A rare case of Phialemonium obovatum keratitis.

PURPOSE: We report a rare case of Phialemonium obovatum fungal keratitis in a patient sustaining a corneal laceration from impact with a piece of moldy plaster. OBSERVATIONS: The patient was treated with topical voriconazole with resolution of active keratitis and formation of a stromal scar. The patient's final visual acuity was 20/20 in the affected eye. CONCLUSIONS AND IMPORTANCE: There is only one other case of Phialemonium obovatum keratitis reported in the literature. The patient in the previous case required amniotic membrane transplantation for persistent stromal melting with resultant visual acuity of hand motions only. The present case demonstrates that the early use of topical antifungal medication with close follow-up can prevent corneal perforation and result in excellent visual acuity.

Management of Corneal Bee Sting Injuries.

PURPOSE: To review the management of keratitis after corneal bee stings and to report a case of deep stromal corneal infiltrate secondary to a retained bee stinger managed conservatively in a patient who presented three days after unsanitary manipulation of the stinger apparatus. METHODS: Case report and review of literature. RESULTS: A 57-year-old male beekeeper was evaluated for pain, blurry vision, and photosensitivity after a corneal bee sting. Of note, the venom sac had been removed with dirty tweezers three days prior to his visit. On exam, a focal infiltrate with diffuse edema was seen surrounding a retained bee stinger in the peripheral cornea. Trace cells in the anterior chamber were also noted. Based on a high suspicion for infectious keratitis, a conservative treatment strategy was elected. Administration of broad-spectrum topical antibiotics with concomitant abstention of corticosteroids led to rapid resolution of the symptoms. Over 16 months of follow-up, the stinger has remained in situ without migration and the patient has maintained 20/20 visual acuity without complications. There is debate on the preferred method for the management of corneal injury secondary to bee stings, especially when it is associated with a retained stinger. We herein present our findings in our appraisal of reported cases. CONCLUSION: In the aftermath of an ocular bee sting, close surveillance for inflammation and infection is essential. Individual manifestations of these injuries vary in timing, type, and severity; therefore, the accessibility of the stinger and the evolving clinical picture should guide therapeutic decisions.

Peripheral ulcerative keratitis in sarcoidosis: a case report.

PURPOSE: To document a case of peripheral ulcerative keratitis (PUK) that progressed to corneal perforation in the setting of recently diagnosed sarcoidosis. DESIGN: Observational case report. METHODS: A 42-year-old white woman presented with a 2-day history of tearing and decreased vision OD, secondary to PUK with corneal perforation. Slit-lamp evaluation revealed bilateral peripheral corneal thinning with vascularized scarring. History, clinical examination, chart review, peripheral lamellar keratoplasty, serologies, and bronchoscopy with biopsy were performed. RESULTS: After lamellar keratoplasty, visual acuity was 20/400 OD and 20/20 OS. She was treated with oral prednisone and high-dose Cytoxan therapy. One year postperforation, she received a limbus-to-limbus penetrating keratoplasty OD. One year after penetrating keratoplasty, the patient's BCVA OD is 20/40. She has stable scarring OS. Workup has revealed serologic and pathologic evidence of sarcoidosis without evidence of any other seropositive vasculitic disease. CONCLUSION: This patient represents the first known case report of PUK in sarcoidosis. Oral Cytoxan, steroids, and topical cyclosporine have stabilized the disease process in this patient.

Efficacy of surgical simulator training versus traditional wet-lab training on operating room performance of ophthalmology residents during the capsulorhexis in cataract surgery.

PURPOSE: To compare the operating room performance of ophthalmology residents trained by traditional wet-lab versus surgical simulation on the continuous curvilinear capsulorhexis (CCC) portion of cataract surgery. SETTING: Academic tertiary referral center. DESIGN: Prospective randomized study. METHODS: Residents who chose to participate and provided informed consent were randomized to preoperative CCC training in the wet lab or on a simulator. Residents completed pre-practice demographic questionnaires including habits of daily living. After completion of their preoperative training (wet lab versus simulator), residents performed their first CCC of the clinical rotation under the direct supervision of an attending physician as part of their standard training at the facility. Residents then completed satisfaction questionnaires regarding their preoperative training. Two attending surgeons reviewed and graded each video of operating room performance. The mean score between the 2 attending physicians was used as the individual performance score for each of the 12 performance criteria. The overall score was calculated as the sum of these 12 individual performance scores (standardized). RESULTS: Ten residents trained in the wet lab and 11 on the simulator. There was no significant difference in overall score between the 2 groups (P=.608). There was no significant difference in any individual score except time (wet-lab group faster than simulator group) (P=.038). CONCLUSIONS: Preoperative simulator training prepared residents for the operating room as effectively as the wet lab. The time to pass the simulator curriculum was predictive of the time and overall performance in the operating room. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Metastatic choriocarcinoma to the choroid with concurrent optic nerve involvement: a case report and review of the literature.

PURPOSE: To describe a case of choroidal metastasis of choriocarcinoma, which presented as a rapidly progressive hemorrhagic retinal detachment with concurrent optic nerve involvement suggestive of inflammation or metastasis. METHOD: This is a case report of a 43-year-old patient with a known history of choriocarcinoma metastases to both lungs who presented with 1 week of right eye pain and decreased vision. Dilated fundus examination was significant for a large, bullous, hemorrhagic retinal detachment, with the appearance of an underlying choroidal mass in the superonasal retina. Magnetic resonance imaging result was significant for a 1.6 × 1.3-cm heterogeneous mass in the right globe, suggestive of metastasis, and inflammatory changes in the sclera, optic nerve, and optic nerve sheath. Additionally, hemorrhagic metastases were found in the right occipital and left frontal lobes. RESULTS: To our knowledge, this is the first case of metastatic choriocarcinoma to the choroid with concurrent optic nerve involvement. CONCLUSION: Choroidal metastases may be diagnosed in the setting of more widespread central nervous system involvement and should be investigated accordingly.

Orbital decompression: current concepts.

The orbit in Graves disease undergoes expansion in soft tissue content as a result of the infiltration of orbital fat, extraocular muscles, and the lacrimal gland. Compression of the intraorbital contents leads to disorders of the lid-corneal interface, keratopathy, motility disturbances, exophthalmos, and optic neuropathy. Orbital decompression has traditionally been reserved for those patients with unremitting optic neuropathy. This article provides a historical review of orbital decompression, as well as a review of the evolution of surgical approaches toward both soft tissue and bony decompression. Recent trends in surgical management include fat decompression, more extensive posterior sculpting of the lateral wall, and direct approaches to the medial wall. Preoperative predictors of diplopia and hypoglobus are addressed, as are the various techniques that are employed to limit new postoperative strabismus. The roles of endoscopy and combined surgical techniques are also reviewed. Expanded indications for decompression and its effect on increased intraocular pressure are discussed as well.