Presumptive ocular tuberculosis: A case series of rare cases.

Ocular tuberculosis (TB) may present with various clinical manifestations and may involve any part of the eye. In 80% of cases, pulmonary involvement is not found. Here, we are presenting three cases of presumptive ocular TB with three rare manifestations. The first case is of bilateral retinal detachment involving one eye after another, the second case is of tubercular phlyctenular keratoconjunctivitis with keratolysis, and the third case is of bilateral neuroretinitis with extensive cerebral involvement. Despite the availability of various tests, clinical findings, tuberculin skin test, chest X-ray, and computed tomography of the chest is still the primary basis of diagnosis of ocular TB in the tubercular endemic area, even in rare cases.

The Use of Corneoscleral Grafts to Maintain Tectonic Stability in Severe Keratolysis.

Severe corneal ulcerations, causing major keratolysis with large perforation of the cornea or extending to the limbal region, are an ophthalmic emergency. In these cases, a larger corneoscleral graft can be transplanted to restore tectonic integrity, alleviate pain, save vision, and prevent loss of the eye. Chart review of 34 patients with a corneoscleral graft ≥9.5 mm was conducted. Primary endpoints of the study were tectonic stability defined as no need for another keratoplasty or enucleation. In addition, visual acuity, postoperative complications, and secondary procedures were analyzed. In total, 12 patients (35%) were female. The mean age at transplantation was 65 ± 19 years. The underlying disease was a perforated infectious corneal ulcer in 30 cases (88%). Mean follow up was 675 ± 789 days. Tectonic stability at the end of the follow-up was maintained with a probability of 56% in a Kaplan-Meier analysis. Another penetrating keratoplasty was necessary in six cases (17%) and enucleation in five cases (15%). A corneoscleral transplant remains a viable treatment option to prevent enucleation in severe keratolysis. In our study, this was possible in about half of the cases. Postoperative complications, secondary surgeries, and markedly reduced visual acuity put the advantages into perspective.

Randomized controlled trial and cost-effectiveness analysis: Comparing chlorhexidine scrub, ZnO-nanoparticle socks, and their combination in pitted keratolysis treatment.

A cost-effective treatment for pitted keratolysis (PK) is the use of 4% chlorhexidine scrub. Zinc oxide nanoparticle (ZnO-NP)-coated socks have also shown efficacy in PK prevention. In this study, we aimed to assess the cost-effectiveness and safety of combined 4% chlorhexidine scrub and ZnO-NP-coated sock treatment compared to monotherapy. This randomized, controlled trial included 60 male security guards and hospital porters aged ≥18 with PK. Participants were randomly assigned to one of three treatment groups: 4% chlorhexidine scrub, ZnO-NP-coated socks, or combination therapy. Treatment outcomes were evaluated after 4 weeks. Incremental cost-effectiveness ratios (ICERs) were calculated using cost-utility analysis. The greatest reduction in visual analog scale scores for foot odor was observed in the combination therapy group, but it was nonsignificant (P = 0.186). Clinical improvement was observed across all groups. The cost-utility analysis revealed that chlorhexidine scrub and regular socks were the least expensive options. The placebo and ZnO-NP-coated sock group had an ICER of US $31 082/quality-adjusted life years (QALYs) gain, while the combination therapy gained US $45 105/QALYs compared to the chlorhexidine scrub and regular sock group. Based on our findings, for the treatment of PK, 4% chlorhexidine scrub remains the most cost-effective choice.

Exploring the Potent Combination of Quercetin-Boronic Acid, Epalrestat, and Urea Containing Nanoethosomal Keratolytic Gel for the Treatment of Diabetic Neuropathic Pain: In Vitro and In Vivo Studies.

Transdermal penetration of therapeutic moieties from topical dosage forms always remains a challenge due to the presence of permeation impeding keratin which should be addressed. The purpose of the study was to formulate quercetin and 4-formyl phenyl boronic acid (QB complex) used for the preparation of nanoethosomal keratolytic gel (EF3-G). The QB complex was confirmed by Fourier transform infrared spectroscopy while skin permeation, viscosity, and epalrestat entrapment efficiency were used for the optimization of nanoethosomal gel. The keratolytic effect of the proposed nanoethosomal gel with urea (QB + EPL + U) was calculated in rat and snake skin. The spherical shape of nanoethosomes was confirmed by scanning electron microscopy. According to the findings of stability studies, viscosity decreases as temperature increases, proving their thermal stability. The negative charge of optimized EF3 with 0.7 PDI proved narrow particle size distribution with homogeneity. Optimized EF3 showed two folds increase of epalrestat permeation in highly keratinized snake skin as compared to rats' skin after 24 h. Antioxidant behaviors of EF3 (QB) > QB complex > quercetin > ascorbic acid proved reduction of oxidative stress in DPPH reduction analysis. Interestingly, the hot plate and cold allodynia test in the diabetic neuropathic rat model reduced 3-fold pain as compared to the diabetic control group which was further confirmed by in vivo biochemical studies even after the eight week. Conclusively, ureal keratolysis, primary dermal irritation index reduction, and improved loading of epalrestat render the nanoethosomal gel (EF3-G) ideal for the treatment of diabetic neuropathic pain.

Keratolysis exfoliativa-like eruption induced by ranolazine.

Dermatoses affecting palms may represent a dermatologic challenge from both the diagnostic, and therapeutic point of view. Patients with supposedly occupational dermatitis can spend months or even years in a frustrating attempt to avoid contact with possible irritants or allergens. To underline the importance of a thorough unbiased analysis of the patient's history and clinical features, we present the iconic case of a bricklayer affected by a chronic, disabling desquamation of palms which in the end was classified as keratolysis exfoliativa (KE) attributed to ranolazine-intake, an antianginal drug. To the best of our knowledge, this specific adverse effect of druginduced KE of palms has never been reported before in association with ranolazine.

Antibacterial Effect of Lemongrass (Cymbopogoncitratus) against the Aetiological Agents of Pitted Keratolyis.

Pitted keratolysis (PK) is a bacterial skin infection mostly affecting the pressure-bearing areas of the soles, causing unpleasant symptoms. Antibiotics are used for therapy, but the emergence of antiobiotic resistance, makes the application of novel topical therapeutic agents necessary. The antibacterial effects of 12 EOs were compared in the first part of this study against the three known aetiological agents of PK (Kytococcus sedentarius, Dermatophilus congolensis and Bacillus thuringiensis). The results of the minimal inhibitory concentration, minimal bactericidal concentration and spore-formation inhibition tests revealed that lemongrass was the most effective EO against all three bacterium species and was therefore chosen for further analysis. Seventeen compounds were identified with solid-phase microextraction followed by gas chromatography-mass spectrometry (HS-SPME/GC-MS) analysis while thin-layer chromatography combined with direct bioautography (TLC-BD) was used to detect the presence of antibacterially active compounds. Citral showed a characteristic spot at the Rf value of 0.47, while the HS-SPME/GC-MS analysis of an unknown spot with strong antibacterial activity revealed the presence of α-terpineol, γ-cadinene and calamenene. Of these, α-terpineol was confirmed to possess an antimicrobial effect on all three bacterium species associated with PK. Our study supports the hypothesis that, based on their spectrum, EO-based formulations have potent antibacterial effects against PK and warrant further investigation as topical therapeutics.

Fungal keratitis: Mechanisms of infection and management strategies.

Fungal corneal ulcers are an uncommon, yet challenging, cause of vision loss. In the United States, geographic location appears to dictate not only the incidence of fungal ulcers, but also the fungal genera most encountered. These patterns of infection can be linked to environmental factors and individual characteristics of fungal organisms. Successful management of fungal ulcers is dependent on an early diagnosis. New diagnostic modalities like confocal microscopy and polymerase chain reaction are being increasingly used to detect and identify infectious organisms. Several novel therapies, including crosslinking and light therapy, are currently being tested as alternatives to conventional antifungal medications. We explore the biology of Candida, Fusarium, and Aspergillus, the three most common genera of fungi causing corneal ulcers in the United States and discuss current treatment regimens for the management of fungal keratitis.

Novel technique of tetra trephination for elliptical-shaped tectonic patch grafts in peripheral sterile keratolysis.

PURPOSE: To describe a novel technique of tectonic patch grafts for elliptical-shaped peripheral sterile keratolysis with iris prolapse. METHODS: We performed a full thickness corneo-scleral patch graft in five eyes of five patients with elliptical-shaped peripheral sterile keratolysis with perforation and iris tissue prolapse. In this technique, four disposable trephines with predetermined diameter were employed to fashion both the host and the donor without any free-hand dissection. An intact anatomical integrity of the globe without the need for any repeat tectonic measures was considered as a successful outcome. RESULTS: The mean age was 34.2 ± 10.2 years (18-45). The mean total surgical time and donor preparation time was 94.4 ± 7.12 min and 7.6 ± 1.14 min, respectively. The intraoperative course was uneventful in all cases and all eyes had a well-maintained corneal integrity till 6 months follow up. CONCLUSION: We describe a simple, reproducible, and time-saving technique of performing elliptical shaped corneoscleral patch grafts for peripheral corneal perforations with iris prolapse.

Pattern of Skin Diseases and Occupational Dermatoses among Paddy Field Workers in Kashmir Valley: A Cross-Sectional Study from North India.

INTRODUCTION: Paddy farming is one of the main occupations in Kashmir valley. The workers associated with paddy are exposed to variety of irritants such as manures, fertilizers, and pesticides, besides getting exposed to intense sunlight for long hours due to the nature of their work. All these factors can potentially either trigger skin diseases or can worsen them. AIM: The aim of this study was to find out the prevalence and pattern of various skin disorders among paddy field workers in Kashmir valley. MATERIALS AND METHODS: This was a cross-sectional descriptive study in which 600 workers engaged in paddy farming in different areas of Kashmir valley were screened. The diagnosis was made on clinical grounds and wherever deemed necessary, relevant investigations were carried out to establish the nature of the disease. RESULTS: A total of 600 workers were evaluated for the presence of skin disorders. Two hundred thirty workers (38.3%) were found to have skin lesions, while the rest, i.e. 370 (61.7%) were free from any skin problem. Out of the total skin lesions, infectious ones were seen in 40.4%, while non-infectious accounted for 59.6% cases. The main non-infectious disorders included melasma, followed by hand and foot eczemas, hyperkeratosis of palms and soles and callosities/cuts, while among the infectious group the major chunk was formed by bacterial infections followed by fungal, viral, and parasitic. Pitted keratolysis and intertrigo were the most common bacterial and fungal infections respectively. CONCLUSION: A large number of skin diseases were seen in paddy field workers, with some diseases showing an occupational nature.

Randomized, controlled trial testing the effectiveness and safety of 2.5% and 5% benzoyl peroxide for the treatment of pitted keratolysis.

BACKGROUND: The appropriate dosage and duration of topical benzoyl peroxide gel (BP) treatment of pitted keratolysis (PK) is controversial. OBJECTIVE: To compare the effectiveness and safety of topical 2.5% and 5% BP for the treatment of PK. MATERIALS AND METHODS: This randomized, controlled trial was conducted at Chumpol Naval Rating School, Chonburi, Thailand. Naval rating cadets with PK were randomly assigned to either a 2.5% or a 5% BP group and were requested to apply the related medication on each sole once daily, for 2 weeks. RESULTS: All 42 and 47 participants who were treated with 2.5% and 5% BP, respectively, were included in the later analysis. Self-evaluation of the foot odor level using a visual analog scale (VAS) showed significant decreases for both groups (p<.001). The pitted lesions were evaluated by dermatologists and found to have improved in the 2.5% and 5% BP groups (69.0% versus 63.8%, respectively; p=.457). Side effects did not statistically differ between the two groups (p>.05). CONCLUSIONS: Either 2.5% or 5% BP can be used for the treatment of PK and foot malodor. Due to the similarities in their efficacies and side effects, the use of 2.5% BP may be preferable.

Enzymatic Digestion of Porcine Corneas Cross-linked by Hypo- and Hyperosmolar Formulations of Riboflavin/ultraviolet A or WST11/Near-Infrared Light.

Purpose: To assess enzymatic digestion rate after Riboflavin (RF) and Water-Soluble-Taurine (WST11) based corneal cross-linking (CXL), with or without the addition of high molecular weight dextran (RF-D and WST-D). Methods: Eighty-eight paired porcine corneas were cross-linked by either RF (n = 11) or RF-D (n = 11) and ultraviolet light (UVA), or WST11 (n = 11) or WST-D (n = 11) and near-infrared (NIR) light, or used as paired control (n = 44). Corneal buttons of treated and paired control eyes were placed in a 0.3% collagenase solution. Time to full digestion and remaining dry sample weight after six hours were compared. Results: A strong treatment effect was seen with all four formulations, as all controls had been fully digested whilst all treated samples were still visible at the experiment's endpoint. After irradiation, central corneal thickness was significantly higher in samples treated with hypo-osmolar formulations, compared to dextran enriched formulations (P < 0.001). Dry sample weight after digestion was nonsignificantly different between corneas treated by the four different formulations (P = 0.102). Average dry sample weight was 1.68 ± 0.6 (n = 10), 2.19 ± 0.50 (n = 8), 1.48 ± 0.76 (n = 11), and 1.54 ± 0.60 (n = 9) mg, for RF, RF-D, WST11, and WST-D treated samples, respectively. Enzymatic resistance was similar for RF and WST based CXL (P = 0.61) and was not affected by the addition of dextran (P = 0.221). Conclusions: Both RF and WST11 based CXL significantly increases resistance to enzymatic digestion, with similar effect for hypo-osmolar and hyperosmolar (dextran enriched) formulations. Translational Relevance: Our findings indicate these formulations are interchangeable, paving the way for the development of novel PACK-CXL protocols for thin corneas and deep-seated infections.

The foot microbiome.

BACKGROUND: The human skin microbiome is represented by bacteria, fungi, viruses, and mites. AIMS: Every human being possess their own unique skin microbiome because intrinsic and environmental factors have a significant impact on the quality and quantity of microorganism. Every site of the body is a separate microbial niche. PATIENTS: The feet are one of the most unique and heterogeneous microbial niches of human body with areas that differ by skin thickness, anatomical features, distribution of sweat glands, pH, and the availability of oxygen. RESULTS: Healthy skin of the foot is inhabited by Corynebacteriaceae, Micrococcaceae, Propionibacteriaceae, Actinobacteria, Clostridiales, Lactobacillaceae, Streptococcaceae, Enterobacteriaceae, Moravellaceae, Neisseriaceae, Pastereullaceae, and Proteobacteria. The most common fungi present on the feet are Malassezzia, Cryptococcus, Aspergillus, Rhodotorula, Epicoccum, Saccharomyces, Candida, Epidermophyton Microsporum, and Trichophyton. CONCLUSIONS: The disturbance of the foot microbiome causes dysbiosis and may lead to pitted keratolysis, fungal, and viral infections or even to protothecosis.

Tolio: Foot Rot in Grand Canyon River Runners.

Treating skin disorders in wilderness settings is often challenging. In this report we describe common skin conditions affecting the feet of river runners on the Colorado River in Grand Canyon National Park. These conditions are frequently referred to by river runners with a catchall term, "tolio." Several skin disorders have been identified as components of tolio, with the most prevalent currently being pitted keratolysis. We present a case of pitted keratolysis in a river guide occurring during a multiday river trip, where treatment can be difficult. Prevention is often more important.

Fluocinolone acetonide intravitreal implant as a therapeutic option for severe Sjögren's syndrome-related keratopathy: a case report.

BACKGROUND: In this report, we present the results of a severe case of Sjögren's syndrome-related keratopathy after fluocinolone acetonide 190-µg intravitreal implant (Iluvien®; Alimera Sciences Inc.) therapy. CASE PRESENTATION: A 52-year-old Caucasian woman with Sjögren's syndrome secondary to autoimmune hepatitis and primary sclerosing cholangitis was admitted to our emergency department owing to bilateral corneal ulcers and corneal perforation in the left eye following exposure keratopathy in an artificially induced coma. Within the following months, recurrent fulminant keratolysis with perforations required multiple penetrating keratoplasties and amniotic membrane transplants in both eyes. With new signs of severe keratolysis, an intravitreal fluocinolone acetonide implant was injected off-label in the left eye, and a third penetrating keratoplasty was performed 2 weeks later. In the 6 months of follow-up after the last penetrating keratoplasty, no more surgical interventions were needed in the eye with the fluocinolone acetonide implant. The corneal surface remained stable, and intraocular pressure was normal. During this time frame, two further penetrating keratoplasties, one vitrectomy, and five amniotic membrane transplants were performed in the fellow eye owing to relapsing keratolysis and perforations. CONCLUSIONS: To the best of our knowledge, this is the first report of fluocinolone acetonide intravitreal therapy in a patient with corneal disease. In the 6-month follow-up period, no surgical intervention was needed in the eye with the fluocinolone acetonide implant, whereas further penetrating keratoplasties and amniotic membrane transplants were performed in the fellow eye. Intravitreal fluocinolone acetonide may be considered as a treatment option in severe cases of autoimmune corneal disease.

Cost-effectiveness analysis and safety of erythromycin 4% gel and 4% chlorhexidine scrub for pitted keratolysis treatment.

Background: Studies of Pitted keratolysis (PK) treatment are limited. Objectives: To study cost-effectiveness and to compare the safety of 4% chlorhexidine scrub with 4% erythromycin gel, for PK infections. Materials and methods: This cohort study was conducted on naval rating cadets with a clinical diagnosis of PK at Chumpol Naval Rating School, Thailand in 2016. Participants were randomly treated with either 4% erythromycin gel or 4% chlorhexidine scrub for 4 weeks. The clinical examinations were evaluated at the baseline and at 1 and 2 months after treatment. A decision-tree model was used to evaluate the costs, resource utilization and outcomes as quality-adjusted life-years (QALYs). Results: Of 344 naval rating cadets, 125 (36.3%) were diagnosed with PK. Sixty-four were treated with erythromycin. Approximately 80% of participants had complete resolution Foot odor were significantly improved at 2 months (p < .001) for both groups. No adverse effects were reported. Total cost for 4 weeks' treatment with the erythromycin gel and chlorhexidine scrub was US$77.34, US$51.9, respectively. Chlorhexidine treatment and erythromycin gel had 0.1526 and 0.1425 QALYs, respectively. Conclusions: treatment of PK with either 4% chlorhexidine scrub or 4% erythromycin gel had similar outcomes. However, using chlorhexidine scrub was more cost-effective.

[Boston Keratoprosthesis with temporal aponeurosis graft: A solution when there seems to be no more]. / Kératoprothèse de Boston avec greffe d'aponévrose temporale : une solution quand il semble ne plus y en avoir.

PURPOSE: To report cases of patients with severe bilateral corneal blindness and recurrent refractory perforation to keratoplasty and conventional treatment, for whom Boston keratoprosthesis (KP) was a satisfactory alternative when combined with a temporalis aponeurosis graft. DESCRIPTION OF CASES: The first patient had progressive Lyell syndrome with spontaneous corneal perforation. The second had a severe graft vs. host reaction with a persistent Seidel-positive descemetocele. Despite repeated penetrating keratoplasties, amniotic membrane (AM) transplantations, and buccal mucosal (BM) grafts, they both experienced recurrent corneal perforation. The only solution thus appeared to be Boston Type I KP surgery. One month postoperatively, the first patient had to receive a temporalis aponeurosis (TA) graft, due to thinning of the recipient graft. Six months postoperatively, his visual acuity (VA) was 1/10 without correction, and the corneal status had been stabilized. The second patient underwent KP and TA graft concurrently. Six months after surgery, VA was 2/10 uncorrected, and the local inflammation had been stabilized. OBSERVATION: Boston type I keratoprostheses constitute an alternative in cases of severe bilateral corneal blindness with perforation refractory to conventional treatment and surgery, with satisfactory visual results. DISCUSSION: Patients with preoperative severe ocular surface disease are at greater risk of postoperative keratolysis. For our patients with a higher risk, TA graft prevented corneal melt. TA seems to be more effective than AM or BM in preventing corneal thinning or melt. CONCLUSION: We would recommend performing a TA graft in combination with Boston KP surgery concurrently as first line treatment in eyes with severe ocular surface inflammation.

Corneal Melt after Boston Keratoprosthesis: Clinical Presentation, Management, Outcomes and Risk Factor Analysis.

PURPOSE: To determine the presentation, risk factors, and outcomes of keratolysis after Boston type I keratoprosthesis (B-KPro). METHODS: Retrospective chart review. RESULTS: A total of 16 (14%) of the 110 eyes (96 patients) which underwent B-KPro implantation developed keratolysis at an average 20 ± 11 months. Retroprosthetic membrane (RPM), infectious keratitis, and corneal dellen were identified in 31%, 25%, and 13% of corneal melts, respectively. Five eyes had keratolysis without a readily identifiable cause. RPM (odds-ratio, OR = 4.4, p = 0.02) and infectious keratitis (OR = 17.6, p<0.0005) were confirmed as significant risk factors. Retinal detachment (p = 0.001) and choroidal detachment (p = 0.003) were more common in eyes with keratolysis. Management included B-KPro removal or exchange (n = 7), amniotic membrane transplantation (n = 1), tectonic corneal transplantation (n = 2), medical treatment (n = 4), and observation (n = 2). CONCLUSIONS: The risk of keratolysis following B-Kpro increases with the development of RPM and infectious keratitis. Patients with keratolysis had higher complication rates and should receive rigorous monitoring.

Infliximab after Boston Keratoprosthesis in Stevens-Johnson Syndrome: An Update.

PURPOSE: To report our experience using intravenous infliximab for the treatment of tissue melt after Boston keratoprosthesis (B-KPro) types I and II in patients with autoimmune disease. METHODS: Case series. RESULTS: We identified four patients who were treated with intravenous infliximab in the context of tissue melt after B-KPro. Stevens-Johnson syndrome-associated corneal blindness was the primary surgical indication for B-KPro implantation in all patients. Two patients received a B-KPro type I and two patients received a B-KPro type II. The patients received intravenous infliximab for skin retraction around B-KPro type II, melting of the carrier graft or leak. Treatment resulted in a dramatic decrease in inflammation and, in some cases, arrest of the melting process. Cost and patient adherence were limiting factors to pursuing infliximab therapy. In addition, one patient developed infusion reactions. CONCLUSIONS: Intravenous infliximab may be considered as globe- and sight-saving therapy for tissue melt after B-KPro.

Single-center, noninterventional clinical trial to assess the safety, efficacy, and tolerability of a dimeticone-based medical device in facilitating the removal of scales after topical application in patients with psoriasis corporis or psoriasis capitis.

INTRODUCTION: Psoriasis is a frequent inflammatory skin disease affecting ~2%-3% of the population in western countries. Scaling of the psoriatic lesions is the most impairing symptom in patients with psoriasis. In contrast to conventional keratolytic treatment concepts containing salicylic acid or urea, a dimeticone-based medical device (Loyon®) removes scales in a physical way without any pharmacological effect. OBJECTIVE: To assess the efficacy and tolerability of a dimeticone-based medical device in removal of scales in patients with psoriasis corporis/capitis under real-life conditions. METHODS: Forty patients with psoriasis capitis or corporis were included and received once-daily treatments for 7 days. Clinical assessment of the psoriasis area severity index score (psoriasis corporis) and the psoriasis scalp severity index score (psoriasis capitis) was performed and evaluated at baseline, after 3 and 7 days of treatment. Baseline scaling scores and redness scores were calculated for two target lesions of the scalp or the body on a 5-point scale each. RESULTS: For the primary efficacy variable scaling score, a statistically significant decrease was observed after treatment, with a relative reduction in scaling of 36.8% after 7 days of treatment within patients affected by psoriasis capitis. Treatment success was achieved in 76.8% of patients with psoriasis capitis, and time to treatment success was evaluated to be 4.14 days for these patients and 4.33 days for patients suffering from psoriasis corporis. CONCLUSION: In conclusion, this trial demonstrated that the dimeticone-based medical device is a safe, well-tolerated, practicable, and efficient keratolytic compound, which can be well implemented in and recommended for standard therapy of psoriasis.