Abstract

PURPOSE:

To identify the associated factors and study the clinical and microbiological characteristics of corneal
ulcers resulting in evisceration and enucleation in elderly patients in a tertiary care hospital.

METHODS:

A review of all patients who required evisceration or enucleation due to microbial keratitis at the
Royal Victorian Eye and Ear Hospital, Melbourne, Australia between July 1998 and November 2007
was performed. Of these, patients more than 60 years of age were included in the study for analysis.

RESULTS:

Forty-seven patients with microbial keratitis were included in the study. The mean age of patients
was 81 +/- 9.39 years. Major ocular factors associated were glaucoma (49%), persistent corneal
epithelial defect (38%) and use of corticosteroid eye drops (23%). Most common associated systemic
factor was rheumatoid arthritis (36%). The indications for evisceration or enucleation were extensive
non-healing microbial keratitis (22/47) and corneal perforation secondary to microbial keratitis
(17/47). Pseudomonas aeruginosa was the most common pathogen, present in 15 patients, and
more than 45% of the strains tested were resistant to chloramphenicol.

CONCLUSIONS:

Corneal ulcers that result in the loss of eye in elderly population are frequently associated with
glaucoma and persistent epithelial defects. The majority of these cases have non-healing microbial
keratitis caused by Pseudomonas aeruginosa.

introduction

Microbial keratitis is a serious acular infectious disease that can lead to significant loss of vision,or
even loss of eye in some cases (1-4) . the severity and outcome of the infection typically depends on
the virulence of the organism, and the visual prognosis relies on prompt intensive antimicrobial
treatment in response to microbiological investigation(5,6)

However ,even with the most intensive aggressive antimicrobial regime, at times treatment may fail,
and consequent uncontrolled infection can lead to more serious conditions like endophthalmitis and
extensive corneal melting,resulting in loss of eye. the outcomes may be less favourable in the elderly
population, in which there are associated ocular and systemic morbidities
in this study we present the clinical and microbiological characteristics of these cases of microbial
keratitis in the elderly

Methods

All cases of microbial keratitis that underwent enucleation or evisceration due to microbial keratitis
at the Royal Victorian Eye and Ear Hospital between July 1998 and November 2007 were identifiied
through a retrospective medical chart review. Of these,cases that were aged more than 60 years
were included in the study for analysis. The human Research Ethics Committe of the hospital
approved the study.

The diagnosis of microbial keratitis was made based on the clinical decision,and defined as the
presence of a corneal infiltrate along with an overlying epithelial defect. At initial presentation, all
cases underwent a detailed evaluation, including obtaining clinical history, recording of visual acuity
and slit-lamp biomicroscopy. Corneal scrapes were obtained using a sterile blade or needle, and
were subjected to microbiological evalution including Grams stain, Blankophor preparation,
chocolate agar, Saborauds Dextrose agar and Thioglycollate broth. A swab was taken for the
detection of herpes virus by polymerase chain reaction. Antibiotic eye drop treatment in the form of
ofloxacin or ciprofloxacin hydrochloride 0.3% was started in all cases on admission. Cyclopegic eye
drops and antiglaucoma therapy were added whenever it was required. The treatment was
modified as indicated by culture results, sensitivity pattern and clinical response.

Results

Of a total of 134 patients that underwent enucleation or evisceration over a period of 9 years at the
Royal Victorian Eye and Ear Hospital, 47 patients with microbial keratitis were included in the study.
Thirty patients (64%) underwnt evisceration, and 17 (36%) underwent enucleation. The number of
females (24) was higher than number of males (23). Mean age of these patients at the time of
diagnosis was 819.39 years (range: 62-100 years). The average duration of symptoms at the time of
presentation was 17.6833.83 days (range 1-180 days). The common indications for enucleation and
evisceration were recalcitrant extensive severe keratitis resulting in painful blind eyes (30
patient,64%) and corneal perforation (17 patients,36 %)(Table 1).

All cases that were subjected to enucleation or evisceration had avisual acuity of NPL (no perception
of light) in the affected eye.

Associated ocular factors as well as pre-existing systemic disease (Table 2) were identified in 45
patients (96%). The most common associated ocular disease was glaucoma, identified in 23/47 (49%)
patients. Most common associated systemic disease was rheumatoid arthritis(36%). Thirty eight
patients (81%) had more than one associated ocular factor, and 34 patients (72%) had more than
one pre-existing systemic disease. On presentation, 17(36%) patients were using chlorampenicol
0.5% in the form of eye drops (n=15) or eye ointment (n=2), six patients were using ciprofloxacin 0.3
% eye drops, and two patients were using ofloxacin 0.3% eye drops. Eleven out of 47 (23%) patients
were on long-term corticosteroid eye drops before presentation (table 2). Two patients had
associated bacterial endophthalmitis that was diagnosed based on clinical and ultrasonographic
findings. In addition to topical antibiotic treatment, intravitreal vancomycin 5% was used in these
patients during the course of the therapy.

Cultures were positive in 33 (70%) patients. Of the,33 had positive isolates, 27(82%) had one
bacterial isolates, and eight (24%) had an additional bacterial isolate. Pseudomonas aeruginosa was
the most common pathogen, present in 15 patients (table 3). Of these 15 cases, three were on
concomitant corticosteroid eye drops. Initial isolates consisted of Gram-positive bacteria in 50% of
cases and gram-negative bacteria in 50% of cases. In six patients (13%), polymerase chain reaction
was positive for herpes simplex virus (HSV). Of these six patients, all had previous history of herpetic
eye disease, and four patients were culture positive for bacteria( Table 3).

Two patients had a positive fungal culture (Aspergillus fumigatus and Canduda albicans). The
patients with Aspergillus fumigatus was also culture-positive for bacteria Corynebacterium,while the
patient with Candida Albicans was culture-positive for Staphylococcus aureus.

All isolated bacteria were tested for antibiotic suspectibility. The in vitro antimicrobial sensitivity
result are shown in table 4. Of strain tested, 60.7% were resistant to neomycin and 45.5% to
chlorampenicol. None were resistant to ofloxacin,tobramycin or ceftazidime.

Treatment of the infection consisted of intensive topical antibiotics. Only one patient received oral
antibiotics in addition to the topical antibiotics. Topical ciprofloxacin hydrochloride 0.3% was the
most commonly used antibiotic (23 eyes).

Discussion

Microbial keratitis is an important cause of severe visual loss in elderly patients in developing as well
as developed countries. Older age along with associated factors such as delay in referral, past ocular
surgery and topical corticosteroid treatment, has been associated with poor visual outcomes as
compared to younger patients [7]. Although previous studies have reported poor visual outcomes in
patients over 60 years of age with microbial keratitis [8], there has been no study from Australia that
has analysed the factor associated with cases of microbial keratitis resulting in loss of eye in the
elderly population. We analysed the cases at our hospital that lost their eyes secondary to microbial
keratitis.
The incidence of poor outcome leading to loss of eye in cases of microbial keratitis in the elderly that
has been reported in other studies varies between 7% and 15%[9-11]. In our hospital , the most
common indications for enucleation and evisceration in this age grup were non resolving severe
keratitis (30 patients,64%) and corneal perforation (17 patients,36 %). The variables found to be
associated with adverse outcomes in cases of microbial keratitis in the past include severe infection
[12-15], advance patient age [13,16,17]. Poor visual acuity at the presentation [13,15,17], associated
herpetic keratitis [14,18], ocular surface disease[12],associated systemic disease [12], prior
treatment with steroid [19], and a delay in seeking treatment [20]. Failure to use fortified antibiotics
has also been found to be associated with poor prognosis in cases with microbial keratitis [20]. In
our patients,glaucoma, persistent epithelial defect and use of corticosteroid eye drops were the
major associated ocular factors associated with eye loss. Association of glaucoma in cases with
severe microbial keratitis has been cited in previous studies [2,21]. The incidence of associated
glaucoma in our study was higher than in previous studies[10,11]. Presence of glaucoma can lead to
corneal epithelial abnormalities directly,as well as due to the use of antiglaucoma medications that
can further predispose to the developement of microbial keratitis.

At the time of presentation, 36% of the patients were using topical chloramopenicol. This is
important,considering the fact that a significant number of bacteria (45%) isolated were resistant to
chloramphenicol. This is important,considering the fact that a significant number of bacteria (45%)
isolated were resistant to chlorampenicol. This may also explain the high level of resistance against
this particular drug. In all these cases , chloramphenicol was started as the first-line therapy by the
attending general practicioner before referring these patients to the specialist. Twenty-three
percent of our patients were on long-term corticosteroid eye drops. Long-term use of corticosteroid
is an important factor that can lead to the occurence of microbial keratitis. The prolonged use of
corticosteroids decreases the efficiacy of the local immune response,increasing the patients
susceptibility to microbial keratitis[22]. Steroid use also increases the risk of acquiring an infection or
worsening the existing infection in these patients,by increasing the virulence of infective organism
[19].

We also studied the association of significant systemic diseases in these patients, and found that
36% of the patients were suffering from rheumatoid arthritis. This is higher than in the previous
studies [10. 11]. Cases with rheumatoid arthritis have associated dry eyes which predispose these
patients to the development of microbial keratitis. In the context of rheumatoid arthritis, corneal
melting and perforation are more likely to occur in the presence of microbial keratitis and dry eyes
[21, 23]. Moreover, patients with rheumatoid arthritis may not be able to instill the drops efficiently,
thereby adding on to the morbidity.
 Severity of microbial keratitis mostly depends on the vinilence of the causative organism. Of
all the bacteria, Pseudomonas is known to cause severe corneal infection that can result in complete
dorneal melting within a very short duration. Laibson et al. [2] have reported Pseudomonas and
Streptococcus as the main causative organisms for the occurence of microbial keratitis in cases
undergoing enucleation or eviseceration. A significant number of cases (35%) in our series also had
infection caused by Pseudomonas, with rapid progression of microbial keratitis and poor outcome.

Prompt diagnosis and effective treatment is a key to the successful management of any case
of microbial keratitis. Delay of even a few hours, especially in cases of microbial keratitis caused by
Pseudomonas, may have an adverse impact on treatment outcome [20]. In their study, Green et al.
Found that poor visual outcomes in cases with microbial keratitis were associated with severe
disease at presentation that may be related to delay in treatment of cases [1]. Ther median duration
of symptomps before initial examination in the study by laibson et al. Was 11.4 days [2]. Another
retrospective review of outcomes of tratment of microbial keratitis in older patients has highlighted
that these individual comprise a heterogenerous group, with multiple associated factors that may
portend poor prognosis in these patients [10]. Our study comprised of elderly patients who
presented with a long history of symptomps averaging about 18 days. This delay was probably an
important risk factor in spreading the infection inside the eyes, thereby leading to a poor visual
outcome.