Retained interface gentian violet ink in Descemet stripping endothelial keratoplasty.

PURPOSE: To present a case of a patient who underwent right Descemet stripping endothelial keratoplasty (DSEK) in whom the gentian violet ink used to mark and orient the donor corneal graft had persisted at the host-graft interface. METHODS: A 57-year-old woman with progressive corneal edema from Fuchs endothelial dystrophy in her right eye underwent a combined phacoemulsification/posterior chamber intraocular lens insertion and DSEK. The host endothelium was stripped in a central 9.0-mm diameter. The endothelial graft was harvested to a depth of 400 µm. The anterior stromal flap was lifted, and the stromal side of the endothelial graft was peripherally marked with a dotted "7" using a Codman gentian violet marker pen and a dot was placed at the center to aid centration. The graft was inserted and centrally positioned. The superior clear corneal wound was closed with 3 × 10/0 nylon interrupted sutures. The patient was instructed to lie face up for the first 48 hours. RESULTS: At 1 week, the graft was well positioned and the central gentian violet mark was not present but the peripheral markings were noted. At 14 months, the cornea was clear with an unaided visual acuity of 20/25 and best-corrected visual acuity of 20/20 but the superior peripheral markings persisted at the graft-host interface. Specular microscopy demonstrated a cell density of 1900 cells per square millimeter. CONCLUSIONS: Gentian violet ink marking used in DSEK operations may persist at the graft-host interface. Small, peripheral markings will minimize the risk of interference with central vision, ink-induced inflammation, and endothelial damage.

Intrastromal injection of antibiotic agent in the management of recalcitrant bacterial keratitis.

Intrastromal injection is a novel method of delivering an antibiotic agent directly to the site of keratitis. Although intrastromal antifungal agents have been used to manage refractory fungal keratitis, the experience with intrastromal antibiotic agents for bacterial keratitis is more limited. We report a case of refractory bacterial keratitis treated with an intrastromal antibiotic agent and discuss the potential for the clinical use of this modality.

Tight orbit syndrome: a previously unrecognized cause of open-angle glaucoma.

PURPOSE: To describe a new syndrome of tight orbit and intractable glaucoma with a poor visual prognosis. METHODS: A retrospective observational case series of six patients seen at two centres between 2001 and 2007 assessing intraocular pressure (IOP), best-corrected visual acuity and visual field. RESULTS: Three men and three women, ranging in age at diagnosis from 14 to 53 years, demonstrated similar orbital features and progressive visual field loss despite intensive management with medication and laser and operative surgery. Highest IOPs ranged from 30 to 50 mmHg. Trabeculectomy and/or glaucoma drainage devices were attempted in five patients but all failed. One patient underwent orbital decompression with achievement of IOP control. Final IOP at last follow-up was variable; only two patients achieved IOP in the normal range, with the rest ranging from 25 to 40 mmHg. All patients had advanced visual field loss. CONCLUSION: Tight orbit syndrome presents a serious clinical challenge. Despite maximum medical therapy and surgical intervention IOP is difficult to control, resulting in progressive visual field loss.

Self-tonometry in glaucoma management--past, present and future.

Glaucoma is the leading cause of irreversible blindness in the world. Diagnosis and management of glaucoma is significantly associated with intraocular pressure, but contemporary office-based measurements are not sufficient to discover diurnal changes and spikes, nor do they demonstrate the effect of medication and compliance. Patient-directed self-tonometry can be taken throughout the day and is therefore the subject of much discussion and research. In this article we review the history of self-tonometry devices and present technologies for the future.

Histopathology of a functioning mitomycin-C trabeculectomy.

The ideal trabeculectomy bleb is diffuse, normally vascularized and characterized by microcystic change in the overlying conjunctiva. We compare and contrast the histopathology of a normally functioning mitomycin-C trabeculectomy site obtained from an eye enucleated for iris melanoma with abnormal blebs discussed in the literature. Representative sections of the normally functioning bleb were examined under the light microscope. The conjunctiva is composed of a uniform three-layered non-keratinizing stratified squamous epithelium overlying a single layer of oedematous basal cells. The conjunctival stroma consisted of loose connective tissue, traversed by capillaries and scattered small cystic spaces lined by endothelial cells. There were no goblet cells and few inflammatory cells and fibroblasts. The scleral trapdoor was evident as a cleft in the scleral wall in communication with the anterior chamber at the surgically created sclerostomy. Because the histopathological findings in our case correlate well with this clinical appearance, we conclude that whereas augmentation with anti-metabolites, such as mitomycin-C, can be associated with significantly altered conjunctival histopathology and consequent hypotony, but, if used carefully, normal architecture is conserved.

Orbital cellulitis as a postoperative complication of sub-Tenon anaesthesia in cataract surgery.

Orbital cellulitis is a rarely reported sight-threatening complication of sub-Tenon anaesthesia. We report a case of orbital cellulitis in a patient who had received sub-Tenon anaesthesia for routine cataract surgery. We discuss the potential under-reporting of complications of sub-Tenon anaesthesia that had a delayed presentation, and the possible association between the use of hyaluronidase in the anaesthetic mixture and orbital cellulitis following sub-Tenon anaesthesia.