Misoprostol with cyclosporin A prolongs corneal allograft survival in an animal model.

Cyclosporin A (CSA) has been shown to prolong corneal allograft survival in a variety of animal models. Misoprostol is a prostaglandin E1 analogue with oral bioavailability and immunosuppressive properties. Misoprostol and CSA are synergistic immunosuppressants in vitro. In the present study, we evaluated the effect of adding misoprostol to a subtherapeutic dose of CSA in the orthotopic allogeneic rat penetrating keratoplasty model. Seventy inbred Lewis rats were recipients of orthotopic corneal allografts from Brown-Norway donors. Ten Lewis rats received orthotopic syngeneic grafts (Lew to Lew). Two separate experiments with 40 animals per trial were performed. In each trial, the rats were divided equally into four groups. Trial A: allogeneic control (A1), syngeneic control (A2), CSA at 10 mg/kg/d (A3), and CSA at 15 mg/kg/d (A4). Trial B: allogeneic control (B1), CSA alone at 7.5 mg/kg/d (B2), misoprostol alone at 1 mg/kg/d (B3), and CSA with misoprostol at 7.5 and 1 mg/kg/d, respectively (B4). Syngeneic control A2 as well as group A4 remained clear through postoperative day 22. The allogeneic control groups A1 and B1, plus treatment groups B2 and B3, rejected their grafts by postoperative day 12. Groups A3 and B4 demonstrated a delay in allograft rejection that continued to be statistically significant through the 12th postoperative day (p < 0.001). We conclude that the addition of systemic misoprostol to CSA can effectively prolong corneal allograft survival in the orthotopic allogeneic rat penetrating keratoplasty model.

Clinical findings in Brown-McLean syndrome.

The Brown-McLean syndrome is a clinical condition with corneal edema involving the peripheral 2 to 3 mm of the cornea. The edema typically starts inferiorly and progresses circumferentially, but spares the central portion of the cornea. Additionally, the edema is associated with a punctate orange-brown pigmentation on the endothelium underlying the edematous areas. Central cornea guttata is frequently seen. This condition occurs most frequently after intracapsular cataract extraction, but may also occur after extracapsular cataract extraction and phacoemulsification, or pars plana lensectomy and vitrectomy. Surgical complications and multiple intraocular procedures are frequently observed in these patients. Less frequently, the Brown-McLean syndrome can occur in eyes that have not had surgery. We studied the clinical characteristics of 43 affected eyes of 32 patients. New findings included Brown-McLean syndrome occurring in two eyes of a phakic patient with intermittent angle-closure glaucoma. Two eyes developed Brown-McLean syndrome after phacoemulsification and one eye developed peripheral edema after pars plana vitrectomy and lensectomy. Additionally, severe, infectious keratitis occurred after rupture of peripheral bullae in two eyes. Patients with this condition should be examined periodically and educated regarding the early clinical signs of corneal ulceration.

Four-incision radial keratotomy for high myopia after penetrating keratoplasty.

BACKGROUND: High amounts of myopia can frequently produce anisometropia and limit visual rehabilitation by conventional means in eyes with clear corneal grafts. This condition is frequently coupled with large amounts of astigmatism. Four-incision radial keratotomy provides a way to reduce myopia in normal individuals. In our present study, we used the technique of four- incision radial keratotomy to reduce myopia in a group of keratoplasty patients who failed conventional visual rehabilitation. Arcuate or transverse keratotomy was used in conjunction with radial keratotomy in eyes with high amounts of astigmatism. METHODS: This study retrospectively examined a group of 11 eyes with penetrating keratoplasty which underwent four-incision radial keratotomy for the treatment of visually disabling myopia. The radial incisions were placed in the graft, inside the graft-host interface. Seven eyes underwent concomitant arcuate relaxing incisions at the graft-host interface for treatment of associated astigmatism. One additional eye had paired straight transverse incisions for the treatment of astigmatism. The mean postoperative follow up was 16 months (range, 3 months to 5 years). RESULTS: There was a mean reduction of the spherical equivalent refraction of 3.48 diopters (D) (range, 0.25 to 7.75 D). The eight eyes undergoing astigmatic surgery showed a mean reduction in keratometric astigmatism of 2.25 D (range, -6.75 to +6.50 D) and refractive astigmatism of 4.63 D (range, -1.50 to -9.50 D). Nine of the 11 eyes had stable or improved best spectacle corrected visual acuity. Two eyes had reduction of best spectacle corrected visual acuity--one due to development of irregular astigmatism and one due to worsening of preexisting macular edema. CONCLUSIONS: Four-incision radial keratotomy can reduce myopia after penetrating keratoplasty when the patient is unable to tolerate spectacle or contact lens correction. It can be combined with relaxing incisions or transverse keratotomy to reduce astigmatism. There is a high amount of variability, and predictability is currently limited by the complex topographical changes occurring in corneal transplants. Complex corneal biomechanical changes may predispose these eyes to the development of irregular astigmatism.

Persistent superficial punctate keratitis after resolution of chlamydial follicular conjunctivitis.

Two cases of follicular conjunctivitis due to Chlamydia trachomatis followed by punctate epithelial keratitis are described. Both cases were initially treated with either oral tetracycline or doxycycline with resolution of the follicles. These two patients subsequently had recurrent, bilateral grayish lesions at various levels in the corneal epithelium that stained in a punctate fashion with fluorescein. There was anterior stromal edema associated with some of these lesions in one case. The lesions were confined mostly to the central cornea. These recurrent lesions were unassociated with a conjunctival reaction, were unresponsive to oral tetracycline, but were exquisitely responsive to low doses of topical steroids. Chlamydial conjunctivitis and the associated keratitis typically shows no response or actual exacerbation of symptoms with topical steroids, and the keratitis shows a predilection for the upper half of the cornea. These patients demonstrate that chlamydial keratoconjunctivitis might result in a clinical appearance consistent with Thygeson's superficial punctate keratitis.

The diagnosis and evaluation of child maltreatment.

Child maltreatment continues to be one of the most common and most difficult problems seen in the emergency room. An early estimate indicated that up to 10% of children under age 6 seen in emergency departments have some form of nonaccidental injury. Recent data suggest that approximately 1% of the child population are victims of maltreatment each year. Many of these cases involve only subtle signs and have great potential to pass undetected. This article provides a review of the various forms of maltreatment, with emphasis on the key points involved in the history, physical examination, and management. The protocol for evaluating maltreatment from the North Carolina Memorial Hospital is presented. This framework will aid the physician in the crucial first step of identifying maltreatment, which, along with diligent follow-up and the assistance of the available social services, offers the best hope for further prevention.