Association between in vitro susceptibility to natamycin and voriconazole and clinical outcomes in fungal keratitis

PURPOSE

To assess the association between minimum inhibitory concentration (MIC) and clinical outcomes in a fungal keratitis clinical trial.

DESIGN

Experimental study using data from a randomized comparative trial.

PARTICIPANTS

Of the 323 patients enrolled in the trial, we were able to obtain MIC values from 221 patients with monocular fungal keratitis.

METHODS

The Mycotic Ulcer Treatment Trial I was a randomized, double-masked clinical trial comparing clinical outcomes of monotherapy with topical natamycin versus voriconazole for the treatment of fungal keratitis. Speciation and determination of MIC to natamycin and voriconazole were performed according to Clinical and Laboratory Standards Institute guidelines. The relationship between MIC and clinical outcome was assessed.

MAIN OUTCOME MEASURES

The primary outcome was 3-month best spectacle-corrected visual acuity. Secondary outcomes included 3-month infiltrate or scar size; corneal perforation and/or therapeutic penetrating keratoplasty; and time to re-epithelialization.

RESULTS

A 2-fold increase in MIC was associated with a larger 3-month infiltrate or scar size (0.21 mm; 95% confidence interval [CI], 0.10-0.31; P < 0.001) and increased odds of perforation (odds ratio, 1.32; 95% CI, 1.04-1.69; P = 0.02). No correlation was found between MIC and 3-month visual acuity. For natamycin-treated cases, an association was found between higher natamycin MIC with larger 3-month infiltrate or scar size (0.29 mm; 95% CI, 0.15-0.43; P < 0.001) and increased perforations (odds ratio, 2.41; 95% CI, 1.46-3.97; P < 0.001). Among voriconazole-treated cases, the voriconazole MIC did not correlate with any of the measured outcomes in the study.

CONCLUSIONS

Decreased susceptibility to natamycin was associated with increased infiltrate or scar size and increased odds of perforation. There was no association between susceptibility to voriconazole and outcome.

Severe microbial keratitis and associated perforation after corneal crosslinking for keratoconus

PURPOSE

To report two cases of microbial keratitis with subsequent corneal perforation immediately following corneal collagen crosslinking (CXL).

METHODS

Retrospective case note review.

RESULTS

First case was a 19 year old female presented with staphylococcal corneal abscess 3 days post CXL procedure. Corneal perforation occurred during hospital admission and was successfully treated with corneal gluing. Microbial keratitis eventually resolved, with both topical and systemic antibiotics therapy, resulting in a vascularized corneal scar. Second case was an 18 year old male whom developed Methicillin Resistant Staphylococcus aureus (MRSA) corneal abscess 5 days after CXL procedure for progressive keratoconus. Corneal perforation occurred 48 h after presentation and patient underwent uneventful corneal gluing. Although infective keratitis was successfully treated with topical therapy, patient had visual outcome of count fingers due to scarring.

CONCLUSIONS

CXL has been widely used in the treatment of corneal ectatic conditions and complications, such as infective keratitis, are uncommon post procedure. We present two cases of severe microbial keratitis with subsequent corneal perforation within 7 days of CXL. The exact mechanism for the accelerated keratolysis process is unclear. Nonetheless, patients should be well-informed of such potentially devastating complication.

Presentation and Management Outcomes of Corneal and Scleral Perforations in Geriatric Nursing Home Residents

We compared the clinical presentation and treatment outcomes of corneal and scleral perforations in geriatric nursing home residents, geriatric community residents, and non-geriatric population. The medical records of patients who were treated for corneal and scleral perforations at the Prince of Wales Hospital, Hong Kong between January 1, 2004 and May 1, 2013, were reviewed retrospectively. Of 144 cases, 53 (37%) occurred in the geriatric population, of which 16 (11%) lived in nursing homes, and 37 (26%) were community residents. There were 91 (63%) patients in the non-geriatric group. The mean age of the patients in nursing home geriatric group was 86.5 years (87.5% females). The most common etiology of perforation was trauma. Rupture due to fall was more common in geriatric patients (P < 0.001) whereas laceration due to penetrating eye injury was more common in non-geriatric patients (P < 0.001). There were more cases of infection leading to spontaneous perforation in geriatric nursing home group compared to the other groups (P = 0.001). In the geriatric nursing home group, visual acuity at presentation (P < 0.001) and postoperative visual acuity (P = 0.012) was worse compared to the other groups. Our study showed that corneal and scleral perforations in the geriatric nursing home residents carry a poor visual prognosis. The causes and anatomical outcomes of such events in geriatric age group differ from those in the general population. In our study, geriatric patients residing in nursing homes had worse baseline as well as posttreatment visual acuity, compared to community residents.

Prevalence and antimicrobial susceptibilities of anaerobic bacteria isolated from perforated corneal ulcers by culture and multiplex PCR: an evaluation in cases with keratitis and endophthalmitis

BACKGROUND

Anaerobic bacteria play an important role in eye infections; however, there is limited epidemiologic data based on the the role of these bacteria in the etiology of keratitis and endophthalmitis. The aim of this re- search is to determine the prevalence of anaerobic bacteria in perforated corneal ulcers of patients with keratitis and endophthalmitis and to evaluate their antimicrobial susceptibilities.

METHODS

Corneal scrapings were taken by the ophthalmologist using sterile needles. For the isolation of anaerobic bacteria, samples were inoculated on specific media and were incubated under anaerobic conditions obtained with Anaero-Gen (Oxoid & Mitsubishi Gas Company) in anaerobic jars (Oxoid USA, Inc. Columbia, MD, USA). The molecular identification of anaerobic bacteria was performed by multiplex PCR and the susceptibilities of an- aerobic bacteria to penicillin, chloramphenicol, and clindamycin were determined with the E test (bioMerieux).

RESULTS

51 strains of anaerobic bacteria belonging to four different genuses were detected by multiplex PCR and only 46 strains were isolated by culture. All of them were found susceptible to chloramphenicol whereas penicillin resistance was found in 13.3% of P.anaerobius strains, clindamycin resistance was found in 34.8% of P.acnes and 13.3% of P. anaerobius strains. Additionnaly, one strain of P. granulosum was found resistant to clindamycin, one strain of B. fragilis and one strain of P.melaninogenica were found resistant to penicillin and clindamycin.

CONCLUSIONS

Routine analyses of anaerobes in perforated corneal ulcers is inevitable and usage of appropriate molecular methods, for the detection of bacteria responsible from severe infections which might not be deter- mined by cultivation, may serve for the early decision of the appropriate treatment. Taking into account the in- creasing antimicrobial resistance of anaerobic bacteria, alternative eye specific antibiotics effective against anaer- obes are needed to achieve a successful treatment.

The Prognostic Value of Persistent Culture Positivity in Fungal Keratitis in the Mycotic Antimicrobial Localized Injection Trial

PURPOSE

To evaluate the utility of repeat cultures at days 3 and 7 after starting antifungal medications for predicting outcomes in fungal keratitis.

DESIGN

Prespecified secondary analysis of the randomized clinical Mycotic Antimicrobial Localized Injection trial.

METHODS

Patients presenting to Aravind Eye Hospital, Pondicherry, India, with fungal keratitis and visual acuity worse than 20/70 received topical natamycin and were randomized to either receive intrastromal injection of voriconazole or topical therapy alone. All subjects received corneal cultures at date of presentation, day 3, and day 7. Outcome measures included 3-week and 3-month visual acuity and scar size, corneal perforation, and/or the need for therapeutic penetrating keratoplasty (TPK). Visual acuity and scar size were analyzed with multiple linear regression controlling for baseline measures. Survival analysis was used to analyze the risk of corneal perforation and/or need for TPK.

RESULTS

Of the 70 study subjects with fungal keratitis, 25 of 69 (36%) remained culture positive at day 3, and 20 of 62 (32%) were culture positive at day 7. Culture positivity at day 3 conferred a hazard ratio of 2.8 for requiring TPK (P = .03) but was not a statistically significant predictor of perforation, scar size, or final visual acuity. Culture positivity at day 7 had a hazard ratio of 3.5 for requiring TPK (P = .003). Those with positive cultures at day 7 had on average 3 logMAR lines worse visual acuity at 3 months (95% confidence interval 0.9 to 5.2 logMAR lines, P = .006) and 1.1 mm larger scar size at 3 months after controlling for baseline measures (95% confidence interval 0.1 to 2.2 mm; P = .03).

CONCLUSIONS

While not as predictive as day 7 cultures, culture positivity at day 3 after starting treatment is a significant predictor of the need for TPK in patients with moderate-to-severe filamentous fungal keratitis. This has applications for risk stratification, and may facilitate earlier consideration of TPK in high-risk patients.

Presentation, aetiology and outcomes of corneal ulceration in Sjogren's Syndrome

PURPOSE

To report the clinical course of corneal ulceration/perforation in patients with Sjogren's syndrome.

METHODS

Retrospective descriptive study of patients diagnosed with Sjogren's syndrome (primary and secondary) and corneal ulceration over past 8 years at tertiary eye care network. Assessed parameters were demographics, clinical details, microbiological profile, types of intervention and their outcomes.

RESULTS

Forty-six eyes of 44 patients (11 males; mean age, 50 years) had corneal ulceration (28 eyes) or perforation (18 eyes) at the time of presentation. Of 46 eyes, 38 had sterile ulceration/perforation and rest 8 showed microorganism on microscopy or culture. The location was peripheral in 63% of eyes and it was the first presenting sign of Sjogren's syndrome in 26% of patients. All 43 eyes (3 lost to follow-up after intervention) had successful management of corneal ulceration/perforation. Twenty-eight eyes with ulceration required medical management alone in 15 eyes, soft contact lens and isobutylcyanoacrylate in 12 eyes, and amniotic membrane grafting in one eye. Four eyes with ulceration worsened and required penetrating keratoplasty (n = 2), and amniotic membrane grafting (n = 2). Corneal perforations were successfully managed with isobutylcyanoacrylate patch and BCL (n = 15), corneal patch graft (n = 2) and multilayered amniotic membrane grafting (n = 1). The average time taken for ulcers to heal was 49 days over a mean follow-up duration of 10 months.

CONCLUSION

Corneal ulceration or perforation in Sjogren's syndrome is often sterile and can be a presenting sign of undiagnosed SS. These patients usually respond to intensive medical therapy and bandage contact lens and isobutylcyanoacrylate patch application.

Corneal perforation with preseptal cellulitis in a patient with acute lymphocytic leukemia

We report a case of corneal perforation with preseptal cellulitis in a patient with acute lymphocytic leukemia (ALL). A 17-yr-old female patient who was undergoing combination chemotherapy for ALL was referred due to upper lid swelling and pain in the right eye for 2 days. Visual acuity in the right eye was 20/20. Initial examination showed no abnormal findings, other than swelling of the right upper eyelid. Computed tomography showed a finding of preseptal cellulitis. Microbiologic study of bloody and purulent discharge revealed Serratia marcescens. Corneal melting and perforation with iris prolapse were detected in the right eye on the 16th day. Emergent tectonic keratoplasty was performed. Seven months after surgery, visual acuity in the right eye was 20/300, and the corneal graft was stable.

[Mechanical corneal injury diagnosis using infrared spectroscopy]

Method for express diagnosis of mechanical corneal injury using infrared spectroscopic analysis of tear fluid is proposed. Differential diagnosis of open and closed corneal injuries in absence of clinical data is presented. Clinical material is provided by patients with open globe injuries--25 patients (25 eyes) and 25 patients (25 eyes) with closed globe injuries. 20 healthy adults (40 eyes) were included into the control group. Proposed method allows to develop treatment strategy, determine extent of surgical interventions in corneal trauma and predict the course of posttraumatic process and complications as well.

Lacrimal drainage pathway disease-associated keratopathy effectively diagnosed with dacryoendoscopy: a report of two cases

BACKGROUND

We described two cases of lacrimal drainage pathway disease-associated keratopathy (LDAK) wherein lacrimal irrigation tests revealed no abnormalities, and there were few signs and symptoms suggestive of lacrimal drainage pathway disease.

CASE PRESENTATION

Case 1 involved a 66-year-old woman with Sjögren's syndrome who presented with corneal perforation in her left eye. Slit-lamp examination revealed a non-infiltrative corneal ulcer and perforation in the inferior peripheral cornea. LDAK was suspected; however, there were minimal signs of lacrimal drainage pathway disease. Despite treatment with contact lenses and topical steroids, there was no improvement. Dacryoendoscopy was performed, revealing multiple concretions within the canaliculus. LDAK caused by lacrimal canaliculitis was confirmed, and the corneal ulcer rapidly re-epithelialized after removing the concretions. Case 2 involved a 78-year-old woman with Sjögren's syndrome who presented with epiphora in her right eye. Slit-lamp examination revealed two non-infiltrative ulcers in the inferior cornea, one of which had perforated. LDAK was suspected, but there were minimal signs of lacrimal drainage pathway disease. Dacryoendoscopy was performed, revealing concretions within the lacrimal sac and confirming chronic dacryocystitis. After removing the concretions, the corneal ulcer rapidly re-epithelialized.

CONCLUSIONS

We encountered two cases of LDAK that presented with minimal signs of lacrimal drainage pathway disease. When LDAK is suspected, dacryoendoscopy is a valuable tool for diagnosing lacrimal drainage pathway disease and removing concretions.

The incidence of severe complications in acanthamoeba keratitis: Qualitative and quantitative systematic assessment

Acanthamoeba keratitis (AK) is a rare, sight-threating corneal infection. The disease is challenging to diagnose and treat, and the amoeba can rapidly encyst, persisting in the tissue and causing recurrences. Medical therapy is conventionally considered the first line treatment, but advanced cases could require more invasive treatments like a "chaud" corneal transplant. We review the incidence of severe complications in patients affected by AK. Of 439 reports screened, 158 met our inclusion criteria. Incidence of severe complications was low, with 2.21 % patients developing perforation, 1 % requiring evisceration/enucleation and less than 1 % developing endophthalmitis. Corneal transplantation was required in 16.68 % of the cases. According to our results, and considering the reported incidences of these complications in other infectious keratitis, AK patients have an overall low risk of developing perforation, endophthalmitis, and enucleation/evisceration. Nevertheless, data available in the literature remain poor, and further randomized control trials are needed to confirm our findings.

Pterygium combined with corneal perforation: a case report

BACKGROUND

Pterygium is a common ocular surface disease. Pterygium combined with corneal perforation is rare.

CASE PRESENTATION

A 28-year-old female patient visited our outpatient clinic due to sudden onset of blurred vision and increased tearing in her left eye. The visual acuity was 1.0 OD and intraocular pressure (IOP) of 19.5 mmHg for the right eye with no significant abnormalities found in the anterior and posterior segments. The visual acuity of her left eye was 0.06, and IOP was 6.2 mmHg. A triangular vascular membranous tissue was seen in her left eye below the nose growing into the cornea and the pupil area was not touched. Slit-lamp examination revealed a tiny round corneal perforation in 8 o'clock position of the lesion area. Hospital diagnosis was given as pterygium combined with corneal perforation. The patient was treated with levofloxacin eye drops and autologous serum-based eye drops.

CONCLUSIONS

We report a rare case of pterygium combined with corneal perforation. Perforation is a very rare complication of pterygium. This patient received proper treatment and good result was seen. This article aimed to improve clinicians' understanding of pterygium.

Interface fluid syndrome caused by the corneal perforation injury after small incision lenticule extraction: a case report

BACKGROUND

To report a case of interface fluid syndrome (IFS) following traumatic corneal perforation repair after small incision lenticule extraction (SMILE).

CASE PRESENTATION

A 23-year-old woman, with a past history of SMILE, was struck in the left eye with a barbecue prod and subsequently underwent corneal perforation repair at local hospital. Primary wound repaired with a single 10 - 0 nylon suture at the area of leakage. After the surgery, her best corrected visual acuity (BCVA) was 20/30. Four days later, she presented at our hospital with blurred vision, and interface fluid syndrome (IFS) was diagnosed. Intraoperative optical coherence tomography (iOCT) was used to guide the resuturing of the corneal perforation in the left eye, followed by anterior chamber gas injection. At the first postoperative month, the BCVA was 20/25. The corneal cap adhered closely to the stroma, the surface became smooth.

CONCLUSIONS

This case illustrates that any corneal perforation following lamellar surgery, including SMILE, may lead to IFS. It is crucial to consider the depth of corneal perforation, and intraoperative optical coherence tomography (iOCT) plays a unique role in the repair procedure.

Dupilumab-Associated Bilateral Conjunctival Papillomas and Corneal Perforation

PURPOSE

We report a unique case of significant human papillomavirus-associated conjunctival papillomas and severe corneal ulceration leading to corneal perforation in a patient treated with dupilumab for atopic dermatitis.

METHODS

This study is a case report and literature review of severe corneal side effects related to dupilumab.

RESULTS

A 27-year-old man with severe atopic dermatitis and no ocular history was administered dupilumab 300 mg via subcutaneous injections every 2 weeks with an excellent response. Following the onset of treatment, the patient developed conjunctivitis, conjunctival papillomas, and dry eyes, which were initially treated with lubricating eye drops. Fourteen months after commencing dupilumab, he had a rapid onset of painful visual loss in the OD accompanied by severe bilateral conjunctival injection and was found to have a central corneal ulcer and diffuse papillomas on the palpebral and bulbar conjunctiva. Despite management with intravenous methylprednisolone and topical dexamethasone, the patient's corneal ulcer progressed to a corneal melt, resulting in perforation 2 months after diagnosis, which necessitated a corneal graft.

CONCLUSIONS

We present the third reported case of dupilumab-associated corneal perforation and the first case to our knowledge of dupilumab-associated conjunctival papillomas. As dupilumab usage increases, awareness of these potential complications among prescribers is essential.

Secondary bacterial corneal infection caused by Myroides species in primary fungal keratitis

A middle-aged male patient presented with a central corneal perforation in a deep stromal infiltrate in his left eye. An emergency therapeutic penetrating keratoplasty was performed. Microbiological evaluation of the corneal scraping specimen revealed septate fungal filaments on stains. However, culture reports after 24 hours from the scraping sample and the excised half corneal button showed growth of gram-negative bacilli. This pathogen was identified as an aerobic, non-fermentative, gram-negative, bacillus by conventional microbiology and confirmed as Myroides species by the VITEK 2 Compact system (bioMérieux, Marcy l'Etoile, France). Susceptibility to chloramphenicol was noted based on which the patient was treated with topical chloramphenicol 0.5%. No recurrence of the infection was noted. This is the first reported case of corneal infection with the Myroides species of bacteria which, heretofore, have been known to cause endocarditis and urinary tract infections.

Complicated corneal ulcer. Case report

Corneal ulcers are considered an ophthalmologic emergency because of their potential to permanently impair vision or perforate the eye. The therapeutic management includes medical therapy and in case of failure, surgical care such as amniotic membrane transplantation. We present the case of a 76-year-old male, admitted for sudden visual loss in the left eye, associated with ocular pain, tearing, and photophobia. The patient was diagnosed with superficial ulcerative keratitis with hypopyon and acute exogenous anterior uveitis for which he underwent medical treatment, both general and topic, with a good evolution during a month. After a month, the patient presented with the corneal ulcer perforated. Surgery was performed in the left eye by covering the ocular surface with an amniotic membrane using the Motowa's sandwich technique. After one year, the same patient was successfully operated for cataract removal and posterior chamber intraocular lens implantation in the left eye.

Hybrid technique of tuck-in Tenon's patch graft and tissue adhesives and bandage contact lens (TABCL) for large corneal perforation in microbial keratitis

We describe the hybrid technique of tuck-in Tenon's patch graft (TPG) and tissue adhesive bandaged contact lens (TABCL) for large corneal perforations (>5 mm) with intact surrounding stroma. Management of large corneal perforation is often challenging, and urgent availability of donor cornea might be difficult; Tenon patch alone does not provide tectonic support; hence, this hybrid technique can be used safely in large perforations. This involves freshening the perforation edges, creating a 360 0 stromal pocket, harvesting a Tenon's graft 1 mm oversized, tucking into the pocket, and suturing. Then areas of leakage were noted, and only those areas were supplemented with minimal cyanoacrylate glue (CG) at the graft edges. This technique was used in two eyes, one with a large corneal perforation and intact surrounding stroma and the other with 4 mm corneal fistula post healed keratitis with a failed primary TPG alone, and led to epithelialization and a smooth corneal surface at 6 weeks. The advantages include autologous tissue, cost-effective, easily available, minimal post-operative inflammation, vascularization, and surface irregularity.

Early Endothelialization of Ab Interno Stromal Tectonic Patch in the Management of Corneal Perforation Secondary to Bacterial Keratitis

PURPOSE

The purpose of this study was to describe a novel surgical technique using an ab interno stromal patch to treat corneal perforation and to present the histological findings of the patch after its removal during definitive mushroom keratoplasty.

METHODS

The endothelium had already been removed with the submerged cornea using backgrounds away (SCUBA) technique.

RESULTS

The patient was managed successfully with a sutureless ab interno stromal tectonic patch. Two months later, definitive mushroom keratoplasty was performed and the patch was sent for histological examination. Immunohistochemistry revealed a reactive endothelium covering the posterior surface of the graft. Nine months later, her best-corrected visual acuity was 6/9.

CONCLUSIONS

This is the first case to our knowledge demonstrating that stromal tectonic grafts without the endothelium can successfully attach to the host tissue and seal a perforation. The stroma may undergo reendothelialization and begin to restore vision, even before penetrating keratoplasty.

Patch Transplant in Corneal Perforations: Time, Method, and Cause

OBJECTIVES

We present demographic data and clinical features of corneal perforations repaired with patch grafts prepared from residual donor corneal rims.

MATERIALS AND METHODS

For this retrospective study, we evaluated patients who underwent corneal perforation repair with corneal or corneoscleral patch grafts. We recorded demographic data, as well as perforation cause, examination notes, tissue type-size used, follow-up time, and additional surgeries. Anterior segment photographs were also evaluated. Transplanted tissues were prepared from residual donor corneas used in penetrating keratoplasty and were manually adjusted to the precise size of the wound.

RESULTS

Fifteen patients were enrolled in the study. Mean age of the patients was 64.9 ± 19.7 years (range, 15-81 years) with a female-to-male ratio of 0.85. The causes of perforation were grouped as inflammation, infection, and trauma. The main indications were inflammation (n = 7; 46.7%) and infection (n = 6; 40%), followed by trauma (n = 2; 13.3%). All patients demonstrated preservation of globe integrity during the follow-up time; however, 1 patient's eye required regrafting with limbal conjunctival excision due to melting and leakage. Three eyes required permanent tarsorrhaphy to control progressive exposure keratopathy, and 2 eyes underwent penetrating keratoplasty to cure scar-related corneal opacity.

CONCLUSIONS

Patch grafts are effective surgical interventions to assure and maintain globe integrity in corneal perforations. The main advantage seems to be that patch grafting allows special preparations for wound architecture. Moreover, in clinics performing keratoplasty, these patch tissues are readily available.

Customized therapeutic deep anterior lamellar keratoplasty in perforated Mooren's ulcer: A novel technique

We describe customized therapeutic deep anterior lamellar keratoplasty (DALK) for treating a perforated Mooren's ulcer. Slit-lamp biomicroscopy revealed corneal perforation (3.5 mm × 3.0 mm) with iris prolapse. The corneal melt extended from 9.0 o'clock to 4.0 o'clock. The peripheral edge of the ulcer was sloping, whereas the medial edge showed undermining. Immunological tests did not reveal any evidence of systemic autoimmune disease. In view of extensive peripheral corneal melt with large corneal perforation, the patient needed tectonic keratoplasty. The penetrating graft is not only technically demanding but also results in a poor visual outcome. We advised customized tectonic DALK. We used two different-sized trephines to obtain appropriate-sized donor tissue and avoided manual dissection. The post-surgery period was uneventful. He was prescribed topical steroids and oral methotrexate. He achieved 6/9 aided visual acuity at 4 months and maintained it until the last follow-up at 36 months.

Proportion and characteristics of lacrimal drainage pathway disease and keratopathy in non-infectious corneal perforation using lacrimal syringing test

Lacrimal drainage pathway disease-associated keratopathy (LDAK) has been associated with corneal perforation, which arises from both infectious and non-infectious corneal disorders. However, patients with corneal perforation are often not routinely tested for LDAK, and the potential risk posed by LDAK in the development of corneal ulcers has not been investigated in detail. This study aimed to assess the proportion and characteristics of LDAK in patients with non-infectious corneal perforation using lacrimal syringing test. This study enrolled 56 patients with corneal perforation treated at Saitama Medical University Hospital between January 2016 and September 2022. The causes of corneal perforation were trauma (n = 17, 30%), infection (n = 19, 34%), non-infection (n = 16, 29%), and unknown (n = 4, 7%). A lacrimal syringing test was performed on 12 patients with non-infectious corneal perforation and 4 with an unknown diagnosis. Among the 16 patients with non-infectious corneal perforation, 13 (81%) had lacrimal drainage disease, but only 3 (19%) patients had lacrimal puncta, as revealed by slit-lamp examinations. The primary bacterial species identified in lacrimal obstructive disease and lacrimal canaliculitis were Staphylococcus spp. and Actinomycetes spp. respectively. Lower temporal and peripheral corneal perforations were common. All patients underwent lacrimal surgery, and 6 (38%) were treated for corneal perforation without corneal surgery. Interestingly, several patients with LDAK who did not exhibit any lacrimal duct obstruction on slit-lamp examination. The study findings demonstrate the significance of the lacrimal syringing test for assessing LDAK in patients with corneal perforation, indicating LDAK as a potential cause of corneal perforation.

Evaluation of Cyanoacrylate Tissue Adhesive Glue Application Outcomes in Corneal Thinning and Perforation

OBJECTIVES

Corneal thinning and perforation are ocular emergencies necessitating urgent intervention to prevent visual impairment or enucleation. Cyanoacrylate tissue adhesive is frequently used to maintain globe integrity in these cases. However, gaps remain in understanding the outcomes of corneal gluing and the factors influencing its efficacy. This case series evaluates the clinical characteristics and outcomes of glue application in corneal thinning and perforation.

METHODS

A retrospective chart review was conducted on patients treated for corneal thinning and perforation at the University of Florida between January 2012 and May 2023. Demographic data, clinical history, glue application details, and posttreatment outcomes were collected and analyzed.

RESULTS

The study included 128 eyes from 125 subjects. Corneal perforation was found in 71 eyes (55.5%), mostly centrally (49.2%). The leading cause of perforation/thinning was microbial infection (45.3%). The average number of glue applications per eye was 1.66. Within 1 month, 23 patients (18.0%) required only glue reapplication, 37 (28.9%) required surgical intervention (regardless of glue reapplication), and 68 (53.1%) required no further treatment. Factors significantly linked to gluing failure (requiring surgery within 1 month) in univariate analysis included large perforation size, microbial infection, ocular surface disorder, single glue application, and indirect application via sterile drape. Multivariate analysis showed that only large perforation size was significantly associated with gluing failure.

CONCLUSION

Corneal glue application is an effective temporizing measure for corneal thinning and perforation, with multiple applications potentially providing added stability to the globe. However, the need for surgical intervention is high.