Potential blindness from nutritional xerophthalmia in autistic patients.

BACKGROUND: Vitamin A is vital to retinal rod function and epithelial cell differentiation. Although uncommon in the developed world, vitamin A deficiency (VAD) secondary to poor diets or gastrointestinal disease has been reported and can lead to xerophthalmia, which is characterized by night blindness and a spectrum of ocular surface changes. Patients with autism spectrum disorder have been shown to have restrictive diets secondary to sensory issues leading to rejection of foods except for those of certain color or texture. METHODS: We present a case series of 6 pediatric patients with autism who developed varying degrees of xerophthalmia due to VAD, which resulted from restrictive eating. RESULTS: All patients presented with a history of eye irritation that was not relieved by antibiotic or allergy eye drops. Further questioning revealed they had restrictive diets consisting of only or mostly white and tan foods, and serum vitamin A testing confirmed severe VAD. Most stages of xerophthalmia were completely reversed with vitamin A supplementation, but in 2 patients more advanced xerophthalmia resulted in irreversible blindness and ocular damage. CONCLUSIONS: Both pediatricians and pediatric eye care providers must be vigilant for VAD as an etiology of eye irritation, photophobia, or new-onset visual impairment in autistic children. A review of the child's diet must be implemented as a standard part of routine history taken in this vulnerable population. Early identification and vitamin A supplementation can prevent irreversible ocular compromise and vision loss.

Seasonal, geographic, and antimicrobial resistance patterns in microbial keratitis: 4-year experience in eastern Pennsylvania.

PURPOSE: The aim of this study was to review the demographics, causative organisms, seasonal and geographic variation, and antimicrobial resistance patterns of microbial keratitis at our institution over a 4-year period. METHODS: Electronic medical records of all patients with microbial keratitis who underwent corneal culturing at a single institution in eastern Pennsylvania between January 1, 2009 and December 31, 2012 were reviewed. RESULTS: A total of 311 patients representing 323 instances of infectious keratitis were analyzed. The most frequently implicated organisms in contact lens-related infections were Pseudomonas aeruginosa for bacteria and Fusarium species for fungus, compared with Staphylococcus aureus and Candida species in non-contact lens-associated bacterial infections. Bacterial keratitis occurred most frequently in spring and least frequently in winter (P = 0.024). Patients who live in large fringe metro (suburban) areas accounted for the highest proportion of infectious keratitis cases. P. aeruginosa and methicillin-sensitive S. aureus isolates were highly susceptible to fluoroquinolones, whereas 32% of coagulase-negative staphylococcus isolates tested were resistant to moxifloxacin and gatifloxacin, and all methicillin-resistant S. aureus organisms tested were resistant to these 2 fluoroquinolones. No organisms tested were resistant to tobramycin, gentamicin, or vancomycin. No fungal infections tested were resistant to voriconazole. CONCLUSIONS: Most infectious keratitis occurred in nonwinter months and in patients from suburban counties. Although fluoroquinolones were effective against the most common bacteria, staphylococcal species exhibited a high rate of resistance, representing a therapeutic challenge given the increasing use of fluoroquinolones as first-line monotherapy. No organisms tested were resistant to tobramycin, gentamicin, vancomycin, or voriconazole.

Treatment of mucous membrane pemphigoid with mycophenolate mofetil.

PURPOSE: To evaluate the clinical outcomes of mycophenolate mofetil (MMF) treatment of mucous membrane pemphigoid (MMP). METHODS: This is a retrospective analysis of consecutive patients with clinical MMP seen in the Ocular Surface Disease Clinic at the Wills Eye Institute, between January 1, 2004, and December 31, 2010, treated with MMF. The main outcomes measured were control of inflammation and discontinuation of MMF. RESULTS: A total of 23 MMP patients taking MMF were identified. The median age of the MMF-treated patients was 77.0 years. Eleven of the 23 patients (47.8%) had biopsy-proven MMP. All patients were at least Foster grading system stage 2, with most stage 3 or 4. Eight patients (34.8%) failed previous treatments with dapsone, methotrexate, prednisone, azathioprine, cyclophosphamide, or 6-mercaptopurine. The average duration of MMF treatment was 23.32 ± 33.17 months (range 1-124.83 months, median 7.4 months). Of the 23 patients with MMP, control of inflammation was achieved with MMF within 3 months for 56.5% [95% confidence interval (CI) 54.5-59.6], within 6 months for 69.6% (95% CI 65.2-76.6), and within 12 months for 82.6% (95% CI 75.3-92.4) of the patients. Nineteen patients (82.4%) achieved control of inflammation, with 16 of the 19 (84.2%) achieving control of inflammation with MMF as monotherapy. Fifteen patients were treated with MMF as initial therapy. Twenty-one percent of patients (5 of 23) were taken off MMF for failure of inflammatory control (4) or an allergic reaction (1). CONCLUSIONS: Treatment of MMP with MMF in this uncontrolled case series resulted in control of inflammation in the majority of patients with minimal side effects. Our data support consideration of MMF as an initial treatment option for active ocular MMP.