Needle decompression of the eye! Emergent management of a vision threatening surgical complication.

Acute angle-closure glaucoma (AACG) is a medical emergency that can cause permanent visual deficits without prompt recognition. From 2006 to 2011, nearly 12 million visits to emergency departments (ED) in the United States were ophthalmologic in nature, making it crucial for emergency physicians to be familiar with the diagnosis and treatment of ophthalmologic emergencies. AACG can be precipitated by several mechanisms including pupillary block, anticholinergic medications, and sympathomimetic medications. We present a rare case of angle-closure glaucoma status post pneumatic retinopexy with cryotherapy due to migration of an intravitreal gas bubble into the anterior chamber with emphasis on understanding how retinal surgery types lead to significant differences in management.

More Than Just Torsion: An Unusual Case of Testicular Pain.

Testicular pain has a wide differential and the nonspecific presentation should be triaged rapidly for urgent diagnosis and treatment. Scrotal pyoceles are uncommon collections of purulent fluid between the visceral and parietal tunica vaginalis, usually secondary to acute epididymo-orchitis, intra-abdominal infection, or trauma. Epididymitis and epididymo-orchitis are generally secondary to sexually transmitted infections or urinary tract pathogens. Epidymo-orchitis can compromise the testicular blood supply, leading to a microinfarction and rupture through the tunica albuginea; inflammatory and infectious material then translocate into the tunica vaginalis leading to the formation of a pyocele. Ultrasonography is the preferred method of diagnostic imaging, which can show a classic "falling snow" sign, loculations, or gas. The treatment for a scrotal pyocele is pain control, fluid resuscitation, broad-spectrum antibiotics, and early urology/general surgery consultation. In such cases, Fournier gangrene (FG) should be clinically ruled out and the presence of signs of Fournier gangrene should be met with an urgent surgical consult.

Nicotine oxidation by genetic variants of CYP2B6 and in human brain microsomes.

Common variation in the CYP2B6 gene, encoding the cytochrome P450 2B6 enzyme, is associated with substrate-specific altered clearance of multiple drugs. CYP2B6 is a minor contributor to hepatic nicotine metabolism, but the enzyme has been proposed as relevant to nicotine-related behaviors because of reported CYP2B6 mRNA expression in human brain tissue. Therefore, we hypothesized that CYP2B6 variants would be associated with altered nicotine oxidation, and that nicotine metabolism by CYP2B6 would be detected in human brain microsomes. We generated recombinant enzymes in insect cells corresponding to nine common CYP2B6 haplotypes and demonstrate genetically determined differences in nicotine oxidation to nicotine iminium ion and nornicotine for both (S) and (R)-nicotine. Notably, the CYP2B6.6 and CYP2B6.9 variants demonstrated lower intrinsic clearance relative to the reference enzyme, CYP2B6.1. In the presence of human brain microsomes, along with nicotine-N-oxidation, we also detect nicotine oxidation to nicotine iminium ion. However, unlike N-oxidation, this activity is NADPH independent, does not follow Michaelis-Menten kinetics, and is not inhibited by NADP or carbon monoxide. Furthermore, metabolism of common CYP2B6 probe substrates, methadone and ketamine, is not detected in the presence of brain microsomes. We conclude that CYP2B6 metabolizes nicotine stereoselectively and common CYP2B6 variants differ in nicotine metabolism activity, but did not find evidence of CYP2B6 activity in human brain.

Investigating the effect of proteoglycan 4 on hyaluronan solution properties using confocal fluorescence recovery after photobleaching.

BACKGROUND: The objective of this study was to use confocal fluorescence recovery after photobleaching (FRAP) to examine the specific and dose-dependent effect of proteoglycan 4 (PRG4) on hyaluronan (HA) solutions of different molecular weight; and assess the effect of reduction and alkylation (R/A) of PRG4 on its effects on HA solutions. METHODS: Confocal FRAP was used to determine the diffusion coefficient of fluorescein isothiocyanate (FITC)-dextran tracer (Dt) through 1500 kDa and 500 kDa HA solutions (0-3.3 mg/ml) ± PRG4 or a control protein, bovine serum albumin (BSA), at physiological (450 µg/ml) or pathophysiological (45 µg/ml) concentrations. The effect of PRG4 or R/A PRG4 on 1500 kDa HA solutions was also investigated. Empirical constants obtained from fitting data to the universal scaling equation were used to calculate the average distribution of apparent mesh sizes. RESULTS: PRG4 at both 45 and 450 µg/ml slowed the diffusion of the FITC-dextran tracer for all concentrations of HA and caused a decrease in the apparent mesh size within the HA solution. This effect was specific to PRG4, not observed with BSA, but not dependent on its tertiary/quaternary structure as the effect remained after R/A of PRG4. CONCLUSIONS: These results demonstrate that PRG4 can significantly alter the solution properties of HA; PRG4 essentially reduced the permeability of the HA network. This effect may be due to PRG4 entangling HA molecules through binding and/or HA crowding PRG4 molecules into a self-assembled network. Collectively these findings contribute to the understanding of PRG4 and HA interaction(s) in solution and therefore the function of SF in diarthroidal joints.

Successful treatment of community-acquired methicillin-resistant Staphylococcus aureus purulent myopericarditis.

A previously healthy 48-year-old active duty man, who had been treated for an elbow abscess 3 weeks earlier, presented to an emergency department in Bahrain with tachycardia, pericardial friction rub and jugular venous distention. Cardiac tamponade was confirmed on transthoracic echocardiogram and he was taken for emergent pericardiocentesis. Pericardial fluid cultures grew community-acquired methicillin-resistant Staphylococcus aureus Despite ongoing treatment with intravenous vancomycin, he developed a recurrent fibrinous pericardial effusion and constrictive pericarditis requiring pericardiectomy. Though he initially did well postoperatively, he developed drug reaction with eosinophilia and systemic symptoms syndrome in response to vancomycin. He was transitioned to ceftaroline and started on high-dose steroids. He recovered during a week-long admission and was discharged home. Several weeks later at follow-up he was doing well and had resumed moderate intensity exercise.

Ischemic Conditioning: Implications for Emergency Medicine.

Ischemic conditioning refers to the ability of brief episodes of controlled hypoperfusion around the time of an acute ischemic event to protect the target organ from reperfusion injury. A considerable body of literature suggests that interventions as simple and safe as repetitively inflating a blood pressure cuff could reduce the size and long-term morbidity of myocardial and cerebral infarction. This review introduces and summarizes the body of evidence contributing to these impressions.

Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema of the Small Bowel-A Surgical Abdomen Mimic.

BACKGROUND: Angioedema is an infrequent complication of the use of angiotensin-converting enzyme inhibitors (ACEi) that has an incidence of up to 0.5%. The oropharynx is most commonly affected. Angioedema of the small bowel is a much rarer occurrence; it uniformly presents with abdominal pain of variable duration. CASE REPORT: A 51-year-old man presented to the emergency department (ED) with generalized abdominal pain, emesis, diarrhea, and bloating. Medical history was significant for hypertension and medications included captopril, metoprolol and aspirin. Vital signs and laboratory tests were unremarkable. Due to the presence of significant abdominal tenderness with guarding on examination, a FAST (focused assessment with ultrasound in trauma) examination was performed and revealed free fluid in the abdomen. A computed tomography scan of the abdomen was quickly obtained, which revealed a large amount of simple-appearing free fluid within the abdomen and mucosal edema throughout the small bowel. The patient underwent an emergent diagnostic laparoscopy and was ultimately diagnosed with angioedema of the small bowel, deemed secondary to captopril usage. Captopril was discontinued and symptoms gradually resolved with supportive care. When imaging is obtained in cases such as this one, small bowel submucosal edema and ascites are often present. Supportive care and cessation of ACEi usage are the cornerstones of treatment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In patients on ACEi, it is important to keep this diagnosis in mind to potentially avoid an unneeded surgical intervention, as the condition is self-limiting and can be treated primarily with supportive measures.

Efficacy of commercially available topical cyclosporine A 0.05% in the treatment of meibomian gland dysfunction.

OBJECTIVE: To investigate the efficacy of topical cyclosporine A 0.05% (tCsA) (Restasis, Allergan Pharmaceuticals) in the treatment of meibomian gland dysfunction (posterior blepharitis). METHODS: Thirty-three patients with symptomatic meibomian gland dysfunction were randomized in a prospective study to either tCsA or placebo (Refresh Plus preservative-free artificial tears), 2 times daily for 3 months. They were evaluated at baseline and at 1, 2, and 3 months for subjective symptoms and objective signs including meibomian gland inclusions, lid margin vascular injection, tarsal telangiectasis, fluorescein staining, tear breakup time, and Schirmer scores. RESULTS: Twenty-six patients completed the study. All patients were tested for ocular symptoms, lid margin vascularity, tarsal telangiectasis, meibomian gland inclusions, tear breakup time, and fluorescein staining. At the 3-month visit, the tCsA group showed a greater improvement in ocular symptoms than the placebo group, but this difference was not statistically significant. At the 3-month visit, several objective examination findings were statistically significantly (P < 0.05) improved in the tCsA group compared with the placebo group. These differences included lid margin vascular injection, tarsal telangiectasis, and fluorescein staining. The most significant finding (P = 0.001) was the greater decrease in the number of meibomian gland inclusions in the tCsA group compared with the placebo group. CONCLUSIONS: Topical CsA may be helpful in the treatment of meibomian gland dysfunction (posterior blepharitis). Topical CsA did not induce an improvement in the symptoms, but it did decrease the number of meibomian gland inclusions in patients with meibomian gland dysfunction.

Childhood onset of pterygia in twins.

PURPOSE: To report a case of childhood onset of pterygia in twins. METHODS: Twelve-year-old male twins had nasal lesions on the left eye of twin A and on the right eye of twin B. Both lesions were excised with superior conjunctival autograft. RESULTS: Histopathologic examination showed the lesions to be pterygia. Other pedigrees of familial pterygia have been described. However, to the authors' knowledge, this young age at onset has not been documented with histopathology in twins. CONCLUSIONS: This case report documents the youngest age at onset of pterygia in twins, with histologic confirmation. It suggests a genetic or developmental cause for pterygium formation.

Penetration of topically applied gatifloxacin 0.3%, moxifloxacin 0.5%, and ciprofloxacin 0.3% into the aqueous humor.

PURPOSE: To investigate the aqueous penetration of 3 commercially available ophthalmic fluoroquinolones. DESIGN: Prospective, double-masked, clinical study. PARTICIPANTS: Fifty-two eyes of 52 patients. INTERVENTION: Fifty-two patients undergoing cataract surgery were given preoperative topical gatifloxacin 0.3% (Zymar), moxifloxacin 0.5% (Vigamox), or ciprofloxacin 0.3% (Ciloxan). The patients were instructed to use their antibiotic drops 4 times a day for 3 days before surgery. On the day of surgery, patients were given their assigned antibiotic every 15 minutes for 3 doses, 1 hour before their procedure. At the time of surgery, 0.1 ml of aqueous fluid was aspirated from the anterior chamber with an air cannula needle attached to a tuberculin syringe. The aspirate was immediately stored at -70 degrees C. MAIN OUTCOME MEASURE: Fluoroquinolone concentrations were determined by reverse-phase high-pressure liquid chromatography assay technique with ultraviolet detection at a wavelength of 275 nm. RESULTS: Mean aqueous concentration of gatifloxacin in 16 eyes was 0.63 microg/ml (standard deviation [SD], 0.30), moxifloxacin in 14 eyes was 1.31 microg/ml (SD, 0.46), and the mean concentration of ciprofloxacin in 22 eyes was 0.15 microg/ml (SD, 0.11). CONCLUSIONS: Both moxifloxacin (P<0.001) and gatifloxacin (P<0.005) penetrated the aqueous humor at significantly higher levels than ciprofloxacin. Moxifloxacin penetrated into the aqueous humor at significantly higher levels than gatifloxacin (P<0.05). The anterior chamber levels of moxifloxacin and gatifloxacin may be due to the difference in antibiotic concentration.

Prevention of recurrent Reis-Bücklers dystrophy following excimer laser phototherapeutic keratectomy with topical mitomycin C.

PURPOSE: To report a case of excimer laser phototherapeutic keratectomy (PTK) for Reis-Bücklers dystrophy with a single intraoperative application of adjunctive topical 0.02% mitomycin C (MMC). METHODS: Interventional case report and review of the literature. RESULTS: A 73-year-old woman with visually significant Reis-Bücklers dystrophy underwent PTK of her right eye with 0.02% adjunctive MMC for visual rehabilitation. Before treatment, best corrected visual acuity (BCVA) was 20/400. The left eye had previously undergone PTK on 2 occasions without MMC, and the dystrophy had recurred following each treatment. One year after the procedure, her MMC-treated cornea remains clear with no recurrence of Reis-Bücklers dystrophy. CONCLUSIONS: The use of topical MMC in conjunction with PTK may be a safe and effective treatment of Reis-Bücklers dystrophy and may be helpful in preventing recurrence of the disease.

Flap folds after femtosecond LASIK.

PURPOSE: To report a case of bilateral flap folds after a laser-assisted in situ keratomileusis (LASIK) procedure in which the flap was created by the femtosecond laser. METHODS: Retrospective chart review. RESULTS: A 43-year-old white woman underwent bilateral simultaneous LASIK. The corneal flap was created with the femtosecond laser. Postoperatively, the patient noted significantly decreased visual acuity, glare, and haloes. She was diagnosed with corneal flap striae, which were treated unsuccessfully with a lifting and stretching procedure, but responded to subsequent bilateral flap suturing. CONCLUSIONS: Despite the increased accuracy in flap creation with the femtosecond laser, large flap folds may develop.

Chryseobacterium meningosepticum keratitis.

PURPOSE: To describe a case of a corneal ulcer caused by Chryseobacterium meningosepticum in an eye without significant comorbidities. DESIGN: Interventional case report. METHODS: Retrospective case review. RESULTS: A 48-year-old man presented with a corneal ulcer in his right eye and was treated with ofloxacin and fortified bacitracin ophthalmic solution. Cultures grew C. meningosepticum, and the infection resolved. Two previous case reports in the literature have described ocular infections with this bacterium, both in postoperative patients with significant ocular comorbidities. CONCLUSIONS: This is the first report of ocular infection with C. meningosepticum in an eye with no significant comorbidities.