Úlcera de Mooren: 30 años de seguimiento / Mooren's ulcer: 30 years of follow-up

CASO CLÍNICO: Mujer de 33 años de raza blanca que consultó por sensación de cuerpo extraño, epífora y dolor intenso, de un mes de evolución, en ambos ojos (AO). El examen biomicroscópico objetivó una úlcera corneal periférica bilateral. Precisó tratamiento con inmunomoduladores y fue intervenida en el ojo izquierdo de queratoplastia en corona semi-circular, queratoplastia penetrante, conjuntivo-córneo-escleroplastia, recubrimiento de mucosa bucal, osteo-queratoprótesis tibial y, finalmente, de desprendimiento de retina. DISCUSIÓN: La úlcera de Mooren es una afección corneal inmunológica que requiere tratamiento inmunomodulador, reservándose el quirúrgico ante el riesgo inminente de perforación, cuando esta ha ocurrido, o en los casos de necrosis aguda

CASE REPORT: A 33-year-old Caucasian female presented with epiphora, ocular pain, and foreign body sensation in both eyes for one month. Examination revealed bilateral peripheral corneal ulcers. The patient had been treated with immunomodulators, and she was treated in the left eye with peripheral semi-circular keratoplasty, penetrating keratoplasty, conjunctival-corneal-scleroplasty, buccal mucosal graft, tibial osteo-keratoprosthesis and finally, retinal detachment. DISCUSSION: Mooren's ulcer is an immunological corneal disease. This lesion must be treated initially with immunomodulators. Surgical treatment should be considered when a risk of corneal perforation is present, when the perforation appears, or under acute necrosis

Mooren's ulcer: 30 years of follow-up. / Úlcera de Mooren: 30 años de seguimiento.

CASE REPORT: A 33-year-old Caucasian female presented with epiphora, ocular pain, and foreign body sensation in both eyes for one month. Examination revealed bilateral peripheral corneal ulcers. The patient had been treated with immunomodulators, and she was treated in the left eye with peripheral semi-circular keratoplasty, penetrating keratoplasty, conjunctival-corneal-scleroplasty, buccal mucosal graft, tibial osteo-keratoprosthesis and finally, retinal detachment. DISCUSSION: Mooren's ulcer is an immunological corneal disease. This lesion must be treated initially with immunomodulators. Surgical treatment should be considered when a risk of corneal perforation is present, when the perforation appears, or under acute necrosis.

Precrystalline posterior chamber intraocular lens for surgical correction of severe myopia.

PURPOSE: To report early experience with a posterior chamber precrystalline intraocular lens designed for correction of severe myopia from -10 to -30 diopters. This intraocular lens respects the transparent crystalline lens and does not interfere with accommodation. METHOD: The concave-convex methylmethacrylate lens, with flexible haptics that are supported in the sulcus, is placed behind the iris, in front of the lens, and centered with the pupil. RESULTS: From July 1995 to November 1998, 149 precrystalline lenses have been inserted with few, generally reversible complications, which are now largely prevented by adequate modification of the intraocular lens. Correction has been satisfactory and stable. CONCLUSION: Although follow-up is relatively short, precrystalline lens placement may be considered an important contribution to the surgical management of severe myopia to improve the patient's vision and, consequently, quality of life.

Extrusion of abnormal endothelium into the posterior corneal stroma in a patient with posterior polymorphous dystrophy.

PURPOSE: To report the presence of abnormal endothelium that extruded into the posterior corneal stroma in a patient with posterior polymorphous dystrophy. METHODS: The corneal button of a man who underwent penetrating keratoplasty for posterior polymorphous dystrophy was examined by light and electron microscopy. Immunoperoxidase staining for cytokeratins, vimentin, and the endothelial antigen recognized by monoclonal antibody 2B4.14.1 antigen was performed. Two-color immunofluorescence staining for simultaneous detection of cytokeratins and 2B4.14.1 antigen was also done. RESULTS: Much of the endothelium had characteristic features of epithelium-like cells, and abnormalities in Descemet's membrane were present. Curious oval and slit-like spaces in the posterior stroma were lined by epithelium-like endothelial cells and were continuous with the anterior chamber through defects in Descemet's membrane. CONCLUSION: These abnormalities in the posterior stroma have not previously been described in histopathologic reports of posterior polymorphous corneal dystrophy and are likely an unusual variation in the spectrum of this hereditary disorder.

Permalens hydrogel intracorneal lenses for spherical ametropia.

PURPOSE: To assess the efficacy, stability, and safety of Permalens hydrogel intracorneal lenses for the correction of spherical ametropia 6 years after implantation. METHODS: Implantation of intracorneal hydrogel lenses was performed by the same surgeon (JIBM) in five aphakic and five high myopic eyes. The lens closet to corneal vertex refraction was used. Refractive outcomes, keratometry, keratography, endothelial cell count, and corneal topography were studied. RESULTS: Corneal tolerance to the hydrogel implants was maintained throughout for 6 years with no alteration in endothelial cell count. All myopic eyes showed regression of achieved correction. The aphakic eyes showed no statistically significant difference between the results at 1 month and those obtained at 1 and 6 years. CONCLUSIONS: Hyrdogel intracorneal lenses are well tolerated and the refractive results are stable in aphakic patients. They may be considered when intraocular lenses cannot be placed in aphakic patients, but are not now in clinical use.

Storage, surgery, outcome, complications, and new developments in corneal and conjunctival grafts.

This review covers last year's literature on corneal, limbal, and conjunctival transplantation including tissue storage and eye banking. In this area, the main themes were related to a better evaluation of tissue viability and the exclusion of disease transmission. An analysis of the changing indications for penetrating keratoplasty shows the differences between American and European series. Most efforts in relation to surgical techniques are oriented toward obtaining better refractive results, whereas the study of large series sheds new light on the risk factors for graft failure and other complications. Limbal transplants have acquired the status of a new field in the surgical treatment of ocular surface disease, particularly in relation to corneal stem cell deficiencies.

Coralline hydroxyapatite keratoprosthesis in rabbits.

BACKGROUND: The ideal keratoprosthesis will have a curvature similar to that of the recipient cornea and allow the tissue to grow into the supporting material. We developed a support for a keratoprosthesis made of porous hydroxyapatite, which is highly biocompatible, biointegrable, non-biodegradable, and colonizable. METHODS: We implanted the keratoprosthesis unilaterally in the right eyes of 12 New Zealand rabbits, intralamellarly and between a homologous episclerokeratoplasty (with and without conjunctival flap) for 12 months. Pathology studies and technetium-99 bone scans were performed. RESULTS: We found good vascularization, no signs of infection or extrusion, no epithelial downgrowth, and no adverse tissue reaction. CONCLUSION: A clinical trial of this keratoprosthesis is warranted.

Forceps and vacuum injuries to the cornea: histopathologic features of twelve cases and review of the literature.

Histopathologic and ultrastructural features were examined from 11 cases of corneal injury from obstetrical forceps and one case from vacuum extraction. Four major types of histopathologic features were observed. Type I (n = 4) included large tears of Descemet's membrane with a fragment of Descemet's membrane extending into the anterior chamber at one end of the tear and scroll formation at the other end. Type II (n = 6) consisted of scrolls of Descemet's membrane at each margin of the original break. Type III (n = 2) included those with small breaks in Descemet's membrane and healing by fibrosis at and posterior to the original tear. Type IV (n = 1) contained a small break in Descemet's membrane with minimal fibrosis. Transmission electron microscopy revealed Descemet's scrolls and retrocorneal fibrous tissue. Scanning electron microscopy revealed folds in Descemet's membrane and attenuation or absence of endothelium. Spindle- and stellate-shaped cells and pigment granules were present in the area of the tear in most cases. A review of the literature is presented.

[Corneal reinnervation after lamellar refractive corneal surgery]. / Korneale Reinnervation nach lamellärer refraktiver Hornhautchirurgie.

In a retrospective study corneal sensitivity after refractive autokeratoplasty for correction of myopia was measured. Thirty-eight patients operated on for keratomileusis in situ and 18 patients for keratomileusis myopica were examined with the Draeger esthesiometer between 1 and 23 months after surgery. Three measurements points were on the refractive disc, two others on the untouched cornea. After keratomileusis myopica, the corneal reinnervation is significantly delayed compared to keratomileusis in situ. In the first group sensitivity is normal after 2 years and in the second group after 1 year. Even refraction and visual acuity depend on metabolism and reorganization of the tissue after surgery. Besides retarded cell repopulation and disturbed stromal metabolism--caused by toxic and cryopreservation effects--the dissection depth of the refractive ablation is responsible for these phenomena.

Reevaluation of corneal dystrophies of Bowman's layer and the anterior stroma (Reis-Bücklers and Thiel-Behnke types): a light and electron microscopic study of eight corneas and a review of the literature.

To clarify whether Reis-Bücklers' and Thiel-Behnke's corneal dystrophies are one entity or whether two distinct corneal dystrophies of Bowman's layer and the superficial stroma (CDB) exist, 28 corneal specimens with clinically suspected diagnosis of CDB were examined by light and electron microscopy, and the literature was reviewed. Eight specimens came from patients with a honeycomb-shaped pattern of opacities at the level of Bowman's layer. Study of those eight specimens disclosed destruction of Bowman's layer, a subepithelial fibrocellular tissue with an undulant configuration, absence of the epithelial basement membrane in many areas and the presence of "curly" collagen fibers with a diameter of 9-15 nm. We concluded that two distinct autosomal dominant CDB exist and propose the designations CDB type I (synonyms: geographic or "true" Reis-Bücklers' dystrophy) and CDB type II (synonyms: honeycomb-shaped or Thiel-Behnke's dystrophy). The eight corneas of our series were characterized as CDB type II. CDB I is clinically characterized by confluent geographic opacities at the level of Bowman's layer, histopathologically by bandshaped granular Masson-positive subepithelial deposits, and ultrastructurally by the presence of "rod-shaped bodies" and may be a superficial variant of granular dystrophy. Visual loss is significantly greater in CDB I, and recurrences after keratoplasty or keratectomy seem to be earlier and more extensive in CDB I. Most cases reported thus far in the literature as "Reis-Bücklers' dystrophy" are CDB II (honeycomb-shaped or Thiel-Behnke's dystrophy).

[Corneal reinnervation after keratomileusis in situ and keratomileusis myopica--a comparison]. / Hornhautreinnervation nach Keratomileusis in situ und Keratomileusis myopica--Ein Vergleich.

BACKGROUND: In a retrospective study corneal sensitivity after keratomileusis in situ and keratomileusis myopica was measured. METHOD: 5 points on the cornea were measured with the Draeger aesthesiometer at 18 eyes after keratomileusis myopica and at 66 eyes after keratomileusis in situ. RESULTS: The ingrowth of corneal nerve fibres is delayed after keratomileusis myopica compared to keratomileusis in situ because of delayed stromal repopulation of keratocytes and disturbances of stromal metabolism due to toxic effects of the cryopreservation solution.

[Lens surgery: yesterday, today and tomorrow]. / Linsenchirurgie: gestern, heute und morgen.

Short review of the evolution of lens surgery since the beginning of our century up to the present time: from extracapsular to intracapsular extraction and back again to the modern version of extracapsular extraction. From the beginning of intraocular lens implantation to modern intraocular lenses and, finally, a focus on the future toward the possibilities of "restoration" of the lens to recuperate not only visual acuity but also accommodation.

Cataract surgery and IOL implantation. More than 40 years of personal experience. My present criteria and considerations.

The author refers his personal experience with different types of IOL since 1950. After an initial period of enthusiasm (1950 to 1961) the author abandoned the techniques of Ridley, Strampelli and Dannheim, because of the considerable incidence of severe complications directly related to the IOL. Over many years he emphasized the serious postoperative complications which appeared in the course of the years, even with the different new types of IOL which acquired a certain prestige. With the new posterior chamber lenses placed in the capsular bag, the results became more encouraging and the author resumed IOL implantation with this type of lenses after an adequate period of observation and experimentation. The present criteria, technique and results of the author are discussed together with some considerations on future research work to develop new techniques for substitution of the opacified lens and also to attempt to restore accommodation.

Initial human experience with Permalens myopic hydrogel intracorneal lens implants.

BACKGROUND: Previous nonhuman primate experimentation has demonstrated the successful use of Permalens hydrogel intracorneal lens implants for the correction of hyperopic and myopic refractive errors. This article documents the first human experience with myopic Permalens hydrogel intracorneal lens implants. METHODS: In this article, we report an 18-month follow up on five patients implanted with minus power hydrogel intracorneal lenses. All surgery and follow-up examinations were performed in Bogota, Columbia. The mean preoperative spherical refraction was -14.00 +/- 5.00 diopters (range, -9.5 to -19.00 D). RESULTS: Corrections of up to 13.00 D were achieved. Corrections deviated from the predicted correction by a mean of -5.00 +/- 2.10 D (range, -2.80 to -8.00 D). No significant surgical or postoperative complications were noted. Visual recovery was rapid, usually achieving maximum acuity within 1 month. CONCLUSIONS: Successful myopic refractive changes were accomplished in all five human subjects. The major problem with the study to date has been a significant undercorrection of the preoperative refraction. We anticipate that further empirically derived relationships between hydrogel lens power and refractive change will allow a more accurate prediction of refractive result. Also, the ability to surgically interchange myopic hydrogel inlays should allow correction of any residual refractive errors.

Histopathology of human keratorefractive lenticules.

Eight human corneal lenticules (three from keratophakia, two from hypermetropic keratomileusis, and three from myopic keratomileusis) were examined by light and electron microscopy. The keratophakic lenticules were removed for optical reasons 3, 3.5, and 6 months after surgery. Microscopically, all displayed hypocellularity, mature collagen fibrils and microfibrils, keratocyte ghosts, and keratocytic debris. The hypermetropic keratomileusis specimens were removed at 13 and 14 months postoperatively, the first because of opacities from enzymatic digestion of the cornea, and the second due to contact lens-induced erosion of Bowman's layer and decreased lacrimal secretion. Ultrastructurally, both lenticules exhibited fractures in Bowman's layer, and the 14-month specimen showed multilayered squamous epithelia. The myopic keratomileusis specimens were removed at 4, 8, and 48 months postoperatively due to opacification of the interface caused by delayed epithelial healing, detergent trauma, and previous epithelization, respectively. Electron microscopy revealed fractures in Bowman's layer, subepithelial fibrocellular growth, sparse keratocyte populations of the anterior stroma, porous collagen bundles, keratocytic debris, and regions of epithelial ingrowth.

Congenital idiopathic corneal endotheliopathy.

Two unrelated boys had a history of bilateral corneal clouding at birth following uncomplicated full-term gestations and spontaneous vaginal deliveries (without forceps). Clinical examinations disclosed bilateral corneal edema, no inflammation, and normal intraocular pressures. There was no history of similarly affected family members. The patients underwent penetrating keratoplasty at ages 4 months (patient 1) and 12 years (patient 2). Light and electron microscopic studies of the corneal buttons from both patients revealed areas of degeneration of the endothelium and separation of rounded endothelial cells. The morphologic features were strikingly similar to those in two acquired forms of corneal disorders--autoimmune endotheliopathy and "acute endotheliitis." Immunocytologic and in situ hybridization studies for herpes simplex virus were not consistent with either productive or latent corneal infection. Ultrastructural changes in Descemet's membrane reflect delayed or abnormal development of the postnatal nonbanded layer in patients 1 and 2, respectively. These suggest an intrauterine insult that resulted in endothelial dysfunction. The histologic and ultrastructural features of these two congenital cases are not typical of those seen in any of the recognized causes of congenital corneal clouding. We propose that these cases represent a unique congenital corneal endotheliopathy of undetermined origin.