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Clinical Pearls

Alexander, Larry*

doi: 10.1097/OPX.0000000000000061

This month, “Clinical Communications,” under the clinical editorship of Editorial Board member Larry Alexander, OD, FAAO, includes color image content and optional supplementary digital content, with no cost to our authors.

Each article in this section is followed by a clinical comment by our clinical editor, emphasizing the clinical take-home message. We provide these “Clinical Pearls” of the publication following the article’s title, authors, and abstract. The full text and illustrations are found online with the colored images and any video clips.

Dr. Larry Alexander provides all of the clinical comments (“Clinical Pearls”) on each article in “Clinical Communications.” This is all part of our OVS program to enrich the clinical content of OVS and make it very accessible, in color and motion, to clinicians, readers, and authors alike.

Tony Adams, OD, PhD, FAAO

Editor in Chief

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Clinical Cases

Intravitreal Bevacizumab for Ocular Metastasis of Multiple Myeloma

Qiang Zhou, Jianhong Liang, and Hong Lu



Purpose. Multiple myeloma is the most common plasma cell tumor; however, ocular plasmacytomas are rare. Few cases of binocular metastasis have been reported. The authors review a case study using intraocular bevacizumab to treat secondary glaucoma and binocular metastasis from multiple myeloma.

Case Report. A 59-year-old woman with a 13-month history of multiple myeloma was found to have a suspected masquerade syndrome OS and subsequently developed a neovascular glaucoma within 2 months. Intravitreal bevacizumab injection OS controlled the intraocular pressure and inhibited ocular metastasis. The methods of therapy administration in this case are consistent with procedures commonly used in clinical practice when using bevacizumab to treat other etiologies, such as choroidal neovascular membranes. Lost to follow-up until 2 months later, the patient presented with ocular metastasis OD with the same changes as observed OS. Conjunctival biopsy revealed subconjunctival plasmoma OD. After intravitreal bevacizumab injection, neovascular glaucoma OD was partly controlled.

Conclusions. Secondary ocular plasmacytoma, despite its rarity, should be considered in patients with multiple myeloma. Intravitreal bevacizumab injection may be a promising treatment for ocular metastases and associated secondary or neovascular glaucoma.

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Descemet Membrane Endothelial Keratoplasty in Eyes with Glaucoma Implants

Ludwig M. Heindl, Konrad R. Koch, Franziska Bucher, Deniz Hos, Philipp Steven, Hans-Reinhard Koch, and Claus Cursiefen



Purpose. This study aims to analyze the feasibility of Descemet membrane endothelial keratoplasty (DMEK) in the management of corneal endothelial decompensation in eyes with glaucoma implants.

Case Report. A 62-year-old male patient with bullous keratopathy after trabeculectomy and Baerveldt shunt implantation for contusion glaucoma of the right eye (case 1) underwent surgical tube trimming with a DMEK procedure. A 54-year-old male patient with Descemet stripping automated endothelial keratoplasty (DSAEK) failure and dislocation in the presence of an Ahmed glaucoma valve and an artificial iris in the right eye (case 2) was treated by removal of the DSAEK graft and subsequent DMEK procedure. In both eyes, the DMEK graft could be successfully inserted, unfolded, positioned in front of the glaucoma tube, and attached to the host stroma by air injection into the anterior chamber. Postoperatively, both corneas cleared with complete graft attachment and stable glaucoma tube position. After 3 days, peripheral graft detachment occurred in case 1 and was managed successfully with one intracameral air reinjection. Case 2 revealed intraocular pressure (IOP) elevation up to 30 mm Hg in the immediate postoperative period, treated successfully by antiglaucoma medications. Within 1-year follow-up, visual acuity improved from hand movements to 20/63 and 20/32, respectively; endothelial cell density decreased by 36% and 42%, respectively; and the IOP ranged between 7 and 14 mm Hg in both cases without treatment.

Conclusions. Descemet membrane endothelial keratoplasty seems to be feasible in the management of corneal endothelial decompensation in eyes with glaucoma implants. Graft attachment, IOP, and endothelial cell density should be followed up closely.

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Latanoprost-Induced Prostaglandin-Associated Periorbitopathy

Joseph Tan and Stanley Berke



Purpose. To report, with supporting photo-documentation, cases of latanoprost-induced prostaglandin-associated periorbitopathy (PAP).

Case Series. Retrospective small case series with three cases. Chart review with photo-documentation of clinical features of prostaglandin-associated periorbitopathy resulting from latanoprost use. Patients developed involution of dermatochalasia, blepharoptosis, deepening of orbital sulci, and flattening of lower eyelid bags after a mean usage period of 6 years (3 to 8 years).

Conclusions. Latanoprost can cause PAP, although it has a lower risk and longer latency of onset than those with bimatoprost and travoprost. Clinicians should be aware of this side effect and monitor for signs periodically. Chronic unilateral prostaglandin use may cause unfavorable asymmetry in the appearance of the periorbital area.

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Clinical Report

Central Vault in Dry Eye Patients Successfully Wearing Scleral Lens

Jeffrey Sonsino and Dora Sztipanovits Mathe



Purpose. Scleral contact lenses are used to treat symptoms of severe dry eyes. Procedures for fitting scleral lenses have been vague because of lack of standardized guidelines. This retrospective case series sought to establish average vault over central cornea in successful scleral lens wearers with dry eyes.

Methods. Anterior segment optical coherence tomography was used to measure the distance between the posterior lens surface and cornea in 20 eyes of 12 consecutive patients successfully fit in the Vanderbilt Scleral Lens Clinic.

Results. Mean vault was 380 ± 110 μm. There was no correlation between vault and corneal curvature or vault and visual acuity.

Conclusions. With a large SD in average vault, precision in central vault does not seem to be important in scleral contact lenses for successful fit for dry eyes.

© 2013 American Academy of Optometry