Infectious endophthalmitis in adult eyes receiving Boston type I keratoprosthesis.

PURPOSE: To report the clinical characteristics of infectious endophthalmitis after Boston type I keratoprosthesis (K-Pro) implantation. DESIGN: Retrospective study. PARTICIPANTS: One hundred forty-one adult eyes receiving a K-Pro at a single institution from May 2004 through July 2008. METHODS: A retrospective chart review was performed of all adult eyes receiving a K-Pro at the University of Rochester from May 2004 through July 2008. Those patients identified as having been treated for exogenous bacterial endophthalmitis were reviewed for demographic data, indication for K-Pro, bandage contact lens use, prophylactic antibiotic use, timing and clinical presentation of endophthalmitis, gram stain and culture results of intraocular fluid, timing and presentation of any subsequent episodes of endophthalmitis (recurrent endophthalmitis), and preoperative and postoperative visual acuity through August 2010. MAIN OUTCOME MEASURES: Incidence of endophthalmitis, time to occurrence, recurrence rates, visual outcomes, and risk factors associated with K-Pro endophthalmitis. RESULTS: Ten (7.1%) of 141 eyes of 130 adult patients were diagnosed and treated for bacterial endophthalmitis. Average time to endophthalmitis developing after K-Pro was 9.8 months (standard deviation [SD], 6.2 months; range, 2-25 months). Coagulase-negative staphylococci were identified in 7 eyes. In 7 of the 10 eyes, recurrent endophthalmitis developed that occurred at a mean of 4 months (SD, 3.9 months; range, 1-13 months) after resolution of the initial episode. At each episode of endophthalmitis, no eye was receiving vancomycin ophthalmic drops and most eyes were receiving only fluoroquinolone ophthalmic drops for prophylaxis. CONCLUSIONS: Infectious endophthalmitis after K-Pro implantation has a higher incidence, delayed onset, and high risk for recurrence compared with postoperative endophthalmitis associated with more common intraocular procedures such as cataract surgery. The concurrent use of topical vancomycin is recommended because it seems to be important in reducing the incidence and recurrence of endophthalmitis and because fluoroquinolone ophthalmic drops do not seem to be sufficient prophylaxis in these eyes.

Intrastromal Antibiotic Injection in Polymicrobial Keratitis: Case Report and Literature Review.

Bacterial keratitis (corneal infection) caused by more than one organism is rare and exceedingly difficult to treat due to variable antibiotic susceptibilities. Intrastromal injections of antibiotics may be necessary to achieve higher drug concentrations at the site of infection, particularly in the case of deep stromal disease refractory to topical therapy. However, while this approach is increasingly used for fungal keratitis, there is a paucity of the literature regarding the use of intrastromal antibiotics bacterial keratitis. In the current case, an 86-year-old patient presented with a left corneal ulcer with corresponding microbiologic cultures positive for Staphylococcus epidermidis, Staphylococcus aureus, and Achromobacter species. The ulcer continued to progress despite maximal topical antibiotic treatment yet demonstrated marked improvement after two intrastromal injections of moxifloxacin administered 2 weeks apart. Polymicrobial keratitis can be particularly challenging to eradicate despite maximal topical antibiotic therapeutics. Intrastromal corneal injections provide a mechanism for drug delivery directly to the site of infection and thus may represent an important alternative in refractory cases.

Short-term, high-dose hydroxychloroquine corneal toxicity.

PURPOSE: To describe the corneal findings and management of a 61-year-old female with vortex keratopathy following short term, high dose hydroxychloroquine used in the setting of a clinical trial for recurrent breast cancer. OBSERVATIONS: The patient was found to have significant corneal vortex keratopathy without retinal pathology within 3 months of 1200 mg daily hydroxychloroquine treatment as an adjuvant medication for cancer therapy. Cessation of the medication led to the resolution of the corneal verticillata within 1 month yet the vision did not return to baseline. Ultimately, remaining irregular astigmatism and ocular surface disease required a scleral contact lens to achieve a BSCVA of 20/25 OU. CONCLUSIONS AND IMPORTANCE: Hydroxychloroquine-induced vortex keratopathy is largely considered dose and duration dependent and is uncommon with most standard treatment algorithms. However, with increasing use of high-dose hydroxychloroquine in adjunct cancer therapy, corneal findings are likely to become more frequent. Persistent visual impairment may occur, thus increased understanding of this pathology can aid in counseling patients and guiding treatment recommendations.

Cellular Infiltrate in Rheumatoid Arthritis-associated Paracentral Corneal Ulceration.

PURPOSE: To investigate an immunopathogenesis of central and paracentral corneal ulceration associated with rheumatoid arthritis. METHODS: Sparse infiltrating cells in the ulcer area were identified by immunohistochemistry applied to archived formalin fixed, paraffin embedded tissues that had been recovered from patients undergoing penetrating keratoplasty necessitated by rheumatoid-associated central or paracentral corneal ulceration. RESULTS: Clinically, the ulcers presented as non-infiltrated lesions with a modicum of other ocular inflammation. Sparse T-lymphocytes were consistently identified in the subepithelial areas adjacent to the ulcer, with some neutrophils and macrophages in the stroma. B-lymphocytes were not detected. MHC Class II antigens reactivity was noted on some infiltrating cells and on corneal endothelium of two specimens. CONCLUSIONS: Immunohistochemistry of archival tissue facilitated detection and identification of sparse infiltrate in this infrequent corneal melting. Selective, consistent finding of T-lymphocyte infiltration in the ulcer area supports an immunopathogenesis of this clinical entity.

Prior hospital admission predicts thirty-day hospital readmission for heart failure patients.

BACKGROUND: Hospital readmission is a significant health burden. More than 20% of heart failure (HF) patients are readmitted within 30 days of discharge leading to billions of dollars in health care expenditures. However, the role of prior hospital admissions to predict 30-day readmission for HF patients is not fully understood. METHODS: We retrospectively analyzed HF hospitalization data for 4 years at a single medical center. Association between prior admission and 30-day readmission after HF hospitalization was assessed using a multivariate logistic regression model. RESULTS: A total of 1,999 patients with index HF hospitalizations were identified, and 366 of them (18%) were readmitted within 30 days. The rate of readmission was 14%, 20%, and 33% in patients with 0, 1, ≥ 2 prior admissions. Patients with one prior admission had a 50% higher risk (confidence interval [CI] 1.10-2.05, p = 0.011) for readmission, while those with ≥ 2 prior admissions had a more than 3-fold increase in readmission (CI 2.27-4.09, p < 0.001), after adjustments for relevant clinical covariates. Prior hospital admission provided incremen-tal value in predicting readmissions, shown by the significant improvement in the readmission predictive model (C-statistics increased from 0.57 to 0.63). However, neither the length of stay nor recency of prior admission was a significant factor in predicting readmissions. CONCLUSIONS: Hospital admission prior to an index HF hospitalization is associated with a significantly increased risk for 30-day hospital readmission and could be used to identify patients at high-risk for readmission and potentially target interventions to reduce the risk of readmission for these patients.