Successful treatment of an extensively drug-resistant pseudomonal ulcer associated with contaminated artificial tears.

Purpose: To report a case of bacterial keratitis caused by an extensively drug-resistant (XDR) Pseudomonas aeruginosa strain linked to contaminated artificial tears in the United States. The ulcer was successfully treated without perforation or extracorneal spread. Observations: An 81-year-old patient presented with a corneal ulcer of the right eye. The patient had a notable complex ocular history including glaucoma and corneal edema from corneal decompensation after prolonged retained lens fragment. Despite starting hourly fortified tobramycin and vancomycin eye drops, the infiltrate grew significantly by the next day. Bacterial culture grew Pseudomonas aeruginosa that was resistant to all tested antibiotics except for intermediate susceptibility to colistin and susceptibility to cefiderocol. Tobramycin-soaked collagen shields were applied daily for three days, and the patient was started on fortified colistin eye drops. The ulcer improved and, after seven weeks of therapy, the infiltrate resolved and resulted in a large central corneal scar. Conclusions and Importance: A combination of fortified colistin and tobramycin (administered via a combination of fortified eye drops and tobramycin-soaked collagen shields) appears to be an effective treatment option for extensively drug-resistant Pseudomonas aeruginosa corneal ulcers.

Inflamed nonlimbal scleral dermoid masquerading as nodular scleritis.

A 5-year-old boy presented with unilateral, focal superonasal conjunctival injection in the absence of vision changes or trauma. He was treated with a topical steroid for possible phlyctenule or episcleritis, but the lesion progressed to an elevated nodule, raising concern for nodular scleritis with no evidence of posterior involvement. Systemic work-up for underlying inflammatory conditions was unremarkable. There was some improvement in the level of injection with topical steroid, topical fluoroquinolone, and oral nonsteroidal anti-inflammatory drugs, but the nodular lesion persisted. Excisional biopsy revealed an inflamed dermoid cyst in the sub-Tenon's space.

[A woman with palpitations, dyspnoea and a heart murmur]. / Een vrouw met palpitaties, dyspneu en een hartgeruis.

A 35-year-old female came to the ER with palpations, dyspnoea and some thoracic chest pain. During physical examination we heard a diastolic murmur. Using transoesophageal echocardiography and MRI we made the diagnosis of congenital quadricuspid aortic valve (type A) with moderate aortic regurgitation.

Limitations in imaging common conjunctival and corneal pathologies with fourier-domain optical coherence tomography.

PURPOSE: To describe the limitations of Fourier-domain optical coherence tomography (OCT) in imaging common conjunctival and corneal pathology. MATERIALS AND METHODS: Retrospective, single-center case series of 40 patients with conjunctival and cornea pathology. RESULTS: Fourier-domain OCT imaged laser in situ keratomileusis (LASIK) flaps in detail, including its relation to other corneal structures and abnormalities. Similarly, in infectious or degenerative corneal disorders, Fourier-domain OCT successfully showed the extent of infiltration or material deposition, which appeared as hyper-reflective areas. In cases with pterygium, the underlying cornea could not be imaged. All cases of common conjunctival pathologies, such as nevus or pinguecula, were successfully imaged in detail. Nevi, scleritis, pterygium, pinguecula, and subconjunctival hemorrhage were hyper-reflective lesions, while cysts and lymphangiectasia were hyporeflective. The details of the underlying sclera were not uniformly imaged in conjunctival pathologies. Fourier-domain OCT imaged the trabeculectomy bleb in detail, whereas the details of structures of the anterior chamber angle were not routinely visualized in all cases. CONCLUSIONS: Light scatter through vascularized, densely inflamed, or thick lesions limits the imaging capabilities of Fourier-domain anterior segment OCT.

Impact of simulator training on resident cataract surgery.

BACKGROUND: Virtual reality surgery simulation training improves resident performance as measured by the simulator itself and wet-lab performance. This study aims to determine whether virtual surgery simulator training improves actual resident cataract surgery performance. METHODS: The first 50 phacoemulsification cases of 20 residents, at a single residency program (Henry Ford Hospital), were retrospectively compared as two groups: before (2007-8) and after (2009-10) introduction of the Eyesi virtual surgery simulator to the surgical training program. Primary outcomes were the incidence of posterior capsule tears and operation duration. All residents received traditional didactic and wet-lab training. Instructor surgeons were surveyed for their impression of the simulator's contribution to resident surgical training. RESULTS: The nonsimulator and simulator groups each comprised 500 cases with 40 and 35 posterior capsule tears respectively. Capsular tear rates for the nonsimulator and simulator groups were 8.8 % and 10 % respectively for the first 25 cases, and 7.2 % and 3.6 % (P = 0.11) respectively for cases 26 through 50 . The percentage of long cases (defined as >40 min) for cases 10 through 50 was 42.3 % and 32.4 % (P = 0.005) for the nonsimulator and simulator groups respectively. CONCLUSIONS: Virtual reality surgical simulator training mildly shortens the learning curve for the first 50 phacoemulsification cases. The less adept residents appear to benefit most.

Interstitial keratitis secondary to severe hidradenitis suppurativa: a case report and literature review.

PURPOSE: To report a patient who presented with bilateral interstitial keratitis in association with severe hidradenitis suppurativa. METHODS: Case report. RESULTS: An 18-year-old African American woman with severe active hidradenitis suppurativa of the axillae and groin presented with a 2-week history of bilateral blurry vision. On examination, best-corrected visual acuity was counting fingers in the right eye and 20/70 in the left eye. Slit-lamp examination revealed diffuse vascularization of the corneal stroma with surrounding infiltrates bilaterally. In the left eye, corneal thinning and an epithelial defect were present in an area of infiltrate. Our clinical impression at that time was bilateral interstitial keratitis with secondary bacterial keratitis in the left eye. Topical therapy, prednisolone acetate 1% in the right eye, and ofloxacin in the left eye, was instituted. A systemic workup, including antinuclear antibody, rheumatoid factor, Lyme titer, cytoplasmatic staining antineutrophil cytoplasmic antibodies, perinuclear staining antineutrophil cytoplasmic antibodies, erythrocyte sedimentation rate, Venereal Disease Research Laboratory, rapid plasma reagin, basic metabolic panel, angiotensin-converting enzyme level, and a chest x-ray was negative. Topical steroids were used in the left eye after resolution of the bacterial keratitis. The interstitial keratitis responded to topical steroids and remained in remission after steroid taper. However, bilateral interstitial keratitis recurred coincident with a severe flare of hidradenitis suppurativa within 1 month of discontinuing the topical steroids. A course of subcutaneous adalimumab injections (40 mg/mL every 2 weeks) for hidradenitis suppurativa was implemented. Both her dermatological and ocular conditions responded to this therapy and have remained in remission through 7 months of follow-up. CONCLUSIONS: Hidradenitis suppurativa is a rare cause of bilateral interstitial keratitis. Patients may experience simultaneous exacerbations of both dermatological and ocular manifestations. Systemic treatment with adalimumab can improve both dermatological and ocular conditions.