Recently, longitudinal spectral-domain OCTA follow-up of CNV from several diseases including nAMD showed the overall decrease in greatest linear dimension and area after anti-VEGF treatment , although type 1 NV may be more resistant . In this current case, en-face SS-OCTA using an intensity and phase-based contrasting microangiography algorithm-(OMAGC) with 100,000 A-scans per second, clearly demonstrated a vascular trunk of the extrafoveal type 1 NV and the type 2, “medusa-like” component , which was leaking into the subretinal space. We elected to use combination treatment with bevacizumab and PDT to target the type 2 component with anti-VEGF, and PDT to decrease the size and flow and prevent maturation of the extrafoveal, type 1 lesion. Successful combined treatment has been similarly observed in myopic classic CNV  and in PCV . Type 1 NV has been shown to be quite extensive on OCTA and may represent a more chronic, mature neovascular complex resistant to repetitive anti-VEGF therapy [9,12]. Early treatment with combined anti-VEGF and PDT therapy may be more effective in pruning the type 2, subretinal component and controlling the type 1, sub-RPE vessels before abnormalization therefore possibly preventing future recurrence and need for continuous anti-VEGF injections.
The risk of chorioretinal atrophy after PDT remains a significant issue. It has been speculated based on conventional FA, which showed early hypoperfusion of the choroidal circulation, that PDT may damage the normal choroidal vascular network . In this case, we did note that there was minimal collateral damage to the surrounding normal choriocapillaris. Even with presumed accurate identification of the NV membrane with conventional FA or indocyanine green angiography (ICGA), the size of the treatment area may still be overestimated due to borders of the lesion being obscured by dye leakage. SS-OCTA allows for a clear and objective identification of the extent of the lesion; and future use of OCTA when planning PDT treatment may be warranted to accurately identify the required treatment area especially due to its increased depth Sildenafil mesylate compared to FA or ICGA.
Instruction on appropriate contact lens hygiene is important to reduce the risk of adverse events. One of the most significant complications of contact lens wear is microbial keratitis. Up to 65% of all new microbial keratitis cases are caused by contact lens wear [1,2]. The incidence of microbial keratitis is 0.1–0.2% in soft extended-wear contact lens users [3–5]. Contact lens-related complications and keratitis cost an estimated $175 million annually in the United States and involve more than 250,000 clinician hours .
We report a case of bacterial keratitis in a contact lens user secondary to Pantoea agglomerans and Escherichia vulneris, Gram-negative bacteria that are extremely rare in the human eye. A PubMed review did not yield any prior reports of bacterial keratitis associated with either of these organisms. In addition, this is the first report of the antibiotic sensitivities of E. vulneris in the setting of an ocular infection.
On presentation, visual acuities were 20/30 OD and 20/25 OS. Examination of the right eye was normal. Slit lamp examination of the left eye revealed 1+ diffuse conjunctival injection and a 2.5 mm round paracentral corneal epithelial defect inferiotemporal to the visual axis involving 20% of the stroma. The patient was started on ciprofloxacin hourly when awake and homatropine 2% every 8 h. There was no change in symptoms the following day, and vision had decreased to 20/60 OS. Corneal scrapings were sent for routine and fungal cultures. The cultures were positive for P. agglomerans, E. vulneris, and Staphylococcus sp. Antibiotic sensitivities showed P. agglomerans and E. vulneris pansensitive to all tested antibiotics and Staphylococcus sp. resistant to clindamycin, erythromycin, gentamicin and oxacillin. Fig. 1 shows gram staining and growth plates for P. agglomerans and E. vulneris. Complete antibiotic sensitivities are shown in Table 1. The patient was started on fortified vancomycin and tobramycin drops, alternating between the two every hour when awake. The symptoms and clinical exam improved over several weeks, antibiotics were tapered and visual acuity returned to 20/25. At the last examination, the patient had only minimal punctate epithelial defects in the area of the ulcer, and was recommended to use artificial tears.