Multi-resistant Enterobacter cloacae dacryocystitis and preseptal cellulitis: case and review of literature.

A 61-year-old man with no significant past medical history presented to a quaternary ophthalmic referral center with acute right-sided medial canthal pain, periorbital edema, and erythema despite oral antibiotic therapy. CT imaging confirmed the presence of right preseptal cellulitis and lacrimal sac aspiration identified Enterobacter cloacae. A diagnosis of acute right-sided dacryocystitis with preseptal cellulitis was made. He was successfully treated with broadening of antibiotic therapy to intravenous meropenem. Symptomatic resolution was noted on follow-up without evidence of disease recurrence. This unusual case of Enterobacter cloacae dacryocystitis and preseptal cellulitis highlights the increasing prevalence and challenges of treating these uncommon organisms.

Two-year outcomes of patients presenting to Sydney Eye Hospital with neovascular glaucoma.

BACKGROUND: Neovascular glaucoma (NVG) is a sight-threatening condition that is often refractory to treatment. Current management principles are yet to be standardized due to lack of evidence. We studied the interventions used to treat NVG at Sydney Eye Hospital (SEH) and the two-year surgical outcomes. METHODS: We performed a retrospective audit of 67 eyes of 58 patients with NVG from January 1, 2013, to December 31, 2018. Intraocular pressure (IOP), best-corrected visual acuity (BCVA), number of medications, repeat surgery, recurrent neovascularization, loss of light perception and pain were studied. RESULTS: The average age of the cohort was 59.67 years (SD 14.22). The most common etiologies were proliferative diabetic retinopathy (35 eyes; 52.2%), central retinal vein occlusion (18 eyes; 26.9%) and ocular ischemic syndrome (7 eyes; 10.4%). 70.1% of eyes (47) received vascular endothelial growth factor injections (VEGFI), 41.8% (28 eyes) received pan-retinal photocoagulation (PRP) and 37.3% (25 eyes) received both prior to or within the first week of presentation to SEH. The most common initial surgical interventions were trans-scleral cyclophotocoagulation (TSCPC) (36 eyes; 53.7%) and Baerveldt tube insertion (18 eyes; 26.9%). 62.7% of eyes (42 eyes) failed (IOP > 21 or < 6 mmHg for two consecutive reviews, further IOP-lowering surgery or loss of light perception) during follow-up. Initial TSCPC failed in 75.0% (27/36 eyes) compared with 44.4% (8/18 eyes) after Baerveldt tube insertion. CONCLUSION: Our study reinforces the refractory nature of NVG, often despite intensive treatment and surgery. Improvements in patient outcomes may be achieved with earlier consideration of VEGFI and PRP. This study identifies the limitations of surgical interventions for NVG and highlights the need for a standardized management approach.

Infective Necrotizing Scleritis After XEN Gel Stent With Mitomycin-C.

PURPOSE: The purpose of this study was to report a case of infective necrotizing scleritis following XEN Gel Stent with mitomycin-C. METHODS: Case report. This is a case report of a 68-year-old woman. RESULTS: XEN Gel Stent glaucoma surgery enhanced with mitomycin-C 0.04% and combined with cataract surgery was performed at a regional center to manage the patient's primary open-angle glaucoma. Past medical history was significant for rheumatoid arthritis requiring treatment with methotrexate and adalimumab. Periocular pain and swelling developed 14 months after the initial operation, followed by a rapid deterioration of visual acuity to 20/60, intraocular pressure of 4 mm Hg, and worsening pain 5 months later. On initial presentation to Sydney Eye Hospital, 180 degrees of scleral necrosis was evident with a moderate anterior segment inflammatory reaction and a large temporal choroidal effusion due to hypotony. Empirical hourly topical ofloxacin and cephalothin 5% drops, with oral moxifloxacin, were initiated. Conjunctival swab grew Staphylococcus aureus and Staphylococcus lugdunensis. Significant clinical improvement occurred, but the XEN Gel Stent became exposed after 9 days of treatment with worsening hypotony. Urgent surgical revision was performed to remove the XEN Gel Stent and apply a tutoplast plug with overlying amniotic membrane graft. Intraocular pressure gradually improved over 6 weeks to 15 mm Hg with reversal of hypotonous changes, and visual acuity stabilized at 20/40. CONCLUSIONS: To our knowledge, this is the first reported case of necrotizing scleritis following XEN Gel Stent insertion. It is a reminder that infection should always be the primary differential diagnosis in patients with surgical-induced necrotizing scleritis.