Delayed Bacterial Endotheliitis and Endophthalmitis 11 Years after Cataract Surgery.

Infective endophthalmitis is an uncommon complication following intraocular surgery. Chronic endophthalmitis may present some time after intraocular surgery, making the diagnosis challenging. Cutibacterium acnes is a well-recognised causative agent of these chronic infections. Practitioners should be aware of the conditions required to culture this slow-growing organism. We report a case of delayed low-grade endophthalmitis presenting 11 years after cataract surgery. Cutibacterium acnes and Staphylococcus warneri were cultured from Descemet's membrane biopsy following three failed previous attempts at microbiological studies. Clinical features of the infection included discrete white granules on the iris, endothelium, and within the capsular bag of the patient's right eye. The patient presented with no signs of systemic infection and the left eye was normal on examination. Bullous keratopathy, secondary to endothelial dysfunction was a feature of this infection. This retrospective case report illustrates the prolonged periods for which Cutibacterium acnes can remain latent before causing clinical signs. While uncommon, endothelial involvement may occur and clinicians should consider low-grade infective endophthalmitis in cases with corneal oedema.

Patient-Reported Outcomes in Keratoconus: A Save Sight Keratoconus Registry Study.

PURPOSE: The aim of this study was to evaluate the quality-of-life (QoL) status in keratoconus severity subgroups using the Keratoconus Outcomes Research Questionnaire (KORQ) and to determine the relationship between the QoL scores and the standard clinical variables. METHODS: A cross-sectional study was conducted using prospective, web-based Save Sight Keratoconus Registry data. Rasch analysis was conducted on the KORQ data using the Andrich Rating Scale Model. Comparative analysis included Welch t test and 1-way ANOVA. Associations between visual acuity, corneal curvature, and minimum corneal thickness with KORQ scores were evaluated with Pearson correlation and multiple regression adjusted for age and sex. RESULTS: The KORQ was completed by 542 patients with keratoconus (male, 67.7%; mean age, 31.6 years). Keratoconus severity, based on Kmax, was mild [<48 diopter (D)], moderate (48-55 D), and severe (>55 D) in 26.3%, 45.0%, and 28.7% of patients, respectively. Activity limitation (AL) and symptoms (SY) scales of the KORQ had robust psychometric properties including well-functioning response categories, unidimensionality, excellent measurement precision, and satisfactory fit statistics. In a group-wise analysis, the female patients had significantly lower AL and SY scores. Similarly, the severe keratoconus group had the worst AL and SY scores. Contact lens wearers had worse KORQ scores than the spectacles wearers. Overall, statistically significant but weak correlations between KORQ scores and visual acuity and corneal curvature (Kmax and K2) (Pearson r, 0.11-0.35) were observed. The correlations for SY were weaker than for AL scores. CONCLUSIONS: Female sex, contact lens wear, reduced visual acuity, and higher disease severity were associated with worse AL and SY scores in keratoconus. Although the correlations between clinical and QoL scores were statistically significant, the low magnitudes suggested a complex relationship between clinical parameters and patient-reported outcomes.

Psychometric Properties of the Keratoconus Outcomes Research Questionnaire: A Save Sight Keratoconus Registry Study.

PURPOSE: The aim of this study was to evaluate the psychometric properties of the Keratoconus Outcomes Research Questionnaire (KORQ) in patients enrolled in the Save Sight Keratoconus Registry. METHODS: A cross-sectional study was conducted utilizing prospectively collected web-based registry data. The psychometric properties of the KORQ were assessed using both classical test theory and Rasch analysis. Andrich group rating scale variant of the Rasch analysis was conducted using Winsteps software, Version 3.92.1. RESULTS: The KORQ was completed by 189 patients with keratoconus (men, 67.7%; white, 69.8%; median age 29 years; better eye median values: visual acuity, 75 LogMAR letters; Kmax, 51.3 D; K2, 46.5 D; thinnest pachymetry, 485 µm). Cronbach's α for the "Activity Limitation" and "Symptoms" scales were 0.95 and 0.91, respectively, with both scales free from floor or ceiling effects. On Rasch analysis, the category thresholds were ordered and well-spaced for both scales. The Activity Limitation scale had excellent psychometric properties including person separation index (3.6), unidimensionality (variance explained, 65.4%), fit statistics (<1.3 MnSq), and measurement range (3.6 logits). Similarly, the Symptoms scale had satisfactory psychometric properties including person separation index (2.5), unidimensionality (variance explained, 54.3%), fit statistics (<1.30 MnSq except for 1 item), and measurement range (2.0 logits). Both scales were well targeted to the population and free of differential item functioning. CONCLUSIONS: The KORQ is a psychometrically robust patient-reported outcome measure for evaluating quality of life parameters in keratoconus. It enables routine collection and monitoring of meaningful patient-reported outcome data in clinical settings, including registries.

Bilateral Blebs Secondary to Spontaneous Scleral Perforations.

PURPOSE: To report an unusual case of bilateral spontaneous scleral perforations. METHODS: A 34-year-old woman presented with bilateral conjunctival blebs and decreased vision in both eyes. There was no history of ocular trauma or surgery and no previous ophthalmic or systemic conditions that may have contributed to the scleral perforations. RESULTS: Best-corrected visual acuity was 20/40 in both eyes and intraocular pressures were 6 mm Hg in the right and 5 mm Hg in the left. There was associated bilateral hypotonous maculopathy confirmed with optical coherence tomography. Slit-lamp biomicroscopy revealed bilateral inferonasal conjunctival blebs in otherwise normal anterior segments. Ultrasound biomicroscopy suggested an opening between the anterior chambers and subconjunctival spaces of both eyes. The patient underwent sequential repair of the perforations with sclerocorneal patch grafts. Intraoperatively crescentic perforating scleral clefts were noted in both eyes, with abnormal and friable surrounding tissue. Histopathology revealed degeneration of the sclera with absence of normal lamellar collagenous architecture and structure. At 9 months postoperative for each eye, the best-corrected visual acuity had improved to 20/20 on both eyes and intraocular pressures were 20 mm Hg on the right and 10 mm Hg on the left. Macular anatomy and thickness were restored in both eyes. CONCLUSIONS: Spontaneous scleral perforations without prior history of trauma or surgery is extremely rare. The underlying cause in our patient is hypothesized to be a coloboma with spontaneous perforation given its location and histopathology. If symptomatic it can successfully be repaired with a patch graft.

Blood flow in intracranial aneurysms treated with Pipeline embolization devices: computational simulation and verification with Doppler ultrasonography on phantom models.

PURPOSE: The aim of this study was to validate a computational fluid dynamics (CFD) simulation of flow-diverter treatment through Doppler ultrasonography measurements in patient-specific models of intracranial bifurcation and side-wall aneurysms. METHODS: Computational and physical models of patient-specific bifurcation and sidewall aneurysms were constructed from computed tomography angiography with use of stereolithography, a three-dimensional printing technology. Flow dynamics parameters before and after flow-diverter treatment were measured with pulse-wave and color Doppler ultrasonography, and then compared with CFD simulations. RESULTS: CFD simulations showed drastic flow reduction after flow-diverter treatment in both aneurysms. The mean volume flow rate decreased by 90% and 85% for the bifurcation aneurysm and the side-wall aneurysm, respectively. Velocity contour plots from computer simulations before and after flow diversion closely resembled the patterns obtained by color Doppler ultrasonography. CONCLUSION: The CFD estimation of flow reduction in aneurysms treated with a flow-diverting stent was verified by Doppler ultrasonography in patient-specific phantom models of bifurcation and side-wall aneurysms. The combination of CFD and ultrasonography may constitute a feasible and reliable technique in studying the treatment of intracranial aneurysms with flow-diverting stents.

Long-term outcomes of deep anterior lamellar keratoplasty versus penetrating keratoplasty in Australian keratoconus patients.

PURPOSE: The aim of this study is to compare long-term visual and surgical outcomes after performing deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK) for keratoconus. METHODS: This is a retrospective review of 73 consecutive patients with keratoconus, managed with DALK or PK, between 2000 and 2010, by a single surgeon. Data were collected on baseline parameters, best-corrected visual acuity (BCVA) in logarithm of the mean angle of resolution (logMAR), subjective refraction, graft survival, and complications. RESULTS: Thirty-one (42.5%) eyes underwent a DALK, and 42 (57.5%) eyes underwent a PK. All PK-operated and 29 out of 31 (93.5%) DALK-operated eyes remained clear at the last review. Postoperative complications were significantly more frequent after PK (57.1%) than after DALK (26.5%; P = 0.0197). The mean BCVA was not significantly different for DALK (0.14 logMAR, SD 0.2) versus PK (0.05 logMAR, SD 0.11); however, eyes that underwent PK were more likely to achieve a BCVA of 0.0 logMAR (P = 0.0029). Subjective refraction and method of visual correction (spectacles or contact lenses) were similar for each group. CONCLUSIONS: DALK-operated patients in this study showed similar graft survival, fewer postoperative complications, and equivalent refractive outcomes. No significant difference in the mean BCVA was noted between DALK and PK cases.

Design of anthropomorphic flow phantoms based on rapid prototyping of compliant vessel geometries.

Anatomically realistic flow phantoms are essential experimental tools for vascular ultrasound. Here we describe how these flow phantoms can be efficiently developed via a rapid prototyping (RP) framework that involves direct fabrication of compliant vessel geometries. In this framework, anthropomorphic vessel models were drafted in computer-aided design software, and they were fabricated using stereolithography (one type of RP). To produce elastic vessels, a compliant photopolymer was used for stereolithography. We fabricated a series of compliant, diseased carotid bifurcation models with eccentric stenosis (50%) and plaque ulceration (types I and III), and they were used to form thin-walled flow phantoms by coupling the vessels to an agar-based tissue-mimicking material. These phantoms were found to yield Doppler spectrograms with significant spectral broadening and color flow images with mosaic patterns, as typical of disturbed flow under stenosed and ulcerated disease conditions. Also, their wall distension behavior was found to be similar to that observed in vivo, and this corresponded with the vessel wall's average elastic modulus (391 kPa), which was within the nominal range for human arteries. The vessel material's acoustic properties were found to be sub-optimal: the estimated average acoustic speed was 1801 m/s, and the attenuation coefficient was 1.58 dB/(mm·MHz(n)) with a power-law coefficient of 0.97. Such an acoustic mismatch nevertheless did not notably affect our Doppler spectrograms and color flow image results. These findings suggest that phantoms produced from our design framework have the potential to serve as ultrasound-compatible test beds that can simulate complex flow dynamics similar to those observed in real vasculature.

Direct surgical repair of corneal perforation in pellucid marginal degeneration: a case series.

PURPOSE: To report a novel technique for repairing corneal perforations in 5 eyes of 3 patients with pellucid marginal degeneration (PMD). Four cases were successfully repaired with corneal sutures and 1 case required a penetrating keratoplasty. METHODS: Retrospective case series of corneal perforation repairs in the setting of PMD. RESULTS: Four perforations were managed successfully with primary closure resulting in acceptable best spectacle-corrected visual acuity and stable corneal topography. One corneal perforation required a penetrating keratoplasty after unsuccessful suture repair. CONCLUSIONS: Primary repair of corneal perforations in cases of PMD can be achieved with corneal suturing alone. This technique may achieve a satisfactory visual and topographic outcome with minimal complications.

Topical Cyclosporin A in the treatment of acute graft rejection: a randomized controlled trial.

BACKGROUND: Corneal graft rejection is the commonest cause of graft failure. Currently, intensive topical steroid is the treatment for graft rejection.We hypothesized that the use of topical Cyclosporin A (CsA) 0.05%, specifically Restasis (Allergan) in addition to intensive steroids would aid in the reversal and treatment of endothelial graft rejection. METHODS: In a randomized double masked control study, we recruited 108 patients with acute endothelial graft rejection. They were randomized to two groups. The first group received intensive prednisolone acetate and placebo. The second group received intensive prednisolone acetate and Restasis. RESULTS: There was no difference between the baseline characteristics for the two groups. Nine out of 54 in the placebo group and five out of 54 (16.7% vs. 9.2% P = 0.23) in the treatment group were exited from the study because of worsening signs despite treatment. No significant difference was found between the two groups for time to reversal and resolution. Side-effects of the treatment include increased intraocular pressure and punctate epithelial erosions.These changes most likely relate to the use of intensive prednisolone acetate. CONCLUSION: The use of commercially available CsA as an adjunct to topical steroids does not appear to improve the outcome of graft rejection.