Case Report: Acanthamoeba Keratitis Management in a First-trimester Pregnant Patient.

SIGNIFICANCE: Lacrimal punctal plugs may prevent the teratogenicity of the treatment used in infectious keratitis. Its use should be strongly considered in these cases. PURPOSE: We present the case of a 7-week pregnant patient with Acanthamoeba keratitis. CASE REPORT: The patient was a contact lens user with photophobia, redness, and intense pain in the right eye that started 2 weeks earlier. Corrected visual acuity was 20/63 (0.5 logMAR). Biomicroscopy revealed a ciliary injection, perineural infiltrates, and corneal edema. Confocal microscopy and culture confirmed the diagnosis of Acanthamoeba keratitis. Prior to treatment with amebicidal eye drops, plugs were implanted in the lacrimal puncta to reduce the risk of drugs' teratogenicity. Three months after initiating amebicidal treatment, a melting ulcer of immunological etiology developed, which was treated with ReGeneraTing Agent eye drops, carboxymethyl glucose polysulfate (Cacicol; Théa, Clermont-Ferrand, France). CONCLUSIONS: Lacrimal occlusion with punctal plugs is one of the available options available in cases of pregnant patients to reduce the risk of teratogenicity.

Peripheral Ulcerative Keratopathy following Systemic Treatment with Bortezomib: A Case Report.

A 60-year-old patient was diagnosed with multiple myeloma in November 2020, and started treatment in December 2020 with bortezomib, dexamethasone, and thalidomide. Four months later, he presented to the ophthalmology emergency department with inflammation and pain in the left eye. Examination of the anterior segment revealed severe, mixed anterior squamous blepharitis with significant bilateral palpebral inflammation, dysfunction of the meibomian glands, and several styes on both eyelids bilaterally. A peripheral ulcerative keratopathy was detected while examining the left eye cornea, with an inferior infiltrate and significant thinning, approximately 5 mm in length, at the limbal margin (Figure 1). Tear break-up time was shortened bilaterally. In addition to palpebral hygiene and oral treatment with doxycycline 100 mg every 24 hours, the patient was prescribed the following topical treatment without preservatives: artificial tears with lipid emulsion, netilmicin 0,3% 0,4 ml eye drops every 6 hours and dexamethasone 1 mg/ml every 8 hours.

Adverse events of antibody-drug conjugates on the ocular surface in cancer therapy.

Antibody-drug conjugates consist of a monoclonal antibody attached to a cytotoxic therapeutic molecule by a connector. This association allows a highly specific therapy, which increases their effectiveness and decreases their potential toxicity. This new therapy emerged approximately 20 years ago; since then, numerous combinations have appeared in the field of treatment-related neoplasms as an alternative for patients who do not achieve good results with conventional treatment options. Adverse effects of these drugs on the ocular surface are frequent and varied. Their prevalence ranges from 20 to 90% depending on the drug and administration condition, probably due to multiple receptor-mediated factors or mechanisms not mediated by specific receptors, such as macropinocytosis. These adverse events can greatly limit patients' comfort; thus, the objectives of this article were, in the first place, to compile the information currently available on different types of adverse effects of antibody-drug conjugates on the ocular surface, including pathophysiology, prevalence, and treatment, and in second place, to contribute to the correct identification and management of these events, which will result in a lower rate of cessation of treatment, which is necessary for the survival of candidate patients.

Conjunctival Inflammation and Panuveitis as Manifestations of Ig-G4-Related Disease: A Case Report.

PURPOSE: To report a case of isolated conjunctival inflammation as initial manifestation of IgG4-related disease and subsequent development of panuveitis. CASE REPORT: A 75-year-old female presented with a diffuse mass lesion in the temporal area of the left eye, involving the conjunctiva, and an abscessed corneal ulcer. An incisional biopsy was diagnostic of IgG4-related disease with an elevated IgG4/IgG ratio (>40%) and the presence of >10 cells that tested positive for IgG4/CGA. No other ocular, orbital or systemic manifestations were noted at the time of diagnosis. After a year of treatment with topical dexamethasone, oral prednisone, and methotrexate, the patient developed panuveitis, which was controlled by increasing steroids and switching to rituximab. CONCLUSION: IgG4-related disease is a rare entity that can be particularly challenging to diagnose if it manifests in an atypical manner. Continuous follow-up of patients is crucial as relapses and worsening of symptoms can occur despite treatment.

Clostridium Septicum Endogenous Endophthalmitis as the Initial Manifestation of Colorectal Carcinoma: Clinical Case Report and Literature Review.

PURPOSE: To describe the presentation and clinical course of a case of endogenous endophthalmitis caused by Clostridium septicum, an anaerobic and gram positive bacteria. METHODS: Observational report of a clinical case presented in Spain. CLINICAL CASE: A 61-year-old male patient was referred to our hospital with a diagnosis of endophthalmitis of his left eye since ten days prior to presentation, and a history of poor response to medical treatment. Evisceration was performed, and C. septicum was isolated from a sample of the vitreous humor. Fourteen days after surgery, the patient returned with orbital cellulitis, and exenteration was performed. Forty-two days after initial presentation, colonoscopy revealed an adenocarcinoma of the proximal colon. Surgical resection of the tumor was performed, and clinical recovery was achieved. CONCLUSIONS: iSystemic C. septicum infection without a traumatic cause has been associated with malignancy, although an initial presentation of endophthalmitis has rarely been reported. In cases of clostridial endogenous endophthalmitis, investigation for colorectal carcinoma is indicated.

Generation of a Biomimetic Substitute of the Corneal Limbus Using Decellularized Scaffolds.

Patients with severe limbal damage and limbal stem cell deficiency are a therapeutic challenge. We evaluated four decellularization protocols applied to the full-thickness and half-thickness porcine limbus, and we used two cell types to recellularize the decellularized limbi. The results demonstrated that all protocols achieved efficient decellularization. However, the method that best preserved the transparency and composition of the limbus extracellular matrix was the use of 0.1% SDS applied to the half-thickness limbus. Recellularization with the limbal epithelial cell line SIRC and human adipose-derived mesenchymal stem cells (hADSCs) was able to generate a stratified epithelium able to express the limbal markers p63, pancytokeratin, and crystallin Z from day 7 in the case of SIRC and after 14-21 days of induction when hADSCs were used. Laminin and collagen IV expression was detected at the basal lamina of both cell types at days 14 and 21 of follow-up. Compared with control native limbi, tissues recellularized with SIRC showed adequate picrosirius red and alcian blue staining intensity, whereas limbi containing hADSCs showed normal collagen staining intensity. These preliminary results suggested that the limbal substitutes generated in this work share important similarities with the native limbus and could be potentially useful in the future.

Improved Tear Film Stability in Patients with Dry Eye After Hyaluronic Acid and Galactoxyloglucan Use.

PURPOSE: Artificial tears only provide transient relief for dry eye. To the best of our knowledge, this is the first study to objectively compare treatment with artificial tears with Keratograph 5M, which allows accurate and objective investigation of dry eye and artificial tear treatment. We aimed to evaluate whether a preservative-free combination of 0.4% hyaluronic acid and 0.2% galactoxyloglucan can improve dry eye using the new topographer, Keratograph 5M. PATIENTS AND METHODS: This prospective longitudinal, single-arm interventional cohort study was performed at a tertiary referral center and involved 20 patients with dry eye (40 eyes). Preservative-free artificial tears were administered every 3 h. The participants underwent clinical and instrumental evaluations at baseline, 15, 30, 60, 90 and 120 min after instillation and 1 week and 1 month after treatment. Baseline values were considered as the controls. All patients were assessed with Keratograph 5M for non-invasive Keratograph first break-up time and non-invasive Keratograph average break-up time, conjunctival hyperemia, and tear meniscus height. Ocular surface staining with fluorescein was evaluated using the slit-lamp and fluorescein break-up time examinations, and the Ocular Surface Disease Index score was recorded for each patient. RESULTS: The signs and symptoms improved after 1 month of preservative-free 0.4% hyaluronic acid and 0.2% galactoxyloglucan treatment. There was a significant increase in the non-invasive Keratograph first break-up time and non-invasive Keratograph average break-up time at 15, 30, 60, and 90 min, and 1 week and 1 month (P < 0.05) and a decrease in hyperemia, corneal staining, and Ocular Surface Disease Index scores after 1 week and 1 month (P < 0.05). No treatment-related adverse event was observed. CONCLUSION: A combination of 0.4% hyaluronic acid and 0.2% galactoxyloglucan artificial tears seems effective for treating dry eye. Keratograph 5M can objectively detect these changes during the follow-up period.

Plasma Rich in Growth Factors for the Treatment of Cicatrizing Conjunctivitis.

PURPOSE: The objective was to evaluate the clinical results obtained from the use of immunosafe plasma rich in growth factors (isPRGF) in the treatment of patients with cicatrizing conjunctivitis (CC) who had not responded to the usual therapy. PATIENTS AND METHODS: This is a retrospective study that included patients diagnosed with CC, in whom isPRGF was used in different phases (I: eye drops; II: eye drops and injectable; III: eye drops, injectable and surgical treatment) to achieve control of the inflammation. As a clinical follow-up of the patients, the better corrected visual acuity (BCVA), degree of inflammation (measured from 1 to 4), the severity of the CC, Schirmer I test, IOP and TBUT were analyzed. The adverse events were also evaluated. RESULTS: Ten eyes (6 patients) were evaluated, 50% corresponded to Stevens-Johnson Syndrome and 50% to ocular mucous membrane pemphigoid. The mean age was 59.7 ± 16.5 (39-80) years, and 50% were women. Fifty per cent of the cases were initially considered severe CC, and 10% of the cases (one eye of one patient) were considered severe CC at the end of the treatment (p = 0.046). The initial degree of inflammation was 2 in 4 eyes, 3 in two eyes, and 4 in 4 eyes, and final inflammation degree was 1 in all cases (p = 0.004). Twenty per cent of the cases achieved stability in Phase I of the treatment with immunosafe PRGF, 70% with both Phases I and II, and only one case underwent Phase III to achieve stability. The IOP improved significantly (p = 0.027) though the BCVA, TBUT and Schirmer I test showed no significant changes. The follow-up time was 23.1 ± 6.7 (13.6-30.3) months. No adverse effects were reported. CONCLUSION: Treatment with PRGF technology in its injectable and topical immunosafe formulations may be a novel alternative for the treatment of patients with CC, given its complement activity modulating effect, as well as its anti-inflammatory, antifibrotic and regenerative properties.

In vivo confocal microscopy indicates an inverse relationship between the sub-basal corneal plexus and the conjunctivalisation in patients with limbal stem cell deficiency.

BACKGROUND/AIMS: Limbal stem cell deficiency (LSCD) is characterised by a marked decrease in limbal stem cells. It is classified primarily using subjective slit-lamp observations. In vivo confocal microscopy (IVCM) can non-invasively provide objective information on the condition of the limbal niche, the corneal epithelial basal cell density and the corneal sub-basal nerve plexus density (SND). We here used IVCM to evaluate changes in SND to improve LSCD classification. METHODS: We evaluated and classified 38 patients (76 eyes, 44 with LSC and 32 control eyes) using the Rama, López-García and Deng (clinical and confocal) classifications and evaluated the concordance of the confocal and clinical classifications. We constructed a logistic regression model using multivariate analysis to correlate different degrees of conjunctivalisation with IVCM parameters and used receiver operating characteristic (ROC) curve analysis to establish the SND cut-off value with maximum diagnostic sensitivity and specificity. RESULTS: The classification systems correlated moderately at best (kappa, 0.449). The corneal SND of cases (6469±6295 µm/mm2) was less (p<0.001) than in controls (20911±4142 µm/mm2). The SND, but not basal cell density, played a protective role against conjunctivalisation (OR, 0.069; 95% CI 0.008-0.619; p=0.01). An SND cut-off value of 17 215 µm/mm2 yielded a sensitivity and specificity of 95.5% and 90.6%, respectively, for LSCD diagnosis. CONCLUSION: The density of the corneal sub-basal nerve plexus was inversely related to conjunctivalisation in LSCD. Further studies are needed to verify this and to elucidate the directionality between these factors.

Keratograph 5M As A Useful And Objective Tool For Evaluating The Ocular Surface In Limbal Stem Cell Deficiency.

PURPOSE: In limbal stem cell deficiency, both the Ocular Surface Disease Index (OSDI) questionnaire and tear break-up time (BUT) are comparable between traditional methods and the Keratograph 5M. In this study, we aimed to correlate OSDI with Keratograph 5M interviewed OSDI, as well as slit-lamp tear BUT with Keratograph 5M noninvasive tear break-up time (NIKBUT) in limbal stem cell deficiency. PATIENTS AND METHODS: Thirty-eight limbal stem cell-deficiency patients (76 eyes) from Virgen Macarena-Rocio Hospital (Seville, Spain) underwent this diagnostic test study. All patients completed the traditional OSDI. We measured the BUT, performed a Keratograph 5M analysis of NIKBUT first (employed for the analysis) followed by the average NIKBUT, the level of dryness, and conducted the OSDI questionnaire through an interview. For each pair of tests, we analyzed the means and applied an intraclass correlation coefficient (r), creating a Bland-Altman plot for data dispersion. RESULTS: Average values were 47.5 points (±25.8), and 47.3 points (±27.5) for traditional OSDI and Keratograph OSDI, respectively (P =0.87); the r value indicates good agreement (0.72). The Bland-Altman plot followed a linear pattern, and the results were similarly distributed. The NIKBUT mean was shorter than the BUT mean (P = 0.007); the r value indicates moderate agreement (0.574). The Bland-Altman plot formed an almost horizontal line, with almost all values between the mean and two standard deviations. CONCLUSION: Keratograph 5M is useful for the evaluation of the ocular surface in limbal stem cell deficiency. NIKBUT can substitute BUT based on its advantages of being noninvasive, objective, with intraobserver and interobserver repeatability and reliability. The Keratograph 5M OSDI is comparable to the traditional questionnaire.