Tectonic Keratoplasty Using Acellular Preserved Human Cornea for the Inciting Eye in Sympathetic Ophthalmia

Purpose@#We report a case of sympathetic ophthalmia in which the inciting eye was treated with a tectonic keratoplasty using acellular preserved human cornea.Case summary: A 68-year-old man whose left eye was injured by a nail visited our institute complaining of a recent decrease in bilateral vision. The best corrected visual acuity was 0.32 for the right eye and 0.16 for the left. On slit-lamp examination, a superior peripheral corneal perforation with no wound leakage due to iris plugging was seen in the left eye (i.e., the inciting eye). The right eye (i.e., the sympathizing eye) had mutton-fat keratic precipitates and copious fibrinoid strands in the anterior chamber. Bilateral exudative retinal detachment with choroidal folds was prominent in both eyes. The next day, the necrotic iris lump was removed from the inciting eye and adhesiolysis of the iris and tectonic keratoplasty using acellular preserved human cornea were performed. Systemic steroid was started immediately postoperatively. The exudative retinal detachment improved in both eyes and cataract surgery was undertaken for the inciting eye 4 months later. Twenty-one months after the initial visit, the uncorrected visual acuity was 1.0 in the inciting eye, and both eyes had a sunset glow fundus appearance, without optic atrophy or recurrent chorioretinitis. @*Conclusions@#Tectonic keratoplasty using acellular preserved human cornea with anti-inflammatory treatment may be a favorable therapeutic option for the inciting eye with peripheral corneal perforation in sympathetic ophthalmia.

Two cases of late-onset cardiovascular toxicities after a single injection of local anesthetics during supraclavicular brachial plexus block - A report of two cases -

Local anesthetics systemic toxicity (LAST) is a grave complication of regional anesthesia that usually occurs immediately after local anesthetics injection. Here, we report on rare late-onset toxicity cases after supraclavicular brachial plexus blocks. Case: Two patients underwent surgery for radius fractures. We used lidocaine 100 mg and ropivacaine 150 mg for blocking and infused dexmedetomidine for intraoperative sedation. The 63-year-old male patient’s blood pressure dropped to 87/60 mmHg after 3 h 15 min after blocking. Ventricular fibrillation occurred 10 min later. After five defibrillations, electrocardiography showed ventricular tachycardia that was normalized through one cardioversion. The 54-year-old female patient’s heart rate decreased to 35 beats/min 2 h 30 min after blocking. Her vital signs returned to normal after administering atropine, ephedrine, epinephrine, and lipid emulsion. Conclusions: Physicians should remember that LAST may occur long after local anesthetic injection and be aware of factors that may adversely affect the course of LAST.

Clinical Factors Associated with the Early Reduction of Corneal Sensitivity in Herpes Zoster Ophthalmicus

Purpose@#To identify clinical factors associated with the early reduction of corneal sensitivity (CS) in patients with herpes zoster ophthalmicus (HZO). @*Methods@#Total 30 subjects were divided into two groups according to the occurrence of an early reduction of CS (group 1, normal CS; group 2, decreased CS). The demographics, ocular manifestations of HZO, and the ocular surface parameters were compared between two groups. Then, the relative risks of variables were analyzed to expect the early decrease of CS by HZO using logistic regression analysis. @*Results@#Among total 30 subjects, the CS decreased in 10 subjects (3.2 ± 1.4 cm, group 2) and the other 20 subjects revealed normal CS (6.0 ± 0.0 cm, group 1). The age was higher in the group 2 (67.0 ± 16.6 years) than in group 1 (48.0 ± 17.6 years, p = 0.013), but sex and the comorbidity of diabetes mellitus was not difference between groups. The presence of corneal punctate epithelial erosions was a single factor among the ocular manifestations of HZO, which discriminated group 1 (5%) and group 2 (60%, p = 0.002). The ocular surface staining scores (i.e., National Eye Institute scores and Sjögren’s International Collaborative Clinical Alliance ocular surface score) were higher in group 2 (p = 0.001 and p = 0.021, respectively) than in group 1. The existence of corneal punctate epithelial erosions revealed as a sole risk factor for the early reduction of CS (odds ratio = 33.085; p = 0.016). @*Conclusions@#It is necessary to pay attention to the possible occurrence of neurotrophic keratopathy especially in older patients with HZO showing an initial presence of corneal punctate epithelial erosions.

Refractory Recurrent Corneal Erosion after Descemet’s Stripping Automated Endothelial Keratoplasty

Purpose@#To report a case of refractory recurrent corneal erosion that occurred after Descemet’s stripping automated endothelial keratoplasty (DSAEK) in iridocorneal endothelial syndrome.Case summary: A 62-year-old male patient with iridocorneal endothelial syndrome planned to undergo ultrathin DSAEK. At the surgery, corneal epithelial debridement was performed using a No. 15 blade to enhance the surgical field visibility. Three corneal venting incisions were made before graft insertion in the recipient eye. The corneal epithelium was healed at postoperative 1 week. However, the epithelium detached at 2 weeks postoperatively. The loosened epithelium was peeled off, and a therapeutic bandage contact lens was applied. Thereafter, the corneal epithelial detachment did not improve, despite repeated corneal epithelial debridement, prolonged therapeutic bandage contact lens wear, applications of 5% sodium chloride eyedrops and autoserum eyedrops, and intake of doxycycline, steroids, and valaciclovir. Anterior stromal puncture was performed three times, and the corneal epithelium eventually attached at postoperative 8 weeks. Although recurrent corneal erosion was not observed at postoperative 10 weeks, acute graft rejection occurred but improved with immunosuppressive treatment. The corrected visual acuity was 0.8 after cataract surgery, which was performed at 1 year after DSAEK. @*Conclusions@#Refractory recurrent corneal erosion may occur after DSAEK surgery. In such a case, an aggressive treatment including the repeated anterior stromal puncture technique may be helpful.

Adult-onset Atypical Stevens-Johnson Syndrome with HLA-A*11:01 and HLA-A*31:01 Alleles

Purpose@#We report a case of adult-onset atypical Stevens-Johnson syndrome (SJS) in which only the oral and ocular mucosae were involved, without skin lesions. Case summary: A 33-year-old man was referred to our institute with recent severe oral mucositis and bilateral conjunctival hyperemia and pseudomembrane formation, which occurred 5 days after taking cold medicine, including a non-steroidal anti-inflammatory drug, acetaminophen and cefaclor, for pharyngitis with fever. At the initial visit, the patient had an epithelial defect of the bulbar and tarsal conjunctiva in both eyes. Conservative treatment using topical eye drops was started, with suspicion of atypical SJS. In addition, HLA-A alleles were typed to assess possible genetic susceptibility to the relevant drugs, and HLA-A*11:01 and HLA-A*31:01 alleles were confirmed. Immunoglobulin (Ig) G against Mycoplasma pneumoniae was positive and IgM was negative at 10 months after the initial onset of disease. One year after the disease onset, autologous serum eye drops, oral and topical steroids, 0.1% cyclosporine eye drops, and antibiotic eye drops were maintained and the corneal and conjunctival erosions were much improved. @*Conclusions@#Although atypical SJS is very rare, it is important to suspect it early by taking a history of any preceding medication or possible concurrent mycoplasma pneumonia, because atypical SJS may affect the oral and ocular mucosae without skin lesions.

Inter-eye Difference of the Intraocular Lens Power Calculation in a Case with Bilateral Posterior Keratoconus

Purpose@#To report a case with bilateral circumscribed posterior keratoconus with different results of refractive error between eyes after cataract surgery. Case summary: A 57-year-old man was referred for decreased vision and suspected keratoconus in both eyes. The corrected visual acuity was 0.04 in the right eye and 0.2 in the left eye. On slit-lamp microscopy and anterior-segment optical coherence tomography (AS-OCT) examination, the excavation of the posterior corneal surface was observed in the central area of the right eye and in the mid-to-inferior area of the left eye. Considering the posterior corneal refractive power measured within the 8-mm zone on AS-OCT, we expected the postoperative hyperopic shift in the refractive error of 2.61 diopters (D) in the right eye and 2.17 D in the left eye. Accordingly, the adjusted predicted refractive error was determined as -0.68 D in the right eye and -1.06 D in the left eye, based on the Barrett Universal II formula. The postoperative values of the spherical equivalent by manifest refraction was -1.0 D in the right eye and -3.0 D in the left eye at 1 month, which was close to the predicted target in the right eye, but myopic by approximately 2.0 D in the left eye, compared to the predicted values. @*Conclusions@#In patients with bilateral circumscribed posterior keratoconus, the location, depth, and area of the excavation of the posterior corneal surface should be considered independently in both eyes to calculate the intraocular lens power more accurately.

Contributing Factors Affecting Ocular Discomfort on Instillation and Compliance of 0.1% Cyclosporine A Cationic Nanoemulsion

Purpose@#We investigated the contributing factors affecting the ocular discomfort on instillation and compliance of 0.1% cyclosporin A (CsA) cationic nanoemulsion eye drops. @*Methods@#We enrolled patients who were prescribed 0.1% CsA eye drops (Ikervis®) and who filled out an eye drop satisfaction questionnaire to assess ocular discomfort on instillation (questions Q1-Q4) and compliance of eye drops (Q5-Q7). First, to identify the contributing factors affecting the early ocular discomfort of 0.1% CsA instillation and compliance, Q1-Q7 scores were correlated with respect to age, sex, instillation period duration, meibomian gland dysfunction, tear secretion, corneal sensitivity, corneal erosions, Sjögren's International Collaborative Clinical Alliance ocular staining score (OSS), tear matrix metalloproteinase 9 (MMP-9), and ocular surface disease index in patients who completed the first questionnaire within the first 3 months of instillation of 0.1% CsA (referred to as Cohort 1). Second, to evaluate the change in ocular discomfort on instillation and compliance, along with the prolonged instillation of 0.1% CsA, the changes in individual scores for questions Q1-Q7 were analyzed in patients who completed at least two or more serial questionnaires (corresponding to Cohort 2). @*Results@#In Cohort 1 (74 eyes in 39 patients), the scores for ocular discomfort on instillation (Q1-Q4) were higher in females and correlated negatively with the instillation period duration and age and positively with tear secretion, corneal erosions, OSS, and tear MMP-9 grades. The higher the grade of tear MMP-9, the lower the compliance score of Q5. In Cohort 2 (34 patients), the scores for ocular discomfort on instillation tended to decrease as the cumulative instillation period lengthened. @*Conclusions@#The results of this study may aid clinicians in explaining to patients the ocular discomfort on instillation of 0.1% CsA, so as to improve treatment compliance.

Short-term Changes in the Tear Matrix Metalloproteinase 9 Level and Ocular Surface Discomfort after Cataract Surgery

Purpose@#We explored changes in the various clinical parameters of dry eye disease (DED), including the tear matrix metalloproteinase 9 (MMP-9) level, soon after cataract surgery. We sought correlations between such changes and ocular surface discomfort. @*Methods@#In 106 patients (106 eyes) who underwent cataract surgery, we evaluated meibomian gland dysfunction, tear secretion, corneal sensitivity, tear break-up time, corneal erosion status, the Sjögren’s International Collaborative Clinical Alliance (SICCA) ocular staining score, tear osmolarity, the tear MMP-9 level, and the ocular surface disease index (OSDI) before, and 1 week and 1 month after surgery. All eyes were instilled with topical moxifloxacin, a steroid, and a non-steroidal anti-inflammatory drug daily for 1 month postoperatively. The 1-month delta OSDI scores correlated with the 1-month delta DED parameters. We compared the latter parameters between patients in whom the MMP-9 level decreased (MMP-9-decreased group) at 1 month with those in whom it did not (MMP-9-not decreased group). @*Results@#Overall, 89.5% of total patients exhibited preoperative DED. The tear MMP-9 level fell at 1 month postoperatively, tear secretion (evaluated using the Schirmer I test) decreased at 1 week, and the OSDI scores fell at both 1 week and 1 month. We found no significant correlation between the 1-month delta OSDI scores and the 1-month delta DED parameters. The 1-month OSDI score fell to a significantly greater extent in the MMP-9-decreased group. @*Conclusions@#Routine, local anti-inflammatory treatment after cataract surgery may briefly reduce the tear MMP-9 level and ocular surface discomfort.

Solitary Conjunctival Xanthoma at the Plica Semilunaris

Purpose@#To report a case of conjunctival xanthoma occurring at the plica semilunaris.Case summary: A 39-year-old female with no specific medical history visited our hospital due to a recent incidental detection of a painless mass in the nasal conjunctiva of her right eye. Slit-lamp bio-microscopic examination revealed a yellowish movable oval mass with inner semi-translucency in the temporal area of the plica semilunaris. The vertical length of the mass was approximately 8 mm. It was well-demarcated at its temporal border; however, the nasal border was obscured behind the plica semilunaris. Considering a possible conjunctival reactive lymphoid hyperplasia, topical and systemic steroids as well as oral doxycycline were administrated for 1 week; however, the lesion showed no improvement. An excisional biopsy was performed; pathological diagnosis indicated conjunctival xanthoma. The patient’s blood lipid profile was within the normal range. @*Conclusion@#Conjunctival xanthoma can develop near the plica semilunaris. Because it is difficult to distinguish xanthoma from other diseases including orbital fat prolapse or lymphoproliferative disease, rapid biopsy would be helpful for an early diagnosis.

Conjunctival Pyogenic Granuloma after Sub-tenon’s Block

Purpose@#We report a case of conjunctival pyogenic granuloma that developed after sub-Tenon’s block at the inferotemporal conjunctival quadrant during cataract surgery.Case summary: A 74-year-old male patient with senile cataract, diabetic retinopathy and open-angle glaucoma, who was using a combination of timolol/tafluprost and brimonidine eyedrops, underwent uneventful cataract surgery after sub-Tenon’s block at the inferotemporal conjunctival quadrant of his right eye. Moxifloxacin, 1% prednisolone acetate and 0.1% bromfenac sodium hydrate were administered daily for 1 month post-surgery, by which time a pink-colored, oval-shaped granulomatous mass had developed on the inferotemporal conjunctiva, at the site of the sub-Tenon’s block. Dexamethasone and antibiotic combination eye drops were administered without resection of the mass, which had markedly regressed after 2 weeks and disappeared completely 6 weeks after treatment. @*Conclusions@#Patients should be informed of the possibility of conjunctival pyogenic granuloma prior to cataract surgery using sub-Tenon’s block, and it is important to carefully check the block site and compliance with eyedrops at follow-up visits. Conjunctival pyogenic granuloma can be successfully treated with topical steroids.

Adult-onset Atypical Stevens-Johnson Syndrome with HLA-A*11:01 and HLA-A*31:01 Alleles

Purpose@#We report a case of adult-onset atypical Stevens-Johnson syndrome (SJS) in which only the oral and ocular mucosae were involved, without skin lesions. Case summary: A 33-year-old man was referred to our institute with recent severe oral mucositis and bilateral conjunctival hyperemia and pseudomembrane formation, which occurred 5 days after taking cold medicine, including a non-steroidal anti-inflammatory drug, acetaminophen and cefaclor, for pharyngitis with fever. At the initial visit, the patient had an epithelial defect of the bulbar and tarsal conjunctiva in both eyes. Conservative treatment using topical eye drops was started, with suspicion of atypical SJS. In addition, HLA-A alleles were typed to assess possible genetic susceptibility to the relevant drugs, and HLA-A*11:01 and HLA-A*31:01 alleles were confirmed. Immunoglobulin (Ig) G against Mycoplasma pneumoniae was positive and IgM was negative at 10 months after the initial onset of disease. One year after the disease onset, autologous serum eye drops, oral and topical steroids, 0.1% cyclosporine eye drops, and antibiotic eye drops were maintained and the corneal and conjunctival erosions were much improved. @*Conclusions@#Although atypical SJS is very rare, it is important to suspect it early by taking a history of any preceding medication or possible concurrent mycoplasma pneumonia, because atypical SJS may affect the oral and ocular mucosae without skin lesions.

Inter-eye Difference of the Intraocular Lens Power Calculation in a Case with Bilateral Posterior Keratoconus

Purpose@#To report a case with bilateral circumscribed posterior keratoconus with different results of refractive error between eyes after cataract surgery. Case summary: A 57-year-old man was referred for decreased vision and suspected keratoconus in both eyes. The corrected visual acuity was 0.04 in the right eye and 0.2 in the left eye. On slit-lamp microscopy and anterior-segment optical coherence tomography (AS-OCT) examination, the excavation of the posterior corneal surface was observed in the central area of the right eye and in the mid-to-inferior area of the left eye. Considering the posterior corneal refractive power measured within the 8-mm zone on AS-OCT, we expected the postoperative hyperopic shift in the refractive error of 2.61 diopters (D) in the right eye and 2.17 D in the left eye. Accordingly, the adjusted predicted refractive error was determined as -0.68 D in the right eye and -1.06 D in the left eye, based on the Barrett Universal II formula. The postoperative values of the spherical equivalent by manifest refraction was -1.0 D in the right eye and -3.0 D in the left eye at 1 month, which was close to the predicted target in the right eye, but myopic by approximately 2.0 D in the left eye, compared to the predicted values. @*Conclusions@#In patients with bilateral circumscribed posterior keratoconus, the location, depth, and area of the excavation of the posterior corneal surface should be considered independently in both eyes to calculate the intraocular lens power more accurately.

Contributing Factors Affecting Ocular Discomfort on Instillation and Compliance of 0.1% Cyclosporine A Cationic Nanoemulsion

Purpose@#We investigated the contributing factors affecting the ocular discomfort on instillation and compliance of 0.1% cyclosporin A (CsA) cationic nanoemulsion eye drops. @*Methods@#We enrolled patients who were prescribed 0.1% CsA eye drops (Ikervis®) and who filled out an eye drop satisfaction questionnaire to assess ocular discomfort on instillation (questions Q1-Q4) and compliance of eye drops (Q5-Q7). First, to identify the contributing factors affecting the early ocular discomfort of 0.1% CsA instillation and compliance, Q1-Q7 scores were correlated with respect to age, sex, instillation period duration, meibomian gland dysfunction, tear secretion, corneal sensitivity, corneal erosions, Sjögren's International Collaborative Clinical Alliance ocular staining score (OSS), tear matrix metalloproteinase 9 (MMP-9), and ocular surface disease index in patients who completed the first questionnaire within the first 3 months of instillation of 0.1% CsA (referred to as Cohort 1). Second, to evaluate the change in ocular discomfort on instillation and compliance, along with the prolonged instillation of 0.1% CsA, the changes in individual scores for questions Q1-Q7 were analyzed in patients who completed at least two or more serial questionnaires (corresponding to Cohort 2). @*Results@#In Cohort 1 (74 eyes in 39 patients), the scores for ocular discomfort on instillation (Q1-Q4) were higher in females and correlated negatively with the instillation period duration and age and positively with tear secretion, corneal erosions, OSS, and tear MMP-9 grades. The higher the grade of tear MMP-9, the lower the compliance score of Q5. In Cohort 2 (34 patients), the scores for ocular discomfort on instillation tended to decrease as the cumulative instillation period lengthened. @*Conclusions@#The results of this study may aid clinicians in explaining to patients the ocular discomfort on instillation of 0.1% CsA, so as to improve treatment compliance.

Short-term Changes in the Tear Matrix Metalloproteinase 9 Level and Ocular Surface Discomfort after Cataract Surgery

Purpose@#We explored changes in the various clinical parameters of dry eye disease (DED), including the tear matrix metalloproteinase 9 (MMP-9) level, soon after cataract surgery. We sought correlations between such changes and ocular surface discomfort. @*Methods@#In 106 patients (106 eyes) who underwent cataract surgery, we evaluated meibomian gland dysfunction, tear secretion, corneal sensitivity, tear break-up time, corneal erosion status, the Sjögren’s International Collaborative Clinical Alliance (SICCA) ocular staining score, tear osmolarity, the tear MMP-9 level, and the ocular surface disease index (OSDI) before, and 1 week and 1 month after surgery. All eyes were instilled with topical moxifloxacin, a steroid, and a non-steroidal anti-inflammatory drug daily for 1 month postoperatively. The 1-month delta OSDI scores correlated with the 1-month delta DED parameters. We compared the latter parameters between patients in whom the MMP-9 level decreased (MMP-9-decreased group) at 1 month with those in whom it did not (MMP-9-not decreased group). @*Results@#Overall, 89.5% of total patients exhibited preoperative DED. The tear MMP-9 level fell at 1 month postoperatively, tear secretion (evaluated using the Schirmer I test) decreased at 1 week, and the OSDI scores fell at both 1 week and 1 month. We found no significant correlation between the 1-month delta OSDI scores and the 1-month delta DED parameters. The 1-month OSDI score fell to a significantly greater extent in the MMP-9-decreased group. @*Conclusions@#Routine, local anti-inflammatory treatment after cataract surgery may briefly reduce the tear MMP-9 level and ocular surface discomfort.

Solitary Conjunctival Xanthoma at the Plica Semilunaris

Purpose@#To report a case of conjunctival xanthoma occurring at the plica semilunaris.Case summary: A 39-year-old female with no specific medical history visited our hospital due to a recent incidental detection of a painless mass in the nasal conjunctiva of her right eye. Slit-lamp bio-microscopic examination revealed a yellowish movable oval mass with inner semi-translucency in the temporal area of the plica semilunaris. The vertical length of the mass was approximately 8 mm. It was well-demarcated at its temporal border; however, the nasal border was obscured behind the plica semilunaris. Considering a possible conjunctival reactive lymphoid hyperplasia, topical and systemic steroids as well as oral doxycycline were administrated for 1 week; however, the lesion showed no improvement. An excisional biopsy was performed; pathological diagnosis indicated conjunctival xanthoma. The patient’s blood lipid profile was within the normal range. @*Conclusion@#Conjunctival xanthoma can develop near the plica semilunaris. Because it is difficult to distinguish xanthoma from other diseases including orbital fat prolapse or lymphoproliferative disease, rapid biopsy would be helpful for an early diagnosis.

Conjunctival Pyogenic Granuloma after Sub-tenon’s Block

Purpose@#We report a case of conjunctival pyogenic granuloma that developed after sub-Tenon’s block at the inferotemporal conjunctival quadrant during cataract surgery.Case summary: A 74-year-old male patient with senile cataract, diabetic retinopathy and open-angle glaucoma, who was using a combination of timolol/tafluprost and brimonidine eyedrops, underwent uneventful cataract surgery after sub-Tenon’s block at the inferotemporal conjunctival quadrant of his right eye. Moxifloxacin, 1% prednisolone acetate and 0.1% bromfenac sodium hydrate were administered daily for 1 month post-surgery, by which time a pink-colored, oval-shaped granulomatous mass had developed on the inferotemporal conjunctiva, at the site of the sub-Tenon’s block. Dexamethasone and antibiotic combination eye drops were administered without resection of the mass, which had markedly regressed after 2 weeks and disappeared completely 6 weeks after treatment. @*Conclusions@#Patients should be informed of the possibility of conjunctival pyogenic granuloma prior to cataract surgery using sub-Tenon’s block, and it is important to carefully check the block site and compliance with eyedrops at follow-up visits. Conjunctival pyogenic granuloma can be successfully treated with topical steroids.

Pseudallescheria boydii Necrotizing Scleritis Treated with Several Antifungal Agents

Purpose@#We report a case of post-pterygium excisional Pseudallescheria boydii (P. boydii) necrotizing scleritis successfully treated with multi-antifungal agents.Case summary: A 73-year-old female with a history of pterygium excision 6 years prior was referred to our institute because of worsening scleritis in the left eye during high-dose, 2-week steroid treatment. On the initial visit, an oval ulcer was observed in the temporal sclera adjacent to the limbus. All steroids were stopped and 1% voriconazole, 5% natamycin, 2.5% vancomycin, and 5% ceftazidime eyedrops were applied every hour and oral voriconazole 200 mg prescribed once a day, but the scleral necrosis continued to worsen. On day 10, the filamentous fungus P. boydii was isolated; 0.5% caspofungin eyedrops were added and the topical voriconazole concentration increased to 2%. Six weeks later, despite epithelization over the scleral necrosis, choroidal detachment developed. The antifungal treatment was continued and a dispersive, ophthalmic viscosurgical device inserted in the anterior chamber. At 14 weeks of treatment, the scleral necrosis was completely epithelialized and the choroidal detachment had disappeared. @*Conclusions@#When encountering a case of P. boydii-caused necrotizing scleritis developing after pterygium excision surgery, long-term intensive treatment with several antifungal agents must be considered.

Two Cases of Atypical Allergic Conjunctivitis Caused by Topical Administration of Brimonidine

Purpose@#To report two cases of atypical conjunctival lesions that differ from the well-known typical papillary or follicular conjunctivitis after the use of brimonidine.Case summary: In the first case, a 46-year-old female patient diagnosed with binocular normal tension glaucoma visited our hospital. After topical application of 1% brinzolamide/0.2% brimonidine fixed-combination eye drops for 7 months, a number of yellow follicles confined to the left upper bulbar conjunctiva with mild conjunctival injection and conjunctival edema were observed under slit lamp microscopy examination. After stopping brimonidine for 2 weeks, conjunctival injection and follicles decreased and, 1 month later, bulbar conjunctival follicles had disappeared completely. Since changing the eye drops to a brinzolamide/timolol fixed combination, there was no recurrence of the condition. In the second case, a 70-year-old female patient who had been diagnosed with binocular normal tension glaucoma a year ago had been using 0.15% brimonidine. On slit lamp examination, bilateral eyelid edema and overall diffuse conjunctival tissue hypertrophy and multiple follicles appeared on the upper and lower palpebral conjunctiva, the bulbar conjunctiva, the conjunctival fornix, and the lacrimal caruncle. Bilateral conjunctival biopsy was performed to differentiate conjunctival lymphoma, and granulomatous inflammation was confirmed by biopsy. After stopping 0.15% brimonidine treatment and changing to latanoprost, conjunctival lesions improved and there was no recurrence. @*Conclusions@#If atypical conjunctival lesions are observed in patients using topical brimonidine, side effects related to brimonidine should be considered. Our results indicated marked improvement within 2 weeks of stopping brimonidine treatment.

Lamellar Graft of an Acellular, Preserved Human Cornea for Recurrent Anterior Granuloma in Stevens-Johnson Syndrome

Purpose@#We describe a patient with Stevens-Johnson syndrome who exhibited recurrent anterior corneal granulomas after corneal perforation (despite multiple amniotic membrane [AM] transplantations); the patient was successfully treated by lamellar grafting of an acellular, preserved human cornea.Case summary: Corneal granulomas developed four times in a 46-year-old man who had been diagnosed with Stevens-Johnson syndrome 17 years priorly and who had undergone multiple AM transplantations after corneal perforation. A corneal granulomatous mass recurred 2 months prior to presentation in our clinic; it rapidly increased in size. With the patient under general anesthesia, the corneal mass was excised and a 4.0-mm-diameter, acellular preserved human cornea (Halo; Eversight Inc., Palo Alto, CA, USA) was grafted. A similarly sized AM was placed over the grafted cornea. Although the engrafted cornea exhibited stromal infiltration 1 month after surgery, the keratitis improved following brief antibiotic treatment. At 8 months postoperatively, the wound was stable; no granuloma recurrence, no graft melting, and no suspected microbial keratitis were observed in the region of the graft. @*Conclusions@#In patients with Stevens-Johnson syndrome and recurrent anterior granulomas (despite multiple AM transplantations), a lamellar graft of acellular, preserved human cornea may be a good therapeutic choice.

Lamellar Corneal Graft Using Acellular Preserved Human Cornea for Perforated Anterior Scleral Staphyloma

Purpose@#To report a case of acquired perforated anterior scleral staphyloma treated successfully by lamellar grafting of the acellular preserved human cornea.Case summary: A 39-year-old male patient with anterior scleral staphyloma at the superior scleral area near the corneal limbus of the right eye which occurred after congenital cataract surgery visited our hospital due to bleeding and excessive tearing in his right eye. Slit lamp bio-microscopic examination revealed a Seidel-positive perforation with bleeding at the anterior scleral staphyloma. Under general anesthesia, conjunctiva was dissected from the scleral staphyloma. Amniotic membrane (AM) was transplanted over the perforated area and an acellular preserved human cornea (Halo; Eversight Inc., Palo Alto, CA, USA) was grafted over the AM. To aid the vascularization over the grafts, an advancement flap of the adjacent Tenon’s capsule was constructed. Thereafter, the recipient cornea was tattooed for cosmetic purposes. At 4 months postoperatively, the wound had stabilized without perforation recurrence, and staphyloma protrusion had improved. @*Conclusions@#In a case of a perforated anterior scleral staphyloma, restorative transplantation using acellular preserved human corneal tissue may be a good therapeutic alternative, given that the cornea is easy to suture, is thick enough to compress the protruding area, and has a low risk of graft stretching or melting compared with the sclera.