Keratoprosthesis prophylaxis: is it time for a paradigm shift?

The Boston Type I Keratoprosthesis has been improving in both design and safety since its inception. Due to particular features inherent in the Boston Type I Keratoprosthesis eye and certain aspects of the ocular surface, special attention is required to maintain these implanted devices. There is currently a prominent role for keratoprosthesis prophylaxis; it is designed to prevent infectious complications like keratitis and endophthalmitis. This standard-of-care therapy has anecdotally been shown to improve outcomes; however, it has not been examined in the setting of controlled clinical trials. Moreover, concerns remain with the chronic utilization of topical antibiotics in that they may engender antibiotic resistance and select for opportunistic populations to establish a foothold on the ocular surface. We believe and introduce the idea that there is merit in exploring other compounds besides antibiotics for prophylaxis such as antiseptics like povidone-iodine. Specifically developed formulations of povidone-iodine may prove useful in both improving keratoprosthesis safety and simultaneously mitigating concerns regarding antibiotic resistance.

Preoperative Diagnostic Angiogram and Endovascular Aortic Stent Placement for Appleby Resection Candidates: A Novel Surgical Technique in the Management of Locally Advanced Pancreatic Cancer.

Background. Pancreatic adenocarcinoma of the body and tail usually presents late and is typically unresectable. The modified Appleby procedure allows resection of pancreatic body carcinoma with celiac axis (CA) invasion. Given that the feasibility of this technique is based on the presence of collateral circulation, it is crucial to confirm the presence of an anatomical and functional collateral system. Methods. We here describe a novel technique used in two patients who were candidates for Appleby resection. We present their clinical scenario, imaging, operative findings, and postoperative course. Results. Both patients had a preoperative angiogram for assessment of anatomical circulation and placement of an endovascular stent to cover the CA. We hypothesize that this new technique allows enhancement of collateral circulation and helps minimize intraoperative blood loss when transecting the CA at its takeoff. Moreover, extra length on the CA margin may be gained, as the artery can be transected at its origin without the need for vascular clamp placement. Conclusion. We propose this novel technique in the preoperative management of patients who are undergoing a modified Appleby procedure. While further experience with this technique is required, we believe that it confers significant advantages to the current standard of care.

The etiology of infectious corneal ulceration in Sierra Leone.

The microbial etiology of infectious corneal ulceration in Sierra Leone has been investigated. Patients either presenting to district health centers or encountered on rural surveillance expeditions with suspected infectious ulcerative keratitis were recruited into the study. Infectious corneal ulceration was defined as clinical evidence of corneal infection with epithelial defect with or without hypopyon. Cultures were obtained in a standard fashion and subsequent microbial analysis performed on all specimens. Seventy-three (73) cases of suspected infectious ulcerative keratitis were obtained between January 2005 and January 2006. The most commonly isolated organisms from microbial cultures of infected eyes were Gram-negative bacteria (45.2%), Gram-positive bacteria (37.0%), and fungal species (35.6%). Mixed bacterial and fungal organisms were isolated from ten eyes (13.7%) and no organisms were isolated from four eyes (5.5%). There is a high incidence of Gram-negative and fungal ulcerative keratitis in the population studied in Sierra Leone. Empirical therapy for corneal ulceration in this region should be aimed towards treatment of bacterial, fungal, and mixed infections.

A combination povidone-iodine 0.4%/dexamethasone 0.1% ophthalmic suspension in the treatment of adenoviral conjunctivitis.

INTRODUCTION: The objective of this pilot study was to determine the preliminary efficacy of a novel ophthalmic suspension containing povidone-iodine 0.4% and dexamethasone 0.1% in the treatment of adenoviral conjunctivitis. METHODS: A prospective, open-label, single-armed, phase II clinical trial in humans. Eligible patients with the clinical signs and symptoms of acute conjunctivitis who tested positive for adenoviral antigen by Rapid Pathogen Screening (RPS) Adeno Detector were enrolled in a single treatment arm consisting of a combination povidone-iodine 0.4%/dexamethasone 0.1% sterile ophthalmic suspension given four times daily for a minimum of 5 days. RPS Adeno Detector testing was performed at baseline and at each follow-up visit along with ocular fluid sampling by conjunctival swabs. Subsequent analysis performed on all swabs included both adenoviral titer by quantitative polymerase chain reaction (qPCR) and cell culture with confirmatory immunofluorescence (CC-IFA). The primary endpoint was clinical resolution of conjunctival injection and discharge. Secondary measures included reduction of qPCR titers and eradication of infectious virus as determined by CC-IFA. RESULTS: A total of nine eyes of six patients with clinical signs and symptoms of acute viral conjunctivitis and a positive RPS Adeno Detector test result were enrolled in the study. In eight/nine eyes enrolled in the study, clinical resolution was observed by day 3 or day 4. In six/six eyes with detectable adenovirus by qPCR, significant reduction in viral titer was seen by day 3, day 4, or day 5. In five/six eyes with infectious virus confirmed by CC-IFA at enrollment, elimination of infectivity was achieved by day 4 or day 5. One patient was lost to followup. CONCLUSIONS: An ophthalmic suspension containing povidone-iodine 0.4% and dexamethasone 0.1% may be a useful agent in the treatment of acute RPS Adeno Detector-positive conjunctivitis. A further placebo-controlled study with a larger number of patients is warranted.

Normal ocular flora in healthy eyes from a rural population in Sierra Leone.

PURPOSE: To identify the normal conjunctival flora in a rural population in Sierra Leone and compare the normal ocular flora of a developing country with that of the developed world. METHODS: Conjunctival swabs obtained from healthy right eyes of 276 residents of Masungbo, Sierra Leone, were analyzed for growth of microorganisms. RESULTS: The most commonly isolated organisms from conjunctival swabs of healthy eyes were coagulase-negative Staphylococcus (28.6%), fungus (26.0%), Staphylococcus aureus (19.9%), Gram negatives other than Pseudomonas/Haemophilus (9.8%), Nocardia/Actinomyces (6.5%), and Pseudomonas aeruginosa (6.2%). CONCLUSIONS: There is a high prevalence of fungal and bacterial colonization of healthy eyes in a rural population of Sierra Leone. A relationship may exist between resident normal flora and the etiology of ocular infections.