Ocular and cerebral infarction from periocular filler injection.

A 20-year-old woman presented with loss of vision in her right eye and a "black nose" after receiving hyaluronic acid filler injections in her right glabella 1 month prior. Her vision was no light perception, and external examination revealed resolving skin necrosis at the nasal tip. A dilated fundus exam showed a fibrotic membrane emanating from a pale optic nerve and a diffusely atrophic retina with sclerotic vessels. An MRI demonstrated scattered right-sided parietal lobe infarcts. These findings were consistent with inadvertent cannulation of the supraorbital artery, followed by injection of filler into the internal carotid circulation. The product traveled in a retrograde fashion, occluding the right ophthalmic artery, right dorsal nasal artery, and arterial segments to the Circle of Willis. This case highlights the importance of understanding the complex vascular architecture of the periorbita and the mechanism by which such occlusions occur.

Outcome after surgical repair of partial anomalous pulmonary venous connection.

OBJECTIVE: To review the operative results of 55 cases of partial anomalous pulmonary venous connection (PAPVC). METHODS: This retrospective case series of 55 cases of PAPVC operated from January 2011 to June 2016 at CPE Institute of cardiology, Multan. Baseline characteristics of patients, their operative findings and results were retrieved from the hospital record. RESULTS: Operation for PAPVC was performed in 55 patients. Patient's age varied from 3-28 years (mean 12.56±7.49), their weight was 9-62 kg mean (25.61±16.28). There were 41(74.5%) males and 14(25.5%) females. 49(89.0%) patients had right sided PAPVC associated with ASD moreover 3(5.4%) cases had right pulmonary vein draining into right atrium. While there was only one case having left sided PAPVC (1.8%) and two cases (3.6%) of bilateral PAPVC (4%). Reassuringly, there was not a single mortality. However, one patient developed junctional rhythum, which was successfully controlled on amiodarone. SVC obstruction having 6mmHg gradient was observed in one case however patient is doing well and is on follow up since 9 months. CONCLUSION: Surgical correction of PAPVC generally carries highly reproducible results with low morbidity.

Utilization of Online Resources by Patients in an Ophthalmic Emergency Department.

Objective To describe the utilization of online resources by patients prior to presentation to an ophthalmic emergency department (ED) and to assess the accuracy of online resources for ophthalmic diagnoses. Methods This is a prospective survey of patients presenting to an ophthalmic ED for initial evaluation of ocular symptoms. Prior to evaluation, patients completed surveys assessing ocular symptoms, Internet usage, and presumed self-diagnoses. Demographics and characteristics of Internet usage were determined. Accuracy of self-diagnoses was compared between Internet users and nonusers. Diagnoses were classified as high or low acuity based on agreement between senior authors. Results A total of 144 patients completed surveys. Mean (standard deviation) age was 53.2 years (18.0). One-third of patients used the Internet for health-related searches prior to presentation. Internet users were younger compared with nonusers (48.2 years [16.5] vs. 55.5 years [18.3], p = 0.02). There were no differences in sex, ethnicity, or race. Overall, there was a threefold difference in proportion of patients correctly predicting their diagnoses, with Internet users correctly predicting their diagnoses more often than nonusers (41 vs. 13%, p < 0.001). When excluding cases of known trauma, the difference in proportion increased to fivefold (Internet users 40% vs. nonusers 8%, p < 0.001). Upon classification by acuity level, Internet users demonstrated greater accuracy than nonusers for both high- (42 vs. 17%, p = 0.03) and low (41 vs. 10%, p = 0.001)-acuity diagnoses. Greatest accuracy was in cases of external lid conditions such as chalazia and hordeola (100% [4/4] of Internet users vs. 40% (2/5) of nonusers), conjunctivitis (43% [3/7] of Internet users vs. 25% [2/8] of nonusers), and retinal traction or detachments (57% [4/7] of Internet users vs. 0% [0/4] of nonusers). The most frequently visited Web sites were Google (82%) and WebMD (40%). Patient accuracy did not change according to the number of Web sites visited, but patients who visited the Mayo Clinic Web site had greater accuracy compared with those who visited other Web sites (89 vs. 30%, p = 0.003). Conclusion Patients with ocular symptoms may seek medical information on the Internet before evaluation by a physician in an ophthalmic ED. Online resources may improve the accuracy of patient self-diagnosis for low- and high-acuity diagnoses.

Agrobacterium radiobacter Endophthalmitis Associated with Baerveldt Tube Exposure.

Agrobacterium radiobacter is a Gram-negative bacillus and a rare cause of endophthalmitis. An 85-year-male presented with late-onset endophthalmitis associated with exposure of an inferonasal Baerveldt tube. The patient was initially treated with anterior chamber paracentesis and intravitreal antibiotics. Aqueous humor culture revealed A. radiobacter resistant to cefazolin, ceftazidime, amikacin, tobramycin, and trimethoprim-sulfamethoxazole. Subsequently, the patient underwent explantation of the glaucoma drainage implant (GDI). After initial improvement, the patient had clinical worsening and was diagnosed with recurrence. Subsequent treatment involved explantation of the second GDI in addition to pars plana vitrectomy with silicone oil infusion, intraocular lens removal, and administration of intravitreal antibiotics. Visual acuity improved but remained at count fingers at 2 weeks. This is the first reported patient with A. radiobacter endophthalmitis associated with an exposed GDI. This report illustrates the resistant nature of this organism in addition to the efficacy of silicone oil administration and intraocular prosthesis explantation.

Emergent Ophthalmic Surgical Care at a Tertiary Referral Center During the COVID-19 Pandemic.

PURPOSE: This study characterized the delivery of emergent ophthalmic surgical care during April 2020 of the coronarvirus disease-19 (COVID-19) pandemic compared with the same interval the previous year. DESIGN: Retrospective observational before-and-after study. METHODS: This study reviewed and characterized each emergent and/or urgent procedure performed during April 2020 and April 2019 at a single tertiary ophthalmology referral center. Information collected included the details of patient presentation, diagnosis, surgical procedure, and preoperative COVID-19 testing. RESULTS: In total, 117 surgical procedures were performed on 114 patients during the month of April 2020 compared with 1,107 performed in April 2019 (P < .0001). Retinal detachment repair was the most common procedure (n = 37; 31.6%) in April 2020, whereas elective cataract surgery (n = 481; 47.3%) was the most common procedure in April 2019. The mean age of patients was 50.0 years in April 2020 compared with 59.0 years (P < .0001) the previous year. During April 2020, the mean age of surgeons performing procedures was 42.3 years compared with 48.4 years (P < .0001) during April 2019. In April 2020, all but 5 patients (96%) had reverse transcriptase polymerase chain reaction based COVID-19 testing before their procedure. One patient (0.88%) had a positive COVID-19 test. CONCLUSIONS: The COVID-19 pandemic decreased our institution's surgical volume in April 2020 to approximately 10% of the usual volume. The pandemic changed the type of cases performed and led to a statistically significant decrease in both the age of our surgeons and patients relative to the same interval in the previous year. Broad preoperative screening led to 1 positive COVID-19 test in an asymptomatic patient.

Impact and Trends in Global Ophthalmology.

Purpose of Review: Our goal is to provide a review of the impact, global estimates, and projection of vision impairment as well as ongoing systems for eye care delivery. Recent Findings: Many of the blinding diseases in developing countries are preventable or curable, but the lack of ophthalmologists, the lack of education, and the lack of access to any eye care are some of the major obstacles encountered. Summary: As our world becomes more interconnected through globalization, the interactions between different cultures and populations increase. Global ophthalmology is a field dedicated to building sustainable eye care delivery systems to deliver high-quality care in minimal resource settings, with the aim of reducing blindness around the world.

Clinical outcomes of 4-point scleral fixated 1-piece hydrophobic acrylic equiconvex intraocular lens using polytetrafluoroethylene suture.

PURPOSE: To report the visual outcomes and complications of scleral fixated intraocular lenses (IOLs) using Gore-Tex suture. METHODS: The current study is a retrospective noncomparative case series including patients who underwent scleral fixation of IOL (Akreos AO60) using Gore-Tex suture from August 2015 to March 2017 at a university teaching center. Primary outcome measures were visual acuity and complications at last follow-up. RESULTS: The current study included 49 eyes of 48 patients. Mean follow-up duration postsurgery was 6.9 months (range: 0.9-29.4 months). The indications for secondary IOL surgery were dislocated IOL in 16/49 (33%), subluxed IOL in 9/49 (18%), dislocated or subluxed crystalline lens in 9/49 (18%), traumatic cataract in 8/49 (16%), and complicated cataract surgery in 7/49 (14%). Mean best-corrected logMAR visual acuity improved from 1±0.7 (20/200 Snellen equivalent) preoperatively to 0.5±0.5 (20/63 Snellen equivalent) at last follow-up. There were no intraoperative complications noted. Early postoperative complications included significant persistent corneal edema (longer than 1 week) in 4/49 (8.2%), ocular hypertension (intraocular pressure ≥25 mmHg) in 8/49 (16.3%), hypotony (intraocular pressure ≤5 mmHg) in 6/49 (12.2%), cystoid macular edema 3/21 (6.1%), IOL tilt 2/49 (4.1%), hyphema in 2/49 (4.1%), and vitreous hemorrhage in 5/49 (4.8%). There was one case of recurrent retinal detachment. One patient presented with an erosion of the Gore-Tex suture through the conjunctiva resulting in a purulent scleritis 6 months after the initial surgery, and was managed with removal of the IOL, debridement, and cryotherapy. Forty-one of 49 patients completed 3-month follow-up, among which visual acuity improved, deteriorated, or remained same compared to baseline in 27/49 (55.1%), 8/49 (16.3%), and 6/49 (12.2%) eyes, respectively. CONCLUSION: In the current study, visual acuity outcomes were generally favorable. The complications were largely transient. Significant complications included a suture-related infection, which required removal of the IOL, and a recurrence of a retinal detachment.

Prevalence, risk factors, and morbidity of eye lid laxity in a veteran population.

PURPOSE: The aim of this study was to study prevalence, risk factors, and morbidity of eyelid laxity in a veteran population. METHODS: This prospective cross-sectional study with a retrospective chart review included 150 subjects evaluated from either an outpatient eye clinic or a geriatric clinic at the Miami Veterans Affairs Hospital from June through August 2013. Clinical data were gathered from a questionnaire and a computerized medical record system including demographics, medical history, and ocular irritation history. Upper and lower eyelid laxity was clinically graded. Main outcome measures were prevalence of eyelid laxity, risk factors for its presence, and its correlation to ocular surface symptoms. RESULTS: Fifty-four percent of participants (n = 81) had laxity (grade 1 or higher) in either upper and/or lower eyelids. Risk factors for eyelid laxity in our population included older age, higher body mass index, and a diagnosis of sleep apnea. Patients with any eyelid laxity (grade 1 or more in any eyelid) had a 2.23-fold risk of severe ocular surface symptoms (score of 12 or higher on the dry eye questionnaire 5) compared with those without laxity (95% confidence interval, 1.15-4.31; P = 0.017), and this was primarily driven by the presence of upper eyelid laxity. CONCLUSIONS: We found high prevalence of eyelid laxity in our population, and its presence was associated with significant ocular surface morbidity. This study reinforces the need to incorporate dynamic eyelid testing into ophthalmic examination in patients with ocular surface discomfort.

Current Thoughts in Fungal Keratitis: Diagnosis and Treatment.

Fungal keratitis remains a challenging and often elusive diagnosis in geographic regions where it is endemic. Marred by delays in diagnosis, the sequelae of corneal fungal infections, though preventable, can be irreversible. Recent studies and advances in the arena have broadened the approach and treatment to mycotic keratitis. This review will discuss current diagnostic modalities of fungal keratitis and will particularly focus on treatment regimens. It will also explore future therapeutic models and critique the potential benefit of each.