Exophiala jeanselmei keratitis: case report and review of literature.

PURPOSE: To describe a patient with Exophiala jeanselmei keratitis and to review the prior cases reported in the literature. METHODS: We report one patient with keratitis after remote injury and chronic steroid use and review the six prior reported cases. RESULTS: Culture plates from corneal scraping revealed growth of the dematiaceous fungi, E. jeanselmei, a rare causative organism of ocular infection. The patient underwent therapy with topical and intracameral antifungals and subsequently required a corneal transplant. Biopsy of the donor graft confirmed the diagnosis of E. jeanselmei. This is the first reported case to use intracameral antifungal agents and the first biopsy proven case. Half of reported cases experienced associated trauma, and severity was generally related to delay in diagnosis. CONCLUSIONS: Trauma and chronic topical steroid use contributed to the development of severe keratitis in this patient. Patients on chronic steroids should be monitored closely. Topical, subconjunctival, and intracameral antifungals have all been effective in treating this pathogen. If diagnosed and treated early, E. jeanselmei keratitis can have a good visual outcome.

Fungal keratitis and contact lenses: an old enemy unrecognized or a new nemesis on the block?

PURPOSE: To review studies of fungal keratitis related to contact lenses and determine whether the recent insurgence is a new phenomenon or an exacerbation of an ongoing trend. METHODS: A review of the recent literature on contact lens-related fungal ulcers and a comparison to older studies. RESULTS: The incidence of fungal keratitis associated with contact lenses increased from 5% in the 1980s to between 10% and 25% in the 1990s and was noted to be 44% in Florida at the turn of the century. The most recent study from Florida showed that the incidence had increased from 29% in the late 1990s to 52% in the early 2000s, even before the Fusarium keratitis epidemic in 2004 and 2005. This increase mainly represented an increase in the number related to nontherapeutic contact lenses. CONCLUSIONS: Contact lens-related fungal keratitis was relatively rare 20 years ago. However, the incidence has progressively increased since then. Contact lens-related fungal ulcers had become more common even before the recent Fusarium keratitis epidemic. This change may be related to changing contact lens care habits and younger patients being fitted with contact lenses.

Fungal keratitis: emerging trends and treatment outcomes.

PURPOSE: To review the trends, risk factors, causative organisms, treatment, and outcomes of fungal keratitis at the authors' institution. METHODS: A retrospective review of the records of consecutive patients diagnosed with fungal keratitis at the authors' institution from January 1999 to June 2006. RESULTS: Eighty-four patients were diagnosed with fungal keratitis during this period. The average age of the patients was 48 years, and 64% were male. Until 2004, trauma (51%) and contact lens use (40%) were the major risk factors. After 2005, contact lens use (52%) surpassed trauma as the most common risk factor (29%). The percentage of fungal ulcers caused by nontherapeutic contact lenses increased from 21% between 1999 and 2001 to 32% between 2002 and 2004 and to 45% in 2005 and 2006. Eighty-six percent of cultured organisms were filamentous. Fusarium (41%) was the most commonly isolated genus, followed by Candida (14%), Curvularia (12%), and Aspergillus (12%). Visual acuity was worse than 20/200 in 56% of patients at presentation. Final visual acuity was 20/40 or better in 70% of patients treated with medication alone and 16% of patients requiring therapeutic keratoplasty. Surgical intervention in the acute phase was necessary in 23% of patients. Seventy-four percent of medically treated patients had dual topical antifungal therapy. Natamycin 5% and amphotericin B 0.15% were the most commonly used drugs. CONCLUSIONS: Contact lenses are a major risk factor for fungal keratitis. The incidence of contact lens-related fungal keratitis was increasing even before the Fusarium outbreak in 2005 and 2006. Good visual outcomes can be achieved by aggressive dual topical antifungal therapy.

Is addition of a third or fourth antiglaucoma medication effective?

PURPOSE: To study the intraocular pressure (IOP)-lowering effect of adding a third or a fourth antiglaucoma medication to preexisting antiglaucoma medical therapy, for a follow-up period of one year. PATIENTS AND METHODS: The authors performed a retrospective, nonrandomized, noncomparative, interventional study including all patients seen by a single glaucoma specialist at the University of Florida Eye Clinic between January 1, 2000 and December 31, 2000, who had a third or a fourth antiglaucoma medication added to their existing regimen of two or three antiglaucoma medications, respectively. The main outcome measured was IOP at 2, 6, 9, and 12 months after addition of an antiglaucoma medication. "Efficacy" success was defined as a decrease in intraocular pressure of greater than or equal to 20% from baseline, without a change in the antiglaucoma medical therapy. Also, "safety outcome" was analyzed based on the need for surgical intervention and/or the occurrence of intolerable side effects to the antiglaucoma medications leading to discontinuation of their use. RESULTS: Sixty-seven patients had a third, and 29 patients had a fourth antiglaucoma medication added to their existing regimen. Analysis for a specific time point showed a success rate of 48% at 2 months (n = 65), 47% at 6 months (n = 47), and 41% at 1 year (n = 39) after addition of a third antiglaucoma medication and 59% at 2 months (n = 29), 45% at 6 months (n = 22), and 55% at 1 year (n = 20) after addition of a fourth antiglaucoma medication. By Kaplan-Meier analysis the cumulative probability of achieving efficacy success (> or = 20% IOP decrease from baseline) was 33% at 6 months and 23% at 1 year after adding a third medication (Group A), and 43% at 6 months and 18% at 1 year after adding a fourth medication (Group B). Combining both efficacy and safety outcomes decreased the cumulative probability of success to 27% and 14% in Group A, and 31% and 14% for Group B, at 6 months and 1 year respectively. CONCLUSION: Addition of a third and fourth antiglaucoma medication produces a clinically significant reduction in IOP in about 40 to 60% of patients at any single time point. However, the cumulative probability of success including safety outcomes is relatively poor at 6 months and 1 year. This suggests that adding another antiglaucoma medication to a regimen of two or three medications frequently does not achieve a significant (> or = 20%) fall in IOP.

Expression of connective tissue growth factor after glaucoma filtration surgery in a rabbit model.

PURPOSE: Connective tissue growth factor (CTGF) appears to play a significant role in mediating fibrosis in several tissues. To gain further understanding of the role of CTGF in the scar formation that occurs after glaucoma filtering surgery (GFS), experiments were performed in a rabbit model. METHODS: . Three experiments were performed: (1) CTGF and transforming growth factor (TGF)-beta expression were measured quantitatively after GFS, using ELISA. (2) After GFS conjunctival bleb tissues were immunostained for the presence of CTGF and TGF-beta. (3) Exogenous CTGF was injected into mitomycin-C (MMC)-treated filtering blebs and the scaring response compared to TGF-beta and physiological saline-injected blebs. RESULTS: CTGF and TGF-beta were expressed maximally by day 5 after surgery and were both shown to be present in the bleb tissues after GFS. The addition of exogenous CTGF and TGF-beta increased the rate of failure of GFS blebs. CONCLUSIONS: These data support the hypothesis that CTGF plays an important role in scarring and wound contracture after GFS. Inhibition of CTGF synthesis or its action may help prevent bleb failure and improve long-term GFS outcomes.