EyeWorld India March 2019 Issue

64 March 2019 EWAP CORNEA os 500 mg 2x/day. By month 3, UCVA was slightly improved at 0.6 logMAR, but by the time we reached 4 months of treatment, the patient had become irritated at the medication regimen and oral antibiotics,” Dr. Hua said. Dr. Hua observed that the lesions underwent further changes between the fourth and fifth months of treatment (day 137), with the evolution of the lesions from creamy to whiter and sharper over time. Day 143: Repeat DMEK surgery A repeat DMEK was performed on day 143. The graft exchange was carried out in the operating room, under air. “With a scraper we took out the first DMEK graft,” Dr. Hua explained. “The lesions, however, did not come out with the graft; they were still adhering to the stroma. A microbiologist was on standby to check the specimen by culture and staining. With the scraper we manually had to take out the infiltrates and rinsed with balanced salt solution.” The microbiology report showed the presence of M. chelonae DNA in the infiltrates. The culture was still positive for living mycobacteria in the eye. The staining was also positive for the organism. After the DMEK exchange, the patient’s UCVA was 0.7. In the first 2 weeks after surgery, he was not given corticosteroid eye drops. He received systemic antibiotics in addition to the previous regimen, which was maintained. Dr. Hua was able to examine the patient shortly before the ESCRS Winter Meeting and was satisfied with the patient’s progress. Antibiotics were stopped by month 5. He said that he would be checking the patient again to exclude any recurrences. EWAP References 1. De Groote MA, Huitt G. Infections due to rapidly growing mycobacteria. Clin Infect Dis. 2006;42:1756–63. 2. Ryu YJ, et al. Diagnosis and treatment of nontuberculous mycobacterial lung disease: clinicians’ perspectives. Tuberc Respir Dis (Seoul). 2016;79:74–84. 3. Akram SM, Bhimji SS. Mycobacterium chelonae. StatPearls. May 16, 2017. Editors’ note: Dr. Hua has no financial interests related to his comments. Contact information Hua: oogziekten@uzleuven.be clumped together, with a more classic appearance that looks like branching or unbranching bamboo. It is not uncommon for the fungal smear to be negative, and the fungal culture can take 5–20 days for final results. I will initiate oral and topical anti-fungal therapy based on the confocal microscopy. Acanthamoeba can be more challenging to identify. The double-walled cysts of Acanthamoeba are often sparse and can be difficult to highlight among other debris and white cells within the infectious infiltrate.” Treatment recommendations Once you have an idea of what the infectious agent is, you’ll need to modify your treatment, according to Dr. Ayres. The majority of corneal ulcers are bacterial and Gram positive; fungi and Acanthamoeba make up only a few percent of infections. If the fluoroquinolone antibiotic is not working, adding a second agent may help. Penicillin derivatives may not be effective when treating Gram positive bacteria, however, because methicillin resistance is growing among ocular pathogens and many organisms resistant to methicillin will be multi-drug resistant, Dr. Ayres said. Vancomycin is a good choice, if you have easy access to it, but consider trimethoprim if you don’t, he said. Chlorofluoroquinolones like besifloxacin are also a good option. Besifloxacin has a lower mean inhibitory concentration than other antibiotics and has never been used systemically, so there is little chance of resistance, he said. It’s important to remember that not all ulcers are the same; the treatment may depend on the ulcer’s size and how much of an inflammatory reaction is present, according to Dr. Ayres. For smaller ulcers that are less than 2.5mm in diameter, have a minimal anterior chamber reaction, and are not threatening the visual axis, culturing the tissue is a good idea but not essential, he said. Add a second antibiotic to kill any methicillin- resistant organisms, consider using besifloxacin, and continue using drops hourly until you see a clinical improvement, Dr. Ayres said. Be aware that the ulcer may progress for 24–48 hours even with appropriate management. Absolutely get a culture for large ulcers, where there is a deep, vision-threatening ulceration and a large inflammatory response, Dr. Ayres continued. But don’t hold off on treatment if you can’t culture the organism; change your treatment from a fluoroquinolone to fortified antibiotics hourly around the clock until you see an improvement, he said. EWAP Editors’ note: Dr. Ayres has financial interests with Bausch + Lomb (Bridgewater, New Jersey). Dr. Beckman has no financial interests related to his comments. Dr. Berdahl has financial interests with Alcon (Fort Worth, Texas), Allergan, (Dublin, Ireland), and Bausch + Lomb. Dr. Mah has financial interests with Allergan, Bausch + Lomb, and Novartis (Basel, Switzerland). Dr. Yeu has financial interests with Johnson & Johnson Vision (Santa Ana, California). Contact information Ayres: bfast33@comcast.net Beckman: kenbeckman22@aol.com Berdahl: johnberdahl@gmail.com Mah: Mah.Francis@Scrippshealth.org Yeu: eyeulin@gmail.com How to treat corneal ulcers unresponsive to fluoroquinolones – from page 62 Atypical mycobacterial - from page 63