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AIM: To report the outcomes of anterior vitrectomy using high speed cutter for scleral fixated intraocular lens (SFIOL) implantation in patients with posterior capsular rupture. METHODS: Medical records of 51 patients with posterior capsular rupture who received high speed cutter anterior vitrectomy via limbal incision with SFIOL implantation from June 2011 to December 2013 were reviewed retrospectively for visual outcomes and complications. RESULTS: Totally 51 eyes of 51 patients were identified (23 males and 28 females). Mean age at surgery was 67.2±15y (range 27-91y), with mean follow-up of 23±8.2mo (range 12-40mo). The 49 (96.1%) eyes had improvement or unchanged of final postoperative visual acuity. The most common complication was vitreous haemorrhage (5.9%) and transient rise in intraocular pressure (5.9%) which all spontaneously resolved. CONCLUSION: High speed cutter anterior vitrectomy via limbal incision is a safe and effective method for those with posterior capsular rupture for SFIOL implantation.

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BACKGROUND/AIMS: To compare the long-term outcomes of primary pterygium surgery with combined conjunctival rotational autograft and mitomycin C (CRA-MMC), mitomycin C alone (MMC) and limbal conjunctival autograft (LCAU). METHODS: The outcomes of primary pterygium excision followed by conjunctival rotational autograft (CRA) combined with intraoperative 0.02% MMC for 5 min (group 1, CRA-MMC, n=61) were compared with historical control groups consisting of, pterygium excision with MMC (group 2, n=47), and, pterygium excision with limbal conjunctival autograft (LCAU) (group 3, n=29). The main outcome measures were recurrence rate and complications. RESULTS: The mean follow-up period was 101±3 months, 138±2 and 137±2 months in the CRA-MMC, MMC and LCAU groups respectively. Recurrence was noted in one patient (1.6%) in the CRA-MMC, 12 patients with MMC (25.5%) and 2 patients with LCAU (6.9%). The difference in recurrence rate between CRA-MMC and MMC was statistically significant (p<0.001). Early postoperative complications included 3 conjunctival cysts (1 from the CRA-MMC, 2 with MMC alone), 2 symblephara (1 in the MMC group, 1 in the LCAU group), and 1 granuloma in the CRA-MMC group. CONCLUSIONS: Pterygium excision followed by CRA-MMC or LCAU are effective means of preventing recurrence. The use of CRA-MMC in pterygium excision may be considered for cases where conventional autograft harvesting is contraindicated or when large grafts for double-head pterygium are required.

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The purpose of this study was to assess the long-term outcome of patients with symptomatic bullous keratopathy after amniotic membrane transplant. A retrospective cohort study includes that 20 patients with symptomatic bullous keratopathy, who have underwent amniotic membrane transplant at the Department of Ophthalmology & Visual Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital & Alice Ho Miu Ling Hospital, Hong Kong between 04/1998 and 06/2011, were invited back. Clinical examination was performed, including, pain score assessment (pain score out of 10), epithelial healing, and vision. A total of 21 eyes of 20 patients returned for our study. The majority of eyes experienced pain reduction (94 %), with a significant mean pain score difference of 6.8 ± 2.6, 2-tail p < 0.001 (99 % CI 4.9-8.7). The mean pre-operative and post-operative pain scores were 7.3 ± 2.9 and 0.5 ± 1.0, respectively. 16 eyes (76 %) were completely pain free, and 10 eyes (47 %) remained symptom free after a mean follow-up of 39.0 ± 36.3 months (range 5-171 months). The median epithelial healing time was 2 weeks (range 1-20 weeks). Amniotic membrane transplant may be considered as a longer-term treatment for bullous keratopathy patients, especially in patients with poorer visual prognosis, but it may also be used as an interim measure for patients awaiting corneal transplant.

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BACKGROUND: Endothelial keratoplasty (EK) is used increasingly for the management of cases with endothelial dysfunction. Long-term outcomes of the surgery are not widely reported in the literature. We report our experience of EK in Chinese eyes at a University teaching hospital. METHODS: Retrospective analysis was performed for all cases of EK performed between 2005 and 2009. Data analyzed included indication for surgery, associated surgical procedures, complications, best-corrected visual acuity (BCVA) and overall graft survival. RESULTS: Overall, 22 eyes of 21 patients underwent EK (13 males, 8 females, mean age 71.8 ± 11.3 years). Pseudophakic bullous keratopathy was the leading indication for surgery (n = 12) followed by Fuchs' endothelial dystrophy (n = 4), or both (n = 3). Other indications for surgery included failed penetrating keratoplasty (n = 2) and endothelial decompensation due to multiple surgeries (n = 1). Triple procedure was performed in 5 (22.7%) cases. Complications were noted in the form of postoperative interface hemorrhage (n = 2, 9%) and graft dislocation (n = 1, 4.5%). The mean postoperative endothelial cell density was 1069 ± 585.8 cells/mm(2). The mean postoperative pachymetry was 675.8 ± 108.5 µm. The mean preoperative and postoperative intraocular pressure was 11.3 ± 3.2 and 13.9 ± 4.5 mmHg respectively. At the last follow-up (mean, 47.4 ± 13.7 months), BCVA was ≥20/70 in 9 (40.9%) cases. Causes of poor BCVA included primary graft failure (n = 4), graft decompensation (n = 4), advanced glaucoma (n = 2) and irreversible graft rejection (n = 2). Graft remained clear in 12 (54.5%) cases at the last follow-up. Average graft survival was 19.7 ± 17.7 months (median 17.5 months). CONCLUSIONS: Nearly half of the EK grafts in our study survived over a period of five years. Graft failure, glaucoma and graft rejection were the main causes of poor graft survival.

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PURPOSE: Implantation of a scleral-fixated intraocular lens (SFIOL) for the surgical management of aphakia in the absence of capsular support is a safe procedure with a low risk of complications in the early postoperative period. However, data on long-term functional outcome are limited. The purpose of this study is to assess the long-term outcome and complication profile of SFIOL implantation in a cohort of Chinese patients. METHODS: All patients who had undergone primary or secondary SFIOL implantation between 1997 and 2008 were retrospectively reviewed for visual outcomes and complications. Patients' demographic data and information on baseline preoperative visual acuity, indication for surgery, postoperative complications, latest postoperative visual acuity and indication for any subsequent surgical procedures were collected and analysed. RESULTS: 104 eyes of 99 patients (51 males and 48 females) were identified. Mean age at surgery was 67.1 ± 13 years (range 32-88 years), with a mean follow-up of 73.4 ± 43 months (range 12-180 months). 72% of patients had unchanged or improved final postoperative visual acuity. 25 of 104 eyes (24.0%) had postoperative complications, with suture-related complications being the most common. 13 eyes (12.5%) required further procedures for postoperative complications. Suture breakage leading to lens subluxation occurred in two eyes (1.9%). CONCLUSIONS: SFIOL implantation is valuable for the management of aphakia in the absence of capsular support, and our visual outcomes and complication rates are comparable to other case series. The long-term outcomes and safety profile are favourable, but potential long-term suture-related problems should be discussed with the patients before surgery.

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Penetrating keratoplasty is the replacement of a diseased cornea with a full-thickness donor graft. In the last century, this 'gold standard' procedure was long established as the treatment of choice for various corneal diseases. The classical indications for a penetrating keratoplasty entailed optical, tectonic, therapeutic, and cosmetic issues. Over the past decade however, surgical advances have now enabled operations involving the cornea to be performed with a major shift in emphasis, such that penetrating keratoplasty has given way to lamellar (layered) keratoplasty. This review provides the latest updates on developments in the field of corneal transplantation and the nomenclature of different types of component surgery, particularly from the perspective of Hong Kong.

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PURPOSE: To report the occurrence and management of recurrent hemorrhage after Descemet stripping endothelial keratoplasty (DSEK) in a patient with pseudophakic bullous keratopathy. METHODS: An 84-year-old Chinese woman on two oral antiplatelet drugs underwent DSEK in her left eye. Preoperative best-corrected visual acuity was 20/30 OD and 14/200 OS. Intraoperative bleeding was noted from the iris root. Surgery was completed uneventfully, and interface was thoroughly irrigated in the end. Slit lamp examination on the first postoperative day showed a dense interface hemorrhage and an intraocular pressure of 24 mm Hg. Repeat interface irrigation was carried out on postoperative day 4, but the hemorrhage appeared again on the following day. Donor lenticule was well apposed to the corneal stroma, and visual acuity was hand motions in the operated eye. No further surgical interventions were performed. Corticosteroid eye drops were continued four times a day in the operated eye, and the patient was advised weekly follow-up. RESULTS: Over the next 4 weeks, the interface blood gradually started to clear from the central cornea. At the end of 4 months postoperatively, the interface hemorrhage disappeared completely. A final best-corrected visual acuity of 20/80 was achieved. Specular microscopy revealed an endothelial cell density of 1375 cells/mm2. CONCLUSIONS: Interface hemorrhage is a known complication after DSEK surgery. Recurrent hemorrhage may be expected in patients on oral antiplatelet treatment. In cases without associated graft dislocation, conservative management can still result in good visual outcome.

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OBJECTIVE: To compare the safety profiles of intracameral cephalosporins in cataract surgery. PATIENTS AND METHODS: In this controlled trial, 129 patients were randomized to one of four groups to receive 1 mg of one of three cephalosporins - cefazolin, cefuroxime, or ceftazidime, or normal saline - given intracamerally during cataract surgery. Central endothelial cell density (ECD) and retinal center point thickness (CPT) were determined by specular microscopy and ocular coherence tomography, respectively, before and at 3 months after surgery. RESULTS: There were no statistical significant differences in the changes of ECD and CPT between eyes receiving intracameral cephalosporin and control. CONCLUSION: The use of intracameral cefazolin, cefuroxime, or ceftazidime (1 mg in 0.1-mL solution) at the time of cataract surgery had no significant effect on ECD and CPT postoperatively.

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PURPOSE: To describe the novel use of combined conjunctival rotational autograft (CRA) and intraoperative 0.02% mitomycin C (MMC) in the treatment of primary pterygium and to evaluate its safety and efficacy. METHODS: Prospective interventional case series comparing with historical controls was conducted. Patients with primary pterygium underwent pterygium excision, MMC was applied to the scleral bed after the surface conjunctiva was harvested, and the CRA was sutured back with a 180-degree rotation. Patients were followed for a minimum of 1 year. RESULTS: Sixty-seven eyes from 67 patients participated in the study, of which 31 (46.3%) were men and 36 (53.7%) were women. The mean age was 58 +/- 10.6 years, (range 36-79 years). There were 2 recurrences (3%), one occurring at month 3 and the other at month 9. Compared with historical controls, CRA-MMC resulted in significantly fewer recurrences than MMC alone (P = 0.005) when adjusted for age and was equally effective when compared with limbal-conjunctival autografts. The main postoperative problem was graft injection, which was noted in 41 eyes (61%) at 1 year. CONCLUSIONS: To the best of our knowledge, this was the first study on the combined use of CRA and MMC in the treatment of primary pterygium. CRA with MMC was found to be effective in the prevention of recurrence. Although injection remained as a cosmetic concern, it was a safe alternative to limbal-conjunctival autograft in cases where mobilizing autologous conjunctival tissue would not be feasible.

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We report a case of paraneoplastic pemphigus (PNP) as an uncommon but severe cause of cicatrising conjunctivitis. Initially diagnosed as drug eruptions, the patient's condition did not improve despite cessation of chemotherapy. Immunohistological confirmation of PNP has led to the use of combined oral prednisolone and intravenous immunoglobulin. Her ocular conditions stabilised with complete recovery of vision. PNP is a rare disease that can present with ocular involvement. Ophthalmologists should play an active role in monitoring and treatment of ocular surface complications such as symblepharon formation, severe dry eye and epithelial breakdown. Vigorous and prompt treatment is the key to successful prevention of irreversible and blinding complications. The atypical feature in this case is the presence of eosinophilic infiltration on histology that is a feature of allergic aetiologies rather than classical PNP.

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PURPOSE: To study the relationship between pupil size and light intensity using the Procyon pupillometer. SETTING: University based clinic. METHODS: In this retrospective study, 20 consecutive patients had pupil size assessment with the Procyon pupillometer under 3 different light conditions--4, 0.4, and 0.04 lux. Correlation was established using the log unit of the light intensity and pupil size. RESULTS: The correlation coefficient for the association between pupil size and log unit of light intensity in all eyes was significant (P<.001). The mean correlation coefficient for the association between pupil size and log unit of light intensity in all patients was 0.968 +/- 0.089 (SD) in the right eye and 0.970 +/- 0.031 in the left eye. CONCLUSION: The linear relationship between the pupil size and the log unit of the light intensity showed a tight correlation in all cases. These results can be useful in the comparing pupil size with pupillometers that work under different light conditions.

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PURPOSE: To report the in vivo confocal microscopic findings of posterior polymorphous endothelial dystrophy (PPED). METHODS: Four patients with PPED from 2 unrelated families and 2 asymptomatic children of an index patient were included in this observational case series. The eyes of the 6 subjects were examined by confocal light microscopy. RESULTS: Confocal microscopy demonstrated craters, streaks, and cracks over the corneal endothelium surface. Pleomorphism and polymegathism were present in eyes with PPED. Guttae and clusters of abnormal endothelial cells were also identified in corneas of these PPED patients. These findings were absent in eyes without clinical manifestations of PPED. CONCLUSIONS: In vivo confocal microscopy is potentially useful for excluding suspected cases of subclinical PPED. Abnormalities in the Descemet membrane and endothelium were observed.

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A 46-year-old man developed surgically induced necrotizing scleritis (SINS) 7 months following uneventful primary bare sclera pterygium excision. The patient underwent two scleral patch grafts for SINS but despite the use of cyclophosphamide and azathioprine, the scleral patch grafts failed within 1 month of surgery on both occasions. Tacrolimus was used for his third scleral patch graft. No recurrence of necrotizing scleritis was observed for 2 years. Tacrolimus may be considered as a valuable adjunctive immunosuppressant in the management of resistant necrotizing scleritis.

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A 56-year-old Chinese man diagnosed with Thygeson's keratitis by clinical biomicroscopy was examined using a tandem scanning confocal microscope. Among normal superficial epithelial cells, clumps of markedly enlarged epithelial cells were identified. Multiple highly reflective filamentary structures were observed in the deeper layers. Most of these lesions were linear; some demonstrated curled ends and others demonstrated branching lesions with 'sprouts'. No inflammatory cells were evident in the areas of corneal stroma sampled. In vivo confocal microscopy may be helpful in the diagnosis of Thygeson's superficial keratitis. To the best of our knowledge, we report the first in vivo confocal images of focal desquamation of epithelium and intraepithelial hyper-reflective linear lesions in English literature.

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OBJECTIVE: Orthokeratology is a process by which the corneal curvature is flattened by sequentially fitting rigid gas permeable contact lenses of decreasing central curvature. There has been a resurgence of interest with the recent introduction of reverse geometry lenses. Although promising results have been described in reducing the myopic refractive error, the use of these lenses can be associated with corneal problems, as reported in this case series. DESIGN: Observational case series. PARTICIPANTS: Six children with orthokeratology-related corneal ulcers. METHODS: Consecutive cases of orthokeratology lens (OKL)-related corneal ulcers in children presented to a tertiary referral center (March 1999-June 2001) were reviewed. MAIN OUTCOME MEASURES: Preinfection and postinfection visual acuity, refraction, any organisms identified. RESULTS: Six children between the ages of 9 and 14 years (mean = 12.1) were treated. The male:female ratio was 1:5. All cases were unilateral, with equal numbers of left and right eyes. All children wore the OKL at night for a duration of 8 to 12 hours, with the onset of infection between 3 and 36 months (mean = 16.6) of OKL wear. All of the patients suffered a resultant best-corrected visual acuity loss. Five of the 6 cases were culture positive for Pseudomonas aeruginosa. CONCLUSIONS: In view of the temporary benefits of orthokeratology, together with a known increased risk of infection associated with overnight lens wear, parents of children considering orthokeratology must be informed and warned of the potential for permanent loss of vision. The ophthalmic community should have a heightened awareness of the associated complications.

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PURPOSE: To report a case of orthokeratology lens-related Pseudomonas corneal ulcer in an adult. METHODS: Case report. RESULTS: A 37-year-old man presented with a 1-day history of painful red eye. He was a soft contact lens wearer before he started on nocturnal orthokeratology lens wear of 8 to 10 hours per night 9 months ago. Corneal scraping sent for culture revealed a heavy growth of Pseudomonas aeruginosa. The patient was treated with intensive topical fortified tobramycin and ceftazidime drops. The ulcer healed with a residual paraxial corneal scar. Although his best-corrected visual acuity (BCVA) recovered from finger counting (8/200) at presentation to 20/30, he suffered visual loss from a premorbid BSCVA of 20/15. His contrast sensitivity (Vector Vision CSV 1000 test) performance was also worse than his fellow eye. CONCLUSION: Nocturnal orthokeratology lens wear may be associated with an increased risk of infection.

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PURPOSE: To describe bilateral conjunctival chemosis and central serous chorioretinopathy in a patient with graft-vs-host disease after bone marrow transplant. DESIGN: Interventional case report. METHODS: A 45-year-old Chinese woman developed blurring of vision 16 days after bone marrow transplant for multiple myeloma. She had graft-vs-host disease 11 days after bone marrow transplantation. On examination, vision was 0.6 in the right eye and 0.3 in the left eye. Bilateral conjunctival chemosis and multiple central serous chorioretinopathy were present. RESULTS: Treatment of graft-vs-host disease with high-dose systemic corticosteroid and cyclosporin led to the resolution of the conjunctival chemosis and central serous chorioretinopathy 3 months later. Visual acuity improved to 0.8 in both eyes. CONCLUSION: Choroidal infiltrate in graft-vs-host disease may contribute to choroidal hyperpermeability, which leads to the development of central serous chorioretinopathy in postbone marrow transplant patients.

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OBJECTIVE: To analyze surgical outcomes of primary rhegmatogenous retinal detachment in high myopes. MATERIALS AND METHODS: Medical records of 201 patients who underwent vitreoretinal surgeries for primary retinal detachments were reviewed. Fifty-two eyes of 51 patients with at least 5.00 diopters (D) of myopia were included. RESULTS: The mean refractive error was -9.8+/-5.4 D (mean +/- SD). Macula was off in 29 (55.8%) eyes. Thirty-six (69.2%) and 16 (30.8%) eyes received scleral buckling (SB) and pars plana vitrectomy (PPV), respectively. Primary anatomical success rate was 86.1% and 75.0% in the SB and PPV group, respectively. The anatomical success rate after 2 operations was 94.4% and 100% in the SB and PPV group, respectively. Twenty-three (63.1%) patients from SB group and 10 (62.5%) patients from PPV group attained postoperative best-corrected visual acuity of 20/60 or better. CONCLUSION: The anatomical and visual outcomes of primary rhegmatogenous retinal detachment in myopes of five or more diopters seem favorable after surgery.

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