Intraocular pressure elevation from topical difluprednate use

IntroductionDifluprednate ophthalmic emulsion 0.05% (Durezol?, Alcon, Fort Worth, Texas) is a topical difluorinated derivative of prednisolone with potent anti-inflammatory activity. Difluprednate 0.05% has a reported associated increase in intraocular pressure (IOP) in 3% of patients. Although the occurrence may be low, the possible elevation in IOP may be substantially higher than commonly encountered with other topical steroids.Case ReportsA 49-year-old black man presented with a traumatic anterior uveitis recalcitrant to traditional prednisolone acetate 1% treatment. The patient was switched to difluprednate 0.05% in an attempt to better control the ocular inflammation. Although the patient did not exhibit an IOP response after 4 weeks of treatment with prednisolone acetate 1%, he did experience a pressure response within 2 weeks of initiating difluprednate treatment, resulting in an IOP increase from 9 mmHg to 48 mmHg with subsequent microcystic edema.A 44-year-old black woman presented with recurrent scleritis resistant to topical prednisolone acetate, loteprednol etabonate, and oral nonsteroidal anti-inflammatory therapy. Topical loteprednol 0.5% was replaced by difluprednate 0.05%. All evidence of ocular inflammation was eradicated with the changed therapy. IOP rose in the difluprednate-treated eye from 18 mmHg to 34 mmHg over the course of 18 days. In both cases, the IOP elevation was managed rapidly with the discontinuation of difluprednate and temporary use of IOP-reducing agents with no lasting adverse effects.ConclusionDifluprednate 0.05% is a new topical therapeutic option indicated for the treatment of inflammation and pain management associated with ocular surgery with an off-label potential for treatment of other anterior segment inflammatory conditions. However, clinicians need to be aware of the potential risk for significant and potentially rapid onset of IOP increase with this medication and manage patients accordingly.     

Intraocular lens implantation without the use of ophthalmic viscosurgical device

The purpose of this study was to determine whether single-piece hydrophilic acrylic intraocular lens can be safely implanted without the use of ophthalmic viscosurgical devices. This retrospective study comprised 100 eyes having phacoemulsification and intraocular lens implantation without the use of ophthalmic viscosurgical device. 80 eyes with the use of a viscosurgical device are used as control group. In this intraocular lens implantation technique, the anterior chamber was maintained with an irrigation cannula and intraocular lens was implanted with a lens injector. Visual acuity, corneal clarity and edema, intraocular pressure, and corneal endothelial cell count were evaluated preoperatively and postoperatively at days 1, 7, and 30. Corneal endothelial cell count was repeated 2 weeks after surgery. Complications of this technique were also evaluated. No significant complications of this intraocular lens implantation technique, such as posterior capsule rupture, intraocular lens buttonholing, zonular dialysis, Descemet’s tear/detachment, occurred. On the seventh postoperative day, 90 % of eyes achieved 20/20 or better vision. There was no difference in corneal endothelial cell loss between viscoelastic device-used and not-used cases (p = 0.356). When implanting intraocular lens without the use of ophthalmic viscosurgical device, significant intraoperative complications did not occur. The possible advantages are shortened surgery time, avoidance of postoperative IOP spike from ocular viscosurgical device (OVD) remnant, and reduced cost.     

Intraocular gnathostomiasis

We report a rare case of intraocular Gnathostomiasis, where a live worm, intracameral in location, was successfully removed. Its identity was confirmed by microscopy.     

Intraocular ossification

Following a general introduction to the problem of heterotopic bone formation the pathogenetic stages of intraocular ossification are described. Intraocular ossification was found in 30 (7%) of 423 eyes enucleated between 1974 and 1984. In 60% of the eyes the ossification was associated with trauma, in 25% with chronic uveitis. Bone formation started between four and 44 years after the onset of ocular disease and in most cases originated in the retinal pigment epithelium.     

Intraocular coccidioidomycosis

A case of unsuccessfully treated coccidioidomycosis with intraocular manifestations is presented. Fever, skin lesions and a variety of constitutional symptoms dominated the clinical course. At autopsy there were extensive systemic dissemination and conspicuous intraocular lesions involving the uveal tract. The ocular and systemic features and the immunologic aspects of Coccidioidomycosis are discussed. Previously reported intraocular cases are reviewed and compared to our case.     

Intraocular biopsy

This article discusses the indications for intraocular tumor biopsy, the techniques used for obtaining material, and the approaches for analysis of these specimens.     

Intraocular choristoma

Choristomas have been reported in the orbit, cornea, conjunctiva, uvea, retina, and optic nerve. Many reports have described the choristoma mainly in the epibulbar area, but little is known of the choristoma that occurs intraocularly. We reviewed the literature and summarized the reports that described the choristoma inside the eyes. Iris, ciliary body, choroid, and optic nerve head are the commonly affected tissues. In the anterior uveal tissue, an ectopic lacrimal gland is common and appears as a pinkish, nodular, fleshy mass. Its clinical course largely depends on the enlargement of the accompanying cyst. Osseous choristoma is mainly found in the choroid in young female patients. Although it is regarded as a benign tumor, it grows progressively and can decrease visual function. Treatment consists of close observation and possibly surgical intervention. Fortunately, most of the intraocular choristomas do not need aggressive treatment.     

Intraocular lymphoma

There are two distinct forms of intraocular lymphoma. One originates within the central nervous system (CNS) and is called primary CNS lymphoma. The second form arises outside the CNS and metastasizes to the eye. When primary CNS lymphoma initially involves the retina, it is named primary intraocular lymphoma (PIOL). Although PIOL is a rare malignancy, the incidence has dramatically increased in the past 15 years. Typical clinical manifestations include blurred vision and floaters. Ophthalmic examination reveals vitreitis and subretinal infiltrates. Diagnosis of PIOL can be difficult and requires neuroimaging, examination of the cerebrospinal fluid and/or vitreous. Molecular analysis detecting immunoglobulin gene rearrangements and ocular cytokine levels showing elevated interleukin (IL)-10 with an IL-10 to IL-6 greater than 1.0 are helpful adjuncts for the diagnosis. Treatment includes systemic chemotherapy and radiation with current regimens favoring the use of chemotherapy first. In contrast, metastatic systemic lymphoma, like other metastatic ocular tumors, is usually confined to the uvea, in particular the choroid. Compared with PIOL, metastatic systemic lymphomas have a much lower prevalence, better prognosis, and are less likely to create a diagnostic dilemma.