An uncommon case of brucellosis with ocular presentation / Um caso incomum de brucelose com apresentação ocular

ABSTRACT We report an unusual case of brucellosis presented with headache, diminished vision, papillitis and multiple peripapillary hemorrhages accompanied by subretinal fluid extending up to macula. Diagnosis of brucellosis was made based on positive polymerase chain reaction of cerebrospinal fluid sample for Brucella species DNA, accompanied by a raised titer of anti-brucella antibodies. Patient showed remarkable improvement on triple drug therapy in form of doxycycline, rifampicin and ceftriaxone.

RESUMO Relatamos um caso incomum de brucelose apresentada com cefaleia, visão diminuída, papilite e múltiplas hemorragias peripapilares acompanhadas por fluido sub-retinal, estendendo-se até a mácula. O diagnóstico de brucelose foi feito com base na reação em cadeia da polimerase positiva de amostra de líquido cefalorraquidiano para DNA de espécies de Brucella, acompanhada por um título elevado de anticorpos antibrucela. O paciente apresentou melhora notável com a terapia tripla com drogas na forma de doxiciclina, rifampicina e ceftriaxona.

Infectious keratitis in southern Brazil: a comparison culture negative and culture positive patients / Ceratite infecciosa no sul do Brasil: comparação entre pacientes com cultura negativa e positiva

Abstract Purpose: To compare clinical-epidemiological profile and treatment outcome between culture negative and culture positive keratitis patients. Methods: Patients with suspected infectious keratitis seen at two ophthalmic hospitals in Curitiba, Brazil, between June 2014 and April 2016, were prospectively studied. Ophthalmological exam with corneal scraping and microbiological tests were performed. Data regarding follow up, surgical interventions and treatment outcome were collected after 12 weeks of the first visit trough medical chart review. From the results of the culture, two groups were formed: culture negative keratitis (CNK) and culture positive keratitis (CPK). Results: According to inclusion criteria 21 patients were classified as culture negative keratitis and 20 patients as culture positive keratitis. The number of patients on antibiotic drops at the first visit was greater in CNK group (90.5% versus 60%; p=0.032). Surgical procedures were necessary in 3 patients (15%) in CNK group and in 7 patients (36,8%) in CPK group (p=0.155). Treatment success was achieved by 85% (17/20) of the patients in CNK group and by 61% (11/18) of the patients in CPK group (p=0.144). There was no significant difference between groups regarding age, gender, place of residence, presence of comorbidities, risk factors for infectious keratitis, duration of symptoms and characteristics of corneal ulcer. Conclusions: Previous treatment with antibiotics correlates with negative culture results. There was no significant difference in treatment outcome between culture negative and culture positive keratitis patients.

Resumo Objetivo: Comparar os perfis clinico-epidemiológicos e os desfechos entre pacientes com ceratite com cultura positiva e pacientes com ceratite com cultura negativa. Métodos: Pacientes com ceratite infecciosa, atendidos em dois hospitais oftalmológicos em Curitiba, Brasil, entre junho de 2014 e abril de 2016, foram estudados prospectivamente. Exame oftalmológico, raspado de córnea e exames microbiológicos foram realizados no primeiro atendimento. Os dados quanto a seguimento e desfecho foram coletados após 12 semanas do primeiro atendimento através de revisão de prontuário. A partir dos resultados das culturas, dois grupos foram formados: ceratite com cultura negativa e ceratite com cultura positiva. Resultados: Vinte e um pacientes foram classificados como ceratite com cultura negativa e 20 como ceratite com cultura positiva. O número de pacientes em uso de colírio antibiótico no primeiro atendimento foi maior no grupo de cultura negativa (90,5% versus 60%; p=0,032). Sete pacientes (37%) no grupo cultura positiva precisaram de procedimentos cirúrgicos no manejo da ceratite, versus 3 pacientes (15%) do grupo cultura negativa (p=0,155). Oitenta e cinco por cento (17/20) dos pacientes do grupo cultura negativa alcançaram sucesso no tratamento, contra 61% (11/18) dos pacientes no grupo cultura positiva (p=0,144). Não houve diferença entre os grupos quanto a idade, gênero, local de procedência, presença de comorbidades, fatores de risco, duração dos sintomas e características da úlcera de córnea. Conclusão: Tratamento prévio com colírio de antibiótico correlaciona-se com resultados negativos de cultura. Não houve diferença no desfecho após tratamento entre os pacientes com cultura negativa e cultura positiva.

Neurosyphilis and ocular syphilis clinical and cerebrospinal fluid characteristics: a case series / Características clínicas e liqúoricas de pacientes com neurossífilis e sífilis ocular: uma série de casos

ABSTRACT Background During the first decade of this century, a significant increase in the incidence of syphilis was documented. Objective To study clinical and laboratory characteristics of central nervous system and ocular syphilis. Methods A retrospective case series of 13 patients with a clinical and laboratory diagnosis of neurosyphilis and/or ocular syphilis who had been admitted to the Neurology and Neuro-ophthalmology Service of the Hospital de Clínicas, Federal University of Paraná. Results Nine patients had a diagnosis of neurosyphilis and two of them also had ocular syphilis. Four patients had a diagnosis of ocular syphilis alone. Among the patients with a diagnosis of neurosyphilis, six had symptomatic syphilitic meningitis, of whom one manifested as cranial nerve palsy alone, one as cranial nerve palsy plus ocular syphilis, two as transverse myelitis (syphilitic meningomyelitis), one as meningitis worsening the patient's myasthenia gravis symptoms and one as meningitis plus ocular syphilis. Additionally, we diagnosed three patients with meningovascular neurosyphilis. In the univariate analysis, patients without ocular syphilis showed greater levels of total protein and white blood cells in the cerebrospinal fluid than patients with ocular syphilis. Conclusion This Brazilian case series of patients with neurosyphilis and ocular syphilis highlights the wide variability of this disease. A high degree of diagnostic suspicion is necessary when facing neurological and ocular symptoms for rapid diagnosis and appropriate management of patients.

RESUMO Introdução Na primeira década deste século observou-se um aumento significativo da incidência de sífilis no mundo. Objetivo Estudar características clínicas e laboratoriais da sífilis no Sistema Nervoso Central e da sífilis ocular. Métodos Estudou-se, retrospectivamente, uma série de treze casos com diagnóstico clínico e laboratorial de neurossífilis e/ou sífilis ocular, admitidos aos Serviços de Neurologia ou Neuroftalmologia do Hospital de Clínicas da Universidade Federal do Paraná. Resultados Nove pacientes tiveram diagnóstico de neurosífilis e dois destes apresentaram concomitantemente sífilis ocular. Quatro pacientes tiveram somente o diagnóstico de sífilis ocular. Dos pacientes com diagnóstico de neurosífilis, seis apresentaram meningite sifilítica sintomática, dentre os quais um se apresentou com paralisia isolada de par craniano, um com paralisia de par craniano associada sífilis ocular, dois com mielite transversa (manifestação de meningomielite), um com meningite que agravou sintomas de Miastenia Gravis e um com meningite isolada associada a sífilis ocular. Houve 3 casos de neurosífilis meningovascular. Na análise univariada, pacientes sem manifestações oculares de sífilis apresentaram maiores níveis proteína total e leucócitos do que os pacientes com sífilis ocular. Conclusão Essa série brasileira de casos de pacientes com neurosífilis e sífilis ocular destaca a alta variabilidade clínica desta doença. Alto grau de suspeição diagnóstica é necessário quando em frente a sintomas neurológicos e oculares para rápido diagnóstico e adequado manejo dos pacientes.

Celulitis orbitaria complicada por absceso subperióstico debido a infección por Streptococcus pyogenes / Orbital cellulitis complicated by subperiosteal abscess due to Streptococcus pyogenes infection

Resumen: Introducción: La celulitis orbitaria es una enfermedad infecciosa muy frecuente en la edad pediátrica que puede provocar el desarrollo de severas complicaciones. Los principales microorganismos involucrados son Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae y Moraxella catarrhalis, que juntos corresponden al 95% de los casos. También se pueden presentar Streptococcus beta hemolíticos y microorganismos anaerobios, que corresponden a menos del 5% de los casos. Se presenta un caso poco frecuente de celulitis orbitaria complicada por absceso subperióstico ocasionado por Streptococcus pyogenes (estreptococo beta hemolítico del grupo A). Caso clínico: Paciente masculino de 9 años de edad con antecedente de trastorno por déficit de atención e hiperactividad desde los 5 años de edad. Inició su padecimiento actual por presentar eritema en canto externo del ojo derecho; posteriormente, aumento de volumen periorbicular con limitación de apertura palpebral, progresión a proptosis, dolor a los movimientos oculares y secreción conjuntival purulenta. Los estudios de imagen subperióstico reportaron absceso y preseptal derecho con celulitis extraocular. Se inició manejo empírico con antibióticos, drenaje quirúrgico y cultivo del material purulento. De este, se aisló Streptococcus pyogenes. Conclusiones: Debido a la implementación de los esquemas de vacunación desde la década de los 90 contra H. influenza y S. pneumoniae, los casos por estos patógenos han disminuido, provocando que nuevas bacterias tomen su lugar como causantes de la infección. La importancia de considerar a S. pyogenes como etiología de celulitis orbitaria radica en la rápida progresión para la formación de abscesos, así como los pocos casos descritos en la literatura.

Abstract: Background: Orbital cellulitis is an infectious disease that is very common in pediatric patients, in which severe complications may develop. Etiological agents related to this disease are Haemophilus influenzae B, Staphylococcus aureus, Streptococcus pneumoniae and Moraxella catarrhalis, which correspond to 95% of cases. Moreover, Streptococcus beta hemolytic and anaerobic microorganisms may also be present corresponding to < 5% of the cases. We present an uncommon case of cellulitis complicated by sub-periosteal abscess caused by Streptococcus pyogenes (Group A beta hemolytic streptococcus). Case report: A 9-year-old male patient with a history of deficit disorder and hyperactivity since 5 years of age. His current condition started with erythema in the external edge of the right eye, increase in peri-orbicular volume with limitation of eyelid opening, progression to proptosis, pain with eye movements and conjunctival purulent discharge. Image studies reported subperiosteal abscess and preseptal right with extraocular cellulitis. The patient started with empirical antibiotic treatment, surgical drainage and culture of purulent material from which Streptococcus pyogenes was isolated. Conclusions: Due to the implementation of vaccination schemes against H. influenza and S. pneumoniae since the 90s, the cases by these pathogens have decreased, causing new bacteria to take place as the cause of the infection. The importance of considering S. pyogenes as an etiology of orbital cellulitis is the rapid progression to abscess formation, and the few cases described in the literature.

Factors Affecting Treatment Outcome of Graft Infection Following Penetrating Keratoplasty

PURPOSE: To evaluate the factors affecting treatment outcome of graft infection following penetrating keratoplasty (PKP). METHODS: In this retrospective study, 28 patients who underwent PKP between January 2005 and January 2013 and who were diagnosed with graft infection were classified into a treatment success group or a treatment failure group. Demographic and clinical characteristics, as well as the results of the microbiologic investigation, were analyzed and compared. A subsequent binary logistic regression analysis was performed to identify the prognostic factors affecting treatment outcome. RESULTS: Graft infection occurred at a mean of 38.29 +/- 36.16 months (range, 1 to 96 months) after PKP. Seventeen patients developed bacterial keratitis, and 11 patients developed fungal keratitis. Overall, of the 28 patients, nine (32.1%) were classified in the treatment failure group. Multivariate analysis identified pre-existing graft failure (p = 0.019), interval longer than 72 hours between donor death and PKP (p = 0.010), and fungal infection (p = 0.026) as significant risk factors for treatment failure. CONCLUSIONS: Pre-existing graft failure, extended interval between donor death and PKP, and fungal infection were important risk factors for treatment failure of graft infection following PKP.

A Case of Syphilitic Outer Retinitis Mimicking Acute Zonal Occult Outer Retinopathy

No abstract available.

Suspected Bacterial Endophthalmitis Following Sustained-release Dexamethasone Intravitreal Implant: A Case Report

A 58-year-old man admitted to our opthalmology department with the complaint of branch retinal vein occlusion. He was treated with intravitreal Ozurdex in the right eye. Two days after the injection, the patient presented with ocular pain and the visual acuity was hand movement. A diagnosis of endophthalmitis was made. We performed emergent pars plana vitrectomy (PPV) and the implant was removed from the vitreous cavity using a retinal forceps. A combination of vancomycin 1.0 mg and amikacin 0.4 mg was injected intravitreally. However, because of the blurring in the vitreus one week after the procedure, phacoemulsification and a repeat PPV was performed. Five days after the last procedure the signs and symptoms of endophthalmitis were resolved. Our case demonstrated that endophthalmitis could develop after intravitreal implantation of Ozurdex. Surgical removal of the implant and immediate vitrectomy seems to be a useful treatment option in these cases.

Clinical characteristics and outcomes of patients admitted with presumed microbial keratitis to a tertiary medical center in Israel / Características clínicas e desfechos dos pacientes internados com diagnóstico de ceratite microbiana em um centro terciário em Israel

PURPOSES: Microbial keratitis is commonly diagnosed worldwide, and continues to cause significant ocular morbidity, requiring prompt and appropriate treatment. The objective of this study is to describe the clinical characteristics and outcomes of patients with presumed microbial keratitis admitted to The Goldschleger Eye Institute, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel. METHODS: A cross-sectional study was conducted, in which the medical records of patients with presumed microbial keratitis admitted during a period of 3 years were reviewed. RESULTS: Keratitis was diagnosed in 276 patients (51% males and 48.9% females). The mean age was 39.29 ± 22.30 years. The hospital length of stay ranged from 1 to 65 days (mean 5.69 ± 5.508). Fortified antibiotics were still used at discharge in 72% of the cases. Overall visual acuity improved significantly from the time of admission to the 1st-week follow up visit showing a p<0.001 on the Wilcoxon signed ranks test. Contact lens wearing was present in 36.1% of the patients, although there was no significant relation with severity of the presentation and visual outcome (p>0.05). The degree of hypopyon and cells in the anterior chamber was significantly related to the hospital length of stay (r Spearman=0.31; p<0.001 and r Spearman=0.21; p<.001, respectively) as well as to a worse visual outcome (r Spearman=0.32; p<0.01 and r Spearman=0.18; p=0.01, respectively). Of all patients, 2.3% required an urgent therapeutic penetrating keratoplasty, and 1% underwent evisceration. There was no enucleation. CONCLUSION: Treating keratitis aggressively and assuring patient compliance is imperative for a good final visual outcome. Inpatient treatment may have a positive impact on this outcome.

OBJETIVOS: Ceratite microbiana é comumente diagnosticada em todo mundo e ainda continua a causar uma significante morbidade ocular. É necessário tratá-la de forma imediata e apropriada. O objetivo deste estudo é descrever as características clínicas e os desfechos dos pacientes com ceratite microbiana presumida que foram internados no Goldschlager Eye Institute, Sheba Medical Center, Tel Aviv University, Israel. MÉTODOS: Um estudo transversal foi realizado onde arquivos hospitalares dos pacientes internados com ceratite microbiana presumida durante um periodo de três anos foram analisados e revisados. RESULTADOS: Ceratite foi diagnosticada em 276 pacientes (51% masculinos e 48,9% femininos). A média de idade foi 39,29 ± 22,30 anos. A duração da internação foi de 1 a 65 dias (média 5,69 ± 5,508). Antibióticos fortificados permaneceram usados na alta em 72% dos casos. A acuidade visual do seguimento da primeira semana após a alta em relação a internação melhorou na media de forma estatisticamente significativa (p<0,001 usando Wilcoxon signed ranks test). O uso de lentes de contato estava presente em 36,1% dos pacientes, porém não houve relação estatisticamente significativa entre a gravidade da apresentação clínica e a acuidade visual nestes pacientes (p>0,05). O grau de hipópio e células na câmara anterior foram estatisticamente significativos em relação ao tempo de internação (r Spearman=0,0.31; p<0,001 and r Spearman=0,21; p<0,001, respectivamente) e para a acuidade visual (r Spearman=0,32; p<0,01 e r Spearman=0,18; p=0,01, respectivamente). De todos os pacientes, apenas 2,3% necessitaram ceratoplastia penetrante urgente e 1% necessitaram evisceração. Não houve enucleações. CONCLUSÕES: Tratar a ceratite de forma agressiva e garantir a aderência do paciente ao tratamento é imperativo para o bom resultado visual final. O tratamento internado pode ter um impacto positivo neste desfecho.

Self-inflicted Chronic Bacterial Keratoconjunctivitis Using Self Semen

This case report describes a case of self-inflicted chronic bacterial keratoconjunctivitis involving the patient's own semen. A 20-year-old male soldier was referred to our clinic for the evaluation of refractory chronic bacterial conjunctivitis. Over the previous 4 months, he had been treated for copious mucous discharge, conjunctival injection, and superficial punctate keratitis in both eyes at an army hospital and a local eye clinic. Despite the use of topical and systemic antibiotics according to the results of conjunctival swab culture, there was no improvement. During the repeated smear and culture of conjunctival swabs, surprisingly, a few sperm were detected on Gram staining, revealing that the condition was self-inflicted bacterial keratoconjunctivitis involving the patient's own semen. Thus, in cases of chronic keratoconjunctivitis that do not respond to appropriate antibiotic treatment, self-inflicted disease or malingering should be considered.

Late-Onset Citrobacter koseri Endophthalmitis with Suture Exposure after Secondary Intraocular Lens Implantation

A 54-year-old male patient was seen in clinic for ocular pain and decreased vision in the right eye with duration of two days. He underwent a cataract operation for his right eye 12 years ago, then a sclera-fixated secondary intraocular implantation and pars plana vitrectomy three years ago due to intraocular lens dislocation. At the initial visit, his visual acuity was restricted to the perception of hand motion. An edematous cornea, cells, flare with hypopyon, and exposed suture material at were observed at the six o'clock direction by slit lamp. Vitreous opacity was noted from B-scan ultrasonography. The patient was diagnosed with late-onset endophthalmitis and an intravitreal cocktail injection was done. On the next day, the hypopyon was aggravated, and therefore a pars plana vitrectomy was performed. A vitreous culture tested positive for Citrobacter koseri. After 12 weeks, the best corrected visual acuity of the right eye improved to 0.7 and a fundus examination revealed a relatively normal optic disc and retinal vasculature. We herein report the first case of endophthalmitis caused by Citrobacter koseri in Korea. Exposed suture material was suspected as the source of infection in this case and prompt surgical intervention resulted in a relatively good visual outcome.

A Case of Stenotrophomonas maltophilia Keratitis Effectively Treated with Moxifloxacin

A 70-year-old man with a long history of diabetes mellitus presented to our hospital (Department of Ophthalmology, Sahm Yook Medical Center, Seoul, Korea) complaining of severe ocular pain and visual disturbance in his left eye that had started three days prior to admission. A round 3.7 x 5.0 mm dense central stromal infiltrate with an overlying epithelial defect was noted on slit-lamp examination. Following corneal scrapings and culture, topical 0.5% moxifloxacin and 0.5% tobramycin were administered hourly. A few days later, Stenotrophomonas maltophilia was isolated in a bacterial culture from a corneal specimen. According to the results of susceptibility tests, topical 0.5% moxifloxacin was given every hour and 0.5% tobramycin was stopped. The patient's clinical features improved steadily with treatment. The corneal epithelium healed rapidly, and the infiltrate resolved within four weeks of the initiation of treatment. The patient's best corrected visual acuity improved from hand motion to 20 / 25.

A Case of Stenotrophomonas maltophilia Keratitis Effectively Treated with Moxifloxacin

A 70-year-old man with a long history of diabetes mellitus presented to our hospital (Department of Ophthalmology, Sahm Yook Medical Center, Seoul, Korea) complaining of severe ocular pain and visual disturbance in his left eye that had started three days prior to admission. A round 3.7 x 5.0 mm dense central stromal infiltrate with an overlying epithelial defect was noted on slit-lamp examination. Following corneal scrapings and culture, topical 0.5% moxifloxacin and 0.5% tobramycin were administered hourly. A few days later, Stenotrophomonas maltophilia was isolated in a bacterial culture from a corneal specimen. According to the results of susceptibility tests, topical 0.5% moxifloxacin was given every hour and 0.5% tobramycin was stopped. The patient's clinical features improved steadily with treatment. The corneal epithelium healed rapidly, and the infiltrate resolved within four weeks of the initiation of treatment. The patient's best corrected visual acuity improved from hand motion to 20 / 25.

Sífilis ocular: Presentación de diez casos y revisión de la literatura / Ocular syphilis: Ten new cases and review of the literature

Introduction: Ocular manifestations in patients with syphilis may involve almost any of the structures of the eye. Objectives: To describe ten new cases of syphilis with eye involvement and to briefly discuss the management and therapy of such condition. Material and Methods: Ten cases were retrospectively studied over 13 years. Demographic factors, ophthalmologic examination, and laboratory tests were assessed. Results: Seven of the 10 cases were male and 3 were female. The mean age of patients was 39,7 years. Disease presentation included: panuveitis (6 patients), optic neuritis (3), retinal vasculitis (1) and Argyll-Robertson pupil (1). Cerebrospinal fluid VDRL test was positive in 6 patients and 3 patients were HIV (+). Conclusions: Syphilis is able to display diverse ophthalmologic manifestations. Not in all the cases the CSF-VDRL test was positive. Antitreponemal therapy generates a fast and effective response in the affected patients.

Introducción: Las manifestaciones oculares de los pacientes con sífilis pueden comprometer cualquiera de las estructuras del ojo. Objetivos: Describir diez nuevos casos de sífilis con compromiso ocular y realizar una breve discusión de su manejo y tratamiento. Pacientes y Métodos: Se estudiaron, de forma retrospectiva, diez casos en un período de 13 años. Se evaluaron factores demográficos, exámenes oftalmológico y de laboratorio. Resultados: De los diez casos, 7 eran hombres y 3 mujeres. El promedio de edad fue de 39,7 años. Las presentaciones fueron: panuveítis (n: 6), neuritis óptica (n: 3), vasculitis retinal (n: 1) y pupila de Argyll-Robertson (n: 1). Se obtuvo VDRL (+) en líquido cefalorraquídeo en 6 pacientes y serología para VIH (+) en 3 pacientes. Conclusiones: La sífilis puede producir variadas manifestaciones oftalmológicas. No en todos los casos el VDRL resultó positivo en el LCR. El tratamiento anti-treponémico produce una rápida y efectiva respuesta en los pacientes afectados.

Pyomyositis of extraocular muscle: Case series and review of the literature.

Pyomyositis is a primary acute bacterial infection usually caused by Staphylococcus aureus. Any skeletal muscle can be involved, but the thigh and trunk muscles are commonly affected. Only three cases of extraocular muscle (EOM) pyomyositis have been reported. We herein present four cases of isolated EOM pyomyositis. Three of our cases presented with acute onset of proptosis, pain, swelling and redness. One patient presented with mass in the inferior orbit for 4 months. One patient had central retinal artery occlusion on presentation. None of them had marked systemic symptoms. Computed tomography scan of all patients showed a typical hypodense rim enhancing lesion of the muscle involved. Three patients were started on intravenous antibiotics immediately on diagnosis and the pus was drained externally. Two patients underwent exploratory orbitotomy. In conclusion, it should be considered in any patient presenting with acute onset of orbital inflammation. Management consists of incision and drainage coupled with antibiotic therapy.

Neuro-retinitis asociada a enfermedad por arañazo de gato: Presentación de dos casos y revisión de la literatura / Cat scratch disease associated neuroretinitis: Clinical report and review of the literature

La infección por Bartonella henselae se presenta característicamente con adenopatías regionales y fiebre de intensidad variable, entidad conocida como “enfermedad por arañazo de gato”. Alrededor de 5 a 10 por ciento de los casos desarrolla compromiso ocular, entre los que destacan el síndrome óculo-glandular de Parinaud, la neuro-retinitis y la retino-coroiditis focal. A continuación se presentan dos pacientes con infección aguda por B. henselae y compromiso ocular. Ambos recibieron tratamiento y evolucionaron con recuperación completa de la visión.

Cat scratch disease is the main clinical presentation of Bartonella henselae infection. However, ocular manifestations of bartonellosis occur in about 5 to 10 percent of the patients, mainly presenting as neuroretinitis, choroiditis or oculoglandular syndrome of Parinaud. We describe two patients with documented B. henselae infection and typical ocular compromise. Both patients were treated and had a favorable visual outcome.

Acute postoperative endophthalmitis by Gemella haemolysans.

Endophthalmitis is a rare and serious post-surgical complication. We report a case of acute postoperative endophthalmitis after an uneventful cataract surgery caused by a commensal organism, Gemella haemolysans. The patient was successfully treated with vitrectomy and intravitreal antibiotics like vancomycin, along with topical cefazolin.

A rare and an unusually delayed presentation of orbital actinomycosis following avulsion injury of the scalp.

We report a rare case of orbital swelling presenting one year after head trauma. An initial fine needle aspiration cytology revealed it to be an infected organizing hematoma. However, broad-spectrum antibiotics did not resolve the infection and the orbital lesion continued to grow in size, as evaluated by magnetic resonance imaging. Incisional biopsies were done, which were reported as orbital actinomycosis. Patient has responded well to treatment with penicillin. This case is of interest due to the delayed presentation of an orbital complication of head trauma and the rare infection with actinomyces. It also highlights the importance of using appropriate antibiotics, as well as the need for long-term treatment.

Disseminated orbital actinomycetoma: A case report.

Mycetoma is a chronic granulomatous infection. Lower extremities are commonly involved. A 20-year-old male came with complaints of multiple sinuses on scalp, left eyelid swelling with a sinus and dystopia, since one year. On examination there was relative proptosis in left eye of 2 mm. Computed tomography scan showed soft tissue swelling of the pre-septal area of the left upper eyelid with orbital involvement. Magnetic resonance imaging showed increased left orbital volume and evident dystopia. Microbiology testing of the erosive scalp and lid lesions showed genus Nocardia, suggestive of actinomycetoma. This case is presented as it shows an unusual involvement of the orbit.

Úlcera de Mooren bilateral / Bilateral Mooren's ulcer

Objetivo: describir el caso de un paciente con úlcera de Mooren bilateral en el Hospital de San José. Metodología: revisión y análisis de historia clínica. Resultados: paciente de 21 años sin antecedentes sistémicos, de ocupación carnicero, que consultó por ojo rojo, fotofobia y lagrimeo en ojo izquierdo y ardor en el derecho de dos días de evolución. Refería haber presentado seis episodios similares en los últimos seis meses. Al examen se encontró una úlcera corneana periférica en OD entre meridianos 9:00 y 11:00 y en el OI entre 1:00 y 6:00, de forma alargada, con borde anterior serpiginoso, levantado, infiltrado y socavado, y con compromiso parcial del epitelio. Se diagnosticó úlcera de Mooren bilateral, se inició tratamiento tópico con prednisona, ciclosporina, diclofenaco, lubricantes, inhibidor de la colagenasa y lente de contacto terapéutico. Se solicitaron exámenes paraclínicos y valoración por medicina interna, descartando enfermedad sistémica asociada. Después se solicitaron linfocitos totales, linfocitos CD2, CD4 y CD8, C3, C4, IgA total sérica, anticuerpos anticisticerco y coproscópico seriado. Conclusiones: por la rareza de esta entidad en nuestro medio y por interés académico presentamos este caso, cuyo diagnóstico fue clínico, haciendo énfasis en las características biomicroscoscópicas de esta patología.

Objective: to describe the case of one man with bilateral Mooren´s ulcer diagnosed at Hospital de San José. Methodology: review and analysis of clinical record. Results: the patient is a 21-year old man with no systemic antecedents, he is a butcher and presented with a 2-day history of: red eye, photophobia and increased tears on left eye and burn sensation in right eye. He refers six similar episodes in the last six months. Medical examination revealed peripheral corneal ulcers located between meridians 9:00 and 11:00 in the right eye and between 1:00 and 6:00 in the left eye; ulcers were: elongated, sinuous, elevated, infiltrative, excavated and partially compromised the overlying epithelium. Diagnosis was: bilateral Mooren´s ulcers. Treatment with topical prednisone, cyclosporine, diclofenac, lubricants, collagenase inhibitors and therapeutic contact lenses was initiated. Lab work-up and internal medicine consultation ruled out associated systemic disease. Further lab work-up including total lymphocyte, CD2, CD4 and CD8 lymphocyte count, determination of C3, C4, total serum IgA, and cysticercoids antibodies and serial stool examination was requested. Conclusions: we report this case for this condition rarely occurs in our setting and for being of academic interest. The diagnosis was clinical, and biological/ microscopic features of this condition are highlighted.

Two Cases of Corneal Ulcer due to Methicillin-Resistant Staphylococcus aureus in High Risk Groups

Considering the popular use of antibiotic-containing eyedrops in Korea, it is important to know the emerging antibiotic-resistant strains of bacteria before treating infectious eye diseases. This is especially important in high-risk groups because of the high incidence of resistant infections and the subsequent treatment requirements. We report two cases of methicillin-resistant Staphylococcus aureus (MRSA) corneal ulcers in high-risk groups. The first case involved a patient who had keratitis after using antibiotic- and steroid-containing eyedrops to treat a corneal opacity that developed after repeated penetrating keratoplasty. The second case involved a patient who used antibiotic-containing eyedrops and a topical lubricant on a regular basis for >1 month to treat exposure keratitis due to lagophthalmos. The second patient's problems, which included a persistent superficial infiltration, developed after brain tumor surgery. Both cases showed MRSA on corneal culture, and the corneal ulcers improved in both patients after the application of vancomycin-containing eyedrops. In conclusion, MRSA infection should be considered in corneal ulcers that have a round shape, mild superficial infiltration, and slow progression, especially in high-risk groups. This report includes descriptions of the characteristic features, antibiotic sensitivities, prevention, and successful treatment with vancomycin-containing eyedrops for MRSA corneal ulcers.