Subpalpebral Antibiotic Lavage as Safe, Emergent, and Cost-Effective Management of Acute Infectious Keratitis Related to Contact Lens Overwear: Case Report and Literature Review.

PURPOSE: The aim of this study is to describe the technique of subpalpebral antibiotic lavage (SAL), which is a highly therapeutic, efficient, and cost-effective method for managing severe bacterial keratitis. METHODS: This case report describes a 26-year-old woman with severe bacterial keratitis in the right eye due to contact lens overwear, with progressive corneal thinning, a hypopyon, impending perforation, and marked visual loss to perception of light despite treatment with intensive topical antibiotics. This was managed with SAL that involves the insertion of a cannula transcutaneously into the upper conjunctival fornix to provide continuous antibiotic irrigation of the ocular surface. RESULTS: By 11 weeks after presentation, the cornea and anterior chamber appeared clinically quiescent, and visual acuity improved to 20/40 corrected in the right eye. CONCLUSIONS: Bacterial keratitis is a potentially blinding condition for which contact lens wear is an important risk factor. Most cases are successfully managed with topical medications; however, in cases of treatment failure, a second-line approach such as SAL can be sight-saving. SAL uses readily available equipment for the delivery of high concentrations of antibiotics to the ocular surface, thus increasing therapeutic efficacy and reducing nursing staff workload. Despite its advantages, the literature reveals apparent underutilization of this technique.

Mycobacterium hemophilum infection presenting as filamentary keratopathy in an immunocompromised adult.

PURPOSE: To report a case of Mycobacterium hemophilum of the eye. METHODS: Case report with pathologic correlation. A 55-year-old Malaysian man with a 3-year history of graft-versus-host disease presented with dry eye and keratopathy. RESULTS: The diagnosis was not initially evident, despite biopsy specimens of the conjunctiva. Definitive diagnosis was made after dermatology consultation suggested a histoid variant of lepromatous leprosy, prompting Ziehl-Neelsen staining of the initial and subsequent conjunctival biopsies with subsequent polymerase chain reaction testing. Anti-M. hemophilum treatment resulted in prompt resolution of ocular signs. CONCLUSIONS: Mycobacterium hemophilum is a rare condition, affecting mainly immunocompromised patients. Although filamentary keratopathy has been described as common manifestations of leprosy, to date, no ocular manifestations of M. hemophilum have been described. Conjoint management with infectious disease and clinical microbiology is imperative to ensure accurate diagnosis and appropriate early intervention. The effect of systemic immunosuppression is relevant in such patients.

Disseminated mucormycosis and orbital ischaemia in combination immunosuppression with a tumour necrosis factor alpha inhibitor.

Disseminated mucormycosis, with pulmonary and cerebral angioinvasive disease, developed in a 65-year-old woman with rheumatoid arthritis being treated with combination immunosuppression including adalimumab. Clinical presentation included progressive orbital ischaemia. To the best of the authors' knowledge, this is the first reported case of disseminated mucormycosis in a patient treated with a tumour necrosis factor inhibitor. Important pathophysiological factors are considered.

Deep anterior lamellar keratoplasty using the manual dissection technique of Melles: a histopathologic correlation.

PURPOSE: To report the histopathologic findings in the host tissue of 2 human keratoconic corneas undergoing maximum-depth anterior lamellar keratoplasty (MDALK) using the manual dissection technique described by Melles. METHODS: Corneal buttons were examined from 2 patients with keratoconus who underwent MDALK using the manual dissection technique of Melles and converted to penetrating keratoplasty after rupture of the lamellar bed. Manual dissection was performed in 1 patient, and combined manual and viscoelastic dissection of Descemet membrane (DM) was performed in the other. RESULTS: Light microscopy of the corneal buttons showed a deep pre-Descemet dissection plane with minimal residual stroma. DM appeared to be thinned in both eyes and measured 3 to 8 microm in thickness. CONCLUSION: By using the manual dissection technique of Melles, LK can be performed exposing the smooth DM of the recipient bed. We confirmed exposure of DM in patient corneas, using this technique by light microscopy. There may be an increased risk of rupture of DM during surgery when this membrane is thinned, particularly in patients with keratoconus. This surgical technique allows conversion to penetrating keratoplasty after rupture of DM.

Mycobacterium tuberculosis presenting as chronic red eye.

PURPOSE: To report a case of tuberculosis of the conjunctiva. METHODS: Case report with pathologic correlation. A 17-year-old man who had relocated to Australia from Liberia presented with chronic unilateral conjunctivitis. RESULTS: The diagnosis was not initially evident, despite 2 separate biopsy specimens, conjunctival cultures, and polymerase chain reaction testing. Definitive diagnosis was made after repeated histologic examination. Antituberculous treatment resulted in prompt resolution of all ocular signs. CONCLUSION: Tuberculous conjunctivitis is now a very rare condition in the developed world. Definitive diagnosis requires the identification of Mycobacterium tuberculosis organisms in conjunctival biopsy specimens-either through microscopic detection of acid-fast bacilli or more sensitive culture techniques.

Selective death of lens epithelial cells using demineralized water and Triton X-100 with PerfectCapsule sealed capsule irrigation: a histological study in rabbit eyes.

BACKGROUND: Sealed irrigation of the capsular bag after removal of the cataractous lens isolates the interior of the capsular bag from the anterior segment, permitting isolated targeting of lens epithelial cells (LECs) in vivo using pharmacologic agents while minimizing the risk of damage to other intraocular structures. OBJECTIVES: To assess the ability to deliver a nonspecific, extremely toxic agent (Triton X-100) directly to the LECs after crystalline lens removal, and to assess the eyes histologically for evidence of collateral damage. METHODS: Twelve eyes from 6 New Zealand White rabbits were divided into 3 groups of 4 eyes that underwent phacoaspiration of the crystalline lens. Group 1 was a control. In group 2, the anterior segment was irrigated with Triton X-100 and demineralized water for injection for 5 minutes. In group 3, the lens capsule was isolated from the anterior segment using sealed capsule irrigation (SCI) with PerfectCapsule (Milvella Pty Ltd, Sydney, Australia). After surgery, the rabbits were humanely euthanized. The enucleated eyes were immediately fixed in 10% neutral buffered formalin, histological analysis was performed to assess the corneal endothelium, iris, and retina, and the capsular bag and residual equatorial LECs were assessed. RESULTS: The capsular bag was sealed and inflated under SCI in all treated eyes in group 3. Histological evaluation revealed no evidence of collateral damage in group 1 and group 3. Significant histological damage to the cornea, iris, and peripheral retina was noted in group 2. Histological evaluation of each capsular bag suggests presence of LECs in group 1 and group 2. In the presence of SCI, Triton X-100 caused almost complete destruction of LECs in the capsular bag. CONCLUSIONS: Results suggest that SCI allows selective delivery of toxic agents directly into the capsular bag, preventing collateral damage to surrounding intraocular structures. The PerfectCapsule device kept the capsular bag well inflated intraoperatively, which may allow the isolated, safe delivery of pharmacologic agents into the capsular bag during cataract surgery. Clinical Relevance Postoperative proliferation of LECs in the capsular bag remains the most frequent complication of cataract surgery. Unprotected intraocular infusion of cytotoxic drugs, antimetabolites, or hypo-osmotic agents during cataract surgery has the potential risk of causing toxic effects in corneal endothelium and adjacent intraocular tissues. Selective delivery of pharmacologic/hypo-osmotic agents into the capsular bag requires positive pressure inflation of the bag and is now possible using an SCI device. This device allows the surgeon to reseal the capsular bag intraoperatively, achieve positive pressure inflation of the capsular bag, and direct selective targeting of LECs.

A tribute to Charles David Kelman MD: ophthalmologist, inventor and pioneer of phacoemulsification surgery.

Charles David Kelman was born in Brooklyn, New York, USA, on 23 May 1930 and passed away in Boca Raton, Florida, USA, on 1 June 2004 at the age of 74 years after a long battle with cancer. He received a Bachelor of Science degree from Tufts University in 1950 and completed medical studies at the University of Geneva, Switzerland, in 1956. He was Clinical Professor of Ophthalmology at New York Medical College and an Attending Surgeon at New York Eye and Ear Infirmary and Manhattan Eye, Ear and Throat Hospital. Although a prolific inventor, he will be best remembered for developing phacoemulsification, following his realization while sitting in a dentist's chair, that ultrasonic vibrations could be used to emulsify the aged crystalline lens through a very small incision. His pioneering work revolutionized cataract surgery. He also pioneered cryo-extraction of cataracts, the use of freezing for the repair of retinal detachments and designed numerous ophthalmic instruments and intraocular lenses. Dr Kelman received numerous awards, including the American Academy of Ophthalmology Achievement Award (1970), the Ridley Medal from the International Congress of Ophthalmology (1990), and the Inventor of the Year Award from The New York Patent, Trademark and Copyright Law Association (1992). Most recently (2003), Dr Kelman was honoured by the American Academy of Ophthalmology with the Laureate Recognition award. Dr Kelman was also an accomplished Broadway producer, composer and jazz saxophonist. With his demise, the ophthalmic and medical community lost a famed inventor with multifaceted talents and one of the great ophthalmologists of the twentieth century.

Posterior capsule opacification: a review of the aetiopathogenesis, experimental and clinical studies and factors for prevention.

Posterior capsule opacification (PCO, secondary cataract, after cataract) is a nagging postsurgical complication following extracapsular cataract surgery (ECCE) and intraocular lens (IOL) implantation. PCO should be eliminated since it has deleterious sequelae and Neodynium: Yttrium Aluminium Garnet (Nd: YAG) laser treatment often is an unnecessary financial burden on the health care system. PCO following cataract surgery could be a major problem, since patient follow-up is difficult and the Nd:YAG laser is not always available. Advances in surgical techniques, IOL designs/biomaterials have been instrumental in bringing about a gradual and unnoticed decrease in the incidence of PCO. We strongly believe that the overall incidence of PCO and hence the incidence of Nd:YAG laser posterior capsulotomy is now rapidly decreasing - from 50% in the 1980s and early 1990s to less than 10% currently. Superior tools, surgical procedures, skills and appropriate IOL designs have all helped to significantly reduce this complication. In this article, we review the aetio pathogenesis, experimental and clinical studies and propose surgical and implant-related factors for PCO prevention. Careful application and utilisation of these factors by surgeons could lead to a significant reduction is secondary cataract, the second most common cause of visual loss worldwide.

Bilateral leukemic orbital infiltration presenting as proptosis and narrow-angle glaucoma.

A 71-year-old man with acute myeloid leukemia presented with bilateral uveal and orbital leukemic infiltration presenting as tense bilateral proptosis, orbital inflammation, and acute-angle closure glaucoma. B-scan ultrasonography revealed uveoscleral thickening and anterior rotation of the ciliary body. Orbital CT and MRI showed bilateral proptosis with streaking of intraconal fat. Temporary pressure lowering occurred after lateral canthotomy and inferior cantholysis. Definitive treatment included systemic chemotherapy and steroids. Over a 2-week period, vision improved and proptosis resolved, and the intraocular pressure returned to normal. The patient died of cerebral complications of his illness after 6 weeks. This is the first reported case of orbital and ocular leukemic infiltration presenting simultaneously as tense proptosis and narrow-angle glaucoma.

Phantom vision: a graphic description.

An 80-year-old man, who is an experienced artist, underwent orbital exenteration for invasive squamous cell carcinoma. After exenteration, the patient noted a persistent, colored visual phenomenon. The phantom vision continued unchanged to 9 months after surgery (the time of writing), when the patient presented a graphic and written description of phantom vision.

Postoperative Morganella morganii endophthalmitis associated with subclinical urinary tract infection.

We report a case of Morganella morganii acute endophthalmitis following clear corneal phacoemulsification cataract surgery in which a coincident asymptomatic chronic urinary tract infection was detected postoperatively. Morganella morganii is a gram-negative bacillus that inhabits the gastrointestinal tract and is part of the normal fecal flora. It is an opportunistic pathogen usually encountered in postoperative and nosocomial settings, causing urinary tract and wound infections. Chronic urinary tract infection may be a risk factor for postoperative endophthalmitis. A dipstick urinalysis before elective cataract surgery in elderly patients with a history of recurrent urinary tract infections may be considered.

Pneumatization of the intraorbital optic nerve after severe head trauma.

Radiological evidence of pneumatization of the intraorbital optic nerve sheath following severe head trauma in an adult is reported. A young man was admitted to the emergency department following a high-speed motorcycle accident with unconsciousness, forehead laceration, and multiple fractures of the skull and extremities. On admission, the pupils were dilated and fixed. Computed tomography revealed right subdural hematoma with midline shift, brain stem hemorrhage, contusion of the left temporal lobe, multiple facial bone fractures, cerebral edema with intracerebral air, and meningeal pneumatization of the optic nerve sheaths bilaterally. This case demonstrates that after severe head trauma, air may extend in the optic nerve sheath, which could be a marker of severe optic nerve injury.