Alternaria fungal dacryocystitis with cutaneous fistula: a case report.

Alternaria is a fungal genus that can cause opportunistic human infection in immunocompromised hosts. While the majority of clinical manifestations are cutaneous or subcutaneous infections, there are reports of oculomycosis, which is most commonly present as keratomycosis or endophthalmitis.Here, we present a rare case of Alternaria dacryocystitis with cutaneous fistula in a diabetic patient. The patient was referred with a non-healing medial canthal wound and an initial biopsy report showing "ruptured hair follicle;" re-examination of the biopsy specimen with fungal stains led to the diagnosis of alternariosis. The patient underwent surgical debridement and systemic antifungal treatment, with complete resolution of the infection. In order to initiate prompt treatment and prevent invasive disease, fungal infection should be considered in an immunocompromised patient with chronic dacryocystitis and cutaneous fistula or a nonhealing medial canthus wound.

Sutureless ophthalmic surgery: a scaffold-enhanced bioadhesive technique.

PURPOSE: Bioadhesives have had limited use in ophthalmic surgery. Problems with these adhesives have included inadequate tensile strength and difficulty with their application to the tissue site. We evaluated a scaffold-enhanced cyanoacrylate bioadhesive composite as an alternative to sutures in ophthalmic surgery, including strabismus procedures. METHODS AND MATERIALS: The bioadhesive composite consisted of 2-octyl-cyanoacrylate combined with either a poly(L-lactic-co-glycolic acid) (PLGA) scaffold or a rehydrated porcine small intestine submucosa (SIS) scaffold. Extraocular rectus muscle and sclera were obtained from rabbits (n = 40) and were used, with these bioadhesive composites, to produce rectus muscle-to-sclera, sclera-to-sclera, and rectus muscle-to-rectus muscle adhesions. Control adhesions were created with cyanoacrylate only. The breaking load of the tissue repair was measured with a material strength-testing machine. RESULTS: In all cases, the scaffold-enhanced cyanoacrylate adhesions were significantly stronger (P < 0.001) than the cyanoacrylate alone. The rectus muscle-to-sclera adhesions were greater than the in vivo forces reported for the horizontal rectus muscles in humans in extreme gaze. CONCLUSION: This scaffold-enhanced bioadhesive composite produced initial muscle-sclera adhesions with strength satisfactory for strabismus surgery. It also may be applicable to other categories of ophthalmic surgery as a substitute for sutures.

A new technique of tissue repair for ophthalmic surgery.

Ophthalmic surgery currently utilizes suture materials to repair wounds created during eye operations. Although effective, suture-based techniques can result in complications that further impair the patient's vision, such as retinal detachment and scleral perforation associated with strabismus (eye muscle) surgery. Two techniques currently under development avoid sutures altogether, yielding similar strength results, reduced operating time, and simpler methods of repair. The first of these techniques employs a light-activated scaffold-enhanced protein solder to re-adhere the tissue. The second technique utilizes commercially available bioadhesives that have been scaffold-enhanced to improve their handling characteristics. A comparison of these two techniques is given. Initial tensile strength results show a higher strength of repair when a scaffold is utilized, with significantly less variations within each experimental group. Repairs formed using the scaffold-enhanced cyanoacrylate adhesives were the strongest. The tensile strength of extraocular muscle-to-sclera adhesions was 72% stronger than cyanoacrylate alone (4.2 +/- 0.2 N vs. 2.4 +/- 0.4 N) and 78% stronger than native tissue (2.3 +/- 0.4 N). Sclera-to-sclera adhesions were 60% stronger than adhesions formed with cyanoacrylate alone (3.9 +/- 0.2 N vs. 2.5 +/- 0.4 N), while the tensile strength of extraocular muscle-to-extraocular muscle adhesions were 81% of native extraocular muscle tensile strength (5.6 +/- 0.2 N vs. 6.2 +/- 0.3 N), and 50% stronger than adhesions formed using cyanoacrylate alone (3.6 +/- 0.4 N). The data analysis and resulting conclusions favor the less invasive adhesive technique as an alternative for tissue reattachment during ophthalmic procedures. Future experiments will examine the optimization of application parameters and detail tensile strength time course studies.

Vascular perfusion of choroidal melanoma by 3.0 tesla magnetic resonance imaging.

PURPOSE: Because signal-to-noise performance improves with increased magnetic field strength, the quality of magnetic resonance images is greater at 3.0 tesla (T) than at 1.5 T. Because of the longer T1 values at higher field strength, intravenously administered magnetic resonance contrast agents provide improved T1 enhancement at 3.0 T. We have used these factors to obtain high-quality contrast-enhanced imaging of small intraocular lesions using a standard head radiofrequency volume coil. Specifically, we have examined lesion size and magnitude of maximum contrast enhancement in a series of intraocular melanomas before and during therapy. METHODS: Eighteen patients with intraocular masses were examined by 3.0 T magnetic resonance imaging (MRI) including intravenous contrast enhancement. Precontrast images were acquired through the orbits followed by sequential postcontrast images at 1-minute intervals for 5 minutes. The magnitude of contrast enhancement of the lesion, extraocular muscles, and brain parenchyma was measured as a percentage increase in magnetic resonance signal over the preenhancement signal intensity. RESULTS: Lesions demonstrated different levels of enhancement ranging up to 130%. Three patterns of enhancement--0% to 20%, 20% to 50%, and >50%-were identified. Brain parenchyma, benign lesions, and responsive tumors following brachytherapy with 125I demonstrated enhancement of less than 20%. Four choroidal melanomas showed intermediate (20% to 50%) levels of enhancement. Four malignant lesions (three melanomas, one metastatic tumor), as well as the extraocular muscles, showed strong, rapid enhancement (>50%). Four patients who had MRI studies before and following plaque brachytherapy ultimately demonstrated a decline in the contrast enhancement following treatment. CONCLUSIONS: Contrast enhancement of intraocular lesions measured by 3.0 T MRI demonstrates different patterns of enhancement that may be useful for indicating the degree of malignancy and in monitoring response to therapy.

A light-activated surgical adhesive technique for sutureless ophthalmic surgery.

OBJECTIVE: To investigate a scaffold-enhanced, light-activated bioadhesive technique as a substitute for sutures in ophthalmic surgery. CLINICAL RELEVANCE: Suture use in ophthalmic surgery is technically demanding and time consuming and may be associated with serious complications such as inadvertent ocular penetration, which can result in retinal detachment and endophthalmitis. Bioadhesive surgery could eliminate many complications and limitations associated with the use of sutures. METHODS: The bioadhesive was composed of a poly(L-lactic-co-glycolic acid) (PLGA) porous scaffold doped with a protein solder mix composed of serum albumin and indocyanine green, which was activated with a diode laser. Extraocular rectus muscle-to-extraocular rectus muscle, sclera-to-sclera, and extraocular rectus muscle-to-sclera adhesions were created in freshly harvested tissue followed by tensile-strength testing of these surgical adhesions. RESULTS: Optimum tensile strength for muscle-to-muscle repair was achieved with 50% wt/vol bovine serum albumin and 0.5 mg/mL of indocyanine green saturated into a PLGA porous scaffold and activated with an 808-nm diode laser. The tensile strength was 81% of the native muscle's tensile strength (mean +/- SD, 433 +/- 70 g vs 494 +/- 73 g). Sclera-to-sclera adhesions achieved a mean +/- SD tensile strength of 295 +/- 38 g, whereas that for extraocular rectus muscle-to-sclera adhesions was 309 +/- 37 g. CONCLUSION: Sutureless surgery using this bioadhesive technique for various ophthalmic procedures appears feasible and may result in reduced surgical complications and cost.