Efficacy of a Topical Heparan Sulfate Mimetic Polymer on Ocular Surface Discomfort in Patients with Cogan's Epithelial Basement Membrane Dystrophy.

Purpose: Treatment of persistent ocular discomfort in patients with Cogan's epithelial basement membrane dystrophy (EBMD) is a challenge for ophthalmologists. This study aimed to determine the efficacy of a topical heparan sulfate mimetic polymer (HSMP) in reducing ocular discomfort in EBMD patients. Methods: This retrospective, noninterventional study included 22 consecutive patients in 3 tertiary ophthalmological units with spontaneous, recurrent, acute ocular pain, resistant to various topical lubricants. After EBMD diagnosis, HSMP treatment was initiated while lubricating eye drops were continued. The main study outcome was the change in ocular discomfort assessed using the ocular surface disease index (OSDI) from initiation of treatment to last follow-up visit. Results: The mean OSDI decreased from 46.7 ± 22.3 to 31.6 ± 17.4 (P < 0.001) at first visit and 32.5 ± 17.9 (P < 0.01) at last visit. The rate of patients with severe ocular surface disease (OSDI >33) decreased from 68.2% to 36.4% at first visit and 42.9% at last visit. After a median follow-up of 8.5 months, 7 (31.8%) patients discontinued the HSMP treatment due to a marked improvement in ocular surface comfort and no recurrence of ocular pain, 5 (22.7%) due to lack of efficacy, and 1 (4.5%) due to an ocular adverse event (not treatment related). Eight patients continued treatment after the last visit and 1 patient was lost to follow-up. Globally, HSMP prevented acute painful episodes in 11 (61.1%) of 18 patients followed for ∼4 months. Conclusions: Topical HSMP may be an option for alleviating ocular discomfort in patients with EBMD resistant to standard symptomatic treatments.

Persistent Impairment of Quality of Life in Patients with Herpes Simplex Keratitis.

PURPOSE: To evaluate the quality of life (QoL) in patients with quiescent herpes simplex keratitis compared with control patients without ocular herpes. DESIGN: Prospective, case-control study. PARTICIPANTS: Thirty-three patients with a unilateral and relapsing herpes simplex keratitis (HSK group) that was quiescent during evaluation (no acute episode in the past 3 months) and 66 patients with no history of HSK (control group). Both groups were age and gender matched. METHODS: Three previously validated QoL questionnaires were used in this study: the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25), Glaucoma Quality of Life 17 (Glau-QoL17) questionnaire, and Ocular Surface Disease Quality of Life (OSD-QoL) questionnaire. Each questionnaire covered various aspects of the disease. MAIN OUTCOME MEASURES: The outcomes of the 3 questionnaires were compared between groups. For the HSK group, the results were correlated to the clinical findings and the history of herpetic disease. RESULTS: The mean total questionnaire scores of the 3 QoL questionnaires were significantly lower in the HSK group compared with controls (NEI VFQ-25: 70.5±3.8 vs. 91.1±0.8, P < 0.0001; Glau-QoL17: 68.2±3.1 vs. 87.9±1.0, P < 0.0001; and OSD-QoL: 65.4±2.9 vs. 93.1±0.6, P < 0.0001, respectively). In the HSK group, the level of visual acuity (VA) in the affected eye had the greatest impact on QoL, inducing lower QoL results related to "general vision," "distance activities," "dependency," "peripheral vision," "self-image," "daily living," and "driving" dimensions. Decreased VA in the unaffected eye also negatively affected "self-image" and "driving" results. Patients with frequent HSK relapses had lower QoL related to "ocular pain" and "acknowledgement." CONCLUSIONS: Even during a quiescent phase of the disease, unilateral and relapsing HSK significantly impairs the QoL of patients to a similar level as most sight-threatening diseases. The decrease of VA has the greatest overall effect, but other factors also significantly affect QoL, such as the frequency of relapses.

Diffusion tensor magnetic resonance imaging of trigeminal nerves in relapsing herpetic keratouveitis.

BACKGROUND: Corneal hypoesthesia is the landmark of HSV and VZV keratitis and can lead to neurotrophic keratitis. Diffusion tensor imaging (DTI) is a new magnetic resonance imaging (MRI) derived technique, which offers possibilities to study axonal architecture. We aimed at assessing the potential impact of recurrent HSV or VZV-related keratitis on the axonal architecture of trigeminal nerves using DTI. DESIGN: Prospective non-interventional study. PARTICIPANTS: Twelve patients and 24 controls. METHODS: DTI using MRI of the trigeminal fibers and corneal esthesiometry using the Cochet-Bonnet esthesiometer were acquired for patients affected by unilateral and recurrent HSV or VZV-related keratitis (3 months after the last corneal inflammatory event), and control subjects with no history of ocular or neuronal disease affecting the trigeminal pathways. MAIN OUTCOME MEASURES: Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were compared between the 2 eyes of both patients and controls, and correlated with corneal esthesiometry. RESULTS: FA was lower in the trigeminal fibers ipsilateral to the affected eye compared to the non-affected side (0.39±0.02 versus 0.46±0.04, P=0.03). This difference was more important than the intra-individual variability observed in controls. Concomitantly, the asymmetry in ADC results was significantly correlated with the loss of corneal sensitivity in the affected eye. CONCLUSIONS: Corneal hypoesthesia related to HSV and VZV keratitis is associated with persistent modifications in the architecture and functionality of the trigeminal fibers. These results add further explanation to the pathogenesis of HSV and VZV-induced neurotrophic keratitis, which may occur despite an apparent quiescence of the disease.

Biometry and intraocular lens power calculation results with a new optical biometry device: comparison with the gold standard.

PURPOSE: To evaluate the agreement in axial length (AL), keratometry (K), anterior chamber depth (ACD) measurements; intraocular lens (IOL) power calculations; and predictability using a new partial coherence interferometry (PCI) optical biometer (AL-Scan) and a reference (gold standard) PCI optical biometer (IOLMaster 500). SETTING: Service d'Ophtalmologie, Hopital Bicêtre, APHP Université, Paris, France. DESIGN: Evaluation of a diagnostic device. METHODS: One eye of consecutive patients scheduled for cataract surgery was measured. Biometry was performed with the new biometer and the reference biometer. Comparisons were performed for AL, average K at 2.4 mm, ACD, IOL power calculations with the Haigis and SRK/T formulas, and postoperative predictability of the devices. A P value less than 0.05 was statistically significant. RESULTS: The study enrolled 50 patients (mean age 72.6 years±4.2 SEM). There was a good correlation between biometers for AL, K, and ACD measurements (r=0.999, r=0.933, and r=0.701, respectively) and between IOL power calculation with the Haigis formula (r=0.972) and the SRK/T formula (r=0.981). The mean absolute error (MAE) in IOL power prediction was 0.42±0.08 diopter (D) with the new biometer and 0.44±0.08 D with the reference biometer. The MAE was 0.20 D with the Haigis formula and 0.19 with the SRK/T formula (P=.36). CONCLUSION: The new PCI biometer provided valid measurements compared with the current gold standard, indicating that the new device can be used for IOL power calculations for routine cataract surgery. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Optical aberrations in patients with recurrent herpes simplex keratitis and apparently normal vision.

AIMS: To analyse high-order aberrations (HOA), modulation transfer function (MTF) and Strehl ratio in patients with a history of herpes simplex keratitis (HSK) and apparently normal vision. METHODS: Fifteen patients with a history of recurrent unilateral HSK and normal Snellen visual acuity (0 logMAR) were enrolled. Eyes with HSK (HSK group) were statistically compared with normal fellow eyes (Control group). HOA, MTF and Strehl ratio were measured using the OPD-SCAN II (Nidek Co, Gamagori, Japan) aberrometer. Measures were performed at least 3 months after the last episode of herpes. Statistical significance was indicated by p<0.05. RESULTS: Despite apparently normal vision in both eyes (as assessed by routine visual acuity charts), significantly higher total HOA, trefoil and tetrafoil were present in the HSK group compared with the Control group. The MTF and strehl ratio were lower in the HSK group compared with the Control group. In the HSK group, eyes with corneal opacities tended to present with greater optical aberrations than eyes with a clear cornea. CONCLUSIONS: Using patients as their own controls, the outcomes of this study indicate that eyes with recurrent HSK with no apparent decrease in visual acuity (0 logMAR) have significantly greater optical aberrations than eyes with no past history of herpetic disease. This outcome may explain some visual complaints of HSK patients, such as a decrease in contrast quality or reduced colour perception, compared with the unaffected contralateral eye despite apparently normal vision in both eyes.

Impairment of lacrimal secretion in the unaffected fellow eye of patients with recurrent unilateral herpetic keratitis.

PURPOSE: To assess the impact of recurrent unilateral herpetic keratitis (HK) on the tear secretion of the unaffected fellow eye. DESIGN: Prospective, noninterventional study. PARTICIPANTS AND CONTROLS: Thirty-five patients with a history of recurrent unilateral HK (clinically quiescent for at least 3 months) (HK group) and 35 patients who were age- and sex-matched with no history of corneal disease (control group). METHODS: Tear osmolarity, tear instability (tear break-up time [TBUT]), tear reflex (Schirmer's I test), and central corneal sensitivity with the Cochet-Bonnet esthesiometer (Luneau, France) were measured in the HK and control groups. MAIN OUTCOME MEASURES: Tear osmolarity, TBUT, Schirmer's I, and central corneal sensitivity were compared between the affected and unaffected eyes of the HK and control groups. RESULTS: Tear osmolarity and tear secretion reflex were similar between the affected and unaffected eyes of the HK group. Corneal sensitivity and TBUT were statistically lower in the affected eyes compared with the unaffected eyes in the HK group (P = 0.001 and P<0.001, respectively). The central corneal sensitivity of unaffected eyes in the HK group was not significantly different from that in the control group (P>0.05). The tear stability and tear secretion reflex were decreased and tear osmolarity was increased in the unaffected eyes of the HK group compared with the control group (P<0.05, all cases). The difference between unaffected and control eyes varied according to the type of HK. All 4 tests were modified in patients with neurotrophic keratitis (KN). In the keratouveitis subgroup, only corneal sensitivity was normal, whereas Schirmer's I results were also normal in patients with archipelago keratitis. Tear osmolarity was consistently affected in both eyes of herpetic patients. CONCLUSIONS: Tear function is impaired in the unaffected eyes of patients with unilateral recurrent HK, even when the disease is apparently quiescent. The higher severity of results in the unaffected fellow eye of patients with KN in comparison with other herpes subgroups suggests that recurrent HK induces a reduction in the afferent pathways of the tear secretion reflex from the affected eye, leading to tear dysfunction in the unaffected eye. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Retinal emboli in cholesterol crystal embolism.

Cholesterol crystal embolism (CCE) is a rare and severe multisystemic disorder. It results from a massive release of cholesterol crystals from widespread atherosclerotic disease. The main difference with atherosclerosis is the severity and the quantity of the embolic events that occur during the course of the disease, eventually leading to multivisceral failure and death. The symptoms are multiple and make it a diagnostic challenge. Fundoscopic examination can be of great help, showing retinal emboli in up to 25% of the cases, and has been rarely described in the ophthalmologic literature. We report the case of a 77-year-old man with acute renal failure after coronarography. Retinal emboli seen in the fundus confirmed the diagnosis of cholesterol crystal embolism and thus prevented any further invasive investigations. In this case, anticoagulants must be stopped and any further endovascular procedure proscribed. Although impossible for this patient, peritoneal dialysis should be preferred to hemodialysis because it does not need any anticoagulation. Systemic corticosteroid can be used in the acute phase. Fundoscopic examination should be performed each time cholesterol crystal embolism is suspected. When typical emboli are seen in the retina, it permits avoiding invasive investigations and saving precious time for the management of this potentially lethal disease.

Macular oedema following rituximab infusion in two patients with Wegener's granulomatosis.

Rituximab, a monoclonal antibody now widely used to treat autoimmune diseases, has been reported to be effective against refractory Wegener's granulomatosis and its ophthalmic involvement. Herein, we report on 2 patients with refractory Wegener's granulomatosis and scleritis in whom cystoid macular oedema occurred several weeks after rituximab infusions. Notably, scleritis had already resolved when macular oedema was diagnosed. One patient's macular oedema was successfully treated with a subtenon injection of triamcinolone but recurred soon after she received a second cycle of rituximab as maintenance therapy. To our knowledge, to date no ophthalmic side effect has been reported after rituximab administration. The short time between each rituximab infusion and the onset of cystoid macular oedema strongly suggests a causal link.