Rare cause of diffuse alveolar haemorrhage and subconjunctival haemorrhage rescued by extracorporeal membrane oxygenation and rituximab.

A previously healthy man in his 20s presented with acute respiratory distress syndrome and subconjunctival haemorrhage. Imaging was indicative of pervasive pulmonary haemorrhage. There was no evidence of renal involvement. The patient rapidly deteriorated with aggravating respiratory failure regardless of invasive mechanical ventilation and required extracorporeal membrane oxygenation (ECMO). This maintained the patient adequate time to allow aggressive therapy. Skin biopsy indicated leucocytoclastic vasculitis. Given that the patient was C-antinuclear cytoplasmic autoantibody (ANCA) positive, pulse dose steroids and rituximab were initiated for the suspicion of ANCA-associated vasculitis (AAV) which resulted in improvement of airspace disease and subconjunctival haemorrhage. Only a few cases reported successful use of ECMO in severe diffuse alveolar haemorrhage (DAH) due to AAV, but no case was in DAH combined with subconjunctival haemorrhage. The need for systemic anticoagulation with pre-existing haemorrhage is still a challenging dilemma.

[Retrospective investigation of spontaneous bloody tears: a report of 27 cases].

Objective: To summarize clinical experience on the clinical feature, etiology and treatment of patients with spontaneous bloody tears as the initial symptom. Methods: Retrospective series of case studies. The clinical data and follow-up data of 27 cases of bloody tears as the first symptom in Lacrimal Center of Ophthalmology, the Third Medical Center of Chinese PLA General Hospital from June 2015 to December 2018 were reviewed. The clinical feature, specific cause, diagnosis, treatment and prognosis of these cases were evaluated. Results: A total of 27 cases were collected in this study. The patients were 10 males (37.0%) and 17 females (63.0%), including 21 adults (≥ 18 years old, 77.8%) and 6 minors (<18 years old, 22.2%). There were 22 monocular cases (81.5%) and 5 binocular cases (18.5%). Five cases (18.5%) were bleeding from the eye and other parts of the body, and 22 cases (81.5%) were bleeding only from the eye. There were 19 cases (70.4%) with hematic epiphora and secretions from the punctum, 3 cases (11.1%) with blood-stained tears, and 7 cases (25.9%) with blood-like tears. With regard to etiology, 6 cases (22.2%) were combined with systemic lesions, one of which was granulomatosis with polyangiitis and five of which (<18 years old) were idiopathic bloody tears. Twenty-one cases (77.8%) were local lesions, including 18 cases only involving the lacrimal system, 2 cases only involving the ocular surface, and 1 case involving both the lacrimal system and the ocular surface. Among the 21 cases with local lesions, 5 cases were induced by foreign body, 6 cases were induced by simple inflammation, and 10 cases were induced by tumor including 1 case with conjunctival benign tumor and 9 cases with tumor of the lacrimal system (5 with malignant tumor and 4 with benign tumor). Patients with idiopathic bloody tears received psychological and medical treatment, and interictal discharge was lengthened. One case of granulomatosis with polyangiitis was treated by trans-nasal endoscopic dacryocystorhinostomy. With the recurrence of granulomatosis and polyangiitis, bloody tears recurred after surgery. One patient with conjunctival hemangioma was untreated. Lesions in the lacrimal duct system were removed and dacryocystorhinostomy was performed. In this study, 2 patients (1 with small cell neuroendocrine carcinoma and 1 with adenoid cystic adenocarcinoma) died and the other had a good prognosis. Conclusions: Among the cases of bloody tears, adults and local lesions are more common. Most of the lesions are located in the lacrimal system and are tumors. The main treatment is to remove the lesions, and if necessary, to expand the resection and reconstruct the lacrimal duct. Idiopathic bloody tears occur in minors, who are gave psychotherapy and necessary medical treatment. (Chin J Ophthalmol, 2020, 56: 53-58).

Clinical outcome observation of the embolization of orbital vascular malformation with medical glue under direct intra-operative view.

BACKGROUND: Orbital vascular malformation often encircles normal tissue with ill-defined borders. It is easy to bleed during resection operation, making surgical treatment difficult and lesions hard to be removed completely. In this study we aimed to summarize the treatment outcomes by embolizing orbital vascular malformation with intraoperative intracavitary injection of medical glue . METHODS: A retrospective observational and cross-sectional case series study enrolled 31 patients (male = 9, female = 22) with orbital vascular malformations, who were treated from March 2008 to September 2017 at our institution. The clinical features, operation records, pathological reports and follow-up data were analyzed. RESULTS: The location of vascular malformations involved intraorbital (14 cases), superficial area of eyelid and/or face (7 cases), both intraorbital and superficial area (10 cases). Imaging examination showed a solitary mass with regular shape in 8 cases and a space occupying lesion with irregular shape and ill-defined margins in 23 cases. There were 9 cases had optic nerve involved. Surgical debulkling were performed via skin incision on the mass surface (5 cases), lateral orbitotomy (2 cases), and anterior orbitotomy (24 cases). During the operation, lesions were partly exposed and injected with medical glue. The amount of injected glue was 0.25 ml to 2.5 ml in divided doses. The lesions and remnant glue were removed after the glue had turned hard. The whole procedure caused less bleeding and was easier performing than usual. Topical skin aseptic inflammation took place on the same side of the superficial eyelid lesions in 3 cases. One patient suffered from sudden central retinal artery embolism on the third day post operation. With timely rescue and appropriate procedure, visual acuity recovered to 20/32. There were no recurrences in 29 cases. CONCLUSIONS: Embolization of orbital vascular malformation with medical glue intraoperatively made it easy to control hemorrhage. Surgeons should be careful with glue application methods in order to avoid complications.

Secuelas oftalmológicas por traumatismo con paintball: estudio de casos / Opthalmological sequelae due to paintball injuries: Case studies

OBJETIVO: Describir las secuelas oftalmológicas de pacientes con diagnóstico de traumatismo ocular contuso por paintball. MATERIAL Y MÉTODOS: Se incluyeron 14 casos con diagnóstico de traumatismo ocular contuso por paintball, que fueron atendidos en el Servicio de Consulta Prioritaria de la Clínica Barraquer en Bogotá, Colombia. A todos los pacientes se les realizó un examen oftalmológico completo con sus respectivos controles según su evolución. RESULTADOS: La frecuencia de los traumatismos oculares por paintball fue del 3,01%. Se evaluaron 14 ojos, rango de edad de 9 a 49 años. Los casos fueron unilaterales, una mujer y 13 hombres, agudeza visual inicial menor a 20/30 en 12 ojos. Solo 5 ojos evolucionaron satisfactoriamente, a 3 se les intervino quirúrgicamente. Los casos que no experimentaron mejoría de su agudeza visual estuvieron relacionados con problemas de polo posterior, siendo las más frecuentes las alteraciones maculares, la rotura coroidea, el desprendimiento coroideo, el desgarro retiniano y los pliegues en retina. En 3 ojos se evidenció mejoría clínica de la agudeza visual secundaria a procesos hemorrágicos que se resolvieron con tratamiento médico. En uno de ellos se realizó tratamiento quirúrgico del cristalino con implante de lente intraocular. En 2 ojos la su recuperación visual fue muy satisfactoria y en otro el 100%. CONCLUSIÓN: El paintball ha tomado fuerza como deporte y recreación utilizando proyectiles de pintura que se disparan con armas de aire comprimido, conlleva riesgos de presentar diversos traumatismos que pueden generar episodios catastróficos en términos de salud visual y con repercusiones en la calidad de vida de los afectados

OBJECTIVE: Describe the ophthalmological sequelae of patients diagnosed with blunt eye injury by paintball. MATERIAL AND METHODS: There were a total 14 cases with a diagnosis of blunt trauma by paintball were treated at the ophthalmology emergency department of the Barraquer Clinic in Bogotá, Colombia. All patients underwent a complete ophthalmological examination with their respective controls according to their outcome. RESULTS: The frequency of eye trauma by paintball was 3.01%. Fourteen eyes were evaluated, age range from 9 to 49 years. Cases were unilateral, 1 woman and 13 men, initial visual acuity less than 20/30 in 12 eyes. Only 5 eyes progressed satisfactorily, and 3 were surgically intervened. The cases that did not show any improvement in visual acuity were related to posterior pole problems, with the most frequent being macular alterations, choroidal rupture, choroidal detachment, retinal tear, and retinal folds. In 3 eyes, clinical improvement of visual acuity was evidenced secondary to haemorrhagic processes that resolved with medical treatment. One of them underwent surgical treatment of the lens with an intraocular lens implant. In 2 eyes, the visual recovery was very satisfactory and 100% in another. CONCLUSION: Paintball has increased as a sport and recreational activity, where paint projectiles are fired with compressed air weapons. It carries risks of suffering various trauma that can lead to catastrophic episodes, in terms of visual health, and repercussions on the quality of life of those affected

Opthalmological sequelae due to paintball injuries: Case studies. / Secuelas oftalmológicas por traumatismo con paintball: estudio de casos.

OBJECTIVE: Describe the ophthalmological sequelae of patients diagnosed with blunt eye injury by paintball. MATERIAL AND METHODS: There were a total 14 cases with a diagnosis of blunt trauma by paintball were treated at the ophthalmology emergency department of the Barraquer Clinic in Bogotá, Colombia. All patients underwent a complete ophthalmological examination with their respective controls according to their outcome. RESULTS: The frequency of eye trauma by paintball was 3.01%. Fourteen eyes were evaluated, age range from 9 to 49 years. Cases were unilateral, 1 woman and 13 men, initial visual acuity less than 20/30 in 12 eyes. Only 5 eyes progressed satisfactorily, and 3 were surgically intervened. The cases that did not show any improvement in visual acuity were related to posterior pole problems, with the most frequent being macular alterations, choroidal rupture, choroidal detachment, retinal tear, and retinal folds. In 3eyes, clinical improvement of visual acuity was evidenced secondary to haemorrhagic processes that resolved with medical treatment. One of them underwent surgical treatment of the lens with an intraocular lens implant. In 2eyes, the visual recovery was very satisfactory and 100% in another. CONCLUSION: Paintball has increased as a sport and recreational activity, where paint projectiles are fired with compressed air weapons. It carries risks of suffering various trauma that can lead to catastrophic episodes, in terms of visual health, and repercussions on the quality of life of those affected.

Delayed suprachoroidal hemorrhage after cataract surgery: A case report and brief review of literature.

RATIONALE: To report a case of 44-year-old man with delayed suprachoroidal hemorrhage (DSCH) 2 days after cataract surgery. PATIENT CONCERNS: The patient developed sudden onset of ocular pain and reduction of visual acuity on his left eye 2 days after receiving conventional cataract operation. DIAGNOSES: The ocular conditions were accessed by best-corrected visual acuity, intraocular pressure, slit lamp examination, fundus photography, and B-scan ultrasound. Fundus color photograph revealed a raised choroidal mass and extensive subretinal hemorrhage. B-scan ultrasound also confirmed features of choroidal hemorrhage. Thus, he was diagnosed as DSCH. INTERVENTIONS: He received conservative treatments for 1 month. OUTCOMES: The involved eye recovered well. LESSONS: DSCH is a rare but dreaded complication occurring in intraocular operations. Conservative managements or surgeries may be beneficial for the recovery of visual acuity.

Hemorrhage and Infarction of the Conjunctiva and Orbit in Essential Thrombocythemia.

An 82-year-old woman who had a history of essential thrombocythemia presented with ocular pain, bleeding, and decreased visual acuity of the left eye. Orbital computed tomography revealed a relatively well-defined homogenous mass-like lesion in the left subconjunctival and intraconal space. Conjunctival biopsy showed acute inflammation with necrosis, vascular ectasia with thrombosis and hemorrhage. After the treatment with hydroxyurea and anagrelide, her symptom and lesion were markedly improved. Hematologic disorders like essential thrombocythemia should be considered in patients with severe spontaneous bleeding around the eye.

Intracorneal stromal hemorrhage in dogs and its associations with ocular and systemic disease: 39 cases.

OBJECTIVE: To describe clinical features of dogs diagnosed with stromal intracorneal hemorrhage (ICH). ANIMALS STUDIED: Retrospective case series of 39 dogs (44 eyes) with ICH. PROCEDURES: Medical records of dogs evaluated by the Cornell University ophthalmology service were searched to identify animals with a clinical diagnosis of ICH between 2005 and 2014. Signalment and clinical details, including concurrent ocular disease, concurrent systemic disease, diagnostic tests performed, outcome of hemorrhage, presenting client complaint, and treatment, were recorded. RESULTS: Intracorneal hemorrhage was identified in 44 eyes of 39 dogs. The mean (±standard deviation) age of dogs was 11.5 years (±2.8 years). The Bichon Frise breed and older dogs were statistically over-represented relative to the entire ophthalmology service canine referral population during the same time period. Concurrent ocular disease was present in 40 eyes (91%) and included keratoconjunctivitis sicca, cataracts, and corneal ulcers. Twenty-three dogs (59%) suffered from concurrent systemic disease, most frequently diabetes mellitus, hyperadrenocorticism, hypothyroidism, and systemic hypertension. Less commonly, life-threatening systemic conditions were identified in dogs with ICH including immune-mediated hemolytic anemia, immune-mediated thrombocytopenia, metastatic neoplasia, and sepsis. Intracorneal hemorrhage was found in all corneal locations, and corneal vascularization was present in each affected eye. CONCLUSIONS: Intracorneal hemorrhage is an uncommon condition in dogs that occurs in association with corneal vascularization. The risk of ICH may be increased due to certain ocular and systemic diseases. Although uncommon, ICH may also be an ocular manifestation of severe immune-mediated, infectious, and neoplastic systemic diseases in dogs.

Incidence and management of haemorrhagic Descemet membrane detachment in canaloplasty and phacocanaloplasty.

PURPOSE: To report the incidence and management of haemorrhagic Descemet membrane detachment (HDMD) in canaloplasty and phacocanaloplasty. METHODS: This study included 105 eyes of 92 patients with uncontrolled open angle glaucoma who underwent canaloplasty and phacocanaloplasty between 2010 and 2014. Eyes that developed either HDMD or non-HDMD were identified. The main outcome measures were the development of HDMD and non-HDMD, best corrected visual acuity, recovery time after Descemet membrane detachment (DMD), intra-ocular pressure (IOP) and number of antiglaucoma medications. Each eye was managed according to the time of development, type and extent of DMD. RESULTS: Ten eyes (9.5%) developed DMD- four eyes underwent canaloplasty (3.8%) and six eyes underwent phacocanaloplasty (5.7%). Three of 10 eyes developed non-HDMD while seven of 10 developed HDMD, the majority of HDMD cases occurred in combination with phacocanaloplasty (five of seven). The non-HDMD eyes resolved completely within 2 weeks without intervention. One eye with HDMD was observed for 2 weeks, before a 15% sulphur hexafluoride (SF6) intracameral injection was given. The patient developed a dense corneal stain that was resolving slowly over 30 months. One eye with HDMD underwent YAG laser membranotomy 2 weeks after being identified, which regained corneal transparency 1 month after treatment, while the remaining five eyes underwent immediate surgical drainage and regained corneal transparency 1 day post-procedure. CONCLUSION: HDMD occurred in up to 6.7% in canaloplasty and phacocanaloplasty procedures, mostly during catheter withdrawal and the viscodilation step. Early recognition and management prevented further manipulation.

Haemolacria: A Novel Approach to Lesion Localization.

PURPOSE: To report the use of punctal plugs as a new modality to assist in the localization of lesions providing symptomatic relief in patients with haemolacria during their workup. METHODS: Retrospective case series. RESULTS: One boy and one girl, ages 16 and 20, respectively, reported spontaneous bloody tearing. Workup included probing and irrigation of the nasolacrimal system, blood and coagulation profiles, blood typing, serum hormone levels, conjunctival biopsy, and imaging. All findings were normal and failed to suggest a cause in any of the cases. Punctal plugs were inserted into each patient's inferior punctum OS without complication. On initial follow-up visits, each patient reported cessation of bloody tears OS with continued bloody tears OD. Over time, both patients experienced complete cessation of haemolacria in both eyes. CONCLUSIONS: Haemolacria is a condition caused by a group of disorders that result in the production of tears that are partially composed of blood. The large majority of cases result in a specific diagnosis. Only rarely does workup result in undetermined etiology. The novel approach of utilizing punctal plugs in the management of haemolacria may not only provide symptomatic relief for lesions distal to and including the punctum, but also assists in anatomic localization in idiopathic cases.

Spectral-domain optical coherence tomography of emulsified subretinal silicone oil presenting as a macular inverted pseudohypopyon.

The authors present a rare case of an inverted pseudohypopyon due to subretinal emulsified silicone oil in the macula of a patient who underwent pars plana vitrectomy surgery for repair of retinal detachment with proliferative vitreoretinopathy 1 year prior to presentation of this finding. The patient's predisposing diagnosis is pathologic myopia.

[Morphologically reasonable application of 1.44 microm Nd:YAG laser in ocular surgery for distant hemostasis in conjunctival and episcleral vessels].

The article discusses morphological changes in bulbar conjunctiva and episclera after experimental exposure to Nd:YAG laser radiation at 1.44 pm in comparison to the effect of diathermal coagulator Mira TR4000. The results proved the use of 1.44 microm Nd:YAG laser in ocular surgery for distant hemostasis morphologically reasonable. Non-contact and directional laser treatment is more delicate as it produces smaller irradiated area. The depth of penetration and tissue heating is very limited. Neither excessive reparation, nor scarring is found in the exposed area. On the contrary, diathermy is a contact procedure associated with irregular distribution of heat, which causes large tissue burns and necrosis with subsequent adherent scar formation.

Bilateral subhyaloid haemorrhage in a conscious patient: a new spectrum of ocular involvement by Plasmodium falciparum.

A 24-year-old woman presented with a history of high-grade fever with rigours since 3 days and bilateral sudden loss of vision since 6 h. She was conscious, oriented and her vitals were stable. She had a temperature of 101°F, anaemia, thrombocytopaenia, normal white cell count and moderate splenomegaly. On testing visual activity, she could only perceive hand movements although her pupils were bilaterally equal, and normal in size and reaction. On indirect ophthalmoscopy, optic discs were normal bilaterally; however, fovea of both eyes was masked by subhyaloid haemorrhage. Peripheral smear showed gametocytes of Plasmodium falciparum. The patient was started on arteminsinin-combined therapy and advised to be in propped-up position to help resolution of the haemorrhage. The patient was afebrile in 4 days and follow-up fundus examination showed gradual resolution of the haemorrhage. After two months, the patient regained normal visual acuity in both eyes; however, it took nearly 3 months for complete resolution of the haemorrhage.

Management of the 'tight orbit' and associated visual loss.

PURPOSE OF REVIEW: To review the most recent literature on the management of the orbit under high pressure (the tight orbit) with threatened visual loss. RECENT FINDINGS: Definitive management of traumatic optic neuropathy remains unclear, lacking randomized head-to-head treatment option trials. Instead, numerous case series and anecdotal reports show benefit in each of the four treatment modalities currently in use, but a multitude of variables confound cross-study comparison. In contrast, the management of orbital hemorrhage and orbital emphysema is well known. A number of immunomodulatory protocols have recently arisen for the medical suppression of Graves' ophthalmopathy, but when surgical decompression is required, most authors currently favor a combined transconjunctival and endoscopic endonasal approach. SUMMARY: This article reviews the anatomy, pathophysiology, diagnosis, and intervention of the 'tight orbit' with associated visual loss. Guidelines for the intervention are given.