Therapeutic Penetrating Keratoplasty Research Articles

Clinical, microbiologic, and treatment outcomes of dematiaceous fungal keratitis - A retrospective study.

Dematiaceous fungi, the third most common causative organism of fungal keratitis, constitute 3.5% to 43.5% of fungal keratitis worldwide. Several studies on filamentous fungi (Aspergillus and Fusarium) are available as opposed to that on dematiaceous fungal keratitis. This study aims to describe the profile of dematiaceous fungal keratitis in South India. This institutional cohort study on culture-proven dematiaceous fungal keratitis was performed in a single ophthalmology referral center in South India for a 6-year period. Records were analyzed for demographic, clinical, microbiological, and treatment outcomes for 3 months from the date of presentation. This study comprised 312 cases involving dematiaceous fungal keratitis (DFK). During the study period, DFK accounted for 10% of microbial keratitis and 24.6% of fungal keratitis cases. The mean (standard deviation) age was 54 (14) years. Males were commonly affected (73.4%). Keratitis was ≤1/3rd depth in 47.8% of cases. Fifty-four cases (17.3%) demonstrated surface pigmentation, and 69 cases (22.1%) had endothelial plaque. Curvularia spp. (99 eyes, 31.7%) was the most common fungal isolate among the speciated fungi. Topical medications resulted in the healing of 63.5% of cases. A total of 193 cases (79%) healed, and 49 cases had to undergo therapeutic penetrating keratoplasty (TPK). Early TPK was performed for 20 cases (40.8%). Seventeen eyes (34.6%) maintained clear grafts at the end of 3 months. In this extensive study on DFK, we report a high incidence of this group of fungal keratitis. We found an excellent healing rate in our cohort of patients.

Use of a novel four-point iris fixated IOL to manage aphakia and to prevent angle closure glaucoma after therapeutic penetrating keratoplasty

Glaucoma after penetrating keratoplasty (PKP) is a well-known complication that may be associated with significant visual morbidity and graft failure. Herein, we report the successful use of a novel four-point iris-fixated intraocular lens (IOL) in two patients who presented with aphakia and uncontrolled glaucoma secondary to synechial angle closure after therapeutic PKP. Having an IOL device that corrects aphakia, as well as mechanically opens the angle by keeping the peripheral iris away from the cornea, can be another valuable alternative in the armamentarium of surgeons managing the twin problems of aphakia and angle-closure glaucoma.

Study of demographic profile, risk factor, clinical profile and microbiological profile of corneal ulcer

: To study the demographic factors, risk factors, microbiological profile and clinical course of patients with corneal ulcer presenting to Minto Regional institute of ophthalmology Bangalore.: A total of 876 patients diagnosed with infective corneal ulcer from January 2018 to January 2020 were retrospectively reviewed and analyzed for demographic profile, risk factors, clinico-microbiological profile at Minto Regional institute of ophthalmology Bengaluru. Among the 876 patients, 596 (68.04%) were male and 280 (31.96%) were females. 613(69.97%) were in the age group of 51-60 years. 85.04% belonged to low socioeconomic class. History of injury from vegetative matter was the leading cause and was seen in 264(30.14%) patients. Among the 613 (69.98%) culture positive patients, 410 (46.81%) were positive for fungi, while 203 (23.17%) were positive for bacteria. 674(76.94%) out of 876 responded to conservative management alone, while 202 (23.06%) patients required therapeutic penetrating keratoplasty. Fungal corneal ulcers caused by Aspergillus were the most common type, followed by bacterial corneal ulcers due to Staphylococcus aureus. Incidence of fungal corneal ulcer is very high among agricultural and industrial workers. Lack of awareness and delayed treatment leads to corneal blindness. This emphasizes the need for awareness among at risk population and also shall guide clinicians in decision making regarding empirical treatment.

STUDY OF CLINICAL PROFILE AND RISK FACTORS OF INFECTED CORNEAL ULCERS AT RURAL TERTIARY CARE HOSPITAL

Introduction: A corneal ulcer is a discontinuation in normal epithelial surface of cornea associated with necrosis of the surrounding corneal tissue. It is a major worldwide cause of preventable corneal blindness that is mostly under-reported but can be responsible every year for 1.5–2.0 million new cases of monocular blindness. Detailed studies of severe sight-threatening infectious keratitis are therefore important as they provide valuable information on the detection of etiology, predisposing factors, and visual outcomes to form the development of management strategies and protocols. Aims and Objectives: To study the clinical profile and known risk factors of infected corneal ulcers at rural tertiary care hospital. Materials and Methods: An Observational, Descriptive Cross-Sectional Hospital-based study was conducted after Institutional Ethical Committee (IEC) at the Department of Ophthalmology, DVPRMC, Loni. A total of 70 patients with infected corneal ulcers were screened and evaluated from June 2022 to May 2023 for a duration of 1 year. We studied the infected corneal ulcer patients above 18 years old attending to our hospital OPD. Results: 57% of patients were male and 43% were female. 66% of patients gave a history of trauma. The most common clinically diagnosed ulcer was fungal, representing 53% of all ulcers, followed by bacterial (27%) and viral (13%). There were also 2 cases each of acanthamoeba (3%) and pythium (3%) ulcers. 62.8% of cases were above 50 years old. In our study 73% of suspected fungal corneal ulcers were KOH smear-positive and 70% of suspected bacterial corneal ulcers were gram-positive. All cases were advised medical management. Out of those 43% were also advised therapeutic penetrating keratoplasty. Conclusion: Corneal ulcers are commonly seen in adult male farmers and laborers with ocular trauma in rural areas and fungal ulcer is the most common type of ulcer. Late presentation with corneal perforation requires therapeutic penetrating keratoplasty.

Three cases of recalcitrant Paecilomyces keratitis in Southern California within a short period

BackgroundThe aim of this report is to describe the risk factors, clinical course, and characteristics of three cases of Paecilomyces keratitis presenting concurrently within three months in the same location. We used in vivo confocal microscopy and histopathology to corroborate our clinical findings.ObservationsThree eyes of three elderly patients with culture-proven Paecilomyces keratitis were included in this series. These patients resided within a 15-mile radius and presented to a tertiary care eye institute in Southern California between February and April 2022. All three eyes experienced a prolonged, recalcitrant course with recurrence of keratitis in donor corneal tissue despite antifungal therapy and multiple therapeutic penetrating keratoplasties. In vivo confocal microscopy, histopathology, and microbiologic findings corroborated the diagnosis of fungal keratitis with Paecilomyces. With surgical intervention and extensive medical therapy, all three cases resolved after the addition of oral Posaconazole.ConclusionsPaecilomyces is a rare cause of infectious keratitis. Herein we report three similar cases in elderly patients. All had prolonged, recalcitrant infections that required multiple treatment modalities. Our cases, which were supported by in vivo confocal microscopy and histopathology, highlight the importance of timely and aggressive therapy to prevent recurrence.

Teleophthalmology in revolutionizing postoperative management of therapeutic penetrating keratoplasty during the COVID-19 pandemic

This case report highlights the successful management of a patient with microbial keratitis who underwent urgent therapeutic penetrating keratoplasty and received postoperative follow-up through teleconsultation during the coronavirus disease 2019 (COVID-19) pandemic. The use of teleophthalmology allowed for remote monitoring of the patient’s graft survival, medication administration, and treatment compliance. The benefits of teleophthalmology are manifold. Teleophthalmology has proven to be invaluable for specialized eye care, reducing socioeconomic burdens, and improving access to health care, particularly in rural areas. This report demonstrates potential of teleconsultation in postoperative care. However, there is still need for further advancement in technology and infrastructure to optimize teleophthalmology services.

Pediatric corneal transplantation: techniques, challenges, and outcomes.

Pediatric corneal transplant is a highly demanding and technically challenging procedure for the cornea surgeon in today's era. These cases pose unique challenges in clinical and surgical management. The indications of pediatric corneal transplant can be therapeutic, tectonic, optical, and cosmetic. Pediatric patients undergoing corneal transplants are at a high risk of graft infection, failure, rejection, dehiscence, and amblyopia due to young age, robust immune system, increased incidence of trauma, and compliance issues. The other factors contributing to graft failure can be allograft rejection, secondary glaucoma, corneal vascularization, multiple surgeries, vitreous prolapse, and lack of treatment compliance. A successful corneal transplant in children depends on meticulous preoperative evaluation, uneventful surgery, the expertise of a corneal surgeon, and regular and timely postoperative follow-up. Therapeutic and optical penetrating keratoplasty are the most commonly performed transplants in children. However, with the advancements in surgical technique and management protocol, the current focus has shifted toward lamellar keratoplasty. Lamellar keratoplasty offers early visual recovery and potentially fewer complications. Visual rehabilitation through corneal transplant in otherwise blind eyes can be a boon for the children. Recently, keratoprostheses have been promising in children with multiple graft failures. The current review gives insights into epidemiology, etiology, indications, clinical characteristics, investigations, management options, recent advances, and the future of pediatric corneal transplants. As surgical techniques continue to grow and comprehension of pediatric corneal transplants is improving, we can safeguard these eyes with the best possible anatomical and functional outcomes.

Trends in keratoplasty from central and northern India. Part II: Types of keratoplasty.

To report the types of keratoplasty and analyze trends over a period of two decades in central and northern India. This was a retrospective review of eye bank registries of six tertiary eye care centers located in central and north India from 2005 to 2021. The indications and various keratoplasty procedures were compared between 2005-2012 and 2013-2021 to analyze the trend. A total of 13,223 corneal grafts were performed, of which therapeutic penetrating keratoplasty (TPK) (5719, 43.3%) was the most common procedure, followed by optical penetrating keratoplasty (OPK) (5528, 41.8%), Descemet stripping endothelial keratoplasty (DSEK) (1279, 9.7%), deep anterior lamellar keratoplasty (DALK) (376, 2.8%), Descemet membrane endothelial keratoplasty (DMEK) (215, 1.6%), patch grafts (75, 0.6%), and keratoprostheses (31, 0.2%). Overall, OPK procedures decreased (-14.1%, P < 0.001), but TPK (+3.1%, P < 0.019), DSEK (+7.1%, P < 0.001), and DMEK (+1.9%, P < 0.001) procedures increased. Although there was an increasing trend in the use of DALK (+0.8%, P < 0.083) and keratoprostheses (+0.3%, P = 0.074) procedures, the trends were not statistically significant. In keeping with worldwide trends, an increasing trend in lamellar keratoplasties was observed in central and northern India during the past decade. The trend was significant for DSEK. However, as corneal ulcers and scars were the major indications for keratoplasty, TPK and OPK remained the most common procedures.

Demography, Clinical Features and Outcome of Bacterial Keratitis Presenting in Tertiary Eye Care in Nepal

Background and Objectives: Bacterial keratitis is an important cause of ocular morbidity in developing country like Nepal and this warrants a detail study of it including its outcome.&#x0D; Material and Methods: Data of demography, clinical features and risk factors of bacterial keratitis were segregated from our previous cross-sectional study of microbial keratitis and retrospective data of treatment and outcome were taken from electronic medical record.&#x0D; Results: Among 123 cases of bacterial keratitis, 111 had bacteria isolated in the culture whereas 12 had bacteria seen only in Gram stain. Average age of patients was 52.6 years; 65(52.8%) were female; 68.3% of total subjects were farmers. Patients had visited the tertiary hospital at an average of 12.9 days since onset of symptoms. Of culture isolates, 55 were Streptococcus pneumonia followed by Staphylococcus aureus (n­­=25) and Streptococcus viridians (n=14). Regarding clinical characteristics, 78(63.4%) cases had hypopyon; 24.3% (n=30) had infiltrate size of &gt;¼ of corneal surface; 16(13.0%) were either perforated or impending to perforate at presentation. Trauma was the main risk factor in 35% (n=43), followed by topical steroid (19.5%, n=24) and dacryocystitis (16.2%, n=20). Patients were treated with combination of fortified cefazoline and amikacin or monotherapy with moxifloxacin or ofloxacin. Overall, 90(73.2%) responded to medical treatment, 19(15.4%) underwent therapeutic penetrating keratoplasty and 3(2.4%) needed evisceration. Smaller sized ulcers had better healing rates (81%) with statistical significance.&#x0D; Conclusion: Patients with bacterial ulcers present late in tertiary eye center causing increased morbidity and even loss of eyes. Awareness, protective measures from trauma and proper treatment has to be undertaken for controlling its occurrence and for better prognosis of the ulcers.

Gamma-irradiated corneas for therapeutic penetrating keratoplasty, anterior lamellar keratoplasty, and sclera for glaucoma valve surgery

Objectives: To report clinical outcomes of gamma-irradiated donor cornea (GIDC) for therapeutic penetrating keratoplasty (TPK), deep anterior lamellar keratoplasty (DALK) and gamma-irradiated donor sclera (GIDS) for glaucoma patch graft (GPG) in glaucoma filtering surgery (GFS) with Ahmed glaucoma valve (AGV). Materials and Methods: A prospective non-randomized, non-comparative, interventional case series of GIDC and GIDS involving 26 patients, of which 20 received GIDC (11 TPK, 9 DALK) and 6 GIDS (6 GPG). Main outcome measures were post-operative tissue characteristics as epithelialization and tissue clarity; and complications including rejection, infection, corneal melt, and other adverse effects. Results: Study included 26 patients, of these 20 received GIDC (11 TPK, 9 DALK) and 6 GIDS (6 GPG). Mean follow up was 8.32 ± 2.31 months. Corneal epithelium healed in 6.2 ± 2.58 days. Graft clarity was achieved in 9 (100%) DALK patients. Only 1 eye (3.8%) had a corneal melt. There were no incidences of rejection or infection in the follow up time. Conclusion: Gamma-irradiated sterilization of donor cornea and sclera is a new innovation to enhance utilization of donor tissue. GIDC is a promising treatment option for TPK and DALK; GIDS for GPG with good epithelialization time and tissue clarity. Gamma irradiation of both donor cornea and sclera achieved adequate sterilization and provided a long shelf life.

Case Series: Mixed Infectious Keratitis by Pythium insidiosum and Fungal Species.

This case series is the first to illustrate mixed infection from Pythium sp. and fungal species in corneal ulcer. This case series aimed to alert all toward the possibility of both Pythium sp. and fungal species infection in case of nonresponding corneal ulcer treated with either antifungals or antipythium drugs alone. Increased suspicion of mixed infection in case of nonresponding fungal/ Pythium keratitis may facilitate early and prompt management. Six patients presented with signs of either fungal or Pythium keratitis. They underwent ophthalmological examinations, smear examinations, cultures, and polymerase chain reaction (PCR). Therapeutic penetrating keratoplasty was performed in cases where symptoms worsened after treatment with either antifungal or antipythium drugs. The half corneal button (HCB) was shared for histopathological and microbiological examinations. In the first case, smear examination from corneal scraping (CS) revealed Pythium -like filaments, which were confirmed with PCR; however, Aspergillus nidulans grew in culture. In the second case, iodine-potassium iodide (IKI) staining was positive for Pythium ; however, PCR was positive for both Pythium and fungus, which was further confirmed by DNA sequencing. In the third case, IKI staining and HCB were positive for Pythium ; however, PCR was positive for fungus, which was identified as Candida saitoana with DNA sequencing. In the fourth case, Pythium grew in the CS culture; however, Candida sp. grew in the HCB culture. In the fifth case, Cladosporium sp. grew in culture from CS; however, Pythium insidiosum grew from the anterior chamber exudate after therapeutic penetrating keratoplasty. In the sixth case, smear examination revealed septate fungal filaments, and Cladosporium sp. grew in culture; however, HCB on histopathological examination showed features of Pythium keratitis. In unresponsive cases of Pythium or fungal keratitis, diagnostic modalities such as IKI and PCR should be implemented as a routine practice, in addition to smears and cultures.

Small-aperture intraocular lens implantation after multiple penetrating keratoplasties secondary to penetrating ocular trauma

Introduction: The small-aperture intraocular lens (IOL) is a recently introduced IOL that can provide favorable central visual acuity in patients with irregular corneas. This case describes a patient with multiple prior penetrating keratoplasties secondary to ocular trauma that achieved a favorable outcome with the aforementioned IOL. Patient and Clinical Findings: A 66-year-old man presented with a penetrating corneal injury that was successfully repaired but was eventually complicated by fungal keratitis requiring a therapeutic penetrating keratoplasty (PKP). The patient had a prolonged postoperative course complicated by multiple graft failures and finally stabilized after a third PKP. Through the protracted course, the patient developed a brunescent cataract, and the multiple PKPs resulted in significant irregular astigmatism. Diagnosis, Intervention, and Outcomes: The patient underwent cataract surgery in the affected eye with implantation of a small-aperture IOL 18 months after his initial injury. The patient's uncorrected distance visual acuity was 20/20 at six months post-operatively and he reported excellent quality of vision. Conclusions: This case represents the first use of the small-aperture IOL in a patient with prior PKP since its U.S. Food and Drug Administration approval. The small-aperture IOL can overcome high levels of corneal irregularities and provide favorable visual acuity in complex eyes.

OUTCOME OF THERAPEUTIC PENETRATING KERATOPLASTY IN A TERTIARY EYE HOSPITAL IN NEPAL

Background: Therapeutic penetrating keratoplasty is the most common variety of keratoplasty performed in the developing countries. The objective of this study was to assess the outcome of therapeutic penetrating keratoplasty in infective keratitis. Methods: This was a hospital based retrospective study where medical records of patients who underwent therapeutic penetrating keratoplasty between July 2021 and December 2022 were analyzed. Data collected included demographic parameters, indications for surgery, microbiology of the ulcers, donor details. Success was evaluated in terms of eradication of the disease, anatomical stability, graft clarity and visual acuity. SPSS software version 20.0 was used for statistical analysis. The mean, standard deviation, frequency and percentage were calculated Results: Sixty-seven patients of therapeutic penetrating keratoplasty who completed 2 months of follow-up after surgery were included in the study. Corneal scrapings and corneal buttons were positive for organisms in 19 cases (90.47%) and 20 cases (29.85%) respectively. In all,out of 67 eyes, 30 (44.77%) were positive for organisms in smear or culture or both, of which 27 cases showed pure fungus and 3 cases showed pure bacteria. Aspergillus (8, 29.62%) was the commonest fungus isolated. Eradication of infection after the primary procedure was seen in 48 cases (71.64%). Anatomical success was seen in 60 eyes (89.50%), clear grafts were seen in 23 eyes (34.32%). Visual acuity of ≥6/60 was seen in 14 eyes (20.89%). Conclusions: Therapeutic penetrating keratoplasty provided good success in terms of maintaining anatomical integrity and helps in eradication of infection while giving satisfactory functional outcome.

Outcomes of Pre-Descemet Endothelial Keratoplasty for Failed Therapeutic Penetrating Keratoplasty.

The aim of this study was to analyze the outcomes of pre-Descemet endothelial keratoplasty (PDEK) for failed therapeutic penetrating keratoplasty. This was a retrospective, interventional study that involved 12 eyes of 12 patients with failed therapeutic penetrating keratoplasty that underwent PDEK. All cases had a minimum follow-up of 12 months. The main outcome measures were best-corrected visual acuity, graft clarity, endothelial cell density loss, and graft survival. Corneal clarity was graded on a scale from 0 to 4, where grade 4 denoted an absolutely clear cornea and grade 0 denoted a totally opaque cornea. Three cases underwent PDEK, 6 cases PDEK with phacoemulsification, and 3 cases underwent PDEK with pupilloplasty. The mean follow-up period for all cases was 18.5 ± 4.9 months. The mean preoperative and postoperative best-corrected visual acuity (in Snellen decimal equivalent) was 0.02 ± 0.01 and 0.54 ± 0.17, respectively, at the last follow-up. Postoperatively, corneal clarity grade 4 was present in 9 eyes, grade 3 in 2 eyes, and grade 2 in 1 eye. Mild subepithelial haze was noted in 2 eyes. The percentage of endothelial cell density loss was 28.2% ± 10.6%. No correlation was observed between the postoperative graft clarity and preoperative specular count (r = -0.021, P = 0.512). Rebubbling was performed for 1 eye that developed partial graft detachment in the first postoperative week. One patient had an episode of rejection that was managed with systemic and topical steroids. In patients with failed therapeutic penetrating keratoplasty, PDEK can be a useful alternative for visual rehabilitation as it demonstrates favorable visual outcomes with a good graft survival rate.

Demography, clinical features, and outcome of fungal keratitis presenting in tertiary eye care in Nepal

Background: Fungal keratitis is an important cause of ocular morbidity in developing countries. Aims and Objectives: To study fungal keratitis in detail along with its outcome. Materials and Methods: This is a retrospective study of fungal keratitis that had presented between October 2013 and March 2015. Results: 168 fungal ulcers were enrolled. 145 had fungus isolated in the culture; 23 had fungal elements seen only in potassium hydroxide mount examination. The average age of patients was 46.7 years. 55.3% were male. 75% were farmers. Patients presented at an average of 23.6 days since the onset of symptoms. In 85 cases (50.6%), trauma was the risk factor followed by steroid use (12.5%, n=21) and diabetes mellitus (7.7%, n=13). 72 out of 85 cases of trauma were due to vegetative matter. 94 (55.9%) ulcers had hypopyon. 56 (33.3%) ulcers had infiltrate size of ≥¼ of corneal surface. 12 (7.1%) ulcers were perforated at presentation. Out of 145 fungal isolates, Aspergillus species and Fusarium species were isolated in equal numbers (n=41, 28.3% each), followed by unidentified hyaline fungus (14.4%, n=21). The ulcers were treated with combination of topical natamycin 5% and fluconazole 0.3% with or without oral fluconazole. 111 (66.1%) fungal ulcers improved with medical treatment, 37 (n=22.0%) underwent therapeutic penetrating keratoplasty, 6 (3.6%) were eviscerated and outcome unknown in 14 (8.3%). Smaller-sized ulcers, ulcers without hypopyon and those presenting within 7 days had better prognosis (&gt;80% healing with medical treatment) with statistical significance. Conclusion: Farmers were constantly at risk of fungal keratitis due to work-related trauma. Fungal ulcers presented late with large sized ulcers and with complications, thus making treatment challenging and necessitating surgical intervention. Timely treatment had better prognosis.

Long-term outcomes of therapeutic corneal transplants performed in a tertiary eye care hospital in South India.

This study aimed to review the demographics, clinical characteristics, and long-term outcomes of therapeutic penetrating keratoplasty (TPK) performed in a tertiary eye care hospital. Case records of 149 therapeutic transplants (135 patients) that were performed during the calendar year 2016 were retrospectively analyzed, and outcomes were measured until 3 years of follow-up. Information on demographics, presentation characteristics, keratoplasty indications, offending microbe, and secondary surgical interventions was studied. The final outcome was classified in terms of therapeutic, anatomical, and functional outcomes. The median age of the recipients was 55 years with 61% men. The most common indications for TPK were perforated infectious ulcer (45.9%), nonhealing ulcers (29.9%), and graft infections (17.4%). Fungal etiology was noted in 61.2% and bacterial etiology in 17.4% of the eyes. Therapeutic success was achieved in 130 eyes (89%) at the end of 1 month. Anatomical success was achieved in 130 (98.5%) and 88 patients (86.3%) at the end of 1 and 6 months, respectively. At the 6-month time point, 78 patients (76.5%) attained functional success with vision better than light perception. Three-year follow-up data were available for 23.7% of recipients, of which only 12 patients (37.5%) retained a clear graft either after a primary therapeutic or secondary optical keratoplasty. Therapeutic keratoplasty is highly effective in eradicating infection and providing anatomical integrity. However, timely intervention can aid in achieving the best functional outcome.

Therapeutic Penetrating Keratoplasty for Severe Fungal Keratitis in a Thai Tertiary Care Center

Objective: To evaluate the outcomes of therapeutic penetrating keratoplasty (TPK) performed for severe fungal keratitis. Materials and Methods: Medical records of all patients who underwent TPK in Siriraj Medical Center between April 2010 and July 2020 were culled, and those in which fungal pathogens were definitively identified were studied. Patient records with follow up less than three months were excluded. Patient demographic data, outcome measures and complications following TPK were recorded. The primary outcome was eradication of the fungal infection. Secondary outcomes were preservation of anatomical integrity, graft survival and achievement of visual acuity (VA) greater than or equal to 3/60. Results: Sixty patients met the study criteria and were included in the analysis. The mean patient age was 56 (range: 23-79) years, and most patients were men (46, 77%). The mean follows up time was 30.87 months (range1.61-122.71). Fifteen eyes (25%) sustained corneal perforation before undergoing TPK. Graft survival was 30% at 1 year, 18% at 5 years, and 11% at 10 years. The most common organism was fusarium (23 patients, 38%). The median duration from presentation to surgery was 14 (8-21) days. Disease eradication was achieved in 44 patients (73%) and VA better than 3/60 was achieved in 14 (23%). Anatomical integrity was maintained in 46 (76%) eyes. Repeat PKP was performed in 15 patients (25%), most commonly for recurrent infection. Conclusion: TPK offers a good chance of disease eradication and maintenance of anatomical globe integrity and is a reasonable therapeutic option in patients with severe fungal infection.

Two-step strategy-conjunctival flap covering surgery combined with secondary deep anterior lamellar keratoplasty for the treatment of high-risk fungal keratitis.

To investigate whether the two-step strategy [conjunctival flap covering surgery (CFCS) combined with secondary deep anterior lamellar keratoplasty (DALK)] is effective for patients with high-risk fungal keratitis (FK). In this noncomparative, retrospective case series, 10 subjects (6 males, 4 females) with a mean age of 56.5±7.1 (range 47-72)y with high-risk FK undergone the two-step strategy were included. Reported outcome measures were healing of the corneal ulcer, recurrence of FK, reject reaction, improvement in best corrected visual acuity (BCVA) and relevant complications. The average diameter of corneal infiltrates was 7.50±0.39 mm, ranging from 6.94 to 8.13 mm. The mean depth of corneal infiltrates was 422.4±77.1 µm, ranging from 350 to 535 µm. The mean corneal thickness was 597.4±117.3 µm, ranging from 458 to 851 µm. Hypopyon and endothelial plaques were presented in all patients. The period between the two steps was 3.65±0.9 (ranging from 3 to 5)mo. The graft diameter was 7.75±0.39 mm. At the last follow-up (average 9.25±3.39, ranging from 5.5 to 17mo), no fungal recurrence or graft rejection appeared, and all patients showed improvement of BCVA. One patient suffered from liver function impairment due to oral voriconazole for 4wk and recovered spontaneously after 1wk of drug withdrawal. The two-step strategy is safe and effective in the treatment of high-risk FK by transforming intentional therapeutic penetrating keratoplasty during acute infection to later optical DALK. It is a practical strategy, especially in areas lacking fresh donor corneas and eye bank services.

CASE REPORT: Multidrug-resistant Pseudomonas keratitis and sequential endophthalmitis treated with chlorhexidine and piperacillin-tazobactam

Purpose To report the clinical course and treatment strategies employed in management of a case of multidrug-resistant Pseudomonas aeruginosa keratitis progressing to endophthalmitis. The drug-resistant strain was later traced to use of contaminated EzriCare Artificial Tears in a multi-state cluster outbreak. Observations A 57-year-old male patient with a history of Descemet stripping automated endothelial keratoplasty was referred for a culture-positive Pseudomonas corneal ulcer in the right eye that had been treated with several weeks of topical moxifloxacin, fortified vancomycin and tobramycin, and intravitreal injections for endophthalmitis. His cornea was cultured off of antibiotics and grew only rare Propionibacterium acnes. Topical antibiotics and steroids were reduced, but his condition rapidly deteriorated with leading to corneal melt, perforation, and endophthalmitis. Repeat corneal cultures and sensitivity analyses revealed growth of a strain of Pseudomonas aeruginosa that was resistant to fluoroquinolones, aminoglycosides, cephalosporins, monobactams, and carbapenems, and only intermediate susceptibility to piperacillin-tazobactam. The patient underwent a therapeutic penetrating keratoplasty and was subsequently initiated on an intensive regimen of topical chlorhexidine and polymyxin-B/trimethoprim. He also underwent a pars plana vitrectomy with anterior chamber washout, followed by serial injections of intravitreal piperacillin-tazobactam at a dose of 225 mg/0.1 mL. After 8 weeks of intensive treatment, there was gradual with healing of his ocular surface, regression of his hypopyon and posterior inflammation, and no signs of recurrent infection. A public health investigation ultimately revealed that his infection was one of several cases involved in a multistate cluster outbreak of extensively drug-resistant Pseudomonas ocular infections that were traced to the use of contaminated EzriCare Artificial Tears. Conclusions and Importance Multidrug-resistant keratitis and endophthalmitis caused by multidrug-resistant Pseudomonas keratitis requires consideration of nonconventional antimicrobial agents and experimental therapeutic alternatives. Topical chlorhexidine and intravitreal piperacillin-tazobactam are currently nonconventional therapies in the context of bacterial keratitis and endophthalmitis, but were safe and effective in the management of multidrug-resistant Pseudomonas aeruginosa ocular infection.

Clinical Features, Risk Factors, and Management of Candida Keratitis

ABSTRACT Background/Aims To determine the clinical features, predisposing factors, and management of infectious keratitis caused by Candida spp. Methods Retrospective chart review. Results The medical records of 52 patients (54 eyes) with Candida keratitis were available for statistical analysis. Thinning of the corneal stroma was identified in 34 eyes (63.0%), and corneal perforation occurred in 16 eyes (29.6%). Corneal thinning and perforation were more common in Candida albicans compared with non-albicans (P-val < .001, P = .09, respectively). The most common predisposing factors for Candida keratitis were topical steroid use (21 patients, 40.4%), previous corneal transplantation (17 patients, 32.7%), and preexisting ocular surface disease (15 patients, 28.8%). Fourteen eyes (25.9%) required cyanoacrylate glue application and 10 eyes (18.5%) underwent therapeutic penetrating keratoplasty (TPK). Conclusion Local immunosuppression and ocular surface disease play an important role in Candida keratitis. C. albicans appears to be more invasive compared with non-albicans spp.