An Antibiotic Nanobomb Constructed from pH-Responsive Chemical Bonds in Metal-Phenolic Network Nanoparticles for Biofilm Eradication and Corneal Ulcer Healing.

In the treatment of refractory corneal ulcers caused by Pseudomonas aeruginosa, antibacterial drugs delivery faces the drawbacks of low permeability and short ocular surface retention time. Hence, novel positively-charged modular nanoparticles (NPs) are developed to load tobramycin (TOB) through a one-step self-assembly method based on metal-phenolic network and Schiff base reaction using 3,4,5-trihydroxybenzaldehyde (THBA), ε-poly-ʟ-lysine (EPL), and Cu2+ as matrix components. In vitro antibacterial test demonstrates that THBA-Cu-TOB NPs exhibit efficient instantaneous sterilization owing to the rapid pH responsiveness to bacterial infections. Notably, only 2.6 µg mL-1 TOP is needed to eradicate P. aeruginosa biofilm in the nano-formed THBA-Cu-TOB owing to the greatly enhanced penetration, which is only 1.6% the concentration of free TOB (160 µg mL-1 ). In animal experiments, THBA-Cu-TOB NPs show significant advantages in ocular surface retention, corneal permeability, rapid sterilization, and inflammation elimination. Based on molecular biology analysis, the toll-like receptor 4 and nuclear factor kappa B signaling pathways are greatly downregulated as well as the reduction of inflammatory cytokines secretions. Such a simple and modular strategy in constructing nano-drug delivery platform offers a new idea for toxicity reduction, physiological barrier penetration, and intelligent drug delivery.

A comparison of antimicrobial regimen outcomes and antibiogram development in microbial keratitis: a prospective cohort study in Alexandria, Egypt.

INTRODUCTION: Antimicrobial resistance in microbial keratitis has not been previously explored in Alexandria. We aim to recommend effective therapies through identification of etiological agents, determination of antimicrobial susceptibilities, and comparing outcomes of empiric topical antimicrobials. METHODS: In this 2022 prospective cohort conducted in Alexandria Main University Hospital cornea clinic, antimicrobial susceptibilities of isolated microorganisms from corneal scrapings were detected and antibiograms were developed. Bacterial (BK), fungal (FK), or mixed fungal/bacterial keratitis (MFBK) patients on empiric regimens were compared for ulcer healing, time-to-epithelialization, best-corrected visual acuity, interventions, and complications. RESULTS: The prevalent microorganisms in 93 positive-cultures were coagulase-negative staphylococci (CoNS, 30.1%), Pseudomonas aeruginosa (14%), and Aspergillus spp. (12.9%). CoNS were susceptible to vancomycin (VAN, 100%) and moxifloxacin (MOX, 90.9%). Gram-negative bacteria showed more susceptibility to gatifloxacin (90.9%) than MOX (57.1%), and to gentamicin (GEN, 44.4%) than ceftazidime (CAZ, 11.8%). Methicillin-resistance reached 23.9% among Gram-positive bacteria. Fungi exhibited 10% resistance to voriconazole (VRC). Percentages of healed ulcers in 49 BK patients using GEN + VAN, CAZ + VAN and MOX were 85.7%, 44.4%, and 64.5%, respectively (p = 0.259). Their median time-to-epithelialization reached 21, 30, and 30 days, respectively (log-rank p = 0.020). In 51 FK patients, more ulcers (88.9%) healed with natamycin (NT) + VRC combination compared to VRC (39.1%) or NT (52.6%) (p = 0.036). Their median time-to-epithelialization was 65, 60, and 22 days, respectively (log-rank p < 0.001). The VRC group required more interventions (60.9%) than NT + VRC-treated group (11.1%) (p = 0.018). In 23 MFBK patients, none healed using NT + CAZ + VAN, while 50% healed using VRC + CAZ + VAN (p = 0.052). Regimens had comparable visual outcomes and complications. CONCLUSION: Based on the higher detected susceptibility, we recommend empiric MOX in suspected Gram-positive BK, gatifloxacin in Gram-negative BK, and GEN + VAN in severe BK. Due to better outcomes, we recommend NT + VRC in severe FK. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT05655689. Registered December 19, 2022- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05655689?cond=NCT05655689.&draw=2&rank=1.

Decreased levels of interleukin-6 level in tears and clinical changes in subjects with moderate-to-severe infection corneal ulcers treated with platelet-rich fibrin lysate eye drops.

PURPOSE: To assess the change of interleukin-6 (IL-6) levels in tears and ocular clinical parameters in corneal ulcer patients with moderate-to-severe infection after adjunctive therapy with platelet-rich fibrin (PRF) lysate-eyedrops compared with autologous serum eyedrops. MATERIALS AND METHODS: This study was a randomized double-blind controlled trial, which compared two groups of patients at Dr. Sardjito Hospital, Yogyakarta. A total of 42 patients (42 eyes) were divided into the control group (21 patients) and the intervention group (21 patients). All patients received antibacterial/antifungal therapy based on the etiology, and an adjunctive eyedrop therapy: autologous serum eyedrops for the control group and PRF lysate eyedrops for the intervention group. The IL-6 levels and clinical changes in patients, such as the area of corneal defects, pericorneal injection, and the level of blepharospasm were measured at the baseline, day 6, and day 13 after starting the treatment. RESULTS: Compared to baseline, the mean IL-6 level in day 13 decreased by 426.6 ± 665.4 pg/ml (P = 0.005) and 1283.7 ± 1569.1 pg/ml (P = 0.079) in the intervention and control groups, respectively. However, the difference between the two groups was not statistically significant (P = 0.164). In term of corneal defect area, there was a significant decrease at day 6 and day 13 in both groups but there was no statistically significant difference between the two groups in all time points. Similarly, the proportion of blepharospasm and pericorneal injection severity appeared to improve especially on day 13 in both groups but were not statistically different between the two. CONCLUSION: There was a statistically significant decrease in IL-6 levels in the tears in patient using PRF lysate, but there was no significant difference when compared to those using autologous serum. The difference in defect area, degree of blepharospasm, and pericorneal injection was not statistically significant between the two treatment options.

The effect of social determinants of health on severity of microbial keratitis presentation at a tertiary eye care hospital in Southern India.

Purpose: Understanding the association between social determinants of health (SDoHs) and microbial keratitis (MK) can inform underlying risk for patients and identify risk factors associated with worse disease, such as presenting visual acuity (VA) and time to initial presentation. Methods: This was a cross-sectional study was conducted with patients presenting with MK to the cornea clinic at a tertiary care hospital in Madurai, India. Patient demographics, SDoH survey responses, geographic pollution, and clinical features at presentation were collected. Descriptive statistics, univariate analysis, multi-variable linear regression models, and Poisson regression models were utilized. Results: There were 51 patients evaluated. The mean age was 51.2 years (SD = 13.3); 33.3% were female and 55% did not visit a vision center (VC) prior to presenting to the clinic. The median presenting logarithm of the minimum angle of resolution (logMAR) VA was 1.1 [Snellen 20/240, inter-quartile range (IQR) = 20/80 to 20/4000]. The median time to presentation was 7 days (IQR = 4.5 to 10). The average particulate matter 2.5 (PM2.5) concentration, a measure of air pollution, for the districts from which the patients traveled was 24.3 µg/m3 (SD = 1.6). Age- and sex-adjusted linear regression and Poisson regression results showed that higher levels of PM2.5 were associated with 0.28 worse presenting logMAR VA (Snellen 2.8 lines, P = 0.002). Patients who did not visit a VC had a 100% longer time to presentation compared to those who did (incidence rate ratio = 2.0, 95% confidence interval = 1.3-3.0, P = 0.001). Conclusion: Patient SDoH and environmental exposures can impact MK presentation. Understanding SDoH is important for public health and policy implications to mitigate eye health disparities in India.

Effects of platelet-rich plasma on corneal re-epithelization and metalloproteinase expression in the cornea of sheep with experimentally-induced infectious keratoconjunctivitis.

Background and Aim: Infectious bovine keratoconjunctivitis is the most crucial ophthalmic disease among ruminants worldwide. Moraxella is the bacteria generally associated with this disease and leads to keratitis, conjunctivitis, corneal ulcers, or blindness. Platelet-rich plasma (PRP) effects in corneal ulcers and different ocular superficial diseases in animals and humans are beneficial and enhance rapid healing and improvement, but the effects in infectious keratoconjunctivitis in ruminants are uncertain. This study aimed to examine the effect of PRP on re-epithelization, corneal tissue, clinical signs, and matrix metalloproteinase (MMP) expression in sheep with infectious keratoconjunctivitis. Materials and Methods: Eighteen sheep were divided into three groups and subjected to a disease-induction experiment. Group 1 (G1) was administered 1.0 mL PRP subconjunctivally, Group 2 (G2) was administered 1.0 mL PRP subconjunctivally and 50 µL gentamicin drops, and the control group (CG) was administered 50 µL saline solution topically every 12 h. Clinical ophthalmologic examination, fluorescein staining, and photography were carried out. Ulcerated areas were measured employing J-Image software. Five and eleven days following the procedure, half of the animals from each group were euthanized, and their corneas were evaluated by histopathology and zymography. Results: Control Group and G2 epithelialized more rapidly. The CG exhibited fewer clinical signs of ocular disease. In histopathological analysis, in G2, alterations were observed only in the epithelium. The CG and G1 exhibited alterations in the epithelium, stroma, and Descemet's membrane. In zymography, a decline in MMP-2 expression in the animals treated with PRP was detected. Matrix metalloproteinase-9 was significantly expressed in the animals treated with PRP monotherapy, whereas PRP + gentamicin and CG caused a decrease. Conclusion: Platelet-rich plasma alone did not demonstrate any beneficial effect on re-epithelialization, a decline in clinical signs, tissue alterations, and expression of metalloproteinases. Platelet-rich plasma combined with gentamicin was capable of suppressing MMPs, primarily MMP-9, but do not display positive effects in re-epithelization, reduction of clinical signs, or tissue effects. These outcomes are similar to those discovered in untreated animals, so the use of PRP in patients with infectious keratoconjunctivitis does not offer greater benefits in sheep. Additional research is required to validate the results of PRP use in natural disease presentation.

A scoping review of patients' barriers to eye care for glaucoma and keratitis.

In this scoping review, we examine underlying causes of loss to follow-up for chronic (glaucoma) and acute (corneal ulcers) eye conditions using the Penchansky and Thomas access to care framework. We explore barriers by World Health Organization income levels and by studying geographical location. We identified 6,363 abstracts, with 75 articles retrieved and 16 meeting inclusion criteria. One article discussed barriers to follow-up care for people with corneal ulcers, and the other 15 were for people with glaucoma. The most frequent barriers to care were affordability, awareness, and accessibility. The international studies had a greater percentage of studies report acceptability as a barrier to loss to follow-up. Countries with universal healthcare included affordability as a loss to follow-up barrier, emphasizing that cost goes beyond the ability to pay for direct treatment costs. Understanding and addressing barriers to follow-up care can aid the goal of continued care and decrease the risk of poor outcomes and vision loss.

Resultados de los pacientes operados de queratoplastia terapéutica en la provincia de Matanzas

Introducción: la queratoplastia terapéutica se define como un procedimiento cuyo propósito es contribuir a erradicar o reducir la infección cuando la terapia médica máxima no es eficaz para lograr este fin. Objetivo: evaluar la evolución y resultados de los pacientes operados de queratoplastia terapéutica. Materiales y métodos: se realizó un estudio descriptivo transversal en un universo de 15 pacientes con diagnóstico de úlcera grave corneal. Dichos pacientes fueron operados de queratoplastia terapéutica en el Servicio de Córnea del Hospital Universitario Comandante Faustino Pérez Hernández, de la provincia de Matanzas, entre abril de 2017 y febrero de 2020, y dieron su consentimiento informado para participar en la investigación. Resultados: predominó el sexo masculino, con un 53,3 % y una media de edad de 58,8 años. Como factores predisponentes, prevaleció el antecedente de trauma en el 33,3 %, seguido del uso de lentes de contacto y la diabetes mellitus como enfermedad sistémica asociada. Las úlceras de etiología micótica predominaron en el 26,6 % de los casos; la perforación corneal y el descemetocele se presentaron en el 40 % y 26,6 % de los pacientes respectivamente. Durante el primer mes, las complicaciones postoperatorias más frecuentes fueron la recidiva de la sepsis y la necrosis del injerto. Por su parte, la opacidad y vascularización corneal fueron las secuelas más frecuentes. Conclusiones: la demora en iniciar el protocolo de tratamiento adecuado provoca cuadros severos de la enfermedad, realizando queratoplastia "en caliente" en córneas perforadas o con necrosis, que devienen complicaciones postoperatorias y secuelas no alentadoras para los pacientes.

Introduction: therapeutic keratoplasty is defined as a procedure whose purpose is to help eradicate or reduce the infection when maximum medical therapy is not efficacious to achieve this end. Objective: to evaluate the evolution and results of the patients operated on therapeutic keratoplasty. Materials and methods: a cross-sectional, descriptive study was carried out in a universe of 15 patients with a diagnosis of severe corneal ulcer. The patients underwent therapeutic keratoplasty surgeries in the Cornea Service of the Clinical Surgical University Hospital Comandante Faustino Perez Hernandez, in the province of Matanzas, between April 2017 and May 2020, and gave their informed consent to participate in the research. Results: male gender predominated, with 53.3% and a mean age of 58.8 years. As predisposing factors, trauma antecedent predominated in 33.3%, followed by the use of contact lenses and diabetes mellitus as associated systemic disease. Ulcers of mycotic etiology predominated in 26.6% of the cases; corneal perforation and descemetoceles occurred in 40% and 26.6% of the cases respectively. During the first month, the most frequent postsurgery complications were recidival sepsis and graft necrosis. On the other hand, corneal opacity and vascularization were the most frequent sequels. Conclusions: the delay in initiating the adequated protocol treatment causes severe symptoms of the disease that lead to "in hot" keratoplasty in perforated or necrosed corneas, causing postsurgery complications and non-encouraging sequels for patients.

Advances and prospects of platelet-rich plasma therapy in veterinary ophthalmology.

In the recent decades, there has been a significant uptick on the use of platelet-rich plasma (PRP) as a better alternative for ophthalmologic therapies in pathologies, primarily of the ocular surface. PRP is a class of liquid platelet concentrate containing a supra-physiological concentration of platelets in a relatively small amount of plasma. Its potential to heal various tissues has piqued interest in its therapeutic application as a biomaterial in regenerative medicine. It is currently a popular therapeutic agent in plastic surgery, cardiothoracic surgery, reconstructive surgery, and even oral and maxillofacial surgery. Based on the data from in vitro and in vivo studies, it can be concluded that PRP possesses adequate therapeutic potential in ocular pathologies, especially those involving cornea. In addition, the high concentrations of growth factors (TGF-ß, VEGF, EGF) present in the PRP accelerate the healing of the corneal epithelium. PRP has great therapeutic prospects in veterinary ophthalmology as a regenerative therapeutic modality. However, several variables are yet to be defined and standardized that can directly affect the efficacy of PRP application in different ophthalmic conditions. There is a shortage of research on the use of PRP in ocular surface defects compared to the number of studies and reports on the use of autologous and allogeneic serum eye drops. Therefore, a data-driven approach is required to generate consensus/guidelines for the preparation, characterization, and therapeutic use of PRP in veterinary ophthalmology. This review aims to inform readers of the latest research on PRP, including its preparation methods, physiological and biochemical properties, clinical applications in veterinary ophthalmology, and their safety and efficacy.

Urgent unmet needs in the care of bacterial keratitis: An evidence-based synthesis.

Bacterial corneal infections, or bacterial keratitis (BK), are ophthalmic emergencies that frequently lead to irreversible visual impairment. Though increasingly recognized as a major cause of global blindness, modern paradigms of evidence-based care in BK have remained at a diagnostic and therapeutic impasse for over half a century. Current standards of management - based on the collection of corneal cultures and the application of broad-spectrum topical antibiotics - are beset by important yet widely underrecognized limitations, including approximately 30% of all patients who will develop moderate to severe vision loss in the affected eye. Though recent advances have involved a more clearly defined role for adjunctive topical corticosteroids, and novel therapies such as corneal crosslinking, overall progress to improve patient and population-based outcomes remains incommensurate to the chronic morbidity caused by this disease. Recognizing that the care of BK is guided by the clinical axiom, "time equals vision", this chapter offers an evidence-based synthesis for the clinical management of these infections, underscoring critical unmet needs in disease prevention, diagnosis, and treatment.

Estabilidad del colirio de insulina para el tratamiento de úlceras corneales refractarias / Stability of insulin eye drops in the treatment of refractory corneal ulcers

Objetivo: Determinar y comparar la estabilidad físico-química y microbiológica de dos colirios de insulina 25 UI/ml elaborados con suerofisiológico o balanced salt solution bajo diferentes condiciones de conservación durante 120 días.Método: Los colirios se elaboraron por triplicado con insulina Actrapid®100 Ul/ml y balanced salt solution o suero fisiológico como vehículo, yfueron conservados a temperatura ambiente (25 °C), en nevera (2-8 °C)o congelador (–20 °C) durante 120 días. Se determinó la concentraciónde insulina mediante cromatografía liquida de ultra alta resolución, laosmolalidad y el pH a días 0, 3, 7, 15, 30, 60, 90 y 120. Asimismo, seextrajeron muestras para estudios microbiológicos en los días 0, 15, 30,60, 90 y 120.Resultados: La formulación elaborada con suero fisiológico mantuvola concentración de insulina por encima del 90% con respecto a la inicialtras 120 días de estudio en todas las condiciones de temperatura. En elcaso del colirio elaborado con balanced salt solution, la concentraciónse mantuvo estable en ambiente y congelador tras 120 días, aunque ennevera descendió por debajo del 90% a día 90 de estudio. Los valoresde osmolalidad y pH se mantuvieron constantes en ambas formulacionesy condiciones de conservación. No se observó crecimiento microbiológico en ninguna de las muestras retiradas.Conclusiones: El colirio de insulina 25 UI/ml elaborado con suerofisiológico es estable 120 días, conservado tanto a temperatura ambientecomo en nevera o congelador, protegido de la luz. Con balanced saltsolution permanece estable 120 días a temperatura ambiente y congelador, reduciéndose el periodo de validez a 90 días en el caso de laconservación en nevera. (AU)

Objective: To determine and compare the physicochemical and microbiological stability of two 25 IU/mL insulin eye drop formulations madewith normal saline and a balanced salt solution, respectively, stored for120 days under various conditions.Method: Eye drops were compounded in triplicate with 100 IU/mLActrapid® insulin and either normal saline or a balanced salt solution asvehicles, and they were stored alternatively at room temperature (25 °C),in a refrigerator (2-8 °C) or in a freezer (–20 °C) for 120 days. Insulinconcentrations were determined by ultra-high resolution liquid chromatography, and osmolality and pH values were measured at days 0, 3, 7,15, 30, 60, 90 and 120. Likewise, samples were extracted for microbiological studies on days 0, 30, 60, 90 and 120.Results: The formulation made with normal saline maintained insulinconcentrations above 90% of the baseline level after 120 days acrossall temperature conditions. In the case of the balanced salt solution-basedeye drops, insulin concentration when stored at room temperature or inthe freezer remained stable after 120 days, although insulin concentrationwhen stored in the refrigerator fell below 90% on day 90 of the study.Osmolality and pH values remained constant in both formulations andacross all storage conditions. No microbiological growth was observedin any of the samples. Conclusions: 25 IU/mL insulin eye drops made with normal salineremain stable for 120 days whether they are stored at room temperature,in a refrigerator or in a freezer, provided that they are protected fromlight. When made with a balanced salt solution, they remain stable for120 days at room temperature and in a freezer, their shelf life being reduced to 90 days in the case of storage in a refrigerator. (AU)

Image-Based Differentiation of Bacterial and Fungal Keratitis Using Deep Convolutional Neural Networks.

Purpose: Develop computer vision models for image-based differentiation of bacterial and fungal corneal ulcers and compare their performance against human experts. Design: Cross-sectional comparison of diagnostic performance. Participants: Patients with acute, culture-proven bacterial or fungal keratitis from 4 centers in South India. Methods: Five convolutional neural networks (CNNs) were trained using images from handheld cameras collected from patients with culture-proven corneal ulcers in South India recruited as part of clinical trials conducted between 2006 and 2015. Their performance was evaluated on 2 hold-out test sets (1 single center and 1 multicenter) from South India. Twelve local expert cornea specialists performed remote interpretation of the images in the multicenter test set to enable direct comparison against CNN performance. Main Outcome Measures: Area under the receiver operating characteristic curve (AUC) individually and for each group collectively (i.e., CNN ensemble and human ensemble). Results: The best-performing CNN architecture was MobileNet, which attained an AUC of 0.86 on the single-center test set (other CNNs range, 0.68-0.84) and 0.83 on the multicenter test set (other CNNs range, 0.75-0.83). Expert human AUCs on the multicenter test set ranged from 0.42 to 0.79. The CNN ensemble achieved a statistically significantly higher AUC (0.84) than the human ensemble (0.76; P < 0.01). CNNs showed relatively higher accuracy for fungal (81%) versus bacterial (75%) ulcers, whereas humans showed relatively higher accuracy for bacterial (88%) versus fungal (56%) ulcers. An ensemble of the best-performing CNN and best-performing human achieved the highest AUC of 0.87, although this was not statistically significantly higher than the best CNN (0.83; P = 0.17) or best human (0.79; P = 0.09). Conclusions: Computer vision models achieved superhuman performance in identifying the underlying infectious cause of corneal ulcers compared with cornea specialists. The best-performing model, MobileNet, attained an AUC of 0.83 to 0.86 without any additional clinical or historical information. These findings suggest the potential for future implementation of these models to enable earlier directed antimicrobial therapy in the management of infectious keratitis, which may improve visual outcomes. Additional studies are ongoing to incorporate clinical history and expert opinion into predictive models.

A safer alternative approach to penetrating keratoplasty in opaque corneas.

Background: This video demonstrates a useful technique of keratoplasty which can be routinely undertaken by all surgeons when imaging modalities such as anterior segment optical coherence tomography are not available and prior patient history is not forthcoming. Purpose: To demonstrate a technique of lamellar separation and layer by layer removal of host cornea when dealing with keratoplasty in perforated corneal ulcers, adherent leucomas, dense corneal opacities, which obscure visualization of the iris and anterior chamber details. Synopsis: In this video, we demonstrate penetrating keratoplasty in a failed opacified graft with iridocorneal adhesions, with no visualization of anterior chamber details. Lamellar dissection of the host cornea is done starting at its periphery and moving centrally, with gentle peeling of the superficial layers, the epithelium and bulk of stroma, following which, the deeper portion of the cornea is dissected and separated from underlying adherent iris tissue. Layer by layer separation allows better visualization through the remaining thin layers of the cornea. This permits fine dissection and layered removal of the cornea, thereby avoiding injury to iris and lens. Debulking of the host cornea decreases the force that is needed to be applied to separate adherent iris tissue from the host cornea, and reduces the chances of sudden entry into the anterior chamber and subsequent damage to the iris or lens. This also reduces the chance of iris tears, iridodialysis and bleeding from the iris and helps maintain iris integrity, which is essential intraoperatively for protection of lens and anterior chamber formation, and to avoid glare and photophobia postoperatively. Preventing iris damage also reduces the chances of formation of peripheral anterior synechiae (PAS), which can predispose to graft rejection, graft failure and secondary glaucoma. Highlights: Layer by layer corneal separation beginning inside the graft host junction, careful separation of iridocorneal adhesions and PAS is a helpful technique to optimally preserve the anterior segment anatomy during difficult cases of penetrating keratoplasty. Online Video Link: https://youtu.be/ZmQQhuOnAh4.

Update on diagnosis and management of refractory corneal infections.

Infectious keratitis is a medical emergency resulting in significant visual morbidity. Indiscriminate use of antimicrobials leading to the emergence of resistant or refractory microorganisms has further worsened the prognosis. Coexisting ocular surface diseases, delay in diagnosis due to inadequate microbiological sample, a slow-growing/virulent organism, or systemic immunosuppressive state all contribute to the refractory response of the ulcer. With improved understanding of these varied ocular and systemic factors contributing to the refractory nature of the microbes, role of biofilm formation and recent research on improving the bioavailability of drugs along with the development of alternative therapies have helped provide the required multidimensional approach to effectively diagnose and manage cases of refractory corneal ulcers and prevent corneal perforations or further dissemination of disease. In this review, we explore the current literature and future directions of the diagnosis and treatment of refractory keratitis.

Clinical and instrumental assessment of the corneal healing in moderate and severe neurotrophic keratopathy treated with rh-NGF (Cenegermin).

PURPOSE: To evaluate corneal healing in patients with moderate and severe neurotrophic keratitis (NK) treated with topical rh-NFG (Cenegermin). METHODS: Twenty-one patients (12F and 9M) aged from 21 to 93 years (62.5 ± 19.4) with moderate and severe NK were enrolled in the study. The patients were divided into 2 groups accordingly to the severity of the disease. The underlying causes of NK were determined. The VAS questionnaire was dispensed. The ocular examination comprised slit lamp evaluation, ocular surface assessment with Keratograph 5M (Oculus, Germany), corneal sensitivity with Cochet-Bonnet esthesiometer (Lunneaux, France) and corneal thickness measurement with AC-OCT (DRI, Triton, Topcon, Japan). The drops of Cenegermin 0.002% were administrated 6 times daily for 8 weeks. All participants were evaluated at baseline, after 4 and 8 weeks of the treatment. The area of corneal defect with maximum diameter less than 0.5 mm was considered as healed. The main outcome measures were corneal healing, corneal sensitivity recovery and corneal thickness in the ulcer group. RESULTS: The herpetic keratitis was the most common cause of NK. Thirteen eyes were affected by severe grade of NK with corneal ulcer and 8 eyes presented a moderate grade. After 8 weeks a complete healing of the corneal defects was registered both in moderate and severe NK. Significant increase of the corneal sensitivity and thickness were registered. CONCLUSIONS: The rh-NGF (Cenegermin) resulted effective in the treatment of the severe and moderate NK with significant recovery of the corneal sensitivity and healing of the corneal defects in both groups.

The Role of Hi-Tech Devices in Assessment of Corneal Healing in Patients with Neurotrophic Keratopathy.

To prove the role of high-tech investigation in monitoring corneal morphological changes in patients with neurotrophic keratopathy (NK) using Keratograph 5M (K5M) and anterior segment OCT (AS-OCT), corneal healing was monitored with Keratograph 5M (Oculus, Wetzlar, Germany) and AS-OCT (DRI, Triton, Topcon, Tokyo, Japan) in 13 patients (8F and 5M), aged from 24 to 93 years (67.8 ± 19) with severe NK, who were treated with Cenegermin 0.002% (20 µg/mL) (Oxervate®, Dompè, Farmaceutici Spa, Milan, Italy). The surface defects were evaluated on Keratograph 5M with ImageJ software and the corneal thickness variations were measured using DRI-Triton OCT software. Instrumental procedures were performed at baseline, and after 4 and 8 weeks of the treatment, respectively. The main outcome measures were reduction of the ulcers' area and corneal thickness recovery. The mean area of the corneal ulcers was reduced between baseline and 4 weeks examination in all patients, and at 8 weeks all ulcers were completely healed. An increase of the corneal thickness was evidenced between the baseline visit and after the 4- and 8-week follow-up, respectively. Additionally, only in collaborating subjects the In Vivo Confocal Microscopy (IVCM) was performed with HRT Rostock Cornea Module (Heidelberg Eng GmbH) to study the corneal nerves fibres. High-tech diagnostics with K5M, AS-OCT and IVCM proved useful in the assessment of corneal morphology and the healing process in patients with NK and could be extended to assess other corneal pathologies.

Medical management and resolution of perinatal bilateral exophthalmia and secondary corneal ulcers in an Antillean manatee (Trichechus manatus manatus) neonate from Puerto Rico.

OBJECTIVE: To present a novel case of perinatal bilateral exophthalmos and corneal ulcers in a neonate Antillean manatee and describe the medical treatment that led to the resolution of the observed clinical signs and vision restoration. ANIMAL STUDIED: A manatee stranded alone in Puerto Rico on July 5, 2020. RESULTS: The manatee was found in critical condition with pronounced exophthalmos, lagophthalmos, and corneal opacification of both eyes (OU). Vision impairment was evident due to the lack of ocular menace reflex and bumping into the tank's walls. Biomicroscopy revealed conjunctival hyperemia and chemosis, limited third eyelid movement, but had viscous tears present OU. Dense, full-thickness, white to cream-colored cellular infiltrates affected 70% of the cornea with peripheral active vascularization OU. Rubeosis iridis was also present OU. Treatment consisted of supportive medical management, including nutritional support and topical treatment for ulcerative keratitis. Resolution of the corneal ulcers and functional vision were achieved after 6 weeks of therapy. Currently, bilateral, mild, intermittent exophthalmos is observed with no adverse clinical signs, and the calf is in good health. CONCLUSIONS: The extent of bilateral corneal disease on a neonatal calf may be a result of an intrauterine infection or possible trauma at or right after birth. While the latter may have led to exophthalmia and consequent corneal disease, the exact cause could not be determined. Supportive therapy and medical management of infectious keratitis were successful and led to vision recovery. This is the first report of ocular pathology in a neonatal manatee.

Gore-Tex- as an adjuvant to Tenon's patch graft for large perforated corneal ulcers during Covid times.

PURPOSE: Covid-19 has profoundly affected the day-to-day lives of individual citizens. It has strained all aspects of health care including eye banking and corneal transplantation. Although elective procedures like optical Keratoplasty can be postponed, management of perforating ulcers needs tectonic Keratoplasty to avoid permanent ocular morbidities. It has become inevitable for corneal surgeons to innovate newer methods of treatment for such corneal diseases. The large corneal perforations if left untreated may lead to permanent visual loss. An alternative method of managing a large peripheral corneal perforation of size 5 × 5.5 mm was done using Tenons patch graft with Gore-tex in a 50-year-old female patient, during the lockdown. OBSERVATIONS: Tenons graft with Gore-tex, effectively sealed the large corneal perforation in our case without iris incarceration, favourable for future visual rehabilitation. CONCLUSIONS AND IMPORTANCE: Tenons and Gore-tex are readily available. It is not necessary to rely on the donor corneas or the distributing eye banks during this pandemic situation. In the future, this procedure can reduce the burden of the pre-existing increase in the gap between the need and supply of donor corneas in developing countries.

DSP missense variant in a Scottish Highland calf with congenital ichthyosis, alopecia, acantholysis of the tongue and corneal defects.

BACKGROUND: Ichthyosis describes a localized or generalized hereditary cornification disorder caused by an impaired terminal keratinocyte differentiation resulting in excessive stratum corneum with the formation of more or less adherent scales. Ichthyosis affects humans and animals. Two rare bovine forms are reported, the severe harlequin ichthyosis and the less severe congenital ichthyosis, both characterized by a severe orthokeratotic lamellar hyperkeratosis. RESULTS: A 2-weeks-old purebred Scottish Highland calf was referred because of a syndrome resembling congenital ichthyosis. The clinical phenotype included diffuse alopecia and a markedly lichenified skin covered with large and excessive scales. Additionally, conjunctivitis and ulceration of the cornea were noted. Post-mortem examination revealed deep fissures in the diffusely thickened tongue and histopathological findings in the skin confirmed the clinical diagnosis. Whole-genome sequencing of the affected calf and comparison of the data with control genomes was performed. A search for private variants in known candidate genes for skin phenotypes including genes related with erosive and hyperkeratotic lesions revealed a single homozygous protein-changing variant, DSP: c.6893 C>A, or p.Ala2298Asp. The variant is predicted to change a highly conserved residue in the C-terminal plakin domain of the desmoplakin protein, which represents a main intracellular component of desmosomes, important intercellular adhesion molecules in various tissues including epidermis. Sanger sequencing confirmed the variant was homozygous in the affected calf and heterozygous in both parents. Further genotyping of 257 Scottish Highland animals from Switzerland revealed an estimated allele frequency of 1.2%. The mutant allele was absent in more than 4800 controls from various other cattle breeds. CONCLUSIONS: This study represents the first report of combined lesions compatible with congenital ichthyosis, alopecia, acantholysis of the tongue and corneal defects associated with a DSP missense variant as the most likely underlying cause. To the best of our knowledge, this study is also the first report of a DSP-related syndromic form of congenital ichthyosis in domestic animals. The results of our study enable genetic testing to avoid the unintentional occurrence of further affected cattle. The findings were added to the Online Mendelian Inheritance in Animals (OMIA) database (OMIA 002243-9913).

Long-term clinical outcome and satisfaction survey in patients with neurotrophic keratopathy after treatment with cenegermin eye drops or amniotic membrane transplantation.

PURPOSE: Neurotrophic keratopathy (NK) is a degenerative corneal disease caused by damage of trigeminal innervation. The purpose of this study is to evaluate the clinical outcomes and patient-reported satisfaction of treatment with amniotic membrane transplantation (AMT) or cenegermin eye drops in patients with NK. METHODS: Clinical charts of patients with NK treated with AMT (group A) or cenegermin eye drops (group B), with at least 12 months of follow-up, were reviewed for demographics, medical history, corneal healing, and disease recurrence. Patient satisfaction was evaluated by a newly developed questionnaire investigating patient's appreciation of treatment of NK (2 items) and satisfaction with NK treatment outcomes (5 items). RESULTS: At the end of treatment, complete corneal healing was observed in 13/15 (86%) patients in group A and in 23/24 (96%) in group B. At 12 months follow-up, 6/13 patients (46%) in group A and 3/23 patients (13%) in group B showed recurrence of NK (p = 0.037). Survival analysis showed that group B remained recurrence free for a significantly longer period of time than the group A (p = 0.028). Patients in group B showed a significantly higher satisfaction when compared with patients in group A (total score: 65.7 ± 15.7 vs 47.4 ± 12.8, p = 0.003), both in terms of patients' appreciation of treatment (78.3 ± 15.9 vs 52.2 ± 30, p = 0.020) and satisfaction with treatment outcomes (60.7 ± 21 vs 45.4 ± 13.3, p = 0.037). CONCLUSIONS: Treatment of NK with cenegermin was associated with long-term maintenance of corneal integrity and a higher degree of patient satisfaction.

Ocular Injury Caused by the Bombardier Beetle.

We report a case of ocular injury caused by a bombardier beetle in a young boy. Ocular injuries due to this coleoptera have not previously been reported. An 11-year-old boy experienced an eye injury while trying to place a bombardier beetle inside an anthill. The boy was diagnosed with a second-degree burn on the skin of the upper right eyelid and conjunctival and corneal erosion in the right eye. The condition resolved completely after 2 weeks of appropriate treatment. Education about the dangers of playing with insects is crucial to prevent this type of lesions.