Comparisons of deep learning algorithms for diagnosing bacterial keratitis via external eye photographs.

Bacterial keratitis (BK), a painful and fulminant bacterial infection of the cornea, is the most common type of vision-threatening infectious keratitis (IK). A rapid clinical diagnosis by an ophthalmologist may often help prevent BK patients from progression to corneal melting or even perforation, but many rural areas cannot afford an ophthalmologist. Thanks to the rapid development of deep learning (DL) algorithms, artificial intelligence via image could provide an immediate screening and recommendation for patients with red and painful eyes. Therefore, this study aims to elucidate the potentials of different DL algorithms for diagnosing BK via external eye photos. External eye photos of clinically suspected IK were consecutively collected from five referral centers. The candidate DL frameworks, including ResNet50, ResNeXt50, DenseNet121, SE-ResNet50, EfficientNets B0, B1, B2, and B3, were trained to recognize BK from the photo toward the target with the greatest area under the receiver operating characteristic curve (AUROC). Via five-cross validation, EfficientNet B3 showed the most excellent average AUROC, in which the average percentage of sensitivity, specificity, positive predictive value, and negative predictive value was 74, 64, 77, and 61. There was no statistical difference in diagnostic accuracy and AUROC between any two of these DL frameworks. The diagnostic accuracy of these models (ranged from 69 to 72%) is comparable to that of the ophthalmologist (66% to 74%). Therefore, all these models are promising tools for diagnosing BK in first-line medical care units without ophthalmologists.

Multimodal Imaging of Atypical Acute Syphilitic Posterior Placoid Chorioretinitis Mimicking a White Dot Syndrome.

As rates of infectious syphilis continue to rise in the U.S., it is important to be familiar with known manifestations of ocular syphilis as well as report presentations not previously described in the literature. Here, the authors report a case of a 49-year-old myopic woman presenting with bilateral white dots characteristic of a white dot syndrome; these white dots were not evident on slit-lamp examination and became obvious on fundus autofluorescence. She tested positive and was successfully treated for syphilis. This case demonstrates that ocular syphilis can present with white dots and should be on the differential diagnosis of white dot syndromes. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e52-e55.].

Long-Term Outcomes of Oral Anti-Tubercular Therapy in Patient with Tubercular Dacryoadenitis: A Case Series.

Purpose: To describe the clinico-radiological features and long-term outcomes in patients with tubercular dacryoadenitis (TbD) Methods: Retrospective, observational study of TbD patients who underwent a thorough clinical examination, orbital imaging study, and tailored ancillary investigations. Polymerase chain reaction (PCR) and microscopy were done in specific cases. A 4-drug anti-tubercular therapy (ATT) was started and clinical response was monitored in all. Patients with a minimum follow-up of 6 months "off-ATT" were included. Results: All patients were women and three presented with pain, blepharoptosis, and bilateral involvement. In all, ESR was raised, Mantoux test was positive and orbital imaging revealed enlarged lacrimal gland/s. Positive PCR and granulomatous inflammation on microscopy were seen in two patients. At a mean follow-up of 17.25 months, all women responded with no relapse or clinical recurrence. Conclusion: Bilateral lacrimal gland enlargement, positive Mantoux & PCR with early response to ATT may provide sufficient evidence for diagnosing TbD.

In Vivo Confocal Microscopy Cellular Features of Host and Organism in Bacterial, Fungal, and Acanthamoeba Keratitis.

PURPOSE: To determine cellular features of fungal (FK), Acanthamoeba (AK), and bacterial keratitis (BK) using HRT3 in vivo confocal microscopy (IVCM). DESIGN: Prospective observational cross-sectional study. METHODS: Eligible participants were adults with microbiologically positive FK, AK, or BK, of size ≥ 3 mm, attending Aravind Eye Hospital from February 2012 to February 2013. Exclusion criteria were descemetocele or perforation. At presentation, IVCM imaging was performed, then corneal scrapes were obtained for culture/light microscopy. An experienced grader (masked to microbiology/clinical features) assessed IVCM images for presence/absence of normal keratocyte-like morphology, stellate interconnected cells with/without visible nuclei, dendritiform cells (DFCs), inflammatory cells in a honeycomb distribution, and organism features. Statistical significance was assessed by logistic regression, adjusted for age, sex, ulcer size, and symptom duration. Main outcome measures were presence/absence of IVCM features in FK, AK, BK. RESULTS: A total of 183 participants had FK, 18 AK, 17 BK. Acanthamoeba appeared as bright spots (16/18, 89%), double-walled cysts (15/18, 83%), or signet rings (3/18, 17%), and often formed clusters after topical steroid use (univariable odds ratio [OR] 9.98, 95% confidence interval [CI] 1.02-97.96, P = .048). BK was associated with bullae in anterior stroma (OR 9.99, 95% CI: 3.11-32.06, P < .001). Honeycomb distribution of anterior stromal inflammatory cells was associated with FK (univariable OR 2.74, 95% CI: 1.01-7.40, P = .047). Aspergillus ulcers were associated with stromal DFCs (OR 11.05, 95% CI: 1.49-82.13, P = .019) and Fusarium ulcers with stellate appearance of interconnected cell processes with nuclei (OR 0.24, 95% CI: 0.09-0.65, P = .005). CONCLUSION: Specific cellular and structural features observed using IVCM in microbial keratitis may be associated with organism.

Bilateral choroiditis as the only sign of persistent Mycobacterium intracellulare infection following haematogenous spread in an immunocompromised patient.

An immunocompromised patient had positive blood cultures for Mycobacterium intracellulare and no identifiable organ seeding was started on treatment. One month later, the patient was clinically well with negative blood cultures but drug-induced myelotoxicity had developed. Ocular fundus examination at this time revealed bilateral choroidal granulomas which changed patient management.

Bilateral Orbital Abscesses After Strabismus Surgery.

Infectious orbital complications after strabismus surgery are rare. Their incidence is estimated to be 1 case per 1,100 surgeries and include preseptal cellulitis, orbital cellulitis, subconjunctival and sub-Tenon's abscesses, myositis, and endophthalmitis. This report describes the case of an otherwise healthy 3-year-old boy who underwent bilateral medial rectus recession and disinsertion of the inferior obliques. A few days after surgery, the patient presented with bilateral periorbital edema and inferotemporal chemosis. A series of CT scans with contrast revealed inferotemporal orbital collections OU. The patient immediately underwent transconjunctival drainage of fibrinous and seropurulent collections in the sub-Tenon's space and experienced rapid improvement a few days later. The patient is reported to be in stable condition in a follow-up examination performed more than a year after the reported events.

Infectious Complication Following Midface Reconstruction With Calcified Triglyceride.

This case report describes an infectious complication related to the use of calcified triglyceride (Kryptonite Bone Cement) in post-traumatic midface reconstruction. Ultimately, the infected material required removal, and the facial deformity was repaired with subsequent procedures. The literature suggests that bone cement products should be used with caution when in contact with the paranasal sinuses.

Incidence of periorbital necrotising fasciitis in the UK population: a BOSU study.

BACKGROUND: Periorbital necrotising fasciitis (PNF) is a devastating infection of subcutaneous soft tissue and underlying fascia causing severe morbidity and even loss of life. Few case reports of PNF exist and there are no prospective epidemiological studies. METHODS: A prospective observational study was undertaken using the British Ophthalmological Surveillance Unit reporting system. Questionnaires were sent to reporting ophthalmologists in the UK seeking cases of PNF over a 2-year period. RESULTS: 30 new cases were confirmed. 16 of the reported cases followed a precipitating event, 9 cases followed trauma and 3 followed surgery. ß-haemolytic Streptococcus A was the causative organism identified in 76%, either alone or with concurrent infection, and antibiotic sensitivities are discussed. Systemic complications occurred in the majority of cases (66.6%), with sepsis and death occurring in 10%. Over 50% of surviving patients had subsequent morbidity, reduced acuity (<6/18) being common. CONCLUSION: PNF is a rare, dangerous condition. This study identified an incidence of 0.24 per 1,000,000 per annum in the UK. ß-haemolytic Streptococcus A is the most common causative organism. Mortality remains a potential outcome, and survivors suffer significant morbidity. Early intravenous antibiotic management with a consensus favouring penicillin and clindamycin combined with debridement.

Rhinotillexomania: a rare cause of medial orbital wall erosion.

The authors report a rare case of medial orbital wall erosion with an orbital inflammatory mass and resultant lacrimal obstruction secondary to rhinotillexomania. A 67-year-old male with known history of compulsive nose picking (rhinotillexomania) sought treatment for complaints of watering in his OD. Examination revealed a blocked right inferior canaliculus. Nasal endoscopy showed a large nasal septal defect with multiple areas of crusting and bleeding. Hematologic investigations were normal. CT scan confirmed a large nasal septal and right medial orbital wall defect with an adjacent soft tissue mass in the medial orbit. Investigations ruled out systemic pathology. Histologic examination of medial orbital mass, sinus, and nasal mucosa revealed a reactive inflammatory infiltrate with surface Gram-positive cocci. The authors hypothesized that the patient had enlarged an existing nasal septal defect due to repetitive nose picking resulting in recurrent infection and inflammation of sinuses, leading to erosion of his medial orbital wall.

Case report of orbital cellulitis and necrotizing fasciitis from melioidosis.

A 48-year-old Thai male farmer presented with progressive swelling of the right eyelid and high-grade fever. His visual acuity declined and the right side of his forehead developed a necrotic skin lesion with a purulent discharge. CT of the orbits suggested orbital cellulitis with subperiosteal abscess. Intravenous ceftriaxone and clindamycin were given empirically but then switched to vancomycin and meropenem because of rapid deterioration together with clinical sepsis. Burkholderia pseudomallei was isolated from the blood 3 days after the treatment, and the antibiotics were then switched to intravenous ceftazidime. The liver enzymes were elevated, and imaging of the abdomen revealed liver and splenic abscesses. After 14 days, the patient showed marked clinical improvement, became afebrile, and regained his OD visual acuity. A repeat CT of the orbit showed improvement with no subperiosteal abscess. The antibiotic was then switched to oral trimethoprim/sulfamethoxazole in combination with doxycycline for 6 months.

Delayed Eikenella corrodens orbital infection after fracture repair.

Orbital cellulitis and abscess after fracture repair are rare. Ophthalmic infection with Eikenella species is even more unusual, but can be severe. We report a case of Eikenella corrodens infection in a 28-year-old man who underwent zygomaticomaxillary and orbital floor blowout fracture surgery 4 years before presentation. Eikenella species are often resistant to frequently used empiric antibiotics, and because of specific growth conditions, easily missed on standard cultures. Appropriate efforts should be made to identify and treat E. corrodens in atypical orbital and periocular infections.

Acute periorbital infections: who needs emergent imaging?

OBJECTIVES: Computed tomography (CT) is used often in the evaluation of orbital infections to identify children who are most likely to benefit from surgical intervention. Our objective was to identify predictors for intraorbital or intracranial abscess among children who present with signs or symptoms of periorbital infection. These predictors could be used to better target patients for emergent CT. METHODS: This was a retrospective cohort study of all patients admitted to an urban pediatric tertiary care emergency department between 1995 and 2008. We included otherwise healthy patients with suspected acute clinical periorbital or orbital cellulitis without a history of craniofacial surgery, trauma, or external source of infection. Immunocompromised patients and patients with noninfectious causes of periorbital swelling were excluded. Variables analyzed included age, duration of symptoms, highest recorded temperature, previous antibiotic therapy, physical examination findings, laboratory results, and interpretation of imaging. CT scans of the orbit were reread by a neuroradiologist. RESULTS: Nine hundred eighteen patients were included; 298 underwent a CT scan, and of those, 111 were shown to have an abscess. Although proptosis, pain with external ocular movement, and ophthalmoplegia were associated with presence of an abscess, 56 (50.5%) patients with abscess did not experience these symptoms. Other variables associated with the presence of an abscess in multivariate analysis were a peripheral blood neutrophil count greater than 10,000/microL, absence of infectious conjunctivitis, periorbital edema, age greater than 3 years, and previous antibiotic therapy (P < .05 for all). Our recursive partitioning model identified all high-risk (44%) patients as well as a low-risk (0.4%-2%) group (Rsq = 0.27). CONCLUSIONS: We confirmed that patients with proptosis and/or pain or limitation of extraocular movements are at high risk for intraorbital abscess, yet many do not have these predictors. Other features can identify patients who do not have such obvious predictors but do have significant risk of disease. A recursive partitioning model is presented.

Posttraumatic Stenotrophomonas maltophilia infectious scleritis.

PURPOSE: To describe the history, clinical presentation, and successful surgical and antibiotic management of a case of posttraumatic infectious scleritis secondary to Stenotrophomonas maltophilia. METHODS: A 51-year-old white man presented with worsening light sensitivity, localized conjunctival hyperemia, and a painful scleral nodule in his right eye that developed over a period of 1 month after minor ocular trauma. The patient was treated by his referring ophthalmologist for "episcleritis" with fluorometholone 0.1%, 1 drop 4 times a day, since injury onset without clinical improvement. Evaluation consisted of slit-lamp examination, ultrasound biomicroscopy, and surgical exploration with tissue cultures and histology. RESULTS: Ultrasound biomicroscopy of the right eye revealed the presence of a dome-shaped mass overlying an area of partial-thickness scleral laceration in the inferotemporal quadrant. The scleral nodule was surgically excised, and the scleral laceration was repaired with one 8-0 nylon suture. Culture results revealed infection by S. maltophilia, which was resistant to gentamicin, tobramycin, and trimethoprim-sulfamethoxazole. The patient experienced immediate pain relief after surgery, and treatment was continued with both topical ciprofloxacin 0.3% and prednisolone acetate 1% for 1 month with full recovery. CONCLUSIONS: S. maltophilia should be considered in the differential diagnosis of posttraumatic infectious scleritis. Submission of appropriate surgical specimens for microbiologic analysis and adequate antibiotic therapy may prevent the development of endophthalmitis in cases of suspected posttraumatic infectious scleritis.

Dacryoadenitis caused by methicillin-resistant Staphylococcus aureus.

A healthy 23-year-old man developed swelling of his left upper eyelid, conjunctival chemosis, and ocular motility restriction associated with epiphora and purulent discharge from the lacrimal ductules. Clinical examination, imaging, and culture results disclosed dacryoadenitis caused by community-acquired methicillin-resistant Staphylococcus aureus. To our knowledge, this is the first reported case of methicillin-resistant S. aureus-associated dacryoadenitis.

Methicillin-resistant ascending facial and orbital cellulitis in an operation Iraqi Freedom troop population.

PURPOSE: To present a descriptive case series of methicillin-resistant ascending facial and orbital cellulitis in an Operation Iraqi Freedom troop population. METHODS: A physician's transfer records of patients cared for and or transferred from the 31st and 86th Combat Support Hospitals during Operation Iraqi Freedom between September 2004 and March 2005 were reviewed. Cases of facial and orbital cellulitis caused by a nasal mucosal source were included in the case series. RESULTS: Five cases of ascending facial and/or orbital cellulitis caused by an aggressive nasal source are reported. All nasal microabscess cultures demonstrated methicillin-resistant Staphylococcus aureus species. None of the patients complained of nasal pain as the chief complaint, and all patients overlooked the follicular abscess at or inside the nares. CONCLUSIONS: Occult nasal infections with methicillin-resistant Staphylococcus aureus can be the source of an aggressive ascending facial and orbital cellulitis. The nasal source can be overlooked because of the distracting presentation of the orbital and systemic findings. With the increasing prevalence of community-acquired methicillin-resistant Staphylococcus aureus infections, a nasal examination and nasal culture can greatly assist in the diagnosis and management of patients presenting with orbital cellulitis without a clear source of infection.

Retrobulbar orbital abscess secondary to dacryocystitis in a neonate.

A retrobulbar orbital abscess secondary to congenital dacryocystitis is extremely rare. External abscess drainage, probing, and syringing with broad spectrum intravenous antibiotics was performed in a 22-day-old neonate who was examined for congenital dacryocystitis complicated by retrobulbar orbital abscess formation.

Septic pulmonary embolism associated with orbital abscess and sinusitis.

A 13-year-old white boy was admitted to an outside institution for antibiotic treatment of right preseptal cellulitis. He subsequently developed a right orbital abscess, which could not be located on surgical exploration. On postoperative day 2, he developed acute chest pain and was transferred to Children's Hospital of Michigan for evaluation and treatment. CT of the thorax demonstrated multiple, bilateral lower lobe lesions consistent with septic pulmonary embolism. The right orbit was re-explored with successful drainage of an intraconal orbital abscess. He was treated with intravenous antibiotics with subsequent improvement of the orbital cellulitis and chest pain. He was discharged home on intravenous antibiotics. At 1 month, follow-up chest CT demonstrated near resolution of the lung lesions.

Subretinal abscess after scleral buckling surgery: a rare risk of retinal surgery.

CASE REPORT: Intraocular infections after scleral buckling surgery for retinal detachment are very rare. COMMENTS: We document, on ultrasound B-scan, a rare case of subretinal abscess after scleral buckling surgery.