Differentiation of Active Corneal Infections from Healed Scars Using Deep Learning.

PURPOSE: To develop and evaluate an automated, portable algorithm to differentiate active corneal ulcers from healed scars using only external photographs. DESIGN: A convolutional neural network was trained and tested using photographs of corneal ulcers and scars. PARTICIPANTS: De-identified photographs of corneal ulcers were obtained from the Steroids for Corneal Ulcers Trial (SCUT), Mycotic Ulcer Treatment Trial (MUTT), and Byers Eye Institute at Stanford University. METHODS: Photographs of corneal ulcers (n = 1313) and scars (n = 1132) from the SCUT and MUTT were used to train a convolutional neural network (CNN). The CNN was tested on 2 different patient populations from eye clinics in India (n = 200) and the Byers Eye Institute at Stanford University (n = 101). Accuracy was evaluated against gold standard clinical classifications. Feature importances for the trained model were visualized using gradient-weighted class activation mapping. MAIN OUTCOME MEASURES: Accuracy of the CNN was assessed via F1 score. The area under the receiver operating characteristic (ROC) curve (AUC) was used to measure the precision-recall trade-off. RESULTS: The CNN correctly classified 115 of 123 active ulcers and 65 of 77 scars in patients with corneal ulcer from India (F1 score, 92.0% [95% confidence interval (CI), 88.2%-95.8%]; sensitivity, 93.5% [95% CI, 89.1%-97.9%]; specificity, 84.42% [95% CI, 79.42%-89.42%]; ROC: AUC, 0.9731). The CNN correctly classified 43 of 55 active ulcers and 42 of 46 scars in patients with corneal ulcers from Northern California (F1 score, 84.3% [95% CI, 77.2%-91.4%]; sensitivity, 78.2% [95% CI, 67.3%-89.1%]; specificity, 91.3% [95% CI, 85.8%-96.8%]; ROC: AUC, 0.9474). The CNN visualizations correlated with clinically relevant features such as corneal infiltrate, hypopyon, and conjunctival injection. CONCLUSIONS: The CNN classified corneal ulcers and scars with high accuracy and generalized to patient populations outside of its training data. The CNN focused on clinically relevant features when it made a diagnosis. The CNN demonstrated potential as an inexpensive diagnostic approach that may aid triage in communities with limited access to eye care.

Bilateral dacryocystitis complicated by unilateral retrobulbar abscess in a five-week-old infant.

Retrobulbar orbital abscess in children is a rare condition, and diagnosis and management can be challenging. We report the case of a 5-week-old male infant with retrobulbar orbital abscess secondary to acute dacryocystitis developed from a dacryocystocele. The patient presented with respiratory difficulty, sepsis and progressive clinical findings suggestive of post-septal cellulitis. He was successfully treated with endonasal incision of subturbinate dacryocystoceles followed by probing of the lacrimal ducts. Congenital dacryocystocele must be considered a differential diagnosis in infants with respiratory difficulty and may develop into a vision- and life-threatening condition requiring immediate intervention.

Bilateral choroiditis as the only sign of persistent Mycobacterium intracellulare infection following haematogenous spread in an immunocompromised patient.

An immunocompromised patient had positive blood cultures for Mycobacterium intracellulare and no identifiable organ seeding was started on treatment. One month later, the patient was clinically well with negative blood cultures but drug-induced myelotoxicity had developed. Ocular fundus examination at this time revealed bilateral choroidal granulomas which changed patient management.

[Placoid chorioretinopathy in systemic infections]. / Placoid chorioretinopathiák szisztémás fertozésekben.

INTRODUCTION AND AIM: To present two cases of placoid chorioretinopathy (ocular syphilis and ocular tuberculosis) and underline the importance of differential diagnosis. METHOD: Two young female patients presented with unilateral loss of vision. Fundus examination showed yellowish placoid lesions in the posterior pole in both cases. RESULTS: Performing fluorescein angiography and laboratory investigations, ocular syphilis was diagnosed in our first case and intraocular tuberculosis was diagnosed in our second case. CONCLUSION: It is important to determine the etiology of the placoid choriaretinopathies due to the different prognosis and therapy and the exclusion of systemic diseases. A comprehensive evaluation of these patients is inevitable for the correct diagnosis and appropriate management. Orv Hetil. 2018; 159(22): 863-869.

Lacrimal gland abscesses: Case series and literature review.

Acute dacryoadenitis with abscess formation has been rarely described. We describe four cases that resolved with incision and drainage. This includes a retrospective case series of four patients with radiologically confirmed lacrimal gland abscesses and a review of the reported cases in the literature. Computed tomography showed characteristic rim enhancing collections with central attenuation in all four cases. All patients presented with ptosis, upper eyelid erythema, and severe pain similar to scleritis. Injection of the conjunctiva and sclera was present in two patients, and a third patient presented with expression of purulent discharge onto the ocular surface upon palpation of the lacrimal gland. All patients were treated with intravenous antibiotics and underwent incision and drainage with subsequent improvement. All were monitored for 24 to 48 hours and discharged on oral antibiotics. There were no complications or recurrences. Lacrimal gland abscess formation is a rare complication of dacryoadenitis, and in our experience these patients respond well to incision and drainage in combination with systemic antibiotics.

[The clinical manifestations and imaging characteristics of acute syphilitic posterior placoid chorioretinitis].

Objective: To investigate the clinical manifestations and imaging characteristics of acute syphilitic posterior placoid chorioretinitis (ASPPC). Methods: Retrospective study of 10 patients diagnosed ASPPC in the Department of Ophthalmology, Beijing Tongren Hospital from 2011 to 2016, including 6 males (10 eyes involved) and 4 females (8 eyes involved) with an age of (43.4±11.6) years (range, 26-60 years). Their clinical manifestations and imaging characteristics were summarized. Results: All 10 ASPPC patients complained about the reduction of visual acuity, and the majority of them had both eyes involved. The initial visual acuity ranged from finger count to 0.8, with an average of 0.4 and a median visual acuity of 0.3. The intraocular pressure was in the normal range. The inflammation of anterior chamber occurred in only one patient (1/10). The lesions were located at the posterior pole as shown on fundus photographs. There are six placoid lesions, four yellowish massive lesions and seven mixed lesions (placoid and yellowish massive lesions). Partial or whole disappearance, abnormality and opacity of the ellipsoid layer, retinal pigment epithelial (RPE) nodules, and cells in the vitreous body were observed by optical coherence tomography. There were partial detachment between the neuronal retina and RPE layer with fine-sand like hypereflective dots. The lesion size and morphology on autofluorescence (AF), fundus fluorescence angiography (FFA) and indocyanine green angiography (ICG) were almost consistent with those on fundus photography. The lesions were hyperautofluorescent in a placoid or massive shape. The lesions on FFA showed slight hyperfluorescence with unclear edges from the venous phase, and the fluorescence increased with the time and leaked in the late phase. Vascular walls showed blood staining in the late phase. The lesions on ICG showed hypofluorescence with hyperfluorescence and hypofluorescence dots like fine needles in the middle and late phases. Conclusion: ASPPC mainly occurs among the young adults without gender difference. The characteristic is the contradiction between sever clinical symptoms and slight signs on the fundus. The lesion area shown on fundus photography, FFA, ICG and AF is consistent, as well as injuries of the ellipsoid layer, RPE nodules and cells in the vitreous body. The above manifestations and imaging characteristics of ASPPC are significant for the diagnosis and differential diagnosis. (Chin J Ophthalmol, 2017, 53:352-357).

[Imaging and Laboratory Diagnostics for Tuberculosis]. / Bildgebung und Labordiagnostik bei Tuberkulose.

Diagnosis of tuberculosis (TB) is difficult, since symptoms are often very unspecific or lacking. However active, prompt and accurate diagnosis is the key element in the public health response to tuberculosis and the cornerstone of tuberculosis control. Different diagnostic methods for an assured diagnosis of TB are necessary. Chest radiography is a useful keystone to identify tuberculosis, but diagnosis of tuberculosis cannot be established by radiography alone. CT scanning is used in patients without pathological chest radiography but clinically suspected active TB and to differentiate TB from other diseases. Radiological appearance is primarily determined by the immune status of patients and caverns and disseminated disease foci are often observed. Laboratory diagnostic methods include microscopic identification of acid-fast mycobacteria from any body fluid (especially sputum), as well as isolation and characterisation of mycobacteria in culture. It is then possible to type the pathogens by the shape of their colony, their growth behavior and their biochemical characteristics. These methods are regarded as the gold standard in diagnosis of active TB. In patients who are highly suspected of having TB, but whose sputum specimens tested negative for mycobacteria, a nucleic acid amplification test is additionally performed. Moreover, sensitivity testing with first and second line antitubercular drugs is applied as standard. Laboratory diagnostic testing of cellular immunity against pathogenic mycobacteria employs the tuberculin skin test (TST, Mantoux tuberculin test) or the more specific interferon γ test to determine γ interferon released by T lymphocytes stimulated in vitro. The new ELISA and ELISPOT procedures exhibit higher test specificity and less cross reactivity to NTM (non-tuberculosis mycobacteria), are independent of BCG-vaccination status and correlate better with the degree of exposure than does the TST.

Orbital cellulitis and corneal ulcer due to Cedecea: First reported case and review of the literature.

Cedecea is a gram-negative bacterium from the family Enterobacteriaceae, rarely associated with human infection. We report the first case of an orbital cellulitis and corneal ulcer due to Cedecea in a patient who sustained a motor vehicle accident and was then found to have a retained wooden orbital foreign body.

INNOVATIVE MULTIPLANAR RECONSTRUCTION AND VOLUME-RENDERED COMPUTED TOMOGRAPHY IN THE ASSESSMENT OF SCLERAL BUCKLE-RELATED COMPLICATIONS.

PURPOSE: To describe the role of multiplanar reconstruction and three-dimensional volume-rendered imaging in the assessment of silicon-based scleral buckle (SB)-related complications. METHODS: Five eyes of five patients with SB-related complications where the history, surgical notes, and clinical examination proved inconclusive were included. Unenhanced axial orbital computed tomography images of all patients were acquired parallel to orbitomeatal line, and images were reviewed in orthogonal planes. The volume rendition of the imaged volume was evaluated in various tilts, with special reference to the spatial relationship of the band-buckle to the globe and bony orbit. All patients underwent imaging-assisted SB removal. RESULTS: Imaging assisted in in vivo localization of the obscure band or buckle in all five eyes. Band was seen as hyperdense structure encircling whole of the globe, whereas buckle was seen as segmental, broad, hyperdense structure with scleral indentation. Presence of SB was identified in three patients, and globe integrity was shown in the other two. Abnormal anterior displacement of band and buckle was demonstrated in three cases on volume-rendered imaging in relation to lateral orbital rim. Focal exuberant soft-tissue proliferation around the buckle was present in all patients, suggesting chronic inflammation and infection. Successful removal of band and buckle could be achieved, and all patients were relieved of their preoperative complaints. No complication occurred during intraoperative and postoperative period. CONCLUSION: Use of multiplanar reconstruction and three-dimensional volume-rendered computed tomography imaging played a pivotal role in surgical success.

Bilateral Orbital Abscesses After Strabismus Surgery.

Infectious orbital complications after strabismus surgery are rare. Their incidence is estimated to be 1 case per 1,100 surgeries and include preseptal cellulitis, orbital cellulitis, subconjunctival and sub-Tenon's abscesses, myositis, and endophthalmitis. This report describes the case of an otherwise healthy 3-year-old boy who underwent bilateral medial rectus recession and disinsertion of the inferior obliques. A few days after surgery, the patient presented with bilateral periorbital edema and inferotemporal chemosis. A series of CT scans with contrast revealed inferotemporal orbital collections OU. The patient immediately underwent transconjunctival drainage of fibrinous and seropurulent collections in the sub-Tenon's space and experienced rapid improvement a few days later. The patient is reported to be in stable condition in a follow-up examination performed more than a year after the reported events.

Infectious Complication Following Midface Reconstruction With Calcified Triglyceride.

This case report describes an infectious complication related to the use of calcified triglyceride (Kryptonite Bone Cement) in post-traumatic midface reconstruction. Ultimately, the infected material required removal, and the facial deformity was repaired with subsequent procedures. The literature suggests that bone cement products should be used with caution when in contact with the paranasal sinuses.

Case report of orbital cellulitis and necrotizing fasciitis from melioidosis.

A 48-year-old Thai male farmer presented with progressive swelling of the right eyelid and high-grade fever. His visual acuity declined and the right side of his forehead developed a necrotic skin lesion with a purulent discharge. CT of the orbits suggested orbital cellulitis with subperiosteal abscess. Intravenous ceftriaxone and clindamycin were given empirically but then switched to vancomycin and meropenem because of rapid deterioration together with clinical sepsis. Burkholderia pseudomallei was isolated from the blood 3 days after the treatment, and the antibiotics were then switched to intravenous ceftazidime. The liver enzymes were elevated, and imaging of the abdomen revealed liver and splenic abscesses. After 14 days, the patient showed marked clinical improvement, became afebrile, and regained his OD visual acuity. A repeat CT of the orbit showed improvement with no subperiosteal abscess. The antibiotic was then switched to oral trimethoprim/sulfamethoxazole in combination with doxycycline for 6 months.

Rhinotillexomania: a rare cause of medial orbital wall erosion.

The authors report a rare case of medial orbital wall erosion with an orbital inflammatory mass and resultant lacrimal obstruction secondary to rhinotillexomania. A 67-year-old male with known history of compulsive nose picking (rhinotillexomania) sought treatment for complaints of watering in his OD. Examination revealed a blocked right inferior canaliculus. Nasal endoscopy showed a large nasal septal defect with multiple areas of crusting and bleeding. Hematologic investigations were normal. CT scan confirmed a large nasal septal and right medial orbital wall defect with an adjacent soft tissue mass in the medial orbit. Investigations ruled out systemic pathology. Histologic examination of medial orbital mass, sinus, and nasal mucosa revealed a reactive inflammatory infiltrate with surface Gram-positive cocci. The authors hypothesized that the patient had enlarged an existing nasal septal defect due to repetitive nose picking resulting in recurrent infection and inflammation of sinuses, leading to erosion of his medial orbital wall.

Delayed Eikenella corrodens orbital infection after fracture repair.

Orbital cellulitis and abscess after fracture repair are rare. Ophthalmic infection with Eikenella species is even more unusual, but can be severe. We report a case of Eikenella corrodens infection in a 28-year-old man who underwent zygomaticomaxillary and orbital floor blowout fracture surgery 4 years before presentation. Eikenella species are often resistant to frequently used empiric antibiotics, and because of specific growth conditions, easily missed on standard cultures. Appropriate efforts should be made to identify and treat E. corrodens in atypical orbital and periocular infections.

Evaluation of Ultrasound Biomicroscopy Combined with Color Doppler Flow Imaging in the Diagnosis of Primary Lacrimal Canaliculitis.

Purpose: To explore the performance of ultrasound biomicroscopy (UBM) and color Doppler flow imaging (CDFI) in the diagnosis of primary lacrimal canaliculitis.Methods: Subjects with relevant symptoms of canaliculitis were prospectively recruited. UBM and CDFI were performed for presumptive diagnosis. Microbiology and histopathology were performed for definitive diagnosis.Results: A total of 37 cases were recruited, including 25 cases of canaliculitis and 12 cases of non-canaliculitis. Pathogens were isolated in 13 canaliculitis cases, and the leading pathogens were Actinomyces (4 cases) and Streptococcus (4 cases). UBM and CDFI identified 24 canaliculitis cases (sensitivity = 96%) and 11 non-canaliculitis cases (specificity = 92%). The predictive factors for canaliculitis were lumen wall thickness >0.25 mm (P = .019) and intracanalicular concretions (P = .010). Other typical features were enlarged lumen (2.16 ± 0.25 mm) and hot-wheel sign-on CDFI (84%). These image findings were congruent with histopathologic changes.Conclusion: Ultrasonography is a valuable tool to assist the diagnosis of canaliculitis.(Clinical trial registration number: ChiCTR1900025411).

ACUTE SYPHILITIC POSTERIOR PLACOID CHORIORETINITIS: MULTIMODAL IMAGING AND ELECTROPHYSIOLOGIC FINDINGS BEFORE AND AFTER TREATMENT.

PURPOSE: To describe the clinical course of acute syphilitic posterior placoid chorioretinitis (ASPPC) in the preplacoid stage, placoid stage, and after treatment with penicillin. METHOD: A retrospective case report of serial multimodal imaging and electrophysiology studies of a patient with ASPPC, with 18 months of follow-up. RESULTS: A 47-year-old man presented with bilateral panuveitis. The patient defaulted follow-up and returned when his vision deteriorated. Tests for neurosyphilis and retroviral disease were positive, and treatment was initiated. The earliest change on serial optical coherence tomography was loss of the signal from the reflective band corresponding to the ellipsoid zone. In the placoid stage, there was nodular thickening of the retinal pigment epithelium. The ellipsoid zone signals reappeared after treatment. Fundus fluorescein angiogram at presentation showed peripapillary vasculitis and disk leakage; indocyanine green angiography revealed multiple hypofluorescent spots in the peripapillary region and posterior pole that was not visible clinically. The angiographic abnormalities resolved after treatment. Electrophysiology demonstrated bilateral maculopathy and reduction of both a- and b-waves from dark-adapted and light-adapted responses at presentation. The b-waves (inner retina) recovered partially with treatment. CONCLUSION: To the best of our knowledge, this is the first case report of the multimodal imaging and electrophysiology findings in a patient with acute syphilitic posterior placoid chorioretinitis, before the development of the classic placoid lesion. Improvement of structural and functional pathology after systemic treatment is demonstrated.

Comparisons of deep learning algorithms for diagnosing bacterial keratitis via external eye photographs.

Bacterial keratitis (BK), a painful and fulminant bacterial infection of the cornea, is the most common type of vision-threatening infectious keratitis (IK). A rapid clinical diagnosis by an ophthalmologist may often help prevent BK patients from progression to corneal melting or even perforation, but many rural areas cannot afford an ophthalmologist. Thanks to the rapid development of deep learning (DL) algorithms, artificial intelligence via image could provide an immediate screening and recommendation for patients with red and painful eyes. Therefore, this study aims to elucidate the potentials of different DL algorithms for diagnosing BK via external eye photos. External eye photos of clinically suspected IK were consecutively collected from five referral centers. The candidate DL frameworks, including ResNet50, ResNeXt50, DenseNet121, SE-ResNet50, EfficientNets B0, B1, B2, and B3, were trained to recognize BK from the photo toward the target with the greatest area under the receiver operating characteristic curve (AUROC). Via five-cross validation, EfficientNet B3 showed the most excellent average AUROC, in which the average percentage of sensitivity, specificity, positive predictive value, and negative predictive value was 74, 64, 77, and 61. There was no statistical difference in diagnostic accuracy and AUROC between any two of these DL frameworks. The diagnostic accuracy of these models (ranged from 69 to 72%) is comparable to that of the ophthalmologist (66% to 74%). Therefore, all these models are promising tools for diagnosing BK in first-line medical care units without ophthalmologists.

Clinical and pathological observation and treatment of chronic orbital osteomyelitis.

PURPOSE: To evaluate diagnosis, treatment, and histopathologic changes of chronic orbital osteomyelitis. METHODS: We retrospectively analyzed the history, clinical manifestations, computed tomography (CT) scans, histopathology, treatment methods, and outcomes for 6 patients with chronic orbital osteomyelitis at the Department of Ophthalmology, West China Hospital, from January 1988 to January 2008. RESULTS: One of the 6 patients had a history of frontal sinusitis, 4 patients had a history of trauma, and the remaining patient had a history of lateral orbitotomy. All patients had red swelling of the skin at the orbital margin, fistula formation, and pus emerging repeatedly from the fistulae. CT scans showed that sequestrum and abscess had formed in all patients. Those patients were treated by radical debridement and antibiotics with satisfactory results. Histopathologic examination showed that in 6 patients the bone trabeculae disappeared from the sequestra, abscess formed around the sequestra, and vessel dilation occurred in the areas of pathologic change with inflammatory cell infiltration. Two sequestra were completely encapsulated by fibrous connective tissue and formed involucrum. CONCLUSIONS: Chronic orbital osteomyelitis was often found in patients with a traumatic history who had received improper or delayed treatment when injured. The main clinical features included low-grade inflammation, pus, sequestrum and fistulation. Pathologic characteristics were formation of sequestrum, abscess and involucrum. Clinical manifestations and CT scan allowed accurate diagnoses, and radical treatment using a combination of debridement and antibiotics provided satisfactory results.