Robert E. Fintelmann

Characteristics of endophthalmitis in patients with the Boston keratoprosthesis.

Purpose: To determine the characteristics of endophthalmitis in patients with the Boston keratoprosthesis. Methods: Retrospective chart review of 4 out of 35 patients who underwent implantation of the Boston keratoprosthesis on the Wills Eye Cornea service between 2001 and 2007 and developed infectious endophthalmitis. Results: All 4 patients had keratoprosthesis surgery due to previous corneal transplant failure. The incidence of endophthalmitis was 11.4%. All patients were on topical antibiotic prophylaxis with a fluoroquinolone and 1 of the 4 patients was also using vancomycin drops. All 4 patients underwent a tap and inject and were admitted for intensive intravenous and topical antibiotics for 3 to 7 days. Culture positive results were found in 3 of the 4 vitreous samples: 2 coagulase-negative Staphylococcus, and 1 Pseudomonas and Staphylococcus aureus. Minimum Inhibitory Concentration data showed high resistance to fourth-generation fluoroquinolone antibiotics in all isolates. All patients recovered significant vision, except 1 patient who developed fluctuating vision secondary to vitreoretinal traction bands, which developed secondary to the endophthalmitis. Conclusion: Endophthalmitis can occur after Boston keratoprosthesis at a significant rate, even in low-risk patients on prophylactic antibiotic drops. Given our experience with these patients and vancomycin, we recommend its prophylactic use. The increasing resistance of gram-positive organisms to fluoroquinolones and the need for close patient follow-up to encourage adherence to preventive regimens are further supported in this report.

Prophylaxis of postoperative endophthalmitis following cataract surgery: current status and future directions.

Endophthalmitis is an uncommon but potentially devastating intraocular infection that can occur after routine cataract surgery. Although a broad spectrum of organisms have been shown to cause acute postoperative endophthalmitis, most cases are caused by Gram-positive bacteria, which may be introduced at the time of surgery from colonization of adjacent conjunctiva or eyelid skin. Risk factors for the development of endophthalmitis following cataract surgery include patient age, intraoperative surgical complications and poor wound construction. There are several antibacterial strategies employed to prevent postoperative endophthalmitis, with topical, intracameral and subconjunctival delivery being the most common. Worldwide, there seems to be significant regional variance in the type and method of prophylactic antibacterial regimens; for example, topical fluoroquinolones are commonly used in the US, while intracameral cephalosporins are employed widely in Europe. The optimal antibacterial strategy for the prevention of endophthalmitis should be safe, inexpensive and broad in microbiological activity spectrum, while not requiring patient compliance for its effectiveness.

Stepwise approach to establishing an ophthalmology wet laboratory

Wet laboratories (wet labs) play an increasingly important role in ophthalmology surgical residency training. We summarize the necessary components in establishing and maintaining a well-functioning wet lab and offer a stepwise guide for educators to improve the quality of the wet lab experience. We present 6 key factors in creating an ophthalmology wet lab; that is, setting up the physical space, establishing appropriate faculty and curriculum, obtaining the practice eye, stabilizing the eye, preparing the eye, and funding the wet lab.

Posterior polymorphous dystrophy associated with nonkeratoconic steep corneal curvatures.

Purpose: To report a case series of eyes with posterior polymorphous corneal dystrophy and steep nonkeratoconic corneas. Methods: Retrospective, descriptive, nonrandomized case series. Results: Thirty-five eyes of 18 patients (14 cases from 6 families and 4 isolated cases) with diffuse posterior polymorphous corneal dystrophy had mean topographic simulated keratometry readings of 52.21 diopters (D), with a range of 46.47 D to 59.86 D and an SD of 3.69 D, with no slit-lamp or topographic findings suggestive of keratoconus. Conclusions: The patients in this series demonstrate diffuse posterior polymorphous corneal dystrophy and nonkeratoconic steep corneas.

Subconjunctival injections and povidone-iodine washings for the treatment of giant fornix syndrome.

Purpose: Giant fornix syndrome is a chronic copiously purulent conjunctivitis seen in elderly patients with dehiscence of the levator palpebrae superioris aponeurosis. We report a case of giant fornix syndrome secondary to methicillin-resistant Staphylococcus aureus conjunctivitis that was recalcitrant to standard treatment modalities, and we describe 2 novel interventions for this condition, which succeeded in eradicating the infection. Methods: Case report. Results: After failing an aggressive treatment course of topical antibiotics and corticosteroids and after demonstrating an inability to tolerate oral antibiotics, the patient was treated with supratarsal subconjunctival injections of vancomycin and triamcinolone, followed by repeated sweepings of the conjunctival fornices with 10% povidone-iodine on a cotton swab. The patients symptoms improved dramatically after the antibiotic and corticosteroid injections and ultimately resolved completely after multiple povidone-iodine sweepings. Conclusions: In patients with giant fornix syndrome who are recalcitrant to or intolerant of aggressive topical and systemic therapy, supratarsal subconjunctival injections of antibiotics and corticosteroids and sweeping of the conjunctival fornices with povidone-iodine are 2 local treatments which may be useful in eradicating the infection.

Oral Azithromycin for the Treatment of Meibomitis

Oral Azithromycin for the Treatment of Meibomitis Common treatment regimens for meibomitis include eyelid hygiene, lubricants, topical antibiotics, topical steroids, and systemic medications.1 Azithromycin is a macrolide antibiotic with robust antimicrobial and anti-inflammatory properties,2 and topical azithromycin, 1%, ophthalmic solution (AzaSite) has been shown to be efficacious in treating anterior and posterior blepharitis.3 Azithromycin’s pharmacokinetic profile adds to its potential value in treating meibomitis: a single 1-g oral dose results in high conjunctival tissue and tear fluid concentrations that persist for at least 14 days.4 Pulsed oral azithromycin has been reported to improve ocular signs and symptoms in patients with papulopustular rosacea.5 Based on this, azithromycin has potential efficacy in treating meibomitis using a short, pulsed dosing regimen, and we have used azithromycin in this fashion for the treatment of symptomatic meibomitis. We performed a retrospective review of patients receiving oral azithromycin for meibomitis to determine its impact on relieving patients’ symptoms.

Ocular Surface Disease Secondary to Vitamin A Deficiency in the Developed World: It Still Exists

Report of Cases. Case 1. A 79-yearold woman with a 15-year history of primary biliary cirrhosis and secondary Sjögren syndrome presented with a 1-year history of chronic conjunctivitis refractory to treatment with topical antibiotics. Three months prior, the patient underwent a tectonic penetrating keratoplasty in her right eye because of a perforated corneal ulcer. She had nyctalopia for 2 years. Her visual acuity was 20/200 OD and counting fingers at 3 ft OS. In addition to diffuse punctate epithelial erosions in both eyes, she had a peripheral corneal ulcer in the left eye, which was treated with topical antibiotics. Five days later, the ulcer had progressed to a small perforation. This was managed with cyanoacrylate glue and a bandage contact lens. Her vitamin A level was 20 μg/dL (to convert to micromoles per liter, multiply by 0.0349) (reference range, 38-98 μg/dL). After intramuscular vitamin A administration, the patient’s ocular condition stabilized, and she was discharged to follow up with her local ophthalmologist. Case 2. A 54-year-old woman with a 10-year history of primary biliary cirrhosis was referred for severe dry eyes starting 6 months prior, which were unsuccessfully treated with cyclosporine A, 0.05%, and frequent lubrication. On examination, her visual acuity was 20/25 OD and 20/30 OS. Schirmer I test results were abnormal in both eyes. She had diffuse punctate epithelial erosions with filaments in both eyes and interpalpebral lissamine green staining. Her vitamin A level was 11 μg/dL, and she started treatment with vitamin A ointment, 0.01%, once daily at bedtime and oral vitamin A supplementation. Her symptoms and staining pattern improved significantly over 1 month. Case 3. A 9-year-old autistic boy was referred for visual loss, in addition to red eyes and decreased night vision, over the past 4 months as noted by his mother. He had been diagnosed as having chronic conjunctivitis, which was unsuccessfully treatedwithacorticosteroid-antibiotic combination.Onexaminationunder anesthesia, he had chronic bilateral nonhealing epithelial defects, a relativeafferentpupillarydefect inthe left eye, and profound optic atrophy in the left eye greater than in the right eye. His visual acuity was not attainable because of lack of cooperation. It was later discovered that his diet consisted exclusively of french fries. His vitamin A level was 3 μg/dL. His epithelialdefectshealedwithfrequent lubricationandremainedhealedwith oral vitamin A supplementation. Case 4. A 26-year-old homeless and severely depressed woman presented with recurrent corneal ulcers and corneal perforation necessitating penetrating keratoplasty in the right eye. Her ocular condition was thought to be secondary to severe atopic disease. On examina-

Thygeson superficial punctate keratitis and scarring.

Purpose: Thygeson superficial punctate keratitis (TSPK), a chronic, inflammatory disease, has traditionally been taught to resolve spontaneously and without scarring. We present 4 cases with TSPK who developed sight-altering scarring after a prolonged disease course. Methods: Retrospective chart review of cases seen at the Proctor Medical Group. Results: Patients age ranged from 31 to 68 years. All patients were male and had been symptomatic from 2 to 53 years. Follow-up period ranged from 1 month to 35 years. All 3 patients developed significant corneal scarring. Case 1 had bilateral corneal thickening and a Salzmann nodule with vascularization. Case 2 had bilateral stromal opacification. Case 3 developed corneal scarring to the point of needing an anterior lamellar corneal transplant. Pathological evaluation of this tissue showed disruption of the Bowman layer with band keratopathy, thickening of the basement membrane, and subepithelial fibrosis. The diagnosis of TSPK in these cases was never in doubt, 2 of the cases having been diagnosed by Dr Thygeson. Conclusions: Prolonged corneal inflammation associated with TSPK can cause visually significant scarring of the anterior corneal stroma. In those patients with chronic disease, the use of a topical corticosteroid may be needed not just for comfort but to reduce the risk of corneal scarring.

Recurrent Lecythophora mutabilis keratitis and endophthalmitis after deep anterior lamellar keratoplasty

ner segment–outer segment junction of the photoreceptor layers and hyperreflectivity of the retinal pigment epithelial layer (Figure 2C). Improved visualization of these changes is likely owing to the greater axial resolution of the hs-UHROCT at 3.5 μm compared with the 5-μm axial resolution of the spectral-domain OCT as well as denser A-scan acquisition by the hs-UHR-OCT. The hs-UHROCT uses a broader bandwidth light source to achieve higher axial resolution. Normal internal controls of the left eye (Figure 2B and D) are included for comparison. Retinaldisruption incommotio retinae isdemonstrated at the level of the outer and inner photoreceptor layers and retinal pigment epithelial layer using prototype hs-UHROCT. These in vivo findings are consistent with results of previous histologic studies of commotio retinae.

Anterior uveitis associated with high-dose cytosine arabinoside.

Purpose: To report a case of anterior uveitis associated with high-dose cytosine arabinoside (Ara-C) treatment. Design: Observational case report. Methods: A 14-year-old girl was seen for pain, redness, and photophobia shortly after finishing a cycle of high-dose Ara-C. Results: Portable slit-lamp examination revealed bilateral diffuse fine keratic precipitates, indicative of a nongranulomatous anterior uveitis. This was treated successfully with a course of topical prednisolone acetate 1%. Conclusions: Ophthalmologists who are asked to evaluate patients on high-dose Ara-C for a “red eye” should consider anterior uveitis as a potential diagnosis.