Punctate Epithelial Keratopathy Research Articles

Contact lens‐related complications

The use of contact lens is very popular and its global market is growing. They have numerous applications, some well‐established and others still not consensual but which have been gaining more and more approval, namely refractive errors, dry eye management, post refractive surgery rehabilitation, persistent epithelial defects, cosmetic approaches and drug delivery systems. Unfortunately, there are some complications caused by their use, some of them sight threatening. The purpose of this presentation is to review these problems and to provide a better understanding of them.The major mechanisms implicated are numerous: trauma, decreased corneal oxygenation, reduced corneal and conjunctival lubrication, allergic and inflammatory responses and infection. However, depending on the complication we are talking about, there are other factors involved, such as contact lens‐related factors (material, design, fit and wearing schedule) and environmental factors (ocular surface condition, external environment, occupational factors, medications and compliance).The symptomatology experienced by patients ranges from hypoesthesia and mild conjunctival hyperemia to photophobia, contact lens intolerance and even decreased visual acuity.Many complications have been described. The most important (most common or most serious) are contact lens discomfort (CLD), dry eye, corneal deepithelialization (CD), sterile infiltrates (SI), corneal neovascularization (CNV), infectious keratitis (IK) and giant papillary conjunctivitis (GPC). Superior epithelial arcuate lesion, contact lens‐related peripheral ulcer, corneal distortion, hypoesthesia, ptosis, pinguecula, corneal edema, allergy aggravation, herpes reactivation and endothelial changes have also been described.CLD is an episodic or persistent adverse ocular sensation related to lens wear with a variable incidence in the literature, ranging from 23% to 94% in different series, being less common with soft lenses. Dry eye plays its role acting as a risk factor for CLD and/or as a consequence of contact lens use. CD manifests as punctate epithelial keratopathy, epithelial abrasions, foreign body tracks, corneal dellen, microcysts, vacuoles, mucin balls and dimple veiling. GPC is one of the most common adverse effects of contact lenses and the papillary reaction of the upper tarsal conjunctiva is the main feature of this entity. CNV is the formation of new vessels basically found in capillaries and venules of the pericorneal plexus, which may progress to the corneal stroma. They are much more associated with soft contact lenses, especially in extended wearers. Of note, contact lens use is one of the most common causes of CNV usually highlighted. SI are the result of an immunological reaction, often do not contain overlying epithelial defect or anterior chamber reaction and may manifest as stromal deep opacities. IK may be caused by bacteria, viruses, fungus or parasites and prompt immediate care and close revaluations to anticipate disastrous outcomes.Conservative measures play a role in almost all complications and their prevention, such as patient education, lubrication, contact lens exchange when applicable and modification of environmental factors. Addressing and learning how to prevent or quickly diagnose all these complications is crucial to prevent serious consequences.

Severe Exposure Keratopathy Leading to Sterile Corneal Perforation Treated Successfully by Lamellar Corneal Patch Graft: A Case Report

We reported a case of corneal perforation due to longstanding exposure keratopathy treated successfully with lamellar corneal patch graft, conjunctival flap, and lateral tarsorrhaphy. A 75-year-old male presented with ocular pain and decreased visual acuity in his right eye since 2 weeks ago. On external examination, lagophthalmos in the right eye was evident. Visual acuity was hand motion on slit-lamp examination. 2×3 mm perforated area in the right cornea accompanied by adjacent corneal melting and diffuse punctate epithelial keratopathy were observed. The anterior chamber was flat. Intraoperatively, a 7×2.5 mm-diameter corneal patch graft was fashioned manually; its thickness was reduced and placed over the perforated area, successfully sealed the cornea, a partial bipedicle conjunctival flap was also applied over the graft, and lateral tarsorrhaphy was performed. Four weeks after surgery, Corrected Distance Visual Acuity (CDVA) improved to Counting Finger (CF) 20 cm. The lamellar corneal patch graft was intact without a leak, and the conjunctival flap was partially removed retracted. Corneal perforation can occur in patients with severe exposure to keratopathy, and corneal patch graft is a good option when a sizeable corneal perforation (≥3 mm diameter) is not amenable to corneal gluing.

Corneal endothelial and central corneal thickness changes in patients with type II diabetes mellitus

Objective The aim of this study was to evaluate the changes in corneal endothelium (endothelial cell morphology and density) and central corneal thickness (CCT) in type II diabetes mellitus. Background Worldwide, the incidence of type II diabetes mellitus is increasing, reaching epidemic proportions in developing countries. Diabetes mellitus can affect almost all structures of the eye; it can cause anterior ischemic optic neuropathy, glaucoma, cataract, retinal vascular occlusions, and retinopathy. Corneal damage such as endothelial defects, punctate epithelial keratopathy, recurrent corneal erosions, and persistent epithelial defects may occur. The disease affects the corneal endothelial cells and corneal thickness. Patients and methods This analytical and descriptive study included 200 eyes of 100 diabetic patients and 100 healthy controls, 98 left and 102 right eyes; there were 125 were female and 80 male patients. Patients' ages ranged between 41 and 65 years. The following parameters were evaluated in the current study in both the healthy control group and age-matched patients with type II diabetes mellitus: central corneal thickness, endothelial cell count, coefficient of variation, and percentage of hexagonal cells. Results Endothelial cell density in the diabetic group (2262.1 ± 344.5 cells/mm2) was significantly lower than that in the control group (2623.07 ± 187.1 cells/mm2, Conclusion Type II diabetes causes a significant alteration in corneal structure and function in the long term. Our study seems to confirm the effect of diabetes duration and poor glycemic control on CCT and endothelial cell structure and morphology.

Tacrolimus Eye Drops as Adjunct Therapy in Severe Corneal Endothelial Rejection Refractory to Corticosteroids.

To evaluate the safety and efficacy of tacrolimus eye drops as adjunctive therapy in the treatment of severe corneal endothelial rejection after penetrating keratoplasty refractory to corticosteroids. In this prospective interventional case series, 11 eyes of 11 patients assessed for severe corneal endothelial rejection, with an inadequate response to topical, local, and systemic corticosteroids, were treated with either 0.01% or 0.05% tacrolimus eye drops 4 times daily. Improvement in signs of rejection, visual function, and development of complications were monitored. The duration of steroid treatment before intervention was 8.1 ± 1.4 days (range = 7-11). Patients were subsequently administered topical tacrolimus 0.01% or 0.05% qid. The time to clinical improvement was 10.3 ± 3.4 days (range = 3-17). The time to rejection reversal was 27.8 ± 16.3 days (range = 7-52). After 3 months, 10 patients (90.8%) demonstrated clinical improvement, and complete restoration of graft clarity was achieved in 5 patients (45.4%). In responsive cases, steroid therapy was successfully tapered off after 60.2 ± 19.7 days (range = 36-93). The best spectacle-corrected visual acuity improved from 1.7 ± 0.9 to 0.8 ± 0.5 logMAR (P = 0.0016). Reported side effects included stinging on drop instillation and punctate epithelial keratopathy. Tacrolimus eye drops may be able to play an adjunctive therapeutic role in patients with severe corneal endothelial rejection refractory to conventional steroid treatment. Controlled studies are needed to further investigate the role of tacrolimus in this setting.

Post-external dacryocystorhinostomy lagophthalmos.

To describe lagophthalmos and eyelid closure abnormality after external dacryocystorhinostomy (DCR). A retrospective review of medical records and postoperative photographs of 79 patients who underwent external DCR for nasolacrimal duct obstruction and developed eyelid closure abnormality and lagophthalmos with or without exposure keratopathy was conducted. Collected data included age, sex, indication for surgery, laterality, length and type of incision, length of follow-up duration, presence of punctate epithelial keratopathy, and time for resolution of eyelid closure abnormalities. Twenty-seven patients with 28 external dacryocystorhinostomy had postoperative eyelid closure abnormalities. Male to female ratio was 1:6. The mean age was 40.1 years (range 9-80 years). All surgeries were performed through diagonal skin incision. Lagophthalmos involving the medial third of the palpebral fissure was noticed in 28.6 % of cases. All patients had hypometric blink mainly of the upper eyelid. One patient had punctate epithelial keratopathy. Resolution of lagophthalmos was noticed over a period of 1-5 weeks with an average of 3 weeks. None of the patients continued to have residual hypometric blink or punctate keratopathy at the last follow-up time. The mean follow-up period was 4.2 months (range 3-6 months). Eyelid closure abnormality and lagophthalmos after external DCR are underestimated problems. Spontaneous resolution is seen in all cases weeks to months after surgery.

Clinical results of 40 years of paediatric keratoplasty in a single university eye clinic

To evaluate indications for paediatric keratoplasty in recipients aged ≤16 years and assess long-term clinical outcome. Recipients were identified from records of the Danish Cornea Bank. Data were collected from patient journals, clinical follow-up examinations and questionnaires and stratified into pre-, peri- and postoperative variables. Diagnoses were classified into acquired traumatic, acquired nontraumatic and congenital groups. Recipients were divided into groups of <8 and ≥8 years. Data were analyzed using relative percentages and Kaplan-Meier survival plots. Thirty-three out of sixty identified recipients (73 keratoplasties in 63 eyes) were invited. Twenty-four accepted, seven still attended follow-up in our clinic. Follow-up data reached 95% of the eligible recipients (median follow-up 11 years). Twenty-three per cent were <8 years and 77%≤8 years. Diagnoses were mainly acquired nontraumatic (69%), acquired traumatic (12%) and congenital (7%). Indications were primarily optical (52%) or tectonic (41%). Graft survival was best in the acquired nontraumatic group (except regrafts) (median survival 15-20 years) and poorest in the regraft subgroup as well as the acquired traumatic and congenital groups (median survival 1-2 years). Graft failure was higher in the youngest with predisposing risk factors and in combined procedures. In terms of indications, visual improvement and eye preservation was achieved in 70%. Paediatric keratoplasty was successful regarding indication. Graft survival was best in the acquired nontraumatic group and poorest in the congenital group. Vascularization and/or combined risk factors, additional surgeries and young recipient age influenced negatively on graft survival.

Cultured Autologous Oral Mucosal Epithelial Cell Sheet (CAOMECS) Transplantation for the Treatment of Corneal Limbal Epithelial Stem Cell Deficiency

Total bilateral corneal limbal epithelial stem cell deficiency (LSCD) cannot be treated with the surgical transplantation of autologous limbus or cultured autologous limbal epithelium. Transplantation of allogenic limbal epithelium is possible but requires immunosuppressive treatments. Cultured autologous oral mucosal epithelial cell sheet (CAOMECS) is a transparent, resistant, viable, and rapidly bioadhesive cell sheet, cultured with the UpCell-Insert technology (CellSeed, Inc., Tokyo, Japan), which allows for grafting onto the patient's corneal stroma without suturing. It has therefore been proposed as an alternative treatment for LSCD. The objectives were to assess the safety and efficacy of CAOMECS, using a prospective Gehan's design. Safety was measured in terms of ocular adverse events during the study period, and efficacy was measured using a composite criterion based on epithelial defect, punctate epithelial keratopathy, conjunctival epithelium on the cornea, number of vascular pediculi, and vessel activity. CAOMECS was found to be safe and effective. In total, 26 eyes of 25 patients received a graft. Two patients experienced serious adverse events classified as not product related. Twenty-five patients were included in the efficacy analysis, as one patient was lost to follow-up. The treatment was found to be effective in 16 of 25 patients at 360 days after grafting. Of the 23 patients who completed follow-up at 360 days, 22 had no ulcers, and 19 showed a decrease in the severity of the punctate epithelial keratopathy. CAOMECS is a well-tolerated and safe tissue-engineered product. These results suggest its efficacy for reconstructing the ocular surface in patients with total bilateral corneal LSCD.

Nonsurgical Management of Epiblepharon Using Hyaluronic Acid Gel

A 4-month-old infant with epiblepharon of the right lower eyelid presented with medial eyelashes touching the corneal surface in primary gaze and resultant punctate epithelial keratopathy. Hyaluronic acid gel (Juvederm Ultra) 0.2 ml was injected in the suborbicular plane in the valley above the abnormal skin fold. Immediate out-turning of the eyelid margin was obtained, which persisted at 1-week, 1-month, and 4.5-month follow-up visits with no lash-corneal touch even in down gaze. Epiblepharon, which often self corrects with increasing age, can be effectively corrected with this minimally invasive nonsurgical option when it is symptomatic, and is a threat to the corneal health.

Role of epidermal growth factor receptor (EGFR) in corneal remodelling in diabetes

This study examined the role of epidermal growth factor receptor (EGFR) signalling on the organization and remodelling of collagen fibrils (CFs) and proteoglycans (PGs) in the stroma of diabetic rat cornea. Diabetes was induced in female Wistar rats (n = 5) by streptozotocin (STZ) injection (55 mg/kg). Treatment with a selective inhibitor of EGFR tyrosine kinase, AG1478, was started on the same day as the induction of diabetes and administered every other day for 4 weeks. Corneas were fixed in 4% paraformaldehyde at 4 degrees to allow for analysis of CF diameters and in 2.5% glutaraldehyde in sodium acetate buffer containing cuprolinic blue to enable the study of PG distribution. AnalySIS soft imaging software was used to analyse CFs and PGs. Epithelial thickness, and median diameter and area fraction of CF in corneal stroma were decreased in diabetic rat cornea compared with normal cornea (p < 0.001), whereas the median PG area and area fractions were significantly increased (p < 0.001). Treatment with AG1478, although it had no action on normal cornea, prevented these diameter and area fraction changes in CFs and PGs. The cornea of AG1478-treated diabetic rats showed a slight increase in CF diameter and area fraction and a decreased number density. These data show that the distribution of corneal stroma CFs and PGs was altered after 4 weeks of diabetes and that, furthermore, treatment with an EGFR signalling inhibitor normalized these abnormalities. The data suggest that EGFR plays an important role in the development of diabetes-induced corneal remodelling.

Management of Symptomatic Meesmann Dystrophy

Meesmann dystrophy is a non-progressive autosomal dominant corneal epithelial dystrophy characterized by intraepithelial cysts, which is likely to be caused by an intraepithelial metabolic abnormality. Cases may be asymptomatic or be associated with symptoms of irritation, lacrimation, and photophobia. Palliative treatment includes ocular lubricants, cycloplegia, and therapeutic contact lenses. In severe cases, management with epithelial debridement, phototherapeutic keratectomy, and lamellar keratoplasty has been advocated. Most recently, the genetic and molecular basis of Meesmann dystrophy have been explored, and mutations in the genes encoding corneal epithelial keratins have been reported. This report describes a case of Meesmann dystrophy with unusually severe symptoms and punctate epithelial keratopathy managed with a therapeutic contact lens.

Aggravated Dry Eye After Laser In Situ Keratomileusis in Patients With Sjögren Syndrome

To report 2 patients with Sjögren syndrome (SS) who had no or mild dry eye symptoms preoperatively but developed severe and refractory dry eye after laser in situ keratomileusis (LASIK). Two women with well-controlled early-stage SS developed severe dry eye, punctate epithelial keratopathy, and refractive regression 15 and 2 months after LASIK. Both patients were treated with punctal occlusions, artificial tears, fluorometholone 0.02% eyedrops, autologous serum, and systemic immunosuppressants. Ten months after treatment, both patients exhibited only minor improvements in dry eye symptoms on the basis of changes in Schirmer test results, corneal fluorescein staining, and refractive errors, whereas their tear breakup time and corneal sensation remained unchanged. Severe and refractory dry eye can develop after LASIK in patients with preexisting well-controlled early-stage SS.

A technique for the reconstruction of lower eyelid marginal defects

Objectives:To report on a new one-step technique for the reconstruction of lower eyelid marginal defects.Method:Retrospective case series of 5 patients with lower eyelid basal cell carcinomas abutting the eyelid margin....

Comparison of tobramycin 0.3%/dexamethasone 0.1% and tobramycin 0.3%/loteprednol 0.5% in the management of blepharo-keratoconjunctivitis

In this clinical trial, investigators compared the effectiveness of 2 commercially formulated antibiotic/steroid combinations - tobramycin 0.3%/dexamethasone 0.1% (Tobradex; Alcon, Fort Worth, Tex) and tobramycin 0.3%/loteprednol 0.5% (Zylet; Bausch & Lomb Inc., Rochester, NY) - for rapidly controlling inflammation in patients with blepharo-keratoconjunctivitis. Investigators in this randomized, parallel-group, double-masked study examined 40 eyes of 40 patients with blepharo-keratoconjunctivitis. Patients received tobramycin 0.3%/dexamethasone 0.1% or tobramycin 0.3%/loteprednol 0.5% twice daily in the test eye, according to the randomization schedule. At baseline, the ocular surface was graded on a scale of 3 (extensive) to 0 (minimum) for 4 components: blepharitis, conjunctivitis, ocular discharge, and corneal punctate epithelial keratopathy (PEK). Only those patients with moderate to extensive inflammation (cumulative score >6) were included in the study. At follow-up 3 to 5 d later, the ocular surface was regraded so that treatment response could be evaluated. No statistically significant difference was noted between groups in pretreatment scores for blepharitis (P=.31), discharge (P=.62), conjunctivitis (P=1.0), and PEK (P=.57), or for total ocular inflammation (P=.87). Mean posttreatment scores were as follows: total ocular surface scores, 1.8 and 3.4 (P=.002); blepharitis scores, 0.9 and 1.35 (P=.017); discharge scores, 0.2 and 0.6 (P=.025); and conjunctivitis scores, 0.15 and 0.6 (P=.013) for tobramycin/dexamethasone and tobramycin/loteprednol, respectively. Corneal PEK scores were not significantly different between treatments. Tobramycin 0.3%/dexamethasone 0.1% significantly decreased clinical signs of ocular inflammation (ie, blepharitis, discharge, conjunctivitis) and total ocular inflammation scores when compared with tobramycin 0.3%/loteprednol 0.5% in patients with moderate to severe blepharo-keratoconjunctivitis. The 2 regimens also provided comparably rapid decreases in corneal PEK.

Early Results of Penetrating Keratoplasty following Limbal Stem Cell Transplantation

To describe the early results of penetrating keratoplasty (PKP) in patients who had earlier received limbal transplantation (LT). Prospective, non-comparative interventional case series comprising of four patients with limbal stem cell deficiency (LSCD) due to chemical injury (Cases 1, 2, 4) and xeroderma pigmentosum (Case 3). Cadaveric kerato-limbal allografts or living-related conjunctival-limbal allografts were done in four eyes followed by PKP for visual rehabilitation 3-4.5 months later. The following details were noted: demographics, primary aetiology, type of limbal transplant (cadaveric or living-related), immunosuppression, vision and ocular surface stability before and after LT and PKP, surgical complications and outcome of PKP. Three eyes received living-related conjunctival-limbal allotransplantation and one received cadaveric kerato-limbal allograft. Duration of follow up after PKP ranged from 4 to 11 months. Visual acuity improved in the early postoperative period in all patients but reduced in 2 due to endothelial rejection and after trans-scleral cyclophotocoagulation for medically uncontrolled glaucoma. The ocular surface remained stable in all patients. All patients were started on immunosuppression on the first postoperative day. This was continued till the last follow-up visit. Post-PKP complications were punctate epithelial keratopathy, corneal allograft rejection and secondary glaucoma (one patient each). Satisfactory visual rehabilitation is possible after PKP following LT without compromising ocular surface stability. However, a prolonged and close follow-up is warranted to avert complications.

Excruciating Headache but Nothing Obvious, Look at the Skin!

Herpes zoster ophthalmicus is usually easily recognized by the periorbital vesicular rash restricted to the ophthalmic division of the trigeminal nerve. But sometimes the rash is not so obvious, despite...

Scleral dellen after bilateral adjustable suture medial rectus muscle resection

Ocular complications after strabismus surgery in a large study population were recently reported. The most frequent of these complications included pseudoptosis, corneal dellen, conjunctival folds, and punctate epithelial keratopathy. We report the occurrence of a rare complication, scleral dellen, occurring in a healthy 30-year-old man after bilateral adjustable suture medial rectus muscle resection for residual exotropia.

Involutional lateral entropion of the upper eyelids: a new physical finding in asian patients.

To describe a new physical finding called involutional lateral entropion (ILE) of the upper eyelid found in Asian patients. A prospective case series study of 53 consecutive patients with ILE of the upper eyelid, from the practice of one of the authors (J.G.C.), was performed. All of the patients in this series were Asian. Clinical findings on ocular examination, symptoms, age, and sex were obtained and tabulated. The mean +/- SD age of patients was 68.9 +/- 10.1 years (range, 41-88 years); 70% were women and 30% were men. All patients presented with in-turning of only the lateral aspect of the upper eyelid bilaterally. The presenting symptoms were foreign-body sensation (85%), tearing (77%), eye redness (34%), eye pain (26%), and itchiness at the lateral canthal area (25%). Clinical findings included lateral dermatochalasis (100%), trichiasis (100%), lateral canthal eyelid laxity (100%), localized lateral conjunctivitis (42%), punctate epithelial keratopathy (11%), blepharitis (11%), and distichiasis (8%). We describe ILE of the upper eyelid in Asian patients and explain the anatomic correlates responsible for this condition.

Effect of artificial tears on corneal surface regularity, contrast sensitivity, and glare disability in dry eyes

Objective To investigate the effects of artificial tears on corneal surface regularity and visual function in dry eyes. Design Nonrandomized, comparative trial. Participants Forty patients (40 eyes) with dry eyes with (group 1, n = 15 eyes) or without (group 2, n = 25 eyes) punctate epithelial keratopathy and a normal control group of 20 individuals (20 eyes) with no ocular abnormalities (group 3). Methods In both dry and normal eyes, the surface regularity index (SRI), surface asymmetry index (SAI), and potential visual acuity (PVA) were measured by computer-assisted videokeratography (TMS-1; Computed Anatomy, New York, NY). Spatial-contrast sensitivity and glare disability were also measured before and 1 minute after instillation of artificial tears. Main outcome measures Differences in SRI, SAI, PVA, spatial-contrast sensitivity, and glare disability between groups, before instillation of tears, and within groups, after instillation of tears. Results Compared with group 3, eyes in group 1 had significantly worse SRI, SAI, PVA, and contrast sensitivity (incomplete glare disability data precluded analysis) before instillation of artificial tears. Differences in corneal surface regularity and visual function between groups 2 and 3 were not significant except for a significantly increased glare disability at low spatial frequency (1.5 cycles per degree [cpd]) in group 2. Significant improvement in SRI, SAI, PVA, and contrast sensitivity were observed after instillation of artificial tears in group 1. In groups 2 and 3, the only significant changes were improvement in glare disability at 1.5 cpd and worsening of the SRI, respectively. Conclusions Tear film changes in dry eye patients may lead to irregularities on the corneal surfaces, causing glare disability. However, these changes may be too subtle in the early stages of dry eyes to be detected by corneal topography or contrast sensitivity measurements. Significant improvement in SRI, SAI, PVA, and contrast sensitivity were found after instillation of artificial tears in dry eyes with punctate epithelial keratopathy.

Oral erythromycin treatment for childhood blepharokeratitis

Blepharokeratitis is a chronic external ocular and adnexal inflammatory condition marked by erythematous and edematous lid margins, lid margin crusting and scaling, meibomian gland inflammation and inspissation, and conjunctival hyperemia. The associated keratitis usually involves the inferior cornea and is characterized by punctate epithelial keratopathy and marginal stromal infiltrates. The inflammation sometimes leads to corneal thinning, scarring, and vascularization. The standard therapy for adult blepharokeratitis includes lid hygiene, topical cortico-steroid preparations, and topical antibiotics. Oral tetracycline and its analogues, doxycycline and minocycline, are used in adults to treat associated meibomian gland dysfunction. Whereas blepharitis is common in children, blepharokeratitis is rare and is often associated with severe ocular and psychosocial morbidity. Treatment of youths may be problematic because of poor compliance with lid hygiene and therapy that includes drops and ointment.1 Furthermore, the use of tetracycline and its analogues is contraindicated in children aged less than 8 years because it may cause dental enamel abnormalities. Isolated case reports have suggested that erythromycin may be a reasonable alternative to tetracycline in childhood blepharokeratitis.2,3 We report on the successful treatment of this condition with oral erythromycin in 5 children.J AAPOS 2000;4:379-80.

Postoperative Topical Mitomycin C in Conjunctival Squamous Cell Neoplasia

To report the efficacy of topical mitomycin C in preventing local recurrences after incomplete surgical excision of conjunctival squamous cell neoplasia. Four patients presented with unilateral conjunctival tumors. Excisional biopsy results revealed conjunctival intraepithelial neoplasia with an intact basement membrane. Neoplastic cells were present in at least one of the surgical borders of the excised conjunctiva in all four cases. Patients were treated with topical mitomycin C 0.02% three times daily for 2 weeks to prevent recurrences. All four patients were free of clinically detectable tumors after a mean follow-up period of 20 months (range, 16-23 months). Side effects included mild discomfort, redness, photophobia, and punctate epithelial keratopathy that subsided on discontinuation of the medication. Postoperative topical mitomycin C application may be a useful adjunct to prevent recurrences in patients with incompletely excised conjunctival squamous cell neoplasia.