Observation of Retrocorneal Plaques in Patients With Infectious Keratitis Using Anterior Segment Optical Coherence Tomography

Viral Anterior Uveitis: A Practical and Comprehensive Review of Diagnosis and Treatment

Anterior uveitis is the most common type of uveitis worldwide. The etiologies of anterior uveitis can be divided into infectious and non-infectious (idiopathic, autoimmune, autoinflammatory, trauma, and others). The viral pathogens most commonly associated with infectious anterior uveitis include Herpes Simplex Virus, Varicella-Zoster Virus, Cytomegalovirus, and Rubella Virus. Other emerging causes of viral anterior uveitis are West Nile Virus, Human-Immunodeficiency Virus, Epstein-Barr Virus, Parechovirus, Dengue Virus, Chikungunya Virus, and Human Herpesvirus type 6,7, and 8. Early recognition allows prompt management and mitigates its potential ocular complications. This article provides an updated literature review of the epidemiology, clinical manifestations, diagnostic tools, and treatment options for viral anterior uveitis.

Misdiagnosed as Fungal Keratitis: Herpes Simplex Virus-1 Keratitis Confirmed by Next-Generation Sequencing

Objective: The purpose of this study was to report a case of herpes simplex virus-1 (HSV-1) keratitis misdiagnosed as fungal keratitis due to its clinical presentation being similar to that of fungal keratitis, ultimately diagnosed by NGS. Patients and Methods: A 59-year-old male presented with reduced vision in the right eye, combined with a history of trauma with vegetative matter. The corneal ulcer was accompanied with feathery infiltration, satellite lesion, and endothelial plaques. In vivo confocal microscopy (IVCM) showed hyper-reflective linear, thin, and branching interlocking structures. Fungal keratitis was diagnosed. Voriconazole 100 mg orally daily, topical tobramycin and 1% voriconazole were initiated empirically right away. The condition was aggravated and penetrating keratoplasty was performed. Anterior segment optical coherence tomography (AS-OCT) demonstrated the presence of plaques with a clear boundary between plaques and endothelium, resembling the AS-OCT images observed in cases of viral keratitis. Next-generation sequencing (NGS) further detected HSV-1 deoxyribonucleic acid, and no fungal component was found. Antifungal agents were discontinued and antiviral treatments were added. Results: We successfully treated a patient with HSV-1 keratitis who was misdiagnosed due to clinical features and IVCM findings similar to fungal keratitis. The patient's infection was controlled. At 2 years after surgery, the cornea recovered well. Conclusions: HSV-1 keratitis with atypical clinical presentation can be easily misdiagnosed. This case report emphasizes the importance of NGS in diagnosing the pathogens of keratitis.

Differentiation of acanthamoeba keratitis from other non-acanthamoeba keratitis: Risk factors and clinical features

INTRODUCTION

Infectious Keratitis is one of the most common ocular emergencies seen by ophthalmologists. Our aim is to identify the risk factors and clinical features of Acanthamoeba Keratitis (AK).

METHODS

This retrospective chart review study was conducted at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, and included all the microbial keratitis cases, male and female patients of all ages. The main outcome is the differentiation between various microbial keratitis types.

RESULTS

We included 134 consecutive eyes of 126 persons. We had 24 cases of acanthamoeba keratitis, 22 bacterial keratitis, 24 fungal keratitis, 32 herpetic keratitis, and 32 bacterial co-infection. Contact lens wear was found in 33 eyes (24.6%). Among acanthamoeba keratitis patients, 73% were ≤ 39 years of age, and 73% were females (P <0.001). Also, in AK cases, epithelial defect was found in all cases (100%), endothelial plaques were found in 18 eyes (69.2%), 12 cases had radial keratoneuritis (46.2%), and ring infiltrate was found in 53.8% of AK cases.

CONCLUSIONS

We determined the factors that increase the risk of acanthamoeba infection and the clinical characteristics that help distinguish it from other types of microbial keratitis. Our findings suggest that younger females and patients who wear contact lenses are more likely to develop acanthamoeba keratitis. The occurrence of epitheliopathy, ring infiltrate, radial keratoneuritis, and endothelial plaques indicate the possibility of acanthamoeba infection. Promoting education on wearing contact lenses is essential to reduce the risk of acanthamoeba infection, as it is the most significant risk factor for this infection.

Clinical Applications of Anterior Segment Optical Coherence Tomography: An Updated Review

Since its introduction, optical coherence tomography (OCT) has revolutionized the field of ophthalmology and has now become an indispensable, noninvasive tool in daily practice. Most ophthalmologists are familiar with its use in the assessment and monitoring of retinal and optic nerve diseases. However, it also has important applications in the assessment of anterior segment structures, including the cornea, conjunctiva, sclera, anterior chamber, and iris, and has the potential to transform the clinical examination of these structures. In this review, we aim to provide a comprehensive overview of the potential clinical utility of anterior segment OCT (AS-OCT) for a wide range of anterior segment pathologies, such as conjunctival neoplasia, pterygium, scleritis, keratoconus, corneal dystrophies, and infectious/noninfectious keratitis. In addition, the clinical applications of AS-OCT (including epithelial mapping) in preoperative planning and postoperative monitoring for corneal and refractive surgeries are discussed.

The pre-Descemet's layer (Dua's layer, also known as the Dua-Fine layer and the pre-posterior limiting lamina layer): Discovery, characterisation, clinical and surgical applications, and the controversy

The pre-Descemet's layer/Dua's layer, also termed the Dua-Fine layer and the pre-posterior limiting lamina layer, lies anterior to the Descemet's membrane in the cornea, is 10 μm (range 6-16) thick, made predominantly of type I and some type VI collagen with abundant elastin, more than any other layer of the cornea. It has high tensile strength (bursting pressure up to 700 mm of Hg), is impervious to air and almost acellular. At the periphery it demonstrates fenestrations and ramifies to become the core of the trabecular meshwork, with implications for intraocular pressure and glaucoma. It has been demonstrated in some species of animals. The layer has assumed considerable importance in anterior and posterior lamellar corneal transplant surgery by improving our understanding of the behaviour of corneal tissue during these procedures, improved techniques and made the surgery safer with better outcomes. It has led to the innovation of new surgical procedures namely, pre-Descemet's endothelial keratoplasty, suture management of acute hydrops, DALK-triple and Fogla's mini DALK. The discovery and knowledge of the layer has introduced paradigm shifts in our age old concepts of Descemet's membrane detachment, acute corneal hydrops in keratoconus and Descemetoceles, with impact on management approaches. It has been shown to contribute to the pathology and clinical signs observed in corneal infections and some corneal dystrophies. Early evidence suggests that it may have a role in the pathogenesis of keratoconus in relation to its elastin content. Its contribution to corneal biomechanics and glaucoma are subjects of current investigations.

Nonsurgical Management of Severe Viral Keratitis with Hypopyon and Retrocorneal Plaques: A Case Series

INTRODUCTION

Severe viral keratitis with hypopyon and retrocorneal plaques is easily misdiagnosed as it mimics fungal or bacterial keratitis and is more likely to undergo emergency therapeutic penetrating keratoplasty (TPK) in the presence of active infection, resulting in poor outcomes. This case series offers some important insights for the management strategy of severe viral keratitis.

METHODS

This retrospective case series involved five patients with unilateral severe infectious keratitis with hypopyon over 3 mm and retrocorneal endothelial plaques. Testing for corneal sensation, microscopy, culture, and anterior segment optical coherence tomography (ASOCT) were performed.

RESULTS

At presentation, all five cases had visual acuity of counting fingers (CF) or worse, large centrally located ulcer with clean ulcer surface, hypopyon, and retrocorneal plaques with reduced corneal sensation. ASOCT demonstrated the presence of retrocorneal plaques with clear space between corneal endothelium and plaques. All cases received systemic and topical ganciclovir and topical steroids. Two patients received intravenous immunoglobulin (IVIG) weekly for 2 weeks. Complete resolution was achieved in all cases except one patient who underwent TPK because of diffuse anterior synechiae of the iris, with recurrence of infection after 10 days. The patients who received IVIG showed resolution earlier compared to the other patients.

CONCLUSIONS

Evaluation of characteristics of retrocorneal plaques by ASOCT and reduced corneal sensation are valuable aids in diagnosis of complicated viral keratitis. Conservative medical management may be a viable option even in severe cases. IVIG may have a role in speedy resolution of severe cases, but more research is needed to confirm this.

Development and multi-center validation of machine learning model for early detection of fungal keratitis

BACKGROUND

Fungal keratitis (FK) is a leading cause of corneal blindness in developing countries due to poor clinical recognition and laboratory identification. Here, we aimed to identify the distinct clinical signature of FK and develop a diagnostic model to differentiate FK from other types of infectious keratitis.

METHODS

We reviewed the electronic health records (EHRs) of all patients with suspected infectious keratitis in Beijing Tongren Hospital from January 2011 to December 2021. Twelve clinical signs of slit-lamp images were assessed by Lasso regression analysis and collinear variables were excluded. Three models based on binary logistic regression, random forest classification, and decision tree classification were trained for FK diagnosis and employed for internal validation. Independent external validation of the models was performed in a cohort of 420 patients from seven different ophthalmic centers to evaluate the accuracy, specificity, and sensitivity in real world.

FINDINGS

Three diagnostic models of FK based on binary logistic regression, random forest classification, and decision tree classification were established and internal validation were achieved with the mean AUC of 0.916, 0.920, and 0.859, respectively. The models were well-calibrated by external validation using a prospective cohort including 210 FK and 210 non-FK patients from seven eye centers across China. The diagnostic model with the binary logistic regression algorithm classified the external validation dataset with a sensitivity of 0.907 (0.774, 1.000), specificity 0.899 (0.750, 1.000), accuracy 0.905 (0.805, 1.000), and AUC 0.903 (0.808, 0.998).

INTERPRETATION

Our model enables rapid identification of FK, which will help ophthalmologists to establish a preliminary diagnosis and to improve the diagnostic accuracy in clinic.

FUNDING

The Open Research Fund from the National Key Research and Development Program of China (2021YFC2301000) and the Open Research Fund from Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beijing Tongren Hospital, Beihang University &Capital Medical University (BHTR-KFJJ-202001) supported this study.

A case of Candida albicans-induced fungal keratitis in a Chihuahua dog – with a focus on optical coherence tomographic features

A 4-year-old Chihuahua dog was referred for bilateral corneal ulcers. Slightly raised white fluorescein-positive plaque-like corneal lesions in both eyes appeared as intense hyperreflective areas with posterior shadowing on optical coherence tomography (OCT). Based on corneal cytology and culture, Candida albicans-induced fungal keratitis was diagnosed. Despite treatment, on OCT, endothelial plaques, increased stromal infiltration thickness, vertical shapes of the ulcer edge, and necrotic stromal space were judged to be aggravation of the disease, and surgery was performed. Conjunctival grafting surgery with topical 1% voriconazole effectively resolved fungal keratitis. OCT can provide detailed and objective information related to the disease prognosis.

Clinical Observation of Corneal Endothelial Plaques With Fungal and Bacterial Keratitis by Anterior Segment Optical Coherence Tomography and In Vivo Confocal Microscopy

PURPOSE

Endothelial plaque is an important sign of fungal keratitis and is related to diagnosis, surgical indications, and prognosis. However, bacterial keratitis sometimes involves fibrin formation on the back corneal surface, similar to endothelial plaques. Because corneal infiltration interferes with precise observation of the posterior corneal plaque, distinguishing pathogens with a slitlamp is difficult. We hope to assist clinicians in early diagnosis and timely treatment by observing the connection state of endothelial plaques and the corneal endothelium through anterior segment optical coherence tomography (AS-OCT) and the different forms of endothelial plaques in infectious keratopathy through in vivo confocal microscopy (IVCM).

METHODS

We analyzed 52 patients in the Eye Hospital of the First Affiliated Hospital of Harbin Medical University who were clearly diagnosed with fungal or bacterial keratitis with endothelial plaques. All patients underwent AS-OCT and IVCM on admission.

RESULTS

According to the smear, IVCM, or fungal and bacterial culture results, the patients were diagnosed with fungal (28 patients) or bacterial keratitis (24 patients). AS-OCT in 25 patients diagnosed with fungal keratitis revealed that the corneal endothelium-endothelial plaque boundary was unclear and wavy, and 24 patients had unclear cell boundaries and a large number of compactly distributed inflammatory cells in the endothelial layer according to IVCM. AS-OCT in 23 patients diagnosed with bacterial keratitis revealed clear corneal endothelium-endothelial plaque boundaries, and insufficient endothelial cell boundaries with a large number of visible and scattered inflammatory cell structures were observed through IVCM in 22 patients.

CONCLUSIONS

Corneal endothelial plaque detection by AS-OCT and IVCM can be used for early diagnosis of infectious keratitis.

Therapy for contact lens-related ulcers

PURPOSE OF REVIEW

The current review covers the current literature and practice patterns of antimicrobial therapy for contact lens-related microbial keratitis (CLMK). Although the majority of corneal ulcers are bacterial, fungus and acanthamoeba are substantial contributors in CLMK and are harder to treat due to the lack of commercially available topical medications and low efficacy of available topical therapy.

RECENT FINDINGS

Topical antimicrobials remain the mainstay of therapy for corneal ulcers. Fluoroquinolones may be used as monotherapy for small, peripheral bacterial ulcers. Antibiotic resistance is a persistent problem. Fungal ulcers are less responsive to topical medications and adjunct oral or intrastromal antifungal medications may be helpful. Acanthamoeba keratitis continues to remain a therapeutic challenge but newer antifungal and antiparasitic agents may be helpful adjuncts. Other novel and innovative therapies are being studied currently and show promise.

SUMMARY

Contact lens-associated microbial keratitis is a significant health issue that can cause vision loss. Treatment remains a challenge but many promising diagnostics and procedures are in the pipeline and offer hope.

Endothelial Biopsy for the Diagnosis and Management of Culture-Negative Retrocorneal Fungal Keratitis With the Assistance of Optical Coherence Tomography Imaging

PURPOSE

To report a case of a culture-negative deep fungal corneal infection that was diagnosed after histopathology of an anterior segment optical coherence tomography-guided endothelial biopsy.

METHODS

A 22-year-old woman with history of contact lens wear and concomitant topical steroid use presented with a mid-stromal corneal infiltrate that failed to respond to oral acyclovir and topical fortified antibiotics. Although cornea stains, cultures, and confocal microscopy showed negative results, there was high clinical suspicion for fungal keratitis. After 2 months on topical natamycin, oral voriconazole, and serial intrastromal and intracameral voriconazole injections, the infiltrate enlarged and deepened. Imaging with anterior segment optical coherence tomography revealed that the infection had progressed to an endothelial plaque.

RESULTS

Diagnostic endothelial biopsy was performed in the operating room. Cultures showed again negative results, whereas histopathology of the removed specimen revealed fungal elements. The postoperative edema at the site of the biopsy resolved over the course of 4 weeks, and a posterior stromal scar formed. Serial intrastromal and intracameral voriconazole injections were continued for the first postoperative month. At the 1-year and the 3-year follow-up examinations, the patient's vision was 20/20 without recurrence.

CONCLUSIONS

Intraoperative scraping of the endothelial plaque and histopathologic evaluation of the specimen proved to be of utmost importance for definitive diagnosis and resolution of the culture-negative deep fungal infection in this case. This young patient's cornea was retained and vision remains excellent.

Effective diagnosis by real-time PCR of herpes simplex diffuse endotheliitis that is similar in appearance to fungal keratitis: case series

Purpose

Herpes simplex diffuse endotheliitis with accompanying feathery infiltration is difficult to diagnose due to corneal findings that are similar to fungal keratitis. This case series reports on the effectiveness of using real-time polymerase chain reaction (PCR) to diagnose herpes simplex diffuse endotheliitis that is similar in appearance to fungal keratitis.

Methods

After extracting corneal smear sample DNA, samples were then applied to two independent PCR assays, a qualitative multiplex 24-pathogen strip PCR assay, and a quantitative real-time PCR assay of herpes simplex virus type 1 (HSV-1).

Results

All 3 cases showed ciliary injection, feathery infiltration in the corneal stroma and hypopyon, which are corneal findings similar to that observed for fungal keratitis. Retrocorneal plaques, which showed clear boundaries between the corneal endothelial surfaces and retrocorneal plaques in anterior segment optical coherence tomography, were observed in 2 out of 3 cases. Corneal scraping was performed in all cases, followed by initiation of antifungal treatment. However, real-time PCR of the corneal scraping detected 6.0 × 10⁶, 1.0 × 10⁵ and 5.0 × 10⁵ copies/μg glyceraldehyde 3-phosphate dehydrogenase (GAPDH) of HSV-1 DNA per each microgram of the samples. Fungi were not cultured in any of the cases. After switching the medication from antifungal to antiviral, the feathery corneal infiltration was cured with only mild scarring.

Conclusions

Real-time PCR was an effective tool in diagnosing HSV diffuse endotheliitis with feathery infiltration. Topical corticosteroids in conjunction with oral and topical antivirals were an effective treatment.

The Value of Anterior Segment Optical Coherence Tomography in Different Types of Corneal Infections: An Update

Anterior segment optical coherence tomography (AS-OCT) is a modality that uses low-coherence interferometry to visualize and assess anterior segment ocular features, offering several advantages of being a sterile and noncontact modality that generates high-resolution cross-sectional images of the tissues. The qualitative and quantitative information provided by AS-OCT may be extremely useful for the clinician in the assessment of a wide spectrum of corneal infections, guiding in the management and follow-up of these patients. In clinical practice, infections are routinely evaluated with slit-lamp biomicroscopy, an examination and imaging modality that is limited by the physical characteristics of light. As a consequence, the depth of pathology and the eventually associated corneal edema cannot be accurately measured with the slit-lamp. Therefore, it represents a limit for the clinician, as in vivo information about corneal diseases and the response to treatment is limited. Resolution of corneal infection is characterized by an early reduction in corneal edema, followed by a later reduction in infiltration: both parameters can be routinely measured with standardized serial images by AS-OCT.

Beauveria bassiana keratitis: Management of an atypical clinical presentation

We report an atypical presentation of Beauveria bassiana keratitis which unusually presented in a 85-year-old patient with a corneal ulcer with an anterior segment inflammation and hypopyon. Despite negative culture and unspecific results from panfungal PCR-based sequencing, the patient was treated for a presumed fungal infection. Following clinical deterioration an emergency surgical intervention with apposition of a corneal patch was performed. Infection resolution was achieved following the introduction of systemic voriconazole to the topical one.

Noninvasive Diagnosis of Viral Keratouveitis with Retro-corneal Endothelial Plaques: A Case Series

Purpose: The aim of this study was to evaluate the noninvasive diagnostic methods in managing the herpetic keratouveitis with retro-corneal endothelial plaques.Methods: 12 patients suspected to have unilateral herpetic keratouveitis with retro-corneal endothelial plaques were included. Slit lamp photos, AS-OCT, IVCM and corneal scraping culture were taken in all cases to help diagnosing and managing the disease. All patients received systemic and topical anti-viral treatment immediately and combined with topical steroids three days later.Results: Corneal scraping culture ruled out bacterial and fungal infection. AS-OCT showed that the boundaries between the corneal endothelial surface were clear in all patients. Corneal endothelial density and subbasal nerve plexus significantly decreased in all patients. Endothelial plaques reduced or disappeared in all patients with the treatment.Conclusions: Retro-corneal endothelial plaques and hypopyon are associated clinical manifestations of viral keratouveitis. AS-OCT and IVCM enhanced early detection and assessment during the follow-ups of the disease.

Ocular Phaeohyphomycosis Caused by Veronaea botryose: A Novel Fungal Infection in Human Beings

PURPOSE

To describe an aggressive, refractory case of Veronaea botryosa-associated mycokeratitis progressing to endophthalmitis.

METHODS

Observational case report and review of relevant literature.

RESULTS

An 80-year-old man with a history of lung cancer and diabetes mellitus type 2 presented as an emergent referral to the corneal service with a corneal ulcer and associated endothelial plaque that responded initially to topical steroid and antiviral therapy but subsequently progressed to fungal endophthalmitis. The patient underwent an emergent penetrating keratoplasty and pars plana vitrectomy. Despite multiple negative Grocott methenamine silver smears, gram stains, eye cultures (aerobic, anaerobic, and fungal), and inconclusive confocal microscopy, the host corneal tissue pathology revealed melanin-containing fungi (phaeohyphomycosis). Further speciation of the pathology specimen revealed mold and phenotypic characterization and DNA sequencing confirmed V. botryose.

CONCLUSIONS

Veronaea botryose is a rare fungal infection with previously reported human cutaneous, subcutaneous, and submucosal infections. This is the first documented case of phaeohyphomycosis caused by V. botryosa infection in human ocular tissue.

Endothelial Plaques as Sign of Hyphae Infiltration of Descemet's Membrane in Fungal Keratitis

Background

To evaluate the relationship between corneal endothelial plaques and fungal hyphae infiltration in fungal keratitis.

Methods

Retrospective cross-sectional study of 60 fungal keratitis patients who underwent keratoplasty between January 2013 and March 2017. The endothelial plaques were graded as follows: grade 1, 1–3 endothelial plaques; grade 2, 4–8 endothelial plaques; and grade 3, more than 8 endothelial plaques or dense, merging endothelial plaques. The fungal pathogen culture and histopathology of diseased Descemet's membrane were evaluated.

Results

According to endothelial plaque grading, 3 patients were grade 1, 29 patients were grade 2, and 28 patients were grade 3. The PK surgery was performed in 57 patients with endothelial plaques of grade 2 and grade 3 and DALK surgery in 3 patients of grade 1. The predominating fungal pathogens were Aspergillus species (63.2%). All 57 patients with grade 2 and grade 3 had fungal hyphae in Descemet's membrane based on calcofluor white staining or PAS staining. In patients with grade 3, more hyphae and inflammatory cells were found in Descemet's membrane. The immunohistochemical staining of endothelial plaques revealed that CD15 and CD68 were positive in most cells. During the follow-up, 2 out of 3 patients who underwent DALK had recurrent fungal keratitis.

Conclusions

Endothelial plaques are considered as a sign of hyphae infiltrating Descemet's membrane. PK should be performed once plaques are detected in endothelium during the surgery.

Anterior segment optical coherence tomography imaging in peripheral ulcerative keratitis, a corneal structural description

Background

Anterior segment optical coherence tomography (AS OCT) is a helpful tool used to diagnose and manage many corneal conditions, but its use has not been reported in case of peripheral ulcerative keratitis (PUK). The aim of this study is to describe AS OCT findings in cases of PUK.

Methods

Retrospective observational case series of six eyes presenting with a PUK and proven systemic vasculitis. Clinical course, slit lamp photographs, and AS OCT findings were the main outcomes.

Results

The AS OCT findings were found to correlate with the ocular disease’s level of activity. In the acute stage, an absence of corneal epithelium, a scrambled appearance of the anterior stroma and a heterogeneous stromal reflectivity were observed. During the reduction of disease level activity, an irregular hyporeflective epithelium, a smoother anterior stroma, and a homogenous hyperreflective stroma were seen. At the healed stage, a filling of the corneal defect by a hyporeflective thick epithelium, the persistence of the hyperreflective underlying stroma, and a demarcation line were observed. The mean total corneal thickness at last follow-up was significantly thicker (509 ± 147 μm) compared with the mean corneal thickness at onset (408 ± 131 μm; P = 0.03).

Conclusions

AS OCT provides an assessment of structural changes occurring in PUK, useful for its diagnosis and monitoring.

Safety of retrocorneal plaque aspiration for managing fungal keratitis

PURPOSE

To evaluate the safety of retrocorneal plaque aspiration in patients with fungal keratitis.

STUDY DESIGN

Retrospective study.

METHODS

A retrospective case series of fungal keratitis seen at Kyoto Prefectural University of Medicine between November 2013 and September 2018. Patients with retrocorneal plaque who underwent retrocorneal plaque aspiration for the diagnosis and treatment of fungal keratitis were included. The retrocorneal plaques were either aspirated using a tuberculin syringe with a 27-gauge blunt needle or were directly pulled out using a forceps. The anterior chamber was carefully washed out using bimanual irrigation and aspiration (I/A). Diagnosis accuracy and treatment safety were evaluated.

RESULTS

Five eyes of five patients aged 68.4 ± 13.0 years old (range: 45-81 years) were included. Three of the five patients (60%) were positive for fungus obtained from corneal scrapings. Retrocorneal plaque aspiration improved the diagnosis accuracy to five out of five patients (100%), including two cases positive to Fungiflora Y^® staining. Three of the five patients (60%) had good response rapidly after retrocorneal plaque aspiration, and two patients received therapeutic keratoplasty. All cases were finally stabilized without severe complications.

CONCLUSION

Retrocorneal plaque aspiration may be useful for the precise diagnosis of fungal keratitis.

The clinical and microbiological features and outcomes of fungal keratitis over 9 years in Sydney, Australia

To describe the clinical features, management and outcomes in patients with fungal keratitis at the Sydney Eye Hospital, Australia, over a 9-year period to guide appropriate initial therapy. A retrospective case review was conducted. Patients diagnosed with fungal keratitis from 1 January 2009 to 31 December 2017 were identified from hospital coding and pathology databases. Data were extracted from the medical records. A total of 55 episodes from 51 patients were included. Mean age was 60 ± 20 years (range: 19-91 years), and 33 were male. The fungal species was not identified in two patients. Predisposing factors included ocular surface disease in 17 eyes (32%); corneal disease, 15 (28%); corneal trauma, 12 (23%); and contact lens wear, 13 (24.5%). Fusarium spp. (15, 27%) and Candida parapsilosis (10, 18%) were the most common isolates. The median visual acuity at presentation was 1.3 logMAR (range: 0 to 3) and after treatment 0.7 logMAR (range: -0.02 to 3) (P = .008). Despite medical therapy, most commonly with natamycin and topical and oral voriconazole, surgical intervention was required in 21 eyes (40%); including antifungal injections in 9 (16%); corneal transplantation, 16 (30%); evisceration, 2 (4%); and enucleation, 1 (2%). A poor visual outcome was recorded in 27 of 43 (63%) patients. Fungal keratitis remains a cause of significant ocular morbidity; the majority of patients face a poor outcome despite intense medical and at times surgical treatment. In our setting, fungal keratitis was more commonly associated with corneal or ocular surface disease.

Severity Assessment of Acute Hydrops Due to Recurrent Keratoconus after Penetrating Keratoplasty Using Anterior Segment Optical Coherence Tomography

Purpose: To compare the clinical characteristics of acute hydrops between eyes with recurrent keratoconus and eyes with treatment-naïve keratoconus.Methods: Six eyes with acute hydrops caused by recurrent keratoconus (recurrent group) and 29 eyes with acute hydrops due to treatment-naïve keratoconus (naïve group) were included. We collected data from anterior-segment optical coherence tomography (AS-OCT), corneal topography and medical records. With AS-OCT, we investigated the location of Descemet's membrane break, the length and frequency of Descemet's membrane detachment, and the speed of corneal thinning before acute hydrops.Results: Descemet's membrane breaks were detectable in 6 cases in the recurrent group (100%) and 7 cases in the naïve group (70%). Distance from the break to the central line was 2-3 mm in the recurrent group, and less than 1 mm in the naïve group (p < .001). Detachment length was significantly greater in the recurrent group than in the naïve group (p = .003). Steep corneal power values tended to increase before acute hydrops in the recurrent group, but the difference between groups was not significant (observation period; 6.03 ± 2.67, 7.36 ± 5.53 years, respectively). Penetrating keratoplasty was required in 5 cases (83%) in the recurrent group, and 8 cases (28%) in the naïve group (p = .02).Conclusions: Acute hydrops due to recurrent keratoconus occurred around graft-host junctions and was more severe than that in eyes with treatment-naïve keratoconus. Severity assessment of Descemet's membrane detachment using AS-OCT provided clues not only for diagnosis, but also for predicting prognosis.