1. Clinico-Microbiological Profile of Bacterial Keratitis in Shield Ulcers Jagadesh C. Reddy Abhishek Arunkumar Hoshing, Virender S. Sangwan The authors have no financial interests in the subject matter of this presentation ID: 17668

2. Purpose The purpose of this study was to describe the clinico-microbiological profiles and outcomes of treatment of bacterial keratitis in patients with shield ulcers due to vernal keratoconjunctivitis (VKC)

3. Methods Study design: Retrospective review of clinical records Study location: Cornea service, LV Prasad Eye Institute, India Study duration: January 2000 to December 2012 Study ethics: Approved by the institutional review board and was conducted in strict adherence to the tenets of the Declaration of Helsinki

4. Methods Data collected: Demographics Clinical features History of allergy Duration of VKC Visual acuity Culture & sensitity of organisms Duration of use of antibiotics and steroids, Resolution time Complications

5. Results Number of eyes33 Age, years11 +/- 6 years Gender, Mala : Female27:5 Laterality, Right eye : left eye 20:13 Duration of Vernal kerato conjunctivitis 44 +/- 35 months Duration of symptoms17 +/- 20 days Type of Vernal kerato conjunctivitis Mixed : 82% Palpebral: 18% Table-1, Patient characteristics

6. Results ParameterNumber (percentage) Pain21 (64%) Redness28 (85%) Itching18 (54%) Watering22 (67%) Discharge15 (45%) Photophobia18 (54%) Chemosis in the cornea8 (24%) Cellularity30 (91%) Plaque12 (36%) AC cells12 (36%) Hypopyon8 (24%) Table-2, Patient’s clinical features

7. Results At presentation, 9 (27%) patients were antibiotics, 2 (6%) patients on antifungals, 9 (27%) patients on steroids and 14 (42%) patients on antiallergic topical medications Based on smear examination fortified Cefazolin and Ciprofloxacin eye drops were started which were modified based on sensitivity report Topical antibiotics were used for at least a mean of 17 days Steroids were started simultaneously in 15 % of patients In 85% of eyes the steroids were started at least after 8 days (mean) of topical antibiotic usage

8. Results-Microbiological Profile SmearCultureCOGentA Ga t VCeCh 1 -N.meningitidis SSSSS RSS 2 - P.Alcaligenes CoNS SSR R SNA R 3 GPCStrep.PneumoniaSSNA SSSS 4 GPCStaph.aureusSNAS S 5 GPCStrep.PneumoniaSSRNASSSS 6 GPCNIL-------- 7 -H.Parainfluenza SSSSS NA N 8 GPCNo-------- 9 -Corynebacterium sRSSNARSSR 10 GNBKlebsiella spSSSNASRRS 11 GNCB Moglobinophillus Hemophilus sp SISI RRRR NA R NA SRSR RRRR RRRR SRSR 12 GPCStrep.PneumoniaSSRNASSSS 13 GPCCorynebacterium sRSSNARSSR 14 GNCNeisseria SpSSSSSNA S

9. Results-Microbiological Profile SmearCultureCOGentA Ga t VCeCh 15 GPCNo -------- 16 GNCNeisseria sicca RSSSSNA S 17 GPCNo -------- 18 - Staph.aureus Moraxella sp RRRR IIII SSSS SSSS SSSS NA SSSS 19 GPBNo 20 GNB Pseudomonas Sp Klebsiella Sp SSSS SSSS SSSS SSSS SSSS NA RSRS 21 GPCStaph.aureus RSSSSSSS 22 - Hemophilus sp SSSSSNA S 23 GPCStrept.pneumonia SSSRSSSI 24 GPCAlph.hemoly.strep SNAS S 25 GPCStrept.pneumonia SNAS S 26 GNBMoraxella sp. SSSSSNA S 27 GPCAlph.hemoly.strep SSINASSSS 28 GPBCorynebacterium s SSSNASSSS

10. Results-Microbiological Profile SmearCultureCOGentA Ga t VCeCh 29 GPBBacillus sp SSSNASSSS 30 GPCStrept pneumonia SSSRSSSS 31 GPCStrept pneumonia SSSNASSSS 32 GPC Strept pneumonia Brevibacterium SSSS SSSS SSSS NA SSSS SSSS SSSS SRSR 33 GPCStrept pneumonia SSSRSSSS GPC- gram positive cocci, GNB- gram negative cocci, GPB- gram positive bacilli, GNCB-gram negative cocco bacilli, Sp- species, S- sensitive, R- resistant, I- intermediate, NA- not applicable, C- ciprofloxacin, 0- ofloxacin, Gent- gentamycin, A- amikacin, Gat- gatifloxacin, V- vancomycin, Ce- cefazolin, Ch- chloramphenicol Complete resolution was seen at a mean of 20 days Surgical intervention was needed in 4 patients (12%) Three eyes required tissue adhesive application for corneal perforation and one eye required therapeutic penetrating keratoplasty

11. Conclusions Bacterial keratitis in shield ulcers due to VKC usually resolves completely with medical management Clinical diagnosis of secondary infection in a shield ulcer is a diagnostic challenge but thorough history and clinical features aid to a great extent The organisms isolated are sensitive to most of the commonly used antibiotics

12. References 1.Gedik S, Akova YA, Gür S. Secondary bacterial keratitis associated with shield ulcer caused by vernal conjunctivitis. Cornea. 2006 ;25:974-6. 2: Arora R, Gupta S, 2.Raina UK, Mehta DK, Taneja M. Penicillium keratitis in vernalKeratoconjunctivitis. Indian J Ophthalmol. 2002;50:215-6.3: 3.Jain V, Mhatre K, Nair AG, Shome D, Natarajan S. Aspergillus keratitis in vernal shield ulcer--a case report and review. Int Ophthalmol. 2010;30:641-4. 4.Reddy JC, Basu S, Saboo US, Murthy SI, Vaddavalli PK, Sangwan VS. Management, clinical outcomes, and complications of shield ulcers in vernal keratoconjunctivitis. Am J Ophthalmol. 2013 ;155:550-559.