Impact of Cataract Surgery on IOP and Ocular Structures in Normotensive Patients and Primary and Exfoliation Open-Angle Glaucoma Patients.

Purpose: The aim of this study was to evaluate and compare the changes in Intraocular Pressure (IOP) and other ocular parameters: the Anterior Chamber Angle (ACA), Anterior Chamber Volume (ACV), and Anterior Chamber Depth (ACD) during phacoemulsification surgery in Greek patients with normotensive eyes and those with well-controlled Open-Angle Glaucoma (OAG). Additionally, parameters such as the Corneal Thickness (CCT), Axial Length (AL), Central Macular Thickness (CMT), and Retinal Nerve Fibre Layer (RNFL) were also examined. Patients and Methods: This was a prospective observational case-control study that included 50 phakic eyes, 25 normotensive (Group 1), and 25 with OAG: 15 Primary Open-Angle Glaucoma (POAG) and 10 Exfoliation Glaucoma (EXG) (Group 2). Ophthalmic assessment included IOP measurements, ocular biometry, and anterior and posterior segment optical coherence tomography evaluation of the aforementioned ocular parameters, prior and 6 months after phacoemulsification surgery. Results: At the 6 months post-operative review, a greater IOP reduction was recorded in eyes with OAG, in comparison to normotensive ones (5.3mmHg and 1.6 mmHg respectively). In addition, a significant but similar increase was recorded in the values of the ACA, ACV, and ACD of both groups between the pre- and the post-op period. Furthermore, the CCT and AL values remained unaltered. Finally, there was a non-statistically significant change in the mean CMT and the mean average RNFL of both groups. Conclusion: Eyes with OAG tend to undergo a greater reduction in IOP post-phacoemulsification surgery, in comparison to normotensive eyes. This reduction may not be solely attributed to ocular anatomical changes after phacoemulsification surgery but may also be due to the remodeling of the trabecular meshwork and the ciliary body. This may be especially true in the case of OAG eyes, which already start off with a compromised trabecular endothelium prior to surgery.

Three-Year Results of Simultaneous Transepithelial Phototherapeutic Keratectomy and Conventional Photorefractive Keratectomy (Cretan Protocol Plus) Followed by Corneal Crosslinking for Keratoconus.

PURPOSE: The aim of this study was to present the 3-year outcomes after simultaneous transepithelial phototherapeutic keratectomy (t-PTK) and conventional photorefractive keratectomy (PRK) followed by corneal crosslinking (CXL) for keratoconus. METHODS: In this prospective, interventional case series, patients with progressive keratoconus underwent simultaneous t-PTK and conventional PRK followed by CXL (Cretan protocol plus). Visual, refractive, and topographic outcomes were evaluated along with endothelial cell density (ECD) preoperatively and at 1, 2, and 3 years postoperatively. RESULTS: Twenty-two patients (31 eyes) were enrolled. No intraoperative or postoperative complications were observed in any of the patients. Logarithm of the minimum angle of resolution (logMAR) mean uncorrected and mean corrected distance visual acuity improved from 0.81 ± 0.40 and 0.18 ± 0.21 preoperatively to 0.38 ± 0.33 ( P < 0.001) and 0.06 ± 0.12 ( P < 0.001) at 3-year follow-up. Mean spherical equivalent improved from -5.39 ± 3.89 diopters (D) preoperatively to -2.29 ± 2.65 D ( P < 0.001) at 3 years postoperatively. Mean corneal astigmatism reduced from -4.70 ± 2.86 D preoperatively to -3.55 ± 2.45 D ( P = 0.001) at 3 years postoperatively. No ECD alterations were observed throughout the 3-year follow-up ( P > 0.05). CONCLUSIONS: Simultaneous t-PTK and conventional PRK followed by CXL seems to be an effective and safe treatment for progressive keratoconus over 3-year follow-up.

The Effect of Diabetes Mellitus on Corneal Endothelial Cells and Central Corneal Thickness: A Case-Control Study.

PURPOSE: The aim of this study was to evaluate the characteristics of corneal endothelial cells and central corneal thickness (CCT) in patients with diabetes mellitus (DM), comparing them with those of healthy subjects (controls) and to determine potential factors affecting the corneal parameters in patients with DM. METHODS: Participants in this study were 72 patients with DM and 88 healthy controls. Diabetic patients were further classified into groups depending on the severity of diabetic retinopathy (no retinopathy, mild, moderate, severe non-proliferative diabetic retinopathy, and proliferative diabetic retinopathy). All participants underwent non-contact specular microscopy to evaluate corneal endothelium parameters and CCT, while factors affecting endothelial cell density and CCT in patients with DM were also analyzed. RESULTS: Patients with DM presented significantly decreased endothelial cell density compared to controls (2,297.9 ± 311.3 and 2,518.3 ± 243.7 cells/mm2, respectively; p < 0.001), while the two groups did not differ significantly in any other measured corneal parameter. In the diabetic group, the multivariate analysis showed a significant association between decreased endothelial cell density and increased HbA1c (p < 0.001), longer DM duration (p = 0.003), and more severe diabetic retinopathy status (p = 0.008). CONCLUSION: DM seems to affect the corneal endothelium, since endothelial cell density was decreased in the diabetic group, while duration of disease, HbA1c levels, and severity of retinopathy were significantly associated with changes in endothelial cell density and should be taken into account.

Long-term Comparison of Combined t-PTK and CXL (Cretan Protocol) Versus CXL With Mechanical Epithelial Debridement for Keratoconus.

PURPOSE: To compare the long-term outcomes of corneal cross-linking (CXL) for the treatment of keratoconus using two different techniques for epithelial removal: transepithelial phototherapeutic keratectomy (t-PTK) and mechanical epithelial debridement. METHODS: In this prospective, comparative, interventional case series, 26 patients (30 eyes) with progressive keratoconus underwent CXL treatment. Fifteen eyes (13 patients) underwent epithelial removal with t-PTK (Cretan protocol) and 15 eyes (13 patients) underwent mechanical epithelial debridement (Dresden protocol) during CXL. Visual, refractive, and keratometric outcomes were evaluated preoperatively and at 1, 2, 3, and 4 years postoperatively. RESULTS: No intraoperative or postoperative complications were observed in any of the patients. In the Cretan protocol group, mean uncorrected (UDVA) and corrected (CDVA) visual acuity improved from 0.99 ± 0.42 and 0.33 ± 0.28 logMAR preoperatively to 0.75 ± 0.32 (P = .018) and 0.21 ± 0.16 (P = .024) logMAR at 4 years postoperatively, respectively. In the Dresden protocol group, mean UDVA improved from 0.83 ± 0.47 logMAR preoperatively to 0.63 ± 0.40 logMAR (P = .033) at 4 years postoperatively, whereas mean CDVA did not demonstrate a statistically significant improvement postoperatively (P > .05). In the Cretan protocol group, mean corneal astigmatism improved from -6.19 ± 4.54 diopters (D) preoperatively to -4.68 ± 3.10 D (P = .041) at last follow-up, whereas in the Dresden protocol group there was no statistically significant difference postoperatively (P > .05). CONCLUSIONS: Epithelial removal with t-PTK during CXL (Cretan protocol) resulted in better visual, refractive, and keratometric outcomes compared with mechanical epithelial debridement over a long-term follow-up. [J Refract Surg. 2019;35(10):650-655.].

Normal-tension glaucoma: Pathogenesis and genetics.

Normal-tension glaucoma (NTG) is a multifactorial optic neuropathy which, similar to open-angle glaucomas, is characterized by progressive retinal ganglion cell death and glaucomatous visual field loss. The major distinction of NTG from open-angle glaucomas is that the intraocular pressure (IOP) does not exceed the normal range. Missing the major risk factor and target of therapy, the elevated IOP, NTG poses a clinical challenge. Several insightful reviews have been published on the pathophysiology of NTG describing the possible underlying mechanisms. The current literature available also suggests that a significant percentage of patients with NTG (as high as 21%) have a family history of glaucoma, indicating a genetic predisposition to the disease. These facts strengthen the indication that NTG remains an enigmatic process. The aim of this review was to summarize the vascular, mechanical and genetic components considered to be responsible for NTG development and to discuss the mechanisms through which they are involved in the pathogenesis of NTG.

Combined transepithelial phototherapeutic keratectomy and conventional photorefractive keratectomy followed simultaneously by corneal crosslinking for keratoconus: Cretan protocol plus.

PURPOSE: To evaluate the visual, refractive, and topographic outcomes after combined transepithelial phototherapeutic keratectomy (PTK) and conventional photorefractive keratectomy (PRK) followed simultaneously by corneal crosslinking (CXL) for keratoconus. SETTING: Vardinoyiannion Eye Institute of Crete, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece. DESIGN: Prospective case series. METHODS: Patients with progressive keratoconus had simultaneous conventional PRK followed by CXL; the corneal epithelium was removed using transepithelial PTK (Cretan protocol plus). The visual, refractive, and topographic outcomes and the endothelial cell density (ECD) were evaluated preoperatively and 1, 3, 6, and 12 months postoperatively. RESULTS: Forty-three patients (55 eyes) were enrolled. The mean uncorrected and corrected distance visual acuities improved significantly from 0.98 ± 0.63 (SD) logarithm of minimum angle of resolution (logMAR) and 0.20 ±â€¯0.23 logMAR preoperatively to 0.39 ±â€¯0.35 logMAR (P < .001) and 0.08 ±â€¯0.16 logMAR (P < .001) 12 months postoperatively, respectively. The mean spherical equivalent improved significantly from -4.67 ±â€¯4.00 diopters (D) preoperatively to -2.24 ±â€¯2.81 D (P < .001) at 12 months. The mean steep keratometry (K) and flat keratometry readings decreased significantly from 50.30 ±â€¯5.00 D and 45.62 ±â€¯3.10 D preoperatively to 46.27 ±â€¯3.90 D (P < .001) and 43.46 ±â€¯3.00 D (P < .001) 12 months postoperatively, respectively. No ECD alterations were observed throughout the follow-up (P > .05). CONCLUSION: Combined transepithelial PTK and conventional PRK followed simultaneously by CXL was effective in corneal stabilization and vision improvement in keratoconic patients.

Fourier analysis algorithm for the posterior corneal keratometric data: clinical usefulness in keratoconus.

PURPOSE: To develop an algorithm for the Fourier analysis of posterior corneal videokeratographic data and to evaluate the derived parameters in the diagnosis of Subclinical Keratoconus (SKC) and Keratoconus (KC). METHODS: This was a cross-sectional, observational study that took place in the Eye Institute of Thrace, Democritus University, Greece. Eighty eyes formed the KC group, 55 eyes formed the SKC group while 50 normal eyes populated the control group. A self-developed algorithm in visual basic for Microsoft Excel performed a Fourier series harmonic analysis for the posterior corneal sagittal curvature data. The algorithm decomposed the obtained curvatures into a spherical component, regular astigmatism, asymmetry and higher order irregularities for averaged central 4 mm and for each individual ring separately (1, 2, 3 and 4 mm). The obtained values were evaluated for their diagnostic capacity using receiver operating curves (ROC). Logistic regression was attempted for the identification of a combined diagnostic model. RESULTS: Significant differences were detected in regular astigmatism, asymmetry and higher order irregularities among groups. For the SKC group, the parameters with high diagnostic ability (AUC > 90%) were the higher order irregularities, the asymmetry and the regular astigmatism, mainly in the corneal periphery. Higher predictive accuracy was identified using diagnostic models that combined the asymmetry, regular astigmatism and higher order irregularities in averaged 3and 4 mm area (AUC: 98.4%, Sensitivity: 91.7% and Specificity:100%). CONCLUSIONS: Fourier decomposition of posterior Keratometric data provides parameters with high accuracy in differentiating SKC from normal corneas and should be included in the prompt diagnosis of KC.

Fourier analysis of videokeratography data: Clinical usefulness in grade I and subclinical keratoconus.

PURPOSE: To evaluate the contribution of Fourier analysis of videokeratographic data in the diagnosis of subclinical keratoconus and keratoconus. SETTING: Eye Institute of Thrace, Democritus University, Alexandroupolis, Greece. DESIGN: Observational case series. METHODS: The following Pentacam-derived parameters, resulting from Fourier decomposition of keratometric data, were evaluated for their diagnostic capacity using receiver operating curves: spherical component and eccentricity, maximum decentration, regular astigmatism in the center and in the periphery, mean astigmatism, irregularities, regular astigmatism in the center plus the irregularities, and total astigmatism. Logistic regression was performed to identify a combined diagnostic model. RESULTS: The study comprised 80 keratoconus eyes, 55 eyes diagnosed with subclinical keratoconus, and 50 normal eyes. Significant differences were detected in spherical eccentricity, maximum decentration, irregularities, regular astigmatism in the center and in the periphery, regular astigmatism in the center plus the irregularities, mean astigmatism, and total astigmatism parameters between the groups. Almost all parameters had high diagnostic ability in both study groups (area under the curve >90%). Among individual parameters, those with the highest predictive accuracy were the regular astigmatism in the center plus the irregularities (subclinical keratoconus 97.6%, keratoconus 98.8%) and the maximum decentration (subclinical keratoconus 91.4%, keratoconus 98.5%). Sufficient predictive accuracy (subclinical keratoconus 99.4, keratoconus 100%) was identified in a diagnostic model that combined the regular astigmatism in the center plus the irregularities and the maximum decentration. CONCLUSION: Fourier decomposition of keratometric data provided parameters with high accuracy in differentiating corneas with subclinical keratoconus from normal corneas and should be included to allow prompt diagnosis of keratoconus. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Ocular rigidity, ocular pulse amplitude, and pulsatile ocular blood flow: the effect of axial length.

PURPOSE: Previous studies have shown a negative correlation between axial length (AL) and pulsatile ocular blood flow (POBF). This relation has been questioned because of the possible confounding effect of ocular volume on ocular rigidity (OR). The purpose of this study was to investigate the relation between AL, as a surrogate parameter for ocular volume, and OR, ocular pulse amplitude (OPA), and POBF. METHODS: Eighty-eight cataract patients were enrolled in this study. A computer-controlled device comprising a microdosimetric pump and a pressure sensor was used intraoperatively. The system was connected to the anterior chamber and used to raise the intraocular pressure (IOP) from 15 to 40 mm Hg, by infusing the eye with a saline solution. After each infusion step, the IOP was continuously recorded for 2 seconds. Blood pressure and pulse rate were measured during the procedure. The OR coefficient was calculated from the pressure volume data. OPA and POBF were measured from pressure recordings. RESULTS: Median AL was 23.69 (interquartile range 3.53) mm. OR coefficient was 0.0218 (0.0053) µL(-1). A negative correlation between the OR coefficient and AL (ρ = -0.641, P < 0.001) was documented. Increasing AL was associated with decreased OPA (ρ = -0.637, P < 0.001 and ρ = -0.690, P < 0.001) and POBF (ρ = -0.207, P = 0.053 and ρ = -0.238, P = 0.028) at baseline and elevated IOP, respectively. CONCLUSIONS: Based on manometric data, increasing AL is associated with decreased OR, OPA, and POBF. These results suggest decreased pulsatility in high myopia and may have implications on ocular pulse studies and the pathophysiology of myopia.

Complications of intrastromal corneal ring segment implantation using a femtosecond laser for channel creation: a survey of 850 eyes with keratoconus.

PURPOSE: To report complications after the implantation of intrastromal corneal ring segments (Keraring; Mediphacos, Belo Horizonte, Brazil) in keratoconic eyes using a femtosecond laser (IntraLase; Advanced Medical Optics, Santa Ana, California, USA) for channel creation. METHODS: Retrospective chart review of 531 patients (850 eyes) who underwent Keraring insertion using a femtosecond laser for channel creation. Intraoperative and postoperative complications were recorded. RESULTS: Intraoperatively, there were 22 (2.7%) cases of incomplete channel formation. The rest of the intraoperative complications were galvo lag error (system malfunction) [five eyes (0.6%)], endothelial perforation [five eyes (0.6%)] and incorrect entry of the channel [two eyes (0.2%)]. Postoperatively, there were 11 (1.3%) cases of segment migration, two (0.2%) cases of corneal melting and one (0.1%) case of mild infection. The overall complication rate was 5.7% (49 cases out of 850 eyes). CONCLUSION: In this study, intracorneal ring segment implantation using a femtosecond laser for channel creation was related to a number of complications. The most common complications were incomplete channel creation (intraoperatively) and segment migration (postoperatively).

Changing indications for penetrating keratoplasty in Greece, 1982-2006: a multicenter study.

PURPOSE: To evaluate the leading indications for penetrating keratoplasty (PKP) and their trends in Greece during the period 1982 to 2006. METHODS: Retrospective data review of 1,929 patients (2233 eyes) who underwent PKP in the period between 1982 and 2006 at three cornea transplantation units of three hospitals in Greece (Athens General Hospital, Heraklion University Hospital of Crete, and Thessaloniki University Hospital). Indications were classified into nine different groups: keratoconus, herpes simplex keratitis, microbial (nonviral) keratitis (fungal, bacterial, and acanthamoeba), aphakic/pseudophakic corneal edema, posttraumatic corneal scars, chemical/thermal injury, regraft, Fuchs' endothelial dystrophy, and other. RESULTS: The leading indications for PKP, in order of decreasing frequency, were aphakic/pseudophakic corneal edema (n = 649 [29.1%]), keratoconus (n = 580 [26%]), regraft (n = 265 [11.9%]), microbial (nonviral) keratitis (n = 188 [8.4%]), posttraumatic corneal scar (n = 171 [7.7%]), herpes simplex keratitis (n = 104 [4.6%]), Fuchs' endothelial dystrophy (n = 104 [4.6%]), chemical/thermal injury (n = 61 [2.7%]), and other (n = 111 [5%]). The prevalence of regrafts as an indication for PKP increased during the study period. CONCLUSIONS: Aphakic/pseudophakic corneal edema was the most common indication for PKP in a multicenter series in Greece followed by keratoconus. The number of regrafts dramatically increased during the 25-year period.

Long-term results of intranasal laser-assisted dacryocystorhinostomy with the use of a surgical microscope.

OBJECTIVE: To address the long-term results of our method that combines intranasal laser-assisted dacryocystorhinostomy with the use of surgical microscope. METHODS: The procedure is a modification of the West method. A retrospective series of the long-term results are presented in 105 patients that underwent 118 DCR procedures, over the past 6 years. Selection criteria were mainly acquired idiopathic nasolacrimal duct obstruction. RESULTS: 113 DCR cases (95.8%) were free of symptoms postoperatively (mean follow-up: 24 months). CONCLUSION: Our method when compared with traditional methods is correlated with excellent postoperative long-term results.

Treatment of chronic dry eye: focus on cyclosporine.

To review the current treatment of chronic dry eye syndrome, focusing on cyclosporine A (CsA), a systematic literature search was performed using PubMed databases in two steps. The first step was oriented to articles published for dry eye. The second step was focused on the use of CsA in dry eye. A manual literature search was also undertaken based on citations in the published articles. The knowledge on the pathogenesis of dry eye syndrome has changed dramatically during the last few years. Inflammation and the interruption of the inflammatory cascade seem to be the main focus of the ophthalmologic community in the treatment of dry eye, giving the anti-inflammatory therapy a new critical role. The infiltration of T-cells in the conjuctiva tissue and the presence of cytokines and proteasis in the tear fluid were the main reason introducing the use of immunomodulator agents such as corticosteroids, cyclosporine, and doxycicline in order to treat dry eye syndrome. CsA emulsion is approved by the FDA for the treatment of dry eye, while clinical trials of this agent have demonstrated efficacy and safety of CsA. CsA seems to be a promising treatment against dry eye disease. New agents focused on the inflammatory pathogenesis of this syndrome in combination with CsA may be the future in the quest of treating dry eye. More studies are needed to determine the efficacy, safety, timing, and relative cost/effect of CsA.

Human amniotic membrane transplantation for tube exposure after glaucoma drainage device implantation.

We present a case of conjunctival melting over the tube of a glaucoma shunt, which was successfully repaired with amniotic membrane transplantation.

Long-term follow-up of Intacs in keratoconus.

PURPOSE: To evaluate long-term follow-up of Intacs microthin prescription inserts (Addition Technology, Inc, Fremont, California, USA) for the management of keratoconus. DESIGN: A long-term (five years) retrospective, follow-up study. METHODS: Seventeen eyes of 15 patients with keratoconus ages 24 to 52 years (mean age +/- standard deviation [SD], 34.0 +/- 10.5 years) who had completed five years of follow-up (mean follow-up +/- SD, 67.2 +/- 7.5 months; range, 58 to 78 months) were included. Two Intacs segments of 0.45-mm thickness were inserted in the cornea of each eye, aiming at embracing the keratoconus area to try to achieve maximal flattening. RESULTS: No late postoperative complications occurred in this series of patients. At five years, the spherical equivalent error was statistically significantly reduced (pre-Intacs, mean +/- SD -5.54 +/- 5.02 diopters [D]; range, -12.50 to 3.63 D; -3.02 +/- 2.65 D; range, -8.25 to 1.88 D) (P = .01). Pre-Intacs uncorrected visual acuity (UCVA) was 20/50 or worse in all eyes (range, counting fingers to 20/50), whereas, at the last follow-up examination, 10 (59%) of 17 eyes had UCVA of 20/50 or better (range, counting fingers to 20/32). Six eyes (35%) maintained the pre-Intacs best spectacle-corrected visual acuity (BSCVA) and one eye lost 3 lines of BSCVA, whereas the rest of the 10 eyes (59%) experienced a gain of one up to 8 lines. CONCLUSIONS: After five years, intracorneal ring segments implantation improved UCVA, BSCVA, and refraction in the majority of the keratoconus patients. There was no evidence of progressive sight-threatening complications in this study.

Long-term follow-up of Intacs for post-LASIK corneal ectasia.

OBJECTIVE: To report long-term follow-up of Intacs microthin prescription inserts for the management of post-LASIK corneal ectasia. DESIGN: Long-term (5 years), retrospective, nonrandomized study. PARTICIPANTS: Eight eyes of 5 patients with post-LASIK corneal ectasia (3 men and 2 women) ages 31 to 54 years (mean age+/-standard deviation [SD], 41.60+/-9.24 years) who had completed 5 years of follow-up (mean follow-up +/- SD, 60.1+/-4.9 months; range, 57-68 months). INTERVENTION: Two Intacs segments, inserted in the usual fashion, were used for low myopia correction (1 each nasally and temporally), with thickness based on the residual refraction of the patients. MAIN OUTCOME MEASURES: Manifest refraction, uncorrected and best spectacle-corrected visual acuity, patient satisfaction, topography, and confocal microscopy analysis. RESULTS: No intraoperative or late postoperative complications occurred in this series of patients. At 5 years, the SE error was statistically significantly reduced (pre-Intacs mean+/-SD, -5.47+/-2.66 diopters [D]; range, -11.50 to -3.00 D) to -2.56+/-3.44 D (range, -9.50 to 1.5 D; P = 0.01). At the end of the first postoperative year, refractive stability was obtained and remained stable during the follow-up period with no significant changes between the interval meantime (P>0.05). Pre-Intacs uncorrected visual acuity was 20/100 or worse in all eyes (range, counting fingers-20/100), whereas at the last follow-up examination, 6 (75%) of 8 eyes had uncorrected visual acuity of 20/40 or better (range, counting fingers-20/25). Two eyes (25%) maintained the pre-Intacs best spectacle-corrected visual acuity, whereas the rest of the eyes (6 eyes; 75%) experienced a gain of 1 or 2 lines. At the end of the first postoperative year, uncorrected and best-spectacle corrected visual acuity and topographic stability were obtained and were shown to have remained stable during the follow-up period with no significant changes between the interval meantime. Lamellar channel deposits were observed in confocal microscopy at or adjacent to the intrastromal ring segment. CONCLUSIONS: Refractive stability was maintained for up to 5 years in the treatment of post-LASIK corneal ectasia after Intacs implantation. There was no evidence of progressive time-dependent corneal ectasia, late regression, or sight-threatening complications in this study.

Late onset of serologic positive titers in a patient with Parinaud's oculoglandular syndrome.

PURPOSE: To report a case of Parinaud's oculoglandular syndrome (POS) in which, despite the initially negative, a late onset of serologic positive titers was observed. METHODS: Case report. RESULTS: A 65-year-old man was examined for a foreign body in the left eye associated with granulomatous nodule on the palpebral conjuctiva, chemosis and a swollen preauricular lymph node. Despite the initially negative serologic titers to Bartonella henselae, a clinical diagnosis of POS was made and treatment was instituted initially with oral ciprofloxacin (500 mg twice a day). Three weeks later, serologic positive titers were found which confirmed the diagnosis of POS. CONCLUSION: Even though the improvements in diagnostic testing such as indirect immunofluorescence antibody, negative titles could be initially observed, confusing the diagnostic process. Other techniques (such as polymerase chain reaction (PCR) testing) should be also taken into consideration in cases with increased clinical suspicious of B. henselae indections.

Treatment of atopic eyelid disease using topical tacrolimus following corticosteroid discontinuation in a patient with open-angle glaucoma.

PURPOSE: To report a case of atopic eyelid disease treatment using topical tacrolimus in a patient with open-angle glaucoma following corticosteroid discontinuation. DESIGN: Interventional case report. METHODS: A 59-year-old white man with a history of treated open-angle glaucoma (latanoprost 0.005%) was referred to our department for atopic eyelid disease. The patient had received previous treatment with topical corticosteroid ointments (hydrocortisone acetate 1%/dexamethasone 0.1% ointments) that, even though they were effective in controlling atopic eyelid disease, were complicated by markedly elevated intraocular pressure (IOP) (steroid responder). Topical steroids were discontinued while other treatment modalities (such as eyelid hygiene, artificial tears, topical antihistamine drugs, topical mast cell stabilizers, or topical/oral antibiotics) were proven ineffective. RESULTS: Topical tacrolimus 0.03% ointment (Protopic; Fujisawa, Dublin, Ireland) was applied to the eyelid skin twice daily. An improvement of eyelid inflammation was observed while eczematous skin lesions and erosions were resolved within 15 days. After 6 months of continued topical tacrolimus treatment, there was no evidence of atopic dermatitis recurrence. During this period IOP remained controlled without any evidence of deregulation. CONCLUSIONS: Treatment of atopic eyelid disease with topical tacrolimus, following corticosteroid discontinuation in a steroid responder patient with open-angle glaucoma, seems to be an effective alternative treatment to corticosteroids without the risk of IOP increase.

Study of conjunctival goblet cell morphology and tear film stability in pseudoexfoliation syndrome.

BACKGROUND: Tear secretion and tear film stability seem to be influenced by pseudoexfoliation syndrome (PEX). Histopathological evaluation of conjunctival goblet cells in PEX patients might explain the influence on tear film stability. METHODS: In a prospective, cross-sectional study, 40 eyes of 40 patients with PEX (study group) had measurement of Schirmer test with anesthesia and break-up time prior to cataract surgery. At the end of an uneventful operation, a 1 x 1.5 mm sample of conjunctival tissue was obtained and light and electron microscopy were performed. Results were compared with a control group. Histology evaluation was masked. Primary outcome measures included Schirmer test with anesthesia, break-up time, goblet cell density and morphological character of conjunctiva and conjunctival goblet cells. RESULTS: Both Schirmer test and break-up time values were significantly lower (P= 0.01 and P= 0.001) in the PEX patients (mean 10.6 mm and 8.6 s respectively) than in the control group (13.4 mm and 12.3 s respectively). The number of goblet cells in patients with PEX compared with the control group showed no statistically significant difference (P= 0.66). Use of trichrome stain revealed significant differences in the staining properties of goblet cells between patients with PEX and controls. On electron microscopy, typical pseudoexfoliation filaments were found in the connective tissue of conjunctiva of PEX patients. Remarkable changes of mucin pockets in the study group were also noticed; they had extremely irregular distribution, various forms of size and appearance and even complete collapse. CONCLUSION: Pseudoexfoliation seems to alter basic features of goblet cell morphology, thus affecting tear film stability. Further studies are necessary to determine the exact mechanism.

Iontophoresis-gentamicin delivery into the rabbit cornea, using a hydrogel delivery probe.

PURPOSE: To evaluate the efficacy of penetration of gentamicin into the cornea of rabbits using iontophoresis with a hydrogel-gentamicin containing probe. METHODS: Eight of 10 groups (groups 3-10) of 6 rabbits (one eye per rabbit), underwent corneal iontophoresis using soft stable hydroxyethyl methacrylate hydrogel discs (80% water content) loaded with gentamicin sulphate which were mounted on an iontophoresis probe. The studied current intensities were 0, 0.1, 0.3 and 0.6 mAmp, and the durations of iontophoresis were 10 and 60 sec. Two control groups received 1.4% topical drops of gentamicin every 5 min for 1 hr (group 1) or sub-conjunctival injection of 10 mg gentamicin (group 2). Following sacrifice, aqueous humour was taken, corneas were excised, and gentamicin concentration was determined in aqueous humour and cornea samples. RESULTS: Post-iontophoresis, the concentration of gentamicin in the corneas ranged from high (88.60 +/- 38.64 microg ml(-1)) to very low (0.10 +/- 0.89 microg ml(-1)). Both the control groups and those rabbits treated with current intensity of 0.1 mAmp or greater obtained therapeutic gentamicin levels in the corneas. Use of iontophoresis for 60 sec or current intensity greater than 0.1 mAmp obtained corneal gentamicin levels not different from sub-conjunctival injection. Application of current intensity of 0.1 mAmp or greater gave corneal gentamicin concentrations comparable to topical application of the drug, except when 0.6 mAmp were used for 60 sec (p = 0.05). Increasing current intensity or duration of iontophoresis significantly increased (p = 0.001 for both) gentamicin penetration into the cornea. Current intensity had more influence (Beta2 = 0.40) than duration (Beta2 = 0.13) on drug penetration. A significant interaction was found between the duration of iontophoresis and the current intensity. Very small or no concentrations of the drug were discovered in the anterior chambers of rabbits. CONCLUSIONS: Iontophoresis using hydrogel-gentamicin probe may deliver therapeutic concentrations of gentamicin into the cornea.