A 77-year-old man with a recent diagnosis of kappa light chain IgA multiple myeloma presented with amaurosis fugax of the left eye, jaw claudication, and arthritis. Erythrocyte sedimentation rate (ESR) was 11 and C-Reactive Protein (CRP) was 2. The patient underwent subsequent left temporal artery biopsy. Examination by light microscopy revealed an amorphous, hypocellular, eosinophilic staining material infiltrating the internal elastic lamina (Fig 1A and B, arrow) (hematoxylin and eosin, magnification 40× and 100×, respectively).

PURPOSE:To report a case of delayed-onset bilateral scleral thinning and calcium deposition following a cosmetic ocular-whitening procedure (I-BRITE(®)).METHODS:A 33-year-old male patient with a history of right-sided ptosis repair and left-sided anterior uveitis had previously undergone bilateral I-BRITE treatment for chronic conjunctival hyperemia. Four years after the procedure, the patient was referred to our institution with bilateral scleral thinning and overlying calcific depositions. A literature review was performed through PubMed from 1980 through 2014 using the search terms 'cosmetic', 'ocular', 'conjunctivectomy', 'regional conjunctivectomy', 'I-BRITE', 'eye-whitening', 'scleritis', 'necrotizing scleritis', 'anterior uveitis', 'mitomycin C', '5-fluorouracil', and 'bevacizumab', along with associated cross-referencing from relevant articles.RESULTS:Examination of the patient revealed bilateral necrotizing scleritis within the nasal region of both eyes. Calcified plaques were also present within the areas of scleromalacia, along with epithelial defects demonstrated with fluorescein staining. Although evidence of previous intraocular inflammation was apparent within the left eye, there were no active signs of inflammation evident within either eye on initial presentation. Complication rates reported in the literature include: scleral thinning (1.8%), calcific plaque formation (2.9%), fibrovascular proliferation (13%), diplopia (1.2%), elevation of intraocular pressure (4.2%), and recurrence of conjunctival hyperemia (2.1%).CONCLUSION:Cosmetic ocular whitening procedures have an attendant high complication rate, and have been associated with several adverse postoperative complications, which have in turn generated several reservations regarding the veritable benefit of the procedure. Many postsurgical complications may demonstrate delayed apparition, varying from several months to several years after primary surgical intervention as in the case reported here.

Dr. Valenzuela: An 82-year-old man developed a right abduction deficit and horizontal double vision. He was diagnosed with ocular myasthenia based on positive acetylcholine receptor blocking and binding antibodies. His double vision resolved with azathioprine and prednisone. Four years later, he experienced a central retinal vein occlusion in the right eye. He was treated with intravenous tissue plasminogen activator without improvement and his vision stabilized at 20/50 in that eye, with a 0.6 log unit right relative afferent pupillary defect (RAPD). Seven years later, he developed right brow numbness that progressed to dysesthesia and allodynia within a year. Four years after the onset of right brow numbness, the patient had resection of basal and squamous cell skin cancers of the head and neck. Because of concerns of increasing skin cancer, thrombocytopenia, and elevated liver enzymes, azathioprine was reduced. Prednisone was continued. Seven months later, he reported stabbing pain in his right cheek and right facial weakness. This prompted brain magnetic resonance imaging (MRI). Dr. Osborn: The contrast-enhanced, fat-suppressed MRI shows well-delineated right intraconal mass adjacent to the optic nerve sheath (Fig. 1). No other abnormalities are present. Specifically, the right trigeminal and facial nerves appeared normal.FIG. 1.: Postcontrast coronal (A) and axial (B) T1 magnetic resonance imaging with fat suppression show a well-delineated right intraconal mass (arrows) adjacent to the optic nerve sheath.Dr. Valenzuela: The patient was evaluated in the neuro-ophthalmology clinic because of recurrence of horizontal diplopia and worsening right facial weakness. Visual acuity was 20/50, right eye and 20/20, left eye with a 0.6 log unit right RAPD. Visual field testing of the right eye revealed a central scotoma; the field of the left eye was full. Color vision was impaired on the right and stereovision was reduced. Extraocular motility showed a significantly limited (−3) abduction of the right eye and mild (−1) adduction and supraduction deficits of the left eye. The anterior and posterior segments were normal. There was no proptosis. The patient's neurologic examination was normal except for decreased sensation to light touch over the distribution of the maxillary and mandibular divisions of the right trigeminal nerve. In addition, the patient could not raise his right eyebrow and had flattening of his right nasolabial fold. Because of the recent dose reduction of azathioprine, the patient was thought to have worsening myasthenia, and his prednisone was increased without any improvement. Although the facial weakness and diplopia could be explained by worsening myasthenia, the decreased sensation in his right face could not. With his constellation of findings and the presence of an enhancing intraconal mass, there was concern for metastatic disease, perineural invasion (PNI), or leptomeningeal carcinomatosis. The patient underwent Mohs surgery of his scalp for squamous cell skin cancer. There was poor wound healing. Because of worsening right facial weakness, pain, and numbness, MRI was repeated 8 months after his previous study. Dr. Osborn: This study shows that the right intraconal mass adjacent to the optic nerve sheath has slightly increased in size (Fig. 2) compared with the study carried out 8 months earlier (Fig. 1). There is no thickening or contrast enhancement of the trigeminal or facial nerves (not shown).FIG. 2.: Contrast-enhanced coronal (A) and axial (B) T1 magnetic resonance imaging show a slight increase in the size of the right orbital mass (arrows).Dr. Valenzuela: A number of diagnoses had been considered in this patient, including metastatic squamous or basal cell carcinoma, lymphoma, leptomeningeal carcinomatosis, chronic central nervous system infection, and neoplastic PNI. The diagnosis of cranial nerve and leptomeningeal disease can be difficult to establish when imaging does not reveal enhancement of affected nerves or leptomeninges. Although cerebrospinal fluid samples are only positive for malignant cells in 54% of first lumbar puncture in patients with leptomeningeal metastasis (1), we recommended a lumbar puncture. Our patient declined this procedure, preferring to be followed without further intervention. At 3-month follow-up, his vision remained stable, with a persistent right abduction deficit, but the subtle elevation and adduction deficit of the left eye resolved. Although the orbital mass did not explain the patient's initial clinical findings and was not accompanied by worsening optic nerve function, when the second MRI showed enlargement of the lesion, a biopsy was performed. Dr. Palmer: The biopsy of the right intraconal orbital mass shows multiple fingers of tumor cells with round basophilic staining nuclei and cytoplasm, typical of metastatic squamous cell carcinoma (SCC) (Fig. 3A). The mass stains diffusely with p63 (Fig. 3B), cytokeratins 5/6 (Fig. 3C), and AE 1/3 (Fig. 3D) and E-cadherin (Fig. 3E), indicating squamous cell differentiation. Staining for estrogen receptors was negative (Fig. 3F), arguing against a breast origin of the lesion. Stains for CD3 and CD20 also were negative (Fig. 3G, H), excluding lymphoma and other lymphoid tumors.FIG. 3.: Histopathology of right orbital mass. A. Squamous cell carcinoma is seen infiltrating the connective tissue (hematoxylin and eosin, ×400). The lesion is consistent with squamous cell differentiation as it stained differently for p63 (B), cytokeratins 5/6 (C), AE 1/3 (D) and E-cadherin (E) (B, ×200; C, ×400; D, ×400; E, ×400). Negative staining for estrogen (F) excludes a tumor of breast origin and negative for CD3 (G) and CD20 (H) excludes lymphoma and other lymphoid tumors (F, ×200; G, ×200; H, ×200).Dr. Valenzuela: At 17-month follow-up, the patient died. An MRI done 1 month previous to his death showed normal trigeminal and facial nerves on the right. However, there was new enhancement of the left facial nerve along the internal auditory canal (Fig. 4).FIG. 4.: Postcontrast, fat-suppressed axial T1 magnetic resonance imaging performed 1 month before death shows interval appearance of enhancement along the geniculate and labyrinthine segments of the left facial nerve that appears slightly thickened (arrow). The right internal auditory canal is not shown on this image, but the right facial nerve appeared normal.The patient had survived 6 years from the onset of his facial numbness. An autopsy was not performed. Final Diagnosis Metastatic, poorly differentiated SCC with presumed PNI of the trigeminal and facial nerves. Dr. Valenzuela: The terms PNI and perineural spread (PNS) are used to describe involvement of nerves by certain tumors. PNI is microscopic infiltration of the nerve by tumor cells, whereas PNS describes gross tumor spread along a nerve that is, at least in part, distinct from the main tumor mass. The right facial pain, weakness, and dysesthesias in our patient could be explained by PNI of the trigeminal and facial nerves from metastatic, poorly differentiated SCC. His diplopia with bilateral motility deficits could have been due to undertreatment of his preexisting ocular myasthenia, although all cranial nerve deficits also could have been due to leptomeningeal carcinomatosis. Although we cannot exclude carcinomatous meningitis as a cause for our patient's neurological and visual deficits, repeated normal brain imaging, the length of time of his clinical course, and his overall well-being over this time, make this diagnosis unlikely. PNI is an insidious form of tumor growth and is more often a feature of malignant than benign lesions. The prevalence of PNI in cases of SCC is 2.5%–5%. The following factors increase the risk of PNI: tumor size >2 cm, male gender, forehead location, recurrences, and previous treatment (2). PNI most often involves the maxillary, mandibular, and facial nerves. The pterygopalatine fossa plays an important role in the involvement of these nerves. This fossa is a small space just behind the maxillary sinus and in front of the pterygoid plates of the sphenoid bone. An important feature of the pterygopalatine fossa is the many connections that it affords to other areas of the cranium. The fossa communicates with the orbit, nasal cavity, and infratemporal fossa through the inferior orbital fissure, sphenopalatine foramen, and pterygomaxillary fissure. Once the tumor reaches the pterygopalatine fossa or the foramen rotundum, it can spread into the cavernous sinus, Meckel cave and, eventually, along the cisternal portion of the trigeminal ganglion into the lateral aspect of the pons. Likewise, from the pterygopalatine fossa through the Vidian canal, tumor can spread to the petrous bone to involve the facial nerve. Other cranial nerves that can be affected by PNI include the oculomotor, abducens, and hypoglossal. Typically, these patients present with facial pain, paresthesias, ptosis, diplopia, facial weakness, ophthalmoparesis, or a combination of these manifestations (3). Nevertheless, Nemzek et al (4) reported that 30%–60% of patients remain asymptomatic. There are 3 current theories regarding the pathophysiology of PNI. First, nerve cell adhesion molecule (NCAM), an immunoglobulin with several functions including adhesion, proliferation, and migration of neural cells, is expressed in a large percentage of adenoid cystic carcinomas (ACCs). Although its role in PNI of SCC is not as well defined, Vural et al (5) showed that 93% of specimens from patients with PNS stained positive for NCAM. Second, tyrosine kinase A, one of a family of cell surface receptors with high affinity for polypeptide growth factors, cytokines, and hormones, is expressed along with nerve growth factor in 95% of cases of PNI from SCC of the tongue (6). Finally, Toll-like receptor 3 (TLR3), a protein encoded by the TLR3 gene, plays a key role in pathogen recognition by producing Type I interferons, and TLR3 expression is significantly correlated with poor differentiation and PNI of SCC of the head and neck (7). In 1998, Nemzek et al (4) conducted a retrospective review of imaging findings in 19 patients with evidence of PNI. Among these patients, 10 had SCC, 4 ACC, 1 poorly differentiated carcinoma of unknown origin, 1 salivary duct carcinoma, 1 mucoepidermoid carcinoma, 1 had a chordoma, and 1 meningioma. The trigeminal nerve and its branches were involved in 85% of these patients. The authors concluded that MRI sensitivity in determining PNI was 95%. Bowyer et al (8) reported a 24% false-negative rate with MRI but concluded that MRI is better than computed tomography in detecting PNI. Although a consensus on treatment guidelines for patients with PNI has not been established, most patients undergo surgery followed by radiation therapy. This regimen results in a local control rate of 50%–85%, with the ultimate prognosis depending, in part, on pretreatment imaging findings. The absolute 5-year survival rate is 50% in patients with MRI funding of PNI compared with 86% in patients whose imaging studies are unremarkable (P = 0.048) (9). In summary, PNI is a known complication of SCC of the head and neck, and most commonly affects the trigeminal and facial nerves. Biopsy of asymptomatic lesions may help to confirm diagnosis. The imaging findings in PNI can be subtle, variable, and even normal despite clear-cut clinical findings.

The purpose of the study is to evaluate the stability and ease of replacement of a new modular intraocular lens (IOL) system consisting of a hydrophobic acrylic base unit and a hydrophobic acrylic optic in the rabbit model.

Background: To evaluate the effect of varying levels of power on phacoemulsification efficiency using the CENTURION Vision System.Methods: Formalin-soaked porcine lenses were divided into 2-mm cubes; 0.9-mm, balanced tips were used. Torsional power levels were tested from 10% to 100% at 10% intervals. Vacuum was set to 550mmHg, aspiration to 50 ml/min, and intraocular pressure at 50 mmHg. Efficiency (time to lens removal) and chatter (number of lens fragment repulsions from the tip) were determined.Results: Increasing torsional power up to 60% increased efficiency. This effect was linear from 30 to 60% power (R-2 = .90; P < 0.05). There were no significant differences in efficiency past 60%. Chatter was highest at 10% power and decreased linearly (R2 = .87; P = 0.007) as power was increased up to 60% power, and chatter did not improve above this power level.Conclusions: Power improved efficiency only up to a 60% power level, and then was negligible. Chatter correlated well with power up to the 60% level, so that as power was increased, chatter decreased. Because there are no additional benefits in efficiency past 60% power, and because chatter is minimal at 60% power, we recommend torsional ultrasound at 60% as the optimal power setting for using the CENTURION System for phacoemulsification.l

PURPOSE: To evaluate the effect of vacuum and aspiration rates on phacoemulasification efficiency and chatter using a monitored forced infusion system.DESIGN: In vitro animal study.METHODS: SETTING: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah. PROCEDURES: Formalin-soaked porcine lenses were divided into 2 mm cubes (tip diameter, 0.9 mm). Vacuum levels were tested at 200, 300, 400, and 500 mm Hg; aspiration rates at 20, 35, and 50 mL/min. Torsional power was set at 60% and intraocular pressure at 50 mm Hg.RESULTS: Increasing vacuum increased efficiency regardless of aspiration rates (R-2 = 0.92; P = .0004). Increasing aspiration further increased efficiency when vacuum was at 400 and 500 mm Hg (P = .004 for 20 vs 35 mL/min, P = .0008 for 35 vs 50 mL/min). At 200 and 300 mm Hg, efficiency only improved when increasing aspiration to 35 mL/min (P <.0001 with 20 vs 35 + 50 mL/min). Chatter improved with increasing vacuum, up to 400 mm Hg (P = .003 for 200 vs 306 mm Hg and P = .045 for 300 vs 500 mm Hg). A similar trend of improved chatter was seen with increasing levels of aspiration.CONCLUSIONS: Vacuum improved efficiency up to 500 mm Hg independent of flow. Flow has an additive effect on efficiency through 50 mL/min,, when vacuum is at 400 mm Hg or higher, and only up to 35 mL/min at vacuums less than 400 mm Hg. Chatter correlated with both vacuum and flow such that increasing either parameter decreases chatter, up to 400 mm Hg with vacuum. (C) 2016 Elsevier Inc. All rights reserved.

Postoperative capsule opacification is a multifactorial physiological consequence of cataract surgery that remains the most common complication of this procedure. A literature review that included several intraocular lenses (IOLs) and endocapsular devices studied in our laboratory found that devices maintaining the capsular bag in an open or expanded state were associated with improved bag clarity. This observed effect likely occurs secondary to the complex interactions of myriad mechanisms, which include formation of a barrier to lens epithelial cell (LEC) migration, mechanical compression of residual LECs, mechanical stretch at the level of the capsule equator, maintenance of overall bag contour, and enhanced endocapsular circulation of aqueous humor. We review the designs of endocapsular devices and IOLs that minimize the degree of postoperative capsule opacification by preventing capsular bag collapse and discuss the underlying mechanisms that contribute to this phenomenon.None of the authors has a financial or proprietary interest in any material or method mentioned.

Postoperative capsule opacification is a multifactorial physiological consequence of cataract surgery that remains the most common complication of this procedure. A literature review that included several intraocular lenses (IOLs) and endocapsular devices studied in our laboratory found that devices maintaining the capsular bag in an open or expanded state were associated with improved bag clarity. This observed effect likely occurs secondary to the complex interactions of myriad mechanisms, which include formation of a barrier to lens epithelial cell (LEC) migration, mechanical compression of residual LECs, mechanical stretch at the level of the capsule equator, maintenance of overall bag contour, and enhanced endocapsular circulation of aqueous humor. We review the designs of endocapsular devices and IOLs that minimize the degree of postoperative capsule opacification by preventing capsular bag collapse and discuss the underlying mechanisms that contribute to this phenomenon.

PURPOSE:To evaluate the stability and capsular bag opacification of a smooth or a patterned silicone protective membrane implanted in the bag with secondary placement of an intraocular lens (IOL).SETTING:John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA.DESIGN:Experimental study.METHODS:Twelve New Zealand rabbits had bilateral implantation of a protective membrane and an IOL or an IOL alone. Three groups of 8 eyes each received the IOL and the smooth protective membrane, the IOL and the patterned membrane, or the IOL alone. Slitlamp examination was performed weekly for 4 weeks. The rabbits were then humanely killed and their globes enucleated. Capsular bag opacification was scored based on the Miyake-Apple view, and the eyes underwent histopathology.RESULTS:At 4 weeks, the mean central posterior capsule opacification (PCO) score was 0.28 ± 0.32 (SD) in all eyes with a protective membrane and 2.08 ± 1.28 in eyes with the IOL alone (P < .00001, Student t test). Peripheral PCO and Soemmerring ring formation were also significantly less in eyes with the protective membrane. Histopathologically, the posterior capsules were relatively clear in most IOLs with the protective membrane. The smooth and patterned protective membranes showed a significant difference in overall capsular bag opacification formation compared with the IOLs without the membrane.CONCLUSIONS:The circular geometry of the protective membrane led to expansion of the capsular bag and appeared to prevent capsular bag opacification. Further studies are warranted to assess whether the pattern on the device's posterior surface further enhances this effect.FINANCIAL DISCLOSURE:No author has a financial or proprietary interest in any material or method mentioned.

BackgroundIncorrect lens power remains one of the most common reasons for intraocular lens explantation/exchange. We evaluated stability and effect on capsular bag opacification of a new foldable modular lens system, with a base component and an optic component in rabbit eyes.MethodsBilateral phacoemulsification was performed on six rabbits; one eye received the test lens (Harmoni Modular Lens, ClarVista Medical), whereas the other received a single-piece hydrophobic acrylic control lens (SA60AT, Alcon). Slit-lamp examinations were performed at postoperative weeks 1, 2, 3, 4 and 6. All rabbits were sacrificed at week 6. After enucleation, the eyes were examined grossly from the Miyake-Apple view. Following, all globes were sectioned and processed for histopathological examination.ResultsThe modular lens was stable in all six rabbits. Uveal biocompatibility was similar to or better in the test eyes when compared with control eyes up to 6 weeks postoperatively. Overall, capsular bag opacification was found to be significantly lower in the test eyes when compared with control eyes. At the 6-week gross examination, central posterior capsule opacification was scored as 0.580.73 in the test group, and as 3.00 +/- 1.26 in the control group (paired two samples for means t-test; two-tail P=0.005).ConclusionsThe Harmoni Modular system remains stable within the capsular bag after implantation. Due to the design of the base component featuring long loops, along with peripheral anterior and posterior square edges, the lens appeared to prevent overall capsular bag opacification in the rabbit model.

We describe the case of a patient who had cataract surgery with implantation of the hydrophilic acrylic Tetraflex accommodating intraocular lens (IOL), with subsequent development of capsulorhexis phimosis and in-the-bag IOL subluxation. Contraction of the capsular bag secondary to fibrosis resulted in significant anterior flexing of the lens haptic component. Explantation of the IOL capsular bag complex was required 7 years after implantation. Histopathologic analysis demonstrated multiple areas of thick anterior subcapsular fibrosis. Pseudoexfoliative material was present throughout the surface of the lens capsule. Intraocular lenses manufactured from hydrophilic acrylic material are highly flexible and may be more susceptible to capsule contraction, even in the absence of predisposing ocular and systemic conditions. This case highlights the importance of developing guidelines regarding patient screening and selection for the appropriate use of accommodating and other highly flexible IOLs.

PURPOSE:To evaluate pulse type technology used to remove lens fragments during phacoemulsification.SETTING:John A. Moran Eye Center Laboratories, University of Utah, Salt Lake City, Utah, USA.DESIGN:Experimental study.METHODS:Lens nuclei soaked in 10 mL of 10% neutral buffered formalin for 2 hours were placed in 10 mL of balanced salt solution. Lenses were cut into 2 mm × 2 mm cubes; no more than 36 hours later, cubes were randomly selected for testing. Two aspiration and 2 vacuum settings were assessed at moderate- and high-flow and vacuum (30 mL/min and 300 mm/Hg, low-flow vacuum; 50 mL/min and 500 mm/Hg, high-flow vacuum), with continuous 50 milliseconds on and off (long pulse) and 6 milliseconds on and off (micropulse) ultrasound.RESULTS:There was a significant difference in efficiency favoring micropulse compared with combined long pulse and continuous pulse in high-flow vacuum at 80% power (P = .018) and between combined long pulse and continuous pulse versus micropulse in high-flow vacuum at 20% power (P = .019). Low-flow vacuum micropulse was more efficient than continuous (19.7%) (P < .0001) and long pulse (22.7%) (P < .0001). Continuous and long pulses were not significantly different from one other. There was a significant difference in chatter rates between high-flow vacuum and low-flow vacuum when all results were compared (P < .0001), with no additional significant differences found.CONCLUSION:Micropulse technology was better than continuous and long pulse at moderate but not high-flow and vacuum settings. At the higher setting, chatter was observed less often, with all modalities more efficient than the lower setting.

Majid Moshirfar,1 Michael V McCaughey,2 Carlton R Fenzl,3 Luis Santiago-Caban,4 Gregory D Kramer,3 Nick Mamalis3 1Department of Ophthalmology, Francis I Proctor Foundation, University of California San Francisco, San Francisco, CA, USA; 2University of New Mexico School of Medicine, Albuquerque, NM, USA; 3John A Moran Eye Center, University of Utah, Salt Lake City, UT, USA; 4Department of Ophthalmology, University of Puerto Rico School of Medicine, San Juan, PR, USA Purpose: To report a case of delayed-onset bilateral scleral thinning and calcium deposition following a cosmetic ocular-whitening procedure (I-BRITE®).Methods: A 33-year-old male patient with a history of right-sided ptosis repair and left-sided anterior uveitis had previously undergone bilateral I-BRITE treatment for chronic conjunctival hyperemia. Four years after the procedure, the patient was referred to our institution with bilateral scleral thinning and overlying calcific depositions. A literature review was performed through PubMed from 1980 through 2014 using the search terms ‘cosmetic’, ‘ocular’, ‘conjunctivectomy’, ‘regional conjunctivectomy’, ‘I-BRITE’, ‘eye-whitening’, ‘scleritis’, ‘necrotizing scleritis’, ‘anterior uveitis’, ‘mitomycin C’, ‘5-fluorouracil’, and ‘bevacizumab’, along with associated cross-referencing from relevant articles.Results: Examination of the patient revealed bilateral necrotizing scleritis within the nasal region of both eyes. Calcified plaques were also present within the areas of scleromalacia, along with epithelial defects demonstrated with fluorescein staining. Although evidence of previous intraocular inflammation was apparent within the left eye, there were no active signs of inflammation evident within either eye on initial presentation. Complication rates reported in the literature include: scleral thinning (1.8%), calcific plaque formation (2.9%), fibrovascular proliferation (13%), diplopia (1.2%), elevation of intraocular pressure (4.2%), and recurrence of conjunctival hyperemia (2.1%).Conclusion: Cosmetic ocular whitening procedures have an attendant high complication rate, and have been associated with several adverse postoperative complications, which have in turn generated several reservations regarding the veritable benefit of the procedure. Many postsurgical complications may demonstrate delayed apparition, varying from several months to several years after primary surgical intervention as in the case reported here. Keywords: necrotizing scleritis, scleromalacia, cosmetic ocular whitening