I. J. Udell

Visual Outcome and Bacterial Sensitivity After Methicillin-Resistant Staphylococcus aureus–Associated Acute Endophthalmitis

PURPOSE To determine the frequency, visual outcome, and bacterial sensitivity in cases of methicillin-resistant Staphylococcus aureus (MRSA)-associated acute postoperative endophthalmitis occurring after cataract surgery. DESIGN Retrospective, consecutive, observational case series. METHODS Sixty-four cases of acute endophthalmitis occurring within six weeks after cataract surgery were identified over a three-year interval at a single vitreoretinal practice. Cases related to MRSA were studied and visual outcomes and bacterial sensitivities were recorded. RESULTS Thirty-three of the 64 eyes were culture positive, and six of the 33 cases (18.2%) demonstrated MRSA infection. All six eyes were started on fluoroquinolone antibiotics two or three days before surgery. Corneal abnormalities were noted in five of the six cases (83.3%), ranging from wound infection to diffuse corneal opacification. Visual acuity at last follow-up was no light perception (NLP) in two eyes, hand movements in two eyes, and 20/30 or better in two eyes. One eye with NLP vision underwent enucleation within three days of presentation because of panophthalmitis and impending sepsis. All six organisms were sensitive in vitro to both gentamicin and vancomycin. No organism was sensitive to any fluoroquinolone antibiotic, although not all organisms were tested against all fluoroquinolones. CONCLUSIONS MRSA infection accounts for 18% of culture-positive cases of endophthalmitis in this study and was associated with a poor visual outcome in two-thirds of our patients. MRSA organisms may be resistant in vitro to all generations of fluoroquinolone antibiotics, but do seem to be sensitive to gentamicin and vancomycin. The incidence of MRSA endophthalmitis seems to have increased significantly since the Endophthalmitis Vitrectomy Study was published in 1996.

Paraproteinemic Keratopathy: The Expanding Diversity of Clinical and Pathologic Manifestations.

PURPOSE To describe 7 patients with paraproteinemic keratopathy and to highlight the clinical and pathologic diversity of this rare entity and the importance of timely, systemic evaluation. DESIGN Retrospective, multicenter collaborative case series. PARTICIPANTS Seven patients with paraproteinemic keratopathy. METHODS Clinical and pathologic records were reviewed to identify patients with well-documented corneal immunoglobulin deposits. Detailed ophthalmologic and medical histories were assembled. In 6 patients, corneal tissue was evaluated histochemically and immunohistochemically; in selected cases, corneal tissue was evaluated by in situ hybridization and ultrastructurally. MAIN OUTCOME MEASURES Visual acuity and anterior segment examination at presentation and follow-up; local therapy; systemic diagnosis and management; and histopathologic, immunohistochemical, in situ hybridization, and ultrastructural findings. RESULTS Seven patients were identified with corneal immunoglobulin deposition. In addition to previously reported crystalline, nummular, patch-like, and lattice-like corneal opacities, prominent corneal vascularization was present in 2 patients mimicking interstitial keratitis and limbal stem cell deficiency. All patients had evidence of paraproteinemia in a setting of monoclonal gammopathy of undetermined significance, smoldering plasma cell myeloma, or Waldenström macroglobulinemia. Corneal findings were the first manifestation of systemic disease in 4 patients, and the diagnosis was not suspected in 3 of these patients. Pathologic evaluation of biopsied corneal and conjunctival tissues demonstrated immunoglobulin deposits. Previously unreported ultrastructural patterns in the cornea were noted: large scroll-like immunotactoid deposits, immune complex-like deposits, and randomly arranged fibrils morphologically intermediate between amyloid and immunotactoid deposits. Surgical intervention to improve vision was performed in 4 patients, with recurrence of deposits in 3 patients. Three patients underwent systemic therapy with diminution of the deposits and improvement in vision in 1 patient. CONCLUSIONS The clinical and pathologic expressions of corneal immunoglobulin deposits are protean and present a diagnostic challenge. Early recognition of this rare entity is important to address the potentially serious associated systemic disease.

Spontaneous Descemet Membrane Detachment 20 Years After Penetrating Keratoplasty for Keratoconus.

Purpose: To report 2 cases of spontaneous Descemet membrane (DM) detachment 20 years after penetrating keratoplasty for keratoconus. Methods: A retrospective chart review of 2 patients was performed. Results: Two male patients—ages 59 and 50—presented 21 and 25 years, respectively, after uncomplicated penetrating keratoplasty for keratoconus, complaining of foreign body sensation. Best-corrected vision was 20/40 and 20/30, respectively. For both patients, slit-lamp examination revealed peripheral corneal thinning and steepening and temporal peripheral microcystic edema of the graft without any sign of rejection. Subsequent anterior segment optical coherence tomography demonstrated a DM detachment localized to the area of the corneal edema. One patients DM failed to reattach after anterior chamber air injection and he then underwent successful Descemet stripping automated endothelial keratoplasty with resultant best-corrected vision of 20/20. The other patient failed mechanical incision at the graft–host interface with air injection for possible retrocorneal membrane and then successfully underwent a sequential cataract and Descemet stripping automated endothelial keratoplasty with visual acuity of 20/30. Conclusions: Spontaneous DM detachment more than 2 decades after uncomplicated penetrating keratoplasty for keratoconus is a previously unrecognized entity. Novel imaging modalities such as anterior segment optical coherence tomography should be used to identify this clinically difficult to detect etiology of microcystic corneal edema. The cause of DM detachment is unclear, but it may be because of mechanical forces from a retrocorneal membrane or from progressive keratoconus leading to peripheral host corneal steepening and thinning.