Corneal Ulcer Management

Purpose: To examine predisposing factors, treatment costs, and visual outcome of microbial keratitis in an ophthalmic casualty and inpatient population. Design: Retrospective medical records review. Participants: Fifteen-to 64-year-olds with microbial keratitis treated at the Royal Victorian Eye and Ear Hospital between May 2001 and April 2003 (n ϭ 291). Methods: Risk factors were identified from patient files. Demographic, clinical, and microbiological data; severity; outpatient visits; hospital bed days; and vision loss were examined. Main Outcome Measures: Cost to treat (Australian dollars), vision loss, and factors influencing these outcomes. Results: Ocular trauma (106/291 [36.4%]) and contact lens (CL) wear (98/291 [33.7%])

To evaluate the efficacy of multilayer amniotic membrane transplantation for reconstruction of corneal epithelium and stroma in the context of deep corneal ulcers. Prospective, noncomparative, interventional case series. Eleven consecutive patients with deep corneal ulcers refractory to conventional treatment; six patients had herpetic keratitis and five had other forms of neurotrophic keratitis. Multilayer amniotic membrane transplantation with kryopreserved human amniotic membrane. Integrity of corneal epithelium and stroma, opacification, and appearance of grafted membrane during 12 months follow-up. Amniotic membrane transplantation markedly reduced ocular inflammation in all patients. Epithelium healed above all corneal ulcers within 4 weeks and remained stable in 9 of 11 patients for 1 year. Two patients with recurrent epithelial defect suffered from severe neurotrophic keratitis. Following transplantation the amniotic membranes gradually dissolved over a period of 12 months, ...

We have documented changes in expression of collagenolytic/gelatinolytic enzymes of the matrix metalloproteinase family (MMP) in healing or ulcerating corneal wounds of rat or rabbit. Correlation of our findings with specific changes in the extracellular matrix of the repair tissue suggests two different roles for the enzymes, MMP-2 and MMP-9. MMP-2 is expressed in undamaged corneal stroma where it may degrade the occasional collagen molecule that becomes damaged. After corneal wounding, expression of this enzyme is increased and much of it appears in the active form. These changes persist for at least seven months, suggesting that MMP-2 is involved in the prolonged process of collagen remodelling in the stromal repair tissue. MMP-9 is expressed in the epithelial layer of repair tissue with a timing suggesting it might participate in controlling resynthesis of the basement membrane. MMP-9 also appears to be involved in degradation of the epithelial basement membrane that precedes corneal ulceration.

The cornea is a major protective shield of the interior of the eye and represents two thirds of its refractive power. It is made up of three tissue layers that have different developmental origins: the outer, epithelial layer develops from the ectoderm overlying the lens vesicle, whereas the stroma and the endothelium have mesenchymal origin. In the adult organism, the outermost corneal epithelium is the most exposed to environmental damage, and its constant renewal is assured by the epithelial stem cells that reside in the limbus, the circular border of the cornea. Cell turnover in the stromal layer is very slow and the endothelial cells probably do not reproduce in the adult organism. However, recent experimental evidence indicates that stem cells may be found in these layers. Damage to any of the corneal layers leads to loss of transparency and low vision. Corneal limbal stem cell deficiency results in severe ocular surface disease and its treatment by transplantating ex vivo expanded limbal epithelial cells is becoming widely accepted today. Stromal and endothelial stem cells are potential tools of tissue engineering and regenerative therapies of corneal ulcers and endothelial cell loss. In the past few years, intensive research has focused on corneal stem cells aiming to improve the outcomes of the current corneal stem cell transplantation techniques. This review summarizes the current state of knowledge on corneal epithelial, stromal and endothelial stem cells. Special emphasis is placed on the molecular markers that may help to identify these cells, and the recently revealed mechanisms that could maintain their ''stemness'' or drive their differentiation. The techniques for isolating and culturing/ expanding these cells are also described. '

Staphylococcus aureus is the most important and common pathogen that infects patients following cataract surgery, laser in situ keratomileusis, and photorefractive keratectomy. It is reported to be the second most common pathogen causing bacterial keratitis around the world. Of special concern are increasing reports of postoperative methicillin-resistant S aureus (MRSA) infection. For example, MRSA wound infections have been reported with clear corneal phacoemulsification wounds, penetrating keratoplasty, lamellar keratoplasty, and following ex vivo epithelial transplantation associated with amniotic membrane grafts. These and other data suggest that MRSA has become increasingly prevalent worldwide. In this article, we review the current medical literature and describe the current challenge of ocular MRSA infections. Recommendations are made based on an evidence-based review to identify, treat, and possibly reduce the overall problem of this organism. No author has a financial or pr...

Fluoroquinolones are a class of synthetic antibacterial agents that were approved for ocular therapy in 1991 and have become popular therapy for the treatment and prevention of various ocular infections. These agents are synthetic, broad-spectrum, rapidly bactericidal, and have good penetration into ocular tissues. Their main mechanism of action is the inhibition of bacterial enzymes needed for bacterial DNA synthesis. However, antibiotic resistance occurred swiftly to the earlier fluoroquinolones and better fluoroquinolones were needed. The fourth-generation fluoroquinolones, such as moxifloxacin and gatifloxacin, have enhanced activity against gram-positive bacteria while retaining potent activity against most gram-negative bacteria. These fourth-generation fluoroquinolones have improved penetration into the anterior chamber and have also demonstrated increased in vivo efficacy in several animal models of ocular infections. In addition, topical ophthalmic antibiotic products can deliver antibiotic concentrations directly to the eye that are thousands of times higher than their MICs. This article reviews published data describing the in vitro potency of moxifloxacin and its in vivo activity for treating and preventing experimental ocular infections. (Surv Ophthalmol 50:S16-S31, 2005. Ć 2005 Elsevier Inc. All rights reserved.) Key words. antibiotic activity • antibiotic potency • antibiotic resistance • in vitro • in vivo • MICs • moxifloxacin • VIGAMOXă

To investigate the incidence, culture results, treatment, and visual outcomes of infectious keratitis after laser in situ keratomileusis (LASIK) worldwide, the Cornea Clinical Committee of the American Society of Cataract and Refractive Surgery (ASCRS) contacted 8600 United States and international ASCRS members by e-mail and asked them to respond to a questionnaire about post-LASIK infectious keratitis. One hundred sixteen infections were reported by 56 LASIK surgeons who had performed an estimated 338 550 procedures. Seventy-six cases presented in the first week after surgery, 7 during the second week, 17 between the second and fourth weeks, and 16 after 1 month. Forty-seven cases were not diagnosed on initial presentation. The most common organisms cultured were atypical mycobacteria and staphylococci. Empiric therapy is not recommended as most of the organisms are opportunistic and not responsive to conventional therapy. Flap elevation and culturing should be performed when post-LASIK infectious keratitis is suspected.

Objective: Fungal keratitis is a serious ocular infection that is considered to be rare among contact lens wearers. The recent Fusarium keratitis outbreak raised questions regarding the background rate of Fusariumrelated keratitis and other fungal keratitis in this population.

Rabbits received nonpenetrating central corneal knife wounds. Immediately after wounding, a single 2.5 or 5.0 fxg dose of mesodermal growth factor (MGF) was applied topically to the wound. Controls were treated with saline. Electron microscopic studies compared, the healing responses of the control and treated animals over a 7-day period. MGF toas a potent mitogen for keratocytes in rabbit corneas. The single dose enhanced fibroblast proliferation and metabolic activity. Control wounds were not healed after 7 days, whereas those of treated, animals showed complete healing.

To study levels and activity of matrix metalloproteinase (MMP)-1 and -9 and their tissue inhibitor (TIMP-1) in tears of patients with vernal keratoconjunctivitis (VKC), with and without severe corneal damage. METHODS. Tear samples were obtained from 16 patients with active VKC and 10 normal control subjects, after clinical evaluation and tear cytology. Tear levels of pro-MMP-1, pro-MMP-9, and TIMP-1 were measured by enzyme-linked immunosorbent assay (ELISA). Collagenase and gelatinase activity were measured in tears by MMP activity assays. Immunohistochemistry was performed on a fragment of superficial keratectomy from two vernal corneal ulcers. RESULTS. Tear levels of pro-MMP-1 and pro-MMP-9 were significantly increased in patients with VKC compared with control subjects (P Ͻ 0.001). MMP-1/TIMP-1 and MMP-9/TIMP-1 molar ratios were significantly increased (P Ͻ 0.001) in VKC. MMP-1 and MMP-9 activities were significantly increased in VKC tears compared with control samples (P Ͻ 0.005). MMP-9 activity correlated significantly with corneal involvement and giant papillae formation. Immunohistochemistry showed positive staining for MMP-9, fibronectin, and eosinophil cationic protein (ECP) on the superficial corneal stroma of the ulcer bed, but no inflammatory cells. CONCLUSIONS. Increased levels and activity of MMP-1 and -9 and an imbalance between MMPs and TIMP may be involved in the pathogenesis of VKC. (Invest Ophthalmol Vis Sci. 2003;44: 3052-3058)

Background This is a retrospective, chart-reviewed study of patients diagnosed with infectious corneal ulcers at the Ophthalmology Department of the National University of Asunción in Paraguay. The microbiological culture results are described, as well risk factors for the development of fungal keratitis. Methods After obtaining approval from the Institutional Review Board, an analysis of medical charts from 1988 to 2001 was conducted and 660 patients were identified to have been diagnosed with infectious corneal ulcers due to bacteria or fungi. Demographic data were recorded, including age, gender, occupation and geographic location of their home and work (city or rural). Other information collected included the history of the presenting illness, past and current use of ocular medications and whether or not they had a history of trauma or contact lens use. Each patient had an eye examination performed by an ophthalmologist and corneal scrapings were obtained for cultures in all cases. Microbiologic culture results were analyzed. Results Twenty-one percent (136/660) of the specimens collected from the patients’ conjunctiva and cornea were sterile in all culture media. Of the 524 (79%) positive cultures, 267 were due to bacteria (51%), 136 to fungi (26%), and 121 (23%) cultures yielded both fungi and bacteria. Of the 430 isolated bacteria approximately 25% (103) were coagulase negative Staphylococcus, followed by 23% (94) Staphylococcus aureus, 14% (60) Pseudomonas aeruginosa and 13% (56) Streptococcus pneumoniae. Acremonium species accounted for 40% (79) of all fungi identified, followed by Fusarium species (15%) (41). Approximately two-thirds of the patients were male (n = 435). For those patients for whom a history was available, approximately half had a history of trauma. Of these, half of these again involved foreign bodies. Over-the-counter medications were used commonly, and most of those patients had a delay in diagnosis of over 1 week. Risk factors for fungal keratitis as opposed to bacterial keratitis were male gender, agricultural occupation, age between 30 and 59, history of trauma and self-medication. Conclusions The results of this study provide demographic data on patients with infectious corneal ulcers in Paraguay. Common causes of such ulcers are both bacteria and fungi. Most patients had self-medicated, and most had delayed seeking professional medical care.

This study evaluated the epidemiology of Pseudomonas aeruginosa keratitis in contact lens (CL) wearers; the relationships between CL storage case contamination and CL hygiene practice and between CL hygiene and the development of keratitis. Sixteen CL wearers with keratitis were compared with 44 asymptomatic controls. Lens hygiene practice was assessed and CL care materials, domestic water sites and endogenous sites were evaluated microbiologically. Poor CL hygiene was not associated with Ps. aeruginosa keratitis. There was an association between keratitis and bacterial contamination of the CL and storage case (P < 00005). Lens and storage case contamination were not significantly associated with poor hygiene. No domestic or endogenous source for Ps. aeruginosa was found. Causative organisms may be derived from other sources, but CLs and CL storage cases provide a favourable environment for Ps. aeruginosa colonization. Changing the CL care environment to one less favourable for Ps. aeruginosa may help to eliminate this problem.

To compare the therapeutic success, visual outcomes, complications, and graft survival rates of therapeutic deep anterior lamellar keratoplasty (TDALK) and therapeutic penetrating keratoplasty (TPK) for advanced infectious keratitis. Retrospective, comparative study. One hundred twenty-three patients (126 eyes) with medically uncontrolled infectious keratitis of bacterial, fungal, or acanthamoeba etiologies who underwent TDALK (n = 26) or TPK (n = 100 eyes; 80 nonperforated ulcers; 20 perforated ulcers; mean follow-up in TDALK, 12.9 months; in TPK, 21.3 months). We performed TDALK for infections confined to the corneal stroma and the technique used was either manual lamellar dissection or Anwar&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s big bubble technique for total stromal removal. Therapeutic penetrating keratoplasty was performed for either nonperforated or perforated ulcers. Comparison with respect to recurrence of infection, visual acuity, graft survival, and complications was made. Baseline characteristics of the patients were analyzed using the chi-square test. Kaplan-Meier survival analysis was used to evaluate graft survival. Therapeutic success (eradication of infection) or therapeutic failure (recurrence of original infection in cornea or sclera, or as endophthalmitis), graft survival (clarity), and best-corrected visual acuity (BCVA). Therapeutic success rate of 84.6% was achieved in the TDALK group and 88% in the TPK group (P = 0.74); of the 12 eyes with recurrence of infection in the TPK cohort, 6 developed endophthalmitis with poor outcomes. A BCVA of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or =6/9 was achieved in 50% of patients in the TDALK group and 20.2% in the TPK group (P = 0.01). Mean improvement of acuity was 7.27 lines in the TDALK group and 4.76 lines in the TPK group (P = 0.01). Kaplan-Meier survival analysis at 1 year showed better graft survival for TDALK (90%) compared with TPK (78.4%). For medically unresponsive infectious keratitis, TDALK may be considered instead of TPK yielding similar graft survival, without an increased risk of disease recurrence.

To evaluate the role of intrastromal injection of voriconazole in the management of deep recalcitrant fungal keratitis.Interventional case series.Setting: Cornea services at a tertiary care teaching hospital. Patients: Three eyes of three patients with deep stromal recalcitrant fungal keratitis not responding to topical antifungal medications. Intervention Procedure: Voriconazole 50 micrograms/0.1 ml was injected circumferentially around the fungal abscess in the corneal stroma as an adjunctive to the topical antifungal therapy. Main Outcome Measure: Main outcome measure was a reduction in size of the abscess and resolution of the infection.Before the intracorneal injection, all three eyes had gradually worsening lesions on topical medications. After the intervention, a faster reduction in the size of corneal infiltration was documented and a complete resolution of the ulcers was seen within three weeks in all cases.Targeted delivery of voriconazole by intracorneal injection may be a safe and effective way to treat cases of deep-seated recalcitrant fungal keratitis responding poorly to conventional treatment modalities.

To conduct a therapeutic exploratory clinical trial comparing clinical outcomes of treatment with topical natamycin vs topical voriconazole for fungal keratitis. Methods: The multicenter, double-masked, clinical trial included 120 patients with fungal keratitis at Aravind Eye Hospital in India who were randomized to receive either topical natamycin or topical voriconazole and either had repeated scraping of the epithelium or not. Main Outcome Measures: The primary outcome was best spectacle-corrected visual acuity (BSCVA) at 3 months. Other outcomes included scar size, perforations, and a subanalysis of BSCVA at 3 months in patients with an enrollment visual acuity of 20/40 to 20/400. Results: Compared with those who received natamycin, voriconazole-treated patients had an approximately 1-line improvement in BSCVA at 3 months after adjusting for scraping in a multivariate regression model but the difference was not statistically significant (P=.29). Scar size at 3 months was slightly greater with voriconazole after adjusting for scraping (P=.48). Corneal perforations in the voriconazole group (10 of 60 patients) were not significantly different than in the natamycin-treated group (9 of 60 patients) (PϾ.99). Scraping was associated with worse BSCVA at 3 months after adjusting for drug (P=.06). Patients with baseline BSCVA of 20/40 to 20/400 showed a trend toward a 2-line improvement in visual acuity with voriconazole (P=.07). Conclusions: Overall, there were no significant differences in visual acuity, scar size, and perforations between voriconazole-and natamycin-treated patients. There was a trend toward scraping being associated with worse outcomes. Application to Clinical Practice: The benefit seen with voriconazole in the subgroup of patients with baseline visual acuity of 20/40 to 20/400 needs to be validated in a confirmatory clinical trial.

Nine cases of Acanthamoeba keratitis not associated with contact lens wear were diagnosed between July 1987 and August 1989. Patients were treated with topical neomycin-polymyxin B-bacitracin (Neosporin) drops alone or in combination with either miconazole nitrate or ketoconazole drops. At the time of data collection four patients were available for follow-up for an average of 4 months; however, four patients were unavailable for follow-up and one is still undergoing treatment. In four patients corneal infiltrates cleared completely with topical medication (Neosporin, two patients; Neosporin plus miconazole, two patients). Simple laboratory methods were found to be adequate for the diagnosis of Acanthamoeba keratitis. Therapy with Neosporin drops can result in resolution of corneal infiltrates due to Acanthamoeba species.

Ocular infection with Pseudomonas aeruginosa triggers extensive host inflammatory response and corneal damage. The purpose of present study was to investigate the gene expression of pro-inflammatory mediators interleukin (IL)-1 beta, IL-6, tumour necrosis factor-alpha (TNF-alpha),macrophage inflammatory protein (MIP)-2 and cytokine-induced neutrophil chemoattractant (KC) in the mouse eye challenged with P. aeruginosa. Scratched mouse corneas were infected with three phenotypes of P. aeruginosa individually. Total RNA was extracted from mouse eyes at 4 h, 8 h,16 h and 24 h post-challenge. Single stranded cDNA was synthesized from total RNA by reverse transcription and then subjected to polymerase chain reaction (PCR) using specific primers for IL-1 beta, IL-6, TNF-alpha, MIP-2 and KC. Results revealed three patterns of cytokines and chemokines expression in response to ocular infection with three phenotypes of P. aeruginosa. Ocular infection with the invasive strain induced the highest levels of IL-1 beta, IL-6, MIP-2 and KC mRNA, followed by the infection with the cytotoxic strain. Ocular infection with the CLARE strain induced the lowest levels of IL-1 beta, IL-6, MIP-2 and KC mRNA. The expression of TNF-alpha mRNA was very low and irregular following P. aeruginosa challenge. These data indicate that over-expression of pro-inflammatory cytokines and chemokines may represent a vigorous immune response and therefore may contribute to corneal damage during P. aeruginosa infection.

During a one-year survey 283 corneal ulcers from 274 patients were seen at St John's Eye Unit of Baragwanath Hospital. Central bacterial ulcers constituted the largest problem, and the commonest isolate in this group was Streptococcus pneumoniae. Mycotic and dendritic keratitis were relatively uncommon, while marginal catarrhal ulceration secondary to chronic staphylococcal lid disease was frequently seen. The microbiology of the various ulcers is described, and the placing of organisms into classes is stressed in determining significance of isolates. Many of the patients were male Africans who were either manual labourers or unemployed. Half the patients had used topical antibiotics before presentation.

Ocular mucous membrane pemphigoid presents some of the most challenging dilemmas in anterior segment management. Diagnosis is made difficult by the insensitivity of immunopathological investigations and the differential diagnosis of other scarring conjunctival disorders. The management of the associated ocular surface disease involves control of blepharitis, dry eye, filamentary keratitis, keratinization, lid malposition, and persistent epithelial defect, as well as the identification and avoidance of toxicity. Inflammation associated with the underlying disorder demands the use of systemic immunosuppressive therapy in many patients. New biological immunotherapies have been used when conventional immunosuppressive therapies fail. Ophthalmic plastic surgery is essential for the management of lid malposition and corneal exposure. Improving vision may require the use of specialized contact lenses, cataract surgery, and corneal and ocular surface reconstructive surgery. All surgery must be integrated with ocular surface treatment and immunosuppressive treatment to avoid disease exacerbations.

To investigate the incidence and epidemiologic factors involved in the development of microsporidial keratitis. The association of host immune status and clinical pattern, clinical features, and the role of fluoroquinolone monotherapy in treatment are also examined. Retrospective, noncomparative case series. All cases (124 patients, 134 eyes) of microsporidial keratitis confirmed with modified trichrome stain positive of corneal scrape over a 4-year period. Epidemiologic factors were observed. Host immune status with human immunodeficiency virus (HIV) serology and CD4/CD8 analysis was performed when consent was obtained. Visual acuity (VA) and slit-lamp examination throughout the course of keratitis was recorded. Treatment used included topical fluoroquinolones (ciprofloxacin 0.3%, moxifloxacin 0.5%, gatifloxacin 0.5%, levofloxacin 0.5%, or norfloxacin 0.3%) as monotherapy or in combination with topical fumagillin and/or systemic albendazole. Where corneal edema developed, ultrasound corneal pachymetry was recorded. Demographic features and epidemiologic factors, including host immune status. Clinical features and disease course, including the response to different therapeutic regimes. Patients ranged in age from 11 to 68 years (mean, 31.9; median, 30) with a male:female ratio of 8:1 (females n = 17 [13.7%]). We performed HIV serology and CD4/CD8 in 45.9% of cases (n = 57); all the cases tested were negative with normal T-cell indices. Epidemiologic factors included soil exposure (50%), contact lens wear (21.1%), and topical steroid treatment (17.1%). The VA on presentation ranged from 20/20 to 20/100 (median, 20/30) with no loss in lines of VA on resolution. Common features were follicular papillary conjunctivitis and coarse punctate epithelial lesions in 3 patterns--diffuse, peripheral, and paracentral--evolving into nummular keratitis before resolution. Resolution occurred in 99% of cases on topical fluoroquinolone monotherapy. Four patients had recurrent disease that resolved with repeat fluoroquinolone or fluoroquinolone/oral albendazole combination. Two new clinical features were identified--diffuse endotheliitis (19.4%) with corneal edema and limbitis. This study identifies an increasing incidence of microsporidial keratitis in Singapore with a strong correlation with prior soil exposure. Diffuse endotheliitis and limbitis have not been described and resolves with topical steroid therapy. Topical fluoroquinolone monotherapy is a valid treatment option.

To elucidate risk factors, microbial culture results, and visual outcomes for infectious keratitis after photorefractive keratectomy (PRK). Multicenter, retrospective chart review, case report, and literature review. The records of 12 patients with infectious keratitis after PRK were reviewed. Causative organism, response to medical treatment, and visual outcome. Infectious keratitis developed in 13 eyes of 12 patients after PRK. Organisms cultured were Staphylococcus aureus (n = 5), including a bilateral case of methicillin-resistant Staphylococcus aureus; Staphylococcus epidermidis (n = 4); Streptococcus pneumoniae (n = 3); and Streptococcus viridans (n = 1). Four patients manipulated their contact lenses, and 2 patients were exposed to nosocomial organisms while working in a hospital environment. Prophylactic antibiotics used were tobramycin (nine cases), polymyxin B-trimethoprim (three cases), and ciprofloxacin (one case). Final best spectacle-corrected visual acuity ranged from...

PURPOSE: To describe the clinical manifestations and confocal microscopic findings in a patient with delayed mustard gas keratopathy. METHOD: Case report. A 32-year-old veteran who had participated in the Iran-Iraq conflict was exposed to mustard gas in 1988. Ocular abnormalities in 1996 and 1998 and corneal confocal microscopic findings in 1998 are presented. RESULTS: In 1996, slit-lamp examination disclosed bilateral limbal changes with tortuous blood vessels and full-thickness corneal alterations. In 1998, the right eye had porcelain-white episcleral changes and adjacent peripheral ulcerative keratopathy. Confocal microscopy demonstrated irregular-appearing epithelial and basal epithelial cells. The anterior stroma was remarkable for spindle-like keratocytes, diffuse fibrillar inhomogeneities and the presence of highly reflective material. CONCLUSIONS: Mustard gas keratopathy is a uncommon cause of ocular damage, but it may lead to delayed ocular damage. (Am J Ophthalmol 1999;128:506 -507.

Paecilomyces lilacinus is a fungal pathogen which is generally resistant to amphotericin B and certain other antifungals and is an uncommon cause of devastating fungal keratitis. In the present studies, we evaluated topical voriconazole as therapy for P. lilacinus keratitis in rabbits. Thirty eyes of 15 rabbits were studied. In five animals, the uninfected left eye was treated twice daily with voriconazole (drug control, uninfected eye). In these same animals, the right eye was infected with P. lilacinus but not treated with voriconazole (infection control eye). By day 5, the infection controls had lesions of >2.4 mm in diameter, with conjunctivitis and severe hypopyon, and were sacrificed. In the other 10 rabbits (voriconazole treatment), the right eyes were infected with P. lilacinus and treated with voriconazole beginning on day 3 after infection. Voriconazole therapy caused lesions to decrease during 8 days of therapy, after which rabbits were sacrificed (11 days postinfection). Hyphal masses were present in the control infected eyes and absent in treated infected eyes. Voriconazole was detected in all tissues of treated eyes. Topical voriconazole is effective treatment for P. lilacinus experimental keratitis, and it penetrates more deeply than the corneal tissue.

To evaluate the in vitro activity of fluoroquinolones against Mycobacterium abscessus and Mycobacterium chelonae isolated from outbreaks of infectious keratitis in Brazil. Micobacterial isolates were recovered from infectious keratitis cases related outbreaks that occurred in Brazil after LASIK for myopia. Two outbreaks occurred in Rio de Janeiro in 1998 and 1999, and 3 in São Paulo between 2000 and 2003. All laboratorial analysis, including molecular identification and antibiotic susceptibility testing with determination of the minimum inhibitory concentration (MIC) levels for ciprofloxacin, ofloxacin, gatifloxacin, and moxifloxacin, were performed at Universidade Federal de São Paulo in Brazil. Fifteen samples were identified as M. chelonae, and 3 were identified as M. abscessus. The outbreaks studied were designated SP-1 in 2000; SP-2 in 2000-2001; and SP-3 in 2003, R1 in 1988 and R2 in 1999. All but 1 of the M. chelonae were resistant to all fluoroquinolones with an MIC90 greater than 32 microg/mL. The only susceptible isolate had MIC levels for ciprofloxacin, ofloxacin, gatifloxacin, and moxifloxacin of 0.38 microg/mL, 0.032 microg/mL, 0.047 microg/mL, and 0.19 microg/mL, respectively. MIC levels for all 3 M. abscessus isolates tested were greater then 32 microg/mL for all fluoroquinolones tested. Fluoroquinolone MICs for 17 M. abscessus and M. chelonae isolates recovered from infectious keratitis cases in Brazil indicate that they are not susceptible to these drugs in vitro. Further studies to investigate the in vivo effectiveness of fluoroquinolones against mycobacteria are required because in vitro tests do not support their use in the treatment of micobacterial keratitis in this particular geographic area.