Comparison of topical methylprednisolone 1% versus placebo in stevens – johnson syndrome and/or toxic epidermal necrolysis.

Objective: To study the efficacy of topical methylprednisolone compared with placebo in patients with Stevens-Johnson syndrome (SJS) and/or toxic epidermal necrolysis (TEN). Methods: Thirty-six patients were prospectively studied at Siriraj Hospital. The clinical severity score for ocular involvement was classified as mild, moderate and severe. In 12 patients with moderate severity, 1% methylprednisolone eye drop was added four times daily in one eye and 0.5% normal saline as placebo in another eye for one week. In 2 severe cases, these medications were added every 2 hours till bedtime for one week and four times daily for another week. Results: The average age of 14 patients was 50 ± 16.2 years (± SD), with female preponderance (12). Common precipitating factors were carbamazepine, nevirapine, phenytoin and dimenhydrinate. The common associated diseases were HIV. Five patients were not given systemic corticosteroid due to infection, and minimal skin involvement. The total severity score change in each group was the same at one month. In an average of 7.6 months follow up, most patients recovered normal appearance except for two eyes of the placebo group and one eye of the methylprednisolone group. The percentage of dry eye in the Schirmer test and the rose bengal score in the topical methylprednisolone eyes were not significantly less than in the control eyes. However, less tear production was statistically significant in patients with systemic corticosteroid. Conclusion: Topical corticosteroid might be used cautiously in early stages of SJS or TEN.

Sjögren-like syndrome after bone marrow transplantation.

OBJECTIVE: To study the incidence of dry eye in Sjögren-like syndrome, graft-versus-host disease (GVHD) in hematological patients undergoing bone marrow transplantation (BMT). MATERIAL AND METHOD: Prospective, cross-sectional study in twenty-six patients that were planned for BMT (group I). Twenty-nine patients undergoing BMT before study were classified as group II no GVHD (9), and group III with GVHD (20). Thirty-two normal subjects were controls. All subjects were examined by slit lamp biomicroscopy and had their tear samples analyzed about tear osmolarity. They were also evaluated for aqueous tear production by phenol red thread test, Schirmer test without anesthesia, tear film stability by tear break-up time (TBUT), and rose bengal staining 2 weeks before BMT (for group I) as well as 6 weeks, 3 months, and 6 months after BMT. The patients with GVHD were followed up 1 month later. Main outcome measures were amount of tear production, tear film stability, and dry eye symptoms. RESULTS: Average aqueous tear production in group III was less than control and group II (p < 0.001). Mean TBUT in group III was faster than control (p < 0.001) and group I before BMT (p = 0.001). Mean score of rose bengal staining in group III was more than control and group I before BMT (p < 0.001). Keratoconjunctivitis sicca and red eye developed in 27.5%, and 20% of group III, with incidence of dry eye by Schirmer test without anesthesia (67.5%). This compares with group II having incidence of dry eye of 16.7%. However, 42.3% of group I before BMT had dry eye compared with 9.4% in the controls (p < 0.001). CONCLUSION: Trend of dry eye in patients with BMT and GVHD were higher than no-GVHD group. Doctors should be aware of ocular symptoms and signs of dry eye in patients with BMT and follow-up for proper management.

Quality of life assessment before and after laser in situ keratomileusis.

Objective: To assess the health-related quality of life in patients who underwent conventional laser in situ keratomileusis (LASIK). Methods: Eighty-five patients who underwent LASIK at the Excimer Unit at Siriraj Hospital were enrolled in the study. They were asked to complete a quality of life questionnaire before and after having an operation at 1, 3 and 6 months. The details of the questionnaire were published elsewhere. The questionnaire included 19 items in four categories and one independent item. Paired t-test, non parametric test and repeated measures were performed to compare pre- and post-operation results. Results: Of the total, there were 51 females (58.6%). Patients’ ages ranged from 16-50 years, with a mean age of 30.7 ± 8.7 (years ± SD). Cronbach’ alpha coefficients of the questionnaire were 0.74-0.81. In one-month (n=67), three-month (n=42) and 6-month (n=14) follow-ups, patients tended to score better on visual tasks and had a significantly better score satisfaction and emotional feeling domain. However, their score on the eye symptoms domain was worse after one month and got better after three months. In general, patients were satisfied with the results of the operation on follow-ups. Conclusion: The quality of life for patients undergoing LASIK has improved. Patients have better uncorrected vision, with more satisfaction and emotional feeling. Although they have more eye symptoms resulting from the operation, they were very satisfied with the results.

Tonometry after laser in situ keratomileusis treatment: a preliminary study in Thai patients.

OBJECTIVE: To evaluate the change in intraocular pressure (IOP) measurement by Goldmann applanation tonometer after Laser in Situ Keratomileusis (LASIK) for myopia and myopic astigmatism, and to assess the correlation between the changes of lOP reading and the reduction of central corneal thickness (CCT) after LASIK in Thai patients. STUDY DESIGN: Prospective correlational study. MATERIAL AND METHOD: LASIK was performed on 65 eyes of 33 patients for correction of myopia and myopic astigmatism. IOP was measured by Goldmann applanation tonometer before and 3 months after LASIK. The correlation between the change in IOP reading and the change in central corneal thickness were evaluated. RESULTS: IOP reading was significantly reduced by mean of 2.9 +/- 2.5 mmHg (p = 0.0001). The authors used Pearson analysis to study the correlation between the change in IOP and the reduction of CCT. In subgroup analysis the patients were divided by degree of myopia: group 1, myopia less than -3 diopters (D) (n = 14); group 2, myopia -3 to -6 D (n = 31); group 3, myopia greater than -6 D (n = 20)). The result showed more correlation in higher myopia group (Pearson; r = 0.158 in group 3, r = -0.098 in group 2 and r = -0.102 in group 1). CONCLUSION: Goldmann applanation tonometry underestimates the IOP in thin cornea. Variability in CCT is a potent confounder of this tonometry technique. Therefore, it has important implications for considering CCT measurement incorporated with Goldmann applanation tonometry for glaucoma diagnosis especially in myopic patients who undergo LASIK surgery.

Development of a health-related quality of life questionnaire for Thai patients with rhinoconjunctivitis.

The objective of this study was to develop a disease-specific questionnaire for patients with rhinoconjunctivitis. All patients were recruited at the Out-Patient Clinic at Siriraj Hospital. Related topics were gathered from several sources, and a list of 63 items was produced. In phase I, the first version of the questionnaire was completed by 363 patients. Forty-eight items were identified by clinical impact analysis during the item removal process, two more questions were then added, giving a total of 50. Two hundred and forty-three patients completed the second version questionnaire in phase II. The average time taken to complete the questionnaire was 6.38 minutes. The item removal process in phase II was achieved by a multi-step process. There were 36 items in the third version questionnaire which consisted of six dimensions and two independent items as follows: symptoms (17 items), physical functioning (3 items), role limitations (3 items), sleep (3 items), social functioning (3 items), emotions (5 items), general health (1 item), and absenteeism (1 item). The scores of each item ranged from 1 to 5; a lower score indicating a better quality of life. Data from the selected 36 items was extracted to test the validity and reliability of the final version. The floor and ceiling effects of the scores for each dimension were low. Multitrait multi-item analysis was conducted to examine construct validity. The scaling success of convergent and divergent validity was 100% and 94%, respectively. Internal consistency determined by Cronbach's alpha coefficient, was satisfactory (0.79-0.87). The study indicates that the questionnaire is suitable for use in clinical settings. While the test results are encouraging, further work needs to be done on the test-retest reliability and on responsiveness.

Comparison of topical lomefloxacin 0.3 per cent versus topical ciprofloxacin 0.3 per cent for the treatment of presumed bacterial corneal ulcers.

PURPOSE: To compare the efficacy and safety of topical lomefloxacin 0.3 per cent with topical ciprofloxacin 0.3 per cent for treating mildly severe suspected bacterial corneal ulcers. METHOD: This prospective, randomized, double-masked controlled clinical trial was conducted on 41 patients (41 eyes) with suspected bacterial corneal ulcers who were randomized into 2 groups: 23 patients were in the lomefloxacin group and 18 patients in the ciprofloxacin group. All of these corneal ulcers were scraped for gram's stain, KOH preparation and microbiologic cultures before starting treatment. The clinical success rate, the time to cure, the rates of treatment failures, ocular signs and symptoms and the adverse effects of the study medication were evaluated. RESULTS: Topical lomefloxacin is equivalent clinically and statistically to topical ciprofloxacin. No statistically significant treatment differences were found between lomefloxacin (100%) and ciprofloxacin (100%) in terms of success rate. Similarly, no differences were noted in the time to cure (p > 0.05), the treatment failure, or the resolution of the clinical signs and symptoms (p > 0.05). The adverse effects of lomefloxacin were superficial punctate keratitis (26.1%) and irritation (8.7%), whereas those of ciprofloxacin were superficial punctate keratitis (22.2%), white precipitate (11.1%) and irritation (11.1%). However, no statistically significant differences of these adverse effects were found between the two groups (p > 0.05). CONCLUSION: Lomefloxacin ophthalmic solution (0.3%) is equivalent clinically and statistically to ciprofloxacin ophthalmic solution (0.3%) for the treatment of mildly severe presumed bacterial corneal ulcers without statistically significant differences in the adverse effects and discomfort.

Topical cyclosporine 0.5 per cent and preservative-free ketorolac tromethamine 0.5 per cent in vernal keratoconjunctivitis.

A prospective, randomized cross-over study was conducted in patients with vernal keratoconjunctivitis, successfully treated with cyclosporine, to evaluate the efficacy of cyclosporine 0.5 per cent compared with preservative-free ketorolac tromethamine 0.5 per cent. Patients received topical cyclosporine in both eyes along with an assessment of the severity of their conjunctivitis. In cyclosporine-treated patients, medication was discontinued 1 week before evaluation, then the medication was started for I month, and washed out 1 week before the other drug was started. Symptoms of itching, foreign body sensation, tearing, photophobia, discharge, burning, conjunctival injection, chemosis, giant papilla, keratopathy and intraocular pressure were evaluated weekly. There was a statistically significant decrease in all symptoms of cyclosporine-treated eyes at day 7, 14 and 30 and all signs at day 21 and 30. In ketorolac-treated eyes, there was a significant difference in itching, foreign body sensation, photophobia, tearing, mucous discharge, all symptoms, chemosis, giant papillae and conjunctival injection at day 7, and overall symptoms at day 14. Compared to cyclosporine-treated eyes at day 7, kotorolac-treated eyes had significantly fewer symptoms. Topical cyclosporine 0.5 per cent reduces symptoms and signs slower than preservative-free ketorolac tromethamine 0.5 per cent.

Vernal keratoconjunctivitis in Thailand.

A prospective, cross-sectional and randomized cross-over study was conducted to study the clinical features and treatment outcome among Thai patients with vernal keratoconjunctivitis (VKC). History-taking and eye examinations were performed. Mild cases of VKC were given topical antihistamine four times daily. Moderate and severe cases of VKC were treated with topical lodoxamide four times a day. Severe cases of VKC were given topical corticosteroids. Moderate and severe cases of VKC, which were refractory to treatment with either corticosteroids or a mast cell stabilizer had topical cyclosporine 0.5% instilled four times daily. Five patients were exposed to two different treatment regimens in sequence. As main outcome measures, itching, foreign body sensation, photophobia, conjunctival injection, papillae and chemosis were evaluated weekly. The patients with the palpebral type of VKC had daily symptoms, which were more severe and triggered by house-dust with a significant difference among the groups. Limbal VKC was associated with allergic rhinitis more commonly than palpebral VKC. Positive results of skin prick testing to acacia, careless weed, mold, Johnson grass and cow's milk were significantly more common in patients with palpebral VKC. The most common symptoms and signs were found in the mixed type of VKC. Purulent discharge, pannus and lid erythema were found in the palpebral type. Levocabastine hydrochloride was sufficient for mild cases of limbal VKC; lodoxamide for the limbal and mixed types. Prednisolone acetate was the drug of choice in severe cases of any type but only for a short period of time. The success rate of topical cyclosporine in the palpebral type was lower than in the limbal type due to an intolerable burning sensation. Topical cyclosporine used in 4 patients with limbal and palpebral type had a success rate of 100% which was greater than in the lodoxamide group (66.7%, 0%). Compared with topical corticosteroid-treated eyes in one patient, the success rate in topical cyclosporine-treated eyes was not success. Grading the severity of each type of VKC is crucial to obtain good response of any medication and compliance. Topical cyclosporine 0.5% can be an alternative drug to relieve symptoms and signs of VKC in order to avoid steroid-induced glaucoma.

Comparison of topical prednisolone acetate, ketorolac tromethamine and fluorometholone acetate in reducing inflammation after phacoemulsification.

AIMS: To compare the efficacy and ocular adverse effects of topical prednisolone acetate, ketorolac tromethamine, and fluorometholone acetate in reducing inflammation after phacoemulsification. METHOD: One hundred and twenty eyes were enrolled in a prospective, investigator-masked, randomized controlled trial. Each drug was prescribed 4 times a day for 28 days. The following data were recorded weekly: visual acuity, intraocular pressure, slit lamp biomicroscopy, grading of cells and flare in the anterior chamber, and ocular symptoms. RESULTS: The number of eyes with a minimal amount of cells in the anterior chamber in the ketorolac group was less than the prednisolone group on day 7 (11:20, p = 0.008) and day 14 (23:31, p = 0.015), and than fluorometholone group on day 7 (11:21, p = 0.011). Intraocular pressure in the prednisolone group was higher than the ketorolac group on day 21 (14.6:12.2 mmHg, p = 0.016). One eye in the prednisolone group had intraocular pressure of 32 mmHg. Burning sensation was reported frequently in the ketorolac group. CONCLUSION: All 3 drugs were effective in reducing post-operative inflammation. The efficacy of prednisolone acetate and fluorometholone acetate was comparable. Ketorolac tromethamine showed less efficacy than corticosteroids, however, it did not induce ocular hypertension.

Drug-induced stevens-johnson syndrome.

A patient with arthritis receiving allopurinol for 4 weeks developed Stevens-Johnson syndrome (SJS). SJS is a potentially life-threatening adverse drug reaction and is most commonly associated with the sulfa antibiotics, allopurinol, NSAIDs, and anticonvulsants. The skin reaction spread symmetrically over the body and involved the conjunctiva. The diagnosis and different models of treatment for this case are discussed. Alternative treatments for gouty arthritis are presented. Strategic planning for novel research opportunities arising from this disease is outlined.

A murine model of fusarium keratitis.

Experimental Fusarium keratitis in a mouse model was studied for its pathogenesis, the variability of clinical response, the optimum exposure of the concentration of fungi, and the recovery of colony forming units (CFU). Fusarium solani was injected intrastromally into 40 mouse corneas in two groups with concentrations of 1.7*106 in group I and 1.1*108 in group II. The severity of keratitis, opacification and neovascularization was observed at 24 hour intervals for 3 days. At each observation 5 mouse corneas from each group were enucleated, homogenized, cultured into Sabouraud dextrose agar and CFU were counted after 24 and 48 hours incubation. The results 72 hours after injection revealed that keratitis in mouse group II was more severe than in mouse group I. Therefore, a Fusarium concentration of 1.1*108 CFU/ml is capable of establishing infection. The culture results should be observed after 24 hours incubation period.

Quantitative study on normal corneal endothelial cells.

The study of corneal endothelial cells count was carried out by specular microscope among 76 normal subjects (34 male, 42 female) with ages range between 17-76 years (mean 35-88 years). There were 141 eyes included in the study (64 male, 77 female). The endothelial cells count was expressed in cells/mm.2 The findings were 2697 + 346, 2640 + 382, 2327 + 243 and 2334 + 332 among the age groups below 29, 30-39, 40-49 and over 50 years respectively, with the average of 2594 + 381. With sex distribution the findings among age groups classified in male were 2651 + 384, 2647 + 375, 2290 + 97 and 2256 + 290, with the average of 2546 + 392, and in female were 2721 + 322, 2632 + 391, 2366 + 325 and 2419 + 352 respectively with the average of 2634 + 366. The endothelial cells count in female were higher than male and decreased with advancing ages.