatment strategies.

PURPOSE OF REVIEW To provide opinions on the potential impact of increasing use of steroids by various formulations, as recent approvals have switched intranasal steroids to over-the-counter (OTC) status. Systemic glucocorticosteroids are the predominant formulations available only by prescription, whereas low-dose dermatological formulations are also available OTC. The recently approved OTC intranasal steroid has generated questions on their potential adverse effects, especially on the eye. RECENT FINDINGS Oral and ophthalmic steroids have the most potent impact on the development of increased intraocular pressure (IOP) and lens opacifications (ILO), but other factors such as age, race and comorbidities (e.g. hypertension, diabetes and smoking) also play a role. There are no biomarkers that have been established to identify populations at additional risk. However, individuals of Caribbean, African, Hispanic or Asian ancestry have a higher predilection for the development of glaucoma and thus may be predisposed to IOP. ILO has been noted to have a slight increase with intranasal corticosteroids, but no specific correlations with the development of cataracts. SUMMARY The OTC placement of intranasal steroid may cause a subset of genetically sensitive individuals to earlier development of IOP and ILO, but the socioeconomic benefit for patients with allergies having access to the 'OTC open formulary' appears to warrant consideration with caveats of monitoring the effect at large, especially in susceptible populations such as those with a family history or specific ancestries.

Purpose of review The purpose of this review is to assess the most recent findings and literature on the effect of minerals and antioxidant vitamins in the prevention of development and progression of cataract. Recent findings To retrieve most recent and relevant articles for this review, an intense and thorough search was conducted in databases and journal articles. Experts in the field of study were also contacted to know what the current opinions were in their practice. The data retrieved were qualitatively analysed and synthesized in order to arrive with the most objective conclusions. The result on the use of single antioxidant supplement did not show any significant effect on the cataract. A combination of antioxidant vitamins such as vitamins C and E may have a synergistic effect on cataract prevention; however, more studies need to be conducted to prove this. Summary There are still inconsistent results on the exact antioxidant and the required amount needed to prevent cataract. On the basis of the insufficient and inconsistent results of recent trials reviewed it is not clear that antioxidant vitamins and minerals nor that healthy diets prevent the development and progression of cataract.

Purpose To assess the use of ultra–high-resolution (UHR) optical coherence tomography (OCT) in the diagnosis of ocular surface lesions. Design Prospective, noncomparative, interventional case series. Participants Fifty-four eyes of 53 consecutive patients with biopsy-proven ocular surface lesions: 8 primary acquired melanosis lesions, 5 amelanotic melanoma lesions, 2 nevi, 19 ocular surface squamous neoplasia lesions, 1 histiocytosis lesion, 6 conjunctival lymphoma lesions, 2 conjunctival amyloidosis lesions, and 11 pterygia lesions. Intervention Ultra–high-resolution OCT imaging of the ocular surface lesions. Main Outcome Measures Clinical course and photographs, UHR OCT image, and histopathologic findings. Results Ultra–high-resolution OCT images of all examined ocular surface lesions showed close correlation with the obtained histopathologic specimens. When clinical differential diagnosis of ocular surface lesions was broad, UHR OCT images provided optical signs indicating a more specific diagnosis and management. In cases of amelanotic melanoma, conjunctival amyloidosis, and primary histiocytosis and in 1 case of ocular surface squamous neoplasia, UHR OCT was instrumental in guiding the diagnosis. In those cases, UHR OCT suggested that the presumed clinical diagnosis was incorrect and favored a diagnosis that later was confirmed by histopathologic examination. Conclusions Correlations between UHR OCT and histopathologic findings confirm that UHR OCT is an adjunctive diagnostic method that can provide a noninvasive means to help guide diagnosis and management of ocular surface lesions. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

The immune response based on immunoglobulin E (IgE) evolved as a defense against specific parasitic infections. In the absence of active helminthic infections, the immune system has redirected its IgE epitopes toward innocuous environmental antigens. Helminths and aeroallergens have a similar stereotypical IgE response to unique antigens that can not be explained by chance alone. This study was designed to evaluate potential homology between conserved protein domains embedded in parasitic organisms and aeroallergens. Search and retrieval systems for nucleotide and protein sequences (Entrez, BLAST, and National Center for Biotechnology Information) were searched to identify conserved domains between allergens and certain parasites. A total score was developed that correlated positively with homology between compared sequences. Over 2000 domains were examined. We found matches with a high total score (>100) that signified a strong positive correlation between sequences in allergens (n = 30) and parasites (n = 13). Multiple shared conserved domains were identified between parasites and allergens. Parasite-allergen combinations with the most significant homology (greatest total score) were Plasmodium falciparum enolase and Hev b9 (total score, 612), Schistosoma mansoni albumin and Fel d 2 (total score, 991), Ascaris lumbricoides tropomyosin and Ani s3 (total score, 531), and Wuchereria bancrofti trypsin and Blo t3 (138). Homologous conserved domains exist in specific parasites and allergens, consistent with the theory that the human IgE-eosinophil immune response to common allergens is a direct consequence of stimulation by parasitic organisms.

Seasonal allergic conjunctivitis (SAC) is an inflammatory response of the conjunctiva triggered by exposure to seasonal allergens. Treatment options for SAC include artificial tears, antihistamines, decongestants, mast cell stabilizers, nonsteroidal anti-inflammatory drugs, dual antihistamine/mast cell stabilizers, immunotherapy and corticosteroids. Topical, intranasal and systemic formulations of corticosteroids have traditionally provided the most effective relief of the inflammation and signs and symptoms associated with severe, acute exacerbations of SAC. However, steroid-induced ocular and systemic side-effects have limited the prescribing of these agents. This limitation of traditional corticosteroids led to the development of modified corticosteroids that retain the anti-inflammatory mechanism of action of traditional corticosteroids with a much-improved safety profile because of their rapid breakdown to inactive metabolites after exerting their activity. The development of one such novel corticosteroid, loteprednol etabonate (LE), led to the insertion of an ester (instead of a ketone) group at the carbon-20 (C-20) position of the basic corticosteroid structure. Clinical trials assessing this C-20 ester corticosteroid have demonstrated similar efficacy to C-20 ketone corticosteroids in the prevention or treatment of the signs and symptoms of SAC but with a greatly improved safety profile, as the C-20 ester corticosteroid is less likely to elevate intraocular pressure. In addition, the ketone at the C-20 position has been implicated in the formation of cataract, while nonketolic corticosteroids do not form Schiff base intermediates with lens proteins, which is a common first step in cataractogenesis. The clinical relevance of the C-20 ester corticosteroid class, as modelled by LE, is that they provide both effective and safe treatment of the inflammation associated with SAC and relief of its signs and symptoms. Loteprednol etabonate offers a well-tolerated treatment option for patients with debilitating acute exacerbations as well as chronic forms of the disease.

This article reviews the complications of laser-assisted in-situ keratomileusis (LASIK) associated with ocular allergy. This review will provide guidance and heighten the need for a more comprehensive allergic evaluation before recommending LASIK procedure to patients. The material provided allows enhanced awareness of the potential postsurgical effects on allergic responses of the ocular surface and management thereof.Ocular allergy is often underdiagnosed and has been previously reported only in a handful of peer-reviewed journals as the cause for ocular irritation and visual morbidity in post-LASIK dry eye disease. Diffuse lamellar keratitis is one complication of LASIK that has been linked to atopic individuals. LASIK causes significant inflammation in normal eyes, which is only exacerbated in atopic patients. Atopy may be a contributing factor in patients with patients with post-LASIK dry eye symptoms. Further investigation is required to better understand the complications of LASIK in allergic patients.LASIK surgery has been associated with increased anterior surface inflammatory processes that include dry eye syndromes and ocular allergy. In addition, poorer outcomes of LASIK procedures have been reported in patients with moderate to severe ocular allergies and chronic forms of allergic conjunctivitis, which is an absolute contraindication to the LASIK procedure. We propose preoperative and postoperative management algorithms for allergic LASIK candidates.

Pseudohypopyon is a rare clinical presentation of meta-static disease in the eye. The authors report a case of anterior chamber pseudohypopyon in a 74-year-old man with a history of primary central nervous system and spleen lymphoma, as well as lung, prostate, and bladder carcinoma. A diagnostic vitrectomy and anterior chamber paracentesis of the involved eye was performed that confirmed non–small-cell carcinoma of lung primary.

Atopic dermatitis, a chronic disease seen by allergist-immunologists, has both dermatologic and ocular manifestations. The ocular component is often disproportionately higher than the dermatologic disease. Even if skin abnormalities seem well controlled, these patients require ophthalmic evaluation. Atopic keratoconjunctivitis in atopic dermatitis patients is characterized by acute exacerbations and requires maintenance therapy for long-term control. Future studies will continue to emphasize the use of steroid-sparing, immunomodulating agents that have the potential to provide long-lasting anti-inflammatory control with a more favorable side-effect profile.