Recurrent fungal keratitis and endophthalmitis.

PURPOSE: To report a case of recurrent fungal sclerokeratitis and endophthalmitis with a very successful outcome due to aggressive combined surgical and medical therapy. To discuss the management of this potentially devastating infection. METHODS: A 65-year-old man presented with 6 months of left eye redness and irritation after injury from organic matter propelled from an airboat. Initially, he had been treated with foreign body removal, antibiotics, and steroids. He was diagnosed with reactive sclerokeratitis at presentation and was treated with steroids. However, when he did not improve, cultures were obtained and Acremonium species filamentous fungi was identified. Despite treatment with appropriate topical and systemic antifungals, his fungal sclerokeratitis progressed to endophthalmitis. Two therapeutic penetrating keratoplasties (PKs) with iridectomy and intraocular amphotericin B were necessary to eradicate the fungal infection. RESULTS: Visual acuity was restored to 20/25-3 with correction 9 months after initial presentation. There was no recurrence of fungal infection after the second therapeutic PK. CONCLUSION: The possible reasons for recurrence of fungal infection are discussed. The role of timely and aggressive medical and surgical intervention for fungal sclerokeratitis and endophthalmitis in restoring excellent vision is emphasized.

Nontuberculous mycobacterial keratitis in south Florida.

OBJECTIVE: This study aimed to review the clinical features, therapeutic response, and histopathology of cases of nontuberculous mycobacterial keratitis at the Bascom Palmer Eye Institute. DESIGN AND PARTICIPANTS: Retrospective review of medical records, clinical photographs, histopathology, and microbiology of 24 cases of nontuberculous acid-fast keratitis over the past 15 years. RESULTS: Causal organisms included Mycobacterium chelonae (16), M. fortuitum (3), M. avium-intracellulare (2), M. nonchromogenicum (1), M. triviale (1), and M. asiaticum (1). Clinically, the keratitis had a superficial location except in those patients with a history of surgery. Amikacin was the most commonly used antibiotic (63%). Three patients were treated with Clarithromycin. In one patient, it was stopped because of toxicity; the other two had resolution of their infiltrates. Fifty-five percent did not respond to topical antimicrobial therapy. The organisms as a group were sensitive to amikacin and Clarithromycin and resistant to the fluoroquinolones. Sixty-four percent of the group that failed to respond to medical treatment were treated with steroids after the diagnosis was known, in comparison to 44% of the group treated successfully with medications. The histopathology of the patients treated with steroids showed minimal inflammation despite a large number of organisms, in contrast to the dense infiltrates seen in the specimens from patients not treated with topical steroids. CONCLUSION: Nontuberculous mycobacterial keratitis is a chronic insidious infection that is often unresponsive to medical therapy. The authors recommend that steroids be withheld. Based on the authors' experience of three patients, topical Clarithromycin may hold promise as a therapeutic agent. Lamellar keratectomy or penetrating keratoplasty should be considered in those patients who do not respond to medical therapy or those who have recurrent exacerbations on attempted weaning of topical antibiotic therapy.

Conrad Berens Lecture. The management of infectious keratitis as we approach the 21st century.

PURPOSE: To determine the role of cultures in the management of ulcerative keratitis, and to determine the role and selection of either commercially available monotherapy versus combined fortified antibiotics in the treatment of bacterial keratitis. METHODS: The ocular microbiology files at the Bascom Palmer Eye Institute for the years 1969-1997 were reviewed; as were outpatient data at the Bascom Palmer Eye Institute/Anne Bates Leach Eye Hospital for the 20 years 1978-1997 to arrive at an annual incidence of suspected infectious keratitis. An ulcerative keratitis/management survey of the membership of the Castroviejo Cornea Society in 1995 was also conducted. RESULTS: For the period 1969-1997, a total of 5,845 eyes were cultured for suspected infectious keratitis. The incidence of keratitis was 3.1 per 1,000 clinic visits. Forty-nine percent of the cultures were positive--82% bacterial isolates, 16% fungal isolates, and 2% parasites. Pseudomonas aeruginosa represented 20% of the bacterial isolates from 1969 through 1997, increasing to 32% and 39% during the two five-year intervals in the decade 1978-1987, and decreasing to 20% during the period 1993-1997. CONCLUSIONS: 1) Perform corneal scrapings in selected patients with suspected infectious keratitis when risk factors are present, when there is a large central infiltrate, or when empirical therapy has failed. 2) In community/hospital based practice continue to culture all cases of suspected infectious keratitis. 3) Use fortified antibiotics for more severe keratitis. 4) Use monotherapy with a fluoroquinolone and/or other commercially available antibiotics for mild or less suspect keratitis. 5) A third alternative is to combine fortified cefazolin with a fluoroguinolone.

Mutation hot spots in 5q31-linked corneal dystrophies.

Mutations in the BIGH3 gene on chromosome 5q31 cause four distinct autosomal dominant diseases of the human cornea: granular (Groenouw type I), Reis-Bücklers, lattice type I, and Avellino corneal dystrophies. All four diseases are characterized by both progressive accumulation of corneal deposits and eventual loss of vision. We have identified a specific recurrent missense mutation for each type of dystrophy, in 10 independently ascertained families. Genotype analysis with microsatellite markers surrounding the BIGH3 locus was performed in these 10 families and in 5 families reported previously. The affected haplotype could be determined in 10 of the 15 families and was different in each family. These data indicate that R555W, R124C, and R124H mutations occurred independently in several ethnic groups and that these mutations do not reflect a putative founder effect. Furthermore, this study confirms the specific importance of the R124 and R555 amino acids in the pathogenesis of autosomal dominant corneal dystrophies linked to 5q.

Clinical evidence for hepatitis B transmission resulting from corneal transplantation.

PURPOSE: Two cases of hepatitis B virus (HBV) infection after penetrating keratoplasty are presented. METHODS: An extensive clinical and serologic investigation of these two transplant recipients was performed. In addition, the medical histories, autopsy reports, and specimens of blood from the two deceased corneal tissue donors were retrieved and studied. RESULTS: Serum from both donors was positive for hepatitis B surface antigen; the clinical history and serologic testing of both recipients strongly suggest that the HBV infection in each case was acquired from donor corneal tissue. CONCLUSION: To our knowledge, these are the first documented cases of HBV infection after corneal transplantation. Eye banks should continue to screen donors for HBV.

A comparison of two selective interrupted suture removal techniques for control of post keratoplasty astigmatism.

PURPOSE: Two selective interrupted suture removal techniques were compared to determine which technique resulted in earliest, best visual acuity and least postoperative astigmatism. METHODS: Sixty-five consecutive optical penetrating keratoplasties were performed using 12 interrupted 10-0 nylon sutures and a 12-bite continuous 10-0 nylon suture, and were alternately assigned to 1 of 2 selective suture removal groups. All patients had refraction, keratometry, and videokeratoscopy postoperatively, starting at 6 weeks. Six weeks postoperatively, Group I underwent simultaneous removal of six alternate sutures, with the first of the 6 sutures removed at the steepest meridian, while Group II had selective sutures removed only at the steepest meridian, if associated with greater than 2 diopters of astigmatism in that meridian. Subsequently, interrupted sutures were then selectively removed until the resultant astigmatism approached 3.0 diopters or less. Measurements of resultant astigmatism are reported prior to selective suture removal, following selective suture removal, at 6 months postoperatively, at the completion of all selective suture removal, and at the final visit. RESULTS: At 6 months, residual astigmatism after the 2 techniques of selective suture removal, as measured by refraction, keratometry, and computer-assisted videokeratoscopy, was 2.8, 3.0 and 3.4 diopters for Group I, and 2.2, 2.6 and 3.7 diopters for Group II. At 1 year, the average final visit, astigmatism was 2.5, 2.4 and 2.7 diopters for Group I, and 2.1, 2.0 and 2.3 diopters for Group II. By the final visit, a best corrected vision of 20/50 or better was achieved in 86% of eyes in Group I and in 65% of eyes in Group II, and there was a significant difference in average keratometry of 47.4 diopters in Group I compared to 46.0 diopters in Group II and, as measured by videokeratoscopy, 47.9 diopters in Group I compared to 45.8 diopters in Group II. CONCLUSIONS: Selective suture removal by either technique reduces keratoplasty astigmatism with residual interrupted and continuous sutures in place. The combined use of refraction, keratometry, and videokeratoscopy probably provides more reliable and reproducible quantitative measurements of astigmatism. Minimizing astigmatism by selective suture removal is a major factor in the attempt to achieve excellent and visual function in the majority of patients who have undergone penetrating keratoplasty.

Endophthalmitis associated with microbial keratitis.

PURPOSE: The purpose of the study is to investigate possible risk factors, organisms cultured, and visual acuity outcomes of endophthalmitis associated with microbial keratitis. METHODS: Records were reviewed of all patients with both positive corneal and positive intraocular cultures at the Bascom Palmer Eye Institute between January 1, 1990, and March 31, 1995. RESULTS: Thirteen (92.9%) of 14 patients identified had documented keratitis before the diagnosis of endophthalmitis was made. Thirteen (92.9%) patients recently had used 1% prednisolone acetate eye drops, 2 (14.3%) received oral prednisone, and 5 (35.7%) were being treated for systemic conditions associated with relative immune dysfunction. Eight (57.1%) patients had a history of ocular surgery, and seven (50.0%) had wound abnormalities. Eight (57.1%) patients lacked an intact posterior capsule, four (28.6%) had a corneal perforation, and three (21.4%) had a history of dry eye. Gram-negative organisms (7), Staphylococcus aureus (3), streptococcal species (2), and fungi (4) were the most frequently isolated organisms. Coagulase-negative staphylococci were not isolated. Six (42.9%) patients achieved a post-treatment visual acuity of 20/200 or better. Three (21.4%) patients underwent enucleation or evisceration. Although not statistically significant, there was an association between appropriate initial antibiotic therapy and improved visual outcomes. CONCLUSION: Patients in whom endophthalmitis associated with microbial keratitis develops have a frequent history of corticosteroid use, systemic conditions associated with relative immune dysfunction, lack of an intact posterior capsule, dry eye, wound abnormalities, and/or corneal perforation. In general, agents cultured consisted of organisms less frequently reported to be the causative agents in series of postoperative and post-traumatic endophthalmitis. Post-treatment visual outcomes generally were poor.

Useful visual outcomes after treatment of Bacillus cereus endophthalmitis.

PURPOSE: Bacillus cereus endophthalmitis occurring after penetrating ocular trauma has been almost always associated with a poor visual outcome. The purpose of our study was to review and report patients who had useful visual acuity outcomes. METHODS: The study group consisted of five patients from a single medical center with penetrating ocular trauma and endophthalmitis caused by B. cereus. The study population was derived from a review of the microbiology records, clinical records, and operative reports of patients with culture-proven, post-traumatic endophthalmitis over a 15-year period. Patients were only included if the final visual acuity outcomes were 20/200 or better. RESULTS: All five patients had penetrating ocular injuries, and four patients had a retained intraocular foreign body. Endophthalmitis was diagnosed preoperatively in three patients and intraoperatively in two patients. All patients underwent pars plana vitrectomy and injection of intravitreal and periocular antibiotics. Postoperatively, a rhegmatogenous retinal detachment developed in three patients between 4 weeks and 12 months after the injury (average, 19 weeks); all retinal detachments were reattached with additional vitreoretinal surgery. Final postoperative visual acuities were 20/200 (two patients), 20/30 (one patient), and 20/25 (two patients). The postoperative follow-up time interval ranged from 12 months to 30 months (average, 19.2 months). CONCLUSION: The current series adds further support to the observation that certain eyes with post-traumatic B. cereus endophthalmitis may be associated with preservation of anatomic integrity and restoration of useful visual acuity.

Corneoscleral block excision of postoperative anterior chamber cysts.

PURPOSE: To describe the clinical presentation, surgical treatment and histopathology of three cases of cystic epithelial ingrowth occurring after cataract surgery. METHODS: Three patients developed anterior chamber cysts, two with an associated conjunctival bleb and fistula, following extracapsular cataract and phacoemulsification surgery. The technique of block excision and corneoscleral graft was used in the three patients. RESULTS: There was no evidence of recurrence twenty-six, twenty-three and seven months postoperatively. Visual acuities were 20/30, 20/20-2 and 20/25-2, with mild astigmatism and well controlled intraocular pressure. Histopathology illustrated that conjunctival and corneal epithelium invaded the anterior chamber through a wound defect. CONCLUSION: At this time, block excision with a corneoscleral graft may be the most definitive surgical treatment of cystic epithelial ingrowth.

Defects in an injection-molded intraocular lens.

Injection-molded intraocular lenses may undergo structural changes when exposed to solvents and fixatives during post-mortem examination. We report a case in which this phenomenon was seen in an injection-molded lens. We were able to duplicate these changes by immersing injection-molded lenses in 60% alcohol for 48 hours.

Experimental postoperative endophthalmitis.

Various inocula of vancomycin-sensitive E faecalis (EF01), S aureus (SA02), S epidermidis (SE03), and B cereus (BC04), were intravitreally inoculated into an aphakic rabbit model with and without vancomycin, with or without vitrectomy. A summation average of the clinical response mean scores of various inocula (10(3), 10(5), 10(7) cfu) in the absence of therapy ranked these etiologic agents in the order of severity as SE03 (1.4), BC04 (1.8), EF01 (2.3), and SA02 (2.8). These favorably compared with the histopathology cavitary/noncavitary mean scores in increasing order of severity: SE03 (1.7/0.6), BC04 (1.7/0.9), EF01 (2.4/1.1), and SA02 (2.5/1.5), compared with control eyes (1.1/0.4). If the inoculum was increased to 10(7) cfu, SE03 (2.4/0.9) and BC04 (2.8/2.0) could equate EF01 and SA02. Treatment with 1 mg of vancomycin, with or without vitrectomy, did not significantly alter the overall inflammatory response to these four endophthalmitis isolates. No treatment was necessary to achieve > 99.9% killing effect by 72 hours when testing BC04, while any of the treatment modalities during 72 hours achieved 99.9% killing effect when testing SE03. No treatment modality achieved a 99.9% killing effect when testing EF01 or SA02. No single in vitro result could predict the in vivo microbiologic behavior of this model. Further research is needed to better understand the role of antiinflammatory agents, multiple drug therapy, and multiple-injection single-drug therapy with or without vitrectomy, and their impact on the inflammatory response in the aphakic model, to better treat endophthalmitis and thus improve visual prognosis.

Nosocomial endophthalmitis survey. Current incidence of infection after intraocular surgery.

The authors reviewed the incidence of hospital-linked postoperative endophthalmitis at the Bascom Palmer Eye Institute between January 1, 1984 and June 30, 1989. After 30,002 intraocular surgical procedures, the following incidence of culture-proven endophthalmitis was observed: (1) extracapsular cataract extraction (ECCE) with or without intraocular lens (IOL) implantation--0.072% (17 of 23,625 cases); (2) pars plana vitrectomy--0.051% (1 of 1974 cases); (3) penetrating keratoplasty (PKP)--0.11% (2 of 1783 cases); (4) secondary IOL--0.30% (3 of 988 cases); and (5) glaucoma filtering surgery--0.061% (1 of 1632 cases). A statistically significant (P = 0.038, Fisher's exact test, two-tailed) increased incidence of endophthalmitis occurred in diabetic (0.163%, 6 of 3686 cases) compared with nondiabetic (0.055%, 11 of 19,939 cases) patients undergoing ECCE with or without IOL implantation. The authors also reviewed the incidence of postoperative endophthalmitis after intracapsular cataract extraction (ICCE) with and without IOL and observed an incidence of 0.093% (7 of 7552) in cases operated on between September 1, 1976 and December 31, 1982.

Ulcerative keratitis associated with contact lens wear.

From October 1982 through June 1986, 658 patients developed ulcerative keratitis. In 196 of these patients it was contact lens-related. Fifty-nine patients wore extended-wear contact lenses for cosmetic purposes. On culture, Pseudomonas species was the organism most frequently isolated from the ulcers associated with contact lens wear. No cases of fungal keratitis were found in the contact lens group as compared to 40 cases (17%) in the noncontact lens group. Compared to results of a similar study covering January 1977 through September 1982, current results showed a larger number of patients using extended-wear lenses for cosmetic reasons (59 vs one) and overall younger age.

Coagulase-negative staphylococcal endophthalmitis. Increase in antimicrobial resistance.

The predicted sensitivities of common organisms guide initial antibiotic therapy in endophthalmitis. The authors suspected a change in the expected sensitivity of coagulase-negative staphylococci when three cases of endophthalmitis due to multiply resistant organisms failed to respond to intravitreal cefazolin and gentamicin. The authors reviewed 48 cases from 1982 to 1986, compared these with 28 cases from 1973 to 1981, they found increased resistance to gentamicin (35 versus 0%, P less than 0.05) and increased resistance to methicillin (27 versus 19%). Eight cases were resistant to both antibiotics, including the three clinical failures. Final vision was unrelated to antimicrobial resistance. Since cephalosporins may be ineffective clinically against methicillin-resistant staphylococci, concomitant gentamicin resistance may render intravitreal cefazolin and gentamicin inadequate for their treatment. No isolates were resistant to vancomycin. Vancomycin and aminoglycoside, used intravitreally in the initial management of endophthalmitis, would be anticipated to provide better coverage than cefazolin and aminoglycoside for endophthalmitis due to the staphylococci, as well as for infections due to streptococcal and bacillus species.

Lymphogranuloma venereum conjunctivitis with a marginal corneal perforation.

The authors have recently treated a case of Parinaud's oculoglandular syndrome due to Chlamydia trachomatis serotype L2, a causative agent of lymphogranuloma venereum (LGV). The ocular manifestations included a mixed papillary-follicular conjunctivitis with fleshy superior limbal lesions in both eyes. A superior marginal corneal perforation requiring a therapeutic corneal graft was present in the right eye. The patient had vaginitis, inguinal lymphadenopathy, a history of Sjögren's syndrome, and seropositivity to human immunodeficiency virus (HIV). The ocular disease resolved completely after 6 weeks of oral tetracycline therapy.

Exogenous fungal endophthalmitis.

The authors report 19 cases of exogenous fungal endophthalmitis managed between 1969 and 1986. These developed after ocular surgery (5 cases), after trauma (6 cases), by intraocular spread from fungal keratitis (4 cases), after therapeutic keratoplasty for keratitis (3 cases), and by spontaneous infection of a filtration bleb (1 case). The diagnosis of endophthalmitis was made from 3 days to 4 months after surgery or trauma. In patients with preexisting keratitis, endophthalmitis was noted 2 weeks to 5 months after the onset of keratitis. Seventeen cases were caused by filamentous fungi; two were caused by yeast. Fusarium (6 cases) and Acremonium (3 cases) accounted for approximately one half of the isolates. Forty-two percent of the patients recovered 20/400 or better acuity (3 of 5 postoperative cases, 4 of 6 trauma cases, and 1 of 4 keratitis cases). The clinical and microbiologic features of these cases are presented, and recommendations for management are offered.