Validation of a Comprehensive Clinical Algorithm for the Assessment and Treatment of Microbial Keratitis.

PURPOSE: To validate a comprehensive clinical algorithm for the assessment and treatment of microbial keratitis (MK). DESIGN: Retrospective cohort study. METHODS: The "1, 2, 3 Rule" for the initial management of MK was conceived by Vital and associates in 2007 to inform the decision as to when to perform corneal cultures. The rule is invoked when any 1 of 3 clinical parameters is met: ≥1+ anterior chamber cells, ≥2 mm infiltrate, or infiltrate ≤3 mm distance from the corneal center. When the rule is met, we added the mandatory use of fortified topical antibiotics after cultures are obtained. We compared outcomes of cases presenting to Massachusetts Eye and Ear 2 years before (Group I, n = 665) and after (Group II, n = 767) algorithm implementation. The primary composite outcome was a vision-threatening complication, such as corneal perforation. RESULTS: At a median follow-up of 67.0 and 60.0 days, respectively, 172 patients experienced a vision-threatening complication (Group I, 12.9% vs Group II, 11.2%, P = .51). While the algorithm codified conventional management practice at either end of disease severity, the effect of algorithm-augmented care was best appreciated in patients with lesions satisfying only 1 criterion. In this group, there was an increase in the proportion of patients undergoing culture at presentation (54.6% vs 67.7%, P = .006), fortified antibiotic prescription (29.7% vs 53.9%, P < .001), and reduction in vision-threatening complications (9.7% vs 1.8%, P = .001). The proportion of patients who were not cultured at presentation but later required culturing decreased (13.4% vs 5.1%, P = .001), as did patients who did not meet any criteria but were nonetheless cultured (23.9% vs 8.5%, P < .001). Multiple logistic regression showed that all algorithm parameters were independently associated with outcome: ≥1+ anterior chamber cells (odds ratio [OR] 1.66, 95% confidence interval 1.09-2.52); ≥2 mm infiltrate (OR 4.74, 2.68-8.40); and ≤3 mm from corneal center (OR 2.82, 1.85-4.31), confirmed with comparison to a bootstrapped sample (n = 10,000). CONCLUSIONS: The implementation of this algorithm reduced vision-threatening complications for patients with lesions satisfying only 1 criterion, arguably the most difficult patients in whom to judge disease severity. Implementation also led to a decrease in patients receiving unnecessary care.

Use of Tachosil® as an adjuvant therapeutic option in neurotrophic keratopathy in order to prevent perforation.

We present two cases of women who suffered from neurotrophic keratopathy (one of them had undergone penetrating keratoplasty) which had led to corneal thinning. Tachosil® was used as an adjuvant treatment after topical medication by itself failed in both cases. To our knowledge, there are no reported cases of the use of Tachosil® in corneal grafts.

Queratoglobo. Presentación de caso / Keratoglobus. Case presentation

RESUMEN Se presenta un caso clínico de un varón de 27 años de edad, con una ectasia corneal y presencia de queratoglobo en ambos ojos. La manifestación clínica fue disminución lenta y progresiva de la agudeza visual en ambos ojos y dolor en el ojo izquierdo. Al examen oftalmológico se constató hidrops corneal agudo en ojo izquierdo y otras complicaciones corneales, propias de esta anomalía. Se realizó un estudio oftalmológico que permitió un diagnóstico certero. Se aplicó la terapéutica correspondiente y se sugirieron otras opciones terapéuticas (AU).

ABSTRACT We present the clinical case of a male patient, aged 27 years, with corneal ectasia and keratoglobus in both eyes. The clinical manifestation was progressive and slow decrease of the visual acuity in both eyes and pain in the left eye. At the ophthalmologic examination, acute corneal hydrops was found in the left eye, and also other complications that are proper of this anomaly. An ophthalmologic study was carried out that lead to an accurate diagnosis. The correspondent therapy was applied and several therapeutic options were suggested (AU).

Creation and validation of a simulator for corneal rust ring removal.

OBJECTIVE: To create and validate a simulation model for corneal rust ring removal. METHODS: Rust rings were created on cadaveric eyes with the use of small particles of metal. The eyes were mounted on suction plates at slit lamps and the trainees practiced rust ring removal. An inexperienced cohort of medical students and first year ophthalmology residents (n=11), and an experienced cohort of senior residents and faculty (n=11) removed the rust rings from the eyes with the use of a burr. Rust ring removal was evaluated based on removal time, percentage of rust removed and incidence of corneal perforation. A survey was administered to participants to determine face validity. RESULTS: Time for rust ring removal was longer in the inexperienced group at 187±93 seconds (range of 66-408 seconds), compared to the experienced group at 117±54 seconds (range of 55-240 seconds) (p=0.046). Removal speed was similar between groups, at 4847±4355 pixels/minute and 7206±5181 pixels/minute in the inexperienced and experienced groups, respectively (p=0.26). Removal percentage values were similar between groups, at 61±15% and 69±18% (p=0.38). There were no corneal perforations. 100% (22/22) of survey respondents believed the simulator would be a valuable practice tool, and 89% (17/19) felt the simulation was a valid representation of the clinical correlate. CONCLUSION: The corneal rust ring simulator presented here is a valid training tool that could be used by early trainees to gain greater comfort level before attempting rust ring removal on a live patient.

Management of severe and refractory Mooren's ulcers with rituximab.

PURPOSE: Management of severe and refractory Mooren's ulcers is challenging as it encompasses tectonic surgical treatment and aggressive immunosuppressive therapies. Efficacy of rituximab in the management of severe Mooren's ulcers has never been reported. METHODS: Five patients (six eyes) from the Cornea and External Disorders department at the Rothschild Ophthalmologic Foundation (Paris, France) were treated for severe Mooren's ulcer unresponsive to conventional treatments between 2008 and 2016. Conventional treatment included topical steroid and ciclosporin 2%, high doses of systemic corticosteroids and/or cyclophosphamide and conjunctival resection with amniotic membrane graft. These patients received two infusions of 1000 mg of rituximab at 2 weeks interval. Epithelial healing, inflammation, additional surgery, systemic corticosteroids and rituximab-related side effects were reported. RESULTS: The mean follow-up was 46.8 months. Following rituximab treatment, we observed a complete healing of Mooren's ulcer within 2 weeks in all patients. Peripheral lamellar keratoplasty was associated when peripheral corneal perforation occurred (5/6 affected corneas). Systemic corticosteroids had been discontinued in all patients. Two recurrences occurred 13 and 53 months after the first rituximab infusion and where successfully treated with a new infusion. No rituximab-related adverse events were reported. CONCLUSIONS: Rituximab was effective in the management of severe Mooren's ulcers and could be an alternative to cyclophosphamide. Additional studies should assess the role of this biotherapy in the management of immunological corneal ulcer.

The Use of Conjunctival Pedicle Flaps to Prevent Corneal Perforation in Graft-Versus-Host Disease.

PURPOSE: We report the clinical outcomes of two chronic graft-versus-host disease (cGVHD) corneal thinning cases that were successfully treated with conjunctival pedicle flaps in an effort to prevent impending corneal perforation. METHODS: The patients were treated with topical and systemic corticosteroids, therapeutic contact lenses, lubricants, and punctual plugs. Conjunctival pedicle flaps were used because conventional treatments had failed, and corneal perforation was imminent. RESULTS: Both patients were successfully treated with conjunctival pedicle flaps. Following conjunctival flap removal, one patient had corneal clarity restored following penetrating keratoplasty. CONCLUSIONS: Conjunctival pedicle flaps provided a strong barrier for the corneal surface and stabilized anterior chamber in cGVHD patients with impending corneal perforation following allogeneic hematopoietic stem cell transplant.

Urgent Therapeutic Grafting of Platelet-Rich Fibrin Membrane in Descemetocele.

PURPOSE: To report the clinical and histopathological results of a novel autologous scaffold grafting, platelet-rich fibrin (PRF) membrane, in cases with descemetocele. METHODS: Three patients with severe corneal stromal melting and central descemetocele caused by neurotrophic keratopathy and infective keratitis underwent PRF membrane grafting on the central cornea for the prevention of imminent corneal perforation. After a quiescent 3-month period, penetrating keratoplasty and cataract extraction were performed for visual rehabilitation in 1 patient and host corneal tissue was examined histopathologically. RESULTS: Pain was significantly relieved, conjunctival inflammation was markedly resolved, and the central descemetocele area became thicker with scar formation in all patients. Histopathological examination revealed fibrosis formation over the descemetocele area without any tissue gap. Newly formed tissue containing irregular corneal lamellae covered the fibrosis formation and accounted for the prevention of perforation. CONCLUSIONS: Temporary PRF membrane grafting may be an alternative intervention to avoid impending corneal perforation in cases with severe descemetocele.

A bandage contact lens prevents extrusion of ocular contents.

A 76 year old male presents with a corneal perforation in a phthisical eye. Definitive treatment in the form of an evisceration was delayed by 38 days. During this period a bandage contact lens prevented extrusion of ocular contents through an enlarging corneal perforation. This case demonstrates that a bandage contact lens can be effective in the immediate management of large corneal perforations whilst awaiting urgent definitive treatment.

Images in clinical medicine: Bilateral corneal perforation.

A 61-year-old woman with long-standing rheumatoid arthritis presented with the sensation of a foreign body in her right eye; she reported no symptoms in her left eye. The patient had systemic symptoms associated with her rheumatoid arthritis and was taking naproxen.

Fibrin glue for prevention of recurrent epithelial ingrowth under a LASIK flap with a central buttonhole defect.

A 61-year-old woman presented with a paracentral buttonhole flap defect associated with a linear tear, extensive epithelial ingrowth, and macrostriae in the right eye. A laser in situ keratomileusis enhancement had been performed 3 weeks earlier. The epithelial ingrowth was removed after careful lifting of the flap, and tissue adhesive was used postoperatively as a barrier to further ingrowth. Six months postoperatively, the patient's corrected distance visual acuity had improved to 20/20 and the slitlamp examination showed no evidence of recurrent epithelial ingrowth. This case presents a novel approach to the management of a buttonhole defect.

VIP and growth factors in the infected cornea.

PURPOSE: Vasoactive intestinal peptide (VIP) is an anti-inflammatory neuropeptide that downregulates proinflammatory cytokines and promotes healing in a susceptible model of P. aeruginosa keratitis. Growth factors also play a role in corneal healing and restoration of tissue homeostasis after wounding. However, whether VIP treatment modulates growth factors to promote healing in the infected cornea remains untested and is the purpose of this study. METHODS: C57BL/6 (B6) mice were injected with VIP and mRNA and protein levels, and immunostaining for EGF, FGF, HGF, and VEGF-A were done. Exogenous treatment with a mixture of the growth factors also was tested and levels of cytokines, defensins, and bacterial counts were determined. RESULTS: Real-time RT-PCR, immunostaining, and ELISA data demonstrated that treatment with VIP enhanced levels of EGF, FGF, and HGF during disease, and that VEGF-A, and associated angiogenic molecules also were increased by VIP. Moreover, immunohistochemical studies confirmed that both epithelial and stromal cells participated in growth factor production. Most notably, treatment with a mixture of EGF, FGF, and HGF after disease onset, prevented corneal perforation when compared with controls. This outcome was associated with downregulation of proinflammatory cytokines such as macrophage inflammatory protein-2 (MIP-2), upregulation of anti-inflammatory cytokines such as TGF-ß, and antimicrobials ß-defensins 2 and 3, as well as decreased plate counts at 1 day postinfection (p.i.) (P = 0.0001). CONCLUSIONS: Collectively, the data provide evidence that VIP treatment modulates growth factors, angiogenic molecules, and defensins in the infected cornea and that this in turn promotes healing and restoration of tissue homeostasis.