Endoscopic Endonasal Optic Nerve Decompression in a Patient With Invasive Fungal Sinusitis Invasion Into the Orbital Apex: Intraoperative Video and Literature Review.

Invasive fungal sinusitis (IFS) is rare but potentially fatal in immunocompromised patients. Orbital extension of IFS can cause visual loss or ophthalmoplegia, and the rate of recovery of visual acuity can be low even after treatment with antifungal agents and sinus surgery. In this case, optic nerve decompression with the endoscopic endonasal approach was successful for the treatment of visual loss in a patient with IFS with orbital apex extension. The authors describe the recovery of visual acuity after optic nerve decompression in a patient with IFS who had exhibited visual loss caused by invasion into the orbital apex. The authors also provide an intraoperative video and literature review.

Corneal melt secondary to eosinophilic granulomatosis with polyangiitis.

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare antineutrophil cytoplasmic antibody-associated vasculitis that can affect any organ system. It is most often characterised by chronic airway inflammation along with prominent peripheral blood eosinophilia, although the disease can affect the cardiovascular, gastrointestinal, renal or central nervous systems. Ocular manifestations are uncommon and when they do occur, are varied in their clinical presentations. To the best of our knowledge, this is the first case of corneal melt secondary to EGPA to have been reported.

Orbital apex syndrome secondary to aspergilloma masquerading as a paranasal sinus tumor: A case report and literature review.

RATIONALE: Orbital apex syndrome is a complex clinical disorder featuring a collection of cranial nerve deficits characterized by impairment of the extraocular muscles, the ophthalmic branch of the trigeminal nerve, and even the optic nerve. Sino-orbital aspergillosis is rare but aggressive infection. Surgical resection accompanied by antifungal medication is advised currently. PATIENT CONCERNS: We report a 61-year-old woman diagnosed as aspergilloma presenting with the characteristic manifestations and imaging features of orbital apex syndrome. DIAGNOSES: Paranasal sinus tumor was misdiagnosed initially according to magnetic resonance imaging of the orbit. Finally aspergilloma was diagnosed by pathologic report. INTERVENTIONS: The anti-fungal medication, voriconazole, was administered immediately. Surgical excision was also done due to the poor response to medical treatment. OUTCOMES: Postoperative follow-up showed no recurrence of aspergillosis but the vision was lost permanently. LESSONS: Invasive sino-orbital aspergillosis as an aggressive disease with highly invasive patterns and it may be misdiagnosed as tumors. To achieve better prognosis and survival, clinicians should be aware of this distinct manifestation.

The impact of ocular tuberculosis on vision after two months of intensive therapy

ABSTRACT Tuberculosis is an infectious disease of global importance with major economic and social burden accounting for 25% of all avoidable deaths in developing countries. Extrapulmonary involvement may occur either in association with clinically apparent pulmonary tuberculosis or in isolation. This cross-sectional descriptive study aimed to evaluate the impact of ocular tuberculosis in visual acuity at baseline and after two months of intensive anti-tuberculous therapy. A sample of 133 pulmonary tuberculosis patients, seven disseminated tuberculosis, and three pleural tuberculosis patients was evaluated. All patients underwent routine ophthalmic evaluation, including assessment of visual acuity, biomicroscopy, applanation tonometry, indirect ophthalmoscopy, and fluorescent angiography as appropriate. None of the patients had impaired visual acuity due to tuberculosis. A rate of 4.2% (6/143) of ocular involvement was found. None of the patients with ocular involvement were HIV-infected. Of the six patients with ocular involvement, five met the diagnostic criteria for probable and one for possible ocular lesions. As for the type of ocular lesions, two patients had bilateral findings: one had sclerouveitis and the second had choroidal nodules. The other four patients presented with unilateral lesions: peripheral retinal artery occlusion in the right eye (one case), choroidal nodules in the left eye (one case), and choroidal nodules in the right eye (two cases). Patients progressed favorably after two month of intensive therapy, with no significant reduction in vision.

Ocular manifestations of rickettsia in children: common but frequently overlooked.

We review two cases of ocular manifestations of Rickettsia conorii infection in children. A girl who presented unilateral visual loss with focal retinitis and macular oedema and a boy with unilateral central scotoma and bilateral anterior uveitis. Progressive functional and anatomic recovery was observed after oral antibiotics and steroids were initiated.

Klebsiella endophthalmitis as the herald of occult colorectal cancer.

A 67-year-old Chinese man presented with acute loss of vision and pain in the left eye with hypopyon in the anterior chamber. The patient was afebrile with no systemic symptoms at presentation. Diagnosis of endogenous endophthalmitis was made with vitreous tap yielding Klebsiella pneumoniae Pars plana vitrectomy was performed twice to clear the infection. Thorough investigations showed no septic foci. Whole body positron emission tomography CT revealed a rectal tumour and biopsy showed adenocarcinoma. He was treated with neoadjuvant chemoirradiation followed by surgery to resect the tumour. Vision in the left eye was hand movement at 12 months postoperatively. This case illustrates Klebsiella endogenous endophthalmitis might be a herald of occult colorectal cancer. Bacteria might gain access into bloodstream via mucosal defect in the tumour.

Wound botulism, its neurological manifestations, treatment and outcomes: A case series from the Glasgow outbreak, 2015.

Background and aims We examined the neurological manifestations, treatment and outcomes of a subset of 25 patients within the largest ever outbreak of wound botulism in Europe. Methods and results All 25 cases were intravenous drug users. The most common presenting symptom was dysarthria in 19/25 (76%), followed by dysphagia in 12/25 (48%), blurred vision in 10/25 (40%) and double vision in 8/25 (32%). Microbiological analysis confirmed the diagnosis in nine cases (36%). Duration of admission positively correlated with time to antitoxin, time to wound debridement and female sex. Conclusion As the outbreak continued, hospital stays shortened, reflecting growing awareness of the outbreak and quicker treatment initiation.

[A case of orbital apex syndrome due to aspergillus infection that avoided loss of visual acuity by optic canal decompression].

A 71-year-old woman was admitted to our hospital complaining of left orbital pain, headache, diplopia and left-sided ptosis, which she had suffered for two months. On examination, the patient had loss of visual acuity, left-sided ptosis, lateral gaze disturbance, and was diagnosed as having left orbital apex syndrome. An abnormal signal to the left orbital cone was detected on MRI. Serum ß-D-glucan was increased, and serum Aspergillus antigen and antibody were both positive. Although antifungal drugs (voriconazole and liposomal amphotericin B) were administered, the symptoms deteriorated. The patient then underwent optic nerve decompression surgery and was treated with intravenous methylprednisolone, which gradually improved the patient's symptoms, Aspergillus hyphae were confirmed by pathological examination. To obtain good prognosis for patients with orbital apex syndrome associated with Aspergillus infection, optic nerve decompression surgery should be considered.

Granulomatous uveitis and reactive arthritis as manifestations of post-streptococcal syndrome.

To report a case of bilateral granulomatous post-streptococcal syndrome uveitis in association with reactive arthritis as manifestation of post-streptococcal syndrome. To our knowledge, this could represent the first reported case in the literature. A 9-year-old girl, with no past ocular history, presented with a 5-day history of bilateral blurred vision, red eyes, photophobia and walking difficulties because of a right ankle pain. Ophthalmic examination disclosed a visual acuity limited to hand motion, mutton-fat keratic precipitates, anterior chamber cells and posterior synechiae in both eyes. Ocular pressure was normal. Physical examination showed a fever (38 °C), inflammatory ankle arthritis and scarlet fever (streptococcal lesion). Anti-streptococcal lysine O titer was 419 µ/ml. The patient was treated with topical steroids, cycloplegics, high-dose oral steroids and preventive course of penicillin with total improvement and no recurrence. Post-streptococcal syndrome should be considered in the etiology of acute bilateral granulomatous uveitis in children, and anti-streptococcal lysine O titer should be considered in serodiagnostic testing.

Orbital aspergillosis in immunocompetent patients.

PURPOSE: To describe clinical, ultrasonographic, radiological and histopathological features of orbital aspergillosis in immunocompetent patients. METHODS: Medical records of immunocompetant individuals with orbital aspergillosis between November 1995 and November 2010 were reviewed. RESULTS: Thirty-five cases (27 males, 8 females) were reviewed. Mean age at presentation was 37.63 (8-73) years and mean duration of symptoms was 12.03 (0.5-84) months. Proptosis (22.63%) and mass lesion (13.37%) were the commonest presenting complaints. Presenting visual acuity was better than 6/9 in 21 (60%) and no perception of light in 3 (8%). Ocular motility restriction was noted in 25 (71%). The commonest clinical differential diagnosis was non-specific orbital inflammatory disease (NSOID) (10.29%) followed by malignancy (7.20%). CT showed infiltrative lesions with bone destruction in 22 (63%), contiguous paranasal sinus involvement in 22 (63%) and intracranial extension in 10 (29%). Diagnosis was by histopathology and microbiological evaluation. Fungal cultures revealed Aspergillus flavus in 30 (86%) and Aspergillus fumigatus in 5 (14%). Treatment included conservative medical management in 18 (51%) and surgical debulking in 17 (49%). Average follow-up was 37.6 (3-183) months, and patient survival was 33/35 (94%). CONCLUSIONS: Though orbital aspergillosis is commonly seen in immunocompromised patients, it should be suspected in young immunocompetent individuals presenting with proptosis of insidious onset and infiltrating lesions involving the paranasal sinuses. Definitive diagnosis is achieved by histopathological and microbiological evaluation. Systemic steroids should be avoided prior to definitive diagnosis. Prolonged systemic antifungal therapy with an option of additional debulking of lesions provides good disease control with improved survival.

Endogenous endophthalmitis associated with intravenous drug abuse.

PURPOSE: To describe demographics, characteristics, and management of eyes with endogenous endophthalmitis (EE) in intravenous drug abusers. METHODS: Retrospective chart review of patients with EE who presented to University Hospital, New Jersey Medical School between January 2005 and October 2012. RESULTS: Thirty-four patients presented with a clinical diagnosis of EE during this time period. Eighteen patients (53%) had a history of intravenous drug abuse with at least 15 of the 18 patients reporting intravenous heroin abuse. Average age was 43 years (24-61 years), 13 were men. Three patients had bilateral involvement. Mean time from the onset of symptoms to presentation was 10 days (range, 1-42 days). Presenting vision in the affected eye ranged from 20/100 to no light perception; the majority of patients had vision of counting fingers or worse. All patients were admitted to the hospital for intravenous antimicrobials and further workup. Final best-corrected visual acuity at the last follow-up ranged from 20/20 to no light perception, with most patients having final vision of 20/400 or worse. CONCLUSION: We reviewed 21 eyes of 18 patients with EE and concurrent intravenous drug abuse over an 8-year period; our study shows extremely poor visual prognosis associated with EE in this setting.

Significant visual increase following infectious keratitis after collagen cross-linking.

PURPOSE: To report a patient who developed a left paracentral stromal scar due to infectious keratitis that occurred after corneal collagen cross-linking (CXL) for progressive keratoconus. The flattening effect of the scar led to an increase in visual acuity. METHODS: The corneal scar and flattening effect on the anterior corneal curvature were assessed by slit-lamp photography, high-resolution Scheimpflug imaging, and corneal confocal microscopy. RESULTS: Three days after CXL, a corneal bacterial infection occurred in the left cornea and was treated with local antibiotics that led to a paracentral scar. Twenty-one days after CXL, a flattening of the anterior curvature of >11.00 diopters was observed. As a consequence, corrected distance visual acuity improved by five lines. CONCLUSIONS: Corneal remodeling may lead to a homogenization of the anterior corneal surface and an increase in visual acuity. Remodeling may not only occur spontaneously following CXL, but also following an event that results in focal corneal scarring, such as corneal infection. In a highly irregular keratoconic cornea, the benefit of the flattening effect of a scar may outweigh the increase in aberrations and light scatter.