Addressing corneal opacity after herpes zoster infection.

A 15-year-old boy was referred for corneal opacity evaluation. The patient had a previous herpes zoster virus (HZV) infection-varicella-zoster virus (VZV)-with ocular manifestation 1 year ago. After the infection, he developed a central corneal scar and decreased corrected distance visual acuity (CDVA) in the right eye. The slitlamp examination showed the right eye with central corneal opacity (involving anterior stroma), lacuna area between the haze, fluorescein negative, and no vascularization near the scar (Figure 1JOURNAL/jcrs/04.03/02158034-202406000-00019/figure1/v/2024-07-10T174224Z/r/image-tiff). The patient had been treated with oral valacyclovir and topical corticosteroids without any improvement of visual acuity or changes in opacity within the 1-year follow-up. His CDVA was 20/200 (-4.50 -0.75 × 25) in the right eye and counting fingers (-4.00) in the left eye. Intraocular pressure was 12 mm Hg in both eyes. Fundoscopy was normal in the right eye, but he had a macular scar in the left eye (diagnosed when he was 7 years). The left eye had no cornea signs. The patient has no comorbidity or previous surgeries. Considering this case, a corneal central scar in a 15-year-old boy, legally single eye only, and assuming it is an opacity in the anterior stroma, would you consider surgery for this patient? If so, which would you choose: Would you consider an excimer laser treatment of his ametropia while partially removing his opacity, a phototherapeutic keratectomy (PTK), or a PTK followed by a topography-guided treatment, femtosecond laser-assisted anterior lamellar keratoplasty (FALK), or deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty (depending on the scar depth)? Would you consider prophylactic acyclovir during and after surgery? Would you consider any other surgical step to prevent delayed corneal healing-persistent epithelial defect? Before the surgical approach, would you consider treating this patient with topical losartan (a transforming growth factor [TGF]-ß signaling inhibitor)? Would you first perform the surgery (which one) and then start the medication? Furthermore, if so, how long would you treat this patient? Would you consider treatment with another medication?

Descriptive analysis of the type and design of contact lenses fitted according to keratoconus severity and morphology.

PURPOSE: Keratoconus is characterized by bilateral asymmetrical corneal ectasia that leads to inferior stromal thinning and corneal protrusion. There is currently a lack of consensus regarding the most efficacious method for fitting contact lenses in patients with keratoconus, given the various topographical patterns and evolution grades observed in affected populations. The purpose of the present study was to evaluate the association between keratoconus evolution grade and topography pattern and the type and design of fitted contact lens. METHODS: We performed a retrospective analysis of contact lenses fitted in a total of 185 patients with keratoconus (325 eyes). Keratoconus was classified as either grade I, II, III, or IV based on keratometry and cone morphology (nipple, oval, globus, or indeterminate) results. RESULTS: A total of 325 eyes were evaluated in the present study. Of the 62 eyes classified as grade I, 66.1% were fitted with monocurve contact lenses. Of the 162 eyes classified as grade I and II, 51%, 30%, and 19% were fitted with adapted monocurve rigid gas-permeable contact lenses (RGPCL), bicurve lenses, and others lens types, respectively. Bicurve lenses were fitted in 52.1% and 62.2% of eyes classified as grade III and IV, respectively. Of the eyes classified as grade III and IV, monocurve and bicurve RGPCL were fitted in 26% and 55%, respectively. In eyes with oval keratoconus, 45%, 35%, and 20% were fitted with monocurve lenses, bicurve lenses, and other lens types, respectively. In eyes with round cones (nipple morphology), 55%, 30%, and 15% were fitted with bicurve lenses, monocurve lenses, and other lens types, respectively. CONCLUSION: Monocurve RGPCL were most frequently fitted in patients with mild to moderate keratoconus and oval cones morphology, while bicurve lenses were more frequently fitted in patients with severe and advanced keratoconus. This was probably because bicurve lenses are more appropriate for round cones due to increased corneal asphericity.

Descriptive analysis of the type and design of contact lenses fitted according to keratoconus severity and morphology / Análise descritiva dos tipos e parâmetros das lentes de contato adaptadas de acordo com o grau evolutivo e a morfologia do ceratocone

ABSTRACT Purpose: Keratoconus is characterized by bilateral asymmetrical corneal ectasia that leads to inferior stromal thinning and corneal protrusion. There is currently a lack of consensus regarding the most efficacious method for fitting contact lenses in patients with keratoconus, given the various topographical patterns and evolution grades observed in affected populations. The purpose of the present study was to evaluate the association between keratoconus evolution grade and topography pattern and the type and design of fitted contact lens. Methods: We performed a retrospective analysis of contact lenses fitted in a total of 185 patients with keratoconus (325 eyes). Keratoconus was classified as either grade I, II, III, or IV based on keratometry and cone morphology (nipple, oval, globus, or indeterminate) results. Results: A total of 325 eyes were evaluated in the present study. Of the 62 eyes classified as grade I, 66.1% were fitted with monocurve contact lenses. Of the 162 eyes classified as grade I and II, 51%, 30%, and 19% were fitted with adapted monocurve rigid gas-permeable contact lenses (RGPCL), bicurve lenses, and others lens types, respectively. Bicurve lenses were fitted in 52.1% and 62.2% of eyes classified as grade III and IV, respectively. Of the eyes classified as grade III and IV, monocurve and bicurve RGPCL were fitted in 26% and 55%, respectively. In eyes with oval keratoconus, 45%, 35%, and 20% were fitted with monocurve lenses, bicurve lenses, and other lens types, respectively. In eyes with round cones (nipple morphology), 55%, 30%, and 15% were fitted with bicurve lenses, monocurve lenses, and other lens types, respectively. Conclusion: Monocurve RGPCL were most frequently fitted in patients with mild to moderate keratoconus and oval cones morphology, while bicurve lenses were more frequently fitted in patients with severe and advanced keratoconus. This was probably because bicurve lenses are more appropriate for round cones due to increased corneal asphericity.

RESUMO Objetivo: O ceratocone é uma ectasia corneana bilateral e assimétrica que leva a afinamento corneano inferior e protrusão da córnea, não existe consenso sobre qual é o melhor caminho para adaptar lentes de contato em pacientes com ceratocone, considerando seus diferentes padrões topográficos e graus de evolução. O objetivo desse estudo é associar o grau de evolução e padrão topográfico com o tipo/desenho da lente adaptada. Métodos: Análise retrospectiva das lentes de contato adaptadas em 185 pacientes com ceratocone (325 olhos) no Departamento de Lentes de Contato. O ceratocone foi classificado de acordo com a ceratometria em graus I, II, III e IV e de acordo com a morfologia em cone redondo, oval, globoso e indeterminado. Resultados: Foram avaliados 325 olhos. Em 66,1% dos olhos com grau I foi adaptada lente monocurva. Dos 162 olhos classificados como graus I e II foram adaptadas lentes monocurva em 51%, bicurva em 30% e outros em 19%. Em relação aos olhos grau III, em 52,1% foram adaptadas lentes bicurvas e o mesmo aconteceu em 62,2% dos olhos com grau IV. Apenas 26% dos olhos grau III ou IV receberam lentes monocurva, com necessidade de bicurvas em 55%. 45% dos cones ovais foram adaptados com lentes monocurva, 35% com bicurvas e 20% com outros tipos, enquanto 55% dos cones redondos foram adaptados com lentes bicurvas, apenas 30% com monocurvas e 15% com outros desenhos. Conclusão: Lentes de contato rígida gás-permeável (LCRGP) monocurvas são mais frequentemente utilizadas em ceratocones leves e moderados e em ovais, enquanto bicurvas são mais usadas para casos graves e avançados e em cones redondos.

Endophthalmitis: a rare but devastating metastatic bacterial complication of hemodialysis catheter-related sepsis.

There are many infectious complications related to vascular access in patients undergoing maintenance hemodialysis. We report two cases of endophthalmitis as a metastatic infection associated with a tunneled catheter and a temporary dual lumen catheter. Both patients were diabetic. A 61-year-old female on maintenance hemodialysis by a jugular tunnelized catheter during the past year was receiving parenteral antibiotics for catheter salvage due to fever episodes in the last 3 months. She was admitted to the hospital presenting pain, proptosis, conjunctival hyperemia, corneal infiltrate, and visual acuity of no light perception (NLP). A 51-year-old male recently undergoing hemodialysis by a temporary dual lumen catheter presented fever. His catheter was removed, but he was admitted to the hospital presenting fever, decreased vision, edema, and pain in his left eye. On examination, eyelid edema, conjunctival hyperemia, purulent secretion, hypopyon in the pupils, and visual acuity of NLP were verified. A diagnosis of endogenous endophthalmitis was made in both patients on clinical grounds and computed tomography. Evisceration of the left eye was the first option of treatment for both patients due to poor vision. Cultures of the eviscerated ocular globes showed Staphylococcus hemolyticus and Staphylococcus aureus, respectively. After evisceration, both patients received treatment, had a good outcome, and were discharged to continue their hemodialysis program. Metastatic bacterial endophthalmitis is a rare complication of dialysis catheter-related bacteremia. When suspected, urgent ophthalmologic evaluation and treatment are needed to reduce the risk of losing vision in the affected eye.