Case of fungal endophthalmitis developed after subtenon injections of triamcinolone acetonide

BACKGROUND: We report a case of fungal endophthalmitis which developed after subtenon injections of triamcinolone acetonide (TA). CASE: A 63-year-old man had Graves' ophthalmopathy. He had received subtenon injections of TA in his left eye. He was admitted to Kimura Eye & Internal Medicine Hospital because of a subconjunctival abscess with inflammatory cells in the anterior chamber. Although we treated it as a suspected bacterial infection at the first visit, it deteriorated rapidly. Because prolonged antibiotics and antifungal therapy seemed ineffective, we performed diagnostic surgery. The lower sclera around the subtenon injections of TA was hard and thick, and a white spotty lesion and retinal detachment were seen on the lower retina. A culture of the Tenon sac showed filamentous fungus. After the surgery the subconjunctival abscess recurred because intravenous antifungal therapy had been discontinued. A culture of the abscess identified Alternaria sp. The subconjunctival abscess, thickened sclera, and retinal exudate were limited to the region of the sub-Tenon injection of TA, We conclude that the sclera had been permeated by hyphae of Alternaria sp. CONCLUSION: In this case, critical infection was caused by the sub-Tenon injections of TA.     

Effect of prophylactic brimonidine instillation on bleeding during strabismus surgery in adults

PURPOSE: To investigate the effects of preoperative brimonidine-purite 0.15% instillation on intraoperative bleeding and postoperative subconjunctival hemorrhage during strabismus surgery in adult patients. DESIGN: Randomized comparative interventional case series. METHODS: One hundred and eighteen eyes of 90 consecutive adult patients were instilled with either a single drop of brimonidine-purite 0.15% (42 eyes), phenylephrine 1% (38 eyes), or sodium hyaluronate 0.1% (38 eyes) 15 minutes prior to strabismus surgery. Intraoperative bleeding and postoperative subconjunctival hemorrhage were graded on a scale of one to three. The scores were compared among the study groups. RESULTS: Scores of the intraoperative bleeding and the postoperative subconjunctival hemorrhage of the treatment groups were significantly less than that of the control group (P < .001). The scores of the brimonidine group were similar to those of the phenylephrine group (intraoperative bleeding score, P = .405; subconjunctival hemorrhage score, P = .722). CONCLUSIONS: Topical brimonidine administration before strabismus surgery may reduce intraoperative bleeding and postoperative subconjunctival hemorrhage in adult patients.     

Augenmuskeloperationen in kombinierter Tropf- und Subkonjunktivalanästhesie

A retrospective study of a consecutive series of 284 cases of strabismus surgery under local anesthesia is presented. A total of 284 operations on the extraocular muscles, performed with topical and subconjunctival application of local anesthetics-in some cases combined with anesthesiological sedation and monitoring-were analyzed retrospectively for adverse effects or complications caused by the type of anesthesia chosen. No ophthalmological complications caused by the mode of anesthesia and no vital complications occurred. In three cases, the intended surgery could not be fully completed due to discomfort of the patient caused by pain perception.In this case series, combined topical and subconjunctival anesthesia in strabismus surgery had a low frequency of complications.     

Intraoperative adjustable suture strabismus surgery under topical and subconjunctival anesthesia

BACKGROUND AND OBJECTIVE: To assess the postoperative surgical results of intraoperative adjustable suture strabismus surgery under topical and subconjunctival anesthesia. PATIENTS AND METHODS: For 44 patients who had undergone intraoperative adjustable suture technique under topical anesthesia, the deviations were measured preoperatively, at 1 day, 1 month, and 3 months postoperatively, and at the last postoperative follow-up visit. The mean follow-up period was 7.8 months. RESULTS: Thirty-three patients had exotropia and 11 had esotropia. Mean age was 28.8 years. The success rates for exotropia and esotropia at the last follow-up visit were 81.8%. CONCLUSION: Intraoperative adjustable suture strabismus surgery under topical and subconjunctival anesthesia is the recommended surgical technique due to the successful results and various advantages compared with non-adjustable surgery, including the decreased rates of overcorrection or undercorrection that appear immediately after surgery and reoperation. Postoperative "drift" toward the original deviation was observed under longer follow-up periods than other studies.     

Late-onset progressive strabismus associated with a hydrogel scleral buckle.

A hydrophilic implant for scleral buckling was developed in 1980. Advantages include softness and elasticity, no dead spaces, ability to gradually absorb and release antibiotics, and stimulating production of a fibrous capsule around the implant. Short-term fellow studies in rabbits showed no clinical or histologic complications. Long-term complications of the hydrogel scleral buckle have emerged in the las 10 years. These included fragmentation, subconjunctival bulging, intraocular erosion, migration, and restriction of extraocular movement. We recently encountered a patient with progressive restrictive strabismus beginning 8 years after retinal detachment repair with a MIRAgel (hydrogel; MIRA, Uxbridge, MA) scleral buckle. Worsening complaints of diplopia and discomfort led to strabismus surgery. Untreatable retinal detachment resulted in enucleation.     

Infected conjunctival pyogenic granuloma at strabismus surgery site mimicking conjunctival abscess

We present a rare case of infected pyogenic conjunctival granuloma mimicking a conjunctival abscess as complication of strabismus surgery in a Saudi girl with exotropia. Despite administration of local antibiotics following strabismus surgery, a patient presented with localised redness and discharge after three weeks. The patient was afebrile with no signs of pre-septal or orbital cellulitis. After culture (Staphylococcus aureus) sensitivity testing the patient was prescribed oral Amoxicillin and Clavulanate and reviewed under general anaesthesia. A 55?mm² conjunctival pyogenic granuloma was noted. A punch biopsy specimen indicated inflammatory and histiocytic cells. The addition of steroid to the medical therapy resulted in a quiet eye after three weeks.     

Acquired central fusional disruption with spontaneous recovery

Acquired loss of central fusion occurs most frequently after severe head trauma. It has also been described as a result of disruption of binocular function by unilateral deprivation from a cataract and following mid-brain injury due to vascular lesions, tumours or abscess. Symptoms include diplopia in all positions of gaze associated with a squint of variable size. Occasionally some patients experience a spontaneous, partial recovery of fusion, which may be manipulated with strabismus surgery to minimise diplopia. Recovery of fusion may take months or even a few years to occur. We present two cases of patients who lost fusion but later regained it spontaneously with a high degree of stereopsis. Neither patient required strabismus surgery. In the first case, fusion was lost following a severe head injury which resulted in unconsciousness and a unilateral vitreous haemorrhage. The second case followed the removal of a long-standing, unilateral cataract.     

Acquired central fusional disruption with spontaneous recovery

Acquired loss of central fusion occurs most frequently after severe head trauma. It has also been described as a result of disruption of binocular function by unilateral deprivation from a cataract and following mid-brain injury due to vascular lesions, tumours or abscess. Symptoms include diplopia in all positions of gaze associated with a squint of variable size. Occasionally some patients experience a spontaneous, partial recovery of fusion, which may be manipulated with strabismus surgery to minimise diplopia. Recovery of fusion may take months or even a few years to occur. We present two cases of patients who lost fusion but later regained it spontaneously with a high degree of stereopsis. Neither patient required strabismus surgery. In the first case, fusion was lost following a severe head injury which resulted in unconsciousness and a unilateral vitreous haemorrhage. The second case followed the removal of a long-standing, unilateral cataract.     

Lidocaine hypersensitivity after subconjunctival injection

CASE REPORT: We report a rare case of hypersensitivity in a 63-year-old man who received subconjunctival lidocaine, cefazolin, and gentamicin for corneal abscess. Significant palpebral swelling and erythema were observed several hours after the injection. Nine months later, he received subconjunctival lidocaine, vanco-mycin, and ceftazidime for a new corneal abscess. After several hours, the eyelids were red and swollen, with mild blistering and scaling of the cheek. Two patch tests for lidocaine were negative. During follow-up, lateral tarsorrhaphy was performed under local anesthesia with lidocaine; erythema and swelling of eyelids and cheek appeared, resolving after several days. COMMENTS: Sensitivity to lidocaine can appear after subconjunctival injection. Patch tests may be negative, but the allergy suspected by the recurrence of clinical signs after rechallenge with lidocaine. Ester anesthetics can be used for local anesthesia.     

Postoperative results of absorbable, subconjunctival adjustable sutures.

BACKGROUND: Adjustable sutures have improved our ability to treat patients with strabismus. Inherent with its use, however, is the postoperative chore of dealing with the exposed sutures necessitating intervention in all patients. We describe a new surgical technique that utilizes a fornix incision in which absorbable sutures are placed in the subconjunctival space. METHODS: We conducted a retrospective review of patients in which this technique was utilized. Thirty patients were identified. RESULTS: Twenty-one patients required postoperative manipulation; ten were aligned in the postoperative recovery area in the period prior to discharge and eight in an office setting between days 1 and 4 postoperatively. Three patients were adjusted at both times. The patients adjusted in the immediate postoperative period experienced slightly less discomfort. Twenty-seven of the 30 patients (90%) had successful surgical outcome. Postoperative complications included more tissue response than is normally seen: four patients had a suture granuloma and two patients had a subconjunctival infection postoperatively. CONCLUSION: The use of absorbable subconjunctival sutures in strabismus surgery reduces the need for postoperative manipulation in some patients and allows for delayed adjustment in other patients.     

Ophthalmic presentations and long-term outcomes of subconjunctival and atypical orbital myocysticercosis

Purpose:To study the clinical presentation, radiological features, diagnosis, and treatment response in subconjunctival and atypical orbital myocysticercosis.Methods:Retrospective analysis of diagnosed subconjunctival and atypical (strabismus, diplopia, and blepharoptosis) orbital myocysticercosis was performed. A diagnostic criterion (2 of the 3) among clinical features, radiological findings, and treatment response was used in our study. A minimum of “post-treatment” follow-up of 12 months was observed.Results:Thirty-five patients were included with a mean age of 16 years having male predominance (n = 22, 62.8%). All had a unilateral presentation, with 24 (68.6%) patients having subconjunctival cysticercosis, of which 22 were located in close proximity of the rectus muscle insertion. At presentation, 10 patients had diplopia, 7 had strabismus, and 6 had face turn. Pseudo Duane’s and pseudo-Brown’s syndrome were noted in 5 and 4 patients, respectively. Radiologically, single muscle myositis without scolex was seen in 12 (34.3%) cases. All patients first received medical treatment, and surgical intervention (cyst removal) was attempted after treatment failure. Complete resolution of symptoms was noted in 22 (after medical treatment only) and in 8 (after surgery).Conclusion:In the majority, the subconjunctival cysticercosis is found in proximity to the rectus muscle insertion, as a part of orbital myocysticercosis. In atypical scenarios, a satisfactory response to medical treatment can be considered as diagnostic of cysticercosis.     

Orbital cellulitis complicating strabismus surgery: a case report and review of the literature.

Orbital cellulitis is a rarely reported, but potentially vision- and life-threatening complication after strabismus surgery. To date, only seven cases of orbital cellulitis complicating strabismus surgery have been reported in the world literature, and only two cases were reported in adult patients, both occurring more than 100 years ago. We describe a case of unilateral orbital cellulitis after bilateral strabismus surgery in an adult. Early diagnosis (aided by computed tomography) and aggressive intravenous antibiotic therapy resulted in a favorable visual outcome. Diagnosis and management are discussed, and this case is compared with previous cases in the literature.     

Infectious scleritis after pars plana vitrectomy because of methicillin-resistant Staphylococcus aureus resistant to fourth-generation fluoroquinolones

PURPOSE: To describe a case of infectious scleritis caused by methicillin-resistant Staphylococcus aureus (MRSA) after pars plana vitrectomy despite treatment with topical fourth-generation fluoroquinolones. METHODS: Single interventional case report. RESULTS: A 72-year-old man presented with scleral thinning and subconjunctival abscess 1 month after pars plana vitrectomy. Microbiological studies including cultures and antibiotic sensitivity were performed. Culture of the scleral abscess showed growth of MRSA resistant to fourth-generation fluoroquinolones and sensitive to vancomycin and erythromycin. Treatment with a combination of topical vancomycin and systemic erythromycin for 6 weeks resolved the infectious scleritis. CONCLUSIONS: MRSA can be a cause of infectious scleritis after ocular surgery without a clear source despite surgical prophylaxis with topical fourth-generation fluoroquinolones.     

斜視手術后肥大性結膜瘢痕的治療

目的觀察應用5-氟脲嘧啶(5-FU)聯合康寧克通-A局部注射治療斜視手術后肥大性結膜瘢膜的臨床療效.方法用5-FU 2.5mg、康寧克通-A4mg對41例斜視手術后肥大性結膜瘢痕作局部注射,每周1次,共1～2次.結果隨訪6月～3年,顯效率78.05%(32例),有效率21.95%(9例).副作用有局部結膜水腫、結膜下出血及角膜上皮損傷.結論 5-FU聯合康寧克通-A局部注射是治療斜視手術后肥大性生結膜瘢痕的一種安全有效的方法.     

局部麻醉或辅助地西泮在斜视矫正术中的作用

目的　应用面部表情分级评分（ｆａｃｅｒａｔｉｎｇｓｃａｌｅ,ＦＲＳ）、焦虑评分（ｓｅｌｆ-ｒａｔｉｎｇａｎｘｉ-ｅｔｙｓｃａｌｅ,ＳＡＳ）,观察共同性斜视矫正术患者应用局部麻醉及麻醉前应用地西泮注射液的效果,比较手术前、后的疼痛情况、焦虑、术中牵拉不适及术后随访情况。方法　对２０１２年８月至２０１４年８月在我院住院的眼科共同性斜视患者８８例（１０８眼）,年龄１１～４０岁,进行显微镜下斜视矫正术,采用随机、对照、双盲的研究方法,随机分为两组:对照组４４例５４眼（局部注射盐酸罗哌卡因注射液）,用药组４４例５４眼术前辅助肌肉注射地西泮注射液０．２ｍＬ·ｍｇ－１。记录术中、术后１ｈ的ＦＲＳ、ＳＡＳ,同时记录术中患者手术时间、牵拉反射及随访情况。结果　用药组与对照组患者术中、术后ＦＲＳ差异均有统计学意义（均为Ｐ＜０．０５）。用药组与对照组患者ＳＡＳ评分术中、术后差异均有统计学意义（均为Ｐ＜０．０５）。用药组手术时间较对照组缩短（均为Ｐ＜０．０５）;用药组患者牵拉反射不适减轻,与对照组差异有统计学意义（Ｐ＜０．０５）,同时用药组患者手术中生命体征平稳,更好配合医师手术。结论　局部麻醉手术辅助术前应用抗焦虑、镇静药物行斜视矫正术具有较好的镇痛效果;明显缓解因术中精神紧张、疼痛及恶心等所致眼位异常,提高手术舒适度、减轻术后不适感,术中医师操作顺利、术后眼位复位较好。     

A型肉毒毒素注射与手术治疗儿童共同性斜视的临床比较

目的比较A型肉毒毒素(BTA)注射与手术治疗儿童共同性斜视的疗效。 方法纳入2018年4月至2019年8月就诊于北京同仁医院眼科中心的共同性斜视患儿142例作为研究对象。其中,男性74例,女性68例;年龄3~15岁,平均年龄(7.2±2.6)岁。按照家属的选择意愿分为注射组和手术组。注射组患儿采用BTA眼外肌注射治疗,手术组患儿采用斜视矫正术治疗。检查并记录治疗前与治疗后6个月患儿的斜视度、双眼视觉功能以及并发症情况,治疗后6个月患儿的眼位正位率等指标。注射组和手术组患儿斜视度与双眼视觉功能的定量数据,用均数±标准差描述,采用独立样本t检验进行组间比较,采用配对样本t检验进行组内比较。患儿双眼视觉功能的定性数据,眼位正位率与并发症等指标的描述采用频数和百分率表示,采用卡方检验进行组间比较。 结果治疗后6个月,注射组患儿的眼位正位率为58.2%,手术组患儿的眼位正位率为69.3%。两组患儿眼位正位率的比较,差异无统计学意义(χ²＝1.90,P>0.05)。注射组患儿斜视度绝对值在注射前和注射后6个月分别为(35.23±6.69)△和(12.35±10.16)△;手术组患儿斜视度绝对值在手术前和手术后6个月分别为(35.40±8.74)△和(9.16±9.43)△。治疗前与治疗后6个月,两组患儿斜视度绝对值的比较,差异无统计学意义(t＝-0.13,1.92;P>0.05)。注射组和手术组患儿在治疗后6个月随访时,具有正常同视机Ⅰ级功能(同时视)的分别有25例(占39.1%)和38例(占50.7%);具有正常同视机Ⅱ级功能(融合视)的分别有43例(占67.2%)和70例(占93.3%);具有正常同视机Ⅲ级功能(立体视)的分别有26例(占40.6%)和37例(占49.3%);具有正常近立体视功能的分别有27例(占42.2%)和38例(占50.7%),与治疗前相比均有所增加。治疗后6个月,手术组具有同视机Ⅱ级功能(融合视)患儿的比例高于注射组,差异有统计学意义(χ²＝15.52,P<0.05),其余差异均无统计学意义(χ²＝1.88,1.06,0.99;P>0.05)。注射组所有患儿主诉出现复视,16例患儿表现出轻度上睑下垂和结膜下出血,均于随访1~3个月时消失。 结论对于斜视度为中低度数(15△~50△)的患儿,BTA注射与手术治疗儿童共同性斜视在治疗后6个月临床疗效相近,是一种安全有效的治疗方法。     

我国斜视显微手术的探索

随着手术显微镜引进眼科手术,开启了眼科显微手术时代,开创了现代白内障手术和玻璃体手术新纪元.当眼科显微手术时代走过了半个世纪后,国际上还是倡导戴2～3倍放大镜做斜视手术.显微手术仅仅是内眼手术的专利吗?我国斜视显微手术的最早报告见于20世纪90年代初,探索在显微镜下实施直肌睫状血管分离术,其后未见跟进.本世纪以来,一些日常做内眼显微手术的专家和一些显微手术训练基础好的青年骨干坚持探索斜视显微手术.在这个过程中,中华医学会斜视与小儿眼科学组积极引导探索其健康发展,努力发掘显微手术在斜视矫正术中的积极意义,并探索提高手术质量.2011年6月在济南召开的第14届全国斜视与小儿眼科学术会议对这一问题又进行了热烈交流和讨论.本文结合发展现状,总结了斜视显微手术的目的和意义,提出了健康发展斜视显微手术的措施与建议.     

The fat adherence syndrome and strabismus after retina surgery

The etiology of persistent strabismus after retina surgery has been poorly understood. Seven patients with acquired restrictive strabismus after retina surgery were surgically explored for the cause of the strabismus. In each case, the fat adherence syndrome was identified as playing a significant role in causing the restriction. In four patients, restriction secondary to the fat adherence syndrome was the sole cause of the strabismus. Other contributing causes included a misplaced muscle in two patients and a sponge under a muscle in one patient. Our conclusion is that the fat adherence syndrome is an important cause of restrictive strabismus after retina surgery and that this complication can be minimized by avoiding surgical maneuvers that violate Tenon's capsule and expose extraconal fat.     

Use of botulinum toxin in small-angle heterotropia and decompensating heterophoria: a review of the literature

Botulinum toxin has been used extensively in strabismus management. However, less is published regarding its use in small-angled manifest deviations or decompensating heterophorias, where an alternative to surgery is required. The aim of this review is to look at the use and effectiveness of botulinum toxin in managing small-angled manifest deviations, both constant and intermittent, and decompensating heterophorias. These types of strabismus can prove difficult to manage, as the angle present is often too small for surgery to be advised, but it may still cause a cosmetic or symptom-producing problem. A search of the English speaking literature was undertaken using Medline facilities as well as a limited manual search of non-Medline journals and transactions. A brief overview is provided for mechanisms of action, complications and dose effects, and diagnostic and therapeutic uses of botulinum toxin. The main reported complications are those of ptosis, induced vertical deviation and subconjunctival haemorrhage. The higher the dose, the greater the risk of complications. In small-angle strabismus, botulinum toxin is reported as particularly useful in cases of acquired and acute-onset esotropia in aiding maintenance of binocular vision. It is useful for additional management of surgically under- or over-corrected esotropia, particularly for those with potential for binocular vision. Less effect is reported in primary exotropia versus primary esotropia. It is the management of choice for consecutive exotropia, particularly when patients have had previous multiple surgery and where there is a risk for postoperative diplopia. Botulinum toxin has a specific role in decompensated heterophoria, allowing the visual axes a chance to 'lock on' and subsequently maintain binocular vision. Successful outcomes are reported after 1-2 injections only but the results are best in cases of heterophoria with little near-distance angle disparity.     

Retrobulbar hemorrhage following strabismus surgery

Retrobulbar hemorrhage, although a well-known complication of retrobulbar injection, periocular injections, and periocular surgeries, is not routinely associated with strabismus surgery. We present a case of delayed orbital hemorrhage occurring in a young boy 2 days after strabismus surgery.