PACK Cross-Linking as Adjuvant Therapy Improves Clinical Outcomes in Culture-Confirmed Bacterial Keratitis.

PURPOSE: We recently showed the positive clinical effects of combining accelerated corneal cross-linking (PACK-CXL) with antibiotic treatment in patients with presumed bacterial keratitis. In this study, we compare the impacts of a combined PACK-CXL/standard antibiotic treatment (PACK-ABX group) with standard antibiotic treatment alone (ABX group) in patients with culture-confirmed bacterial keratitis. METHODS: We reviewed patients with moderate and severe bacterial keratitis and confirmed bacterial cultures. Clinical outcomes were compared for standard antibiotic treatment alone, before the initiation of PACK-CXL, and after adjuvant use of PACK-CXL. RESULTS: A total of 47 eyes of 47 patients were included: 26 eyes in the PACK-ABX group and 21 eyes in the ABX group. Pathogens, baseline demographics (besides age), and clinical parameters were similar between the 2 groups. The PACK-ABX patients had better final uncorrected visual acuity [mean difference 0.57 Logarithm of the Minimum Angle of Resolution, 95% Confidence Interval (CI): 0.16-0.99, P = 0.07] and best-corrected visual acuity (mean difference 0.70 Logarithm of the Minimum Angle of Resolution, 95% CI: 0.23-1.16, P = 0.04), shorter reepithelialization time (mean difference 9.63 days, 95% CI: 3.14-16.12, P = 0.004), and reduced number of clinic visits (mean difference 4.8 meetings, 95% CI: 1.4-8.2, P = 0.007) and need for tectonic grafts (0 vs. 33.3%, P = 0.002). A multivariate analysis controlling for age, sex, ulcer size, and Gram stain showed that PACK-ABX treatment remained significantly associated with reepithelialization time (ß = 14.5, P = 0.001). CONCLUSIONS: In our study, PACK-CXLs addition to the standard of care in cases of culture-proven bacterial keratitis had a positive effect on the final visual acuity and time to resolution, compared with the standard-of-care treatment.

A Novel Marking Technique for Descemet Membrane Endothelial Graft Using an Ophthalmic Viscoelastic Device.

PURPOSE: To describe the viscoelastic marking technique, a novel marking technique of Descemet membrane endothelial keratoplasty (DMEK) grafts that enables usage of a single donor cornea for 2 surgeries-one that uses Descemet membrane and endothelium (DMEK) and the other using the stroma and Bowman layer. METHODS: A retrospective case analysis was performed on 26 eyes of 26 consecutive patients who underwent DMEK using the "viscoelastic marking technique." In this novel technique, an ophthalmic viscoelastic device (Healon 5) is placed over the endothelial side. Descemet membrane is then folded in half over the ophthalmic viscoelastic device with the stromal side up, and the F mark is drawn on the stromal side of the folded Descemet membrane. Primary outcome was best spectacle-corrected visual acuity, and secondary outcomes included graft detachment and rebubble rate, graft failure, and endothelial cell density. RESULTS: Mean best spectacle-corrected visual acuity improved significantly from 1.0 ± 0.7 logarithm of the minimum angle of resolution (LogMAR) before the surgery to 0.9 ± 0.7 LogMAR, 0.5 ± 0.6 LogMAR, 0.4 ± 0.2 LogMAR, and 0.4 ± 0.4 LogMAR at 1, 3, 6, and 12 months after surgery, respectively. Seven eyes (27%) had partial graft detachment that required air injection. Primary failure occurred in 3 eyes (11%). There were no free-floating donors or recognized inverted donors. The endothelial cell density loss at 12 months after surgery was a cell-loss rate of 38.3%. CONCLUSIONS: The viscoelastic marking technique is a simple, approachable, and safe technique for marking DMEK grafts while preserving the anterior cornea for additional surgery.

Accelerated Corneal Cross-linking as an Adjunct Therapy in the Management of Presumed Bacterial Keratitis: A Cohort Study.

PURPOSE: To compare the outcomes of accelerated photoactivated chromophore for keratitis corneal cross-linking (PACK-CXL) as an adjunct treatment for bacterial keratitis (PACK-CXL plus standard antibiotic therapy) for patients receiving only standard antibiotic therapy. METHODS: Retrospective cohort study of outcomes of patients with moderate infectious presumed bacterial keratitis (ulcer diameter 2 to 7 mm and stromal depth < 300 µm) were compared before and after initiation of a new treatment protocol of PACK-CXL in addition to standard antibiotic treatment. RESULTS: A total of 70 eyes of 70 patients were included: 39 eyes in the PACK-CXL plus antibiotic (PACK-ABX) group and 31 eyes in the antibiotic only (ABX) control group. The PACK-ABX group showed shorter times to complete reepithelialization (9.3 ± 6.0 vs 16.0 ± 12.7 days, P = .01) and did not require tectonic emergency keratoplasty (0% versus 19.4%, P = .006). The PACK-ABX group also showed a higher percentage of eyes with complete reepithelialization in 6 days or less (46.2% vs 6.5%, P < .001) and a trend for shorter hospitalizations (6.3 ± 5.0 vs 8.5 ± 4.5 days, P = .06). A multivariate analysis controlling for age showed that PACK-ABX treatment remained significantly associated with early ulcer reepithelialization (odds ratio = 0.09, 95% confidence interval = 0.02 to 0.48, P = .005). CONCLUSIONS: This study validates previous findings regarding the use of accelerated PACK-CXL in the treatment of bacterial keratitis. Adding PACK-CXL improved clinical outcomes (reducing healing time) when compared to antibiotics alone. [J Refract Surg. 2020;36(4):258-264.].

Accelerated Corneal Cross-Linking With Photoactivated Chromophore for Moderate Therapy-Resistant Infectious Keratitis.

PURPOSE: To evaluate the effect of accelerated corneal cross-linking with photoactivated chromophore (PACK-CXL) as additional treatment for therapy-resistant infectious keratitis. METHODS: In this interventional cohort study, 20 patients (11 men and 9 women), aged 65.5 (interquartile range = 21.5-78.5) years, who were hospitalized for moderate-sized therapy-resistant bacterial corneal ulcers (11/20 microbiologically confirmed) were treated with hypoosmolar 0.1% riboflavin solution and Ultraviolet A (UVA) irradiation for 3 minutes at 30 mW/cm (5.4 J/cm) as additional therapy to standard antimicrobial treatment. RESULTS: We did not observe any adverse effects of accelerated PACK-CXL on the corneal stroma or limbus. The median ulcer size was 3.00 (2.63-4.50) mm, the median time to reepithelialization was 6.50 (5.00-18.0) days, and the mean hospitalization period was 8.5 ± 4.5 days. Tectonic keratoplasty became necessary in 1 patient (5%). CONCLUSIONS: Our results suggest that accelerated PACK-CXL may provide an antimicrobial effect similar to the 1 low-intensity, slow setting (30 minutes at 3 mW/cm) and may be used as additional treatment in moderate-sized therapy-resistant infectious keratitis.

Perinatal outcome in cases of latent syphilis during pregnancy.

OBJECTIVE: To investigate factors associated with latent syphilis and pregnancy outcome among women with latent syphilis. METHODS: A retrospective population-based study was conducted to compare all pregnancies among women with and without latent syphilis at Soroka University Medical Center, Be'er-Sheva, Israel, between 1988 and 2010. Stratified analysis using a multiple logistic regression model was performed to control for confounders. RESULTS: Of the 219656 deliveries during the study period, 159 (0.1%) involved women with latent syphilis. Multivariate analysis with backward elimination revealed the following conditions to be significantly associated with latent syphilis: fetal growth restriction (odds ratio [OR] 2.20; 95% confidence interval [CI], 1.07-4.49; P=0.03); drug abuse (OR 9.95; 95% CI, 1.31-75.46; P=0.02); tobacco use (OR 3.35; 95% CI, 1.74-6.45; P<0.05); and Jewish (vs Bedouin) ethnicity (OR 4.05; 95% CI, 2.65-6.20; P<0.05). CONCLUSION: Women with latent syphilis are at risk for adverse maternal and perinatal outcomes, including fetal growth restriction. Careful surveillance of these high-risk pregnancies should be considered.