Delayed Wound Healing After Radial Keratotomy

Delayed Wound Healing After Radial Keratotomy

Vol. 99, No. 4 Letters to the Journal 485 Fig. 1 (Slomovic, Parrish, and Sherman). Clear donor cornea with opacified host Descemet's membrane locat...

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Vol. 99, No. 4

Letters to the Journal

485

Fig. 1 (Slomovic, Parrish, and Sherman). Clear donor cornea with opacified host Descemet's membrane located 3 mrn posteriorly before neodymium-YAG laser treatment.

Fig. 2 (Slomovic. Parrish, and Sherman). Two hours after laser treatment the previously clear donor graft has developed marked corneal edema and folds. Note openings in Descemet's membrane.

cern. 1.2 We report a case of transient corneal edema and endothelial cell loss after a neodymium-YAG laser was used to open an opacified Descernet's membrane inadvertently left behind after penetrating keratoplasty. Best corrected visual acuity before laser treatment was 20/400 and the intraocular pressure was 13 mm Hg. An opacified host Descernet's membrane was located approximately 3 mm posterior to a clear donor graft (Fig. 1). Central corneal thickness was 0.49 mm by pachymetry. The central corneal endothelial cell count, determined with a wide-field specular microscope, was 2,220 cells/rnm". The anterior chamber was quiet and the remainder of the ocular findings were within normal limits. A 2.5-mm central circular opening was made in the opacified Descemet's membrane with a Q-switched neodymium-YAG laser and a contact lens. Initial laser energies were 0.8 rn] per pulse and 2 pulses per burst, increasing to 1.4 m] per pulse and 4 pulses per burst. Opening the membrane required a total of 570 pulses. Two hours postoperatively the previously clear donor tissue developed marked corneal edema and folds (Fig. 2). Central corneal thickness was 0.89 mm. A moderate flare and cell response was produced. The intraocular pressure was 12 mm Hg. Topical 1 % prednisolone acetate was instilled and continued four times daily during the following week. Within seven days the cornea appeared to be clear and the edema subsided. Ninety-nine days later, visual acuity was 20/50, the cornea was clear, and the central corneal thickness had returned to the preoperative status, 0.5 mm. The central corneal endothelial cell count, however, had decreased from 2,220 cells/rnm" to 950 cells/mm", We believe that this case was remarkable in two respects. First, it suggested that Descemet's mern-

brane is a much more difficult tissue to cut with the neodymium-YAG laser than the posterior capsule, requiring the use of higher energy levels to perform a membranotomy. Secondly, this case confirmed previous observations that optical breakdown in the anterior segment can have a detrimental effect on the corneal endothelium which is probably related to the amount of energy used and the proximity of optical breakdown to the endothelium. 1.2

References 1. Meyer, K. T., Pettit, T. H., and Straatsma, B. R.: Neodymium YAG laser. Acute corneal endothelial trauma. ARVO Abstracts. Supplement to Invest. Ophthalmol. Vis. Sci. Philadelphia, J. B. Lippincott, 1983, p. 126. 2. Schubert, H. D., and Trokel, S.: Endothelial repair following Nd:YAG laser injury. Invest. Ophthaimoi. Vis. Sci. 25:971, 1984.

Delayed Wound Healing Keratotomy

After

Radial

Louis J. Girard, M.D., Jorge Rodriguez, M.D., Norma Nino, M.D., and Mae Wesson, M.D. Inquiries to Louis J. Girard, M.D., Twelve Oaks Towers, Suite 500, 4126 Southwest Freeway, Houston, Texas 77027.

Radial keratotomy incisions appear to close rapidly because the epithelium grows over the wound. Stro-

486

April, 1985

AMERICAN JOURNAL OF OPHTHALMOLOGY

Council for Scientific Research, American University of Beirut Medical Center.

Inquiries to Elias 1. Traboulsi. M.D .• American University of Beirut. Medical Center. P.O. Box 113-6044. Beirut. Lebanon.

Figure (Girard and associates). Reopening of radial keratotomy incisions six months postoperatively when arc incisions for astigmatism were made.

mal healing, however, can be delayed for prolonged periods. A 27-year-old man was examined in August 1981. His uncorrected visual acuity in the left eye was 20/400. Refraction under cycloplegia was -3.00 -4.75 x 175 = 20/20. On Sept. 17, 1981, the patient underwent radial keratotomy in this eye. His myopia was corrected but the astigmatism prevented a good uncorrected visual acuity (uncorrected visual acuity, 20/100; cycloplegic refraction, +0.75 -4.25 x 170 = 20/20). On Feb. 28, 1982, almost six months postoperatively, two arc incisions were made at the 12 and 6 o'clock meridians. The corneal wounds from the radial keratotomies came open with the arc incisions, showing that the original incisions had not closed after six months (Figure). A bandage contact lens was applied and the corneal incisions gradually healed. When the patient was last examined on April 18, 1983, his uncorrected visual acuity was 20/40+ and the cycloplegic refraction was -1.00 -1.00 x 45 = 20120. With the proliferation of radial keratotomy and other types of refractive corneal surgery, ophthalmic surgeons should be aware of delayed wound healing in comeal incisions.

The association of chronic mucocutaneous candidiasis and polyglandular autoimmune disease in siblings is diagnostic of the recessively inherited candidiasis-endocrinopathy syndrome;' The autoimmune endocrinopathies include idiopathic hypoparathyroidism, idiopathic Addison's disease, Hashimoto's thyroiditis, and juvenile diabetes mellitus. Other associated diseases of autoimmune character are pernicious anemia, hypogonadism, and keratoconjunctivitis sicca. Chronic mucocutaneous candidiasis usually appears before overt endocrinopathy. 2 The character of the responsible mutant gene is unknown, but an inherited defect of cell-mediated immunity is postulated. 1 Gass" described a syndrome of keratoconjunctivitis, superficial moniliasis, hypoparathyroidism, and Addison's disease in three of his patients and in nine others described in the literature. The ocular findings in these patients included photophobia,

TABLE SUMMARY OF CLINICAL DATA CLINICAL DATA

PATIENT 1

PATIENT 2

Chronic mucocutaneous candidiasis

Present

Present

Idiopathic hypoparathyroidism

Present

Absent

Hashimoto's thyroiditis

Present

Present

Alopecia

Present

Present

Idiopathic Addison's disease

Absent

Absent

Diabetes mellitus

Absent

Absent

Anemia

Present

Present

Developmental retardation

Present

Present

Autoantibodies

Present

Present

Hyperqamrnaqlobultnernia

Present

Present

Present

Present

?

Present

Photophobia, blepharospasm

Present

Absent

Loss of eyebrows and eyelashes

Present

Present

Recurrent blepharitis

Present

Absent

Immunologic findings

Depressed cell-mediated immunity Boyden chamber lazy neLitrophiis

Ocular Findings In the Candidiasis-Endocrinopathy Syndrome Elias I. Traboulsi, M.D., Dimitri T. Azar, M.D., Nabil [arudi, M.D., and Vazken M. Der Kaloustian, M.D. Departments of Ophthalmology and Pediatrics and the National Unit of Human Genetics of the Lebanese National

Ocular findings

Corneal epithelial scarring

Present

Present

Abnormal Schirmer test

Absent

Absent

Ocular surface staining

Absent

Absent

Keratic precipitates

Absent

Present'

Cataract

Absent

Absent

'In the left eye.