The Ocular Microbiome Is Altered by Sampling Modality and Age.

Background: Studies of the ocular microbiome have used a variety of sampling techniques, but no study has directly compared different sampling methods applied to the same eyes to one another or to a reference standard of corneal epithelial biopsy. We addressed this lack by comparing the microbiome from three conjunctival swabs with those of corneal epithelial biopsy. Methods: Twelve eyes (11 patients) were swabbed by calcium alginate swab, cotton-tipped applicator, and Weck-Cel cellulose sponge before a corneal epithelial biopsy (48 samples). We then performed 16S rRNA gene sequencing and universal 16S rRNA gene real-time polymerase chain reaction. Negative/blank controls were used to eliminate contaminants. An analysis was performed to examine the concordance of the three swab types to corneal epithelial biopsy. The effect of patient age on the ocular microbiome as determined by epithelial biopsy was also examined. Results: The ocular microbiome from corneal epithelial biopsies consisted of 31 genera with a relative abundance of 1% or more, including Weisella, Corynebacterium, and Pseudomonas. Of the three swab types, Weck-Cel differed the most from corneal biopsies based on beta-diversity analysis. Cotton swabs were unable to capture the Bacteroides population seen on epithelial biopsy. Therefore, calcium alginate swabs seemed to be the closest to epithelial biopsies. Older patients (≥65 years old) had higher alpha diversity (P < 0.05) than younger patients. Differential abundance testing showed that there were 18 genera that were differentially abundant between the two age groups, including Streptococcus and eight members of the Proteobacteria phylum. Conclusions: We demonstrate that ocular sampling method and patient age can greatly affect the outcome of sequencing-based analysis of the ocular microbiome. Translational Relevance: By understanding the impact of different sampling methods on the results obtained from the ocular surface microbiome, future research on the topic will be more reproducible, leading to a better understanding of ocular surface microbiome in health and disease.

Role of in vivo confocal microscopy in the diagnosis of infectious keratitis.

PURPOSE: To investigate the utility of in vivo confocal microscopy (IVCM) in the diagnosis of infectious keratitis (IK). METHODS: Retrospective chart review of 46 patients with a final diagnosis of IK were included in the study. All patients received IVCM corneal imaging using the Heidelberg Retinal Tomography III system. All available scans were randomized and analyzed in a masked fashion. Sensitivity and specificity of IVCM in diagnosing bacterial keratitis (BK), Acanthamoeba keratitis (AK), fungal keratitis (FK), and HSV viral keratitis (VK) were assessed. RESULTS: The pooled sensitivity and specificity of IVCM in identifying atypical IK (AK and FK cases combined) were 85.3% (95% CI 68.2-94.5%) and 100% (95% CI 74.7-100%), respectively. The sensitivity and specificity of IVCM in identifying BK were 66.7% (95% CI 35.4-88.7%) and 89.2% (95% CI 73.4-96.5%), respectively. The sensitivity and specificity of IVCM in identifying VK were 100% (95% CI 46.3-100%) and 93.2% (95% CI 80.3-98.2%). Additionally, IVCM was able to make the correct diagnosis in 8 out of the 11 atypical keratitis cases misdiagnosed clinically. In the AK subgroup, IVCM was more accurate than clinical assessment (16 vs. 11). In the FK subgroup, IVCM were as accurate as clinical assessment, but did correct one misdiagnosed cases by identfying fungal hyphae. CONCLUSION: IVCM is an non-invasive imaging modality that can rapidly and accurately diagnose IK even for experienced corneal specialists. In complex cases of polymicrobial infection, IVCM may guide the correct clinical diagnosis and initiation of the appropriate treatment.

Correlation between Guttata Severity and Thickness of Descemet's Membrane and the Central Cornea.

Purpose: To characterize and correlate guttata severity, Descemet's membrane thickness (DMT), central cornea thickness (CCT) in corneas with guttae using specular microscopy and spectral-domain optical coherence tomography (SD-OCT) and test the Doheny Image Reading Center (DIRC) specular microscopy-based corneal guttata severity scale. Methods: Forty-nine eyes of 49 patients with guttata and 36 eyes of age-matched of 36 normal controls were enrolled in the study. Three images of the central cornea and four of the peripheral cornea (inferior, superior, nasal and temporal) of each eye were taken using the Konan NSP-9900 specular microscope. A volume scan of the central cornea cross-section was collected on each eye using the Heidelberg Spectralis SD-OCT. The density of endothelial guttata based on specular images was graded on a 0-4 scale, and the Descemet's membrane thickness (DMT) and central corneal thickness (CCT) were manually measured by two trained graders. Results: The DIRC corneal guttata severity scale showed good reproducibility of all corneal endothelial images (weighted Kappa = 0.87). Mean DMT was 16.1 ± 2.4 µm in controls and 25.5 ± 10.9 µm in corneas with guttata (P < 0.001). Mean CCT was 552 ± 26 µm in controls and 603 ± 55 µm in corneas with guttata (P < 0.001). Guttata severity was significantly correlated with both DMT (r = 0.743, P < 0.001) and CCT (r = 0.569, P < 0.001). Age was moderately correlated with DMT (r = 0.472, P = 0.003) and mildly correlated with guttata severity (r = 0.285, P = 0.031), but was not correlated with CCT (r = 0.058, P = 0.681). Guttatta grade 3 corneas displayed an increase in DMT and guttata grade 4 was associated with a significant increase in CCT. Conclusions: The DMT and CCT are increased in corneas with guttata. The higher density of guttae is correlated with increased thickness. Specular microscopy combined with SD-OCT can be used as a good approach to assess the severity of FECD.

Reduction of Acanthamoeba Cyst Density Associated With Treatment Detected by In Vivo Confocal Microscopy in Acanthamoeba Keratitis.

PURPOSE: Acanthamoeba keratitis (AK) is a severe vision-threatening ocular infection that is frequently a diagnostic challenge. Treatment course is lengthy and often not fully effective. Contact lens wear has been recognized as the prime risk factor for AK. In vivo confocal microscopy (IVCM) is a noninvasive imaging modality that allows direct visualization of potential causative pathogens in real time with an established utility in the diagnosis of AK. In this study, we aim to assess the utility of IVCM in monitoring disease progression in contact lens wearers with culture-confirmed keratitis. METHODS: Fourteen eyes from 11 patients with culture-confirmed AK were included in this retrospective study. IVCM was performed during the patient's initial visit and all follow-up visits. All available confocal sequences were reviewed and graded in a masked fashion. Density of Acanthamoeba cyst infiltration and changes in the cyst density as a percentage of baseline cyst density measured at each patient's initial visit were calculated. A univariate regression analysis was performed to assess the association between treatment and changes in cyst density per month of treatment. RESULTS: Acanthamoeba cysts were identified by IVCM in all of these culture-confirmed cases of keratitis. Mean cyst density in the central cornea at presentation was 99 ± 64.9 cells per square millimeter (range, 38-255/mm). Cyst density in our study population significantly decreased by approximately 5.3% with each month of antiamebic treatment (P = 0.001; R = 0.41). CONCLUSIONS: Reduction in Acanthamoeba cyst density with treatment can be monitored by IVCM, which in turn can be used clinically in prognostication and disease monitoring of AK.

Laboratory Results, Epidemiologic Features, and Outcome Analyses of Microbial Keratitis: A 15-Year Review From St. Louis.

PURPOSE: To evaluate the laboratory results and prognostic factors of poor clinical outcomes in microbial keratitis cases over 15 years at Saint Louis University. DESIGN: Retrospective cohort and trend study. METHODS: Microbiological and clinical information from culture-positive cases seen at Saint Louis University from 1999 to 2013 were reviewed retrospectively. Statistical analyses were used to determine microbiological and antibiotic susceptibility trends. Prognostic factors of poor clinical outcome from the literature were used to create multivariate regression models to describe our cohort. RESULTS: Gram-positive organisms predominated (48%), followed by gram-negative organisms (34%) and fungi (16%). The most commonly isolated organism was Pseudomonas aeruginosa (21%). Oxacillin-resistant rates of Staphylococcus aureus and coagulase-negative staphylococci were 45% and 43%, respectively. Only the proportion of Pseudomonas changed significantly over time (P = .02). The only antibiotic found to lose efficacy over time was gentamicin for gram-positive organisms (P = .005). Multivariate logistic regression analyses revealed that major complications were associated with large ulcers (P < .006), fungal cases (P < .001), and comorbid ophthalmic conditions (P < .001). Poor healing was associated with large ulcers (P < .001) and fungal cases (P < .001). Lastly, poor visual outcome was associated with large ulcers (P < .01) and age ≥ 60 years (P < .02). CONCLUSIONS: In the St Louis area, oxacillin-resistant organisms, Pseudomonas aeruginosa, and fungi are commonly recovered from microbial keratitis cases with a disproportionally high incidence. Hence, empiric antibiotic choice should reflect these trends. Special care needs to be taken for patients with large ulcers and fungal infections, as well as elderly patients with comorbid ophthalmic conditions, as these patients have worse clinical outcomes.

Evaluation of Corneal Epithelial Thickness Imaged by High Definition Optical Coherence Tomography in Healthy Eyes.

PURPOSE: To evaluate corneal epithelial thickness (CET) and corneal thickness (CT) in healthy eyes using spectral domain optical coherence tomography. METHODS: Thirty-six healthy eyes were imaged using the Cirrus high-definition (HD)-optical coherence tomography device. The average CET and CT were assessed using Cirrus Review Software within predefined concentric corneal ring-shaped zones. Specific regions of CET (superior, inferior, temporal, nasal, superonasal, inferotemporal, superotemporal, and inferonasal) were also assessed. The difference between zones was compared between males and females. RESULTS: The average CET was 48.3, 47.1, 46.1, and 45.8 µm in the 4 concentric zones (0-2, 2-5, 5-7, and 7-9 mm), respectively (P < 0.001). The average CT was 533.5, 550.8, and 579.4 µm in the 3 zones (0-2, 2-5, and 5-7 mm), respectively (P < 0.001). There was no statistically significant correlation between CET and CT in any of the measured zones. Males had thicker corneas than did females in each of the 3 CT zones (P < 0.05), but CET did not differ significantly. The CET superonasal-inferotemporal in 2.0 to 5.0 mm and CET superotemporal-inferonasal in 5.0- to 7.0-mm zones were significantly thinner in males than in females (-1.15 vs. 0.9 µm, -3.5 vs. -1.9 µm), respectively (P < 0.05). CONCLUSIONS: Optical coherence tomography-based analysis of CET reveals that it is thinner in the periphery, whereas the total corneal thickness is greater. Although total CT seems to be influenced by sex, CET is not. Regional and sex-based variations in CT may need to be considered when assessing corneal and epithelial alterations in the setting of disease.

Reproducibility of Central Corneal Thickness Measurements in Normal Eyes Using the Zeiss Cirrus 5000 HD-OCT and Pentacam HR.

OBJECTIVES: To determine the repeatability and reproducibility of Central Corneal Thickness (CCT) measurements using two different anterior segment imaging modalities, including those obtained with the new anterior segment lens attachments for the Cirrus 5000 HD-OCT. METHODS: A total of 32 eyes from 16 normal volunteers (8 male, 8 female) were enrolled in this prospective study. CCT was measured by the same examiner using the Cirrus 5000 HD-OCT and Pentacam HR. The results of CCT obtained by each method were averaged and compared using t-test analysis. The agreement between the measurement methods was evaluated. Coefficient of Repeatability (CoR) and Intra-Class Correlation Coefficient (ICC) were computed. RESULTS: The mean measurements taken with the Cirrus OCT anterior chamber lens (CCTAC), HD cornea lens (CCTHDC) and pachymetry scans (CCTPach) were 545.35 ± 31.02, 537.87 ± 26.82, and 532.04 ± 29.82 µm, respectively. The mean CCT obtained with the Pentacam (CCTPent) was 545.51 ± 30.71 µm. CCTPent were significantly higher than CCTHDC and CCTPach (p< 0.0001). In contrast, the CCTPent and CCTAC were similar (p=0.87). CCT, as evaluated by the two different instruments, showed excellent correlation (r > 0.98, p< 0.0001) with an ICC > 0.99 (95% CI, 0.97 - 0.99). CoR was the highest for CCTPach (3.7 ± 1.4, 95% CI (3.0- 4.6)). CONCLUSION: CCT measurements from the Cirrus OCT using the new anterior segment lens attachments and the Pentacam HR are highly correlated. This should allow the use of a standardized correction factor if necessary to inter-relate the measurements between the two devices.

Quantitative Analysis of Depth, Distribution, and Density of Cysts in Acanthamoeba Keratitis Using Confocal Microscopy.

PURPOSE: To quantify the density, distribution, and depth of invasion of cysts in the corneas of eyes with acanthamoeba keratitis (AK) by in vivo confocal microscopy (IVCM) with a novel scanning pattern. METHODS: The medical records of patients with AK evaluated at the Doheny Eye Center UCLA between September 2014 and July 2016 were reviewed retrospectively. Patients with clinically diagnosed AK underwent IVCM at various time points during their clinical course. Five corneal locations were scanned at each time point: the central area and 4 standard points on the peripheral cornea corresponding to temporal, nasal, inferior, and superior locations. The IVCM scans were manually graded to quantify the maximum depth of invasion and density of cysts. RESULTS: Twenty-one eyes of 18 patients with visible cysts on IVCM were included. Mean cyst density at presentation was 214.1 ± 120.2/mm (range: 64-484 cells/mm), and the average cyst depth was 164.3 ± 81.2 µm (range: 17-290 µm). In 17 eyes, the average cyst depth was 139.4 ± 68.6 µm (range: 17-245 µm), mean cyst density was 177.9 ± 99.6/mm, and an average of 1.4 ± 1.3 quadrants was infiltrated at presentation, and reached clinical resolution with medical treatment without surgical intervention. Four eyes that ultimately underwent therapeutic penetrating keratoplasty had cysts in all 4 quadrants and deeper cyst infiltration; the average cyst depth in these corneas was 270.5 ± 17.5 µm (range: 252-290). CONCLUSIONS: Eyes with AK requiring therapeutic keratoplasty were more likely to have a deeper and more diffuse penetration of cysts in the cornea compared with those resolving with medical treatment.

Indications for Keratoplasty at 3 Academic Centers from 2002 to 2012.

OBJECTIVES: To determine whether indications for keratoplasty differ between academic centers and the Eye Bank Association of America (EBAA) annual statistics from 2002 to 2012. METHODS: A retrospective review was performed for the indications for keratoplasty from 2002 to 2012 based on surgical specimens originating from three different academic centers. Data were compared with statistical reports obtained from the EBAA for the corresponding years. RESULTS: From 2002 to 2007, at Washington University in St Louis (WU), the most common indication for keratoplasty was graft failure at 31.6%. At St Louis University, the most common indications for keratoplasty were pseudophakic and aphakic bullous keratopathy (PBK/ABK) at 34.6% followed closely by graft failure at 32.7%. Combining the 2002 to 2007 EBAA data, the most common indication for keratoplasty was PBK/ABK at 19.5%, whereas regrafts accounted for only 13.0% of keratoplasties. From 2008 to 2012, regrafts accounted for 41.9% of keratoplasties at WU and 33.1% of keratoplasties at University of California, Davis. In contrast, the EBAA data showed that only 11.4% of keratoplasties were regrafts. CONCLUSIONS: Graft failure accounted for approximately 30% to 40% of indications for keratoplasties at three academic centers from 2002 to 2012, which was more than double and in some cases triple that of the EBAA data during this period. These higher frequencies of regrafting may represent a referral bias of patients with complicated cases to academic centers who then require multiple keratoplasties.

Etiologies, Quantitative Hypoesthesia, and Clinical Outcomes of Neurotrophic Keratopathy.

OBJECTIVES: To report a series of patients with neurotrophic keratopathy and to correlate visual outcomes with the causative condition, grade of ulceration, and degree of cornea hypoesthesia. METHODS: A retrospective review of patients with neurotrophic keratopathy was conducted. The causality, visual acuities, ulcer grade, quantitative corneal sensitivity, treatments, and ocular comorbidities were recorded. RESULTS: Forty-six eyes were identified, and 20 experienced corneal sensation quantified by the Cochet-Bonnet aesthesiometer. Diabetes followed by herpes simplex and neurosurgical sequelae were the most common causes. Grade II ulcers were the most commonly seen ulcers. Twenty-eight percent of eyes failed conservative treatment and required surgical therapy. Overall, the initial (20/289) and final (20/158) acuities were poor, although the improvement was significant (P=0.05). However, there was no difference in visual recovery by disease (P=0.46). There was little correlation between ulcer grade and visual improvement (rs=0.24). Corneal sensation ranged from 0 to 3 cm generally for all causality of disease. There were little correlations between corneal hypoesthesia and ulcer grade (rs=-0.25), between corneal hypoesthesia and visual improvement (r=0.16), or between corneal hypoesthesia and final visual outcome (r=-0.36). A large percentage of eyes had significant ocular comorbidities. CONCLUSIONS: Visual outcomes for neurotrophic keratopathy can be poor because of both the cornea and the underlying disease. We did not find correlations regarding the causality of the disease, severity of ulceration, or degree of hypoesthesia with visual recovery or outcome. We hope future studies will shed further light on the disease to help better predict patient outcomes and thereby improve therapies.

Assessment of risk factors for oxacillin-resistant ocular flora in eyes having cataract surgery.

PURPOSE: To assess the risk factors for eyes of cataract surgery patients harboring oxacillin-resistant Staphylococcus species on the ocular surface. SETTING: Ambulatory surgical center, Saint Louis University, Saint Louis, Missouri, USA. DESIGN: Prospective in vitro laboratory study of a patient cohort. METHODS: Conjunctival cultures were obtained on the day of surgery from eyes scheduled for cataract surgery. Patients answered a questionnaire about risk factors that might lead to having oxacillin-resistant Staphylococcus organisms in their eyes. The factors tested were age, sex, race, recent systemic and topical antibiotic usage, recent hospitalization, and exposure to healthcare and institutional settings. Logistic regression analysis was performed. RESULTS: Of the 183 eyes cultured, 128 (70.0%) tested positive for Staphylococcus organisms, of which 70 (54.7%) were oxacillin-resistant. Only recent antibiotic usage was statistically significantly associated with the presence of oxacillin-resistant organisms (odds ratio, 8.2; 95% confidence interval, 2.2-30.5; P=.002). The other risk factors were not statistically significantly associated: age (P=.06), sex (P=.33), race (P=.34), recent hospitalization (P=.94), and exposure to healthcare and institutional settings (P=.10). CONCLUSIONS: Although the nonophthalmic literature has reported various risk factors for the harboring of oxacillin-resistant organisms, in the eyes in this study, only antibiotic usage within 30 days preoperatively was significantly associated with the colonization of oxacillin-resistant organisms on the ocular surface. This finding is important to ophthalmic surgeons when considering perioperative antibiotic prophylaxis. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Microbial keratitis in los angeles: the doheny eye institute and the los angeles county hospital experience.

OBJECTIVE: To evaluate the spectrum and antibiotic susceptibility panel of infectious keratitis at a major tertiary care referral eye center and a major county hospital in Southern California. DESIGN: Retrospective case series. PARTICIPANTS: All cultured infectious keratitis cases from July 1, 2008, through December 31, 2012, from the Doheny Eye Institute (DEI) and the Los Angeles County + University of Southern California Medical Center (LAC+USC) were evaluated. METHODS: Microbiology records were reviewed retrospectively. MAIN OUTCOME MEASURES: Microbial isolates as well as antibiotic susceptibility patterns were analyzed. RESULTS: One hundred eighty-four (63%) of 290 cases showed positive culture results at DEI and 152 (82%) of 186 cases showed positive culture results at LAC+USC. Gram-positive pathogens were found to be the most common at both DEI (70%) and LAC+USC (68%), with coagulase-negative Staphylococcus being the most common gram-positive organism (58% at DEI and 44% at LAC+USC). Pseudomonas aeruginosa was the most common gram-negative organism (57% at DEI and 43% at LAC+USC). Ciprofloxacin and levofloxacin susceptibility for all tested pathogens was 73% at DEI and 81% at LAC+USC (P = 0.16). Oxacillin-resistant Staphylococcus aureus (ORSA) was found in 42% of cases at DEI and in 45% of cases at LAC+USC (P = 1.00). CONCLUSIONS: There is no significant difference in the spectrum of pathogens or antibiotic susceptibility of pathogens at DEI versus LAC+USC, and ORSA was found in approximately half of all S. aureus samples.

Two-year outcomes of an initial series of DSAEK cases in normal and abnormal eyes at an inner-city university practice.

PURPOSE: To report our initial series of Descemet stripping automated endothelial keratoplasty (DSAEK) patients with 2 years of follow-up and to compare the complications and outcomes between normal and abnormal eyes. METHODS: Records of all patients who underwent DSAEK between April 2007 and April 2009 were reviewed. Eyes were categorized as "normal" or "abnormal" for comparison. Two risk factors, anterior chamber compromise and glaucoma tube/bleb, were analyzed for association with tissue detachment. RESULTS: Thirteen DSAEKs were performed on 13 "normal" eyes, and 18 DSAEKs were performed on 15 "abnormal" eyes. The lenticule detachment rates were 15.4% in the normal group and 41.2% in the abnormal group (P = 0.13). The difference in endothelial cell loss was not significant until 1.5 years postoperatively in favor of the abnormal group (P = 0.024). The mean starting vision was 20/115 for the normal group and 20/322 for the abnormal group (P = 0.06). At 2 years, the mean visual acuity was 20/47 for the normal group and 20/34 for the abnormal group (P = 0.44). Risk factor analyses indicated that glaucoma tubes/blebs were not related to lenticule detachment (P = 0.45), whereas anterior chamber compromise was related to lenticule detachment (P = 0.031). CONCLUSIONS: Complication rates for abnormal eyes are higher than those for normal eyes, and risk factor analyses suggest that marked anterior chamber compromise is related to lenticule detachment. However, if DSAEK is successful for these compromised eyes, the visual outcomes compare favorably with normal eyes through 2 years of follow-up.

Ocular flora and their antibiotic resistance patterns in the midwest: a prospective study of patients undergoing cataract surgery.

PURPOSE: To determine the spectrum of conjunctival flora and the antibiotic susceptibility profiles of patients undergoing cataract surgery at a Midwestern university. DESIGN: Prospective in vitro laboratory investigation of a patient cohort. METHODS: Conjunctival cultures were obtained from patients undergoing cataract surgery at a single ambulatory center on the day of surgery before the instillation of any ophthalmic medications. Isolates and antibiotic susceptibility profiles were identified using standard microbiological techniques. RESULTS: A total of 183 eyes were cultured, yielding 225 isolates. Twenty-seven eyes (14.8%) showed no growth. Coagulase-negative staphylococci (CNS) were the most commonly isolated organisms (74.8%). Overall susceptibility was highest for gentamicin (94%), which was also true of the CNS isolates (95.0%). A total of 64.5% of CNS isolates were sensitive to ciprofloxacin; 30.1% of CNS isolates were resistant to ≥3 classes of antibiotics; 46.6% of CNS isolates were oxacillin-resistant, and they were more resistant to antibiotics than their oxacillin-sensitive counterparts (P < .001), including fluoroquinolones (P < .001). Among eyes with multiple CNS strains, 41.4% had different antibiotic susceptibility profiles even though they were the same species. CONCLUSIONS: Our cohort harbored organisms with similar rates of antibiotic resistance as elsewhere in the country, including oxacillin resistance; however, the rate of fluoroquinolone resistance was less than in other reports. A surprisingly large proportion of different CNS strains from the same eye harbored different antibiotic susceptibility profiles. Our in vitro results, along with those of other investigators, should prompt further dialogue regarding antibiotic of choice for perioperative surgical prophylaxis in ophthalmic surgery.

Resistant Fusarium keratitis progressing to endophthalmitis.

OBJECTIVE: To report a case of multidrug-resistant Fusarium sp keratitis that progressed to endophthalmitis and that eventually required enucleation. METHODS: Case report and literature review. Isolate identification and susceptibility testing were performed by the Fungus Testing Laboratory at San Antonio, TX. RESULTS: A 52-year-old soft contact lens wearer had a corneal abrasion and developed a corneal infiltrate. Examination of corneal scrapings revealed filamentous hyphae with septation and conidia. Despite aggressive antifungal therapy with topical natamycin, amphotericin B, and systemic fluconazole, the keratitis progressed, and a penetrating keratoplasty was performed. Histopathologic analysis of the corneal button showed disruption of Descemet's membrane with periodic acid-Schiff-positive fungal hyphae on both sides. Recurrent infection of the graft and progression to endophthalmitis was treated with repeated intravitreal amphotericin B injections, repeat penetrating keratoplasties, and pars plana vitrectomies. Even after systemic use of itraconazole, voriconazole, and posaconazole and topical use of voriconazole, the infection progressed and an enucleation was required. Isolate identification and susceptibility testing found a multidrug-resistant Fusarium solani species complex, partially sensitive to natamycin only. CONCLUSIONS: Multidrug-resistant Fusarium sp is rare and may have devastating consequences in patients with advanced keratitis progressing to endophthalmitis. Such an extensive multidrug resistance is surprising in that resistance to antifungal treatment is supposedly rare. Empirical antifungal therapy is usually instituted using one or more antifungal agents, without checking antifungal sensitivities. In light of the growing concern for increased emergence of resistant strains, we propose a lower threshold to check for sensitivities in the face of unresponsive fungal infections.

Surgical management of non-traumatic pediatric ectopia lentis: A case series and review of the literature.

PURPOSE: To report a small series of pediatric patients with ectopia lentis that underwent limbal-approach lensectomy and vitrectomy and scleral-fixated intraocular lens implantation and to review the literature on the topic of surgical management of ectopia lentis. METHOD: A retrospective review of 13 eyes of seven patients that underwent lensectomy, vitrectomy, and scleral-fixated intraocular lens implantation and a review of the ophthalmic literature. RESULTS: In our series, the average age at surgery was 70.3 ± 13.8 months and the average length of follow-up was 23.8 ± 5.9 months. The mean pre-operative visual acuity was 0.86 ± 0.17 which improved to 0.23 ± 0.09 post-operatively (p < 0.001). No complications were encountered in our series. A review of the literature found that amblyopia was the biggest vision-limiting factor. In general, the literature suggested that a higher percentage of eyes that were left aphakic achieved better vision than those implanted with a scleral-fixated intraocular lens. However, there may be selection bias in that more eyes receiving an intraocular lens may have pre-existing amblyopia. The complication rates for lensectomy or scleral-fixated intraocular lens implantation were low in the literature. In the latter group, suture breakage and resultant intraocular lens dislocation is a worrisome late complication. CONCLUSION: Surgical intervention for ectopia lentis via vitrectomy techniques yields good result. In cases of unilateral aphakia or in settings where compliance with aphakic refractive correction is questionable and amblyopia is a constant threat, scleral-fixated intraocular lens implantation is highly encouraged. However, long-term follow-up is required due to the risk of suture breakage and resultant intraocular lens dislocation over time.