A Case of Primary Open-angle Glaucoma With Conjunctival Laceration After Micropulse Transscleral Cyclophotocoagulation.

PURPOSE: We report a case of primary open-angle glaucoma with conjunctival laceration after micropulse transscleral cyclophotocoagulation (MP-CPC). PATIENTS AND METHODS: A 74-year-old man with primary open-angle glaucoma underwent MP-CPC using a Cyclo G6 device (IRIDEX) due to an increase in intraocular pressure (IOP) to 25 mm Hg in his left eye. At 1 week after surgery, IOP had decreased to 12 mm Hg. However, at 2 months after surgery, IOP had increased again to 25 mm Hg. MP-CPC was performed again at 3 months after the first surgery using a Cyclo G6 device, in accordance with treatment guidelines outlined by the manufacturer. Before the MP-CPC treatment, the patient received anesthesia with 2% lidocaine in the sub-Tenon space. A large amount of subconjunctival hemorrhage was observed in the sub-Tenon space. RESULTS: At 1 day after the second MP-CPC treatment, an arc-shaped conjunctival erosion and a brown lesion were observed in the MP-CPC-irradiated area in the lower hemisphere. The possibility of scleral laceration was considered. The IOP was 25 mm Hg and no aqueous humor leakage was observed. The wound had become enlarged. At 20 days after the second MP-CPC, the patient was hospitalized to close the wound. During the repair surgery, the brown lesion was easily detached from the sclera. There was conjunctival laceration, but no scleral laceration. Pathologic examination revealed that the exfoliated tissue contained abundant clots, connective tissue, and elastic fibers. CONCLUSION: Special care and consideration are required when performing MP-CPC in cases of severe subconjunctival hemorrhage.

Correlation analysis of the clinical features and prognosis of acute ocular burns-exploration of a new classification scheme.

PURPOSE: To explore a new classification scheme for acute ocular burns. METHODS: Medical records of 345 patients (450 eyes) with acute ocular burns treated at Shandong Eye Institute between January 2013 and January 2018 with a 12-month minimum follow-up were retrospectively reviewed. A total of 8 parameters in the acute phase were evaluated and graded on a scale from 0 to 3 according to their severity. RESULTS: The key factors affecting the prognosis of acute ocular burns were conjunctival involvement (386 eyes, 85.8%), corneal epithelial defect (349 eyes, 77.6%), and limbal ischemia (244 eyes, 54.2%). Visual acuity in 181/450 eyes (40.2%) was worse than 6/60. The injury severity of the cornea, limbus, bulbar conjunctiva, eyelid, and fornix and intraocular signs in the acute phase was significantly correlated with the logarithm of the minimum angle of resolution (logMAR) visual acuity (correlation coefficient [R] 0.481-0.933, P < 0.0001) and corneal opacification, neovascularization, and symblepharon scores in the stable phase (R 0.513-0.855, P < 0.0001). The mean total score for the 8 parameters in the acute phase was 5.34 ± 4.04 (range 0-14); higher scores indicated worse visual acuity (R = 0.899, P < 0.0001). The total score for acute-phase parameters was significantly correlated with that for the stable-phase parameters (R = 0.872, P < 0.0001). CONCLUSIONS: The severity of acute-phase parameters is significantly correlated with the final visual outcome and prognosis. The new grading scheme can help clinicians more accurately analyze the degree of ocular burns, determine a reasonable treatment protocol, and rationally evaluate the prognosis.

A Case of Conjunctival Bee Sting Injury with Review of the Literature on Ocular Bee Stings.

BACKGROUND Ocular bee stings have been rarely described in the literature, and their management is controversial. A case of conjunctival bee sting with retention of the stinger for 48 hours is presented with a review of the literature on the complications and management of ocular bee sting injury. CASE REPORT A 22-year-old beekeeper presented to the Emergency Department with mild symptoms from a conjunctival bee sting that he had received 48 hours previously. The stinger was removed in the Emergency Department, and topical antibiotic and anti-inflammatory treatment with corticosteroid were given. There were no complications in this case. However, review of the literature has shown that although the outcome from ocular bee stings can be mild, as in this case, ocular bee stings can result in severe visual symptoms that require amniotic membrane transplant (AMT). Management commonly includes removal of the stinger and both topical and systemic treatment with corticosteroids. The main complications include cataracts, inflammation of the anterior chamber, optic neuropathies, and changes in ocular pressure. CONCLUSIONS Ocular bee stings have been rarely described in the literature, and the management remains controversial. As this case has shown, removal of the stinger and the use of topical treatment with antibiotics and corticosteroids can prevent potentially serious complications that may affect vision. Early and regular follow-up with ocular imaging may be required when symptoms persist.

Ant Bites Conjunctival Tissue: The ABCs of Removing an Ocular Ant Foreign Body.

BACKGROUND: A variety of insect-related ocular injuries have been reported in the literature. However, no reports have been published documenting injuries resulting from exposure of the ocular surface to ants. This is surprising, given the relatively ubiquitous presence of ants. This is the first known case report to describe various techniques utilized in the removal of ants from the ocular surface. CASE REPORT: This case report details the presentation of a distressed 24-year-old woman who presented to the Emergency Department with an ocular foreign body associated with pain and increased lacrimation. She was identified to have an ant adherent to her conjunctiva. Various techniques of removal were performed, with the ant finally removed without any trauma to underlying tissues. CONCLUSION: This is the first case report to detail various techniques utilized in the removal of ants from the ocular surface, and discusses salient features that treating physicians should be aware of in managing patients presenting with ant bites.

Corneal and conjunctival injury seen in urgent care centres in Israel.

PURPOSE: Corneal and conjunctival injuries (CCI) comprise a large portion of the cases presenting to hospital-based emergency departments (ED) with ocular involvement. Urgent Care Centres (UCC) offer community based emergency care at lower cost than hospital-based emergency departments (ED) and with greater temporal convenience than primary care office settings. While CCI prevalence and treatment at hospital-based EDs has been well studied, this is the first report, to our knowledge, on CCI demographics and aetiology presenting to UCCs. METHODS: This retrospective study was approved by the institutional ethics committee. The setting is a UCC system in Israel, modelled on USA urgent care facilities, consisting of 17 branches at the time of the study. Electronic medical record data (between November 1, 2015 and October 31, 2016) of patients diagnosed with corneal disorder, foreign body or eye disorder were retrieved and reviewed for inclusion/exclusion criteria. Data collected included gender, age, chief complaint, diagnosis, treatment and discharge status (sent home or referred to ED). International Classification of Diseases, Ninth Revision (ICD-9) codes were assigned to each record based on a review of all fields. UCC results were compared to all ED patients in Israel using data from a public report. Data were analysed by descriptive statistics and logistic regression analysis. RESULTS: Of the 602 074 charts screened, 4797 patients presented with CCI (0.8%). The average age was 32.6 ± 18.2 years and 71.3% were male. Among these, 26.4% were referred to the ED compared to 6.8% from the entire UCC cohort. ICD-9 code Foreign body (FB) of the eye was the most common cause of CCI (56.5%) followed by the following ICD-9 codes: trauma (18.1%), chemical in the eye (11.1%) and corneal disorder due to a contact lens (5.1%). Logistic regression analyses showed the following risk factors for ED referral: age (22-64), male gender, ICD-9 code FB, work-related injury and the presence of a clinical abrasion in the eye. CONCLUSIONS: The aetiology of ocular injury at UCC is similar to previous studies of ED. Most CCI can be treated at UCC saving ED resources and underscores the importance of this mode of health care delivery in the overall health system.

Prospective study of the sensitivity of the Wood's lamp for common eye abnormalities.

OBJECTIVE: The Wood's lamp, a handheld instrument that uses long-wave ultraviolet (UV) light with magnification of 2-3 times, is commonly used by non-ophthalmologists for examining patients with eye complaints. The goal of current research was to determine the sensitivity and specificity of the Wood's lamp for common eye abnormalities. STUDY DESIGN: We examined a convenience sample of patients, 18 years of age and older, who presented for eye complaints to an urgent clinic of a large ophthalmology practice. This prospective observational trial was performed from December 2016 until July 2017. An ophthalmologist examined the patient's eyes with a Wood's lamp, followed by examination of the eyes using a slit lamp. The Wood's lamp was compared with the slit lamp, which served as the gold standard. RESULTS: There were 73 patients recruited. The mean age of study subjects (29 female and 44 male) was 49 years. The overall sensitivity of the Wood's lamp was 52% (38/73; 95% CI 40% to 64%). Based on the principal final diagnosis made with the slit lamp, the Wood's lamp only detected 9 of 16 corneal abrasions, 5 of 10 corneal ulcers, 5 of 9 corneal foreign bodies, 0 of 4 cases of non-herpetic keratitis, 1 of 2 cases of herpes keratitis, 1 of 5 rust rings and 18 of 28 other diagnoses. CONCLUSIONS AND RELEVANCE: Examination using the Wood's lamp fails to detect many common eye abnormalities. Our findings support the need for a slit lamp examination of patients with eye complaints whenever possible.

Management of Conjunctival Perforation and XEN Gel Stent Exposure by Stent Repositioning Through the Anterior Chamber.

In recent years, minimally invasive glaucoma surgery has emerged as a novel approach to lowering intraocular pressure. This technique, which is usually reserved for mild to moderate cases, is less invasive than classic filtration surgery and potentially offers a better safety profile. The XEN Gel Stent is implanted through a minimally invasive, ab interno procedure to create a subconjunctival pathway. Conjunctival tissue disruption is minimal, and flow is restricted to avoid hypotony. Data on the optimal approach to managing complications associated with this procedure are limited due to the relatively recent commercialization of this device. Here, we report a case of a persistent leaking bleb caused by XEN Stent exposure, which was managed by ab interno repositioning of the stent through the anterior chamber and direct suturing of the conjunctival defect.

Self-insertion of foreign bodies into the orbit and periocular tissue.

We describe six patients with 12 separate episodes of self-inflicted periocular foreign body injuries, which presented to our institution recently. All patients were male, relatively young (mean 28.5 years old), incarcerated, and had significant underlying psychiatric conditions. The subjects had inserted staples (6), paperclips (2), or other small metallic wire segments (4) into the periocular region. Most cases (9/12) involved concurrent self-inflicted injury to other body parts. Ten cases involved foreign bodies inserted through the palpebral conjunctiva into the upper eyelid, while two cases involved insertion into the orbit. Identification and surgical retrieval of foreign bodies was successful in most cases (9/11) but was not attempted in one case. Self-inflicted periocular injuries, while rare, are challenging cases for which the ophthalmologist should be prepared. A multidisciplinary approach, including psychiatric assessment and treatment, is important for optimal care.

Paediatric ocular super glue injuries: assessment of two cases.

In this report, we elaborate the clinical findings and the optimal management of two cases with ocular glue injuries in two paediatric patients. Both the patients were presented to the ocular emergency with completely closed eyelid and periocular erythema. The eyelids were completely closed due to matting of the eyelashes with glue retention up to lash roots. Thus, in both cases, after the application of local anaesthetic agent, immediate lash trimming was performed along with the removal of crystallised glue particles. However, the ocular surface showed only congestion in absence of any added corneal complications. Patients were followed up with standard treatment protocol as per chemical injuries. Until the end of 5 months, the clinical course was uneventful.

Bevacizumab Promotes T-Cell-Mediated Collagen Deposition in the Mouse Model of Conjunctival Scarring.

Purpose: We determine the effects of bevacizumab on collagen production in a mouse model of conjunctival scarring. Methods: Experimental surgery was performed as described for the mouse model of conjunctival scarring, and bevacizumab was introduced by conjunctival injection. The capacity of bevacizumab to recognize conjunctival VEGF-A was determined by ELISA. Col1a1 was measured by real-time PCR and immunoblotting. T cells and collagen were visualized by immunofluorescence and picrosirius red staining of bleb cryosections. Conjunctival CD4+ or CD8a+ T cells were counted by flow cytometry. Mouse splenic T cells were cultured with bevacizumab/IgG and their numbers, cell cycle, and collagen production were measured using a cell counter, flow cytometry, and sircol soluble collagen assay, respectively. Reconstitution experiments in severe combined immunodeficiency (SCID) mice were performed by injection of freshly isolated T cells on day 2 postoperatively. Results: Bevacizumab recognized approximately 20% of endogenous murine VEGF-A. Injection of bevacizumab raised Col1a1 expression in the blebs at mRNA and protein levels. Bevacizumab did not induce collagen in conjunctival fibroblasts, but increased CD4+ and CD8a+ cell numbers as well as collagen production by these cells. Collagen appeared to accumulate in the vicinity of T cells in the bevacizumab-treated blebs. While SCID blebs did not show elevated collagen levels, reconstitution with CD4+ or CD8a+ cells resulted in increased Col1a1 expression at mRNA and protein levels. Conclusions: Bevacizumab increased collagen production in the mouse model of conjunctival scarring. This collagen induction was mediated by T cells that were also stimulated by bevacizumab to increase in numbers.

Conjunctival repair after glaucoma drainage device exposure using collagen-glycosaminoglycane matrices.

BACKGROUND: To report the results of the repair of conjunctival erosions resulting from glaucoma drainage device surgery using collagen-glycosaminoglycane matrices (CGM). METHODS: Case series of 8 patients who underwent revision surgery due to conjunctival defects with exposed tubes through necrosis of the overlying scleral flap and conjunctiva after Baerveldt drainage device surgery. The defects were repaired by lateral displacement of the tube towards the sclera, with a slice of a CGM as a patch, covered by adjacent conjunctiva. RESULT: Successful, lasting closure (follow-up of 12 to 42 months) of the conjunctival defects was achieved without any side-effects or complications in all eight cases. CONCLUSIONS: Erosion of the drainage tube, creating buttonholes in the conjunctiva after implantation of glaucoma drainage devices, is a potentially serious problem. It can be managed successfully using a biodegradable CGM as a patch.

Manejo de la perforación conjuntival y Seidel tardío poscirugía XEN® / Management of conjunctival perforation and late Seidel after XEN® surgery

Caso clínico: Mujer de 78 años con antecedentes de cirugía XEN®. A los 18 meses de seguimiento se observa perforación conjuntival a nivel del implante, decidiéndose intervención quirúrgica. En esta se constató un trayecto subconjuntival corto (0,5 mm). Se intenta, sin éxito, extraerlo mediante tracción, sin embargo, el XEN® se rompe con facilidad. Finalmente se decide seccionarlo hasta nivel escleral, y suturar la conjuntiva. Durante la primera semana poscirugía existe disminución de la presión intraocular (6 mmHg), para posteriormente aumentar progresivamente hasta 25, optándose por iniciar tratamiento médico. Discusión: La exposición conjuntival del XEN® es una complicación rara, pero potencialmente grave. Para evitarla es importante una técnica quirúrgica meticulosa durante su implantación. En caso de suceder es importante identificar la causa. Si es debida al trayecto subconjuntival corto, una alternativa terapéutica es la sección del implante a este nivel para evitar nuevas complicaciones (AU)

Clinical case: The case concerns a 78 year-old woman with a history of XEN® surgery, in whom a conjunctival perforation was observed at the implant level at 18-months of follow-up, for which surgical intervention was decided. During surgery a short subconjunctival portion was found (0.5 mm). An unsuccessful attempt was made to extract it by traction, but the XEN® broke easily. Finally, it was decided to cut it to scleral level, and suture the conjunctiva. During the first week there was a decrease in intraocular pressure (6 mmHg), to subsequently increase to 25, and deciding to start medical treatment. Discussion: Conjunctival exposure of the XEN® stent is a rare but potentially serious complication. To avoid it, a meticulous surgical technique is important when implanting it. If this occurs, it is important to identify the cause. If it is due to a short subconjunctival portion, a therapeutic alternative is to cut the implant at this level to avoid further complications (AU)

Management of conjunctival perforation and late Seidel after XEN® surgery. / Manejo de la perforación conjuntival y Seidel tardío poscirugía XEN®.

CLINICAL CASE: The case concerns a 78 year-old woman with a history of XEN® surgery, in whom a conjunctival perforation was observed at the implant level at 18-months of follow-up, for which surgical intervention was decided. During surgery a short subconjunctival portion was found (0.5mm). An unsuccessful attempt was made to extract it by traction, but the XEN® broke easily. Finally, it was decided to cut it to scleral level, and suture the conjunctiva. During the first week there was a decrease in intraocular pressure (6mmHg), to subsequently increase to 25, and deciding to start medical treatment. DISCUSSION: Conjunctival exposure of the XEN® stent is a rare but potentially serious complication. To avoid it, a meticulous surgical technique is important when implanting it. If this occurs, it is important to identify the cause. If it is due to a short subconjunctival portion, a therapeutic alternative is to cut the implant at this level to avoid further complications.