Elevated Intraocular Pressure in Burn Patients Undergoing Fluid Resuscitation: An Opportunity to Avoid Orbital Compartment Syndrome

Objective This study aims to discuss clinical characteristics of burn patients who developed elevated intraocular pressure (IOP). We propose management strategies to prevent orbital compartment syndrome before invasive treatment is required.

Methods A retrospective review of 47 burn patients at the University of California San Diego (UCSD), Burn Intensive Care Unit (ICU; major regional burn center for San Diego county), was analyzed for demographics, fluid resuscitation volumes, and physical exam findings. Patients requiring topical treatment for high-IOP, defined as ≥30 mm Hg in either or both eyes, were compared with those who did not require treatment, using the t-test and Fisher's exact test. Linear regression tested for an association between peak IOP and fluid volume. Logistic regression evaluated the association between total fluid and treatment of high IOP, while adjusting for other characteristics.

Results Six of 47 patients required IOP-lowering treatment. Of the patients requiring treatment, one drop of dorzolamide/timolol in both eyes twice daily was the most common treatment recommendation. Presence of periocular burns was a significant risk factor in patients who required treatment for high IOP. No patients developed orbital compartment syndrome or required surgical intervention to lower IOP. The mean total fluid volume delivered in the first 24 hours was 0.8 times the level prescribed by fluid resuscitation guidelines.

Conclusion By treating early clinical signs and properly managing fluid resuscitation, development of orbital compartment syndrome in burn patients can be avoided.

Differentiating Veins From Arteries on Optical Coherence Tomography Angiography by Identifying Deep Capillary Plexus Vortices

PURPOSE

To introduce a simple method for differentiating retinal veins from arteries on optical coherence tomography angiography (OCTA).

DESIGN

Cross-sectional pilot study.

METHODS

Four default en face slabs including color depth encoded, grayscale full-thickness retina, superficial plexus, and deep capillary plexus (DCP) from nine 3×3-mm and nine 6×6-mm OCTA scans were exported and aligned. Nine ophthalmologists with minimum OCTA experience from 2 eye institutions were instructed to classify labeled vessels as arteries or veins in 3 stages. Classification was performed based on graders' own assessment at stage 1. Graders were taught that a capillary-free zone was an anatomic feature of arteries at stage 2 and were trained to identify veins originating from vortices within the DCP at stage 3. Grading accuracy was analyzed and correlated with grading time and graders' years in practice.

RESULTS

Overall grading accuracy in stages 1, 2, and 3 was (50.4% ± 17.0%), (75.4% ± 6.0%), and (94.7% ± 2.6%), respectively. Grading accuracy for 3×3-mm scans in stages 1, 2, and 3 was (49.9% ± 16.3%), (79.2% ± 9.6%), and (96.9% ± 3.1%), respectively. Accuracy for 6×6-mm scans in stages 1, 2, and 3 was (51.4% ± 20.8%), (72.3% ± 7.9%), and (93.2% ± 3.3%), respectively. Grading performance improved significantly at each stage (all P < .001). No significant correlation was found between accuracy and time spent grading or between accuracy and years in practice (r = -0.164 to 0.617, all P ≥ .077).

CONCLUSIONS

We describe a simple method for accurately distinguishing retinal arteries from veins on OCTA, which incorporates the use of vortices in the DCP to identify venous origin.

Vitreoretinal lymphoma followed by systemic diffuse large B cell lymphoma

Vitreoretinal lymphoma as the presenting diagnosis in association with a systemic lymphoma without central nervous system involvement is exceedingly rare, and the classification of this condition is not well-established. Here, we describe a patient with intermittent blurry vision in the left eye for 2 years in the setting of a recent incidental diagnosis of diffuse large B cell lymphoma from an axillary lymph node biopsy. The diagnosis of panuveitis with an extensive exudative retinal detachment was made. The patient was treated with pars plana vitrectomy as well as systemic chemotherapy, intrathecal methotrexate, intravitreal methotrexate, and intravitreal rituximab with good post-operative outcomes.

A Novel Pathogenic Variant in NDP Gene With Incomplete Penetrance Manifests as X-Linked Familial Exudative Vitreoretinopathy

Familial exudative vitreoretinopathy (FEVR) is a rare hereditary ocular disorder characterized by incomplete or abnormal development of peripheral retinal vasculature. The genes responsible for this disorder are associated with the wingless-related integration site (Wnt) signaling pathway, a critical pathway for the development of normal retinal vasculature. A pathogenic variant in any one of these genes may disrupt retinal vasculogenesis. Furthermore, the type and number of pathogenic variants may influence the severity of disease and clinical course. Here, the authors identify a novel pathogenic variant in the NDP gene, not previously described in the literature. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:120-124.].

Management of inadvertent needle penetration resulting in subretinal triamcinolone acetonide and retinal detachment

Purpose

To report management of inadvertent needle penetration during subtenons triamcinolone acetonide administration resulting in retinal detachment.

Observations

A 71-year-old female with history of diabetes, hypothyroidism, and mild myopia underwent subtenons triamcinolone acetonide (TA) injection in the right eye for nodular scleritis. There was unexpected patient movement concurrent with the injection resulting in needle penetration, subretinal and intravitreal injection of TA, superotemporal retinal break, and macula-involving retinal detachment. The patient underwent partial subretinal TA removal, successful retinal detachment repair, and recovered 20/25 visual acuity.

Conclusions and importance

In spite of prominent subretinal TA and retinal detachment, successful repair of retinal detachment and recovery of good visual acuity is possible.

Multi-drug resistant Mycobacterium chelonae scleral buckle infection

Purpose

To describe a case of Multi-drug resistant Mycobacterium chelonae scleral buckle infection.

Observations

A 56 year-old male with history of retinal detachment repair with scleral buckle 20 years prior presented with 8 months of intermittent pain and redness in the left eye. The patient was diagnosed with scleral buckle infection, the buckle was removed, and cultures revealed multi-drug resistant Mycobacterium chelonae. The postoperative course included orbital cellulitis treated with systemic linezolid, clarithromycin, and imipenem. All systemic antibiotics were discontinued on post-operative day 25, visual acuity improved to 20/25, the retina remained attached, and no recurrence occurred over 3 years of follow-up.

Conclusions and importance

NTM infections are typically chronic and often require lengthy treatment. SB infection is rare, but often associated with biofilm and antibiotic resistance. In spite of removing the SB, anchoring sutures, sheath surrounding the buckle and associated biofilm, a prolonged course of systemic antibiotics may be necessary in some patients.

Clinical features, antimicrobial susceptibilities, and treatment outcomes of patients with culture positive endophthalmitis after penetrating keratoplasty

Purpose

To report the clinical features organisms and treatment outcomes in patients with endophthalmitis after penetrating keratoplasty (PK)

Methods

Retrospective noncomparative case series.

Results

Eleven eyes of 11 patients with culture positive endophthalmitis after PK were included. The time to diagnosis of endophthalmitis from last PK was less than 1 week in 3/11 (27%), between 1 and 4 weeks in 3/11 (27%), and greater than one month in 5/11 (46%) (range 2–924 days). The distribution of isolates included gram positive (GP) 9/11 (82%), gram negative (GN) 1/11 (9%), and fungal 1/11 (9%) species, respectively. Of GP bacteria tested, 9/9 (100%) were sensitive to Vancomycin. Of fungal isolates tested, none (0/1) were sensitive to Amphoteracin, Fluconazole, and/or Voriconazole. Among patients with rim culture data available, 1/7 (14%) donor rims were culture positive for Candida glabrata and 6/7 (86%) were culture negative. Patients were treated with primary tap and inject in 10/11 (91%) and primary vitrectomy in 1/11 (9%). VA of ≥5/200 was present in 2/11 (18%) at time of endophthalmitis diagnosis, and was recorded in 6/11 (55%) at last follow-up.

Conclusions and Importance

Patients with endophthalmitis after PK presented at variable time points after surgery. Gram positive organisms were the most common isolate. VA outcomes after treatment were generally poor.

Management of Retinopathy of Prematurity--Use of Anti-VEGF Therapy

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness worldwide. Although laser photocoagulation re-mains the gold standard for treating threshold and prethreshold disease (type 1 ROP), the off-label use of anti‒vascular endothelial growth factor (anti-VEGF) therapy to treat ROP is increasing. Benefits include acute regression of ROP, growth of retinal vasculature beyond the demarcation line, lesser degree of myopia and peripheral visual field loss, and avoidance of sedation and intubation required for laser. However, controversies regarding anti-VEGF in this vulnerable population persist including choice of anti-VEGF agent, dosing, systemic absorption, safety, and late recurrence. This review updates recent evidence regarding the use of anti-VEGF therapy in the management of ROP.

Clinical Features, Antibiotic Susceptibilities, and Treatment Outcomes of Endophthalmitis Caused by Staphylococcus epidermidis

PURPOSE

To report the clinical features, antibiotic susceptibilities, and visual acuity outcomes with endophthalmitis caused by methicillin-sensitive Staphylococcus epidermidis and methicillin-resistant S. epidermidis.

DESIGN

Retrospective case series.

PARTICIPANTS

All patients seeking treatment at a tertiary referral center between 2006 and 2016 with endophthalmitis caused by S. epidermidis.

METHODS

All records were reviewed for patients with a clinical diagnosis of endophthalmitis and positive vitreous culture results for S. epidermidis. Data were compared with the prior series at the same institution.

MAIN OUTCOME MEASURES

Clinical settings, antibiotic susceptibilities, and visual acuity.

RESULTS

Among 96 eyes of 96 patients, the most common postprocedural clinical settings were cataract surgery (47/96 [49%]), intravitreal injection (21/96 [22%]), trauma (8/96 [8%]), glaucoma surgery (7/96 [7%]), and penetrating keratoplasty (5/96 [5%]). The initial treatment included intravitreal vancomycin and ceftazidime in 89 of 96 eyes (93%) and intravitreal vancomycin and amikacin in 7 of 96 eyes (7%). A vitreous tap and injection with antibiotics was performed as the initial treatment in 83 of 96 eyes (86%) and pars plana vitrectomy was performed in 13 of 96 eyes (14%). All isolates were sensitive to vancomycin in both decades. In the most recent series, visual acuity at last follow-up was 5/200 or better in 68 of 96 eyes (71%) compared with 71 of 86 eyes (83%) in the prior study. In the current study, susceptibility to methicillin and moxifloxacin was present in 45 of 96 eyes (47%) and 29 of 85 eyes (34%), respectively, compared with 34 of 86 eyes (40%) and 27 of 39 eyes (69%) in the prior study. Final visual acuity was not significantly different between those eyes that were methicillin or fluoroquinolone sensitive and those that were resistant.

CONCLUSIONS

In the current and prior series, all S. epidermidis isolates were sensitive to vancomycin. Visual acuity outcomes were not dependent on methicillin or fluoroquinolone sensitivity.

Comparison of Regional vs. General Anesthesia for Surgical Repair of Open-Globe Injuries at a University Referral Center

PURPOSE

This study compares the clinical features and physician selection of either Regional Anesthesia (peribulbar or retrobulbar block) with Monitored Anesthesia Care (RA-MAC) or General Anesthesia (GA) for open globe injury repair.

DESIGN

A non-randomized, comparative, retrospective case series at a University Referral Center.

PARTICIPANTS

All adult repairable open globe injuries receiving primary repair between January 1st, 2004 and December 31st, 2014 (11 years). Exclusion criteria were patients less than 18 years of age and those treated with primary enucleation.

METHODS

Data was gathered via retrospective chart review.

MAIN OUTCOME MEASURES

Data collected from each patient was age, gender, injury type, location, length of wound, presenting visual acuity, classification of anesthesia used, duration of the procedure performed, months of clinical follow-up, and final visual acuity.

RESULTS

During the 11 years study period, 448 patients were identified who had open globe injuries with documented information on zone of injury. Globe injury repair was performed using RA-MAC in 351/448 (78%) patients and general anesthesia in 97/448 (22%) patients. Zone 1, 2 and 3 injuries were recorded in 241, 135, and 72 patients respectively. The rates in specific zones, of RA-MAC versus GA were as follows: Zone 1 - 213/241 (88%) vs 28/241 (12%), Zone 2 - 104/135 (77%) vs 31/135 (23%) and Zone 3 - 34/72 (47%) vs 38/72 (53%). Open globe injuries repaired under RA-MAC had significantly shorter wound length (p<0.001), more anterior wound location (p<0.001) and shorter operative times (p<0.001). RA-MAC cases also had a better presenting and final visual acuity (p<0.001). Neither class of anesthesia conferred a greater visual acuity improvement (p=0.06). The use of GA did not cause any delay in the time elapsed from injury until surgical repair (p=0.74).

CONCLUSIONS

RA-MAC is a reasonable alternative to GA for the repair of open globe injuries in selected adult patients. RA-MAC was selected more often for Zone 1 and Zone 2 injuries. For eyes with Zone 3 injuries, there are equal selection ratio for RA-MAC and GA.

Adenoid cystic carcinoma of the lacrimal gland in a 14-year-old male

Adenoid cystic carcinoma (ACC) of the lacrimal gland is an aggressive, malignant epithelial neoplasm. This tumor is rarely seen in adults and even less commonly seen in children and adolescents; thus, there have been no large studies to date describing the optimal treatment of this malignancy in the pediatric population. Here, we report a case of lacrimal gland ACC in a 14-year-old male treated with neoadjuvant intra-arterial chemotherapy followed by globe-sparing tumor resection and chemoradiation. At 2-year follow-up, he remains disease free without evidence of tumor recurrence.

Antiphosphospholipid syndrome presenting with amaurosis fugax and cotton wool spots

Purpose

To describe the importance of considering vaso-occlusive disease on the differential diagnosis of a patient presenting with amaurosis fugax (AF) and unilateral cotton wool spots (CWS).

Observations

A 69-year-old female with history of obesity, hyperlipidemia and recent orthopedic surgery, presented with 3 days of worsening monocular AF and CWS in the right eye. She was diagnosed with antiphosphospholipid syndrome based on positive serologic testing for antiphosphatidylserine IgM, anticardiolipin IgM. The patient was treated with lipid lowering medication, long-term aspirin, and has followed a weightloss and physical therapy program under medical supervision. The CWS resolved and AF symptoms have not recurred.

Conclusions and importance

Antiphospholipid syndrome can be considered in the differential diagnosis of patients presenting with AF, assymetric CWS, and/or rapid progression of symptoms.

Avascular Retinal Findings in a Child With Achondroplasia

The authors present clinical and angiographic findings in a 12-year-old girl with achondroplasia who presented with bilateral retinal peripheral nonperfusion and unilateral rhegmatogenous retinal detachment, which has not been previously described in achondroplasia. This report contributes incremental knowledge regarding aberrant retinal vascular phenomena observed in pediatric disease states and implicates the possible role of mutations in the FGFR3 gene in peripheral vascular abnormalities. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:272-274.].

Epidemiology of Herpes Zoster Ophthalmicus: Recurrence and Chronicity

PURPOSE

A hospital-based epidemiology study to describe herpes zoster ophthalmicus (HZO) prevalence and risk factors for recurrent and chronic disease.

DESIGN

Retrospective, hospital-based cohort study.

PARTICIPANTS

All patients evaluated in the Broward and Miami Veterans Administration Healthcare System (MIAVHS) during the study period.

METHODS

Retrospective medical record review of patients seen in the MIAVHS from January 1, 2010, through December 31, 2014, with a HZO clinical diagnosis. Assessment of the patient's clinical course was defined by the following: an acute episode of HZO was defined as quiescence of disease within 90 days of initial presentation, HZO recurrence was defined as any recurrent eye disease or rash 90 days or more after quiescence of disease was noted off therapy, and chronic HZO was defined as active disease persisting more than 90 days from initial presentation.

MAIN OUTCOME MEASURES

Main outcome measures included the frequency of HZO with and without eye involvement, HZO recurrence rates, and risk factors for recurrent or chronic HZO.

RESULTS

Ninety patients with HZO were included in the study. The mean age at incident episode of HZO was 68±13.8 years (range, 27-95 years). Most patients were white (73%), immune competent (79%), and did not receive zoster vaccination at any point during the follow-up (82%). Patients were followed for a mean of 3.9±5.9 years (range, 0-33 years). The period prevalence of HZ in any dermatome was 1.1%, the frequency of HZ involving V1 (HZO) was 0.07%, and the frequency of HZO with eye involvement was 0.05%. The overall 1-, 3-, and 5-year recurrence rates for either recurrent eye disease or rash were 8%, 17%, and 25%, respectively. Ocular hypertension (hazard ratio [HR], 4.6; 95% confidence interval [CI], 1.3-16.5; odds ratio [OR], 6.7; 95% CI, 1.5-31.2) and uveitis (HR, 5.7; 95% CI, 1.7-19.0; OR, 6.7; 95% CI, 1.5-31.2) increased the risk of recurrent and chronic disease.

CONCLUSIONS

This study supports newer data indicating that a significant proportion of patients experience recurrent and chronic HZO. Further study is needed to guide preventative and therapeutic approaches to recurrent and chronic HZO.

Methotrexate in the treatment of pemphigus vulgaris: experience in 23 patients

BACKGROUND

The standard treatment for patients with pemphigus vulgaris has long consisted of high-dose glucocorticoids. Studies regarding the use of methotrexate in pemphigus vulgaris date back to 1968, but few have quantitatively described a steroid-sparing effect conferred by methotrexate.

OBJECTIVES

We sought to evaluate the efficacy of methotrexate in 23 patients with pemphigus vulgaris, using the drug's steroid-sparing effect as the primary indicator of clinical improvement. We investigated whether methotrexate could be used as monotherapy in some patients.

METHODS

Retrospective chart review was used to analyse the records of patients with pemphigus vulgaris treated with methotrexate at the New York University Langone Medical Center for at least three consecutive months between 2000 and 2012. Diagnosis was made by tissue biopsy and either direct or indirect immunofluorescence tests and enzyme-linked immunosorbent assay.

RESULTS

Improvement in clinical symptoms was observed in 91% of patients. Sixteen patients (70%) were eventually weaned completely off prednisone, with a mean time to discontinuation of 18 months. In total 23% of patients enjoyed a partial steroid-sparing effect, requiring a mean maintenance dose of prednisone of 6·75 mg daily. Two patients (9%) developed possible adverse events requiring cessation of the drug, and one patient received no therapeutic benefit from the drug.

CONCLUSIONS

Methotrexate is a useful and well-tolerated therapy with considerable steroid-sparing effect in patients with pemphigus vulgaris. It may be considered a first-line adjuvant therapy in the treatment of this difficult disease.

Mastication induced retrobulbar hemorrhage

Retrobulbar hemorrhage is a feared potentially sight threatening complication after orbital decompression surgery. We present a patient, 36 hours after surgery, while forcefully biting, suddenly developed a retrobulbar hemorrhage arising from the temporalis muscle causing an orbital compartment syndrome. Rapid intervention with canthotomy and cantholysis was associated with recovery of vision from absent light perception to 20/20. A mastication induced retrobulbar hemorrhage has not been previously described.

Interaction between dextromethorphan and norpethidine in rats

With increasing interest in the application of dextromethorphan in pain control, it is probable that patients will receive this drug in combination with analgesics such as opioids, giving rise to the potential for previously unobserved drug interactions. The interaction between dextromethorphan, and its pharmacologically active metabolite dextrorphan, and norpethidine, a toxic metabolite of pethidine, was examined in rats. Rats were assigned to receive dextromethorphan (0, 20 or 40 mg/kg) or dextrorphan (0, 15 or 30 mg/kg) combined with norpethidine (0, 28 or 42 mg/kg). The occurrence of seizures, myoclonic jerks and shivering was recorded for 60 min after drug administration. Norpethidine produced dose-related increases in the incidence of seizures, myoclonic jerks and shivering. Dextromethorphan, but not dextrorphan, increased the incidence of these behaviours. It is recommended that extreme caution be exercised if dextromethorphan and pethidine are to be used together.

Reduced Purkinje cell size in the cerebellar vermis of elderly patients with schizophrenia

OBJECTIVE

The authors' goal was to compare the size and linear density of Purkinje cells in the cerebellar vermis of subjects with and without schizophrenia.

METHOD

Blocks of alcohol-fixed cerebellar vermis were dissected at autopsy from the brains of 14 elderly patients with schizophrenia and 13 elderly subjects with no history of neuropsychiatric illness. The blocks of vermis were sectioned and stained with 1% cresyl violet. The linear density and cross-sectional area of Purkinje cells were measured by using computer-assisted image analysis. The subjects with schizophrenia had been assessed with clinical rating scales within 1 year prior to death.

RESULTS

The average cross-sectional areas of Purkinje cells of the patients with schizophrenia were significantly smaller (by 8.3%) than those of the subjects without neuropsychiatric illness. No difference in Purkinje cell linear density was observed between the two groups. Significant correlations were seen between Purkinje cell size and scores on the Mini-Mental State, the Brief Psychiatric Rating Scale, and the antipsychotic drug dose.

CONCLUSIONS

These data indicate cerebellar involvement in schizophrenia; they are also consistent with reports of reduced neuronal size in other brain regions of patients with schizophrenia. These findings support a model of wide-spread central nervous system abnormality in schizophrenia.

The pharmacokinetics of a single dose of artemisinin in subjects with liver cirrhosis. Bach Mai-Amsterdam Research Group on Artemisinin

Artemisinin is mainly eliminated by hepatic transformation. To investigate whether the clearance of artemisinin in patients with liver cirrhosis is different from healthy volunteers, a pharmacokinetic study was performed in male Vietnamese patients with Child B cirrhosis of the liver who received 500 mg of artemisinin orally. The results were compared to those found in a previous study in healthy subjects. The mean (+/- SD) area under the concentration time curve was 2365 (+/- 1761) h ng/ml; the mean (+/- SD) clearance, 382 (+/- 303)L/h. The elimination half life was 4 (+/- 1.3) h extimated by log-linear regression and 2.4 +/- 0.9 h estimated by non-linear regression using a one-compartment first order elimination model. The mean (+/- SD) absorption time was 1.55 (+/- 0.8) h. These results were not different from the results of healthy subjects and show that liver disease has no effect on the availability and clearance of oral artemisinin, indicating that artemisinin has an intermediate hepatic extraction ratio and that there is no significant first pass effect.

The pharmacokinetics of a single dose of artemisinin in patients with uncomplicated falciparum malaria

The pharmacokinetics of artemisinin was studied in 11 Vietnamese patients with uncomplicated falciparum malaria after a single 500 mg oral dose. Curative treatment with mefloquine (15 mg/kg) was provided 24 hr after the artemisinin dose. Artemisinin concentrations were measured by high-performance liquid chromatography with electrochemical detection. The following pharmacokinetic results were found (all mean +/- SD); calculated volume of distribution/bioavailability = 22.8 +/- 16.6 L.kg-1, mean absorption time = 1.16 +/- 0.92 hr, calculated maximum concentration = 364 +/- 250 micrograms.L-1 occurring at 2.88 +/- 1.71 hr after drug intake, and an elimination half-life of 2.72 +/- 1.76 hr. Bioavailability was low. These results do not differ from results in healthy subjects. Parasites disappeared rapidly, with a mean parasite clearance time of 36 hr. No relationship was found between pharmacokinetics and the parasite elimination rate. Tolerance to the single dose of artemisinin was good. No adverse effects were detected. In conclusion, pharmacokinetics of a single dose of artemisinin for uncomplicated falciparum malaria is not different from findings in healthy subjects. A single dose of 500 mg of artemisinin is effective in reducing parasitemia in nonsevere lalciparum malaria and is well-tolerated.