Mycobacterium Keratitis After Laser in situ Keratomileusis

PURPOSE

The authors report two cases of Mycobacterium keratitis following LASIK.

METHODS

The case reports are based on a retrospective review of clinical history and associated findings.

RESULTS

Two patients developed infectious keratitis after undergoing laser in situ keratomileusis (LASIK). In case #1, the infection developed after manipulation of the lamellar flap to remove epithelium from the stromal bed. In case #2, prior radial keratotomy may have been a contributing factor to development of the infection. Corneal infiltrates appeared as focal, white, stromal deposits. Cultures isolated Mycobacterium fortuitum from case #1 and Mycobacterium chelonae from case #2. Topical fortified amikacin, clarithromycin, tobramycin, and ciprofloxacin eventually controlled the infection. Topical prednisolone acetate and bandage contact lenses were necessary to control inflammation and pain. Infiltrates were slow to resolve until focal necrosis eroded through the flaps leading to rapid clearing of the infiltrates; however, scarring of the cornea developed at the site of necrosis. Visual recovery was good in the first case but limited in the second.

CONCLUSIONS

Mycobacterium keratitis complicating LASIK may be difficult to eradicate until the sequestered stromal infiltrate drains. Rapid recognition of the causative organism and aggressive medical and surgical management of the infection may improve the outcome.

The use of Molteno implant and anterior chamber tube shunt to encircling band for the treatment of glaucoma in keratoplasty patients

This retrospective study reviews the results of 35 keratoplasty patients with complex corneal and glaucoma disease, who received Molteno-type (n = 25) or anterior chamber tube shunt to encircling band (ACTSEB)-type (n = 10) implant for the treatment of difficult glaucomas. The implant was placed before the keratoplasty in 14 eyes, during the keratoplasty procedure in 6 eyes, and subsequent to the corneal surgery in 15 eyes. Mean follow-up for the keratoplasty was 25.46 months (range, 6-58 months) and 24.74 months (range, 7-42 months) for the seton procedure. Graft rejection occurred in 12 (34%) of 35 eyes and was progressive in 9 eyes. Nonimmunologic failure was seen in 9 (26%) of 35 eyes. Grafts were repeated in ten eyes with eight of these (80%) remaining clear at a mean of 14.4 months. Considering the results of the repeat grafts, 25 (71%) of 35 eyes achieved clear transplants. Overall, 46% of patients had final visual acuities of 20/100 or better and 69% had final visual acuities of 20/400 or better. The mean preoperative intraocular pressure (IOP) of 34.54 mmHg (range, 14-68 mmHg; standard deviation [SD], 11.51) was lowered to a mean of 14.65 mmHg (range, 6-30 mmHg; SD, 4.49). In the final analysis, 30 (86%) of 35 eyes were judged successful from a glaucoma standpoint. We conclude that the Molteno- and ACTSEB-type implants are viable treatment alternatives in this difficult glaucoma group.

Atypical corneal manifestations of multiple myeloma. A clinical, histopathologic, and immunohistochemical report

A 52-year-old male developed bilateral subepithelial amorphous corneal deposits as well as diffuse noniridescent anterior stromal haze of unknown etiology. The deposits increased in density and a penetrating keratoplasty was performed in one eye when vision became sufficiently compromised. Pathological evaluation of the tissue included light and electron microscopy and immunohistochemical studies. The deposits were identified as monoclonal IgG kappa immunoglobulins and a systemic workup confirmed the diagnosis of a previously unsuspected multiple myeloma. The clinical course was characterized by the noncrystalline nature of the deposits, recurrence of the myeloma protein within the graft, and the poor response of the cornea to systemic therapy. In addition, profound ocular morbidity occurred, with a final visual acuity of 20/200 OD and 20/400 OS.

Comparison of lacrimation kinetics in dry eye patients and normals

A 100 mm long and 5 mm wide filter paper strip enclosed in a transparent plastic sheath to prevent evaporation was used to determine the time dependence of wetting of the strip in the anesthetized eyes of dry eye patients and age-matched normals. Prior to the measurements, the paper strips were extracted by lipid solvents and marked at every millimeter length. Wetted length data were plotted against time and the resulting wetting curves were analyzed to obtain the time dependence of the tear secretion rate during lacrimation. Every eye studied exhibited an exponentially decaying tear secretion rate that could be characterized by three kinetic parameters per cycle: the initial and final tear secretion rates and the secretion decay coefficient. The eyes of the sicca patients showed a much simpler lacrimation pattern than did the controls: 60% of the dry eyes exhibited a one-cycle lacrimation pattern while only 5% of the normal group did so. The tear secretion kinetic parameters characterizing the lacrimation pattern reduced to one-cycle were compared. Both the dry eyes and the control eyes started to lacrimate at about the same high initial secretion rate. However, the lacrimation rate was found to decrease faster and to a lower final rate in dry eye patients as opposed to normal controls.

A subretinal neovascular membrane as a complication of endogenous Candida endophthalmitis

A 21-year-old woman developed endophthalmitis and a macular chorioretinal lesion secondarily to a Candida infection. She had been receiving intensive systemic antibiotic and steroid therapy for pelvic inflammatory disease. Blood cultures confirmed a Candida albicans septicemia, and amphotericin B was administered intravenously. As the eye inflammation resolved, healing of the chorioretinal lesion was complicated by the development of a subretinal neovascular membrane. The authors hypothesize that the formation of the membrane was related to an inflammatory alteration of the pigment epithelium--Bruch's membrane--choriocapillaris complex. To the authors' knowledge, this is the first such report following a Candida infection of the eye.

Possible significance of cilioretinal arteries in open-angle glaucoma

To study the possible prognostic significance of the cilioretinal artery in open-angle glaucoma, the disc stereophotographs of one hundred consecutive patients with bilateral open-angle glaucoma were reviewed for the presence of cilioretinal arteries. The charts of 20 patients with unilateral cilioretinal arteries were then studied for the extent of the optic disc cupping and visual field damage. Despite the absence of a significant difference in the intraocular pressure between the two groups, eyes with cilioretinal arteries showed larger cup/disc ratios and more visual field damage when compared to the contralateral eyes without cilioretinal arteries in the same patients.