Publications by authors named "Darlene Miller"

172 Publications

Postoperative Endophthalmitis Caused by (Formerly ) Acnes: Case Series and Review.

Case Rep Ophthalmol 2021 Jan-Apr;12(1):1-10. Epub 2021 Jan 7.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA.

We report the clinical features, treatment strategies and outcomes in a series of patients with infectious endophthalmitis after cataract surgery caused by , formerly known as . This retrospective case series includes six eyes of six patients with chronic postoperative endophthalmitis caused by culture-proven from December 2010 to July 2019 at a University referral center. All patients underwent prior cataract extraction with intraocular lens (CE/IOL) implantation. The mean time between cataract surgery and the microbiologic diagnosis of endophthalmitis was 7.4 ± 5.2 months (range 1.5-17 months). The average time from obtaining the specimen to culture positivity was 7.7 ± 4.4 days (range 3-15 days). Three eyes (50%) presented with hypopyon and three eyes (50%) presented with prominent keratic precipitates without hypopyon. Presenting visual acuity ranged from 20/25 to 2/200. Initial treatments included intravitreal antibiotics alone ( = 2), pars plana vitrectomy (PPV) with partial capsulectomy and intravitreal antibiotics ( = 3), and pars plana vitrectomy with IOL removal and intravitreal antibiotics ( = 1). Follow-up treatments included IOL removal ( = 2), intravitreal antibiotics ( = 1), and topical antibiotics ( = 1). The best-corrected visual acuity at last follow-up was 20/70 or better in all patients. In a literature review, the clinical features and treatment outcomes for all case series of delayed-onset postoperative endophthalmitis caused by ( = 120) are listed. A definitive cure (the absence of recurrent inflammation) was achieved in 100% of patients that underwent IOL removal, in 77% of those that underwent PPV/partial capsulectomy and intravitreal antibiotics, and in 18% of cases treated with intravitreal antibiotics alone. Endophthalmitis after CE/IOL caused by is characterized by slowly progressive intraocular inflammation and has a protracted course from surgery to microbiologic diagnosis. Visual outcomes are generally favorable, but IOL explantation may be necessary for definitive cure.
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http://dx.doi.org/10.1159/000510208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7879283PMC
January 2021

Nutritionally variant streptococci causing endophthalmitis associated with intravitreal anti-vascular endothelial growth factor injection.

Am J Ophthalmol Case Rep 2021 Mar 27;21:101019. Epub 2021 Jan 27.

Department of Ophthalmology, Bascom Palmer Eye Institute, 900 NW 17th St., Miami, FL, USA.

Purpose: To describe the clinical course and microbial properties of the first two reported cases of nutritionally variant Streptococci ( and ) endophthalmitis following intravitreal anti-vascular endothelial growth factor injection (IVI).

Observations: A 74 year-old female developed endophthalmitis following IVI. The patient underwent a pars plana vitrectomy and visual acuity recovered to 20/30 in six weeks. Similarly, an 88 year-old male developed endophthalmitis after IVI. After a pars plana vitrectomy, the visual acuity recovered to 20/60 at five weeks.

Conclusions And Importance: Endophthalmitis due to species has traditionally resulted in uniformly poor visual outcomes. However, nutritionally variant Streptococci, now reclassified as and species, appear to have a less aggressive clinical course and better visual acuity outcomes. To the authors' knowledge, these are the first reports of nutritionally variant Streptococci following IVI related endophthalmitis.
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http://dx.doi.org/10.1016/j.ajoc.2021.101019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7851176PMC
March 2021

UV-Photokeratitis Associated with Germicidal Lamps Purchased during the COVID-19 Pandemic.

Ocul Immunol Inflamm 2021 Jan 20;29(1):76-80. Epub 2020 Nov 20.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA.

Purpose: To report photokeratitis caused by the improper use of germicidal lamps purchased during the COVID-19 pandemic.

Methods: Case series.

Results: Seven patients presented with acute ocular surface pain after exposure to UV-emitting germicidal lamps. Visual acuity was 20/30 or better in 13 of 14 eyes (93%). Anterior segment examination revealed varying degrees of conjunctival injection and diffusely distributed punctate epithelial erosions (PEEs) in every patient. No intraocular inflammation was identified across the cohort and all fundus examinations were normal. Treatment varied by provider and included artificial tears alone or in combination with antibiotic ointments and/or topical steroids. Five patients were followed via telehealth, one patient returned for an in-office visit, and one patient was lost to follow-up. Five of six patients endorsed complete resolution of symptoms within 2-3 days.

Conclusions: Patients should follow manufacturer recommendations when using UV-emitting germicidal lamps and avoid direct exposure to the ocular surface.
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http://dx.doi.org/10.1080/09273948.2020.1834587DOI Listing
January 2021

Characterization of Pseudomonas aeruginosa isolates from patients with endophthalmitis using conventional microbiologic techniques and whole genome sequencing.

J Ophthalmic Inflamm Infect 2020 Sep 28;10(1):25. Epub 2020 Sep 28.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL, 33136, USA.

Purpose: To demonstrate antibiotic susceptibility and genomic virulence factor profiles of Pseudomonas aeruginosa isolates from patients with culture-confirmed endophthalmitis.

Methods: Clinical isolates from patients diagnosed with pseudomonas endophthalmitis were included. Laboratory antibiotic susceptibility testing and whole genome sequencing was performed on all isolates.

Results: In the current study, 8 patients had vitreous culture-confirmed endophthalmitis due to P. aeruginosa. All isolates were multi-drug resistant but sensitive to ceftazidime and each fluoroquinolone tested. Whole genome sequencing revealed a total of 179 unique genes. The most common type of virulence genes included those involved in adherence and the secretion system. Seven of 8 (88%) isolates were of the cytoinvasive phenotype (exoST) and no isolates contained exoU.

Conclusions: P. aeruginosa associated endophthalmitis is often multi-drug resistant and demonstrates a variety of virulence factors with those involved in adherence and the secretion system being the most common.
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http://dx.doi.org/10.1186/s12348-020-00216-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7520479PMC
September 2020

Chronic, Recurrent Bacterial Endophthalmitis Caused by : Clinical Features and Management.

Int Med Case Rep J 2020 9;13:265-269. Epub 2020 Jul 9.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, FL, 33136, USA.

A 79-year-old man presented to a tertiary referral center from the Dominican Republic with an opaque corneal graft and a diagnosis of chronic, recurrent culture-positive endophthalmitis of the left eye. The patient had a history of penetrating keratoplasty for Fuchs' dystrophy and had undergone multiple intraocular surgeries including pars plana vitrectomy and anterior chamber wash out for the diagnosis and management of chronic endophthalmitis. After being referred, the patient underwent a third PKP, removal of his intraocular lens (IOL), capsulectomy, and injection of intravitreal antibiotics. All surgical specimens demonstrated the growth of . Five months after surgery, the graft remained clear without evidence of infection and best-corrected visual acuity was 20/350.
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http://dx.doi.org/10.2147/IMCRJ.S259899DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358084PMC
July 2020

Genotypic and Phenotypic Antibiotic Resistance in Staphylococcus Epidermidis Endophthalmitis.

Ophthalmic Surg Lasers Imaging Retina 2020 05;51(5):S13-S16

Background And Objective: To evaluate antibiotic resistance patterns in Staphylococcus epidermis endophthalmitis isolates, identify antibiotic resistance genes, and compare this to their phenotypic resistance.

Materials And Methods: Retrospective case series of S. epidermidis isolates from January 2012 to December 2017. Phenotypic resistance was determined from minimum inhibitory concentration values. Genotypic resistance was determined from DNA microarray. The relationship between these was analyzed using Cohen's kappa and predictive value.

Results: Seventy-five isolates were included. More than 60% were resistant to methicillin and erythromycin. Approximately 60% possessed the resistance genes for methicillin and erythromycin, and 25% for clindamycin. There was near perfect agreement between genotype and phenotype for erythromycin and methicillin (kappa = 0.88 and 0.89, respectively). Approximately 98% (P < 0.0001) of isolates with erythromycin and methicillin resistance genes and 90% (P = 0.0006) with clindamycin resistance genes were phenotypically resistant to those antibiotics. None were resistant to vancomycin.

Conclusion: The relationship between genotypic and phenotypic antibiotic resistance highlights that resistance may be polygenic, and genes may be silent. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:S13-S16.].
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http://dx.doi.org/10.3928/23258160-20200108-02DOI Listing
May 2020

Systemic Miltefosine as an Adjunct Treatment of Progressive Keratitis.

Ocul Immunol Inflamm 2020 May 29:1-9. Epub 2020 May 29.

Anne Bates Leach Eye Clinics, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine , Miami, Florida, USA.

Purpose: To report our experience with oral miltefosine (MLT) as an adjunct treatment for progressive keratitis (AK).

Methods: Retrospective case series of all patients who underwent treatment with oral MLT for AK at Bascom Palmer Eye Institute from 2017 to 2020.

Results: Six females from 16 to 55 years old, with a microbiologic diagnosis of , were treated with MLT and standard medical treatment. Four of the six cases deteriorated after initiating treatment and three required a therapeutic keratoplasty. Two patients improved after 1 week of MLT and optical penetrating keratoplasty was performed after clinical resolution. Microbiologic culture of corneal buttons was negative in all cases. All corneal grafts remain clear at last follow-up with best-corrected visual acuity of 20/40 or better.

Conclusion: Oral MLT may be a viable adjunctive therapy for recalcitrant AK; however, its use may be associated with a severe inflammatory reaction. Further studies are needed to evaluate its efficacy and variable clinical response.
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http://dx.doi.org/10.1080/09273948.2020.1758156DOI Listing
May 2020

Endophthalmitis Caused by following Intravitreal Aflibercept for Diabetic Retinopathy.

Case Rep Ophthalmol 2020 Jan-Apr;11(1):22-27. Epub 2020 Jan 9.

Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida, USA.

is a gram-negative bacillus rarely implicated in ocular disease. A 79-year-old male who performed extensive yardwork following intravitreal injection with aflibercept for diabetic macular edema developed endophthalmitis caused by on post-injection day 7. The patient was treated with vitreous tap and intravitreal injection of vancomycin and ceftazidime with clearance of the infection and restoration of his baseline visual acuity at 20/80.
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http://dx.doi.org/10.1159/000505227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098332PMC
January 2020

In vitro Susceptibilities of Methicillin-Susceptible and Resistant Staphylococci to Traditional Antibiotics Compared to a Novel Fluoroquinolone.

J Ophthalmic Inflamm Infect 2020 Feb 27;10(1). Epub 2020 Feb 27.

Department of Ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA.

Background: To assess the in-vitro efficacy of delafloxacin, a new fourth generation fluoroquinolone, against Staphylococcus vitreous isolates from patients with clinically diagnosed endophthalmitis. This is the first investigation of delafloxacin in ocular tissues.

Methods: Intravitreal isolates of culture-proven S. aureus and S. epidermidis were identified between 2014 and 2018. Minimum inhibitor concentrations (MIC) were determined using ETEST strips. The antibiotic susceptibilities were tested against a panel of drugs including glycopeptides such as vancomycin, as well as traditional and newer fluoroquinolones (levofloxacin, moxifloxacin, and delafloxacin).

Results: Of 45 total isolates identified between 2014 and 2018, 13% (6) were methicillin-resistant S. aureus (MRSA), 9% (4) were methicillin-sensitive S. aureus (MSSA), 53% (24) were methicillin-resistant S. epidermidis (MRSE), and 24% (11) were methicillin-sensitive S. epidermidis (MSSE). Among the fluoroquinolones, resistance rates were 61% for levofloxacin, 50% for moxifloxacin, and 12% for delafloxacin. Inter-class comparisons between delafloxacin and the two other fluoroquinolones demonstrated higher Gram-positive susceptibility to delafloxacin (p < 0.01). MIC90 values were lowest for delafloxacin (1.0 μg/mL) compared to levofloxacin (8.0 μg/mL) and moxifloxacin (8.0 μg/mL). Vancomycin was 100% effective against all isolates with MIC90 value of 0.75 μg/mL.

Conclusion: Compared to levofloxacin and moxifloxacin, the newer fluoroquinolone delafloxacin demonstrated the lowest MICs values and lowest rates of resistance for Gram-positive in-vitro S. epidermidis and S. aureus vitreous isolates.
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http://dx.doi.org/10.1186/s12348-020-0200-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044395PMC
February 2020

Rose bengal photodynamic antimicrobial therapy to inhibit Pseudomonas aeruginosa keratitis isolates.

Lasers Med Sci 2020 Jun 23;35(4):861-866. Epub 2019 Dec 23.

Ophthalmic Biophysics Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 1638 NW 10th Avenue, #117A, Miami, FL, 33136, USA.

To evaluate the in vitro efficacy of rose bengal and riboflavin photodynamic antimicrobial therapy for inhibition the growth of four Pseudomonas aeruginosa (P. aeruginosa) isolates. Four different clinical P. aeruginosa isolates were collected from patients with confirmed keratitis. Each strain was mixed with either sterile water, 0.1% riboflavin solution, or 0.1% rose bengal solution to yield a final bacteria concentration of 1.5 × 10 CFU/mL. Aliquots from each suspension were plated onto nutrient agar in triplicate. Plates were separated into two groups: (1) no irradiation and (2) 5.4 J/cm of radiant exposure with custom-made LED irradiation sources. Separate irradiation sources were used for each photosensitizer. The riboflavin groups used a UV-A light source (375 nm) and rose bengal groups used a green light source (525 nm). Plates were photographed at 72 h and custom software measured bacterial growth inhibition. Growth inhibition to riboflavin and rose bengal PDAT showed strain-dependent variability. All four strains of P. aeruginosa showed greatest growth inhibition (89-99%) in the green irradiated-rose bengal group. The UV-A-irradiated riboflavin showed inhibition of 24-44%. UV-A irradiation only showed minimal inhibition (7-14%). There was little inhibitory effect in the non-irradiated photosensitizer groups. Rose bengal PDAT had the greatest inhibitory effect on all four P. aeruginosa isolates. In the UV-A-irradiated riboflavin group, there was moderate inhibition within the irradiation zone; however, there was no inhibition in the non-irradiated groups. These results suggest that rose bengal PDAT may be an effective alternative treatment for Pseudomonas aeruginosa infections.
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http://dx.doi.org/10.1007/s10103-019-02871-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261617PMC
June 2020

Post-Traumatic Endophthalmitis Caused by .

Case Rep Ophthalmol 2019 Sep-Dec;10(3):312-318. Epub 2019 Sep 11.

Department of Ophthalmology, Bascom Palmer Eye Institute, Miami, Florida, USA.

Purpose: To present a previously unreported cause of bacterial endophthalmitis manifesting as delayed post-traumatic endophthalmitis ultimately responsive to total capsulectomy.

Case Report: A patient presented with chronic endophthalmitis that occurred after ocular trauma with organic material and was eventually isolated. After a prolonged treatment course, including two pars plana vitrectomies and total capsulectomy, the patient achieved 20/80 visual acuity at 1-year follow-up.

Conclusion: This is the first reported patient with endophthalmitis due to , a Gram-positive bacillus found in soil that rarely causes human infection. The infection had a delayed presentation despite early prophylactic antibiotics and was ultimately eliminated with total capsulectomy. Removal of lens and lens capsule may be necessary in the management of post-traumatic endophthalmitis unresponsive to more conservative therapy, particularly in cases involving atypical organisms and lens capsule violation.
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http://dx.doi.org/10.1159/000502413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6787431PMC
September 2019

Rose Bengal Photodynamic Antimicrobial Therapy for Patients With Progressive Infectious Keratitis: A Pilot Clinical Study.

Am J Ophthalmol 2019 12 5;208:387-396. Epub 2019 Sep 5.

Anne Bates Leach Eye Center, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA; Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA. Electronic address:

Purpose: To report clinical outcomes of rose bengal photodynamic antimicrobial therapy (RB-PDAT) as an adjunct treatment for severe, progressive infectious keratitis.

Design: Consecutive interventional case series.

Methods: Patients with progressive infectious keratitis unresponsive to standard medical therapy underwent RB-PDAT at the Bascom Palmer Eye Institute from January 2016 through March 2018. RB-PDAT was performed by applying a solution of rose bengal (0.1% or 0.2% RB in balanced salt solution) to the de-epithelialized cornea for 30 minutes, followed by irradiation with a 6 mW/cm custom-made green LED source for 15 minutes (5.4 J/cm).

Results: The current study included 18 patients (7 male and 11 female) ranging from 17 to 83 years old. Acanthamoeba was the most frequent microbe (10/17; 59%), followed by Fusarium spp. (4/17; 24%), Pseudomonas aeruginosa (2/17; 12%), and Curvularia spp. (1/17; 6%); 1 patient had no confirmed microbiologic diagnosis. Main clinical risk factor for keratitis included contact lens wear (79%). The average area of epithelial defect prior to first RB-PDAT was 32 ± 27 mm and average stromal depth hyperreflectivity measured with anterior segment optical coherence tomography was 269 ± 75 μm. Successful RB-PDAT (avoidance of therapeutic keratoplasty) was achieved in 72% of the cases, with an average time to clinical resolution (decreased pain and inflammation with re-epithelialization and infiltrate resolution) of 46.9 ± 26.4 days after RB-PDAT. Time of follow-up after RB-PDAT was 13.3 ± 5.7 months.

Conclusion: RB-PDAT can be considered as an adjunct therapy for cases of severe, progressive infectious keratitis before performing a therapeutic keratoplasty.
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http://dx.doi.org/10.1016/j.ajo.2019.08.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7184264PMC
December 2019

Antimycotic Efficacy and Safety of a New Cold Corneal Storage Medium by Time-Kill and Toxicity Studies.

Cornea 2019 Oct;38(10):1314-1321

Alchilife S.r.l., Ponte San Nicolò, Italy.

Purpose: To evaluate a new corneal cold storage medium including an antimycotic tablet (Kerasave, AL.CHI.MI.A. S.r.l.).

Methods: Kerasave and tryptone soy broth (control) were inoculated with 10 and 10 colony-forming units (CFU)/mL of 6 Candida isolates (Candida albicans [n = 4], Candida tropicalis [n = 1], and Candida glabrata [n = 1]). Minimum inhibitory concentrations (MICs) were determined using amphotericin B Etest strips. Sterile porcine corneas contaminated with 10 CFU/mL of each isolate were incubated in Kerasave and control at 4°C. Growth rate and Log10 reduction at 4°C at different time intervals were determined for liquid samples and tissue homogenates. Kerasave biocompatibility was assessed according to ISO 10993-5 and ISO 10993-10.

Results: No C. albicans or C. tropicalis colonies were recovered from Kerasave inoculated with 10 CFU/mL after incubation for 3 days at 4°C. C. glabrata was inhibited but not killed after 3 days at 4°C. Four of the 6 strains contaminated with 10 CFU/mL demonstrated a significant ≥ 3 Log10 reduction in media and tissue homogenates within 5 days as compared to controls (p < 0.01). Amphotericin B MICs ranged from 0.19 to 0.38 μg/mL for C. albicans (n = 3) and C. tropicalis (n = 1). C. glabrata showed reduced susceptibility (0.5 μg/mL) and 1 C. albicans was resistant to amphotericin B (≥ 1 μg/mL). Kerasave was not cytotoxic, irritating, or sensitizing according to the ISO standards.

Conclusions: Kerasave showed high antifungal efficacy against susceptible fungal strains at 4°C in the presence and absence of corneal tissue. Resistant strains to amphotericin B were not eliminated by Kerasave. Kerasave is not cytotoxic, irritating, or sensitizing.
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http://dx.doi.org/10.1097/ICO.0000000000002068DOI Listing
October 2019

Long-term outcomes of riboflavin photodynamic antimicrobial therapy as a treatment for infectious keratitis.

Am J Ophthalmol Case Rep 2019 Sep 1;15:100481. Epub 2019 Jun 1.

Anne Bates Leach Eye Hospital, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.

Purpose: To report the long-term outcomes of three patients with infectious keratitis treated with riboflavin photodynamic antimicrobial therapy (PDAT).

Observations: Case series reporting three patients with infectious keratitis unresponsive to standard medical treatment who underwent riboflavin photodynamic antimicrobial therapy (PDAT) as an adjunct therapy. One male and two female patients were treated, the median age of presentation was 58 years (range, 29-79 years). The organisms isolated and treated were , , and Different risk factors to develop corneal infection ulcers were identified, including corneal abrasion in a contact lens user, history of penetrating keratoplasty with chronic use of topical corticosteroids, and organic trauma. The median follow-up was 47 months (range 37-54 months), and there were no complications secondary to riboflavin PDAT treatment. Two cases underwent optical penetrating keratoplasty after infection was resolved and ocular surface was quiet for at least 3 years.

Conclusions And Importance: Riboflavin PDAT can be used as an adjunct treatment in infectious keratitis to strengthen the corneal collagen fibers, delay keratolysis, and allow more time for antimicrobials to work and this way prevent a corneal perforation.
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http://dx.doi.org/10.1016/j.ajoc.2019.100481DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6556526PMC
September 2019

In Vitro Susceptibilities of Vitreous Candida Endophthalmitis Isolates to Newer and Traditional Antifungal Agents.

Ophthalmic Surg Lasers Imaging Retina 2019 05;50(5):S13-S17

Background And Objective: To investigate in vitro microbiological susceptibilities of Candida vitreous endophthalmitis isolates using traditional and newer antifungal agents.

Materials And Methods: The current study is a retrospective, consecutive case series of 17 vitreous culture-proven Candida endophthalmitis isolates from 2011 to 2017 from Bascom Palmer Eye Institute. Susceptibilities to echinocandins, triazoles, polyenes, and nucleoside analogs were obtained.

Results: The study isolates consisted of 59% C. albicans, 17% C. glabrata, 12% C. tropicalis, and 12% C. parapsilosis. Isolates demonstrated 100% sensitivity to all antifungals tested except anidulafungin (85% sensitive) and fluconazole (88.2% sensitive). Comparing in-class agents, minimum inhibitory concentration (MIC) values for voriconazole were lower than other triazoles, whereas micafungin had lower MIC values compared with other echinocandins.

Conclusion: Both traditional and newer antifungals included agents that were highly efficacious against in vitro Candida species. Although the authors' study data suggest that older, established antifungals are likely adequate for the treatment of Candida endophthalmitis, newer antifungal agents also can be considered. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:S13-S17.].
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http://dx.doi.org/10.3928/23258160-20190108-04DOI Listing
May 2019

Novel Use of Fluorescence In Situ Hybridization for the Rapid Identification of Microorganisms in Endophthalmitis and Keratitis.

Ophthalmic Surg Lasers Imaging Retina 2019 05;50(5):S9-S12

Background And Objective: To evaluate an application of fluorescence in situ hybridization (FISH) for the rapid identification of bacterial and fungal pathogens causing endophthalmitis and keratitis and compare time to detection with other laboratory methods.

Materials And Methods: Culture-positive isolates obtained from vitreous and corneal samples were tested. Organisms tested were Staphylococcus aureus, coagulase-negative staphylococci, Pseudomonas aeruginosa, Candida albicans, C. glabrata, and C. parapsilosis. Inoculi were prepared to a final concentration between 1 × 10 colony-forming units (CFU)/mL to 1 × 10 CFU/mL. Samples were hybridized with peptide nucleic acid probes for pathogens using the QuickFISH protocol (AdvanDx; OpGen, Gaithersburg, MD), and the slides were read with fluorescence microscopy.

Results: Of the 29 total isolates tested, 28 yielded positive identification. S. aureus was identified in four out of five vitreous samples, whereas coagulase-negative staphylococci were identified in all vitreous samples. Mixed staphylococci culture was identified in all samples. P. aeruginosa was identified in all six keratitis samples. C. albicans, C. glabrata, C. parapsilosis, and mixed fungal culture were identified respectively in eight of eight samples at minimal concentration of 1 × 10 CFU/mL. There were no false-negatives. Time to detection was 20 minutes after the 12- to 18-hour inoculation period and provided an identification 6 hours sooner than by polymerase chain reaction (PCR) and 1 to 2 days sooner than by routine culture.

Conclusions: This small study demonstrates the sensitive, specific, and rapid detection of gram-positive bacteria, gram-negative bacteria and fungi using FISH probes in isolates from endophthalmitis and keratitis samples. This method decreases time to identification and reduces labor intensity compared with routine PCR and culture methods. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:S9-S12.].
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http://dx.doi.org/10.3928/23258160-20190108-03DOI Listing
May 2019

Clinical Features, Antibiotic Susceptibilities, and Treatment Outcomes of Endophthalmitis Caused by Staphylococcus epidermidis.

Ophthalmol Retina 2018 05 2;2(5):396-400. Epub 2017 Nov 2.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida. Electronic address:

Purpose: To report the clinical features, antibiotic susceptibilities, and visual acuity outcomes with endophthalmitis caused by methicillin-sensitive Staphylococcus epidermidis and methicillin-resistant S. epidermidis.

Design: Retrospective case series.

Participants: All patients seeking treatment at a tertiary referral center between 2006 and 2016 with endophthalmitis caused by S. epidermidis.

Methods: All records were reviewed for patients with a clinical diagnosis of endophthalmitis and positive vitreous culture results for S. epidermidis. Data were compared with the prior series at the same institution.

Main Outcome Measures: Clinical settings, antibiotic susceptibilities, and visual acuity.

Results: Among 96 eyes of 96 patients, the most common postprocedural clinical settings were cataract surgery (47/96 [49%]), intravitreal injection (21/96 [22%]), trauma (8/96 [8%]), glaucoma surgery (7/96 [7%]), and penetrating keratoplasty (5/96 [5%]). The initial treatment included intravitreal vancomycin and ceftazidime in 89 of 96 eyes (93%) and intravitreal vancomycin and amikacin in 7 of 96 eyes (7%). A vitreous tap and injection with antibiotics was performed as the initial treatment in 83 of 96 eyes (86%) and pars plana vitrectomy was performed in 13 of 96 eyes (14%). All isolates were sensitive to vancomycin in both decades. In the most recent series, visual acuity at last follow-up was 5/200 or better in 68 of 96 eyes (71%) compared with 71 of 86 eyes (83%) in the prior study. In the current study, susceptibility to methicillin and moxifloxacin was present in 45 of 96 eyes (47%) and 29 of 85 eyes (34%), respectively, compared with 34 of 86 eyes (40%) and 27 of 39 eyes (69%) in the prior study. Final visual acuity was not significantly different between those eyes that were methicillin or fluoroquinolone sensitive and those that were resistant.

Conclusions: In the current and prior series, all S. epidermidis isolates were sensitive to vancomycin. Visual acuity outcomes were not dependent on methicillin or fluoroquinolone sensitivity.
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http://dx.doi.org/10.1016/j.oret.2017.08.025DOI Listing
May 2018

Molecular epidemiology and resistance profiles among healthcare- and community-associated keratitis isolates.

Infect Drug Resist 2019 11;12:831-843. Epub 2019 Apr 11.

Anne Bates Leach Eye Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA,

Purpose: To characterize the molecular, epidemiological, and resistance profiles of methicillin-resistant (MRSA) and methicillin-susceptible (MSSA) keratitis isolates.

Patients And Methods: We used a combination of standard microbiological techniques and DNA microarray analysis to characterize the molecular and antibiotic resistance profiles of 75 keratitis isolates collected over an 11-year period (2006-2016).

Results: Two major USA clonal complexes (CC), CC5 (n=30, 40%) and CC8 (n=28, 37.3%), accounted for 77.3% of the collected isolates. USA100, traditionally healthcare associated (n=18/47, 38.3%), and USA300, traditionally community associated (n=12/47, 25.5%), were the dominant MRSA strains. Four (22.2%) of the USA100 MRSA isolates were recovered from patients with no prior healthcare exposure. Eleven (91.7%) of the USA300 isolates were recovered from patients with documented healthcare risk factors. MSSA isolates were polyclonal (n=13). Ninety-three percent of MSSA infections were of healthcare origin. Thirty-seven of 61 (60.6%) healthcare- and 11 of 14 (78.6%) community-associated strains were resistant to three or more antibiotic classes. Sixty-eight percent (n=51) of isolates harbored three of more resistance determinants (genes). The Panton-Valentine Leucocidin gene was detected in 11 (14.7%) of the study isolates. The majority (72.7%) of the strains were members of the USA300 MRSA clone.

Conclusion: Clonal complexes CC5 and CC8 were the most frequent clones detected among both the MSSA and the MRSA keratitis isolates. USA100 and USA300 clones were the dominant MRSA genotypes. The USA300 MRSA clone has become a leading cause of healthcare-associated keratitis in South Florida. The USA100 MRSA clone has emerged as an increasing cause of community-associated corneal infections in our outpatient population. This shifting epidemiology coupled with the increasing prevalence of multidrug resistance among both MSSA and MRSA keratitis is a cause of concern.
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http://dx.doi.org/10.2147/IDR.S190245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6469469PMC
April 2019

Interfacial Behavior of Fumonisin B1 Toxin and Its Degradation on the Membrane.

Langmuir 2019 02 6;35(7):2814-2820. Epub 2019 Feb 6.

Department of Chemistry , University of Miami , 1301 Memorial Drive , Coral Gables , Florida 33146 , United States.

Fumonisin B1 (FB1), the most abundant component of the fumonisin family, is highly responsible for fungal infections. In this paper, our main aim is to study the surface chemistry and spectroscopic properties of the FB1 molecule and observe the impact of green LED light on the FB1 Langmuir monolayer. From the surface chemistry and spectroscopic studies, we found that the FB1 molecule forms a self-assembled Langmuir monolayer which is sufficient to mimic its interaction with the corneal tissues. The irradiation of green LED light on the FB1 Langmuir monolayer showed the degradation of the FB1 when compared to that in the absence of light. This observation reveals that FB1 molecules lose their tendency to stay as a Langmuir monolayer. The degradation observed on the interface was compared with the bulk phase of FB1. The bulk phase observation also indicated the degradation tendency which reinforced the observed interfacial property of FB1.
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http://dx.doi.org/10.1021/acs.langmuir.8b03505DOI Listing
February 2019

Composition and Comparison of the Ocular Surface Microbiome in Infants and Older Children.

Transl Vis Sci Technol 2018 Nov 30;7(6):16. Epub 2018 Nov 30.

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.

Purpose: Unlike other microbiomes of the body, the composition of the ocular surface microbiome (OSM) in children has yet to be thoroughly explored. Our goal was to evaluate the OSM in young infants and compare its composition to older children using both culture dependent and independent methodologies to assess for differences with age.

Methods: Prospective, observational, cross-sectional study of children <18 years of age at a university-based institution. The mucosal surfaces of both eyes, nose and throat were swabbed with a forensic-quality swab. Half of the swab was plated for culture and the other half underwent 16S sequencing. Culture results and microbiome diversity were analyzed.

Results: Fifty patients (mean age 37 months, range 1-168 months) were enrolled. Forty-seven eyes of 30 patients had positive cultures; four eyes grew >1 species. Culture positive patients were older (43 vs. 29 months, = 0.19). Additionally, older children had greater diversity than children under 6 months of age by 16S sequencing ( = 0.05). species were predominant by culture (35/52 isolates) and by 16S sequencing. The OSM was fairly similar to the nose microbiome, whereas the throat microbiome differed significantly and had a higher abundance of ( = 0.001).

Conclusions: The OSM is predominantly composed of species in children, as demonstrated by both culture dependent and culture independent methods. Older children were more likely to have growth on culture and have more a complex bacterial milieu with 16S sequencing.

Translational Relevance: 16S sequencing provides more robust information regarding the composition of the microbiomes than culture dependent methods.
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http://dx.doi.org/10.1167/tvst.7.6.16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6269136PMC
November 2018

Modeling the seasonality of Methicillin-resistant infections in hospitals with environmental contamination.

J Biol Dyn 2019 22;13(sup1):99-122. Epub 2018 Aug 22.

a Department of Mathematics, University of Miami , Coral Gables , FL , USA.

A deterministic mathematical model with periodic antibiotic prescribing rate is constructed to study the seasonality of Methicillin-resistant (MRSA) infections taking antibiotic exposure and environmental contamination into consideration. The basic reproduction number for the periodic model is calculated under the assumption that there are only uncolonized patients with antibiotic exposure at admission. Sensitivity analysis of with respect to some essential parameters is performed. It is shown that the infection would go to extinction if the basic reproduction number is less than unity and would persist if it is greater than unity. Numerical simulations indicate that environmental cleaning is the most important intervention to control the infection, which emphasizes the effect of environmental contamination in MRSA infections. It is also important to highlight the importance of effective antimicrobial stewardship programmes, increase active screening at admission and subsequent isolation of positive cases, and treat patients quickly and efficiently.
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http://dx.doi.org/10.1080/17513758.2018.1510049DOI Listing
March 2020

Microbiology and biofilm of corneal sutures.

Br J Ophthalmol 2018 11 12;102(11):1602-1606. Epub 2018 Aug 12.

Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA.

Aim: To investigate the relationships between corneal suture bacteriology, biofilm and the clinical setting using culture studies and scanning electron microscopy (SEM).

Methods: This is a prospective, observational study of patients with a history of penetrating keratoplasty presenting to a tertiary cornea clinic for routine or symptoms-related corneal suture removal. We documented for each patient the suture clinical setting (quiescent, exposed and keratitis-related), retention time, antimicrobial therapy, bacterial growth on culture studies, and bacterial presence and biofilm coverage on SEM.

Results: There were significantly different culture positivity rates between the quiescent (8%), exposed (12%) and keratitis-related (60%) suture groups (p=0.039). As expected, keratitis-related sutures had the longest retention time compared with quiescent and exposed ones (p=0.02). The biofilm coverage score was higher for sutures from the keratitis-related and exposed groups, although this trend was not statistically significant (p=0.90). Higher biofilm scores were seen in samples that also yielded a positive culture result (p=0.36) and in samples with bacterial presence on SEM images (p=0.16 and p=0.73). Both of these were important trends but not statistically significant.

Conclusions: Evidence for active bacterial and biofilm presence on corneal sutures was found. Corneal sutures should be considered for removal sooner, before becoming exposed and/or keratitis-related. Traditional culture studies and SEM imaging are helpful in investigating biofilm and its clinical importance. More studies of the spectrum of bacterial growth on embedded biomedical devices such as corneal sutures are needed.
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http://dx.doi.org/10.1136/bjophthalmol-2018-312133DOI Listing
November 2018

Effect of clinical parameters on the ocular surface microbiome in children and adults.

Clin Ophthalmol 2018 2;12:1189-1197. Epub 2018 Jul 2.

Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL,

Purpose: To perform a pilot study to characterize the effect of clinical parameters on the ocular surface microbiome (OSM) in children and adults using 16s ribosomal RNA sequencing.

Methods: Prospective, cross-sectional study using 16s sequencing to evaluate the OSM. Comparisons were made in bacterial composition by 1) age, 2) gender, 3) sampling location of the ocular and periocular surfaces, and 4) topical drop use. 16s sequencing was performed using Illumina MiSeq 250 and analyzed using Qiime.

Results: Thirty patients (15 children [mean 3.7 years], 15 adults [mean 60.4 years]) were sampled. Both principal coordinate analysis and unifrac distance analysis showed significant differences in the composition between the pediatric and adult OSMs (both =0.001). The eyelid margin microbiota did not show any distinct clustering compared to conjunctiva within the pediatric samples but tended to show a distinction between anatomic sites in adult samples. No differences in OSM were noted by topical drop use.

Conclusion: 16s sequencing is a useful tool in evaluating the OSM in patients of all ages, showing a distinct difference between pediatric and adult microbiomes.
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http://dx.doi.org/10.2147/OPTH.S166547DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6040630PMC
July 2018

0.01% Hypochlorous Acid as an Alternative Skin Antiseptic: An In Vitro Comparison.

Dermatol Surg 2018 12;44(12):1489-1493

Department of Ophthalmology, Oculoplastic & Reconstructive Surgery, Bascom Palmer Eye Institute, Miami, Florida.

Objective: Compare the in vitro efficacy of hypochlorous acid 0.01% (HA), povidone iodine 5% (PI), chlorhexidine gluconate 4% (CHG), and isopropyl alcohol 70% (IPA) against common skin microorganisms.

Materials And Methods: Time-kill studies were conducted against methicillin-susceptible Staphylococcus aureus (MSSA) and Staphylococcus epidermidis (MSSE), methicillin-resistant S. aureus (MRSA) and S. epidermidis (MRSE), Candida albicans, Corynebacterium species (striatum and amycolatum), Propionibacterium acnes, Pseudomonas aeruginosa, Streptococcus pyogenes, Staphylococcus capitis, and Staphylococcus xylosus.

Results: Methicillin-resistant S. aureus: Bactericidal effect was immediate for HA and IPA. For PI and CHG, the effect occurred at 1 and 10 minutes, respectively. Methicillin-resistant S. epidermidis: Hypochlorous acid, IPA, and PI had immediate bactericidal effects, whereas CHG required 1 minute. Methicillin-susceptible Staphylococcus aureus: All agents had bactericidal effects at 1 minute. C. species, S. pyogenes, P. aeruginosa, and P. acnes: All antiseptics demonstrated immediate bactericidal effects. Methicillin-susceptible Staphylococcus epidermidis and S. capitis: Hypochlorous acid and IPA had immediate effect, whereas PI and CHG required 1 minute. C. albicans: Hypochlorous acid, IPA, and PI were immediately bactericidal, whereas CHG required 1 minute. S. xylosus: Hypochlorous acid and CHG were immediately bactericidal, whereas IPA and PI required 1 and 2 minutes, respectively.

Conclusion: In vitro studies of HA 0.01% were observed to have equal or more efficacious antiseptic properties compared with IPA, CHG, and PI. Future studies will be needed to investigate its role in periocular use.
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http://dx.doi.org/10.1097/DSS.0000000000001594DOI Listing
December 2018

Endophthalmitis Associated With Intravitreal Injections of Anti-VEGF Agents at a Tertiary Referral Center: In-House and Referred Cases.

Ophthalmic Surg Lasers Imaging Retina 2018 05;49(5):313-319

Background And Objective: To report the incidence rates, causative organisms, and visual acuity (VA) outcomes in patients with endophthalmitis associated with intravitreal injection of anti-vascular endothelial growth factor inhibitors.

Patients And Methods: Retrospective case series between 2005 and 2017.

Results: The study included 39 eyes of 39 patients, including 27 (69%) referred and 12 (31%) institutional patients. The use of topical antibiotics after an injection was gradually phased out at the authors' institution, where the preinjection rate of all clinically suspected endophthalmitis was 0.013% (24 of 183,898). The most common isolates were coagulase-negative Staphylococcus and Streptococcus. A VA of 5/200 or better was achieved in 21 of 39 eyes (54%) overall and in two of 15 eyes (13%) infected with Streptococcus.

Conclusions: The rate of post-intravitreal injection endophthalmitis is low. Outcomes were generally poor, and the worst were associated with Streptococcus. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:313-319.].
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http://dx.doi.org/10.3928/23258160-20180501-04DOI Listing
May 2018

Multiplex Polymerase Chain Reaction Assay for Screening of Mycotoxin Genes From Ocular Isolates of Fusarium species.

Cornea 2018 Aug;37(8):1042-1046

Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL.

Purpose: To identify mycotoxin genes among clinical ocular isolates of Fusarium species and to correlate these with clinical outcomes of Fusarium keratitis.

Methods: Fifty-four clinical isolates of Fusarium were retrieved from the Bascom Palmer Eye Institute Ocular Microbiology Laboratory data bank. Multiplex polymerase chain reactions were run to confirm the identification of Fusarium species [internal transcribed spacer sequence, translation elongation factor 1-α (TEF) and β-tubulin] and to detect the presence of genes encoding production of fumonisin B mycotoxins (FUM1 and FUM8) and trichothecene mycotoxins (deoxynivalenol and nivalenol). The presence or absence of mycotoxins was compared with patient outcomes.

Results: Forty-three (79%) of the 54 isolates were confirmed as Fusarium species, by an internal transcribed spacer sequence in 3 (5.6%) and by TEF in 43 (79.6%) of the 54 isolates. Fumonisin biosynthetic gene 1 (FUM1) was detected in 57.4% (n = 31/54) of the Fusarium isolates. No FUM8, deoxynivalenol genes, and nivalenol genes were detected among these in the clinical isolates group. Initial best-corrected visual acuity ranged from 20/25 to 20/80 in the FUM1 gene-negative group and from 20/20 to light perception in the FUM1 gene-positive group. There was no difference in the time to cure between both groups. The presence of FUM1 genes in 5 fungal isolates seemed to be associated with progression to penetrating keratoplasty in the 5 patients from whom the fungi were isolated. Fusarium solani was recovered from all patients requiring penetrating keratoplasty.

Conclusions: Fumonisin B biosynthetic gene 1 may be common among clinical Fusarium isolates and contribute to worse initial visual acuity and high-risk progression to penetrating keratoplasty.
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http://dx.doi.org/10.1097/ICO.0000000000001607DOI Listing
August 2018