Semi-Autologous Corneal Transplantation with Simultaneous Bilateral Surgery: A Case Report.

The present report describes a case of semi-autologous corneal transplantation with bilateral surgery using two operating microscopes simultaneously. An 86-year-old man with history of six prior failed penetrating keratoplasties in his right eye presented with decreased vision. His other eye was deeply amblyopic but had a clear 30-year-old Castroviejo-square graft with an endothelial cell count of 803 cells/mm2. A semi-autologous graft was performed from the left eye to the right. Surgery was performed simultaneously on both eyes by two different surgeons using a standard ophthalmic operating microscope as well as a second ENT microscope. Upon trephination of the right failed corneal graft, vitreous opacities were noted and sent for culture. The semi-autologous tissue was directly transferred from the left eye to the right without any storage in preservation media to avoid endothelial cell loss. The semi-autologous graft remained clear in the immediate postoperative period. However, the vitreous cultures grew coagulase-negative Staphylococcus. Despite all efforts, the patient eventually developed a retinal detachment and vision in the right eye decreased to light perception. Autologous penetrating keratoplasty is an option for patients with loss of corneal function in a potentially seeing eye and a clear cornea in a contralateral eye with poor visual potential due to non-corneal disease. This case is unique in that part of the autologous penetrating keratoplasty had an old square graft in the center and corneal transplant surgery was done simultaneously in both eyes. It also highlights chronic indolent endophthalmitis as a potential cause of multiple graft failures.

American Academy of Optometry Microbial Keratitis Think Tank.

SIGNIFICANCE: Think Tank 2019 affirmed that the rate of infection associated with contact lenses has not changed in several decades. Also, there is a trend toward more serious infections associated with Acanthamoeba and fungi. The growing use of contact lenses in children demands our attention with surveillance and case-control studies. PURPOSE: The American Academy of Optometry (AAO) gathered researchers and key opinion leaders from around the world to discuss contact lens-associated microbial keratitis at the 2019 AAO Annual Meeting. METHODS: Experts presented within four sessions. Session 1 covered the epidemiology of microbial keratitis, pathogenesis of Pseudomonas aeruginosa, and the role of lens care systems and storage cases in corneal disease. Session 2 covered nonbacterial forms of keratitis in contact lens wearers. Session 3 covered future needs, challenges, and research questions in relation to microbial keratitis in youth and myopia control, microbiome, antimicrobial surfaces, and genetic susceptibility. Session 4 covered compliance and communication imperatives. RESULTS: The absolute rate of microbial keratitis has remained very consistent for three decades despite new technologies, and extended wear significantly increases the risk. Improved oxygen delivery afforded by silicone hydrogel lenses has not impacted the rates, and although the introduction of daily disposable lenses has minimized the risk of severe disease, there is no consistent evidence that they have altered the overall rate of microbial keratitis. Overnight orthokeratology lenses may increase the risk of microbial keratitis, especially secondary to Acanthamoeba, in children. Compliance remains a concern and a significant risk factor for disease. New insights into host microbiome and genetic susceptibility may uncover new theories. More studies such as case-control designs suited for rare diseases and registries are needed. CONCLUSIONS: The first annual AAO Think Tank acknowledged that the risk of microbial keratitis has not decreased over decades, despite innovation. Important questions and research directions remain.

Novel Use of Fluorescence In Situ Hybridization for the Rapid Identification of Microorganisms in Endophthalmitis and Keratitis.

BACKGROUND AND OBJECTIVE: To evaluate an application of fluorescence in situ hybridization (FISH) for the rapid identification of bacterial and fungal pathogens causing endophthalmitis and keratitis and compare time to detection with other laboratory methods. MATERIALS AND METHODS: Culture-positive isolates obtained from vitreous and corneal samples were tested. Organisms tested were Staphylococcus aureus, coagulase-negative staphylococci, Pseudomonas aeruginosa, Candida albicans, C. glabrata, and C. parapsilosis. Inoculi were prepared to a final concentration between 1 × 102 colony-forming units (CFU)/mL to 1 × 108 CFU/mL. Samples were hybridized with peptide nucleic acid probes for pathogens using the QuickFISH protocol (AdvanDx; OpGen, Gaithersburg, MD), and the slides were read with fluorescence microscopy. RESULTS: Of the 29 total isolates tested, 28 yielded positive identification. S. aureus was identified in four out of five vitreous samples, whereas coagulase-negative staphylococci were identified in all vitreous samples. Mixed staphylococci culture was identified in all samples. P. aeruginosa was identified in all six keratitis samples. C. albicans, C. glabrata, C. parapsilosis, and mixed fungal culture were identified respectively in eight of eight samples at minimal concentration of 1 × 104 CFU/mL. There were no false-negatives. Time to detection was 20 minutes after the 12- to 18-hour inoculation period and provided an identification 6 hours sooner than by polymerase chain reaction (PCR) and 1 to 2 days sooner than by routine culture. CONCLUSIONS: This small study demonstrates the sensitive, specific, and rapid detection of gram-positive bacteria, gram-negative bacteria and fungi using FISH probes in isolates from endophthalmitis and keratitis samples. This method decreases time to identification and reduces labor intensity compared with routine PCR and culture methods. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:S9-S12.].

Multiplex Polymerase Chain Reaction Assay for Screening of Mycotoxin Genes From Ocular Isolates of Fusarium species.

PURPOSE: To identify mycotoxin genes among clinical ocular isolates of Fusarium species and to correlate these with clinical outcomes of Fusarium keratitis. METHODS: Fifty-four clinical isolates of Fusarium were retrieved from the Bascom Palmer Eye Institute Ocular Microbiology Laboratory data bank. Multiplex polymerase chain reactions were run to confirm the identification of Fusarium species [internal transcribed spacer sequence, translation elongation factor 1-α (TEF) and ß-tubulin] and to detect the presence of genes encoding production of fumonisin B mycotoxins (FUM1 and FUM8) and trichothecene mycotoxins (deoxynivalenol and nivalenol). The presence or absence of mycotoxins was compared with patient outcomes. RESULTS: Forty-three (79%) of the 54 isolates were confirmed as Fusarium species, by an internal transcribed spacer sequence in 3 (5.6%) and by TEF in 43 (79.6%) of the 54 isolates. Fumonisin biosynthetic gene 1 (FUM1) was detected in 57.4% (n = 31/54) of the Fusarium isolates. No FUM8, deoxynivalenol genes, and nivalenol genes were detected among these in the clinical isolates group. Initial best-corrected visual acuity ranged from 20/25 to 20/80 in the FUM1 gene-negative group and from 20/20 to light perception in the FUM1 gene-positive group. There was no difference in the time to cure between both groups. The presence of FUM1 genes in 5 fungal isolates seemed to be associated with progression to penetrating keratoplasty in the 5 patients from whom the fungi were isolated. Fusarium solani was recovered from all patients requiring penetrating keratoplasty. CONCLUSIONS: Fumonisin B biosynthetic gene 1 may be common among clinical Fusarium isolates and contribute to worse initial visual acuity and high-risk progression to penetrating keratoplasty.

Long-term outcomes of the aphakic snap-on Boston type I keratoprosthesis at the Bascom Palmer Eye Institute.

PURPOSE: To determine the indications, long-term clinical and visual outcomes, and complications of the aphakic snap-on type I Boston keratoprosthesis (KPro). DESIGN: Retrospective, non-comparative case series. METHODS: Forty-five eyes of 43 patients with type I aphakic snap-on KPros with at least 1 year of follow-up were included. The past medical histories, preoperative indications, best-corrected visual acuities (BCVAs), postoperative complications, and retention rates were analyzed. RESULTS: The most common indication for KPro implantation was a failed corneal graft (89%). The mean preoperative BCVA was count fingers-hand motion (2.14±0.45 logarithm of minimum angle of resolution [logMAR]), which initially improved to 20/200 (1.04±0.85 logMAR; P<0.0001). At the last examination, 24 eyes (53%) maintained some visual gain, 22% retained their preoperative visual acuity, and 24% lost vision due to postoperative events and underlying ocular comorbidities. Postoperative complications included retroprosthetic membranes (8/45, 18%), corneal melts (5/45, 11%), glaucoma progression (6/45, 13%), and endophthalmitis or sterile vitritis (6/45, 13%). The KPro retention rate was 89%, with a mean follow-up of 51 months. The mean BCVA at the last visit was 20/1,400 (1.82±0.92 logMAR). CONCLUSION: Most patients experienced improved visual acuity after the implantation of the aphakic, snap-on type I KPro; however, the visual gains were not sustained over time, correlating with the onset of postoperative complications.

Clinical Features, Antibiotic Susceptibility Profile, and Outcomes of Infectious Keratitis Caused by Stenotrophomonas maltophilia.

PURPOSE: Stenotrophomonas maltophilia, an uncommon cause of infectious keratitis, is difficult to treat because of its resistance to multiple antibiotics. The purpose of this study is to describe the clinical features, antibiotic susceptibility profile, and outcomes of S. maltophilia keratitis. METHODS: A retrospective review of records from 1987 to 2016 identified 26 eyes of 26 patients who were treated at the Bascom Palmer Eye Institute for an S. maltophilia corneal ulcer. Clinical data were analyzed as to predisposing factors, clinical presentation, antibiotic susceptibility, treatment selection, and clinical outcomes. RESULTS: Median age at presentation was 65 years (range, 16-98). Twelve patients were using topical corticosteroids, 8 patients had a history of penetrating keratoplasty, and 9 were contact lens wearers. All patients received topical antibiotics, 2 required therapeutic penetrating keratoplasty, and 1 was enucleated. At presentation, 57.7% (15/26) of the patients had visual acuity of 20/400 or worse. At the final visit, only 30.4% (7/23) of the patients had visual acuity worse than 20/400, whereas 65.2% (15/23) of the patients had 20/100 or better. Almost all isolates (25/26, 96.2%) were susceptible to fluoroquinolones and 77.3% (17/22) of them to polymyxin B/trimethoprim. Only 33.3% (5/15) of the tested isolates were susceptible to aminoglycosides and 58.3% (7/12) to cephalosporins. CONCLUSIONS: Infectious keratitis due to S. maltophilia presents a treatment challenge because of its resistance to aminoglycosides and cephalosporins, which are typically used for empiric broad-spectrum gram-negative coverage as fortified solutions. Fluoroquinolones and polymyxin B/trimethoprim should be considered instead in cases of S. maltophilia infection.

Impact of Total Pars Plana Vitrectomy on Postoperative Complications in Aphakic, Snap-On, Type 1 Boston Keratoprosthesis.

PURPOSE: To determine the impact of total pars plana vitrectomies (PPVs) with peripheral shaving of the vitreous base on the rates of postoperative complications in patients with aphakic, snap-on type I Boston keratoprostheses (KPros). DESIGN: Retrospective, consecutive case series. PARTICIPANTS: A total of 48 eyes in 46 patients with implantation of aphakic, snap-on type 1 Boston KPros performed at a tertiary care facility between January 1, 2007, and December 31, 2013, were included. METHODS: The cumulative incidences of postoperative complications were compared between patients who underwent total PPVs with shaving of the vitreous base (n = 22) and those who had partial PPVs or anterior vitrectomies (AVs) at the time of KPro implantation (n = 26). MAIN OUTCOME MEASURES: Rates of complications between patients who underwent total PPVs and partial PPVs or AVs. RESULTS: The rate of total postoperative complications was lower in the total PPV group (P = 0.018, log-rank test). In particular, eyes that underwent total PPVs had lower rates of retroprosthetic membranes (RPMs) requiring intervention (P = 0.049) and less vision loss due to glaucoma progression (P = 0.046). There was also a trend for fewer corneal melts (P = 0.060) and less sight-threatening complications (P = 0.051) in the total vitrectomy group. There was no difference in the rates of KPro extrusion (P = 0.41), endophthalmitis or vitritis (P = 0.15), retinal detachments (P = 0.76), cystoid macular edema (P = 0.83), or timing of complications between the 2 groups. The mean preoperative and postoperative visual acuities were similar between the 2 groups (P = 0.97). The mean follow-up was 49±22 months. CONCLUSIONS: Eyes that underwent total PPVs during implantation of aphakic, snap-on, type I Boston KPros had less postoperative complications than eyes with partial PPVs or AVs during the average 4 years of follow-up.

Contact-Lens-Associated Purpureocillium Keratitis: Risk Factors, Microbiologic Characteristics, Clinical Course, and Outcomes.

PURPOSE: To study the risk factors, microbiologic characteristics, clinical course, and outcomes of patients with Purpureocillium keratitis at a tertiary eye care center in south Florida. MATERIALS AND METHODS: All medical records during a seven-year period starting January 1, 2007, were reviewed. Twenty-eight culture-proven Purpureocillium keratitis cases with complete medical records presenting to our institution were included in this retrospective, observational case series. Data collected included predisposing factors, therapeutic interventions, treatment duration, and visual outcomes. RESULTS: Twenty patients (71.4%) had a history of soft contact lens use, with only two for therapeutic use. Other identified risk factors were trauma and immunosuppression. Fifteen patients (53.6%) received topical corticosteroid treatment prior to the diagnosis of fungal keratitis. Thirteen patients (46.4%) were on Natamycin treatment prior to Purpureocillium identification. As a group, the average best-corrected visual acuity (BCVA) at presentation was 1.1 logMAR; upon the final evaluation, it was 1.0 logMAR. The BCVA on last evaluation for the eight patients presenting to our institution within two weeks of onset of symptoms was 0.3 log MAR, and all patients in this group responded to medical management. The final BCVA for 20 patients presenting two weeks after onset of symptoms was 1.2 logMAR. There was a significant difference in the final BCVA between Group 1 and Group 2 (p = 0.004), but no difference in steroid use or previous treatments. Previous steroid use tended to extend time to presentation and was significantly associated with a worse final visual outcome (1.2 versus 0.6 logMAR; p = 0.0474). Previous Natamycin use was significantly associated with a worse final visual outcome (1.4 versus 0.6 logMAR; p = 0.014). CONCLUSION: Purpureocillium keratitis can have devastating consequences to visual function and even lead to enucleation. Physicians should make every effort to arrive at an earlier microbiological diagnosis, as this is associated with better outcomes and less need for surgical intervention. The first line use of voriconazole is recommended, and steroid use should be avoided, as their previous use is associated with worse visual outcomes.

Integrating the Internship into Ophthalmology Residency Programs: Association of University Professors of Ophthalmology American Academy of Ophthalmology White Paper.

Future ophthalmologists will need to have broad skills to thrive in complex health care organizations. However, training for ophthalmologists does not take advantage of all of the postgraduate years (PGYs). Although the traditional residency years seem to have little excess capacity, enhancing the internship year does offer an opportunity to expand the time for ophthalmology training in the same 4 PGYs. Integrating the internship year into residency would allow control of all of the PGYs, allowing our profession to optimize training for ophthalmology. In this white paper, we propose that we could capture an additional 6 months of training time by integrating basic ophthalmology training into the intern year. This would allow 6 additional months to expand training in areas such as quality improvement or time for "mini-fellowships" to allow graduates to develop a deeper set of skills.

Clinical Features, Antibiotic Susceptibility Profiles, and Outcomes of Infectious Keratitis Caused by Achromobacter xylosoxidans.

PURPOSE: Reports on Achromobacter xylosoxidans ocular infections are increasing, drawing attention to its emerging role in infectious keratitis. The purpose of this study is to report the clinical features, antibiotic sensitivities, and visual outcomes of infectious keratitis secondary to Achromobacter xylosoxidans. METHODS: A microbiology database and clinical chart review was performed in all patients diagnosed with A. xylosoxidans keratitis at the Bascom Palmer Eye Institute between the years 1987 and 2014. Initial presentation, antimicrobial susceptibilities, minimum inhibitory concentrations (MICs), treatment course, and outcomes were recorded. RESULTS: Twenty-eight patients were identified. The main risk factors were corneal graft (n = 8, 28.6%) and contact lens wear (n = 8, 28.6%). On presentation, visual acuity was 20/100 or worse in 20 (71.2%) patients. Hypopyon was present in 7 (25.0%) patients. In most cases, topical fluoroquinolones or tobramycin were the initial treatment, often accompanied by vancomycin. High susceptibility rates were found for piperacillin [100%, minimum inhibitory concentration for 90% of isolates (MIC90) = 8] and ticarcillin (100%, MIC90 = 16). Low susceptibility rates were documented for ciprofloxacin (46.7%, MIC90 = 8), tobramycin (26.7%, MIC90 = 16), and gentamicin (20%, MIC90 = 16). One (3.6%) patient suffered endophthalmitis. Six (21.4%) patients underwent therapeutic penetrating keratoplasty, and 2 (7.1%) patients had conjunctival flap surgery. Visual acuity at final follow-up was 20/100 or worse in 16 (57.1%) patients. CONCLUSIONS: Infectious keratitis caused by A. xylosoxidans is associated with poor visual outcomes. Fluoroquinolones and aminoglycosides are not appropriate treatments for these ocular infections. Further studies are needed to define the clinical application of compound piperacillin and ticarcillin eye drops.

Role of steroids in the treatment of bacterial keratitis.

Bacterial keratitis can lead to severe visual impairment from corneal ulceration, subsequent scarring, and possible perforation. The mainstay of treatment is topical antibiotics, whereas the use of adjunctive topical corticosteroid drops remains a matter of debate. Herein, we review the rationale for and against the use of topical corticosteroids and we assess their effectiveness and safety in the published randomized controlled trials that have evaluated their role as adjunctive therapy for bacterial corneal ulcers. In the largest study to date, the Steroids for Corneal Ulcers Trial, topical corticosteroid drops were neither helpful nor harmful for the 500 participants as a whole. However, subgroup analyses suggested that topical corticosteroids may be beneficial upon early administration (within 2-3 days after starting antibiotics) for more central corneal ulcers with poorer vision at presentation, for invasive Pseudomonas strains, and for non-Nocardia ulcers. These results are discussed within the limitations of the study.

EPITHELIAL DOWNGROWTH IN THE VITREOUS CAVITY AND ON THE RETINA IN ENUCLEATED SPECIMENS AND IN EYES WITH VISUAL POTENTIAL.

PURPOSE: To report clinical course and visual and anatomical outcomes of six eyes with histopathologically confirmed vitreous cavity and retina epithelial downgrowth. METHODS: This is a retrospective 15-year review of archived pathologic slides and corresponding medical records of patients with vitreous cavity and retina epithelial downgrowth. Posterior segment epithelial downgrowth was defined as epithelial or goblet cells in the vitreous cavity or on the surface of the retina. RESULTS: Histopathologic diagnosis of epithelial downgrowth was made in 122 patients. Of those, 6 patients (5%) had vitreous cavity and retina epithelial downgrowth. Three patients developed blind painful eye, and epithelial downgrowth was identified in enucleated specimens. The other three eyes with visual potential presented with tractional retinal detachments. Epithelial downgrowth was identified in epiretinal membranes obtained during pars plana vitrectomy. The latter group had more previous surgeries (P = 0.03), and all had keratoprosthesis implantation as their last surgery. All three had pathologic specimens obtained at the time of the keratoprosthesis implantation; no anterior segment epithelial downgrowth was noted in two patients, and one patient had involvement of corneal button, iris, and posterior capsule. Final visual acuity ranged from hand motion to light perception. CONCLUSION: In the current study, vitreous cavity and retina epithelial downgrowth occurred after multiple intraocular surgeries, including repair of the open globe injuries both in enucleated specimens and in eyes with visual potential. In eyes with visual potential, keratoprosthesis implantation seems to predispose the development of posterior segment epithelial downgrowth.

Unusually delayed presentation of persistent Descemet's membrane tear and detachment after cataract surgery.

A 51-year-old male who had undergone phacoemulsification in his left eye 11 months prior presented with complaint of sudden onset of blurred vision in the same eye. Review of his clinical course, slit-lamp exam, pachymetry, and specular endothelial microscopy led to the diagnosis of acute hydrops caused by Descemet's membrane dehiscence at the site of the incision. He was initially managed with medical treatment and observation. In the subsequent months of follow-up, the corneal edema and the patient's visual acuity did not improve. Intracameral gas injection was performed 7 months after presentation, but because of persistent corneal edema and nonattached Descemet's membrane, penetrating keratoplasty was performed. Histopathologic examination confirmed the diagnosis. The patient has had a clear corneal graft since then. Although Descemet's membrane detachment is a rather common complication after intraocular surgery, its unusually delayed presentation can also occur, and should not be confused with pseudophakic bullous keratopathy. Many mechanisms have been studied for the development of early tears and detachments after cataract surgery, but little is known about late presentations. The authors explore possible causes, and highlight the importance of instructing patients to avoid eye rubbing and any other type of trauma to the cornea after intraocular surgery.

Cysticidal activity of antifungals against different genotypes of Acanthamoeba.

Antifungal drugs have been proposed as a novel treatment for Acanthamoeba keratitis. The cysticidal activity of several antifungal compounds was tested against different genotypes of culture collection and clinical isolates of Acanthamoeba. Only voriconazole and posaconazole were found to be cysticidal, with no differences in activity observed between clinical and culture collection isolates.

Role of the Vision Van, a mobile ophthalmic outpatient clinic, in the Great East Japan Earthquake.

PURPOSE: The Great East Japan Earthquake of March 11, 2011 triggered powerful tsunami waves off the northeastern Pacific coast of Japan that destroyed almost all of the built-up areas along the coast. The study reported here examined the role played by the Vision Van, a mobile outpatient ophthalmological clinic, in providing eye care to disaster evacuees. METHODS: This was a retrospective case-series study of 2,070 victims (male: 732, female: 1,338) who visited the Vision Van. The subjects' medical records were examined retrospectively and analyzed in terms of age, sex, and date of visit to the Vision Van. Information regarding each patient's chief complaint, diagnosis, medication(s) prescribed, and eyeglasses and contact lenses provided, was also examined. RESULTS: The Vision Van was used to conduct medical examinations on 39 days between April 23 and June 29, 2011. The average number of subjects visiting the Vision Van each day was 53±31 (range: 7-135), with examinations carried out in Miyagi Prefecture and Iwate Prefecture. The most frequent complaint was a need for eye drops (871/2,070 [42.1%]). The second and third most frequent complaints, respectively, were the need for contact lenses (294/2,070 [14.2%]) and eyeglasses (280/2,070 [13.5%]). The most frequent ocular disease diagnosis was cataract (497/2,070 [24.0%]). Eye drops were prescribed to 74.1% of the subjects. CONCLUSION: Mobile clinics such as the Vision Van provide valuable care, in this case, particularly to individuals who lost or left behind eyeglasses or contact lenses while escaping a natural disaster, and to subjects with chronic eye disease.

Mutation K42E in dehydrodolichol diphosphate synthase (DHDDS) causes recessive retinitis pigmentosa.

A single-nucleotide mutation in the gene that encodes DHDDS has been identified by whole exome sequencing as the cause of the non-syndromic recessive retinitis pigmentosa (RP) in a family of Ashkenazi Jewish origin in which three of the four siblings have early onset retinal degeneration. The peripheral retinal degeneration in the affected siblings was evident in the initial examination in 1992 and only one had detectable electroretinogram (ERG) that suggested cone-rod dysfunction. The pigmentary retinal degeneration subsequently progressed rapidly. The identified mutation changes the highly conserved residue Lys42 to Glu, resulting in lower catalytic efficiency. Patterns of plasma transferrin isoelectric focusing gel were normal in all family members, indicating no significant abnormality in protein glycosylation. Dolichols have been shown to influence the fluidity and of the membrane and promote vesicle fusion. Considering that photoreceptor outer segments contain stacks of membrane discs, we believe that the mutation may lead to low dolichol levels in photoreceptor outer segments, resulting in unstable membrane structure that leads to photoreceptor degeneration.