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Grand Round Infective Keratitis associated with Contact Lens Wear

Grand Round Infective Keratitis associated with Contact Lens Wear. Jimmy Lim. History. Referred on 17 th March 2005 OS pain and redness for 4/7. Increasing photophobia. VA OD 6/6 OS 6/36-> 6/9+2. Myope OU –7.50D. Contact Lens Hx. Contact Lens user 5 years.

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Grand Round Infective Keratitis associated with Contact Lens Wear

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  1. Grand RoundInfective Keratitis associated with Contact Lens Wear Jimmy Lim

  2. History • Referred on 17th March 2005 • OS pain and redness for 4/7. • Increasing photophobia. • VA OD 6/6 OS 6/36-> 6/9+2. • Myope OU –7.50D.

  3. Contact Lens Hx • Contact Lens user 5 years. • 1/12 ago switched to monthly disposable soft contact lens. • History of delayed disposal of contact lens. • Wear 16 hours daily. • Uses multipurpose cleansing solution. • Did not take naps, sleep or swim with contact lens on. • No prior topical steroid eye drops use • No prior trauma. • Only washes face with tap water with contact lens on.

  4. Clinical examination • 1.5mm x 1.4mm cornea ulcer para-visual axis. • Ring and feathery infiltrates . • 30% cornea thickness. • AC activity + cells . • No hypopyon. • Cornea edema.

  5. Initial Inx and Rx • Cornea scraping • Chocolate, Blood and Sabouraud’s Agar. • Gram stain. • Admitted. • G. Amphotericin 0.15% hourly. • G.Gentamicin Cefazolin (Fortified) 3 hourly.

  6. Day 5 • Symptomatically improved. • All anibiotics was kept. • Amphotericin decreased 2 hourly. • Clinically . • Edema localised. • AC 2+ cells. • Epithelial defect 1.1mm x 0.8 mm. • Culture no growth so far.

  7. Review • Day 7 • BCVA OS 6/9. • Symptomatically improved. • AC quiet . • Amphotericin decreased 3 hourly. • Day 11 • BCVA OS 6/60. • Increasing photophobia. • AC cells 3+. • Endothelial plaque seen. • Epithelial defect. • Rescraping done + E.Coli non nutrient agar. • Amphotericin increased 1 hourly.

  8. Review • Day 12 • Readmitted for hourly Amphotericin and Moxifloxacin eye drop. • Day 13 • BCVA OS CF closely. • Worsening pain and photophobia. • Lesion 3 x 3.2mm. • Culture still negative. • Added • G.Chlorhexidine and Hexamidine hourly.

  9. Review • Day 14 • Lesion inferiorly necrotic. • Eye drops stopped . • Listed for cornea biopsy 24 later.

  10. Cornea Biopsy • Day 15 • Inadvertent full thickness wound during trephination. • As lesion necrotic and purulent. • Patch graft performed.

  11. Review • Day 16 (Post biopsy Day 1) • BCVA 6/120. • AC cell +. • Hypopyon resolved. • Wound water tight patch clear. • Microbiologist • Adequate sample, no filaments or fungi elements seen. • Stopped cefazolin, gentamicin and anti-acanthomoeba medications. • Added Pred Forte 1% tds, and increased to qds on Day 17.

  12. Review • Day 19 • AC cells +. • Keratitic Precipitates +. • Graft slight edema. • Amphotericin B and moxifloxacin. decreased to 3 hourly and Pred forte 5x/day. • Histopathology dense fibrosis no inflammation, culture no growth.

  13. Review • Day 25 • Large central epithelial defect. • Hypopyon 1mm. • AC cells 2+. • Cloudy cornea. • Loose sutures. • Graft resutured • Scrapes sent Viral culture and HSV 1 & 2 PCR. • Culture for bacteria, fungus and histology. • Started occ Acyclovir 5x/ day and oral Acyclovir 800mg 5x/day.

  14. Review • Day 26 • Infiltrate increased to 4.5mm . • Hypopyon 1mm. • Acyclovir was stopped and Added G. Natamycin hourly and oral Fluconazole 200mg bd.

  15. Review • Day 28 (14th April 2005) • BCVA PL. • Large central abscess. • Hypopyon 2mm. • Culture no growth. • Rescraped • Inadvertent perforation. • Emergency tectonic penertrating keratoplasty.

  16. Tectonic Penetrating Keratoplasty • Day 30 (POD 1) • BCVA 6/120. • Cefazolin and gentamicin 3hourly. • Natamycin qds. • Pred forte 3 hourly. • Fluconazole 200 mg bd. • Hypopyon cleared, some fibrin AC cells 3+.

  17. Post Graft • Fungal culture Fusarium sp. • Slow Epithelial defect healing. • Left Tarsorraphy and Botox injection performed on POD 3, Tarso released POD 14 epithelial healed. • Day 34 (POD 4) • Pred forte -> Dexamethasone PF 3hourly . • Occ Ciloxan qds. • Stopped fortified antibiotics and Pred Forte. • Subsequently uneventful, STO for loose sutures performed.

  18. Last Review • Post PK 9 months. • Graft no sign of rejection. • Ac quiet and deep. • Dexa (preservative free) om. • BCVA 6/7.5.

  19. Literature Review Fusarium Spp. • Epidemiology (I. Doczi, editorial Clinical Microbiology and Infection, 2004) • Hot, humid, tropical climates, (China, India , Thailand, Singapore, Florida). • Rare in temperate countries. • Cornea trauma most common predisposing factor (incidence 31.6% to 89.9%). • Plant and animal matter. • Topical corticosteroids, previous eye surgery, pre-exisitng ocular disease, contact lens wear. • Systemic diseases eg. DM

  20. Possible blinding complication. • 10 out of 159 cases advanced Fusarium keratitis in Florida progressed to endophthalmitis. (Dursun D et al Cornea 2003) • Proliferative and Migratory response (Dong X. et al Current Eye Research 2005) • MMP-9 and MMP-2 • Most active in Day 3 • Degree of inflammation correlate with levels of MMP-9 • Hypae lay parallel to stromal lamellae. • Cytotoxicity (Nalker S.et al Mycoses 2004) • Mycotoxin-producing.

  21. Diagnosis • Stains. • 10% KOH wet mount. • Sabouraud’s agar. • Histology. • PCR based tests(Gaudio PA et al BJO 2002). • Confocal microscopy?

  22. Therapy • Most effective (Kalavathy C M et al Cornea 2005) • Primary Natamycin therapy for filamentous fungal keratitis. • Tetraene polyene antibiotic derived from Streptomyces natalensis. • Dose-related, natamycin is predominantly fungicidal. • Polyenesterol complex alters the permeability of the membrane to produce depletion of essential cellular constituents.

  23. Use of Suconjunctival Fluconazole (Yilmaz S et al AJO 2005) • Penetrating Keratoplasty.

  24. Presentation By

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