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.

Outcomes of Fungal Corneal Ulcer with Impending Perforation after Temporary Suture Tarsorrhaphy.

INTRODUCTION: This study aims to evaluate outcomes and complications of temporary suture tarsorrhaphy (TST) in cases of impending corneal ulcer perforation. MATERIALS AND METHODS: Case records of patients who underwent temporary suture tarsorrhaphy at Mechi Eye Hospital during a period of 18 months were retrospectively evaluated. All the smear positive fungal keratitis with more than 5mm infiltration involving central and/or paracentral cornea with impending corneal perforation were included. Demographic and clinical profile including - visual acuity, indication for temporary suture tarsorrhaphy, duration of signs and symptoms were noted. The outcomes were evaluated after 1 month and 3 months post tarsorrhaphy, in relation with time to epithelial healing, anatomical success rate, best corrected visual acuity, complications associated with non-healing corneal ulcer, number of temporary suture tarsorrhaphy needed and complications of TST. RESULTS: The study included 119 cases of smear positive fungal keratitis with mean age of 51.34 + 15.56 years. In this study, 56.30% of the patients developed epithelial healing at 2 - 4 weeks with mean duration of 23.24 + 12.09 days of temporary suture tarsorrhaphy. Out of 119 patients, the corneal ulcer healed in 84 patients (70.6%), whereas 35 (29.4%) did not heal. Among those with non-healing ulcers, 15 patients (12.6%) had to undergo evisceration. The anatomical success rate was 87.39% which was statistically significant (P = 0.001). Regarding visual outcome, in 62 patients (52.10%) BCVA improved by 2 or more lines, which was statistically significant (P<0.05) resulting in a functional success of 26.89%. CONCLUSION: This study concludes that temporary suture tarsorrhaphy could be a useful option for management of corneal ulcers with impending perforation in eye centers with limited resources settings and high disease burden with good anatomical and functional outcome.

Chlorhexidine in the treatment of microsporidial stromal keratitis and the effect of host immunity: A case series and literature review.

Microsporidial stromal keratitis is an increasingly well-known vision-threatening disease. A large proportion of cases are initially misdiagnosed as herpes simplex keratitis and treated with topical steroids. In most of such cases, medical treatment failed, and corneal transplantation was required. This study reported the results of 0.02% topical chlorhexidine used to treat three cases of microsporidial stromal keratitis and reviewed the literature on the outcomes of microsporidial stromal keratitis treatment. In the first case, histopathology of a specimen from penetrating keratoplasty (PK) revealed severe chronic inflammation involving the entire stromal layer but no microorganism activity after the application of topical chlorhexidine for 10 months. The second case exhibited complete resolution of keratitis after topical chlorhexidine. The patient in the third case did not respond to medical treatment, and therapeutic PK was performed. Histopathological examination revealed numerous microsporidial spores that had colonized in the mid and deep stroma, where few inflammatory cells were observed. These findings explain the variable microsporidial susceptibility to chlorhexidine, suggesting the crucial role of host immunity. In cases of host immunity, topical chlorhexidine may represent a promising option for the treatment of microsporidial stromal keratitis.

Localized surgical debridement for the management of orbital mucormycosis.

PURPOSE: To describe the role of localized debridement and instillation of amphotericin B for the management of orbital mucormycosis post COVID-19 infection with a view to avoid exenteration. METHODS: The records of all patients with orbital mucormycosis post COVID-19 infection in the last 6 months from December 2020 to June 2021 were evaluated, and ten patients were identified who were successfully managed with localized debridement, that is, removing the fungal tissue and necrotic material and amphotericin B gel instillation locally. MRI scan was used to identify the area of fungal infiltration and presence of necrotic material. Early surgery in the form of transconjunctival orbitotomy was performed for disease in the infraorbital fissure area, and superior transcutaneous lid crease approach was employed for disease in the superomedial orbit or medial orbit. Most patients had lid edema, ptosis, and proptosis; this resolved with the medication. Systemic antifungals were given and the follow-up ranged from 1 to 5 months. RESULTS: The ptosis, proptosis, and lid edema subsided in all, except in one patient who had residual ptosis and in one who had residual ophthalmoplegia. Vision deficit did not occur in any patient. All patients were successfully discharged on oral antifungal medication. CONCLUSION: Localized clearance of the fungal tissue and the necrotic material is a good option to avoid exenteration in cases of orbital mucormycosis, avoiding disfigurement and mental trauma to the patient.

Scoring system evaluation for orbital exenteration in patients with rhino-orbito-cerebral mucormycosis.

PURPOSE: To evaluate our patients with rhino-orbito-cerebral mucormycosis according to a new scoring system and to compare those who underwent orbital exenteration persuant to a new threshhold. METHODS: Mucormycosis is a fungal disease that can be of acute onset, aggressive, and angioinvasive. Aggressive surgical debridement, long-term systemic antifungal therapy, and treatment of underlying predisposing factors are essential to the treatment. However, orbital exenteration is a very difficult decision to make, particularly in patients with orbital involvement, because there is little information in the literature, resulting in limited support for making this aggressive surgical decision. In this study, our 43 cases of mucormycosis were evaluated in terms of orbital exenteration using a scoring system (including clinical signs and symptoms, ophthalmoscopic findings, and radiologic results) developed by Shah et al., which establishes indications for orbital exenteration in mucormycosis. RESULTS: According to our study, if the threshold score for exenteration is 19.0, the sensitivity was 100% and specificity was 97%, providing better results than the 23.0 threshold score determined by the reference study for exenteration. When these two score thresholds were compared, there was a statistically significant difference. CONCLUSION: We believe that this scoring system may be beneficial to use for orbital exenteration in patients with mucormycosis. Prospective studies in large case series are required to determine the most appropriate threshold score.

Fusarium keratitis as a growing problem - case report and literature review.

INTRODUCTION AND OBJECTIVES: With the rising number of contact lens users, there has been observed an increasing number of patients admitted to ophthalmology wards with severe keratitis, including those of fungal etiology. One of the most devastating specimens is Fusarium spp. If not diagnosed and treated from the onset of the symptoms, it can lead to severe visual loss, or even blindness. CASE REPORT: This a retrospective case report of a 36-year-old pregnant female diagnosed with Fusarium keratitis, not responding to topical treatment. The problem is discussed and includes the most relevant literature review. RESULTS: Primary therapeutic keratoplasty is prone to failure due to an ongoing inflammation process in the eye, as happened in the described patient. Spread of the infection to the vitreous body necessitated the procedure of penetrating keratoplasty with lens removal, pars plana vitrectomy and silicone oil. After treatment, the inflammation resolved, and best corrected visual acuity at the 6 months follow-up was 0.5 (Snellen charts). CONCLUSIONS: There is currently no treatment for Fusarium keratitis that would offer similar results to those observed in bacterial infection treated early with antibiotics. As systemic therapy with antifungal agents is not an option in pregnant women, they are even more of a challenge. Diagnosis is quite often delayed, leading to deeper infiltration of the cornea, sometimes with vitreous involvement. For such cases, a combined approach is proposed with vitrectomy, lens removal and penetrating keratoplasty. Early surgical intervention may rescue some of the eyes non-responsive to topical and systemic treatment.

Endogenous fungal endophthalmitis following intensive corticosteroid therapy in severe COVID-19 disease.

Purpose: To report endogenous fungal endophthalmitis, postrecovery from severe COVID-19 infection in otherwise immunocompetent individuals, treated with prolonged systemic steroids. Methods: Retrospective chart review of cases with confirmed and presumed fungal endogenous endophthalmitis, following severe COVID-19 disease, treated at two tertiary care referral eye institutes in North India. Results: Seven eyes of five cases of endogenous fungal endophthalmitis were studied. All cases had been hospitalized for severe COVID-19 pneumonia and had received systemic steroid therapy for an average duration of 42 ± 25.1 days (range 18-80 days). All the cases initially complained of floaters with blurred vision after an average of 6 days (range 1-14 days) following discharge from hospital. They had all been misdiagnosed as noninfectious uveitis by their primary ophthalmologists. All eyes underwent pars plana vitrectomy (PPV) with intravitreal antifungal therapy. Five of the seven eyes grew fungus as the causative organism (Candida sp. in four eyes, Aspergillus sp. in one eye). Postoperatively, all eyes showed control of the infection with a marked reduction in vitreous exudates and improvement in vision. Conclusion: Floaters and blurred vision developed in patients after they recovered from severe COVID-19 infection. They had received prolonged corticosteroid treatment for COVID-19 as well as for suspected noninfectious uveitis. We diagnosed and treated them for endogenous fungal endophthalmitis. All eyes showed anatomical and functional improvement after PPV with antifungal therapy. It is important for ophthalmologists and physicians to be aware of this as prompt treatment could control the infection and salvage vision.

A Case of Black Fungal Keratitis Caused by Biatriospora mackinnonii.

PURPOSE: To report a novel case of fungal keratitis caused by Biatriospora mackinnonii (Pyrenochaeta mackinnonii), a dematiaceous fungus (black fungus) that rarely causes dermatological infection, in a patient treated for ocular cicatricial pemphigoid. METHODS: An 81-year-old patient with ocular cicatricial pemphigoid was referred to our hospital because of persistent corneal epithelial defects in his left eye. On examination, a slightly elevated dark lesion in the middle of the erosion and hypopyon was observed in that eye, with smear examination of the obtained specimen revealed a filamentous fungal-like material. Initially, treatment included miconazole and fluconazole ophthalmic solution eye drops, natamycin ophthalmic ointment, and systemic voriconazole, followed surgical scraping of the mass, an anterior chamber lavage, and a subconjunctival injection of miconazole. However, the focus had resistance to the treatment and finally led to corneal perforation; hence, therapeutic penetrating keratoplasty (PKP) was subsequently performed. RESULTS: Mycological testing revealed that the lesions were Candida parapsiliosis and black fungus, with the black fungus classified as B. mackinnonii via DNA sequencing of the internal transcribed spacer and the D1/D2 domains of the 28S rRNA gene. Fungal keratitis caused by B. mackinnonii was resistant to the antifungal drugs, yet was ameliorated by PKP, with no recurrence of fungal keratitis for more than 2 years postoperative. CONCLUSIONS: To the best of our knowledge, this is the first reported case of fungal keratitis caused by B. mackinnonii; however, in this case, PKP surgery resulted in a favorable outcome.

Pars Plana Vitrectomy for Endophthalmitis: Microbiologic Spectrum and Clinical Outcomes.

Purpose: To report visual outcomes, microbiologic spectrum, and antibiotic resistance in endophthalmitis patients undergoing pars plana vitrectomy (PPV).Methods: Retrospective study of 32 patients who underwent PPV with microbial analysis. Linear mixed models were utilized to compare visual acuity (VA).Results: Streptococcal species and coagulase-negative staphylococcus (CoNS) were the most common organisms. No resistance to vancomycin or fluoroquinolones was observed. Culture-negative individuals had better VA and lower incidences of retinal detachment (RD) and hypotony and better VA than culture-positive group at post-surgical month 3 (p = .025) and marginally at month 12 (p = .098). CoNS endophthalmitis (final logMAR VA 0.80) was associated with better VA than Streptococcal endophthalmitis (final logMAR VA 2.36) (p = .001). Secondary RD was observed in 33.3% of non-cataract endophthalmitis.Conclusion: No organisms were resistant to vancomycin or fluoroquinolones. Culture-negative endophthalmitis had better VA and lower rates of RD and hypotony than culture-positive group. A high rate of RD was observed in non-cataract endophthalmitis.

Does Endogenous Endophthalmitis Need a More Aggressive Treatment?

Topic: To focus on endogenous endophthalmitis management, particularly etiology-based medical and surgical therapy.Methods: Literature search of published studies from July 1990 to February 2019 on endogenous endophthalmitis available on PubMed was made without any language constraints.Results: A total of 78 articles were retrieved from 728 initially analyzed and 62 studies were included. Although the superiority of vitrectomy over tap and inject techniques is controversial, the most recent publications favor an early surgical approach for endogenous endophthalmitis. Vitrectomy is useful in severe cases complicated by marked vitreous opacity, retinal detachment, poor initial visual acuity, and more virulent pathogens. Oral or intravenous antibiotics are also necessary to treat systemic infection. Vitrectomy is superior to blood cultures in diagnosing the etiology of infection.Conclusions: Endogenous endophthalmitis is an important cause of visual acuity impairment. Prompt treatment with appropriate use of pharmacological or surgical therapy is mandatory to preserve visual function.Abbreviations: IOP: intra-ocular pressure; AIDS: acquired immune deficiency syndrome; EVS: endophthalmitis vitrectomy study; CEVE: complete and early vitrectomy for endophthalmitis.

Antimicrobial peptides in human corneal tissue of patients with fungal keratitis.

BACKGROUND: Fungal keratitis (FK) is the leading cause of unilateral blindness in the developing world. Antimicrobial peptides (AMPs) have been shown to play an important role on human ocular surface (OS) during bacterial, viral and protozoan infections. In this study, our aim was to profile a spectrum of AMPs in corneal tissue from patients with FK during the active pase of infection and after healing. METHODS: OS samples were collected from patients at presentation by impression cytology and scraping. Corneal button specimens were collected from patients undergoing therapeutic penetrating keratoplasty for management of severe FK or healed keratitis. Gene expression of human beta-defensin (HBD)-1, -2, -3 and -9, S100A7, and LL-37 was determined by quantitative real-time PCR. RESULTS: Messenger RNA expression (mRNA) for all AMPs was shown to be significantly upregulated in FK samples. The levels of HBD-1 and -2 mRNA were found to be elevated in 18/20 FK samples. Whereas mRNA for HBD-3 and S100A7 was upregulated in 11/20 and HBD9 was increased in 15/20 FK samples. LL-37 mRNA showed moderate upregulation in 7/20 FK samples compared with controls. In healed scar samples, mRNA of all AMPs was found to be low and matching the levels in controls. CONCLUSION: AMP expression is a consistent feature of FK, but not all AMPs are equally expressed. HBD-1 and -2 are most consistently expressed and LL-37 the least, suggesting some specificity of AMP expression related to FK. These results will help to identify HBD sequence templates for designing FK-specific peptides to test for therapeutic potential.

Procedures, Visits, and Procedure Costs in the Management of Microbial Keratitis.

PURPOSE: To investigate the burden of procedures, visits, and procedure costs in the management of microbial keratitis (MK). METHODS: Medical records of patients from an academic hospital outpatient facility between December 2013 and May 2018 were retrospectively reviewed. Patients were included if they were older than the age of 18 years, recruited for study of likely MK, and not concurrently undergoing treatment for other acute eye conditions. For procedural costs, Medicare data for billing were obtained using the Center for Medicare and Medicaid Services Physician Fee Lookup tool. RESULTS: A total of 68 patients were included for analysis. Patients were on average 51.3 years (SD = 19.5), 55.9% women (n = 38), and 89.7% White (n = 61). Per person, the average number of procedures was 2.9 (SD = 4.2). The average number of visits was 13.9 (SD = 9.2) over an average of 26.9 weeks (SD = 24.3). Age (P < 0.0001), positive Gram stain (P = 0.03), and mixed Gram stain (P = 0.002) were positively associated with the number of procedures. Age (P = 0.0003), fungal keratitis (P = 0.02), and mixed Gram stain (P = 0.01) were positively associated with the number of visits. Race was inversely associated with the number of procedures (P = 0.045) and visits (0.03). Patients with bacterial keratitis were more likely to have amniotic membrane grafts (P = 0.01) and tarsorrhaphies (P = 0.03) than fungal patients. Across all procedures performed for the management of MK, the mean cost per patient was $1788.7 (SD = $3324.62). CONCLUSIONS: Patients incur many procedural costs and attend many visits during the management of MK. These findings emphasize the importance of patient-provider communication for frequent follow-up care and the potential need to perform procedures for disease management.

Necrotising fungal scleritis with full-thickness scleral melt and circumferential progression: a novel debridement approach.

A 44-year-old Asian Indian woman presented with a history of pain and redness in the left eye for 3 weeks. Scleral congestion with a nodular swelling was present inferotemporally. Raised C reactive protein and positive antinuclear and perinuclear antineutrophil cytoplasmic antibodies suggested autoimmune scleritis. The patient was therefore managed with corticosteroids. Nevertheless, the development of severe pain associated with a scleral abscess led to a revised diagnosis of infectious scleritis. Corticosteroids therapy was halted and urgent debridement was performed. Microbiology confirmed fungal scleritis due to Coprinopsis cinerea Multiple full-thickness circumferential debridements with antifungal therapy resulted in satisfactory anatomical and visual outcomes. This case presented a unique challenge, since laboratory results were misleading, and corticosteroids resulted in a fulminant clinical course. Therefore, aggressive circumferential debridement was performed to achieve the elimination of a rare fungal aetiology of scleritis, which has not been reported previously to cause human infection.

Bilateral non-resolving punctate keratitis in a keratoplasty patient.

This study aimed to report a case of non-resolving bilateral coarse punctate keratitis in a patient with prior bilateral penetrating keratoplasty. In view of non-response to antivirals, corneal epithelial scraping was carried out, which revealed the presence of microsporidial cysts. The infection resolved after a period of 12 days following the diagnosis, during which steroids were discontinued. Microsporidial keratitis needs to be considered in non-resolving coarse punctate keratitis and microbiologic evaluation is essential to establish the diagnosis.

A 10-year review of histopathological findings of enucleated eyes from a tertiary-care center, Pakistan.

OBJECTIVE: To determine the histopathology of enucleated eye specimens. METHODS: The 10-year inventory was conducted at Aga Khan University Hospital, Karachi, and comprised all histopathology reports of enucleated eye specimens received from January 2007 to December 2016 by the Section of Histopathology, Department of Pathology. SPSS 19 was used for data analysis. RESULTS: A total of 232 ocular tissue specimens from 231 patients were evaluated. Ocular tumours were the most common histopathological diagnosis 186(80%). Among tumours, retinoblastoma was the most common 137(59%) followed by malignant melanoma 31(13%) and squamous cell carcinoma 15(6.5%). Overall, 16(6.9%) specimens had degenerative changes secondary to different ocular disorders. Staphyloma and Coat's disease was diagnosed in 3(1.3%) cases each. In 4(1.7%) cases, there was no formal diagnosis. CONCLUSIONS: Early identification of tumours may allow for conservative management and limit the need for enucleations.

Microsporidial stromal keratitis: characterisation of clinical features, ultrastructural study by electron microscopy and efficacy of different surgical modalities.

AIMS: To report the clinical manifestations, ultrastructure and evaluate the efficacy of therapeutic lamellar keratectomy (TLK) and penetrating keratoplasty (PK) for microsporidial stromal keratitis (MSK). METHODS: Fourteen MSK cases between 2009 and 2018 were recruited. Each patient's clinical presentation, light microscopy, histopathology, PCR and electron microscopy (EM) of corneal samples were reviewed. RESULTS: The patients were 70.0±4.7 years old (average follow-up, 4.5 years). Time from symptoms to presentation was 10.6±13.0 weeks. The corneal manifestations were highly variable. Corneal scrapings revealed Gram stain positivity in 12 cases (85.7%) and modified Ziehl-Neelsen stain positivity in 9 (64.3%). Histopathology revealed spores in all specimens, while sequencing of small subunit rRNA-based PCR products identified Vittaforma corneae in 82% of patients. EM demonstrated various forms of microsporidial sporoplasm in corneal keratocytes. All patients were treated with topical antimicrobial agents or combined with oral antiparasitic medications for >3 weeks. As all patients were refractory to medical therapy, they ultimately underwent surgical intervention (TLK in 7, PK in 6 and 1 received TLK first, followed by PK). Postoperatively, the infection was resolved in 78.6% of the patients. Nevertheless, a high recurrence rate (21.4%) was noted during 3-year follow-up, with only two patients retained a final visual acuity ≥20/100. CONCLUSION: MSK usually presents with a non-specific corneal infiltration refractory to antimicrobial therapy. The diagnosis relies on light microscopic examinations on corneal scrapings and histopathological analyses. Surgical intervention is warranted by limiting the infection; however, it was associated with an overall poor outcome.