Comparison of Macular Thickness in Patients with Keratoconus and Control Subjects Using the Cirrus HD-OCT.

PURPOSE: The aim of the present study was to compare macular thickness in patients with keratoconus (KC) with macular thickness in healthy subjects. SUBJECTS AND METHODS: Twenty-six patients with KC and 52 control subjects were included. The macular structure was evaluated using a Zeiss Cirrus HD-OCT. The scan pattern used was 512 × 128, which covers an area of approximately 6 × 6 mm of the retina. The cube volume was assessed as well as macular thickness in each of the 9 sectors defined by the software. RESULTS: The mean signal strength was significantly lower in the KC group (mean 8.4, range 6-10) compared with the control group (mean 9.7, range 7-10), P < 0.0001 (unpaired t-test). There were no significant differences in cube volume (unpaired t-test), cube average thickness, or macular thickness between the KC group and the control subjects in any of the retinal locations (one-way ANOVA). CONCLUSION: Macular structure as measured by OCT in KC subjects should be expected to lie within the range of age and sex matched controls.

Evaluation of the anterior chamber angle in keratoconus and normal subjects.

PURPOSE: To evaluate the anterior chamber angle in keratoconus eyes by use of the Visante™ OCT and Orbscan™ II. METHODS: Anterior chamber angle was measured with the Visante™ OCT and Orbscan™ II in 52 subjects, 26 KC subjects and 26 age and control subjects. RESULTS: When comparing the nasal and temporal angles obtained with the two techniques no correlation was found (R(2) always below 0.01) in either the control subjects or in the KC subjects. Despite this, there was an overall statistically significant difference in mean anterior chamber angles (p<0.001) between Visante™ OCT and Orbscan™ II. There was no statistical difference (p>0.05) between nasal and temporal anterior chamber angles when comparing controls and KC subjects with either of the two instruments. In general, the Visante™ OCT gave a smaller estimate of the anterior chamber angle. CONCLUSION: The values from the Visante™ OCT and Orbscan™ II cannot be interchanged since the difference in measurement of the anterior chamber angle was significantly different between the two instruments.

Vertical imbalance induced by prism-ballasted soft toric contact lenses fitted unilaterally.

Fitting a prism-ballasted soft toric contact lens unilaterally may potentially induce a vergence error that the subject cannot compensate. In the present study, a prism-ballasted (1.5Delta base down) soft toric contact lens was fitted in the right eye only of 10 subjects with normal binocular vision. The effect on binocular vision was evaluated by measuring vertical phoria adaptation and vertical fixation disparity adaptation. The results show that the vertical vergence error induced was well compensated and fully adapted to. However, care might be needed when fitting these lenses unilaterally in subjects with vertical phoria-related problems.

Fibre optic spectrophotometry for the in vitro evaluation of ultraviolet radiation (UVR) spectral transmittance of rabbit corneas.

A fibre optic spectrophotometer front-end system for measuring corneas to overcome shortcomings associated with existing instruments was tested. The system allowed prompt measurement postmortem, minimizing beam pathlength to reduce the effects of scatter and unwanted refraction and eliminated optical interfaces and cuvette media. Rabbit corneas were excised immediately postmortem and placed on a detecting fibre optic coupled to an Ocean Optics spectrophotometer and illuminated by a deuterium-halogen source. The compact instrument with its small beam size allowed tissue profiling at test points across the corneal surface and efficient interchange for comparison of different tissues. This simplified system operation allowed rapid tissue altering to study induced changes on transmittance. The corneal transmittance data showed a consistent sharp cut-off at 320 nm in the ultraviolet radiation (UVR) spectrum, which decayed rapidly from postmortem swelling. Inter- and intra-corneal consistency was demonstrated by comparing data from different regions of the same cornea and those from opposite eyes. Changes to the spectra, particularly in the UVB below 300 nm, were evident when the corneal epithelium was removed, indicating that this layer is not the only corneal UVR filter. The new system reduced much of the variability associated with previous methods, as it rapidly measured corneal transmittance postmortem. Data are in broad agreement with published transmittance curves. The removal of the corneal epithelium revealed a substantial stromal contribution to the overall corneal UVR absorption, suggesting that corneas with pathologically or iatrogenically thinned stromas are less effective UVR blockers.

A novel sensor array for field based ocular ultraviolet radiation measurements.

The intensification of terrestrial solar ultraviolet radiation (UVR) due to the diminution of the ozone layer has promoted a variety of research into establishing the impact of this elevated potential dose of UVR on biological tissues. Certain anterior ocular tissues have been found to be susceptible to damage by incident UVR and potentially blinding diseases such as pterygium are thought to be a direct result of absorbed UVR at the nasal limbus. There is a need for more accurate quantification and localisation of incident UVR at the anterior ocular surface. A novel solar blind photodiode sensor array system has been designed, constructed and tested for this purpose. Initial measurements to quantify the irradiance across the anterior ocular surface within the latitudes known as the 'pterygium belt' provide us with a set of core data for different head orientations and tilt angles and indicate the accuracy and stability of the system.

Proliferation rate of rabbit corneal epithelium during overnight rigid contact lens wear.

PURPOSE: To examine cell proliferation of the normal corneal epithelium and during extended rigid gas-permeable (RGP) lens wear. METHODS: Twenty-three New Zealand White rabbits were fitted unilaterally with either a low oxygen transmissible (Dk/t) or hyper-Dk/t RGP lens, with the other eye serving as a control. The rabbits were injected with 5-bromo-2-deoxyuridine (BrdU) 24-hours later and killed at three time points: 1, 3, and 7 days after injection. Corneas were processed for immunocytochemistry, and sequential digital images were taken from the superior limbus to the central epithelium with an epifluorescence microscope. The total number of BrdU-labeled cell pairs was quantified. RESULTS: The limbus in normal corneas was significantly less populated with BrdU-labeled cells than the central and peripheral epithelium (P < 0.05). The peripheral epithelium adjacent to the limbus was marked by a peak of labeled cells (P < 0.05). Both types of RGP lenses produced an increase in BrdU labeling in the limbus and a dramatic decrease in the central epithelium (80% for low Dk/t, 37% for hyper Dk/t). At day 3 and 7 after BrdU injection, the low-Dk/t lens continued to show decreased BrdU labeling centrally, whereas the limbus remained increased. Hyper-Dk/t lens wear however, showed persistent limbal elevation but equivalent numbers of BrdU-labeled cells centrally at days 3 and 7, compared with control corneas. Keratocytes unexpectedly showed BrdU labeling during RGP lens wear. CONCLUSIONS: Limbus, peripheral, and central epithelium were characterized by different proliferation rates in the normal rabbit cornea. RGP lens wear significantly altered the homeostatic proliferation pattern of the epithelium with the low-Dk/t lens having the most dramatic effect. RGP contact lens wear appears to stimulate proliferation of keratocytes.

Epithelial plugs in radial keratotomy: the origin of incisional keratitis?

PURPOSE: Incisions in radial keratotomy (RK) patients were examined histopathologically to explore the cause of delayed infections occurring following this procedure. METHODS: Four corneas from two successful RK patients were obtained postmortem and 1 cornea from an unsuccessful RK was collected following lamellar keratoplasty. The tissue was prepared for light and transmission electron microscopy. RESULTS: All incisions examined contained an epithelial plug. The average depth of the plugs for left and right corneas in the 2 successful cases were 142.58 microm (range: 36.46-183.04 microm) and 58.44 microm (range: 29.27-115.66 microm), whereas the unsuccessful case these measurements were 121.06 microm (range: 70.03-172.01 microm). In the successful cases, the plugs were on average 4.2 cells deep (range: 2-5) in one case and for the other the plugs were 8.78 cells deep (range: 1.5-11.5) and 2.72 cells wide (range: 2-4). In the unsuccessful case the plugs were on average 6.89 cells deep (range: 5-11) and 8.56 cells wide (range: 4-13). The average epithelial thickness, measured 200 microm on either side away from the plug, was 47.11 microm and 55.09 microm for the successful cases, and 27.52 microm for the unsuccessful case. Degenerate cells were often observed within the plug and along the overlying surface. Lamellae cut during surgery remained severed in all corneas observed. The stroma adjacent to the incision contained an elevated number of stromal cells (8%-78%). CONCLUSIONS: Healing did not include repair of anterior limiting lamina or stromal lamellae, which all remained severed in all incisions observed. Epithelial plugs were invariably present in all incisions regardless of clinical outcome, thus, increasing the distance a basal cell travels to reach the epithelial surface by 2 to 4 times. Since the epithelial cell has a limited life, it is hypothesized that cells originating in the plug may die before reaching the surface, thus, leading to intermittent loss of surface integrity. The loss of the epithelial barrier allows invasion of microorganisms and the delayed onset of keratitis. The larger the plug the greater the possibility of surface defects and resultant infection.

A descriptive and quantitative study of the keratocytes of the corneal stroma of albino rabbits using transmission electron microscopy.

The present morphometric study was designed to assess the dimensions and shape of keratocytes and their nuclei by transmission electron microscopy, and to assess these features in relation to the stromal lamellae. Corneas from 10 albino rabbits were fixed in 2% glutaraldehyde in cacodylate buffer (pH 7.4, 300 mOsm/kg) and embedded in Spurr's epoxy resin. Both transverse and coronal thin sections through the corneal stroma were prepared. The stromal lamellae had an average thickness of 2.45+/-1.15 microm. The average cell thickness of the keratocytes was 1.34+/-0.46 microm (range 0.49-4.76 microm), with the apparent cell thickness being related to the average anterior-posterior thickness of the adjacent lamellae (r = 0.424, P = 0.001)). The relative length and thickness of the cell nucleus, in transverse section, was measured to be 0.65+/-0.13 and 0.76+/-0.10 of the cell body section respectively. As assessed by planimetry, the area of the keratocyte cell body viewed in coronal section was 292+/-118 microm2, with a nucleus-to-cytoplasm ratio of 0.437+/-0.295. The electron micrographs confirmed the presence of gap junctions between keratocyte cell processes, and the occasional presence of centrioles in the cells. Some keratocyte processes were observed to extend from one face of the lamellae to the other, suggesting anterior-to-posterior cell communication. These studies indicate that the keratocyte cell thickness is influenced by the physical pressure exerted by adjacent stromal lamellae. The cell nucleus, while a dominant feature in transverse section, has a normal size in relation to the cell cytoplasm when viewed in coronal section.

Quantification of the ultraviolet radiation (UVR) field in the human eye in vivo using novel instrumentation and the potential benefits of UVR blocking hydrogel contact lens.

BACKGROUND/AIMS: Certain degenerative eye conditions occur predominantly nasally, at the limbal region, and are associated with solar ultraviolet radiation (UVR) induced damage. The relative contribution to the in vivo ocular flux of (a) the reflection of UVR incident on the skin of the nose onto the nasal limbus, and (b) the focusing of UVR incident on the temporal side of the cornea onto the nasal limbus were examined. METHODS: A novel photodiode sensor array was used to measure the UVR field across the eye. In addition, a novel spectrometer set-up was used to measure the spectrum of radiation refracted across the cornea. The efficacy of UVR blocking hydrogel contact lenses in filtering incident UVR was assessed in vivo. RESULTS: Qualitative and quantitative data indicated an increase nasally of UVR. Photodiode readings showed a net UVR increase from the temporal to the nasal side. Transmission curves showed that most UVR incident on the limbal region is either absorbed by, or transmitted through, the ocular tissues. This radiation is filtered by UVR blocking soft contact lens. CONCLUSIONS: An increased UVR flux on the nasal side of the eye, due to reflection off the nasal skin, was identified in vivo. Any UVR passing through the cornea is either absorbed by the conjunctiva and/or transmitted through it onto the sclera where it is absorbed. UVR blocking hydrogel contact lenses can eliminate these sources of UVR.

The acinar and ductal organisation of the tarsal accessory lacrimal gland of Wolfring in rabbit eyelid.

The purpose of this study was to objectively assess the tarsal accessory lacrimal gland of Wolfring and its excretory duct by transmission electron microscopy (TEM). The upper eyelid of 6 female grey rabbits (2 kg) was fixed in the fully extended configuration with buffered glutaraldehyde. At the tarsal/orbital portion of the palpebral conjunctiva, a series of prominent acinar glands were located by both light microscopy and TEM. Cells within the acini were characterised by apical tight junctions and desmosomal connections as well as abundant intra-cytoplasmic osmophillic (secretory) granules. The apical surfaces were profusely decorated with microvilli-like extensions. In the vicinity of the acini, and traversing over several millimetres of adjacent sub-epithelial parenchyma and epithelium, was an extensive system of duct-like spaces lined with secretory cells decorated with microvilli. These ducts run a tortuous course within the palpebral conjunctival epithelium leading to crypt-like termination's along the eyelid inner surface. The tarsal accessory lacrimal gland of Wolfring thus has an acinar structure similar to the main lacrimal glands, and its ducts are lined by secretory cells along the entire tortuous course towards the palpebral conjunctival surface, where the ducts emerge at multiple points at the tarsal/orbital portion of the surface.

Fuchs' endothelial dystrophy: a fresh look at an aging disease.

The increasing number or corneal and intraocular surgeries performed together with longer life expectancy, elevates the risk for developing symptomatic Fuchs' endothelial dystrophy (FED). This article reviews the current understanding of FED, and, in addition, a case of early FED is presented clinically and histopathologically. Two FED corneas from one patient were examined histopathologically using an established histological protocol for light and electron microscopy. FED is an inherited autosomal dominant corneal endothelial disorder with incomplete penetrance that is up to 3 times less likely to develop in men. Treatment options are primarily palliative while surgical intervention routinely involves a penetrating keratoplasty. In this disease process the endothelium produces excessive amounts of basement membrane material of an abnormal composition resulting in the formation of a posterior collagenous layer. Extreme accumulations of this material created mushroom-like formations, guttae, projecting into the anterior chamber. The endothelial cells were extremely thinned over the guttae, to the point where the cells may provide little more than barrier function. Despite a presumably compromised endothelial pump the corneas appeared relatively free of edema clinically and histopathologically. However, some edematous pockets deep in the basal epithelial layer were present suggesting that epithelial involvement occurs at an early stage in the disease. An early diagnosis of FED will help patients and surgeons to better elect optimal surgical timing and procedures. The current trend is to intervene surgically before the patient reaches the painful end-stage. Interestingly, in the case examined, the endothelium presumably provided only a barrier function over large areas with an apparently reduced contribution from the endothelial fluid pump and yet the corneas remained relatively clear. Future research may confirm that decompensation occurs only when complete endothelial coverage is lost. If the endothelial barrier function is more important to corneal transparency than the endothelial pump function in FED, then the relative combination of these two functions in the normal cornea should also be reassessed.

A return to primitive practice? Radial keratotomy revisited.

Recently, a refractive surgeon was quoted in the national and professional press as proposing that radial keratotomy (RK) is to be preferred over laser procedures, such as photorefractive keratectomy (PRK) and laser assisted in situ keratomileusis (LASIK). The rationale for this public recommendation was that the RK procedure achieves better visual results and fewer complications than the laser procedures. Peer reviewed literature on these refractive procedures was surveyed to establish the validity of such a statement and it was found that current data do not support the notion that RK results in better visual outcomes than PRK and LASIK The true incidence of complications is difficult to establish. However, when the post procedure chronic effects are compared between RK, PRK and LA SIK, it becomes apparent that the post-RK patient pays the highest price, by a large margin, in visual quality impairment and corneal health. Although the visual acuity outcomes for low to moderate myopes, when corrected by any of the three refractive procedures considered here, are not dramatically different, we concluded that RK is not the preferred methodology because of its associated chronic visual and corneal health complications.

Keratocytes: no more the quiet cells.

BACKGROUND: In the past, the keratocytes of the adult cornea have been characterized as quiescent cells populating the stroma. Recent research and the introduction of laser refractive procedures have forced us to reassess this notion. METHODS: By reviewing recent, pertinent papers, an attempt was made to give an overview of the new information the scientific community is learning about keratocytes. This overview assesses the heightened interest in the keratocytes, while maintaining a clinical perspective. Where applicable, this information was tied in with our own laboratory observations. RESULTS: It is becoming increasingly clear that keratocytes may play a vital role in regulating the stromal constituents, while also providing structural stability in maintaining the interlamellar organization and, thus, promote corneal transparency. Keratocytes form a communicating network of cells linked in a anterior-posterior fashion, as well as laterally. This ability to communicate appears instrumental in triggering and orchestrating the corneal response in wound healing. External corneal injury, such as epithelial debridement and excimer laser exposure, can cause profound anterior keratocyte loss. These cells are replaced by aggressive stromal cells, which may play an important role in the formation of scar tissue and corneal haze. CONCLUSION: Keratocytes play an important role in both the healthy and the injured cornea. It appears that the improved outcomes of laser refractive procedures will--to a large extent--depend on our ability to maintain keratocyte health, while also controlling the negative effects of cells replacing injured or dead keratocytes.

Shrinkage and distortion of the rabbit corneal endothelial cell mosaic caused by a high osmolality glutaraldehyde-formaldehyde fixative compared to glutaraldehyde.

The purpose of this study was to quantitatively compare cell dimensions and cell layer organization of the corneal endothelium after chemical fixation. Rabbit corneas (9-10 weeks of age) were prepared immediately postmortem for transmission electron microscopy (TEM) and scanning electron microscopy (SEM) using either a widely used high osmolality fixative (glutaraldehyde-formaldehyde, after Karnovsky; 1% formaldehyde, 2.5% glutaraldehyde, 0.1 M cacodylate, pH 7.6, 850 mOsm/kg) or a glutaraldehyde fixative (2% glutaraldehyde in 80 mM cacodylate, pH 7.4, 330 mOsm/kg). With the glutaraldehyde-formaldehyde fixative, TEM revealed gross shrinkage (up to 40%) and distortion of the cytoplasm and organelles, while the regions of the cell-cell junctions were not attenuated but included dilated extracellular space. With the glutaraldehyde fixative, TEM also revealed shrinkage but the cytoplasm was less compact than with the high osmolality fixative. The overall cell shrinkage and relative accentuation of the cell-cell borders was confirmed by SEM, which also revealed that the 11 to 20% area shrinkage was also related to the number of cell sides.

Ultraviolet radiation revisited.

PURPOSE AND METHODS: It is likely that we currently receive a greater lifetime exposure to ultraviolet radiation (UVR) than earlier generations due to increased UVR reaching the earth's surface, our longer life expectancy, and increased activities in UV intense environments. This elevated UVR exposure is likely to lead to a higher incidence of acute and chronic ocular and skin radiation trauma. We reviewed the evidence in the current literature supporting these assertions as well as reports of preventive strategies for blocking UVR. RESULTS: Hawaii is the most UV-intense location on earth as it has the lowest ozone thickness values ever recorded outside the Antarctic zone. It is anticipated that the overall ozone depletion will continue into the next millennium. Significant evidence suggests a correlation between UVR exposure and conjunctival pterygium, photokeratitis, climatic droplet keratopathy and cataracts. The incidence of skin cancer is also on the rise as a result of the increased amount of UVR reaching the earth secondary to the thinning ozone. CONCLUSIONS: There are compelling reasons to counsel our patients on the adverse effects of UVR and to offer them the various options available for UV protection. Sunglasses and UV blocking ophthalmic lenses traditionally have been the most commonly selected forms of UVR protection. The UV blocking hydrogel contact lens, a recent addition to our armamentarium, is a means of blocking UVR.

Impact of glutaraldehyde versus glutaraldehyde-formaldehyde fixative on cell organization in fish corneal epithelium.

The purpose of this study was to examine the impact of a low osmolality glutaraldehyde fixative and a high osmolality glutaraldehyde-formaldehyde fixative on the structural organization of a tissue that could be exposed to low and high osmolality environments. The corneas of freshwater trout were prepared for transmission and scanning electron microscopy using either a fixative of 2% glutaraldehyde in 60 mM cacodylate buffer (pH 7.8, 260 mOsm/l) or a fixative prepared by adding 2.5% glutaraldehyde to a solution of 1% formaldehyde and buffering the solution with 0.1 M cacodylate (pH 7.6, 850 mOsm/l; Karnovsky-type fixative). The corneal epithelial cell layer thickness was greater after glutaraldehyde compared to glutaraldehyde-formaldehyde fixation (67 vs 55 microm), as was the thickness of the superficial cells (5.1 vs 3.4 microm) and basal cells (43 vs 38 microm). The intermediate (wing) cells of the epithelium were, however, less thick after glutaraldehyde fixation (15 vs 18 microm). The width of the squamous, intermediate and basal cells was greater following glutaraldehyde fixation with the effect being greatest in the superficial layers and insignificant at the level of the basal cells. The results show that chemical fixatives with extremes of osmolality cannot only produce different cell sizes in a tissue but also determine the overall organization of the cells in a positional-dependent fashion.

Effect of corticosteroids on rabbits corneal keratocytes after photorefractive keratectomy.

BACKGROUND: To determine the corticosteroid effect on the activity and repopulation of keratocytes after photorefractive keratectomy (PRK). METHODS: A 193-nm excimer laser (VISX Twenty/Twenty) created a central ablation depth of 22 microns (diameter:5 nm) on 22 corneas of 16 albino rabbits. Two ablated eyes were examined 6 hours following PRK. Twelve eyes received no postoperative corticosteroids and eight were treated with topical fluoromethalone for 3 months. Corneas were examined 1, 3, 6, and 12 months after PRK by immunofluorescence and transmission electron microscopy. RESULTS: Corticosteroids reduced haze (p=0.02), but all corneas (treated or untreated) cleared 6 months after PRK. Keratocytes were absent from the anterior 100 microns of the stroma 6 hours after PRK. However, the number and activity of keratocytes were significantly greater in this area in untreated corneas at 1 month and then gradually decreased. By 6 and 12 months, the number of keratocytes approached controls. Treated corneas had fewer keratocytes than either controls or untreated eyes (p<0.01) and by 3 months, a subepithelial acellular zone of 30 to 50 microns thickness appeared and persisted until at last 12 months after PRK. CONCLUSIONS: Corticosteroids have a transient effect in reducing haze and seem to inhibit keratocyte movement, leading to an acellular subepithelial region beneath the ablated area.

Clinical assessment of ocular response to a multipurpose contact lens care solution.

The issue of possible adverse effects of contact lens care solutions on ocular health has been raised in the literature. Possible effects of a multipurpose contact lens care solution (Bausch & Lomb ReNu) on eight measures of ocular function were evaluated relative to the effects of physiological saline (Bausch & Lomb Sensitive Eyes). In a randomized, two-treatment, crossover design, all subjects were treated with each of the two solutions on successive weeks. In 73 subjects, comprised of contact lens and non-lens wearers, tear break-up time was measured using the keratometer mire and fluorescein techniques. Measures of autonomic function were vertical palpebral aperture size, amplitude of accommodation, intraocular pressure, pupil size, conjunctival injection, and pupil reactivity. The results indicated that this multipurpose solution provoked no adverse ocular response as determined by the tear break-up time and autonomic functions, and the multipurpose solution was clinically equivalent to physiological saline. These results apply to both contact lens wearers and non-lens wearers. Additional findings speak of the unreliability of the fluorescein method for measuring tear break-up time.