Fungal Keratitis: Diagnosis, Management, and Recent Advances.

Fungal keratitis is one of the major causes of microbial keratitis that may lead to corneal blindness. Many problems related to diagnosis and therapy are encountered in fungal keratitis, including difficulty in obtaining laboratory diagnoses and the availability and efficacy of antifungal medications. Intensive and prolonged use of antifungal topical preparations may not be enough. The use of antifungal medications is considered the main treatment for fungal keratitis. It is recommended to start antifungal therapy after confirmation of the clinical diagnosis with a smear or positive cultures. Topical application of antifungal medications is a mainstay for the treatment of fungal keratitis; however, systemic, intra-stromal, or intra-cameral routes may be used. Therapeutic keratoplasty is the main surgical procedure approved for the management of fungal keratitis with good success rate. Intrastromal corneal injection of antifungal medications may result in steady-state drug levels within the corneal tissue and prevent intervals of decreased antifungal drug concentration below its therapeutic level. In cases of severe fungal keratitis with deep stromal infiltration not responding to treatment, intracameral injection of antifungal agents may be effective. Collagen cross-linking has been proposed to be beneficial for cases of fungal keratitis as a stand-alone therapy or as an adjunct to antifungal medications. Although collagen cross-linking has been extensively studied in the past few years, its protocol still needs many modifications to optimize UV fluence levels, irradiation time, and concentration of riboflavin to achieve 100% microbial killing.

Impact of contact lens hygiene risk factors on the prevalence of contact lens-related keratitis in Alexandria-Egypt.

BACKGROUND: This study aimed at measuring the effect of contact lens hygiene risk factors on the prevalence of contact lens-related keratitis and identifying the specific risk factors to both microbial and non-microbial keratitis independently. METHODS: A cross-sectional study was conducted at Alexandria Ophthalmology Hospital from May to October 2023. All contact lens wearers attending the outpatient clinic had undergone face-to-face interviews using a standardized validated questionnaire which included demographic data and contact lenses (CLs) hygiene risk factors. Participants were classified into two groups; normal group and keratitis group. Keratitis group was further subdivided into non-microbial and microbial group. RESULTS: The study included 245 contact lens wearers; 149 normal cases, 50 (20.4%) contact lens-related non-microbial keratitis (CLNK) cases, and 46 (18.8%) contact lens-related microbial keratitis (CLMK) cases. Sharing contact lenses and eye trauma were significant risk factors for both CLNK (p=0.036), (p=0.001) and CLMK (p=0.003), (p=0.017). CLs wear duration for more than 12 hours was associated with an increased risk of CLNK by about 4 times (p=0.030) and overnight wear of contact lenses increased the risk of CLNK by 2.6 times (p=0.030). Showering or swimming in lenses was identified as a significant risk factor for CLMK (p=0.012), moreover washing lenses with tap water increased the risk of CLMK (p=0.030). CONCLUSIONS: Poor compliance with contact lenses hygiene rules results in a high prevalence of contact lens-related keratitis. Eye trauma and sharing contact lenses were significant hygiene risk factors for both contact lens-related non-microbial keratitis and contact lens-related microbial keratitis.

Epidemiological profile of microbial keratitis in Alexandria-Egypt a 5 years retrospective study.

OBJECTIVE: To evaluate the epidemiologic profile of microbial keratitis in Alexandria- Egypt, with special emphasis on risk factors, visual outcome and microbiological results. METHODS: This retrospective study reviewed files of patients treated for microbial keratitis during a period of 5 years at Alexandria Ophthalmology Hospital Cornea Clinic, Alexandria- Egypt, between February 2017 and June 2022. The patients were evaluated for the risk factors e.g., trauma, eyelid disorders, co-morbidities, and contact lens use. They were also evaluated for their clinical picture, the identified microorganisms, visual outcomes, and complications. Non-microbial keratitis and incomplete files were excluded from the study. RESULTS: A total of 284 patients were diagnosed as microbial keratitis in our study. Viral keratitis was the most common cause of microbial keratitis (n = 118 (41.55%)), followed by bacterial keratitis (n = 77 (27.11%)), mixed keratitis (n = 51 (17.96%)), acanthamoeba keratitis (n = 22 (7.75%)) and the least cause was fungal keratitis (n = 16 (5.63%)). Trauma was the most common risk factor for microbial keratitis (29.2%). Fungal keratitis had a statistically significant association with trauma (p < 0.001), while the use of contact lenses had a statistically significant association with Acanthamoeba keratitis (p < 0.001). The percentage of culture-positive results in our study was 76.8%. Gram-positive bacteria were the most frequently isolated bacterial isolate (n = 25 (36.2%)), while filamentous fungi were the most frequently isolated fungi (n = 13(18.8%)). After treatment, there was a significant increase in the mean visual acuity among all groups; it was significantly higher in Acanthamoeba keratitis group with a mean difference of 0.262 ± 0.161 (p = 0.003). CONCLUSION: Viral keratitis followed by bacterial keratitis were the most frequent etiologic agents causing microbial keratitis found in our study. Although trauma was the most frequent risk factor for microbial keratitis, contact lens wear was found an important preventable risk factor for microbial keratitis in young patients. Performing culture properly whenever indicated before starting antimicrobial treatment increased the cultures' positive results.

Postkeratoplasty Corneal Plaques: A Case Series.

Purpose: To assess the risk factors and management of corneal plaques formed after keratoplasty. Methods: In this retrospective study, medical records of all eyes with plaques formed on top of corneal grafts performed in the period between January 2014 and January 2022 were reviewed. The retrieved data included prekeratoplasty corneal pathology, ocular risk factors, operative data and complications, plaque management, and chemical composition of the plaques using infrared spectrometer. Results: Thirteen eyes were included in this study. Predisposing ocular comorbidities included ocular surface disorders with variable degrees of dry eye in nine patients, rheumatoid arthritis in three patients, history of herpetic keratitis in two eyes, and cicatrizing conjunctivitis in two patients. Surgical excision and amniotic membrane transplantation (AMT) were performed in 12 eyes. Postoperatively, five eyes showed recurrence after excision, two eyes developed graft vascularization and scarring, and one eye showed persistent epithelial defect and graft scarring, whereas four eyes showed complete epithelialization with mild haze. Rekeratoplasty and AMT were performed in two eyes with no plaque recurrence. Chemical analysis using infrared spectrometry showed that the plaques consisted of ammonium magnesium phosphate and calcium phosphate carbonate in 9 (75%) cases and pure mucus in 3 (25%) cases. Conclusions: Postkeratoplasty corneal plaque formation is an underestimated complication of keratoplasty that may occur after persistent epithelial defects. Ocular surface disorders are the primary predisposing risk factors. In our experience, the prognosis after medical treatment or surgical scraping is guarded, and regrafting can be the only solution to restore graft clarity.

Comparison between three different high fluence UVA levels in corneal collagen cross-linking for treatment of experimentally induced fungal keratitis in rabbits.

INTRODUCTION: The aim of this study was to compare the efficacy of Photo-Activated Chromophore for Keratitis - Corneal Collagen Cross-linking (PACK-CXL) of three different total UVA fluence levels and topical voriconazole in treatment of fungal keratitis experimentally induced in rabbits. METHODS: This is an interventional experimental study including both eyes of 16 rabbits (32 eyes). Fungal keratitis was induced by intrastromal injection of Fusarium Solani into the cornea. The rabbits were then divided into four groups (8 eyes for each) from which group A received Voriconazole eye drops and considered as control group. Group B, C, D received single PACK-CXL session with total fluence levels of 7.2, 10.0 and 15.0 J/cm2 for each respectively. Daily clinical examination was recorded and all corneas were removed for microbiology and histopathology on day ten. RESULTS: The mean clinical signs score eyes treated with high fluence PACK-CXL showed evident clinical improvement from fourth to tenth day of treatment. This improvement was equivalent to that of Voriconazole treatment. The results showed better improvement with increasing the UVA total fluence levels but this difference was not statistically significant (P < 0.05). Similarly, the median CFU/ml declined on increasing UVA fluence but with no statistically significant values. Histopathological examination revealed better improvement of inflammatory signs on higher fluence levels compared to lower ones. CONCLUSIONS: High intensity PACK-CXL (30 mW/cm2) was as effective as Voriconazole in the treatment of fungal keratitis in rabbits. Increasing the fluence of UVA was associated with slightly better clinical outcomes with no added risks. More clinical studies are needed to confirm these results.

Descemet's Membrane Endothelial Keratoplasty and Phacoemulsification: Combined versus Sequential Surgery.

PURPOSE: To compare the outcomes of Descemet's membrane endothelial keratoplasty (DMEK) combined with phacoemulsification versus DMEK following phacoemulsification. METHODS: In this interventional retrospective comparative nonrandomized case series study, patients with Fuchs endothelial corneal dystrophy (FECD) with either cataract or previous cataract surgery with intraocular lens (IOL) implantation were assigned to one of the two groups according to lens status. Group 1 included patients who had cataract and FECD and would undergo triple procedure (phacoemulsification with IOL implantation and DMEK), whereas Group 2 included patients who had FECD and had phacoemulsification with IOL implantation earlier and would undergo DMEK only as a sequential procedure. RESULTS: Postoperative best corrected visual acuity (BCVA) in both groups at 1 week, 1 month, 3 months, and 6 months revealed a statistically nonsignificant difference between the two groups with mean logMAR BCVA at 6 months of 0.07 ± 0.18 and 0.07 ± 0.19 in Group 1 and Group 2, respectively (P > 0.05). The drop in endothelial cell density by the end of the 6th postoperative month was by 39.44% ±7.92 and 38.73% ±8.10 in the triple-procedure group and DMEK only group, respectively (P = 0.005). Total postoperative complications rate and the rebubbling rate were statistically similar between both groups with 13.5% and 12.5% rebubbling rate in Group 1 and Group 2, respectively (P > 0.05). CONCLUSION: Visual outcomes, endothelial cell loss, and rebubbling rate are comparable when DMEK is combined with phacoemulsification or when it is performed as staged procedure, without statistically significant difference in the outcomes.

Traumatic Wound Dehiscence after Keratoplasty: Characteristics, Risk Factors, and Visual Outcome.

Purpose. The study aimed at evaluating the patients' characteristics, risk factors, complications, and visual outcome of traumatic wound dehiscence after keratoplasty. Patients and Methods. A retrospective case series that included 20 eyes of 20 patients who had undergone a previous keratoplasty procedure followed by traumatic wound dehiscence. Records of the selected patients were reviewed. The mean duration of follow-up after repair was 21 months. Included patients were recalled for the final follow-up visit. Results. The procedure of corneal transplantation was penetrating (PKP) in 16 eyes and deep anterior lamellar keratoplasty (DALK) in 4 eyes. The associated anterior segment injuries included iris prolapse in 17 eyes and lens extrusion in 12 eyes. The associated posterior segment injuries included vitreous hemorrhage in 11 eyes and retinal detachment in 4 eyes. The final BSCVA was 0.1 or better in 5 cases (25 %) and was better than hand motions (HM) to less than 0.1 in 7 cases (35 %). Conclusion. Traumatic wound dehiscence following keratoplasty results in poor visual outcome. Cases following DALK may have less wound extent and better final visual outcome. The dehiscence seems most likely to occur during the first year.