IgG4 orbital inflammation in a 5-year-old child presenting as an orbital mass.

IgG4 is a newly known systemic disorder. It can present as orbital inflammation or as an orbital mass. We describe the case of a 5-year-old child with proptosis and globe dystopia who went on to have an orbital biopsy. Initially this was reported to be idiopathic orbital inflammation. After IgG4-RD was considered in the differential, the orbital biopsy was revisited, immunohistochemistry was done and the patient's serum was tested for IgG subclass levels. IgG4-RD was diagnosed and the patient was subsequently treated with prednisone and mycophenolate and made a good recovery. This is the youngest reported case of IgG4-RD in a child.

Antioxidant Activity and Carotenoid Content Responses of Three Haematococcus sp. (Chlorophyta) Strains Exposed to Multiple Stressors.

There has been increasing demands worldwide for bioactive compounds of natural origins, especially for the nutraceutical and food-supplement sectors. In this context, microalgae are viewed as sustainable sources of molecules with an array of health benefits. For instance, astaxanthin is a xanthophyll pigment with powerful antioxidant capacity produced by microalgae such as the chlorophyte Haematococcus sp., which is regarded as the most suitable organism for the mass production of this pigment. In this study, three Haematococcus sp. strains were cultivated using a batch mode under favourable conditions to promote vegetative growth. Their environment was altered in a second phase using a higher and constant illumination regime combined with either exposure to blue LED light, an osmotic shock (with NaCl addition) or supplementation with a phytohormone (gibberellic acid, GA3), a plant extract (ginger), an herbicide (molinate) or an oxidant reagent (hydrogen peroxide). The effects of these stressors were evaluated in terms of antioxidant response and astaxanthin and ß-carotene accumulation. Overall, strain CCAP 34/7 returned the highest Trolox Equivalent Antioxidant Capacity (TEAC) response (14.1-49.1 µmoL Trolox eq. g- 1 of DW), while the highest antioxidant response with the Folin-Ciocalteu (FC) was obtained for strain RPFW01 (62.5-155 µmoL Trolox eq. g- 1 of DW). The highest ß-ß-carotene content was found in strain LAFW15 when supplemented with the ginger extract (4.8 mg. g- 1). Strain RPFW01 exposed to blue light returned the highest astaxanthin yield (2.8 mg. g- 1), 5-fold that of strain CCAP 34/7 on average. This study documents the importance of screening several strains when prospecting for species with potential to produce high-value metabolites. It highlights that strain-specific responses can ensue from exposure of cells to a variety of stressors, which is important for the adequate tailoring of a biorefinery pipeline.

Modulation of the metabolite content of the unicellular rhodophyte Porphyridium purpureum using a 2-stage cultivation approach and chemical stressors.

There have been growing interests in microalgal biotechnology for the biorefining of bioactive compounds such as carotenoid pigments, ω-3 fatty acids, antioxidants or antimicrobials for sectoral applications in the pharmacology, nutraceutical and cosmetic fields. This study focused on the unicellular marine rhodophyte Porphyridium purpureum CCAP 1380/1 A, which was cultivated via a two-stage batch growth mode for 10 days using hydrogen peroxide (H2O2), the phytohormone methyl jasmonate (MJ) and three plant extracts (Passiflora incarnata, Panax ginseng and Valeriana officinalis). The microalgal biomass was then analysed for its protein, phycoerythtin, carbohydrate and pigment composition together with its pigment content and antioxidant activity. Of note, MJ increased the protein and phycoerythtin content (up to 225 µg BSA eq./mg DW and 15 mg/ml, respectively) while both the MJ and H2O2 treatments increased carotenoid pigment yields (ß-carotene and zeaxanthin, up to 5 and 4 mg/g, respectively). Carbohydrates were enhanced ∼10 fold by the Valeriana officinalis treatment (up 192 µg starch eq./mg). Overall, neutral lipids and antioxidants were mostly negatively affected by the plant extracts. The greatest antioxidant activity registered was obtained with the H2O2 treatment (15 µmol Trolox eq./g DW with TEAC assay). P. purpureum contains multiple valuable compounds of commercial interest. These results indicate that they can be favorably modulated using specific cultivation regimes and chemical enhancers, thereby facilitating the exploitation of the biomass by applying a suitable co-refinery pipeline.

Comparative Response of Marine Microalgae to H2O2-Induced Oxidative Stress.

There have been growing interests in the biorefining of bioactive compounds from marine microalgae, including pigments, omega-3 fatty acids or antioxidants for use in the nutraceutical and cosmetic sectors. This study focused on the comparative responses of five marine microalgal species from different lineages, including the dinoflagellate Amphidinium carterae, chlorophyte Brachiomonas submarina, diatom Stauroneis sp., haptophyte Diacronema sp. and rhodophyte Rhodella violacea, to exposure during their batch growth to hydrogen peroxide (H2O2). A. carterae returned an enhanced signal with the DPPH assay (8.8 µmol Trolox eq/g DW) when exposed to H2O2, which was associated with reduced pigment yields and increased proportions in saturated C16 and C18 fatty acids. B. submarina showed enhanced antioxidant response upon exposure to H2O2 with the DPPH assay (10 µmol Trolox eq/g DW), a threefold decrease in lutein (from 2.3 to 0.8 mg/g) but a twofold increase in chlorophyll b (up to 30.0 mg/g). Stauroneis sp. showed a downward response for the antioxidant assays, but its pigment yields did not vary significantly from the control. Diacronema sp. showed reduced antioxidant response and fucoxanthin content (from 4.0 to 0.2 mg/g) when exposed to 0.5 mM H2O2. R. violacea exposed to H2O2 returned enhanced antioxidant activity and proportions of EPA but was not significantly impacted in terms of pigment content. Results indicate that H2O2 can be used to induce stress and initiate metabolic changes in microalgae. The responses were however species-specific, which would require further dosage optimisation to modulate the yields of specific metabolites in individual species.

Seeing clearly: the dominant and recessive nature of FOXE3 in eye developmental anomalies.

FOXE3 is a lens-specific transcription factor with a highly conserved forkhead domain previously implicated in congenital primary aphakia and anterior segment dysgenesis. Here, we identify new recessive FOXE3 mutations causative for microphthalmia, sclerocornea, primary aphakia, and glaucoma in two extended consanguineous families by SNP array genotyping followed by a candidate gene approach. Following an additional screen of 236 subjects with developmental eye anomalies, we report two further novel heterozygous mutations segregating in a dominant fashion in two different families. Although the dominant mutations were penetrant, they gave rise to highly variable phenotypes including iris and chorioretinal colobomas, Peters' anomaly, and isolated cataract (cerulean type and early onset adult nuclear and cortical cataract). Using in situ hybridization in human embryos, we demonstrate expression of FOXE3 restricted to lens tissue, predominantly in the anterior epithelium, suggesting that the extralenticular phenotypes caused by FOXE3 mutations are most likely to be secondary to abnormal lens formation. Our findings suggest that mutations in FOXE3 can give rise to a broad spectrum of eye anomalies, largely, but not exclusively related to lens development, and that both dominant and recessive inheritance patterns can be represented. We suggest including FOXE3 in the diagnostic genetic screening for these anomalies.

Combined immunosuppression and radiotherapy in thyroid eye disease (CIRTED): a multicentre, 2 × 2 factorial, double-blind, randomised controlled trial.

BACKGROUND: Standard treatment for thyroid eye disease is with systemic corticosteroids. We aimed to establish whether orbital radiotherapy or antiproliferative immunosuppression would confer any additional benefit. METHODS: CIRTED was a multicentre, double-blind, randomised controlled trial with a 2 × 2 factorial design done at six centres in the UK. Adults with active moderate-to-severe thyroid eye disease associated with proptosis or ocular motility restriction were recruited to the trial. Patients all received a 24 week course of oral prednisolone (80 mg per day, reduced to 20 mg per day by 6 weeks, 10 mg per day by 15 weeks, and 5 mg per day by 21 weeks) and were randomly assigned via remote computerised randomisation to receive either radiotherapy or sham radiotherapy and azathioprine or placebo in a 2 × 2 factorial design. Randomisation included minimisation to reduce baseline disparities in potential confounding variables between trial interventions. Patients and data analysts were masked to assignment, whereas trial coordinators (who monitored blood results), pharmacists, and radiographers were not. The radiotherapy dose was 20 Gy administered to the retrobulbar orbit in ten to 12 fractions over 2 to 3 weeks. Azathioprine treatment was provided for 48 weeks at 100-200 mg per day (dispensed as 50 mg tablets), depending on bodyweight (100 mg for <50 kg, 150 mg 50-79 kg, 200 mg for ≥80 kg). The primary outcomes were a binary composite clinical outcome score and an ophthalmopathy index at 48 weeks, and a clinical activity score at 12 weeks. The primary analysis was based on the intention-to-treat allocation and safety was assessed in all participants. This study is registered with ISRCTN, number 22471573. FINDINGS: Between Feb 15, 2006, and Oct 3, 2013, 126 patients were recruited and randomly assigned to groups: 31 patients to radiotherapy plus azathioprine, 31 to sham radiotherapy and azathioprine, 32 to radiotherapy and placebo, and 32 to sham radiotherapy and placebo. Outcome data were available for 103 patients (54 for sham radiotherapy vs 49 for radiotherapy and 53 for placebo vs 50 for azathioprine), of whom 84 completed their allocated treatment of radiotherapy or sham radiotherapy and 57 continued to take azathioprine or placebo up to 48 weeks. There was no interaction betweeen azathioprine and radiotherapy (pinteraction=0·86). The adjusted odds ratio (ORadj) for improvement in the binary clinical composite outcome measure was 2·56 (95% CI 0·98-6·66, p=0·054) for azathioprine and 0·89 (0·36-2·23, p=0·80) for radiotherapy. In a post-hoc analysis of patients who completed their allocated therapy the ORadj for improvement was 6·83 (1·66-28·1, p=0·008) for azathioprine and 1·32 (0·30-4·84, p=0·67) for radiotherapy. The ophthalmopathy index, clinical activity score, and numbers of adverse events (161 with azathioprine and 156 with radiotherapy) did not differ between treatment groups. In both groups, the most common adverse events were mild infections. No patients died during the study. INTERPRETATION: In patients receiving oral prednisolone for 24 weeks, radiotherapy did not have added benefit. We also did not find added benefit for addition of azathioprine in the primary analysis; however, our conclusions are limited by the high number of patients who withdrew from treatment. Results of post-hoc analysis of those who completed the assigned treatment suggest improved clinical outcome at 48 weeks with azathioprine treatment. FUNDING: National Eye Research Centre, Above and Beyond, and Moorfields Eye Charity.

Air reflux after external dacryocystorhinostomy.

OBJECTIVE: To ascertain the prevalence of air reflux after external dacryocystorhinostomy, its natural history, and its relation to symptomatic cure. METHODS: More than a year after lacrimal surgery, patients were contacted via a structured telephone interview and were questioned about air reflux and lacrimal symptoms. RESULTS: Interviews were completed by 77 patients (98 operations). Postoperative air reflux had been noted after 46 of 98 operations (47%) and persisted in 36 of 46 eyes (78%), at a mean follow-up of 58 months. Reflux occurred in 36% (8 of 22) of eyes after membranectomy, a rate similar to that without membranectomy (38 of 76 eyes; [50%]); the relative risk of air reflux with membranectomy was 0.7 (95% confidence interval, 0.4-1.3; P = .30). Overall, symptomatic improvement was achieved in 85% of procedures (83 eyes). Reflux was associated with a higher success rate (relative risk, 1.22; P = .02) and was significantly less likely to be associated with unchanged or worse symptoms (relative risk of failure, 0.28; P = .03). CONCLUSIONS: Air reflux is common after external dacryocystorhinostomy, is associated with symptomatic success, and generally persists but is rarely troublesome. Membranectomy does not increase the incidence of reflux, suggesting that the valve of Rosenmüller may not act as a 1-way valve for air flow.

Risk factors for elevated intraocular pressure in uveitis.

PURPOSE: To determine the prevalence of raised intraocular pressure (IOP) in patients with uveitis and to identify risk factors for raised IOP in patients with uveitis. PATIENTS AND METHODS: Consecutive case notes of 257 patients (402 eyes) attending a specialist uveitis clinic during a three-month period were reviewed. Patients with raised IOP were identified and further evaluated. Risk factors for raised IOP were determined. RESULTS: The prevalence of raised IOP in the study eyes was 41.8%. The prevalence of raised IOP requiring treatment was 29.8%. Raised IOP was found in 26.0% of eyes with acute uveitis and 46.1% of eyes with chronic uveitis. This difference was significant (P = 0.002). Similarly the prevalence of raised IOP requiring treatment in acute and chronic uveitis was 15.1% and 33.8%, respectively. This difference was also significant (P = 0.002). Active inflammation was significantly associated with raised IOP (P = 0.031). Steroid usage, increasing age, and number of years since diagnosis were significantly correlated with raised IOP (P = 0.008, P = 0.022, and P = 0.006, respectively); 9.6% of the study eyes developed glaucoma. The majority of these eyes (69.7%) were treated medically. The remainder (30.3%) required both medical and surgical management. CONCLUSION: Raised IOP is significantly more common in patients with chronic intraocular inflammation than those with acute uveitis. Risk factors for elevated IOP that should enable closer monitoring of 'at-risk' eyes have been identified.

Merkel cell carcinoma of the eyelid: management and prognosis.

IMPORTANCE: The literature on Merkel cell carcinoma (MCC) of the eyelid remains scarce, and there has yet to be a study using the most up-to-date TNM staging system for this rare but aggressive tumor. OBJECTIVE: To analyze the TNM stage, management, and outcomes of patients with MCC of the eyelid. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case series of 21 patients from 5 tertiary referral centers in the United Kingdom and Australia with primary MCC of the eyelid presenting at a median age of 77 years, with median follow-up of 54 months. Tumors were staged according to the American Joint Committee on Cancer, 7th edition, TNM criteria for eyelid carcinoma and MCC. MAIN OUTCOMES AND MEASURES: TNM stage, treatment modalities, and clinical outcome. RESULTS: The eyelid carcinoma TNM stages were T2aN0M0 for 5 patients, T2bN0M0 for 7 patients, T3aN0M0 for 4 patients, T3bN0M0 for 3 patients, T2bN1M0 for 1 patient, and T3aN1M0 for 1 patient. The MCC TNM stages were T1N0M0 for 12 patients, T2N0M0 for 7 patients, T1N1M0 for 1 patient, and T2N1M0 for 1 patient. One patient had a sentinel lymph node biopsy, and 8 patients underwent head/neck imaging. Eighteen patients underwent a wide local excision, 12 with a paraffin section and 6 with a frozen section. Two patients underwent Mohs surgery, 1 of whom required an orbital exenteration. Twelve patients (57%) received adjuvant radiotherapy, and 2 patients received chemotherapy. The local recurrence rate was 10%, the regional nodal recurrence rate was 10%, and the distant metastatic recurrence rate was 19%. The lowest T category tumor metastasizing to both regional nodes and distant locations was a T2a (eyelid TNM)/T1 (Merkel TNM) tumor measuring 8 mm. Two patients with T3a (eyelid TNM)/T2 (Merkel TNM) tumors died of metastatic MCC. CONCLUSIONS AND RELEVANCE: The majority of patients with MCC of the eyelid present with localized eyelid disease of T category T2 (eyelid TNM)/T1 (Merkel TNM). A wide local excision with margin control remains the mainstay of treatment, whereas the use of radiotherapy is institution specific. Tumors with a low T category are associated with regional nodal and distant metastatic disease. It may therefore be reasonable to consider a sentinel lymph node biopsy or strict regional lymph node surveillance for all MCCs of the eyelid, regardless of T category or size.

Transpositional Autokeratoplasty in a Patient with Unilateral Choroidal Melanoma and Contralateral Exposure Keratopathy.

Penetrating keratoplasty was required to improve corneal clarity in the left eye, which had suffered chronic exposure keratopathy following a cerebellopontine angle tumor with facial nerve involvement. The right eye had a large choroidal melanoma, which had failed brachytherapy, but the cornea was transparent and healthy. The right eye corneal button was sutured to the left eye host and a donor corneal button was sutured to the right eye rim. The right eye was subsequently enucleated. Two years later, the patient had 6/12 visual acuity with a clear graft and no tumor seeding in the host eye. Although limited opportunities arise to employ transpositional autokeratoplasty, where appropriate, it offers an alternative to conventional allokeratoplasty with a lower risk of immune rejection.