Amir A. Azari

Seasonal, geographic, and antimicrobial resistance patterns in microbial keratitis: 4-year experience in eastern Pennsylvania.

Purpose: The aim of this study was to review the demographics, causative organisms, seasonal and geographic variation, and antimicrobial resistance patterns of microbial keratitis at our institution over a 4-year period. Methods: Electronic medical records of all patients with microbial keratitis who underwent corneal culturing at a single institution in eastern Pennsylvania between January 1, 2009 and December 31, 2012 were reviewed. Results: A total of 311 patients representing 323 instances of infectious keratitis were analyzed. The most frequently implicated organisms in contact lens-related infections were Pseudomonas aeruginosa for bacteria and Fusarium species for fungus, compared with Staphylococcus aureus and Candida species in non–contact lens-associated bacterial infections. Bacterial keratitis occurred most frequently in spring and least frequently in winter (P = 0.024). Patients who live in large fringe metro (suburban) areas accounted for the highest proportion of infectious keratitis cases. P. aeruginosa and methicillin-sensitive S. aureus isolates were highly susceptible to fluoroquinolones, whereas 32% of coagulase-negative staphylococcus isolates tested were resistant to moxifloxacin and gatifloxacin, and all methicillin-resistant S. aureus organisms tested were resistant to these 2 fluoroquinolones. No organisms tested were resistant to tobramycin, gentamicin, or vancomycin. No fungal infections tested were resistant to voriconazole. Conclusions: Most infectious keratitis occurred in nonwinter months and in patients from suburban counties. Although fluoroquinolones were effective against the most common bacteria, staphylococcal species exhibited a high rate of resistance, representing a therapeutic challenge given the increasing use of fluoroquinolones as first-line monotherapy. No organisms tested were resistant to tobramycin, gentamicin, vancomycin, or voriconazole.

Autologous serum eye drops for the treatment of ocular surface disease.

Objective: To examine the evidence for the role of autologous serum eye drops (ASD) in disease of the ocular surface. Methods: A search of the literature published through May 2014 using PubMed, the ISI Web of Knowledge database, and the Cochrane Library was performed. Qualified articles were selected after review of titles, abstracts, and references. Results: There was a significant improvement in either symptoms or some of the clinical examination findings, including tear breakup time, corneal staining, Schirmer values, and impression cytology in eyes with persistent corneal epithelial defect, graft-versus-host disease, Sjögren- and non–Sjögren-related dry eye disease, limbal stem-cell deficiency, recurrent corneal erosion, superior limbic keratoconjunctivitis, and postrefractive surgery. However, most of the studies were nonrandomized in nature. Conclusions: Despite the paucity of strong supporting evidence from randomized double-masked clinical studies, there seems to be a trend toward superiority of ASD in alleviating some of the clinical signs and symptoms associated with corneal pathology in a variety of conditions that affect the ocular surface compared with conventional lubricating drops/ointments.

Safety and efficacy of autologous serum eye drop for treatment of dry eyes in graft-versus-host disease.

Abstract Purpose: To evaluate the treatment of autologous serum eye drops (ASED) on dry eyes in patients with graft-versus-host disease (GVHD). Methods: A retrospective chart review of 35 patients with a history of ocular GVHD following hematopoietic stem cell transplantation that used ASED to alleviate dry eye symptoms was performed. Patients were categorized into three different groups. If patients had available ophthalmic data before and after starting treatment was group 1 (n = 14), had available ophthalmic data after starting treatment in group 2 (n = 10) and had available ophthalmic data before treatment or did not have any data after starting treatment in group 3 (n = 11). Data were collected on patient’s age, gender, primary diagnosis, visual acuity and fluorescein corneal staining were collected on individual eyes in order to evaluate the efficacy of the ASED on alleviating dry eye-related signs and symptoms. Results: No adverse ocular effect from the ASED was found in our series (except one fungal keratitis). All patients reported either improvement (55%) or stability (45%) in their ocular symptoms upon the use of ASED. In patients with available data before and after starting treatment, the corneal staining score improved by a median of 1 (p = 0.003) and the LogMAR visual acuity had a non-significant improvement. Conclusion: In our study, ASED used by patients with ocular GVHD were both safe and effective. ASED should be considered in patients with GVHD who suffer from dry eyes.

Outcomes of Wound Dehiscence Post Penetrating Keratoplasty

Purpose: Penetrating keratoplasties (PKs) carry a lifetime risk of developing wound dehiscence, which can lead to severe consequences to vision. To better understand the risk, we analyzed the characteristics and outcomes of a series of patients with wound dehiscence post-PK. Methods: Data were collected retrospectively on 31 eyes from 30 patients with a history of wound dehiscence repair post-PK between January 1, 2009, and April 30, 2014, and followed up at the Cornea Service at Wills Eye Hospital. Only patients who had surgical repair of an open wound dehiscence were included, excluding those with wound slippage but no aqueous leak. Results: The mean age at wound dehiscence was 56 years with a mean time from PK to dehiscence of 9.8 years. Among the 31 eyes, 26 (26/31, 84%) had trauma-induced dehiscence, while 5 had unknown causations or no reported trauma. The mean size of dehiscence was 153 ± 66 degrees. Visual outcomes ranged from 20/50 to no light perception, with a majority between 20/100 and hand motion (18/30, 60%). Twenty eyes (20/26, 76%) lost their lens at dehiscence. All 10 phakic eyes lost their lenses. Five patients retained their lens implants and had a better mean visual outcome (average = 20/400) than the 10 patients who lost their implants (average = 20/800) (1 lens status was unknown postdehiscence). Conclusions: Wound dehiscence is a lifelong risk after PK regardless of the age, indication for corneal transplant, and time since transplant. A better visual outcome was associated with retained pseudophakia and clear corneas.

Complications in DSEK: Prevention and Management

Endothelial keratoplasty, most commonly Descemet’s stripping endothelial keratoplasty (DSEK), has become the procedure of choice for endothelial diseases. DSEK provides many unique advantages compared to traditional penetrating keratoplasty; these includes smaller risk of suprachoroidal hemorrhage during the surgery, minimal to no induced astigmatism, lower chance of wound dehiscence, and lower rates of rejection. However, DSEK carries its own set of specific risks and complications. Most common complications of DSEK surgery are posterior graft dislocation, glaucoma, and endothelial graft rejection. Other complications include graft folds, graft interface opacity, decentered graft, epithelial downgrowth, and endophthalmitis. Some of these complications may be encountered more frequently with certain surgical techniques. For example, a large clear corneal incision carries a higher risk of induced astigmatism and epithelial downgrowth than a more peripheral scleral tunnel incision. The risk of epithelial downgrowth is also increased if corneal venting incisions are made. There may be a greater risk of endothelial damage in bifold and push through techniques compared to when special insertion devices are used during the surgery [1]. In this chapter, we will explore some of the more frequently encountered complications in DSEK that may occur in various stages of the surgery as well as in the postoperative course. Predisposing factors that lead to complications and ways to prevent them will also be discussed. In addition, appropriate management of the complications when they do occur will be described.

Trocar-Assisted, Sutureless, Scleral-Fixated Intraocular Lens Implantation Combined With Penetrating Keratoplasty.

Purpose: To evaluate the results of trocar-assisted, sutureless, scleral-fixated (SSF) intraocular lens (IOL) implantation combined with penetrating keratoplasty (PKP). Methods: This study comprised 4 eyes (4 patients) undergoing trocar-assisted SSF-IOL implantation during PKP. The combined technique was performed in 3 eyes of 3 patients with bullous keratopathy and in 1 eye with central corneal opacity. Two eyes had anterior chamber IOL implants, and 2 were aphakic. All eyes had inadequate capsular support. Evaluated parameters were biomicroscopy, corrected distance visual acuity, intraocular pressure, IOL position, and corneal graft status. Intraoperative and postoperative complications and additional surgeries were recorded. Results: The mean follow-up period was 28.3 ± 3.5 months. Trocar-assisted SSF-IOL implantation with PKP was successfully performed in all eyes. Visual acuity improved in all patients. During the follow-up period, a well-stabilized IOL without any IOL-related complication was obtained in all eyes. In one eye with corneal scarring and aphakic glaucoma caused by trauma, drug-resistant glaucoma developed 6 months after surgery requiring Express glaucoma shunt surgery. In one eye with a history of central retinal vein occlusion, repeat keratoplasty was performed after 10 months because of graft rejection. Conclusions: Trocar-assisted SSF-IOL implantation combined with PKP is an alternative method for visual rehabilitation in the eyes with bullous keratopathy and corneal scarring without sufficient capsular support.

Fyodorov–Zuev Keratoprosthesis

Fyodorov–Zuev keratoprosthesis is one of the oldest designs for the artificial cornea. This implant was developed in Russia and it is widely used in Russia and China but not well known to the rest of the world. The implant consists of a titanium plate which is embedded within the corneal stroma and an optical cylinder which is in contact with the aqueous humor in one end and tear film in the other end. The surgery can be performed either in a single stage or in two separate stages separated by 3 months. The implant is generally offered to patients with history of multiple failed corneal transplants. Over 90 % of patients experience an improvement in vision. Graft retention is over 70 % for patients undergoing Fyodorov–Zuev keratoprosthesis. The complications include aqueous leak, granulation tissue overgrowth, uveitis, endophthalmitis, and glaucoma.