Ocular manifestation of giant cell arteritis vs AL-amyloidosis: similar presentations but different approaches.

Light chain (AL) amyloidosis may present with the features of vasculitis, including giant cell arteritis (GCA). Similarities between GCA and AL-amyloidosis can potentially cause confusion in diagnosis, in which case, temporal artery biopsy (TAB) should be performed to make a definitive diagnosis. Herein we report a case of a bilateral anterior ischaemic optic neuropathy (AION), showing evidence of AL-amyloidosis on the temporal artery biopsy. A 75-year-old male with AL-amyloidosis secondary to monoclonal gammopathy of undetermined significance (MGUS) presented to our hospital for subacute painless progressive visual impairment. Based on his elevated inflammatory markers and his age, he was suspected to have giant cell arteritis. However, a temporal artery biopsy excluded GCA, and the Congo red staining was positive for amyloid deposition. This present case reveals that AL-amyloidosis may present with visual impairment, high inflammatory markers, and involvement of temporal arteries, concerning for GCA. TAB with Congo red staining is found to be crucial for making the correct diagnosis.

Combined DSEK and Transconjunctival Pars Plana Vitrectomy.

We report here three patients who underwent combined Descemet's stripping with endothelial keratoplasty and transconjunctival pars plana vitrectomy for bullous keratopathy and posterior segment pathology. A surgical technique and case histories are described. Anatomic and visual outcomes of combined Descemet's stripping with endothelial keratoplasty and vitrectomy were excellent. Our experience provides technical guidelines and limitations. The combined minimally invasive techniques allow for rapid anatomical recovery and return of function and visual acuity in a single sitting.

Recurrent Squamous Cell Carcinoma of the Eyelid Presenting as Trigeminal Neuralgia.

This paper describes two patients with squamous cell carcinoma (SCC) of the periocular and periorbital skin who presented with trigeminal neuralgia. Both patients had previous cutaneous SCC of the scalp treated successfully with surgical resection but later presented with neuro-ophthalmic findings suggesting perineural invasion (PNI) of SCC. PNI of SCC in the periocular skin or orbit can lead to devastating effects if malignant cells seed into the orbit and adjacent cranial nerves as our two patients developed an orbital apex syndrome. Patients with a history of SCC of the scalp and forehead who later develop neuro-ophthalmological deficits or patients with persistent ocular symptoms should, in particular, be followed with a low threshold for cutaneous SCC or PNI of recurrent disease. SCC metastasizing into the periocular tissues and orbit by neural invasion is rare and carries a poor prognosis. The urgency for a prompt diagnosis and evaluation by a multidisciplinary team is warranted to prevent untoward outcomes of this skin cancer.

The safety and efficacy of photorefractive keratectomy after laser in situ keratomileusis.

PURPOSE: To determine the safety and efficacy of performing photorefractive keratectomy (PRK) in corneas previously treated with laser in situ keratomileusis (LASIK) surgery. METHODS: Fifteen eyes of 14 patients who had initially received LASIK for the treatment of myopia and compound myopic astigmatism were evaluated. Variables included existence of and/or type of flap complication associated with the original LASIK procedure, refractions before and after (3 and 6 months) PRK, uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), and the development of complications after PRK such as haze, scarring, double vision, or ghosting. RESULTS: All 15 eyes were available for analysis at 6 months. Eleven eyes had experienced flap complications during the initial LASIK procedure and 4 eyes had experienced complications in the LASIK postoperative period. Characteristics prior to performing PRK included 11 myopic and 4 hyperopic eyes. By 6 months after PRK treatment, 87% of eyes had UCVA > or = 20/40, 53% had > or = 20/25, and 40% had > or = 20/20. All eyes had BSCVA of > or = 20/30, with 73% being > or = 20/20. No eye had lost 2 lines of BSCVA and only 1 eye lost 1 line of BSCVA. Sixty percent of eyes were within 1.0 diopters (D) of emmetropia, and 40% were within 0.5 D of emmetropia. A trend towards undercorrection and surgical induction of astigmatism as confirmed by vector analysis was noted. No eye developed significant haze or scarring. CONCLUSIONS: Photorefractive keratectomy may be a safe procedure to perform in corneas previously treated with LASIK surgery. Results show good reduction of refractive error and improvement of UCVA and BSCVA. A significant undercorrection of astigmatism was attributed to surgically induced astigmatism. Further studies are necessary to determine the long-term safety and stability of outcomes.

Ketorolac for the regression of myopic LASIK overcorrection.

OBJECTIVE: To determine whether ketorolac (Acular) treatment and other factors influence regression after LASIK-induced consecutive hyperopia. METHODS: Seventy-two eyes of 51 patients who had undergone LASIK for myopia and compound myopic astigmatism and who experienced consecutive hyperopia of at least +0.50 diopters within the first postoperative week were analyzed. The consenting patients were treated with ketorolac (Acular). Data were collected over a period of 2 months. Primary preoperative variables included age, eye, preoperative manifest and cycloplegic refractions, and pachymetry. Postoperative variables included presence of microstriae and treatment with ketorolac. Treatment success was measured as reduction of consecutive hyperopia. RESULTS: Thirty-seven eyes were treated, and 35 eyes were in the control group. Mean start time for treatment with ketorolac was 9 days after surgery (range 3-35 days). Mean treatment time was 24.5 days (range 10-63 days). Both groups were matched for all preoperative variables except for age, including manifest and cycloplegic refraction, eye treated, and pachymetry. Treated patients were on average 9 years older than the control group. There was no significant difference in the overall rate of regression between the 2 groups at the 1-month and 2-month periods. Thicker preoperative corneas in all eyes had a sporadic association with reduction of consecutive hyperopia. CONCLUSIONS: Ketorolac does not improve consecutive hyperopia after LASIK for myopia and compound myopic astigmatism when compared with a matched control group. Pachymetry appears to be a determining factor in the degree of regression experienced after consecutive hyperopia. This finding warrants further investigation.

Retinal evaluation of patients on chronic amiodarone therapy.

PURPOSE: To determine whether retinal electrophysiologic changes can be detected and correlated with funduscopic findings in patients with the long-term use of amiodarone. METHODS: Eleven patients ranging in age from 52 to 67 years were recruited from the Stanford University Medical Center Department of Cardiology for ophthalmologic examination. Patients had received amiodarone at various dosages ranging from 100 to 800 mg daily for at least 15 months. Clinical indications for the use of amiodarone included atrial fibrillation, ventricular arrhythmias, and congestive heart failure. All patients underwent retinal electrophysiology studies (full-field and multifocal electroretinograms) in addition to a complete ophthalmologic examination and fluorescein angiography. RESULTS: No patients were found to have significant vision loss. Funduscopic examination and fluorescein angiography showed mild age-related changes in four patients, three of whom had nonspecific foveal pigmentary alterations. Multifocal and full-field electroretinograms were mostly unremarkable, and the mildly subnormal findings in a few patients showed no consistent pattern to suggest a toxic cause. Dosage, duration of amiodarone exposure, patient age, and underlying cardiac disease did not appear to correlate with these findings. CONCLUSIONS: No significant adverse retinal funduscopic changes or electrophysiologic effects could be correlated with amiodarone exposure in this small series of patients. Routine electrophysiologic and funduscopic screening of patients receiving amiodarone does not seem warranted, although future prospective controlled studies may be required to exclude the possibility of progressive abnormalities in patients with preexisting age-related macular degeneration.

Laser in situ keratomileusis for myopia and compound myopic astigmatism using the Technolas 217 scanning-spot laser.

PURPOSE: To evaluate the safety, efficacy, predictability, and visual results of laser in situ keratomileusis (LASIK) using the Bausch & Lomb Technolas(R) 217 scanning-spot laser for the treatment of myopia and compound myopic astigmatism. SETTING: Stanford Eye Laser Center, Stanford, California, USA. METHODS: In a prospective study, 110 eyes of 58 patients with a mean spherical equivalent (SE) of -4.87 diopters (D) +/- 2.5 (SD) (range -1.0 to -11.4 D) had LASIK for myopia and compound myopic astigmatism using the Technolas 217 scanning-spot laser. The primary outcome variables included preoperative and postoperative best spectacle-corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA), achieved versus attempted correction, vector analysis of astigmatism, and complications. RESULTS: One hundred ten eyes were available for analysis at 3 months. The mean SE refraction was reduced 95% (mean -0.23 +/- 0.4 D), and astigmatism was reduced 70% (mean 0.28 +/- 0.3 D). One day postoperatively, 100% of eyes had a UCVA of 20/40 or better, 96% had 20/25 or better, 77% had 20/20 or better, and 39% had 20/15 or better. At the 3-month examination, 100% of eyes had a UCVA of 20/40 or better, 95% had 20/25 or better, 83% had 20/20 or better, and 48% had 20/15 or better. Ninety percent of eyes were within +/-0.5 D of emmetropia. No eye lost 2 or more lines of BSCVA. CONCLUSIONS: The Technolas 217 scanning-spot laser produced excellent postoperative UCVA and BSCVA. It was predictable, safe, and effective for the treatment of myopia and compound myopic astigmatism. Long-term follow-up is needed to assess the stability of the procedure.

Iatrogenic keratoconus as a complication of radial keratotomy.

A 47-year-old man with a family history of keratoconus had uneventful bilateral radial keratotomy (RK) with astigmatic keratotomy (AK) enhancements 12 years earlier. He noticed a gradual onset of blurry vision with progressively increasing myopic shift. Visual acuity remained poor even with spectacles or soft contact lenses. Slitlamp examination revealed 16 well-healed RK scars and 2 AK scars with marked corneal steepening inferiorly in an area of astigmatic enhancement in the left eye but an otherwise normal fellow eye with 16 well-healed RK scars. He subsequently had penetrating keratoplasty for decreased vision not correctable by rigid gas-permeable contact lenses. Microscopic examination of the corneal button showed findings consistent with keratoconus. This case represents the first documented incidence of corneal ectasia as a complication of primary RK.

Progression to end-stage glaucoma after laser in situ keratomileusis.

We describe 2 patients, one a glaucoma suspect because of family history and the other with juvenile glaucoma. Both patients developed complications after laser in situ keratomileusis that required frequent topical steroids, leading to steroid-induced glaucoma. In both cases, corneal edema from the acute rise in intraocular pressure (IOP) caused inaccurate IOP measurement by standard methods. The inability to recognize glaucoma early may have resulted in significant irreversible vision loss.