Atypical presentations of orbital cellulitis caused by methicillin-resistant Staphylococcus aureus.

PURPOSE: To evaluate the epidemiologic and clinical features of orbital cellulitis caused by methicillin-resistant Staphylococcus aureus (MRSA). DESIGN: Multicenter, retrospective case series. PARTICIPANTS: Fifteen patients with culture-positive MRSA orbital cellulitis. METHODS: All recent cases of orbital cellulitis at several hospitals and surgical centers were reviewed, and cases with culture-positive MRSA from aspirates were identified. The data collected and analyzed retrospectively included patient demographics, medical history, presenting sign, imaging results, surgical procedure performed, surgical culture results, visual acuity at presentation and last follow-up, and duration of antibiotics. MAIN OUTCOME MEASURES: Presenting sign, radiographic evidence of paranasal sinus disease, radiographic evidence of multiple orbital abscesses, presence or absence of antecedent upper respiratory infection, and final visual acuity. RESULTS: Fifteen cases were identified. The mean patient age was 31.9 years (standard deviation, 24.2 years). Lid swelling was the presenting sign in 14 of 15 patients. No patients had a preceding upper respiratory infection, and only 1 patient had antecedent eyelid trauma. Only 3 of 15 patients had documented adjacent paranasal sinus disease on imaging. Lacrimal gland abscess or dacryoadenitis was the presenting finding in 5 of 15 patients. Multiple orbital abscesses were identified in 4 of 15 patients by computed tomography or magnetic resonance imaging. Fourteen of 15 cases required surgical intervention. Four of 15 cases had loss of visual acuity to light perception or worse. All 4 of these cases had a delay in referral for surgical intervention. CONCLUSIONS: In these 15 patients with MRSA orbital cellulitis, the typical clinical setting of orbital cellulitis was absent; chiefly, there was no identified antecedent upper respiratory illness, nor was there a preceding traumatic injury. Lid swelling in the absence of recent upper respiratory illness, lacrimal gland focus, multiple orbital abscesses, and lack of adjacent paranasal sinus disease may be predictive factors that suggest MRSA as the causative organism of orbital cellulitis. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Anti-VEGF therapy for glaucoma.

PURPOSE OF REVIEW: The role of antivascular endothelial growth factor (anti-VEGF) agents in treating various ophthalmic diseases is currently being investigated. There have been many advances in the understanding of how anti-VEGF agents work and speculation on when to implement them clinically for neovascular glaucoma. Recent studies exploring the utility of anti-VEGF agents for wound modulation after trabeculectomy reveal promising results. RECENT FINDINGS: Anti-VEGF agents have been shown to be beneficial in treating neovascular glaucoma. Their use leads to regression of both iris and angle neovascularization, intraocular pressure control when the angle remains open and, in many cases, prompts symptomatic improvement. In addition, research on the wound modulatory properties of anti-VEGF agents has revealed a dose-dependent inhibition of fibroblast proliferation. Studies exploring the use of anti-VEGF agents at time of trabeculectomy or in bleb revision procedures suggest a beneficial effect on bleb survival and subsequent improvement in intraocular pressure control. Prospective randomized clinical trials are still needed. SUMMARY: The recent use of anti-VEGF agents for neovascular glaucoma as well as wound modulation after trabeculectomy has shown great promise. Through future research, the antiangiogenic and antifibroblastic properties of anti-VEGF agents may prove to be beneficial in patients being treated for various forms of glaucoma.

Resolution of pityriasis rubra pilaris-induced cicatricial ectropion with systemic low-dose methotrexate.

PURPOSE: To report a case of pityriasis rubra pilaris (PRP)-induced bilateral lower eyelid cicatricial ectropion that resolved with systemic low-dose methotrexate. DESIGN: Observational case report. METHODS: A retrospective case review of a patient with cicatricial ectropion caused by PRP. RESULTS: A 82-year-old female presented with bilateral lower eyelid cicatricial ectropion secondary to PRP. The patient did not systemically respond to conventional oral retinoid therapy. She was treated with low-dose methotrexate and experienced dramatic resolution of her signs and symptoms, including complete resolution of her bilateral cicatricial ectropion. CONCLUSION: Systemic treatment of PRP with low-dose methotrexate may result in successful treatment of cicatricial ectropion without surgery.

The use of prostaglandin analogs in the uveitic patient.

Glaucoma is a disease process characterized by progressive optic nerve damage and corresponding visual field loss. It may be further categorized into either primary open-angle glaucoma or secondary glaucoma. These secondary glaucomas include glaucomas associated with uveitis and inflammation. Prostaglandin analogs (PGA) have been used to help lower intraocular pressure (IOP) in these often difficult to manage eyes. However, controversy exists concerning their use in uveitic patients due to the theoretically higher risk of anterior uveitis, development of cystoid macular edema (CME), and reactivation of herpes simplex keratitis (HSK). There is little evidence that PGA disrupt the blood-aqueous barrier and only anecdotal evidence suggesting an increased risk of these rare findings. PGA may be used in uveitic glaucoma when other topical treatments have not lowered IOP to the patient's target range.

Retinal nerve fiber layer thickness in patients receiving chronic anti-vascular endothelial growth factor therapy.

PURPOSE: To evaluate the effects of multiple intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents on the thickness of the retinal nerve fiber layer (RNFL) in patients with wet age-related macular degeneration (ARMD). DESIGN: Retrospective, observational, consecutive case series of patients diagnosed with wet ARMD. METHODS: Forty-one eyes of 37 consecutive patients (25 female and 12 male; mean age 79.2 ± 8.7 years) who underwent treatment with pegaptanib, bevacizumab, and/or ranibizumab for ARMD followed by sequential RNFL thickness measurement by optical coherence tomography (OCT) were studied. Patients were included in the analyses if they had greater than 10 total anti-VEGF injections, RNFL measurements prior to the first injection, and at least 12 months of follow-up. Patients were divided into 3 groups depending on which anti-VEGF agent(s) they received. The OCT RNFL measurements at the initial and final follow-up were used for analyses. RESULTS: Average follow-up for all patients was 27.0 ± 9.7 months and they received an average of 16.0 ± 5.5 intravitreal injections. The average RNFL thickness at presentation was 92.4 ± 15.2 µm and at last follow-up was 93.8 ± 15.2 µm (P = .68). There were no statistically significant differences in RNFL measurements when comparing between individual anti-VEGF treatment groups. CONCLUSION: Long-term treatment with anti-VEGF agents did not lead to significant changes in RNFL thickness in a patient population with wet ARMD. Despite the possibility of repeated intraocular pressure (IOP) fluctuations after intravitreal injections and known neurotrophic properties of VEGF in the eye, chronic therapy with intravitreal anti-VEGF agents does not appear to adversely affect RNFL thickness. Further prospective studies with longer follow-up are needed to corroborate the findings of this study.

Effects of prostaglandin analog therapy on the ocular surface of glaucoma patients.

PURPOSE: To quantify changes in tear break-up time (TBUT), corneal staining and ocular surface disease index (OSDI) in glaucoma patients after switching therapy from latanoprost with 0.02% benzalkonium chloride (BAK) to travoprost with sofZia(). METHODS: Prospective consecutive case series evaluating patients before and 8 weeks after switching from latanoprost with BAK to travoprost with sofZia() in patients with baseline TBUT less than 6 seconds. RESULTS: Forty eyes of 20 consecutive patients using latanoprost with BAK were switched to travoprost with sofZia(). Mean TBUT prior to starting travoprost was 2.02 +/- 0.71 seconds and increased to 6.34 +/- 1.31 seconds 8 weeks after the switch (p < 0.001). Mean inferior corneal staining scores decreased from 2.40 +/- 0.87 to 1.38 +/- 0.59 (p < 0.001). Mean OSDI scores decreased from 26.31 +/- 8.25 to 16.56 +/- 6.19 (p < 0.001). DISCUSSION: This report focuses on the status of the ocular surface, as documented by TBUT, corneal staining and OSDI, in patients switched from latanoprost with BAK to travoprost without BAK. The switch resulted in a statistically significant increase in TBUT and decreases in corneal staining and OSDI in patients with low baseline TBUT values. CONCLUSION: BAK, a common preservative for glaucoma drops, may increase OSD by disrupting the tear film and increasing conjunctival inflammation. In this study, a change from a BAK-preserved prostaglandin analog (PGA) to a non-BAK-preserved PGA resulted in a measurable improvement of TBUT, corneal staining and OSDI. Further studies are needed to better understand the impact of BAK-preserved medications on the ocular surface.