Overview of Short-Term and Intermediate-Term Corneal Storage Solution: Comparison of Clinical Outcomes and Need For Future Research.

ABSTRACT: Corneal donor tissue preservation techniques have incrementally improved since the introduction of McCarey-Kaufman storage solution from short-term storage to intermediate duration of storage with the advent of organ culture and Optisol GS storage solutions. Improved understanding of the corneal endothelial cell physiology has helped in designing newer storage solutions, such as the Life 4C and Cornea Cold. The incorporation of antibiotics, ATP precursors, minerals, and vitamins has improved the viability of tissues. In addition, these modifications to the newer storage solutions have increased the endothelial longevity and metabolic activity. Despite these advances, the duration of tissue storage has largely been restricted to 2 weeks in Optisol GS and 4 weeks in organ culture. The role and cost-effectiveness of antifungal supplementation and the need for improved epithelial preservation are additional areas that need to be explored. This review intends to summarize the efficacy and viability of donor corneas in different tissue storage solution and compare clinical outcomes while providing an insight into the challenges in developing newer methods of corneal preservation.

The Effect of Light Exposure on the Efficacy and Safety of Amphotericin B in Corneal Storage Media.

IMPORTANCE: The proportion of postkeratoplasty fungal infections is rising steadily. However, the most commonly used corneal storage medium in the United States, Optisol-GS, does not contain an antifungal additive. OBJECTIVES: To determine the lowest concentration of amphotericin B supplementation in Optisol-GS that will eliminate fungal contaminants effectively without resulting in toxic effects to the cornea and to determine what role light exposure plays in the efficacy and safety of amphotericin B supplementation. DESIGN, SETTING, AND MATERIALS: An in vitro laboratory efficacy study measured fungal colony growth in 10 vials of Optisol-GS supplemented with different concentrations of amphotericin B after inoculation with Candida albicans in light-exposed and light-protected conditions. Two vials each were supplemented with amphotericin B at concentrations of 0.06, 0.12, or 0.225 µg/mL; the remaining 2 vials received no C albicans inoculation and no antifungal supplementation (negative controls). After 24 hours, 1 vial from each pair was exposed to light for the remainder of the study. On days 2, 7, and 14, 1 mL of solution was removed from each vial and incubated at 36°C for 48 hours. In a separate safety study, 12 pairs of corneas were divided between amphotericin B supplementation and the control condition; 4 corneas each received the different amphotericin B concentrations. An additional 4 pairs of corneas were stored in the 0.225-µg/mL concentration, and 1 cornea from each pair was exposed to light for the duration of the study. Data were collected November 16, 2014, and analyzed from November 16 to 18, 2014, for the efficacy study; they were collected from April 14 to May 27, 2015, and analyzed from May 28 to 30, 2015, and on December 23, 2015, for the safety study. MAIN OUTCOMES AND MEASURES: Fungal colony growth was measured from the Optisol-GS vials. Corneal endothelial cell density, endothelial cell viability, and epithelial toxic effects were measured in stored corneas. RESULTS: In the efficacy study, Optisol-GS supplemented with concentrations of 0.06 and 0.12 µg/mL of amphotericin B eliminated all fungal contaminants by day 7 and reduced fungal growth on day 2 by a mean of 3.5 colony-forming units (95% CI, -6.19 to 13.20 colony-forming units; P = .34), a 77.8% decline compared with the postoperative controls. Optisol-GS supplemented with the 0.255-µg/mL concentration of amphotericin B eliminated all fungal contaminants by day 2. In the safety study, no evidence was found of toxic effects to the cornea in corneas stored in Optisol-GS supplemented with amphotericin B at any concentration compared with paired controls. No difference in the efficacy or safety of the light-exposed compared with light-protected amphotericin B-supplemented Optisol-GS was identified. CONCLUSIONS AND RELEVANCE: In this study, Optisol-GS supplemented with a 0.255-µg/mL concentration of amphotericin B effectively eliminated fungal contaminants within 48 hours and did not result in added toxic effects to the cornea. These results do not prove that amphotericin B should be added to Optisol-GS; larger-scale studies and cost-benefit analyses need to be completed. Given the increasing incidence of postkeratoplasty fungal infection, however, the addition of amphotericin B to Optisol-GS deserves further investigation.

Medical management of blepharitis.

PURPOSE OF REVIEW: Blepharitis is one of the most common ocular pathologies encountered in the clinical setting. Despite its prevalence, successful treatment is often difficult. The purpose of this review is to provide an update on the medical management of blepharitis. RECENT FINDINGS: The available treatment options for blepharitis have expanded rapidly in recent years. Eyelid hygiene remains the foundation of most treatment regimens, but the addition of topical and oral antibiotics, steroids, and calcineurin inhibitors is showing promising results. Dietary considerations and interventional procedures may also play a role in the future of blepharitis management. SUMMARY: Although a curative therapy for blepharitis is unlikely in the near future, several novel treatment options may result in better control of this chronic condition.

Efficacy and safety of antifungal additives in Optisol-GS corneal storage medium.

IMPORTANCE: Optisol-GS, the most common corneal storage medium in the United States, contains antibacterial but no antifungal supplementation. Most postkeratoplasty endophthalmitis and keratitis cases are now of a fungal origin. OBJECTIVE: To assess the efficacy and safety of voriconazole and amphotericin B in reducing Candida species contamination of Optisol-GS under normal storage conditions. DESIGN, SETTING, AND PARTICIPANTS: In vitro laboratory study using 15 pairs of research-grade donor corneas and 20-mL vials of Optisol-GS. INTERVENTIONS: Twenty vials of Optisol-GS were supplemented with either voriconazole at 1×, 10×, 25×, or 50× minimum inhibitory concentration (MIC) or amphotericin B at 0.25×, 0.5×, 1×, or 10× MIC. Known concentrations of Candida albicans and Candida glabrata were each added to a set of vials. Safety studies were performed by separating 15 pairs of donor corneas into unsupplemented Optisol-GS or Optisol-GS plus an antifungal. MAIN OUTCOMES AND MEASURES: Efficacy outcomes were viable fungal colony counts determined from samples taken on days 2, 7, and 14 immediately after removal from refrigeration and after warming to room temperature for 2 hours. Safety outcomes included percentage of intact epithelium and endothelial cell density on days 0, 7, and 14, as well as percentage of nonviable endothelial cells by vital dye staining on day 14. RESULTS: Growth of C albicans and C glabrata was observed in all voriconazole-supplemented vials. In contrast, there was no growth of either organism in amphotericin B-supplemented vials, except at 0.25× and 0.5× MIC on day 2, when viable counts of C glabrata were reduced by 99% and 96%, respectively. Compared with paired controls, with the exception of Optisol-GS plus amphotericin B at 10× MIC, donor corneas in supplemented Optisol-GS appeared to have no difference in endothelial cell density reduction, percentage of intact epithelium, or percentage of nonviable endothelial cells. CONCLUSIONS AND RELEVANCE: The addition of amphotericin B to Optisol-GS may significantly improve activity against contamination with Candida species, the primary cause of fungal infection after corneal transplantation. This study found significant endothelial toxic effects at the maximal concentration of amphotericin B.

Xerophthalmia and intracranial hypertension in an autistic child with vitamin A deficiency.

The authors present a 10-year-old boy with autism and idiopathic intracranial hypertension referred for evaluation of dry eyes. When questioned, the patient's parents reported that he had a restricted diet. Laboratory testing revealed hypovitaminosis A. The symptoms and signs of xerophthalmia rapidly resolved with oral and topical vitamin A supplementation.

Subconjunctival injections and povidone-iodine washings for the treatment of giant fornix syndrome.

PURPOSE: Giant fornix syndrome is a chronic copiously purulent conjunctivitis seen in elderly patients with dehiscence of the levator palpebrae superioris aponeurosis. We report a case of giant fornix syndrome secondary to methicillin-resistant Staphylococcus aureus conjunctivitis that was recalcitrant to standard treatment modalities, and we describe 2 novel interventions for this condition, which succeeded in eradicating the infection. METHODS: Case report. RESULTS: After failing an aggressive treatment course of topical antibiotics and corticosteroids and after demonstrating an inability to tolerate oral antibiotics, the patient was treated with supratarsal subconjunctival injections of vancomycin and triamcinolone, followed by repeated sweepings of the conjunctival fornices with 10% povidone-iodine on a cotton swab. The patient's symptoms improved dramatically after the antibiotic and corticosteroid injections and ultimately resolved completely after multiple povidone-iodine sweepings. CONCLUSIONS: In patients with giant fornix syndrome who are recalcitrant to or intolerant of aggressive topical and systemic therapy, supratarsal subconjunctival injections of antibiotics and corticosteroids and sweeping of the conjunctival fornices with povidone-iodine are 2 local treatments which may be useful in eradicating the infection.

Treatment of multidrug-resistant Flavobacterium indologenes keratitis with trimethoprim-sulfamethoxazole.

PURPOSE: To describe the history, clinical presentation, and successful medical management of a case of multidrug-resistant Flavobacterium indologenes keratitis. METHODS: An 83-year-old pseudophakic female presented with a 2-day history of decreased visual acuity, light sensitivity and dull ocular pain in her right eye. Two weeks before presentation, the patient had been treated for a red eye with combination topical loteprednol etabonate (0.5%) and tobramycin (0.3%) eye drops. Corneal scrappings were performed by the referring ophthalmologist, and hourly administration of gatifloxacin 0.3% eye drops was started. Evaluation consisted of slit lamp examination, organism identification, and antibiotic sensitivity testing. RESULTS: Examination of the right eye revealed a central 5-mm X 2-mm anterior stromal infiltrate with an overlying epithelial defect. Gatifloxacin 0.3% eye drops were stopped, and hourly topical fortified vancomycin (50 mg/mL) and ceftazidime (50 mg/mL) eye drops were instituted. Oxidase-positive gram-negative bacilli were identified in the thioglycollate broth on day 3, and therefore, vancomycin was discontinued and hourly ciprofloxacin 0.3% eye drops were added to the regimen. The cultures ultimately grew F. indologenes, which was highly resistant to all antibiotics tested except for trimethoprim-sulfamethoxazole. Accordingly, ciprofloxacin 0.3% and ceftazidime were discontinued. The patient was started on hourly topical trimethoprim (16 mg/mL)/sulfamethoxazole (80 mg/mL) eye drops, resulting in clinical control of the infection over a period of 1 month. CONCLUSIONS: Flavobacterium indologenes keratitis can be resistant to treatment with many medications, and antibiotic susceptibility profile testing in these cases may provide crucial information to help eradicate the infection.