Long-term outcome of autologous fascia lata grafting with conjunctival flap overlay in horses with ulcerative keratitis and keratomalacia.

OBJECTIVES: To describe the technique, postoperative complications, and outcome after autologous fascia lata grafting with conjunctival flap overlay in horses with ulcerative keratitis and keratomalacia. STUDY DESIGN: Retrospective case series. ANIMALS: Eleven horses with ulcerative keratitis and keratomalacia. METHODS: Horses included had undergone fascia lata grafting with conjunctival flap overlay due to impending or recent corneal perforation. Preceding therapy, lesion characteristics, postoperative complications, and short- and long-term outcomes were recorded. RESULTS: Postoperative complications included complete (1/11) or partial (2/11) dehiscence of the conjunctival flap and fascia lata graft, postoperative pneumonia (1/11), intermittent hypercreatinemia (2/11) and mild uveitis after trimming of the conjunctival flap (9/10). The donor sites healed without complications (11/11). A satisfactory short-term outcome (at cessation of medical therapy) was achieved in all horses (11/11). Long-term follow-up (median 29 months, range 7-127 months) was available for 10/11 horses. A comfortable eye with functional vision was achieved in 9/10 horses with long-term follow-up, including 3/4 horses with prior corneal perforation and 1/11 horses in which the fascia lata graft completely dehisced 15 days after surgery. Enucleation was required in a single horse (1/10) after phthisis bulbi developed 7 months postoperatively. CONCLUSION: Fascia lata grafting with conjunctival flap overlay appears to be a viable solution for globe preservation in horses with ulcerative keratitis and keratomalacia. Long-term ocular comfort with functional visual outcomes can be achieved in most cases with limited concerns for donor site morbidity while bypassing acquisition, storage or lesion-size limitations related to other biomaterials.

Haemophilus Influenzae-Induced Corneal Ulcer and Endophthalmitis Triggered by Hair Dye.

ABSTRACT: The present report describes a 79-year-old woman developed eye pain in her right eye after accidental exposure to the hair dye when she dyed her hair. Her visual acuity was no light perception and intraocular ocular pressure was 10 mmHg in her right eye. Slit-lamp biomicroscopy revealed a huge corneal ulcer with the central cornea almost perforated and severe hypopyon in anterior chamber and moderate opacity in vitreous. Time-of-flight mass-spectrum of cornea scraping confirmed that the pathogen was haemophilus influenzae. Right-eye enucleation was performed. Topical chloramphenicol eye drops (0.25%) and ciprofloxacin (0.3%) and the ceftezole intravenous infusion were applied. The infection was controlled and the patient recovered well on 1 month follow-up. Doctors should be aware of the diagnosis and treatment of this complication associated with the application of hair dye as the popularity of this procedure increases.

A novel herpesvirus associated with chronic superficial keratitis and proliferative conjunctivitis in a great horned owl (Bubo virginianus).

An adult great-horned owl (Bubo virginianus; GHOW) presented with a history of recurrent corneal ulceration of the right eye (OD). Findings included ulcerative superficial keratitis, proliferative conjunctivitis, and iris pigmentary changes. The ulcer was initially nonresponsive to medical therapy, but showed rapid and appropriate healing following diamond burr debridement. Proliferative conjunctivitis markedly improved following topical antiviral therapy with cidofovir 1%, interferon alpha 2B ophthalmic solutions, and oral l-lysine. Histopathologic evaluation of a conjunctival biopsy revealed epithelial features suspicious for viral cytopathic changes and intranuclear structures suspicious for viral inclusions, suggestive of a possible viral-induced papillomatous conjunctivitis. A novel alphaherpesvirus, referred to as Strigid Herpesvirus 1 (StrHV1), was identified using PCR and gene sequencing. This case represents a new clinical manifestation of a previously unreported herpesvirus in the GHOW. Identification of the herpes virus was critical to administration of appropriate therapy and resolution of the conjunctivitis, and corneal epithelial debridement promoted resolution of the chronic corneal epithelial defect.

A dot hybridization assay for the diagnosis of bacterial keratitis.

PURPOSE: To evaluate a bacterial dot hybridization (BDH) assay for the diagnosis of bacterial keratitis (BK). METHODS: Sixty-one qualified corneal scrapings from 61 patients with suspected microbial keratitis were collected consecutively and prospectively. Among the 61 patients, 16 cases were BK and 45 cases were non-BK, including fungal keratitis, viral keratitis, parasitic keratitis, and non-microbial keratitis. Molecular diagnosis of BK in these corneal scrapes was performed using the BDH assay with three universal bacterial probes (PB1, PB2, and PB3) and three genus-specific probes (Aci, Klb, and Psu) to detect Acinetobacter, Klebsiella, and Pseudomonas, respectively. Signals were standardized after grayscale image transformation for objective validation using receiver operating characteristic (ROC) curves. RESULTS: The standardized intensities for the three universal probes differed statistically significantly between the BK group and the non-BK group. Based on the ROC curves, the sensitivities of PB1, PB2, and PB3 were 81.3%, 81.3%, and 93.8%, and the specificities were 71.1%, 88.9%, and 91.1%, respectively. The sensitivity and specificity of the Psu probe were 92% and 100%, respectively, while those of the Aci and Klb probes could not be estimated because there were no BK cases caused by Acinetobacter spp. or Klebsiella spp. CONCLUSIONS: The BDH assay is an effective molecular approach to improve the diagnosis of BK. Because the bias from bacterial contamination on the ocular surface can be minimized with signal standardization, the assay has the potential to be adopted for routine clinical practice.

Necrotising Scleritis and Peripheral Ulcerative Keratitis Associated with Rheumatoid Arthritis Treated with Rituximab.

Background Rheumatoid arthritis is a chronic and common inflammatory autoimmune disease. This primarily involves the synovia of the joints, but can cause many extra-articular manifestations as well, including peripheral ulcerative keratitis (PUK) and necrotising scleritis. These are often a threat to vision; they significantly compromise not only the eye's structural integrity but are also important for prognosis and need urgent management. History and signs Three cases of peripheral ulcerative keratitis associated with rheumatoid arthritis were recorded in the electronic databank of the Jules Gonin Uveitis Clinic, two with necrotising scleritis and peripheral ulcerative keratitis and one with only peripheral ulcerative keratitis. They were all followed at Jules Gonin Eye Hospital (Lausanne, Switzerland), conjointly with the Department of Rheumatology at the Centre Hospitalier Universitaire Vaudois (Lausanne, Switzerland). Therapy and Outcome Good initial therapeutic response was observed in the two patients who received rituximab therapy. The patient who received only high dose corticosteroid developed massive colon perforation as well as acute renal insufficiency a few days after her ocular event. Conclusion From our limited number of patients, we found that the two patients who received the induction therapy with rituximab were stabilised from an ocular standpoint; however, rituximab had to be switched to other molecules, either due to other systemic symptoms from the disease itself or due to adverse effect of this treatment. This contributes to the increasing number of reports that rituximab can be an effective treatment for refractory ocular complications of rheumatoid arthritis (RA), at least as an induction therapy.

Corneal cross-linking in the treatment of corneal ulcers.

PURPOSE OF REVIEW: New treatments for corneal ulcers are needed to address challenges with antibiotic resistance, cost, and specificity requiring timely pathogen identification. This review assesses the evidence regarding safety and efficacy of corneal cross-linking (CXL) as an adjunct or stand-alone treatment. RECENT FINDINGS: To date approximately 200 clinical cases of CXL used with various types of infectious keratitis have been reported in about 30 publications. Most employed the CXL protocol developed for keratoconus as an adjunct to antibiotics for resistant ulcers, and a number of cases resolved after this intervention. However, a few studies raised concerns about resurgence and perforation when CXL was utilized with deep fungal infections. The infiltrate depth is an important consideration, because the standard CXL treatment is cytotoxic (to keratocytes) to a depth of approximately 200-300 µm and 50% of the energy is absorbed within the first 100 µm. CXL was used successfully as a monotherapy in approximately 16 eyes with early bacterial or shallow fungal infections. SUMMARY: Further work is needed to develop optimized CXL protocols for treatment of corneal ulcers, define the appropriate conditions for use, and determine the safety and efficacy relative to standard antibiotic treatments.

[E-PTFE Membrane for the Management of Perforated Corneal Ulcer]. / E-PTFE Membran für die Behandlung von perforiertem Hornhautulkus.

Purpose: To present the surgical management of perforated corneal ulcer using PRECLUDE® Pericardial Membrane, composed of expanded polytetrafluoroethylene (e-PTFE; GORE-TEX®), as an alternative surgical procedure in patients at high risk of graft rejections and to evaluate side effects for a prolonged period. Patients and Methods: The study included all patients who were admitted to our department and underwent surgical repair of perforated corneal ulcer with the e-PTFE membrane between 2010 and 2015. In total, 8 patients (8 eyes) were enrolled. Medical records of all patients were retrospectively reviewed. The operation was performed under peribulbar anaesthesia. Non-absorbable, microporous, watertight 0.1 mm thick e-PTFE membrane was used to close the corneal ulcer. The membrane was cut to overlap the defect adequately and to achieve the desired tissue attachment without preparing the conjunctiva or superficial trephination of the cornea. The membrane was fixed to the healthy cornea with several non-absorbable sutures (Prolene® 10.0), in order to achieve the proper stress without wrinkling. Results: Five of 8 patients were treated for systemic immunological diseases. Sjögren's syndrome was diagnosed in 2 patients, granulomatosis with polyangiitis in one, vasculitis with a history of previous sclerokeratitis in one and systemic lupus erythematosus in one. In 2 patients, corneal perforation was observed as a complication of corneal infection and in one patient as a late complication of a severe chemical burn. Corneal perforations were successfully covered with e-PTFE membrane in all patients. E-PTFE membrane was well tolerated in all patients and the eye was always preserved. After 3 to 4 months, the membrane was removed in 7 patients. The underlying cornea was thin, firm, stable and vascularised. In one patient with Sjögren's syndrome, the e-PTFE membrane is still in place. Conclusion: Surgical management of perforated corneal ulcer using E-PTFE membrane may be the method of choice for eye preservation or for delayed corneal transplantation. Our results confirmed that the procedure is safe and effective, especially in high risk patients. After removing the membrane, penetrating keratoplasty can be performed as a definitive treatment in all eyes where an improvement in visual acuity is expected.

Corneal Ulcer Leading to Evisceration or Enucleation in a Tertiary Eye Care Center in Thailand: Clinical and Microbiological Characteristics.

BACKGROUND: Very severe corneal infection can lead to permanent visual loss, and there is still inadequate knowledge about these severe cases. OBJECTIVE: To identify clinical and microbiological characteristics of corneal ulcers resulting in evisceration or enucleation in a tertiary eye care center in Thailand. MATERIAL AND METHOD: A retrospective chart review was performed of all patients who required evisceration or enucleation due to corneal ulcer at Rajavithi Hospital, Bangkok, Thailand between October 2008 and September 2013. RESULTS: One hundred patients who underwent evisceration or enucleation as a result of corneal ulcer were included in the study. The mean age of the patients was 56.5 ± 12 years, most cases were referred from other hospitals (93%), and 13% of patients were diabetic. At presentation, visual acuity was worse than 5/200 in almost all cases (98%), and trauma (66%), especially by organic substances (36%), was the most common cause. Most cases had full thickness infiltration (81%) with mean size of 6.6 ± 2 mm. Corneal perforation was found in 18% of patients at presentation, and 60% of corneal scraping cultures were positive. Bacteria were the most common pathogens (65%), leading by Pseudomonas aeruginosa (10 cases), and the most common fungus was Fusarium spp. (7 cases). Secondary glaucoma (39%) and corneal perforation (25%) were the main ocular complications. Over half of the patients (52%) needed therapeutic or tectonic surgical intervention during admission. Following evisceration (94%) or enucleation (6%), 23 cases had wound complications that required further surgical treatment. Bacterial infection was found to increase the risk of wound complications more than infection by other pathogen groups (40.9%, p = 0.013). CONCLUSION: Despite aggressive medical and surgical treatments, very severe corneal ulcers at referral can lead to loss of an eye. Bacterial infection, especially by Pseudomonas aeruginosa, following eye trauma was the most common cause. Evisceration in bacterial corneal ulcers had greater wound complications than ulcers infected by other pathogens.

Outcome of Urgent Penetrating Keratoplasty for Corneal Ulcer at Thammasat University Hospital.

OBJECTIVE: To determine the eye integrity preservation after urgent penetrating keratoplasty (PKP) for corneal ulcer at Thammasat University Hospital. MATERIAL AND METHOD: A retrospective review of patients who underwent urgent PKP between September 2005 and January 2015 was conducted. Demographic data, predisposing factors, organisms, indication for surgery, time of urgent corneal graft registry, and preservation rate of eye integrity were analyzed. RESULTS: Fifty-five patients (55 eyes) registered for urgent corneal graft registry from eye bank and 22 eyes underwent urgent PKP There were 14 males (63.6%) and 8 females (36.4%). A mean age was 55.9±15.4 years. The most common predisposing factor was ocular trauma in 11 eyes (50.0%) and the most common indication for surgery was severe corneal ulcer in 11 eyes (50.0%). The mean time of urgent corneal graft registiy was 22.1±1 7.2 days (3-70 days). The present study could preserve eye integrity in post urgent PKP in 18 eyes (81.8%). Other 4 eyes (18.2%) could not preserve the eye integrity. In 33 eyes who did not underwent urgent PKP 20 eyes (60.6%) could preserve eye integrity, 10 eyes (30.3%) underwent primary evisceration and 3 eyes (9.1%) underwent primary enucleation due to extensive ocular infection. CONCLUSION: Urgent PKP of corneal ulcer could provide satisfactory in eye integrity preservation.

[Treatment of large corneal perforations with acellular multilayer of corneal stromal lenticules harvested from femtosecond laser lenticule extraction].

OBJECTIVE: To describe a novel surgical technique for the treatment of large corneal perforations by using acellular multilayer of corneal stromal lenticules. METHODS: Prospective study. The acellular tissue used for the repair was harvested from myopic patients during the femtosecond laser (FS) refractive surgery. Informed consent, blood test and donor eligibility were obtained in each case. Three or four layers of lenticules were stacked up and stored at -80°C in pure sterile glycerin. The diameter is 6.0 to 6.5 mm and central thickness was 300 to 400 µm. If the diameter of the corneal ulcer perforation was larger than 3 mm and corneal grafts were not available, we used this kind of patches to seal the perforations. It was a retrospective case series study. Five cases of corneal ulcer perforation were enrolled in this study. One was neuropathic keratitis, one was atopic keratoconjunctivitis, and the other three were fungal keratitis. Acellular multilayer of stromal lenticules were used in these cases for emergent therapy. RESULTS: The sealing of the perforation and the re-establishment of the anterior chamber were achieved successfully in all the cases. For the pericentral perforations, visual recovery was achieved. And efficient palliative management was done for the central perforations. CONCLUSIONS: The reported technique seems to represent a good alternative emergency procedure for the management of large corneal perforations. It is a very useful method for Chinese hospitals where the shortage of cornea donors is a very serious problem and the amount of FS surgeries are increasing.

[Urgent therapeutic penetrating autokeratoplasty for a purulent corneal ulcer in the only functional eye].

The article presents a case of severe purulent corneal ulcer in the only functional eye of a young patient with Frank-Kamenetsky glaucoma and high-degree myopia. Combination therapy was ineffective and the patient developed a descemetocele. Due to the absence of cadaver corneas and small size of the only available conserved Alloplant cornea, the contralateral cornea (of the blind eye, which was enucleated under general anesthesia) was used for urgent therapeutic penetrating autokeratoplasty. Postoperative period was complicated with ocular hypertension, which was surgically resolved. To overcome the critical situation around keratoplasty, with results from Russian regulation gaps, the authors suggest creating interregional eye banks in large cities that would provide sampling, conservation and storage control of donor material in accordance with the existing legislation.

Case Report: Vision-Threatening Fungal Keratitis in a Service Member Stationed at Guantanamo Bay.

Fungal keratitis is a major cause of corneal blindness worldwide. Compared to other types of infectious keratitis, fungal keratitis has a relatively poor prognosis because of various factors such as delayed patient presentation and diagnosis. Although associated in earlier studies with poverty and low socioeconomic status, military personnel stationed in tropical and subtropical climates, in low-resource settings, are at risk. Here, we report a case of a 20-year-old active duty contact lens-wearing military service member stationed at Guantanamo Bay who developed a severe vision-threatening fungal keratitis in her left eye. Enhancing health and safety precautions in at-risk settings, maintaining vigilance, and leveraging new imaging modalities will be important to ensure early recognition and treatment.

Locality is the strongest predictor of expert performance in image-based differentiation of bacterial and fungal corneal ulcers from India.

PURPOSE: This study sought to identify the sources of differential performance and misclassification error among local (Indian) and external (non-Indian) corneal specialists in identifying bacterial and fungal keratitis based on corneal photography. METHODS: This study is a secondary analysis of survey data assessing the ability of corneal specialists to identify acute bacterial versus fungal keratitis by using corneal photography. One-hundred images of 100 eyes from 100 patients with acute bacterial or fungal keratitis in South India were previously presented to an international cohort of cornea specialists for interpretation over the span of April to July 2021. Each expert provided a predicted probability that the ulcer was either bacterial or fungal. Using these data, we performed multivariable linear regression to identify factors predictive of expert performance, accounting for primary practice location and surrogate measures to infer local fungal ulcer prevalence, including locality, latitude, and dew point. In addition, Brier score decomposition was used to determine experts' reliability ("calibration") and resolution ("boldness") and were compared between local (Indian) and external (non-Indian) experts. RESULTS: Sixty-six experts from 16 countries participated. Indian practice location was the only independently significant predictor of performance in multivariable linear regression. Resolution among Indian experts was significantly better (0.08) than among non-Indian experts (0.01; P < 0.001), indicating greater confidence in their predictions. There was no significant difference in reliability between the two groups ( P = 0.40). CONCLUSION: Local cornea experts outperformed their international counterparts independent of regional variability in tropical risk factors for fungal keratitis. This may be explained by regional characteristics of infectious ulcers with which local corneal specialists are familiar.

Ocular hypertension and glaucoma incidence in patients with scleritis.

BACKGROUND: Scleritis belongs to the group of chronic inflammatory eye diseases that may cause ocular hypertension (OHT) and secondary glaucoma (SG). Aim of this study was to identify the incidence and risk factors for OHT and SG with regard to the scleritis form. METHODS: Single-center retrospective analysis of all consecutive patients with scleritis. RESULTS: A total of 271 scleritis patients (161 women, mean age 51.0 ± 16.9 years) were enrolled. The median follow-up was 17.0 ± 21.4 months (range 6-116). Of these patients, 56 (21 %) showed an intraocular pressure (IOP) increase with an open chamber angle at any time during follow-up. Another four patients (7 %) had secondary angle-closure glaucoma. An increase in IOP was found more frequently in patients with necrotizing (42 %) than in those with posterior (30 %), nodular (18 %) or diffuse anterior scleritis (18 %, p = 0.022). Most patients (82 %) developed the pressure increase during acute scleritis episodes. Initially, 72 % of patients with increased IOP were classified as OHT; this figure had decreased to 56 % at the end of follow-up. In the course of disease, the IOP normalized in 13 %. The univariate analysis of risk factors showed an increased risk in the presence of anterior uveitis, peripheral ulcerative keratitis, posterior synechiae, and previous cataract surgery. CONCLUSIONS: An increase in IOP occurs in about one-fifth of patients with scleritis. The initial pressure elevation occurs mostly in the acute phase of disease. An increase in pressure is found most often in patients with necrotizing scleritis.

[Corneal ulcer caused by Serratia marcescens: case report].

A case of corneal ulcer caused by Serratia marcescens is reported in a patient with history of corneal microtrauma. Biological features (pathogenicity factors, antibiotic resistance) of isolated culture were characterized. Keratitis cases caused by this agent were analyzed.

Mapping prognostic factors for globe survival in panophthalmitis using logistic regression and Cox proportional hazard models: A retrospective study.

Purpose: The aim of this study was to report the outcomes of panophthalmitis and to identify factors significantly affecting globe survival in the disease. Methods: This was a retrospective study on patients with panophthalmitis in a tertiary hospital between January 1, 2017, and December 31, 2019. The demographics, treatment details, culture results, and final outcomes were recorded. Logistic regression and Cox proportional hazards (CPH) were calculated to identify variables associated with globe loss. A P < 0.05 was considered significant. Results: Eighty-five eyes of 85 patients (31 culture positive) were eligible for review. The mean age of the participants was 55.21 ± 20.17 years with a male-to-female ratio of 2.04:1. Corneal ulcer (38.82%; n = 33) and open globe injuries (OGIs) (38.82%; n = 33) were the most common etiologies. Pseudomonas aeruginosa (n = 10; 11.76%) was the most common isolate. The mean duration of hospital stay was 7.58 ± 2.32 days. Overall, 44 (51.76%) globes could be salvaged. The need for evisceration (P = 0.901) and hospital stays (P = 0.095) were similar for culture-positive and -negative cohorts. The unadjusted logistic regression and CPH models showed that culture sterility did not affect globe survival [OR = 1.210 (0.501-2.950), P = 0.668; HR = 1.176 (0.617-2.243), P = 0.623]. The adjusted logistic regression and the CPH models showed that corneal ulcers [OR = 10.900 (2.460-48.200), P = 0.002; HR = 5.393 (1.603-18.140), P = 0.006] and OGI [OR = 7.360 (1.650-32.700), P = 0.009; HR = 4.548 (1.321-15.660), P = 0.016] were significantly associated with globe loss. Conclusion: Corneal ulcer or OGI as the primary etiology is detrimental to globe survival in panophthalmitis.

From the diagnosis of infectious keratitis to discriminating fungal subtypes; a deep learning-based study.

Infectious keratitis (IK) is a major cause of corneal opacity. IK can be caused by a variety of microorganisms. Typically, fungal ulcers carry the worst prognosis. Fungal cases can be subdivided into filamentous and yeasts, which shows fundamental differences. Delays in diagnosis or initiation of treatment increase the risk of ocular complications. Currently, the diagnosis of IK is mainly based on slit-lamp examination and corneal scrapings. Notably, these diagnostic methods have their drawbacks, including experience-dependency, tissue damage, and time consumption. Artificial intelligence (AI) is designed to mimic and enhance human decision-making. An increasing number of studies have utilized AI in the diagnosis of IK. In this paper, we propose to use AI to diagnose IK (model 1), differentiate between bacterial keratitis and fungal keratitis (model 2), and discriminate the filamentous type from the yeast type of fungal cases (model 3). Overall, 9329 slit-lamp photographs gathered from 977 patients were enrolled in the study. The models exhibited remarkable accuracy, with model 1 achieving 99.3%, model 2 at 84%, and model 3 reaching 77.5%. In conclusion, our study offers valuable support in the early identification of potential fungal and bacterial keratitis cases and helps enable timely management.

Bilateral Necrotizing Scleritis with Scleral Melt associated with Herpes Simplex Infection: A Case Report.

Objective (Aim): The article is a case report of a very rare case of bilateral herpes simplex virus infection associated with bilateral necrotizing scleritis with scleral melt in an elderly north Indian female of lower middle socioeconomic status. Methods: A 65-year-old female presented to our clinic with a wide variety of presentations ranging initially from neurotropic corneal ulcer to necrotizing scleritis with scleral melt for 2 years. The patient records were evaluated and computed. A PubMed literature search on herpes scleritis was conducted and reviewed. Results: A keen sense of judgment, timely management, and patient counseling are crucial for a rapid and favorable outcome. Conclusions: Bilateral necrotizing scleritis with scleral melt can be a rare atypical presentation of herpes simplex keratitis. In such atypical cases, diagnosis may be challenging. Associated clinical findings, history of herpes keratitis, which may be recurrent, and response to antiviral drugs, may give clues towards the diagnosis in such atypical cases. In addition to this, surgical intervention should not be delayed if it seems inevitable. Abbreviations: RE = right eye, LE = left eye, BCL = bandage contact lens, KP = keratic precipitate, mm = millimeter, mg = milligram.