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Acanthamoeba keratitis is an uncommon but devastating complication of contact lens wear causing significant ocular morbidity. Six consecutive cases occurring in Western Australia in an 18-month period are reported. In all cases either poor contact lens hygiene or an association with swimming pools and contact lens use is a feature. There is invariably a delay in making the diagnosis, with the appearance frequently mistaken for herpes simplex keratitis. In all cases corneal biopsy was required to confirm the diagnosis. Of the six patients, four responded to medical therapy alone, one required a corneal graft and one required enucleation. We suggest that earlier rather than later corneal biopsy is important in unresponsive cases of culture-negative keratitis, especially in contact lens wearers. We would agree that the treatment of choice is intensive topical propamidine and neosporin. Prevention by strict adherence to contact lens care and hygiene is urged. [ABSTRACT FROM AUTHOR]

We report three cases of partial spontaneous canthal cross union, a rare complication in cases where Hughes flaps are used to reconstruct lower eyelid defects that also involve the canthi. All cases of spontaneous cross union were identified within 2 months of uneventful division of Hughes' flap. Two cases were successfully divided with good aesthetic results although one patient was not keen on surgery, as it was aesthetically acceptable to him. The postulated mechanism was either the proximity of the divided nonepithelial margins or the failure to trim the residual upper eyelid tarsoconjunctival remnant. We recommended adequate trimming of the residual upper eyelid tarsoconjunctival remnant and an early postoperative review to prevent adhesions from developing. [ABSTRACT FROM AUTHOR]

A case of Mycobacterium chelonae keratitis is described. As with any infective keratitis, appropriate treatment depends upon rapid and accurate microbiological assessment of corneal scraping. Acid-fast stains such as Ziehl-Nielson should be performed, particularly in chronic corneal ulcers, as only these stains will distinguish mycobacteria from the more common diphtheroid organisms. The mycobacterium chelonae organism was sensitive only to tetracyclines. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article by Steven D. Pearson and Peter B. Bach regarding Medicare reimbursement on high dose seasonal influenza vaccines in the October 2010 issue.

Background: The use of non-vitamin K oral anticoagulants (NOACs) has increased steadily following marketing approval; however, their relative safety in nonvalvular atrial fibrillation (NVAF) patients in real-world clinical practice remains unclear., Objective: To compare the risk of major bleeding during anticoagulation therapy between warfarin and NOACs., Methods: This retrospective cohort study analyzed administrative claims data on new NVAF users of warfarin, dabigatran, apixaban, or rivaroxaban in routine clinical care from November 2010 to February 2015 in a commercially insured population in the United States. The primary outcome was time to first major bleeding event requiring hospitalization. Patients were followed until discontinuation or switch of anticoagulants, health plan disenrollment, death, or end of study. All patient characteristics were balanced after propensity score inverse probability of treatment (IPT) weighting. Event rates by type of anticoagulant exposure were compared using IPT-weighted Cox proportional hazards models., Results: The study cohort comprised 44,057 patients who used warfarin (n = 23,431), dabigatran (n = 8,539), apixaban (n = 3,689), and rivaroxaban (n = 8,398). Overall mean (SD) age was 70 (12) years, and 41% of the patients were women. A total of 2,337 major bleeding events occurred during 36,636.2 person-years of follow-up. The unadjusted rate of major bleeding with warfarin was 6.0 per 100 person-years versus 2.8 with dabigatran, 3.3 with apixban, and 5.0 with rivaroxaban. Relative to warfarin, major bleeding risk was lower with dabigatran (HR = 0.67, 95% CI = 0.60-0.76) and apixaban (HR = 0.52, 95% CI = 0.41-0.67). Compared with rivaroxaban, major bleeding risk was also lower with dabigatran (HR = 0.67, 95% CI = 0.58-0.78) and apixaban (HR = 0.52, 95% CI = 0.40-0.68). Major bleeding risk was similar for rivaroxaban and warfarin. Relative to apixaban, dabigatran was associated with a significantly higher risk of major gastrointestinal bleeding (HR = 1.43, 95% CI = 1.09-1.88)., Conclusions: Study results were consistent with safety findings from pivotal clinical trials comparing NOACs with warfarin and added the perspective of a large real-world observational study that compared bleeding risks associated with NOACs during anticoagulation therapy. Apixaban and dabigatran were associated with lower major bleeding risk compared with warfarin or rivaroxaban; however, apixaban had a lower risk of major gastrointestinal bleeding than dabigatran. These findings can help inform the choice of an optimal agent, which must balance effectiveness and bleeding risk in complex patients., Disclosures: This study was funded by Anthem. Adeboyeje, Sylwestrzak, and Barron are employees of HealthCore, a wholly owned and independently operated subsidiary of Anthem. White, Rosenberg, Abarca, and Crawford are employees of Anthem. Study concept and design were primarily contributed by Adeboyeje and Sylwestrzak, along with the other authors. Adeboyeje took the lead in data collection, along with Sylwestrzak and Barron. Data interpretation was performed primarily by Rosenberg, Crawford, and Redberg, with assistance from the other authors. The manuscript was written by all the authors and revised primarily by White, Abarca, and Redberg, along with the other authors.

Purpose: To report the efficacy of the Quickert procedure in the first case series of involutional entropion in an elderly Asian population, and to introduce the technique to Asian ophthalmologists including general ophthalmologisits and ophthalmic trainees., Methods: We conducted a retrospective review of 13 consecutive patients underwent the Quickert procedure for involutional entropion by occasional eyelid surgeons at Tokushima University Hospital or Mino Tanaka Hospital from September 2003 to April 2010. Demographic data, including gender, age, history of previous eyelid surgery, systemic disease, recurrence of entropion, postoperative complications, and symptoms were analyzed., Results: There were 5 male (38.5%) and 8 female (61.5%) subjects with a mean age of 77.8 years. Three patients underwent previous surgery for entropion were included. Entropion was rectified in all patients by a single Quickert procedure, and no recurrence was observed for a maximum of 89 months after the surgery. Although notching of the eyelid margin and mild symblepharon were observed in one patient, no symptoms associated with these complications were reported., Conclusion: The Quickert procedure can be one of the surgical procedures of choice for involutional entropion and should be common surgical approach for occasional eyelid surgeons in Asia as well as in western countries.

Purpose: To study the outcomes of AlphaCor implantation., Methods: : The AlphaCor artificial cornea is indicated for corneal blindness not treatable by donor grafting. Prospective preoperative and follow-up data were collected. Data were evaluated using SPSS for statistical analysis of outcomes, trends, and associations., Results: This report includes data returned through February 28, 2006, for all 322 devices implanted, with mean follow-up in situ of 15.5 months and a maximum of 7.4 years. The probability of AlphaCor retention at 6 months and 1 and 2 years for protocol cases was 92%, 80%, and 62%, respectively, and off-label cases were at higher risk (P = 0.010), as were cases not prescribed medroxyprogesterone (MPG; P = 0.001). Currently, the most common complications were stromal melting, fibrous reclosure of the posterior lamellar opening, and white intraoptic deposits, with incidences in 2005 of 11.4%, 5.1%, and 2.6%, respectively. MPG seems to protect against melts, and eyes with a history of herpetic keratitis were not at increased risk. A history of glaucoma or the presence of tubes did not affect device retention. Complications culminated in loss of an eye in 1.3%. Mean preoperative visual acuity (VA) was hand movements. The VA achieved postoperatively (light perception to 20/20) was affected by previous pathology and postoperative course, with a mean improvement of 2 lines., Conclusion: AlphaCor provides a treatment option where a donor tissue graft would not succeed in severe corneal conditions, while being reversible to a donor graft in the event of complications for anatomic integrity. Surgical technique and adjunctive therapies are evolving with experience. Continued data collection is important for a fuller understanding of AlphaCor's role.

Purpose: There is currently no standardized methodology that permits preoperative prediction of the surgical technique or drug regimen for corneal grafting most likely to succeed for an individual patient. A score factor related to the chance of successful penetrating keratoplasty (PK) may assist in standardization of graft outcome reporting and evidence-based management., Methods: The Risk Score (RS) is based on factors shown to reduce the probability of 1-year survival of conventional PK in increments, using published Australian Corneal Graft Registry data. To asses its validity, Kaplan-Meier survival curves from 156 corneal replacement surgeries, stratified by preoperative RS, were used to derive the probability of survival at 1 year for donor PK, with or without systemic immunosuppression, and for synthetic PK with the AlphaCor artificial cornea. The probability of survival was then plotted against RS for each regimen, producing a family of curves., Results: The mean RS for immunosuppressed cases was higher than for nonimmunosuppressed cases. The AlphaCor group had the highest scores. AlphaCor survival is little affected by the factors that affect the risk of graft survival, whereas the probability of donor graft survival, immunosuppressed or not, is inversely related to RS., Conclusions: This study was designed to test a method that allows objective comparison of outcomes of different methods of corneal replacement for different risk categories. Analysis of this small dataset supports the validity of the concept and suggests that the Risk Score is a useful descriptive statistic. With a sufficient sample size, statistically significant evidence of the optimum management method for an individual patient with a particular risk profile could be determined such that a prospective patient's preoperative RS could be used to assist management decisions. In particular, data allowing separation of different immunosuppression regimes would be useful. Functional outcomes such as visual acuity would be more significant clinically than the survival end point used in this study and the system also could be adapted to different follow-up periods.

Purpose: To describe clinical outcomes after a novel type of corneal surgery, implantation of an artificial cornea, AlphaCor , and to evaluate outcomes in comparison with alternative keratoprostheses and high-risk grafts., Methods: Case reports and data from a noncontrolled clinical trial and a literature review., Results: The probability of AlphaCor retention to 1 year is 80%. Postoperative best corrected visual acuity ranges from Perception Light to 20/30. The most significant complications are stromal melts and optic depositions, for both of which the main risk factors have been identified. Complications can be managed without loss of the eye., Conclusion: Results from the clinical trial period have helped to determine the indications and risk factors for AlphaCor surgery and to refine surgical techniques. Continued monitoring of outcomes as the series increases will allow a more accurate determination of comparative outcomes. The series provides preliminary evidence that AlphaCor may have a lower incidence of complications than traditional keratoprostheses and may prove to be preferable to a donor graft in high-risk cases.

Purpose: This study was conducted to evaluate the effect of topical medroxyprogesterone (MPG) following KPro implantation in human subjects in whom donor tissue grafts had been contraindicated by high risk of failure., Methods: Outcomes of implantation of the Chirila KPro, now known as AlphaCor, were reviewed with respect to postoperative MPG therapy. Ten of 45 (22%) patients had received MPG for a period of 12 months, while 35/45 (78%) had not. MPG treatment was halted because the drug is not approved as an adjunctive treatment of KPro patients. The main outcome measures were the incidence and timing of corneal stromal melting and visual acuity., Results: Of those untreated with MPG, 34% developed a melt (mean follow-up 9.7 months), whereas of those who received MPG, 60% developed a melt (mean follow-up 28.4 months). However, mean time to melt onset for untreated cases was 8.8 months, whereas mean time to melt onset for treated cases was 23.2 months. There is a statistically significant association between time to melt onset, where melts occurred, and MPG therapy (chi2 = 0.001). In both groups, melts were strongly associated with a history of ocular HSV, which represented 17.1% of untreated and 20% of treated cases and is now considered a contraindication for AlphaCor. Preoperative visual acuities were in the range Perception Light (PL)-Count Fingers (CF) in all cases, whereas mean best postoperative best corrected visual acuity was 20/200 (range PL-20/30) in untreated cases and was 20/120 [range Hand Movements (HM)-20/30)] in MPG-treated cases., Conclusions: Although MPG may not influence the underlying incidence of melt-related complications, which are likely to be associated with other risk factors especially HSV, it may have a protective effect with regard to melt onset and severity. Controlled studies would assist evaluation of its use in this indication.