Contact-Lens-Associated Purpureocillium Keratitis: Risk Factors, Microbiologic Characteristics, Clinical Course, and Outcomes.

PURPOSE: To study the risk factors, microbiologic characteristics, clinical course, and outcomes of patients with Purpureocillium keratitis at a tertiary eye care center in south Florida. MATERIALS AND METHODS: All medical records during a seven-year period starting January 1, 2007, were reviewed. Twenty-eight culture-proven Purpureocillium keratitis cases with complete medical records presenting to our institution were included in this retrospective, observational case series. Data collected included predisposing factors, therapeutic interventions, treatment duration, and visual outcomes. RESULTS: Twenty patients (71.4%) had a history of soft contact lens use, with only two for therapeutic use. Other identified risk factors were trauma and immunosuppression. Fifteen patients (53.6%) received topical corticosteroid treatment prior to the diagnosis of fungal keratitis. Thirteen patients (46.4%) were on Natamycin treatment prior to Purpureocillium identification. As a group, the average best-corrected visual acuity (BCVA) at presentation was 1.1 logMAR; upon the final evaluation, it was 1.0 logMAR. The BCVA on last evaluation for the eight patients presenting to our institution within two weeks of onset of symptoms was 0.3 log MAR, and all patients in this group responded to medical management. The final BCVA for 20 patients presenting two weeks after onset of symptoms was 1.2 logMAR. There was a significant difference in the final BCVA between Group 1 and Group 2 (p = 0.004), but no difference in steroid use or previous treatments. Previous steroid use tended to extend time to presentation and was significantly associated with a worse final visual outcome (1.2 versus 0.6 logMAR; p = 0.0474). Previous Natamycin use was significantly associated with a worse final visual outcome (1.4 versus 0.6 logMAR; p = 0.014). CONCLUSION: Purpureocillium keratitis can have devastating consequences to visual function and even lead to enucleation. Physicians should make every effort to arrive at an earlier microbiological diagnosis, as this is associated with better outcomes and less need for surgical intervention. The first line use of voriconazole is recommended, and steroid use should be avoided, as their previous use is associated with worse visual outcomes.

Clinical course and origin of epithelium in cases of epithelial downgrowth after Descemet stripping automated endothelial keratoplasty.

PURPOSE: The aim of this study was to report a case series of epithelial downgrowth associated with Descemet stripping automated endothelial keratoplasty (DSAEK) and to explore the origin of the anterior chamber corneal epithelium. METHODS: This is a case series and literature review. RESULTS: Three histopathologically confirmed cases of epithelial downgrowth after DSAEK were identified. All cases were treated with argon laser ablation, intracameral 5-fluorouracil, and intraocular surgery. Recurrent epithelial downgrowth occurred in 2 of 3 cases. Fluorescent in situ hybridization analysis with fluorescent probes for X and Y chromosomes was used to analyze epithelial downgrowth tissues in all cases. All 3 cases were consistent with donor tissue origin of epithelial downgrowth tissue. However, this could only be confirmed in 1 case. The donor and the recipient were the same sex in 2 cases; thus, no definitive conclusion was possible in these patients. CONCLUSIONS: There have been multiple reports of epithelial downgrowth after DSAEK. We include additional evidence to support the role of donor tissue corneal cells as the source of epithelium in some of these cases. It is surprising that donor tissue would be tolerated immunologically by the patient in these cases. We propose that tolerance for donor epithelium may be mediated through anterior chamber-associated immune deviation.

Effect of cornea donor graft thickness on the outcome of Descemet stripping automated endothelial keratoplasty surgery.

PURPOSE: To determine whether Descemet stripping automated endothelial keratoplasty (DSAEK) donor cornea graft thickness impacts measurements of best spectacle-corrected visual acuity (BSCVA), refractive error and intraocular pressure (IOP). DESIGN: Retrospective chart review in a tertiary care center at Duke University Eye Center. METHODS: We studied 460 eyes that had undergone DSAEK surgery. They were segregated into three groups based on the thickness of the donor graft: <100 µm (n = 67 eyes); 100-150 µm (n = 316 eyes); and >150 µm (n = 77 eyes). The three graft-thickness groups were assessed at about 6 months postoperatively for measurement of BSCVA, spherical equivalent, and IOP. RESULTS: Baseline demographics were similar in the three groups. All groups experienced significant improvement in BSCVA (mean ± SD = -0.34 ± 0.50 logMAR); mild hyperopic shift (mean ± SD = 0.48 ± 1.7 D); and stability in IOP measurements (mean ± SD = 0.19 ± 4.8 mm Hg). There were no significant differences in groups according to donor graft thicknesses with respect to change in BSCVA (P = 0.8); hyperopic shift (P = 0.76); or IOP measurement (P = 0.56). CONCLUSIONS: DSAEK significantly improves BSCVA. DSAEK graft thickness may not play an important role in the final BSCVA, refractive error, or accuracy of IOP measurement. The ideal DSAEK graft thickness to minimize graft-related complications remains to be determined.

Increased Rates of Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) Graft Failure and Dislocation in Glaucomatous Eyes with Aqueous Shunts.

PURPOSE: To investigate the rates of Descemet's stripping automated endothelial keratoplasty (DSAEK) graft dislocation and failure in glaucomatous eyes, including eyes with history of trabeculectomy and/or aqueous shunts. METHODS: A retrospective, case-control study on a total of 424 consecutive eyes undergoing DSAEK at an academic setting compared 96 glaucomatous eyes to a control group of 328 eyes. Pre- and post DSAEK procedure data was aggregated for up to 2 years (mean follow-up, 6.5±6.9 months) including rates of graft dislocation and failure. RESULTS: Out of 96 glaucomatous eyes, 20 had undergone trabeculectomy, 27 had received one or more aqueous shunts, 12 had undergone both procedures and 37 were on medical therapy. Complete DSAEK graft dislocation and failure occurred in 2.7% and 3% of non-glaucomatous patients, respectively. Eyes with history of aqueous shunt surgery experienced graft dislocation and failure rates of 26.0% (OR=4.6, 95% CI 1.5-13.7, p=0.0067) and 26.0% (OR=10.3, 95% CI 3.8-27.1, p<0.0001), respectively. In contrast, glaucomatous eyes only on medical therapy (p=0.13) or with history of trabeculectomy (p>0.40) had no significant increase in graft dislocation or failure rates. CONCLUSION: Eyes with medically controlled glaucoma or prior trabeculectomy demonstrated comparable rates of graft dislocation and failure as compared to controls. Aqueous shunt surgery was associated with increased rates of graft dislocation and failure after DSAEK.

Anatomy and physiology of the cornea.

The importance of the cornea to the ocular structure and visual system is often overlooked because of the cornea's unassuming transparent nature. The cornea lacks the neurobiological sophistication of the retina and the dynamic movement of the lens; yet, without its clarity, the eye would not be able to perform its necessary functions. The complexity of structure and function necessary to maintain such elegant simplicity is the wonder that draws us to one of the most important components of our visual system.

Differential expression of retinal pigment epithelium (RPE) IP-10 and interleukin-8.

Interferon-gamma induced protein of 10 kDa (IP-10) is a C-X-C chemokine that attracts T lymphocytes and inhibits angiogenesis. In this study, we investigated the expression of IP-10 by human retinal pigment epithelial cells (HRPE) and compared IP-10 expression to that of interleukin-8 (IL-8), which is a leukocytic chemoattractant and pro-angiogenic factor. Cultured HRPE cells were incubated with either IL-1 beta (0.2-20 ng/ml) or tumor necrosis factor (TNF)-alpha (0.2-20 ng/ml) alone or in combination with interferon-gamma (IFN-gamma) (1000 U/ml). HRPE cells were also incubated with: (1) media conditioned by activated human T lymphocytes (CM), or (2) the same CM treated with neutralizing antibodies to IL-1, TNF, and/or IFN-gamma. IL-8 and IP-10 protein levels were measured by ELISA and mRNA levels by Northern blot analysis of HRPE cells. HRPE cells produced very high levels of IP-10 in response to either IL-1 beta/IFN-gamma, TNF-alpha/IFN-gamma or CD3-activated T-lymphocyte CM. The levels of IP-10 were at least tenfold higher (p<.001) than IL-8 measured in the same samples. Neutralizing antibodies to TNF and IFN-gamma, but not to IL-1, abrogated the ability of the CD3-activated T lymphocytes CM to induce HRPE IP-10 (p<.001). HRPE cells produce differential levels of IP-10 and IL-8 in response to various combinations of recombinant and T-lymphocyte-secreted pro-inflammatory cytokines. This may be important in evolving inflammatory and angiogenic ocular responses.