Devastating endophthalmitis following penetrating ocular injury during night sleep from orthodontic headgear: case report and literature review

Clinical Insights: Antimicrobial Therapy for Infectious Uveitis

Infectious uveitis is a major global cause of vision impairment. Despite the eye's immune privilege, afforded by the blood-ocular barrier that restricts microbial entry, several pathogens such as bacteria, viruses, fungi, and parasites can still infiltrate and cause ocular infections and complications. Clinicians often encounter significant challenges in treating infectious uveitis due to limited or ineffective treatment options. Modern molecular techniques and imaging can aid in diagnosing and assessing intraocular infections. Various antimicrobial therapies exist, spanning topical and systemic treatments, but these are constrained by issues like drug concentration, penetration, effective duration, toxicity, and side effects. Treatment approaches also differ based on the infection's etiology. This review provides recent updates on antimicrobial therapies from a clinical perspective, covering topical, systemic, and regional treatments for infectious uveitis.

Orthodontic maximum anchorages in malocclusion treatment: A systematic review and network meta-analysis

OBJECTIVE

We did a network meta-analysis and systematic review among patients seeking for maximum anchorage and provided a guidance of selecting certain systems in clinical practice.

METHODS

Seven databases were searched, and randomized controlled trials (RCTs) published with no language restrictions from January 1994 to February 2021 comparing any of the following seven anchorage systems for maximum anchorage orthodontic treatment were selected(PROSPERO: CRD42019117995). A network meta-analysis (NMA) was then conducted to integrate direct evidence with indirect evidence based on logical inference to compare and rank treatments for maximum anchorages in the capacity of maintaining anchorage and duration of total treatment time.

RESULTS

Nine publications with 522 participants were considered eligible and were taken into evaluation. According to the capacity of anchorage reinforcement, three skeleton anchorages including miniscrew implants, midpalate implants and Onplant midpalate implants were significantly more effective than conventional anchorages including headgears, TPAs and Nance buttons respectively. According to conventional anchorages, headgears and Nance buttons were significantly more effective than TPA. The strategy ranking reflected the same results as above. However, miniscrew implants required the longest total treatment time.

CONCLUSIONS

In general, miniscrew impants are most effective in reserving anchorage. Nance buttons require the least total treatment time. Total evidence is graded as moderate. Midpalatal implants might be the best choice when doing treatment planning because it has the most favorable balance between effectiveness and treatment time. But data analysis of the acceptability and acquisition cost of those anchorage systems must be done to make final decisions.

Classical pathology of sympathetic ophthalmia presented in a unique case

The ocular pathology of sympathetic ophthalmia is demonstrated in a 10 year-old boy who sustained a penetrating left globe injury and subsequently developed sympathetic ophthalmia in the right eye two months later. Two and a half weeks following extensive surgical repair of the left ruptured globe, he developed endophthalmitis and was treated with oral and topical fortified antibiotics. One month after the initial injury, a progressive corneal ulcer of the left eye led to perforation and the need for emergent corneal transplantation. The surgical specimen revealed fungus, Scedosporium dehoogii. The boy received systemic and topical anti-fungal therapy. Two months following the penetrating globe injury of the left eye, a granulomatous uveitis developed in the right eye. Sympathetic ophthalmia was suspected and the patient began treatment with topical and oral corticosteroids. Given the concern of vision loss secondary to sympathetic ophthalmia in the right eye, as well as poor vision and hypotony in the injured eye, the left eye was enucleated. Microscopically, granulomatous inflammation with giant cells was noted within a cyclitic membrane which filled the anterior and posterior chamber of the left globe. Other classic features including Dalen-Fuchs nodules were identified. Small, choroidal, ill-defined granulomas and relative sparing of the choriocapillaris were present. Molecular analysis did not identify evidence of remaining fungal infection. The pathology findings were consistent with previously described features of sympathetic ophthalmia. The present case is unique in that co-existing fungal infection may have potentiated the risk for developing sympathetic ophthalmia in the fellow eye.

Pressure-induced alopecia from orthodontic headgear

Every treatment in the dental specialty has its own set of complications, Orthodontic therapy being no exception. Such a problem during the course of treatment puts the specialist in a dilemma as to whether to continue or stop the treatment. One such case in which during headgear therapy, a rare complication such as alopecia was encountered has been dealt with in this paper. This case report shows its effective management while still continuing treatment, thus leading to the desired result. It emphasizes on the importance of maintaining a balance between the benefts and risks of a treatment.

CLINICAL RELEVANCE

The use of headgear can lead to the rare complication of alopecia and the clinician should be aware of it.

OBJECTIVE

The reader should understand the psychological implications of alopecia and also to carry out the treatment after assessing the risk/beneft ratio.

Bacterial endophthalmitis in the age of outpatient intravitreal therapies and cataract surgeries: host-microbe interactions in intraocular infection

Bacterial endophthalmitis is a sight threatening infection of the interior structures of the eye. Incidence in the US has increased in recent years, which appears to be related to procedures being performed on an aging population. The advent of outpatient intravitreal therapy for management of age-related macular degeneration raises yet additional risks. Compounding the problem is the continuing progression of antibiotic resistance. Visual prognosis for endophthalmitis depends on the virulence of the causative organism, the severity of intraocular inflammation, and the timeliness of effective therapy. We review the current understanding of the pathogenesis of bacterial endophthalmitis, highlighting opportunities for the development of improved therapeutics and preventive strategies.

Endophthalmitis after intravitreal injection: the importance of viridans streptococci

PURPOSE

To determine the rate of postinjection endophthalmitis and compare microbial etiology and outcomes in office-based injection-related endophthalmitis versus those acquired after operating room procedures.

METHODS

Retrospective, observational case series. Consecutive cases of endophthalmitis seen at Retina Consultants of Houston between July 2000 and July 2010 were classified as postsurgical or post-intravitreal injection. Cases secondary to glaucoma surgery, trauma, and endogenous sources were excluded. Main study measures were incidence of endophthalmitis, microbiology results, and visual outcomes.

RESULTS

In all, 109 cases of endophthalmitis were identified: 88 postsurgical and 21 post-intravitreal injection (3 from clinical trials and 5 from outside ophthalmologists). A total of 33,580 intravitreal injections were performed at Retina Consultants of Houston (endophthalmitis rate = 0.04%, 13 of 33,580; 95% confidence interval, 0.02-0.07%). The most common organisms isolated overall were coagulase-negative staphylococci, while viridans streptococci, a component of human oral flora, was identified over three times more often in the postinjection group compared with the postsurgical group. Compared with all other culture-positive cases related to intravitreal injection, postinjection endophthalmitis secondary to viridans streptococci presented much more rapidly (P < 0.001) and final visual outcomes were much worse (P = 0.004)

CONCLUSION

Although the overall risk of postinjection endophthalmitis is low, viridans streptococci were identified over three times more frequently in postinjection cases compared with postsurgical cases and these cases had much worse clinical outcomes. The office-based setting for intravitreal injections may lead to a higher risk for infection from oral pathogens.

Temporary Anchorage Device: An Epitome of Anchorage in Orthodontic Treatment

One of the most important phases of oral health is the form and function of the oral mechanism. Recently, pediatric dentists are concerned with the obvious esthetic disabilities and the pathologic implications of the malposed teeth. Interceptive and functional orthodontic treatment is playing a major role in these discrepancies. Anchorage is an important consideration in orthodontics, particularly if force is applied entirely to the teeth. For many years, clinicians have searched for a form of anchorage that does not rely on patient cooperation. During the last few decades, a wealth of new information has accumulated to such an extent that the present authors thought it appropriate to let these advances make an impact by suggesting a revised definition and classification of anchorage. This paper also gives a brief insight on evolution of anchorage and its application in pediatric dentistry.

Sympathetic ophthalmia

BACKGROUND

Sympathetic ophthalmia (SO) is a rare, bilateral, non-necrotizing, granulomatous uveitis that occurs after ocular trauma or surgical procedures to one eye threatening sight in the fellow eye. The pathophysiology is not clearly understood, but it appears that the disrupted integrity of the inciting eye leads to an autoimmune hypersensitivity reaction against the exposed ocular antigens in the injured eye as well as in the sympathizing eye. More recently, vitreoretinal surgery has been noted to be a risk factor for the development of SO.

METHODS

Medline search for case reports of sympathetic ophthalmia with links to full text in English yielded articles for review of patient demographics, clinical presentation and examination, therapies and final visual acuity.

RESULTS

Eighty-six patients with SO were included in this review. Sixty-two patients were male and 24 were female with an average age of 46 years. Injuries accounted for 47% of patients while ocular surgery was reported in 44% of patients with pars plana vitrectomy occurring in 21%. Most patients reported reduced vision and presented with uveitis. Ninety-five percent of them received systemic corticosteroid therapy and 75% of patients also received immunomodulators. About 70% of patients had improved visual acuity in their sympathizing eye at their last reported evaluation.

CONCLUSIONS

Sympathetic ophthalmia warrants prompt evaluation and treatment to maintain a favorable visual outcome. Ocular surgeries including vitreoretinal surgery and cyclodestructive procedures have been noted to be risk factors for the development of sympathetic ophthalmia. With current medical management including corticosteroids and immunomodulators visual prognosis is relatively good.