Transcript 880: Corneal Infections in Eyes with Epithelial Basement Membrane

Melissa B Daluvoy MD, Neelofar Ghaznawi MD,
Kristin M Hammersmith MD, Edwin S Chen MD,
Christopher J Rapuano MD, Elisabeth J Cohen MD
Cornea Service, Wills Eye Institute, Thomas Jefferson University Hospital, Philadelphia,
Pennsylvania, USA
The authors have no financial interest in the subject matter of this poster
 Epithelial basement membrane dystrophy (EBMD) is the most common
anterior corneal dystrophy.
 Histopathologically , the epithelial basement membrane has poorly
functioning adhesion complexes leading to a weak attachment of
epithelium to Bowman’s membrane; making these corneas more
susceptible to spontaneous or recurrent erosions
1
(RES) .
 Any break in the epithelium can predispose a cornea to microbial infection.
 One study of corneal infections (n=1786) reported 0.6% were secondary to
2
RES .
In our experience EBMD is a small, but real, risk for infectious
keratitis.
Clinical photograph of a patient
with epithelial basement dystrophy
Courtesy of Edwin S. Chen, MD
Histopathology of degenerated epithelial
cells trapped in abnormal epithelium;
presents clinically as a microcyst.
Courtesy of Ralph Eagle, MD
To describe infectious keratitis due to
underlying hereditary EBMD and EBM
changes from previous trauma.
 We performed a retrospective chart review of patients with
infectious keratitis secondary to EBMD from 1/1/2007 to 9/30/2009
at a tertiary care center.
 Patients with recent trauma, bullous keratopathy, or contact lens
wear were excluded.
 Laterality of EBMD changes, history of remote trauma, RES, and
social, medical and ocular history were recorded.
 The active treatment for the keratitis, duration of follow-up and
time to resolution, vision as well as culture results and
complications were also noted.
 Thirteen patients were identified.


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

All patients were referred for consultation after onset of infection and initiation of some
form of treatment.
Average age at onset of the infection was 61.6 +/-12.8 years; 61.5% were female.
All cases had unilateral infections; 61.5% were of the right eye.
92.3% had EBMD in both eyes
23.1% had reported history of remote trauma in the affected eye
46.2% had reported history of RES in the affected eye.
 Clinical findings on presentation included infiltrate (100%), epithelial defect(85%),
hypopyon(23%), and stromal edema(69%).
 All were treated with topical antibiotics

8 (61.5%) were cultured: 5 (62.5%) of those were positive
st
 6 (46.2%) patients were started on fortified antibiotics/antifungals on their 1 visit.
 Pathogens included S. aureus, S. epidermidis, P. aeruginosa, MRSA, and Candida.
 One patient was hospitalized and treated for corneal perforation.
5 Not cultured
Tx= flouroquinolones
Candida & haemophilus
3=No Growth
13 Patients
Coag-neg Staph
8 Cultured
5=Positive
Staph Aur.
Pseudomonas
MRSA
Pt/
Sex
Age EBMD Tr.
Hx
RES Culture
Treatment/Course
F/u
VA on Final
Present- VA
1/F
50 OU
+
+
2/F
66 OU
-
UK Not done
polysporin oint; new hypopyon w/ d/c of moxiflozacin –restarted;Pred Ac. 1% added
day 68
Gatifloxacin, ciprofloxacin oint
1 visit
3/F
92 OU
-
UK Not done
Gatifloxacin, polysporin oint, BCL
6 days
20/200 20/40
4/F 56 OU
-
+
Not done
Bacitracin oint
1 visit
20/20
5/M 52 OU
+
+
Candida & Topical F. gentamycin, F vancomycin, voriconazole, atropine, PO cefazolin, timolol, * 305 days 20/80 20/50
Day
4
perforation
repaired
with
glue
&
BCL,
PO
voriconazole,
brinonidine,
hemophilis
ation
No Growth Topical Voriconazole, amphotericin, and moxifloxacin; oral voriconazole; atropine;
dorzolamide, moxifloxacin,
F. cefazolin, F. tobramycin, scopolamine
99 days
20/400 20/60
20/20
3 days
20/80 20/40
89 days
CF
UK
Coag Neg Atropine, topical levofloxacin, erythromycin oint
Staph
UN Not done Topical levofloxacin, azithromycin ophthalmic solution
35 days
20/30 20/30
9/F 52 OS
-
-
Not done
Topical levofloxacin, polysporin oint
10 days
20/50 20/40
10/M 58 OU
UK
+
S. Aureus
F. cefazolin, F. tobramycin, cyclopentolate
1 visit
CF
11/F 81
OU
+
45 days
HM
12/F 59 OU
-
UN Pseudomo Topical gatifloxacin, F. cefazolin, scopolamine, muro oint, ciprofloxacin oint, PO
doxycycline,
Day
31
Pred
Ac
1%
added
nas
UN No Growth Topical F. Vancomycin, F. gentamycin, scopolamine, polysporin oint, Day 22
13/M 50 OU
UK
+
107 days
CF
6/F 65 OU
-
-
7/M 52 OU
-
+
8/M 68 OU
No Growth
MRSA
loteprednol added
Topical F. cefazolin, F. tobramycin, scopolamine, polysporin oint, moxifloxacin, Day
19 loteprednol added
20/40
20/20
0
53 days 20/70 20/30
20/25
3-8
# of patients
3 cultured; all were pos:
Pseudomonas; S. aureus (2)
McElvanney (1999)
Tabery (1998)
2 cultured = all neg
Ionides (1997)
11 cultured = S. aureus (2)
1 cultured = all neg
Jaros (1986)
5 cultured = all neg
Shoch (1985)
0
2
4
6
8
10
12
 EBMD is known to cause considerable morbidity including ocular pain, RES
and decreased
8
vision .
 Infectious keratitis is a vision threatening complication that can lead to
scarring and perforation.
 Our series had a 62.5% culture positivity rate with a wide variety of organisms.
 Given the serious ocular morbidity associated with infectious keratitis we
recommend intense antimicrobial treatment as first line therapy.
 When counseling patients regarding the prognosis and treatment of EBMD or
faced with an ulcer of unknown etiology, ophthalmologists should consider the
possibility of infectious complications caused by EBMD.
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