A case of intramuscular hemangioma presenting with large-angle hypertropia

PURPOSE: To report the case of a patient with large-angle hypertropia of an intramuscular hemangioma of the right superior rectus muscle (SR). METHODS: A 63-year-old man with progressive vertical deviation of the right eye for the past 6 months visited our strabismus department; his condition was not painful. An examination indicated that he had 60PD of right hypertropia at distance and near in primary gaze. Additionally, a significant limitation of his downgaze was noted. The right eye appeared mildly proptotic, and the upper and lower eyelids were slightly edematous. Corrected vision was 20/20 in both eyes. RESULTS: Orbital magnetic resonance imaging (MRI) studies revealed fusiform enlargement of the right superior rectus muscle, with prominent but irregular enhancement following gadolinium administration. Incisional biopsy revealed an intramuscular hemangioma in the superior rectus muscle with cavernous-type vessels. CONCLUSIONS: This case demonstrates that intramuscular hemangioma should be considered in the differential diagnosis of isolated extraocular muscle enlargement and unusual strabismus.     

Infectious crystalline keratopathy caused by Serratia marcescens

PURPOSE: To report the case of a 70-year-old woman with Serratia infectious crystalline keratopathy. METHODS: Case report. RESULTS: This is a report of a 70-year-old woman with a history of chronic open-angle glaucoma and trachoma with lagophthalmos, entropion, and trichiasis in both eyes who developed crystalline keratopathy after penetrating keratoplasty and cataract extraction in the right eye followed up with treatment with long-term topical steroids. Ten months after the initial penetrating keratoplasty and cataract extraction, the patient had decreased visual acuity, intense pain, and tearing in the right eye. Corneal cultures showed Serratia marcescens. Topical steroids were discontinued, and treatment with tobramycin and vancomycin ophthalmic solution every hour was initiated. Despite 1 week of aggressive therapy, there was an increase in corneal infiltrate, epithelial defects, and melting, which eventually involved the peripheral recipient cornea. Therapeutic penetrating keratoplasty, debridement of the peripheral cornea, and amniotic membrane transplantation were performed. Antibiotic agents were used postoperatively. There has been no evidence of recurrent infection. The best-corrected visual acuity improved to 6/15 at the 6-month follow-up period after the second intervention. CONCLUSIONS: S. marcescens may cause infectious crystalline keratopathy after penetrating keratoplasty in patients treated with long-term topical steroids. Therapeutic penetrating keratoplasty, surgical debridement, and amniotic membrane transplantation may be necessary when the clinical response to intensive medical treatment is inadequate.     

Frog saliva-induced toxic keratopathy: a case report

Corneal toxicity due to exposure to many chemicals and medications have been described in the literature. We present a case of toxic keratopathy by corneal exposure to salivary secretion of a frog. A 40-year-old male patient reported a sudden splash of frog saliva in his right eye while he was examining it at a close distance. Corneal punctate epitheliopathy and stromal oedema and Descemet folds were the initial clinical findings, which completely recovered on the 2nd control day of topical dexamethasone and ofloxacin treatment. We aimed to show the toxic effects of animal-derived secretions on the cornea as a rare cause of toxic keratopathy.     

Corneal myxoma arising in a patient with repeated phototherapeutic keratectomies

PURPOSE: We report the clinical and pathologic findings of a corneal myxoma that was diagnosed in a cornea that had undergone phototherapeutic keratectomy (PTK). METHODS: A corneal myxoma was identified in a full-thickness keratoplasty specimen obtained from a 51-year-old man with a history of a forceps injury to his right eye at birth. The patient had presented with corneal edema and bullous keratopathy, which was treated on 3 occasions with PTK, resulting in progressive, persistent milky-white clouding of the cornea. This represents the eighth case of corneal myxoma in the reviewed literature and the first described after PTK. Thorough histopathologic and ultrastructural analyses were conducted. RESULTS: The histochemical, immunohistochemical, and electron microscopic findings were consistent with previously reported corneal myxomas. Most of the reported myxomas arising in the cornea presented with a history of prior corneal disease or injury and showed absence or disruption of Bowman layer histopathologically, as was found in our patient. CONCLUSION: The pathogenesis of corneal myxomas involves a reactive process that requires an antecedent affliction, in contrast to the neoplastic mesenchymal histogenesis of myxomas characterized in other parts of the body.     

A case report and review of filamentary keratitis.

BACKGROUND: Filamentary keratitis is most often a chronic corneal condition, characterized by filaments attached at one or both ends to the cornea. Patients often experience foreign body sensation, grittiness, discomfort, photophobia, blepharospasm, and increased blinking. Filamentary keratitis is commonly the result of aqueous deficient dry eye syndrome. Management options include lubrication, punctal occlusion, removal of filaments, hypertonic saline, mucolytic agents, anti-inflammatory agents, and therapeutic contact lenses. CASE REPORT: A 58-year-old man came to us with acute symptoms of pain, photophobia, and redness x 2 days 0.S. The diagnosis of filamentary keratitis was made based on the clinical findings of positively staining mucus strands attached to the superior cornea. The patient was also found to have dry eye, blepharitis, and floppy eyelid syndrome. Numerous treatment regimens were implemented, including lubrication with non-preserved artificial tears, lubricating ointment, and topical steroids. The patient's condition was finally best managed with silicone plug punctal occlusion and therapeutic contact lenses. CONCLUSION: Filamentary keratitis can be a recurrent and incapacitating condition that may prove difficult to manage.     

Visual recognition time in strabismus: small-angle versus large-angle deviation.

PURPOSE: To measure the possible differences in monocular detection time of a threshold visual acuity stimulus (recognition time [RT]) between patients with small-angle and large-angle strabismus. METHODS: Ten patients with free alternating esotropia were tested (10 to 18 years old): five with small-angle esotropia (< or = 7 degrees), five with large-angle esotropia (15 degrees to 20 degrees). Six age-matched normal subjects served as controls. The RT of the threshold stimulus was measured in both eyes sequentially for stimuli presented in the center of a computer monitor (RT 1). Moreover, we measured the time necessary for identifying the same threshold visual acuity stimulus generated on the computer screen in the moment in which fixation is taken up by one eye after occlusion of the second eye (RT 2). Using the same setting, RT was also measured monocularly in all strabismic and normal subjects who were originally looking at a luminous fixation point positioned horizontally at 6.5 and 15 degrees from the center of the monitor (RT 3). RESULTS: The multivariate analysis of variance for repeated measures indicated that there was no statistical difference in RT 1 between groups. The mean RT 2 was significantly longer (p<0.001) in large-angle strabismic eyes when compared with that of normal control eyes. The mean RT 2 in small-angle strabismic eyes did not differ significantly from that of normal eyes. Finally, RT 3 (both at 6.5 degrees and 15 degrees of eccentricity) did not show any significant difference in the three different study groups. CONCLUSIONS: The authors hypothesized that alternating strabismus patients may have a significant advantage in maintaining a small-angle deviation, as a large-angle deviation would require longer RT in the moment the deviated eye takes up fixation. It can be speculated that the extension of re-fixation movement, obviously shorter in small-angle strabismus patients, is the main factor responsible for longer RT occurring in large-angle strabismus patients.     

Corneal injury by anti-misting agent in swim goggles: a case report

PURPOSE: To report a case of corneal injury by swim goggle anti-misting agent. METHODS: Case report. RESULTS: A 47-year-old man presented with ocular injury caused by swim goggle anti-misting agent. Two weeks previously, the patient felt sudden ocular pain and grit after pool water flooded his goggles while swimming. Before the patient's swim, a copious amount of anti-misting agent was sprayed inside his goggles. On examination, severe corneal epithelial defect and stroma edema of the right eye were noted. Best-corrected visual acuity (BCVA) was 20/40. Right eye corneal thickness was 625 microm. Topical corticosteroids, antibiotic eye drops, and oral tetracycline were started. After 1 week of treatment, the epithelial defect of his right cornea improved slightly. Stromal edema decreased mildly. Epithelial defect persisted at 1 month follow-up. Right eye BCVA remained 20/40. Three months after treatment, the right eye epithelial defect healed completely. Mild diffuse superficial stromal opacity was noted. BCVA improved to 20/20. At 1-year follow-up, right eye corneal thickness was 547 microm, which was thinner than the left eye. Right eye corneal endothelial cell density measured approximately 1500 cells/mm2, which was less than the left eye at 2300 cells/mm2. The faint, diffuse stromal opacity disappeared; however, white subepithelial plaques were noted in the cornea centers. After 1 month of treatment with topical corticosteroids, the plaques subsided completely. The corneas remained clear at 2-year follow-up. CONCLUSION: Anti-misting agent can cause severe corneal injuries, including persistent epithelial defects, stromal edema and opacity, endothelial cell loss, and subepithelial plaque.     

压贴三棱镜治疗获得性斜视的临床疗效观察

目的:探讨对麻痹性斜视出现的复视用压贴三棱镜的非手术治疗及疗效观察。方法:对麻痹性斜视14例患者,通过眼部检查、验光配戴框架眼镜,有上睑下垂的患者,配戴自制支架框架眼镜,反复测量斜视度后,压贴相应度数的膜状三棱镜矫正复视,检查同视机Ⅰ级视功能。结果:患者14例中复视完全消失9例,5例明显好转,6例有代偿头位的,头位消失,8例有同视机Ⅰ级视功能。结论:对于麻痹性斜视不适合做手术的患者,用压贴三棱镜,可以有效改善患者复视及代偿头位,能改善患者生活质量,又不影响原发病的治疗。     

Corneal graft rejection and recurrent anterior uveitis associated with intraocular cilium

A 60-year-old male patient with pseudophakic bullous keratopathy in his right eye underwent corneal transplantation. Graft rejection occurred and the patient was regrafted 1 year later. The postoperative course was complicated with recurrent anterior uveitis attacks. In his right eye, he had a cilium in the posterior chamber at the five o'clock position between the intraocular lens and iris. The cilium was removed and the patient was free of any anterior uveitis or corneal rejection for 18 months. Eyes harboring corneal transplants and suffering frequent rejection, or chronic recurrent anterior uveitis should be examined carefully for the possible presence of foreign bodies.     

Graphic analysis of paralytic strabismus with the Lancaster red-green test

We used the Lancaster red-green test to monitor changes in ocular alignment in patients with paralytic strabismus. By inferring the position of the right eye and that of the left eye at many different positions of gaze and then plotting the data on a graph, one can derive a static eye position curve. The location of the curve relative to the line depicting normal ocular alignment ( orthophoria ) indicates whether there is an esodeviation or an exodeviation . The slope of a line drawn tangent to the curve indicates, for that particular point, whether the deviation is concomitant or not and which eye is relatively weak or restricted and by how much. This graphic technique provides a simple, sensitive, and quantitative measure of ocular alignment that may be especially useful for detecting subtle changes in the relative positions of the two eyes. This method may be a useful adjunct in the planning and evaluation of therapy for patients with paralytic strabismus.     

Corneal staining after treatment with topical tetracycline

PURPOSE: The purpose of this paper is to report a case of corneal staining after treatment with topical tetracycline. METHODS: A patient with crystalline keratopathy caused by Streptococcus viridans after corneal transplantation was treated topically with tetracycline eye drops, based on results of bacterial sensitivity testing. After 3 weeks of intensive treatment, the donor cornea was stained with a brownish hue, which was ascribed to the tetracycline drops. RESULTS: One patient with crystalline keratopathy developed corneal staining after intensive treatment with topical tetracycline eye drops. After a year of follow-up, the staining of the cornea had not changed significantly. CONCLUSION: Hourly topical tetracycline eye drops may induce corneal pigmentation. To our knowledge, this is the first published case report of corneal staining caused by tetracycline eye drops.     

Case report: Bitoric RGP lens used in the correction of astigmatism caused by trauma

A 28-year-old white male was referred to our office after having his lacerated right cornea surgically repaired following an accident. Because of the high degree of corneal toricity and irregular astigmatism present, the patient was fit with a bitoric rigid gas permeable lens that provided excellent vision.     

Neurotrophic keratopathy--a post-LASIK case report

BACKGROUND: Neurotrophic keratopathy is a degenerative affection of the cornea caused by impairment of corneal sensitivity and represents a therapeutic challenge for ophthalmologists. The present article concentrates on the etiology, pathogenesis, diagnosis, therapeutic aspects and future therapeutic models for treating neurotrophic keratopathy and will present a case report: Also we evaluate the effects of autologous serum eye drops in bilateral LASIK-induced neurotrophic keratopathy with epithelial breakdown revealed by positive fluorescence and rose bengal staining and reduced tear film break-up time. METHODS: We treated a 42-year-old patient with post-LASIK neurotrophic keratopathy and tear film instability with autologous serum eye drops (5 x daily) and emulsion eye drops (Refresh Endura, Allergan, Irvine, CA, USA) after insertion of punctal plugs. RESULTS: Stabilization of vision, healing of the epithelium and reduction of the previously experienced symptoms like redness, itching and burning were achieved within 6 weeks. 10 months after changing therapy, the patient only complained about slight pain during lid movement. CONCLUSIONS: Severe denervation after bilateral LASIK disrupts ocular tear film dynamics and causes irritation symptoms of the ocular surface. Autologous serum eye drops may be an effective treatment of severe epithelial breakdown and be helpful to reestablish the disturbed ocular surface integrity, as shown by negative vital staining. Therefore, autologous serum eye drops represent a significant approach in the therapy of LASIK-induced severe dry eye and associated pain.     

Neurotrophic corneal ulcer after retrobulbar injection of chlorpromazine

An 80-year-old woman with a painful, poorly seeing right eye underwent retrobulbar chlorpromazine injection for pain control. After the injection, the patient's symptoms improved; however, a neurotrophic ulcer developed within 2 weeks after the procedure. It is postulated that chlorpromazine may lead to sensory denervation to the cornea with the subsequent development of neurotrophic keratopathy, as observed in this case. Awareness of this potential adverse effect is important for proper patient safety, education, and postinjection management.     

Neuro-ophthalmologic multiple lesions in craniocerebral trauma

The authors present the case of a child, 8 years old, victim of a car accident, suffering a cranio-cerebral trauma. The posttraumatic injuries were: bitemporal cranial fractures, LE VI nerve palsy with secondary convergent strabismus, left posttraumatic optic neuropathy with poor vision, right deafness, nasal bone fracture, left paramedian mandibular fracture. Four months later the child developed proptosis due to a high-flow carotid-cavernous fistula, on the site of the good eye, RE, which was clinically diagnosed and confirmed by the results of MRI, MRA and cerebral angiography. Considering the ophthalmologic and neurologic risks of this pathologic condition, the surgery was performed, using an external device (Silverstone clamp) with the purpose of progressive and adjustable control of the fistula thrombosis. The postoperative result was fistula thrombosis, preserving the visual acuity and visual field, with a residual hypertonia on the right eye. The peculiarity of the case consist in the small age of the patient and the severity of neuro-ophthalmologic lesions. The child will live for the rest of his life with a single well-seeing eye, whose function could be at risk at any moment, related to the posttraumatic vascular changes at the level of the right cavernous sinus.     

Rectus muscle posterior tenon fixation as an inactivation procedure

PURPOSE: To report a surgical technique and the results of rectus muscle posterior Tenon fixation as an inactivation procedure for treatment of Duane syndrome, restrictive strabismus, and long-standing paralytic strabismus, which conventionally require large rectus muscle recession. DESIGN: Prospective, interventional case series. METHODS: Three eyes in three Duane syndrome patients, one eye in one myopic strabismus fixus patient, one eye in one complete third nerve palsy patient, and one eye in complete sixth nerve palsy patient underwent rectus muscle inactivation by disinsertion and posterior Tenon fixation of its insertion. The main outcome measures were the postoperative eye position in all patients, the presence of upshoot or downshoot on adduction, and, in Duane syndrome patients only, the height of the palpebral fissure. RESULTS: In Duane syndrome patients, the upshoot and the downshoot were improved markedly, and the height of the palpebral fissure was increased on adduction after the operation as compared with before the operation; the other patients had improved ocular alignment after surgery. CONCLUSIONS: We believe that rectus muscle inactivation by fixation of its insertion to posterior Tenon is an effective and less invasive technique for achieving profound weakening of a rectus muscle compared with periosteal fixation of the rectus muscle.     

Keratitis caused by Verticillium species

PURPOSE: To report a case of fungal keratitis caused by Verticillium species. METHODS: A 50-year-old man developed pain, redness, and an infiltrate in his left eye and had no history of trauma. The cornea showed superficial, white, stromal infiltrates and epithelial ulceration with a dendritic margin. The clinical features suggested herpetic keratitis, and the patient was treated with topical antiviral medication. Two weeks later, his condition deteriorated. Examination of the left eye showed stromal infiltrates with a feathery margin and epithelial ulceration with its covering white exudates. Corneal scrapings were taken for direct microscopic examination and culture. RESULTS: Corneal scraping showed the presence of fungal filaments. The fungus was identified as Verticillium species. Topical amphotericin B and systemic fluconazole were started after discontinuing the antiviral treatment. Clinically, the inflammation subsided during the 3 weeks after treatment. CONCLUSION: This is a rare case of infectious keratitis caused by Verticillium species. Rare species of fungal infection should be considered in the differential diagnosis of stromal keratitis refractive to conventional medical treatment.     

Kornealer Tumor nach Vorderkammerlinsenimplantation bei Marfan-Syndrom

A 57-year-old male patient with Marfan syndrome presented at our clinic with a whitish gelatinous corneal tumour in the right eye. The initial examination revealed pronounced corneal oedema, bullous keratopathy, as well as an iris-fixed anterior chamber lens implanted 7?years previously. After the tumour was removed, the anterior chamber lens was explanted and keratoplasty was explanted and a two stage keratoplasty was performed. Histological analysis of the tumour and the cornea revealed vimentin and a number of smooth muscle actin (SMA)-positive tumour cells. The cornea below the tumour displayed a partially absent Bowman's layer and extensive pannus tissue. The characteristics of the corneal tumour and the subjacent cornea as described above are typical of secondary corneal myxoma. The influence of Marfan syndrome, a systemic connective tissue disorder present in the patient, on the etiopathogenesis of the corneal myxoma could not be fully determined.     

Pseudokeratoconus caused by rosacea

PURPOSE: A case of inferior corneal thinning and high astigmatism with features of keratoconus in a patient with long-standing ocular rosacea is described. METHODS: Axial curvature mapping was performed with the Tomey TMS-1 videokeratoscopy instrument and corneal thickness mapping was performed with the Orbscan Corneal Topography System (CTS). Tear clearance was assessed by measuring the concentration of fluorescein in the tear fluid with a fluorometer. RESULTS: There were inferior corneal thinning and opacification in both eyes. Tear fluorescein clearance was markedly delayed in the right eye. There was asymmetric inferior corneal steepening in both eyes with I-S values of 1 in the right eye and 5.9 in the left eye. There were 5.9 diopters of astigmatism at 85 degrees in the right eye and 7.3 diopters of astigmatism at 73 degrees in the left eye. Corneal pachymetry mapping with the Orbscan CTS showed a normal central corneal thickness and maximal thinning in the inferotemporal periphery of the right cornea and inferonasal periphery of the left cornea. CONCLUSION: Chronic ocular rosacea can produce inferior corneal thinning and high astigmatism with some features of keratoconus. The inferior pattern of thinning in rosacea may be related to chronic exposure of the inferior cornea to inflammatory and matrix-degrading factors in the inferior tear meniscus.     

Large subconjunctival emphysema causing diplopia and lagophthalmos

PURPOSE: To describe a patient who developed diplopia, lagophthalmos and exposure keratopathy due to a large subconjunctival emphysema. METHODS: A 24-year-old man sustained an injury in his left eye from a compressed air hose. The patient complained of pain and diplopia. He underwent slit-lamp examination, funduscopy and computed tomography. RESULTS: Ophthalmic examination revealed a decrease in vision in the left eye to 0.5, a conjunctival laceration adjacent to the medial limbus, subconjunctival hemorrhage, a large subconjunctival emphysema, lagophthalmos, hypertropia and superficial punctate keratopathy. The posterior pole was intact as were the orbital bones. Two weeks after the injury the conjunctival emphysema, diplopia, lagophthalmos and superficial keratopathy resolved, and visual acuity improved to 1. CONCLUSIONS: Large subconjunctival emphysema can result in diplopia, lagophthalmos and exposure keratopathy.