Outcomes of cataract surgery in eyes with ocular melanoma treated with iodine-125 brachytherapy.

PURPOSE: To evaluate visual and surgical outcomes of cataract surgery in eyes with a history of iodine-125 (I125) brachytherapy for ocular melanoma. SETTING: Department of Ophthalmology, David Geffen School of Medicine at UCLA and the Stein Eye Institute, Los Angeles, California, USA. DESIGN: Retrospective case series. METHODS: Patients with ocular melanoma treated by I125 brachytherapy who subsequently had cataract surgery were evaluated. The recorded data included tumor size, location, preoperative ocular comorbidities, corrected distance visual acuity (CDVA), operative complications, and brachytherapy-related maculopathy before and after surgery. RESULTS: Thirty-two eyes of 32 patients were included. The mean age at the time of cataract surgery was 66.1 years. The median follow-up was 53.5 months. There were no intraoperative complications. Eighteen eyes (56.3%) had a history of preoperative radiation retinopathy, 10 involving the macula. Between 2 weeks and 4 weeks postoperatively, 22 eyes (68.8%) had an improvement in CDVA (≥2 lines). Seven of 10 eyes that failed to improve had radiation maculopathy. By the last follow-up examination, 13 eyes (40.6%) had improved CDVA, 9 eyes (28.1%) were worse (≥2 lines), and 10 eyes (31.3%) were unchanged (within ±1 line). Of 15 eyes that lost CDVA gains achieved between 2 weeks and 4 weeks postoperatively, 9 eyes had new-onset or worsening maculopathy. Cataract surgery had no effect on local tumor control or distant metastasis. CONCLUSIONS: Cataract surgery after I125 brachytherapy for ocular melanoma improved CDVA in most eyes during the immediate postoperative period. Gains were often lost with further follow-up. Progression of radiation maculopathy was primarily responsible for subsequent visual decline.

Immunohistological evaluation of the healing response at the flap interface in patients with LASIK ectasia requiring penetrating keratoplasty.

PURPOSE: To evaluate the healing response at the flap interface in corneas with LASIK ectasia that required penetrating keratoplasty (PK). METHODS: Corneas of five patients who developed corneal ectasia after LASIK (range: 2.5 to 5 years postoperative) were collected after corneal transplant surgery. The corneas were bisected and processed for conventional histologic analysis and immunofluorescence. RESULTS: Light microscopy showed a hypocellular fibrotic scar at the wound margin compared with the adjacent corneal stroma in all eyes. All corneas had positive staining for alpha-smooth muscle actin (SMA), a myofibroblast marker. In one eye, alpha-SMA cells were located in the fibrotic scar region in the area of the semicircular ring of haze along the margin of the LASIK flap corresponding to an area of epithelial ingrowth. In all other eyes, alpha-SMA positive cells were fewer and mainly located in the superficial stroma under the epithelial wound margin surface. Type III collagen was minimal or absent in the central zone and wound margin of all corneas except for the cornea with epithelial ingrowth present in the hypercellular fibrotic scar region. Chondroitin sulfate was stronger in the periphery of the flap wound coinciding with a higher presence of alpha-SMA-positive cells in that region. Positive staining for matrix metalloproteinase 9 (MMP-9) in the paracentral wound margin scar was seen. CONCLUSIONS: A wound-healing process characterized by absence of significant fibrosis and myofibroblasts at the wound edge in the flap interface was noted in all keratectatic eyes. However, changes in the composition of collagen and the presence of MMP-9 at the wound edge several years after LASIK indicates active wound remodeling that may explain the ongoing loss of tissue and tendency of the cornea to bulge.

Novel therapeutic approach in the management of band keratopathy using amniotic membrane transplantation with fibrin glue.

A 91-year-old man with advanced glaucoma, status post trabeculectomy, and pseudophakia had a symptomatic recurrent band and bullous keratopathy in his left eye. Three previous ethylenediaminetetraacetic acid chelations with immediate recurrence of the calcic band keratopathy with frequent breakdown produced recurrent painful corneal epithelial defects. The calcified lesions were removed surgically, resulting in a smooth ocular surface. An 8-mm, 100-micron trephination was performed and a 360 degrees corneal lamellar peripheral dissection pocket was created. After covering the denuded corneal surface, the edges of the amniotic membrane were introduced into the pocket and secured using fibrin sealant. Additional amniotic membrane was glued to the nasal en temporal corneal areas and a collagen shield was applied. Wound healing was completed in 10 days and a stable ocular surface was restored without pain or inflammation. During the follow-up period, no recurrence of the band keratopathy was observed.

Safety and stability of laser in situ keratomileusis for myopic correction performed under thin flaps.

BACKGROUND: To determine the safety and long-term refractive stability of laser in situ keratomileusis (LASIK) performed under thin flaps (<110 microm) and to compare them with those of conventional thicker flaps (>110 microm). METHODS: This retrospective study consisted of 120 myopic eyes of 68 patients who underwent LASIK performed with the use of the Moria M2 microkeratome and the Technolas Keracor 117C excimer laser. Indicators of efficacy, predictability, and long-term stability were followed for 1 year after surgery and were compared among 3 groups of patients that varied according to the flap thickness used: thin (<110 microm, n = 29), medium (111-139 microm, n = 47) and thick (>140 microm, n = 44). RESULTS: One year after myopic LASIK, the mean spherical equivalent refraction for the thin-flap group A was -0.37 (standard deviation [SD] 0.44) diopters (D); medium-flap group B was -0.48 (SD 0.55) D; and thick-flap group C was -0.43 (SD 0.45) D. The percentage of eyes with spherical equivalent refraction within SD 0.50 D and SD 1.00 D of emetropia was 84% and 92% for group A, 82% and 91% for group B, and 79% and 90% for group C, respectively. Buttonholes were encountered in 3% of eyes in group A compared with 0% in the other 2 groups. Epithelial ingrowth and peripheral flap striae occurred in 7% and 7% in group A, 2% and 2% in group B, and 2% and 0% in group C, respectively. INTERPRETATION: Thin-flap LASIK (<110 microm) produces more intra- and early post-operative complications compared with thick-flap LASIK (>110 microm). However, if a thin flap is created and there are no complications, or if the complications are successfully managed, there does not appear to be any difference in the long-term refractive results.

Scheduled follow-up after a pediatric emergency department visit for asthma: a randomized trial.

OBJECTIVES: Follow-up with a primary care provider (PCP) is recommended after an emergency department (ED) visit for asthma to assess clinical status and develop a management plan to improve future care. However, previous ED-based studies of urban children with asthma have reported low follow-up rates. The objective of this study was to determine whether scheduling an appointment at the time of an ED visit improves PCP follow-up for urban children. A secondary goal was to assess the effect of this intervention on short-term health outcomes and the use of recommended preventive controller medications. METHODS: This randomized trial enrolled a convenience sample of children who were 2 to 18 years old and discharged after treatment for acute asthma in an urban children's hospital ED. Both intervention and control subjects were instructed to follow up with their PCP within 3 to 5 days. Study staff assisted intervention subjects to call their PCP from the ED and schedule an appointment. When follow-up could not be scheduled, assistance continued after ED discharge by telephone until an appointment date was confirmed. Study outcomes included PCP visits, asthma-related morbidity, and daily use of preventive medication 4 weeks after the ED visit. Outcomes were assessed by telephone interview and confirmed by PCP record review. RESULTS: A total of 278 eligible subjects were enrolled over 8 months; intervention and control groups were similar by demographic variables and PCP type as well as by asthma history, symptoms, and previous medication use. Only 38% of subjects reported using a daily controller medication, although 70% described persistent asthma symptoms for which these are recommended. For the intervention group, follow-up appointments were successfully obtained during the ED visit for 24% of subjects; when unsuccessful, a median of 3 telephone calls (range: 1-14) were needed to confirm that an appointment had been scheduled. During the 4 weeks after the ED visit, intervention subjects were more likely than controls to follow up with their PCP (64% vs 46%; relative probability for follow-up: 1.4; 95% confidence interval: 1.1-1.7). Study groups did not differ in return ED visits, missed school or work, or the percentage reporting daily use of a controller medication (58% vs 54%) 4 weeks after the ED visit. The median time to the next PCP visit was shorter among intervention subjects (13 vs 54 days). CONCLUSIONS: Scheduling an appointment after an ED visit increased the likelihood that urban children with asthma would follow up with a PCP. An appointment could not be obtained during the ED visit for most children. Other interventions are needed to improve linkage between ED and primary care for asthma and to improve the use of controller medications.