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Koji Hirano,1 Hidenori Tanaka,2 Kumiko Kato,3 Kaoru Araki-Sasaki4 1Department of Ophthalmology, Fujita Health University Bantane Hospital, Nagoya, Aichi, 454-8509, Japan; 2Department of Ophthalmology, Fujita Health University School of Medicine, Toyoake, Aichi, 470-1192, Japan; 3Department of Ophthalmology, Mie University Graduate School of Medicine, Tsu, Mie, 514-8507, Japan; 4Department of Ophthalmology, Kansai Medical University, Hirakata, Osaka, 573-1010, JapanCorrespondence: Koji HiranoDepartment of Ophthalmology, Fujita Health University Bantane Hospital, 6-10, Otoubashi 3-cho-me, Nakagawa-ku, Nagoya, Aichi, 454-8509, JapanTel +81-52-321-8171Fax +81-52-322-4734Email kojihira@fujita-hu.ac.jpPurpose: In clinical practice we sometimes encounter patients with severe corneal ulcers who have been treated with topical corticosteroids. This study reviewed the clinical features and visual outcomes of these patients and investigated the background of the prescription of topical corticosteroids.Patients and Methods: The medical records of patients who visited the Cornea Service at Fujita Health University Bantane Hospital and were treated for infectious keratitis from April 2016 to March 2020 were retrospectively reviewed. Patients treated with topical corticosteroids before a culture-proven diagnosis were studied in terms of demographics, best-corrected visual acuity at arrival and at last visit, the clinical course after visit, ocular history, and combination therapy by the previous ophthalmologist.Results: Out of the 200 eyes of 197 patients with infectious keratitis, 14 eyes of 14 patients were treated with topical corticosteroids before a culture-proven diagnosis. All 14 patients were referred, as they had severe keratitis that could not be cured with topical antibiotics and corticosteroids. Based on the culture results, we diagnosed Acanthamoeba keratitis (AK) in six patients, fungal keratitis (FK) in two patients, bacterial keratitis (including a suspected case) i

Koji Hirano,1 Hidenori Tanaka,1,2 Kumiko Kato,3 Kaoru Araki-Sasaki4 1Department of Ophthalmology, Ban Buntane Hotokukai Hospital, School of Medicine, Fujita Health University, Nagoya, Aichi 454-8509, Japan; 2Department of Ophthalmology, School of Medicine, Fujita Health University, Toyoake, Aichi 470-1192, Japan; 3Department of Ophthalmology, Mie University School of Medicine, Tsu, Mie 514-8507, Japan; 4Department of Ophthalmology, Japan Community Health Care Organization Hoshigaoka Medical Center, Hirakata, Osaka 573-8511, Japan Background: Deep anterior lamellar keratoplasty (DALK) is indicated to correct high astigmatism in patients with keratoconus (KC) and no evidence of Descemet’s membrane rupture. However, some patients with KC experience graft rejection-like inflammatory reactions within 2 months (usually in the first week) after DALK. The aim of this study was to identify the characteristics and influencing factors of these reactions by reviewing the records of patients who underwent DALK or penetrating keratoplasty (PKP) for KC or other corneal problems.Methods: We retrospectively reviewed the medical records of patients who underwent DALK for KC (DALK/KC), PKP for KC (PKP/KC), or DALK for other corneal problems (DALK/non-KC) at Ban Buntane Hotokukai Hospital between January 2006 and December 2015 and who were followed for more than 1 year. We collected data on the characteristics and incidence of severe inflammatory graft reactions in the early postoperative phase (ie, within 2 months after keratoplasty) and visual outcomes after these inflammatory reactions.Results: Postoperative inflammatory reactions characterized by persistent epithelial defects, loose suture with infiltration, and vessel invasion occurred in seven of eleven DALK/KC patients, three of 50 DALK/non-KC patients, and none of five PKP/KC patients. These reactions were nonresponsive to topical steroids, and suture removal was required. Although a clear corneal graft in the pupilla

Norihiko Tou,1 Ryohei Nejima,2 Yoshifumi Ikeda,3 Yuichi Hori,4 Kaoru Araki-Sasaki,5 Kazunori Miyata,2 Yoshitsugu Inoue,3 Akihiko Tawara1 1Department of Ophthalmology, University of Occupational and Environmental Health, Fukuoka, 2Miyata Eye Hospital, Miyazaki, 3Division of Ophthalmology and Visual Science, Faculty of Medicine, Tottori University, Tottori, 4Department of Ophthalmology, Toho University Sakura Medical Center, Chiba, 5Ideta Eye Hospital, Kumamoto, Japan Purpose: The purpose of this study was to evaluate the clinical utility of SG17, an ophthalmic antimicrobial susceptibility measurement plate.Design: This was a multicenter, retrospective, observational study.Patients and methods: Using clinical isolates from patients with ocular infections, drug susceptibility testing using the Clinical Laboratory and Standards Institute standards was routinely conducted at five facilities. The minimum inhibitory concentrations of the isolated strains were determined using SG17 at the Research Foundation for Microbial Diseases of Osaka University. The records of antimicrobial drugs used and the therapeutic course were evaluated for all cases. The susceptibility results from SG17 and routine methods used at each facility were compared.Results: A total of 112 bacterial strains were isolated from 92 patients. Of these cases, keratitis was the most common (52.2%), followed by conjunctivitis (21.7%) and others (26.1%). Principal signs and symptoms resolved in all patients, indicating that therapeutic effects had been achieved. With SG17, drug susceptibility was determined in 98.9% of isolates compared with 30.4% of isolates determined using conventional methods. By adapting the Clinical Laboratory and Standards Institute standards to SG17 results, we found that 91.3% of patients were susceptible and 7.6% were resistant. In five patients, drugs with a resistant evaluation were initially administered with no effect, and the patients were then switched to drugs with a susceptib

Kaoru Araki-Sasaki,1,2 Atsuko Fukumoto,1 Yasuhiro Osakabe,3 Hideya Kimura,1 Shinichiro Kuroda1 1Nagata Eye Clinic, Nara, Japan; 2Department of Ophthalmology, Japan Community Health Care Organization, Hoshigaoka Medical Center, Osaka, Japan; 3Department of Molecular Pathology, Tokyo Medical University, Tokyo, Japan Abstract: The purpose of this study was to describe the clinical characteristics of fungal keratitis caused by Candida albicans in an eye after Descemet stripping automated endothelial keratoplasty (DSAEK). A 72-year-old male with a history of three trabeculectomies, cataract surgery, and two DSAEK procedures developed a corneal ulcer in his right eye two years after his last DSAEK. Fungal keratitis was most likely related to the immunosuppressive conditions that occurred due to the previous operations, the continuous use of steroid eye drops, and the use of disposable soft contact lenses. A smear and culture from the ulcer detected Candida albicans. Slit-lamp examination showed the characteristic feature was the presence of interface infiltrates located between the host and the graft cornea and in the enlarged area around the ulcer. Two weeks after intense antimycotic treatments with voriconazole, miconazole, and natamycin, perforation of the cornea occurred and further therapeutic penetrating keratoplasty was required. Histological analysis revealed an accumulation of infiltrated cells and fibrotic tissue. The poor prognosis for fungal keratitis that occurs in eyes after undergoing DSAEK may be related to the rapid expansion of inflammatory cells through the interface between the host and the graft. In eyes that develop fungal keratitis after DSAEK, special attention should be paid to the possibility that perforation could occur in these patients. Keywords: DSAEK, Candida albicans, fungal keratitis, keratomycosis, post-operative infection

Kaoru Araki-Sasaki,1 Yasuhiro Osakabe,2 Hideki Fukuoka,3 Ryuichi Ideta,4 Koji Hirano5 1Department of Ophthalmology, Japan Community Health Care Organization, Hoshigaoka Medical Center, Hirakata, 2Department of Molecular Pathology, Tokyo Medical University, Tokyo, 3Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, 4Ideta Eye Hospital, Kumamoto, 5Department of Ophthalmology, Ban Buntane Hotokukai Hospital, School of Medicine, Fujita Health University, Nagoya, Japan Purpose: To describe observations by ultrahigh-resolution optical coherence tomography (OCT) in a secondary corneal amyloidosis (SCA) patient with histological analysis of excised tissue. A unique finding under OCT of her fellow eye is also described.Case: A 39-year-old female had suffered from trichiasis in both of her eyes for more than 30 years. Slit-lamp examination showed a milky-white soft mass on her left cornea and a linear opacity on the fellow cornea at the cilia-attached region. OCT demonstrated the presence of a mass region within a thin epithelial layer and no destruction of Bowman’s layer in her left cornea. In the fellow cornea, which exhibited a linear opacity, a high-density spot in Bowman’s layer was observed at the cilia-attached region covered by the epithelial layer, with normal thickness. Histological examination of the excised cornea showed that the mass was positive with both Congo red and antilactoferrin antibody.Conclusion: SCA, amyloid gradually accumulates above Bowman’s layer, occupying the epithelial layer, with no destruction of Bowman’s layer until the advanced stage. A high-density spot in Bowman’s layer might be the first stage of SCA. Keywords: OCT, secondary corneal amyloidosis, lactoferrin, cornea

Kaoru Araki-Sasaki1, Hiroko Sonoyama1, Tsutomu Kawasaki1, Nariyasu Kazama1, Hidenao Ideta1, Yoshitsugu Inoue21Ideta Eye Hospital, Kumamoto City, Kumamoto, Japan; 2Department of Ophthalmology, Tottori University, Koyama-Minami, Tottori, Japan Abstract: The paper reports on Candida albicans ocular infection modified by steroid eye drops. A 74-year-old male complained of conjunctival injection and pain in his right eye three months after pterygium and cataract surgery. After treatment with antibiotics and steroid eye drops for three days, he was referred to our hospital. Clear localized corneal endothelial plaque with injection of ciliary body was observed. No erosion of the corneal epithelium, or infiltration of stromal edema was observed, suggesting that the pathological organism derived from the intracameral region. Because ocular infection was suspected, steroid eye drops were stopped, which led immediately to typical infectious keratitis in the pathological region, with epithelial erosion, fluffy abscess, stromal infiltration, and edema. For diagnostic purposes, the plaque was surgically removed with forceps and the anterior chamber was irrigated with antibiotics. The smear and culture examination from the plaque revealed C. albicans surrounded by neutrophils. However, aqueous fluid and fibrous tissue after gonio procedure contained no mycotic organisms. Topical fluconazole, micafungin, and pimaricin with oral itraconazole (150 mg/day) were effective. Special attention is needed when prescribing steroid eye drops to treat corneal disease especially postoperatively. Diagnosing infectious keratitis is sometimes difficult because of modification by some factors, such as postoperative conditions, scarring, and drug-induced masking. Here, we report on mycotic keratitis modified by postoperative steroid administration. Keywords: Candida albicans, cataract surgery, steroid, mycotic keratitis

Hiroko Sonoyama1, Kaoru Araki-Sasaki1, Shigeyasu Kazama1, Tsutomu Kawasaki1, Hidenao Ideta1, Atsuko Sunada2, Seishi Asari2, Yoshitsugu Inoue3, Kozaburo Hayashi41Ideta Eye Hospital, Kumamoto, Kumamoto, Japan; 2Department of Laboratory for Clinical Investigation, Osaka University Hospital, Suita, Osaka, Japan; 3Division of Ophthalmology and Visual Science, Department of Medicine of Sensory and Motor Organ, Tottori University, Yonago, Tottori, Japan; 4Immunology and Virology Section Lab, Immunology, NEI, NIH, Bethesda, MD, USAAbstract: Clinical findings and treatment of keratomycosis caused by Beauveria bassiana, an entomopathogenic filamentous fungus, are described for an 80-year-old woman, who was referred to the hospital for ocular pain and redness on the 9th day after an ocular injury caused by the frame of her glasses. She had a long history of recurrent diabetic iritis and continuously used topical antibiotics and corticosteroids. At her first visit, a slit-lamp examination indicated a corneal ulcer confined within the superficial stromal layer, along with a slight infiltration and edema. Only a very few inflammatory cells were seen in the anterior chamber. Direct microscopic examination of corneal scrapings revealed septate fungal hyphae with zig-zag rachis and budding that was subsequently identified as B. bassiana by slide culture. Topical voriconazole with miconazole, pimaricin and oral itraconazole were effective and the lesion disappeared leaving only a mild scar at 2 months. The sensitivity of B. bassiana to various antimycotic agents was confirmed by broth microdilution, agar dilution with the Clinical Laboratory Standard Institute standard, and a disk method using topically applied concentrations. B. bassiana, which exhibits a characteristic appearance in smears and causes superficial keratomycosis, is sensitive to voriconazole with miconazole, pimaricin, and itraconazole.Keywords: Beauveria bassiana, keratomycosis, filamentous fungus, voriconazole, corn