Diagnosis of an unusual orbital abscess following sub-Tenon's steroid injection: a case report.

Orbital abscesses are caused by infection within or near the orbit and show obvious signs of pain, proptosis and raised inflammatory markers. Diagnosis is based on clinical features and radiological imaging, and requires early antibiotics and often surgical drainage to save vision. Sub-Tenon's injections of triamcinolone acetonide (TA) have caused localized infections in previous reports, which have responded to therapeutic interventions. Here we report a case where a delayed presentation of an orbital abscess secondary to sub-Tenon's TA for persistent post-operative cystoid macular oedema, without obvious signs of infection, rapidly progressed to cause orbital compartment syndrome. Despite treatment, the patient lost complete vision in the affected eye. This case discusses the rare and unusual cause of abscess formation and a diagnostic dilemma.

Nodular fasciitis of the orbit: rapid growth phase post iatrogenic incisional trauma.

Nodular fasciitis (NF) is a benign, reactive, myofibroblastic proliferative solitary lesion that commonly develops in the subcutaneous or superficial fascia. We present a case of a 35-year-old male with a rapidly enlarging upper eyelid mass postiatrogenic incisional trauma. Subsequent en toto excisional biopsy demonstrated NF. Given the rapid clinical course of this patient and the reactive nature of NF, we hypothesize that the initial incisional trauma likely incited an inflammatory response resulting in rapid proliferation and growth of the lesion. NF accounts for <1% of all orbital lesions, and is often a clinically and pathologically difficult diagnosis to make given its propensity to mimic other benign and malignant conditions. Therefore, we recommend that en toto biopsies of orbital lesions in this anatomical area be performed rather than incisional biopsies.

Identification of a Staphylococcus aureus amidase catalytic domain inhibitor to prevent biofilm formation by sequential virtual screening, molecular dynamics simulation and biological evaluation.

Staphylococcus aureus (S. aureus) is one of the common causes of implant associated biofilm infections and their biofilms are resistant to antibiotics. S. aureus amidase (AM) protein, a cell wall hydrolase that cleaves the amide bond between N-acetylmuramic acid and L-alanine residue of the stem peptide, is several fold over-expressed under biofilm conditions. Previous studies demonstrated an autolysin mutant in S. aureus that lacks the AM protein, is highly impaired in biofilm development. We carried out a structure-based small molecule design using the crystal structure of AM protein catalytic domain to identify inhibitors that can block amidase activity and therefore inhibits S. aureus biofilm formation. Sequential virtual screening followed by pharmacokinetic analysis and bioassay studies filtered 25 small molecules from different databases. Two compounds from the SPECS database, SPECS-1 and SPECS-2, were selected based on the best docking score and minimum biofilm inhibitory concentration towards S. aureus biofilms. SPECS-1 and SPECS-2 were further tested for their structural/energetic stability in complex with the AM protein using molecular dynamics simulation and MM-GBSA techniques. In vitro, biofilm inhibition studies on different surfaces confirmed that treatment with SPECS-1 and SPECS-2 at a concentration of 250 µg/ml exhibited significant prevention and disruption of S. aureus biofilms. Finally, the in vitro anti-biofilm activities of these two compounds were validated against Methicillin-resistant S. aureus clinical isolates. We concluded that the discovered compounds SPECS-1 and SPECS-2 are safe and exhibit biofilm preventive and disruption activity for inhibiting the S. aureus biofilms and hence can be used to treat implant-associated biofilm infections.

Mechanistic understanding of Phenyllactic acid mediated inhibition of quorum sensing and biofilm development in Pseudomonas aeruginosa.

Pseudomonas aeruginosa depends on its quorum sensing (QS) system for its virulence factors' production and biofilm formation. Biofilms of P. aeruginosa on the surface of indwelling catheters are often resistant to antibiotic therapy. Alternative approaches that employ QS inhibitors alone or in combination with antibiotics are being developed to tackle P. aeruginosa infections. Here, we have studied the mechanism of action of 3-Phenyllactic acid (PLA), a QS inhibitory compound produced by Lactobacillus species, against P. aeruginosa PAO1. Our study revealed that PLA inhibited the expression of virulence factors such as pyocyanin, protease, and rhamnolipids that are involved in the biofilm formation of P. aeruginosa PAO1. Swarming motility, another important criterion for biofilm formation of P. aeruginosa PAO1, was also inhibited by PLA. Gene expression, mass spectrometric, functional complementation assays, and in silico data indicated that the quorum quenching and biofilm inhibitory activities of PLA are attributed to its ability to interact with P. aeruginosa QS receptors. PLA antagonistically binds to QS receptors RhlR and PqsR with a higher affinity than its cognate ligands N-butyryl-L-homoserine lactone (C4-HSL) and 2-heptyl-3,4-dihydroxyquinoline (PQS; Pseudomonas quinolone signal). Using an in vivo intraperitoneal catheter-associated medaka fish infection model, we proved that PLA inhibited the initial attachment of P. aeruginosa PAO1 on implanted catheter tubes. Our in vitro and in vivo results revealed the potential of PLA as anti-biofilm compound against P. aeruginosa.

Multidrug-resistant Fusarium keratitis: diagnosis and treatment considerations.

Mycotic keratitis is an ocular infective process derived from any fungal species capable of corneal invasion. Despite its rarity in developed countries, its challenging and elusive diagnosis may result in keratoplasty or enucleation following failed medical management. Filamentous fungi such as Fusarium are often implicated in mycotic keratitis. Bearing greater morbidity than its bacterial counterpart, mycotic keratitis requires early clinical suspicion and initiation of antifungal therapy to prevent devastating consequences. We describe a case of multidrug-resistant mycotic keratitis in a 46-year-old man who continued to decline despite maximal therapy and therapeutic keratoplasty. Finally, enucleation was performed as a means of source control preventing dissemination of a likely untreatable fungal infection into the orbit. Multidrug-resistant Fusarium is rare, and may progress to endophthalmitis. We discuss potential management options which may enhance diagnosis and outcome in this condition.

Allergic contact dermatitis: a case series and review for the ophthalmologist.

Eyelid dermatitis is most commonly caused by an allergenic response, potentially from exposure at another site, rather than from local toxicity. Yet allergic contact dermatitis is a diagnosis often missed by ophthalmologists. The authors review the literature and detail their experience relating to the causes, clinical features and management of this condition. 14 patients over a 2-year period that were referred to the oculoplastic service for a further opinion were reviewed in a retrospective, non-comparative study. All patients underwent patch testing for diagnosis. 8 of the 14 patients had delays of more than 6 months from symptoms to diagnosis. In six of these, this was greater than 1 year. Similar delays are reported in the literature. 79% of the cases were referred by ophthalmologists. Although two of the patients were biopsied, this did not help in making the diagnosis. 13 patients had disease restricted to the eyelids, though only five of these had direct contact of the allergen with the eyelids. Two patients were also sensitised to topical steroid creams prescribed for their treatment. All patients improved after removal of the allergen. Further clinical features and management options from the literature are reviewed and discussed.

Radiological pitfalls in patients with inducible dynamic proptosis.

We report two patients presenting with marked clinical unilateral enophthalmos who had positional variability and dynamic proptosis on valsalva. On orbital imaging, enophthalmos was not documented and in fact, globe proptosis of the same side was reported for one of the patients. During CT and MRI scanning patients are often instructed to hold their breath to eliminate motion artefact. This may inadvertently induce dynamic proptosis. The radiological pitfalls of imaging patients with inducible dynamic proptosis and how to identify such patients are discussed.

Benign fibrous histiocytoma of the eyelid mimicking keratoacanthoma.

We report a case of benign fibrous histiocytoma (BFH) of the medial canthus that mimicked keratoacanthoma in clinical appearance and growth. Excisional biopsy confirmed the diagnosis of the cellular subtype of benign fibrous histiocytoma. These types of BFH are typically more aggressive in growth, with a high recurrence rate and a tendency to undergo autonomous growth at other sites. The diagnosis of BFH should also be considered among those that appear typical of keratoacanthoma. Similar to other rapidly enlarging eyelid tumors, prompt excisional biopsy is recommended.

Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology.

HYPOTHESIS: A handheld wand-scanning device (1.5 lb, battery powered, 10 x 10 x 1.5 in) has been developed to detect commonly used surgical gauze sponges, which have been tagged with a radiofrequency identification (RFID) chip. We tested the hypothesis that this wand device has a successful detection rate of 100%, with 100% specificity and 100% sensitivity. DESIGN: Prospective, blinded, experimental clinical trial. SETTING: Stanford University Medical Center, Stanford, Calif. PATIENTS: Eight patients undergoing abdominal or pelvic surgery. INTERVENTIONS: Eight untagged sponges (1 control per patient) and 28 RFID sponges were placed in the patients. Just before closure, the first surgeon placed 1 RFID sponge (adult laparotomy tape; 18 x 18 in, 4-ply) in the surgical site, while the second surgeon looked away so as to be blinded to sponge placement. The edges of the wound were pulled together so that the inside of the cavity was not exposed during the detection experiments. The second (blinded) surgeon used the wand-scanning device to try to detect the RFID sponge. MAIN OUTCOME MEASURES: A successful detection was defined as detection of an RFID sponge within 1 minute. We also administered a questionnaire to the surgeon and nurse involved in the detections to assess ease of use. RESULTS: The RFID wand device detected all sponges correctly, in less than 3 seconds on average. There were no false-positive or false-negative results. CONCLUSIONS: We found a detection accuracy of 100% for the RFID wand device. Despite this engineering success, the possibility of human error and retained sponges remains because handheld scanning can be performed incorrectly.

Barriers to diabetes self-management education programs in underserved rural Arkansas: implications for program evaluation.

BACKGROUND: Diabetes prevalence has reached epidemic proportions. Diabetes self-management education (DSME) has been shown to improve preventive care practices and clinical outcomes. In this study, we discuss the barriers faced during the implementation of DSME programs in medically underserved rural areas of Arkansas. CONTEXT: Arkansas is a rural state, with most southeastern counties experiencing a shortage of health care professionals. The Arkansas Diabetes Prevention and Control Program and its partners established 12 DSME programs in underserved counties with a high prevalence of diabetes. METHODS: DSME programs were delivered by a registered nurse and a dietitian who provided 10 to 13 hours of education to each program participant. Baseline, 6-month, and year-end data were collected on preventive care practices, such as daily blood glucose monitoring, foot examination, systolic and diastolic blood pressure, and glycosylated hemoglobin level, among the participants in newly established DSME programs. CONSEQUENCES: Of the 12 DSME programs established, 11 received American Diabetes Association recognition. The number of participants in the DSME programs increased 138% in 1 year, from 308 in February 2003 to 734 in March 2004. Preventive care practices improved: daily blood glucose monitoring increased from 56% to 67% of participants, and daily foot examinations increased from 63% to 84% of participants. Glycosylated hemoglobin decreased by an average of 0.5 units per participant who completed the program. However, many anticipated and a few unanticipated barriers during the implementation of the program could not be overcome because of the lack of an evaluation plan. INTERPRETATION: Although results point to potential benefits of preventive care practices among DSME participants, interpretation of findings was limited by sample size. Sample size limitations are traced to barriers to assessing program outcome. Program evaluation should be integrated into the planning phase to ensure adequate measures of program effectiveness.

Removal of a capsular tension ring from the anterior chamber angle.

A 75-year-old woman presented with unexplained ocular hypertension 4 weeks after phacoemulsification. Steroid response was diagnosed initially until a misplaced capsular tension ring (CTR) was identified in the drainage angle. We describe the technique used to successfully remove the CTR from the drainage angle with minimal trauma. This case illustrates the importance of the initial surgical technique used for CTR insertion and emphasizes the role of gonioscopy in such a case.

Health and safety hazards in Northwest agriculture: setting an occupational research agenda.

BACKGROUND: Agriculture is among the most hazardous occupations in the United States. Research can provide new insights about disease and injury and serve as the foundation for occupational health and safety policies. The determination of research priorities can be problematic. Public participation approaches offer opportunities to identify and integrate various perspectives. METHODS: The agenda process was modeled on the NIOSH National Occupational Research Agenda. Center staff contacted representatives of producer groups, labor, health care, academia, and public agencies to participate in telephone interviews and a daylong workshop. RESULTS: Twelve research priorities were identified: musculoskeletal disorders; respiratory disease; skin disease; traumatic injuries; chemical exposures; special populations at risk; social and economic foundations of workplace safety; risk communication barriers; diagnostic approaches; hazard control technology; intervention effectiveness; and surveillance research methods. CONCLUSIONS: The agenda process engaged stakeholders in priority setting. The resulting document is a useful guide for occupational safety and health in agriculture.