Combined Phototherapeutic Keratectomy and Peripheral Anterior Stromal Puncture for the Treatment of Recurrent Corneal Erosion Syndrome

Purpose@#To investigate the efficacy of the combined phototherapeutic keratectomy (PTK) and peripheral anterior stromal puncture (ASP) compared with that of PTK alone in patients with recurrent corneal erosion syndrome (RCES). @*Methods@#The medical records of 25 patients (25 eyes) who underwent combined treatment of PTK and peripheral ASP for RCES from March 2016 to May 2017 were retrospectively reviewed. Twenty-three patients (23 eyes) treated with PTK alone from March 2015 to February 2016 served as a control group. All surgeries were performed by a single surgeon. This retrospective clinical study comprised 48 patients (48 eyes) who were followed up for more than 18 months. Clinical records of age, sex, laterality, etiology of RCES, and history of recurrence after treatment were evaluated. @*Results@#Twenty-five eyes were treated with combined PTK and ASP, and 23 eyes were treated with PTK only. The mean follow-up period was 19.63 ± 2.97 and 19.75 ± 6.83 months, respectively. There were no differences in baseline parameters between the groups. In the combined treatment group, one patient experienced recurrence 6 months after the surgery. In the single treatment group, five patients showed recurrence at 4, 7, 8, 11, and 13 months after the surgery, respectively.Compared to the single treatment group, the combined treatment group showed significantly lower recurrence rate (p < 0.05).All recurred patients required no additional treatment except temporary therapeutic contact lenses and topical lubricants. @*Conclusions@#Our findings suggest that combined treatment of PTK and peripheral ASP is effective in alleviation of symptoms and prevention of recurrence in refractory RCES compared with treatment using PTK alone.

Clinical Aspects of Phlyctenular Keratoconjunctivitis Using a Tear Film Interferometer

PURPOSE: To evaluate clinical findings in phlyctenular keratoconjunctivitis patients and assess the function and morphology of Meibomian glands using an interferometer (LipiView®, TearScience, Morrisville, NC, USA) in such patients.METHODS: This retrospective study included 19 eyes of 13 patients diagnosed with phlyctenular keratoconjunctivitis. The lipid layer thickness (LLT) and meibograph of each eye was quantified by tear interferometry. Tear film break-up time (TBUT) and corneal staining score were measured. Meibomian gland morphology (lid margin vascularity, plugging of gland orifices, lid margin irregularity, lid margin thickening, and partial glands) was evaluated based on anterior photographs and meibographs.RESULTS: The mean age was 21.3 years (8–44 years). Mean BUT and Oxford corneal staining scores were 2.6 ± 1.2 seconds and 1.9 ± 0.8, respectively. Abnormal findings of the Meibomian glands were observed in all patients. The mean LLT was 79.6 ± 27.4 µm and the incomplete eye blinking frequency was 3.8 ± 5.9 during 20 seconds. The graphs of the tear lipid layer showed various patterns such as flat, up-hill, down-hill, and mixed.CONCLUSIONS: Meibomian gland dysfunctions and changes in the tear film lipid layer were noted in patients with phlyctenular keratoconjunctivitis. These factors are to be considered for the treatment of phlyctenular keratoconjunctivitis in young patients under 10 years of age.

Changes in Tear Volume after 3% Diquafosol Treatment in Patients with Dry Eye Syndrome: An Anterior Segment Spectral-domain Optical Coherence Tomography Study

PURPOSE: To evaluate changes in the tear meniscus area and tear meniscus height over time in patients with dry eye syndrome, using anterior segment spectral-domain optical coherence tomography after the instillation of 3% diquafosol ophthalmic solution. METHODS: Sixty eyes from 30 patients with mild to moderate dry eye syndrome were included. Tear meniscus images acquired by anterior segment spectral-domain optical coherence tomography were analyzed using National Institutes of Health's image-analysis software (ImageJ 1.44p). Tear meniscus area and tear meniscus height were measured at baseline, 5 minutes, 10 minutes, and 30 minutes after instillation of a drop of diquafosol in one eye and normal saline in the other eye. Changes in ocular surface disease index score, tear film break-up time, corneal staining score by Oxford schema, and meibomian expressibility were also evaluated at baseline, and after 1 week and 1 month of a diquafosol daily regimen. RESULTS: Sixty eyes from 30 subjects (mean age, 29.3 years; 8 men and 22 women) were included. In eyes receiving diquafosol, tear volume was increased at 5 and 10 minutes compared with baseline. It was also higher than saline instilled eyes at 5, 10, and 30 minutes. Changes in tear volume with respect to baseline were not statistically different after the use of diquafosol for 1 month. Ocular surface disease index score, tear film break-up time, and Oxford cornea stain score were significantly improved after 1 week and 1 month of daily diquafosol instillation, but meibomian expressibility did not change. CONCLUSIONS: Topical diquafosol ophthalmic solution effectively increased tear volume for up to 30 minutes, compared to normal saline in patients with dry eye syndrome.

Comparison of Anterior Segment Measurements Using Scanning-Slit Topography and Optical Low-Coherence Reflectometry (OLCR) Biometry

PURPOSE: To compare the results of anterior segment biometry including white-to-white (WTW) between scanning-slit topography (ORBscan IIz(R), Bausch & Lomb), optical low-coherence reflectometry (OLCR) biometry (Lenstar(R), Haag-Streit), and Castroviejo calipers. METHODS: Measurements on 72 eyes of 36 patients that underwent refractive surgery were measured using ORBscan(R), Lenstar(R), and calipers and compared. Ocular biometry parameters used in this study included the WTW, central corneal thickness, anterior chamber depth (ACD), keratometry, and pupil size. RESULTS: The WTW measurements using ORBscan(R) and calipers (11.57 +/- 0.35 mm and 11.58 +/- 0.34 mm, respectively) were statistically similar. However, the measurement using Lenstar(R) (12.05 +/- 0.40 mm) was significantly greater than with the other methods (p < 0.001). Central corneal thickness and keratometry measurements using ORBscan(R) were greater than when using Lenstar(R) (p = 0.01 for both). ACD and pupil size measurement using Lenstar(R) were greater than when using ORBscan(R) (p < 0.001 for both). CONCLUSIONS: Because WTW and ACD measurements using Lenstar(R) were greater than when using ORBscan(R) and calipers, unexpected high-vaulting may be observed due to the selection of a larger-sized posterior chamber phakic intraocular lens. Therefore, the differences in measurements obtained when using these methods should be considered.

Comparison of Anterior Segment Measurements Using Scanning-Slit Topography and Optical Low-Coherence Reflectometry (OLCR) Biometry

PURPOSE: To compare the results of anterior segment biometry including white-to-white (WTW) between scanning-slit topography (ORBscan IIz(R), Bausch & Lomb), optical low-coherence reflectometry (OLCR) biometry (Lenstar(R), Haag-Streit), and Castroviejo calipers. METHODS: Measurements on 72 eyes of 36 patients that underwent refractive surgery were measured using ORBscan(R), Lenstar(R), and calipers and compared. Ocular biometry parameters used in this study included the WTW, central corneal thickness, anterior chamber depth (ACD), keratometry, and pupil size. RESULTS: The WTW measurements using ORBscan(R) and calipers (11.57 +/- 0.35 mm and 11.58 +/- 0.34 mm, respectively) were statistically similar. However, the measurement using Lenstar(R) (12.05 +/- 0.40 mm) was significantly greater than with the other methods (p < 0.001). Central corneal thickness and keratometry measurements using ORBscan(R) were greater than when using Lenstar(R) (p = 0.01 for both). ACD and pupil size measurement using Lenstar(R) were greater than when using ORBscan(R) (p < 0.001 for both). CONCLUSIONS: Because WTW and ACD measurements using Lenstar(R) were greater than when using ORBscan(R) and calipers, unexpected high-vaulting may be observed due to the selection of a larger-sized posterior chamber phakic intraocular lens. Therefore, the differences in measurements obtained when using these methods should be considered.

A Case of Syphilitic Scleritis Initially Misdiagnosed as Noninfectious Nodular or Fungal Scleritis

PURPOSE: To report a case of syphilitic scleritis initially misdiagnosed as noninfectious nodular or fungal scleritis. CASE SUMMARY: A 63-year-old female, who had severe headaches and ocular pain in her left eye despite treatment with topical and oral NSAIDs for the past 4 months, was transferred from a local clinic. The patient had a history of pterygium excision in the same eye 4 years prior. Upon presentation, she had a scleromalacia with calcified plaque at the nasal conjunctiva. An erythematous nodular elevated lesion was observed in the superonasal sclera. Microbiological smear and cultures were performed to exclude infectious scleritis. Under the suspicion of noninfectious nodular scleritis, the patient was prescribed topical oral steroid and oral NSAIDs. Candida parapsilosis was identified by the microbiological culture. Under the suspicion of fungal scleritis, oral fluconazole and topical amphotericin B were administered, but the lesions did not improve. On the 23rd day of treatment, we discovered the patient had a history of syphilis. The serology test was negative for RPR and FTA-ABS IgM but positive for FTA-ABS IgG. Under the suspicion of syphilitic scleritis, oral doxycycline (200 mg bid) was administered and benzathine penicillin M (2.4 million units) was injected intramuscularly 3 times at 1-week intervals. After the doxycycline and benzathine penicillin therapy, the pain and nodular erythematous lesions were completely resolved. CONCLUSIONS: As shown in this case, syphilitic scleritis should be considered when the patient is resistant to other conventional treatments and shows positive serological tests for syphilis. This is important because syphilitic scleritis is usually aggravated by steroid treatment but can be cured by proper anti-syphilitic chemotherapy.

Comparison of Colvardpupillometer, ORBScan II and Sirius in Determining Pupil Size for Refractive Surgery

PURPOSE: To compare pupil size measured by Colvard(R)pupillometer, ORBScan II(R), Sirius(R) and analyze correlation between pupil size and night vision disturbance after refractive surgery according to measuring methods. METHODS: Two hundred eyes of one hundred patients who underwent refractive surgery were retrospectively evaluated. Pupil size was measured with Colvard(R)pupillometer, Sirius(R) in the scotopic light condition and with ORBScan II(R), Sirius(R) in the photopic light condition. Patients filled out questionnaire about night vision disturbance at postoperative three months. Correlation between pupil size according to measuring methods and night vision disturbance was evaluated. RESULTS: The mean age of patient was 26 years and number of male patients was 36. In scotopic light condition, pupil size measured with Colvard(R)pupillometer (6.76 mm) was significantly larger than that of Sirius(R) (6.53 mm) (p < 0.001). In photopic light condition, pupil size measured with ORBScan II(R) (3.98 mm) was significantly smaller than that of Sirius(R) (4.41 mm) (p < 0.001). Night vision disturbance were correlated with pupil size and Sirius(R) in the scotopic light condition had strongest correlation among three measuring method (r = 0.44). CONCLUSIONS: Sirius(R) tends to measure pupil size smaller than Colvard(R)pupillometer in the scotopic light condition. The correlation between night vision disturbance and pupil size was highest in Sirius(R).

Clinical Usefulness of a Thermal-Massaging System for Treatment of Dry Eye with Meibomian Gland Dysfunction

PURPOSE: To evaluate the clinical usefulness of KCL 990(R) for the treatment of dry eye with meibomian gland dysfunction (MGD). METHODS: Patients (n = 54 eyes, 27 subjects) diagnosed with dry eye with MGD were recruited for a prospective, one-month clinical trial. Patients received a twice-a-day 15-minute treatment using the KCL 990(R). Effectiveness parameters included patient symptom scores using the Ocular Surface Disease Index (OSDI) questionnaires, tear osmolarity measured with TearLab(R) (TearLab Corporation, San Diego, CA, USA), classical tear break-up time (TBUT), and objective TBUT value using an Optical Quality Analysis System (OQAS(R), Visiometrics, Castelldefels, Spain). Data are presented for pre-treatment (baseline) and at 1 week and 1 month post-treatment. An objective TBUT value was estimated in each eye when the optical scattering index (OSI) started to increase consistently, and data were obtained at pretreatment (baseline) and at 1 month post-treatment. RESULTS: The symptom scores on OSDI questionnaires, tear osmolarity, and tear break-up time improved significantly from baseline to one week (p < 0.05). This improvement was maintained with no significant regression at 1 month (p < 0.05). The objective TBUT value decreased significantly at 1 month (p < 0.05). CONCLUSIONS: KCL 990(R) contributed to improve not only signs and symptoms of dry eye with MGD, but also the function of the tear film and ocular surface.

Development of EKC after Eximer Laser Photorefractive Surgery and Subsequent Recurrence of EKC-like Keratitis

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.

Prognosis and Survival Rate of Penetrating Keratoplasty in Corneal Dystrophy and Corneal Degeneration

PURPOSE: To investigate the prognosis, survival rate and curve on the eyes for corneal dystrophy and corneal degeneration, we performed statistical analysis. METHODS: Forty-one recipients (62 eyes) have received penetrating keratoplasty for corneal dystrophy and corneal degeneration for about 14 years from April 1984 to October 1997. We analyzed survival rate and curve on sex, age and type of corneal dystrophy and corneal degeneration. RESULTS: Mean age was 35 years and sex distribution of recipient was predominant in female patients (M: 16 recipients, 19 eyes, F: 25 recipients, 43 eyes). In the causative disease of first keratoplasty, corneal dystrophy and corneal degeneration were 46 eyes and 16 eyes. Granular type was the most common type of keratoplasty. In 62 grafts, graft rejection was developed in 19 eyes (30.6%). Graft rejection periods ranged from 53 days to 10 years and 3 months. Mean graft rejection time was 2 years and 8 months. In this study, 5 years survival rate developed in 75% of corneal dystrophy and developed in 31% of corneal degeneration. The statistical analysis showed significant relationship between survival rate and disease type (p=0.0032, p0.05). CONCLUSIONS: This result suggests that corneal dystrophy was higher than corneal degeneration in survival rate with statistically significant difference. But sex and age did not have influence on survival rate.

One Year Clinical Result of Successful LASIK Using VISX Star

To evaluate the one year efficacy, visual recovery and stability for the correction of myopia we reviewed the 65 eyes successfully underwent LASIK from Dec.1996 to June 1997. All the visual acuity was calculated by logarithmic mean scale.Mean uncorrected visual acuity[UCVA]was 1.39 +/-0.44 and 0.16 +/-0.12 before and one year after LASIK, respectively.One year visual outcome after LASIK was better in the eyes under -6.0 diopter[D]than the eyes over-10.0D [P<0.05].Uncorrected visual acuity of 1 year after LASIK was 20/25 or better in all myopic eyes better than -6.0D and in 36 percent of eyes over-10.0D.Mean spherical equivalent[SE]was -8.71D and -0.8D before and one year after LASIK, respectively.Spherical equivalent less than +/- 1.0 diopter was 85.7 percent of the eyes under -6.0D and in 39.3 percent of the eyes over than -10.0D.Myopic regression was prominent from 1 week to 2months[P<0.05]and stable after 6 months[P<0.05]. With these results it was found that the efficacy of LASIK in visual acuity and the stability of myopic regression were related reversely with severity of myopia.

A Case of Primary Mantle Cell Lymphoma on the Conjunctiva

MCL (Mantle cell lymphoma) is a subtype of B-cell non-Hodgkin`s lymphoma and has been established as a clinicopathologic entity in 1991. Although the prognosis of MCL is poor because it is systemically disseminated at the time of diagnosis in most patients and responds poorly to chemotherapy, the authors experienced a primary mantle cell lymphoma without systemic lymphadenopathy through chest PA, orbit neck chest abdomen CT, bone marrow biopsy, and bone scan in a 56-year-old man who presented with conjunctival mass in right eye. The patient was treated with surgical excision and radiotherapy due to confinement to the conjunctiva. We also report the case with a recent review of the ophthalmic literature.

Effect of Laser in Situ Keratomieusis on Astigmatic Correction

We studied the effect of LASIK(laser in situ keratomileusis) on the correction of astigmatism for patients with simple myopia & compound myopic astigmatism. LASIK was performed on 147 eyes of 108 patients using VISX STAR. All the cases were divided into two groups by the amount of underlying astigmatism: 64 eyes for simple myopic group(equal or less than 0.5D) and 83 eyes for compound myopic astigmatism group(more than 0.75D). The attemped correction for refractive error was determind by cycloplegic refraction. We evaluated the changes of refractive error, uncorrected visual acuity, best corrected visual acuity, corneal topography, corneal thickness and keratometry before operation, one day, one week,two months and six months after operation. Uncorrected visual acuity improved from 0.062+/-0.056 before operation to 0.821+/-0.215 at six months after operation in simple myopic group and from 0.069+/-0.068 to 0.735+/-0.224 in compound myopic group. Spherical equivalent was reduced from -8.135+/-2.096D before operation to -0.765+/-1.186D at six months after operation in simple myopic group and from -9.498+/-3.181D to -1.022+/-1.504D in compound myopic astigmatic group. Mean astigmatism increased from -0.300+/-0.205D before operation to -0.703+/-0.553D at six months after operation in simple myopic group and was reduced from -1.640+/-1.047D to -1.075+/-0.811D in compound myopic astigmatic group. Decentration of ablation from the pupil center was ranged between 0.00 and 1.42mm(mean 0.449+/-0.341mm) in all the patients by corneal topography. It was 0.446+/-0.333mm in simple myopic group and 0.452+/-0.353mm in compound myopic astigmatic group respectively. The patients with a decentration more than 1.00mm showed a statistically significant astigmatism than those with a decentration equal or less than 1.00mm.With these results it is suggested that LASIK with VISX STAR would be effective in correction of astigmatism equal or more than 0.75D. In contrast, it is not effective in correction of astigmatism equal or less than 0.5D.

Effect of Excimer Laser Photorefractive Keratectomy on the Induction of Astigmatism in Rabbits

Twenty eight rabbit eyes which underwent astigmatic photorefractive keratectomy with excimer laser were analyzed to evaluate the effect of excimer laser photorefractive keratectomy on high astigmatic refractive error. Non-astigmatic eyes were divided into 4 groups according to their operative technique for inducing astigmatism(Group I: 50micrometer ablation with no astigmatism, Group II: 3.00 diopter with the rule astigmatism, Group III: 6.00 diopter with the rule astigmatism, Group IV: 9.00 diopter with the rule astigmatism). During the follow-up period, changes of astigmatism were examed with corneal topography, The results were as follows; 1. Two months after surgery, the mean achieved astigmatisms were 0.23(Group I), 1.78(Group II), 2.63(Group III) 2.65 diopters(Group IV), respectively. 2. Mean astigmatic induction rates of the group II,III and IV were 59.4%, 48.3% and 29.48%, respectively, Astigmatic induction rate of group II, in which the attempted astigmatism was -3.00 diopters, was highest(P<0.05) 3. Highly achieved astigmatism at postoperative 7 days regressed in all groups except group I(P<0.05). The regression was most significantly progressed in group IV, but the regression pattern did not reveal any statistically significant difference between the groups(P<0.05) 4. In SEM study, the rabbit cornea samples showed the different irregularities. Deeper ablation group tissues exhibited a much rougher surface appearance than shallow ablation group tissues. In this study, it was concluded that the achieved astigmatism and induction rate of astigmatism were statistically significant correlation(P<0.05), but the induction rate was smaller compared to the attempted astigmatism, and increased tendency for regression.

Phototherapeutic Keratectomy for the Treatment of Persistent Epithelial Defect

Persistent epithelial defect (PED) is an important ocular surface disorder. These defects can be frustrating chronic diseases as in the cases of inflammation, chemical burn, denervated cornea, tear deficiency and radiation keratitis. Therapeutic modalities that have been utilized in the treatment of PED included topical steroid, patching, bandage soft contact lenses, superficial keratectomy and anterior stromal puncture. We reported here the use of 193 nm excimer laser phototherapeutic keratectomy (PTK) for the treatment of indolent and persistent epithelial defect as the new Therapeutic device for PED. Twelve eyes diagnosed as PED were treated with Summit excimer laser phototherapeutic keratectomy. All cases were failed to cover the epithelium with therapeutic contact lenses. The laser treatments(diameter 1mm, depth 5micrometer) were delivered to sites surrounding the epithelial defect area for promoting of the epithelial ingrowth. All cases received PTK were covered with new epithelium in two or three days as shown by photorefractive keratectomy and remained completely healed through at least three months follow-up period. We found PTK with the 193 nm excimer laser to be a safe, effective treatment modeling for PED that is unresponsive to conventional therapy.

A Clinical Study of Risk Factors of Graft Rejection for Penetrating Keratoplasty

Penetrating keratoplasty was performed on 185 eyes. We analyzed the relative risk about the high and low risk groups, sex, age, complication, neovascularization, and graft size. In 185 grafts, graft rejection was developed in 60 eyes(32.4%). In the low risk group, there was the most graft rejection in 17 keratoconus eyes(62.9%) and in the high risk group, in 18 eyes with vascularized corneal scar. Graft rejection was developed in 33 eyes(47.8%) of the high risk group and developed in 27 eyes(23.3%) of the low risk group. The high risk group increased the risk of graft rejection(Relative risk=3.022, P value=0.001). Graft rejection developed in 33 eyes(25%) with non-vascularization and in 27 eyes(52%) with neovascularization. Neovascularization increased the risk of graft rejection (Relative risk=3.273, P value0.5). Mean preoperative visual acuity was 0.048 and mean postoperative visual acuity was 0.4. In the high risk group the mean postoperative corrected visual acuity was 0.25 and in the low risk group it was 0.5.

A Case of Nanophthalmos

Nanophthalmos is a rare disease that results from arrested development of the globe after closure of the embryonic fissure and is characterized by a small eye with thickened sclera, uveal effusion, non-rhegmatogenous retinal detachment and narrow angle glaucoma. Treatments include medical, laser and surgical theraphy for glaucoma, and surgical treatments like scleral resection, anterior sclerotomy and vortex vein decompression surgery for the drainage of the uveal effusion, etc. We experienced a case of nanophthalmos with narrow angle glaucoma and choroidal effusion in 34 year-old male patients. Anterior sclerotomy for the drainage of the uveal effusion was performed and the scleral tissue obtained. Histopathologic study on the sclera showed abnormal collagen fibers.