Purpose: To compare the clinical outcomes of patients with Acanthamoeba keratitis (AK) according to the existence of hypopyon. Methods: A retrospective analysis of microbiologically confirmed AK cases over the past 15 years was conducted. Nine eyes with hypopyon (group 1) and 29 eyes without hypopyon (group 2) were analyzed to study the differences in these 2 groups of AK eyes. The cases were diagnosed using conventional microscopic analysis with staining techniques with smear and cultural methods and were treated according to diagnosis. Results: There was no difference in the demographic profiles and duration of symptoms before first visit in the 2 groups. The presenting corneal features, presenting best-corrected visual acuity, and final best-corrected visual acuity were significantly different between groups ( P = 0.042, P = 0.002, P = 0.001, respectively). There were significant differences between groups in microbiologic diagnosis ( P < 0.001): bacteria with Acanthamoeba (0/9 in group 1 vs. 4/29 in group 2), fungus with Acanthamoeba (7/9 in group 1 vs. 0/29 in group 2), and Acanthamoeba only (2/9 in group 1 vs. 25/29 in group 2). The eyes with fungus and AK coinfection showed worse visual prognosis. Conclusions: AK with hypopyon can be a representative sign of fungal coinfection, which has a trend of a worse visual prognosis. It should immediately alert clinicians to initiate early antifungals and antiamoebics.
PURPOSE:To describe the outcome measures, metrics used, and clinical results reported in regulatory trials of the US Food and Drug Administration-approved therapeutics for the treatment of dry eye disease. METHODS:For each trial, data were extracted regarding study design, interventions, and physician-measured clinical outcomes related to ocular surface (corneal and conjunctival vital dye staining score) and tear film (tear production and tear stability) parameters. Main outcome measures details of clinical assessment methods and characteristics of trial patients. RESULTS:Results from 19 trials were included. Reported efficacy end points varied considerably and included Schirmer test, performed with or without topical anesthesia, and analyzed using 2 distinct metrics: mean change from baseline at the final study visit, or responder analyses defined as the proportion of participants achieving a ≥10-mm increase from baseline. Measures of tear film stability were assessed using fluorescein tear film break-up time, with outcomes reported as mean change from baseline in seconds. Ocular surface damage was evaluated through corneal and conjunctival vital dye staining, using 4 different corneal and 3 different conjunctival grading scales, with results expressed as mean change from baseline in total staining scores. Some studies reported corneal staining responder analyses, defined as the proportion of participants achieving a ≥3-grade improvement from baseline. CONCLUSIONS:Heterogeneity among the included studies hindered direct cross-study comparisons, resulting in few meaningful cross-medication comparisons. This review underscores the need for validated, clinically meaningful dry eye disease outcome measures and standardized trial methodologies to advance therapeutic development and facilitate robust cross-study comparisons.
PURPOSE:This study evaluated the clinical efficacy of a pharmacist-led antimicrobial stewardship program augmented by metagenomic next-generation sequencing (mNGS) for managing rare, multidrug-resistant Elizabethkingia keratitis. METHODS:We conducted a retrospective case series of 5 male patients (mean age 56.4 years) diagnosed with Elizabethkingia keratitis (3 E. meningoseptica, 2 Elizabethkingia anophelis) between 2020 and 2025. Initial microbiological identification relied on corneal scraping culture and MALDI-TOF MS, while mNGS was strategically used in 1 complex case to identify potential copathogens. Clinical pharmacists provided interventions including minimum inhibitory concentration-guided therapy and the extemporaneous preparation of fortified antibiotic eye drops, such as 2% amikacin and 10% piperacillin/tazobactam. We assessed clinical outcomes, visual acuity (LogMAR), and the length of hospital stay. RESULTS:Although conventional culture confirmed Elizabethkingia species in all cases, mNGS offered critical genomic insights in 1 complex case by detecting culture-negative co-pathogens Nocardia pneumoniae and Fusarium proliferatum, which directly guided the addition of targeted antifungal and antibacterial therapy. All Elizabethkingia isolates demonstrated extensive resistance to carbapenems and cephalosporins. After pharmacist-led interventions, mean visual acuity improved significantly from 1.56 ± 0.77 to 0.90 ± 0.25 LogMAR. Furthermore, the length of hospital stay decreased markedly from 40 days in the index case to an average of 10.7 ± 4.9 days in the final 3 cases as diagnostic and therapeutic protocols were refined. CONCLUSIONS:Integrating clinical pharmacists within a multidisciplinary team, supported by mNGS for comprehensive polymicrobial detection, enables precision pharmacotherapy for multidrug-resistant Elizabethkingia keratitis. This approach promotes successful ocular salvage and visual recovery while substantially improving clinical efficiency through shortened hospitalization.
PURPOSE:To predict the diagnostic value of the fluorescein-assisted labial salivary gland test (FAST) in diagnosing Sjögren disease (SjD) and its correlation with biopsy positivity. METHODS:Consecutive patients presenting with aqueous-deficient dry eye, that is, dry eye symptoms plus Schirmer less than 10 mm in 1 eye and positive ocular staining, were investigated for SjD using serology and labial minor salivary gland (MSG) biopsy. Using the FAST technique, the number of actively secreting MSGs and the flow rate were calculated in μL/min. Receiver operating characteristic curves, sensitivity, and specificity were calculated. RESULTS:Of 43 patients with aqueous-deficient dry eye, 23 (56.6%) had a focus score greater than 1, and 2 were seropositive for SS-A or SS-B. Twenty-seven (62.8%) reported dry mouth, of which only 14 were biopsy-positive. The median gland number and mean MSG flow rate were 11 (interquartile range, 11) 0.81 ± 0.8 μL/min in biopsy-positive cases, and 18.5 (8) 1.4 ± 0.9 μL/min in biopsy-negative cases, respectively. Receiver operating characteristic analysis demonstrated that both flow and gland number were associated with biopsy positivity. Flow showed moderate diagnostic performance (area under curve (AUC) = 0.68), with an optimal cutoff of <1.21 μL/min yielding 73.9% sensitivity and 73.7% specificity. Gland number demonstrated better discrimination (AUC = 0.73), with a cutoff of <14.5 providing 69.6% sensitivity and 78.9% specificity. There was a moderately positive correlation between the glandular area observed on histology and gland number and flow. CONCLUSIONS:FAST can assist in identifying the labial biopsy site containing confluent, actively secreting glands, especially near the lip commissures, and in increasing the glandular area captured on histology in suspected SjD patients.
Purpose: To provide the first detailed ophthalmologic and multimodal imaging characterization of corneal involvement in a patient with genetically confirmed Prolidase deficiency. Methods: Observational case report Results: A 21-year-old man was referred for ophthalmologic evaluation after diagnosis of Prolidase deficiency (homozygous c.825delC, p.Phe275Leufs*46, in PEPD ) during investigation for recurrent infections and immune dysregulation. Best-corrected visual acuity was 7/10 in the right eye and counting fingers at 1 m in the left eye. Slit-lamp biomicroscopy demonstrated bilateral, asymmetric corneal disease with diffuse opacification, epithelial and subepithelial fibrosis, anterior stromal haze, and circumferential limbal neovascularization in the left eye, and milder superior corneal involvement in the right eye. Corneal sensitivity was bilaterally reduced. Anterior segment optical coherence tomography revealed diffuse heterogeneous stromal reflectivity, a stromal demarcation line, and superior corneal thinning. In vivo confocal microscopy demonstrated fibrotic epithelial changes, a fragmented subbasal nerve plexus, inflammatory cell infiltration including dendritic cells, fine stromal deposits compatible with imidodipeptide accumulation, and significantly reduced keratocyte density. Conclusions :These findings reveal a progressive corneal keratopathy driven by a dual pathomechanism of impaired collagen homeostasis and chronic immune-mediated inflammation, paralleling features of other hereditary collagen disorders. Systematic ophthalmologic surveillance should be incorporated into the routine management of all patients with Prolidase deficiency.
PURPOSE:To report anatomical and visual acuity outcomes of surgical detachment of iridocorneal and lenticulocorneal adhesions in pediatric patients with mild to moderate congenital corneal opacity (CCO). METHODS:An observational study with a longitudinal design including 16 eyes of 10 patients, aged between 8 months and 15 years, with CCO, irido- or lenticulocorneal adhesions and detectable Descemet membrane (DM) reflectivity in anterior segment optical coherence tomography (AS-OCT) images, treated by surgical detachment of iridocorneal or lenticulocorneal adhesions between 2011 and 2025 at the Helsinki University Hospital. The main outcome measures were best-corrected visual acuity (BCVA), anatomical outcome assessed with AS-OCT, and surgical complications. RESULTS:The median age at surgery was 13 months (range, 5-56), and follow-up time from presentation to the last appointment ranged from 7 to 166 months (median 154). No intraoperative complications were recorded. Of the 11 eyes of 7 patients aged between 13 and 15 years and thereby with completed visual development, 4 had a BCVA of 0.2 to 0.4, 5 of 0.6 to 1.0, and 1 of 1.2 logMAR. One eye was legally blind. The anterior segment anatomy was stable after surgery, showing mild corneal clarification. In a patient who had lenticulocorneal adhesions detached, cataract surgery became timely only after 11 years at the age of 13. CONCLUSIONS:Surgical detachment of iridocorneal and lenticulocorneal adhesions in mild to moderate CCO with detectable Descemet membrane AS-OCT reflectivity enabled stable anatomical and BCVA outcomes without major complications.
PURPOSE:Infectious keratitis has a profound impact on patients quality of life (QoL). Patient-reported outcome measures (PROMs) provide an invaluable method to capture subjective patient experiences and support practitioners in health care delivery. The primary and secondary objectives of this review were to systematically evaluate PROM tools used in infectious keratitis and evaluate the quality and content of PROMs in use for infectious keratitis. METHODS:The protocol implemented for review was published in PROSPERO (CRD42023464686). A literature review was performed in PubMed, MEDLINE OVID, Embase OVID, Cochrane, Scopus, Web of Science, and PsycINFO in October 2023. Full-length studies, published in English, featuring named and externally validated PROMs which were used to evaluate QoL outcomes of patients with infectious keratitis, were included. Nonvalidated PROMs used in patients with infectious keratitis were excluded. Studies including but not explicitly defining corneal pathologies were also excluded. Psychometric quality, validity, and risk of bias of each PROM were assessed using previously validated criteria. RESULTS:Eight studies evaluated PROMS in infectious keratitis, with 8 different PROMs (1 generic, 7 ophthalmic but not keratitis-specific) used. Patients with infectious keratitis demonstrated impaired QoL in all PROMs, domains representing vision and visual function most impaired. Dependence, mobility, and mental and emotional state were also affected. Only 1 paper (13%) used psychometric analysis to validate the PROMs before use. CONCLUSIONS:Infectious keratitis has a negative impact on patient's QoL, across multiple domains. A variety of PROMS have been used to assess QoL in keratitis with most awaiting validation for infectious keratitis.
PURPOSE:To evaluate the magnetic resonance imaging (MRI) safety of iron oxide-containing pigments previously used in femtosecond laser-assisted keratopigmentation (KTP). METHODS:Twelve pigment formulations were initially screened using MRI to identify the most magnetically reactive sample. Standardized pigment amounts equivalent to clinical use were measured with a precision microbalance. Temperature changes were monitored with fiber optic thermometry in porcine corneas with and without pigment after femtosecond laser tunnel creation during a standard MRI protocol. Pigment motility was assessed by suspending impregnated filter paper in MRI-safe glass jars and observing potential movement within the bore. MRI sequences were analyzed for image distortion. RESULTS:No measurable temperature increase was observed in pigment-containing or control porcine corneas during MRI exposure. No pigment movement was detected; the impregnated filter paper remained stable without displacement, deflection, or torque. MRI revealed a localized signal at the pigment site, causing mild distortion limited to the corneal region, with no interference in adjacent or posterior ocular structures. CONCLUSIONS:Iron oxide-containing pigments (Biotic Phocea, France) used in KTP did not cause heating, motility, or clinically significant imaging artifacts during MRI. Although localized corneal signal distortion was noted, it did not hinder the visualization of deeper eye tissues. These findings support the safety of MRI in patients with prior KTP using iron oxide pigments, including those who had initial pigments implanted.
PURPOSE:To compare the clinical features and treatment outcomes between culture-negative (CN) and culture-positive (CP) fungal keratitis. METHODS:Clinical and microbiology data of patients diagnosed with fungal keratitis at a Tertiary Eye Care Centre in eastern India between January 2021 and December 2022 were retrospectively reviewed. Collected data included demographic details (age, gender, profession), ocular and systemic predisposing factors, history of ocular trauma, clinical presentation, smear and culture reports, management modalities, and treatment outcomes. RESULTS:Among 283 smear-positive fungal keratitis cases, 152 were CN and 131 were CP. Age, gender, history of ocular trauma, and duration of symptoms were comparable between CP and CN cases (P = 0.1082, 0.4411, 0.3307, and 0.7920, respectively). Absence of prior antimicrobial therapy was more common in the CP group (P = 0.0004). CP cases presented with a poorer visual acuity (P < 0.0001) and larger infiltrate area (P < 0.0001). CN cases showed better outcomes with medical management (P = 0.0028) and shorter treatment duration (P = 0.0435). In contrast, CP cases required more surgical interventions (P = 0.0081), particularly "major" surgical interventions such as therapeutic penetrating keratoplasty, vitreoretinal surgery, and evisceration (P = 0.0125). CP cases had higher rates of treatment failure (P = 0.0442) and worse visual acuity outcomes (P = 0.2831). CONCLUSIONS:CP fungal keratitis is associated with worse presenting visual acuity, larger infiltrate, and poorer treatment outcomes compared with CN fungal keratitis. Culture positivity in fungal keratitis can, therefore, serve as a prognostic indicator for disease severity and may necessitate more aggressive medical management or earlier surgical intervention.
PURPOSE:To compare 5-year endothelial cell density (ECD) outcomes after Descemet membrane endothelial keratoplasty (DMEK) using peripherally trephinated donor tissue (DMEK-pD) versus centrally trephinated donor tissue (DMEK-cD) in eyes with corneal endothelial dysfunction of various etiologies. METHODS:This retrospective comparative nonrandomized interventional cohort study included 428 eyes of 383 patients who underwent DMEK-pD (n = 205) or DMEK-cD (n = 223), with assignment based on surgeon preference, performed either alone or combined with cataract surgery using a standardized no-touch technique. All grafts were surgeon-prepared intraoperatively. ECD was measured at 6 months and annually up to 5 years. Corrected distance visual acuity, postoperative complications, and secondary graft failure (SGF) were recorded. Comparative and subgroup analyses were performed according to underlying diagnosis. RESULTS:Mean ECD was significantly higher in the DMEK-pD group at all postoperative time points: 2368 ± 224 versus 2024 ± 312 cells/mm2 at 6 months, 1942 ± 284 versus 1698 ± 352 cells/mm2 at 2 years, and 1534 ± 279 versus 1280 ± 394 cells/mm2 at 5 years (all P < 0.001). Visual acuity improvement was comparable between groups (P = 0.15). Subgroup analysis demonstrated the greatest long-term ECD preservation in eyes with Fuchs endothelial corneal dystrophy undergoing DMEK-pD (P < 0.001). Postoperative complication rates were similar in both groups. SGF occurred more frequently in DMEK-cD (10.8%) than DMEK-pD (5.9%), although the difference was not statistically significant (P = 0.13). CONCLUSIONS:DMEK using DMEK-pD demonstrates sustained long-term ECD advantages over centrally trephinated DMEK in heterogeneous endothelial diseases, without compromising visual outcomes or safety. This suggests that a simple donor preparation modification may enhance graft longevity without altering surgical technique.
PURPOSE:To evaluate postoperative ocular surface complications following cataract surgery in patients with ocular graft-versus-host disease (oGVHD). METHODS:A retrospective cohort study was conducted using deidentified patient data from a multicenter federated electronic health record network from 2013 to 2025. Cataract surgery patients were categorized into 3 cohorts: oGVHD (n = 1483), hematopoietic stem cell transplantation (HSCT) recipients with graft-versus-host disease (GVHD) without ocular involvement (n = 1558), and controls without prior HSCT or GVHD (n = 693,399). After 1:1 propensity score matching, postoperative complications, vision-threatening corneal events (VTCE), and treatment escalation were compared between groups using Cox proportional hazards models to estimate hazard ratios (HRs). Associations between preoperative ocular surface activity timing and postoperative risk were assessed. Preoperative ocular surface optimization was evaluated in an exploratory analysis. RESULTS:oGVHD was associated with increased VTCE risk compared with controls (HR: 1.87; P < 0.001) and HSCT recipients with GVHD but no ocular involvement (HR: 1.36; P = 0.007). oGVHD was also associated with greater escalation of ocular surface management, including medical therapy, amniotic membrane grafting, and tarsorrhaphy (all P < 0.05), with differences persisting through 1 year of follow-up. Postoperative risk increased as preoperative ocular surface activity occurred closer to surgery, with the highest VTCE risk observed when activity occurred within 30 days before surgery (HR: 3.78; P < 0.001). Preoperative ocular surface optimization was associated with lower VTCE risk (HR: 0.56; P = 0.042). CONCLUSIONS:oGVHD is associated with increased postoperative ocular surface complications and therapeutic escalation after cataract surgery, with risk rising as preoperative disease activity approaches surgery. Preoperative ocular surface optimization may mitigate risk, supporting perioperative management.
PURPOSE:To report the graft detachment and rebubbling rate of pre-Descemet endothelial keratoplasty (PDEK) in patients with Fuch dystrophy and pseudophakic bullous keratopathy. METHODS:In this prospective interventional study of 131 eyes (131 patients), the main-outcome measures were visual acuity, graft detachment and rebubbling rate, pachymetry, and endothelial cell count (ECD) loss. RESULTS:The mean age of graft recipients was 64.5 ± 12.3 years(range 21-87 years); the mean donor age was 25.1 ± 8.7 years(range 10-70 years); and mean graft size was 7.5 ± 0.4 mm. Four eyes (3%) experienced partial graft detachment. Inferotemporal detachment was detected in 2 eyes, inferior in 1 eye, and central detachment in 1 eye. Two cases with graft detachment had no air bubble in the anterior chamber and 2 cases had less than 20% air in anterior chamber on the first postoperative day (POD). The graft detachment was detected on first POD in 2 cases, on second POD in 1 case and on third POD in 1 case. The mean ECD loss was 22.3%, whereas the ECD loss for eyes that underwent rebubbling was 24.8%. There was significant improvement in visual acuity (P < 0.001). Postoperative best-corrected visual acuity was not dependent on donor age, donor specular count, or PDEK graft size. There was no significant correlation between ECD loss and postoperative best-corrected visual acuity (P = 0.524). The mean preoperative central corneal thickness was 758 ± 152.1 μm, whereas the mean postoperative central corneal thickness was 541.3 ± 90.8 μm (P = 0.000). No incidence of graft failure or rejection was observed during 18 months of follow-up. CONCLUSIONS:PDEK offers satisfactory visual outcomes and has a favorable complication profile with lower rate of graft detachment and rebubbling rate of 3%.
PURPOSE:To describe a novel technique for managing anterior chamber (AC) instability during endothelial keratoplasty in eyes with compromised anterior segment architecture through posterior segment pressurization via intravitreal balanced salt solution (BSS) injection. METHODS:In eyes with distorted iris anatomy, large peripheral iridectomies, prior vitrectomy, or iris-lens diaphragm instability undergoing Descemet stripping automated endothelial keratoplasty (DSAEK) or Descemet membrane endothelial keratoplasty, intraocular air or gas may migrate posteriorly, destabilizing the AC and compromising graft apposition. We describe a technique in which approximately 0.2 mL of BSS is injected through the pars plana into the vitreous cavity using a 30-gauge needle, providing transient posterior segment pressurization to stabilize the globe. After injection, the needle is maintained in position with gentle plunger control for approximately 2 minutes to allow stabilization of posterior segment pressure and sustained globe firmness. RESULTS:The technique was successfully applied in 3 complex cases: 1) an 81-year-old man with atonic pupil, postvitrectomy, and glaucoma tube shunt undergoing DSAEK; 2) an 82-year-old female postvitrectomy patient undergoing DSAEK; and 3) 77-year-old man with large peripheral iridectomy undergoing Descemet membrane endothelial keratoplasty. All cases achieved stable AC configuration and secure graft attachment without excessive air/gas fill or posterior gas migration. CONCLUSIONS:Posterior intravitreal BSS injection provides an effective method to stabilize the iris-lens diaphragm and maintain AC architecture during endothelial keratoplasty when conventional air/gas injection alone is insufficient.
