We aimed to elucidate the effects of antimicrobial eye drops used in the perioperative period of ophthalmic surgery on the ocular surface microbiome by metagenomic analysis. Twenty-eight eyes from 15 patients (mean age 74.1 years) with no history of eye drop use within 3 months before cataract surgery were included in this study. Gatifloxacin eye drops were used in all patients in the perioperative period. The antimicrobial eye drops were started 3 days before surgery. They were discontinued after conjunctival sac specimen collection for 2 weeks after the surgery. Conjunctival sac specimens were collected to investigate the alterations in the ocular surface microbiome by meta-16S analysis targeting the V3-V4 region of the bacterial 16S rRNA gene. Principal coordinate analysis showed that the bacterial composition tended to be different before and 2 and 4 weeks after surgery. Individual observations on six eyes showed that the bacterial composition at 12 weeks after surgery was closer to that before surgery than to that at 4 weeks after surgery in two eyes, while the bacterial composition in the remaining four eyes was different at various time points. Before surgery, Firmicutes, Proteobacteria, and Bacteroidetes were predominant; however, 2 weeks after surgery, the proportion of Proteobacteria increased and that of Firmicutes decreased. A similar trend was noticed 4 weeks after surgery, although antibacterial eye drops had been discontinued 2 weeks after surgery. The Shannon–Weaver coefficient showed a decreasing trend at 2-, 4-, and 12-weeks post operation compared to that before operation. The diversity of the microbiome decreased significantly at 2- and 4-weeks after surgery when compared to that before surgery (p < 0.05). The ocular surface microbiome is easily disrupted by antimicrobial eye drops, and it needs recovery time. In such cases, the ocular surface microbiome is presumed to contain many antimicrobial-resistant bacteria. In some cases, it may not recover, and a new microbiome is formed.

Smear microscopic examination and culture of the corneal scrapings are the gold standards for the diagnosis of bacterial keratoconjunctivitis. High-sensitivity molecular biological examinations of the ocular surface specimens are used clinically. However, the results require careful interpretation to avoid the unintentional detection of indigenous bacteria. Results of conventional and state-of-the-art examinations require clinical verification for specificity and sensitivity. In this study, smear microscopic examination, culture, and nanopore sequencing using the MinION of ocular surface specimens from eight clinically diagnosed bacterial keratoconjunctivitis cases were performed and compared. Seven of the eight cases (87.5%) were smear positive and five (62.5%) were culture positive. The former showed the same genus in >60% of the classified reads as one specific bacterium inferred from the smear microscopy when sequenced by the MinION. In two of the three culture-negative cases, the smear-positive images were highly reminiscent of the species comprising most of the MinION sequences. Four of the five culture-positive cases were consistent with the most prevalent bacteria in the sequencing results. Probable contamination among specimens processed on the same day were observed. In conclusion, the microscopic examination of the corneal scraping specimens may be more sensitive and specific than the culture examination. Additionally, although metagenomic analysis using the MinION contributes to more precise medication for bacterial keratoconjunctivitis, contamination can affect the results.

Purpose: To determine the in vitro antimicrobial activity of quinolones against major bacterial isolates from the ocular surface bacterial flora of patients in a tertiary hospital for selection of optimal antibiotic eye drop during the perioperative stage. Methods: The conjunctival sac scraping of 933 patients who underwent ophthalmic surgery was cultivated and bacterial species of the isolates were identified. The minimum inhibitory concentrations (MICs) of gatifloxacin (GFLX), moxifloxacin (MFLX), levofloxacin (LVFX), and tosufloxacin (TFLX) were measured by microdilution methods. The cumulative percentages of MICs of 4 quinolones against major bacteria were calculated. The concentrations of quinolones inhibiting 50% (MIC50) and 90% (MIC90) of the major bacteria were compared. Results: The study mainly included 784 patients scheduled for cataract surgery, 73 for vitrectomy, 30 for corneal transplantation, 30 for conjunctival surgery, 11 for eyelid surgery. The most frequently isolated bacterium was coagulase-negative Staphylococci (CNS) (184 strains), followed by Corynebacterium (107 strains), Staphylococcus aureus (33 strains), Streptococcus (18 strains), and Enterococcus (13 strains). The percentages of methicillin-sensitive CNS isolates for which MIC of GFLX, MFLX, LVFX, and TFLX was 0.06 μg/mL or less were 8.0%, 13.4%, 5.4%, and 63.4%, respectively. Similarly, the percentage for Corynebacterium was 23.0%, 23.0%, 0%, and 35.6%, respectively. MIC50 of TFLX for Streptococcus and Enterococcus showed the lowest values, 0.12 and 0.25 μg/mL, respectively. Conclusions: Among 4 quinolones, TFLX has the highest in vitro antimicrobial activity against major bacterial isolates from the ocular surface bacterial flora of patients in a tertiary hospital.

Background: Rebamipide ophthalmic suspension was launched in Japan in 2012 and is used for the treatment of dry eye. Case Presentation: We report two cases of orbital abscess, which resulted from dacryocystitis that occurred after administration of rebamipide ophthalmic suspension. Computed tomography images showed an eyeball deformity in one case and exophthalmos in the other. In both cases, light microscopy, scanning electron microscopy and energy dispersive X-ray examinations revealed lacrimal sac concretions, which contained calcium phosphate crystals that were surrounded by microorganisms. Lacrimal sac concretion removal from the lacrimal sacs during dacryocystorhinostomies was performed on both patients. Although the postoperative outcome was favorable in one case, vision was lost in the other case due to the development of retinal artery occlusion as a complication of the orbital abscess, despite lacrimal sac concretion removal and administration of antimicrobials. Conclusions: This is the first case report to highlight that rebamipide ophthalmic suspension can cause an orbital abscess via development of lacrimal sac concretion. Ophthalmologists should be aware that rebamipide ophthalmic suspension might induce the formation of concretion in the lacrimal sac.

The present study elucidated the pathogenesis of allergic symptoms (AS) related to contact lens (CL) wear by assaying CL care solutions in lens storage cases and tears from subjects with AS using molecular biology techniques. A total of 15 CL storage cases were collected from subjects with AS (n=9) and healthy, asymptomatic control CL wearers (n=6). Bacterial populations in CL care solutions and tears were assayed by culture and 16S rDNA sequencing. Histamine levels in tears were measured by high‑performance liquid chromatography. Western blot analysis was performed to identify the bacteria recognized by tear IgE from subjects with AS. No significant differences were found in the culture results between the subjects with AS and asymptomatic subjects. Histamine was detected in 2 subjects with AS. Meta‑16S rDNA sequencing identified a cluster of 4 subjects with AS that were distinguished from others by principal coordinate analysis. Detailed population analysis revealed that the abundance of Gram‑positive bacteria in the microbiomes of CL care solutions used by the subjects with AS were higher than those of asymptomatic subjects (42.24±9.47 vs. 16.85±22.76% abundance). Among these, Streptococcus was the dominant genus (12.1‑18.3% abundance). Tear microbiome analysis revealed that the abundance of Streptococcus in the subjects with AS was significantly higher than that in other subjects (19.02±5.50 vs. 3.08±3.35%, P<0.01). Western blot analysis demonstrated that the tear IgE in all subjects with AS reacted with Streptococcus (100%), but not with Staphylococcus. On the whole, these results provide novel insight into the pathogenesis of AS and identify Streptococcus as an important factor in AS associated with CL wear.

BACKGROUND: Subtenon injection of triamcinolone acetonide (STTA) has been widely adopted in the clinical setting of ophthalmology and its infectious complications are rare. However, orbital abscess following STTA has been reported in seven cases. Furthermore, although eye infections due to Exophiala species are uncommon, there have been 19 cases to date. E. jeanselmei, E. phaeomuriformis, E. werneckii, and E. dermatitidis have been reported to cause human eye infections; however, to the best of our knowledge, orbital abscess caused by E. dermatitidis has not yet been reported. We describe the first documented case of fungal orbital abscess caused by E. dermatitidis following STTA. We also review the related literature of orbital abscess following STTA, as well as eye infections caused by the four Exophiala species. CASE PRESENTATION: The patient was a 69-year-old Japanese woman with diabetic mellitus. She had a macular oedema in her right eye, which occurred secondary to branch retinal vein occlusion. An orbital abscess caused by E. dermatitidis occurred 4 months after the second STTA for the macular oedema, which was successfully treated by a surgical debridement and systemic administration of voriconazole. CONCLUSIONS: Our findings in the patient and from our literature survey caution ophthalmologists to the fact that STTA can cause fungal orbital infections, especially in diabetic patients. Furthermore, surgical treatment is one of the most important risk factors.

Intraoperative optical coherence tomography (iOCT) is widely used in ophthalmic surgeries for cross-sectional imaging of ocular tissues. The greatest advantage of iOCT is its adjunct diagnostic efficacy, which facilitates to decision-making during surgery. Since the development of microscopic-integrated iOCT (MIOCT), it has been widely used mainly for vitreoretinal and anterior segment surgeries. In corneal transplantation, MIOCT allows surgeons to visualise structure underneath the turbid and distorted cornea, which are impossible to visualise with a usual microscope. Real-time visualisation of hard-to-see area reduces the operation time and leads to favorable surgical outcomes. The use of MIOCT is advantageous for a variety of corneal surgical procedures. Here, we have reviewed articles focusing on the utility of iOCT  and MIOCT in penetrating keratoplasty, deep anterior lamellar keratoplasty, Descemet stripping automated endothelial keratoplasty, and Descemet membrane endothelial keratoplasty. The applications of MIOCT to corneal surgery in terms of surgical education for trainees, emergency surgery, and novel surgery are also discussed, with our cases performed using RESCAN® 700.

Rationale:Contact lens storage cases are known to be contaminated by a significant number of bacteria. However, histamine-producing Raoultella species has not been reported to contaminate contact lens storage case.Patient concerns:A 27-year-old woman with keratoconjunctivitis that developed in the left eye owing to a cosmetic contact lens and poor hygiene was referred to our hospital. The corrected visual acuity was hand motion.Diagnoses:Corneal infection other than Acanthamoeba keratitis (AK) and corneal hypoxia were excluded.Interventions:We initiated empirical therapy for AK, although no cysts or trophozoites were detected in the cornea and in the lens care solution. Analysis of 16S rDNA sequences from the lens care solution yielded the highest homology with Raoultella species, which are histamine-producing bacteria. Histamine was estimated to be 492 ng/mL in the lens care solution.Outcomes:Her clinical course was distinct from that of usual AK cases. The corrected visual acuity increased up to (1.2) only 5 days after initiating empirical therapy.Lessons:To our knowledge, this is the first report to indicate an association between histamine-producing bacteria and keratoconjunctivitis. We should pay an attention to the microbial contamination of contact lens storage cases by histamine producing bacteria.

Ocular infection is caused by both endogenous (resident) and exogenous (environmental) microbes. As the ocular surface interacts with both outer environment and its own resident microbiota, clinical ocular samples are predicted to contain a diverse set of microorganisms. Microscopy of sample smears is an important step in the diagnostic process of infectious diseases to interpret the culture results. Traditional culture techniques have several limitations in the detection and/or identification of uncharacterized bacteria of environmental origin. Molecular biological techniques, such as polymerase chain reaction of pathogen-specific virulence genes, 16S rRNA gene clone library analysis, and nextgeneration sequencing of 16S rDNA amplicons, compensate for diagnostic culture techniques in diagnosing infectious diseases. These techniques are expected to provide novel insights into the ocular microbiota and pathology of ocular infections. In this article, we describe various ocular infections, including contact lens- related keratitis, silicone buckle infection, and dacryocystitis, which were analyzed using molecular biological techniques. The advantages and disadvantages of these highly sensitive and inclusive microbiological detection systems for ocular infections are discussed.

Sjogren's syndrome (SS) is a systemic autoimmune disease characterized by severe inflammation of exocrine glands such as the salivary and lacrimal glands. When it affects the lacrimal glands, many patients experience keratoconjunctivitis due to severely dry eyes. This study investigated the pathological and immunological characteristics of ocular lesions in a mouse model of SS. Corneal epithelial injury and hyperplasia were confirmed pathologically. The number of conjunctival mucin-producing goblet cells was significantly decreased in the SS model mice compared with control mice. Expression levels of transforming growth factor (TGF)-beta, interleukin (IL)-6, tumor necrosis factor (TNF)-alpha, and C-X-C motif chemokine (CXCL) 12 were significantly higher in the corneal epithelium of the SS model mice than in control mice. Inflammatory lesions were observed in the Harderian, intraorbital, and extraorbital lacrimal glands in the SS model mice, suggesting that the ocular glands were targeted by an autoimmune response. The lacrimal glands of the SS model mice were infiltrated by cluster of differentiation (CD)4(+) T cells. Real-time reverse transcription-polymerase chain reaction (RT-PCR) revealed significantly increased mRNA expression of TNF-alpha, TGF-beta, CXCL9, and lysozyme in the extraorbital lacrimal glands of the SS model mice compared with control mice. These results add to the understanding of the complex pathogenesis of SS and may facilitate development of new therapeutic strategies.

Background: Polymicrobial keratitis with fungus and bacteria can lead to blindness and is challenging to treat. Here, we introduce a case of fungal keratitis caused by two different strains in addition to definite bacterial super-infection caused by an alpha-Streptococcus sp., and describe the importance of microscopic examination. Case presentation: A 74-year-old woman, who had a past history of infection with leprosy, presented with conjunctival hyperaemia, pain, and corneal opacity in her right eye. Under the presumptive diagnosis of infectious keratitis, corneal scrapings were stained by various reagents and inoculated on several agar plates. Microscopic findings of the scrapings revealed fungi and a small number of Gram-positive cocci. Multiple anti-fungal therapies with levofloxacin ophthalmic solution were administered. Although empiric treatment was initially effective, keratitis recurred 10 days after its initiation. Repeated corneal scraping revealed an abundance of Gram-positive chain cocci and a small amount of fungi, resulting in the switching of an antibiotic medication from levofloxacin to moxifloxacin and cefmenoxime. Keratitis resolved gradually after the conversion. Stemphylium sp., Acremonium sp., and alpha-Streptococcus sp. were simultaneously isolated from the corneal scrapings. Conclusions: To the best of our knowledge, this is the first case of fungal keratitis caused by Stemphylium sp., and also the first case of super-infection in the cornea caused by two different fungi and one bacterium. Microscopic examination of the corneal scrapings was beneficial in rapid decision of changing to appropriate drug according to the dominancy of pathogenicity.

Objective: To investigate the surfaces and principal elements of the colorants of cosmetically tinted contact lenses (Cos-CLs). Methods: We analyzed the surfaces and principal elements of the colorants of five commercially available Cos-CLs using scanning electron microscopy with energy-dispersive x-ray analysis. Results: In two Cos-CLs, the anterior and posterior surfaces were smooth, and colorants were found inside the lens. One lens showed colorants located to a depth of 8 to 14 mu m from the anterior side of the lens. In the other lens, colorants were found in the most superficial layer on the posterior surface, although a coated layer was observed. The colorants in the other three lenses were deposited on either lens surface. Although a print pattern was uniform in embedded type lenses, uneven patterns were apparent in dot-matrix design lenses. Colorants used in all lenses contained chlorine, iron, and titanium. In the magnified scanning electron microscopy images of a certain lens, chlorine is exuded and spread. Conclusions: Cosmetically tinted contact lenses have a wide variety of lens surfaces and colorants. Colorants may be deposited on the lens surface and consist of an element that has tissue toxicity.

目的:慢性C型肝炎に対するインターフェロン(IFN)治療中に,黄斑部に漿液性網膜剥離が生じた2症例の報告。症例:1例は56歳男性,他の1例は41歳男性で,1例はIFN 2剤併用,他の1例は3剤併用による治療を受けていた。1例は投与49日目に左眼,6日後に右眼に漿液性網膜剥離が生じ,光干渉断層計(OCT)でこれに相当する所見があった。IFNを中止し,5週後に寛解した。他の1例はIFN開始から61日目に両眼の視力が低下し,黄斑部に漿液性網膜剥離があり,OCTでこれに相当する所見があった。治療を中止し,4週後に寛解した。両症例とも,蛍光眼底造影で蛍光漏出はなかった。結論:IFNの全身投与が黄斑部の漿液性網膜剥離の誘因であったと推定される。両症例とも,IFNの投与中止で寛解した。(著者抄録)

目的:多発性後極部網膜色素上皮(MPPE)がある2例4眼に,低照射エネルギー光線力学的療法を行った報告。症例:症例はそれぞれ61歳と67歳の男性である。1例は1年前からステロイド薬の全身投与を受け,視力障害で当科を受診した。他の1例は多発性骨髄腫に対して10年前からプレドニゾロンを内服していた。3年前にMPPEが発症し,複数回の光凝固を受けたが改善しなかった。所見:両症例とも両眼のMPPEと診断し,1例には嚢胞様黄斑浮腫があった。通常の半量のverteporfinを用いた低照射エネルギー光線力学的療法を両症例の両眼に行った。4眼中3眼で漿液性網膜剥離が改善し,中心窩下の脈絡膜厚が減少した。うち2眼で視力が改善し,4眼中1眼では所見に改善がなかった。結論:MPPEに対し,低照射エネルギー光線力学的療法が4眼中3眼で奏効し,1眼では無効であった。(著者抄録)

目的:裂孔原性網膜剥離に対する硝子体手術後に特徴的な白斑を認めた症例を報告する。症例:45歳,男性。右眼裂孔原性網膜剥離の診断で当科を紹介受診した。所見:右眼矯正視力は0.02で眼底の上耳側に裂孔があり,黄斑を含む網膜剥離を認めた。右眼の硝子体手術を施行し速やかに網膜は復位した。術後2週目に以前の剥離境界部の剥離網膜側に沿って眼底自発蛍光で過蛍光となる円形の白斑を認めた。白斑部の自発蛍光は術後4週目で最も過蛍光になり,術後12週目で自然に消失した。結論:部分的に円形に残存した剥離網膜下に視細胞外節由来物質が蓄積し,自発蛍光にて過蛍光となる白斑を形成したと推測した。(著者抄録)

To date, there has been only one published report on the infectious sclerokeratitis caused by Metarhizium anisopliae, which is an entomopathogenic fungus. Regarding corneal infection, three reports have been published to date. Although the prognoses of the corneal infections are favourable, prognosis when scleral infection is involved is very poor. A 76-year-old patient presented with foreign body sensation in the left eye. Microscopic examination with Fungi Flora Y staining of the corneal scraping revealed fungal infection. The conjunctiva was melted by the infection over a wide area. Although intensive medications were administered, an emergency surgery was necessary because scleral thinning, corneal perforation and lens prolapse occurred. The fungal isolate was identified as M. anisopliae by sequencing the internal transcribed spacer region. Herein, we report the second known case worldwide of M. anisopliae sclerokeratitis, and we review the literature related to the ocular infections.

カラーコンタクトレンズ(cosmetic tinted contact lens:カラーCL)の顔料厚と角膜上皮障害の関係を検討する目的で、黒色顔料をレンズ前面に格子状に印刷することで、顔料厚が異なる試作カラーCL3種を作製した。顔料厚は、A<B<Cの順に厚くした。これらカラーCLの各々3枚と、素材、含水率、直径、ベースカーブ、度数が試作レンズと同じ市販のレンズ3枚を、全身麻酔下で白色家兎12匹12眼に装用させ、眼瞼を縫合し72時間連続装用させた。72時間後に開瞼してレンズを外し、フルオレセイン染色をして細隙灯顕微鏡で角膜上皮障害の程度を観察した。市販レンズとレンズA装用眼では、中央角膜に軽度の点状表層角膜炎を認めた。レンズB装用眼では、点状表層角膜炎や角膜びらんを認めた。レンズCでは、3眼とも角膜びらんを認め、多発している個体があった。カラーCLでは、印刷顔料厚の違いが角膜上皮障害発生に関係し、その厚さに依存して角膜上皮障害は重症化する。(著者抄録)

目的:裂孔原性網膜剥離(RRD)術後に黄斑円孔を伴う再剥離を生じた2症例を報告する。症例1:54歳、男性、右眼、RRDに対して25ゲージ経毛様体扁平部硝子体切除術(pars plana vitrectomy:PPV)を施行した24日後に黄斑円孔を認め、その23日後RRDの再発を生じた。症例2:57歳、男性、右眼、RRDに対して強膜内陥術を施行した2週間後に黄斑円孔およびRRDの再発を認めた。経過:いずれの症例に対してもPPVを施行し内境界膜剥離も行ったが復位しなかった。PPVと輪状締結術、部分バックルを併用して行い復位を得た。結論:RRD術後に黄斑円孔を伴う再剥離を生じ、PPV単独では治癒しなかったことから強膜内陥術の併用を考慮する必要があると思われた。(著者抄録)

角膜移植術後のドライアイに対するジクアホソルナトリウム(以下、ジクアホソルNa)点眼薬の効果について検討した。角膜移植術後のドライアイ症例10例10眼において、Schirmer試験第I法測定値(以下、Schirmer値)、涙液層破壊時間(tear film breakup time:BUT)、角結膜上皮障害染色スコアリング(以下、スコア)、および臨床経過について、ジクアホソルNa点眼薬投与前と投与1ヵ月後を比較した。角膜内皮細胞密度と角膜厚は、投与前3ヵ月以内、投与後3ヵ月以内に測定可能であった症例で、投与前後の値を比較した。Schirmer値には有意差はなかったが、BUTは有意に上昇し、スコアは有意に減少した。角膜内皮細胞密度と角膜厚の平均値に著変はなかった。視力低下・拒絶反応・感染症をきたした症例はなかった。角膜移植術後のドライアイに対してジクアホソルNa点眼薬投与は有効であると考えられた。(著者抄録)

十数年来の角膜ヘルペスの既往がある77歳の男性が、感染性角膜炎をきたして再来した。左眼の傍中心部角膜に角膜膿瘍があり、前房蓄膿を伴い、視力は指数弁であった。角膜炎は、再発性角膜ヘルペスのため菲薄化していた部位を中心に発症していた。角膜擦過物の塗抹検鏡でグラム陽性桿菌が検出された。患者の都合から、複数種類の抗菌点眼薬の頻回点眼や抗菌薬の全身投与は実施せず、1.5%レボフロキサシン点眼薬の1日3ないし4回点眼で初期治療を開始した。角膜擦過物の培養で、レボフロキサシン高度耐性Corynebacteriumが分離された。治療開始から2週間後には角膜炎は消退しており、追加投薬を必要としなかった。1.5%レボフロキサシン点眼薬は、頻回点眼しなくともキノロン耐性Corynebacteriumによる角膜炎を消炎できる可能性がある。(著者抄録)

Background: In clinical settings, bacterial infections are usually diagnosed by isolation of colonies after laboratory cultivation followed by species identification with biochemical tests. However, biochemical tests result in misidentification due to similar phenotypes of closely related species. In such cases, 16S rDNA sequence analysis is useful. Herein, we report the first case of an Achromobacter-associated buckle infection that was diagnosed by 16S rDNA sequence analysis. This report highlights the significance of Achromobacter spp. in device-related ophthalmic infections. Case presentation: A 56-year-old woman, who had received buckling surgery using a silicone solid tire for retinal detachment eighteen years prior to this study, presented purulent eye discharge and conjunctival hyperemia in her right eye. Buckle infection was suspected and the buckle material was removed. Isolates from cultures of preoperative discharge and from deposits on the operatively removed buckle material were initially identified as Alcaligenes and Corynebacterium species. However, sequence analysis of a 16S rDNA clone library using the DNA extracted from the deposits on the buckle material demonstrated that all of the 16S rDNA sequences most closely matched those of Achromobacter spp. We concluded that the initial misdiagnosis of this case as an Alcaligenes buckle infection was due to the unreliability of the biochemical test in discriminating Achromobacter and Alcaligenes species due to their close taxonomic positions and similar phenotypes. Corynebacterium species were found to be contaminants from the ocular surface. Conclusions: Achromobacter spp. should be recognized as causative agents for device-related ophthalmic infections. Molecular species identification by 16S rDNA sequence analysis should be combined with conventional cultivation techniques to investigate the significance of Achromobacter spp. in ophthalmic infections.

Purpose: The purpose of this study is to describe the ineffectiveness of intrastromal voriconazole injection for filamentous fungal keratitis by contrasting the effectiveness for yeast keratitis. Methods: We examined seven fungal keratitis patients prospectively. All yeast was identified by molecular phylogenetic analyses of the chromosomal regions coding for the D1/D2 domain of the large-subunit 26S ribosomal RNA gene. All filamentous fungi were identified by the sequencing of internal transcribed spacers of the ribosomal DNA gene regions. Approximately 0.1 mL of voriconazole diluted with saline to 1.0% was injected with a 30-gauge needle inserted obliquely into the three to five clear cornea sites around the abscess. All subjects were administered natamycin ointment and oral itraconazole. When needed, intravenous micafungin, voriconazole, and/or intracameral voriconazole were added. Clinical courses were observed by the slit lamp microscope. Histopathology was examined when the corneas were removed. Results: All cases that were caused by yeast healed quickly after injections. Two cases of keratitis caused by Fusarium, and one case caused by Aspergillus, did not heal completely. In the Fusarium cases, additional antifungal medications (3.0% topical voriconazole and intravenous injection of micafungin) were needed. After optical penetrating keratoplasty in one of the cases, fungi were found in the deep stroma of the removed cornea. In the case of Aspergillus keratitis, pathological findings also showed fungi deep in the stroma of the removed cornea and the keratitis recurred after therapeutic penetrating keratoplasty. Conclusion: Intrastromal voriconazole injection is successful in treating yeast keratitis. However this is not the case for filamentous fungal keratitis. © 2014 Niki et al.

Background: Topical therapy is effective for dry eye, and its prolonged effects should help in maintaining the quality of life of patients with dry eye. We previously reported that the oral administration of rebamipide (Reb), a mucosal protective agent, had a potent therapeutic effect on autoimmune lesions in a murine model of Sjogren's syndrome (SS). However, the effects of topical treatment with Reb eyedrops on the ocular lesions in the murine model of SS are unknown. Methods and Finding: Reb eyedrops were administered to the murine model of SS aged 4-8 weeks four times daily. Inflammatory lesions of the extraorbital and intraorbital lacrimal glands and Harderian gland tissues were histologically evaluated. The direct effects of Reb on the lacrimal glands were analyzed using cultured lacrimal gland cells. Tear secretions of Reb-treated mice were significantly increased compared with those of untreated mice. In addition to the therapeutic effect of Reb treatment on keratoconjunctivitis, severe inflammatory lesions of intraorbital lacrimal gland tissues in this model of SS were resolved. The mRNA expression levels of IL-10 and mucin 5Ac in conjunctival tissues from Reb-treated mice was significantly increased compared with those of control mice. Moreover, lactoferrin production from lacrimal gland cells was restored by Reb treatment. Conclusion: Topical Reb administration had an anti-inflammatory effect on the ocular autoimmune lesions in the murine model of SS and a protective effect on the ocular surfaces.

Purpose: We report a case of methicillin-resistant Staphylococcus aureus (MRSA) keratitis after Descemet's stripping automated endothelial keratoplasty (DSAEK). Case Report: An 87-year-old woman who had undergone a DSAEK 4 months previously was referred to Tokushima University Hospital with a diagnosis of infectious keratitis after DSAEK. A white abscess and infiltration in the inferior cornea of the right eye were observed. We started an empiric therapy using topical levofloxacin and chloramphenicol on the basis of the microscopic findings of the corneal scraping concurrently with cultivation of the cornea. Results: A strain of MRSA was isolated from the corneal sample. Although the strain was susceptible to chloramphenicol, it was resistant to quinolone. The keratitis improved rapidly due to empiric therapy, and topical steroids could be resumed 6 days after initiation of the empiric therapy. Conclusions: To our knowledge, this is the first case of MRSA keratitis, and the second case of bacterial keratitis, after DSAEK. MRSA keratitis can occur following uneventful DSAEK. The empiric therapy on the basis of results from a light microscopic examination of a Gram-stained corneal scraping and restarting topical steroids in the early stages of medication contributed to the good clinical course of this case. © 2013 S. Karger AG, Basel.

The surgical indication for Descemet-stripping automated endothelial keratoplasty (DSAEK) is largely limited to phakic or pseudophakic cases of endothelial dysfunction with normal pupils, because the endothelial lenticule is generally attached to the recipient cornea by use of gas tamponade into the anterior chamber. Although it may be desirable for vitrectomized cases with aniridia and aphakic bullous keratopathy without capsule support to undergo DSAEK, one of the major problems is lenticule detachment during surgery or in the postoperative period. To perform DSAEK in such cases, special surgical techniques are needed in order to facilitate adhesion of the lenticule. Herein, we describe a suture technique for attaching the endothelial lenticule in DSAEK for aniridic and aphakic cases that have undergone vitrectomy for traumatic vitreoretinal disease. © 2012 Eguchi et al, publisher and licensee Dove Medical Press Ltd.

Purpose: To report the clinical ndings of 2 patients with focal choroidal excavation in the macula detected by spectral-domain optical coherence tomography (SD-OCT). Methods: Three eyes of 2 patients with a focal macular choroidal excavation detected by SD-OCT were studied. The eyes were examined by fundus autofluorescence (FAF), fluorescein angiography, fundus-related microperimetry, and multifocal electroretinography (mfERG). Results: In spite of a complaint of metamorphopsia, the visual acuity was normal in 2 eyes. SD-OCT demonstrated a choroidal excavation in the macula but the foveal contour was normal in 3 eyes. The excavation involved the outer retinal layers up to the external limiting membrane in all eyes, and a type 2 secondary choroidal neovascularization (CNV) developed in 1 of the 3 eyes. There were areas of hypoautouorescence in the FAF images, and areas of decreased retinal sensitivity determined by microperimetry. These areas corresponded to the choroidal excavation in all eyes. The P1 amplitudes of the mfERGs were decreased in the fovea of 1 eye without a CNV. Conclusions: The choroidal excavation remained stable for 3 years in 2 eyes, a secondary CNV developed in 1 eye during the course of the disease. More cases and longer follow-up periods will be necessary to determine the etiology, clinical course, and visual prognosis of eyes with a choroidal excavation. Copyright © 2012 S. Karger AG, Basel.

Peroxisome proliferator-activated receptor gamma (PPARγ) was detected in the exosome fraction of the culture media of human umbilical vein endothelial cells, indicating that PPARγ, a nuclear protein, can be released into the extracellular fluid. PPARγ mRNA expression levels in membrane samples, and the PPARγprotein concentrations in aqueous humor and vitreous fluid samples were significantly higher in patients with proliferative diabetic retinopathy (PDR) than control patients. We observed a significant positive correlation between the PPARγlevels and vascular endothelial growth factor levels or clinical stage of retinopathy in the aqueous humor and vitreous fluid of PDR patients. Taken together, PPARγ may be a therapeutic target for diabetic retinopathy.