Rapid Office-Based Diagnosis of Demodex Using an Innovative Smartphone-Aided Intraocular Lens Tool.

ABSTRACT: Demodex is an important pathogen causing eyelid and eyelash diseases. This article describes a quick, efficient, cost-effective office-based imaging of demodex with the help of an intraocular lens (IOL) and smartphone-aided innovated tool. Eyelid photography of a 56-year-old man with suspected demodex infestation was obtained using a 20-diopter (D) IOL over the smartphone camera called as Anterior Segment Photography using IOL (ASPI). A video or photograph of the epilated eyelash was taken using four 30-D IOLs attached to the smartphone camera to form an optical system called IOLSCOPE, which clearly detected the demodex parasite. The importance of ASPI and IOLSCOPE for the rapid office-based diagnosis of demodex pathogen in peripheral health centers devoid of slitlamp and microscopes has been emphasized here.

Office-Based Rapid Diagnosis and Management of External Ophthalmomyiasis Via Smartphone-Aided Innovative Tools in an Under-Resourced Setting.

PURPOSE: To evaluate the use of smartphone-based innovative tools named Anterior segment photography with intraocular lens (ASPI) and smartphone based intraocular lens microscope (IOLSCOPE) to demonstrate, treat, and diagnose the patients of ophthalmomyiasis caused by Oestrus ovis. METHODS: A retrospective interventional case series of six patients infested with O. ovis presenting in a rural health center with symptoms of burning, itching, watering, and foreign body sensation diagnosed with ophthalmomyiasis. Diagnosis and treatment were performed using an innovative imaging technique that is, an optical system formed by intraocular lens (IOL) and smartphone. RESULTS: The smartphone-based ASPI clearly detected and removed the moving larvae from the ocular surface, followed by microbiological diagnosis of O.ovis larvae with the help of an IOLSCOPE. CONCLUSION: The importance of ASPI and IOLSCOPE for the management of ophthalmomyiasis in peripheral health centers devoid of slitlamp and microscopes has been emphasized here.

PHOTODYNAMIC THERAPY-INDUCED ACUTE EXUDATIVE MACULOPATHY: Incidence, Clinical Features, and Long-Term Outcomes.

PURPOSE: To describe the incidence, clinical features, and long-term outcomes of photodynamic therapy (PDT)-induced acute exudative maculopathy (PAEM) in patients who underwent PDT for various indications. METHODS: This retrospective observational case series included all cases who developed massive serofibrinous macular exudation within a week after PDT. Medical records of patients with post-PDT exudative events were reviewed for relevant data and imaging abstraction including optical coherence tomography and indocyanine green angiography features and were subjected to analysis. RESULTS: The incidence rate of PAEM was 4.52%, being noted in 8 eyes (out of 177 PDT sessions in 155 eyes) with a mean age of 70.25 ± 6.65 years. Pre-PDT factors commonly associated with PAEM included age ≥65 years (87.5%), clinical diagnosis of polypoidal choroidal vasculopathy (75%), spot size ≥3,500 µm (100%), best-corrected visual acuity of 20/40 or better (87.5%), low-fluence PDT (87.5%), and the first exposure to PDT (75%). Photodynamic therapy-induced acute exudative maculopathy was noted at a mean interval of 2.9 ± 1.7 days (2-7 days) after PDT. Photodynamic therapy-induced acute exudative maculopathy resulted in significant decrease in mean best-corrected visual acuity from logMAR 0.29 ± 0.21 (approximate Snellen equivalent 20/39) to logMAR 0.91 ± 0.37 (approximate Snellen equivalent 20/163) [P = 0.0018], and significant increase in mean central macular thickness from 228.1 ± 71.8 µm to 481.4 ± 154.8 µm (P = 0.0029). Photodynamic therapy-induced acute exudative maculopathy resolved to baseline or even better tomographic status at a mean interval of 4.6 ± 1.2 weeks, resulting in complete visual recovery compared with baseline. During mean follow-up of 77.8 ± 46.4 weeks after PDT, no activity was noted for a mean duration of 26.3 ± 42.5 weeks after resolution. At final visit, mean best-corrected visual acuity and central macular thickness was logMAR 0.49 ± 0.28 (approximate Snellen equivalent 20/62) and 153.6 ± 40.0 µm, respectively, with underlying pathology being stable in 50% of the eyes. CONCLUSION: Photodynamic therapy-induced acute exudative maculopathy is an uncommon complication with self-resolving course and favorable prognosis. Patients undergoing PDT should be warned of the possibility of PAEM. The factors frequently associated with PAEM include elderly age (>65 years), clinical diagnosis of polypoidal choroidal vasculopathy, larger spot size (≥3,500 µm), pre-PDT best-corrected visual acuity of 20/40 or better, low-fluence PDT, and the first exposure to PDT.

Polybacterial community analysis in human conjunctiva through 16S rRNA gene libraries.

The conjunctival sac of healthy human harbours a variety of microorganisms. When the eye is compromised, an occasional inadvertent spread happens to the adjacent tissue, resulting in bacterial ocular infections. Microbiological investigation of the conjunctival swab is one of the broadly used modality to study the aetiological agent of conjunctiva. However, most of the time such methods yield unsatisfactory results. Hence, the present study intends to identify the bacterial community in human conjunctiva of pre-operative subjects through 16S rRNA gene libraries. Out of 45 samples collected from preoperative patients undergoing cataract surgery, 36 libraries were constructed with bacterial nested-PCR-positive samples. The representative clones with unique restriction pattern were generated through Amplified Ribosomal DNA Restriction Analysis (ARDRA) which were sequenced for phylogenetic affiliation. A total of 211 representative clones were obtained which were distributed in phyla Actinobacteria, Firmicutes, α-Proteobacteria, ß-Proteobacteria, γ-Proteobacteria, Bacteroidetes, and Deinococcus-Thermus. Findings revealed the presence of polybacterial community, especially in some cases even though no bacterium or a single bacterium alone was identified through cultivable method. Remarkably, we identified 17 species which have never been reported in any ocular infections. The sequencing data reported 6 unidentified bacteria suggesting the possibility of novel organisms in the sample. Since, polybacterial community has been identified consisting of both gram positive and gram negative bacteria, a broad spectrum antibiotic therapy is advisable to the patients who are undergoing cataract surgery. Consolidated effort would significantly improve a clear understanding of the nature of microbial community in the human conjunctiva which will promote administration of appropriate antibiotic regimen and also help in the development of oligonucleotide probes to screen the predominant pathogens for early predisposition.

POLYPOIDAL CHOROIDAL VASCULOPATHY ASSOCIATED WITH CENTRAL SEROUS CHORIORETINOPATHY: Pachychoroid Spectrum of Diseases.

PURPOSE: To study multimodal imaging features of polypoidal choroidal vasculopathy (PCV) associated with central serous chorioretinopathy (CSC) in the same eye. METHODS: A retrospective observational study of cases of suspected PCV which underwent indocyanine green angiography, fundus fluorescein angiography and optical coherence tomography was done, to look for simultaneous typical CSC-like active leak in the same eye. The relevant history, best-corrected visual acuity, optical coherence tomography, fundus fluorescein angiography, and indocyanine green angiography findings were analyzed. RESULTS: From 226 patients reviewed, 195 patients had PCV from which 6 eyes (3.07%) with features of PCV associated with typical CSC-like active leak in the same eye were identified; 3 men and 3 women with a mean age of 62.6 years. Optical coherence tomography showed notched pigment epithelial detachment in two and irregular peaked pigment epithelial detachment in four cases with subretinal fluid and/or subretinal haemorrhage over a thick choroid with dilated outer choroidal vessels. Fundus fluorescein angiography showed stippled hyperfluorescence at polyp area and a separate typical CSC-like active leak-Inkblot in three and Smokestack in three cases. On indocyanine green angiography, multiple polyps were noted with choroidal hyperpermeability in late phase at the site of CSC leak. CONCLUSION: The coexistence of PCV with typical CSC-like active leaks and a thick choroid in the same eye simultaneously provides strong evidence that these diseases have an association and support the hypothesis that these conditions may originate from predisposed thick choroid.

Exophiala dermatitidis Endophthalmitis: Case Report and Literature Review.

We report a case of a 59-year-old male patient with a postoperative fungal infection of the left eye. A dark-pigmented yeast, Exophiala dermatitidis (previously known as Wangiella dermatitidis), was identified from the culture of the biopsy taken from the posterior capsule. The infection was successfully eradicated by a combination of surgical and medical (i.e., voriconazole and fluconazole) treatment. This is the first report of successfully treated E. dermatitidis endophthalmitis, which demonstrates that a prompt and aggressive antifungal therapy combined with surgical intervention is necessary to prevent vision loss in cases of endophthalmitis due to Exophiala species. Beside the case description, we also aim to provide a literature review of previously reported eye infections caused by Exophiala species in order to help the future diagnosis and management of the disease.

Antifungal Susceptibility and Phylogeny of Opportunistic Members of the Genus Fusarium Causing Human Keratomycosis in South India.

Fusarium species are reported frequently as the most common causative agents of fungal keratitis in tropical countries such as India. Sixty-five fusaria isolated from patients were subjected to multilocus DNA sequencing to characterize the spectrum of the species associated with keratitis infections in India. Susceptibilities of these fusaria to ten antifungals were determined in vitro by the broth microdilution method. An impressive phylogenetic diversity of fusaria was reflected in susceptibilities differing at species level. Typing results revealed that the isolates were distributed among species in the species complexes (SCs) of F. solani (FSSC; n = 54), F. oxysporum (FOSC; n = 1), F. fujikuroi (FFSC; n = 3), and F. dimerum (FDSC; n = 7). Amphotericin B, voriconazole, and clotrimazole proved to be the most effective drugs, followed by econazole.

Filamentous fungal infections of the cornea: a global overview of epidemiology and drug sensitivity.

Fungal keratitis is a serious suppurative, usually ulcerative corneal infection which may result in blindness or reduced vision. Epidemiological studies indicate that the occurrence of fungal keratitis is higher in warm, humid regions with agricultural economy. The most frequent filamentous fungal genera among the causal agents are Fusarium, Aspergillus and Curvularia. A more successful therapy of fungal keratitis relies on precise identification of the pathogen to the species level using molecular tools. As the sequence analysis of the internal transcribed spacer (ITS) region of the ribosomal RNA gene cluster (rDNA) is not discriminative enough to reveal a species-level diagnosis for several filamentous fungal species highly relevant in keratitis infections, analysis of other loci is also required for an exact diagnosis. Molecular identifications may also reveal the involvement of fungal species which were not previously reported from corneal infections. The routinely applied chemotherapy of fungal keratitis is based on the topical and systemic administration of polyenes and azole compounds. Antifungal susceptibility testing of the causal agents is of special importance due to the emergence and spread of resistance. Testing the applicability of further available antifungals and screening for new, potential compounds for the therapy of fungal keratitis are of highlighted interest.

Identification of polybacterial communities in patients with postoperative, posttraumatic, and endogenous endophthalmitis through 16S rRNA gene libraries.

Endophthalmitis is a potential vision-threatening complication following surgical procedures (postoperative endophthalmitis [POE]), trauma (posttraumatic endophthalmitis [PTE]), and bacteremic seeding of the eye from a distant infection site (endogenous endophthalmitis [EE]). Several studies have revealed the polybacterial characteristics of endophthalmitis, which make the administration of antibiotics to treat the disease challenging. However, until now, the polybacterial communities of POE, PTE, and EE have not been precisely studied. Hence, the present study was designed to identify the bacterial community of endophthalmitis through 16S rRNA gene libraries. Of the 40 intraocular samples tested, 30 libraries were constructed with bacterial nested-PCR-positive samples. The obtained recombinant clones were screened through amplified rRNA gene restriction analysis (ARDRA) to identify unique clones. The multiple types of ARDRA patterns (P=0.345) and diverse bacterial sequences (P=0.277) within the libraries revealed the polybacterial nature of infection in POE, PTE, and EE. Moreover, to the best of our knowledge, this is the first report on polybacterial infection in EE. Gram-positive bacteria, including Bacillus spp. (n=19), Streptococcus spp. (n=18), Staphylococcus spp. (n=6), Exiguobacterium spp. (n=3), Gemella spp. (n=2), Enterococcus spp. (n=2), a Lysinibacillus sp. (n=1), a Clostridium sp. (n=1), and a Nocardia sp. (n=1), and Gram-negative bacteria, including Serratia spp. (n=18), Pseudomonas spp. (n=10), Enterobacter spp. (n=8), Acinetobacter spp. (n=3), Pantoea spp. (n=3), a Haemophilus sp. (n=1), and a Massilia sp. (n=1), were identified. Interestingly, among them, 10 bacterial species were not previously reported to be associated with endophthalmitis or other ocular infections. Besides, the presence of 4 unidentifiable clones suggests the possibility of novel organisms that might cause eye infections. Therefore, it is recommended that, in addition to the polybacterial nature of POE, PTE, and EE infections, the spectrum of the pathogenic bacterial community identified in this work should be considered while administering antibiotic therapy in suspected endophthalmitis cases.

A novel mutation in the NR2E3 gene associated with Goldmann-Favre syndrome and vasoproliferative tumor of the retina.

PURPOSE: Various autosomal recessive retinal dystrophies are reported to be associated with mutations in nuclear receptor subfamily 2, group E, member 3 (NR2E3, also called PNR) gene. The present study proposed to understand the clinical and genetic characteristics of the family of a patient with an ocular phenotype consistent with Goldmann-Favre syndrome (GFS) and vasoproliferative tumors of the retina (VPTRs). METHODS: Twelve family members of the proband from three generations underwent complete ophthalmic examination, including best-corrected visual acuity with Snellen optotypes, tonometry, biomicroscopic examination, indirect ophthalmoscopy after pupillary dilatation, computerized perimetry, optical coherence tomography, fundus photography, intravenous fluorescein angiography, and electroretinography (ERG). All the study subjects underwent genetic analysis of the entire coding region of the NR2E3 gene with the bidirectional DNA sequencing approach. Hundred healthy individuals were screened for the variant. RESULTS: The phenotype of the proband had features of GFS with VPTRs. The tumors showed complete resolution with cryotherapy and transpupillary thermotherapy (TTT). Sequencing of the entire coding region of the NR2E3 gene in the proband revealed a novel homozygous c.1117 A>G variant that led to the amino acid change from aspartic acid to glycine at position 406 (p.D406G). This change was present in the homozygous state in affected family members and in the heterozygous state in unaffected family members, and was undetectable in the control subjects. The identified novel p.D406G homozygous mutation was at an evolutionarily highly conserved region and may possibly affect the protein function (Sorting Intolerant From Tolerant [SIFT] score = 0.00). CONCLUSIONS: Patients with GFS may present with retinal VPTRs that respond to therapy with cryotherapy and TTT. Molecular genetic studies helped to identify a novel p.D406G mutation in the affected members, which will aid in confirming the diagnosis, for genetic counseling of family members and potentially provide some form of therapy for the affected patients.

Multimodal imaging of epiretinal neovascularization associated with type 3 macular neovascularization.

PURPOSE: To report a case of type 3 macular neovascularization presenting with an epiretinal neovascularization. METHODS: Case report. RESULTS: A 65-year-old gentleman presented with complaints of reduced vision in the left eye (LE) having a best corrected visual acuity (BCVA) of 20/200. Based on fundus examination and multimodal imaging findings he was diagnosed with type 3 macular neovascularization (MNV). An additional unusual finding was the presence of an epiretinal membrane (ERM) and epiretinal neovascularization (ERN), with the latter finding being confirmed on optical coherence tomography angiography (OCTA). He underwent three doses of intravitreal ranibizumab injection following which there was reduction in the epiretinal vascularity. CONCLUSIONS: Multimodal imaging of this case highlights the presence of epiretinal neovascularization associated with type 3 MNV, which has not been reported previously.

Fusarium keratitis in South India: causative agents, their antifungal susceptibilities and a rapid identification method for the Fusarium solani species complex.

Seventy Fusarium isolates derived from human keratomycosis were identified based on partial sequences of the ß-tubulin (ß-TUB) and translation elongation factor 1α (EF-1α) genes. Most of the isolates were confirmed as members of the F. solani species complex (75.71%), followed by the F. dimerum species complex (8.57%), the F. fujikuroi species complex (8.57%), the F. oxysporum species complex (4.29%) and the F. incarnatum-equiseti species complex (2.86%). A combined phylogenetic tree was estimated including all the 70 isolates. Isolates belonging to different species complexes formed separate clades. In this study, we also report the first isolation of F. napiforme from human keratomycosis. A new method based on a specific EcoRI restriction site in the EF-1α gene was developed for the rapid identification of F. solani. In vitro antifungal susceptibilities of the isolates to seven antifungals were determined by broth microdilution method. Terbinafine, natamycin and amphotericin B proved to be the most effective drugs, followed by voriconazole. The minimal inhibitory concentrations of clotrimazole, econazole and itraconazole were generally high (≥64 µg ml(-1) ). The interactions between the two most effective antifungals (natamycin and terbinafine) were determined by checkerboard microdilution method. Synergism (71.8%) or no interaction (28.2%) was revealed between the two compounds.

Epidemiology of Aspergillus keratitis at a tertiary care eye hospital in South India and antifungal susceptibilities of the causative agents.

In recent years, Aspergillus species are reported frequently as aetiological agents of fungal keratitis in tropical countries such as India. Our aim was to evaluate the epidemiological features of Aspergillus keratitis cases over a 3-year period in a tertiary eye care hospital and to determine the antifungal susceptibilities of the causative agents. This study included culture proven Aspergillus keratitis cases diagnosed between September 2005 and August 2008. Data including prevalence, predisposing factors and demography were recorded, the isolates were identified by morphological and molecular methods and the minimum inhibitory concentration values of antifungal agents towards the isolates were determined by the microdilution method. Two hundred Aspergillus isolates were identified among 1737 culture proven cases. Most of the aspergilli (75%) proved to be A. flavus, followed by A. fumigatus (11.5%). Sixteen (8%) isolates belonged to species that are recently identified causative agents of mycotic keratitis. Most of the infected patients (88%) were adults ranging from 21 to 70 years of age. Co-existing ocular disease was confirmed in 16.5% of the patients. Econazole, clotrimazole and ketoconazole were notably active against A. flavus. Aspergillus keratitis is a significant problem in patients with ocular lesions in South-Indian States, warranting early diagnosis and initiation of specific antifungal therapy to improve outcome.

POLYPOIDAL CHOROIDAL VASCULOPATHY ASSOCIATED WITH SECTOR RETINITIS PIGMENTOSA.

PURPOSE: To report a case of polypoidal choroidal vasculopathy associated with sector retinitis pigmentosa. METHODS: Case report. RESULTS: A 63-years-old woman presented with complaints of having painless progressive reduction of vision in the left eye (LE) for the past 6 months. On examination, her best-corrected visual acuity was 20/20 in the right eye and 20/125 in the LE. Based on fundus examination and multimodal imaging findings, both eyes were diagnosed to have sector retinitis pigmentosa, and an associated active extramacular polypoidal choroidal vasculopathy was seen in the LE. Spectral-domain optical coherence tomography also revealed choroidal thinning in both eyes. Patient underwent bevacizumab injection in the LE. At 1-month posttreatment, her best-corrected visual acuity remained stable in the LE, and spectral-domain optical coherence tomography showed reduction in subretinal fluid and size of the polypoidal lesion. CONCLUSION: Polypoidal choroidal vasculopathy, a pachychoroid disease, could occur in association with retinitis pigmentosa, in the setting of thin choroids, and multimodal imaging is important to differentiate it from Type-1 macular neovascularization.

Co occurrance of Macular Telangiectasia type 2 with hemorrhagic polypoidal choroidal vasculopathy and response to anti-vascular endothelial growth factor.

We report the case of a 57-year-old female patient who presented with defective vision in the right eye due to large hemorrhagic pigment epithelial detachment with subretinal hemorrhage near the arcades with scattered retinal pigment epithelium (RPE) alteration at the macula and minimal vitreous hemorrhage inferiorly. The left eye showed right angle perifoveal dipping venule with RPE alteration temporal to the fovea, intraretinal RPE stellate plaque at the macula area. Multimodal imaging features including color fundus photo, red-free photograph, optical coherence tomography (OCT), enhanced depth imaging OCT, fundus fluorescein angiography, indocyanine green angiography, and OCT angiography were studied along with treatment response. One eye showed features of macular telangiectasia Type 2 (MacTel 2) with polypoidal choroidal vasculopathy (PCV) (hemorrhagic type) and the other eye showed features of MacTel 2 with pachychoroid pigment epitheliopathy. This report highlights the hitherto undescribed co-occurrence of MacTel 2 with bilateral pachychoroid and with unilateral hemorrhagic PCV in one eye and its favorable outcome with anti-vascular endothelial growth factor therapy.

PACHYCHOROID DISEASE ASSOCIATED WITH GEOGRAPHIC ATROPHY AND SUBRETINAL DRUSENOID DEPOSITS.

PURPOSE: To report an atypical case of pachychoroid spectrum disease associated with subretinal drusenoid deposits and geographic atrophy. METHODS: Case report. RESULTS: A 67-year-old woman presented for a routine examination. Her best-corrected visual acuity was 20/20 in both eyes. Based on fundus examination and multimodal imaging findings, the presence of subretinal drusenoid deposits and geographic atrophy was seen in the right eye, which was associated with pachychoroid. The left eye revealed two active polypoidal lesions suggestive of polypoidal choroidal vasculopathy with subretinal drusenoid deposits, geographic atrophy, and a thick choroid with dilated outer choroidal vessels. She underwent an intravitreal injection of ranibizumab followed by focal laser to the polypoidal lesion in the left eye. At 3-month posttreatment, her best-corrected visual acuity was maintained at 20/20 in the left eye, with a good anatomical outcome. CONCLUSION: This case highlights a previously unreported unique association of a pachychoroid disease spectrum with geographic atrophy and with subretinal drusenoid deposits.

Safety and efficacy of intravitreal anti vascular endothelial growth factor for severe posterior retinopathy of prematurity with flat fibrovascular proliferation.

BACKGROUND: Intravitreal anti-vascular endothelial growth factor (IVA) injection is known to cause contraction of fibrovascular proliferation (FVP), when present in severe retinopathy of prematurity (ROP). AIM: To assess the structural outcomes of IVA injection in the treatment of severe posterior ROP with significant FVP. METHODS: It was a retrospective study in which 36 eyes of 18 preterm babies who developed > 4 clock hours of FVP in zone I or posterior zone II, were treated with either intravitreal 0.625 mg bevacizumab or intravitreal 0.2 mg of ranibizumab. Favorable structural outcome included resolution of plus disease and FVP without the development of tractional retinal detachment. Secondary outcome measure included either full retinal maturation at follow-up or development of recurrent disease requiring additional treatment. Adverse outcomes included progression to retinal detachment. RESULTS: The mean gestational age of the 18 preterm babies was 30 wk (range 27-36), and mean birth weight was 1319 g (range 650-1980 g). Mean post-menstrual age (PMA) at the time of primary treatment was 35.5 wk (range 31-41 wk). All eyes showed regression of plus disease and FVP. 5 eyes of 3 babies showed reactivation of disease and were treated with repeat IVA (n = 2 eyes) or peripheral laser photocoagulation (n = 3 eyes) respectively. 16 out of 36 (44%) reached retinal vascular maturation at final follow up at 5 years. CONCLUSION: There was good resolution of severe posterior ROP with FVP with IVA, with retinal maturity of 44% at 5 year follow-up and a reactivation rate of 13.8%. When the IVA injection is given prior to 37 wk PMA, while disease is in phase 2, it is less likely to cause contracture of pre-existing FVP.