Corneal Lesions Research Articles

Microbiological Profile and Clinical Characteristics of Bacterial Keratitis with Poor Visual Outcome

Purpose: To compare clinical characteristics between the poor visual outcome (PVO) and good visual outcome (GVO) groups in culture-proven bacterial keratitis.Methods: A total of 230 cases (44 and 186 eyes in the PVO and GVO groups, respectively) of culture-proven bacterial keratitis, treated between January 2007 and December 2020, were reviewed retrospectively. The PVO group included cases with the final best-corrected visual acuity (BCVA) of less than 0.1 and no improvement compared to the initial BCVA. The remaining cases were included in the GVO group. The microbiological profiles, epidemiology, predisposing factors, and clinical characteristics were compared between the PVO and GVO groups, and the risk factors for PVO were analyzed.Results: Staphylococcus spp. and Pseudomonas spp. were common isolates in both the PVO and GVO groups, with no significant differences in the distribution of isolates. There were no significant differences between the groups in terms of sex, seasonal distribution, corneal trauma, and prior topical steroid use, but contact lens wear was significantly less in the PVO group. Significant risk factors for PVO were age ≥60 years (Z = 4.22, two-proportion Z-test), central corneal lesions (Z = 3.80), epithelial defect size ≥5 mm<sup>2</sup> (Z = 3.74), prior ocular surgery (Z = 3.63), hypopyon (Z = 3.42), previous ocular surface disease (Z = 3.32), and diabetes (Z = 3.12).Conclusions: In patients with bacterial keratitis, PVO was associated with older age, severe initial corneal findings, previous ocular disease history, and diabetes, but not with the causative pathogen itself.

Single-cell atlas of keratoconus corneas revealed aberrant transcriptional signatures and implicated mechanical stretch as a trigger for keratoconus pathogenesis

Keratoconus is a common ectatic corneal disorder in adolescents and young adults that can lead to progressive visual impairment or even legal blindness. Despite the high prevalence, its etiology is not fully understood. In this study, we performed single-cell RNA sequencing (scRNA-Seq) analysis on 39,214 cells from central corneas of patients with keratoconus and healthy individuals, to define the involvement of each cell type during disease progression. We confirmed the central role of corneal stromal cells in this disease, where dysregulation of collagen and extracellular matrix (ECM) occurred. Differential gene expression and histological analyses revealed two potential novel markers for keratoconus stromal cells, namely CTSD and CTSK. Intriguingly, we detected elevated levels of YAP1 and TEAD1, the master regulators of biomechanical homeostasis, in keratoconus stromal cells. Cyclical mechanical experiments implicated the mechanical stretch in prompting protease production in corneal stromal cells during keratoconus progression. In the epithelial cells of keratoconus corneas, we observed reduced basal cells and abnormally differentiated superficial cells, unraveling the corneal epithelial lesions that were usually neglected in clinical diagnosis. In addition, several elevated cytokines in immune cells of keratoconus samples supported the involvement of inflammatory response in the progression of keratoconus. Finally, we revealed the dysregulated cell-cell communications in keratoconus, and found that only few ligand-receptor interactions were gained but a large fraction of interactional pairs was erased in keratoconus, especially for those related to protease inhibition and anti-inflammatory process. Taken together, this study facilitates the understanding of molecular mechanisms underlying keratoconus pathogenesis, providing insights into keratoconus diagnosis and potential interventions.

Case Series of Patients With Hereditary Benign Intraepithelial Dyskeratosis.

The purpose of this retrospective case series was to compare the outcomes of different treatment options for patients diagnosed with hereditary benign intraepithelial dyskeratosis (HBID). The study is designed as a single-institution retrospective chart review of patients who were clinically diagnosed with HBID during their care at the Duke Eye Center. Patient demographics were obtained, and disease course after different therapies was analyzed. Seventeen patients were diagnosed with HBID. 52.9% (9/17) of patients identified with HBID reported Native American ancestry. Medical therapy alone failed to reduce the size or number of corneal lesions in any patient identified in this study. Ten of the 17 patients required surgical intervention. Two eyes received corneal biopsies, 3 eyes received a full conjunctival lesion excision with amniotic membrane grafting, 12 eyes received superficial keratectomy with amniotic membrane grafting, and 1 eye received keratoprosthesis. Lesion recurrence was seen in 9 of the 10 patients treated with surgical excision with an average time to recurrence of 1.5 and 2 months for conjunctival excisions and superficial keratectomy, respectively, when excluding patients who missed scheduled postoperative follow-up appointments. Hereditary benign intraepithelial dyskeratosis is a rare and poorly understood disorder that predominantly affects people with Native American ancestry. Medical therapy only provides symptomatic relief, and patients who receive surgical excision almost always develop recurrence. As a result, we recommend future investigations focus on identifying the optimal surgical technique and timing to limit the morbidity of HBID and improve outcomes.

Laser-Induced Ocular Lesions with Thulium Fiber Laser in Endourology: An Ex Vivo Study.

Introduction and Objectives: The thulium fiber (Tm-F) laser is currently studied as an alternative to the holmium: yttrium-aluminum-garnet (Ho:YAG) laser, the gold standard for endocorporeal laser lithotripsy. We aimed to evaluate the ex vivo effects of an accidental Tm-F laser exposure on bovine eyes and to test the protective action of different eyeglasses in preventing eye lesions in case of an accident. Methods: A 50-W TFL generator (IPG Photonics®, Russia) with a wavelength of 1940 nm and 200-μm core diameter fibers (CDFs) were used. The laser fiber tip was pointed perpendicularly at different distances (0, 1, 3, 5, 8, and 10 cm, respectively) to the pupil center of the bovine eye. The Tm-F laser was activated for 1 or 3 seconds at three different settings (0.5 J-20 Hz, 1 J-10 Hz, and 2 J-10 Hz, respectively). The experiment was repeated using laser safety glasses and eyeglasses. After lasering, eye samples were immersed in a 0.5% fluorescein serum (Faure-Ciba-Geigy®, Switzerland), then rinsed with saline. White and blue light examination looked for localized epithelial burns (LEBs), extended epithelial burns (EEBs), superficial corneal ulcerations (SCUs), and deep corneal ulcerations (DCUs). Results: A total of 68 bovine eyes were used. Despite the laser settings, both DCU (contact) and SCU (1 cm) developed without eye protection for 1 and 3 seconds of lasering. At the 3-cm fiber-eye distance, only burning lesions were observed. Over 5 cm, no lesion was found. At contact or 1-cm fiber-eye distance, pulse energy did not change the lesion grade, but at 3 cm, high pulse energy led to higher grade corneal lesions (0.5 J-10 Hz:LEB; 1 J-10 Hz:EEB). Despite the fiber-eye distance, no corneal lesions were reported in the laser safety glass or eyeglass group for 1 second of laser exposure. Conclusions: Our study highlights the risk of eye damage caused by Tm-F. Without proper eye protection, the Tm-F laser can cause corneal lesions up to 5 cm in distance with 1 second of exposure despite laser settings. Only dedicated protective eyeglasses are effective for long exposures.

Corneal Keloid in Lowe Syndrome

An 18-year-old man with oculocerebrorenal Lowe syndrome was referred due to a corneal lesion of the right eye, which had worsened over the past 10 years (Fig A-C). He underwent cataract surgery and trabeculectomy in early childhood. Histopathological examination (Fig D) revealed epithelial hyperplasia, subepithelial hyaline deposits, Bowman’s layer thinning and disruption, thick and irregularly arranged collagen fibers, and lymphoplasmacytic infiltration. Although the pathophysiology of corneal keloids in Lowe syndrome remains unknown, the lesion started from the inferior limbus, and has been associated with limbal neovascularization since first observation (Magnified version of Fig A-D is available online at www.aaojournal.org).

A Case of Iris Neovascularization in Severe Fungal Keratitis Treated with Intracameral Bevacizumab

Purpose: We report a case in which iris neovascularization (NVI) improved after intracameral bevacizumab injection in a patient who exhibited fungal keratitis with NVI.Case summary: A 47-year-old man experienced a tree branch-induced injury to his right eye and was treated for keratitis for 1 month. However, his condition deteriorated and he was referred to our hospital. Initial slit lamp biomicroscopy findings showed a large, thick central deep stromal infiltration with a concentric circle shaped feathery-like margin, epithelial defect, satellite lesion, fungal ball, hypopyon, and NVI. Aspergíllus fumigatus was isolated in the corneal scraping culture. Amphotericin B, voriconazole, and natamycin were administered as topical treatment along with systemic amphotericin B. After treatment, the corneal lesions gradually improved, but NVI worsened. After the 5th week, total hyphema occurred; anterior chamber irrigation and intracameral bevacizumab injection were performed. Two weeks postoperatively, the NVI exhibited complete regression; corneal stromal melting with descemetocele appeared after 8 weeks. Penetrating keratoplasty was performed and NVI was no longer observed at 6 months after surgery.Conclusions: For the treatment of iris neovascularization in patients with infectious keratitis, intracameral bevacizumab injection at an appropriate time may be effective.

Controlling herpetic inflammatory lesions by inhibiting glucose metabolism- on the different outcome of using 2DG and metformin

Abstract Ocular infection with herpes simplex virus-1 (HSV-1) results in a blinding immunoinflammatory lesion. Control can be achieved by inhibiting the metabolism of cells principally involved in lesion development. Inhibiting glucose metabolism with 2DG achieves this effect but if therapy is used when replicating virus is still present, herpes simplex encephalitis (HSE) is likely to ensue. We report that using metformin to inhibit glucose metabolism can also minimize herpetic ocular lesions and this occurs without the usual complication of HSE. We try to provide a mechanistic explanation for the different outcomes. We show that the innate cell response in corneal lesions was similarly diminished by both metabolic therapies, but the effects on the composition of cellular T responses differed. Thus 2DG had more inhibitory effects than metformin on CD4 Th1 T cells, the main orchestrators of corneal lesions as well as on Foxp3+ Treg, cells responsible for controlling lesions. Metformin therapy had minimal inhibitory effects on Treg such that the representation of Treg markedly increased in comparison to Th1 cells. The responses occurring in the trigeminal ganglia, the site to which HSV spreads and then sets up permanent latency, was also investigated. The nature of the inflammatory responses at the site differed in untreated and animals treated with 2DG or metformin. Thus, both therapies resulted in diminished inflammatory responses particularly the innate cell composition. The inhibitory effects of 2DG against the CD8 content of the inflammatory reaction (cells advocated as involved in containing latency and stopping virus from disseminating to the brain) was significantly greater than was the metformin therapy. Supported by grants from NIH (R21AI142862 and R01EY005093)

A proof-of-concept study for the efficacy of dispirotripiperazine PDSTP in a rabbit model of herpes simplex epithelial keratitis

Herpes simplex keratitis is an important infectious cause of blindness worldwide. The mainstay of antiviral therapy is treatment with long-established nucleoside analogues orally or topically. However, the emergence of resistant strains may become a major health concern in the future. Therefore, the development of backup antiherpetic medicines is urgently needed. Small molecule PDSTP is known to be active against herpes simplex type 1 strains in vitro, affecting early host-pathogen interactions. Here, we evaluated its preclinical efficacy in a rabbit model of herpes simplex epithelial keratitis. The mean course of keratitis and the corneal lesions in the 1.0% PDSTP gel group was statistically significantly less than in the negative control group and was comparable to that in the aciclovir group. These findings open up new opportunities for the development of antiherpetic drugs with an original mechanism of action.

Occurrence of potentially highly pathogenic free-living amoebae in ready made salads from restaurants in Jatai, Goias, Brazil

Free-living amoebae (FLA) are part of a group of protozoa found worldwide and in the most diverse environments. They resist various temperatures and disinfection methods, and are a risk to human health. Pathogenic strains grow at high temperatures and under hyperosmolarity conditions. Some FLA genera are mainly related to primary amoebic meningoencephalitis (PAM), skin ulcerations, corneal lesions, kidney and lung infections and keratitis. Therefore, studies that assess the pathogenic potential of FLA are public health issues of great concern. We aimed to evaluate the pathogenic potential of FLA isolated in salads from restaurants in vitro, using osmotolerance and thermotolerance tests. Forty-five isolates were used from ready-made salads purchased in restaurants in Jatai, Goias. Twelve isolates subjected to the osmotolerance test (26.6%) showed growth in 0.5 M mannitol, 18 (40.0%) in 1.0 M mannitol and 16 (35.5%) in 1.5 M mannitol, 13 (28.8%) isolates did not show growth. Four isolates that underwent the thermotolerance test (8.9%) showed growth at 25°C, 8 (17.8%) showed growth at 30°C, 3 (6.7%) showed growth at 37°C and 30 (66.7%) did not show growth. With the indices obtained in the present study, we concluded that 15.6% of the isolates were osmotolerant and thermotolerant. Our findings highlight a public health problem once these FLA are associated with harboring or being harbored by microorganisms responsible for diseases such as diarrhea and meningitis. Measures are required to improve food hygiene and so avoid FLA-related health problems. KEY WORDS: Pathogenicity; osmotolerance test; thermotolerance test; food contamination; free-living amoebae.

Inhibition of Galectin-3 Impairs Antifungal Immune Response in Fungal Keratitis.

Galectin-3 is one of the galectin family members which are master regulators of immune homeostasis, especially in infectious diseases. However, its mechanism of immune regulation in fungal keratitis has not been thoroughly studied. Our study is aimed at clarifying the role of galectin-3 in the fungal keratitis mouse model in vivo, thereby providing a new biomarker of antifungal therapy. In our study, aspergillus, the most common pathogenic fungi of fungal keratitis, was identified and isolated by corneal tissue fungus culture. Then, the RNA expression levels of galectin family members in corneas of the mouse model with aspergillus fumigatus keratitis were screened by transcriptome sequencing (RNA-seq). The expression of the galectin-3 was detected by quantitative real-time Polymerase Chain Reaction (qPCR), enzyme-linked immunosorbent assay (ELISA), and immunofluorescence in the corneal tissue of the fungal keratitis mouse model. Recruitment of neutrophils and the co-immunofluorescence of galectin-3 and related markers in corneal tissue were determined by flow cytometry analysis and immunofluorescence staining. The regulatory role of galectin-3 for proinflammatory cytokines and neutrophils was validated by the knockout mouse model. Galectin-3 knockout deteriorated the condition for the inhibition of galectin-3 was benefecial for fungi to survive and thrive in corneal lesions. These results demonstrated that in the ocular fungal infection, galectin-3 is capable of regulating the pathogenesis of fungal keratitis by modulating neutrophil recruitment. The deterioration of fungal keratitis and increased fungal load in corneal lesions of galectin-3 knockout mice proved the regulatory role of galectin-3 in fungal keratitis. In conclusion, galectin-3 is going to be an essential target to modulate neutrophil recruitment and its related antifungal immune response in fungal keratitis.

Clinical Outcomes of Minimally Invasive Corneal Neurotization After Cerebellopontine Angle Neurosurgical Procedures

PurposeTo report 12 patients with neurotrophic keratopathy due to the trigeminal nerve injury after intracranial tumor surgeries underwent minimally invasive corneal neurotization and evaluate the outcomes of corneal reinnervation.MethodsTwelve patients (12 eyes) with neurotrophic keratopathy caused by the trigeminal nerve injury after intracranial surgeries received minimally invasive corneal neurotization. All the preoperative central corneal sensation was under 5 mm, and minimally invasive corneal neurotization was performed over 6 months after the intracranial surgery. Follow-up was conducted 1 week and 1 month after the surgery and then every 3 months. Twelve healthy age-matched participants were enrolled as controls. The indicators included corneal sensation, best-corrected visual acuity, corneal nerve fiber length and branch density, diameter of nerve trunk, corneal ulcer lesion ratio, and sensation of the contralateral forehead.ResultsMean follow-up was 24.7 ± 7.1 months. Mean central corneal sensation rose from 0.4 ± 1.4 to 31.7 ± 21.8 mm. Corneal nerve fiber length improved from 9.56 ± 5.00 to 14.96 ± 4.65 mm/mm2 and corneal nerve branch density and diameter of nerve trunk both increased (p < .01 and p < .05, respectively). Corneal lesion ratio decreased from 0.17 ± 0.12 to 0.10 ± 0.10 (p < .01).ConclusionsMinimally invasive corneal neurotization promotes corneal reinnervation for patients with neurotrophic keratopathy induced by the trigeminal nerve injury after intracranial surgeries. The process of corneal reinnervation after minimally invasive corneal neurotization often lasts over 12 months, and it takes about 18 months to return to a higher level. Corneal sensation and corneal nerve fiber length are related to clinical outcomes such as corneal ulcer lesion and best-corrected visual acuity. The effect on the sensation of the contralateral side forehead is temporary, and most patients can restore normal forehead sensation of the contralateral side.

Reactive Oxygen Species─Responsive Lipid Nanoparticles for Effective RNAi and Corneal Neovascularization Therapy

Corneal neovascularization (CNV) is a common disease that affects the vision ability of more than 1 million people annually. Small interfering RNA (siRNA) delivery nanoparticle platforms are a promising therapeutic modality for CNV treatment. However, the efficient delivery of siRNA into cells and the effective release of siRNA from delivery vehicles in a particular cell type challenge effective RNAi clinical application for CNV suppression. This study reports the design of a novel reactive oxygen species (ROS)-responsive lipid nanoparticle for siRNA delivery into corneal lesions for enhanced RNAi as a potential CNV treatment. We demonstrated that lipid nanoparticles could efficiently deliver siRNA into human umbilical vein endothelial cells and release siRNA for enhanced gene silencing by using the upregulated ROS of CNV to promote lipid nanoparticle degradation. Moreover, the subconjunctival injection of siRNA nanocomplexes into corneal lesions effectively knocked down vascular endothelial growth factor expression and suppressed CNV formation in an alkali burn model. Thus, we believe that the strategy of using ROS-responsive lipid nanoparticles for enhanced RNAi in CNV could be further extended to a promising clinical therapeutic approach to attenuate CNV formation.

PROTEIN MARKERS OF HYPOXIA AND ANGIOGENESIS IN TEAR FLUID OF PATIENTS WITH TRAUMATIC CORNEAL INJURY

The aim of our study was to evaluate tear levels of some protein endpoints that can reflect intensities of hypoxia, angiogenesis and tissue remodeling in wounded cornea. Methods. We examined 21 patients (21 eyes) with nonpenetrating corneal injuries. The patients underwent standard ophthalmological examination including previous history and ocular symptoms, visual acuity test, complete anterior and posterior eye segments examination using slit lamp biomicroscopy, evaluation of corneal staining with fluorescein, ophthalmoscopy. Healthy volunteers (n = 10) served as a control. Tear fluid was collected from patients and control volunteers with the use of a disposable tip micropipette. From the lower arch of the conjunctiva without instillation of anesthetic, tears were collected in a sterile plastic Eppendorf tube and frozen at -20 oC before laboratory examination. Proteins of tear fluids were separated by SDS-PAGE (loading 50 µg total protein per track). Then, levels of hypoxia inducible factor 1α (HIF-1α), vascular endothelial growth factor (VEGF), and angiostatins were measured by western blot. Active MMP-9 levels were evaluated by gelatin zymography. The results of blot and zymography assays were processed by densitometric software and then analyzed statistically with the use of Mann-Whitney U-test. Results. Elevated HIF-1α (P&lt;0.001) and angiostatins (P&lt;0.05) levels were revealed by western blot in tear fluid samples collected from patients with injured cornea in comparison with the control group. It is noteworthy that extremely low amounts of VEGF were detected in tear fluid from injured eyes, in spite of abundance of its transcription inducer HIF-1α. Dramatically increased levels of active MMP-9 were found in the tear fluids of patients with corneal wounds, while no significant collagenolytic activity was observed in tears from healthy eyes. There is a strong correlation between extent of corneal lesions and changes in markers expression. Conclusions. Tear levels of HIF-1α and angiostatin as well as MMP-9 activity could represent valuable biomarkers of corneal injury severity in traumatic eye.

MicroRNAs Expression in Response to rhNGF in Epithelial Corneal Cells: Focus on Neurotrophin Signaling Pathway.

Purpose. Nerve growth factor efficacy was demonstrated for corneal lesions treatment, and recombinant human NGF (rhNGF) was approved for neurotrophic keratitis therapy. However, NGF-induced molecular responses in cornea are still largely unknown. We analyzed microRNAs expression in human epithelial corneal cells after time-dependent rhNGF treatment. Methods. Nearly 700 microRNAs were analyzed by qRT-PCR. MicroRNAs showing significant expression differences were examined by DIANA-miRpath v.3.0 to identify target genes and pathways. Immunoblots were performed to preliminarily assess the strength of the in silico results. Results. Twenty-one microRNAs (miR-26a-1-3p, miR-30d-3p, miR-27b-5p, miR-146a-5p, miR-362-5p, mir-550a-5p, mir-34a-3p, mir-1227-3p, mir-27a-5p, mir-222-5p, mir-151a-5p, miR-449a, let7c-5p, miR-337-5p, mir-29b-3p, miR-200b-3p, miR-141-3p, miR-671-3p, miR-324-5p, mir-411-3p, and mir-425-3p) were significantly regulated in response to rhNGF. In silico analysis evidenced interesting target genes and pathways, including that of neurotrophin, when analyzed in depth. Almost 80 unique target genes (e.g., PI3K, AKT, MAPK, KRAS, BRAF, RhoA, Cdc42, Rac1, Bax, Bcl2, FasL) were identified as being among those most involved in neurotrophin signaling and in controlling cell proliferation, growth, and apoptosis. AKT and RhoA immunoblots demonstrated congruence with microRNA expression, providing preliminary validation of in silico data. Conclusions. MicroRNA levels in response to rhNGF were for the first time analyzed in corneal cells. Novel insights about microRNAs, target genes, pathways modulation, and possible biological responses were provided. Importantly, given the putative role of microRNAs as biomarkers or therapeutic targets, our results make available data which might be potentially exploitable for clinical applications.

Role of Damage-Associated Molecular Patterns (DAMPs/Alarmins) in Severe Ocular Allergic Diseases.

Severe ocular allergic diseases, such as atopic keratoconjunctivitis and vernal keratoconjunctivitis, cause severe allergic inflammation in the conjunctiva and corneal epithelial damage, resulting in visual disturbances. The involvement of damage (danger)-associated molecular patterns (DAMPs/alarmins) in the pathogenesis of these diseases has been recognized. Alarmins released from damaged corneal epithelial cells or eosinophils play a critical role in the induction of corneal lesions, vicious loop of corneal injury, and exacerbation of conjunctival allergic inflammation. Alarmins in the conjunctiva also play an essential role in the development of both allergic inflammation, based on the acquired immune system, and type 2 inflammation by innate immune responses in the ocular surface. Therefore, alarmins may be a potentially important therapeutic target in severe refractory ocular allergic diseases.

Coin-shaped corneal endothelial scar in herpes zoster ophthalmicus: a case report

BackgroundHerpes zoster ophthalmicus includes a wide spectrum of lesions at the ocular surface, including epithelial, stromal, endothelial keratitis, and uveitis. Thus far, the occurrence of corneal endothelial disorder in herpes zoster ophthalmicus and the causative virus have not been confirmed, and the differential diagnosis and establishment of therapeutic strategies are challenging. Corneal endothelial coin-shaped lesions are well known to occur in cytomegalovirus-related corneal endotheliitis but have not been reported in patients with herpes zoster ophthalmicus.Case presentationA 39-year-old Asian female was referred to our ophthalmology department with recurrent anterior uveitis accompanied by coin-shaped corneal endothelial scar-like lesions that appeared after right facial herpes zoster. Diffuse corneal stromal haziness was mostly limited in the anterior stroma. The coin-shaped corneal endothelial lesions were separate from stromal lesions and showed a high-reflective scar-like line in sections of anterior segment optical coherence tomography. Anterior uveitis recurred each time she discontinued oral antiviral drug treatment for 12 months after the first event, but was remitted by the maintenance medications of combined topical ganciclovir gel with oral valaciclovir, at a dose lower than the usual adult dose, for acute or recurrent zoster-associated anterior uveitis. Corneal endothelial function remained normal and corneal endothelial and stromal lesions were unchanged throughout the treatment and follow-up period.ConclusionsIn patients with a history of facial herpes zoster with coin-shaped corneal endothelial scar accompanying recurrent anterior uveitis, suspicion for active varicella-zoster virus is warranted, and prolonged intake of oral antiviral agents is required despite varicella-zoster virus DNA not being detected in aqueous humor.

Anterior segment OCT findings and atypical refractive changes secondary to Epstein-Barr virus–associated nummular keratitis

Introduction: This case study described refractive changes that can occur in the setting of Epstein-Barr virus (EBV)-associated nummular keratitis (NK) and highlighted the role that anterior segment optical coherence tomography can serve in diagnosis and management of this disease. Patient and Clinical Findings: A 15-year-old girl developed subepithelial and anterior stromal corneal lesions and experienced progressive decline in the corrected distance visual acuity. She also developed a significant myopic shift with increased keratometric and refractive astigmatism. Diagnosis, Intervention, and Outcomes Targeted laboratory testing was performed. A diagnosis of chronic EBV-associated NK was made, and the patient was treated with systemic valacyclovir and topical steroids. Clinical appearance of lesions and corrected distance visual acuity improved, although refractive and keratometric changes persisted. Conclusions: Significant and persistent refractive changes can occur in the setting of EBV-associated NK, similar to those seen after conductive keratoplasty. Anterior segment optical coherence tomography can be a potentially helpful supplementary diagnostic imaging modality to avoid invasive testing in such cases.

Dry eye disease and meibomian gland dysfunction among a clinical sample of type 2 diabetes patients in Ghana.

To evaluate dry eye disease and meibomian gland dysfunction among type 2 diabetes patients. A hospital-based cross-sectional study was conducted. Parameters assessed included meibum expressibility and quality, Schirmer test 1, tear breakup time (TBUT), ocular surface staining, blink rates and Ocular Surface Disease Index (OSDI) scores. Dry eye was diagnosed based on a combination of subjective symptoms, tear function and ocular surface staining. Prevalence of DED and MGD were 72.3% and 55.3% respectively. Symptomatic dry eye (OSDI scores) was significantly associated with duration of diabetes (rs = 0.11, P = 0.028) and the presence of conjunctival disorders (OR = 2.09, P = 0.002). MGD was a risk factor for DED (OR = 1.99, P = 0.008); ocular surface damage, the presence of eye lid lesions, abnormal Schirmer test and reduced TBUT were significantly associated with MGD, the strongest predictor being ocular surface damage (OR = 3.21, P = 0.001). OSDI scores had no association with the presence of corneal lesions possibly due to reduced corneal sensitivity. DED and MGD were prevalent among the patients and therefore there is the need for dry eye assessment as a routine clinical management protocol for patients with type 2 diabetes.

Corneal Ulcer in a Sheep - Treatment with Third Eyelid Flap

Background: Corneal ulcers are frequently reported in the literature in several species, however, the treatment of traumatic lesions on the corneal surface of ruminants is still poorly described. The use of the third eyelid flap is questioned when applied to deep ulcers, since the technique prevents the evolutionary follow-up of corneal healing and compromises care. However, several authors report its successful use for the treatment of superficial and deep corneal ulcers. This technique protects the ocular surface and prevents the occurrence of new lesions or their aggravation. The aim of this study was to report the treatment of corneal ulcers in sheep through the third eyelid flap associated with the use of topical antibiotics.Case: A 2-year-old Dorper sheep, with ocular discomfort, conjunctival hyperemia and mucopurulent secretion in the left eye, was assisted in a private rural property in the West region of Bahia, Brazil. The owner reported that before seeking veterinary help he used a spray based on oxytetracycline and hydrocortisone, which worsened the animal's condition. Upon inspection, it was observed eyelid asymmetry, slight lateralization of the head to the left, periorbital alopecia on the left face, intense blepharospasm in the left eye, with projection of the third eyelid occurring at times. The ophthalmic examination was performed after application of anesthetic eye drops based on proxymetacaine to reduce eye discomfort. A corneal stromal lesion, edema and fibrovascular tissue in the left eye were identified, but the cause of the lesion was not defined, with lagophthalmia, entropion, dystychiasis or ectopic cilia being ruled out. So, it was suggested that the lesion had occurred by a foreign body, such as dust or feed fiber. The contralateral eye showed no changes, Schirmer 15 mm, no changes in sensory and sensory reflexes and negative fluorescein. No signal clinical disease. Due to the severity of the lesion, it was performed a third eyelid flap associated with drug treatment with ciprofloxacin eye drops, every 8 h for 21 days. The animal was placed in the right lateral decubitus position and palpebral akinesia was achieved with the application of 2 mL lidocaine without vasoconstrictor in the region of the auriculopalpebral nerve. This was followed by the routine performance of the third eyelid flap.Discussion: The delay in seeking veterinary care and the application of spray based on oxytetracycline and hydrocortisone aggravated the lesion, since the corticosteroid delays corneal healing and favors the aggravation of the lesion. After desensitization of the cornea, the animal allowed eye manipulation and it was possible to observe the lesion and choose the best treatment, with option for the third eyelid flap because it is a simple and fast technique, does not require special equipment or materials, ideal for performed in the field and is widely used in the treatment of injuries involving the cornea and, besides that, helps to contain corneal perforation and protect the ocular surface. Corneal debridement was also performed to remove necrotic debris and improve drug action, in addition to using broad-spectrum antibiotic eye drops until complete regeneration of the lesion. Twenty-one days after the surgical procedure, the patient had no ocular discomfort, the flap was removed and no changes in the corneal surface were observed. The treatment was considered satisfactory for the healing of the corneal ulcer, guaranteed the esthetics and visual function of the sheep.Keywords: keratitis, surgery, ciprofloxacin, ocular, ruminant.

Long-Term Follow-up of Epstein Viral Keratitis

A 39-year-old woman diagnosed with chronic fatigue syndrome developed unilateral non-suppurative stromal keratitis (Fig A). Topical steroid therapy led to sharply demarcated opacities consistent with Epstein-Barr viral (EBV) keratitis (Fig B). Antibody (ab) to EBV nuclear antigen was 1:256, to viral capsid antigen 1:320; ab to early antigen was positive. Steroid therapy was discontinued after 1 month. Three months later the cornea was quiet (Fig C). The patient was observed 5 years later, with almost complete clearing of the corneal lesions (Fig D).