Publications by authors named "Eduardo C Alfonso"

70 Publications

American Academy of Optometry Microbial Keratitis Think Tank.

Optom Vis Sci 2021 Mar;98(3):182-198

Department of Ophthalmology and Visual Sciences, Case Western Reserve University, and University Hospitals of Cleveland Eye Institute, Cleveland, Ohio Northeastern Eye Institute, Scranton, Pennsylvania C Schnider Insights & More, Brush Prairie, Washington Toronto Eye Care, Toronto, Ontario, Canada Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida School of Optometry and Vision Science, University of New South Wales, Sydney, New South Wales, Australia Clinical Trial Consultant, Atlanta, Georgia U.S. Centers for Disease Control and Prevention, Atlanta, Georgia Massachusetts Eye and Ear, Cornea Service, Harvard Medical School, Boston, Massachusetts Department of Ophthalmology and Visual Science, College of Medicine, Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Illinois School of Optometry, University of California, Berkeley, Berkeley, California iBiomedical Consulting, Jacksonville, Florida University of Houston College of Optometry, Houston, Texas Departments of Ophthalmology, and Physiology and Biophysics, University of California, Irvine, Irvine, California Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland University of Illinois Eye and Ear Infirmary, Chicago, Illinois

Significance: Think Tank 2019 affirmed that the rate of infection associated with contact lenses has not changed in several decades. Also, there is a trend toward more serious infections associated with Acanthamoeba and fungi. The growing use of contact lenses in children demands our attention with surveillance and case-control studies.

Purpose: The American Academy of Optometry (AAO) gathered researchers and key opinion leaders from around the world to discuss contact lens-associated microbial keratitis at the 2019 AAO Annual Meeting.

Methods: Experts presented within four sessions. Session 1 covered the epidemiology of microbial keratitis, pathogenesis of Pseudomonas aeruginosa, and the role of lens care systems and storage cases in corneal disease. Session 2 covered nonbacterial forms of keratitis in contact lens wearers. Session 3 covered future needs, challenges, and research questions in relation to microbial keratitis in youth and myopia control, microbiome, antimicrobial surfaces, and genetic susceptibility. Session 4 covered compliance and communication imperatives.

Results: The absolute rate of microbial keratitis has remained very consistent for three decades despite new technologies, and extended wear significantly increases the risk. Improved oxygen delivery afforded by silicone hydrogel lenses has not impacted the rates, and although the introduction of daily disposable lenses has minimized the risk of severe disease, there is no consistent evidence that they have altered the overall rate of microbial keratitis. Overnight orthokeratology lenses may increase the risk of microbial keratitis, especially secondary to Acanthamoeba, in children. Compliance remains a concern and a significant risk factor for disease. New insights into host microbiome and genetic susceptibility may uncover new theories. More studies such as case-control designs suited for rare diseases and registries are needed.

Conclusions: The first annual AAO Think Tank acknowledged that the risk of microbial keratitis has not decreased over decades, despite innovation. Important questions and research directions remain.
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http://dx.doi.org/10.1097/OPX.0000000000001664DOI Listing
March 2021

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

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

Long-term outcomes of the aphakic snap-on Boston type I keratoprosthesis at the Bascom Palmer Eye Institute.

Clin Ophthalmol 2018 15;12:331-337. Epub 2018 Feb 15.

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

Purpose: To determine the indications, long-term clinical and visual outcomes, and complications of the aphakic snap-on type I Boston keratoprosthesis (KPro).

Design: Retrospective, non-comparative case series.

Methods: Forty-five eyes of 43 patients with type I aphakic snap-on KPros with at least 1 year of follow-up were included. The past medical histories, preoperative indications, best-corrected visual acuities (BCVAs), postoperative complications, and retention rates were analyzed.

Results: The most common indication for KPro implantation was a failed corneal graft (89%). The mean preoperative BCVA was count fingers-hand motion (2.14±0.45 logarithm of minimum angle of resolution [logMAR]), which initially improved to 20/200 (1.04±0.85 logMAR; <0.0001). At the last examination, 24 eyes (53%) maintained some visual gain, 22% retained their preoperative visual acuity, and 24% lost vision due to postoperative events and underlying ocular comorbidities. Postoperative complications included retroprosthetic membranes (8/45, 18%), corneal melts (5/45, 11%), glaucoma progression (6/45, 13%), and endophthalmitis or sterile vitritis (6/45, 13%). The KPro retention rate was 89%, with a mean follow-up of 51 months. The mean BCVA at the last visit was 20/1,400 (1.82±0.92 logMAR).

Conclusion: Most patients experienced improved visual acuity after the implantation of the aphakic, snap-on type I KPro; however, the visual gains were not sustained over time, correlating with the onset of postoperative complications.
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http://dx.doi.org/10.2147/OPTH.S144403DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818861PMC
February 2018

Clinical Features, Antibiotic Susceptibility Profile, and Outcomes of Infectious Keratitis Caused by Stenotrophomonas maltophilia.

Cornea 2018 Mar;37(3):326-330

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

Purpose: Stenotrophomonas maltophilia, an uncommon cause of infectious keratitis, is difficult to treat because of its resistance to multiple antibiotics. The purpose of this study is to describe the clinical features, antibiotic susceptibility profile, and outcomes of S. maltophilia keratitis.

Methods: A retrospective review of records from 1987 to 2016 identified 26 eyes of 26 patients who were treated at the Bascom Palmer Eye Institute for an S. maltophilia corneal ulcer. Clinical data were analyzed as to predisposing factors, clinical presentation, antibiotic susceptibility, treatment selection, and clinical outcomes.

Results: Median age at presentation was 65 years (range, 16-98). Twelve patients were using topical corticosteroids, 8 patients had a history of penetrating keratoplasty, and 9 were contact lens wearers. All patients received topical antibiotics, 2 required therapeutic penetrating keratoplasty, and 1 was enucleated. At presentation, 57.7% (15/26) of the patients had visual acuity of 20/400 or worse. At the final visit, only 30.4% (7/23) of the patients had visual acuity worse than 20/400, whereas 65.2% (15/23) of the patients had 20/100 or better. Almost all isolates (25/26, 96.2%) were susceptible to fluoroquinolones and 77.3% (17/22) of them to polymyxin B/trimethoprim. Only 33.3% (5/15) of the tested isolates were susceptible to aminoglycosides and 58.3% (7/12) to cephalosporins.

Conclusions: Infectious keratitis due to S. maltophilia presents a treatment challenge because of its resistance to aminoglycosides and cephalosporins, which are typically used for empiric broad-spectrum gram-negative coverage as fortified solutions. Fluoroquinolones and polymyxin B/trimethoprim should be considered instead in cases of S. maltophilia infection.
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http://dx.doi.org/10.1097/ICO.0000000000001486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806132PMC
March 2018

Impact of Total Pars Plana Vitrectomy on Postoperative Complications in Aphakic, Snap-On, Type 1 Boston Keratoprosthesis.

Ophthalmology 2017 10 17;124(10):1504-1509. Epub 2017 May 17.

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

Purpose: To determine the impact of total pars plana vitrectomies (PPVs) with peripheral shaving of the vitreous base on the rates of postoperative complications in patients with aphakic, snap-on type I Boston keratoprostheses (KPros).

Design: Retrospective, consecutive case series.

Participants: A total of 48 eyes in 46 patients with implantation of aphakic, snap-on type 1 Boston KPros performed at a tertiary care facility between January 1, 2007, and December 31, 2013, were included.

Methods: The cumulative incidences of postoperative complications were compared between patients who underwent total PPVs with shaving of the vitreous base (n = 22) and those who had partial PPVs or anterior vitrectomies (AVs) at the time of KPro implantation (n = 26).

Main Outcome Measures: Rates of complications between patients who underwent total PPVs and partial PPVs or AVs.

Results: The rate of total postoperative complications was lower in the total PPV group (P = 0.018, log-rank test). In particular, eyes that underwent total PPVs had lower rates of retroprosthetic membranes (RPMs) requiring intervention (P = 0.049) and less vision loss due to glaucoma progression (P = 0.046). There was also a trend for fewer corneal melts (P = 0.060) and less sight-threatening complications (P = 0.051) in the total vitrectomy group. There was no difference in the rates of KPro extrusion (P = 0.41), endophthalmitis or vitritis (P = 0.15), retinal detachments (P = 0.76), cystoid macular edema (P = 0.83), or timing of complications between the 2 groups. The mean preoperative and postoperative visual acuities were similar between the 2 groups (P = 0.97). The mean follow-up was 49±22 months.

Conclusions: Eyes that underwent total PPVs during implantation of aphakic, snap-on, type I Boston KPros had less postoperative complications than eyes with partial PPVs or AVs during the average 4 years of follow-up.
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http://dx.doi.org/10.1016/j.ophtha.2017.04.016DOI Listing
October 2017

Integrating the Internship into Ophthalmology Residency Programs: Association of University Professors of Ophthalmology American Academy of Ophthalmology White Paper.

Ophthalmology 2016 09 14;123(9):2037-41. Epub 2016 Jul 14.

Northwestern University, Feinberg School of Medicine, Chicago, Illinois.

Future ophthalmologists will need to have broad skills to thrive in complex health care organizations. However, training for ophthalmologists does not take advantage of all of the postgraduate years (PGYs). Although the traditional residency years seem to have little excess capacity, enhancing the internship year does offer an opportunity to expand the time for ophthalmology training in the same 4 PGYs. Integrating the internship year into residency would allow control of all of the PGYs, allowing our profession to optimize training for ophthalmology. In this white paper, we propose that we could capture an additional 6 months of training time by integrating basic ophthalmology training into the intern year. This would allow 6 additional months to expand training in areas such as quality improvement or time for "mini-fellowships" to allow graduates to develop a deeper set of skills.
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http://dx.doi.org/10.1016/j.ophtha.2016.06.021DOI Listing
September 2016

Clinical Features, Antibiotic Susceptibility Profiles, and Outcomes of Infectious Keratitis Caused by Achromobacter xylosoxidans.

Cornea 2016 May;35(5):626-30

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

Purpose: Reports on Achromobacter xylosoxidans ocular infections are increasing, drawing attention to its emerging role in infectious keratitis. The purpose of this study is to report the clinical features, antibiotic sensitivities, and visual outcomes of infectious keratitis secondary to Achromobacter xylosoxidans.

Methods: A microbiology database and clinical chart review was performed in all patients diagnosed with A. xylosoxidans keratitis at the Bascom Palmer Eye Institute between the years 1987 and 2014. Initial presentation, antimicrobial susceptibilities, minimum inhibitory concentrations (MICs), treatment course, and outcomes were recorded.

Results: Twenty-eight patients were identified. The main risk factors were corneal graft (n = 8, 28.6%) and contact lens wear (n = 8, 28.6%). On presentation, visual acuity was 20/100 or worse in 20 (71.2%) patients. Hypopyon was present in 7 (25.0%) patients. In most cases, topical fluoroquinolones or tobramycin were the initial treatment, often accompanied by vancomycin. High susceptibility rates were found for piperacillin [100%, minimum inhibitory concentration for 90% of isolates (MIC90) = 8] and ticarcillin (100%, MIC90 = 16). Low susceptibility rates were documented for ciprofloxacin (46.7%, MIC90 = 8), tobramycin (26.7%, MIC90 = 16), and gentamicin (20%, MIC90 = 16). One (3.6%) patient suffered endophthalmitis. Six (21.4%) patients underwent therapeutic penetrating keratoplasty, and 2 (7.1%) patients had conjunctival flap surgery. Visual acuity at final follow-up was 20/100 or worse in 16 (57.1%) patients.

Conclusions: Infectious keratitis caused by A. xylosoxidans is associated with poor visual outcomes. Fluoroquinolones and aminoglycosides are not appropriate treatments for these ocular infections. Further studies are needed to define the clinical application of compound piperacillin and ticarcillin eye drops.
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http://dx.doi.org/10.1097/ICO.0000000000000798DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5545926PMC
May 2016

Role of steroids in the treatment of bacterial keratitis.

Clin Ophthalmol 2016 27;10:179-86. Epub 2016 Jan 27.

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

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.
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http://dx.doi.org/10.2147/OPTH.S80411DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4734801PMC
February 2016

EPITHELIAL DOWNGROWTH IN THE VITREOUS CAVITY AND ON THE RETINA IN ENUCLEATED SPECIMENS AND IN EYES WITH VISUAL POTENTIAL.

Retina 2015 Aug;35(8):1688-95

*Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, Florida; and †Florida Lions Ocular Pathology Laboratory, Bascom Palmer Eye Institute, University of Miami, Miami, Florida.

Purpose: To report clinical course and visual and anatomical outcomes of six eyes with histopathologically confirmed vitreous cavity and retina epithelial downgrowth.

Methods: This is a retrospective 15-year review of archived pathologic slides and corresponding medical records of patients with vitreous cavity and retina epithelial downgrowth. Posterior segment epithelial downgrowth was defined as epithelial or goblet cells in the vitreous cavity or on the surface of the retina.

Results: Histopathologic diagnosis of epithelial downgrowth was made in 122 patients. Of those, 6 patients (5%) had vitreous cavity and retina epithelial downgrowth. Three patients developed blind painful eye, and epithelial downgrowth was identified in enucleated specimens. The other three eyes with visual potential presented with tractional retinal detachments. Epithelial downgrowth was identified in epiretinal membranes obtained during pars plana vitrectomy. The latter group had more previous surgeries (P = 0.03), and all had keratoprosthesis implantation as their last surgery. All three had pathologic specimens obtained at the time of the keratoprosthesis implantation; no anterior segment epithelial downgrowth was noted in two patients, and one patient had involvement of corneal button, iris, and posterior capsule. Final visual acuity ranged from hand motion to light perception.

Conclusion: In the current study, vitreous cavity and retina epithelial downgrowth occurred after multiple intraocular surgeries, including repair of the open globe injuries both in enucleated specimens and in eyes with visual potential. In eyes with visual potential, keratoprosthesis implantation seems to predispose the development of posterior segment epithelial downgrowth.
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http://dx.doi.org/10.1097/IAE.0000000000000495DOI Listing
August 2015

Contact-Lens-Associated Purpureocillium Keratitis: Risk Factors, Microbiologic Characteristics, Clinical Course, and Outcomes.

Semin Ophthalmol 2017 27;32(2):157-162. Epub 2015 Feb 27.

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

Purpose: To study the risk factors, microbiologic characteristics, clinical course, and outcomes of patients with Purpureocillium keratitis at a tertiary eye care center in south Florida.

Materials And Methods: All medical records during a seven-year period starting January 1, 2007, were reviewed. Twenty-eight culture-proven Purpureocillium keratitis cases with complete medical records presenting to our institution were included in this retrospective, observational case series. Data collected included predisposing factors, therapeutic interventions, treatment duration, and visual outcomes.

Results: Twenty patients (71.4%) had a history of soft contact lens use, with only two for therapeutic use. Other identified risk factors were trauma and immunosuppression. Fifteen patients (53.6%) received topical corticosteroid treatment prior to the diagnosis of fungal keratitis. Thirteen patients (46.4%) were on Natamycin treatment prior to Purpureocillium identification. As a group, the average best-corrected visual acuity (BCVA) at presentation was 1.1 logMAR; upon the final evaluation, it was 1.0 logMAR. The BCVA on last evaluation for the eight patients presenting to our institution within two weeks of onset of symptoms was 0.3 log MAR, and all patients in this group responded to medical management. The final BCVA for 20 patients presenting two weeks after onset of symptoms was 1.2 logMAR. There was a significant difference in the final BCVA between Group 1 and Group 2 (p = 0.004), but no difference in steroid use or previous treatments. Previous steroid use tended to extend time to presentation and was significantly associated with a worse final visual outcome (1.2 versus 0.6 logMAR; p = 0.0474). Previous Natamycin use was significantly associated with a worse final visual outcome (1.4 versus 0.6 logMAR; p = 0.014).

Conclusion: Purpureocillium keratitis can have devastating consequences to visual function and even lead to enucleation. Physicians should make every effort to arrive at an earlier microbiological diagnosis, as this is associated with better outcomes and less need for surgical intervention. The first line use of voriconazole is recommended, and steroid use should be avoided, as their previous use is associated with worse visual outcomes.
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http://dx.doi.org/10.3109/08820538.2015.1011342DOI Listing
March 2017

Unusually delayed presentation of persistent Descemet's membrane tear and detachment after cataract surgery.

Clin Ophthalmol 2014 28;8:1629-32. Epub 2014 Aug 28.

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

A 51-year-old male who had undergone phacoemulsification in his left eye 11 months prior presented with complaint of sudden onset of blurred vision in the same eye. Review of his clinical course, slit-lamp exam, pachymetry, and specular endothelial microscopy led to the diagnosis of acute hydrops caused by Descemet's membrane dehiscence at the site of the incision. He was initially managed with medical treatment and observation. In the subsequent months of follow-up, the corneal edema and the patient's visual acuity did not improve. Intracameral gas injection was performed 7 months after presentation, but because of persistent corneal edema and nonattached Descemet's membrane, penetrating keratoplasty was performed. Histopathologic examination confirmed the diagnosis. The patient has had a clear corneal graft since then. Although Descemet's membrane detachment is a rather common complication after intraocular surgery, its unusually delayed presentation can also occur, and should not be confused with pseudophakic bullous keratopathy. Many mechanisms have been studied for the development of early tears and detachments after cataract surgery, but little is known about late presentations. The authors explore possible causes, and highlight the importance of instructing patients to avoid eye rubbing and any other type of trauma to the cornea after intraocular surgery.
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http://dx.doi.org/10.2147/OPTH.S65520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4155894PMC
September 2014

Endophthalmitis prophylaxis for cataract surgery: are intracameral antibiotics necessary?

JAMA Ophthalmol 2014 Nov;132(11):1269-70

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

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http://dx.doi.org/10.1001/jamaophthalmol.2014.2052DOI Listing
November 2014

Cysticidal activity of antifungals against different genotypes of Acanthamoeba.

Antimicrob Agents Chemother 2014 Sep 7;58(9):5626-8. Epub 2014 Jul 7.

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

Antifungal drugs have been proposed as a novel treatment for Acanthamoeba keratitis. The cysticidal activity of several antifungal compounds was tested against different genotypes of culture collection and clinical isolates of Acanthamoeba. Only voriconazole and posaconazole were found to be cysticidal, with no differences in activity observed between clinical and culture collection isolates.
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http://dx.doi.org/10.1128/AAC.02635-14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4135811PMC
September 2014

Role of the Vision Van, a mobile ophthalmic outpatient clinic, in the Great East Japan Earthquake.

Clin Ophthalmol 2014 7;8:691-6. Epub 2014 Apr 7.

Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan.

Purpose: The Great East Japan Earthquake of March 11, 2011 triggered powerful tsunami waves off the northeastern Pacific coast of Japan that destroyed almost all of the built-up areas along the coast. The study reported here examined the role played by the Vision Van, a mobile outpatient ophthalmological clinic, in providing eye care to disaster evacuees.

Methods: This was a retrospective case-series study of 2,070 victims (male: 732, female: 1,338) who visited the Vision Van. The subjects' medical records were examined retrospectively and analyzed in terms of age, sex, and date of visit to the Vision Van. Information regarding each patient's chief complaint, diagnosis, medication(s) prescribed, and eyeglasses and contact lenses provided, was also examined.

Results: The Vision Van was used to conduct medical examinations on 39 days between April 23 and June 29, 2011. The average number of subjects visiting the Vision Van each day was 53±31 (range: 7-135), with examinations carried out in Miyagi Prefecture and Iwate Prefecture. The most frequent complaint was a need for eye drops (871/2,070 [42.1%]). The second and third most frequent complaints, respectively, were the need for contact lenses (294/2,070 [14.2%]) and eyeglasses (280/2,070 [13.5%]). The most frequent ocular disease diagnosis was cataract (497/2,070 [24.0%]). Eye drops were prescribed to 74.1% of the subjects.

Conclusion: Mobile clinics such as the Vision Van provide valuable care, in this case, particularly to individuals who lost or left behind eyeglasses or contact lenses while escaping a natural disaster, and to subjects with chronic eye disease.
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http://dx.doi.org/10.2147/OPTH.S58887DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3984055PMC
April 2014

Mutation K42E in dehydrodolichol diphosphate synthase (DHDDS) causes recessive retinitis pigmentosa.

Adv Exp Med Biol 2014 ;801:165-70

Bascom Palmer Eye Institute, University of Miami, 900 NW 17th St, 33136, Miami, FL, USA,

A single-nucleotide mutation in the gene that encodes DHDDS has been identified by whole exome sequencing as the cause of the non-syndromic recessive retinitis pigmentosa (RP) in a family of Ashkenazi Jewish origin in which three of the four siblings have early onset retinal degeneration. The peripheral retinal degeneration in the affected siblings was evident in the initial examination in 1992 and only one had detectable electroretinogram (ERG) that suggested cone-rod dysfunction. The pigmentary retinal degeneration subsequently progressed rapidly. The identified mutation changes the highly conserved residue Lys42 to Glu, resulting in lower catalytic efficiency. Patterns of plasma transferrin isoelectric focusing gel were normal in all family members, indicating no significant abnormality in protein glycosylation. Dolichols have been shown to influence the fluidity and of the membrane and promote vesicle fusion. Considering that photoreceptor outer segments contain stacks of membrane discs, we believe that the mutation may lead to low dolichol levels in photoreceptor outer segments, resulting in unstable membrane structure that leads to photoreceptor degeneration.
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http://dx.doi.org/10.1007/978-1-4614-3209-8_21DOI Listing
July 2014

A novel rat contact lens model for Fusarium keratitis.

Mol Vis 2013 27;19:2596-605. Epub 2013 Dec 27.

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

Purpose: The aim of this study was to develop and characterize a new contact lens-associated fungal keratitis rat model and to assess the ability of non-invasive spectral-domain optical coherence tomography (SD-OCT) to detect pathological changes in vivo in fungal keratitis.

Methods: We used SD-OCT to image and measure the cornea of Sprague Dawley rats. Fusarium infection was initiated in the rat eye by fitting Fusarium solani-soaked contact lenses on the experimental eye, while the control animals received contact lenses soaked in sterile saline. The fungal infection was monitored with periodic slit-lamp examination and in vivo SD-OCT imaging of the rat eye, and confirmed by histology, counting of viable fungi in the infected rat cornea, and PCR with specific primers for Fusarium sp.

Results: We imaged and measured the rat cornea with SD-OCT. Custom-made contact lenses were developed based on the OCT measurements. Incubation of contact lenses in a F. solani suspension resulted in biofilm formation. We induced contact lens-associated Fusarium keratitis by fitting the rat eyes for 4 h with the Fusarium-contaminated contact lenses. The SD-OCT images of the cornea correlated well with the slit-lamp and histopathological results and clearly defined clinical signs of infection, namely, increased corneal thickening, loss of epithelial continuity, hyper-reflective areas representing infiltrates, and endothelial plaques characteristic of fungal infection. Moreover, in three cases, SD-OCT detected the infection without any clear findings on slit-lamp examination. Infection was confirmed with histological fungal staining, PCR, and microbiological culture positivity.

Conclusions: We developed a highly reproducible rat contact lens model and successfully induced contact lens-associated Fusarium keratitis in this model. The clinical presentation of contact lens-associated Fusarium keratitis in the rat model is similar to the human condition. SD-OCT is a valuable tool that non-invasively revealed characteristic signs of the fungal infection and could provide sensitive, objective monitoring in fungal keratitis.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3874048PMC
July 2014

Emerging 8-methoxyfluoroquinolone resistance among methicillin-susceptible Staphylococcus epidermidis isolates recovered from patients with endophthalmitis.

J Clin Microbiol 2013 Sep 3;51(9):2959-63. Epub 2013 Jul 3.

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

Fluoroquinolones remain the most commonly used antimicrobials for the prevention and management of bacterial endophthalmitis. Coagulase-negative staphylococci are the most frequently recovered pathogens. Increasing resistance among this group has paralleled the presence of methicillin resistance. From 2005 to 2010, we recovered 38 methicillin-susceptible Staphylococcus epidermidis (MSSE) isolates from endophthalmitis patients at our institute, including 15 (39.5%) isolates resistant to gatifloxacin and moxifloxacin, members of the C-8-methoxyfluoroquinolones family. Mutations in the quinolone resistance-determining regions (QRDR) of gyrA and parC were determined and correlated with fluoroquinolone MICs based on Etests of these 15 MSSE isolates. High-level resistance (MIC, >32 μg/ml) to gatifloxacin and moxifloxacin was documented for 46.7% of the MSSE isolates, and low-level resistance (MIC, 2 to 4 μg/ml) was determined for 53.3%. The MICs for ciprofloxacin, levofloxacin, and ofloxacin were >32 μg/ml for all isolates. The amino acid substitution Ser84Phe in gyrA was found among all isolates. A second mutation in gyrA (Glu88Lys) resulted in high-level resistance to moxifloxacin and gatifloxacin. Almost all (92.8%) isolates presented double point mutations in the parC gene at codons 80 and 84 with different combinations. Eighty-seven percent of the patients had prior exposure to topical 8-methoxyfluoroquinolones. Prior exposure to the 8-methoxyfluoroquinolones may contribute to the selection of MSSE strains containing multiple mutations in the QRDRs of gyrA and parC that results in low- and high-level resistance to these agents.
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http://dx.doi.org/10.1128/JCM.00846-13DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3754617PMC
September 2013

Streptococcal endophthalmitis in pediatric keratoprosthesis.

Ophthalmology 2013 Jul;120(7):1506-7.e1

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

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http://dx.doi.org/10.1016/j.ophtha.2013.02.001DOI Listing
July 2013

Delayed-onset endophthalmitis associated with corneal suture infections.

J Ophthalmic Inflamm Infect 2013 Jun 11;3(1):51. Epub 2013 Jun 11.

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

Background: The purpose of the current study was to report the microbiology, risk factors, and treatment outcomes in patients with delayed-onset endophthalmitis associated with corneal suture infections. For this retrospective consecutive case series, a search of the ocular microbiology department database was performed to identify all patients with positive corneal and intraocular cultures (anterior chamber and/or vitreous) between 01 January 1995 and 01 January 2010. A subset of patients with a history of corneal suture infections and delayed-onset endophthalmitis was identified.

Results: Over the 15-year period of the study, 68 patients were identified to have both positive corneal and intraocular cultures. Among them, six patients were identified to have a culture-proven, delayed-onset endophthalmitis that developed from a culture-positive corneal suture infection. All of the patients in the current study were using topical corticosteroids at the time of diagnosis. In four of six patients, there was documented manipulation of a suture before the development of endophthalmitis. Streptoccocus was identified as the causative organism in five of six patients in the current study. All of the Streptoccocus isolates were sensitive to vancomycin. The single case of Serratia marcescens endophthalmitis was sensitive to amikacin, ceftazidime, ciprofloxacin, gentamicin, and tobramycin. Treatment modalities varied and were guided by the attending ophthalmologist depending upon clinical presentation. One patient with severe Streptococcus pyogenes keratitis and endophthalmitis underwent a primary enucleation after developing a wound dehiscence. Of the remaining five patients, all received topical and intravitreal antibiotics. Therapeutic penetrating keratoplasty was performed in three patients. Pars plana vitrectomy was performed in two patients. Visual acuity outcomes ranged from 20/150 to no light perception.

Conclusions: In the current study, Streptococcus was isolated in nearly all patients with delayed-onset endophthalmitis associated with corneal suture infections. Topical steroid use and suture manipulation were identified as associated factors for developing endophthalmitis. Visual acuity outcomes were poor despite the prompt recognition of endophthalmitis and appropriate antibiotic therapy.
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http://dx.doi.org/10.1186/1869-5760-3-51DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3717107PMC
June 2013

Fusarium keratitis: genotyping, in vitro susceptibility and clinical outcomes.

Cornea 2013 May;32(5):667-73

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

Purpose: To determine differences in the clinical characteristics and antifungal susceptibility patterns among molecularly characterized ocular Fusarium sp isolates.

Methods: Fifty-eight isolates of Fusarium sp obtained from 52 eyes of 52 patients were retrieved from the Ocular Microbiology Laboratory of the Bascom Palmer Eye Institute and grown in pure culture. These isolates were characterized based on DNA sequence analysis of the ITS1/2 and ribosomal deoxyribonucleic acid regions. Antifungal susceptibilities were determined for each isolate using broth microdilution methods, and the corresponding medical records were reviewed to determine the clinical outcomes.

Results: Fusarium solani isolates had significantly higher values of minimum inhibitory concentration for 90% isolates (MIC90) with voriconazole than F. non-solani organisms (16 and 4 μg/mL, respectively). Isolates of F. solani also exhibited a significantly longer time to cure (65 vs. 40.5 days), a worse follow-up best-corrected visual acuity (20/118 vs. 20/36), and an increased need for urgent surgical management (7 vs. 0 penetrating keratoplasties) when compared with those of F. non-solani.

Conclusions: This is the first report to examine the correlation between ocular genotyped Fusarium sp and clinical outcomes. It supports the overall worse prognosis of F. solani versus F. non-solani isolates, including higher voriconazole resistance by the former. The clinical implementation of molecular-based diagnostics and antifungal efficacy testing may yield important prognostic and therapeutic information that could improve the management of fungal ocular infections.
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http://dx.doi.org/10.1097/ICO.0b013e318277ac74DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3622819PMC
May 2013

Comparative in vitro susceptibility of besifloxacin and seven comparators against ciprofloxacin- and methicillin-susceptible/nonsusceptible staphylococci.

J Ocul Pharmacol Ther 2013 Apr 4;29(3):339-44. Epub 2013 Jan 4.

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

Purpose: Besifloxacin is a novel fluoroquinolone antibiotic developed to provide alternative coverage for ocular pathogens with current and emerging in vitro and in vivo resistance to present fluoroquinolones and other commonly dispensed ocular antibiotics. The purpose of this study was to investigate the in vitro efficacy of besifloxacin and 7 comparators against ciprofloxacin- and methicillin-susceptible and nonsusceptible staphylococcal isolates from conjunctivitis, blepharitiis, keratitis, endophthalmitis, and other ocular surface disorders.

Methods: Nonconsecutive ocular Staphylococcus aureus (N=154) and Coagulase-negative Staphylococcus (N=89, including 84 Staphylococcus epidermidis) isolates collected from patients presenting during the 6 years (2003-2008) were evaluated using frozen minimal inhibitory concentration (MIC) panels containing serial dilutions (μg/mL) of besifloxacin (0.004-32), moxifloxacin (0.004-128), ciprofloxacin (0.03-256), azithromycin (0.12-128), oxacillin (0.03-32), gentamicin (0.03-128), trimethoprim (0.5-16), and vancomycin (0.12-32).

Results: Among the fluoroquinolones group, besifloxacin had the lowest MIC90s. MIC90 values (μg/mL) for besifloxacin (4) was 8-fold lower than for moxifloxacin (32) and 32-fold lower than ciprofloxacin (128). Among the nonfluoroquinolone comparators, vancomycin (2) had the lowest MICs followed by gentamicin (16) and trimethoprim (16). Besifloxacin MIC90s (μg/mL) were lowest for isolates recovered from the lacrimal sac (0.25), followed by lids (1), conjunctiva (2), keratitis (4), and intraocular fluids (4).

Conclusions: Due to its improved coverage for ciprofloxacin- and methicillin-resistant staphylococci, besifloxacin may offer extended coverage for some ocular pathogens resistant to current fluoroquinolones recovered from a diverse group of ocular sources. Ninety-five percent of all isolates were covered by a besifloxacin MIC90 of 4 μg/mL.
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http://dx.doi.org/10.1089/jop.2012.0081DOI Listing
April 2013

Endothelial graft failure after contralateral autologous corneal transplantation.

Cornea 2013 Jun;32(6):745-50

Surgical Division, Miami Veterans Administration Medical Center, Miami, FL 33125, USA.

Purpose: To report on outcomes after contralateral autologous penetrating keratoplasty (APK).

Design: Case series.

Patient Population: Five patients who received a contralateral APK and a simultaneous allogeneic penetrating keratoplasty in the donor eye at the Bascom Palmer Eye Institute and the Miami Veterans Affairs Hospital.

Results: The median patient age at the time of surgery in our 5 patients was 67 years (range, 58-88 years); 4 patients were male and 1 female, and 1 patient was white and 4 were black. The surgery was uneventful in all cases, and no operative or immediate postoperative complications occurred in either eye. Follow-up time ranged from 18 to 54 months (mean, 35 months; median, 34 months). During this time, 4 of the autologous grafts failed because of endothelial attenuation. Identified risk factors for failure in the autologous eyes included the presence of a glaucoma tube (5/5), previous graft failure (4/5), and anterior synechiae (2/5).

Conclusions: This study is the first to describe graft failure because of slow endothelial attenuation after APK. This study underscores the importance of nonimmunologic factors in endothelial cell loss after corneal transplant surgery and highlights the need for further research to understand and modulate endothelial loss.
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http://dx.doi.org/10.1097/ICO.0b013e31826dff17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3568247PMC
June 2013

Infectious keratitis progressing to endophthalmitis: a 15-year study of microbiology, associated factors, and clinical outcomes.

Ophthalmology 2012 Dec 1;119(12):2443-9. Epub 2012 Aug 1.

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

Purpose: To describe the incidence, microbiology, associated factors, and clinical outcomes of patients with infectious keratitis progressing to endophthalmitis.

Design: Nonrandomized, retrospective, consecutive case series.

Participants: All patients treated for culture-proven keratitis and endophthalmitis between January 1, 1995 and December 31, 2009, at the Bascom Palmer Eye Institute.

Methods: Ocular microbiology and medical records were reviewed on all patients with positive corneal and intraocular cultures over the period of the study. Univariate analysis was performed to obtain P values described in the study.

Main Outcome Measures: Microbial isolates, treatment strategies, and visual acuity (VA) outcomes.

Results: A total of 9934 corneal cultures were performed for suspected infectious keratitis. Only 49 eyes (0.5%) progressed to culture-proven endophthalmitis. Fungi (n = 26) were the most common responsible organism followed by gram-positive bacteria (n = 13) and gram-negative bacteria (n = 10). Topical steroid use (37/49 [76%]) was the most common associated factor identified in the current study, followed by previous surgery (30/49 [61%]), corneal perforation (17/49 [35%]), dry eye (15/49 [31%]), relative immune compromise (10/49 [20%]), organic matter trauma (9/49 [18%]), and contact lens wear (3/49 [6%]). There were 27 patients in whom a primary infectious keratitis developed into endophthalmitis, and 22 patients in whom an infectious keratitis adjacent to a previous surgical wound progressed into endophthalmitis. Patients in the primary keratitis group were more likely to be male (22/27 [81%] vs 8/22 [36%]; P = 0.001), have history of organic matter trauma (8/27 [30%] vs 1/22 [5%]); P = 0.030), and have fungal etiology (21/27 [78%] vs 5/22 [23%]; P<0.001). Patients in the surgical wound-associated group were more likely to use topical steroids (20/22 [91%] vs 17/27 [63%]; P = 0.024). A VA of ≥ 20/50 was achieved in 7 of 49 patients (14%), but was <5/200 in 34 of 49 (69%) at last follow-up. Enucleation or evisceration was performed in 15 of 49 patients (31%).

Conclusions: Progression of infectious keratitis to endophthalmitis is relatively uncommon. The current study suggests that patients at higher risk for progression to endophthalmitis include patients using topical corticosteroids, patients with fungal keratitis, patients with corneal perforation, and patients with infectious keratitis developing adjacent to a previous surgical wound. Patients with sequential keratitis and endophthalmitis have generally poor visual outcomes.

Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.
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http://dx.doi.org/10.1016/j.ophtha.2012.06.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3490005PMC
December 2012

Comparative in vitro antifungal susceptibility activity of amphotericin B versus amphotericin B methyl ester against Candida albicans ocular isolates.

J Ocul Pharmacol Ther 2012 Dec 12;28(6):589-92. Epub 2012 Jul 12.

Bascom Palmer Eye Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida 33418, USA.

Purpose: To compare in vitro susceptibility of amphotericin B (AMB) and amphotericin B methyl ester (AME) (a more soluble and less toxic formulation of AMB) against Candida albicans isolates recovered from human cases of endophthalmitis.

Methods: The in vitro susceptibility of AMB and AME was determined for C. albicans isolates recovered from endophthalmitis (N=10) and for C. albicans ATCC reference strain 90028 using the Clinical and Laboratory Standards Institute M27-A2 (NCCLS/CLSI) broth dilution method. All isolates were obtained from samples of vitreous humor of patients with suspected endophthalmitis within the last 5 years at the Bascom Palmer Eye Institute, University of Miami Miller School of Medicine (Miami, FL).

Results: The minimal inhibitory concentrations (MICs) of AME were equal to or lower than values for AMB in 7 of the 10 isolates; range: AME (0.125-1 μg/mL) versus (0.5-1 μg/mL) for AMB. The MIC(90) value of both drugs was equal (1 μg/mL). Compared with AMB, the minimal fungicidal concentrations (MFCs) of AME were equal to or lower in 8 of 10 isolates; range: AME (0.125-2 μg/mL) versus AMB (0.25-4 μg/mL). MFC(90) values of AME (1 μg/mL) was slightly superior to AMB (2 μg/mL). The MIC of the quality control strain (ATCC(®) 90028) was within an acceptable range.

Conclusions: AME was equivalent to AMB in vitro against C. albicans. This formula may offer a slightly more efficient and less toxic formulation for the treatment of Candida endophthalmitis.
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http://dx.doi.org/10.1089/jop.2012.0048DOI Listing
December 2012

Acanthamoeba keratitis: the persistence of cases following a multistate outbreak.

Ophthalmic Epidemiol 2012 Aug;19(4):221-5

Centers for Disease Control and Prevention.

Purpose: To describe the trend of Acanthamoeba keratitis case reports following an outbreak and the recall of a multipurpose contact lens disinfection solution. Acanthamoeba keratitis is a serious eye infection caused by the free-living amoeba Acanthamoeba that primarily affects contact lens users.

Methods: A convenience sample of 13 ophthalmology centers and laboratories in the USA, provided annual numbers of Acanthamoeba keratitis cases diagnosed between 1999-2009 and monthly numbers of cases diagnosed between 2007-2009. Data on ophthalmic preparations of anti-Acanthamoeba therapies were collected from a national compounding pharmacy.

Results: Data from sentinel site ophthalmology centers and laboratories revealed that the yearly number of cases gradually increased from 22 in 1999 to 43 in 2003, with a marked increase beginning in 2004 (93 cases) that continued through 2007 (170 cases; p < 0.0001). The outbreak identified from these sentinel sites resulted in the recall of a contact lens disinfecting solution. There was a statistically significant (p ≤ 0.0001) decrease in monthly cases reported from 28 cases in June 2007 (following the recall) to seven cases in June 2008, followed by an increase (p = 0.0004) in reported cases thereafter; cases have remained higher than pre-outbreak levels. A similar trend was seen in prescriptions for Acanthamoeba keratitis chemotherapy. Cases were significantly more likely to be reported during summer than during other seasons.

Conclusion: The persistently elevated number of reported cases supports the need to understand the risk factors and environmental exposures associated with Acanthamoeba keratitis. Further prevention efforts are needed to reduce the number of cases occurring among contact lens wearers.
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http://dx.doi.org/10.3109/09286586.2012.681336DOI Listing
August 2012

Treating uncorrected refractive error in adults in the developing world with autorefractors and ready-made spectacles.

Clin Exp Ophthalmol 2011 Nov 21;39(8):729-33. Epub 2011 Apr 21.

Bascom Palmer Eye Institute, Miami, Florida 33136, USA.

Background: To evaluate a method for treating uncorrected refractive error in adults in the developing world.

Design: Prospective, cross-sectional study in outpatient community health centres.

Participants: Eight hundred and forty subjects aged 18 and older from rural villages in Haiti and Belize.

Methods: Undilated refractive error screening exams were conducted over a 5-day period in rural Haiti and Belize using portable autorefractors. Isometropic, spherical, ready-made spectacles were provided to patients with bilateral refractive error, astigmatism ≤ 1 dioptre in each eye and visual acuity worse than 6/9 in each eye. Visual acuity was measured with and without corrective spectacles.

Main Outcome Measures:   The mean visual improvement and median final visual acuity after treatment with ready-made glasses.

Results: Eight hundred and forty patients aged 18 and older were screened with autorefractors. One hundred and eighty-nine subjects (22.5%) were found to have visually significant bilateral refractive error. Fifty-eight per cent (110/189) of these patients met criteria for treatment with ready-made spectacles. Visual acuity improved an average of 4.2 lines in the better eye and 4.1 lines in the worse eye with corrective glasses. The median visual acuity in the better eye was 6/6 after treatment.

Conclusion: Autorefractors and ready-made spectacles allow for effective treatment of uncorrected refractive error in adults in the developing world.
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http://dx.doi.org/10.1111/j.1442-9071.2011.02546.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4139100PMC
November 2011

Clinical and microbiological characteristics of fungal keratitis in the United States, 2001-2007: a multicenter study.

Ophthalmology 2011 May 4;118(5):920-6. Epub 2011 Feb 4.

The George Institute for Global Health, the University of Sydney, Sydney, Australia.

Objective: To study the epidemiology, clinical observations, and microbiologic characteristics of fungal keratitis at tertiary eye care centers in the United States.

Design: Retrospective multicenter case series.

Participants: Fungal keratitis cases presenting to participating tertiary eye care centers.

Methods: Charts were reviewed for all fungal keratitis cases confirmed by culture, histology, or confocal microscopy between January 1, 2001, and December 31, 2007, at 11 tertiary clinical sites in the United States.

Main Outcome Measures: Frequency of potential predisposing factors and associations between these factors and fungal species.

Results: A total of 733 cases of fungal keratitis were identified. Most cases were confirmed by culture from corneal scraping (n = 693) or biopsies (n = 19); 16 cases were diagnosed by microscopic examination of corneal scraping alone; and 5 cases were diagnosed by confocal microscopy alone. Some 268 of 733 cases (37%) were associated with refractive contact lens wear, 180 of 733 cases (25%) were associated with ocular trauma, and 209 of 733 cases (29%) were associated with ocular surface disease. No predisposing factor was identified in 76 cases (10%). Filamentous fungi were identified in 141 of 180 ocular trauma cases (78%) and in 231 of 268 refractive contact lens-associated cases (86%). Yeast was the causative organism in 111 of 209 cases (53%) associated with ocular surface disease. Yeast accounted for few cases of fungal keratitis associated with refractive contact-lens wear (20 cases), therapeutic contact-lens wear (11 cases), or ocular trauma (21 cases). Surgical intervention was undertaken in 26% of cases and was most frequently performed for fungal keratitis associated with ocular surface disease (44%). Surgical intervention was more likely in cases associated with filamentous fungi (P = 0.03). Among contact lens wearers, delay in diagnosis of 2 or more weeks increased the likelihood of surgery (age-adjusted odds ratio = 2.2; 95% confidence interval, 1.2-4.2).

Conclusions: Trauma, contact lens wear, and ocular surface disease predispose patients to developing fungal keratitis. Filamentous fungi are most frequently the causative organism for fungal keratitis associated with trauma or contact lens wear, whereas yeast is most frequently the causative organism in patients with ocular surface disease. Delay in diagnosis increases the likelihood of surgical intervention for contact lens-associated fungal keratitis.
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http://dx.doi.org/10.1016/j.ophtha.2010.09.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3673009PMC
May 2011