Interface Scopulariopsis gracilis fungal keratitis following Descemet's stripping automated endothelial keratoplasty (DSAEK) with a contaminated graft.

PURPOSE: To report for the first time a case of interface Scopulariopsis gracilis fungal keratitis following Descemet's stripping automated endothelial keratoplasty (DSAEK) with a contaminated graft. METHODS: A 57-year-old man with bilateral keratoconus and previous bilateral penetrating keratoplasties (PK) developed graft failure in association with marked corneal ectasia. He underwent a successful DSAEK. Unfortunately, a contaminated graft was transplanted and the following morning we were contacted by the eye bank to inform us a slow-growing fungus had been detected in the culture plates inoculated with dextran solution used to store the issued corneoscleral button. Immediate patient review revealed four infiltrates in the interface between the donor and the recipient tissue. The patient returned to theatre for the removal of the infected graft and was successfully treated with topical amphotericin 0.15%, voriconazole 1% and oral voriconazole and later oral itraconazole. Two intracameral injections of 5 µg in 0.1 ml of amphotericin B were also performed. RESULTS: A reference laboratory cultured and identified the fungus as Scopulariopsis gracilis species. The patient responded to treatment and eventually achieved a spectacle-corrected logMAR visual acuity of 0.3 following a delayed PK. CONCLUSION: Scopulariopsis gracilis fungal keratitis is a rare infection, and the species can be difficult to eradicate. This is the first case report of an infection secondary to a contaminated graft with the species, and we report its successful treatment with an excellent visual outcome.

Oral antivirals for preventing recurrent herpes simplex keratitis in people with corneal grafts.

BACKGROUND: Ocular herpes is a viral infection of the eye caused by the herpes simplex virus (HSV), a double-stranded DNA virus. Corneal scarring caused by herpes simplex keratitis (HSK) is the leading infectious cause of penetrating corneal graft in high-income countries. Acyclovir is an antiviral drug known to have a protective effect against recurrences in herpetic eye disease. While there are some studies which have evaluated the effects of intervention with oral antiviral in preventing such recurrences in people with corneal grafts, a systematic review of all comparative clinical trials has not been previously undertaken. OBJECTIVES: To assess the efficacy of oral antivirals such as acyclovir in any dosage when taken for six months or more, in preventing recurrence of herpetic keratitis in people having corneal graft surgery for herpetic keratitis. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 5), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to June 2016), Embase (January 1980 to June 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 1 June 2016. We handsearched conference proceedings and contacted authors of the included studies and researchers active in the field. SELECTION CRITERIA: We included randomised controlled trials (RCTs). People enrolled in these trials had corneal grafts for HSK. The intervention was oral antivirals for six months or more following the corneal graft surgery, and this was compared to no treatment or placebo. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. We contacted trial investigators for any clarification or missing information. We graded the certainty of the evidence using GRADE. MAIN RESULTS: We included three trials, involving 126 participants, comparing the use of oral acyclovir to no treatment or placebo. Two studies were conducted in single centres in Turkey and the USA, and one was multi-centred in the Netherlands. In general, the studies were poorly reported and it was difficult to judge the extent to which bias had been avoided.Oral acyclovir may reduce the risk of recurrence of herpetic keratitis (risk ratio (RR) 0.29, 95% confidence interval (CI) 0.13 to 0.64, 126 people, low-certainty evidence). Based on data from the included trials, this corresponds to approximately 23 fewer cases of HSK recurrence (95% CI 29 fewer cases to 12 fewer cases) per 100 corneal graft operations if oral acyclovir is used.Oral acyclovir may reduce the risk of graft failure (RR 0.40, 95% CI 0.16 to 0.97, 126 people, low-certainty evidence). Based on data from the included trials, this corresponds to approximately 13 fewer cases of graft failure (95% CI 18 fewer cases to 1 fewer cases) per 100 corneal graft operations if oral acyclovir is used.None of the studies reported any serious side effects of the antivirals necessitating stoppage or change. None of the trials reported outcomes over the long term (more than two years) or any data on quality of life. AUTHORS' CONCLUSIONS: Compared to placebo or to no treatment, oral antiviral (acyclovir) may reduce the risk of recurrence of herpetic keratitis in the first 12 months in eyes that have undergone corneal graft surgery.

Atypical hydrops in keratoconus.

To report the clinical presentation, progress and management of atypical acute hydrops. A retrospective case study of three patients with keratoconus, two of whom had previously undergone penetrating keratoplasty. The patients underwent full ophthalmological examination and digital slit-lamp imaging of the cornea throughout the course of the condition. The two patients who had previously undergone keratoplasty had spontaneous hydrops primarily affecting the host bed but in one case extended to the graft inferiorly; however, in the third patient it was traumatic in origin. The Descemet's tear affected the host rim in only one patient, which resolved spontaneously. In another patient, the hydrops was related to an internal dehiscence of the graft-host junction and had to be managed by an endothelial transplant covering the dehisced graft-host junction. In the third patient, hydrops secondary to trauma was also associated with acute haemops. Progression of keratoconus post keratoplasty can occur exclusively in the recipient bed leading to acute hydrops in the host sparing the transplanted cornea. The progressive thinning and ectasia of the recipient bed can also result in internal graft-host dehiscence leading to chronic oedema. Rapid entry of aqueous or blood cells into the corneal stroma following acute rupture of the Descemet's membrane suggests that the abnormal stroma of the eye with keratoconus may have an important role to play in the pathogenesis of acute hydrops/haemops.

Profile of sight-threatening infectious keratitis: a prospective study.

PURPOSE: To prospectively study patients presenting with sight-threatening corneal ulcers with a view to identify the predisposing factors, causative organisms, clinical signs and treatment outcomes. METHODS: Prospectively, over 3-year period, all cases with serious infective keratitis presenting to Queens Medical Hospital in Nottingham, UK, were recruited. Detailed information on the aetiology, culture results, signs & symptoms, the treatment given and the patient's response was collected and statistically analysed. RESULTS: One hundred and forty-three eyes of 129 patients were enrolled. Thirty-one patients were managed as out-patients, and 98 were treated as in-patients. The mean duration of admission was 9 ± 13 days but was significantly higher in older patients and in Acanthamoeba keratitis cases. The important risk factors were ocular surface disease (32%), contact lens wear (26%) and previous ocular surgery (20%). Old age, deep infiltration, steroid use and poor initial vision were risk factors for prolonged course of treatment in bacterial keratitis. Corneal scrapings were done in 89% of the cases, but positive results were obtained only in 41.7%. Staphylococcus aureus was the most common isolated bacteria (18.8%). Acanthamoeba and Pseudomonas aeruginosa were the second and third common causative organisms (16.6% and 15%, respectively). Overall, 8.3% needed corneal grafting, which survived in 83.3% and eradicated infection in 100%. CONCLUSION: Microbial keratitis is an important cause of ocular morbidity. Previous ocular disease is an important predisposing factor. Old age, steroid use and poor presenting visual acuity are important prognostic indicators. Corneal grafting is an effective option for managing recalcitrant corneal infections.

Outcomes of deep anterior lamellar keratoplasty following successful and failed 'big bubble'.

AIM: The most popular technique for deep anterior lamellar keratoplasty (DALK) is the 'big bubble' (BB) technique wherein air is injected in the cornea to create a bubble that separates Descemet's membrane (DM) from the stroma. An attempt to create a BB often results in the cornea being filled with numerous small bubbles without the formation of a BB. Manual dissection is then required to complete the procedure. The aim of the study is to compare these two groups, successful BB versus failed bubble (FB) dissection to determine whether the clinical outcomes were different. METHODS: In this retrospective comparative study, 46 patients out of 52 who underwent DALK for various corneal stromal diseases such as keratoconus, stromal dystrophy or corneal scarring (caused by different conditions) were included in the analysis. BB was achieved in 25 patients and in the remaining 21 patients a BB separation of the DM was not possible necessitating manual lamellar dissection of stroma to get as close to the DM as possible. RESULTS: The authors compared best-corrected visual acuity, contrast sensitivity, astigmatism, interface densitometry and Scheimpflug pachymetry in the two groups. Postoperative corneal thickness was higher in the 'small bubbles' group (mean 628.9 vs 564.1 µm; p<0.0005), but there was no significant difference in best-corrected visual acuity, astigmatism, contrast sensitivity and densitometry between the groups. CONCLUSIONS: In DALK, manual lamellar dissection is a reasonable alternative when BB separation of the DM is not achieved.

Alcohol debridement of the corneal epithelium in PRK and LASEK: an electron microscopic study.

PURPOSE: To determine the plane of cleavage of the corneal epithelium and smoothness of underlying stroma, after alcohol debridement in photorefractive keratectomy (PRK) and laser subepithelial keratectomy (LASEK). METHODS: The epithelial flap from six patients undergoing alcohol delamination of corneal epithelium before PRK and the epithelium and stroma from three eye bank donor eyes were fixed and processed for transmission (TEM) and scanning electron microscopy (SEM). The smoothness of the underlying stroma was studied by SEM and the plane of cleavage was determined by morphologic examination and morphometric measurements of basement membrane attached to the epithelial flap, using image-analysis software. RESULTS: A very smooth stromal bed, ideal for PRK was seen in the stroma of all three eye bank donor eyes after alcohol delamination. The plane of cleavage was determined to be at the hemidesmosomal attachments, including the most superficial part of the lamina lucida of the basement membrane. CONCLUSIONS: Alcohol delamination of the corneal epithelium before PRK or LASEK consistently results in a very smooth cleavage at the level of the hemidesmosomal attachments, including the superficial lamina lucida. It leaves behind a very smooth surface, which is ideal for PRK. It also allows for an intact epithelial flap to be lifted as a sheet from the corneal surface and hence is ideally suited for the LASEK technique.