Severe Cocaine-Induced Midline Destructive Lesions (CIMDL) Leading to Orbital Apex Syndrome and Peripheral Ulcerative Keratitis.

PURPOSE: To describe a case of cocaine-induced midline destructive lesions (CIMDL) associated with ocular autoimmune disease.Methods: Observational case report. RESULTS: A 45-year-old man with history of chronic osteolytic sinusitis due to cocaine abuse presented with sudden vision loss in right eye. Ophthalmic examination revealed fixed right mydriasis with extraocular movements limitation and optic disc swelling. Computed tomography showed an orbital infiltrating mass. The diagnosis of orbital-apex syndrome secondary to CIMDL was established. Steroids and antibiotics therapy were started without vision improvement. At 6-months follow-up, a corneal ulcer with characteristics of peripheral ulcerative keratitis (PUK) was evidenced, coinciding with an upper respiratory bacterial infection. CONCLUSIONS: CIMDL and PUK share common pathogenic pathways, with implication of autoimmune factors and exposure to infective antigens. We hypothesized that chronic cocaine use, along with persistent bacterial infection, could have triggered an inflammatory reaction, which contributed to CIMDL development and the appearance of PUK.

Fungal Necrotizing Scleritis After Intravitreal Injection Therapy.

PURPOSE: To report a case of infectious necrotizing scleritis secondary to Aspergillus terreus after intravitreal injection therapy. METHODS: This is a case report with literature review. RESULTS: A 98-year-old woman receiving intravitreal aflibercept injections for neovascular age-related macular degeneration in the left eye presented with severe pain, redness, and purulent discharge at the injection site. She was initially treated with topical fortified antibiotics, and clinical improvement was achieved, although microbial cultures showed negative results. Two months later, she presented with severe ocular pain and was diagnosed with anterior necrotizing scleritis. Scleral scrapings were collected for cultures, and intensive topical antibiotic therapy was reintroduced. Evaluation for autoimmune etiology and microbiological testing showed negative results. Because of the progression of the scleral necrotic area, empirical therapy with topical voriconazole was initiated, and surgical debridement was performed. Finally, the culture was positive for A. terreus. The modified therapy consisted of topical voriconazole and oral voriconazole for 3 months with an excellent clinical outcome. CONCLUSIONS: To our knowledge, this is the first case of fungal necrotizing scleritis secondary to intravitreal injection. Diagnosis was delayed due to its chronic clinical course and the slow fungal growth in culture media, but the combined medical and surgical approach resulted in a satisfactory outcome.

Choroidal lymphoma diagnosed by polymerase chain reaction-based clonality assessment.

PURPOSE: To report a case of primary choroidal lymphoma that was confirmed by polymerase chain reaction-based clonality testing. CASE REPORT: A 50-year-old woman presented with unilateral progressive vision loss. Fundus examination and B-ultrasonography demonstrated diffuse choroidal thickening without vitritis. Pars plana vitrectomy and subretinal biopsy were performed, and histopathologic analysis revealed choroidal B-cell lymphoid hyperplasia without evidence of neoplasia. Extraocular extension was ruled out, and transitory improvement was observed with oral steroids. After 1-year follow-up, she was referred to our hospital and clonality testing was performed using the samples taken months before. First, we used a forensic DNA extraction kit, and then, a multiplex polymerase chain reaction was carried out using the IgH Rearrangements Molecular Analysis Kit. Clonal rearrangement was identified for the immunoglobulin heavy chain framework regions 1 and 2, and B-cell choroidal lymphoma was confirmed. The patient began treatment with intravitreal rituximab, but no response was observed. Finally, complete regression was achieved using external beam radiotherapy. CONCLUSION: Polymerase chain reaction-based clonality testing can be a valuable tool to confirm a choroidal lymphoproliferative process.

The Role of Plasma Calprotectin in Non-infectious Uveitis.

PURPOSE: To investigate the role of plasma calprotectin in non-infectious uveitis. METHODS: This is an observational both cross-sectional and prospective study. Patients with active non-infectious uveitis were recruited as well as nonuveitic controls. Plasma calprotectin was determined and an ophthalmological examination was performed for both patients and controls. Independent variables possibly influencing levels of plasma calprotectin were recorded and analyzed. Categorical variables were compared by chi-square test (applying correction by continuity if necessary). T-test (or Kruskal-Wallis when appropriate) was used to compare averages. Multiple linear regression analysis was used to assess relationship between plasma calprotectin levels and independent variables. Spearman coefficient was calculated in order to establish correlation between plasma calprotectin and anterior chamber cell grading. Changes in plasma calprotectin levels between the flare beginning and its resolution were determined with mixed model for repeated measures. R software (version 3.6.0) was used to perform the statistical analysis. RESULTS: We included 74 patients and 40 controls in the cross-sectional study. Plasma calprotectin levels were higher in uveitis patients compared to those of controls (p = .003), being higher in younger patients and patients with posterior uveitis. No correlation between calprotectin and anterior chamber inflammation degree was found (p = .198). For the prospective study, we included 36 patients. We found no significant differences in calprotectin levels between active and inactive uveitis (p = .344). CONCLUSIONS: Plasma calprotectin levels are elevated in uveitis patients and are influenced by age and anatomical location of uveitis. Further investigation is needed to assess the relationship between calprotectin and uveitis activity.

Ophthalmic and Neuro-ophthalmic Manifestations of Coronavirus Disease 2019 (COVID-19).

PURPOSE: To describe a case of inflammatory chorioretinopathy and Adie's syndrome possibly associated with COVID-19. METHODS: Observational case report. RESULTS: A 51-year-old woman developed fever, cough, and headache followed by retro-ocular pain and reading impairment. She tested positive for SARS-COV-2 infection by qualitative real-time reverse-transcriptase-polymerase-chain-reaction. The slit-lamp and funduscopic exam revealed abnormal pupillary response and yellowish creamy deep chorioretinal lesions, which were not present in previous examinations. Instillation of pilocarpine demonstrated denervation supersensitivity, and it was suggestive of bilateral Adie tonic pupil. A comprehensive work-up ruled out other systemic, autoimmune, or infectious diseases. CONCLUSIONS: This case illustrates the possible association between multifocal chorioretinitis and Adie's syndrome, and the SARS-COV-2 infection in humans. Further investigation of virus infectivity specifically within ocular tissues has to be conducted.