Medication by Proxy: The Devolution of Psychiatric Power and Shared Accountability to Psychopharmaceutical Use Among Soldiers in America's Post-9/11 Wars.

With the United States military stretched thin in the "global war on terror," military officials have embraced psychopharmaceuticals in the effort to enable more troops to remain "mission-capable." Within the intimate conditions in which deployed military personnel work and live, soldiers learn to read for signs of psychopharmaceutical use by others, and consequently, may become accountable to those on medication in new ways. On convoys and in the barracks, up in the observation post and out in the motor pool, the presence and perceived volatility of psychopharmaceuticals can enlist non-medical military personnel into the surveillance and monitoring of medicated peers, in sites far beyond the clinic. Drawing on fieldwork with Army personnel and veterans, this article explores collective and relational aspects of psychopharmaceutical use among soldiers deployed post-9/11 in Iraq and Afghanistan. I theorize this social landscape as a form of "medication by proxy," both to play on the fluidity of the locus of medication administration and effects within the military corporate body, and to emphasize the material and spatial ways that proximity to psychopharmaceuticals pulls soldiers into relationships of care, concern and risk management. Cases presented here reveal a devolution and dispersal of biomedical psychiatric power that complicates mainstream narratives of mental health stigma in the US military.

Pharmaceutical Creep: U.S. Military Power and the Global and Transnational Mobility of Psychopharmaceuticals.

In 2006, the United States Department of Defense developed for the first time official criteria for the use of psychopharmaceuticals "in theater"-in the physical and tactical spaces of military operations including active combat. Based on fieldwork with Army soldiers and veterans, this article explores the transnational and global dimensions of military psychopharmaceutical use in the post-9/11 wars. I consider the spatial, material, and symbolic dimensions of what I call "pharmaceutical creep"-the slow drift of psychopharmaceuticals from the civilian world into theater and into the military corporate body. While pharmaceutical creep is managed by the U.S. military as a problem of gatekeeping and of supply and provisioning, medications can appear as the solution to recruitment and performance problems once in theater. Drawing on soldiers' accounts of medication use, I illuminate the possibilities, but also the frictions, that arise when routine psychopharmaceuticals are remade into technologies of global counterinsurgency.

Analysis of the Lipolytic Activity of Whole-Saliva and Site-Specific Secretions from the Oral Cavity of Healthy Adults.

It is currently unclear how the process of fat digestion occurs in the mouth of humans. This pilot study therefore aimed to quantify the levels of lipolytic activity at different sites of the mouth and in whole saliva. Samples of whole saliva and from 4 discrete sites in the oral cavity were collected from 42 healthy adult participants. All samples were analyzed for lipolytic activity using two different substrates (olive oil and the synthetic 1,2-o-dilauryl-rac-glycero-3-glutaric acid-(6'-methylresorufin) ester (DGGR)). Bland⁻Altman analyses suggested that the two assays gave divergent results, with 91% and 23% of site-specific and 40% and 26% of whole-saliva samples testing positive for lipolytic activity, respectively. Non-parametric multiple comparisons tests highlighted that median (IQR) of lipolytic activity (tested using the olive oil assay) of the samples from the parotid 20.7 (11.7⁻31.0) and sublingual 18.4 (10.6⁻47.2) sites were significantly higher than that of whole saliva 0.0 (0.0⁻35.7). In conclusion, lipolysis appears to occur in the oral cavity of a proportion of individuals. These findings give a preliminary indication that lipolytic agent activity in the oral cavity may be substrate-specific but do not discount that the enzyme is from sources other than oral secretions (e.g., microbes, gastric reflux).

Fog of War: Psychopharmaceutical "Side Effects" and the United States Military.

The unprecedented reliance today on psychiatric drugs to maintain mission readiness in war and to treat veterans at home has been the subject of ethical debate in the United States. While acknowledging these debates, I advocate for an ethnography of how US soldiers and veterans of the Iraq and Afghanistan wars themselves articulate political and ethical tensions in their experiences of psychiatric drug treatment. Detailing one army veteran's interpretations of drug effects as narrated through the lens of his current antiwar politics, I examine the radicalizing transformations of self and subjectivity that he attributes both to his witnessing drug use in Iraq and to the neurochemical effects of his own medications. Playing on the biomedical notion of "side effects," I highlight surprising political and ethical openings that can surface when psychopharmaceuticals and war intersect. Psychotropic medication use offers a critical realm for furthering the ethnographic study of the lived tensions and contradictions of military medicine and medicalization as revealed in militarized embodied experience.

Upregulation of distinct collagen transcripts in post-surgery scar tissue: a study of conjunctival fibrosis.

Excessive accumulation of collagen is often used to assess the development of fibrosis. This study aims to identify collagen genes that define fibrosis in the conjunctiva following glaucoma filtration surgery (GFS). Using the mouse model of GFS, we have identified collagen transcripts that were upregulated in the fibrotic phase of wound healing via RNA-seq. The collagen transcripts that were increased the most were encoded by Col8a1, Col11a1 and Col8a2 Further analysis of the Col8a1, Col11a1 and Col8a2 transcripts revealed their increase by 67-, 54- and 18-fold, respectively, in the fibrotic phase, compared with 12-fold for Col1a1, the most commonly evaluated collagen gene for fibrosis. However, only type I collagen was significantly upregulated at the protein level in the fibrotic phase. Type VIII and type I collagens colocalized in fibrous structures and in ACTA2-positive pericytes, and appeared to compensate for each other in expression levels. Type XI collagen showed low colocalization with both type VIII and type I collagens but can be found in association with macrophages. Furthermore, we show that both mouse and human conjunctival fibroblasts expressed elevated levels of the most highly expressed collagen genes in response to TGFß2 treatment. Importantly, conjunctival tissues from individuals whose GF surgeries have failed due to scarring showed 3.60- and 2.78-fold increases in type VIII and I collagen transcripts, respectively, compared with those from individuals with no prior surgeries. These data demonstrate that distinct collagen transcripts are expressed at high levels in the conjunctiva after surgery and their unique expression profiles may imply differential influences on the fibrotic outcome.

Characterization of the cyanobacteria and associated bacterial community from an ephemeral wetland in New Zealand.

New Zealand ephemeral wetlands are ecologically important, containing up to 12% of threatened native plant species and frequently exhibiting conspicuous cyanobacterial growth. In such environments, cyanobacteria and associated heterotrophs can influence primary production and nutrient cycling. Wetland communities, including bacteria, can be altered by increased nitrate and phosphate due to agricultural practices. We have characterized cyanobacteria from the Wairepo Kettleholes Conservation Area and their associated bacteria. Use of 16S rRNA amplicon sequencing identified several operational taxonomic units (OTUs) representing filamentous heterocystous and non-heterocystous cyanobacterial taxa. One Nostoc OTU that formed macroscopic colonies dominated the cyanobacterial community. A diverse bacterial community was associated with the Nostoc colonies, including a core microbiome of 39 OTUs. Identity of the core microbiome associated with macroscopic Nostoc colonies was not changed by the addition of nutrients. One OTU was highly represented in all Nostoc colonies (27.6%-42.6% of reads) and phylogenetic analyses identified this OTU as belonging to the genus Sphingomonas. Scanning electron microscopy showed the absence of heterotrophic bacteria within the Nostoc colony but revealed a diverse community associated with the colonies on the external surface.

Comparison of D1´- and D1-containing PS II reaction centre complexes under different environmental conditions in Synechocystis sp. PCC 6803.

In oxygenic photosynthesis, the D1 protein of Photosystem II is the primary target of photodamage and environmental stress can accelerate this process. The cyanobacterial response to stress includes transcriptional regulation of genes encoding D1, including low-oxygen-induction of psbA1 encoding the D1´ protein in Synechocystis sp. PCC 6803. The psbA1 gene is also transiently up-regulated in high light, and its deletion has been reported to increase ammonium-induced photoinhibition. Therefore we investigated the role of D1´-containing PS II centres under different environmental conditions. A strain containing only D1´-PS II centres under aerobic conditions exhibited increased sensitivity to ammonium chloride and high light compared to a D1-containing strain. Additionally a D1´-PS II strain was outperformed by a D1-PS II strain under normal conditions; however, a strain containing low-oxygen-induced D1´-PS II centres was more resilient under high light than an equivalent D1 strain. These D1´-containing centres had chlorophyll a fluorescence characteristics indicative of altered forward electron transport and back charge recombination with the donor side of PS II. Our results indicate D1´-PS II centres are important in the reconfiguration of thylakoid electron transport in response to high light and low oxygen.

Updates on the Surgical Management of Pediatric Glaucoma.

Childhood glaucoma is known to be one of the most challenging conditions to manage. Surgical management is more complicated than in adults because of differences in anatomy from adults along with variations in anatomy caused by congenital and developmental anomalies, wide-ranging pathogenetic mechanisms, a more aggressive healing response, and a less predictable postoperative course. Challenges in postoperative examination and management in less cooperative children and the longer life expectancies preempting the need for future surgeries and reinterventions are also contributing factors. Angle surgery is usually the first-line treatment in the surgical management of primary congenital glaucoma because it has a relatively good success rate with a low complication rate. After failed angle surgery or in cases of secondary pediatric glaucoma, options such as trabeculectomy, glaucoma drainage devices, or cyclodestructive procedures can be considered, depending on several factors such as the type of glaucoma, age of the patient, and the severity and prognosis of the disease. Various combinations of these techniques have also been studied, in particular combined trabeculotomy-trabeculectomy, which has been shown to be successful in patients with moderate-to-advanced disease. Newer nonpenetrating techniques, such as viscocanalostomy and deep sclerectomy, have been reported in some studies with variable results. Further studies are needed to evaluate these newer surgical techniques, including the use of modern minimally invasive glaucoma surgeries, in this special and diverse group of young patients.

Environmental pH affects photoautotrophic growth of Synechocystis sp. PCC 6803 strains carrying mutations in the lumenal proteins of PSII.

Synechocystis sp. strain PCC 6803 grows photoautotrophically across a broad pH range, but wild-type cultures reach a higher density at elevated pH; however, photoheterotrophic growth is similar at high and neutral pH. A number of PSII mutants each lacking at least one lumenal extrinsic protein, and carrying a second PSII lumenal mutation, are able to grow photoautotrophically in BG-11 medium at pH 10.0, but not pH 7.5. We investigated the basis of this pH effect and observed no pH-specific change in variable fluorescence yield from PSII centers of the wild type or the pH-dependent ΔPsbO:ΔPsbU and ΔPsbV:ΔCyanoQ strains; however, 77 K fluorescence emission spectra indicated increased coupling of the phycobilisome (PBS) antenna at pH 10.0 in all mutants. DNA microarray data showed a cell-wide response to transfer from pH 10.0 to pH 7.5, including decreased mRNA levels of a number of oxidative stress-responsive transcripts. We hypothesize that this transcriptional response led to increased tolerance against reactive oxygen species and in particular singlet oxygen. This response enabled photoautotrophic growth of the PSII mutants at pH 10.0. This hypothesis was supported by increased resistance of all strains to rose bengal at pH 10.0 compared with pH 7.5.

Gene expression indicates a zone of heterocyst differentiation within the thallus of the cyanolichen Pseudocyphellaria crocata.

Development of the symbiotic association in the bipartite lichen Pseudocyphellaria crocata was investigated by characterizing two regions of the thallus. Thallus organization was examined using microscopy. A HIP1-based differential display technique was modified for use on Nostoc strains, including lichenized strains. Northern hybridization and quantitative real-time polymerase chain reaction were used to confirm differential display results, and determine expression levels of key cyanobacterial genes. Photosystem II yield across the thallus was measured using pulse-amplitude modulated fluorescence. Microscopy revealed structural differences in the thallus margins compared with the centre and identified putative heterocysts in both regions. Differential display identified altered transcript levels in both Nostoc punctiforme and a lichenized Nostoc strain. Transcript abundance of cox2, atpA, and ribA was increased in the thallus margin compared with the centre. Expression of cox2 is heterocyst specific and expression of other heterocyst-specific genes (hetR and nifK) was elevated in the margin, whereas, expression of psbB and PSII yield were not. Structural organization of the thallus margin differed from the centre. Both regions contained putative heterocysts but gene expression data indicated increased heterocyst differentiation in the margins where photosystem II yield was decreased. This is consistent with a zone of heterocyst differentiation within the thallus margin.

The register of "complaint": psychiatric diagnosis and the discourse of grievance in the south Indian mental health encounter.

In the language of the medical file, "complaint" refers to the symptoms and ailments reported by the patient. In this article, I draw on ethnographic fieldwork conducted between 2004 and 2007 in the mental healthcare setting in South India to argue that the typology of "complaint" and the dialogic exchanges involved in its production mark a far wider catchment area for the allegations and grievances that circulate between patient, kin, clinician, and observing anthropologist. I propose the notion of the register of complaint as a hermeneutic for grappling with the emotionally charged, interactional processes of accusation, arbitration, and reportage that drive clinical modes of inquiry and evaluation in the South Indian mental health encounter. Ethnographic case studies suggest that grievance and accusation command both a vital directive force and evidentiary role in the social, moral, and emotional work of psychiatric diagnosis. [complaint, diagnosis, kinship and family, emotion,

The masquerades of a childhood ciliary body medulloepithelioma: a case of chronic uveitis, cataract, and secondary glaucoma.

Ciliary body medulloepitheliomas in childhood often masquerade other intraocular conditions due to its insidious nature as well as its secondary effects on proximal intraocular tissues in the anterior chamber. We report a case where a ciliary body medulloepithelioma in a two-year-old boy presents with chronic uveitis, cataract, and an uncontrolled secondary glaucoma after an innocuous blunt ocular trauma. The diagnosis was only made after the occurrence of a ciliary body mass. We discuss the clinical features of ciliary body medulloepitheliomas, the implications of a delayed diagnosis and treatment as well as the concern of periorbital tumor seeding with the use of an aqueous shunt implant in this case.

Tales of decline: reading social pathology into individual suicide in South India.

In the south Indian state of Kerala, the nation's so-called suicide capital, suicide can often appear self-evident in meaning and motivation to casual onlookers and experts alike. Drawing on explanatory accounts, rumors, and speculative tales of suicide collected between 2004 and 2007, this article explores the ontological power of certain deaths to assert themselves as always-already known on the basis of perceived and reported demographic patterns of suicide. I demonstrate the ways suicides are commonly read, less through the distinct details of their individual case presentations than "up" to broader scales of social pathology. Shaped by the intertwined histories of public health intervention and state taxonomic knowledge in India, these "epidemic readings" of suicide enact a metonymy between individual suffering and ideas of collective decline that pushes the suicide case to fit-and thus to stand for-aggregate trends at the level of populations. Focusing on how family navigated the generic meanings and motivations ascribed to the deaths of their loved ones, I argue that the ability of kin to resist, collude with, or strategically deploy epidemic readings in their search for truth and closure hinged significantly on their classed fluency in the social, legal, and bureaucratic discourses of suicide.

Matched comparison of rotational stability of 1-piece acrylic and plate-haptic silicone toric intraocular lenses in Asian eyes.

PURPOSE: To evaluate and compare the postoperative rotational stability of a 1-piece acrylic toric intraocular lens (IOL) (Acrysof) and a plate-haptic silicone toric IOL (Staar) in Asian eyes. SETTING: Singapore National Eye Centre, Singapore. DESIGN: Prospective randomized control trial. METHODS: Eyes of Chinese patients having cataract surgery were randomized to receive the acrylic toric IOL or the silicone toric IOL. Postoperatively, patients returned at 1 day, 1 week, and 1 and 3 months. The eyes were dilated and slitlamp retroillumination photography of the toric IOL was performed to assess rotational stability. RESULTS: The acrylic IOL was implanted in 24 eyes and the silicone IOL in 26 eyes. The mean age of the patients was 68.2 years (range 42 to 82 years). The mean IOL rotation from baseline to 3 months postoperatively was 4.23 ± 4.28 degrees in the acrylic IOL group and 9.42 ± 7.80 degrees in the silicone IOL group; the difference was statistically significant (P=.01). Of the acrylic IOLs, 73% were rotated less than 5 degrees at 3 months; none was rotated more than 15 degrees at 3 months. The silicone toric IOLs showed greater rotational movement, with 37% being rotated less than 5 degrees and 21% being rotated more than 15 degrees. CONCLUSION: The acrylic toric IOL had better rotational stability than the silicone toric IOL.

Expression profile of inflammatory cytokines in aqueous from glaucomatous eyes.

PURPOSE: To determine the proinflammatory cytokine profile of aqueous humor from glaucomatous eyes. METHODS: Aqueous humor samples were prospectively collected from 38 eyes (26 primary open angle glaucoma [POAG] and 12 primary angle closure glaucoma [PACG] eyes) of 37 medically treated glaucoma patients and 23 cataract subjects recruited in an institutional setting in this case-controlled study. The main outcome measure was to quantify the levels of 29 inflammatory cytokines in the aqueous of glaucoma and cataract subjects using a multiplexed cytokine analysis. Data on patient demographics, duration of glaucoma, preoperative intraocular pressure (IOP) as well as duration of anti-glaucoma therapy were also collected for correlation analysis. RESULTS: Mean duration of glaucoma was 53.8 months (range 1-360 months). Aqueous obtained from the glaucoma patients showed increased concentration of interleukin (IL)-9 (p=0.032), IL-12 (p=0.003), interferon (IFN)-α (p=0.034), IFN-γ (p=0.002), monokine induced by interferon-gamma (MIG or CXCL9) (p=0.006), and IL-10 (p=0.050), compared to the cataract group. The POAG group had higher IL-12 (p=0.011), IFN-γ (p=0.005), and CXCL9 (p=0.047) levels than controls, while the PACG group had higher interleukin-8 (CXCL8) (p=0.015) and CXCL9 (p=0.023) levels than the controls. No significant correlation was observed between aqueous cytokine level and preoperative IOP and duration of glaucoma. Duration of topical Timolol and Alphagan therapy correlated negatively with CXCL8 (r=-0.588, p=0.035), respectively. CONCLUSIONS: Primary glaucoma is associated with an aqueous inflammatory response and this is different between POAG and PACG groups. Duration of glaucoma treatment may have an effect on cytokine profile in the aqueous.

Randomized, controlled trial of a sustained delivery formulation of 5-fluorouracil for the treatment of failing blebs.

PURPOSE: To determine the efficacy of a subconjunctival injection of hyaluronic acid (HA) with 5-fluorouracil (5FU) formulation as an adjunct in reviving bleb function by needling. DESIGN: Prospective, randomized, controlled trial. PARTICIPANTS: Fifty patients with previous trabeculectomy and scheduled by the managing physician for a needling intervention. METHODS: One eye of each patient was randomized to receive needling with HA-5FU mixture or needling with subconjunctival injection of 5FU solution alone. MAIN OUTCOME MEASURES: The primary outcome was the percentage of subjects with an intraocular pressure (IOP) <15 mmHg without any medications at 3 months. Secondary outcomes included the need for additional needling procedures and changes in bleb morphology. RESULTS: Forty-nine subjects (25 in the HA-5FU group and 24 in the 5FU group) completed 3 months of follow-up. At baseline, there was no significant difference between the groups in terms of demographic features, subtype of glaucoma, vertical cup-to-disc ratio, or visual field indices. The mean number of glaucoma medications at baseline was higher in the 5FU group (0.8±1.1 [mean ± standard deviation] vs. 0.2±0.6, P = 0.04). An IOP <15 mmHg without medications was reached in 48.0% of subjects in the HA-5FU group and in 33.3% of subjects in the 5FU group (P = 0.2). At 3 months, both groups demonstrated a significant decrease in IOP from baseline (HA-5FU: decrease of 5.9 mmHg [95% confidence interval, 3.4-8.4]; 5FU: decrease of 6.0 mmHg [95% confidence interval, 3.2-8.2]; P<0.001 for both). Intergroup comparisons for IOP change from baseline was not significant (P = 0.9). However, repeat needling was required more frequently in the 5FU group compared with the HA-5FU group (50.0% vs. 12.0%; P = 0.004). There were no significant differences in the number of reported adverse events, bleb vascularity, or morphology between the 2 groups. CONCLUSIONS: Subconjunctival injection of HA-5FU to revive bleb function after bleb needling is as effective as 5FU solution. Fewer repeat needlings were required after treatment with HA-5FU, suggesting that the use of a combined formulation of HA-5FU may improve the overall outcomes of bleb needlings.

Making time for the children: self-temporalization and the cultivation of the antisuicidal subject in south India.

This article examines suicide prevention among children in India's "suicide capital" of Kerala to interrogate the ways temporalization practices inform the cultivation of ethical, life-avowing subjects in late capitalism. As economic liberalization and migration expand consumer aspiration in Kerala, mental health experts link the quickening of material gratification in middle-class parenting to the production of insatiable, maladjusted, and impulsively suicidal children. Experiences of accelerated time through consumption in "modern" Kerala parenting practice reflect ideas about the threats of globalization that are informed both by national economic shifts and by nostalgia for the state's communist and developmentalist histories, suggesting that late capitalism's time­space compression is not a universalist phenomenon so much as one that is unevenly experienced through regionally specific renderings of the past. I demonstrate how experts position the Malayali child as uniquely vulnerable to the fatal dangers of immediate gratification, and thus exhort parents to retemporalize children through didactic games built around the deferral of desires for everyday consumer items. Teaching children how to wait as a pleasurable and explicitly antisuicidal way of being reveals anxieties, contestations, and contradictions concerning what ought to constitute "quality" investment in children as temporal subjects of late capitalism. The article concludes by bringing efforts to save elite lives into conversation with suicide prevention among migrants to draw out the ways distinct vulnerabilities and conditions of precarity situate waiting subjects in radically different ways against the prospect of self-destruction.

A 5-year retrospective review of Asian ectropion: how does it compare to ectropion amongst non-Asians?

INTRODUCTION: This study reviews the differences in demographics and surgical outcomes between ectropion in Asian and non-Asian eyes. MATERIALS AND METHODS: Medical records of surgically corrected ectropion cases from January 2002 to December 2006 were reviewed. Preand postoperative lid-globe apposition was graded: grade 0 with normal lid-globe apposition, grade 1 with punctal ectropion, grade 2 with partial lid eversion and scleral show, grade 3 with conjunctival hyperemia and thickening and grade 4 as for grade 3 with exposure keratitis. RESULTS: Sixty-nine eyes in 50 patients underwent surgical correction of lower lid ectropion, making up 3.3% of all lid procedures performed. Eighty-four percent of patients were above 50 years of age, 72% were males and 88% were Chinese. Involutional change was the commonest aetiology, accounting for the majority of bilateral cases. The mean duration to surgery was 10.0 ± 16.0 months. The most frequent preoperative severity grade was 2. Lateral tarsal strip (LTS) was the commonest procedure performed, comprising 91.3% of eyes. The mean duration of postoperative review was 19.4 ± 19.2 months (range, 1 to 74 months). Postoperative improvement of at least one grade was observed in 98% while normal lid-globe apposition was achieved in 76% of eyes. CONCLUSIONS: Involutional change is the most common cause of ectropion amongst both Asians and non-Asians. Ectropion is less prevalent amongst Asians as a result of anatomical differences and possibly reduced sun exposure. The LTS procedure is the most commonly performed surgical procedure for the successful correction of ectropion in both Asians and non-Asians.

Combined treatment with bevacizumab and 5-fluorouracil attenuates the postoperative scarring response after experimental glaucoma filtration surgery.

PURPOSE: This study evaluated the use of combined bevacizumab with 5-fluorouracil (5-FU) on postoperative scarring and bleb survival after experimental glaucoma filtration surgery in comparison to the agents alone. METHODS: Filtration surgery was performed on 26 female New Zealand White rabbits. The rabbits were allocated to one of four treatments: 5-FU combined with bevacizumab, 5-FU alone, bevacizumab alone, or phosphate buffered saline (PBS). The subconjunctival injections were administered immediate postoperatively and weekly for 3 weeks. Clinical assessment and bleb photography were performed. Histologic staining determined the presence of subconjunctvial fibrosis and mRNA expression of collagen I and fibronectin in the tissue was quantified. RESULTS: Bevacizumab in combination with 5-FU resulted in a greater antifibrotic effect compared with monotherapy with 5-FU or bevacizumab alone, as evidenced by the attenuation in fibronectin and mature collagen I expression and deposition (P < 0.05). In addition, this was associated with a 100% bleb survival at day 28 in the combined treatment group compared with monotherapy (50% bevacizumab [P < 0.05] and 25% 5-FU [P < 0.001]). Conjunctival vascularity significantly reduced with bevacizumab treatment both alone and in combination with 5-FU. CONCLUSIONS: The results provide compelling evidence that combined bevacizumab and 5-FU offers superior antifibrotic effect over monotherapy in a model of glaucoma filtration surgery, while prolonging bleb survival at the same time. A synergistic effect is suggested to be present.

Acanthamoeba keratitis associated with contact lens wear in Singapore.

PURPOSE: To describe an outbreak of Acanthamoeba keratitis (AK) cases among contact lens wearers. DESIGN: Retrospective cohort study. METHODS: Patients with AK were included. Relevant demographic and clinical data were obtained from case records, and patients were interviewed using a standardized questionnaire. Contact lens practices, including type of contact lens and solution used, were noted. In addition, clinical features at presentation, management, and clinical outcomes were recorded. RESULTS: Forty-two patients (affecting 43 eyes) treated between 2000 and 2007 were included. Diagnosis was made by microbiologic culture in 35 cases and by microbiologic and histologic analysis in 2 cases, whereas the remainder were diagnosed based on clinical features and response to treatment. There was a gradual increase in cases since 2005, with a sharp increase in 2007, when 8 local patients were treated. Of 30 patients where contact lens solution data were available, 18 reported using a Complete brand Multipurpose solution (Advanced Medical Optics, Santa Ana, California, USA) before the infection. Among resident cases treated since February 2006, 7 (63%) of 11 patients used a Complete brand solution. Suboptimal hygiene practices were found in all patients interviewed. Fifteen patients required corneal grafting, with 11 undergoing therapeutic deep lamellar keratoplasty (DLK), 2 undergoing optical penetrating keratoplasty (PK), 1 undergoing optical DLK, and 1 undergoing therapeutic PK. The remainder were treated successfully medically with combination antiamebic therapy. The average duration of therapy was 116.2 days (range, 15 to 283 days). Of patients with radial keratoneuritis with or without epithelial disease, 83.3% achieved final vision of 20/40 or better, whereas this was achieved in 41.7% of those with ring infiltrate. Twenty-five percent of patients with ring infiltrate had final visual acuity of counting fingers or worse, whereas no patient with keratoneuritis and epithelial disease had final vision worse than counting fingers. CONCLUSIONS: There was an increase in the number of contact lens users with AK seen in the major eye departments of Singapore. Most of our patients also reported using a Complete brand Multipurpose solution before infection, and this parallels a similar outbreak in the United States. Increasing severity of infection was associated with worse visual outcome.