Fungal Necrotizing Scleritis After Intravitreal Injection Therapy.

PURPOSE: To report a case of infectious necrotizing scleritis secondary to Aspergillus terreus after intravitreal injection therapy. METHODS: This is a case report with literature review. RESULTS: A 98-year-old woman receiving intravitreal aflibercept injections for neovascular age-related macular degeneration in the left eye presented with severe pain, redness, and purulent discharge at the injection site. She was initially treated with topical fortified antibiotics, and clinical improvement was achieved, although microbial cultures showed negative results. Two months later, she presented with severe ocular pain and was diagnosed with anterior necrotizing scleritis. Scleral scrapings were collected for cultures, and intensive topical antibiotic therapy was reintroduced. Evaluation for autoimmune etiology and microbiological testing showed negative results. Because of the progression of the scleral necrotic area, empirical therapy with topical voriconazole was initiated, and surgical debridement was performed. Finally, the culture was positive for A. terreus. The modified therapy consisted of topical voriconazole and oral voriconazole for 3 months with an excellent clinical outcome. CONCLUSIONS: To our knowledge, this is the first case of fungal necrotizing scleritis secondary to intravitreal injection. Diagnosis was delayed due to its chronic clinical course and the slow fungal growth in culture media, but the combined medical and surgical approach resulted in a satisfactory outcome.

Fulminant scleral abscess secondary to infected scleral buckle with Moraxella species.

We here report a case of scleral buckle infection with fulminant scleral abscess secondary to Moraxella species. A 54-year-old chronic alcoholic male with a history of retinal detachment repair, with scleral buckle 8 years prior, presented with complaints of severe pain, redness, and swelling in the right eye since 2 weeks. The patient was diagnosed with scleral buckle infection, the buckle was removed, and cultures revealed Moraxella species. The postoperative course included fulminant scleral abscess treated with dual antibiotic therapy that included ceftriaxone and moxifloxacin. All systemic antibiotics were discontinued after 3 weeks, retina remained attached, and no recurrence occurred over a 1-year follow-up. Moraxella, though commonly associated with bacterial keratitis, can also lead to buckle infection, especially in chronic alcoholic and immunocompromised patients. In buckle infection, infected buckle along with sutures should be immediately removed without damaging underlying compromised sclera. Lastly, culture and drug sensitivity play a very important role in buckle infections.

Cryopreservation (-20°C) of equine corneoscleral tissue: Microbiological, histological, and ultrastructural study.

OBJECTIVE: To evaluate microbiological, histological, and ultrastructural characteristics of short-term cryopreserved (STC) equine corneoscleral tissue (<1 year), and to compare it with long-term cryopreserved (LTC) tissue (>7 years). ANIMALS STUDIED: Thirty-four healthy equine globes. PROCEDURE: After a decontamination protocol, globes were enucleated and stored at -20°C in broad-spectrum antibiotics. Corneoscleral tissue was evaluated at different storage periods: 1 month-1 year (20 eyes) and 7-9 years (12 eyes). Two eyes were used as controls. Microbiologic study included direct (blood, McConkey, and Sabouraud agars) and enrichment (brain-heart infusion broth) cultures. Cryopreservation artifacts were evaluated by hematoxylin-eosin. Corneoscleral collagen organization and number of normal and dead keratocytes were established by transmission electron microscopy. RESULTS: All microbiologic direct cultures were negative. Enrichment cultures were positive in 12.5% of corneal and 59.4% of scleral tissues (pcornea  = 0.136; psclera  = 1.000). Cryopreservation artifacts were most commonly observed in LTC tissues (P = 0.002). Normal keratocytes were predominant in STC corneas (STC 60% and LTC 0%) and apoptotic ones in LTC (STC 40% and LTC 90%), whereas necrotic keratocytes were only seen in LTC (LTC 10%) (P = 0.001). No structural differences were detected in collagen organization between STC and LTC (pcornea  = 1.000; psclera  = 0.703). CONCLUSIONS: Cryopreservation of equine corneoscleral tissue did not yield direct bacterial contamination. Apoptosis is the main cause of death of cryopreserved equine keratocytes. Based on the lack of significant structural differences between STC and LTC samples, these cryopreserved tissues could potentially be used for tectonic support for at least 9 years without structural or microbiological impediment.

Interventions and Outcomes in Patients with Infectious Pseudomonas scleritis: A 10-Year Perspective.

Purpose: To identify interventional factors associated with improved visual results and faster time to resolution for patients with Pseudomonas scleritis. Methods: Retrospective study analyzing inciting factors, therapeutic modalities, and outcomes of patients with Pseudomonas scleritis. Results: A total of 24 patients were analyzed; 22 were treated as outpatients. All had resolution of infection and 58% (n = 14) maintained ≥20/200 vision. Medical therapy included topical and oral antibiotics; seven received additional subconjunctival injections; two were admitted for IV antibiotics. Patients presenting with ≥20/200 vision were more likely to maintain this level of vision (n = 8, 80%) compared to those presenting with severe vision loss (n = 5, 36%) (p = 0.04). A similar proportion of patients who received (n = 8, 61%) and did not receive (n = 5, 39%) oral steroids achieved 20/200 vision or better once infection resolved, p = 1.0. Conclusions: Pseudomonas scleritis can be successfully managed in the outpatient setting. Oral steroids do not appear harmful in the treatment of this disease.

Presumed Tuberculous Sclerokeratitis Presenting with Hypopyon.

Purpose: To describe a case of presumed tuberculous sclerokeratitis which presented with anterior uveitis and hypopyon Methods: A retrospective chart review Results: A 23-year-old female presented with nodular scleritis, peripheral corneal opacities, and severe anterior chamber reaction with hypopyon. Her Mantoux test and interferon gamma release assay were positive and high-resolution computerized tomography of chest revealed right hilar lymphadenopathy. Aqueous aspirate from anterior chamber paracentesis of her right eye was negative for Mycobacterium tuberculosis genome. She responded to antitubercular treatment and oral corticosteroid Conclusions: Tuberculous sclerokeratitis can rarely present with hypopyon and pose a challenge in diagnosis for the clinicians.

Cryopreservation (-20 °C) of canine corneoscleral tissue: histological, microbiological, and ultrastructural study.

OBJECTIVE: To evaluate microbiological, histological, and ultrastructural characteristics of short-term cryopreserved (STC) canine corneoscleral tissue (<1 year) and to compare it with long-term cryopreserved (LTC) tissue (>6 years). ANIMALS STUDIED: Thirty-six healthy canine globes. PROCEDURE: After a decontamination protocol, globes were enucleated and stored at -20 °C. Corneoscleral tissue was evaluated at different periods: <1 year (20 eyes) and >6 years (12 eyes). Four eyes were used as controls. Microbiologic study included direct (blood, McConkey and Sabouraud agars) and enrichment (brain-heart infusion broth) cultures. Cryopreservation artifacts were evaluated by hematoxylin-eosin. Corneoscleral collagen organization and number of normal and dead keratocytes were established by transmission electron microscopy (TEM). Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) was also used for keratocyte characterization. RESULTS: Corneal microbial growth was observed in 25% of the direct STC cultures, and in 47.4% and 16.7% of the enriched STC and LTC cultures, respectively. Scleral STC direct cultures were 30% positive, while enrichment cultures were positive in 66.7% and 16.7% of the STC and LTC, respectively (P = 0.011). Cryopreservation artifacts were higher in LTC tissues (P < 0.001). Apoptotic keratocytes were predominant by TEM and TUNEL, in both STC and LTC. Minimal structural differences were detected in collagen organization between STC and LTC. CONCLUSIONS: Cryopreservation of canine corneoscleral tissue seems to reduce bacterial contamination over time. Apoptosis is the main way of death of cryopreserved canine keratocytes. Based on the lack of significant structural differences between STC and LTC samples, these cryopreserved tissues could potentially be used for tectonic support for at least 8 years without structural or microbiological impediment.

Incidence and Outcomes of Positive Donor Corneoscleral Rim Fungal Cultures after Keratoplasty.

PURPOSE: To determine the incidence of positive corneoscleral donor rim fungal cultures after keratoplasty and to report clinical outcomes of grafts with culture-positive donor rims. DESIGN: Retrospective cohort study. PARTICIPANTS: Consecutive donor corneas and keratoplasty recipients at a single tertiary referral center over 20 years. METHODS: Patient charts were reviewed to determine the incidence of positive donor rim fungal cultures and clinical outcomes of all grafts using contaminated tissue. MAIN OUTCOME MEASURES: The primary outcome measures were positive donor rim fungal culture results and the development of postkeratoplasty fungal infection using corresponding corneal tissue. The secondary outcome measure was the impact of postoperative prophylaxis on donor tissue-associated infections. RESULTS: A total of 3414 keratoplasty cases were included in the statistical analysis. Seventy-one cases (2.1%) were associated with a fungal culture-positive donor rim. Candida species were cultured in 40 cases (56.3%). There was a higher incidence of positive rim cultures over the last 5 years of the analytic period compared with the first 15 years (P = 0.018). Fungal keratitis developed in 4 cases (5.6%), and all patients required further surgical intervention to achieve cure. There were no cases of fungal endophthalmitis. Empiric antimycotic prophylaxis initiated at the time of positive culture result reduced the incidence of keratitis from 15.8% in untreated cases to 1.9% in treated cases (P = 0.056). CONCLUSIONS: Positive donor rim fungal cultures are uncommon, but carry an unacceptably high risk of postoperative fungal infection. This risk may be reduced with prophylactic antimycotic therapy when culture-positive donor rims are identified.

Cryopreservation (-20 °C) of feline corneoscleral tissue: histologic, microbiologic, and ultrastructural study.

OBJECTIVE: To evaluate microbiological, histologic, and ultrastructural characteristics of short-term cryopreserved (STC) feline corneoscleral tissue (<1 year) and to compare it with long-term cryopreserved (LTC) tissue (>7 years). ANIMALS STUDIED: Twenty healthy feline globes were obtained from 2003 to 2013. PROCEDURE: After a decontamination protocol, globes were enucleated and stored at -20 °C in broad-spectrum antibiotics. Corneoscleral tissue was evaluated at different storage periods: <1 year (10 eyes) and >7 years (8 eyes). Two eyes were used as controls. Microbiologic study included direct (blood, McConkey, and Sabouraud agars) and enrichment (brain-heart infusion broth) cultures. Cryopreservation artifacts were evaluated by hematoxylin-eosin. Corneoscleral collagen organization and number of normal and dead keratocytes were established by transmission electron microscopy. RESULTS: Although microbiologic cultures were positive only in STC [direct (20.8%); enrichment (37.5%)], significant differences between periods were only found in enrichment cultures (P = 0.006). Cryopreservation artifacts were most commonly observed in LTC tissues (P < 0.001). Normal keratocytes were predominant in STC corneas (STC 58.3%, LTC 12.5%) and apoptotic ones in LTC (STC 41.7%, LTC 75%), whereas necrotic keratocytes were only seen in LTC (LTC 12.5%) (P = 0.046). No structural differences were detected in collagen organization between STC and LTC (Pcornea = 0.147; Psclera = 0.362). CONCLUSIONS: Cryopreservation of feline corneoscleral tissue seems to reduce bacterial contamination over time. Apoptosis is the main cause of death of cryopreserved feline keratocytes. Based on the lack of significant structural differences between STC and LTC samples, these cryopreserved tissues could potentially be used for tectonic support for at least 10 years without structural or microbiological impediment.

Evaluation of Corneas from Donors With Septicemia for Use in Corneal Transplant.

PURPOSE: To evaluate if donor corneas obtained from deaths occurring because of septicemia can be used for corneal transplantation. STUDY DESIGN: Prospective study. METHODS: Eleven septicemic donor corneas were used in the study and 10 donor corneas from deaths because of causes other than septicemia were used as controls. Blood culture reports of all patients who had donated eyes were collected, and the pathogenic organisms causing septicemia were noted. On obtaining the eyeballs, aqueous and vitreous samples were sent for polymerase chain reaction to analyze for eubacterial and panfungal genomes. Corneal and scleral tissues (3 × 3 mm) were sent for culture in brain heart infusion media. Growth from each of the samples was checked to ascertain if the same organism was isolated in all. RESULTS: One corneal and 3 scleral culture reports in the sepsis group and 1 corneal and 1 scleral culture report in the control group showed positive growth. Normal conjunctival/eyelid commensal organisms were isolated from all culture-positive samples and did not correlate with the pathogenic organism causing the septicemia. Three aqueous and vitreous samples in the sepsis group and 4 samples of aqueous and vitreous in the control group that tested positive for eubacterial genome showed no corresponding growth in the culture report of cornea and sclera. CONCLUSIONS: Corneal tissues harvested from septicemic donors do not necessarily harbor the pathogenic organisms causing the septicemia, suggesting that such corneas may be suitable for transplantation.

Clinical manifestations and outcome of tuberculous sclerokeratitis.

AIM: To study the clinical manifestations and outcome of patients with tuberculous sclerokeratitis treated with antituberculous therapy without concomitant use of systemic steroids. METHODS: We reviewed retrospectively the medical records of eight consecutive patients with tuberculous sclerokeratitis. Patients were treated unsuccessfully with topical and/or systemic steroids. They underwent complete ophthalmic examination, systemic evaluation, laboratory investigations and imaging. Tuberculin skin test was done with purified protein derivative (PPD) on all patients. The diagnosis of tuberculous sclerokeratitis was made based on clinical findings of scleritis with adjacent peripheral corneal stromal keratitis, positive PPD test of 15 mm of induration or more, response to antituberculous treatment (ATT) within 4 weeks and exclusion of other causes of sclerokeratitis. Antituberculous drugs were given for a minimum of 6 months without concomitant use of corticosteroids. The outcome measure was resolution of the ocular surface inflammation of the sclera and cornea. RESULTS: Eight consecutive patients with a diagnosis of tuberculous sclerokeratitis were included. There were one male and seven female patients. The mean age was 29 years with an age range of 7-43 years. The involvement of the sclera was nodular in six patients and diffuse in two. The involvement of the cornea consisted of peripheral corneal stromal inflammation adjacent to the area of scleritis. Patients responded to antituberculous medications with complete resolution of the sclerokeratitis without topical or systemic anti-inflammatory agents. CONCLUSIONS: Antituberculous medications can lead to complete resolution of the sclerokeratitis without concomitant use of steroids, or other anti-inflammatory agents.

Intraocular penetration of systemic antibiotics in eyes with penetrating ocular injury.

PURPOSE: To determine whether penetrating scleral or corneal injury can enhance intraocular penetration of systemic moxifloxacin, vancomycin, and ceftazidime. METHODS: Thirty rabbits were divided into 3 groups for each antibiotic and then further subdivided to receive either scleral or corneal injury to the right eye. The left eye served as a control. Intravenous antibiotics were given following injury, and eyes were subsequently enucleated. Vitreous antibiotic concentration was determined by high-performance liquid chromatography analysis. Plasma concentration was measured for comparison. RESULTS: Intravitreal moxifloxacin concentration was unchanged by injury. Minimum inhibitory concentration (MIC90) was achieved in the vitreous against the most common gram-positive endophthalmitis-causing organisms. Intravitreal vancomycin levels were not enhanced by injury and did not reach the MIC90 for gram-positive organisms commonly causing intraocular infection. Intravitreal ceftazidime was increased in the injured eyes, 67% and 73% higher in scleral and corneal injury eyes. It reached MIC90 of many gram-negative bacteria. CONCLUSIONS: Intravitreal antibiotic penetration of systemic antibiotics with or without penetrating ocular injury varies depending on the antibiotic. For prevention or treatment of gram-positive-bacteria-causing endophthalmitis, intravitreal vancomycin is necessary and provides the most reliable coverage. Systemic ceftazidime can be used for many gram-negative bacteria, but intravitreal injection is recommended for better coverage, especially for more-potent organisms. Systemic moxifloxacin can be considered for most gram-positive and -negative infections due to its excellent intraocular penetration and broad coverage, but the patient's previous history of its topical use and increasing resistance patterns must be considered.

Impact of eye bank lamellar tissue cutting for endothelial keratoplasty on bacterial and fungal corneoscleral donor rim cultures after corneal transplantation.

PURPOSE: To determine if the lamellar cut of donor tissue for endothelial keratoplasty (EK) by an eye bank facility is associated with a change in the prevalence of positive bacterial or fungal donor rim cultures after corneal transplantation. METHODS: A retrospective review was conducted of bacterial and fungal cultures of donor rims used for corneal transplantation at a tertiary eye care center from January 1, 2003, to December 31, 2008, with tissue provided by a single eye bank. The cases were divided into 2 groups. Group 1 ("no-cut") included keratoplasty procedures in which a lamellar cut was not performed. Group 2 ("precut") included EK procedures in which a 4-hour period of prewarming of tissue followed by a lamellar cut was performed in the eye bank before tissue delivery to the operating surgeon. RESULTS: There were 351 donor rim cultures in group 1 and 278 in group 2. Bacterial cultures were positive in 30 donor rims (8.5%) in group 1 and 13 (4.7%) in group 2 (P = 0.058). Positive bacterial cultures were not associated with any postoperative infections. Fungal cultures were positive in 8 donor rims (2.3%) in group 1 and 7 (2.5%) in group 2 (P = 1.0). Positive fungal cultures were associated with 2 cases (13.3%) of postoperative fungal infections. CONCLUSIONS: Corneal donor tissue can be precut for EK by trained eye bank personnel without an increased risk of bacterial or fungal contamination.

Conjunctival swabs and corneoscleral rim cultures from corneal transplantation donors as possible early indicators for posttransplant endopthalmitis.

PURPOSE: To determine by microbiological examinations the rate of conjunctiva and corneoscleral rim contamination of cadaver donor tissues. METHODS: A prospective review of culture results for 98 cadaver donor conjunctival swabs [mean age 76.4 ± 12.9 years (±SD)]. Transplant patients were evaluated both before and after disinfection with gentamicin. Individual parameters evaluated included detection rates of bacteria, variety of detected bacteria, time interval from donor death to tissue harvest and age of donors. RESULTS: Before disinfection, 60 out of 98 conjunctival swabs exhibited microbial growth, while only 36 out of 98 exhibited growth after disinfection (p = 0.0006). Longer intervals between death and tissue harvest were associated with higher positive microbial growth rates. Prior to disinfection, culture-positive donors (74.1 ± 13.6 years) were significantly younger than culture-negative donors (79.8 ± 10.8 years) (p = 0.024). Positive donor rim cultures were noted in 2 out of the 22 corneal transplantations. Microorganisms isolated from the corneal grafts matched those found in the conjunctiva. CONCLUSIONS: It is recommended that the corneoscleral buttons be removed as soon as possible. Cultures of conjunctival swabs collected from donors after disinfection may be useful in determining treatment for postoperative infections occurring after corneal transplantation.

Fungal scleral keratitis caused by Phomopsis phoenicicola.

We report a case of scleral keratitis caused by Phomopsis phoenicicola. Pterygium surgery was a predisposing factor, and the patient was treated with natamycin and fluconazole eye drops and oral fluconazole. The fungus was identified by sequencing of the internal transcribed spacer (ITS) region of the fungal ribosomal DNA (rDNA) locus and confirmed on the basis of its typical pycnidia and conidia.

Late-onset intrascleral dissemination of Stenotrophomonas maltophilia scleritis after pterygium excision.

PURPOSE: To report a case of pterygium excision-related infectious scleritis with late-onset intrascleral dissemination. METHODS: Case report. RESULTS: A 72-year-old female patient was referred for Stenotrophomonas maltophilia scleritis after undergoing pterygium excision 18 years earlier. Surgical debridement and a tectonic corneal patch graft, along with conjunctival flap, were performed to repair the scleral defect after treatment with fortified topical and systemic antibiotics. However, intrascleral dissemination of scleritis occurred 5 months after the initial episode. CONCLUSIONS: Intrascleral dissemination of S. maltophilia scleritis after pterygium excision might be delayed because of limited invasiveness and inherent resistance to several antibiotics. Long-term follow-up may be needed to protect against the possibility of late-onset intrascleral dissemination.

Fungal scleritis with exudative retinal detachment.

PURPOSE: To report a case of fungal scleritis associated with exudative retinal detachment. DESIGN: A rare case report. METHODS: Nonresolving fungal scleritis mimicking noninfective scleritis was treated with systemic and topical antifungals and low topical steroids after diagnosis was established on scleral scraping. Even after complete resolution of scleritis, exudative retinal detachment persisted. RESULTS: The patient was advised of a possible need to undergo vitreo retinal surgery if exudative retinal detachment persisted for more than a month after complete resolution of the scleritis component. CONCLUSION: Infective scleritis must be ruled out in cases of longstanding scleritis not responding to immunosuppressives.