The treatment of ocular hypotony after trabeculectomy with a scleral lens: A case series

PurposeOcular hypotony after trabeculectomy may be treated medically, surgically and with a tamponade. Three cases are reported in which a scleral lens was applied to treat ocular hypotony after mitomycin C (MMC) augmented trabeculectomy.MethodsIn this retrospective case series the records of three eyes of three patients who developed ocular hypotony after they had undergone trabeculectomy augmented with MMC were evaluated. The patients were between 11 and 69 years of age and the intraocular pressure (IOP) after surgery ranged between 3 and 6 mmHg. All three patients showed a negative Seidel test; one had suspected hypotonic maculopathy and one had a collapsed anterior chamber. After unsuccessful treatment with large bandage lenses all three patients were subsequently fitted with a scleral lens. The scleral lens was fitted to fully cover and compress the bleb. Scleral lenses were worn continuously with a check-up after one night of wear and subsequent check-ups when needed. One patient continued to wear the scleral lens for a further 6.5 months on a daily wear basis.ResultsIn all three eyes the IOP was higher after wearing the scleral lens. Two patients stopped wearing the scleral lens after the IOP was stable. One patient developed a cataract; the cataract surgery was combined with a bleb revision and scleral lens wear was therefore discontinued.DiscussionThe scleral lens might be a useful tool in the treatment of ocular hypotony after trabeculectomy augmented MMC surgery. The effect of the scleral lens on the ocular pressure is unpredictable. Caution is advised in vulnerable corneas due to risk factors such as hypoxia and infection. Further research is warranted to establish the safety of the procedure, the patient selection and the overall success in a larger patient group.     

Case report: Utilization of a scleral lens to mitigate exposure keratopathy and associated mental health decline

PurposeTo report a case of acute exposure keratopathy with comorbid depression and improvement of both conditions with the use of a scleral lens (SL).ObservationsA 72-year-old male with a past ocular history significant for extensive basal cell carcinoma (BCC) excision of the right upper and lower eyelids presented for evaluation of exposure keratitis and consideration of a SL for the right eye. Examination was notable for post-surgical irregular lid margins with lagophthalmos, trichiasis and an Oxford Grade I staining of the central exposed cornea. Medical history was notable for chronic severe depression and anxiety with suicidal ideation. Upon treatment with a SL, the patient noted ocular comfort, and reported significantly improved affect.Conclusion and importanceCurrently, there is no peer reviewed literature reporting on the management of exposure keratopathy in the setting of comorbid affective disorders. This case highlights the improvement in quality of life for a patient with exposure keratitis and severe depression with suicidal ideation and points to the potential utilization of a SL to mitigate the risk of mental health decompensation.     

Very long term success of pterygium surgery with conjunctival graft

Purpose

To examine to the very long term prognosis (16 years in average) of pterygium surgery with superior or inferior conjunctival graft.

Clinical efficacy of amniotic membrane transplantation in the treatment of various ocular surface diseases.

PURPOSE: To investigate the efficacy of permanent amniotic membrane transplantation (AMT) for the treatment of various ocular surface diseases. METHODS: The medical records of 62 eyes from 58 patients who had undergone permanent AMT were reviewed. The amniotic patches were grafted for the treatment of neurotrophic ulcers (n=15), inflammatory corneal ulcers (n=15), scleral ulcers (n=11), painful bullous keratopathy (n=8) and pterygium as an adjuvant to a conjunctival autograft (n=13). Cryo-preserved or freeze-dried amniotic membrane (AM) were used. The overall success rate, the interval to epithelialization, pain-subsiding time, and complications were evaluated. The pain relief and the full epithelialization interval in the bullous keratopathy patients given the cryo-preserved AM were compared with those given the freeze-dried AM. RESULTS: The success rate in the patients with neurotrophic ulcer, inflammatory corneal ulcer, scleral ulcer and bullous keratopathy were 93.3%, 66.7%, 92.9% and 100%, respectively. A conjunctival autograft with AMT showed a 100% success rate without recurrence. The time to re-epithelialization was 24.4+/-24.2, 20.4+/-5.8, and 16.9+/-7.0 days in patients with neurotrophic, inflammatory and scleral ulcers, respectively (p=0.431). The pain relief interval in the cryo-preserved and freeze-dried AM group was 17.7 and 23.3 days, and the re-epithelialization interval was 29 and 22 days, respectively, which was insignificant. CONCLUSIONS: AMT has a high success in the treatment of neurotrophic, scleral ulcer, bullous keratopathy and pterygium with a low rate of complications but presented only partial success in the treatment of inflammatory corneal ulcers. The clinical efficacy of AMT was not related to the methods used to preserve the AM.     

Filtering bleb-induced giant papillary conjunctivitis.

BACKGROUND: Pathogenesis of giant papillary conjunctivitis is still elusive and many hypotheses are being proposed to explain the irritative symptoms associated with it. The research data available to date shows that mechanical, immunological and allergic components are involved in this to various extents. We report a rare cause of giant papillary conjunctivitis which was induced by a large filtering bleb following trabeculectomy surgery for glaucoma. METHOD: A 30-year-old female, operated for glaucoma filtering surgery in her right eye 15 years back, presented with ocular irritation. Clinical evaluation revealed two giant papillae on the superior tarsal conjunctiva which coincided with the large filtering bleb with its peripheral extension. The fellow eye was normal and no association with any allergic disorders was noted. RESULT: The patient responded symptomatically to the topical application of anti-inflammatory and anti-allergic medications. The giant papillae decreased considerably in size but the diffuse papillary response persisted. CONCLUSION: Though multiple etiological factors have been proposed for the giant papillary conjunctivitis, only a single case report is available where a filtering bleb is the causative factor. The mechanical irritation caused by the large-sized bleb seems to be the provoking agent in our case taking into consideration the position of the papillae that coincides with the peripheral extension of the bleb.     

Scleral contact lenses in the pediatric population—Indications and outcomes

PurposeTo report the use of a custom-designed, scleral contact lens (SL) in the treatment of pediatric patients.MethodsThe medical records of all patients under 15 years of age fitted with SL from March 2018 through February 2020 were retrospectively reviewed. Ophthalmic diagnosis, prior surgical intervention, lens wearing failures, and duration of lens use are reported.ResultsLenses were dispensed to 18 patients (24 eyes). Main indications for SL fitting were refractive error correction (n = 18: keratoconus (KCN), traumatic corneal scarring, corneal transplant status, and aphakia) and ocular surface protection and optimization (n = 6: neurotrophic keratitis and chronic blepharokeratoconjunctivitis). Patient age ranged from 16 months to 14 years (mean, 9.9 ± 3.5 years (mean ± standard deviation (SD)). Patients fitted for surface disease indications were significantly younger, 8.8 ± 2.5 years. The mean maximal keratometry reading in patients with keratoconus was 64.0 ± 12.6 diopters (D). In six eyes with advanced KCN (Kmax 71.8 ± 11.0 D) and three eyes with traumatic scarring, SL use obviated the need for keratoplasty. Fifteen patients (83 %) continued scleral lens wear with a mean follow-up period of 9.2 ± 7.4 months. Complications included one case of corneal graft rejection and one corneal abrasion associated with lens insertion.ConclusionsThe goals of SL fitting in pediatric patients are visual rehabilitation and ocular surface protection. Pediatric patients with advanced keratoconus and traumatic corneal scarring are most appreciative of the benefits of scleral lenses. The challenges associated with SL fitting and the training process did not preclude long-term SL wear.     

Influence of Caffeine on the Repair of Mitomycin C Induced DNA Damage

Caffeine potentiated MMC induced lethality in Salmonella typhimurium strains proficient in excision and recombinant repair but not in excision or recombinant repair deficient strains. Caffeine was found to inhibit the removal of interstrand DNA crosslinks induced by MMC in strains proficient for excision repair but not in a strain deficient in excision repair. Our results indicate that the potentiation by caffeine of MMC induced lethality in S. typhimurium is primarily due to the inhibition by caffeine of excision repair of interstrand DNA crosslinks.     

Impression cytology of a case of conjunctival metaplasia associated with oral carbamazepine use?

PURPOSE: To report a case of conjunctival squamous metaplasia associated with oral carbamazepine use. METHODS: Following completion of an ocular comfort questionnaire, biomicroscopy and a phenol red thread test, impression cytology from the inter-palpebral zone (nasal) of the bulbar conjunctival surface was undertaken using a Millcell-CM filter after topical anaesthesia with oxybuprocaine 0.4%. The filter was stained with Giemsa and colour images taken at 400x magnification by light microscopy. The images were graded and also a 35 mm was prepared. From the projected image, an overlay method was used to outline the borders such that the cell and nucleus area, and the longest and shortest dimensions could be measured by planimetry. RESULTS: A male subject, added 22 years, presented with slight conjunctival injection but no substantial symptoms and only slight surface staining with fluorescein. The subject reported use of oral carbamazepine (200mg, b.d.s.). Impression cytology showed large sheets of squamous cells (grade 2-3) with few goblet cells. The average cell area was 1509 microm(2), the long:short dimension ration averaged 1.42 and the average nucleus/cytoplasm (N/C) value was just 0.092 (or 1:11.5 as a ratio). CONCLUSIONS: Since the drug has been reported to be excreted in the tear film, and with no other risk factors (such as contact lens wear, smoking or dry eye disease), the squamous metaplasia is attributed to the use of carbamazepine.     

Acanthamoeba keratitis associated with misuse of daily disposable contact lenses.

PURPOSE: To report a case of Acanthamoeba keratitis that occurred in a daily disposable contact lens wearer. METHOD: Case report. RESULTS: A 70-year-old gentleman presented to eye casualty with a red left eye with reduced vision and corneal epithelial changes. Acanthamoeba keratitis was not suspected initially as he was a daily disposable contact lens wearer. This led to a delay of 17 days in initiating treatment. He responded well to topical polyhexamethylene biguanide and propamidine and made a full recovery. CONCLUSION: Acanthamoeba keratitis can occur in patients who reuse daily disposable contact lenses. A diagnosis of Acanthamoeba keratitis can be difficult to make and should be considered in all patients who wear contact lenses, including daily disposable lenses. All patients who wear daily disposable contact lenses should be reminded that the benefits of this modality of contact lens are only possible if the lenses are worn once and thrown away.     

Anterior eye shape in emmetropes,low to moderate myopes,and high myopes

PurposeMyopia prevalence has increased in recent years, including the levels of high myopia. While myopia has been associated with scleral remodelling and changes in posterior scleral shape, there has been little research examining how myopia affects in-vivo anterior sclera shape. We compared anterior scleral shape in emmetropes, low to moderate myopes, and high myopes.MethodsIn this prospective study, the Eye Surface Profiler instrument was used to quantify anterior eye surface shapes of forty-five young adult participants (58 % females) aged between 18 and 35 years, including 15 emmetropes, 15 low to moderate myopes, and 15 high myopes. Sagittal height and axial radius of curvature of regions over the nasal and temporal corneal periphery and anterior sclera were exported and analysed.ResultsAfter quality control of the data, 39 and 43 subjects had data analysed from the nasal and temporal sides, respectively. The nasal sides of the surfaces of the corneal periphery and anterior sclera had greater sagittal height in high myopes than in emmetropes across all regions (mean sagittal heights 2.44 ± 0.07 and 2.21 ± 0.04 mm, respectively, p = 0.02), but no significant differences were found between low to moderate myopes with emmetropes or with high myopes. No significant refractive group differences occurred for temporal anterior eye surface height. High myopes’ nasal-temporal asymmetry of sagittal height was less than of emmetropes (means 0.20 ± 0.07 and 0.46 ± 0.06 mm, respectively, p = 0.02). High myopes also exhibited less nasal-temporal axial radius of curvature asymmetry than emmetropes (mean 0.35 ± 0.08 and 0.71 ± 0.08 mm, respectively, p = 0.01) across all regions.ConclusionsHigh myopes exhibited a different anterior eye surface shape than emmetropes, having greater sagittal height in the nasal corneal periphery and anterior sclera. There was less nasal-temporal asymmetry of sagittal height and axial radius of curvature in high myopes than in emmetropes. Asymmetric growth of the eye associated with myopia development may be the underlying reason. These findings have implications for design of contact lenses, particularly soft and larger rigid lenses such as mini-sclerals.     

Acanthamoeba keratitis in patients wearing scleral contact lenses

Purpose

To report a series of cases of Acanthamoeba keratitis (AK) in scleral lens wearers with keratoconus to determine whether this type of contact lens presents a greater risk for development of infection. Methods: This study reports three patients who wore scleral contact lenses to correct keratoconus and developed AK. The diagnoses of AK were established based on cultures of the cornea, scleral contact lenses, and contact lens paraphernalia. This study investigated the risk factors for infections. Results: The possible risks for AK in scleral contact lens wearers are hypoxic changes in the corneal epithelium because of the large diameter and minimal tear exchange, use of large amounts of saline solution necessary for scleral lens fitting, storing the scleral lens overnight in saline solution rather than contact lens multipurpose solutions, not rubbing the contact lens during cleaning, and the space between the cornea and the back surface of the scleral lens that might serve as a fluid reservoir and environment for Acanthamoeba multiplication. Two patients responded well to medical treatment of AK; one is still being treated. Conclusions: The recommendations for use and care of scleral contact lenses should be emphasized, especially regarding use of sterile saline (preferably single use), attention to rubbing the lens during cleaning, cleaning of the plunger, and overnight storage in fresh contact lens multipurpose solutions without topping off the lens solution in the case.     

Airbag induced corneal ectasia.

PURPOSE: To report a case of airbag induced corneal ectasia. METHODS: Case report. RESULTS: A patient 3 years post-LASIK developed bilateral corneal ectasia worse in the right eye following airbag deployment in a road traffic accident. At last follow up, best corrected vision was 20/40 with -4.00/-4.00 x 25 in the right eye and 20/25 with -1.25/-0.50 x 135 in the left eye. CONCLUSIONS: This is a rare presentation of trauma induced ectasia in a patient post-LASIK. It is possible that reduction in biomechanical integrity of the cornea from prior refractive surgery contributed to this presentation.     

Scleral lens after intracorneal ring segments in patients with keratoconus

Background

To report the use of scleral lens (ScCL) to improve vision in patients having keratoconus who had intracorneal ring segment (ICRS) surgery.

Cultivation and characterization of pterygium as an ex vivo study model for disease and therapy

Purpose

Development of ex vivo model to study pathogenesis, inflammation and treatment modalities for pterygium.

Seasonal variation in the composition and melting behavior of milk fat

Dairy bulk tank milk was sampled during 1 yr from 2 conventional (C1 and C2) and 1 organic dairy (O1) for studying the seasonal variation as well as the variation between dairies in the composition and properties of milk fat. The composition of fatty acids (FA) as well as triglycerides (TAG) in milk fat was analyzed, and the melting properties of milk fat were analyzed by use of differential scanning calorimetry. The main differences in fat content and composition of FA in milk fat between dairies included a higher fat content, greater proportion of C18:0, and smaller proportion of C16:0 in milk from dairy C2, which could be associated with a higher frequency of Jersey herds supplying milk to this dairy. The organic milk was characterized by a higher proportion of C18:3n-3, C18:2 cis-9,trans-11, C6 to C14, a lower proportion of C18:1 cis-9, and a higher melting point of the low-melting fraction. The TAG composition showed a greater proportion of C24 to C38 TAG in milk fat from dairy O1 and a greater proportion of C52 to C54 TAG in milk fat from dairy C2, which was in accordance with the differences in FA composition. Melting point of the low-melting fraction was higher for milk fat from dairy O1 compared with dairies C1 and C2, whereas no differences between dairies were observed with respect to melting points of the medium- and high-melting fractions. The seasonal variation in FA composition was most pronounced for dairy O1 although similar patterns were observed for all dairies. During the summer, the content of C18:0 and C18:1 cis-9 in milk fat was greater, whereas the content of C14:0 and C16:0 was lower. In addition, the content of C18:2 cis-9,trans-11 and C18:1 trans-11 increased in late summer for dairy O1. The differential scanning calorimetry thermograms of individual milk fat samples could be divided into 3 groups by principal component analysis. For dairy O1, summer samples belonged to group 1, spring and autumn samples to group 2, and winter samples to group 3. For dairy C1 winter samples (group 2), were separated from other samples (group 1), and for dairy C2 all samples were in group 1. Individual melting points were related to FA composition, and the melting point of the low-melting fraction was positively correlated to the content of C14:0 and C16:0 in milk fat and negatively correlated to the content of C18:1 cis-9 and C18:0.     

Transient corneal epithelial bullae associated with large diameter scleral lens wear: A case series

With the increased fitting of scleral lenses by eye care practitioners, complications with lens wear need to be considered. Several prior studies have addressed complications specific to scleral lens wear and the incidence of hypoxia with extended wear, but few report the presence of epithelial bullae. This case series investigates three patients with differing ocular surface diseases, yet all developed transient epithelial bullae with concurrent large diameter scleral lens wear. These bullae appear to form due to weakened connections in the corneal epithelium at the level of basement membrane and Bowman’s layer and flatten within minutes of lens removal. These bullae need to be further studied, as they can increase the patient’s risk of epithelial defects, infections, and other complications in already compromised corneas.     

Cogan-Reese syndrome with Iris cyst: A novel presentation

PurposeTo report an atypical case of Cogan-Reese syndrome associated with iris cyst in a young adult male.MethodsSlit-lamp biomicroscopic examination, swept-source anterior segment optical coherence tomography (ASOCT) and ultrasound bio-microscopy (UBM) were done to evaluate and characterize the nature of the iris cyst. Gonioscopy, specular microscopy and confocal microscopy were attempted, but unsuccessful due to the large corneal opacity.ResultsOn slit-lamp biomicroscopy, a large nasal corneal opacity with overlying band-shaped keratopathy was noted, with history suggestive of a trivial non-penetrating trauma and likely healed corneal ulcer. Through the temporal clear cornea, the iris displayed altered pattern with overlying shiny membrane and multiple, small, discrete, hyperpigmented, irregular nodules suggestive of Cogan-Reese syndrome. On the nasal side, an iris cyst with typical ‘stuck-on appearance’ onto the endothelium was visible. ASOCT and UBM failed to show any evidence of epithelial downgrowth or Descemet membrane disintegrity, ruling out the possibility of a post-traumatic implantation iris cyst.ConclusionThe occurrence of iris cyst in this case of Cogan-Reese syndrome is unique, and could be related to the disease pathogenesis, or a rare co-incidental finding.     

BCLA CLEAR - Scleral lenses

Scleral lenses were the first type of contact lens, developed in the late nineteenth century to restore vision and protect the ocular surface. With the advent of rigid corneal lenses in the middle of the twentieth century and soft lenses in the 1970’s, the use of scleral lenses diminished; in recent times there has been a resurgence in their use driven by advances in manufacturing and ocular imaging technology. Scleral lenses are often the only viable form of contact lens wear across a range of clinical indications and can potentially delay the need for corneal surgery. This report provides a brief historical review of scleral lenses and a detailed account of contemporary scleral lens practice including common indications and recommended terminology. Recent research on ocular surface shape is presented, in addition to a comprehensive account of modern scleral lens fitting and on-eye evaluation. A range of optical and physiological challenges associated with scleral lenses are presented, including options for the clinical management of a range of ocular conditions. Future applications which take advantage of the stability of scleral lenses are also discussed. In summary, this report presents evidence-based recommendations to optimise patient outcomes in modern scleral lens practice.     

Surface coverage with single vs. multiple gaze surface topography to fit scleral lenses

Objectives

To determine surface coverage of measurements using the sMap3D^® corneo-scleral topographer in patients presenting for scleral lens fitting.