Arrest Outcome Consortium Registry Analysis [AOCRA 2022]: Outcome Statistics of Cardiac Arrest in Tertiary Care Hospitals in India, Analysis of Five Year Data of Indian Online Cardiac Arrest Registry, www.aocregistry.com.

Aim and background: To publish data with outcome statistics from our online cardiac arrest (CA) outcome consortium (AOC) online registry. Materials and methods: Data on cardiac arrest (CA) from tertiary care hospitals were collected on the AOC registry online portal from January 2017 to May 2022. Survival endpoints from cardiac arrest events like ROSC, and survival at hospital discharge with neurological status at discharge were analyzed and presented. Studies of demographics, the association of outcome with age, gender, bystander CPR, low and no flow times, and admission lactate were also done along with suitable statistical analysis. Results: Out of 2,235 CA, 2,121 received CPR (1,998 IHCA, 123 Out of hospital Cardiac Arrest (OHCA)) as 114 were DNR. The males-female ratio was 70:30. Average age at arrest was 58.7 years. 26% OHCA received bystander CPR but survival advantage was not significant. (with 16%, without 14% p = 0.78). Asystole (67.7%), Pulseless Electrical Activity (PEA) (25.6%), and VF/pVT (6.7%) as first rhythm significantly influence survival (4.9, 8.6 and 39.4%: p < 0.001) ROSC was achieved in 355 (16.7%), with 173 (8.2%) alive and 141 (6.6%) having good (CPC ≤ 2) neurological state at discharge. At discharge, survival as well as CPC ≤ 2 outcomes were significantly better in females. On multivariate regression analysis, first rhythm and low flow time influence survival at discharge. Admission lactate (available only in 102 OHCA) was lower in survivors than non-survivors 10.3 vs 11.5 mmol/L but the difference was not statistically significant (p = 0.397]. Conclusion: Data from our AOC registry shows poor overall survival from CA. The Female gender had a higher survival rate. Ventricular Fibrillation/Pulseless Ventricular Tachycardia (VF/pVT) as first rhythm and low flow time influence the survival to discharge (CTRI/2022/11/047140). How to cite this article: Clerk AM, Patel K, Shah BA, Prajapati D, Shah RJ, Rachhadia J, et al. Arrest Outcome Consortium Registry Analysis [AOCRA 2022]: Outcome Statistics of Cardiac Arrest in Tertiary Care Hospitals in India, Analysis of Five Year Data of Indian Online Cardiac Arrest Registry, www.aocregistry.com. Indian J Crit Care Med 2023;27(5):322-329.

Clinical profile and surgical outcome of pars plana vitrectomy in non-diabetic vitreous hemorrhage.

Background: Spontaneous vitreous hemorrhage is one of the common causes of ocular emergency. There are very few prospective studies on the clinical profile and surgical outcomes for patients with dense vitreous hemorrhage caused by non-diabetic and non-traumatic till date to our knowledge. Objectives: This study was conducted to better understand the etiologies, clinical profile, surgical outcome, and visual prognosis following pars plana vitrectomy for dense vitreous hemorrhage in adults with non-traumatic and non-diabetic retinopathy. Design: This was a prospective interventional study. Methods: This study was conducted in Mechi Eye Hospital (Birtamod, Nepal) from October 2018 to September 2019. All consecutive cases, 46 eyes of 46 patients, with vitreous hemorrhage that underwent vitrectomy were included in our study. There were 14 (30.4%) female and 32 (69.6%) male patients, and the average age at presentation was 43.74 ± 16.19 (17-84) years. The success rate of surgery in terms of visual outcome was evaluated. Results: The most common cause of vitreous hemorrhage was retinal vasculitis with fibrovascular changes and vascular sheathing 19 (41%). The indication of vitrectomy on patient demand was 20 (43.5%). Success rate of surgery in terms of visual outcome (functional outcome) was defined as final visual acuity of >6/60 which was 86.9%. Conclusion: The most common cause of spontaneous vitreous hemorrhage in our study was retinal vasculitis with fibrovascular changes and vascular sheathing. Vitrectomy has a good surgical outcome for spontaneous vitreous hemorrhage in terms of visual outcome (functional outcome) unless guarded by other factors like chorioretinal atrophy followed by optic atrophy and epiretinal membrane.

Anesthetic management of right brachiocephalic artery aneurysm causing tracheal compression.

The airway compression poses a challenge for the anesthesiologist in airway management during aneurysm repair surgery.

Subretinal Cysticercosis in a Challenging Case: A Case Report.

Ocular cysticercosis occurs rarely and may involve various parts of the eye including subretinal space. We report a case of a 42 years-old female with diminution of vision in the right eye for one month and no vision in the left eye for 10 years. Best corrected visual acuity in the right eye was 5/60. Fundus examination showed whitish round elevated cystic mass temporal to the macula. It was confirmed as a subretinal cyst by Brightness scan and Magnetic Resonance Imaging. The subretinal cyst was removed in toto by pars plana vitrectomy followed by histopathological examination of the cyst which confirmed the diagnosis of cysticercosis. This case report highlights the importance of early diagnosis of subretinal cysticercosis which could threaten the vision in a one-eyed patient. Pars plana vitrectomy could be an effective method for subretinal cyst removal in toto even in a challenging case.

Clinical Phenotype of FASTKD2 Mutation.

Mitochondrial disorders (MIDs) are frequently multisystemic in nature and cause significant morbidity and mortality. Accurate assessment of mitochondrial disease prevalence has been difficult in the past. Primary MIDs are due to mutations in mitochondrial DNA (mtDNA) or nuclear DNA (nDNA)-located genes. Here we report cases of two siblings who presented to the pediatric emergency department with status epilepticus. Initially, the elder sibling was treated for metabolic encephalopathy and viral encephalitis, during his admission to the hospital. On treatment with multiple antiepileptic drugs, the status epilepticus subsided. A provisional diagnosis of mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes was made. Magnetic resonance imaging showed diffusion restriction in the left temporal lobe, insular cortex, and left lentiform nucleus, which completely resolved on follow-up after 1 month. His sudden demise in May 2019 due to status epilepticus, and a similar case presentation in his younger sibling, prompted us to do a genetic analysis test. The exome sequence revealed FASTKD2 mutation, a rare variant. This case report helps in increasing the awareness among the clinicians about the clinical presentation of FASTKD2 mutation case.

Effect of Goal-directed Hemodynamic Therapy in Postcardiac Surgery Patients.

BACKGROUND AND AIMS: Early goal-directed therapy (EGDT) provides preset goals to be achieved by intravenous fluid therapy and inotropic therapy with earliest detection of change in the hemodynamic profile. Improved outcome in cardiac surgery patients has been shown by perioperative volume optimization, while postoperative intensive care unit (ICU) stay can be decreased by improving oxygen delivery. Our aim of this study was to study the outcome of EGDT in patients undergoing elective cardiac surgery. MATERIALS AND METHODS: This is a prospective single institute study involving a total of 478 patients. Patients were divided into group I, who received standard hospital care, and group II, who received EGDT. Postoperatively, patients were observed in ICU for 72 hours. Hemodynamics, laboratory data, fluid bolus, inotrope score, complication, ventilatory time, and mortality data were collected. RESULTS: Postoperative ventilatory period (11.12 ± 10.11 vs 9.45 ± 8.87, p = 0.0719) and frequency of change in inotropes (1.900 ± 0.9 vs 1.19 ± 0.61, p = 0.0717) were lower in group II. Frequency of crystalloid boluses (1.33 ± 0.65 vs 1.75 ± 1.09, p = 0.0126), and quantity of packed cell volume (PCV) used (1.63 ± 1.03 vs 2.04 ± 1.42, p = 0.0364) were highly significant in group II. Use of colloids was higher in group II and was statistically significant (1.98 ± 1.99 vs 3.05 ± 2.17, p = 0.0012). The acute kidney injury (AKI) rate was (58 (23.10%) vs 30 (13.21%), p = 0.007) lower and statistically significant (p = 0.007) in group II. CONCLUSION: Early goal-directed therapy reduces the postoperative ventilatory period, frequency of changes in inotropes, and incidence of AKI, and decreases ventilation hours, number of times inotropes changed, and AKI. HOW TO CITE THIS ARTICLE: Patel H, Parikh N, Shah R, Patel R, Thosani R, Shah P, et al. Effect of Goal-directed Hemodynamic Therapy in Postcardiac Surgery Patients. Indian J Crit Care Med 2020;24(5):321-326.

Does It Matter: Total Hip Arthroplasty or Lumbar Spinal Fusion First? Preoperative Sagittal Spinopelvic Measurements Guide Patient-Specific Surgical Strategies in Patients Requiring Both.

BACKGROUND: In patients requiring both total hip arthroplasty (THA) and lumbar spinal fusion (LSF), consideration of preoperative sagittal spinopelvic measurements can aid in the prediction of postfusion compensatory changes in pelvic tilt (PT) and inform adjustments to traditional THA cup anteversion. This study aims to identify relationships between spinopelvic measurements and post-THA hip instability and to determine if procedure order reveals a difference in hip dislocation rate. METHODS: Patients at a single practice site who received both THA and LSF between 2005 and 2015 (292: 158 = LSF prior to THA, 134 = THA prior to LSF) were retrospectively reviewed for incidents of THA instability. Those with complete radiograph series (89) had their sagittal (standing) spinopelvic profiles measured preoperatively, immediately postoperatively, and 3 months, 6 months, 1 year, 1.5 years, and 2 years postoperatively. Measured parameters included lumbar lordosis (LL), pelvic incidence (PI), PT, and sacral slope (SS). RESULTS: No significant differences in dislocation rates between operative order groups were elicited (7/73 LSF first, 4/62 THA first; Z = 0.664, P = .509). Compared to nondislocators, dislocators had lower LL (-10.9) and SS (-7.8), and higher PT (+4.3) and PI-LL (+7.3). Additional risk factors for dislocation included sacral fusion (relative risk [RR] = 3.0) and revision fusion (RR = 2.7) . Predictive power of the model generated through multiple regression to characterize individual profiles of post-LSF PT compensation based on perioperative measurements was most significant at 1 year (R2 = 0.565, F = 0.000456, P = .028) and 2 years (R2 = 0.741, F = 0.031, P = .001) postoperatively. CONCLUSION: In performing THA after LSF, it is theoretically ideal to proceed with THA at a postfusion interval of at least 1 year, beyond which further compensatory PT change is minimal. However, the order of surgical procedure revealed no statistical difference in hip instability rates. In cases characterized by large PI-LL mismatch (larger or less predictable compensation profiles) or large SS or LL loss (considerably atypical muscle recruitment), consideration of full functional anteversion range between sitting and standing positions to account for abnormalities not appreciated with standing radiographic assessment alone may be warranted.

Survivorship of the Modular Femoral Revision Stem.

The geriatric population represents a rapidly growing segment of society with prolonged life expectancies and more active lifestyles. Many of these patients have already undergone primary total hip arthroplasty (THA) and are presenting with aseptic loosening, polyethylene wear, osteolysis, or periprosthetic fractures. Therefore, the demand for hip revision procedures is expected to grow. Currently, there are many modular implant options available for use in complicated revision THA. Early results of modular femoral revision systems are promising for the treatment of the deficient femur in complex revision THA. The objective of this study was to evaluate component survivorship of a modular femoral revision system in revision THA. A retrospective review was conducted using electronic health records of patients who underwent revision THA performed by 1 of 3 surgeon investigators from 2010 through 2014. The authors included all patients who underwent a revision THA using a specific modular femoral revision system. The authors evaluated component survivorship and time to re-revision THA. Fifty-one revision THAs were included. Seven patients required a second revision THA (13.7%; 95% confidence interval, 4%-23%). Mean time to re-revision THA was 4.88±3.9 months. Kaplan-Meier survivorship using re-revision for any reason was 86.3% at 60 months. This study showed excellent component survivorship of the specific modular femoral revision system in revision THA. [Orthopedics. 2019; 42(5):294-298.].

Anomalous origin of a pulmonary artery in a teenager with tetralogy of Fallot with associated double aortic arch and coronary arteriovenous fistula.

We report the case of a 14-year-old female who had tetralogy of Fallot along with anomalous origin of the left pulmonary artery from the ascending aorta with co-dominant double aortic arch forming a complete vascular ring compressing the oesophagus along with a left main coronary artery to right ventricular outflow tract fistula. She underwent surgical correction without conduit placement.

Aspirin Alone Is Not Enough to Prevent Deep Venous Thrombosis After Total Joint Arthroplasty.

Thromboembolic events after total joint arthroplasty are potentially devastating complications. This study evaluated the efficacy of 4 different anticoagulants in preventing deep venous thrombosis and pulmonary embolism after total joint arthroplasty. The demographics and anticoagulant use (warfarin, enoxaparin, and aspirin with and without outpatient mechanical pumps) for patients who underwent primary unilateral total joint arthroplasties performed by a single surgeon from January 2013 to October 2014 were retrospectively reviewed. All patients underwent lower extremity ultrasound at the 3-week postoperative visit. A total of 613 primary unilateral total joint arthroplasties met the study inclusion criteria. There were 288 primary total knee arthroplasties and 325 primary total hip arthroplasties. The patients were 62.2% female, having a mean age of 67.6±10.6 years and a mean body mass index of 30.2±5.9 kg/m2. There were 119 patients in group 1 (aspirin alone), 40 patients in group 2 (aspirin plus pumps), 246 patients in group 3 (warfarin), and 208 patients in group 4 (enoxaparin). The overall 3-week symptomatic and asymptomatic deep venous thrombosis and symptomatic pulmonary embolism rates in the entire cohort were 5.7% and 0.3%, respectively. The venous thromboembolism rate was significantly affected by the anticoagulant of choice (P<.01). Compared with aspirin alone, warfarin decreased the risk of venous thromboembolism (P<.01). Increasing age led to increased risk of venous thromboembolism (P=.05). This study indicated that aspirin chemoprophylaxis alone was not as efficacious as warfarin and enoxaparin in preventing asymptomatic and symptomatic venous thromboembolism found during routine postoperative surveillance with lower extremity ultrasound. Aspirin alone may be inadequate and should be augmented with an outpatient mechanical pump as part of multimodal prophylaxis. [Orthopedics. 2019; 42(1):48-55.].

Effect of Red Blood Cell Storage Duration on Outcome After Paediatric Cardiac Surgery: A Prospective Observational Study.

BACKGROUND: Retrospective reviews have found the use of stored packed red blood cells (PRBCs) in priming to be associated with increased risk of postoperative complications. The purpose of study was to prospectively investigate the influence of duration of storage of PRBCs used in priming the cardiopulmonary bypass (CPB) circuit on the metabolic profile of the patients, and postoperative outcome after paediatric cardiac surgery. METHODS: Between January 2015 and December 2015, 198 consecutive children operated for cardiac surgery using CPB and received blood for priming the circuit were included. Patients were divided into two groups based on the duration of storage of the blood, newer PRBCs group who received blood stored for ≤14days and the older PRBCs group who received blood stored for >14 days. RESULTS: Mean duration of blood storage used for priming in newer PRBCs blood group (n=103) was 8.4±3.7days while it was 21.9±4.5days in older PRBCs group (n=95). Metabolic parameters of the PRBCs improved to physiological limits in both the groups after initiation of CPB. Postoperative hepatic, pulmonary, haematological complications, sepsis and multi-organ failure were more in the old PRBCs group. However, the difference was not significant. Similarly, there was no significant difference in incidence of prolonged mechanical ventilation, intensive care unit stay and hospital stay and mortality between the two groups. CONCLUSIONS: Metabolic parameters of the stored blood become normal after initiation of CPB irrespective of duration of storage. In paediatric patients without significant co-morbidity, undergoing cardiac surgery, transfusion of washed stored blood up to 28days in CPB priming is safe especially if lesser amount of transfusion is required.

Is it safe? Outpatient total joint arthroplasty with discharge to home at a freestanding ambulatory surgical center.

BACKGROUND: Total joint arthroplasty (TJA) is trending toward shorter hospitalizations; as a result, there are many ambulatory surgical centers (ASCs) starting to perform outpatient TJA. However, there are limited studies examining the safety of outpatient TJA in the freestanding ASC setting. This study aims to evaluate 30-day and 90-day complication rates in patients who underwent outpatient TJA at a freestanding, independent ASC with direct discharge to home. METHODS: A retrospective cohort review using health records was performed on the first 115 TJAs performed between August 2015 and March 2017 by one of the 4 orthopedic surgeons. Before the first TJA, the ASC had developed a multidisciplinary TJA pathway. RESULTS: Of the 115 TJAs, 37 (32%) were total hip arthroplasties (THAs), 53 (46%) total knee arthroplasties (TKAs), and 25 (22%) unicompartmental knee arthroplasties, with a mean age of 57 ± 7 years and body mass index of 30 ± 5 kg/m2. There were no intraoperative or direct ASC-related complications. There was 1 instance (0.9%) of a postoperative minimally displaced intertrochanteric femur fracture after THA due to a fall treated nonoperatively complication within 30 days of surgery. Of the 90-day complication events, there were 2 patients (2%) with postoperative arthrofibrosis of the knee after TKA requiring manipulation under anesthesia, 1 postoperative patellar tendon rupture during therapy after TKA requiring surgical repair and 1 delayed hematogenous infection after international travel after THA requiring 2-staged exchange. CONCLUSIONS: Outpatient TJA with discharge to home at a freestanding, independent ASC is a safe option after development of a multidisciplinary TJA pathway.

Factors Affecting the Outcome of Scleral Buckling Surgery for Primary Rhegmatogenous Retinal Detachment.

INTRODUCTION: Scleral buckle surgery retains a special place in treatment of retinal detachment despite development of new and advanced vitreoretinal surgical techniques. The outcome of any retinal detachment surgery depends on correct selection of patient, type and nature of detachment, and the expertise. This study aims to evaluate various other parameters that determine the outcome of scleral buckle surgery. METHOD: Records of 55 patients with primary rhegmatogenous retinal detachment treated with scleral buckling over a duration of 18 months that had a minimum of 3-month follow-up were retrospectively reviewed. Preoperative and postoperative characteristics were recorded. Parameters that were evaluated to determine the outcome were best-corrected visual acuity (BCVA), anatomical success, and complications. RESULTS: A total of 51 eyes of 50 patients that met the inclusion criteria were included. Mean age was 41 ± 19.9 years (range: 9 to 83). Primary anatomical success was achieved in 80.4%. Parameters significantly associated with the anatomical outcome of surgery were status of lens, preoperative visual acuity, and extent of retinal detachment. There was a significant improvement of visual acuity postoperatively. CONCLUSION: Scleral buckle surgery is a highly effective surgery in uncomplicated retinal detachment cases, and single surgery success rates are better in cases with good preoperative visual acuity, partial detachment, and clear crystalline lens.

Imageless Navigation Improves Intraoperative Monitoring of Leg Length Changes during Total Hip Arthroplasty for Legg-Calve-Perthes Disease: Two Case Reports.

Legg-Calve-Perthes disease is a rare condition characterized by avascular necrosis and malformation of the femoral head. For many patients, total hip arthroplasty (THA) is the only viable treatment option; however, there are challenges associated with THA in this population, primarily the equalization of leg lengths. Here, we present two cases of Legg-Calve-Perthes disease treated via total hip arthroplasty with the assistance of an imageless, computer-assisted navigation device. In each case, the device provided intraoperative data on leg length in real time, allowing for improved accuracy of component placement. Postoperative leg lengths were confirmed to be equalized in each case using radiographs. These cases are, to our knowledge, the first such cases using imageless navigation during THA and demonstrate the benefits of such assistive technologies in challenging cases such as Legg-Calve-Perthes disease.

Computer-assisted navigation in Birmingham hip resurfacing: A case report.

Component malpositioning during Birmingham hip resurfacing increases the risk for component wear, metallosis, component loosening, and the likelihood of dislocation and revision surgery. Computer-assisted navigation can increase the accuracy to which components are placed, and the utilization of this technology in Birmingham hip resurfacing is increasing. The present report summarizes the accuracy of acetabular component positioning in a Birmingham hip resurfacing case utilizing navigation. Intraoperative C-arm fluoroscopy following the use of the navigation tool confirmed excellent seating, positioning, and stability of the acetabular component. In addition, post-operative antero-posterior radiographs confirmed device accuracy and revealed a stable joint with no evidence of acetabular loosening or femoral fracture. Computer-assisted navigation may therefore be an effective tool to improve the accuracy of component positioning during Birmingham hip resurfacing.

Outcomes of Silicone Oil Removal in Complex Retinal Detachment.

INTRODUCTION: Pars plana vitrectomy in combination with intraocular tamponade with silicone oil is a standard technique in the treatment of complex retinal detachment. Although the use of silicone oil has improved the results of retinal detachment surgery, its removal is recommended due to the ocular complications related to its long term use. However, retinal redetachment can occur after silicone oil removal. OBJECTIVE: To evaluate the anatomical and visual outcome after silicone oil removal (SOR) in eyes with complicated retinal detachment. MATERIAL AND METHODS: We retrospectively analyzed 64 eyes of 64 consecutive patients of silicone oil removal over a period of 12 months. All eyes had undergone standard 3 ports pars plana vitrectomy with silicone oil placement for complicated retinal detachment. Cases that completed at least 1 month follow up duration after SOR were included in the study. Anatomical success after SOR was achieved in 56 of 64 eyes (87.5%). Seven of 8 redetachments (87.5%) were seen in eyes with silicone oil tamponade duration of less than 6 months. Visual acuity improved or was stabilized in 49 of 64 eyes (76.6%). Using paired T-test, it was found that there was no significant difference in pre and post SOR visual acuity. Postoperative ocular hypertension, corneal decompensation, band shaped keratopathy and hypotony was observed in 9.4%, 4.7%, 6.4% and 21.9% respectively. CONCLUSION: Although there was no significant improvement in visual acuity, redetachment and complication rates were comparable to other studies. The duration of endotamponade was not significantly associated with the redetachment rate. Key words: Silicone oil removal, Redetachment, Visual outcome, Keratopathy, ocular hypertension.

Risk Factors for Delayed Extubation after Ventricular Septal Defect Closure: a Prospective Observational Study.

OBJECTIVE: The objective of our study was to determine the feasibility of early extubation and to identify the risk factors for delayed extubation in pediatric patients operated for ventricular septal defect closure. METHODS: A prospective, observational study was carried out at our Institute. This study involved consecutive 135 patients undergoing ventricular septal defect closure. Patients were extubated if feasible within six hours after surgery. Based on duration of extubation, patients were divided two groups: Group 1= extubation time ≤ 6 hours, Group 2= extubation time >6 hours. RESULTS: A total of 99 patients were in Group 1 and 36 patients in Group 2. Duration of ventilation was 4.4±0.9 hours in Group 1 and 25.9±24.9 hours in Group 2 (P<0.001). Univariate analysis showed that young age, low weight, low partial pressure of oxygen, trisomy 21, multiple ventricular septal defect, high vasoactive inotropic score, transient heart block and low cardiac output syndrome were associated with delayed extubation. However, regression analysis revealed that only trisomy 21 (OR: 0.248; 95%CI: 0.176-0.701; P=0.001), low cardiac output syndrome (OR: 0.291; 95%CI: 0.267-0.979; P=0.001), multiple ventricular septal defect (OR: 0.243; 95%CI: 0.147-0.606; P=0.002) and vasoactive inotropic score (OR: 0.174 95%CI: 0.002-0.062; P=0.039) are strongest predictors for delayed extubation. CONCLUSION: Trisomy 21, low cardiac output syndrome, multiple ventricular septal defect and high vasoactive inotropic score are significant risk factors for delay in extubation. Age, weight, pulmonary artery hypertension, size of ventricular septal defect, aortic cross-clamp and cardiopulmonary bypass time did not affect early extubation.

Ocular metastasis from breast carcinoma simulating anterior scleritis: a case report.

BACKGROUND: Breast cancer is one of the commonest sources of ocular metastasis. Patients with ocular metastatic disease can present with a variable clinical picture. Patients with a history of breast cancer presenting with any eye symptom should be evaluated with consideration of ocular metastasis. CASE PRESENTATION: We report a case of ocular metastasis in a 46-year-old Brahmin woman presenting with right eye pain. She had been treated for stage IIIc left-sided breast cancer 2 years ago with six cycles of chemotherapy with docetaxel, adriamycin, and cyclophosphamide after undergoing modified radical mastectomy. An ophthalmic examination revealed a tender subconjunctival swelling superotemporally on retracting right upper eyelid. This finding alone indicated anterior scleritis. On examining fundus under mydriasis, an amelanotic subretinal mass could be visualized in the posterior pole superotemporal to macula. An orbital magnetic resonance imaging revealed a mass of 2 × 1 cm in size in the subretinal space of her right eye. Computed tomography of her chest was then done and showed multiple metastases in both lungs. CONCLUSION: This case report highlights the fact that any unusual ocular presentation, even one simulating anterior scleritis, in a patient with a history of breast cancer should raise suspicion of metastasis.