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Microbial Keratitis and Endophthalmitis After the Boston Type 1 Keratoprosthesis

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Microbial Keratitis and Endophthalmitis After the Boston Type 1 Keratoprosthesis CLINICAL SCIENCE Microbial Keratitis and Endophthalmitis After the Boston Type 1 Keratoprosthesis Michael D. Wagoner, MD, PhD,*† Jeffrey D. Welder, MD,* Kenneth M. Goins, MD,* and Mark A. Greiner, MD*† Key Words: keratoprosthesis, corneal transplant, microbial keratitis, Purpose: To determine the incidence, ocular surface disease endophthalmitis associations, microbiological profile, and clinical course of post- operative infections after implantation of the Boston type 1 (Cornea 2016;35:486–493) keratoprosthesis (KPro-1). Methods: A retrospective chart review was conducted of all cases he Boston type 1 keratoprosthesis (KPro-1) offers an of the KPro-1 performed at a tertiary eye care center between Talternative to traditional corneal transplantation in eyes January 1, 2008, and December 31, 2014. with a poor prognosis for primary or repeat keratoplasty.1–4 Results: Seventy-five KPro-1 procedures were included in the The procedure has a distinct advantage of bypassing analysis. Postoperative infections occurred in 13 eyes (17.3%) immunologic-mediated endothelial rejection, a complication with an incidence of 0.064 cases per eye-year. The Kaplan–Meier that may compromise graft clarity after penetrating kerato- 5 probability of an infection-free graft was 0.96, 0.90, 0.88, 0.87, plasty (PKP). The KPro-1 optic does not depend on fi and 0.86 at years 1 through 5, respectively. The rate of infections a healthy corneal epithelium or precorneal tear lm to was greater in eyes with ocular surface disease (26.3% vs. 8.1%, provide satisfactory visual acuity, a feature that is particu- P=0.06), especially in those with a history of chemical or larly beneficial in eyes with chronic ocular surface disor- 6,7 thermal injury or herpes zoster keratopathy (P=0.001). There ders. However, these visual benefits can be compromised were 8 cases (10.7%) of microbial keratitis due to either fungi (5 by ocular surface–related issues that contribute to the 8–10 cases) or bacteria (3 cases). There were 7 cases (9.3%) of development of microbial keratitis and/or endophthalmi- 11–15 endophthalmitis due to bacteria (5 cases) or intraocular extension tis and the resultant potential for device extrusion and 16 of fungal keratitis (2 cases). The incidence of microbial keratitis irreversible ocular injury. and endophthalmitis was 0.034 and 0.03 cases per eye-year, Multiple management strategies have been introduced respectively. Therapeutic management of the infected eyes to reduce vision-threatening postoperative infections after – required graft and device removal in 7 eyes (53.8%). After keratoprosthesis implantation.17 21 Soft contact lenses have completion of microbiologic treatment, 7 eyes (53.8%) had lost been used to reduce the risk of epithelial-related microbial – more than 2 lines of the best-corrected preinfection visual acuity, infections.17 20 Systemic doxycycline and topical progesta- including 5 eyes with endophthalmitis that had hand motion tional corticosteroids have been used to reduce inflammation vision or worse. nonmicrobial ulceration and help prevent secondary infec- tions due to graft–host and graft–device dehiscence.17–20 Conclusions: Postoperative infections are a serious issue that Prophylactic antibiotics, antiseptics, and antifungal agents compromises device retention and visual outcomes after have been used to reduce microbial colonization of the ocular keratoprosthesis implantation. surface and the associated risk of microbial keratitis and/or endophthalmitis.21–25 There is no evidence-based consensus on the com- Received for publication October 9, 2015; revision received November 4, position or duration of an optimal postkeratoprosthesis 2015; accepted November 11, 2015. Published online ahead of print prophylactic regimen.5,17–25 Theprolongeduseofsoft January 14, 2016. contact lenses may be associated with an increased risk of From the *Department of Ophthalmology and Visual Sciences, University of 26,27 Iowa Hospitals and Clinics, University of Iowa Carver College of gram-negative keratitis, especially in this population Medicine, Iowa City, IA; and †Cornea Research Center, Stephen A. Wynn with a high burden of ocular surface disease (OSD). Institute for Vision Research, Department of Ophthalmology and Visual Extended use topical vancomycin, fluoroquinolones, and Sciences, University of Iowa Carver College of Medicine, Iowa City, IA. steroids may be associated with an overall increased risk Supported in part by the Beulah and Florence Chair in Cornea/External Disease and Refractive Surgery, the UIHC Cornea Research Fund, and of postoperative infections, especially those caused by the M. D. Wagoner and M. A. Greiner Cornea Excellence Fund. drug-resistant organisms and fungi.9,10,15,28,29 In this The authors have no conflicts of interest to disclose. study, we have endeavored to determine the incidence, Reprints: Michael D. Wagoner, MD, PhD, Cornea Research Center, Stephen OSD association, microbiological profile, and clinical A. Wynn Institute for Vision Research, Room 4184 MERF, 375 Newton Rd, Iowa City, IA 52242-1091 (e-mail: [email protected]). course of postkeratoprosthesis microbial keratitis and/ Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. or endophthalmitis. 486 | www.corneajrnl.com Cornea Volume 35, Number 4, April 2016 Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Cornea Volume 35, Number 4, April 2016 Microbial Keratitis and Endophthalmitis PATIENTS AND METHODS were provided for all new surgical cases, as well as for This study was approved by the Institutional Review existing postoperative cases. Board of the University of Iowa Hospitals and Clinics In eyes with a corneal infiltrate, a complete microbio- (UIHC) and conformed to the requirements of the United logical evaluation was performed as per previously described 5 States Health Insurance Portability and Accountability Act methods. Intensive topical antibiotic therapy was initiated with and the tenets of the Declaration of Helsinki. A retrospective fortified vancomycin (25 mg/mL) and, depending on the chart review was performed of all cases of KPro-1 implan- preference of the treating ophthalmologist, with fortified tation at UIHC between January 1, 2008, and December 31, ceftazidime (50 mg/mL), fortified tobramycin (16 mg/mL), or fl 2014. Procedures that were done in eyes in which a previous a fourth-generation uoroquinolone. The antibiotic regimen fi graft failed or in which the KPro-1 was the primary corneal was adjusted, as necessary, on the basis of the identi cation of fi procedure were included in the statistical analysis. Eyes with the bacterial isolate, the susceptibility pro le, and the clinical fi previous keratoprosthesis procedures were excluded from the course. If a fungal isolate was identi ed, intensive topical – analysis. Follow-up data were obtained, when available, therapy was initiated with topical amphotericin B (1.5 5.0 mg/ through June 30, 2015. mL) and voriconazole (10 mg/mL), as well as oral voricona- The main outcome measure was postoperative infec- zole (200 mg). The antifungal regimen was adjusted, as fi tions with microbial keratitis and/or endophthalmitis. These necessary, on the basis of the susceptibility pro le and clinical events were defined by characteristic clinical findings of an course. When necessary, the device was removed and replaced infectious process combined with microbiological confirma- with another KPro-1, if possible. tion with a positive corneal or vitreous isolate, respectively. In eyes with suspected microbial endophthalmitis, Cases of clinically suspected microbial keratitis or endoph- a diagnostic vitreous tap was performed, followed by an thalmitis that had a negative microbiological evaluation were intravitreal injection with vancomycin (1 mg/0.1 mL) and, not included in the analysis. Secondary outcome measures depending on the preference of the treating ophthalmologist, either ceftazidime (2.25 mg/0.1 mL) or amikacin (0.4 mg/0.1 included the microbiological profile, association of infections mL). In cases with suspected intraocular extension of with OSD, changes in the incidence of infections during the a confirmed case of fungal keratitis, an intravitreal injection course of the study, and the clinical course of infected eyes, with amphotericin (5 mg/0.1 mL) and voriconazole (100 mg/ including the need for device removal and replacement and 0.1 mL) was performed at the time of diagnostic tap and final visual outcome. topical antifungal therapy was continued as per the clinical The KPro-1 procedures were performed by experienced course. When necessary, the device was removed and UIHC corneal surgeons using previously described techni- 30,31 replaced with a tectonic PKP. ques. A polymethylmethacrylate back-plate was used in All data were entered using Microsoft Office Excel all cases performed before February 2012. Thereafter, a tita- (Microsoft Corporation, Redmond, WA). Data that were nium back-plate was used. A glaucoma drainage device collected from the patient medical record included patient (GDD) was implanted by an experienced UIHC glaucoma age, surgical diagnosis, antimicrobial prophylaxis regimen, surgeon in every case without a GDD. In cases with a previous follow-up intervals (surgery to most recent examination or to GDD that was not functioning adequately, a new GDD was development of microbial keratitis and/or endophthalmitis, implanted or a revision of the existing device was done. whichever came first), postoperative infections
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