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Purpose To determine if smartphone photography could be a useful adjunct to blindness prevalence surveys by providing an accurate diagnosis of corneal opacity. Methods A total of 174 patients with infectious keratitis who had undergone corneal culturing over the past 5 years were enrolled in a diagnostic accuracy study at an eye hospital in South India. Both eyes had an ophthalmologist-performed slit lamp examination, followed by anterior segment photography with a handheld digital single lens reflex (SLR) camera and a smartphone camera coupled to an external attachment that provided magnification and illumination. The diagnostic accuracy of photography was assessed relative to slit lamp examination. Results In total, 90 of 174 enrolled participants had a corneal opacity in the cultured eye and no opacity in the contralateral eye, and did not have a penetrating keratoplasty or missing photographs. Relative to slit lamp examination, the sensitivity of corneal opacity diagnosis was 68% (95%CI 58-77%) using the smartphone's default settings and 59% (95%CI 49-69%) using the SLR, and the specificity was 97% (95%CI 93-100%) for the smartphone and 97% (95%CI 92-100%) for the SLR. The sensitivity of smartphone-based corneal opacity diagnosis was higher for larger scars (81% for opacities 2 mm in diameter or larger), more visually significant scars (100% for eyes with visual acuity worse than 20/400), and more recent scars (85% for eyes cultured in the past 12 months). Conclusion The diagnostic performance of a smartphone coupled to an external attachment, while somewhat variable, demonstrated high specificity and high sensitivity for all but the smallest opacities.

A 55-year-old Caucasian woman presented with a 1-week history of left eye redness and blurred vision. Her medical history included previous small bowel resection and ileostomy for ischaemic bowel. Ophthalmic examination revealed a left corneal ulcer requiring hospital admission for intensive topical antibiotics. Overnight she became systemically unwell and was diagnosed with urinary tract infection requiring intravenous antibiotics. Her corneal condition deteriorated resulting in corneal perforation, which required a surgical gluing procedure. Despite surgery, the cornea perforated on two further occasions. At this stage, vitamin A deficiency (VAD) was suspected, due to the corneal melting response that was occurring. VAD was subsequently confirmed by serology and had occurred in this case due to malabsorption as a result of short bowel syndrome caused by previous small bowel surgery. The patient was treated with intramuscular vitamin A and eventually made a good visual and systemic recovery.

In this article, which is part of the Currents in One Health series, the role of naturally occurring ocular disease in animals is reviewed with emphasis on how the understanding of these ocular diseases contributes to one health initiatives, particularly the pathogenesis and treatment of ocular diseases common to animals and humans. Animals spontaneously develop ocular diseases that closely mimic those in humans, especially dry eye disease, herpes virus infection (cats), fungal keratitis (horses), bacterial keratoconjunctivitis, uveitis, and glaucoma. Both uveitis and glaucoma are common in domestic animals and humans, and many similarities exist in pathogenesis, genetics, and response to therapy. Furthermore, the study of inherited retinal disease in animals has particularly epitomized the one health concept, specifically the collaborative efforts of multiple disciplines working to attain optimal health for people and animals. Through this study of retinal disease in dogs, innovative therapies such as gene therapy have been developed. A unique opportunity exists to study ocular disease in shared environments to better understand the interplay between the environment, genetics, and ocular disease in both animals and humans. The companion Currents in One Health by Gilger, AJVR, December 2022, addresses in more detail recent studies of noninfectious immune-mediated animal ocular disease and their role in advancing ocular health globally.

Mooren's ulcer (MU) is a chronic and painful ulcerative keratitis that is difficult to diagnose, especially when concealed beneath the pterygium, which is a common, benign, wedge-shaped, fleshy tissue growth of the conjunctiva extending onto the cornea. The coexistence of MU and pterygium is extremely rare. A 41-year-old man presented with a 2-month history of unprovoked redness, pain, and blurred vision in the right eye. Corneal epithelial defects around the pterygium head were noted upon slit-lamp examination and fluorescein staining. The patient was initially misdiagnosed with a corneal epithelial defect and pterygium. The initial treatments with anti-inflammatory and corneal epithelial growth promotion tear agents failed. Anterior segment optical coherence tomography (AS-OCT) showed corneal stromal lysis thinning, and in vivo confocal microscopy (IVCM) revealed marked inflammatory cell infiltration and stromal degeneration. We suspected the pathology was an immune-related or tumor-related corneal ulcer. The MU concealed beneath the pterygium was diagnosed by histopathological examination of a biopsy specimen that presented typical localized loss of the corneal epithelium and Bowman's layer, stromal degeneration, and inflammatory cell infiltration. Finally, we performed lamellar keratoplasty (LKP) combined with pterygium excision surgery. The patient recovered with no complications or recurrence during the 1-year follow-up period. Few cases of MU concealed beneath the pterygium have been reported. It is beneficial to rule out the pathological changes concealed beneath the pterygium, combined with multiple means of examination such as slit-lamp examination, AS-OCT, and IVCM. A histopathological examination should be performed to establish a diagnosis.

In a multicenter, prospective study of filamentous fungal keratitis in Greece, predisposing factors, etiology, treatment practices, and outcome, were determined. Corneal scrapings were collected from patients with clinical suspicion of fungal keratitis, and demographic and clinical data were recorded. Fungal identification was based on morphology, molecular methods, and matrix assisted laser desorption ionization time-of-flight mass-spectrometry. A total of 35 cases were identified in a 16-year study period. Female to male ratio was 1:1.7 and median age 48 years. Corneal injury by plant material, and soft contact lens use were the main risk factors (42.8% and 31.4%, respectively). Trauma was the leading risk factor for men (68.1%), contact lens use (61.5%) for women. Fusarium species were isolated more frequently (n = 21, 61.8%). F. solani was mostly associated with trauma, F. verticillioides and F. proliferatum with soft contact lens use. Other fungi were: Purpureocillium lilacinum (14.7%), Alternaria (11.8%), Aspergillus (8.8%), and Phoma foliaceiphila, Beauveria bassiana and Curvularia spicifera, one case each. Amphotericin B and voriconazole MIC

To discuss peripheral ulcerative keratitis, with a focus on the evaluation and management of associated systemic diseases.Peripheral ulcerative keratitis (PUK) is a sight-threatening condition that is often defined by the presence of a crescent-shaped area of peripheral corneal thinning, an epithelial defect, and an inflammatory corneal infiltrate. It is highly associated with rheumatoid arthritis, systemic necrotizing vasculitides like granulomatosis with polyangiitis, and collagen vascular diseases like systemic lupus erythematosus. Undertreated PUK carries a risk of vision loss and premature death.Multidisciplinary collaboration between the ophthalmologist, rheumatologist, and other consultants is required. Early and aggressive steroid-sparing therapy should be considered in cases due to noninfectious systemic disease.

To evaluate the new Standardization of Uveitis Nomenclature (SUN) classification criteria for uveitides by applying them to patients in an academic uveitis practice.Evaluation of classification criteria.The charts of all patients attending the uveitis service at the University of Colorado Hospital between January 1, 2013, and December 31, 2020, were reviewed. Patients with scleritis, ocular cicatricial pemphigoid, and peripheral ulcerative keratitis were excluded. We attempted to classify each patient's uveitis using the SUN classification criteria. Classification attempts were made within the relevant anatomical or infectious categories for their pathology but did not necessarily have to match their clinical diagnosis by a uveitis specialist. We recorded whether classification was possible as well as their clinical diagnosis by a uveitis specialist.All patients attending the uveitis clinic at our academic institution between January 1, 2013, and December 31, 2020, were reviewed. Of the 1143 patients with uveitis, 572 (50.0%) had a disease that was not listed in the SUN classification system, and so no attempt to classify these patients was possible. Of the remaining 571 patients, 522 (91.4%) were able to be classified by SUN and in 492 (94.3%) of the 522 cases, their SUN classification matched their clinical diagnosis by a uveitis specialist.Half of the patients at an academic uveitis practice had a disease for which no SUN classification criteria existed. In cases where classification by SUN could be attempted, the system performed well and generally agreed with their clinical diagnosis.

Rheumatoid arthritis (RA) is an autoimmune disease that primarily affects the joints. Extra-articular manifestations (EAMs) are common and may affect up to 40.6% of patients. Ocular EAM can occur in 39% of the patients. The cornea is involved by different pathogenic mechanisms and corneal disease varies from mild symptoms to severe corneal ulceration and melting with visual loss. Severe corneal involvement is associated with increased mortality in RA patients. We aimed to review the prevalence, mechanisms, management and overall impact of corneal involvement in RA patients.Corneal involvement is frequent among RA patients. With the wider use of systemic immunosuppression, in particular the disease-modifying antirheumatic drugs (DMARDs), and with improvement of surgical techniques, spontaneous and surgery-related corneal ulceration and melting is becoming less common. However, RA patients are still at risk and should be carefully managed.RA-related corneal complications are associated with a decreased quality of life and poor ocular and systemic prognosis. Prompt recognition and a multidisciplinary approach involving topical ophthalmic management and systemic immunosuppression are the key factors to maintain ocular integrity and avoid a lethal outcome.

ZusammenfassungHintergrundZiel der Studie war es, den Einfluss einer simultanen Amnionmembrantransplantation (AMT), des Hornhaut(HH)-Status (eigene HH vs. Transplantat [TPL]) und der Grunderkrankung auf die Erfolgs- und Rezidivraten des autologen Serums (AS) bei therapieresistenten Epitheldefekten zu evaluieren.Patienten und MethodenVon 2007 bis 2019 wurden 990 Therapien mit AS an 703 Augen von 645 Patienten retrospektiv untersucht. Erfasst wurden das Vorliegen einer Erosio oder Ulkus, die Anwendung einer AMT, der HH-Status und die Grunderkrankung. Zielgrößen waren die Epithelschlussrate innerhalb 4 Wochen und die Rezidivrate nach Epithelschluss. Die mediane Beobachtungszeit betrug 50 Monate.ErgebnisseEin Epithelschluss zeigte sich bei 73,6 % und ein Rezidiv bei 27,4 %. Eine AMT wurde signifikant häufiger bei Ulzera (p p = 0,048) angewandt. Ohne AMT ergab sich eine signifikant höhere Epithelschlussrate (p p p = 0,47). Auf dem TPL zeigte sich eine signifikant höhere Rezidivrate (p = 0,004) und ein schnelleres Rezidivauftreten (p = 0,03), v. a. ≤6 Monate nach Epithelschluss. Die Grunderkrankungen zeigten einen signifikanten Unterschied in der Epithelschluss- (p = 0,02) und Rezidivrate (p SchlussfolgerungenDas AS stellt eine effektive Therapieoption bei therapieresistenten Epitheldefekten dar. Es zeigt auf dem TPL eine hohe Erfolgsrate bei zugleich höherer Rezidivneigung. Bei simultaner AMT ist wegen der erhöhten Komplexität des zugrunde liegenden Problems mit geringeren Erfolgsraten zu rechnen. Das AS ist bei verschiedenen Grunderkrankungen erfolgreich einsetzbar, mit Limitationen bei der kongenitalen Aniridie.

Globally, infectious keratitis is the fifth leading cause of blindness. The main predisposing factors include contact lens wear, ocular injury and ocular surface disease. Staphylococcus species, Pseudomonas aeruginosa, Fusarium species, Candida species and Acanthamoeba species are the most common causal organisms. Culture of corneal scrapes is the preferred initial test to identify the culprit organism. Polymerase chain reaction (PCR) tests and in vivo confocal microscopy can complement the diagnosis. Empiric therapy is typically commenced with fluoroquinolones, or fortified antibiotics for bacterial keratitis; topical natamycin for fungal keratitis; and polyhexamethylene biguanide or chlorhexidine for acanthamoeba keratitis. Herpes simplex keratitis is mainly diagnosed clinically; however, PCR can also be used to confirm the initial diagnosis and in atypical cases. Antivirals and topical corticosteroids are indicated depending on the corneal layer infected. Vision impairment, blindness and even loss of the eye can occur with a delay in diagnosis and inappropriate antimicrobial therapy.

Introduction: This study aims to evaluate outcomes and complications of temporary suture tarsorrhaphy (TST) in cases of impending corneal ulcer perforation. Materials and methods: Case records of patients who underwent temporary suture tarsorrhaphy at Mechi Eye Hospital during a period of 18 months were retrospectively evaluated. All the smear positive fungal keratitis with more than 5mm infiltration involving central and/or paracentral cornea with impending corneal perforation were included. Demographic and clinical profile including – visual acuity, indication for temporary suture tarsorrhaphy, duration of signs and symptoms were noted. The outcomes were evaluated after 1 month and 3 months post tarsorrhaphy, in relation with time to epithelial healing, anatomical success rate, best corrected visual acuity, complications associated with non-healing corneal ulcer, number of temporary suture tarsorrhaphy needed and complications of TST. Results: The study included 119 cases of smear positive fungal keratitis with mean age of 51.34 + 15.56 years. In this study, 56.30% of the patients developed epithelial healing at 2 – 4 weeks with mean duration of 23.24 + 12.09 days of temporary suture tarsorrhaphy. Out of 119 patients, the corneal ulcer healed in 84 patients (70.6%), whereas 35 (29.4%) did not heal. Among those with non-healing ulcers, 15 patients (12.6%) had to undergo evisceration. The anatomical success rate was 87.39% which was statistically significant (P = 0.001). Regarding visual outcome, in 62 patients (52.10%) BCVA improved by 2 or more lines, which was statistically significant (P

© Copyright Clinical and Experimental Rheumatology 2022, Objectives: Relapsing polychondritis (RP) evolves with variable and intermittent involvement of cartilage and proteoglycan-rich structures. Ocular manifestations are present in up to two-thirds of RP patients. Necrotising scleritis (NS) and peripheral ulcerative keratitis (PUK) may be inaugural and may lead to eye perforation and vision loss. We aimed to review NS and PUK in RP, in order to characterise them, to identify successful treatment options and unmet needs. Methods: A systematic review of the currently available evidence in PubMed, EMBASE and Scopus was performed according to PRISMA, including observational studies, single case reports and case series of NS/PUK in RP. Study design, number of patients, age, gender, treatment and outcome, were extracted. Two RP patients also provided their opinion. Results: Five case reports and two case series were eligible for inclusion. We identified 10 RP patients with eye-threatening complications (NS and/or PUK), 9 adults (2 males, 7 females, aged 35-72, median age 57.6 years) and one paediatric patient (F, 11 years). Apart from glucocorticoids, cyclophosphamide was effective in 4 patients; infliximab, high-dose immunoglobulins, dapsone, or cyclosporine were also successfully employed in a case each. Surgical repair was reported in 2 cases. Conclusions: Ocular inflammation is often bilateral and recurring in RP; NS/PUK are rare complications. All patients who develop NS/PUK should be specifically questioned for RP signs and symptoms. Early institution of immunosuppressive therapies is mandatory. Increasing awareness, physicians' and patients' education and a multidisciplinary approach may help improve the prognosis of these serious complications of RP.

To compare the incidence of corneal injury during general anesthesia (GA) and the immediate post-operative period in eyes protected with topical ocular lubricant alone with eyes protected with topical lubricant followed by complete eyelid closure using tape.One hundred client-owned dogs (200 eyes) undergoing GA for MRI scan.Patients had ocular lubricant applied to both eyes upon induction of anesthesia. One eye was taped closed immediately after induction for the duration of anesthesia using Strappal® tape (BSN medical™; treatment group), and the other eye was not taped (control group). Eyes were randomly allocated to a treatment group. Ophthalmic examination was performed before and after anesthesia; the examiner was masked to eye treatment groups. Corneal injury was defined as corneal ulceration or corneal erosion. A McNemar's test was used to compare the incidence of corneal injury between groups. A paired-samples t-test was used to compare Schirmer-1 tear test (STT-1) readings between groups.Sixteen eyes (8%) developed corneal erosion. No corneal ulceration occurred. There was no significant difference between incidence of corneal erosion between groups (p = .454). There was a significant decrease in STT-1 readings following GA in both groups (p .001), with no significant difference in STT-1 between groups (p = .687). No adverse effects of taping the eye closed were observed.Taping the eyes closed during GA had no additional benefit to the lubrication protocol used in this study.

Fungal corneal ulcers are an uncommon, yet challenging, cause of vision loss. In the United States, geographic location appears to dictate not only the incidence of fungal ulcers, but also the fungal genera most encountered. These patterns of infection can be linked to environmental factors and individual characteristics of fungal organisms. Successful management of fungal ulcers is dependent on an early diagnosis. New diagnostic modalities like confocal microscopy and polymerase chain reaction (PCR) are being increasingly used to detect and identify infectious organisms. Several novel therapies, including crosslinking and light therapy, are currently being tested as alternatives to conventional antifungal medications. We explore the biology of Candida, Fusarium, and Aspergillus, the three most common genera of fungi causing corneal ulcers in the United States and discuss current treatment regimens for the management of fungal keratitis.

Fungal keratitis, an infective disease of the cornea, represents a serious diagnostic and therapeutic problem that, if not recognized on time, could lead to irreversible eye damage. Herein we report a case of fungal keratitis due to Fusarium spp. infection. The 60-year-old man was admitted to our clinic due to an atraumatic acute onset of the disease, with a decrease in the visual acuity, photophobia, redness, and severe pain in the right eye. Clinical observation revealed an ulcer that affected 1/3 of the cornea and a hypopion in the anterior chamber. After the first results of microbiological analyzes, local and systemic antifungal therapy was applied. Due to the fact that the patient voluntarily left the treatment, there was a drastic worsening of the local findings as a full thickness total corneal infiltrate with more intense anterior chamber reaction. Finally, evisceration was performed. Given the fact that fungal keratitis is more prevalent in developing countries, official protocols and available effective antifungals are crucial for adequate treatment and a favorable outcome of this infection.

Corneal ulcers are a common cause of blindness in low-income and middle-income countries, usually resulting from traumatic corneal abrasions during agricultural work. Antimicrobial prophylaxis of corneal abrasions can help prevent corneal ulcers, but delays in the initiation of therapy are frequent. We aimed to assess whether a community-based programme for corneal ulcer prevention would reduce the incidence of corneal ulceration.A cluster-randomised trial was performed in village development committees (VDCs) in Nepal. VDCs in the catchment area of Bharatpur Eye Hospital, Nepal with less than 15 000 people were eligible for inclusion. We randomly assigned (1:1) VDCs to either an intervention group or a control group. In the intervention VDCs, existing female community health volunteers (FCHVs) were trained to diagnose corneal abrasions and provide a 3-day course of ophthalmic antimicrobials to their patients. In the control VDCs, FCHVs did not provide this intervention. Participants were not masked given the nature of the intervention. Both groups were followed up for 3 years for photographic evidence of corneal ulceration. The primary outcome was the incidence of corneal ulceration, determined by masked assessment of corneal photographs. The analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT01969786.We assessed 112 VDCs, of which 24 were enrolled. The study was performed between Feb 4, 2014, and Oct 20, 2017. 12 VDCs were randomly assigned to the intervention group and 12 to the control group. 252 539 individuals were included in the study (130 579 in the intervention group and 121 960 in the control group). FCHVs diagnosed and provided antimicrobials for 4777 corneal abrasions. The census identified 289 corneal ulcers among 246 893 person-years in the intervention group (incidence 1·21 cases [95% CI 0·85-1·74] per 1000 person-years) and 262 corneal ulcers among 239 170 person-years in the control group (incidence 1·18 cases [0·82-1·70] per 1000 person-years; incidence rate ratio 1·03 [95% CI 0·63-1·67]; p=0·93). Medication allergy was self-reported in 0·2% of participants.We did not detect a reduction in the incidence of corneal ulceration during the first 3 years of a community-based corneal ulcer prevention programme. Further study might be warranted in more rural areas where basic eye care facilities are not available.National Eye Institute.

TO report the corneal manifestations in patients with COVID-19-associated rhino-orbito-cerebral mucormycosis (ROCM).This study was a retrospective, observational, and record-based analysis of patients of ROCM with corneal involvement.A total of 220 patients were diagnosed with ROCM over a period of 3 months. Thirty-two patients had developed corneal manifestations. The mean age at diagnosis was 52.84 ± 12.8 years. The associated risk factors were systemic mucormycosis, uncontrolled diabetes, recent COVID-19 infection, and injudicious use of systemic steroids. Twenty-nine patients were known diabetics, 32 had recent COVID-19 infection, and 13 gave a history of injudicious use of steroids. The right eye (RE) was affected in nine patients, the left eye (LE) in 20 patients, and both eyes in three patients. Nine patients had a round-oval corneal ulcer. One patient each had a perforated corneal ulcer with uveal prolapse, sealed perforated corneal ulcer, spontaneously healed limbal perforation, diffuse corneal haze with hyphemia, panophthalmitis, diffuse corneal stromal abscess, limbal ischemia, anterior uveitis with posterior synechiae, inferior corneal facet, and filamentary keratitis. Three patients each had a corneal melt and inferior conjunctival xerosis with chemosis. Orbital exenteration was performed in six patients. Five patients with corneal ulcers healed. Topical eye drops of amphotericin (0.5 mg/ml) cycloplegic, antiglaucoma medications, and lubricant eye drops were started along with systemic antifungals.Central corneal ulcer was the most common manifestation of mucormycosis. A concentration as low as 0.5 mg/ml of amphotericin eye drops was effective in the treatment.

Cataract remains the leading cause of reversible blindness worldwide. Inflammatory postoperative complications remain a significant challenge associated with cataract phacoemulsification. These include corneal melting, also known as aseptic keratomalacia, a sight-threatening inflammatory condition that precedes corneal perforation. Case description: a 70-year-old patient underwent cataract phacoemulsification and subsequently developed indomethacin induced corneal erosion. Despite 2 months of conservative treatment, the erosion progressed to a corneal ulcer. To prevent corneal perforation, a prophylactic conjunctival flap was performed. Dry eye disease and Sjogren's syndrome were diagnosed postoperatively. Follow-up was 5 years. Conclusions: the presented case demonstrates for the first time the role of indomethacin as a trigger of corneal melting after cataract phacoemulsification. Corneal melting, potentially leading to corneal perforation, may occur after successful surgery not only in patients with diagnosed dry eye disease and systemic collagenosis but also in asymptomatic patients. Torpid progression, resistance to conventional therapy and a high risk of corneal perforation require a specialist to select appropriate therapeutic and surgical treatment methods as soon as possible. Treatment begins with withdrawal of NSAIDs, local and systemic steroid therapy, intensive corneal lubrication and objective monitoring using anterior segment optical coherence tomography.

Purpose To report the effectiveness of the surgical procedure of the tarsoconjunctival flap (FTC) in patients with severe ocular surface impairment refractory to previous conventional treatments. Methods A retrospective, noncomparative, consecutive case series. Results Pillar tarsoconjunctival flap (PTCF) was performed in eight eyes of eight patients. Three patients had neurotrophic corneal ulcer (NCU), three had exposure keratopathy and two had corneal melting. Seven of them had satisfactory postoperative results, showing total corneal re-epithelialization that lasted throughout the postoperative follow-up (mean 10.33 ± 2.65 months [SD], range 6 to 12 months). Mean time for the re-epithelization was 11.28 ± 8.97 days [SD] (range 4 to 30 days). Conclusion This study suggest PTCF is a valid alternative to tarsorrhaphy in cases of persistent epithelial defect (PED) or NCU resistant to conventional treatments. Notwithstanding, prospective comparative trials comparing PTFC with conventional and/or novel therapies in PED or NCU are needed to corroborate these findings.

This study quantifies the performance of an international cohort of cornea specialists in image-based differentiation of bacterial and fungal keratitis, identifying significant regional variation and establishing a reference standard for comparison against machine learning models.

The purpose of this study was to report a case of fungal keratitis resistant to standard-of-care antimicrobial treatment and successful resolution, thanks to the repeated high-fluence accelerated photoactivated chromophore for keratitis-corneal cross-linking (PACK-CXL).This was a case report.A 79-year-old male patient with previous Descemet membrane endothelial keratoplasty presented with a corneal ulcer that was resistant to topical antimicrobial therapy and amniotic membrane placement. Fungal keratitis was diagnosed, and the cornea was on the verge of perforation. After over a month of topical and systemic therapy without marked improvement, the patient underwent 2 repeated high-fluence accelerated CXL procedures (7.2 J/cm2 using a UV irradiation of 30 mW/cm2 for 4 minutes) over an interval of 8 days (accumulated fluence of 14.4 J/cm2), which resulted in significant clinical improvement, with consolidation into a quiescent scar.PACK-CXL protocols delivering a total UV fluence of 5.4 J/cm2 (as per the original Dresden protocol for corneal ectasia cross-linking) can be an effective primary therapy for initial or superficial corneal infections because approximately half of the energy is absorbed in the first 100 μm of a riboflavin-soaked cornea. However, fungal keratitis may require higher fluences than 5.4 J/cm2 because, unlike ectatic corneas, corneal ulcers are not transparent, and the infection may involve deep stroma. This case illustrates how repeated high-fluence accelerated PACK-CXL can be used to successfully treat fungal keratitis resistant to conventional topical and systemic medications.

Purpose Thermosensitive in situ gels have been around for decades but only a few have been translated into ophthalmic pharmaceuticals. The aim of this study was to combine the thermo-gelling polymer poloxamer 407 and mucoadhesive polymers chitosan (CS) and methyl cellulose (MC) for developing effective and long-acting ophthalmic delivery systems for L-carnosine (a natural dipeptide drug) for corneal wound healing. Methods The effect of different polymer combinations on parameters like gelation time and temperature, rheological properties, texture, spreading coefficients, mucoadhesion, conjunctival irritation potential, in vitro release, and ex vivo permeation were studied. Healing of corneal epithelium ulcers was investigated in a rabbit’s eye model. Results Both gelation time and temperature were significantly dependent on the concentrations of poloxamer 407 and additive polymers (chitosan and methyl cellulose), where it ranged from

To evaluate the outcomes of canine patients diagnosed with corneal ulceration associated with presumed calcareous corneal degeneration (CCD) that were treated with diamond burr keratotomy (DBK) and ongoing postoperative topical 3% or 4% Ethylenediaminetetraacetic acid (EDTA).Retrospective assessment of CCD cases treated with ongoing topical EDTA following DBK between 2011 and 2020 at Veterinary Ophthalmic Referrals. Descriptive statistics of the study population were assessed, and a survival analysis was performed using R statistical software.A total of 51 eyes from 41 dogs were assessed, with small terrier breeds overrepresented (27/41, 65.9%). Median age of dogs at the time of diagnosis was 14.3 years (range 8-17.2 years). Following DBK, the median time to commencement of topical EDTA was 11 days (range 0-28 days). Cases were followed for a median duration of 216 days (range 42-1379 days). Corneal ulceration recurred in 7/51 (13.7%) eyes at a median duration of 80 days (range 63-156 days). The probability of recurrence of corneal ulceration associated with CCD at 12 months was 15.6% (95% CI: 4.1-25.7%). A second DBK procedure followed by ongoing topical EDTA was performed in 4/7 (57.1%) of the recurred eyes. These retreated eyes had no further recurrence recorded and a median follow-up time of 401 days (range 120-858 days).Ongoing topical EDTA following DBK is an effective adjunct treatment method for CCD with reduced rates of recurrence of CCD-associated corneal ulceration when compared to published rates of recurrence when treated with DBK alone.

Purpose: to study the effectiveness of the use of thrombofibrin clot of platelet-rich plasma (PRP) in patients with corneal ulcers. Material and methods. A clinical study, conducted by the Department of Traumatology and Reconstructive Surgery of Helmholtz National Medical Research Center of Eye Diseases, involved 20 patients, aged from 22 to 82, with corneal ulcers of inflammatory and burn genesis more than 100 microns deep. All patients got coated with a thrombofibrin PRP clot from autologous blood. Prior to the study, all patients received standard treatment for 2 weeks to 3 months, including multiple amniotic membrane coating, with no effect. The thrombofibrin clot was produced by the Scientific Department of Biotechnology and Transfusiology of the N.V. Sklifosovsky Research Institute for Emergency Medicine. The ready clot was placed on the surface of the cornea and covered with an amniotic membrane. The membrane was fixed to the episclera along the border of the limb with a circular suture, whereupon autologous serum was injected along the limb in 4 quadrants, to be followed by temporary lateral blepharography. Results. On the 2nd day following the procedure, the patients noted a decrease in lacrimation and pain in the operated eye. As shown by optical coherence tomography, the average depth of the corneal ulcer at the beginning of the study in all patients was 129 ± 28.5 microns. On the 5th day, the depth lowered to an average of 71 ± 32.6 microns, and on the 10th day, to 23.3 ± 15.1 microns. In 7 patients (35%), complete healing of the defect was observed on the 15th day, while in 9 patients (45%) it was stated between the 16th and the 20th day. Thus, the average time of healing of the ulcer with complete epithelization occurred was 15 days. In four patients with the consequences of severe burns (20%), the ulcer did not heal due to extensive damage to the limbal zone. Conclusion. The use of a thrombofibrin PRP clot in combination with amniotic membrane transplantation allows achieving a stable and fairly rapid healing of corneal ulcers of various origins. However, this method is ineffective in patients with limbal cell insufficiency, severe burns and extensive damage to the limbal zone. In such cases, it is advisable to use more radical surgical methods, such as buccal or limbal cell transplantation, or allolimbal transplantation.

To assess the inter-rater agreement of corneal cytology findings in canine ulcerative keratitis by veterinary surgeons of different training levels and the agreement of corneal cytology with culture.Dogs with progressive ulcerative keratitis were prospectively recruited for corneal cytology and culture. Corneal cytology slides were reviewed by veterinary surgeons of different training levels (three general practitioners, three ophthalmologists and three pathologists). The inter-rater agreement of cytology findings and agreement of cytology with culture was assessed using the kappa measure of agreement.The study included 145 corneal cytology samples from 143 dogs (145 eyes) with progressive ulcerative keratitis. Positive cultures were obtained from 81 of 145 (56%) eyes. The most commonly isolated pathogens were Streptococcus canis, Pseudomonas aeruginosa and Staphylococcus pseudintermedius. The results demonstrated increased inter-rater agreement of corneal cytology and increased agreement with culture with increased ocular pathology expertise (pathologists ophthalmologists general practitioners).This study provides important information about the diagnostic value of corneal cytology in canine ulcerative keratitis and the most common pathogens involved in such cases in the UK. Based on the results of this study, cytology findings should be interpreted in conjunction with the expertise of the observer. For maximal pathogen identification, both cytology and culture should be considered.

The aim of this study was to analyze the risk factors, microbiological profile, and treatment efficacy in pediatric microbial keratitis (MK) and to identify clinical biomarkers prognosticating outcome.A retrospective analysis was conducted from patients younger than 16 years with MK-excluding viral, marginal, or interstitial keratitis. Data pertaining to predisposing factors, symptom duration, prior treatment, ulcer characteristics, microbiological profile, time to resolution, and final outcome were recorded. Statistical analysis was performed. The mixed-effects linear regression model with random intercept was used to evaluate factors affecting time to resolution.Among 218 episodes of 215 pediatric patients with MK, the geometric mean of central [median 3 mm, interquartile range (IQR) 1-4.3 mm] and peripheral ulcers (median 1 mm, IQR 1-2.5 mm) was significantly different ( P0.0001). Organisms identified were bacteria (56.9%), fungi (31.5%), and acanthamoebae (2.3%). Of 172 cases (78.8%), which resolved in a median resolution time of 22 days (IQR, 11-44 days), 107 (81.6%) with absent/negative microbiology healed on empirical therapy. On multivariate analysis, peripheral ulcers and geometric mean ulcer size affected time to resolution. Significantly higher percentage of eyes, which worsened or perforated, were on topical steroids compared with those which healed (31.8% vs. 9.2%, P = 0.0061).Good outcome even in culture negative cases suggests empirical therapy may be instituted for nonsevere peripheral pediatric MK; however, the importance of a microbiological workup cannot be underscored enough. Ulcer location and geometric mean size of ulcer may be used as clinical prognostic markers for resolution.

Purpose To evaluate the therapeutic effect of incorporating continuous administration of voriconazole in the treatment of recalcitrant fungal keratitis. Methods In this prospective case study, 5 consecutive patients (5 eyes) with fungal keratitis were treated with a standard protocol after the failing maximal conventional medical treatment. The protocol involved continuous lavage of the ulcer with 1% voriconazole through an irrigator for 2 h, twice a day, combined with local and systemic antifungals. Visual acuity, slit lamp findings of the ulcer, and fungal hyphae density by confocal microscope were documented, respectively. Results In 4 patients, the clinical symptoms and slit lamp examination were significantly improved after only 3 days of treatment. The hyphae were shown to decrease in number and morphologically fragmented in corneal stroma by confocal microscopy. After the infection was controlled, 2 cases required further keratoplasty. In one case, the treatment was deemed ineffective and a conjunctival flap had to be created to help control the infection. In all 5 patients, the best spectacle-corrected visual acuity had improved after treatment. With more than 3 months of follow-up, no recurrence of infection was seen in any cases. Conclusion Our treatment protocol demonstrated improvement in the treatment of clinically resistant fungal keratitis. Continuous lavage of voriconazole is easy to be implemented and well-tolerated by patients. Modification of the current protocol should be further explored to optimize the therapeutic effectiveness in future.

Objective The aim of this retrospective study was to review the clinical data and outcomes of patients that suffered ectopic cilium (EC). Animals studied One hundred and twelve dogs from multiple private practices in France, with a clinical diagnosis of EC were included in the study. Results The mean age of affected dogs was 2.3 years. There were 64 females and 48 males. The most represented breeds were the Shi Tzu, the French Bulldog, the English Bulldog and the Chihuahua. Eleven dogs were affected bilaterally. The upper eyelid was implicated in 93.5% of the cases, with the median portion being the most affected. No statistical difference was observed between the right and the left eye. EC were associated with distichiasis in 50% of the cases. Pigmentation of the conjunctiva at the point of exit of the EC was present in 58% of the cases. EC were short in 75% and long in 25% of the cases. Corneal complications were statistically associated with short EC. The corneal lesions associated with EC were keratitis (94%), corneal granuloma (0.8%), corneal fibrosis (2.7%), corneal degeneration (0.8%), superficial corneal ulcer (68.7%), deep corneal ulcer (8%) and perforating corneal ulcer (0.8%). The surgeries which consisted of the removal of the hair follicle was successful in 88.4% of the cases. Conclusion EC is a rare condition which can be treated successfully by the removal of the hair follicles. It must be suspected in cases of corneal lesions unresponsive to medical treatment.

Purpose: We comparatively analyzed the microbiological profiles, predisposing factors, clinical aspects, and treatment outcomes of patients with polymicrobial and monomicrobial bacterial keratitis.Methods: A total of 194 cases of culture-proven bacterial keratitis treated between January 2007 and December 2016 were reviewed. Microbiological profiles, the epidemiology, predisposing factors, clinical characteristics, and treatment outcomes were compared between the polymicrobial group (polymicrobial bacterial keratitis [PBK]; 29 eyes, 62 isolates) and monomicrobial (monomicrobial bacterial keratitis [MBK]; 165 eyes, 165 isolates) group.Results: The most common isolates were Enterobacter (24%) in the PBK group and Staphylococcus (22%) in the MBK group. There were no significant differences between the two groups in previous ocular surface disease, previous ocular surgery, prior topical steroid use, epithelial defect size, and hypopyon. Age ≥60 years (PBK vs. MBK, 31% vs. 51%, p = 0.048), symptom duration (4.7 days vs. 8.0 days, p = 0.009), and contact lens use (34% vs. 18%, p = 0.036) were significantly different between the two groups. Regarding treatment outcomes, epithelial healing time ≥10 days, the final best-corrected visual acuity (BCVA), a need for surgical intervention, and the rate of poor clinical outcome were not significantly different between the two groups. Significant risk factors for a poor clinical outcome in all patients were an initial BCVA Z = 6.33, two-proportion Z-test), an epithelial defect size ≥5 mm2 (Z = 4.56), and previous ocular surface disease (Z = 4.36).Conclusions: Polymicrobial bacterial keratitis, compared to monomicrobial bacterial keratitis, was more significantly associated with younger age, contact lens use, and shorter symptom duration.

Peripheral ulcerative keratitis (PUK) is an inflammatory condition of the peripheral cornea with hallmark features of epithelial defects and stromal destruction as a result of a complex interplay of factors including host autoimmunity and the peculiar anatomic and physiologic features of the peripheral cornea and environmental factors. PUK may be the result of local or systemic causes and infectious or noninfectious causes. Arriving at a specific etiological diagnosis requires a meticulous clinical workup that may include a battery of laboratory and radiological investigations. Management by a team of internists or rheumatologists and ophthalmologists and judicious use of immunosuppressive agents may yield favorable results minimizing adverse effects. We review current clinical knowledge on the diagnosis and management of PUK.

PURPOSE To describe the effectiveness and safety of nicergoline in patients with epithelial corneal defect or corneal ulcer due to neurotrophic keratitis (NK). METHODS A prospective case series review was performed in 14 patients with NK who started treatment with nicergoline as an off-label prescription from January to November 2020. Patients with a epithelial defect or corneal ulcer due to NK were treated with oral nicergoline. RESULTS/SERIAL CASES Complete corneal healing was observed in 10 (71.4%) of the 14 patients after 25.6 ± 26.60 days (range 7-90) with nicergoline. In three (21.5%) patients wound healing was not achieved, and one patient (7.1%) was lost to follow-up. The mean time between diagnosis and the starting of nicergoline was 10.92 ± 8.85 days (0-28). No adverse effects of nicergoline were observed. CONCLUSION Nicergoline as an adjunctive treatment for NK showed a potential use in the healing of epithelial defect in real-life clinical practice.

Purpose To describe a new technique for sutureless and glue-free amniotic membrane transplantation (AMT) and to investigate its effectiveness to treat corneal persistent epithelial defects (PEDs), compared to bandage contact lens (BCL) application alone. Methods We performed AMT with “contact lens sandwich technique” (CLS-AMT) in 8 consecutive patients with central/para-central (up to 4.00 mm from the geometrical centre) PED/ulceration and we retrospectively compared the results with 11 BCL procedures. Results The procedures were performed successfully with no complications. CLS-AMT showed significantly shorter healing time than BCL (24.0 ± 19.1 vs 42.9 ± 14.6 days; P Conclusion CLS-AMT technique, based on the suction effect due to the superposition of a bandage contact lens on the AM-ring complex, represents a quick, low cost, easy to perform and nearly non-invasive AMT technique. This approach is able to provide adequate fixation of AM, and it seems to be a safe and effective treatment for patients with PEDs.

PURPOSE The purpose of this study was to characterize rates of opioid prescription for different ulcerative keratitis types. METHODS This cohort study included patients diagnosed with ulcerative keratitis according to the University of Michigan electronic health record data between September 1, 2014 and December 22, 2020. Ulcerative keratitis was categorized by etiologic type (bacterial, fungal, viral, acanthamoeba, inflammatory, polymicrobial, or unspecified) using rule-based data classification that accounted for billing diagnosis code, antimicrobial or antiinflammatory medications prescribed, laboratory results, and manual chart review. Opioid prescriptions were converted to morphine milligram equivalent and summed over 90 days from diagnosis. Opioid prescription rate and amount were compared between ulcerative keratitis types. RESULTS Of 3322 patients with ulcerative keratitis, 173 (5.2%) were prescribed at least 1 opioid for pain management within 90 days of diagnosis. More patients with acanthamoeba (32.4%), fungal (21.1%), and polymicrobial (25.0%) keratitis were treated with opioids compared with bacterial (6.7%), unspecified (2.9%), or viral (1.8%) keratitis (all Bonferroni adjusted P < 0.05). For the 173 patients who were prescribed opioids, a total of 353 prescriptions were given within 90 days of diagnosis, with half given within the first week after diagnosis. The quantity of opioid prescribed within 90 days from diagnosis was not significantly different between ulcerative keratitis types (P = 0.6559). Morphine milligram equivalent units prescribed ranged from 97.5 for acanthamoeba keratitis to 112.5 for fungal keratitis. CONCLUSIONS The type of ulcerative keratitis may influence the opioid prescription rate. Providers can better serve patients needing opioids for pain management through improved characterization of pain and development of more tailored pain management regimens.

Microbial keratitis is devastating corneal morbidity with a variable spectrum of clinical manifestations depending on the infective etiology. Irrespective of the varied presentation delayed treatment can lead to severe visual impairment resulting from corneal ulceration, possible perforation, and subsequent scarring. Corticosteroids with a potent anti-inflammatory activity reduce host inflammation, thus minimizing resultant scarring while improving ocular symptoms. These potential effects of corticosteroids have been applied widely to treat various corneal diseases ranging from vernal keratoconjunctivitis to dry eye disease. However, antimicrobial therapy remains the mainstay of treatment in microbial keratitis, whereas the use of adjunctive topical corticosteroid therapy remains a matter of debate. Understandably, the use of topical corticosteroids is a double-edged sword with pros and cons in the treatment of microbial keratitis. Herein we review the rationale for and against the use and safety of topical corticosteroids in the treatment of infective keratitis. Important considerations, including type, dose, efficacy, the timing of initiation of corticosteroids, use of concomitant antimicrobial agents, and duration of corticosteroid therapy while prescribing corticosteroids for microbial keratitis, have been discussed. This review intends to provide new insights into the therapeutic utility of steroids as adjunctive treatment of corneal ulcer.

BACKGROUND Tyrosinemia Type II (TYRII) is a rare autosomal recessive inborn error of metabolism caused by deficiency of tyrosine aminotransferase (TAT), leading to hypertyrosinemia. TYRII patients often present in the first year of life with ocular and cutaneous findings, including corneal ulcers, pseudodendritic keratitis, and palmoplantar hyperkeratosis. The corneal involvement is often mistaken for herpes simplex virus (HSV) keratitis, which is a much commoner condition. CASE REPORT A previously healthy 10-month-old male infant was referred to Ophthalmology for acute onset photophobia. Bilateral dendritiform corneal lesions raised the suspicion for herpetic keratitis. Additionally, a papular, crusted lesion was found on his thumb after a few days of hospitalization, also raising concerns about HSV. The patient's clinical condition seemed to improve under intravenous acyclovir and supportive treatment. A conjunctival swab and crusted lesion on the thumb were tested for HSV using a polymerase chain reaction (PCR) technique, and both were negative. Nevertheless, given the clinical presentation and the favorable course of signs and symptoms, hospital discharge was planned with oral acyclovir. It was halted by an alternative diagnosis of autosomal recessive inborn error of metabolism, tyrosinemia type II, confirmed by elevated plasma tyrosine level and later by molecular analysis requested as a confirmatory investigation by the genetics medical team. CONCLUSIONS The corneal involvement in TYRII is often mistaken for HSV keratitis, and clinical course alone should not halt further investigations to rule out TYRII. Clinicians should suspect TYRII clinically when its characteristic ocular dendritiform lesions are present, namely in infancy or early childhood, and even in the absence of its typical cutaneous palmoplantar hyperkeratosis plaques.

Patients frequently present to general practitioners (GPs) with discomfort and a red eye due to corneal ulceration, defined as a defect in the corneal epithelium and underlying stroma. A myriad of conditions may lead to corneal ulcers, and prompt diagnosis and adequate management is needed to prevent visual morbidity.The aim of this article is to assist clinicians/GPs to 1) determine the likely cause of a corneal ulcer and 2) understand the management of corneal ulcers, including the timing of referral to an ophthalmologist.Corneal ulcers are typically painful and reduce vision. A good understanding of the clinical presentation of corneal ulcers can aid diagnosis and guide treatment. Urgent referral of trauma and infectious keratitis to an ophthalmologist can prevent endophthalmitis and loss of vision and/or the eye. GPs can play an important part in timely referral, in some cases initiating oral antiviral treatment, and by educating patients on preventive measures, especially contact lens hygiene.

To differentiate Pythium keratitis from fungal keratitis using clinical signs, to explore usefulness of various signs as diagnostic prognosticators, and develop a clinical scoring system.A retrospective review of medical records and archived clinical photographs of patients with culture-positive Pythium keratitis and hyaline filamentous fungal keratitis was conducted at a tertiary eye institute to explore characteristics of ulcers that may aid diagnosis.Full-thickness corneal stromal keratitis (P = 0.055), a dry ulcer surface (P = 0.010), tentacles (P0.0001), intrastromal dots (P0.0001), ring infiltrates (P = 0.024), reticular patterns (P0.0001), and peripheral furrows (P0.0001) were clinical signs associated with Pythium keratitis. Multiple regression analysis identified tentacles (odds ratio: 24.1, 95% confidence interval (CI): 3.8-158.1, P = 0.001) and peripheral furrows (odds ratio: 60.6, 95% CI: 5.1-712.3, P = 0.001) as independent diagnostic prognosticators for Pythium keratitis. The positive and negative likelihood ratios of a dry ulcer surface, tentacles, intrastromal dots, ring infiltrates, reticular patterns, and peripheral furrows predicting Pythium keratitis were 1.6, 13.6, 17.9, 4.3, 30.7, 15.3 and 0.4, 0.4, 0.7, 0.9, 0.6 and 0.8, respectively. The presence of two or more of these clinical signs (excluding a dry ulcer surface) had a sensitivity of 55.6% and a false positive rate of 1.4%.Tentacles, intrastromal dots, ring infiltrates, reticular patterns, and peripheral furrows are clinical signs to be considered for the diagnosis of Pythium keratitis and the presence of two or more signs has a very low false positive rate.

Background We present the results of penetrating keratoplasty (PKP) after previous treatment with a total conjunctival flap in two patients. Case reports Patient 1, a 66-year-old with a history of bilateral cement chemical burn in 1986 and external right-sided limbokeratoplasty in 2008 was treated externally with a total conjunctival flap in the right eye in 2014 due to a persistent corneal ulcer with imminent perforation. Best-corrected visual acuity (BCVA) in the right eye was light sensation, intraocular pressure on palpation was within normal range. Clinically, total conjunctival flap was present. Patient 2 was treated externally in May 2015 due to acanthamoeba keratitis in the left eye with a deep anterior lamellar keratoplasty (DALK). A re-DALK was also performed externally in the same month. A third DALK was performed externally in August 2015 due to a persistent corneal ulcer, followed by a total conjunctival flap 2 weeks later. BCVA of the left eye was light sensation and intraocular pressure on palpation was within the normal range. Results Patient 1 was treated with removal of the conjunctival flap in the right eye and penetrating central re-keratoplasty (hand-held Barron trephine; graft diameter 8.5/8.75 mm). Simultaneously, lens extraction and intraocular lens implantation were performed (as a triple procedure). Additionally, amniotic membrane transplantation (AMT) as patch and a temporal lateral tarsorrhaphy were performed. BCVA 6 months postoperatively was 0.1. The graft was clear, without any signs of rejection. Patient 2 was treated on the left eye with removal of the conjunctival flap and a penetrating central keratoplasty (hand-held Barron trephine; graft diameter 7.0/7.5 mm). An AMT as patch and a temporal lateral tarsorrhaphy were simultaneously performed. Cataract surgery was performed 3 months postoperatively and BCVA of the right eye was 0.1 thereafter. The graft was clear, without any signs of rejection. Conclusion The conjunctival flap is a treatment of last resort of the (almost) penetrated corneal ulcer, which is to be used only when a keratoplasty is technically impossible. Provided the eye structure and retinal function are preserved, partial visual rehabilitation can possibly be achieved through a PKP after excision of the conjunctival flap, even years after corneal blindness.

Peripheral keratitis (PK) is a group of destructive inflammatory diseases of the juxtalimbal corneal stroma that are associated with an epithelial defect, the presence of inflammatory cells in the stroma, and progressive destruction of the corneal stroma. The causes of PK may be as follows: pathology of the eyelids and skin diseases, systemic infectious diseases, as well as a number of non-infectious immune disorders and diffuse connective tissue diseases. The clinical picture of peripheral infectious keratitis (PIK) is characterized by the formation of infiltrates on the periphe­ry of the cornea and the formation of crescent-shaped ulcerations of the cornea. PIK are most common in inflammatory diseases of the conjunctiva, the edges of the eyelids (in seborrheic blepharitis, staphylococcal blepharitis, and rosacea). Differential diagnosis of PIK must be performed with keratitis in case of systemic connective tissue diseases, marginal keratitis in case of lagophthalmos, Mooren’s ulcer, autoimmune diseases of the body involving the mucous membranes and surface of the eye in the pathological process. The main principles of PIC treatment are finding out the cause, controlling the inflammatory process and stimulating corneal regeneration. In the comprehensive therapy for PIK, antibiotics, collagenase inhibitors, reparative drugs, artificial tears, mydriatics are used, as well as combination drugs, which include a bactericidal antibiotic and a corticosteroid. For the treatment of PK associated with the disease of the edges of the eyelids and skin, a combination of antibacterial and glucocorticoid drugs is necessary with control of the underlying disease., Периферические кератиты (ПК) — это группа деструктивных воспалительных заболеваний стромы юксталимбальной роговицы, которые ассоциируются с дефектом эпителия, присутствием клеток воспаления в строме и прогрессирующим расплавлением стромы роговицы. Причинами развития ПК могут быть патология век и заболевания кожи, системные инфекционные заболевания, а также ряд неинфекционных иммунных расстройств и диффузных болезней соединительной ткани. Клиническая картина периферических инфекционных кератитов (ПИК) характеризуется формированием инфильтратов на периферии роговицы и образованием серповидных изъязвлений роговицы. ПИК наиболее часто встречаются при воспалительных заболеваниях конъюнктивы, краев век (при себорейных блефаритах, стафилококковых блефаритах, а также розацеа). Дифференциальную диагностику ПИК необходимо проводить с кератитами при системных заболеваниях соединительной ткани, краевым кератитом при лагофтальме, язвой Мурена, аутоиммунными заболеваниями организма с вовлечением в патологический процесс слизистых оболочек и поверхности глаза. Главными принципами лечения ПИК являются выяснение причины, контроль над воспалительным процессом и стимуляция регенерации роговицы. В комплексной терапии ПИК используют антибиотики, ингибиторы коллагеназы, репаративные, слезозаместительные препараты, мидриатики, а также комбинированные препараты, в состав которых входит бактерицидный антибиотик и кортикостероид. Для лечения ПК, ассоциированных с заболеванием краев век и кожи, необходима комбинация антибактериальных и глюкокортикоидных препаратов с конт­ролем основного заболевания., Периферичні кератити (ПК) — це група деструктивних запальних захворювань строми юксталімбальної рогівки, що асоціюються з дефектом епітелію, присутністю клітин запалення у стромі і прогресуючим розплавленням строми рогівки. Причинами розвитку ПК можуть бути патологія повік і захворювання шкіри, системні інфекційні захворювання, а також низка неінфекційних імунних розладів і дифузних хвороб сполучної тканини. Клінічна картина периферичних інфекційних кератитів (ПІК) характеризується формуванням інфільтратів на периферії рогівки і утворенням серпоподібних виразок рогівки. ПІК найбільш часто зустрічаються при запальних захворюваннях кон’юнктиви, країв повік (при себорейних блефаритах, стафілококових блефаритах, а також розацеа). Диференційну діагностику ПІК необхідно проводити з кератитами при системних захворюваннях сполучної тканини, крайовим кератитом при лагофтальмі, виразкою Мурена, автоімунними захворюваннями організму з залученням до патологічного процесу слизових оболонок і поверхні ока. Головними принципами лікування ПІК є з’ясування причини, контроль над запальним процесом і стимуляція регенерації рогівки. У комплексній терапії ПІК використовують антибіотики, інгібітори колагенази, репаративні, сльозозамісні препарати, мідріатики, а також комбіновані препарати, до складу яких входить бактерицидний антибіотик і кортикостероїд. Для лікування ПК, асоційованих із захворюванням країв повік і шкіри, необхідна комбінація антибактеріальних і глюкокортикоїдних препаратів із контролем основного захворювання.

Background: A Gram-positive spore forming bacilli, aerobe or facultative anaerobe is Bacillus cereus. It is ubiquitous which disperse in the environment. Bacillus is a potential pathogen accountable for fulminant human infectious disease and hardly ever contribute to eye infections. Case Presentation: A 35-year-old farmer came to ophthalmology OPD on February 2019, and the patient complained of acute onset left eye pain with diminution of vision. There was history of eye injury by the vegetation (thorn). There was presence of corneal ulcer. The patient was not immunocompromised. Corneal scrapping was collected from left eye. On Gram staining from corneal scrapping only two Gram positive bacilli, with occasional pus cell and fibrinous exudate was seen. Culture on blood agar medium it showed beta haemolytic, about 2-5 mm in diameter, big flat, irregular edges and greyish white colonies which were oval, slightly granular but not dry. On Mac -Conkey agar medium it showed non lactose fermenting, big flat, irregular colonies. From colonies Gram staining showed Gram positive bacilli with spore. They were motile, catalase positive, oxidase positive, reduced nitrate to nitrite and were resistant to penicillin. The identification was also confirmed by Vitek. Conclusion: This case highlights the importance of cultivation, detection and antibiotic susceptibility test rather than treating patients with ocular infection empirically. Keywords: Corneal ulcer, Bacillus species, Bcereus

OBJECTIVE To document the effectiveness and outcome of corneal grafting using acellular porcine corneal stroma (APCS) for veterinary use (BioCorneaVet™ ) to restore corneal integrity in dogs. METHODS A review of medical records of patients that underwent keratoplasty with APCS graft to repair deep corneal defects, descemetoceles, and perforations between 2019 and 2021 was carried out. Only animals with intact dazzle reflex, consensual PLR before the surgery and a minimum follow-up of four weeks were considered for the study, with forty dogs (1 eye each) meeting the inclusion criteria. RESULTS Brachycephalic breeds were the most frequently represented, and 20 right eyes and 20 left eyes were affected with 25 perforations, 8 descemetoceles, and 9 deep stromal defects (1 eye had both perforation and descemetocele). Most of the patients had concurrent ocular diseases or had undergone previous surgery on the other eye. Two different thickness of xenograft was used (300 or 450 µm), and the diameter ranged from 3 to 10 mm. Postoperative complications included mild to severe corneal vascularization, partial dehiscence, melting, and glaucoma. Follow-up time ranged from 28 to 797 days (mean: 233 days). Ocular integrity was maintained in 37/40 cases (92.5%), and vision was preserved in 36 cases (90%). CONCLUSION The use of APCS (BioCorneaVet™ ) is an effective surgical treatment for deep stromal defects, descemetocele, and perforations in dogs, providing a good tectonic support and preserving anatomical integrity and vision. The cosmetic appearance was considered good in all the cases and continued to improve with time.

A 20-year-old male presented with acute lower limb oligoarthritis and enthesitis followed by acute onset redness, watering, pain and decreased vision in the right eye. He had recent history of diarrhoea with fever. Erythrocyte sedimentation rate and high-sensitivity C-reactive protein (hsCRP) were raised and human leukocyte antigen-B27 was positive. The best corrected visual acuity (BCVA) in the right eye was 20/120 and it showed a paracentral shallow corneal ulcer of size 3 x 4 mm with underlying dense stromal infiltrates and haze. Microbiological evaluation of corneal scrapings was reported as Staphylococcus hominis. The epithelium healed on topical antibiotics in one week, but there were persistent punctate erosions and pleomorphic anterior stromal infiltrates and haze. The residual keratitis healed completely on topical steroids in ten days, with BCVA improving to 20/20. A diagnosis of reactive arthritis with immune-mediated keratitis was made.

PURPOSE To report the successful treatment of 3 cases of recalcitrant fungal keratitis (FK) with high-dose oral posaconazole. METHODS This is a series of 3 patients from a single academic center with a culture-positive FK who were treated with oral posaconazole after failing to respond to conventional treatments. RESULTS All 3 patients had a history of contact lens wear. Two of the 3 cases were culture positive for Fusarium and the other for Paecilomyces. The infections of all 3 failed to respond to conventional antifungal therapies including varying combinations of topical, systemic, and intraocular antifungal therapies. All 3 cases rapidly responded to high-dose oral posaconazole ranging from 500 to 600 mg once daily. In 1 case, multiple courses of high-dose therapy were required to treat delayed recurrences of a latent infection. There were no significant adverse effects with the elevated dose, and treatment was administered with the guidance of an infectious disease specialist. CONCLUSIONS In cases of recalcitrant FK failing to respond to conventional therapies, high-dose posaconazole, in the delayed-release tablet formulation, can be an effective treatment option.

Background: Inflammation of the cornea is known as keratitis. Microbial keratitis is a great challenge for the physicians due to its varied presentation, overlapping symptoms and rapid progression. Though bacterial keratitis is the most prevalent in developing countries but recent increasing trend of fungal keratitis carries a significant risk factors and one of the leading causes of vision loss. Early diagnosis and treatment are the cornerstone for its effective control. Purpose: To determine the outcome and efficacy of treatment with topical natamycin and topical voriconazole in different groups. Materials and Methods: It was a randomised, prospective, comparative, experimental study. The study populations were selected according to inclusion and exclusion criteria after proper evaluation. The study populations were divided into Group A (treated with 1% topical natamycin) and group B (treated 5% topical voriconazole. The patients were followed up subsequently. Data were collected, tabulated in Excel sheet and analyzed in percentage, proportion, t-test and chi square (2) test. The statistically significant was considered if p value

PURPOSE To ascertain the clinicomicrobiological correlation and evaluate the prognostic factors associated with medical resolution in cases of Curvularia, Alternaria, and Scedosporium keratitis. METHODS A retrospective review of clinical and microbiological records of culture-proven cases of Curvularia, Alternaria, and Scedosporium keratitis from 2017 to 2019 was performed. Multivariate logistic regression analyses were performed to assess the predictive factors for medical resolution. RESULTS There were a total of 79 eyes of 79 patients. Among these, there were 56 (70.8%), 15 (18.9%), and 8 (10.1%) patients with Curvularia, Scedosporium, and Alternaria keratitis, respectively. Clinical resolution with medical treatment was achieved in 46 of 56 (82.1%) patients with Curvularia keratitis, 8 of 15 (53.3%) patients with Scedosporium, and 7 of 8 (87.5%) patients with Alternaria keratitis. In comparison between Curvularia and Scedosporium, macroscopic pigmentation [18/56 (32.1%)] of anterior stromal plaque-like infiltrate [20/56 (35.7%)] was clinically more in cases with Curvularia, whereas larger diameter of the infiltrate, P = 0.002, posterior stromal infiltrate (40%), P = 0.03, and hypopyon, P = 0.009, were more common with Scedosporium. Multivariate logistic regression analysis, by backward elimination, showed that maximum dimension of the infiltrate (P = 0.01; odds ratio = 0.52, 95% confidence interval, 0.31-0.86) and presence of a hypopyon (P = 0.02; odds ratio = 0.12, 95% confidence interval, 0.02-0.71) were significant factors that were not favoring medical resolution. CONCLUSIONS Larger size of the infiltrate, posterior stromal involvement, and presence of a hypopyon are poor prognostic indicators among all 3 species. Variation in species is not a predictor of clinical resolution.

Objectives: To study the current practice patterns and opinions in the treatment of corneal bacterial ulcers among Saudi ophthalmologists. Methods: A web-based online survey was conducted in Saudi Arabia to randomly selected ophthalmologists who were registered with Saudi commission for health specialties during the study period between August 2018 to December 2018 using a structured self-administered questionnaire. Results: Of the respondents, general ophthalmologists were 32 (58.2%) and cornea specialists were 23 (41.8%). The mean years of practice was 6.6±6.1 [mean±SD]. Among the respondents 53 (96.4%) treated corneal ulcer cases, most of them 51 (92.7%) agreed there is a relation between the use of contact lenses and ocular ulcers. Fifty respondents indicated that they prescribed antibiotics for the treatment of corneal ulcer. About 12 (52.2%) of the cornea specialist and 22 (68.8%) of general ophthalmologists prefer to use culture of ulcer (Scrapping and gram staining of ulcer) diagnostic tests prior to treatment of corneal ulcers. Fortified antibiotic used was given higher advantage and the management of ocular ulcers differed according to the severity of each case. Conclusion: In conclusion, results found that the management of corneal ulcers varies from specialist to general ophthalmologist. All the respondents agreed that they prescribed two broad spectrum antibiotics to treat an advanced corneal ulcer. Additionally, most of the respondents believed that fourth generation fluoroquinolones were less effective in comparison to fortified, broad-spectrum antibiotics. Key words: Corneal bacterial ulcers, Antibiotics, Fluoroquinolones, Broad spectrum antibiotics, Fortified antibiotics.

Background-Visual impairment due to corneal ulceration has for long been acknowledged as leading cause of blindness both worldwide and in India only next to Cataract. The aetiology for infective corneal ulcer varies considerably with occupation of patients in different regions of India. Thus, continuing with empirical management without lab diagnosis leads to protracted clinical course. So, understanding the microbial profile of corneal ulcers in agriculture dependent population of Southern Assam helps in improved management of this morbidity. Aims- To 1) Find the prevalence of infected corneal ulcers in untreated patients attending Ophthalmology department of a tertiary care hospital of Southern Assam. 2) Study the pattern of microbial aetiology in the infected corneal ulcer cases. 3) Find the association of infected corneal ulcers with various attributing factors. Method-Corneal scrapings from 86 routine untreated cases of corneal ulceration from Ophthalmology Department were studied prospectively from Dec2017 to Jan2019 and subjected to Gram staining and direct examination with 10%KOH. Culture on SDA and Blood Agar were incubated at 25°C and 37°C respectively and followed up for 3 weeks before declaring sterile. Antimicrobial sensitivity was performed for bacterial isolate and yeast-like species. Slide culture and LPCB tease mount were done for identification of moulds. Result- Out of the 86 cases, 58 were positive in direct microscopy, of which 44 were culture positive. Of the 28 samples negative in direct microscopy, 2 were positive by Culture. Bacterial isolates were found in 5 cases and fungal aetiology in 41 cases. Conclusion- The prevalence of infected corneal ulcer as per standard of Culture positivity is 53.5% (46/86). Mycotic involvement was found in 90% cases. Important fungal isolates identified were Aspergillus species, Penicillium species, Curvularia species, Fusarium species, Sarocladium species. Higher prevalence was significantly associated with harvesting season, agricultural practice and history of trauma while diabetes and steroid intake were not significantly associated with mycotic ulcers. Keywords: Corneal ulcer, Assam, Fungal, Fusarium, Sarocladium, Pseudomonas.