Topical mitomycin C chemotherapy for conjunctival melanoma and PAM with atypia

AIM—To evaluate topical mitomycin C (MMC) chemotherapy in the treatment of conjunctival melanoma and primary acquired melanosis with atypia.
METHODS—In a phase I clinical trial, 10 patients with conjunctival melanoma and/or primary acquired melanosis with atypia were treated with topical MMC 0.04% four times daily. Four patients were given MMC for 28 days as a primary treatment. Six patients were treated with MMC for 7 days after excision and cryotherapy in an effort to improve local control. In this series, 10 patients have been followed for an average of 29 months.
RESULTS—All patients were noted to develop transient keratoconjunctivitis during treatment. One patient also developed a transient corneal epithelial defect. Decreased conjunctival pigmentation was noted in the four patients where topical chemotherapy was used as a primary treatment. Nodular tumours were resistant to topical MMC chemotherapy. Of the six patients treated within 2 weeks after primary excision and cryotherapy, there has been no tumour recurrence or symblepharon formation. Nine of the 10 study patients have maintained within one line of their pretreatment visual acuity. No retinal or optic nerve toxicity was noted.
CONCLUSION—Since no complications which might preclude further investigation of topical MMC chemotherapy occurred, it was concluded that topical MMC chemotherapy was tolerated as a treatment for conjunctival melanoma and primary acquired melanosis with atypia.

Keywords: conjunctival melanoma; primary acquired melanosis; mitomycin C     

Corneoscleral transplantation for end stage corneal disease

AIM—To describe the prognosis and complications of corneoscleral transplantation in the management of end stage eye disease.
METHODS—A case series is presented of 23 patients who have undergone corneoscleral transplantation (11 mm). Patients were examined for visual acuity, intraocular pressure, recurrence of disease process, epithelialisation of the graft, signs of rejection, and other potential complications.
RESULTS—14 patients retained their eye, with six maintaining a clear graft. Vision ranged from 6/30 to no perception of light. 13 patients developed glaucoma (range 25-69 mm Hg), with six patients requiring surgical intervention. 12 patients required tarsorrhaphy to promote epithelialisation. Only two grafts resulted in typical rejection.
CONCLUSIONS—The technique of corneoscleral transplantation can salvage otherwise end stage eye disease, but the results are poor with respect to maintenance of vision. These patients need careful follow up because of potential complications of glaucoma, epithelial defects, rejection, and recurrence of disease.

Keywords: corneoscleral graft; end stage corneal disease; sclerokeratoplasty     

Comparison of the efficacy of diclofenac and betamethasone following strabismus surgery

AIMS—To compare the relative anti-inflammatory potency and safety of topical diclofenac-gentamicin with beta methasone-neomycin following strabismus surgery.
METHODS—A single centre, single observer, prospective, randomised, and double masked clinical trial of 25 children undergoing bilateral symmetrical horizontal strabismus surgery was carried out. One eye received diclofenac-gentamicin and the contralateral eye received betamethasone-neomycin; both treatments were instilled four times a day for 4 weeks postoperatively. Ocular inflammation was assessed at 1 and 4 weeks postoperatively, objectively by comparison with a photographic chart and subjectively by questionnaire.
RESULTS—There was no statistically significant difference in the rate of resolution of the inflammatory response between each group at both visits.
CONCLUSION—Diclofenac appears to be as effective as betamethasone in controlling postoperative inflammation following strabismus surgery and may offer a safer alternative to the use of topical steroids.

     

Topical anaesthesia with oxybuprocaine versus sub-Tenon's infiltration with 2% lignocaine for small incision cataract surgery

AIMS—To determine whether topical anaesthesia in small incision self-sealing phacoemulsification cataract surgery provides comparable anaesthesia to sub-Tenon's infiltration.
METHODS—Thirty five patients undergoing small incision self-sealing phacoemulsification cataract surgery were allocated randomly to receive topical anaesthesia with 0.4% oxybuprocaine or sub-Tenon's infiltration with 2% lignocaine. Pain experienced during the operation was assessed by asking the patient to score on a visual analogue graphic pain score chart.
RESULTS—The median pain score for the topical group (3) was significantly higher than that of the sub-Tenon's group (0) (p = 0.004).
CONCLUSION—Sub-Tenon's infiltration is superior to topical anaesthesia in ensuring patient comfort during small incision scleral tunnel self-sealing phacoemulsification cataract surgery.

     

Dry eye and Meige's syndrome

AIMS—To determine the relation between dry eye and Meige's syndrome.
METHODS—325 patients with dry eye were divided into those responsive to topical and other forms of treatment (n=276) and those who were not (n=49). A neuropsychiatric examination was performed to check for Meige's syndrome in the latter group.
RESULTS—Twenty eight (57%) of the treatment unresponsive patients were diagnosed with Meige's syndrome.
CONCLUSIONS—There is a subgroup of patients with dry eye who do not respond to simple therapy. More than half of these patients have Meige's syndrome and need psychiatric, as well as ophthalmic, care.

     

Corneal infiltration after recurrent corneal epithelial erosion

AIMS—To describe the clinical features of patients with a history of recurrent corneal epithelial erosion who develop acute corneal infiltration.
METHODS—The records were reviewed of patients who had previously been examined and treated for recurrent corneal epithelial erosion and who presented again with signs suggestive of a microbial keratitis.
RESULTS—11 patients were described; one patient presented with similar signs on two occasions. There was typically a paracentral epithelial defect >2 mm in diameter with an associated stromal infiltrate and an intense anterior uveitis. Three patients had a hypopyon, and four developed a subepithelial ring infiltrate. Samples were taken for microscopy and bacterial culture, with a positive isolate from two of 12 episodes (16%). Treatment with topical antibiotics and topical corticosteroid resulted in rapid re-epithelialisation and a reduction of inflammation. There was good visual outcome for all eyes, with a recurrence or symptoms of epithelial erosion in only one eye after a mean follow up period of 18 months.
CONCLUSIONS—Corneal infiltrates are an uncommon complication of recurrent corneal epithelial erosion. Despite the intensity of the infiltration the majority are culture negative using established techniques. There is typically rapid resolution and a good visual outcome, with a tendency for the episode to mark the end of further symptoms of epithelial erosion.

     

Treatment of common ocular allergic disorders; a comparison of lodoxamide and NAAGA

BACKGROUND/AIMS—Lodoxamide tromethamine and N-acetyl-aspartyl glutamic acid (NAAGA) are mast cell stabilisers, both of which have been shown to be effective in the treatment of allergic conjunctivitis. The aim of this study was to compare the two compounds in patients with common ocular allergic disorders.
METHODS—73 patients participated in a double masked, randomised multicentre study. Diagnoses were chronic allergic conjunctivitis, vernal conjunctivitis, seasonal and atopic conjunctivitis. 36 patients were treated with lodoxamide 0.1% and 37 with NAAGA 4.9%, the drops being instilled four times daily for up to 56 days.
RESULTS—The overall opinion of the physicians and the patients was in favour of lodoxamide at day 10 of the study. At this time, 86% of lodoxamide treated and 49% of NAAGA treated patients considered they had improved. The patients' opinion favoured lodoxamide at day 28 and both physicians' and patients' evaluations were in favour of lodoxamide at day 42. Evaluation of signs and symptoms indicated superiority of lodoxamide at days 42 and 56. Both treatments were well tolerated.
CONCLUSION—While both lodoxamide and NAAGA treatments are associated with clinical improvements in patients with allergic conjunctivitis, lodoxamide may have an earlier onset of action.

Keywords: allergic conjunctivitis; lodoxamide; NAAGA; topical therapy     

Randomised, controlled trial of spirometric changes in elderly people receiving timolol or betaxolol as initial treatment for glaucoma

AIM—To investigate respiratory and cardiovascular side effects in elderly people in the first 12 months after commencing topical β antagonists.
METHODS—40 patients (mean age 74 years) were recruited to a randomised, masked study. Spirometry, pulse, and blood pressure were recorded before, 1 month, and 12 months after starting topical therapy with either timolol 0.5% twice daily or betaxolol 0.5% twice daily.
RESULTS—After 1 month five of 20 patients allocated timolol and three of 20 given betaxolol had discontinued it for respiratory reasons, not always accompanied by symptoms. There were no significant differences in changes in mean values of spirometry, pulse, or blood pressure between groups. No further changes were made in therapy for respiratory reasons in the following year. One patient suffered a hypotensive stroke within 2 days of starting timolol.
CONCLUSIONS—By performing spirometry before starting topical β antagonist therapy and repeating it after 1 month most patients at risk of respiratory impairment can be identified.

Keywords: spirometry; elderly; timolol; betaxolol; glaucoma     

Retinopathy of prematurity: systemic complications associated with different anaesthetic techniques at treatment

BACKGROUND—Treatment of retinopathy of prematurity (ROP) in the UK is subject to considerable regional variation in terms of anaesthetic support. Change in practice at St Mary's neonatal medical unit from topical to general anaesthesia and, subsequently, to sedation/analgesia allowed comparison of the impact of these three modalities on infants' early postoperative course in a consecutive, non-randomised, observational study.
METHODS—The study population consisted of 30 babies undergoing treatment of threshold ROP. Twelve were treated using topical anaesthesia alone (group A), six using general anaesthesia (group B), and 12 using sedation/analgesia combined with elective intubation and artificial ventilation (group C). Daily measurements of infant health were recorded starting 4 days preoperatively and continuing for 7 days postoperatively to facilitate the formulation of a cardiorespiratory stability index as follows: (0) improvement from baseline, (1) no change from baseline, (2) mild instability, (3) marked instability, and (4) life threatening event.
RESULTS—Within the first 48 hours postoperatively in group A 5/12 showed mild instability and 4/12 showed marked instability (including three babies suffering life threatening events requiring emergency resuscitation). In group B within the first 48 hours postoperatively 1/6 showed mild and 1/6 showed marked instability, and in group C 5/12 babies showed mild instability alone. There was a significant difference for cardiorespiratory stability scores between the three groups overall for the 7 days postoperatively (repeated measures ANOVA, p = 0.018).
CONCLUSIONS—Premature infants undergoing cryotherapy for ROP who were treated using topical anaesthesia alone had more severe and protracted cardiorespiratory complications.

     

Successful treatment of optic neuropathy in association with systemic lupus erythematosus using intravenous cyclophosphamide

BACKGROUND—Optic neuropathy is a rare manifestation of systemic lupus erythematosus (SLE). In a previous series most patients with optic neuropathy in association with SLE had a final visual acuity of 20/200 or less despite corticosteroid therapy.
METHODS—Three patients (five affected eyes) with severe retrobulbar optic neuropathy in association with SLE were treated promptly with intravenous cyclophosphamide and corticosteroids.
RESULTS—All patients recovered excellent visual acuity.
CONCLUSION—Although optic neuropathy in association with SLE might have several different aetiologies, intravenous cyclophosphamide should be strongly considered as a therapeutic alternative.

     

Adenoid squamous carcinoma of the conjunctiva—a clinicopathological study of 14 cases

AIMS—In order to determine the clinicopathological features and optimum management of a series of patients with adenoid squamous cell carcinoma of the conjunctiva, all cases of squamous cell carcinoma (SCC) of the conjunctiva and cornea on file in the registry of the ophthalmic pathology at the Armed Forces Institute of Pathology were reviewed.
METHODS—On histopathological examination, a predominant adenoid or pseudoglandular pattern due to islands of neoplastic squamous or epidermoid cells surrounded by acantholytic cells was necessary for inclusion in the study. Histochemical and transmission electron microscopic studies (TEM) were performed. Clinical features of all the patients were extracted from the charts.
RESULTS—The anatomical location of the 14 tumours was corneoscleral limbus (seven patients) and bulbar conjunctiva (seven patients). Eight patients presented with inflammatory signs and irritation (red eye, tearing, foreign body sensation), while six patients developed a slowly growing, painless mass. Histochemical and TEM studies showed extracellular hyaluronic acid and no intracellular mucin. Of the two patients initially treated by enucleation, one was free of disease after 2 years while the second patient had recurrence in the socket and died of brain metastases despite wide orbital excision and radiotherapy. All five patients with recurrent tumours initially had irritated red eyes and two required enucleation. One such patient, after orbital exenteration and radiotherapy, died of unrelated disease.
CONCLUSION—The study demonstrates that adenoid SCC of the conjunctiva often presents with inflammatory signs. The tumour is locally aggressive and may metastasise and should, therefore, be histopathologically differentiated from the less aggressive conventional squamous cell carcinoma. Optimum treatment includes wide excision with documented histological clear margins of resection on permanent sections and frequent follow up.

     

Activated protein C resistance in patients with central retinal vein occlusion

AIM/BACKGROUND—A new defect in the anticoagulant system has recently been discovered—activated protein C resistance. The frequency of this disorder has been shown to be increased in young patients (<50 years of age) with central retinal vein occlusion. This study was carried out to determine if there was any overrepresentation of activated protein C resistance in patients >50 years of age with central retinal vein occlusion.
METHODS—Blood samples were obtained from 83 patients >50 years of age and with a history of central retinal vein occlusion. The blood samples were analysed for activated protein C resistance with standard clinical laboratory methods.
RESULTS—In this material 11% of the patients were resistant to activated protein C. The normal incidence of activated protein C resistance in the same geographical area is 10-11%.
CONCLUSION—Activated protein C resistance does not seem to be a cause of central retinal vein occlusion in people older than 50 years.

     

Assessment of a standard treatment protocol on visual outcome following presumed bacterial endophthalmitis

AIMS—The aim of this prospective study was, firstly, to judge the effect of early aggressive treatment with a standardised regimen of high dose broad spectrum intraocular and systemic antibiotics on visual outcome and, secondly, to assess the sensitivity of isolated organisms to the treatment regimen utilised.
METHODS—Thirty two consecutive patients presenting with presumed bacterial endophthalmitis were treated and completed follow up. In every case, intraocular sampling was undertaken and treatment with intraocular vancomycin, amikacin, and systemic ciprofloxacin was commenced immediately, followed by systemic steroids 1 day later.
RESULTS—In 69% of patients vision improved with 47% achieving a final visual acuity of 6/36 or better and 31% achieving 6/12 or better. Of the intraocular samples taken from post-surgical and post-traumatic cases, 10/27 (37%) and 3/5 (60%) were culture positive, respectively. All the bacteria isolated were sensitive to at least one of the three antibiotics used.
CONCLUSIONS—The study demonstrated that the combination of vancomycin, amikacin, and ciprofloxacin is adequate as a standard regimen for the treatment of most patients with suspected bacterial endophthalmitis. The prognosis for a good visual outcome, however, remains poor with 15/27 (55%) post-surgical and 2/5 (40%) post-traumatic cases achieving a final acuity of 6/60 or less.

     

Natural history of recurrent erosion syndrome—a 4 year review of 117 patients

AIMS/BACKGROUND—Recurrent erosion syndrome encompasses a group of mixed aetiologies for which there are a number of methods of management which may influence the course of the disease.
METHODS—The outcomes of a cohort of patients initially treated with topical lubricants were studied. 117 consecutive patients presenting over 1 year with a history of recurrent erosions were enrolled, baseline characteristics were documented, and treatment with lubricants was initiated. Patients were surveyed 4 years later inquiring about symptoms and treatments required.
RESULTS—A total of 94 (80%) of the initial cohort were contacted. The mean age was 44 years and the sex distribution was 44 males to 50 females. The mean period of follow up was 48 months. 55 (59%) were still symptomatic with attacks occurring at a median frequency of 60 days. 13 patients (24%) complained of an episode at least every week and 28 patients (51%) suffered at least every month. The median pain score (analogue scale of 1-10) was 2.5. Seventy five per cent (n=21) of patients with epithelial basement membrane dystrophy (EBMD) were symptomatic compared with those with a traumatic aetiology among whom 46% (n=28) were symptomatic. This difference was significant (p=0.02). Those with EBMD were more likely to be continuing to use topical lubricants than the trauma group.
CONCLUSION—Patients with a traumatic aetiology are less likely to suffer chronic recurrent erosion syndrome than those with EBMD.

Keywords: recurrent erosion syndrome; aetiology; chronicity     

Intrascleral dissemination of infectious scleritis following pterygium excision

AIMS—To assess the clinical pictures, possible pathogenesis, management, and therapy of patients with infectious scleritis associated with multifocal scleral abscesses following pterygium excision.
METHODS—The records of patients with infectious scleritis after pterygium excision who developed multifocal scleral abscesses presenting from 1988 to the end of 1995 were reviewed. Early culture of abscesses was performed, and topical, systemic antimicrobials, or both were given to all patients. Fourteen eyes were operated on in addition to antimicrobial treatment.
RESULTS—The initial culture reports of scleral ulcers identified Pseudomonas species in 12 of these 18 patients, Aspergillus in one, Mycobacterium fortuitum in one, and mixed organisms in four. Subsequent abscess cultures were taken from 15 of the infected eyes, and revealed the same organism as the initial culture in 12. Associated complications included four serous retinal detachments, three choroidal detachments, two double detachments, five complicated cataracts, and four recurrences of the initial infection. Four eyes required eventual enucleation and 11 eyes regained useful vision.
CONCLUSIONS—With subsequent abscess cultures proving to be the same organism as found in the initial ulcer, the abscess formation appears to represent intrascleral dissemination. Early diagnosis and appropriate, prolonged topical plus systemic antimicrobial treatment are essential to halt the progression of such severe infections.

Keywords: infectious scleritis; scleral abscess; pterygium excision     

Role of impression cytology during hypovitaminosis A

AIMS—Evaluation of the morphological damage to the ocular surface of patients operated for biliopancreatic diversion for pathological obesity and the correlation of impression cytology with vitamin A plasma levels, adaptometry, and other general variables.
METHODS—48 patients (15 males, 33 females, age range 21-73) and 34 normal subjects were examined with fluorescein and rose bengal, a plasma dose of vitamin A, and adaptometry. The results of the various tests were subdivided into three levels (0 = normal, 1 = moderately altered, 2 = seriously altered). The impression cytology and adaptometry results were correlated with vitamin A levels and other patient data (age, nutritional condition, time since operation, percentage weight loss). All the examinations were repeated after intramuscular therapy with vitamin A.
RESULTS—Corneoconjunctival alterations visible with fluorescein and rose bengal staining were present in 67.7% of cases, impression cytology alterations in 93.7%, adaptometric alterations in 82.2%; vitamin A plasma levels were below normal in 95.8% of cases. After the therapy with vitamin A a significant reduction was found for every examination. The correlation between impression cytology and adaptometry and vitamin A plasma levels and between corneoconjunctival alterations and vitamin A plasma levels was significant. There was no significant correlation between impression cytology and nutritional condition, age time since operation, and percentage weight loss.
CONCLUSION—These results show impression cytology is a specific indicator for hypovitaminosis A because it is not influenced by other factors related to the general condition of the patient. Many patients with hypovitaminosis A not demonstrating ocular symptoms of changes visible with fluorescein and rose bengal showed alterations with impression cytology.

Keywords: hypovitaminosis A; vitamin A; impression cytology     

In vivo immunofluorescence to diagnose herpes simplex virus keratitis in mice

BACKGROUND/AIMS—Herpes simplex virus keratitis (HSK) is the most common cause of corneal blindness in the Western world. Delay in the treatment of HSK can lead to a more significant corneal scar and topical steroid treatment in unsuspected active HSK can lead to corneal melting. Current culture techniques for herpes simplex virus (HSV) take several days and commercially available HSV laboratory based diagnostic techniques such as Herpchek vary in sensitivity. This study was conducted to assess the viability of a new, quicker, and simpler method to diagnose HSK.
METHODS—Direct immunofluorescence was used in vivo in a masked study to diagnose HSK in mice using a standard slit lamp with cobalt blue illumination. Murine monoclonal fluorescently labelled antibody was applied to the cornea for 10 or 20 minutes and then washed off with phosphate buffered solution. Mice with HSK were stained with either fluorescently labelled monoclonal antibody against HSV or fluorescently labelled monoclonal antibody against cytomegalovirus. Mice with corneal abrasions of non-viral origin were given fluorescently labelled monoclonal antibody against HSV.
RESULTS—Fluorescence was seen only in the mice with HSK given fluorescently labelled monoclonal antibody against HSV. This observation was confirmed upon microscopic immunofluorescent imaging of the corneal epithelial sheets.
CONCLUSION—In vivo immunofluorescence may be useful in the clinical diagnosis of HSK.

     

Ultrasound biomicroscopic measurement of anterior chamber angle in premature infants

AIM—To establish normative values for the anterior segment in premature infants in relation to postconceptional age and birth weight.
METHODS—Anterior segments were measured in 39 premature infants, 25 to 39 weeks' gestational age by use of ultrasound biomicroscopy and a muscle hook with topical anaesthesia.
RESULTS—Anterior chamber depth, trabecular-iris angle, angle opening (trabecular-iris) distances at 250 and 500 µm from the scleral spur, and the thickness of the thickest part of the iris showed linear increases in relation to postconceptional age and birth weight.
CONCLUSIONS—Ultrasound biomicroscopy is a powerful tool for obtaining precise images and measurement of the anterior segment in preterm neonates. Normative values were established for anterior segment dimensions in relation to postconceptional age and birth weight.

     

Azithromycin for ocular toxoplasmosis

AIMS—To investigate the efficacy of azithromycin in patients with ocular toxoplasmosis.
METHODS—11 immunocompetent patients with ocular toxoplasmosis were treated with azithromycin (500 mg the first day, followed by 250 mg/day for 5 weeks). Ocular and systemic examinations were performed during active retinitis episodes and all patients were followed for at least 1 year.
RESULTS—The intraocular inflammation disappeared within 4 weeks in seven patients, including two cases with progressive retinitis despite previous treatment with pyrimethamine, sulphadiazine, and folinic acid. Recurrence of retinitis occurred in three patients (27%) within the first year of follow up. No systemic side effects of azithromycin were encountered.
CONCLUSION—These results indicate that although azithromycin cannot prevent recurrent disease it may be an effective alternative for patients with ocular toxoplasmosis who cannot tolerate standard therapies.

Keywords: azithromycin; ocular toxoplasmosis     

Acute effect of metipranolol on the retinal circulation

AIM—To assess the effect of topical and systemic application of a β adrenergic receptor blocker on retinal haemodynamics.
METHODS—24 healthy subjects were included in this double masked, randomised, placebo controlled crossover study. Metipranolol, a non-selective β adrenergic receptor blocking agent was used as test drug. In all subjects arm-retina time, arteriovenous passage time, arterial mean dye velocity, the arterial vessel diameters, and capillary flow velocity were quantified from digital video fluorescein angiograms.
RESULTS—A significant effect was observed on the arteriovenous passage time (p<0.05), the arterial mean dye bolus velocity (p<0.05), and capillary blood velocity (p<0.05), but not on the arterial vessel diameter. The arterial mean dye bolus velocity and capillary blood velocity increased after application of the test drug (topical and systemic). In tandem with this a decrease of the arteriovenous passage time was observed. The perfusion pressure increased after topical application and remained unchanged after systemic application of metipranolol.
CONCLUSIONS—This study shows that systemic as well as topical application of metipranolol leads to increased retinal blood flow velocities. The implications of these results for treatment with β adrenergic receptor blockers is not clear. However, in view of these data it is very unlikely that treatment with metipranolol has a negative effect on retinal blood flow.

Keywords: retinal microcirculation; β adrenergic blockers; scanning laser ophthalmoscopy