Prospective, Randomized Clinical Trial of Povidone-Iodine 1.25% Solution Versus Topical Antibiotics for Treatment of Bacterial Keratitis.

PURPOSE: To compare povidone-iodine 1.25% ophthalmic solution with topical antibiotics for treatment of bacterial keratitis in areas of the world where use of effective topical antibiotics may not be an option. STUDY DESIGN: Randomized, controlled, investigator-masked clinical trial. METHODS: We randomized 172 individuals with bacterial keratitis to topical treatment with povidone-iodine or antibiotics (neomycin-polymyxin B-gramicidin in the Philippines; ciprofloxacin 0.3% in India). Using survival analysis, we compared intervals from start of treatment to "presumed cure" (primary outcome measure, defined as a closed epithelial defect without associated inflammatory signs) and to "recovering" (residual epithelial defect <1 mm2 with only minimal inflammation). RESULTS: Median interval to presumed cure in the Philippines was 7 days for povidone-iodine and 7 days for neomycin-polymyxin B-gramicidin (95% confidence interval [CI] for difference in median interval, -9.5 to 0.7 days) and in India was 12 days for povidone-iodine and 17 days for ciprofloxacin (95% CI, -35.2 to 3.2 days). Hazard ratio (HR) for presumed cure among those treated with povidone-iodine (vs antibiotics) was 1.46 in the Philippines (95% CI, 0.90-2.36; P = .13) and 1.70 in India (95% CI, 0.73-3.94; P = .22). Comparisons of intervals to recovering and HR for recovering also revealed no significant differences between treatment groups in either country. CONCLUSIONS: There is no significant difference between the effect of topical povidone-iodine 1.25% and topical antibiotics commonly available in the developing world for treatment of bacterial keratitis. Povidone-iodine 1.25%, which is widely available and inexpensive, can be considered for treatment of bacterial keratitis when antibiotic treatment is not practical.

Keratoconjunctivitis caused by an unusual retained conjunctival foreign body: a frequently unrecognized entity.

PURPOSE: The purpose of this study is to describe a case series of keratoconjunctivitis caused by a retained bindi (dot) in six children who presented to a tertiary eye care facility in Southern India. PATIENTS AND METHODS: Over a period of 11 years (January 2000 and January 2012), six children (all female, ranging in age from 6 months to 3 years) were diagnosed with ocular manifestations subsequent to a retained bindi. RESULTS: All patients presented with redness, photophobia, extensive lacrimation, and blepharospasm. Two patients presented with mucopurulent conjunctivitis, three patients with suppurative keratitis and one patient presented with corneal epithelial defect. After removal of the foreign body the response to topical antibiotics was good in five of six cases, whereas one patient required therapeutic keratoplasty. CONCLUSIONS: Young children presenting with unilateral keratitis and conjunctivitis should alert the clinician to the possibility of a retained foreign body in the eye.

Spectrum of bacterial keratitis at a tertiary eye care centre in India.

AIM: To report the aetiological spectrum and susceptibility patterns of bacteria isolated from patients with corneal ulceration. METHOD: The microbiological data of all patients with suspected infectious corneal ulceration who presented to the ocular microbiology service at this centre between 2005 and 2012 were reviewed retrospectively. RESULT: Microorganisms were recovered from 1665 (77%) of the 2170 ulcers. Bacterial isolates accounted for 1205 of the organisms isolated. The most common bacterial pathogens isolated were various species of Staphylococcus, representing 777 (64.5%), followed by Staphylococcus spp. (148; 12.3%) and Pseudomonas aeruginosa (117; 9.7%). High percentages of Gram-positive bacteria were susceptible to gatifloxacin (>94%), followed by ofloxacin and moxifloxacin. Almost 90% of Pseudomonas aeruginosa isolates were susceptible to ciprofloxacin and moxifloxacin. Sixty-two (44%) of 140 isolates of Streptococcus pneumoniae, 79 (14.8%) of 534 isolates of Staphylococcus epidermidis, and 33 (14%) of 234 isolates of Staphylococcus aureus were resistant to three or more antibiotics. CONCLUSION: Staphylococcus spp. were the most common bacterial pathogens isolated from patients with keratitis in this setting. High percentages of Gram-positive and Gram-negative bacteria were susceptible to gatifloxacin and moxifloxacin, respectively. Interestingly, a high percentage of Streptococcus pneumoniae isolates were found to be resistant to three or more antibiotics.

Fibrinous anterior uveitis following laser in situ keratomileusis.

A 29-year-old woman who underwent laser in situ keratomileusis (LASIK) for myopic astigmatism in both eyes presented with severe pain, photophobia and decreased visual acuity in the left eye eight days after surgery. Examination revealed severe anterior uveitis with fibrinous exudates in the anterior chamber, flap edema and epithelial bullae. Laboratory investigations for uveitis were negative and the patient required systemic and intensive topical steroids with cycloplegics to control the inflammation. This case demonstrates that severe anterior uveitis may develop after LASIK and needs prompt and vigorous management for resolution.

Visual outcome and corneal topography after eccentric "shaped" corneal grafts.

PURPOSE: To study the clinical and visual outcome and corneal topography in eyes that underwent full-thickness or lamellar eccentric-"shaped" (biconvex/crescentic) corneal grafts. SETTING: Tertiary care center in south India. METHODS: In this retrospective, interventional, noncomparative case series, eccentric-shaped corneal grafts were performed in 10 eyes (10 patients). Biconvex grafts were performed in 7 eyes, and crescentic grafts were done in 3 eyes. The indications for biconvex grafts were peripheral infected corneal ulcer (3 eyes), limbal dermoid (1 eye), squamous cell carcinoma at limbus (1 eye), rheumatoid arthritis-associated peripheral corneal melt (1 eye), and peripheral corneal perforation of unknown etiology (1 eye). Crescentic graft was performed for perforated Mooren ulcer in 3 eyes. RESULTS: All grafts were tectonically effective. Three grafts developed stromal haze with fine vascularization. Visual acuity was equal to or better than that before surgery in all eyes but one. This eye had deterioration in visual acuity because of progression of cataract. Corneal topography was performed in 5 eyes, which revealed corneal asymmetry but regular central corneal surface. CONCLUSION: Shaped corneal grafts for peripheral corneal diseases are tectonically viable and result in good visual outcomes.

Simplified technique for deep anterior lamellar keratoplasty.

PURPOSE: To describe a new technique for performing deep anterior lamellar keratoplasty (DALK) that can be done without special instruments and where deep stromal dissection can be performed under direct visualization. METHODS: In this prospective, noncomparative case series, DALK was performed by first creating a scleral pocket incision to initiate corneal dissection and continuing further dissection under direct visualization after partial trephination. Fourteen eyes of 13 patients with corneal pathology not involving endothelium were operated on by using the new technique. RESULTS: Accidental entry into the anterior chamber occurred in only 1 eye (7.1%). After a mean follow-up of 10.3 +/- 4 months, the graft was clear in 12 eyes (92.3%), and all 12 eyes had a best-corrected visual acuity of 20/60 or better at this time. CONCLUSIONS: Our technique for DALK offers an alternative to the currently used techniques.

Traumatic intralenticular abscess: a case series.

PURPOSE: To report the clinical presentation, management and outcome of eyes with traumatic intralenticular abscess. METHODS: In this interventional case series, records of eight patients (eight eyes) with intralenticular abscess developing following trauma were reviewed. All patients underwent extracapsular cataract extraction with intracameral antibiotics with or without pars plana vitrectomy. Main outcome measures studied were resolution of infection and final visual outcome. RESULTS: Lens abscess developed in six eyes following penetrating injury and in two eyes following intraocular penetration of caterpillar hair. Gram positive cocci were cultured from the lens aspirate in five eyes and Staphylococcus epidermidis was the most common organism isolated. Cataract extraction resulted in control of the infection in all eyes and seven eyes (87.5%) had a favourable visual outcome. CONCLUSION: Early lens extraction with intracameral antibiotics in eyes with intralenticular abscess allows control of infection with good visual outcome.

Bilateral Pseudomonas keratitis without predisposing factors.

Bilateral keratitis usually occurs in predisposed individuals such as contact lens wearers, those suffering from malnutrition and immunodeficiency or patients undergoing bilateral refractive corneal surgery. We report a 30-year-old man without any obvious predisposing factors who presented with complaints of pain and decreased vision in both eyes. Examination revealed corneal ulcers in both eyes, which on microbiological culture grew Pseudomonas aeruginosa. The patient underwent a therapeutic keratoplasty in the right eye while the left eye was managed medically. Bilateral Pseudomonas keratitis can develop in the absence of any obvious predisposing factors.

Optical coherence tomography in choroidal tuberculosis.

PURPOSE: To report the optical coherence tomographic (OCT) features in eyes with tuberculous choroidal granuloma. DESIGN: Interventional case series. METHODS: Nine eyes of nine patients with tuberculous granuloma of the choroid were studied using OCT scans. RESULTS: OCT scan through the lesions revealed a distinctive feature of attachment between the retinal pigment epithelial- choriocapillaris layer and the neurosensory retina over the granuloma ("contact" sign). This was associated with surrounding subretinal fluid and inflammatory infiltrate in the deeper retinal layers. CONCLUSIONS: OCT can be useful in the differentiating choroidal tuberculous granulomas from noninflammatory lesions with a similar clinical appearance.

Anterior chamber contamination during phacoemulsification and manual small-incision cataract surgery.

PURPOSE: To compare the per-operative contamination of anterior chamber among eyes undergoing manual small-incision cataract surgery (MSICS) and phacoemulsification (PE). DESIGN: Prospective, randomized, interventional clinical trial. METHODS: In this study conducted at a tertiary-care center in southern India, 150 eyes undergoing cataract surgery were randomly allocated to undergo MSICS (group A, 75 eyes) and PE (group B, 75 eyes). Aqueous samples were taken before and at the end of surgery. Collected material was subjected to standard microbiological analysis. No preoperative antibiotics were used, but povidone-iodine 5% drops were instilled before surgery. Main outcome measures studied were the incidence of positive cultures in aqueous samples obtained from eyes in both groups. RESULTS: The incidence of anterior chamber contamination in the MSICS group (4%) did not significantly differ from the PE group (2.7%; P = .65). CONCLUSIONS: Incidence of anterior chamber contamination is similar among eyes undergoing MSICS and PE.

Comparison of topical gatifloxacin 0.3% and ciprofloxacin 0.3% for the treatment of bacterial keratitis.

PURPOSE: To compare the bacteriologic and clinical efficacy of gatifloxacin and ciprofloxacin for the treatment of bacterial keratitis. DESIGN: Prospective, randomized clinical trial. METHODS: A total of 104 eyes of 104 patients with bacterial keratitis seen at a tertiary eye-care center were randomized to treatment with gatifloxacin 0.3% eyedrops (GAT group, 50 eyes) or ciprofloxacin 0.3% eyedrops (CIP group, 54 eyes). Patients and the treating physician were masked to the antibiotic being used. Main outcome measure studied was healing of the ulcer. Patients lost to follow-up before complete healing were excluded from further analysis. RESULTS: A significantly higher proportion of ulcers in the GAT group exhibited complete healing compared with those in the CIP group (39 eyes [95.1%] vs 38 [80.9%]; P=.042). Gatifloxacin demonstrated a significantly better action than ciprofloxacin against gram-positive cocci in vitro (P<.001), and the percentage of ulcers caused by these pathogens that healed in the GAT group was significantly better than in the CIP group (P=.009). Mean time taken for healing of ulcer and the efficacy against gram-negative bacteria did not significantly differ between the two groups. CONCLUSIONS: Gatifloxacin had a significantly better action against gram-positive cocci both in vitro and in vivo when compared with ciprofloxacin. In view of these organisms being the leading cause of keratitis worldwide, gatifloxacin may be a preferred alternative to ciprofloxacin as the first-line monotherapy in bacterial keratitis.

Microbial keratitis at extremes of age.

PURPOSE: To study the risk factors, clinical presentation, response to treatment and outcome of microbial keratitis occurring in patients at extremes of age (ie, children and the elderly) and to compare them with microbial keratitis affecting the general adult population. METHODS: In this prospective, nonrandomized, analytical clinical study, all patients presenting with microbial keratitis and undergoing microbiological workup over a 1-year period were evaluated using a dedicated corneal ulcer protocol. Patients were divided into 3 groups based on age: (1) pediatric group if the age was 16 years or younger, (2) elderly group if the age was 65 years or older, and (3) control group if the age was between 17 and 64 years. Features studied included microbiological profile, predisposing factors, clinical presentation, response to treatment, and final visual outcome. RESULTS: A total of 269 eyes of 269 patients were studied (26 in the pediatric group, 55 in the elderly group, and 188 in the control group). Culture positivity rates were similar in all the groups. The elderly and control groups had a similar incidence of fungal and bacterial keratitis, but the pediatric group had a significantly lower incidence of fungal keratitis (P = 0.001). Trauma was the most common predisposing factor in all groups. Elderly patients tended to present with a higher incidence of central ulcers (P = 0.04), severe ulcers (P = 0.04), and poor visual acuity (P = 0.003) as compared with the control group. The percentage of ulcers healing with medical treatment alone was significantly more in the pediatric group (P = 0.004), while the incidence of poor visual outcome was greater in the elderly group (P = 0.006) as compared with the control group. CONCLUSIONS: Microbial keratitis in pediatric patients is more likely to be of bacterial etiology, and nonsevere ulcers in this age group have a better chance of resolution with medical therapy alone when compared with that in the general adult population. Conversely, elderly patients with microbial keratitis tend to present with severe, central ulcers with a significant risk of having a poor visual outcome.

Anterior "lenticonus" in exfoliation syndrome.

Presence of exfoliation syndrome (XFS) is associated with an increased risk of complications during cataract surgery. This risk is, in part, dependent on the severity of XFS. We describe a central bulge ("lenticonus") in the anterior lens capsule of some eyes with XFS. This finding is associated with very fragile zonules and a high risk for intraoperative zonular dialysis.

Comparison of topical itraconazole 1% with topical natamycin 5% for the treatment of filamentous fungal keratitis.

PURPOSE: To compare the clinical efficacy of itraconazole 1% eyedrops with a standard therapy regimen (natamycin 5% eyedrops) for topical monotherapy of fungal keratitis. METHODS: Patients presenting with suspected uniocular microbial keratitis over a period of 12 months (January to December 2002) underwent detailed clinical examination and microbiological investigation. One hundred consecutive patients with direct smear- and/or culture-proven fungal keratitis were enrolled in the study after obtaining informed consent. The ulcers were categorized as severe or nonsevere. The first 50 consecutive patients received primary therapy with topical natamycin hourly, and the next 50 consecutive patients received topical itraconazole hourly. The primary efficacy criteria were the physician's judgment of clinical success, cure rate, and the rate of treatment failure. RESULTS: The diagnosis of fungal keratitis was established by positive microscopy and culture findings in 88 patients and by positive microscopy alone in 12 patients. Species of Fusarium, Aspergillus, and Curvularia were the principal isolates. Thirty-six (72%) of 50 patients (28 of 37 with nonsevere keratitis and 8 of 13 with severe keratitis) showed a favorable response to primary natamycin therapy (mean duration, 20.5 days), while 30 (60%) of 150 patients (25 of 38 with nonsevere keratitis and 5 of 12 with severe keratitis) exhibited a favorable response to primary itraconazole therapy (mean duration, 23.1 days). In keratitis due to Fusarium spp, 19 (79%) of 24 patients showed a favorable response to natamycin, which was significantly greater than the 8 (44%) of 18 patients who showed a favorable response to itraconazole (P < 0.02). However, no such difference was evident in keratitis due to Aspergillus spp or Curvularia spp; in keratitis due to Aspergillus spp, favorable responses were noted in 6 (54.5%) of 11 patients receiving natamycin and 5 (50%) of 10 patients receiving itraconazole, while in keratitis due to Curvurlaria spp, such responses occurred in both patients receiving natamycin and in 8 (89%) of 9 patients receiving itraconazole. Both antifungal formulations were generally well tolerated with no obvious adverse effects. CONCLUSIONS: Topical natamycin should continue to be considered as the treatment of choice for filamentous fungal keratitis; when natamycin is unavailable, topical itraconazole therapy could be used, particularly if the infections are due to Aspergillus or Curvularia spp.

Outcome analysis of cataract surgery following therapeutic keratoplasty.

PURPOSE: To assess the results of cataract surgery, in terms of visual outcome and effect on graft survival, in eyes that have previously undergone therapeutic penetrating keratoplasty for infective keratitis. METHODS: Case records of patients who had undergone cataract surgery alone (group A) or in combination with regrafting (group B) following initial therapeutic penetrating keratoplasty between January 2000 and December 2001 were reviewed retrospectively. Main outcome measures studied were visual acuity, astigmatism, and effect of the cataract surgery on graft survival. Results were compared with eyes undergoing cataract surgery after optical keratoplasty and between eyes in groups A and B. RESULTS: Frequency of cataract surgery after therapeutic keratoplasty was significantly greater than that following optical keratoplasty [68 (52%) versus 47 (21%); P<0.001]. Fifty-eight eyes of 58 patients undergoing cataract surgery after therapeutic penetrating keratoplasty were analyzed in detail. Mean follow-up period was 8.9 months (+/-7.6 months). Thirty eyes underwent cataract surgery alone (group A), and 28 eyes underwent cataract surgery with regrafting (group B). Eyes that had undergone therapeutic keratoplasty were significantly more likely to have opaque grafts requiring regrafting at the time of cataract surgery than eyes that had undergone optical keratoplasty [28 (48.3%) versus 5 (10.6%); P<0.001]. Incidence of graft failure after cataract surgery did not differ significantly in eyes that had undergone therapeutic or optical keratoplasty. Final visual acuity at last follow-up was 6/12 or better in 25 eyes (43%). There were no significant differences between eyes in groups A and B in terms of final visual acuity, astigmatism, or graft failure rates. CONCLUSIONS: Visual results of cataract surgery following therapeutic keratoplasty are comparable to those following optical keratoplasty. Combining a repeat keratoplasty for a failed graft with the cataract surgery does not significantly affect the final outcome.

Trimethoprim-sulphamethoxazole therapy in Nocardia keratitis.

PURPOSE: To describe the clinical features, microbiological features and treatment outcome of nine patients with Nocardia keratitis treated with topical trimethoprim- sulphamethoxazole drops. METHODS: Retrospective review of nine patients with culture-proven Nocardia keratitis. RESULTS: Nine patients with Nocardia keratitis were treated with topical trimethoprim-sulphamethoxazole drops. The average duration of treatment was 25 +/- 9 days. Five of the nine patients presented with superficial ulcers with margins studded with yellowish white discrete pinhead sized infiltration; the other four patients had deep stromal infiltration. Complete healing of the ulcer was achieved in six out of the nine patients with topical trimethoprim- sulphamethoxazole alone or in combination with ciprofloxacin 0.3% eye drops. CONCLUSION: Topical application of trimethoprim-sulphamethoxazole appears to be effective therapy for superficial keratitis due to Nocardia.