Sterile endophthalmitis after intravitreal injection of triamcinolone acetonide: case report and literature review.

Objectives: The first purpose is to present the diagnosis and therapeutic approach in a patient with sterile endophthalmitis associated with triamcinolone acetonide injection. The secondary objective is to assess the incidence of this complication and to summarize the risk factors described in the literature. Case presentation: A 76-year-old male patient presented for painless, unilateral, decreased visual acuity, four days after cataract surgery and simultaneously intravitreal triamcinolone acetonide injection for diabetic macular edema in the right eye. The diagnosis of sterile endophthalmitis was made. Eight days after the presentation, the symptoms subsided, the maximum corrected visual acuity reaching that before the procedures. Discussions: The incidence of sterile endophthalmitis varies in the literature between 0% and 23.8%. Visual prognosis is good, although the pathogenesis is not fully understood. Preservatives in injectable solutions have been suggested, however, there are studies in which inflammation was also present with preservative-free products. The particle size of triamcinolone was analyzed, demonstrating an association between smaller particles and an increased frequency of adverse reactions of this type. History of uveitis, posterior capsule rupture following cataract surgery, and Irvine-Gass syndrome are other associations described. Conclusion: The physiopathological mechanism of sterile endophthalmitis is not fully understood. However, the visual prognosis is good, the final vision being dependent on the underlying pathology.

Multiple ocular manifestations in a patient diagnosed with herpes zoster ophthalmicus: case report.

Objective: Our purpose was to present a case of a patient diagnosed with herpes zoster ophthalmicus with multiple ocular manifestations. Case presentation: A 70-year-old Caucasian male presented to the hospital for headache and skin hyperesthesia on the scalp and forehead on the left side. The diagnoses of herpes zoster ophthalmicus and acute conjunctivitis were made for the left eye. The patient was followed up for 6 months and during that period the following diagnoses were made for the same eye: peripheral sterile corneal infiltrates, episcleritis, and hypertensive anterior uveitis. Discussions: Herpes zoster ophthalmicus occurs when the reactivation of the dormant virus involves the ophthalmic division of the trigeminal nerve. The most frequent ocular presentations are conjunctivitis, keratitis, uveitis, episcleritis, and scleritis. The standard therapy consists of antivirals, such as acyclovir, valacyclovir, and famciclovir to limit the replication of the virus. The patient's risk factors, the course of treatment, and the severity of the disease, all affect the prognosis, which is highly variable. Prevention of the disease consists of vaccination with one of the following two vaccines, Zostavax and Shingrix. Conclusions: Final visual acuity for the left eye remained 1 despite numerous manifestations of the disease. Abbreviations: VZV = Varicella-zoster virus, BCVA = best-corrected visual acuity, OU = both eyes, OD = right eye, OS = left eye, IOP = intraocular pressure, NCT = non-contact tonometer, ZVX = Zostavax vaccine.

Diagnostic and therapeutic challenges in non-specific orbital inflammation - a case report.

Objective: The aim of this report is to present the diagnostic and therapeutic approach in a case of non-specific orbital inflammation complicated with sight-threatening exposure keratopathy. Case presentation: An 81-year-old female patient presented to our Ophthalmology Department for left, painful, unilateral exophthalmia and decreased vision in the same eye. The clinical examination revealed left proptosis, inferior dystopia, upper lid edema, erythema and moderate retraction, ocular motility restriction, chemosis and corneal epithelial defect. The keratopathy complicated in evolution with hypopyon. The patient received treatment for the exposure keratopathy and, after every specific cause of unilateral exophthalmia was ruled out using imagistic and laboratory examinations, systemic corticosteroid treatment was initiated. Although the response to treatment was prompt, it was incomplete because of the long-standing evolution. Discussions: In this case, the diagnosis was difficult because a malignant breast tumor was encountered and an orbital biopsy was impossible to be performed. The presence of exposure keratopathy complicated with hypopyon imposed the exclusion of an infectious process and delayed the initiation of the corticosteroid therapy. Conclusions: The diagnosis and treatment of this disease represent a challenge given the need to rule out all the local and systemic conditions that may present with exophthalmia.

A case report of a patient with severe thyroid eye disease.

Objective: Our aim was to present a rare case of a middle-aged male patient, diagnosed with Graves' orbitopathy, which had an atypical rapid unilateral onset. Initially, the left eye presented exophthalmos, eyelid retraction, corneal ulceration, and pannus formation with an important vascular component due to corneal exposure. The same symptoms developed in the right eye within a short period of time. Methods: A 52-year-old man presented in our department with bilateral proptosis, decrease in visual acuity, and orbital pain, which developed initially in the left eye seven months before the right eye. Slit lamp examination revealed conjunctival hyperemia, purulent discharge, chemosis and inflammation of the caruncle in both eyes. The fluorescein eye stain test was positive due to corneal ulceration with the presence of cells and flare in anterior chamber in the RE (right eye). The LE (left eye) presented a corneal pannus. We documented the changes using a slit lamp biomicroscope, a fundus camera, orbital ultrasonography, and contrast CT (computer tomography) scans. Discussions: The severe Graves' ophthalmopathy represents a challenge both in active or inactive phase. Medical and surgical therapies should be taken into consideration in order to prevent the complications following corneal perforation or optic neuropathy. Also, ophthalmic, and systemic adverse reactions of systemic steroids used in the treatment of Graves' disease are important in the prognosis of the visual outcome. Conclusions: The management of Graves' ophthalmopathy is multidisciplinary and needs a very good therapy adherence in order to achieve a satisfactory prognosis and quality of life.

Intraocular Pressure Measurement after Penetrating Keratoplasty.

Assessing the intraocular pressure is a difficult but crucial task in the follow-up of patients that have undergone penetrating keratoplasty. Early recognition of elevated intraocular pressure and/or glaucoma and establishment of the appropriate treatment is essential to ensure the best possible visual outcome for patients dealing with this feared complication. Although Goldmann applanation tonometry is still the gold standard for measuring the intraocular pressure, its limitations in postkeratoplasty eyes, due to postoperative modified corneal morphology, have led to the search for more suitable alternatives. This review is the result of a comprehensive literature search in the MEDLINE database that aims to present glaucoma in the context of perforating keratoplasty, the corneal properties with impact on ocular pressure measurement, and the results achieved with the most important tonometers that have been studied in this pathology. Goldmann applanation tonometry remains the reference for intraocular pressure assessment even in corneas after penetrating keratoplasty. However, some promising alternatives have emerged, the most important of which are the Pascal dynamic contour tonometry, the Tono-Pen XL, the ocular response analyzer, and the iCare. All have advantages and disadvantages but have proved to be appropriate alternatives, especially in cases in which Goldmann applanation tonometry cannot be used.

Unilateral Mooren's ulcer in a patient with bilateral partial optic nerve atrophy - a case report.

Objective: The aim of this report is to present the diagnostic and therapeutic approach in a case of long standing peripheral ulcerative keratitis of a patient with already decreased visual acuity due to preexistent optic nerve partial atrophy. Case presentation: A 58-year-old male patient presented to our clinic with unilateral pain, photophobia, tearing and decreased visual acuity in the right eye. The symptomatology began 4 months prior to the presentation, after trauma with a vegetative corneal foreign body, for which he received treatment in another Ophthalmology Service. After every specific cause of peripheral ulcerative keratitis was excluded, using extensive laboratory testing, the diagnosis of unilateral Mooren's ulcer in the right eye was established and the topical steroid treatment was initiated. A very good response to the treatment was observed, with complete resolution of the affliction. Discussions: Mooren's ulcer represents an idiopathic form of peripheral ulcerative keratitis. The diagnostic approach in this type of cases consists in the exclusion of infectious etiology (to safely use topical steroids) and of specific autoimmune etiologies. As the evolution of this pathology is severe with frequent complications, the treatment must be initiated as soon as possible. Conclusions: Despite being a rare diagnosis, Mooren's ulcer must be considered in cases in which clinical and paraclinical presentation is highly suggestive. A rapid therapeutic approach can offer good results despite the usual severe evolution of this disease.

A systematic review of euthyroid Graves' disease (Review).

Euthyroid Graves' Disease (EGD) is a challenging pathology, due to its atypical clinical manifestations and the absence of abnormal thyroid function. Typically, thyroid ophthalmopathy is associated with elevated thyroid hormone levels and with the presence of thyrotropin receptor antibodies (TRAb) but a low percentage of patients remain euthyroid without developing hyperthyroidism during long-term follow-up periods. Although it is considered a different pathology, it shares a lot of similarities with Graves' disease, rendering the diagnosis more difficult. It is also important to note that ophthalmopathy may be the first clinical manifestation of Graves' disease and that thyroid function examinations do not present abnormalities over a long period. Treatment choices for euthyroid disease do not differ from those described in Graves' ophthalmopathy. However, it is considered that since euthyroid patients develop milder ophthalmic symptoms and their clinical activity score is lower, they tend to have better responses to treatment. Moreover, atypical sight-threatening cases such as exposure keratopathy and dysthyroid optic neuropathy with variable responses to therapy also exist. Disease management consists of a favorable collaboration between ophthalmologists and endocrinologists because patients with EGD can develop thyroid abnormalities over time. In conclusion, the diagnosis of EGD is difficult, clinical manifestations and evolution are variables depending on several factors, including the heterogeneity of TRAb. This review aimed to identify the characteristics of this disease by reviewing the clinical studies and case reports published in previous years.

Phacolytic glaucoma - case report.

We presented a case of a 76-year-old male patient with phacolytic glaucoma and a rather atypical clinical presentation. The sudden onset of intense pain forced the patient to seek medical help and by doing so, further damage of the optic nerve was prevented and a good visual acuity was obtained following cataract surgery.

Papillitis in Neurosyphilis.

We present a case of a 47-year-old female patient, with papillitis in the right eye and anterior uveitis in both eyes, as a manifestation of untreated neurosyphilis.

The effect of intravitreal bevacizumab in a rare case of retinal dystrophy with secondary cystoid macular edema.

The authors presented a clinical case of retinitis punctate albescens in a 26-year-old female patient, with a family history of typical retinitis pigmentosa (father) and bilateral cystoid macular edema treated with anti-VEGF (bevacizumab).

Penetrating keratoplasty: from aid dependence to independence.

The authors present five cases of bilateral corneal disorders, on which they performed penetrating keratoplasty. All five patients were clinically blind and after the surgery on one eye, they gained their visual independence. Visual acuity, intraocular pressure, fundus examination, and ultrasonography were used to evaluate the patients before and after the surgery.