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Neel S Vaidya,1,2 Arvin Daneshmand,3 Randy J Epstein,1,2 Parag A Majmudar,1,2 Michael W Belin,4,5 Edward C Parsons,5 Roy S Rubinfeld5– 7 1Chicago Cornea Consultants, Highland Park, IL, USA; 2Department of Ophthalmology, Rush University Medical Center, Chicago, IL, USA; 3Georgetown University Medical School, Washington, DC, USA; 4Department of Ophthalmology, University of Arizona, Tucson, AZ, USA; 5CXL Ophthalmics, LLC, Encinitas, CA, USA; 6Department of Ophthalmology, Georgetown University Medical School/Washington Hospital Cente, Washington, DC, USA; 7Re:Vision Private Practice, Rockville, MD, USACorrespondence: Neel S Vaidya, Chicago Cornea Consultants, 806 Central Ave Suite 300, Highland Park, IL, 60035, USA, Email nsv@chicagocornea.comPurpose: To assess the change in corneal pachymetry after a novel epithelium-on (EpiSmart®) corneal crosslinking procedure (CXL).Methods: Eyes treated as part of the open-label, non-controlled arm of the study “Collagen Crosslinking with Ultraviolet-A in Asymmetric Corneas” (NCT01097447) were examined at baseline, 3-, 6- and 12-months post-CXL. Thinnest pachymetry readings based on Pentacam (OCULUS GmbH, Wetzlar, Germany) were recorded.Results: A total of 101 eyes met the study inclusion criteria. Thinnest pachymetric readings at baseline averaged 451 ± 50 microns. The mean (± SD) minimum thickness was 450 ± 46 microns at 3 months, 452 ± 47 microns at 6 months, and 451 ± 48 microns at 12 months post-CXL. The changes from baseline (mean ± SE) at 3, 6, and 12 months post-CXL were − 1.2 ± 1.5 microns, 0.5 ± 1.6 microns, and 0.4 ± 1.6 microns, respectively. Student’s t-tests showed no statistically significant change in pachymetry from baseline for any exam period.Conclusion: This study demonstrated that, after EpiSmart® epithelium-on CXL, there was no substantial corneal thinning observable on Scheimpflug tomography out to 12 months.Keywords: corneal thinning, cross-linking, epithelium-on, keratoconus, pachymetry, post-surgical ectasia

The aim of this study was to assess changes in visual acuity after epithelium-on ("epi-on") corneal crosslinking after a diagnosis of keratoconus.Subjects with corneal ectatic diseases were enrolled in a prospective, randomized, controlled, open-label, multicenter trial. Subjects were randomized to 1 of 3 treatment groups and treated with an epi-on crosslinking system including riboflavin/sodium iodide and pulsed UVA exposure (EpiSmart® , CXL Ophthalmics, Encinitas, CA). The UVA treatment groups were 2.4 J/cm2 over 20 minutes, 3.6 J/cm2 over 20 minutes, and 3.6 J/cm2 over 30 minutes. The primary end point was logarithm of the minimum angle of resolution corrected distance visual acuity (CDVA). Secondary end points were logarithm of the minimum angle of resolution uncorrected distance visual acuity (UCVA), maximum corneal curvature (Kmax), and minimum corneal thickness. Data were assessed 6 and 12 months post-operatively, using t-tests for differences from baseline.Two thousand two hundred twenty-eight subjects were treated with epi-on crosslinking. One thousand nine hundred twenty-two subjects had a diagnosis of keratoconus; other treated eyes had postsurgical and other ectasias. At 6 and 12 months, the subjects with keratoconus demonstrated significant improvements in CDVA, UCVA, and Kmax; minimum corneal thickness was unchanged. One hundred ninety-five subjects (8.7%) reported at least 1 adverse event (AE). A mild corneal epithelial defect was reported in 31 cases (1.4%) and was the only AE reported in1% of subjects. There were no serious AEs related to the treatment.EpiSmart® epi-on crosslinking resulted in mean improvements in CDVA, UCVA, and Kmax at both 6 and 12 months and an excellent safety and efficacy profile in subjects with keratoconus, with few significant side effects. Differences between UVA treatment groups were not significant.

Roy S Rubinfeld,1 Glenwood G Gum,2 Jonathan H Talamo,1,3 Edward C Parsons1 1CXL Ophthalmics, LLC, Encinitas, CA, USA; 2Absorption Systems California, LLC, San Diego, CA, USA; 3Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USACorrespondence: Roy S RubinfeldCXL Ophthalmics, LLC, 3131 Connecticut Avenue NW #2809, Washington DC, 20008, USATel +1 240 305-1010Email rsrubinfeld@gmail.comPurpose: To evaluate effects of sodium iodide (NaI) on riboflavin concentration in corneal stroma before and during ultraviolet A (UVA) light exposure using a novel transepithelial corneal collagen crosslinking (CXL) procedure (EpiSmart CXL system, CXL Ophthalmics, Encinitas CA).Methods: Riboflavin solutions with NaI (Ribostat, CXL Ophthalmics, Encinitas CA) and without NaI were used for CXL in rabbits using EpiSmart. A pilot study determined sufficient riboflavin loading time. Four rabbits were dosed and monitored. Riboflavin fluorescence intensity was assessed from masked slit-lamp photos. A 12 min loading time was selected. Sixteen additional rabbits received the two formulae in contralateral eyes for CXL. Riboflavin uptake was assessed at 0, 10, 15, 20, 25, and 30 min of UVA exposure using a scale for riboflavin fluorescence previously validated against stromal concentration. Post sacrifice, corneal stromal samples were analyzed for concentrations of riboflavin and riboflavin 5ʹ-phosphate.Results: Eyes dosed with NaI riboflavin had higher riboflavin grades compared to eyes dosed with the NaI-free riboflavin formulation immediately after riboflavin loading and persisting throughout UVA exposure, with significantly higher (P < 0.01 to < 0.05) riboflavin grades from 15 through 25 min of UVA exposure. Riboflavin grades decreased more slowly in eyes dosed with NaI riboflavin through 25 minutes of UVA exposure. Minor conjunctival irritation was noted with or without NaI.Conclusion: The addition of NaI to riboflavin solution is associated with increased riboflavin concentration in corneal stroma throughout a clinically relevant time course of UVA exposure. This effect may be a combination of enhanced epithelial penetration and reduced riboflavin photodegradation and should enhance intrastromal crosslinking.Keywords: corneal crosslinking, crosslinking, riboflavin, iodide, keratoconus, ectasia

Mazen M Sinjab,1,2 Roy S Rubinfeld,3,4 Kirsten Wagner,5,6 Edward C Parsons Jnr,7 Arthur B Cummings,8 Michael W Belin9 1Dr. Mazen Eye Clinic, Medcare Hospitals and Centres, Dubai, United Arab Emirates; 2Al Zahra Medical Group, Damascus, Syria; 3Department of Ophthalmology, Georgetown University Medical School/Washington Hospital Center, Washington, DC, USA; 4Re:Vision Private Practice, Rockville, MD, USA; 5Department of Ophthalmology, Medstar Georgetown University Hospital, Washington, DC, USA; 6Department of Ophthalmology, Medstar Washington Hospital Center, Washington, DC, USA; 7CXL Ophthalmics, Encinitas, CA, USA; 8Wellington Eye Clinic, Dublin, Ireland; 9Department of Ophthalmology, University of Arizona, Tucson, AZ, USACorrespondence: Roy S Rubinfeld 3131 Connecticut Ave, NW, #2809, Washington, DC, 20008, USAEmail Doctor@revisedeye.comPurpose: To assess the effectiveness of a novel treatment for patients with advanced corneal ectasia and loss of visual acuity (VA). Conductive keratoplasty (CK) is performed to improve VA followed by epithelium-on (epi-on) corneal crosslinking (CXL) to stabilize the cornea after CK.Methods: Retrospective, exploratory cohort study. Patients with keratoconus or postsurgical ectasia and best spectacle-corrected distance VA (CDVA) ≤ 20/40 were included. Conductive keratoplasty was performed (ViewPoint CK System, Refractec, Inc., Bloomington, MN); followed a day later by epi-on CXL (CXLUSA/CXLO, Bethesda, MD/CXLO Encinitas, CA). Measures included uncorrected distance visual acuity (UDVA) and CDVA, as well as refractive and tomographic measures and tomographic indices.Results: Data from 50 eyes of 45 patients were analyzed. Mean follow-up was 15.1 ± 12.2 months (range: 2 to 51). Overall, UDVA and CDVA improved postoperatively. Subjective refraction and tomographic metrics did not show consistent changes, but changes in tomographic indices were associated with treatment follow-up time. At the 1-year visit, mean UDVA significantly improved over baseline (P = 0.009) by approximately 3 lines; mean CDVA improved significantly (P = 10− 5) by approximately 2 lines. No eye lost lines of CDVA. Change in the Index of Surface Variance (ISV) was associated with treatment, and the D-Index trended over follow-up time.Conclusion: Conductive keratoplasty with a proprietary epi-on CXL treatment improved vision in patients with advanced ectasia This CK/epi-on CXL treatment offers the possibility of improved VA for patients with compromised vision due to ectasia.Keywords: conductive keratoplasty, CK, corneal crosslinking, crosslinking, keratoconus, ectasia, thermokeratoplasty

To evaluate the effect of riboflavin-ultraviolet (UV)-A corneal crosslinking (CXL) without epithelial removal on ectatic corneal disease.Woolfson Eye Institute, Atlanta, Georgia, USA.Prospective observational study.Patients were treated with a new riboflavin formulation without epithelial removal, then exposed to UV light (365 nm) at 4 mW/cmFive hundred twelve eyes of 308 patients with keratoconus or forme fruste keratoconus and 80 eyes of 55 patients with ectasia after laser in situ keratomileusis (LASIK) were treated with the new riboflavin formulation without epithelial removal; 229 patients received bilateral treatments, 95 of which were simultaneous. The mean UDVA and CDVA improved by 1 to 1.5 Snellen lines at 1 and 2 years postoperatively (P .0001). Mean Kmax decreased by 0.48 D at 2 years postoperatively (P = .0002). Mean total HOAs and coma decreased by 36% (P .0001) and 37% (P = .0002), respectively, at 2 years postoperatively. Kmax decreased more than 1 D in three times as many eyes as it increased more than 1 D (P .0001). No eyes progressed, and there was no loss of effect between 1 and 2 years postoperatively. No vision-threatening events were observed. Pain typically resolved within 24 hours, and visual acuity returned to preoperative levels in 1 to 2 days.Epithelium-on CXL using this new protocol halted the progression of keratoconus and ectasia after LASIK. It was safer and provided more rapid visual recovery than CXL with epithelial removal, allowing routine bilateral, simultaneous treatment.

PURPOSE: There has been a recent explosion in the variety of techniques used to accomplish corneal cross-linking (CXL) for the treatment of ectatic corneal diseases. To understand the success or failure of various techniques, we review the physicochemical basis of corneal CXL and re-evaluate the current principles and long-standing conventional wisdom in the light of recent, compelling, and sometimes contradictory research. METHODS: Two clinicians and a medicinal chemist developed a list of current key topics, controversies, and questions in the field of corneal CXL based on information from current literature, medical conferences, and discussions with international practitioners of CXL. RESULTS: Standard corneal CXL with removal of the corneal epithelium is a safe and efficacious procedure for the treatment of corneal ectasias. However, the necessity of epithelium removal is painful for patients, involves risk and requires significant recovery time. Attempts to move to transepithelial corneal CXL have been hindered by the lack of a coherent understanding of the physicochemistry of corneal CXL. Misconceptions about the applicability of the Bunsen-Roscoe law of reciprocity and the Lambert-Beer law in CXL hamper the ability to predict the effect of ultraviolet A energy during CXL. Improved understanding of CXL may also expand the treatment group for corneal ectasia to those with thinner corneas. Finally, it is essential to understand the role of oxygen in successful CXL. CONCLUSIONS: Improved understanding of the complex interactions of riboflavin, ultraviolet A energy and oxygen in corneal CXL may provide a successful route to transepithelial corneal CXL.

A 41-year-old man presented 10 years after uneventful laser in situ keratomileusis (LASIK) with symptomatic post-LASIK ectasia. He had treatment with the classic Dresden epithelium-off technique and presented 4 years later with progression of the ectasia. He was subsequently retreated with conductive keratoplasty (CK) followed by a new proprietary epithelium-on corneal collagen crosslinking (CXL) procedure using a proprietary transepithelial riboflavin formulation and delivery system on the following day. One year after retreatment, the patient noted stable vision in the treated eye with a corrected distance visual acuity (CDVA) of 20/60 + . Thus, epithelium-on CXL, if performed with appropriate formulations and delivery technology as well as careful attention to appropriate riboflavin loading of the stroma, can stabilize an ectatic cornea. In addition, when performed prior to CXL, CK can induce a significant, lasting improvement in corneal shape and CDVA. This technique merits further study.

Purpose To compare the corneal stromal riboflavin concentration and distribution using 2 transepithelial corneal crosslinking (CXL) systems. Setting Absorption Systems, San Diego, California, USA. Design Experimental study. Methods The stromal riboflavin concentration of 2 transepithelial CXL systems was compared in rabbit eyes in vivo. The systems were the Paracel/Vibex Xtra, comprising riboflavin 0.25% solution containing TRIS and ethylenediaminetetraacetic acid and an isotonic solution of riboflavin 0.25%, (Group 1) and the CXLO system (Group 2). Manufacturers’ Instructions For Use were followed. The intensity of riboflavin fluorescence by slitlamp observation 10, 15, and 20 minutes after instillation was graded on a scale of 0 to 5. The animals were humanely killed and the corneal stromal samples analyzed with liquid chromatography and mass spectrometry. Results The mean riboflavin fluorescence intensity grades in Group 1 (4 eyes) were 3.8, 4.8, and 4.8 at 10, 15, and 20 minutes, respectively. The mean grades in Group 2 (3 eyes) were 2.0, 2.3, and 2.0, respectively. The riboflavin distribution was uniform in Group 1 but not in Group 2. The mean riboflavin concentration by liquid chromatography and mass spectrometry was 27.0 μg/g stromal tissue in Group 1 and 6.7 μg/g in Group 2. A stromal riboflavin concentration theoretically adequate for CXL, 15 μg/g, was achieved in all eyes in Group 1 and no eyes in Group 2. Slitlamp grading correlated well with liquid chromatography and mass spectrometry concentration (R2 = 0.940). Conclusions The system used in Group 1 produced corneal riboflavin concentrations that were theoretically adequate for effective transepithelial CXL (≥15 μg/g), while the system in Group 2 did not. Slitlamp grading successfully estimated the corneal riboflavin concentration and can be used to ensure an adequate concentration of riboflavin in the cornea for transepithelial CXL.

Corneal cross linking (CXL) has significant supporting evidence suggesting that it stabilizes keratoconus (KC) and increases corneal rigidity. Randomized clinical trials demonstrating this in a statistically significant manner would still be welcomed however.

Keratoconus and other corneal conditions associated with progressive stromal thinning including keratectasia after laser-assisted in situ keratomileusis (LASIK) and pellucid marginal degeneration represent therapeutic challenges. Until recently, available therapies including contact lenses, epikeratoplasty, intrastromal corneal rings, and corneal transplantation targeted, in principle, the abnormal shape of the cornea by mechanical means. The underlying molecular pathogenic mechanisms of corneal ectasia were not addressed with any of these therapies until the introduction of corneal collagen cross-linking to clinical practice in 1999.1 This breakthrough clinical application was the result of multiple laboratory observations and discoveries made over preceding decades. Early experiments of Cannon and Foster2 showed that degraded normal collagen or synthesis of abnormal collagen might play a role in the pathogenesis of keratoconus. This concept was later confirmed by subsequent clinical and experimental studies. Keratoconus was characterized by progressive stromal thinning and ectasia3 as a result of increased expression of lysosomal and proteolytic enzymes4–7 and decreased concentration of protease inhibitors,5,8 which result in corneal thinning and altered configuration of corneal collagen lamellae.9,10

Purpose To elucidate risk factors, clinical course, visual outcomes, and treatment of culture-proven methicillin-resistant Staphylococcus aureus (MRSA) infectious keratitis following refractive surgery. Design Interventional case series. Methods Multicenter chart review of 13 cases of MRSA keratitis following refractive surgery and literature review. Results Thirteen eyes of 12 patients, nine of whom were either healthcare workers or exposed to a hospital surgical setting, developed MRSA keratitis following refractive surgery. All patients presented with a decrease in visual acuity and complaints of pain or irritation in the affected eye. Common signs on slit-lamp biomicroscopy were corneal epithelial defects, focal infiltrates with surrounding edema, conjunctival injection, purulent discharge, and hypopyon. All patients were diagnosed with infectious keratitis on presentation and treated with two antibiotics. All eyes were culture-positive for MRSA. Conclusions According to a computerized MEDLINE literature search, this is the first case series of MRSA infectious keratitis following refractive surgery, the first reports of MRSA keratitis after refractive surgery in patients with no known exposure to a healthcare facility, the first report of MRSA keratitis after a laser in situ keratomileusis (LASIK) enhancement, and the first reports of MRSA keratitis after prophylaxis with fourth-generation fluoroquinolones. MRSA keratitis is a serious and increasing complication following refractive surgery. Patients with exposure to a healthcare environment should be considered at additional risk for developing MRSA keratitis. However, in addition, surgeons should now be vigilant for community-acquired MRSA. Prompt identification with culturing and appropriate treatment of MRSA keratitis after refractive surgery is important to improve visual rehabilitation.

Purpose: To report serious complications caused by recutting laser in situ keratomileusis (LASIK) flaps for enhancement and reconsider the current preferred method of LASIK enhancement. Setting: Multiple surgeon practices. Methods: This retrospective noncomparative nonconsecutive case series comprised LASIK patients in the private practices of 9 experienced refractive surgeons and those reported in a survey of refractive surgeons. Case histories, refractions, corneal topographies, slitlamp photographs, and measurements of uncorrected and best corrected (BCVA) visual acuity after recutting LASIK flaps were collected. Surveys of refractive surgeons and an analysis of changing practice trends among the authors and these surgeons were assessed. Results: In 12 cases, significant loss of BCVA and subjective visual difficulties resulted from recutting LASIK flaps. Most surveyed surgeons had changed their practice from recutting to lifting flaps even 9 to 10 years postoperatively with good results. Conclusion: Recutting flaps for enhancement should be avoided unless other alternatives are unavailable. J Cataract Refract Surg 2003; 29:2306–2317  2003 ASCRS and ESCRS

* BACKGROUND AND OBJECTIVE: Mitomycin-C has been shown to dramatically reduce pterygium recurrence rates; however, its use has been associated with serious complications, especially in higher cumulative doses. The authors investigated the safety and efficacy of progressively reducing dosages of mitomycin-C as an adjunct to pterygium surgery. * PATIENTS AND METHODS: Four hundred eighty-one consecutive primary and recurrent pterygia were surgically excised in a prospective nonrandomized trial using five different mitomycin-C dosages. Recurrence was defined as fibrovascular tissue over the corneoscleral limbus onto clear cornea in the area of previous pterygium excision. * RESULTS: Seventy-seven patients in a control group without mitomycin-C had a recurrence rate of 65% with a mean follow-up of 33 months. A group of 77 patients treated with 0.4 mg/ml of mitomycin-C, four times per day for 2 weeks, had a recurrence rate of 2.5% with 6 (10%) serious complications (mean follow-up 34 months). A group of 22 patients treated with 0.2 mg/ml of mitomycin-C, four times per day for 10 days, had a recurrence rate of 55% with 3 (7.3%) non-vision-threatening complications (mean follow-up 32 months). A group of 16 patients treated with 0.2 mg/ml of mitomycin-C intraoperatively for 3 minutes without conjunctival closure had a recurrence rate of 44% with no complications (mean follow-up 35 months). Finally, a group of 289 patients treated with 0.2 mg/ml of mitomycin-C intraoperatively for 3 minutes with conjunctival closure had a recurrence rate of 2.7% and no complications (mean follow-up 26 months). * CONCLUSION: Although the authors' results with single application are encouraging, the use of mitomycin for pterygia remains controversial. The biologic potency of this agent, the duration of its action, and the dearth of large-scale controlled, randomized trials demand cautious individual judgment by the surgeon when considering the use of this potent drug. [Ophthalmic Surg Lasers 1997;28:662-669.]

Intraoperative cytology is an alternative and sometimes preferred method to frozen section in the rapid evaluation of surgical biopsies. This report describes the cytological, histological, and immunohistochemical features of a case of mixed pigmented/nonpigmented pleomorphic adenoma of the ciliary body with clinical and morphological features reminiscent of malignant melanoma. The characteristic cyto-histomorphology of this unusual tumor and its distinguishing features from malignant melanoma are discussed.

We report the first case of methicillin-resistant Staphylococcus aureus (MRSA) ulcerative keratitis after routine bilateral laser in situ keratomileusis. Within 24 hours of initial ulceration the lamellar flap melted, disintegrating into necrotic fragments. Recognition of lamellar flap infections followed by immediate medical and surgical management is critical to preserving vision.

Anterior stromal puncture has recently been proposed as a new treatment for recalcitrant cases of recurrent corneal erosion. Concerns about the risks of corneal perforation and scarring, as well as doubts regarding its efficacy have prevented many patients from benefiting from this procedure. We introduce a new, inexpensive, commercially available instrument designed to standardize this technique, minimize scarring, and prevent corneal perforation. In a clinical trial involving 25 consecutive patients with recurrent erosions resistant to vigorous conservative treatment, the first 11 patients underwent stromal puncture in which a straight tuberculin needle was used; the following 14 were treated with a newly designed prototype needle. All patients in this series remained free of erosions after completion of stromal puncture, except for one woman with marked diffuse anterior basement membrane dystrophy, who went on to develop spontaneous bilateral erosions. Follow-up ranged from 2 months to 30 months (mean, 13 months). There were no complications of stromal puncture, and subjective and objective evaluations revealed no significant postoperative glare. Microscopic analysis of eye bank eyes subjected to anterior stromal puncture procedures demonstrated that the new prototype needle provided shallower penetration and thus less likelihood of perforation or excessive scarring than the straight needle. Also, postoperative discomfort and scarring appeared to be significantly less in patients treated with the prototype needle.

* BACKGROUND AND OBJECTIVE: Intraocular pressure (IOP) estimation by Goldmann tonometry is inaccurate in the immediate postoperative period after penetrating keratoplasty. For this reason, many corneal surgeons use a finger tension (FT) IOP estimation technique in the early post-keratoplasty period. The authors performed a prospective clinical study to evaluate the accuracy of this traditional technique. * PATIENTS AND METHODS: FT estimates were performed by three experienced corneal surgeons on 68 patients on the first and second days after penetrating keratoplasty. These estimates were compared with MacKay-Marg (MM) tonometry readings for these patients. * RESULTS: The mean confident FT from the pooled data of the three surgeons exceeded the MM reading by 5.0 mm Hg (22.6 vs. 17.6). The mean FT exceeded the MM reading by only 3.9 mm Hg for the most accurate surgeon. Some observers were significantly more accurate than others, however, lid edema and tenderness of the globe markedly diminished the FT accuracy of all of the observers at significance levels of P < .001 and P < .01, respectively. Among all of the FT estimates, in only one patient (2%) did the FT underestimate the MM reading by more than 10 mm Hg. * CONCLUSION: The authors' results suggest that for some patients, and for some surgeons, the FT or digital method of IOP estimation remains useful for detecting elevated IOP early after corneal transplantation if the proper technique is used and substantial lid edema and patient discomfort are absent. [Ophthalmic Surg Lasers 1998;29:213-215.]

To describe a novel topographic curvature pattern, vertical D, which was present in some keratoconus suspects. This pattern was detected retrospectively in 2 patients who developed post-LASIK ectasia and prospectively in 4 patients who had other corneal abnormalities suggestive of keratoconus.Retrospective interventional case series and prospective cross-sectional study.After vertical D topographic curvature patterns were noted in 2 patients (3 eyes) who developed post-LASIK ectasia, 1168 consecutive potential refractive surgical candidates (2336 eyes) evaluated at a refractive center were screened to detect this vertical D pattern.Placido disc-based curvature topography, ultrasound pachymetry, and elevation-based Scheimpflug topography were performed on these patients.Corneal curvature topographic patterns, central keratometry, inferior-superior and nasal-temporal ratios, skewed radial axis value, Humphrey Atlas PathFinder corneal analysis, corneal thickness, and corneal anterior and posterior elevation.Four additional patients (7 eyes) with vertical D patterns were found (prevalence, 0.34%). In addition to this vertical D pattern, these patients had central corneal thickness500 microm and/or posterior corneal protrusion20 microm or positive results on keratoconus detection analyses. The 10 eyes with the vertical D pattern had more horizontal (nasal-temporal ratio) than vertical (inferior-superior ratio) curvature asymmetry: 0.98+/-0.04 diopters versus 0.44+/-0.2 diopters (paired t test, P0.001).We propose that vertical D is a novel corneal curvature pattern reflecting horizontal asymmetry that was present in keratoconus suspect patients even if standard keratoconus analyses' results were negative.

We report the case of a 66-year-old black woman who presented with concomitant acute infectious keratitis, bacteremia, and septic arthritis caused by Streptococcus pneumonia. The septic arthritis resolved rapidly with surgical drainage and intravenous antibiotics, but despite aggressive topical and intravenous antibiotic therapy for the infectious keratitis, the cornea perforated, the patient developed endophthalmitis, and the eye eventually was eviscerated. To the best of our knowledge this is the first reported case of this nature. This patient had undergone splenectomy > 50 years prior to developing these infections. Although the risk of serious infection in clinically significant bacteremia is greatest in the perioperative period after splenectomy, these patients are at increased risk of such events for a lifetime. Because encapsulated bacteria, especially Pneumococcus, pose the greatest risk of sepsis and infection in asplenic patients, pneumococcal vaccination of penicillin prophylaxis must always be considered in these patients. A careful and complete medical history and systemic evaluation remain a crucial element of the evaluation and management of serious infectious keratitis.

Signs of keratoconus, including Munson's sign, apical thinning, and Vogt's striae, developed in a 41-year-old woman 6 years after successful penetrating keratoplasty. Screening donor corneas for ectatic diseases may prevent such occurrences.

Background: The use of topical mitomycin (mitomycin-C) as a medical adjunct to pterygium and glaucoma surgery is increasing. Methods: The authors report on a series of 10 patients who experienced serious, vision-threatening complications associated with the use of this drug after pterygium surgery. Results: Complications included severe secondary glaucoma (4 patients), corneal edema (3 patients), corneal perforation (1 patient), corectopia (2 patients), iritis (8 patients), sudden onset mature cataract (2 patients), scleral calcification (1 patient) and incapacitating photophobia and pain (8 patients). Two patients required penetrating keratoplasties and a third required three lamellar keratoplasties. Another patient underwent four additional surgeries including a conjunctival Z-plasty, scleral patch grafting, and conjunctival autografting before his intractable pain and photophobia resolved 15 months after the original surgery. Because of these complications, 6 patients required a total of 20 return visits to the operating room after their original pterygium surgery. In 5 eyes, visual acuity remained at 20/200 or less. Three of the six patients with the most severe complications had concomitant chronic external diseases (rosacea [3 patients], ichthyosis [1 patient], keratitis sicca [1 patient]). Conclusion: The authors urge extreme caution in the use of mitomycin. If mitomycin is used, the lowest possible concentration should be applied for the shortest time period in an effort to avoid these complications. A prospective multicenter study of the ophthalmic use of this medication is needed.

A 30-year-old man sustained exposure of his eyes, face, and neck involving 4% of body surface area to hydrofluoric acid. He was treated with immediate lavage and topical calcium gluconate. Because free fluoride ions from ocular and facial exposures can form complexes with body stores of calcium and magnesium, the patient was transferred to a burn unit for cardiac and electrolyte monitoring. He was also treated with calcium gluconate skin injections, pulmonary nebulizer therapy, and topical antibiotics and corticosteroids. In another case, a 25-year-old man with less severe exposure to hydrofluoric acid was treated as an outpatient with topical antibiotics, corticosteroids, and cycloplegia. If an ophthalmologist is the first to treat a patient with chemical exposure, the history of hydrofluoric acid exposure must be obtained, and the burn team and other medical specialists must be quickly consulted to avoid potentially fatal complications.

Purpose To describe a novel topographic curvature pattern, vertical D, which was present in some keratoconus suspects. This pattern was detected retrospectively in 2 patients who developed post-LASIK ectasia and prospectively in 4 patients who had other corneal abnormalities suggestive of keratoconus. Design Retrospective interventional case series and prospective cross-sectional study. Participants After vertical D topographic curvature patterns were noted in 2 patients (3 eyes) who developed post-LASIK ectasia, 1168 consecutive potential refractive surgical candidates (2336 eyes) evaluated at a refractive center were screened to detect this vertical D pattern. Methods Placido disc-based curvature topography, ultrasound pachymetry, and elevation-based Scheimpflug topography were performed on these patients. Main Outcome Measures Corneal curvature topographic patterns, central keratometry, inferior–superior and nasal–temporal ratios, skewed radial axis value, Humphrey Atlas PathFinder corneal analysis, corneal thickness, and corneal anterior and posterior elevation. Results Four additional patients (7 eyes) with vertical D patterns were found (prevalence, 0.34%). In addition to this vertical D pattern, these patients had central corneal thickness 20 μm or positive results on keratoconus detection analyses. The 10 eyes with the vertical D pattern had more horizontal (nasal–temporal ratio) than vertical (inferior–superior ratio) curvature asymmetry: 0.98±0.04 diopters versus 0.44±0.2 diopters (paired t test, P Conclusions We propose that vertical D is a novel corneal curvature pattern reflecting horizontal asymmetry that was present in keratoconus suspect patients even if standard keratoconus analyses' results were negative.

Objective To examine the histologic and ultrastructural features of human corneas after successful laser in situ keratomileusis (LASIK) in 2 patients post mortem. Methods Portions of 4 corneas were processed for histology, transmission electron microscopy, and scanning electron microscopy. Results Case 1 had undergone LASIK 3 months prior to death and case 2 had undergone LASIK 20 months prior to death. A Hansatome (Bausch & Lomb Surgical Inc, Clarement, Calif) microkeratome with a 180-µm plate had been used for case 1 and an Automated Corneal Shaper (Chiron Corporation, Munich, Germany) with a 160-µm plate had been used for case 2. Histologically, the LASIK flap measured 160 µm and 150 µm in thickness in case 1 and case 2, respectively. Corneas from both cases exhibited minor epithelial ingrowth into the wound, reactive keratocytes at the wound margin, irregular collagen fibrils in the wound bed, and severed collagen bundles at the flap hinge. These findings were more pronounced in case 1 than in case 2, and the wound interface was virtually imperceptible in case 2. Additionally, the corneas from case 1 contained periodic acid-Schiff–positive electron dense material and wide-spaced collagen at the wound interface, and there was an absence of corneal nerves. Conclusions These findings show that changes caused by wound repair that are present at 3 months are minor 20 months after LASIK.

Purpose Topical anesthetics are commonly used prior to obtaining bacterial cultures in ulcerative keratitis. We performed an in vitro study designed to test both the bacteriostatic and bactericidal effects of commercially available preserved topical anesthetic agents. Methods Proparacaine, tetracaine, cocaine, and sterile water solutions were applied to filter paper disks, which were then placed on Mueller-Hinton agar plates that had previously been inoculated with known quantities of Pseudomonas aeruginosa and Staphylococcus aureus. After 24 h of incubation, zones of inhibition were measured and recorded. Results Proparacaine strongly inhibited the growth of S. aureus at all concentrations (0.5%, 0.25%, 0.125%) and inhibited growth of P. aeruginosa at 0.5% and 0.25% but not at 0.125% concentration. Tetracaine also inhibited S. aureus at 0.5% and inhibited P. aeruginosa at 0.5% and 0.25% concentrations. Cocaine exhibited no inhibition of S. aureus and exhibited mild inhibition of P. aeruginosa growth only at the 4% concentration. Conclusions The in vitro antibacterial effect of topical anesthetics suggests one possible reason why bacterial culture yields in clinical ulcerative keratitis are suboptimal. We propose that clinicians consider the use of a 1% or 2% cocaine solution instead of standard commercial topical anesthetics in the management of individual cases of ulcerative keratitis and in future clinical bacterial keratitis studies.

Purpose. We present the clinicopathologic correlations of two cases and two other clinical cases of topical anesthetic abuse keratopathy that were originally diagnosed as Acanthamoeba keratitis because of ring keratitis presentation and characteristic history. Methods. Four patients who were referre

Objective: To investigate the mechanism of action of corneal anterior stromal puncture (ASP) in humans. Design: Immunocytochemical techniques were used to localize fibronectin, type IV collagen, and laminin in human corneas with bullous keratopathy, some of which had undergone ASP. Corneal specimens were obtained from transplant procedures performed in a related clinical study. Setting: Outpatients in private practice settings. Patients: Nine patients with recurrent erosion secondary to bullous keratopathy who were judged to be poor candidates for keratoplasty. Interventions: Anterior stromal puncture was performed on each patient using a standardized needle, and corneal transplants were performed on patients whose erosions did not resolve after ASP. Primary Outcome Measures: Subjective comfort and slit-lamp verification of resolution of rupture of bullae and erosions in patients who underwent ASP; Nomarski differential interference contrast photography, immunohistochemical staining, and light microscopy were applied to the corneal specimens. Results: All three matrix glycoproteins were observed in the epithelial basement membrane of normal corneas. In patients with bullous keratopathy who did not undergo ASP, the epithelial basement membrane of the cornea did not stain with antibodies against human fibronectin, type IV collagen, or laminin. In patients with bullous keratopathy who underwent ASP, all three major proteins were present at the puncture sites and in the reactive subepithelial pannus adjacent to the puncture site. Epithelial basement membrane of untreated regions showed little or no staining. Conclusions: The results suggest that the absence of these extracellular matrix proteins in the epithelial basement membrane of patients with bullous keratopathy may be an important factor in the development of poor epithelial adhesion and secondary erosions. Anterior stromal puncture may promote epithelial reattachment, at least in bullous keratopathy, by stimulating the production of extracellular matrix proteins that are important in the attachment of epithelial cells to the underlying connective tissue. Epithelial-stromal reactions and the development of subepithelial fibrosis may also play a role in reestablishing epithelial attachment.

Unlike Corynebacterium diphtheriae and Propionibacterium acnes, the pleomorphic gram-positive rods known as diphtheroids are generally regarded as nonpathogenic contaminants of the human external eye. We reviewed five years of microbiology records at Wills Eye Hospital and studied a series of eight cases of apparently infectious keratitis associated with heavy growth of diphtheroids on cultures of ulcer scrapings. All of these cases included indolent ulcers that occurred almost exclusively in elderly patients (mean age, 72 years; range, 11 to 92 years). All patients had preexisting ocular conditions that compromised the corneal surface such as exposed corneal sutures, eyelid surgery, aphakic extended wear contact lenses, viral keratitis, and diabetes mellitus. No other pathogens were isolated. All infections responded well to antibiotic therapy with all organisms sensitive to cefazolin and all but one sensitive to gentamicin.

Management of the intraocular lens (IOL) at the time of penetrating keratoplasty (PK) for pseudophakic bullous keratopathy has been based on lens-related factors and coexisting anterior segment abnormalities. The authors reviewed the results of PK for 102 cases of pseudophakic bullous keratopathy (43 anterior chamber, 50 iris-supported, and 9 posterior chamber) with respect to: (1) the type of IOL, (2) coexisting abnormalities, and (3) management of the IOL at surgery. Graft failure after 2 years of follow-up was: (1) retained iris-supported IOLs, 9%; (2) retained anterior chamber IOLs, 60%; (3) retained posterior chamber intraocular lenses (PC IOL), 0%; (4) removed IOLs, 9%; and (5) exchanged IOLs, 20%. After 5 years of follow-up, 13 of 13 PKs with retained closed-loop anterior chamber IOLs had failed. Visual results were best in eyes with retained iris-supported, rigid anterior chamber or PC IOLs and when the IOL was removed without replacement. The authors recommend that closed-loop anterior chamber lenses and unstable lenses of any type be removed or exchanged and that well-fixated PC IOLs and iris-clip IOLs be retained at the time of PK for pseudophakic bullous keratopathy.

A 5-year-old girl with acute lymphoblastic leukemia undergoing induction chemotherapy experienced acute proptosis while agranulocytotic and febrile. Orbital biopsy showed leukemic infiltration, and complete resolution was achieved with local irradiation and chemotherapy. Early onset orbital involvement is highly unusual in acute lymphoblastic leukemia. In the setting of agranulocytosis and fever, rapidly enlarging intraorbital masses require urgent ophthalmologic attention. Immediate biopsy is indicated to distinguish between several treatable conditions including opportunistic infection, hemorrhage, and neoplastic infiltration.