A case of late-onset Klebsiella oxytoca keratitis treated with topical imipenem after deep anterior lamellar keratoplasty / Caso de ceratite de início tardio por Klebsiella oxytoca tratado com imipenem tópico após ceratoplastia lamelar anterior profunda

ABSTRACT The aim of this study was to discuss a case of late-onset Klebsiella oxytoca keratitis after deep anterior lamellar keratoplasty and its treatment. A 21-year-old female patient presented with redness and effluence in the left eye at 5 months after uncomplicated deep anterior lamellar keratoplasty surgery. In the examination, a single suture was loosened in the superior nasal region and there was an infiltration area and epithelial defect in the graft and recipient bed junction in the area of the loose suture. Topical fortified vancomycin and fortified ceftazidime treatment was started empirically hourly, but there was insufficient response. After K. Oxytoca growth in a swab and suture culture taken from the patient, fortified vancomycin was replaced with fortified imipenem. It was observed that the infiltration area rapidly regressed and the epithelial defect was closed after fortified imipenem treatment. Fortified imipenem may be considered as an alternative treatment, especially in cases in which there is no response to treatment and culture growth is detected.(AU)

RESUMO O objetivo deste estudo é discutir um caso de ceratite tardia por Klebsiella oxytoca, após ceratoplastia lamelar anterior profunda, bem como seu tratamento. Uma paciente de 21 anos apresentou vermelhidão e efluxo no olho esquerdo 5 meses após cirurgia de ceratoplastia lamelar anterior profunda sem complicações. Ao exame, havia uma única sutura solta na região nasal superior e uma área de infiltração com defeito epitelial no enxerto e na junção com o leito receptor na área da sutura solta. Iniciou-se empiricamente um tratamento tópico com vancomicina e ceftazidima fortificada de hora em hora, porém com resposta insuficiente. Após o crescimento de K. oxytoca a partir de cultura de swab e sutura retirados da paciente, a vancomicina fortificada foi substituída por imipenem fortificado. Observou-se que a área de infiltração regrediu rapidamente e que o defeito epitelial foi fechado com o tratamento com imipenem fortificado. O imipenem fortificado pode ser considerado um tratamento alternativo, especialmente nos casos sem resposta ao tratamento e detecção de crescimento na cultura.(AU)

A case of late-onset Klebsiella oxytoca keratitis treated with topical imipenem after deep anterior lamellar keratoplasty.

The aim of this study was to discuss a case of late-onset Klebsiella oxytoca keratitis after deep anterior lamellar keratoplasty and its treatment. A 21-year-old female patient presented with redness and effluence in the left eye at 5 months after uncomplicated deep anterior lamellar keratoplasty surgery. In the examination, a single suture was loosened in the superior nasal region and there was an infiltration area and epithelial defect in the graft and recipient bed junction in the area of the loose suture. Topical fortified vancomycin and fortified ceftazidime treatment was started empirically hourly, but there was insufficient response. After K. Oxytoca growth in a swab and suture culture taken from the patient, fortified vancomycin was replaced with fortified imipenem. It was observed that the infiltration area rapidly regressed and the epithelial defect was closed after fortified imipenem treatment. Fortified imipenem may be considered as an alternative treatment, especially in cases in which there is no response to treatment and culture growth is detected.

The Role of Optical Coherence Tomography Signal Strength in the Diagnosis and Follow-up of Patients with Posterior Capsular Opacification Treated with Nd:YAG Laser Capsulotomy

Objectives: To investigate the relationship between optical coherence tomography (OCT) signal strength (SS) and visual acuity in patients with posterior capsule opacification (PCO) and evaluate the effect of PCO on retinal thickness measurements. Materials and Methods: Forty-one eyes of 35 patients who were diagnosed with PCO were included in the study. Patients with any anterior or posterior segment pathology other than PCO were excluded. After ophthalmologic examination, pupil dilation was induced using 0.5% tropicamide and OCT images were acquired. The assessment was repeated 1 month after Nd:YAG laser capsulotomy and postoperative values were compared with baseline values. Results: The patients' mean best corrected visual acuity (BCVA) was 0.28±0.13 preoperatively and 0.78±0.09 postoperatively (p<0.0001). Strong positive correlations were observed between BCVA and SS both pre- and postoperatively (p<0.0001 and p=0.01, respectively). Central retinal thickness (CRT) and SS increased significantly postoperatively (p<0.0001 for both). OCT SS and CRT were strongly correlated preoperatively (p=0.001) but not postoperatively (p=0.46). Conclusion: OCT SS correlates with visual acuity in patients with PCO, and PCO can affect the accuracy of objective data obtained with OCT.

Scleral fixated intraocular lens implantation with a modified Z-suture technique.

PURPOSE: To evaluate visual outcomes and complications in scleral fixated intraocular lens (IOL) implantation with the modified Z-suture technique. MATERIALS AND METHODS: Thirty-five eyes of 35 patients (20 male, 15 female) were included in the study. Patients underwent scleral fixated IOL implantation using the modified Z-suture technique and were followed in terms of visual acuity and complications. RESULTS: Mean postoperative follow-up time was 12.46 ± 7.46 months. Mean best corrected visual acuity was 1.35 ± 0.91 logMAR preoperatively and 0.48 ± 0.39 logMAR postoperatively, and difference was statistically significant (p < 0.001). No suture-related complications were observed during follow-up in any of the patients. Slight infero-temporal dislocation of the IOL was observed at postoperative 5 months in one patient (2.85%) who experienced blunt trauma. It caused no optical disturbance, and repeated surgery was not advised. Transient intravitreal hemorrhage was observed in two patients (5.7%) who underwent combined scleral fixation and pupilloplasty. DISCUSSION: The modified Z-suture technique is simple, fast, and was determined to be safe in terms of complications. However, long-term outcomes should be evaluated in larger patient groups.

Expression of prostaglandin E2 receptor subtypes in human pterygium and normal conjunctiva: immunohistochemical study.

PURPOSE: In the present study, we aimed to evaluate the expression of EP receptors in primary and recurrent human pterygium tissues. METHODS: Pterygium samples were collected from 65 patients with primary pterygium and 16 patients with recurrent pterygium. Normal conjunctival tissues were collected from nasal interpalpebral area from 17 patients without systemic and any other ocular pathology. Expression of EP receptors was evaluated by immunohistochemistry. The median value for each receptor staining score (RSS) was determined in normal conjunctival specimens. In this study, RSS of > median value was defined as positive staining or high expression and ≤ median value as negative staining or weak expression in specimens. Chi-square test was used for statistical analysis, and p value of less than 0.05 was considered significant. RESULTS: Stromal expression of EP1 was significantly higher in primary and recurrent pterygium specimens compared to normal conjunctival tissues (p = 0.007 and p = 0.002, respectively). Epithelial expressions of EP2 and EP3 were significantly lower in primary pterygium specimens compared to normal conjunctival tissues (p = 0.005 and p < 0.0001, respectively), and stromal expressions were insignificant. Stromal expression of EP4 was significantly higher in primary and recurrent pterygium specimens compared to normal conjunctival tissues (p = 0.002 and p = 0.012, respectively). CONCLUSIONS: Expression of EP receptors has been up- or downregulated in primary and recurrent pterygium tissues, and these receptors may play a role in formation and recurrence of pterygium.

Secondary Glaucoma Associated with Encircling Scleral Buckle Migration into the Cornea.

Transmuscular migration of the encircling band through rectus muscles and straddling of the cornea has only been reported in a few cases previously in the literature. This rare condition has never been associated with glaucoma. In this report, we aimed to describe a unique case with transmuscular migration of encircling buckle as a probable cause of glaucoma. A 17-year-old female presented with transmuscular migration of buckle and high intraocular pressure (IOP). Limbal/corneal migration of the silicone band was thought to be the main reason for the IOP rise; therefore, scleral band removal was performed. One month after removal, the patient was free of glaucoma medications and IOP was within normal limits. The retina remained attached during all postoperative visits. Transmuscular migration of the encircling band through rectus muscles and straddling of the cornea may act as a trigger for glaucoma.

Inducing ocular allergy with beta-lactoglobulin: a new experimental model.

PURPOSE: To develop a new experimental ocular allergy animal model induced by beta-lactoglobulin (BLG), a major cow's milk allergen, and to discuss the clinical, histopathological and immunohistochemical findings. METHODS: Forty Balb/c mice were randomized and separated into groups of 10. Groups were determined according to the different concentrations of BLG drops used. Study groups were immunized with 2.5, 5 or 10 mg/ml topical BLG (groups 2, 3 and 4, respectively) following intraperitoneal injection for the systemic immunization. The control group (group 1) was immunized with aluminium hydroxide (alum) alone within the same intervals. After ocular challenge, all the animals were evaluated clinically, histopathologically (mast cell and eosinophil infiltration) and immunhistochemically in terms of both T helper type 1- (IFNgamma, TNFalpha) and T helper type 2- (IL-3, IL-4, IL-5, IL-10) specific cytokines. RESULTS: Both clinical and immunohistochemical findings showed that an allergic conjunctivitis was induced in all study groups, with an optimized dosage of topical 5 mg/ml BLG. The conjunctivitis was associated with both Th1 and Th2 response, with a slight predominance of Th1 reaction. CONCLUSION: We describe a new murine model of acute allergic conjunctivitis induced by BLG. We believe that this new preliminary model has the immune parameters of the late phase of acute allergic conjunctivitis and it provides an alternative means for studying the pathogenesis and future treatments of ocular allergy. Our results should be enhanced with more detailed cellular and humoral parameters.

Effects of intravitreal bevacizumab in repeated doses: an experimental study.

PURPOSE: To evaluate the effects of repeated 1.25-mg intravitreal bevacizumab injections on cornea and uveoretinal tissues using histologic and biochemical analyses. METHODS: Twenty-four New Zealand albino rabbits were used. Twelve rabbits received an injection of bevacizumab in their right eyes three times with an interval of 25 days (Group 1); their contralateral eyes served as controls (Group 2). Six rabbits had an injection of vehicle in both eyes (Group 3), with the same regimen as bevacizumab, and six rabbits' eyes were used as a sham group (Group 4). Enucleated eyes were used for histologic and biochemical analyses, which included the activities of caspase 3 and 8 enzymes, glutathione content, catalase activity, and malondialdehyde content. RESULTS: No inflammation in aqueous humor and no sign of corneal or uveoretinal toxicity was found in bevacizumab-injected eyes. The difference of activity of corneal caspase 8 enzyme between Groups 1 and 2 and between Groups 1 and 4 was statistically significant (P < 0.05). In the uveoretinal tissue, in Group 1, the activities of caspase 3 and 8 enzymes were the lowest, and uveoretinal malondialdehyde content was also significantly lower than Group 4. CONCLUSION: A repeated dose of intravitreal bevacizumab injection did not cause a toxic effect on cornea and uveoretinal tissue. Biochemically, it also did not cause any apoptosis, oxidative reaction, or lipid peroxidation. Instead, bevacizumab injection caused a considerable decrease in the apoptotic enzyme activities and lipid peroxidation in the uveoretinal tissue. Further studies are needed to be conducted for possible detrimental side effects and apoptotic and oxidative effects of repeated bevacizumab injections on both the injected and the contralateral eyes.

Uncommon associations with ataxia-telangiectasia: vitiligo and optic disc drusen.

Ataxia-telangiectasia (A-T) is an autosomal recessive condition presented by progressive cerebellar ataxia, oculocutaneous telangiectasia, humoral and cellular immunodeficiencies and a predisposition to malignancy. We report on a 13 years old male patient with the diagnosis of A-T associated with uncommon clinical features; optic disc drusen and vitiligo. To our knowledge, this is the first report of A-T associated with these findings.

An unexpected outcome of blunt ocular trauma: rupture of three muscles.

INTRODUCTION: Traumatic strabismus due to isolated extraocular muscle rupture is uncommon. Treatment usually depends on the severity of both the subjective and objective findings. METHODS: We report a male patient with restricted abduction and supraduction in the right eye follow ing a blunt ocular trauma. The exploration revealed the rupture of superior rectus, superior oblique, and lateral rectus muscles. Only lateral rectus muscle could be sutured to the proximal segment. Superior rectus and superior oblique muscles were severed brutally, so that repairing was not possible. RESULTS: On the day after exploration and primary suturation, there was 25 prism diopters (PD) hypotropia and 15 PD esotropia in his right eye with severe limited supraduction and abduction. His major complaint was a large vertical diplopia which resolved partially with the prismatic glasses prescribed. After 6 months follow-up, medial rectus and inferior rectus recession was performed in the right eye. The patient had a limited but improved abduction after the operation. He was orthotropic and had a single binocular vision in the primary position. DISCUSSION: In suspected extraocular muscle ruptures, orbital imaging methods and surgical exploration should be considered promptly. MRI may be mandatory to demonstrate the severed muscles in cases with persistent diplopia and normal CT. Prognosis is usually better in patients having partial extraocular muscle damage and treatment options should be evaluated on patient basis.

Persistent pupillary membranes in 3 siblings.

We report 3 siblings from a nonconsanguineous white family with bilateral persistent pupillary membranes with dissimilar forms of severity. Two of the patients required no treatment; 1 was treated surgically for occlusion of the pupillary axis and moderate visual acuity decrease. Anterior segment examination was otherwise normal in the siblings. Although persistent pupillary membranes are usually sporadic, cases in which they are associated with other anterior chamber abnormalities might be inherited autosomal dominant. To our knowledge, this is the first report of a familial isolated persistent papillary membrane case with no other anterior chamber abnormality.

Effect of caffeic acid phenethyl ester on treatment of experimentally induced methicillin-resistant Staphylococcus epidermidis endophthalmitis in a rabbit model.

This study investigated the anti-inflammatory effects of caffeic acid phenethyl ester (CAPE), a natural bee-produced compound, and compared it with corticosteroids in the treatment of experimentally induced methicillin-resistant Staphylococcus epidermidis (MRSE) endophthalmitis in addition to intravitreal antibiotics. An experimental endophthalmitis model was produced in 24 New Zealand albino rabbits by unilateral intravitreal injection of 0.1 ml of 4.7 x 10(4) colony-forming units (CFU) methicillin-resistant S. epidermidis. The animals were then divided randomly into three treatment groups and a control group, group 1 (six rabbits), received only intravitreal vancomycin (1.0 mg/0.1 ml); group 2 (six rabbits), received both intravitreal vancomycin (1.0 mg/0.1 ml) and intravitreal dexamethasone (400 microg/0.1 ml) and group 3 (six rabbits), received both intravitreal vancomycin (1.0 mg/0.1 ml) and subtenon CAPE (10 mg/0.3 ml) after 24 h post-infection. No treatment was given to the control group. Treatment efficacy was assessed by clinical examination, vitreous culture and histopathology. There were no statististically significant differences between clinical scores of all groups in examinations at 24 and 48 h post-infection (p = 0.915 and p = 0.067 respectively), but in examinations at 72 h post-infection and after 7 days post-infection, although the clinical scores of treatment groups were not significantly different from each other, they were significantly lower than the control group (p < 0.05). The culture results of all groups were sterile. As a result, CAPE was found to be as effective as dexamethasone in reducing inflammation in the treatment of experimental MRSE endophthalmitis when used with antibiotics. More studies are needed to determine the optimal administration route and effective dosage of this compound.

Intravitreal triamcinolone acetonide treatment for serpiginous choroiditis.

PURPOSE: To report the efficacy of intravitreal triamcinolone acetonide injection for acute treatment of a patient with serpiginous choroiditis. METHODS: A 50-year-old male patient with serpiginous choroiditis presenting with the complaint of decreased visual acuity in his right eye for the last 10 days. The best corrected visual acuity (BCVA) of the patient was counting finger from 1 meter. Fundus examination and fundus fluorescein angiography of right eye revealed active macular choroiditis in right eye. Intravitreal triamcinolone acetonide (4 mg/0.1 ml) was injected into vitreous, and the patient was followed with visual acuity testing, intraocular pressure measurement, and fundus examination, including fundus fluorescein angiography. RESULTS: Visual acuity of the patient improved to 20/100 after 2 weeks in spite of the triamcinolone crystals, and to 20/50 after 4 weeks with a single dose intravitreal triamcinolone acetonide injection. Complete resolution of the active lesion has been maintained during the 6 months of follow-up. CONCLUSIONS: Single dose intravitreal triamcinolone acetonide injection is sufficient for controlling the active lesions in serpiginous choroiditis. It needs further evaluation as an alternative treatment for achieving rapid and significant visual acuity recovery.

Serum oxidant/antioxidant balance in exfoliation syndrome.

BACKGROUND: To evaluate the relationship between the serum oxidant-antioxidant balance and the presence of exfoliation syndrome (XFS) in a prospective study. METHODS: The study group comprised 27 cases of XFS. Serum concentrations of myeloperoxidase, malondialdehyde, vitamins A, C and E, catalase and total antioxidant were measured and compared with an independent group by t-test. RESULTS: Serum myeloperoxidase, vitamins A and E, catalase and total antioxidant parameters were not statistically different among the groups (P >0.05). Serum vitamin C concentrations were significantly lower and malondialdehyde concentrations were significantly higher in cases of XFS when compared with the control group (P=0.008 and P=0.002, respectively). CONCLUSION: An altered oxidant-antioxidant balance may play a role in the pathogenesis of XFS.