Closantel toxicity.

Closantel is a broad-spectrum antihelminthic agent. It is a veterinary drug used only in animals-usually cattle, sheep and goats. A man in his 60s accidentally ingested approximately 1500 mg closantel. His visual acuity deteriorated. Optical coherence tomography (OCT) showed disruption of the outer retinal layers. Electroretinography identified abnormalities in macula and inner retinal function. He received methylprednisolone 1 g daily intravenously for 3 days. Improvements in both his visual acuity and OCT appearance followed. This case illustrates the profoundly destructive effect of this drug on humans even when consumed in low dose. We provide a concise summary of the small number of cases of closantel toxicity in humans, previously reported, for future reference as needed by others.

An nusual ocular manifestation of multiple myeloma.

A man in his 70s with a history of multiple myeloma presented with a 4-day history of right ptosis and a rapidly enlarging upper eyelid mass. On examination, a large, firm, smooth, pink lesion was found to descend from the conjunctiva of the superior fornix. The patient underwent excision biopsy. Histopathological analysis demonstrated monoclonal plasma cells expressing light-chain kappa, consistent with extramedullary plasmacytoma. Clinical ophthalmic manifestations of multiple myeloma are rare but also diverse. Ocular surface manifestations of multiple myeloma are extremely uncommon. Variable examination findings mean those involving the conjunctiva and may be particularly challenging to diagnose. Secondary ocular extramedullary plasmacytoma, despite its rarity, should be considered in patients with multiple myeloma.

Tectonic Descemet's stripping automated endothelial keratoplasty for corneal perforation.

We report the use of Descemet stripping automated endothelial keratoplasty (DSAEK) for the treatment of sterile corneal perforation after trauma. In an eye with corneal perforation and cataract due to trauma, cataract surgery and DSAEK were performed. Corneal integrity was promptly restored and the patient avoided tectonic anterior lamellar and penetrating keratoplasty. DSAEK may be performed for the management of corneal perforation.

Insidious ocular surface lesion in an 81-year-old woman.

Ocular surface melanoma (OSM) is rare. An 81-year-old Caucasian woman presented with a 4-month history of right eye pain and reduced vision. Histopathological examination of the excisional biopsy identified invasive amelanotic melanoma of the conjunctiva expressing Melan A and SOX10. X-ray of chest, CT of liver and MRI of the brain and orbit did not identify macroscopic metastases. She was given adjuvant topical mitomycin-C 0.04% for four cycles of 2 weeks. Her vision improved and the cornea was clear at 6 months.

Ptosis, ophthalmoplegia and corneal endothelial disease - ocular manifestations of mitochondrial disease.

PURPOSE: To describe two patients with bilateral ptosis, ophthalmoplegia, cataracts and corneal endothelial disease requiring corneal transplantation. OBSERVATIONS: Histopathological analysis of muscle biopsy samples from both patients identified features consistent with a mitochondrial cytopathy. A single multigenic mitochondrial deoxyribonucleic acid (DNA) deletion was detected in the first patient. Pathogenic mutations in the POLG gene which codes for mitochondrial DNA polymerase, tasked with replicating the mitochondrial genome were identified in the second patient. CONCLUSION: The collection of clinical features present in both cases described can be explained by a diagnosis of mitochondrial disease. IMPORTANCE: Corneal endothelial disease, in addition to ptosis, ophthalmoplegia, cataract, pigmentary retinopathy and optic atrophy should be recognised as a feature of mitochondrial disease.

Rhegmatogenous retinal detachments: primary reattachment rates and visual outcomes over a 4-year period.

BACKGROUND AND AIMS: To describe rhegmatogenous retinal detachment surgery in a Dublin tertiary referral centre over a 4-year period and to examine factors predictive of surgical and anatomical success. METHODS: A retrospective study was performed by reviewing the surgical log and the charts of patients who underwent a primary retinal detachment repair in a specialist centre over a 4-year period between 2012 and 2015. We excluded exudative and tractional cases. Multiple parameters were recorded including macular status, visual acuity, type of procedure, complications and visual and anatomical outcomes at 6 months post operation. Primary reattachment rate was calculated alongside change in visual acuity. Chi-square testing and analysis of variance were utilized to determine the effect which lens status, macular status, extent of breaks and type of procedure had on outcome and visual success. RESULTS: A total of 613 primary rhegmatogenous retinal detachment repairs were performed over the 4-year period. Our primary reattachment rate was calculated to be 88.58% (annual range 85.25-91.30%) with a perioperative complication rate of 2.94%. We noted a statistical significant improvement in VA with a median logMAR VA of 1.0 at presentation to 0.5 at 6 months post procedure. Macular status (chi-square test p = 0.15, X2 = 2.072) and lens status (chi-square test p = 0.2974, X2 = 1.086) had no statistical effect on the final anatomical outcome. However, eyes with giant retinal tears were more likely to redetach than those without (chi-square test p = 0.0069, X2 = 7.3). There was no statistical significant difference in the proportion of eyes achieving visual success by surgery category (one-way ANOVA analysis p = 0.501). CONCLUSIONS: This is the first study of its kind in Ireland and will help surgeons benchmark their results against international standards in the future. Accurate recording of logMAR acuity and intraoperative complications is imperative to assist with prospective studies.

Choroidal Melanoma Metastatic to the Contralateral Medial Rectus After Orbital Exenteration

A 78-year-old Caucasian woman presented with pain in her right and only eye that was worse on abduction. Her history was significant for a choroidal melanoma affecting her left eye for which she underwent an orbital exenteration 12 years previously. Computed tomography and magnetic resonance imaging of the right orbit identified a mass lesion affecting the medial rectus, suspicious for metastatic melanoma. A histopathological diagnosis of metastatic melanoma was subsequently made following biopsy of the right medial rectus.

Acquired lacrimal drainage apparatus obstruction in children.

BACKGROUND: Pediatric acquired lacrimal drainage apparatus (LDA) obstruction is much rarer than congenital LDA obstruction. Its etiology and treatment outcomes have not been well defined. Our aim was to examine the etiology and management of acquired LDA obstruction in children and report the results of its management. METHODS: We retrospectively reviewed the medical records of patients ≤16 years of age who presented with acquired epiphora to investigate the causes and describe the management of this condition. RESULTS: A total of 31 patients (16 males [52%]) were included. Mean age of patients was 10.9 years (range, 3-16). The main causes of acquired LDA obstruction were keratoconjunctivitis, herpes simplex blepharokeratoconjunctivitis, and trauma. Silicone tube intubation, endonasal or external dacryocystorhinostomy, and the insertion of lacrimal bypass tubes were the mainstays of management. CONCLUSIONS: It is important to suspect acquired LDA obstruction in children with acquired, persistent epiphora. Surgical management is similar to that in adults.

National incidence of eyelid cancer in Ireland (2005-2015).

AIMS: We report on the incidence of cutaneous eyelid tumours in Ireland over the 11-year-period from 2005 to 2015, we identify associations between demographic factors and cutaneous eyelid tumour risk. METHODS: Skin cancers, including basal cell carcinoma (BCC), squamous cell carcinoma (SCC), melanoma, and other cancers, located on the eyelid or canthus according to ICD-10 coding, as registered by the National Cancer Registry of Ireland (NCRI), were captured from the period 2005 to 2015. Age standardised rates (ASR) were calculated according to the European Standard Population (2013). Longitudinal data analysis using linear regression, and associations with age and sex were evaluated with the statistics program R. RESULTS: There were 4824 patients diagnosed with eyelid BCC during the study period, the ASR in men and women was mean 15.87 and 13.49 per 100,00, respectively. The relative risk for eyelid BCC in men compared with women was 1.18, age was associated with incidence. There were 528 patients diagnosed with SCC; the ASR of eyelid SCC in men and women was 2.10 and 1.39 per 100,000, respectively, and increased in women annually (ß = 0.07, p = 0.0005). The relative risk for eyelid SCC in men compared with women was 1.51, and age was exponentially associated with SCC. Melanoma and other eyelid tumours were uncommon-50 and 55 cases, respectively. CONCLUSION: Incidence of both BCC and SCC increases with age and male sex. The incidence of eyelid SCC is increasing in women, and under age 50, eyelid BCC is more common in women than men. SYNOPSIS: We describe the recent incidence of eyelid cancers in Ireland, from National Cancer Registry Data. We find eyelid BCC, and also SCC, are associated with increased age. Rate of eyelid SCC is increasing in women.

Hybrid Neurofibroma/Schwannoma of the Orbit.

A 68-year-old female presented for assessment of a space occupying lesion of her right orbit, demonstrated on MRI. An upper lid crease anterior orbitotomy was performed and the lesion excised completely. Postoperatively, she had reduced sensation in the distribution of the supraorbital nerve. Histopathologic examination of the excised lesion revealed a hybrid neurofibroma/schwannoma. This represents the fourth reported case of such a lesion arising within the orbit.

Lacrimal Gland Orbital Lobe Cysts Associated With Lymphoid Hyperplasia or Mucosa-Associated Lymphoid Tissue Lymphoma in Patients With Chronic Autoimmune Disease.

Large cysts in the orbital lobe of the lacrimal gland are rare and are associated with Sjögren syndrome and B-cell mucosa-associated lymphoid tissue lymphoma. The authors describe 4 new cases of large orbital lobe lacrimal gland cysts. The first 2 patients, both with Sjögren syndrome, had unilateral cysts associated with chronic inflammation. Mucosa-associated lymphoid tissue lymphoma was also identified in the cyst wall of the second case and could not be completely excluded in the first case. The third patient, with a history of rheumatoid arthritis, had bilateral cysts, again associated with mucosa-associated lymphoid tissue lymphoma. The fourth patient, with no history of systemic disease, had a unilateral cyst associated with reactive lymphoid hyperplasia. Finally, the authors report the long-term outcomes of 3 previously reported cases.

Health technology assessment: A primer for ophthalmology.

Rising healthcare costs and increasing demands for health care require techniques to choose between competing uses and even rationing of health care. Economic evaluations and health technology assessments are increasingly a means to assess the cost effectiveness of healthcare interventions so as to inform such resource allocation decisions. To date, the adoption of health technology assessments, as a way of assessing cost effectiveness, in ophthalmology has been slower, relative to their implementation in other specialities. Nevertheless, demands for eye services are increasing due to an ageing population. The prevalence of conditions such as glaucoma, cataract, diabetic eye disease and age-related macular degeneration increases with age, and it is predicted that global blindness will triple by 2050. So there is a challenge for ophthalmologists to ensure that they can contribute to, interpret, critically evaluate, and use findings from economic evaluations in their clinical practice. To aid this, this article serves as a primer on the use of health technology assessments to assess cost effectiveness using economic evaluation techniques for ophthalmologists. Healthcare systems face many challenges worldwide - changing demographics and evolution of new technologies are only going to intensify. With this in mind, ophthalmology needs to be ready and able to engage with health economists to prepare, interpret, critically evaluate and use findings of economic evaluations and health technology assessments.

Successful reconstruction of an ocular defect resulting from granulomatosis with polyangiitis, following treatment with rituximab.

PURPOSE: To report a unique case of orbital inflammatory disease which was ultimately diagnosed as granulomatosis with polyangitis (GPA) and thus successfully treated. OBSERVATION: A 47 year-old man presented with a rapidly progressive necrotic soft tissue mass within the medial antero-superior aspect of the right eyelid and orbit. He also had transient retinal vasculitis in the left. Serology, histology and imaging were atypical of, but consistent with, GPA. He was thus successfully treated with intravenous rituximab followed by reconstruction of the medial eyelid. CONCLUSION AND IMPORTANCE: A high index of suspicion of GPA is required in orbital inflammatory disease, especially when typical diagnostic findings are absent.

Interface Fungal Keratitis After Descemet Stripping Automated Endothelial Keratoplasty: A Review of the Literature With a Focus on Outcomes.

PURPOSE: To examine the management and associated outcomes of reported cases of interface fungal infection after Descemet stripping automated endothelial keratoplasty (EK). METHODS: A literature review identified reports of interface fungal infection after Descemet stripping automated EK. Data retrieved from the same included patient demographics, surgical procedure undertaken, donor rim culture result, clinical course, and outcome. A review of the relevant literature was also conducted. RESULTS: Twenty-four cases of interface fungal infection after Descemet stripping automated EK were analyzed. Mean age of those affected was 66 years with range 52 to 85 years. Interface fungal infection after Descemet stripping automated EK was noted at a mean of 49.2 days postoperatively. Candida species were the causative infection in 79% cases. Penetrating keratoplasty was eventually performed in 79% of cases. The mean posttreatment best-corrected visual acuity was 0.44 logMAR. CONCLUSIONS: Penetrating keratoplasty is frequently required to eliminate interface fungal infection after Descemet stripping automated EK. A satisfactory visual outcome is usually achieved.

Paediatric retinal detachment: aetiology, characteristics and outcomes.

AIM: To provide contemporary data on the aetiology, clinical features and outcomes of paediatric retinal detachment. METHODS: A retrospective review of all those under 16y who underwent surgical repair for retinal detachment at a single centre between the years 2008 and 2015 inclusive was performed. In each case the cause of retinal detachment, the type of detachment, the presence or absence of macular involvement, the number and form of reparative surgeries undertaken, and the surgical outcome achieved was recorded. RESULTS: Twenty-eight eyes of 24 patients, 15 (62.5%) of whom were male and 9 (37.5%) of whom were female, their mean age being 11.6y and range 2-16y developed retinal detachment over the eight year period studied. Trauma featured in the development of retinal detachment in 14 (50.0%) cases. Retinal detachment was associated with other ocular and/or systemic conditions in 11 (39.3%) cases. A mean of 3.0 procedures with a range of 1-9 procedures per patient were undertaken in the management of retinal detachment. Complex vitrectomy combined with scleral buckling or complex vitrectomy alone were those most frequently performed. Mean postoperative visual acuity was 1.2 logMAR with range 0.0-3.0 logMAR. In 22 of 26 (84.6%) cases which underwent surgical repair the retina was attached at last follow-up. CONCLUSION: Aggressive management of paediatric retinal detachment including re-operation increases the likelihood of anatomical success. In cases where the retinal detachment can be repaired by an external approach alone there is a more favourable visual outcome.

Final anatomic and visual outcomes appear independent of duration of silicone oil intraocular tamponade in complex retinal detachment surgery.

AIM: To report anatomic and visual outcomes following silicone oil removal in a cohort of patients with complex retinal detachment, to determine association between duration of tamponade and outcomes and to compare patients with oil removed and those with oil in situ in terms of demographic, surgical and visual factors. METHODS: We reported a four years retrospective case series of 143 patients with complex retinal detachments who underwent intraocular silicone oil tamponade. Analysis between anatomic and visual outcomes, baseline demographics, duration of tamponade and number of surgical procedures were carried out using Fisher's exact test and unpaired two-tailed t-test. RESULTS: One hundred and six patients (76.2%) had undergone silicone oil removal at the time of review with 96 patients (90.6%) showing retinal reattachment following oil removal. Duration of tamponade was not associated with final reattachment rate or with a deterioration in best corrected visual acuity (BCVA). Patients with oil removed had a significantly better baseline and final BCVA compared to those under oil tamponade (P=0.0001, <0.0001 respectively). CONCLUSION: Anatomic and visual outcomes in this cohort are in keeping with those reported in the literature. Favorable outcomes were seen with oil removal but duration of oil tamponade does not affect final attachment rate with modern surgical techniques and should be managed on a case by case basis.

Pyoderma gangrenosum affecting the eye, orbit, and adnexa. A review.

While pyoderma gangrenosum (PG) most commonly affects the skin it can also involve other organs. It rarely affects the eye, orbit, or adnexa. Its early recognition and proper management with prompt initiation of immunosuppressive therapy are essential for the preservation of the eye and, in turn, vision, in these cases. Here, we review the limited literature already published regarding ocular involvement in PG.

Orbital abscess following posterior subtenon injection of triamcinolone acetonide.

Orbital cellulitis is a serious sight threatening and potentially life threatening condition which can be complicated by orbital abscess formation. Posterior subtenon (PST) injection of corticosteroid is commonly used in the treatment of posterior segment inflammation including post-operative macular oedema. We report a case of orbital abscess formation as a late complication of PST triamcinolone acetonide and discuss the presentation, diagnosis and management.