Perforated Corneal Ulcer Research Articles

A Case of Fulminant Serratia marcescens Panophthalmitis After Penetrating Keratoplasty

Purpose: To report the first case of fulminant Serratia marcescens panophthalmitis after penetrating keratoplasty (PK). Methods: This is a report of a patient who developed fulminant panophthalmitis shortly after undergoing PK with anterior chamber intraocular lens placement. Slit-lamp examination, B-scan ultrasound (B scan), and orbital computed tomography of the left eye (OS) were performed to further evaluate the patient. Tissue culture and histopathologic examination of the corneal specimen were completed to confirm the diagnosis. Results: A 78-year-old pseudophakic woman presented with 2 days of increasing pain, swelling, and purulent discharge after uneventful PK and secondary anterior chamber intraocular lens placement OS. Examination was notable for light perception without projection, elevated intraocular pressure of 48 mmHg, and a perforated corneal ulcer. B scan demonstrated diffuse vitreous opacities and membranes. Orbital computed tomography demonstrated proptosis and high-attenuation material within the left globe. Canthotomy, vitreous sampling, and antibiotic injections were performed. Corneal tissue cultures grew S. marcescens. Therapeutic PK was performed, but after rapid decompensation, the eye was eviscerated. Conclusions: This is the only reported case of fulminant S. marcescens panophthalmitis after PK. S. marcescens panophthalmitis is an aggressive and rapidly progressive infection with poor visual outcomes despite appropriate intravitreal and systemic antibiotic therapy.

Cyanoacrylate glue: An emerging alternative for sealing of corneal perforation

Maintaining corneal wound integrity is an important goal in corneal perforations resulting from either traumatic or non- traumatic etiology. Tissue adhesives (TA’s) are group of synthetic or naturally occurring compounds, which helps in wound reconstruction and have emerged as alternatives to conventional sutures. Our study aims to evaluate the efficacy N- butyl cyanoacrylate TA in corneal perforations following infectious keratitis by assessment of its morphological and functional outcome. A prospective observational study conducted over a period of 6 months on 42 eyes of 42 patients with perforated corneal ulcer, fulfilling the inclusion criteria, presenting to our outpatient department. A standard technique was used to apply TA to the site of perforation under topical anaesthesia in all patients and they were followed-up for a period of 6 weeks. Data analysis was done using SPSS software (Version 22) and P value calculated by Pearson Chi-square test (Fisher exact test). P- value < 0.05 was considered statistically significant. Morphological outcome in this study showed statistically significant relationship with causative organism and size of the perforations (p<0.05). The functional outcome showed statistically significant relationship with location of perforation, duration of symptoms and duration of stay of glue (p<0.05). TA’s works well when the corneal perforation is <1.5 mm in diameter. The morphological outcome of TA depends upon etiology, size of perforations and complications significantly. Functional outcome of tissue adhesive shows significant association with location of perforation, duration of symptoms and stay of glue.

Establishment of a corneal ulcer prognostic model based on machine learning

Corneal infection is a major public health concern worldwide and the most common cause of unilateral corneal blindness. Toxic effects of different microorganisms, such as bacteria and fungi, worsen keratitis leading to corneal perforation even with optimal drug treatment. The cornea forms the main refractive surface of the eye. Diseases affecting the cornea can cause severe visual impairment. Therefore, it is crucial to analyze the risk of corneal perforation and visual impairment in corneal ulcer patients for making early treatment strategies. The modeling of a fully automated prognostic model system was performed in two parts. In the first part, the dataset contained 4973 slit lamp images of corneal ulcer patients in three centers. A deep learning model was developed and tested for segmenting and classifying five lesions (corneal ulcer, corneal scar, hypopyon, corneal descementocele, and corneal neovascularization) in the eyes of corneal ulcer patients. Further, hierarchical quantification was carried out based on policy rules. In the second part, the dataset included clinical data (name, gender, age, best corrected visual acuity, and type of corneal ulcer) of 240 patients with corneal ulcers and respective 1010 slit lamp images under two light sources (natural light and cobalt blue light). The slit lamp images were then quantified hierarchically according to the policy rules developed in the first part of the modeling. Combining the above clinical data, the features were used to build the final prognostic model system for corneal ulcer perforation outcome and visual impairment using machine learning algorithms such as XGBoost, LightGBM. The ROC curve area (AUC value) evaluated the model’s performance. For segmentation of the five lesions, the accuracy rates of hypopyon, descemetocele, corneal ulcer under blue light, and corneal neovascularization were 96.86, 91.64, 90.51, and 93.97, respectively. For the corneal scar lesion classification, the accuracy rate of the final model was 69.76. The XGBoost model performed the best in predicting the 1-month prognosis of patients, with an AUC of 0.81 (95% CI 0.63–1.00) for ulcer perforation and an AUC of 0.77 (95% CI 0.63–0.91) for visual impairment. In predicting the 3-month prognosis of patients, the XGBoost model received the best AUC of 0.97 (95% CI 0.92–1.00) for ulcer perforation, while the LightGBM model achieved the best performance with an AUC of 0.98 (95% CI 0.94–1.00) for visual impairment.

Use of the PRECLUDE® pericardial e-PTFE membrane in ophthalmology

This article provides an overview of the diverse applications of the PRECLUDE® pericardial e-PTFE membrane in ophthalmology. The e-PTFE membrane was found to be safe and effective as an alternative surgical procedure for perforating corneal ulcer closures. It could be a method of choice for eye preservation or during delayed corneal transplantation, especially in immunocompromised patients. After membrane removal, penetrating keratoplasty can be performed as a definitive treatment with better prognosis as “à-chaud” keratoplasty in all eyes, as a prognosis of visual acuity improvement is expected. E-PTFE membrane implantation for use after uneventfully performed trabeculectomy with still-uncontrolled postoperative intraocular pressure (IOP) in severe refractory glaucoma represents an additional approach for treating uncontrolled secondary glaucoma. This modified trabeculectomy can be used as surgical treatment and for refractory traumatic glaucoma cases. The e-PTFE membrane can be used in cases where antimetabolite-related risk must be avoided. Our new surgical treatment after trabeculectomy is a simple and safe procedure and can be used as a filtration-modulating device in all refractory glaucomas.

Ochrobactrum anthropi infection following corneal transplantation -a case report and review of literature

BackgroundOchrobactrum anthropi is widely distributed and primarily infects patients with compromised immune functions . Historically, O. anthropi has been considered to possess low toxicity and pathogenicity; however, recent studies suggest that it may in fact cause severe purulent infections. In this case study, we examine a case of O. anthropi infection following corneal transplantation, exploring the occurrence and outcomes of such post-operative infections.Case presentationA retrospective analysis of cases involved examinations, genetic testing for diagnosis, and subsequent treatment. In patients undergoing partial penetrating keratoplasty with a fungal corneal ulcer perforation, anterior chamber exudation and purulence were observed post-surgery. Despite antifungal treatment, genetic testing of the anterior chamber fluid and purulent material confirmed O. anthropi infection. The use of antimicrobial treatment specifically targeting O. anthropi was found to be effective in treating the infection.ConclusionInflammatory reactions following corneal transplantation should be should be monitored for the presence of other infections. Genetic testing has significant implications for clinical diagnosis and treatment.

New-onset keratitis associated with epidermal growth factor receptor-based targeted therapies in Han Chinese patients with lung cancer: A multi-center cohort study

PurposeTo determine the risk and incidence of keratitis following treatment with epidermal growth factor receptor inhibitors (EGFRi) and subtypes of EGFRi-associated keratitis. MethodsThis multi-center cohort study included EGFRi-treated patients and non-users with lung cancer between 2010 and 2023. EGFRi included first-generation agent gefitinib and erlotinib, second-generation agent afatinib, and third-generation agent osimertinib. The primary outcome was new-onset keratitis. Cox proportional hazard models with multivariable adjustment were applied to determine the effect of EGFRi on keratitis over time. Subgroup analyses were conducted, stratified by agents of EGFRi. Sub-outcome analyses were performed to identify the subtypes of EGFRi-associated keratitis. ResultsA total of 1549 EGFRi-treated patients and 6146 non-users were included. 38 (2.5%) EGFRi-treated patients developed keratitis. The incidence of keratitis in EGFRi-treated patients was significantly higher than that in controls (incidence rate, IR, per 1000 person-years = 14.7 vs 4.49, p < 0.0001). EGFRi-treated patients presented with an increased risk for keratitis (adjusted hazard ratio, aHR = 3.14, 95% CI = 1.85–5.35, p < 0.001). Erlotinib (aHR = 2.64, 95% CI = 1.35–5.15, p = 0.004), afatinib (aHR = 4.42, 95% CI = 2.17–9.02, p < 0.001), and osimertinib (aHR = 4.67, 95% CI = 1.60–13.64, p = 0.005), but not gefitinib (aHR = 2.30, 95% CI = 0.96–5.55, p = 0.063), significantly contributed to the risk of keratitis. Subtypes of EGFRi-associated keratitis included corneal ulcer (IR = 2.31 vs 0.166, p < 0.0001) and keratoconjunctivitis (IR = 9.27 vs 2.91, p < 0.0001). None of the EGFRi-treated patients developed perforated corneal ulcer, interstitial and deep keratitis, or corneal neovascularization. ConclusionTreatment with EGFRi was associated with an increased risk of keratitis. Ocular toxicity of EGFRi was highest for third-generation agents, followed by second-generation agents, and then first-generation agents.

Keratoprosthetics as a visual rehabilitation method in patients with graft-versus-host disease

The article is concerned with the treatment of a patient with allogeneic hematopoietic stem cell transplantation (HSCT) complicated by graft-versus-host disease with severe ocular manifestations. Hematopoietic stem cell transplantation is the standard therapy for a number of hemoblastoses and hereditary blood diseases, ensures the restoration of the immune system, however, in 40–60% of cases it is complicated by the development of graft-versus-host disease, with a five-year survival rate of no more than 40%. Patient S., 22 years old, was admitted to the ophthalmological center of Saint Petersburg Multifield Hospital No. 2 in 2019 with a diagnosis of “Acute keratitis, corneal ulcer of both eyes”. History of hematopoietic stem cell transplantation in 2018, complicated by graft-versus-host disease with multiorgan damage development was present. In total during the period 2019–2022, 7 tectonic keratoplasties were performed on both eyes, as well as penetrating keratoplasty on the left eye. After inflammation setback and left eye vascularized corneal leukoma formed, in December 2022, the first stage of keratoprosthetics (installation of the support element) was performed, and in May 2023, the second stage (implantation of the optical cylinder) took place. Visual acuity in one month after the implantation of the keratoprosthesis increased from light perception to 20/100, no correction possible. The use of “classical” methods of corneal ulcer perforation treatment in patients with graft-versus-host disease is ineffective due to the severe ocular surface xerosis, and keratoprosthetics seems to be the only effective method for restoring visual functions.

EFFECTIVENESS AND SAFETY OF AMNIOTIC MEMBRANE GRAFTING FOR CORNEAL SURFACE DISORDER: A RANDOMIZED CLINICAL STUDY

Objective: The aim of the study was to evaluate the effectiveness and safety of freeze-dried amniotic membrane grafting (AMG) and compare it against traditional medical therapy for the management of corneal surface disorders. Methods: A randomized clinical trial was conducted on 60 patients with corneal surface disorders who were randomized equally either into the AMG group (n=30) or medical management group (n=30). Patients in both groups were followed up for 8 weeks after receiving group-specified intervention or till complete resolution (whichever was earlier). Treatment outcome, healing time, improved vision, decreased pain, recurrence rate, and corneal clarity were the main outcome metrics. Results: The most common corneal disorder was persistent epithelial defect (38.33%), closely followed by impending perforated corneal ulcer (31.66%). Majority of the patients (36.66%) had corneal involvement of &gt;75%, while 31.66% had involvement ranging from 50 to 75%. The success rate of AMG (96.7%) was significantly higher than that of medical management (76.7%) in the treatment of corneal surface disorders (p=0.022). During the follow-up period, the incidence of allergic reactions was slightly lower in the AMG group (6.7%) compared to the medical management group (10.0%). Overall, the incidence of side effects and other complications was low in both the AMG group and the medical management group. The severity of side effects was comparable in both the study groups (p=0.886). The recurrence rate of corneal surface disorders in the in the AMG group (6.7%) was statistically lower than that in the medical management group (26.7%) (p=0.037). Conclusion: The findings of the present study supported the use of AMG as an effective and safe alternative to medical management for the treatment of conditions affecting the corneal surface.

Experience of using autologous cornea for deep and penetrating keratoplasty in dogs and cats

This paper presents a generalized experience in the treatment of deep corneal ulcers, descemetoceles and perforated corneal ulcers in which keratoplasty was used using autologous cornea. Deep corneal ulcers are characterized by an acute inflammatory process and the risk of developing many complications leading to loss of vision. Conservative treatment of such pathologies takes a long time and is not always successful. Keratoplasty for corneal transplantation is considered an effective method. The outcome of the operation depends on the transplanted material and postoperative treatment tactics. The work conducted a study on the effectiveness of using autologous cornea in 32 animals with subsequent inclusion of a regenerative drug in the treatment regimen. The authors describe the clinical picture, the surgical technique, and provide the results of dynamic observation of animals. Based on the results of clinical observations, it was established that the use of autologous cornea for deep corneal ulcers can be an effective treatment method. In none of the 32 cases examined, rejection was recorded, while the morphofunctional characteristics of the cornea were preserved. Drug maintenance therapy, including a regenerative drug, showed good results in the postoperative period. The use of a regenerative drug accelerated the healing process and made it possible to maintain the transparency of the cornea and its curvature.

The Clinical and Microbiological Characteristics of Fungal Keratitis in COVID-19 Period

Abstract Context: In India, the incidence of fungal keratitis ranges from 44% to 47%, due to its tropical environment and huge at-risk agricultural population. The emergence of COVID-19 has influenced the medical management of fungal keratitis. Aim: The aim of this study was to assess the clinical and microbiological characteristics of fungal corneal ulcers during COVID-19 period. Settings and Design: This was a cross-sectional study of 1-year duration. Subjects and Methods: Fifty-two KOH mount-positive and fungal culture-positive patients were included in the study. Ophthalmic examination, including best-corrected visual acuity, slit-lamp examination, fluorescent staining was done, Anterior segment optical coherence tomography (ASOCT). Corneal scraping was sent for 10% KOH mount and fungal cultures with Sabouraud’s dextrose agar for growth. Statistical Analysis Used: The Statistical Package for the Social Sciences (Version 20) was used for statistical analysis. Results: Fifty-two KOH mount and fungal culture-positive patients were included, with a mean age of 50.88 years. 53.8% were farmers. 55.6% had a history of trauma with organic matter. The common signs noted were an irregular, dry looking, central corneal ulcer measuring 2-5mm extending 20-50% deep, mid stromal infiltration, satellite lesions and surrounding stromal oedema. Eleven presented with perforation. The best-corrected visual acuity was hand movements (32.7%). The KOH mount positive among the screened patients was 46.7%, of which 52 were culture positive. Aspergillus fumigatus (61.5%) was the predominant cause of mycotic keratitis. Conclusion: Mycotic keratitis was mostly caused by filamentous fungus and was most frequently observed among farmers. COVID-19 has increased the cases of perforated corneal ulcers, and ASOCT was the noninvasive, feasible tool to assess the cornea.

Silicon-dried corneal graft crosslinking as a means to increase the effectiveness of urgent keratoplasty

Purpose: to evaluate the effectiveness of silicon-dried cornea, previously subjected to corneal collagen UVA crosslinking, for urgent keratoplasty.Material and methods. 28 patients (16 males, 12 females), diagnosed with perforating corneal ulcer of various etiologies, underwent penetrating keratoplasty for eye-preserving purposes. 14 patients (the main group) underwent transplantation of a silicon-dried cornea, previously subjected to corneal collagen crosslinking according to the standard (Dresden) protocol while the remaining 14 patients (comparison group) underwent penetrating keratoplasty with not pre-treated silicon-dried cornea. In the postoperative period, we measured the time of primary complete epithelization of the graft and assessed the presence/absence of ulcers and erosions of the corneal graft 1, 3, 6 and 12 months after the discharge from the hospital. For this purpose, all patients underwent corneal biomicroscopy with corneal surface preliminary stained with a 1% sodium fluorescein solution.Results. Complete epithelization in both the main group and the comparison group was found to take place, on average, at the same time after surgery. However, over the entire observation period, the main group showed fewer relapses of ulcers and corneal graft erosions than the comparison group.Conclusion. The use of silicon-dried cornea, subjected to corneal collagen cross-linking, increases the effectiveness of perforated corneal ulcer treatment in emergency surgical care.

Evaluation Outcomes and Complications of Temporary Suture Tarsorrhaphy (TST) in Cases of Impending Corneal Ulcer Perforation

Introduction: A corneal ulcer, a defect of the corneal epithelium involving the underlying stroma, is a potentially vision-threatening ocular emergency. Even with prompt treatment patients can suffer significant morbidity with complications including corneal scarring or perforation, development of glaucoma, cataracts or anterior and posterior synechiae, and vision loss. Objective: to evaluate outcomes and complications of temporary suture tarsorrhaphy (TST) in cases of impending corneal ulcer perforation. Methods: In this retrospective study was carried out at Department of Ophthalmology, Ad-din Akij Medical College, Khulna and Eye Hospital, Khulna, Bangladesh from January to June 2022. All cases of fungal keratitis that had undergone TST after evaluation were included. Patients with a minimum follow up of 3-month post tarsorrhaphy were included in the study. Information reviewed included patient age and sex, visual acuity (VA) at presentation, size and location of the ulcer, indication for TST, duration of signs and symptoms before TST, time to epithelial healing after TST, complications associated with non-healing corneal ulcer, complications of TST, number of TST needed and the duration of follow up. Results: During the 12 months study period, 300 cases were planned for TST out of which 90 patients (30.0%) fulfilling the inclusion and exclusion criteria were included for the study. There were not any cases of both eye involvement. Mean age of the patients in this study was 50.34+ 14.56 years (range 20—85 years) with a male-to-female ratio of 2.22:1. Only 3 patients (2.52%) had a VA of more than 6/60, 31 patients (34.44%) had VA between 6/60 to counting finger-close to face (CF-CF) and 57(63.33%) had hand movement (HM) to perception of light (PL) at first visit. The patients presented to the cornea service 3 to 45 days (mean 19.34+10.62 days) after the onset of symptoms, with only 7.57% of the patients presenting within 1 week. Out of 90 patients, 64 patients ....

Complications of a Giant Cavernous Carotid Artery Aneurysm

Cavernous carotid aneurysms (CCAs) differ from other intracranial aneurysms in that most are asymptomatic and are generally considered benign as there is a low risk of rupture. More common than complications from rupture are complications from the mass effect of the aneurysm itself on nearby structures.1,2 This report describes a case of a giant right CCA that progressed in size despite multiple surgical repairs that resulted in near- complete ophthalmoplegia and neurotrophic keratitis which led to a perforated corneal ulcer and subsequent enucleation.

The Use of Corneoscleral Grafts to Maintain Tectonic Stability in Severe Keratolysis.

Severe corneal ulcerations, causing major keratolysis with large perforation of the cornea or extending to the limbal region, are an ophthalmic emergency. In these cases, a larger corneoscleral graft can be transplanted to restore tectonic integrity, alleviate pain, save vision, and prevent loss of the eye. Chart review of 34 patients with a corneoscleral graft ≥9.5 mm was conducted. Primary endpoints of the study were tectonic stability defined as no need for another keratoplasty or enucleation. In addition, visual acuity, postoperative complications, and secondary procedures were analyzed. In total, 12 patients (35%) were female. The mean age at transplantation was 65 ± 19 years. The underlying disease was a perforated infectious corneal ulcer in 30 cases (88%). Mean follow up was 675 ± 789 days. Tectonic stability at the end of the follow-up was maintained with a probability of 56% in a Kaplan-Meier analysis. Another penetrating keratoplasty was necessary in six cases (17%) and enucleation in five cases (15%). A corneoscleral transplant remains a viable treatment option to prevent enucleation in severe keratolysis. In our study, this was possible in about half of the cases. Postoperative complications, secondary surgeries, and markedly reduced visual acuity put the advantages into perspective.

Case Report of Candida Parapsilosis Keratitis After Cataract Surgery Leading to Corneal Perforation

Purpose:The objective of this study was to report and document a rare case ofCandida parapsilosiskeratitis that occurred following a routine clear corneal incision cataract surgery, ultimately resulting in a perforated corneal ulcer and subsequent need for a penetrating keratoplasty (PK). By presenting this case, the study aims to contribute to the existing literature and raise awareness about the potential risk ofC. parapsilosiskeratitis as a complication of cataract surgery.Methods:In this case report, we describe the presentation and management of a rare fungal infection following routine cataract extraction in an 80-year-old male patient. The patient initially received treatment for suspected endophthalmitis and bacterial keratitis but experienced worsening symptoms, including a small corneal perforation. Upon referral to the clinic, the patient exhibited a fluffy stromal infiltrate near the cataract wound site, an epithelial defect, and a hypopyon. Treatment with compounded topical 1% voriconazole was initiated but did not prevent the progression of the corneal perforation. Attempts to seal the perforation with corneal glue were unsuccessful, leading to the decision to perform a PK. During the surgery, corneal tissue was biopsied and cultured to identify the causative agent.Results:Following PK, the corneal cultures revealed the growth ofC. parapsilosis, confirming the fungal nature of the infection. The patient was then reinitiated on topical voriconazole for a prolonged course of 7 months. Throughout this period, the patient was closely monitored and followed up in the clinic. Fortunately, there were no recurrences of the fungal lesion during this time.Conclusions:No prior cases of a perforated corneal ulcer resulting fromC. parapsilosiskeratitis after routine cataract surgery have been reported in the literature to our knowledge. Our patient experienced postoperative complications characterized by recurrent inflammation, which was treated with potent and frequent topical steroids. This treatment masked the underlying mycotic infection and contributed to corneal perforation. Ultimately, the patient underwent a successful PK procedure to remove the infectious nidus, followed by an extended 7-month course of topical voriconazole. No recurrence of the lesion was observed. Therefore, clinicians should be vigilant for mycotic keratitis, specificallyC. parapsilosis, in patients who display late-onset, persistent inflammation and white plaques at the clear corneal incision site after cataract surgery. The combination of PK and an extended postoperative treatment with topical antifungal agents proves to be an effective strategy for managing corneal perforations caused byC. parapsilosiskeratitis.

Graft Outcome of Corneal Patch for Perforated Corneal Ulcer

Background: Corneal patch graft (CPG) is a part of the tectonic penetrating keratoplasty procedure performed on the perforated corneal ulcer. This procedure involves filling affected areas with full or partial-thickness cornea donors. This study aimed to determine the clinical results of corneal patch grafts in perforated corneal ulcers.&#x0D; Methods: A retrospective study assessing clinical results of CPG on the perforated corneal ulcer with iris prolapse. Clinical assessments include graft condition, anterior chamber depth (ACD), and visual acuity after surgery, with a follow-up duration of up to 8 weeks.&#x0D; Results: Twenty-one cases of perforated corneal ulcer with iris prolapse in 15 males (71.4%) and 6 females (28.6%). Locations of ulcer are peripheral and paracentral corneal. Visual acuity showed around light perception (LP) to 0.4. The most common etiology for corneal ulcers was infection (88.9%), followed by non-infection (Mooren’s ulcer) (11.1%). The graft condition after surgery showed promising results in 18 cases (85.7%), infection in 1 case (4.8%), and melting in 2 cases (9.5%). Adequate ACD was obtained in 77.8% of cases. An increase in visual acuity was shown in 44.4% of cases, depending on the location and severity of the ulcer.&#x0D; Conclusion: A corneal patch graft is an appropriate choice in treating perforated corneal ulcers to maintain ocular integrity (tectonic keratoplasty). However, in non-infectious ulcers, this procedure has not shown a good result, which may be related to disease progressivity.

Management of perforated corneal ulcer with iris prolapse by cyanoacrylate glue: A case report

We report a rare case of perforated corneal ulcer due to recurrent viral keratitis with stromal necrosis and iris prolapse. The patient was 75 years old farmer, normotensive, diabetic, and presented with complaints of pain, watering, photophobia, redness and dimness of vision in the left eye. The left eye's visual acuity was perception of light and projection of rays in all four quadrants. Slit lamp examination found swollen eyelids, matted eyelashes, congested conjunctiva, seidel test positive, an inferonasal corneal perforation, shallow anterior chamber, irregular pupil, and prolapse of the iris through the perforated cornea. The patient was diagnosed with a left-sided perforated corneal ulcer (recurrent viral keratitis with stromal necrotizing variety) having iris prolapse. The perforation was sealed by cyanoacrylate glue and a soft bandage contact lens. This improved the patient’s condition. Early medical and surgical interventions thus can save vision as well as the eyeball.

Analysis of clinical manifestations and imaging characteristics of in vivo confocal microscopy for Nocardia keratitis

Objective: To analyze the clinical manifestations and imaging characteristics of in vivo confocal microscopy (IVCM) for Nocardia keratitis. Methods: It was a retrospective case series study. Medical records of 16 consecutive patients (16 eyes) with Nocardia keratitis were collected from the Department of Ophthalmology at Beijing Tongren Hospital, Capital Medical University between 2018 and 2022. The group consisted of 11 males and 5 females. The inclusion criteria for the study were the presence of typical clinical manifestations of Nocardia keratitis and at least one positive pathogenic test (corneal scraping or microbial culture) indicating Nocardia infection. The medical history, clinical and microbiological examination data of the patients were analyzed, including risk factors, diagnosis time, clinical manifestations, diagnostic methods, strain isolation, cure time, and best corrected visual acuity before and after treatment. This study utilized techniques such as slit lamp microscopy, in vivo confocal microscopy (IVCM), scraping cytology, microbial culture, and mass spectrometry identification. Results: The main risk factors for Nocardia keratitis included plant or foreign body injuries (5 out of 16 cases), contact lens use (4 out of 16 cases), and surgery (2 out of 16 cases). The average time to diagnosis was (20.8±11.8) days, with the shortest time being 8 days and the longest being 60 days. The best corrected visual acuity was less than 0.05 in 7 patients, between 0.05 to 0.3 in 7 patients, and greater than or equal to 0.3 in 2 patients. The typical symptoms included superficial gray-white infiltration in a wreath-like pattern on the cornea, corneal ulcers with dry and gray-white necrotic tissue coverage, and in severe cases, corneal ulcer perforation. Nocardia corneal infection was identified in 12 out of 16 cases by scraping cytology, 9 out of 16 cases by mass spectrometry, and 8 out of 16 cases by both methods. IVCM showed the presence of fine and moderately reflective filamentous hyphae in the subepithelial and superficial stromal layer of the cornea, arranged in elongated, beaded, and branched structures. Infiltration of many hyper-reflective round inflammatory cells was also seen around the hyphae. Fourteen cases were treated with medication and 2 cases were treated with corneal transplantation. The average cure time was (37.5±25.2) days and there were no cases of recurrence during the follow-up period (all greater than 6 months). Conclusions: Nocardia keratitis is primarily characterized by dense, round, or wreath-like infiltration in the early stage, and by gray-white dry necrotic secretion and hypopyon on the surface of corneal ulcers in the middle and late stages. Fine, branched or beaded, and moderately reflective filamentous structures are the hallmark of the corneal lesion on the IVCM images.

SMILE lenticule versus amniotic membrane graft (AMG) augmented with platelet-rich plasma (PRP) for the treatment of perforated corneal ulcer.

To evaluate the safety and efficacy of stromal lenticule obtained from small-incision lenticule extraction (SMILE) surgery versus amniotic membrane graft (AMG) augmented with platelet-rich plasma (PRP) for the treatment of perforated corneal ulcers and compare the results between the two groups. This is a comparative retrospective study that included 40 eyes with medium-sized corneal perforations, which were classified into two equal groups of 20 eyes each; group (A) was treated with SMILE lenticule graft and group (B) was treated with AMG augmented with PRP. Pre- and postoperative evaluations were carried out using both slit-lamp (SL) examination and anterior segment optical coherence tomography (AS-OCT), including closure of perforation, complete healing, and best corrected visual acuity (BCVA). Complete closure of the perforation was achieved in both groups. However, healing was faster in the SMILE lenticule group than in the AMG with PRP group (P < 0.05). Complete healing was achieved inboth groups: 100% in SMILE lenticule group and 95% in AMG with PRP group (P > 0.05). Both groups had few insignificant complications (30% in each), which were managed. Both methods achieved adequate healing of corneal perforations within few weeks without significant complications. However, the stromal lenticule obtained from small-incision lenticule extraction (SMILE) surgery tended to be safer with faster healing than AMG with PRP.

Ocular manifestations in a case of herpes zoster ophthalmicus with human immunodeficiency virus

Abstract This is a case report of human immunodeficiency virus infection whose primary presentation was with herpes zoster ophthalmicus with sterile corneal perforation which is unusual. A 48-year-old female patient presented with redness and painful decrease in vision in the right eye for the past two weeks. Examination revealed skin lesions in right side of face, with complete ptosis in right eye with restricted ocular movements suggestive of third nerve palsy. Slit lamp examination revealed sterile perforated peripheral corneal ulcer in right eye. Screening of viral markers revealed that patient was positive for human immunodeficiency virus. The case was treated conservatively with oral antivirals, topical antibiotics, and lubricants. The patient was started on highly active antiretroviral therapy from nearby antiretroviral therapy centre. We planned to do a corneal patch graft for the patient but the patient was not willing for any surgical intervention.