Survey of ocular abnormalities in draft horses.

OBJECTIVE: To determine the prevalence of ocular disease in draft horses in the United States. ANIMALS: Draft horses of various breeds and ages. PROCEDURE: Nondilated ophthalmic examination was performed using slit lamp biomicroscopy and indirect ophthalmoscopy. Intraocular pressures were measured when possible. RESULTS: One hundred sixty-five draft horses were examined. Age range: 10 days to 33 years (mean 10.8 years, median 10 years); 87 geldings (52.7%), 71 mares (43.0%), 7 stallions (4.2%); 64 Percherons (38.8%), 51 Belgians (30.9%), 29 Clydesdales (17.6%), 15 Shires (9%), and 6 other draft breed (3.6%). Intraocular pressure: mean 24.7 mmHg OD, range 13-37 mmHg; mean 25.0 mmHg OS, range 11-37 mmHg. Vision-threatening disease was present in 9 horses (5.5%): complete cataracts 1, post-traumatic optic nerve atrophy 1, uveitis and secondary glaucoma 1, retinal detachment 1, large chorioretinal scar 3, phthisis bulbi 2. Non-vision-threatening ocular disease was present in 56 horses (33.9%) involving one or more ocular structures: eyelid trauma/notch defect 14 (8.5%), SCC-type adnexal lesions 12 (7.3%), corneal scars 16 (9.7%), keratitis 6 (3.6%), corpora nigra cyst 15 (9.1%), incipient/punctate cataract 50 (30.3%), vitreous degeneration 10 (6.1%), asteroid hyalosis 1, "bullethole" chorioretinal scars 3, RPE coloboma 1. Linear keratopathy was present in 28 horses (17%) with 2/28 having concurrent vision threatening ocular disease. CONCLUSIONS: Ocular abnormalities, in particular minor cataracts, were relatively common in this population, but not typically vision-threatening. Additionally, this survey demonstrated a greater prevalence of linear keratopathy in draft horses compared with reports in other breeds; however, it does not appear to be associated with concurrent ocular disease.

Retrobulbar respiratory epithelial orbital cyst in a dog: A case report.

A 10-month-old female, neutered French Bulldog presented with a history of unilateral right-sided intermittent conjunctivitis and exophthalmos. The patient suffered blunt force trauma to the right eye after a tennis ball impact approximately five months prior to presentation. Examination identified the patient was visual with exophthalmos, lateral strabismus, conjunctival hyperaemia, episcleral congestion, and papilloedema. Magnetic resonance imaging and ultrasonography identified an approximately two centimeter diameter fluid-filled structure directly posterior to the globe leading to displacement of the optic nerve and distortion of the posterior globe wall. Centesis of the lesion demonstrated neutrophilic and macrophagic inflammation with evidence of prior hemorrhage. Within four weeks, the structure had re-filled to its original size and was subsequently excised in its entirety, via a lateral orbitotomy. Histopathologic findings indicated a non-keratinising orbital cyst, the lining of which was consistent with a respiratory epithelial cyst. Recurrence had not occurred seven months' post-surgery. To the author's knowledge, previous reports of retrobulbar respiratory epithelial cysts have not been documented in animals.

Diagnosis and surgical management of a retrobulbar abscess causing unilateral exophthalmos in a Boer goat.

A 10-year-old Boer goat wether presented for unilateral exophthalmos of 2- to 3-week duration. Ocular ultrasonography and computed tomography (CT) were utilized in the diagnosis of the patient's orbital disease and surgical planning. Exenteration was performed under the same general anesthetic event as CT. Cytology, culture, and histopathology were performed after exenteration. Cytology was consistent with a mixed bacterial infection. Culture confirmed the presence of Streptococcus ovis. Histopathology on the enucleated globe and mass revealed no evidence of tumor and confirmed intraocular extension of retrobulbar inflammation. Histopathologic diagnosis was consistent with severe chronic orbital pyogranuloma and fibrinosuppurative endophthalmitis confined to the subretinal space. The abscess recurred in the orbital space 2 weeks postoperatively; the orbit was explored. Repeat culture was consistent with S. ovis, Staphylococcus schleigeri subspecies coagulans, and Fusobacterium necrophorum. Complete resolution was obtained after drainage and lavage of the orbit. Abscess is cited as a cause of exophthalmos in small ruminants, but no individual case reports exist. Advanced imaging allowed presumptive diagnosis and surgical planning. Histopathology confirmed intraocular extension of retrobulbar disease.

Orbital apex syndrome secondary to an orbital sarcoma in a dog.

A 12-year-old castrated male cocker spaniel dog was presented with a 4-week history of left episcleral injection and pawing at the face. Clinical examination findings included left internal and external ophthalmoplegia, left dorsal strabismus, pain opening the mouth, and intermittent amaurosis. Imaging studies revealed a left orbital apex mass with adjacent sphenoid bone lysis and extension into the cranial cavity. A left exenteration was performed and histopathology confirmed an orbital soft tissue sarcoma. Key clinical message: This report describes an orbital tumor causing orbital apex syndrome. This condition should be differentiated from cavernous sinus syndrome as the latter does not course with optic neuropathy.

Syndrome de l'apex orbitaire secondaire à un sarcome orbitaire chez un chien. Un épagneul mâle castré âgé de 12 ans fut présenté avec une histoire d'injection épisclérale gauche et frottage de la face d'une durée de 4 semaines. Les trouvailles de l'examen clinique incluaient une ophtalmoplégie interne et externe à gauche, un strabisme dorsal à gauche, de la douleur lors de l'ouverture de la gueule et une amaurose intermittente. Les examens par imagerie ont révélé une masse dans l'apex orbitaire gauche avec lyse de l'os sphénoïde adjacent et extension dans la cavité crânienne. Une exentération gauche fut effectuée et l'histopathologie confirma un sarcome des tissus mous orbitaires.Message clinique clé:Ce rapport décrit une tumeur orbitaire causant un syndrome de l'apex orbitaire. Cette condition devrait être distinguée du syndrome du sinus caverneux étant donné que ce dernier n'évolue pas avec une neuropathie optique.(Traduit par Dr Serge Messier).

Self-limiting Orbital Emphysema Following Ocular Evisceration and Demonstration of Nasolacrimal-Oropharyngeal Communication in a South African Ostrich (Struthio camelus australis).

A 25-year-old, male, sanctuary-owned, South African ostrich (Struthio camelus australis) was evaluated for orbital emphysema after evisceration of a nonvisual and chronically irritated eye. On initial ophthalmic examination, the ostrich's left eye displayed severe corneal fibrosis, broad anterior synechia, and a shallow anterior chamber, all suggestive of a previous corneal perforation. Conjunctival hyperemia and eyelid crusts were also present, reportedly associated with chronic rubbing. Evisceration of the left eye was performed by excising the eyelid margins, conjunctiva, nictitans, cornea, and intraocular contents. Four weeks postoperatively, a nonpainful, fluctuant swelling of the surgical site was noted. Trocarization of the surgical site verified orbital emphysema and served to temporarily decompress the orbit. Orbital emphysema reoccurred within 48 hours but gradually regressed without intervention over the subsequent 9 months. A Jones test was performed in the healthy, right eye and demonstrated clear communication to the oropharynx. To our knowledge, this is the first reported case of an evisceration performed on an ostrich and the first reported case of orbital emphysema in any avian species. It is probable that the emphysema noted in this case was secondary to nasolacrimal duct-oropharynx communication.

Magnetic resonance imaging findings in dogs with orbital inflammation.

OBJECTIVES: To describe MRI features of canine retrobulbar inflammation, their association with clinical findings and outcome and to assess the value of MRI in detecting orbital foreign bodies. MATERIALS AND METHODS: Clinical records of dogs with confirmed (23 of 31) and suspected (eight of 31) retrobulbar inflammation that underwent low field MRI studies were analysed retrospectively. RESULTS: Of the 31 dogs included in the study there was abscessation in 19. Extraocular myositis (27 of 31) was concurrent with strabismus in three cases. Of 25 patients with exophthalmos, 14 had concurrent optic nerve swelling and, of these, five had permanent loss of vision. There was no vision loss in patients without nerve swelling. One case of suspected retinal detachment on MRI was confirmed clinically. Extensive abnormal contrast enhancement in the temporalis, masseter and pterygoideus muscles was associated with facial (n=3) and trigeminal nerve deficits (n=1). Three patients with inflammation extending into the nasal cavity and frontal sinus (one of 31) or meningeal contrast enhancement (two of 31), showed optic and oculomotor nerve deficits. On MRI a foreign body was not visible in 20 of 31 case or "appeared likely" in 11 of 31 dogs. A foreign body was found at surgery in one case. CLINICAL SIGNIFICANCE: MRI outlines the extent of retrobulbar inflammation. Clinical findings were associated with imaging findings. MRI overestimated the presence of foreign bodies.

Three-dimensional printing of orbital and peri-orbital masses in three dogs and its potential applications in veterinary ophthalmology.

OBJECTIVE: To describe the technique and utility of three-dimensional (3D) printing for orbital and peri-orbital masses and discuss other potential applications for 3D printing. ANIMALS STUDIED: Three dogs with a chronic history of nonpainful exophthalmos. PROCEDURES: Computed tomography (CT) and subsequent 3D printing of the head was performed on each case. CT confirmed a confined mass, and an ultrasound-guided biopsy was obtained in each circumstance. An orbitotomy was tentatively planned for each case, and a 3D print of each head with the associated globe and mass was created to assist in surgical planning. RESULTS: In case 1, the mass was located in the cranioventral aspect of the right orbit, and the histopathologic diagnosis was adenoma. In case 2, the mass was located within the lateral masseter muscle, ventral to the right orbit between the zygomatic arch and the ramus of the mandible. The histopathologic diagnosis in case 2 was consistent with a lipoma. In case 3, the mass was located in the ventral orbit, and the histopathologic diagnosis was histiocytic cellular infiltrate. CONCLUSIONS: Three-dimensional printing in cases with orbital and peri-orbital masses has exceptional potential for improved surgical planning and provides another modality for visualization to help veterinarians, students, and owners understand distribution of disease. Additionally, as the techniques of 3D printing continue to evolve, the potential exists to revolutionize ocular surgery and drug delivery.

Orbital and Subcutaneous Emphysema Following Enucleation and Respiratory Distress in a Japanese Chin.

A 7 yr old, neutered male Japanese chin presented to the Cummings School of Veterinary Medicine at Tufts University (CSVMTU) for evaluation of chronic unilateral orbital swelling that worsened following an episode of respiratory distress. The left eye had been enucleated 5 yr previously. Intermittent mild-to-moderate left orbital swelling had been noted by the owner since the initial surgery. Examination demonstrated a moderate-to-severe, soft, fluctuant swelling involving the left orbit with erythema of the overlying skin. Crepitus was noted over the occipital tuberosity. Computed tomography revealed a large volume of gas involving the left orbit. The gas extended caudally within the subcutaneous tissues to both hemimandibles, dorsal to the cranium, and partially surrounded the cranial neck. The presence of a mucosa-lined, air-filled space with a patent nasolacrimal duct was noted on orbital exploration. The lining was removed and the duct closed. Histopathology confirmed the presence of an epithelial lining. No recurrence of the swelling was observed on examination 8 wk after surgery. This is the first report documenting acute worsening of orbital swelling following an episode of respiratory distress. This case highlights the importance of addressing the nasolacrimal duct while performing an enculeation in a brachycephalic dog.

Management of Orbital Diseases.

Orbital diseases are common in dogs and cats and can present on emergency due to the acute onset of many of these issues. The difficulty with diagnosis and therapy of orbital disease is that the location of the problem is not readily visible. The focus of this article is on recognizing classical clinical presentations of orbital disease, which are typically exophthalmos, strabismus, enophthalmos, proptosis, or intraconal swelling. After the orbital disease is confirmed, certain characteristics such as pain on opening the mouth, acute vs. chronic swelling, and involvement of nearby structures can be helpful in determining the underlying cause. Abscesses, cellulitis, sialoceles, neoplasia (primary or secondary), foreign bodies, and immune-mediated diseases can all lead to exophthalmos, but it can be difficult to determine the cause of disease without advanced diagnostic imaging, such as ultrasound, magnetic resonance imaging, or computed tomography scan. Fine-needle aspirates and biopsies of the retrobulbar space can also be performed.

Surgical management of canine refractory retrobulbar abscesses: six cases.

OBJECTIVE: To report the clinical presentation, surgical treatment and outcomes of dogs with retrobulbar abscesses refractory to intra-oral lancing and antibiotics. METHODS: Medical records from January 2006 through September 2014 were reviewed and dogs with retrobulbar abscesses failing treatment with antibiotics and intra-oral lancing were included. Clinicopathologic, imaging and surgical details were extracted from the medical records. Referring veterinarians and owners were interviewed via telephone for follow-up data. RESULTS: A total of six dogs were included in the study. The most common clinical signs were pain upon opening of the mouth, exophthalmos and prolapsed nictitans. Computed tomography was performed in five dogs, ultrasound in four and magnetic resonance imaging in one. Imaging identified an abscess in all dogs, with a suspected foreign body in four dogs. Surgical approach was a modified lateral orbitotomy in five dogs. No foreign body was identified during surgery in all dog. All dogs surviving to discharge did not have recurrence of clinical signs (follow-up time range: 27 to 95 months). CLINICAL SIGNIFICANCE: Dogs with retrobulbar abscesses refractory to standard therapy can experience long-term resolution of clinical signs with surgical treatment, most commonly via a modified lateral orbitotomy.

Differentiation between inflammatory and neoplastic orbital conditions based on computed tomographic signs.

OBJECTIVE: To identify computed tomographic (CT) signs that could be used to differentiate inflammatory from neoplastic orbital conditions in small animals. ANIMAL STUDIED: Fifty-two animals (25 cats, 21 dogs, 4 rabbits, and 2 rodents). PROCEDURE: Case-control study in which CT images of animals with histopathologic diagnosis of inflammatory (n = 11), neoplastic orbital conditions (n = 31), or normal control animals (n = 10) were reviewed independently by five observers without the knowledge of the history or diagnosis. Observers recorded their observations regarding specific anatomical structures within the orbit using an itemized form containing the following characteristics: definitely normal; probably normal; equivocal; probably abnormal; and definitely abnormal. Results were statistically analyzed using Fleiss' kappa and logistic regression analyses. RESULTS: The overall level of agreement between observers about the presence or absence of abnormal CT signs in animals with orbital disease was poor to moderate, but was highest for observations concerning orbital bones (κ = 0.62) and involvement of the posterior segment (κ = 0.52). Significant associations between abnormalities and diagnosis were found for four structures: Abnormalities affecting orbital bones (odds ratio [OR], 1.7) and anterior ocular structures (OR, 1.5) were predictive of neoplasia, while abnormalities affecting extraconal fat (OR, 1.7) and skin (OR, 1.4) were predictive of inflammatory conditions. CONCLUSIONS: Orbital CT is an imaging test with high specificity. Fat stranding, a CT sign not previously emphasized in veterinary medicine, was significantly associated with inflammatory conditions. Low observer agreement probably reflects the limited resolution of CT for small orbital structures.

Dacryocystography in a cat with orbital pneumatosis.

A 2-year-old neutered male European short-haired cat was presented for a persistent discharge from the scar of previous left eye enucleation, performed 6 months prior by the referring veterinarian. A surgical exploration of the orbit was performed and retained nictitating membrane glandular and conjunctival tissues were removed. Eleven days later, the cat developed an orbital pneumatosis caused by retrograde movement of air through a patent nasolacrimal system and diagnosed by survey radiographic examination of the skull. Nasolacrimal system patency was assessed by dacryocystography performed by injection of iodinated contrast medium under pressure into the orbital cavity. Computed tomography dacryocystography confirmed the radiographic findings. The condition resolved following dacryocystography, possibly as an inflammatory response to the contrast medium. To our knowledge, this is the first case of orbital pneumatosis reported in a cat.

[Rhinoorbitocerebral zygomycosis caused by Rhizopus microsporus in a roe deer (Capreolus capreolus)]. / Rhinoorbitozerebrale Zygomykose durch Rhizopus microsporus bei einem Reh (Capreolus capreolus).

An one-year-old male roe deer (Capreolus capreolus) with abnormal behaviour was shot in order to exclude rabies virus infection. The 12.8 kg weighing animal was emaciated and revealed an asymmetric head with protruding left eye and expositional keratitis. There was a grey whitish soft mass within the caudal nasal cavity, which had infiltrated the frontal cerebrum through the cribriform plate and the retrobulbar tissue through the orbita. Histologically, the mass consisted of a chronic granulomatous inflammation with plentiful fungal hyphae. Fungal culture revealed mold fungi of the zygomycotic genus Rhizomucor, which were differentiated as Rhizopus microsporus by MALDI-TOF mass spectrometry and DNA-sequencing. Rhinoorbitocerebral zygomycosis has to be considered as a differential diagnosis for nasal and orbital tumour-like lesions and as a cause of abnormal behaviour of roe deer.

[Computed tomography diagnosis of a retrobulbar abscess in a white tiger]. / Computertomographische Diagnostik eines retrobulbären Abszesses bei einem weißen Königstiger.

SUBJECT: Etiologic diagnosis of a retrobulbar process is essential for the initiation of a causative therapy. Penetrating foreign bodies and tooth root abscesses, but also neoplastic processes have to be considered as a differential diagnosis for a retrobulbar swelling. The objective of this case report of a tiger with a retrobulbar process was to demonstrate the diagnostic value of computed tomography for making a causative diagnosis. MATERIAL AND METHODS: General examination of the tiger as well as subsequent computed tomography and surgical extraction of a fractured fourth premolar tooth of the left upper jaw was carried out under general anaesthesia. Collected alveolar tissue samples underwent cytological, histopathological and microbiological analyses. RESULTS AND CLINICAL RELEVANCE: Computed tomography was able to allocate the origin of the retrobulbar abscess to the left 4th premolar tooth of the upper jaw. The cytological, histopathological and microbiological examination of the recovered alveolar material confirmed the diagnosis of purulent-necrotic abscess-forming inflammation as a result of a mixed bacterial infection. The present case report demonstrates the diagnostic accuracy of computed tomography for the diagnosis of a retrobulbar process of unknown origin.

Complications from residual adnexal structures following enucleation in three dogs.

CASE DESCRIPTION: A 3-year-old neutered male Lhasa Apso (dog 1) was evaluated because of chronic swelling at an 8-month-old enucleation site, a 10-year-old spayed female Japanese Chin (dog 2) was evaluated because of chronic swelling at a 6-year-old enucleation site and chronic discharge from a 1-year-old enucleation site, and a 7-year-old spayed female Yorkshire Terrier (dog 3) was evaluated because of chronic discharge from a 3-month-old enucleation site. CLINICAL FINDINGS: In all dogs, surgical exploration revealed substantial retention of adnexal remnants within the original enucleation sites. Diagnoses of subcutaneous membrana nictitans inclusion cyst, orbital pneumatosis, and conjunctival mucocele were made in dogs 1, 2, and 3, respectively. TREATMENT AND OUTCOME: Following cyst excision, dog 1 received a short course of treatment with amoxicillin-clavulanic acid and deracoxib. There was no recurrence of clinical signs over a 2-month follow-up period. For dog 2, conjunctival tissue was excised, and the opening of the lower nasolacrimal canaliculus was cauterized. The patient received postoperative administration of deracoxib as well as orbifloxacin and clindamycin pending bacterial culture results, which were negative. There was no recurrence of clinical signs over an 8-month follow-up period. For dog 3, adnexal remnants were excised. The patient received postoperative administration of amoxicillin-clavulanic acid and meloxicam. There was no recurrence of clinical signs over a 6-month follow-up period. CLINICAL RELEVANCE: Findings in the dogs of this report highlight the need for complete removal of the ocular adnexa to minimize the risk of complications of enucleation in the long-term follow-up period.

Orbito-nasal cyst in a young European short-haired cat.

PURPOSE: To describe a case of an orbito-nasal cyst in a cat. PROCEDURE: An 18-month-old male European short-haired cat was presented to the Ophthalmology service of the Vetsuisse Faculty, University of Zurich for a subcutaneous swelling in the medial canthal region of the right eye (OD). Ophthalmologic, ultrasound and CT examinations, and fine needle aspiration were performed. After lesion excision, the removed tissue was submitted for histopathology. CT examination was repeated 5 months after removal of the cyst. RESULTS: Ophthalmologic examination revealed a large fluctuant swelling inferonasal to OD. Despite patent lacrimal puncta, only the first few mm of the lacrimal canaliculi could be cannulated. A normal globe with moderate enophthalmos was present. Ultrasound examination showed a well-defined lobulated cyst-like structure in the right orbit, inferonasal and anterior to the eye. CT examination revealed extension of this lesion through the medial orbital wall into the right nasal cavity. Fine needle aspiration confirmed the cystic nature of the lesion. An orbito-nasal cyst was diagnosed. The orbital part of the cyst was dissected from the surrounding tissue and excised from the periosteum in the medial orbital wall defect. Part of the maxillary bone was removed to allow removal of the cyst from the nasal cavity. Histologically, the cyst wall consisted of a single to multilayered, mostly cuboidal epithelium and surrounding connective tissue. Follow-up revealed a good functional result and no recurrence 7 months after cyst removal. CONCLUSIONS: Similar orbito-nasal cystic structures were reported in dogs but not in cats.

Intracranial extension of retrobulbar blastomycosis (Blastomyces dermatitidis) in a dog.

Blastomycosis (Blastomyces dermatitidis) is a fungal disease that is endemic in the southern United States. This case report illustrates the clinical, MRI and histopathologic findings in a dog with invasion of a retrobulbar blastomycotic lesion into the calvarium. A 5-year-old intact female Weimaraner was referred for a 2-month history of change in behavior and recent onset of visual deficits. Magnetic resonance imaging (MRI) examination revealed a large (5.8 × 2.0 × 2.5 cm) mass extending from the left orbit through a circular defect in the left cranioventral aspect of the calvarium caudally to the level of the pituitary fossa and interthalamic adhesion. The mass was heterogeneously iso- to hypointense on T2-W images, slightly hypointense on T1-W images, did not attenuate on fluid attenuated inversion recovery (FLAIR) images, and did not show evidence of susceptibility artifact on T2*-W gradient recalled echo (GRE) images. Vasogenic edema and associated mass effect were noted. The mass showed strong homogeneous contrast enhancement with well-defined margins and had thickening of the adjacent meninges (dural tail sign). Based on MRI findings a malignant neoplastic process was considered most likely and the patient was placed on oral prednisone to decrease peri-tumoral inflammation. The dog initially improved but was euthanized 3 weeks later for worsening clinical signs. Histopathologic assessment of the mass revealed marked pyogranulomatous optic neuritis with intralesional fungal yeasts consistent with blastomycosis (Blastomyces dermatitidis). To our knowledge this is the first report of invasion of a retrobulbar blastomycotic lesion into the calvarium in a dog.

Retrobulbar thrombus in a cat with systemic hypertension.

This report describes a 14-year-old neutered male Norwegian Forest cat that was evaluated for a complaint of inappetence, lethargy, and ocular protrusion with third eyelid prolapse. The systemic blood pressure was elevated at 205/129 mmHg. Fundic examination revealed severe retinal hemorrhage in both eyes. Based on an ultrasound study of the retrobulbar area, a thrombus caudal to the right globe was suspected. Over 18 days, the cat exhibited significant clinical improvement as well as good blood pressure control. To our knowledge this is the first report of a retrobulbar thrombus in a cat with systemic hypertension.

Invasive mould infections of the naso-orbital region of cats: a case involving Aspergillus fumigatus and an aetiological review.

CASE AND CONTEXT: This report describes a cat diagnosed with sinonasal-orbital Aspergillus fumigatus infection using advanced imaging, histopathology and culture. Aetiology, clinical aspects and treatment of this rare and devastating infection are discussed with reference to a literature review of invasive mould (ie, filamentous fungal) infections involving tissues of the naso-orbital region of cats. PRESENTATIONS: Invasive fungal infections can present with different localisations (nasal passages, sinuses, orbits, subcutaneous space, palate, etc) depending on the species involved and its means of introduction into the tissues. Localised subcutaneous lesions (swellings, ulcerations, masses, nodules, etc), without concomitant signs of nasal/orbital disease, generally result from traumatic injuries and subsequent inoculation of fungal spores into the subcutaneous space. In contrast, naso-ocular involvement and concurrent signs of nasal disease (nasal discharge, sneezing, masses protruding from the nostrils) generally result from inhalation of spores, with subsequent spread of infection into the nasal planum or penetration of overlying bone and invasion of the subcutaneous space. Aspergillus species typically show such an invasion mechanism and frequently affect orbital tissues. Dematiaceous fungi (ie, filamentous fungi with brown/black hyphae) are reported to cause solitary, less invasive, slowly developing lesions, probably as a result of traumatic injuries with inoculation of fungal propagules. Accordingly, the subcutaneous space is more frequently primarily involved. TREATMENT AND OUTCOME: Whatever the mould species, reported treatment options include surgery and a series of antifungal drugs. The outcome is frequently poor, especially for Aspergillus infections, although various measures can be taken to maximise the chances of success, as discussed in this report.