Atypical mycobacterial keratitis: Clinical outcome in nonrefractive surgery cases.

PURPOSE: To identify the predisposing factors, clinico-microbiological profiles, and treatment responses in patients with atypical mycobacterial keratitis. METHODS: The study retrospectively analyzed patients who presented at a tertiary eyecare center in eastern India with atypical mycobacterial keratitis between 2008 and 2021. The diagnostic criteria included cases positive for acid-fast bacilli on Ziehl-Nielsen stain or culture. The antibiotic susceptibility pattern was observed, and treatment was initiated accordingly. RESULTS: Out of the 29 cases, ocular predisposing factors were present in 62.1% with an antecedent history of trauma, and vegetative matter was the most common risk factor. There was no predisposing association with systemic conditions in any case. A long lag time was observed between the onset of corneal infection and presentation in 79.3% of cases, with the average time being 43.7 days. Clinical signs mimicked fungal keratitis in most cases. Typical cracked windshield appearance was only observed in two cases. Two patients presented with clinical pictures like peripheral ulcerative keratitis. Topical amikacin was used as treatment in 28 cases. Based on disk diffusion assay, 28 (96.5%) isolates were sensitive to amikacin. Twelve (41.3%) were sensitive to vancomycin, six (20.6%) to gatifloxacin, six (20.6%) to ciprofloxacin, and four (13.7%) to moxifloxacin. Twelve participants showed good final visual acuity posttreatment, which improved to over two lines of Snellen's visual acuity chart (44.5%). CONCLUSION: Atypical mycobacteria keratitis may not present with classically described clinical features. The duration of presentation, clinical presentation, special microbiological stains, targeted therapy, and antibiotic susceptibility patterns are the key to successfully managing these intractable infections and obtaining favorable outcomes.

Microbiological Profile of Culture-Positive Fungal Keratitis.

PURPOSE: To examine the microbiological profile of cases of culture-positive fungal keratitis presenting to a tertiary eye care center in eastern India. METHODS: Microbiology records of all culture-positive microbial keratitis patients presenting to L V Prasad Eye Institute, Bhubaneswar, between January 2020 and December 2021, were retrospectively reviewed. Collected data included smear results of culture-positive fungal or mixed infections, the species isolated, and the time taken for organisms to grow in each media. RESULTS: Fungal keratitis formed 36% of all culture-positive microbial keratitis, whereas mixed infections (fungi and other organisms) formed 8.5%. The most common fungal species isolated was Fusarium spp. (25.8%). The most common bacteria involved in mixed infection with fungi was Staphylococcus spp. (54.8%). The positivity of potassium hydroxide+calcofluor white stain in detecting fungal filaments was 89.0% and that of Gram stain was 76.1%. Culture-positive cases of fungal keratitis showed most frequent growth on potato-dextrose agar (77.6%). A similar pattern was observed in culture-positive mixed infections (Sabouraud dextrose agar [SDA]: 84%). Most frequent growth of bacteria in mixed infections was seen in thioglycolate broth (54.7%). The shortest time to achieve significant fungal growth was observed in blood agar (BA) and chocolate agar (CA) (2.2/2.3 days, and 1.8/2 days for fungal keratitis and mixed infections, respectively). Filamentous hyaline fungi took the shortest time to achieve significant growth (2.8 days), whereas yeast forms took the longest (5 days). CONCLUSION: This study highlights the importance of combined use of both solid and liquid culture media, especially potato dextrose agar (PDA)/SDA and CA, to arrive at a definitive diagnosis of fungal keratitis and possible bacterial co-infection, which forms a significant proportion of cases with fungal keratitis. In resource-poor laboratories, two culture media, either SDA or PDA, along with BA, may be plated to detect mixed infections. Examination of stained smears of corneal samples provides an inexpensive method of rapid diagnosis of fungal keratitis when culture media is not available.

Keratic Precipitates: An Overlooked Sign of Microsporidial Stromal Keratitis?

PURPOSE: To elucidate a distinctive clinical feature in cases of microsporidial stromal keratitis (MSK). METHOD: A retrospective observational study of cases with a histopathological and/or microbiological diagnosis of MSK on corneal biopsy or host corneal button between 2016 and 2022 was conducted. RESULTS: Eighteen cases with a confirmed histopathological and/or microbiological diagnosis of MSK were detected. Careful review of slit-lamp photographs revealed the presence of pigmented keratic precipitates (KPs) beyond the area of stromal keratitis in five out of eighteen cases (27.7%). CONCLUSION: The presence of pigmented KPs beyond the area of lesion can alert the clinician to keep microsporidia as a differential cause for stromal keratitis. Management can be tailored accordingly for a better outcome.

Safety and Efficacy Profile of Corneas Harvested From Donors of Drowning Victims.

PURPOSE: The aim of this study was to analyze the tissue quality and outcomes of corneal transplants from donor corneal tissues harvested from drowning victims. METHODS: This retrospective study was conducted on corneal tissues harvested from drowning victims between March 2018 and September 2022. Details of the tissue quality and outcomes after keratoplasty were collected from the eye bank and outpatient records. RESULTS: Thirty-four donor corneas were collected from drowning victims during the study period. The mean age of the donors was 37.1 ± 20.3 years. The mean donor-to-preservation time was 4.9 ± 2.6 hours. The mean endothelial cell density was 3025 ± 271 cells/mm 2 . Twenty donor corneas (58.8%) were used at our institute, 2 were stored in glycerol for future use, and 12 were transported to other transplant centers. The overall utilization was 94.1% (32/34 corneas). Of the 20 corneas used at our institute, 17 were used for optical grafts and 3 for therapeutic indications. Of the 17 optical grafts, 10 were used for optical penetrating keratoplasty, 6 for endothelial keratoplasty, and 1 for anterior lamellar keratoplasty. The most common indication for keratoplasty was regrafting the previously failed grafts (25%). None of the transplanted eyes developed an infection in the immediate postoperative period. Eight eyes had clear grafts after 3 months. Of the 12 tissues transferred to other keratoplasty centers, 10 were used for optical grafts and 2 for therapeutic/tectonic grafts. CONCLUSIONS: Donor corneas retrieved from drowning victims may be considered safe for transplantation. The postoperative outcomes of the tissues obtained from these donors were satisfactory. Hence, these donor corneas can be optimally used in routine transplantation procedures.

Case Series: Mixed Infectious Keratitis by Pythium insidiosum and Fungal Species.

SIGNIFICANCE: This case series is the first to illustrate mixed infection from Pythium sp. and fungal species in corneal ulcer. PURPOSE: This case series aimed to alert all toward the possibility of both Pythium sp. and fungal species infection in case of nonresponding corneal ulcer treated with either antifungals or antipythium drugs alone. Increased suspicion of mixed infection in case of nonresponding fungal/ Pythium keratitis may facilitate early and prompt management. CASE REPORTS: Six patients presented with signs of either fungal or Pythium keratitis. They underwent ophthalmological examinations, smear examinations, cultures, and polymerase chain reaction (PCR). Therapeutic penetrating keratoplasty was performed in cases where symptoms worsened after treatment with either antifungal or antipythium drugs. The half corneal button (HCB) was shared for histopathological and microbiological examinations. In the first case, smear examination from corneal scraping (CS) revealed Pythium -like filaments, which were confirmed with PCR; however, Aspergillus nidulans grew in culture. In the second case, iodine-potassium iodide (IKI) staining was positive for Pythium ; however, PCR was positive for both Pythium and fungus, which was further confirmed by DNA sequencing. In the third case, IKI staining and HCB were positive for Pythium ; however, PCR was positive for fungus, which was identified as Candida saitoana with DNA sequencing. In the fourth case, Pythium grew in the CS culture; however, Candida sp. grew in the HCB culture. In the fifth case, Cladosporium sp. grew in culture from CS; however, Pythium insidiosum grew from the anterior chamber exudate after therapeutic penetrating keratoplasty. In the sixth case, smear examination revealed septate fungal filaments, and Cladosporium sp. grew in culture; however, HCB on histopathological examination showed features of Pythium keratitis. CONCLUSIONS: In unresponsive cases of Pythium or fungal keratitis, diagnostic modalities such as IKI and PCR should be implemented as a routine practice, in addition to smears and cultures.

Use of Ethylenediaminetetraacetic Acid in Chronic Calcium-Based Chemical Injury.

PURPOSE: This study presents the successful management of a patient with chronic chemical-based injury using ethylenediaminetetraacetic acid (EDTA) chelation. METHODS: This is a case report of a 59-year-old man who presented to us 2 months after a bilateral, accidental, ocular injury with lime particles at his workplace. RESULTS: The patient was initially managed with extensive debridement and amniotic membrane grafting for both eyes. At 4-month follow-up, the left eye appeared to have extensive calcium-based plaques. 0.02N EDTA chelation was performed for his left eye. Postchelation, the visual acuity improved to 20/800. At 1-week follow-up, a repeat EDTA chelation was performed. The corneal clarity improved further, and the patient recovered a visual acuity of 20/200. CONCLUSIONS: EDTA chelation in the setting of calcium deposition in the chronic phase of chemical injuries can be reasonably effective.

Rho-kinase inhibitors: Role in corneal endothelial disorders.

PURPOSE: This exhaustive review of published literature aims to put forth the current understanding, and experiences of the role Rho-kinase inhibitors play in the management of corneal endothelial disorders. METHODS: A meticulous search for PubMed and Medline databases was carried out using keywords 'rho-kinase inhibitors', 'corneal endothelial disorders', 'rho-kinase inhibitors in corneal endothelial disorders', and 'fuchs endothelial corneal dystrophy'. The articles published in last five years relevant to the area of interest were selected and compiled in a chronological order to write this review. RESULTS: Published research shows the proven role of rho-kinase inhibitors in promoting endothelial proliferation and suppressing its apoptosis. It has shown to be effective in the treatment of endothelial diseases and endothelial cell loss due to other causes in small clinical studies. It has also shown to promote growth of human corneal endothelial cell culture suitable for transplantation. The side effects of topical rho-kinase inhibitors are minimal and self-limiting. CONCLUSION: Rho-kinase inhibitors show immense promise in providing a non-surgical therapy for treatment of endothelial disorders. If consistent results are demonstrated through large clinical trials then this can be a major breakthrough in treating endothelial decompensation and reduce our dependence on endothelial keratoplasty for the same.

Carbide Gun-Related Ocular Injuries: A Case Series.

PURPOSE: The purpose of this study was to report a case series of sight-threatening ocular injuries caused by calcium carbide guns used as fire crackers. METHODS: Medical records of 15 eyes of 14 patients with ocular injuries caused while using carbide guns, visiting the Institute, from January 2021 to January 2022, were retrospectively reviewed. The collected data included patients' demography (age, sex), presenting ophthalmic features, management, and outcome. Grade I and II ocular injuries were managed medically. All grade III-V injuries were managed using Amniotic Membrane Transplantation. RESULTS: All patients were male. The mean age of the patients was 23.57 ± 11.76 years. According to the Dua classification, 5 eyes (33.3%) had Grade I-II ocular surface burns, 3 eyes (20%) had grade III burns, and 7 eyes (46.6%) had grade IV-VI burns. Presenting visual acuity ranged between hand movements to 20/50, and in 6 eyes (40%), the visual acuity was ≤20/200. Five eyes were managed medically alone, and 10 (66.6%) eyes needed surgical intervention (Amniotic Membrane Transplantation). After a mean follow-up of 14.23 ± 11.92 weeks, complete epithelization was seen in 10 eyes (66.6%). Partial limbal stem cell deficiency and its sequelae such as conjunctivalization of the cornea were noted in 7 eyes (46.6%). CONCLUSIONS: Calcium carbide-related ocular injuries can result in corneal blindness secondary to limbal stem cell deficiency in young individuals. Loss of vision in this age group can lead to loss of economic productivity and cosmetic disfigurement. More advocacy efforts are thus needed to prevent these injuries.

Acremonium keratitis: Risk factors, clinical characteristics, management, and outcome in 65 cases.

Purpose: To study the risk factors, clinical presentation, management options, and outcomes in cases of culture-proven Acremonium keratitis. Methods: Medical and microbiology records of culture-proven Acremonium keratitis from Jan 2007 to Dec 2019 at a tertiary eye care center were reviewed. Details of clinical findings on each visit and operating notes were reviewed from the medical records. All cases were subjected to corneal scraping at the first visit for microbiological investigation consisting of direct smear examination and culture. Topical natamycin 5% was the mainstay of medical treatment. Surgical treatment was considered for nonresponding patients. Results: During the 13-year study period, 65 cases of culture-proven Acremonium keratitis were identified out of 1605 cases of fungal keratitis. Trauma was the most common predisposing factor in 32 cases (49.2%). The average area of the corneal stromal infiltrate was 24.8 mm2 at the initial presentation. Hypopyon at the time of presentation was evident in 28 (43.1%) cases. Staphylococcus spp. was the most common (n = 22, 33.8%) organism coexistent with Acremonium. Direct microscopy of corneal scraping was positive for fungal filaments in 57/65 (87.6%) cases. Medical management alone was given in 44 patients (67.6%). Age (>50 years) and treatment delay (>15 days) were found to be independent risk factors for the poor final visual outcome (VA <20/60). Conclusion: When treated early, Acremonium keratitis responds well to medical therapy with currently available topical antifungals. However, advanced and nonresponding cases require surgical intervention for resolution of the infection.

Efficacy of montelukast in preventing seasonal recurrence of vernal keratoconjunctivitis in children.

BACKGROUND: Vernal keratoconjunctivitis is a chronic, seasonally exacerbated, allergic inflammation of the eye. The study aims to evaluate the efficacy and safety of oral montelukast in treating vernal keratoconjunctivitis in pediatric patients. METHODS: This is a 26-week, prospective, randomized, open-label study. Fifty-eight patients were randomly assigned to two groups-the treatment (montelukast) and control groups. At the beginning of the study, both the groups received topical loteprednol etabonate (0.1%) in tapering doses for a month, and topical olopatadine (0.1%) for the first 3 months. Symptoms and signs observed before and after treatment and assigned scores were studied. The primary efficacy endpoint was change in the mean score on the visual analog scale (VAS) for each subjective symptom. The secondary efficacy endpoint was change in the total score of objective signs. RESULTS: The montelukast group showed clinically relevant improvements in the signs and symptoms of vernal keratoconjunctivitis, compared to the control group. There was considerable improvement in clinical signs. Individual symptoms such as redness, itching, foreign body sensation, and tearing showed significant improvement at 6 months follow-up. The gradual improvement in symptoms until the last visit was statistically more significant within montelukast group. Mean VAS score showed statistically significant improvement in itching (p < 0.001) and redness (p < 0.008) in montelukast group even at 3 months. No adverse events were reported in either group. CONCLUSIONS: Montelukast was found to be safe and effective as a long-term therapy to prevent relapse in moderate to severe vernal keratoconjunctivitis.

Colistin resistance in Gram-negative ocular infections: prevalence, clinical outcome and antibiotic susceptibility patterns.

PURPOSE: To study the prevalence, antibiotic susceptibility profile, clinical outcomes and plasmid-mediated transfer of colistin resistance (CLR) among Gram-negative bacilli (GNB) isolates from different ocular infections. DESIGN: Prospective case-control study in eastern India. METHODS: Consecutive ocular samples with GNB isolates from clinically diagnosed cases of microbial keratitis, infectious endophthalmitis and orbital infections were included. Inclusion criteria were significant GNB growth from ocular samples and > 6 weeks follow-up. Clinical outcomes were determined by disease-specific criteria for each clinical group. Antibiotic susceptibility was tested by broth microdilution for colistin and Kirby-Bauer disc diffusion method for others. Plasmid detection for CLR genes mcr-1 and mcr-2 genes was done by standard protocols. RESULTS: Sixty GNB isolates were studied. Overall prevalence of CLR (intrinsic plus acquired) was 40% (n = 24), acquired being 37.5% of CLR isolates (n = 9). The prevalence varied from 45.5% (10/22) and 45% (9/20) in microbial keratitis and infectious endophthalmitis, respectively, to 26.3% (5/19) in orbital infections. Clinical outcomes in CLR patients were significantly worse in microbial keratitis (p = 0.018) and orbital infections (p = 0.018), and comparable to colistin-susceptible ones (p = 0.77) in infectious endophthalmitis. CLR isolates had significantly higher resistance to Amikacin, Gentamicin and Ceftazidime but were susceptible to Piperacillin, Carbapenems and fluoroquinolones. Plasmids mcr-1 and mcr-2 were detected in 6.25% (n = 1) and 25%(n = 4), respectively, of the 16 tested isolates. CONCLUSIONS: CLR is highly prevalent in ocular isolates and affects clinical outcomes. CLR isolates may still remain susceptible to Carbapenems, Piperacillin and fluoroquinolones. Plasmid mcr-1- and mcr-2-mediated CLR remains low in ocular infections.

Fungal scleritis masquerading as surgically induced necrotizing scleritis: a case report.

INTRODUCTION: The object of this case is to report the clinical findings, microbiological findings and management of a case of fungal scleritis following cataract surgery, which mimicked surgically induced necrotizing scleritis. CASE PRESENTATION: A 72-year-old Asian (Indian) man presented with scleritis following cataract surgery at another facility. He had been treated elsewhere for suspected scleritis, primarily with steroids followed by empiric antibiotic and antifungal agents. At our institute he underwent a complete microbiological workup and a scleral patch graft. The scleral scraping revealed fungal filaments. He was treated postoperatively with topical and systemic antifungal agent along with topical cyclosporine. The follow-up examination at 5 months revealed that the scleral patch graft was successful in maintaining the integrity of his globe and restoring partial vision. CONCLUSIONS: Fungal scleritis may mimic surgically induced necrotizing scleritis. Early diagnosis and prompt management can prevent progression of the disease and further devastating complications.

Bilateral response after unilateral subconjunctival bevacizumab injection in a child with Stevens-Johnson syndrome.

Bevacizumab is widely used for several ocular conditions, including age-related macular degeneration, diabetic retinopathy, corneal neovascularization, neovascular glaucoma, and retinopathy of prematurity. We describe a 14-year-old patient with Stevens-Johnson syndrome in whom subconjunctival injection of bevacizumab in one eye caused bilateral regression of corneal neovascularization.

Nocardia scleritis-clinical presentation and management: a report of three cases and review of literature.

AIM: This study aims to describe the clinical features and management of Nocardia scleritis. METHODS: The authors retrospectively reviewed medical charts of three patients with microbiologically proven Nocardia scleritis and reviewed literature. RESULTS: All the patients presented with areas of well-demarcated, circumscribed abscess. No specific clinical feature could be attributed to the causative organism. Nocardia was identified by smear and culture from the scleral exudates. The medical management was based on the antibiotic sensitivity. Surgical exploration of the suppurated area along with the healthy margins was done on all patients. Two patients required multiple explorations. All three patients resolved with a good visual and tectonic outcome. The literature review also suggests a good outcome with prolonged medical management though the preferred antibiotic has changed over the years. CONCLUSION: Though the prevalence of a disease like Nocardia scleritis is low, the results suggest that specific diagnosis and appropriate management can lead to a good outcome.

Push-pull technique of capsulorhexis for fibrous plaques on anterior capsules in pediatric cataract surgery.

We describe the adaptation of two-incision push-pull technique for performing continuous capsulorhexis in children's eyes with anterior capsules having large fibrous plaque in the center. This technique uses the fibrous plaque as a template for directing the force vectors to achieve a controlled tear and a continuous capsulorhexis. We used the technique in 12 eyes of six children with successful capsulorhexis in 10 eyes and peripheral extension of rhexis in 2 eyes.

Unusual presentation of phacolytic glaucoma: simulating microbial keratitis.

The differential diagnoses for phacolytic glaucoma are acute angle closure glaucoma, open angle glaucoma with uveitis, neovascular glaucoma, and glaucoma secondary to trauma. We report an unusual case where the dislocated cataractous lens firmly adherent to the corneal endothelium evoked a cellular reaction similar to phacolytic glaucoma but clinically appeared like a deep corneal abscess. The 73-year-old lady presented with severe photophobia, pain, and redness in the left eye for two months despite being on antibiotics and antifungals. Anterior chamber wash revealed a cataractous lens buried within the infiltrate, which was removed and sent for histopathological examination. Postoperatively she was treated with topical ofloxacin, homatropine, dorzolamide, timolol, and tapering dose of steroids. Histological confirmation of inflammation, histiocytic response, and giant cells around the lens material confirmed the ongoing phacolytic process. Photophobia, pain, and redness subsided following removal of the lens and surrounding cellular reaction. At her last visit, four months after surgery, she was comfortable.