Faculty Bibliography

OBJECTIVE:To study the safety and efficacy of topical bevacizumab in the treatment of corneal neovascularization (NV). DESIGN/METHODS:In a prospective, open-label, noncomparative study, 10 eyes from 10 patients with stable corneal NV were treated with topical bevacizumab, 1.0%, for 3 weeks and followed up for up to 24 weeks. MAIN OUTCOME MEASURES/METHODS:The primary safety variables were the occurrence of ocular and systemic adverse events throughout the course of the study. The primary efficacy variables were neovascular area, the area of the corneal vessels themselves; vessel caliber, the mean diameter of the corneal vessels; and invasion area, the fraction of the total corneal area covered by the vessels. RESULTS:From baseline visit to the last follow-up visit, mean reductions were 47.1% (standard deviation [SD], 36.7%) for neovascular area, 54.1% (SD, 28.1%) for vessel caliber, and 12.2% (SD, 42.0%) for invasion area. The decreases in neovascular area and vessel caliber were statistically significant (P= .001 and P< .001, respectively). However, changes in invasion area did not achieve statistical significance (P= .19). Visual acuity and central corneal thickness showed no significant changes. Topical bevacizumab was well tolerated with no adverse events. CONCLUSIONS:Short-term topical bevacizumab therapy reduces the severity of corneal NV without local or systemic adverse effects. APPLICATION TO CLINICAL PRACTICE/CONCLUSIONS:Topical bevacizumab provides an alternative therapy in the treatment of stable corneal NV. TRIAL REGISTRATION/BACKGROUND:clinicaltrials.gov Identifier: NCT00559936.

PURPOSE/OBJECTIVE:The purpose of this study was to report the efficacy of topical cyclosporine 0.05% at a frequency of 3 to 4 times daily in severe dry eye disease. METHODS:We retrospectively identified a cohort of patients with severe dry eye disease who had shown inadequate response to at least a 4-month course of treatment with twice-daily use of topical cyclosporine 0.05% but who showed significant improvement to more frequent dosing. RESULTS:Twenty-two patients, including 13 patients with ocular graft-versus-host disease and 9 patients with primary or secondary Sjögren's syndrome, were included. After a minimum of a 2-month course of treatment with more frequent dosing of cyclosporine 0.05% (3 times a day in 7 patients and 4 times a day in 15 patients), overall dry eye symptoms were improved in 15 (68.2%) patients (9 patients with ocular graft-versus-host disease and 6 patients with Sjögren's syndrome). Mean corneal fluorescein staining scores (National Eye Institute scale of 0-15) improved (decreased) from the baseline (precyclosporine use) by -3.5 (range, 0 to -7) in patients with ocular graft-versus-host disease (P < or = 0.0008) and -2.8 (range, 0 to -5) in patients with Sjögren's syndrome (P < or = 0.001). After treatment with high-frequency use of cyclosporine 0.05%, the global physician assessment of dry eye status was favorable (improved) in 16 (72.7%) patients. Three (13.6%) patients reported new-onset symptoms of burning or irritation with the use of high-frequency dosing of topical cyclosporine. No other associated adverse effect was reported. CONCLUSION/CONCLUSIONS:These data suggest that patients with severe dry eye may require more frequent dosing of topical cyclosporine 0.05% than twice daily.

PURPOSE/OBJECTIVE:To report a case of Pseudomonas aeruginosa keratitis that progressed to posterior scleritis. METHODS:Observational case report. RESULTS:A 64-year-old woman was treated for P. aeruginosa keratitis. Twelve days later, she was diagnosed with posterior scleritis and treated with oral ciprofloxacin. Her condition progressed, ultimately resulting in enucleation. Histopathology confirmed posterior scleritis, a previously unreported complication of P. aeruginosa keratitis. CONCLUSION/CONCLUSIONS:P. aeruginosa keratitis may progress to posterior scleritis, a potentially devastating complication.

We present 5 patients with oil-drop cataracts in whom the underlying lenticular cause of myopic regression after laser in situ keratomileusis (LASIK) had been missed by their ophthalmologists. As a result, the patients were scheduled for or had had LASIK enhancement before presentation to us. After oil-drop cataracts were diagnosed, phacoemulsification was performed successfully in at least 1 eye of all patients. These cases underscore the importance of considering lens-induced myopia in refractive surgery patients, especially those with an unstable preoperative refraction or postoperative myopic regression. Refractive surgery in these cases can unnecessarily complicate the measurement of intraocular lens strength in cataract surgery.

PURPOSE/OBJECTIVE:To report corneal decompensation after laser in situ keratomileusis (LASIK) in a patient with Fuchs' endothelial dystrophy. METHODS:Observational case report. RESULTS:A 47-year-old woman with cornea guttata without symptoms or findings of corneal edema had uneventful LASIK for -5.50 -0.50 x 150 in the right eye and -4.00 -1.25 x 170 in the left eye. Postoperatively, she developed corneal edema, with significant loss of best-corrected visual acuity in both eyes. Preoperative corneal thickness was 587 microm in the right eye and 549 microm in the left eye, measured by ultrasound pachymetry. These readings were 550 and 560 microm on day 67 postoperatively. Endothelial cell counts showed means of 1209 and 1661 cells/mm2 in the right and left eyes, respectively. CONCLUSION/CONCLUSIONS:Caution is suggested when considering LASIK in eyes with severe cornea guttata.

Laser subepithelial keratomileusis (LASEK) is a relatively new refractive surgical technique that purportedly combines the advantages of laser in-situ keratomileusis (LASIK) and photorefractive keratectomy (PRK). Like LASIK, on the one hand, it employs a "flap" and consequently has the advantages of faster visual recovery, less postoperative pain, reduced stromal haze, and faster epithelial healing than PRK. Like PRK, on the other hand, because the procedure is performed on the anterior cornea, there are virtually no flap- or interface-related complications per se. It may thus be safer for patients who are at an inherently higher risk of developing flap complications, such as those with small palpebral fissures, deep-set eyes, corneal basement membrane dystrophy, and extremely steep or flat corneas. Furthermore, it conserves precious stroma in eyes with thin corneas or high myopia, which otherwise may not qualify for LASIK. It may also be more apropos for patients whose jobs or recreational activities put them at a higher risk of corneal trauma. In a very timely fashion, for reasons discussed below, LASEK may also prove to be superior to LASIK in customized ablations.

Refractive surgery is still one of the most innovative and evolving fields in ophthalmology. With the advent of customized ablation, a change in paradigm has been established: the primary goal of refractive surgery is not only to eliminate spectacles but to improve or at least prevent deterioration of the optical performance of the eye. Wavefront-guided refractive surgery has, as a new goal, to correct or at least minimize all optical aberrations of the eye, and consequently to improve or preserve visual performance, especially under scotopic conditions.

BACKGROUND:Detection of keratoconus has become a critical issue in patients who are potential candidates for refractive surgical procedures. In eyes with early stages of keratoconus, slit-lamp corneal changes are either absent or too subtle for detection, and keratometry may be normal. Videokeratography systems have greater sensitivity for detection of such cases, but interpretation of the topographic map is sometimes difficult, especially when pathologies with similar topographic patterns are suspected. We introduce an index using corneal topography for detection of keratoconus. METHODS:From March 1994 to December 1995, a total of 513 unoperated eyes, with no pathology other than keratoconus, from 283 consecutive patients were categorized into three groups based on slit-lamp examination and corneal topographic findings. Those with clinically obvious keratoconus were placed in the first group (53 eyes [10.3%]), those with keratoconus suspect comprised the second group (17 eyes [3.3%]), and the third group was that of normal eyes (443 eyes [86.4%]). In all videokeratographs of these eyes, the highest rate of corneal power changes (in diopters per millimeter) away from the apex (the point of maximum power) to the periphery was measured along its semimeridian. This index, called the "highest rate of steepening (HRS)", was statistically analyzed in the three groups. RESULTS:The mean +/- SD of highest rate of steepening was 3.60 +/- 1.70 D/mm (range 1.59 to 7.53 D/mm) in the clinically obvious keratoconus group, 1.59 +/- 0.21 D/mm (range 1.35 to 1.98 D/mm) in the keratoconus suspect group, and 0.72 +/- 0.31 D/mm (range 0.18 to 1.63 D/mm) in normal eyes. There was a highly statistically significant difference in the means of highest rate of steepening in the three groups (p < 0.0001). A small overlap in the highest rate of steepening ranges was shown among the three groups. Considering the first and second groups as cases of keratoconus, and 1.40 D/mm as the optimum cut-off value for highest rate of steepening, a sensitivity of 95.7% (67 out of 70 cases were detected), a specificity of 96.4% (16 false-positive cases), and an accuracy of 96.3% was obtained. CONCLUSION/CONCLUSIONS:The highest rate of steepening may be a useful measure for keratoconus screening with videokeratography. Validation is needed to evaluate its accuracy.