Faculty Bibliography

BACKGROUND:Infectious keratitis after PRK remains a rare but potentially devastating complication. HISTORY AND SIGNS/METHODS:Medical records of 3 male patients with infectious keratitis after uneventful PRK for myopia and astigmatism were reviewed retrospectively. PRK was performed using the Wavelight Allegretto excimer laser. Postoperative care included a bandage contact lens (BCL) for 5 days, topical antibiotics, ketorolac, and artificial tears. THERAPY AND OUTCOME/RESULTS:Keratitis presented 2 - 4 days postoperatively. In one case, each culture was negative (case 1), and was positive for Streptococcus pneumoniae (case 2) and Staphylococcus aureus (case 3). Final BSCVA (best spectacle corrected visual acuity) after intensive antibiotic treatment and removal of BCL were 1.0 (case 1), 0.9 (case 2) and 0.3 correctable to 0.8 with pinhole (case 3). CONCLUSIONS:Postoperative broad-spectrum antibiotics are mandatory after PRK to prevent infectious keratitis. However, resistant organisms are more and more common. The presence of a bandage soft contact lens after surgery is an unfavourable element that may increase risk of infection. Based on our case series, we suggest limiting soft contact lens wear during the two postoperative days even if the corneal ulceration is not healed.

PURPOSE/OBJECTIVE:To report persistent subepithelial haze in two patients following femtosecond LASIK associated with creation of a thin flap. METHODS:Subepithelial haze was assessed by slit-lamp photography, high-resolution Scheimpflug imaging, and corneal confocal microscopy. RESULTS:Two patients showed distinct subepithelial haze and reduced corrected distance visual acuity at 3 months after LASIK with a think-flap generated by a femtosecond laser. The extent of haze was documented, and the haze was treated topically with steroids up to 12 weeks. The haze was localized approximately 20 to 40 microm below Bowman's layer and dissolved slowly during the 2 months of treatment. At 6 months after surgery, uncorrected visual acuity was 20/20. CONCLUSIONS:Subepithelial haze formation represents a new potential complication in the thin-flap LASIK.

BACKGROUND:To evaluate the frequency of anterior surface breakdown for three techniques of evisceration with primary implant placement: the "classic" technique, the "scleral modification" technique, and the novel "scleral patch" technique. METHODS:Retrospective comparative case series with 73 consecutive eviscerations with primary implants that were performed in the Eye Clinic Rotterdam between January 2003 and January 2007. RESULTS:The operations involved the classic technique for 55% of the patients, scleral modification for 29%, and the novel scleral patch technique for 16%. In all, 9.6% of the patients had conjunctival breakdown: six in the classic group and one in the patch group. Although the frequency of this complication was higher in the classic group, the difference was not significant (P>0.05, chi-square test). Anterior surface breakdown was not related to implant size or prior eye surgery. CONCLUSION/CONCLUSIONS:Compared with the scleral modification and scleral patch techniques, conjunctival breakdown and implant extrusion were seen more frequently after classic evisceration with implant placement. Implant size or indication for surgery were not related to the frequency of these complications.

Deviated nose correction is difficult and constitutes a very different issue from septal deviation. When correcting this deformity, traces of asymmetry can be detected. The authors demonstrate facial asymmetry accompanying deviated noses, and such asymmetry is usually ignored by surgeons who typically concentrate only on nose deformities.A total of 5822 pre- and postrhinoplasty photographs related to 547 women and 124 men were reviewed. Out of the total population, the following 3 groups were selected: group A, gross nose and face asymmetry; group B, nose asymmetry with no facial deformity; group C, facial asymmetry with straight nose. Different measurements were applied to the selected photos, presented in . These included measurement from the lateral canthi to the lateral mouth corners (D1) and from the midface to each most lateral part of the zygomatic arch (D2). Measurements from one side were compared with those from the contralateral side to identify true anatomic differences, as presented in .(Table is included in full-text article.)(Figure is included in full-text article.)There was a significant difference in the nose and face deformity group, as evidenced by a meaningful difference in both the D1 and D2 measurements.We report a significant growth retardation of the midface and orbit on the concave side of the nose. This impediment may serve as the etiology for many asymmetries of the face and nose.

We report a case of bilateral lacrimal gland involvement as the first sign of Waldenstrom's macroglobulinaemia in a patient with sarcoidosis. Histological analysis of an incisional biopsy revealed a lymphoplasmocytic lymphoma consistent with Waldenstrom's macroglobulinaemia. No noncaseating granulomas were encountered. Systemic treatment was initiated and resulted in complete resolution of the lesions. In a patient with a systemic disease, such as sarcoidosis, and lacrimal gland involvement, a biopsy of the lacrimal gland mass should be taken to make a correct diagnosis and start appropriate treatment.

PURPOSE/OBJECTIVE:To compare 2 sequences of combined intrastromal corneal ring segment (ICRS) implantation and ultraviolet/riboflavin-mediated corneal collagen crosslinking (CXL) in progressive keratoconus. SETTING/METHODS:Dunya Eye Hospital, Istanbul, Turkey. METHODS:In this prospective comparative randomized consecutive study, CXL was followed by ICRS implantation (Group 1) or ICRS implantation was followed by CXL (Group 2). Uncorrected (UDVA) and corrected (CDVA) distance visual acuities, spherical equivalent (SE), manifest cylinder (cylinder), and mean keratometry (K) were compared preoperatively and postoperatively. RESULTS:The mean interval between treatments was 7 months +/- 2 (SD) (mean follow-up, 13 +/- 1 months). The mean UDVA and CDVA improved in both groups (UDVA: 0.07 +/- 0.09 to 0.25 +/- 0.12, Group 1, and 0.11 +/- 0.09 to 0.32 +/- 0.21, Group 2; CDVA: 0.24 +/- 0.11 to 0.41 +/- 0.20 and 0.22 +/- 0.16 to 0.55 +/- 0.2, respectively). The mean SE, cylinder, and mean K values decreased in both groups (SE: -7.13 +/- 3.34 D to -2.98 +/- 2.33 D, Group 1, and -7.05 +/- 5.54 D to -2.81 +/- 4.08 D, Group 2; cylinder: -4.38 +/- 2.03 D to -2.62 +/- 1.93 D and -4.68 +/- 2.60 D to -2.20 +/- 1.67 D, respectively; mean K: 52.47 +/- 4.01 D to 48.31 +/- 3.65 D and 52.06 +/- 4.93 D to 48.08 +/- 4.13 D, respectively). Overall, there was more improvement in CDVA, SE, and mean K in Group 2 than in Group 1. CONCLUSION/CONCLUSIONS:Implantation of ICRS followed by CXL resulted in greater improvement of keratoconus.

BACKGROUND:Successful inflation of a tissue expander (TE) and coverage of the face with tissue of similar colour and texture is usually limited by the amount of skin generated during the reconstruction process. Overexpanding the TE device generates an increased flap size and an overall better reconstructive outcome. PATIENTS AND METHODS/METHODS:A total of 86 TEs were inserted into 48 burn patients with head and neck burn scars. In each case, a TE was inserted with subsequent overexpansion to 2-4 times the manufacturer's stated maximum volume. RESULTS:Using the above technique, we gained more transferable skin, which was then used to cover the defects. The rates of major and minor complications were the same as those obtained in previous studies. Illustrations of several representative cases are also included. CONCLUSIONS:Overinflation of smaller TEs minimises complication rates typically associated with this procedure. Cutaneous overexpansion can usually achieve the desired flap dimensions by overinflation of the implant well beyond the manufacturer's stated maximum volume, thus ensuring its success and allowing for better coverage of the defects.

PURPOSE/OBJECTIVE:To compare geometrical shape factors of keratoconus corneas after cross-linking (CXL) by means of Scheimpflug imaging with those of untreated fellow eyes. SETTING/METHODS:Institut für Refraktive und Ophthalmo-Chirurgie, Zürich, Switzerland. METHODS:Scheimpflug imaging of the anterior segments was performed with the Pentacam (Oculus, Wetzlar, Germany) in 21 patients with progressive keratectasia before and after CXL. Only 1 eye per patient was treated with corneal cross-linking using the riboflavin/UV-A approach, the fellow eye serving as control. The following corneal parameters and their postoperative evolution during 1 year after treatment have been evaluated: minimal curvature radius and its location, thickness at the thinnest point, location of the thinnest point, anterior and posterior elevation, conoid asphericity constants of the anterior and posterior surface, and 7 keratoconus indices. Statistical comparison was performed by means of the Wilcoxon test. RESULTS:None of the treated eyes showed topographic progression in contrast to the untreated group where 8 eyes experienced significant progression. Minimal curvature radius increased significantly after 1 year compared with preoperative (6.14-6.21 mm), whereas in the untreated fellow eye, it significantly decreased (6.94-6.86 mm). Minimal corneal thickness was significantly reduced after treatment (P < 0.002 at 12 months). The cornea showed an evolution toward a more regular shape as indicated by a significant reduction in 4 of 7 keratoconus indices. No complications of CXL occurred in this small study group. CONCLUSIONS:After cross-linking, the corneal shape undergoes a process of regularization. This process is active during the first year after treatment and may continue. Longer follow-up is warranted to estimate the full amount of regression of the keratectasia after CXL.

Corneal collagen crosslinking (CXL) with riboflavin and ultraviolet-A light is a method for treating progressive keratectasia. The currently accepted treatment parameters induce collagen crosslinking in the anterior 250 to 350 microm of corneal stroma. To protect the endothelium, CXL inclusion criteria require a minimum corneal thickness of 400 microm after removal of the epithelium. In advanced keratoconus, however, progressive corneal thinning often leads to a remaining stromal thickness of less than 400 microm. We have therefore modified the current treatment protocol by preoperatively swelling thin corneas to a stromal thickness of at least 400 microm using hypoosmolar riboflavin solution. This treatment protocol was performed in a case series of 20 patients, and no complications were observed. Preoperative swelling of the cornea safely broadens the spectrum of CXL indications to thin corneas that would otherwise not be eligible for treatment.