Rhino-orbital-cerebral mucormycosis (ROCM): a comprehensive case review.

The objective of this paper is to review a recent case of rhino-orbital-cerebral mucormycosis that involved the successful treatment of an immunocompromised male patient that took place in a deployed military setting. In this interventional case review, a comprehensive evaluation of predisposing factors, presenting signs and symptoms, diagnostic evaluation, and treatment will be discussed in detail. The patient was a 38-yr-old noncompliant insulin-dependent diabetes mellitus Iraqi man whose initial presentation encompassed nonspecific signs and symptoms consistent with sinusitis. Symptoms progressed rapidly including the development of acute visual loss, unilateral facial edema, fixed dilated right pupil, loss of extraocular movements, and oropharyngeal eschar formation. With this progressive clinical picture, a diagnosis of mucormycosis was made in the absence of histological confirmation due to the nature of the deployed environment. Treatment included hospitalization for combined intervention with intravenous antifungal therapy and a series of surgeries which ultimately resulted in orbital exenteration and preservation of life. Successful treatment was attributed to having a high index of suspicion in the clinical presentation of nonspecific otorhinolaryngological and ophthalmological symptoms superimposed with underlying predisposing immunocompromised host conditions.

Corneal refractive power estimation and intraocular lens calculation after hyperopic LASIK.

PURPOSE: To identify key independent variables in estimating corneal refractive power (KBC) after hyperopic LASIK. DESIGN: Retrospective study. PARTICIPANTS: We included 24 eyes of 16 hyperopic patients who underwent LASIK with subsequent phacoemulsification and posterior chamber intraocular lens (IOL) implantation in the same eye. METHODS: Pre-LASIK and post-LASIK spherical equivalent (SE) refractions and topographies, axial length, implant type and power, and 3-month postphacoemulsification SE were recorded. Using the double-K Hoffer Q formula, corneal power was backcalculated for every eye (KBC), regression-based formulas derived, and corresponding IOL powers calculated and compared with published methods. MAIN OUTCOME MEASURES: The Pearson correlation coefficient (PCC) and arithmetic and absolute corneal and IOL power errors. RESULTS: Adjusting either the average central corneal power (ACCP(3mm)) or SimK based on the laser-induced spherical equivalent change (DeltaSE) resulted in an estimated corneal power (ACCP(adj) and SimK(adj)) with highest correlation with KBC (PCC=0.940 and 0.956, respectively) and lowest absolute corneal estimation error (0.37+/-0.45 and 0.38+/-0.39 diopter [D], respectively). The ACCP(adj) closely mirrored published DeltaSE-based adjustments of central corneal power on different topographers, whereas DeltaSE-based SimK adjustments varied across platforms. Using ACCP(adj) or SimK(adj) in the double-K Hoffer Q, using ACCP(3mm) or SimK in single-K Hoffer Q and adjusting the resultant IOL power based on DeltaSE, or applying Masket's formula all yielded accurate and similar IOL powers. The Latkany method consistently underestimated IOL power. The Feiz-Mannis and clinical history methods yielded poor IOL correlations and large IOL errors. CONCLUSION: After hyperopic LASIK, adjusting either corneal power or IOL power based on DeltaSE accurately estimates the appropriate IOL power.

Confocal assessment of the corneal response to intracorneal lens insertion and laser in situ keratomileusis with flap creation using IntraLase.

PURPOSE: To assess the response of the cornea to hydrogel intracorneal lens (ICL) insertion or laser in situ keratomileusis (LASIK) with IntraLase (IntraLase Corp.) at the cellular level. SETTING: Department of Ophthalmology, University of Texas Southwestern Medical Center, Dallas, Texas, USA. METHODS: Twenty patients (29 eyes) were evaluated by in vivo confocal microscopy 1 to 6 months postoperatively: 20 eyes had LASIK with flap creation by IntraLase, and 9 eyes had ICL insertion (8 following IntraLase). RESULTS: For LASIK with IntraLase, keratocyte activation and/or interface haze was detected in 8 of 20 eyes. The remaining eyes had interface particles but no cell activation. Keratocyte activation was generally limited to a few cell layers adjacent to the interface. However, 2 patients exhibited multiple layers of activation and increased extracellular matrix (ECM) reflectivity (haze) surrounding the interface by confocal microscopy. Both patients also had clinical haze and photophobia. For ICLs, following insertion, 5 of 9 eyes had activated keratocytes adjacent to the implant surfaces. The largest amount of cell activation and ECM haze detected by confocal microscopy was in 2 patients with significant clinical haze. Structures with an epithelioid morphology were detected on some implant surfaces. Epithelial thickness was 33.3 microm +/- 2.3 (SD) in the ICL eyes and 49.2 +/- 6.5 microm in the LASIK with IntraLase eyes. CONCLUSIONS: Both LASIK with IntraLase and ICL insertion following IntraLase induced keratocyte activation, which may underlie clinical observations of haze in some patients. Intracorneal lens implant also induced thinning of the overlying corneal epithelium.

Secondary glaucoma associated with advanced acanthamoeba keratitis.

PURPOSE: To describe the association of acanthamoeba keratitis and glaucoma, to establish an incidence of glaucoma in patients with acanthamoeba keratitis, to discuss treatment options and outcomes in these patients, and to describe the histopathologic findings and pathogenesis of glaucoma secondary to acanthamoeba keratitis. METHODS: After Institutional Review Board approval, the charts of all patients suspected of having acanthamoeba keratitis at Aston Ambulatory Center at The University of Texas Southwestern Medical Center were reviewed. Inclusion criteria were as follows: diagnosis of acanthamoeba keratitis by positive confocal microscopy or culture, diagnosis of glaucoma or ocular hypertension secondary to acanthamoeba keratitis, and at least 6 months of follow-up. Exclusion criteria included a previous diagnosis of glaucoma or ocular hypertension and any history of intraocular surgery before the development of glaucoma. The date of keratitis development, pneumotonometry on initial and follow-up examinations, glaucoma medications used, and surgical procedures performed were tabulated. RESULTS: Twenty patients (20 eyes) were included. Six (30%) eyes developed secondary glaucoma during the review period. Of the patients treated for glaucoma with medication alone, the visual acuity of three (75%) of four became light perception or no light perception. Three of six patients required glaucoma drainage device implantation for intraocular pressure control. Of these, the vision of one eye became no light perception, and the other two eyes maintained better than 20/100 vision. Histopathologic examination showed chronic inflammation of the trabecular meshwork and angle closure. No acanthamoeba organisms were found in the angle structures. CONCLUSIONS: The development of secondary glaucoma is not uncommon in acanthamoeba keratitis and is a poor prognostic sign in patients with acanthamoeba keratitis, because most progress to light perception or no light perception vision. Histopathologic findings suggest an inflammatory angle-closure mechanism, apparently without direct infiltration of the organism. The glaucoma associated with acanthamoeba keratitis is often severe and frequently requires surgical intervention for intraocular pressure control and vision preservation.

Use of bioglass for orbital volume augmentation in enophthalmos: a rabbit model (oryctolagus cuniculus).

PURPOSE: To investigate the clinical and histologic response of Novabone-C/M as an osteoproductive alloplastic implant for volume augmentation in the orbit in the treatment of enophthalmos and to compare its outcome alone versus its use in combination with autogenous bone or Medpor granules. METHODS: Novabone-C/M, a bioactive silicone glass material, was implanted in the subperiosteal space of the left orbit of 12 New Zealand White rabbits. The animals were divided into 3 groups, each with 4 animals, based on the material implanted in the orbit: group 1, Novabone alone; group 2, Novabone plus Medpor granules; and group 3, Novabone plus autogenous bone fragments. All rabbits were studied clinically, radiographically, and histologically at 1-, 3-, and 6-month intervals. Animals underwent preoperative and postoperative computed tomography (CT) with 3-dimensional reconstruction, proptosis measurements, and volumetric analysis. Orbit specimens were studied histologically with mineralized bone stain (MIBS) to look for bone formation, reactivity, infection, implant resorption, and migration. RESULTS: There were no signs of significant inflammation or infection. Subcutaneous migration of the implant was seen radiographically but not clinically in groups 1 and 3. Induced proptosis averaged 2.5 mm (at 1 month) and showed regression in all groups over a 6-month period but was not statistically significant. Implant volume was markedly reduced in all groups, averaging 69% in group 1, 37% in group 2, and 59% in group 3 at 6 months. New bone formation and bone remodeling was present in all 3 groups at 3 months and only in group 2 at 6 months. The rate and amount of implant remodeling and bone formation was greatest in the Novabone/Medpor group (group 2). CONCLUSIONS: Bioglass particulate is biocompatible, easy to use in the orbit, and stimulates bone growth. Bioglass is associated with volume loss and migration over 6 months and may not provide adequate volume augmentation in the orbit when used alone for the treatment of enophthalmos. The duration and amount of bone formation may be enhanced when Novabone is used in conjunction with Medpor.