Human MPox (Monkeypox) Virus Membranous Keratoconjunctivitis With Transient Corneal Hypoesthesia and Late Symblepharon Formation: A Novel Case and Clinical Implications

PURPOSE

The aim of this study was to describe a case of corneal involvement as an early manifestation of ocular disease in the 2022 human mpox (monkeypox) virus outbreak.

METHODS

This is a single case report with longitudinal care.

RESULTS

A 47-year-old immunocompetent man presented with viral conjunctivitis before development of skin lesions or systemic symptoms. Subsequently, he developed membranous keratoconjunctivitis and a corneal epithelial defect. Orthopoxvirus-positive polymerase chain reaction test from his ocular surface was positive. The epithelial defect did not heal with conservative treatment but was successfully treated with amniotic membrane transplantation over 8 days. Reduced corneal sensation was noted after epithelial healing, and polymerase chain reaction from the ocular surface remained positive at 17 days from symptom onset, with slowly recovering conjunctivitis at 21 days. Continued membrane formation required repeated removal but significantly improved with topical corticosteroid treatment after epithelial healing by 29 days of symptom onset. Corneal sensation normalized by 87 days from symptom onset at which time symblepharon were noted but PCR testing from the ocular surface was negative.

CONCLUSIONS

Early corneal involvement of human monkeypox virus is possible. Transient corneal hypoesthesia may be due to acute inflammation. Chronic inflammatory changes can result in symblepharon. These findings have potential implications in patient care and corneal donation.

Early Complications With Preloaded Descemet Membrane Endothelial Keratoplasty Are Not Dependent on Optisol-GS Washout or Trypan Blue Restaining

PURPOSE

To describe the intraoperative and early postoperative complications using preloaded Descemet membrane endothelial keratoplasty (DMEK) grafts with intraocular injection of the graft in Optisol-GS and omission of trypan blue restaining.

METHODS

This is a retrospective case series of 132 consecutive eyes with Fuchs endothelial dystrophy or endothelial failure who underwent DMEK using preloaded donor tissue prepared as previously described. The graft was not restained with trypan blue by the surgeon, and Optisol-GS was injected with the graft into the eye instead of being rinsed from the injector. Early postoperative complications (0-8 wk) including intraoperative fibrin formation, intraocular inflammation, elevated intraocular pressure, partial graft detachment requiring rebubble, and early graft failure were recorded.

RESULTS

No eyes developed intraoperative fibrin formation or postoperative inflammation (such as toxic anterior segment syndrome) or elevated intraocular pressure. For eyes with Fuchs corneal dystrophy, our rebubble rate was 21% (22/106 eyes). Early graft failure was noted in 2% (3/132 eyes), which is similar to previous reports.

CONCLUSIONS

Our results suggest that injection of Optisol-GS into the anterior chamber during DMEK graft injection does not lead to increases in intraoperative or early postoperative complications. Trypan blue restaining is not necessary for intraoperative visualization. This simplification can reduce graft manipulation and save time and resources for this procedure.

Contrast Sensitivity After Wavefront-Guided and Wavefront-Optimized PRK and LASIK for Myopia and Myopic Astigmatism

PURPOSE

To compare contrast sensitivity among participants undergoing wavefront-guided or wavefront-optimized photorefractive keratectomy (PRK) or LASIK for the treatment of myopia or myopic astigmatism 12 months after surgery.

METHODS

In a prospective, randomized clinical trial, 215 participants with myopia ranging from -0.50 to -7.25 diopters (D) and less than -3.50 D of manifest astigmatism electing to undergo either LASIK or PRK were randomized to receive wavefront-guided or wavefront-optimized treatment. Corrected Super Vision Test (Precision Vision, La Salle, IL) high contrast and small letter contrast sensitivity, uncorrected postoperative contrast sensitivity function, and uncorrected and corrected distance visual acuity were measured preoperatively and at 1, 3, 6, and 12 months postoperatively.

RESULTS

There was a significant difference within each of the four groups over time when measuring high contrast visual acuity (P < .001) and small letter contrast sensitivity (P < .001), with the most significant decrease occurring 1 month postoperatively. However, there were no significant differences when comparing the four groups for high contrast sensitivity (P = .22) or small letter contrast sensitivity (P = .06). The area under the logarithm of contrast sensitivity function did not differ significantly over time (P = .09) or between groups (P = .16). A pairwise comparison of preoperative to 12-month CDVA showed a significant improvement in all groups (P < .017). The change in CDVA was also significantly different between groups as determined by one-way analysis of variance (P = .003).

CONCLUSIONS

Wavefront-guided and wavefront-optimized PRK and LASIK procedures maintained high contrast, small letter contrast sensitivity, and contrast sensitivity function 12 months postoperatively. Although the recovery period for visual performance was longer for PRK versus LASIK, there was no significant difference in treatment type or treatment profile at 12 months postoperatively. [J Refract Surg. 2018;34(9):590-596.].

Wavefront-optimized surface retreatments of refractive error following previous laser refractive surgery: a retrospective study

Background

Retreatments are sometimes necessary to correct residual or induced refractive errors following refractive surgery. Many different combinations of primary treatment methods and retreatment techniques have been studied, however, few studies have investigated wavefront-optimized (WFO) technology for retreatment following primary refractive surgery. This study aimed to report the outcomes of WFO photorefractive keratectomy (PRK) retreatments of refractive error following previous laser refractive surgery with PRK, laser in situ keratomileusis (LASIK), or laser-assisted subepithelial keratectomy (LASEK).

Methods

We reviewed records of patients who underwent WFO PRK retreatments using the Allegretto Wave Eye-Q 400 Hz Excimer Laser System (Alcon Surgical) between January 2008 and April 2011 at Walter Reed Army Medical Center and Madigan Army Medical Center. Outcomes were recorded in terms of uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent (MRSE), corrected distance visual acuity (CDVA), and complications at 1 month (M), 3 M, and 6 M post-op.

Results

Seventy-eight patients (120 eyes) underwent WFO PRK retreatment during the study period. Primary surgery was surface ablation in 87 eyes (78 PRK, 9 LASEK) and LASIK in 33 eyes. The mean spherical equivalent before retreatment was −0.79 ± 0.94 D (−3.00 to 1.88 D). UDVA was ≥ 20/20 in 69 eyes (60.0 %) at 1 M, 54 eyes (71.1 %) at 3 M, and 27 eyes (73.0 %) at 6 M follow-up. MRSE was within ±0.50 D of emmetropia in 78 eyes (67.8 %) at 1 M, 59 eyes (77.6 %) at 3 M, and 25 eyes (67.6 %) at 6 M follow-up. CDVA was maintained within ±1 line of pre-op in 113 of 115 eyes (98.3 %) at 1 M, 74 of 76 eyes (97.4 %) at 3 M, and 37 eyes (100 %) at 6 M follow-up.

Conclusion

Although follow-up was limited beyond 3 M, WFO PRK retreatments in patients with residual refractive error may be a safe and effective procedure. Further studies are necessary to determine the long-term safety and stability of outcomes.

Severe eye injuries in the war in Iraq, 2003-2005

PURPOSE

To document the incidence and treatment of patients with severe ocular and ocular adnexal injuries during Operation Iraqi Freedom.

DESIGN

Retrospective hospital-based observational analysis of injuries.

PARTICIPANTS

All coalition forces, enemy prisoners of war, and civilians with severe ocular and ocular adnexal injuries.

METHODS

The authors retrospectively examined severe ocular and ocular adnexal injuries that were treated by United States Army ophthalmologists during the war in Iraq from March 2003 through December 2005.

MAIN OUTCOME MEASURES

Incidence, causes, and treatment of severe ocular and ocular adnexal injuries.

RESULTS

During the time data were gathered, 797 severe eye injuries were treated. The most common cause of the eye injuries was explosions with fragmentation injury. Among those injured, there were 438 open globe injuries, of which 49 were bilateral. A total of 116 eyes were removed (enucleation, evisceration, or exenteration), of which 6 patients required bilateral enucleation. Injuries to other body systems were common.

CONCLUSIONS

Severe eye injuries represent a significant form of trauma encountered in Operation Iraqi Freedom. These injuries were most commonly caused by explosion trauma.

The Effect of Moxifloxacin and Gatifloxacin on Long-term Visual Outcomes Following Photorefractive Keratectomy

PURPOSE

To compare the effect of gatifloxacin and moxifloxacin on visual outcomes after photorefractive keratectomy (PRK).

METHODS

Thirty-five PRK patients were treated postoperatively with gatifloxacin (Zymar) in one eye and moxifloxacin (Vigamox) in the fellow eye. Postoperative regimens were otherwise identical. In a previous study (initial phase), we evaluated epithelial healing. In this study (second phase), we compared uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), manifest spherical equivalent (MSE), and corneal haze at 6 months postoperatively for 32 patients using the Wilcoxon signed ranks test.

RESULTS

No statistically significant difference was noted between eyes treated with Zymar and Vigamox in terms of UCVA, BSCVA, MSE, or corneal haze at 6 months postoperatively. Two (6%) Vigamox-treated eyes versus 0 (0%) Zymar-treated eyes lost one line of BSCVA from preoperative examination. Median UCVA and MSE were equivalent for both groups.

CONCLUSIONS

At 6 months after PRK, there was no significant difference in visual outcomes with either antibiotic.

Digital imaging to assist preoperative planning for ipsilateral rotational autokeratoplasty

A 14-month-old child with a central corneal scar underwent rotational autografting of his cornea to clear his visual axis. This was accomplished through eccentric trephination and 180 degree rotation of the central cornea. A preoperative image of the patient's cornea was manipulated digitally using a common commercial image-processing software package. This allowed accurate prediction of the best trephine size and location prior to surgery. Digital imaging played an important role in preoperative surgical planning and demonstrates the potential for tele-ophthalmology.

AcanthamoebaKeratitis in a U.S. Army Soldier after Unauthorized Use of Contact Lenses in the Combat Theater

A 25-year-old active duty Army E-5 developed severe infectious keratitis in his left eye secondary to soft contact lens (CL) wear while deployed in Iraq, necessitating evacuation to Walter Reed Army Medical Center for further evaluation and treatment. Initial clinical examination at Walter Reed Army Medical Center was suggestive of Acanthamoeba keratitis, a serious corneal pathogen associated with CL wear. In vivo confocal microscopy demonstrated Acanthamoeba cysts in the epithelium and anterior stroma, and smears and cultures from an epithelial biopsy specimen confirmed the diagnosis of Acanthamoeba keratitis. To our knowledge this is the first reported case of Acanthamoeba keratitis in a soldier wearing CLs in the combat theater. Because of the inability to maintain proper lens hygiene in a combat or field environment, the risk of developing a potentially sight-threatening corneal infection is significant. This unfortunate case of a devastating eye infection serves as a reminder of the current Army policy, which prohibits the use of CLs during gas chamber exercises, field training, and combat.

Night Firing Range Performance following Photorefractive Keratectomy and Laser In Situ Keratomileusis

OBJECTIVE

To investigate the effect of laser refractive surgery on night weapons firing.

METHODS

Firing range performance was measured at baseline and postoperatively following photorefractive keratectomy and laser in situ keratomileusis. Subjects fired the M-16A2 rifle with night vision goggles (NVG) at starlight, and with iron sight (simulated dusk). Scores, before and after surgery, were compared for both conditions.

RESULTS

No subject was able to acquire the target using iron sight without correction before surgery. After surgery, the scores without correction (95.9 +/- 4.7) matched the preoperative scores with correction (94.3 +/- 4.0; p = 0.324). Uncorrected NVG scores after surgery (96.4 +/- 3.1) exceeded the corrected scores before surgery (91.4 +/- 10.2), but this trend was not statistically significant (p = 0.063).

CONCLUSION

Night weapon firing with both the iron sight and the NVG sight improved after surgery. This study supports the operational benefits of refractive surgery in the military.

Corneal Iron Line Following LASIK With Epithelial Ingrowth

PURPOSE

To report a new corneal iron line following keratorefractive surgery.

METHODS

Case report and review of the literature. A 51-year-old man developed epithelial ingrowth after otherwise uneventful LASIK surgery. The patient, satisfied with an uncorrected visual acuity of 20/25 and otherwise asymptomatic, declined to have his flap relifted to treat the ingrowth.

RESULTS

Six months postoperatively a corneal iron line was noted at the leading edge of the epithelial ingrowth. Vision remained stable.

CONCLUSIONS

: Epithelial iron lines have been reported with a number of conditions, including post-refractive procedures. This is the first report of an iron line associated with epithelial ingrowth following LASIK.

The effect of fourth-generation fluoroquinolones gatifloxacin and moxifloxacin on epithelial healing following photorefractive keratectomy

PURPOSE

To compare the rate of epithelial healing following photorefractive keratectomy (PRK) with two commercially available fourth-generation fluoroquinolones, gatifloxacin (Zymar, Allergan, Irvine, California) and moxifloxacin (Vigamox, Alcon Laboratories, Fort Worth, Texas).

DESIGN

Double-masked, randomized, prospective trial.

METHODS

Thirty-five subjects received gatifloxacin in one eye and moxifloxacin in the fellow eye following PRK with a 9.0-mm epithelial defect. Patients were examined daily after surgery until the epithelium had healed completely in both eyes. Beginning on post-operative day 3, photos were taken and used to confirm epithelial healing or measure the area of residual epithelial defects. Healing times and defect sizes were compared using the Wilcoxon signed-ranks test.

RESULTS

Both eyes healed on the same day in 18 of the 35 subjects (51.4%). In 13 of 35 (37.1%) subjects, the moxifloxacin-treated eye healed first, compared with only four of 35 (11.4%) subjects whose gatifloxacin-treated eye healed first. All six of the eyes that took 2 days longer than their fellow eye to heal were gatifloxacin-treated. Median healing time for both groups was 4 days (moxifloxacin range: 3 to 7 days; gatifloxacin range: 3 to 9 days; P = .01), but only 69% of gatifloxacin-treated eyes had healed by day 4 compared with 80% of the moxifloxacin-treated eyes. Overall, on each post-operative day, defect sizes were greater for the gatifloxacin-treated eyes. This difference was statistically significant on day 4 (P = .027).

CONCLUSIONS

Eyes treated with moxifloxacin healed faster and had smaller defects compared with those treated with gatifloxacin. This provides another factor to consider in selecting antibiotic prophylaxis for corneal refractive surgery.

Comparison of two techniques of marking the horizontal axis during excimer laser keratorefractive surgery for myopic astigmatism

PURPOSE

To compare two methods of limbal marking used during laser refractive surgery for myopic astigmatism.

DESIGN

Retrospective chart review.

METHODS

Forty-two eyes of 42 patients who underwent photorefractive keratectomy (PRK) or laser-assisted in-situ keratomileusis (LASIK) for myopic astigmatism were marked preoperatively to identify the horizontal axis. In 18 eyes, marks were placed at the slit lamp (SL) with the slit beam set at 180 degrees as a reference. In 24 eyes, marks were placed in the laser room (LR) immediately before reclining under the laser. All treatments were performed with the Alcon LADARVision excimer laser system. Vector analysis of postoperative cylinder and reduction in cylinder and uncorrected and best-corrected visual acuity were evaluated for both groups.

RESULTS

The mean postoperative magnitude of error was -0.19 +/- 0.44 diopters for the LR group and -0.09 +/- 0.42 diopters for the SL group (P = .439, NS). Both groups had a mean angle of error indicating an overall counterclockwise rotation of axis with an angle of error of 6.3 +/- 8.7 degrees for the LR group and 8.0 +/- 10.2 degrees for the SL group (P = .562, NS).

CONCLUSIONS

We found no significant difference in outcomes with an overall trend toward undercorrection of cylinder in both groups, leaving room for improvement after refractive surgery for myopic astigmatism.

Surgical technique for suture fixation of an acrylic intraocular lens in the absence of capsule support

We present a technique for suture fixation of an intraocular lens (IOL) in the absence of capsule support. This technique is useful for the treatment of aphakia and the management of IOL complications or cataract surgery when all capsule support is lost.

Topical anesthetic abuse ring keratitis: report of four cases

PURPOSE

We present the clinicopathologic correlations of two case and two other clinical cases of topical anesthetic abuse keratopathy that were originally diagnosed as Acanthamoeba keratitis because of ring keratitis presentation and characteristic history.

METHODS

Four patients who were referred to us with suspected Acanthamoeba keratitis are included. Each was initially treated for amoebic keratitis, by using established protocols, and only later was the true origin (topical anesthetic abuse) uncovered. The clinical and surgical histories, pathologic analysis of the corneal specimens, and follow-up of < or = 4 years are included.

RESULTS

Our four cases show another cause for ring infiltration of the cornea. Two cases resulted in corneal transplantation and multiple other medical or surgical treatments in an attempt to restore vision but had poor outcomes of finger-counting vision. Two other cases responded to intensive medical treatments with return of useful vision. Evaluation of the surgical specimens revealed a previously unpublished finding of near total cell death within the corneal stroma.

CONCLUSION

Topical anesthetic abuse resulting in sight-threatening keratitis may be seen as a masquerade syndrome in many cases. Because of the often poor outcome, we must be aware of this entity, prevent abuse, and be vigilant in our prohibition of topical anesthetic for any therapeutic use.