Maria Elena Gregory

Incidence of periorbital necrotising fasciitis in the UK population: a BOSU study

Background Periorbital necrotising fasciitis (PNF) is a devastating infection of subcutaneous soft tissue and underlying fascia causing severe morbidity and even loss of life. Few case reports of PNF exist and there are no prospective epidemiological studies. Methods A prospective observational study was undertaken using the British Ophthalmological Surveillance Unit reporting system. Questionnaires were sent to reporting ophthalmologists in the UK seeking cases of PNF over a 2-year period. Results 30 new cases were confirmed. 16 of the reported cases followed a precipitating event, 9 cases followed trauma and 3 followed surgery. β-haemolytic Streptococcus A was the causative organism identified in 76%, either alone or with concurrent infection, and antibiotic sensitivities are discussed. Systemic complications occurred in the majority of cases (66.6%), with sepsis and death occurring in 10%. Over 50% of surviving patients had subsequent morbidity, reduced acuity (<6/18) being common. Conclusion PNF is a rare, dangerous condition. This study identified an incidence of 0.24 per 1 000 000 per annum in the UK. β-haemolytic Streptococcus A is the most common causative organism. Mortality remains a potential outcome, and survivors suffer significant morbidity. Early intravenous antibiotic management with a consensus favouring penicillin and clindamycin combined with debridement.

Combined amniotic membrane transplant and anterior stromal puncture in painful bullous keratopathy: clinical outcome and confocal microscopy.

OBJECTIVE To report the outcomes of anterior stromal micropuncture (ASP) combined with amniotic membrane transplantation (AMT) in the management of painful bullous keratopathy (BK) with poor visual potential, and to assess amniotic membrane (AM) retention. DESIGN Case series, retrospective review. PARTICIPANTS Twelve eyes of 12 patients with BK causing intractable pain or discomfort and poor visual potential, treated between March 2006 and October 2008 at Gartnavel General Hospital, Glasgow. METHODS Epithelial debridement was followed by ASP and the amniotic membrane was stabilized with a purse-string 10/0 nylon corneal suture and a bandage contact lens. During a mean follow-up of 67 weeks (range, 27-139 weeks), pain relief, epithelial healing, visual changes, confocal microscopy, and appearance of new bullae were evaluated. Success was defined as complete resolution or significant improvement in pain. RESULTS Twelve eyes of 12 patients, mean age 61 years (range, 40-88 years), were identified. Corneal epithelial healing was complete in 11 eyes 1 month postoperatively. Pain and conjunctival inflammation resolved in 11 patients (91.67%) and improved from severe to mild in the remaining patient. Incorporation of the AMT was observed on slit-lamp biomicroscopy in all eyes and was confirmed using confocal microscopy at final follow-up. CONCLUSIONS ASP combined with AMT is safe and effective, alleviates pain and discomfort, reduces ocular inflammation, and promotes epithelial healing and resolution of bullae in patients with BK with poor visual potential. There was long-term evidence of amniotic membrane graft retention in all eyes after the procedure, suggesting that ASP may improve the long-term retention rate of AM.

Bilateral full thickness macular holes in association with serpiginous choroiditis.

Purpose: To report serpiginous choroiditis associated with full thickness macular holes (FTMH). Design: Interventional case report. Methods: A 58-year-old female with bilateral serpiginous choroiditis developed right-sided blurred vision and metamorphopsia. Ocular assessment, FFA, OCT, and right macular hole surgery were performed. Results: Preoperative visual acuity was 6/36 right, 6/9 left. Fundus assessment found bilateral geographic chorioretinal scarring, epiretinal membranes, right FTMH, and mild vitritis. OCT revealed bilateral FTMHs. Pars plana vitrectomy, membrane peel, and gas tamponade resulted in right macular hole closure, visual acuity improvement (6/18) and resolution of metamorphopsia. Conclusions: Macular hole may be another posterior segment complication of serpiginous choroiditis.

Dorsal Midbrain Syndrome with Loss of Motor Fusion: a Rare Association

Introduction: Dorsal midbrain syndrome (DMS) is characterized by upgaze paralysis, convergence-retraction nystagmus, and eyelid retraction. Impaired downgaze and pupillary light-near dissociation may co-exist, while less common features including exotropia and convergence paralysis have also been described. However, loss of motor fusion is not a well recognised finding in DMS. Purpose: To describe DMS associated with loss of motor fusion. Methods: Retrospective case series. Results: Five patients (age 21-80 years) presented with features of DMS due to severe head injury (n=1), brainstem stroke (n=3) and pinealoma (n=1). All five complained of constant diplopia with horizontal and vertical separation and had an exotropia (range 20Δ to 70Δ), absent convergence and motor fusion. Two underwent strabismus surgery and subsequently had a variable improvement in their motor fusion. The remaining three patients were managed with occlusion. Conclusion: This case series illustrates the complexity of ocular motility findings associated with DMS and highlights the potential difficulties in the management of patients with loss of motor fusion.

Observation of the in vivo movement of host keratocytes into donor tissue following corneal graft; a novel technique

Background/aims The cornea is a highly cellular structure that exists in a dynamic state of cell loss, renewal and replacement. The limbus contains corneal epithelial stem cells. The progenitor or stem cell of the keratocyte remains poorly defined. The authors sought to investigate the in vivo movement of corneal stromal and epithelial cells using a chromosome in situ hybridisation (CISH) technique on human tissue. Methods Four explanted sex-mismatched human corneal buttons were studied using the CISH technique to identify corneal epithelial and keratocyte cells containing the Y chromosome. Keratocyte identity and lack of infiltrating inflammatory cells were confirmed by immunohistochemistry. The sex mismatch of donor (XX) and host (XY) suggested any identified Y chromosomes cells were of host origin having migrated into the donor tissue. Results Host corneal epithelial cells were identified in all four buttons, and corneal stromal keratocytes were present in three of the four specimens in the central corneal area. Conclusion Defining the corneal cell movements and the location of the progenitor or stem cells has important clinical implications. This study has successfully used the CISH technique to demonstrate the in vivo centripetal movement of corneal stromal keratocytes and epithelial cells. The CISH technique may allow further investigation of the corneal stromal dynamics using archival tissue.

Excision of granulation tissue and free conjunctival autograft in the management of necrotizing scleritis.

Purpose: To describe a novel use of conjunctival autograft in the management of surgically induced scleral necrosis that occurred after squint surgery. Methods: Interventional case report. Results: A 22-year-old man underwent bilateral adjustable squint surgery. Two weeks postoperatively, he developed conjunctival retraction and an area of scleral necrosis/melting with 80% thinning. The surrounding conjunctiva was markedly inflamed with raised edges. Screening for autoimmune and vasculitic conditions did not provide any positive results. The conjunctiva surrounding the area of scleral melt was excised and the area covered by a conjunctival autograft resulting in complete healing of the scleral melt within 1 month of surgery. Conclusion: The pathogenesis of surgically induced scleral necrosis not associated with autoimmune conditions may be the result of the products of inflammation and lytic enzymes released by the surrounding conjunctival tissue initiating the scleral melting process. This type of surgically induced scleral necrosis may be successfully managed by excision of the surrounding inflamed conjunctiva, thus removing a potential source of collagenases, and covering the exposed sclera by a conjunctival transplant obviating the need for prolonged high-dose immunosuppression.

Recurrent Fungal Keratitis Following Penetrating Keratoplasty: An Unusual Source of Infection

Report of a Case. A 75-year-old woman visited us in 2007 with left ocular discomfort for 1 month. She had previous bilateral penetrating keratoplasties (for the right eye in 1998 and for the left eye in 2004) for decompensated Fuch’s endothelial dystrophy. She had undergone trabeculectomy with mitomycin C (in 2006) and was using topical dexamethasone sodium phosphate, 0.1%, daily in the left eye. Her medical history included uterine carcinoma, treated Hodgkin lymphoma, pulmonary embolism, emphysema, hypertension, ischemic heart disease, hyperthyroidism, and renal failure. Visual acuity was 6/12 (20/40) OD with clear corneal graft and 6/36 (20/100) OS. Examination of the left eye revealed a deep stromal infiltrate measuring 2 1.3 mm and with hypopyon (Figure, A). Steroid eyedrops were temporarily stopped, and treatment with cefuroxime sodium, 5%, and gentamicin sulfate, 0.3%, was commenced. Anterior chamber tap and corneal biopsy yielded a heavy growth of C parapsilosis. The treatment regimen was changed to intensive topical fluconazole, 0.2%, ofloxacin, and oral voriconazole (400 mg loading followed by 200 mg twice daily). Topical dexamethasone was reintroduced owing to evidence of rejection at day 7 and was gradually tapered as the abscess and graft edema resolved over the following 2 months. Keratitis recurred 2 months after discontinuing antifungal agents (Figure, B). Empirical treatment with fluconazole, 0.2%, and oral itraconazole, 100 mg twice daily, was commenced. Gentamicin, 1.5%, and cefuroxime, 5%, were added, and itraconazole was changed to voriconazole as the keratitis progressed

The intraoperative use of polydioxanone foil to reduce the risk of sino-orbital fistula formation in orbital exenteration

ABSTRACT Background: Orbital exenteration is a radical surgical procedure resulting in deformity. It involves removal of the globe, optic nerve, extra-ocular muscles, orbital fat, lacrimal gland, and peri-osteum. Sino-orbital fistula (SOF) formation is a common documented post-operative complication, usually connecting the orbit and the ethmoid sinus. SOFs can cause leaks of serous fluid, and act as an entry site for pathogens into the orbit leading to socket infection and breakdown. Methods: This retrospective study analyzed exenterations performed over a 22-year period (1993—2015) at the National Ocular Oncology Service Centre for Scotland. PDS is a crystalline, biodegradable polyether-ester that is strong with good shape-memory and flexibility. Orbital exenterations with and without the use of PDS foil were compared in terms of SOF formation. Results: A total of 30 exenterations were performed during the study period. A total of 29 were analyzed. Choroidal malignant melanoma was the most common indication for performing orbital exenteration (n = 7, 24.14%). The most common post-operative complications seen were SOF (n = 8, 27.59%). A total of 8 out 21 (38.10%) cases not using PDS developed SOFs. By contrast, none of nine patients receiving PDS plates developed SOFs (p = 0.0332). Conclusions: This is the first study to compare SOF rate in patients undergoing exenteration with and without the use of PDS foil. PDS foil is a safe material, which has effectively reduced the incidence of SOF formation

Bilateral central retinal artery occlusion in a patient with primary central nervous system lymphoma

Dear Editor Primary intraocular lymphoma (PIOL), a subset of primary central nervous system lymphoma (PCNSL), is the commonest neoplastic masquerade syndrome, often leading to delay in diagnosis and poor prognosis [1]. We report a case of bilateral central retinal artery occlusion (CRAO) preceding ocular recurrence of PCNSL. A 58-year-old male had a left frontal lobe tumour debulked in September 2007. Histology showed a diffuse large B-cell lymphoma in keeping with PCNSL. Staging eye examination at the time was negative. In spite of methotrexate-based chemotherapy, the CNS lymphoma progressed, requiring total brain radiotherapy. Further scanning in February 2008 showed complete response to treatment. His concurrent medical problems included steroid-induced diabetes, hypertension and pulmonary embolism for which he was on low molecular weight heparin. He presented to the ophthalmic department with a 4-week history of right-sided painless visual loss in March 2008. Eye examination revealed no perception of light in the right eye, afferent pupillary defect, pale oedematous retina, a cherry red spot, and segmentation of blood within the retinal vessels caused by CRAO. Left visual acuity was 6/60; fundoscopy revealed background diabetic retinopathy, and age-related macular degeneration. History, clinical examination, and investigations were negative for giant cell arteritis (normal erythrocyte sedimentation rate, C-reactive protein, and blood count). The patient returned 1 month later with painful right rubeotic glaucoma, hyphaema, and vitreous haemorrhage restricting fundoscopy. B-scan ultrasonography revealed a highly reflective choroidal mass, measuring 15.9 × 18.1 mm and 4 mm in height, associated with retinal detachment (Fig. 1). Lymphomatous infiltration was suspected. A substantial vitreous biopsy was negative. Staging magnetic resonance imaging excluded intracerebral recurrence, optic nerve/sheath, and systemic involvement. Despite topical treatment the right eye remained painful and was enucleated. Histopathological examination revealed a necrotic tumour with viable peripheral rim, with sheets of lymphoid cells replacing the retina and confined to the subretinal space. Immunohistochemical staining showed the tumor cells were positive for CD20, MUM-1, BCL-2 with patchy staining for CD30, and were negative for BCL6 and CD10.The proliferation fraction with Ki-67 was high (95%). This confirmed diffuse large B-cell lymphoma identical to the original brain biopsy. A thrombus was identified within a central vessel, in keeping with CRAO. The retina was necrotic, with no vascular invasion. The optic nerve was atrophic, and free from tumour infiltration. Left vision subsequently decreased to perception of light in September 2008. Examination confirmed CRAO. Two weeks later, the retinal oedema decreased and pale retinal creamy lesions with retinal exudation and vitritis became evident, suggesting left ocular lymphoma. Further staging and lumbar puncture confirmed significant recurrent CNS lymphoma, but no evidence of optic nerve/sheath infiltration. A course of palliative left orbital irradiation was completed in November 2008. Unfortunately, the patient died in January. Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.