Outcome of Therapeutic Keratoplasty in Hopeless Microbial Keratitis Cases Otherwise Advised Evisceration.

PURPOSE: To study the outcome of therapeutic keratoplasty in severe microbial keratitis cases otherwise advised evisceration. METHODS: A retrospective, single-center clinical audit included 28 patients with severe microbial keratitis presenting from April 2014 to April 2016. Patients with microbial keratitis either affecting more than 2 quadrants of the limbus and/or cases with infections involving more than 180 mm of the cornea who were advised evisceration by more than one ophthalmologist were included. Cases with endophthalmitis were excluded. At 3 months, the outcome was "success" if resolution of infection occurred without recurrence and evisceration was not required. Success was termed "complete" if best vision was 6/24 or better and "partial" otherwise. The outcome was termed a "failure" if infection recurred in the graft or the eye was eviscerated. RESULTS: Mean age of the patients (male:female, 17:11) was 49.5 years, and the mean duration of symptoms before surgery was 28.6 days. Evisceration was required in 2/28 cases. The outcome was "success" in 22/28 cases (78.6%)-complete (10/22); partial (12/22)-and "failure" in 6/28 cases. The outcome was poorer in general in fungal keratitis (n = 16) than bacterial keratitis (n = 7). CONCLUSIONS: Primary evisceration is best avoided in infections limited to the anterior segment. Even in hopeless cases, every eye deserves a fair chance.

Indications for destructive ocular surgeries in Nigeria.

INTRODUCTION: Destructive ocular surgery (DOS) means eye loss. An audit of its indications would be useful in reducing its incidence. OBJECTIVE: To determine indications for destructive ocular surgeries. MATERIALS AND METHODS: The case records (files) of all the patients who had DOS in a tertiary health facility in Nigeria from January 2004 to December 2011 were reviewed retrospectively. The information extracted include the bio data, indication for DOS, type of surgery performed and history of the use of traditional eye medications (TEM) and willingness to use an artificial eye (AE). RESULTS: Thirty-seven patients had DOS. The mean age of the patients was 35.51years (SD 21.6) and the male to female ratio was 2.1:1. Evisceration was the commonest DOS performed , in 30 eyes (81.1 %). The most common indication for DOS was intraocular infection, in 15 eyes (40.5 %), followed, among others, by trauma in 13 (35.1 %) and malignant ocular tumours in 4 (10.8 %). There was association between age and indication for DOS (P = 0.032). Many patients, 15 (40.5%), used TEM and most, 34 (91.9%), refused an artificial eye (AE) after surgery. CONCLUSIONS: The most common indication for DOS in this study was intraocular infection. Evisceration was the commonest destructive eye surgery offered.

Streptococcus endophthalmitis outbreak after intravitreal injection of bevacizumab: one-year outcomes and investigative results.

PURPOSE: To report the 1-year clinical outcomes of an outbreak of Streptococcus endophthalmitis after intravitreal injection of bevacizumab, including visual acuity outcomes, microbiological testing, and compound pharmacy investigations by the Food and Drug Administration (FDA). DESIGN: Retrospective consecutive case series. PARTICIPANTS: Twelve eyes of 12 patients who developed endophthalmitis after receiving intravitreal bevacizumab prepared by a single compounding pharmacy. METHODS: Medical records of patients were reviewed; phenotypic and DNA analyses were performed on microbes cultured from patients and from unused syringes. An inspection report by the FDA based on site visits to the pharmacy that prepared the bevacizumab syringes was summarized. MAIN OUTCOME MEASURES: Visual acuity, interventions received, time to intervention, microbiological consistency, and FDA inspection findings. RESULTS: Between July 5 and 8, 2011, 12 patients developed endophthalmitis after intravitreal bevacizumab from syringes prepared by a single compounding pharmacy. All patients received initial vitreous tap and injection, and 8 patients (67%) subsequently underwent pars plana vitrectomy (PPV). After 12 months follow-up, outcomes have been poor. Seven patients (58%) required evisceration or enucleation, and only 1 patient regained pre-injection visual acuity. Molecular testing using real-time polymerase chain reaction, partial sequencing of the groEL gene, and multilocus sequencing of 7 housekeeping genes confirmed the presence of a common strain of Streptococcus mitis/oralis in vitreous specimens and 7 unused syringes prepared by the compounding pharmacy at the same time. An FDA investigation of the compounding pharmacy noted deviations from standard sterile technique, inconsistent documentation, and inadequate testing of equipment required for safe preparation of medications. CONCLUSIONS: In this outbreak of endophthalmitis, outcomes have been generally poor, and PPV did not improve visual results at 1-year follow-up. Molecular testing confirmed a common strain of S. mitis/oralis. Contamination seems to have occurred at the compounding pharmacy, where numerous problems in sterile technique were noted by public health investigators.

Deep anterior lamellar keratoplasty using acellular corneal tissue for prevention of allograft rejection in high-risk corneas.

PURPOSE: To determine whether deep anterior lamellar keratoplasty (DALK) using acellular glycerol-cryopreserved corneal tissue (GCCT) could prevent allograft rejection in high-risk corneas. DESIGN: Prospective, randomized, comparative study. SETTINGS: The Eye Hospital, Wenzhou Medical College, Zhejiang, China. STUDY POPULATION: All patients with herpes simplex virus keratitis, bacterial keratitis, fungal keratitis, or ocular burn, who were eligible as per study design, were invited to participate. OBSERVATION PROCEDURES: According to randomized block design, all patients received either GCCT or fresh corneal tissue (FCT) during DALK. Best-corrected visual acuity (BCVA), slit-lamp microscopy, and in vivo confocal microscopy examinations at 1 week and 1, 3, 6, 12, and 24 months after surgery were analyzed. Kaplan-Meier survival analysis was used to evaluate graft survival rate. MAIN OUTCOME MEASURES: Therapeutic success, 2-year rejection-free graft survival rate and 2-year graft survival rate, in vivo confocal microscopy results, BCVA, and endothelial cell density. RESULTS: Postoperative BCVA of 20/40 or better at the last follow-up visit was achieved in 57.6% (19/33) of eyes in the GCCT group and in 54.8% (17/31) of the FCT group. No graft rejection occurred in the GCCT group, while in the FCT group 10 episodes of stromal rejection developed in 7 eyes. Overall, the rejection-free graft survival rate at 2 years was significantly higher in the GCCT group as compared with the FCT group (100.0%, 78.8% respectively, P = .006). CONCLUSIONS: Deep anterior lamellar keratoplasty using acellular glycerol-preserved cornea could prevent allograft rejection and promote graft survival rate in high-risk corneas.

Resuturing following penetrating keratoplasty: a retrospective analysis.

AIM: To examine the clinical profile of cases requiring resuturing following penetrating keratoplasty (PKP) at a tertiary care eye hospital. METHODS: The medical records of 947 consecutive patients who had undergone PKP between 1998 and 2006 were reviewed retrospectively and cases that were resutured during this period were analysed. The main parameters studied were indications for PKP, suturing techniques, causes of resuturing, visual acuity outcome and post-resuturing complications. RESULTS: The incidence of resuturing was 5.4% (51 eyes). The number of cases requiring resuturing was higher in corneal grafts performed for microbial keratitis (12%) than those for keratoconus (10%) and corneal endothelial decompensation (2.5%; p = 0.08). Wound dehiscence was the leading cause for resuturing (43%), followed by loose or broken sutures (37.3%). The most common complications after resuturing were occurrence of microbial keratitis (7.8%) and graft failure (5.9%). DISCUSSION: Resuturing may have to be performed more commonly for corneal transplantation surgery done for microbial keratitis and keratoconus. The major indications for resuturing are wound dehiscence and loose/broken sutures.

Did the spectrum of endophthalmitis change? A study comprising 13 years experience with operative therapy of endophthalmitis.

PURPOSE: The authors wondered whether the spectrum of endophthalmitis and the type of therapy had changed. METHODS: Files of patients who were operated upon for endophthalmitis between 1988 and 2000 were retrospectively analyzed. They were divided into Group 1 (operated upon 1988 to 1994) and Group 2 (1995 to 2000). RESULTS: Group 1 consisted of 83 patients (43.4% female, mean age 63.9 years), Group 2 of 108 (38.9% female, mean age 64.6 years). Bilateral endophthalmitis occurred in 8.4% of Group 1 patients (3.7% of Group 2 patients). Patients in both groups took on average 1.2 drug types against various internal diseases. The mean interval between first symptoms and presentation in the clinic was 45.7 days in Group 1 (19 days in Group 2; difference statistically significant). There were 63% (Group 1) (70% [Group 2]) cases of postoperative endophthalmitis, among them 58% (Group 1) (63% [Group 2]) after cataract extraction, 6% (Group 1) (5% [Group 2]) after glaucoma surgery, 20% (Group 1) (17% [Group 2]) endogenous and 17% (Group 1) (13% [Group 2]) post traumatic. In Group 2 slightly more Gram-negative bacteria were found. As an initial procedure the following were performed: vitrectomy (70% [Group 1], 88% [Group 2]), removal of crystalline lens (11% [Group 1], 10% [Group 2]), removal of pseudophakos (2% [Group 1], 12% [Group 2]), opening of posterior capsule (1% [Group 1], 9% [Group 2]), and anterior chamber irrigation (36% [Group 1], 43% [Group 2]), often combining procedures. There were significantly more vitrectomies and openings of the posterior capsule in Group 2. Neither the spectrum of secondary and tertiary procedures nor the reasons for such surgery differed in both groups. Neither visual acuity at initial presentation (0.1) nor at final follow-up (0.3) differed between the two groups. The rate of enucleation was less in Group 2 (6% versus 11%) although not statistically significantly. CONCLUSIONS: In Group 2 there were slightly more Gram-negative bacteria and the time interval between initial symptoms and presentation in the clinic had decreased. This can be interpreted as an increase in the severity of the endophthalmitis cases. The final visual acuity was identical in both groups, the enucleation rate improved.

Therapeutic keratoplasty for infectious keratitis: a review of the literature.

PURPOSE: This article provides a review of the literature on various aspects of therapeutic keratoplasty, including indications, techniques, complications and outcome, and its application in cases of infectious keratitis. METHODS: Various articles on therapeutic keratoplasty (including English- and non-English-language publications) were analyzed. Selection of the articles was based on a Medline search for articles using the key words therapeutic keratoplasty, penetrating keratoplasty, therapeutic keratoplasty for infectious keratitis, non-healing corneal ulcer, microbial keratitis, and perforated corneal ulcer. Abstracts in English were used for non-English articles. RESULTS: Therapeutic keratoplasty has a definitive role in the management of progressive bacterial, fungal, Acanthamoeba, and viral keratitis refractory to medical treatment. Management of bacterial keratitis has higher functional success and anatomic cure rate compared with fungal, viral and Acanthamoeba keratitis. Therapeutic keratoplasty offers a cure rate of up to 100% in bacterial and fungal keratitis, whereas the recurrence of infection after Acanthamoeba keratitis is frequent. Visual outcome depends on various factors such as the causative agent, timing of surgery, degree of inflammation, type of donor material used, and size of the graft used. For example, larger grafts have a higher incidence of graft rejection and failure compared to smaller grafts. The primary aim of the procedure is to reestablish the integrity of the globe and to eliminate the infectious disease process. Visual rehabilitation is a secondary outcome. CONCLUSIONS: This review helps to elucidate the various aspects of therapeutic keratoplasty, including indications, preoperative assessment, surgical techniques, postoperative management, complications, and anatomic and functional outcome.

Infectious keratitis after laser refractive surgery.

PURPOSE: To report two cases of infectious keratitis, one fungal after photorefractive keratectomy (PRK) and the other bacterial after laser in situ keratomileusis (LASIK). DESIGN: Two interventional case reports. PARTICIPANTS: Case 1 is a male who was seen 3 weeks after PRK with a corneal ulceration. Case 2 involves a female who was seen 7 weeks after LASIK with interface granularity. RESULTS: Cultures in case 1 were identified as Scopulariopsis species, and despite intensive treatment, a therapeutic penetrating keratoplasty (PK) was eventually performed. Case 2 had cultures identified as Mycobacterium chelonae and also ultimately required a therapeutic PK. CONCLUSIONS: Two unusual infectious keratitides are reported after different laser refractive surgery techniques.

Twenty-five-year panorama of corneal immunology: emerging concepts in the immunopathogenesis of microbial keratitis, peripheral ulcerative keratitis, and corneal transplant rejection.

PURPOSE: To describe the most recent advances in our understanding of the cellular and molecular mechanisms involved in the immunopathogenesis of corneal immunoinflammatory disorders including microbial keratitis, peripheral ulcerative keratitis. and allograft rejection. METHODS: Review of the published peer-reviewed literature that has contributed significantly to our modern understanding of corneal immunology. In addition, the authors have summarized the information in conceptual diagrams that highlight the critical cellular and molecular pathways that lead to corneal immune responses in the two most thoroughly studied corneal immune disorders, herpes simplex keratitis (HSK) and transplant rejection. RESULTS: In spite of the wide array of molecular and cellular factors that mediate corneal immunity, critical mechanistic facets are shared by the various corneal immunoinflammatory disorders. These include activation and migration of local antigen-presenting cells (APCs), including Langerhans cells (LCs), upregulation in pleiotropic proinflammatory cytokines such as interleukin-1 (IL-1) and tumor necrosis factor-alfa (TNF-alpha) that can mediate a wide array of immune functions in addition to up-regulating protease expression. and chemokines that play a critical role on the one hand in attracting nonantigen-specific inflammatory cells such as neutrophils and on the other in attracting CD4+ T helper type 1 (Th1) cells that mediate most of the destruction in the cornea. CONCLUSIONS: In the last 25 years, we have seen our field develop from a descriptive stage into a new phase where the fundamental processes that mediate and effect corneal immunity are being accurately deciphered. It is anticipated that this new knowledge will allow development of specific molecular and genetic therapeutic strategies that could target critical steps in the immunopathogenesis of disease without the untoward side-effects of nonspecific generalized immune suppression that still remains the standard of care today.

Amniotic membrane transplantation for ocular surface reconstruction.

AIMS: To evaluate the efficacy of amniotic membrane transplantation (AMT) for ocular surface reconstruction. METHODS: 10 consecutive patients who underwent AMT were included. The indications were: group A, cases with persistent epithelial defect after corneal abscess (n = 1), radiation (n = 1), or chemical burn (n = 3); group B, cases with epithelial defect and severe stromal thinning and impending or recent perforation, due to chemical burn (two patients, three eyes) or corneal abscess (n = 2); group C, to promote corneal epithelium healing and prevent scarring after symblepharon surgery with extensive corneo-conjunctival adhesion (n = 1). Under sterile conditions amniotic membrane was prepared from a fresh placenta of a seronegative pregnant woman and stored at -70 degrees C. This technique involved the use of amniotic membrane to cover the entire cornea and perilimbal area in groups A and B, and the epithelial defect only in group C. RESULTS: The cornea healed satisfactorily in four of five patients in group A, but the epithelial defect recurred in one of these patients. After AMT three patients underwent limbal transplantation and one penetrating keratoplasty and cataract extraction. In group B amniotic membrane transplantation was not helpful, and all cases underwent an urgent tectonic corneal graft. Surgery successfully released the symblepharon, promoted epithelialisation and prevented adhesions in the case of group C. CONCLUSION: AMT was effective to promote corneal healing in patients with persistent epithelial defect, and appeared to be helpful after surgery to release corneo-conjunctival adhesion. Most cases required further surgery for visual and ocular surface rehabilitation. Amniotic membrane used as a patch was not effective to prevent tectonic corneal graft in cases with severe stromal thinning and impending or recent perforation.

Clinical confocal microscopy.

Because it provides much higher magnification and better optical sectioning than a slit-lamp biomicroscope, confocal microscopy is ideally suited for clinical imaging of the cornea. One important clinical application of confocal microscopy has been the early detection and diagnosis of a number of infectious conditions, including infection with Acanthamoeba and microsporidium species, fungal keratitis, and contact lens-associated bacterial keratitis. Confocal microscopy has also been used for temporal evaluation of corneal wound healing following refractive surgery and penetrating keratoplasty. With the development of the new technique of quantitative confocal microscopy through-focusing, confocal microscopy can be used to measure epithelial, stromal, and corneal thickness accurately and reproducibly in human patients. Furthermore, conofocal microscopy through-focusing can be used to determine the initial photoablation depth, changes in epithelial, stromal, and corneal thickness, and subepithelial haze following photorefractive keratectomy.

Prognostic factors associated with the visual outcome after vitrectomy for endophthalmitis.

BACKGROUND: Functional results following vitrectomy with intraocular and systemic antibiotic treatment for endophthalmitis are influenced by numerous factors. METHODS: A retrospective study of 65 cases of endophthalmitis treated between October 1988 and May 1994 at the Department of Ophthalmology, University of Cologne, Germany was conducted. All eyes underwent pars plana vitrectomy and intraocular and systemic antibiotic treatment. RESULTS: Vision of 20/400 or better could be obtained in 66% of eyes following extracapsular cataract extraction and intraocular lens implantation (ECCE + IOL), in 62% after severe eye injury, in 36% of eyes after intraocular surgery for other reasons than cataract extraction with lens implantation and in 33% of patients with endogenous endophthalmitis. Vision of 20/50 or better could be achieved in 41% of eyes following ECCE + IOL and additional systemic steroid treatment. In 22% of cases primary silicone endotamponade was performed; 57% of these eyes obtained visual acuity of 20/400 or better. Fifteen patients (23%) suffered diabetes mellitus; 20/400 vision or better could be achieved in 73% of these eyes. Visual acuity of hand movements or better before vitrectomy was associated with 20/400 vision or better in 69% of cases, whereas ambulatory vision could be attained in only 33% of patients with visual acuity of worse than hand movements at the initial presentation. Visual acuity of less than 20/400 was found in all eyes with haemolytic streptococcal infections. CONCLUSION: Prompt treatment of endophthalmitis is crucial. Additional treatment using systemic steroids and, if necessary, silicone oil can improve the functional outcome in some cases.

Corneal and external disorders and refractive surgery.

A review of disorders of the anterior segment of the eye may show new avenues of research as well as clinical perspectives arising from recently accumulated data. It will have to select new theoretical and clinical findings, which may most probably be apt to survive the test of time, thus providing a long-standing stimulus in science. This body of scientific work in corneal and external disorders may be divided into infectious and noninfectious entities as well as refractive and tectonic or structural problems. In this review, we will focus on the inflammatory implications of anterior segment ocular disease, and mention some evolving diagnostic features and new treatment modalities, as well as opinions on refractive surgery complicated by inflammation.

Diagnostic pars plana vitrectomy report of a 21-year retrospective study.

PURPOSE: To review the experience of diagnostic pars plana vitrectomies (PPV). METHODS: The authors reviewed 405 consecutive diagnostic PPV's performed between November 1973 and October 1994. RESULTS: Diagnostic vitrectomy was performed in 215 (53%) of 405 eyes for suspected endophthalmitis. Of those 215 cases, acute inflammation was confirmed in 62 (28.8%), 60 (27.9%) had microbial organisms present and 36 (16.7%) were culture-positive. Microbial organisms were observed microscopically in 31 (20%) of 156 patients suspected of postoperative endophthalmitis. Of those 31 cases, 23 (74%) were gram-positive, eleven (37%) of 30 eyes had organisms associated with glaucoma filtering procedures and 20 (16%) of 126 eyes had organisms with non-filtering procedures. The pooled percentage of eyes that developed postoperative endophthalmitis as a complication during the period July 1990 thru June 1994 is 5 (0.046%) out of a heterogeneous group of 10,898 cases operated on at the Wilmer Eye Institute for cataract, glaucoma, corneal transplant, pars plana vitrectomy and retinal detachment. Bacteria were identified microscopically in 6 (18%) of 34 post-traumatic cases. Microbial organisms were identified in 23 (92%) of 25 cases with an endogenous infection. Patients with endogenous infections had the most fungal infections, and the majority were in males. Neoplasms were diagnosed in 58 (14%) of the 405 cases. The most common neoplasm was ocular lymphoma 42 (72%), 69% of which were in females. Only 42 (48.3%) of 87 patients clinically suspected of having ocular lymphoma, actually had ocular lymphoma. Those negative for lymphoma were significantly older (67.4 +/- 10 years) compared to those with lymphoma (60.4 +/- 14 years) (P = 0.01). CONCLUSION: Diagnostic PPV has proved to be valuable in confirming and establishing various clinical diagnoses.

Peribulbar anesthesia for primary vitreoretinal surgery.

We prospectively studied the efficacy of peribulbar anesthesia in 76 consecutive patients who underwent vitreoretinal surgery. The mean duration of anesthesia was 124.74 +/- 50.17 minutes, and the mean duration of akinesia, 151.5 +/- 54.45 minutes. Adequate anesthesia and akinesia, independent of the duration of surgery, was obtained in 26 of 33 (78.8%) patients who underwent vitrectomy; 9 of 32 (28.1%) who underwent scleral buckling; and 2 of 11 (18.2%) who underwent vitrectomy combined with scleral buckling. In all, topical and systemic supplementation of drugs for inadequate anesthesia or akinesia allowed 32 of the 33 (97%) vitrectomies, 30 of the 32 (94%) scleral buckling procedures, and all 11 of the combined surgeries to be completed as planned. Three (4%) patients vomited, moved, or were restless, resulting in an operative complication or postponement of surgery. Fifty-eight (76%) said they would desire similar anesthesia if subsequent surgery was needed in the same or fellow eye. We conclude that peribulbar anesthesia should be considered primarily for patients requiring vitreous surgery alone, and as an alternative for patients requiring scleral buckling or combined surgery for whom general anesthesia is contraindicated.

[Microsurgery to treat lesions in or near the eyeball wall].

Four sub-retinal cysticerci and 12 cases of nonmagnetic intraocular foreign bodies near the eyeball wall were first localized with indirect ophthalmoscopy and then removed successfully under surgical microscopy. Three layers, ie white sclera, black supra-choroid pigment and light brown choroidal tissue with white vascular pattern were encountered before reaching the sub-retinal larval. The ischemic appearance of the choroid probably was caused by compression of the larval underneath it. Intraocular foreign bodies usually appeared in the wound accompanied by liquified vitreous as soon as the incision was made. If intraocular inflammation exist, foreign body can be found within the pus or dense exudates.