Case Report: Burkholderia pseudomallei-Caused Sclerokeratitis.

This report is on a 45-year-old male patient without underlying disease who presented with a Burkholderia pseudomallei-caused keratoscleritis in his right eye. Slit-lamp examination revealed multiple, indistinct corneal infiltrations with subconjunctival/scleral abscesses. Corneal tissue culture was positive for B. pseudomallei and confirmed by mass spectrometry. The patient was treated with fortified ceftazidime, fortified gentamicin eyedrops, and intravenous ceftazidime injection. Penetrating keratoplasty, including intracameral ceftazidime injections, was undertaken due to corneal lesion worsening. Scleral debridement with subconjunctival ceftazidime injections were undertaken due to the progression of the scleral abscess. After 2 months, the corneal and scleral lesions were inactive, and the systemic and topical antibiotics were tapered. This is the first case report of B. pseudomallei-caused keratoscleritis with photography. The patient was seen in an endemic geographical area with multiple corneal infiltrations and subconjunctival/scleral abscess. Systemic and topical antibiotics accompanied with surgery should be considered.

Predictors for Dry Eye Diseases in Patients with Systemic Sclerosis.

Purpose: To evaluate the prevalence of dry eye disease (DED) in patients with both limited and diffuse subtypes of systemic sclerosis (SSc) and to determine the predictive factors associated with the occurrence of DED. Patients and Methods: This was a prospective consecutive cross-sectional study of patients with SSc. Each patient underwent a comprehensive ophthalmological evaluation. The Ocular Surface Disease Index (OSDI) was used to assess the symptoms of DED. Tear break up time (TBUT), Schirmer I and ocular surface staining (OSS) were used for objective tests. Patients were diagnosed DED using the DEW II diagnostic method which included both symptom and objective tests. The collected data of patients with and without DED were compared to find out possible associated factors. Logistic regression analysis was used to determine the effects of these factors. Results: Eighty-four SSc patients (25 limited and 59 diffuse subtypes) were studied. The prevalence of DED in SSc patients was 52.38%. The OSDI, tear break up time (TBUT), Schirmer I and ocular surface staining (OSS) were not significantly different between SSc subtypes. Among the 46 symptomatic patients, DED was noted in 44 (52.38%). Most patients (61.4%) were mixed aqueous deficiency-evaporative dry eye type (both TBUT and Schirmer I test positive). The mean age and the median of disease duration in DED patients were higher than those without DED with statistically significant difference (P = 0.004 and 0.019). Conclusion: DED was common in patients with SSc. The predictors for the occurrence of DED were older age and longer disease duration. Therefore, OSDI and objective tests for DED should be evaluated in all SSc patients, particularly those with older age and longer disease duration.

Role of Immunotherapy in Pythium insidiosum Keratitis.

Pythium keratitis is a potentially devastating ocular condition. Incidence of Pythium keratitis has been reported in tropical and subtropical areas. In previous reports, there were no effective or standard treatments, and combinations of medication, immunotherapy, and surgery were proposed. Pythium insidiosum antigen immunotherapy (PIAI) showed an acceptable safety profile, but its efficacy is questionable in Pythium keratitis. This retrospective review included 10 eyes from 10 patients. All cases were confirmed diagnosis of P. insidiosum keratitis by culture and/or polymerase chain reaction. Three doses of PIAI were injected at 2-week intervals in all patients. The infiltration diameter ranged from 5.2 mm to total corneal involvement, and eight cases (80%) had hypopyon. Therapeutic penetrating keratoplasty (TPK) or scleral graft were undertaken in nine cases. Enucleation was done in one case on the first visit. A second TPK was undertaken in three cases, and two globes were saved. Two cases in the globe salvage group received voriconazole via eyedrops and intracameral injection. No case received either linezolid or azithromycin. Three of nine eye globes (33.33%) were saved. PIAI did not show efficacy in the treatment of Pythium keratitis. Radical surgery including resurgery in recurrence is an approved effective treatment. The recently reported medications may offer supportive management.

Anterior Segment Optical Coherence Tomography Images in Microsporidial Keratoconjunctivitis.

PURPOSE: To describe the findings of anterior segment optical coherence tomography (AS-OCT) in patients with microsporidial keratoconjunctivitis. METHODS: The observational study included 13 eyes from 13 patients. Slit-lamp photography and AS-OCT were performed using the Swept source OCT before corneal scraping. All cases were positive for Gram-chromotrope (modified trichrome) staining for Microsporidia spp. RESULTS: Three significant AS-OCT findings were observed. First, hyperreflective dots were limited to the epithelial layers of the cornea, and second, there were no extensions into the stromal layer in all cases. Last, hyperreflective dots slightly raised above the epithelial surface were observed in most cases (12/13%, 92.3%). CONCLUSIONS: AS-OCT represents an alternative, noninvasive tool to diagnose microsporidial keratoconjunctivitis, especially if corneal scraping is not possible.

Effect of Eyelid Margin Cleaning on Conjunctival and Eyelid Bacterial Flora Before Intraocular Surgery.

PURPOSE: To compare the bacterial cultures of the lower eyelid margins and lower fornices between ocular irrigations with and without eyelid margin cleaning before intraocular surgery. METHODS: A prospective study was carried out that included 102 eyes from 51 patients undergoing intraocular surgery between December 2016 and April 2017. In each patient, the surgical eye (control group) only received ocular irrigation and the opposite eye (study group) received ocular irrigation with eyelid margin cleaning. Normal saline solution was used in all procedures. In each group, samples from the lower eyelid margins and lower fornices were cultured before and after cleaning. Povidone iodine and antibiotic eye drops were instilled after specimen collection. RESULTS: The most common bacterial isolate of all groups was Staphylococcus spp. There were no statistically significant differences of positive cultures between the control and study groups in either lower eyelid margins (Odds ratio [OR], 2.19; 95% CI, 0.84-5.72) nor lower fornices (OR, 0.93; 95% CI, 0.43-2.00). In addition, there were no statistically significant differences of positive cultures between before and after eyelid cleanings from both lower eyelid margins (OR, 2.74; 95% CI, 0.53-14.24) and lower fornices (OR, 0.73; 95% CI, 0.21-2.57). CONCLUSIONS: Eyelid margin cleaning with normal saline solution immediately before intraocular surgery did not help to decrease microbial loading on the ocular surfaces. The rate of bacterial contamination, however, was not increased which could be due to not performing eyelid compression.

Multiplex Polymerase Chain Reaction Assay for Screening of Mycotoxin Genes From Ocular Isolates of Fusarium species.

PURPOSE: To identify mycotoxin genes among clinical ocular isolates of Fusarium species and to correlate these with clinical outcomes of Fusarium keratitis. METHODS: Fifty-four clinical isolates of Fusarium were retrieved from the Bascom Palmer Eye Institute Ocular Microbiology Laboratory data bank. Multiplex polymerase chain reactions were run to confirm the identification of Fusarium species [internal transcribed spacer sequence, translation elongation factor 1-α (TEF) and ß-tubulin] and to detect the presence of genes encoding production of fumonisin B mycotoxins (FUM1 and FUM8) and trichothecene mycotoxins (deoxynivalenol and nivalenol). The presence or absence of mycotoxins was compared with patient outcomes. RESULTS: Forty-three (79%) of the 54 isolates were confirmed as Fusarium species, by an internal transcribed spacer sequence in 3 (5.6%) and by TEF in 43 (79.6%) of the 54 isolates. Fumonisin biosynthetic gene 1 (FUM1) was detected in 57.4% (n = 31/54) of the Fusarium isolates. No FUM8, deoxynivalenol genes, and nivalenol genes were detected among these in the clinical isolates group. Initial best-corrected visual acuity ranged from 20/25 to 20/80 in the FUM1 gene-negative group and from 20/20 to light perception in the FUM1 gene-positive group. There was no difference in the time to cure between both groups. The presence of FUM1 genes in 5 fungal isolates seemed to be associated with progression to penetrating keratoplasty in the 5 patients from whom the fungi were isolated. Fusarium solani was recovered from all patients requiring penetrating keratoplasty. CONCLUSIONS: Fumonisin B biosynthetic gene 1 may be common among clinical Fusarium isolates and contribute to worse initial visual acuity and high-risk progression to penetrating keratoplasty.

Role of Confocal Microscopy in the Diagnosis of Pythium insidiosum Keratitis.

PURPOSE: To investigate the role of in vivo confocal microscopy for detection of Pythium insidiosum keratitis. METHODS: Medical records and confocal microscopy findings of 20 patients (21 eyes) with culture- or polymerase chain reaction-proven P. insidiosum keratitis diagnosed at the Khon Kaen University Eye Center from January 2009 to December 2015 were retrospectively reviewed. Confocal microscopy was performed using Nidek ConfoScan 4. The images from 21 eyes with P. insidiosum keratitis and 4 other fungal keratitides were analyzed visually for morphology of the hyphae and special characteristics that would enable physicians to distinguish P. insidiosum keratitis from other fungal keratitides. RESULTS: A total of 21 eyes of 20 patients were included in the study. Fourteen (70%) were men, and 6 (30%) were women. In vivo confocal microscopy was able to identify hyphae in 20 of 21 eyes (95%). Beaded string-like hyperreflective branching structures with mean branching angles at 78.6 degrees or thin hyperreflective long lines were found in confocal microscopy findings of P. insidiosum keratitis. The diameter of the hyphae varied from 1.5 to 7.5 µm. CONCLUSIONS: P. insidiosum keratitis is a severe progressive infectious corneal disease that causes vision loss in most patients. Confocal microscopy may provide rapid in vivo visualization of P. insidiosum hyphae in corneal tissues, but it cannot distinguish P. insidiosum from other fungal keratitides. Culture identification with zoospore induction or polymerase chain reaction remains the most reliable means to confirm the diagnosis of P. insidiosum keratitis.

Successful treatment of Chrysosporium keratitis with voriconazole.

OBJECTIVE: To report a patient with severe Chrysosporium keratitis successfully treated by voriconazole. METHOD: Case report. RESULTS: A 37-year-old healthy male presented with irritation, pain and reduced vision in his left eye after mud contamination. Examination demonstrated corneal stromal infiltration, endothelial plaque and hypopyon. Corneal scrapings demonstrated numerous septate hyphae, and specimen cultures were positive for Chrysosporium sp. The lesion did not respond to aggressive topical 5% natamycin, 0.15% topical amphotericin B and oral itraconazole. The patient was then treated by topical 1% voriconazole every hour. Intracameral and intrastromal voriconazole injections (50 µg/0.1 mL) were also undertaken. The keratitis was significantly improved after voriconazole. CONCLUSION: To the best of the authors' knowledge, this is the first report on the use of voriconazole for Chrysosporium keratitis. Voriconazole may be an effective alternative to conventional antifungal agents in some cases of fungal keratitis. It should be considered before shifting to therapeutic keratoplasty.

Penicillium keratitis in a HIV-infected patient.

A 36-year-old HIV-positive man presented with symptoms of redness, blurred vision and foreign body sensation in his right eye for 3 months. The slit lamp examination revealed deep stromal infiltration with a feathery margin in an otherwise minimal anterior chamber reaction. A corneal scraping was negative. Confocal microscopy demonstrated an abnormal large hyper-reflective oval shape in the corneal stroma. Corneal infiltration did not show improvement after topical, intrastromal and intracameral antifungal treatment. Therapeutic penetrating keratoplasty was performed to eradicate the infection. Corneal button culture and histopathological results confirmed the diagnosis of Penicillium marneffei keratitis. No recurrent infection occurred after corneal transplantation. This appears to be the first report of P. marneffei keratitis in an HIV-infected patient. Although it is an uncommon condition, it should be one of the differential diagnoses in an HIV-infected patient presenting with keratitis.

Outcome of Therapeutic Penetrating Keratoplasty Using Glycerol-Preserved Donor Corneas in Infectious Keratitis.

PURPOSE: To report the surgical outcomes and complications of therapeutic penetrating keratoplasty (TPK) using glycerol-preserved corneas in infectious keratitis. METHODS: This is a retrospective, noncomparative case series of patients with severe infectious keratitis who received TPK using glycerol-preserved corneas from 2004 to 2014 in the Department of Ophthalmology, Srinagarind Hospital, Khon Kaen University. The medical records were reviewed for baseline characteristics, visual outcomes, recurrence rate, wound integrity, secondary glaucoma, and donor cornea storage times. RESULTS: Twenty-two eyes from 22 patients were included. Age ranged from 28 to 85 years and the donor cornea sizes ranged from 7.5 to 9.5 mm. The most common causative agents were fungi (16/22, 72.7%). Eleven patients (50.0%) developed secondary glaucoma and 7 patients (31.8%) had wound leakage. Recurrence of infection was observed in 15 patients (68.2%) and 9 patients (40.9%) received enucleation or evisceration. Thirteen globes (59.1%) were saved and the final visual acuites ranged from 1/60 to light perception. The storage times of donor corneas varied between 2 days and 62 months. The length of donor cornea storage did not affect the success rate of surgical outcome. CONCLUSIONS: TPK using glycerol-preserved corneas has a high rate of secondary glaucoma and recurrence of infection with unsatisfactory visual results. These corneas may be used as temporary emergency transplants in infectious keratitis when fresh corneas are unavailable to meet demands.

Clinical Features, Risk Factors, and Treatments of Microsporidial Epithelial Keratitis.

OBJECTIVE: To report the clinical manifestations, risk factors, and treatments of microsporidial epithelial keratitis in Thailand. METHODS: Twenty eyes of 19 patients were diagnosed and the clinical presentations, risk factors, and management were analyzed. RESULTS: Of 19 patients, six patients (32%) had no apparent risk factors. Predisposing factors included soil exposure (6/19, 32%), water contamination (6/19, 32%), and eye liner (1/19, 4%). Twelve cases (63%) were detected in the rainy season. All cases presented with disseminated, punctated, elevated, epithelial keratitis. Corneal scrapings with Gram-chromotrope staining were positive in all patients. Moxifloxacin 0.5% eye drops were given and all 16 patients experienced complete resolution. Three recurrent cases were resolved with only topical moxifloxacin without corneal scraping or swabbing. CONCLUSIONS: Predisposing factors were not found in some patients; thus, corneal scraping with staining should be considered in cases having a high index of suspicion. The incidence is increased during the rainy season; therefore, clinicians should have more awareness during these times. Debridement with topical moxifloxacin eye drops, without any systemic medication, may be an effective treatment. Corneal scraping or swabbing may not be required in recurrences.

A randomized controlled trial comparing dexamethasone with loteprednol etabonate on postoperative photorefractive keratectomy.

PURPOSE: To compare loteprednol etabonate 0.5%/tobramycin 0.3% (Zylet(®)) with dexamethasone 0.1%/tobramycin 0.3% (Tobradex(®)) in terms of the epithelial healing time, postoperative visual acuity, corneal haziness score, and intraocular pressure (IOP) in postoperative treatment after photorefractive keratectomy (PRK). METHODS: This prospective, randomized, double-masked (participants and assessors blinded) controlled study included 32 patients who underwent PRK. The patients were allocated equally into 2 groups by block randomization to receive either loteprednol etabonate (Lot) or dexamethasone (Dex) for 1 month after the surgery. The epithelial healing time, uncorrected visual acuity (UCVA), corneal haziness score, and IOP were evaluated at 1 week, 1 month, and 3 months. RESULTS: The corneal epithelium was healed within 3 days in both groups; however, the epithelium was closed on the second day in 3 cases in the Lot group compared with 1 case in the Dex group. No significant differences were found for UCVA at 1 and 3 months (Fisher exact test, P>0.01). Similarly, there was no statistically significant difference in corneal haziness scores between the 2 groups at 1 and 3 months (Mann-Whitney U test, P>0.05). The number of patients experiencing significantly increased IOP (≥5 mmHg) from baseline at any visit for the Lot group (1/16 patients) was fewer than for the Dex group (3/16 patients). CONCLUSIONS: Loteprednol etabonate was effective in postoperative PRK management and was significantly less likely to produce elevations in IOP than was dexamethasone.

Contamination risk of 100% autologous serum eye drops in management of ocular surface diseases.

PURPOSE: To evaluate the sterility and safety of 100% nonpreserved, autologous, serum eye drop treatment in patients with ocular surface diseases. METHODS: A total of 147 autologous serum bottles (294 samples) from 21 patients with ocular surface diseases were included. Seven bottles with autologous serum were prepared for each patient, and each bottle was used for only 1 day, then discarded. Two samples from each bottle were taken (before use and after 24 hours of use) and then cultured in standard media. The culture plates were held for at least 6 weeks or until no growth could be confirmed. To monitor safety, all patients were admitted and evaluated for the occurrence of infection. RESULTS: In the pretreatment group, 4 samples from 4 patients (1.36%) were positive for bacteria and 7 samples from 7 patients (2.38%) were positive for fungi. In the 24-hour-after-treatment group, 1 culture (0.34%) was positive for bacteria, and 6 samples (2.04%) from 6 patients were positive for fungi. Aspergillus spp and Fonsecaea spp were the most common organisms identified in any of the cultures. Neither clinical nor microbiological evidence of infection was demonstrated in any patient during the treatment or follow-up periods. CONCLUSIONS: Although no ocular surface infection was observed, the patients under 100% autologous serum eye drops therapy should be closely monitored for clinical evidence of fungal and bacterial infections.