Amniotic Membrane Transplantation in the Management of Corneal Ulceration Following Infectious Keratitis.

PURPOSE: To report on the outcomes of amniotic membrane transplantation (AMT) for corneal ulceration following infectious keratitis. METHOD: In this retrospective cohort study of 654 patients with culture-proven infectious keratitis from 8 hospitals in Galicia (Spain), a total of 43 eyes of 43 patients (6.6%) underwent AMT for postinfectious corneal ulceration. The indications for AMT were sterile persistent epithelial defects, severe corneal thinning or perforation. RESULTS: AMT was successful in 62.8% of cases, with 37.2% requiring an additional surgery. Median time to healing was 40.0 days (IQR 24.2-101.7 days) and final BCVA was lower than baseline (p = 0.001). Ulcers were large (>3 mm) in 55.8% of cases. Previous herpetic keratitis and topical steroid use were more common in patients who received AMT (p < 0.001). 49 microorganisms (43 bacteria and 6 fungi) were isolated. CONCLUSIONS: AMT is a therapeutic option for complications following infectious keratitis, which present with a sterile persistent epithelial defect, significant corneal thinning or perforation.

Necrotizing scleritis due to Hormographiella aspergillata.

PURPOSE: To report the management and outcome of a case of necrotizing scleritis due to Hormographiella aspergillata. METHODS: Case report. RESULTS: A 79-year-old woman developed scleral inflammation following accidental trauma with a gorse plant in her left eye. An abscess formed at the site of the injury, which was surgically drained. Filamentous fungi were identified from the abscess contents, and oral voriconazole and topical voriconazole and natamycin drops were prescribed. Phenotypic analysis confirmed the presence of Hormographiella aspergillata, with low minimum inhibitory concentrations (MIC) for voriconazole and amphotericin B. Two weeks later the patient presented with an area of necrotizing scleritis which required surgical debridement and scleral grafting. Three months later, the scleral inflammation had resolved leaving an area of scleromalacia. CONCLUSIONS: Hormographiella aspergillata is a common environmental fungus that has recently emerged as a human pathogen and a rare cause of scleritis. To the best of our knowledge, this is the first report of scleritis in which a pure culture of H. aspergillata was obtained. Successful management poses a challenge as there are limited reports on antifungal susceptibility and a combination of medical and surgical treatment is often required.

Corneal Ulcer due to Monkeypox Infection.

PURPOSE: To report a rare case of keratitis due to monkeypox infection. METHODS: A 45-year-old male presented with an epithelial corneal ulcer 20 days following initial diagnosis of monkeypox from genital and perioral lesions. PCR analysis of the epithelium confirmed the presence of human monkeypox virus. RESULTS: The patient was hospitalized, and ganciclovir gel, as well as povidone iodine 0.6% and moxifloxacin eyedrops were prescribed. Oral tecovirimat 600 mg was administered during 14 days. A therapeutic contact lens was used. Twenty days after the initial diagnosis of keratitis, the corneal defect closed leaving a faint subepithelial haze, and visual acuity was 0.8. CONCLUSIONS: This is an uncommon case report of epithelial keratitis due to human monkeypox. PCR positivity for monkeypox in the corneal epithelium confirmed the presence of viral material in the cornea.

Clinical evaluation of meibomian gland dysfunction in patients with keratoconus.

PURPOSE: To investigate the association of keratoconus (KC) with meibomian gland dysfunction (MGD) and to describe the epidemiological characteristics of MGD in this disease. METHODS: In this observational study, 120 KC patients seen in the Department of Ophthalmology of the Complexo Hospitalario Universitario de Santiago de Compostela and 87 controls were analyzed. The Ocular surface disease index (OSDI) questionnaire was administered and several DED tests and an evaluation of the meibomian glands and lid margin were performed. MGD signs and DED tests were compared between the groups. Symptoms were further analyzed in patients and controls with and without MGD. RESULTS: KC was significantly associated with MGD after adjusting for age and sex [adjusted odds ratio (ORa), 2.40]. The frequency of MGD in KC patients [59 (49.2%) KC patients and 25 (28.7%) controls had MGD] correlated with the severity of KC (r = 0.206) (P = 0.020). Mean OSDI score in KC patients with and without MGD was 31.1 ± 24.1 and 35.2 ± 26.0 (P = 0.326), and 17.2 ± 22.7 and 13.3 ± 14.1 in controls with and without it (P = 0.366). The most common MGD signs coincided in both groups. Staining with fluorescein (P = 0.000) and lissamine green (P = 0.019) was higher in KC patients, but no differences were detected with TBUT (P = 0.116) or the Schirmer test (P = 0.637). Hypersecretory MGD was the most prevalent variant in both groups. CONCLUSIONS: MGD and DED are common in KC patients. MGD correlates with the severity of KC and is indistinguishable from MGD in patients without KC. No association was found with symptoms. Patients with KC should be screened for MGD because of its possible clinical implications. Further research is needed to clarify the role of MGD in KC patients.

SARS-CoV-2 in Conjunctiva and Tears and Ocular Symptoms of Patients with COVID-19.

This study investigates the presence of SARS-CoV-2 in conjunctival secretions and tears and evaluates ocular symptoms in a group of patients with COVID-19. We included 56 hospitalized patients with COVID-19 in this cross-sectional cohort study. Conjunctival secretions and tears were collected using flocked swabs and Schirmer strips for SARS-CoV-2 reverse-transcriptase polymerase chain reaction (RT-PCR). Assessment of ocular surface manifestations included an OSDI (Ocular Surface Disease Index) questionnaire. Patients had been admitted to hospital for an average of 2.4 days (range 0-7) and had shown general symptoms for an average of 7.1 days (range 1-20) prior to ocular testing. Four (7.1%) of 56 conjunctival swabs and four (4%) of 112 Schirmer strips were positive for SARS-CoV-2. The mean E-gene cycle threshold values (Ct values) were 31.2 (SD 5.0) in conjunctival swabs and 32.9 (SD 2.7) in left eye Schirmer strips. Overall, 17 (30%) patients presented ocular symptoms. No association was found between positive ocular samples and ocular symptoms. This study shows that SARS-CoV-2 can be detected on the conjunctiva and tears of patients with COVID-19. Contact with the ocular surface may transmit the virus and preventive measures should be taken in this direction.

Prevalence of conjunctival shrinkage and its association with dry eye disease: results from a population-based study in Spain.

PURPOSE: The aim of this study was to describe the epidemiological characteristics of conjunctival shrinkage (CS) and the association between this disorder and dry eye disease (DED) in a general adult population in northwestern Spain. METHODS: A total of 1155 subjects 40 years or older were selected using an age-stratified random sample procedure in O Salnés (Spain). A standardized DED symptom questionnaire was administered, and a comprehensive ophthalmic evaluation that included DED tests was carried out. Disappearance of half or more of any of the lacunar folds after maximum abduction was considered evidence of CS. The prevalence and associations of CS and its relationship with DED symptoms and signs were investigated. RESULTS: From 937 eligible subjects, 622 (66.4%) participated [mean age (SD), 63.4 (14.5) years, range, 40-96, 37.0% males]. The prevalence of CS was 38.2% [95% confidence interval (CI), 35.0-41.5]. This prevalence increased with aging (P < 0.001) and was not associated with sex (P = 0.696). The prevalence of symptoms, abnormal tear breakup time, fluorescein and rose bengal staining was significantly higher among subjects with CS. After controlling for age and sex, outdoor activity was directly (adjusted odd ratio, 1.83) and high level of education was inversely (adjusted odd ratio, 0.43) associated with CS. No associations were found with ocular or systemic diseases. CONCLUSIONS: CS is a common pathological reaction that can be used as an indicator of moderate to severe DED. Aging and outdoor activity are strongly associated factors. The simplicity and reproducibility of this diagnosis recommend its inclusion in DED diagnostic and grading schemes.

Donor age and gestational age influence on growth factor levels in human amniotic membrane.

PURPOSE: Amniotic membrane (AM) is used as a biomaterial for reconstruction in ocular surface surgery. This study investigated the influence of interdonor variations and processing and preservation procedures applied to the AM on growth factors and protein levels. METHODS: Samples of human AM from thirteen donors were analysed. Collected donor data were age, parity and gestational age. Total protein amount was measured in extracts of intact AM nonpreserved, lyophilized and cryopreserved, at -80°C and in liquid nitrogen. An enzyme-linked immunosorbent assay (ELISA) was used to assay growth factors protein levels for epidermal growth factor, basic fibroblast growth factor (bFGF), hepatocyte growth factor (HGF), keratinocyte growth factor (KGF), transforming growth factor beta1 (TFG-ß(1) ) and nerve growth factor (NGF). Univariate and multivariate statistical analyses were used to study the influence of the preservation method applied and interdonor variations on growth factors levels. RESULTS: We detected important variations in growth factors and protein concentrations between samples from different donors. Total protein amount, bFGF, HGF, KGF and TGF-ß(1) showed lower levels in samples from donors with higher gestational ages and donor ages, for all groups. CONCLUSION: The variability in the biochemical composition of AM from different donors is considerable, and it is related with donor factors as donor age and gestational age. As AM biochemical composition has a role in its therapeutic effects, these variations could affect the clinical results of amniotic membrane transplantation and must be taken into account in donor selection processes.

Corneal Imaging with Pentacam After Descemet's Membrane Perforation During Deep Anterior Lamellar Keratoplasty.

The usefulness of Pentacam in the diagnosis and management of Descemet's membrane perforation during deep anterior lamellar keratoplasty (DALK) was described and reported. A 59-year-old man with neurotrophic keratitis was operated on DALK procedure. The big-bubble technique was used without apparent complications. A double anterior chamber was observed on the first postoperative day. After days, sulphur hexafluoride (SF(6)) in isoexpansile concentration was successfully injected into the anterior chamber. The Pentacam (Oculus, Wetzlar, Germany) imaging was performed. Correlations between Pentacam findings and clinical signs were evaluated. Pentacam imaging is a useful technique to diagnose and document the progress of surgical complications after DALK.

Effects of lyophilization on human amniotic membrane.

PURPOSE: This study aimed to evaluate the effects of lyophilization and cryopreservation on human amniotic membrane (HAM) in terms of histological characteristics and growth factor levels. METHODS: Non-preserved, lyophilized and cryopreserved HAM samples from 13 placentas were investigated. The morphological characteristics of HAM were evaluated using light and electron microscopy. Immunohistochemical methods were also applied to assess the distribution of collagen IV in the basement membrane. Total protein amounts were measured in extracts of intact amniotic membrane from non-preserved, lyophilized and cryopreserved samples. An enzyme-linked immunosorbent assay (ELISA) was used to assay growth factor protein levels for epidermal growth factor, fibroblast growth factor basic, hepatocyte growth factor, keratinocyte growth factor, transforming growth factor-beta1 and nerve growth factor. RESULTS: Histological examination of lyophilized and cryopreserved human amniotic membrane showed similar results. Immunohistochemistry showed presence of collagen IV throughout the basement membrane, both in cryopreserved and lyophilized samples. Total protein amount was higher in cryopreserved samples, without statistical significance. Growth factors ELISA did not show statistically significant differences except for fibroblast growth factor basic, with higher levels in cryopreserved amniotic membrane. CONCLUSIONS: Lyophilization maintains the histological structure of HAM, but seems to cause greater reductions in total protein amount and growth factor concentration than cryopreservation.

Pterygium surgery: conjunctival autograft using a fibrin adhesive.

PURPOSE: To evaluate the efficiency and safety of using a fibrin adhesive (Tissucol Duo, Baxter AG, Vienna, Austria) to avoid the need for sutures during conjunctival autograft surgery for primary pterygium. METHODS: Twenty patients (20 eyes) with primary nasal pterygium were subjected to conjunctival autograft surgery. The free conjunctival graft placed over the bare sclera was fixed to the surrounding conjunctiva and cornea using the fibrin glue. An occlusive patch was applied. The outcome of surgery and any possible complications were periodically assessed. RESULTS: Mean patient age was 54.9 years (28-75 years). The mean follow-up time was 26.05 +/- 3.15 (SD) weeks. The time of surgery was 15 to 20 minutes. During the postoperative course, none of the patients felt pain, and only 5/20 (25%) had the mild sensation of the presence of a foreign body. In 18/20 (90%) patients, the conjunctival autograft was observed to be correctly positioned and fixed in all the follow-up exams. No sutures were used during or after surgery. There were no cases of regrowth of the pterygium. CONCLUSION: Our findings demonstrate the safety and efficiency of Tissucol Duo as a conjunctival adhesive for pterygium autograft surgery as treatment of primary pterygium. Because of its fast and easy application, this product considerably reduces the time of surgery. Its use also avoids complications derived from sutures and diminishes the sensation of a foreign body in the eye following surgery.

Fluorescein angiographic features of the congenital hypertrophy of the retinal pigment epithelium in the familial adenomatous polyposis.

PURPOSE: To asses the prevalence of fluorescein angiographic features in bilateral and multifocal Congenital Hypertrophy of the Retinal Pigment Epithelium (CHRPE) in patients with a diagnosis of familial adenomatous polyposis. METHODS: We performed prospective angiographic and clinical examination of 49 CHPRE lesions in 15 patients. RESULTS: About 77.5% of CHRPE lesions were close to retinal vessels. The retinal vascular changes observed overlying and surrounding the CHRPE were: capillary non-perfusion with an area greater than 0.5 disc diameters (41%), capillary microaneurysms (4%), chorioretinal anastomoses (6.2%), attenuation of retinal vessels (4%), choriocapillary vessels inside the lacunae (6.2%) and in the depigmented marginal halo (18.4%). Depigmented streaks in contact with one or both edges of the CHRPE were observed in 79.6% of the lesions. About 9.6% of the lesions were not seen on ophthalmoscopy and could only be detected by angiography. CONCLUSIONS: Even though the diagnosis of CHRPE is clinical, fluorescein angiography may be useful in confirming the diagnosis, as well as detecting additional lesions not seen by means of ophthalmoscopic examination.

Value of the congenital hypertrophy of the retinal pigment epithelium in the diagnosis of familial adenomatous polyposis.

BACKGROUND: Several kinds of congenital hypertrophy of the retinal pigment epithelium (CHRPE) have been described in patients with familial adenomatous polyposis (FAP). This study aims to assess which properties of CHRPE better predict FAP and investigate whether a relationship exists between specific CHRPE characteristics and FAP variants. METHODS: We examined 286 subjects, Group I--patients with FAP plus individuals "at risk"; n = 173; Group II--controls n = 113. Retinal lesions were classified in five types (A-E) and different characteristics (distribution, number, shape, size, pigmentation and site) were evaluated. RESULTS: The most common lesions in affected subjects were types A-D (83.4%) whilst in the "at risk" and control groups were type E. Greater numbers of lesions and bilateral distribution occurred more frequently among affected subjects than in other participants (p < 0.001). Large lesions with mixed pigmentation were associated with polyposis (p > 0.5). Controls had solitary CHRPE lesions (3.5%) and types C and E lesions (23%). The cumulative sensitivities and specificities of CHRPE were 42 and 97%, respectively. CHRPE was most common among those with classical FAP, but no specific characteristic was associated with any particular FAP variant. CONCLUSIONS: Pigmented fundal lesions are highly pleomorphic and represent the variable expression of a common genetic defect of growth regulation. No association was found between CHRPE characteristics and specific FAP variants.

Multilayer amniotic membrane transplantation in the treatment of corneal perforations.

PURPOSE: To determine if multilayer amniotic membrane transplantation (AMT) is useful in the treatment of corneal perforations, and in particular to assess to what extent efficacy is affected by perforation size. METHODS: Fifteen patients (15 eyes) with corneal perforations of different sizes were divided into 3 groups: group A (microperforation, 6 eyes), group B (0.5-1.5 mm, 4 eyes), and group C (>1.5 mm, 5 eyes). The corneal perforation was caused by autoimmunity-related ulcer (3 eyes), neurotrophic ulcer (9 eyes), infectious keratitis (1 eye), or postkeratoplasty ulcer (2 eyes). Two layers of AM (for microperforations) or 3-4 layers (for the other groups) were trimmed to the size of the ulcer and sutured in place with interrupted 10-0 nylon sutures. In all cases, a bandage contact lens was then applied. RESULTS: Mean epithelialization time was 3.7 weeks (range 2-6). Mean time to recovery of corneal stroma thickness was 10.1 weeks (range 7-15). In all cases, ocular inflammation subsided within 2-5 weeks. The treatment was judged successful in 73% (11/15) of eyes. Three of the 4 unsuccessful treatments were of perforations 3 mm or more in diameter; of the 5 eyes with perforations of more than 1.5 mm in diameter, only 2 were treated successfully. CONCLUSIONS: These results suggest that multilayer AMT is effective for treating corneal perforations with diameter less than 1.5 mm. The technique may be a good alternative to penetrating keratoplasty, especially in acute cases in which graft rejection risk is high.

Topical mitomycin C in the treatment of pigmented conjunctival lesions.

PURPOSE: To assess the clinical efficacy of topical mitomycin C (MMC) 0.04% for the treatment of patients with pigmented conjunctival lesions. Clinical efficacy was evaluated on the basis of reduction in lesion size and degree of pigmentation and histologic study. METHODS: Two patients, one with primary acquired conjunctival melanosis with atypia and another with conjunctival melanoma, were treated with topical MMC 0.04%. Before treatment, a biopsy was performed that confirmed the diagnosis and the absence of atypical melanocytes beyond the basal layer. In both patients, MMC was administered with sponges, while one patient additionally received MMC 0.04% drops. Each treatment cycle lasted 14 days, with repetition after 3 months when necessary. Follow-up was weekly, then monthly, and then every 6 months up to 3 years. RESULTS: Treatment with topical MMC 0.04% not only reduced the size and degree of pigmentation clinical lesions in both patients but also eradicated atypical conjunctival melanocytes as observed in histologic studies. In the patient with primary acquired conjunctival melanosis, adjunct cryotherapy was required, along with various cycles of MMC, to reduce the pigmented areas of skin of the internal canthus and caruncle. In the second case, only MMC was used. No severe adverse reactions to the treatment were observed. After 3 years of follow-up, no clinical relapse has been detected. CONCLUSION: Topical MMC 0.04% is an option worth considering for the treatment of pigmented conjunctival lesions, particularly as an adjunct to other forms of treatment.