Diffuse lamellar keratitis associated with tabletop autoclave biofilms: case series and review.

PURPOSE: To report a diffuse lamellar keratitis (DLK) cluster attributed to autoclave reservoir biofilm and to review the risk and prevention of DLK and toxic anterior segment syndrome (TASS) caused by such biofilms. SETTING: Refractive Surgery Center, University of California, Berkeley. DESIGN: Observational case-control study and review of literature. METHODS: Eyes were evaluated for DLK following laser in situ keratomileusis (LASIK) over a 5-year period. Multiple changes in surgical and operating room protocols were prompted by a cluster of DLK cases. The autoclave reservoir chamber wall was cultured for microbial contamination. The MEDLINE database was used to identify relevant past publications. RESULTS: From January 7, 2010, to December 18, 2014, 1115 eyes received LASIK. Between September 2, 2010, and June 11, 2012, 147 eyes of 395 LASIK cases developed DLK (37.2%). Systematic modifications in surgical protocols were unsuccessful in ending the prolonged cluster of DLK cases until the STATIM 2000 autoclave was replaced with a new STATIM autoclave and a reservoir sterilization and surveillance protocol implemented. Over the subsequent 30 months, DLK incidence was reduced to 2.2% (14 DLK cases from 632 total LASIK cases, P < .0001). The retired autoclave reservoir chamber wall cultures grew Pseudomonas aeruginosa and the Burkholderia cepacia complex. CONCLUSIONS: Fluid reservoirs of tabletop steam autoclaves can readily develop polymicrobial biofilms harboring microbial pathogens, whose inert molecular byproducts can cause DLK and TASS when introduced to the eye by surgical instruments. Stringent reservoir cleaning and maintenance may significantly reduce this risk by preventing and removing these biofilms.

Toxic anterior segment syndrome caused by autoclave reservoir wall biofilms and their residual toxins.

PURPOSE: To identify etiology of toxic anterior segment syndrome (TASS) after uneventful phacoemulsification. SETTING: EyeMD Laser and Surgery Center, Oakland, California. DESIGN: Retrospective case series. METHODS: Patient charts with TASS were reviewed. Reservoirs of 2 autoclaves associated with these cases were cultured for bacterial contamination. Cultures were performed on 23 other autoclave reservoirs at surgery centers in the local area. The main outcome measures were the incidence of TASS and prevalence of bacterial biofilm contamination of autoclave reservoirs. RESULTS: From 2010 to 2013, 11 935 consecutive cataract surgeries were performed at 1 center by multiple surgeons with no reported TASS. Between January 1, 2014, and January 15, 2015, 10 cases of TASS occurred out of 3003 cataract surgeries; these patients' charts were reviewed. Cultures of 2 Statim autoclave reservoir walls grew Bacillus species, Williamsia species, Mycobacterium mucogenicum, and Candida parapsilosis. Scanning electron microscopy of reservoir wall sections showed prominent biofilm. The 2 autoclaves were replaced in January 2015. Subsequently, 2875 cataract surgeries were performed with no reported TASS (P < .001, χ2 test). Eighteen of 23 additional regional autoclaves were also contaminated with bacterial biofilms. CONCLUSIONS: Toxic anterior segment syndrome was strongly associated with bacterial biofilm contamination of autoclave reservoirs. An etiological mechanism might involve transport of heat-stable bacterial cell antigens in the steam with deposition on surgical instrumentation. Data suggest widespread prevalence of bacterial biofilms on fluid-reservoir walls, despite adherence to manufacturer guidelines for cleaning and maintenance. Prevention or elimination of autoclave fluid-reservoir biofilms might reduce the risk for postoperative TASS. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Swept-Source Optical Coherence Tomography and OCT Angiography of Minocycline-Induced Retinal and Systemic Hyperpigmentation.

This is a report of an 80-year-old man with a history of rosacea and rhinophyma treated for 15 years with oral minocycline who developed significant minocycline-induced hyperpigmentation. He also had a history of Fuchs' endothelial dystrophy and had undergone penetrating keratoplasty in the right eye. Best-corrected visual acuity was 20/60 in both eyes. Examination revealed slate-grey hyperpigmentation of his body, face, and sclera and black, confluent pigmentation in the central maculae of both eyes. Green wavelength fundus autofluorescence demonstrated speckled hyperautofluorescence in the right eye, and swept-source OCT and OCTA demonstrated pigmented epithelial detachments and significant signal blocking without choroidal neovascularization.

Penetrating keratoplasty performed by residents.

OBJECTIVE: To report the results of penetrating keratoplasty performed by residents. METHOD: A retrospective medical record review of all patients undergoing penetrating keratoplasty performed by residents at our institution from April 1998 to April 2002. RESULTS: Forty penetrating keratoplasty procedures were performed by 8 residents. The most common indication was keratoconus (17 eyes [43%]), followed by corneal scarring (14 eyes [35%]). Mean preoperative best-corrected visual acuity was 20/250. No intraoperative complications were reported. Mean follow-up time was 15 months. Postoperatively, mean best-corrected visual acuity was 20/40, mean postoperative astigmatism was 3.4 +/- 2.1 diopters, and graft survival was 92.5%. Postoperative complications included elevated intraocular pressure, wound dehiscence, and endophthalmitis. MAIN OUTCOME MEASURES: Best-corrected visual acuity, postoperative astigmatism, graft survival, and intraoperative and postoperative complications. CONCLUSION: Residents can be introduced to penetrating keratoplasty and achieve surgical success with intraoperative and postoperative complication rates similar to those previously published.