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Purpose. To report the use of infliximab in the rapid stabilization of a case of progressive, bilateral rheumatoid peripheral ulcerative keratitis (PUK) that failed to respond to conventional immunosuppressive therapy. Methods. A single interventional case report. Results. A patient with rheumatoid arthritis presented with bilateral PUK following a 2-month history of ocular discomfort and redness. His systemic prednisolone (PDN) and methotrexate (MTX) were increased and, despite an initial favorable response, bilateral recurrent corneal perforations ensued. Both eyes underwent cyanoacrylate glue repair, amniotic membrane transplantation (AMT), and penetrating keratoplasty (PKP). Recurrence of the disease and bilateral perforations of the second PKP in both eyes prompted administration of intravenous infliximab immediately after the fourth PKP. The disease activity rapidly settled in both eyes, and at eighteen-month followup, after 12 infliximab infusions, the PUK remains quiescent with no further graft thinning or perforation. Conclusion. Infliximab can be used to arrest the progression of severe bilateral rheumatoid PUK in cases that are refractory to conventional treatment.

In small-incision cataract surgery, developments in machinery and software enable surgeons to use very low levels of ultrasound power to limit endothelial cell damage during phacoemulsification. Ultrasound energy is used to generate transient cavitation, the process in which gas bubbles are pulled out of the solution by excursion of the phaco probe and then violently implode, releasing energy and causing subsequent destruction of nuclear material. 1,2 The Sovereign WhiteStar phacoemulsification system (Advanced Medical Optics, Inc.) delivers ultrasound in a series of micropulses, each lasting tens of microseconds, rather than as a continuous stream of energy, and this has been shown to increase the efficiency of the ultrasound. 3,4 The greater efficiency is partly because transient cavitation tends to occur early in each segment of activated ultrasound; ie, many short pulses are more efficient than one long one. 5,6 In WhiteStar ICE technology, there is an additional burst of ultrasound at the start of each micropulse. This corresponds to an additional excursion of the phaco tip at the beginning of the micropulse, and thus creates a space between the phaco tip and the nuclear material ahead of it into which more gas-rich fluid can flow. During the remainder of the micropulse, when the normal excursion of the phaco probe is resumed, a greater degree of cavitation can occur within this extra volume of fluid. We looked at whether the WhiteStar ICE modified ultrasound delivery system allows the surgeon to increase cutting power without increasing energy output. PATIENTS AND METHODSThe study included consecutive eyes having routine phacoemulsification at a single-center randomized study at a university hospital. Each eye had cataract surgery with the Sovereign WhiteStar system alone or with the modified ultrasound delivery component of ICE. Eyes were randomly allocated to each group just before surgery using random number tables, with odd numbers assigned to the ICE group and even numbers to the without ICE group. The power settings using the Variable WhiteStar (VWS) system were the same in both groups: sculptingdmaximum power 60%, power ratio DB (ultrasound activation cycle: 8 ms on and 4 ms off, ie, 67% on); segment removald maximum power 50% (occluded) (unoccluded 20%), power ratio CD (6 ms on and 8 ms off, ie, 43% on) occluded (VWS unoccluded). The grade of cataract on dilated examination just before surgery was noted. The stop-and-chop method was used in each eye. At the end of each procedure, the equivalent phaco time (EPT) was recorded. This is calculated by the machine's software by continuously monitoring the power level activated over the course of the operation and then calculating the time for which the equivalent of 100% power would be activated. This value is essentially the area under the curve in the power versus time graph. The total ultrasound time (foot pedal activation time) and the mean phaco power were also recorded. These values were compared between the 2 groups. RESULTSFifty-eight eyes were en...

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Because the digital estimate can be misleading, the OKBT-20/30 tonometer or a similar device should be used routinely to ensure each eye is left with a desirable IOP at the end of cataract surgery.