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Corneal Infections in the setting of Epithelial Basement Membrane Dystrophy

Corneal Infections in the setting of Epithelial Basement Membrane Dystrophy.

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Corneal Infections in the setting of Epithelial Basement Membrane Dystrophy

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  1. Corneal Infections in the setting of Epithelial Basement Membrane Dystrophy Melissa B DaluvoyMD, NeelofarGhaznawi MD, Kristin M Hammersmith MD, Edwin S Chen MD, Christopher J Rapuano MD, Elisabeth J Cohen MDCornea Service, Wills Eye Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA The authors have no financial interest in the subject matter of this poster

  2. Introduction: • 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 (RES)1. • 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 RES2. In our experience EBMD is a small, but real, risk for infectious keratitis.

  3. 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

  4. Purpose: To describe infectious keratitis due to underlying hereditary EBMD and EBM changes from previous trauma.

  5. Methods: • 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, bullouskeratopathy, 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.

  6. Results: • 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 • 6 (46.2%) patients were started on fortified antibiotics/antifungals on their 1st visit. • Pathogens included S. aureus, S. epidermidis, P. aeruginosa, MRSA, and Candida. • One patient was hospitalized and treated for corneal perforation.

  7. Results:

  8. Results:

  9. Previous studies: culture results3-8 3 cultured; all were pos: Pseudomonas; S. aureus (2) 2 cultured = all neg 11 cultured = S. aureus (2) 1 cultured = all neg 5 cultured = all neg

  10. Conclusion: • EBMD is known to cause considerable morbidity including ocular pain, RES and decreased vision8. • 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.

  11. References: • Anterior Segment The Requisits. Rapuano, Luchs, Kim. Mosby, 2000. • Ibrahim YW, Boase DL, Cree IA. Epidemiological characteristics, predisposing factors and 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. ActaOphthalmol. 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; 87:378-382. • 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.

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