Detección de Acanthamoeba por reacción en cadena de la polimerasa en tiempo real en líquidos de conservación de lentes de contacto / Detection of Acanthamoeba sp. by real-time polymerase chain reaction in contact lens solutions

RESUMEN Objetivo: Estandarizar una técnica de reacción en cadena de la polimerasa en tiempo real para la detección del parásito e identificar Acanthamoeba en líquidos conservantes de lentes de contacto. Métodos: Se realizó un estudio descriptivo observacional de corte transversal sobre la técnica de reacción en cadena de la polimerasa en tiempo real para la detección de Acanthamoeba, en el Instituto de Investigaciones en Ciencias de la Salud de la ciudad de Asunción, en Paraguay. Se analizaron 110 líquidos conservantes aportados por usuarios sanos de lentes de contacto, mediante reacción en cadena de la polimerasa en tiempo real y cultivo en medio PAGE - SDS. Resultados: Se estandarizó con éxito la técnica de reacción en cadena de la polimerasa en tiempo real con límite de sensibilidad de 1 pg/µL. Se aisló Acanthamoeba a partir de una muestra (1 por ciento) por método de cultivo, mientras que la carga parasitaria en el líquido conservante fue inferior al límite de detección de la reacción en cadena de la polimerasa en tiempo real. El ADN obtenido del cultivo de dicha muestra fue positivo para Acanthamoeba por este método. Conclusión: El sistema estandarizado presenta buena sensibilidad y podrá ser incorporado en los laboratorios que cuentan con acceso a equipos de reacción en cadena de la polimerasa en tiempo real para un diagnóstico rápido y más eficiente en casos de sospechas de queratitis amebiana. Recomendamos el uso combinado de métodos moleculares y cultivo para aumentar la potencia del diagnóstico, sobre todo en muestras donde la carga parasitaria es muy baja(AU)

ABSTRACT Objective: Standardize a real-time polymerase chain reaction technique for detection of the parasite and identify Acanthamoeba in contact lens solutions. Methods: A cross-sectional observational descriptive study was conducted about a real-time polymerase chain reaction technique for detection of Acanthamoeba at the Institute of Health Sciences Research in the city of Asunción, Paraguay. A total 110 solutions were analyzed, which were provided by healthy contact lens users, by real-time polymerase chain reaction and culture in SDS-PAGE medium. Results: Successful standardization was achieved of the real-time polymerase chain reaction technique with a sensitivity limit of 1 pg/µl. Acanthamoeba was isolated from one sample (1 percent) by culture, whereas the parasite load in the contact lens solution was below the detection limit of the real-time polymerase chain reaction technique. The DNA obtained from the culture of that sample was positive for Acanthamoeba by the real-time polymerase chain reaction technique method. Conclusion: The system standardized exhibits good sensitivity and may be incorporated into laboratories with real-time polymerase chain reaction technique equipment for a rapid and more efficient diagnosis of suspected amoebic keratitis. We recommend the combined use of molecular methods and culture to enhance diagnostic power, mainly in samples where the parasite load is very low(AU)

Situación del diagnóstico de Queratitis Amebiana en Paraguay / Status of the diagnosis of Amebic Keratitis in Paraguay

Las amebas de vida libre (AVL) existen ampliamente distribuidas en la naturaleza, donde el género Acanthamoeba es la más frecuentemente aislada en diversos ambientes del suelo, aire y agua y está asociada a enfermedades en humanos. Su capacidad para vivir en ambientes adversos se debe a su baja demanda de alimentación y a que en su ciclo biológico tiene un estadio en forma de quiste, lo que la hace muy resistente. El hombre, como hospedero puede desarrollar infecciones en el sistema nervioso central, en la piel y los pulmones. A nivel ocular es capaz de afectar la córnea y producir queratitis. Por lo tanto es considerado un importante agente etiológico de patologías humanas. En esta revisión se aborda la biología, patogénesis y los mecanismos de defensa del ser humano frente a la infección por Acanthamoeba. Además a esto, de los factores de riesgo por el uso de lentes de contacto y malos hábitos de higiene del usuario y por último el abordaje diagnóstico microbiológico y molecular. Esta herramienta ha ido mejorando con el avance de la tecnología, indispensable para la temprana identificación y el logro de una oportuna y eficaz intervención clínica y terapéutica. Finalmente exponemos la situación actual en relación a los métodos de diagnóstico con que se cuentan y los escasos reportes clínicos existentes en Paraguay. Palabras clave: Acanthamoeba sp., Lentes de contacto, Queratitis.

Free-living amoeba (FLA) exist widely in nature, where the genus Acanthamoeba is the most frequently isolated in various environments of soil, air and water. It is associated with diseases in human. Its ability to live in adverse environments is due to the low food demand and that in its biological cycle it has a cyst-shaped stage, which makes it very resistant. Man, as a host, can acquire infections in the central nervous system and in the skin and lungs. On the ocular level, it can affect the cornea and cause keratitis. Therefore, it is considered an important etiological agent of human pathologies. This review addresses the biology, pathogenesis and human defense mechanisms against Acanthamoeba infection. In addition to this, the review explores the risk factors related to the use of contact lenses and poor hygienic behavior of the users, and finally the microbiological and molecular diagnosis. This particular tool has been improved with the advancement of technology and is essential for timely identification and the achievement of a good clinical and therapeutic intervention. Finally, we present the current situation in Paraguay regarding the few existing clinical reports and the diagnostic methods available. Key words: Acanthamoeba sp., Contact lenses, Keratitis.

Características de los pacientes pediátricos con miopía por encima de 6 dioptrías / Characteristics of pediatric patients with greater than 6 diopter myopia

RESUMEN Objetivo: Identificar las características de los pacientes pediátricos con miopías por encima de 6 dioptrías. Métodos: Se realizó un estudio descriptivo y observacional, de corte longitudinal, en 43 niños entre 3 y 15 años de edad con diagnóstico de miopía igual o mayor de 6 dioptrías en uno o ambos ojos (72 ojos), quienes acudieron a la consulta del Servicio de Oftalmología Pediátrica y Estrabismo del Instituto Cubano de Oftalmología "Ramón Pando Ferrer" durante el periodo comprendido entre enero y diciembre del año 2018. Las variables del estudio fueron la edad, el sexo, el color de la piel, la miopía (isometrópica y anisometrópica), la longitud axial, la agudeza visual con corrección, el tipo de corrección óptica, la presencia y el grado de estereopsia. Resultados: Predominó el grupo de 3 a 5 años (34,4 por ciento), el sexo femenino y el color de la piel blanca. La longitud axial aumentó junto con el equivalente esférico de los pacientes. La corrección más usada correspondió a los cristales, aunque se demostró estadísticamente que con los lentes de gas permeables los pacientes presentaban mejor agudeza visual (p= 0,016), donde se registró también la media más alta de equivalente esférico. De 43 pacientes, 20 (46,5 por ciento) no presentaron estereopsia. Los pacientes con anisometropías (64 por ciento) no presentaron estereopsia, lo que fue estadísticamente significativo. Conclusiones: Con los lentes de gas permeables los pacientes presentan mejor agudeza visual y mayor equivalente esférico. La mayor cantidad de pacientes sin estereopsia corresponde a las miopías por anisometropías(AU)

ABSTRACT Objective: Identify the characteristics of pediatric patients with greater than 6 diopter myopia. Methods: An observational descriptive longitudinal study was conducted of 43 children aged 3-15 years diagnosed with myopia equal to or greater than 6 diopters in one or both eyes (72 eyes) who attended the Pediatric Ophthalmology and Strabismus Service at Ramón Pando Ferrer Cuban Institute of Ophthalmology from January to December 2018. The variables considered were age, sex, skin color, myopia (isometropic or anisometropic), axial length, corrected visual acuity, type of optical correction, and presence and degree of stereopsis. Results: A predominance was found of the 3-5 years age group (34.4 percent), female sex and white skin color. Axial length increased with spherical equivalent. The most common correction was glasses, but it was statistically demonstrated that gas permeable lenses provided better visual acuity (p= 0.016) and the highest spherical equivalent mean. Of the 43 patients evaluated, 20 (46.5 percent) did not present stereopsis. Patients with anisometropia (64 percent) did not present stereopsis, which constituted a statistically significant fact. Conclusion: Gas permeable lenses provide better visual acuity and a greater spherical equivalent. Most of the patients without stereopsis have anisometropic myopia(AU)

La queratitis, y el desafío de encontrarse en medio del camino / Keratitis and the challenge of being in the middle of the road

La córnea es un órgano transparente e inmunológicamente privilegiado, debido a la falta de vasos sanguíneos, distribución y acomodación de sus fibras de colágeno. Sus ingeniosos métodos de defensa incluyen barreras físicas como el epitelio corneal, el recambio y composición de la película lágrima, y finalmente, la protección recibida del medio ambiente por medio del párpado. La córnea tiene 5 capas, incluyendo un epitelio de 5 a 7 células de espesor, estroma y endotelio, con capas de apoyo entre el estroma y las otras dos capas. A la infección de la córnea secundaria a bacterias, hongos, ó protozoarios se le conoce como queratitis1, una afección que amenaza a la visión y que puede llegar a perforación corneal o a una extensión de la infección como la endoftalmitis. De hecho, la complicación más seria de la queratitis es la ceguera producida por cicatrización corneal(AU)

Lentes de contato provocando conjuntivite por Ralstonia Pichettii / Contact lenses causing conjunctivity by Ralstonia Pichettii

Resumo O presente relato apresenta o caso de conjuntivite causada por Ralstonia pichettii em paciente imunocompetente usuária de lente de contato. A bactéria isolada da solução utilizada para desinfecção das lentes R. pichettii não pertente a microbiota humana mas infecta pacientes imunodeprimidos e está presente em soluções aquosas. Não há padronização de sensibilidade para esta bactéria e poucos antibióticos foram testados para bactérias não fermentadoras da glicose. Devido ao reduzido perfil de sensibilidade aos antimicrobianos demonstrado pela R. pichettii, torna-se importante a identificação correta deste agente etiológico em quadros de conjuntivite e ceratites. Este relato de caso ilustra que R. Pickettii é um patógeno mais importante do que se pensava anteriormente.

Abstract The present report reports a case of conjunctivitis caused by Ralstonia pichettii in an immunocompetent patient wearing a contact lens. The bacterium isolated from the solution used to disinfect R. pichettii does not belong to the human microbiota but infects immunodepressed patients and is present in aqueous solutions. There is no standardization of sensitivity for this bacterium and few antibiotics have been tested for non-fermenting glucose bacteria. Due to the reduced antimicrobial sensitivity profile demonstrated by R. pichettii, it is important to correctly identify this etiologic agent in conjunctivitis and keratitis. This case report illustrates that R. Pickettii is a more important pathogen than previously thought.

Contact lens-related bilateral and simultaneous Acremonium keratitis / Ceratite bilateral e simultânea por Acremonium relacionada ao uso de lentes de contato

Abstract This is a case of bilateral and simultaneous Acremonium keratitis related to intermittent and alternating eye soft contact lens use, which has a delayed diagnose, presented amphotericin B resistance with persistent hypopyon and had a positive response to topical natamycin. Besides the unusual presentation, there was no history of trauma or contact with vegetable matter, usually associated to the majority of cases of keratomicosys by filamentous fungi.

Resumo Trata-se de um caso de ceratite bilateral e simultânea por Acremonium relacionada ao uso intermitente e sem respeitar a lateralidade do uso de lentes de contato gelatinosas. Houve diagnóstico tardio, apresentando resistência a anfotericina B e hipópio persistente, com resposta positiva a natamicina tópica. Além da forma incomum de apresentação, não houve histórico de trauma ou contato com material vegetal, associado à maioria dos casos de ceratite por fungos filamentosos.

Epidemiological profile of infectious keratitis / Perfil epidemiológico da ceratite infecciosa

Abstract Objective: To evaluate the epidemiologic aspects of cornea ulcers in a referred ophthalmology private practice center. Methods: Retrospective study over electronic files of patients treated for corneal ulcers during a period of 7 years by the same physician (RJMF) at Centro de Olhos São Francisco, between june 2007 and june 2014. These patients were evaluated for risk factors such as: trauma causes, co-morbidities and contact lenses use. They were also evaluated by the microorganism found at the smears, treatment and patient's outcome. Patients that didn't return with the smears results or that didn´t have a complete follow-up were excluded from the study. Results: A total of 242 patients were fully treated during this period. 55 patients were excluded and 187 patients were included. 28.88% (54/187) were positive for gram negative bacteria, 27.81% (52/187) for filamentous fungi, 16.04% (29/187) for gram positive bacteria and only 1.07% for acanthamoeba. Twenty-four patients had negative cultures and 21 patients had combined infections (bacteria + fungi or other combination). Corneal collagen Cross-linking was effective on melting arrest in 16 of the 16 patients that we have submitted to this procedure during 2008 and 2009. Among all the patients that had corneal infection and were previously using contact lenses, 81% were infected by pseudomonas or pseudomonas associated with other gram negative bacteria. Filamentous fungi had a strong association with physical trauma. While use of saline solution for contact lenses cleaning had a strong association with gram negative bacteria and biological trauma, a strong association with combined infection. Conclusion: Gram negative bacteria (Pseudomonas) followed by filamentous fungi (Fusarium sp) were the most frequent etiologic agent found in our study. Cross-link was effective on corneal melting arrest. Pseudomonas aeruginosa was the most frequent isolated agent on hydrophilic contact lenses wearers.

Resumo Objetivo: Avaliar os aspectos epidemiológicos de úlceras de córnea em um centro privado de referência oftalmológica. Métodos: Estudo retrospectivo a partir de arquivos eletrônicos de pacientes tratados por úlceras de córnea durante um período de 7 anos pelo mesmo médico (RJMF) no Centro de Olhos São Francisco, entre Junho de 2007 e Junho de 2014. Estes pacientes foram avaliados quanto a fatores de risco, trauma, co-morbidades, uso de lentes de contato, tipo de microrganismo encontrado, tratamento e evolução do doente. Os pacientes que não retornaram com os resultados das culturas ou que não possuíam um seguimento completo foram excluídos do estudo. Resultados: Um total de 242 pacientes foram tratados durante este período. 55 pacientes foram excluídos e 187 foram incluídos no estudo. 28,88% (54/187) foram positivos para as bactérias gram-negativas, 27,81% (52/187) para fungos filamentosos, 16,04% (29/187) para as bactérias gram-positivas e apenas 1,07% para acanthamoeba. Vinte e quatro pacientes tiveram culturas negativas e 21 pacientes tinham infecções combinadas (bactérias fungos + ou outra combinação). O Cross-link foi eficaz em interromper o melting em 16 dos 16 pacientes que se submeteram a este procedimento durante 2008 e 2009. Entre todos os pacientes que tiveram infecção de córnea e usavam previamente lentes de contato, 81% foram infectados por pseudomonas isolada ou pseudomonas associada ou não a outras bactérias gram-negativas. Os fungos filamentosos tiveram uma forte associação com trauma físico, uso de solução salina para a limpeza de lentes de contato teve uma forte associação com bactérias gram- negativas e trauma biológico, uma forte associação com a infecção combinada. Conclusão: Bactérias Gram negativas (em especial, Pseudomonas) seguido por fungos filamentosos (Fusarium sp) foram os agentes etiológicos mais freqüentemente encontrados em nosso estudo. O Cross-linking foi eficaz em interromper o melting de córnea. Pseudomonas aeruginosa foi o agente isolado mais frequente em usuários de lente de contato hidrofílica.

Visual rehabilitation using mini-scleral contact lenses after penetrating keratoplasty / Reabilitação visual após transplante penetrante de córnea com lentes de contato mini-esclerais

ABSTRACT Purpose: To report the visual rehabilitation outcomes and complications of patients fitted with mini-scleral rigid gas-permeable (RGP) contact lenses (mini-SCLs) after penetrating keratoplasty. Methods: We retrospectively reviewed 27 eyes (21 patients) that were fitted with mini-SCLs between October 2013 and December 2014. We analyzed demographic data, previous corneal disorders, visual outcomes, interval from keratoplasty to contact lens fitting, topographic and specular microscope data, fitted contact lens parameters, and complications. The patients were divided into two groups according to the elapsed time since surgery: Group A, grafts with <10 years (n=14 eyes); and Group B, grafts with ≥10 years (n=13 eyes). Results: Lens use was discontinued in four eyes, and microbial keratitis developed in one eye during follow-up. No corneal graft rejection was observed. The mean interval between grafting and initial contact lens fitting was 10.6 ± 7.3 years (range: 1-29 years). The most frequent reason for keratoplasty was keratoconus (22 eyes, 81.4%). The mean contact lens-corrected visual acuity (CLCVA) was 0.09 ± 0.12 logMar (range: 0.50-0.00 logMar). The average topographic astigmatism, mean steepest keratometry (Kmax), and average cellularity on specular microscopy were 6.19 ± 3.49 diopters (D), 58.4 ± 7.8 D, and 1,231 ± 723 cells/mm2, respectively. Conclusions: Mini-SCL use allowed successful visual rehabilitation after corneal keratoplasty, particularly in patients who required corrective lenses for low visual acuity and were unable to wear RGP contact lenses. Our results indicate that mini-scleral lenses may be an option for the treatment of corneal irregularities, such as those associated with keratoplasty.

RESUMO Objetivos: Avaliar a reabilitação visual e complicações com o uso de lentes de contato rígidas gás-permeáveis mini-esclerais em pacientes submetidos ao transplante penetrante de córnea. Métodos: Estudo retrospectivo de 27 olhos (21 pacientes) adaptados com lentes de contato mini-esclerais entre outubro de 2013 e dezembro de 2014. Informações demográficas, doença corneana prévia, acuidade visual, tempo decorrido entre transplante e adaptação da lente, dados topográficos e de microscopia especular, parâmetros da lente de contato adaptada e complicações foram analisadas. Os pacientes foram divididos em dois grupos, levando em consideração o tempo decorrido do transplante de córnea: menos de 10 anos (Grupo A, n=14 olhos) e mais de 10 anos (Grupo B, n=13 olhos). Resultados: Quatro olhos desistiram do uso da lente de contato e 1 paciente apresentou quadro de ceratite infecciosa durante o período de acompanhamento. Não ocorreu episódio de rejeição de botão corneano transplantado durante o período avaliado. O tempo médio entre o transplante e a adaptação da lente de contato foi de 10,6 ± 7,3 anos (variação de 1 a 29 anos) e a causa mais frequente de ceratoplastia foi ceratocone (22 olhos, 81,4%). A acuidade visual média corrigida com lente de contato foi de 0,09 ± 0,12 logMar (variação de 0,50 a 0.00 logMar). O astigmatismo topográfico médio foi de 6,19 ± 3,49 dioptrias (D), a ceratometria média mais curva (Kmax) foi 58,4 ± 7,8 D e a celularidade média na microscopia especular foi 1.231 ± 723 células/mm2. Conclusões: Este estudo retrospectivo mostra o sucesso da adaptação de lentes de contato mini-esclerais na reabilitação visual após o transplante de córnea, especialmente em pacientes com baixa acuidade visual com óculos e intolerância ao uso de lentes de contato rígidas gás-permeáveis. Nossos resultados demonstram que as lentes de contato mini-esclerais são um opção para córneas com irregularidades corneanas, assim como aquelas após o transplante de córnea.

Unilateral acanthamoeba keratitis following the use of cosmetic contact lens

Colored lenses were first designed for patients with eye pathologies, such as aniridia or corneal opacity. However, in recent years they have become readily available over-the-counter as cosmetic accessories. Widespread use of these lenses has been noted among young adults. Acanthamoeba keratitis is a rare cause of corneal infection, which is associated with poor visual prognosis. Over the past ten years, improvements in the management of this infection have been documented, yet the best treatment is still primary prevention. Hence, contact lens wearers must be provided with proper instructions regarding contact lens hygiene. We present a case of unilateral Acanthamoeba keratitis in a cosmetic contact lens wearer who presented with a month history of right eye pain, photophobia, redness and blurred vision. The contact lenses were obtained over the counter, and a history of poor contact lens hygiene was found. The patient was started on empirical treatment initially. The treatment was modified once the diagnosis was confirmed via Giemsa Stain of corneal scrapings, which showed Acanthamoeba cysts. The patient improved markedly and was discharged from the hospital. The disease classically has a slowly progressive, chronic course, with frequent remission periods. Our patient was lost to follow-up due to poor compliance and failure to adhere to guidelines

Comportamiento clinicoepidemiológico de los pacientes con diagnóstico de úlcera grave de la córnea / Clinical and epidemiological behavior of patients suffering severe corneal ulcers

Objetivo: describir el comportamiento clinicoepidemiológico de la úlcera grave de la córnea en pacientes ingresados en el Instituto Cubano de Oftalmología Ramón Pando Ferrer, entre los años 2010 y 2014. Métodos: se realizó un estudio observacional, de corte transversal, de 223 pacientes. Se estudiaron las siguientes variables: edad, sexo, procedencia, ocupación, enfermedades oculares y sistémicas, cirugía previa, trauma no quirúrgico, uso de lentes de contacto, esteroides previos, tiempo de evolución, forma clínica y germen aislado. Para el análisis estadístico se utilizaron porcentajes, media, prueba no paramétrica de probabilidad exacta de Fisher, chi cuadrado de Pearson y prueba U de Mann Whitney. Resultados: la edad promedio fue de 46,3 ± 21,9. Predominaron los pacientes con edades de 60 años o más (31,4 por ciento), sexo masculino (57,0 por ciento), procedencia rural (57,8 por ciento). El uso de lentes de contacto (22,4 por ciento) fue el factor predisponente más frecuente. La mediana de los días de evolución al ingreso fue de 7,0 días. La forma clínica de presentación más frecuente fue la úlcera estromal (86,5 por ciento) y la úlcera corneal perforada (7,2 por ciento). En el 69,2 por ciento de los cultivos se obtuvieron bacterias, a predominio de las gram negativas (Pseudomona). El 33,3 por ciento correspondió a hongos filamentosos. Conclusiones: la queratitis infecciosa grave se caracteriza por su presencia en adultos mayores, sexo masculino y procedencia rural. El factor predisponente más frecuente es el uso de lentes de contacto. Las bacterias gram negativas se aíslan con mayor frecuencia(AU)

Objective: to describe the clinical and epidemiological behavior of severe corneal ulcer in patients admitted to Ramón Pando Ferrer Cuban Institute of Ophthalmology from 2010 through 2014. Methods: observational and cross-sectional study of 223 patients.. The following variables were studied: age, sex, origin, occupation, eye and systemic diseases, previous surgery, non-surgical trauma, contact lens wear, previous steroids, duration, clinical form and isolated germ. For the statistical analysis, the study used percentages, means, nonparametric Fisher´s exact probability test, Pearson´s Chi Square, Mann Whitney´s U test. Results: mean age was 46,3 ± 21,9. Patients aged 60 years or older (31,4 percent), males (57,0 percent), rural origin (57,8 percent) predominated. Wearing contact lenses (22,4 percent) was the most common predisposing factor. The median of days of progression on admission was 7 days. The most frequent clinical form of presentation was stromal ulcer (86,5 percent) and perforated corneal ulcer (7,2 percent). In 69,2 percent of cultures, bacteria was obtained, being the Gram negative (Pseudomonas) predominant. The 33,3 percent of cultures were filamentous fungi. Conclusions: severe infectious keratitis was present in older adults, males and of rural origin. The most common predisposing factor was the contact lens wear. Gram negative bacteria were more frequently isolated(AU)

Úlceras corneales en usuarios de lentes de contacto / Corneal ulcers in contact lens wearers

El empleo de lentes de contacto se ha incrementado a nivel mundial. En la actualidad su uso no se restringe solamente a la corrección óptica, sino que se utilizan con fines terapéuticos, ya que generan comodidad y estética en múltiples afecciones oculares. Es de esperar el creciente aumento de las complicaciones relacionadas con el uso de estos, por ser la queratitis bacteriana potencialmente grave y devastadora para el globo ocular. Se realizó una revisión bibliográfica acerca de las úlceras corneales en portadores de lentes de contacto con el objetivo de describir su epidemiología y las formas de prevenir esta complicación(AU)

The use of contact lenses has increased worldwide. Their current uses comprise optical correction as well as therapeutic purposes since they bring comfortableness and esthetics in a number of ocular diseases. It is expected that contact lenses-related complications will grow because bacterial keratitis is potentially severe and devastating for the eyeball. A literature review on the presence of corneal ulcers in contact lens wearers was made to describe the epidemiology and the ways of preventing this complication(AU)

Contact Lens-associated Nocardial Necrotizing Scleritis

A 52 year-old, contact lens-wearing man presented with progressive right eye pain and redness for one month. He had been evaluated and treated for necrotizing scleritis by multiple eye care specialists prior to presentation. He underwent a complete systemic work-up for both autoimmune and infectious causes of scleritis, including a culture. The culture revealed heavy growth of Nocardia asteroides complexes. The patient was treated with topical amikacin and oral Bactrim. Following several weeks of antibiotic treatment, the patient's infection resolved completely, and his visual acuity returned to baseline status. Nocardia is a rare but potentially devastating cause of necrotizing scleritis that may affect contact lens wearers without an associated keratitis. Prompt recognition and early treatment with appropriate antimicrobial agents are critical to achieve a favorable outcome.

Les keratites amibiennes

L'objectif de cette revue generale est de decrire les caracteristiques des agents responsables des keratites amibiennes; les principes de leur diagnostic positif ainsi que les modalites de leur traitement.Les keratites amibiennes surviennent dans la majorite des cas chez des porteurs de lentilles de contact. Les manifestations cliniques peuvent etre atypiques. Les prelevements; en particulier corneens; permettent de rechercher les amibes par des examens directs et des cultures ou d'identifier leur acide desoxyribo- nucleique par reaction de polymerisation en chaine; cette derniere technique etant plus sensible. La microscopie confocale; permet par ailleurs; de rechercher in vivo des kystes amibiens. Le traitement medical; peut etre institue en cas de forte suspicion clinique du diagnostic. Les protocoles therapeutiques de premiere intention se basent sur l'association de collyres presentant une activite kysticide; le plus souvent un biguanide et une diamidine; pendant plusieurs semaines. Le pronostic visuel est lie a la severite du tableau initial et au delai de mise en route d'un traitement efficace. Les sequelles visuelles peuvent etre invalidantes d'ou l'interet de porter un diagnostic precoce

Alterations tear film ferning in contact lens users

The tear film is a fluid that covers the cornea which establishes a high quality refractive surface for the corneal epithelium. Here we investigated the alterations in tear film feming due to contact lens wear and compared it with normal and artificial tear ferning. The tear samples were collected from 4 normal individuals and 4 contact lens users aged from 22 to 34 years. The tear samples were pulled out from the eye by a small duct and observed under light microscopes. Artificial tears 'Refresh Plus', from 'Allercan' were purchased from a shop. In artificial tears, the structure of ferning in the centre and periphery were similar to each other under light microscope where as in normal tears, peripheral ferning was mildly denser compared to the centre. In the contact lens user tear film, ferning was faint under the light microscope. The ferning of tear film of was in the form of circle in the centre and a string of circles at periphery. There was minor difference between normal and artificial tear ferning. The contact lens user tear ferning was very thin compared to normal and artificial tear ferning. This could be due to less lipid content in the tears of contact lens user. The contact lens use affects the tear ferning. This could be due to loss of lipid content in the tears especially in the central region

Lente de contato escleral na reabilitação ocular de pacientes com síndrome de Stevens-Johnson / Scleral contact lens for ocular rehabilitation in patients with Stevens-Johnson syndrome

OBJETIVO: Avaliar a eficácia do uso das lentes de contato esclerais no manejo das sequelas oculares de pacientes portadores de síndrome de Stevens-Johnson. MÉTODOS: Foram avaliados, retrospectivamente, pacientes com sequelas oculares da síndrome de Stevens-Johnson que iniciaram o uso de lente de contato escleral. Os pacientes foram submetidos a avaliação subjetiva dos sintomas através de um questionário; exame oftalmológico (medida da acuidade visual, biomicroscopia, coloração da superfície ocular com colírio de fluoresceína, teste de Schirmer). RESULTADOS: Dez olhos de 7 pacientes foram analisados. A acuidade visual dos pacientes variou de movimentos de mão a 20/25. Todos os pacientes apresentavam algum grau de opacidade corneal e simbléfaro leve. A lente de contato escleral foi adaptada com sucesso em 90 por cento dos olhos. Em todos estes casos os pacientes referiram melhora dos sintomas e da visão. Com relação aos achados biomicroscópicos observou-se melhora da hiperemia conjuntival e da ceratite, e diminuição da secreção mucosa em 90 por cento dos olhos. CONCLUSÕES: Foi possível uma adaptação bem sucedida da lente de contato escleral em grande parte dos pacientes, com melhora dos sintomas e da acuidade visual provavelmente consequentes à melhora da regularização da superfície ocular. As lentes de contato esclerais representam uma importante e acessível alternativa para a redução da limitação ocasionada pelos danos sequelares da síndrome de Stevens-Johnson.

PURPOSE: To evaluate the efficacy of scleral contact lenses use on the management of ocular sequelae from Stevens-Johnson syndrome patients. METHODS: In a retrospective study, patients who suffered sequelae of Stevens-Johnson syndrome and started the use of scleral contact lenses were followed. Patients were submitted to an evaluation of symptoms through a questionnaire; ophthalmologic exam (visual acuity measurement, biomicroscopy, ocular surface staining with fluorescein drops, Schirmer test). RESULTS: Ten eyes of seven patients were analyzed. Visual acuity varied from hand movements to 20/25. All patients presented some degree of corneal opacity and slight symblepharon. In patients whose adaptation to scleral contact lenses was successful (90 percent), they all refered improvement of symptoms and sight. As for the biomicroscopic findings it was observed an improvement of conjunctival hyperemia and keratitis and a reduction of the mucous secretion in 90 percent the cases. CONCLUSIONS: A successful adaptation to scleral contact lenses was feasible on most patients, with relief of symptoms and better visual acuity, probably due to regularization of the surface. Scleral contact lenses represent an important and accessible alternative to reduce the limitations inferred by the damages from Stevens-Johnson syndrome.

Microbial keratitis in the elderly: a 32-year review / Ceratite infecciosa em idosos: revisão de 32 anos

PURPOSE: To describe the demographic characteristics, associated factors and causative agents of infectious keratitis in the elderly in a tertiary referral center in São Paulo, Brazil. METHODS: A retrospective review of all patients aged 60 years and over with a presumptive diagnosis of infectious keratitis who had material collected for microbiological analysis, between the years 1975 and 2007 (32-year span). RESULTS: From a total of 7,060 age-independent cases of microbial keratitis, 1,545 cases in the elderly were reviewed, which had a mean age of 71.0 ± 7.8 years, ranging from 60 to 101 years. There were 707 males (45.6 percent) and 838 females (54.3 percent). Associated factors were: past ocular surgery (25.1 percent), ocular trauma (7.2 percent) and contact lens use (3.0 percent). Bacterioscopy was positive in 40.5 percent of cases. Culture positivity for any agent was 53.5 percent (bacteria 47.0 percent, fungi 6.1 percent, Acanthamoeba 0.4 percent). The most frequent bacteria were the gram-positive cocci (mostly coagulase-negative Staphylococci) and gram-negative bacilli (mostly the genera Pseudomonas, Moraxella and Proteus), while the most frequent fungi were the filamentous (mostly the genus Fusarium). CONCLUSIONS: This study represents a large series of microbial keratitis in the elderly in a single referral center. The most important factor associated with this condition in the elderly was past ocular surgery. The most frequent causative agents were bacteria, especially gram-positive cocci and gram-negative bacilli.

OBJETIVO: Descrever as características demográficas, fatores associados e agentes etiológicos das ceratites infecciosas em idosos em um centro de referência terciário em São Paulo, Brasil. MÉTODOS: Análise retrospectiva de todos os pacientes a partir de 60 anos com diagnóstico clínico de ceratite infecciosa que tiveram material colhido para análise microbiológica, entre os anos de 1975 e 2007 (intervalo de 32 anos). RESULTADOS: De um total de 7.060 casos de ceratite infecciosa em todas as idades, 1.545 casos em idosos foram revisados. A idade média foi de 71,0 ± 7,8 anos, variando de 60 a 101 anos. Foram 707 homens (45,6 por cento) e 838 mulheres (54,3 por cento). Os principais fatores associados foram: cirurgia ocular prévia (25,1 por cento), trauma ocular (7,2 por cento) e uso de lentes de contato (3,0 por cento). Bacterioscopia foi positiva em 40,5 por cento dos casos. A positividade das culturas para qualquer agente foi de 53,5 por cento (bactérias 47,0 por cento, fungos 6,1 por cento, Acanthamoeba 0,4 por cento). As bactérias mais frequentes foram os cocos gram positivos (principalmente Staphylococcus coagulase negativo) e bacilos gram negativos (principalmente Pseudomonas, Moraxella e Proteus), enquanto os fungos mais frequentes foram os filamentosos (Fusarium). CONCLUSÕES: Este estudo representa até o momento a maior série de casos de ceratite infecciosa em idosos em um centro único. O fator mais associado a esta condição em idosos foi cirurgia ocular prévia. Os agentes etiológicos mais frequentes foram as bactérias, principalmente cocos gram positivos e bacilos gram negativos.

Pigment Deposition of Cosmetic Contact Lenses on the Cornea after Intense Pulsed-Light Treatment

We report a case of corneal deposition of pigments from cosmetic contact lenses after intense pulsed-light (IPL) therapy. A 30-year-old female visited our outpatient clinic with ocular pain and epiphora in both eyes; these symptoms developed soon after she had undergone facial IPL treatment. She was wearing cosmetic contact lenses throughout the IPL procedure. At presentation, her uncorrected visual acuity was 2/20 in both eyes, and the slit-lamp examination revealed deposition of the color pigment of the cosmetic contact lens onto the corneal epithelium. We scraped the corneal epithelium along with the deposited pigments using a no. 15 blade; seven days after the procedure, the corneal epithelium had healed without any complications. This case highlights the importance of considering the possibility of ocular complications during IPL treatment, particularly in individuals using contact lenses. To prevent ocular damage, IPL procedures should be performed only after removing the lenses and applying eyeshields.

Evaluation of Three Different Methods to Establish Animal Models of Acanthamoeba Keratitis

PURPOSE: To produce animal models of Acanthamoeba keratitis and to evaluate the advantages and adaptation range of each of the three methods employed. MATERIALS AND METHODS: Mice and Wistar rats in three groups of 15 rats and 15 mice each were used to establish the models. Right corneas in group A were scratched and challenged with Acanthamoeba. Those in group B were scratched and covered with contact lenses incubated with Acanthamoeba. Those in group C received an intrastromal injection of Acanthamoeba. Five rats and 5 mice in each group were used for histopathological investigations and the other 10 in each group were used for clinical evaluation. The models were evaluated by slit lamp examination, microscopic examination and culture of corneal scrapings, HE staining of corneal sections, and pathological scoring of the infections. RESULTS: Four rats and 6 mice in group A, 7 rats and 8 mice in group B, and 10 rats and 10 mice in group C developed typical Acanthamoeba keratitis. CONCLUSION: Corneal scratching alone has the lowest infection rate, while scratching and then covering with contaminated contact lenses has a moderate rate of infection and most closely mimics what happens in most human infections. Intrastromal injection of Acanthamoeba gives a much higher infection rate and more severe Acanthamoeba keratitis.

Diabetes mellitus y lentes de contacto / Diabetes mellitus related to use of contact lenses

Cada día aumenta el número de diabéticos diagnosticados que demandan como método de compensación para los defectos de refracción las lentes de contacto. Debido a la escasa información que se tiene sobre el tema, dedicamos nuestro trabajo a realizar una revisión sobre la relación de estos dos temas: lentes de contacto y diabetes, con el justo ánimo de brindar una atención más completa a nuestros pacientes(AU)

Every day increases the figure of diagnosed diabetic patients requiring a compensatory method for refraction defects the use of contact lenses. Due to the non-available information on this matter, this paper is aimed to make a review on relation between these two topics: contact lenses and diabetes to offer a more complete care to our patients(AU)