Ring Infiltrate Research Articles

Ocular Cicatricial Pemphigoid in Young Patients.

The purpose of this study is to report ocular cicatricial pemphigoid (OCP) occurring in young patients. Relevant literature is also reviewed. Medical records of patients aged 30 years or younger who were treated for OCP between August 2021 and May 2023 at a tertiary care eye institute were reviewed. The most common differential diagnoses of cicatrizing conjunctivitis, such as Stevens-Johnson syndrome sequelae, chemical injury, chronic topical/systemic drug use, autoimmune connective tissue disorders, or allergic eye diseases, were ruled out based on clinical history, examination, and the Cicatrizing Conjunctivitis Score described by Shanbhag et al. The diagnosis of OCP was confirmed by positive direct immunofluorescence of oral mucosal and/or conjunctival biopsy in a majority of the patients. Seven patients fulfilled the criteria for a diagnosis of OCP. The mean age at presentation was 21.86 ± 5.25 years (13-28 years). Some of the patients presented with relatively atypical features for OCP such as corneal immune ring infiltrate and bilateral corneal perforation. Six patients exhibited systemic mucosal lesions, and the direct immunofluorescence yield was 85.71%. All patients required aggressive immunosuppressive treatment. OCP is classically described as a rare disease that occurs in old age. This case series highlights the importance of a higher index of suspicion for diagnosing OCP at a younger age. Early administration of immunosuppressive agents can potentially control severe ocular surface inflammation and its sequelae.

Differentiation of acanthamoeba keratitis from other non-acanthamoeba keratitis: Risk factors and clinical features.

Infectious Keratitis is one of the most common ocular emergencies seen by ophthalmologists. Our aim is to identify the risk factors and clinical features of Acanthamoeba Keratitis (AK). This retrospective chart review study was conducted at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, and included all the microbial keratitis cases, male and female patients of all ages. The main outcome is the differentiation between various microbial keratitis types. We included 134 consecutive eyes of 126 persons. We had 24 cases of acanthamoeba keratitis, 22 bacterial keratitis, 24 fungal keratitis, 32 herpetic keratitis, and 32 bacterial co-infection. Contact lens wear was found in 33 eyes (24.6%). Among acanthamoeba keratitis patients, 73% were ≤ 39 years of age, and 73% were females (P <0.001). Also, in AK cases, epithelial defect was found in all cases (100%), endothelial plaques were found in 18 eyes (69.2%), 12 cases had radial keratoneuritis (46.2%), and ring infiltrate was found in 53.8% of AK cases. We determined the factors that increase the risk of acanthamoeba infection and the clinical characteristics that help distinguish it from other types of microbial keratitis. Our findings suggest that younger females and patients who wear contact lenses are more likely to develop acanthamoeba keratitis. The occurrence of epitheliopathy, ring infiltrate, radial keratoneuritis, and endothelial plaques indicate the possibility of acanthamoeba infection. Promoting education on wearing contact lenses is essential to reduce the risk of acanthamoeba infection, as it is the most significant risk factor for this infection.

Comparison of therapeutic effects between big-bubble deep anterior lamellar keratoplasty and penetrating keratoplasty for medically unresponsive Acanthamoeba keratitis

PurposeTo compare the outcomes of big-bubble deep anterior lamellar keratoplasty (BB-DALK) and penetrating keratoplasty (PKP) in the management of medically unresponsive Acanthamoeba keratitis (AK).MethodsThis retrospective study included 27 eyes of BB-DALK and 24 eyes of PKP from a tertiary ophthalmology care centre. Glucocorticoid eye drops were subsequently added to the treatment plan 2 months postoperatively based on the evaluation using confocal laser scanning microscopy. The clinical presentations, best-corrected visual acuity (BCVA), postoperative refractive outcomes, graft survival, and Acanthamoeba recurrence were analyzed.ResultsThe AK patients included in the study were in stage 2 or stage 3, and the percentage of patients in stage 3 was higher in the PKP group (P = 0.003). Clinical presentations were mainly corneal ulcers and ring infiltrates, and endothelial plaques, hypopyon, uveitis and glaucoma were more common in the PKP group (P = 0.007). The BCVA and the graft survival rate showed no statistically significant differences between the two groups at 1 year after surgery. However, 3 years postoperatively, the BCVA of 0.71 ± 0.64 logMAR, the graft survival rate of 89.5%, and the endothelial cell density of 1899 ± 125 cells per square millimeter in the BB-DALK group were significantly better than those of the PKP group (P = 0.010, 0.046, and 0.032, respectively). 3 eyes (11.1%) in the BB-DALK group and 2 eyes (8.3%) in the PKP group experienced Acanthamoeba recurrence, but the rates showed no statistically significant difference between the two groups (P = 1.000). In the PKP group, immune rejection and elevated intraocular pressure were observed in 5 and 6 eyes, respectively.ConclusionCorneal transplantation is recommended for AK patients unresponsive to antiamoebic agents. The visual acuity and graft survival can be maintained after BB-DALK surgery. Acanthamoeba recurrence is not related to the surgical approach performed, whereas complete dissection of the infected corneal stroma and delayed prescribing of glucocorticoid eye drops were important to prevent recurrence.

First report of a ring corneal ulcer caused by Cladorrhinum bulbillosum posing a diagnostic debacle: A case report

A young diabetic male patient presented with a ring infiltrate and hypopyon of 1-day onset in the left eye. Though we suspected acanthamoeba keratitis, the initial smear report showed fungal filaments. So, we started dual topical with systemic antifungals. On day 3, the ring was filled with a reddish-brown infiltrate, and the culture grew pale-gray fungal colonies. A clinical diagnosis of dematiaceous fungi was made, commonly observed at our clinic is Curvularia, which responds to the chosen treatment combination. Due to clinical worsening, we considered therapeutic penetrating keratoplasty that got delayed until diabetic control. With further worsening, we re-scraped with a day off medication and performed confocal microscopy and polymerase chain reaction (PCR). The organism was identified as Cladorrhinum bulbillosum from the DNA extract from colonies grown in blood agar when subjected to PCR-based sequencing carried out in the ABI 3130 genetic analyzer. The patient underwent therapeutic penetrating keratoplasty on day 11.

Pearls and Paradigms in the Management of Acanthamoeba Keratitis: A Review

Abstract Acanthamoeba keratitis (AK) generally displays a protracted course with significant morbidity. This is partly due to the fact that it is often misdiagnosed as viral or fungal keratitis. It is associated most with contact lens (CL) wear in developed countries, and exposure to soil or unsanitary water in the developing countries. The textbook description of AK includes the presence of ring infiltration, radial keratoneuritis, and disproportionate pain. Of the patients that presented to our tertiary care center, only 40% had a history of CL use, and 33% had a ring infiltrate. Corneal scraping for microbiological culture on non-nutrient agar serves as the gold standard for diagnosis. Corneal biopsy and confocal microscopy hold diagnostic value in deeper lesions, and polymerase chain reaction and newer molecular techniques are emerging as rapid and effective tools. Biguanides are the drug of choice for AK. But it is important to reconstitute these drugs in correct dosages; otherwise, corneal toxicity can take place. The use of corticosteroids in AK is a matter of debate. We have used corticosteroids in cases with persistent keratitis, severe pain, and extra-corneal manifestations under the cover of amoebicidal therapy. Surgical intervention in the acute phase is reserved for advanced AK with limbus encroachment, perforations, or fulminant corneal abscesses. AK is thus a severe, potentially blinding disease, where a prompt diagnosis ensuring the timely commencement of amoebicidal therapy is an essential component of improving the patient’s prognosis. In this article, we have discussed the presentation, challenges in diagnosis and management, and our experience in managing AK.

Cutaneous arteritis with intimal fibrin ring and immature myeloid cell infiltrate: lymphocytic thrombophilic arteritis or histiocytoid polyarteritis nodosa?

The ongoing debate on whether lymphocytic thrombophilic arteritis (LTA) is a separate disease or a type of polyarteritis nodosa (PAN) has yet to be settled. In this study, we analyzed the nature of infiltrating cells in LTA to resolve this controversy. Skin biopsies from five female patients (mean age 29.4years, age range 16-45years) diagnosed with LTA were immunostained for CD3, CD20, CD68, lysozyme, myeloid cell nuclear differentiation antigen, myeloperoxidase, and PU.1. Immunohistochemistry revealed that the majority of mononuclear cells in all five cases were not lymphocytes but myelomonocytic cells. Given that the infiltrating cells are of the myelomonocyte lineage including immature myeloid cells, PAN was deemed the more appropriate diagnosis for the five cases rather than LTA. Whether PAN with immature myeloid cells (histiocytoid PAN) is the same disease as conventional PAN with mature neutrophils requires further investigation.

Acanthamoeba keratitis – Clinical signs and potential specific conservative treatment

AbstractAcanthamoeba keratitis is a “chameleon”. It presents classically with greyish epithelial changes, perineuritis, superficial multifocal stromal infiltrates and ring infiltrate. In the presence of clinical signs, polymerase chain reaction, in vitro culture or histopathological examination have to be used to confirm the diagnosis. In vivo confocal microscopy is applied as an early non‐invasive ad‐hoc diagnostic method. Our finding emphasizes that pre‐testing the in vitro susceptibility of the AK isolate with the non‐nutrient E. coli agar plate assay against the anti‐amoebic drug intended for treatment will give valuable information on whether the drug is likely to be active on the Acanthamoeba isolate in vivo.

Acanthamoeba keratitis – Specific conservative treatment or surgery?

AbstractClinical signs of acanthamoeba keratitis are in early stages grey‐dirty epithelium, pseudodendritiformic epitheliopathy, perineuritis, multifocal stromal infiltrates, ring infiltrate and in later stages scleritis, iris atrophy, anterior synechiae, secondary glaucoma, mature cataract, and chorioretinitis. Our finding emphasizes that pre‐testing the in vitro susceptibility of the AK isolate with the non‐nutrient E. coli agar plate assay against the anti‐amoebic drug intended for treatment will give valuable information on whether the drug is likely to be active on the Acanthamoeba isolate in vivo. In therapy resistant cases, surgical treatment options such as corneal cryotherapy, amniotic membrane transplantation, riboflavin‐UVA cross‐linking, and penetrating keratoplasty are applied.

Clinical differentiation of Pythium keratitis from fungal keratitis and development of a scoring system.

To differentiate Pythium keratitis from fungal keratitis using clinical signs, to explore usefulness of various signs as diagnostic prognosticators, and develop a clinical scoring system. A retrospective review of medical records and archived clinical photographs of patients with culture-positive Pythium keratitis and hyaline filamentous fungal keratitis was conducted at a tertiary eye institute to explore characteristics of ulcers that may aid diagnosis. Full-thickness corneal stromal keratitis (P = 0.055), a dry ulcer surface (P = 0.010), tentacles (P < 0.0001), intrastromal dots (P < 0.0001), ring infiltrates (P = 0.024), reticular patterns (P < 0.0001), and peripheral furrows (P < 0.0001) were clinical signs associated with Pythium keratitis. Multiple regression analysis identified tentacles (odds ratio: 24.1, 95% confidence interval (CI): 3.8-158.1, P = 0.001) and peripheral furrows (odds ratio: 60.6, 95% CI: 5.1-712.3, P = 0.001) as independent diagnostic prognosticators for Pythium keratitis. The positive and negative likelihood ratios of a dry ulcer surface, tentacles, intrastromal dots, ring infiltrates, reticular patterns, and peripheral furrows predicting Pythium keratitis were 1.6, 13.6, 17.9, 4.3, 30.7, 15.3 and 0.4, 0.4, 0.7, 0.9, 0.6 and 0.8, respectively. The presence of two or more of these clinical signs (excluding a dry ulcer surface) had a sensitivity of 55.6% and a false positive rate of 1.4%. Tentacles, intrastromal dots, ring infiltrates, reticular patterns, and peripheral furrows are clinical signs to be considered for the diagnosis of Pythium keratitis and the presence of two or more signs has a very low false positive rate.

Severe marginal sterile keratitis in a patient with staphylococcal endophthalmitis after phacoemulsification

Postoperative endophthalmitis is sight-threatening, severe inflammation in posterior vitreous cavity and anterior chamber. Marginal keratitis with infiltrates or ulcers following endophthalmitis can be infectious or sterile, but the etiologies related to intraocular infection have rarely been reported. Here we present an unusual case of severe marginal keratitis with sterile infiltrates concomitant with staphylococcal endophthalmitis after phacoemulsification. Creamy white ring infiltrates at the corneolimbal junction was found with severe vitritis. With antibiotics treatment, endophthalmitis improved while the corneal infiltrates progressed. After corneal specimens yielded negative results, the corneal infiltrates improved under proper topical corticosteroid without marked sequelae. In conclusion, noninfectious, immune-related marginal sterile keratitis may develop in patients with staphylococcal endophthalmitis after phacoemulsification.

Peripheral Sterile Corneal Ring Infiltrate after Accelerated Cross-linking.

Peripheral Sterile Corneal Ring Infiltrate after Accelerated Cross-linking.

Corneal ring infiltrate in fungal keratitis

Corneal ring infiltrate in fungal keratitis

Acanthamoeba Keratitis- Camouflage Entity in Eastern Nepal: A Case Series

Acanthamoeba keratitis is a sight-threatening corneal infection and is a growing clinical problem in the world. Though Acanthamoeba keratitis is considered uncommon and rarely reported in Nepal, we encountered six cases in 2019. All patients had redness, photophobia, decreased vision, and pain with ring infiltrate. Ten percent potassium hydroxide mount revealed Acanthamoeba cyst in all cases. Non-nutrient agar overladen with Escherichia coli revealed feeding tracks and Polymerase Chain Reaction revealed T4 genotype Acanthamoeba in four cases. Amoebicidal treatment was started with chlorhexidine 0.02% eye drop half-hourly and supplementary treatment included moxifloxacin eye drop, a combination of polymyxin B sulfate, neomycin sulfate, and bacitracin eye ointment. After treatment, one patient had the best-corrected visual acuity of 6/9 while others had a visual outcome of hand movement. A high level of clinical suspicion and wet mount examination of specimen from infected corneal tissue are essential to aid in rapid diagnosis.

Paracentral sterile ring infiltrate after corneal crosslinking in a child

A child with a paracentral sterile ring infiltrate presenting 3 days after corneal crosslinking (CXL) surgery for keratoconus is reported. The uninterrupted ring-shaped infiltration was seen along the epithelial healing margin in the paracentral cornea. The infiltration was approximately 120 µm deep in the anterior stroma and had sharply defined edges. Swab samples showed negative results. Sterile corneal infiltrate was diagnosed, and the patient was started on topical steroids in addition to the current treatment. The infiltration gradually resolved in the follow-up examinations. Visual loss or permanent corneal haze was not observed at the first month postoperatively. Patients should be carefully evaluated for complications such as sterile infiltrates in the short-term after CXL. An immune response mechanism triggered by the combination of epithelial healing, individual's hypersensitivity, and UV-A irradiation may be etiologically responsible.

Innate and Adaptive Gene Single Nucleotide Polymorphisms Associated With Susceptibility of Severe Inflammatory Complications in Acanthamoeba Keratitis.

PurposeOver a third of patients with Acanthamoeba keratitis (AK) experience severe inflammatory complications (SICs). This study aimed to determine if some contact lens (CL) wearers with AK were predisposed to SICs due to variations in key immune genes.MethodsCL wearers with AK who attended Moorfields Eye Hospital were recruited prospectively between April 2013 and October 2014. SICs were defined as scleritis and/or stromal ring infiltrate. Genomic DNA was processed with an Illumina Low Input Custom Amplicon assay of 58 single nucleotide polymorphism (SNP) targets across 18 genes and tested for association in PLINK.ResultsGenomic DNA was obtained and analyzed for 105 cases of AK, 40 (38%) of whom experienced SICs. SNPs in the CXCL8 gene encoding IL-8 was significantly associated with protection from SICs (chr4: rs1126647, odds ratio [OR] = 0.3, P = 0.005, rs2227543, OR = 0.4, P = 0.007, and rs2227307, OR = 0.4, P = 0.02) after adjusting for age, sex, steroids prediagnosis, and herpes simplex keratitis (HSK) misdiagnosis. Two TLR-4 SNPs were associated with increased risk of SICs (chr9: rs4986791 and rs4986790, both OR = 6.9, P = 0.01). Th-17 associated SNPs (chr1: IL-23R rs11209026, chr2: IL-1β rs16944, and chr12: IL-22 rs1179251) were also associated with SICs.ConclusionsThe current study identifies biologically relevant genetic variants in patients with AK with SICs; IL-8 is associated with a strong neutrophil response in the cornea in AK, TLR-4 is important in early AK disease, and Th-17 genes are associated with adaptive immune responses to AK in animal models. Genetic screening of patients with AK to predict severity is viable and this would be expected to assist disease management.

Acanthamoeba Keratitis in Egypt: Characteristics and Treatment Outcomes.

PurposeTo study the predisposing factors, clinical manifestations, and treatment outcome of patients with Acanthamoeba keratitis (AK) at Tanta University’s Ophthalmology Hospital in Tanta, Egypt.MethodsA retrospective study of 42 patients (44 eyes) with Acanthamoeba keratitis who had medical records available for review over 4 years.ResultsForty-four eyes of 42 patients were treated for AK over the study period. In 29 eyes (65.8%), AK was related to contact lens wear. Severe ocular pain was the main presenting symptom in 38 eyes (86.3%). The most common ocular signs were radial perineural corneal infiltrates (65.9%), pseudo-dendrites (43.2%), ring infiltrates (45.5%), and diffuse stromal infiltration (59%). Acanthamoeba was detected by culture, smear, and in-vivo confocal microscopy (IVCM) in 25 eyes (56.8%), while in 19 eyes (43.2%) the diagnosis was based solely on the clinical findings. IVCM was effective in detection of Acanthamoeba in cases with early presentation, while culture was more sensitive in late presentation with corneal melting. The mean duration of treatment was 73.3 ± 23.7 days. Surgical intervention in the form of tectonic grafts or amniotic membrane transplant was required in five cases (11.3%) due to progressive corneal thinning and perforation. Seventeen patients (38.6%) had 0.2 or better final best-corrected visual acuity after treatment.ConclusionThe diagnosis of AK remains a major challenge for most ophthalmologists. Contact lens abuse is the major risk factor. Early diagnosis and appropriate treatment of AK with biocidal agents can improve the final outcome and help avoid surgical intervention. IVCM is an excellent tool for early diagnosis of AK.

Polymicrobial Keratitis: Risk Factors, Clinical Characteristics, Bacterial Profile, and Antimicrobial Resistance.

To describe clinical characteristics, complications, and the most prevalent microorganisms causing polymicrobial keratitis and their antibiotic sensitivities. A cross-sectional study including a consecutive analysis of patient's records with a diagnosis of bacterial keratitis with a positive culture and antibiogram report were included. Patients were grouped into those having monomicrobial and polymicrobial infection. Features studied included demographic and clinical characteristics, risk factors, Gram stain, cultures, and antibiotic sensitivity. We included 656 patients; in 31.5% more than one microorganism was found. Seven hundred and twenty-three gram-positive bacteria were isolated, and 336 (46.5%) had polymicrobial keratitis. One hundred sixty-one gram-negative bacteria were isolated, and 99 (61.5%) from polymicrobial keratitis. Fourteen (0.60%) patients presented ring infiltrate, and 10 (71.42%) of those patients had polymicrobial keratitis (X2 10.654, P=0.001). Multivariate analysis showed that patients with history of contact lens use (odds ratio [OR] of 1.78, P=0.042), coexistent autoimmune disease (OR 4.64, P=0.03), irregular edges of the infiltrate (OR 2.06, P=0.005), and ring infiltrate (OR 6.034, P=0.005) have a higher risk for developing polymicrobial infection. In the polymicrobial group, gram-positive and gram-negative organisms showed a high sensitivity to Netilmicin. We found a high incidence of polymicrobial keratitis. Our results suggest that it should be suspected in patients with a history of contact lens use, coexistent autoimmune disease, infiltrates with indistinct edges, and ring infiltrates. Sensitivities to moxifloxacin are lower than those reported in previous studies, but sensitivity to Netilmicin is higher.

Delayed diagnoses of Acanthamoeba keratitis at a tertiary care medical centre.

To determine the prevalence and reasons for delays in diagnosis in patients with Acanthamoeba keratitis (AK) presenting to Wilmer Eye Institute, Baltimore, Maryland. This retrospective study analysed all patients with culture-positive AK seen between 2012 and 2019 at a tertiary referral centre. Patient demographic information, clinical history, risk factors, symptom duration, referral patterns, slit lamp examination findings, visual acuity and need for surgery were collected. The study included 45 eyes of 43 patients. On average, patients were symptomatic for 52.6 days before culture collection. Thirty-one percent of patients were diagnosed within 28 days of symptom onset while 69% were diagnosed after 28 days. Before presentation to a tertiary care centre, 69% of patients were evaluated by an ophthalmologist outside of this institution and 27% were evaluated by a provider other than an ophthalmologist. AK was most commonly misdiagnosed as herpetic keratitis, occurring in 38% of patients. The strongest risk factor for AK was contact lens use. Only 11% of patients presented with the classic ring infiltrate and 82% had pain. Patients with an early versus late diagnosis had a mean Snellen visual acuity (VA) of 20/224 versus 20/296 at presentation (p = 0.33) and a mean Snellen VA of 20/91 versus 20/240 at final visit (p = 0.07). 11% of patients required a therapeutic penetrating keratoplasty. Delayed diagnosis of AK in our cohort occurred due to a misdiagnosis as herpetic keratitis, non-specific clinical signs including the lack of pain in a number of patients, and a delay in referral to a tertiary care centre. Any contact lens wearer with an atypical keratitis should be referred promptly for Acanthamoeba cultures.

Chameleon-Like Corneal Disorders: Acanthamoeba Keratitis

Acanthamoeba keratitis is a "chameleon". It presents classically with greyish epithelial changes, perineuritis, superficial multifocal stromal infiltrates and ring infiltrate. In the presence of clinical signs, polymerase chain reaction, in vitro culture or histopathological examination have to be used to confirm the diagnosis. In vivo confocal microscopy is applied as an early non-invasive ad-hoc diagnostic method.

Acanthamoeba keratitis in Australia: demographics, associated factors, presentation and outcomes: a 15-year case review.

To report the demographics, frequency of potential predisposing factors, presentation and outcomes of Acanthamoeba keratitis (AK) at a quaternary eye hospital in Sydney, Australia over a 15-year period. A retrospective review of all patients diagnosed with AK at the Sydney Eye Hospital, Sydney, Australia between January 2002 and December 2016 was conducted. A total of 52 patients with AK at the quaternary referral hospital in Sydney, Australia, between January 2002 and December 2016, were included. The most commonly documented potential predisposing factors were contact lens wear (83%) and organic trauma (10%) in the non-contact lens wearers. An initial misdiagnosis of herpetic eye disease was made in 37% of patients. The presenting clinical features in order of frequency included; punctate epitheliopathy in 65% (n = 34), perineural infiltrate 46% (n = 24), stromal infiltrates 46% (n = 24), anterior uveitis 39% (n = 20), epithelial defect 35% (n = 18), limbitis 31% (n = 16), pseudo-dendrite 19% (n = 10), and ring infiltrate 4% (n = 7). Twenty-seven of the patients completed their follow-up at the Sydney Eye Hospital, improving their vision from 1.02 logMAR at presentation to 0.57 logMAR at last follow-up. Thirty-nine complications developed in 32 eyes and included corneal scarring and vascularisation, three patients experienced recurrences of AK and one patient developed a late-onset scleritis. In Australia, AK occurred predominantly in contact lens wearers with typical clinical features including epitheliopathy and perineural infiltrates. The patient demographics, frequency of potential predisposing factors and clinical presentation of AK were similar to case series from the UK and New Zealand.