REACTIVE AMYLOID A PROTEIN AMYLOIDOSIS IN THE SETTING OF INFECTIVE ENDOCARDITIS MANIFESTING AS BILATERAL ORBITOPATHY AND CHOROIDOPATHY.

PURPOSE: To describe a case of amyloid A protein amyloidosis that produced an orbital inflammatory response with a novel presentation. METHODS: Case report. RESULTS: A 24-year-old Caucasian women with a history of intravenous heroin use was hospitalized for tricuspid valve endocarditis and methicillin-resistant Staphylococcus aureus bacteremia, as well as acute renal failure. She received hemodialysis and intravenous daptomycin and had negative blood cultures for 3 weeks, when she developed sudden bilateral orbital swelling and blurred vision. Visual acuity was 20/200 in the right eye and 20/400 in the left eye. Examination revealed proptosis, conjunctival chemosis and desiccation, optic disk swelling, creamy choroidal infiltrates, and inferiorly located exudative retinal detachments in both eyes. Multimodal imaging demonstrated thickening of the sclera, choroid, and choriocapillaris as well as outer retinal disruption, subretinal fluid, and deposits of hyperfluorescent debris within the choriocapillaris, outer retina, and vitreous. Oral prednisone at 60 mg per day resolved the choroidal infiltrates and exudative detachments. Persistent nephrotic syndrome called for a renal biopsy, which demonstrated amyloid A protein amyloidosis. CONCLUSION: Orbital and choroidal Amyloid A protein amyloidosis can induce a local inflammatory response manifesting as orbital swelling, papillitis, posterior scleritis, choroiditis, and exudative retinal detachment, which responds to steroid therapy. The underlying pathology is likely a reactive inflammatory, vasoocclusive process involving the choriocapillaris and orbital vasculature to the presence of amyloid fibrils.

Povidone-iodine concentration and dosing in cataract surgery.

Iodine has been recognized as an effective bactericide since the 1800s, and povidone-iodine (PI) solution has been applied to the ocular surface and periocular skin since the 1980s to prevent endophthalmitis in cataract surgery. In vitro, PI solution kills bacteria quickly at dilute concentrations (0.05%-1.0%). In many instances, PI kills bacteria more quickly at these dilute concentrations than more conventional (5%-10%) concentrations. This is due to greater availability of diatomic free iodine in dilute solution, the bactericidal component of PI. The toxicity of PI, both in vitro and clinically, has been shown to be related to concentration. Current American Academy of Ophthalmology and the European Society of Cataract and Refractive Surgeons recommendations regarding PI use suggest using 5% PI before surgery. An alternative dosing strategy uses dilute PI repetitively throughout cataract surgery (0.25% every 30 seconds). We review the povidone-iodine literature with attention to basic science and use of dilute PI.