Lamellar keratectomy using an automated microkeratome.

PURPOSE: To evaluate the effectiveness of treating anterior corneal pathology by performing a superficial lamellar keratectomy with an automated microkeratome. METHODS: Retrospective chart review of 10 eyes (8 patients) seen in a subspecialty referral practice for anterior segment disease. With the use of an automated microkeratome, a lamellar flap was created, which was then surgically excised. RESULTS: Ten eyes of eight patients were followed for a mean of 5.4 months (range, 4 to 10 months). Subjective visual acuity and/or sensation of ocular irritation improved in 10 of 10 eyes. Mean improvement in Snellen best-corrected visual acuity was 1.8 lines (range, -1 to +3 lines). One patient lost 1 line of Snellen acuity due to progression of a posterior subcapsular cataract. Mean change in spherical equivalent was +0.5 diopters (range, -1.60 to +4.25 diopters), and mean improvement in corneal clarity (1 to 4 scale) was 1.8. Mean preoperative pachymetry was 589.0 microm (range, 507 to 741 microm). Mean postoperative pachymetry was 461.3 microm (range, 370 to 564 microm). Recurrence of pathology (band keratopathy and Salzmann's nodular degeneration) occurred in two patients. In one patient, immunohistochemical staining of corneal tissue from the lamellar dissection confirmed the diagnosis of herpes simplex virus type 1 stromal keratitis, improving the course of postoperative care. CONCLUSION: Lamellar keratectomy with the use of an automated microkeratome is a safe and effective method for removing superficial anterior corneal opacities. For selected cases, it offers specific advantages over other surgical modalities. In particular, this procedure may induce far less hyperopic shift than would the equivalent amount of tissue removal by performing excimer laser phototherapeutic keratectomy.

Candida parapsilosis keratitis following treatment of epithelial ingrowth after laser in situ keratomileusis.

PURPOSE: To present a case of Candida parapsilosis following laser in situ keratomileusis (LASIK). METHODS: Retrospective chart review. RESULTS: A case report of a 51-year-old woman who underwent bilateral LASIK is presented. Two weeks after the procedure, the patient presented with epithelial ingrowth OD. The ingrowth was treated with flap lifting and scraping, followed by postoperative antibiotics. Four weeks later, the patient presented with numerous interface infiltrates. Smears were positive for yeast forms and cultures grew Candida parapsilosis. Administration of topical and systemic antifungal therapy resulted in clearing of the infection with partial visual recovery. CONCLUSIONS: To our knowledge, this represents the first reported case of a post-LASIK Candida parapsilosis keratitis. A high degree of suspicion coupled with rapid and appropriate treatment can result in visual recovery.

Arthrographis keratitis mimicking acanthamoeba keratitis.

OBJECTIVE: To describe a case of keratomycosis caused by Arthrographis kalrae, mimicking Acanthamoeba keratitis. METHODS: Case report. RESULTS: A 23-year-old female contact lens wearer developed dendritic keratitis in her amblyopic eye (OD). Baseline vision was 20/50. Treatment with trifluridine 1% resulted in resolution of the dendrite, but an area of stromal haze developed, spreading to a discontinuous ring shape, and the vision dropped to 20/200. Photophobia was intense, and pain was out of proportion to the examination. Cultures were sent, and empiric treatment of Acanthamoeba was begun, without subsequent improvement. After 4 weeks, cultures were positive for a fungal species. Amphotericin 0.5% drops were begun, with moderately rapid resolution of the active keratitis. At last follow-up, best-corrected vision was 20/100. Review of the culture showed the organism to be Arthrographis kalrae. CONCLUSION: Arthrographis kalrae has been reported only once before as an ocular pathogen. As in the previously reported case of Arthrographis, our patient's presentation was strongly suggestive of Acanthamoeba keratitis.

Hyperthermic treatment of post-LASIK corneal striae.

PURPOSE: To investigate the effect of hyperthermia for the treatment of long-standing corneal flap striae after laser in situ keratomileusis (LASIK). SETTING: TLC Laser Eye Center, Garden City, New York, USA. METHODS: Patients with visually significant flap striae at least 3 weeks post-LASIK were offered hyperthermic treatment. The central 6.0 mm of epithelium was removed from affected corneas, and the flaps were elevated. A striae removal spatula was heated to 65 degrees C in sterile water, and both sides of the flaps were mechanically massaged with the spatula for 5 to 10 minutes until the striae were visually reduced. RESULTS: Thirty-six eyes of 34 patients were treated with hyperthermia to remove corneal striae. All patients had a clinical reduction in striae. The mean pretreatment best corrected visual acuity (BCVA) was 20/44, improving to 20/25 on follow-up (mean follow-up 16.4 months). Patients subjectively noted reduced haze and glare and no loss of BCVA. There were no serious flap complications. CONCLUSION: Hyperthermic treatment is a safe, effective treatment option for corneal striae after LASIK.

Conservative treatment of meibomian gland dysfunction.

PURPOSE: To evaluate the effectiveness of lid hygiene and preservative-free artificial tears for the treatment of meibomian gland dysfunction (MGD) during a 6-week period. METHODS: Suitable patients with MGD were educated about their disease and instructed to begin a regimen of lid hygiene, which included the application of a heated saline solution and the use of nonpreserved artificial tears. Baseline measurements obtained at the time of enrollment included basic tear secretion test, tear breakup time, a questionnaire grading MGD symptoms (i.e., burning, irritation, itching, sharp pains, foreign body sensation, and hazy vision), and lid margin slitlamp photographs. All measurements except for basic tear secretion were repeated at the 6-week follow-up visit. Photographs were unlabeled, and two cornea specialists graded them in a masked fashion for the presence of lid erythema, irregularity, thickness, meibomian gland capping, and telangiectasis. RESULTS: Thirty-seven patients with a clinical diagnosis of MGD were enrolled, and 26 patients (70%) completed the study. Initial measurement of basic tear secretion averaged 17 mm and was more than 10 mm in 81% of eyes. The tear breakup time was prolonged by an average of 3.4 seconds; in 30% of cases, it was normalized to 10 seconds or more. Symptoms improved in 88% of cases; among those, symptoms were graded mild or less in 83%, and none in 39%. Photographs before and after treatment were not significantly different. CONCLUSIONS: In this noncontrolled case-cohort study of selected patients with MGD, lid hygiene and preservative-free artificial tears significantly improved tear breakup time and relieved symptoms of the condition.

Flap folds after femtosecond LASIK.

PURPOSE: To report a case of bilateral flap folds after a laser-assisted in situ keratomileusis (LASIK) procedure in which the flap was created by the femtosecond laser. METHODS: Retrospective chart review. RESULTS: A 43-year-old white woman underwent bilateral simultaneous LASIK. The corneal flap was created with the femtosecond laser. Postoperatively, the patient noted significantly decreased visual acuity, glare, and haloes. She was diagnosed with corneal flap striae, which were treated unsuccessfully with a lifting and stretching procedure, but responded to subsequent bilateral flap suturing. CONCLUSIONS: Despite the increased accuracy in flap creation with the femtosecond laser, large flap folds may develop.

Slitlamp stretching of the corneal flap after laser in situ keratomileusis to reduce corneal striae.

PURPOSE: To examine the efficacy of treating immediate postoperative corneal striae and poor flap alignment by stretching the corneal flap at the slitlamp with a cotton-tip applicator and compare the results using this technique with those using the conventional technique of refloating the flap with balanced salt solution (BSS(R)). SETTING: TLC Laser Eye Center, Garden City, New York, USA. METHODS: Charts of 7154 eyes having laser in situ keratomileusis (LASIK) were reviewed retrospectively. During the 11 months prior to January 1, 2000, 3516 eyes had LASIK. Patients with flap striae or a malpositioned flap at the immediate slitlamp evaluation were treated by refloating the flap (Group A). During the 11 months subsequent to January 1, 2000, 3638 eyes had LASIK. Patients with flap striae or a malpositioned flap at the immediate slitlamp evaluation were treated by flap stretching with a cotton-tip applicator (Group B). The number of eyes that required retreatment for flap striae was analyzed. RESULTS: Twenty-nine eyes in Group A (0.82%) required retreatment for visually significant flap striae after day 1, and 11 eyes in Group B (0.30%) required retreatment. A loss of best corrected visual acuity occurred in 3 Group A eyes and 2 Group B eyes. CONCLUSIONS: During the immediate postoperative period, stretching the flap with a cotton-tip applicator was a simple, safe, and effective technique for reducing visually significant flap striae. Unlike refloating the flap with BSS, flap stretching at the slitlamp does not require additional anesthesia, exposure time, or dehydration of the ocular surface.

Efficacy and wound-temperature gradient of whitestar phacoemulsification through a 1.2 mm incision.

PURPOSE: To evaluate the efficacy and wound-temperature gradients of WhiteStar micropulse technology using bimanual phacoemulsification without an irrigation sleeve through a 1.2 mm incision. SETTING: Island Eye Surgicenter, Carle Place, New York, USA. METHODS: Ten patients had bimanual phacoemulsification using micropulse technology without an irrigation sleeve through a 1.2 mm clear corneal incision. A thermocouple consisting of a 30-gauge copper wire was inserted into clear cornea directly adjacent to the wound to digitally record temperature gradients at the wound. Endothelial cell counts were evaluated preoperatively and postoperatively in all patients. RESULTS: All 10 patients maintained corneal clarity with no sign of thermal damage to the wound. The maximum corneal wound temperatures during phacoemulsification ranged from 24 degrees C to 34 degrees C, well below the temperature of collagen shrinkage. The endothelial cell loss at 3 months was 7%. CONCLUSIONS: Because of the decreased thermal effect with WhiteStar technology, an irrigation sleeve over the phacoemulsification needle is superfluous. As a result, bimanual phacoemulsification can be safely performed through a 1.2 mm incision.

Subconjunctival mitomycin C as adjunctive therapy before pterygium excision.

PURPOSE: To evaluate the safety and efficacy of subconjunctival mitomycin C as adjunctive therapy before pterygium surgery. DESIGN: Prospective noncomparative case series. PARTICIPANTS: Thirty-six eyes of 36 patients. INTERVENTION: Thirty-six eyes of 36 patients prospectively received 0.1 ml of 0.15 mg/ml mitomycin C subconjunctivally injected into the head of the pterygium 1 month before bare sclera surgical excision. MAIN OUTCOME MEASURE: Recurrence of pterygia. RESULTS: The pterygia resolved in 34 (94%) of 36 eyes, with a recurrence rate of 6% over a mean follow-up of 24.4 months. No wound-healing complication developed in any patient. CONCLUSIONS: Subconjunctival mitomycin C is an effective treatment before pterygium excision. Subconjunctival injection allows exact titration of mitomycin C delivery to the activated fibroblasts and minimizes epithelial toxicity.

The effect of hinge position on corneal sensation and dry eye after LASIK.

PURPOSE: To investigate the effect of hinge position on corneal sensation and dry eye syndrome after laser in situ keratomileusis (LASIK). DESIGN: Prospective, randomized, self-controlled trial. PARTICIPANTS: Fifty-two patients >/=18 years of age undergoing bilateral LASIK. INTERVENTION: Patients underwent bilateral LASIK with the superior-hinge Hansatome microkeratome in one eye and the nasal-hinge Amadeus microkeratome in the other eye. In all eyes, the flaps were 160 micro m thick, with a diameter of 9.5 mm. MAIN OUTCOME MEASURES: Masked Cochet-Bonnet esthesiometry was performed centrally before surgery and at 1 week, 1 month, 3 months, and 6 months after surgery. Dry eye was evaluated at the same time intervals with lissamine green corneal and conjunctival staining, Schirmer testing with anesthesia, and tear-film breakup time. Subjective evaluation of dry eye sensation was performed at 3 and 6 months after surgery. RESULTS: Corneal sensation was reduced in eyes with either superior- or nasal-hinge corneal flaps at 1 week, 1 month, and 3 months after surgery (P < 0.001). Compared with preoperative values, a significant reduction in corneal sensation remained at 6 months in corneas with superior-hinge flaps (P < 0.001) but not in corneas with nasal-hinge flaps (P = 0.263). Mean corneal sensation was greater in corneas with a nasal-hinge flap compared with corneas with a superior-hinge flap at all postoperative visits (P < 0.001). The loss of sensation was greatest at 1 week and showed improvement at each subsequent time interval up to 6 months. Overall, dry eye signs and symptoms were greatest during the immediate postoperative period and improved at all subsequent time intervals. Dry eye signs and symptoms were generally greatest in the eyes with a superior-hinge flap and milder in eyes with a nasal-hinge flap. CONCLUSIONS: The long posterior corneal nerves, which innervate the cornea, enter the eye at 3- and 9-o'clock. A superior-hinge flap transects both arms of the neuroplexus, whereas a nasal hinge transects only the temporal arm. LASIK results in a significant reduction in corneal sensation. Corneal sensation and dry eye signs and symptoms decreased immediately after LASIK and improved at all time periods between 1 week and 6 months in eyes with both a nasal-hinge flap and a superior-hinge flap. However, the loss of corneal sensation and presence of dry eye syndrome were greater in eyes with a superior-hinge flap than in eyes with a nasal-hinge flap.

Herpes simplex reactivation following laser in situ keratomileusis and subsequent corneal perforation.

PURPOSE: To present a case of corneal perforation secondary to herpes simplex reactivation after laser in situ keratomileusis (LASIK) and its subsequent management. METHODSL A case report of a 69-year-old man who underwent LASIK after penetrating keratoplasty for herpes simplex keratitis (HSK) is presented. RESULTS: The patient is a 69-year-old man who had a penetrating keratoplasty of the right eye 6 years prior for corneal scarring secondary to HSK. A spectacle refraction of -13.25 + 6.00 x 45 yielded 20/60 visual acuity in his grafted eye. LASIK was performed, and the patient's visual acuity without correction on postoperative day 1 was 20/60. Ten days after LASIK, the patient developed thinning of the cornea at the temporal edge of the flap, which perforated the following day. The perforation site was glued with cyanoacrylate adhesive and covered with a soft contact lens. After 7 months, a 4-mm lamellar keratoplasty and conjunctivoplasty was performed. Nine months after surgery, the patient's visual acuity without correction is 20/50 and the graft remains intact. CONCLUSION: Herpes simplex keratitis may be a contraindication for LASIK in postkeratoplasty patients. Bandage contact lenses and cyanoacrylate adhesive can be used successfully to manage the rare complication of corneal perforation after LASIK.

Topical cyclosporin A in the management of therapeutic keratoplasty for mycotic keratitis.

PURPOSE: To investigate the efficacy of topical cyclosporine A 0.5% as a substitute for corticosteroids in the management of therapeutic keratoplasties for mycotic keratitis. METHODS: Prospective, nonrandomized interventional case series. Three patients with culture-proven mycotic keratitis underwent therapeutic keratoplasties. All were treated with topical cyclosporine A 0.5% postoperatively as a primary or an adjunctive therapy for prevention of allograft rejection. The patients were followed up from 15 to 42 months for maintenance of graft clarity and best-corrected visual acuity. RESULTS: Two of three patients maintained clear grafts while using topical cyclosporine A 0.5% twice daily with best-corrected visual acuity of 20/40 and 20/50. One patient developed an opacified graft secondary to preexisting ocular surface disease. CONCLUSIONS: Topical cyclosporine A 0.5% may be a useful adjunct in the management of therapeutic keratoplasties for mycotic keratitis.