Severe chemical eye injuries - clinical outcomes and associated socio-economic factors.

Aims: To describe clinical outcomes, management, and socio-economic impact of severe acute chemical eye injuries in a tertiary hospital. Methods: 37 patients required emergency admission to the Royal Victoria Infirmary eye ward between April 2013 and September 2015. Demographics, best corrected distance visual acuity (BCDVA), causative agent, degree of limbal stem cell deficiency (LSCD), management and socio-economic data were evaluated. Results: Mean age on admission was 34.5 years (SD 16.3; range 16-82); 30 males (81.1%); 22 bilateral (59.5%). Causative agent: alkali in 30 cases (81.1%); acid in three cases (8.1%); and unknown in four cases (10.8%). Fifteen cases (40.5%) were assaults, 12 (32.5%) work-related accidents, nine (24.3%) domestic accidents and one (2.7%) undetermined. Eleven patients (29.7%) were unemployed, 18 (48.6%) were labourers, three (8.1%) were students, three (8.1%) were retired and two (5.4%) were professionals. Mean admission time was five days (SD 3.2; range 1-12). Mean follow-up time was 170.5 days (range 1-946). Mean cost of admission was £2478 (range £274-5785). Five patients (13%; seven eyes) developed total or partial limbal stem cell deficiency, all being assaults. Conclusions: Main causative agent in our study was alkali, with young men in the working age being most frequently involved. Many patients required prolonged hospital admission and costly follow-up. The majority of cases were assaults, mostly occurring in unemployed patients. All the limbal stem cell deficiency cases were due to assaults. We believe that socio-economic factors play an important role in the cause, severity and cost of chemical eye injuries. Lay Summary: Acute chemical eye injuries have a significant and extensive impact on patients' visual function outcomes and vision-related quality of life, with consequent enormous burden to affected individuals, their families and society. We believe that by understanding the socio-economic environment, we may not only be able to enforce safety measures to tackle the increasing rate of severe chemical eye injuries in our community, but also to develop collaborative programmes with the community, educating the population on the seriousness of chemical eye injuries, and with the local authorities, trying to understand the clustering of assaults in areas and tackling the associated socio-economic risk factors, such as unemployment. Given the increasing rate of assaults using chemicals in recent times, it is also important to assess availability of adequate victim support programmes and develop good interaction with relevant local, regional and national authorities to ensure all aspects of community security service are in place to be able to address any potential deficiencies in line with police and home office guidelines. Keeping in mind that the best action plan is always prevention. However, when an ocular injury does occur it is evident that significant morbidity and visual sequelae can result and affect the socio-economic status of the victims despite our best current medical and surgical care.

Repeat corneal collagen cross-linking after failure of primary cross-linking in keratoconus.

BACKGROUND: Primary corneal collagen cross-linking (CXL) stabilises 96% of progressive keratoconus. There is limited evidence for the treatment of choice when this fails. We present 10 years of repeat CXL and compare with our published experience of primary CXL to (1) identify perioperative risk factors of primary CXL failure and (2) demonstrate the safety and efficacy of repeat CXL. METHODS: Patients undergoing repeat accelerated epithelium-off CXL at St James's University Hospital, Leeds, UK January 2012-August 2022 were identified through electronic patient record, and compared with a previously published cohort of primary CXL patients at the same site. RESULTS: Twenty-one eyes underwent repeat CXL. The mean interval between primary and repeat CXL treatments was 47.1 months (SD 22.5). Twenty (95%) eyes stabilised after repeat CXL at a mean follow-up of 29.9 months. These cases were compared with 151 cases of primary CXL from our previous study. Patients failing primary CXL were significantly younger (21.3 years (SD 7.0) vs 26.7 years (SD 6.5), p=0.0008). Repeat CXL and primary CXL induced a similar amount of flattening of Kmax (-1.2 D (SD 3.9) vs -0.7 D (SD 4.4), p=0.22). A small, but clinically insignificant, improvement in best-corrected visual acuity was found in the repeat CXL group (-0.04 (SD 0.17) vs -0.05 (SD 0.13), p=0.04). No complications of repeat CXL were noted. CONCLUSION: Younger age may be associated with failure of primary CXL. Repeat CXL is an effective and safe treatment for progressive keratoconus despite primary CXL.

Repeated Intracameral Amphotericin B: A Safe Approach for Management of Fungal Anterior Chamber Reactivations After Therapeutic Penetrating Keratoplasty.

PURPOSE: The aim of this study was to describe the safe use of repeated intracameral amphotericin B for anterior chamber reactivations after therapeutic penetrating keratoplasty for Fusarium solani keratitis. METHODS: A 49-year-old woman monthly soft contact lens wearer with a history of overuse and swimming in her lenses presented with a red painful left eye. Her vision was 0.5 logMAR and there was a poorly demarcated corneal infiltrate. Although corneal scrapes and a corneal biopsy were negative, confocal microscopy showed fungal hyphae. After failure of medical treatment, therapeutic penetrating keratoplasty was performed. Fusarium solani sensitive to amphotericin was isolated. There was pan-azole resistance. The patient was managed with topical amphotericin B, and repeated anterior chamber reactivations were managed with intracameral amphotericin B 5 µg in 0.1 mL on 9 occasions over 5 months after sensitivities were known. Topical cyclosporine was used as the sole immunomodulator postoperatively, with no topical steroid use over the 4-year follow-up period. RESULTS: There were no episodes of graft rejection and no endothelial, lenticular, or retinal toxicity. The best-corrected visual acuity is -0.1 logMAR and the endothelial cell count is 2160/mm 2 . CONCLUSION: This report describes the safe and effective use of repeated intracameral amphotericin (cumulative 45 µg) in anterior chamber reactivations after therapeutic penetrating keratoplasty and highlights the role of fungal sensitivity in guiding treatment in refractory cases. It also demonstrated the successful use of topical cyclosporin as the sole postoperative immunomodulatory therapy despite repeated recurrence of infection and consequent increased inflammation in the postoperative period.

Understanding Ocular Surface Inflammation in Tears Before and After Autologous Cultivated Limbal Epithelial Stem Cell Transplantation.

INTRODUCTION: We aimed to determine the expression of inflammatory cytokines in the tears of patients with unilateral total limbal stem cell deficiency (TLSCD) caused by chemical burns before and after autologous cultivated limbal epithelial stem cell transplantation (CLET). METHODS: Tear samples were collected from both eyes of 23 patients with unilateral TLSCD and 11 healthy controls, at fixed timepoints before and after CLET. Dissolved molecules were extracted from Schirmer's strips using a standardised method and analysed on an array plate of ten inflammatory cytokines (V-Plex Proinflammatory Panel 1 Human Kit, MSD). RESULTS: IL1ß expression was significantly elevated in the TLSCD eye compared with the unaffected eye at baseline (p < 0.0001) but decreased to normal 3 months post-CLET (p = 0.22). IL6 and IL8 were unaffected at baseline but significantly elevated in the TLSCD eyes at 1 month post-CLET (p = 0.001 and p < 0.0001, respectively). IL6 returned to normal at 3 months and IL8 at 6 months post-CLET. There was a significant renewed increase in IL1ß, IL6 and IL8 expression at 12 months post-CLET (p < 0.0001, p = 0.0001 and p = 0.0003, respectively). IFNγ, IL10 and IL12p70 expression were significantly reduced in both eyes of patients with unilateral TLSCD at all timepoints. CONCLUSION: IL1ß is a specific marker of inflammation in TLSCD eyes that could be therapeutically targeted pre-CLET to improve stem cell engraftment. At 12 months post-CLET the spike in levels of IL1ß, IL6 and IL8 coincides with cessation of topical steroids, suggesting ongoing subclinical inflammation. We therefore recommend not discontinuing topical steroid treatment in cases where penetrating keratoplasty is indicated; however, further investigation is needed to ascertain this. TRIAL REGISTRATION: European Union Drug Regulating Authorities Clinical Trials Database (EuDRACT 2011-000608-16); ISRCTN (International Standard Randomised Controlled Trial Number (isrctn51772481).

Microbial Keratitis in Corneal Transplants: A 12-Year Analysis.

PURPOSE: To investigate the frequencies, trends, and in vitro drug susceptibilities of the causative pathogens in corneal transplant microbial infections in Manchester Royal Eye Hospital. METHODS: Corneal scrape results recorded by the microbiology service between 2004 and 2015 were extracted from an established database. This microbiological data was matched with a separate database of all corneal transplant procedures performed in our centre over this time period. Patient records were examined to collect specific patient data and to confirm the diagnosis of microbial keratitis. RESULTS: A total of 1508 grafts had been performed at our centre in this period. 72 episodes of graft microbial keratitis were identified from 66 eyes that had undergone keratoplasty procedures. Mean age was 56, and 51% of subjects were male. Ninety-three percent of microbial keratitis episodes occurred in penetrating keratoplasty procedures and 6% in deep anterior lamellar keratoplasty procedures. No endothelial grafts presented with infections throughout this time period. Of the 79 organisms identified, 73% were gram positive, 23% gram negative and 4% fungi. With regard to gram-positive organisms, vancomycin and gentamicin showed 100% and 91% susceptibility, respectively. Ofloxacin had a resistance rate of 13.7%. In terms of gram-negative organisms, gentamicin and chloramphenicol showed 100% sensitivity, with cefuroxime showing 69%. Resistance rates were less than 15% in all tested gram-negative antimicrobials. CONCLUSION: This paper describes the largest collection of corneal transplant infections identified within the UK. This finding may aid clinicians in predicting possible causative organisms for microbial keratitis and aid antibiotic choice.

Next-Generation Sequencing of the Ocular Surface Microbiome: In Health, Contact Lens Wear, Diabetes, Trachoma, and Dry Eye.

OBJECTIVES: To assess publications examining the occurrence, composition, and clinical significance of a microbiome at the ocular surface. METHODS: MEDLINE, EMBASE, and Google Scholar were searched. Reference lists of included articles were also searched for relevant citations. All publications up to June 1, 2019, were analyzed. RESULTS: Eleven articles and 1 abstract were included, analyzing 661 patients. Articles generally report bacteria to the genus level. The presence of DNA associated with diverse bacterial species was reported including pathogenic species, such as Pseudomonas and Neisseria. Bacterial DNA that makes up the microbiome, such as Acinetobacter, Actinomyces, Aquabacterium, Bradyrhizobium, Corynebacterium, Sphingomonas, Staphylococcus, and Streptococcus, in other parts of the body was found. The putative ocular microbiome is consistent between right and left eyes and is affected by contact lens use (higher Pseudomonas levels) and blepharitis (higher Staphylococcus levels). CONCLUSIONS: There is a significant likelihood that there is at least a transitory ocular surface microbiome, with Acinetobacter, Corynebacterium, Propionibacterium, Staphylococcus, and Streptococcus detected in at least 7 of 11 studies. However, further investigation attempting to control for environmental and methodological contaminants (Aquabacterium and Bradyrhizobium are commonly identified as contaminants in DNA extraction kits) is required. Bacteria, such as Propionibacterium, Staphylococcus, and Streptococcus, capable of causing sight-threatening infections may reside on a healthy ocular surface. With greater understanding, we can establish whether elements of the ocular surface microbiome are harmful or protective (despite their small quantities); furthermore, new therapeutic agents can be identified to treat and prevent ocular surface infection and inflammation.

Stenotrophomonas maltophilia-A Case Series of a Rare Keratitis Affecting Patients With Bandage Contact Lens.

OBJECTIVES: Stenotrophomonas maltophilia is an opportunistic pathogen known to form biofilms on contact lens and case surfaces that may result in permanent visual loss in cases of microbial keratitis. Because of its multiple drug resistance and extremely low incidence, there is little consensus on treatment. We investigated the predisposing factors, management, and visual outcomes in a small case series of patients to better inform the management of this rarely reported keratitis. METHODS: Retrospective analysis of medical records was performed at a single tertiary referral center between 2011 and 2017. The case notes of each microbiology confirmed S. maltophilia keratitis were examined. RESULTS: Six cases were identified (four men) with a median age of 62 years (range 1 month-90 years) and pre-existing ocular surface disease in all cases. At presentation, four patients were using bandage contact lenses and three were on topical antibiotic and steroid medications. Initial antibiotic treatment was intensive topical 0.3% ofloxacin and 5% cefuroxime, which was modified based on corneal scrape culture and sensitivity and clinical findings. One patient chose not to complete the treatment course. The 5 remaining patients had complete resolution of ulceration over a mean of 2.9 months (SD 0.8 months). CONCLUSIONS: Contact lens in the context of ocular surface problems, prolonged topical antibiotic and steroid treatments may predispose to S. maltophilia, a rare cause of keratitis. We report successful treatment with case-specific combinations of topical antibiotics such as fluoroquinolone, cotrimoxazole, and/or cephalosporin agents, although visual outcomes remain poor due to corneal scar.

Managing Malnutrition in Older Persons Residing in Care Homes: Nutritional and Clinical Outcomes Following a Screening and Intervention Program.

This study aimed to establish prevalence of malnutrition in older adult care home residents and investigate whether a nutritional screening and intervention program could improve nutritional and clinical outcomes. A community-based cohort study was conducted in five Newcastle care homes. 205 participants entered; 175 were followed up. Residents already taking oral nutritional supplements (ONS) were excluded from interventions. Those with Malnutrition Universal Screening Tool (MUST) score of 1 received dietetic advice and ≥2 received dietetic advice and were prescribed ONS (220 ml, 1.5 kcal/ml) twice daily for 12 weeks. Body mass index (BMI), MUST, mini nutritional assessment score (MNA)®, mid upper arm muscle circumference (MAMC), and Geriatric Depression Scale (GDS) were recorded at baseline and 12 weeks. Malnutrition prevalence was 36.6% ± 6.6 (95% CI). A higher MUST was associated with greater mortality (p = 0.004). Type of intervention received was significantly associated with change in MUST score (p < 0.001); dietetic advice resulting in the greatest improvement. There were no significant changes in BMI (p = 0.445), MAMC (p = 0.256), or GDS (p = 0.385) following the interventions. Dietitian advice may slow the progression of nutritional decline. In this study oral nutritional supplements over a 3-month period did not significantly improve nutritional status in malnourished care home residents.