Fungal keratitis after amniotic membrane placement.

Purpose: We present two cases of fungal keratitis following amniotic membrane transplantation, including Sistotrema biggsiae and Fusarium keratitis. Observations: A 76-year-old female with a history of anterior basement membrane dystrophy referred for reduced vision and left eye pain ten days following AMT at an outside facility. Despite topical management, the patient continued to worsen clinically, with a recalcitrant course of Fusarium keratitis requiring conjunctival flap, cryotherapy, and intracameral and intrastromal injection. The second case involved a 46-year-old male with a history of recurrent corneal erosions referred for blurry vision and pain in his left eye seven days following AMT. He was found to have Sistotrema biggsiae keratitis and had remarkable visual improvement with topical management. Conclusions: Fungal keratitis following amniotic membrane placement has not been reported presenting within ten days after transplantation. This is the first report of Sistotrema biggsiae infection in humans. This case series highlights the risk of severe recalcitrant microbial keratitis presenting within days after AMT placement and recognizing fungal etiologies not previously reported in literature. The risk of keratitis following AMT should be considered with close patient follow up, especially in patients with monocular vision.

Corneal Ulcers with NOD2 Mutations Presenting with Mixed Syndromic Phenotype.

PURPOSE: To report a case of corneal ulcers in a patient with NOD2 mutations unique to but phenotypically resembling well-characterized syndromic phenotypes like Blau syndrome. OBSERVATION: A 25-year-old female with a medical history of type I diabetes mellitus, Asperger syndrome, and neuropathy presented with bilateral corneal ulcers. Her visual acuity was 20/200 OU. Macular edema was identified OS, and posterior synechiae OS suggested a history of anterior uveitis.Genetic testing confirmed NOD2 mutations, and her tear film was positive for matrix metallopeptidase 9. Recent intravenous immunoglobulin therapy improved her neuropathy, and an aggressive regimen of erythromycin ointment and lubrication has improved her ophthalmic symptoms. CONCLUSION AND IMPORTANCE: This case advances our understanding of NOD2's role in regulating inflammatory processes of the eye. In addition to precipitating uveitis, patients with these mutations may also be at increased risk of developing corneal pathology related to their reduced capacity to moderate inflammatory processes.

"Marginal keratitis following COVID 19 vaccination".

Purpose: To describe a novel case of marginal keratitis following COVID 19 vaccination. Methods: Case report. Results: A 68-year-old female received the Moderna COVID 19 vaccine. She then developed ocular irritation and peripheral corneal opacities that are characteristic of marginal keratitis. Her symptoms responded well to steroid and antibiotic ophthalmic medications. She received her second dose of the Moderna vaccine while still taking her eye drops and was then able to taper off her drops without a recurrence of symptoms. Conclusions: Marginal keratitis represents a localized type III hypersensitivity reaction of the cornea. The SARS-CoV-2 virus that causes COVID 19 gains entry into the cell via binding of the spike protein with the ACE2 receptor. It is this spike protein that is the target for mRNA COVID-19 vaccines, such as the Moderna vaccine, allowing spike protein antigen recognition by the human immune system. The cornea has been found to have significant levels of ACE2 receptors, potentially allowing for the cornea to become a site for the antigen-antibody complex deposition necessary for a type III hypersensitivity response. This reaction should be recognized so that treatment may be provided during the initial episode and the cornea may be monitored following subsequent vaccinations.

Ultra-wide field imaging to assess the optic nerve and retina in Boston type I and II keratoprosthesis patients.

BACKGROUND: The ability to view the posterior segment in keratoprosthesis (Kpro) implanted patients is limited. The purpose of this retrospective, observational study was to investigate the use of ultra-wide field (UWF) scanning laser ophthalmoscopy imaging and its utility for serial evaluation of the retina and optic nerve in patients with either a Boston type I or II Kpro. METHODS: A retrospective chart review was performed for patients with a Boston type I or II Kpro seen at The Ohio State University Wexner Medical Center. Images were graded for quality by two masked observers on a defined four-point scale ("Poor", "Fair", "Good", or "Very good") and assessed for visible posterior segment anatomy. Interobserver agreement was described using the Kappa statistic coefficient (κ) with 95% confidence intervals. RESULTS: A total of 19 eyes from 17 patients were included in this study. Eighteen eyes had a type I Kpro, while one eye had a type II Kpro. UWF imaging from 41 patient visits were reviewed by two observers. Interobserver agreement between the two graders was fair for image quality (κ = 0.36), moderate for visibility of the macula with discernible details (κ = 0.59), moderate for visibility of the anterior retina with discernable details (κ = 0.60), and perfect agreement for visibility of the optic nerve with discernible details (κ = 1.0). In 6 eyes, UWF imaging was performed longitudinally (range 3-9 individual visits), allowing for long-term follow-up (range 3-46 months) of posterior segment clinical pathology. CONCLUSIONS: UWF imaging provides adequate and reliable visualization of the posterior segment in Kpro implanted patients. This imaging modality allowed for noninvasive longitudinal monitoring of retinal and optic nerve disease in this selected patient population.

Combined Rothia dentocariosa and Streptococcus viridans Corneal Ulcer in an Immunocompromised Patient.

Keratitis is a very common condition seen by ophthalmologists. However, many factors can complicate the treatment of this depending on the causative organism and other patient comorbid conditions. The objective of this clinical case report is to highlight the treatment of keratitis caused by Rothia dentocariosa. It also looks at the unique considerations in keratitis presentations for patients immunocompromised by chemotherapy agents. Our patient is a 58 yo female undergoing chemotherapy with folinic acid, fluorouracil, irinotecan, and panitumumab who presented with several days of a red, painful right eye with mucous discharge. Cultures were positive for Rothia dentocariosa and Streptococcus viridans. The patient ultimately underwent a conjunctival flap procedure as medical therapy with proper oral and topical antibiotics failed to resolve keratitis. This case is unique as previously, only a couple of cases of keratitis caused by Rothia dentocariosa have been reported and none of those patients were immunocompromised nor failed antibiotic therapy.

Chryseobacterium indologenes Keratitis: Successful Treatment of Multidrug-Resistant Strain.

A 72-year-old male with history of monocular vision with complete vision loss in his right eye from previous retinal detachment presented with 20/200 vision in the left eye with a corneal ulcer. Culture was obtained, and the patient was started on fortified tobramycin, fortified vancomycin, and amphotericin. Despite the antibiotics, the patient did not significantly improve, after which another culture was obtained before the patient was taken to the surgery for cryotherapy and a partial conjunctival flap. The culture identified Chryseobacterium indologenes. There have been fewer than a handful of cases reported in the last three decades with different antibiotic susceptibility profiles. Our patient was successfully treated with ciprofloxacin and ceftazidime with the final vision of 20/40.

Congenital Smooth Muscle Hamartoma Obscuring the Cornea.

Congenital smooth muscle hamartoma is a benign proliferation of smooth muscle that most commonly presents in the lumbosacral area or proximal extremities. Although exceedingly rare, congenital smooth muscle hamartomas have been reported to occur in ocular structures such as the brow, eyelid, and conjunctival fornix. This case describes an atypical congenital bulbar lesion in a newborn male which obscured the cornea. The lesion, which appeared to originate from the bulbar conjunctiva and/or the limbus, was excised at 5 months of age. Pathologic evaluation was consistent with congenital smooth muscle hamartoma. The authors of this report believe it is the first to describe a patient with a congenital smooth muscle hamartoma of the bulbar conjunctiva/limbus.

Toxic Anterior Segment Syndrome with Intracameral Moxifloxacin: Case Report and Review of the Literature.

A case of severe anterior segment toxicity secondary to high-volume, undiluted intracameral moxifloxacin for endophthalmitis prophylaxis is reported. We examine the other reported cases of toxicity after intracameral moxifloxacin, as well as iris depigmentation and transillumination syndromes after oral and topical fluoroquinolone exposure. Additionally, we review the literature on safety, efficacy, and appropriate dosing of intracameral antibiotics with a focus on moxifloxacin.

Subepithelial Corneal Deposits Associated with Exemestane.

This is a case report of corneal deposits noted in a 69-year-old female patient taking the aromatase inhibitor, exemestane, after undergoing a mastectomy and chemotherapy for breast cancer. The patient presented to our eye clinic for a new-onset floater in one eye, and bilateral subepithelial opacities were found incidentally on exam. The patient completed a 5-year course of the medication shortly after her initial visit with us and was noted to have a slight improvement in the density of the opacities on a follow-up visit 3 months later. We believe these corneal changes were most likely secondary to exemestane. The effect of aromatase inhibitors on the eye deserves further exploration as an increasing number of patients are prescribed these medications.

Incidence of cystoid macular oedema with intracameral cephalosporin or vancomycin in cataract surgery.

Purpose: To compare the incidence of pseudophakic cystoid macular oedema (CME) in patients who receive intracameral cephalosporin versus intracameral vancomycin during cataract surgery.Methods: A retrospective chart review was conducted on subjects with the diagnosis of CME between January 1 2010 and July 31 2017. Inclusion criterion was the documentation of CME after cataract extraction. Exclusion criteria were intraoperative complication, prior history of macular oedema, epiretinal membrane, uveitis, other pre-existing retinal pathology, or other post-operative pathology including other ocular surgery in the post-operative period.Results: The final analysis included 89 eyes with optical coherence tomography (OCT) proven CME. The incidence of pseudophakic CME in our population of 10,165 cataract surgeries after applying the above-stated exclusion criteria was 0.88%. The incidence of pseudophakic CME in subjects who received intracameral cephalosporin was 0.87% (mean age in years 69 ± 11; 31 male [39%], 48 female [61%]). The incidence of pseudophakic CME in subjects who received intracameral vancomycin was 0.96% (mean age in years 66 ± 13; 4 male [40%], 6 female [60%]). Pearson's chi-square test demonstrated no significant difference between these groups (p = 0.7705).Conclusions: There was no statistical difference in the incidence of pseudophakic CME in subjects who received intracameral cephalosporin versus intracameral vancomycin during cataract surgery.

Optical Analysis and Reappraisal of the Peripheral Light Focusing Theory of Nasal Pterygia Formation.

Purpose: Pterygia are much more common nasally than temporally. Ultraviolet (UV) radiation is a major risk factor. Coroneo proposed that the nasal preference is caused by the "peripheral light focusing effect," (PLF), in which UV at an oblique angle passes through temporal cornea and is concentrated on and damages nasal limbal stem cells. This study evaluates whether the PLF is sufficient to explain the nasal preference. Methods: Whereas Coroneo and colleagues derived the maximum PLF intensity gain (UV concentration factor) as a function of incident angle (i.e., different nasal limbal positions were used for different incident angles) the current analysis derived intensity gain at a fixed position such at the nasal corneo-limbal junction (CLJ). This provided a measure of the total PLF irradiation at this position, which was compared to total direct irradiation of nasal and temporal limbus at the corresponding positions (e.g., CLJs). In Part 1, analysis was performed like that of Coroneo, using horizontally incident UV; in Part 2, the analysis was extended to include incident rays above and below the horizontal. Results: In both part 1 and part 2 of the study, the limbal UV irradiation of the nasal limbus from the PLF was not sufficient to explain the strong nasal location preference of pterygia. Conclusions: The analysis calls into question the PLF explanation of nasal location preference. Other explanations of the nasal preference, and of pterygium pathogenesis, should be considered, such as temporal to nasal tear flow carrying substances such as cytokines to the nasal limbus.

Conjunctival Flaps: A Case Series and Review of the Literature.

PURPOSE: The purpose of this study was to examine the outcomes of conjunctival flaps performed at our institution. METHODS: The medical records of all patients who underwent a total or partial conjunctival flap surgery over the course of a 6-year period from 2010 to 2015 were reviewed to identify the ocular diagnoses and perform a retrospective review of the preoperative and postoperative course. RESULTS: Thirty-five patients received a conjunctival flap during the 6-year period, 20 partial flaps and 15 total flaps. Infectious keratitis or corneal ulceration accounted for 25 (71.4%) of the cases. The remaining flaps were performed for corneal perforation, graft rejection, bullous keratopathy, and secondary corneal edema. Seven patients had recession of their flap postoperatively, and 14 went on to have further surgical intervention. Conjunctival flap surgery successfully stabilized the patient's ocular surface in 97.1% of the cases. CONCLUSION: Conjunctival flap surgery is an important and useful surgical option in the treatment of ocular surface disease, especially recalcitrant infectious keratitis and corneal ulcers.

Combined Candida dubliniensis and Candida albicans Keratitis following a Chemical Injury.

Candida dubliniensis is an uncommon source of ocular infections and has only been reported in a single previous case of keratitis. This report documents the course of a combined Candida dubliniensis and Candida albicans keratitis following a chemical injury. Antifungal sensitivities of the two different Candida species are also demonstrated.

Keratoglobus with ARCL1B (EFEMP2 gene) cutis laxa.

PURPOSE: To report a case of keratoglobus in a patient with autosomal recessive (AR) cutis laxa. OBSERVATIONS: A 38 year old male presented with decreased vision in both eyes uncorrectable with spectacles and a history of corneal rupture in the left eye from incidental trauma a decade prior. His ocular exam was consistent with keratoglobus. His medical and family history indicated AR cutis laxa. CONCLUSIONS AND IMPORTANCE: We believe that this is the first reported case of keratoglobus associated with cutis laxa.

Donor, Recipient, and Operative Factors Associated With Increased Endothelial Cell Loss in the Cornea Preservation Time Study.

Importance: Determining factors associated with endothelial cell loss after Descemet stripping automated endothelial keratoplasty (DSAEK) could improve long-term graft survival. Objective: To evaluate the associations of donor, recipient, and operative factors with endothelial cell density (ECD) 3 years after DSAEK in the Cornea Preservation Time Study. Design, Setting, and Participants: This cohort study was a secondary analysis of data collected in a multicenter, double-masked, randomized clinical trial. Forty US clinical sites with 70 surgeons participated, with donor corneas provided by 23 US eye banks. Individuals undergoing DSAEK for Fuchs dystrophy or pseudophakic/aphakic corneal edema were included. Interventions: The DSAEK procedure, with random assignment of a donor cornea with a preservation time of 0 to 7 days or 8 to 14 days. Main Outcomes and Measures: Endothelial cell density at 3 years as determined by a reading center from eye bank and clinical specular or confocal central endothelial images. Results: The study included 1090 participants (median age, 70 years) with 1330 affected eyes (240 bilateral cases [22.0%]), who underwent DSAEK for Fuchs dystrophy (1255 eyes [94.4%]) or pseudophakic/aphakic corneal edema (PACE) (75 eyes [5.6%]). Of these, 801 eyes (60.2%) belonged to women and 1207 (90.8%) to white individuals. A total of 749 participants (913 eyes; 164 [21.9%] bilateral cases) had functioning grafts with acceptable endothelial images preoperatively and at 3 years postoperatively and were included in this analysis. Factors associated with a lower ECD at 3 years (estimated effect with 99% CI) in the final multivariable model included donors with diabetes (-103 [-196 to -9] cells/mm2), lower screening ECD (-234 [-331 to -137] per 500 cells/mm2), recipient diagnosis of PACE (-257 [-483 to -31] in cells/mm2), and operative complications (-324 [-516 to -133] in cells/mm2). Endothelial cell loss (ECL) from a preoperative measurement to a 3-year postoperative measurement was 47% (99% CI, 42%-52%) for participants receiving tissue from donors with diabetes vs 43% (99% CI, 39%-48%) without diabetes; it was 53% (99% CI, 44%-62%) for participants diagnosed with PACE vs 44% (99% CI, 39%-49%) for those diagnosed with Fuchs dystrophy, and 55% (99% CI, 48%-63%) in participants who experienced operative complications vs 44% (99% CI, 39%-48%) in those who did not. No other donor, recipient, or operative factors were significantly associated with 3-year ECD. Conclusions and Relevance: Donor diabetes, lower screening ECD, a PACE diagnosis in the recipient, and operative complications were associated with lower ECD at 3 years after DSAEK surgery and may be associated with long-term graft success. While causation cannot be inferred, further studies on the association of donor diabetes and PACE in recipients with lower 3-year ECD warrant further study.

Cost effect of surgeon and patient discretion in regard to cataract surgery.

PURPOSE: The purpose of this study is to examine the cost effect of surgeon and patient discretion in regard to cataract surgery and how this affects population health care costs. METHODS: A model of cataract progression was created from preexisting published data and combined with mortality data and Medicare cataract statistics to estimate the effect of mortality on decreasing the rate of cataract surgery if surgery was delayed until any cataract progression occurred. RESULTS: Five-year cataract progression rates were determined for a given patient age, sex, and type of cataract. Combined with 5-year death rates, delaying surgery until progression occurred resulted in a 1.1% decrease in surgery for nuclear sclerosis at age 45 that increased to a 33.8% decrease by age 90; a 1.5% decrease in surgery for cortical cataract at age 45 that increased to a 51.1% decrease by age 90; and a 1.6% decrease in surgery for posterior subcapsular at age 45 that increased to a 59.7% decrease by age 90. The effect of this decrease in surgical volume on Medicare was estimated to result in a 13% overall decrease in cataract surgery annually at a cost of ~$660 million dollars per year. CONCLUSION: Overall, we conclude that surgeon and patient discretion in regard to cataract surgery has a substantial cost effect with the potential to reduce surgical volume by as much as 13% by the decision to delay surgery as a result of patient mortality.

Lack of relationship between cigarette smoking and alcohol use with dysplasia grade in ocular surface squamous neoplasia.

OBJECTIVE: To evaluate smoking and alcohol use as risk factors for higher-grade dysplasia in a population of patients with histopathologically proven ocular surface squamous neoplasia. MATERIALS AND METHODS: This is a retrospective chart review of data extracted from a database comprising demographic information and medical diagnosis information based on International Classification of Disease codes. Outcome measures were analyzed using the Wilcoxon two-sided test, a non-parametric t-test. RESULTS: Database review yielded 35 patients with ocular surface squamous neoplasia lesions proven by histopathologic analysis. The mean age was 64.51 years with SD 17.54 years. Patients were 28.57% female and 71.43% male. Nearly all patients were White (88.57%), and 5.71% were African American, 2.86% Hispanic, and 2.86% Other. There was no significant difference in dysplasia grade between smokers and non-smokers (P=0.7044), those who used alcohol vs did not use alcohol (P=0.2470), those who used tobacco and alcohol vs those who did not (P=0.5117), and those who used either tobacco or alcohol vs those who did not (P=0.8259). CONCLUSION: No statistically significant relationship was found between high-grade dysplasia and cigarette smoking, alcohol use, or both cigarette smoking and alcohol use.

Candida dubliniensis: A novel cause of fungal keratitis.

A 45-year-old female with history of contact lens wear presented with a persistent corneal ulcer that was unresponsive to topical moxifloxacin. The patient's exam was concerning for fungal keratitis. Cultures were obtained, and the patient was started on fortified amphotericin B drops and oral voriconazole. The cultures identified Candida dubliniensis as the causative organism. The patient's exam worsened despite treatment, and the decision was made for surgery. At the time of surgery, her cornea was found to have unexpectedly perforated. She underwent cryotherapy; tectonic penetrating keratoplasty; anterior chamber tap; intracameral voriconazole, amphotericin B, and cefuroxime; and a partial conjunctival flap. Pathology from the cornea showed GMS and PAS stains positive for fungal forms. C. dubliniensis is a yeast closely related to Candida albicans that was first described in 1995 as a cause of oral candidiasis in patients with AIDS. There are a few published cases of endophthalmitis due to C. dubliniensis in the ophthalmology literature, but to our knowledge, no cases of fungal keratitis due to this organism have been reported. C. dubliniensis is a novel cause of fungal keratitis that can be difficult to identify and treat but is felt to be less virulent than C. albicans and generally susceptible to available anti-fungal therapies.

Donor, Recipient, and Operative Factors Associated with Graft Success in the Cornea Preservation Time Study.

PURPOSE: To associate donor, recipient, and operative factors with graft success 3 years after Descemet stripping automated endothelial keratoplasty (DSAEK) in the Cornea Preservation Time Study (CPTS). DESIGN: Cohort study within a multicenter, double-masked, randomized clinical trial. PARTICIPANTS: One thousand ninety individuals (1330 study eyes) with a median age of 70 years undergoing DSAEK for Fuchs endothelial corneal dystrophy (94% of eyes) or pseudophakic or aphakic corneal edema (PACE; 6% of eyes). METHODS: Eyes undergoing DSAEK were randomized to receive a donor cornea with preservation time (PT) of 0 to 7 days (n = 675) or 8 to 14 days (n = 655). Donor, recipient, and operative parameters were recorded prospectively. Graft failure was defined as regraft for any reason, a graft that failed to clear by 8 weeks after surgery, or an initially clear graft that became and remained cloudy for 90 days. Failure in the first 8 weeks was classified further as primary donor failure or early failure, in the absence or presence of operative complications, respectively. Proportional hazards and logistic regression models were used to estimate risk ratios (RR) and 99% confidence intervals (CIs) for graft failure. MAIN OUTCOME MEASURES: Graft success at 3 years. RESULTS: One thousand two hundred fifty-one of 1330 grafts (94%) remained clear at 3 years and were considered successful. After adjusting for PT, tissue from donors with diabetes (RR, 2.35; 99% CI, 1.03-5.33) and operative complications (RR, 4.21; 99% CI, 1.42-12.47) were associated with increased risk for primary or early failure. Preoperative diagnosis of PACE (RR, 3.59; 99% CI, 1.05-12.24) was associated with increased risk for late failure by 3 years after surgery compared with Fuchs dystrophy. Graft success showed little variation among other factors evaluated, including donor age (RR, 1.19 per decade; 99% CI, 0.91-1.56 per decade), preoperative donor endothelial cell density (RR, 1.10 per 500 cells; 99% CI, 0.74-1.63 per 500 cells), graft diameter (RR, 1.22 per 1 mm; 99% CI, 0.39-3.76 per 1 mm), and injector use for graft insertion (RR, 0.92; 99% CI, 0.40-2.10). CONCLUSIONS: Descemet stripping automated endothelial keratoplasty success in the early and entire postoperative period is more likely when the donor did not have diabetes and was without operative complications and in the long-term postoperative period in recipients with Fuchs dystrophy compared with those with PACE. Mechanisms whereby diabetic donors and PACE recipients reduce the rate of graft success after DSAEK warrant further study.

Magnusiomyces capitatus: a new and emerging pathogen linked to keratomycosis.

We describe our experience managing a case of fungal keratitis in a 71-year-old immunocompetent woman. Intracameral cultures isolated Magnusiomyces capitatus, a dimorphic commensal microbe with limited pathogenicity, in an immune competent patient. Repeated corneal cultures for bacteria and fungus were negative. Initial broad-spectrum topical fortified antibiotics were eventually escalated to include topical natamycin and voriconazole and oral voriconazole. The patient underwent emergent corneal transplantation, but recurrent infection eventually required anterior chamber washout and intracameral injection of amphotericin B. A combination of topical, systemic, intracameral administration of voriconazole, intracameral administration of amphotericin B, anterior chamber washout, and penetrating keratoplasty were required to clear the infection.