Keratomycosis and keratoplasty

Three cases of corneal perforation in keratomycosis are reported. In the first two cases the etiological diagnosis had been made from the anatomo-pathological examination of the excised corneal buttons. The mycotic origin in the third case was known before perforation from corneal cultures. Although the prognosis of this condition is usually poor, the post-keratoplasty evolution in the three cases was uncomplicated. The authors analyse the peculiarities of corneal mycotic abscess and discuss the appropriate diagnostic approach and management. Treatment must be performed before intraocular mycotic invasion occurs, because of the poor intraocular diffusion of antifungal agents. In this case, penetrating keratoplasty is not as dangerous as previously reported; and moreover, allows simultaneous treatment of the mycosis and the anatomical and functional repair of the cornea.     

Fresnel membrane prisms: clinical experience

BACKGROUND: There are few published reports on the clinical application of Fresnel membrane prisms in the treatment of diplopia in adults. The authors describe the use of these prisms in patients with fourth and sixth cranial nerve palsies, restrictive motility caused by thyroid-related orbital disease, and convergence insufficiency. METHODS: Of 209 patients who had been treated with Fresnel prisms, 141 were selected. The database included patients from a private practice in Montreal, seen from 1988 to 1996, and patients seen by orthoptists in the ophthalmology department of a children's hospital in Montreal between 1992 and 1996. All the patients had diplopia associated with fourth (48 patients) or sixth (43 patients) cranial nerve palsy, thyroid-related orbitopathy (18 patients) or convergence insufficiency (32 patients). After qualitative and quantitative assessment of the ocular misalignment, a Fresnel prism was selected for power and axis and for appropriate location on the spectacle lens. Ocular dominance and side of paresis or restriction were also considered in the placement of the prism. The patient's response to treatment was documented. RESULTS: The Fresnel prisms were oriented horizontally in 72 patients (51%), vertically in 55 (39%) and obliquely in 14 (10%). They were placed on the spectacle lens before the nondominant eye in 127 cases (90%), either covering the entire lens, or on the upper or lower segment or both. The patients were followed for an average of 15 (range 2 to 96) months. Of the 141 patients 113 (80%) had a successful outcome, with relief of their diplopia. Twenty-seven patients (19%) eventually had the prismatic correction ground into the lens, 70 (50%) chose to wear the Fresnel prism on a permanent basis because incorporation into the lens was not possible or because of cost, and 17 (12%) used the Fresnel prism as a temporary device before or after surgery. Most patients who converted to incorporated prisms did so when the prismatic power became stable, usually after 6 to 8 months. Eight patients (6%) stopped using the prism because of associated side effects, such as blurred vision, persistent diplopia, torsion or optical aberrations. INTERPRETATION: The Fresnel prism is an excellent device in treating diplopia in adult patients. It is a reasonable permanent option when incorporating the prism into the spectacle lens is not possible. A fused blurred image caused by a Fresnel prism placed in front of the nondominant eye is preferable to double but clear images.     

Keratomycosis caused by Acremonium Recifei,treated with keratoplasty,Miconazole and Ketoconazole

A patient is discussed who developed a fungal corneal ulcer due to Acremonium (Cephalosporium) Recifei after a piece of a coconut flew into his eye while he was cracking it. Treatment consisted of keratoplasty, Miconazole as ointment and intravenously, and Ketaconazole orally. Diagnosis and treatment of fungal corneal ulcers are discussed briefly.     

3 years' clinical experience with IOGEL lenses

A total of 63 IOGEL PC-12 and 12 IOGEL 1103 intraocular lenses have been implanted at Lausanne and Basle University Eye Hospitals, and followed up for up to 3 years. In general, the functional and anatomic results are good. From a comparison of the behavior of IOGEL lenses implanted in the sulcus and capsular bag it is concluded that given a suitable surgical technique the IOGEL 1103 lens with implantation in the capsular bag may be recommended.     

Candida interface keratitis after deep anterior lamellar keratoplasty: clinical, microbiologic, histopathologic, and confocal microscopic reports

PURPOSE: To report the clinical, histopathologic, microbiologic, and confocal microscopic features of Candida keratitis after deep anterior lamellar keratoplasty (DALK). METHODS: We performed clinical, confocal scan, microbiologic and histopathologic examinations on two corneas from 2 young patients who underwent DALK for keratoconus. RESULTS: The first patient presented with asymptomatic white to cream-colored interface deposits 2 months after DALK. The confocal scan disclosed clusters of hyperreflective, fine granular deposits at the region of interface, with no evidence of inflammation or hyphaelike structures. The clinical presumption of possible "epithelial downgrowth" was suggested, and because of the progression of these lesions, irrigation of the interface was considered. Finally, penetrating keratoplasty was performed because of a rupture in the Descemet membrane. Histopathologic examination of the cornea disclosed yeastlike structures within the interface area. The microbiologic results of the irrigation fluid showed Candida glabrata. The second patient presented with a symptomatic infiltration of the inferior interface close to the suture site 2.5 months after DALK. The confocal scan showed foci of inflammation with clusters of hyperreflective round-shaped structures that resembled epithelial cells. Clinically, there was a suggestion of epithelial downgrowth, and subsequently, penetrating keratoplasty was performed because of the progression of the lesion. Histopathologic examination of the cornea disclosed an acute and chronic granulomatous keratitis caused by yeastlike structures. The microbiologic results revealed infection with Candida albicans. CONCLUSIONS: These are the first reported occurrences of interface Candida keratitis after DALK and with different confocal features. The clinical and the confocal features of interface Candida keratitis may be similar to those seen in epithelial downgrowth, which may postpone correct diagnosis and treatment. Candida keratitis should be considered in cases of interface deposits after any form of lamellar keratoplasty.     

Keratomycosis--a retrospective histopathologic and microbiologic analysis

In this retrospective study, the results of concurrent histopathologic and microbiologic examinations of 61 corneal buttons were evaluated. These revealed histologic fungus identification in 77.04% of cases compared with culture examination which yielded fungal growth in 75.4% of cases. Mixed fungal and bacterial infection caused difficulty not only in isolation but also in demonstrating fungus in the tissue sections. Staphylococcus epidermidis was the most common isolate in cases of mixed infection. Aspergillus was the most prevalent nondematiaceous fungus. Dematiaceous fungi were isolated in culture in only 10.8% of our cases, and in none of them was the histopathology positive, indicating that they might have been contaminants.     

Pigmented plaque presentation of dematiaceous fungal keratitis: a clinicopathologic correlation

PURPOSE: To evaluate the clinical, microbiologic, and histopathologic features of dematiaceous fungal keratitis cases presenting with pigmented, raised, plaque-like infiltrate. STUDY DESIGN: Consecutive case series. METHODS: Microbiology-proven cases of fungal keratitis presenting with a pigmented infiltrate were included in the study. A detailed clinical and microbiological evaluation was performed in all cases. The lesion was removed by superficial keratectomy, and the specimen was subjected to histopathologic examination. Patients presenting with a large infiltrate had penetrating keratoplasty, and the corneal button was submitted for histopathology examination. RESULTS: We enrolled 15 cases in the study. There were 11 men and 4 women. The mean age of the patients was 48.5 years (range 27-68 years). The patients presented to us with duration of symptoms ranging from 7 to 60 days (mean 27.6 +/- 15.6, median 30). The visual acuity was better than 20/200 in 9 (60%) cases. The infiltrate size varied from 4.3 to 64 mm2 (mean 26.9 +/- 16.6, median 22.5). Ten (66.7%) cases had a central infiltrate. The infiltrate was dry and raised, with brown to black pigmentation on its surface. Corneal scrapings revealed septate fungal filaments in all cases and the characteristic brown to black pigmentation of the fungal cell wall in 10 (66.7%) cases. Although there was a significant growth of dematiaceous fungi on culture in all cases, species identification could be done in 3 cases only. Examination of tissue sections revealed a carpet of pigmented fungal filaments on the corneal surface (n = 12, 92.3%) associated with mild to moderate inflammation (n = 11, 84.7%) and tissue destruction. Nine out of 11 cases that had keratectomy resolved with medical therapy. CONCLUSIONS: The pigmented plaque-like infiltrate in dematiaceous fungal keratitis consists of surface colonization of pigmented fungal filaments associated with mild to moderate inflammation and tissue destruction of the underlying corneal stroma.     

Endophthalmitis after penetrating keratoplasty: microbiologic spectrum and susceptibility of isolates

PURPOSE: To present the microbial spectrum and susceptibilities of isolates in endophthalmitis following penetrating keratoplasty. DESIGN: Interventional case series. METHODS: The 1,074 consecutive cases of endophthalmitis presenting to Wills Eye Hospital between 1989 and 2000 were reviewed. Fourteen patients with endophthalmitis after penetrating keratoplasty were identified, and vitreous biopsy isolates from these patients were examined. RESULTS: Eleven (78.6%) of 14 vitreous samples were culture-positive, and two others (14.3%) had organisms viewed on pathology specimen, for a total of 13 (92.9%) organism-proven cases of endophthalmitis. Isolates included 10 (76.9%) gram-positive cocci (six Streptococcus sp., three Staphylococcus sp., one identified on pathology specimen only) and three (23.1%) gram-negative organisms (Proteus mirabilis, Serratia marcescens, one identified on pathology specimen only). Susceptibilities to organism-appropriate antibiotic testing are reported, including cefazolin (six of eight, 75.0%), ciprofloxacin (four of seven, 57.1%), nafcillin (four of six, 66.7%), and vancomycin (seven of seven, 100.0%). CONCLUSION: This is the largest series on microbial susceptibilities in postpenetrating keratoplasty endophthalmitis. We report a high percentage of culture-positivity, and a high incidence of gram-positive species, and in particular Streptococcus species, with all tested gram-positive organisms susceptible to vancomycin.     

First clinical experience with anecortave acetate (Retaane)

BACKGROUND: Anecortave acetate is an angiostatic cortisene which is injected as a posterior juxtascleral depot and has been shown to be effective in the treatment of exudative age-related macular degeneration (AMD). The compound is not yet approved in Switzerland but can be used as "compassionate use" in individual cases. PATIENTS AND METHODS: An uncontrolled case series with standardised documentation of ETDRS visual acuity, near acuity, need for magnification and fluorescein angiography was performed. RESULTS: 22 eyes of 19 patients (8 male, 11 female, average age 78.8 years) were treated with a posterior juxtascleral depot injection (PJD) of 15 mg anecortave acetate. The mean change in visual acuity after 3 months in eyes treated with anecortave acetate was -2.6 ETDRS letters corresponding to 0.52 Snellen lines. 3/20 eyes gained more than 1 line. 11/20 eyes showed stable visual acuity (+/- 1 Snellen line, +/- 5 ETDRS letters). 5/20 eyes developed moderate vision loss (one to two Snellen lines, 6-10 ETDRS letters). 1/20 lost 18 ETDRS letters (> 3 Snellen lines). There were no moderate or severe adverse events. CONCLUSIONS: A PJD of 15 mg anecortave acetate is safe and well tolerated. In eyes with occult CNV without recent progression or with residual neovascular activity after photodynamic therapy anecortave acetate may be an alternative therapeutic option before considering intravitreal anti-VEGF agents due to the much less invasive character and lower risk profile.