Cornea

Medication Burden for Patients With Bacterial Keratitis Purpose: To understand medication use and patient burden for treatment of bacterial keratitis (BK). Methods: A retrospective study was conducted examining medical records of adult patients with BK in an academic cornea practice. Data collected included medications used in the treatment of BK, dosing of medications, and the number and total duration of clinical encounters. Costs of medications were estimated using the average wholesale pharmacy price. Linear regression analysis was used to investigate associations of medication use with patient demographics and corneal culture results and reported with beta estimates (β) and 95% confidence intervals (95% CIs). Results: Forty-eight patients with BK (56% female) were studied. Patients were treated for a median of 54 days with 10 visits, 5 unique medications, 587 drops, and 7 prescriptions. The estimated median medication cost was $933 (interquartile range: $457–$1422) US dollars. Positive bacterial growth was significantly associated with more visits (β: 6.16, 95% CI: 1.75–10.6, P = 0.007), more days of treatment (β: 86.8, 95% CI: 10.8–163, P = 0.026), more prescribed medications (β: 2.86, 95% CI: 1.04–4.67, P = 0.003), and more doses of medications (β: 796, 95% CI: 818–1412, P = 0.012) compared with patients who did not undergo corneal scraping. Patients were prescribed 132 more drops of medication for every 10 years of older age (β: 132, 95% CI: 18.2–246, P = 0.024). Sex and income were not associated with medication burden or treatment length. Conclusions: Older patients and those with positive cultures incur the most medication burden in treatment of BK. Providers should be aware of medication usage and cost burden as it may affect compliance with treatment.

Microbial Keratitis in Stevens–Johnson Syndrome: A Prospective Study Purpose: To evaluate the microbiological profile and outcome in cases with infective keratitis in Stevens–Johnson syndrome (SJS). Methods: Eighty-three eyes of 68 patients with SJS presenting with microbial keratitis were recruited and managed with standard antimicrobial therapy. Results: Microbial keratitis developed in 34% of patients with SJS (83 eyes, 68 patients) over a period of 5 years. Four eyes (4.8%) had a history of concurrent topical steroid use at the onset of keratitis. Mean baseline best-corrected visual acuity was 1.8 ± 0.9 logMAR units. The site of corneal ulceration was central in 52 eyes (62.6%), paracentral in 17 eyes (20.5%), and peripheral in 14 eyes (16.8%). The mean ulcer area was 3.9 ± 2.7 mm2. Approximately 15 of 24 (62.5%) culture-positive eyes had bacterial infection, most of which (80%) were caused by Gram-positive bacteria. Polymicrobial infection was noted in 7 of 24 eyes (29.1%). Although 57 of 83 (68.6%) eyes healed with medical therapy, 26 of 83 (31.3%) eyes had corneal perforation and were managed with cyanoacrylate glue application (30.7%) or therapeutic keratoplasty (69.3%). Systemic infection as an inciting factor of SJS and an early presentation for keratitis were the major risk factors associated with corneal perforation. Large mean ulcer size, paracentral ulcers, and punctal involvement were associated with a good visual outcome. Conclusions: Infective keratitis in SJS is common, and unlike routine cases, surgical intervention is often required. However, the antibiotic sensitivity pattern suggests that resistance is not that high.

Anterior Segment Optical Coherence Tomography Images in Microsporidial Keratoconjunctivitis Purpose: To describe the findings of anterior segment optical coherence tomography (AS-OCT) in patients with microsporidial keratoconjunctivitis. Methods: The observational study included 13 eyes from 13 patients. Slit-lamp photography and AS-OCT were performed using the Swept source OCT before corneal scraping. All cases were positive for Gram-chromotrope (modified trichrome) staining for Microsporidia spp. Results: Three significant AS-OCT findings were observed. First, hyperreflective dots were limited to the epithelial layers of the cornea, and second, there were no extensions into the stromal layer in all cases. Last, hyperreflective dots slightly raised above the epithelial surface were observed in most cases (12/13%, 92.3%). Conclusions: AS-OCT represents an alternative, noninvasive tool to diagnose microsporidial keratoconjunctivitis, especially if corneal scraping is not possible.

Toxic Keratitis After Application of Custard Apple Seed for Head Lice Infestation Purpose: To report the clinical features and outcomes of toxic keratitis after application of powdered custard apple seeds for hair washing for head lice infestation. Methods: Retrospective review of all patients with toxic keratitis after application of powdered custard apple seed for head lice infestation during the time period from January 2015 to December 2017. Demographic details, clinical features, and visual outcomes were documented. Results: Thirty-one eyes of 19 patients with toxic keratitis after application of crushed custard apple seeds for head lice infestation were included in the study. Eighteen females and 1 male with a median age of 14 years [interquartile range (IQR) 12–34 years] presented with severe epiphora, congestion, photophobia, and defective vision (median logMar visual acuity 0.4, IQR 0.2–0.8) after application of custard apple seed powder for hair washing. Ten eyes (32.2%) had an epithelial defect (median size 9 mm2, IQR 5–12 mm2), and 21 (67.7%) eyes had punctate epithelial erosions. All the patients were treated with topical antibiotics, and at 3 days follow-up, all of them had resolution of symptoms and signs with a median logarithm of the minimum angle of resolution (logMAR) visual acuity of 0 (IQR 0–0.2). Conclusions: Health education about the harmful effect of this traditional practice for head lice infestation will prevent further similar events.

Tuck-In Tenon Patch Graft in Corneal Perforation Purpose: To describe the outcomes of tuck-in tenon patch graft (TPG) in the management of corneal perforation up to 5-mm size. Methods: Thirty-one cases of sterile corneal perforation (3–5 mm) underwent autologous TPG. The technique included, freshening of the edges, measuring the size of defect, creating a 360-degree stromal pocket around the perforation margin, harvesting the tenon graft followed by tucking into the stromal pocket, and application of cyanoacrylate glue or suturing the graft using 10-0 monofilament nylon suture. The main outcome measure was rate of healing (percentage of cases healed). Results: The mean age was 52.3 ± 8.9 years with 22 male and 9 female patients. The various etiologies of corneal perforation included trauma (n = 10), neurotrophic keratitis (n = 11), and peripheral ulcerative keratitis (n = 10). The mean size of corneal perforation was 4.2 ± 0.6 mm (range 3–5 mm). The mean duration of epithelial healing was 25.7 ± 6.7 days. Best-corrected visual acuity improved from 1.8 ± 0.4 to 1.2 ± 0.4 logarithm of the minimum angle of resolution units at 4 weeks after surgery (P ≤ 0.01). Twenty-seven (87.1%) cases healed with formation of a leucomatous scar at 16.9 ± 2.7 weeks, whereas 4 cases had a flat anterior chamber. In three-fourths of the cases, a corneal graft was performed. In one case, graft resuturing was performed for post-op aqueous leak, which healed with the formation of a corneo-iridic scar. Conclusions: TPG is a safe, simple, inexpensive, and an effective technique for the management of corneal perforations. The advantages include the autologous nature of the graft, cost effectiveness, and easy availability.

Safety and Efficacy of Supratarsal Triamcinolone for Treatment of Vernal Keratoconjunctivitis in Ireland Purpose: To describe the clinical features, risk factors, and treatment outcomes after supratarsal injection of triamcinolone for vernal keratoconjunctivitis (VKC). Methods: A retrospective review of all patients treated with supratarsal triamcinolone for VKC between February 2002 and May 2017 at the Royal Victoria Eye and Ear Hospital and Our Lady's Children Hospital Crumlin, Dublin, Ireland, was performed. Results: Twenty-five patients, 46 eyes, and 145 injections were included for analysis. The mean age at first injection was 9.1 ± 5.7 years. Ninety-six percent of the patients were male. A seasonal variation was noted, with 59 injections (41%) of triamcinolone administered for acute and refractive cases of VKC in the summer compared with 35 (24%), 35 (24%), and 16 (11%) in the spring, autumn, and winter months, respectively. The most common presenting complaint was red eye, which was seen in all cases. Hay fever (64%) was the most common associated systemic disease. Each eye required, on average, 3.2 injections (range 1–9 injections), and the mean duration from the onset of symptoms to final treatment was 3.03 years (range 0–7.9 years). The mean presenting and final visual acuities were 0.33 and 0.11 logarithm of the minimum angle of resolution, respectively (P < 0.0001). During our study period, no patient experienced intraocular pressure rise requiring treatment, development of lenticular opacity, or ptosis after supratarsal injection of triamcinolone. Conclusions: In this case series, supratarsal triamcinolone was used in cases of VKC in which topical medications had failed to control the disease process. All patients reported improvement after treatment. There were no cases of intraocular pressure rise, lenticular opacity, or ptosis development after treatment.

Subtenon Bupivacaine for Postoperative Pain in Patients Undergoing Pterygium Excision: A Double-Blinded Randomized Control Trial Purpose: Patients undergoing primary pterygium excision with autologous conjunctival autograft and human tissue adhesive in New Zealand, currently receive subconjunctival anesthesia with oral postoperative analgesia for pain. Our aim was to investigate the potential added benefit of intraoperative subtenon bupivacaine to this regimen. Methods: A double-blinded, placebo-controlled, randomized trial was conducted at 2 centers. All patients received topical and subconjunctival anesthesia intraoperatively, with standardized oral analgesia as required postoperatively. Participants were allocated to receive subtenon bupivacaine 0.5% or placebo at the conclusion of surgery. Corneal epithelial defect and conjunctival graft size were recorded. Pain and ocular surface irritation were assessed (Likert scale) immediately postoperatively at 3, 6, 12, 24, and 36 hours. Cumulative oral analgesia consumption (doses) was reported at 24 and 36 hours. Results: Forty-two patients were randomized with participants evenly matched at baseline. Postoperative pain at all time points ≤24 hours was significantly less (2.4 vs. 1.2; P < 0.04) in the bupivacaine arm with no difference at 36 hours (P = 0.27). Ocular surface irritation was also significantly less at all time points ≤12 hours (4.8 vs. 1.3; P < 0.01) with no difference at 24 hours (P = 0.10). Analgesia consumption was less in the bupivacaine arm at 24 (6.5 vs. 2.5; P < 0.01) and 36 hours (7.6 vs. 3.4; P < 0.01). No complications were observed. Conclusions: Intraoperative subtenon bupivacaine improves patient comfort after pterygium excision by reducing pain, irritation, and requirement for oral analgesia after surgery.

Changes in Corneal Biomechanical Properties After Descemet Membrane Endothelial Keratoplasty Purpose: To evaluate the course of corneal biomechanical properties (corneal hysteresis and corneal resistance factor) after Descemet membrane endothelial keratoplasty (DMEK) in patients with Fuchs endothelial dystrophy (FECD). Methods: In this prospective study, we consecutively included 49 patients with FECD with an indication for DMEK. Central corneal thickness, measured using the Oculus Pentacam, and corneal hysteresis (CH) and corneal resistance factor (CRF), both measured using the Reichert Ocular Response Analyzer, were examined preoperatively, 3 months, and 6 months after DMEK. Results: CH was significantly increased 6 months postoperatively (8.66 ± 2.50 mm Hg) compared with preoperative baseline (7.43 ± 1.56 mm Hg). Preoperative CRF (7.89 ± 1.68 mm Hg) increased significantly 6 months after DMEK (8.49 ± 1.71 mm Hg). Preoperative central corneal thickness showed a significant decrease from 629 ± 58 μm to 550 ± 40 μm after 3 months and 535 ± 40 μm after 6 months postoperatively. Conclusions: DMEK affects both measured corneal biomechanical properties in patients with FECD: CH and CRF. This has to be taken into account for the accuracy of intraocular pressure measurements.

Effect of Graft Shift Direction on Graft Detachment and Endothelial Cell Survival After Descemet Membrane Endothelial Keratoplasty Purpose: To investigate the effects of graft shift orientation on clinical outcomes after Descemet membrane endothelial keratoplasty (DMEK). Methods: This study used intraoperative video images to retrospectively examine the effect of graft shift direction in 50 eyes of 50 patients. Correlations were assessed between graft shift direction and multiple parameters. Results: The graft detachment rate was higher in eyes with an inferior graft shift than in those without (superior, 0% and 5.0%; nasal, 0% and 20.0%; inferior, 16.7% and 55.0%; temporal, 16.7% and 45.0%; and any segment, 23.3% and 65.0%; for graft shift–negative and graft shift–positive cases, respectively). Postoperative endothelial cell density reduction was higher in eyes with an inferior graft shift (1 month, 23.6% ± 13.7% and 37.5% ± 18.8%; 3 months, 31.6% ± 16.4% and 45.2% ± 15.2%; and 6 months, 39.8% ± 14.9% and 50.7% ± 16.6%; for graft shift–negative and graft shift–positive cases, respectively). Eyes with a superior graft shift had lower postoperative endothelial cell density reduction than those without (1 month, 36.9% ± 16.6% and 20.0% ± 13.1%; 3 months, 45.3% ± 13.3% and 27.4% ± 16.2%; and 6 months, 51.3% ± 14.6% and 35.9% ± 14.5%; for graft shift–negative and graft shift–positive cases, respectively). Graft shift direction did not affect postoperative best-corrected visual acuity or central corneal thickness. Conclusions: Graft shift direction in DMEK, especially inferior graft shift, affected the postoperative graft detachment rate. Superior graft shift had a beneficial effect on postoperative corneal endothelial values. These data suggest that inferior graft shift should be avoided in DMEK.

Anterior Chamber Rebubbling With Perfluoropropane (C3F8) After Failed Rebubbling Attempts for Persistent Descemet Membrane Endothelial Keratoplasty Graft Detachments Purpose: To describe the clinical outcomes of using C3F8 as a tamponade agent for the attachment of partially detached Descemet membrane endothelial keratoplasty (DMEK) grafts after failure of previous rebubbling attempts. Methods: Interventional case series. We reviewed the medical records of all DMEK surgeries performed at Rabin Medical Center (Petach Tikva, Israel) between January 2016 and December 2018 in which 10% C3F8 tamponade was used for graft reattachments. Patient demographic details, indication for surgery, early postoperative endothelial cell loss, postoperative visual acuity, intraoperative and postoperative complications as well as graft survival were noted. Results: Five patients were included in this case series. Indications for DMEK were pseudophakic bullous keratopathy (n = 3), failed penetrating graft (n = 1), and Fuchs endothelial dystrophy (n = 1). In 4 of 5 cases, SF6 tamponade was used at the end of the initial DMEK surgery. In 1 case, air tamponade was used. In all cases, partial graft detachment was seen 1 to 2 weeks postoperatively, and anterior chamber rebubbling was performed using 20% SF6 gas. A second C3F8-assisted rebubbling was performed 10 to 70 days after the primary DMEK surgery. In all cases, complete graft attachment was achieved, and the corneas cleared. Early endothelial cell loss rates averaged at 44% ± 26% (range 20%–74%). One case which had a previous trabeculectomy with chronic preoperative and postoperative hypotony had failed 6 months after surgery. All the other grafts were clear at last visit. Conclusions: Tamponade using nonexpansile 10% C3F8 gas can attach partially detached DMEK grafts after the failure of previous air- or SF6-assisted rebubbling attempts.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com