Debulking corneal biopsy with tectonic amniotic membrane transplantation in refractory clinically presumed fungal keratitis.

The treatment of fungal keratitis (FK) is challenging due to the subacute indolent course, and initial misdiagnosis. In this retrospective case series, we highlight both the diagnostic and therapeutic roles of corneal biopsy together with amniotic membrane transplantation (AMT) in patients with refractory clinically presumed FK. Debulking biopsy and tectonic AMT were performed during the initial presentation. Biopsy specimens were sent for KOH smears and cultures. After KOH smears confirmed the presence of fungal elements, topical voriconazole 1% was prescribed for the first 72 h then tailored according to the clinical response and the culture results. The outcome measures were complete resolution of infection and restoration of corneal integrity. Cases associated with culture proven bacterial keratitis were excluded. Twelve cases were included in the study. KOH smears confirmed the presence of fungal growth in all specimens. Cultures grew Aspergillus in 6/12 cases, sensitive to voriconazole (5/6) and amphotericin (3/6); Fusarium (4/12), sensitive to both voriconazole and amphotericin; and no growth in 2/12 cases. Amphotericin 0.15% eye drops were added to the 7 cases with proven sensitivity and to the remaining 2 culture negative cases. Gradual resolution of infection was seen in all cases after 35.6 ± 7.8 days. In FK, a debulking biopsy simultaneously with AMT help decrease the microbial load, suppress the inflammatory process, support the corneal integrity, confirm the presence of fungal pathogen.

Clinical outcomes of corneal neurotization using sural nerve graft in neurotrophic keratopathy.

OBJECTIVE: To evaluate the efficacy of corneal neurotisation using sural nerve graft coaptation of the contralateral supratrochlear nerve in unilateral neurotrophic keratopathy and corneal anesthesia. Corneal neuralization has emerged as a potential option in the treatment of neurotropic keratopathy, however not free from the predicament. We evaluated the long-term outcome of corneal neurotisation in the treatment of unresponsive unilateral neurotropic keratopathy using surgical variations to mimic and expedient the surgical procedure. METHODS: A Prospective interventional study involving patients with unilateral neurotrophic keratopathy (NK) who did not respond to medical measures was conducted. The study parameters evaluated were best-corrected visual acuity improvement, ocular surface evaluation parameters [tear break-up time (TBUT), Schirmer's 1, and ocular surface staining scores (corneal and conjunctival staining)], central corneal sensation (Cochet Bonnet esthesiometer), sub-basal nerve fiber length (SBNFL), and sub-basal nerve fiber density (SBNFD) determined by central confocal microscopy at recruitment and during follow-up at 1-month, 3-month, 6-month, 9-month and 12-month respectively, following corneal neurotization. RESULTS: Eleven eyes of 11 patients with unilateral neurotrophic keratopathy (NK) who underwent corneal neurotisation were studied. The mean follow-up was 10.09±2.31months (range, 6-12). Mean best corrected visual acuity in log MAR at baseline, 1.35±0.52 improved significantly to 1.06±0.76 (P = 0.012) at 3 months and continued to 0.55±0.60 (P = 0.027) at 12 months. There was a significant reduction in NK grade severity and improvement in the ocular surface as early as 1 month, and central corneal sensations (P = 0.024) as soon as 3 months. Mean corneal SBNF improved from 3.12±1.84 mm/mm2 to 4.49±1.88 at 1 month (P = 0.008), 13.31±3.61 mm/mm2 (P = 0.028) at 12 months. Mean central corneal SBNFD evident at 6 months was 1.83±2.54no/mm2 (P = 0.018) and 4.90±3.12no/mm2 (P = 0.028) at 12 months. CONCLUSION: This study substantiates the routine practice of corneal neurotisation by simplifying the intricacies observed during the procedure.

Semiscleral Contact Lens Use After Direct Corneal Neurotization for Neurotrophic Keratopathy.

PURPOSE: To describe a case of a patient treated for neurotrophic keratopathy (NK) with direct corneal neurotization (CN), where a modification to the CN technique allowed for semiscleral contact lens use postoperatively. OBSERVATION: Our patient had successful CN with improved corneal sensation. During the procedure, a 1.0 mm gutter was created between the limbus and nerve graft to allow for semiscleral contact lens fitting. CONCLUSIONS: With the use of preoperative planning and a limbal gutter during CN, a semiscleral contact lens can serve as a well-tolerated postoperative management option to improve visual acuity and protect the corneal surface in patients with NK.

A novel technique of penetrating keratoplasty to prevent intraocular contents extrusion for infectious keratitis.

PURPOSE: To evaluate the safety and the effectiveness of our novel penetrating keratoplasty for infectious keratitis. METHODS: Retrospective, noncomparative, interventional case series of patients with infectious keratitis who received the novel penetrating keratoplasty technique were analyzed. A prepared plastic sheet was located between the diseased cornea and iris-lens diaphragm. After the diseased lesions were removed, the graft was positioned on the plastic sheet and sutured to the recipient bed. The plastic sheet was pulled out from the anterior chamber before the all interrupted sutures were placed. The intra- and post-operative complications, the outcome of the graft and the number of corneal endothelial cells were analyzed. RESULTS: A total of 82 eyes of 82 patients was included. The mean follow-up period was 29 ± 16 months (range from 13 to 45 months). No intraocular content extrusion, simultaneous cataract extraction and suprachoroidal hemorrhage occurred. Direct contact between the infectious cornea and the graft was successfully avoided. Greater than expected endothelial cell reduction or complications were not found. CONCLUSIONS: This modified technique effectively prevents the extrusion of intraocular contents while avoiding the direct contact with donor endothelium during the procedure. The occurrence rate of complications such as endothelial cell loss is not higher than the conventional methods.

Repeat deep anterior lamellar keratoplasty (DALK) for failed primary DALK.

Purpose: To evaluate the effectiveness of repeat deep anterior lamellar keratoplasty (DALK) in patients of previous failed DALK. Methods: : A retrospective analysis of records of seven patients who had undergone repeat DALK following the failure of the primary DALK was done. The indications for repeat surgery, time elapsed since the first surgery, and pre- & postoperative best-corrected visual acuity (BCVA) were noted for all the patients. Results: The follow-up period ranged between one- to four-year post repeat DALK. The indication of primary DALK was keratoconus with vernal keratoconjunctivitis (VKC) (n = 3), corneal amyloidosis (n = 2), Salzman nodular keratopathy (n = 1), and healed keratitis (n = 1). The need for repeat surgery arose when the BSCVA dropped to less than 20/200. The time interval elapsed since the first surgery ranged from two months to four years. Postoperatively, the BSCVA improved from 20/120 to 20/30 at the end of one-year post repeat DALK in all except one patient. All regrafts were clear at the most recent examination, performed after a mean period of 18 months after the secondary graft. No complication was encountered during the resurgery. The dissection of the host bed was easier in the second surgery owing to weaker adhesions. Conclusion: The prognosis for repeat DALK for failed DALK is excellent, and the outcomes of secondary grafts were comparable to those of primary DALK grafts. Re DALK offers the advantage of an easier dissection and lower chances of graft rejection compared to penetrating keratoplasty.

Trachipleistophora hominis: molecular characterization of a rare pathogen causing microsporidial stromal keratitis.

The authors report the clinical and microbiological findings of a unique case of stromal keratitis caused by a rare microsporidium, Trachipleistophora hominis. This case of stromal keratitis was in a 49-year-old male with a history of COVID-19 infection and diabetes mellitus. Corneal scraping specimens revealed numerous microsporidia spores upon microscopic examination. PCR of the corneal button revealed the presence of T. hominis infection, which could be controlled by penetrating keratoplasty surgery. The graft was clear with no recurrence of infection until the last follow-up 6 weeks postsurgery. This is the first case of human stromal keratitis caused by this organism in a post-COVID infection, confirmed by molecular diagnosis.

Infectious Keratitis After Keratorefractive Surgery: Update and Review of the Literature.

OBJECTIVES: To summarize the clinical manifestations, microbiological profile, treatment, and prognosis of corneal infections after different keratorefractive surgery. METHODS: To obtain relevant studies, English-language databases, including PubMed, Ovid Embase, Web of Science, and CLNAHL, were searched from January 1979 to March 2022. The fundamentals of the literature, clinical characteristics, pathogens, and treatments were retrieved for each included article. RESULTS: Eighty-four studies involving 306 infectious eyes were included in this review. Risk factors of potential infection included a history of blepharitis, contact lens usage, and contaminated surgical instruments. The mean onset time was 22.9±38.7 days (range: 1 day to 3 years). The most common organism isolated from infectious keratitis after keratorefractive surgery were Staphylococcus aureus , followed by Mycobacterium and coagulase-negative Staphylococcus . Most of the infections after refractive procedures were sensitive to medical treatment alone, and the ultimate best-corrected visual acuity after medical treatment was as follows: 20/20 or better in 82 cases (37.0%), 20/40 or better in 170 cases (76.5%), and worse than 20/40 in 52 cases (23.5%). Surgical interventions including flap lift, flap amputation, ring removal, and keratoplasty were performed in 120 eyes (44.5%). CONCLUSIONS: Most infections after keratorefractive surgery occur within a week, whereas more than half of the cases after laser-assisted in situ keratomileusis happen after about a month. Gram-positive cocci and mycobacterium are the most common isolates. Infections after LASIK, intracorneal ring (ICR) implantation, and small incision lenticule extraction, which primarily occur between the cornea layers, require irrigation of the tunnels or pocket with antibiotics.

Outcomes of therapeutic penetrating keratoplasty in Pythium insidiosum keratitis managed with a combination of antibiotics.

Purpose: To describe the clinical outcomes of therapeutic penetrating keratoplasty (TPK) in patients with Pythium insidiosum keratitis following treatment with anti-pythium therapy (APT) consisting of linezolid and azithromycin. Methods: A retrospective review of medical records from May 2016 to December 2019 of patients with P. insidiosum keratitis was carried out. Patients who were treated with APT for a minimum of 2 weeks and then subsequently underwent TPK were included in the study. Data on demographic characteristics, clinical features, microbiology characteristics, and intraoperative details, postoperative outcomes were documented. Results: A total of 238 cases of Pythium keratitis were seen during the study period and 50 cases that satisfied the inclusion criteria were included. The median of the geometric mean of the infiltrate was 5.6 mm (IQR 4.0-7.2 mm). The patients received topical APT for a median of 35 days (IQR 25-56) prior to surgery. The most common indication of TPK was worsening keratitis (41/50, 82%). No recurrence of infection was observed. An anatomically stable globe was noted in 49/50 eyes (98%). The median graft survival rate was 2.4 months. A clear graft was present in 10 eyes (20%) with a final median visual acuity of 20/125 after a median follow-up period of 18.4 months (IQR 11-26 months). Graft size of less than 10 mm [OR: 5.824 (CI:1.292-41.6), P = 0.02] was found to be significantly associated with a clear graft. Conclusion: Performing TPK following the administration of APT has good anatomical outcomes. A smaller graft of <10 mm was associated with a higher chance of graft survival.

Management of corneal perforations in dry eye disease: Preferred practice pattern guidelines.

Corneal perforations in eyes with dry eye disease (DED) are difficult to manage due to the interplay of several factors such as the unstable tear film, surface inflammation, and the underlying systemic disease affecting the wound healing process, and the eventual outcome. A careful preoperative examination is required to identify the underlying pathology, and status of ocular surface and adnexa, rule out microbial keratitis, and order appropriate systemic workup in addition to assessing the perforation itself. Several surgical options are available, which include tissue adhesives, multilayered amniotic membrane grafting (AMT), tenon patch graft (TPG), corneal patch graft (CPG), and penetrating keratoplasty (PK). The choice of procedure depends upon the size, location, and configuration of the perforation. In eyes with smaller perforations, tissue adhesives are effective treatment modalities, whereas AMT, TPG, and CPG are viable options in moderate-sized perforations. AMT and TPG are also preferable in cases where the placement of a bandage contact lens may be a challenge. Large perforations require a PK, with additional procedures such as tarsorrhaphy to protect the eyes from the associated epithelial healing issues. Conjunctival flaps are considered in eyes with poor visual potential. The management of the acute condition is carried out in conjunction with measures to improve the tear volume bearing in mind the chances of delayed epithelialization and re-perforation in these cases. Administration of topical and systemic immunosuppression, when indicated, helps improve the outcome. This review aims to facilitate clinicians in instituting a synchronized multifaceted therapy for the successful management of corneal perforations in the setting of DED.

Conjoint fascial sheath suspension with levator muscle advancement for severe blepharoptosis.

In patients with severe blepharoptosis, the function of the levator muscle is usually weak. Even if a large amount of levator is resected, under-correction and recurrence often occur postoperatively. Frontalis suspension is the first choice for severe ptosis; however, the external orbital lifting force of the frontalis causes non-physiological eyelid movement. Conjoint fascial sheath (CFS) is a fibrous tissue which can provide dynamic movement of upper eyelids and has been applied for the treatment of mild and moderate blepharoptosis in recent years. This study aims to assess the efficacy and safety of CFS suspension combined with levator muscle advancement for treating severe blepharoptosis. A retrospective study included 44 patients (60 eyelids) with severe ptosis who underwent the modified technique. Preoperatively, levator muscle function and margin reflex distance 1 (MRD1) were measured. Surgical outcomes, symmetry results and complications were evaluated postoperatively. At the 12-18 months follow-up, adequate or normal correction was achieved in 56 eyelids (93.3%), and 37 patients (84.1%) presented good or fair symmetry results. The most common complication was conjunctival prolapse, which was observed in six eyelids (10.0%), followed by lid fold deformity and under-correction. No exposure keratitis was recorded. In conclusion, the modified technique can physically elevate the eyelid with limited tissue injury and is effective for the correction of severe ptosis. Both satisfactory functional and esthetic results were achieved, and severe complications (such as exposure keratitis) were not observed.

Unusual case of dislocation of cyanoacrylate glue into the anterior chamber.

A patient with history of previous right eye penetrating keratoplasty for viral keratitis presented with an inferonasal graft melt, loose sutures and a flat anterior chamber (AC) in the same eye. B-scan ultrasound revealed 360° choroidal detachment. Cyanoacrylate adhesive and bandage contact lens were placed to restore ocular integrity. About 5 weeks after the procedure, the glue was found inside the AC with healed corneal melt. An emergency procedure was planned to remove the intraocular glue to prevent long-term toxicity. During the procedure, glue was found adherent to the intraocular lens (IOL), which necessitated an IOL exchange. Following the procedure, the eye settled well with residual scarring and an uncorrected visual acuity of 6/60, which improved to 6/18 with a pinhole. We discuss this case of late dislocation of the glue into the AC, which was managed with an IOL exchange highlighting a rare complication of corneal glueing.

Perforation in interstitial keratitis associated with hidradenitis suppurativa: medical and surgical management.

We present a case of bilateral interstitial keratitis leading to perforation in a woman with hidradenitis suppurativa (HS). A woman in her mid-20s with a history of HS and Grave's disease was referred to the corneal service with loss of vision and pain in both eyes since childhood. She was found to have circumferential thinning and steepening affecting her peripheral cornea bilaterally. Corrected distance visual acuity with spectacles was in the right eye 6/7.5, and in the left 6/30, with local thinnest area of 209 and 217 µm in the right and left eyes, respectively. She experienced recurring episodes of redness and irritation, and perforation occurred. The corneal perforation was managed with cyanoacrylate glueing, followed by a local conjunctival flap. Systemic immunosuppression with mycophenolate mofetil and adalimumab was commenced, with improvement after 18 months of treatment. Dermatologists and ophthalmologists should be aware of this association given its potential severity.

Posterior lamellar keratectomy for recalcitrant deep stromal keratitis: A case report.

PURPOSE: To describe a new technique for management of recalcitrant deep stromal keratitis using posterior lamellar keratectomy. METHODS: A 66-year-old pseudophakic male presented with deep stromal corneal infiltrates, extending from 2 to 4 o'clock in the vicinity of the limbus of the left eye, 3 months after phacoemulsification. The infiltrates failed to respond to empirical topical medications, anterior chamber wash and intrastromal injection. Posterior lamellar keratectomy was done to debulk the infectious load. In this technique the diseased posterior lamella was excised through a sclerocorneal lamellar pocket without a donor graft. RESULTS: The infection subsided within 2 weeks after posterior lamellar keratectomy. Patient achieved best corrected visual acuity (BCVA) of 20/60 with complete resolution of symptoms at 2 weeks follow up. Till the last follow-up at 6 months, the patient maintained BCVA of 20/60 with no sign of recurrence or corneal decompensation at the keratectomy site. CONCLUSION: Posterior lamellar keratectomy is a simple, effective and inexpensive technique for management of small, peripheral, deep-seated recalcitrant keratitis. It leads to radical treatment of the disease like therapeutic penetrating keratoplasty but in a less invasive manner and without a donor graft.

Recurrent Filamentous Fungal Keratitis Caused When the Primarily Selected Graft Diameter was Too Small.

PURPOSE: To establish the importance of using a sufficiently large corneal graft in primary penetrating keratoplasty in order to prevent recurrence of fungal keratitis. OBERSERVATIONS: A 58-year-old female patient underwent emergency penetrating keratoplasty (diameter 7.0 mm, double running suture) for therapy-resistant fungal keratitis (Fusarium solani) at an external eye clinic. Despite intensive antifungal therapy, new fungal infiltrates appeared in the host cornea after a few days. The patient was referred to our department for further treatment. On first presentation, circular infiltrates were seen around the corneal graft with anterior chamber involvement and therapy-resistant hypopyon. We performed an emergency penetrating repeat keratoplasty (diameter of 13.0 mm, 32 interrupted sutures) combined with anterior chamber lavage and intracameral and intrastromal drug injection. CONCLUSION AND IMPORTANCE: Fungal keratitis sometimes has a frustrating clinical course. Therefore, early diagnosis with effective therapy initiation is of the utmost importance. In cases of penetrating keratoplasty, optimal planning and timing (before anterior chamber involvement) should be provided. Sufficient safety distance must be ensured in the choice of graft diameter, fixation with multiple interrupted sutures, and anterior chamber lavage, as well as intracameral and intrastromal drug administration. Incomplete excision carries a risk of recurrence and endophthalmitis in the course. Close postoperative control is necessary to detect early recurrences.

Surgical management of infectious keratitis.

The successful management of infectious keratitis is usually achieved with a combination of tools for accurate diagnosis and targeted timely antimicrobial therapy. An armamentarium of surgical interventions is available in the acute stage which can be resorted to in a step wise manner or in combination guided by the response to treatment. Simple surgical modalities can facilitate accurate diagnosis e.g. corneal biopsy and alcohol delamination. Surgery to promote epithelial healing can vary from tarsorrhaphy, amniotic membrane transplantation or conjunctival flaps depending on the extent of infection, visual prognosis, availability of tissue and surgeon's experience. Collagen crosslinking has been increasingly utilized with successful results to strengthen the cornea and reduce the infective load consequently the need for further elaborate surgical interventions. It has shown encouraging results specially in superficial bacterial and fungal keratitis but for deeper infections, viral and acanthamoeba keratitis, its use remains questionable. When globe integrity is compromised, corneal gluing is the most commonly used procedure to seal small perforations. In larger perforations/fulminant infections a tectonic/therapeutic graft is advisable. Partial thickness grafts are increasingly popular to treat superficial infection or internally tamponade perforations. Peripheral therapeutic grafts face challenges with potential requirement for a manually fashioned graft, and increased risk of rejection due to proximity to the limbal vessels. Late stage visual rehabilitation is likely to require further surgical interventions after complete resolution of infection and inflammation. A preliminary assessment of corneal sensation and integrity of the ocular surface are key for any successful surgical intervention to restore vision.

Pars plana vitrectomy and therapeutic keratoplasty in endophthalmitis and infectious keratitis.

PURPOSE: To describe the anatomical and functional outcomes of patients with infectious keratitis (IK) and secondary endophthalmitis who underwent penetrating keratoplasty (PK) after pars plana vitrectomy (PPV) assisted by temporary keratoprosthesis (TKP). METHODS: An observational retrospective case series was performed. Data were collected from January 2013 to July 2020. Patients over 18 years old with a clinical and microbiological diagnosis of IK, and clinical, ultrasonographic, and or microbiological diagnosis of endophthalmitis were included. Anatomical success was defined as infection resolution with preservation of the ocular globe integrity. No change or improvement of best-corrected visual acuity (VA) at the last follow-up was considered as a functional success. RESULTS: A total of 32 eyes of 32 patients were analyzed. The anatomic success was obtained in 87.5% eyes in which the infection was eradicated. The 63% patients maintained or improved their best-corrected VA, 37.5% ended up with hand motion VA. CONCLUSIONS: Our results suggest that PPV assisted by TKP followed by PKP can be a good approach for treating patients with endophthalmitis secondary to IK while allowing further visual improvement after an optical PK. Further prospective studies need to be done to evaluate final visual rehabilitation of these patients.

Bilateral Corneal Neurotization for Ramos-Arroyo Syndrome and Developmental Neurotrophic Keratopathy: Case Report and Literature Review.

PURPOSE: The purpose of this study was to report the use of bilateral corneal neurotization for neurotrophic keratitis in the setting of Ramos-Arroyo syndrome. METHODS: The case report and surgical technique are described in detail in this article, as well as a review of the literature on corneal neurotization for congenital corneal anesthesia. RESULTS: We report a 17-year-old patient who underwent bilateral corneal neurotization for neurotrophic keratitis secondary to corneal anesthesia in Ramos-Arroyo syndrome. Corneal neurotization was performed with great auricular nerve transfers extended by sural nerve autografts. CONCLUSIONS: We present the treatment of neurotrophic keratopathy with corneal neurotization in a patient with Ramos-Arroyo syndrome. We describe how bilateral corneal neurotization using the great auricular nerve technique is a safe and effective procedure for patients with congenital/developmental corneal anesthesia.

Combined Therapeutic Penetrating Keratoplasty and Pars Plana Vitrectomy for the Treatment of Infectious Keratitis Endophthalmitis: Mexican Endophthalmitis Study Group Protocol 4.

PURPOSE: The purpose of this study was to assess the role of combined surgical treatment of therapeutic penetrating keratoplasty and pars plana vitrectomy in the anatomical and functional outcome of infectious keratitis endophthalmitis. METHODS: This study reviewed the medical records of 4 participating centers in the United States and Mexico. This study included patients with a clinical diagnosis of infectious keratitis endophthalmitis who had been treated with an early therapeutic penetrating keratoplasty and pars plana vitrectomy as the main treatment for endophthalmitis. From each medical record, the study retrieved demographic data, relevant medical and drug history, baseline clinical manifestation of endophthalmitis, best-corrected visual acuity, and the need for enucleation/evisceration for the control of the infection or any other reason through the follow-up. RESULTS: The study included 48 patients (50.15 ± 20.6 years). The mean follow-up time was 13 ± 0.5 months. The mean best-corrected visual acuity at baseline was 2.1 ± 0.25 logarithm of the minimum angle of resolution. At month 12 was 2.09 ± 0.61 logarithm of the minimum angle of resolution ( P = 0.9). The overall prevalence of enucleation/evisceration was 8.3% (95% confidence interval: 2.32%-19.98%). The prevalence of a vision of no-light perception was 20.8% (95% confidence interval: 2.32%-19.98%). CONCLUSIONS: Combined surgery for severe cases of infectious keratitis endophthalmitis eradicates the infection in most cases, while significantly improving the overall outcomes.

Corneal neurotization in the management of neurotrophic keratopathy: A review of the literature.

Neurotrophic keratopathy (NK) is a rare degenerative disease in which damage to the corneal nerves leads to corneal hypoesthesia or anesthesia. Neurotrophic corneal ulcers are notoriously difficult to treat and can lead to blindness. Corneal neurotization (CN) is a recent surgical technique aimed at restoring corneal sensation and may offer a definitive treatment in the wake of NK. Herein, we review the surgical techniques utilized in direct and indirect CN. Technical considerations, outcomes, current limitations and future perspectives are also discussed. This article highlights the key points of this promising procedure and biological aspects that will help provide the best treatment options for patients with severe NK.