Queratitis por Mycobaterium abscessus: comunicación del primer caso en Paraguay / Keratitis due to Mycobaterium abscessus: first case report in Paraguay

Resumen Se presenta un caso clínico de queratitis por Mycobacterium abscessus en una mujer de 76 años, residente en la ciudad de Asunción, sin traumatismo ni cirugía ocular previa y con antecedente de una queratouveitis herpética. Por tratarse de una queratitis causada por un agente etiológico poco frecuente y por la importancia de un diagnóstico correcto y oportuno para la instauración del tratamiento adecuado, se comunica el primer caso de queratitis por micobacterias en Paraguay.

Abstract We present a clinical case of keratitis caused by M. abscessus in a 76-year-old female patient, resident in the city of Asunción, without trauma or previous ocular surgery and with a history of herpetic keratouveitis. Because it is a keratitis caused by a rare etiological agent and because of the importance of a correct and timely diagnosis for the establishment of appropriate treatment, the present case is reported, the first of Mycobacteria keratitis in Paraguay.

Fungal keratitis management in a referral cornea center in Brazil / Manejo de ceratites fúngicas em centro de referência no Brasil

Abstract Purpose: To report etiological diagnosis, predisposing risk factors, therapeutic strategies and visual outcome of patients treated at the Department of Ophthalmology of Federal University of São Paulo. Methods: This is a retrospective, descriptive, and observational study from medical and laboratory records of the Department of Ophthalmology of Federal University of São Paulo, including all patients with culture proven fungal keratitis in 5 years, from October 2012 through October 2017. Results: There were 2260 fungi microbiologic test requests. Of these, 140 samples had positive cultures for fungi and sixty-six patients were followed at our clinic. Forty-five patients (68.2%) were men, and the mean age was 48.06 (±17.39) years. Fusarium spp. was the most frequently isolated fungus (32 cases; 48.5%), followed by Candida parapsilosis (12 cases; 18.2%). Thirty-four patients (51.5%) underwent intracameral injection of amphotericin B (5 µg per 0.1 ml). In 11 patients (32.3%), infection was eradicated after intracameral amphotericin B associated to topical antifungal treatment and, in 23 patients (67.7%), therapeutic keratoplasty was needed. No complication related to intracameral amphotericin B injection was observed in this series. Forty-three patients (65.1%) ended up with therapeutic keratoplasty. Three patients (4.5%) evolved to evisceration or enucleation. At the last follow-up visit, 53 patients (80.3%) had visual acuity worse than 20/200. Conclusion: Despite current antifungals drugs and distinct administration strategies, fungal keratitis remains challenging. Delayed antifungal therapy may explain poor clinical outcomes. Intracameral amphotericin B associated to topical antfungal treatment seems to be a safe and helpful alternative for non-responsive fungal keratitis. But it is important to formulate other treatment strategies, hence to improve patients' outcomes, since most patients ended-up with significant visual impairment even after current treatment.

Resumo Objetivo: Descrever diagnósticos etiológicos, fatores de risco, estratégias terapêuticas e resultados visuais de pacientes com ceratite fúngica tratados no Departamento de Oftalmologia da Universidade Federal de São Paulo. Métodos: Trata-se de um estudo retrospectivo, descritivo e observacional, a partir da análise de prontuários médicos e laboratoriais do Departamento de Oftalmologia da Universidade Federal de São Paulo, incluindo todos os pacientes com ceratite fúngica comprovada por cultura no período de outubro de 2012 a outubro de 2017. Resultados: Foram realizadas 2260 solicitações de testes microbiológicos. Destas, 140 amostras apresentaram culturas positivas para fungos, e 66 pacientes foram acompanhados em nosso serviço. Quarenta e cinco pacientes (68,2%) eram do sexo masculino, e a média de idade foi de 48,06 (± 17,39) anos. Fusarium spp. foi o fungo mais freqüentemente isolado (32 casos; 48,5%), seguido por Candida parapsilosis (12 casos; 18,2%). Trinta e quatro pacientes (51,5%) foram submetidos à injeção intracameral de anfotericina B (5 µg por 0,1 ml). Destes, 11 pacientes (32,3%) tiveram a infecção erradicada. Nos outros 23 pacientes (67,7%), o transplante terapêutico foi necessário. Nenhuma complicação relacionada à injeção intracameral de anfotericina B foi observada neste estudo. No total, 43 pacientes (65,1%) evoluíram para transplante terapêutico, e 3 pacientes (4,5%) foram submetidos à evisceração ou enucleação. Cinquenta e três pacientes (80,3%) apresentaram acuidade visual final pior que 20/200. Conclusões: Apesar dos diversos medicamentos antifúngicos atuais e vias de administração, o tratamento das ceratites fúngicas permanece desafiador. O atraso no início do tratamento adequado pode justificar o desfecho clínico desfavorável de grande parte dos pacientes. A injeção intracameral de anfotericina B mostrou-se uma alternativa terapêutica segura para ceratites fúngicas refratárias. Mas outras estratégias de tratamento devem ser formuladas, visando melhorar os resultados visuais dos pacientes.

Post-laser in situ keratomileusis interface Arthrographis kalrae keratitis / Interface de pós-laser ceratomileuse in situ Arthographis Kalrae ceratite

ABSTRACT We describe a case of keratomycosis caused by Arthographis kalrae after excimer laser keratomileusis. A 38-year-old female developed stromal keratitis eight weeks after refractive surgery. She developed severe corneal stromal infiltration and mild anterior segment inflammation, which could not be treated with topical voriconazole 1%, but topical natamycin 5% ameliorated her condition. A reactivation of keratomycosis symptoms was observed; therefore, longer treatment was administered to the patient. It has been reported that A. kalrae keratomycosis is associated with exposure to soil and contact lens usage. However, the patient, who lived in a rural location, was neither involved in gardening activities nor had a history of wearing contact lenses. This is the first case of post-refractive A. kalrae keratomycosis.

RESUMO Descrevemos um caso de ceratomicose por Arthographis kalrae após ceratomileusis por excimer laser. Uma mulher de 38 anos desenvolveu ceratite estromal oito semanas após a cirurgia refrativa. Ela desenvolveu infiltração estromal grave da córnea e uma leve inflamação do segmento anterior, que não pode ser tratada com voriconazol tópico a 1%, mas a natamicina tópica a 5% melhorou sua condição. Uma reativação dos síntomas de ceratomicose foi observada; portanto, tratamento mais prolongado foi administrado a paciente. Tem sido relatado que a ceratomicose por A. kalrae está associada à exposição ao solo e ao uso de lentes de contato. No entanto, a paciente, que vivía em um local rural, não estava envolvida em atividades de jardinagem e nem tinha histórico de uso de lentes de contato. Este é o primeiro caso de ceratomicose pós-refrativa por A. kalrae.

Infectious keratitis in southern Brazil: a comparison culture negative and culture positive patients / Ceratite infecciosa no sul do Brasil: comparação entre pacientes com cultura negativa e positiva

Abstract Purpose: To compare clinical-epidemiological profile and treatment outcome between culture negative and culture positive keratitis patients. Methods: Patients with suspected infectious keratitis seen at two ophthalmic hospitals in Curitiba, Brazil, between June 2014 and April 2016, were prospectively studied. Ophthalmological exam with corneal scraping and microbiological tests were performed. Data regarding follow up, surgical interventions and treatment outcome were collected after 12 weeks of the first visit trough medical chart review. From the results of the culture, two groups were formed: culture negative keratitis (CNK) and culture positive keratitis (CPK). Results: According to inclusion criteria 21 patients were classified as culture negative keratitis and 20 patients as culture positive keratitis. The number of patients on antibiotic drops at the first visit was greater in CNK group (90.5% versus 60%; p=0.032). Surgical procedures were necessary in 3 patients (15%) in CNK group and in 7 patients (36,8%) in CPK group (p=0.155). Treatment success was achieved by 85% (17/20) of the patients in CNK group and by 61% (11/18) of the patients in CPK group (p=0.144). There was no significant difference between groups regarding age, gender, place of residence, presence of comorbidities, risk factors for infectious keratitis, duration of symptoms and characteristics of corneal ulcer. Conclusions: Previous treatment with antibiotics correlates with negative culture results. There was no significant difference in treatment outcome between culture negative and culture positive keratitis patients.

Resumo Objetivo: Comparar os perfis clinico-epidemiológicos e os desfechos entre pacientes com ceratite com cultura positiva e pacientes com ceratite com cultura negativa. Métodos: Pacientes com ceratite infecciosa, atendidos em dois hospitais oftalmológicos em Curitiba, Brasil, entre junho de 2014 e abril de 2016, foram estudados prospectivamente. Exame oftalmológico, raspado de córnea e exames microbiológicos foram realizados no primeiro atendimento. Os dados quanto a seguimento e desfecho foram coletados após 12 semanas do primeiro atendimento através de revisão de prontuário. A partir dos resultados das culturas, dois grupos foram formados: ceratite com cultura negativa e ceratite com cultura positiva. Resultados: Vinte e um pacientes foram classificados como ceratite com cultura negativa e 20 como ceratite com cultura positiva. O número de pacientes em uso de colírio antibiótico no primeiro atendimento foi maior no grupo de cultura negativa (90,5% versus 60%; p=0,032). Sete pacientes (37%) no grupo cultura positiva precisaram de procedimentos cirúrgicos no manejo da ceratite, versus 3 pacientes (15%) do grupo cultura negativa (p=0,155). Oitenta e cinco por cento (17/20) dos pacientes do grupo cultura negativa alcançaram sucesso no tratamento, contra 61% (11/18) dos pacientes no grupo cultura positiva (p=0,144). Não houve diferença entre os grupos quanto a idade, gênero, local de procedência, presença de comorbidades, fatores de risco, duração dos sintomas e características da úlcera de córnea. Conclusão: Tratamento prévio com colírio de antibiótico correlaciona-se com resultados negativos de cultura. Não houve diferença no desfecho após tratamento entre os pacientes com cultura negativa e cultura positiva.

Estudo epidemiológico das queratites infeciosas internadas num centro hospitalar terciário - revisão de 5 anos / Epidemiological study of infeccious keratitis in inpatients of a terciary hospital center - revision of 5 years

Resumo Objetivo: A queratite infeciosa é uma doença de incidência relativamente elevada e é responsável por um número importante de internamentos. Neste estudo pretende-se estudar diversas características epidemiológicas e clínicas associadas às queratites infeciosas de alto risco num hospital terciário em Portugal. Métodos: Realizou-se um estudo retrospetivo, onde foram incluídos todos os doentes internados por abcesso da córnea no Centro Hospitalar Universitário do Porto (CHUP), entre Abril de 2013 a Março de 2018. Caracterizou-se a população em relação aos fatores de risco, apresentação clínica, tempo de internamento, resultados de culturas, resistência antibiótica in vitro, tratamento efetuado e resultado funcional. Resultados: O estudo incluiu 105 doentes. Os principais fatores de risco foram antecedentes de cirurgia de córnea, uso de lentes de contacto e história recente de trauma ocular. 74,3% dos doentes tiveram cultura positiva com 87,9% a corresponderem a cultura bacteriana pura, sendo a Pseudomonas aeruginosa e o Streptococcus pneumoniae os agentes etiológicos mais frequentes. 27,9% das culturas positivas eram resistentes a 3 ou mais classes de antibióticos. Todos os doentes iniciaram tratamento com colírios fortificados. 29,5% dos doentes necessitaram de realizar transplante de córnea. Ao final de 6 meses de seguimento, apenas 20,9% apresentavam AV>20/40. Conclusão: Na maioria dos casos, a etiologia foi bacteriana. Observou-se um número considerável de bactérias multirresistentes. Apesar do tratamento ter permitido uma melhoria da visão na maioria dos casos, um número considerável de doentes ficou com sequelas visuais importantes.

Abstract Objective: Infectious keratitis is a pathology with a high incidence and is responsible for a large number of prolonged stay hospital admissions. The purpose was to analyze the epidemiological and clinical data associated with high risk microbial keratitis at a central hospital in Portugal. Methods: A retrospective study of all inpatients presenting with corneal abscess in Centro Hospitalar Universitário do Porto, from April 2013 to March 2018 was performed. Target population was characterized by risk factors, clinical features, length of stay, culture results, in vitro antibiotic resistance, treatment and outcome. Results: This study included 105 patients. The main risk factors were previous corneal surgery, contact lenses wear and recent history of ocular trauma. 74.3% of patients had a positive culture, 87.9% of these corresponding to a pure bacterial culture, with Pseudomonas aeruginosa and Streptococcus pneumoniae being the most common pathogens. 27.9% of positive cultures were resistant to 3 or more classes of antibiotics. All patients began treatment with fortified drops. 29.5% of patients required a corneal transplant. After 6 months of follow-up, only 20.9% presented a VA>20/40. Conclusion: Most cases were caused by bacteria. A considerable number of multi-resistant bacteria was identified. Despite most cases having improved after treatment, a large number of patients had a significant visual acuity sequelae.

Fusarium solani keratitis: role of antifungal susceptibility testing and identification to the species level for proper management

ABSTRACT We report a patient with fungal keratitis caused by a multiresistant Fusarium solani in a tertiary care hospital located in southern Brazil. A 55-year-old man with a history of ocular trauma presented with keratitis in left eye. The patient has a complicated clinical course and failed to respond to local and systemic antifungal treatment, and required eye enucleation. Despite multiple topical, intraocular and systemic antifungal treatments, hyphal infiltration persisted in the corneal transplant causing continuous recurrences. The cultures of corneal biopsy scrapings were positive for Fusarium spp. The organism was identified to species level by multi-locus sequencing for translation elongation factor 1 alpha (EF-1α), and RNA polymerase II subunit (RPB2). In vitro antifungal susceptibility testing of the isolate by the broth microdilution method, according to CLSI M38-A2, disclosed susceptibility to natamycin and resistance to amphotericin B, voriconazole, itraconazole and fluconazole. Considering previous unsuccessful antifungal treatments due to multiple drug resistance, the eye was enucleated. Our case report illustrates that management of fungal keratitis remains a therapeutic challenge. Optimal treatment for F. solani infection has not yet been established and should include susceptibility testing for different antifungal agents.

A case of recurrent keratitis caused by Paecilomyces lilacinus and treated by voriconazole / Uso do voriconazol na ceratite recorrente causada por fungo Paecilomyces lilacinus

ABSTRACT - We describe here a case of a 21-year-old woman who presented with low visual acuity, pain, and hyperemia in the left eye for 45 days. Her eye had extensive corneal infiltrate, with melting and a central perforation that was glued with cyanoacrylate, but with Seidel (+). She underwent tectonic corneal transplantation, and anterior chamber lavage with subconjunctival infiltration with voriconazole, as well as intracameral injections of amphotericin B. Laboratory tests revealed Paecilomyces lilacinus as the infectious agent. The patient was then maintained with oral voriconazole and eye drops for three months, after which the infection was considered cured. However, in the sixth postoperative month she presented with endothelial rejection, and two weeks later signs of recurrence of the fungal infection. She was treated with two further washes of the anterior chamber and subconjunctival injection of voriconazole, followed by intravenous voriconazole that was replaced with drops after ten days. The infection initially worsened, but then regressed, and at last follow-up, the patient was still infection-free.

RESUMO - Descrevemos aqui um caso de uma mulher de 21 anos que apresentou baixa acuidade visual, dor e hiperemia no olho esquerdo por 45 dias. O olho apresentava infiltrado corneano extenso, com fusão e perfuração central colada com cianoacrilato, mas com Seidel (+). Ela foi submetida a transplante de córnea tectônica e lavagem de câmara anterior com infiltração subconjuntival com voriconazol, além de injeções intracamerais de anfoterecina B. Testes laboratoriais revelaram Paecilomyces lilacinus como agente infeccioso. A paciente foi então mantida com voriconazol oral e colírio por período de três meses, após o qual a infecção foi considerada curada. No entanto, no sexto mês de pós-operatório, ela apresentou rejeição endotelial e, duas semanas após, sinais de recidiva de infecção fúngica. Ela foi tratada com mais duas lavagens de câmara anterior e injeção subconjuntival de voriconazol, seguida por voriconazol intravenoso que foi substituído por gotas após 10 dias. A infecção piorou inicialmente, mas depois regrediu e, no último seguimento, o paciente ainda estava livre de infecção.

Non-viral microbial keratitis in adults: clinical and laboratory aspects

Abstract This study compares patients with and without non-viral microbial keratitis in relation to sociodemographic variables, clinical aspects, and involved causative agent. Clinical aspects, etiology and therapeutic procedures were assessed in patients with and without keratitis that were diagnosed in an Eye Care Center in Campo Grande, MS, Brazil. Patients were divided into two groups: (a) cases: 64 patients with non-viral microbial keratitis diagnosed at biomicroscopy; and (b) controls: 47 patients with other eye disorders that were not keratitis. Labor activity related to agriculture, cattle raising, and contact lens use were all linked to keratitis occurrence (p < 0.005). In patients with keratitis, the most common symptoms were pain and photophobia, and the most frequently used medicines were fourth-generation fluoroquinolones (34.4%), amphotericin B (31.3%), and natamycin (28.1%). Microbial keratitis evolved to corneal perforation in 15.6% of cases; transplant was indicated in 10.9% of cases. Regarding the etiology of this condition, 23 (42.2%) keratitis cases were caused by bacteria (Pseudomonas aeruginosa, 12.5%), 17 (39.1%) by fungi (Fusarium spp., 14.1% and Aspergillus spp., 4.7%), and 4 (6.3%) by Acanthamoeba. Patients with keratitis present with a poorer prognosis. Rapid identification of the etiologic agent is indispensable and depends on appropriate ophthalmological collection and microbiological techniques.

Natamicina versus voriconazol para queratitis fúngica / Natamycin versus voriconazole for fungal keratitis

INTRODUCCIÓN: La queratitis infecciosa de origen fúngico afecta principalmente a personas de países tropicales y subtropicales, y constituye una importante causa de ceguera prevenible. Los antifúngicos tópicos, en particular la natamicina y el voriconazol, se consideran efectivos, pero no está claro cuál de ellos constituye la mejor alternativa de tratamiento. MÉTODOS: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos tres revisiones sistemáticas que en conjunto incluyeron tres estudios primarios, todos correspondientes a ensayos aleatorizados. Concluimos que natamicina probablemente se asocia a mejor agudeza visual tras la infección, y que previene la perforación corneal y/o la necesidad de realizar queratoplastia terapéutica en comparación a voriconazol en queratitis fúngica.

INTRODUCTION: Infectious keratitis of fungal origin mainly affects people in tropical and subtropical countries, and is an important cause of preventable blindness. Topical antifungals, particularly natamycin and voriconazole, are considered effective, but it is not clear which one is the best treatment alternative. METHODS: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified three systematic reviews including three studies overall,all of which were randomized trials. We concluded natamycin probably is associated with better visual acuity after infection, and it prevents corneal perforation and/or need to perform therapeutic keratoplasty compared to voriconazole in fungal keratitis.

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.

Detection of herpes simplex-1 and -2 and varicella zoster virus by quantitative real-time polymerase chain reaction in corneas from patients with bacterial keratitis / Detecção de vírus herpes simplex tipo 1 e 2 e varicella zoster por reação em cadeia de polimerase em tempo real em córneas de pacientes com ceratites bacterianas

ABSTRACT Objective: Bacterial keratitis occurs worldwide, and despite recent developments, it remains a potentially blinding condition. This study assesses the presence of herpes simplex virus (HSV-1 and -2) and varicella zoster virus (VZV) by quantitative real-time polymerase chain reaction (qPCR) in corneal scrapings from patients with bacterial keratitis. Methods: A total of 65 patients with clinical diagnoses of infectious corneal ulcers prospectively underwent clinical eye examinations. Corneal scrapings were investigated by Gram staining, Giemsa staining, culture, and qPCR (the study group). Risk factors and epidemiological data were recorded. The control group comprising 25 eyes with typical herpes dendritic keratitis was also analyzed by qPCR. Results: From the study group (n=65), nine patients (13.8%) had negative smears, cultures, and qPCR findings. Fifty-six (86.2%) patients had positive cultures: 51 for bacteria, 4 for fungi, and 1 for amoebae. Of the patients who had positive bacterial cultures, qPCR identified 10 patients who were also positive for virus: one for VZV and nine for HSV-1. Of the 25 patients in the control group, 21 tested positive for HSV-1 by qPCR analysis. Conclusions: Herpes may be present in patients with bacterial corneal ulcers, and qPCR may be useful in its detection.

RESUMO Objetivo: Ceratites bacterianas ocorrem mundialmente e apesar dos novos desenvolvimentos permanece como uma condição que pode levar à cegueira. Avaliar a presença de herpes simples (-1 e -2) e vírus varicella zoster (VZV) por reação em cadeia quantitativa de polimerase em tempo real (qPCR) em raspados corneanos de pacientes com ceratite bacteriana. Métodos: Sessenta e cinco pacientes com ceratite infecciosa foram submetidos a raspados corneanos estudados para gram, Giemsa, cultura e qPCR (grupo de estudo). Foram avaliados fatores de risco e epidemiológicos. O grupo controle foi composto por 25 casos de úlcera dendrítica típica por herpes analisados por qPCR. Resultados: Do grupo de estudo (n=65), nove pacientes (13,8%) apresentaram cultura, qPCR e raspado negativos. Cinquenta e seis (86,2%) pacientes apresentaram cultura positiva, 51 para bacteria, 4 para fungo e 1 para ameba. A qPCR identificou 10 pacientes do grupo de cultura positiva para bactéria que também foram positivos para vírus, um VZV e 9 para HSV-1. Dos 25 pacientes que compunham o grupo controle, 21 apresentaram qPCR positivo para HSV-1. Conclusão: Herpes pode estar presente em pacientes com úlceras de córnea bacterianas e a qPCR pode ser útil na sua detecção.

Microbiological and epidemiological study of infectious keratitis in children and adolescents / Estudo microbiológico e epidemiológico da ceratite infecciosa em crianças e adolescentes

ABSTRACT Purpose: To analyze epidemiological and microbiological aspects of microbial keratitis in children and adolescents. Methods: This retrospective cohort study was conducted at the Department of Ophthalmology and Visual Science, Escola Paulista de Medicina, Universidade Federal de São Paulo, between July 15, 1975, and December 31, 2010. We analyzed corneal samples from 859 patients with clinical suspicion of infectious keratitis, comparing epidemiological and microbiological characteristics of bacterial keratitis with those of non-bacterial and non-viral keratitis. We also compared Gram-positive and Gram-negative pathogens in patients with bacterial keratitis. We created a susceptibility profile of the bacterial microorganisms studied. Results: Of the 859 patients, 346 (40.3%) showed positive culture results for non-viral microorganisms. Teenagers (13-18 years) made up the group with the highest number of patients with keratitis (164, 47.4%). The most frequent risk factors for keratitis were trauma (33.5%) and previous ocular surgery (24.9%). Gram-positive bacteria (71.8%) were the most often isolated, with coagulase-negative Staphylococcus (23.8%) the most prevalent microorganism. Logistic regression analysis showed age (p=0.002), topical antimicrobial drug use (p=0.01), and trauma due to non-chemical burns (p=0.005) were risk factors for non-bacterial keratitis. Age (p=0.01) was also a risk factor for Gram-negative bacterial keratitis. Conclusion: Our study showed that in the age range studied, the prevalence of keratitis caused by Gram-negative bacteria or by the non-viral microorganisms evaluated increases with age. Previous use of topical antimicrobial drug and trauma due to non-chemical burns are associated with non-bacterial keratitis. Knowledge of the risk factors and the microorganisms involved may help improve treatment of keratitis in children and adolescents and minimize visual impairment.

RESUMO Objetivos: Descrever o perfil epidemiológico e microbiológico de ceratite microbiana em crianças e adolescentes. Métodos: Estudo retrospectivo tipo coorte, utilizando fichas laboratoriais de pacientes, atendidos no Departamento de Oftalmologia e Ciências Visuais - Escola Paulista de Medicina - Universidade Federal de São Paulo, entre 15 de julho de 1975 a 31 de dezembro de 2010. Foram comparados pacientes com ceratite bacteriana e não bacteriana (não viral). Entre os pacientes com ceratite bacteriana, foram comparados aqueles em que a ceratite foi causada por bactérias Gram positivas e Gram negativas. O perfil de sensibilidade dos microrganismos bacterianos aos antimicrobianos também foi estudado. Resultados: Foram analisadas amostras corneanas de 859 pacientes com suspeita clínica de ceratite infecciosa, na faixa etária estudada. Destes, 346 (40,3%) apresentaram resultados de culturas positivas para microrganismos não virais. Adolescentes (13 a 18 anos) compuseram o grupo com maior número de pacientes com ceratite (164-47,4%). Os principais fatores de risco foram trauma (33,5%) e cirurgias oculares prévias (24,9%). Bactérias Gram positivas foram isoladas com maior frequência (71,8%), sendo prevalente o patógeno Staphylococcus coagulase negativo (23,8%). De acordo com a análise de regressão logística, idade (p=0,002), uso tópico de drogas antimicrobianas (p=0,01) e trauma por queimadura não química (p=0,005) foram fatores predisponentes para ceratite não bacteriana. Idade (p=0,01) também foi fator de risco para ceratite causada por bactérias Gram negativas. Conclusões: Nosso estudo mostrou que quanto maior a idade, na faixa etária estudada, maior a probabilidade da ceratite ser causada por bactérias Gram negativas e/ou por outros microrganismos não virais avaliados. O uso tópico de drogas antimicrobianas prévias e trauma devido à queimadura não química predispõe à ceratite não bacteriana. O conhecimento dos fatores de risco e dos microrganismos envolvidos resultarão em tratamento específico da ceratite em crianças e adolescentes, com menores danos visuais.

Caracterización clinicoepidemiológica y microbiológica en úlceras corneales bacterianas y micóticas / Clinical, epidemiological and microbiological characterization of bacterial and mycotic ulcers

Objetivo: describir la asociación entre aspectos clinicoepidemiológicos y los resultados microbiológicos en pacientes con queratitis infecciosa ingresados en el Servicio de Córnea del Instituto Cubano de Oftalmología Ramón Pando Ferrer en el período 2010-2014. Métodos: se realizó un estudio observacional descriptivo, de corte transversal, de 39 ojos. Se estudiaron las variables edad, sexo, tiempo de evolución, tratamiento previo con antibióticos, factores predisponentes y concordancia del tratamiento empírico. Se utilizaron medidas de resumen para variables cualitativas y cuantitativas, prueba no paramétrica de probabilidad exacta de Fisher, prueba de Chi cuadrado de Pearson y Prueba U de Mann Whitney. Resultados: en los aislamientos de bacterias, el 42,3 por ciento de los pacientes eran menores de 30 años; 53,8 por ciento pertenecían al sexo femenino y el tiempo de evolución promedio fue de 7 días. Los factores predisponentes fueron: enfermedad ocular previa (23,1 %), uso de lentes de contacto (30,8 por ciento) y enfermedades sistémicas (11,5 por ciento). Los mayores de 69 años (46,5 por ciento), el sexo masculino (92,3 por ciento); el tiempo de evolución promedio de 14,5 días y el antecedente de traumatismo ocular no quirúrgico (15,4 por ciento) se observaron en aislamientos micóticos. La perforación corneal se produjo en el 7,7 por ciento de los crecimientos bacterianos; en crecimientos micóticos el 15,4 por ciento desarrolló descemetocele y el 23,1 por ciento perforación corneal. Se realizó queratoplastia penetrante en el 30,8 por ciento(AU) Conclusiones: los aislamientos bacterianos son más frecuentes en pacientes jóvenes, del sexo femenino y con antecedentes de enfermedad ocular previa y uso de lentes de contacto, mientras que la etiología micótica se produce en pacientes del sexo masculino, mayores de 60 años y con antecedentes de trauma corneal no quirúrgico

Objective: to describe the association of clinical and epidemiological aspects with the microbiological results of patients with infectious keratitis, who were admitted to the corneal service of "Ramon Pando Ferrer" Cuban Institute of Ophthalmology in the period of 2010 to 2014. Methods: cross-sectional, descriptive and observational study of 39 eyes. The analyzed variables were age, sex, time of progression, previous antibiotic treatment, predisposing factors and agreement of the empirical treatment. Summary measures for qualitative and quantitative variables; non-parametric Fisher´s exact probability test, Pearson´s Chi square test, and Mann Whitney's U test. Results: in the bacterial isolates, 42.3 percent of patients were younger than 30 years; 53.8 percent were females and average time of progression of disease was 7 days. The predisposing factors were previous eye disease (23.1 percent), use of contact lenses (30.8 percent) and systemic diseases (11.5 percent). Regarding mycotic isolates, patients aged over 69 years (46.5 percent), males (92.3 percent), average time of progression of 14.5 percent and history of non surgical ocular trauma (15.4 percent) predominated. The corneal perforation occurred in 7.7 percent of bacterial infection whereas 15.4 percent developed descemetocele and 23.1 percent corneal perforation in the mycotic infection group. Penetrating keratoplasty was performed in 30.8 percent of patients. Conclusions: bacterial isolates were more frequent in young female patients with a history of previous ocular diseases and contact lenses whereas mycotic etiology was more commonly observed in males over 60 years and history of non surgical corneal trauma(AU)

Epidemiologia de ceratites fúngicas tratadas com ceratoplastia penetrante através de achados histopatológicos / Epidemiology of fungal keratitis treated with penetrating keratoplasty by means of histopathologic findings

RESUMO Objetivo: Estudar, através do exame histopatológico, a epidemiologia de ceratites fúngicas tratadas com ceratoplastia penetrante terapêutica, enfatizando a presença de cirurgia ocular prévia. Métodos: Inicialmente, o estudo foi observacional e transversal de botões corneanos provenientes de ceratoplastia penetrante no período de 2006-2015 enviados para exame histopatológico ao banco de olhos do Hospital Geral de Fortaleza. Os tecidos foram corados com Hematoxilina-eosina, PAS ou Grocott, e examinados com microscópio óptico. Foram selecionados casos com diagnóstico histopatológico de ceratite fúngica. Após a selecão, realizamos revisão de prontuários buscando idade e sexo do paciente, data(s) do(s) transplante(s) por ceratite fúngica, diagnóstico clínico précirúrgico, presença/tipo de cirurgias anteriores e/ou posteriores. Incluímos 62 botões corneanos de 55 pacientes. Resultados: A maioria dos pacientes era do sexo masculino. Apenas 7 (11,29%) casos tiveram recidiva da infecção tratada cirurgicamente. 10 (16,13%) casos possuíam cirurgia ocular prévia a ceratite fúngica tratada por transplante. Nenhum caso teve ceratite fúngica como diagnóstico clínico pré-cirúrgico. A principal forma de fungo no exame histopatológico foi forma leveduriforme isolada, seguida pela leveduriforme associada à filamentosa. O aspecto predominante da membrana de Descemet foi livre de fungos. Conclusão: Demonstramos o potencial curativo das ceratites fúngicas quando tratadas com ceratoplastia penetrante terapêutica e uma possível associação do fator cirurgia ocular prévia ao desenvolvimento dessas infecções. Características do exame histopatológico foram abordadas diferente de outros estudos que, em sua maioria, citam apenas o exame microbiológico. A dificuldade no diagnóstico clínico précirúrgico foi ressaltada, o que pode ter contribuído com a evolução dos casos estudados para tratamento cirúrgico.

ABSTRACT Objective: To study, by means of histopathological examination, the epidemiology of fungal keratitis treated with penetrating keratoplasty therapy, emphasizing the presence of previous ocular surgery. Methods: Initially, we made an observational and cross-sectional study of corneal buttons from penetrating keratoplasty in the 2006-2015 period sent for histopathological examination at the Hospital Geral de Fortaleza Eye Bank.Tissues were stained with hematoxylin-eosin, PAS or Grocott, and examined with an optical microscope. We selected the cases with histopathological diagnosis of fungal keratitis. After the selection, we carried out a review of records seeking for age and sex of patients, date(s) of the graft(s) made to treat fungal keratitis, preoperative clinical diagnosis, presence/type of earlier and/or subsequent surgeries.We included 62 corneal buttons from 55 patients. Results: Most patients were male. Only 7 (11.29%) cases had recurrence of the surgically treated infection. 10 (16.13%) cases had eye surgery prior to fungal keratitis treated by transplant. No cases had fungal keratitis as preoperative clinical diagnosis.The main form of fungus in histopathological examination was isolated yeast form, followed by the yeast form associated with the filamentous form.The predominant aspect of Descemet's membrane was free of fungus. Conclusion: We demonstrated the healing potential of fungal keratitis when treated with penetrating therapeutic keratoplasty and the possible association of previous eye surgery factor for the development of these infections. Characteristics of histopathological examination have been approached differently from other studies that mostly specify only the microbiological examination. The difficulty in preoperative clinical diagnosis was highlighted, which may have contributed to the evolution of the cases studied for surgical treatment.

Correlação clínico-patológica em ceratites fúngicas e uma possível evidência de infecção oportunista: relato de dois casos / Clinicopathological correlation in fungal keratitis and a possible evidence of opportunistic infection: a report of two cases

RESUMO Os autores relatam dois casos de ceratite fúngica, que apresentam em comum no exame histopatológico: a ausência de epitélio, sem ulceração e a integridade da camada de Bowman com a presença de formas fúngicas no seu interior. São sugeridos prováveis mecanismos de recidiva das ceratites fúngicas, ressaltando uma possível "via externa não usual", por meio da penetração do fungo através da camada de Bowman íntegra. A existência desta infecção oportunista não está relatada na literatura oftalmológica e são necessárias mais evidências para que seja considerada como tal.

ABSTRACT The authors describe two cases of fungal keratitis which, upon histopathological examination, are found to have in common the absence of epithelium, without ulceration and the lack of integrity of the Bowman's layer with the presence of fungal forms in their interior. Through them the authors suggest probable mechanisms of recurrence of fungal keratitis, highlighting the possible existence of an "unusual external route" that would occur by the fungus penetration through the full Bowman layer. Although these findings appear not yet reported or recovered in the ophthalmic literature, the authors suggest that they could be possible opportunistic infection signals which, however, require more evidence to be considered as such.

Early post-LASIK flap amputation in the treatment of aggressive, branching keratitis: a case report / Amputação precoce de pedículo de LASIK para o tratamento de ceratite ramificada agressiva: relato de caso

ABSTRACT Infectious keratitis is rare following laser vision correction. We present a case of aggressive fungal keratitis caused by Aspergillus flavus, following laser in situ keratomileusis (LASIK) in the setting of a unique environmental risk factor. We describe the key features of the acute case presentation, which guided empirical medical and surgical treatment, resulting in the most favorable outcome found in the literature, to date.

RESUMO Ceratites infecciosas são raras após a correção da visão a laser. Apresentamos um relato de caso de uma ceratite fúngica agressivo por Aspergillus flavus, após ceratomileuse a laser "in situ" (LASIK) em situação peculiar de fator de risco ambiental. Nós descrevemos as principais características da apresentação caso agudo, que orientou tratamento médico e cirúrgico empírico, demonstrando resultado mais favorável do que o encontrado na literatura até o momento.

Multi-resistant Enterococci and Morganella morganii: a rare cause of complicated keratitis

An eighty-five-year-old female presented with preexisting conditions of benign essential hypertension, dyslipidemia, chronic renal failure and diabetes mellitus type 2. She had gastroenteritis, pain and redness in right [blind] eye with corneal decompensation, scarring and right-eye corneal ulcer with hypopyon. Corneal scrapings sent for culture report revealed growth of Morganella Morganii and Enterococci Corneal ulcer was successfully treated with topical and oral antibiotics

Queratitis micótica: identificación de especies en Valparaíso / Fungal keratitis: identification of species in Valparaíso

Introducción: La queratitits micótica puede ser provocada por una amplia variedad de especies, tanto por hongos filamentosos como levaduras. Objetivo: Conocer las especies involucradas en queratitits micótica durante el decenio 2003-2013 en la ciudad de Valparaíso. Materiales y método: Se revisaron los casos de queratitis micótica diagnosticados durante el periodo 2003-2013 en la cátedra de Micología de la Universidad de Valparaíso. Las muestras fueron tomadas con tórulas estériles, las cuales fueron sembradas en agar sabouraud y una vez obtenido el desarrollo de las especies se traspasaron a medios de cultivo especiales. La identificación se realizó por morfofisiología y en el caso de Candida además por pruebas bioquímicas. Resultados: Se diagnosticaron 10 pacientes con queratitis micótica, de ellos 6 fueron hombres. 8 pacientes tenían el antecedente de lesión traumática corneal. Las especies más frecuentes fueron Aspergillus fumigatus y Fusarium oxysporum. También se aislaron especies como Fusarium dimerumy Exophiala jeanselmei. Conclusión: De los 10 casos de queratitis micótica diagnosticados, la mayoría tenía el antecedente de lesión traumática corneal. Los géneros más aislados fueron Aspergillus y Fusarium.

Introduction: Fungal keratitis can be caused by a wide variety of species, either filamentous as yeast fungi. Objective: To determine the species involved in fungal keratitis during the decade 2003-2013 in the city of Valparaiso. Materials and Methods: The cases of fungal keratitis diagnosed in the depar tment of Mycology, University of Valparaiso, were reviewed for the period 2003-2013. Samples were taken with sterile swabs, which were seeded in Sabouraud agar and after obtaining the development of species, were transferred to special culture media. Identification was performed by morphophysiology and in the case of Candida further biochemical tests. Results: 10 patients were diagnosed with fungal keratitis, of which 6 were men. 8 patients had a history of traumatic corneal injury. The most frequent species were Aspergillus fumigatus and Fusarium oxysporum. Species Fusarium dimerum and Exophiala jeanselmei were also isolated. Conclusion: Of the 10 cases of fungal keratitis diagnosed, most had a history of traumatic corneal injury. The most isolated genus were Aspergillus and Fusarium.

Distribuição das ceratites infecciosas em hospital terciário no Brasil / Distribution of infectious keratitis in a tertiary hospital in Brazil

OBJETIVO: Investigar sazonalidade de ceratities infecciosas em serviço terciário no Brasil. MÉTODOS: Estudo retrospectivo de dados coletados do Laboratório de Microbiologia Ocular do Departamento de Oftalmologia da Universidade Federal de São Paulo de 2005 a 2009. Foram definidas como ceratites infecciosas aquelas com cultura positiva para o agente. Dados foram distribuídos de acordo com os meses do ano e modelos de regressão linear com variáveis "dummy" foram utilizados para testar sazonalidade. RESULTADOS: Foram diagnosticados 1.468 casos de ceratite infecciosa durante o período do estudo. Bactérias foram responsáveis por 80,3% dos casos seguidas por fungos (7%), Acanthamoeba (6%) e casos mistos (6,7%). Testes estatísticos não mostraram sazonalidade para bactérias (p=0,064), fungos (p=0,379), Acanthamoeba (p=0,062) ou casos mistos (p=0,441). CONCLUSÃO: Não foi observada sazonalidade nas ceratites infecciosas em nossa amostra.

PURPOSE: To investigate the seasonality of infectious keratitis in a tertiary hospital in Brazil. METHODS: Charts from the Ocular Microbiology Laboratory of the Department of Ophthalmology of the Federal University of Sao Paulo were reviewed from 2005 to 2009. Infectious keratitis were defined as those with positive culture. Data were distributed monthly and linear regressions with seasonal dummy models were used to test for seasonal trends. RESULTS: Total of 1,468 cases of keratitis was diagnosed during the study period. Bacterial keratitis were reponsible for 80.3% of all cases, followed by fungal (7%), and Acanthamoeba (6%); 6.7% were mixed cases. Statistical tests showed that there were no seasonal trends for bacteria (p=0.064), fungi (p=0.379), Acanthamoeba (p=0.062) or mixed infections (p=0.441). Conclusions: No seasonal trends for infectious keratitis were observed in our sample.

Clinical characteristics and outcomes of patients admitted with presumed microbial keratitis to a tertiary medical center in Israel / Características clínicas e desfechos dos pacientes internados com diagnóstico de ceratite microbiana em um centro terciário em Israel

PURPOSES: Microbial keratitis is commonly diagnosed worldwide, and continues to cause significant ocular morbidity, requiring prompt and appropriate treatment. The objective of this study is to describe the clinical characteristics and outcomes of patients with presumed microbial keratitis admitted to The Goldschleger Eye Institute, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel. METHODS: A cross-sectional study was conducted, in which the medical records of patients with presumed microbial keratitis admitted during a period of 3 years were reviewed. RESULTS: Keratitis was diagnosed in 276 patients (51% males and 48.9% females). The mean age was 39.29 ± 22.30 years. The hospital length of stay ranged from 1 to 65 days (mean 5.69 ± 5.508). Fortified antibiotics were still used at discharge in 72% of the cases. Overall visual acuity improved significantly from the time of admission to the 1st-week follow up visit showing a p<0.001 on the Wilcoxon signed ranks test. Contact lens wearing was present in 36.1% of the patients, although there was no significant relation with severity of the presentation and visual outcome (p>0.05). The degree of hypopyon and cells in the anterior chamber was significantly related to the hospital length of stay (r Spearman=0.31; p<0.001 and r Spearman=0.21; p<.001, respectively) as well as to a worse visual outcome (r Spearman=0.32; p<0.01 and r Spearman=0.18; p=0.01, respectively). Of all patients, 2.3% required an urgent therapeutic penetrating keratoplasty, and 1% underwent evisceration. There was no enucleation. CONCLUSION: Treating keratitis aggressively and assuring patient compliance is imperative for a good final visual outcome. Inpatient treatment may have a positive impact on this outcome.

OBJETIVOS: Ceratite microbiana é comumente diagnosticada em todo mundo e ainda continua a causar uma significante morbidade ocular. É necessário tratá-la de forma imediata e apropriada. O objetivo deste estudo é descrever as características clínicas e os desfechos dos pacientes com ceratite microbiana presumida que foram internados no Goldschlager Eye Institute, Sheba Medical Center, Tel Aviv University, Israel. MÉTODOS: Um estudo transversal foi realizado onde arquivos hospitalares dos pacientes internados com ceratite microbiana presumida durante um periodo de três anos foram analisados e revisados. RESULTADOS: Ceratite foi diagnosticada em 276 pacientes (51% masculinos e 48,9% femininos). A média de idade foi 39,29 ± 22,30 anos. A duração da internação foi de 1 a 65 dias (média 5,69 ± 5,508). Antibióticos fortificados permaneceram usados na alta em 72% dos casos. A acuidade visual do seguimento da primeira semana após a alta em relação a internação melhorou na media de forma estatisticamente significativa (p<0,001 usando Wilcoxon signed ranks test). O uso de lentes de contato estava presente em 36,1% dos pacientes, porém não houve relação estatisticamente significativa entre a gravidade da apresentação clínica e a acuidade visual nestes pacientes (p>0,05). O grau de hipópio e células na câmara anterior foram estatisticamente significativos em relação ao tempo de internação (r Spearman=0,0.31; p<0,001 and r Spearman=0,21; p<0,001, respectivamente) e para a acuidade visual (r Spearman=0,32; p<0,01 e r Spearman=0,18; p=0,01, respectivamente). De todos os pacientes, apenas 2,3% necessitaram ceratoplastia penetrante urgente e 1% necessitaram evisceração. Não houve enucleações. CONCLUSÕES: Tratar a ceratite de forma agressiva e garantir a aderência do paciente ao tratamento é imperativo para o bom resultado visual final. O tratamento internado pode ter um impacto positivo neste desfecho.