ABSTRACT
PURPOSE: To describe a cluster of Mycobacterium chelonae keratitis cases involving patients who underwent laser in-situ keratomileusis (LASIK) at a single refractive surgery center. DESIGN: Descriptive case series of four patients and cohort study to identify disease associations. METHODS: Examination schedules, diagnostic tests, and therapy were based on best medical judgment. Isolates from three patients were compared by pulsed-field gel electrophoresis. Epidemiologic studies were performed to identify the source of infection. RESULTS: Seven of eight eyes developed M. chelonae keratitis following bilateral simultaneous LASIK. Each patient was thought to have diffuse lamellar keratitis initially, but all seven eyes were noted to have opacities suggestive of infectious keratitis by 13 to 21 days after surgery. All eyes had undergone hyperopic LASIK over four days in April 2001 by one surgeon in a community-based refractive surgery center. A cohort study of all patients undergoing LASIK at the same center in April 2001 revealed that M. chelonae keratitis occurred only in persons undergoing correction of hyperopia (seven of 14 eyes vs. none of 217 eyes undergoing myopic LASIK, P <.001). The only difference identified between procedures was use of masks created from a soft contact lens in hyperopic LASIK. Three isolates (three patients) were indistinguishable by pulsed-field gel electrophoresis. Eyes were treated with a combination of antimicrobial agents, including topical azithromycin in three patients, with resolution of infection in all eyes over 6 to 14 weeks. The source of infection was not identified on environmental cultures. CONCLUSION: Postoperative nontuberculous mycobacterial keratitis can occur in an epidemic fashion following LASIK. Topical amikacin, azithromycin, clarithromycin, ciprofloxacin, or a combination of these agents, appears to be effective treatment for these infections.
Subject(s)
Eye Infections, Bacterial/etiology , Keratitis/etiology , Keratomileusis, Laser In Situ/adverse effects , Mycobacterium Infections, Nontuberculous/etiology , Mycobacterium chelonae/isolation & purification , Anti-Bacterial Agents , Bacterial Proteins/analysis , California , Cluster Analysis , Cohort Studies , Cornea/microbiology , Cornea/surgery , Drug Therapy, Combination/therapeutic use , Electrophoresis, Gel, Pulsed-Field , Eye Infections, Bacterial/drug therapy , Eye Infections, Bacterial/epidemiology , Eye Infections, Bacterial/microbiology , Female , Humans , Hyperopia/surgery , Keratitis/drug therapy , Keratitis/epidemiology , Keratitis/microbiology , Middle Aged , Mycobacterium Infections, Nontuberculous/drug therapy , Mycobacterium Infections, Nontuberculous/epidemiology , Mycobacterium Infections, Nontuberculous/microbiologySubject(s)
Alcaligenes/isolation & purification , Cornea/microbiology , Corneal Ulcer/microbiology , Eye Infections, Bacterial , Gram-Negative Bacterial Infections , Wound Infection/microbiology , Adult , Anti-Bacterial Agents , Cornea/pathology , Corneal Ulcer/drug therapy , Corneal Ulcer/pathology , Drug Therapy, Combination/administration & dosage , Drug Therapy, Combination/therapeutic use , Eye Infections, Bacterial/drug therapy , Eye Infections, Bacterial/etiology , Eye Infections, Bacterial/pathology , Eye Injuries/complications , Eye Injuries/pathology , Gram-Negative Bacterial Infections/drug therapy , Gram-Negative Bacterial Infections/etiology , Gram-Negative Bacterial Infections/pathology , Humans , Male , Ophthalmic Solutions , Recurrence , Time Factors , Visual Acuity , Wound Infection/drug therapy , Wound Infection/pathologyABSTRACT
A 48-year-old man had simultaneous bilateral photorefractive keratectomy (PRK). The surgeon who performed the PRK did not see the patient in follow-up, and there was confusion regarding the comanaging doctor. Therefore, the patient was not examined immediately postoperatively. Several days later, he was hospitalized for an unrelated, painful orthopedic problem and heavily sedated. Seven days after the PRK, an ophthalmologist was consulted for ocular irritation and discharge. Examination showed bilateral, purulent conjunctivitis and severe infectious keratitis in the left eye. The patient was treated with periocular and topical antibiotics. Corneal cultures yielded Staphylococcus aureus. The keratitis resolved slowly, leaving the patient with hand motion visual acuity. A corneal transplant and cataract extraction was performed 15 months later, resulting in a best corrected visual acuity of 20/400 because of glaucomatous optic nerve damage. Severe infectious keratitis may occur after PRK. Poor communication between the surgeon, comanaging doctor, and patient may result in treatment delay.
Subject(s)
Corneal Ulcer/microbiology , Eye Infections, Bacterial , Photorefractive Keratectomy/adverse effects , Staphylococcal Infections , Staphylococcus aureus/isolation & purification , Surgical Wound Infection/microbiology , Anti-Bacterial Agents , Cataract Extraction , Conjunctivitis, Bacterial/microbiology , Conjunctivitis, Bacterial/pathology , Conjunctivitis, Bacterial/therapy , Cornea/microbiology , Cornea/pathology , Cornea/surgery , Corneal Transplantation , Corneal Ulcer/pathology , Corneal Ulcer/therapy , Drug Therapy, Combination/administration & dosage , Eye Infections, Bacterial/microbiology , Eye Infections, Bacterial/pathology , Eye Infections, Bacterial/therapy , Humans , Lasers, Excimer , Male , Middle Aged , Ophthalmic Solutions , Staphylococcal Infections/microbiology , Staphylococcal Infections/pathology , Staphylococcal Infections/therapy , Surgical Wound Infection/pathology , Surgical Wound Infection/therapy , Visual AcuityABSTRACT
PURPOSE: To compare the clinical characteristics of early- versus late-onset keratitis after radial keratotomy (RK) and astigmatic keratotomy (AK). SETTING: Referral subspecialty practice. METHODS: This retrospective review comprised 19 patients with infectious keratitis after RK and AK. Early- versus late-onset groups were analyzed for predisposing conditions; infiltrate location, size, and depth; microbiologic data; and final visual outcome. RESULTS: Ten patients in the early-onset group developed keratitis within a mean of 7.4 days after surgery (range 3 to 14 days). Nine patients in the late-onset group developed keratitis a mean of 5.4 years after surgery (range 1.5 to 15.0 years). Staphylococcus aureus was the predominant organism in the early-onset group and Pseudomonas aeruginosa in the late-onset group. In the early-onset group, most infiltrates occurred in the paracentral aspect of the RK incision and extended to the middle or posterior stroma. In the late-onset group, most infiltrates occurred in the peripheral portion of the RK incision and were localized to the superficial stroma. A hypopyon was present in 7 of 10 ulcers in the early group and in 1 of 9 in the late group. Two patients in the early group developed endophthalmitis. Most patients in the late-onset group had incisional pseudocysts; 2 had other risk factors for keratitis. Final visual acuity was 20/40 or better in 7 of 10 patients in the early group and in 8 of 9 patients in the late group. CONCLUSIONS: Early-onset corneal ulcers after incisional refractive keratotomy were usually paracentral and deep, whereas late-onset ulcers were usually peripheral and superficial. Despite the predominance of Staphylococcus and Pseudomonas in the early- and late-onset groups, respectively, a variety of organisms may be responsible for infections in keratotomy incisions.
Subject(s)
Astigmatism/surgery , Corneal Ulcer/microbiology , Eye Infections, Bacterial , Keratotomy, Radial/adverse effects , Pseudomonas Infections , Staphylococcal Infections , Adult , Aged , Cornea/microbiology , Cornea/pathology , Cornea/surgery , Corneal Ulcer/pathology , Eye Infections, Bacterial/etiology , Eye Infections, Bacterial/pathology , Humans , Middle Aged , Pseudomonas Infections/etiology , Pseudomonas Infections/pathology , Pseudomonas aeruginosa/isolation & purification , Referral and Consultation , Retrospective Studies , Staphylococcal Infections/etiology , Staphylococcal Infections/pathology , Staphylococcus aureus/isolation & purification , Visual AcuityABSTRACT
A 45-year-old man developed endophthalmitis after a radial keratotomy (RK) enhancement. He developed severe intraocular inflammation, hypopyon, and dense vitreous membranes 4 days after the enhancement surgery. Cultures of the corneal wound yielded a heavy growth of Streptococcus viridans. The inflammation subsided after treatment with intraocular, intravenous, and topical antibiotics. The patient subsequently developed a cataract and retinal detachment. This case demonstrates the risk of endophthalmitis after RK enhancement.
Subject(s)
Endophthalmitis/microbiology , Eye Infections, Bacterial/etiology , Keratotomy, Radial/adverse effects , Streptococcal Infections/etiology , Anterior Chamber/microbiology , Anterior Chamber/pathology , Anterior Chamber/surgery , Anti-Bacterial Agents , Astigmatism/surgery , Cataract/etiology , Drug Administration Routes , Drug Therapy, Combination/administration & dosage , Drug Therapy, Combination/therapeutic use , Endophthalmitis/drug therapy , Endophthalmitis/pathology , Eye Infections, Bacterial/drug therapy , Eye Infections, Bacterial/pathology , Humans , Male , Middle Aged , Retinal Detachment/etiology , Streptococcal Infections/drug therapy , Streptococcal Infections/pathology , Streptococcus/isolation & purification , Surgical Wound Infection/drug therapy , Surgical Wound Infection/etiology , Surgical Wound Infection/pathologyABSTRACT
PURPOSE/METHODS: A case of severe Aspergillus keratitis after radial keratotomy manifested as a discrete midstromal infiltrate along a radial incision. Despite aggressive treatment with topical amphotericin B and oral itraconazole, the patient required a therapeutic penetrating keratoplasty. RESULTS/CONCLUSIONS: Histopathologic examination disclosed a corneal ulcer with numerous septate, branching hyphae throughout the stroma, and marked stromal necrosis. Aspergillus species should be included among the microbial pathogens responsible for infectious keratitis after radial keratotomy. If infectious keratitis is suspected, comprehensive cultures for bacteria and fungi should be obtained.
Subject(s)
Aspergillosis/etiology , Aspergillus fumigatus/isolation & purification , Corneal Ulcer/microbiology , Eye Infections, Fungal/etiology , Keratotomy, Radial/adverse effects , Amphotericin B/therapeutic use , Aspergillosis/pathology , Aspergillosis/therapy , Cornea/microbiology , Cornea/pathology , Corneal Ulcer/pathology , Corneal Ulcer/therapy , Eye Infections, Fungal/pathology , Eye Infections, Fungal/therapy , Female , Humans , Itraconazole/therapeutic use , Keratoplasty, Penetrating , Microbial Sensitivity Tests , Middle AgedABSTRACT
We report two unusual causes of giant papillary conjunctivitis (GPC). One patient developed GPC secondary to and elevated filtering bleb. Another patient developed focal GPC secondary to elevated calcific plaques (band keratopathy). The first patient's symptoms improved after treatment with sodium cromolyn drops. GPC resolved in the second patient after superficial keratectomy was performed. These cases represent two unusual causes of GPC and emphasize the role of mechanical trauma as a causative factor.
Subject(s)
Conjunctivitis, Allergic/etiology , Adult , Aged , Calcinosis/complications , Calcinosis/surgery , Conjunctivitis, Allergic/drug therapy , Corneal Diseases/complications , Corneal Diseases/surgery , Cromolyn Sodium/therapeutic use , Glaucoma/surgery , Humans , Male , Ophthalmic Solutions/therapeutic use , Trabeculectomy/adverse effectsABSTRACT
We reviewed the charts of 114 consecutive patients who underwent penetrating keratoplasty with transscleral fixation of a posterior chamber intraocular lens. Two patients died within three months of follow-up and were excluded from the study. In the remaining 112 patients, follow-up ranged from four to 47 months (mean, 17.2 months). Postoperative visual acuity improved in 95 patients (85%), remained the same in 13 patients (11.5%), and worsened in four patients (3.5%). In 71 patients with at least one year of follow-up, best-corrected visual acuity was 20/40 or better in 17 patients (24%), 20/50 to 20/80 in 25 patients (35%), 20/100 to 20/400 in 17 patients (24%), and counting fingers or worse in 12 patients (17%). Problems with lens decentration, tilt, dislocation, or scleral suture-related infections were minimal. Glaucoma and cystoid macular edema were the most common causes of decreased visual acuity. Four patients (3.6%) developed intraoperative choroidal detachments. Three patients (2.7%) developed rhegmatogenous retinal detachments early in the postoperative course.
Subject(s)
Keratoplasty, Penetrating , Lenses, Intraocular , Sclera/surgery , Suture Techniques , Adult , Aged , Aged, 80 and over , Cataract Extraction , Eyeglasses , Female , Follow-Up Studies , Humans , Male , Middle Aged , Postoperative Complications , Visual AcuityABSTRACT
We report a case of diphtheroid keratitis that occurred in a compromised cornea. Corneal cultures yielded heavy growth of Corynebacterium striatus on blood and chocolate agar. The infection responded slowly to treatment with topical fortified cefazolin and fortified tobramycin. This case demonstrates that diphtheroids are capable of causing ocular infections and should not routinely be dismissed as contaminants or commensals.
Subject(s)
Corynebacterium Infections , Eye Infections, Bacterial/microbiology , Keratitis/microbiology , Aged , Aged, 80 and over , Cefazolin/administration & dosage , Cefazolin/therapeutic use , Corynebacterium/drug effects , Corynebacterium/isolation & purification , Corynebacterium Infections/drug therapy , Drug Therapy, Combination , Eye Infections, Bacterial/drug therapy , Female , Humans , Keratitis/drug therapy , Tobramycin/administration & dosage , Tobramycin/therapeutic useABSTRACT
Two patients developed Acanthamoeba keratitis associated with the use of disposable extended-wear hydrogel contact lenses. Both patients removed, irrigated, and reinserted the contact lenses without disinfecting them. One patient wore the lenses on a daily basis, rinsed the lenses in tap water, stored them overnight, and discarded them weekly. Both infections were treated successfully. In a third patient, Acanthamoeba species was cultured from two pairs of disposable lenses that had been stored in cases rinsed with well water. Potential benefits from disposable contact lens wear are negated when patients do not comply with a continuous wearing schedule.
Subject(s)
Amebiasis , Contact Lenses/adverse effects , Disposable Equipment , Keratitis/etiology , Adolescent , Corneal Opacity/etiology , Corneal Opacity/therapy , Corneal Transplantation , Disinfection , Female , Humans , Keratitis/drug therapy , Middle Aged , Therapeutic IrrigationABSTRACT
We retrospectively reviewed the charts of 56 consecutive patients who had undergone penetrating keratoplasty with transscleral fixation of a posterior chamber intraocular lens. Follow-up ranged from 3 to 28 months (mean, 11.1 months). Postoperative visual acuity improved in 46 patients (82%), remained the same in eight (14%), and worsened in two (3.6%). In 32 patients with at least 10 months' follow-up, best corrected visual acuity as measured with a pinhole or hard contact lens was 20/40 or better in 12 (38%), 20/50 to 20/10 in 10 (31%), and 20/200 or worse in 10 (31%). Problems with lens decentration, tilt, or scleral suture-related infections were minimal. Glaucoma was the msot common cause of decreased vision in patients with 10 or more months' follow-up. Three patients (5.4%) developed rhegmatogenous retinal detachments early in the postoperative course.
Subject(s)
Keratoplasty, Penetrating/adverse effects , Lenses, Intraocular/adverse effects , Sclera/surgery , Adult , Aged , Aged, 80 and over , Corneal Diseases/complications , Corneal Diseases/surgery , Female , Follow-Up Studies , Glaucoma/etiology , Humans , Male , Middle Aged , Prognosis , Retinal Detachment/etiology , Retrospective Studies , Surgical Procedures, Operative/methods , Visual AcuityABSTRACT
Topical ocular anesthetic abuse is a serious disorder causing keratitis and persistent epithelial defects. It may be the result of either prescription by the patient's eye care practitioner, theft from the practitioner's office, or occult additives in therapeutic medications. The authors report observations of six individuals suffering from this disorder which suggest that persistent epithelial defects, corneal stromal ring infiltrates, disproportionate pain, and prescription or nonprescription substance abuse may be factors involved. Penetrating keratoplasty was required to treat corneal perforation in two patients, and permanent corneal structural damage was noted in two eyes. Two eyes had a relentless downhill course culminating in enucleation. Because five of the six patients were diagnosed and treated as having presumed Acanthamoeba keratitis during the course of their disease, topical ocular anesthetic use should be included in the differential diagnosis of chronic keratitis and may masquerade as Acanthamoeba keratitis. The authors believe that practitioners should not prescribe or dispense topical anesthetics and should avoid clinical settings which provide an opportunity for the theft of topical ocular anesthetics.
Subject(s)
Anesthetics, Local/adverse effects , Corneal Diseases/chemically induced , Substance-Related Disorders/complications , Acanthamoeba Keratitis/diagnosis , Acanthamoeba Keratitis/drug therapy , Administration, Topical , Adult , Anti-Bacterial Agents/therapeutic use , Eye Enucleation , Female , Humans , Keratoplasty, Penetrating , Male , Ophthalmic Solutions , Substance-Related Disorders/psychologyABSTRACT
We report a patient who developed severe intraocular fibrin formation following penetrating keratoplasty and vitrectomy surgery. The fibrin response worsened despite aggressive treatment with topical steroids. On the second postoperative day, 25 micrograms of intracameral tissue plasminogen activator was administered, resulting in rapid resolution of the fibrin response. The graft remained clear. We believe tissue plasminogen activator may be useful in selected cases of severe, recalcitrant postkeratoplasy fibrin formation.
Subject(s)
Eye Diseases/etiology , Keratoplasty, Penetrating/adverse effects , Tissue Plasminogen Activator/therapeutic use , Vitrectomy/adverse effects , Eye Diseases/drug therapy , Female , Fibrin/metabolism , Fibrosis , Humans , Middle AgedABSTRACT
We report a case of Listeria monocytogenes endophthalmitis that presented as a recalcitrant keratouveitis in a nonimmunocompromized patient. L. monocytogenes was recovered from the patient's aqueous, vitreous, and two of three blood cultures. He was treated with topical, subconjunctival, and systemic antibiotics, but the visual outcome was poor, possibly because of late diagnosis. A review of previous cases of L. monocytogenes endophthalmitis demonstrates unique features of this infection: (a) presentation as an anterior uveitis or keratouveitis with elevated intraocular pressure, (b) endogenous origin, and (c) frequent occurrence in nonimmunocompromized patients.
Subject(s)
Endophthalmitis/diagnosis , Eye Infections, Bacterial/diagnosis , Keratitis/diagnosis , Listeriosis/diagnosis , Uveitis/diagnosis , Aged , Ampicillin/therapeutic use , Cefazolin/therapeutic use , Drug Therapy, Combination , Endophthalmitis/drug therapy , Eye Infections, Bacterial/drug therapy , Humans , Keratitis/complications , Keratitis/drug therapy , Listeriosis/drug therapy , Male , Uveitis/complications , Uveitis/drug therapy , Visual AcuityABSTRACT
We studied three cases of Capnocytophaga keratitis that demonstrated stromal necrosis and a ring infiltrate. In all cases, the keratitis occurred in a previously diseased or traumatized cornea. One patient was treated with chronic antiamoebic therapy for presumed Acanthamoeba keratitis. Two cases resulted in corneal perforation. Laboratory isolation was difficult because of slow, fastidious growth. Capnocytophaga is not uniformly sensitive to commonly used topical antibiotics such as the cephalosporins and aminoglycosides, but may respond to treatment with topical clindamycin.
Subject(s)
Bacterial Infections , Keratitis/etiology , Adult , Aged , Aged, 80 and over , Capnocytophaga , Corneal Diseases/surgery , Eye Injuries/complications , Female , Humans , Keratitis/chemically induced , Keratitis/pathology , Male , Necrosis , Postoperative Complications , Solvents/adverse effects , Wounds, Nonpenetrating/complicationsABSTRACT
Six patients with various forms of retinitis pigmentosa who were misdiagnosed as having neurologic disease are presented. In five of the patients, visual field defects were misinterpreted as being secondary to a neurologic rather than a retinal problem. In two patients, optic nerve drusen, which accompanied the retinal degeneration, were mistaken for papilledema. Since the diagnosis of retinitis pigmentosa is not always obvious on ophthalmoscopy, the clinician must be aware of the various manifestations of this disorder and be able to distinguish visual field defects on a retinal from a neurologic basis.
Subject(s)
Retinitis Pigmentosa/diagnosis , Adolescent , Adult , Brain Diseases/diagnosis , Diagnosis, Differential , Female , Humans , Male , Middle Aged , Retinitis Pigmentosa/genetics , Visual FieldsABSTRACT
Clinical and laboratory findings of 47 patients with ocular infections secondary to Neisseria gonorrhoeae during a 5 1/2-year period were reviewed. In 16 patients (34%), corneal involvement was noted. Six of these patients had a severe ulcerative keratitis resulting in permanent visual loss and five required surgery for a corneal perforation. Patients with corneal involvement were older and presented later in the course of their disease than patients with isolated conjunctival involvement (P less than 0.005). An out-patient regimen of intramuscular antibiotics (either penicillin, cephalosporin, or spectinomycin [Trobicin]) appeared to be effective for infections limited to the conjunctiva in adults. If a topical antibiotic ointment is used in addition to parenteral antimicrobial agents, the authors' laboratory sensitivities suggest that erythromycin may be the drug of choice.
Subject(s)
Gonorrhea/complications , Keratoconjunctivitis/etiology , Acute Disease , Adolescent , Adult , Child , Child, Preschool , Conjunctiva/pathology , Cornea/pathology , Gonorrhea/pathology , Gonorrhea/therapy , Humans , Infant , Infant, Newborn , Keratoconjunctivitis/pathology , Keratoconjunctivitis/therapy , Male , Middle AgedABSTRACT
Branhamella catarrhalis, formerly known as Neisseria catarrhalis, has structural similarities to Neisseria gonorrhoeae, but is generally considered to be nonpathogenic. We studied the clinical and laboratory data of four previously reported cases and six additional cases of B. catarrhalis keratitis. All patients had a predisposing ocular or systemic condition, or both. There were various clinical characteristics, but in most cases the infiltrate occurred in the central or paracentral cornea. A prompt response to treatment with a cephalosporin and aminoglycoside antibiotic was noted in all cases. Two patients had corneal perforations, which probably resulted from a delay in treatment. Gram-negative diplococci from corneal scrapings may not necessarily represent N. gonorrhoeae.