Noninfectious Corneal Disorders

This chapter discusses noninfectious corneal disorders, caused by an immune inflammation such as phlyctenular keratoconjunctivitis, marginal staphylococcal keratitis, peripheral ulcerative keratitis, Mooren's ulcer, interstitial keratitis, rosacea keratitis, etc. Mooren's ulcer, which is considered one of the most severe diseases, is presented with serial photos of follow-ups within 3 years with different complications, management of the condition, and results. A severe case of rosacea keratitis associated with anterior uveitis is included in this chapter too. Thygeson's superficial punctate keratitis case is shown as well, but the disease is very rare in Middle Eastern populations. The material in this chapter also includes filamentary, neurotrophic, and exposure keratitis. A rare disorder like anesthetic abuse keratopathy, caused by topical excess use of anesthetic drops, is presented with before and after treatment photos to illustrate that the condition, if treated appropriately, can leave minimal scarring.

Ocular related emergencies in Spain during the COVID-19 pandemic, a multicenter study

Purpose To evaluate ophthalmological emergencies (OE) during the COVID-19 pandemic comparing them with the same period of the previous year. Methods Retrospective observational study of all OE visits in four tertiary hospitals in Spain comparing data from March 16th to April 30th, 2020 (COVID-19 period) and the same period of 2019 (pre-COVID-19 period). Severity of the conditions was assessed following Channa et al. publication. Data on demographics, diagnosis and treatments were collected from Electronic Medical Records. Results During lockdown, OE significantly declined by 75.18%, from 7,730 registered in the pre-COVID-19 period to 1,928 attended during the COVID-19 period (p < 0.001). In 2019, 23.86% of visits were classified as emergent, 59.50% as non-emergent, and 16.65% could not be determined. In 2020, the percentage of emergent visits increased up to 29.77%, non-emergent visits significantly decreased to 52.92% (p < 0.001), and 17.31% of the visits were classified as “could not determine”. During the pandemic, people aged between 45 and 65 years old represented the largest attending group (37.89%), compared to 2019, where patients over 65 years were the majority (39.80%). In 2019, most frequent diagnosis was unspecified acute conjunctivitis (11.59%), followed by vitreous degeneration (6.47%), and punctate keratitis (5.86%). During the COVID-19 period, vitreous degeneration was the first cause for consultation (9.28%), followed by unspecified acute conjunctivitis (5.63%) and punctate keratitis (5.85%). Conclusions OE visits dropped significantly during the pandemic in Spain (75.18%), although more than half were classified as non-urgent conditions, indicating a lack of understanding of the really emergent ocular pathologies among population.

Anti-glaucoma agents-induced pseudodendritic keratitis presumed to be herpetic simplex keratitis: a clinical case series

Anti-glaucoma agents-induced corneal toxicity may be misdiagnosed as herpetic simplex keratitis (HSK). In our study, nineteen glaucoma patients were presumed to have HSK before referral. Corneal lesions were classified into (I) linear pseudodendritic lesions formed by elevated opacified cells, (II) linear pseudodendritic lesions formed by grouped superficial punctate keratitis (SPK), (III) satellite full-thickness epithelial defects, (IV) satellite lesions formed by elevated opacified cells, and (V) geographic lesions formed by grouped SPK. We observed thirty-one events, with 15 in the lower and 16 in the central corneas. There were 21 (67.7%) type II, five (16.1%) type V, two (6.5%) of each for types III and IV, and one (3.2%) type I events. Among linear lesions (types I and II), 17 (77.3%) had horizontal and 5 (22.7%) had curvilinear orientations. Exposure duration to the last-added anti-glaucoma agent was three days to 14.5 years. About half of the events (16/31, 51.6%) used prostaglandin analogues, and 30/31 (96.8%) applied benzalkonium chloride (BAK)-containing agents. All lesions resolved within two months after decreasing offending medications or enhancing protection of ocular surface. In conclusion, anti-glaucoma agents-induced pseudodendritic keratitis presents majorly in central-lower cornea as horizontally linear lesions, and BAK-containing agents are observed in the most events.

Acute Stromal Keratitis Following the Vitrectomy for the Treatment of Myopic Tractional Maculopathy in Lupus

Purpose: To report a case of acute stromal keratitis after vitrectomy for the treatment of myopic tractional maculopathy in a lupus patient.Case summary: A lupus patient who were treated with low dose steroid complained of decreased visual acuity due to myopic tractional maculopathy with fovea detachment. No evidence of intraocular inflammation was observed. The best-corrected visual acuity (BCVA) was 20/40. We performed the vitrectomy and removal of epiretinal membrane and internal limiting membrane. BCVA of 20/80 at day 1 decreased to hand motion at day 5. Severe corneal edema and superficial punctate keratitis that were observed did not improve three days after the anti-herpetic treatment. Based on this, we diagnosed her as immune-mediated acute stromal keratitis in lupus, and treated with oral methylprednisolone of 20 mg. The corneal edema improved rapidly following high dose systemic steroid. Myopic fovea detachment also improved. Improvement of BCVA was limited to 20/80 at six months, compared to the baseline one.Conclusions: We observed the development of acute stromal keratitis after vitrectomy for the myopic tractional maculopathy in the patient with lupus. High dose systemic steroid improved this corneal complication. Increased dose of systemic steroid should be considered before and after vitrectomy in lupus patients.

Topical tacrolimus in ocular Graft Versus Host Disease

Purpose: To evaluate the safety and efficacy of topical tacrolimus eye drops in the treatment of patients with ocular Graft Versus Host Disease (GVHD).MethodsTen consecutive patients with ocular GVHD were included retrospectively. All patients were treated with topical tacrolimus (0.01% - 0.03%) twice daily. Five patients were given adjunctive topical steroids for 4 to 6 weeks. The outcome measures included improvement of symptoms of photophobia, ocular pain and discharge and signs of superficial punctate keratitis and conjunctival hyperemia. Clinical assessment was carried out before, during and on the last visit after treatment.ResultsThere were 9 males and 1 female patients. The mean age was 30 years (range 5 to 51). All patients had bilateral ocular involvement. Duration of treatment ranged from 2 to 22 months (mean 6.5 months). There was improvement of symptoms in 8/10 (80%), superficial punctate keratitis in 8(40%) out of the 20 eyes and conjunctival hyperemia in 12 (66%) out of 18 eyes. The response to treatment was noted to be late following initiation of therapy (Average 3 weeks; range 1 to 8 weeks). Patients given adjunctive steroids responded faster. The main adverse ocular side effects were burning sensation, redness and swollen lids.ConclusionTopical tacrolimus is a safe and effective long-term therapy in the treatment of patients with ocular GVHD. Adjunctive short-term use of topical steroids may lead to faster response to topical tacrolimus therapy. Patients should be encouraged to continue use of topical tacrolimus as the onset of action may be delayed.

Ocular related emergencies in Spain during the COVID-19 pandemic, a multicenter study.

PURPOSE: To evaluate ophthalmological emergencies (OE) during the COVID-19 pandemic comparing them with the same period of the previous year. METHODS: Retrospective observational study of all OE visits in four tertiary hospitals in Spain comparing data from March 16th to April 30th, 2020 (COVID-19 period) and the same period of 2019 (pre-COVID-19 period). Severity of the conditions was assessed following Channa et al. publication. Data on demographics, diagnosis and treatments were collected from Electronic Medical Records. RESULTS: During lockdown, OE significantly declined by 75.18%, from 7,730 registered in the pre-COVID-19 period to 1,928 attended during the COVID-19 period (p<0.001). In 2019, 23.86% of visits were classified as emergent, 59.50% as non-emergent, and 16.65% could not be determined. In 2020, the percentage of emergent visits increased up to 29.77%, non-emergent visits significantly decreased to 52.92% (p<0.001), and 17.31% of the visits were classified as “could not determine”. During the pandemic, people aged between 45 and 65 years old represented the largest attending group (37.89%), compared to 2019, where patients over 65 years were the majority (39.80%). In 2019, most frequent diagnosis was unspecified acute conjunctivitis (11.59%), followed by vitreous degeneration (6.47%), and punctate keratitis (5.86%). During the COVID-19 period, vitreous degeneration was the first cause for consultation (9.28%), followed by unspecified acute conjunctivitis (5.63%) and punctate keratitis (5.85%). CONCLUSIONS: OE visits dropped significantly during the pandemic in Spain (75.18%), although more than half were classified as non-urgent conditions, indicating a lack of understanding of the really emergent ocular pathologies among population.

Ocular related emergencies in Spain during the COVID-19 pandemic, a multicenter study.

Purpose: To evaluate ophthalmological emergencies (OE) during the COVID-19 pandemic comparing them with the same period of the previous year. Methods: Retrospective observational study of all OE visits in four tertiary hospitals in Spain comparing data from March 16th to April 30th, 2020 (COVID-19 period) and the same period of 2019 (pre-COVID-19 period). Severity of the conditions was assessed following Channa et al. publication. Data on demographics, diagnosis and treatments were collected from Electronic Medical Records. Results: During lockdown, OE significantly declined by 75.18%, from 7,730 registered in the pre-COVID-19 period to 1,928 attended during the COVID-19 period (p<0.001). In 2019, 23.86% of visits were classified as emergent, 59.50% as non-emergent, and 16.65% could not be determined. In 2020, the percentage of emergent visits increased up to 29.77%, non-emergent visits significantly decreased to 52.92% (p<0.001), and 17.31% of the visits were classified as “could not determine”. During the pandemic, people aged between 45 and 65 years old represented the largest attending group (37.89%), compared to 2019, where patients over 65 years were the majority (39.80%). In 2019, most frequent diagnosis was unspecified acute conjunctivitis (11.59%), followed by vitreous degeneration (6.47%), and punctate keratitis (5.86%). During the COVID-19 period, vitreous degeneration was the first cause for consultation (9.28%), followed by unspecified acute conjunctivitis (5.63%) and punctate keratitis (5.85%). Conclusions: OE visits dropped significantly during the pandemic in Spain (75.18%), although more than half were classified as non-urgent conditions, indicating a lack of understanding of the really emergent ocular pathologies among population.

Using pre-existing social networks to determine the burden of disease and real-life needs in rare diseases: the example of Thygeson's superficial punctate keratitis

Background Thygeson’s superficial punctate keratitis (TSPK) is a rare and still poorly understood disease of the ocular surface, responsible for recurrent episodes of photophobia and eye pain. While TSPK is considered as a benign condition, a subset of patients has frequent recurrences or even chronic disease, two situations in which there are currently no therapeutic guidelines. We used a preexisting Facebook TSPK patient support group to assess the clinical journey and the burden of disease of TSPK. Results An online survey was sent to the patient support group. The first part of the questionnaire gathered information on demographics and the patient’s clinical journey [diagnostic modalities, symptoms, duration and frequency of recurrent episodes (RE), efficacy and tolerance to treatments]. The second part focused on quality of life (QoL) using the Ocular Surface Disease-QoL (OSD-QoL) questionnaire. Seventy-two patients out of 595 members of the support group completed the questionnaire during the 3-months study period. Eighty percent of patients developed symptoms before 30 years old, and 47% reported a delay in the diagnosis above 1 year. Sixty percent of patients reported over 5 RE yearly, and 18% of RE lasted more than 3 months. Forty percent of all patients used cyclosporine eyedrops (50% of those with > 5 episodes/year) and it was perceived as effective by 72% of these patients. The impact on daily life activities was judged as severe by 22% of patients, while 38% reported reduced professional activity and 80% were deeply saddened by their eye condition. Conclusion TSPK patients may present with frequent recurrences and/or chronic disease, that result in a severe impact on QoL, and an off-label use of topical immunomodulatory eye drops, suggesting the urgent need for controlled studies. The utility of using social networks for rare ophthalmic disease research includes, faster data collection, data from patients across the globe, and also raises relevant questions about their real needs.

Thygeson’s superficial punctate keratitis (TSPK): a paediatric case report and review of the literature

Background Thygeson’s superficial punctate keratitis (TSPK) is reportedly a rare disease with an insidious onset, numerous remissions and exacerbations, and a long duration. The corneal lesions are elevated, whitish–grey in colour, and granular in the intraepithelium. A few reported cases of TSPK exist, and paediatric experience is limited. Due to the unknown aetiology and controversial treatment strategies for TSPK, we performed a literature review to summarize the criteria for the diagnosis, treatment and prognosis of TSPK to provide a basis for the treatment of TSPK in paediatric patients. Case presentation The clinical course of a boy with TSPK who repeatedly presented with episodes of tearing, photophobia and foreign body sensation in both eyes is described. Irritation was uncontrollable with antiviral and antibiotic medications, and it was managed by corticosteroids. No recurrence was reported at the 1-year follow-up after corticosteroid replacement and tapering. Conclusions The clinical features, treatment and prognosis between adult and paediatric TSPK patients have many similarities. The diagnosis of TSPK in children is more difficult, leading to missed diagnosis. TSPK needs to be carefully differentiated from other types of keratitis, especially intraepithelial secondary and other infectious ocular surface diseases.