Acute corneal perforation 1 week following uncomplicated cataract surgery: the implication of undiagnosed dry eye disease and topical NSAIDs

Bromfenac-induced neurotrophic keratitis in a corneal graft

A man in his 30s, with a history of two operated penetrating keratoplasty (PK), primarily for viral keratitis, presented with pain, redness and diminution of vision in his left eye of 4 days duration. Postoperatively, he was prescribed oral antivirals, topical steroid eyedrops, lubricants and antiglaucoma medications. Eight months after transplantation, an epithelial defect with heaped up margins was noted on anterior segment evaluation on a routine follow-up visit. On checking his medications, it was found that the patient was unknowingly using bromfenac drops in place of brimonidine tartrate for the past month. A diagnosis of neurotrophic keratitis was made in the setting of PK performed for viral keratitis, incited by use of topical bromfenac. The patient was prescribed preservative-free lubricants with immediate discontinuation of bromfenac drops. Topical steroid drops were withheld till the epithelial defect healed. Complete healing of the defect was noted after 4 weeks of therapy.

Host Defense Peptides at the Ocular Surface: Roles in Health and Major Diseases, and Therapeutic Potentials

Sight is arguably the most important sense in human. Being constantly exposed to the environmental stress, irritants and pathogens, the ocular surface – a specialized functional and anatomical unit composed of tear film, conjunctival and corneal epithelium, lacrimal glands, meibomian glands, and nasolacrimal drainage apparatus – serves as a crucial front-line defense of the eye. Host defense peptides (HDPs), also known as antimicrobial peptides, are evolutionarily conserved molecular components of innate immunity that are found in all classes of life. Since the first discovery of lysozyme in 1922, a wide range of HDPs have been identified at the ocular surface. In addition to their antimicrobial activity, HDPs are increasingly recognized for their wide array of biological functions, including anti-biofilm, immunomodulation, wound healing, and anti-cancer properties. In this review, we provide an updated review on: (1) spectrum and expression of HDPs at the ocular surface; (2) participation of HDPs in ocular surface diseases/conditions such as infectious keratitis, conjunctivitis, dry eye disease, keratoconus, allergic eye disease, rosacea keratitis, and post-ocular surgery; (3) HDPs that are currently in the development pipeline for treatment of ocular diseases and infections; and (4) future potential of HDP-based clinical pharmacotherapy for ocular diseases.

Reducing omission of eye drops during hospital admission

Background/aims

Chronic ophthalmic conditions, such as glaucoma and dry eye disease, are frequently encountered debilitating eye conditions that can lead to substantial reduction in vision and quality of life. However, there is ongoing evidence to suggest that topical ophthalmic therapy is inappropriately omitted on admission to hospital. The primary aim of this audit was to investigate the trust adherence to the National Institute for Health and Care Excellence guideline on the prescribing standard of eye drops during hospital admission. The secondary aim was to raise awareness and ensure successful compliance with national standards to reduce unintentional omission of eye drops on admission and subsequent complications.

Method

Electronic medical records of all medical and surgical adult inpatients were studied prospectively on two different occasions. The quality of documentation of eye drops in clerking notes, the length of time taken between the admission and prescription of eye drops, and the accuracy of the prescription were examined. Following the initial audit, interventions focusing on clinician education were implemented. This includes highlighting the importance of eye drops in all departmental mandatory introductory sessions and putting up posters on all the wards as prompts. The same data collection method was used in the reaudit.

Results

In the initial audit, 64 (mean age 81.8±8.9 years) patients with regular prescriptions for eye drops were identified; 38 (59.4%) patients had eye drops for dry eye disease only, 20 (31.3%) patients had eye drops for glaucoma only, and six (9.4%) patients had eye drops for both. In the reaudit, 57 (mean age 76.7±15.3 years) patients were identified; 42 (73.7%) patients had eye drops for dry eye disease only, 10 (17.5%) patients had eye drops for glaucoma only, and five (8.8%) patients had eye drops for both. Following the intervention, there was a significant improvement in documentation of ocular diagnosis and eye drops on clerking notes from 41% to 65% (P=0.008), and eye drop reconciliation within 24 hours of admission improved from 45% to 75% (P=0.0008). All patients (100%) received the correct eye drop prescription before and after the intervention.

Conclusions

Education is effective in promoting adherence to national guidelines and reducing the incidence of inappropriate omission of eye drops on admission to hospital.

Risk Factors, Clinical Outcomes, and Prognostic Factors of Bacterial Keratitis: The Nottingham Infectious Keratitis Study

Background/Aim: To examine the risk factors, clinical characteristics, outcomes, and prognostic factors of bacterial keratitis (BK) in Nottingham, UK.

Methods: This was a retrospective study of patients who presented to the Queen's Medical Centre, Nottingham, with suspected BK during 2015–2019. Relevant data, including the demographic factors, risk factors, clinical outcomes, and potential prognostic factors, were analysed.

Results: A total of 283 patients (n = 283 eyes) were included; mean age was 54.4 ± 21.0 years and 50.9% were male. Of 283 cases, 128 (45.2%) cases were culture-positive. Relevant risk factors were identified in 96.5% patients, with ocular surface diseases (47.3%), contact lens wear (35.3%) and systemic immunosuppression (18.4%) being the most common factors. Contact lens wear was most commonly associated with P. aeruginosa whereas Staphylococci spp. were most commonly implicated in non-contact lens-related BK cases (p = 0.017). At presentation, culture-positive cases were associated with older age, worse presenting corrected-distance-visual-acuity (CDVA), use of topical corticosteroids, larger epithelial defect and infiltrate, central location and hypopyon (all p < 0.01), when compared to culture-negative cases. Hospitalisation was required in 57.2% patients, with a mean length of stay of 8.0 ± 8.3 days. Surgical intervention was required in 16.3% patients. Significant complications such as threatened/actual corneal perforation (8.8%), loss of perception of light vision (3.9%), and evisceration/enucleation (1.4%) were noted. Poor visual outcome (final corrected-distance-visual-acuity of <0.6 logMAR) and delayed corneal healing (>30 days from initial presentation) were significantly affected by age >50 years, infiltrate size >3 mm, and reduced presenting vision (all p < 0.05).

Conclusion: BK represents a significant ocular morbidity in the UK, with ocular surface diseases, contact lens wear, and systemic immunosuppression being the main risk factors. Older age, large infiltrate, and poor presenting vision were predictive of poor visual outcome and delayed corneal healing, highlighting the importance of prevention and early intervention for BK.

Real-world experience of using ciclosporin-A 0.1% (Ikervis) in the management of ocular surface inflammatory diseases

PURPOSE

To report the real-world experience of using topical ciclosporin, Ikervis, in the management of ocular surface inflammatory diseases (OSIDs).

METHODS

This was a retrospective study of patients treated with Ikervis for OSIDs at the Queen's Medical Centre, Nottingham, between 2016 and 2019. Relevant data, including demographics, indications, clinical parameters, outcomes and adverse events, were collected and analysed for patients who had completed at least 6 months follow-up. For analytic purpose, clinical outcome was categorised as 'successful' (resolved or stable disease), 'active disease' and 'drug intolerance'.

RESULTS

463 patients were included; mean age was 51.1±21.6 years, with a 59.0% female predominance. Mean follow-up was 14.6±9.2 months. The most common diagnosis was dry eye disease (DED; 322, 69.5%), followed by allergic eye disease (AED; 53, 11.4%) and ocular mucous membrane pemphigoid/Steven-Johnson syndrome (OMMP/SJS; 38, 8.2%). Successful treatment was achieved in 343 (74.1%) patients, with 44 (9.5%) requiring additional treatment and 76 (16.4%) reporting drug intolerance. The efficacy of Ikervis was highest in DED (264, 82.0%), followed by OMMP/SJS (25, 65.8%) and post-keratoplasty (7, 50.0%; p<0.001). Logistic regression analysis demonstrated age <70 years (p=0.007), AED (p=0.002) and OMMP/SJS (p=0.001) as significant predictive factors for Ikervis intolerance. AED and post-keratoplasty were 8.16 times (95% CI, 2.78 to 23.99) and 13.98 times (95% CI, 4.22 to 46.28), respectively, more likely to require additional treatment compared with DED.

CONCLUSIONS

Ikervis is a useful steroid-sparing topical treatment for managing OSIDs in the real-world setting. Preparations with improved tolerability are needed to benefit a larger number of patients.

Potential of mesenchymal stem cells as topical immunomodulatory cell therapies for ocular surface inflammatory disorders

Ocular surface inflammatory disorders (OSIDs) are a group of highly prevalent, heterogeneous diseases that display a variety of aetiologies and symptoms and are risk factors for serious complications, including ocular and cornea impairment. Corneal inflammation is a common factor of all OSIDs, regardless of their cause or symptoms. Current medications include over-the-counter lubricating eye drops, corticosteroids, and ciclosporin, which either do not treat the corneal inflammation or have been associated with multiple side effects leading to alternative treatments being sought. Regenerative medicine cell therapies, particularly mesenchymal stem cells (MSCs), have shown great promise for immunosuppression and disease amelioration across multiple tissues, including the cornea. However, for successful development and clinical translation of MSC therapy for OSIDs, significant problems must be addressed. This review aims to highlight considerations, including whether the source of MSC isolation impacts the efficacy and safety of the therapy, in addition to assessing the feasibility of MSC topical application to the cornea and ocular surface through analysis of potential scaffolds and cell carriers for application to the eye. The literature contains limited data assessing MSCs incorporated into scaffolds for corneal administration, thus here we highlight the necessity of further investigations to truly exploit the potential of an MSC-based cell therapy for the treatment of OSIDs.

Cataract Surgery in Dry Eye Disease: Visual Outcomes and Complications

Purpose: To describe the visual outcomes and complications following cataract surgery in dry eye disease (DED). Methods: This retrospective study included 668 eyes of 399 patients with DED, who underwent cataract surgery between 2011 and 2019 at our multi-tier ophthalmology hospital network. Based on etiology, they were divided into three groups: cicatrizing conjunctivitis (CC), meibomian gland dysfunction (MGD), and Sjogren's syndrome (SS). The data on demographics, visual impairment, surgical technique, visual outcomes, and complications were collected using an electronic medical record system. Median LogMAR best corrected visual acuity (BCVA) with interquartile range (IQR) was compared using Wilcoxon's rank sum test. Results: The median age at which cataract surgery was performed was 58 (IQR: 47-65) years. Etiology of DED was CC in 279, MGD in 255, and SS in 134 eyes. Most (471) eyes underwent phacoemulsification, under peribulbar anesthesia (548) through a temporal clear corneal incision (209) with foldable intraocular lens implantation (417). The overall median LogMAR BCVA improved from 1.1 (IQR: 0.6-2.1) at baseline to 0.3 (IQR: 0.1-0.7) and 0.1 (IQR: 0-0.65) at 1 and 6 weeks (p < 0.0001) post-operatively. The median 6 weeks post-operative BCVA was 0.3, 0.1, and 0.1 in CC, MGD, and SS, respectively, and significantly better than at baseline (p < 0.0001). The leading cause of sub-optimal vision was corneal scarring (44; 9%), and the most common complication was posterior capsular rupture with vitreous loss (23; 3%). Conclusion: Cataract surgery has good visual outcomes in patients with DED, without any disconcerting rate of complications. Pre-existing keratopathy is the main determinant of the extent of post-operative visual recovery.