Search

Objective Fungal keratitis is a serious ocular infection that is considered to be rare among contact lens wearers. The recent Fusarium keratitis outbreak raised questions regarding the background rate of Fusarium -related keratitis and other fungal keratitis in this population. Design Retrospective, multicenter case series. Participants Six hundred ninety-five cases of fungal keratitis cases who presented to 1 of 10 tertiary medical centers from 2001 to 2007. Methods Ten tertiary care centers in the United States performed a retrospective review of culture-positive fungal keratitis cases at their centers between January 2001 and December 2007. Cases were identified using microbiology, pathology, and/or confocal microscopy records. Information was collected on contact lens status, method of diagnosis, and organism(s) identified. The quarterly number of cases by contact lens status was calculated and Poisson regression was used to evaluate presence of trends. The Johns Hopkins Medicine Institutional Review Board (IRB) and the IRBs at each participating center approved the research. Main Outcome Measures Quarterly number of fungal keratitis cases and fungal species. Results We identified 695 fungal keratitis cases; 283 involved the use of contact lenses. The quarterly number of Fusarium cases increased among contact lens wearers (CLWs) during the period that ReNu with MoistureLoc (Bausch & Lomb, Rochester, NY) was on the market, but returned to prior levels after withdrawal of the product from the market. The quarterly frequency of other filamentous fungi cases showed a statistically significant increase among CLWs comparing October 2004 through June 2006 with July 2006 through December 2007 with January 2001 through September 2004 ( P Conclusions The quarterly number of Fusarium fungal keratitis cases among CLWs returned to pre-Renu with Moistureloc levels after removal of the product from the market. However, the number of other filamentous fungal keratitis cases, although small, seems to have increased among refractive CLWs. Reasons for these apparent increases are unclear. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references.

Background: Histopathologic studies of this unusual keratitis caused by Capnocytophaga species have not been reported previously. Methods: The authors report the light microscopic and ultrastructural findings of three patients with a distinctive necrotizing keratitis caused by an anaerobic gramnegative bacillus. In three patients, ages 19, 81, and 91 years, a necrotizing stromal keratitis developed; two of these patients had a previous penetrating keratoplasty for pseudophakic bullous keratopathy. The first patient did not have ocular surgery previously and was treated initially for presumed Acanthamoeba keratitis. Results: By light microscopy, all three keratectomy specimens were strikingly similar and showed a necrotizing and/or suppurative stromal keratitis displaying myriad slender, fusiform, gram-negative bacilli located anterior to Descemet's membrane and extending into the deep corneal stroma, assuming a "picket fence" appearance. Cultures of the cornea in case 1 grew Capnocytophaga ochracea . For the remaining two patients, a diagnosis presumptively was made based on characteristic histopathologic features. Results of electron microscopic examination showed numerous bacilli that were mostly extracellular; occasional organisms were phagocytosed by macrophages. Conclusion: The histopathologic features of Capnocytophaga keratitis are unique; therefore, a presumptive diagnosis can be made based on the morphology and location of the bacilli in the keratectomy specimens. To the authors' knowledge, this is the first study describing the typical histopathologic and electron microscopic findings of Capnocytophaga keratitis.

Purpose: To evaluate the efficacy of topical corticosteroids in treating herpes simplex stromal keratitis. Methods: The authors performed a randomized, double-masked, placebo-controlled, multicenter clinical trial of 106 patients with active herpes simplex stromal keratitis who had not received any corticosteroids for at least 10 days before study enrollment. Patients were assigned to the placebo group (n = 49) or the steroid group (topical prednisolone phosphate; n=57); both regimens were tapered over 10 weeks. Both groups received topical trifluridine. Visual acuity assessment and slit-lamp biomicroscopy were performed weekly for 10 weeks, every other week for an additional 6 weeks or until removal from the trial, and at 6 months after randomization. Results: The time to treatment failure (defined by specific criteria as persistent or progressive stromal keratouveitis or an adverse event) was significantly longer in the steroid group compared with the placebo group. Compared with placebo, corticosteroid therapy reduced the risk of persistent or progressive stromal keratouveitis by 68%. The time from randomization to resolution of stromal keratitis and uveitis was significantly shorter in the steroid group compared with the placebo group even though both groups included patients who were removed from the study and treated with topical corticosteroids according to best medical judgment. Nineteen (33%) of the steroid-treated patients and 11(22%) of the placebo-treated patients completed the 10 weeks of protocol therapy and had stable, noninflamed corneas after 16 weeks. At 6 months after randomization, no clinically or statistically significant differences in visual outcome or recurrent herpetic eye disease were identified between the steroid and placebo groups. Conclusions: The topical corticosteroid regimen used in this study was significantly better than placebo in reducing persistence or progression of stromal inflammation and in shortening the duration of herpes simplex stromal keratitis. Postponing steroids during careful observation for a few weeks delayed resolution of stromal keratitis but had no detrimental effect as assessed by visual outcome at 6 months.

Background: Infectious crystalline keratopathy is a distinctive clinical entity characterized by bacterial replication within the cornea without inflammation. The authors report on a patient with infectious crystalline keratopathy due to Streptococcus pneumoniae serotype 11F. They used this isolate to study the contribution of the pneumococcal polysaccharide capsule to the pathogenesis of the infectious crystalline keratopathy. Methods: Aliquots containing 10 6 colony-forming units of pneumococci serotype 11F, serogroup 9 or 15, were inoculated into New Zealand white rabbit corneas. The corneas were examined at 24, 48, and 72 hours. Representative corneas were excised at 24 hours and processed for histopathologic analysis. Results: Pauci-inflammatory crystalline lesions developed in all corneas inoculated with the serotype 11F ocular isolate by 24 hours. Suppurative keratitis developed in control corneas inoculated with serogroup 9 or 15 pneumococci. The nonocular 11F isolates produced lesions with some features compatible with infectious crystalline keratopathy. Conclusion: Different pneumococcal serotypes vary in their ability to produce infectious crystalline keratopathy. Because serotype differences reflect differences in the antigenic polysaccharides of the bacterial capsule, this study suggests that properties of the pneumococcal capsule may influence the initial development of infectious crystalline keratopathy.

Purpose: Topical corneal anesthetic abuse is a self-inflicted injury, causing profound corneal morbidity. Superimposed infection is an important complicating factor. The authors report four patients with confirmed topical anesthetic abuse of the cornea, in whom Candida keratitis developed. Methods: A retrospective review of the medical records of four patients with confirmed topical corneal anesthetic abuse and fungal keratitis. Results: A 21-year-old woman, two 28-year-old women, and a 35-year-old man were included in the study. All these patients sustained a corneal injury, prompting the chronic use of topical anesthetics (0.5% proparacaine hydrochloride in 3 patients, and 0.5% tetracaine hydrochloride and 0.4% benoxinate hydrochloride in the other). Corneal findings included epithelial defects in all patients, focal infiltrate in one patient, and ringshaped stromal infiltrate in three patients. Topical anesthetic was discontinued, all patients initially were treated empirically with antibacterial agents, and three patients received topical corticosteroids. Subsequent corneal cultures grew Candida spp, Candida albicans specifically in three patients, and local and systemic antifungal therapy was started. Corneas in two patients re-epithelialized; a conjunctival flap was performed on another patient with a descemetocele; and the remaining patient was lost to follow-up, although repeat fungal cultures yielded no growth. Conclusions: Corneal superinfection with Candida may occur during topical anesthetic abuse. Therapy includes discontinuation of the anesthetic and institution of antifungal therapy.

Two 6-month-old white boys developed localized multifocal white nodules of the anterior corneal stroma without evidence of antecedent trauma, inflammatory disease, or familial occurrence. The first patient had bilateral lesions initially; the second patient initially had unilateral involvement followed by a corneal nodule in the second eye at 11 years of age. Light and electron microscopic studies of the lesions in both patients were similar and disclosed stromal nodules composed of proliferating myofibroblasts, activated fibroblasts, and haphazardly arranged fascicles of collagen. Immunohistochemical studies revealed that the spindle cells within the nodules expressed immunoreactivity for vimentin and alpha-smooth muscle actin. Management options for these slowly progressive corneal lesions include lamellar versus penetrating keratoplasty and topical corticosteroids.

Staphylococcus epidermidis has been reported with increasing frequency as a cause of bacterial endophthalmitis. Over the past eight years 18 consecutive postsurgical cases have been treated by combined antibiotic-corticosteroid therapy without intravitreal antibiotics or vitrectomy. Fourteen (78%) achieved a final visual acuity of 20/50 or better. When these cases were added to similarly reported cases in the literature, 72% achieved this level of vision. By contrast, 42% of adequately documented cases in the literature treated by intravitreal antibiotics, and 42% treated additionally by vitrectomy, achieved a vision of 20/50 or better. S. epidermidis is an organism with a low order of virulence. The use of intravitreal antibiotics and vitrectomy do not appear to be necessary for effective treatment.

Successful therapy of postsurgical fungal endophthalmitis is restricted by the lack of safe, effective antifungal agents which penetrate the eye following multiple routes of administration. The proper steps in management of suspected postsurgical fungal endophthalmitis are (1) procurement of intraocular fluid for smear and culture, (2) initiation of broad antifungal therapy, and (3) modification of antifungal therapy based on the clinical response, drug tolerance, and results of laboratory determinations. On the basis of existing data and currently available agents, the preferred initial therapy is topical natamycin (pimaricin) 5%, oral flucytosine, and intravenous amphotericin B. The role of therapeutic pars plana vitrectomy has not been adequately defined. Corticosteroids should not be administered in the early stages of therapy. Miconazole may be an effective alternate agent for exogenous fungal endophthalmitis. This report includes the first case of postsurgical fungal endophthalmitis (Aspergillus conicus) treated successfully with topical and intravenous miconazole.

A randomized, double-masked, placebo-controlled multicenter study was conducted for 6 weeks in 12 centers to evaluate the efficacy and safety of cromolyn sodium 4% ophthalmic solution (Opticrom) for the treatment of active bilateral vernal conjunctivitis. Objective clinical signs were graded weekly by an ophthalmologist while patients kept a daily record of the severity of their symptoms. Sixty-five patients completed the study; 35 received cromolyn sodium and 30 were treated with a matching placebo (the drug vehicle). Statistically significant differences in favor of cromolyn sodium treatment were found for conjunctival injection, limbal injection, limbal edema, tearing, and symptoms summary score. There were few side effects (usually mild stinging and burning which did not require drug stoppage). Only one patient required drug discontinuation for possible drug- or vehicle-related side effects. Cromolyn sodium was found to be significantly more effective than placebo in treating the signs and symptoms of vernal keratoconjunctivitis (VKC). When results were stratified in terms of the atopic status of the patient, it was clear that the allergic patients responded better to cromolyn sodium than did those in whom allergic (IgE-mediated) factors appeared unimportant in the disease process.

Hereditary benign intraepithelial dyskeratosis (HBID) is a rare disorder characterized by autosomal dominant inheritance, onset in childhood, bilateral limbal conjunctival plaques, chronic relapsing course of ocular irritation and photophobia, and oral lesions resistant to medical and surgical therapy. The lesions are characterized histologically by dyskeratosis, acanthosis, parakeratosis, and a variable amount of subepithelial inflammation. The patients in all previously reported cases have been descendants of Halowar Indians from North Carolina. This report illustrates the typical clinical and histologic findings of HBID in two siblings who, along with their parents and grandparents, were born in Texas.

The authors identified nine patients with culture-proven keratitis after radial keratotomy (RK). Three patients became infected in the immediate post-operative period, and six patients had delayed-onset keratitis. Gram-negative rods were the predominant pathogens in late-onset keratitis (4 of 6 infections). Gram-positive cocci were implicated in all three postoperative infections. The inferior corneal quadrants were involved in seven of nine patients. Two episodes of late-onset keratitis were associated with contact lens wear. Five of these patients had transverse incisions or greater than eight radial cuts. All six patients regained visual acuity of 20/40 or better. Two additional cases of early-onset and six cases of late-onset keratitis with many features similar to these cases have been reported previously.

A prospective, randomized, double-masked, placebo-controlled clinical trial was conducted to study the effects of oral acyclovir on 55 patients with acute herpes zoster ophthalmicus. Treatment with oral acyclovir resulted in more prompt resolution of signs and symptoms, particularly in patients treated within 72 hours after onset of skin rash ( P P = 0.03). Interim analysis of this longitudinal study suggests that the incidence and severity of secondary ocular inflammatory disease was reduced by acyclovir. Prolonged observation of these patients is ongoing to determine if oral acyclovir reduces post-herpes zoster neuralgia or the late ocular complications of ophthalmic zoster.

Thirty-eight patients with fungemia were examined prospectively for development of endophthalmitis. Endophthalmitis was present in 10 of 27 (37%) patients with Candida albicans fungemia. Only one patient with nonalbicans fungemia developed endophthalmitis. Of the preselected factors studied, only hemodialysis and parenteral hyperalimentation correlated with an increased incidence of endophthalmitis. Antibody titers by latex agglutination were of little predictive value for endophthalmitis. Antigen titers by latex agglutination were performed in four cases with endophthalmitis. Antigenemia was demonstrated in three of the four patients, all of whom had negative antibody serologies. Although inconclusive, the preliminary data indicate the test may prove to be of clinical value. Periodic ophthalmoscopic examinations should be considered mandatory in the evaluation of patients with fungemia.

Corneal subepithelial infiltration resembling adenoviral keratitis developed in two patients with serologic evidence of systemic Epstein-Barr viral (EBV) infection and nondetectable antibody levels for adenovirus (ADV). These cases suggest that EBV is capable of mimicking more commonly recognized corneal infectious disease entities.

Seventy-one nonimmunocompromised patients with herpes zoster ophthalmicus, presenting within seven days of onset of characteristic skin eruption, were enrolled in a prospective, longitudinal, randomized, double-masked, placebo-controlled trial with oral acyclovir. In a previous interim report we noted more prompt resolution of dermatomal signs and symptoms with acyclovir treatment. There was also a reduction of viral shedding in acyclovir-treated patients coupled with a trend to greater rate of microdissemination of the virus in placebo-treated patients (Cobo LM, et al. Ophthalmology 1985; 92:1574-83). While further substantiating these findings, we report that a ten-day course of treatment with oral acyclovir (600 mg, five times a day) is well-tolerated and significantly reduces the incidence and severity of the most common complications of herpes zoster ophthalmicus: dendritiform keratopathy, stromal keratitis, and uveitis. While this acyclovir treatment regimen reduces the zoster-related pain during the acute phase of the disease, especially in patients treated within 72 hours of onset of skin lesions, it has no evident effect on either incidence, severity, or duration of post-herpetic neuralgia in the patients studied.

The successful management of suppurative microbial keratitis requires five steps: (1) make the clinical diagnosis, (2) perform the proper laboratory procedures, (3) initiate antimicrobial therapy, (4) modify the initial therapy, and (5) terminate therapy. The most helpful guidelines to decision-making in these steps are: (1) the clinical impression, (2) severity of keratitis, (3) results of laboratory studies, (4) disease potential of the responsible organism, and (5) effectiveness and toxicity of various antimicrobial agents. Selection of initial antibiotics ideally should be directed by interpretation of the corneal smears. The preferred initial antibiotic for keratitis caused by a Gram-positive coccus is cefazolin; for a Gram-negative rod, gentamicin; and for a filamentous fungi or yeast, natamycin. Broad, antibacterial therapy should be reserved for suspected bacterial keratitis with negative smears or for severe infections with antecedent treatment. Miconazole may be an effective, alternate agent in fungal keratitis. The safety and efficacy of corticosteroids in microbial keratitis have not been established.

We have identified seven patients with clinical and serological features suggestive of Epstein-Barr viral (EBV) stromal keratitis. Four had discrete, sharply demarcated, multifocal, pleomorphic or ring-shaped granular anterior stromal opacities with normal intervening stroma, seemingly distinct from adenoviral or herpes simplex stromal keratitis. Two had soft, blotchy, pleomorphic, multifocal infiltrates, predominantly involving the peripheral cornea at all depths, and with minimal neovascularization, resembling syphilitic stromal keratitis. One patient had features or both forms of keratitis. OUr experience suggests that EBV may be more commonly associated with stromal keratitis than recognized previously.