Corneal perforation in ocular graft-versus-host disease

Purpose

Corneal perforation is a rare, vision-threatening complication of ocular graft-versus-host disease (GVHD) and is not well understood. Our objective was to examine the clinical disease course and histopathologic correlation in patients who progressed to this outcome.

Methods

This study is a retrospective case series from four academic centers in the United States. All patients received a hematopoietic stem cell transplant (HSCT) prior to developing ocular GVHD. Variables of interest included patient demographics, time interval between HSCT and ocular events, visual acuity throughout clinical course, corticosteroid and infection prophylaxis regimens at time of corneal perforation, medical/surgical interventions, and histopathology.

Results

Fourteen eyes from 14 patients were analyzed. Most patients were male (86%) and Caucasian (86%), and average age at time of hematopoietic stem cell transplant was 47 years. The mean interval between hematopoietic stem cell transplant and diagnosis of ocular graft-versus-host disease was 9.5 months, and between hematopoietic stem cell transplant and corneal perforation was 37 months. Initial best-corrected visual acuity was 20/40 or better in 9 eyes, and all eyes had moderate or poor visual outcomes despite aggressive management, including corneal gluing in all patients followed by keratoplasty in 8 patients. The mean follow-up after perforation was 34 months (range 2–140 months). Oral prednisone was used prior to perforation in 11 patients (79%). On histopathology, representative specimens in the acute phase demonstrated ulcerative keratitis with perforation but minimal inflammatory cells and no microorganisms, consistent with sterile corneal “melt” in the setting of immunosuppression; and in the healed phase, filling in of the perforation site with fibrous scar.

Conclusions

In these patients, an extended time interval was identified between the diagnosis of ocular graft-versus-host disease and corneal perforation. This represents a critical window to potentially prevent this devastating outcome. Further study is required to identify those patients at greatest risk as well as to optimize prevention strategies.

A masquerader? Paecilomyces must be distinguished from Penicillium in fungal keratitis: a report of two contrasting cases

We describe the clinical outcomes of two contrasting cases of fungal keratitis due to Paecilomyces spp. The first case involving a 58-year-old woman was complicated by an initial laboratory misidentification as Penicillium and consequently a delay in treatment with an optimised antifungal regimen. The patient had a protracted clinical course that required a total of four penetrating keratoplasties. However, an accurate diagnosis was promptly made in the second case, a 46-year-old woman, which resulted in a satisfactory outcome after penetrating keratoplasty. Our principal aim was to highlight a diagnostic challenge relating to the accurate microbial identification of Paecilomyces spp. This can be difficult given its morphological similarity to Pencillium, and confusion over the two genera has resulted in misdiagnoses reported previously. Our report aims to raise awareness of this potential laboratory misidentification, which can affect clinical decision-making in guiding antimicrobial therapy.

Novel CHST6 gene mutations in 2 unrelated cases of macular corneal dystrophy

PURPOSE

To investigate the possible mutations in the carbohydrate sulfotransferase 6 (CHST6) gene of 2 unrelated cases of macular corneal dystrophy (MCD) and to report atypical stromal deposits in one of them.

METHODS

Corneal tissues were stained with antisulfated keratan sulfate (KS), antitransforming growth factor beta 1-induced protein (TGFBIp), thioflavin-T, alcian blue, and Masson trichrome. Sequencing was performed to identify potential mutations in the CHST6 gene and the fourth and twelfth exons of the TGFBI gene.

RESULTS

Alcian blue staining revealed the presence of multiple subepithelial and intrastromal mucopolysaccharide deposits, confirming the diagnosis of MCD in both cases. Immunofluorescence staining in case 1 revealed the presence of sulfated KS only in the keratocytes and select endothelial cells, consistent with MCD type IA. Preferential expression of sulfated KS was observed in keratocytes and extracellular stromal matrix in case 2, consistent with MCD type II. Atypical subepithelial and superficial stromal deposits were observed in case 1, which stained positively with alcian blue, eosin, Masson trichrome, and thioflavin-T indicating the presence of hyaline and amyloid materials. CHST6 gene sequencing revealed 2 heterozygous mutations in case 1 (a p.Arg211Gln and a novel mutation of p.Arg177Gly) and a novel homozygous mutation of p.Pro186Arg in case 2. No mutations were found in exons 4 or 12 of the TGFBI gene in case 1.

CONCLUSIONS

Secondary hyalinosis and amyloidosis occur in a case of MCD type IA with a novel p.Arg177Gly mutation in CHST6. A novel p.Pro186Arg mutation in CHST6 is associated with MCD type II in an African American.

Unexpected corneal endothelial cell decompensation after intraocular surgery with instruments sterilized by plasma gas

PURPOSE

Ten cases of unexpected corneal endothelial cell decompensation occurring after routine intraocular surgery using instruments sterilized with a new plasma gas protocol are described.

DESIGN

A retrospective observational case series with 1 year of follow-up was conducted.

RESULTS

All patients had corneal decompensation and nonreactive pupils after surgery. Six patients required penetrating keratoplasty. Three patients partially recovered pupillary function. Visual acuity at 1 year ranged from 20/20 to hand motion (HM). One patient with an anterior chamber intraocular lens (ACIOL) experienced optic atrophy and HM vision despite resolution of corneal edema.

CONCLUSIONS

Toxic corneal endothelial cell destruction syndrome was associated with the introduction of plasma gas sterilization protocols.

Recurrent corneal ulcerations associated with smokeable methamphetamine abuse

PURPOSE

We studied a case of chronic, recurrent, bilateral, corneal ulcerations associated with smokeable methamphetamine abuse, commonly known as "ice," in an otherwise healthy 31-year-old woman.

METHODS

Every few months the patient had recurrent corneal ulcerations. Each time, she was hospitalized and treated successfully with topical antibiotics.

RESULTS

Even though she had undergone numerous formal attempts at drug rehabilitation, she continued to have relapses, and ulceration recurred only during periods of smokeable methamphetamine abuse.

CONCLUSION

Illicit use of smokeable methamphetamine may result in corneal ulceration.

Cystic hydrops and spontaneous perforation in Fuchs' superficial marginal keratitis

PURPOSE

We studied a case of Fuchs' superficial marginal keratitis in which cystic corneal hydrops developed in one eye, and spontaneous corneal perforation occurred in the fellow eye.

METHODS

The patient underwent bilateral annular corneoscleral lamellar patch grafts for tectonic support.

RESULTS

The patient had an uncomplicated postoperative course and visual acuity of 20/25 bilaterally.

CONCLUSION

Stromal loss in Fuchs' superficial marginal keratitis may be severe enough to result in cystic corneal hydrops. Patients with this disorder should be counseled regarding the possibility of corneal perforation.

Penetrating keratoplasty and transscleral fixation of posterior chamber lens

We reviewed the outcome in 115 patients who underwent penetrating keratoplasty and transscleral fixation of a posterior chamber lens. One patient died soon after surgical procedures, and nine patients were lost to follow-up, leaving a cohort of 105 patients. Mean follow-up time was 26.8 months (range, six to 43 months). Visual acuity of 20/40 or better was found in 29 patients (27.6%) and 20/50 to 20/200 in 37 patients (35.2%). Reasons for poor visual outcome included cystoid macular edema in ten patients (9.5%), age-related macular degeneration in six patients (5.7%), and retinal detachment in four patients (3.8%). None of the patients developed lens decentration. There were no instances of hyphema and only one patient had a perioperative limited suprachoroidal hemorrhage. New-onset increase in intraocular pressure developed in 20 of 66 patients (30.3%). Analysis of the 39 patients with preoperative increase in intraocular pressure that required medical treatment demonstrated an improvement in 13 patients (33.3%), worsening in 12 patients (30.8%), and unchanged status in 14 patients (35.9%). The exposed haptic suture was covered by using one of the following three alternative methods: a conjunctival flap, a scleral flap, or a corneal tissue button. Exposure of the haptic suture through the conjunctiva was a complication in 21 patients (20%). Of these 16 (76.1%) occurred in the group with a conjunctival covering, five (23.8%) occurred in the group with a scleral flap, and none occurred in the corneal tissue button group. This study demonstrated that transscleral fixation of a posterior chamber lens is a viable option in the treatment of patients undergoing penetrating keratoplasty and intraocular lens implantation with absent capsular support.

Posterior infectious crystalline keratopathy with Staphylococcus epidermidis

Two cases of infectious crystalline keratopathy located in the posterior stroma after penetrating keratoplasty are presented. Topical steroids and suture removal were risk factors in both cases. In the first case, a moderate anterior chamber reaction was present. Crystalline infiltrates persisted on topical and systemic steroid therapy. In the second case, deep corneal ulceration, hypopyon, and vitreitis were noted. A vitreous aspirate showed rare gram-positive cocci in pairs. The corneal ulceration and crystalline keratopathy persisted despite intravitreal and topical antibiotics. Therapeutic penetrating keratoplasty was performed in both cases. Staphylococcus epidermidis sensitive to vancomycin was isolated from corneal tissue. Light microscopy documented aggregates of gram-positive bacteria anterior to Descemet's membrane, with an overlying keratitis. Electron microscopy in the second case showed all bacteria within stromal keratocytes. No clinical recurrence was seen using topical vancomycin. As demonstrated in the cases presented, infectious crystalline keratopathy can occur exclusively in the deeper layers of the cornea. Isolation of S. epidermidis, associated inflammation, and intraocular spread of organisms are rare findings.

Histologic study of eyes with transsclerally sutured posterior chamber intraocular lenses

We studied the postmortem histologic characteristics of two eyes that had undergone penetrating keratoplasty and transscleral suturing of a posterior chamber intraocular lens for bullous keratopathy. The eyes were studied three days postoperatively in a 79-year-old man with pseudophakia and six months postoperatively in an 83-year-old man with aphakia. We also removed a posterior chamber intraocular lens in a 73-year-old woman who had an epithelial downgrowth three months postoperatively. In the first two cases, only one of four haptics was successfully positioned in the sulcus. Histologic study disclosed a thin fibrous capsule surrounding the haptics at their attachment site, no inflammation around the transscleral portion of the suture, and exposure of a suture tip externally. In the third case, the intraocular lens fell back into the vitreous cavity after the fixation sutures were cut externally at the time of surgical removal. Stability of the lens in all three cases was primarily a result of intact transcleral sutures and not fibrous encapsulation or ciliary sulcus placement of haptics.

Traumatic air blast injury with intracranial, bilateral orbital, and mediastinal air

Air at 75 lbs/sq in from an air compressor hose struck a 19-year-old man in his right eye. Injected through a superior conjunctival laceration, the air entered subcutaneous, mediastinal, and bilateral orbital and intracranial spaces. High-resolution computed tomography scanning of the head and orbits revealed air adjacent to the right optic nerve throughout the orbit. We hypothesize that air was injected intracranially, but extradurally, through the superior orbital fissure. The patient suffered no visual loss.

A temperature-dependent choice in cell differentiation

Ascension of the cell mass during culmination was observed to be temperature-sensitive in strain HH31 of the cellular slime mold Dictyostelium discoideum. A sequence of additional developmental abnormalities was also observed both preceeding and succeeding culmination. Slugs reared at the restrictive temperature (27 degrees C), in contrast to those reared at the permissive temperature (22 degrees C), were deficient in the expression of six prespore markers and elevated in the production of four prestalk markers. Following attempted culmination at the restrictive temperature, the majority of cells were stalk cells according to fluorescence, phase contrast, electron microscopic, biochemical, and plating efficiency criteria. These findings were correlated with a general diminution of staining of slug cell Membrane extracts on polyacrylamide gels with FITC-wheat germ agglutinin. The effect of the higher temperature was readily reversible prior to terminal differentiation. An interdependence of several of the changes was suggested by the observation that in two derivative strains the temperature-dependence of these changes was coordinately altered. In summary, a large fraction of the slug cells of HH31 appear to be temperature-dependent in their choice of pathways of cell differentiation, this change is related to a modification of the cell surface, and the choice made in the slug is remembered by cells as they terminally differentiate.