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Purpose To survey the demographics, risk factors, microbiology, and outcomes for infectious keratitis in Asia. Design Prospective, nonrandomized clinical study. Methods Thirteen study centers and 30 sub-centers recruited consecutive subjects over 12-18 months, and performed standardized data collection. A microbiological protocol standardized the processing and reporting of all isolates. Treatment of the infectious keratitis was decided by the managing ophthalmologist. Subjects were observed for up to 6 months. Main outcome measures were final visual acuity and the need for surgery during infection. Results A total of 6626 eyes of 6563 subjects were studied. The majority of subjects were male (n = 3992). Trauma (n = 2279, 34.7%) and contact lens wear (n = 704, 10.7%) were the commonest risk factors. Overall, bacterial keratitis was diagnosed in 2521 eyes (38.0%) and fungal keratitis in 2166 eyes (32.7%). Of the 2831 microorganisms isolated, the most common were Fusarium species (n = 518, 18.3%), Pseudomonas aeruginosa (n = 302, 10.7%), and Aspergillus flavus (n = 236, 8.3%). Cornea transplantation was performed in 628 eyes to manage ongoing infection, but 289 grafts (46%) had failed by the end of the study. Moderate visual impairment (Snellen vision less than 20/60) was documented in 3478 eyes (53.6%). Conclusion Demographic and risk factors for infection vary by country, but infections occur predominantly in male subjects and are frequently related to trauma. Overall, a similar percentage of bacterial and fungal infections were diagnosed in this study. Visual recovery after infectious keratitis is guarded, and corneal transplantation for active infection is associated with a high failure rate.

Background/purpose: To describe the clinical and histologic characteristics of ocular surface squamous neoplasia (OSSN) and evaluate factors significant in recurrence at a university hospital in North Taiwan. Methods: Patient charts, clinical features, and pathology records were retrospectively reviewed in patients with pathology-proved OSSN from January, 1994 to December, 2014. Clinicopathologic correlation was analyzed. Results: Thirty-six patients were recruited. Mean age was 63.4 ± 13.0 (ranging from 23 to 87) years old. OSSN was predominant in men (21/36). Clinical appearances included papilliform in 17 eyes, gelatinous in 11 eyes, leukoplakic in 3 eyes, and 5 eyes in corneal intraepithelial neoplasia (CIN). Of 31 conjunctival OSSN, there were 4 in CIN I, 11 in CIN II, 13 in CIN III, and 3 in squamous cell carcinoma. Superior location was associated with higher-grade OSSN. Although statistical analysis was not significant, papilliform and multifocal lesions showed a trend of high-grade OSSN. The stages of tumor were 4, 5, 26, and 1 eye(s) in T1 to T4, respectively. Recurrence of disease occurred in 9 cases (25%) with mean recurrence time of 20.6 (range: 4 to 65) months. Multifocal lesion has a higher tendency for recurrence. Conclusion: Superior location was associated with high-grade OSSN, and papilliform OSSN might have a tendency of severe and invasive lesions. Multifocal lesions might be associated with higher-grade OSSN and higher recurrence rates. Keywords: Carcinoma in situ, Conjunctival neoplasms, Intraepithelial neoplasms, Pathology, Recurrence

Purpose To propose a new adjustment method and present the clinical result of wavefront-guided myopic laser-assisted in situ keratomileusis (LASIK) retreatment with an aspheric program-targeted central ablation depth to avoid refractive overcorrection. Methods Thirty-two eyes (of 20 consecutive patients) that underwent wavefront-guided LASIK myopic retreatment between January 2009 and February 2012 after primary wavefront-guided LASIK for myopia were included. Wavefront-guided retreatments were performed using the Bausch and Lomb Technolas 217z100 excimer laser system. Wavefront-guided retreatments were adjusted by setting the ablation depth corresponding to the ablation depth determined by the aspheric program. The refractive outcome, visual outcome, and outcome of high-order aberrations (HOAs) were analyzed. Linear mixed models were also used to evaluate the predicting factors for retreatment offset. Results Mean age was 29.5 ± 3.1 years. Spherical equivalent (SE) before retreatment was -1.0 ± 0.44 diopters (D) (range, -2.25 to -0.5). Twelve months postoperatively, SE was -0.03 ± 0.12 D, and 31 of 32 eyes had an uncorrected visual acuity 20/20 or better. All eyes were within ±0.5 D. None of the eyes had lost >2 lines of Snellen visual acuity. Safety and efficacy indices were 1.03 and 1.00, respectively. Total HOA, coma, and trefoil were reduced significantly (P = 0.028, P = 0.036, P = 0.034, respectively). Predictive factors for the amount of offset required are significantly related to preoperative SE (P = 0.006) and spherical aberration (P = 0.03, adjusted by SE). Conclusions Setting the target ablation depth using the aspheric program provided high refractive predictability with a satisfactory visual outcome, significant reduction of HOAs, and no overcorrections.

Purpose To investigate the differential expression of stem cell factor (SCF) and thymic stromal lymphopoietin (TSLP) and their correlation to mast cells, between patients diagnosed with superior limbic keratoconjunctivitis (SLK) and normal subjects. Methods A laboratory investigation included 22 surgical specimens of the superior bulbar conjunctiva from 17 patients with medically refractory SLK and 5 control subjects who underwent cataract or retinal surgery. Protein expression of tryptase, SCF, and TSLP in conjunctival specimens was detected by immunohistochemistry. The number of mast cells was correlated with immunohistochemistry intensity of SCF and TSLP. Results In patients with SLK, higher immunostaining intensity of SCF and TSLP was found in the conjunctival epithelium than that in the conjunctival subepithelial stroma. SCF and TSLP staining in the conjunctival epithelium was significantly more intense in patients with SLK than in normal subjects. In addition, there was a significant correlation between the number of tryptase (+) mast cells in conjunctival subepithelial stroma and TSLP immunointensity in the conjunctival epithelium and subepithelial stroma. Conclusions Overexpression of SCF and TSLP was found in the conjunctival epithelium of patients with SLK. Significant correlation between TSLP grading and the number of mast cells was also found. SCF and TSLP may be involved in promoting mast cell migration and activation contributing to the pathogenesis of SLK.

Ex vivo culture or regeneration of corneal endothelial cells often is subjected to gradual endothelial-mesenchymal transition and loss of function. Here, we found that during ex vivo culture, bovine corneal endothelial cells underwent endothelial-mesenchymal transition and had an up-regulated expression and activity of matrix metalloproteinases. Inhibition of matrix metalloproteinase activity in confluent bovine corneal endothelial cells decreased the level of endothelial-mesenchymal transition regulators: snail and slug. The phosphorylation and degradation of the key Wnt signaling pathway modulator active β-catenin also were accelerated with the broad-spectrum matrix metalloproteinase inhibitor Marimastat, which may result from decreased N-cadherin shedding and increased intact N-cadherin molecules on the cell membrane. Intracameral injection of Marimastat also suppressed basic fibroblast growth factor–induced endothelial-mesenchymal transition in a rat corneal endothelium cryo-injury model and significantly diminished the corneal edema. Our study indicated that inhibition of matrix metalloproteinase activity can reverse endothelial-mesenchymal transition and preserve the function of corneal endothelial cells both during ex vivo culture and in vivo . This may offer a potential therapeutic target in regenerative medicine for the treatment of corneal endothelial dysfunctions.

Background/Purpose: To evaluate the efficacy of autologous serum eye drops for patients with recalcitrant laser-assisted in situ keratomileusis (LASIK)-induced neurotrophic epitheliopathy (LINE) unresponsive to conventional treatment, and to determine the possible predisposing risk factors of these patients. Methods: We enrolled 10 consecutive patients (20 eyes) undergoing femtosecond-assisted myopic LASIK surgery presenting with recalcitrant LINE for > 1 year. Another 340 patients (713 eyes) receiving femtosecond-assisted myopic LASIK without recalcitrant LINE were set as controls. Possible risk factors associated with recalcitrant LINE were investigated. Twenty percent autologous serum treatment was prescribed to 20 eyes. The efficacy of autologous serum was assessed with ocular surface conditions, tear function, and the change of best-corrected visual acuity. Results: Age older than 30 years [odds ratio (OR) = 7.74; 95% confidence interval (CI), 1.74–34.50], flap thickness < 110 μm (OR = 3.47; 95% CI, 1.22–9.73), and a flap diameter < 8.5 mm (OR = 5.38; 95% CI, 1.95–14.85) pose higher risks in femtosecond laser-assisted myopic LASIK. All eyes (100%) achieved remission after autologous serum treatment. The visual acuity before treatment was 0.49 ± 0.41 in LogMAR, and the visual acuity after treatment was 0.14 ± 0.22 in LogMAR. Time to achieve remission was 8.26 ± 11.87 weeks. Mean relapse-free survival after discontinuing autologous serum was 47 weeks. Conclusion: Risk factors of recalcitrant LINE in femtosecond laser-assisted myopic LASIK were identified as older age, a thinner flap (

PURPOSE To report a de novo R124C mutation of transforming growth factor β-induced (TGFBI) gene in one of dizygotic twins with corneal dystrophy of the Bowman layer. CASE REPORT An 11-year-old boy was one of dizygotic twins and had a history of bilateral blurred vision and recurrent corneal erosion. Examination of the visual acuity demonstrated 20/40 in his each eye. Biomicroscopy showed bilaterally central corneal subepithelial opacities and some dot opacities in the superficial stroma. Anterior segment optical coherence tomography demonstrated most hyperreflective opacities at the subepithelial layer with some interspersed opacities in the superficial stroma. Confocal microscopy revealed irregular hyperreflective materials in the Bowman layer and the superficial stroma. Several rough filaments were found in the middle layer of stroma, corresponding to a feature of amyloid lattice. The corneas of his parents and dizygotic sister were clear. Sequencing of the TGFBI gene revealed an R124C mutation in the affected boy but not in his three healthy family members. CONCLUSIONS A de novo R124C mutation of the TGFBI gene may occur in one of dizygotic twins. Patients with an R124C mutation may have clinical features like corneal dystrophy of the Bowman layer. Confocal microscopy can be used to detect subclinical lattice lines, thereby facilitating differential diagnosis.

PURPOSE Moxifloxacin (MOX), a fourth generation fluoroquinolone (FQ), has a wide antibacterial spectrum, but may show cytotoxicity characterized by high productions of reactive oxygen species (ROS). This study investigated the protective role of a common antioxidant agent, resveratrol (trans-3,5,4'-trihydroxystilbene), against the cytotoxicity caused by MOX. METHODS Experiments were performed with a human corneal epithelial cell line (HCECs; ATCC-CRL-11515). Another commonly used FQ, levofloxacin (LEV), and the most commonly used preservatives, benzalkonium chloride (BAC), were also used for comparison with MOX. Cell viability and morphologic changes after treatment were evaluated with trypan blue exclusion assay, propidium iodine/annexin V-FITC staining, and flow cytometry. Chemiluminescence immunoassay was used for ROS quantification. MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assay, wound healing assay, and intracellular detections of oxidative stress were performed to evaluate the effects of resveratrol. RESULTS The MOX group, similar to the BAC group, showed significant cell shrinkage and death compared with the LEV group. High ROS production in HCECs of MOX group was observed both by chemiluminescence immunoassay and intracellular images. Within the observations of MTS [3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium] assay, live cell images, and wound healing process in vitro, the cytotoxic effects of the MOX and BAC groups were opposed by resveratrol. Human corneal epithelial cells pretreated with resveratrol demonstrated better cell viability and healing rate in the early stage. CONCLUSIONS The protective effects of antioxidant agents indicate that MOX, similar to BAC, causes oxidative stress-related cell damage. The results also inspired us to think about a "supplementary regimen" to increase safety and decrease the adverse effect in the treatment of corneal infections.

To evaluate the factors affecting clinical outcomes of correcting cumulative refractive errors or irregular astigmatism after radial keratotomy (RK) using mini-scleral lenses.We retrospectively analyzed 36 eyes receiving mini-scleral lenses after RK from July 2011 to June 2016. Analyses included age, refractive errors, best spectacle-corrected visual acuity (BSCVA), best contact lens-corrected visual acuity (BCLCVA), topographic indices, RK treatment zone diameter (TZD), power difference (PrD) within the RK treatment zone, and decentration distance (DD) of the RK treatment zone center. An increase of three lines or more of Snellen visual acuity was considered a successful fitting.Of the eyes fitted with mini-scleral lenses, the BCLCVA (logarithm of the minimum angle of resolution [logMAR] 0.19±0.22) was significantly better than the BSCVA (logMAR 0.47±0.30). Twenty-three patients (64%) had a successful fitting. There was no statistically significant difference between successful and unsuccessful fittings with regard to age, prefitting refractive error, BSCVA, corneal astigmatism, simulated steep/flat K values, surface regularity index, TZD, or PrD. However, successful fittings had better centration of treatment zones with an average DD of 0.54±0.44 mm compared with a DD of 0.92±0.53 mm in the unsuccessfully fitted eyes. In addition, our case series showed that there was a negative impact on fitting outcomes in the presence of small central clear zones resulting from central incisions or scars.Although decentration of the RK treatment zone and small central clear zones were related to less optimal fitting results, mini-scleral lenses are a feasible option to correct cumulative refractive errors and irregular astigmatism in post-RK patients.

Purpose To determine the presence of monocarboxylate transporter (MCT) in human and rabbit corneal epithelium and its role in transcellular fluorescein transportation in the cornea. Methods The presence of MCTs in human and rabbit corneal epithelium was determined by RT-PCR and immunohistochemistry. Intracellular fluorescein uptake experiment was performed using cultured human corneal epithelial cells (HCECs). The involvement of MCT in fluorescein uptake was determined by addition of MCT inhibitors to HCECs and acute dry eye model on New Zealand albino rabbits by spectrophotometry, corneal impression cytology, and external eye photographs. Results MCT-1 and MCT-4 were identified in both human and rabbit corneal epithelia. A longer treatment period and a lower pH value in culture medium increased fluorescein uptake in HCECs. Fluorescein uptake in HCECs was decreased following addition of MCT inhibitors in a concentration-dependent manner. Impression cytology under fluorescent microscopy showed intracellular fluorescein staining in the rabbit cornea with acute dry eye treatment that was decreased following topical treatment of MCT inhibitors. Conclusions Fluorescein ingress in corneal epithelial cells is mediated by the MCT family. Further study of MCT-mediated transport on HCECs may potentially benefit differential diagnosis and contribute better understandings of ocular surface disorders.

Purpose Optic neuritis is highly correlated with multiple sclerosis and is a major cause of acute visual loss and long-term neuronal degeneration. Primary cerebral hypoperfusion has been reported in brain demyelinating diseases. This study investigated whether peripapillary perfusion is changed in patients with acute optic neuritis (AON). Methods This three-year cohort study was conducted from September 1 2012, to August 31, 2015. Two hundred and forty-one patients with non-glaucomatous acute optic neuropathy were screened, and 42 non-highly myopic patients who had suffered their first episode of unilaterally idiopathic AON were studied. All cases received spectral-domain optical coherence tomography (OCT) examination, general survey, and standard corticosteroid therapy. OCT images were analyzed using a customized MATLAB program for measuring peripapillary choroidal thickness (PCT). Multivariate regression models were constructed to identify factors that are significantly related to peripapillary perfusion. Results Decreased PCT was found in eyes experiencing AON combined with disc swelling (the ratio of lesion eye PCT/fellow eye PCT was 0.87 ± 0.08; range, from 0.75 to 1.00). In comparison to the healthy fellow eyes, approximately every 26% increase in the thickness of the retinal nerve fiber layer due to axonal swelling was associated with a 10% decreased thickness of PCT. Thinner PCT is also correlated with poorer trough vision, which may lead to poorer final vision. These findings were obvious in patients with optic papillitis but not in patients with retrobulbar neuritis. Conclusions Peripapillary vascular hypoperfusion was found in patients experiencing AON combined with disc swelling. These findings are unlike those for other ocular inflammatory diseases but are consistent with cerebral hypoperfusion, which is found in brain demyelinating diseases; thus, these findings may represent a new neurovascular model in this field.

Purpose To evaluate the corneal epitheliotropic abilities of two commercialized human platelet lysates (HPLs) and to compare the results with other blood derivatives, including human peripheral serum (HPS) and bovine fetal serum (FBS). Methods In vitro, human corneal epithelial cells were incubated in various concentrations (0%, 3%, 5% and 10%) of blood derivatives. Two commercialized HPLs, including UltraGRO TM (Helios, Atlanta, GA) and PLTMax (Mill Creek, Rochester, MI), were tested and compared with HPS and FBS. Scratch-induced directional wounding assay was performed to evaluate cellular migration. MTS assay was used to evaluate cellular proliferation. Cellular differentiation was examined by scanning electron microscopy, inverted microscopy and transepithelial electrical resistance. Sprague-Dawley rats were used to evaluate the effects of the blood derivatives on corneal epithelial wound healing in vivo. Different blood derivatives were applied topically every 2 hours for 2 days after corneal epithelial debridement. The concentrations of epidermal growth factor (EGF), transforming growth factor -β1 (TGF-β1), fibronectin, platelet-derived growth factor-AB (PDGF-AB), PDGF-BB, and hyaluronic acid in different blood derivatives were evaluated by enzyme-linked immunosorbent assay (ELISA). Results In vitro experiments demonstrated statistically comparable epitheliotropic characteristics in cellular proliferation, migration, and differentiation for the two commercialized HPLs compared to FBS and HPS. Cells cultured without any serum were used as control group. The epitheliotropic capacities were statistically higher in the two commercialized HPLs compared to the control group (p

PURPOSE To determine the association of type III secretion system (T3SS) genotype with antibiotic susceptibility, serotypes, and clinical manifestation of centrally located Pseudomonas aeruginosa keratitis. METHODS Clinical characteristics of P. aeruginosa keratitis cases from 2001 to 2011 were analyzed. Each strain was serotyped and genotyped for T3SS exotoxin genes. Antibiotic sensitivity and minimum inhibitory concentrations were determined with agar dilution method. Prognostic factors affecting final visual outcomes and time to re-epithelialization were analyzed using linear and Cox regression models. RESULTS Forty-four invasive and 28 cytotoxic strains were identified. Invasive strains occurred mostly in males (P = 0.03) with older age (P = 0.009) and ocular surgery or trauma history (P = 0.006), poor presenting (P = 0.04) and final (P < 0.0001) best spectacle-corrected visual acuity (BSCVA), and larger infiltration size (P = 0.03). Cytotoxic strains were associated with contact lens wear (P < 0.0001). Poor prognostic factors for final BCVA after adjusting for sex, age, and contact lens wear included invasive strains (P = 0.02), larger infiltration area (P = 0.02), deeper infiltrations (P = 0.02), and presence of hypopyon (P = 0.09). Factors affecting complete re-epithelialization time included invasive strains (P = 0.02), infiltration area (P = 0.01), depth (P = 0.02), and hypopyon (P = 0.03) after adjusting for age and sex. Serotypes 2, 6, and 11 were more commonly found among all isolates. A trend to increased fluroquinolone resistance is noted for invasive strains, although not reaching statistically significant difference. CONCLUSIONS Cytotoxic strains are associated with contact lens wear while invasive strains are related to poor prognosis and increased resistance to fluoroquinolones. Clinicians should be aware of the two different genotypes of P. aeruginosa affecting prognosis.

PURPOSE We used a rabbit model to evaluate the interface embedded between the recipient corneas and transplanted donor corneal discs after non-Descemet's stripping automated endothelial keratoplasty (nDSAEK). METHODS Unilateral DSAEK and nDSAEK surgeries were performed on New Zealand white rabbits. In vivo confocal microscopy was performed to show: the changes in corneal endothelial cells embedded between the recipient corneas and the transplanted donor corneal discs (CEEB); and the interface opacity by z profile. Immunohistochemistry were performed to evaluate the functional change of CEEB at post-nDSAEK 3 months. Transmission electron microscopy was performed to evaluate the morphology of CEEB after nDSAEK at post-nDSAEK 1, 3, and 6 months. RESULTS In vivo confocal microscopy showed a time-dependent decrease in the density of CEEB at postoperative 1, 2, or 3 months (P < 0.01). Interface opacity was higher in the nDSAEK group than the DSAEK group at all examination points, but the difference was statistically insignificant. At 3 months after surgery, the CEEB were negative for Na(+)/K(+)-ATPase staining. Staining with TUNEL showed apoptotic changes in some areas. During a 6-month observation, the CEEB showed a time-dependent thickening and loss of uniform thickness of cellular morphology. At 3 and 6 months post nDSAEK, extensions of the cellular processes into the donor graft stroma combined with intracellular vacuoles containing collagen-like materials were also found. CONCLUSIONS After non-Descemet's stripping automated endothelial keratoplasty, the CEEB showed decreased density, loss of pump function, apoptosis and changed morphology. However, the interface opacity was not significantly greater compared with DSAEK eyes.

Purpose To present the clinical features of four cases with bilateral anterior amorphous corneal opacity. Methods A retrospective study in four patients with bilateral anterior amorphous corneal opacity was conducted. Examinations included visual acuity, keratometry, slit-lamp biomicroscopy, confocal microscopy, anterior segment optical coherence topography, and histology. Results Three female and one male patients (mean age, 52.3 ± 8.9 years) showed bilaterally oval, amorphous sheetlike corneal opacities with central depression and thinning. Superior limbal opacities were observed in two of these patients. The best-corrected visual acuity ranged from 20/50 to 20/400, and the mean of the keratometry was 39.81 ± 3.97 D (diopters). They had mild dry eyes. The anterior segment optical coherence topography demonstrated hyporeflective abnormalities in the anterior depressed stroma in these four patients. Confocal microscopy revealed large round cells at the epithelial layer in one patient, and amorphous opacities with some strand-shaped opacities in the anterior stroma in all four patients. The mean of the corneal endothelial cells density in the eight eyes was 1521 ± 402 cells/mm2. Central corneal stromalysis occurred in three patients, and descemetocele developed in two eyes. One patient received penetrating keratoplasty and two underwent lamellar keratoplasty. The histology of the corneal specimen revealed edematous basal epithelial cells, focal collagen disorganization in the thin stroma, and wartlike excrescences in a thickened Descemet's membrane. Conclusion Anterior amorphous corneal opacity is a rare keratopathy and may be one kind of rare corneal degeneration or dystrophy. Corneal stromalysis may occur in hyporefrective amorphous opacities and progress to descemetocele.

Background/PurposeTo analyze the preoperative conditions and postoperative outcomes of phacoemulsification and intraocular lens implantation in Taiwanese patients with uveitis.MethodsThis retrospective, consecutive case series study included 121 eyes of 84 patients with uveitis who underwent phacoemulsification and intraocular lens implantation from July 1996 to May 2006. The demographic data, postoperative outcomes, complications, and risk factors with regard to visual prognosis were analyzed. Visual acuity was converted from the Snellen equivalent to logMAR values.ResultsThis study included 51 men and 70 women with a mean ± SD age of 44.6 ± 18.4 years. The three most common diseases were idiopathic uveitis, Behcet's disease, and Vogt–Koyanagi–Harada disease. The best-corrected visual acuity improved from 1.52 ± 0.83 logMAR units preoperatively to 0.37 ± 0.59 logMAR units postoperative (p

The aim of this study was to investigate the therapeutic role of preservative-free artificial tears containing hyaluronic acid and high potassium ion concentration (HA/high-K artificial tears) on mechanically scraped or alkali-induced corneal epithelial defects in rats.We created mechanically scraped epithelial defects on the corneas of 24 Sprague-Dawley (SD) rats (three groups of eight rats) and alkali-induced epithelial defects on the corneas of 27 SD rats (three groups of nine rats). Then we applied topical 0.3 per cent or 0.15 per cent HA/high-K artificial tears four times daily for 1.5 days and compared its effect with that of topical phosphate buffered saline (PBS). The fluorescein staining analysis and histological examination were performed immediately after and at 12, 24 and 36 hours after injury.In the mechanical scraping model, the areas of fluorescein staining in the eyes after topical application of 0.3 per cent HA/high-K artificial tears were significantly smaller than those after PBS treatment at 12 and 24 hours after injury. At 36 hours, the staining areas of both 0.3 per cent and 0.15 per cent HA/high-K artificial tears-treated eyes were found to be significantly smaller than those of the PBS-treated eyes. In the alkali burn model, the promotion of corneal epithelial wound healing after treatment with 0.3 per cent and 0.15 per cent HA/high-K artificial tears was not significantly different compared to that after treatment with PBS.Hyaluronic acid and high potassium ion concentration artificial tears promoted corneal epithelial wound healing in the mechanical scraping model; however, in the alkali burn model, no significant beneficial effect of this treatment was observed.

Two children with shield ulcer in vernal keratoconjunctivitis unresponsive to steroid therapy received plaque removal by superficial keratectomy, followed by amniotic membrane transplantation (AMT). Hematoxylin and eosin staining of the excised corneal specimen revealed a thick layer of eosinophilic material attached to the Bowman's layer. These deposits were positive for eosinophil granule major basic protein, as confirmed by an immunohistochemical study. The shield ulcer healed after the amniotic membrane was removed. No recurrent corneal plaque developed, although corneal opacity complicated in both cases. Lamellar keratectomy with AMT offers an effective management by removing the cytotoxic plaques and protecting the denuded stroma from deposition of inflammatory debris.

Recent studies indicate that caspase-2 is involved in the early stages of apoptosis, particularly before the occurrence of mitochondrial damage. Here we report the important role of the coenzyme Q10 (CoQ10) on the activity of caspase-2 upstream of mitochondria in ethanol (EtOH)-treated corneal fibroblasts. After EtOH exposure, cells produce excessive reactive oxygen species formation, p53 expression, and most importantly, caspase-2 activation. After the activation of the caspase-2, the cells exhibited hallmarks of apoptotic pathway, such as mitochondrial damage and translocation of Bax and cytochrome c, which were then followed by caspase-3 activation. By pretreating the cells with a cell-permeable, biotinylated pan-caspase inhibitor, we identified caspase-2 as an initiator caspase in EtOH-treated corneal fibroblasts. Loss of caspase-2 inhibited EtOH-induced apoptosis. We further found that caspase-2 acts upstream of mitochondria to mediate EtOH-induced apoptosis. The loss of caspase-2 significantly inhibited EtOH-induced mitochondrial dysfunction, Bax translocation, and cytochrome c release from mitochondria. The pretreatment of CoQ10 prevented EtOH-induced caspase-2 activation and mitochondria-mediated apoptosis. Our data demonstrated that by blocking caspase-2 activity, CoQ10 can protect the cells from mitochondrial membrane change, apoptotic protein translocation, and apoptosis. Taken together, EtOH-induced mitochondria-mediated apoptosis is initiated by caspase-2 activation, which is regulated by CoQ10.

Purpose To evaluate the role of protein tyrosine phosphatase (PTP) in controlling the integrity of cell–cell junction and intercellular permeability in postconfluent bovine corneal epithelial cells. Methods Confluent cultures of bovine corneal epithelial cells were treated with different concentrations of general phosphate inhibitors andsodium orthovanadate for varying periods. An MTS assay was used to confirm no cellular death under the treatment profile. Immunocytochemical (ICC) analysis was performed to demonstrate protein tyrosine phosphorylation after treatment with sodium orthovanadate, and the effect of sodium orthovanadate on junctional proteins such as p120, α-catenin, occludin, ZO-1, and ZO-2. Western blot analysis was used to analyze the changes in p120, α-catenin, occludin, ZO-1, and ZO-2 after treatment. Paracellular permeability was evaluated by transepithelial electrical resistance (TER). Results During the whole course of treatment, no significant cellular death was noticed. Dose- and time-dependent effects of sodium orthovanadate on protein tyrosine phosphorylation were confirmed by ICC. ICC also demonstrated the dose- and time-dependent effect of sodium orthovanadate on the disruption of p120, α-catenin, occludin, ZO-1, and ZO-2. However, results of Western blot analysis showed no change in the expression levels of p120, α-catenin, occludin, ZO-1, and ZO-2. Dose- and time-dependent increase of paracellular permeability was evaluated by TER. Conclusion Inhibition of protein tyrosine phosphatase activity can increase protein tyrosine phosphorylation. A dose- and time-dependent release of cell–cell contacts and increased transepithelial permeability were found in postconfluent culture of bovine corneal epithelial cells.

Background/Purpose Accuracy of ocular alignments is emphasized in laser refractive surgery. We evaluate pupil centroid shift and cyclotorsion and the correlation between both eyes in bilateral wavefront-guided laser refractive surgery. Methods A retrospective study was performed to analyze pupil centroid shift and cyclotorsion using an iris registration system of Zyoptix 100 platform in 186 eyes of consecutive 93 patients at National Taiwan University Hospital. Pearson’s correlation analysis was used. Results The mean pupil centroid shift was 0.179 ± 0.096 mm, and 42.2% of eyes had more than 0.2 mm shift between wavefront measurement with dilated pupil and laser ablation with undilated pupil. When the pupil was pharmacologically dilated, pupil centers predominantly shifted to inferonasal direction (59% of eyes). The vertical shift was larger than the horizontal shift. The correlations between both eyes in horizontal and vertical shifts were statistically significant, indicating a symmetric mirror pattern. A good opposite correlation of pupil centroid shifts was observed between in wavefront measurement and in laser treatment. The mean amount of cyclotorsion between the seated and supine positions was 3.22 ± 2.53° with a maximum of 13.51°. A total of 112 eyes (60.2%) had cyclotorsion > 2°, while 39 eyes (21.0%) had cyclotorsion > 5°. Moderate correlation was observed between cyclotorsion of both eyes and was statistically significant. Conclusion Inferonasal pupil centroid shift as the pupil pharmacologically dilated and a significant amount of cyclotorsion with good correlation between both eyes was observed in refractive surgery and could be compensated by iris registration.

When corneal endothelial cells (CECs) are diseased or injured, corneal endothelium can be surgically removed and tissue from a deceased donor can replace the original endothelium. Recent major innovations in corneal endothelial transplantation include replacement of diseased corneal endothelium with a thin lamellar posterior donor comprising a tissue-engineered endothelium carried or cultured on a thin substratum with an organized monolayer of cells. Repairing CECs is challenging because they have restricted proliferative ability in vivo. CECs can be cultivated in vitro and seeded successfully onto natural tissue materials or synthetic polymeric materials as grafts for transplantation. The optimal biomaterials for substrata of CEC growth are being investigated. Establishing a CEC culture system by tissue engineering might require multiple biomaterials to create a new scaffold that overcomes the disadvantages of single biomaterials. Chitosan and polycaprolactone are biodegradable biomaterials approved by the Food and Drug Administration that have superior biological, degradable, and mechanical properties for culturing substratum. We successfully hybridized chitosan and polycaprolactone into blended membranes, and demonstrated that CECs proliferated, developed normal morphology, and maintained their physiological phenotypes. The interaction between cells and biomaterials is important in tissue engineering of CECs. We are still optimizing culture methods for the maintenance and differentiation of CECs on biomaterials.

PURPOSE To investigate whether sensory input or motor signal of the extraocular muscle is the main activator of suppression in human intermittent exotropia (X(T)). METHODS A case-control study was performed. Ten subjects with X(T) and 10 control participants were enrolled. The divergence range between both eyes when binocular vision was maintained was measured by using stereotests with a self-written computer program mimicking a troposcope. The break point, defined as the deviation angle at which stereopsis broke during eye deviation, was compared between the experimental and control groups by using a t test. RESULTS The median near deviation angle in the experimental group was 42.5 prism diopters (PD) (mean, 44.5 ± 10.82 PD). The mean break point was 40.45 ± 10.79 PD in the X(T) group and 26.86 ± 2.62 PD in the control group (P = 0.003). The mean ratio of the break point to the near deviation angle was 0.92 ± 0.23 in the X(T) group, with the ratio close to 1 in 7 of 10 subjects. CONCLUSIONS Binocular vision can be maintained if similar images are projected onto corresponding retinas during the tropic phase of X(T). The antidiplopic mechanism in X(T) patients (i.e., suppression) is evoked by sensory input from binocular rivalry rather than by motor signal of the extraocular muscle.

Purpose To report the incidence, microbiological profile, graft survival, and determining factors of microbial keratitis after penetrating keratoplasty (PK). Design Observational case series. Methods The study involved 51 patients (52 eyes) who were treated at a single tertiary referral center during a 10-year period. Retrospective chart review included medical records of all patients diagnosed with microbial keratitis after penetrating keratoplasty at the National Taiwan University Hospital between January 2000 and December 2009. The main outcome measures were incidence of graft infection, microbial profile, and graft survival status. Results There were 871 PKs performed and 67 episodes in 52 eyes of culture-positive microbial keratitis during the study period. There were 32 infectious episodes (47.8%) in the first year post-PK and 35 episodes (52.2%) after the first year post-PK. Forty-four gram-positive bacterial isolates (57.9%), 17 gram-negative bacterial isolates (22.4%), and 15 fungal isolates (19.7%) were found. Twenty-three (34.3%) grafts remained clear after the infection episode with a mean follow-up of 1127 days (range, 25–3962 days). There was no difference in graft survival rate regarding the original indication of PK or offending pathogen. Suture-related infection was associated with decreased risk of graft failure ( P = .02), while the factor associated with increased risk of graft failure was usage of antiglaucoma agents ( P = .01). Conclusion Infectious keratitis after penetrating keratoplasty leads to a high graft failure rate. Such complications can occur before or after the first year post-PK.

Corneal endothelial cells (CECs) play a crucial role in maintaining corneal clarity through active pumping. A reduced CEC count may lead to corneal edema and diminished visual acuity. However, human CECs are prone to compromised proliferative potential. Furthermore, stimulation of cell growth is often complicated by gradual endothelial-mesenchymal transition (EnMT). Therefore, understanding the mechanism of EnMT is necessary for facilitating the regeneration of CECs with competent function. In this study, we prepared a primary culture of bovine CECs by peeling the CECs with Descemet's membrane from the corneal button and demonstrated that bovine CECs exhibited the EnMT process, including phenotypic change, nuclear translocation of β-catenin, and EMT regulators snail and slug, in the in vitro culture. Furthermore, we used a rat corneal endothelium cryoinjury model to demonstrate the EnMT process in vivo. Collectively, the in vitro primary culture of bovine CECs and in vivo rat corneal endothelium cryoinjury models offers useful platforms for investigating the mechanism of EnMT.

The genus Fusarium comprises many species, including Fusarium oxysporum, Fusarium solani, Fusarium graminearum and Fusarium verticillioides, and causes severe infections in plants and humans. In clinical settings, Fusarium is the third most frequent mould to cause invasive fungal infections after Aspergillus and the Mucorales. F. solani and F. oxysporum are the most prevalent Fusarium spp. causing clinical disease. However, few effective antifungal drugs are available to treat human and plant Fusarium infections. The cationic peptide antibiotic polymyxin B (PMB) exhibits antifungal activity against the human fungal pathogens Candida albicans and Cryptococcus neoformans, but its efficacy against Fusarium spp. is unknown. In this study, the antifungal activity of PMB was tested against 12 Fusarium strains that infect humans and plants (banana, tomato, melon, pea, wheat and maize). PMB was fungicidal against all 12 Fusarium strains, with minimum fungicidal concentrations of 32 µg/mL or 64 µg/mL for most strains tested, as evidenced by broth dilution, methylene blue staining and XTT reduction assays. PMB can reduce the germination rates of conidia, but not chlamydospores, and can cause defects in cell membrane integrity in Fusarium strains. PMB exhibits synergistic activity with posaconazole and can potentiate the effect of fluconazole, voriconazole or amphotericin B against Fusarium spp. However, PMB does not show synergistic effects with fluconazole against Fusarium spp. as it does against Candida glabrata and C. neoformans, indicating evolutionary divergence of mechanisms between yeast pathogens and the filamentous fungus Fusarium.

Background To report seven cases diagnosed as cytomegalovirus endotheliitis and treated with topical 2% ganciclovir following penetrating keratoplasty. Design A retrospectively comparative case series. Participants A retrospective interventional case series, including seven eyes of seven patients with cytomegalovirus endotheliitis after penetrating keratoplasty. Methods Clinical and immunological characteristics were studied in seven penetrating keratoplasty cases with positive quantitative polymerase chain reaction results for cytomegalovirus DNA from aqueous taps and treated with topical 2% ganciclovir. Main Outcome Measures Clinical features and responses to topical 2% ganciclovir. Results Seven immunocompetent patients experienced acute anterior inflammation with graft oedema and pigmented keratic precipitates after penetrating keratoplasty. Their immunological profiles showed immunoglobulin G cytomegalovirus (+) and immunoglobulin M cytomegalovirus (–) in all cases. Topical 2% ganciclovir was prescribed every 2 to 3 h daily as induction therapy and every 4 h as long-term maintenance therapy. All cases had undetectable cytomegalovirus DNA after follow-up aqueous taps. Topical 2% ganciclovir preserved endothelium of cytomegalovirus-infected grafts at early stage and also provided a steady anticytomegalovirus environment for further regrafting in failed grafts at late stage. Acute inflammation reactivated in two cases and was suppressible by steroid under topical ganciclovir. No delayed re-epithelialization and any toxicity were observed. To date, no case treated in this way had displayed cytomegalovirus recurrence. Conclusions Continuous topical 2% ganciclovir and a topical steroid adjusted by anterior inflammation are suggested after penetrating keratoplasty in all cases with cytomegalovirus endotheliitis to prevent cytomegalovirus recurrence.

Purpose This work was conducted in order to study the intraocular lens (IOL) power predictability of formulas provided by the American Society of Cataract and Refractive Surgery (ASCRS) website for patients who had undergone myopic laser refractive surgery. Methods In this retrospective study, we analyzed 11 eyes (from nine patients) that had previously undergone myopic laser-assisted in situ keratomileusis or photorefractive keratectomy and experienced subsequent phacoemulsification and posterior-chamber IOL implantation. Using the adjusted central K (keratometry), axial length, and the SRK/T formula, we compared the original desired refraction to the manifest refraction 1 month after cataract surgery. According to the postoperative manifest refraction, we compared the IOL power calculated using the different methods on the ASCRS website. Results Before cataract surgery, the mean adjusted central K reading was 35.90 diopters (D) (range 29.24–41.58 D), and the mean axial length was 28.53 mm (range 25.77–32.79 mm). Postoperatively, the mean arithmetic refractive prediction error was 0.50 D (range −1.72 D to 2.33 D), and the mean absolute error was 1.07 D (range 0.01–2.33 D). The most reliable method was the Masket method in combination with the double K Holladay I formula. The predictability of the adjusted central K method and the Masket method in combination with the single-K SRK/T formula was as precise as that of the modified Masket method in combination with the double K Holladay I formula and the Shammas method in combination with the Shammas-PL formula. Conclusion ASCRS offers the use of a postrefractive IOL calculator online, free of charge. The Masket method in combination with the double K Holladay I formula is the best choice for IOL power prediction after laser-assisted in situ keratomileusis or photorefractive keratectomy surgery. The adjusted central K method is a convenient and effective strategy with which to correct central corneal power. However, double K formulas designed for adjusted central K should be used for more accurate predictions of lens position.

Background/Purpose To compare the efficacy and safety of topical cromolyn between with and without preservative for the treatment of allergic conjunctivitis. Methods A double-masked study was performed in patients with allergic conjunctivitis. Each cromolyn sodium 2% ophthalmic solution with or without 0.01% benzalkonium chloride (BAK) was randomized to apply on either eye. The efficacy and safety were evaluated every other week by a questionnaire about ocular itching, redness and foreign body sensation, and objective scores of conjunctival redness, chemosis, cornea erosion and discharge using slit-lamp biomicroscopy. An overall response was also rated by physician's impression. Results A total of 37 subjects were enrolled in this study but only 33 completed the study. All of subjective questionnaire scores showed a significant improvement after treatment in both groups. Objective score of redness significantly decreased after treatment in either groups but not chemisos or discharge. After 4-week treatment, corneal erosion diminished significantly in the group without preservative but not in the group with 0.01% BAK. There was no significant difference between with and without 0.01% BAK groups in each subjective or objective score. No adverse effect related with medication was observed. Conclusion Cromolyn 2 % ophthalmic solution was effective and safe to treat allergic conjunctivitis. A short-term use of cromolyn 2 % ophthalmic solution with 0.01% BAK would not cause any significant toxicity in patients with allergic conjunctivitis. Preservative-free cromolyn may be beneficial to the compromised eyes or eyes required of long-term medication.

PURPOSE To assess the accuracy of measuring intraocular pressure (IOP) through a soft contact lens (SCL) with different refractive powers using a noncontact tonometer (NCT). METHODS Thirty-two healthy adult volunteers free of glaucoma or corneal disease participated in this study. IOP was measured in the right eyes without SCLs and with different lens powers, from -3.0 to -12.0 D as measured by NCT. IOP of the left eyes was also measured, as an internal control. Corneal curvature was measured in both eyes using an autokeratometer. Sixteen volunteers wore one brand of SCL (group A) and the other 16 wore a different brand, with 2 different curvatures (groups B and C). Statistical data were analyzed by SPSS using the Wilcoxon signed rank test for comparison of IOP readings and multiple linear regression analysis for the relationship among power of contact lenses, corneal power, and difference in IOP measurements. RESULTS The difference in mean IOP between eyes without lenses and those with lenses was statistically significant in lens with -6.0 D and below in all 3 groups. The decrease in IOP significantly correlated with the refractive power of contact lenses in all 3 groups. The difference in IOP measurements was influenced by the mean K in group A but not in group B or C. There was no statistically significant difference in the IOP measurements in the left eyes or in the mean K between the right and left eyes. CONCLUSIONS IOP measurement through myopic SCLs by NCT may be inaccurate and tends toward underestimation, especially in high myopic lenses. A strong relationship exists between IOP reduction and myopic lens power.

PURPOSE To compare the corneal epitheliotrophic capacity of different human blood-derived preparations, including cord blood serum (CBS), peripheral blood serum (PBS), and fresh frozen plasma (FFP) on bovine corneal epithelial cells. MATERIALS AND METHODS The concentrations of epithelial growth factor, transforming growth factor β1, insulin-like growth factor 1, hyaluronic acid, fibronectin, albumin, glucose, and calcium in different human blood derivatives were evaluated using enzyme-linked immunosorbent assay or biochemical methods. Cultivated bovine corneal epithelial cells were incubated with various blood derivatives, and cell proliferation, migration, and differentiation were evaluated by colorimetric assay, Boyden chamber chemotaxis assay, wounding assay, scanning electron microscopy, and transepithelial electric resistance measurements. Wound closure was assessed using a scratch-induced directional wounding assay. RESULTS Of the 3 human blood derivatives evaluated, CBS had the highest concentrations of epithelial growth factor, transforming growth factor β1, and hyaluronic acid (P < 0.05). FFP had the lowest concentration of calcium and the highest concentration of glucose (P < 0.05). CBS demonstrated the highest ability to promote cellular proliferation, followed by PBS and FFP (P < 0.05). CBS was also the best in promoting cellular differentiation because scanning electron microscopy demonstrated coherent monolayers of flattened and polygonal-shaped cells with evenly distributed microvilli. Transepithelial electric resistance was noted to be the highest for cells incubated in CBS, indicating formation of well-differentiated cells with functional tight junction (P < 0.05). Cells cultivated with FFP were the least capable of promoting proliferation, migration, and differentiation. CONCLUSIONS Different human blood derivatives may have different concentrations of epitheliotrophic factors. CBS is generally superior to PBS in promoting corneal epithelial proliferation and differentiation.

To determine the effects on corneal neovascularization (NV) and lipid deposition after subconjunctival injection of bevacizumab in patients who had NV associated with lipid keratopathy.A case interventional study enrolled 18 patients (18 eyes) with lipid keratopathy. We gave monthly subconjunctival injections of bevacizumab from 3 to 10 times during the follow-up period according to the clinical response. We evaluated the centricity, extent, and percentage of involved corneal surface (PICS) of the corneal NV; the density and PICS of the corneal lipid deposition; and best-corrected visual acuity before and after treatment. We analyzed the treatment effects using Wilcoxon and Student t tests.After the treatment, the change in best-corrected visual acuity was less than 2 lines. The extent, centricity, and PICS of the corneal NV and the density and PICS of the corneal lipid deposition decreased significantly after treatment (P = 0.014/0.002/0.001 and 0.001/0.001, respectively). No eyes had side effects.The effects of subconjunctival injection of bevacizumab in treating corneal NV associated with lipid deposition were significant in some patients.

Anesthetic toxic keratitis is rare and presents as a ring keratitis, which is often misdiagnosed as Acanthamoeba keratitis. Here, we report an unusual case of toxic keratitis caused by topical abuse of a dilute anesthetic. A 26-year-old woman presented with bilateral corneal edema, ring infiltrates, pigmented keratic precipitate, Descemet's membrane folding, and strong anterior chamber reactions 2 weeks after laser subepithelial keratomileusis surgery. Tracing back her medical history, topical dilute 0.1% proparacaine was prescribed and frequently used for 1 month. Toxic keratitis was suspected. After discontinuation of the topical anesthetic and initiation of treatment with topical 20% autologous serum, complete corneal epithelialization was achieved within 1 week. Corneal infiltrates and anterior chamber reaction gradually subsided. Vision improved from finger counting to 20/20 in the right eye and 20/25 in the left eye, but confocal microscopy showed decreased corneal endothelial cells. Topical abuse of a dilute topical anesthetic can cause severe toxic keratitis and endothelial cell loss. The physician must be aware of the signs of topical anesthetic abuse and should not prescribe even a dilute anesthetic for long-term use. Autologous serum can help in the recovery of toxic keratitis.

To evaluate the clinical effect of interferon beta-1a on optic neuritis (ON) relapse in patients with multiple sclerosis (MS) in Taiwan.Data were collected from 23 MS patients with ON at National Taiwan University Hospital between January 1, 1993 and February 1, 2007. Twenty-three MS patients with ON received interferon beta-1a (Rebif) 44 microg via subcutaneous injection three times weekly. All patients received corticosteroids pulse therapy followed by oral prednisolone for acute ON. The annual relapse rate (ARR) of ON in these MS patients before and after the use of interferon beta-1a (Rebif) was the main clinical parameter of outcome in this study.The ARR of ON was lower in the posttreatment period than in the pretreatment period (P = 0.0068). Thirteen patients (56.5%) had improved final visual acuity (2 lines), and the other ten patients (43.5%) had stable final visual outcome (-2 linesX2 lines). In addition, no recurrence of ON was noted in 15 patients (65.2%) during the posttreatment period.The use of interferon beta-1a 44 microg via subcutaneous injection three times weekly did not increase the ON attacks in MS patients receiving this treatment. In addition, beneficial effects were found with the use of interferon beta-1a on these patients.

Aims: It was the aim of this study to perform a review of the clinical features, treatments and outcomes of patients with idiopathic sclerosing orbital inflammation (ISOI) in Taiwan. Methods: All patients with histologically confirmed ISOI from 1995 to 2007 at the National Taiwan University Hospital were included. We reviewed the medical charts to see the clinical presentation, treatment modalities, treatment efficacy and final clinical status of these patients. Results: Six male and 3 female patients ranging in age from 33 to 82 years were included. The most common symptoms were pain and blurred vision (both 77.8%). Reduced visual acuity and proptosis were the most common signs (both 89%). Five patients received oral steroid treatment with/without pulse therapy combined with tissue removal, the response to which was good in 1 patient and partially effective in the other 4 patients. One patient received oral steroids and surgery, followed by radiotherapy, with only partial response. Patients with oral prednisolone or surgery only all had poor responses. Conclusion: ISOI is rare and also difficult to diagnose and manage. Early intervention with steroids/immunosuppressants combined with surgical debulking procedures may result in control or regression of this recalcitrant disease.

To compare the cytotoxicity of different fluoroquinolones (FQs) towards human corneal epithelial cells (HCECs). HCECs were incubated with FQs (norfloxacin, ciprofloxacin, ofloxacin, levofloxacin, moxifloxacin, and gatifloxacin), both as commercial ophthalmic formulations and as unpreserved solutions. Cells incubated in different formulations of gentamicin, cefazolin, and benzalkonium chloride (BAC) were also compared. A cell viability assay, using 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium (MTS) assay, was used to evaluate the drug effects on cell viability after five incubation times (30 min, 1 h, 4 h, 8 h, and 24 h). Transepithelial electrical resistance (TEER) was measured with a voltohmmeter to help understand changes in paracellular permeability at five time points (4 h, 8 h, 12 h, 24 h, and 48 h). Cell morphology was observed with an inverted fluorescence microscope, with multiple stage position and in time-lapse mode. The preserving solutions and BAC at concentrations above 0.005% significantly decreased cell viability, when assayed by MTS. Increased paracellular permeability and decreased membrane integrity were also observed by TEER measurements and inverted fluorescence microscopy. Ofloxacin and levofloxacin were both free of preservatives and showed the least cytotoxicity towards HCECs in commercial FQ eye drops. The cytotoxicity observed with FQ eye drops seems to be caused mainly by the preservative, which induced a significant decrease in membrane integrity and increased paracellular permeability. We found the new generation of FQs (moxifloxacin and gatifloxacin) no less cytotoxic towards HCECs than the old generation ones.

Purpose To evaluate the clinical outcomes in patients with recurrent corneal erosions who received anterior stromal puncture by use of neodymium:yttrium–aluminum–garnet (Nd:YAG) laser. Design Retrospective, nonrandomized, consecutive case series. Participants From 2000 to 2005, 33 eyes of 33 patients with unilaterally recurrent macroform corneal erosions showing poor response to conservative management who were treated with Nd:YAG laser were studied. Intervention Anterior corneal stromal puncture with Nd:YAG laser was performed in the loosened epithelium or epithelial defect area. The causes and frequency of corneal erosions and the spot numbers and total energy of the Nd:YAG laser were recorded. Slit-lamp biomicroscopic examination, refraction, corneal topography, and times of laser were reviewed. A questionnaire regarding the preoperative and postoperative difference in the intensity of pain and frequency of corneal erosion was provided. Main Outcome Measures Rate of recurrence and pain assessment by numerical rating scale. Results Sixteen eyes were completely symptom free and 12 eyes had mild pain but no evidence of recurrent corneal erosion after operation. Five eyes had repeated episodes of recurrent corneal erosion. Eyes with a traumatic cause responded better to Nd:YAG laser therapy than those without. The frequency of corneal erosions and the severity of pain significantly improved in eyes with macroform and symptom-only recurrence. There was no significant change in refraction, but corneal surface regularity slightly improved after surgery. No adverse reaction was observed during follow-up. Conclusions Anterior stromal puncture by Nd:YAG laser is an effective and simple procedure to treat recurrent corneal erosion. It can ameliorate the frequency of attacks and the intensity of pain. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Corneal wound healing is one of the major issues in ocular surface reconstruction and ocular surface diseases. Amniotic membrane (AM) transplantation is an excellent treatment modality to promote corneal wound healing and treat corneal diseases. It is interesting and valuable to search for another synthetic and biocompatible substitute for the study of mechanism of AM and the treatment of ocular surface disorders. Chitosan, the second-most abundant polymer in nature, has many biological advantages such as biocompatibility, biodegradability, hemostatic activity, and wound-healing property to be used as biomedical applications. The purpose of this project is to evaluate the phenotype of cultured corneal epithelial cells in vitro on synthetic chitosan membrane (CM). We cultivated bovine corneal epithelial cells on CM and AM, and then evaluated their phenotypes. The viability of the respective cell cultures was investigated using the 3-[4,5-dimethylrhiazol-2-yl]-2,5-diphenyl tetrazolium bromide (MTT) assay. The cytotoxicity of CM and AM to corneal epithelial cells was evaluated by lactate dehydrogenase (LDH) assay. The morphology of cultivated corneal epithelial cells on CM and AM was observed by scanning electron microscopy. Additionally, immunocytochemical stainings were used to confirm the phenotype of corneal epithelial cells. In MTT and LDH assays we found that the CM can support the growth of cultured corneal epithelial cells in good condition with minimal toxicity. The SEM and immunohistocytochemistry showed that the phenotype of corneal epithelial cells is compatible with that of AM. We conclude that the CM has the potential to be a suitable biomaterial for treating ocular surface disorders.

To evaluate the activation of ERK, a MAP kinase, in the regulation of proliferation and migration of rabbit corneal endothelial cells during the healing process after scrape wound injury.Cultured rabbit corneal endothelial cells were used in this study. Immunocytochemistry and Western blot analysis were performed to demonstrate the phosphorylation of ERK after scrape injury. The injured cell sheets were treated with different concentrations of ERK inhibitor, PD98059. The wound closure at 24, 48, and 72 hr following injury was evaluated. In order to evaluate the role of proliferation during wound healing, immunocytochemistry with Ki67 and 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium inner salt (MTS) assay were performed. The role of cell migration in wound healing was evaluated by quantification with the time lapse microscopic video imaging system.Immunocytochemical and Western blot analysis revealed phosphorylation of ERK in the rabbit corneal endothelial cells after wounding. Inhibition of ERK phosphorylation by PD58059 resulted in a dose-dependent delay of wound closure. The inhibition of wound healing became significant from 48 to 72 hr in cells treated with 10 and 50 micro M of PD58059 (p0.05). ERK inhibition suppressed cell proliferation as indicated by Ki67 immunostaining and MTS assay. The time lapse microscopic video imaging analysis indicated delayed cell migration caused by PD98059.ERK activation regulates wound repair of rabbit corneal endothelial cells. Both cell proliferation and migration are involved in this process.

Schnyder crystalline corneal dystrophy (SCCD) is a rare autosomal dominant disease characterized by progressive corneal opacification resulting from abnormal deposition of cholesterol and phospholipids. Recently, six different mutations on the UBIAD1 gene on chromosome 1p36 were found to result in SCCD. The purpose of this article is to further characterize the mutation spectrum of SCCD and identify structural and functional consequences for UBIAD1 protein activity. DNA sequencing was performed on samples from 36 individuals from 14 SCCD families. One affected individual was African American and SCCD has not been previously reported in this ethnic group. We identified UBIAD1 mutations in all 14 families which had 30 affected and 6 unaffected individuals. Eight different UBIAD1 mutations, 5 novel (L121F, D118G, and S171P in exon 1, G186R and D236E in exon 2) were identified. In four families with DNA samples from both affected and unaffected individuals, the D118G, G186R, T175I, and G177R mutations cosegregated with SCCD. In combination with our previous report, we have identified the genetic mutation in UBIAD1 in 20 unrelated families with 10 (including 5 reported here), having the N102S mutation. The results suggest that N102S may be a mutation hot spot because the affected families were unrelated including Caucasian and Asian individuals. There was no genotype phenotype correlation except for the T175I mutation which demonstrated prominent diffuse corneal haze, typically without corneal crystals. Protein analysis revealed structural and functional implications of SCCD mutations which may affect UBIAD1 function, ligand binding and interaction with binding partners, like apo E.

PURPOSE: To compare the bacteriostatic effects, corneal cytotoxicity, and ability to seal corneal incisions among fibrin glue and 2 commercially available cyanoacrylate derivatives: N-butyl cyanoacrylate and methoxypropyl cyanoacrylate. METHODS: The bacteriostatic activities of these tissue glues were verified by measuring the zones of bacterial growth inhibition surrounding the adhesive droplets on agar plates inoculated with Staphylococcus aureus, Streptococcus pneumoniae, Pseudomonas aeruginosa, Escherichia coli, or Mycobacterium chelonae. Corneal cytotoxicity was tested by a direct contact method by using cultured bovine corneal epithelial cells, keratocytes, and corneal endothelial cells challenged with droplets of adhesives. Each of the cells was treated with droplets of adhesives. The ability to seal corneal incisions was verified by calculating the maximum intraocular pressure resistant to leakage of rabbit corneal stab wounds sealed with tissue adhesives. RESULTS: Methoxypropyl cyanoacrylate and N-butyl cyanoacrylate showed bacteriostatic effects against S. aureus, S. pneumoniae, and M. chelonae but not P. aeruginosa and E. coli. In contrast, fibrin glue had no such effects against either Gram-positive or -negative bacteria (P < 0.01). Methoxypropyl cyanoacrylate showed the highest levels of corneal cytotoxicity, followed by N-butyl cyanoacrylate. Fibrin glue, however, showed minimal cytotoxicity (P < 0.01). Methoxypropyl cyanoacrylate and N-butyl cyanoacrylate also displayed a greater ability to seal corneal incisions than that of fibrin glue (P < 0.01). CONCLUSIONS: The bacteriostatic effects, corneal cytotoxicity, and ability to seal corneal incisions differed among the 3 compounds tested. These different properties should be considered when choosing tissue adhesives during corneal surgery.

Purpose To report a case of acute bilateral corneal opacity related to bacterial blepharoconjunctivitis. Methods Interventional case report. An 18-month-old boy had bilateral red eyes with discharge and periorbital eczema. Bilateral corneal opacity suddenly developed 1 week later. Results All clinical assessments and laboratory evaluations of viral infection and autoimmune profiles were negative except for growth of coagulase-negative staphylococcus and propionibacterium acnes from conjunctival discharge. After systemic and topical antibiotic treatment, the opacity and inflammation of both eyes decreased. The left cornea became clear, but the right eye had a sequela of corneal opacity with stromal neovascularization and conjunctival scarring. Penetrating keratoplasty was performed in the right eye 6 months later. Histology at that time showed neovascularization in the deep stroma with perivascular mononuclear cell infiltration and decreased endothelial cells. Conclusions Acute bilateral corneal opacity is rare but may occur in children with bacterial blepharokeratoconjunctivitis. Ocular surface inflammation may be induced by bacterial toxin reaction. Combined use of antibiotics and steroids may save the vision in such patients.

PURPOSE: To investigate the role of heredity in determining refractive variables, anterior corneal curvature, and anterior corneal aberrations. METHODS: Thirty-three monozygotic and 10 dizygotic twin pairs were enrolled in this study. Corneal curvature, corneal astigmatism, and corneal topography were obtained from computerized videokeratoscope. The CTView program was used to compute anterior corneal aberrations from corneal height data of the videokeratoscope. Correlation analysis was performed to investigate the symmetry of the refractive error, corneal curvature, corneal astigmatism, and anterior corneal aberrations between right and left eyes of each twin pair. Heritability [h2) of these parameters was also calculated. RESULTS: Positive correlations were noted between right and left eyes for spherical power, total astigmatism, mean corneal curvature, and corneal astigmatism. In monozygotic twins, vertical coma, secondary vertical coma, spherical aberration, and secondary spherical aberration were moderately correlated. In dizygotic twins, vertical coma, secondary horizontal coma, and spherical aberration were moderately correlated. In unrelated controls, secondary vertical coma, secondary horizontal coma, and secondary spherical aberration were moderately correlated. Root-mean-square (RMS) of higher order aberrations (3rd to 6th orders), RMS of spherical aberration, and RMS of coma were moderately correlated between right and left eyes in all three groups. Heritability of spherical aberration, RMS of spherical aberration, and corneal astigmatism (ft2=0.56, 0.44, and 0.46) were greater than those of refractive power, corneal curvature, and other higher order aberrations. CONCLUSIONS: These results suggest that corneal astigmatism and spherical aberration possess a greater genetic predisposition than those of other refractive errors and higher order aberrations. [J Refract Surg. 2007;23:257-265.]

PURPOSE Accurate diagnosis and early recognition of dry eye symptoms are important in the management of dry eye disease (DED). This study aimed to evaluate concordance between patient and clinician assessment of DED severity and treatment response. METHODS This cross-sectional study was conducted in 2 ophthalmology clinics in Taiwan. Clinicians assessed severity based on the Dry Eye Workshop severity grading (levels 1-4; where 4 = most severe), whereas patients completed the Ocular Surface Disease Index questionnaire. To evaluate the treatment response, patients completed the Subject Global Assessment scale, and clinicians independently assessed patients using the Clinical Global Impression scale. RESULTS A total of 466 patients were included. Clinicians graded 88.3% of patients as level 1/2, 9.0% as level 3, and 2.7% as level 4 Dry Eye Workshop severity, whereas 44.9% of patients reported normal/mild symptoms, 17.1% with moderate severity, and 38.0% with severe DED. Patients were primarily treated with artificial tears. The clinician assessed 10.3% of patients as unchanged on disease severity after treatment and 88.0% as improved, whereas 49.2% of patients reported dry eye symptoms being almost the same after treatment and 34.6% reported improved symptoms. There was low agreement between clinician and patient assessments in terms of disease severity (rho = 0.17, P < 0.001) and treatment response (rho = 0.22, P < 0.001). CONCLUSIONS There were marked differences in the degree of DED severity and treatment response between patient and clinician assessment. Clinicians may underestimate DED severity and persistence of dry eye symptoms after treatment with artificial tears.Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01942226.

Purpose: To report the in-vivo confocal microscopic findings of dendritiform cells in the central corneal epithelial layer in a case of mixed bacterial keratitis associated with severe immunologic reaction. Design: Observational case report. Methods: A 25-year-old male suffered from contact lens-related mixed bacterial keratitis with a dense eccentric immune ring. In-vivo confocal microscopy was performed to study the different layers of the central and peripheral cornea in the lesion and the fellow eye. Results: Several dendritiform cells were found in the basal and superficial epithelial layers of the central cornea in the lesion eye, which was also the area of the dense immune ring formation. No such cells could be identified in the fellow eye or the unaffected area of the lesion eye. Conclusion: Corneal dendritiform cells, possibly dendritic or Langerhans cells, can be identified in severe corneal immunologic conditions using in-vivo confocal microscopy. The role of these cells in ocular immunity is i...