The tarsal pillar technique for narrowing and maintenance of the interpalpebral fissure.

We describe a tarsorrhaphy technique whereby an ipsilateral upper-eyelid tarsal pillar is sutured to a corresponding lower-eyelid recipient site. This technique allows maintenance of a narrowed interpalpebral fissure indefinitely, yet is easy to reverse without incurring lid-margin damage. Additionally, the procedure can be adjusted postoperatively to either narrow or widen the initial surgical result. We report our combined surgical experience in 35 consecutive procedures using this technique to treat eyes with exposure-related keratopathy of varied etiology, including facial nerve palsies, combined facial nerve palsy and trigeminal neuropathy with an anesthetic cornea, Graves' disease, congenital craniofacial anomalies, and severe keratitis sicca syndrome. The procedure was successful in improving exposure keratopathy symptoms in all 35 cases. Complications, reflecting the authors' learning curve with this new procedure, included intermarginal pyogenic granulomas, stretching of the tarsal pillar, minor lower-eyelid-margin eversion, and tarsal pillar dehiscence.     

Pemphigoid-like ocular lesions in patients with graft-versus-host disease following allogeneic bone marrow transplantation

We present two patients who developed keratitis sicca and pemphigoid-like symptoms following allogeneic bone marrow transplantation (BMT). The diagnosis of ocular graft-versus-host disease (GvHD) was considerably delayed in both. They were admitted to the reference ophthalmology and posttransplant care departments years after allogeneic BMT, when skin biopsy revealed changes typical for chronic GvHD. In both cases either systemic or local immunosuppressive treatment led to improvement of the clinical condition but did not significantly change patients' quality of life.     

Early gold weight eyelid implantation for facial paralysis

Facial paralysis can result in serious keratopathy because of corneal exposure and inadequate lacrimation. Thirty-seven patients underwent thirty-eight gold weight upper lid implants to rehabilitate paralysis of the eyelid from various causes. When indicated, implantation was combined with lower lid ectropion repair, medial canthoplasty or brow lift. Because of encouraging results in patients with longstanding facial paralysis, "early" implantation (within 1 month of paralysis) was offered to patients with severe lagophthalmos in whom (1) a severe neural injury was documented at the time of transtemporal surgery or (2) delayed, incomplete return of function was expected. Gold weight implantation resulted in excellent eyelid closure, protection, and cosmesis. There were no infections or extrusions. Lagophthalmos and exposure keratitis resolved or were significantly improved in all patients, and most were able to dispense with eyedrops and salves. Visual acuity improved in 95% of patients--a benefit even those without preoperative keratitis often achieved. A mild worsening of one patient's pre-existing astigmatism developed, which resolved after reimplantation with a lighter weight. The implant is easily removed from those patients who, having undergone early implantation, eventually recover adequate function. Gold weight loading has become our procedure of choice for eyelid rehabilitation.     

Complications of penetrating keratoplasty: graft infections

Microbial infection of a corneal transplant is a complication that is a bane to all corneal surgeons, the sequelae of which can be devastating. Identified risk factors include exposed, loose, or broken sutures; persistent epithelial defects or severe punctate keratopathy; soft contact lens wear including therapeutic lenses; graft hypoesthesia; kerato-conjunctivitis sicca; previous herpetic eye disease; graft failure; ocular adnexa and lid abnormalities; and ongoing external and corneal infections. Management includes preventive measures, microbiologic diagnostic procedures, and antibiotic therapy. Infectious crystalline keratopathy is a unique corneal infection that predominantly occurs in corneal transplants. It is characterized by the slowly progressive development of needle-like opacities in the corneal stroma and is most commonly caused by streptococcal species. Another group of infections that occur in grafts is recurrence of an infectious process for which the patient was originally grafted. Two notable pathogens in this group include Acanthamoeba and herpes simplex.     

Eye signs in anaesthesia and intensive care

Ophthalmology can be unfamiliar territory for the anaesthetist and intensivist. This updated article describes the clinical signs that may indicate injury to the eye, relevant to the operating theatre and intensive care environments. Patients are at risk of corneal abrasions, exposure keratopathy and chemosis. Prone positioning of patients, a task all too familiar to medical and nursing staff throughout the coronavirus disease (COVID-19) pandemic, is associated with additional risks of ischaemic optic neuropathy and acute glaucoma. The intensivist should also be alert to signs of ocular infection, for example, conjunctivitis, microbial keratitis and endophthalmitis. Ocular injury in the trauma patient requires prompt evaluation and management of sight-threatening conditions.     

The effectiveness of the pigtail probe method of repairing canalicular lacerations.

The pigtail probe method of repairing canalicular lacerations is a widely used technique, however its long-range effectiveness has never been documented. By evaluating statistical data on 51 canalicular lacerations, and then examining 30 patients who had been repaired by the pigtail probe we were able to conclude that: a left inferior canalicular laceration, in a young male, following assault is the most common presentation; that this method objectively yields a 36.6% patency rate with a 10% incidence of iatrogenic damage to the uninvolved side; that 73.3% of the failures remained asymptomatic; secondary to keratitis sicca, a functioning conjunctival canalicular fistula, or the patent remaining canaliculus; and that the inferior canaliculus appears to be symptomatically more important than the superior canaliculus. It is suggested that all canalicular lacerations be repaired, but that the pigtail probe method be abandoned.     

Infectious crystalline keratopathy occurring in an eye subsequent to glaucoma filtering surgery with postoperative subconjunctival 5-fluorouracil

We present a case of infectious crystalline keratopathy occurring after 5-fluorouracil filtering surgery. The patient had discrete, branching, white crystalline lesions in the anterior corneal stroma. Cultures grew Streptococcus viridans, and gram-positive cocci were demonstrated in corneal tissue biopsy specimens. Toxic and immunosuppressive properties of 5-fluorouracil may have participated in the pathogenesis of the infectious crystalline keratitis.     

Pulmonary function abnormalities in Sjögren's syndrome and the sicca complex.

The frequency of pulmonary involvement in a group of 20 patients with Sjögren's syndrome or the sicca complex was evaluated with pulmonary function studies. In 12 patients pulmonary functional abnormalities were demonstrated. The most common abnormality was airway obstruction. Nine out of 13 patients with the limited variant of the disease (sicca complex) and three out of seven patients with the complete syndrome had abnormal pulmonary function.     

Eye signs in anaesthesia and intensive care

Ophthalmology can be unfamiliar territory for the anaesthetist and intensivist. This article describes the signs associated with iatrogenic injury to the eye in the operating theatre and the intensive care unit. Patients are at risk of corneal abrasions, exposure keratopathy and chemosis. The prone patient encounters an additional risk of ischaemic optic neuropathy and acute glaucoma. In the intensive care setting, the intensivist should be alert to signs of ocular infection, for example, conjunctivitis, microbial keratitis and endophthalmitis. In the trauma patient, careful evaluation of the eye is required to rule out sight-threatening conditions such as retrobulbar haemorrhage, globe rupture, orbital fractures and retinal detachment.     

医护品管圈在降低危重症患者暴露性角膜炎的发生率中的应用

［摘要］ 目的 探讨医护品管圈在降低ICU 患者危重症患者暴露性角膜炎发生率中的应用效果。方法 成立ICU医护品管圈小组,确立活动主题为降低危重症患者暴露性角膜炎的发生率,更新、强化护理人员暴露性角膜炎相关知识、规范眼部相关操作。选择实施医护品管圈前（2018年1~2月）58名ICU患者为对照组。选择医护品管圈实施后（2018年3～4月）81例ICU患者为干预组,比较两组暴露性角膜炎的发生率。结果 与对照组相比,干预组暴露性角膜炎的发生率较低（P<0.05）。结论 正确运用医护品管圈可降低危重症患者暴露性角膜炎的发生率,并且能提高圈员的综合护理能力。     

Preliminary clinical report of alternate episodes of Posner–Schlossman syndrome and viral keratitis

Posner–Schlossman syndrome (PSS) and viral keratitis have a shared pathogen and are common diseases in China, but there are few case reports on whether these two diseases occur concurrently or alternately. After long-term clinical observations, six patients with alternating episodes of PSS and viral keratitis were confirmed at our hospital in the past 10 years. Of the six patients, three were female and three were male. Four patients had monocular PSS with ipsilateral monocular viral keratitis, one had monocular PSS with bilateral viral keratitis, and one had bilateral PSS with bilateral viral keratitis. Of the six cases, three had epithelial viral keratitis and three had endothelial viral keratitis. In four cases, the interval between the onset of the two diseases ranged from 8 days to 3 years, and two cases showed overlapping manifestations of the two diseases in 3 to 6 days, both with incomplete absorption of keratic precipitates. The six cases had intermittent episodes of both diseases and significant loss of corneal sensation during the onset of viral keratitis, and were effectively treated with antiviral therapy. PSS and viral keratitis may alternate episodically, and clinical attention should be paid to these conditions. The mechanism of the alternate episodes might be associated with viral infection and the use of glucocorticoids.     

再次穿透性角膜移植原因临床分析

目的分析行再次穿透性角膜移植（repeatpenetratingkeratoplasty,RPK）患者的原发病以及再次角膜移植的直接原因。方法调查1999年1月1日～2008年12月31日在青岛眼科医院和山东省眼科医院接受穿透性角膜移植的患者资料,对其中行RPK患者的资料进行回顾性分析,分析RPK患者的原发病和RPK的直接原因以及高危受者RPK的直接原因。结果10年间共有2922例患者（3455只眼）接受了穿透性角膜移植手术,其中接受RPK共206例患者（215只眼）。RPK受者中男性148例,女性58例,平均年龄（39．2±17．6）岁。原发病依次为单纯疱疹病毒性角膜炎（19％）、化脓性角膜炎（18％）、角膜裂伤（14％）、角膜烧伤（13％）、大泡性角膜病变（11％）、角膜变性或营养不良（9％）、角膜白斑（7％）、圆锥角膜（6％）、植片混浊（2％）、其他（1％）。RPK的直接原因依次为角膜移植片慢性失功（45％）、移植角膜排斥反应（27％）、角膜移植片溃疡（18％）、原发病复发（7％）、其他（3％）。其中高危受者RPK的前两位原因分别为移植角膜排斥反应（46％）和角膜移植片慢性失功（31％）;非高危受者RPK的前两位原因分别为角膜移植片慢性失功（60％）和角膜移植片溃疡（17％）。结论RPK受者原发病以感染性疾病为主;排斥反应和角膜移植片慢性失功造成的角膜移植片混浊分别是高危和非高危受者接受RPK的主要原因。     

The incidence of preoperative endothelial dystrophy in pseudophakic bullous keratopathy

To investigate the contribution of endothelial dystrophy to the subsequent development of pseudophakic bullous keratopathy, we retrospectively reviewed the clinical records and histopathologic specimens of pseudophakic patients who had undergone penetrating keratoplasty for corneal decompensation. Conclusive evidence of endothelial dystrophy was found in a majority (18 of 27, 67%) of patients who developed pseudophakic bullous keratopathy following implantation of a posterior chamber intraocular lens. By contrast, the incidence in a comparable group of 51 pseudophakic bullous keratopathy patients with anterior chamber intraocular lenses was low (six of 51, 12%) (P less than 0.01). In analyzing the relative risk of post-surgical corneal decompensation, one cannot implicate a particular intraocular lens without considering pre-existing endothelial dystrophy.     

Herpes Zoster Ophthalmicus

The management of herpes zoster (HZ) usually involves a multidisciplinary approach aiming to reduce complications and morbidity. Patients with herpes zoster ophthalmicus (HZO) are referred to ophthalmologists for prevention or treatment of its potential complications. Without prompt detection and treatment, HZO can lead to substantial visual disability. In our practice, we usually evaluate patients with HZO for corneal complications such as epithelial, stromal, and disciform keratitis; anterior uveitis; necrotizing retinitis; and cranial nerve palsies in relation to the eye. These are acute and usually sight-threatening. We recommend oral acyclovir in conjunction with topical 3% acyclovir ointment, lubricants, and steroids for conjunctival, corneal, and uveal inflammation associated with HZO. Persistent vasculitis and neuritis may result in chronic ocular complications, the most important of which are neurotrophic keratitis, mucus plaque keratitis, and lipid degeneration of corneal scars. Postherpetic complications, especially postherpetic neuralgia (PHN), are observed in well over half of patients with HZO. The severe, debilitating, chronic pain of PHN is treated locally with cold compresses and lidocaine cream (5%). These patients also receive systemic treatment with NSAIDs, and our medical colleagues cooperate in managing their depression and excruciating pain. Pain is the predominant symptom in all phases of HZ disease, being reported by up to 90% of patients. Ocular surgery for HZO-related complications is performed only after adequately stabilizing pre-existing ocular inflammation, raised intraocular pressure, dry eye, neurotrophic keratitis, and lagophthalmos. Cranial nerve palsies are common and most often involve the facial nerve, although palsy of the oculomotor, trochlear, and abducens nerves may occur in isolation or (rarely) simultaneously. In our setting, complete ophthalmoplegia is seen more often than isolated palsies, but recovery is usually complete. Vasculitis within the orbital apex (orbital apex syndrome) or brainstem dysfunction is postulated to be the cause of cranial nerve palsies. A vaccine of a lyophilized preparation of the oka strain of live, attenuated varicella-zoster virus is suggested for patients who are at risk of developing HZ and has been shown to boost immunity against HZ virus in older patients.     

Penetrating keratoplasty combined with flexible anterior chamber lens implantation

We present an initial report on flexible anterior chamber lens implantation in 14 aphakic or pseudophakic bullous keratopathy patients undergoing penetrating keratoplasty. With a minimum follow-up of 12 months, the improvement in visual acuity and graft clarity is encouraging.     

Pseudophakic keratoplasty: posterior chamber lens implantation in the presence of ruptured capsule

A technique is described for implantation of a posterior chamber intraocular lens during keratoplasty for bullous keratopathy when a large capsulotomy and vitreous prolapse are present. Seven cases of pseudophakic or aphakic bullous keratopathy with anterior chamber, iris-fixated, or no intraocular lens in place are reported. A completely intact posterior capsule is not necessary to support safely a sulcus-fixated posterior chamber lens. Anterior segment reconstruction, careful removal of existing intraocular lenses (except a posterior chamber lens), vitrectomy through the ruptured posterior capsule, and assessment of the remaining posterior capsule rim are important surgical objectives.     

Is the relationship between spondyloarthropathy and Sjögren's syndrome in women coincidental? A study of 13 cases

OBJECTIVE: To determine the prevalence of Sjogren's syndrome (SS) in women with spondyloarthropathy (SpA). METHODS: Forty-one women with SpA manifesting as inflammatory back pain and/or peripheral arthritis were diagnosed as having ankylosing spondylitis, undifferentiated spondyloarthropathy, psoriatic arthritis, or enteropathic arthropathy based on accepted criteria. A validated questionnaire was used to look for sicca symptoms in the SpA group and in 102 controls with degenerative rheumatic diseases. Women with SpA and sicca symptoms and/or positive antinuclear antibodies (ANA) were investigated for SS by minor salivary gland biopsy. In the SpA group, the following tests were done: HLA B27; HLA DR, DQ; ENA; and serology for CMV, EBV, HIV, hepatitis B, and hepatitis C. RESULTS: Thirteen women (31.7%) met European criteria for SS, compared to three (2.9%) of the controls. Of the 41 women with SpA, 16 (39%) were ANA-positive. ANA were detected in eight of the 16 (50%) patients with SS. HLA B27 was present in 11 of the 13 (84.6%) SS patients. HLA DR 04.04 and DQ 03.03 seemed more common in SS patients, but the difference was not statistically significant. CONCLUSION: SS was far more common in the women with SpA (31.7%) than in the controls (2.9%), suggesting that the SpA-SS association may not be coincidental.     

Bilateral Z-flap pharyngoplasty in the treatment of rhinolalia

A technique using a bilateral Z-flap pharyngoplasty in the treatment of rhinolalia is reviewed. Also reviewed is the historical development of the surgical treatment of rhinolalia. Sixteen patients with rhinolalia and 3 patients with pharyngitis sicca who were treated by this technique have been followed for up to 16 years, and have shown marked improvement in speech.     

Clinical and morphological features of kidney involvement in primary Sj?gren's syndrome.

BACKGROUND: Primary Sj?gren's syndrome is a connective tissue disorder affecting primarily the lacrimal and salivary glands, resulting in xerophtalmia and xerostomia. Extraglandular manifestations are frequent and may include renal involvement. METHODS: We studied the prevalence and nature of kidney involvement in 60 Italian patients with primary Sj?gren's syndrome, diagnosed according to the European classification criteria. The following renal laboratory tests were performed in all patients: electrolytes in serum and in 24-h urine, creatinine in serum and in 24-h urine, venous pH and HCO(3)(-), urinalysis, urine culture, urinary osmolality and urine pH. A water deprivation test was performed in patients with morning urine osmolalities below the reference values adjusted for age. An oral ammonium chloride loading test was performed in patients with urine pH above 5.5 from morning samples. Renal biopsy was performed in patients with renal involvement. RESULTS: Sixteen patients (27%) had laboratory evidence of tubular and/or glomerular dysfunction. A variable degree of creatinine clearance reduction was found in eight patients (13%); frank distal tubular acidosis in three (5%); hypokalaemia in four (7%); and pathological proteinuria in 12 (20%). Urine concentrating capacity was defective in 10 out of 48 (21%) tested patients. Only four patients presented with overt clinical manifestations, including hypokalaemic tetraparesis (1), nephrotic syndrome (2), recurrent renal stones with flank pain and haematuria (1). In two patients, signs of renal involvement preceded the onset of sicca syndrome. Renal biopsies from nine patients showed tubulo-interstitial nephritis in six and glomerular disease in three. Patients with renal involvement had a significantly shorter disease duration compared with patients without renal abnormalities. CONCLUSIONS: Kidney involvement is a frequent extraglandular manifestation of primary Sj?gren's syndrome. It is rarely overt and may precede the onset of subjective sicca syndrome.     

Lˈassociation spondylarthropathie féminine-syndrome de Gougerot-Sjögren est-elle fortuite ? À propos de 13 cas

Objective. To determine the prevalence of Sjögrenˈs syndrome (SS) in women with spondyloarthropathy (SpA). Methods. Forty-one women with SpA manifesting as inflammatory back pain and/or peripheral arthritis were diagnosed as having ankylosing spondylitis, undifferentiated spondyloarthropathy, psoriatic arthritis, or enteropathic arthropathy. A validated questionnaire was used to look for sicca symptoms in the SpA group and in 102 controls with degenerative rheumatic diseases. Women with SpA and sicca symptoms and/or positive antinuclear antibodies (ANA) were investigated for SS by minor salivary gland biopsy. In the SpA group, the following tests were done: HLA B27; HLA DR, DQ; ENA; and serology for CMV, EBV, HIV, hepatitis B, and hepatitis C. Results. Thirteen women (31.7%) met European criteria for SS, compared to three (2.9%) of the controls. Of the 41 women with SpA, 16 (39%) were ANA-positive. ANA were detected in eight of the 16 (50%) patients with SS. HLA B27 was positive in 11 of the 13 (84.6%) SS patients. HLA DR 04.04 and DQ 03.03 seemed more common in SS patients, but the difference was not statistically significant. Conclusion. SS was far more common in the women with SpA (31.7 %) than in the controls (2.9 %), suggesting that the SpA-SS association may not be coincidental.