Infectious crystalline keratopathy

Infectious crystalline keratopathy was first reported by Gorovoy and colleagues in 1983 when they identified bacteria colonizing a cornea after a penetrating keratoplasty. Subsequent cases have elaborated on the organisms responsible and the management outcomes. Patients present with a white or gray branching opacity originating from an epithelial defect, commonly after a penetrating keratoplasty. Local immunosuppression contributes to the quiescent nature and the limited inflammatory response associated with infectious crystalline keratopathy. Diagnosis of the infective pathogens may be difficult, with a corneal scraping often being too superficial to obtain an adequate specimen. A biofilm is present that advantages microorganism survival, reduces antibiotic bioavailability, and inhibits diagnostic microbial detection. Treatment begins with topical antimicrobials, initially broad spectrum and then targeted to microorganism sensitivity. Adjunctive therapies to enhance the efficacy of treatment include disruption of the microorganism biofilm by laser, intrastromal antibiotics, and keratectomy. In recalcitrant cases, or where corneal scarring ensues, corneal transplantation is required.     

Infectious crystalline keratopathy caused by Serratia marcescens

PURPOSE: To report the case of a 70-year-old woman with Serratia infectious crystalline keratopathy. METHODS: Case report. RESULTS: This is a report of a 70-year-old woman with a history of chronic open-angle glaucoma and trachoma with lagophthalmos, entropion, and trichiasis in both eyes who developed crystalline keratopathy after penetrating keratoplasty and cataract extraction in the right eye followed up with treatment with long-term topical steroids. Ten months after the initial penetrating keratoplasty and cataract extraction, the patient had decreased visual acuity, intense pain, and tearing in the right eye. Corneal cultures showed Serratia marcescens. Topical steroids were discontinued, and treatment with tobramycin and vancomycin ophthalmic solution every hour was initiated. Despite 1 week of aggressive therapy, there was an increase in corneal infiltrate, epithelial defects, and melting, which eventually involved the peripheral recipient cornea. Therapeutic penetrating keratoplasty, debridement of the peripheral cornea, and amniotic membrane transplantation were performed. Antibiotic agents were used postoperatively. There has been no evidence of recurrent infection. The best-corrected visual acuity improved to 6/15 at the 6-month follow-up period after the second intervention. CONCLUSIONS: S. marcescens may cause infectious crystalline keratopathy after penetrating keratoplasty in patients treated with long-term topical steroids. Therapeutic penetrating keratoplasty, surgical debridement, and amniotic membrane transplantation may be necessary when the clinical response to intensive medical treatment is inadequate.     

Penetrating keratoplasty in infants.

PURPOSE: To analyze graft survival and visual outcome after penetrating keratoplasty in infants with congenital corneal opacity. METHODS: We retrospectively reviewed the records of 11 patients with congenital corneal opacity who underwent penetrating keratoplasty as infants. Six patients had a diagnosis of Peter's anomaly, 1 of congenital hereditary endothelial dystrophy, 1 of posterior polymorphous dystrophy, and 2 of sclerocornea, and in the other patient, the cause of the opacity was unknown. RESULTS: In total, 26 penetrating keratoplasties were performed on 16 eyes of 11 infants. All patients initially underwent surgery before the age of 13 months. Five patients underwent bilateral penetrating keratoplasty, and 10 of the transplants were repeat operations on eyes that had already had at least one previously failed graft. The age of the infants at the time of first penetrating keratoplasty ranged from 2 to 56 weeks (median, 13 weeks). The graft survival time for all transplants ranged from 3 to 137 months (median, 16 months). Overall first graft survival at 12 months was 61% (95% CI, 33%-81%), with 10 of 16 eyes retaining a clear corneal graft. Peter's anomaly, lensectomy, and repeat penetrating keratoplasty were factors most highly associated with poor graft survival and a low final visual acuity. CONCLUSION: Early penetrating keratoplasty for congenital corneal opacity may prevent deprivation amblyopia. Although this procedure carries a high risk of failure, particularly in those patients with Peter's anomaly, careful case selection, optical correction, and management of postoperative amblyopia may result in a successful visual outcome.     

Infectious crystalline keratopathy caused by Gemella haemolysans

PURPOSE: To report a novel case of infectious crystalline keratopathy after penetrating keratoplasty caused by Gemella haemolysans. METHODS: Observational case report. Patient notes and literature review. RESULTS: A 51-year-old woman presented with the clinical picture of infectious crystalline keratopathy 18 months after a second penetrating keratoplasty was performed for corneal decompensation secondary to recurrent herpes simplex infection. Corneal biopsy yielded a heavy growth of G. haemolysans. Initial treatment was made up of frequent topical vancomycin 0.5% and was later changed to topical cefuroxime 5% and ofloxacin 0.3%. Snellen visual acuity after complete resolution of the keratitis was 6/60 as a result of a residual corneal scar. CONCLUSIONS: Gemella haemolysans may be an etiologic agent in infectious crystalline keratopathy. A corneal biopsy may be diagnostic but may also promote healing by allowing direct access of antibiotics to deep-seated infected tissue and by altering the growth environment of the organism.     

Effectiveness of topical bevacizumab in bilateral primary lipid keratopathy

CASE REPORT: A 75-year-old man with bilateral idiopathic lipid keratopathy underwent a penetrating keratoplasty in the left eye. One month later, there was deep corneal neovascularisation extending across the bed and the graft-host interface, with a whitish opacity surrounding the vessels. Topical bevacizumab (25mg/mL) was administered 4 times daily for 2 months with partial regression of corneal neovascularization. DISCUSSION: Topical bevacizumab may be useful in preventing a recurrence of lipid deposition after penetrating keratoplasty in patients with bilateral primary lipid keratopathy, although its long-term efficacy needs to be assessed.     

Posterior infectious crystalline keratopathy with Staphylococcus epidermidis

Two cases of infectious crystalline keratopathy located in the posterior stroma after penetrating keratoplasty are presented. Topical steroids and suture removal were risk factors in both cases. In the first case, a moderate anterior chamber reaction was present. Crystalline infiltrates persisted on topical and systemic steroid therapy. In the second case, deep corneal ulceration, hypopyon, and vitreitis were noted. A vitreous aspirate showed rare gram-positive cocci in pairs. The corneal ulceration and crystalline keratopathy persisted despite intravitreal and topical antibiotics. Therapeutic penetrating keratoplasty was performed in both cases. Staphylococcus epidermidis sensitive to vancomycin was isolated from corneal tissue. Light microscopy documented aggregates of gram-positive bacteria anterior to Descemet's membrane, with an overlying keratitis. Electron microscopy in the second case showed all bacteria within stromal keratocytes. No clinical recurrence was seen using topical vancomycin. As demonstrated in the cases presented, infectious crystalline keratopathy can occur exclusively in the deeper layers of the cornea. Isolation of S. epidermidis, associated inflammation, and intraocular spread of organisms are rare findings.     

Borrelia-associated crystalline keratopathy with intracorneal detection of Borrelia garinii by electron microscopy and polymerase chain reaction

PURPOSE: First report of a patient with Borrelia-associated crystalline keratopathy with intracorneal evidence of Borrelia garinii by polymerase chain reaction (PCR) and electron microscopy (EM). METHODS: Report of a 67-year-old patient with medical history of recurrent iridocyclitis and arthritis presented with a bilateral, progressive, asymmetric crystalline keratopathy, which was particularly pronounced in the peripheral temporal superior cornea. After penetrating keratoplasty, crystalline keratopathy with stromal haziness recurred. Corneal regrafting was performed. The corneal specimen from the penetrating keratoplasty was examined by light and EM as well as by PCR. RESULTS: In the explanted corneal graft, as well as retrospectively in the corneal specimen from the first keratoplasty, spirochetelike bodies and fragments were detected by light and EM. Borrelia burgdorferi sensu lato DNA was demonstrated by broad-range (16S rDNA) PCR. A more precise identification as Borrelia garinii serotype 5 was possible by analyses of the flaB and ospA gene sequences. Borrelia-specific serological tests showed borderline titers in immunofluorescence and weak reaction in immunoblot, respectively. CONCLUSIONS: This case illustrates that borreliae must be considered as a cause of crystalline keratopathy; Borrelia-specific serological tests can be false negative; explanted cornea specimens of etiologically unclear crystalline keratopathy should be analyzed by EM or PCR for detection of pathogens; and prolonged antibiotic treatment might be effective to prevent progression or recurrence of the disease.     

Indications of penetrating keratoplasty in northern India

PURPOSE: To identify the indications for penetrating keratoplasty in northern India. METHODS: All the eye bank records of penetrating keratoplasties performed during the period from June 1997 to November 2003 at Rajendra Prasad Center for Ophthalmic Sciences were reviewed. RESULTS: During this period, 2022 penetrating keratoplasties were performed. The leading indications for penetrating keratoplasty were corneal scarring (38.03%) followed by acute infectious keratitis (28.38%), regrafting (11.5%), aphakic bullous keratopathy (7.27%), pseudophakic bullous keratopathy (6.18%), and corneal dystrophy (3.85%). Healed infectious keratitis (19.83%) was the most common subcategory among the eyes with corneal scarring followed by traumatic corneal scars (16.71%). Healed (19.83%) and active keratitis (28.38%) together accounted for the majority of keratoplasties (48.21%). In cataract-related corneal edema (13.45%), aphakic bullous keratopathy (7.27%) was almost as frequent as compared with pseudophakic bullous keratopathy (6.18%). CONCLUSIONS: Corneal infections either active or healed are the most common indication for keratoplasty in northern India.     

角膜移植术后排斥反应的防治探讨

目的:为控制角膜移植术后发生排斥反应,探讨防治排斥反应的有效途径。方法:对73例73眼穿透性角膜移植术患者术后排斥反应发生率进行回顾性分析。结果:患者73眼中28眼发生免疫排斥反应(38%),其中高危角膜病变21眼,非高危角膜病变7眼,有角膜新生血管者占88%,排斥反应发生时间为术后2wk～3a,以内皮型排斥反应为主(43%)。经药物联合治疗,角膜排斥反应得到明显抑制,有效率达61%。结论:高危角膜病变免疫排斥反应几率明显增加,发生时间及持续时间较长,因此应根据不同角膜病变在术前、术中、术后采取相应措施减少排斥反应发生率。     

Penetrating keratoplasty for varicella-zoster virus keratopathy

PURPOSE: To examine and report the results of penetrating keratoplasty performed in patients with varicella-zoster virus keratopathy. METHODS: The authors retrospectively reviewed the records of 15 patients who had penetrating keratoplasty for varicella-zoster virus keratopathy from January 1989 through December 1998 on the Cornea Service at Wills Eye Hospital. RESULTS: Twelve patients had a preoperative diagnosis of herpes zoster ophthalmicus, and three, of varicella. Four eyes had lateral tarsorrhaphies performed in conjunction with penetrating keratoplasty. Three eyes had endothelial rejection episodes that responded well to treatment with topical steroids. One eye had a regraft 1 month after primary failure, and this second graft also failed because of recurrent neurotrophic keratopathy. Three eyes that had repeated penetrating keratoplasty for graft failure had clear grafts at the last examination. At an average follow-up time of 50 months, 13 (86.7%) grafts remained clear, and the best corrected visual acuity was 20/100 or better in eight (53.3%) eyes. Five patients had decreased visual acuity because of retinal diseases. CONCLUSION: Although varicella-zoster virus keratopathy is an uncommon indication for penetrating keratoplasty, effective visual rehabilitation can be achieved in these patients. Careful postoperative management, frequent lubrication, and lateral tarsorrhaphies to protect the corneal surface are major factors in the successful outcome of these cases.     

Infectious crystalline keratopathy associated with topical anesthetic abuse

Two patients with infectious crystalline keratopathy associated with topical anesthetic abuse are described. No previously reported predisposing factors existed, including topical corticosteroid use during active Herpes simplex or Acanthamoeba keratitis, or following penetrating keratoplasty. Cultures from corneal biopsies of both patients grew Streptococcus viridans. Both infections resulted in corneal scarring with vascularization. Ultimately, corneal transplantation was performed in one case.     

Implantation of scleral-sutured posterior chamber intraocular lenses during penetrating keratoplasty

PURPOSE: To evaluate the clinical outcome in 29 patients (29 eyes) who underwent penetrating keratoplasty and scleral-fixation of an intraocular lens. METHODS: The indications for penetrating keratoplasty with scleral-fixation of an intraocular lens were anterior chamber pseudophakic corneal edema, aphakic corneal edema, trauma, and corneal scars. Patients with pseudophakic corneal edema underwent IOL exchange and penetrating keratoplasty and patients with lens subluxation underwent cataract extraction and penetrating keratoplasty in the same operation session. RESULTS: Preoperative spectacle-corrected visual acuity was hand motion in 13 eyes (44.8%) and 20/400 in 18 eyes (61.5%). Postoperative spectacle-corrected visual acuity of 20/400 or better was observed in 25 eyes (86.2%). At last follow-up, 26 corneal grafts (89.7%) remained clear. Three grafts (10.3%) failed, two because of glaucoma and one because of endophthalmitis. Glaucoma was observed in 7 eyes. CONCLUSION: Trans-scleral fixation of intraocular lenses combined with penetrating keratoplasty was a useful surgical technique in eyes with keratopathy and lacking posterior capsular support.     

Implantation of posterior chamber intraocular lenses by suture fixation without capsular and zonular support

We implanted sulcus-fixated posterior chamber intraocular lenses (PCL) in three cataractous, six aphakic, and four eyes during penetrating keratoplasty due to corneal opacity in the absence of capsular and zonular support. This technique has been successfully performed in all cases and produced good visual outcome in 12 eyes (93%). In four eyes which had penetrating keratoplasty and the fixation of PCL, one developed vitreous hemorrhage and one developed corneal graft rejection.     

Gemella haemolysans infectious crystalline keratopathy

PURPOSE: To report a case of infectious crystalline keratopathy caused by Gemella haemolysans. METHODS: Observational case report. A 65-year-old woman underwent penetrating keratoplasty for contact lens-related Acanthamoeba keratitis and developed a nonhealing epithelial defect. Despite continued prophylaxis with topical gatifloxacin, small superficial stromal opacities were noted and cultured 6 months after penetrating keratoplasty. The opacities coalesced into a fine, crystalline keratopathy in the superficial stroma with persistent overlying epithelial defect. RESULTS: Culture results from corneal scraping showed more than 100 colonies of G. haemolysans. Topical vancomycin was instituted, with complete resolution of the crystalline keratopathy and epithelial defect over the next 2 months. CONCLUSIONS: G. haemolysans can be a causative organism of infectious crystalline keratopathy. This infection can arise in a postkeratoplasty patient despite prophylaxis with a fourth-generation fluoroquinolone.     

Indications for and outcomes of penetrating keratoplasty performed by resident surgeons

PURPOSE: To analyze the indications for and outcomes of penetrating keratoplasty (PKP) performed by resident surgeons at both county hospital and Veterans Affairs facilities. DESING: Observational case series. METHODS: Retrospective review of 79 eyes from 61 patients undergoing PKP from January 1, 1997, through December 31, 2001, to determine indications for surgery and outcomes, including graft clarity and final visual acuity. RESULTS: There were 52 (65.8%) primary and 27 (34.2%) repeat transplants performed. Follow-up after surgery averaged 21.9 months. Indications for PKP included failed graft, 23 (29.1%), bullous keratopathy, 17 (21.5%), keratoconus, 16 (20.3%), corneal scar, 15 (19.0%), corneal perforation from infection, 5 (6.3%), and Fuchs endothelial dystrophy, 3 (3.8%). Twenty-one eyes had pre-existing ocular disease limiting final acuity. Overall, 51 grafts (64.6%) remained clear. More primary than repeat grafts remained clear (75% vs 44.4%, P =.012) and achieved 20/40 or better final acuity (30.8% vs 11.8%, P =.05). Excluding failed grafts or eyes with limited visual potential, final acuities achieved were: 19 (47.5%) 20/40 or better, 18 (45%) 20/50 to 20/150, 3 (7.5%) 20/200 or worse. Grafts remaining clear by indication were: failed graft, 9 (39.1%); keratoconus, 14 (87.5%); bullous keratopathy, 13 (76.5%); corneal scar, 10 (66.7%); corneal perforation, 2 (40%); Fuchs, 3 (100%). Eyes achieving final acuity of 20/40 or better by indication were: keratoconus, 9 (56.2%); failed graft, 3 (13%); bullous keratopathy, 3 (17.7%); corneal scar, 2 (13.3%); corneal perforation, 0 (0%); Fuchs, 2 (66.7%). CONCLUSIONS: County hospital and Veterans Affairs facilities provide a challenging subset of patients for penetrating keratoplasty. Failed graft was the leading indication for transplantation for our population. Graft clarity and final visual acuity varied by indication for transplantation. Resident surgeons can achieve favorable results for penetrating keratoplasty performed at these venues, especially for primary transplants.     

人工晶体眼大泡性角膜病变的穿透性角膜移植

目的:研究人工晶体眼大泡性角膜病变行穿透性角膜移植的临床效果和保留或取出原人工晶体的适应证。方法:应用穿透性角膜移植治疗人工晶体植入术后大泡性角膜病变。结果:13例(13眼),术中保留原人工晶体11眼,取出原人工晶体2眼。术后随访平均16个月。随访期间角膜移植片全部透明,术后绝大部分病例视力获得提高,其中视力矫正达到0.2以上有5眼。结论:穿透性角膜移植是治疗人工晶体植入术后大泡性角膜病变有效方法。只要人工晶体位于囊袋内,位置正常,术中应保留原人工晶体,手术安全,术后视力恢复良好。眼科学报1998;14:227～228。     

Candida parapsilosis keratitis

PURPOSE: To present clinical, microbiologic, and histopathologic features of keratitis due to Candida parapsilosis. METHODS: Clinicomicrobiologic evaluation of four patients (four eyes) with culture-proven C. parapsilosis keratitis. The patients were evaluated for symptoms, visual acuity, clinical observations, microbiologic examination of corneal scrapings, and pathologic examination of corneal buttons. RESULTS: Three cases were observed after penetrating keratoplasty, and one case occurred after inhalation of corticosteroids. Clinical presentation of C. parapsilosis keratitis showed a great diversity. There was one case of crystalline keratopathy and three cases of suppurative corneal infiltrate. Histopathology of corneal buttons showed interlamellar accumulations of yeast. Medical treatment included topical amphotericin B and systemic triazoles. Penetrating keratoplasty was required in three patients. CONCLUSION: Risk factors for C. parapsilosis keratitis may include corticosteroid use and prior corneal transplantation. The prognosis of C. parapsilosis keratitis with antifungal and surgical therapy may vary from good visual outcome to intraocular extension with phthisis bulbi.     

Infectious crystalline keratopathy

Infectious crystalline keratopathy was first described in 1983. affected corneal grafts generally show progressive scarring and often require penetrating keratoplasty. We present a patient in whom infectious crystalline keratopathy developed 3 months after surgery. The infection was successfully treated with antibiotic therapy.     

Clinical indications for and procedures associated with penetrating keratoplasty, 1983-1988

We reviewed the preoperative clinical indications and associated surgical procedures for 2,299 penetrating keratoplasties performed at our institution from 1983 through 1988. Pseudophakic bullous keratopathy was the most common indication overall, accounting for 526 cases (23%). A marked increase was noted in the incidence of pseudophakic bullous keratopathy as an indication for penetrating keratoplasty beginning in 1985. The association of anterior chamber intraocular lenses in eyes with pseudophakic bullous keratopathy undergoing penetrating keratoplasty increased from 19 of 43 cases (44%) in 1983 to 79 of 108 cases (73%) in 1988. The incidence of intraocular lens exchange at the time of penetrating keratoplasty in cases of pseudophakic bullous keratopathy increased from six of 43 (14%) in 1983 to 63 of 108 (58%) in 1988. Other major indications for penetrating keratoplasty included Fuchs' dystrophy (375 cases, 16%), keratoconus (348 cases, 15%), aphakic bullous keratopathy (331 cases, 14%), and regraft (233 cases, 10%). Cataract extraction, with or without intraocular lens implantation, was combined with penetrating keratoplasty in 397 of 1,532 phakic eyes (26%). The incidence of triple procedure (penetrating keratoplasty, cataract extraction, and intraocular lens implantation) increased from 27 of 248 phakic eyes (11%) in 1983 to 68 of 258 phakic eyes (26%) in 1988.