Ocular Pox Lesions in a Male Patient With Monkeypox Treated With Tecovirimat.

This case report describes the treatment of ocular pox lesions with tecovirimat in a male patient with monkeypox infection.

Rapid keratitis and perforation after corneal collagen cross-linking.

PURPOSE: To describe a case of rapid keratitis and corneal perforation after epithelium off collagen cross-linking. OBSERVATIONS: We report a case of a 17-year-old male who underwent collagen cross-linking with the protocol and device approved by the United States Food and Drug Administration (FDA) that developed a corneal infiltrate 3 days after the procedure. He later developed corneal thinning and perforation on day 5 requiring the use of cyanoacrylate glue and a Kontur lens. Despite initial improvement in the infiltrate with fortified antibiotics he later had leakage of aqueous around the glue and a flat chamber requiring an emergent penetrating keratoplasty on postoperative day 16. CONCLUSION AND IMPORTANCE: While collagen cross-linking has been very effective for treating keratoconus and is being recommended more frequently since FDA approval in the United States, severe complications such as corneal perforation requiring early transplant can still occur.

Treatment Limitations With PROSE (Prosthetic Replacement of the Ocular Surface Ecosystem): One Centers Experience.

OBJECTIVES: The prosthetic replacement of the ocular surface ecosystem (PROSE) device is used to treat difficult-to-manage ocular surface disease (OSD) and ectasia. Previous studies have demonstrated positive treatment outcomes. This study aims to document treatment failures to better tailor treatment and address limitations with its use. METHODS: Retrospective chart review of consecutive PROSE fits performed at Northwell Health from 2012 to 2016. Reasons for patient discontinuation of treatment were documented, and potential risk factors for treatment failure were assessed. RESULTS: The total number of eyes treated was 125. Fifty five eyes had ectasia, 67 had OSD, and 3 had both ectasia and OSD. A total of 8/125 (6.4%) of eyes failed treatment; 6/8 (75%) of failed treatments had worsening corneal edema, all of which had presumed risk factors for lower endothelial cell counts. Two eyes discontinued use secondary to intractable debris on the device, blurring vision. The most common diseases in patients failing therapy in descending order included: keratoconus and Fuch's dystrophy, ectasia after penetrating keratoplasty, and graft versus host disease. Those with presumed risks factors for lower endothelial cell counts (Fuch's dystrophy and patients with previous penetrating keratoplasty) were more likely to fail (22.2%) compared with those without a risk of a low endothelial cell count (1.6%). CONCLUSION: Although PROSE use has high success, corneal edema secondary to endothelial dysfunction is a potential limitation that may lead to treatment failure. Patients with lower endothelial cell counts after penetrating keratoplasty or with Fuch's dystrophy were more likely to fail treatment.

Spontaneous Descemet Membrane Detachment 20 Years After Penetrating Keratoplasty for Keratoconus.

PURPOSE: To report 2 cases of spontaneous Descemet membrane (DM) detachment 20 years after penetrating keratoplasty for keratoconus. METHODS: A retrospective chart review of 2 patients was performed. RESULTS: Two male patients-ages 59 and 50-presented 21 and 25 years, respectively, after uncomplicated penetrating keratoplasty for keratoconus, complaining of foreign body sensation. Best-corrected vision was 20/40 and 20/30, respectively. For both patients, slit-lamp examination revealed peripheral corneal thinning and steepening and temporal peripheral microcystic edema of the graft without any sign of rejection. Subsequent anterior segment optical coherence tomography demonstrated a DM detachment localized to the area of the corneal edema. One patient's DM failed to reattach after anterior chamber air injection and he then underwent successful Descemet stripping automated endothelial keratoplasty with resultant best-corrected vision of 20/20. The other patient failed mechanical incision at the graft-host interface with air injection for possible retrocorneal membrane and then successfully underwent a sequential cataract and Descemet stripping automated endothelial keratoplasty with visual acuity of 20/30. CONCLUSIONS: Spontaneous DM detachment more than 2 decades after uncomplicated penetrating keratoplasty for keratoconus is a previously unrecognized entity. Novel imaging modalities such as anterior segment optical coherence tomography should be used to identify this clinically difficult to detect etiology of microcystic corneal edema. The cause of DM detachment is unclear, but it may be because of mechanical forces from a retrocorneal membrane or from progressive keratoconus leading to peripheral host corneal steepening and thinning.

The Association of Demodex with Chalazia: A Histopathologic Study of the Eyelid.

PURPOSE: To investigate the association of Demodex with chalazia and to describe the associated histopathologic changes in the eyelid tissue. METHODS: In a retrospective histopathologic case-control study, 78 ectropion/entropion repair eyelid wedge resections were examined. Serial sections were obtained on formalin-fixed, paraffin-embedded tissues, stained with hematoxylin-eosin and studied by light microscopy. Thirty-eight patient specimens had evidence of chalazia and 40 did not. The main outcome measures included quantification of total eyelid hair follicles, meibomian glands, Demodex folliculorum and Demodex brevis; determining the presence of lipogranulomatous and non-lipogranulomatous inflammation, hair follicle and meibomian gland duct dilatation and hyperkeratinization, and meibomian gland acinar dilation, keratinization, and atrophy. RESULTS: There was a significantly greater mean number of D. folliculorum in biopsies with chalazia, when compared with biopsies without chalazia (5.55 vs. 2.68, p = 0.044). The presence of D. folliculorum was strongly associated with hair follicle duct dilatation and hyperkeratinization and with perifollicular nongranulomatous inflammation (p = 0.00). Hair follicle duct dilatation, hyperkeratinization, and perifollicular inflammation were also independently associated with chalazia (p = 0.040 and 0.031, respectively). D. brevis was observed only in meibomian glands with chalazia (mean = 0.342), but this finding did not reach statistical significance; p= 0.068. CONCLUSION: While the authors cannot establish causality between Demodex and chalazia, these findings suggest that D. folliculorum indirectly may be involved in the pathogenesis of chalazia via its effect on the anterior eyelid margin.

Paraproteinemic Keratopathy: The Expanding Diversity of Clinical and Pathologic Manifestations.

PURPOSE: To describe 7 patients with paraproteinemic keratopathy and to highlight the clinical and pathologic diversity of this rare entity and the importance of timely, systemic evaluation. DESIGN: Retrospective, multicenter collaborative case series. PARTICIPANTS: Seven patients with paraproteinemic keratopathy. METHODS: Clinical and pathologic records were reviewed to identify patients with well-documented corneal immunoglobulin deposits. Detailed ophthalmologic and medical histories were assembled. In 6 patients, corneal tissue was evaluated histochemically and immunohistochemically; in selected cases, corneal tissue was evaluated by in situ hybridization and ultrastructurally. MAIN OUTCOME MEASURES: Visual acuity and anterior segment examination at presentation and follow-up; local therapy; systemic diagnosis and management; and histopathologic, immunohistochemical, in situ hybridization, and ultrastructural findings. RESULTS: Seven patients were identified with corneal immunoglobulin deposition. In addition to previously reported crystalline, nummular, patch-like, and lattice-like corneal opacities, prominent corneal vascularization was present in 2 patients mimicking interstitial keratitis and limbal stem cell deficiency. All patients had evidence of paraproteinemia in a setting of monoclonal gammopathy of undetermined significance, smoldering plasma cell myeloma, or Waldenström macroglobulinemia. Corneal findings were the first manifestation of systemic disease in 4 patients, and the diagnosis was not suspected in 3 of these patients. Pathologic evaluation of biopsied corneal and conjunctival tissues demonstrated immunoglobulin deposits. Previously unreported ultrastructural patterns in the cornea were noted: large scroll-like immunotactoid deposits, immune complex-like deposits, and randomly arranged fibrils morphologically intermediate between amyloid and immunotactoid deposits. Surgical intervention to improve vision was performed in 4 patients, with recurrence of deposits in 3 patients. Three patients underwent systemic therapy with diminution of the deposits and improvement in vision in 1 patient. CONCLUSIONS: The clinical and pathologic expressions of corneal immunoglobulin deposits are protean and present a diagnostic challenge. Early recognition of this rare entity is important to address the potentially serious associated systemic disease.

Recurrence of Ocular Surface Squamous Neoplasia Treated With Excisional Biopsy and Cryotherapy.

PURPOSE: To evaluate the recurrence rate of ocular surface squamous neoplasias (OSSN) after excision and cryotherapy in an academic cornea practice and to determine factors associated with recurrence. DESIGN: Retrospective interventional case series. METHODS: All cases of OSSN from 1998 through 2013 that were treated with excisional biopsy and adjunctive cryotherapy were retrospectively reviewed. Clinical characteristics upon presentation including size of lesion, location, and atypical features were noted. All recurrences of OSSN after excision and cryotherapy were noted and categorized in relation to clinical characteristics, pathologic grade, and margin involvement. RESULTS: Forty-three cases of OSSN from 42 patients were analyzed with a median follow-up of 29 months. A total of 32.6% of subjects had dysplasia and 67.4% had squamous cell carcinoma (SCC). A total of 83.7% of subjects had both corneal and conjunctival involvement while 16.3% had conjunctival involvement only. Overall, 3 recurrences were observed, all of which had margin involvement; nonetheless, the majority of incompletely excised OSSN (25/28) showed no recurrence. The recurrence rate at 6 months was 2.3%. Recurrence at 1 year, 2 years, and 5 years remained stable at 7.1%. CONCLUSIONS: Excision with cryotherapy is an effective treatment for the majority of OSSN cases, even among cases with pathologic evidence of tumor at the margin, with an overall recurrence rate of 7.1% at 1 year, 2 years, and 5 years.

Descemet stripping endothelial keratoplasty for the treatment of combined fuchs corneal endothelial dystrophy and keratoconus.

PURPOSE: To report the first case series of patients with Fuchs corneal endothelial dystrophy (FCD) and keratoconus (KCN) who underwent Descemet stripping endothelial keratoplasty (DSEK). METHODS: This is a retrospective case series of 6 eyes of 4 patients with combined FCD and KCN who underwent DSEK at 3 different centers. Clinical information collected included corneal topography measurements, central corneal thickness, and endothelial cell count. Visual outcomes and change in keratometric measurements were evaluated. RESULTS: The follow-up for patients ranged from 10 to 72 months. The best-corrected visual acuity was 20/40 or better in all 6 eyes. The mean keratometric measurements decreased in all cases (range of 0.5-5.8 diopters); however, topography still demonstrated an inferior steepening in each case. CONCLUSIONS: Patients with FCD and KCN have been previously reported as being managed with penetrating keratoplasty. We present 6 eyes of 4 patients who were managed with DSEK for the FCD. Topographically, the characteristic inferior steepening of KCN did not change; however, all patients with DSEK had flatter postoperative keratometric measurements with improved visual acuity. If a DSEK is performed for FCD before apical corneal scarring from KCN, a good visual outcome may be achieved.

Immunologic graft rejection in descemet's stripping endothelial keratoplasty and penetrating keratoplasty for endothelial disease.

OBJECTIVE: To evaluate and compare the cumulative incidence and risk factors for first-episode immunologic graft rejection in Descemet's stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PK) and to identify potential risk factors for rejection. DESIGN: Retrospective chart review. PARTICIPANTS: All patients who underwent PK or DSAEK for endothelial disease at the Department of Ophthalmology, North Shore LIJ, between January 2004 and June 2010. METHODS: One hundred sixty-nine PK cases and 122 DSAEK cases were reviewed. All patients had a minimum of 3 months of follow-up, with median follow-up of 36 months in the PK group and 29 months in the DSAEK group. MAIN OUTCOME MEASURES: Cumulative incidence of first-episode immunologic graft rejection in PK and DSAEK cohorts. Risk factors for graft rejection were reviewed. RESULTS: Cumulative incidence of rejection was not significantly different between the DSAEK and PK cohorts (P<0.1324). However, among patients without glaucoma, the risk of rejection in PK was higher than that in DSAEK (hazard ratio [HR], 5.56). Prior incisional glaucoma surgery imparted a 3.15 times greater risk of rejection regardless of transplant type. Phakic patients were more likely to experience rejection than patients with a posterior chamber intraocular lens (HR, 3.23; P<0.0266), but not more likely than those with an anterior chamber intraocular lens or who were aphakic. Graft failure occurred within 6 months in 31% of PK rejections and none of the DSAEK rejections. CONCLUSIONS: Descemet's stripping automated endothelial keratoplasty and PK did not show a statistically significant difference in the incidence of rejection; however, among nonglaucomatous eyes, there were significantly fewer rejections in those that underwent DSAEK.

Textural interface opacity after descemet stripping automated endothelial keratoplasty: a report of 30 cases and possible etiology.

PURPOSE: Descemet stripping automated endothelial keratoplasty (DSAEK) has its own set of complications including interface abnormalities. This case series presents the largest number of patients who developed textural interface opacity (TIO) at the graft-host interface after DSAEK. METHODS: This is a retrospective multicenter case series of 30 patients from 7 institutions with the finding of TIO. Clinical information collected included donor preparation details, recipient information, and surgical technique. Clinical outcomes included best-corrected visual acuity and status of TIO appearance at the last follow-up visit. Slit-lamp photographs were analyzed and compared. RESULTS: The majority of the patients (73%) had a best-corrected visual acuity of 20/40 or better. Four of the donor tissues were prepared with a microkeratome blade with the same lot number. Six patients had a central interface space between host and donor stromal surfaces--presumed interface fluid but potentially viscoelastic. A slight majority (57%) of patients had improvement in the severity of TIO, with 20% noted to have a complete resolution of TIO (mean follow-up of 11.9 months). Two clinical types of TIO were seen: an elongated type and a punctate type. CONCLUSIONS: Most patients with TIO after DSAEK obtain good visual outcomes. TIO spontaneously improves or even resolves during follow-up without intervention. The etiology of this condition is unknown, but we propose 2 different mechanisms. The elongated type could be secondary to an irregular cut of the donor with the microkeratome blade. The punctate type may be secondary to retained viscoelastic.

Progressive growth in epibulbar complex choristomas: report of 2 cases and review of literature.

PURPOSE: To report 2 patients with progressive complex choristomas and to review the literature on this subject. DESIGN: Interventional case reports. METHODS: Clinical and pathologic correlation was performed on 2 patients with progressive epibulbar choristomas. PubMed database was searched to identify all the previously reported cases of progressive epibulbar choristomas (using key words choristoma, dermoid, growth, progression, and evolution). RESULTS: Growth of the epibulbar choristomas was noted in infancy in 1 patient with oculoectodermal syndrome and in puberty in another otherwise healthy patient. Both lesions were identified histopathologically as complex choristomas. In addition to the characteristic choristomatous tissues, both lesions demonstrated increased vascularity, inflammatory infiltrate, and fibroblast proliferation within myxomatous stroma. Review of the literature identified 4 patients with progressive complex choristomas, 1 of whom demonstrated histopathologic findings similar to those of the 2 cases reported here. CONCLUSIONS: Epibulbar choristomas rarely enlarge, likely secondary to reactive changes within the tissue manifested by increased vascularity, inflammatory cell infiltration, and fibroblast proliferation with deposition of myxomatous stroma.

Full-thickness corneal "vent incisions": how deep does the epithelium penetrate?

PURPOSE: To evaluate epithelial cell penetration produced by full-thickness "vent incisions." METHODS: Six donor human corneas with intact epithelium were placed on an artificial anterior chamber. Four perforating paracentral vent incisions were made in each cornea using a diamond knife. RESULTS: Twenty incisions were analyzed. Of the 20 wounds, 9 (45%) wounds demonstrated introduction of epithelial cells. Of these, 8 (89%) had epithelial cells at the level of the anterior half of the stroma, 3 (33%) had cells at the level of the posterior half of the stroma, and 1 (11%) had cells on the endothelium. CONCLUSIONS: Full-thickness vent incisions, as performed with Descemet stripping automated endothelial keratoplasty, introduced epithelium into the stroma as deep as the endothelium. This may prove a source of epithelial ingrowth.

Retrospective review of graft dislocation rate associated with descemet stripping automated endothelial keratoplasty after primary failed penetrating keratoplasty.

PURPOSE: To report the rate of graft dislocation in patients who underwent Descemet stripping automated endothelial keratoplasty (DSAEK) after a previous penetrating keratoplasty (PKP). METHODS: Institutional review board-approved, multicenter, retrospective chart review. Inclusion criteria included: prior failed PKP and subsequent DSAEK. The primary outcomes measured in this study were the presence of a graft dislocation, rate of rebubble, and graft attachment. Additional variables included: presence of a prior glaucoma drainage device, graft-to-host size disparity, number of sutures remaining in PKP, and stripping of the Descemet membrane at the time of DSAEK surgery. RESULTS: Ninety patients (97 eyes) were included in the study. In 31% (30 of 97), the endothelial graft dislocated after surgery. All 30 cases required a rebubble except 1, which reattached spontaneously. Ninety-eight percent (95 of 97) of all grafts remained attached for the duration of the follow-up period. Only 2 eyes (2.2%) required repeat graft. Endothelial grafts dislocated in 67% of patients with glaucoma draining devices. The dislocation rate for grafts larger than the host was 12 of 49 (24%), equal to the host was 3 of 17 (18%), and smaller than the host was 8 of 19 (42%). Dislocations occurred in 5 of 21 (24%) of grafts with sutures remaining and 22 of 76 (29%) of those with all sutures out. Five of 12 (42%) cases of grafts performed without stripping the Descemet had dislocations. CONCLUSIONS: The graft dislocation rate in DSAEK procedures after PKP is comparable to that after primary DSAEK cases. Donor grafts that are smaller than the host PKP and the presence of prior glaucoma drainage devices are risk factors for higher rates of graft dislocation.

Spontaneous reattachment of Descemet stripping automated endothelial keratoplasty lenticles: a case series of 12 patients.

PURPOSE: To review 12 cases of postoperative detachment and spontaneous reattachment of Descemet stripping automated endothelial keratoplasty (DSAEK) lenticles. DESIGN: Retrospective, observational case series. METHODS: This was a review of patients undergoing DSAEK at 7 institutions. Patients who had a significant detachment of their DSAEK lenticle during the postoperative period were identified and divided into 2 groups. Significant detachment was defined as either complete central interface fluid with bare peripheral attachment (group 1) or a free-floating lenticle in the anterior chamber (group 2). Patients who subsequently had a spontaneous reattachment of the lenticle were identified, with data regarding surgical technique and intraoperative and postoperative complications collected for analysis. RESULTS: Our cohort consisted of 12 eyes of 12 patients who met the definition of significant postoperative detachment with subsequent spontaneous reattachment. Four patients had complete central detachment with peripheral attachment (group 1), whereas 8 patients had a free-floating lenticle (group 2). Ten of the 12 patients had a successful outcome as defined as an attached and clear DSAEK lenticle. In our study, reattachment was seen as early as 5 days and as late as 7 months after surgery, with reattachment in 9 of 12 patients by day 25. CONCLUSIONS: Spontaneous reattachment of detached DSAEK lenticles may occur during the postoperative period. The decision of when to bring the patient back for a rebubble ultimately must be made on a case-by-case basis.

Preservative-free low-dose dexamethasone for the treatment of chronic ocular surface disease refractory to standard therapy.

PURPOSE: To evaluate the short-term safety and efficacy of topical preservative-free dexamethasone 0.01% for the treatment of ocular surface disease and/or tearing refractory to conventional treatments. METHODS: Retrospective chart review of all patients who received topical unpreserved dexamethasone 0.01% (Leiters Pharmacy, San Jose, CA). Follow-up visits were reviewed for subjective responses to the formulation and intraocular pressure. Responses were graded as significant/complete resolution of symptoms (50%-100% improvement), mild (25%-50% improvement), or no improvement. RESULTS: Thirty-one patients received topical unpreserved dexamethasone 0.01% for the treatment of ocular surface disease. Follow up ranged from 4 to 60 months (average, 11.5 weeks). Twenty patients (65%) reported moderate or complete resolution of ocular symptoms. Seven patients (22%) had mild improvement in their symptoms. Four patients (13%) had no change in ocular symptoms. No patient in our series developed an elevation of intraocular pressure greater than 5 mm Hg above baseline intraocular pressure. No patient developed intraocular pressure greater than 22 mm Hg. CONCLUSIONS: Topical nonpreserved 0.01% dexamethasone could be an effective therapy for recalcitrant chronic ocular surface disease.

Safety of overnight orthokeratology for myopia: a report by the American Academy of Ophthalmology.

OBJECTIVE: To review the published literature to evaluate the safety of overnight orthokeratology (OOK) for the treatment of myopia. METHODS: Repeated searches of peer-reviewed literature were conducted in PubMed (limited to the English language) and the Cochrane Central Register of Controlled Trials (no language limitations) for 2005, 2006, and 2007. The searches yielded 495 citations. The panel reviewed the abstracts of these articles and selected 79 articles of possible clinical relevance for review. Of these 79 full-text articles, 75 were determined to be relevant to the assessment objective. RESULTS: No studies were rated as having level I evidence. Two premarket applications to the Food and Drug Administration were rated as having level II evidence. There were 2 studies rated as having level II evidence. The main source of reports of adverse events associated with OOK was 38 case reports or noncomparative case series (level III evidence). CONCLUSIONS: The prevalence and incidence of complications associated with OOK have not been determined. Complications, including more than 100 cases of infectious keratitis resulting from gram-positive and gram-negative bacteria and Acanthamoeba, have been described in case reports and case series representing observations in undefined populations of OOK users. Data collection was nonstandard. Risk factors for various complications cannot be determined. Because OOK puts patients at risk for vision-threatening complications they may not encounter otherwise, sufficiently large well-designed cohort or randomized controlled studies are needed to provide a more reliable measure of the risks of treatment and to identify risk factors for complications. Overnight orthokeratology for slowing the progression of myopia in children also needs well-designed and properly conducted controlled trials to investigate efficacy. Because of variations in orthokeratology practice, a wide margin of safety should be built into OOK regimens. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Visual outcome and bacterial sensitivity after methicillin-resistant Staphylococcus aureus-associated acute endophthalmitis.

PURPOSE: To determine the frequency, visual outcome, and bacterial sensitivity in cases of methicillin-resistant Staphylococcus aureus (MRSA)-associated acute postoperative endophthalmitis occurring after cataract surgery. DESIGN: Retrospective, consecutive, observational case series. METHODS: Sixty-four cases of acute endophthalmitis occurring within six weeks after cataract surgery were identified over a three-year interval at a single vitreoretinal practice. Cases related to MRSA were studied and visual outcomes and bacterial sensitivities were recorded. RESULTS: Thirty-three of the 64 eyes were culture positive, and six of the 33 cases (18.2%) demonstrated MRSA infection. All six eyes were started on fluoroquinolone antibiotics two or three days before surgery. Corneal abnormalities were noted in five of the six cases (83.3%), ranging from wound infection to diffuse corneal opacification. Visual acuity at last follow-up was no light perception (NLP) in two eyes, hand movements in two eyes, and 20/30 or better in two eyes. One eye with NLP vision underwent enucleation within three days of presentation because of panophthalmitis and impending sepsis. All six organisms were sensitive in vitro to both gentamicin and vancomycin. No organism was sensitive to any fluoroquinolone antibiotic, although not all organisms were tested against all fluoroquinolones. CONCLUSIONS: MRSA infection accounts for 18% of culture-positive cases of endophthalmitis in this study and was associated with a poor visual outcome in two-thirds of our patients. MRSA organisms may be resistant in vitro to all generations of fluoroquinolone antibiotics, but do seem to be sensitive to gentamicin and vancomycin. The incidence of MRSA endophthalmitis seems to have increased significantly since the Endophthalmitis Vitrectomy Study was published in 1996.

Clinical response of contact lens-associated fungal keratitis to topical fluoroquinolone therapy.

PURPOSE: To report 5 cases of fungal keratitis associated with contact lens wear that resolved or significantly improved without antifungal therapy. METHODS: Observational case report of 5 patients with a history of contact lens wear who presented with infectious keratitis. Two patients had growth of fungal species on corneal microbiologic cultures, and of the remaining 3 patients, 2 showed fungal elements on confocal microscopy. All 5 patients exhibited growth of fungal species on contact lens microbiologic cultures. All patients received topical fluoroquinolone therapy as initial treatment. RESULTS: In 3 cases, of whom 2 were treated with moxifloxacin 0.5%, the keratomycosis resolved completely on topical fluoroquinolone therapy. One case was switched to topical tobramycin 14 mg/mL and cefazolin 50 mg/mL with complete resolution of the infection. The final case showed marked initial improvement on fluoroquinolone therapy but was subsequently treated with natamycin 5%. CONCLUSIONS: Fungal keratitis associated with soft contact lens wear may occasionally present in a less aggressive form. Topical fluoroquinolone therapy may be an adjunct to the innate immune response in eradicating less fulminant keratomycosis.