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Traumatic paralytic esotropia due to 6th nerve palsy is not uncommon but difficult to manage. We reported a case of 38‑year‑old male who sustained head injury in road traffic accident 15 years ago and inward deviation of his left eye. His vision in right eye was 20/20 and counting fingers at one foot in the left eye. He had >70 prism diopters esotropia in the left eye with restriction of movements in all directions of gaze except adduction. His forced duction test was positive. Examinations of the anterior and posterior segments of both eyes were within normal limits. Magnetic resonance imaging suggested old traumatic insult in the left eye. Diagnosis of left eye traumatic 6th nerve palsy with medial rectus contracture was made. Left medial rectus recession with hangback sutures and Hummelsheim procedure were performed. Postoperatively, the patient's vision in the left eye had improved to 20/80 the esotropia had reduced to 15 prism diopters (delta).

PURPOSE: We compared the efficacy of different contact lens disinfection systems to eliminate adenovirus. METHODS: Laboratory study evaluating the elimination of adenoviral ocular isolates by contact lens disinfection systems. Hard (gas permeable) and soft contact lenses were contaminated with adenovirus serotypes 8 and 19, and then they were disinfected with chemical, hydrogen peroxide, and heat sterilization systems. The survival of the adenovirus was determined by the shell vial technique. RESULTS: Adenovirus survived chemical and hydrogen peroxide disinfection but not heat sterilization. CONCLUSION: Because heat sterilization is not readily available to sterilize adenovirus contaminated contact lenses, it may be prudent for patients with adenoviral keratoconjunctivitis to dispose of unclean contact lenses.

Purpose: To understand the pathogenic evolution of viral keratoconjunctivitis in Kaohsiung, Taiwan, a retrospective molecular and clinical analysis was conducted. Methods: From January 1990 to December 1994, conjunctival swab samples from patients suspected of having viral conjunctivitis were collected for viral culture isolation, neutralization test (NT), and endonuclease cleavage analysis. Six restriction endonucleases, comprising HindIII, BamHI, SalI, SstI, SmaI, and PstI, were used for cleavage. Clinical examinations of patients were performed by two senior ophthalmologists. Results: Twenty-one cases of a new genotype of adenovirus (Ad) type 8, designated as Ad8H, were discovered in the 27 detected adenovirus cases. The Ad8H has a distinct cleavage pattern, especially by HindIII and SalI. The Ad8H keratoconjunctivitis induced more subconjunctival hemorrhage (33.3%), keratitis (33.3%), and lymphadenopathy (85.7%) than other genotypes of Ad8 previously isolated in Kaohsiung, Taiwan. Conclusion: We have discovered a new genotype, Ad8H, which was prevalent as the main pathogen of the adenoviral keratoconjunctivitis in Kaohsiung, Taiwan from 1990 to 1994. Adenovirus type 8 is evolving into more genotypes with a trend towards more severe symptoms, including subconjunctival hemorrhage, keratitis, and lymphadenopathy.

To determine the efficacy of a new formulation of topical dexamethasone 0.1%/povidone-iodine 0.4% (FST-100) in reducing clinical symptoms and infectious viral titers in a rabbit model of adenoviral keratoconjunctivitis.Rabbit corneas were inoculated bilaterally with 2×10(6) plaque-forming-units (PFU) of adenovirus type 5 (Ad5) after corneal scarification. Animals were randomized 1:1:1:1 (five rabbits per group) to FST-100, 0.5% cidofovir, tobramycin/dexamethasone (Tobradex; Alcon Laboratories, Fort Worth, TX) ophthalmic suspension, and balanced salt solution (BSS; Alcon Laboratories). Treatment began 12 hours after viral inoculation and continued for 7 consecutive days. The eyes were clinically scored daily for scleral inflammation (injection), ocular neovascularization, eyelid inflammation (redness), friability of vasculature, inflammatory discharge (pus), and epiphora (excessive tearing). Eye swabs were collected daily before treatment for the duration of the study. Virus was eluted from the swabs and PFU determined by titration on human A549 cells, according to standard procedures.The FST-100 treatment resulted in significantly lower clinical scores (P0.05) than did the other treatments. The 0.5% cidofovir exhibited the most ocular toxicity compared with FST-100, tobramycin/dexamethasone, and balanced salt solution treatments. FST-100 and 0.5% cidofovir significantly (P0.05) reduced viral titers compared with tobramycin/dexamethasone or balanced salt solution.FST-100 was the most efficacious in minimizing the clinical symptoms of adenovirus infection in rabbit eyes. FST-100 and 0.5% cidofovir were both equally effective in reducing viral titers and decreasing the duration of viral shedding. By providing symptomatic relief in addition to reducing infectious virus titers, FST-100 should be a valuable addition to treatment of epidemic adenoviral keratoconjunctivitis.

This research focuses on four cases of patients having undergone eximer laser photorefractive surgery who were diagnosed with adenoviral keratoconjunctivitis during the postoperative period and who later developed epidemic keratoconjunctivitis (EKC)-like keratitis. Two of the patients had undergone laser-assisted subepithelial keratectomy (LASEK), one had undergone laser in situ keratomileusis and one had photorefractive keratectomy. After the surgery adenoviral keratoconjunctivitis and recurrent late-developing EKC-like keratitis were observed in the patients. Recurrent late-developing EKC-like keratitis occurred in one of the patients, who had received LASEK as many as three times. The others had only one or two episodes.The corneal infiltrates of keratitis mainly occurred in the central cornea. Successful resolution of recurrent late-developing EKC-like keratitis was achieved through the use of topical steroids without sequelae and the final best-corrected visual acuity was as good as the base line. These keratitis infiltrates have been presumed to represent an immune response to the suspected adenoviral antigens deposited in corneal stroma during the primary adenoviral infection. Previous reports argued that patients with a history of adenoviral ketatoconjunctivitis were succeptible to adenoviral keratoconjunctivitis becoming reactivated; however, in our research, our patients had their first adenoviral infections after the eximer laser photorefractive surgery and reactivation was confirmed. We recommend that attention be paid to adenoviral infection after laser refractive operations, because these patients seem to have more frequent recurrences.

Currently, there is no effective treatment for ocular adenoviral infections that occur in epidemics worldwide, produce significant patient morbidity, and cause substantial economic losses. We tested several new antivirals in vitro, and found that ( S )-HPMPC, ( S )-HPMPA, and 2′-nor-cyclic GMP demonstrated significant serotype-dependent inhibitory activity by plaque reduction assay (ID 50 = 0.017−17.0 μ g/ml) against common clinical ocular isolates and standard adenoviral serotypes (Ad 1, Ad 5, Ad 8, and Ad 19). ( S )-HPMPC was the least toxic (CD 50 in A549 cells = 306 μ g/ml), and ( S )-HPMPC and ( S )-HPMPA had high selectivity indices.

Objective To evaluate the efficacy of 0.2% cidofovir eyedrops and 1% cyclosporine eyedrops administered 4 times daily (qid) to treat acute adenoviral keratoconjunctivitis. Methods A randomized, controlled, double-masked study was conducted on 39 patients with acute adenoviral keratoconjunctivitis of recent onset. Patients were divided into 4 treatment groups: (1) cidofovir qid, (2) cyclosporine qid,(3) cidofovir + cyclosporine qid, and (4) sodium chloride qid (control). The diagnosis was confirmed using adenoviral polymerase chain reaction from conjunctival swabs. Duration of treatment was 21 days. Main Outcome Measures Severity of conjunctival hyperemia, conjunctival chemosis, superficial punctate keratitis during treatment, and presence and severity of corneal subepithelial infiltrates were evaluated using a clinical score. Duration until subjective improvement of symptoms was recorded. Results Subjective improvement of local symptoms was accelerated in the cyclosporine group. All other clinically relevant variables showed no statistically significant difference among the 4 treatment groups. Particularly, we did not find a difference in the frequency of corneal subepithelial infiltrates at the end of treatment. Conclusions Use of cidofovir, cyclosporine, or both did not accelerate the improvement of clinical symptoms of acute adenoviral keratoconjunctivitis compared with the natural course of the infection as demonstrated by this pilot study. This might be because of the wide spectrum of the clinical course of the infection, low sensitivity to cidofovir, too low of a concentration of cidofovir, or early cessation of viral replication in the course of the infection. The effect of a higher concentration of topical cidofovir with and without cyclosporine requires investigation in a larger group of patients.

We conducted a prospective, randomized, double-blind, placebo-controlled clinical trial investigating the use of topical human fibroblast interferon (HuIFN-beta) 7.5 x 10(5) IU/ml, one drop 5 times daily, in the treatment of acute epidemic conjunctivitis. Of 50 patients who were initially enrolled, tear-film cultures for adenovirus were positive from 26% for type 8, 12, or 19. Based upon a quantifiable conjunctivitis severity score of 37 patients evaluated after approximately 1 week of therapy, analysis of covariance showed a statistically significant greater improvement with topical HuIFN-beta compared with placebo for affected left eyes (P = 0.02) but not for right eyes (P = 0.5), an effect that could not be adequately explained. We suggest that a higher dosage of topical HuIFN-beta may prove useful in the control of more severely affected cases. This trial provides guidelines for future investigations of interferon in the treatment and prophylaxis of adenoviral keratoconjunctivitis.

• Two years after typical signs and symptoms of epidemic keratoconjunctivitis developed in a 67-year-old woman, in whom locally effective steroids were not used for treatment, a lamellar graft was transplanted because of marked visual disturbances that were due to corneal opacities. Histopathology of the cornea revealed notable changes in the superficial stroma, including Bowman's membrane, with some lymphocytic infiltration of the stroma and the overlying epithelium. Electron microscopy showed no virus-like particles.

Purpose To report late onset corneal ectasia following myopic LASIK. Methods A retrospective cohort case series. Nineteen patients with late onset corneal ectasia following LASIK procedure were examined at The Eye Center, Riyadh, Saudi Arabia. Patients underwent LASIK for myopia with spherical equivalent ranging from −1.4 to −13.75diopters. Age and gender, history of systemic or local diseases, and time of onset of corneal ectasia were recorded. Eye examination and corneal topographical analyses were done before and after LASIK surgery. Results Nineteen patients (29 eyes) with late onset corneal ectasia were identified from 1998 to 2008 in 13 male and six female patients. The mean follow-up period was 108±23months (range 72–144months). No patient had pre-operative identifiable risk factors for corneal ectasia and the mean time of onset was 57±24months (range 24–120months after LASIK). The pre-operative values included mean central pachymetry 553±25μm, mean keratometry reading of 42.9±1.5diopters, average oblique cylinder of 1.4±1.2diopters, posterior surface elevation of 26±2.1diopters, corneal flap thickness of 160μm, mean spherical equivalent of −5.6±3.6diopters, and calculated residual corneal stromal bed thickness was 288±35μm. Three (5 eyes) patients developed ectasia after pregnancy. Three (4 eyes) patients developed corneal ectasia following severe adenoviral keratoconjunctivitis and had positive PCR for adenovirus type 8. Conclusions Corneal ectasia may develop many years after LASIK surgery and symptoms could go undetected for some time. Pregnancy and adenoviral keratoconjunctivitis occurred post-operatively in six patients.

• Three patients with soft contact lenses had acute onset of a red eye that clinically appeared consistent with an adenoviral keratoconjunctivitis. The signs and symptoms cleared within five to ten days in all three patients. When the patients reinserted their lenses after their initial episodes, the same signs and symptoms again developed, including follicular conjunctivitis, punctate keratitis, and subepithelial infiltrates. All three were using preserved solutions for soft lens disinfection, and when switched to thermal disinfection with saline tablets, a recurrence of the syndrome did not develop when the lenses were replaced. This syndrome seems related to a toxic or allergic reaction to the preservatives in the contact lens disinfecting solutions. Similar patients who have an acute or chronic, red, irritated eye should stop their lens wear and later should change their disinfection technique to one that uses unpreserved saline solution to eliminate the problem.

Twenty patients with epidemic keratoconjunctivitis without typical subepithelial corneal infiltrates early in the course of their disease were treated in a double-blind regimen with either topical administration of corticosteroid or nonsteroid eye drops for four weeks, four times daily. The corneal infiltrates failed to appear while on steroid therapy in a significant number of patients compared to placebo drops. Subepithelial corneal infiltrates were noted to occur on cessation of administration of corticosteroid drops but once again disappeared if steroids were reinstituted up to one year later. This was also shown in a second double-blind study involving 17 patients nine to twelve months after their initial adenoviral type 8 ocular infection.

• At present, there is no effective chemotherapeutic agent available for the treatment of adenoviral keratoconjunctivitis. Recent evidence suggests that trifluridine (3FT) may effectively inhibit the replication of some adenovirus serotypes known to cause keratoconjunctivitis. The ability of 3FT to inhibit two reference strains of adenoviruses, type 8 and type 19, was examined using cell cultures. Two second-passage isolates of adenoviruses, identified as serotype 13, were also tested. Compared with untreated, virusinfected cell cultures, drug-treated cell cultures developed a lesser degree of cytopathic effect following infection with all three serotypes. Virus production was reduced in the drug-treated cell cultures: approximately tenfold for type 8, more than 1,000-fold for type 19, and 5,000-fold for the type 13 isolates.

To the Editor. —I read with interest the OctoberArchivesarticle by Margulies and Mannis 1 in which they listed five causes of dendriform lesions of the cornea (herpes simplex, herpes zoster, systemic tyrosinemia, Thygeson's superficial punctate keratitis, and contact lens wear). During the last three years, we have seen two cases of dendriform lesions in adenovirus keratoconjunctivitis (Figure). In both, immunofluorescence and viral cultures for herpes simplex were negative. In both cases we were able to culture adenovirus, and the clinical manifestation and course were typical of adenoviral keratoconjunctivitis. Hence, adenoviral keratoconjunctivitis may be added to the list of dendriform lesions of the cornea.