Management Of Microbial Keratitis Research Articles

Role of traditional healers in the management of microbial keratitis in eastern Nepal

Background Microbial Keratitis (MK) is a leading cause of corneal blindness due to infection and its consequences, with a higher incidence in resource-limited nations. Hospital-based patient records from different parts of Nepal suggest patients often use traditional eye medicine to treat MK. Traditional healers (TH) within the community are often the first point of care for MK management. Little is known of their practice, perceptions, and knowledge around MK management. We aimed to understand the role of traditional healers in the management of MK in south-eastern Nepal. Methods A cross-sectional, mixed method, descriptive study was conducted in the Siraha district of Nepal. A total of 109 traditional healers consented to participate in a survey of knowledge, attitude, and practices. Some participants were also invited to participate in in-depth interviews and focus group discussions. Interviews and focus groups were conducted and recorded in the Maithili language by a native speaking interviewer and transcribed into English. Descriptive analysis was performed for the survey. Data saturation was considered the endpoint for qualitative data collection, and a thematic was analysis applied. Results Traditional healers believe that infection of the eye can be caused by trauma, conjunctivitis, or evil spirits. They were unclear about differentiating MK from other eye conditions. They provided various types of treatment. Some were confident that they could treat severe ulcers that had not responded to medical therapy, while others thought treating larger diameter ulcers would be difficult. Although there were mixed responses in referring patients with MK, the majority of TH were willing to refer. Conclusion In a weak health system, traditional healers may help address barriers to healthcare access and reduce delays to definitive care, upon integration into the formal health system and referral pathway.

Analysis of corneal scrape outcomes in NHS Ayrshire and Arran

Aims/Purpose: Corneal scrape is a key diagnostic procedure in the management of microbial keratitis. Safe technique for corneal scrape is a requirement of the Royal College of Ophthalmology (RCOphth) curriculum; national and international best practice guidelines exist (1, 2). The purpose of our project is to evaluate the local method of scraping in Ayrshire and Aran, Scotland. The primary aims of this project are to determine: the current method of corneal scraping, the yield of positive samples and impact on safe patient care.Methods: The corneal scrape samples submitted to microbiology from Ayr Casualty Clinic were analysed between 1st November 2021–19th December 2022. An audit was taken of the equipment available in clinical areas of the Ophthalmology department and the technique used by on‐call clinicians. Through liaising with microbiology, a local poster was created with guidelines for performing corneal scrape and placed in the eye casualty department with appropriate equipment set up.Results: There was large variation in the clinical technique used to perform the corneal scrapes. None of the on‐call clinicians were able to perform the technique to the published standard. There were no slides, agar plates or needles available for use. One third of clinicians described the correct technique but had no access to the correct equipment. Two‐thirds did not describe the correct technique. Twenty‐two samples were submitted between 01/11/2021–19/12/2022. All samples were cultured, however there were only two positive samples.Conclusions: Uncertainty and clinical variation exist in the clinical technique used to perform this key diagnostic procedure. There are no guidelines available in the casualty clinic or on‐call room and the necessary equipment is unavailable. The next steps include the creation of a local protocol with correct equipment available to improve the diagnostic yield.

The role of corneal biopsy in the management of microbial keratitis.

Corneal biopsy helps in diagnosing deep-seated or recalcitrant lesions of microbial keratitis (MK). We aim to analyze its role in managing these challenging cases. This is a retrospective review of 22 cases of corneal biopsy at our institute from January 2010 to December 2021. Data were retrospectively collected using the electronic medical record (EMR) system. Those cases of indolent, progressive MK or deep-seated lesions where cornea scraping was not possible were considered for corneal biopsy to establish the microbiological diagnosis. The primary aims of our study were to analyze the indications, success rates, and outcomes for biopsy patients in our series. Additional outcomes that were analyzed included the average time from presentation to biopsy, the type of causative organism isolated from the biopsy by either histopathological or microbiological method, and the frequency and outcome of surgical interventions performed. Descriptive statistics using mean (±standard deviation) and median (±range) were used to interpret the demographic data. Overall, 15 of 22 patients (68%) had a positive corneal biopsy after microbiological or histopathological examinations. The most identified organism was microsporidia (n = 4,30.7%), followed by mycobacteria (n = 2,15.4%), gram-negative bacilli (n = 2,15.4%), acid-fast bacilli (n = 1,7.6%), fungus (n = 2,15.4%), gram-positive cocci (n = 1,7.6%), and mixed bacterial infection (n = 1,7.6%). Corneal biopsy should be considered a diagnostic modality for patients with deep-seated or unresponsive MK. It can improve the treatment for MK, ensuring targeted therapy.

Challenges in management of microbial keratitis during COVID-19 pandemic related lockdown: a comparative analysis with pre pandemic data.

PurposeTo study the challenges of managing microbial keratitis(MK) during the COVID19 pandemic related lockdown and assess the outcomes of treatment at a tertiary cornea service.MethodsRetrospective, non comparative study of electronic medical records of MK presenting to a network of four tertiary care cornea services. The medical history, presenting clinical features, microbiology work up and treatment outcomes were analyzed. The primary outcome measure was final outcome at last follow up. Secondary outcomes measures were non-compliance to treatment due to travel restrictions, therapeutic PKP not done due non availability of corneal tissues. Results- MK was noted in 330 eyes of 330 patients between April and May 2020. Of these 237(71.8%) were males. Median age was 45 years(IQR, 33-56). Low socioeconomic status noted in 102(30.9%). Patients travelling beyond the district from where the hospital was located comprised of 64.9%(n=214). At a median follow up of 32 days(IQR, 9-54), 118(35.8%) patients had resolved, with medical management, 73(22.1%) patients were under active treatment, 139(42.1%) were lost to follow up. Sixty-six patients(20%) were non-compliant to treatment of which 59 could not follow appointment schedule due to travel restrictions. Therapeutic PKP (TPK) was planned in 48/128 (37.5%) patients, but was performed in only 34/48 (70.8%) due to non-availability of donor corneas.ConclusionsAbnormal social circumstances due to the COVID pandemic and the ensuing impediments to travel for access to health care affected compliance to treatment of ocular emergencies such as microbial keratitis.

Procedures, Visits, and Procedure Costs in the Management of Microbial Keratitis.

To investigate the burden of procedures, visits, and procedure costs in the management of microbial keratitis (MK). Medical records of patients from an academic hospital outpatient facility between December 2013 and May 2018 were retrospectively reviewed. Patients were included if they were older than the age of 18 years, recruited for study of likely MK, and not concurrently undergoing treatment for other acute eye conditions. For procedural costs, Medicare data for billing were obtained using the Center for Medicare and Medicaid Services Physician Fee Lookup tool. A total of 68 patients were included for analysis. Patients were on average 51.3 years (SD = 19.5), 55.9% women (n = 38), and 89.7% White (n = 61). Per person, the average number of procedures was 2.9 (SD = 4.2). The average number of visits was 13.9 (SD = 9.2) over an average of 26.9 weeks (SD = 24.3). Age (P < 0.0001), positive Gram stain (P = 0.03), and mixed Gram stain (P = 0.002) were positively associated with the number of procedures. Age (P = 0.0003), fungal keratitis (P = 0.02), and mixed Gram stain (P = 0.01) were positively associated with the number of visits. Race was inversely associated with the number of procedures (P = 0.045) and visits (0.03). Patients with bacterial keratitis were more likely to have amniotic membrane grafts (P = 0.01) and tarsorrhaphies (P = 0.03) than fungal patients. Across all procedures performed for the management of MK, the mean cost per patient was $1788.7 (SD = $3324.62). Patients incur many procedural costs and attend many visits during the management of MK. These findings emphasize the importance of patient-provider communication for frequent follow-up care and the potential need to perform procedures for disease management.

Long-term outcomes of therapeutic penetrating keratoplasty for microbial keratitis in a tertiary care center in Turkey

To present the long-term results of therapeutic keratoplasty for microbial keratitis in moderate to advanced phases. The medical records of 44 patients who underwent therapeutic keratoplasty for microbial keratitis at the ophthalmology clinic of a training and research hospital between June 2012 and March 2018 were reviewed in this retrospective study. Of the 65 patients that underwent TPKP, 44 eyes of 44 patients met the inclusion criteria and enrolled in this study. The most commonly found predisposing factor for keratitis was a history of trauma (n = 17, 38.6%), and most of them had occurred with a vegetative matter (n = 14, 31.8%). The most common clinically suspected cause was fungal (n = 17, 38.6%) followed by bacterial (n = 12, 27.3%). In 26 (59.1%) cases, the causative microorganism could not be proved with a microbial culture. The most common causative microorganism was Staphylococcus spp. (n = 4, 9.1%), followed by Fusarium solanii (n = 3, 6.8%). The mean follow-up time was 42 (range 12-54) months. At the last follow-up visit, anatomical success was achieved in 40 (90.9%) cases and the BCVA of more than half of the patients was over 1.0 (logMAR, n = 24, 54.5%). Most commonly seen complication was found to be secondary glaucoma (n = 19, 43.2%), followed by cataracts (n = 9, 34.6%) and graft rejection (n = 12, 27.3%). TPKP offers a definitive solution in the management of microbial keratitis with high rates of anatomical and functional success. However, secondary glaucoma is the most common complication after TPKP, which was seen in almost half of the patients.

The management of microbial keratitis within Uganda’s primary health system: a situational analysis

Background: Microbial keratitis (MK) frequently leads to sight-loss, especially when the infection is severe and/or appropriate treatment is delayed. The primary health system as an entry point plays a central role in facilitating and directing patient access to appropriate care. The purpose of this study was to describe the capacity of primary health centres in Uganda in managing MK. Methods: We carried out a rigorous assessment of primary health centres and mid-cadre training schools in South Western Uganda. Through interviews, checklists and a picture quiz, we assessed capacity and knowledge of MK management. In addition, we interviewed the heads of all the mid-cadre training schools to determine the level of eye health training provided in their curricula. Results: In total, 163 health facilities and 16 training schools were enrolled. Of the health facilities, only 6% had an Ophthalmic Clinical Officer. Only 12% of the health workers could make a diagnosis of MK based on the clinical signs in the picture quiz. Although 35% of the facilities had a microscope, none reported doing corneal scraping. None of the facilities had a stock of the recommended first line treatment options for MK (ciprofloxacin and natamycin eye drops). Among the training schools, 15/16 had an eye health component in the curriculum. However, the majority (56%) of tutors had no formal expertise in eye health. In 14/16 schools, students spent an average of two weeks in an eye unit. Conclusions: Knowledge among health workers and capacity of health facilities in diagnosis and management of MK was low. Training for eye health within mid-cadre training schools was inadequate. More is needed to close these gaps in training and capacity.

The management of microbial keratitis within Uganda's primary health system: a situational analysis.

Background: Microbial keratitis (MK) frequently leads to sight-loss, especially when the infection is severe and/or appropriate treatment is delayed. The primary health system as an entry point plays a central role in facilitating and directing patient access to appropriate care. The purpose of this study was to describe the capacity of primary health centres in Uganda in managing MK. Methods: We carried out a rigorous assessment of primary health centres and mid-cadre training schools in South Western Uganda. Through interviews, checklists and a picture quiz, we assessed capacity and knowledge of MK management. In addition, we interviewed the heads of all the mid-cadre training schools to determine the level of eye health training provided in their curricula. Results: In total, 163 health facilities and 16 training schools were enrolled. Of the health facilities, only 6% had an Ophthalmic Clinical Officer. Only 12% of the health workers could make a diagnosis of MK based on the clinical signs in the picture quiz. Although 35% of the facilities had a microscope, none reported doing corneal scraping. None of the facilities had a stock of the recommended first line treatment options for MK (ciprofloxacin and natamycin eye drops). Among the training schools, 15/16 had an eye health component in the curriculum. However, the majority (56%) of tutors had no formal expertise in eye health. In 14/16 schools, students spent an average of two weeks in an eye unit. Conclusions: Knowledge among health workers and capacity of health facilities in diagnosis and management of MK was low. Training for eye health within mid-cadre training schools was inadequate. More is needed to close these gaps in training and capacity.

Microbial keratitis—A review of epidemiology, pathogenesis, ocular manifestations, and management

Purpose: To review updated knowledge on the epidemiology, pathogenesis, clinical features, and treatment of microbial keratitis (MK). Source of Data: International and local journals containing current literature on MK were sourced through the Internet. Study Selection: Findings consistent with our objectives were compiled and reviewed. Data Extraction: Data were extracted using endnotes. Results: MK is a sight-threatening ocular infection caused by bacteria, fungi, and protist pathogens. The pathogenesis comprises molecular mechanisms describing microbial activities which involve virulence and host factors responsible for ocular tissue damage and progression in keratitis. Clinical features include redness, pain, tearing, blurred vision, and inflammation, but symptoms vary depending on the causative agent. The primary treatment goal is the elimination of causative organism in addition to neutralization of virulence factors and healing of damaged host tissue. A timely review of our current understanding of MK with the recent advances in its treatment will ensure improved management outcomes. Conclusion: Optimal outcome from management of MK will require an updated knowledge of its pathogenesis, clinical features, and treatment protocols, especially in sub-Saharan Africa where its prevalence is on the increase.

Current State of In Vivo Confocal Microscopy in Management of Microbial Keratitis

Purpose: The purpose of this study was to review the current literature on in vivo confocal microscopy of the cornea and to discuss the current clinical indications for its use in microbial keratitis.Methods: Review of select recent literature on in vivo confocal microscopy and atypical microbial keratitis.Results: Delayed diagnosis of Acanthamoeba and fungal keratitis is typical, resulting in significant vision loss. This is partially due to the low sensitivity and time delay of corneal cultures. In the hands of an experienced viewer, the confocal microscope has been found to have a sensitivity of up to 90% in the diagnosis of Acanthamoeba keratitis and close to 80% for fungal keratitis.Conclusion: In vivo confocal microscopy is emerging as a tool for rapid diagnoses in severe infectious keratitis with high sensitivity. In addition, it can be used to monitor treatment response, allowing guidance to clinicians for medical or surgical management.

The value of aetiology in the diagnosis of infectious keratitis

Microbial keratitis is one of the major causes of blindness in China. The rapid and unequivocal identification of the causative organism is the key point for the rational antimicrobial therapy and restoration of the vision. It is difficult for the physician to choice the first step in the management of microbial keratitis: starting antimicrobial therapy after the identification of the causative organism, or starting therapy even there is no organism identification. The authors thought that it is urgent to start the antimicrobial therapy for microbial keratitis, however, the causative organism identification should be performed in time. This steps are necessary for the high diagnostic rate and cure rate of microbial keratitis, also for improving physician's consciousness of causative organism diagnosis.

Corneal deposits and topical ofloxacin—the effect of polypharmacy in the management of microbial keratitis

To report six cases of corneal deposits after administration of topical ofloxacin in the treatment of bacterial keratitis. Six cases of microbial keratitis treated with multiple topical medications, including topical ofloxacin, resulted in corneal precipitates and poor wound healing. In five cases, the precipitates resolved with discontinuation of ofloxacin treatment. However, in one patient, some residual deposits persisted following discontinuation of ofloxacin. The cornea epithelialised, but deposits were identified subepithelially. Fluoroquinolone antibiotic drops have been extensively used in bacterial keratitis because of their ease of availability, broad spectrum of activity, and lack of toxicity. While corneal precipitates have been reported with cases of topical ciprofloxacin and norfloxacin, little has been documented on corneal deposits and topical ofloxacin in the treatment of bacterial keratitis. The predisposing factors resulting in corneal deposits and the role of polypharmacy are important features that may impair epithelialisation. Clinical management should be aimed at reducing the toxic environment and promoting ocular surface stability.

Therapeutic penetrating keratoplasty for microbial keratitis in Taiwan from 1987 to 2001

Purpose To determine the surgical outcomes of therapeutic penetrating keratoplasty (PKP) and its role in the management of microbial keratitis. Design Interventional case series. Methods We retrospectively performed a chart review of the hospital records of all 151 patients undergoing therapeutic PKP for culture-proven microbial keratitis at the National Taiwan University Hospital during a 14 year-period (1987–2001). Patients were divided into three categories: (1) bacterial keratitis; (2) fungal keratitis; and (3) acanthamoebic keratitis. Each of the following criteria was evaluated: (1) graft clarity 1 month and 1 year postoperatively; (2) cure of the disease; and (3) anatomical success rate. Results A total of 108 therapeutic PKP met the criteria. Therapeutic PKP eradicated the infection in 37/41 of patients with bacterial keratitis, 36/52 of patients with fungal keratitis, and 13/15 of patients with acanthamoebic keratitis. 22/32 of grafts of bacterial keratitis, 20/39 of fungal keratitis, and 11/14 of acanthamoebic keratitis remained clear at 1 year postoperatively. A higher percentage of graft clarity at 1 year postoperatively was achieved in all three categories when grafts were 8.5 mm or less compared with larger grafts. All five patients with secondary endophthalmitis observed at the time of therapeutic PKP experienced a progression of infection despite aggressive surgical treatment, and had to be enucleated. Conclusions Therapeutic PKP is valuable in the management of microbial keratitis that is unresponsive to medical therapy. A higher percentage of clear graft was found when grafts were smaller in all three categories. Surgical results are worse for patients with fungal keratitis, regardless of graft clarity, anatomical success, or infection eradication rate.

Microbial keratitis after laser in situ keratomileusis.

To review the literature on microbial keratitis reported after laser in situ keratomileusis (LASIK). Forty-one eyes have been reported to have microbial keratitis after LASIK. The causative organisms vary from gram positive bacteria to atypical mycobacteria, fungal, and viral pathogens. The infection is usually acquired intraoperatively, but may also be caused by postoperative contamination. A majority of the patients present within 72 hours of the surgery with an acute onset of symptoms. Management of microbial keratitis after LASIK includes aggressive topical fortified antibiotic therapy, irrigation of stromal bed with antibiotic solution after lifting the flap, and sending the scraping of the infiltrate for microbiological evaluation. The keratitis heals with scarring and a best spectacle-corrected visual acuity of 20/40 or better can be obtained in the majority of the patients. Microbial keratitis is a sight-threatening complication of LASIK.

Results of Therapeutic Penetrating Keratoplasty

To determine the anatomic and visual results of therapeutic penetrating keratoplasty (PK) and its role in the management of corneal disease. The authors reviewed the records of all of their patients who had undergone therapeutic PK over the past 9 years and evaluated each for the following criteria: cure of disease, graft clarity, and visual acuity. Patients were divided into seven categories: (1 and 2) bacterial and fungal keratitis, (3 and 4) herpetic keratitis, with and without inflammation, (5) acanthamoebic keratitis, (6) perforations due to keratoconjunctivitis sicca, and (7) other causes of perforation. In microbial keratitis, therapeutic PK eradicated the disease in all cases. Seventy-three percent of grafts for bacterial keratitis and 60% for fungal keratitis remained clear. A higher percentage of clarity was achieved when grafts were 9.0 mm or less. Seven patients with secondary endophthalmitis were cured with a surgical approach including therapeutic PK. In herpetic keratitis with active inflammation, only 36% of grafts remained clear, and inflammation recurred in 36%. All perforations due to post-herpetic persistent epithelial defects in "quiet" eyes were grafted successfully. In patients with severe keratoconjunctivitis sicca, eyes were anatomically stabilized in 83%, but all grafts failed because of complications from ocular surface disease. Therapeutic PK is valuable in the management of microbial keratitis that does not respond to antimicrobial therapy. Results are poorer for patients with herpetic keratitis, although selected patients respond to therapeutic PK when other methods of management have failed. Patients with perforations due to keratoconjunctivitis sicca have a uniformly poor prognosis for graft clarity.

The role of penetrating keratoplasty in the management of microbial keratitis

Penetrating keratoplasty was performed as an emergency procedure in 52 eyes which had perforated from acute microbial keratitis and in a further 11 where perforation had not yet occurred. The results are compared with those of keratoplasty in 33 non-infected perforations and 20 eyes where there had been microbial keratitis which had responded to medical therapy leaving a scarred cornea. This latter group had both a better five year survival (90%) compared to all the others (51%), p less than 0.05, and achieved significantly better visual acuities, p less than 0.005.

Causation and Management of Microbial Keratitis in Subtropical Africa

Microbial keratitis is a major cause of corneal blindness in developing countries. One hundred thirty-one episodes of corneal infection in 120 patients over an 11-month period from Soweto, South Africa, were reviewed. Severe staphylococcal lid disease, trauma, and the secondary infection of climatic droplet keratopathy were the major precedents. Unilateral mixed patterns of infection, bilateral keratitis, and childhood keratitis were common. Staphylococci, streptococci, or gram-negative enteric bacilli were the usual causative organisms. Admission rates of corneal perforation were high. Small perforations often could be managed medically without tissue glue. In developing countries, logistic problems necessitate subconjunctival antibiotic therapy; the nursing staff may be too overextended to satisfactorily maintain topical antibiotic regimens. Effective, inexpensive antibiotic dosing schedules, which are appropriate for use by the general medical officer and ancillary health worker, must be developed.

Decision-making in the Management of Microbial Keratitis

The successful management of suppurative microbial keratitis requires five steps: (1) make the clinical diagnosis, (2) perform the proper laboratory procedures, (3) initiate antimicrobial therapy, (4) modify the initial therapy, and (5) terminate therapy. The most helpful guidelines to decision-making in these steps are: (1) the clinical impression, (2) severity of keratitis, (3) results of laboratory studies, (4) disease potential of the responsible organism, and (5) effectiveness and toxicity of various antimicrobial agents. Selection of initial antibiotics ideally should be directed by interpretation of the corneal smears. The preferred initial antibiotic for keratitis caused by a Gram-positive coccus is cefazolin; for a Gram-negative rod, gentamicin; and for a filamentous fungi or yeast, natamycin. Broad, antibacterial therapy should be reserved for suspected bacterial keratitis with negative smears or for severe infections with antecedent treatment. Miconazole may be an effective, alternate agent in fungal keratitis. The safety and efficacy of cortico-steroids in microbial keratitis have not been established.

Symposium on Medical and Surgical Diseases of the Cornea

Like so many of the previous transactions of the New Orleans Academy of Ophthalmology, the most recent volume dealing with the cornea and external diseases of the eye is an excellent compendium of current concepts. In 26 chapters plus a series of round-table discussions, the nine contributing authors cover a broad spectrum of topics ranging from the pathogeneses of recurrent herpes simplex to orthokeratology. The central 13 chapters of this book are devoted largely to keratoplasty, including specialized techniques and management of complications. Several of these chapters are noteworthy for their practical approach to surgical problems. In addition to the surgical material, medical therapeutics is well represented, and the reader will be updated on the recent advances in antiviral therapy and extended-wear contact lenses. Particularly outstanding are the chapters on the management of microbial keratitis and stromal herpes. If this volume suffers any major criticisms, they are related to its