Contact Lens Versus Non-Contact Lens-Related Corneal Ulcers at an Academic Center.

PURPOSE: To compare the infectious contact lens-related corneal ulcer (CLRU) and non-CLRU cases at Saint Louis University. METHODS: Retrospective review of corneal ulcer cases identified by search of the ophthalmology and microbiology department databases between 1999 and 2016. RESULTS: Six hundred seventy-seven cases of corneal ulcers were identified, of which 46% were CLRU. CLRU cases were seen more commonly in younger patients (P<0.001) and women (P=0.03) than non-CLRU cases. Many of the infections were vision-threatening as defined by central/paracentral location (73% CLRU and 71% non-CLRU [P=0.60]) and large size of ulcer >2 mm in 36% CLRU and 51% non-CLRU (P=0.002). Causative pathogen in cultured CLRU was predominately Pseudomonas species (44%, P<0.001 vs. the non-CLRU group), other gram-negative (6%), gram-positive (33%), fungi (13%), and Acanthamoeba (5%). Comparatively, cultured non-CLRU was predominately gram-positive (64%, P<0.001 vs. the CLRU group), gram-negative (26%), and fungi (11%). The combined oxacillin-resistant Staphylococcus aureus and coagulase-negative Staphylococcus isolates were 35% and 34%, respectively. Despite the progressive increase in the number of corneal ulcers seen, the annual trend for any one particular organism for either CLRU cases or non-CLRU cases did not change significantly. CONCLUSIONS: Most of the cases were non-CLRU. CLRU was disproportionately associated with Pseudomonas species and non-CLRU with Staphylococcal species. Fungal infections were predominately caused by filamentous organisms in both groups. Acanthamoeba keratitis was exclusively associated with CL use.

Laboratory Results, Epidemiologic Features, and Outcome Analyses of Microbial Keratitis: A 15-Year Review From St. Louis.

PURPOSE: To evaluate the laboratory results and prognostic factors of poor clinical outcomes in microbial keratitis cases over 15 years at Saint Louis University. DESIGN: Retrospective cohort and trend study. METHODS: Microbiological and clinical information from culture-positive cases seen at Saint Louis University from 1999 to 2013 were reviewed retrospectively. Statistical analyses were used to determine microbiological and antibiotic susceptibility trends. Prognostic factors of poor clinical outcome from the literature were used to create multivariate regression models to describe our cohort. RESULTS: Gram-positive organisms predominated (48%), followed by gram-negative organisms (34%) and fungi (16%). The most commonly isolated organism was Pseudomonas aeruginosa (21%). Oxacillin-resistant rates of Staphylococcus aureus and coagulase-negative staphylococci were 45% and 43%, respectively. Only the proportion of Pseudomonas changed significantly over time (P = .02). The only antibiotic found to lose efficacy over time was gentamicin for gram-positive organisms (P = .005). Multivariate logistic regression analyses revealed that major complications were associated with large ulcers (P < .006), fungal cases (P < .001), and comorbid ophthalmic conditions (P < .001). Poor healing was associated with large ulcers (P < .001) and fungal cases (P < .001). Lastly, poor visual outcome was associated with large ulcers (P < .01) and age ≥ 60 years (P < .02). CONCLUSIONS: In the St Louis area, oxacillin-resistant organisms, Pseudomonas aeruginosa, and fungi are commonly recovered from microbial keratitis cases with a disproportionally high incidence. Hence, empiric antibiotic choice should reflect these trends. Special care needs to be taken for patients with large ulcers and fungal infections, as well as elderly patients with comorbid ophthalmic conditions, as these patients have worse clinical outcomes.

Report of the Eye Bank Association of America Medical Review Subcommittee on Adverse Reactions Reported From 2007 to 2014.

PURPOSE: To investigate the incidence of adverse reactions after corneal transplantation, reported to the Eye Bank Association of America. METHODS: Incidence of adverse reactions from January 1, 2007, to December 31, 2014, was analyzed. RESULTS: Of the 354,930 transplants performed in the United States, adverse reactions were reported in 494 cases (0.139%). Primary graft failure (PGF) predominated (n = 319; 0.09%) followed by endophthalmitis (n = 99; 0.028%) and keratitis (n = 66; 0.019%). The procedure type predominantly associated with PGF was endothelial keratoplasty (EK) in 56% (n = 180; 11 per 10,000 grafts), followed by penetrating keratoplasty (PK) in 42% (n = 135; 6.9 per 10,000 grafts). The procedure type predominantly associated with endophthalmitis and keratitis was EK in 63% (n = 104; 6.3 per 10,000 grafts) followed by PK in 34% (n = 56; 2.8 per 10,000 grafts), anterior lamellar keratoplasty in 1% (n = 2; 2.7 per 10,000 grafts), and keratoprosthesis in 1% (n = 2; 12.4 per 10,000 grafts). Although the incidence of PGF and endophthalmitis between PK and EK was noteworthy, the difference was not statistically significant (P = 0.098). Endophthalmitis-associated pathogens were isolated in 78% of cases: predominantly Candida species (65%), gram-positive organisms (33%), and gram-negative rods (2%). Keratitis-associated pathogens were isolated in 64% of cases: predominantly Candida species (81%), Herpes simplex virus (7%), gram-negative organisms (7%), and gram-positive organisms (5%). CONCLUSIONS: PGF was the most commonly reported adverse reaction, disproportionately associated with EK. An increasingtrend in the rate of endophthalmitis and keratitis was observed, disproportionately associated with EK and Candida species.

Indications for Keratoplasty at 3 Academic Centers from 2002 to 2012.

OBJECTIVES: To determine whether indications for keratoplasty differ between academic centers and the Eye Bank Association of America (EBAA) annual statistics from 2002 to 2012. METHODS: A retrospective review was performed for the indications for keratoplasty from 2002 to 2012 based on surgical specimens originating from three different academic centers. Data were compared with statistical reports obtained from the EBAA for the corresponding years. RESULTS: From 2002 to 2007, at Washington University in St Louis (WU), the most common indication for keratoplasty was graft failure at 31.6%. At St Louis University, the most common indications for keratoplasty were pseudophakic and aphakic bullous keratopathy (PBK/ABK) at 34.6% followed closely by graft failure at 32.7%. Combining the 2002 to 2007 EBAA data, the most common indication for keratoplasty was PBK/ABK at 19.5%, whereas regrafts accounted for only 13.0% of keratoplasties. From 2008 to 2012, regrafts accounted for 41.9% of keratoplasties at WU and 33.1% of keratoplasties at University of California, Davis. In contrast, the EBAA data showed that only 11.4% of keratoplasties were regrafts. CONCLUSIONS: Graft failure accounted for approximately 30% to 40% of indications for keratoplasties at three academic centers from 2002 to 2012, which was more than double and in some cases triple that of the EBAA data during this period. These higher frequencies of regrafting may represent a referral bias of patients with complicated cases to academic centers who then require multiple keratoplasties.

Two-year outcomes of an initial series of DSAEK cases in normal and abnormal eyes at an inner-city university practice.

PURPOSE: To report our initial series of Descemet stripping automated endothelial keratoplasty (DSAEK) patients with 2 years of follow-up and to compare the complications and outcomes between normal and abnormal eyes. METHODS: Records of all patients who underwent DSAEK between April 2007 and April 2009 were reviewed. Eyes were categorized as "normal" or "abnormal" for comparison. Two risk factors, anterior chamber compromise and glaucoma tube/bleb, were analyzed for association with tissue detachment. RESULTS: Thirteen DSAEKs were performed on 13 "normal" eyes, and 18 DSAEKs were performed on 15 "abnormal" eyes. The lenticule detachment rates were 15.4% in the normal group and 41.2% in the abnormal group (P = 0.13). The difference in endothelial cell loss was not significant until 1.5 years postoperatively in favor of the abnormal group (P = 0.024). The mean starting vision was 20/115 for the normal group and 20/322 for the abnormal group (P = 0.06). At 2 years, the mean visual acuity was 20/47 for the normal group and 20/34 for the abnormal group (P = 0.44). Risk factor analyses indicated that glaucoma tubes/blebs were not related to lenticule detachment (P = 0.45), whereas anterior chamber compromise was related to lenticule detachment (P = 0.031). CONCLUSIONS: Complication rates for abnormal eyes are higher than those for normal eyes, and risk factor analyses suggest that marked anterior chamber compromise is related to lenticule detachment. However, if DSAEK is successful for these compromised eyes, the visual outcomes compare favorably with normal eyes through 2 years of follow-up.

Resistant Fusarium keratitis progressing to endophthalmitis.

OBJECTIVE: To report a case of multidrug-resistant Fusarium sp keratitis that progressed to endophthalmitis and that eventually required enucleation. METHODS: Case report and literature review. Isolate identification and susceptibility testing were performed by the Fungus Testing Laboratory at San Antonio, TX. RESULTS: A 52-year-old soft contact lens wearer had a corneal abrasion and developed a corneal infiltrate. Examination of corneal scrapings revealed filamentous hyphae with septation and conidia. Despite aggressive antifungal therapy with topical natamycin, amphotericin B, and systemic fluconazole, the keratitis progressed, and a penetrating keratoplasty was performed. Histopathologic analysis of the corneal button showed disruption of Descemet's membrane with periodic acid-Schiff-positive fungal hyphae on both sides. Recurrent infection of the graft and progression to endophthalmitis was treated with repeated intravitreal amphotericin B injections, repeat penetrating keratoplasties, and pars plana vitrectomies. Even after systemic use of itraconazole, voriconazole, and posaconazole and topical use of voriconazole, the infection progressed and an enucleation was required. Isolate identification and susceptibility testing found a multidrug-resistant Fusarium solani species complex, partially sensitive to natamycin only. CONCLUSIONS: Multidrug-resistant Fusarium sp is rare and may have devastating consequences in patients with advanced keratitis progressing to endophthalmitis. Such an extensive multidrug resistance is surprising in that resistance to antifungal treatment is supposedly rare. Empirical antifungal therapy is usually instituted using one or more antifungal agents, without checking antifungal sensitivities. In light of the growing concern for increased emergence of resistant strains, we propose a lower threshold to check for sensitivities in the face of unresponsive fungal infections.

Surgical management of non-traumatic pediatric ectopia lentis: A case series and review of the literature.

PURPOSE: To report a small series of pediatric patients with ectopia lentis that underwent limbal-approach lensectomy and vitrectomy and scleral-fixated intraocular lens implantation and to review the literature on the topic of surgical management of ectopia lentis. METHOD: A retrospective review of 13 eyes of seven patients that underwent lensectomy, vitrectomy, and scleral-fixated intraocular lens implantation and a review of the ophthalmic literature. RESULTS: In our series, the average age at surgery was 70.3 ± 13.8 months and the average length of follow-up was 23.8 ± 5.9 months. The mean pre-operative visual acuity was 0.86 ± 0.17 which improved to 0.23 ± 0.09 post-operatively (p < 0.001). No complications were encountered in our series. A review of the literature found that amblyopia was the biggest vision-limiting factor. In general, the literature suggested that a higher percentage of eyes that were left aphakic achieved better vision than those implanted with a scleral-fixated intraocular lens. However, there may be selection bias in that more eyes receiving an intraocular lens may have pre-existing amblyopia. The complication rates for lensectomy or scleral-fixated intraocular lens implantation were low in the literature. In the latter group, suture breakage and resultant intraocular lens dislocation is a worrisome late complication. CONCLUSION: Surgical intervention for ectopia lentis via vitrectomy techniques yields good result. In cases of unilateral aphakia or in settings where compliance with aphakic refractive correction is questionable and amblyopia is a constant threat, scleral-fixated intraocular lens implantation is highly encouraged. However, long-term follow-up is required due to the risk of suture breakage and resultant intraocular lens dislocation over time.

Genotype of lattice corneal dystrophy (R124C mutation in TGFBI) in a patient presenting with features of avellino corneal dystrophy.

PURPOSE: To present a patient with a genotype usually associated with lattice corneal dystrophy but with clinical and histopathologic features of advanced Avellino corneal dystrophy. METHODS: Penetrating keratoplasty was performed with subsequent histopathologic analysis. For genetic testing, a 5-mL blood sample was taken after informed consent. Genetic sequencing was performed by the John and Marcia Carver Laboratory of the University of Iowa. The mutation was identified by direct sequencing through the positions of the coding sequences of the TGFBI gene that have been previously reported to have genetic variations (exons 4 and 11-14). RESULTS: Corneal examination revealed bilateral lattice and multiple confluent subepithelial and anterior stromal granular opacities. Histopathologic examination showed amyloid deposits by Congo red stain and hyaline deposits by Masson trichrome stain, consistent with a diagnosis of Avellino dystrophy. Automated DNA sequencing revealed a heterozygous Arg124Cys (R124C) mutation in the coding sequence of the TGFBI gene on chromosome 5q31. Recurrent granular deposits developed in the corneal graft 14 months after surgery. CONCLUSIONS: Our case presented with clinical and histopathologic findings consistent with a diagnosis of Avellino dystrophy and exhibited a genotype with R124C mutation. Avellino dystrophy has not previously been reported to be associated with the R124C mutation, which is usually associated with lattice corneal dystrophy. This also raises the issue as to whether classification of the corneal stromal dystrophies should be based primarily on phenotype/histopathology or on genotyping.

Clinical phenotypes associated with the complement factor H Y402H variant in age-related macular degeneration.

PURPOSE: To determine whether the complement factor H (CFH) Y402H variant is associated with specific age-related macular degeneration (AMD) clinical phenotypes. DESIGN: Retrospective, case-control study. METHODS: One hundred and eighty-eight white subjects with AMD and 189 control subjects were genotyped for the T-to-C polymorphism in exon 9 of the CFH gene by restriction-fragment length analysis and deoxyribonucleic acid (DNA) sequencing using genomic DNA from mouthwash samples. AMD phenotypes were characterized by clinical examination, fundus photography, and fluorescein angiography. RESULTS: Heterozygosity for the at-risk genotype (TC) increased the likelihood for AMD 2.1-fold (95% confidence interval [CI], 1.3 to 3.3), whereas homozygosity for the genotype (CC) increased the likelihood for AMD 6.5-fold (95% CI, 3.4 to 12.5) in our population. The C allele was associated significantly with predominantly classic choroidal neovascularization (odds ratio [OR], 2.01; 95% CI, 1.34 to 3.30). Neovascular lesion size was similar among the three genotypes (P = .67). CONCLUSIONS: The Y402H CFH variant carried a significantly increased risk for developing AMD in our population. Genotype and phenotype correlations regarding choroidal neovascular lesion type were observed.