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Purpose Describe presumed microbial keratitis cases resulting in evisceration/enucleation from 2012 to 2016 in Sydney, Australia. Methods A retrospective case review included 33 patients. Cases were identified from pathology and hospital coding data. Sociodemographic and clinical details were collated. Results Mean age was 79 years (range: 38-100 years), and 64% female. There were 30 eviscerations and 3 enucleations, at a median time of 8 days (range: 1-270 days) due to endophthalmitis (n = 15, 45%). Major ocular associated factors included topical corticosteroid use in 12 patients (36%), exposure keratopathy in 4 (12%), ectropion in 3 (9%), degenerative corneal disease in 3 (9%), and corneal graft in 2 (6%). Pseudomonas aeruginosa was the most common isolate with no reports of antimicrobial resistance. Conclusions Educating elderly patients with a history of topical corticosteroid use, corneal or ocular surface disease about prompt hospital presentation and treatment of microbial keratitis may decrease the probability of losing the eye.

The purpose of this study was to describe demographics, predisposing factors, clinical features, treatment, and outcomes of microbial keratitis cases resistant to antimicrobials.A retrospective case series was conducted. All patients with microbial keratitis resistant to antimicrobials who underwent a corneal scrape and culture from 2012 to December 2016 at the Sydney Eye Hospital were included. Cases were identified from pathology and hospital coding data. Coagulase-negative staphylococci (CoNS), Staphylococcus aureus (S. aureus), and Corynebacterium spp. resistant to cefalotin, chloramphenicol, ciprofloxacin, or gentamicin were analyzed.One hundred fifteen episodes had a resistant CoNS, 24 S. aureus, and 12 Corynebacterium spp. Antimicrobial resistance was associated with older women (67%, median age 83 years) with Corynebacterium spp. (P0.001), corneal graft, and previous topical steroid use. Larger epithelial defects (P = 0.203) and infiltrates (P = 0.180) were more likely to be associated with Corynebacterium spp., but not statistically significant. At the initial and final visits, resistant S. aureus (75% vs. 67%) and Corynebacterium spp. (78% vs. 80%) cases were more likely to be classified as blind (3/60) compared with CoNS (45% vs. 28%) (P = 0.011 vs. P = 0.004). Corneal perforation occurred more often in resistant S. aureus cases (P0.001), whereas slow and nonhealing epithelial defects needing other procedures were more likely to occur with resistant Corynebacterium spp. (P0.001).Patients with resistant CoNS were younger and presented with smaller ulcers and moderate vision loss. Visual and clinical outcomes were significantly better for resistant CoNS than for those with resistant S. aureus or Corynebacterium spp.

PURPOSE: The study aimed to test whether symptomatic dry eye in aromatase inhibitor (AI) patients is associated with the clinical features of evaporative dry eye. METHODS: A cross-sectional, observational study of postmenopausal women treated with AI was conducted. Clinical information was gathered from their treating clinician. Ocular and treatment symptoms were assessed using validated questionnaires. Clinical assessments were performed to assess for dry eye. The primary outcome measure for this study was dry eye symptoms measured via questionnaire. The secondary outcome measures were clinical signs of dry eye and hormone levels. RESULTS: A total of 25 women on AI were recruited. 64% of women reported symptoms of dry eye (ocular surface disease index ≥ 13). Higher tear osmolarity (323 vs 307 mOsm/L, p = 0.002) and increased meibomian gland dropout (4 vs 1, p = 0.002) were observed in patients with symptomatic dry eye when compared to asymptomatic patients. Multivariate logistic regression identified that longer duration of AI use and higher tear osmolarity increased the likelihood of a patient experiencing dry eye symptoms. CONCLUSION: Our study found increased tear osmolarity and meibomian gland drop out in women on AI with symptomatic dry eye. Longer duration of AI therapy and higher tear osmolarity may increase the risk of developing dry eye.

BACKGROUND/OBJECTIVES: To describe the predisposing factors, pathogens and outcomes in patients with clinical presumed concomitant microbial and herpes simplex keratitis (HSK) at Sydney Eye Hospital, Australia over a 5-year period. SUBJECTS/METHODS: A retrospective case review was conducted. Patients with clinical presumed concomitant microbial and HSK from 2012 to 2016 were identified from pathology and hospital coding databases. Data were extracted from the medical records. VA was converted to the logarithm of the minimum angle of resolution (logMAR). ‘Poor’ outcome was defined as final VA worse than 6/60, or decrease in VA during treatment, or presence of complication, or needed surgical intervention. RESULTS: 126 episodes in 121 patients were included; median age 70 years (range 18–96); 56% male. Predisposing factors included blepharitis 20/126 (16%) cases, and corneal transplantation 19 (15%). Forty-six (37%) cases had prior HSK. Coagulase-negative staphylococci 51/116 (44%), Staphylococcus aureus 11 (9%), and Pseudomonas aeruginosa 11 (9%) were the most common isolates. The median VA at initial visit was 1.7 logMAR (range 0.04–2.7) and at final visit, 0.98 logMAR (range 0–2.7) (P

PURPOSE The aim of this study was to report topical steroid usage in bacterial keratitis and analyze the effects of steroids on patients' outcomes to the main causative organisms. DESIGN A retrospective case-series. METHODS This study included all patients with corneal scrape positive bacterial keratitis from January 2012 to December 2016 at the Sydney Eye Hospital, Sydney, Australia. Cases were identified from pathology results and hospital coding, and data collected from medical records. RESULTS A total of 313 eyes from 308 patients with a mean age of 51 years [interquartile range (IQR) 36-72] were included. Of these patients, 192 (61%) were treated with topical steroids. High-dose steroids were prescribed in 22 (11%) cases, regular-dose in 88 (46%), and low-dose in 82 (43%). The median time until the implementation of steroid use was 4 days (IQR 3-7). Patients prescribed with topical steroids had significantly longer healing times than the "no steroid" group (11 vs 6.5, P

Purpose: To report the microbiological and clinical profiles, and outcomes of patients with microbial keratitis who had ocular surface disease (OSD) at the Sydney Eye Hospital, Australia over a 5-year period.Methods: A retrospective case-series study was conducted. Patients diagnosed with microbial keratitis who had a history of OSD (dry eye, blepharitis, Steven Johnson syndrome (SJS) and ocular cicatricial pemphigoid (OCP)) from 1st January 2012 to 31st December 2016 were identified from hospital coding and pathology data. Data were extracted from the medical records.Results: 189 eyes from 171 patients with a mean age of 60 ± 19 years (range 20-96 years) were included. OSD included blepharitis (79%), dry eye (25%), SJS (4%) and OCP (2%). Coagulase-negative Staphylococcus (CoNS) (48%) were the most common isolated microorganism, made up of mostly Staphylococcus epidermidis (n = 37, 48%), Staphylococcus capitis (n = 16, 21%), and Staphylococcus warneri (n = 10, 13%). Median visual acuity at initial presentation was 0.52 logMAR and 0.30 logMAR at final visit. Median healing time was 12 days (IQR 6-27). The most common initial antimicrobial treatment prescribed was a combination of topical fortified cephalothin and gentamicin (n = 65, 34%); or topical ofloxacin (n = 56, 30%). Complications occurred in 69 eyes (37%), mainly non or slow-healing epithelial defects (n = 53, 43%) or corneal perforations (n = 24, 20%); and were more common in the elderly (n = 48/69, 70%).Conclusion: Microbial keratitis can affect those with OSD. In our setting, CoNS were the main organisms identified. Furthermore, patients prescribed a combination therapy of fortified antibiotics had poorer outcomes compared to monotherapy fluoroquinolones.

Meibomian gland dysfunction is one of the most common ocular disorders encountered by ophthalmologists and is the leading cause of evaporative dry eye. The disease causes significant morbidity in the population such that patients seek treatment. Multiple clinical studies on pharmacological and mechanical interventions for the treatment of meibomian gland dysfunction have been evaluated. However, there is limited comparative clinical evidence for the effectiveness of these interventions. This review paper aims to report the clinical evidence for pharmaceutical interventions for meibomian gland dysfunction in order to guide clinicians in the management of the disease.

PURPOSE The aim of this study was to report the clinical profile and microbiological of patients with microbial keratitis post accelerated corneal collagen cross-linking (CXL). METHODS A retrospective case series of all patients diagnosed with microbial keratitis post-CXL who attended the Sydney Eye Hospital, Australia from January 1, 2012 to December 31, 2019 were included. Patients were identified from hospital coding and pathology data. Data were extracted from patients' medical records. RESULTS Eleven eyes from 10 patients with a mean age of 29 ± 11 years (range 16-48) were included. The median time of infection after CXL surgery was 4 days [interquartile range (IQR) 3-83]. Median initial and final Visual acuity at presentation were 1.3 logMAR (IQR 1-2.0) and 0.8 logMAR (IQR 0.6-1.2), respectively. The culture positivity rate was 92%, identifying 13 isolates, predominately made up of coagulase-negative Staphylococcus (n = 6, 50%) and Staphylococcus aureus (n = 3, 25%). The median epithelial healing time was 30 days (IQR 15-53). CONCLUSIONS Post-CXL microbial keratitis was predominately associated with gram-positive bacteria and in some cases delayed epithelialization. Microbial keratitis post-CXL may lead to moderate to poor patient outcomes.

This study investigated antimicrobial resistance (AMR) profiles from a cohort of patients with bacterial keratitis treated at Sydney Eye Hospital, 1 January 2017 – 31 December 2018. These AMR profiles were analysed in the context of the current Australian empiric regimens for topical therapy: ciprofloxacin/ofloxacin monotherapy versus combination therapy of cefalotin/cephazolin plus gentamicin. At our Centre, combinations of (i) chloramphenicol plus gentamicin and (ii) chloramphenicol plus ciprofloxacin are alternatively used, so were also analysed. Three hundred and seventy-four isolates were cultured prospectively: 280/374 (75%) were gram positive, and 94/374 (25%) were gram negative. Coagulase-negative staphylococci comprised 173/374 (46%). Isolates included Staphylococcus aureus (n = 43/374) 11%; Streptococcus pneumoniae (n = 14/374) 3.7%; and Pseudomonas aeruginosa (n = 50/374) 13%. Statistical comparison was performed. There was no significant difference between cover provided either of the current Australian recommendations: ciprofloxacin/ofloxacin vs cefalotin/cephazolin plus gentamicin (5.3% vs 4.8%, respectively; p = 0.655). However, the combination of chloramphenicol plus an anti-pseudomonal agent (ciprofloxacin/ofloxacin or gentamicin) had significantly improved cover. Chloramphenicol plus gentamicin was superior to ciprofloxacin/ofloxacin (1.9% vs 5.3% resistance respectively; p = 0.007), and cefalotin/cephazolin plus gentamicin (1.9% vs 4.8%; p = 0.005). Chloramphenicol plus ciprofloxacin was superior to ciprofloxacin/ofloxacin monotherapy (1.3% vs 5.3%; p ≤ 0.001), and to cefalotin/cephazolin plus gentamicin (1.3% vs 4.8%; p = 0.003). Chloramphenicol plus gentamicin versus chloramphenicol plus ciprofloxacin/ofloxacin were equivalent (p = 0.48). There was no demonstrated in vitro superiority of either the current empiric antibiotic regimens. For our setting, for bacterial keratitis, chloramphenicol in combination offered superior in vitro cover. Broadened surveillance for ocular AMR is urgently needed across jurisdictions.

PURPOSE To report predisposing factors, clinical features, microbiology spectrum, antibiotic resistance, antimicrobial therapy, and outcomes of patients with a previous laser in situ keratomileusis (LASIK) surgery and diagnosed with presumed microbial keratitis. SETTING Sydney Eye Hospital, Sydney, New South Wales, Australia. DESIGN Retrospective case review. METHODS Patients were identified from pathology and hospital coding data from 2012 to 2016. Inclusion criteria were all patients with a previous LASIK surgery, a presumed diagnosis of microbial keratitis, and a corneal scrape performed and aged older than 18 years. Demographics, clinical details, and outcomes were collated from the medical records. RESULTS Sixteen patients were included, with median age of 41.5 years (range 22 to 85 years) and 56.2% of women. The median time between LASIK procedure and microbial keratitis presentation was 38.3 months (interquartile range 6.7 to 77.45 months). Cultures were positive for bacteria in 12 (75%) of 16 scrapes. Of the bacterial isolates, 12 (85.7%) were gram-positive and 2 (14.3%) gram-negative. Sensitivity profiles for the isolated bacteria were similar between fortified antibiotics (cefalotin and gentamicin) and commercial products (chloramphenicol and ofloxacin). Complications included the need for tectonic grafts, nonhealing epithelial defects, thinning, and neovascularization. CONCLUSIONS Late onset of keratitis after LASIK can occur with no positive cultures for nontuberculous mycobacteria, no interface involvement, and no other usual features reported in case series of infectious keratitis in LASIK patients. It has a similar clinical course to non-LASIK keratitis, such that the surgery may not have been a risk factor for infection.

Purpose: Corneal culturing requires understanding of aseptic non-touch technique and avoidance of possible contaminants. Currently, there is no formal training in the technique and registrars are typically taught by another registrar in the emergency setting.The aim of the study was to develop an evidence-based instructional video for the corneal scrape procedure in microbial keratitis. The study then aims to assess the effect of the instructional video on clinician performance of the corneal scrape procedure.Method: An instructional video for corneal scraping was developed by identifying key steps for the procedure based on available evidence from a review of the literature and clinical practice. A prospective observational comparative case series that included clinicians at the Sydney Hospital/Sydney Eye Hospital, NSW Australia was conducted. Clinicians performing corneal scrapes had their performance of the procedure assessed prior to and after viewing the instructional video.Results: Sixteen key steps to follow in performing the corneal scrape procedure were found and demonstrated in the instructional video. Fourteen clinicians were observed performing 24 corneal scrapes in 24 patients with a median age of 56 years (IQR 34-65 years) and 45% male. Pre-video 11 scrapes were observed vs 13 scrapes post-video. Descriptive data were summarised and non-parametric categorical data analyzed using IBM SPSS (version 1.0.0.800) to perform chi-square and Wilcoxon signed-rank tests. Statistical significance was defined as p < .05. The steps of the corneal scrape procedure were performed correctly by a greater number of clinicians post-video compared to pre-video (p = .003). There was a significant improvement in inoculation of agar plates with cross-hatched streaks (92% post- vs 55% pre-video) and the maintenance of an intact agar surface (92% post vs 55% pre-video) (p = .033).Conclusion: An instructional video optimized the performance of corneal scraping, by ophthalmology trainees, in patients with microbial keratitis.

To provide recent data on patient demographics, clinical profile and outcomes of patients with microbial keratitis over a 5-year period at the Sydney Eye Hospital, and to identify seasonal variations of the main causative organisms. A retrospective study of patients with a clinical diagnosis of microbial keratitis and corneal scrape performed between 1 January 2012 and 31 December 2016. Clinical information was gathered from medical records and pathology data. One thousand fifty-two eyes from 979 patients with a mean age of 54.7 ± 21.5 years (range 18–100 years) were included. The majority of cases were bacterial (65%) followed by polymicrobial (2.4%), fungi (2.3%), and culture-negative (31%). Common risk factors for microbial keratitis were contact lens wear (63%) and previous topical steroid use (24%). Factors significantly associated with poor patient outcomes in the multivariate model were age, visual acuity, and epithelial defect size (p

To describe the clinical features, management and outcomes in patients with fungal keratitis at the Sydney Eye Hospital, Australia, over a 9-year period to guide appropriate initial therapy. A retrospective case review was conducted. Patients diagnosed with fungal keratitis from 1 January 2009 to 31 December 2017 were identified from hospital coding and pathology databases. Data were extracted from the medical records. A total of 55 episodes from 51 patients were included. Mean age was 60 ± 20 years (range: 19-91 years), and 33 were male. The fungal species was not identified in two patients. Predisposing factors included ocular surface disease in 17 eyes (32%); corneal disease, 15 (28%); corneal trauma, 12 (23%); and contact lens wear, 13 (24.5%). Fusarium spp. (15, 27%) and Candida parapsilosis (10, 18%) were the most common isolates. The median visual acuity at presentation was 1.3 logMAR (range: 0 to 3) and after treatment 0.7 logMAR (range: -0.02 to 3) (P = .008). Despite medical therapy, most commonly with natamycin and topical and oral voriconazole, surgical intervention was required in 21 eyes (40%); including antifungal injections in 9 (16%); corneal transplantation, 16 (30%); evisceration, 2 (4%); and enucleation, 1 (2%). A poor visual outcome was recorded in 27 of 43 (63%) patients. Fungal keratitis remains a cause of significant ocular morbidity; the majority of patients face a poor outcome despite intense medical and at times surgical treatment. In our setting, fungal keratitis was more commonly associated with corneal or ocular surface disease.

To document the findings of corneal biopsies for progressive microbial keratitis in a large tertiary referral institution. A retrospective medical records review of all patients who underwent at least one corneal biopsy for the diagnosis of microbial keratitis at Sydney Eye Hospital, Australia between January 1, 2010 and December 31, 2016 was performed. Thirty-eight patients (18 men and 20 women) underwent a corneal biopsy for progressive microbial keratitis unresponsive to broad-spectrum topical antimicrobials. Risk factors for microbial keratitis included contact lens wear in 8 (21%), recent intraocular surgery in 5 cases (13%), recent agricultural trauma in 3 cases (8%), exposure keratopathy due to Graves’ orbitopathy in 1 case (3%), and profound systemic immunosuppression due to chemotherapy for leukaemia in 1 case (3%). The remaining 20 patients had no identifiable risk factors. Fifteen patients (39%) had a positive biopsy result, which identified bacteria in 6 cases and Mycobacteria in 1 case, both by culture of the biopsy specimen. Three cases of fungus were identified on culture of biopsy specimen, two of which were also confirmed on histopathology and an additional case was identified from histopathology alone. A single case of Acanthamoeba was diagnosed by culture and histopathology, and an additional 3 cases were diagnosed on histopathology alone. A corneal biopsy yielded new organisms in 73% (11/15) cases where the culture results of biopsy specimens were positive. Corneal biopsy is an important tool in the diagnosis of progressive keratitis, often identifying causal organisms not found on corneal scraping alone.