Bilateral Large Orbital Lymphoma With Proptosis.

Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoid malignancy in adults. It is an aggressive malignancy and requires a multidisciplinary approach with various modalities which include chemotherapy, radiotherapy as well as immunotherapy. A 63-year-old Malay male patient with underlying type 2 diabetes mellitus, hypertension, ischemic heart disease, and stage II chronic kidney disease presented with a one-month history of bilateral eye proptosis associated with lid swelling and red eye. He also complained of progressive right eye blurring of vision. Visual acuity was counting fingers on the right and 6/18 on the left. On examination, the relative afferent pupillary defect was negative. There was bilateral eye proptosis, conjunctival chemosis, and restricted extra-ocular movement in all gazes. There was also exposure keratopathy over the right eye, and intraocular pressure was raised. Bilateral cervical and axillary lymph nodes were palpable. A computerized tomography scan of the brain and orbit revealed bilateral orbital masses with no bony erosions. An incisional biopsy over the upper lid confirmed the diagnosis of diffuse large B-cell lymphoma with multiple myeloma-1 (MUM-1) positivity which defines the activated B-cell subtype (ABC). He was co-managed with a hematologist and was commenced on the rituximab-cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP) chemotherapy regime. Bilateral eye proptosis, chemosis, and restriction of extra-ocular movement resolved after the completion of treatment. However, right eye vision remains poor as the patient developed central self-sealed corneal perforation with iris plugging which has healed with scarring. Diffuse large B-cell orbital lymphoma is a fast-growing and aggressive tumor, hence early diagnosis and prompt multi-disciplinary treatment are crucial for a good outcome.

Trichosporon Endophthalmitis Following Cataract Surgery: A Case Report.

Fungal infections always pose a predicament to management and prognosis. The saprophytic fungus, Trichosporon inkin commonly causes endogenous infection in immunocompromised individuals. We report a case of exogenous T. inkin endophthalmitis successfully treated with voriconazole, pars plana vitrectomy, and removal of the source of infection. A 51-year-old gentleman with suboptimal control of diabetes presented with a right painful red eye for a week after undergoing an uneventful phacoemulsification with a posterior chamber intraocular lens implant more than a month prior. He presented with intense inflammation in the right anterior chamber that did not respond to steroid challenge. Ultrasound B scan showed vitreous opacities with no loculations. The culture of vitreous humor was negative. Systemic investigations were also normal. Despite being given multiple intravitreal antibiotics, his right eye got worse. He then underwent vitrectomy and intraocular lens explantation, in which the culture of the lens grew Trichosporon Inkin. He was subsequently started on the appropriate antifungals (topical, intravitreal, and systemic) based on the minimum inhibitory concentration of the antifungal sensitivity test. The patient eventually showed significant clinical improvement, and intraocular inflammation was subsiding after six months of treatment. His best corrected visual acuity improved to 6/12 with Snellen's visual acuity chart.

Case Series on Endogenous Klebsiella pneumoniae Endophthalmitis: More Than Meets the Eye.

Endogenous endophthalmitis (EE) is a rare but potentially sight-threatening disease with an appreciable mortality rate. Diabetes mellitus remains the most frequently associated condition especially in the Asian population, which potentiates Klebsiella pneumoniae involvement. Endogenous Klebsiella pneumoniae endophthalmitis (EKE) usually has a poor final visual outcome despite treatment with intravitreal and systemic antibiotics. We report three cases of EKE with systemic involvement Klebsiella pneumoniae invasive syndrome (KPIS). KPIS was diagnosed in three patients with multiple comorbidities who presented with a blurring of vision and eye redness. Patient 1 was a 63-year-old Malay man diagnosed with left eye panophthalmitis with multifocal liver and prostate abscesses. He underwent drainage of the liver abscess and eventually evisceration of the left eye due to scleral perforation. Patient 2 was a 66-year-old Malay woman diagnosed with left eye endophthalmitis. Due to hemodynamic instability, vitrectomy was delayed and eventually sustained corneal perforation and eviscerated. The patient eventually succumbed to infection. Patient 3 was a 42-year-old Malay woman diagnosed with KPIS, renal abscess, lung abscess, and left endogenous endophthalmitis. She underwent a vitrectomy but her postoperative vision remained poor. All patients received multiple intravitreal antibiotics and systemic antibiotics. KPIS is frequently associated with catastrophic disabilities. Our cases highlight the importance of an early suspicion of systemic involvement in patients presenting with EKE. Prompt diagnosis, emergent radiographic evaluation, early adequate drainage, and appropriate treatment with antibiotics potentially improve survival and visual prognosis.

Scedosporium apiospermum: A Rare Cause of Aggressive Orbital Apex Syndrome.

Orbital apex syndrome (OAS) is a localized orbital cellulitis at the orbital apex that can cause vision loss from optic neuropathy and ophthalmoplegia involving multiple cranial nerves. Herein, we report a rare and rapidly progressive case of OAS secondary to fungal pansinusitis caused by Scedosporium apiospermum in an immunocompromised patient following the extraction of abscessed teeth. A 48-year-old man with diabetes mellitus who had failed to adhere to his treatment presented with complaints of a right-sided headache and toothache for two weeks, with nausea and vomiting for two days prior to presentation. The patient was treated for septic shock secondary to the dental abscesses. Non-contrast brain computed tomography (CT) showed no significant intracranial abnormalities other than pansinusitis. Four days later, dental extraction was performed. The patient reported progressive painless blurring of the vision in his right eye following the dental extractions and was referred to the ophthalmology department. Subsequent examinations revealed decreased optic nerve function and ophthalmoplegia in his right eye and dental caries in the upper molars, with a mucopurulent discharge from the right sphenoid region. The clinical diagnosis was OAS. Pus near the orbital apex was drained surgically. Methicillin-resistant Staphylococcus aureus was isolated from the pus and a nasal swab. Tissue culture from the septal wall yielded S. apiospermum. The patient's condition deteriorated, despite intensive antibiotic and antifungal treatment and repeated surgical debridement. The disease progressed rapidly to his left eye. Sixty-seven days after the inital presentation, his visual acuity (VA) of both eyes was classified as no perception of light (NPL). The patient discharged himself from the hospital (at own risk discharge) and subsequently failed to attend a scheduled appointment in the ophthalmology clinic. If immunocompromised patients present with OAS, fungal infections should be ruled out. Prompt and aggressive treatment using a multidisciplinary approach is mandatory in cases of potentially life-threatening and vision-threatening fungal infections.