Frederick H. Theodore

The Diagnostic Value of a Ring Infiltrate in Acanthamoebic Keratitis

During the past ten years it has become increasingly apparent that acanthamoebae can directly infect the cornea, usually after trauma, associated with contaminated water or soft contact lens wear. Thirteen cases of acanthamoebic keratitis have been published. In only three of these cases was the diagnosis first made by microbiologic methods, while in the others it was made only after pathologic examination of resected corneal specimens or enucleated eyes. We report three additional cases, two of which were accurately diagnosed by corneal scrape-smears and cultures before penetrating keratoplasty was performed. The reason for the accurate laboratory diagnosis in these cases was the presence of a diagnostic paracentral annular corneal infiltrate or abscess, a feature identified in over two-thirds of the earlier cases but one which has not been adequately emphasized or pursued for its early diagnostic value. We review the other clinical and epidemiological features of this entity, microbiological diagnostic techniques, the pathologic aspects, the role of topically and systemically administered medicaments, and finally point out the almost unavoidable role of penetrating keratoplasty after the temporizing effects of medical treatments have been achieved.

Contact Lens Induced Keratopathy: A Severe Complication Extending the Spectrum of Keratoconjunctivitis in Contact Lens Wearers

A 21-year-old woman developed bilateral keratoconjunctivitis from contact lens wear, which progressed to diffuse corneal scarring and vascularization after the patient refused to discontinue wearing contact lenses. The visual disturbance became so severe that a penetrating keratoplasty had to be performed in one eye for visual rehabilitation. Examination of the penetrating keratoplasty specimen disclosed destruction of Bowmans membrane throughout the superior half of the cornea, which was replaced by a fibrous scar that was only midly chronically inflamed. Deep vascularization occurred within the stroma. This case represents an extreme expression of a recently characterized syndrome consisting of conjunctival and corneal changes in patients who may be allergic to contact lenses or the solutions used in conjunction with their care. In the milder end of the spectrum, there is superior epibulbar conjunctival injection with associated tarsal injection, and a mild superficial punctate keratopathy without filaments. Some earlier workers have termed this syndrome a variant of superior limbic keratoconjunctivitis in association with contact lens wear, but this leads to confusion with Theodores classical superior limbic keratoconjunctivitis, to which the present entity bears no etiologic relationship; it also fails to show many of the findings of Theodores disease. In mild cases, we would recommend the term contact lens-induced keratoconjunctivitis, and in the more severe cases, such as demonstrated by our patient, we would suggest the term contact lens-induced keratopathy.

Etiology and diagnosis of fungal postoperative endophthalmitis.

Delayed infections after ocular surgery (especially cataract) are usually due to saprophytic contaminant fungi of relatively low pathogeneicity. About 20 different varieties of fungi have been cultured from such eyes. Thus, as far as the eye is concerned, there is no such thing as a harmless, benign fungus. Mycotic postoperative endophthalmitis is a distinct entity with a typical clinical picture, easily diagnosed once learned. Laboratory tests are often positive. Since the visual result is poor even if the eye is saved, prevention and early recognition are our primary concerns. In this regard, a recent episode of 12 infections from contaminated intraocular lens neutralizing solutions as well as other sporadic instances of fungal infection after lens implantation must be noted.