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Efficacy and limitation of sutureless amniotic membrane transplantation for acute toxic epidermal necrolysis [Case Report]

Shay, Elizabeth; Khadem, John J; Tseng, Scheffer C G
PURPOSE:: The purpose of this case report is to describe the efficacy and limitation of ProKera, a sutureless medical device containing amniotic membrane, for treating acute ocular manifestations of toxic epidermal necrolysis (TEN). METHODS:: ProKera was inserted in both eyes at day 10 after onset of ocular symptoms in a 5-year-old boy suffering from acute TEN, manifesting conjunctival inflammation, large conjunctival defects, pseudomembrane formation, and total corneal epithelial defects. RESULTS:: At 9-month follow-up, insertion of ProKera resulted in complete reepithelialization, clear corneas, and vision of 20/20 in both eyes. However, because ProKera only covered the cornea and perilimbal conjunctiva, these 2 eyes still showed some conjunctival inflammation several months after discharge from the hospital. Eventually, 1 eye showed mild lid margin keratinization and cicatricial entropion, and both eyes showed trichiasis. CONCLUSIONS:: These data suggest that ProKera, when inserted during the acute stage of TEN, may be effective in healing corneal epithelial defects and preventing corneal sequelae. Because of the limited area covered, ProKera may not prevent cicatricial complications in the fornix, tarsus, and eyelid margin as effectively as sutured amniotic membrane transplantation
PMID: 20098313
ISSN: 0277-3740
CID: 107375

Photodynamic biologic tissue glue in perforating rabbit corneal wounds

Khadem JJ; Dana MR
OBJECTIVE: To evaluate the in vivo wound modulating effects of a new biologic tissue adhesive. BACKGROUND DATA: Biological tissue glue can serve as an important adjunct technology in the treatment of a number of ocular conditions, including closure of corneal wounds. These experiments were performed to evaluate the wound healing effects of a new photodynamic biologic tissue glue (PBTG) in perforating rabbit corneal incisions. METHODS: Perforating corneal wounds were created in 12 pigmented rabbits. Two perforating incisions were made 180 degrees apart 2 mm from the limbus. One incision in each eye was closed with a single interrupted 10-0 nylon suture, and the other closed with PBTG. Rabbits were followed biomicroscopically and sacrificed at 1-, 3-, and 7-week intervals for histological evaluation of their corneal wounds. RESULTS: There were no clinical signs of PBTG-related toxicity in any of the rabbits. Compared to control wounds, all glued corneas had greater epithelial filling, less stromal edema, and fewer inflammatory cells at the 1-, 3-, and 7-week stages and showed greater overall wound maturation. CONCLUSION: Our data suggest that PBTG is an effective and nontoxic tissue adhesive that accelerates normal corneal wound healing
PMID: 11799976
ISSN: 1044-5471
CID: 37691

Complications of surgery for subfoveal choroidal neovascularization

Fleckner MR; Hochman MA; Buzney SM; Weiter JJ; Tolentino FI; Khadem JJ
Advancing surgical techniques have made the surgical excision of subfoveal CNV possible in all cases. However, serious surgical complications lead to a limited visual outcome in many cases. The major complications that cause poor visual outcome are related to poor case selection and include injury to the RPE, with secondary atrophy of the choriocapillaris and damage to the neurosensory retina, and a high rate of persistent or recurrent CNV. Patients with POHS have localized disease of the RPE-Bruch's membrane complex and typically have CNV growing between the RPE and neurosensory retina (type 2 CNV). These patients have the best visual prognosis postoperatively because of the potential for maintaining native RPE beneath the fovea. Patients with AMD typically have CNV growing beneath the RPE (type I CNV). These patients are poor surgical candidates because the surgical excision of type I CNV is almost always associated with debridement of native subfoveal RPE and a poor visual outcome. Presently, all surgical studies have been retrospective and are characterized by limited follow-up. Therefore, whether surgical excision of subfoveal CNV is beneficial as compared to mere observation is uncertain. A large, randomized, prospective study currently is being performed. These Submacular Surgery Trials will attempt to determine whether these surgical procedures are more efficacious than observation and whether the benefits outweight the risks of surgery in these patients
PMID: 10713926
ISSN: 0020-8167
CID: 37692

Practice patterns in diabetic retinopathy: part 1: analysis of retinopathy follow-up

Khadem JJ; Buzney SM; Alich KS
OBJECTIVE: To evaluate ophthalmologists' management of diabetic patients. METHODS: A multiple-choice questionnaire was mailed to all ophthalmologists in New York (1985), Florida (1990), and Massachusetts (1993 and 1996). Questions included practice patterns, methods used in examination, use of photography and fluorescein angiography, indications for laser treatment, and intervals for follow-up of selected conditions. Responses were tabulated and compared between surveys and with the American Academy of Ophthalmology Preferred Practice Pattern. RESULTS: In this first report, we detail follow-up patterns of various grades of retinopathy. Physicians increasingly used duration of diabetes as a criterion in determining the length of follow-up for adults, despite persistent ambiguities for children. There were notable changes over time in nearly all aspects of follow-up for both general ophthalmologists and retina specialists. Retina specialists were less likely to treat proliferative disease, more likely to follow up patients with preproliferative disease sooner, and used longer follow-up intervals for short-duration diabetic patients, whereas a small percentage of general ophthalmologists continued to recommend treatment for background disease. CONCLUSION: There were noticeable trends toward Diabetes 2000 recommendations over time, although there remained many areas where further education appeared warranted
PMID: 10369596
ISSN: 0003-9950
CID: 37693

Melanocytomas of the optic nerve and uvea

Khadem JJ; Weiter JJ
Melanocytomas are an example of changing attitudes toward clinical management of intraocular tumors. They also might exemplify the power of pathological examination and follow-up in patient care and treatment. Prior to the observations of Zimmerman [10], most patients with melanocytomas underwent enucleation. Today, these patients are followed up conservatively and continue to enjoy vision. Melanocytomas are fairly uncommon tumors found more often in blacks and hyperpigmented individuals than in whites. Women are slightly more likely to have this tumor than are men. Melanocytomas are uniformly densely hyperpigmented lesions found on the optic nerve, choroid, ciliary body, and iris and are benign, stationary tumors that seldom cause symptoms or secondary complications. In patients with papillary melanocytomas, the most common visual disturbance is enlargement of the blind spot. With larger tumors, an afferent pupillary defect may be noted. Ciliary body and iris tumors may cause secondary anterior segment complications such as glaucoma, hyphema, or ectopia. Dispersion of pigment by melanocytomas is common and should not necessarily be interpreted as a sign of malignant transformation. Ancillary tests such as fluorescein angiography, ICG angiography, ultrasonography, CT, MRI, and the 32P test are of little clinical benefit in differentiating between melanocytomas and malignant melanomas and may lead to erroneous conclusions. Treatment for melanocytomas is conservative, its mainstay being serial clinical examinations, fundus photography, and visual field examinations to record tumor size and document growth. Lesions that grow rapidly may have transformed to a malignant melanoma and should be treated accordingly
PMID: 9429938
ISSN: 0020-8167
CID: 37694