Delayed Superficial Migration of Retained Hyaluronic Acid Years Following Periocular Injection.

Cosmetic injection of hyaluronic acid (HA) and other fillers is increasingly common, and the late complications of these relatively new procedures are now coming to medical attention. Three patients with delayed periocular swelling that began years after injection of HA are described, with CT, MRI, and histopathologic characterization. While HA fillers are marketed as having a temporary effect of several months, the authors demonstrate that they may persist in the body for up to 9 years. Unlike most previous reports, there was no inflammatory reaction or encapsulation, simply infiltration into more superficial subcutaneous layers. All cases improved after surgical biopsy and hyaluronidase injections. Delayed periocular swelling after filler injections from several years prior can mimic serious medical conditions. With a detailed history and high index of suspicion, one may avoid a costly and invasive workup.

Treatment of presumed Nocardia endophthalmitis and subretinal abscess with serial intravitreal amikacin injections and pars plana vitrectomy.

A 64-year-old man with a past medical history of liver transplantation on chronic immunosuppressive therapy presented with gradual worsening of vision over 2 months in his right eye. His recent history of Aspergillus and Nocardia pneumonia with positive bronchoalveolar lavage, in concert with vitritis and subretinal abscess, were concerning for endogenous endophthalmitis. A sputum culture and transbronchial lung biopsy stains grew Nocardia farcinica although aqueous humor sampling was negative. He was treated with four serial amikacin intravitreal injections over the course of 4 weeks. Pars plana vitrectomy for worsening macular traction and subsequent cataract surgery resulted in significant clinical and anatomic improvement of vision to 20/60 and consolidation of the subretinal abscess.

Malpractice Litigation in Ophthalmic Trauma.

OBJECTIVE: To report and analyze the causes and outcomes of malpractice litigation in ophthalmic trauma. METHODS: The Westlaw® database was reviewed for ophthalmology litigation in the United States between 1930 and 2014. All ophthalmic trauma cases were included and compared to non-traumatic ophthalmology malpractice cases. RESULTS: Forty-four ophthalmic trauma cases were included. Of these cases, 90.9% of ophthalmic trauma plaintiffs were male compared to 54.8% of plaintiffs in ophthalmology as a whole (P=<0.001); 34.1% of cases involved minor plaintiffs compared to 6.4% in ophthalmology as a whole (P=<0.001). Cases involving minors were more likely to be resolved in favor of the plaintiff than cases involving adult plaintiffs (53.3% vs 37.9%); however, this was not found to statistically significant (P=0.35). Overall, 54.5% of cases were resolved in favor of defendants; 40.9% of cases were resolved via jury trial with 50.0% resulting in payments to plaintiffs compared to the 29.6% rate of plaintiff verdicts in ophthalmology as a whole. Open globe injuries represented 61.4% of cases; 55.6% of these cases had intraocular foreign bodies and 37.0% developed endophthalmitis. Most cases (63.6%) alleged insufficient intervention. Of these cases, 31.8% of cases involved surgical or procedural claims, and 4.5% involved medical claims only. CONCLUSION: Males and minors were overrepresented among plaintiffs in ocular trauma litigation. Most cases involved open globe injuries, often complicated by retained intraocular foreign bodies and endophthalmitis. Analysis of malpractice litigation in ophthalmic trauma calls attention to commonly litigated scenarios to improve clinical practice and to inform risk management.

Uveitis and Juvenile Psoriatic Arthritis or Psoriasis.

PURPOSE: To describe the phenotype of the uveitis that accompanies juvenile psoriatic arthritis or psoriasis. DESIGN: Observational case series. METHODS: Setting: Two university-based referral clinics: 1 in England, 1 in the United States. STUDY POPULATION: Five children with uveitis and psoriatic arthritis and 1 with uveitis and psoriasis Observational Procedure: Retrospective chart review. MAIN OUTCOME MEASURES: Demographics of subjects such as age and sex; description of ocular and joint disease; surgical and other complications; medical treatment. RESULTS: Five of the 6 children in this series had the onset of disease at or before age 6 (P = .0008 compared to expected age of onset for psoriatic arthritis in childhood). All children in this series had an inadequate response to topical corticosteroids. Most of the children were treated with systemic corticosteroids for many months, yet all of them went on to require methotrexate. Therapy with systemic methotrexate did not suffice, as all the patients also required some form of biologic therapy. Five of 6 had surgeries such as vitrectomy, cataract extraction, or a procedure for glaucoma control. CONCLUSIONS: The observations suggest that the uveitis that accompanies juvenile psoriatic arthritis might be a distinct disease that is particularly severe when its onset affects children aged 6 years or younger.

Acute Retinal Necrosis: Presenting Characteristics and Clinical Outcomes in a Cohort of Polymerase Chain Reaction-Positive Patients.

PURPOSE: To identify determinants of adverse outcomes in acute retinal necrosis (ARN), presenting characteristics and incidence rates of vision loss and ocular complications in a cohort of polymerase chain reaction (PCR)-positive eyes were analyzed. DESIGN: Retrospective observational cohort study. METHODS: Forty-one eyes of 36 patients with clinically diagnosed ARN, PCR-positive for herpes simplex virus or varicella zoster virus and evaluated between January 2002 and June 2013, were included. Main outcome measures included incidence rates of vision loss and retinal detachment (RD). RESULTS: Presenting visual acuity was generally poor (20/50 to >20/200 in 27%; 20/200 or worse in 56%). The incidence rate of ≤20/200 was 0.66/eye-year (EY), (95% confidence interval [CI], 0.32/EY to 1.22/EY); the rate of light perception or no light perception vision was 0.07/EY (95% CI, 0.02/EY to 0.16/EY). During follow-up, 59% of eyes developed at least 1 RD (rate = 0.40/EY, 95% CI, 0.19/EY to 0.58/EY). Eyes with retinitis involving ≥25% of the retina at presentation detached at nearly 12 times the rate, as compared to those with <25% retinal involvement (0.70/EY vs 0.06/EY; P = .001). Development of an RD was the greatest determinant of adverse visual outcomes, with 4% of eyes, that had experienced at least 1 RD, achieving a best-corrected visual acuity of ≥20/40 compared to 53% of eyes that never detached (P = .0003). CONCLUSIONS: Poor outcomes in ARN were common in this cohort. RD confers the greatest risk of incident vision loss, and once 25% or more of the retina is involved the risk of RD and visual loss increases significantly.

Recovery of outer retinal laminations on optical coherence tomography after treatment of cancer associated retinopathy.

PURPOSE: To report novel optical coherence tomography findings in a case of anti-α-enolase cancer associated retinopathy. OBSERVATIONS: An elderly female presented with bilateral decreased vision and a recent diagnosis of ovarian carcinoma. Optical coherence tomography demonstrated bilateral loss of outer retinal structures and macular edema. Serum testing found antibodies against α-enolase and 82-84 kDa proteins. Outer retinal structures showed recovery, macular edema resolved and repeat anti-retinal antibody testing became negative following cancer therapy and topical difluprednate treatment. CONCLUSIONS AND IMPORTANCE: Cancer associated retinopathy is a paraneoplastic disease that results in damage to retinal structures through an autoimmune response. The damage is generally considered to be irreversible; however, in rare cases, such as observed here, retinal structures may demonstrate recovery after treatment.

Gene Expression Profiling and Heterogeneity of Nonspecific Orbital Inflammation Affecting the Lacrimal Gland.

Importance: Although a variety of well-characterized diseases, such as sarcoidosis and granulomatosis with polyangiitis, affect the lacrimal gland, many patients with dacryoadenitis are diagnosed as having nonspecific orbital inflammation (NSOI) on the basis of histology and systemic disease evaluation. The ability to further classify the disease in these patients should facilitate selection of effective therapies. Objective: To test the a priori hypothesis that gene expression profiles would complement clinical and histopathologic evaluations in identifying well-characterized diseases and in subdividing NSOI into clinically relevant groups. Design, Setting, and Participants: In this cohort study, gene expression levels in biopsy specimens of inflamed and control lacrimal glands were measured with microarrays. Stained sections of the same biopsy specimens were used for evaluation of histopathology. Tissue samples of patients were obtained from oculoplastic surgeons at 7 international centers representing 4 countries (United States, Saudi Arabia, Canada, and Taiwan). Gene expression analysis was done at Oregon Health & Science University. Participants were 48 patients, including 3 with granulomatosis with polyangiitis, 28 with NSOI, 7 with sarcoidosis, 4 with thyroid eye disease, and 6 healthy controls. The study dates were March 2012 to April 2017. Main Outcomes and Measures: The primary outcome was subdivision of biopsy specimens based on gene expression of a published list of approximately 40 differentially expressed transcripts in blood, lacrimal gland, and orbital adipose tissue from patients with sarcoidosis. Stained sections were evaluated for inflammation (none, mild, moderate, or marked), granulomas, nodules, or fibrosis by 2 independent ocular pathologists masked to the clinical diagnosis. Results: Among 48 patients (mean [SD] age, 41.6 [19.0] years; 32 [67%] female), the mclust algorithm segregated the biopsy specimens into 4 subsets, with the differences illustrated by a heat map and multidimensional scaling plots. Most of the sarcoidosis biopsy specimens were in subset 1, which had the highest granuloma score. Three NSOI biopsy specimens in subset 1 had no apparent granulomas. Thirty-two percent (9 of 28) of the NSOI biopsy specimens could not be distinguished from biopsy specimens of healthy controls in subset 4, while other examples of NSOI tended to group with gene expression resembling granulomatosis with polyangiitis or thyroid eye disease. The 4 subsets could also be partially differentiated by their fibrosis, granulomas, and inflammation pathology scores but not their lymphoid nodule scores. Conclusions and Relevance: Gene expression profiling discloses clear heterogeneity among patients with lacrimal inflammatory disease. Comparison of the expression profiles suggests that a subset of patients with nonspecific dacryoadenitis might have a limited form of sarcoidosis, while other patients with NSOI cannot be distinguished from healthy controls.

Periocular triamcinolone acetonide injections for control of intraocular inflammation associated with uveitis.

PURPOSE: To describe the effectiveness of periocular corticosteroid injections for the control of intraocular inflammation associated with noninfectious uveitis. METHODS: A total of 81 patients (109 eyes) who received a periocular injection were evaluated for active inflammation, visual acuity, intraocular pressure, degree of intraocular inflammation, and the presence of ocular complications, including macular edema. RESULTS: Of all eyes, 36% (95%CI: 25%, 45%) demonstrated clinical resolution of inflammation at the 1-month visit after first injection, and 48% (95%CI: 37%, 59%) at 3 months. For multiple injections, 50% (95%CI: 28%, 72%) demonstrated resolution of inflammation at 1 month after the last injection, and 41% (95%CI: 20%, 63%) resolution of inflammation at 3 months after the last injection. Of the 49 eyes that initially responded, the estimated median time to recurrence was 7.6 months. CONCLUSIONS: Approximately half of the treated eyes had resolution of intraocular inflammation at 3 months after corticosteroid injection.