Methicillin-resistant Staphylococcus aureus-associated orbital cellulitis: a case series.

PURPOSE: In recent years, methicillin-resistant Staphylococcus aureus (MRSA) orbital cellulitis (OC) has drawn increasing clinical and public health concern. We present a case series of MRSA OC encountered at four Australian tertiary institutions. METHODS: A multi-centre retrospective case series investigating MRSA OC in Australia from 2013 to 2022. Patients of all ages were included. RESULTS: Nine cases of culture-positive non-multi-resistant MRSA (nmMRSA) OC were identified at four tertiary institutions across Australia (7 male, 2 female). Mean age was 17.1 ± 16.7 years (range 13-days to 53-years), of which one was 13 days old, and all were immunocompetent. Eight (88.9%) patients had paranasal sinus disease, and seven (77.8%) had a subperiosteal abscess. Four (44.4%) had intracranial extension, including one (11.1%) case which was also complicated by superior sagittal sinus thrombosis. Empirical antibiotics, such as intravenous (IV) cefotaxime alone or IV ceftriaxone and flucloxacillin, were commenced. Following identification of nmMRSA, targeted therapy consisting of vancomycin and/or clindamycin was added. Nine (100%) patients underwent surgical intervention. Average hospital admission was 13.7 ± 6.9 days (range 3-25 days), with two patients requiring intensive care unit (ICU) admission due to complications related to their orbital infection. All patients had favourable prognosis, with preserved visual acuity and extraocular movements, following an average follow-up period of 4.6 months (range 2-9 months). CONCLUSION: NMMRSA OC can follow an aggressive clinical course causing severe orbital and intracranial complications across a wide demographic. However, early recognition, initiation of targeted antibiotics and surgical intervention when required can effectively manage these complications and achieve favourable visual outcomes.

Disseminated thrombosis of the internal jugular vein, superior ophthalmic vein and cavernous sinus as the primary manifestation of occult malignancy: a case report.

Internal jugular vein (IJV) thrombosis is a life-threatening condition most often associated with local risk factors such as head or neck infection or central venous catheterisation. Underlying malignancy is a rare but important aetiology to consider in patients presenting with spontaneous IJV thrombosis. We describe a case of necrotic cervical lymphadenopathy with thrombosis of the IJVs, cavernous sinuses and superior ophthalmic veins in a patient with metastatic squamous cell carcinoma, which was further complicated by an orbital compartment syndrome. The differential diagnosis of IJV thrombosis includes a range of infective, metastatic and thrombophilic pathologies. This case illustrates that, in the absence of an underlying precipitating factor, spontaneous IJV thrombosis should prompt further systemic investigations. Furthermore, patients with thrombotic events affecting the orbital venous drainage system should be monitored closely for signs of an acute orbital compartment syndrome.

Radiological analysis of orbital lymphoma histological subtypes.

PURPOSE: To characterise the radiological features of orbital lymphoma subtypes. METHODS: This was a multicentre, retrospective study to analyse radiological and clinical characteristics of orbital lymphoma by histological subtype across two sites within Australia and the United States. RESULTS: A total of eighty-eight patients were included. The most common subtypes were extranodal marginal zone lymphoma [EMZL] (48, 54.5%), follicular lymphoma [FL] (16, 18.2%), and diffuse large B-cell lymphoma [DLBCL] (15, 17.0%). Clinically, significant associations were found between DLBCL and vision change (p < .01), pain (p < .01), extraocular movement limitation (p = .01), and optic neuropathy (p = .01). Radiologically, there was no significant difference between the individual histopathological sub-groups with respect to bone destruction (p = .30), optic nerve involvement (p = .30) and diffuse appearance (p = .84). However, if categorised as either aggressive or indolent, aggressive lymphoma subtypes were significantly more likely to demonstrate globe indentation radiologically than indolent subtypes (Odds Ratio = 5.5, 95% CI: 1.3, 23.3; p = .02). CONCLUSIONS: DLBCL was significantly associated with vision change, pain, extraocular movement limitation and optic neuropathy clinically. Aggressive lymphoma subtypes were significantly more likely to demonstrate globe indentation radiologically. Otherwise, there were no significant differences between lymphoma subtypes and radiological findings on MRI and CT.

Optic nerve infiltration in systemic non Hodgkin lymphoma.

Optic nerve infiltration secondary to systemic non-Hodgkin lymphoma (NHL) is a rare phenomenon. We present a 55-year-old man with low-grade systemic NHL who initially presented with an isolated optic neuropathy and non-specific neurological symptoms. We further present a literature review of systemic NHL with radiological evidence of optic nerve infiltration. On magnetic resonance imaging, the characteristic features include optic nerve enhancement and enlargement, while leptomeningeal enhancement is uncommon. Cerebrospinal fluid analysis and optic nerve sheath biopsy can return false negative results, and when such investigations are inconclusive, biopsy of the optic nerve substance has a high diagnostic yield. Although rare, lymphomatous optic nerve infiltration must be considered in the differential diagnosis of a pale swollen optic disc.

Extensive orbital inflammation in an anophthalmic socket: is the Bioceramic implant a bystander or a participant?

Purpose: Porous orbital implants are commonly used materials following enucleation or evisceration. Implant-associated inflammation is a rare but serious complication which may necessitate explantation. Observations: We report a case of a patient who developed extensive orbital inflammation six months after implantation of a vicryl (polyglactin 910) mesh-wrapped Bioceramic (aluminum oxide) spherical implant. An orbital biopsy demonstrated an extensive fibroinflammatory reaction with multinucleated giant cells. Removal of the implant resulted in complete resolution of symptoms. Conclusions and importance: We surmise that the Bioceramic implant played a significant contributory role in this patient's orbital inflammation, a complication which has not been described previously.

Changing trends in glaucoma surgery within Australia.

BACKGROUND: Limited data are available on glaucoma surgical trends in Australia. METHODS: Nationwide study of glaucoma surgery in Australia over 17-year period from 2001 to 2018. The Australian Institute of Health, Welfare and Ageing hospitalisation database was used to review age- and gender-specific trends in glaucoma surgeries from 2001 to 2018 in Australian public and private hospitals. RESULTS: Although there was an increase in the absolute number of trabeculectomy procedures from 2926 to 3244 over the 17-year study period, this represented a decline in the age-standardised and gender-standardised number of trabeculectomy procedures from 15.1 to 13.2 procedures per 100 000 persons. However, during this same period, there was a dramatic increase in the number of glaucoma drainage devices (GDD) from 119 to 3262 procedures, representing an age-standardised and gender-standardised increase from 0.6 to 13.3 procedures per 100 000 persons. Negative binomial regression analysis revealed a decrease in trabeculectomy procedures of 1.1% per year, while there was increase in GDD insertions of 16.3% per year (p<0.001 for both). When stratified by age group, there was a statistically significant interaction in both trabeculectomy and GDD rates by age groups over time (p<0.001 for both). Trabeculectomy procedures decreased to a greater extent in those aged >60 years, compared with stable or increasing rates in younger age groups. GDD insertion rates demonstrated a progressively greater increase in older compared with younger age groups. CONCLUSION: Our findings demonstrate changing trends in the surgical management of advanced glaucoma in Australia, likely reflecting updated evidence regarding the role of GDD surgeries.

Diagnostic Utility of Diffusion-Weighted Imaging and Apparent Diffusion Coefficient for Common Orbital Lesions: A Review.

PURPOSE: To review and summarize the existing literature surrounding the clinical use of diffusion-weighted imaging and apparent diffusion coefficient (ADC) as diagnostic tools in differentiating common orbital lesions. METHODS: A systematic literature review on the use of ADC and diffusion-weighted imaging sequences for orbital imaging was performed. Only original research articles that reported ADC values for benign or malignant lesions were included. RESULTS: Malignant orbital tumors have an overall lower mean ADC value than benign masses. Orbital lymphoma is characterized by consistently lower ADC values compared with other malignant orbital masses; a threshold value less than 0.775 × 10 -3 mm 2 /s has been proposed to distinguish orbital lymphoma from other neoplastic and non-neoplastic orbital masses. To differentiate orbital inflammatory disease from lymphoma, an ADC threshold greater than 0.92 × 10 -3 mm 2 /s has been proposed. CONCLUSIONS: Orbital masses encompass a host of benign and malignant etiologies and can present a diagnostic challenge on both clinical and radiological assessment. Recent advanced MRI techniques such as diffusion-weighted imaging and ADC can improve the diagnostic specificity for orbital disease, particularly in differentiating benign from malignant lesions and lymphoma from orbital inflammatory disease.

IgG4-related Disease Presenting as Isolated Cicatrising Conjunctivitis.

A 46-year-old male presented with a 12-month history of trichiasis and was found to have significant, progressive cicatrization of the tarsal conjunctiva causing entropion of the upper and lower eyelids. A biopsy confirmed the diagnosis of IgG4-related cicatrizing conjunctivitis in the absence of any other organ involvement, a previously unreported manifestation of this immune-mediated disease.