Severe Infectious Keratitis Research Articles

Bilateral Infectious Keratitis After Implantation of Intrastromal Corneal Ring Segments

To report the development of bilateral infectious keratitis after implantation of intrastromal corneal ring segments (ICRSs). Retrospective case report. A 20-year-old woman presented with photophobia, decreased vision, and pain 11 days after uncomplicated implantation of ICRSs for keratoconus in both eyes. Bilateral corneal stromal infiltrates were noted at the site of ICRSs implantation. The patient was started on frequent topical fortified antibiotics in both eyes. Despite aggressive medical management, stromal infiltrates progressed, necessitating removal of ICRSs from both corneas to control infectious keratitis and melting of cornea. Retrospective case report of a 20-year-old woman who developed bilateral severe infectious keratitis 11 days after uncomplicated implantation of ICRSs for keratoconus. Cultures obtained at the time of initial presentation yielded Streptococcus viridans. Patient responded well to the treatment and was left with stromal scars in both corneas. Although rare, simultaneous implantation of ICRSs may carry a risk of severe bilateral infectious keratitis. Early recognition of infection, aggressive treatment with antibiotics, and, in some cases, removal of ICRSs may be necessary to prevent serious sight-threatening complication of this refractive procedure.

Large-Diameter Penetrating Keratoplasty: Indications and Outcomes

To report the indications and outcomes of patients who underwent large-diameter penetrating keratoplasty (LDPK) for the management of peripheral corneal disease. A retrospective chart review and data analysis of patients who underwent LDPK was performed. A retrospective chart review of 35 eyes of 32 patients undergoing LDPK between May 2000 and December 2006 at the Cincinnati Eye Institute/University of Cincinnati was completed. Corneal grafts 8.75 mm or larger were designated as large grafts. Graft diameter ranged from 8.75 mm to 10.0 mm. Indications for cornea transplantation included keratoconus (19), pellucid marginal degeneration (two), keratoconus and pellucid marginal degeneration (five), Fuchs endothelial dystrophy (one), corneal stromal scar (one), postradial keratotomy irregular astigmatism (two), and repeat penetrating keratoplasty (five). No evidence of preoperative stromal neovascularization was seen in any eye. Five of 35 eyes had experienced one previous graft failure. Minimum follow up was 12 months (range, 12-91 months) with a mean follow up of 29.8 months. Preoperative best-corrected visual acuity was 20/100 (range, 20/25 to hand movements), and postoperative best-corrected visual acuity was 20/32 (range, 20/20-20/125). Postoperatively, 43% of patients had 20/40 or better uncorrected visual acuity. Average postoperative manifest cylinder was +2.19 D (range, none to +4.75 D) with 77% of patients having less than +3.00 D of cylinder. The postoperative immunosuppression regimen included topical corticosteroid and topical cyclosporine 0.05%. The incidence of cataract formation in our study was 14.2%. The incidence of secondary glaucoma was 8.8%. Cornea graft rejection was noted in six of 35 eyes with resolution in 4/6. Repeat cornea transplant was required in one of six eyes for severe infectious keratitis, and one of six eyes was lost to follow up. At last follow up, 33 of 35 original grafts were clear with one graft lost to follow up and one eye requiring repeat keratoplasty. No graft rejection was experienced by any patient with a history of prior graft failure. LDPK may result in less postoperative astigmatism without an increased risk of graft failure if managed correctly postoperatively. Topical cyclosporine 0.05% may be a useful adjunct to decrease the incidence of graft rejection and failure. Ophthalmologists performing penetrating keratoplasty should consider a LDPK to reduce postoperative astigmatism and improve visual acuity outcomes in their patients.

No sutures corneal grafting—A novel use of overlay sutures and fibrin glue in Deep Anterior Lamellar Keratoplasty

To describe a case where Deep Anterior Lamellar Keratoplasty (DLK) was performed using overlay sutures and fibrin glue alone, without the need to directly suture the corneal button. Deep Anterior Lamellar Keratoplasty was performed using a modified Melles technique on a 21-year-old patient who had stromal scarring secondary to severe infective keratitis. Overlay sutures and fibrin glue were used to secure the donor button and then a bandage contact lens was inserted. No sutures were required to directly suture the donor button to host tissue. All securing sutures were removed 4 weeks after the surgery. Six months post surgery, the graft was clear and the patient rehabilitated by wearing acceptable astigmatic spectacle correction. The patients visual acuity in the affected eye was 6/12 wearing a spectacle prescription of -0.25/-3.25x160. The use of overlay sutures and fibrin glue in DLK is a time efficient and effective technique. We propose that this technique may be used routinely in cases where donor corneal button appears to fit well in the stromal bed at the time of surgery, that is, where there is no disparity in the thickness of the donor button compared to the host bed.

AcanthamoebaKeratitis in a U.S. Army Soldier after Unauthorized Use of Contact Lenses in the Combat Theater

A 25-year-old active duty Army E-5 developed severe infectious keratitis in his left eye secondary to soft contact lens (CL) wear while deployed in Iraq, necessitating evacuation to Walter Reed Army Medical Center for further evaluation and treatment. Initial clinical examination at Walter Reed Army Medical Center was suggestive of Acanthamoeba keratitis, a serious corneal pathogen associated with CL wear. In vivo confocal microscopy demonstrated Acanthamoeba cysts in the epithelium and anterior stroma, and smears and cultures from an epithelial biopsy specimen confirmed the diagnosis of Acanthamoeba keratitis. To our knowledge this is the first reported case of Acanthamoeba keratitis in a soldier wearing CLs in the combat theater. Because of the inability to maintain proper lens hygiene in a combat or field environment, the risk of developing a potentially sight-threatening corneal infection is significant. This unfortunate case of a devastating eye infection serves as a reminder of the current Army policy, which prohibits the use of CLs during gas chamber exercises, field training, and combat.

Spectrum of Fungal Keratitis in North China

To report the epidemiological features, laboratory findings, and treatment outcomes in patients with fungal keratitis in north China. Retrospective hospital-based study. A total of 654 patients diagnosed with fungal keratitis at the Shandong Eye Institute from January 1999 to December 2004. The medical records of 654 inpatients (654 eyes) with fungal keratitis were reviewed retrospectively for demographic features, risk factors, seasonal variation, clinical characteristics, laboratory findings, and treatment strategy. Patient history, ocular examination findings by slit-lamp biomicroscopy, laboratory findings from direct smear examination and fungal culture, and treatment protocol. Fungal keratitis constituted 61.9% of cases of severe infective keratitis among the inpatients at the Shandong Eye Institute during the 6 years. Males (60.6%) were more likely to be affected by fungal keratitis than females (39.4%). Almost one third of the patients (203) were middle aged (41-50 years old). Corneal trauma (51.4%), especially injury from plants (25.7% in all patients), was the most commonly associated risk factor. The incidence of fungal keratitis was higher in harvest seasons, including summer and autumn. An increasing tendency of incidence was noted in more recent years. Direct microscopic examination of the corneal scraping samples stained with potassium hydroxide showed positivity in 88.7% of the eyes. The fungal isolates were of Fusarium species in 437 eyes (73.3%) and Aspergillus species in 72 eyes (12.1%). Surgical interventions were performed in 604 eyes (92.4%), including therapeutic penetrating keratoplasty in 399 eyes (66.0%) and therapeutic lamellar keratoplasty (LK) in 177 eyes (29.3%). Globe integrity was preserved in 626 eyes (95.7%). With Fusarium species being the most commonly isolated pathogens, fungal keratitis is the leading cause of severe infective corneal ulcers in north China. Direct microscopic examination with potassium hydroxide wet mounts proves to be a rapid, simple, inexpensive diagnostic means. Corneal transplantation continues to be the most effective approach for the treatment of severe fungal keratitis. Early surgery, especially LK, can be considered if aggressive topical therapy does not achieve early disease control.

Mikrobielle Keratitis

To determine the risk factors and the influence of complementary/alternative medicines (CAM) for infectious keratitis in a monsoon-free region of the Sultanate of Oman. Retrospective single center cohort study. Demographic data, risk factors, and pathogens. Patients with purulent stromal keratitis admitted from 2001-2004 were evaluated for clinical and microbiological data, CAM use, duration of hospitalization, and outcome of treatment. chi(2)-test, Z-test. A total of 320 patients (326 eyes) out of 7,524 admissions had severe infectious stromal keratitis requiring inpatient treatment. The average age was 35.1+/-2.5 years (range 1.5-63 years), the male:female ratio was 2:3 in the age group >or=13 years and 2:1 in the age group <or=12 years. Unsuccessful treatment by traditional healers prior to presentation was recorded for 203 patients (62.3%). Ocular risk factors included severe trachomatous dry eye conditions, meibomianitis and soft contact lens overwear. Systemic compromising risk factors were diabetes mellitus and medical immunosuppression. A total of 215 patient eyes (66%) had delayed or no healing (therapy drop-outs), and hospitalization (45 days) was significantly prolonged compared to the 111 antibiotic responders (26 days) (p<0.001). All eyes of patients with prior CAM had worse vision at admission and after therapy (p<0.001), and 97 eyes of patients with uncontrolled diabetes (p<0.001) and 68 eyes of patients with immunosuppression (p<0.001) had a poor visual outcome (vision <0.1). Thirteen eyes perforated. A negative microbiological result correlated with worse final vision (p<0.05). All 13 perforated eyes had received prior CAM (p<0.001). Trachoma, trauma and contact lens overwear are significant risk factors for infectious keratitis in Oman and correlate with specific age groups. Delay in treatment due to the first-line utilization of CAM showed a significant adverse impact on outcome.

Subpalpebral Lavage Antibiotic Treatment for Severe Infectious Scleritis and Keratitis

To report the subpalpebral lavage therapy for the treatment of infectious scleritis and keratitis. Six patients were admitted for treatment of severe infectious scleritis and keratitis and were initiated on the subpalpebral lavage system after showing no improvement with topical fortified antibiotics. A continuous antibiotic lavage was applied until clinical sterility was achieved and topical steroids were gradually added to control concomitant inflammation. All 6 patients had resolution of their infections and achieved a stable ocular surface with no inflammation. One patient required a corneal transplant for active inflammation and corneal thinning, 1 had a transplant for a dense central corneal scar, and 1 patient underwent corneal transplant and cataract extraction. One case was a Pseudomonas keratitis in a blind eye, which rapidly resolved and has remained stable. Four patients required additional surgeries, which included 3 corneal transplants, 2 cataract extractions, and 1 glaucoma aqueous shunt. Continuous irrigation of the eye can improve scleral penetration of antibiotics. Subpalpebral lavage provides continuous irrigation and may be effective in the treatment of infectious scleritis of a variety of etiologies.

Six‐year review of Acanthamoeba keratitis in New South Wales, Australia: 1997–2002

AbstractAim: To assess the incidence and risk factors for Acanthamoeba keratitis (AK), the diagnostic interval, and the efficacy and outcome of current treatment among the population of New South Wales, Australia.Methods: A retrospective review was carried out of all cases of AK treated at the Sydney Eye Hospital between January 1997 and December 2002.Results: Twenty patients were identified with a mean follow up of 24.8 ± 21.5 months. Acanthamoeba keratitis constitutes 4.7% of severe infective keratitis treated at Sydney Eye Hospital. The mean interval from first presentation to diagnosis was 26.6 ± 35.1 days overall; 17.2 ± 33.1 days for those presenting directly to our unit (69% being diagnosed within 72 h of presentation), and 44.1 ± 34.0 days for those first presenting elsewhere. Of those with a diagnostic delay &gt;1 month, 57% had been mistakenly diagnosed with Herpes simplex keratitis. Sixteen (80%) wore contact lenses, and eight (40%) had additional risk factors including poor lens hygiene. Complications occurred in 16 (80%), with seven (35%) requiring surgical intervention. Visual acuity improved in 18 (90%), worsened in two patients (10%), and 75% achieved 6/12 or better at last follow up.Conclusions: Acanthamoeba keratitis is a rare infection, and contact lens wear remains the commonest association, with poor hygiene constituting significant additional risk. The visual outcome has improved with the availability of effective amoebicidal agents, but patients with a diagnostic delay and non‐contact lens wearers are at increased risk of recurrent disease. A high index of clinical suspicion remains the most effective strategy in implementing early treatment, and enabling a favourable outcome.

This issue of Acta

This issue of Acta

Infectious keratitis after photorefractive keratectomy in a comanaged setting

A 48-year-old man had simultaneous bilateral photorefractive keratectomy (PRK). The surgeon who performed the PRK did not see the patient in follow-up, and there was confusion regarding the comanaging doctor. Therefore, the patient was not examined immediately postoperatively. Several days later, he was hospitalized for an unrelated, painful orthopedic problem and heavily sedated. Seven days after the PRK, an ophthalmologist was consulted for ocular irritation and discharge. Examination showed bilateral, purulent conjunctivitis and severe infectious keratitis in the left eye. The patient was treated with periocular and topical antibiotics. Corneal cultures yielded Staphylococcus aureus. The keratitis resolved slowly, leaving the patient with hand motion visual acuity. A corneal transplant and cataract extraction was performed 15 months later, resulting in a best corrected visual acuity of 20/400 because of glaucomatous optic nerve damage. Severe infectious keratitis may occur after PRK. Poor communication between the surgeon, comanaging doctor, and patient may result in treatment delay.