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65 consecutive patients with presumed microbial keratitis and negative culture tests for bacteria and fungi obtained by corneal curettage were evaluated. All patients had undergone local broad spectrum antibiotic therapy for at least 5 days with no clinical improvement. After 48–72 h of wash-out they underwent scraping of the superior tarsal conjunctiva for cytological examination of cellular morphology in Scanning Electron Microscopy (SEM). The presence of pathogenic microorganisms was detected with this method in 62 of these patients, towards which specific therapy was carried out. Clinical improvement and eradication of microorganisms previously detected by SEM examination were observed in all positive patients over a time between 10 and 49 days. In three patients, no microorganisms were detected, but the presence of inflammatory cells (eosinophils and mast cells) or dry eye findings. This method could be useful to detect the presence of non-isolated microorganisms at common culture tests. The resolution of the infectious keratitis and the eradication of the pathogens at the subsequent cytological examination of cellular morphology in Scanning Electron Microscopy support the validity of the proposed method. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate demographic, socioeconomic, and clinical factors associated with nonadherence with initial follow-up after a diagnosis of infectious keratitis., Methods: A retrospective chart review of patients aged 18 to 60 years who were diagnosed with infectious keratitis at the Wills Eye Hospital Emergency Room from March 2019 to September 2019 was conducted. The primary outcome was nonadherence with initial follow-up recommendation and included patients who did not follow-up in the time frame requested by the diagnosing physician and those who were lost to follow-up., Results: Two hundred and seventeen patients were included with a mean age of 39.0±11.6 years, and 38.2% of patients were nonadherent. Patients who identified as non-Hispanic White were more likely to be nonadherent compared with Hispanic White patients (odds ratio [OR]=5.00, 95% confidence interval [CI]: 1.27-20.00, P =0.021). Additional variables associated with nonadherence included lower income (OR=0.92, 95% CI: 0.85-0.99, P =0.020) and government versus private insurance (OR=2.13, 95% CI: 1.09-4.15, P =0.027). Among clinical variables, patients not cultured at the initial evaluation were more likely to be nonadherent (OR=2.54, 95% CI: 1.36-4.77, P =0.004)., Conclusions: Race, income, insurance, and corneal culturing had associations with follow-up nonadherence. Identifying barriers to follow-up for infectious keratitis may have important implications in preventing vision loss and other complications., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Contact Lens Association of Ophthalmologists.)

Objective: The objective of this study is to assess the therapeutic efficacy of low-temperature plasma ablation (LTP) combined with drug treatment in the treatment of fungal keratitis (FK) caused by various pathogens, thereby establishing a clinical foundation for the use of LTP in treating FK., Methods: A retrospective study was performed, including 76 patients (76 eyes) with FK diagnosed at the Affiliated Eye Hospital of Nanchang University. The patients were categorized into the Fusarium group, Alternaria group, Aspergillus group, and other genus groups based on positive results from biological cultures. Key clinical parameters, including best-corrected visual acuity (BCVA), maximum ulcer lesion diameter, and healing grades, were assessed and compared at baseline (pre-treatment), on postoperative day 3, and at postoperative week 3., Results: The study demonstrated that the BCVA (LogMAR) of all patients revealed no significant differences at postoperative day 3 (F = 2.54, p = 0.063) and week 3 (F = 1.86, p = 0.143). Although BCVA improved to varying degrees compared to preoperative levels, the changes were not statistically significant (p > 0.05). After treatment with LTP combined with pharmacotherapy across all four groups, an average of 53 patients (69.74%) achieved grade I healing, with the group effect being nonsignificant (F = 2.85, p = 0.071), while the effect of time post-treatment was significant (F = 67.85, p < 0.001). Additionally, the corneal scar diameter at postoperative week 3 was significantly smaller compared to the preoperative lesion diameter (p < 0.05). Multiple comparisons revealed significant differences in scar diameter among patients with grade I healing at postoperative week 3 (F = 3.48, p = 0.023), with notable differences observed between the Alternaria and Fusarium groups (p = 0.017). The average rate of grade III healing, defined by the occurrence of corneal perforation and/or the need for therapeutic penetrating keratoplasty, was 7.89%., Conclusion: Low-temperature plasma ablation demonstrates effective therapeutic outcomes for FK caused by various pathogens that are unresponsive to pharmacological treatments, with no significant complications., Competing Interests: Declarations. Conflict of interest: The authors declare no competing interests. Ethics approval and consent to participate: This study was conducted with approval from the Ethics Committee of The Affiliated Eye Hospital, Jiangxi Medical College, Nanchang University (No.YLP201810003). This study was conducted in accordance with the declaration of Helsinki. Written informed consent was obtained from all participants. Informed consent for publication: All participants signed a document of informed consent., (© 2025. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: To assess the spectrum of organisms causing microbial keratitis and their in-vitro anti-microbial sensitivities out of 2 hospitals in the East Midlands Region of the United Kingdom., Methods: A retrospective review was undertaken of all patients who underwent corneal scrapes for infectious keratitis between 2011 and 2021 at Royal Derby Hospital (RDH) in Derby and between 2009 and 2021 at King's Mill Hospital in Mansfield., Results: In total, the results of 645 corneal scrapes (from 622 patients) were analysed after exclusions. Of these, 307 (47.6%) yielded positive cultures. The mean patient age was 52.6 ± 22.1 years (Mean ± St Dev) across both sites and 332 (51.4%) were from female patients. At RDH, there were 195 positive corneal scrape cultures, from which 250 species of organisms were isolated. At RDH, 64% (160/250) were Gram-positive bacteria, 32% (81/250) were Gram-negative bacteria, 2.4% (6/250) were Acanthamoeba species and 1.2% were fungi (3/250). At KMH, there were 112 positive cultures, from which 128 species of organisms were isolated. 14 corneal scrapes from KMH were polymicrobial. At KMH, 96% (123/128) were bacterial (51% Gram positive, 45% Gram negative), 3/128 (2.3%) were fungi and 2/128 (1.6%) were Acanthamoeba. Sensitivity testing confirmed that the fluoroquinolone class of antibiotics appeared to be effective against the majority isolates across the two hospital sites., Conclusion: There are differences in microbiological profiles between these neighbouring hospitals covering neighbouring populations. Despite these differences, reassuringly, the current first-line fluoroquinolone monotherapy treatment is an appropriate first-line treatment for both hospital sites., Competing Interests: Declarations. Conflict of interest: The authors declare no competing interests., (© 2025. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Fungal keratitis can develop after plant injury or after prolonged glucocorticoid use. Typical manifestations include corneal infiltrates, satellite lesions, plaques, and an immune ring. Some cases exhibit atypical signs, requiring reliance on etiological examination. Notably, fungi previously deemed nonpathogenic to humans can cause keratitis with rare clinical manifestations. This report details the clinical signs and successful treatment outcomes of keratitis caused by Phaeoisaria sp., Case Presentation: A 51-year-old man visited the ophthalmology clinic with ongoing eye pain and a history of corneal iron foreign body removal two months earlier. Examination revealed a brownish ulcer with clear borders, swelling, and redness, indicating the presence of rust. Although the initial cultures were negative, a rare fungus called Phaeoisaria sp. was eventually identified as causative agent. The patient completed six weeks of antifungal treatment and showed no signs of recurrence at the 7-month follow-up visit., Conclusions: Patients with a history of corneal foreign bodies should also be informed of the possibility of atypical corneal fungal infection., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Written informed consent was obtained from the patient for publication of this case report. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Corneal ulcer is one of the most important ophthalmic emergencies. A portable, recordable, and smartphone-attachable slit-lamp device called the "Smart Eye Camera" (SEC) is introduced to compare evaluating corneal ulcers between the SEC and the conventional slit-lamp. A total of 110 participants were included in the study, consisting of 55 patients with corneal ulcers and 55 age- and gender-matched healthy volunteers as controls. The participants were first subjected to examination by a conventional slit lamp. The video recording with SEC and imaging with a slit lamp were done by a non-medical person. Both SEC videos and slit-lamp photos were reported by two independent ophthalmologists and compared with a slit-lamp examination as a gold standard. The average age of the study participants was 48.85 ± 20.45 years and 68 participants (61.8%) were male. All corneal ulcers were detected by two ophthalmologists using SEC. Ulcer size evaluated in slit lamp and SEC horizontally (Intraclass Correlation Coefficient (ICC); 0.90, 95% CI; 0.84-0.94) and vertically (ICC; 0.90, 95% CI; 0.84-0.94) is correlated about 90%. Hypopyon size (ICC; 0.95, 95% CI; 0.92-0.97), and corneal epithelial defect (CED) size horizontally (ICC; 0.94, 95% CI; 0.91-0.96) and vertically (ICC; 0.94, 95% CI; 0.91-0.96) also correlated about 94%. The infiltration pattern evaluated by SEC was consistent with the pattern evaluated in slit lamps in more than 80% of patients. The SEC is so accurate in diagnosing corneal ulcers and its reliability makes it a valuable telemedicine device., Competing Interests: Declarations. Competing interests: The authors declare no competing interests. Ethics approval and consent to participate: The local ethics committee of the Tehran University of Medical Sciences, in accordance with Helsinki’s Ethical Principles, endorsed this study (IR.TUMS.FARABIH.REC.1403.002). Consent for publication: Patients have given written informed consent to publish their data, without identifying them., (© 2025. The Author(s).)

Purpose: To investigate the incidence of microbial keratitis among Japanese patients wearing orthokeratology (ortho-k) lenses STUDY DESIGN: Retrospective multicenter study METHOD: This study was conducted at 4 hospitals in Japan and involved 1438 patients who had been prescribed ortho-k lenses and had worn them for at least 3 months. Data on patient demographics, lens characteristics, lens care systems, and presence of microbial keratitis were extracted from the medical records. Duration of ortho-k lens wear was calculated from the original fitting date to the patient's last visit, with the total years of lens wear used as person-years of lens wear. The incidence of microbial keratitis was calculated by dividing the number of infected cases by the total person-years of lens wear for all enrolled participants., Results: Among the 1438 patients, 753 were male and 685 were female, with a mean age of 12.7 ± 5.4 years. The mean duration of ortho-k lens wear was 5.2 ± 4.5 years, and the mean lens power was -3.52 ± 1.41 D. The total person-years of lens wear for all enrolled patients was 7415. Four cases of microbial keratitis were identified, resulting in an overall incidence of microbial keratitis of 5.4 (95% CI: 1.0-9.8) per 10,000 patient-years among ortho-k lens wearers., Conclusion: This study represents the largest sample size to date for estimating the incidence of microbial keratitis associated with ortho-k lenses. The incidence was similar to or slightly lower than that of previous studies on ortho-k-related microbial keratitis and also comparable to that of daily wear soft contact lenses., Competing Interests: Declarations. Conflict of interest: T. Hiraoka, Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events (Topcon, SEED, Menicon, Johnson & Johnson, Alpha corporation, Alcon, Santen, Senju); S. Matsumura, Consulting fees (Cooper Vision), Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events (Menicon, Cooper Vision, Santen, Welch Allyn, Nikon, Senju, Ophtecs); Y. Hori, Grants or contracts to the author’s institution (Alcon, Novoxel), Consulting fees (Cooper Vision), Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events (Santen, Senju, Johnson & Johnson, Menicon, Ophtecs, Alcon, Lumenis, HOYA); K. Kamiya, Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events (Alcon, Johnson & Johnson, STAAR Surgical, HOYA, ZEISS, Santen, Senju, Otsuka, Kowa, Nikon, SEED, Cooper Vision); K. Miyata, None; T. Oshika, Consulting fees (Santen, Alcon, HOYA, Johnson & Johnson), Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events (Topcon, HOYA, TOMEY, Johnson & Johnson, Novartis, Alcon, Santen, Senju)., (© 2024. Japanese Ophthalmological Society.)

Purpose: To compare the prognosis and efficacy of acellular porcine corneal stroma (APCS) with different thicknesses for the treatment of fungal corneal ulcers by lamellar keratoplasty (LKP)., Methods: A total of 52 patients who underwent LKP with APCS for the treatment of fungal corneal ulcers were included in this retrospective study. Patients were divided into 2 groups according to the different thicknesses of APCS (0.30 ± 0.05 mm, L2 group, n = 20; 0.40 ± 0.05 mm, L3 group, n = 32). Observation indicators included best corrected visual acuity, graft transparency, corneal neovascularization, ocular irritation symptoms, corneal epithelial healing time, graft survival, central corneal thickness at 1 year after surgery, and postoperative complications., Results: Compared with the L3 group, the L2 group had better postoperative best corrected visual acuity and graft transparency ( P < 0.001), less corneal neovascularization ( P < 0.001), and lower incidence of complications ( P < 0.05). There were significant differences in ocular irritation symptoms between the 2 groups ( P < 0.05) at 3 and 6 months postoperatively, which might be related to the higher recurrence rate and graft rejection rate in the L3 group. The comparison of postoperative epithelial healing time also showed significant differences in 2 groups ( P < 0.01). The 1-year survival rate was up to 63.5% in both groups, with no significant difference ( P < 0.05). However, the risk of transplantation was less in the L2 group. Both APCS thicknesses could provide adequate central corneal thickness at 1 year after surgery ( P > 0.05)., Conclusions: APCS was safe and effective in the treatment of fungal corneal ulcers by LKP. Thinner grafts should be preferred for LKP for fungal corneal ulcers to reduce the risk of grafting., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

This case report discusses a case of granulomatosis with polyangiitis (GPA) initially presenting with lacrimal gland involvement and subsequently developing additional features. GPA is a disease known for inflammation in the respiratory tract and kidneys. A 63-year-old male patient presented with a mass, swelling, and ptosis in the right upper eyelid. The patient was referred to us when his symptoms had persisted and worsened despite topical and oral antibiotic therapy administered at another center. Based on clinical and laboratory findings from evaluation and consultations, GPA was diagnosed and confirmed by biopsy. The patient initially presented with necrotizing scleritis and later developed peripheral ulcerative keratitis and anterior uveitis, which regressed under cyclophosphamide treatment but progressed to exudative retinal detachment due to orbital involvement. Clinical remission was achieved after adding rituximab therapy. Presentation with lacrimal gland involvement may serve as an initial manifestation of locally aggressive orbital and adnexal GPA, which can exhibit variable clinical features. Rapid diagnosis and aggressive treatment are critical for preserving vision and preventing complications in patients with GPA., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors., (©Copyright 2024 by the Turkish Ophthalmological Association / Turkish Journal of Ophthalmology published by Galenos Publishing House.)

Aim: To validate the diagnostic performance of a custom 96-micro-organism TaqMan PCR card (iCAM) for microbial keratitis (MK) from a single corneal epithelial sample., Methods: Patients over the age of 18 referred to Cambridge University Hospital with MK were recruited in this single-site prospective cohort study between September 2021 and January 2023. An ocular-specific, customised microarray card (iCAM) was constructed according to primer and probe nucleotide sequences developed in our department to detect bacteria, viruses, Acanthamoeba and fungi commonly implicated in MK using a single corneal epithelial sample. Part of the corneal epithelial sample was taken for conventional cultures per local protocol, followed by iCAM array. Microbial detection rate and positive predictive value (PPV) were evaluated., Results: 38 corneal epithelial samples from 32 patients with MK and 4 control samples from healthy participants were obtained from 36 consecutive patients. A causative microbe was isolated in 15/34 samples (44%) using the iCAM test, compared with 15 by conventional methods (44%). iCAM test processing time varied between 6 and 24 hours compared with up to 7 days for conventional tests. Combined, the microbial detection rate was 65%, with the correlation between methods at 62%. The iCAM test could detect all major micro-organism groups with 56% sensitivity and 60% PPV., Conclusions: The iCAM test can detect bacterial, fungal, viral and protozoan organisms using one corneal epithelial sample. The limitations include small patient cohort size and reduced volume of available corneal epithelial sample when shared between the iCAM PCR test and conventional culture methods utilised in the study. A multicentre trial is being planned to validate the clinical impact of using iCAM test on accuracy of diagnosis, early institution of appropriate antimicrobials and clinical outcomes., Trial Registration Number: ISRCTN17422545., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To provide a comprehensive overview of predisposing factors and clinical-microbiological profile of neonatal corneal ulcer., Methods: The literature search was undertaken in PubMed, SCOPUS, Embase, Web of Science, and Google Scholar databases on published papers from inception to May 31, 2023. The included articles were independently assessed for methodological quality using a Joanna Briggs Institute checklist. Weighted analysis was utilized, assigning a weight of one to each case report and a weight equivalent to the sample size for the case series/original studies., Result: We included 34 relevant case reports/series and one original study. Seventy-four neonates were enrolled with a boy-to-girl ratio of 1.3:1 and a median age of 17 days (1-27 days). Prematurity and neonatal intensive care unit (NICU) care (21.6%), congenital horizontal tarsal kink (13.5%), neonatal herpes infection (13.5%), congenital entropion (5.4%), and jaundice (5.4%) were the most common potential risk factors and coexisting conditions. Microbiology evaluation showed positive results in 53.8% (21/39 cases). Viral and bacterial infections were the most common cause, followed by fungal infections. Herpes virus (18.9%), Pseudomonas aeruginosa (18.9%%) and Staphylococcus epidermidis (6.7%) were the most prevalent causative agents. Negative microbiology was significantly more common in neonates with structural abnormalities (14.9%) compared to others (6.8%) ( p  = 0.01)., Conclusion: Based on the findings of reported studies, this systematic review has increased awareness of the risk factors and etiologies that lead to developing corneal ulcers in neonates.

Purpose: To characterize the ocular inflammatory manifestations of inflammatory bowel disease (IBD) and examine the impact of ocular inflammation on IBD treatment., Methods: A single-center retrospective chart review of patients with an IBD diagnosis and ophthalmology visit between January 2016 and January 2022 was conducted. Patients with a diagnosis of uveitis, scleritis, or peripheral ulcerative keratitis (PUK) confirmed by an optometrist or ophthalmologist were included., Results: Charts of 1320 IBD patients were reviewed; 42 patients with uveitis, 2 patients with scleritis, and 2 patients with PUK were identified. Anterior uveitis was the most common form of uveitis (38/42, 90.5%), often in an episodic (31/38, 81.6%) and unilateral (19/38, 50.0%) pattern. Four patients (4/42, 9.5%) had posterior segment uveitis: two with panuveitis, one with intermediate uveitis, and one with posterior uveitis. Patients on systemic therapy for IBD did not routinely undergo changes to therapy following the development of ocular inflammation (27/36, 75.0%). Therapy alterations were more frequent with the development of posterior segment uveitis, scleritis, or PUK (4/6, 66.7%) compared with anterior uveitis (5/30, 16.7%). In 10 patients, uveitis onset preceded IBD diagnosis; in these patients, tumor necrosis factor (TNF) inhibitors were often used at the time of subsequent IBD diagnosis (5/10, 50.0%)., Conclusions: Unilateral anterior uveitis was the most common form of ocular inflammation among patients with IBD. Development of uveitis did not routinely require modification of immunomodulatory therapies; however, therapy changes were more common with posterior segment uveitis, scleritis, and PUK.

Purpose: To assess the demographic characteristics, ophthalmic and systemic presentations, and risk factors impacting the outcomes in patients diagnosed with peripheral ulcerative keratitis (PUK)., Methods: This retrospective study includes patients diagnosed with PUK at a tertiary care center over 13 years. A descriptive analysis of the demographics, clinical history, and presentation was performed. A reverse risk analysis was performed to assess the PUK resolution in patients with underlying autoimmune and non-autoimmune etiologies. Finally, we evaluated the correlation between treatment duration and final best corrected visual acuity (BCVA) and continuous and categorical variables., Results: A total of 58 eyes of 51 patients with a mean age of 59.67 ± 13.41 years diagnosed with PUK were included in the study; 58.82% were female. The resolution duration was significantly shorter in patients with autoimmune etiologies (vs. non-autoimmune etiologies, P = 0.028) and female patients (vs. male patients, P = 0.008). The BCVA worsened in patients with non-autoimmune etiologies after treatment ( P = 0.17). Despite worse BCVA at presentation in patients with underlying autoimmune etiologies, significantly better final vision outcomes were observed ( P = 0.04). Linear regression analysis showed that longer treatment duration ( P = 0.001; R 2 = 0.1704) and worse vision ( P = 0.002; R 2 = 0.1502) at presentation were the primary risk factors of poor vision outcomes. Similarly, the treatment duration was significantly longer in male compared with female patients ( P < 0.001; R 2 = 0.2027)., Conclusions: The clinical outcomes in PUK with underlying autoimmune disorders were observed to be better than non-autoimmune etiologies, which may be attributed to the early detection of the PUK-related changes and aggressive medical management. A delayed diagnosis of PUK leads to poor vision outcomes., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To report a rare case of fungal keratitis caused by Cryptococcus neoformans , highlighting its unique morphological features using in vivo confocal microscopy (IVCM)., Methods: This was a retrospective case report. A 66-year-old man presented with foreign body sensation and blurred vision in his left eye for over 10 months., Results: His best-corrected visual acuity was 20/20. Slit-lamp examination revealed a gray-white lesion approximately 4-5 mm in the superficial layer of the central cornea without epithelial defects. The IVCM images revealed numerous round or round-like pathogens, each with a central highly reflective body surrounded by a dark ring, ranging in size from 5 to 30 µm, and to a maximum of 85 µm, observed in the corneal epithelium and superficial stroma. No obvious inflammatory cell infiltration was observed in the lesions or endothelium. C. neoformans infection was confirmed. The round pathogens completely disappeared after 8 weeks of treatment with topical amphotericin B and voriconazole eye drops., Conclusion: Fungal keratitis caused by C. neoformans is rare and easily overlooked due to atypical clinical signs and symptoms. This case reports the unique morphological features of C. neoformans in the cornea using IVCM for the first time, facilitating rapid, noninvasive auxiliary diagnosis of C. neoformans keratitis and treatment follow-up.

A 23-year-old woman was referred for low visual acuity in the left eye after a corneal ulcer associated with contact lens use 2 years previously. The patient had a history of contact lens use, reported use of antibiotic eye drops with improvement of infection, and subsequent scarring. There were no comorbidities. The manifest refraction was -3.25 -2.25 × 180 (20/20) in the right eye and was -2.00 esf -2.00 × 165 (20/80) in the left eye. The patient demands a solution in a reasonable time because of the need for functional vision and possible restoration of her binocular functions. The slitlamp examination revealed a corneal scar partially affecting the visual axis (Figure 1JOURNAL/jcrs/04.03/02158034-202412000-00016/figure1/v/2024-12-12T192825Z/r/image-tiff). Corneal topography revealed an irregular pattern and spectral-domain optical coherence tomography (OCT) examinations revealed scarring in the anterior stroma (Figures 2 and 3JOURNAL/jcrs/04.03/02158034-202412000-00016/figure2/v/2024-12-12T192825Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202412000-00016/figure3/v/2024-12-12T192825Z/r/image-tiff). Given the patient's refraction, corneal scar, and visual demands, would you perform photorefractive keratectomy (PRK) treatment to correct ametropia and partially remove the anterior stroma? Would you perform excimer laser treatment for therapeutic purposes guided by topography? Would you opt for a 2-stage treatment, regularizing the cornea with neutral phototherapeutic keratectomy (PTK) or PRK treatment guided by topography and then correcting the ametropia? Considering the OTC maps, would you perform a femtosecond laser-assisted anterior lamellar keratoplasty (FALK), deep anterior lamellar keratoplasty (DALK), or even penetrating keratoplasty? Would you consider any other surgical step to prevent delayed cornea healing-persistent epithelial defect?, (Copyright © 2024 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To report an unusual case of bilateral aggressive Mooren ulcer that occurred in the setting of bilateral pterygia and showed a relentless course during pregnancy., Methods: A 39-year-old woman of Black African ethnicity, 36-week pregnant, presented to the eye casualty with bilateral nasal corneal ulcer and associated melt around preexisting pterygia. A detailed workup including microbial evaluation, culture and sensitivity, polymerase chain reaction for herpes simplex virus, varicella zoster virus, and cytomegalovirus, inflammatory blood profile, autoimmune markers, and human leucocyte antigen (HLA) screening was undertaken. Treatment was initiated in a stepwise approach., Results: Infections and systemic autoimmune and rheumatologic conditions were ruled out. A diagnosis of bilateral Mooren ulcer was made by exclusion. The peripheral blood was positive for HLA DQ2. As the condition seemed refractory to medical management (topical steroids and intravenous pulse methylprednisolone followed by oral prednisolone and topical cyclosporine), urgent bilateral conjunctival resection with multilayered amniotic membrane transplantation was performed to reduce the inflammatory stimulus and keratolysis. Stabilization of the condition warranted the need for systemic immunosuppressive agents. Using a multidisciplinary approach, in liaison with Obstetricians and Rheumatologists, the patient was planned for an earlier elective Cesarean section and commencement of oral mycophenolate mofetil postpartum, which aided in successful control of the disease., Conclusions: Mooren ulcer could follow an aggressive course during pregnancy, especially in the setting of preexisting pterygium. The complex hormonal and immunological changes during pregnancy and the delivery of inflammatory mediators directly onto the cornea by pterygium could contribute to the severity. A well-planned, stepwise, and multidisciplinary management is pivotal for the treatment of this condition., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Although monkeypox-related ophthalmic disease (MPXROD) is rare, visual impairing complications have been reported. At present, tecovirimat is the standard-of-care antiviral treatment. In this MPXROD case, the effect of tecovirimat was assessed with PCR analysis of tear samples and concurrent monitoring of inflammation with laser flare photometry (LFP)., Case Description: The patient presented with a palpebral lesion and a corneal ulcer in his right eye, with complete absence of the corneal epithelium, high intraocular pressure and anterior uveitis. MPXV-DNA was detected in tear samples with real-time PCR (RT-PCR). A total volume of 0.5 ml tear-wash was aspirated from the inferior fornix, following instillation of saline onto the ocular surface. In addition, LFP was used to quantify inflammation in both eyes. Viral load in tear samples was detected prior to treatment initiation. In the left eye, tear samples tested negative for MPXV-DNA one week post-treatment while MPXV-DNA was still detected in the right eye, before reaching undetectable levels four weeks post-treatment. Objective quantification of anterior chamber inflammation through LFP demonstrated gradual decrease that was more pronounced in the affected right eye and coincided with the clinical improvement of the corneal ulcer., Conclusions: This case of Mpox related corneal ulcer with associated uveitis manifests the feasibility of monitoring the antiviral effect of tecovirimat with virus detection in tear samples and LFP. Our observations indicate that tecovirimat resulted in viral load reduction in both eyes. RT-PCR MPXV detection in tear samples and LFP represent noninvasive tools that could assist with treatment response monitoring., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To elucidate a distinctive clinical feature in cases of microsporidial stromal keratitis (MSK)., Method: A retrospective observational study of cases with a histopathological and/or microbiological diagnosis of MSK on corneal biopsy or host corneal button between 2016 and 2022 was conducted., Results: Eighteen cases with a confirmed histopathological and/or microbiological diagnosis of MSK were detected. Careful review of slit-lamp photographs revealed the presence of pigmented keratic precipitates (KPs) beyond the area of stromal keratitis in five out of eighteen cases (27.7%)., Conclusion: The presence of pigmented KPs beyond the area of lesion can alert the clinician to keep microsporidia as a differential cause for stromal keratitis. Management can be tailored accordingly for a better outcome.

We describe the hybrid technique of tuck-in Tenon's patch graft (TPG) and tissue adhesive bandaged contact lens (TABCL) for large corneal perforations (>5 mm) with intact surrounding stroma. Management of large corneal perforation is often challenging, and urgent availability of donor cornea might be difficult; Tenon patch alone does not provide tectonic support; hence, this hybrid technique can be used safely in large perforations. This involves freshening the perforation edges, creating a 360 0 stromal pocket, harvesting a Tenon's graft 1 mm oversized, tucking into the pocket, and suturing. Then areas of leakage were noted, and only those areas were supplemented with minimal cyanoacrylate glue (CG) at the graft edges. This technique was used in two eyes, one with a large corneal perforation and intact surrounding stroma and the other with 4 mm corneal fistula post healed keratitis with a failed primary TPG alone, and led to epithelialization and a smooth corneal surface at 6 weeks. The advantages include autologous tissue, cost-effective, easily available, minimal post-operative inflammation, vascularization, and surface irregularity., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Purpose: To report the hastened recovery of two nonresponding fungal corneal ulcer cases after using intrastromal injections of autologous buffy coat (a component of blood rich in leucocytes) as an adjuvant to topical antifungal therapy., Methods: Microbiologically proven non-responding cases (>2 weeks of treatment) of fungal corneal ulcers who visited the cornea specialty clinic of our hospital were explained the disease and adjuvant intrastromal autologous buffy coat treatment, which would be repeated if effective. Then, well-informed and written consent was obtained from the patients for the treatment. The study adhered to the tenets of the Declaration of Helsinki. An in vitro experiment was also carried out to prove the hypothesis by growing fungi on a donor button and injecting it with the buffy coat of a healthy volunteer., Results: The study showed immediate positive outcomes, with patients showing faster lesion resolution with decreasing lesion size, resolving hypopyon, and complete clinical recovery in both cases in less than seven days., Discussion: Intrastromal autologous buffy coat shows promise as an adjunct therapy for difficult fungal corneal ulcers, enhancing local immunity and healing. This approach may reduce treatment time and risks, though further studies are needed to confirm these findings., Conclusion: Intrastromal buffy coat for recalcitrant fungal ulcers is a promising treatment modality as it provides both local immunity and growth and repair stimulus to the diseased cornea. However, a long-term randomized control trial is needed to evaluate the results further., Competing Interests: The authors state no conflict of interest., (© 2024 The Authors.)

Purpose: To investigate the clinical features and visual outcome of infectious keratitis associated with orthokeratology (Ortho-K) lens in Korean pediatric patients., Methods: We retrospectively reviewed medical records of patients diagnosed with Ortho-K lens-related infectious keratitis from June 2005 to April 2020 at a tertiary referral hospital. Patients' demographics, clinical features, microbiological evaluation, and treatment methods were assessed, and factors related to final visual outcomes were analyzed., Results: The study included 26 eyes from 26 patients (19 female and 7 male patients; mean age, 11.9 years), with an average Ortho-K lens wear duration of 33.7 ± 21.2 months. The highest number of cases occurred in summer (11 of 26 cases, 42.3%). Central or paracentral corneal lesions were observed in 25 cases (96.2%), with a mean corneal epithelial defect size of 5.13 mm2. Pseudomonas aeruginosa was the most commonly isolated organism (n = 5), followed by Serratia marcescens (n = 4). All patients responded to medical treatment without needing surgical intervention. 72% of cases achieved favorable visual outcomes (Snellen best-corrected visual acuity [BCVA] >6 / 12), while 8% experienced severe visual impairment (Snellen BCVA ≤6 / 60) due to residual central corneal opacities. Multivariable analysis showed that non-summer seasons (p = 0.043), duration from symptom onset to presentation (p = 0.040), and corneal epithelial defect size (p = 0.002) were significantly associated with final logarithm of the minimum angle of resolution BCVA. Failed autorefraction at presentation due to an Ortho-K-related infectious keratitis lesion was a significant predictor of poor final visual outcome (Snellen BCVA ≤6 / 12; odds ratio, 38.995; p = 0.030)., Conclusions: Ortho-K lens-related infectious keratitis can lead to permanent corneal opacities and potentially devastating visual outcomes in children. Delayed time to presentation, large corneal lesions, failure of autorefraction, and non-summer seasons were associated with poorer outcomes. Proper education and early detection would be key to safe use of orthokeratology lenses in pediatric patients.

Purpose: The aim of this study was to evaluate the role of anterior segment optical coherence tomography during follow-up of infectious keratitis and to assess response to treatment., Methods: This was a prospective, consecutive, observational clinical series of cases. Twenty-three eyes of 23 patients with clinically proven fungal keratitis were included in the study. The patients received medical treatment according to clinical diagnosis, and follow-up was performed weekly. Slit-lamp examination and photography, and anterior segment optical coherence tomography were performed at initial and follow-up visits until corneal healing occurred. The main outcome measures included infiltrate depth, width, and density; central corneal thickness; minimal corneal thickness; corneal thickness at the site of the lesion; and stromal thickness at the center of the lesion., Results: Twenty-three eyes of 23 patients (17 men and 6 women), mean age 42.5 ± 19 (8-66) years, were clinically diagnosed with fungal keratitis. Localization was central in 14 cases and paracentral/peripheral in 9 cases. Healing time was 6 to 12 weeks. Minimal corneal thickness, corneal thickness at the site of lesion, and stromal thickness at the center of lesion, and also infiltrate width and depth changed significantly from the first visit to the healing stage at the last follow-up (0.009, 0.001, 0.007, 0.001, and <0.001, respectively)., Conclusions: In cases of fungal keratitis, anterior segment optical coherence tomography can provide the clinician with a quantitative assessment of a number of corneal parameters that can be used to determine effectiveness of therapy and confirm complete healing of the lesions that cannot be achieved by clinical evaluation., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To evaluate characteristics, etiologies, and outcomes of peripheral ulcerative keratitis (PUK) in Thailand., Methods: Retrospective study., Results: Forty-three eyes from 34 patients were enrolled, with a mean age of 53.44 ± 15.48 years. PUK affected women more than men (1.6:1) and resulted in unilateral lesions more frequently than bilateral lesions (2.8:1). Redness (56.3%) was the most common presenting symptom followed by pain (43.8%) and irritation (40.6%). The three most common etiologies were Mooren's ulcer (52.9%), rheumatoid arthritis (20.6%), and Graves' disease (8.8%). Corneal thinning was significantly more common in unilaterality ( p  = 0.004) and less common when the lesion was located in the superior cornea ( p  = 0.031). Surgery was also more frequently performed in case of unilateral PUK ( p  = 0.026). Perforation was observed in 5 eyes (11.6%) and recurrence after treatment was identified in 8 eyes (18.6%)., Conclusion: Nearly half of PUK cases are associated with several systemic causes. Accordingly, careful physical examination and investigation are important. Unilateral lesions could serve as potential risk factors in identifying patients at risk of thinning and perforation, which could prevent further damage to the eye and vision loss.

Objective: To describe a patient diagnosed with Exophiala jeanselmei keratitis., Methods: We report a case of a patient who developed infectious keratitis following laser in situ keratomileusis and chronic topical steroid use for approximately six months in both eyes. An atypical infiltrate containing dark pigmentation was noted in the left eye on the initial presentation. During treatment, the infiltrates of the right eye began to exhibit a similar pigmentation., Results: Early treatment with topical antifungals was initiated in the left eye and later in the right eye once culture results returned. Both eyes recovered with good vision after approximately one month., Conclusions: Patients treated with postoperative topical corticosteroids should be cautioned of potential adverse effects of chronic use and have close follow-up. If infectious keratitis develops, particularly after two weeks, then atypical organisms, such as fungi, should be considered. In addition, our case highlights the significance of recognizing and associating dark-pigmentation with fungal etiologies., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Contact Lens Association of Ophthalmologists.)

Purpose: To report on the outcomes of amniotic membrane transplantation (AMT) for corneal ulceration following infectious keratitis., Method: In this retrospective cohort study of 654 patients with culture-proven infectious keratitis from 8 hospitals in Galicia (Spain), a total of 43 eyes of 43 patients (6.6%) underwent AMT for postinfectious corneal ulceration. The indications for AMT were sterile persistent epithelial defects, severe corneal thinning or perforation., Results: AMT was successful in 62.8% of cases, with 37.2% requiring an additional surgery. Median time to healing was 40.0 days (IQR 24.2-101.7 days) and final BCVA was lower than baseline ( p  = 0.001). Ulcers were large (>3 mm) in 55.8% of cases. Previous herpetic keratitis and topical steroid use were more common in patients who received AMT ( p  < 0.001). 49 microorganisms (43 bacteria and 6 fungi) were isolated., Conclusions: AMT is a therapeutic option for complications following infectious keratitis, which present with a sterile persistent epithelial defect, significant corneal thinning or perforation.

Background/aims: To determine the clinical features, predisposing factors, and management of infectious keratitis caused by Candida spp., Methods: Retrospective chart review., Results: The medical records of 52 patients (54 eyes) with Candida keratitis were available for statistical analysis. Thinning of the corneal stroma was identified in 34 eyes (63.0%), and corneal perforation occurred in 16 eyes (29.6%). Corneal thinning and perforation were more common in Candida albicans compared with non-albicans ( P-val  < .001, P  = .09, respectively). The most common predisposing factors for Candida keratitis were topical steroid use (21 patients, 40.4%), previous corneal transplantation (17 patients, 32.7%), and preexisting ocular surface disease (15 patients, 28.8%). Fourteen eyes (25.9%) required cyanoacrylate glue application and 10 eyes (18.5%) underwent therapeutic penetrating keratoplasty (TPK)., Conclusion: Local immunosuppression and ocular surface disease play an important role in Candida keratitis. C. albicans appears to be more invasive compared with non-albicans spp.

Purpose: An increase in fungal and particularly filamentous keratitis has been observed in many geographic areas, mostly in contact lens wearers. This study seeks to characterize long-term trends in fungal keratitis in a continental climate area to provide guidance for diagnosis and treatment., Design: Retrospective multicentric case series., Methods: Cases of microbiology-confirmed fungal keratitis from 2003 to 2022 presenting to tertiary care centers across Canada were included. Charts were reviewed for patient demographics, risk factors, visual acuity, and treatments undertaken., Results: A total of 138 patients were identified: 75 had yeast keratitis while 63 had filamentous keratitis. Patients with yeast keratitis had more ocular surface disease (79% vs 28%) while patients with filamentous keratitis wore more refractive contact lenses (78% vs 19%). Candida species accounted for 96% of all yeast identified, while Aspergillus (32%) and Fusarium (26%) were the most common filamentous fungi species. The mean duration of treatment was 81 ± 96 days. Patients with yeast keratitis did not have significantly improved visual acuity with medical treatment (1.8 ± 1 LogMAR to 1.9 ± 1.5 LogMAR, P = .9980), in contrast to patients with filamentous keratitis (1.4 ± 1.2 LogMAR to 1.1 ± 1.3 LogMAR, P = .0093)., Conclusions: Fungal keratitis is increasing in incidence, with contact lenses emerging as one of the leading risk factors. Significant differences in the risk factors and visual outcomes exist between yeast keratitis and filamentous keratitis which may guide diagnosis and treatment., (Crown Copyright © 2024. Published by Elsevier Inc. All rights reserved.)

Purpose: Artificial intelligence (AI)-tools hold great potential to compensate for missing resources in health-care systems but often fail to be implemented in clinical routine. Intriguingly, no-code and low-code technologies allow clinicians to develop Artificial intelligence (AI)-tools without requiring in-depth programming knowledge. Clinician-driven projects allow to adequately identify and address real clinical needs and, therefore, hold superior potential for clinical implementation. In this light, this study aimed for the clinician-driven development of a tool capable of measuring corneal lesions relative to total corneal surface area and eliminating inaccuracies in two-dimensional measurements by three-dimensional fitting of the corneal surface., Methods: Standard slit-lamp photographs using a blue-light filter after fluorescein instillation taken during clinical routine were used to train a fully convolutional network to automatically detect the corneal white-to-white distance, the total fluorescent area and the total erosive area. Based on these values, the algorithm calculates the affected area relative to total corneal surface area and fits the area on a three-dimensional representation of the corneal surface., Results: The developed algorithm reached dice scores >0.9 for an automated measurement of the relative lesion size. Furthermore, only 25% of conventional manual measurements were within a  ± 10% range of the ground truth., Conclusions: The developed algorithm is capable of reliably providing exact values for corneal lesion sizes. Additionally, three-dimensional modeling of the corneal surface is essential for an accurate measurement of lesion sizes. Besides telemedicine applications, this approach harbors great potential for clinical trials where exact quantitative and observer-independent measurements are essential.

Corneal infection is a major public health concern worldwide and the most common cause of unilateral corneal blindness. Toxic effects of different microorganisms, such as bacteria and fungi, worsen keratitis leading to corneal perforation even with optimal drug treatment. The cornea forms the main refractive surface of the eye. Diseases affecting the cornea can cause severe visual impairment. Therefore, it is crucial to analyze the risk of corneal perforation and visual impairment in corneal ulcer patients for making early treatment strategies. The modeling of a fully automated prognostic model system was performed in two parts. In the first part, the dataset contained 4973 slit lamp images of corneal ulcer patients in three centers. A deep learning model was developed and tested for segmenting and classifying five lesions (corneal ulcer, corneal scar, hypopyon, corneal descementocele, and corneal neovascularization) in the eyes of corneal ulcer patients. Further, hierarchical quantification was carried out based on policy rules. In the second part, the dataset included clinical data (name, gender, age, best corrected visual acuity, and type of corneal ulcer) of 240 patients with corneal ulcers and respective 1010 slit lamp images under two light sources (natural light and cobalt blue light). The slit lamp images were then quantified hierarchically according to the policy rules developed in the first part of the modeling. Combining the above clinical data, the features were used to build the final prognostic model system for corneal ulcer perforation outcome and visual impairment using machine learning algorithms such as XGBoost, LightGBM. The ROC curve area (AUC value) evaluated the model's performance. For segmentation of the five lesions, the accuracy rates of hypopyon, descemetocele, corneal ulcer under blue light, and corneal neovascularization were 96.86, 91.64, 90.51, and 93.97, respectively. For the corneal scar lesion classification, the accuracy rate of the final model was 69.76. The XGBoost model performed the best in predicting the 1-month prognosis of patients, with an AUC of 0.81 (95% CI 0.63-1.00) for ulcer perforation and an AUC of 0.77 (95% CI 0.63-0.91) for visual impairment. In predicting the 3-month prognosis of patients, the XGBoost model received the best AUC of 0.97 (95% CI 0.92-1.00) for ulcer perforation, while the LightGBM model achieved the best performance with an AUC of 0.98 (95% CI 0.94-1.00) for visual impairment., (© 2024. The Author(s).)

Purpose: To describe the first case of Pythium insidiosum keratitis masquerading as dematiaceous fungal keratitis in a seropositive male., Case Summary: A 44-year-old seropositive male previously treated for acute retinal necrosis presented with pain and defective vision in the right eye following a mud injury 5 days back. Presenting visual acuity was hand movements close to the face. Ocular examination revealed a 7 × 7 mm dense, greyish-white mid stromal infiltrate with pigmentation and few tentacles. The clinical diagnosis suggested fungal keratitis. Corneal scraping on 10% KOH and Gram stain revealed slender, aseptate hyaline hyphae. Before culture results, the patient was treated with topical 5% natamycin and 1% voriconazole, but the infiltrate progressed. Culture on 5% sheep blood agar revealed white fluffy, submerged, shiny, and appressed colonies, and Pythium insidiosum was confirmed by zoospore formation. The patient was further managed with topical linezolid 0.2% hourly, azithromycin 1% hourly, and adjuvant drugs., Conclusion: This is an uncommon presentation of Pythium keratitis masquerading as dematiaceous fungal keratitis in an immunocompromised male.

Purpose: To report the first case of Rhizopus sp keratitis in a 15-year-old male patient who had undergone a conventional Epi-off CXL procedure for progressive keratoconus., Methods: A 15-year-old male studying at school presented with defective vision in both eyes recently. He was diagnosed with progressive keratoconus in the right eye more than left eye. After the conventional CXL procedure, the patient developed corneal ulcer on third postoperative day., Results: The microbiological diagnosis of both BCL and ulcer revealed Rhizopus sp. The patient responded to topical antifungals, and the ulcer entirely healed with a large central scar., Conclusion: Rhizopus keratitis is rare in a healthy individual. Ours is the first case report of Rhizopus keratitis in patient undergone CXL., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To compare corneal haze between active ulcer and healed scarring using a Scheimpflug densitometry., Materials and Methods: A prospective longitudinal study enrolled 30 patients (30 eyes) with ulcerative keratitis (UK). Each subject's corneal optical density (COD) was measured with a Scheimpflug corneal densitometry, Pentacam® AXL (Oculus GmbH, Wetzlar, Germany), at the active ulcerative and complete scarring stage. The COD data were analyzed through distinct methods (inbuilt, sorted annular partitions, and ulcer-matching densitometric maps). We compared different CODs to select the better index for clinically monitoring the transition from corneal ulceration to healed scar., Results: The CODs of the periphery (P = 0.0024) and outside of the active ulcer (P = 0.0002) significantly decreased after scarring. Partitioning the cornea into different depths and annular zones, the anterior layer, center layer, and the 2-6 mm annular zone had a more remarkable COD decrease after scar formation. The 3rd-sorted COD in the anterior layer revealed the highest area under the receiver-operating characteristic curves (0.709), in which 90% of subjects had COD reduction during the ulcer-to-scar transition., Conclusions: Aside from subjective judgment based on clinical signs, the Scheimpflug tomography-based densitometry could provide objective and efficient monitoring of the corneal opacity evolution in UK patients. Because the 3rd-sorted annular COD is a better index than the inbuilt or mapping CODs in differentiating active ulcers from healed scars, this COD could be a clinically promising parameter to monitor the progression of UK patients., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Ochrobactrum anthropi is widely distributed and primarily infects patients with compromised immune functions . Historically, O. anthropi has been considered to possess low toxicity and pathogenicity; however, recent studies suggest that it may in fact cause severe purulent infections. In this case study, we examine a case of O. anthropi infection following corneal transplantation, exploring the occurrence and outcomes of such post-operative infections., Case Presentation: A retrospective analysis of cases involved examinations, genetic testing for diagnosis, and subsequent treatment. In patients undergoing partial penetrating keratoplasty with a fungal corneal ulcer perforation, anterior chamber exudation and purulence were observed post-surgery. Despite antifungal treatment, genetic testing of the anterior chamber fluid and purulent material confirmed O. anthropi infection. The use of antimicrobial treatment specifically targeting O. anthropi was found to be effective in treating the infection., Conclusion: Inflammatory reactions following corneal transplantation should be should be monitored for the presence of other infections. Genetic testing has significant implications for clinical diagnosis and treatment., (© 2024. The Author(s).)

Purpose: To report a case of ulcerative keratopathy following implantation of acellular porcine corneal stroma (APCS) in a patient with keratoconus (KC)., Methods: A 58 year-old patient initially presented with an ulcerative keratopathy in the left eye. Previously, several corneal procedures (including radial keratotomy, laser-in-situ keratomileusis, crosslinking) were performed for KC. Eight months ago, an APCS lenticule (Xenia corneal implant, Gebauer Medizintechnik GmbH, Neuhausen, Germany) was implanted into a stromal pocket because of progressive keratectasia. Visual acuity was hand movement. Anterior segment optical coherence tomography showed a space between the APCS lenticule and the host stroma. Excimer laser-assisted penetrating keratoplasty (PKP, 8.0/8.1 mm) was performed in the left eye. The corneal explant was investigated by light and transmission electron microscopy., Results: Best-corrected visual acuity was 20/40 six weeks after PKP. Light microscopy demonstrated a stromal ulceration down to the APCS lenticule. No stromal cells could be found within the APCS lenticule eight months after implantation. The APCS lenticule did not show a green stain of the collagens with Masson-Goldner staining and exhibited a strong Periodic acid-Schiff positive reaction. Electron microscopy of the APCS lenticule revealed cross-linked collagen lamellae without cellular components. Close to the interface, corneal collagen lamellae of the host cornea were disorganized. Few vital keratocytes were present on the surface of the lenticule and appeared to cause mechanical disruption of the host stroma along the lenticule-stroma interface., Conclusion: APCS implantation may lead to severe complications such as ulcerative keratopathy in otherwise uncomplicated KC corneas. In such cases, excimer laser-assisted PKP or Deep Anterior Lamellar Keratoplasty are the methods of choice to restore visual acuity., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Purpose: The purpose of this study was to report a case of peripheral ulcerative keratitis in a patient diagnosed with corneal polymerase chain reaction (PCR) and a positive mpox culture., Methods: This is a case report., Results: An immunocompetent 54-year-old man was diagnosed with conjunctivitis in his left eye 15 days after being diagnosed with mucocutaneous monkeypox. He received treatment with dexamethasone 0.1% and tobramycin 0.3% eye drops for 2 weeks. Two weeks after discontinuing this treatment, he developed peripheral ulcerative keratitis and a paracentral epithelial defect. Mpox keratitis was diagnosed by corneal culture and PCR. Corneal inflammation persisted for more than 6 months, manifested as corneal epithelial defect, limbitis, endotheliitis, neurotrophic changes, and trabeculitis. This persistence was observed alongside positive corneal PCR results, despite undergoing 2 courses of trifluorothymidine, 2 courses of oral tecovirimat, and intravenous cidofovir. An amniotic membrane transplantation was then performed., Conclusions: Persistent corneal pain and replication are possible with the mpox virus, even in immunocompetent patients. Having received treatment with topical corticosteroids before antiviral treatment for the pox virus may have contributed to the severity and persistence of the clinical condition. Cycle threshold PCR values can be used to support the diagnosis and monitor treatment effectiveness., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Peripheral ulcerative keratitis (PUK) is an inflammatory disease of the peripheral cornea, which may frequently be associated with several rare, but potentially life-threatening systemic diseases. The inflammatory pathogenesis of PUK results from humoral and cell-mediated inflammation. The diagnosis is usually based on the typical clinical findings and always requires detailed diagnostic testing to identify a potential systemic underlying disease. Treatment includes topical and systemic immunosuppressive and immunomodulatory therapeutic strategies and, in the event of impending or existing perforation, also various surgical interventions. PUK is a potentially blinding disease that initially affects the periphery, but, if left untreated, can lead to destruction of the entire cornea. Interdisciplinary diagnostic testing and therapy are crucial to preserve vision in the affected patients and reduce morbidity and mortality. The following article provides an overview of the pathophysiology, clinical findings, possible underlying systemic diseases, relevant differential diagnoses and therapeutic strategies., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht./The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Purpose: To describe the bacterial findings by a targeted sequencing approach from corneal samples of patients with microbial keratitis and factors influencing culture outcome of indirectly inoculated corneal specimen., Methods: Prospective inclusion of patients fulfilling predefined criteria of microbial keratitis. Samples from the corneal lesion were collected and dispensed in liquid transport medium, from which both culture and targeted amplification and sequencing of the V3-V4 region of the 16S rRNA gene were carried out. Additional standard corneal culture from the corneal lesions was also performed. Factors influencing culture outcome of indirectly inoculated corneal samples were identified by a multivariate regression model incorporating quantitative data from sequencing., Results: Among the 94 included patients with microbial keratitis, contact lens wear (n = 69; 73%) was the most common risk factor. Contact lens wearers displayed significant differences in the bacterial community composition of the corneal lesion compared to no lens wearers, with higher abundance of Staphylococcus spp., Corynebacterium spp., and Stenotrophomonas maltophilia. Targeted sequencing detected a potential corneal pathogen in the highest proportional abundance among 9 of the 24 (38%) culture-negative patients with microbial keratitis. Age, bacterial density in the sample, and prior antibiotic treatment significantly influenced culture outcome of indirectly inoculated corneal samples., Conclusion: Targeted sequencing may provide insights on pathogens in both culture negative episodes of microbial keratitis and among subgroups of patients with microbial keratitis as well as factors influencing culture outcome of indirectly inoculated corneal samples., (© 2023. The Author(s).)

A 60-year-old patient was diagnosed with multiple myeloma in November 2020, and started treatment in December 2020 with bortezomib, dexamethasone, and thalidomide. Four months later, he presented to the ophthalmology emergency department with inflammation and pain in the left eye. Examination of the anterior segment revealed severe, mixed anterior squamous blepharitis with significant bilateral palpebral inflammation, dysfunction of the meibomian glands, and several styes on both eyelids bilaterally. A peripheral ulcerative keratopathy was detected while examining the left eye cornea, with an inferior infiltrate and significant thinning, approximately 5 mm in length, at the limbal margin (Figure 1). Tear break-up time was shortened bilaterally. In addition to palpebral hygiene and oral treatment with doxycycline 100 mg every 24 hours, the patient was prescribed the following topical treatment without preservatives: artificial tears with lipid emulsion, netilmicin 0,3% 0,4 ml eye drops every 6 hours and dexamethasone 1 mg/ml every 8 hours.

Purpose: To evaluate and compare the results of the conjunctival flap (CF) and cryopreserved amniotic membrane graft (AMG) in the management of fungal corneal ulcers either with complications or non-responsive to medical treatment., Study Design: A retrospective observational study., Methods: Medical records of 30 patients with culture-positive fungal corneal ulcer treated with either CF or AMG (15 eyes in each group) in real world settings were retrieved for analysis. After the surgical procedure, patients were followed up on days 1, 7, 14, 21, 30, 60, 90, 120, and 180 to explore the outcomes of the operations along with complications., Results: Infecting fungi were of genus Fusarium (n = 11), Aspergillus (n = 10), Mucor (n = 4) and Penicillium (n = 10). The most common indication was resistant ulcer with perforation. After the procedure, epithelization was completed in 11(73.33%) patients in the CF, and 13 patients in the (86.67%) AMG group. Visual acuity improvement was significantly better in the latter group (CF: 1 [6.67%] vs. AMG: 7 [46.67%], p = 0.023). Flap failure occurred in 4 patients (26.67%) from the CF and 2 (13.33%) from the AMG group. No significant differences were found between the two groups regarding success rate (p = 0.651), epithelialization time (p = 0.691), healing of corneal ulcer (p = 0.651), and postoperative stability (p = 0.651) of the flaps., Conclusions: CF and AMG are both effective for the management of refractory fungal corneal ulcers. However, AMG appears to improve visual acuity better than CF., (© 2024. Japanese Ophthalmological Society.)

Purpose: Microbial keratitis is a sight-threatening condition with a higher incidence in agrarian populations. In countries with a high indigent population, due to financial and other constraints, patients prefer to seek therapy locally rather than travel to advanced centres. The aim of this study is to describe the epidemiology, clinical characteristics, and outcomes of 60 consecutive patients with microbial keratitis managed at a rural centre., Methods: Descriptive case series. All patients clinically diagnosed with infectious keratitis were included. Corneal scrapings were obtained and microbiological identification was done by Gram stain. Anti-microbial therapy was commenced based on smear findings and the patients were followed up till disease resolution., Results: Sixty eyes of 60 patients were diagnosed with microbial keratitis in the study period. The mean age was 47.43 ± 18.69 years. Male:female ratio was 47:53. Risk factors included ocular trauma in the majority of patients (46/60; 76.7%). Microorganisms were identified on 75.6% of smears, with fungal filaments (65.4%) being the most common. Ulcers were central in over half (32/60; 53.3%), and > 3 mm in diameter in over three-fourths (81.6%) of patients. Forty-four patients (73.3%) achieved treatment success whereas 16/60 (26.6%) required referral to our tertiary-eye care facility for management. The median time to resolution was 14 days (IQR 10-26 days)., Conclusion: Our series demonstrates the feasibility of microbiology-guided therapy in microbial keratitis by ophthalmologists at the secondary rural eye-care level. Two-thirds of the patients could be successfully managed at the rural centre and only severe cases needed a referral to tertiary centres., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: This review examined existing literature to determine various ocular manifestations of liver pathologies, with a focus on metabolic deficiencies as well as viral and immune liver conditions., Methods: Recent data were compiled from PubMed from 2000 to 2020 using keywords that were relevant to the assessed pathologies. Ocular presentations of several liver pathologies were researched and then summarized in a comprehensive form., Results: Several ocular manifestations of liver disease were related to vitamin A deficiency, as liver disease is associated with impaired vitamin A homeostasis. Alcoholic liver cirrhosis can result in vitamin A deficiency, presenting with Bitot spots, xerosis, and corneal necrosis. Congenital liver diseases such as mucopolysaccharidoses and peroxisomal disorders are also linked with ocular signs. Viral causes of liver disease have associations with conditions like retinal vasculitis, keratoconjunctivitis sicca, retinopathies, Mooren's ulcer, and Sjogren's syndrome. Autoimmune hepatitis has been linked to peripheral ulcerative keratitis and uveitis., Conclusions: Building strong associations between ocular and liver pathology will allow for early detection of such conditions, leading to the early implementation of management strategies. While this review outlines several of the existing connections between hepatic and ophthalmic disease, further research is needed in the area in order to strengthen these associations., (© 2024. The Author(s).)

Purpose: This study sought to identify the sources of differential performance and misclassification error among local (Indian) and external (non-Indian) corneal specialists in identifying bacterial and fungal keratitis based on corneal photography., Methods: This study is a secondary analysis of survey data assessing the ability of corneal specialists to identify acute bacterial versus fungal keratitis by using corneal photography. One-hundred images of 100 eyes from 100 patients with acute bacterial or fungal keratitis in South India were previously presented to an international cohort of cornea specialists for interpretation over the span of April to July 2021. Each expert provided a predicted probability that the ulcer was either bacterial or fungal. Using these data, we performed multivariable linear regression to identify factors predictive of expert performance, accounting for primary practice location and surrogate measures to infer local fungal ulcer prevalence, including locality, latitude, and dew point. In addition, Brier score decomposition was used to determine experts' reliability ("calibration") and resolution ("boldness") and were compared between local (Indian) and external (non-Indian) experts., Results: Sixty-six experts from 16 countries participated. Indian practice location was the only independently significant predictor of performance in multivariable linear regression. Resolution among Indian experts was significantly better (0.08) than among non-Indian experts (0.01; P < 0.001), indicating greater confidence in their predictions. There was no significant difference in reliability between the two groups ( P = 0.40)., Conclusion: Local cornea experts outperformed their international counterparts independent of regional variability in tropical risk factors for fungal keratitis. This may be explained by regional characteristics of infectious ulcers with which local corneal specialists are familiar., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Purpose: The ocular manifestations of Monkeypox virus (Mpox) infection remain incompletely characterized. Our goal is to present a case series of non-healing corneal ulcers with associated uveitis caused by Mpox infection as well as management recommendations for Mpox-related ophthalmic disease (MPXROD)., Methods: Retrospective case series., Results: Two male patients with recent hospitalization for systemic Mpox infection presented with non-healing corneal ulcer associated with anterior uveitis and severe IOP elevation. Despite initiation of conservative medical treatment including corticosteroid treatment for uveitis, in both cases, there was clinical progression with enlarging cornea lesions. Both cases received oral tecovirimat with complete healing of the corneal lesion., Conclusions: Corneal ulcer and anterior uveitis are rare complications of Mpox infection. Although Mpox disease is generally anticipated to be self-limited, tecovirimat may be an effective intervention in poorly healing Mpox keratitis. Corticosteroids should be used with caution in Mpox uveitis, as they might lead to worsening infection.

Purpose: To report a rare case of keratitis due to monkeypox infection., Methods: A 45-year-old male presented with an epithelial corneal ulcer 20 days following initial diagnosis of monkeypox from genital and perioral lesions. PCR analysis of the epithelium confirmed the presence of human monkeypox virus., Results: The patient was hospitalized, and ganciclovir gel, as well as povidone iodine 0.6% and moxifloxacin eyedrops were prescribed. Oral tecovirimat 600 mg was administered during 14 days. A therapeutic contact lens was used. Twenty days after the initial diagnosis of keratitis, the corneal defect closed leaving a faint subepithelial haze, and visual acuity was 0.8., Conclusions: This is an uncommon case report of epithelial keratitis due to human monkeypox. PCR positivity for monkeypox in the corneal epithelium confirmed the presence of viral material in the cornea.

Purpose: To compare the efficacy and rapidity of direct microscopic detection of fungal elements from corneal ulcers between 10% potassium hydroxide (KOH) and 1% Chicago Sky Blue 6B (CSB) in 10% KOH (CSB-KOH)., Methods: Thirty patients with clinically suspected fungal keratitis were recruited. Participants with impending corneal perforation were excluded. Two slides were smeared with corneal ulcer scrapings from the ulcer's edge and base for comparison of fungal staining solutions. One slide was infused with KOH, and the other slide was filled with CSB-KOH. Additional scraping was collected for inoculation on Sabouraud dextrose agar for fungal culture. The sensitivity, specificity and rapidity of both stainings were analyzed., Results: The sensitivity of fungal culture, KOH, and CSB-KOH were 43.75% (95% confidence interval [CI], 19.75%-70.12%), 62.50% (95% CI, 35.43%-84.80%), and 87.50% (95% CI, 61.65%-98.45%), respectively. The specificity were 100% (95% CI, 69.15%-100%) of both stainings and fungal culture which analyzed from 16 fungal keratitis cases by laboratory and clinical diagnosis. Mean CSB-KOH examination time was quicker than KOH with the mean time difference of 5.6 minutes (95% CI, 3.22-7.98 minutes) and p-value &lt; 0.001., Conclusions: CSB-KOH was more effective and faster than KOH in detecting fungal elements from corneal ulcers. Therefore, CSB-KOH may be beneficial in diagnosing fungal keratitis and preventing blindness. Moreover, to the best of our knowledge, this is the first use of CSB stain in fungal keratitis detection.