Necrotizing fasciitis of eyelid secondary to parotitis

PURPOSE: Evaluation of a patient with necrotizing fasciitis of the eyelid spreading from parotid gland. METHODS: Interventional case report. The patient admitted with rapidly progressive swelling, redness, and pain of four eyelids, and whole face. Pathogenic microorganism was searched, laboratory tests were evaluated. Intensive medical treatment and necrotic wound debridement was performed. RESULTS: The patient had been receiving oral cephalosporin at the time she was referred to our hospital, but her infection had spread rapidly under this treatment. In addition to her eyelid necrosis, septic shock developed within 24 hours. No pathogenic microorganism was detected in cultures. The patient responded to intravenous sulbactam ampicillin, surgical debridement of necrotic wound and supportive medical care. Moderate ptosis was the only complication observed in this patient. Reconstructive surgery was not needed. CONCLUSIONS: With prompt antibiotic treatment and surgical debridement, cosmetic and functional success may be obtained in necrotizing fasciitis cases rarely seen with parotid gland origin.     

Oral pilocarpine for the treatment of keratoconjunctivitis sicca with central corneal irregularity

A 31-year-old female physician with bilateral myopia had unilateral myopic laser in situ keratomileusis in the right eye. The patient was overcorrected with the initial treatment and had 2 subsequent hyperopic treatments, resulting in central corneal irregularity. During the course of treatment, the patient was diagnosed with Sj?gren's syndrome with marked keratoconjunctivitis sicca. The patient had anisometropia, aniseikonia, and monocular diplopia and was unable to tolerate contact lenses. Oral pilocarpine (Salagen) was prescribed, which improved salivation, lacrimation, and keratoconjunctivitis sicca. The patient was able to tolerate rigid gas-permeable contact lenses to achieve 20/20 visual acuity in both eyes and regain binocular vision.     

Case of cancer-associated retinopathy in which immediate treatment succeeded

PURPOSE: Cancer-associated retinopathy (CAR) leads to progressive loss of visual functions and a small number of reports have described effective treatment for the disease. We herein report a case of a CAR patient whose visual acuity improved with corticosteroid and a radical treatment of the tumor. CASE: A 70-year-old man with rapidly progressive loss of visual acuity and visual field was referred to our clinic. The visual acuity of the patient had decreased to finger count OD and 20/30 OS at the initial visit, though visual acuity three weeks before the initial visit was 20/16 in both eyes. The patient suffered from night blindness, Goldmann perimetry revealed ring-like scotoma, and the electroretinogram was negative. Fundus examination showed only attenuation of the vessels but no apparent sign of retinal degeneration. Chest computed tomography (CT) revealed a small cell carcinoma in the lung of 1.2 cm diameter. One week after the initial visit, as the visual acuity in both eyes decreased to hand motion, the patient was treated with chemotherapy, radiation, and corticosteroid pulse therapy. After the treatment, the visual acuity of the patient improved to 20/50 OD and 20/67 OS, but the visual field of the patient did not improve. The tumor in the lung was disappeared on CT. CONCLUSION: Corticosteroid treatment for CAR patients may be effective when performed rapidly after clinical symptoms appear.     

KAB与KAP医学行为管理学模式在角膜塑形术治疗中的应用

医学行为管理学是从医学的角度出发对患者的心理活动及身体行动进行干预和管理的科学,包括“知识-态度-行为（knowledge-attitude-behaviour,KAB）”和“知识-态度-实践（knowledge-attitude-practice,KAP）”两种运行模式,即指在患者充分理解治疗原理的基础上,树立患者对疾病正确、积极的认知态度,并在整个实际治疗过程中最大程度上争取患者的心理及身体行为配合。目前此种医学行为管理模式主要应用于儿童治疗,目的是提高儿童患者的依从性,保障治疗的安全与有效。角膜塑形镜验配的各环节都渗透着对医学行为管理学介入的需求。本文将对医学行为管理学模式（KAB与KAP模式）在角膜塑形镜治疗中所发挥的指导性作用,从医患沟通、验配、摘戴教育、随访复查四大治疗环节方面进行论述。另外,统计分析患者接受验配医师讲解前后对角膜塑形术治疗认识、理解程度评分及验配医师对患者在医患沟通前后的依从性评分,验证医学行为管理对角膜塑形术治疗的积极导向作用。     

CMV retinitis after intravitreal triamcinolone acetonide injection in a patient with Behçet’s uveitis

We report the case of a patient with Behçet’s uveitis who developed cytomegalovirus (CMV) retinitis after intravitreal triamcinolone acetonide (IVTA) injection. We reviewed the patient’s chart for the purpose of this report. An IVTA injection was performed for treatment of severe panuveitis in the left eye of a 30-year-old male patient with Behçet’s disease. Systemic treatment included high dose corticosteroid and azathioprine. Fourteen weeks after IVTA, extensive areas of necrotizing retinitis developed in the left eye. Polymerase chain reaction of serum and vitreous samples was positive for CMV DNA. Serum anti-CMV IgG was positive, IgM was negative, anti-HIV antibody was negative, complete blood count was normal, and CD4 count was 1,060 cells/μl. The patient responded well to intravitreal ganciclovir injection performed twice and intravenous ganciclovir treatment administered for five weeks. Local immunosuppression with IVTA may cause CMV retinitis. Awareness of this serious complication is important for correct diagnosis and treatment.     

Histopathology of eyes enucleated after endoresection of choroidal melanoma

PURPOSE: To demonstrate the histopathologic features of eyes enucleated after endoresection for choroidal melanoma to assess the complications of this treatment and to determine indications for further treatment after endoresection in the setting of possible tumor recurrence. DESIGN: Retrospective, observational case series. PARTICIPANTS: Sixty-one consecutive patients who had undergone endoresection for uveal melanoma. METHODS: Eyes that had undergone enucleation after endoresection were identified, and their charts and histologic characteristics were reviewed. Pertinent features were described. One patient was excluded because enucleation was performed as a primary treatment when endoresection was abandoned at the time of his initial treatment. MAIN OUTCOME MEASURES: The outcome measures included: reasons for enucleation; tumor recurrence; and location, clinical, and histologic characteristics of each recurrence. RESULTS: Twelve eyes were identified that had undergone enucleation after endoresection. The reasons for enucleation were: (1) local tumor recurrence detected by ophthalmoscopy (2 patients) or echography (1 patient); (2) opaque media preventing adequate ophthalmoscopy (4 patients); (3) blind and painful eye of uncertain cause (1 patient); and (4) a combination of blind eye and limited fundus view (4 patients), which was the result of untreatable retinal detachment (3 patients) and endophthalmitis (1 patient). Eight of 12 patients had recurrent choroidal melanoma. Recurrences were all located adjacent to the resection site, although in 1 patient there was extensive diffuse recurrence throughout the eye. The recurrence was visible clinically in 3 patients and obscured because of opaque media (2 patients), a combination of inadequate echography and retinal detachment (1 patient), retinal detachment (1 patient), and endophthalmitis (1 patient). CONCLUSIONS: Recurrent disease occurred at the site of the primary tumor with no seeding except in 1 patient, whose marginal recurrence was not immediately detected and treated because of opaque media. As with other treatments conserving the eye, enucleation should be performed if adequate ocular examination is not possible, and follow-up should be lifelong.     

Case of recurrent fungal endophthalmitis with suspected Munchausen syndrome

PURPOSE: To report recurrent fungal endophthalmitis which developed after endogenous fungal endophthalmitis. The patient was suspected to be suffering from Munchausen syndrome. CASE: A 44-year-old woman contracted endogenous fungal endophthalmitis in her right eye in October 2000. After the endophthalmitis was healed by vitrectomy, corneal ulcer and endophthalmitis repeatedly occurred in the eye from an unknown cause. The patient finally lost the sight of her right eye. The corneal ulcer and endophthalmitis resulted from self-injury for which we found material evidence in the course of the treatment. Munchausen's syndrome was suspected but the patient persistently refused to see a psychiatrist. CONCLUSION: We must be prepared to provide mental and psychiatric care in addition to ophthalmological treatment for such a case.     

Treatment of primary intraocular lymphoma with oral trofosfamide: report of two cases and review of the literature

Background The prognosis of primary intraocular lymphoma (PIOL) is poor. Due to frequent ocular and/or CNS relapses, the optimal treatment for PIOL has not yet been defined. This is the first report of PIOL treatment with trofosfamide.Methods The first patient with a newly diagnosed PIOL was not considered eligible for high-dose methotrexate-based systemic chemotherapy due to comorbidities. The second patient had a primary central nervous system lymphoma, which was resistant to three chemotherapy regimens and responded to whole-brain irradiation. A tumor relapse in the eye was treated with local radiotherapy with initial success; however, the tumor subsequently recurred. The first patient received oral trofosfamide 150 mg daily, the second 400 mg daily (reduced after 5 months of therapy to 300 mg daily) over 5 consecutive days, followed by a 5-day drug-free interval.Results In both patients, complete remission was achieved, which lasted for 8+ and 18 months, respectively. Except for a temporary asymptomatic decrease in hemoglobin in the first patient, no toxicity was observed.Conclusions Trofosfamide may offer an alternative treatment option for PIOL with a very favorable side effect profile. The exact role of trofosfamide in the treatment of PIOL remains to be defined.     

Latanoprost-induced iris color darkening: a case report with long-term follow-up

PURPOSE: To determine the effect on iris color of discontinuing latanoprost (LP) treatment in a patient with pronounced iris color darkening, and to assess the possible role of sympathetic innervation. METHODS: In a patient demonstrating pronounced iris color darkening in both eyes after treatment with LP for 6 months, magnified iris color photographs were taken at 3- to 6-month intervals for 5 years after discontinuation of LP treatment. Pupillary testing for sympathetic insufficiency was performed with cocaine 10% or hydroxyamphetamine 1%. RESULTS: The iris color did not appreciably change after discontinuing LP. The cocaine-induced increase in pupillary diameter was considerably greater for the control subject than for the patient who demonstrated the LP-induced color change. CONCLUSIONS: Latanoprost-induced iris color darkening does not appreciably change for several years after discontinuing treatment. Some eyes that show LP-induced darkening may have relative ocular sympathetic insufficiency.     

Delayed treatment of choroidal melanoma due to pregnancy

PURPOSE: The authors report a 27-year-old woman who presented with a large, choroidal melanoma when she was 28 weeks pregnant. Following detailed discussion with the patient, the decision was made to postpone any surgical treatment until after the birth of her child. METHODS: Case report. RESULTS: The patient had successful transscleral local resection of the tumor with 6/12 vision 6 months later. Cytogenetic studies showed a low risk of subsequent metastases. CONCLUSIONS: This case illustrates that deferring the treatment of a choroidal melanoma presenting during pregnancy can be a reasonable treatment plan, if the patient is highly motivated to keep the eye.     

Intravitreal bevacizumab injection in patients with choroidal neovascularization due to choroid rupture after blunt-head trauma

Purpose To describe and report the effect of intravitreal bevacizumab (Avastin) as primary treatment for secondary choroidal neovascularization (CNV) after choroidal rupture due to blunt-head trauma. Design Interventional case report. Methods The study was of the left eye of a patient who presented with choroidal neovascularization secondary to choroidal rupture due to blunt-head trauma. The patient received single intravitreal injection of 1.25 mg (0.05 ml) bevacizumab as treatment for CNV after informed consent was signed. The patient underwent fundus fluorescein angiography (FA) and optic coherence tomography (OCT) before the bevacizumab injection and then again three months after. Visual acuity was also measured before and after treatment. The patient was re-examined on the first day, and monthly thereafter. After intravitreal injection of bevacizumab the visual and anatomic responses were observed. Results The patient showed regression of the neovascularization three months after injection of bevacizumab. There was no loss of vision in the immediate postoperative period and at the 3rd month vision improved from 20/60 to 20/20. Central retinal thickness decreased. No cataract progression, endophthalmitis, or injection-related complications were observed. Conclusions Our study shows that intravitreal 1.25 mg bevacizumab can be an effective alternative treatment for choroidal neovascularization (CNV) due to choroidal rupture. The authors have no proprietary interest in the material used in this study.     

Toxoplasma gondii: an atypical presentation of toxoplasma as optic disc swelling and hemispherical retinal vein occlusion treated with intravitreal clindamycin

Background To present a case of toxoplasmosis with an atypical presentation and treated successfully with intravitreal clindamycin. Method A young Brazilian woman presented with panuveitis and disc swelling with associated hemispheric vascular occlusion in one eye. The presumed diagnosis was of a papillitis with vasculitis due to an unknown inflammatory condition. Results Following treatment with intravenous corticosteroids, macular star appeared 1 week after treatment. On the 2nd week, a focus of retinitis appeared, and the patient was started on antitoxoplasma treatment. This was poorly tolerated, and the patient was injected with intravitreal clindamycin. Inflammation eventually settled and an organized lesion typical of toxoplasma chorioretinitis was observed. Conclusion We describe an unusual presentation and the detrimental effects of toxoplasmosis in an otherwise immunocompetent subject. As the patient was not tolerating systemic antitoxoplasma treatment, intravitreal injection was administered and proved to be effective and well tolerated.     

Clofazimine-induced bull's-eye retinopathy

Bull's-eye retinopathy has multiple associations. We report a case of bull's-eye retinopathy presumed to be secondary to clofazimine (Lamprene) treatment of a 30-year-old patient with acquired immunodeficiency syndrome (AIDS). Pretreatment baseline eye exam of this patient was normal except for bilateral cotton-wool spots. However, follow-up exam 5 months later revealed bilateral anterior pigmentary corneal deposits in a whorl pattern, a presumed infectious retinitis in the left eye, and bilateral annular macular pigmentary abnormalities. The patient was taken off clofazimine treatment, but died 1 month later. The authors suggest that patients being treated with clofazimine be examined for drug-related corneal and retinal lesions.     

A New Approach to an Old Problem

A patient with progressive visual loss was found to have an optic nerve sheath meningioma. The patient was treated with stereotactic radiotherapy, a computer-guided stereotactic technique that minimizes the risk of radiation-induced optic neuropathy. Six months after treatment, the patient was doing well and showed no signs of radiation-induced optic neuropathy.     

Idiopathic, bilateral panuveitis--efficacy of general steroidotherapy and intravitreal dexamethason injection. Case report

This paper presents the comparison of different schemes of two kinds of general steroidotherapy in one case of idiopathic, bilateral panuveitis and effectiveness of intravitreal dexamethason to one eye. The effectiveness of the treatment was mainly concerned on best corrected visual acuity, the illustration of macular retinal area in OCT (optic coherence tomography), where the reduction of cystic macular oedema was detected and the pictures of fluorescein angiography. The observation and the treatment has lasted for 3 years. At the beginning, the patient received general steroidotherapy (medrol), which lasted seventy four days. Improvement of clinical symptoms lasted only four months. The similar therapy the patient obtained once more. The symptoms of illness returned, after the same period of time. Then the intravitreal dexamethason (Posurdex) was injected. The better visual acuity and improvement of clinical symptoms was observed for three months. The patient couldn't obtain posurdex once more. The physician decided to apply the different scheme of general steroidotherapy. The observation after finished treatment, lasted over one year. Clinical symptoms of the illness retracted. The fluorescein angiography of the eyes were correct and the structure of the macular retinal area presented in optical coherence tomography were regular. The observation of the patient is continued.     

PRK-pTK as a treatment for a patient with Thygeson's superficial punctate keratopathy.

PURPOSE: This article reports a case in which Thygeson's superficial punctate keratopathy was treated with photorefractive keratectomy (PRK) combined with phototherapeutic keratectomy (PTK). METHODS: A 20-year-old white woman in good health who had a 2-year history of Thygeson's superficial punctate keratopathy in both eyes was evaluated for refractive surgery to treat myopia. The patient had experienced multiple recurrences of the Thygeson's during the preceding 2-year period. Previous treatment had consisted of topical steroids with good response to therapy but recurrences once the topical therapy was stopped. After discussing different options, the patient underwent uncomplicated PRK-PTK for treatment of her myopia, and her postoperative course was uneventful. RESULTS: Eight months after undergoing PRK-PTK, the patient has excellent uncorrected visual acuity (20/20 in both eyes) and has experienced no recurrences of Thygeson's superficial punctate keratopathy. CONCLUSIONS: Successful treatment of Thygeson's superficial punctate keratopathy in a patient with a low myopia may be achieved with the use of combined PRK-PTK procedures.     

Visudyne photodynamic therapy and feeder vessel occlusion: rationale of a synergistic association and clinical options

PURPOSE: Visudyne photodynamic therapy (PDT) has provided considerable improvement in patient care of subfoveal choroidal neovascularization (CNV). Patients tend to loose vision for a few months after the initial treatment, but the 4-year proven stability in vision most often provides an acceptable quality of life, sometimes with additional low vision rehabilitation. The initial visual acuity loss, borderline cost-effectiveness, and subgroups of patients not responding to PDT warrant improving the symptomatic treatment of subfoveal CNV. Today, the most tempting solution would be to combine PDT with an occlusion of the feeder vessel (FV). METHODS: Two patients are described in whom the feeder vessel was occluded using modifications of the classic PDT treatment method. The FV was identified in both patients using fluorescein and indocyanine green angiographies at a recorded video rate using a modified scanning laser ophthalmoscope (Rodenstock SLO). The feeder vessel of the first patient was occluded by minimal photocoagulation immediately after a Visudyne PDT treatment in order to take advantage of the reduced blood flow within the feeder vessel. The second patient presenting a subfoveal FV was treated using a modified PDT treatment called feeder-vessel PDT. The photosensitizing agent was activated by a first classic spot covering the lesion, followed immediately by a small spot focused on the feeder vessel. RESULTS: Both subfoveal CNVs were successfully and selectively occluded and some visual acuity was gained following the treatment. CONCLUSION: Occlusion of the feeder vessel is an appealing clinical option that is complementary to Visudyne PDT. Both treatment methods presented here could provide additional options to close subfoveal CNV with an optimal efficacy-risk ratio.     

Fungal retinitis: a case of Torulopsis glabrata infection treated with miconazole.

Presumptive embolic chorioretinal Torulopsis glabrata infection is described in a patient who had received prolonged intravenous antibiotic therapy. The ocular findings are compared and contrasted with embolic lesions due to Candida albicans. The patient was treated for 6 weeks with intravenous miconazole. During this time there was shrinkage of the ocular lesions, some improvement in vision and abolition of fungaemia. Improvement in tests of immune function during treatment suggests that an early immunological deficit was secondary to the infection. Intravenous miconazole is a relatively nontoxic alternative to amphotericin and deserves further evaluation in the treatment of ocular mycosis.     

Interferon-alpha for the treatment of retinal vasculitis associated with human T-lymphotropic virus type I myelopathy (HAM)

Interferon-alpha was effective for the treatment of retinal vasculitis and vitreous opacity in a patient with human T-lymphotropic virus type I associated myelopathy (HAM). The patient was a 40-year-old male with retinal vasculitis, vitreous opacity and Koeppe's iris nodules. Systemic administration of corticosteroid hormone was not fully effective for the treatment of ocular involvements except for iris nodules. After Interferon-alpha treatment, given 3 million IU/day as the intramuscular injection for 4 weeks, the retinal vasculitis subsided and vitreous opacity disappeared.     

Fourth-generation fluoroquinolone-resistant bacterial keratitis after refractive surgery

We report the first 2 cases of bacterial keratitis resistant to fourth-generation fluoroquinolones after laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK). The first patient had Pseudomonas aeruginosa keratitis after PRK despite treatment with moxifloxacin. The second patient was on gatifloxacin post-LASIK when she had methicillin-resistant Staphylococcus aureus (MRSA) keratitis diagnosed. In both cases, culture susceptibilities showed isolates resistant to moxifloxacin and gatifloxacin, and treatment with topical aminoglycosides and surgical intervention was necessary to effect a cure. These cases show the potential limitations in the coverage of these antibiotics.