Topical Lubricants Research Articles

Anterior Segment Nd:YAG Laser Procedures: to Study Intraocular Pressure Spikes and Their Prevention

Purpose: To find out quantum of increase in intraocular pressure (IOP) following anterior segment Nd: YAG laser procedures and extent to which this increase is preventable by different groups of anti-glaucoma drugs. Methods: Study design: Cross sectional, randomized, double blind analytical study. One hundred and seventy four eyes of 174 patients who underwent anterior segment Nd:YAG laser procedures {peripheral iridotomy (LPI)/ capsulotomy (YLC)}, using energy limited to 50 mJ, were randomized into five groups. Patients in group 1, 2, 3, 4 and 5 received topical Brimonidine tartarate 0.2%, oral Acetazolamide 250mg, topical Dorzolamide hydrochloride 2%, lubricating eye drops plus oral calcium tablets and topical Timolol maleate 0.5% respectively. Patients getting active topical drug were additionally given oral calcium and those getting oral active drug were given topical lubricating drops in a double blind manner. Intraocular pressure was measured at 1, 3, 5 and 24 hours post laser. Results: Rise of IOP from baseline to 1, 3, 5 or 24 hours was not found to be significant in any of the groups receiving ocular hypotensive drug (p>0.05). In the placebo group, the rise of IOP was significant only in one patient at 1, 3 and 5 hours post laser which came down to insignificant levels at 24 hours. Conclusion: Limiting the use of energy (< 50 mJ/ sitting) during Nd:YAG laser procedures may prevent post laser IOP spikes and obviate the use of ocular hypotensive drugs. In high risk cases, amongst the anti glaucoma drugs, α agonists can be prescribed.

Infection Rates Comparing Topical Antibiotic versus Antibiotic-Free Ointment in Blepharoplasty Surgery

Introduction: The purpose of the study was to determine the rate of postoperative surgical-site infections following blepharoplasty by comparing patients using topical antibiotic ointment and those using topical lubricating ointment without antibiotic. Materials and Methods: In an observational, cohort study, 2 similar groups of patients were evaluated for rates of allergic reactions and postoperative infections. For 15 months, 384 consecutive patients, (171 men, 213 women; age range = 38 to 87 years; mean age = 69.2 years), underwent bilateral upper eyelid blepharoplasty. Postoperatively, patients applied bacitracin ophthalmic ointment twice a day for 7 days. Patients with a known allergy to bacitracin were excluded. For the subsequent 9 months, a second cohort of 158 patients, (64 men, 94 women; age range = 30 to 96 years; mean age= 69.3 years) used sterile Refresh PM ophthalmic ointment twice a day for 7 days. All patients had surgery at 1 of 2 fully accredited surgery centers. Both cohorts underwent identical betadine preparations, and all procedures were performed under sterile conditions with full gloves, gowns, and drapes. Surgical technique, instruments, and suture materials were consistent in both groups. Patients were seen 1 week following surgery. Results: In the bacitracin group, 14 of 384 (3.65%) patients had an allergic reaction to the ointment characterized by bilateral erythema, swelling, and itching without any evidence of purulent material along the incision line. In 1 patient (0.26%) a positive culture indicated infection with a methicillin-sensitive Staphylococcus species. In the group using Refresh PM, 10 of 158 (6.3%) patients had a culture-positive surgical-site infection characterized by erythema and purulent material along the incisions. All but 1 infection was bilateral. All cultures grew community-acquired methicillin-resistant Staphylococcus aureus. The study was discontinued in light of the high incidence of infection. Conclusions: In these very similar age-matched cohorts, a lower rate of infection (P < .001) was identified in patients using topical antibiotic ointment postoperatively.

Safety and Efficacy of Lacrimal Drainage System Plugs for Dry Eye Syndrome: A Report by the American Academy of Ophthalmology

To review the published literature assessing the efficacy and safety of lacrimal drainage system plug insertion for dry eye in adults. Literature searches of the PubMed and Cochrane Library databases were last conducted on March 9, 2015, without date restrictions and were limited to English language abstracts. The searches retrieved 309 unique citations. The primary authors reviewed the titles and abstracts. Inclusion criteria specified reports that provided original data on plugs for the treatment of dry eyes in at least 25 patients. Fifty-three studies of potential relevance were assigned to full-text review. The 27 studies that met the inclusion criteria underwent data abstraction by the panels. Abstracted data included study characteristics, patient characteristics, plug type, insertion technique, treatment response, and safety information. All studies were observational and rated by a methodologist as level II or III evidence. The plugs included punctal, intracanalicular, and dissolving types. Fifteen studies reported metrics of improvement in dry eye symptoms, ocular-surface status, artificial tear use, contact lens comfort, and tear break-up time. Twenty-five studies included safety data. Plug placement resulted in ≥50% improvement of symptoms, improvement in ocular-surface health, reduction in artificial tear use, and improved contact lens comfort in patients with dry eye. Serious complications from plugs were infrequent. Plug loss was the most commonly reported problem with punctal plugs, occurring on average in 40% of patients. Overall, among all plug types, approximately 9% of patients experienced epiphora and 10% required removal because of irritation from the plugs. Canaliculitis was the most commonly reported problem for intracanalicular plugs and occurred in approximately 8% of patients. Other complications were reported in less than 4% of patients on average and included tearing, discomfort, pyogenic granuloma, and dacryocystitis. On the basis of level II and III evidence in these studies, plugs improve the signs and symptoms of moderate dry eye that are not improved with topical lubrication, and they are well tolerated. There are no level I studies that describe the efficacy or safety of lacrimal drainage system plugs.

The treatment of carcinoma in situ and squamous cell carcinoma of the conjunctiva with fractionated strontium-90 radiation in a population with a high prevalence of HIV.

This study explores the safety and efficacy of strontium 90 (Sr-90) brachytherapy as the sole adjuvant therapy for carcinoma in situ (CIS) and squamous cell carcinoma (SCC) of the conjunctiva in a high HIV prevalent area. This is a retrospective case review of patients treated with 60 Gray Sr-90 brachytherapy in four divided doses after resection with a 2 mm margin and histological confirmation. Cryotherapy or alcohol debridement was not performed at the time of excision due to limited resources. Two plaque sizes, 8.5 mm and 18 mm, were used. Sixty-nine patients were treated and had a median follow-up of 27 months (range 6-127). Thirty-three (47.8%) were HIV-positive. CIS was present in 40.6% and SCC in 59.4%. The surgical margins were positive in 39 (56.5%). Twenty patients (29.0%) were treated with the 18 mm plaque and 49 (71.0%) with the 8.5 mm plaque. Eight (11.6%) patients developed a recurrence at a median of 5 months (range 2-40). Recurrences only occurred in patients treated with the 8.5 mm plaque (p=0.094). There was no significant effect of HIV status, positive margins or staging on the number of recurrences. Treatment side effects were a dry eye in five patients which was successfully managed with topical lubricants, and induced astigmatism of 1 dioptre of cylinder in one patient. Sr-90 brachytherapy is safe and effective in preventing recurrences in ocular surface squamous neoplasia in a high HIV prevalent setting. The 18 mm plaque size is superior to the 8.5 mm plaque size.

English

BACKGROUND: In this case report we describe a very rare case of symblepheron which hasn't been reported in literature till date, triggered by long standing cilia embedded in the subconjuctival space followed by regression of symblepheron by removing the cilia. CASE REPORT: A 65-year-old man, presented to the eye O.P.D of I.G.M.C. Shimla with complaints of irritation and foreign body sensation in the left eye from last 8-9 months. He had no history of trauma, chemical injury or surgery in left eye in the past. He had history of multiple treatments with topical antibiotics and lubricants for the complaints with no relief. Torch light examination revealed a whitish membrane in the lower palpebral conjunctiva. Slit lamp examination revealed two semilunar pseudopockets and partial symblepheron in lower fornix. Further probing revealed two eyelashes embedded in the subconjuctival space in one of the peudopockets. Search with a needle under topical anesthesia under slit lamp magnification enabled the cilia to be removed with little difficulty; the cilia were of the same size and appearance as the patient's own. He was prescribed topical antibiotics and the symblepheron regressed significantly in 8 weeks' time. CONCLUSION: Long term inflammation associated with foreign bodies like embedded cilium in the subconjuctival space may cause unusual presentations like symblepheron as in this case.

Amniotic Membrane Transplantation: A Good Treatment Option for Refractory Neurotrophic Keratitis

Neurotrophic keratitis is a degenerative disease of the corneal epithelium resulting from impaired corneal innervation, possibly leading to perforation. In this report, we present a case with a history of herpetic keratitis, who developed a difficult neurotrophic ulcer despite 10 days of topical lubricant therapy and oral doxycycline. Amniotic membrane transplantation can be considered an effective alternative for treating persistent and progressive neurotrophic corneal ulcers.

Congenital Corneal Anesthesia and Neurotrophic Keratitis: Diagnosis and Management.

Neurotrophic keratitis (NK) is a rare degenerative disease of the cornea caused by an impairment of corneal sensory innervation, characterized by decreased or absent corneal sensitivity resulting in epithelial keratopathy, ulceration, and perforation. The aetiopathogenesis of corneal sensory innervation impairment in children recognizes the same range of causes as adults, although they are much less frequent in the pediatric population. Some extremely rare congenital diseases could be considered in the aetiopathogenesis of NK in children. Congenital corneal anesthesia is an extremely rare condition that carries considerable diagnostic and therapeutic problems. Typically the onset is up to 3 years of age and the cornea may be affected in isolation or the sensory deficit may exist as a component of a congenital syndrome, or it may be associated with systemic somatic anomalies. Accurate diagnosis and recognition of risk factors is important for lessening long-term sequelae of this condition. Treatment should include frequent topical lubrication and bandage corneal or scleral contact lenses. Surgery may be needed in refractory cases. The purpose of this review is to summarize and update data available on congenital causes and treatment of corneal hypo/anesthesia and, in turn, on congenital NK.

Acquired trichomegaly and hypertrichosis after treatment with epidermal growth factor receptor inhibitors

AbstractPurpose To describe a case of acquired trichomegaly and hypertrichosis after treatment with epidermal growth factor receptor inhibitors (EGFR TKI’s).Methods A case‐report.Results We describe the case of an 88‐year old patient treated for metastatic lung carcinoma with EGFR TKI’s. A few weeks after treatment with Afatinib, she presented with a painful squamous blepharitis. Her eyelashes were abnormally long and abundant. After trimming of the eyelashes, lid hygiene and topical lubricants the symptoms disappeared.Conclusion EGFR TKI’s are a new type of oral anti‐tumoral agents with ocular side effects such as keratitis, conjunctivitis, blepharitis and trichomegaly. Symptomatic topical treatment can be successful. This case report has already be published. "Aerts L, Lauwers N, Smets RME. Trichomégalie et hypertrichose acquise. Journal francais d'Ophtalmologie 2014; 37: 339‐341."

Management of dry eye in UK pharmacies.

To investigate the ability of pharmacy staff in the United Kingdom (UK) to diagnose and treat dry eye. A mystery shopper technique to simulate a patient with presumed dry eye was used in 50 pharmacy practices in major towns and cities across the UK. Pharmacies were unaware of their involvement in the study. With the exception of a predetermined opening statement to initiate the consultation, no further information was volunteered. Questions asked, diagnoses given, management strategy advised and staff type was recorded immediately after the consultation. The mean number of questions was 4.5 (SD 1.7; range 1-10). The most common question was the duration of symptoms (56%) and the least common was whether the patient had a history of headaches (2%). All pharmacy staff gave a diagnosis, but the majority were incorrect (58%), with only 42% correctly identifying dry eye. Treatment was advised by 92% of pharmacy staff, with the remaining 8% advising referral directly to the patient's GP or optometrist. Dry eye treatments involved topical ocular lubrication via eye drops (90%) and lipid based sprays (10%). However, only 10% gave administration advice, 10% gave dosage advice, 9% asked about contact lens wear, and none offered follow up although 15% also advised GP or optometrist referral. There is a need for improved ophthalmological training amongst pharmacists and pharmacy staff and establishment of cross referral relationships between pharmacies and optometry practices.

The effect of leflunomide on the eye dryness in secondary Sjögren’s syndrome associated with rheumatoid arthritis and in rheumatoid arthritis patients

The aim of this work was to clarify the effect of leflunomide (LEF) on the eye dryness in patients with secondary Sjögren's syndrome associated with rheumatoid arthritis (RA-sSS) and in patients with rheumatoid arthritis (RA). Seventy-five female patients, 45 with RA-sSS (group A) and 30 with RA (group B), taking methotrexate at a dose of 20mg/week for more than 6months were enrolled in this study. They all had a loading dose of leflunomide then were maintained at a dose of 20mg/day in addition to methotrexate for another 3months. The modified disease activity score (DAS28) was calculated and modified Schirmer's-I test was performed. Assessment of disease parameters was done to all patients before and after 3months of taking LEF. The mean modified Schirmer's-I test showed a significant decrease after 3months of taking LEF in group A (3 ± 1.6 before versus 1.9 ± 1.6 after 3months, P < 0.001), while this difference was non-significant in group B (21.3 ± 10 versus 19.9 ± 11). One patient (group A) developed peripheral ulcerative keratitis (PUK) with exacerbation of disease activity (DAS-28 = 6.9) that improved by taking corticosteroids. Three patients (group A) had aggravation of punctate keratocojunctivitis sicca with punctate erosions without PUK. The condition improved dramatically by stopping LEF and using topical lubricants. We report in this study a significant deterioration of the eye dryness in patients with sSS-RA after 3months of receiving LEF inspite of the significant improvement of their DAS28. This finding was not clearly detected in RA patients. Close monitoring of eye dryness changes by special tests in patients using LEF is recommended, especially in cases with sSS-RA having very low baseline values.

Early Bilateral Amniotic Membrane Transplantation in the Management of Severe Ocular Involvement from Acute Toxic Epidermal Necrolysis in a Chinese Pediatric Patient

Introduction: Toxic Epidermal Necrolysis (TEN) is a rare but potentially life-threatening muco-cutaneous condition associated with idiosyncratic hypersensitivity to certain drugs. Ophthalmic involvement is common, typically affecting the ocular surface and eyelids. Survivors often suffer from resulting bilateral blindness and ocular dryness or pain. Objective: To report the successful management of severe ocular surface disease during the acute stage of toxic epidermal necrolysis using early amniotic membrane transplantation on both eyes in a Chinese paediatric patient. Design: Interventional case report Case report: A 15 year-old Chinese girl was transferred to the intensive care unit of Queen Mary Hospital, Hong Kong with TEN after taking oral cefuroxime and diclofenac. She developed bilateral keratoconjunctivitis, diffuse corneal epithelial defects (80-90% of cornea surface) and later bilateral symblephara. After initial treatment with daily rodding, topical lubricants, steroids and antibiotics, there was no improvement in her condition. Bilateral amniotic membrane transplantation (AMT) was performed over the cornea, fornix, tarsal and bulbar conjunctiva on day 10 of illness. On discharge from the hospital (post-operative week 7), the patient had pinhole visual acuity of 6/7.5 in the right eye and 6/6 the left eye. She was eventually weaned off all topical medication Visual acuity eventually recovered to 6/6 in both eyes by week 20 after surgery. There was mild residual forniceal symblepharon and eyelid margin keratinization. She continues to require regular lubricants for her chronic ocular surface condition. Conclusion: Early use of AMT minimized ocular damage and prevented severe vision loss in a Chinese pediatric patient with severe bilateral ocular surface inflammation secondary to TEN. Effective management is dependent on early and active communication between the patient’s family, pediatricians, intensive care physicians and ophthalmologists.

Treatment of Superior Limbic Keratoconjunctivitis With Topical Tacrolimus 0.03% Ointment

To report 2 cases of superior limbic keratoconjunctivitis (SLK) treated with topical tacrolimus 0.03% ointment (Protopic; Fujisawa Healthcare). A female patient aged 52 years and a male patient aged 21 years presented with SLK in both eyes. Both patients had previously received several treatments [such as topical steroids and lubrication, contact lenses, silicone punctal plugs, and vitamin A eye drops], with no improvement. Because of poor response to initial management, the authors started treatment with topical tacrolimus 0.03% twice a day. Objective tarsal conjunctiva inflammation, bulbar conjunctiva findings (such as hyperemia and thickening), cornea staining, and subjective symptoms were evaluated. A week later, both patients were symptomatically better. Four weeks after treatment initiation, the signs of thickened and hyperemic superior conjunctiva, papillary reaction, and punctate keratopathy were almost resolved. Tacrolimus was successfully tapered in both the patients. There were no side effects. Topical tacrolimus 0.03% ointment may be considered an additional treatment option for SLK.

Use of Extraocular Muscle Flaps in the Correction of Orbital Implant Exposure

PurposesThe study is to describe a new surgical technique for correcting large orbital implant exposure with extraocular muscle flaps and to propose a treatment algorithm for orbital implant exposure.MethodsIn a retrospective study, seven patients with orbital implant exposure were treated with extraocular muscle flaps. All data were collected from patients in Chang Gung Memorial Hospital, Taiwan during 2007–2012. All surgeries were performed by one surgeon (Y.J.T). Patient demographics, the original etiology, details of surgical procedures, implant types, and follow-up interval were recorded. Small exposure, defined as exposure area smaller than 3 mm in diameter, was treated conservatively first with topical lubricant and prophylactic antibiotics. Larger defects were managed surgically.ResultsSeven patients consisting of two males and five females were successfully treated for orbital implant exposure with extraocular muscle flaps. The average age was 36.4 (range, 3–55) years old. Five patients were referred from other hospitals. One eye was enucleated for retinoblastoma. The other six eyes were eviscerated, including one for endophthalmitis and five for trauma. Mean follow-up time of all seven patients was 19.5 (range, 2–60) months. No patient developed recurrence of exposure during follow-up. All patients were fitted with an acceptable prosthesis and had satisfactory cosmetic and functional results.ConclusionsThe most common complication of orbital implant is exposure, caused by breakdown of the covering layers, leading to extrusion. Several methods were reported to manage the exposed implants. We report our experience of treating implant exposure with extraocular muscle flaps to establish a well-vascularized environment that supplies both the wrapping material and the overlying ocular surface tissue. We believe it can work as a good strategy to manage or to prevent orbital implant exposure.

Traumatic tympanic bulla fracture

A Pekingese dog was presented for evaluation of head trauma with ventral head and neck swelling, puncture wounds, palpable mandibular fractures, and loss of menace, severe miosis, and loss of palpebral reflex of the right eye. Computed tomography confirmed multiple mandibular and zygomatic fractures, a right ear canal avulsion, and a complete right tympanic bulla fracture with ventral displacement. The tympanic bulla fracture was managed conservatively. Topical lubrication and antibiotic ointment was prescribed for the right eye. A subtotal hemimandibulectomy was performed to address the mandibular fractures. A temporary oesophagostomy feeding tube was placed. No short-term complications developed as a result of the fractured bulla and avulsed ear canal being left in situ, and no complications were reported 18 months after the injury. To the authors' knowledge this is the first report of a traumatic tympanic bulla fracture in the dog.

Peripheral Hypertrophic Subepithelial Corneal Degeneration: Nomenclature, Phenotypes, and Long-Term Outcomes

To describe the long-term outcomes of peripheral hypertrophic subepithelial corneal degeneration. Retrospective case series. Twenty-two patients under the care of the External Disease Service, Moorfields Eye Hospital. All patients matching clinical diagnostic criteria were included. Symptomatic patients were managed either conservatively or were offered superficial keratectomy in progressive cases where symptom control was inadequate. All excised tissue was examined histologically. Clinical phenotype, symptoms, recurrence rate after surgery, and histopathologic results. Twenty-two white patients (20 women and 2 men; age range, 27-88 years; median age, 42 years) had peripheral, usually bilateral (20/22 [91%]), elevated circumferential peripheral subepithelial corneal opacities and adjacent abnormal limbal vasculature, with or without pseudopterygia in 9 patients (41%), among whom 7 (32%) patients had bilateral disease. Apart from the abnormal vasculature, there were no signs of chronic ocular surface inflammation. Symptoms were ocular surface discomfort in 10 patients (45%), reduced vision in 4 patients (18%), and both of these in 5 patients (23%). Three patients (14%) were asymptomatic. There was no treatment in 6 patients (27%), topical lubricants in 8 patients (36%), spectacles in 1 patient (5%), and superficial keratectomy in 7 patients (32%; 5 bilateral), which was repeated for incomplete primary excision in 1 eye of 2 patients (9%) and for a bilateral recurrence in 1 patient (5%). Median follow-up after excision was 5 years (range, 1-11 years). Histopathologic changes were similar to those observed in pterygia (vascular component) and Salzmann's nodular degeneration (corneal component). Peripheral hypertrophic subepithelial corneal degeneration is an uncommon, usually bilateral, idiopathic disorder, occurring mostly in white women with a distinct phenotype. The condition was first described in 2003. Further cases among some patients have been described in more recent case series of Salzmann's nodular degeneration and diffuse keratoconjunctival proliferation, as well as in the previously described familial pterygoid corneal degeneration. Surgical excision was required in 30% of patients in this series, with infrequent short-term recurrences. The cause is uncertain. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

The activity and damage of blepharokeratoconjunctivitis in children

The syndrome of childhood blepharokeratoconjunctivits (BKC) is frequently underestimated. Total control of the disease is not possible in many cases. Measuring success has been based on clinical experience only. We are implementing a new classification of BKC to define the degree of activity and damage at any stage of the disease and hence measuring success of disease management. It will objectively measure success of our BKC management protocol. A retrospective review of all children with BKC over the last 10 years at tertiary referral centre. Children with significant systemic disorders, atopy, vernal keratoconjunctivitis, or perennial allergic conjunctivitis were excluded. Activity/damage score of the worst affected eye at initial presentation and at last follow-up were included in the statistical analysis. Clinical features were graded, before and after instituting a hierarchical therapeutic protocol comprising lid hygiene, topical/systemic antibiotics, intensive topical glucocorticoids, topical lubricants, and nutritional supplement. Activity (A0-A3) and damage (D0-D3) scoring was applied to grade BKC. Complete success was defined as ability to fully control disease activity i.e. e. from any grade to A0. Partial success meant reduction in activity scoring but not reaching A0 grade. Failure if there was no change or worsening of disease activity. We identified a cohort of 42 patients (84 eyes) with BKC; mean age at onset of symptoms was 4.6 years (0.4-14 years) and at presentation to our center 7 (1-15 years). The median duration of symptoms prior to presentation was 2.22 years (range, 0.01-10 years). 17 Asian and 25 Caucasian patients were followed up for 3.2 years (3 months-10 years). The protocol was followed in 90% of children. All cases where scored as per activity and damage scoring system. All risk factors were analysed. Complete success was achieved in 50%, partial success in 38%, and failure in 12% of children). Recurrences ranged from 0 to 7 times (mean, 2.1). BKC is underestimated in white children. Total control of the disease is not always possible. A protocol based on topical steroids and following a strict regime of treatment is vital for disease control. A classification of BKC based on activity and damage score is an appropriate method to describe the disease and classify it. It allows measuring success of treatment and to compare various modalities of treatments. |Younger age and longer duration of symptoms were common in the failure group. Those with acne rosacea had the worst prognosis and this was statistically significant. Our protocol resulted in full control of the disease in 50% of patients but failed in 12% of cases. Whites with BKC were at risk of severe phenotype that is resistant to treatment. The management of BKC in children is very challenging. Suboptimal treatment of BKC in children may permit a progressively destructive sight-threatening phenotype, which may last into adulthood and cause visual disability. Appropriate aggressive topical steroids and following a strict regime of treatment are vital for disease remission. A novel scoring system, which takes into consideration both activity and damage of BKC, will allow appropriate disease description and classification, measuring success of treatment, and comparing various treatment protocols.

What is the best therapeutic approach if the initial glucocorticoids therapy of active Graves’ orbitopathy fails?

Glucocorticoids are the first-line treatment for active moderate-to-severe and sight-threatening Graves’ orbitopathy. Glucocorticoid therapy, by exerting antiinflammatory and immunomodulatory effects, reduces pain, injection and edema of orbital tissues and provides a substantial relief from optic nerve compression. Although efficiency of both oral and intravenous glucocorticoids is proven, the randomized clinical trials revealed that intravenous therapy is more effective and better tolerated. However, 20-40% of patients respond only partially or do not respond to immunosuppressive treatment. The effectiveness of treatment may be improved by proper selection of patients suspected to have beneficial results, i.e. those with a high degree of disease activity, with orbitopathy of recent onset or recent progression. Corticotherapy may cause major side effects which make treatment continuation impossible. Orbital radiotherapy exerts nonspecific antiinflammatory effect and suppresses radiosensitive lymphocytes infiltrating the orbital space. Orbital radiotherapy remains an effective and safe second-line treatment preferably used in association with glucocorticoids. The combined therapy is more effective than either treatment alone. Sight-threatening Graves’ orbitopathy due to compressive optic neuropathy or corneal ulceration requires immediate intervention. High-dose daily intravenous glucocorticoids are the first-line treatment and if the response is absent or poor within 1-2 weeks the orbital decompression should be performed. Corneal breakdown should be additionally treated with topical lubricants, and sometimes, to provide eyelid closure, with blepharorraphy or tarsorraphy. Unsuccessful oral glucocorticoid treatment of active Graves’ orbitopathy should be an indication for orbital radiotherapy, preferably combined with glucocorticoids, or to a 3 month intravenous methylprednisolone course. If intravenous methylprednisolone was the first treatment and the response is not satisfactory, the intravenous course should be repeated combined with orbital radiotherapy. An alternative approach is combination of oral or intravenous glucocorticoids with cyclosporine for 3-6 months. It was demonstrated that the combined treatment of cyclosporine with oral glucocorticoids resulted in substantial improvement and was useful to reduce the dose of glucocorticoids. In steroid unresponsive Graves’ orbitopathy, biological agents as anti-lymphocyte antibody (anti-CD 20, rituximab) and anti-cytokine antibody (anti-TNFα, etanercept) have shown promise. Theoretically somatostatin analogue pasireotide, with a wider than octreotide or lanreotide binding affinity for various somatostatin receptor subtypes could be also a treatment option. As far as the randomized clinical trials are not available, the use of biological agents and somatostatin analogs is experimental. We hope that the future treatment will be based on pathogenic mechanisms of Graves’ orbitopathy. Small molecule “drug like” TSH receptor neutral antagonists were shown to antagonize TSAb activation of TSH receptor on retroorbital preadipocytes and possibly could be used to treat Graves’ orbitopathy. Currently their effects were determined in the model of orbit cells.

Peripheral corneal ulceration associated with rheumatoid arthritis

Patient: Female, 60Final Diagnosis: Corneal ulcerationSymptoms: Blurred visionMedication: AbataceptClinical Procedure: —Specialty: OphthalmologyObjective:Management of emergency careBackground:To report a case of a patient with rheumatoid arthritis (RA) and associated peripheral corneal ulceration.Case Report:A 60-year-old woman with RA diagnosed 15 years ago, under immunosuppressive therapy (IV abatacept 250 mg/month), demonstrated blurring of vision in her RE (right eye). Visual acuity was 6/10 in the RE and 10/10 in the LE. Slit lamp examination revealed a paracentral superior corneal melt in the RE. Anterior chamber reaction was 2+. Laboratory investigations revealed positive anti-Ro and anti-La, anti-Extractable Nuclear Antigens (anti-ENA, ELISA), while anti-Sm, anti-Rnp, anti-Jo1 and anti-Scl70 were found negative. IgG and IgA serum immunoglobulins were found elevated, but IgE and IgM were within normal levels. Further evaluation for the underlying disease revealed highly elevated rheumatoid factor and C-reactive protein. The patient, who had been receiving anti-TNF during the last 6 months, underwent treatment with topical tobramycin and lubricants and oral prednisone 60 mg/day with tapering doses, to which methotrexate p.os. 15 mg/week was added.The condition improved within a few days after the initiation of prednisone treatment. Re-epithelization occurred 1 week after the onset of the immunosuppressive treatment. Only punctate fluorescein dye uptake was detected in the margins of the lesion.Conclusions:The effective control of the underlying disease and early diagnosis of the dry eye syndrome in RA patients may prevent serious corneal complications such as corneal ulceration. The initiation of treatment with steroids and immunosuppresants was found to halt the progression of keratolysis, and assisted re-epithelization.

Superior limbic keratoconjunctivitis causing chronic ocular irritation in a child

Superior limbic keratoconjunctivitis (SLK) is an uncommon, painful inflammation of the ocular surface localized to the superior sectors of the cornea, limbus, and conjunctiva. The clinical course tends to be chronic, with alternating periods of remission and exacerbation. Many patients experience severe ocular discomfort for long periods. Corneal involvement may induce scarring, astigmatism, and ultimately decreased vision. SLK typically occurs in woman between 20 and 60 years of age. Little is known about the features of SLK in young children because the earliest age described in the literature is adolescence. We report the clinical presentation and management of SLK in a 7-year-old boy who responded well to topical steroids and lubricants.

The effect of pH, dilution, and temperature on the viscosity of ocular lubricants—shift in rheological parameters and potential clinical significance

To investigate the effect of temperature, dilution, and pH on the viscosity of ocular lubricants. Laboratory based investigation of viscosity. No human subjects. Hypromellose 0.3%, sodium hyaluronate 0.4%, carboxymethylcellulose sodium 0.5%/glycerin 0.9%, and carmellose sodium 0.5% were investigated. Ostwald capillary viscometers were utilised for viscosity measurements. The kinematic viscosity of each lubricant was tested quantitatively from 22 to 40 °C, and over a pH range of 5-8 under isothermal conditions. The kinematic viscosity of each eye drop was also tested under dilution by varying the mass fraction of each eye drop under isothermal conditions. Changes in kinematic viscosity. Hypromellose 0.3% had an initial pH of 8.34, while the other lubricants had a pH close to neutral. From 22 to 35 °C, the kinematic viscosity of sodium hyaluronate 0.4 fell by 36% from 37.8 to 24.4 mm(2)/s, carboxymethylcellulose sodium 0.5%/glycerin 0.9% fell by 35% from 16.98 to 11.1 mm(2)/s, hypromellose fell by 37% from 6.89 to 3.69 mm(2)/s, and carmellose sodium 0.5% fell by 25% from 2.77 to 1.87 mm(2)/s. At 32 °C only sodium hyaluronate 0.4%, and carboxymethylcellulose sodium 0.5%/glycerin 0.9% retained sufficient kinematic viscosity to maintain precorneal residence. Kinematic viscosities of all the topical lubricants were unaffected by pH but decreased significantly with dilution. This study suggests that currently used ocular lubricants have limited bioavailability due to reductions in viscosity by temperature and dilutional changes under physiological conditions. Developing lubricants with stable viscosities may maximise therapeutic efficacy.