Role of in vivo confocal microscopy in the diagnosis of infectious keratitis.

PURPOSE: To investigate the utility of in vivo confocal microscopy (IVCM) in the diagnosis of infectious keratitis (IK). METHODS: Retrospective chart review of 46 patients with a final diagnosis of IK were included in the study. All patients received IVCM corneal imaging using the Heidelberg Retinal Tomography III system. All available scans were randomized and analyzed in a masked fashion. Sensitivity and specificity of IVCM in diagnosing bacterial keratitis (BK), Acanthamoeba keratitis (AK), fungal keratitis (FK), and HSV viral keratitis (VK) were assessed. RESULTS: The pooled sensitivity and specificity of IVCM in identifying atypical IK (AK and FK cases combined) were 85.3% (95% CI 68.2-94.5%) and 100% (95% CI 74.7-100%), respectively. The sensitivity and specificity of IVCM in identifying BK were 66.7% (95% CI 35.4-88.7%) and 89.2% (95% CI 73.4-96.5%), respectively. The sensitivity and specificity of IVCM in identifying VK were 100% (95% CI 46.3-100%) and 93.2% (95% CI 80.3-98.2%). Additionally, IVCM was able to make the correct diagnosis in 8 out of the 11 atypical keratitis cases misdiagnosed clinically. In the AK subgroup, IVCM was more accurate than clinical assessment (16 vs. 11). In the FK subgroup, IVCM were as accurate as clinical assessment, but did correct one misdiagnosed cases by identfying fungal hyphae. CONCLUSION: IVCM is an non-invasive imaging modality that can rapidly and accurately diagnose IK even for experienced corneal specialists. In complex cases of polymicrobial infection, IVCM may guide the correct clinical diagnosis and initiation of the appropriate treatment.

Reduction of Acanthamoeba Cyst Density Associated With Treatment Detected by In Vivo Confocal Microscopy in Acanthamoeba Keratitis.

PURPOSE: Acanthamoeba keratitis (AK) is a severe vision-threatening ocular infection that is frequently a diagnostic challenge. Treatment course is lengthy and often not fully effective. Contact lens wear has been recognized as the prime risk factor for AK. In vivo confocal microscopy (IVCM) is a noninvasive imaging modality that allows direct visualization of potential causative pathogens in real time with an established utility in the diagnosis of AK. In this study, we aim to assess the utility of IVCM in monitoring disease progression in contact lens wearers with culture-confirmed keratitis. METHODS: Fourteen eyes from 11 patients with culture-confirmed AK were included in this retrospective study. IVCM was performed during the patient's initial visit and all follow-up visits. All available confocal sequences were reviewed and graded in a masked fashion. Density of Acanthamoeba cyst infiltration and changes in the cyst density as a percentage of baseline cyst density measured at each patient's initial visit were calculated. A univariate regression analysis was performed to assess the association between treatment and changes in cyst density per month of treatment. RESULTS: Acanthamoeba cysts were identified by IVCM in all of these culture-confirmed cases of keratitis. Mean cyst density in the central cornea at presentation was 99 ± 64.9 cells per square millimeter (range, 38-255/mm). Cyst density in our study population significantly decreased by approximately 5.3% with each month of antiamebic treatment (P = 0.001; R = 0.41). CONCLUSIONS: Reduction in Acanthamoeba cyst density with treatment can be monitored by IVCM, which in turn can be used clinically in prognostication and disease monitoring of AK.

Quantitative Analysis of Depth, Distribution, and Density of Cysts in Acanthamoeba Keratitis Using Confocal Microscopy.

PURPOSE: To quantify the density, distribution, and depth of invasion of cysts in the corneas of eyes with acanthamoeba keratitis (AK) by in vivo confocal microscopy (IVCM) with a novel scanning pattern. METHODS: The medical records of patients with AK evaluated at the Doheny Eye Center UCLA between September 2014 and July 2016 were reviewed retrospectively. Patients with clinically diagnosed AK underwent IVCM at various time points during their clinical course. Five corneal locations were scanned at each time point: the central area and 4 standard points on the peripheral cornea corresponding to temporal, nasal, inferior, and superior locations. The IVCM scans were manually graded to quantify the maximum depth of invasion and density of cysts. RESULTS: Twenty-one eyes of 18 patients with visible cysts on IVCM were included. Mean cyst density at presentation was 214.1 ± 120.2/mm (range: 64-484 cells/mm), and the average cyst depth was 164.3 ± 81.2 µm (range: 17-290 µm). In 17 eyes, the average cyst depth was 139.4 ± 68.6 µm (range: 17-245 µm), mean cyst density was 177.9 ± 99.6/mm, and an average of 1.4 ± 1.3 quadrants was infiltrated at presentation, and reached clinical resolution with medical treatment without surgical intervention. Four eyes that ultimately underwent therapeutic penetrating keratoplasty had cysts in all 4 quadrants and deeper cyst infiltration; the average cyst depth in these corneas was 270.5 ± 17.5 µm (range: 252-290). CONCLUSIONS: Eyes with AK requiring therapeutic keratoplasty were more likely to have a deeper and more diffuse penetration of cysts in the cornea compared with those resolving with medical treatment.

PROSE Treatment in Atypical Ocular Graft-Versus-Host Disease.

PURPOSE: To report a case of persistent epithelial defects in a patient with ocular chronic graft-versus-host disease that required coordinated modulation of systemic immunosuppressive treatment and overnight wear of Prosthetic Replacement of the Ocular Surface Ecosystem (BostonSight PROSE, Needham, MA) devices to achieve ocular surface healing. CASE REPORT: The case of a 38-year-old male patient who presented with a 2-year history of ocular chronic graft-versus-host disease, ocular burning, pain, light sensitivity, and a 3-week history of bilateral corneal epithelial defects is presented. Standard therapies and an initial PROSE treatment utilizing customized scleral lenses were unsuccessful in resolving his ocular complications. A second trial of PROSE treatment involving overnight wear of the devices in combination with increased systemic immunosuppressant therapy ultimately allowed ocular surface healing and improved his discomfort, vision, and quality of life. CONCLUSIONS: Sight-threatening complications of ocular chronic graft-versus-host disease often require a multidisciplinary approach. Persistent corneal epithelial defects may require increased systemic immunosuppression and extension of PROSE treatment to overnight wear.

Use of Prosthetic Replacement of the Ocular Surface Ecosystem Scleral Lenses in Patients with Ocular Chronic Graft-versus-Host Disease.

The purpose of this study was to evaluate the impact of prosthetic replacement of the ocular surface ecosystem (BostonSight PROSE, Boston Foundation for Sight, Needham, MA) treatment, utilizing customized scleral devices, on visual acuity, visual function, and ocular surface changes in patients with ocular chronic graft-versus-host disease (cGVHD). A retrospective analysis was performed on 79 eyes of 40 patients with cGVHD referred to the University of Southern California department of ophthalmology between November 2009 and July 2013 for PROSE treatment. This analysis included an assessment of ocular symptoms and visual function before and after treatment using the Ocular Surface Disease Index (OSDI) survey. Pre- and post-treatment visual acuity and clinical data were also compared. Twenty-eight male patients and 12 female patients were included in this study. The average age was 56.1 years (range, 27 to 74). Of the 79 eyes treated, 71 (90%) showed improved visual acuity with PROSE treatment. Fifty-seven eyes (72%) experienced a 2- or greater line visual acuity improvement and 14 eyes (18%) experienced a 1-line improvement. Average logarithm of the minimal angle of resolution improved from .49 ± .52 to .16 ± .44 (P < .0001), which correlates to a Snellen score improvement of approximately 20/60 to 20/30. Sixty-six of 79 eyes (84%) showed decreased corneal staining after treatment. All 9 eyes presenting with filamentary keratitis and 3 eyes with epithelial defects demonstrated complete healing of the epithelial surface after PROSE fitting. At post-treatment follow-up, 8 patients had died and 3 stopped wearing their devices. Of the remaining 29 patients, average OSDI scores improved from 72.6 ± 20.1 to 21.1 ± 14.9 (P < .0001). PROSE therapy, utilizing customized scleral lenses, can reduce ocular symptoms, improve visual acuity, and improve ocular surface integrity or appearance in patients with ocular cGVHD.

Early surgical debridement in the management of infectious scleritis after pterygium excision.

PURPOSE: The purpose of this study was to report outcomes of infectious scleritis after pterygium surgery, managed with antibiotic therapies and early scleral debridement. METHODS: Retrospective chart review of 13 consecutive cases of infectious scleritis after pterygium excision between 1999 and 2009 was conducted. Collected data included prior medical and surgical history, latency period between pterygium surgery and presentation of infectious scleritis, culture and histopathologic findings, antibiotic regimen, length of hospital stay, visual acuity before and after treatment, and complications. RESULTS: Median follow-up was at 14 months. Twelve patients underwent prompt surgical debridement after infectious scleritis diagnosis (median, 2.5 days). Debridement was delayed in one patient. Median hospital stay was 3 days. Best-corrected visual acuity improved in ten patients, remained stable in one patient, and decreased in two patients following treatment. Complications included scleral thinning requiring scleral patch graft (1/13), glaucoma (3/13), and progression to phthisis bulbi (1/13). No patients required enucleation. CONCLUSIONS: In contrast to the generally poor outcomes in the literature, early surgical debridement of pterygium-associated infectious scleritis appears to offer improved prognosis.

Optical coherence tomography of corneal and scleral melts.

Corneal and scleral melts can be difficult to assess by slit-lamp due to the overlying opacity. The authors demonstrate the role of optical coherence tomography (OCT) in the diagnosis and management of two cases of corneal and scleral melt. A high-speed anterior segment OCT system operating at a 1310-nm wavelength was used. Cross-sectional OCT images showed the depth and extent of the melt. OCT images were obtained through an opaque pannus in one case and through a calcium plaque in the other. OCT images at the follow-up examination revealed a thin fluid space between the amniotic graft and cornea and its subsequent resolution in the first case and the fits of an epicardial graft and a subsequent clear lamellar corneal graft in the second case. OCT images allow physicians to assess melts through opaque media and subsequent graft integration after repair.