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Purpose: To report the indications, outcomes, and complications of therapeutic penetrating keratoplasty (Th PK) in patients with corneal perforation and/or nonhealing corneal ulceration., Methods: A retrospective review was conducted of 51 eyes of 51 patients undergoing Th PK between January 1, 2006 and April 15, 2016. Data collected included patient demographics, visual acuity (VA), size of the corneal infiltrate and epithelial defect, degree of corneal thinning/perforation, microbiological results, surgical details, and postoperative complications., Results: The average age at presentation was 56.0 years (range 6-92 years), and most of the patients were females (n=31, 60.8%). Th PK was performed for corneal perforation in 28 eyes (54.9% of cases), nonhealing corneal ulcer in 16 eyes (31.4% of cases), and imminent risk of corneal perforation in 7 eyes (13.7% of cases). Infection was the most common reason for performing a Th PK and was present in 92.3% (47/51) of all cases. Of the infectious cases, the most common etiologies were bacterial (44.7%, 21/47) and fungal (31.9%, 15/47). The most common identifiable risk factor for undergoing a Th PK was a history of contact lens wear, which was seen in 32.7% of patients. Initial anatomic success was achieved in all patients after performing Th PK. Most patients (33/51; 64.7%) had clear grafts at their last follow-up examination. There was an improvement in VA in 70.2% (33/47, where data were available) of the patients at the final postoperative visit compared with the preoperative visit. Average best postoperative VA (1.14±0.88 logarithm of the minimum angle of resolution [LogMAR]; 20/276) was significantly better than the presenting (1.98±0.68 LogMAR; 20/1910) and preoperative (2.18±0.55 LogMAR; 20/3,027) visual acuities (P<0.0001). The most common complication after Th PK was cataract, which was present in 81.8% (27/33) of phakic eyes in which lens status could be assessed, followed by graft failure (47.1%; 24/51), and secondary glaucoma (45.1%; 23/51). Five eyes developed infection in the therapeutic graft, four eyes had persistent corneal epithelial defect at their last follow-up visit, and two eyes underwent evisceration., Conclusions: Therapeutic penetrating keratoplasty achieves anatomic success and it is a useful procedure for restoring a stable cornea in cases in which infection fails to heal or when the cornea perforates. Furthermore, Th PK achieves corneal clarity and improves vision in most patients.

Purpose: The aim of this study was to review the demographics, causative organisms, seasonal and geographic variation, and antimicrobial resistance patterns of microbial keratitis at our institution over a 4-year period., Methods: Electronic medical records of all patients with microbial keratitis who underwent corneal culturing at a single institution in eastern Pennsylvania between January 1, 2009 and December 31, 2012 were reviewed., Results: A total of 311 patients representing 323 instances of infectious keratitis were analyzed. The most frequently implicated organisms in contact lens-related infections were Pseudomonas aeruginosa for bacteria and Fusarium species for fungus, compared with Staphylococcus aureus and Candida species in non-contact lens-associated bacterial infections. Bacterial keratitis occurred most frequently in spring and least frequently in winter (P = 0.024). Patients who live in large fringe metro (suburban) areas accounted for the highest proportion of infectious keratitis cases. P. aeruginosa and methicillin-sensitive S. aureus isolates were highly susceptible to fluoroquinolones, whereas 32% of coagulase-negative staphylococcus isolates tested were resistant to moxifloxacin and gatifloxacin, and all methicillin-resistant S. aureus organisms tested were resistant to these 2 fluoroquinolones. No organisms tested were resistant to tobramycin, gentamicin, or vancomycin. No fungal infections tested were resistant to voriconazole., Conclusions: Most infectious keratitis occurred in nonwinter months and in patients from suburban counties. Although fluoroquinolones were effective against the most common bacteria, staphylococcal species exhibited a high rate of resistance, representing a therapeutic challenge given the increasing use of fluoroquinolones as first-line monotherapy. No organisms tested were resistant to tobramycin, gentamicin, vancomycin, or voriconazole.

Objective: To report the therapeutic practice patterns of silicone hydrogel (SiH) bandage soft contact lenses (BSCL) and the resultant rate of microbial keratitis (MK)., Methods: A retrospective case series of patients treated with therapeutic BSCLs for ocular surface disease from January 2006 to January 2009 in a tertiary care cornea practice. All patients had a history of ocular surface disease., Results: Seventy-four patients were treated with a therapeutic SiH BSCL (102 intervals of use) for complicated ocular surface disease. Two patients developed infectious corneal infiltrates (2/102, 2.0%) [corrected]. Two of 3 MK episodes were in patients with limbal stem-cell deficiency (2/102, 2.0%)., Conclusions: Therapeutic SiH BSCLs were safely used in most patients. However, results suggest that prophylactic antibiotic use did not eliminate the risk for MK with SiH BSCL use in patients with chronic ocular surface disease.

Purpose: To report the long-term results of keratoplasty in patients with herpes zoster ophthalmicus (HZO)., Methods: All 14 patients underwent keratoplasty for a corneal scar or a perforated corneal ulcer due to HZO at the Wills Eye Institute from January 1999 to August 2011., Results: We performed 9 penetrating keratoplasties and 1 deep anterior lamellar keratoplasty for corneal scarring, and 4 tectonic penetrating keratoplasties for perforated corneal ulceration due to HZO. Eight of the 14 eyes had a temporary tarsorrhaphy concurrent with graft. Postoperative follow-up time ranged from 12 to 132 months (mean 64 ± 38). Postoperatively, the most common complications were dense superficial punctate keratopathy and severe dry eye because of neuropathic keratopathy in 8 eyes, graft rejection in 5 eyes, and secondary glaucoma in 4 eyes. All grafts were clear, and best spectacle-corrected visual acuity was 20/40 or better in 6 eyes (42.8%) and 20/100 or better in 9 eyes at their final evaluation (64.2%)., Conclusions: Although the sample size is small, we demonstrate that very good visual results in long-term follow-up can be achieved when keratoplasty is performed in patients with herpes zoster virus keratopathy. We believe that longer quiescent waiting period between active herpes zoster ocular involvement and keratoplasty may promote better visual results.

Purpose: To evaluate the changes and trends in the number and characteristics of contact lens-related ulcers (CLRUs) and to compare the results with those of previously published series at our institution., Methods: Medical records of all patients diagnosed with presumed bacterial corneal ulcers seen at the Cornea Service, Wills Eye Institute, between January 1, 2004, and December 31, 2007, were retrospectively reviewed., Results: Five hundred seven corneal ulcers were identified. Of these, 223 (43.9%) were contact lens (CL) related and 284 (56.1%) were not CL related. The proportion of CLRU showed a significant increase over time (P = 0.003), with significantly greater percentage of CLRU in 2006 and 2007 compared with 2004 (P = 0.004 and P = 0.005, respectively). One hundred thirty-one (58.7%) of the 223 CLRU patients were men. Many CLRUs were vision threatening, with 45.7% (92 of 201) more than 4 mm in size, 36.3% (81 of 223) associated with hypopyon, and 46.4% (103 of 222) central or paracentral in location. Pseudomonas aeruginosa was the most frequent agent isolated in CLRUs, found in 75 (63.0%) of 119 positive cultures. Soft daily-wear frequent replacement lenses were the most common lenses associated with corneal ulcers and were used in 68 (33.5%) of 203 cases. There was a history of overnight wear of CLs in more than half of the cases (121 of 223, 54.3%). Of these, 21 (9.4%) were not approved for overnight wear., Conclusions: There was a significant increase in the number of cases of presumed bacterial keratitis associated with soft CL wear over the study period from 2004 to 2007 at our institution. The significant increase in CLRU noted from 1996 to 1999 to 1999 to 2002 reported previously seems to have continued between 2004 and 2007.

Purpose: To report trends in fungal keratitis from a single institution between 1999 and 2008., Methods: Retrospective chart review of the patients presenting to the cornea service with fungal keratitis from April 1999 to December 2008., Results: Seventy-eight eyes of 76 patients were identified. The most common predisposing factors included contact lens use (35.9%), trauma (21.8%), and history of penetrating keratoplasty (15.4%). There was a significant increase in the rate of contact lens-related Fusarium infections over time, which peaked in 2005 and 2006 (P = 0.021). Almost 40% of fungal keratitis cases [11 of 28 eyes (39.3%)] were soft contact lens-related Fusarium infections in 2005 and 2006, and this decreased to less than 10% [2 of 25 eyes (8%)] in 2007 and 2008. The odds of having a contact lens-related Fusarium infection in 2005-2006 compared with 2007-2008 was 4.40 (95% confidence interval of 0.60-32.50) (P = 0.178). Despite the decrease in contact lens-related Fusarium infections, the number of fungal infections remained elevated in 2007 (10 eyes) and 2008 (14 eyes), including contact lens-related infections (3 in 2007 and 6 in 2008)., Conclusions: A definite increase in the number of fungal keratitis cases began in 2004 and continued through 2006 during the Fusarium outbreak associated with ReNu with MoistureLoc. Despite the decrease in contact lens-related Fusarium infections, the overall number of fungal keratitis cases remained high through 2008. Fungal keratitis was more often associated with contact lens use than with trauma in this time.

Purpose: To determine the in vitro susceptibility of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant coagulase-negative Staphylococcus (MRCNS) isolates to various antibiotics., Methods: All cases of bacterial keratitis caused by Staphylococcus species during 2006 and 2007 were identified. The isolates were divided according to species and susceptibility to methicillin into 4 groups: methicillin-susceptible S. aureus, methicillin-susceptible coagulase-negative Staphylococcus, MRSA, and MRCNS. Routine susceptibility testing for Staphylococcus species to methicillin and 19 other antibiotics was performed using the MicroScan POS Breakpoint Combo Panel Type 20., Results: One hundred fifty-seven isolates were identified. Forty isolates were S. aureus, including 21 MRSA, and 117 isolates were coagulase-negative Staphylococcus, including 29 MRCNS. All MRSA isolates were susceptible to gentamicin, linezolid, rifampin, tetracycline, and vancomycin and were resistant to penicillin, cefazolin, cefepime, azithromycin, erythromycin, and ofloxacin. Ninety percent of MRSA isolates were resistant to fourth-generation fluoroquinolones. All MRCNS isolates were susceptible to vancomycin, chloramphenicol, linezolid, and rifampin and were resistant to penicillin, cefazolin, cefepime, and azithromycin. Sixty-five percent of the MRCNS isolates were susceptible to fourth-generation fluoroquinolones and gentamicin., Conclusions: All MRSA and MRCNS isolates were sensitive to vancomycin, linezolid, and rifampin. MRSA isolates were generally sensitive to gentamicin and tetracycline and resistant to fourth-generation fluoroquinolones. MRCNS isolates were not consistently sensitive to gentamicin, tetracycline, or fourth-generation fluoroquinolones.

Purpose: To report a series of 5 patients with soft contact lens (SCL) related fungal keratitis caused by unusual organisms diagnosed at the Wills Eye Institute, Cornea Service in 2008., Methods: Chart review of patients with SCL related Alternaria and Paecilomyces keratitis diagnosed in 2008 was performed. Causes of these fungal infections were compared to previous years., Results: During a period from 1999 to 2007, among 64 patients with fungal keratitis, Alternaria was isolated from one case after corneal foreign body removal in 2004, and Paecilomyces was not isolated in any of these patients. In 2008, however, 5 patients with SCL-related atypical fungal keratitis were diagnosed. Alternaria was isolated from 2 cases and Paecilomyces from 3 cases. All patients wore Acuvue SCL (Johnson & Johnson Vision Care): Acuvue Oasys, Acuvue Advance, and Acuvue 2 (1 case each) and Acuvue unspecified (2 cases). A total of 2 patients with Alternaria and 1 patient with Paecilomyces used ReNu or a generic-brand solution manufactured by Bausch & Lomb; 2 with Paecilomyces keratitis used Opti-free Replenish solution. A total of 3 patients wore lenses for daily wear and 2 wore them occasionally for overnight wear. The patients were treated with either voriconazole drops alone or combined with voriconazole 200 mg pills or Natamycin 5% drops. Three patients responded well to treatment. One patient with Paecilomyces keratitis developed a corneal perforation managed with tissue adhesive. One Paecilomyces keratitis patient required an emergency penetrating keratoplasty because of a perforated corneal ulcer present at the initial examination., Conclusions: We report 2 cases of Alternaria and 3 cases of Paecilomyces keratitis in patients wearing frequent replacement lenses and using multipurpose solutions diagnosed during 2008. We want to raise awareness of fungal keratitis caused by unusual organisms associated with SCL wear.

Purpose: To report an outbreak of Fusarium keratitis in contact lens (CL) wearers in the northeastern United States., Methods: Over a 41-month period, all cases with culture-proven corneal ulceration secondary to Fusarium at 2 tertiary care eye centers were identified through the microbiology departments of each institution, and a retrospective review of charts was performed. Statistical analyses were performed to evaluate a possible association of Fusarium keratitis with specific CL and CL solution brands., Results: Fifteen cases of Fusarium keratitis were reported at the 2 tertiary centers between July 2005 and May 2006 (16.4 cases/yr) compared with 6 cases over the previous 30 months from January 2003 to June 2005 (2.4 cases/yr). All 15 of the more recent cases were CL users, and none had a history of trauma. All 15 patients claimed use of ReNu brand contact lens solution when they developed keratitis. Twelve (80.0%) of 15 patients were Acuvue soft contact lens users. Ten (66.7%) of 15 patients used tap water to rinse their contact lens cases. Six (40.0%) of 15 cases have thus far required corneal transplantation., Conclusions: The incidence of corneal ulceration secondary to Fusarium has increased sevenfold over the reported 11-month period at 2 tertiary eye care centers in the northeastern United States compared with the previous 30 months. There seems to be an association between the recent outbreak of Fusarium keratitis among CL users and the use of ReNu contact lens solution. Medical treatment of Fusarium keratitis may be ineffective, and emergent penetrating keratoplasty (PKP) may be required in some patients. CL users and their physicians should reconsider the risks of CL use and discuss proper lens care techniques.

Purpose: We report 4 cases of corneal ulcers associated with drug abuse. The pathogenesis of these ulcers and management of these patients are also reviewed., Methods: Review of all cases of corneal ulcers associated with drug abuse seen at our institution from July 2006 to December 2006., Results: Four patients with corneal ulcers associated with crack cocaine use were reviewed. All corneal ulcers were cultured, and the patients were admitted to the hospital for intensive topical antibiotic treatment. Each patient received comprehensive health care, including medical and substance abuse consultations. Streptococcal organisms were found in 3 cases and Capnocytophaga and Brevibacterium casei in 1 patient. The infections responded to antibiotic treatment. Two patients needed a lateral tarsorrhaphy for persistent epithelial defects., Conclusions: Aerosolized crack cocaine use can be associated with the development of corneal ulcers. Drug abuse provides additional challenges for management. Not only treatment of their infections but also the overall poor health of the patients and increased risk of noncompliance need to be addressed. Comprehensive care may provide the patient the opportunity to discontinue their substance abuse, improve their overall health, and prevent future corneal complications.