Amniotic membrane transplantation as part of a multimodal management approach to Streptococcus pyogenes necrotizing keratoconjunctivitis.

Streptococcus pyogenes (group A beta-hemolytic Streptococcus, GABHS) causes a range of human infections, including necrotizing fasciitis and toxic shock syndrome, because it produces exotoxins that damage host cells, facilitate immune evasion, and serve as T cell superantigens. GABHS conjunctivitis is rare. We report a case of membranous conjunctivitis in a 3-year-old child who was treated with a combination of targeted bactericidal antimicrobials, toxin-synthesis inhibition, and amniotic membrane transplantation.

Increased incidence of adult gonococcal keratoconjunctivitis at two tertiary eye hospitals in Western Europe: clinical features, complications and antimicrobial susceptibility.

BACKGROUND: Gonorrhoea is on the rise: between 2021 and 2022, a 50% and a 33% increase in diagnoses was seen, respectively, in England and the Netherlands. A concurrent rise in gonococcal keratoconjunctivitis (GKC) is a serious concern due to the potentially devastating visual complications. METHODS: This is a retrospective case series of adult GKC from two Western European tertiary ophthalmology centres between 2017 and July 2023. The clinical features, ocular complications and antimicrobial susceptibilities are reported within. RESULTS: An increased incidence was recorded at both centres, with 11 confirmed cases in the first 7 months of 2023, compared with ≤3 per year in 2017-2022. CONCLUSION: The notable increase of GKC cases in our centres in 2023 may indicate a rise across Western Europe. Enhanced, sustained, national surveillance of GKC is essential to establish incidence and antimicrobial susceptibility, to inform treatment guidelines and guide appropriate public health response.

Investigation of the pathogens contributing to naturally occurring outbreaks of infectious bovine keratoconjunctivitis (pinkeye) using Next Generation Sequencing.

Infectious bovine keratoconjunctivitis (IBK), commonly known as pinkeye, has a marked negative impact on the economy of the cattle industry. Moraxella species, including Mor. bovis and Mor. bovoculi, which have been associated with this disease, colonize clinically healthy eyes as well, suggesting that there are intrinsic changes that may occur to the ocular microbiota or the involvement of additional unrecognized organisms that contribute to IBK. To evaluate this, 104 ocular swabs collected from eyes with IBK or clinically healthy eyes from 16 different cattle herds were subjected to 16 S rRNA gene PCR and next generation sequencing (NGS) analysis. Organisms detected were similar across the herds and there was no difference in the total number of bacterial groups detected among IBK cases and controls. However, the percentages of the different organisms detected varied between the two groups, including Moraxella spp., with more Moraxella spp. in eyes with IBK than controls. Further, using culture and whole genome NGS, a new species of Moraxella (suggested name Mor. oculobovii) was detected from the eyes of cattle from two farms. This strain is non-hemolytic on blood agar, is missing the RTX operon, and is likely a non-pathogenic strain of the bovine ocular microbiome. Alteration of the ocular microbiota composition may have a predisposing role, enhancing bacterial infection and the occurrence of clinical IBK. Future studies are required to evaluate if these changes are permanent or if there is a shift in the microbiome following recovery from the infection and how antibiotics might affect the microbiome.

Microsporidia-Associated Anterior Uveitis After Keratoconjunctivitis.

OBJECTIVE: The aim of this study was to describe the clinical features and management of uveitis associated with microsporidial keratoconjunctivitis (MKC). METHODS: The medical records of clinically diagnosed or microbiologically proven patients with MKC between July 2016 and August 2021 were reviewed. Patients with documented evidence of keratic precipitates (KPs) or anterior chamber cells were analyzed for their demography, clinical features, and treatment. Patients with microsporidial stromal keratitis and herpes simplex virus keratouveitis were excluded from the study. RESULTS: Of the 2212 patients reviewed within the study period 171 of 172 eyes (7.7%) had documented evidence of KPs and/or anterior chamber cells. The patients' mean age was 43.8 ± 13.8 years, and there were more men (n = 120). The mean duration of appearance of KPs was 6.9 ± 5.5 days, and 28% (n = 48 of 171) appeared on the day of presentation. Superficial punctate keratitis was central and diffuse in 48 and 49 patients, respectively. The treatment was either lubricant alone (45.3%; 78 eyes) or combined with topical steroids (54.7%; 94 eyes). The mean duration of the resolution was longer in the "corticosteroid" than "no corticosteroid" group: KPs: 15.3 ± 6.5 days versus 12.3 ± 5.8 days ( P = 0.007) and superficial punctate keratitises: 15.4 ± 9.4 days versus 11.7 ± 6.2 days ( P = 0.01). The presenting visual acuity with a pinhole was 0.26 ± 0.26 (logMAR) and it improved to 0.03 ± 0.07 on resolution ( P < 0.0001, paired t test). CONCLUSIONS: Uveitis after MKC is a self-limiting entity that often resolves without corticosteroid. One must exercise caution in using steroids in the presence of active corneal lesions.

Bacteria associated with infectious keratoconjunctivitis outbreak in confined lambs.

Introduction. Infectious keratoconjunctivitis is a significant ocular disease found in confined sheep. Little information about the aetiological agents and their antimicrobial susceptibility is available.Gap Statement. There is limited information on the aetiological agents involved in keratoconjunctivitis outbreaks in sheep.Aim. The present research aimed to determine the bacterial aetiological factors involved in an outbreak of infectious keratoconjunctivitis in confined lambs.Methodology. Ocular swabs were collected from 23 randomly selected lambs, which were classified into three groups according to the severity of the lesion: group I (N=6; no ocular involvement), group II (N=8; less severe injuries) and group III (N=9; more severe injuries). Isolation of aerobic bacteria and antimicrobial susceptibility tests were carried out. Molecular detection of Mollicutes was performed, and positive samples were tested to confirm the presence of the following species: Mycoplasma conjunctivae, Mycoplasma agalactiae and Mycoplasma mycoides subsp. capri.Results. Moraxella sp. and Mollicutes were detected in all groups, but we inferred that Moraxella sp. are only significant in the early stages of the disease. M. conjunctivae was detected in all tested groups, while M. agalactiae was detected in samples of group III only. One strain of Moraxella sp. was resistant to erythromycin and showed intermedite resistance to tetracycline.Conclusion. The presence of these species confirms their importance in the aetiology of this disease, and the low resistance profile observed in the studied farm suggested an increased cure success rate.

Relatedness of type IV pilin PilA amongst geographically diverse Moraxella bovoculi isolated from cattle with infectious bovine keratoconjunctivitis.

Introduction. Moraxella bovoculi is frequently isolated from the eyes of cattle with infectious bovine keratoconjunctivitis (IBK; pinkeye). As with M. bovis, which has been causally linked to IBK, M. bovoculi expresses an RTX (repeats in the structural toxin) cytotoxin that is related to M. bovis cytotoxin. Pilin, another pathogenic factor in M. bovis, is required for corneal attachment. Seven antigenically distinct pilin serogroups have been described in M. bovis.Hypothesis/Gap Statement. Multiple different serogroups exist amongst type IV pilin encoded by M. bovis, however, it is not known whether M. bovoculi exhibits a similar degree of diversity in type IV pilin that it encodes.Aim. This study was done to characterize a structural pilin (PilA) encoded by M. bovoculi isolated from cases of IBK to determine if diversity exists amongst PilA sequences.Methodology. Ninety-four isolates of M. bovoculi collected between 2002 and 2017 from 23 counties throughout California and from five counties in four other Western states were evaluated.Results. DNA sequencing and determination of deduced amino acid sequences revealed ten (designated groups A through J) unique PilA sequences that were ~96.1-99.3 % identical. Pilin groups A and C matched previously reported putative PilA sequences from M. bovoculi isolated from IBK-affected cattle in the USA (Virginia, Nebraska, and Kansas) and Asia (Kazakhstan). The ten pilin sequences identified were only ~74-76 % identical to deduced amino acid sequences of putative pilin proteins identified from the previously reported whole-genome sequences of M. bovoculi derived from deep nasopharyngeal swabs of IBK-asymptomatic cattle.Conclusions. Compared to the diversity reported between structural pilin proteins amongst different serogroups of M. bovis, M. bovoculi PilA from geographically diverse isolates derived from IBK-affected cattle are more conserved.

Dual Molecular Diagnosis of Microsporidia (Encephalitozoon hellem) Keratoconjunctivitis in an Immunocompetent Adult.

PURPOSE: To report a case of microsporidia (Encephalitozoon hellem) keratoconjunctivitis acquired through avian transmission in an immunocompetent adult, diagnosed by metagenomic deep sequencing (MDS), and confirmed by polymerase chain reaction. METHODS: A case report. RESULTS: An 18-year-old woman was referred with unilateral keratoconjunctivitis unresponsive to topical and systemic therapy after exposure to birdcage debris. Slit-lamp examination of the left eye revealed a follicular papillary reaction of the palpebral conjunctiva and multiple corneal punctate epithelial opacities that stained minimally with fluorescein. In vivo confocal microscopy revealed bright double-walled structures and smaller bright round structures in the superficial epithelial debris and epithelium. Molecular diagnosis with MDS of E. hellem was confirmed by polymerase chain reaction. Clinical resolution and normalization of in vivo confocal microscopy was observed after a 6-week course of topical azithromycin. The patient elected a 3-week course of topical voriconazole 1% for definitive antimicrosporidial treatment, with no evidence of persistent infection 1 month later. CONCLUSIONS: Microsporidial (E. hellem) keratoconjunctivitis can occur through avian transmission in immunocompetent hosts. Topical azithromycin may be effective against this pathogen. MDS has utility in the diagnosis of atypical keratoconjunctivitis.

Queratoconjuntivitis por Vittaforma corneae: una enfermedad emergente entre los viajeros que regresan del sudeste asiático / Vittaforma Corneae keratoconjunctivitis: An emerging pathology among travelers returning from Southeast Asia

La queratoconjuntivitis por Microsporidium es un cuadro infrecuente. Se ha asociado a brotes epidémicos en Asia relacionados con la exposición a agua o tierra contaminada. Habitualmente estos cuadros son autolimitados y leves, pero pueden tener evoluciones prolongadas. Presentamos el caso de una paciente de 29 años que comenzó con dolor, enrojecimiento, visión borrosa en su ojo derecho tras su vuelta de un viaje a Singapur y que no mejoró tras un tratamiento convencional frente a conjuntivitis. Fue diagnosticada de queratoconjuntivitis por Microsporidium mediante PCR y tinción con PAS del epitelio corneal. El tratamiento inicial fue desbridamiento epitelial, albendazol oral y voriconazol, levofloxacino y propamidina, pero la enfermedad conjuntival y corneal no cedió hasta que si introdujeron corticoides tópicos 5 meses después para tratar la limbitis. Debemos tener la sospecha de queratitis por Microsporidium en casos de queratitis unilateral y conjuntivitis, sobre todo en pacientes que vuelvan de Asia

Microsporidium keratoconjunctivitis is an very rare disease. It is related to outbreaks in Asia due to exposure to contaminated water or soil. Microsporidium keratoconjunctivitis is a a self-limited disease, but it could have long term courses. We present the case of a 29 year old woman who started with pain, redness and blurred vision after a holiday in Singapore and did not respond to conjunctivitis treatment. PCR sequencing and PAS staining of corneal epithelial biopsy identified Vittaforma corneae as the causative organism. Treatment was initiated with corneal debridement, oral albendazol, and intensive topical voriconazole, levofloxacin and propamidine, but the conjunctival and corneal disease was only resolved 5 months later with the introduction of topical steroids to treat her severe limbitis. Suspicion of Microsporidium keratoconjunctivitis should be raised amongst ophthalmologists in unilateral keratitis with mild conjunctivitis in travelers from Asia

Effect of scleral lens use on conjunctival microbiota.

AIM: This study aimed to investigate the effect of scleral lens (SL) use on conjunctival microbiota. METHOD: A total of 26 eyes of 26 patients using an SL and 25 eyes of 25 healthy controls were included in the study. The samples were obtained from the lower fornices of the eyes using sterile swabs. For the bacteriological examination, a bacterial culture was obtained by inoculating the samples on chocolate agar, blood agar, MacConkey agar, and fluid thioglycollate medium. After 24-48 h of incubation at 37 0C, the growth of different colonies of bacteria was identified using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (Bruker MALDI Biotyper). RESULTS: The mean age of the study group was 41.6 ± 19.1 years (18-65); the mean age of the control group was 40 ± 6 (21-62) (p = 0.69). There were 10 male patients and 16 female patients in the study group and 9 male patients and 16 female patients in the control group (p = 0.86). The mean duration of SL use was 13.7 ± 13.4 months (1-42 months). No bacterial growth was observed in 17 (65.4 %) of the 26 eyes in the SL group and 5 (20 %) of the 25 eyes in the control group (p = 0.001). The most commonly observed microorganisms were Staphylococcus epidermidis (S.epidermidis) and Staphylococcus aureus (S.aureus) in both groups. CONCLUSION: SL users were found to have a higher rate of culture negativity in comparison to the healthy controls, suggesting that SLs have a significant effect on conjunctival microbiota.

A 2-year randomized blinded controlled trial of a conditionally licensed Moraxella bovoculi vaccine to aid in prevention of infectious bovine keratoconjunctivitis in Angus beef calves.

BACKGROUND: Infectious bovine keratoconjunctivitis (IBK) in beef cattle has major welfare and production implications. Effective vaccination against IBK would also reduce antibiotic use in beef production. OBJECTIVE/HYPOTHESIS: To evaluate the efficacy of a conditionally licensed commercial IBK vaccine containing Moraxella bovoculi bacterin. Primary working hypothesis was that animals vaccinated with 2 doses of the commercial M. bovoculi vaccine would have a lower risk of disease. ANIMALS: Spring born calves at a university cow-calf herd. After excluding animals with ocular lesions, calves eligible for prevention assessment in 2017 and 2018 were 163 (81 vaccinated, 82 unvaccinated) and 207 (105 vaccinated, 102 unvaccinated). One hundred sixty two and two hundred and six calves completed the follow-up period in 2017 and 2018, respectively. METHODS: A randomized controlled trial. The trial design was a 2-arm parallel trial with a 1:1 allocation ratio. RESULTS: In both years, calves receiving the vaccine had more IBK. This effect was small. The pooled risk ratio was 1.30 (95% confidence interval 0.84-2.01). The pooled unadjusted difference in mean weight (kg) at weaning was -0.88 (95% confidence interval-7.2-5.43). CONCLUSIONS AND CLINICAL IMPORTANCE: We were unable to document that the M. bovoculi bacterin vaccine had a protective effect for the incidence of IBK in our single herd in a 2-year study.

Anterior Segment Optical Coherence Tomography Images in Microsporidial Keratoconjunctivitis.

PURPOSE: To describe the findings of anterior segment optical coherence tomography (AS-OCT) in patients with microsporidial keratoconjunctivitis. METHODS: The observational study included 13 eyes from 13 patients. Slit-lamp photography and AS-OCT were performed using the Swept source OCT before corneal scraping. All cases were positive for Gram-chromotrope (modified trichrome) staining for Microsporidia spp. RESULTS: Three significant AS-OCT findings were observed. First, hyperreflective dots were limited to the epithelial layers of the cornea, and second, there were no extensions into the stromal layer in all cases. Last, hyperreflective dots slightly raised above the epithelial surface were observed in most cases (12/13%, 92.3%). CONCLUSIONS: AS-OCT represents an alternative, noninvasive tool to diagnose microsporidial keratoconjunctivitis, especially if corneal scraping is not possible.

Detection of Chlamydiaceae in ocular swabs from Australian pre-export feedlot sheep.

Infectious Ovine Keratoconjunctivitis (IOK) is a contagious ocular disease of sheep. A range of organisms have been observed as the aetiological agents of IOK. In this study, the presence of chlamydial pathogens (C. pecorum, C. abortus, C. psittaci) in conjunctival swabs was tested for. The swabs were collected from sheep with varying grades of IOK in an Australian pre-export feedlot. The sheep had been rejected from a shipment because of the eye disease. The relative contribution of chlamydial pathogens to IOK and the rejection of animals was evaluated. In total, 149 conjunctival swabs were taken from rejected sheep (IOK Grades 1 to 6; n = 126) as well as those with healthy eyes (Grade 0; n = 23). Screening for chlamydial pathogens was done using species-specific qPCR assays. Chlamydial DNA was detected in 35.6% (53/149) of conjunctival samples. C. pecorum was the most predominant species with an overall prevalence of 28.9% (43/149). C. psittaci prevalence was 6.7% (10/149). Both organisms were detected in healthy as well as IOK-affected eyes. All swabs tested negative for C. abortus. The results from this study demonstrate that Chlamydia spp can be readily detected in sheep presenting with IOK. The zoonotic C. abortus was not detected in any of the samples in this study, providing further evidence to the suggestion that this pathogen remains absent from Australia. Although the exact contribution of Chlamydia spp in the IOK pathogenesis is unclear, such studies are anticipated to be of benefit to Australian domestic and live export production systems.

Acremonium and trichosporon fungal keratoconjunctivitis in a Leopard Gecko (Eublepharis macularius).

A 6-year-old male leopard gecko (Eublepharis macularius) was presented with a 2-year history of recurrent dysecdysis involving the ocular surface of both eyes. Ophthalmic examination revealed ocular surface desiccation and multifocal superficial ulcerative keratitis with patchy remnants of retained shed. Other abnormalities included stomatitis and mandibular and maxillary osteomyelitis. Topical and systemic antibiotic therapy, oral vitamin A, and improved husbandry conditions resolved the stomatitis and osteomyelitis but did not improve the ocular surface. Corneal cytology collected with a cytobrush revealed branching hyphae and budding yeast consistent with fungal keratitis. Fungal culture grew Acremonium sp. and Trichosporon sp. The addition of topical antifungal therapy improved the ocular surface health, but the patient was euthanized 7 weeks after initial presentation for persistent vomiting and dyspnea. Necropsy was declined. This case describes the first case of fungal keratitis caused by Acremonium sp. and Trichosporon sp. in a reptile.

Chlamydia trachomatis presenting as preseptal cellulitis in a 3-year-old girl.

Inclusion conjunctivitis usually presents with lid swelling, red eye, foreign body sensation, and a mucopurulent discharge in association with a follicular reaction involving the palpebral and bulbar conjunctiva and semilunar fold. Similar to epidemic keratoconjunctivitis, it may present with preauricular lymphadenopathy, superficial punctate keratitis, and subepithelial corneal infiltrates, which tend to be more peripheral. We present the case of preseptal cellulitis in a 3-year-old child, caused by nonconsensual sexual contact with chlamydia trachomatis.

A multiplex real-time PCR assay for the detection and differentiation of five bovine pinkeye pathogens.

Infectious bovine keratoconjunctivitis (IBK), also known as pinkeye, is one of the most common eye diseases in cattle. Several pathogens have been associated with IBK cases, however, Moraxella bovis, Moraxella bovoculi, Mycoplasma bovis, Mycoplasma bovoculi and bovine herpesvirus type 1 (BHV-1) are most frequently observed. A multiplex real-time PCR assay using two reactions was developed for the detection and differentiation of these five pathogens. Detection sensitivities of the multiplex assays were compared to singleplex reactions testing for the same targets. Correlation coefficients (R2) of >0.99, and PCR efficiencies between 92 and 106% were demonstrated in all singleplex and multiplex real-time PCR reactions. The limits of detection (LOD) of multiplex assays for Moraxella bovis, Moraxella bovoculi, Mycoplasma bovis, Mycoplasma bovoculi and BHV-1 were 19, 23, 25, 24 and 26 copies per reaction, respectively. No cross amplification was observed for specificity testing of 179 IBK positive clinical samples and 55 non-target clinical samples. Percentage of clinical samples positive for Mycoplasma bovoculi, Moraxella bovoculi, Moraxella bovis, BHV-1 and Mycoplasma bovis were 88.8% (159/179), 75.9% (136/179), 60.3% (108/179), 11.7% (21/179) and 10.0% (18/179), respectively. Moraxella bovis, Moraxella bovoculi and Mycoplasma bovoculi were more prevalent than Mycoplasma bovis and BHV-1 in IBK samples collected from animals in this study population. Our data indicates that the multiplex real-time PCR panel assay is highly sensitive and highly specific for the detection and differentiation of the five major pathogens associated with bovine pinkeye.

Ocular Whipple Disease: Report of Three Cases.

Purpose: To emphasize the different manifestations of ocular involvement in Whipple disease with challenge in establishing the diagnosis as clinical, laboratory, and histological features could mimic other uveitis entities. Methods: Case reports of three patients. Results: The first patient was an African male suffering from a chronic bilateral keratoconjunctitivitis that was initially misdiagnosed as a chronic allergic conjunctivitis. The second patient was an Italian female who presented with bilateral vitritis, whereas the third patient was an Italian male suffering from a chronic bilateral panuveitis. The diagnosis of ocular Whipple in the first and third case was made by a positive T. whipplei PCR from the ocular specimen, and the second patient had detection of T. whipplei from extraocular sites. Conclusions: Whipple disease can have protean manifestations in the eye including an isolated ocular surface involvement manifested as keratitis.

Outbreak of Microsporidial Keratoconjunctivitis Associated With Water Contamination in Swimming Pools in Taiwan.

PURPOSE: To report an outbreak of microsporidial keratoconjunctivitis resulting from a swimming pool in Taiwan. DESIGN: Retrospective case series. METHODS: The records of 13 teenagers (15 eyes) contracting microsporidial keratoconjunctivitis after swimming in a local swimming pool were reviewed. Corneal scrapings were collected in all eyes at a tertiary referred hospital in June 2017. Gram stain, modified Kinyoun acid-fast stain, polymerase chain reaction (PCR), and gene analysis of the microsporidian 16S ribosomal RNA (rRNA) were examined in all 15 cases. RESULTS: Symptoms occurred 1-12 days after the water contact. At presentation, all eyes showed nonpurulent conjunctivitis and small, plaque-like epithelial lesions peripherally (n = 6), centrally (n = 3), both peripherally and centrally (n = 5), or centrally with superficial punctate keratopathy (n = 1). During the follow-up period, 10 eyes developed central superficial punctate keratopathy (n = 6) or subepithelial haze or infiltrates, which were distributed centrally (n = 2) or peripherally (n = 3), following development of plaque-like epithelial lesions. The results of Gram stain and modified Kinyoun's acid-fast stain were confirmatory in 10 cases (67%). All 15 cases yielded positive PCR results and were all identified to be Vittaforma corneae. All followed-up eyes healed without sequelae using topical levofloxacin and betamethasone eye drops. CONCLUSIONS: Microsporidial keratoconjunctivitis can develop from contact with swimming pool water. The clinical course initially manifested as rapidly resolving conjunctivitis and peripheral plaque-like epithelial lesions, followed by paracentral or central plaque-like epithelial lesions, which evolved into subepithelial haze or infiltrates.