Pediatric bacterial keratitis: clinical features, causative organisms, and outcome during a 13-year study period.

OBJECTIVE: To review the clinical features, causative organisms, complications, and outcomes of patients with pediatric bacterial keratitis at a tertiary care eye hospital. METHODS: We conducted a retrospective study at a tertiary care eye centre on clinically diagnosed pediatric patients with bacterial keratitis between 2007 and 2019. Poor outcomes were labelled if any of the following were present: final best-corrected visual acuity worse than 20/200, a drop in best-corrected visual acuity by 1 line or more, perforated corneas, endophthalmitis, and graft failure. RESULTS: The study included 43 cases of bacterial keratitis. Female and male patients represented 60.5% and 39.5% of the sample, respectively, with a mean age of 9.3 ± 5.9 years. The rate of culture positivity was 60.5%. The most common causative organisms were coagulase-negative Staphylococcus (23.1%), Pseudomonas (23.1%), and Streptococcus pneumoniae (19.2%). Culture-positive bacterial keratitis was associated with infiltrates ≥2 mm (p = 0.039), as determined by the results of multivariate analysis. Gram-positive and gram-negative bacteria exhibited 100% sensitivity to the tested fluoroquinolones. Complications included visually significant scars (55.8%), cataracts (14.0%), perforations (9.3%), corneal neovascularization (7.0%), nonhealing epithelial defects (7.0%), and endophthalmitis (4.7%). Corneal perforation was associated with the development of endophthalmitis (p < 0.001). On multivariate analysis, the only factor associated with a poor outcome was poor presenting visual acuity (p = 0.020). CONCLUSION: Gram-positive bacteria were the most common cause of pediatric microbial keratitis. Positive cultures were associated with larger infiltrates. The only adverse prognostic factor was poor presenting vision.

Corneal Perforation in a Patient Treated with Atezolizumab-Bevacizumab Combination Therapy for Unresectable Hepatocellular Carcinoma.

BACKGROUND Immune checkpoint inhibitors (ICIs) targeting the programmed cell death protein 1 (PD-1), or its ligand PD-L1, are the mainstay treatment for several metastatic malignant conditions. ICIs are associated with multiple toxic adverse events affecting various organs, known collectively as immune-related adverse events (irAEs). Dry eye, uveitis, ocular myasthenia, and cicatrizing conjunctivitis are well-recognized ocular irAEs associated with ICIs. CASE REPORT We present a case of 69-year-old man who presented with paracentral, punch-out corneal perforation in the left eye, associated with bilateral severe ocular surface disease 3 weeks after receiving the second dose of atezolizumab-bevacizumab combination therapy for the treatment of unresectable hepatocellular carcinoma. Corneal gluing using cyanoacrylate glue was performed along with bandage contact lens application and temporary tarsorrhaphy to seal the corneal perforation and improve the ocular surface. On the subsequent follow-ups, the corneal glue was unstable and dislodged. Thus, penetrating keratoplasty was performed to salvage the globe along with holding the combination therapy. At the 8-month follow-up, the graft remained clear, and the ocular surface improved substantially in both eyes. CONCLUSIONS Ocular irAEs associated with immune-modulating agents can lead to vision-threatening complications. Therefore, communications between oncologists and ophthalmologists in a multidisciplinary team would be of utmost importance for early detection and timely management of any ocular-related adverse events associated with the use of immunotherapy agents.

Three-years outcomes of simultaneous photorefractive surgery and customized corneal cross-linking for keratoconus.

PURPOSE: To report the efficacy of customized cross-linking (CXL) in halting progression of keratoconus when combined with photorefractive procedures. METHODS: Seven eyes from 7 patients with documented progressive keratoconus were treated with customized CXL (customized ultraviolet-A irradiance pattern centered on the maximum posterior elevation with total energy levels ranging from 5.4 up to 10 J/cm2 , and an energy fluence of 9 mW/cm2) combined with photorefractive procedures. Four patients underwent simultaneous transepithelial photorefractive keratectomy (T-PRK) plus customized CXL, and three patients underwent simultaneous transepithelial phototherapeutic keratectomy (T-PTK) plus customized CXL. Tomographic parameters (Kmax, pachymetry of the thinnest point and maximal elevation of posterior float and regularization index) and best spectacle-corrected visual acuity (BSCVA) were compared preoperatively and 3 years postoperatively. RESULTS: All eyes showed a decrease in the maximal curvature Kmax, and none of eyes showed progression. Six eyes showed a flattening of 3 or more diopters (D). On average, Kmax decreased by - 4.8 ± 2.5 D, and the BSCVA improved by 0.04 ± 0.07 logarithm of the minimal angle of resolution. The mean value of regularization index was 8.7 ± 3.8 D. Mild corneal haze occurred in two eyes, and superficial apical scar occurred in one eye. None of the eyes had a vision-threatening complication. CONCLUSION: Customized CXL combined with photorefractive procedure (T-PRK/T-PTK) resulted in long lasting flattening effect and strong regularization of keratoconic corneas along with improvement of BSCVA over a 3-year follow-up.

Leptospermum Medical Grade Manuka Honey Ointment in the Treatment of Persistent Corneal Epithelial Defect.

BACKGROUND: To study the efficacy of 100% Leptospermum medical grade Manuka honey ointment in persistent corneal epithelial defects (CEDs). METHODS: Case series. RESULTS: Case 1 was a 25-year-old female patient who presented to the cornea clinic with a persistent CED (3.5 mm), following acanthamoeba keratitis, that had failed to respond to heavy, frequent lubrication drops and ointment. Two weeks later, after starting Leptospermum honey ointment (4 times per day), the CED healed totally. Case 2 was a 48-year diabatic, single-eyed female patient who presented with a persistent CED (1.5 × 1.5 mm) that had failed to respond to heavy, frequent lubrication drops and ointment. The CED healed three weeks after starting Leptospermum honey ointment (4 times per day). CONCLUSIONS: Leptospermum honey ointment can be a potential treatment for persistent epithelial defect.

The Impact of the COVID-19 Pandemic on Ophthalmic Outpatient Care in a Tertiary Care Center in Riyadh.

In this paper, we measured the impact of a full COVID-19 lockdown on ophthalmic patients after a period of lockdown in Saudi Arabia, from March to September 2020. A cross-sectional analytical study was carried out on 180 patients who had their appointments delayed or canceled due to the lockdown. Data was collected from electronic medical records and patients via voice calls using a validated questionnaire that were analyzed using a multivariable binary regression analysis. The results show no statistically significant mean difference in visual acuity when comparing pre- and post-lockdown measurements. The median number of appointment cancellations/delays per patient was two, and the estimated delay for the first canceled appointments was equal to 178.8 days. Of the cohort studied, 15.4% of patients faced delays in necessary surgical and therapeutic interventions; 22.1% of patients sought eye care at other institutions due to the delay, and 15% of those were seen by doctors unspecialized in ophthalmology. The odds of dissatisfaction with care were higher in patients who experienced cancellations in a surgical procedure and patients who experienced difficulty in obtaining medications. In conclusion, the pandemic hampered ophthalmic patients' access to medications. Subjective visual outcomes of patients were also negatively affected; however, the change in objective visual parameters was not statistically significant.

The Precision of Ophthalmic Calipers: A Potential Reason for Clinical and Surgical Errors.

Purpose The study aimed to determine the precision of different ophthalmic calipers used in our tertiary eye care center. Methods All Castroviejo calipers available in the operating room, minor treatment room, and intravitreal injection clinic were included in the study. All calipers were evaluated at four screening points (1, 5, 10, and 15 mm) on a standard ruler and compared to their expected corresponding readings on the caliper scale. If any caliper showed a discrepancy of ≥0.5 mm at any of the screening points, the caliper underwent further analysis on 10 measurement points. Results Forty-one calipers were evaluated, of which 16 (39%) showed at least one point of ≥0.5 mm discrepancy on the caliper reading scale. Six calipers had errors >0.5 mm and two calipers had measurement errors of 1 mm in at least one point between 1-15-mm ruler measurement points. The majority of calipers (15/16) overestimated lengths. Conclusion Calipers are prone to damage with prolonged use that may affect their precision. Thus, calipers should be calibrated against a standard ruler prior to use even if they look grossly intact. Regular screening of calipers is recommended to identify any discrepancy and prevent avoidable complications.

Preoperative universal screening for COVID-19 in patients undergoing ophthalmic surgeries: Experience from a tertiary eye care center in Saudi Arabia.

PURPOSE: This study aims to determine the frequency of coronavirus disease-2019 (COVID-19) among patients scheduled for elective and emergency ophthalmic surgeries in a tertiary eye care center in Saudi Arabia. METHODS: This observational retrospective study was performed between June 1, 2020, and October 31, 2020, in a single tertiary eye care center in Riyadh, Saudi Arabia. All patients who were given appointments for elective or emergency surgeries were included in the study. All patients underwent preoperative nasopharyngeal and oropharyngeal reverse transcription-polymerase chain reaction testing for severe acute respiratory syndrome coronavirus-2 virus. Retrospective chart review of all patients who tested positive for COVID-19 was performed for the demographic and clinical information; presence of symptoms upon presentation, nature, and urgency of the scheduled surgical intervention; and the overall outcomes. RESULTS: A total of 727 patients were scheduled for elective or emergency ophthalmic surgeries during the study period. The mean age of all patients was 61.3 years, 407 were males (55.9%) and 320 were females (44.1%). Of 727 patients tested for COVID-19, the test was positive in 17 (2.3%) patients. All patients who tested positive for COVID-19 were asymptomatic at the time of swabbing. No patient-related perioperative complications or health-care workers' affection secondary to exposure to positive cases were documented. CONCLUSION: The study showed that almost 1 in 43 patients scheduled for elective or emergency ophthalmic surgeries may be positive for COVID-19. All positive cases were asymptomatic at the time of swabbing, underscoring the importance of the routine preoperative screening for COVID-19.