Trends and Clinical Outcomes of Fungal Keratitis in Canada: A 20-year Retrospective Multicentre Study.

PURPOSE: An increase in fungal and particularly filamentous keratitis has been observed in many geographic areas, mostly in contact lens wearers. This study seeks to characterize long-term trends in fungal keratitis in a continental climate area to provide guidance for diagnosis and treatment. DESIGN: Retrospective multicentric case series. METHODS: Cases of microbiology-confirmed fungal keratitis from 2003 to 2022 presenting to tertiary care centers across Canada were included. Charts were reviewed for patient demographics, risk factors, visual acuity, and treatments undertaken. RESULTS: A total of 138 patients were identified: 75 had yeast keratitis while 63 had filamentous keratitis. Patients with yeast keratitis had more ocular surface disease (79% vs 28%) while patients with filamentous keratitis wore more refractive contact lenses (78% vs 19%). Candida species accounted for 96% of all yeast identified, while Aspergillus (32%) and Fusarium (26%) were the most common filamentous fungi species. The mean duration of treatment was 81 ± 96 days. Patients with yeast keratitis did not have significantly improved visual acuity with medical treatment (1.8 ± 1 LogMAR to 1.9 ± 1.5 LogMAR, P = .9980), in contrast to patients with filamentous keratitis (1.4 ± 1.2 LogMAR to 1.1 ± 1.3 LogMAR, P = .0093). CONCLUSIONS: Fungal keratitis is increasing in incidence, with contact lenses emerging as one of the leading risk factors. Significant differences in the risk factors and visual outcomes exist between yeast keratitis and filamentous keratitis which may guide diagnosis and treatment.

Perception of Canadian ophthalmologists on immediately sequential bilateral cataract surgery: insights and implications.

OBJECTIVE: To evaluate the perception of immediately sequential bilateral cataract surgery (ISBCS) among Canadian ophthalmologists. DESIGN: An anonymous survey was sent to all active members of the Canadian Ophthalmological Society. METHODS: Basic demographic information, cataract surgery practice patterns, and perceived advantages, disadvantages, and concerns regarding ISBCS were collected from respondents. RESULTS: A total of 352 ophthalmologists answered the survey. Among these, 94 respondents (27%) practice ISBCS routinely, 123 (35%) practice ISBCS in exceptional cases, and 131 (37%) do not practice ISBCS. ISBCS practitioners were significantly younger than nonpractitioners (p < 0.001) and had a shorter duration of practice (p < 0.001). The prevalence of ISBCS practitioners also varied significantly by province (p < 0.001): most practitioners who routinely practice ISBCS were from Quebec (n = 44; 48%), where financial disincentives are lowest in the country. The main work setting of ISBCS practitioners was academic centres (n = 39; 42%) as opposed to private or community settings (p < 0.001). The main reason for performing ISBCS was more efficient operating theatre use (n = 142; 65%). The main concerns regarding ISBCS were the risk of bilateral complications (n = 193; 57%) and the lack of refractive outcomes for second-eye surgery (n = 184; 52%). The COVID-19 pandemic positively influenced the view of 152 respondents (43%), but this was mostly among practitioners who already performed ISBCS routinely (n = 77; 84%). CONCLUSIONS: ISBCS practitioners are more likely younger ophthalmologists working in academic centres. Quebec has the highest prevalence of ISBCS practitioners. ISBCS practitioners were positively influenced by the COVID-19 pandemic to offer ISBCS more often compared with non-ISBCS practitioners.

Intraocular methotrexate for epithelial downgrowth: long-term outcomes in a multicentre case series.

BACKGROUND/AIMS: Sheet-like type of epithelial downgrowth (EDG) is not easily amenable to surgical excision. We describe long-term outcomes in patients with EDG treated with intraocular methotrexate (MTX). METHODS: This is a retrospective, multicentric case series including 10 eyes (nine patients) treated with intraocular MTX for sheet-like EDG. Relevant ocular history, previous EDG treatments, MTX injection regimen, long-term outcomes and complications are reported. RESULTS: All cases were associated with intraocular surgery. Most patients were treated with 400 µm/0.1 mL MTX injections with a starting frequency of two times per week or weekly injections. Mean and SD number of injections per eye was 16±13 injections and duration of follow-up was 54±36 months (range: 7-120 months). Eradication of EDG was achieved in seven eyes of which one required a second MTX treatment course to achieve eradication, while clinical resolution with recurrence was observed in two. One treatment failure occurred despite eight weekly injections which slowed but did not halt EDG progression; the patient later requested that treatments be stopped given difficulty to come to follow-ups. Surface epitheliopathy developed in eight patients and was used to titrate MTX treatment. Six patients also developed endothelial failure. CONCLUSION: We report the largest case series of diffuse, sheet-like EDG treated with intraocular MTX with follow-ups up to 10 years. Intraocular MTX may be used effectively to achieve eradication of EDG in cases where surgery is not amenable. However, further recommendations to guide treatment remain warranted.

Perception of visual outcomes in patients after delayed compared with immediately sequential bilateral cataract surgery.

PURPOSE: To evaluate patient-reported visual outcomes of immediately sequential bilateral cataract surgery (ISBCS) compared with delayed sequential bilateral cataract surgery (DSBCS). SETTING: Tertiary university teaching hospital of Laval University, Quebec City, Canada. DESIGN: Prospective observational cohort study. METHODS: The Catquest-9SF questionnaire was administered on the day of surgery for ISBCS patients and on the day of first-eye surgery for DSBCS patients who underwent cataract surgery between August and September 2021. The questionnaire was administered again 1 month postoperatively for ISBCS patients and 1 month postoperatively after each surgery for DSBCS patients. RESULTS: 186 patients (ISBCS: n = 152 vs DSBCS: n = 34) were included. At 1 month postoperatively, the Catquest-9SF score of ISBCS patients was significantly lower than that of DSBCS patients after first-eye surgery ( P < .001). Furthermore, the ISBCS group achieved significantly better scores on multiple tasks of the Catquest-9SF, such as reading text in the newspaper ( P < .001) or reading text on television ( P < .001). In multiple linear regression analysis, the type of surgery was the factor most associated with a lower Catquest-9SF score (ß = -0.391, P < .001). 1 month after the second-eye surgery, DSBCS patients had achieved similar Catquest-9SF scores compared with ISBCS patients. CONCLUSIONS: Compared with DSBCS patients, ISBCS patients had significantly greater perceived visual function and fewer vision-related limitations in their daily activities at 1 month postoperatively. This difference lost significance 1 month after the second-eye surgery of DSBCS patients. This patient-reported outcome study did not find evidence of perceived bilateral visual impairment in the early postoperative period after ISBCS.

Immediately sequential bilateral cataract surgery: an academic teaching center's experience.

PURPOSE: To evaluate the safety and outcomes of immediately sequential bilateral cataract surgery (ISBCS) at a Canadian academic teaching center. SETTING: Tertiary university teaching hospital of Laval University, Quebec City, Canada. DESIGN: Retrospective cohort study. METHODS: 2003 consecutive patients (4006 eyes) who underwent ISBCS under topical anesthesia from January 2019 to December 2019 were included. All charts were retrospectively reviewed. Outcome measures included intraoperative and postoperative complications, postoperative uncorrected distance (UCVA) and pinhole (PHVA) visual acuities, and autorefraction measurements. RESULTS: 4006 eyes from 1218 (60.8%) female and 785 (39.2%) male patients with a mean age of 74 ± 8 years had a mean preoperative visual acuity of 0.503 logMAR (Snellen 20/63). The mean axial length was 23.53 ± 1.37 mm. Most eyes had monofocal intraocular lenses (IOLs) implanted (n = 3738, 93.3%) followed by toric (n = 226, 5.6%), multifocal (n = 25, 0.6%), and multifocal toric (n = 17, 0.4%) IOLs. Intraoperative complications included 14 (0.3%) posterior capsule ruptures with 5 (0.1%) requiring sulcus IOL placement, and 7 (0.2%) partial zonulysis, with 3 requiring capsular tension rings (0.07%). There were no cases of endophthalmitis or toxic anterior segment syndrome. Mean 5-week postoperative UCVA was 0.223 (Snellen 20/33), PHVA was 0.153 (Snellen 20/28) with a mean spherical equivalent of -0.21 diopters. CONCLUSIONS: ISBCS performed following International Society of Bilateral Cataract Surgeons recommended guidelines is a safe procedure. This cohort of 4006 eyes had very few complications, with none attributable to the surgery being done bilaterally. The UCVA, PHVA, and refractive outcomes were good.

Conjunctival Infiltration in a Child as a Rare Manifestation of IgG4-Related Disease.

PURPOSE: Ocular manifestations of immunoglobulin G4 (IgG4)-related disease are common in children although remain ill-defined because of the disease's rarity. We describe a pediatric case of IgG4-related orbital disease (IgG4-ROD) who presented with persistent conjunctival infiltration before developing lacrimal gland enlargement 3 years later. METHODS: This was a case report. RESULTS: An 8-year-old girl developed forniceal salmon-patch-like conjunctival lesions in her left eye that were refractory to topical corticosteroids. Investigations, including an orbital MRI and 2 conjunctival biopsies, were negative for lymphoma. She was treated with topical corticosteroids and then nonsteroidal antiinflammatory drops. The lesions decreased mildly, and no new lesion emerged. After 3 years, the patient developed a ptosis, new salmon-patch conjunctival lesions, and papillae. Vision deteriorated to 20/80 because of severe punctate epithelial erosions in the left eye, and the Schirmer test was significantly reduced. A repeat MRI revealed an enlarged left lacrimal gland. A biopsy was performed and was compatible with IgG4-ROD. An elevated IgG4 level of 4.61 g/L was also found. The patient was successfully treated with oral prednisone but flared on tapering the dosage. Rituximab was therefore initiated with excellent clinical response, and prednisone was discontinued. Vision returned to 20/20 after aggressive lubrification, punctal plugs, and autologous serum eye drops. Tear function came back to normal, and local treatments were stopped. CONCLUSIONS: This case describes a pediatric case of IgG4-ROD presenting initially with conjunctival follicular reaction, later developing lacrimal gland involvement. Therefore, it is important to consider IgG4-ROD in chronic atypical follicular conjunctival lesions in children, even in the absence of orbital disease.

Intacs with or without same-day corneal collagen cross-linking to treat corneal ectasia.

OBJECTIVE: To compare combined intrastromal corneal ring segment implantation with same-day ultraviolet-A/riboflavin corneal collagen cross-linking (ICRS-CXL) versus ICRS implantation alone in patients with corneal ectasia. DESIGN: Retrospective comparative study. PARTICIPANTS: Sixty-six eyes from 54 patients with corneal ectasia were included in the study. The groups were composed of 32 eyes from 27 patients and 34 eyes from 27 patients for the ICRS-CXL and ICRS groups, respectively. METHODS: We reviewed the charts of all patients who underwent these procedures from November 2008 to February 2011 for preoperative and for up to 1 year postoperative uncorrected (UDVA) and best corrected distance visual acuity (BDVA), refraction, topographical analysis (mean and steepest keratometry [K]), as well as root mean-square (RMS) of higher-order aberrations (HOAs). RESULTS: Overall, a significant improvement was seen in both groups for UDVA, BDVA, sphere, cylinder, mean refractive spherical equivalent (MRSE), mean and steepest K, coma, spherical and total HOA at 12 months. Trefoil did not improve, and higher-order astigmatism worsened in the ICRS group (p = 0.0466). There was no statistically significant difference between the 2 groups for visual acuity, sphere, cylinder, coma, trefoil, and spherical HOA. Outcomes were significantly more improved in the ICRS group for MRSE (p = 0.0082), mean K (p = 0.0021), steepest K (p = 0.0152), and total HOAs (p = 0.0208). No complications were observed. CONCLUSIONS: ICRS-CXL and ICRS alone were both safe and effective in treating corneal ectasia. The ICRS alone group demonstrated better outcomes of MRSE, mean and steepest K, as well as total HOA.

Corneal collagen cross-linking using riboflavin and ultraviolet A for the treatment of mild to moderate keratoconus: 2-year follow-up.

OBJECTIVE: To evaluate the safety and efficacy of corneal ultraviolet A/riboflavin collagen cross-linking (CXL) in patients with mild-to-moderate keratoconus. DESIGN: Retrospective cohort study. PARTICIPANTS: Thirty-nine eyes from 30 patients who underwent CXL for progressive mild and moderate keratoconus were included. METHODS: Clinical charts for keratoconus patients who had undergone CXL alone from November 2008 to February 2011 were reviewed for preoperative and postoperative uncorrected and best corrected distance visual acuity (UDVA and BDVA, respectively), manifest refraction, topographical and Scheimpflug imaging, as well as ultrasound pachymetry and haze. Mean and steepest keratometry, central corneal thickness, and root mean-square from corneal aberrations were extracted from the topography. Central and thinnest corneal thicknesses were extracted from the Scheimpflug imaging RESULTS: A significant improvement in UDVA was seen at 3, 6 and 24 months with an average change in logMAR of 0.39 (p = 0.003) at 24 months compared with baseline. Change in BDVA failed to reach significance, but subgroup analysis showed that a baseline BDVA worse than 0.1 logMAR was associated with better improvement. Stability of refraction, keratometry, and aberrations was demonstrated. Presence of haze was statistically significant up to 12 months (p≤0.001), being maximal at 3 months, then insignificant by 24 months. No complications were observed during the follow-up period. CONCLUSIONS: CXL is a safe and effective stabilizing strategy for progressive mild-to-moderate keratoconus with significant improvement of the UDVA. There was a trend toward improvement of BDVA in patients with lower preoperative BDVA value.

Intracorneal ring segments implantation followed by same-day photorefractive keratectomy and corneal collagen cross-linking in keratoconus.

PURPOSE: To evaluate the efficacy of intrastromal corneal ring segments implantation followed by same-day photorefractive keratectomy (PRK) and ultraviolet-A/riboflavin collagen cross-linking (CXL) in patients with keratoconus. METHODS: Four patients (five eyes) were included in the study. All patients first underwent femtosecond laser-enabled placement of intracorneal ring segments (Intacs, Addition Technology). Uncorrected (UDVA) and corrected distance visual acuity (CDVA) and keratometry readings remained stable for 6 months. Same-day PRK and CXL were subsequently performed in all patients. RESULTS: Six months after Intacs plus PRK/CXL, significant improvements were noted for UDVA, CDVA, spherical equivalent refraction, keratometry, and total aberrations. No patient lost lines of CDVA or developed haze. CONCLUSIONS: The combination of intracorneal ring segments implantation followed by sequential same-day PRK/CXL may be a reasonable option for improving visual acuity in select patients with keratoconus.