Pediatric ocular surface infections: a 5-year review of demographics, clinical features, risk factors, microbiological results, and treatment.

PURPOSE: To evaluate the clinical and microbiological profiles of pediatric patients with ocular surface infections requiring corneal or conjunctival scraping for diagnosis. METHODS: The medical records of 138 consecutive patients aged 18 years or younger who had undergone corneal or conjunctival scraping over a 5-year-period in a tertiary ophthalmic center were reviewed. Demographics, clinical features, risk factors, microbiological results, and treatment were recorded. RESULTS: Ocular surface infections were classified into 4 groups: infectious keratitis (group 1); blepharokeratoconjunctivitis (group 2); conjunctivitis (group 3); and congenital nasolacrimal duct obstruction or dacryocystitis (group 4). The groups had different mean ages of presentation, with group 4 presenting the youngest at 2 years and group 1 presenting the oldest at 14 years. Contact lens wear and blepharitis were the major risk factors. The positive culture rate was 60.9%, of which 65.5% were Gram-positive organisms. Coagulase-negative staphylococci were the most common organisms (23.2%), followed by Pseudomonas aeruginosa (9.4%) and Staphylococcus aureus (8.0%). Microbial yield was highest in group 1 (86%) and lowest in group 3 (38.6%). There were 9 orthokeratology-related infectious keratitis cases (18%) and 9 chlamydial ophthalmia neonatorum cases isolated. CONCLUSIONS: With increasing contact lens wear in the pediatric and adolescent populations and the common occurrence of blepharokeratoconjunctivitis and staphylococcal ocular surface infections, parents and children should be highly vigilant with eyelid hygiene and contact lens practice.

Pressure-cornea-vascular index (PCVI) for predicting disease progression in normal tension glaucoma.

BACKGROUND: It has been shown that the pressure-to-cornea index (PCI), which estimates the relative effects of intraocular pressure (IOP) and central corneal thickness (CCT), may differentiate between glaucoma and non-glaucoma states. The authors investigated the utility of the pressure-cornea-vascular index (PCVI) in predicting field-progression in patients with normal tension glaucoma (NTG). METHODS: PCVI was constructed from PCI (maximum IOP/CCT(3)) extended with risk factors identified as associated with field-progression in a prospective NTG cohort. Receiver operator characteristics and area under the curve (AUC) of a range of constructs were calculated to arrive at an optimal PCVI. RESULTS: 415 eyes from 415 NTG subjects (184 field-progressed and 231 field-stable) with 3 years of follow-up were analysed. The construct PCVI=(maximum pretreatment office IOP × age at presentation × vertical cup-to-disc ratio at presentation × (1.5 if presence of systemic hypertension; 2.5 if presence of disc haemorrhage; 3.5 if presence of both; 1.0 if none))/(CCT(3)×100) (CCT in mm) gave the highest AUC at 0.71 (95% CI 0.66 to 0.76, p<0.001). The mean PCVI were 113.1±76.8 and 69.7±39.7 for progressed and stable NTG groups, respectively (p<0.001). CONCLUSION: PCVI may be useful for predicting progression in NTG with a satisfactory AUC comparable to established scoring systems in neurovascular medicine. Validation of PCVI in other NTG cohorts, preferably of different ethnicity, is necessary. Trial registration number NCT00321386.

Graft suturing for lenticule dislocation after descemet stripping automated endothelial keratoplasty.

PURPOSE: To report the mid-term outcomes of graft suturing in a patient with lenticule dislocation after Descemet stripping automated endothelial keratoplasty (DSAEK). CASE REPORT: A 78-year old woman was found to have graft dislocation involving the nasal half of the cornea after uneventful DSAEK. Graft repositioning, refilling the anterior chamber with air, and placement of four full-thickness 10/0 nylon sutures over the detached area were performed two weeks after the initial surgery. The sutures were removed 6 weeks later. Serial specular microscopy and anterior segment optical coherence tomography were performed. At 18 months, there was good lenticule apposition and a clear graft. CONCLUSION: Anchoring sutures seem to be effective for management of graft detachment following DSAEK.

Simvastatin and disease stabilization in normal tension glaucoma: a cohort study.

PURPOSE: To investigate whether simvastatin use is associated with visual field (VF) stabilization in patients with normal tension glaucoma (NTG). DESIGN: Prospective cohort study (ClinicalTrials.gov Identifier: NCT00321386). PARTICIPANTS: A total of 256 eyes from 256 Chinese subjects with NTG. METHODS: Patients were followed up at 4-month intervals for 36 months for VF progression per Anderson's criteria. Clinical parameters were checked for association with progression in multivariate analysis. MAIN OUTCOME MEASURES: The primary outcome was the association between simvastatin use and VF progression. RESULTS: Thirty-one patients (12.1%) were taking simvastatin (statin+), and 225 patients (87.9%) were not taking simvastatin (statin-). Baseline age, gender, untreated intraocular pressure, VF indices, vertical cup-to-disc ratio, and central corneal thickness (CCT) were comparable between the 2 groups. There were significantly more patients with a history of hypercholesterolemia, systemic hypertension, and ischemic heart disease in the statin+ group. A total of 121 patients (47.3%) showed evidence of VF progression (mean rate of mean deviation loss was -0.30 decibel per year) during the 36 months of follow-up. Simvastatin use was among 8 of 121 patients (6.6%) who progressed compared with 23 of 135 patients (17.0%) who did not progress (P = 0.011). Logistic regression revealed that history of disc hemorrhage (relative risk [RR] 3.26; 95% confidence interval [CI], 1.21-8.76; P = 0.019), history of cerebrovascular accidents (RR 2.28; 95% CI, 1.03-5.06; P = 0.043), and baseline age (per 10 years older; RR 1.38; 95% CI, 1.08-1.76; P = 0.009) were significant risk factors for VF progression, whereas simvastatin use conferred a protective effect (RR 0.36; 95% CI, 0.14-0.91; P = 0.030). CONCLUSIONS: Simvastatin use may be associated with VF stabilization in patients with NTG. A larger scale randomized controlled trial and cost-effectiveness analyses seem warranted.

Silent cerebral infarct and visual field progression in newly diagnosed normal-tension glaucoma: a cohort study.

PURPOSE: To investigate whether the presence of silent cerebral infarct (SCI) is related to field progression in patients with newly diagnosed normal-tension glaucoma (NTG). DESIGN: Prospective cohort study. PARTICIPANTS: A total of 286 eyes from 286 NTG patients: 64 with SCI (SCI+) and 222 without SCI (SCI-). METHODS: Patients were assigned to the SCI+ or SCI- group depending on the presence of SCI as detected by cranial computed tomography scan at baseline. Patients were followed-up at 4-month intervals for 36 months for visual field progression as per Anderson's criteria. MAIN OUTCOME MEASURES: The primary outcome was the association between SCI and field progression. Secondary outcomes include the prevalence of SCI in NTG patients and other risk factors associated with progression. RESULTS: There were no significant differences in the baseline intraocular pressures (IOPs), fluctuation amplitude of pretreatment IOP, baseline visual acuity, vertical cup-to-disc ratio, vertical disc diameter, presenting field indices, and central corneal thickness (CCT) between the 2 groups. Patients with SCI were significantly older compared with SCI- patients (72.4+/-10.7 vs. 63.2+/-14.2 years; P<0.001). Univariate analyses revealed age, fluctuation amplitude of pretreatment IOP, thinner CCT, presence of disc hemorrhage, systemic hypertension, arrhythmia, and SCI were significant for field progression. Silent cerebral infarct was present in 29.6% of field-progressed subjects versus 15.3% of field-stable subjects (P = 0.004). Kaplan-Meier survival analysis revealed that 65.6% of SCI+ versus 45.9% of SCI- patients had progressed (P = 0.003). Cox proportional hazards regression analysis showed disc hemorrhage (hazard ratio [HR], 2.28; 95% confidence interval [CI], 1.54-3.37; P<0.001), SCI (HR, 1.61; 95% CI, 1.09-2.36; P = 0.016), systemic hypertension (HR, 1.48; 95% CI, 1.04-2.10; P = 0.029), and CCT (per 30 mum of thinning; HR, 1.35; 95% CI, 1.16-1.75; P<0.001) were associated with field progression. Other variables significant in the univariate analysis were not significant in the regression model. The most common location of SCI was at the basal ganglia. CONCLUSIONS: Presence of SCI may be an independent risk factor for visual field progression in patients with NTG.

Diamond burr polishing for recurrent corneal erosions: results from a prospective randomized controlled trial.

PURPOSE: To evaluate the use of diamond burr polishing as an in-office treatment for recurrent corneal erosion (RCE). METHODS: A double-masked randomized controlled trial was conducted. Patients with RCE secondary to trauma or anterior basement membrane dystrophy underwent epithelial debridement (ED) or diamond burr superficial keratectomy (DBSK) at the slit lamp. Patients were followed up for 6 months, and the recurrence rates of RCE and visual outcomes were compared. RESULTS: Forty-eight eyes of 48 patients were recruited. The mean +/- SD age was 38.3 +/- 12.9 years. Twenty-five patients underwent DBSK, and 23 patients received ED alone. There was no significant difference in the baseline demographics between the 2 groups. Kaplan-Meier survival analysis showed significantly less major and minor recurrences and less need for repeated surgical interventions in the DBSK group compared with the ED group (P < 0.001). Eyes in the DBSK group also had significantly lower mean magnitude of astigmatism after treatment compared to the ED group (P = 0.021). CONCLUSION: Diamond burr polishing is a safe, convenient, and inexpensive treatment option for the management of RCE and resulted in better outcomes compared to simple epithelial debridement.

Repeatability and reproducibility of pachymetric mapping with Visante anterior segment-optical coherence tomography.

PURPOSE: To determine the repeatability and reproducibility of central and peripheral corneal pachymetry mapping with anterior segment-optical coherence tomography (AS-OCT). METHODS: An observational cross-sectional study involving two groups: 27 healthy eyes and 20 eyes with keratoconus. Each subject underwent scanning sessions with AS-OCT to determine intraobserver repeatability, interobserver reproducibility, and additionally for healthy eyes, intersession reproducibility for different regions of the cornea up to a 10-mm diameter. Main outcome measures were reproducibility and repeatability coefficients, intraclass correlation coefficients, and coefficients of variation of the average central (0-2 mm), pericentral (2-5 mm), transitional (5-7 mm), and peripheral (7-10 mm) corneal thicknesses generated by the Visante AS-OCT (Carl Zeiss Meditec, Inc., Dublin, CA) pachymetric mapping protocol. RESULTS: The coefficients of repeatability were less than 2% in healthy subjects and less than 3% in patients with keratoconus. The reproducibility coefficients were less than 2% and 4% in healthy subjects and patients with keratoconus, respectively. There was no significant difference between scans obtained by different observers or during different visits. The intraclass correlation coefficients were greater than 0.99 and 0.97 in healthy subjects and patients with keratoconus, respectively. CONCLUSIONS: With the pachymetric mapping protocol of Visante AS-OCT, these results suggest that central and peripheral corneal thickness measurements in healthy subjects and in eyes with keratoconus are repeatable and reproducible.

Good visual outcome after prompt treatment of acanthamoeba keratitis associated with overnight orthokeratology lens wear.

PURPOSE: To describe a patient with a good visual outcome after prompt treatment of Acanthamoeba keratitis as a complication of overnight orthokeratology lens wear. METHODS: Interventional case report. RESULTS: A 9-year-old boy experienced pain, photophobia, and redness in his right eye 3 days after visiting a swimming pool. He had been wearing overnight orthokeratology lenses for 5 months for the correction of moderate myopia in both eyes. On examination, best-corrected visual acuity in the right eye was 20/40. A diagnosis of Acanthamoeba keratitis with the presence of the classic feature of perineural infiltrates was made. The patient responded well to treatment with polyhexamethylene biguanide and propamidine isethionate (Brolene). Culture of corneal scrapings and contact lens solution showed heavy growth of Acanthamoeba. Treatment was tapered gradually during the next 4 months, and the final best-corrected visual acuity was 20/25. CONCLUSIONS: Acanthamoeba keratitis may be a vision-threatening complication associated with overnight orthokeratology lens wear. It is essential for eye care professionals to fully explain and warn parents of the potential downsides that may be associated with orthokeratology. Ophthalmologists should have a high level of suspicion of this complication because prompt diagnosis and treatment can result in good visual outcome.

Surgical management of double-head pterygium by using a novel technique: conjunctival rotational autograft combined with conjunctival autograft.

PURPOSE: To describe a novel technique for the surgical management of double-head pterygium and to evaluate its safety and efficacy. METHODS: A prospective noncomparative interventional case series was conducted. Patients with primary double-head pterygium underwent pterygium excision, followed by conjunctival rotational autograft (CRA) combined with conjunctival autograft (CA). CRA was harvested from the larger pterygium and placed over the bare scleral defect of the smaller pterygium with 180-degree rotation. The bare scleral defect of the larger pterygium was covered with CA harvested from the superior bulbar conjunctiva. Patients were followed up for 1 year, and the outcomes and recurrence rates were noted. RESULTS: Twenty patients were recruited into the study, of which 7 (35%) were men and 13 (65%) were women. The mean age was 63.8 years. No intraoperative complication was encountered. Postoperatively, there was significant improvement in best-corrected visual acuity (P = 0.005) and reduction in magnitude of astigmatism (P = 0.016). At 1 year after operation, there were 7 cases of recurrence (35%), but 4 were 1 mm. The main postoperative complication was persistent CRA injection in 9 cases. CONCLUSIONS: CRA combined with CA is a safe alternative in the management of double-head pterygium. Further modifications of the surgical techniques are warranted to decrease prolonged hyperemia of the CRA.

Randomized clinical trial of the efficacy and safety of tropicamide and phenylephrine in preoperative mydriasis for phacoemulsification.

PURPOSE: To compare the mydriatic effect and safety between different concentrations of tropicamide and phenyle-phrine in preoperative mydriasis for phaco-emulsification. METHODS: Two hundred and seventeen consecutive eyes in the same number of Chinese patients undergoing phaco-emulsification under local or topical anaesthesia in a university-based eye hospital were analyzed. Patients were randomized into two groups by cluster randomization, each group receiving a different preoperative mydriatic regimen. Regimen A consisted of tropicamide 1.0% with phenylephrine 2.5%, and Regimen B consisted of tropicamide 0.5% with phenylephrine 0.5%. The main outcome measures were horizontal pupillary diameter, systolic, diastolic and pulse pressure and pulse rate. RESULTS: The group who received Regimen A attained a mean horizontal pupillary diameter of 7.00 +/- 1.06 mm. Their pupils were significantly larger than those receiving Regimen B (6.61 +/- 1.03 mm, P = 0.007). No untoward cardiovascular effects were noted in either groups. CONCLUSION: Regimen A attained better preoperative mydriasis for phacoemulsification than Regimen B. Both regimens were safe with regard to their cardiovascular effects. The combination of tropicamide 1.0% and phenylephrine 2.5% is recommended as preoperative mydriatic for phacoemulsification in Chinese patients who have darkly pigmented irides.

The use of postoperative topical mitomycin C in the treatment of recurrent conjunctival papilloma.

PURPOSE: To describe the use of postoperative topical mitomycin C (MMC) in the treatment of recurrent conjunctival papilloma. METHODS: Case report. RESULTS: We report a 26-year-old man with recurrent conjunctival papilloma despite repeated surgical excision, cauterization, and cryotherapy. He was then treated with excision by cryotherapy, followed by a 2-week course of topical MMC eyedrops prescribed at postoperative day 7 (0.02 mg/mL, four times daily). No recurrence was observed 24 months postoperatively, and no complication was observed during the follow-up period. CONCLUSION: Postoperative topical MMC may be a useful adjunct in the management of recurrent conjunctival papilloma.