Critical appraisal of loteprednol ointment, gel, and suspension in the treatment of postoperative inflammation and pain following ocular and corneal transplant surgery.

PURPOSE: To review comprehensively the available peer-reviewed published articles in the literature on loteprednol suspension, gel, and ointment in the treatment of ocular inflammation and pain following ocular surgery. METHODS: We conducted a PubMed literature search review of all published articles on keywords associated with loteprednol etabonate and ocular surgery. RESULTS: A total of 59 peer-reviewed articles were found in the literature. The focus of the majority of the articles was on the safety and efficacy of loteprednol etabonate 0.5% in postoperative control of inflammation and pain following cataract surgery. There were only three articles with a remote association between loteprednol etabonate and keratoplasty. CONCLUSION: Lotemax® ointment may also have potential as a first-line anti-inflammatory agent of choice in postoperative settings of strabismus and penetrating glaucoma, and following low-risk penetrating keratoplasty procedures.

Management of pediatric corneal limbal dermoids.

This paper reviews the data in the published literature (PubMed from 1937 to 2011) concerning the medical and surgical management of pediatric limbal dermoids. Current standard medical treatment for grade I pediatric limbal dermoids (ie, with superficial corneal involvment) is initially conservative. In stages II (ie, affecting the full thickness of the cornea with/without endothelial involvement) and III (ie, involvement of entire cornea and anterior chamber), a combination of excision, lamellar keratoplasty, and amniotic membrane and limbal stem cell tranplantation are advocated. Combinations of these approaches seem to yield better and more stable long-term ocular surface cosmesis and fewer complications in comparison with traditional methods of excision and lamellar keratoplasty. Management of amblyopia (i.e. occlusion treatment, chemical penalization with/without spectacle wear, etc) must continue after surgical excision to yield optimal results when or if the surgery is done at a younger age.

Surgical management of pediatric limbal dermoids with sutureless amniotic membrane transplantation and augmentation.

PURPOSE: To further evaluate the efficacy of a new surgical technique for removal of pediatric corneal-limbal dermoids and ocular surface reconstruction using multilayered amniotic membrane. METHODS: Three pediatric patients with corneal-limbal dermoid (grade I) in one practice were identified in a retrospective fashion. All patients underwent deep lamellar excision followed by sutureless multilayered amniotic membrane transplantation by a single surgeon (AP). Preoperative and postoperative visual acuity, anterior segment examination, anterior segment B-scan, and cycloplegic refraction were performed. RESULTS: Three patients with ages ranging from 6 months to 18 years had a postoperative follow-up of 9 to 12 months from the time of surgery. This surgical technique achieved rapid postoperative corneal re-epithelialization, reduced postoperative pain, and diminished postoperative scarring in all three patients. Existing preoperative astigmatism remained unchanged throughout the follow-up period. No intraoperative or postoperative complications were noted. CONCLUSION: This surgical approach offers an alternative surgical technique to a simple excision with or without deep lamellar keratoplasty for removal of pediatric corneal-limbal dermoids (grade I). In the management of pediatric limbal dermoids (grade I), surgical excision combined with sutureless multilayered amniotic membrane transplantation eliminates painful postoperative recovery and corneal neovascularization, and can achieve an improved long-term ocular surface cosmesis.

Simultaneous Interface Candida Keratitis in 2 Hosts Following Descemet Stripping Endothelial Keratoplasty With Tissue Harvested From a Single Contaminated Donor and Review of Clinical Literature.

PURPOSE: The objective of this study was to report 2 cases of interface fungal keratitis in 2 separate patients following Descemet stripping automated endothelial keratoplasty (DSAEK) with tissue harvested from the same donor. DESIGN: This was a retrospective simultaneous interinstitutional hosptial-based case reports. METHODS: Two patients with corneal infections following DSAEK were identified from 2 individual practices. Both patients had undergone DSAEK from the same donor. Preoperative and postoperative eye examination included visual acuity, anterior and posterior segment evaluations, and clinical follow-up course from the time of surgery. Methods of medical therapy and surgical intervention are additionally discussed. RESULTS: The 2 patients presented in our series present with interface fungal keratitis postoperatively in the face of the original source coming from a single donor (patient 1: 7 days postoperatively and patient 2: 7 weeks postoperatively). As medical treatment failed in both cases, surgery was undertaken in both cases (therapeutic penetrating keratoplasty). With prompt recognition as well as medical and surgical treatment, patient 1 achieved best corrected visual acuity of 20/30 at 6 months postoperatively, and patient 2 had best corrected visual acuity of 20/80 at 10 months postoperatively. CONCLUSIONS: Fungal keratitis following DSAEK occurs in a sequestered space and therefore represents a treatment challenge with potentially devastating outcome. We recommend an aggressive surgical approach with early removal of the donor button and irrigation with intracameral antifungal agents.

Fibrin-glue assisted multilayered amniotic membrane transplantation in surgical management of pediatric corneal limbal dermoid: a novel approach.

PURPOSE: To report a new surgical technique for excising pediatric corneal limbal dermoid and the post-resection ocular surface reconstruction. METHODS: We describe a method of deep lamellar excision followed by sutureless multilayered amniotic membrane transplantation in surgical management of corneal limbal dermoid. RESULT: This technique achieves a rapid corneal re-epithelization, reduces post-operative pain, and will diminish post-operative scarring. Preoperative corneal astigmatism will persist. CONCLUSION: This method offers an alternative surgical approach in comparison to simple excision in removal of simple pediatric corneal limbal dermoids.

Anterior chamber phakic intraocular lens implantation in children to treat severe anisometropic myopia and amblyopia: 3-year clinical results.

PURPOSE: To evaluate the midterm efficacy of Verisyse anterior chamber phakic intraocular lens (AC pIOL) implantation in reducing clinically significant (>-8.0 diopters) myopic anisometropia in children who have been noncompliant with traditional medical treatment. SETTING: Private practice in affiliation with San Diego Children's Hospital, San Diego, California, USA. METHODS: A retrospective interventional chart review identified highly anisometropic myopic pediatric patients in a single practice who had AC pIOL implantation in the more myopic eye. None of the patients were compliant with spectacle correction or contact lens therapy, and all had dense amblyopia. Preoperative and postoperative visual acuity, stereoacuity, central corneal thickness, motor alignment, and endothelial cell counts were performed in all patients. Occlusion therapy was initiated subsequent to pIOL implantation. RESULTS: The review identified 7 patients ranging in age from 5 to 11 years; the postoperative follow-up was 34 to 36 months. All patients had a significant improvement (>6 lines) in visual acuity postoperatively. The mean corrected distance visual acuity was 20/40 at 3 years. All patients had improved stereoacuity Randot testing, from a mean of 0 seconds of arc preoperatively to a mean of 185 seconds of arc at 3 years. No intraoperative or postoperative complications were identified. CONCLUSIONS: Results indicate that AC pIOL implantation can be considered an alternative modality to manage clinically significant, severe anisometropic myopia in pediatric eyes when there is poor patient compliance with traditional medical treatment. Long-term follow-up of corneal endothelial cell density after pediatric AC pIOL implantation is strongly encouraged.

Pediatric phakic intraocular lens surgery: review of clinical studies.

PURPOSE OF REVIEW: To report on the accumulating peer-reviewed data of phakic intraocular lens (pIOL) implantation in the pediatric population. I evaluate and compare the published peer-reviewed articles for the reported efficacy and complications of phakic intraocular lens implantations in children for correction of clinically significant high refractive errors. RECENT FINDINGS: Multiple studies have shown the relevancy and effectiveness of pIOL implantation as an alternative surgical management for highly significant pediatric ametropia in selective patients who are noncompliant with medical treatment. SUMMARY: In the management of clinically significant severe pediatric ametropic and/or anisometropic myopia or hyperopia and in the event of nonadherence to traditional medical treatment, phakic anterior chamber IOL implantation is currently considered an effective modality of treatment. Long-term follow-up of pediatric patients following pIOL implantation is necessary. Future clinical trials should focus on children of various age groups to assess the variables of visual acuity gain or loss, stereopsis, contrast sensitivity, high-order aberrations, corneal physiology, and long-term complications to accurately and properly address the safety and efficacy of the type of and the best time for pIOL implantation in treatment and/or prevention of amblyopia in children.

Bilateral diffuse lamellar keratitis following consecutive selective laser trabeculoplasty in LASIK patient.

A 48-year-old man with a history of myopic laser in situ keratomileusis (LASIK) had selective laser trabeculoplasty (SLT) for the treatment of glaucoma in the right eye. He subsequently developed grade 2 diffuse lamellar keratitis (DLK). He then elected to have SLT in the left eye and developed grade 1 DLK. To our knowledge, this is the first report of bilateral consecutive late postoperative DLK following SLT after LASIK.

Acquired infantile Horner syndrome and spontaneous internal carotid artery dissection: a case report and review of literature.

Horner syndrome, a triad of ptosis, anisocoria, and anhidrosis, results from interruption in the oculosympathetic pathway. It is classically described as either congenital or acquired to depict its underlying pathophysiology and requisite work-up. We report a case of a 10-month-old infant presenting with an acute onset of left Horner syndrome secondary to a spontaneous extracranial internal carotid artery dissection. To the best of our knowledge, this is the first case report in the literature of acute onset of acquired infantile Horner syndrome in association with spontaneous carotid artery dissection confirmed with magnetic resonance angiogram.

Phakic anterior chamber intraocular lens (Verisyse) implantation in children for treatment of severe ansiometropia myopia and amblyopia: Six-month pilot clincial trial and review of literature.

PURPOSE: The current study aims to evaluate both safety and efficacy of Verisyse() (AMO, Irvine, CA) phakic anterior chamber intraocular lens (IOL) in the reduction of clinically significant (>-8 D) myopic anisometropia in children who are noncompliant to traditional medical treatment including spectacle correction or contact lenses. DESIGN: Retrospective interventional case series. METHODS: Six anisometropic myopic pediatric patients in one practice were identified through chart-review. None of the patients were compliant with specatacle correction or contact lens wear and as a result had dense amblyopia of less than 20/400 by Snellen or Allen visual acuity (mean <20/400). All patients underwent Verisyse() phakic IOL implantation in the more myopic eye by one surgeon (AP). Pre- and post-operative visual acuity, anterior/posterior segment examination, stereoacuity, axial biometry measurements, cycloplegic refraction, and endothelial cell counts were performed in all patients whenever feasible. RESULTS: The age of patients ranged from 5-11 years. The mean post-operative follow-up time was six months from the time of IOL insertion. Improvement in visual acuity >6 lines was achieved in four patients (mean visual acuity of 20/70 at six months). Improvement in stereoacuity was noted in all six patients (from total mean zero seconds-arc to six-months post-operative mean of 500 seconds-arc by randot stereoacuity testing). Improvement of >2 lines of visual acuity lines was achieved in the other two patients. No patient lost any lines of visual acuity. Enhanced physical activity, coordination, and improved social interaction were noted in patients and were reported by the parents. No intra/post-operative complications were noted. DISCUSSION: Irreversible or intractable amblyopia secondary to severe anisometropic myopia is a serious medical concern in the pediatric population. Failure of compliance with contact lens therapy consistently leads to visual loss. Anterior chamber phakic IOLs may provide a safe alternative in treatment of noncompliant anisometropic myopic patients who do not accept spectacle wear or contact lens therapy. CONCLUSION: To reduce or eliminate highly significant anisometropic myopia in children who are noncompliant with traditional medical treatment, phakic anterior chamber IOL implantation may be considered as an alternative modality of treatment.

Clinical findings following Ahmed Glaucoma Valve implantation in pediatric glaucoma.

PURPOSE: To describe clinical findings after Ahmed valve drainage implantation in children. DESIGN: All records in one practice were reviewed to identify and describe clinical findings in all children who had undergone Ahmed Glaucoma Valve S2 model insertion for uncontrolled primary or secondary glaucoma. RESULTS: A total of 6 patients were identified, ranging in age from 2-15 years. Mean follow-up time averaged from 2-5 years from the time of tube insertion. Three patients exhibited pupillary peaking towards the tube of the valve. All patients required additional surgery or additional medications to control intraocular pressure. Lenticular opacification near the tube site developed in one patient. Gradual tube extrusion was also noted in another two patients. CONCLUSION: Multiple clinical events follow the Ahmed valve insertion in children. Pupillary irregularity is the most commonly noted event in this series. To avoid or reduce the risk of this complication, additional or modification of surgical procedures could be considered. The mechanism of such occurrence will further be discussed.

Traumatic and spontaneous scleral rupture and uveal prolapse in osteogenesis imperfecta.

Three cases of severe globe injuries due to scleral fragility in osteogenesis imperfecta patients between the ages of 4 and 15 years are reported. Patient 1 had complete loss of vision. Patients 2 and 3 suffered non-sight-threatening scleral perforation. All 3 patients had no previous knowledge of recommendation for eyewear protection.