Christopher R. Henry

Infectious Keratitis Progressing to Endophthalmitis: A 15-Year Study of Microbiology, Associated Factors, and Clinical Outcomes

PURPOSE To describe the incidence, microbiology, associated factors, and clinical outcomes of patients with infectious keratitis progressing to endophthalmitis. DESIGN Nonrandomized, retrospective, consecutive case series. PARTICIPANTS All patients treated for culture-proven keratitis and endophthalmitis between January 1, 1995 and December 31, 2009, at the Bascom Palmer Eye Institute. METHODS Ocular microbiology and medical records were reviewed on all patients with positive corneal and intraocular cultures over the period of the study. Univariate analysis was performed to obtain P values described in the study. MAIN OUTCOME MEASURES Microbial isolates, treatment strategies, and visual acuity (VA) outcomes. RESULTS A total of 9934 corneal cultures were performed for suspected infectious keratitis. Only 49 eyes (0.5%) progressed to culture-proven endophthalmitis. Fungi (n = 26) were the most common responsible organism followed by gram-positive bacteria (n = 13) and gram-negative bacteria (n = 10). Topical steroid use (37/49 [76%]) was the most common associated factor identified in the current study, followed by previous surgery (30/49 [61%]), corneal perforation (17/49 [35%]), dry eye (15/49 [31%]), relative immune compromise (10/49 [20%]), organic matter trauma (9/49 [18%]), and contact lens wear (3/49 [6%]). There were 27 patients in whom a primary infectious keratitis developed into endophthalmitis, and 22 patients in whom an infectious keratitis adjacent to a previous surgical wound progressed into endophthalmitis. Patients in the primary keratitis group were more likely to be male (22/27 [81%] vs 8/22 [36%]; P = 0.001), have history of organic matter trauma (8/27 [30%] vs 1/22 [5%]); P = 0.030), and have fungal etiology (21/27 [78%] vs 5/22 [23%]; P<0.001). Patients in the surgical wound-associated group were more likely to use topical steroids (20/22 [91%] vs 17/27 [63%]; P = 0.024). A VA of ≥ 20/50 was achieved in 7 of 49 patients (14%), but was <5/200 in 34 of 49 (69%) at last follow-up. Enucleation or evisceration was performed in 15 of 49 patients (31%). CONCLUSIONS Progression of infectious keratitis to endophthalmitis is relatively uncommon. The current study suggests that patients at higher risk for progression to endophthalmitis include patients using topical corticosteroids, patients with fungal keratitis, patients with corneal perforation, and patients with infectious keratitis developing adjacent to a previous surgical wound. Patients with sequential keratitis and endophthalmitis have generally poor visual outcomes. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Epithelial ingrowth after LASIK: clinical characteristics, risk factors, and visual outcomes in patients requiring flap lift.

PURPOSE To describe clinical characteristics, risk factors, and visual outcomes in patients requiring flap lift for epithelial ingrowth following LASIK. METHODS Consecutive, noncomparative, retrospective case series of eyes requiring flap lift for epithelial ingrowth following LASIK from June 2003 through July 2011 at a tertiary care, university-based eye hospital. Main outcome measures were uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) at 1 and 3 months and recurrence of epithelial ingrowth. RESULTS Forty-five eyes were included. Laser in situ keratomileusis retreatment was the most common etiologic factor for epithelial ingrowth (28/45 eyes [62%]). All patients were treated with flap lift and scraping. Mean logMAR UDVA at presentation was 0.28 (Snellen equivalent 20/38). Mean logMAR UDVA at 3 months was 0.17 (Snellen equivalent 20/30) with 53% of eyes 20/25 or better. Mean logMAR CDVA at 3 months was 0.06 (Snellen equivalent 20/23) with 78% of eyes 20/25 or better. Epithelial ingrowth into the central cornea portended a trend towards UDVA worse than 20/25 or worse at 3-month follow-up (hazard ratio [HR] 5.54, 95% confidence interval [CI]: 0.98-31.3, P=.05) and CDVA worse than 20/25 at 3-month follow-up (HR 4.32, 95% CI: 0.85-21.9, P=.08). Recurrence after treatment was 31% at 3 months and 36% at 1 year. Risk factors for recurrence included: infectious etiology of ingrowth (HR 5.7, 95% CI: 1.11-29.1, P=.04), use of microkeratome for primary LASIK (HR 4.64, 95% CI: 1.07-20.1, P=.04), and hyperopic primary LASIK (HR 2.49, 95% CI: 0.98-6.31, P=.06). CONCLUSIONS Patients undergoing flap lift for the treatment of epithelial ingrowth have a relatively high rate of recurrence but good visual acuity outcomes.

Chorioretinal Lesions Presumed Secondary to Zika Virus Infection in an Immunocompromised Adult.

Importance Zika virus has spread rapidly throughout the Americas since 2015. The public health implications of Zika virus infection lend special importance to identifying the virus in unsuspected hosts. Objective To describe relevant imaging studies and clinical features of chorioretinal lesions that are presumably associated with Zika virus and that share analogous features with chorioretinal lesions reported in cases of Dengue fever and West Nile virus. Design, Setting, and Participants This is a case report from an academic referral center in Miami, Florida, of a woman in her 60s from Guaynabo, Puerto Rico, who presented with reduced visual acuity and bilateral diffuse, subretinal, confluent, placoid, and multifocal chorioretinal lesions. The patient was observed over a 5-month period. Main Outcomes and Measures Visual acuity, clinical course, and multimodal imaging study results. Results Fluorescein angiography revealed early hypofluorescence and late staining of the chorioretinal lesions. Optical coherence tomography demonstrated outer retinal disruption in the placoid macular lesions. Zika RNA was detected in a plasma sample by real-time reverse transcription polymerase chain reaction testing and was suspected to be the cause of chorioretinal lesions after other viral and infectious causes were ruled out. Three weeks after the onset of symptoms, the patient’s visual acuity had improved to 20/60 OD and 20/25 OS, with intraocular pressures of 18 mm Hg OD and 19 mm Hg OS. In 6 weeks, the chorioretinal lesions had healed and visual acuity had improved to 20/25 OD and 20/20 OS. Follow-up optical coherence tomography demonstrated interval recovery of the outer retina and photoreceptors. Conclusions and Relevance Acute-onset, self-resolving, placoid, or multifocal nonnecrotizing chorioretinal lesions may be a feature of active Zika virus chorioretinitis, as reported in other Flavivirus infections in adults. Similar findings in potentially exposed adults suggest that clinicians should consider IgM antibody or polymerase chain reaction testing for Zika virus as well as diagnostic testing for Dengue fever and West Nile virus.

Pars plana vitrectomy for vitreous floaters: is there such a thing as minimally invasive vitreoretinal surgery?

Vitreoretinal surgery has undergone remarkable transformations since the first successful pars plana vitrectomy (PPV) was performed by Robert Machemer in 1970. Modern instrumentation and surgical techniques have led to shorter operating times and faster recovery for many patients. This has broadened indications for even lower thresholds of incident visual acuity, but has PPV evolved to the degree to where it can be considered “minimally-invasive?” In the present issue of Retina, Mason et al and Sebag et al describe sutureless, 25-gauge PPV as a successful treatment modality for the management of vitreous floaters associated with posterior vitreous detachment (PVD), myopic vitreopathy, vitreous syneresis, and asteroid hyalosis.[1,2] Both studies report low complications rates and describe a minimalistic approach to surgery that generally involves performing a core vitrectomy, leaving the posterior hyaloid attached in most eyes without pre-existing PVD and preserving the anterior hyaloid face in an attempt to delay cataract formation. More extensive vitreous removal with shaving of the vitreous base is advocated only in cases with retinal breaks. In both of these series, the reported surgical outcomes are favorable. Mason et al retrospectively reviewed 168 eyes of 143 patients undergoing PPV for symptomatic vitreous floaters. Their high surgical success rate was based on 94% of patients rating their experience as a “complete success” and 92% of patients reporting either no symptoms or extremely mild symptoms of floaters after surgery. Complications were relatively few and included 12 eyes (7.1%) with iatrogenic retinal breaks, 2 eyes with transient vitreous hemorrhage, 1 eye with cystoid macular edema, and no eyes with postoperative retinal detachment or endophthalmitis at a mean follow up of 18 months. A visually significant cataract requiring phacoemulsification developed in 9 (16.1%) of the 56 phakic eyes. The authors demonstrated a statistically significant improvement in best corrected visual acuity, which improved from a mean of 20/40 preoperatively to 20/25 postoperatively. In the series by Sebag et al, 76 eyes with symptomatic vitreous floaters underwent PPV. They prospectively evaluated contrast sensitivity in 16 patients and demonstrated a significant improvement using Freiburg Acuity Contrast Testing following surgery. Complete resolution of symptoms was seen in 15/16 (93.8%) patients in this group. Complication rates were retrospectively assessed in 60 patients and were low, with 1 eye (1.7%) developing a macular pucker and no eyes experiencing iatrogenic retinal breaks, vitreous hemorrhage, postoperative retinal detachment or endophthalmitis at a mean follow up of 17.5 months. A visually significant cataract requiring phacoemulsification developed in 8 (23.5%) of the 34 phakic eyes. It is not at all surprising that PPV is successful in resolving symptoms associated with primary vitreous floaters. The most important concern in these patients, however, must be long-term safety. As the authors appropriately emphasize, many of these patients are young, a high percentage are phakic, and nearly all have good preoperative visual acuity, thus there is potential for substantial complications. The excellent surgical outcomes described in these two papers must be contrasted to previous reports in this regard. Two recent large retrospective series out of Europe by De Nie et al and Schulz-Key et al, with longer average follow up of 26.4 and 37 months respectively, report higher complication rates including cataract formation requiring phacoemulsification in 50.0-60.5% of phakic eyes, postoperative retinal detachment in 6.8-10.9% of eyes, and cystoid macular edema in 5.4-5.5% of eyes, some of which was refractory to treatment and resulted in permanent vision loss.[3,4] Other patients lost vision as a result of glaucoma, macular hole formation and photoreceptor disruption. Although patients in these studies underwent primarily 20-gauge and 23-gauge PPV, it is notable that the majority of patients developing retinal detachment did so in a delayed fashion, often years following the original PPV. Tan et al reported a lower retinal detachment rate of 2.5% in a series of mostly 25-gauge PPV cases, but mean follow up was limited to 10.1 months.[5] Additionally, long term data shows an increased risk of open angle glaucoma after pars plana vitrectomy, occurring at a mean of 46 months after surgery in phakic eyes and 18 months in nonphakic eyes.[6] Other rare, but serious risks of PPV include suprachoroidal hemorrhage and endophthalmitis. Furthermore, risks associated with retrobulbar anesthesia should not be dismissed and include vision threatening complications such as retrobulbar hemorrhage, strabismus, and globe perforation as well as life-threatening complications associated with central nervous system spread of anesthesia or adverse reactions to anesthetic agents. Sebag et al suggest that with “modern surgical instrumentation and judicious technique” the risks of surgery can be mitigated and that their study demonstrates that “treating floaters with sutureless 25-gauge vitrectomy without PVD induction can be uniformly safe.” While Mason et al and Sebag et al demonstrate low complication rates in a significant number of eyes, it is important to recognize that these are primarily retrospective studies that are not sufficiently powered to evaluate safety. The authors bring up several other interesting and worthwhile points. Mason et al suggest the following in regards to patients who are bothered by symptomatic vitreous floaters: “From the patients perspective, the ophthalmologist who has ruled out pathology such as retinal breaks has failed to address their health and quality of life.” Here arises the age-old ethical dilemma of balancing beneficence and non-maleficence. As physicians we have an obligation to acknowledge and to be responsive of patient concerns. On the other hand, we have a commitment to our patients to first do no harm. Is a reduction in contrast sensitivity enough of an indication to support this procedure, when a patient has excellent visual acuity? Additionally, patients with vitreous floaters often improve spontaneously as they gravitate out of the visual axis, as opacities move anteriorly and out of focus with progressive vitreous collapse, or as individuals’ psychophysical attention is no longer stimulated as strongly. Subjecting patients to surgery may place them at unnecessary risk when they may have improved with observation alone. The authors of these studies cite impairment in activities of daily living (Mason et al and Sebag et al), contrast sensitivity (Sebag et al) or well-being (Sebag et al) as the primary inclusion criteria for surgical intervention. It is somewhat surprising, however, that hundreds of patients presenting to these centers, over a short time period, would be impaired to the extent that PPV is required. The potential for severe complications should give patients and surgeons a reason to pause before undertaking this procedure for modest levels of functional impairment. In the case of a patient with symptomatic vitreous floaters, we must seek to understand their degree of impairment and to weigh these concerns against potentially-blinding risks of PPV. As the authors in both studies emphasize, vitreous floaters can have a negative impact on quality of life.[1-5,7-8] In fact, a utility analysis performed by Wagle et al found that patients with floaters were willing to trade away an average of 1.1 out of every 10 years of their remaining life to get rid of their floaters, and were willing to take an 11% risk of death and a 7% risk of blindness to get rid themselves of symptoms associated with vitreous floaters.[7] Previous data also demonstrates, using National Eye Institute Visual Function Questionnaire-39, that general vision, near activities, distance activities, and mental health significantly improve in selected patients undergoing PPV for floaters.[9] But, as Mason et al are careful to point out, only in a minority of patients with symptomatic vitreous floaters will activities of daily living be significantly affected. While PPV should be considered in this small subset of patients, it is important that these patients receive proper informed consent in regards to the risks of PPV. This group of patients might be fertile for abuse. One wonders if this movement will evolve to the point where we see the retina specialist advertising “floaterectomies” on billboards or offering office-based PPV for “simple cases” such as these. Only time will tell. However, we do know that all cases of PPV are associated with potential ocular, anesthetic, and systemic risks. Therefore, retina specialists need to be careful in referring to PPV as “minimally-invasive.” Such language has the potential to trivialize the performance of PPV and does a disservice to our profession and our patients. The overriding principle must be good principles.

Delayed-onset endophthalmitis associated with corneal suture infections.

BackgroundThe purpose of the current study was to report the microbiology, risk factors, and treatment outcomes in patients with delayed-onset endophthalmitis associated with corneal suture infections. For this retrospective consecutive case series, a search of the ocular microbiology department database was performed to identify all patients with positive corneal and intraocular cultures (anterior chamber and/or vitreous) between 01 January 1995 and 01 January 2010. A subset of patients with a history of corneal suture infections and delayed-onset endophthalmitis was identified.ResultsOver the 15-year period of the study, 68 patients were identified to have both positive corneal and intraocular cultures. Among them, six patients were identified to have a culture-proven, delayed-onset endophthalmitis that developed from a culture-positive corneal suture infection. All of the patients in the current study were using topical corticosteroids at the time of diagnosis. In four of six patients, there was documented manipulation of a suture before the development of endophthalmitis. Streptoccocus was identified as the causative organism in five of six patients in the current study. All of the Streptoccocus isolates were sensitive to vancomycin. The single case of Serratia marcescens endophthalmitis was sensitive to amikacin, ceftazidime, ciprofloxacin, gentamicin, and tobramycin. Treatment modalities varied and were guided by the attending ophthalmologist depending upon clinical presentation. One patient with severe Streptococcus pyogenes keratitis and endophthalmitis underwent a primary enucleation after developing a wound dehiscence. Of the remaining five patients, all received topical and intravitreal antibiotics. Therapeutic penetrating keratoplasty was performed in three patients. Pars plana vitrectomy was performed in two patients. Visual acuity outcomes ranged from 20/150 to no light perception.ConclusionsIn the current study, Streptococcus was isolated in nearly all patients with delayed-onset endophthalmitis associated with corneal suture infections. Topical steroid use and suture manipulation were identified as associated factors for developing endophthalmitis. Visual acuity outcomes were poor despite the prompt recognition of endophthalmitis and appropriate antibiotic therapy.

Successful treatment of juvenile xanthogranuloma using bevacizumab

Juvenile xanthogranuloma (JXG) is an uncommon non-Langerhans cell histiocytic disorder that occurs predominantly in infants. Traditional treatment of ocular JXG involves the administration of topical or local corticosteroids. We treated 2 children with JXG refractory to local corticosteroid therapy with off-label intraocular bevacizumab. To our knowledge, this is the first report of successful use of bevacizumab for ocular JXG.

Role of steroids in the treatment of bacterial keratitis

Bacterial keratitis can lead to severe visual impairment from corneal ulceration, subsequent scarring, and possible perforation. The mainstay of treatment is topical antibiotics, whereas the use of adjunctive topical corticosteroid drops remains a matter of debate. Herein, we review the rationale for and against the use of topical corticosteroids and we assess their effectiveness and safety in the published randomized controlled trials that have evaluated their role as adjunctive therapy for bacterial corneal ulcers. In the largest study to date, the Steroids for Corneal Ulcers Trial, topical corticosteroid drops were neither helpful nor harmful for the 500 participants as a whole. However, subgroup analyses suggested that topical corticosteroids may be beneficial upon early administration (within 2–3 days after starting antibiotics) for more central corneal ulcers with poorer vision at presentation, for invasive Pseudomonas strains, and for non-Nocardia ulcers. These results are discussed within the limitations of the study.

Endophthalmitis following pars plana vitrectomy for vitreous floaters

A case of Staphylococcus caprae endophthalmitis in a young patient following pars plana vitrectomy for symptomatic vitreous floaters is reported here. Recent literature suggests that there is an increasing trend of performing pars plana vitrectomy for symptomatic floaters. Although rare, the potential risk of endophthalmitis should be explicitly discussed with patients considering surgical intervention for vitreous floaters.

Fluorescein angiography findings in phacomatosis pigmentovascularis

The authors report the fluorescein angiography findings in a 3-month-old patient with phacomatosis cesioflammea, which revealed venous-venous anastomoses in addition to previously undescribed features of peripheral retinal vascular nonperfusion. The authors encourage physicians to consider phacomatosis pigmentovascularis in the differential diagnosis of patients presenting with facial port-wine stain and to screen these patients for peripheral retinal avascularity in addition to glaucoma and primary uveal melanoma.

Clinical outcomes of 4-point scleral fixated 1-piece hydrophobic acrylic equiconvex intraocular lens using polytetrafluoroethylene suture

Purpose To report the visual outcomes and complications of scleral fixated intraocular lenses (IOLs) using Gore-Tex suture. Methods The current study is a retrospective noncomparative case series including patients who underwent scleral fixation of IOL (Akreos AO60) using Gore-Tex suture from August 2015 to March 2017 at a university teaching center. Primary outcome measures were visual acuity and complications at last follow-up. Results The current study included 49 eyes of 48 patients. Mean follow-up duration postsurgery was 6.9 months (range: 0.9–29.4 months). The indications for secondary IOL surgery were dislocated IOL in 16/49 (33%), subluxed IOL in 9/49 (18%), dislocated or subluxed crystalline lens in 9/49 (18%), traumatic cataract in 8/49 (16%), and complicated cataract surgery in 7/49 (14%). Mean best-corrected logMAR visual acuity improved from 1±0.7 (20/200 Snellen equivalent) preoperatively to 0.5±0.5 (20/63 Snellen equivalent) at last follow-up. There were no intraoperative complications noted. Early postoperative complications included significant persistent corneal edema (longer than 1 week) in 4/49 (8.2%), ocular hypertension (intraocular pressure ≥25 mmHg) in 8/49 (16.3%), hypotony (intraocular pressure ≤5 mmHg) in 6/49 (12.2%), cystoid macular edema 3/21 (6.1%), IOL tilt 2/49 (4.1%), hyphema in 2/49 (4.1%), and vitreous hemorrhage in 5/49 (4.8%). There was one case of recurrent retinal detachment. One patient presented with an erosion of the Gore-Tex suture through the conjunctiva resulting in a purulent scleritis 6 months after the initial surgery, and was managed with removal of the IOL, debridement, and cryotherapy. Forty-one of 49 patients completed 3-month follow-up, among which visual acuity improved, deteriorated, or remained same compared to baseline in 27/49 (55.1%), 8/49 (16.3%), and 6/49 (12.2%) eyes, respectively. Conclusion In the current study, visual acuity outcomes were generally favorable. The complications were largely transient. Significant complications included a suture-related infection, which required removal of the IOL, and a recurrence of a retinal detachment.