[Keratic precipitate morphology in various uveitic entities: a confocal scan study]

To characterize keratic precipitate [KP] morphology in different forms of uveitis. One hundred and twenty nine eyes of 93 patients with different forms of uveitis underwent confocal scan and the morphology of KPs were determined. Differences in KP morphologies among different uveitic groups were evaluated. Age ranged from 14 to 67 years [mean: 32.5 +/- 11.2] and 58 cases [62.36%] were female, 38.7% had bilateral uveitis. Almost all types of uveitis disclosed predominantly stippled and globular KPs. Dendritiform KPs were more common in infectious uveitis [P=0.053] and smooth-rounded KPs were significantly more common in non-infectious uveitis [P<0.001]. Dendritiform KPs were observed more commonly in nongranulomatous uveitis than granulomatous ones [P=0.005]. Smooth-rounded KPs were more common in chronic uveitis than acute forms [P<0.001]. The predominant morphology of KPs in Fuchs heterochromic iridocyclitis [FHIC] were dendritiform [80.0%] and infiltrating [78.0%]. The most commonly observed morphology of KPs in intermediate uveitis were dendritiform [56.3%] and smooth-rounded [56.3%]. Cruciform KPs were more frequently seen in cases with FHIC [60.0%]. Morphologic features in bilateral cases were similar. KP morphologies are diverse in different forms of uveitis. Some forms of KPs are less specific such as globular and stippled which exist in almost all types of uveitis. Confocal scan can play a potential role in differentiating infectious from noninfectious uveitis and granulomatous from nongranulomatous uveitis

[ outbreak of nocardia keratitis following photorefractive keratectomy]

To report 3 cases of nocardia keratitis following photorefractive keratectomy [PRK]. Report of Outbreak: Four eyes of 3 patients [2 female and one male] who had undergone PRK by a single surgeon at a single center developed nocardia keartitis 3 to 6 weeks postoperatively. Mean age was 25 [range 23-28] years and mean onset of corneal manifestations was 29 [range 21-40] days after PRK. Corneal smear and culture and confocal scan were performed in all eyes. Two eyes from the first two patients required lamellar keratectomy to debulk the involved stroma and to obtain specimens for microbiologic and histopathologic evaluation. Light microscopic examination disclosed gram-positive and acid-fast filaments of nocardia which were confirmed by the microbiologic results. Diagnosis of nocardia keratitis in the third case was not as challenging as the first two cases because of a high index of suspicion. Confocal scan in all cases disclosed hyperreflective and slender fibril-like structures in the corneal stroma. All eyes responded favourably to topical amikacin and the infection resolved without recurrence. Nocardia is a rare cause of keratitis following PRK. Clinical suspicion along with microbiologic, histopathologic and confocal scanning help to establish the correct diagnosis. The most probable cause of the outbreak was inadequate attention to sterility during surgery

[Unusual neoplastic recurrence in the corneo-scleral limbus: recurrent atypical fibrous histiocytoma followed by intra-epithelial squamous neoplasia]

To report the clinical and histopathological features of recurrent atypical fibrous histiocytoma of the corneo-scleral limbus followed by intra-epithelial squamous neoplasia. A 25-year-old female patient presented with a recurrent vascularized gelatinous mass in the left nasal limbus. The preliminary histopathological diagnosis of the previously excised lesion was an amelanotic malignant melanoma at a private general pathology center. The lesion had recurred after one year and the histopathologic diagnosis was a poorly differentiated malignant melanoma at another pathology center. The lesion recurred again and the specimen was sent to a third histopathologic center where the histopathologic diagnosis revealed spindle cell growth with moderate atypia. A pannus-like lesion occurred in the nasal limbus 3 years later which was excised and sent to the Eye Bank Pathology Laboratory. Reviewing the slides related to the first recurrent lesion and the histopathologic examination of the recently excised specimen disclosed a final diagnosis of atypical fibrous histiocytoma and intra-epithelial squamous neoplasia, respectively. Fibrous histiocytoma is a rare limbal tumor that may have atypical features and can be misdiagnosed as an amelanotic melanoma. This is also a rare report on the occurrence of intraepithelial squamous neoplasia following excision of recurrent fibrous histiocytoma

[Keratocyte density in normal and keratoconic corneas using confoscan]

To compare keratocyte density between normal and keratoconic corneas in non-contact lens wearers. Confocal scanning was performed on 39 corneas of 26 patients with keratoconus and 28 corneas of 14 normal control subjects. None of the cases were contact lens wearer. All individuals underwent ophthalmic examination and computed topography in addition to confocal microscopy. Main outcome measures were anterior [10%], middle [33-67%] and posterior [10%] stromal keratocyte densities. Mean age of the subjects was 27.7 +/- 6.6 [range 18-45] years. Mean keratocyte density in the control group was 736.7 +/- 65.6 cell/mm2 in the anterior stroma, 623.4 +/- 72.6 cell/mm2 in the middle stroma and 608.6 +/- 45.8 cell/mm2 in the posterior stroma. Corresponding values in the keratoconus group were 787.9 +/- 103.5, 665.2 +/- 58.1 and 604.2 +/- 69.0 respectively. No significant difference was noted between the two groups regarding stromal keratocyte density; however stromal keratocyte density significantly decreased from anterior toward posterior stromal layers within both groups. Keratocyte density showed statistically insignificant decrease with aging. Keratocyte density was significantly higher in female subjects [P= 0.019]. No significant difference was seen between normal and keratoconic corneas in terms of stromal keratocyte density

[Confocal and transmission electron microscopic features of endothelial vacuolation in donated corneas]

To report the confocal microscopic features of endothelial vacuolation in donated corneas and to confirm the observed changes by transmission electron microscopy. Confocal and transmission electron microscopy were performed on donated corneas with endothelial vacuole formation on slitlamp biomicroscopy. The ultrastructural findings were also compared with those of a normal-looking endothelium from a keratoconic cornea. Confocal microscopy revealed large numbers of dark round to oval-shaped structures within the endothelium, consistent with vacuolation which was confirmed by light and electron microscopy by the presence of variable-sized cyst-like structures within the endothelial cytoplasm mainly near the posterior cytoplasmic membrane in semithin preparations and observation of electron-lucent and relatively largesized intracytoplasmic vacuoles on transmission electron microscopy. These features were not observed in the normal-looking endothelium of a keratoconic cornea. In this report, confocal microscopic features of endothelial cell vacuolation are presented in donated corneas and confirmed by transmission electron microscopy. The confocal microscopic images can serve as a useful reference image for endothelial vacuolation

[Histopathologic evaluation of trabeculectomy specimens and surgical results in patients with chronic primary glaucoma]

To evaluate the histopathologic features of trabeculectomy specimens and the results of trabeculectomy in relation with these features in patients with chronic primary glaucoma. This interventional case series included 30 eyes of 28 patients with primary chronic glaucoma who underwent trabeculectomy between 2004 and 2006. Each case was followed for 6 months postoperatively. Histopathologic features and results of surgery were evaluated. The surgery considered as successful when resulted in intraocular pressure [IOP] <21 mmHg without antigiancoma medication and as failed when resulted in IOP of > 21 mmHg and need to anti-glaucoma agent. Mean age of patients was 59 [range 20 to 90] years and 18 patients [64.3%] were male. Seventeen patients had chronic primary open angle glaucoma and 11 had primary chronic closed angle glaucoma. The operation was performed as fornix-based method in 16 eyes and limbal-based in 14. The surgery was successful in 26 [86.7%] and failed in 4 [13.3%]. The content of trabeculectomy specimens in the successful cases included trabecular meshwork in 15 [57.7%], only scleral in 6 [23.1%] and only corneal tissue in 5 [19.2%] cases. Out of 15 cases with content of trabecular meshwork, 7 cases [26.9% of successful cases] had all three portions of cornea, trabecular meshwork and sclera. This figure was not observed in any failed cases. The content of trabeculectomy specimens in failed cases included trabecular meshwork in 3 cases and only sclera in one case. The size and position of the site of trabeculectomy is variable and seems to have significant effects on the success rate of the surgery such that surgical resection anterior to the scleral spur increases the chance of surgical success

[Keratocyte density in keratoconus and post-LASIK corneas with and without keratectasia; a confocal scan study]

To compare keratocyte density in stromal layers of the cornea in keratoconus, post-LASIK keratectasia, LASIK without keratectasia, and normal corneas by confocal scan. Thirty-one unscarred corneas from 22 patients with keratoconus, 24 clear corneas from 17 cases with post-LASIK keratectasia, 12 corneas from 7 LASIK cases without keratectasia, and 26 corneas from 13 normal subjects were evaluated using confocal scanning. None of the patients were contact lens wearers. Keratocyte density was determined in three stromal layers and compared with densities in the corresponding layers in control corneas. Cell densities in different corneal layers were also compared among the study groups. Overall, 93 eyes from 59 patients with mean age of 30 +/- 7.3 years were evaluated. There was no difference in mean keratocyte density at 3 stromal layers between the keratoconus and control groups. In the post-LASIK keratectasia group, keratocyte density was significantly lower than controls in the anterior and posterior stromal layers; whereas in LASIK cases without keratectasia it was lower than controls in all 3 stromal layers. No difference in keratocyte density was found between cases with post-LASIK keratectasia and LASIK without keratectasia. In the post-LASIK keratectasia group, there was a significant difference in keratocyte density between the anterior and posterior, and between the middle and posterior stromal layers; such a difference was not observed in the LASIK cases without keratectasia. Mean keratocyte density seems to be lower in post-LASIK keratectasia and LASIK cases without keratectasia as compared to normal corneas. The distribution of keratocytes among different stromal layers was different in the two LASIK groups: there was a non-homogenous distribution of keratocytes in stromal layers in the post-LASIK keratectasia. Whereas the distribution of keratocytes in the post-LASIK cases without keratectasia was homogenous, this latter observation may be a protective factor against corneal ectasia

[Seropositivity for human T-cell lymphotropic virus [HTL V] in donors at the eye bank of I.R. Iran]

To determine the prevalence of Human T-cell Lymphotropic Virus [HTLV] in corneal donors at the Eye Bank of I.R. Iran from 2005 to 2007. Serologic tests for HTLV-1, 2 were performed in all donors at the Eye Bank from August 2005 to July 2007. Hospital and medicolegal reports of HTLV-reactive cases as well as their geographic origin were reviewed. Overall, 5533 donors including 4467 [80.7%] male subjects aged from 2 to 84 years were evaluated. Thirty seven [0.67%] cases with mean age of 45.8 +/- 17 [range 7-84] years were seropositive for HTLV-1, 2 of whom 26 [70.3%] were male. The most common causes of death in HTLV-reactive cases were car accidents [37.8%] followed by cardiovascular diseases [24.3%], falls [10.8%] and drug intoxication [10.8%]. No evidence of neurologic or hematologic disorders was found on reviewing the hospital and medicolegal reports of HTL V -reactive cases. This is the first report on HTLV-reactivity in corneal donors in Iran revealing a prevalence of 1 per 150 cases

[Benign reactive lymphoid hyperplasia of caruncle and plica: report of five cases]

To report five cases of benign reactive lymphoid hyperplasia of the caruncle and plica and describe their clinical course and pathology. Five patients with fish flesh pinkish masses in the caruncle and plica were referred to Labbafinejad Hospital from 1997 to 2006. The masses were excised. Clinical appearance and course as well as pathology and immunohistochemistry confirmed benign reactive lymphoid hyperplasia. They followed for 2-108 months. No complications were detected during the follow up period. In masses of caruncle and plica with above-mentioned appearance, benign reactive lymphoid hyperplasia must be considered in the differential diagnosis. Pathologic and immunohistochemical evaluation should be performed to rule out lymphoma. Removal of these lesions incurs no complications in short-term period

[Sensitivity and specificity of confocal scan in the diagnosis of fungal and acanthamoeba keratitis]

To determine the sensitivity and specificity of confocal scan in the diagnosis of fungal and acanthamoeba keratitis based on the results of corneal and/or contact lens case smear and culture. Confocal scan and corneal and/or contact lens case smear and culture were performed in all patients with a clinical diagnosis of infectious keratitis who were referred to Labbafinejad Medical Center from 2004 to 2006. A total of 133 eyes of 133 patients [52% male] with mean age of 48.0+22.6 years [range 9-83] were included in the study. Previous history of contact lens wear, ocular trauma and ocular surgery was present in 21%, 21% and 38.3%, respectively. Overall, corneal and/or contact lens case smear and culture were positive in 71 eyes [53.4%] for bacteria [40 cases], fungi [16 cases] and acanthamoeba [15 cases]. Confocal scan was positive in 50 cases [37.6%] which revealed hyphalike structures in 27 cases [20.3%] and cyst and/or trophozoite-like structures in 23 cases [17.3%]. The sensitivity and specificity of confocal scan were 100% and 84% for diagnosing acanthamoeba keratitis versus 93.4% and 77.8% for diagnosing fungal keratitis, respectively. In vivo corneal confocal scan is a rapid non-invasive tool for the diagnosis of acanthamoeba and fungal keratitis with high sensitivity and specificity based on smear and culture results. It may also be helpful in excluding fungal or acanthamoeba-like structures in cases with negative bacteriological results and in early bacterial keratitis before clarification of microbiologic results

[Corneal endothelial cell evaluation in donors with aluminum phosphide intoxication]

To evaluate corneal endothelial cells of donors who died from aluminum phosphide intoxication. Endothelial cell count and quality of eight corneas from four donors with aluminum phosphide intoxication were evaluated by slit lamp biomicroscopy and specular microscopy at the Eye Bank of I.R. Iran. Confocal scan examination was carried out only in one of the recipients. Donor age ranged from 21 to 60 years. All corneas were clear and the estimated endothelial cell density was very good to excellent. The endothelial cell density ranged from 2600 to 3300 cell/mm2 with a mean of 2920 cell/mm2. The pleomorphism ranged from 33% to 50% with mean of 40% and the polymegathism ranged from 31% to 39% with mean of 35%. In one recipient, 5 months after penetrating keratoplasty, the endothelial cell density was 2848 cells/mm2 on confocal scan with 40.8% polymegathism and 44.9% pleomorphism. Oral intoxication with aluminum phosphide seems not to affect corneal endothelial cell count and viability. Further experimental study is suggested

[Candida interface keratitis after deep anterior lamellar keratoplasty: clinical, microbiologic, histopathologic and confocal microscopic reports]

To report the clinical, histopathologic, microbiologic and confocal microscopic features of Candida keratitis after deep anterior lamellar keratoplasty [DALK]. The first patient presented with asymptomatic white to cream-colored interface deposits two months after DALK. Confocal scan disclosed clusters of hyper-reflective fine granular deposits in the interface with no evidence of inflammation or hypha-like structures. With a presumptive clinical diagnosis of progressive epithelial down-growth, irrigation of the interface was performed. Finally, penetrating keratoplasty was performed due to rupture in the Descemet's membrane. Histopathologic examination of the cornea disclosed yeast-like structures at the interface area. Microbiologic results of the irrigation fluid demonstrated Candida glabrata. The second patient presented with symptomatic infiltration of the inferior interface close to the suture site 2.5 months after DALK. Confocal scan disclosed foci of inflammation with clusters of hyper-reflective roundshaped structures that resembled epithelial cells. With a clinical diagnosis of epithelial down growth and progression of the lesion, penetrating keratoplasty was performed. Histopathologic examination of the cornea revealed acute and chronic granulomatous keratitis due to yeast-like structures. The microbiologic results demonstrated infection with Candida albicans. Clinical and confocal features of interface Candida keratitis may resemble those of epithelial down-growth, which may postpone correct diagnosis and treatment. Candida keratitis should be considered in cases of interface deposits after any form of lamellar keratoplasty

[Histopathologic evaluation of optic neurotomy with MVR blade and excimer laser in cadaver eyes]

To evaluate the histopathologic features of optic neurotomy with microvitreoretinal [MVR] blade and excimer laser in cadaver eyes. Optic neurotomy was performed in 11 cadaver eyes using 20-gauge MVR blade and in three cadaver eyes with pulsed xenon chloride [XeCl] excimer laser [308 nm] via monofile lightconducting fiber with a core diameter of 200 microns. After tissue processing, hematoxylin and eosin stained slides were used to evaluate the posterior segment of the globes, including the optic nerve head. None of the cases in the MVR neurotomy group had scleral macro- or micro-perforation and no injury was induced to the central retinal vein or artery. In 10 cases, the distance between the neurotomy site and the central retinal vessels ranged from 50 to 500 micro at all histologic levels. In one remaining case this distance was approximately 10 micro on two histologic sections and about 200 micro at a third level. Intra-neural hemorrhage was found in 18% of cases. Neurotomy was successfully induced in two of three cases attempted with the excimer laser. In one case, due to cloudy media, it was not apparent whether the laser successfully induced the neurotomy and no neurotomy was evident on sectioning. MVR induced optic neurotomy is an effective procedure to create scleral outlet relaxation, without significant surgical complications such as scleral perforation or central retinal vascular injury. This preliminary study also demonstrates that the XeCl excimer laser can make nonmechanical cuts with relative ease and reliability

[Intraocular lens calcification: a clinico-pathological report and review of literature]

To report the clinico-pathologic features of an opacified single-piece hydrophilic acrylic intraocular lens [IOL]. A 48-year-old male patient was evaluated for glare and markedly decreased vision in his left eye four years after phacoemulsification and implantation of a single-piece hydrophilic acrylic IOL [Ophthalmed]. Best-corrected visual acuity was 20/60 and there was diffuse milky white opalescence of the IOL on slitlamp biomicroscopy. IOL explantation and exchange was performed and the explanted IOL was evaluated at the Eye Bank pathology laboratory by light microscopy. Full-thickness sections of the optic were stained with Hematoxylin and Eosin [H and E], Von Kossa and Gram Twort's staining methods. Gross examination of the IOL disclosed opacification of the optic and haptics. Microscopic analysis of the sections revealed diffuse fine basophilic granular deposits of variable size within the lens optic parallel to the lens curvature with a clear zone from the optic surface. The deposits were of high calcium content based on the dark brown appearance on Von Kossa staining. This is the first clinico-pathological report of IOL calcification with involvement of optic and haptics in Iran. IOL exchange is an effective treatment in cases with calcified hydrogel IOLs