Gibran S. Khurshid

Management of Endogenous Endophthalmitis

Endogenous endophthalmitis is a potentially blinding ocular infection resulting from hematogenous spread from a remote primary source. Endogenous endophthalmitis accounts for only 2–8% of cases of endophthalmitis and usually occurs in the setting of at least a relatively immunocompromised state. Causes include both gram-positive and gram-negative bacteria and fungi. Streptococcal species are the most commonly implicated bacterial organisms; Candida species are the most commonly implicated fungal organisms. Endogenous mold endophthalmitis is rare and typically occurs in the setting of relative immunocompromise or intravenous drug use. Early diagnosis of endogenous endophthalmitis requires a high degree of suspicion and is critical if vision is to be preserved. Therapeutic management includes hospitalization and delivery of broad-spectrum systemic and intravitreal antibiotics. Vitrectomy may be appropriate in some cases. The prognosis of patients with endogenous endophthalmitis is disappointing; even with aggressive treatment, useful vision (i.e., ability to count fingers or better) is preserved in only about 40% of patients.

Long standing exophytic conjunctival papilloma infected with human papillomavirus

Abstract Background: Most conjunctival papillomas are benign in nature. However, any long standing conjunctival mass should not evade the surveillance of carcinogenicity. Presented here is a case of a long standing

Viral Retinitis in the Cancer Patient

Viral retinitis is a vision-threatening infection of the retina that can occur in both immunocompetent and immunocompromised patients and is primarily caused by the human herpesvirus family of viruses. Prompt recognition and treatment are critical for optimal outcomes. This chapter focuses on cytomegalovirus (CMV) retinitis, acute retinal necrosis (ARN), and progressive outer retinal necrosis (PORN). Presentations of CMV retinitis range from an indolent/granular retinitis to a fulminant/edematous retinitis characterized by necrosis and hemorrhage. ARN is a vaso-occlusive necrotizing retinitis that is usually secondary to herpes zoster or HSV. PORN is characterized by primary involvement of the outer retina, minimal to no vitreous inflammation, and extremely rapid progression. Treatment of CMV retinitis consists of improving the patient’s immune status and then administering induction and maintenance antiviral therapy. For ARN, intravenous acyclovir is the standard initial treatment; oral acyclovir is then employed for variably prolonged periods. Because of PORN’s poor prognosis, a multidisciplinary approach with an infectious disease consultation is favored. In patients with viral retinitis, argon laser photocoagulation posterior to the edge of necrosis may be performed as prophylaxis against retinal detachment, which is the major cause of visual loss after acute manifestations have resolved. Retinal detachments in patients with CMV retinitis have been approached with scleral buckling, gas pneumatic retinopexy, and vitrectomy with either gas or silicone oil tamponade. Visual prognosis is guarded for patients with CMV retinitis or ARN and extremely poor for patients with PORN.

Diagnostic Vitrectomy and the Cancer Patient: Special Considerations

The term diagnostic vitrectomy is used to refer to biopsy of the vitreous or the uvea. In patients with a history of cancer, there is a low clinical threshold for diagnostic vitrectomy as vitritis can represent recurrence of lymphoma or leukemia or an opportunistic infection. The most common clinical scenarios in which diagnostic vitrectomy is performed in cancer patients are new-onset vitreous cellularity in a patient with lymphoma in remission or newly diagnosed lymphoma; vitritis in a patient with recent bone marrow transplantation; atypical retinitis or choroiditis; and atypical iris, ciliary body, or choroidal lesions. In addition, choroidal biopsy is sometimes done to obtain material for cytogenetic studies in patients with uveal melanoma. Vitreous biopsy can be performed successfully with either a two-port or three-port approach; specifics of the technique depend on the vitrector gauge. Uveal biopsy can be performed with fine-needle aspiration biopsy or with transretinal choroidal biopsy with a sutureless vitrectomy system, an approach that is gaining favor. Collaboration and good communication between the ophthalmologist and a pathologist well versed in the handling and analysis of vitreous samples are essential for successful diagnostic vitrectomy.