Risk factors for graft infection in India: a case-control study

Outcomes of Post-Keratoplasty Microbial Keratitis: A 16-Year Analysis

Purpose: To determine the incidence, risk factors (including systemic immunosuppression), and outcomes of microbial keratitis in corneal transplants over a 16-year observation period at a tertiary referral hospital in Poland. Methods: This retrospective cohort study included 125 episodes of infectious keratitis in 117 patients who underwent corneal transplantation between 2008 and 2023 at the Department of Ophthalmology, Medical University of Warsaw, Poland. The data collected included demographics, indications for transplantation, infection rates, risk factors, best-corrected visual acuity (BCVA) at presentation and discharge, changes in visual acuity, and treatments received prior to hospital admission. Clinical signs, symptoms, diagnostic tests, and management strategies were also reviewed. Additionally, the outcomes of surgical interventions, such as therapeutic corneal transplantation and evisceration, were examined. Results: Among the 2869 corneal transplants performed over the 16-year period, the incidence of post-keratoplasty microbial keratitis (PKMK) was 4.35%. The most common indication for transplantation in affected patients was an active infection unresponsive to medical therapy (n = 62, 52%). One-third of PKMK cases occurred in patients with repeat transplants. Median visual acuity prior to infection was 1.6 logMAR, worsening to 2.3 logMAR at presentation. Following treatment, visual acuity improved to a median of 1.9 logMAR at discharge, with no significant improvement by the one-year follow-up. At that time, 75.1% of patients remained legally blind (BCVA ≤ 20/200); 21% recovered to pre-infection visual levels, while 46% experienced additional visual loss due to PKMK. Multivariate regression identified corneal perforation and systemic immunosuppression as independent predictors of poorer visual outcomes (p < 0.001 and p = 0.03, respectively. Conclusions: Microbial keratitis in corneal grafts is associated with poor long-term visual outcomes. At one year post-infection, the median BCVA was 1.9 logMAR, with 75.1% of patients remaining legally blind. Nearly half of the cohort experienced additional visual loss compared to their pre-infection status, underscoring the severity of PKMK and the need for vigilant postoperative care.

Preferred practice guidelines and narrative review on infectious keratitis in ocular surface diseases

Ocular surface disease (OSD) encompasses a variety of additional factors in the natural history of infectious keratitis like disruption of the normal tear film, altered ocular microbiome, adnexal inflammation, de-epithelization of the cornea due to anatomical factors like trichiasis, lid margin keratinization, presence of limbal stem cell deficiency, and other lid related problems. These cases need special attention with respect to lower threshold for inpatient admission and care along with examination and careful corneal scraping to avoid any perforation. The preferable practice patterns in these include documenting epithelial defects using fluorescein stain in the presence of cobalt blue filter, use of preservative-free monotherapy drops in mild to moderate corneal ulcers, quantification of corneal thinning and depth of infiltrate using anterior segment optical coherence tomography, and early tapering of epithelia-toxic drugs with judicious addition of lubricants and steroids. The changes in surgical management involve adopting a lower threshold for procedures that can enhance healing, such as amniotic membrane grafting, electrolysis of trichiasis, and punctal occlusion for severe dry eye disease. Conversely, a higher threshold for therapeutic keratoplasty is preferable as postoperative healing is a major challenge in eyes with OSD. A closer follow-up is vital as healing is slower and risk of reinfection is higher. The long-term management of corneal opacity in OSD is also complex as first-stage ocular surface stabilization is essential prior to keratoplasty.

Infectious keratitis following corneal transplantation: A long-term cohort study

BACKGROUND

To assess the long-term incidence and risk factors for post-keratoplasty infectious keratitis (IK), associated ocular pathogens, and antibiotic resistance profiles.

METHODS

Cohort study including 2553 consecutive penetrating, endothelial, and anterior lamellar keratoplasties performed between 1992 and 2020. Medical and microbiological records of patients clinically diagnosed with IK were retrospectively reviewed.

MAIN OUTCOME MEASURES

cumulative incidence of IK, infectious agent species, and antibiotics resistance profiles.

RESULTS

The average follow-up time after transplantation was 112 ± 96 months. Eighty-nine IK episodes were recorded; microbiological tests were positive in 55/89 (62%). The cumulated incidence of postoperative IK was 5.50%/10.25% at 10/20 years. The occurrence of at least one episode of IK after transplantation was associated with lower graft survival in the long term (p < 0.0001). Rejection risk (adjusted Hazard Ratio, 2.29) and postoperative epithelial complications (HR, 3.44) were significantly and independently associated with a higher incidence of postoperative IK. Infectious agents included 41 bacteria, 10 HSV, 6 fungi, and 1 Acanthamoeba. The rate of antibiotic resistance was 0% for vancomycin, 13% for fluoroquinolones, 20% for rifamycin, 59% for aminoglycosides, and 73% for ticarcillin. In 41% of cases, patients were under prophylactic topical antibiotics before the infectious episode. Topical antibiotics were significantly associated with increased resistance to penicillin, carbapenems, and aminoglycosides.

CONCLUSION

IK (mainly bacterial) is a frequent complication of corneal transplantation in the long term. Vancomycin and fluoroquinolones can be considered as first-line treatments. Prolonged postoperative antibiotic preventive treatment is not advisable as it may increase antibiotic resistance.

Post-Keratoplasty Microbial Keratitis in the Era of Lamellar Transplants-A Comprehensive Review

Microbial keratitis in a post-transplant cornea should be considered a distinct entity from microbial keratitis in a non-transplant cornea. Firstly, the use of immunosuppressive treatments and sutures in corneal transplants changes the etiology of keratitis. Secondly, corneal transplant has an impact on corneal biomechanics and structure, which facilitates the spread of infection. Finally, the emergence of lamellar transplants has introduced a new form of keratitis known as interface keratitis. Given these factors, there is a clear need to update our understanding of and management strategies for microbial keratitis following corneal transplantation, especially in the era of lamellar transplants. To address this, a comprehensive review is provided, covering the incidence, risk factors, causes, and timing of microbial keratitis, as well as both clinical and surgical management approaches for its treatment in cases of penetrating and lamellar corneal transplants.

Local application of silver nitrate as an adjuvant treatment before deep lamellar keratoplasty for fungal keratitis poorly responsive to medical treatment

Objective

The purpose of this study is to evaluate the efficacy and safety of the local application of silver nitrate (LASN) as an adjuvant treatment before deep lamellar keratoplasty (DLKP) for fungal keratitis responding poorly to medical treatment.

Methods

A total of 12 patients (12 eyes) with fungal keratitis responding poorly to medical treatment (for at least 2 weeks) were included. LASN was performed using 2% silver nitrate, the ulcer was cleaned and debrided, and then, the silver nitrate cotton stick was applied to the surface of the ulcer for a few seconds. The effect of LASN was recorded. The number of hyphae before and after treatment was determined by confocal microscope. After the condition of the ulcer improved, DLKP was performed. Fungal recurrence, best-corrected visual acuity (BCVA), loose sutures, and endothelial cell density (ECD) were recorded in detail.

Results

Clinical resolution of corneal infiltration and edema was observed, and the ulcer boundary became clear in all 12 patients after 7-9 days of LASN. Confocal microscopy showed that the number of hyphae was significantly reduced. Ocular pain peaked on days 1 and 2 after treatment, and 9 patients (75%, day 1) and 1 patient (8.3%, day 2) required oral pain medication. During the follow-up period after DLKP, no fungal recurrence and loose sutures were observed. After the operation, the BCVA of all patients improved. The mean corneal ECD was 2,166.83 ± 119.75 cells/mm2.

Conclusion

The LASN was safe and effective and can be well tolerated by patients. Eye pain can be relieved quickly. LASN as an adjuvant treatment before DLKP might be a promising therapeutic strategy.

Incidence and management of early postoperative complications in lamellar corneal transplantation

PURPOSE

To provide a comprehensive review of the incidence, risk factors, and management of early complications after deep anterior lamellar keratoplasty (DALK), Descemet stripping automated keratoplasty (DSAEK), and Descemet membrane endothelial keratoplasty (DMEK).

METHODS

A literature review of complications, that can occur from the time of the transplant up to 1 month after the transplant procedure, was conducted. Case reports and case series were included in the review.

RESULTS

Complications in the earliest postoperative days following anterior and posterior lamellar keratoplasty have shown to affect graft survival. These complications include, but are not limited to, double anterior chamber, sclerokeratitis endothelial graft detachment, acute glaucoma, fluid misdirection syndrome, donor-transmitted and recurrent infection, and Uretts-Zavalia syndrome.

CONCLUSION

It is essential for surgeons and clinicians to not only be aware of these complications but also know how to manage them to minimize their impact on long-term transplant survival and visual outcomes.

A 7-year review of clinical characteristics, predisposing factors and outcomes of post-keratoplasty infectious keratitis: the Nottingham infectious keratitis study

Background/objectives

Post-keratoplasty infectious keratitis (PKIK) is a unique sight-threatening clinical entity which often poses significant therapeutic challenges. This study aimed to examine the clinical presentation, risk factors, management, and clinical outcomes of PKIK.

Methods

This was a retrospective study of all patients who presented to the Queen's Medical Centre, Nottingham, with PKIK between September 2015 and August 2022 (a 7-year period). Relevant data on types of keratoplasty, clinical presentations, causative microorganisms, management, and outcome were analyzed.

Results

Forty-nine PKIK cases, including four cases of interface infectious keratitis, were identified during the study period. The most common graft indications for PKP, DALK and EK were failed grafts (9, 37.5%), keratoconus (6, 54.5%) and Fuchs endothelial corneal dystrophy (FECD; 8, 57.1%), respectively. Staphylococcus spp. were the most commonly identified organisms (15, 50.0%). Bullous keratopathy (18, 36.7%), ocular surface disease (18, 36.7%), and broken/loose sutures (15, 30.6%) were the most common risk factors. Concurrent use of topical steroids was identified in 25 (51.0%) cases. Of 31 functioning grafts at presentation, 12 (38.7%) grafts failed at final follow-up with 15 (48.4%) patients retaining a CDVA of ≥1.0 logMAR. The overall estimated 5-year survival rate post-PKIK was 55.9% (95% CI, 35.9%-75.9%), with DALK having the highest survival rate [63.6% (95% CI, 28.9%-98.3%)], followed by EK [57.1% (95% CI, 20.4%-93.8%)] and PKP [52.7% (95% CI, 25.1%-80.3%)], though no statistical difference was observed (p=0.48).

Conclusions

PKIK represents an important cause of IK and graft failure. Bullous keratopathy, OSD and suture-related complications are the commonest risk factors, highlighting the potential benefit of prophylactic topical antibiotics (for unhealthy ocular surface) and early suture removal (where possible) in reducing the risk of PKIK. Graft survival may be higher in lamellar keratoplasty following PKIK but larger studies are required to elucidate this observation.

Post-Keratoplasty Infectious Keratitis Caused by Elizabethkingia meningoseptica

BACKGROUND Microbial keratitis is a major complication of keratoplasty that is associated with serious ocular sequalae if not adequately treated. The purpose of this case report is to present a case of infectious keratitis following keratoplasty caused by the rare microorganism Elizabethkingia meningoseptica. CASE REPORT A 73-year-old patient presented to the outpatient clinic complaining of a sudden decrease of vision in his left eye. The right eye was enucleated during childhood due to ocular trauma and an ocular prosthesis was placed in the orbital socket. He underwent penetrating keratoplasty 30 years ago for corneal scar and repeated optical penetrating keratoplasty for failed graft in 2016. He was diagnosed with microbial keratitis following optical penetrating keratoplasty in the left eye. Corneal scraping of the infiltrate showed growth of the gram-negative bacteria Elizabethkingia meningoseptica. Conjunctival swab of the orbital socket of the fellow eye was positive for the same microorganism. E. meningoseptica is a rare gram-negative bacterium, which is not part of the normal ocular flora. The patient was admitted for close monitoring and was started on antibiotics. He showed significant improvement after treatment with topical moxifloxacin and topical steroids. CONCLUSIONS Microbial keratitis is a serious complication following penetrating keratoplasty. An infected orbital socket could be a risk factor of microbial keratitis of the fellow eye. A high index of suspicion, along with timely diagnosis and management, may improve the outcome and clinical response and reduce the morbidity associated with these infections. Prevention of infectious keratitis is essential and may be achieved by optimizing the ocular surface and treating the risk factors for infection.

Citrobacter keratitis: predisposing factors and clinical characteristics

PURPOSE

To report predisposing factors, clinical presentation, antibiotic sensitivity, and management of Citrobacter-caused infectious keratitis.

METHODS

We retrospectively reviewed the medical records of culture-proven cases of Citrobacter keratitis in a tertiary referral center for 8 years (from January 2012 to September 2020). Demographic data of the patients, predisposing factors, and presenting signs were extracted.

RESULTS

Eighteen cases of microbial keratitis due to Citrobacter spp. were identified. The median age of the patients was 66 years (range: 10-89, interquartile range : 59-81). Thirteen patients were male and 5 were female. Multiple predisposing factors were identified in all eyes, including ocular surface disease (n = 8), previous corneal surgery (n = 6), and history of ocular trauma (n = 6). Five patients were diabetic. Corrected distance visual acuity (CDVA) of patients was light perception (LP) in 8 patients, hand motion (HM) in 7, counting fingers (CF) at 1 m in 1, and CF at 2 m in 2 patients. Thirteen eyes exhibited hypopyon. An area of corneal thinning was observed in 7 eyes (38.9%). Endophthalmitis due to infectious keratitis developed in one patient. In vitro susceptibility testing confirmed high sensitivity to ceftazidime and aminoglycosides. Medical management consisted primarily of topical amikacin (20 mg/ml) combined with topical cefazoline (50 mg/ml) (72.2%). Surgical tectonic procedures were carried out in 7 eyes (38.9%).

CONCLUSION

Citrobacter spp. is a rare cause of bacterial keratitis.Previous keratoplasty and ocular surface problems are important risk factors. The prognosis is not good and surgical tectonic intervention is required in many cases to resolve the corneal infection.

Infectious keratitis caused by Klebsiella spp.: predisposing factors, presentation, and management

PURPOSE

To study predisposing factors, clinical presentation and management strategies for Klebsiella keratitis.

METHODS

A retrospective case review was performed on clinical records of culture-proven Klebsiella keratitis cases in a tertiary referral center over an 8-year period (from 2012 to 2020).

RESULTS

Thirty eight episodes of culture-proven Klebsiella keratitis were identified in 37 patients. The mean age of the patients was 62.9 years (range, 24-101). Multiple predisposing factors were identified in 33 eyes including history of previous keratoplasty (n = 11) history of ocular trauma (n = 7), preexisting ocular surface disease (n = 7) and diabetes (n = 6). Corrected distance visual acuity (CDVA) at presentation was light perception (LP) in 16 patients, hand motion (HM) in 12, counting fingers (CF) at 50 cm in 5, CF at 1 m in 1, CF at 2 m in 2. One patient had a CDVA of 3/10. On initial examination Hypopyon was detected in 21 eyes. Descemet's membrane folds were present in 1 eye. Corneal thinning was identified in 20 eyes and perforation occurred in 4 patients. Corneal ulcer progressed to endophthalmitis in one patient. Microbiologic sensitivity testing showed that 89.5% isolates were sensitive to amikacin (34/38),88.9%sensitive to ceftazidime (32/36),94.4% were sensitive to gentamicin (34/36),97.2% sensitive to ciprofloxacin (35/36), and 100% to levofloxacin (26/26).Ultimately, one or more surgical procedures was needed in 21 patients.

CONCLUSION

Previous keratoplasty, history of ocular trauma, ocular surface disease and systemic disease such as diabetes are major risk factors for Klebsiella keratitis. In most of the patients, surgical and tectonic procedures were necessary to control the infection.

[Penetrating keratoplasty]

Penetrating keratoplasty is a tissue transplant commonly performed around the world. For over a century, penetrating keratoplasty has been the standard method of treatment for many corneal diseases causing visual impairment. Recently, lamellar anterior keratoplasty (LAK) or lamellar endothelial (LEK) have become preferable options, resulting in fewer complications and faster functional rehabilitation. While penetrating keratoplasty is less frequently indicated, in favor of these lamellar grafts, it has not necessarily become obsolete, and its use remains appropriate for its chosen indications. Functional results are good if the indication for surgery is properly assessed, therapeutic precautions are taken in view of complications, and follow-up aims to improve initial refractive results as needed.

Post penetrating keratoplasty infectious keratitis: Clinico-microbiological profile and predictors of outcome

PURPOSE

To study the clinico-microbiological profile, outcomes and prognostic factors of post penetrating keratoplasty (PKP) infectious keratitis.

METHODS

Retrospective review of medical records of 78 patients with post PKP infectious keratitis presenting between January 2014 and December 2018. Demographic, clinical and microbiological profile was documented and predictors of treatment and graft success were evaluated using univariate and subsequent multivariate logistic regression analysis.

RESULTS

Mean age of patients was 52.17 ± 15.51 years and mean infiltrate size was 19.39 ± 19.68 mm². Mean duration of presentation with infection post PKP was 11.66 ± 10.65 months. Culture positivity was seen in 64 eyes (82.05%). Bacterial growth was observed in 47 eyes (60.25%), fungal growth in 17 (21.79%) and no microbiological growth in 14 eyes (17.94%). At 3 months the visual acuity (VA) improved in 37 eyes (47.44%), did not change in 27 (34.62%) and deteriorated in 14 (17.95%). Graft failure was noted in 53 eyes (73.08%). Surgical intervention was needed in 47 (60.25%) eyes of which most common was therapeutic PKP in 32 eyes (41.02%). Treatment failure was noted with fungal infection (p = 0.05), poorer vision at presentation (p = 0.02), larger infiltrate area (p = 0.002) and graft infection developing before 1 year (p = 0.02). Graft failure was noted with associated endophthalmitis (p = 0.02), poorer VA at presentation (p = 0.01) and larger infiltrate area (p = 0.02).

CONCLUSION

Post PKP infectious keratitis is a sight threatening ocular condition. It is associated with high incidence of graft failure and frequently requires surgical intervention. Fungal etiology, larger infiltrate size, poorer vision at presentation and associated endophthalmitis carries a poorer prognosis.

Post-keratoplasty Infectious Keratitis: Epidemiology, Risk Factors, Management, and Outcomes

Post-keratoplasty infectious keratitis (PKIK) represents a unique clinical entity that often poses significant diagnostic and therapeutic challenges. It carries a high risk of serious complications such as graft rejection and failure, and less commonly endophthalmitis. Topical corticosteroids are often required to reduce the risk of graft rejection but their use in PKIK may act as a double-edged sword, particularly in fungal infection. The increased uptake in lamellar keratoplasty in the recent years has also led to complications such as graft-host interface infectious keratitis (IIK), which is particularly difficult to manage. The reported incidence of PKIK differs considerably across different countries, with a higher incidence observed in developing countries (9.2-11.9%) than developed countries (0.02-7.9%). Common risk factors for PKIK include the use of topical corticosteroids, suture-related problems, ocular surface diseases and previous corneal infection. PKIK after penetrating keratoplasty or (deep) anterior lamellar keratoplasty is most commonly caused by ocular surface commensals, particularly Gramme-positive bacteria, whereas PKIK after endothelial keratoplasty is usually caused by Candida spp. Empirical broad-spectrum antimicrobial treatment is the mainstay of treatment for both PKIK, though surgical interventions are required in medically refractory cases (during the acute phase) and those affected by visually significant scarring (during the late phase). In this paper, we aim to provide a comprehensive overview on PKIK, encompassing the epidemiology, risk factors, causes, management and outcomes, and to propose a treatment algorithm for systematically managing this challenging condition.

Microbial Keratitis in Corneal Transplants: A 12-Year Analysis

Purpose

To investigate the frequencies, trends, and in vitro drug susceptibilities of the causative pathogens in corneal transplant microbial infections in Manchester Royal Eye Hospital.

Methods

Corneal scrape results recorded by the microbiology service between 2004 and 2015 were extracted from an established database. This microbiological data was matched with a separate database of all corneal transplant procedures performed in our centre over this time period. Patient records were examined to collect specific patient data and to confirm the diagnosis of microbial keratitis.

Results

A total of 1508 grafts had been performed at our centre in this period. 72 episodes of graft microbial keratitis were identified from 66 eyes that had undergone keratoplasty procedures. Mean age was 56, and 51% of subjects were male. Ninety-three percent of microbial keratitis episodes occurred in penetrating keratoplasty procedures and 6% in deep anterior lamellar keratoplasty procedures. No endothelial grafts presented with infections throughout this time period. Of the 79 organisms identified, 73% were gram positive, 23% gram negative and 4% fungi. With regard to gram-positive organisms, vancomycin and gentamicin showed 100% and 91% susceptibility, respectively. Ofloxacin had a resistance rate of 13.7%. In terms of gram-negative organisms, gentamicin and chloramphenicol showed 100% sensitivity, with cefuroxime showing 69%. Resistance rates were less than 15% in all tested gram-negative antimicrobials.

Conclusion

This paper describes the largest collection of corneal transplant infections identified within the UK. This finding may aid clinicians in predicting possible causative organisms for microbial keratitis and aid antibiotic choice.

Distribution of Microbial Keratitis After Penetrating Keratoplasty According to Early and Late Postoperative Periods

Objectives:

The aim of this study was to investigate the distribution of microbial agents in the early and late postoperative periods in patients with microbial keratitis (MK) after penetrating keratoplasty (PK).

Materials and Methods:

The records of 36 patients who were clinically diagnosed as having MK after PK were retrospectively reviewed. Culture results were obtained from microbiology records and the organisms that were produced were noted. A case was deemed as viral keratitis based on the clinical appearance, negative cultures, and response to antiviral treatment. Keratitis development times were evaluated in 2 categories: early (within the first year) and late (after year 1) postoperative period. Mann-Whitney U and Kruskal-Wallis tests were used to compare numerical variables that did not show normal distribution and chi-square test was used to compare categorical variables.

Results:

The majority of MK cases were of bacterial origin (55.5%, n=20), followed by viral (41.7%, n=15) and fungal (2.8%, n=1). Of the 15 cases of early postoperative MK, 10 were bacterial, 4 were viral, and 1 was fungal; however, among cases of late postoperative MK, 10 were bacterial and 11 were viral. The majority (65%) of early and late bacterial infections were caused by gram-positive strains (most commonly staphylococci). Gram-positive bacteria caused keratitis significantly earlier than gram-negative bacteria (p=0.037). Viral and gram-negative bacterial MK was more frequent in the late postoperative period, but the difference was not statistically significant.

Conclusion:

In our study, bacterial keratitis was more common in post-keratoplasty MK than viral and fungal keratitis. Gram-positive bacteria were the most common causative agents. The increased incidence of gram-negative bacterial agents and viral keratitis in the late postoperative period can be explained by long-term topical steroid use.

Outcome of Sclerokeratoplasty in Devastating Sclerocorneal Infections

Purpose:

To assess the achievement of anatomical integrity after primary tectonic sclerokeratoplasty procedure and outcome after subsequent secondary procedures to manage devastating corneoscleral infection threatening the structural integrity of the eyeball.

Methods:

This prospective interventional study comprised 60 patients with severe devastating corneoscleral pathology of infective origin with varying degrees of scleral involvement who underwent tectonic sclerokeratoplasty. They were grouped into three groups according to the involvement of scleral quadrants, i.e., Group A with only one quadrant, Group B with two quadrants, and Group C with more than two quadrants. The demographics, clinical features, microbiological status, postoperative complications, need for secondary procedures, and tectonic outcome in terms of anatomical success were analyzed in all three groups during follow-up between 2 and 5 years.

Results:

The donor graft size in Groups A, B, and C was 9.5–10.5, 11–12, and 12.5–14 mm, respectively. Globe integrity after primary procedure was noted in all patients of Group A, 76% of Group B, and 38% of Group C. Reinfection was observed in 19 cases of Groups B and C, from which 5 Group C patients were eviscerated and 14 underwent regrafting. Postoperative complications (suture related, rejection, graft failure, and secondary glaucoma) were encountered more frequently in Group C patients. Secondary procedures (cataract/posterior segment surgery, secondary intraocular lens, and trabeculectomy) were required more in Groups B and C. After regrafting, 7 eyes were salvaged and 7 (3 in Group B and 4 in Group C) resulted in phthisis bulbi. Thus, tectonic outcome was achieved in 80% of cases.

Conclusions:

Sclerokeratoplasty is an effective tectonic treatment for restoring the globe anatomy in severe corneoscleral infection. Outcome depends on involvement of scleral quadrants, graft size, and severity of disease. Subsequent regrafting procedures are required to overcome reinfection of the primary graft.

Resuturing after penetrating keratoplasty without trauma: Indications and results

PURPOSE

To determine the indications, frequency, influential factors and clinical outcomes of resuturing in an atraumatic setting after penetrating keratoplasty (PK).

METHODS

Medical records of all patients who underwent resuturing in the absence of traumatic wound dehiscences after PK between January 1, 2007 and December 31, 2015 were reviewed. The cases were divided into 2 groups: patients with suture-related problems underwent mandatory resuturing (mandatory group), and patients with post-PK ectasia or a progressive increase in K values and surgically induced astigmatism underwent optional resuturing (Optional group). Patient demographics and surgical indications for PK, reasons for and frequency of resuturing, time between PK and resuturing, and clinical outcomes were evaluated.

RESULTS

The frequency of resuturing was 9.03% (59 of 633), and the mean age was 39.15±17.80 years. The most common indication for PK was keratoconus (42.4%) and the interval between PK and resuturing ranged from 0.03 to 32 months. The underlying cause leading to resuturing was suture-related problems in 43 eyes (72.9%), development of ectasia or progressive steepening of the K values and surgically induced astigmatism in 16 eyes (27.1%). The mean visual acuity increased, the K value and astigmatism decreased significantly following resuturing in both the mandatory group and the Optional group (P≤0.2). The decrease in astigmatism and K values was more marked in the Optional group, as expected (P≤0.001).

CONCLUSION

While resuturing is essential in order to obtain wound integrity in the setting of dehiscence, it is effective in terms of achieving higher visual acuities and lower astigmatism and K values in high astigmatism and post-PK ectasia cases.

Microbial keratitis in corneal grafts: predisposing factors and outcomes

PurposeTo identify the nature of microbial keratitis in corneal grafts and the clinical outcomes at a tertiary hospital in the United Kingdom.Patients and methodsA retrospective case series of microbial keratitis in corneal grafts at the Royal Victoria Infirmary, Newcastle upon Tyne over a 17-year period (1997-2014).ResultsA total of 759 consecutive corneal grafts were identified from the Cornea Transplantation database. Of these, 59 episodes of microbial keratitis occurred in 41 eyes of 41 patients (5.4%; 19 male, 46.3%). Median patient age was 73 years (SD=19.4 years). The most common indication for corneal transplantation was bullous keratopathy (11/41, 26.8%). There were 34/59 (57.6%) episodes of culture-positive graft keratitis; Streptococcus pneumoniae and Staphylococcus aureus were each isolated in 5/34 (14.7%) culture-positive episodes. In all, 35/59 (59.3%) episodes of microbial keratitis occurred in 22 previously failed grafts and 3 de novo graft failures. Gram-negative keratitis was more likely to cause reduced BCVA after (χ²-test, P=0.02). Median graft duration was 49.5 months (SD=43.7 months). Failed grafts were significantly older (median 69 vs 27 months, P=0.009).ConclusionThis represents the longest published follow-up data on microbial keratitis and is the only of its kind in the United Kingdom. The incidence of 5.4% is comparable to that within the developed world. Graft age was significantly associated with graft failure in microbial keratitis; the ongoing risk of microbial keratitis warrants providing patients with long-term open access to hospital eye services.

Asymptomatic Infection in Decompensated Full-Thickness Corneal Grafts Referred for Repeat Penetrating Keratoplasty

PURPOSE

We report a case series of asymptomatic infections affecting failed corneal grafts in patients referred for repeat penetrating keratoplasty (PK).

METHODS

In this retrospective, noncomparative, interventional case series, we reviewed the medical records of all repeat PK procedures performed at Villa Serena-Villa Igea private Hospitals (Forlì, Italy) between January 2011 and March 2016. Specifically, preoperative and postoperative slit-lamp examinations, and the results of histological and bacteriological examinations, were noted.

RESULTS

Fifty-three repeat PKs were performed in the study period. All patients were referred because of long-standing graft decompensation with stromal scars or surface irregularities, thus unsuitable for endothelial keratoplasty. None was referred because of presumed infection. Histological examination of the explanted buttons showed the presence of microorganisms of various types in 7 eyes. Cultures were positive in 4 of these cases and in one additional case Staphylococcus aureus was grown in culture, but was not seen in the histology specimen. None of the patients presented with unusual pain, tearing, or discomfort. Preoperative abnormal clinical findings included epithelial defect (n = 6), focal whitening of corneal stroma (n = 5), crystalline keratopathy (n = 1), and an elevated pigmented lesion (n = 1). After repeat PK, recurrence of the infection was seen in 5 of 7 (71%) cases, 2 of which required a third PK procedure.

CONCLUSIONS

Apparently quiet eyes with failed PK can harbor slow-growing asymptomatic infection. An epithelial defect in a failed PK graft should raise suspicion of infection. Routine cultures and histological examination of the excised corneal buttons are instrumental in the diagnosis of these infections and can guide further treatment.

Microbial Keratitis After Penetrating Keratoplasty

PURPOSE

To report the incidence, microbiological profile, graft survival, and determining factors of microbial keratitis after penetrating keratoplasty (PK).

DESIGN

Observational case series.

METHODS

The study involved 51 patients (52 eyes) who were treated at a single tertiary referral center during a 10-year period. Retrospective chart review included medical records of all patients diagnosed with microbial keratitis after penetrating keratoplasty at the National Taiwan University Hospital between January 2000 and December 2009. The main outcome measures were incidence of graft infection, microbial profile, and graft survival status.

RESULTS

There were 871 PKs performed and 67 episodes in 52 eyes of culture-positive microbial keratitis during the study period. There were 32 infectious episodes (47.8%) in the first year post-PK and 35 episodes (52.2%) after the first year post-PK. Forty-four gram-positive bacterial isolates (57.9%), 17 gram-negative bacterial isolates (22.4%), and 15 fungal isolates (19.7%) were found. Twenty-three (34.3%) grafts remained clear after the infection episode with a mean follow-up of 1127 days (range, 25-3962 days). There was no difference in graft survival rate regarding the original indication of PK or offending pathogen. Suture-related infection was associated with decreased risk of graft failure (P = .02), while the factor associated with increased risk of graft failure was usage of antiglaucoma agents (P = .01).

CONCLUSION

Infectious keratitis after penetrating keratoplasty leads to a high graft failure rate. Such complications can occur before or after the first year post-PK.

Clinical Characteristics of Stenotrophomonas maltophilia Keratitis

PURPOSE

Stenotrophomonas maltophilia is an important opportunistic pathogen but an uncommon cause of corneal infections. This study aimed to report the clinical features, antibiotic susceptibility, treatments, and visual outcomes of S. maltophilia keratitis.

METHODS

The medical records of 21 patients with culture-proven S. maltophilia-associated infectious keratitis in our hospital between January 1, 2003, and December 31, 2014, were retrospectively reviewed. The clinical features of patients with S. maltophilia keratitis were compared with those of patients from 17 previously reported cases.

RESULTS

The most common risk factors for S. maltophilia keratitis were preexisting corneal disease or previous corneal surgery (16), followed by soft contact lens wear (9). Nine patients (42.9%) were multifactorial. Polymicrobial infections was detected in 12 eyes (57.1%). All S. maltophilia isolates were susceptible to levofloxacin and moxifloxacin. A total of 17 of 21 patients (81.0%) had favorable responses to topical antimicrobial treatment, and 10 (47.6%) required surgical intervention for promotion of reepithelialization (6) and corneal perforation (4). Final vision ranged from light perception to 20/20. The clinical features of S. maltophilia keratitis in our cases and in previously reported cases were similar.

CONCLUSIONS

S. maltophilia keratitis primarily affects patients with compromised ocular surfaces. S. maltophilia demonstrates in vitro susceptibility and a strong clinical response to fluoroquinolones.

Shifting trends in microbial keratitis following penetrating keratoplasty in Taiwan

To investigate the clinical and microbiological profiles from microbial keratitis following penetrating keratoplasty (PKP) in a tertiary referral center in Taiwan, the medical records of 648 consecutive patients (648 eyes) undergoing PKP between January 2003 and December 2007 were retrospectively reviewed. Patients who subsequently sustained microbial keratitis were enrolled and analyzed for potential risk factors, clinical manifestations, microbiological profiles, complications, graft survival, and final visual outcome. A total number of 42 corneal graft infections (6.5%) were recruited. Mean interval between corneal transplantation and graft infection was 12 ± 9.5 months. Potential risk factors included suture-related problems (31.0%), lid abnormalities (23.8%), persistent epithelial defect (23.8%), contact lens use (14.3%), dry eye (11.9%), and prior rejection episodes (4.8%). Lesions were discovered mostly at the donor-recipient junction ([DRJ] 45.2%). Positive cultures were identified in all of the morbid eyes, of which Pseudomonas aeruginosa was the most common pathogen (38.1%). Despite mandatory hospitalization and topical fortified antibiotics management, complications ensued such as graft failure (71.4%), hypopyon (21.4%), corneal perforation (14.3%), wound dehiscence (11.9%), and endophthalmitis (4.8%). The visual outcome was dismal that graft clarity was achieved in only 12 eyes (28.6%), and that final visual acuity deteriorated to less than 20/200 in 28 eyes (66.7%). In conclusion, microbial keratitis following PKP is a devastating event that severely impairs graft survival rate and postoperative visual outcome which usually occur within the first postoperative year. The incidence of post-PKP microbial keratitis has generally decreased in recent years whilst P. aeroginosa prevails as the leading cause of graft infection in our hospital. Close follow-up by ophthalmologists and elevated self-awareness of patients for at least one year are always encouraged to prevent late-onset infection.

Twelve-year follow-up of penetrating keratoplasty

PURPOSE

To evaluate the long-term outcomes of penetrating keratoplasty (PKP) according to the corneal disease diagnosis and the number of PKP procedures performed.

METHODS

Five-hundred-and-nine eyes from 403 patients who underwent PKP at Miyata Eye Hospital in Japan from 1998 through 2014, were included in this study. Medical charts were retrospectively examined to ascertain the corneal disease diagnosis and the period of graft survival. Graft survival rates were compared among various corneal disease diagnoses and among the number of PKP procedures performed. Changes in corneal endothelial cell density (ECD) were analyzed using a mixed-effects model. The presence/absence of various risk factors was compared between transparent grafts and failed grafts.

RESULTS

The overall rate of graft survival at 12 years was 60.4%. The rates of graft survival in keratoconus was 100%, in corneal dystrophy 100%, in leukoma 70.8%, and in bullous keratopathy 51.7%. The rates of graft survival at 12 years for the first PKP was 65.4% and for the second PKP, 43.4% (p < 0.001). All cases of third PKP and fourth PKP failed within 8 years. Preoperative mean ECD (95% confidence interval) was 2722 (2666-2778) cells/mm²; it decreased exponentially after PKP. Mean ECD was 659 (440-878) cells/mm² at 10 years. Rejection, trauma, and infection occurred significantly more frequently in failed grafts than in transparent grafts.

CONCLUSIONS

The long-term prognosis of PKP depends on the original diagnosis. The long-term prognosis of re-grafting is worse than that of primary grafts. Rejection, trauma, and infection are risk factors for graft failure.

Role of steroids in the treatment of bacterial keratitis

Bacterial keratitis can lead to severe visual impairment from corneal ulceration, subsequent scarring, and possible perforation. The mainstay of treatment is topical antibiotics, whereas the use of adjunctive topical corticosteroid drops remains a matter of debate. Herein, we review the rationale for and against the use of topical corticosteroids and we assess their effectiveness and safety in the published randomized controlled trials that have evaluated their role as adjunctive therapy for bacterial corneal ulcers. In the largest study to date, the Steroids for Corneal Ulcers Trial, topical corticosteroid drops were neither helpful nor harmful for the 500 participants as a whole. However, subgroup analyses suggested that topical corticosteroids may be beneficial upon early administration (within 2–3 days after starting antibiotics) for more central corneal ulcers with poorer vision at presentation, for invasive Pseudomonas strains, and for non-Nocardia ulcers. These results are discussed within the limitations of the study.

Factors Affecting Treatment Outcome of Graft Infection Following Penetrating Keratoplasty

Purpose

To evaluate the factors affecting treatment outcome of graft infection following penetrating keratoplasty (PKP).

Methods

In this retrospective study, 28 patients who underwent PKP between January 2005 and January 2013 and who were diagnosed with graft infection were classified into a treatment success group or a treatment failure group. Demographic and clinical characteristics, as well as the results of the microbiologic investigation, were analyzed and compared. A subsequent binary logistic regression analysis was performed to identify the prognostic factors affecting treatment outcome.

Results

Graft infection occurred at a mean of 38.29 ± 36.16 months (range, 1 to 96 months) after PKP. Seventeen patients developed bacterial keratitis, and 11 patients developed fungal keratitis. Overall, of the 28 patients, nine (32.1%) were classified in the treatment failure group. Multivariate analysis identified pre-existing graft failure (p = 0.019), interval longer than 72 hours between donor death and PKP (p = 0.010), and fungal infection (p = 0.026) as significant risk factors for treatment failure.

Conclusions

Pre-existing graft failure, extended interval between donor death and PKP, and fungal infection were important risk factors for treatment failure of graft infection following PKP.

Clinical and microbiological profile of post-penetrating keratoplasty infectious keratitis in failed and clear grafts

PURPOSE

To comparatively evaluate the clinical and microbiological profiles and treatment outcome of cases with post-penetrating keratoplasty (PK) infectious keratitis in failed and clear grafts.

DESIGN

Retrospective, matched cohort study.

METHODS

All cases of infectious keratitis following penetrating keratoplasty admitted to the Royal Victorian Eye and Ear Hospital, Melbourne, between January 1998 and December 2008 were identified through a retrospective medical chart review. Cases without any surface sutures were selected and divided into 2 groups, microbial keratitis with pre-existing graft failure and microbial keratitis in clear graft on presentation. Demographic, clinical, and microbiological profiles of cases in both groups were analyzed and compared.

RESULTS

Patients in the failed-graft group were older (P = .004) and had an early onset of graft infection (P = .049), compared with patients in the clear-graft group. All patients in the failed-graft group were on long-term corticosteroid drops at the time of presentation (vs 76% in clear-graft group; P = .005). Moraxella sp was more frequently isolated in the failed-graft group (30.4%) compared with the clear-graft group (8%). A higher number of cases in the clear-graft group required surgical intervention in the form of corneal gluing and therapeutic corneal transplantation compared with the failed-graft group (P = .03).

CONCLUSIONS

Prolonged use of corticosteroid eye drops is a major risk factor for the occurrence of postkeratoplasty infectious keratitis in failed and clear grafts. Infections in failed grafts occur earlier as compared to clear grafts, and indolent organisms like Moraxella are prevalent in patients with failed grafts in Australia.

Management of trachomatous keratopathy by automated lamellar therapeutic keratoplasty

PURPOSE

To evaluate the efficacy of automated lamellar therapeutic keratoplasty (ALTK) for the management of anterior corneal stromal scarring caused by trachoma.

METHODS

Seventeen cases of trachomatous keratopathy that were treated by ALTK were retrospectively evaluated. The main outcome measures were uncorrected visual acuity, best-corrected visual acuity (BCVA), keratometry, pachymetry, time to epithelialization, graft clarity, and complications, if any.

RESULTS

The mean age of the patients was 50.3 ± 14.1 years. Five of the 17 cases had Salzmann nodular degeneration. The mean decimal BCVA was 0.06 ± 0.05 preoperatively, which improved to 0.41 ± 0.16 at 12 months, and 12 eyes (70.6%) had a postoperative BCVA of 6/18 or better. The median epithelialization time was 6 days (range, 1-38 days). Persistent epithelial defect developed in 6 eyes, and 1 eye developed graft infection.

CONCLUSIONS

Anterior stromal corneal scarring caused by trachoma can be effectively treated with ALTK. However, occurrence of persistent epithelial defects may complicate the success of this surgery.

Microbial keratitis after penetrating keratoplasty: impact of sutures

PURPOSE

To determine the impact of presence or absence of sutures in cases with post-penetrating keratoplasty (PKP) microbial keratitis.

DESIGN

A 10-year retrospective chart review of post-PKP patients admitted with microbial keratitis at the Royal Victorian Eye and Ear Hospital, Melbourne, between January 1998 and December 2008 was undertaken.

METHODS

Patients were categorized in 2 groups, "sutures present" and "sutures absent." Main parameters evaluated were clinical and microbiological profile and treatment outcome.

RESULTS

One hundred and twenty-two episodes of microbial keratitis were noted in 101 patients: 71 (58.2%) with sutures present and 51 (41.8%) with sutures absent. Overall, pseudophakic bullous keratopathy was the most common indication for keratoplasty (P=.92). Ocular surface disorder was the commonest risk factor associated with the occurrence of infection in both groups (P=.17). Infections caused by Moraxella sp. (P=.001) were significantly more common in the "sutures absent" group. Surgical interventions were required for 47 episodes (39%), with corneal gluing performed in significantly higher number of cases in the "sutures absent" group (40% vs 15%; P=.05). Multivariate analyses did not reveal any significant associations. Final mean visual acuity outcome was poorer in the "sutures absent" group (logMAR 2.10 ± 0.92 vs 1.76 ± 0.96; P=.04).

CONCLUSIONS

Corneal graft infections, in the presence and absence of sutures, share similar indications and risk factors. However, infections caused by indolent microorganisms were more prevalent in grafts without sutures. This group of patients required a higher number of surgical interventions in the form of corneal gluing and the overall visual outcome was poor.

Incidence, occurrence rate, and characteristics of suture-related corneal infections after penetrating keratoplasty

PURPOSE

To report the incidence, occurrence rate, and characteristics of suture-related infections after penetrating keratoplasty (PK).

METHODS

Patients who underwent PK at our institution between January 1, 2002, and July 1, 2006, were cross-referenced with patients diagnosed with corneal infections between January 1, 2002, and July 1, 2007. All patient charts were reviewed retrospectively for occurrence of suture-related infections, duration of follow-up, and clinical characteristics.

RESULTS

Of the 487 PKs performed in 412 patients, 22 eyes of 22 patients developed postoperative corneal infections. Of these, 5 eyes were identified as having suture-related graft infections, yielding an occurrence rate of 1.0%. The average follow-up was 3.46 years per PK, yielding an incidence of 2.96 infections per 1000 PK-years. The mean interval from surgery to infection was 8 months (range: 3-23 months). All culprit sutures were in the interpalpebral zone. No patients were using topical antibiotics at the time of infection, and all patients were using topical corticosteroid drops. Cultured organisms included Staphylococcus aureus (3 cases), coagulase-negative Staphylcoccus (1 case), and S. viridans (1 case). In 2 patients with isolated corneal involvement, topical moxifloxacin was initiated, and the patients responded favorably. In 3 patients with corneal infection and an associated hypopyon or endophthalmitis, vitreous biopsy, intravitreal injections of antibiotics, and fortified topical antibiotics were used. One patient required a repeat PK as a result of the infection. Two eyes eventually became phthisical.

CONCLUSIONS

The rate of suture-related infections after PK may be lower than previously reported. In our patients, suture-related infections all occurred within the first 2 years after surgery, and some of them resulted in significant morbidity, underscoring the importance of patient identification of symptoms and early clinical recognition.

Microbial keratitis following corneal transplantation

PURPOSE

To determine the predisposing risk factors and analyse the clinical and microbiological profiles of microbial keratitis following corneal transplantation.

METHODS

A retrospective analysis was done of hospital records of all patients who presented with microbial keratitis in the corneal graft between July 2000 and June 2005 at the Corneal Unit of Royal Victorian Eye and Ear Hospital, Melbourne, Australia.

RESULTS

Eighty-one episodes of infection were identified in 62 patients over a 5-year period. Thirteen patients had multiple episodes of infection. The mean age of the patients was 70 +/- 16 years (range: 22-92 years). The median time interval between the graft and infection was 17 months (range: 6 days to 385 months). Twenty-two (35%) episodes of primary infection were related to sutures. The associated predisposing risk factors were failed graft (40%), dry eye (18%), Herpes simplex keratitis (8%), and ocular surface disease (8%). Forty-seven (76%) cases were culture positive for bacteria. Ten cases were positive for Herpes simplex virus (HSV) during presentation.

CONCLUSION

Failed graft is a long-term risk factor for graft infection in addition to ocular surface disease and H. simplex keratitis. All the predisposing risk factors increase the risk of recurrent graft infection.

Bacterial Keratitis after Penetrating Keratoplasty

PURPOSE

To determine the incidence, microbiological profile, graft survival, and factors influencing graft survival after the development of bacterial keratitis after penetrating keratoplasty (PK).

DESIGN

Retrospective case series.

PARTICIPANTS

One hundred two patients (102 eyes) treated at a single center during a 5-year period.

METHODS

Retrospective review of the medical records of every patient treated for culture-positive keratitis between January 1, 1998 and December 31, 2002 who previously had undergone penetrating keratoplasty at the King Khaled Eye Specialist Hospital.

MAIN OUTCOME MEASURES

Graft survival and visual outcome.

RESULTS

There were 2103 PKs performed and 102 (4.9%) cases of culture-positive keratitis during the study period. There were 168 bacterial isolates, of which 140 (83.3%) were gram positive, 28 (16.7%) were gram negative, and 1 (0.6%) was acid fast. Only 38 (37.3%) grafts remained clear after a mean follow-up of 985 days (range, 82-2284). The best graft survival was in eyes with PK for keratoconus (83.7%), whereas the poorest grat survival was for previously failed grafts (5.6%). By Kaplan-Meier analysis, there was an immediate steep decline in graft survival to 54.9%, followed by a slow decline to 47.2% by 1 year and 35.8% after 4 years. Factors associated with an increased risk of graft failure were the surgical indication for PK (P<0.001), increasing patient age (P = 0.004), smaller donor (P = 0.001) and recipient (P = 0.0003) graft size, history of previous microbial keratitis (P = 0.02) or endothelial rejection episodes (P = 0.02), and coexisting glaucoma (P = 0.001). The visual outcome was > or =20/40 in only 8 (8.2%) eyes and better than 20/200 in only 21 (21.6%) eyes.

CONCLUSION

The development of bacterial keratitis after PK is a serious complication that is associated with a high incidence of graft failure and poor visual outcome.

Infectious keratitis following keratoplasty

Infectious keratitis following corneal transplantation is one of the leading causes of failure of a corneal graft. The incidence of graft infection is variable, with developing countries having a higher incidence. The majority of the graft infections occur within 1 year of the corneal transplantation. Suture-related problems and persistent epithelial defect are the most common risk factors predisposing to graft infection. Pneumococcus species and Staphylococcus aureus have been found to be the commonest microorganisms in the developed world, whereas Staphylococcus epidermidis is the most often detected microorganism in corneal graft infection in the developing world. The early identification of predisposing risk factors in patients and their appropriate management at the earliest may prevent the occurrence of graft infection and might improve graft survival. Visual prognosis in eyes with post-keratoplasty graft infection is poor even after optimal therapy and there is a high rate of graft decompensation.

Ulcerative Keratitis Caused by Haemophilus Influenzae

PURPOSE

To report the clinical course, treatments, antibiotic sensitivities, and visual outcomes for eyes with ulcerative keratitis caused by Haemophlilus influenzae.

METHODS

The medical records of 10 patients with culture-proven H. influenzae-associated corneal ulcer in a tertiary referral center in a 5-year period (1998-2003) were retrospectively reviewed.

RESULTS

The median age was 61 years (range, 2-83 years). The mean follow-up time was 9.4 months (range, 2-31 months). Risk factors such as previous surgeries (5), herpes simplex keratitis (2), leukoma adherens with calcification (1), and exposure keratitis (1) were identified in 9 patients. In vitro testing of the H. influenzae isolates showed that 6 of 10 were resistant to ampicillin; all were sensitive to amoxicillin/clavulanic acid, ceftriaxone, and cefuroxime. All cases responded well to medical antibiotic treatment. Final best spectacle-corrected visual acuity ranged from no light perception to 20/30.

CONCLUSION

H. influenzae is a rare cause of corneal ulceration. Predisposing factors for infection are usually present. Accurate diagnosis and treatment may preserve ocular integrity and visual acuity.

Central Penetrating Keratoplasty With Peripheral Intrastromal Tuck

PURPOSE

To report a new technique of central penetrating keratoplasty with peripheral intrastromal tuck in cases of chronic corneal decompensation.

METHODS

Central penetrating keratoplasty with peripheral intrastromal tuck was undertaken in 8 eyes with chronic corneal decompensation. An 8-mm donor tissue with a peripheral flange of 2 mm was fashioned and sutured into a 7.5-mm recipient bed having a 2-mm intralamellar pocket. Sixteen full-thickness interrupted sutures were passed. Suture removal was possible as early as 1 month, and all sutures were removed by 4 months.

RESULTS

Postoperative BCVA improved to 20/40 to 20/80 in all eyes, and astigmatism was <4 diopters in all cases at the last follow-up, which ranged from 5 to 16 months.

CONCLUSIONS

Central penetrating keratoplasty with peripheral intrastromal tuck is a useful technique because it allows early suture removal and visual rehabilitation.

Factors affecting eye donation from postmortem cases in a tertiary care hospital

PURPOSE

To evaluate the responses to requests for eye donation from relatives of postmortem cases in a tertiary care hospital in India.

METHODS

In a prospective study, the cases brought for postmortem to the Forensic Medicine Department were screened as potential donors by our team. The next of kin of potential donors were approached and counseled in a systematic manner following a standard interview pattern. Responses were noted in a predesigned performa. The religion, level of literacy, socioeconomic status, relationship with the deceased, prior knowledge of eye donation, willingness for eye donation, and reasons for not donating eyes of the deceased were recorded.

RESULTS

One hundred fifty-nine potential donors were identified from a total of 721 postmortem cases. There were 119 (74.8%) men and 40 (25.2%) women. None of the deceased had previously pledged their eyes for eye donation. Eighty-eight (55.4%) next of kin were already aware of the concept of eye donation, but 71 (44.7%) families had not heard of it before. Willingness for eye donation was seen in 66 (41.5%), whereas 93 (58.5%) families refused eye donation. Of those already aware of eye donation, 39 (44.3%) gave consent for donation. Prior knowledge of eye donation had no influence on willingness for eye donation (P = 0.424). Similarly, literacy (P = 0.338) and socioeconomic status as estimated by a composite socioeconomic scale based on literacy and family income did not have any influence on willingness for eye donation (P = 0.338). Major reasons for not donating eyes included refusal to discuss the issue and dissuasion by distant relatives, legal problems, and religious beliefs.

CONCLUSIONS

In our experience, literacy, socioeconomic status, and prior knowledge of eye donation of next kin had no correlation with donor corneal tissue procurement. Active counseling by a motivated team can be effective even in families with no prior knowledge and low socioeconomic status.

Microbial Keratitis Following Lamellar Keratoplasty

OBJECTIVE

To determine the predisposing factors, etiologic agents, and clinical and visual outcomes in infectious keratitis following lamellar keratoplasty (LK).

METHODS

One hundred thirty-five eyes (135 patients) that had undergone LK were retrospectively analyzed for the occurrence of infectious keratitis following LK. The parameters evaluated were predisposing factors, seasonal variation, indications and type of LK, time interval between LK and infection, site and depth of infection, etiologic organisms, type of treatment, outcome in terms of graft status, secondary surgery, visual acuity, and the donor tissue profile.

RESULTS

The incidence of infectious keratitis following LK was 11.11%. The most significant predisposing factor was persistent epithelial defect (3 eyes) and suture abscesses (3 eyes). Most cases occurred between May and August (9/15). Twelve cases developed infection within 2 weeks of surgery (80%). Seven cases (7/15) occurred with onlay grafts, 6 with inlay grafts, and 2 with large-diameter LK. Cultures of corneal scrapings were positive in 11 eyes (73.3%), and the most common isolated organism was coagulase-negative Staphylococcus (CNS). Only 2 eyes responded to medical therapy, and graft sloughing occurred in 9 cases. Six eyes underwent penetrating keratoplasty to either salvage the integrity of globe or for visual rehabilitation of cases where infection resulted in corneal opacity.

CONCLUSIONS

Infections after LK may not be amenable to antimicrobial therapy and may necessitate the removal of the graft or a therapeutic penetrating keratoplasty.

Visual outcome of cataract surgery with pupillary sphincterotomy in eyes with coexisting corneal opacity

BACKGROUND

To evaluate the visual outcome following cataract surgery with pupillary sphincterotomy in eyes with coexisting corneal opacity.

METHODS

Patients with leucomatous corneal opacity with significant cataract were enrolled for the study. The uncorrected visual acuity and best-corrected visual acuity (BCVA) were recorded and the anterior segment was thoroughly evaluated by a slit lamp biomicroscope before the surgery. Only those patients who had some amount of clear peripheral cornea were selected. Posterior segment pathology was ruled out by indirect ophthalmoscopy after pupillary dilatation, if possible, or by B-scan ultrasonography. Conventional extracapsular cataract extraction with pupillary sphincterotomy was performed and an intraocular lens was implanted. Postoperatively, the eyes were evaluated on day 1, and 1 week and 6 weeks following surgery for similar parameters.

RESULTS

Fourteen eyes of 14 patients were included in the study, of which 13 (92.85%) patients were male. The mean age of the patients was 47.85 +/- 7.37 years. All the eyes had a dense central leucomatous corneal opacity. Twelve (85.71%) eyes had two or more quadrants of deep vascularisation. Sphincterotomy was performed mostly (71.42%) in the nasal or inferonasal quadrant. The intraocular lens was implanted in 13 (92.85%) eyes, and one (7.1%) eye was left aphakic due to the occurrence of a large posterior capsular tear. Preoperatively, all eyes had BCVA < 6/60. At 6 weeks after surgery, all eyes had BCVA >or= 6/60 and four (28.57%) eyes had BCVA >or= 6/18. The mean BCVA preoperatively in these eyes was 0.015 +/- 0.009, which changed to 0.249 +/- 0.102 at 6 weeks following surgery.

CONCLUSIONS

Extracapsular cataract extraction and intraocular lens implantation with pupillary sphincterotomy provides ambulatory and useful vision to patients of cataract with coexisting central leucomatous corneal opacity.

Therapeutic penetrating keratoplasty for microbial keratitis in Taiwan from 1987 to 2001

PURPOSE

To determine the surgical outcomes of therapeutic penetrating keratoplasty (PKP) and its role in the management of microbial keratitis.

DESIGN

Interventional case series.

METHODS

We retrospectively performed a chart review of the hospital records of all 151 patients undergoing therapeutic PKP for culture-proven microbial keratitis at the National Taiwan University Hospital during a 14 year-period (1987-2001). Patients were divided into three categories: (1) bacterial keratitis; (2) fungal keratitis; and (3) acanthamoebic keratitis. Each of the following criteria was evaluated: (1) graft clarity 1 month and 1 year postoperatively; (2) cure of the disease; and (3) anatomical success rate.

RESULTS

A total of 108 therapeutic PKP met the criteria. Therapeutic PKP eradicated the infection in 37/41 of patients with bacterial keratitis, 36/52 of patients with fungal keratitis, and 13/15 of patients with acanthamoebic keratitis. 22/32 of grafts of bacterial keratitis, 20/39 of fungal keratitis, and 11/14 of acanthamoebic keratitis remained clear at 1 year postoperatively. A higher percentage of graft clarity at 1 year postoperatively was achieved in all three categories when grafts were 8.5 mm or less compared with larger grafts. All five patients with secondary endophthalmitis observed at the time of therapeutic PKP experienced a progression of infection despite aggressive surgical treatment, and had to be enucleated.

CONCLUSIONS

Therapeutic PKP is valuable in the management of microbial keratitis that is unresponsive to medical therapy. A higher percentage of clear graft was found when grafts were smaller in all three categories. Surgical results are worse for patients with fungal keratitis, regardless of graft clarity, anatomical success, or infection eradication rate.

Keratoplasty for keratomalacia in preschool children

AIM

To study the results of surgical management of keratomalacia in children.

METHODS

A clinical case series of all children with keratomalacia, admitted to an Indian centre during the period from June 2000 to June 2001 is presented. The parameters evaluated were demographic data, systemic associations, and results of medical and surgical intervention.

RESULTS

29 children with keratomalacia ranging from 2 months to 5 years of age (mean 1.8 (SD 1.4) years) were included in the study. All children belonged to families of lower socioeconomic status. 27 patients (93.1%) had not been immunised at all. The systemic diseases precipitating the onset of keratomalacia included measles (41.37%), pneumonia (31.03%), and acute diarrhoea (37.93%). 36 eyes (66.7%) had total corneal melting and 11 (20.3%) eyes had paracentral corneal melting. In 15 eyes (27.8%) an emergency tectonic penetrating keratoplasty was performed of which only five grafts (33.3%) remained clear at a mean follow up of 7.3 (6.8) months (range 3-24 months). Seven eyes underwent optical penetrating keratoplasty, of which four grafts (57.14%) remained clear at a mean follow up of 6.4 (3.6) months (range 3-12 months). None of these could achieve a visual acuity better than 6/60.

CONCLUSIONS

Corneal grafting surgery in keratomalacia is associated with poor visual outcome.