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.






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.
1. Anterior Segment The Requisits. Rapuano, Luchs, Kim. Mosby, 2000.
2. Ibrahim YW, Boase DL, Cree IA. Epidemiological characteristics, predisposing factors and
3.
4.
5.
6.
7.
8.
9.
10.
microbial profiles of infectious corneal ulcers: the Portsmouth corneal ulcer study. Br J
Ophthalmol. 2009;93:1319-1324.
Schoch DE, Stock EL, Schwartz, AE. Stromal keratitis complicating anterior membrane
dystrophy. Am J Ophthalmol. 1985;100:199-201.
Jaros PA, DeLuise VP. Stromal keratitis with anterior membrane dystrophy. Ann Ophthalmol.
1986;18: 283-284.
Ionides ACW, Tuft SJ, Ferguson VMG, Matheson MM, Hykin PG. Corneal infiltration after
recurrent conreal epithelial erosion. Br. J Ophthalmol. 1997; 81:537-540.
Tabery HM. Corneal stromal infiltrates in patients with recurrent erosions. Acta Ophthalmol.
Scand. 1998;76:589-592.
McElvanney AM. Hypopyon keratitis in corneal epithelial basement membrane dystrophy. Eye.
1999; 13:585-586.
Trobe, JD, Laibson PR. Dystrophic changes in the anterior cornea. Arch Ophthal. 1972; 87:378382.
Hykin PG, Foss AE, Pavesio C, Dart JK. The natural history and mangement of recurrent corneal
erosion: a prospective randomised trial. Eye (London). 1994;8:35-40.
Reidy JJ, Paulus MP, Gona S. Recurrent erosions of the cornea. Cornea. 2000;19(6):767-771.