Showing papers on "corneal ulcer published in 2009"

Microbial keratitis after corneal collagen crosslinking

Abstract: Several infiltrates appeared in the upper midperipheral cornea of a 29-year-old woman who had had uneventful corneal collagen crosslinking (CXL) with riboflavin and ultraviolet-A light (UVA) for the treatment of keratoconus in the right eye. Staphylococcus epidermidis keratitis was confirmed by microbiological studies, which guided treatment with topical fortified antibiotic agents. Before CXL, the best spectacle-corrected visual acuity (BSCVA) in the right eye was 20/25, the manifest refraction was -0.25 -0.25 x 125, and the anterior segment was normal under biomicroscopy. Five months after the procedure, the BSCVA was 20/22, the manifest refraction was +1.00 -2.50 x 40, and slitlamp examination revealed a mild residual haze in the upper midperipheral cornea. Collagen crosslinking with riboflavin-UVA is a minimally invasive method but traditionally requires epithelial removal, which could be a predisposing factor to bacterial keratitis.

Epidemiological characteristics, predisposing factors and microbiological profiles of infectious corneal ulcers: the Portsmouth corneal ulcer study

Abstract: Aim: The aim of the study was to identify the epidemiological characteristics, predisposing factors, and the clinical and microbiological diagnosis of infectious corneal ulcers in a population based in southern England. Methods: A retrospective review was undertaken of the medical records of patients presenting with infectious corneal ulcers at the eye casualty department of Queen Alexandra Hospital, Portsmouth, UK, between January 1997 and December 2003. Results: A total of 1786 patients presented with infectious corneal ulcers, with a mean age of 45 years and female predominance (54.5%). Contact lens wear was the main predisposing factor in 554 patients (31%). Corneal scrapes from 1254 patients grew positive cultures in 800 patients. Gram-positive bacteria accounted for 696 (71.1%) of the total 979 bacterial isolates, while Gram-negative bacteria accounted for 283 (28.9%) with the predominance of Pseudomonas aeruginosa. Nine out of 11 patients with Acanthamoeba keratitis were contact lens wearers. The majority of patients 1728 (96.8%) sought medical help more than once and 34 patients (1.9%) had poor visual outcome. Follow-up was completed in 1633 patients (91.4%) with an average of 11.5 days. Conclusions: Wearing contact lenses remains the most important risk factor for infectious corneal ulcers. Reduction of the rate and severity of infectious keratitis requires continuous education of patients, and of professionals.

Plasmin in tear fluid of patients with corneal ulcers: basis for new therapy.

Abstract: . In a patient with chronic corneal ulcer, resistant to conventional therapy, analysis of tear fluid revealed a high plasmin activity which could be inhibited by aprotinin, an inhibitor of serine proteinases. Therapy with topical aprotinin resulted in rapid epithelialization. After this initial patient, within a period of four months tear fluid specimens of altogether 48 patients with corneal lesions were analyzed, and 32 were found to be positive for proteolytic activity. Of these 18 were treated with topical aprotinin which rapidly promoted corneal epithelial healing. Six of these patients had been treated with conventional therapy for 3–10 weeks but proved to be completely therapy-resistant. Our observations on three successfully treated patients with chemical burns of the cornea indicated appearance of plasmin in tear fluid after a few days correlating with cessation of epithelialization. In all patients, in which tear fluid plasmin activity was followed, the activity disappeared during aprotinin therapy correlating with corneal re-epithelialization. In some patients with low proteolytic activity aprotinin was combined with fibronectin with a beneficial therapeutic effect. No proteolytic activity was found in the tear fluid of control individuals. These preliminary data indicate that in patients with treatment-resistant corneal lesions inhibition of proteolytic activity can assist in epithelial healing. Such an inhibition is likely to be a prerequisite for the proteinase-sensitive cell adhesion proteins such as fibronectin to promote epithelialization.

Escherichia coli keratitis treated with ultraviolet A/riboflavin corneal cross-linking: a case report.

Abstract: PURPOSE. To describe a case of keratitis caused by the Gram-negative Escherichia coli, treated with UVA-riboflavin cross linking. METHODS. Case report. RESULTS. A 78-year-old woman with diabetes presented with a 1-week history of pain, photophobia, foreign body sensation, and lacrimation in the right eye. The patient underwent topical and systemic antimicrobial therapy, without improvement. The authors treated the patient with riboflavin and corneal UVA crosslinking, with the aim to promote healing of the ulceration. One day after the procedure, the corneal ulceration was covered by cicatricial tissue, and the patient reported a significant improvement in symptoms. One month after the treatment, corneal edema was almost completely resolved, corneal ulceration was healed, and the painful symptoms of the patient had disappeared. CONCLUSIONS. UVA-riboflavin crosslinking can be useful for the treatment of corneal ulceration unresponsive to medical treatment. (Eur J Ophthalmol 2009; 19: 295-7)

Riboflavin-UVA Treatment in the Management of Edema and Nonhealing Ulcers of the Cornea

Abstract: Purpose Riboflavin-ultraviolet A (UVA) treatment induces cross-linking and stiffens the corneal stroma. A parallel reduction in stromal swelling and increased resistance to microbial and enzymatic degradation has been suggested. The purpose of this study was to evaluate the potential of riboflavin-UVA treatment in the management of corneal disorders, in particular edema due to endothelial decompensation and non-healing ulcers. Methods Two clinical series are reported, 11 eyes with endothelial decompensation and 14 eyes with non-healing ulcers. Treatment comprised a) abrasion of epithelium (if present), b) instillation of 0.1% riboflavin in saline, and c) irradiation at 365 nm UVA light over approximately 30 minutes (3 mW/cm(2)). Four eyes in the first group were treated twice. Postoperatively, all eyes were followed for at least 3 months. Results Reduction in corneal thickness was observed in 10 of 11 eyes with stromal edema and the majority also experienced improvement in vision. The effect occurred over weeks and lasted for months. Fourteen patients with non-healing ulceration were similarly treated; 6 healed, 8 showed no clear effect. Conclusions In addition to the stiffening of keratoconic and ectatic cornea, riboflavin-UVA treatment is effective in reducing corneal edema and has the potential to heal corneal ulcers.

Topical and Oral Voriconazole in the Treatment of Fungal Keratitis

Abstract: We describe two patients with fungal keratitis refractory to standard antifungal therapy whose conditions were managed with voriconazole. The first case is a patient with endophthalmitis and corneal ulcer due to Candida parapsilosis after receiving a corneal transplant. The patient was treated with amphotericin but showed no signs of improvement. Topical voriconazole, oral voriconazole, and intravitreal voriconazole yielded signs of improvement. The second case is a 63-year-old male who underwent a month of empiric treatment with 0.2% topical amphotericin for fungal keratitis but showed no signs of improvement. Treatment was then provided with 1% voriconazole. Both cases showed effective treatment with voriconazole. Voriconazole may be considered as a new method to treat fungal keratitis refractory to standard antifungal therapy.

Amniotic membrane transplantation for persistent corneal epithelial defects in eyes after penetrating keratoplasty

Abstract: Amniotic membrane transplantation for persistent corneal epithelial defects in eyes after penetrating keratoplasty

Elevation of tear fluid plasmin in corneal disease.

Abstract: Plasmin concentration was determined in tear fluid from 76 eyes showing corneal epithelial disorders, such as corneal ulcers and erosions due to trauma or contact lens wear. Nearly 70% of the eyes with corneal disease had plasmin in their tear fluid, whereas plasmin was present in only 20% of the eyes in a control group of 50 eyes. Re-examination of the plasmin positive control eyes revealed conjunctival bacterial growth or mild subclinical viral infection in most cases. We conclude that plasmin is released into the tear fluid in the presence of corneal or conjunctival lesions or infections, suggesting a pathogenic role of plasmin in these disorders. The significance of the occurrence of plasmin in tear fluid during corneal wound healing is discussed.

Microbial keratitis in Kingdom of Bahrain: Clinical and microbiology study

Abstract: Background: Microbial keratitis is a potentially vision threatening condition worldwide . Knowing the predisposing factors and etiologic microorganism can help control and prevent this problem. This is the first study of its kind in Kingdom of Bahrain. Objective: To study the profile of microbial keratitis in Bahrain with special focus on risk factors, clinical outcome and microbilogical results. Methods: A retrospective analysis of all patients admitted in Salmaniya Medical Complex over a period of three years from January 2005 to January 2007 was performed. A total of 285 patients with keratitis were analysed. Non infectious corneal ulceration were excluded. Data collected from medical records were demographic features, predisposing factors, history of corneal trauma, associated ocular conditions, visual acuity at the time of presentation and the clinical course. Predisposing risk factors measured were contact lens use, presence of blepharitis, diabetes, lid abnormalities, dry eyes, keratoplasty and refractive surgery. For contact lens wearers any contact lens related risk factors that can lead to keratitis were measured . Pearson's chi-square test was used to carry out statistical analysis wherever required. Results: Contact lens wear, as a risk factor for microbial keratitis, formed 40% of the total study population. Other risk factors identified were dry eyes 24 cases (8%), 10 blepharitis (3%), 22 trauma (8%), abnormal lid position 14 cases (5%). 6 patients keratitis in a graft (2%), 3 had refractive surgery (1%). The most common causative organism isolated was pseudomonas aeroginosa (54%) followed by streptococcus 12%, staph 10%, other organisms 6%. 95% of contact lens wearers had pseudomonas Aeroginosa. This was statistically significant (p Conclusion & Recommendation: Contact lens wear is the major risk factor for microbial keratitis in Bahrain. Pseudomonas aeroginosa was the commonest bacteria isolated. Sleeping with the contact lenses is the major risk factor among contact lens wearers. Majority of keratitis patients resulted in permanent scarring on the cornea. Educating the public, especially on contact lens care and precaution, can help reduce this visual morbidity.

Evaluation of the role of ProKera in the management of ocular surface and orbital disorders.

Abstract: Objectives: To report the efficacy and safety profile of sutureless and adhesiveless amniotic membrane device (ProKera, Bio-Tissue, Inc., Miami, FL) in the management of various ocular surface and orbital disorders. Methods: Twenty eyes of 20 patients underwent placement of 21 ProKera implants between March 2006 and July 2007 at the University of Texas Southwestern Medical Center. Patient demographics, indications for placement, and duration of ProKera retention were recorded. Outcomes measured included corneal epithelial healing, visual acuity, patient tolerance, and adverse events. Results: ProKera was most commonly used in patients with corneal neovascularization with or without limbal stem-cell deficiency (10 eyes). Other indications included recurrent pterygium or pseudopterygium (three eyes), anophthalmic orbit contraction (two eyes), persistent epithelial defects (two eyes), severe thinning in a corneal ulcer (one eye), benign hereditary intraepithelial dyskeratosis (one eye), and band keratopathy (one eye). The mean duration of ProKera retention was 25.3 days (range, 0–125) visual acuity improved in 12 eyes (60%). Immediate adverse events included residual epithelial defects after removal (five eyes) and spontaneous extrusion of the implant (four eyes). Six patients (30%) reported eye pain or headache and four eyes (20%) had recurrence of the primary pathology. Conclusions: Sutureless and adhesiveless amniotic membrane transplantation is a safe and effective method to promote healing and reconstruction of the ocular surface and orbit with minimal side effects. Recurrence of the underlying primary pathology remains a concern. The advent of a newer, softer conformer ring may improve patient tolerability and limit discomfort.

Expression of matrix metalloproteinases during experimental Candida albicans keratitis.

Abstract: Fungal infections of the eye are epidemiologically important diseases.1 Fungi such as Candida albicans that are commensals in the conjunctival flora2 3 can become pathogenic with ocular surface injury or dysfunction. Ophthalmic candidiasis is an opportunistic infection of the eye acquired through trauma, surgery, contact lens wear, and chronic keratopathy.4 A murine model of experimental keratitis using a human isolate of C. albicans to induce corneal infection is helpful in understanding the pathogenesis of oculomycosis.5 6 A key early event in posttraumatic C. albicans keratitis involves fungal morphogenesis and invasion that trigger inflammatory and wounding responses.7 We used this model to examine matrix metalloproteinases (MMPs) in the development of keratomycosis. MMPs are proteolytic enzymes involved in multiple physiological and pathologic processes. This family includes collagenases, gelatinases, stromelysins, and matrilysins that are grouped according to their structure and substrate and that are modulated, in part, by tissue inhibitors of metalloproteinases (TIMPs).8 TIMPs consist of a family of four glycoproteins that inhibit MMP activation or activity. TIMPs differ in their affinity for various MMPs; for example, TIMP-1 prevents activation of MMP-9 and can bind to the catalytic site of MMP-9 and other MMPs. Coordinated actions of MMPs and TIMPs are pivotal in maintaining structural homeostasis, and altered regulation disrupts connective tissue integrity through degradation of the extracellular matrix.9 Determining the roles of MMPs in infection and inflammation may lead to new opportunities for controlling corneal ulceration.10 Changes in MMPs occur after corneal trauma and during corneal infection.11 12 13 MMP-9 increases in acute Pseudomonas aeruginosa keratitis and potentiates the severity of bacterial keratitis by degrading corneal stroma and by stimulating the release of proinflammatory cytokines and chemokines that attract polymorphonuclear leukocytes.12 14 15 16 Studies of experimental and human fungal keratitis have also found increased levels of MMP-9 during corneal infection by yeasts and filamentous fungi.17 18 19 20 Hypothesizing that MMP-9 and other MMPs contribute to the initial manifestation of keratomycosis, we systematically examined the expression patterns of 18 MMPs and 4 TIMPs in murine C. albicans keratitis.

Infectious keratitis caused by Aspergillus tubingensis

Abstract: PURPOSE: To report 2 cases of keratomycosis caused by Aspergillus tubingensis. METHODS: The therapeutic courses were recorded for 2 male patients, 52 and 78 years old, with fungal keratitis caused by black Aspergillus strains. Morphological examination of the isolates was carried out on malt extract agar plates. A segment of the beta-tubulin gene was used for molecular identification. Antifungal susceptibilities were determined by the E test method for molds and the broth microdilution technique National Committee for Clinical Laboratory Standards M38-A. RESULTS: A 52-year-old man presented with complaints of pain and redness in the right eye. The patient was successfully treated with natamycin and econazole eyedrops, itraconazole eye ointment, and oral ketoconazole. A 78-year-old man presented with total corneal necrosis in the right eye. A therapeutic keratoplasty was performed, and topical natamycin and econazole were applied. At the postoperative visit after 3 weeks, almost the full corneal graft was clear with formed anterior chamber. Black Aspergillus strains were isolated from the corneal scrapings of both cases and initially identified as Aspergillus niger based on culture characteristics. Sequence analysis of a segment of the beta-tubulin gene revealed that the isolates are representatives of A. tubingensis. CONCLUSIONS: Aspergillus tubingensis is closely related with A. niger, the differentiation of these 2 species is difficult by classical morphological criteria. To our knowledge, the presented cases of fungal keratitis are the first reports on ocular infection caused by A. tubingensis.

Infliximab for the treatment of refractory progressive sterile peripheral ulcerative keratitis associated with late corneal perforation: 3-year follow-up.

Abstract: Purpose To report a case of refractory progressive sterile peripheral ulcerative keratitis (PUK) that resulted in late corneal perforation, despite good initial response to tumor necrosis factor-alpha inhibitor infliximab. Methods Review of the clinical course of a patient with progressive PUK treated with infliximab infusions of 3 mg/kg intravenously. Results A 72-year-old man presented with a visual acuity of 20/200 and a 5-month history of a progressive sterile PUK. More than 90% of the surface area previously unresponsive to 8 weeks of high-dose systemic steroid therapy healed within 1 week of the first infusion. After his second infusion, best-corrected visual acuity improved to 20/30(+2), with 2 small epithelial defects remaining. However, the remaining unhealed cornea thinned to an area of microperforation 6 weeks after his third dose, prompting an increase in dose frequency to every 4 weeks. One month after his fifth infusion, the area of ulceration healed completely. After his seventh infusion, the patient developed a deep venous thrombosis and infliximab was discontinued. After 10 months of remission, clear corneal cataract surgery was performed. Three years after initial presentation, he remains in remission with a corrected visual acuity of 20/20. Conclusions Infliximab was effective in rapidly arresting the progression of a sterile PUK in our patient. Optimal dosing for infliximab in PUK has not been established, and increasing dose frequency to every 4 weeks may be necessary. Despite a progressive PUK resulting in corneal perforation, treatment with infliximab and subsequent visual rehabilitation can result in sustained remission and an excellent visual outcome.

Medical treatment for combined Fusarium and Acanthamoeba keratitis.

Abstract: Purpose: Acanthamoeba and fungal keratitis are rare ocular infections We report cases of combined Fusarium and Acanthamoeba keratitis and the clinical course of medical treatment Methods: We reviewed the medical records of patients treated for culture-proven Acanthamoeba keratitis at a referral centre, during 2001−2006 Results: Eleven consecutive patients were treated for culture-proven Acanthamoeba keratitis during the 5 years, two of whom had combined fungal infections A 29-year-old man presented with ground-glass corneal oedema and epitheliopathy caused by contact lens use The other patient, a 7-year-old girl, had eye trauma that led to a feathery corneal infiltrate Both cases were treated with topical 002% polyhexamethylene biguanide (PHMB), 01% propamidine, 1% clotrimazole and 5% natamycin Therapeutic keratoplasty was not required in either case Conclusions: Timely identification of the pathogen, with repeated culture and smear if necessary, as well as adequate dosage to prevent recurrence is highly recommended in order to preclude the need for therapeutic penetrating keratoplasty

Pythium insidiosum keratitis in contact lens wear: a case report.

Abstract: PURPOSE: The purpose of this study was to report a case of contact lens-related Pythium insidiosum corneal ulcer. METHODS: The authors conducted an interventional case report. We report the clinical presentations, histopathologic findings, and treatments of a patient with P. insidiosum keratitis associated with contact lens wear. RESULTS: A 22-year-old Thai woman presented to our clinic with a nonresponsive, progressive corneal ulcer of the left eye. Slit lamp examination showed a large central ulcer measuring 5.4 x 5.2 mm with underlying dense stromal infiltrates surrounded by subepithelial and superficial stromal opacity in a reticular pattern along with radial perineural-like infiltrates. Histopathologic examination revealed broad, branched, thin-walled nonparallel hyaline hyphae with rare septates consistent with P. insidiosum. The corneal culture confirmed the diagnosis. The infection recurred after multiple therapeutic penetrating keratoplasties. Enucleation was eventually performed to eradicate the infection. No definite report of contact lens-related P. insidiosum keratitis existed in the literature. CONCLUSION: Pythium keratitis may present with central ulcer and radial keratoneuritis similar to acanthamoeba keratitis. Contact lens wear can be a risk factor for this infection. Increasing awareness, early diagnosis, and intervention may improve the prognosis.

Serum albumin, serum antiproteases and polymorphonuclear leucocyte neutral collagenolytic protease in the tear fluid of patients with corneal ulcers

Abstract: Using a micro-electroimmune assay, the concentration of polymorphonuclear leucocyte neutral collagenolytic protease, serum-albumin, alpha-1-antitrypsin and alpha-2-macroglobulin were measured in the tear fluid from 18 eyes of 16 patients with severe, melting corneal ulcers. By this method, PML-c-ase was the first time detected in tear fluid. All proteins normalized during healing of the ulcer. The findings are indicative of an important role for PML-proteases in the degradation of the corneal stroma, and of a regulative effect of the serum antiproteases leaking into the tear fluid from inflamed conjunctival vessels.

Effect of bovine freeze-dried amniotic membrane (Amnisite-BA) on uncomplicated canine corneal erosion.

Abstract: Objective To evaluate the effectiveness of bovine freeze-dried amniotic membrane (FD-AM) (Amnisite-BA™) in the surgical treatment of corneal ulceration in dogs. Animals studied Eight normal Shih-tzu dogs. Procedures The corneas of 16 eyes were scored with an 8.0-mm trephine under general anesthetic and 100% ethanol was applied to remove a standardized button of corneal epithelium. The eyes were treated as described below and the corneas were evaluated 48 h later. The dogs were divided into four treatment groups: (i) control, (ii) amniotic membrane transplantation (AMT), (iii) nictitating membrane flap and (iv) contact lens. The proportion of the corneal wound that healed was calculated and all eyes were enucleated. Histological sections of cornea were assessed with the proliferating cell nuclear antigen (PCNA) assay. Results The proportion of corneas healed in the different treatment groups was (i) 38.02%, (ii) 89.15%, (iii) 52.31%, and (iv) 60.56%. Epithelial healing was significantly increased in the AMT group (ii) (P = 0.001) while groups (iii) and (iv) were not significantly different from the control group (P = 0.537 and P = 0.198, respectively). The number of PCNA positive cells was (i) 275.00, (ii) 740.50, (iii) 285.75 and (iv) 420.59, these varying compared with the control group with statistical significance of (ii) P = 0.002, (iii) P = 0.999, and (iv) P = 0.467. The greatest healing rate and epithelial cell proliferation was achieved with AMT compared to the other treatment regimes. Conclusions The results of this study show that FD-AM transplantation is an effective treatment for enhancing canine corneal wound healing and suggest that the approach will provide superior results compared to conventional treatments for the condition.

Suture-related corneal infections after clear corneal cataract surgery.

Abstract: Three patients at our institution developed corneal infections associated with sutures placed after clear corneal incision cataract surgery. The time to infection was 9 weeks, 22 months, and 33 months. One patient required injection of intravitreal antibiotic agents for presumed endophthalmitis associated with the corneal infection. Two patients were treated with topical fortified antibiotic eyedrops only. Although there was no significant change in visual acuity after resolution of the infection, morbidity from suture-related corneal infections can be significant. Routine suture removal in the early postoperative period may be warranted to prevent such infections.

Anti-inflammatory effects of topical supernatant from human amniotic membrane cell culture on canine deep corneal ulcer after human amniotic membrane transplantation.

Abstract: The objective of this study was to examine the effect of topically applied human amniotic epithelial cell (HAEC) culture supernatant on corneal inflammatory reaction in dogs. Twenty-five dogs were randomly assigned into five groups. The control group consisted of five dogs with normal cornea. Inductions of corneal ulcers were performed using 0.45 cm trephine and human amniotic membrane was transplanted in 20 dogs. These 20 dogs were assigned into four treatment groups: topical antibiotic, topical corticosteroid, topical mock media and topical culture supernatant from HAEC, respectively. Administrations of the testing agents started at 24 h (h) after transplantation four times daily for nine consecutive days. Tears were collected before an operation 24 h after transplantation, but before application of the testing agents on consecutive odd days following transplantation. The concentrations of interleukin-1beta (IL-1beta) and nitric oxide (NO) in tear fluid were measured using canine IL-1beta ELISA kit and Griess assay, respectively. Our analysis indicates that elevations of IL-1beta and NO concentrations are associated with inflammatory conditions in the eyes. Corticosteroid, a reference anti-inflammatory drug, and the culture supernatant from HAEC significantly decreased IL-1beta and NO concentrations. In addition, the clinical signs such as conjunctivitis and neovascularization were decreased in both topical corticosteroid and supernatant from HAEC treated groups. Mock and antibiotic solutions failed to decrease NO and IL-1beta concentrations. In conclusion, topical application of the culture supernatant from HAEC alleviated inflammation in induced-corneal ulcer of dogs, possibly via inhibition of IL-1beta and NO production.

Nepafenac-associated bilateral corneal melt after photorefractive keratectomy.

Abstract: Purpose:We are reporting a case of bilateral corneal melt after photorefractive keratectomy requiring bilateral corneal transplantationsResults:A 35-year-old man underwent uncomplicated photorefractive keratectomy and was treated postoperatively with topical nepafenac, one drop in both eyes every 2

Bipolaris hawaiiensis keratomycosis and endophthalmitis.

Abstract: Following trauma with rice stalk to the left eye, corneal ulcer with abscess and hypopyon developed in an immunocompetent male. Direct examination of the corneal scrapings revealed septate, branched fungal hyphae. Bipolaris hawaiiensis was isolated after culture on blood agar and Sabouraud dextrose agar. Because of delay in diagnosis and appropriate treatment, the patient developed endophthalmitis needing evisceration.

Tarsorraphy in the treatment of persistent corneal lesions

Abstract: . Altogether 38 tarsorraphies were carried out to 19 patients with corneal epithelial defects resistant to conventional therapy. The main operaive indications were lagothalmos (9), dry eyes (12) and inadequate blinking (6 patients). Corneal ulcer was detected in 17 eyes, six of which perforated. All patients had been treated from one week to 16 months (mean 3.5 months) without healing. Retarsorraphy was needed in 6 eyes. In perforations tarsorraphy was combined to tissue adhesive (3 eyes) or to therapeutic contact lens (4 eyes) or to conjunctival flap (2 eyes). The corneal epithelium healed in all except 2 cases (one perforation, one ulcer that is slowly improving). Five of the 6 perforations could also be cured without grafting. One eye of a severely debilitated patient was treated with a Gundersen's conjunctival flap and total tarsorraphy, but remained hazy. We consider, that tarsorraphy is valuable in treating corneal lesions due to lagophthalmos, dry eyes or disturbed lid function. It can also be used in threatening of manifest corneal perforation, if combined with the use of tissue adhesive or therapeutic contact lens.

Orthokeratology associated microbial keratitis.

Abstract: PURPOSE. To report the clinical course, microbiologic findings, treatment, and outcomes of overnight orthokeratology associated microbial keratitis. METHODS. Four cases of overnight orthokeratology associated microbial keratitis are reported. RESULTS. Four patients aged 14–23 years (mean 18 years) who had central or paracentral corneal ulcers were included. Visual acuity at presentation ranged from 20/30 to hand motion. In all cases Pseudomonas aeruginosa was cultured from corneal scrapings or storage solution. In all patients the infection resolved with intensive topical antimicrobial treatment. Final best-corrected visual acuity ranged from 20/25 to 20/200 according to the location, size, and density of the corneal scar, which complicated all cases. CONCLUSIONS. Infectious keratitis is a significant, visual threatening complication of overnight orthokeratology. Eye care practitioners should be aware of this complication and educate their patients of the importance of lens hygiene and prompt medical care when symptoms or signs of keratitis appear. (Eur J Ophthalmol 2009; 19: 133-6)

Fungal Keratitis in a Gopher Tortoise (Gopherus polyphemus)

Abstract: A free-ranging gopher tortoise (Gopherus polyphemus) presented for trauma and blindness. Fibrinous exudate obscured visualization of the globes. This exudative crust extended from the conjunctival fornices through the palpebral fissure and was manually removed. Ophthalmic examination revealed bilateral corneal ulcerations and scarring and phthisis bulbi of the left globe. Histology of the crust revealed a necrotic conjunctivitis with intralesional fungal hyphae. Culture of the corneal ulcer of the left eye isolated moderate growth of a mixed fungal flora consisting of Curvularia sp. and Aspergillus sp. Miconazole ophthalmic solution was administered and the ulcers in both eyes healed, but corneal edema continued. After 2 mo of treatment with miconazole, tramadol, acetylcysteine, hypertonic saline ointment, artificial tears, and hypertonic saline flushes, the right eye was normal with only a small scar. The left eye remained phthisical. This is the first report of fungal keratitis in a wild reptile and a gopher tortoise.

Peripheral ulcerative keratitis after trabeculectomy in a patient with rheumatoid arthritis.

Abstract: Purpose To report the unusual occurrence of peripheral ulcerative keratitis, 10 days after trabeculectomy in a 35-year-old patient with rheumatoid arthritis (RA). Methods Observational case report. Results A 35-year-old patient with RA and secondary Sjogren disease underwent an uneventful fornix-based trabeculectomy. Ten days after surgery, slit-lamp examination revealed a peripheral corneal ulcer extending from 5- to 7-o'clock positions with a surrounding inflammatory infiltrate and adjacent conjunctival injection. The ulcer was treated with systemic and topical steroids, antibiotic eyedrops, artificial tears, and a bandage soft contact lens. Since then, corneal re-epithelialization started and the patient's symptoms subsided. The ulcer improved steadily within 2 months while the patient used a soft contact lens. The ulcer did not reoccur in the 18 months follow-up while the patient remained under systemic treatment. Conclusion This report highlights the importance of careful examination and close postoperative follow-up in patients with RA undergoing any intraocular surgery, to diagnose a possible development of peripheral ulcerative keratitis. Although the incidence is rare, prompt diagnosis of the peripheral ulceration is essential because if untreated it may seriously affect patient's vision.

Oral fluconazole therapy for keratomycosis.

Abstract: A 12-year-old girl with fungal keratitis following injury with a vegetable foreign body was successfully treated with oral fluconazole, a new antifungal agent. The infection resolved completely with good visual recovery. Fluconazole was well tolerated systemically.

Exfoliative epitheliopathy of bullous keratopathy with breaches in the MUC16 Glycocalyx.

Abstract: Pseudophakic and aphakic bullous keratopathy are major indications for penetrating keratoplasty worldwide and account for more than one third of all corneal transplantations in some studies.1–5 Previous histopathologic studies of bullous keratopathy have understandably focused on the endothelial cell loss that constitutes the underlying pathogenic basis for this disorder. However, patients with bullous keratopathy are known to have painful surface epithelial defects, subepithelial bullae, and punctate staining. Bullous keratopathy may be accompanied clinically by superficial epithelial keratopathy.6 Eagle et al.7 noted that bullous keratopathy may manifest findings similar to map dot finger print dystrophy. Abnormalities include complete epithelial denudement, subepithelial bullae, intraepithelial duplication of basement membrane material, intraepithelial microcysts with degenerative material, and degenerative pannus. As expected, endothelial cell numbers are decreased.7 These features and stromal thickening with a degenerative lipid keratopathy have been reported.8 Absent in these descriptions is a quantitative analysis of the epithelial cell layers. In recent years, numerous antibodies to cellular adhesion and membrane proteins have become available. Alterations in the expression of cellular adhesion molecules have been demonstrated in bullous keratopathy, including elevated tenascin C integrins, elevated B6 integrins, and elevated expression of β-catenin throughout the epithelium.9,10 Some of these changes are putatively compensatory to augment interepithelial cell adhesion that has been compromised by bullous keratopathy.11 Some authors have noted increased apoptosis of corneal epithelium in Fuchs' dystrophy although the increase (P = 0.07) for bullous keratopathy was not statistically significant.12,13 Cell cycling inhibitors modulated by P53, P21, and P27 are reduced.14 These data suggest that surface epithelium may be compromised in bullous keratopathy by abnormal cellular and basement membrane adhesion and may be prone to increased cellular shedding. The superficial epithelium of the cornea is especially important because it expresses the ocular mucins MUC16, MUC1, and MUC4, which lubricate and protect the cornea.15–17 MUC16 is the largest corneal epithelial transmembrane mucin (22,000 amino acids) and displays extensive O-glycosylation.18 In human corneas, MUC16 is confined to the superficial apical cells and one subjacent layer.17 MUC16, but not MUC1, is important to prevent the permeability of Rose Bengal dye in islands of human cultured corneal epithelial cells.19,20 The pattern of expression of MUC4 is different from that of MUC1 and MUC16. MUC4 is expressed mainly at the corneal limbus in several layers of epithelium of the rat but perhaps only minimally in the central corneal epithelium of humans.16,21 Some ocular mucins have been shown to be altered in atopic keratoconjunctivitis, corneal ulcer, and dry eye disease.22,23 Given the clinically apparent abnormal surface characteristics and altered expression of adhesion molecules in bullous keratopathy, the hypothesis that exfoliation and cell drop out of the superficial epithelium affect the ocular surface glycocalyx was explored.

A Retrospective Study of Fungal Corneal Ulcers in the South Sharqiyah Region in Oman

Abstract: Objectives: To study the incidence, identify the risk factors and determine the predominant microorganisms and treatment regimen of fungal corneal ulcers. Methods: This was a retrospective analysis of corneal ulcers treated in the Ophthalmology Department of Sur Hospital, Oman, undertaken from January 2004 to December 2007. Medical and microbiology records of thirty two culture proven cases of fungal keratitis were reviewed for risk factors, laboratory findings and response to treatment. Results: Out of the total 242 corneal ulcers, 13.22 % were fungal. Among the 102 culture positive cases, 31.38 % were fungal isolates. Fusarium spp (50%) and Aspergillus spp (34.4%) predominated in the hyaline fungal spectrum. The important risk factors were topical steroid usage in 31.25 % of cases and ocular injury in 25 %. The majority of cases (90.62%) responded to 2% ketoconazole alone or in combination with 0.15% amphotericin B. Conclusion: Fungal ulcer remains one of the leading causes of visual disability. Indiscriminate use of topical steroids and ocular trauma are the most important risk factors. Filamentous fungi are common aetiological agents in this region. Topical ketoconazole and amphotericin B were very effective for most of the cases.