Min Ahn

Clinical aspects and prognosis of mixed microbial (bacterial and fungal) keratitis.

Purpose: To investigate the predisposing factors, clinical presentations, treatment results, and prognosis of keratitis caused by mixed infectious agents (bacteria and fungi). Methods: This is a retrospective study of cases with mixed bacterial and fungal keratitis, presented between January 2000 and December 2007 at a tertiary referral hospital. The study was performed to identify and analyze its risk factors, causative microbial organisms, clinical features, and therapeutic outcomes. Results: Thirty-three cases of mixed bacterial and fungal keratitis in 33 patients were identified. Twenty-one cases (64%) were men, and the mean age was 64.3 ± 10.3 years. The average follow-up time was 7.2 ± 6.6 months. The most common predisposing factor for mixed keratitis was a history of ocular trauma (46%), followed by ocular surface diseases (27%). The mean pretreatment infiltration size was 11.7 ± 12.7 mm2. The most common causative organisms were Staphylococcus epidermidis and Fusarium species. Seventeen cases (52%) underwent various surgical interventions: evisceration in 7 eyes (21%), penetrating keratoplasty in 5 eyes (15%), amniotic membrane transplantation in 5 eyes (15%), and so on. Seventeen cases (52%) were included in the initial treatment failure group. The significant risk factor for initial treatment failure was a large ulcer size (size over 15 mm2) (P = 0.031). Conclusions: The most common risk factor for mixed bacterial and fungal keratitis was ocular trauma, and the most common combination was Staphylococcus epidermidis and Fusarium species. Usually, patients with mixed bacterial and fungal keratitis have poor prognosis. Thus, when the infectious keratitis is running an atypical course or found unresponsive to the initial medical treatment, the possibility of a mixed infection by bacterial and fungal organisms should be considered.

Operating microscope light-induced phototoxic maculopathy after transscleral sutured posterior chamber intraocular lens implantation.

Purpose: The purpose of this study is to report the features of operating microscope light–induced retinal phototoxic maculopathy after transscleral sutured posterior chamber intraocular lens (TSS PC-IOL) implantation. Methods: The charts of 118 patients who underwent TSS PC-IOL implantation surgery at Chonbuk National University Hospital (Jeonju, Korea) between March 1999 and February 2008 were retrospectively reviewed. Fourteen patients underwent combined 3-port pars plana vitrectomy and TSS PC-IOL implantation (vitrectomy group), and 104 patients underwent TSS PC-IOL implantation only (nonvitrectomy group). All surgeries were performed under the same coaxial illuminated microscope. All diagnoses were confirmed through careful fundus examination and fluorescein angiography (FA). Results: Diagnoses of retinal phototoxic maculopathy were established in 10 (8.47%) of 118 TSS PC-IOL implantation cases. Phototoxic maculopathy occurred more frequently in the vitrectomy group than in the nonvitrectomy group (6/14 versus 4/104, respectively; P < 0.001, chi-square = 24.21). Affected patients reported decreased vision and were found to have coarse alterations of the retinal pigment epithelium (RPE). In 5 of the phototoxic maculopathy cases (50%), the visual acuity was 20/200 or worse. Conclusion: Operating microscope light–induced retinal phototoxic maculopathy can occur more frequently after TSS PC-IOL implantation than after casual cataract surgery, especially when TSS PC-IOL is combined with vitrectomy surgery. Surgeons should take precautions to prevent retinal phototoxicity after TSS PC-IOL implantation and vitrectomy.

VISION LOSS FOLLOWING SNAKEBITE IN A PATIENT WITH CONTROLLED APLASTIC ANEMIA

Viper venoms act mainly on blood and blood vessels. Reports of ophthalmic manifestations after snakebite include ptosis and ophthalmoplegia. In the current study, we describe a case that developed bilateral retinal and subretinal hemorrhage following snakebite. Bilateral retinal hemorrhage is a rare ocular complication of snake envenomation and has not been reported with fundus photographs in the literature so far.

Nontuberculous Mycobacterial Infection after Removal of the Exposed Hydroxyapatite

Dear Editor, Numerous complications are associated with hydroxyapatite orbital implants. Implant exposure, the most important complication, differs by study but occurs in approximately 2% to 10% of patients [1]. Nontuberculous mycobacteria (NTM) are generally free-living organisms that can also inhabit body surfaces or cause secretions without causing disease [2]. It is also known that these organisms can cause infection through wound entry. Reported herein is a case of abrupt NTM orbital cellulitis after removal of the exposed hydroxyapatite. A 43-year-old male presented with orbital implant exposure occurring about 1 year earlier. A culture was performed of a sample from the exposure site, but no growth was observed. The patient had undergone evisceration surgery with hydroxyapatite implantation 23 years earlier, due to trauma. Orbital implant removal surgery was initially recommended, but the patient refused. He changed his mind 1 year later and was admitted to the hospital with no sign of infection at the exposure site (Fig. 1A). Prophylactic antibiotic treatment was started, then removal of hydroxyapatite, enucleation with hydroxyapatite reimplantation, and a dermis-fat graft were performed. There were no sign of infection on the removed hydroxyapatite or the surrounding sclera. The removed material was sent to the Laboratory Department for Culture. The operation site was initially stable, although swelling and erythema were noted on postoperative day (POD) #2. Based on these findings, intravenous antibiotic treatment was changed, and 5% ceftazidime and 2.5% vancomycin eyedrops were added. Despite this treatment, the lesion continued to worsen with increased discharge and development into an erythematous lesion (Fig. 1B and 1C). NTM was observed in the culture on POD #7, for which intravenous antibiotics were changed to fourth-generation cephalosporin and vancomycin and polymerase chain reaction (PCR) examination was conducted to identify the subtype of NTM. The lesion continued to worsen, however, and reoperation, graft and hydroxyapatite removal, debridement, and wound irrigation with antibiotics were performed on POD #8. The removed Korean J Ophthalmol 2017;31(4):366-367 ht tps: / /doi.org /10.3341/k jo.2017.0022 Correspondence

Congenital axial high myopia detected by prenatal ultrasound.

High-resolution prenatal ultrasound can allow for early detection and monitoring of many fetal anomalies, including those involving the globe and orbit. The authors present a case of congenital axial high myopia that was diagnosed at 33 gestational weeks and monitored by prenatal ultrasonography. Some systemic abnormalities that can be associated with congenital high myopia are reviewed. High ammetropias, anisometropia, and either axial myopia or axial hyperopia can be detected in utero and give this early detection a greater chance of treating and reversing the devastating effects of amblyopia.

Accidental eyeball perforation by Dermojet syringe.

cient, as Norwegian scabies is resistant and relapsing. Oral ivermectin has been used safely and effectively for the treatment of Norwegian scabies in immunosuppressed patients, in doses ranging from 100–200 mg/kg, at 1-week intervals, for 1–3 times. We did not use oral ivermectin as it is not available in our country. We used 5% permethrin cream, which has a wide margin of safety. Less than 2% of permethrin is absorbed percutaneously, and the drug is rapidly broken down. Complete resolution of the lesions was observed after repeated applications of 5% permethrin cream combined with keratolytic therapy in our patient, and no side effects were observed. Early diagnosis of Norwegian scabies is important in the prevention of the spreading of the infestation as it is an extremely infectious condition. Pruritus and crusted lesions in immunosuppressed patients should suggest the diagnosis of Norwegian scabies.

Recurrent Paecilomyces Keratitis in a Patient with Jones Tube after Conjunctivodacryocystorhinostomy.

Dear Editor, Paecilomyces, which is found in soil and decaying vegetables, is a rare pathogen causing local and systemic infections [1]. We report a rare case of recurrent Paecilomyces keratitis 5 years after Jones tube placement in conjunctivodacryocystorhinostomy (CDCR). A 69-year-old woman was referred by a local ophthalmologist for the management of presumed fungal keratitis in the left eye. One month before presentation, she noted ocular discomfort with decreased vision. She had undergone left eye ocular surgery of CDCR 6 years previous and cataract surgery 2 months previous. After CDCR, she had used daily topical tobramycin and 0.02% fluorometholone eye drops. No known history of ocular trauma, contact lens use, or herpes simplex keratitis was evident. At initial examination, her best corrected visual acuity was finger counting at 30 cm. Slit-lamp examination demonstrated a 2.0 × 2.0-mm-sized epithelial defect with corneal stromal infiltration. There was moderate anterior chamber reaction and linear hypopyon. Corneal scrapings were cultured and confirmed the diagnosis of Paecilomyces infection. Topical amphotericin B 0.125% and voriconazole 1% were started. After 4 weeks of topical antifungal therapy, the epithelial defect and hypopyon were resolved. Her vision was improved to 20 / 50, but corneal opacity and thinning remained. There was no evidence of recurrence during the follow-up. Five years later, the patient presented with reduced vision in the left eye; her visual acuity in the left eye was 20 / 1,000 with spectacle correction. Slit-lamp examination showed geographic ulceration and radial Descemet’s membrane folding at the central cornea including the site of previous corneal opacity and thinning (Fig. 1A and 1B). The additional presence of mild anterior chamber reaction and no hypopyon led to a diagnosis of herpes simplex keratitis, for which acyclovir ointment and topical moxifloxacin were started. Cultures showed no growth of any organism. Geographic ulceration and chamber reaction were improved, but the corneal thinning resulted in a perforation despite treatment. The patient emergently underwent amniotic membrane transplantation and corneal button graft. Two weeks later, she developed a recurrence of keratitis in the graft and 2.0-mm hypopyon. A therapeutic keratoplasty was performed. The previous corneal graft was Korean J Ophthalmol 2016;30(6):479-480 http://dx.doi.org/10.3341/kjo.2016.30.6.479 Correspondence