Hin-Yeung Tsai

Intracameral Voriconazole Injection in the Treatment of Fungal Endophthalmitis Resulting From Keratitis

PURPOSE To report the therapeutic efficacy of intracameral voriconazole injection in the treatment of fungal endophthalmitis resulting from keratitis. DESIGN Retrospective, single-institution, consecutive case series. METHODS Microbiologic and medical records were reviewed for patients with positive intraocular culture results or proven pathologic features for fungal organisms and clinically diagnosed fungal endophthalmitis resulting from keratitis. Ten eyes were treated with an intracameral injection of 100 microg voriconazole. Clinical characteristics, treatment, and causative organisms were analyzed. RESULTS Fusarium and Aspergillus were the most common causative organisms. Voriconazole was injected intracamerally from 1 to 8 times. Of the 7 patients who received 5 or more repeat injections, 6 were caused by Fusarium and 1 by Acremonium. In the remaining 3 patients who were administered 4 or fewer voriconazole injections, the causative organisms were Aspergillus and Alternaria. CONCLUSIONS Intracameral voriconazole injection may be an effective treatment for fungal endophthalmitis contiguously spreading from keratitis.

Pharmacokinetics of Intracameral Voriconazole Injection

ABSTRACT Elimination of voriconazole after intracameral injection exhibited an exponential decay with a half-life of 22 min. Voriconazole levels in the vitreous humor were below the detectable limit. The aqueous concentrations achieved with a 25-μg dose during the first 2 h were greater than the previously reported MICs of organisms most involved in fungal endophthalmitis. A rapid decline in intracameral concentration suggests that frequent supplementation of intracameral voriconazole may be required in clinical settings.

Diffuse lamellar keratitis induced by toxic chemicals after laser in situ keratomileusis.

PURPOSE: To assess whether toxic chemicals produced during autoclaving sterilization were 1 of the main causes of diffuse lamellar keratitis (DLK) and to analyze the clinical outcomes of patients developing DLK after laser in situ keratomileusis (LASIK) treated with intensive topical corticosteroids. SETTING: Department of Ophthalmology, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China. METHODS: A total of 14 eyes of 7 patients received technically smooth LASIK and developed DLK, including 6 severe and 8 mild DLK cases. In all eyes the same microkeratome was used; it was contaminated with toxic chemical materials produced accidentally by coautoclaving instruments and a foam piece. RESULTS: Six eyes of 3 patients developed severe DLK on the same day, and 8 eyes of 4 patients developed mild DLK during the next LASIK surgery. After intensive topical corticosteroid treatment, lamellar infiltrates disappeared in 3 days in mild DLK eyes and 2 weeks in severe DLK eyes. No eye was treated with flap lifting and interface irrigation. For grade 4 DLK, the corneal opacity and flap folds disappeared in 4 weeks. There were no instances of permanent corneal scarring or loss of best spectacle‐corrected visual acuity. CONCLUSIONS: Toxic chemicals produced during instrument autoclaving sterilization are a possible cause of DLK. Immediate diagnosis and treatment with intensive corticosteroid drops are critical and can resolve severe DLK.

Supratarsal triamcinolone injection in the treatment of superior limbic keratoconjunctivitis.

Purpose: To evaluate the efficacy of supratarsal triamcinolone injection in the treatment of superior limbic keratoconjunctivitis (SLK). Methods: Forty eyes of 20 patients were diagnosed with SLK. All eyes with long-standing severe ocular irritation unresponsive to topical steroid and artificial tears were treated with supratarsal triamcinolone injection in addition to ongoing treatment of dry eye. Objective tarsal conjunctiva inflammation, bulbar conjunctiva, cornea staining, and subjective symptom gradings were performed before and after 2 weeks of therapy. All patients underwent laboratory evaluations of underlying systemic abnormalities. Results: All 40 eyes responded well to treatment and had long-term (average, 7.8 months) improvement of irritation and dry sensation and improvement of inflammation and staining of conjunctiva and cornea. Fourteen patients (70%) had associated autoimmune diseases. There were no irreversible complications related to this therapy. Conclusions: Supratarsal triamcinolone injection effectively and rapidly resolved symptoms and signs associated with SLK. It is helpful as primary or adjunctive therapy for SLK.

Comparison of Voriconazole Concentration in the Aqueous Humor and Vitreous between Non-Scraped and Scraped Corneal Epithelium Groups after Topical 1% Voriconazole Application

Purpose: To investigate the penetration of topical 1% voriconazole through the cornea into the aqueous humor in New Zealand white rabbits and to determine the effect of mechanical scraping of the corneal epithelium. Materials and Methods: The right eyes of 29 New Zealand white rabbits were maintained with the epithelium intact, and the left eyes underwent mechanical epithelium debridement of the central 7.5 mm of the cornea. A loading dose consisted of a drop of 1% voriconazole applied every 5 min for the initial half hour and followed by a maintenance dose consisting of a drop every 20 min, which was applied for about 2 hr. Then, the first sample was obtained 5 min after the first seven doses (loading dose) were given, and then four more samples were taken 5 min after four more subsequent drops (maintenance dose). The samples were analyzed by high performance liquid chromatography. Results: The mean aqueous concentration of voriconazole was 33.44 ± 5.77 μg/mL 5 min after the loading dose in the non-scraped group and 57.67 ± 6.77 μg/mL in the scraped group, respectively. The mean aqueous concentration of voriconazole was maintained in a range from 19.97 to 23.70 μg/mL 5 min after the maintenance doses in the non-scraped group and from 44.44 to 49.02 μg/ mL in the scraped group. The mean vitreous concentration of voriconazole ranged from 0.38 to 0.49 μg/mL in the non-scraped group and ranged from 0.72 to 0.94 μg/mL in the scraped group. These levels were statistically significant (P < 0.05) between the scraped and non-scraped groups. Conclusions: Topically administered voriconazole achieved minimum inhibitory concentrations in the aqueous for all the organisms most commonly involved in fungal endophthalmitis and achieved minimum inhibitory concentrations in the vitreous for some pathogenic fungi. The concentrations of voriconazole were higher in the scraped group than in the non-scraped group.

Normal Tension Glaucoma is not Associated With the Interleukin -1?? (???889) Genetic Polymorphism

BackgroundFactors other than intraocular pressure are likely to play a role in the pathogenesis of glaucomatous optic neuropathy, particularly in individuals with normal tension glaucoma (NTG). Recent laboratory evidence has shown that there are potential similarities between Alzheimer disease and NTG in cellular apoptosis leading to neurodegeneration. IL-1α (−889) T allele polymorphism has been found to increase the risk of developing Alzheimer disease. The aim of this study was to test in a Chinese cohort the hypothesis that IL-1α (−889) polymorphism is associated with NTG. MethodsOne hundred sixty-two unrelated patients with NTG were recruited and compared with 167 controls in a Chinese population. Genomic DNA was amplified by polymerase chain reaction, followed by enzymatic restriction fragment length polymorphism technique. Patients and controls were genotyped for the C/T polymorphism at position −889 of the IL-1α gene promoter region. ResultsThere was no significant difference in the frequency of IL-1α (−889) alleles or genotypes in the NTG population compared with that in the control group. ConclusionsWe conclude that C/T polymorphism at position −889 of the IL-1α gene promoter region does not increase the risk of developing NTG. However, further studies on NTG are necessary to investigate the genetic basis and factors involved in the development of the neurodegenerative process.

Aniseikonia Following Pneumatic Retinopexy for Rhegmatogenous Retinal Detachment

PURPOSE To evaluate the characteristics of aniseikonia in patients with rhegmatogenous retinal detachment (RD) after pneumatic retinopexy. DESIGN Prospective, interventional case series study. METHODS Thirty patients who had undergone pneumatic retinopexy as the initial procedure for rhegmatogenous retinal detachment were selected for this study. The principal outcomes included visual acuity, postoperative aniseikonia measured by the New Aniseikonia Test, anatomical success, and measurement of central retinal thickness using optical coherence topography (OCT). These outcomes were measured postoperatively at 3, 6, and 12 months. RESULTS The median patient age was 37 years (range, 13-57 years), with 17 cases of macula-off RD and 13 cases of macula-on RD. All of these patients achieved anatomical success, proven by OCT after surgical repair. Three months after pneumatic retinopexy, 18 patients (60.0%) developed micropsic aniseikonia and aniseikonia was diagnosed in 15 patients (88.2%) in the macula-off RD group, leaving 2 patients (11.8%) unaffected. In the macula-on RD group, 3 patients (23.1%) were found to have aniseikonia, while 10 patients (76.9%) were unaffected. The presence of aniseikonia was strongly linked to the difference in central retinal thickness, between the operated eye and the fellow eye, measured at 12 months postoperatively. CONCLUSION Aniseikonia after pneumatic retinopexy for rhegmatogenous RD may be related to the preoperative macular status. Macula-off RD patients had a higher incidence of aniseikonia, compared to macula-on RD patients, following retina reattachment. There was a moderate to high correlation between the grading of aniseikonia and the difference in central retinal thickness.

Subconjuntival Fat Prolapse after Autogenous Fat Graft: A Case Report

Purpose: To report an extremely rare case of subconjunctival herniated orbital fat and grafted fat after autogenous fat graft.Method: A case report.Results: A 51 year-old non-obese female suffered from redness and several subconjunctival masses in the right eye over the upper and temporal lower subconjunctival areas. The masses were noted after autogenous fat grafting from the abdomen to the periorbital hollows. The ocular examination revealed multiple subconjunctival yellow masses and conjunctival injection. Excision of the subconjunctival fat pad was done one year after autogenous fat graft surgery. The histopathology revealed fatty tissue and lipogranuloma formation with peripheral histiocyte infiltration. The orbital fat and grafted fat herniated between the conjunctiva and the sclera, presumably due to high intra-orbital pressure after fat grafting, resulting in dehiscence of the Tenons capsule.Conclusion: We present an extremely rare case of subconjunctival fat herniation, which could be complicated after autogenous fat graft. Ophthalmologists and plastic surgeons should be aware of the possibility of this complication.

Late-Onset Interface Abscess after LASIK

Purpose: To report a rare case of interface abscess 3 years after laser in situ keratomileusis (LASIK). Method: Observational case report. We described a case of 24-year-old man who had a history of uneventful corneal flap surgery and presented with interface abscess. Results: The corneal flap was lifted and irrigated with antibiotic solution. Pathology of the abscess showed scant viable epithelial cells in cell debris. Upon microbiological investigation, the microorganism isolated was Staphylococcus epidermidis. It is postulated that epithelial injury or hypoxia could induce alterations in the metabolism, break down epithelial protection, and allow epithelial cells and normal flora bacteria to enter spaces with little resistance. Conclusion: Our case indicates that infectious interface abscess can occur several years after corneal flap surgery. Rapid recognition of the causative organism and aggressive medical and surgical management of the infection can improve the prognosis. Epithelial ingrowth may be associated with an increase of the risk of late-onset interface abscess.

Elevated Intraocular Pressure Post-Hemodialysis after Simple Pars Plana Vitrectomy: A Case Report

Purpose: To report a case of marked elevated IOP during and post-dialysis after vitrectomy. Case: a 72 year-old man complained of transient blurred vision of left eye during hemodialysis after vitrectomy. Results: A 72 year-old male presented with marked IOP elevation of his left eye after hemodialysis. This episode did not happen before vitrectomy. Transient blurred vision was complained without headache or nausea when IOP was markedly elevated. Despite medication with timolol and xalatan, the marked IOP elevation of left eye after hemodialysis was still noted. Anterior chamber angle narrowing was found during OPD follow up postoperatively. After consulting with nephroloists, dialyhsate flow rate was shifted from 750ml/min to 500 ml/min and the acetate dialysate was replaced by a bicarbonate type. The marked IOP elevation decreased (55mmHg →35mmHg → 21mmHg). Transient blurred vision of left eye during dialysis rarely happened after dialysate parameters were changed. Conclusion: IOP elevation during or after dialysis is a rate complication in patients with ESRD in the recent years. This has been attributed to dialysate parameters and flow rate. However, if the angle is compromised, especially post-vitrectomy, transient markedly elevated IOP could occur when rapid dialysis is performed.