Candida Colonization on the Surface of Contact Lenses in Long-Term Wearers and Boston Type 1 Keratoprosthesis Patients Presenting as White Mulberry-Shaped Deposits.

PURPOSE: To report Candida colonies on the surface of the contact lens in long-term contact lens wearers and patients with Boston type 1 keratoprosthesis (KPro I). METHODS: A retrospective study was performed based on analyzing cultures from bandage contact lenses with small whitish mulberry-shaped deposits on their surface. RESULTS: Eight samples (from seven patients) were positive for Candida. Seven of the eight were positive for Candida parapsilosis. CONCLUSIONS: The whitish deposits on contact lenses are often Candida colonies that colonize the surface but do not cause an active infection in the eye. C. parapsilosis is well-known for colonizing prosthetic devices. We underline the importance of including Candida species in the differential diagnosis of lens deposits, especially in susceptible patients such as keratoprosthesis carriers.

Extreme Surgical Maneuvers in Fungal Endophthalmitis.

PURPOSE: To present the different evolution of 2 cases of endophthalmitis caused by Fusarium solani, an aggressive filamentous fungus, depending on the medical and surgical treatment performed. METHODS: We present 2 cases of endophthalmitis caused by Fusarium solani. Topical, intrastromal, intravitreal, and systemic antifungal treatment (natamycin, voriconazole, amphotericin B) failed in both cases. Corneal perforation took place in one of them, being unsuccessfully treated with cyanoacrylate and several amniotic membrane transplants. It became necessary to perform a hot penetrating keratoplasty (PK) in both patients. The lenses were removed, and the microbiological analysis showed their colonization by Fusarium solani. In one of the cases, a second PK and a more aggressive pars plana vitrectomy (PPV) were performed after corneal recurrence detected by confocal microscopy, as well as the following therapeutic intra- and postoperative maneuvers: anterior chamber washing with povidone-iodine 5% for 1 min; iridectomy of the infiltrated regions; aspiration of the fungal colonies with vitrector; several air/fluid/amphotericin/voriconazole exchanges during PPV; endodiathermy and endophotocoagulation of the chorioretinitis foci; and intrascleral angle injections of voriconazole and amphotericin. RESULTS: These were the only cases of endophthalmitis caused by Fusarium attended to at our hospital during the last 10 years. In the case in which PPV was performed without those maneuvers, endophthalmitis rapidly recurred in a more aggressive way, so finally it became necessary to eviscerate the globe. On the other hand, in the patient who underwent PPV with the specific surgical maneuvers and postoperative procedures described above, we could preserve the eye and even a vision of hand motion without an intraocular lens. CONCLUSIONS: The main objectives of these surgical procedures are to control the fungal infection and to preserve the ocular globe. It is essential to eliminate all ocular structures (iris, lens, vitreous, etc.) affected by this strain of fungus in order to reduce the risk of recurrence. When indicated, early surgery with the appropriate maneuvers detailed above may make an evisceration unnecessary and even recover some visual acuity.

Irregular Corneas: Improve Visual Function With Scleral Contact Lenses.

OBJECTIVES: To assess visual function in patients with irregular cornea who do not tolerate gas permeable (GP) corneal contact lenses and are fitted with GP scleral contact lenses (Rose K2 XL). METHODS: In this prospective study, we analyzed 15 eyes of 15 patients who did not tolerate GP corneal contact lenses and were fitted with scleral contact lenses (Rose K2 XL). We assessed visual function using visual acuity and the visual function index (VF-14); we used the VF-14 as an indicator of patient satisfaction. The measurements were taken with the optical correction used before and 1 month after the fitting of the Rose K2 XL contact lenses. We also recorded the number of hours lenses had been worn over the first month. RESULTS: Using Rose K2 XL contact lenses, visual acuity was 0.06±0.07 logMAR. In all cases, visual acuity had improved compared with the measurement before fitting the lenses (0.31±0.18 logMAR; P=0.001). VF-14 scores were 72.74±12.38 before fitting of the scleral lenses, and 89.31±10.87 after 1 month of lens use (P=0.003). Patients used these scleral lenses for 9.33±2.99 comfortable hours of wear. CONCLUSIONS: Both visual acuity and VF-14 may improve after fitting Rose K2 XL contact lenses in patients with irregular corneas. In addition, in our patients, these lenses can be worn for a longer period than GP corneal contact lenses.

Transmucosal Boston Keratoprosthesis Type II in a Case of Severe Bilateral Chemical Burn.

PURPOSE: The purpose of this report was to describe a new alternative surgical technique combining oral mucosa and the Boston Keratoprosthesis type II (BKPro II) in a patient with severe chemical burn. METHODS: We present a case of a 37-year-old man who suffered a severe bilateral chemical burn. Visual acuity was light perception and projection in both eyes. After many surgeries, including eyelid reconstruction, eyelashes electrolysis, and amniotic membrane transplants, he presented a corneal thinning in his right eye that was managed with an autologous oral mucosa graft. Considering the limited function of the eyelids, mild symblepharon, and dry ocular surface, we proposed the implantation of a BKPro II. The patient voiced his desire of avoiding complete tarsorrhaphy for better cosmesis. Osteo-odonto-keratoprosthesis or tibial bone keratoprothesis was also discarded at the patient's express wish. A year and a half later, the oral mucosa was transplanted, and once the ocular surface was stabilized, we lift the mucosa 270 degrees and performed the implantation of the BKPro II covering this device with the mucosa trephined avoiding the complete tarsorrhaphy and theraby modifying the standard procedure. RESULTS: After 34 months of follow-up, the patient did not develop any complications, his visual acuity is stable (0.3 decimal), and funduscopic examination showed a pale optic disk, vascular tortuosity, and an epiretinal membrane that remains stable up to this period. CONCLUSIONS: Transmucosal BKPro II may be considered as an alternative surgical technique for implant support in BKPro II carriers who want to improve their cosmesis avoiding, avoid complete tarsorrhaphy, and do not want to be exposed to dental or bone surgeries.

Sterile corneal necrosis after bowman layer transplantation.

Purpose: To report sterile corneal necrosis as a severe and rare complication after Bowman Layer Transplantation (BTL). Methods: A 35-year-old woman with Down syndrome and advanced progressive keratoconus in her left eye was scheduled for a BLT. The patient rubbed her eyes and did not tolerate contact lenses. Following standard technique, a 8mm Bowman layer graft was placed into a intrastromal pocket with no intraoperative complications. Results: Postoperatively, the patient remained stable and topography showed notable central flattening but 17 days after the BTL was performed she developed a sterile corneal necrosis. Conclusions: Many studies have proven the efficacy of this technique as a potential treatment for stabilizing progressive and advanced keratoconus in selected cases. Few complications associated with BTL have been reported, including Bowman Layer tears or buttonholes when obtaining the tissue, very thick grafts or postoperative hydrops but no sterile necrosis described to the date. A combination of the hypotheses raised in this paper may explain this undesirable event.

Transscleral Cyclophotocoagulation for the Treatment of Uncontrolled Glaucoma in a Boston Keratoprosthesis Type II Patient.

Postoperative endoscopic cyclophotocoagulation (CPC) for the treatment of glaucoma in patients with Boston keratoprosthesis type II (BKPro II) was first described in 2017 by Poon et al. (Endoscopic cyclophotocoagulation for the treatment of glaucoma in Boston keratoprosthesis type ii patient. J Glaucoma. 2017 Apr;26(4):e146-9). As we do not have this device, we present a case of transscleral CPC (TSCPC), in a BKPro II patient who had graft versus host disease and developed uncontrolled glaucoma. We dissected plane by plane to expose the bare sclera and performed the procedure as traditionally described. We concluded that this is a safe, controlled, and effective option in this patient population where the glaucoma treatment options are very limited. To the best of our knowledge, this is the first case report to describe the surgical technique of TSCPC in a BKPro II patient.

Changes in the corneal thickness and limbus after 1 year of scleral contact lens use.

PURPOSE: To assess the physiological changes in the cornea over time in patients with irregular cornea fitted with Rose K2 XL gas-permeable scleral contact lenses. METHODS: Prospective study of 16 eyes of patients who did not tolerate gas-permeable corneal contact lenses and were fitted with Rose K2 XL scleral lenses. We assessed the central vault and the corneal thickness centrally and at peripheral regions (2 to 5 mm annulus). All these measures were obtained by anterior segment optical coherence tomography. The measurements were taken immediately after fitting the lenses and 1, 6 and 12 months later. Prior to the study and at 1 year, we performed an objective test for diagnosing limbal stem cell deficiency (Limbokit). RESULTS: The mean vault was 201.7 ± 82.3 µm 20 min after fitting the contact lens; 189.4 ± 94.0 µm at 1 month; 165.1 ± 75.9 µm at 6 months and 142.1 ± 76.8 µm at 1 year, the values at 6 and 12 months being significantly different to baseline. After 1 year, the central corneal thickness had increased by 2.3% (IQR = 5.6), but the changes were only significant for the superior thickness. There is no limbal stem cell deficiency after 1 year of scleral contact lens use. CONCLUSIONS: After use of Rose K2 XL scleral contact lenses, the corneal physiology of patients with an irregular cornea remains unchanged, as assessed by corneal thickness measurements and the Limbokit test. In all cases, however, the vault decreased over time.

Evaluation of the Reliability and Repeatability of Scheimpflug System Measurement in Keratoconus.

PURPOSE: To assess the reliability and repeatability of the parameters obtained using a Scheimpflug system (Pentacam HR-high resolution) for monitoring progression in eyes with keratoconus. METHODS: A prospective study was conducted based on measurements taken with the Pentacam HR in 82 eyes with keratoconus. We calculated the intraclass correlation coefficient (ICC) and the repeatability limit for topographic and aberrometric parameters. RESULTS: All the parameters analyzed had excellent ICCs, above 0.95 in all cases, except for the measurement of the anterior best-fit sphere, for which the ICC was 0.873. The key repeatability limits for the parameters analyzed were as follows: 1.54 diopters (D) for the maximum keratometry in the central cornea, 1.08 D for maximum keratometry, 32.6 degrees for the axis of corneal astigmatism, 11.9 degrees for the coma axis, and 14.2 µm for thinnest corneal thickness. CONCLUSIONS: The level of repeatability of the measurements obtained with a Pentacam HR confirms the usefulness of this system for the diagnosis of keratoconus. Nevertheless, it has certain limitations for monitoring individual progression of keratoconus and planning intrastromal corneal ring segment insertion.