EXTENSIVE ORBITAL AND PARAPHARYNGEAL EMPHYSEMA REQUIRING URGENT CANTHOTOMY AND CANTHOLYSIS AFTER PARS PLANA VITRECTOMY.

PURPOSE: The authors report the emergent management of a case of orbital and parapharyngeal emphysema causing orbital compartment syndrome and signs of peripheral neuropathy days after pars plana vitrectomy. METHODS: Case report. RESULTS: A 20-year-old woman underwent 3-port 23-gauge pars plana vitrectomy in the right eye for total retinal detachment under general anesthesia. All sclerotomies were secured with 7-0 polyglactin 910 (Vicryl; Ethicon) sutures before instillation of 15% C3F8 gas. On the third postoperative day, the patient presented with a 3-mm proptosis, near-total ophthalmoplegia, jaw protrusion, head deviation, tongue protrusion, and facial twitching. Computed tomography showed extensive subcutaneous gas in the right orbit and bilateral parapharyngeal spaces, and a tethered right optic nerve with globe tenting. A decision was made to perform urgent lateral canthotomy and cantholysis. Three hours after canthotomy and cantholysis, her neurologic signs had resolved except for intermittent tongue protrusion, which resolved thereafter. At postoperative Week 7, the patient's vision was 20/70 and her intraocular pressure was 13 mmHg. CONCLUSION: To the authors' knowledge, this is the only report of a modern small-gauge vitrectomy procedure being complicated by orbital compartment syndrome and extensive emphysema causing peripheral neuropathy, and successfully treated with urgent canthotomy and cantholysis.

DELAYED-ONSET STREPTOCOCCUS INTERMEDIUS ENDOPHTHALMITIS FOLLOWING ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR INTRAVITREAL INJECTION.

PURPOSE: Endophthalmitis following intravitreal anti-vascular endothelial growth factor injections is frequently caused by Streptococcus viridans organisms and tends to be aggressive. Herein, we present a case of postinjection Streptococcus viridans endophthalmitis presenting in an atypically delayed fashion with good visual outcome. METHODS: Single clinical case report. RESULTS: A 91-year-old woman treated with aflibercept for exudative age-related macular degeneration of the left eye presented to the emergency department with mild pain and visual acuity decline to counting fingers, pigmented anterior chamber cells and vitreous haze 7 weeks after her most recent intravitreal injection. She had no symptoms of systemic infection. The presumptive diagnosis initially was vitreous hemorrhage. Over 10 days of observation, she developed worsening pain and vitritis suggestive of endophthalmitis, leading us to perform vitrectomy with intravitreal vancomycin and ceftazidime. Vitreous biopsy was culture positive for Streptococcus intermedius , a type of viridans streptococcus typically associated with head and neck abscesses. The infection resolved and the patient's visual acuity returned to her baseline of 20/100, with no recurrence of infection after 4 months of follow-up. CONCLUSSION: The virulence of viridans streptococci capable of producing postinjection endophthalmitis may vary widely. Infection ought to be suspected even in cases of delayed-onset intraocular inflammation.

Human Amniotic Membrane Plug for Chronic or Persistent Macular Holes.

PURPOSE: To report on the use of human amniotic membrane for macular holes at 2 Canadian tertiary care centers. DESIGN: Retrospective cohort study. SUBJECTS: Twenty-two patients with persistent or chronic macular holes. METHODS: Macular hole surgery was performed by 3 vitreoretinal surgeons. MAIN OUTCOME MEASURES: Macular hole closure with complete plugging by human amniotic membrane on spectral-domain OCT. RESULTS: The closure rate was 91% (20 of 22; median follow-up, 7 months), with no statistically significant visual acuity change overall. Complications included subretinal silicone oil (5%), choroidal neovascularization (5%), atrophy (5%), and cystoid macular edema (9%). CONCLUSIONS: Anatomical success with limited visual recovery was observed.

Building Programs to Eradicate Toxoplasmosis Part II: Education.

Purpose of Review: Review work to create and evaluate educational materials that could serve as a primary prevention strategy to help both providers and patients in Panama, Colombia, and the USA reduce disease burden of Toxoplasma infections. Recent Findings: Educational programs had not been evaluated for efficacy in Panama, USA, or Colombia. Summary: Educational programs for high school students, pregnant women, medical students and professionals, scientists, and lay personnel were created. In most settings, short-term effects were evaluated. In Panama, Colombia, and USA, all materials showed short-term utility in transmitting information to learners. These educational materials can serve as a component of larger public health programs to lower disease burden from congenital toxoplasmosis. Future priorities include conducting robust longitudinal studies of whether education correlates with reduced adverse disease outcomes, modifying educational materials as new information regarding region-specific risk factors is discovered, and ensuring materials are widely accessible.

Building Programs to Eradicate Toxoplasmosis Part I: Introduction and Overview.

Purpose of Review: Review building of programs to eliminate Toxoplasma infections. Recent Findings: Morbidity and mortality from toxoplasmosis led to programs in USA, Panama, and Colombia to facilitate understanding, treatment, prevention, and regional resources, incorporating student work. Summary: Studies foundational for building recent, regional approaches/programs are reviewed. Introduction provides an overview/review of programs in Panamá, the United States, and other countries. High prevalence/risk of exposure led to laws mandating testing in gestation, reporting, and development of broad-based teaching materials about Toxoplasma. These were tested for efficacy as learning tools for high-school students, pregnant women, medical students, physicians, scientists, public health officials and general public. Digitized, free, smart phone application effectively taught pregnant women about toxoplasmosis prevention. Perinatal infection care programs, identifying true regional risk factors, and point-of-care gestational screening facilitate prevention and care. When implemented fully across all demographics, such programs present opportunities to save lives, sight, and cognition with considerable spillover benefits for individuals and societies. Supplementary Information: The online version contains supplementary material available at 10.1007/s40124-022-00269-w.

Building Programs to Eradicate Toxoplasmosis Part IV: Understanding and Development of Public Health Strategies and Advances "Take a Village".

Purpose of Review: Review international efforts to build a global public health initiative focused on toxoplasmosis with spillover benefits to save lives, sight, cognition and motor function benefiting maternal and child health. Recent Findings: Multiple countries' efforts to eliminate toxoplasmosis demonstrate progress and context for this review and new work. Summary: Problems with potential solutions proposed include accessibility of accurate, inexpensive diagnostic testing, pre-natal screening and facilitating tools, missed and delayed neonatal diagnosis, restricted access, high costs, delays in obtaining medicines emergently, delayed insurance pre-approvals and high medicare copays taking considerable physician time and effort, harmful shortcuts being taken in methods to prepare medicines in settings where access is restricted, reluctance to perform ventriculoperitoneal shunts promptly when needed without recognition of potential benefit, access to resources for care, especially for marginalized populations, and limited use of recent advances in management of neurologic and retinal disease which can lead to good outcomes. Supplementary Information: The online version contains supplementary material available at 10.1007/s40124-022-00268-x.

Building Programs to Eradicate Toxoplasmosis Part III: Epidemiology and Risk Factors.

Purpose of Review: Review comprehensive data on rates of toxoplasmosis in Panama and Colombia. Recent Findings: Samples and data sets from Panama and Colombia, that facilitated estimates regarding seroprevalence of antibodies to Toxoplasma and risk factors, were reviewed. Summary: Screening maps, seroprevalence maps, and risk factor mathematical models were devised based on these data. Studies in Ciudad de Panamá estimated seroprevalence at between 22 and 44%. Consistent relationships were found between higher prevalence rates and factors such as poverty and proximity to water sources. Prenatal screening rates for anti-Toxoplasma antibodies were variable, despite existence of a screening law. Heat maps showed a correlation between proximity to bodies of water and overall Toxoplasma seroprevalence. Spatial epidemiological maps and mathematical models identify specific regions that could most benefit from comprehensive, preventive healthcare campaigns related to congenital toxoplasmosis and Toxoplasma infection.

Trends of Bacterial Keratitis Culture Isolates in Jerusalem; a 13- Years Analysis.

PURPOSE: To describe the trends in pathogens and antibacterial resistance of corneal culture isolates in infectious keratitis during a period of 13 years at Hadassah-Hebrew University Medical Center. METHODS: A Retrospective analysis of bacterial corneal isolates was performed during the months of January 2002 to December 2014 at Hadassah Hebrew University Medical Center. Demographics, microbiological data and antibiotic resistance and sensitivity were collected. RESULTS: A total of 943 corneal isolates were analyzed during a 13 year period. A total of 415 positive bacterial cultures and 37 positive fungal cultures were recovered, representing 48% of the total cultures. The Annual incidence was 34.78 ± 6.54 cases. The most common isolate was coagulase-negative staphylococcus (32%), which had a significant decrease in trend throughout the study period (APC = -8.1, p = 0.002). Methicillin-resistant Staphylococcus aureus (MRSA) appears to have a decrease trend (APC = -31.2, P = 0.5). There was an increase in the resistance trend of coagulase-negative staphylococci to penicillin (APC = 5.0, P = <0.001). None of the pathogens had developed any resistance to Vancomycin. (P = 0.88). CONCLUSIONS: Coagulase negative staphylococci were the predominant bacteria isolated from patients with keratitis. There was no significant change in the annual incidence of cases of bacterial keratitis seen over the past 13 years. Keratitis caused by MRSA appeared to decrease in contrast to the reported literature.

Trend Analysis of Cancer Mortality and Incidence in Panama, Using Joinpoint Regression Analysis.

Cancer is one of the leading causes of death worldwide and its incidence is expected to increase in the future. In Panama, cancer is also one of the leading causes of death. In 1964, a nationwide cancer registry was started and it was restructured and improved in 2012. The aim of this study is to utilize Joinpoint regression analysis to study the trends of the incidence and mortality of cancer in Panama in the last decade. Cancer mortality was estimated from the Panamanian National Institute of Census and Statistics Registry for the period 2001 to 2011. Cancer incidence was estimated from the Panamanian National Cancer Registry for the period 2000 to 2009. The Joinpoint Regression Analysis program, version 4.0.4, was used to calculate trends by age-adjusted incidence and mortality rates for selected cancers. Overall, the trend of age-adjusted cancer mortality in Panama has declined over the last 10 years (-1.12% per year). The cancers for which there was a significant increase in the trend of mortality were female breast cancer and ovarian cancer; while the highest increases in incidence were shown for breast cancer, liver cancer, and prostate cancer. Significant decrease in the trend of mortality was evidenced for the following: prostate cancer, lung and bronchus cancer, and cervical cancer; with respect to incidence, only oral and pharynx cancer in both sexes had a significant decrease. Some cancers showed no significant trends in incidence or mortality. This study reveals contrasting trends in cancer incidence and mortality in Panama in the last decade. Although Panama is considered an upper middle income nation, this study demonstrates that some cancer mortality trends, like the ones seen in cervical and lung cancer, behave similarly to the ones seen in high income countries. In contrast, other types, like breast cancer, follow a pattern seen in countries undergoing a transition to a developed economy with its associated lifestyle, nutrition, and body weight changes.

The association of tobacco control policies and the risk of acute myocardial infarction using hospital admissions data.

OBJECTIVE: To evaluate the association of a nationwide comprehensive smoking ban (CSB) and tobacco tax increase (TTI) on the risk of acute myocardial infarctions (AMI) in Panama for the period of 2006 - 2010 using hospital admissions data. METHODS: Data of AMI cases was gathered from public and private hospitals in the country for the period of January 1, 2006 to December 31, 2010. The number of AMI cases was calculated on a monthly basis. The risk of AMI was estimated for the pre-CSB period (January 2006 to April 2008) and was used as a reference point. Three post-intervention periods were examined: (1) post-CSB from May 2008 to April 2009 (12 months); (2) post-CSB from May 2009 to November 2009 (7 months); and (3) post-TTI from December 2009 to December 2010 (13 months). Relative risks (RR) of AMI were estimated for each post intervention periods by using a Poisson regression model. Mortality registries for the country attributed to myocardial infarction (MI) were obtained from January 2001 to December 2012. The annual percentage change (APC) of the number of deaths from MI was calculated using Joinpoint regression analysis. RESULTS: A total sample size of 2191 AMI cases was selected (monthly mean number of cases 36.52 ± 8.24 SD). Using the pre-CSB as a reference point (RR = 1.00), the relative risk of AMI during the first CSB period, the second CSB period and post-TTI were 0.982, 1.049, and 0.985, respectively. The APC of deaths from MI from January 2001 to April 2008 was 0.5%. From January 2001 to June 2010 the APC trend was 0.47% and from July 2010 to December 2012 the APC was -0.3%. CONCLUSIONS: The implementation of a CSB and TTI in Panama were associated with a decrease in tobacco consumption and a reduction of the RR of AMI.