[ad_1]
January 06, 2026
9 min read
Key takeaways:
- On stage at OSN New York, experts discussed several unique corneal cases.
- These cases included a fungal infection after PRK and a patient with decreased corneal sensation after LASIK.
At OSN New York, Healio | OSN Cornea/External Disease Board Member Eric D. Donnenfeld, MD, and a panel of experts examined a series of unusual complications that occurred after routine refractive procedures.
The panel broke down how to address antibiotic-resistant corneal infiltrates after surface ablation, fungal infections and promising results with Tryptyr (acoltremon ophthalmic solution 0.003%, Alcon).
Image: Taylor Linaburg, MD
“We’ll see if we can stump these experts on a few of these difficult cases,” Donnenfeld said.
Corneal infiltrate after routine surface ablation
Eric D. Donnenfeld, MD: This case came in a few months ago while Dr. Shoshany was our fellow. The patient underwent an uneventful bilateral surface ablation in New York City and came back to our office 1 week later. One of the patient’s corneas is shown in Figure 1.
Source: Eric D. Donnenfeld, MD
Dr. Shoshany, what was your thought process when this patient walked in? The patient was on an antibiotic already — my usual drop is a fluoroquinolone, ofloxacin or moxifloxacin — and despite the fact that they were taking this antibiotic four times a day, they developed a corneal infiltrate. Would you increase the current antibiotic to every hour, or would you do something differently?
Talia Shoshany, MD: I was definitely worried about infectious keratitis here, potentially resistant to whatever antibiotic the patient is already on. And given the infiltrate’s location and size, I would want to culture this. I was worried about a fungal infection because of the fluffy-looking appearance. Also, the patient was probably on steroids, which is not a great idea.
Talia Shoshany
Donnenfeld: Those were my concerns as well. When a patient has a corneal ulcer and has been on antibiotics, whatever that organism is, it is almost certainly going to be resistant to whatever you have been treating it with. Dr. Starr, what is the weakness of fluoroquinolone, and what does it miss when you talk about antibiotics?
Christopher E. Starr, MD, FACS: It does not do much for fungus and Acanthamoeba, and it is usually not great for gram-positive bacteria. At least in my experience, it is better for gram-negatives. There is a lot of resistance now because we have overused fluoroquinolones for many years.
Donnenfeld: So, you are certainly missing fungus and gram-positives. MRSA would be the most common bacteria that you would be worried about, and if you are going to treat it with an antibiotic, and the patient is already on a fluoroquinolone, what would you add that might cover gram-positives?
Starr: Usually, I use Polytrim (polymyxin B sulfate and trimethoprim ophthalmic solution, AbbVie) for mild gram-positive infections and vancomycin for severe gram-positive infections. I also preferentially choose anti-infective drops that contain benzalkonium chloride (BAK) when treating severe corneal ulcers because BAK itself has antimicrobial potency, and when the epithelium has covered a fluffy infiltrate like this, a little epithelial BAK toxicity can facilitate corneal penetration.
Christopher E. Starr
Donnenfeld: Yes, there are three good commercially available antibiotics for gram-positives: Polytrim, Neosporin (neomycin sulfate, bacitracin zinc and polymyxin B sulfate, Kenvue Brands) and bacitracin. They all have great MRSA coverage, but vancomycin is the gold standard. You would want to use vancomycin if it is available to you.
Fungal infection after PRK
Donnenfeld: The next day, two additional patients who underwent surface ablation were referred to us. One patient had bilateral infiltrates, one had unilateral infiltrates, and corneal scraping revealed fungal elements. As an aside, for those of you who think PRK is safer than LASIK, sometimes it is, but when it comes to infectious disease, there are about five times more infections with PRK than LASIK. PRK has other advantages, though.
The four eyes that were involved are shown in Figure 2. These patients had healthy eyes 1.5 weeks earlier. The top two images are the same patient, the bottom left is the case referenced earlier, and the bottom right is the worst eye, with a hypopyon and pending perforation. This patient was referred to us on prednisolone acetate twice daily. What changes would you make?
Shoshany: I would stop the steroid.
Donnenfeld: Absolutely. If you stop the steroid and the eye is inflamed, you can use a nonsteroidal or you can use cyclosporine. I like natamycin, but I find it does not penetrate tissue well. So, I switched the patient over to topical voriconazole, and we had oral voriconazole as well. The patient then perforated, so we have a perforated fungal ulcer. Dr. Epitropoulos, what do you do?
Alice T. Epitropoulos, MD, FACS: This patient with a fungal corneal infiltrate and corneal perforation should be taken to the operating room without delay.
Donnenfeld: Yes. If the perforation is small, sometimes you can glue it and buy some time. But the problem with glue is it blocks the transmission of antifungal agents, and fungus can grow under the glue. So, we did a therapeutic keratoplasty. Is there any chance that this cornea will survive?
Marguerite B. McDonald, MD, FACS: None.
Marguerite B. McDonald
Donnenfeld: No chance at all. So, I did a keratoplasty and continued with topical medications. In these difficult cases, what I am worried about is not so much the corneal ulcer in the center of the cornea but the corneal ulcer spreading into the sclera. Once these infections get into the sclera, the eye is lost. So, what can you do to reduce the risk of spreading into the sclera?
McDonald: Intrastromal and subconjunctival injections.
Donnenfeld: In a different case, I used a 30-gauge needle and injected voriconazole into the stroma adjacent to where the infection was, and then I gave a subconjunctival injection. I find that this acts as a barricade to prevent the disease from spreading into the sclera.
What postoperative medications would you use in these patients, and when would you start steroids?
McDonald: Topical cyclosporine. I would hold the corticosteroids for a while.
Donnenfeld: Right. An interesting fact is that cyclosporine is derived from the fungus Tolypocladium inflatum Gams. It has potent antifungal effects, so it kills fungus pretty effectively. We like to use a topical cyclosporine, and I like a high concentration. There are a couple of cyclosporines that are available, and I generally like to use something that penetrates well into the tissue. I like higher concentrations than Restasis (cyclosporine ophthalmic emulsion 0.05%, AbbVie), and I use it four times a day.
In this case, I continued with oral and topical cyclosporine and moxifloxacin, and 7 days later, the cultures came back. Two of the infiltrates grew out Paecilomyces lilacinus. I had never seen a fungal ulcer from this, but there are case studies out of Bascom Palmer that showed that oral posaconazole has a better effect than voriconazole. Dr. Shoshany, because this is not a well-tolerated drug, what side effects should we worry about?
Shoshany: There is risk for hepatotoxicity and potentially some arrhythmias. It is important to make sure that the patient follows up with their primary care provider.
Donnenfeld: The patient showed slow improvement, and 6 weeks later during the transplant, the cornea stayed clear, which is amazing. Six months later, we took the sutures out, and the patient developed a mild graft rejection, but other than that, the cornea stayed remarkably clear.
Decreased corneal sensation after hyperopic LASIK
Donnenfeld: A 56-year-old woman presented with poor vision 3 months after hyperopic LASIK — I almost never do hyperopic LASIK on patients older than 50 years any longer — and was referred for topographic PRK. Best corrected visual acuity was 20/50 in the left eye. The patient had seen three eye doctors and was treated with tears, loteprednol and cyclosporine. The tomography is shown in Figure 3. The right eye looked like a classic hyperopic LASIK, and in the left eye, the cornea was a little bit irregular. The ablation was not central, so the patient was referred to me for topographic laser. What is your thought process? I will give you a hint: What is the first thing you want to do in any patient who is considering corneal refractive surgery? You want to check the tear film. Dr. Epitropoulos, you see that the cornea is irregular, but you want some more information, so how would you evaluate the tear film in this patient?
Epitropoulos: It is important to optimize the health of the ocular surface before these patients undergo any kind of refractive surgery, especially hyperopic, because you are getting a wider flap. Then, check for corneal sensation.
Donnenfeld: Right. When we looked at the patient, there was a line of lissamine green staining just below the visual axis (Figure 4). It looked like exposure keratitis to me, but the patient did not undergo blepharoplasty. We did a deeper dive, had the patient close their eyes tightly and found that they did not have a Bell’s phenomenon. The eye did not roll up like the other one, but it did not roll down either, so this patient may have nocturnal lagophthalmos. Then, I measured corneal sensation. What is going on here, Dr. Epitropoulos?
Epitropoulos: She obviously had reduced corneal sensation in that left eye. I am not sure what was causing it.
Starr: The Brill noncontact esthesiometer has recently elevated my ocular surface diagnostic armamentarium immensely because my techs are now testing corneal sensation in the routine “dry eye” workup. The great thing about the Brill is that it does not disrupt the epithelium, and it not only detects reduced corneal sensation in neurotrophic keratitis, but it also detects increased corneal sensitivity in neuropathic corneal pain cases. These diagnoses are often missed entirely or significantly delayed, but with this new diagnostic tool, we are able to screen for, and often diagnose, these less common corneal conditions at the very first visit.
Donnenfeld: Why would someone have monocular decreased corneal sensation?
Epitropoulos: Reduced corneal sensation suggests impairment of the trigeminal nerve. This can occur for several reasons including chronic use of glaucoma drops or herpes simplex virus keratitis, or it could be due to a neurologic reason.
Alice T. Epitropoulos
Donnenfeld: Midway through the exam, the patient said to me, “I didn’t mention it, but 10 years ago, I had an acoustic neuroma and had surgery for that. Could that possibly be important?” So, the patient had an acoustic neuroma and no corneal sensation in that eye. How are you going to manage this patient?
McDonald: I would apply an amniotic membrane while I ordered Oxervate (cenegermin-bkbj ophthalmic solution 0.002%, Dompé).
Donnenfeld: That is what we did. We are presenting a paper at this year’s American Society of Cataract and Refractive Surgery meeting showing that amniotic membranes and contact lenses have a high incidence of corneal infections. We are doing more lid closures, and I have become more interested in cryopreserved amniotic membranes as they have been shown to increase corneal innervation. This patient received a contact lens, but now we are using collagen shields more because of the higher incidence of infection.
The patient did well with this therapy, and the Schirmer score was down. But if the patient did not respond, Dr. McDonald, would you go straight to Oxervate?
McDonald: Yes. They have neurotrophic keratitis, but it takes a few days to get the drug, so the amniotic membrane helps tremendously.
Donnenfeld: I agree. We start with amniotic membranes, and I will sometimes add serum tears to this as well, which I think are underutilized. Before I go to an expensive therapy, I will commonly use a cryopreserved amniotic membrane, I will try serum tears, and then if that does not work, Oxervate is my go-to, which I also think is underutilized in these cases.
Epitropoulos: In addition to the measures already discussed, consider starting the patient on an immunomodulator, adding a high-quality omega-3 and then potentially adding acoltremon.
Donnenfeld: The Schirmer score in that eye was 3. The patient has no corneal sensation, so the reflex to produce tears was not there. We put this patient on cyclosporine in a non-aqueous vehicle and a cross-linked hyaluronic punctal plug. Consider using serum tears.
Additionally, I added acoltremon. This is a new drug just approved by the FDA that I wanted to talk about.
McDonald: Acoltremon is a unique approach to dry eye. In between blinks, our eye actually cools off by a fraction of a degree. This activates the TRPM8 cool-sensing receptors, and that signal shoots through the trigeminal ganglion system to the lacrimal functional unit, producing a natural tear.
There are other receptors on the surface that respond to irritation and pain, but the cool-sensing receptor, TRPM8, is the one that is stimulated here. In a way, it does what Tyrvaya (varenicline solution, Viatris) does but without the bad taste or having to stick something into your nose. A patient’s own tears are the best tears, right? They are better than anything we can give them.
Shoshany: Is this effective even without a working trigeminal nerve?
Donnenfeld: Yes. It has not been studied, but we have had good success with it. The interesting thing about this is that this is an example in which you have basic science being translated into clinical practice. Why do we have basal-controlled metabolism? What is it that gives us the ability to create tears and to control our body temperature? There are two different receptors, as Dr. McDonald said. There is the polymodal receptor, which you can feel — if you cut onions, the irritation is palpable, and if you get a foreign body in your eye, it is palpable — but you do not even know that your eyes are cooling off. The cool-sensing receptors here will sense 0.1°C of cooling in the eyes. When your tear film thins, your eye becomes cooler, so it will produce tears. The results of the FDA trials are impressive, showing that almost 50% of patients who received acoltremon had a Schirmer score increase of more than 10 mm.
For more information:
Eric D. Donnenfeld, MD, of Ophthalmic Consultants of Long Island, can be reached at ericdonnenfeld@gmail.com.
Alice T. Epitropoulos, MD, FACS, of Central Ohio Eye and Plastic Surgery, The Eye Center of Columbus, can be reached at eyesmd33@gmail.com.
Marguerite B. McDonald, MD, FACS, of OCLI Vision in New York, can be reached at margueritemcdmd@aol.com.
Talia Shoshany, MD, of Ophthalmic Consultants of Long Island, can be reached at talia.shoshany@gmail.com.
Christopher E. Starr, MD, FACS, of Weill Cornell Medicine Ophthalmology, can be reached at cestarr@med.cornell.edu.
Sources/Disclosures
Source:
Healio Interviews
Reference:
Disclosures:
Donnenfeld reports having financial disclosures for AbbVie, Alcon and BioTissue. Epitropoulos reports having financial disclosures for Alcon, AbbVie, Aldeyra, Bausch + Lomb, BioTissue, CSI Dry Eye, Dompé, Harrow, PRN and Sun Pharma. McDonald reports having financial disclosures for Alcon, DefEYE and Dompé. Shoshany reports no relevant financial disclosures. Starr reports consulting for Alcon, Allergan/AbbVie, Allgenesis, Amgen, Azura, Bausch + Lomb, BlephEx, Bruder Healthcare, Dompé, Essiri LLC, Eye Care International, Glaukos, Johnson & Johnson Vision, Kala Pharmaceuticals, Lumenis, Novaliq, Novartis, NuVissa, Oculis, Oyster Point Pharma, Quidel, Sight Sciences, Sofia Biologics, Sun Pharma, Syneos, Tarsus Pharmaceuticals, Thea Pharmaceuticals, Trukera Medical and Verséa Ophthalmics and having stock in Essiri Labs, CSI Dry Eye, Sofia Biologics, NuVissa and Ocubio.
Ask a clinical question and tap into Healio AI’s knowledge base.
- PubMed, enrolling/recruiting trials, guidelines
- Clinical Guidance, Healio CME, FDA news
- Healio’s exclusive daily news coverage of clinical data
[ad_2]
Source link
