Cornea and External Disease

PURPOSE: Aqueous tear production decreases after anesthetizing the ocular surface. Loss of the nasolacrimal reflex is a risk factor for neurotrophic keratopathy and keratoconjunctivitis sicca. The purpose of this study was to evaluate the effect of nasal mucosal anesthesia on aqueous tear production.

METHODS: Eleven healthy human volunteers with a normal ocular surface and Schirmer I tear-test scores > 10 mm participated in this study. Schirmer I values were obtained daily for 3 days to establish a normal baseline. On a separate day, the right nasal mucosa was anesthetized with aerosolized 10% lidocaine (Xylocaine). After a 10-min period to allow the anesthetic to take effect and reflex tearing to subside, the Schirmer I test was repeated. A saline nasal spray was used as a control.

RESULTS: Baseline Schirmer I values for both eyes had a mean of 22.98 +/- 1.05 mm (SEM). There was no difference in Schirmer scores between the two eyes after nasal anesthesia (p > 0.6); however, when these were compared with the baseline Schirmer I values, a significant decrease in tear production was noted (p < 0.001). The mean Schirmer I value after nasal anesthesia was 15.18 +/- 1.38 mm (SEM), a 34% decrease from baseline. The difference between the baseline and the normal saline control values was not significant (p = 0.160). There was a significant difference in Schirmer test scores between the saline control and nasal anesthesia groups (p < 0.02).

CONCLUSIONS: In addition to sensory neural stimulation from the ocular surface, sensory stimulation of the nasal mucosa also promotes aqueous tear production. These results may help explain the decreased tear production observed in patients who have nasal mucosal damage, disease, or denervation.

Authors' abstract, Cornea
Miami, FL

Cornea and External Disease

PURPOSE: To evaluate the clinical efficacy of topical mitomycin C (MMC) 0.04% in the treatment of recurrent corneal intraepithelial neoplasia.

METHODS: A 71-year-old man presented with a limbal tumor that had extended onto the inferior temporal quadrant of the left cornea. Superficial lamellar sclerokeratectomy was performed to remove the tumor, which was histopathologically demonstrated to be a corneal intraepithelial neoplasia. Fifteen months after the surgical excision, the tumor recurred at the previous keratectomy site. The patient was treated topically with 0.04% MMC four times daily for 2 weeks, during which time he only had a mild degree of conjunctival hyperemia and ocular pain.

RESULTS: The tumor resolved completely after 2 weeks of treatment and did not recur during the 10-month follow-up.

CONCLUSION: Topical MMC may be an effective alternative treatment for recurrent corneal intraepithelial neoplasia and deserves further evaluation.

Authors' abstract, Cornea
Department of Ophthalmology,
College of Medicine,
National Cheng Kung University,
Tainan, Taiwan, ROC

Cornea and External Disease

PURPOSE: To report the occurrence and follow-up of ectopic, interface, epithelial growth after laser in situ keratomileusis (LASIK) in four eyes (three patients) and provide suggestions for management.

METHODS: Each eye was examined by slit-lamp biomicroscopy, and corneal topography was obtained with the Tomey TMS-1 instrument.

RESULTS: Each eye with epithelium within the interface after LASIK developed interface opacities and surface irregularity. One eye had an early surgical intervention, and three eyes were observed. Each eye lost at least one line of best spectacle-corrected visual acuity and had visual disturbance at the last follow-up visit.

CONCLUSIONS: The presence of epithelium within the lamellar interface is a significant complication after LASIK. In some cases, interface epithelium may be associated with early postoperative inflammation. When reoperation is required to treat this complication, we suggest scraping of both sides of the interface with a metal blade. In some cases, light excimer laser treatment can be used to facilitate epithelial removal.

Authors' abstract, Cornea
Eye Institute,
Cleveland Clinic Foundation,
OH

Cornea and External Disease

PURPOSE: To evaluate the effect of substituting topical cyclosporin A 0.5% for topical corticosteroids in patients with postkeratoplasty glaucoma.

METHODS: Topical cyclosporin A 0.5% was prospectively substituted for topical corticosteroids to treat 25 patients with postkeratoplasty glaucoma.

RESULTS: Twenty-one (84%) of 25 patients showed a reduction in intraocular pressure (IOP) (range, 1-22 mm Hg; mean, 8.7 mm Hg). Follow-up ranged from 3 to 12 months (mean, 5.8). Graft clarity was maintained in all patients, with one allograft rejection episode. Thirteen patients were able to discontinue one or more glaucoma medication(s).

CONCLUSION: Topical cyclosporin A 0.5% may be substituted for topical corticosteroids to aid in the management of postkeratoplasty patients with glaucoma. However, the resultant decrease in IOP may be associated with an increased risk for immune rejections.

Authors' abstract, Cornea
Department of Ophthalmology,
North Shore University Hospital,
Manhasset, New York

Cornea and External Disease

Inflammation of the scelera and episcleral is a common condition. When it affects the anterior uveal tract causing anterior uveitis, the risk for ocular problems is significantly higher.

This study retrospectively examines the records of 172 patients seen by the Massachesetts Eye and Ear Infirmary's Immunology Service. Those with at least one episode of anterior uveitis were compared to those without evidence of anterior uveitis.

Results:

1. Treat the scleritis and the uveitis resolves.

2. Type of scleritis encountered:

   Type	Percentage
   Diffuse	28(38.4%)
   Nodular	11(15.1%)
   Necrotizing	27(57%)
   Scleromalacia	2(2.7%)
   Posterior	5(6.8%)

3. If you develop scleritis associated uveitis, you have a statistically significant risk for a decrease in vision, development of peripheral ulcerative keratitis and glaucoma.

   Scleritis and Other Conditions
   Condition	with Uveitis	without Uveitis	Stats=P
   Decreased vision	36(49.3%)	28(28%)	.0046
   PUK	16(21.9%)	8(8%)	.0095
   Glaucoma	14(19.2)	8(8%)	.0313
   Systemic Disease	39(53.4%)	43(43%)	not stat. sign.
   Bilaterality	22(30.1%)	37(37%)	not stat. sign.

Conclusion: When scleritis is accompanied by anterior uveitis, the ocular prognosis is worse. The authors point out that extension of the inflammation to a deeper ocular coat is probably a sign of a more severe process. From this, earlier intervention should be considered to control the underlying systemic condition.

Raymond Magauran, MD
St. Joseph's Hospital,
Ann Arbor, Michigan

Cornea and External Disease

Nontuberculous Mycobacterium keratitis is characterized by its indolent course and poor response to antibiotic drugs. Between November 1989 and September 1993, 10 eyes diagnosed to have nontuberculous Mycobacterium keratitis underwent therapeutic lamellar keratectomy in conjunction with fortified topical medications. Nine operated eyes (90%) recovered with a shortened course and healed with an inactive scar. Six patients (60%) achieved a visual acuity of 20/40 or better postoperatively. For recalcitrant nontuberculous Mycobacterium keratitis, therapeutic lamellar keratectomy is highly recommendable for patients with intractable paracentral or peripheral ulcer, for uncompliant patients, for patients who cannot tolerate drug-induced ocular toxicity, or when penetrating keratoplasty is to be reserved for late rehabilitation of the eye.

Authors' abstract, Cornea
Taiwan, R.O.C.