The Current State in the Diagnosis of Eyelid Margin Disease: A Clinical Review.

The eyelid margin is vital to ocular surface integrity. Much peer-reviewed literature has been established in eyelid margin inflammation, better known as blepharitis. The purpose is to review and understand the impact of eyelid margin disease. Anterior blepharitis causes inflammation at the eyelash base, ciliary follicles, and the palpebral skin. Posterior blepharitis occurs when there is inflammation with the posterior eyelid margin disease. In common usage, the term "blepharitis" used alone almost always refers to anterior blepharitis. Classification of eyelid margin disease should be based on etiopathogenesis, location, primary vs. secondary, and chronicity. Blepharitis has several etiopathologies (infectious, inflammatory, squamous). MGD can refer to the functional and/or structural problems with the MG. Meibomitis (or meibomianitis) occurs when there is inflammation associated with the MGD. The presence of blepharitis and/or MGD (with or without inflammation) can impact the ocular surface and thereby affect anterior segment and cataract surgeries. This review article evaluates the differential diagnoses of eyelid margin disease, including various forms of blepharitis, MGD, and meibomitis.

EYELID MARGIN DISEASE (BLEPHARITIS AND MEIBOMIAN GLAND DYSFUNCTION): CLINICAL REVIEW OF EVIDENCE-BASED AND EMERGING TREATMENTS.

ABSTRACT: Blepharitis is a common ophthalmic condition with multiple etiologies and no definitive, universal treatment. The treatment modalities for managing lid margin diseases vary depending on the disease's cause, location, and severity. For anterior blepharitis, management options include eyelid hygiene with warm compresses, eyelid scrubs, baby shampoo, and over-the-counter eyelid cleansers. Topical antibiotics and antibiotic-steroid combination drops/ointments for the eye and eyelid may accompany these. For posterior blepharitis/meibomian gland dysfunction (MGD), at-home warm compress or in-office administration of heat therapy/thermal pulsation treatment that aims to clear obstruction in the meibomian glands and restore meibum secretions to maintain a healthy tear film, are recommended. In addition to the above treatment strategies, various other compounds to manage lid margin diseases are in the late stages of development. This review summarizes the available treatment modalities or those in the pipeline for treating blepharitis and MGD.

Common Microbes and Antibiotic Resistance in Ocular Infections at an Urban Public Tertiary Care Hospital.

PURPOSE: We aim to describe ocular infection epidemiology for a public tertiary care hospital in New York City (NYC). METHODS: We retrospectively reviewed 558 patients with ocular isolates from conjunctival, corneal, and intraocular culture from 2009 to 2017 for microbial growth and antimicrobial sensitivities. RESULTS: In total, 185 ocular cultures (33%) had growth and the most commonly isolated microbes overall were Staphylococcus aureus (S. aureus) (23%), coagulase-negative Staphylococcus (CoNS) (23%), Pseudomonas aeruginosa (P. aeruginosa) (16%), and Streptococcus viridans (S. viridans) group (11%). The most common microbes within corneal (n = 61), conjunctival (n = 34), and intraocular isolates (n = 9) were P. aeruginosa (37.7%), S. aureus (35.3%), and S. viridans group (33.3%), respectively. Proportion of isolates exhibiting multi-drug resistance decreased over time (P = .006). CONCLUSIONS: The microbial epidemiology of ocular infection of a public NYC hospital was distinct from other geographic locations, underscoring the importance of examining local profiles to more precisely inform empiric therapy.

Conjunctival Exophytic Schneiderian-type Papillomas: A Rare Occurrence.

Conjunctival papillomas are common tumors that exhibit an exophytic growth pattern, comprised of multiple filiform fronds of squamous epithelium that contain fibrovascular cores. The inverted (endophytic) variety of papilloma, often termed "Schneiderian," rarely occurs on the conjunctiva, with only 15 cases reported to date. Endophytic and exophytic papillomas are well described arising in the sinonasal Schneiderian epithelium where a low rate of malignant transformation may occur in the endophytic type; malignant transformation in exophytic sinonasal papillomas is exceedingly rare. The authors describe 2 cases of exophytic conjunctival papillomas with the morphology of a sinonasal or Schneiderian-type papilloma. Both were pink, sessile acquired growths in women in the sixth decade of life involving the inferior conjunctival fornix or nasal limbus. Nonkeratinizing squamous epithelium along with numerous goblet cells, intraepithelial mucinous cysts, and microabscesses were present. Immunohistochemistry showed reactivity for cytokeratin 7 and wild-type staining for p16 and p53, paralleling the findings in common conjunctival papillomas; both were also driven by low-risk human papillomavirus.

Epibulbar Subconjunctival Apocrine Hidrocystoma.

Apocrine hidrocystomas are benign cystic tumors derived from apocrine sweat glands; they are most commonly located in the skin of the head and neck regions. Ophthalmic occurrences characteristically appear at the lash line and canthi of the eyelid, although rare instances have been described in the conjunctiva, caruncle, and orbit. The authors describe an exceptional instance of a mobile epibulbar subconjunctival apocrine hidrocystoma in a 57-year-old woman without a history of previous ocular injury or surgery. Histopathology of the excised specimen displayed an empty cyst lined by a double layer of cuboidal epithelium with the inner layer exhibiting periodic acid-Schiff-positive apical decapitation secretion. Confirmatory immunohistochemistry included reactivity with cytokeratin-7, smooth muscle actin, D2-40, and CDGFP-15.

Longitudinal changes in the macula and optic nerve in familial dysautonomia.

OBJECTIVE: Familial Dysautonomia (FD) disease, lacks a useful biomarker for clinical monitoring. In this longitudinal study we characterized the structural changes in the macula, peripapillary and the optic nerve head (ONH) regions in subjects with FD. METHODS: Data was consecutively collected from subjects attending the FD clinic between 2012 and 2019. All subjects were imaged with spectral-domain Optical Coherence Tomography (OCT). Global and sectoral measurements of mean retinal nerve fiber layer (RNFL) and macular ganglion cell and inner plexiform layer (GCIPL) thickness, and ONH parameters of rim area, average cup-to-disc (C:D) ratio, and cup volume were used for the analysis. The best fit models (linear, quadratic and broken stick linear model) were used to describe the longitudinal change in each of the parameters. RESULTS: 91 subjects (149 eyes) with FD of ages 5-56 years were included in the analysis. The rate of change for average RNFL and average GCIPL thicknesses were significant before reaching a plateau at the age of 26.2 for RNFL and 24.8 for GCIPL (- 0.861 µm/year (95% CI - 1.026, - 0.693) and - 0.553 µm/year (95% CI - 0.645, - 0.461), respectively). Significant linear rate of progression was noted for all ONH parameters, except for a subset of subjects (24%), with no cupping that did not show progression in any of the ONH parameters. CONCLUSIONS: The rapidly declining RNFL and GCIPL can explain the progressive visual impairment previously reported in these subjects. Among all structural parameters, ONH parameters might be most suitable for longitudinal follow-up, in eyes with a measurable cup.

Corneal Expression of SLURP-1 by Age, Sex, Genetic Strain, and Ocular Surface Health.

PURPOSE: Although secreted Ly6/urokinase-type plasminogen activator receptor-related protein-1 (Slurp1) transcript is highly abundant in the mouse cornea, corresponding protein expression remains uncharacterized. Also, SLURP1 was undetected in previous tear proteomics studies, resulting in ambiguity about its baseline levels. Here, we examine mouse corneal Slurp1 expression in different sexes, age groups, strains, and health conditions, and quantify SLURP1 in human tears from healthy or inflamed ocular surfaces. METHODS: Expression of Slurp1 in embryonic day-13 (E13), E16, postnatal day-1 (PN1), PN10, PN20, and PN70 Balb/C, FVBN, C57Bl/6, and DBA/2J mouse corneas, Klf4Δ/ΔCE corneas with corneal epithelial-specific ablation of Klf4, migrating cells in wild-type corneal epithelial wound edge, and in corneas exposed to pathogen-associated molecular patterns (PAMPs) poly(I:C), zymosan-A, or Pam3Csk4 was examined by QPCR, immunoblots, and immunofluorescent staining. Human SLURP1 levels were quantified by ELISA in tears from 34 men and women aged 18 to 80 years. RESULTS: Expression of Slurp1, comparable in different strains and sexes, was low in E13, E16, PN1, and PN10 mouse corneas, and increased rapidly after eyelid opening in a Klf4-dependent manner. We found Slurp1 was downregulated in corneas exposed to PAMPs, and in migrating cells at the wound edge. Human SLURP1 expression, comparable in different sexes and age groups, was significantly decreased in tears from inflamed ocular surfaces (0.34%) than those from healthy individuals (0.77%). CONCLUSIONS: These data describe the influence of age, sex, genetic background, and ocular surface health on mouse corneal expression of Slurp1, establish the baseline for human tear SLURP1 expression, and identify SLURP1 as a useful diagnostic and/or therapeutic target for inflammatory ocular surface disorders.

Antibiotic Resistance in the Treatment of Staphylococcus aureus Keratitis: a 20-Year Review.

PURPOSE: We compared the resistance patterns of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible Staphylococcus aureus (MSSA) keratitis isolates with the common topically applied ophthalmic antimicrobials. METHODS: We reviewed the antibiotic susceptibility results of 122 MRSA and 276 MSSA keratitis isolates from January 1993 to November 2012. In vitro susceptibility testing of each Staphylococcus aureus (SA) isolate was performed using Kirby-Bauer disk diffusion based on modified serum interpretations for cefoxitin, bacitracin, cefazolin, ciprofloxacin, gatifloxacin, gentamicin, moxifloxacin, ofloxacin, polymyxin B, sulfamethoxazole, tobramycin, and trimethoprim. RESULTS: MRSA represented 30.7% (122 of 398) of the total SA isolates. All the SA isolates were susceptible to vancomycin, whereas they were less susceptible to the fluoroquinolones than to the non-fluoroquinolones. In comparison with MSSA, MRSA was significantly more resistant to all the antibiotics tested other than polymyxin B (both equally resistant) and vancomycin (both equally susceptible) (P < 0.001). Besides vancomycin, MRSA demonstrated the best susceptibilities to sulfamethoxazole (94.3%), bacitracin (89.3%), trimethoprim (88.5%), and gentamicin (86.1%). Additionally, MRSA was found to be significantly more resistant to the second-generation fluoroquinolones (ciprofloxacin and ofloxacin) than to the fourth-generation fluoroquinolones (moxifloxacin and gatifloxacin). An increase in resistance to the fourth-generation fluoroquinolones was detected for both MRSA and MSSA over the study period. CONCLUSIONS: The in vitro susceptibilities of commonly used topical antibiotics differ for MRSA and MSSA isolates; thus, successful treatment of bacterial keratitis should be supported with laboratory studies. Vancomycin remains the treatment of choice for MRSA keratitis. The empiric use of second-generation fluoroquinolones seems to be contraindicated in the treatment of MRSA keratitis.

The verification of nucleic acid amplification testing (Gen-Probe Aptima Assay) for chlamydia trachomatis from ocular samples.

OBJECTIVE: Chlamydia trachomatis conjunctivitis may present with extended symptoms, and it can have social ramifications as a sexually transmitted disease. For appropriate therapy, C. trachomatis conjunctivitis should be diagnosed definitively. This study presents the verification of nucleic acid amplification testing (NAAT; Gen-Probe Aptima Combo 2 assay) for detection of C. trachomatis ribosomal RNA (rRNA) from direct ocular samples. DESIGN: Retrospective laboratory verification study. SUBJECTS: Patients with infectious conjunctivitis. METHODS: A battery of 25 true-positive specimens (direct ocular specimens from patients with symptoms consistent with C. trachomatis conjunctivitis and with previously demonstrated positive polymerase chain reaction [PCR] results for C. trachomatis DNA by Roche Amplicor) and 25 true-negative specimens (direct ocular specimens with culture-positive results for herpes simplex virus [n = 5], adenovirus [n = 5], Haemophilus influenzae [n = 5], and Streptococcus pneumoniae [n = 5]), and transport medium (n = 5) were tested for C. trachomatis rRNA by NAAT. These true-negative specimens have differential etiologic agents of infectious conjunctivitis. The 25 C. trachomatis specimens with PCR-positive results (obtained May 1994-May 2012) and 20 true-negative infectious ocular specimens (obtained December 2008-August 2013) were collected with soft-tipped applicators and placed in transport medium. All excess specimens were stored at -80°C. All samples were centrifuged at 13,000 rpm for 1 hour at 6°C. For each sample, using the Aptima Unisex collection blue swab, a specimen was collected from the conical apex of the storage tube where a pellet was formed. The Aptima Unisex collection swab was placed in a tube of Aptima swab transport medium for testing. All samples were tested in duplicate. MAIN OUTCOME MEASURES: Detection of C. trachomatis rRNA. RESULTS: Of 25 true-positive samples, 24 (96%) were positive by NAAT, whereas 25 of 25 true-negative samples (100%) showed negative results. The sensitivity, specificity, positive predictive value, negative predictive value, and efficiency were determined to be 96%, 100%, 100%, 96%, and 98%, respectively. CONCLUSIONS: The detection of C. trachomatis in ocular specimens by NAAT was verified for laboratory diagnosis. The test will be evaluated prospectively to determine future test performance precisely.

Acute corneal edema with subsequent thinning and hyperopic shift following selective laser trabeculoplasty.

UNLABELLED: We report 4 cases of acute corneal edema with subsequent thinning and hyperopic shift following routine selective laser trabeculoplasty (SLT) for the treatment of primary open-angle glaucoma. Four women from 3 clinical sites developed acute corneal edema and haze within 2 days of uneventful SLT. In the following weeks to months, all treated corneas thinned to below pre-procedure thicknesses with resultant hyperopic shifts of nearly 2.0 diopters (D) to greater than 6.0 D. All eyes were moderately to highly myopic prior to SLT (spherical equivalent from -5.00 to -12.5 D). The corrected distance visual acuity 6 to 11 months after SLT was within 2 Snellen lines of the pre-procedure acuity in all patients; 2 patients required contact lenses. Corneal edema with subsequent corneal thinning and resultant hyperopic shift is an uncommon but possibly underrecognized complication of SLT, the etiology of which remains unknown but may be associated with moderate to high myopia. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Infectious crystalline keratopathy predominantly affecting the posterior cornea.

A case of infectious crystalline keratopathy that affects mainly the posterior stroma is presented. Crystalline infiltrates presented after multiple epithelial defects and chronic topical steroid use following a penetrating keratoplasty in this patient. His epithelial defects persisted and given the deep location of the crystalline infiltrates, a penetrating keratoplasty was performed again. Slit-lamp photo demonstrates the crystalline plaque. Confocal microscopy also documents the aggregates of crystal-like structures. Histology slides are also presented that show the disruption of the stromal-Descemet interface and the predominance of pathology confined to the posterior stroma which has been documented in the literature as a rare finding.

Contact lens fitting and long-term management for the Boston keratoprosthesis.

OBJECTIVES: To examine the types of contact lenses used as bandage lenses in the postoperative management of patients with Boston type 1 keratoprosthesis (K-Pro). We examined the lens parameters, the number of trial lenses used to achieve successful fit, and lens replacement schedule. The strategies to achieving a successful fit in these complex patients are reviewed. METHODS: This was a single-center, retrospective chart review of patients who had undergone implantation of the Boston keratoprosthesis in 1 or more eyes from January 2006 to December 2011. Patients included male and female subjects aged 18 years or older who had been fit with bandage contact lenses as part of their postoperative management. RESULTS: Twenty-two eyes of 15 patients met the criteria for this review. The age range was 30 to 90 years. There were eight men and seven women. The average number of lenses to achieve a successful fit varied from 1 to 8, with an average of 2.22 trial lenses used per patient. By 6 months after the surgery, 12 K-Pro eyes showed visual acuity of 20/200 or better, with 7 of those eyes attaining better than 20/80 best-corrected Snellen distance acuity. CONCLUSIONS: Our results show that it is often necessary to use custom contact lenses for K-Pro patients. Management of poor tear film quality, protein deposition, inflammation, lens replacement schedule, and antibiotic resistance are related considerations.

Development of a practical complete-kill assay to evaluate anti-Acanthamoeba drugs.

IMPORTANCE: Acanthamoeba keratitis is a debilitating eye disease that requires effective topical drug therapy. Currently, there is no standard in vitro test to evaluate anti-Acanthamoeba drugs. OBJECTIVE: To develop a practical in vitro complete-kill assay to assess anti-Acanthamoeba drugs. DESIGN AND SETTING: Isolates of Acanthamoeba strains (n = 15) evaluated in a clinical laboratory. An in vitro laboratory assay was created to determine whether polyhexamethylene biguanide, 0.02%, chlorhexidine digluconate, 0.02%, hexamidine diisethioonate, 0.1%, and voriconazole, 1.0%, were effective in completely killing 15 different isolates of Acanthamoeba at time points of 24, 48, and 72 hours in comparison with a saline control. Each 0.5-mL volume of drug was inoculated with 0.1 mL of Acanthamoeba cysts (range, 1-3 × 10(6)/mL) (determined with a hemacytometer) and allowed to incubate at 30°C. At the time points listed, 0.05 mL from each treatment group was inoculated onto nonnutrient agar overlaid with Enterobacter aerogenes. The plates were microscopically examined for growth 1 and 2 weeks after inoculation. At 2 weeks, all plates were subcultured onto a fresh medium. At another 7 days, the growth in subculture at each time point was graded "1" for growth and "0" for no growth. MAIN OUTCOMES AND MEASURES: The cumulative grades of 3 time points (range, 0-3) for each drug and isolate were nonparametrically compared to determine differences in growth between the drugs. The "kill" incidence rates over the 3 time points were also compared. RESULTS: In vitro testing determined that antiacanthamoebal efficacy (determined by the median growth grade and the kill incidence rate) was more prominent for hexamidine diisethioonate (median growth grade, 0.0; kill incidence rate, 93% [14 of 15 isolates]) and polyhexamethylene biguanide (median growth grade, 0.0; kill incidence rate, 80% [12 of 15 isolates]) than for chlorhexidine digluconate (median growth grade, 1.0; kill incidence rate, 40% [6 of 15 isolates]), voriconazole (median growth grade, 2.0; kill incidence rate, 13% [2 of 15 isolates]), and saline (median growth grade, 3.0; kill incidence rate, 0% [0 of 15 isolates]). CONCLUSIONS AND RELEVANCE: The complete-kill assay appears to provide separation in the effectiveness of different antiamoebic drug solutions. This assay may be helpful for guiding topical Acanthamoeba therapy and providing a practical method to evaluate and screen new anti-infectives in the treatment of Acanthamoeba keratitis.