Late-onset Citrobacter koseri endophthalmitis with suture exposure after secondary intraocular lens implantation

A 54-year-old male patient was seen in clinic for ocular pain and decreased vision in the right eye with duration of two days. He underwent a cataract operation for his right eye 12 years ago, then a sclera-fixated secondary intraocular implantation and pars plana vitrectomy three years ago due to intraocular lens dislocation. At the initial visit, his visual acuity was restricted to the perception of hand motion. An edematous cornea, cells, flare with hypopyon, and exposed suture material at were observed at the six o'clock direction by slit lamp. Vitreous opacity was noted from B-scan ultrasonography. The patient was diagnosed with late-onset endophthalmitis and an intravitreal cocktail injection was done. On the next day, the hypopyon was aggravated, and therefore a pars plana vitrectomy was performed. A vitreous culture tested positive for Citrobacter koseri. After 12 weeks, the best corrected visual acuity of the right eye improved to 0.7 and a fundus examination revealed a relatively normal optic disc and retinal vasculature. We herein report the first case of endophthalmitis caused by Citrobacter koseri in Korea. Exposed suture material was suspected as the source of infection in this case and prompt surgical intervention resulted in a relatively good visual outcome.     

Investigative modalities in infectious keratitis

Standard recommended guidelines for diagnosis of infectious keratitis do exist. Based on an extensive Medline literature search, the various investigative modalities available for aiding the diagnosis of microbial keratitis have been reviewed and described briefly. Preferred practice patterns have been outlined and the importance of routine pre-treatment cultures in the primary management of infectious keratitis has been highlighted. Corneal scraping, tear samples and corneal biopsy are few of the specimens needed to carry out the investigative procedures for diagnosis and for initiating therapy in cases of microbial keratitis. In bacterial, fungal and amoebic keratitis, microscopic examination of smears is essential for rapid diagnosis. Potassium hydroxide (KOH) wet mount, Gram's stain and Giemsa stain are widely used and are important for clinicians to start empirical therapy before microbial culture results are available. The usefulness of performing corneal cultures in all cases of suspected infectious keratitis has been well established. In cases of suspected viral keratitis, therapy can be initiated on clinical judgment alone. If a viral culture is needed, scrapings should directly be inoculated into the viral transport media. In vivo confocal microscopy is a useful adjunct to slit lamp bio-microscopy for supplementing diagnosis in most cases and establishing early diagnosis in many cases of non-responding fungal and amoebic keratitis. This is a non-invasive, high resolution technique which allows rapid detection of Acanthamoeba cysts and trophozoites and fungal hyphae in the cornea long before laboratory cultures give conclusive results. Other new modalities for detection of microbial keratitis include molecular diagnostic techniques like polymerase chain reaction, and genetic finger printing by pulsed field gel electrophoresis.     

Contact lens-related infectious keratitis in Malaysia

Fifty-six contact lens-related corneal ulcers (central in 32; hypopyon in 24 and stromal abscess in 6) were studied. Culture was positive in 78.9%. Corneal ulcers healed with intense antibiotic therapy in nearly all patients. Increased awareness of lens care/disinfection and frequent replacement of storage cases and solution, and early detection of pathogens and intensive appropriate antibiotic therapy are key points in management.     

Photo-activated chromophore for infectious keratitis cross-linking and its efficacy as a treatment modality in managing microbial keratitis

Purpose:To assess Photo Activated Chromophore for Infective Keratitis-Cross Linking (PACK-CXL) and its efficacy as a treatment modality in managing microbial keratitis.Methods:Single Centre prospective interventional study in infectious keratitis. A total of eleven patients were taken who had corneal thickness (CT) more than 400µm. PACK-CXL was performed according to Dresden’s protocol. The response was assessed by slit lamp examination, BCVA and AS-OCT at the time of complete healing.Results:The mean visual acuity at presentation was 1.207logMAR (0.3-3) which improved to mean value of 0.53logMAR (0.3-1). Mean time taken for complete epithelization was 17.45 days (14- 30 days) and that for complete healing was 33.72 days (21- 60 days). Mean CT at the baseline was 650.5± 108µm which reduced on consecutive follow up visits. There was reduction in the symptoms in nine patients except in two. One case reported increase in symptoms with worsening increase in endoexudates and hypopyon, and the other developed drug toxicity due to topical medications.Conclusion:Patients who underwent PACK-CXL showed good and early healing, good remodelling of cornea and improved visual acuity. The recalcitrant cases became responders to the same medications after PACK-CXL. Thus, PACK-CXL works well for both fungal and bacterial keratitis.     

生物工程角膜移植治疗感染性角膜炎

目的：观察生物工程角膜移植治疗感染性角膜炎的疗效,评价其临床应用价值和意义。

方法：对我院35例35眼需要进行手术治疗的感染性角膜炎患者分为3组：观察组15例,使用生物工程角膜施行板层角膜移植手术。对照组有两组：对照1组10例,使用保存人角膜施行板层角膜移植手术; 对照2组10例,实施自体结膜瓣遮盖手术。随访3～20mo,观察视力、感染控制情况以及角膜透明度。

结果：观察组15眼术后感染控制,视力不同程度提高,除1眼在随访中发生植片混浊外,其余14眼植片均维持基本透明。对照1组,除1眼病毒性角膜炎因病毒复发导致角膜混浊外,其余9眼角膜植片维持透明。对照2组,除1眼真菌性角膜溃疡感染加重,行眼内容物剜除术,其余角膜溃疡瘢痕修复。

结论：生物工程角膜是一种新型的人角膜替代材料,为解决逐年增长的角膜病患者与短缺的角膜供体之间的矛盾发挥了作用。     

Single culture media in infectious keratitis.

PURPOSE: To evaluate the usefulness of the various culture media used in the traditional workup in infectious keratitis. METHODS: Microbiology data sheets from all corneal cultures performed at the University of California Davis Medical Center over a 1-year period were reviewed retrospectively. RESULTS: Bacterial cultures were sent in 76 cases. In 19 cases, culture specimens from ulcers were plated onto blood, chocolate, and inhibitory mold agar and were inoculated into an anaerobic medium. In 58 cases, blood and chocolate agar were sent. In 70% of cases, blood and chocolate agar provided identical information. Inhibitory mold agar was positive twice in 39 plates sent. A fungal pathogen had been identified on chocolate agar plates sent for these cases. CONCLUSION: In the evaluation of infectious keratitis, plating onto chocolate agar or blood agar alone is a reasonable alternative to sending multiple cultures.     

Unsuspected infectious keratitis in host corneal buttons

Infectious keratitis may be unsuspected preoperatively in patients undergoing penetrating keratoplasty. We have diagnosed five cases of previously unknown corneal infection discovered only after post-keratoplasty histopathologic examination using specific stains. These cases of preoperatively unsuspected infectious keratitis illustrate examples where histopathologic examination using specialized stains may alert the physician to the need for appropriate postoperative antimicrobial therapy. Furthermore, these cases illustrate the ability of soft contact lenses to mask symptoms of infectious keratitis. Additionally, the clinical appearance of advanced bullous keratopathy may mask signs of infectious keratitis.     

Nummular keratitis associated with infectious mononucleosis

A 16-year-old boy had a severe case of infectious mononucleosis with a rising titer to the Epstein-Barr virus. The patient had developed a nummular keratitis apparently associated with this illness. Because infectious mononucleosis or infection by the Epstein-Barr virus is often subclinical, and many cases of nummular keratitis have been classified as idiopathic in the past, a possible association between the two in such cases should be considered.     

感染性角膜炎的角膜移植术

目的 评价感染性角膜炎角膜移植治疗的临床效果.方法 采用深板层或穿透性角膜移植治疗真菌性角膜溃疡97例(97眼),病毒性伯膜炎21例(21眼),棘阿米巴性角膜炎3例(3眼),共121例(121眼).临床观察2～20月.结果 119眼角膜植片存活,治愈率98.35%;2例复发,复发率1.65%.结论 对药物治疗无效的感染性角膜炎及时行治疗性角膜移植术,是控制感染,挽救眼球,甚至恢复有用视力的有效方法.     

Medical management approach to infectious keratitis

This section provides guidelines on medical therapy of patients with infectious keratitis. In addition to initial empirical therapy, preferred medications, once the organisms responsible are isolated, are discussed. Atypical mycobacterial keratitis following lasik is described. General guidelines for supportive therapy and follow-up, of these patients are presented. Clinical response to treatment and indications for intervention are discussed. Possible causes and approach to cases refractory to medical therapy are discussed.     

Orthokeratology lens-related Pseudomonas aeruginosa infectious keratitis

PURPOSE: To report a case of orthokeratology lens-related Pseudomonas corneal ulcer in an adult. METHODS: Case report. RESULTS: A 37-year-old man presented with a 1-day history of painful red eye. He was a soft contact lens wearer before he started on nocturnal orthokeratology lens wear of 8 to 10 hours per night 9 months ago. Corneal scraping sent for culture revealed a heavy growth of Pseudomonas aeruginosa. The patient was treated with intensive topical fortified tobramycin and ceftazidime drops. The ulcer healed with a residual paraxial corneal scar. Although his best-corrected visual acuity (BCVA) recovered from finger counting (8/200) at presentation to 20/30, he suffered visual loss from a premorbid BSCVA of 20/15. His contrast sensitivity (Vector Vision CSV 1000 test) performance was also worse than his fellow eye. CONCLUSION: Nocturnal orthokeratology lens wear may be associated with an increased risk of infection.     

感染性角膜炎的隔离管理

目的:规范感染性角膜炎的隔离管理.方法:回顾性分析感染性角膜炎患者在住院期间发生交叉感染的危险因素,探讨现行的隔离管理措施是否有效.结果:隔离管理到位,5年的院感发生率为0.08%.结论:规范感染性角膜炎的隔离管理,能有效地预防医院感染.