Cataract surgery in a patient with Brown-McLean syndrome.

The Brown-McLean syndrome is defined by corneal edema that involves the peripheral 2.0 to 3.0 mm of cornea, sparing the central cornea. This syndrome is usually associated with previous cataract surgery but has been reported rarely in patients with other predisposing factors such as angle-closure glaucoma or spontaneous lens absorption with iridodonesis. We describe the clinical course of a 50-year-old man with myotonic dystrophy who had Brown-McLean syndrome with no identifiable predisposition for peripheral corneal edema. Although this syndrome appears to be the result of peripheral endothelial dysfunction, this patient was able to tolerate cataract extraction without developing central corneal edema.

Penetrating eye injury in war.

The percentage of penetrating eye injuries in war has increased significantly in this century compared with the total number of combat injuries. With the increasing use of fragmentation weapons and possibly laser weapons on the battle-field in the future, the rate of eye injuries may exceed the 13% of the total military injuries found in Operations Desert Storm/Shield. During the Iran-Iraq War (1980-1988), eye injuries revealed that retained foreign bodies and posterior segment injuries have an improved prognosis in future military ophthalmic surgery as a result of modern diagnostic and treatment modalities. Compared with the increasing penetrating eye injuries on the battlefield, advances in ophthalmic surgery are insignificant. Eye armor, such as visors that flip up and down and protect the eyes from laser injury, needs to be developed. Similar eye protection is being developed in civilian sportswear. Penetrating eye injury in the civilian sector is becoming much closer to the military model and is now comparable for several reasons.

Pharmacomanipulation of HSV-1 induced chorioretinitis in mice.

In the von Szily mouse model, intracameral inoculation of herpes simplex virus type-1 (HSV-1) results in inflammation of the ipsilateral anterior segment with relative chorioretinal sparing and destructive contralateral chorioretinitis. We studied the effect of the systemic antiviral agent acyclovir (ACV) and anti-HSV-1 antibody therapy in this model. Contralateral chorioretinitis developed in none of the 18 mice receiving ACV from post-inoculation day (pid) 1 (p < 0.0001), in 6 of 10 (60%) mice when treatment was delayed until pid 7 (p = 0.40) and in 14 of 18 (77%) controls. Contralateral disease developed in 8 of 16 (50%) mice that received anti-HSV-1 antibody from pid 1 (p = 0.02), in 13 of 16 (81%) treated from pid 5 (p = 0.64), in 7 of 8 (87.5%) treated from pid 7 (p = 1.0) and in 17 of 20 (85%) controls. We conclude that early treatment with ACV or anti-HSV-1 antibody reduces the incidence of contralateral chorioretinitis in mice.

Corneal melting after avulsion of a Molteno shunt plate.

PURPOSE: We report a case of Molteno shunt avulsion after blunt trauma resulting in corneal melting. The implant's connecting tube had been placed above the superior rectus muscle. METHODS: Case report. RESULTS: After blunt trauma, the secondary plate of a double-plated Molteno implant became completely dislodged anteriorly onto the patient's cornea. The corneal tissue entrapped beneath the avulsed plate was found to have extensive melting requiring emergency explantation of the Molteno implant and corneal grafting. CONCLUSIONS: Corneal melting after Molteno shunt avulsion is a novel finding. Placing a double-plated Molteno implant's connecting tube under the superior rectus muscle might decrease the risk of shunt avulsion after trauma.

Ocular symptoms and signs associated with suramin sodium treatment for metastatic cancer of the prostate.

PURPOSE: Therapy with suramin sodium has been associated with photophobia, iritis, optic atrophy, and vortex keratopathy. We studied the ocular findings in patients who underwent treatment with suramin sodium for metastatic cancer of the prostate. METHODS: In a prospective study, 114 patients who underwent treatment with suramin sodium for cancer of the prostate had an ophthalmologic examination with two weeks of onset of treatment and two weeks after termination of therapy. Additional examinations were performed on patients who developed ocular symptoms during suramin sodium therapy. RESULTS: Nineteen (16.6%) of 114 patients developed ocular symptoms and signs while taking suramin sodium. Thirteen of these patients developed bilateral corneal epithelial whorllike deposits. In ten patients, the corneal deposits were associated with foreign body sensation and lacrimation. Symptoms in all of these patients resolved with topical lubricants. Three patients developed asymptomatic corneal deposits. Seven patients had blurred vision and were found to have a mean hyperopic shift in refractive error of 1.13 +/- 0.45 diopters (range, 0.75 to 2.00 diopters) that persisted throughout their treatment course. None of these patients had a decrease in best-corrected visual acuity. CONCLUSIONS: In this study, ocular symptoms and signs associated with suramin sodium were common but were not considered a dose-limiting toxicity. Hyperopic shift in refractive error is a previously unreported ocular finding in association with suramin sodium therapy.

Phase I and clinical evaluation of a pharmacologically guided regimen of suramin in patients with hormone-refractory prostate cancer.

PURPOSE: This phase I study was designed with the following objectives: (1) to describe the overall and dose-limiting toxicity (DLT) of suramin administered by intermittent short intravenous infusions until DLT or disease progression; (2) to determine the ability of an adaptive control with feedback (ACF) dosing strategy to maintain suramin plasma concentrations within a preselected range; (3) to develop a population model of suramin pharmacokinetics; and (4) to identify preliminary evidence of antitumor activity. PATIENTS AND METHODS: Seventy-three patients with advanced, incurable, solid tumors (including 69 with hormone-refractory prostate cancer) received an initial 5- to 7-day daily loading treatment followed by intermittent infusions individually determined by ACF using a Bayesian algorithm and relying on population models of suramin pharmacokinetics. Treatment was given to three cohorts of patients based on target plasma suramin concentration ranges (peak, 30 minutes postsuramin, and trough on morning of the treatment day), as follows: cohort 1, 175 to 300 micrograms/mL (27 patients); cohort 2, 150 to 250 micrograms/mL (23 patients); and cohort 3, 100 to 200 micrograms/mL (23 patients). All patients were to receive suramin until DLT or disease progression. RESULTS: The DLT was most commonly seen in cohort 1 and included a syndrome of malaise and fatigue, associated with weight loss, anorexia, and changes in taste. Other reversible toxicities were neurologic, renal, cutaneous, edema, lymphopenia and anemia, ophthalmologic, and alopecia. Forty of 67 assessable patients (60%) had a 50% reduction and 25 of 67 (37%) a 75% reduction in prostate-specific antigen (PSA) levels that lasted more than 4 weeks, seven of 18 (40%) had measurable responses, and 18 of 37 (49%) demonstrated major pain improvement. The overall times to disease progression and survival were 170 and 492 days, respectively. CONCLUSION: We have characterized all toxicities with suramin in a pharmacologically guided phase I study designed to maintain plasma suramin concentrations of 100 to 300 micrograms/mL (cohorts 1 to 3). The incidence of grade 3 to 4 neurologic abnormalities was relatively low, particularly in cohorts 2 and 3 (100 to 250 micrograms/mL). Evidence of significant and durable antitumor activity was seen in all three cohorts.

Microbial keratitis in patients infected with the human immunodeficiency virus.

BACKGROUND: Posterior segment complications of systemic infection with the human immunodeficiency virus (HIV) are well recognized. The anterior segment complications often are, however, overlooked. The author treated 20 episodes of nonherpetic infectious keratitis in 17 eyes of 13 patients infected with HIV who presented between August 1990 and May 1994. METHODS: Review of records. RESULTS: Nine patients were women, and four were men. Mean age was 35.2 years. The keratitis was bilateral in four patients, polymicrobial in four, and recurrent in two. The most common infecting organism was Candida albicans (5 eyes), a rare cause of keratitis in immunocompetent individuals. Other organisms included Staphylococcus aureus in four eyes, Staphylococcus epidermidis in four, Bacillus sp in two, and one each Pseudomonas aeruginosa, alpha-hemolytic Streptococcus, Micrococcus sp, and Capnocytophaga sp. Seven eyes retained 20/30 or better visual acuity after treatment, eight had visual acuity of 20/50 or worse, and two were eviscerated. Classic predisposing factors for infectious keratitis were found in only two patients and included contact lens wear and atopy in one patient each. Twelve patients had a history of intravenous drug abuse. CONCLUSION: Infectious keratitis should be recognized as a complication of systemic HIV infection, especially in the context of drug abuse. The prognosis for recovery of vision in these patients often is poor.

Ocular injuries from violence treated at an inner-city hospital.

UNLABELLED: A computerized data base identified 277 patients with violence-related ocular injuries seen during 16 months in an inner-city hospital. They constituted 35% of all patients with ocular injuries during the study period. Their demographics and ocular findings were analyzed. One hundred sixty-seven patients (60%) were black males, 60 (22%) were white males, and 50 (18%) were females (mean age, 29 years). The orbit was injured in 125, the retina/choroid and vitreous in 79, and the optic nerve in ten. Seventeen had penetrating ocular injuries. Nineteen eyes (7%) lost light perception. One hundred forty-six (53%) patients had associated non-ocular injuries, mostly facial fractures. Bludgeons and guns were the weapons most commonly used; theft was the most common motive; drugs and alcohol were prominent in 35 cases. One hundred thirty-three (48%) patients were hospitalized for a mean of 5.5 days and an approximate cost of $975,089. CONCLUSION: the human suffering and economic impact of violence-related ocular injuries are significant.

Bilateral iridocorneal endothelial syndrome: case report and review of the literature.

We present the case of a 47-year-old woman with bilateral iridocorneal endothelial syndrome. The iridocorneal endothelial syndrome has heretofore been considered a unilateral disorder. However, a review of the literature and examination of the patient presented in this report indicate that bilateral occurrence of the iridocorneal endothelial syndrome is not uncommon. Consequently, it may be inappropriate to include unilaterality as a feature distinguishing the iridocorneal endothelial syndrome from similar conditions, most notably posterior polymorphous endothelial dystrophy.

Endogenous Fusarium endophthalmitis in a patient with acute lymphocytic leukemia.

Endogenous fungal endophalmitis is an uncommon complication of systemic mycosis. Only a few cases involving Fusarium have been reported, most with unfavorable visual outcomes. We examined a 31-year-old woman with acute lymphocytic leukemia who developed sudden visual loss in her right eye. A dense, white placoid infiltrate was present in the right macula extending into the vitreous. An iris nodule and hypopyon were present in the left eye. A vitreous aspirate of the right eye was positive for Fusarium species. The patient progressively lost vision despite amphotericin B and 5-fluorocytosine therapy. She died from bronchopneumonia, fungemia, and multisystem failure. Histopathologic study disclosed a panophthalmitis with Fusarium organisms invading all the ocular coats in the right eye. Leukemic infiltrates were present in the left iris, anterior chamber, and trabecular meshwork. The ocular destructiveness of Fusarium may be caused by marked mycotic vascular invasion and occlusion with consequent infarction and necrosis of ocular tissues.

Biomicroscopic and histopathologic observations after corneal laser photocoagulation in a rabbit model of corneal neovascularization.

Corneal neovascularization complicates many anterior segment diseases. Corneal laser photocoagulation using yellow light (577 nm) has been shown to reduce corneal neovascularization. No histopathologic studies of the effects of this treatment on the eye have been reported, however. Target (cornea) and nontarget (iris, lens, retina, and choroid) ocular tissue were studied 1, 24, and 48 h and 5 days after yellow dye corneal laser photocoagulation in a rabbit model of corneal neovascularization. Biomicroscopic examination of the corneas revealed intracorneal hemorrhage in five of 24 (21%) eyes of nonpigmented rabbits. Faint lenticular opacities were observed in two eyes of pigmented rabbits 24 h after laser treatment. Histopathologic examination revealed increased cellularity (neutrophils) (p < 0.005) in the cornea, increasing from 1 h after treatment, peaking 24 h later, and persisting past 5 days. Distortion of the corneal lamellae by red blood cells occurred in eyes in which intracorneal hemorrhage developed. These results indicate that corneal laser photocoagulation using yellow light is a relatively safe procedure for reducing corneal neovascularization.

Recurrent corneal infections in a patient with the acquired immunodeficiency syndrome.

A 29-year-old female intravenous drug abuser infected with the human immunodeficiency virus suffered recurrent, bilateral corneal infections over an 11-month period. Multiple infectious organisms were responsible, including capnocytophaga species, Candida albicans, Staphylococcus aureus, coagulase-negative staphylococcus, and a-streptococcus. One eye was eviscerated because of corneal perforation and loss of vision; the second eye has maintained good vision. Predisposing factors usually associated with corneal infections were absent. Treatment was complicated by extremely poor patient compliance, ongoing intravenous drug abuse, and concurrent multiple extraocular medical problems.

Spontaneous ulcerative keratitis in immunocompromised patients.

We studied the occurrence of ulcerative keratitis in five eyes of four patients who were examined at the University of Maryland Hospital ophthalmology clinic over a 12-month period. All were young women who were intravenous drug abusers, with no known predisposing factors for ulcerative keratitis. Two patients had acquired immunodeficiency syndrome (AIDS), one was human immunodeficiency virus (HIV)-positive, and the fourth refused HIV testing. One had a corneoscleral limbus to corneoscleral limbus keratitis; three had inferiorly located corneal ulcers (bilateral in one patient with AIDS). Corneal cultures disclosed Capnocytophaga species in the corneoscleral limbus to corneoscleral limbus keratitis. The remaining ulcers were polymicrobial; cultures of three grew Candida albicans, cultures of two grew alpha-hemolytic streptococci, cultures of two grew Staphylococcus aureus, and culture of one grew Pseudomonas aeruginosa. Treatment with topical fortified antibiotics and antifungal agents resulted in complete healing in all four inferiorly located ulcers. The corneal ulcer became perforated and the eye was eviscerated. Histopathologic analysis of the eviscerated specimen disclosed acute keratitis with necrosis and no microorganisms.

Infectious scleritis: report of four cases.

While systemic autoimmune diseases are the main possibilities in the differential diagnosis of scleritis, other less common etiologies such as infections must also be considered. The authors report four cases of infectious scleritis to review predisposing factors, clinical characteristics, methods of diagnostic approach, and response to therapy. Two patients had primary scleritis and two patients had secondary scleritis following extension of primary corneal infection (corneoscleritis). Diagnoses included three local infections (one each with Staphylococcus. Acanthamoeba, and herpes simplex) and one systemic infection (Lyme disease). Stains, cultures, or immunologic studies from scleral, conjunctival, and/or corneal tissues, and serologic tests were used to make the diagnosis. Medical therapy, including antimicrobial agents, was instituted in all patients, and surgical procedures were additionally required in two patients (scleral grafting in one and two penetrating keratoplasties in another); the patient who required two penetrating keratoplasties had corneoscleritis and underwent eventual enucleation. Infectious agents should be considered in the differential diagnosis of scleritis.

Intraocular penetration of ketoconazole in rabbits.

We studied penetration of the antifungal agent ketoconazole into the cornea, aqueous humor, and vitreous of rabbits after topical, subconjunctival, and oral administration. The effect of debridement of corneal epithelium on penetration was also investigated. Ketoconazole levels in the cornea and aqueous humor were high after topical or subconjunctival administration, and increased markedly (especially in the cornea) if the corneal epithelium had been debrided before administration of the drug. For example, concentration of ketoconazole in the cornea 1 h after topical drug administration with or without complete corneal epithelial debridement was 44.0 +/- 10.1 and 1,391.5 +/- 130.0 micrograms/g, respectively. Drug levels in the vitreous were not detectable after topical or subconjunctival drug administration, but were improved slightly by prior epithelial debridement (8.3 and 0.12 micrograms/mL after 1 h, respectively). Orally administered ketoconazole resulted in high corneal concentrations (45.0 +/- 7.6 micrograms/g after 1 h) that were still substantial 24 h later (55.0 +/- 7.0 micrograms/g); levels in the aqueous were low.