Long-term Outcomes on de novo Ocular Hypertensive Response to Topical Corticosteroids After Corneal Transplantation.

PURPOSE: To determine incidence, demographics, management, and outcomes of topical steroid-induced ocular hypertension after penetrating keratoplasty (PKP) and to establish effects on intraocular pressure (IOP) and graft rejection when alternate corticosteroids are used. METHODS: A single-center, retrospective review of 568 consecutive PKPs performed between 1997 and 2010 was conducted. Data were collected on demographics, best-corrected visual acuity, surgical indications, lens status, IOP, postoperative management, and incidence of rejection. RESULTS: Eighty eyes (14.1%) of 74 patients were included. The most common indication was keratoconus (28.8%). Twenty-seven eyes (33.8%) were phakic, 46 (57.4%) had a posterior chamber intraocular lens, and 7 (8.8%) had an anterior chamber intraocular lens. Mean postoperative IOP increase was only significant in the anterior chamber intraocular lens group (18.7 mm Hg, SD 10.4; P = 0.02). The average time for developing hypertension was 9.8 months (SD 14.8) postoperatively, with an average IOP increase of 13.3 mm Hg (SD 5.9). Prednisolone acetate 1% was switched to rimexolone 1% in 64 eyes (80%) and to fluorometholone 0.1% in 16 eyes (20%), which alone achieved IOP normalization in 26 eyes (32.5%) (P < 0.01). Fifty-four eyes (67.5%) required additional antiglaucoma medication. An average IOP reduction of 12.3 mm Hg (SD 6.9) was achieved at an average of 2.3 months (SD 5.2) after the switch. Seventeen eyes (21%) developed glaucoma and 13 eyes (16.3%) developed graft rejection after switching formulations, with no statistically significant differences between rimexolone and fluorometholone (P > 0.05). CONCLUSIONS: The use of alternate topical corticosteroids may be considered in cases of steroid-induced ocular hypertension after PKP because they offer good antiinflammatory prophylaxis with reduced hypertensive response.

Patients with Fuchs Endothelial Dystrophy and Cataract Undergoing Descemet Stripping Automated Endothelial Keratoplasty and Phacoemulsification with Intraocular Lens Implant: Staged versus Combined Procedure Outcomes.

Purpose. To compare the surgical outcomes of staged and combined phacoemulsification with intraocular lens implant (phaco+IOL) and Descemet stripping automated endothelial keratoplasty (DSAEK) in patients with Fuchs' endothelial dystrophy and cataract. Setting. Corneoplastic Unit and Eye Bank, Queen Victoria Hospital, East Grinstead, UK. Methods. Retrospective study of patients who had combined phaco+IOL and DSAEK (group 1) or phaco+IOL followed within 2 months by DSAEK (group 2). Patients who had previous eye surgery or any other ocular comorbidities were excluded. Results. There were 28 eyes in group 1 and 31 in group 2. There were no significant differences in the demographics and corneal tissue characteristics of the two groups. The endothelial disc dislocation and rebubbling rate within 1 week in group 1 was 21.42% and in group 2 was 3.2% (P = 0.04), while the endothelial cell density at 12 months was 1510 ± 433 for group 1 and 1535 ± 482 for group 2 (P = 0.89). The mean 12-month logMAR visual acuity was 0.28 ± 0.24 for group 1 and 0.33 ± 0.15 for group 2 (P = 0.38). Conclusions. Although the combined procedure seems to be associated with a higher complication rate the final outcomes seem to be similar to both methods.

Intraocular Lens Opacification following Intracameral Injection of Recombinant Tissue Plasminogen Activator to Treat Inflammatory Membranes after Cataract Surgery.

Purpose. To report 7 cases of intraocular lens (IOL) opacification following treatment of postoperative anterior chamber fibrin with recombinant tissue plasminogen activator (rtPA) after cataract surgery. Methods. Retrospective case series of 7 eyes in 7 patients who developed IOL opacification after receiving rtPA for anterior chamber inflammatory membrane formation resulting from phacoemulsification cataract surgery. Three explanted IOLs were investigated with light microscopy, histochemical analysis, scanning electron microscopy, and X-ray spectrometry. Results. All patients underwent uncomplicated cataract surgery and posterior chamber hydrophilic IOL implantation. Anterior chamber inflammatory membranes developed between 1 and 4 weeks of surgery and were treated with intracameral rtPA. IOL opacification was noted between 4 weeks and 6 years after rtPA treatment with reduced visual acuity, and IOL exchange was carried out in 3 patients. Light microscopy evaluation revealed diffuse fine granular deposits on the anterior surface/subsurface of IOL optic that stained positive for calcium salts. Scanning electron microscopy (SEM) and energy-dispersive X-ray spectrometry (EDS) confirmed the presence of calcium and phosphate on the IOL. Conclusions. Intracameral rtPA, though rapidly effective in the treatment of anterior chamber inflammatory membranes following cataract surgery, may be associated with IOL opacification.

Corneal collagen cross-linking for treating keratoconus.

BACKGROUND: Keratoconus is a condition of the eye that affects approximately 1 in 2000 people. The disease leads to a gradual increase in corneal curvature and decrease in visual acuity with consequent impact on quality of life. Collagen cross-linking (CXL) with ultraviolet A (UVA) light and riboflavin (vitamin B2) is a relatively new treatment that has been reported to slow or halt the progression of the disease in its early stages. OBJECTIVES: The objective of this review was to assess whether there is evidence that CXL is an effective and safe treatment for halting the progression of keratoconus compared to no treatment. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 7), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2014), EMBASE (January 1980 to August 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to August 2014), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to August 2014), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organisation International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We used no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 28 August 2014. SELECTION CRITERIA: We included randomised controlled trials (RCTs) where CXL with UVA light and riboflavin was used to treat people with keratoconus and was compared to no treatment. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the search results, assessed trial quality, and extracted data using standard methodological procedures expected by Cochrane. Our primary outcomes were two indicators of progression at 12 months: increase in maximum keratometry of 1.5 dioptres (D) or more and deterioration in uncorrected visual acuity of more than 0.2 logMAR. MAIN RESULTS: We included three RCTs conducted in Australia, the United Kingdom, and the United States that enrolled a total of 225 eyes and analysed 219 eyes. The total number of people enrolled was not clear in two of the studies. Only adults were enrolled into these studies. Out of the eyes analysed, 119 had CXL (all using the epithelium-off technique) and 100 served as controls. One of these studies only reported comparative data on review outcomes. All three studies were at high risk for performance bias (lack of masking), detection bias (only one trial attempted to mask outcome assessment), and attrition bias (incomplete follow-up). It was not possible to pool data due to differences in measuring and reporting outcomes. We identified a further three unpublished trials that potentially had enrolled a total of 195 participants.There was limited evidence on the risk of progression. Analysis of the first few participants followed up to one year in one study suggested that eyes given CXL were less likely to have an increase in maximum keratometry of 1.5 D or more at 12 months compared to eyes given no treatment, but the confidence intervals (CI) were wide and compatible with no effect or more progression in the CXL group (risk ratio (RR) 0.12, 95% CI 0.01 to 2.00, 19 eyes). The same study reported the number of eyes with an increase of 2 D or more at 36 months in the whole cohort with a RR of 0.03 favouring CXL (95% CI 0.00 to 0.43, 94 eyes). Another study reported "progression" at 18 months using a different definition; people receiving CXL were less likely to progress, but again the effect was uncertain (RR 0.14, 95% CI 0.01 to 2.61, 44 eyes). We judged this to be very low-quality evidence due to the risk of bias of included studies, imprecision, indirectness and publication bias but noted that the size of the potential effect was large.On average, treated eyes had a less steep cornea (approximately 2 D less steep) (mean difference (MD) -1.92, 95% CI -2.54 to -1.30, 94 eyes, 1 RCT, very low-quality evidence) and better uncorrected visual acuity (approximately 2 lines or 10 letters better) (MD -0.20, 95% CI -0.31 to -0.09, 94 eyes, 1 RCT, very low-quality evidence) at 12 months. None of the studies reported loss of 0.2 logMAR acuity. The data on corneal thickness were inconsistent. There were no data available on quality of life or costs. Adverse effects were not uncommon but mostly transient and of low clinical significance. In one trial, 3 out of 12 participants treated with CXL had an adverse effect including corneal oedema, anterior chamber inflammation, and recurrent corneal erosions. In one trial at 3 years 3 out of 50 participants experienced adverse events including mild diffuse corneal oedema and paracentral infiltrate, peripheral corneal vascularisation, and subepithelial infiltrates and anterior chamber inflammation. No adverse effects were reported in the control groups. AUTHORS' CONCLUSIONS: The evidence for the use of CXL in the management of keratoconus is limited due the lack of properly conducted RCTs.

Keratoconus and granular dystrophy.

Concurrent bilateral keratoconus and granular dystrophy is reported in a 32-year-old patient with decreased vision. Initially contact lenses were attempted unsuccessfully to treat the conditions. There are a handful of other reports of these combined pathologies in the literature, and the likelihood of a chance cause or possible genetic linkage between the conditions is discussed.

Study of fluid ingress through clear corneal incisions following phacoemulsification with or without the use of a hydrogel ocular bandage: a prospective comparative randomised study.

PURPOSE: To assess the use of a hydrogel ocular bandage (HOB) on clear corneal incisions in phacoemulsification cataract surgery and determine whether HOB reduces ocular surface contaminants ingress after routine surgery. METHODS: In this prospective randomized controlled study, thirty eyes of patients undergoing uneventful phacoemulsification were recruited consecutively and randomly assigned to have a HOB applied to the corneal incision at the end of the surgery or not. At the end of the surgery, trypan blue (TRB) was instilled on the ocular surface, aqueous fluid was aspirated from the anterior chamber (AC) and its optical density was measured using ultraviolet spectrophotometry. The corneal incisions were examined postoperatively using anterior segment optical coherence tomography. Main outcome measures were concentration of TRB in the AC, corneal incision architecture, intraocular pressure (IOP) and Seidel test. RESULTS: All incisions were Seidel negative. The mean IOP in the immediate postoperative period was 18.1 ± 5.48 mmHg for the intervention group and 16.9 ± 5.7 mmHg for the control group (p > 0.05). No architectural differences of the incisions between the two groups were noted. The total mean length of the three-step corneal incisions in the two groups was 2261.2 ± 96.92 µm and 2263 ± 119.75 µm, respectively (p > 0.05). No trace of TRB was detected in any of the samples. CONCLUSION: Proper surgical wound construction without the use of a HOB is efficient in preventing the ingress of fluid through the main corneal incision postoperatively.

Management of patients with herpes simplex virus eye disease having cataract surgery in the United Kingdom.

To standardize the management of patients with herpetic eye disease scheduled for cataract surgery, a questionnaire was sent to each fellow of the Royal College of Ophthalmologists registered as a consultant with a subspecialty interest in cornea. Most respondents agreed that disease stability was required before cataract surgery was offered; 62.3% would operate on patients in whom the disease had been quiescent for 3 to 6 months. The decision to prescribe prophylactic antivirals divided the respondents, with 58.8% in favor of starting antiviral treatment. Most respondents (72.46%) did not start topical antiviral treatment. In regard to changing topical steroid use postoperatively, 80.9% would not change their routine regimen. Oral acyclovir was the first line of treatment for 92.5%. The conclusions were that a significant period of inactivity should be considered before cataract surgery is performed in patients with herpes simplex virus eye disease. Oral antiviral prophylaxis is common clinical practice, but no change in routine postoperative steroid use is needed.

Interventions for the treatment of uveitic macular edema: a systematic review and meta-analysis.

BACKGROUND: Uveitic macular edema is the major cause of reduced vision in eyes with uveitis. OBJECTIVES: To assess the effectiveness of interventions in the treatment of uveitic macular edema. SEARCH STRATEGY: Cochrane Central Register of Controlled Trials, Medline, and Embase. There were no language or data restrictions in the search for trials. The databases were last searched on December 1, 2011. Reference lists of included trials were searched. Archives of Ophthalmology, Ophthalmology, Retina, the British Journal of Ophthalmology, and the New England Journal of Medicine were searched for clinical trials and reviews. SELECTION CRITERIA: Participants of any age and sex with any type of uveitic macular edema were included. Early, chronic, refractory, or secondary uveitic macular edema were included. We included trials that compared any interventions of any dose and duration, including comparison with another treatment, sham treatment, or no treatment. DATA COLLECTION AND ANALYSIS: Best-corrected visual acuity and central macular thickness were the primary outcome measures. Secondary outcome data including adverse effects were collected. CONCLUSION: More results from randomized controlled trials with long follow-up periods are needed for interventions for uveitic macular edema to assist in determining the overall long-term benefit of different treatments. The only intervention with sufficiently robust randomized controlled trials for a meta-analysis was acetazolamide, which was shown to be ineffective in improving vision in eyes with uveitic macular edema, and is clinically now rarely used. Interventions showing promise in this disease include dexamethasone implants, immunomodulatory drugs and anti-vascular endothelial growth-factor agents. When macular edema has become refractory after multiple interventions, pars plana vitrectomy could be considered. The disease pathophysiology is uncertain and the course of disease unpredictable. As there are no clear guidelines from the literature, interventions should be tailored to the individual patient.

Cyclofenil as a possible cause of non-arteritic anterior ischaemic optic neuropathy.

A 27-year-old woman receiving the steroid drug cyclofenil as a fertility adjunct, experienced blurred vision 24 h after missing a dose and taking a double dose to 'catch up' with her therapeutic protocol. She was found to have a non-arteritic anterior ischaemic optic neuropathy with a visual hemifield defect and impaired optic nerve function, which has not since shown any recovery. This case highlights the prothrombotic potential for the drug when used above normal dosing range, and is therefore of great guidance for those initiating it as a fertility treatment, or in unlicensed use.

Measuring the benefit of 4 years of intravitreal ranibizumab treatment for neovascular age-related macular degeneration.

AIM: To analyse the benefit of intravitreal ranibizumab over 4 years for patients with neovascular age-related macular degeneration (AMD). METHODS: A retrospective case note review of all patients who started treatment between August 2007 and September 2009 in our unit, minimum follow-up 2 years, maximum 4 years. The main outcome measures were: numbers of patients with different levels of vision, changes in visual acuity, number of treatments and numbers remaining under follow-up. RESULTS: 1086 eyes of 1017 patients received treatment. Numbers of patients remaining under follow-up were 892/1017 (87.71%) at 12 months, 730/1017 (71.78%) at 24 months, 468/730 (64.11%) at 36 months and 110/217 (50.69%) at 48 months. The main reasons for patients no longer being under follow-up were the consequences of old age or transfer of care. 50% of patients had 6/18 or better over 4 years. Patients received on average 5.79 ± 2.53, 9.15 ± 3.79, 11.22 ± 4.92 and 13.7 ± 7.84 injections by 12, 24, 36 and 48 months, respectively. CONCLUSIONS: We suggest that the numbers of patients with a particular level of vision may best reflect the actual benefit of AMD treatment provided by a service. Long-term follow-up is required as only 72/730 (10%) had been discharged at 36 months, half of whom had good vision of greater than 60 letters. 83% and 65% of patients needed treatment in the third and fourth year. Follow-up may be for the rest of the patients' life or at some point they may no longer be well enough to attend.

Advances in the diagnosis and treatment of acanthamoeba keratitis.

This paper aims to review the recent literature describing Acanthamoeba keratitis and outline current thoughts on pathogenesis, diagnosis, and treatment as well as currently emerging diagnostic and treatment modalities.

Acute myeloid leukaemia presenting as gaze palsy.

The most frequent initial ocular manifestation of acute myeloid leukaemia (AML) is retinal involvement. Here, we report an unusual case of AML associated with a pontine chloroma presenting with gaze palsy as the initial symptom. A 77-year-old Caucasian man presented to the Eye Casualty complaining of a one-day history of blurred vision. On examination, his face was turned to the left, both eyes were fixed in dextroversion and the patient demonstrated left gaze palsy associated with left motor neurone VII palsy. Baseline blood investigations revealed leucocytosis with 60% circulating myeloblasts. A bone marrow biopsy confirmed the diagnosis of myelomonocytic leukaemia. A CT scan showed a well-circumscribed lesion in the dorsal pons, most likely representing a chloroma. Chloromas or myeloblastomas related to AML are localised extramedullary tumours composed of leukaemic myeloid cells. Chloromas may be present at the time of the initial diagnosis of leukaemia or may precede the diagnosis by 1 month to 2 years; however, their occurrence in the central nervous system is rare, comprising 1-6% of all chloromas. This case illustrates the many different ways that AML can manifest itself in the eyes, and ophthalmologists should be aware of the great variety of presenting symptoms in undiagnosed AML.