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Purpose: Here we report a patient who underwent removal of a retrocorneal plaque and anterior chamber irrigation for acute-stage fungal keratitis. Case report: A 56-year-old woman was referred to the Baptist Yamasaki Eye Clinic, Kyoto, Japan due to refractory infectious keratitis. A white plume infiltration from the superficial to deep corneal stroma was present at the central cornea, and a white giant plaque was present on the posterior surface of the cornea. For diagnostic purposes and to reduce inflammation, the retrocorneal plaque was surgically removed and the anterior chamber was irrigated. Findings obtained from the surgically removed plaque revealed many neutrophils coiled with fibrin and filamentous fungus positive to Fungiflora Y staining. At 1-day postoperative, the amount of inflammation and infiltration were drastically decreased and the infection focus became gradually becoming smaller, finally disappearing at 6-weeks postoperative and with no signs of recurrence. Conclusion: The findings of this study show that surgical intervention can be an effective treatment option for cases of fungal keratitis with retrocorneal plaque.

Purpose: To survey indications and outcomes of amniotic membrane transplantation (AMT) performed under Advanced Medical Healthcare (AMH) in Japan., Methods: Questionnaires were sent to 21 facilities performing AMT under AMH from 2010-2012. Diagnosis, effectiveness, and final outcomes were surveyed. Moreover, we retrospectively examined the diagnosis, treatment effectiveness, and final outcomes in all AMTs performed under AMH at Kyoto Prefectural University of Medicine (KPUM) from April 2009 through June 2013., Results: Clinical data of 311 eyes that underwent AMT under AMH was obtained. Of those, diagnoses included pterygium (n = 148), corneal ulcer/epithelial defect (n = 60), corneal perforation (n = 28), intractable glaucoma (n = 24), and others (n = 51). The surgical outcome was completely or partially successful in 287 eyes (92.3%). The final outcome was effective in 281 eyes (90.4%). A total of 45 eyes of 37 patients underwent AMT under AMH at KPUM. Of those, diagnoses included pterygium (n = 15), recurrence of pterygium (n = 27), and symblepharon (n = 3). The surgical outcome was completely successful in 98% and partially successful in 2%. The final outcome was effective in all cases., Conclusion: AMT performed under AMH in Japan was most common in eyes with pterygium, and was highly effective in these cases, as well as corneal ulcer/epithelial defect, corneal perforation, and intractable glaucoma.

Purpose: To investigate the current status of fungal keratitis in Japan., Methods: The patients with fungal keratitis were examined at 27 facilities in Japan from November 1st 2011 to October 31st 2013, concerning isolates, patient background, clinical findings, treatment and prognosis., Results: Out of 139 cases, 133 were diagnosed as fungal keratitis, of which fungi were isolated from 72 samples of 71 cases (yeast-like fungi 32 strains and filamentous fungi 40 strains). The corrected visual acuity at the first visit of 88 cases (66.2%) was less than 20/200 and 42 cases (31.6%) were involved with deep stromal lesions, indicating high proportion of severe cases in this study. Three months later, 56 cases (42.1%) were still under treatment, and corrected visual acuity of 57 cases (42.9%) was less than 20/200. In cases with yeast-like fungi, there were significantly more cases with past history of corneal diseases, ocular surgery including keratoplasty, and eye drops' use such as steroids than those with filamentous fungi. On the other hand, there were significantly more cases of filamentous fungi, with trauma on the onset and with intervention of previously attending doctors than those with yeast-like fungi. Logistic regression analyses revealed that contact lens wearing was a significant factor of good prognosis, and yeast-like fungi as one of poor outcome compared with no fungal isolation., Conclusion: Although the choice of antifungal drugs has been increasing, fungal keratitis is still severe, refractory and vision-threatening disease.

Purpose: To investigate the causative fungi of fungal keratitis in Japan and their drug susceptibility., Methods: Identification and antifungal susceptibility test for 8 drugs (micafungin, amphotericin B, flucytosine, fluconazole, itraconazole, voriconazole, miconazole and pimaricin) were performed using isolated fungi from patients with fungal keratitis treated at 27 facilities in Japan between November 1, 2011 and October 31, 2013., Results: Fungal strains were detected in 72 (50.7%) out of 142 samples. The major isolates were Fusarium spp. (18), Candida parapsilosis (12), C. albicans (11) and Alternaria spp. (6), in all, fungi of 31 species were identified by gene analysis. In the yeast-like fungi, susceptibility rates were evident for more than 80% in voriconazole, pimaricin, flucytosine, micafungin, amphotericin B and fluconazole. In filamentous fungi, the susceptibility rate was less than 50% except for PMR (90%). Fusarium spp., which were susceptible to amphotericin B and pimaricin, showed lower susceptibility rates compared with other genera., Conclusions: Although various genera and species of fungi cause fungal keratitis, the obtained drug susceptibility data in this study demonstrates the different susceptibility patterns among the major isolates (Fusarium spp., C. parapsilosis, C. albicans and other groups). This is important evidence useful for fungal keratitis treatment.

Purpose: To report the cases with severe infection post excimer laser refractive surgery., Methods: This study involved 6 eyes of 4 women (mean age 38 years, range : 27-51 years) who underwent excimer laser corneal refractive surgery., Results: In all 4 cases, the respective primary causative organisms of the infection were quinolone-resistant methicillin-sensitive Staphylococcus aureus, quinolone-resistant methicillin-resistant Staphylococcus aureus, yeast type fungus, and in 1 case, penicillin-resistant Streptococcus pneumoniae. We initiated topical antibiotics or intensive antifungal treatment, yet due to severe inflammation and ophthalmalgia, analgesic drugs were needed. An average hospitalization period was 38.5 days (range : 22-77 days), and the best spectacle-corrected visual acuity was 0.5 or more than 0.5 post discharge., Conclusions: In the treatment of severe corneal infection post refractive surgery, it is important to identify the primary causative organism. If the response to the initial treatment is poor, such patients should immediately be referred to a special clinic to obtain a better visual outcome.

Unlabelled: Purpose : To report 3 cases of severe ocular infection in elderly patients with dementia., Case Reports: Case 1 involved a 75-year-old man who presented after his wife noticed hyperemia and discharge in his right eye. Corneal infection with perforation was found. Wife-administered antibiotics healed the infection within 1 month. Case 2 involved a 97-year-old man who was referred to us after nursing-home staff members noticed redness and discharge in his right eye. Severe corneal infection with hypopyon was found. Following systemic and topical and antibiotics' administration by the nursing-home staff, the infectious keratitis healed within 2 weeks. Case 3 involved an 80-year-old woman referred to us from another clinic due to persistent epithelial defect in her left eye. Since the defect was accompanied by anterior uveitis and vitreous opacity, we suspected bacterial endophthalmitis. Following systemic and topical antibiotics' administration by family members, signs of infection diminished within 3 weeks. In all 3 cases, medical examination was difficult, topical eye-drop instillation by the patients themselves was impossible., Conclusions: In elderly dementia patients, cognizance of infection, medical examination, and treatment are difficult. Support by family members or nursing-home staff is necessary to obtain improved outcomes.

Purpose: Ultrasound biomicroscopy (UBM) can be used to investigate the appearance of the anterior chamber in infants with congenital corneal opacity. This study investigated the association between the UBM-obtained clinical imaging of anterior chamber morphology and the clinical diagnosis in infants with congenital corneal opacity., Subjects and Methods: This study involved 19 eyes of 10 consecutive infants with congenital corneal opacity, 13 eyes with Peters anomaly (PA, 7 cases) and 6 eye with sclerocornea (SC, 3 cases), recruited at the Kyoto Prefectural University of Medicine, Kyoto, Japan between September 2001 and January 2009. In each subject eye, UBM findings were compared with the clinical diagnosis based on slit-lamp findings and intraocular pressure (IOP)., Results: UBM findings revealed partial angle closure in 10 PA eyes and in 5 SC eyes, absence of Descemet's membrane in 13 eyes and 6 eyes, and funicular fiber from the iris in 12 eyes and 6 eyes. All 6 eyes with SC showed normal IOP, while 9 eyes with PA were diagnosed as glaucoma., Conclusion: Similarities in UBM appearance were observed between PA and SC. PA had a higher incidence of glaucoma; however, there was no relation between IOP and the UBM images.

Purpose: Enterococcus faecalis is a major endophthalmitis-causing pathogen and often causes significant visual impairment. We investigated the clinical background, treatment and the visual outcome of patients with E. faecalis endophthalmitis after cataract surgery., Methods: We retrospectively conducted a postal survey directed mainly at the members of Japanese Society of Cataract and Refractive Surgery, and collected data on 30 eyes of 30 patients with E. faecalis endophthalmitis., Results: The mean age of the patients was 73.5 years, and 10 cases had diabetes mellitus. The average time between cataract surgery and diagnosis of endophthalmitis was 4.8 days, and in 16 cases the disease developed 2 days after surgery. Final visual acuity was better than 40/200 in 13 eyes and 20/200 to no light perception in 15 eyes., Conclusions: E. faecalis caused acute-onset endophthalmitis. The visual outcome of the patients can be divided into good and poor groups.

Purpose: Our previous study of polymorphisms in the HLA-class I genes of 71 Japanese SJS/TEN patients with ocular surface complications and 113 Japanese healthy controls showed that in the Japanese, HLA-A*0206 was strongly associated with SJS/ TEN. In this study, we examined 118 Japanese SJS/ TEN patients with ocular surface complications and a new control group consisting of 220 healthy Japanese volunteers, and investigated the association between HLA class I antigens, HLA-A, B, C, and the SJS/ TEN., Methods: For HLA genotyping we enrolled 118 Japanese patients with SJS/TEN in the chronic or sub-acute phase at Kyoto Prefectural University of Medicine; all presented with ocular surface complications. We also enrolled 220 healthy Japanese volunteers. We performed polymerase chain reaction amplification followed by hybridization with sequence-specific oligonucleotide probes (PCR-SSO). Results : HLA-A*0206 was most strongly associated with Japanese SJS/TEN patients with ocular surface complications (carrier frequency: p = 0.0000000002, OR = 5.2; gene frequency : p = 0.000000007, OR = 4.2)., Conclusion: HLA-A* 0206 is strongly associated with Japanese SJS/TEN patients with ocular surface complications.

Purpose: To evaluate the indications and surgical outcomes of amniotic membrane transplantation (AMT) for ocular-surface disease., Subjects and Methods: This study involved 304 AMTs performed at Kyoto Prefectural University of Medicine between April 1998 and March 2008. Preoperative diagnoses, clinical features, surgical procedures and postoperative outcomes were analyzed retrospectively., Results: Of 304 cases, 145 cases had a pterygium (48 primary, 82 recurrent, and 15 pseudo-pterygium). The recurrence rate at one year was 6.1% among the 99 cases of pterygium followed for at least one year postoperatively. Ninety-three cases had severe ocular surface diseases including ocular pemphigoid (30), chemical or thermal burn (29), Stevens-Johnson syndrome (23), and others (11) AMT and epithelial transplantation was combined in 64 cases, and successful ocular-surface reconstruction was obtained in 88 cases (94.6%). Neoplasia was observed in 22 cases (12 benign, 10 malignant). The ocular-surface was successfully reconstructed in all cases by AMT combined with complete tumor resection. Other preoperative diagnoses included persistent epithelial defects (PED) (15), conjunctival chalasis (12) and uncontrollable glaucoma (11). No cases experienced any AMT-related complication., Conclusions: AMT proved effective for preventing the recurrence of pterygium and for ocular-surface reconstruction in patients with severe ocular-surface disease or ocular-surface neoplasia.

Purpose: To understand the current state of severe contact lens (CL)-associated microbial keratitis in Japan., Method: The survey was conducted by the Japan Contact Lens Society and the Japanese Association for Ocular Infection in 224 facilities from April 2007 to March 2009. Patients who were diagnosed with CL-associated microbial keratitis and hospitalized for treatment were enrolled. Clinical characteristics of the keratitis, microbiologic findings and the status of CL hygiene were studied., Results: A total of 350 patients were investigated, with an average age of 28.0 (9-90) years. Acanthamoeba was identified in 85 (24.3%) corneal specimens and Pseudomonus aeruginosa in 70 (20.0%) cases. One hundred ninety six (56.0%) patients were frequent replacement soft CL users. Extended wearing of daily-use CLs was found in 77 (22.0%) patients. Only 67 cases maintained good CL hygiene by daily rubbing-washing and the poor CL care situation was reviewed., Conclusion: The most frequently detected pathogenic microorganism was Acanthamoeba, followed by Pseudomonus aeruginosa. Our survey showed the importance of keeping good CL hygiene by proper lens care, and improvement of CL-related social regulations is urgently needed.

Purpose: To clarify the characteristic appearances of early-stage Acanthamoeba keratitis (AK) and to investigate the effects of topical steroids on those appearances., Subject and Methods: This study involved 25 eyes of 24 patients diagnosed as early-stage AK at Kyoto Prefectural University of Medicine between October 2002 and June 2008. All patients were contact lens wearers, and 23 patients (96%) were referred from other hospitals. Clinical findings in the medical records of all patients were analyzed retrospectively., Results: Radial keratoneuritis was observed in 20 of 25 eyes (80%), and pseudodendritic lesions were observed in 15 eyes (60%). Only 1 eye (4%) showed neither of these two findings. Of the 10 eyes treated with topical steroids until the first presentation at our hospital, 6 eyes manifested radial keratoneuritis and/or pseudodendritic lesions after the discontinuation of that treatment. The visual prognosis was good in both groups, with or without topical steroid treatment., Conclusions: We found that radial keratoneuritis and pseudodendritic lesions are characteristic appearances of early-stage AK, and that topical steroid treatment might mask these characteristic findings.

Background: Corneal staining with fluorescein resulting from a cause distinct from that of general epithelial barrier disturbance., Case: A 66-year-old woman saw her doctor complaining of blurred vision and foreign-body sensation in her left eye. Superficial punctate keratopathy (SPK) was detected on her left cornea. Following instillation of some eye drops, the patient developed corneal staining with fluorescein. Assuming that the staining was due to drug toxicity, eye-drop instillation was discontinued but the staining did not improve and her doctor then referred her to us. Although we tried glucocorticosteroid and artificial tear eye drops, the staining spread until it covered the patient's cornea almost completely. On a following day, we attempted to observe the patient's cornea by confocal microscopy, yet her corneal epithelium could only partially be seen due to what can best be described as a "black-cloud-like" formation on her cornea. However, immediately following that observation the corneal staining diminished without epithelial disturbance and the patient's symptoms were improved. Suspecting that some foreign materials may be stuck to her cornea, we performed impression cytology and detected the existence of MUC16., Conclusion: The patient's corneal staining may have resulted from her cornea being covered by materials related to MUC16.

Purpose: To study the relationship between ocular surface colonization or infection and nasal carriage of methicillin-resistant Staphylococcus aureus(MRSA) among patients at high risk of infection and those who have already been infected., Subjects and Methods: We isolated MRSA from ocular surface and anterior nares in 35 patients at high risk of MRSA colonization and from 4 patients who had developed an active MRSA ocular infection in the conjunctiva., Results: Of the 7 patients who were carriers of conjunctival MRSA, 5 patients (78%) were found to be carriers of MRSA in the anterior nares. This ratio of nasal carriers is very high compared to the 11% in 28 patients without MRSA in the conjunctiva. All 4 cases who had active infections of MRSA in the cornea or conjunctiva showed MRSA from the nares. Even after MRSA was negative in their eye lesions, MRSA colonization in their nares continued for a long time., Conclusion: A significant relationship exists between MRSA in the ocular surface and MRSA found in the nares.

Background: It is necessary to decrease topical anti-glaucoma medication for severe glaucoma with pseudopemphigoid caused by anti-glaucoma eye drops. Glaucoma filtrating surgery is often needed instead of medication, but the prognosis is poor because it induces scar fomation and makes the filtrating bleb vanish., Case: An 85-year-old male patient with exfoliation syndrome had twice undergone glaucoma surgery about ten years previously. His intra-ocular pressure (IOP) was high despite topical anti-glaucoma medication. At the first examination in our hospital, he had severe superficial punctate keratopathy, blephariticshortening and symblepharon, and we therefore diagnosed severe pseudopemphigoid induced by anti-glaucoma eye drops. Because his IOP could not be controlled by topical and general medication, we conducted a glaucoma filtrating operation using amniotic membrane., Conclusion: The administration of oral anti-inflammatory drugs before and after surgery and the use of amniotic membrane prevented post-operative scar formation and the progress of symblepharon, resulting in the successful control of IOP after surgery.

Purpose: We studied retrospectively the background of postoperative infection after corneal transplantation., Methods: We reviewed the records of 753 eyes that had undergone corneal transplantation at Kyoto Prefectural University of Medicine or the Baptist Eye Clinic over a period of 6 years from April 1994 to March 2000. Patients who developed microbial keratitis after corneal transplantation were evaluated for the incidence of infection, age, the interval between transplantation and infection, microbiological etiology, the use of topical steroids, therapy, and complications., Results: Follow-up after keratoplasty averaged 43.2+/-25.6 months (mean+/-standard deviation). Among 753 eyes examined, microbial keratitis developed in 27 eyes (3.6%), 14 eyes had bacterial, and 13 had fungal infections. The ages at presentation were 51.4+/-21.5 years for bacterial infections, and 66.5+/-11.1 for fungal infections. The time intervals between transplantation and the onset of infection averaged 7.8+/-7.9 months for bacterial infections, and 24.2+/-17.2 for fungal infections. Infections in 7 (50.0%) of the bacterial eyes were caused by methicillin-resistant Staphylococcus aureus (MRSA) or epidermidis (MRSE), and 9 (69.2%) of the fungal infections by yeast type fungus (8 were Candida species). At onset of keratitis, 3 (21.4%) of the bacterial eyes and 6 (46.2%) of the fungal eyes were treated with fluorometholone, and 11 (78.6%) of the bacterial eyes and 7 (53.8%) of the fungal eyes were treated with betamethazone or dexamethasone. The treatment duration until the focus of disappeared was 32.8+/-19.7 days for bacterial eyes, and 74.8+/-56.3 for fungal eyes. Major complications associated with infection included corneal perforation in 2 eyes of both the bacterial (14.3%) and fungal (15.4%) eyes, graft rejection in 4 (28.6%) bacterial eyes and 1 (7.7%) fungal eye, there was no recurrence of infection in the bacterial eyes but there were 3 (23.1%) cases of recurrence in the fungal eyes., Conclusions: Infection after corneal transplantation is opportunistic. Fungal infections occurred later than bacterial infections. Also in fungal infections, the mean age at presentation was higher and the recurrence of infection was more frequent.

Purpose: We report 6 cases of herpes simplex keratitis after ophthalmic surgery, in eyes without clinical history of herpes simplex keratitis., Cases: These cases comprised 6 patients examined at our hospital between April 1992 and November 2001. Past operations were keratoplasty in 5 eyes and cataract surgery in 1 eye. Clinical findings and predisposing factors were evaluated retrospectively. The period between herpetic epithelial keratitis onset and ophthalmic surgery ranged from 1.5 to 79 months. Predisposing factors included corticosteroid therapy and operative wound. The herpetic epithelial lesions were dendritic ulcers in 2 eyes, geographic ulcer in 1 eye, and atypical epithelial lesions in 3 eyes; in all cases, herpes simplex virus (HSV)-DNA was detected by polymerase chain reaction (PCR) in tear fluid. All herpetic epithelial lesions healed with oral and topical acyclovir., Conclusions: When corticosteroids are used following ophthalmic surgery, physicians should be alert to the possibility of herpetic epithelial keratitis, even in patients with no clinical history of herpes simplex keratitis. PCR detection in tear fluid is helpful in diagnosing this disease.

Object: We report a case of intractable recurrent corneal erosion that was unresponsive to any medication, but was cured by psychiatric care after diagnosis of Munchausen syndrome., Case: The patient, a 35-year-old female, who developed pain in her left eye in July, 20 XX, was diagnosed with epidemic keratoconjunctivitis at the hospital where she worked as a nurse. Despite medication, the eye condition gradually worsened. After undergoing examination at many medical institutions, she came to our hospital on October 6, 20 XX. Her left eye manifested superficial punctate keratitis, then exhibited recurring corneal erosion. The eye condition was intractable, total corneal epithelial defect ultimately occurring on December 30. Subsequently, a bottle of hydrochloric acid oxybuprocaine eyedrops was found under her pillow. We therefore suspected that the corneal erosion was due to self-inflicted injury. She consulted a psychiatrist, and was diagnosed with Munchausen syndrome. After about 2 months of therapy in which she was prevented from touching the eye(eye patch etc.), her eye condition improved., Conclusion: This case was not diagnosed as Munchausen syndrome for 5 months. In cases of intractable corneal erosion, the possibility of self-injury should be considered.