Global Keratoconus Foundation - 2010 - World News

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Ocular Manifestations of Transconjunctival Heroin Abuse: A Case Report of an Unusual Route of Substance Abuse: Erratum No abstract available Topical Azithromycin Therapy for Meibomian Gland Dysfunction: Clinical Response and Lipid Alterations Purpose: Meibomian gland dysfunction (MGD) is a common clinical problem that is often associated with evaporative dry eye disease. Alterations of the lipids of the meibomian glands have been identified in several studies of MGD. This prospective, observational, open-label clinical trial documents the improvement in both clinical signs and symptoms of disease and spectroscopic behavior of the meibomian gland lipids after therapy with topical azithromycin ophthalmic solution. Methods: Subjects with symptomatic MGD were recruited. Signs of MGD were evaluated with a slit lamp. Symptoms of MGD were measured by the response of subjects to a questionnaire. Meibum lipid, lipid-lipid interaction strength, and conformation and phase transition parameters were measured using Fourier transform infrared spectroscopy. Results: In subjects with clinical evidence of MGD, changes in ordering of the lipids and resultant alteration of phase transition temperature were identified. Topical therapy with azithromycin relieved signs and symptoms and restored the lipid properties of the meibomian gland secretion toward normal. Conclusions: Improvement in phase transition temperature of the meibomian gland lipid with the determined percent trans rotomer composition of the lipid strongly suggests that the ordering of the lipid molecules is altered in the disease state (MGD) and that azithromycin can improve that abnormal condition toward normal in a manner that correlates with clinical response to therapy. (C) 2010 Lippincott Williams & Wilkins, Inc. Two Cases of Keratoconus Associated With Spontaneous Corneal Perforation We present 2 cases of spontaneous corneal perforation in patients with keratoconus. The first patient developed a corneal scleral fistula 1 year after her initial diagnosis of hydrops. We conclude that adequate eye care education, allergy prophylaxis, and fall precautions may be necessary in patients with keratoconus to prevent corneal perforations. Medical and surgical treatments are both viable first-line treatments for corneal perforations. (C) 2010 Lippincott Williams & Wilkins, Inc. Corneal Neurotization: A Novel Technique for the Anesthetic Cornea Purpose: This report describes and evaluates the efficacy of a novel procedure, direct corneal neurotization using contralateral, supraorbital, and supratrochlear nerves in patients with unilateral facial palsy and corneal anesthesia. Methods: The charts of 6 patients were thoroughly reviewed. Evaluated outcome parameters included corneal sensibility, improvement in best-corrected visual acuity, blink reflex, donor deficit, synesthesia, long-term corneal health, several psychosocial measures, and overall patient satisfaction. Results: The mean age at time of surgery in our study was 41.7 +/- 9.07 years. Average time from denervation to surgery was 7.00 +/- 8.56 years with an average follow-up time of 16.3 +/- 2.42 years. After surgery, all 6 eyes showed improvement of corneal sensibility, visual acuity, and corneal health and remained free of ulcers without adjunctive surgical treatment. Average time to sensibility was 2.80 +/- 2.17 years, and average corneal sensibility improved from 2.00 +/- 4.47 mm before surgery to 27.8 +/- 22.6 mm after corneal neurotization (P < 0.016). Conclusions: Direct neurotization of the cornea using the contralateral, supraorbital, and supratrochlear branches of the ophthalmic division of the trigeminal nerve seems to be an effective method for restoration of corneal sensibility in patients with unilateral facial palsy and anesthetic cornea. This procedure preserves ocular anatomy and cosmesis while restoring function by improving corneal health and visual acuity and by reestablishing the blink reflex. (C) 2010 Lippincott Williams & Wilkins, Inc. Effect of Collagen Cross-linking in Stromal Fibril Organization in Edematous Human Corneas Purpose: To assess structural stromal modifications after riboflavin and UV-A exposure in edematous human corneas. Method: Fourteen eyes with corneal edema were enrolled in the study. In the cross-linking (CXL) group, 7 corneal buttons were obtained from 6 patients who underwent penetrating keratoplasty (PK) 7-90 days after the CXL treatment. The control group was composed of 7 corneal buttons with bullous keratopathy. After the PK, stromal modifications were investigated using immunofluorescence in all corneal grafts. All patients had at least 3 months of corneal edema and were in the eye bank list waiting for keratoplasty. Results: All corneas in the treated group showed a pronounced lamellar zone of collagen fibers highly organized in the anterior stroma, but there was not complete homogeneity between the samples. Corneas with advanced disease and stromal fibrosis were less compacted than ones with mild disease severity. Similarly, those ones that underwent PK 3 months after CXL also showed a decreased effect compared with those with a reduced time between the CXL and the PK. DAPI staining demonstrated a complete fragmentation of keratocytes nuclei in the anterior stroma in all treated corneas, which were absent in the control group. Conclusions: Our study showed an immediate effect of CXL with a limited long-term sustainability. Cross-linked corneas had a pronounced anterior zone of organized collagen fibers. Even the treated corneas with advanced bullous keratopathy and stromal fibrosis had histological evidence of collagen fibers organization, but this effect seems to be decreased compared with corneas in initial stages of the disease. (C) 2010 Lippincott Williams & Wilkins, Inc. Multicenter Open-Label Study Evaluating the Efficacy of Azithromycin Ophthalmic Solution 1% on the Signs and Symptoms of Subjects With Blepharitis Purpose: To evaluate the effect of 4 weeks of treatment with azithromycin ophthalmic solution 1% on eyelid bacterial load, tear cytokines, and signs and symptoms of blepharitis. Methods: Twenty-six subjects (mean age 64.2 years; 65% female; 100% white) with moderate to severe blepharitis received azithromycin ophthalmic solution 1% in the absence of warm compresses or eyelid scrubs for 28 days (twice a day on days 1 and 2 and once a day on days 3-28). Blepharitis signs and symptoms were evaluated at baseline (day 1) and compared with end of treatment (day 29) and 2 follow-up visits (2 and 4 weeks posttreatment). Tear collection and eyelid margin bacterial cultures were performed at baseline and end of treatment. Tear cytokines were measured by a multiplex immunobead assay. Results: Four-week azithromycin treatment demonstrated significant decreases from baseline in investigator-rated signs of meibomian gland plugging, eyelid margin redness, palpebral conjunctival redness, and ocular discharge (P <= 0.002) at day 29, which persisted 4 weeks posttreatment (P <= 0.006). Subject-reported symptoms of eyelid itching, foreign body sensation/sandiness/grittiness, ocular dryness, ocular burning/pain, and swollen/heavy eyelids also demonstrated significant improvement from baseline (P < 0.001 for all symptoms and time points, except P = 0.037 for ocular dryness at visit 4). Eyelid margin culture exhibited significant decreases in coagulase-negative staphylococci and Corynebacterium xerosis bacteria. Changes in tear cytokine concentrations were not observed. Twelve subjects experienced 19 adverse events, 15 of which were ocular and none of which were serious. Conclusions: Azithromycin provided significant improvement in signs and symptoms of blepharitis after 4 weeks of treatment compared with baseline and persisted in the 4-week follow-up period. (C) 2010 Lippincott Williams & Wilkins, Inc. Modified Osteo-Odonto Keratoprosthesis-The Indian Experience-Results of the First 50 Cases Purpose: To study the results of the modified osteo-odonto keratoprosthesis (MOOKP) surgery in bilateral end-stage ocular surface disorders. Methods: The MOOKP surgery is performed as a routine in 3 stages. Stage 1A involves removal of the iris and anterior vitrectomy with a corneal transplant if indicated. Stage 1B + 1C usually performed simultaneously involves harvesting the buccal mucosa and transplanting it onto the ocular surface along with fashioning of the osteo-odonto alveolar lamina. Stage 2 involves transplanting the osteo-odonto alveolar lamina to the eye 3 months later. Results: The MOOKP surgery was completed in 50 eyes of 47 patients with a mean follow-up of 15.38 months (range: 1-54 months). Anatomic success was achieved in 96% of the eyes. Functional success of visual acuity >=20/60 was noted in 66% of eyes. Complications included oroantral fistula (6%), trophic mucosal alterations (8%), lamina exposure (central 6% and peripheral 8%), mucous membrane overgrowth (2%), hypotony (2%), expulsion of optic cylinder (4%), endophthalmitis (2%), glaucoma (20%), sterile vitritis (6%), and retinal detachment (2%). Conclusions: MOOKP is the keratoprosthesis of choice in bilateral end-stage ocular surface disorders in the Indian subcontinent. Complications do occur and have to be recognized and treated early. (C) 2010 Lippincott Williams & Wilkins, Inc. Clinical Impact of Conjunctivochalasis on the Ocular Surface Purpose: To report the clinical impact of conjunctivochalasis on the ocular surface by evaluating the effect of a new concept of conjunctivochalasis operation on the resolution of patients' symptoms and corneal epithelial damage. Also, the association of inflammation with conjunctivochalasis is examined. Patients and Methods: A total of 168 eyes of 131 conjunctivochalasis patients with (50 eyes) or without (118 eyes) dry eye who received the newly designed conjunctivochalasis operation were enrolled. All patients had prominent conjunctivochalasis at the lower tear meniscus and their ocular symptoms were not sufficiently controlled by the usual eyedrop therapy. Subjective symptoms of patients were assessed before and after the operation by questionnaires. Scores of corneal fluorescein staining were evaluated before and after the operation in patients with dry eye. Four samples of the lower part of conjunctiva from non-dry eye conjunctivochalasis patients were investigated by immunostaining and compared with samples from 4 normal conjunctiva and 3 conjunctiva showing inflammation due to Mooren ulcer, ocular cicatricial pemphigoid, and alkali burn. Results: The most frequent chief subjective symptoms before the operation were irritation (51.7%) and lacrimation (31.4%) in conjunctivochalasis patients without dry eye and irritation (80.0%) in those with dry eye. Improvement of the chief symptoms was obtained in 88.2% and 78.0% of these 2 patient groups, respectively. Furthermore, in patients with dry eye, corneal fluorescein staining scores (mean +/- SD) were significantly improved after the operation compared with before the operation: A (area), 0.6 +/- 0.7 and D (density), 0.8 +/- 0.9 versus A, 1.3 +/- 0.5 and D, 1.9 +/- 0.9; P < 0.0001. Based on the immunostaining study, conjunctival samples from eyes with conjunctivochalasis and normal eyes showed negligible inflammation compared with those from inflamed conjunctiva. Conclusions: This study suggests that conjunctivochalasis has a great clinical impact on the ocular surface, and the newly developed operation is very effective in resolving patient complaints and also ocular surface damage in conjunctivochalasis with dry eye. It may also be suggested that the conjunctivochalasis has a negligible association with conjunctival inflammation. (C) 2005 Lippincott Williams & Wilkins, Inc. Effect of Intravitreal Ranibizumab on Corneal Endothelium in Age-Related Macular Degeneration Purpose: To determine the effect of intravitreal injection of ranibizumab on the corneal endothelium in patients with choroidal neovascularization in age-related macular degeneration. Methods: Observational prospective case series study. Fifty-two eyes of 52 consecutive patients (29 men, 23 women; age range, 61-80 years) were evaluated. All participants received monthly intravitreal injections of (0.05 mL, 0.5 mg) ranibizumab for 3 consecutive months; the follow-up period was 6 months. Central corneal specular microscopy was performed before injection and at 7 days and 6 months after the first intravitreal injection. The endothelial cell density, coefficient of variation of cell size, and percentage of hexagonal cells were analyzed, and the central corneal thickness was measured. Results: There were no significant differences in the endothelial cell densities, coefficient of variation of cell sizes, and percentage of hexagonal cells values before injection and at 7 days and 6 months after the first intravitreal ranibizumab injection (P = 0.987, P = 0.822, and P = 0.918, respectively). There was also no significant difference in central corneal thickness measurements before injection and at 7 days and 6 months after the first intravitreal ranibizumab injection (P = 0.325). Conclusion: Repeated intravitreal injections of 0.5 mg of ranibizumab do not seem to cause substantial changes in the corneal endothelium at 6 months. (C) 2010 Lippincott Williams & Wilkins, Inc. Deep Anterior Lamellar Keratoplasty Versus Penetrating Keratoplasty for Keratoconus: A Clinical Trial Purpose: To compare deep anterior lamellar keratoplasty (DALK) using the big-bubble technique to penetrating keratoplasty (PK) in patients with keratoconus. Materials and Methods: In this clinical trial, patients with moderate to advanced keratoconus with poor spectacle-corrected visual acuity and intolerant to contact lens wear were enrolled. DALK was performed using the big-bubble technique, and a full-thickness donor cornea without Descemet membrane was sutured to the recipient bed. PK was performed conventionally with a Hessburg-Barron suction trephine. Three types of suturing were used for both groups. Postoperative refractive errors, best-corrected visual acuity (BCVA), contrast sensitivity function (CSF), and higher order aberrations (HOAs) were compared between the study groups. Results: The study included 81 eyes of 81 patients. Forty-six eyes underwent DALK from which 4 were excluded because of failure to achieve bared Descemet membrane. Thirty-five eyes received PK. Mean patient age was 26.91 +/- 7.9 versus 30.89 +/- 10.3 years in the DALK and PK groups, respectively (P = 0.06). Mean follow-up period was 22.0 +/- 7.9 months in the DALK group and 24.6 +/- 3.5 months in the PK group (P = 0.32). Mean postoperative spherical equivalent refractive error was -3.23 +/- 3.4 diopters in the DALK group versus -2.22 +/- 4.6 diopters in the PK group (P = 0.28), and mean postoperative BCVA was 0.18 +/- 0.08 and 0.15 +/- 0.10 logarithm of the minimum angle of resolution, respectively (P = 0.12). CSF and total aberrations and HOAs were comparable in the study groups. Conclusions: DALK is an effective alternative surgical procedure for patients with keratoconus; the outcomes are comparable to PK in terms of refractive errors, BCVA, CSF, and HOAs. (C) 2010 Lippincott Williams & Wilkins, Inc. Deep Anterior Lamellar Keratoplasty in Herpes Simplex Corneal Opacities Purpose: To report our experience with deep anterior lamellar keratoplasty (DALK) for the treatment of corneal opacities following herpetic keratitis. Methods: A total of 52 eyes of 52 patients with postherpetic stromal scars with intact endothelium were treated in our department with DALK between 2002 and 2006 as a surgical approach to restore corneal transparency. The main outcome measures of the study were the ability to successfully expose DM (descemetic DALK, dDALK), the number of cases with predescemetic plane achieved surgical plane (pdDALK), pre- and postoperative visual acuity, and endothelial cell count. The mean follow-up period was 31 months. Therapeutic protocol, recurrence of herpetic keratitis, and corneal rejection were evaluated. Results: dDALK was done in 45 of 52 cases (86.5%) and pdDALK was done in 7 of 52 cases (13.5%). Ruptures of Descemet's membrane occurred in 2 of 52 cases (3.8%) in our series. No case was converted to penetrating keratoplasty. Postoperative best-spectacle-corrected visual acuity was 20/20 in 27 of 52 cases (52%) and at least 80% of patients achieved 20/30 at long-term follow-up. Average endothelial cell loss was 205.32 cell/mm2. Therapeutic protocol was conducted with long-term therapy with oral antiviral drugs and topic steroids after DALK. No episode of rejection or recurrence was detected in these patients through their last visit. Conclusions: DALK is an alternative and safe procedure to restore vision in cases with significant corneal scarring due to recurrent HSV keratitis with healthy endothelium. Pre- and postoperative antiviral prophylaxis is necessary to prevent recurrence. (C) 2010 Lippincott Williams & Wilkins, Inc. Genotype of Lattice Corneal Dystrophy (R124C Mutation in TGFBI) in a Patient Presenting With Features of Avellino Corneal Dystrophy Purpose: To present a patient with a genotype usually associated with lattice corneal dystrophy but with clinical and histopathologic features of advanced Avellino corneal dystrophy. Methods: Penetrating keratoplasty was performed with subsequent histopathologic analysis. For genetic testing, a 5-mL blood sample was taken after informed consent. Genetic sequencing was performed by the John and Marcia Carver Laboratory of the University of Iowa. The mutation was identified by direct sequencing through the positions of the coding sequences of the TGFBI gene that have been previously reported to have genetic variations (exons 4 and 11-14). Results: Corneal examination revealed bilateral lattice and multiple confluent subepithelial and anterior stromal granular opacities. Histopathologic examination showed amyloid deposits by Congo red stain and hyaline deposits by Masson trichrome stain, consistent with a diagnosis of Avellino dystrophy. Automated DNA sequencing revealed a heterozygous Arg124Cys (R124C) mutation in the coding sequence of the TGFBI gene on chromosome 5q31. Recurrent granular deposits developed in the corneal graft 14 months after surgery. Conclusions: Our case presented with clinical and histopathologic findings consistent with a diagnosis of Avellino dystrophy and exhibited a genotype with R124C mutation. Avellino dystrophy has not previously been reported to be associated with the R124C mutation, which is usually associated with lattice corneal dystrophy. This also raises the issue as to whether classification of the corneal stromal dystrophies should be based primarily on phenotype/histopathology or on genotyping. (C) 2010 Lippincott Williams & Wilkins, Inc. Randomized Clinical Study for Comparative Evaluation of Fourth-Generation Fluoroquinolones With the Combination of Fortified Antibiotics in the Treatment of Bacterial Corneal Ulcers Purpose: Comparative evaluation of efficacy of monotherapy with moxifloxacin (0.5%) or gatifloxacin (0.3%) with combination therapy of cefazolin (5%) and tobramycin (1.3%) in treatment of bacterial corneal ulcers. Methods: Patients diagnosed with bacterial keratitis (ulcer diameter 2-8 mm) were randomized to 1 of the 3 treatment groups (tobramycin 1.3% and cefazolin 5%, gatifloxacin 0.3%, or moxifloxacin 0.5%). After obtaining corneal scrapings, assigned study medication was instilled hourly for 48 hours and tapered as per clinical response. Healing of ulcer, duration to cure, adverse reactions, antibiogram profile, treatment failures, final visual acuity, and corneal opacity size were evaluated. Results: A total of 61 patients were enrolled [cefazolin and tobramycin (n = 20), gatifloxacin (n = 21), and moxifloxacin (n = 20)]. Overall, 57 patients (93%) healed on treatment. On comparison of the mean time taken to heal, no statistically significant difference was found among all the 3 treatment groups (P = 0.98). Positive bacterial culture was obtained in only 38 patients (62%). There was no significant difference in the bacterial isolates in each treatment group. There were 4 (7%) treatment failures (perforation or nonhealing ulcer): 1 (5%) each in moxifloxacin and gatifloxacin group and 2 (10%) in fortified antibiotics group. All regimens were well tolerated. Conclusion: The study failed to find a difference in the efficacy of monotherapy with fourth-generation fluoroquinolones in the treatment of bacterial corneal ulcers of 2-8 mm size when compared with combination therapy of fortified antibiotics. (C) 2010 Lippincott Williams & Wilkins, Inc. Scheimpflug Imaging of Corneas After Collagen Cross-Linking Purpose: To compare geometrical shape factors of keratoconus corneas after cross-linking (CXL) by means of Scheimpflug imaging with those of untreated fellow eyes. Setting: Institut fur Refraktive und Ophthalmo-Chirurgie, Zurich, 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. (C) 2009 Lippincott Williams & Wilkins, Inc. The Effect of Successful Rebubbling After Descemet Stripping Automated Endothelial Keratoplasty on Endothelial Cell Counts Purpose: To examine the effect of successful repositioning/rebubbling of the graft on endothelial cell counts (ECCs) in eyes after Descemet stripping automated endothelial keratoplasty. Methods: This retrospective study reviewed the outcomes of 58 eyes that underwent Descemet stripping automated endothelial keratoplasty. Fifty-one eyes were attached after surgery. Seven were detached and underwent rebubbling with minimal manipulation in 5 and significant manipulation in 2, after which the graft was attached and clear. Visual outcomes and endothelial cell loss at 6 months were compared between eyes that underwent repositioning/rebubbling and those that did not. The following were excluded: 2 eyes that had primary failure, 2 eyes that had rejection, 1 eye that failed to attach after rebubbling, 2 eyes that failed to clear after rebubbling, and 24 eyes that did not have ECC at 6 months. Results: The 2 groups were comparable considering age, preoperative best-corrected visual acuity, surgical variables, combined procedures, donor cell count, and graft size. The mean postoperative spherical equivalent, manifest and topographic astigmatism, uncorrected visual acuity, and best-corrected visual acuity did not differ significantly between the 2 groups at 6 months. Mean pre- and postoperative ECC did not differ significantly between the group that underwent repositioning/rebubbling and the group that did not (preoperative counts 2742 +/- 268 vs. 2747 +/- 353 and postoperative counts 1590 +/- 367 vs. 1746 +/- 491, respectively). Endothelial cell loss also did not differ significantly between the 2 groups, although there was a trend to greater cell loss in the reattachment group (-39.4% +/- 11.1% vs. -38.3% +/- 16.2%, respectively; P = 0.6). Conclusion: Successful reattachment procedure does not seem to cause significant endothelial cell loss. (C) 2010 Lippincott Williams & Wilkins, Inc. Bevacizumab for the Treatment of Corneal Neovascularization Corneal neovascularization (NV) is a severe complication associated with inflammatory or infectious disorders of the cornea. NV may lead to severe reduction in visual acuity and poor prognosis for corneal transplantation and excimer laser refractive surgery. Vascular endothelial growth factor (VEGF), a potent angiogenic factor, has been reported to play a major role in the pathogenesis of corneal NV. Use of an anti-VEGF antibody would seem a theoretically plausible means for treating corneal NV. Recently, bevacizumab, a humanized monoclonal antibody against VEGF, has been reported significantly to inhibit choroidoretinal NV. Several animal and human studies have also reported beneficial effects of bevacizumab against corneal NV; both topical and subconjunctival application were effective. Nonetheless, optimal dosage, route of administration, and possible complications are yet to be fully characterized. This review summarizes the relevant literature and formulates several key questions to guide future use of bevacizumab in the treatment of corneal NV. (C) 2009 Lippincott Williams & Wilkins, Inc. Topical Treatment With 1% Cyclosporine for Subepithelial Infiltrates Secondary to Adenoviral Keratoconjunctivitis Purpose: To evaluate the treatment with topical 1% cyclosporine A (CsA) in patients with subepithelial corneal infiltrates (SEIs). Methods: We retrospectively reviewed the records of 9 patients (12 eyes) before and after the treatment with CsA 1% eyedrops twice daily. All patients had been treated with topical corticosteroids previously without improvement or had to stop the medication secondary to intraocular pressure elevation. The objective data recorded included best-corrected Snellen visual acuity, intraocular pressure, number of medications in use, and evaluation of severity of SEIs (improved, stable, or worse). For their subjective evaluation, patients were asked to complete a questionnaire based on the last follow-up visit. Results: Five males (56%) and 4 females (44%), mean age of 47 +/- 13 years, were included. Mean follow-up on CsA was 13 +/- 7 months. The mean best-corrected Snellen visual acuity (logarithm of the minimum angle of resolution) before and after treatment was 0.42 +/- 0.40 and 21 +/- 0.28, respectively, with no statistically significant improvement. There was statistically significant reduction in the number of medications before and after treatment from 1.88 +/- 1.05 to 1.22 +/- 0.44, respectively (P = 0.049). Six patients (66%) showed clinical improvement, and 3 (34%) were stable during the treatment period. Patients reported statistically significant reduction in the severity of symptoms before and after the treatment. Most of the patients reported no foreign body sensation, glare, or other side effects with topical CsA treatment. Overall, patients noted an improvement in vision and satisfaction with CsA treatment. Conclusions: Topical CsA 1% is a safe and effective alternative treatment in patients with SEIs who do not respond to other treatment modalities or have unwanted side effects from topical steroids. (C) 2010 Lippincott Williams & Wilkins, Inc. Recurrent Blue Nevus of the Corneoscleral Limbus Purpose: To describe an unusual corneoscleral blue nevus. Methods: Review of clinical and histopathological characteristics and previous relevant literature supplemented with immunohistochemical studies. Results: A 13-year-old Pakistani girl presented with a 5 x 2-mm, superotemporal, nonmovable, recurrent, black, limbal nodule. The lesion had been incompletely removed two and a half years earlier. Nonfascicular, variably pigmented, banal, spindle melanocytes with bland nuclei were discovered histopathologically in the conjunctival substantia propria and superficial sclera in the original and recurrent specimens. HMB-45+ and MART-1+ immunostainings established that all the variably pigmented spindle cells were melanocytes. Dispersed plump melanophages displayed clumped melanin granules and were shown to have small nuclei after decolorization. The Ki-67 proliferation index was very low (0.05%), supporting a benign diagnosis. No residual pigmentation after excision and cryotherapy was observed in follow-up examinations during a year and a half. Conclusions: Careful histopathological and immunohistochemical evaluation of recurrent, incompletely excised, blue nevi can determine if they remain benign. Adjunctive cryotherapy was performed to prevent further recurrence, based on results from published data. (C) 2010 Lippincott Williams & Wilkins, Inc. Correction No abstract available Prevalence of Ocular Surface Complaints in Patients With Glaucoma Using Topical Intraocular Pressure-Lowering Medications Purpose: To determine the prevalence of ocular surface disease (OSD) in patients with glaucoma using topical intraocular pressure (IOP)-lowering therapy. Methods: This prospective observational study enrolled patients with primary open-angle glaucoma or ocular hypertension who were on a topical IOP-lowering medication regimen. Enrolled patients completed the ocular surface disease index (OSDI) and OSDI scores (0-100, with 0 representing no symptoms) were calculated for each patient. Medical history, demographics, and concomitant medication information were also collected. Results: Overall, 630 patients from 10 sites participated. Of these, 305 patients (48.4%) had an OSDI score indicating either mild (n = 134, 21.3%), moderate (n = 84, 13.3%), or severe (n = 87, 13.8%) OSD symptoms. OSDI scores were significantly different between patients with and without a prior diagnosis of dry eye syndrome (25.2 +/- 15.4 vs 15.4 +/- 15.8, respectively; P = 0.0036) and between patients who did and did not use artificial tears at the time of study participation (23.0 +/- 15.6 vs 15.3 +/- 15.8, respectively; P = 0.0046). Mean OSDI scores varied significantly with the number of topical IOP-lowering medications used, with higher (more severe) OSDI scores in patients using multiple IOP-lowering medications. Specifically, patients on a single medication had a mean OSDI score of 12.9 +/- 13.1, which was significantly lower than those of patients on 2 (16.7 +/- 17.0; P = 0.007) or 3 medications (19.4 +/- 18.1; P = 0.0001). Conclusions: OSD is prevalent among medically treated patients with glaucoma. The severity of OSD symptoms is positively correlated to the number of IOP-lowering medications used. (C) 2010 Lippincott Williams & Wilkins, Inc.

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