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Purpose: To elucidate a distinctive clinical feature in cases of microsporidial stromal keratitis (MSK)., Method: A retrospective observational study of cases with a histopathological and/or microbiological diagnosis of MSK on corneal biopsy or host corneal button between 2016 and 2022 was conducted., Results: Eighteen cases with a confirmed histopathological and/or microbiological diagnosis of MSK were detected. Careful review of slit-lamp photographs revealed the presence of pigmented keratic precipitates (KPs) beyond the area of stromal keratitis in five out of eighteen cases (27.7%)., Conclusion: The presence of pigmented KPs beyond the area of lesion can alert the clinician to keep microsporidia as a differential cause for stromal keratitis. Management can be tailored accordingly for a better outcome.

Introduction: Although monkeypox-related ophthalmic disease (MPXROD) is rare, visual impairing complications have been reported. At present, tecovirimat is the standard-of-care antiviral treatment. In this MPXROD case, the effect of tecovirimat was assessed with PCR analysis of tear samples and concurrent monitoring of inflammation with laser flare photometry (LFP)., Case Description: The patient presented with a palpebral lesion and a corneal ulcer in his right eye, with complete absence of the corneal epithelium, high intraocular pressure and anterior uveitis. MPXV-DNA was detected in tear samples with real-time PCR (RT-PCR). A total volume of 0.5 ml tear-wash was aspirated from the inferior fornix, following instillation of saline onto the ocular surface. In addition, LFP was used to quantify inflammation in both eyes. Viral load in tear samples was detected prior to treatment initiation. In the left eye, tear samples tested negative for MPXV-DNA one week post-treatment while MPXV-DNA was still detected in the right eye, before reaching undetectable levels four weeks post-treatment. Objective quantification of anterior chamber inflammation through LFP demonstrated gradual decrease that was more pronounced in the affected right eye and coincided with the clinical improvement of the corneal ulcer., Conclusions: This case of Mpox related corneal ulcer with associated uveitis manifests the feasibility of monitoring the antiviral effect of tecovirimat with virus detection in tear samples and LFP. Our observations indicate that tecovirimat resulted in viral load reduction in both eyes. RT-PCR MPXV detection in tear samples and LFP represent noninvasive tools that could assist with treatment response monitoring., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Corneal ulcers, whether melting or indolent, are common in humans and companion animals. Treatment involves local administration of antibiotic eye drops and corneal healing drugs. Compared to traditional treatments for ulcerative keratitis, herbal medicines offer unique advantages, such as potent anti-inflammatory effects and inhibition of proinflammatory cytokines. Curcumin, extracted from the Curcuma Longa plant, possesses extensive pharmacological properties, such as anti-inflammatory, anti-cancer, and antioxidant properties, and is used in various medicines. In this study, we developed a novel ophthalmic drop hydrogel using a formulation of Curcumin NPs encapsulated with β-cyclodextrin and hyaluronic acid, to accelerate corneal healing and improve the quality of healed structures. The formation of Curcumin NPs into Hyaluronic acid-based hydrogels was characterized by zeta, FTIR, and scanning electron microscope (SEM) analyses. A total of 25 healthy male New Zealand Albino rabbits were experimentally induced with ulcerative keratitis and treated individually with topical medication. Rabbits were divided into five groups. Fluorescein dye staining, corneal clarity score, Schirmer tear test, proinflammatory cytokine measurement, and pathologic factors assessments were used to evaluate the optimised Curcumin NPs with β-cyclodextrin in Hyaluronic acid hydrogel. Our results demonstrated that the optimized Curcumin NPs with β-cyclodextrin in hyaluronic acid hydrogel significantly reduced the frequency of medication administration compared to conventional therapies, enhancing the quality of healed structures and effectively treating ulcerative keratitis. All findings in this study provide new insight into designing and fabricating novel ophthalmic medicine for ulcerative keratitis for topical usage., (© 2024. The Author(s).)

Competing Interests: Financial disclosures/conflicts of interest: None reported.

Purpose: The aim of this study was to evaluate the role of anterior segment optical coherence tomography during follow-up of infectious keratitis and to assess response to treatment., Methods: This was a prospective, consecutive, observational clinical series of cases. Twenty-three eyes of 23 patients with clinically proven fungal keratitis were included in the study. The patients received medical treatment according to clinical diagnosis, and follow-up was performed weekly. Slit-lamp examination and photography, and anterior segment optical coherence tomography were performed at initial and follow-up visits until corneal healing occurred. The main outcome measures included infiltrate depth, width, and density; central corneal thickness; minimal corneal thickness; corneal thickness at the site of the lesion; and stromal thickness at the center of the lesion., Results: Twenty-three eyes of 23 patients (17 men and 6 women), mean age 42.5 ± 19 (8-66) years, were clinically diagnosed with fungal keratitis. Localization was central in 14 cases and paracentral/peripheral in 9 cases. Healing time was 6 to 12 weeks. Minimal corneal thickness, corneal thickness at the site of lesion, and stromal thickness at the center of lesion, and also infiltrate width and depth changed significantly from the first visit to the healing stage at the last follow-up (0.009, 0.001, 0.007, 0.001, and <0.001, respectively)., Conclusions: In cases of fungal keratitis, anterior segment optical coherence tomography can provide the clinician with a quantitative assessment of a number of corneal parameters that can be used to determine effectiveness of therapy and confirm complete healing of the lesions that cannot be achieved by clinical evaluation., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To describe a patient diagnosed with Exophiala jeanselmei keratitis., Methods: We report a case of a patient who developed infectious keratitis following laser in situ keratomileusis and chronic topical steroid use for approximately six months in both eyes. An atypical infiltrate containing dark pigmentation was noted in the left eye on the initial presentation. During treatment, the infiltrates of the right eye began to exhibit a similar pigmentation., Results: Early treatment with topical antifungals was initiated in the left eye and later in the right eye once culture results returned. Both eyes recovered with good vision after approximately one month., Conclusions: Patients treated with postoperative topical corticosteroids should be cautioned of potential adverse effects of chronic use and have close follow-up. If infectious keratitis develops, particularly after two weeks, then atypical organisms, such as fungi, should be considered. In addition, our case highlights the significance of recognizing and associating dark-pigmentation with fungal etiologies., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Contact Lens Association of Ophthalmologists.)

To evaluate the efficacy of topical vancomycin and povidone iodine (PI) application on methicillin-resistant Staphylococcus aureus (MRSA) keratitis model in rabbits., MRSA keratitis was induced by injecting 0.1 mL MRSA containing 1000 colony-forming units (CFU) into central cornea of right eyes of 24 New Zealand White rabbits. Animals were divided into four groups ( n  = 6): control (treated with balanced salt solution), 50 mg/mL topical vancomycin, 5% topical PI, and combination; examined before and after treatment, and corneal tissues were harvested for analysis at 9th hour of treatment., Bacterial load was determined as: 7.63 ± 0.82 log10 CFU/g in control group, 6.95 ± 1.66 log10 CFU/g in PI group, 4.67 ± 0.77 log10 CFU/g in combination group, and 4.33 ± 0.71 log10 CFU/g in vancomycin group ( p  = 0.001). Median of total clinical score increased significantly from 7 [range: 5-8] to 11.5 [range: 11-15] ( p  = 0.001) in control group, did not change (6 [range: 5-8] to 7 [range: 5-7]; p  = 0.695) in vancomycin group, increased significantly from 7 [range: 5-8] to 12.5 [range: 10-14] ( p  < 0.001) in PI group, increased significantly from 6.5 [range: 5-7] to 8 [range: 7-9] in combination group ( p  = 0.002). Post-treatment clinical scores for chemosis, conjunctival injection, iritis, hypopyon, epithelial erosion, and corneal infiltrate were significantly lower in vancomycin-treated groups compared to others ( p  < 0.05). In PI-treated groups, especially scores for chemosis, conjunctival injection, epithelial erosion and corneal infiltrate were significantly higher than vancomycin ( p  < 0.05)., Topical vancomycin significantly inhibited bacterial growth in MRSA keratitis. However, PI was ineffective in controlling this growth; additionally, exerted toxic effect on ocular surface. When vancomycin was combined with PI, no additional increase in efficacy of treatment was detected compared to only vancomycin.

Purpose: To report an unusual case of bilateral aggressive Mooren ulcer that occurred in the setting of bilateral pterygia and showed a relentless course during pregnancy., Methods: A 39-year-old woman of Black African ethnicity, 36-week pregnant, presented to the eye casualty with bilateral nasal corneal ulcer and associated melt around preexisting pterygia. A detailed workup including microbial evaluation, culture and sensitivity, polymerase chain reaction for herpes simplex virus, varicella zoster virus, and cytomegalovirus, inflammatory blood profile, autoimmune markers, and human leucocyte antigen (HLA) screening was undertaken. Treatment was initiated in a stepwise approach., Results: Infections and systemic autoimmune and rheumatologic conditions were ruled out. A diagnosis of bilateral Mooren ulcer was made by exclusion. The peripheral blood was positive for HLA DQ2. As the condition seemed refractory to medical management (topical steroids and intravenous pulse methylprednisolone followed by oral prednisolone and topical cyclosporine), urgent bilateral conjunctival resection with multilayered amniotic membrane transplantation was performed to reduce the inflammatory stimulus and keratolysis. Stabilization of the condition warranted the need for systemic immunosuppressive agents. Using a multidisciplinary approach, in liaison with Obstetricians and Rheumatologists, the patient was planned for an earlier elective Cesarean section and commencement of oral mycophenolate mofetil postpartum, which aided in successful control of the disease., Conclusions: Mooren ulcer could follow an aggressive course during pregnancy, especially in the setting of preexisting pterygium. The complex hormonal and immunological changes during pregnancy and the delivery of inflammatory mediators directly onto the cornea by pterygium could contribute to the severity. A well-planned, stepwise, and multidisciplinary management is pivotal for the treatment of this condition., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To describe the prevalence and antibiotic resistance profiles of Pseudomonas aeruginosa isolated from the Asia Cornea Society Infectious Keratitis Study (ACSIKS)., Methods: All bacterial isolates from ACSIKS underwent repeat microbiological identification in a central repository in Singapore. Minimum inhibitory concentration (MIC) determination was conducted for isolates of P. aeruginosa against thirteen antibiotics from 6 different classes, and categorized based on Clinical Laboratory Standard Institutes' reference ranges. The percentage rates of resistance (non-susceptibility) to each antibiotic included isolates of both intermediate and complete resistance. Multi-drug resistance (MDR) was defined as non-susceptibility to at least one agent in three or more antimicrobial classes., Results: Of the 1493 unique bacterial specimens obtained from ACSIKS, 319 isolates were of P. aeruginosa. The majority of isolates were from centers in India (n = 118, 37%), Singapore (n = 90, 28.2%), Hong Kong (n = 31, 9.7%) and Thailand (n = 30, 9.4%). The cumulative antibiotic resistance rate was the greatest for polymyxin B (100%), ciprofloxacin (17.6%) and moxifloxacin (16.9%), and lowest for cefepime (11.6%) and amikacin (13.5%). Isolates from India demonstrated the highest antibiotic resistance rates of all the centers, and included moxifloxacin (47.5%) and ciprofloxacin (39.8%). Forty-eight of the 59 MDR isolates also originated from India. Antibiotic resistance rates were significantly lower in the other ACSIKS centers, and were typically less than 10%., Conclusions: The antibiotic resistance profiles of P. aeruginosa varied between different countries. While it was low for most countries, substantial antibiotic resistance and a significant number of multi-drug resistant isolates were noted in the centers from India., (© 2024. The Author(s).)

Rationale: Compared with intraocular tuberculosis, ocular tuberculosis with ocular surface involvement is rare. Corneal involvement in ocular tuberculosis may include interstitial keratitis or peripheral ulcerative keratitis. We report a case of peripheral ulcerative keratitis directly caused by tuberculosis., Patient Concerns: A 20-year-old man complained of vision loss and pain in the left eye that had lasted for 1 week. A slit lamp examination of the left eye showed a corneal epithelial defect, interstitial corneal edema, and a white irregular infiltrative lesion and ulcer (with the dimension of 2 × 2.5 mm) in the inferior temporal region., Diagnoses: The corneal ulcer was scraped, and the Mycobacterium tuberculosis deoxyribonucleic acid polymerase chain reaction was positive., Interventions and Outcomes: After a month of oral antituberculosis treatment, the corneal ulcer resolved, and the intraocular inflammation improved., Lessons: Peripheral ulcerative keratitis secondary to tuberculosis can be directly caused by M tuberculosis., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: The objective of the study was to identify bacterial pathogens and their antimicrobial sensitivity profile associated with cases of canine progressive ulcerative keratitis., Materials and Methods: Analysis of microbial culture and sensitivity results from dogs with progressive ulcerative keratitis presenting to a UK referral practice between December 2018 and August 2020., Results: Positive bacterial cultures were obtained from 80/148 (54%) of the canine ulcers sampled with 99 bacterial isolates cultured. Streptococcus canis (n = 29), Pseudomonas aeruginosa (n = 19), and Staphylococcus pseudintermedius (n = 16) were the most common isolates. Pseudomonas aeruginosa was more likely to be isolated whether the ulcer was clinically malacic at the time of sampling (OR = 10.1, p < .001). Ulcers treated prior to culture with fusidic acid were 7.6 times more likely to be positive than those treated with any other antimicrobial(s). Bacterial isolates demonstrated resistance against neomycin (85%), fusidic acid (78%), and tetracycline (68%). Conversely, isolates were most likely to be sensitive to gentamicin (88%), ofloxacin (77%), ciprofloxacin (73%), and chloramphenicol (64%). Antimicrobial combinations of chloramphenicol or gentamicin with a fluoroquinolone (ofloxacin or ciprofloxacin) or chloramphenicol combined with gentamicin were the most effective on in vitro analysis (over 90% susceptibility of all isolates)., Conclusion: The most common bacterial species associated with canine progressive ulcerative keratitis in a UK referral population were S. canis, P. aeruginosa, and S. pseudintermedius. Combination antimicrobial therapy is recommended pending culture and sensitivity results given the varied antimicrobial susceptibility profiles and significant bacterial in vitro resistance to antimicrobial monotherapy., (© 2023 American College of Veterinary Ophthalmologists.)

Purpose: To report the first case of Rhizopus sp keratitis in a 15-year-old male patient who had undergone a conventional Epi-off CXL procedure for progressive keratoconus., Methods: A 15-year-old male studying at school presented with defective vision in both eyes recently. He was diagnosed with progressive keratoconus in the right eye more than left eye. After the conventional CXL procedure, the patient developed corneal ulcer on third postoperative day., Results: The microbiological diagnosis of both BCL and ulcer revealed Rhizopus sp. The patient responded to topical antifungals, and the ulcer entirely healed with a large central scar., Conclusion: Rhizopus keratitis is rare in a healthy individual. Ours is the first case report of Rhizopus keratitis in patient undergone CXL., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To describe the first case of Pythium insidiosum keratitis masquerading as dematiaceous fungal keratitis in a seropositive male., Case Summary: A 44-year-old seropositive male previously treated for acute retinal necrosis presented with pain and defective vision in the right eye following a mud injury 5 days back. Presenting visual acuity was hand movements close to the face. Ocular examination revealed a 7 × 7 mm dense, greyish-white mid stromal infiltrate with pigmentation and few tentacles. The clinical diagnosis suggested fungal keratitis. Corneal scraping on 10% KOH and Gram stain revealed slender, aseptate hyaline hyphae. Before culture results, the patient was treated with topical 5% natamycin and 1% voriconazole, but the infiltrate progressed. Culture on 5% sheep blood agar revealed white fluffy, submerged, shiny, and appressed colonies, and Pythium insidiosum was confirmed by zoospore formation. The patient was further managed with topical linezolid 0.2% hourly, azithromycin 1% hourly, and adjuvant drugs., Conclusion: This is an uncommon presentation of Pythium keratitis masquerading as dematiaceous fungal keratitis in an immunocompromised male.

In the treatment of refractory corneal ulcers caused by Pseudomonas aeruginosa, antibacterial drugs delivery faces the drawbacks of low permeability and short ocular surface retention time. Hence, novel positively-charged modular nanoparticles (NPs) are developed to load tobramycin (TOB) through a one-step self-assembly method based on metal-phenolic network and Schiff base reaction using 3,4,5-trihydroxybenzaldehyde (THBA), ε-poly-ʟ-lysine (EPL), and Cu 2+ as matrix components. In vitro antibacterial test demonstrates that THBA-Cu-TOB NPs exhibit efficient instantaneous sterilization owing to the rapid pH responsiveness to bacterial infections. Notably, only 2.6 µg mL -1 TOP is needed to eradicate P. aeruginosa biofilm in the nano-formed THBA-Cu-TOB owing to the greatly enhanced penetration, which is only 1.6% the concentration of free TOB (160 µg mL -1 ). In animal experiments, THBA-Cu-TOB NPs show significant advantages in ocular surface retention, corneal permeability, rapid sterilization, and inflammation elimination. Based on molecular biology analysis, the toll-like receptor 4 and nuclear factor kappa B signaling pathways are greatly downregulated as well as the reduction of inflammatory cytokines secretions. Such a simple and modular strategy in constructing nano-drug delivery platform offers a new idea for toxicity reduction, physiological barrier penetration, and intelligent drug delivery., (© 2024 The Authors. Advanced Science published by Wiley‐VCH GmbH.)

Purpose: The purpose of this study was to report a case of peripheral ulcerative keratitis in a patient diagnosed with corneal polymerase chain reaction (PCR) and a positive mpox culture., Methods: This is a case report., Results: An immunocompetent 54-year-old man was diagnosed with conjunctivitis in his left eye 15 days after being diagnosed with mucocutaneous monkeypox. He received treatment with dexamethasone 0.1% and tobramycin 0.3% eye drops for 2 weeks. Two weeks after discontinuing this treatment, he developed peripheral ulcerative keratitis and a paracentral epithelial defect. Mpox keratitis was diagnosed by corneal culture and PCR. Corneal inflammation persisted for more than 6 months, manifested as corneal epithelial defect, limbitis, endotheliitis, neurotrophic changes, and trabeculitis. This persistence was observed alongside positive corneal PCR results, despite undergoing 2 courses of trifluorothymidine, 2 courses of oral tecovirimat, and intravenous cidofovir. An amniotic membrane transplantation was then performed., Conclusions: Persistent corneal pain and replication are possible with the mpox virus, even in immunocompetent patients. Having received treatment with topical corticosteroids before antiviral treatment for the pox virus may have contributed to the severity and persistence of the clinical condition. Cycle threshold PCR values can be used to support the diagnosis and monitor treatment effectiveness., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Pseudomonas aeruginosa-induced keratitis is one of the most severe and challenging forms of corneal infection, owing to its associated intense inflammatory reactions leading to corneal necrosis and dense corneal scar with loss of vision. Since mesenchymal stem cells (MSCs) are reported to possess antimicrobial and immunomodulatory properties, they can be tested as an adjuvant treatment along with the antibiotics which are the current standard of care. This study aims to investigate the anti-bacterial and immunomodulatory roles of human bone marrow MSC-derived conditioned medium (MSC-CM) in P. aeruginosa-infected human corneal epithelial cells (HCECs) in vitro., Methods: The effect of MSC-CM on the growth of clinical isolates of P. aeruginosa was evaluated by colony-forming unit assay. The expression of inflammatory cytokines (IL-6 and TNF-α) and an antimicrobial peptide (Lipocalin 2) in lipopolysaccharide-treated MSCs and HCECs was analyzed through ELISA. Corneal epithelial repair following infection with P. aeruginosa was studied through scratch assay., Results: Compared to control (P. aeruginosa (5*10 5 ) incubated in DMEM (1 ml) at 37 °C for 16 h), MSC-CM significantly: i) inhibits the growth of P. aeruginosa (159*10 9 vs. 104*10 9  CFU/ml), ii) accelerates corneal epithelial repair following infection with P. aeruginosa (9% vs. 24% closure of the wounded area after 12 h of infection), and iii) downregulates the lipopolysaccharide-induced expression of IL-6, TNF-α and Lipocalin 2 in HCECs. A combination of MSC-CM with an antibiotic, Ciprofloxacin moderately regulated the expression of IL-6, TNF-α, and Lipocalin 2., Conclusion: MSC-CM holds promise as an adjunctive therapeutic approach for P. aeruginosa-induced corneal epithelial damage., Competing Interests: Declaration of competing interest The authors declare that there are no conflicts of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

A 60-year-old patient was diagnosed with multiple myeloma in November 2020, and started treatment in December 2020 with bortezomib, dexamethasone, and thalidomide. Four months later, he presented to the ophthalmology emergency department with inflammation and pain in the left eye. Examination of the anterior segment revealed severe, mixed anterior squamous blepharitis with significant bilateral palpebral inflammation, dysfunction of the meibomian glands, and several styes on both eyelids bilaterally. A peripheral ulcerative keratopathy was detected while examining the left eye cornea, with an inferior infiltrate and significant thinning, approximately 5 mm in length, at the limbal margin (Figure 1). Tear break-up time was shortened bilaterally. In addition to palpebral hygiene and oral treatment with doxycycline 100 mg every 24 hours, the patient was prescribed the following topical treatment without preservatives: artificial tears with lipid emulsion, netilmicin 0,3% 0,4 ml eye drops every 6 hours and dexamethasone 1 mg/ml every 8 hours.

Background: To assess the long-term incidence and risk factors for post-keratoplasty infectious keratitis (IK), associated ocular pathogens, and antibiotic resistance profiles., Methods: Cohort study including 2553 consecutive penetrating, endothelial, and anterior lamellar keratoplasties performed between 1992 and 2020. Medical and microbiological records of patients clinically diagnosed with IK were retrospectively reviewed., Main Outcome Measures: cumulative incidence of IK, infectious agent species, and antibiotics resistance profiles., Results: The average follow-up time after transplantation was 112 ± 96 months. Eighty-nine IK episodes were recorded; microbiological tests were positive in 55/89 (62%). The cumulated incidence of postoperative IK was 5.50%/10.25% at 10/20 years. The occurrence of at least one episode of IK after transplantation was associated with lower graft survival in the long term (p < 0.0001). Rejection risk (adjusted Hazard Ratio, 2.29) and postoperative epithelial complications (HR, 3.44) were significantly and independently associated with a higher incidence of postoperative IK. Infectious agents included 41 bacteria, 10 HSV, 6 fungi, and 1 Acanthamoeba. The rate of antibiotic resistance was 0% for vancomycin, 13% for fluoroquinolones, 20% for rifamycin, 59% for aminoglycosides, and 73% for ticarcillin. In 41% of cases, patients were under prophylactic topical antibiotics before the infectious episode. Topical antibiotics were significantly associated with increased resistance to penicillin, carbapenems, and aminoglycosides., Conclusion: IK (mainly bacterial) is a frequent complication of corneal transplantation in the long term. Vancomycin and fluoroquinolones can be considered as first-line treatments. Prolonged postoperative antibiotic preventive treatment is not advisable as it may increase antibiotic resistance., (© 2024 The Authors. Clinical & Experimental Ophthalmology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Ophthalmologists.)

Purpose: Microbial keratitis is a sight-threatening condition with a higher incidence in agrarian populations. In countries with a high indigent population, due to financial and other constraints, patients prefer to seek therapy locally rather than travel to advanced centres. The aim of this study is to describe the epidemiology, clinical characteristics, and outcomes of 60 consecutive patients with microbial keratitis managed at a rural centre., Methods: Descriptive case series. All patients clinically diagnosed with infectious keratitis were included. Corneal scrapings were obtained and microbiological identification was done by Gram stain. Anti-microbial therapy was commenced based on smear findings and the patients were followed up till disease resolution., Results: Sixty eyes of 60 patients were diagnosed with microbial keratitis in the study period. The mean age was 47.43 ± 18.69 years. Male:female ratio was 47:53. Risk factors included ocular trauma in the majority of patients (46/60; 76.7%). Microorganisms were identified on 75.6% of smears, with fungal filaments (65.4%) being the most common. Ulcers were central in over half (32/60; 53.3%), and > 3 mm in diameter in over three-fourths (81.6%) of patients. Forty-four patients (73.3%) achieved treatment success whereas 16/60 (26.6%) required referral to our tertiary-eye care facility for management. The median time to resolution was 14 days (IQR 10-26 days)., Conclusion: Our series demonstrates the feasibility of microbiology-guided therapy in microbial keratitis by ophthalmologists at the secondary rural eye-care level. Two-thirds of the patients could be successfully managed at the rural centre and only severe cases needed a referral to tertiary centres., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Fungal keratitis (FK) is an infectious eye disease that poses a significant risk of blindness. However, the effectiveness of conventional antifungal drugs is limited due to the intrinsic ocular barrier that impedes drug absorption. There is an urgent need to develop new therapeutic strategies to effectively combat FK. Herein, we synthesized an ultrasmall positively charged carbon dot using a simple stage-melting method. The carbon dot can penetrate the corneal barrier by opening the tight junctions, allowing them to reach the lesion site and effectively kill the fungi. The results both in vitro and in vivo demonstrated that it exhibited good biocompatibility and antifungal activity, significantly improving the therapeutic effect in a mouse model of FK. Therefore, this biophilic ultrasmall size and positive carbon dot, characterized by its ability to penetrate the corneal barrier and its antifungal properties, may offer valuable insights into the design of effective ocular nanomedicines.

Purpose: To compare the efficacy and rapidity of direct microscopic detection of fungal elements from corneal ulcers between 10% potassium hydroxide (KOH) and 1% Chicago Sky Blue 6B (CSB) in 10% KOH (CSB-KOH)., Methods: Thirty patients with clinically suspected fungal keratitis were recruited. Participants with impending corneal perforation were excluded. Two slides were smeared with corneal ulcer scrapings from the ulcer's edge and base for comparison of fungal staining solutions. One slide was infused with KOH, and the other slide was filled with CSB-KOH. Additional scraping was collected for inoculation on Sabouraud dextrose agar for fungal culture. The sensitivity, specificity and rapidity of both stainings were analyzed., Results: The sensitivity of fungal culture, KOH, and CSB-KOH were 43.75% (95% confidence interval [CI], 19.75%-70.12%), 62.50% (95% CI, 35.43%-84.80%), and 87.50% (95% CI, 61.65%-98.45%), respectively. The specificity were 100% (95% CI, 69.15%-100%) of both stainings and fungal culture which analyzed from 16 fungal keratitis cases by laboratory and clinical diagnosis. Mean CSB-KOH examination time was quicker than KOH with the mean time difference of 5.6 minutes (95% CI, 3.22-7.98 minutes) and p-value &lt; 0.001., Conclusions: CSB-KOH was more effective and faster than KOH in detecting fungal elements from corneal ulcers. Therefore, CSB-KOH may be beneficial in diagnosing fungal keratitis and preventing blindness. Moreover, to the best of our knowledge, this is the first use of CSB stain in fungal keratitis detection.

Purpose: The ocular manifestations of Monkeypox virus (Mpox) infection remain incompletely characterized. Our goal is to present a case series of non-healing corneal ulcers with associated uveitis caused by Mpox infection as well as management recommendations for Mpox-related ophthalmic disease (MPXROD)., Methods: Retrospective case series., Results: Two male patients with recent hospitalization for systemic Mpox infection presented with non-healing corneal ulcer associated with anterior uveitis and severe IOP elevation. Despite initiation of conservative medical treatment including corticosteroid treatment for uveitis, in both cases, there was clinical progression with enlarging cornea lesions. Both cases received oral tecovirimat with complete healing of the corneal lesion., Conclusions: Corneal ulcer and anterior uveitis are rare complications of Mpox infection. Although Mpox disease is generally anticipated to be self-limited, tecovirimat may be an effective intervention in poorly healing Mpox keratitis. Corticosteroids should be used with caution in Mpox uveitis, as they might lead to worsening infection.

Purpose: To report a rare case of keratitis due to monkeypox infection., Methods: A 45-year-old male presented with an epithelial corneal ulcer 20 days following initial diagnosis of monkeypox from genital and perioral lesions. PCR analysis of the epithelium confirmed the presence of human monkeypox virus., Results: The patient was hospitalized, and ganciclovir gel, as well as povidone iodine 0.6% and moxifloxacin eyedrops were prescribed. Oral tecovirimat 600 mg was administered during 14 days. A therapeutic contact lens was used. Twenty days after the initial diagnosis of keratitis, the corneal defect closed leaving a faint subepithelial haze, and visual acuity was 0.8., Conclusions: This is an uncommon case report of epithelial keratitis due to human monkeypox. PCR positivity for monkeypox in the corneal epithelium confirmed the presence of viral material in the cornea.

Fungal keratitis (FK) is a dangerous corneal infection that is common in tropical and subtropical areas. Its incidence is extremely high, and ocular trauma and contact lenses can lead to FK, but its common treatment such as using topical antifungal eye drop instillation is often less effective because of several drawbacks of the drugs typically used, including limited ocular penetration, high frequency of dosing, poor biocompatibility, and the potential for severe drug reactions. Therefore, the development of novel drug delivery devices for the treatment of FK is urgent. The urgent need for novel drug delivery devices to treat FK has led to the development of several techniques, including nanoparticles (NPs), in situ forming hydrogels, contact lenses, and microneedles (MNs). However, it is important to note that the main mechanisms differ between these techniques. NPs can transport large amounts of drugs and be taken up by cells owing to their large surface area and small size. In situ forming hydrogels can significantly extend the residence time of drugs because of their strong adhesive properties. Contact lenses, with their comfortable shape and drug-carrying capacity, can also act as drug delivery devices. MNs can create channels in the cornea, bypassing its barrier and enhancing drug bioavailability. This article will go over novel medication delivery techniques for treating FK and make a conclusion about their advantages and limitations in anticipation to serve the best option for the individual therapy of FK.

Purpose: Negative laboratory results make targeting microbial keratitis treatment difficult. We investigated factors associated with laboratory negativity in patients with microbial keratitis in the context of a transition to a new specimen collection method., Methods: Microbial keratitis patients with associated laboratory tests were identified in the electronic health record of a tertiary care facility from August 2012 to April 2022. Patient demographics and laboratory results were obtained. Random sampling of 50% of charts was performed to assess the impact of the ocular history and pretreatment measures. The relationship between probability of negative laboratory results with demographics, ocular history, pretreatment measures, and utilization of a new specimen collection method (i.e. ESwab) was evaluated by multivariable logistic regression., Results: Of 3395 microbial keratitis patients identified, 31% ( n  = 1051) had laboratory tests. Laboratory testing increased over time (slope = 2.5% per year, p  < 0.001; 19.6% in 2013 to 42.2% in 2021). Laboratory negative rate increased over time (slope = 2.2% per year, p  = 0.022; 48.5% in 2013 to 62.3% in 2021). Almost one-third of patients (31.2%, n  = 164) were pretreated with steroids. Over two-thirds of patients were pretreated with antibiotics (69.5%, n  = 367). 56.5% ( n  = 297) of patients were outside referrals. In multivariable regression, patients with corticosteroid pretreatment had lower odds of negative laboratory results (odds ratio [OR] = 0.49, p  = 0.001). There were higher odds of negative laboratory results for every additional antibiotic prescribed to a patient prior to presentation (OR = 1.30, p  = 0.006) and for specimens collected using ESwabs (OR = 1.69, p  = 0.005). Age, prior eye trauma, outside referrals, and contact lens wear were not significantly associated with negative laboratory results., Conclusion: More microbial keratitis associated laboratory tests are being taken over time. Over 60% of tests were negative by 2022. Factors associated with negative laboratory test results included pretreatment with antibiotics and specimens collected with the new collection method.

Purpose: The aim of this study was to validate the C-DU(KE) calculator as a predictor of treatment outcomes on a data set derived from patients with culture-positive ulcers., Methods: C-DU(KE) criteria were compiled from a data set consisting of 1063 cases of infectious keratitis from the Steroids for Corneal Ulcer Trial (SCUT) and Mycotic Ulcer Treatment Trial (MUTT) studies. These criteria include corticosteroid use after symptoms, visual acuity, ulcer area, fungal etiology, and elapsed time to organism-sensitive therapy. Univariate analysis was performed followed by multivariable logistic regressions on culture-exclusive and culture-inclusive models to assess for associations between the variables and outcome. The predictive probability of treatment failure, defined as the need for surgical intervention, was calculated for each study participant. Discrimination was assessed using the area under the curve for each model., Results: Overall, 17.9% of SCUT/MUTT participants required surgical intervention. Univariate analysis showed that decreased visual acuity, larger ulcer area, and fungal etiology had a significant association with failed medical management. The other 2 criteria did not. In the culture-exclusive model, 2 of 3 criteria, decreased vision [odds ratio (OR) = 3.13, P < 0.001] and increased ulcer area (OR = 1.03, P < 0.001), affected outcomes. In the culture-inclusive model, 3 of 5 criteria, decreased vision (OR = 4.9, P < 0.001), ulcer area (OR = 1.02, P < 0.001), and fungal etiology (OR = 9.8, P < 0.001), affected results. The area under the curves were 0.784 for the culture-exclusive model and 0.846 for the culture-inclusive model which were comparable to the original study., Conclusions: The C-DU(KE) calculator is generalizable to a study population from large international studies primarily taking place in India. These results support its use as a risk stratification tool assisting ophthalmologists in patient management., Competing Interests: V.L. Perez has financial relationships with Alcon, Dompe, EyeGate, Kala, Trefoil, Novartis, and Oculis. The remaining authors have no conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: The present clinical case concerns two patients with mycotic keratitis because of Candida parapsilosis in which corneal confocal microscopy presented a characteristic feature of this pathogen. Both described patients used a therapeutic contact lens and administered a therapy with steroid eye drops which are well known predisposing factors for the onset of corneal mycoses. This report can be useful for correctly identifying the pathologic condition and quickly directing the therapy., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2023 Contact Lens Association of Ophthalmologists.)

Infectious ulcerative keratitis is a common disease in racehorses. To improve treatment outcomes, this study aimed to assess the antimicrobial susceptibilities of bacterial and fungal isolates obtained from the cornea of Japanese Thoroughbred racehorses with equine infectious ulcerative keratitis. Bacterial and fungal cultures were performed for 166 corneal swabs from 107 cases. A disc diffusion test and minimum inhibitory concentration test were also performed to assess antimicrobial susceptibility of the bacterial and fungal isolates, respectively. Bacterial and/or fungal isolates were obtained from 85.0% (91/107) of the cases. Staphylococcus was primarily isolated from bacterial isolates, including methicillin-resistant Staphylococcus aureus (MRSA), Aerococcus, Streptococcus, Acinetobacter, and Pseudomonas. Aspergillus was primarily isolated from filamentous fungi, and Debaryomyces species was primarily identified in yeast-like fungi. Ofloxacin resistance was observed in 100% (12/12), 15.9% (7/44), and 25.0% (3/12) of MRSA, Staphylococcus, and Streptococcus isolates, respectively. The prevalence of quinolone-resistant Staphylococci and Streptococci has increased in the past two decades. All Aspergillus isolates were susceptible to voriconazole, whereas other filamentous fungi, including Fusarium, were less susceptible to voriconazole. Further studies are required to determine effective treatments for antimicrobial-resistant isolates., Competing Interests: Declaration of competing interest None., (Copyright © 2023. Published by Elsevier Inc.)

This retrospective study evaluated tear film (TF) interferometry on horses examined in Northern Italy in 2019-2021. The objectives were to evaluate horses affected by keratitis, and to describe TF values in horses with no evidence of ocular disease. All horses received a complete ophthalmic examination and were examined with the Ocular Surface Analyser, Veterinary-setting, prior to eye manipulation, staining and sample collection. Eighteen horses with no evidence of ocular disease were included in the comparison group. Additionally, 46 horses displaying signs of keratitis (neovascularization, corneal opacities, ulceration, epithelial and subepithelial infiltrates) were evaluated. These horses were divided into presumed non-infectious and infectious or presumed infectious keratitis groups (one with proven bacterial origin, and the others with diagnosed or presumptive keratomycosis) with the former including immune-mediated keratitis. From the observations of TF interferometry in the comparison population the authors concluded that for non-invasive break-up time (NIBUT), the estimated preliminary reference interval was 10.4-31.2s, and for tear meniscus height (TMH), it was 0.215-0.457mm. Moreover, within the keratitis population, from an interferometric point of view punctate lesions of the ocular surface were present in all cases of active diagnosed or presumptive subepithelial keratomycosis but not in any of the non-infectious cases, either non-ulcerative or ulcerative. Limitations of the study include a relatively low number of horses examined and the fact that the diagnosis of infectious keratitis was presumptive and based on clinical improvement after treatment in some cases. To the authors' knowledge, this is the first report of TF interferometry performed in horses., Competing Interests: Declaration of competing interest None of the authors have any financial or personal relationships that could inappropriately influence or bias the content of the paper., (Copyright © 2024. Published by Elsevier Inc.)

Purpose: Evaluate the effect of corneal and contact lens-related (CLR) culture results on visual acuity (VA) in patients with microbial keratitis (MK)., Methods: MK patients with corneal and CLR cultures were identified in the University of Michigan electronic health record from August 2012 to April 2022. Test results were classified as laboratory-positive or laboratory-negative. Linear regression was used to examine trends of VA and associations between changes in VA (differences of VA at 90-day and baseline VA) and corneal and CLR culture results, after adjustment for baseline VA. One-sample t-tests were used to test if the slope estimates were different from zero., Results: MK patients ( n  = 50) were on average 49 years old (standard deviation = 20.9), 56% female, and 90% White. Positive corneal and CLR cultures were reported in 60% and 64% of patients, respectively, and 38% reported both. The agreement rate between corneal and CLR culture results was 30% ( n  = 15/50). LogMAR VA improved over time in patients with positive corneal and CLR cultures (Estimate=-0.19 per 10-day increase, p  = 0.002), and in those with negative corneal and positive CLR cultures (Estimate= -0.17 per 10-day increase, p  = 0.004). Compared to patients with negative corneal and CLR cultures, there was a trend toward improvement in VA for patients with positive corneal and CLR cultures (Estimate=-0.68, p  = 0.068), and those with negative corneal and positive CLR cultures (Estimate= -0.74, p  = 0.059), after adjusting for baseline VA., Conclusions: Positive CLR cultures are associated with significant improvement in VA over time. These additional cultures can provide guidance on appropriate antimicrobial selection, especially when corneal cultures are negative.

We describe customized therapeutic deep anterior lamellar keratoplasty (DALK) for treating a perforated Mooren's ulcer. Slit-lamp biomicroscopy revealed corneal perforation (3.5 mm × 3.0 mm) with iris prolapse. The corneal melt extended from 9.0 o'clock to 4.0 o'clock. The peripheral edge of the ulcer was sloping, whereas the medial edge showed undermining. Immunological tests did not reveal any evidence of systemic autoimmune disease. In view of extensive peripheral corneal melt with large corneal perforation, the patient needed tectonic keratoplasty. The penetrating graft is not only technically demanding but also results in a poor visual outcome. We advised customized tectonic DALK. We used two different-sized trephines to obtain appropriate-sized donor tissue and avoided manual dissection. The post-surgery period was uneventful. He was prescribed topical steroids and oral methotrexate. He achieved 6/9 aided visual acuity at 4 months and maintained it until the last follow-up at 36 months., (Copyright © 2023 Copyright: © 2023 Indian Journal of Ophthalmology.)

Purpose: To evaluate the incidence, clinical characteristics, microbiological profile, and therapeutic outcomes of corneal ulcers in individuals with chronic ocular graft-vs-host disease (coGVHD)., Design: Retrospective clinical cohort study., Methods: Review of individuals diagnosed with coGVHD following hematopoietic stem cell transplantation (HSCT) who were seen at the Bascom Palmer Eye Institute between May 2010 and November 2021. Baseline demographics, clinical characteristics, microbiological profile, risk factors for corneal ulceration, and treatment outcomes were collected. Etiology was deemed infectious in individuals with a positive culture or appropriate clinical scenario (presence of stromal infiltrate or hypopyon); otherwise, ulcers were presumed to be noninfectious. Treatment success was defined as reepithelialization with infiltrate resolution, and treatment failure as progression to corneal perforation or keratoplasty. Kaplan-Meier survival analysis estimated the incidence of ulceration. Cox regression analyses examined demographic and risk factors. Infectious and noninfectious ulcer groups were compared using 2-way independent t tests, 1-way analysis of variances, and χ 2 tests, as appropriate., Results: 173 individuals were included (53.7±14.4 years old; 59.0% male). Thirty-three individuals developed an ulcer 74.5±54.3 months after HSCT, with estimated 5- and 10-year incidences of 14% and 30%, respectively. Twenty-two (66.6%) ulcers were deemed infectious (15 microbiologically confirmed, 7 clinically) and 11 (33.3%) were deemed noninfectious. Risk factors for corneal ulceration included Black race (hazards ratio [HR] 2.89, 95% CI 1.30-6.42, P < .01), previous ocular surgery (HR 9.16, 95% CI 3.86-21.72, P < .01), eyelid margin abnormalities (HR 3.44, 95% CI 1.69-6.99, P < .01), and topical steroid use (HR 2.74, 95% CI 1.33-5.62, P < .01). Conversely, contact lens use reduced the risk of corneal ulceration (HR 0.29, 95% CI 0.13-0.66, P < .01). Infectious ulcers had a significantly higher frequency of treatment failure than noninfectious ulcers (57.1% vs 20.0%, P = .04)., Conclusion: Corneal ulceration is a potential complication of coGVHD, with several clinical features identified as risk factors. Infectious ulcers had worse outcomes than noninfectious ulcers., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: Natamycin (NT) is used as a first-line antifungal prescription in the treatment of fungal keratitis (FK) and is commercially available as a 5% w/v ophthalmic suspension. NT shows poor water solubility and light sensitivity. Thus, the present investigation is aimed to enhance the fraction of NT in solution in the commercial formulation by adding cyclodextrins (CDs), thereby improving the delivery of the drug into deeper ocular tissues. Methods: The solubility of NT in different CDs, the impact of ultraviolet (UV) light exposure, stability at 4°C and 25°C, in vitro release, and ex vivo transcorneal permeation studies were performed. Results: NT exhibited the highest solubility (66-fold) in randomly methylated-β-cyclodextrin (RM-βCD) with hydroxypropyl-βCD (HP-βCD) showing the next highest solubility (54-fold) increase in comparison to market formulation Natacyn ® as control. The stability of NT-CD solutions was monitored for 2 months (last-time point) at both storage conditions. The degradation profile of NT in NT-RM-βCD and NT-HP-βCD solutions under UV-light exposure followed first-order kinetics exhibiting half-lives of 1.2 h and 1.4 h, respectively, an almost 3-fold increase over the control solutions. In vitro release/diffusion studies revealed that suspensions containing RM-βCD and HP-βCD increased transmembrane flux significantly (3.1-fold) compared to the control group. The transcorneal permeability of NT from NT-RM-βCD suspension exhibited an 8.5-fold ( P  < 0.05) improvement compared to Natacyn eyedrops. Furthermore, the addition of RM-βCD to NT suspension increases the solubilized fraction of NT and enhances transcorneal permeability. Conclusion: Therefore, NT-RM-βCD formulations could potentially lead to a decreased frequency of administration and significantly improved therapeutic outcomes in FK treatment.

Objective: To evaluate bacterial isolates from corneal stromal ulcerations in dogs and cats in the Netherlands, review their antibiotic susceptibility, determine whether recent topical treatment affected bacterial culture results, and investigate whether (multi-drug) resistance patterns changed over time., Animals Studied: Client-owned dogs and cats were diagnosed with corneal stromal ulceration at the Utrecht University Clinic for Companion Animals between 2012 and 2019., Procedures: Retrospective analysis., Results: In total, 163 samples were collected from 122 dogs (130 samples) and 33 cats. Positive cultures were obtained from 76 canine and 13 feline samples (59% and 39%, respectively) and included Staphylococcus (42 in dogs, 8 in cats), Streptococcus (22 in dogs, 2 in cats), and Pseudomonas (9 in dogs, 1 in cats) species. Significantly fewer positive cultures were found in dogs and cats previously treated with topical antibiotics (χ 2  = 6.52, p = .011 and χ 2  = 4.27, p = .039, respectively). Bacterial resistance to chloramphenicol was more common in dogs previously treated with chloramphenicol (χ 2  = 5.24, p = .022). The incidence of acquired antibiotic resistance did not increase significantly over time. In dogs, the incidence of multi-drug-resistant isolates increased significantly between 2012-2015 and 2016-2019 (9.4% vs. 38.6%, p = .0032)., Conclusions: Staphylococcus, Streptococcus, and Pseudomonas species were the most common bacteria associated with canine and feline corneal stromal ulcerations. Previous treatment with antibiotics affected bacterial culture results and antibiotic sensitivity. Although the overall incidence of acquired antibiotic resistance did not change over time, the incidence of multi-drug-resistant isolates in dogs increased over an 8-year period., (© 2023 The Authors. Veterinary Ophthalmology published by Wiley Periodicals LLC on behalf of American College of Veterinary Ophthalmologists.)

Fungal keratitis (FK) is a serious pathogenic disease usually associated with serious ocular complications. The current mainstay of treatment for FK is topical eye drops; however, poor corneal penetration, low bioavailability of the drug and the need to administer high and frequent doses due to the presence of an effective clearance mechanism in the eye result in poor patient compliance. Nanocarriers can extend the duration of drug action through sustained and controlled release of the drug, protect the drug from ocular enzymes and help overcome ocular barriers. In this review, we discussed the mechanisms of action of antifungal drugs, the theoretical basis for the treatment of FK, and recent advances in the clinical treatment of FK. We have summarized the results of research into the most promising nanocarriers for ocular drug delivery and highlight their efficacy and safety in the therapy., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: The aim of this study was to report the first case of mycotic keratitis caused by Botryosphaeria dothidea ., Methods: A 29-year-old man developed a fungal infection after being hit with chestnut thorns in the left eye. In vivo confocal microscopy, microbial culture, and next-generation sequencing (NGS) were used in the diagnosis of mycotic keratitis., Results: The patient was provisionally diagnosed with mycotic keratitis based on IVCM and promptly received local and systemic antifungal treatment with voriconazole and amphotericin B. Although microbial culture failed to identify the pathogen, NGS revealed B. dothidea as the causative agent. Although the infection was quickly contained, corneal perforation still occurred. Owing to the lack of fresh donor corneas, the patient underwent multilayer amniotic membrane and conjunctival pedicle graft surgery. The infection was successfully controlled, and during the 6-month follow-up, the cornea remained clear in the inferotemporal optical zone., Conclusions: We report a novel phytopathogen- B. dothidea -causing mycotic keratitis . Our case indicates that B. dothidea responds well to voriconazole and amphotericin therapy. This case broadens the spectrum of fungal keratitis and highlights the application of NGS in identifying molds., Competing Interests: The authors indicate no potential conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: We report a unique case of fungal keratitis, caused by the Cladosporium species, which is found to be resistant to multiple drugs, including voriconazole. Cladosporium belongs to the dematiaceous group of fungus, which is present ubiquitous in air, water, food etc. There are only few case reports available about Cladosporium keratitis which shows the successful management with voriconaozle. But in our case, the Cladosporium species was found to be resistant to multiple drugs, including voriconazole, and was successfully managed by topical povidone iodine (PVI) 5%., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Fungal keratitis (FK) is a fungal infection of the cornea, which is part of the eye and causes corneal ulcers and an increased risk of permanent blindness, which is often found in Candida albicans species. Amphotericin B (AMB), which is a group of polyenes as the first-line treatment of FK, is effective in annihilating C. albicans . However, AMB preparations such as eye drops and ointments have major drawbacks, for instance, requiring more frequent administrations, loss of the drug by the drainage process, and rapid elimination in the precornea, which result in low bioavailability of the drug. An ocular dissolving microneedle containing the solid dispersion amphotericin B (DMN-SD-AMB) had been developed using a mixture of poly(vinyl alcohol) (PVA) and poly(vinylpyrrolidone) (PVP) polymers, while the solid dispersion AMB (SD-AMB) was contained in the needle as a drug. This study aims to determine the most optimal and safest DMN-SD-AMB formula for the treatment of FK in the eye as well as a solution to overcome the low bioavailability of AMB eye drops and ointment preparations. SD-AMB had been successfully developed, which was characterized by increased antifungal activity and drug release in vitro compared to other treatments. Furthermore, DMN-SD-AMB studies had also been successfully performed with the best formulation, which exhibited the best ex vivo corneal permeation profile and antifungal activity as well as being safe from eye irritation. In addition, an in vivo antifungal activity using a rabbit infection model shows that the number of fungal colonies was 0.98 ± 0.11 log 10 CFU/mL (F3), 5.76 ± 0.32 log 10 CFU/mL (AMB eye drops), 4.01 ± 0.28 log 10 CFU/mL (AMB ointments), and 9.09 ± 0.65 log 10 CFU/mL (control), which differed significantly ( p < 0.05). All of these results evidence that DMN-SD-AMB is a new approach to developing intraocular preparations for the treatment of FK.

Over the past two decades biologic therapies have seen a rapid uptake in the management of ocular inflammation. Peripheral ulcerative keratitis (PUK), once a harbinger of blindness and mortality in refractory rheumatological disease, is now increasingly being treated with these agents. We conducted a review to evaluate the evidence base for this application and to provide a road map for their clinical usage in PUK, including dosage and adverse effects. A literature search across Medline, Embase and Cochrane Database of Systematic Reviews was undertaken to identify all patients with PUK that were treated with a biologic in a peer viewed article. Overall, whilst the evidence base for biologic use in PUK was poor, reported cases demonstrate an increasingly powerful and effective role for biologics in refractory PUK. This was particularly the case for rituximab in PUK secondary to granulomatous with polyangiitis., Competing Interests: Declaration of Competing Interest We declare this manuscript is original, has not been published before and is not being considered for publication elsewhere. We know of no conflicts of interest associated with the publication, and there has been no significant financial support for this work that could have influenced its outcome. I can confirm that the manuscript has been read and approved for submission by all the named authors., (Copyright © 2023. Published by Elsevier Inc.)

Significance: This case series is the first to illustrate mixed infection from Pythium sp. and fungal species in corneal ulcer., Purpose: This case series aimed to alert all toward the possibility of both Pythium sp. and fungal species infection in case of nonresponding corneal ulcer treated with either antifungals or antipythium drugs alone. Increased suspicion of mixed infection in case of nonresponding fungal/ Pythium keratitis may facilitate early and prompt management., Case Reports: Six patients presented with signs of either fungal or Pythium keratitis. They underwent ophthalmological examinations, smear examinations, cultures, and polymerase chain reaction (PCR). Therapeutic penetrating keratoplasty was performed in cases where symptoms worsened after treatment with either antifungal or antipythium drugs. The half corneal button (HCB) was shared for histopathological and microbiological examinations. In the first case, smear examination from corneal scraping (CS) revealed Pythium -like filaments, which were confirmed with PCR; however, Aspergillus nidulans grew in culture. In the second case, iodine-potassium iodide (IKI) staining was positive for Pythium ; however, PCR was positive for both Pythium and fungus, which was further confirmed by DNA sequencing. In the third case, IKI staining and HCB were positive for Pythium ; however, PCR was positive for fungus, which was identified as Candida saitoana with DNA sequencing. In the fourth case, Pythium grew in the CS culture; however, Candida sp. grew in the HCB culture. In the fifth case, Cladosporium sp. grew in culture from CS; however, Pythium insidiosum grew from the anterior chamber exudate after therapeutic penetrating keratoplasty. In the sixth case, smear examination revealed septate fungal filaments, and Cladosporium sp. grew in culture; however, HCB on histopathological examination showed features of Pythium keratitis., Conclusions: In unresponsive cases of Pythium or fungal keratitis, diagnostic modalities such as IKI and PCR should be implemented as a routine practice, in addition to smears and cultures., Competing Interests: Conflict of Interest Disclosure: None of the authors have reported a financial conflict of interest., (Copyright © 2023 American Academy of Optometry.)

Background: This study evaluates the use of anterior segment optical coherence tomography (AS-OCT) to identify focal changes and inform surgical plans in eyes with Mooren's ulcer., Methods: A total of 18 eyes of 17 patients with Mooren's ulcer were examined prospectively using the AS-OCT system., Results: Optical hyperreflectivity noted on AS-OCT images was in accordance with corneal ulceration, neovascularization, fibrovascular membranes, the junction of the native stromal bed, and the overlying lamellar corneal grafts. Focal corneal ectasia was observed in 13 eyes with a decrease in corneal thickness to ≤0.39 mm. There was a cut-off value of 0.39 mm in corneal thickness between the eyes with and without focal corneal ectasia in the thinned corneal area (Fisher = 0.383, χ 2  = 14.873, P = 0.000). Based on the AS-OCT findings, six eyes were subjected to an individualized lamellar corneal graft. The thickness of the residual cornea after surgery was 47 ± 34 μm less than the presumed healthy corneal thickness before surgery (t = 3.376, P = 0.02). A small corneal perforation covered by a pseudopterygium in Mooren's ulcer was found through AS-OCT but undetectable by slit-lamp biomicroscopy., Conclusions: AS-OCT is a valuable non-contact technique for monitoring corneal thinning in Mooren's ulcer, and assisting surgical design. A decrease in peripheral corneal thickness to ≤0.39 mm may cause focal corneal ectasia., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Bacterial keratitis is a vision-threatening infection of the cornea that is typically treated with antibiotics. However, antibiotics sometimes fail to eradicate the infection and do not prevent or repair the damage caused directly by the bacteria or the host immune response to the infection. Our group previously demonstrated that treatment of Pseudomonas aeruginosa keratitis in rabbits with innovative cold atmospheric plasma (iCAP) resulted in reduced edema, ulcer formation, and bacterial load. In this study, we investigated the efficacy of iCAP treatment in methicillin-resistant Staphylococcus aureus (MRSA). New Zealand white rabbits were infected intrastromally with MRSA then treated with iCAP, moxifloxacin, vancomycin, or combination of iCAP with each antibiotic to assess the safety and efficacy of iCAP treatment compared to untreated controls and antibiotics. iCAP treatment significantly reduced bacterial loads and inflammation, improved anterior chamber clarity, and prevented corneal ulceration compared to untreated controls and antibiotic treatment. Safety assessments of grimace test scores and tear production showed that iCAP was not significantly different from either antibiotic treatment in terms of distress or tear production. Combination iCAP/antibiotic treatment did not appear to provide significant added benefit over iCAP alone. Our findings suggest that the addition of iCAP may be a viable tool in reducing damage to the cornea and anterior chamber of the eye following S. aureus keratitis., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Purpose: The aim of this study was to report a case of peripheral ulcerative keratitis (PUK) associated with lichen planus., Methods: A 42-year-old woman with histological confirmation of lichen planus from an oral buccal mucosa biopsy presented with bilateral peripheral stromal thinning and an epithelial defect, in keeping with PUK., Results: All screening for known causes of PUK were negative, and lichen planus was presumed as the etiological factor. Oral prednisolone 1 mg/kg was initiated, alongside topical steroids and topical ciclosporin. The PUK resolved after 3 months, and a slow-tapering regimen of oral prednisolone was needed to prevent a relapse of ocular surface inflammation. Topical steroids were also tapered and discontinued after 5 months, and the ocular surface remained stable with topical ciclosporin with no relapse after 1 year., Conclusions: Ocular manifestations of lichen planus are rare and mostly involve the conjunctiva; however, PUK might also develop, presumably due to its similar mechanisms with other T-cell autoimmune diseases. Systemic immunosuppression is required initially but further control of the ocular surface can be achieved successfully with topical ciclosporin., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To summarize the evidence base on the use of topical corticosteroids for infectious keratitis., Methods: Narrative review., Results: Infectious keratitis is a painful condition that often results in visually significant corneal stromal scarring, even when antimicrobial therapy is successful. Corticosteroids may reduce inflammation and subsequent scar formation and while relieving the acute ocular pain associated with a corneal ulcer. However, corticosteroids also reduce the host immune response, which could hinder the ability to clear infection. The safety and effectiveness of corticosteroids depends to a large part on the efficacy of the antimicrobials being used to treat the underlying infection. Randomized trials have found that corticosteroids are safe and effective for herpetic keratitis when used with appropriate antiviral therapy, and are safe for bacterial keratitis when used with broad spectrum topical antibiotics. The effectiveness of corticosteroids for bacterial keratitis has not been shown conclusively, although more advanced bacterial corneal ulcers may do better with corticosteroids. No randomized trials have assessed the safety and effectiveness of steroids for fungal or acanthamoeba keratitis. Animal studies suggest corticosteroids may be harmful in fungal keratitis, and observational human studies have found that steroids are harmful for fungal and acanthamoeba keratitis when started prior to anti-amoebics., Conclusions: Topical corticosteroids, when used as an adjunct to antimicrobial therapy, may be beneficial if the antimicrobial being used can effectively clear or suppress the infection, such as in bacterial and herpetic keratitis. Randomized trials would be helpful to further delineate the role of corticosteroids for infectious keratitis., Competing Interests: The author has no funding or conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To determine the demography, risk factors, and causative organisms of microbial keratitis (MK) in Bihar, an eastern state of India., Design: Retrospective study., Methods: We reviewed the demographic, clinical, and microbiological data of 2303 patients with MK (non-viral) presenting between January 2019 and December 2022., Results: This study revealed a predominance of males (65.0%) compared to females (34.9%), with a mean age of 48.4 ± 16.5 years. The majority of patients (63.1%) presented after 2 weeks from the onset of symptoms. The most common risk factor observed was corneal injury (58.1%), followed by ocular surface diseases (13.6%) and diabetes mellitus (13.3%). The majority of patients (73.16%) were involved in agriculture. Prior to presentation, almost all patients (92%) had received topical antibiotics. Unsupervised use of topical corticosteroids was observed in 29.2% of the patients for the median duration of 3 days (odds ratio, 0.17). At presentation, the median size of corneal ulcers was 5 mm, the best-corrected visual acuity was less than 20/400 in 51.4% of patients, and corneal perforation was in 14% of patients. The smear and culture positivity rate were 75.4% and 47.9%, respectively. The common causative organism was fungus (48.8%), followed by bacteria (17.4%). Aspergillus spp. and Staphylococcus spp. were the most commonly identified organisms; a quarter of the patients (24.5%) remained unidentified. All bacteria showed good sensitivity to vancomycin., Conclusion: MK is a significant cause of ocular morbidity in Bihar. The knowledge of epidemiology, risk factors, and microbiological profiles of MK can provide a valuable approach to disease prevention, diagnosis, and management., Competing Interests: None