Endophthalmitis associated with microbial keratitis

[Therapeutic penetrating keratoplasty: indications and results in Tunisia]

PURPOSE

To report the experience of the Tunis Institute of Ophthalmology (Tunisia) in therapeutic penetrating keratoplasty.

METHODS

We retrospectively analyzed 35 patients after therapeutic penetrating keratoplasty over a period of 6 years (between September 2002 and September 2008).

RESULTS

The mean patient age was 49.3 years. Men outnumbered women by a ratio of 2.5 to 1. The mean follow-up was 13.5 months. Corneal diseases within a therapeutic penetrating keratoplasty were divided into infectious keratitis (21 eyes) and noninfectious diseases (14 eyes). Herpetic keratitis was the most common etiology (11 eyes). The anatomical success rate was 92.4%, with infection eradicated in 80% of cases. The graft clarity at the end of follow-up was 54.2%. Rejection was the leading cause of graft opacification (50%). Final visual acuity was better than 1/10 in 25.7% of patients. Recovery of useful vision was observed in 45.7% of patients.

CONCLUSION

Therapeutic penetrating keratoplasty is a surgical technique that has proved its effectiveness in maintaining the integrity of the eyeball. The prognosis for this intervention would probably be better if it could be postponed.

Bacillus cereus-induced permeability of the blood-ocular barrier during experimental endophthalmitis

PURPOSE

The purpose of this study was to determine to what extent blood-retinal barrier (BRB) permeability occurred during experimental Bacillus cereus endophthalmitis and whether tight junction alterations were involved in permeability.

METHODS

Mice were intravitreally injected with 100 colony-forming units of B. cereus, and eyes were analyzed at specific times after infection for permeability to fibrin and albumin, quantitation of intraocular plasma constituent leakage, production of inflammatory cytokines, and alterations in tight junction protein localization and expression at the level of the retinal pigment epithelium.

RESULTS

B. cereus induced the leakage of albumin and fibrin into the aqueous and vitreous humor by 8 hours after infection. BRB permeability occurred as early as 4 hours and increased 13.30-fold compared with uninfected controls by 8 hours. Production of proinflammatory cytokines IL-6, MIP-1alpha, IL-1beta, and KC increased over the course of infection. In the retina, ZO-1 disruption began by 4 hours and was followed by decreasing occludin and ZO-1 expression at 4 and 8 hours, respectively. Tubulin condensation and RPE65 degradation occurred by 12 hours. A quorum-sensing mutant B. cereus strain caused BRB permeability comparable to that of wild-type B. cereus. Wild-type and mutant B. cereus sterile supernatants induced blood-ocular barrier permeability similarly to that of wild-type infection.

CONCLUSIONS

These results indicate that BRB permeability occurs during the early stages of experimental B. cereus endophthalmitis, beginning as early as 4 hours after infection. Disruption of tight junctions at the level of the retinal pigment epithelium may contribute to barrier breakdown. Quorum-sensing dependent factors may not significantly contribute to BRB permeability.

Microbiological profile of culture-proven cases of exogenous and endogenous endophthalmitis: a 10-year retrospective study

PURPOSE

To identify the microbial aetiology of infectious endophthalmitis and to determine the in vitro antibacterial susceptibilities of bacterial isolates.

METHODS

A retrospective analysis was carried out of all patients presenting between January 1997 and December 2006 with clinically diagnosed infectious endophthalmitis who underwent microbiological evaluation. Intraocular specimens (aqueous and vitreous fluids) were collected from all cases of clinically suspected infectious endophthalmitis. In addition to intraocular aspirates, blood specimens from endogenous endophthalmitis, and corneal and scleral scrapes from relevant cases were also collected. The collected intraocular specimens, blood specimens, and corneal and scleral scrapes were subjected to microbiological evaluation.

RESULTS

Samples from 955 patients with endophthalmitis underwent microbiological analysis, of which 424 (44.4%) were found to be culture positive. Of 424, 364 (85.8%) had bacterial growth and the remaining 60 (14.2%) had fungal growth. Among post-surgical endophthalmitis, Gram-negative bacilli (75%) were found to be the predominant cause for developing fulminant onset, Staphylococcus spp. (68.6%) for acute, and Streptococcus spp. (75%) for chronic onset of infections, whereas in post-traumatic endophthalmitis, Gram-negative bacilli (65.2%) were found to be the predominant cause for fulminant onset, Gram-positive bacillus (28.4%) for acute onset, and fungi (52.3%) for chronic onset of infections. Endophthalmitis associated with microbial keratitis was mainly caused by filamentous fungi (37.2%) and Gram-negative bacilli (37.2%). Overall, gatifloxacin (97.7%) showed highest activity against bacterial isolates followed by ciprofloxacin (95.9%) and ofloxacin (95.1%).

CONCLUSION

Gram-negative bacilli cause predominantly fulminant onset, Staphylococci and Gram-positive bacilli acute, and Streptococci, Nocardia, and fungi chronic endophthalmitis. Gatifloxacin demonstrated greatest efficacy against these bacterial isolates.

Exogenous fungal endophthalmitis: microbiology and clinical outcomes

OBJECTIVE

To report the fungal isolates, treatment strategies, and clinical outcomes for a large series of patients with exogenous fungal endophthalmitis.

DESIGN

Retrospective, single institution, consecutive case series.

PARTICIPANTS

All patients treated at Bascom Palmer Eye Institute between January 1, 1990, and June 30, 2006, for culture-proven exogenous fungal endophthalmitis.

METHODS

Microbiologic and medical records were reviewed for all patients with intraocular cultures positive for fungal organisms and clinically diagnosed exogenous endophthalmitis.

MAIN OUTCOME MEASURES

Fungal isolates, treatment strategies, visual acuity, and rate of enucleation.

RESULTS

Culture-positive exogenous fungal endophthalmitis occurred in 41 eyes, including 18 cases (44%) associated with fungal keratitis, 10 cases (24%) occurring after penetrating ocular trauma, and 13 cases (32%) after intraocular surgery. Filamentous fungi (molds) accounted for 35 cases (85%), and Candida species (yeasts) accounted for 6 cases (15%). Although most keratitis cases were caused by Fusarium (13 of 18; 72%), Aspergillus was the most common isolate in postoperative cases (5 of 13; 38%). Open-globe cases were caused by a broader spectrum of fungi. As initial treatment, 30 (73%) patients received intraocular amphotericin B, but at least 3 antifungal agents were used in 24 (59%) cases. At least 1 pars plana vitrectomy was performed in 25 (61%) eyes, and 29 (71%) eyes underwent 3 or more procedures, including surgeries and intraocular injections. Although a final vision of 20/400 or better was achieved in 22 (54%) eyes, all but 1 of these were either in the keratitis (11 of 18) or the postoperative (10 of 13) groups. Conversely, although 10 (24%) of 41 eyes were enucleated, 7 of these were among the open-globe patients.

CONCLUSIONS

This report highlights the differences between the clinical categories of exogenous fungal endophthalmitis. Although 85% of all cases were caused by molds, most commonly Fusarium and Aspergillus, the most common fungal genera varied by clinical category. Amphotericin B was the most commonly used antifungal agent, but most cases were treated with at least 3 different antifungal agents. Final visual outcomes were variable, with the open-globe-associated patients having the poorest outcomes. Overall, 44% of patients achieved a final visual acuity of 20/80 or better.

Bacillus cereus induces permeability of an in vitro blood-retina barrier

Most Bacillus cereus toxin production is controlled by the quorum-sensing-dependent, pleiotropic global regulator plcR, which contributes to the organism's virulence in the eye. The purpose of this study was to analyze the effects of B. cereus infection and plcR-regulated toxins on the barrier function of retinal pigment epithelium (RPE) cells, the primary cells of the blood-retina barrier. Human ARPE-19 cells were apically inoculated with wild-type or quorum-sensing-deficient B. cereus, and cytotoxicity was analyzed. plcR-regulated toxins were not required for B. cereus-induced RPE cytotoxicity, but these toxins did increase the rate of cell death, primarily by necrosis. B. cereus infection of polarized RPE cell monolayers resulted in increased barrier permeability, independent of plcR-regulated toxins. Loss of both occludin and ZO-1 expression occurred by 8 h postinfection, but alterations in tight junctions appeared to precede cytotoxicity. Of the several proinflammatory cytokines analyzed, only interleukin-6 was produced in response to B. cereus infection. These results demonstrate the deleterious effects of B. cereus infection on RPE barrier function and suggest that plcR-regulated toxins may not contribute significantly to RPE barrier permeability during infection.

Research in Dry Eye: Report of the Research Subcommittee of the International Dry Eye WorkShop (2007)

Members of the DEWS Research Subcommittee reviewed research into the basic mechanisms underlying dry eye disease. Evidence was evaluated concerning the tear film, lacrimal gland and accessory lacrimal glands, ocular surface epithelia (including cornea and conjunctiva), meibomian glands, lacrimal duct system and the immune system. Consideration was given to both animal and human research data. Results are presented as a series of information matrices, identifying what is known and providing supporting references. An attempt is made to identify areas for further investigation.

In vitro antifungal activity of the fourth generation fluoroquinolones against Candida isolates from human ocular infections

PURPOSE

To evaluate and compare the in vitro antifungal activity of moxifloxacin and gatifloxacin against Candida species isolated from ocular infections.

METHODS

Tube microdilutions test was used to determine antifungal activity of the agents for 21 Candida isolates and one quality control strain. Drugs evaluated included topical preparations of fluoroquinolones (FQs), moxifloxacin (Vigamox), and gatifloxacin (Zymar). Serial dilutions of moxifloxacin (0.5%, 0.25%, 0.125%) and gatifloxacin (0.3%, 0.15%, 0.075%) were prepared for the microtube dilutions test. Aliquots (0.01 ul) were plated onto Sabouraud agar and colonies were counted.

RESULTS

Both drugs undiluted inhibited greater than 95% of growth at 24 hrs. There was no significant difference between moxifloxacin and gatifloxacin at undiluted concentrations (p = 1.00); however, the mean number of colony forming units in gatifloxacin group was significantly less than that of moxifloxacin at diluted concentrations of the drugs (p < 0.05).

CONCLUSIONS

Current commercial topical preparations of moxifloxacin and gatifloxacin demonstrated a definite in vitro antifungal activity against ocular Candida species; however, clinical efficacy of these agents remains unproven. The greater inhibition of growth of organisms with gatifloxacin compared to moxifloxacin is possibly because of the presence of BAK in Zymar.

Effect of antibacterial honey on the ocular flora in tear deficiency and meibomian gland disease

PURPOSE

To assess for differences in the ocular flora of patients with dry eye caused by tear deficiency and/or meibomian gland disease and to assess the effect of antibacterial honey on the ocular flora in these forms of dry eye.

METHODS

In this prospective, open-label pilot study, bacteria isolated from the eyelid margin and conjunctiva were identified and quantified before and at 1 and 3 months after initiation of treatment with topical application of antibacterial honey 3 times daily. Subjects had non-Sjogren tear deficiency (n = 20), Sjogren syndrome tear deficiency (n = 11), meibomian gland disease (n = 15), and non-Sjogren tear deficiency with meibomian gland disease (n = 20), and there were 18 non-dry eye subjects.

RESULTS

The total colony-forming units (CFUs) isolated from each of the dry eye subgroups before antibacterial honey use was significantly greater than the total CFU isolated from the non-dry eye group. Antibacterial honey use significantly reduced total CFUs for the eyelids and the conjunctiva of dry eye subjects from baseline at month 1 (eyelids: P = 0.0177, conjunctiva: P = 0.0022) and month 3 (eyelids: P < 0.0001, conjunctiva: P < 0.0001). At month 3, there were reductions in total CFUs for all dry eye subgroups such that the CFUs were not significantly different from those of the non-dry eye group.

CONCLUSION

From these results, there is sufficient preliminary data to warrant further study of the effects of antibacterial honey in chronic ocular surface diseases.

Prescribing trends in infectious keratitis: a survey of New Zealand ophthalmologists

PURPOSE

To obtain an overview of the treatment of infectious diseases of the cornea by New Zealand ophthalmologists and to analyse the data in the context of evidence-based treatment recommendations.

METHODS

A questionnaire was sent to all New Zealand ophthalmologists. It comprised 23 multiple-choice questions pertaining to the characteristics of the respondents, the nature of their practice and their prescribing preferences in infectious conjunctivitis and keratitis.

RESULTS

Of the 93 ophthalmologists surveyed, 80.6% returned the questionnaire. Of those in clinical practice, 91.4% regularly treated patients with corneal disease. A subspecialty interest in cornea was stated by 12.5% of these. This paper reports observations for adenoviral conjunctivitis and adenoviral, Herpes simplex, varicella zoster, bacterial, acanthamoebal and fungal keratitis. In some conditions prescribing practice varied dramatically, such as in adenoviral conjunctivitis where 50% of respondents prescribed a corticosteroid and 51.6% an antibiotic, whereas 37.5% prescribed only lubrication or no topical treatment. In other conditions there was a high degree of agreement between ophthalmologists; indeed, all ophthalmologists treated Herpes simplex dendritic keratitis with topical acyclovir. No statistically significant differences in prescribing habits were identified between subspecialist and non-subspecialist groups, although some important clinical differences emerged. There were occasional marked differences in response when the age group of respondents was considered, particularly in relation to the management of adenoviral infections and bacterial keratitis.

CONCLUSIONS

The findings of this survey suggest that the majority of New Zealand ophthalmologists generally follow international guidelines for the management of infectious keratitis. The identified variations in management provide a foundation for informed clinical debate and the development of treatment guidelines, in line with evidence-based recommendations.

Therapeutic penetrating keratoplasty in severe fungal keratitis using cryopreserved donor corneas

AIMS

To investigate whether cryopreserved donor cornea could be used for therapeutic penetrating keratoplasty (PKP) to eradicate the infection, obviate complications, and preserve anatomical integrity in severe fungal keratitis.

METHODS

In this retrospective, consecutive case series, 45 eyes of 45 patients with severe fungal keratitis, which exhibited anterior chamber collapse, corneal perforation, and/or large suppurative corneal infiltrate, received therapeutic PKP after removal of the infected corneal tissue, irrigation of the anterior chamber by 0.2% fluconazole solution, iris dissection of fibrinoid membrane, and iridectomy and therapeutic PKP using corneas cryopreserved at -20 degrees C.

RESULTS

Among 45 eyes, 39 eyes (86.7%) were successfully eradicated the fungal infection without recurrence and maintained their anatomical integrity without any complication. Four of 45 eyes (8.9%) showed postoperative rise of intraocular pressure, of which three were controlled with subsequent antiglaucoma surgeries, whereas one eye needed additional antiglaucoma medications. Two of 45 eyes (4.4%) were enucleated because of uncontrollable fungal infection and secondary retinal detachment, respectively. 23 eyes received subsequent optical PKP and, among them, 21 maintained clear corneal grafts and two suffered from graft failure due to allograft rejections.

CONCLUSION

Cryopreserved donor corneas are effective substitutes in therapeutic PKP to control severe fungal corneal infection and preserve the global integrity, and may offer additional advantages over conventional PKP in reducing allograft rejection, eradicating fungal infection during the postoperative period, and improving the success of optical PKP for visual rehabilitation.

Outcomes of phacoemulsification in patients with dry eye

PURPOSE

To evaluate the outcomes of phacoemulsification in patients with dry eye.

SETTING

Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

METHODS

This study included 25 eyes of 23 patients with dry eye having phacoemulsification. Dry eye was defined as Schirmer I with lidocaine hydrochloride (Xylocaine) score of 5.0 mm after 5 minutes, a tear-film breakup time (TFBUT) of less than 5 seconds, or both. Data were retrospectively analyzed for preoperative and postoperative tear function, postoperative complications, and final visual outcomes.

RESULTS

Of the 23 patients, 18 had age-related dry eye and 5 had secondary Sjögren's syndrome. Twenty-two eyes had predominant aqueous deficiency (Schirmer I with Xylocaine score of 5.0 mm or less), and 3 had a Schirmer score between 6.0 mm and 9.0 mm. The TFBUT was 5 seconds or less in 17 eyes and between 6 seconds and 9 seconds in 8 eyes. The mean preoperative Schirmer score was 4.80 mm +/- 2.01 (SD) (range 2.0 to 9.0 mm) and the mean postoperative score, 3.80 +/- 2.40 mm (range 0 to 7.0 mm). The mean preoperative TFBUT was 4.00 +/- 1.87 seconds (range 0 to 9 seconds) and the mean score at the last follow-up, 3.40 +/- 1.60 seconds (range 0 to 8 seconds). Postoperatively, 8 eyes had superficial punctate keratopathy and 8 had an epithelial defect. The final visual acuity was 6/6 in 13 eyes, 6/9 to 6/12 in 8 eyes, and 6/18 to 6/60 in 4 eyes.

CONCLUSION

Phacoemulsification was safe and led to minimal complications in patients with age-related dry eye with or without associated systemic disorders.

Locally administered ocular corticosteroids: benefits and risks

Corticosteroids, used prudently, are one of the most potent and effective modalities available in the treatment of ocular inflammation. However, they can produce a plethora of adverse ocular and systemic events. In order to optimise and target drug delivery, whilst minimising systemic adverse effects, a diverse range of local ophthalmic preparations and delivery techniques have been developed. Topical drops and ointments remain the primary methods for administration of ocular corticosteroids. However, ocular penetration of topical corticosteroid drops depends upon drug concentration, chemical formulation of corticosteroid, and composition of the vehicle, therefore, apparently small modifications in preparations can produce a more than 20-fold difference in intraocular drug concentration. Periocular injections of corticosteroids continue to have a useful, but limited, therapeutic role and longer acting, intraocular delayed-release devices are in early clinical studies. Although newer corticosteroids with lesser pressure elevating characteristics have been developed, corticosteroid-induced ocular hypertension and glaucoma continue to be significant risks of local and systemic administration. Posterior subcapsular cataract, observed following as little as 4 months topical corticosteroids use, is thought to be due to covalent binding of corticosteroid to lens protein with subsequent oxidation. Inappropriate use of topical corticosteroid in the presence of corneal infections also continues to be a cause of ocular morbidity. Other risks of locally administered ophthalmic corticosteroids include: tear-film instability, epithelial toxicity, crystalline keratopathy, decreased wound strength, orbital fat atrophy, ptosis, limitation of ocular movement, inadvertent intraocular injection, and reduction in endogenous cortisol. This extensive review assesses the therapeutic benefits of locally administered ocular corticosteroids in the context of the risks of adverse effects.

Indecision about corticosteroids for bacterial keratitis: an evidence-based update

PURPOSE

To quantify the effect of topical corticosteroids on bacterial keratitis.

CLINICAL RELEVANCE

Bacterial keratitis is an economically important infection affecting 1 in 10,000 Americans annually. The predisposing factors, prior ocular health, infecting microorganisms, inflammatory severity, and therapeutic choices can affect the course and outcome. Antibacterial treatment is often curative but does not guarantee good vision. Because many treated patients develop a sight-limiting corneal problem, antiinflammatory therapy has sometimes been recommended.

LITERATURE REVIEWED

Publications from 1950 to 2000 that evaluated the effect of corticosteroids on bacterial keratitis in animal experiments, case reports and series, case-comparison and cohort studies, and clinical trials were systematically identified by electronic and manual search strategies.

RESULTS

The use of a topical corticosteroid before the diagnosis of bacterial keratitis significantly predisposed to ulcerative keratitis in eyes with preexisting corneal disease (odds ratio [OR], 2.63; 95% confidence limits [CL], 1.41, 4.91). Once microbial keratitis occurred, prior corticosteroid use significantly increased the odds of antibiotic treatment failure or other infectious complications (OR, 3.75; 95% CL, 2.52, 5.58). However, the effect of a topical corticosteroid with antibiotics after the onset of bacterial keratitis was unclear. Experimental models suggested likely advantages, but clinical studies did not show a significant effect of topical corticosteroid therapy on the outcome of bacterial keratitis (OR, 0.62; 95% CL, 0.25, 1.54).

CONCLUSIONS

Topical corticosteroids increase the risk of infectious complications affecting the cornea but may or may not have an effect during antibacterial therapy. The unproven role of corticosteroids in the adjunctive treatment of bacterial keratitis highlights the need to collect prospective information that would guide appropriate management for this common eye disease.

Bacterial endophthalmitis: epidemiology, therapeutics, and bacterium-host interactions

Endophthalmitis is a severe inflammation of the interior of the eye caused by the introduction of contaminating microorganisms following trauma, surgery, or hematogenous spread from a distant infection site. Despite appropriate therapeutic intervention, bacterial endophthalmitis frequently results in visual loss, if not loss of the eye itself. Although the pathogenicity of bacterial endophthalmitis has historically been linked with toxin production during infection, a paucity of information exists as to the exact mechanisms of retinal toxicity and the triggers for induction of the intraocular immune response. Recently, research has begun to examine the bacterial and host molecular and cellular events that contribute to ocular damage during endophthalmitis. This review focuses on the causative agents and therapeutic challenges of bacterial endophthalmitis and provides current data from the analysis of the role of bacterial virulence factors and host inflammatory interactions in the pathogenesis of eye infections. Based on these and related studies, a hypothetical model for the molecular pathogenesis of bacterial endophthalmitis is proposed. Identifying and understanding the basic mechanisms of these bacterium-host interactions will provide the foundation for which novel, information-based therapeutic agents are developed in order to prevent vision loss during endophthalmitis.

Management of blebitis by members of the American Glaucoma Society: a survey

PURPOSE

To investigate the practice patterns among glaucoma subspecialists in the American Glaucoma Society regarding the management of blebitis.

METHODS

An anonymous survey incorporating 14 questions regarding the management of blebitis was mailed to all current active American Glaucoma Society members, including provisional members, in October 1999.

RESULTS

A total of 319 physicians received the survey, and 204 members (64%) returned surveys. Sixty-nine percent of respondents do not ask their patients with functioning blebs to use topical antibiotics at home for early symptoms of blebitis. Thirty-four percent never or almost never obtain conjunctival cultures at the onset of isolated blebitis, whereas 44% always or usually do. Fifty-one percent prescribe a topical fluoroquinolone alone as the initial empirical treatment of isolated blebitis. Twenty-three percent use a fluoroquinolone in combination with one or two other antibiotics. Twenty-one percent choose a combination of fortified topical agents, usually including a fortified aminoglycoside, vancomycin, or cephalosporin. Thirty-one percent use fortified agents in some combination with or without a fluoroquinolone. Five percent prescribe some other single agent alone. Only 6% routinely use an oral antibiotic in cases of blebitis. Sixty-two percent use topical corticosteroids in conjunction with antibiotic treatment. Of these, 68% start them after initial antibiotic treatment is established or once improvement of blebitis is noted. Fifty-six percent indicated that a moderate or severe anterior chamber reaction, including fibrin, would prompt treatment as a possible endophthalmitis. In a persistently Seidel-positive bleb, 77% generally attempt surgical bleb revision.

CONCLUSIONS

Methods of the management of blebitis differ among members of the American Glaucoma Society. Treatment recommendations generated from randomized clinical trials are needed.

Efficacy and safety of cyclosporin A ophthalmic emulsion in the treatment of moderate-to-severe dry eye disease: a dose-ranging, randomized trial. The Cyclosporin A Phase 2 Study Group

OBJECTIVE

To investigate the efficacy, safety, formulation tolerability, and optimal dosing of a novel cyclosporin A oil-in-water emulsion formulation for the treatment of moderate-to-severe dry eye disease.

DESIGN

Randomized, multicenter, double-masked, parallel-group, dose-response controlled trial.

PARTICIPANTS

Total enrollment: 162 patients; cyclosporin A groups: 129 patients; vehicle group: 33 patients.

INTERVENTION

Patients instilled study medication (cyclosporin A ophthalmic emulsion 0.05%, 0.1%, 0.2%, or 0.4%, or vehicle) twice daily into both eyes for 12 weeks, followed by a 4-week posttreatment observation period.

MAIN OUTCOME MEASURES

EFFICACY

rose bengal staining, superficial punctate keratitis, Schirmer tear test, symptoms of ocular discomfort, and the Ocular Surface Disease Index (OSDI; a measure of symptom frequency and impact on vision-related functioning).

SAFETY

biomicroscopy, cyclosporin A blood levels, conjunctival microbiology, intraocular pressure, visual acuity, and monitoring of adverse events.

RESULTS

In a subset of 90 patients with moderate-to-severe keratoconjunctivitis sicca, the most significant improvements with cyclosporin A treatment were in rose bengal staining, superficial punctate keratitis, sandy or gritty feeling, dryness, and itching, with improvements persisting into the posttreatment period in some treatment groups. There was also a decrease in OSDI scores, indicating a decrease in the effect of ocular symptoms on patients' daily lives. There was no clear dose-response relationship, but cyclosporin A 0.1% produced the most consistent improvement in objective and subjective end points and cyclosporin A 0.05% gave the most consistent improvement in patient symptoms. The vehicle also performed well, perhaps because of its long residence time on the ocular surface. There were no significant adverse effects, no microbial overgrowth, and no increased risk of ocular infection in any treatment group. The highest cyclosporin A blood concentration detected was 0.16 ng/ml. All treatments were well tolerated by patients.

CONCLUSIONS

Cyclosporin A ophthalmic emulsions, 0.05%, 0.1%, 0.2%, and 0.4%, were safe and well tolerated, significantly improved the ocular signs and symptoms of moderate-to-severe dry eye disease, and decreased the effect of the disease on vision-related functioning. Cyclosporin A 0.05% and 0.1% were deemed the most appropriate formulations for future clinical studies because no additional benefits were observed with the higher concentrations.

Two multicenter, randomized studies of the efficacy and safety of cyclosporine ophthalmic emulsion in moderate to severe dry eye disease. CsA Phase 3 Study Group

OBJECTIVE

To compare the efficacy and safety of cyclosporin A ([CsA] 0.05% and 0.1% ophthalmic emulsions) to vehicle in patients with moderate to severe dry eye disease.

DESIGN

Multicenter, randomized, double-masked, parallel-group, 6-month, vehicle-controlled.

PARTICIPANTS

A total of 877 patients with defined moderate to severe dry eye disease (292 to 293 in each treatment group).

METHODS

Two identical clinical trials; patients were treated twice daily with either CsA, 0.05% or 0.1%, or vehicle. The results of these two trials were combined for analysis.

MAIN OUTCOME MEASURES

EFFICACY

corneal and interpalpebral dye staining, Schirmer tear test (with and without anesthesia), tear break-up time, Ocular Surface Disease Index (OSDI), facial expression, patient subjective rating scale, symptoms of dry eye, investigator's evaluation of global response to treatment, treatment success, and daily use of artificial tears.

SAFETY

occurrence of adverse events, best-corrected visual acuity, intraocular pressure, biomicroscopy, and blood trough CsA concentrations.

RESULTS

Treatment with CsA, 0.05% or 0.1%, gave significantly (P < or = 0.05) greater improvements than vehicle in two objective signs of dry eye disease (corneal staining and categorized Schirmer values). CsA 0.05% treatment also gave significantly greater improvements (P < 0.05) in three subjective measures of dry eye disease (blurred vision, need for concomitant artificial tears, and the physician's evaluation of global response to treatment). There was no dose-response effect. Both CsA treatments exhibited an excellent safety profile, and there were no significant topical or systemic adverse safety findings.

CONCLUSIONS

The novel ophthalmic formulations CsA 0.05% and 0.1% were safe and effective in the treatment of moderate to severe dry eye disease yielding improvements in both objective and subjective measures. Topical CsA represents a new pharmacologically based treatment for dry eye disease that may provide significant patient benefits.

A new look at dry eye disease and its treatment

This review examines the impact of moderate to severe dry eye disease on daily life and medical-resource utilization. The results suggest that current treatment paradigms can lead to unacceptable costs in both quality of life and progressive use of healthcare resources. Evidence linking this disease to T-cell-mediated inflammatory processes lays the foundation for understanding the clinical benefits of topical cyclosporine, an immunomodulatory and anti-inflammatory agent.

Enucleation

The three most common indications for enucleation are intraocular malignancy, trauma, and a blind, painful eye. Recommending enucleation is one of the most difficult therapeutic decisions in ophthalmology. In some cases of malignancy, cryotherapy, laser photocoagulation, diathermy, chemotherapy, and radiation therapy may be viable alternatives to surgery. When surgery is chosen, evisceration or exenteration may be alternatives to enucleation. Once the decision is made to perform enucleation or evisceration, the surgeon must choose from several types of implants and wrapping materials. These devices can be synthetic, autologous, or eye-banked tissues. With certain implants, the surgeon must decide when and if to drill for subsequent peg placement. In this review, the authors discuss choices, techniques, complications, and patient consent and follow-up before, during, and after enucleation. Controversies and results of the Controlled Ocular Melanoma Study are summarized.

Corneal biopsy with tissue micro-homogenisation for isolation of organisms in bacterial keratitis

PURPOSE

To evaluate a novel two-stage technique to increase yield of bacteria isolated from infected corneal ulcers.

METHODS

A new blade was designed to remove friable material from infected corneal ulcers. The new blade was used in combination with standard tissue micro-homogenisation equipment in a two-stage technique intended to distribute biopsy samples evenly between relevant agar plates. Patients with presumed-bacterial corneal ulcers underwent sequential corneal sampling using the new two-stage technique and a scalpel blade, used without micro-homogenisation (the order of sampling was varied between two groups). Bacterial isolation rates were compared using the chi-squared test.

RESULTS

Twenty-four patients with presumed-bacterial corneal ulcers were studied. The overall positive bacterial isolation rate was 88%, with identical bacterial isolation rates for the new two-stage technique and the scalpel blade (71%). The new technique isolated bacteria from three ulcers that had initially been 'sterile' when sampled with a scalpel blade. Polymicrobial infections were identified in two ulcers with the new blade where only a single organism had been identified using the scalpel blade (not significantly different).

CONCLUSIONS

The new two-stage technique shows promise for improving bacterial isolation rates from presumed-bacterial corneal ulcers.

Risk factors in microbial keratitis leading to penetrating keratoplasty

OBJECTIVE

To determine the characteristics of infectious corneal ulcers at the time of presentation to the cornea specialist associated with a favorable response to medical therapy versus a poor outcome manifested by the need for penetrating keratoplasty for therapy or visual rehabilitation.

DESIGN

Retrospective, case-control study.

PARTICIPANTS

A total of 162 patient records were reviewed, including the study group of 30 patients and the control group of 132 patients.

INTERVENTION

A retrospective review of all cases of microbial keratitis presenting to the Cornea Service between January 1, 1989 and December 31, 1995 was conducted. The cases were divided into two groups. The study group consisted of patients with microbial keratitis who failed medical therapy and required penetrating keratoplasty. The control group included patients with infectious ulcers who responded to medical therapy alone.

MAIN OUTCOME MEASURES

The influence of demographics, medical and ocular history, delay in presentation to the primary ophthalmologist or the corneal specialist, topical medications, and contact lens usage were compared. Visual acuity and ulcer characteristics were recorded. The statistical significance was evaluated by the chi-square test for independence and multiple logistic regression.

RESULTS

Older age (P=0.001), delay in referral to the corneal specialist (P<0.03), and treatment with topical steroids prior to presentation (P<0.0001) were statistically significant factors associated with the need for penetrating keratoplasty. Steroid use and the delay in referral were correlated. A past history of ocular surgery (P=0.01), poor visual acuity at presentation (P<0.001), and ulcer characteristics, including central location (P<0.0001), large size (P<0.0001), presence of perforation or descemetocele (P<0.0001), limbal involvement (P<0.0001), and hypopyon (P=0.05), were all associated with the need for penetrating keratoplasty.

CONCLUSIONS

Older age, delay in referral to the corneal specialist, topical steroid treatment, past ocular surgery, poor vision at presentation, large size, and central location of the ulcer are risk factors for poor outcome of microbial keratitis, as indicated by the need for penetrating keratoplasty.

Keratitis complicated by endophthalmitis 3 years after astigmatic keratotomy

Endophthalmitis after keratotomy is rare and usually occurs soon after surgery. A 56-year-old woman with mild dry-eye symptoms developed keratitis complicated by endophthalmitis 3 years after astigmatic keratotomy (AK). The keratitis lasted for less than 1 day in the upper keratotomy incision. Corneal cultures yielded. Pseudomonas aeruginosa. Keratitis progressed to endophthalmitis 1 day after the detection of keratitis. The inflammation was controlled with intravitreal, subconjunctival, topical, and systemic antibiotics. This case demonstrates the potential risk of endophthalmitis developing very shortly after late keratitis of AK incisions. Vigorous early treatment and close follow-up seem justifiable in any keratitis associated with a keratotomy incision.