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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 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.
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.