PURPOSE:To describe the histopathology of the cornea in 3 cases of corneal melting associated with diclofenac therapy after refractive surgery procedures.SETTING:Clinic and pathology laboratory.METHODS:Three cases of corneal melting associated with diclofenac therapy (2 after laser in situ keratomileusis [LASIK] and 1 after mini-radial keratectomy enhancement of a LASIK undercorrection) were studied using patient and referring physician interviews, chart reviews, and histopathologic examination of the corneal tissue.RESULTS:In all 3 cases, the flaps were dislocated and the stromal corneal bed was exposed. Diclofenac, generic or brand name, was used in all cases; in 1 case, both generic and brand name were used. Dosing and duration varied, but in all 3 cases diclofenac was used at least 4 times a day for at least 3 days after LASIK. Topical steroids were also prescribed, but 1 patient did not use them. Preoperative medical conditions were present in 2 cases. Histologic analysis showed evidence of an inflammatory response in advanced cases and keratolysis and lack of inflammatory cells in the flaps that were amputated early.CONCLUSIONS:The use of generic or brand-name diclofenac with or without adjunctive topical steroids after LASIK can be associated with corneal melting when the LASIK flap is dislodged and the corneal stromal bed exposed. Caution is recommended with diclofenac use after LASIK in such cases.

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Purpose: Prospective evaluation of the efficacy and safety of subconjunctival triamcinolone injections for resistant, nonnecrotizing, anterior scleritis.Design: Prospective, noncomparative, interventional case series.Participants: Twelve eyes of 10 consecutive patients seen in the Doheny Eye Institute between August 1999 and December 2000 with diffuse, nonnecrotizing anterior scleritis that was resistant to systemic anti inflammatory therapy. Eyes with a history of steroid response were excluded.Intervention: Subconjunctival injection of triamcinolone acetonide to the areas of maximal inflammation.Main Outcome Measures: Scleritis activity, adverse treatment effects, and number of systemic medications required at the end of the follow-up period.Results: Within 1 to 14 days after injection, complete resolution of signs and symptoms was achieved in 11 eyes and partial resolution in 1 eye. Two patients had one recurrence each, 2.5 and 11 months after injection. Six of 10 patients were able to discontinue all systemic therapy (prednisone +/- immunosuppressive drugs); the remaining 4 needed continued oral therapy for systemic indications. Transient ocular hypertension and subconjunctival hemorrhage occurred in one eye each. Median follow-up period was 15 months. No eye developed necrotizing scleritis.Conclusions: Subconjunctival injection of triamcinolone acetonide is a safe and effective treatment for resistant, nonnecrotizing anterior scleritis. It provides rapid effect, is well tolerated, and may spare patients the significant complications and side effects of systemic corticosteroid and immunosuppressive therapy. (C) 2002 by the American Academy of Ophthalmology.

Objective: To report the occurrence of rifabutin-associated hypopyon uveitis in human immunodeficiency virus (HIV)-negative immunocompetent individuals.Design: Retrospective case series,Participants: Three HIV-negative subjects on rifabutin and clarithromycin for Mycobacterium avium complex infections with hypopyon uveitis are described. One subject was iatrogenically immunosuppressed because of a prior lung transplant. Two subjects had no known immunosuppressive conditions.Intervention: Topical and regional steroid therapy. Discontinuation of rifabutin was required in two subjects.Main Outcome Measures: Visual acuity, resolution of hypopyon, anterior uveitis, and vitreitis.Results: All subjects had resolution of hypopyon after therapy, two within 24 hours of beginning topical steroids. Vitreitis resolved with the discontinuation of rifabutin in two subjects. Chronic low-grade anterior uveitis and vitreitis were observed in the remaining subject, whose rifabutin dose was lowered but not discontinued because of active Mycobacterium avium complex osteomyelitis.Conclusions: Rifabutin-associated uveitis is well described in HIV-positive individuals, but it has been reported only once in an HIV-negative individual. We report two cases of hypopyon uveitis in immunocompetent individuals and one case in an immunosuppressed HIV-negative individual. All three subjects were receiving concurrent rifabutin and clarithromycin. Awareness that this entity can occur in HIV negative and nonimmunosuppressed individuals and that it can mimic infectious endophthalmitis may spare the subject from an invasive workup of systemic infection. (C) 2001 by the American Academy of Ophthalmology.

PURPOSE: To identify associations between complications of disease and final visual acuity in patients with Vogt-Koyanagi-Harada disease and to identify prognostic factors for disease outcome.METHODS: All patients diagnosed with Vogt-Koyanagi-Harada disease at the Doheny Eye Institute or the Los Angeles County/University of Southern California Medical Center between 1983 and 1997 were reviewed. Data extracted included initial and final visual acuities, age, gender, ethnicity, complications, treatment, duration of disease, and number of recurrences.RESULTS: One hundred one patients with Vogt-Koyanagi-Harada disease were identified, 68 (67%) of which were female. Mean age was 34 +/- 14 years (range, 8 to 75 years). Asians presented at a significantly older age than all other groups. One hundred three eyes (51%) developed at least one complication, including cataract in 84 eyes (42%), glau- coma in 54 eyes (27%), choroidal neovascular mem branes in 22 eyes (11%), and subretinal fibrosis in 13 eyes (6%), Patients who developed at least one compli cation had a significantly longer median duration of disease and number of recurrent episodes of inflammation (P =.0001 for each) than did those patients who developed no complications, Statistically significant asso ciations existed between poor final visual acuity and greater numbers of complications (P =.001), greater age at onset (P =.03), a longer median duration of disease (P =.03), and greater number of recurrent episodes of inflammation (P =.0004). Eyes possessing a better visual acuity at presentation were more likely to have a better visual acuity at final follow-up (P =.001).CONCLUSIONS: Factors associated with a worse final acuity included increasing numbers of complications, greater age at onset, and worse acuity at presentation. (C) 2001 by Elsevier Science Inc. All rights reserved.).

Purpose. To describe a unique case of retrocorneal membrane with large Descemet's detachment. Methods. Case report of a 65-year-old man reported intermittent cloudy vision in his left eye. The patient underwent serial ocular examinations and slit-lamp photography over 6 weeks. Results. The patient had an inflammatory-appearing membrane that covered 60% of the posterior cornea, with a subtotal Descemet's detachment. Vision was stable at 20/20, and the cornea remained clear. The patient was empirically treated with topical neomycin/polymyxin/dexamethasone, sodium chloride, and oral acyclovir, and his symptoms improved; however, the retrocorneal membrane persisted. Conclusion. This unusual clinical finding may represent reduplicated Descemet's membrane with partial Descemet's detachment secondary to, occult deep herpes simplex keratitis. Other possibilities include spontaneous or traumatic Descemet's tear and detachment.

A 52-year-old man underwent bilateral laser-assisted in situ keratomileusis. Eight months later, he sustained a penetrating corneal injury to the left eye. A dense white infiltrate, unresponsive to antimicrobial therapy, developed in the corneal stroma. Corneal biopsy and eventual penetrating keratoplasty were performed, and both specimens demonstrated fungal elements with branching, septate hyphae. Culture identified the organism as Acremonium atrogriseum. Histopathologic features of this organism and its differentiation from other, more common fungal organisms are discussed herein.

PURPOSETo report the extended clinical course of a case of superficial punctate keratitis of Thygeson.METHODSA 59-year-old woman with a 40-year history of superficial punctate keratitis of Thygeson is presented, providing a forum to discuss the chronicity of the disease, its treatment, and the potential complications.RESULTSOur patient has been treated over the years with mild topical corticosteroids, usually with favorable results. Given the chronicity of superficial punctate keratitis of Thygeson, long-term treatment with topical corticosteroids carries the possible side effects of iatrogenic cataract formation and steroid-induced glaucoma, neither of which was seen in our patient.CONCLUSIONSSuperficial punctate keratitis of Thygeson is usually a benign, self-limited disease with exacerbations and remissions. Ophthalmologists must exercise care when using long-term corticosteroid treatment in this condition.

任何破坏角膜上皮屏障的屈光性激光外科操作,都有发生感染性并发症的潜在危险.随着准分子激光角膜层间磨镶术(LASIK)被更广泛地应用,与LASIK有关的感染性角膜炎病例已被报道1～6.我们现在对5人6只眼在接受LASIK术后继发了角膜溃疡进行报道.

PURPOSE:Androgens are thought to play a role in the regulation of the human lacrimal gland. Androgen receptor mRNA has been isolated from human lacrimal tissue; however, it is not known which cell(s) in human lacrimal tissue may contain androgen receptors. This study is an immunohistochemical investigation of the location and distribution of androgen receptors in human lacrimal tissue.METHODS:Formalin-fixed, paraffin-embedded human lacrimal gland tissues were subjected to established antigen retrieval techniques. This was followed by routine immunohistochemical staining, employing one of two anti-human androgen receptor monoclonal antibodies, each specific for a different antigenic epitope within the receptor molecule.RESULTS:The two anti-human androgen receptor monoclonal antibodies demonstrated similar staining patterns in adjacent tissue sections from the same human lacrimal gland specimens. Specific staining for androgen receptors was observed in the nucleus and cytoplasm of lacrimal acinar cells, as well as in lacrimal duct cells. Both the intensity of staining and the number of cells demonstrating staining varied among specimens. We also observed staining for androgen receptors in interstitial and inflammatory cells distributed between lacrimal acinar units in some specimens.CONCLUSIONS:Androgen receptors are located in human lacrimal gland acinar cell nuclei as observed in other animals. However, the detection of androgen receptors in lacrimal interacinar interstitial and inflammatory cells suggests that androgens may play a role in modulating the activities of cells other than lacrimal cells within the human lacrimal gland.

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In 1986 Rita Levi-Montalcini won, with Stanley Cohen, the Nobel prize for the discovery of nerve growth factor, a polypeptide they found to be integral to the growth and development of the nervous system. In her Nobel lecture reviewing 35 years of research on nerve growth factor, Levi-Montalcini stated, “The submerged areas of the NGF [nerve growth factor] iceberg loom very large.”1 In this issue of the Journal, Lambiase et al. report the dramatic healing action of topically applied nerve growth factor in 12 patients (14 eyes) with neurotrophic corneal ulcers and bring into view yet another part of that . . .

Replacement of the entire anterior segment of the eye is a very ambitious and complex endeavor and it is not known whether the retina remains functional when the anterior structures have been removed. We used routine histo-pathologic evaluation and electroretinographic measurements to determine the structural and functional status of rabbit retinas following surgical removal of the internal anterior structures (iris, ciliary body, and lens) and replacement of the vitreous with silicone oil. In some cases, we were able to record both a scotopic and a photopic electroretinographic response as long as 15 weeks after complete removal of the internal anterior segment structures. Although many hurdles remain and more efficacious surgical techniques and biomaterials need to be developed, our results suggest that, in the rabbit, the retina may continue to function in the absence of critical anterior segment structures.

To further the development of a sclera-attached anterior segment prosthesis we investigated the biocompatibility of expanded polytetrafluoroethylene following its surgical implantation into the rabbit sclera. Thin sheets (250 mu m) of expanded polytetrafluoroethylene were cut into pieces measuring either 2x2, 2x4, 2x8, or 4x8 mm. The pieces were sterilized and placed individually within surgically prepared pockets in the sclera of rabbit eyes. Animals were sacrificed for routine histopathologic evaluation and transmission electron microscopic study of the eyes at 7 days, 14 days, 1 month, and 4 months following surgical implantation. The implants demonstrated excellent compatibility with the sclera and, by 14 days following implantation surgery, exhibited histiocytes, fibroblasts, and blood vessels infiltrating the internodal spaces of the highly porous material. The number of cells and the amount of extracellular matrix material deposited in the implants appeared to increase with time. Transmission electron microscopic studies revealed deposition of collagen within the implants. Our results suggest that expanded polytetrafluoroethylene has potential for use in the development of a sclera-attached prosthetic device.

Intraocular lens placement in the absence of an intact posterior capsule presents a particular challenge to the surgeon. Many options are available: an open-loop anterior chamber lens can be used or a posterior chamber lens can be placed in the ciliary sulcus over residual capsular material or sutured either in the ciliary sulcus or to the posterior aspect of the iris. In the late 1980s, the method of choice at our institution during penetrating keratoplasty was to suture the lens to the posterior aspect of the iris. To evaluate the long-term stability of lenses that were fixed by this method, we reviewed the records of all of these operations performed in our institution over a 52-month period that were followed for at least 1 year. A 7-mm optic, 3-piece posterior chamber intraocular lens with optic positioning holes was used in all the operations. A double-armed 10-0 polypropylene suture was passed

The purpose of this study was to identify new trends in the changing indications for penetrating keratoplasty. We retrospectively reviewed the clinical and pathologic diagnoses of 1,104 corneal buttons that had been submitted to the Estelle Doheny Eye Pathology Laboratory, Los Angeles, during the 5-year period 1989-1993. The leading indications, in order of decreasing frequency, were pseudophakic corneal edema (24.8%), regrafts (21.3%), scarring with or without chronic inflammation (11.1%), keratoconus (7.1%), aphakic corneal edema (6.4%), and ulcerative conditions (5.8%). The incidence of pseudophakic corneal edema remained stable over the study period and was actually surpassed by regraft in the last year of the study. Although pseudophakic corneal edema remains the predominant indication for penetrating keratoplasty, our findings suggest that its occurrence rate has begun to level off.