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Introduction: Allergy is the fifth leading group of chronic diseases, affecting as much as 40% of the first-world population. Its pathophysiology has a genetic component, and is driven by the immune system's sensitized response to antigens and environmental factors. As research continues to uncover the mediators responsible for ocular allergy, the development of novel drugs should progress., Areas Covered: A literature review of allergic conjunctivitis, ocular allergy and their treatment was performed using PubMed and Medline. Additional information is also included from clinicaltrials.gov and associated web sites for drugs currently in clinical trials., Expert Opinion: The initial step of therapy remains identification and avoidance of allergic triggers. The mainstay of treatment is the new generation of dual-acting antihistamines. Drugs that improve the magnitude and duration of relief, with greater subject responder rates, are gradually making their way into the clinic. Allergic conjunctivitis is a relatively easy disease to study because of the availability of models such as the conjunctival allergen challenge. New classes of drugs that target inflammatory pathways or mediators involved in the early and late-phase allergic response are being screened in these models and we are making progress in identifying the next generation of anti-allergic therapy.

Purpose: To evaluate the long-term outcomes of keratoprosthesis as an alternative surgical procedure in the management of aniridic keratopathy., Design: Retrospective, multicenter case series., Methods: Fifteen adult patients (16 eyes) with aniridia who were deemed at high risk for regular donor corneal transplantation underwent a Boston type I keratoprosthesis procedure for visual rehabilitation. Device retention rate, preoperative and postoperative visual acuity, and intraoperative and postoperative complications were studied., Results: The mean age of the patients was 45 (median 50) years. Six of the patients were females. Eleven patients had previously undergone donor corneal transplantations (average two grafts), with failure. In 10 patients, the keratoprosthesis surgery was combined with other procedures such as cataract extraction, tube shunt implantation, vitrectomy, and intraocular lens removal. No intraoperative complications were encountered. The follow-up ranged from two months to 85 months, with a median of 17 months. All devices remained in situ throughout the entire follow-up period. The visual acuity improved in all but one patient from a median of counting fingers (light perception to 20/300) to 20/200 (hand motions to 20/60). Comorbid preoperative conditions particularly optic nerve and foveal hypoplasia limited the final postoperative vision. No endophthalmitis or extrusion of the device occurred. One device required repair procedure without necessitating a removal., Conclusions: Keratoprosthesis offers significant vision benefits in this patient group.

Purpose: To present a case of ulcerative keratitis and impending corneal perforation in a patient with mycosis fungoides (cutaneous T-cell lymphoma) that developed eyelid involvement., Methods: Case report analysis. Cultures and biopsies of the right cornea, conjunctiva, and eyelids were obtained. Biopsy tissue was examined with histologic and immunohistologic stains., Results: This patient with mycosis fungoides involving the eyelids developed corneal exposure and bacterial keratitis with impending corneal perforation. Lamellar keratoplasty and permanent tarsorrhaphy were performed to protect the globe from perforation., Discussion: Mycosis fungoides involving the eyelids is capable of causing severe ocular tissue injury without direct infiltration of the malignant lymphocytes. Preventative medical and surgical measures must be taken to protect the globe.

Purpose: We present a case of peripheral corneal ulceration in a patient with hepatitis C, which rapidly and dramatically responded to intravenous steroid treatment., Methods: Clinical examination and photographs were obtained to document initial presentation and therapeutic response of Mooren's-type ulcers to steroids., Results: Bilateral peripheral corneal ulceration with documented progression responded to intravenous administration of steroids within 5 days., Conclusion: Previous reports of Mooren's-type ulcers in patients with chronic hepatitis C have shown a response to interferon alfa-2b, but not to oral corticosteroid therapy. Given the medical contraindications to interferon use in selected patients and the cost, we suggest a trial of high-dose systemic steroids as a possible therapy.

The unique structure of the human eye as well as exposure of the eye directly to the environment renders it vulnerable to a number of uncommon infectious diseases caused by fungi and parasites. Host defenses directed against these microorganisms, once anatomical barriers are breached, are often insufficient to prevent loss of vision. Therefore, the timely identification and treatment of the involved microorganisms are paramount. The anatomy of the eye and its surrounding structures is presented with an emphasis upon the association of the anatomy with specific infection of fungi and parasites. For example, filamentous fungal infections of the eye are usually due to penetrating trauma by objects contaminated by vegetable matter of the cornea or globe or, by extension, of infection from adjacent paranasal sinuses. Fungal endophthalmitis and chorioretinitis, on the other hand, are usually the result of antecedent fungemia seeding the ocular tissue. Candida spp. are the most common cause of endogenous endophthalmitis, although initial infection with the dimorphic fungi may lead to infection and scarring of the chorioretina. Contact lens wear is associated with keratitis caused by yeasts, filamentous fungi, and Acanthamoebae spp. Most parasitic infections of the eye, however, arise following bloodborne carriage of the microorganism to the eye or adjacent structures.

This study investigates a gelfoam disc device as an alternative topical ophthalmic drug delivery system for pupillary dilation in humans. Gelfoam (Pharmacia & Upjohn) discs were impregnated with 0.60 mg of tropicamide racemate and 1.7 mg of 1-phenylephrine hydrochloride by an ethanol solvent evaporation method. Twenty randomly selected human subjects received baseline examinations, including blood pressure, pulse rate and biomicroscopy of the ocular surface. One impregnated gelfoam disc was placed in the inferior fornix of a randomly selected eye. Simultaneously, the fellow eye was treated with two topically administered drops, one from a phenylephrine hydrochloride 2.5% solution and one from a tropicamide 1% solution. A single, masked observer measured the pupillary diameter in both eyes at various time intervals under constant ambient conditions. Administration of the topical drops was repeated in the fellow eye. At maximum pupillary dilation, the disc was removed, and a post-dilation biomicroscopic exam was performed. Blood pressure and pulse rate were rechecked. The gelfoam-treated eyes' median change in dilation diameter was approximately 25% greater (a two-fold increase in pupillary area) (p< 0.001) at 15.2 min (median time to maximum dilation) than the topically treated fellow eyes. The median change in systolic blood pressure (+1.0 mmHg) and diastolic blood pressure (-1.0 mmHg) was not statistically significant (p>0.1). The average pulse rate was decreased 7 beats per minute (p=0.004). A gelfoam disc may serve as an ophthalmic drug delivery system for pupillary dilation or as a model for other multiple-dose topical drugs.

A Gelfoam based ocular device containing 1.7 mg of phenylephrine and 0.6 mg of tropicamide was formulated and evaluated for pupillary dilation in rabbits. The manufacturing procedure is fairly simple and the required excipients are inexpensive. The in vivo results show that the mydriatic response produced by the proposed device is larger and longer lasting than that produced by eyedrops with an equivalent amount of phenylephrine and tropicamide. The results reported in this study, along with those of previous studies, imply that Gelfoam(R) is a versatile drug carrier for either local or systemic drug delivery via the ophthalmic route., (Copyright.)

Background: Anaphylaxis is a potentially fatal complication of fluorescein angiography. It is diagnosed by clinical signs. Serum beta-tryptase serves as a specific indicator of mast cell activation and of anaphylactic shock that can be detected by radioimmunoassay., Method: This is a report on a 48-year-old woman who developed anaphylaxis during fluorescein angiography. This study investigates the role of beta-tryptase in anaphylactic shock resulting from intravenous fluorescein angiogram., Results: A serum sample of beta-tryptase collected at the time of an adverse reaction to fluorescein angiography was determined by radioimmunassay to be elevated above 20 ng/ml (normal level <1 ng/ml). This indicates massive mast cell activation and anaphylactic shock., Conclusion: This case is the first in which elevated levels of beta-tryptase in serum indicated that the systemic adverse reaction to fluorescein was mast cell dependent. Additionally, beta-tryptase levels can be assayed to detect anaphylactic reactions several hours after a precipitating event.

Purpose: To report two patients with ocular burns from explosion of microwaved eggs that caused direct vision-threatening corneal damage., Methods: The initial examination and treatment of both patients are described., Results: Both patients were initially examined with severe decrease in the visual acuity of both eyes. The first patient required limbal conjunctival transplantation and a subsequent penetrating keratoplasty in the right eye and prolonged treatment of superficial keratitis in the left eye. The second patient sustained bilateral corneal epithelial defects and unilateral intrastromal hemorrhage., Conclusions: Exploding microwaved eggs can cause notable thermal injury to the eyes. The public should be educated about the dangers of cooking eggs in the microwave oven.

A 31-year-old man with the acquired immunodeficiency syndrome presented with herpes zoster ophthalmicus on the right. Five days after he began treatment for the zoster pseudodendrites and skin lesions, he developed superficial punctate keratitis, uveitis, and crusting skin lesions in the left eye. After treatment, the ocular lesions resolved in both eyes without incident. The bilateral manifestation of herpes zoster ophthalmicus is a result of the increased severity associated with immunosuppression caused by the human immunodeficiency virus.

Background: Anterior segment findings in AIDS patients presenting with cytomegalovirus (CMV) retinitis have not been specifically addressed in the American literature., Methods: Our study evaluated 21 AIDS patients with CMV retinitis., Results: Nineteen (90%) of these patients exhibited corneal endothelial deposits concurrent with CMV retinitis. The endothelial deposits were microscopic, opaque, linear flecks arranged in a reticular-like fashion. Of 42 eyes evaluated, 32 (76%) demonstrated active CMV retinitis. Corneal endothelial deposits were noted in 26 (81%) of the 32 eyes with retinitis. These corneal endothelial deposits were absent in the eyes which did not have CMV retinitis., Conclusion: Meticulous examination of the retina of an HIV-positive or AIDS patient who presents with reticularly arranged, linear, flecked corneal endothelial deposits should be performed to ensure that the diagnosis of CMV retinitis can be ruled out.

Purpose/methods: We examined the mast cells in 12 pterygium specimens of patients who underwent primary excisions and the conjunctival specimens of ten normal age-matched control subjects., Results/conclusion: The mean mast cell count per cubic millimeter was twice as high in the pterygium specimens as in the control specimens. Mast cell proliferation and activation may contribute to the pathogenesis of pterygium formation.

Bilateral exudative macular detachments were present on a 64-year-old diabetic Caucasian male who presented with bilateral blurring of vision. Besides the exudative macular detachments there was no diabetic retinopathy or congestive retinopathy, and a previous fluorescein angiogram revealed no focal leakage. Laboratory investigation, bone marrow biopsy, and a bone survey revealed the diagnosis of multiple myeloma.

An 8-year-old boy presented with symptoms compatible with a right internuclear ophthalmoplegia. Magnetic resonance imaging showed a high-intensity signal on T2-weighted images at the level of the medial longitudinal fasciculus. Laboratory evaluation was positive only for sickle cell trait. Sickle cell trait is an uncommon cause for brainstem infarction.

We report a patient with AIDS who developed rapidly progressive, acute outer retinal necrosis. Cytomegalovirus etiology was proposed as a possibility in view of the histopathologic identification of the virus in the fellow concomitantly affected eye. Treatment with ganciclovir resulted in disappearance of the posterior pole lesions and inactivation of the peripheral lesions. We suggest that ganciclovir be used as soon as this condition is suspected in order to optimize the outcome.

Wegener's granulomatosis is a life-threatening condition characterized by the triad of necrotizing granulomatous inflammation of the respiratory tract, vasculitis, and glomerulonephritis. During early stages of the disease, some patients may present with only one or two components of the triad. Other patients may be affected by the limited form of Wegener's which lacks the renal involvement. We report an 18-year-old female who initially presented with bilateral dacryoadenitis. A lacrimal gland biopsy was consistent with Wegener's granulomatosis. A few months later she developed glomerulonephritis and responded well to cyclophosphamide treatment. Wegener's granulomatosis remains a diagnostic challenge and is frequently underdiagnosed. Early diagnosis is crucial in saving many lives because the disease is potentially curable with cytotoxic therapy. Dacryoadenitis may be one of the initial presentations of Wegener's granulomatosis.

Tryptase, a neutral endoprotease, is secreted by activated mast cells in human tissues. Tryptase levels in various body fluids have been used as an indicator of mast cell activation. The authors determined tryptase levels in unstimulated tears collected from the following groups of patients: (1) normal control, (2) nonallergic ocular inflammation, (3) asymptomatic seasonal allergic conjunctivitis, (4) symptomatic seasonal allergic conjunctivitis, (5) vernal conjunctivitis, and (6) contact lens-associated giant papillary conjunctivitis. They also assessed the release of tryptase into the tear fluid after provoking the conjunctiva with (7) allergens, (8) compound 48/80, and (9) rubbing. Tryptase levels were elevated in tears of patients with active ocular allergy and also increased after provoking the conjunctiva with allergens in atopic subjects and with compound 48/80 and rubbing in nonatopic subjects. Tryptase levels in tear fluid may prove useful as a clinical indicator of mast cell involvement in ocular allergic disorders. In provocation experiments, tryptase levels may be used to evaluate and compare different mast cell stabilizing agents.

Soft contact lenses are bathed with tear components during wear and surface deposits accumulate. This report shows that Pseudomonas aeruginosa adheres to the surface of worn extended wear contact lenses in direct proportion to the amount of lens surface deposits as determined by the Rudko method (P less than .05). More hydrophobic bacteria adhered 10 times greater than bacteria which were relatively hydrophilic (P less than .005). The effect upon bacterial adhesion of enzyme and surfactant cleaning of worn extended wear contact lenses was investigated by two independent methods: one involving a high inoculum and the other a low inoculum of Pseudomonas. Treatment of worn lenses with commercially available enzymes such as papain and pork pancreatin as well as treatment with neuraminidase, mannosidase, glucosidase and alkylcarboxylic acid for as long as 48 hours failed to reduce subsequent bacterial adhesion in both the high and low inoculum experiments. We conclude that soft contact lens surface deposits are a major determinant in the adhesion of Pseudomonas aeruginosa to the worn lens surface and that enzyme cleaning of worn lenses does not significantly reduce bacterial adhesion.

Extended wear soft contact lenses are associated with an increased incidence of Pseudomonas aeruginosa keratitis. Because the first step in the pathogenesis of this disease is adherence of the microorganism to the corneal surface, we studied the effect of soft contact lens wear on the adherence of P. aeruginosa to the cornea. Rabbits were fitted for extended wear soft contact lenses in the left eye, and the right eye served as a control. Both eyes were then closed with a partial tarsorrhaphy. After 1-5 days of wear, the lenses were removed and the corneas of the left and right eye were removed. Differences in the number of adherent Pseudomonas and in lectin binding to lens-wearing corneas and non-lens-wearing corneas were determined. After 1, 3, and 5 days of soft contact lens wear, there was a significant increase in the number of P. aeruginosa adherent to the lens-wearing cornea. Three to eight times as many bacteria adhered to the lens-wearing eye as compared with the control eye (p less than 0.05). In addition, a soft contact lens placed in the eye followed by the immediate application of P. aeruginosa resulted in an eightfold increase in adherence of bacteria to the lens-wearing cornea (p less than 0.05). Lens wear also led to an increase in binding of concanavalin A (Con A), wheat germ agglutinin (WGA), and Maclura pomifera agglutinin (MPA) to surface epithelium covered by the lens. These corneal epithelial changes induced by extended wear soft contact lenses may provide some insight as to why soft contact lens wearers are predisposed to Pseudomonas keratitis.

The distribution and concentration of human tryptase-positive, chymase-negative mast cells (MCTS) and tryptase-positive, chymase-positive mast cells (MCTCS) were examined in conjunctival biopsy specimens from subjects with active vernal conjunctivitis (VC; n = 7), giant papillary conjunctivitis (GPC; n = 6), and allergic conjunctivitis (AC; n = 5), and from asymptomatic soft-contact lens wearers (SCL; n = 6) and normal control individuals (n = 19). Carnoy's fixed tissue sections were stained by a double immunohistochemical method using a biotinylated mouse monoclonal antichymase antibody with immunoperoxidase, followed by an alkaline phosphatase-conjugated mouse monoclonal antitryptase antibody. Epithelial mast cells (MCs) were found in all VC specimens (96% MCTCs) and in three GPC specimens (100% MCTCS) but in none of the other groups. In the substantia propria, MCTCS were the predominant type of MC observed in all specimens, accounting for 95% of the total MCs in the normal control group and 100% of the total MCs in the subjects with GPC, AC, and SCL. No significant differences were found in the total MC concentration of the substantia propria among the normal control subjects (11,054 +/- 6327 MCs per cubic millimeter), subjects in the SCL group (13,168 +/- 4685 MCs per cubic millimeter), subjects with GPC (17,313 +/- 8500 MCs per cubic millimeter), and subjects with AC (15,380 +/- 5660 MCs per cubic millimeter). In subjects with VC, the percentage of MCTs (18% +/- 13%) and the total MC concentration (24,689 +/- 18,978 MCs per cubic millimeter) in the substantia propria were significantly increased as compared to the normal control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Commercial preparations of two topical ophthalmic vasoconstrictors were evaluated for whitening ability, duration of action, tolerance, and rebound vasodilation in 11 normal volunteers. Both 0.02% naphazoline HCI and 0.05% tetrahydrozoline HCI significantly reduced baseline redness after a single use (Part I); however, naphazoline produced significantly more whitening than did tetrahydrozoline. Only naphazoline retained its whitening ability after ten days (Part II). The level of redness remained significantly below baseline for eight hours after a single use of either vasoconstrictor and for six hours after multiple use of naphazoline. The diminished effectiveness of tetrahydrozoline after the ten-day test period may encourage its overuse. Neither vasoconstrictor produced rebound vasodilation after discontinuation of use.

We present three adult patients having classic symptoms of ocular allergy with findings confined to the limbus in all eyes. Findings in the cornea and the rest of the bulbar and tarsal conjunctivae were within normal limits. Case 1 had numerous limbal follicles; Case 2 had limbal chemosis 360 degrees; and Case 3 had superior perilimbal conjunctival injection, chemosis, and micropannus formation. Limbal scrapings from all patients revealed abundant eosinophils. There was marked clinical improvement after topical cromolyn sodium 4% treatment. Since the limbus was the only structure involved, the diagnosis of "allergic limbitis" was made. We feel that the limbus is an overlooked structure during ocular examination. As in our three cases, the limbus may be the only area involved in ocular allergy. A careful examination of the limbus may provide important clues for the diagnosis of many ocular inflammatory conditions.

Ten isolates of Pseudomonas aeruginosa obtained from the corneas of patients with Pseudomonas keratitis adhered to soft contact lenses in significantly greater numbers than did six isolates from other body sites (P less than .05). However, there was no predominant serotype among the 10 corneal isolates tested. Isolates grown statically in broth at 37 degrees C formed a pellicle and adhered two times as much to contact lenses as did isolates grown in broth while shaking which did not form a pellicle (P less than .01). The more adherent isolates (grown at 37 degrees C) were shown to be more hydrophobic than the less adherent bacteria (grown at 26 degrees C) by their propensity to accumulate at the interface between hexadecane and saline and their movement into polyethylene glycol from dextran. These corneal isolates agglutinated erythrocytes, a process that was inhibited by dilute solutions (as low as 0.01%) of three commonly used surfactants. These same surfactants inhibited the adherence of Pseudomonas aeruginosa to soft contact lens surfaces by as much as 52%. It is concluded that hydrophobic interactions may significantly contribute to the ability of Pseudomonas aeruginosa to adhere to contact lenses.

Products of arachidonic acid metabolism, prostaglandins and leukotrienes, play an important role in ocular inflammation. In this study, we investigated the efficacies of the cyclo-oxygenase inhibitors (aspirin, indomethacin, and piroxicam) and the lipoxygenase inhibitors (N-hydroxy-arachidonamide (AH) and phenidone) in reducing ocular inflammation induced by arachidonic acid. Administering arachidonic acid topically (0.50% for rabbits and 0.25% for humans) produced a simple model for evaluating the effects of inhibitors on prostaglandins. In rabbits, aspirin, piroxicam and indomethacin all blocked lid closure and chemosis significantly. In humans, aspirin and indomethacin significantly blocked arachidonic acid-induced conjunctival injection. Neither AH nor phenidone blocked any of the signs of ocular inflammation in rabbits or humans. Further testing of phenidone in the presence of the calcium ionophore, ionomycin, also proved negative. Species specificity in arachidonic acid metabolism may account for the different results in humans and rabbits. This model may be a useful tool for comparing the relative efficacies of topical cyclo-oxygenase inhibitors in treating ocular problems.

The adherence of microorganisms to contact lenses may be an important initial step in the pathogenesis of contact lens-associated infectious keratitis. Using a strain of Candida albicans whose interaction with various polymers has been well characterized we systematically investigated the adherence of this pathogen to hard hydrophobic and soft hydrophilic extended-wear contact lenses. Yeasts adhere to the hydrophobic lenses in direct proportion to the wetting angle of the lens whereas yeasts adhere to the hydrophilic lenses in direct proportion to the water content of the lens. Tear proteins such as albumin, lactoferrin, and lysozyme in addition to fibronectin enhance yeast adherence to both types of lenses (P less than 0.01). Concanavalin A reduces adherence of yeasts to both lens types (P less than 0.01). Among tear components however, only mucin (0.5%) consistently reduced yeast adherence to both lens types. Hydrophilic extended wear lenses worn for at least 28 days by normal patients consistently had greater adherence of yeasts than unworn lenses of the same type, often as much as ten-fold or greater yeasts/mm2 of lens surface area (P less than 0.05). These investigations indicate that tear components both in solution and adsorbed to the lens surface enhance microorganism adherence to contact lenses.

Hyper-IgE syndrome (HIE) appears to be related to an immunoregulatory imbalance characterized by severe deficiency of suppressor T cells, elevated levels of IgE antibodies, and repeated infection of various organ systems. We report the association of HIE syndrome in two definite cases and one probable case of vernal conjunctivitis. This association suggests that T cell-mediated imbalance may be one factor in the pathogenesis of vernal conjunctivitis.

Prostaglandin D2 is a secondary mast cell mediator that causes redness, chemosis, mucous discharge, and eosinophil chemotaxis in the eye. It may play an important role in allergic ocular disease. Although histamine is a key mediator of allergic inflammation, antihistamine therapy provides only symptomatic relief. We added aspirin therapy to the treatment regimen of three patients with vernal conjunctivitis. Aspirin acetylates the enzyme cyclooxygenase, thereby preventing the formation of prostaglandin D2. Within two weeks after initiation of aspirin therapy, we noted dramatic improvement in conjunctival and episcleral redness and resolution of keratitis and limbal infiltration. We recommend a trial of oral aspirin as adjunctive therapy for intractable cases of vernal conjunctivitis.

The eye is a mirror that reflects pathologic changes occurring in many organs. The present paper presents eye changes in renal disease including hereditary progressive nephritis, cystic disease of the kidney, cystinosis, and diffuse mesangial sclerosis. It also touches on these changes in some syndromes with major renal involvement.

The adherence of Pseudomonas aeruginosa to extended-wear soft contact lenses (EWSCLs) may be an important initial step in the pathogenesis of EWSCL-associated infectious keratitis. P. aeruginosa tend to adhere more to worn EWSCLs than unworn EWSCLs (P less than 0.05). Normal tear components such as aqueous solutions of albumin, lysozyme, and lactoferrin all significantly enhance adherence of P. aeruginosa to unworn EWSCLs often by as much as 300%. The presence of a 1% solution of sialic acid in the bathing medium significantly reduces the adherence of P. aeruginosa to both unworn and worn lenses. Inhibition of bacterial adherence could also be achieved with the addition of mucin (which contains terminal sialic acid residues in its major sugar chains). Therefore, selective adherence by P. aeruginosa to a specific sugar (sialic acid) may be important in the initial attachment of the bacterium to soft contact lenses.

Three different commercial extended-wear soft contact lenses worn continuously by patients for at least 28 days were stained with fluorescein isothiocyanate-labeled lectins. These lectins detected the presence of alpha-linked or beta-linked D-mannose, D-glucose, D-galactose, L-fucose, N-acetyl-D-glucosamine, N-acetyl-D-galactosamine, and N-acetyl neuraminic acid (sialic acid) on the surfaces of the contact lenses. These saccharides are bound to other sugars that likely account for an integral part of glycoprotein and/or glycolipid deposits on lens surfaces. These tear deposits may contribute to the chemical spoilage of the lens and, furthermore, may serve as specific receptors for pathogenic microorganisms commonly implicated in extended-wear soft contact lens-associated infectious keratitis.