Biomedical subjects
Publications and source records attributed to H Gelender.
The floppy eyelid syndrome represents a chronic conjunctivitis characterized by a triad of (1) a loose upper lid that readily everts on elevating the lid, (2) a soft rubbery tarsus that can be folded on itself, and (3) a diffuse papillary conjunctivitis. Seven cases of this condition are reported, all involving men, and four involving obese patients.
A 5-year-old girl was seen with findings consistent with melanosis oculi and notably decreased vision secondary to dense corneal pigmentation. A penetrating keratoplasty was performed without complications. Light microscopy disclosed dense pigment granules layered in deep stroma just anterior to Descemet's membrane. Electron microscopy revealed these to be melanocytes, without evidence of phagocytic activity. The corneal pigmentation may have resulted from a misdirection of melanocytes in embryogenesis. To our knowledge, the finding of visually notable corneal pigmentation has not been previously reported in association with the syndrome of melanosis oculi.
A five-year, multicenter, collaborative clinical trial of radial keratotomy for myopia is being carried out at nine clinical centers. The study, funded by the National Eye Institute, is recruiting approximately 500 patients aged 21 years or older with -2.00 to -8.00 diopters of physiologic myopia who also meet other clearly defined eligibility criteria. Surgeons use a diamond-bladed micrometer knife to make eight radial incisions in the anterior cornea. The diameter of the central clear zone is determined by the amount of myopia and the depth of the incisions by intraoperative ultrasonic pachymetry. Investigators other than the surgeon gather all pre- and post-operative data. Examinations include measurement of visual acuity with standardized charts, verification of refractions by a second observer, measurement of corneal curvature by keratometry and photokeratoscopy, quantitation of glare with a glare tester, and measurement of the size of individual endothelial cells from specular photomicrographs with a computerized digitizer. A formal psychometric questionnaire is used to evaluate the patients' subjective response. Physician monitors insure adherence to the protocol during site visits and members of the Data and Safety Monitoring Board oversee the progress of the study. Biostatisticians at the Coordinating Center insure complete data collection, process the data, and assist in the interpretation of results.
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A persistent central corneal epithelial defect progressing rapidly by stromal ulceration to descemetocele formation was observed in five elderly patients soon after cataract surgery with intraocular lens implantation. The ulceration occurred in the absence of active inflammation or infection in otherwise clear cornea. Topically applied artificial tears, antibiotics, and corticosteroids failed to control the ulceration although bandage soft contact lens therapy and conjunctival flap helped stabilize the cornea in one case each. Spontaneous perforation in two cases necessitated penetrating keratoplasty.
Two patients had corneal erosions and hypopyon iridocyclitis associated with continuous wear of aphakic soft contact lenses. Both patients were treated with cycloplegia and patching without antibiotics or corticosteroids. Both patients fully recovered.
Bacterial endophthalmitis developed in four patients after cataract surgery sutures were cut. Wound dehiscence was present in three cases, but in one the wound remained intact. Vitreous cultures identified Streptococcus viridans in two cases and Staphylococcus aureus and St. epidermidis in one case each. Antibiotic therapy was administered by intraocular, periocular, topical and systemic routes and three patients underwent vitrectomy. Visual function recovered to 20/50 in two cases and to 20/100 in a third. Retinal detachment in the fourth case resulted in loss of all visual function.
Staphylococcus epidermis endophthalmitis developed nine days after surgery in a 47-year-old man who underwent a 16-incision radial keratotomy during which the cornea was inadvertently perforated. The anterior chamber showed marked cellular reaction and flare and there was a 5% hypopyon inferiorly. There was also a marked cellular reaction in the vitreous, which contained many fluffy white balls. Visual acuity decreased to counting fingers at 1 foot. A pars plana vitrectomy and intraocularly, periocularly, intravenously, and topically administered antibiotics resulted in recovery of the visual acuity to 6/9 (20/30).
A suturing hard contact lens used intraoperatively for penetrating keratoplasty helps stabilize the donor tissue and maintains a controlled anterior chamber. It offers improved tissue control during suturing of the graft. This minimizes manipulation of the donor tissue and protects the endothelium from contact with intraocular structures.
Two patients had multiple, fine, polychromatic corneal crystals on ocular examination. Peripheral corneal biopsies and electron microscopic studies demonstrated that the crystals, which were located solely within the cytoplasm of keratocytes, exhibited an internal periodicity of 10 nm and developed within dilated cisternae of rough-surfaced endoplasmic reticulum. Histochemical studies of the corneal crystals confirmed their proteinaceous nature (immunoglobulin crystals). Serum protein analysis showed that both patients had a monoclonal gammopathy with an elevated IgG level and increased K light chains. The associated proteinopathy was unsuspected in both patients until the nature of the crystals was established. Both patients had a neoplastic process; one had a previous diagnosis of Hodgkin's disease, and multiple myeloma developed in the other on follow-up studies. Clinicians should be aware of the possibility of a malignant disorder in patients with corneal crystal-line deposits.
Papanicolaou smear cytology is a simple diagnostic procedure for the evaluation and management of external ocular lesions. A variety of benign and neoplastic lesions are examined for correlation of clinical, cytologic, and histologic impressions. Accurate correlation in 38 of 41 eyes substantiates the reliability of Papanicolaou smear cytology to differentiate benign from neoplastic ocular lesions. Cytology proved useful in the preoperative evaluation of squamous cell carcinoma and related tumors of the conjunctiva, and malignant melanoma of the conjunctiva. Cytology also was valuable in the detection of tumor recurrence in squamous cell carcinoma and carcinoma-in-situ of the conjunctiva, and in Meibomian gland carcinoma of the eyelid. The accessibility of ocular tumors makes them particularly well suited for cytologic examination.
Diagnostic anterior chamber and vitreous aspiration confirmed an infectious etiology in 78 of 140 eyes (56%) with suspected endophthalmitis. In 27 eyes the vitreous aspirate was positive, while the anterior chamber aspirate was negative. Intraocular antibiotics were used in 88 eyes including 50 which underwent therapeutic vitrectomy. Vision of 20/20 to 20/400 was achieved in 57% of recently operated, culture-positive eyes treated with intraocular antibiotics, and in 59% of those treated with combined vitrectomy and intraocular antibiotics.
Silicone is a material with wide application as an exogenous implant in ophthalmic surgery. Animal trials have indicated that extreme care must be taken in the use of this material in the presence of a viable eye. Acute corneal injury was seen in 10 of 14 rabbit eyes tested with a topical application of RTV silicone in the conjunctival cul-de-sac. Two of the 10 eyes demonstrated delayed healing of the corneal injury. Pretreatment with a viscous ocular lubricant, limited corneal contact time of the hardened forms, thorough and frequent corneal evaluation and prompt appropriate treatment of abnormalities are recommended for the successful use of silicone as an orbital molding material in the presence of the viable globe. For use as an orbital expander or as a stent after soft tissue socket reconstruction, despite its relative softness compared to acrylic orbital conformer, similar precautions must be observed to prevent mechanical corneal injuries.
PURPOSE: The authors report two cases of Mycobacterium keratitis following LASIK. METHODS: The case reports are based on a retrospective review of clinical history and associated findings. RESULTS: Two patients developed infectious keratitis after undergoing laser in situ keratomileusis (LASIK). In case #1, the infection developed after manipulation of the lamellar flap to remove epithelium from the stromal bed. In case #2, prior radial keratotomy may have been a contributing factor to development of the infection. Corneal infiltrates appeared as focal, white, stromal deposits. Cultures isolated Mycobacterium fortuitum from case #1 and Mycobacterium chelonae from case #2. Topical fortified amikacin, clarithromycin, tobramycin, and ciprofloxacin eventually controlled the infection. Topical prednisolone acetate and bandage contact lenses were necessary to control inflammation and pain. Infiltrates were slow to resolve until focal necrosis eroded through the flaps leading to rapid clearing of the infiltrates; however, scarring of the cornea developed at the site of necrosis. Visual recovery was good in the first case but limited in the second. CONCLUSIONS: Mycobacterium keratitis complicating LASIK may be difficult to eradicate until the sequestered stromal infiltrate drains. Rapid recognition of the causative organism and aggressive medical and surgical management of the infection may improve the outcome.
High degrees of surgically induced astigmatism following cataract surgery may limit the desired visual rehabilitation. The induced astigmatism is a reflection of the cataract incision, its closure, and subsequent wound healing. Excessively tight sutures induce central corneal steepening. Wound dehiscence and wound gap cause a flattening of the central cornea along this axis. Wound compression steepens the central curvature. The management of induced astigmatism is directed to the underlying problem. Suture cutting and removal will reduce suture compression of the wound. Repair of wound dehiscence and wound gap will reestablish wound integrity. Incisional keratotomy will compensate the corneal steepening induced by limbal wound compression. The reduction of astigmatism aids visual function by realizing the visual potential of the operated eye.
Evaluation was made of ocular cytologic specimens from 59 patients with clinically suspicious lesions: 47 conjunctival scrapes, 10 vitreous fluid aspirates, 1 corneal scrape and 1 iris cyst aspirate. Tissue correlation was available for 30 of the 59 cases. A control group of 20 normal conjunctival scrapes was also evaluated. Cytomorphologic criteria for normal ocular specimens, inflammatory lesions, premalignant lesions and malignant lesions are presented. These lesions included dysplasia (seven cases), carcinoma in situ (four cases), squamous cell carcinoma (five cases), Meibomian gland carcinoma (three cases), basal cell carcinoma (two cases), metastatic adenocarcinoma (one case), melanoma (two cases) and retinoblastoma (one case). The remaining lesions were nonspecific inflammatory changes and normal variants. The results of this study indicate that cytologic examination of ocular specimens can be a valuable adjunct in the workup of suspected neoplastic eye lesions.