Management of radiation maculopathy.

Radiation maculopathy is a delayed onset complication of radiation exposure. Various host and radiation parameters determine the risk of developing radiation maculopathy, which may be progressive. Total radiation dose delivered to the macula is the most important modifiable factor. Radiation maculopathy is not a singular entity as clinical manifestations reflect combined effects of all damaged tissues. Current treatment using anti-vascular endothelial growth factor agents offers only a short-term, temporary, and modest visual improvement. Avoidance or prevention of radiation maculopathy may be the best option. Use of periocular steroid during plaque brachytherapy may prevent radiation maculopathy over the short term. Newer designs and techniques of delivering radiation to the eye need to be explored.

Precut Post-Laser In Situ Keratomileusis / Photorefractive Keratectomy Donor Corneas for Use in Endothelial Keratoplasty: Potential Impact of Postcut Morphology on Visual Outcomes.

PURPOSE: To evaluate the accuracy, complication rates, cut quality, and degree of induced hyperopic shift of eye bank-prepared post-laser in situ keratomileusis (LASIK)/photorefractive keratectomy (PRK) donor corneas compared to those of non-post-LASIK/PRK donor corneas. METHODS: The cut accuracy and failure rates of all post-LASIK/PRK donor cornea tissue processed for use in Descemet stripping automated endothelial keratoplasty (DSAEK) from January 2012 through December 2016 were compared to control cornea donor tissue. Corneas were analyzed for regularity and morphology of cut using anterior segment optical coherence tomography images. Using a mathematical model, the hyperopic shifts induced by post-LASIK/PRK donor lenticules were compared to the control corneas. RESULTS: During the study period, 733 post-LASIK/PRK and 10 437 non-post-LASIK/PRK donor corneas were processed for DSAEK. Cut accuracy and quality were similar (P > .05), but there was an increased tissue wastage rate of 5.0% compared to 2.2% (P < .000001). For tissue < 100 µm in central thickness (P = .0001), and for tissue between 100 and 150 µm in central thickness (P = .0023), the difference between central and peripheral thickness when comparing the post-LASIK/PRK and control corneas was statistically significant. These differences resulted in a 1.96 diopter (D), 1.60 D, and 2.35 D hyperopic shift when using donor corneas 100 µm, 125 µm, and 150 µm thick, respectively, from post-LASIK/PRK donors compared to 1.11 D, 0.38 D, and 1.96 D from control donors. CONCLUSIONS: Eye bank technicians and surgeons should be aware of the increased risk of tissue wastage when cutting post-LASIK/PRK corneas compared to non-post-LASIK/PRK donors. Surgeons should also be aware of the theoretical increase in hyperopic shift when using post-LASIK/PRK donor corneas compared to non-post-LASIK/PRK donors when cut to less than 150 µm. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Overview of Systemic Candida Infections in Hospital Settings and Report of Candida After DMEK Successfully Treated With Antifungals and Partial Graft Excision.

PURPOSE: To report novel surgical and medical management of intraocular and corneal infection with Candida glabrata that manifested 3 months after Descemet membrane endothelial keratoplasty (DMEK) and to review demographic reasons for increasing fungal contamination of donor tissue. METHODS: Demographics, donor rim cultures, diagnostic tests, management, clinical course, outcomes, and donor mate outcomes are reported for a fungal infection after DMEK. RESULTS: The fungal infection was treated for 3 weeks with a combination of intracameral and intracorneal voriconazole and intracameral and topical amphotericin B (off-label use). After initial improvement, the infection appeared to spread to the posterior chamber and the cornea decompensated. Pars plana vitrectomy was performed, and the fungal plaque and underlying area of the graft (approximately 3 mm area) were excised with the vitrector. After surgical intervention, the voriconazole and amphotericin B injections were discontinued, and oral posaconazole was prescribed for 2 months (off-label use). This combination of surgical and medical management successfully cleared the infection. Surprisingly, corneal edema completely resolved, and central DMEK endothelial cell density was 2506 cells/mm 1 month after discontinuing the antifungal injections, which apparently caused reversible endothelial toxicity. CONCLUSIONS: The incidence of nosocomial fungal infections, particularly non-albicans Candida, is increasing, as are the rates of positive fungal cultures from corneal donor tissue and postkeratoplasty fungal infections. Prospective studies are needed to assess the value of routine donor cultures, compare the safety and efficacy of various prophylactic treatments, and evaluate addition of antifungals to cold storage media.

Systemic Fungal Infections in Donors for Corneal Transplantation.

PURPOSE: To determine the prevalence of postkeratoplasty fungal infection when corneal tissue from donors with a recent medical history of oral thrush or respiratory, urine, wound, sputum, bronchial, tracheal, or throat culture positive for fungus is identified before recovery and after decontamination of the corneal tissue with 5% povidone-iodine flush to the donors' eyes during recovery. METHODS: This is a prospective analysis of corneas from 42 donors with a documented medical history of fungus or positive fungal culture, which were recovered between January 2010 and November 2010. Standard aseptic swab of the donors' corneas before and after application of 5% povidone-iodine solution was performed. Culture results were analyzed in relationship to the donors' medical history and potential posttransplantation infections. RESULTS: Eighty-four eyes from 42 patients were swabbed for cultures during the study period. Seven eyes (8.3%) were positive for fungal growth before treatment with 5% povidone-iodine, whereas there were no positive fungal cultures after treatment (P = 0.007). Fifty-four corneas from this study group were used for corneal transplantation. There were no cases of fungal infection in any postkeratoplasty eyes transplanted from this study group. CONCLUSIONS: In this small study, the overall prevalence of fungal infections after corneal transplantation using corneal donor tissue from donors with a fungal-positive medical history is low. Corneal fungal contamination in donors with a history of fungal infection or a positive fungal culture can be significantly reduced with a 5% povidone-iodine flush.

Amaurosis fugax due to pleomorphic sarcoma in the left atrium.

PURPOSE: This report describes a case of amaurosis fugax due to a rare primary cardiac sarcoma. OBSERVATIONS: A patient who was recently diagnosed with left atrial pleomorphic sarcoma presented with a chief complaint of multiple episodes of intermittent vision loss in the right eye during the course of radiation therapy. CONCLUSIONS AND IMPORTANCE: The authors postulate emboli from the left atrial sarcoma entered systemic circulation and subsequently caused brief episodes of transient occlusion to retinal, ophthalmic and/or ciliary arteries leading to momentary retinal hypoxia. We believe this is a novel finding, previously unreported in the literature, of transient embolic occlusion without permanent visual sequelae due to a malignant primary cardiac pleomorphic sarcoma.

The presentation and clinical significance of sinonasal respiratory epithelial adenomatoid hamartoma (REAH).

BACKGROUND: Sinonasal respiratory epithelial adenomatoid hamartoma (REAH) is a benign glandular proliferation with ciliated epithelium. Little is known about REAH, with only a few published case reports appearing since its original description in 1995. Classically described as an isolated polypoid lesion arising from the nasal septum, more recent descriptions also suggest that REAH can occur among nasal polyps. We report the largest experience with REAH to date, and aim to better understand and characterize this unique entity. METHODS: In this case series, all cases of REAH diagnosed between 2006 and 2011 were reviewed. Clinical presentation, histologic and radiographic features, and operative findings were examined. RESULTS: There were 45 patients 19 females and 26 males, with a mean age of 55.9 years (range, 23-83). Most cases of REAH (33/45, 73%) were found in association with another pathologic process (sinonasal polyposis, adenoiditis, hereditary hemorrhagic telangiectasia [HHT], inverted papilloma [IP], or malignancy). Of these, REAH occurring among diffuse polyposis (79% of cases) represented the large majority. The average Harvard computed tomography (CT) stage for this cohort was 3.1. The other presentation of REAH (12/45, 27%) was an isolated sinonasal mass. In cases of isolated REAH, the majority of lesions (75%) were noted to be originating in the olfactory clefts. CONCLUSION: Isolated REAH, which may mimic a neoplasm, appears to be a different clinical entity than the more common form encountered in association with nasal polyps and inflammation. Further investigation into the etiology and clinical significance is needed.

Eicosanoid signaling and vascular dysfunction: methylmercury-induced phospholipase D activation in vascular endothelial cells.

Mercury, especially methylmercury (MeHg), is implicated in the etiology of cardiovascular diseases. Earlier, we have reported that MeHg induces phospholipase D (PLD) activation through oxidative stress and thiol-redox alteration. Hence, we investigated the mechanism of the MeHg-induced PLD activation through the upstream regulation by phospholipase A2 (PLA2) and lipid oxygenases such as cyclooxygenase (COX) and lipoxygenase (LOX) in the bovine pulmonary artery endothelial cells (BPAECs). Our results showed that MeHg significantly activated both PLA2 (release of [(3)H]arachidonic acid, AA) and PLD (formation of [(32)P]phosphatidylbutanol) in BPAECs in dose- (0-10 µM) and time-dependent (0-60 min) fashion. The cPLA2-specific inhibitor, arachidonyl trifluoromethyl ketone (AACOCF3), significantly attenuated the MeHg-induced [(3)H]AA release in ECs. MeHg-induced PLD activation was also inhibited by AACOCF3 and the COX- and LOX-specific inhibitors. MeHg also induced the formation of COX- and LOX-catalyzed eicosanoids in ECs. MeHg-induced cytotoxicity (based on lactate dehydrogenase release) was protected by PLA2-, COX-, and LOX-specific inhibitors and 1-butanol, the PLD-generated PA quencher. For the first time, our studies showed that MeHg activated PLD in vascular ECs through the upstream action of cPLA2 and the COX- and LOX-generated eicosanoids. These results offered insights into the mechanism(s) of the MeHg-mediated vascular endothelial cell lipid signaling as an underlying cause of mercury-induced cardiovascular diseases.

Exploring the clinical value and implications of routine pathological examination of septoplasty specimens.

OBJECTIVES/HYPOTHESIS: During septoplasty, otherwise normal cartilage and bone are removed and routinely submitted for pathologic examination. According to the College of American Pathologists, however, the examination of bone and cartilage from septoplasty and rhinoplasty may be left to the pathologist's discretion. We explored the processing of tissues removed during septoplasty, examining the clinical value and implications of current practices. STUDY DESIGN: Retrospective chart review. METHODS: Our database was searched for septoplasty (CPT code 30520) procedures performed specifically for the indication of nasal obstruction. RESULTS: Five hundred sixteen consecutive cases from 15 surgeons spanning a 2-year period were identified. In the majority of cases, septal tissues removed during surgery were submitted to pathology. The majority of cases (>90%) involved septoplasty performed in conjunction with another procedure, most commonly addressing the inferior turbinates. All septal specimens received gross examination by a pathologist, and a smaller fraction were also examined histologically. Gross findings included the qualitative appearance of the specimen and dimensional measurements of bone and cartilage fragments. No abnormalities were identified (by gross or histologic examination) in any of the specimens. Associated costs included specimen handling, storage, and pathology fees. CONCLUSIONS: In our health care system, it is common practice to submit tissues removed during septoplasty for pathologic examination. This study demonstrates that routine evaluation of septal tissues following surgery for obstruction has no clinical value whatsoever, and is associated with direct and indirect costs. Given the current health care climate, this practice should be further scrutinized and reconsidered.