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Endothelial keratoplasty is the most commonly performed type of corneal transplant in the United States, currently accounting for 60% of total grafts. The anterior segment complications are well documented; however, the posterior segment complications may not be as familiar to the anterior segment surgeon. These include endophthalmitis, cystoid macular edema (CME), choroidal detachment, graft dislocation to the posterior segment, and retinal detachment. CME is the most common postoperative retinal complication with a reported incidence of up to 12.5%, which usually responds well to topical therapy. This article will review the incidence, prevention and management of posterior segment complications after endothelial keratoplasty.

Purpose: To describe an immunosuppressed patient who developed acute-onset postoperative endophthalmitis caused by a moxifloxacin-resistant strain of Staphylococcus epidermidis after cataract surgery despite the use of intracameral moxifloxacin. Observations: A 76-year old woman with a history of birdshot chorioretinopathy controlled on systemic immunosuppression underwent uneventful cataract surgery in her right eye. Compounded intracameral moxifloxacin 0.2 cc of 1mg/0.1mL (Edge Pharmacy, Syracuse, NY) was injected intraoperatively as prophylaxis, and the patient was placed on a standard regimen of trimethoprim-polymyxin b (10000-0.1unit/mL) and prednisolone acetate 1% postoperatively. Four days later, the patient experienced a sudden decrease in vision in the right eye. Anterior chamber inflammation, vitritis, and vasculitis were seen in the operated eye. The patient underwent a vitreous tap and intravitreal injections of vancomycin (1mg/0.1mL), ceftazidime (2.25mg/0.1mL), and dexamethasone (0.4mg/0.1mL). Cultures grew Staphylococcus epidermidis, resistant to moxifloxacin (MIC ≥8mg/L). The inflammation resolved over two months. Eight months later, the patient underwent uncomplicated cataract surgery in the left eye. Intracameral antibiotics were not used, however her systemic immunosuppressive therapy was held for several weeks perioperatively. One year after the initial surgeries, the patient had an uncorrected visual acuity of 20/20 in each eye. Conclusions and Importance: S. epidermidis, the most common cause of postoperative endophthalmitis, is increasingly resistant to fluoroquinolones. Adequate concentrations of intracameral antibiotics need to be achieved in order to exceed minimal inhibitory concentration values of the targeted pathogen. Although intracameral moxifloxacin has been reported to decrease the rate of endophthalmitis after cataract surgery, it does not eliminate the risk. Keywords: Endophthalmitis, Post-surgical infection, Moxifloxacin, Intracameral antibiotic

The authors report a case of a synthetic fiber granuloma to demonstrate the challenges in diagnosing these lesions and to highlight their histopathologic features. This is the first report in the literature to use histopatho-logic and immunofluorescence studies to characterize the subtype and distribution of macrophages in synthetic fiber granuloma. [ J Pediatr Ophthalmol Strabismus . 2020;57:e92–e95.]

OBJECTIVE: To evaluate the association between dry eye symptoms and neuropathic-like ocular pain features, chronic pain conditions, depression, and anxiety in patients presenting for routine ophthalmic examinations. METHODS: 233 consecutive patients ≥18 years of age presenting to a comprehensive eye clinic between January and August 2016 were included in this study. Information on demographics, chronic pain conditions, medication use, DE symptoms (dry eye questionnaire, DEQ5), NOP complaints (burning; wind, light, and temperature sensitivity), depression and anxiety indices (patient health questionnaire 9, PHQ9 and symptom checklist 90-revised, SCL-90-R) were collected for each individual. Pearson’s correlation was used to evaluate strengths of association. Logistic regression analysis examined risk factors for any (DEQ5≥6) and severe (DEQ5≥12) DE symptoms. RESULTS: The mean age of the population was 46.3 years (±13.0); 67.8% (n=158) were female. Per the DEQ5, 40.3% (n=94) had mild or greater DE symptoms and 12% (n=24) had severe symptoms. Severity of DE symptoms correlated with NOP complaints: burning (Pearson r=0.37, p

Purpose: To describe a patient with late post-operative endophthalmitis and clear cornea tunnel infection caused by Candida parapsilosis that was masquerading as chronic anterior uveitis. Observations: A 62-year old woman with history of uncomplicated cataract surgery 7 months prior and chronic postoperative anterior uveitis, presented with an endothelial plaque, hypopyon, and infiltrates in the capsular bag and within the clear corneal tunnel. Anterior chamber cultures identified C. parapsilosis and pathology of the endothelial plaque showed fungus. Anterior chamber washout, scraping of the endothelial plaque, serial intracameral and intravitreal injections with amphotericin B (10 mcg) failed to control the infection. Pars plana vitrectomy, removal of the intraocular lens and capsular bag, a corneal patch graft, and administration of intravitreal antifungal agents were performed. One year later the patient remains free of recurrence and her best-corrected vision is 20/25 with a rigid gas permeable contact lens. Conclusions: and Importance: Persistent intraocular and intracorneal inflammation after cataract surgery should raise suspicion of endophthalmitis caused by fungi non-responsive to topical and intravitreal antibiotics. Surgical intervention and removal of the nidus of infection, which is often the intraocular lens and capsular bag, may be necessary for a successful outcome. Keywords: Amphotericin B, Clear corneal tunnel infection, Fungal endophthalmitis, Intravitreal antifungals, Voriconazole

PURPOSE To evaluate the epidemiology of persistent postsurgical pain (PPP) manifesting as dry eye (DE)-like symptoms 6 months after surgery. METHODS This single-center study included 119 individuals whose cataract surgeries were performed by a single surgeon at the Bascom Palmer Eye Institute and who agreed to participate in a phone survey 6 months after surgery. Patients were divided into 2 groups: the PPP group was defined as those with a Dry Eye Questionnaire-5 score ≥6 and without PPP as those with a Dry Eye Questionnaire-5 score

A case of retinal arterial macroaneurysm (RAM) is presented with multimodal imaging, including commercially available optical coherence tomography angiography (OCT-A). Following treatment with intravitreal bevacizumab, reduction of flow signal through the RAM is documented. OCT-A provides useful information for the diagnosis and management of at least some patients with RAM, without the need for traditional fluorescein angiography.

We compared the resistance patterns of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible Staphylococcus aureus (MSSA) keratitis isolates with the common topically applied ophthalmic antimicrobials.We reviewed the antibiotic susceptibility results of 122 MRSA and 276 MSSA keratitis isolates from January 1993 to November 2012. In vitro susceptibility testing of each Staphylococcus aureus (SA) isolate was performed using Kirby-Bauer disk diffusion based on modified serum interpretations for cefoxitin, bacitracin, cefazolin, ciprofloxacin, gatifloxacin, gentamicin, moxifloxacin, ofloxacin, polymyxin B, sulfamethoxazole, tobramycin, and trimethoprim.MRSA represented 30.7% (122 of 398) of the total SA isolates. All the SA isolates were susceptible to vancomycin, whereas they were less susceptible to the fluoroquinolones than to the non-fluoroquinolones. In comparison with MSSA, MRSA was significantly more resistant to all the antibiotics tested other than polymyxin B (both equally resistant) and vancomycin (both equally susceptible) (P0.001). Besides vancomycin, MRSA demonstrated the best susceptibilities to sulfamethoxazole (94.3%), bacitracin (89.3%), trimethoprim (88.5%), and gentamicin (86.1%). Additionally, MRSA was found to be significantly more resistant to the second-generation fluoroquinolones (ciprofloxacin and ofloxacin) than to the fourth-generation fluoroquinolones (moxifloxacin and gatifloxacin). An increase in resistance to the fourth-generation fluoroquinolones was detected for both MRSA and MSSA over the study period.The in vitro susceptibilities of commonly used topical antibiotics differ for MRSA and MSSA isolates; thus, successful treatment of bacterial keratitis should be supported with laboratory studies. Vancomycin remains the treatment of choice for MRSA keratitis. The empiric use of second-generation fluoroquinolones seems to be contraindicated in the treatment of MRSA keratitis.

Visual Overview, It is thought that frontostriatal circuits play an important role in mediating conditioned behavioral responses to environmental stimuli that were previously encountered during drug administration. However, the neural correlates of conditioned responses to drug-associated cues are not well understood at the level of large populations of simultaneously recorded neurons, or at the level of local field potential (LFP) synchrony in the frontostriatal network., It is thought that frontostriatal circuits play an important role in mediating conditioned behavioral responses to environmental stimuli that were previously encountered during drug administration. However, the neural correlates of conditioned responses to drug-associated cues are not well understood at the level of large populations of simultaneously recorded neurons, or at the level of local field potential (LFP) synchrony in the frontostriatal network. Here we introduce a behavioral assay of conditioned arousal to cocaine cues involving pupillometry in awake head-restrained mice. After just 24 h of drug abstinence, brief exposures to olfactory stimuli previously paired with cocaine injections led to a transient dilation of the pupil, which was greater than the dilation effect to neutral cues. In contrast, there was no cue-selective change in locomotion, as measured by the rotation of a circular treadmill. The behavioral assay was combined with simultaneous recordings from dozens of electrophysiologically identified units in the medial prefrontal cortex (mPFC) and ventral striatum (VS). We found significant relationships between cocaine cue-evoked pupil dilation and the proportion of inhibited principal cells in the mPFC and VS. Additionally, LFP coherence analysis revealed a significant correlation between pupillary response and synchrony in the 25–45 Hz frequency band. Together, these results show that pupil dilation is sensitive to drug-associated cues during acute stages of abstinence, and that individual animal differences in this behavioral arousal response can be explained by two complementary measures of frontostriatal network activity.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, but potentially blinding diseases that affect the skin and mucous membranes. Although the cutaneous manifestations tend to be self-limited and resolve without sequelae, the chronic ocular complications associated with SJS/TEN can persist despite local therapy. Poor understanding of the underlying pathophysiology and lack of a standardized clinical approach have resulted in a paucity of data in regards to suitable treatment options. Inflammatory cellular infiltration and elevated levels of ocular surface cytokines in the conjunctival specimens of affected patients give credence to an underlying immunogenic etiology. Furthermore, the presence of ongoing ocular surface inflammation and progressive conjunctival fibrosis in the absence of exogenous aggravating factors suggest a possible role for systemic immunomodulatory therapy (IMT). We review in detail the proposed immunogenesis underlying chronic ocular SJS/TEN and the possible utility of systemic IMT.

The authors report in vivo morphology of opaque bubble layers with ultrahigh-resolution anterior-segment optical coherence tomography (UHR-OCT) in 3 patients. Two patients were operated on with a 30-kHz IntraLase femtosecond laser (Abbott Medical Optics, Abbott Park, IL) and one patient was operated on with a 500-kHz VisuMax femtosecond laser (Carl Zeiss Meditec, Jena, Germany). UHR-OCT images from the patient operated on with the 500-kHz femtosecond laser revealed that the opaque bubble layer extended anterior to the flap dissection plane up to Bowman’s membrane. The lamellar flap dissection was incomplete in this patient. The opaque bubble layer in the patients operated on with the 30-kHz femtosecond laser extended posterior to the flap dissection plane and these patients experienced complete lamellar dissections with uncomplicated flap lifts. UHR-OCT imaging can be used to demonstrate the structural characteristics of OBL. It has the potential to be used to predict incomplete lamellar flap dissections in patients with opaque bubble layers.

Purpose To report the first case of endophthalmitis after Descemet's stripping with automated endothelial keratoplasty caused by Mycobacterium abscessus. Methods Observational case report. Results An immunocompetent 88-year-old woman presented with endophthalmitis 2 months after a routine Descemet's stripping with automated endothelial keratoplasty resulting in decreased visual acuity and persistent vitreous opacities despite aggressive medical treatment. She underwent eventual pars plana vitrectomy with explantation of the posterior chamber intraocular lens and tube shunt. Operative cultures isolated Mycobacterium abscessus. With continued antibiotic therapy, the endophthalmitis eventually resolved with significant improvement of visual acuity. Conclusions We report a case of endophthalmitis as a complication of Descemet's stripping with automated endothelial keratoplasty. Although a rare pathogen in endophthalmitis, M. abscessus is difficult to culture and treat. Surgical hypotony combined with contamination of intraoperative materials and/or postsurgical drops are the likely mechanisms of infection.

Purpose To report a novel diagnostic technique and a case series of conjunctival and corneal intraepithelial neoplasia (CCIN) diagnosed and followed up using prototype ultra high-resolution (UHR) optical coherence tomography (OCT). Design Prospective, noncomparative, interventional case series. Participants Seven eyes of 7 consecutive patients with CCIN treated using topical interferon alfa-2b or 5-fluorouracil and 7 eyes of 6 consecutive patients with history of surgically excised pterygia. Intervention Ultra high-resolution OCT imaging of the ocular surface at primary diagnosis of CCIN and during the follow-up period until resolution of the lesion. Ultra high-resolution OCT images of sites of excised pterygia also were captured and compared with images from resolved CCIN patients. Main Outcome Measures Clinical course and photographs, UHR OCT images, and histopathologic findings. Results Ultra high-resolution OCT was capable of providing a noninvasive optical biopsy of all examined CCIN lesions. Ultra high-resolution OCT images of the lesions disclosed a thickened hyperreflective epithelium and abrupt transition from normal to hyperreflective epithelium in all 7 cases. Ultra high-resolution OCT images showed excellent correlation with histopathologic specimens obtained at primary diagnosis of the cases that had incisional biopsies before treatment. All patients were treated medically and were followed up for clinical resolution. In 4 patients, at clinical resolution, UHR OCT images also showed normal epithelial configuration at the site of the treated lesions. In 3 patients, despite apparent clinical resolution, the UHR OCT was able to detect residual disease that was clinically invisible. Continuation of treatment resulted in complete resolution of the residual lesions on the UHR OCT images in all cases. Ultra high-resolution OCT images of patients with surgically excised pterygia demonstrated similar findings to resolved CCIN cases. Conclusions Ultra high-resolution OCT is a novel noninvasive technique to diagnose and manage medically treated CCIN. Using UHR OCT to guide medical treatment could prevent the premature termination of topical treatment in the presence of subclinical disease. A larger sample size is needed for further validation of its sensitivity and specificity. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Purpose To evaluate the safety and tolerability of ranibizumab given via subconjunctival injection in patients with primary pterygium undergoing pterygium surgery with autograft placement. Design Prospective, open-label pilot study. Methods Setting: Single-center, academic practice. Study Population: Ten patients with primary pterygia. bservational Procedure: Subconjunctival ranibizumab (0.5 mg/0.05 mL) administered at the limbus, adjacent to pterygium either 3 days prior to surgery (Group 1, n=5) or at the time of surgery (Group 2, n=5). Patients prospectively followed for 6 months after injection. Main Outcome Measures: Safety and tolerability of subconjunctival ranibizumab as determined by patient reporting, clinical examination, and masked observer interpretation of slit-lamp photographs. Results The median age at presentation was 59 years (range 33 to 71 years); 60% of patients were male. Five patients were randomly assigned to be injected with 0.05 mg ranibizumab via subconjunctival injection 3 days prior to surgery; an additional 5 patients were injected with ranibizumab at the time of surgery. All 10 patients tolerated the injection well. The conjunctival autograft remained intact in the 9 patients whose grafts were secured with sutures. There was dehiscence of the autograft in the 1 patient whose graft was secured with fibrin glue. No other safety concerns arose after 6 months of follow-up. Three pterygium recurrences were noted at 6 months (all patients in Group 1). All remaining patients had a normal surgical bed appearance. Conclusions The data from this small pilot study suggest that 1 subconjunctival injection of ranibizumab in conjunction with pterygium surgery is well tolerated.