Alessandra Sborgia

Endophthalmitis associated with intravitreal injections: office-based setting and operating room setting.

Purpose: To report on the occurrence of endophthalmitis after intravitreal injections (IVI) in two different settings: office-based and operating room. Methods: Consecutive case series. Retrospective review of all patients who underwent IVI by 2 physicians between January 2009 and December 2011. Group A underwent IVI in the examination room in office-based setting and Group B underwent IVI in the operating room. Results: A total of 11,710 IVIs were performed during the study period. Group A: A total of 8,647 IVIs performed including 2,041 ranibizumab, 6,169 bevacizumab, and 437 triamcinolone acetonide. The diagnosis included neovascular age-related macular degeneration (5,376), diabetic macular edema (1,587), retinal vein occlusion (1,068), and miscellaneous diagnosis (616). Group B: A total of 3,063 IVIs performed including 683 ranibizumab, 2,364 bevacizumab, and 16 triamcinolone acetonide. The diagnosis included neovascular age-related macular degeneration (1,836), diabetic macular edema (771), retinal vein occlusion (189), and miscellaneous diagnosis (267). A total of 5 cases (0.043%) of clinically suspected endophthalmitis occurred in 11,710 injections. Three cases (0.035%) occurred in Group A, and 2 cases (0.065%) occurred in Group B. Conclusion: The rate of clinically suspected endophthalmitis after IVIs is low whether the procedure is performed in the office or operating room setting. The findings have implications in terms of the patient convenience, efficiency, and cost of administrating these treatments.

A Rare Case of Primitive Epithelioid Leiomyosarcoma of the Conjunctiva

Purpose: To describe a rare case of conjunctival leiomyosarcoma initially diagnosed as a poorly differentiated squamous cell carcinoma. Methods: Clinical, light microscopic, immunohistochemical, and ultrastructural findings are reported. Results: A 56-year-old Caucasian woman was referred with a history of a progressive, rapidly growing mass in her left eye. Biopsy of the mass and histology yielded a first diagnosis of a poorly differentiated conjunctival squamous cell carcinoma. Orbital exenteration was performed 2 weeks later. Macroscopically, the exenteration specimen showed a soft mass completely involving the conjunctiva and extending to the eyelids and orbital structures. Histological examination revealed a malignant tumour composed of atypical, predominantly epithelioid large cells. Immunohistochemical and ultrastructural studies combined with the light microscopic findings contributed to clarify the diagnosis of epithelioid leiomyosarcoma. The patient was started on chemotherapy and radiotherapy, but died a few months later from widespread metastases. Conclusions: primary involvement of the orbit by a leiomyosarcoma is rare, but this eventuality should be considered in the differential diagnosis of rapidly growing orbital and conjunctival masses.

Orbital Granular Cell Tumor in a Patient with Churg Strauss Syndrome: The Importance of Biopsy

A 65-year-old woman presented with a long standing, progressive exophthalmos of the right eye. Her medical history was significant for Churg Strauss syndrome, and was treated with immunosuppressive therapy. She had undergone two previous orbital biopsies showing inflammatory reactive lymphoid hyperplasia. A diagnosis of orbital inflammation in Churg-Strauss syndrome was suspected, and the immunosuppressive therapy was increased. Because of the lack of response to therapy, a further biopsy was performed, by lateral orbitotomy approach. Biopsy of the mass revealed a granular cell tumor composed of S-100 positive cells with an acidophilic granular cytoplasm and peripheral lymphocytic infiltration. A granular cell tumor, which is very rare in the orbit, should be considered in the differential diagnosis of orbital tumors, and if suspected, an excisional biopsy must be undertaken. Typical hystopathological aspect of the granular cell tumor is characterized by the presence of S-100 positive closely packed polygonal cells with a granular cytoplasm.

Bilateral Ischemic Retinal Vasculitis in Metastatic Cutaneous Melanoma Patient Treated with Dabrafenib and Trametinib: A Case Report

In the last few years, about two-thirds of metastatic melanoma have revealed gene target mutations, which involve v-Raf murine sarcoma viral oncogene homolog B1 (BRAF) or neuroblastoma RAS viral oncogene homolog (NRAS), both along the mitogen-activated protein kinase (MAPK) cell pathway. Biologic targeted agents, such as including BRAF inhibitors and mitogen-activated protein kinase kinase (MEK) inhibitors, have revolutionized the treatment for metastatic melanoma. These drugs administered as a single therapy or in combination, have tripled the median overall survival of patients who reported related ocular adverse events. In two clinical trials on oral Dabrafenib (BRAF inhibitor) (75 or 150 mg twice daily) and Trametinib (MEK inhibitor) (1, 1.5, or 2 mg daily) in combination, rare cases of reversible undefined chorioretinopathy events were reported. This combination regimen has since been approved by the US Food and Drug Administration (2014). The most serious ocular effect of inhibition of the MAPK signaling pathway is retinal vein occlusion but the most common ocular side-effect of Dabrafenib and Trametinib as single treatment is uveitis (including iritis, vitritis), which tends to develop overweeks or months of drug exposure. Usually, uveitis is easilymanagedwith temporary dose interruption, topical and/or systemic steroid therapy without serious sequelae. One case report described a severe bilateral uveitis with vitritis, early patchy choroidal hyperfluorescence and optic disk leakage on fluorescein angiography, resolved after drugs discontinuation without sequelae. Another report described a severe bilateral panuveitis with choroidal thickening, chorioretinal folds, and multiple serous retinal detachments resolved after starting topical corticosteroid treatment and dabrafenib discontinuation. We present here a case of bilateral ischemic retinal vasculitis developed over months of combined therapy.

Anterior capsule staining using micronized triamcinolone in the absence of red reflex

&NA; We describe a technique to stain the anterior lens capsule with micronized triamcinolone to perform a continuous curvilinear capsulorhexis (CCC) during phacoemulsification in the absence of a red reflex due to vitreous hemorrhage. After a self‐sealing clear corneal tunnel incision is performed using a 2.75 mm blade, a dispersive ophthalmic viscosurgical device (OVD) is injected to protect the iridocorneal angle. An air bubble as large as possible is injected into the center of the anterior chamber, and a small amount of micronized triamcinolone is then injected as needed to stain the anterior lens capsule. The OVD injection permits the removal of excessive triamcinolone and protects the corneal endothelium from damage during phacoemulsification. A capsulorhexis forceps is used to perform the CCC. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Interference figures of polarimetric interferometry analysis of the human corneal stroma

A rotating polarimetric 90°-cross linear-filter interferometry system was used to detect the morphological characteristics and features of interference patterns produced in in-vivo corneal stroma in healthy human corneas of 23 subjects. The characteristic corneal isogyres presenting with an evident cross-shaped pattern, grossly aligned with the fixation axis, were observed in all patients with centers within the pupillary dark area, impeding the exact determination of the center point. During the rotational scan in 78.3% of the eyes the cross-shaped pattern of the isogyre gradually separated to form two distinct hyperbolic arcs in opposite quadrants, reaching their maximal separation at 45 degrees with respect to angle of cross-shaped pattern formation. The corneal cross and hyperbolic-pattern repeated every 90° throughout the 360° rotational scan. While the interpretation of the isogyres presents particular difficulties, two summary parameters can be extracted for each cornea: the presence/orientation of a single or two dark areas in post-processed images and isochromes. However, the development of dedicated software for semi-quantitative analysis of these parameters and enantiomorphism may become available in the near future. The possible application of polarimetric interferometry in the field of both corneal pathologies and corneal surgery may be of great interest for clinical purposes.

25-Gauge Vitrectomy in Open Eye Injury with Retained Foreign Body

Purpose. Ocular trauma with retained foreign body is an important cause of visual impairment in working-age population. Clinical status impacts on the timing and planning of surgery. In the last year small gauge vitrectomy has become safer and more efficient, extending the range of pathologies successfully treated. Aims. To evaluate the safety and outcomes in patients with open eye injury with retained foreign body that underwent early 25-gauge vitrectomy. Methods. In this retrospective, noncomparative, interventional case series, we performed 25-gauge vitrectomy on 10 patients affected by open globe injuries with retained foreign body, over 3 years. We analyzed age, wound site, foreign body characteristics, ocular lesions correlated, relative afferent pupillary defect, visual acuity, and intraocular pressure. Follow-up evaluations were performed at 1, 3, and 6 months. According to the clinical status we performed other procedures to manage ocular correlated lesions. Results. The median age of patients was 37 years. The foreign body median size was 3.5 mm (size range, 1 to 10 mm). 25-gauge vitrectomy was performed within 12 hours of trauma. Foreign body removal occurred via a clear corneal or scleral tunnel incision or linear pars plana scleral access. Visual acuity improved in all patients. Endophthalmitis was never reported. Only two cases reported postoperative ocular hypertension resolved within the follow-up. Retinal detachment recurred in one case only. Conclusions. 25-gauge vitrectomy could be considered as early approach to manage open globe injuries with a retained posterior segment foreign body in selected cases with good outcomes and low complication rate.

Analysis of Morphologic and Functional Outcomes in Macular Edema due to Central Retinal Vein Occlusion Treated with Intravitreal Dexamethasone Implant

Purpose To analyze anatomic and functional retinal changes and their correlation after intravitreal dexamethasone implant (DEX implant) in patients with central retinal vein occlusion- (CRVO-) related macular edema (ME) using optical coherence tomography and microperimetry. Methods Fifteen treatment-naïve patients with functional impairment due to CRVO-related ME were enrolled in this prospective interventional case series. Main outcomes were best-corrected visual acuity (BCVA), retinal sensitivity (RS), and central retinal thickness (CRT). Secondary outcomes were ellipsoid zone (EZ) status and fixation behaviour. All patients underwent DEX implant and were retreated according to predefined criteria. Data were prospectively recorded at baseline and at month 1, 3, 6, 9, and 12. Correlation between main outcomes was analyzed. Results Fifteen eyes of 15 patients (9 men, 6 women; mean age 61.8 ± 10.9 years) were included. BCVA and CRT significantly improved at all follow-up visits, while RS significantly improved at 3, 6, 9, and 12 months. EZ status and fixation behaviour did not change significantly. Baseline CRT had a significant negative correlation with BCVA and RS at different follow-up visits (r=−0.52  to −0.63, p ≤ 0.04; r=−0.52, p=0.04; resp.). At all time points, there was not a significant correlation between CRT and BCVA and RS, while RS and BCVA showed a significant correlation, increasing over time (r=−0.72  to −0.89; p < 0.001). Conclusion DEX implant led to a significant morphofunctional improvement. Baseline CRT is predictive of changes of functional outcomes whose correlation increases over time after treatment.

Hyperhomocysteinemia in bilateral anterior ischemic optic neuropathy after conventional coronary artery bypass graft: A case report

BackgroundThe incidence of anterior ischemic optic neuropathy after coronary artery bypass graft procedures ranges from 1.3 to 0.25%. The mechanisms of anterior ischemic optic neuropathy after cardiovascular procedures remain undefined but many systemic and related-to-surgery risk factors could underlie anterior ischemic optic neuropathy. In this case, we report a rare presentation of a bilateral anterior ischemic optic neuropathy after coronary artery bypass graft and speculate on the preoperative hyperhomocysteinemia as an independent risk factor for anterior ischemic optic neuropathy.Case presentationA 56-year-old white man, a tobacco smoker with type 2 diabetes and coronary artery disease, underwent a conventional coronary artery bypass graft with extracorporeal circulation. In spite of ongoing anti-aggregation, antithrombotic, and vasodilator therapy, 10 days after the surgery he complained of severe bilateral visual loss. Funduscopy and fluorescein angiography revealed a bilateral anterior ischemic optic neuropathy. Analysis of preoperative laboratory tests revealed hyperhomocysteinemia.ConclusionHyperhomocysteinemia could increase the risk of ocular vascular damage and bilateral ocular involvement in patients who have undergone conventional coronary artery bypass graft.

Subconjunctival sustained-release dexamethasone implant as an adjunct to trabeculectomy for primary open angle glaucoma

Sir, In the present study, we described the first case series of intraoperative positioning of subconjunctival dexamethasone implant as adjunctive antiscarring agent in patients undergone trabeculectomy for primary open angle glaucoma (POAG). The rationale of subconjunctival dexamethasone implant injection was to reduce the postsurgical overscarring at the site of the bleb, by limiting the first acute inflammatory reaction that represents the primum movens for conjunctival healing. Three eyes of three consecutive patients (three female) with a mean age of 61 ± 14.5 years taking a maximum tolerated dose of intraocular pressure (IOP)-lowering medication for POAG with a recorded IOP of ≥18 mmHg, glaucomatous damage on visual field and underwent trabeculectomy: All patients underwent a limbus-based conjunctival flap with one circumferential and one radial incision, antimetabolite sponge application, and scleral rectangular flap which was sutured with 10-0 nylon suture, sclerostomy with punch a peripheral iridectomy. Before the conjunctival suture with 9-0 vicryl was performed, a subconjunctival apposition without fixation of 0.7 mg sustained-release dexamethasone implant (Ozurdex, Allergan, Inc., Irvine, USA) was obtained. The implant was softly leaned on the sclera posterior to the flap. After 7 days, 1 month, and 2 months, the implant seemed to fragment reducing progressively its dimensions and was no more detectable after 2 months in all eyes [Fig. 1]. Figure 1 Patient with primary open angle glaucoma undergone trabeculectomy and subconjunctival apposition of 0.7 mg sustained-release dexamethasone implant at day 1 (a), day 7 (b), month 1 (c), and month 2 (d). The implant seemed to fragment reducing progressively ... After 2 months, IOP not quite significantly (P = 0.056, nonparametric Mann–Whitney U-test) decreased from 19.3 ± 2.3 mmHg (median: 18, interquartile range [IQR]: 4) at baseline to 15.7 ± 0.6 mmHg (median: 16, IQR: 1) without any glaucoma medication. In all eyes, IOP was ≤16 mmHg (range: 15–16). After 2 months in all the cases, conjunctival scarring at the site of the filtering bleb was not observed. No ocular adverse event or postoperative complications were observed. Corticosteroids have long been used as inflammation modulators of posttrabeculectomy conjunctival healing with significantly success rates, since they act on vascular permeability, as well as white blood cell chemotaxis and function.[1] First evidence of steroids effects in glaucoma surgery came from Starita et al.,[2,3] who investigated the effects of topical and systemic steroids in a randomized prospective trial. They found that topical steroids significantly improved trabeculectomy outcome as compared to the group without steroids at 5 and 10 years. There are studies about the intraoperative subconjunctival injection of triamcinolone acetonide (TA) after bleb-forming filtration surgery.[4] TA injections appeared to be safe in both studies, with no significant adverse events, even if results of a randomized controlled trial about long-term clinical benefits in patients receiving intrableb TA against whom receiving topical steroids only, have not been published yet. The rationale of intraoperative subconjunctival corticosteroid injection was to find a more direct, sustained, and convenient mode of steroid delivery in the operated patients; moreover, the bulk of injected TA would also serve as a barrier between the inflamed conjunctiva and sclera, to avoid adherence in between. In this view, Ozurdex implant would be even more effective than TA, lasting longer and interposing a bigger volume in the conjunctival layers. Subconjunctival implant appears to be well tolerated by operated eyes. However, use of Ozurdex has been associated with several adverse events including posterior subcapsular cataract and a higher risk of eye infections;[5] reasonably, the most threatening glaucoma surgery success is eye pressure increase that may need supplementary IOP lowering medical therapy after trabeculectomy. Effective success of surgery should therefore be taken only several weeks after the operation, when the insert is completely reabsorbed. Limitations of this study were the small sample size and the absence of a control group. The data of this pilot study showed that no serious side effects were noted, subconjunctival Ozurdex was well tolerated and that a controlled study is required to establish the efficacy of this easy to perform the technique. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.