Improved Outcome of Pythium Keratitis With a Combined Triple Drug Regimen of Linezolid and Azithromycin.

PURPOSE: To describe the clinical features, microbiological profile, and outcome of a series of cases of Pythium keratitis treated with topical and oral linezolid and topical azithromycin eye drops. METHODS: This was a retrospective interventional case series of microbiologically and/or histopathologically proven cases of Pythium keratitis seen between October 2016 and December 2019. All patients received a combination of topical linezolid and/or azithromycin eye drops with oral linezolid. Analysis of demographic data, predisposing risk factors, microbiological results, treatment regimen, visual acuity, surgical intervention, and final outcome was performed. A subgroup analysis of cases >6 mm in size was performed. Success was defined as complete resolution on medical management. Failure was defined as worsening of infection necessitating therapeutic penetrating keratoplasty or evisceration. RESULTS: Of 21 cases, 2 were lost to follow up, 1 was diagnosed on histopathology, and 1 received only topical linezolid. Characteristic microbiological features were noted on 10% potassium hydroxide calcofluor white wet mount in 20/21 (95.23%) and Gram stain in 18/21 (85.71%). On triple drug regimen, 14/17 cases (82.35%) resolved. Average time to resolution was 87.64 ± 44.44 days. More than 60% infiltrates (13/21) were large, and 66.66% infiltrates resolved in 109.3 ± 57.06 days. Of the 5 failures, 4 needed therapeutic keratoplasty and 1 needed evisceration. All grafts failed. CONCLUSIONS: The dual topical drug regimen with oral linezolid has good cure rates (over 80%) for Pythium keratitis over prolonged duration. It is recommended to persevere with medical therapy even in large infiltrates because more than two thirds resolved.

Chronic cicatrizing conjunctivitis: A review of the differential diagnosis and an algorithmic approach to management.

Cicatrizing conjunctivitis constitutes a group of chronic local and systemic disorders that cause conjunctival scarring. A systematic approach is required to sift through the clinical history, examination, and laboratory investigations of patients to arrive at the correct diagnosis of the underlying cause. Establishing the etiology is critical, as the therapeutic approach changes based on the cause of conjunctival inflammation. Effective management of patients with the condition requires knowledge of multiple modalities such as systemic immunosuppressive therapy, use of scleral contact lenses, and surgery for ocular surface and vision improvement. We review the clinical features of this condition and present diagnostic and treatment algorithms to help simplify the complexities in its management. This review attempts to place all the relevant information on chronic cicatrizing conjunctivitis together in one place for the benefit of cornea and ocular surface specialists, general ophthalmologists, and ophthalmology residents.

Clinical clues predictive of Stevens-Johnson syndrome as the cause of chronic cicatrising conjunctivitis.

PURPOSE: This study aimed to identify the clinical clues in patients with chronic cicatrising conjunctivitis (CCC), that were suggestive of Stevens-Johnson syndrome (SJS) as the aetiology. METHODS: This was a cross-sectional observational study of 75 patients presenting with CCC from 2016 to 2018. Those with a documented diagnosis of SJS (n=43) were included as cases; while those with a positive serology or tissue biopsy for a non-SJS condition were included as controls (n=32). The features in the medical history and clinical examination that were positively and negatively associated with SJS were scored +1 and -1, respectively. A receiver operating characteristic (ROC) curve analysis was performed to detect the threshold score for optimal sensitivity and specificity of the scoring system. RESULTS: No single feature had absolute sensitivity and specify for SJS. The 10 positive features suggestive of SJS (p<0.0001) included (1) history of: acute conjunctivitis, fever or drug intake preceding conjunctivitis, peeling of skin on pressure, loss of nails and severe morbidity with hospital admission; and (2) clinical features of: skin discoloration, nail disfigurement, lip-margin dermalisation, lid-margin keratinisation and distichiasis. The two negative criteria were history of mucosal ulcers without skin involvement and recurrent mucosal ulceration. On ROC analysis, a score of >5 showed a sensitivity of 90.7% and specificity of 93.8% for the diagnosis of SJS. CONCLUSIONS: The combination of clinical clues identified in this study can help clinicians confirm SJS as the aetiology of conjunctival cicatrisation, especially when reliable documentation of the acute episode is not available.

Comparison of Safety and Efficacy of Botox and Neuronox in the Management of Benign Essential Blepharospasm: A Split-face Study.

PURPOSE: To compare the efficacy and safety of Botox and Neuronox in the management of benign essential blepharospasm (BEB). METHODS: We performed a triple-masked, randomized control study to compare Botox and Neuronox in 48 eyes of 24 patients with BEB. All 24 patients randomly received Botox or Neuronox in the periorbital region in a masked, randomized split-face manner, keeping the injection sites and doses uniform. The toxin preparation, injection, and clinical evaluations were done by three independent observers. Objective outcome measures included improvement in the severity of spasm, grading of the functional visual status, changes in palpebral fissure height, lagophthalmos, superficial punctate keratitis and Schirmer's test at 2 weeks, 6 weeks, and upon conclusion of the effect of the toxin. Subjective outcome measures included duration of the effect and a forced choice stating which half of the face was better. Evaluations were performed through clinical measurements, external digital photography, and high-definition videography. RESULTS: The mean duration of relief from spasms was 3.78 months (standard deviation, 1.58 months; range, 1 to 6 months). The improvement in the objective parameters like severity of spasm and functional visual status was statistically significant at the 2-week and 6-week follow-up visits (p < 0.001). The changes in palpebral fissure height, lagophthalmos, and superficial punctate keratitis were equally observed in both groups. At 2 and 6 weeks, three of 24 (12.5%) and one of 24 (4%) patients, respectively, reported an unequal effect between the two sides of the face, but this difference was not statistically significant. At final follow-up (conclusion of the toxin effect), patients reported equal effect with no preference for either hemiface. No statistically significant differences were found in the comparative analysis between the Neuronox and Botox groups. CONCLUSIONS: Neuronox and Botox are comparable in terms of their safety and efficacy in the management of BEB.

Emerging corneal pathogens: First report of Pseudopestalotiopsis theae keratitis.

A 55-year-old lady developed a corneal ring infiltrate following trauma with a wooden stick. 10% KOH mount of corneal scrapings revealed septate hyaline fungal filaments. White feathery colonies with shiny black dots grew on potato dextrose agar. Characteristic features of Pestalotiopsis spores were seen on Lactophenol cotton blue mount. DNA sequencing showed 99% similarity with Pseudopestalotiopsis theae. Complete resolution was noted with topical and oral antifungals. To the best of our knowledge, this is the first report of Pseudopestalotiopsis keratitis following trauma with vegetative matter highlighting the role of DNA sequencing in identification of rare fungi.