Corneal Allograft Rejection Associated With Herpes Zoster Recombinant Adjuvanted Vaccine.

PURPOSE: The purpose of this article is to report 3 cases of corneal allograft rejection that occurred in temporal proximity to administration of the zoster subunit vaccine (RZV). METHODS: Three cases of corneal transplant rejection that developed after RZV administration were identified. Clinical history, including existence of other risk factors, timing of rejection, corticosteroid therapy at the time of onset of rejection, and course were reviewed. RESULTS: The onset of symptoms occurred 5 weeks after the first RZV dose in 1 patient and 1 and 6 weeks after the second dose in the other 2 patients. Coexisting risk factors included history of endothelial keratoplasty in the fellow eye in 1 patient and previous failure of a penetrating keratoplasty because of rejection in a second patient. The third patient had a history of 1 episode of rejection in a previous graft that resolved and then experienced graft failure over several years. In 2 patients, rejection developed despite relatively high levels of topical steroid therapy: prednisolone acetate 1%, 4 × per day in 1 patient and difluprednate 0.05%, 3 × per day in a second patient. CONCLUSIONS: RZV, which elicits a more robust immune reaction than the zoster live-attenuated vaccine, ZVL, may increase the risk of allograft rejection in immunocompetent patients with preexisting corneal endothelial or penetrating transplants. Based on the available data, it may be reasonable to increase the topical corticosteroid regimen before the first dose, until approximately 3 months after the second dose of ZVL.

Microsporidial Stromal Keratitis: Epidemiological Features, Slit-Lamp Biomicroscopic Characteristics, and Therapy.

PURPOSE: Microsporidial stromal keratitis is a rare form of infectious keratitis, with only 7 cases reported in the United States to date. This study was performed to evaluate risk factors, clinical features, and response to therapy. METHODS: A retrospective review of the medical records of all patients diagnosed with microsporidial stromal keratitis seen in the practices of the authors between 1999 and 2020 was performed. Diagnosis was determined by cytology or histopathology in corneal specimens. Risk factors, presence or absence of distinctive clinical features, and response to medical and surgical therapies were recorded. RESULTS: Nine patients-7M:2F, aged 7 to 99 years-with microsporidial stromal keratitis were identified. Exposures to recreational water and hymenopteran insect bites, both epidemiologically linked risk factors for systemic microsporidial infection, were identified in our patients. Presence of stromal edema with features of disciform keratitis and a distinctive granular keratitis were observed in 6 of 9 and 5 of 9 patients, respectively. Poor response to medical therapy was noted. Penetrating keratoplasty was effective in curing the infection. Final visual acuity was 20/40 or better in 6 of 9 patients. CONCLUSIONS: In patients with slowly progressive keratitis, history of exposure to recreational water or hymenopteran insects should be sought. In patients with corneal edema consistent with disciform keratitis, with evolution to a granular keratitis, microsporidia should be considered in the differential diagnosis. In cases of established microsporidial stromal keratitis, penetrating keratoplasty should be considered if prompt response to medical therapy is not noted.

Polyquaternium-1-Associated Dendritiform Keratopathy.

PURPOSE: To report a case of polyquaternium-1 (Polyquad, PQ-1)-associated dendritiform keratopathy that developed after exposure to the tear substitute Systane (Alcon Laboratories, Inc, Fort Worth, TX). METHODS: A retrospective review of the case was performed. RESULTS: Dendritiform keratopathy developed in the patient after an increase in the use of topical Systane from 4 times per day to every hour. Keratopathy resolved with discontinuation of Systane. CONCLUSIONS: Polyquaternium-1-associated dendritiform keratopathy can occur in patients who have previously tolerated the preservative. Because keratopathy seems to have developed and improved because of dose-dependent factors, the mechanism is more likely toxicity than hypersensitivity.

Clinically Significant Enhancement of Voriconazole Efficacy by Moxifloxacin and Gentamicin in Fungal Keratitis.

PURPOSE: To report the effect of topical antibiotics moxifloxacin 0.3% and gentamicin 0.3% on the clinical efficacy of topical antifungal agent voriconazole 1% in cases of culture- or biopsy-proven fungal keratitis. METHODS: Two cases of fungal keratitis in which the addition of topical moxifloxacin or moxifloxacin and gentamicin led to an improved clinical response to topical voriconazole were reviewed retrospectively. RESULTS: One patient with clinical resistance of his fungal keratitis to both topical voriconazole and natamycin had resolution of his keratitis with the addition of topical moxifloxacin and gentamicin to voriconazole. One patient who had a poor response to topical voriconazole had a dramatic response to the increase of the voriconazole regimen and addition of moxifloxacin. CONCLUSIONS: In a subset of patients with fungal keratitis, the addition of topical moxifloxacin 0.3% or moxifloxacin 0.3% and gentamicin 0.3% may enhance the therapeutic effect of topical voriconazole 1%.

Cure Rate of Fungal Keratitis With Antibacterial Therapy.

PURPOSE: To study the cure rate of fungal keratitis with moxifloxacin 0.3% monotherapy. METHODS: A retrospective review of patients with culture-proven fungal keratitis who initially received moxifloxacin 0.3% monotherapy was performed. RESULTS: Eleven patients with culture-proven fungal keratitis were initially treated with moxifloxacin. One case each of Curvularia and Alternaria keratitis resolved with moxifloxacin monotherapy (18%). CONCLUSIONS: Moxifloxacin may have a significant clinical therapeutic effect in a subset of patients with fungal keratitis. Review of the literature in combination with the current study suggests that in patients with clinical features suggestive of fungal keratitis, if rapid diagnostic tests are negative or not available, pending culture results, initial therapy should include a fluoroquinolone (moxifloxacin or gatifloxacin) and/or an aminoglycoside (tobramycin or gentamicin).

Dendritiform Keratopathy Associated with Exposure to Polyquarternium-1, a Common Ophthalmic Preservative.

PURPOSE: To describe dendritiform keratopathy associated with exposure to polyquaternium-1, a common preservative found in contact lens solutions and tear replacement products. DESIGN: Case series. PARTICIPANTS: Sixteen patients who demonstrated dendritiform keratopathy during topical ophthalmic exposure to polyquaternium-1. METHODS: Records were reviewed of all patients diagnosed with dendritiform keratopathy between 1999 and 2014 who had documented exposure to contact lens care disinfecting solutions or artificial tear solutions containing polyquaternium-1. Patients were excluded who had coexisting potential causes for dendritiform keratopathy, such as prior herpes simplex keratitis, varicella-zoster viral keratitis, the linear form of Thygeson's superficial keratitis, epithelial regeneration line, Acanthamoeba keratitis, mucus plaque keratopathy, medication-related keratopathy, or limbal stem cell deficiency characterized by conjunctivalization of the corneal epithelium. MAIN OUTCOME MEASURES: Effect of discontinuation of exposure to polyquaternium-1 on the dendritiform keratopathy. RESULTS: Sixteen patients demonstrated dendritiform keratopathy after exposure to the preservative polyquaternium-1. Thirteen patients had a history of recent exposure to contact lens disinfecting solutions (Opti-Free, Equate) containing polyquaternium-1. Three patients used a tear replacement product (Systane) containing a polyquaternium-1 preservative. Four patients were treated with antiviral medications for presumed herpes simplex keratitis; 4 patients underwent diagnostic testing for Acanthamoeba keratitis. Two additional patients were diagnosed sequentially with herpes simplex keratitis, then Acanthamoeba keratitis before referral. All dendritiform lesions resolved within 2 to 6 weeks after elimination of exposure to polyquaternium-1. CONCLUSIONS: Ophthalmic products containing polyquaternium-1 may cause dendritiform keratopathy that may be confused with infections of the superficial cornea, such as herpes simplex virus keratitis or Acanthamoeba keratitis.

Chronic Conjunctivitis due to Nocardia nova Complex Formation on a Silicone Stent: A Case Report and Review of the Literature.

Nocardial conjunctivitis associated with silicone tubing is an extremely rare finding. The authors present a case of a 52-year-old woman with previous dacryocystorhinostomy and silicone tube placement 3 years prior who presented with OD redness and discharge for 1 week. On examination, the patient was noted to have mucoid discharge and crusting surrounding the silicone tube. The tube debris was sampled, and the culture was positive for Nocardia nova complex sensitive to trimethoprim/sulfamethoxazole and amikacin. Silicone tube colonization and N. nova complex conjunctivitis are both rare but should be considered in the differential diagnosis of patients with indwelling silicone tubes presenting with chronic conjunctivitis resistant to fluoroquinolones and tobramycin.

Fungal keratitis responsive to moxifloxacin monotherapy.

PURPOSE: To report 5 cases of culture-proven fungal keratitis that resolved with moxifloxacin monotherapy. METHODS: Case reports and review of medical literature. Five patients with fungal keratitis were treated with topical moxifloxacin. RESULTS: All 5 patients had resolution of their infection with topical moxifloxacin monotherapy. CONCLUSIONS: Topical fluoroquinolone agents may have significant antifungal properties. However, the vast majority of fungal keratitis patients cannot be cured with fluoroquinolone monotherapy. An initial response of keratitis to topical fluoroquinolone therapy should not lead to the assumption that the infection is bacterial because the possibility of fungal infection cannot be ruled out on that basis.

Management and outcome of microbial anterior scleritis.

PURPOSE: To evaluate the prevalence, predisposing factors, and outcomes of bacterial and fungal scleritis. METHODS: We reviewed the clinical findings, therapeutic interventions, and visual outcomes of patients with suppurative scleral inflammation without preceding microbial keratitis who had microorganisms isolated from scleral scrapings. DESIGN: Retrospective interventional case series. RESULTS: Of 349 patients with scleritis diagnosed from 1999 to 2009, 6 adults (1.7%) presented with suppurative inflammation of the anterior sclera due to Pseudomonas aeruginosa (2), Streptococcus pneumoniae (2), Staphylococcus aureus (1), and Scedosporium apiospermum/Pseudallescheria boydii (1). Each had ocular surgery of the affected eye before presentation. Intraocular extension occurred in 2 eyes. After local and systemic antimicrobial therapy, all improved without evisceration or enucleation, and 4 attained vision of 20/60 or better. CONCLUSIONS: Bacterial or fungal scleritis is an uncommon ocular infection that can belatedly follow anterior segment procedures. Antimicrobial therapy and surgical intervention can successfully control progressive suppuration and reduce vision-limiting complications.

Clinical and microbiological characteristics of fungal keratitis in the United States, 2001-2007: a multicenter study.

OBJECTIVE: To study the epidemiology, clinical observations, and microbiologic characteristics of fungal keratitis at tertiary eye care centers in the United States. DESIGN: Retrospective multicenter case series. PARTICIPANTS: Fungal keratitis cases presenting to participating tertiary eye care centers. METHODS: Charts were reviewed for all fungal keratitis cases confirmed by culture, histology, or confocal microscopy between January 1, 2001, and December 31, 2007, at 11 tertiary clinical sites in the United States. MAIN OUTCOME MEASURES: Frequency of potential predisposing factors and associations between these factors and fungal species. RESULTS: A total of 733 cases of fungal keratitis were identified. Most cases were confirmed by culture from corneal scraping (n = 693) or biopsies (n = 19); 16 cases were diagnosed by microscopic examination of corneal scraping alone; and 5 cases were diagnosed by confocal microscopy alone. Some 268 of 733 cases (37%) were associated with refractive contact lens wear, 180 of 733 cases (25%) were associated with ocular trauma, and 209 of 733 cases (29%) were associated with ocular surface disease. No predisposing factor was identified in 76 cases (10%). Filamentous fungi were identified in 141 of 180 ocular trauma cases (78%) and in 231 of 268 refractive contact lens-associated cases (86%). Yeast was the causative organism in 111 of 209 cases (53%) associated with ocular surface disease. Yeast accounted for few cases of fungal keratitis associated with refractive contact-lens wear (20 cases), therapeutic contact-lens wear (11 cases), or ocular trauma (21 cases). Surgical intervention was undertaken in 26% of cases and was most frequently performed for fungal keratitis associated with ocular surface disease (44%). Surgical intervention was more likely in cases associated with filamentous fungi (P = 0.03). Among contact lens wearers, delay in diagnosis of 2 or more weeks increased the likelihood of surgery (age-adjusted odds ratio = 2.2; 95% confidence interval, 1.2-4.2). CONCLUSIONS: Trauma, contact lens wear, and ocular surface disease predispose patients to developing fungal keratitis. Filamentous fungi are most frequently the causative organism for fungal keratitis associated with trauma or contact lens wear, whereas yeast is most frequently the causative organism in patients with ocular surface disease. Delay in diagnosis increases the likelihood of surgical intervention for contact lens-associated fungal keratitis.

Atypical corneal immunoglobulin deposition in a patient with dysproteinemia.

PURPOSE: The purpose of this study was to report an unusual pattern of immunoglobulin deposition in the corneas of a patient with dysproteinemia. METHODS: Clinical examination, slit lamp examination, a deep lamellar corneal biopsy, and serum and aqueous protein electrophoresis were obtained. RESULTS: Slit lamp evaluation revealed amorphous, cloud-like opacities in the midperiphery at the level of deep stroma and Descemet's membrane. Electron microscopy demonstrated deep lamellar extracellular deposits consistent with immunoglobin. The serum protein electrophoresis revealed a monoclonal IgG kappa band, but the aqueous electrophoresis showed no bands in the gamma region. CONCLUSION: This case documents a rare pattern of immunoglobulin deposition in the corneas in a patient with gammopathy. Despite its deep corneal distribution, the analysis of the aqueous specimen suggests that the source of the immunoglobulin is through a route other than from the aqueous.

Pathogenesis and outcome of Paecilomyces keratitis.

PURPOSE: To examine the clinical pathology and management of Paecilomyces lilacinus keratitis. DESIGN: Observational case series, literature review, and laboratory study. METHODS: Characteristics and outcome of 17 patients with laboratory-confirmed Paecilomyces keratitis treated at 2 referral centers were combined with 25 previously reported cases. Experimental models were developed by topically inoculating a human corneal isolate of P. lilacinus onto murine eyes and onto human donor corneas. RESULTS: Of 42 reported eyes with Paecilomyces keratitis, 13 (31%) were associated with chronic keratopathy or previous ocular surgery, 11 (26%) followed corneal trauma, and 10 (24%) occurred in soft contact lens wearers. Medical cure occurred in 13 (31%), including 9 of 31 eyes (29%) treated with natamycin or amphotericin B. Penetrating keratoplasty or other surgery was performed in 29 (69%). In vitro testing of P. lilacinus indicated resistance to natamycin and amphotericin B but susceptibility to ketoconazole and voriconazole. Experimental inoculation after superficial scarification established moderately severe corneal paecilomycosis by hyphae and conidia in immunosuppressed mice and in explanted donor corneas. CONCLUSIONS: P. lilacinus is an emerging fungal pathogen that infects corneal tissue by filamentous invasion with occasional intrastromal sporulation. P. lilacinus keratitis does not reliably respond to natamycin or amphotericin B and has often required therapeutic keratoplasty, but topical azole antifungal agents such as voriconazole appear promising.

Rapidly progressive cataract and iris atrophy during treatment of Acanthamoeba keratitis.

PURPOSE: To identify characteristics associated with cataract occurring during the course of Acanthamoeba keratitis. DESIGN: Retrospective observational case series. PARTICIPANTS: Eighty-one laboratory-confirmed patients with Acanthamoeba keratitis. METHODS: Review of clinical records. MAIN OUTCOME MEASURES: Development of cataract during management of Acanthamoeba keratitis. RESULTS: Rapidly progressive crystalline lens opacification occurred in 9 eyes within 4 to 15 weeks after diagnosis of Acanthamoeba keratitis. Three were associated with inflammatory complications, including anterior scleritis (2 eyes) and iridocyclitis (1 eye). Six others had the abrupt onset of a dense cataract, including 5 with iris atrophy, that occurred during the initial 6 months of therapy with chlorhexidine, a diamidine, and adjunctive corticosteroid. Extracapsular cataract extraction was performed with or after penetrating keratoplasty. Secondary glaucoma developed in 6 of 9 eyes subsequent to iris atrophy (4 eyes) or a cyclitic membrane (2 eyes), and 3 eyes underwent trabeculectomy. CONCLUSIONS: Cataract may occur and progress during the management of Acanthamoeba keratitis in association with anterior segment inflammation, iris atrophy, and secondary glaucoma.

Bilateral acanthamoeba keratitis.

PURPOSE: To determine the prevalence and characteristics of binocular involvement among patients with Acanthamoeba keratitis. DESIGN: Retrospective case series. METHODS: Risk factors and outcomes of bilateral infection were explored among consecutive cases of Acanthamoeba keratitis diagnosed at a single institution from 1997 through mid 2007. RESULTS: Fifty eyes were confirmed to have Acanthamoeba keratitis by microbiologic or histopathologic testing; two-thirds occurred during a regional outbreak beginning in 2004. Five (11%) of 45 patients had infection of both eyes, including three with concurrent involvement and two with successive disease of the contralateral cornea. Three binocularly infected patients used soft contact lenses, and two wore rigid gas-permeable lenses. Nine of 10 eyes achieved visual acuity of 20/30 or better after antiamebic therapy. CONCLUSIONS: Bilateral Acanthamoeba keratitis is an infectious complication of contact lens wear. With laboratory confirmation, vision often can be restored with medical therapy.

Successful nonsurgical management of corneal perforation in a patient with autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy.

PURPOSE: To describe a patient with a history of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) who has experienced two episodes of noninfectious corneal ulceration with perforation that has been successfully managed with nonsurgical therapy. METHODS: Case report. RESULTS: An 18-year-old male with a history of APECED has been followed up with recurrent keratoconjunctivitis and episodes of microbial keratitis since 4 years of age. Ophthalmic complications have included two episodes of sterile corneal ulceration associated with corneal perforation. These episodes of stromal ulceration associated with a flat anterior chamber were managed with a bandage contact lens, topical antibiotics, and a topical cycloplegic agent. In one instance, addition of cyclosporine led to reformation of the anterior chamber and arrest of the ulcerative process. CONCLUSION: Sterile corneal ulceration and perforation associated with APECED may be managed medically to avoid surgical intervention, which has been reported to lead to a poor outcome.

IgG-kappa immunoglobulin deposits involving the predescemetic region in a patient with multiple myeloma.

PURPOSE: To report the clinico-pathologic features of corneal deposits in a patient with multiple myeloma with surgical intervention and follow-up. DESIGN: Interventional case report. METHODS: We reviewed the patient's chart and the relevant literature on immunoglobulin corneal deposits and its prognosis. RESULTS: A 52-year-old man with a history of multiple myeloma underwent penetrating keratoplasty sequentially for decreased vision in both eyes secondary to abnormal corneal deposits. Pathologic examination of the keratectomy specimens, including immunohistochemistry and transmission electron microscopy, revealed IgG-kappa immunoglobulin deposits in the predescemetic region in both corneas. After keratoplasty, he regained excellent vision in both eyes, which was maintained at the end of 18 months of follow-up in both eyes despite early signs of recurrence in the right eye. His systemic condition was well controlled during the period of follow-up. CONCLUSION: Corneal deposits in multiple myeloma are well described in the literature, but there are few reports regarding the prognosis and visual function after penetrating keratoplasty. Our report shows that when the systemic condition is well controlled, penetrating keratoplasty has an excellent prognosis in these patients.