Diplopia as the First Sign of Gastric Carcinoma.

Orbital metastasis may be the initial manifestation of a malignancy of unknown origin. The primary locations of orbital metastasis are usually the lung, prostate, gastrointestinal tract, skin, kidney, eye, or thyroid gland. Metastasis of gastric carcinoma to an extraocular eye muscle is extremely rare. A solitary thickening in an extraocular eye muscle with no inflammatory features is suspect for a tumor. Symptoms such as diplopia, proptosis, ptosis, vision loss, or pain may be associated with an orbital malignancy. Our patient, a 67-year-old man known with radically resected prostate cancer, presented with complaints of vertigo with a tendency to fall, headache, and diplopia when looking to the right. As a coincidental finding, swelling of the rectus lateralis muscle of the left eye was observed on imaging. Extensive additional investigations showed that a gastric carcinoma with intraorbital and leptomeningeal metastasis was the cause. In conclusion, a solitary thickened extraocular eye muscle should be recognized in time and examined further.

[Laser pointers are not toys; eye injury with permanent loss of visual acuity]. / Een laserpen is geen speelgoed: oogletsel met blijvend visusverlies.

In the nineteen-nineties, there was much hype in the European media about presumed laser pointer maculopathy. However, the recent introduction of more powerful and therefore more dangerous laser pointers and their easy availability on the internet necessitates vigilance on the issue. This is an urgent matter, as here we report three cases of proven maculopathy due to an unsafe laser pointer. Three boys aged 13, 9 and 12 years used an unsafe laser pointer as a toy and looked repeatedly into the pointer, resulting in a permanent reduction in visual acuity due to macular damage. Laser pointers are not designed to be children's toys or instruments to annoy people in a crowd. Health authorities and the ophthalmic community should be aware of the potential danger of improper use of high-output laser pointers and warn the general public before the widespread availability of unsafe laser pointers and consequently laser pointer-induced macular damage becomes a true social problem.

Temporary divergence paralysis in viral meningitis.

A 43-year-old woman who reported diplopia and headache was found to have comitant esotropia at distance fixation and normal alignment at reading distance (divergence paralysis). Eye movement, including abduction, was normal as was the rest of the neurologic examination. Brain MRI was normal. Lumbar puncture showed an elevated opening pressure and a cerebrospinal fluid formula consistent with viral meningitis. The patient was treated with intravenous fluids and analgesics and with a temporary prism to alleviate diplopia. Within 3 weeks, she had fully recovered. This is the first report of divergence palsy in viral meningitis.

Intravitreal dexamethasone as adjuvant in the treatment of postoperative endophthalmitis: a prospective randomized trial.

PURPOSE: To study whether intravitreal dexamethasone as adjuvant to intravitreal antibiotics improves the outcome in patients with suspected postoperative bacterial endophthalmitis. DESIGN: Prospective randomized clinical trial. SETTING: Tertiary referral center. PATIENT POPULATION: Twenty-nine consecutive patients with suspected postoperative bacterial endophthalmitis within 6 weeks of cataract surgery. INTERVENTION: Patients underwent a vitreous biopsy followed by intravitreal injection of antibiotics (0.2 mg vancomycin and 0.05 mg gentamicin) and 400 microg dexamethasone or placebo. After 3-4 days the intravitreal injection of antibiotics and dexamethasone or placebo was repeated. PRIMARY OUTCOME MEASURE: Snellen visual acuity at 3 and 12 months after treatment. RESULTS: In 20/29 patients (69%) the vitreous cultures were positive. 13/29 patients received dexamethasone. Seven patients had a functionally lost eye (final vision of hand movements or less), in four due to retinal detachment. Visual acuity tended to be better in the dexamethasone treated patients than in those given placebo, at both 3 months (P=0.055) and 12 months (P=0.080). CONCLUSION: This small prospective, placebo-controlled series showed a trend towards a better visual outcome in patients with suspected bacterial endophthalmitis when treatment with intravitreal antibiotics was combined with intravitreal dexamethasone. Our findings justify a larger multicenter randomized study.

Effect of intravitreal dexamethasone on vitreous vancomycin concentrations in patients with suspected postoperative bacterial endophthalmitis.

PURPOSE: To study intravitreal dexamethasone and vancomycin concentrations, when used together in patients with suspected postoperative bacterial endophthalmitis. Animal studies had suggested that dexamethasone might decrease the concentration of vancomycin. DESIGN: Prospective randomized clinical trial in a tertiary referral center. METHODS: Twenty-nine consecutive patients with suspected postoperative bacterial endophthalmitis underwent a vitreous biopsy followed by intravitreal injection of antibiotics (0.2 mg vancomycin, 0.05 mg gentamicin) and 400 mug dexamethasone or placebo. After 3-4 days, the intravitreal injection of antibiotics and dexamethasone or placebo was repeated. In 18 patients, a second biopsy was taken for repeat culture and measurement of vancomycin and dexamethasone concentrations. RESULTS: In 20/29 patients (69%) the first vitreous cultures were positive; the second culture was negative in all cases. Thirteen out of 29 patients received dexamethasone. Dexamethasone concentrations showed an average of 25 ng/ml 3 days after injection, with an estimated half-life of 5.5 h. Vancomycin concentrations in patients given dexamethasone tended to be higher compared with those in the placebo group (P=0.061). CONCLUSION: Intravitreal dexamethasone does not lead to decreased vancomycin concentrations, when given simultaneously in the treatment of patients with suspected bacterial endophthalmitis.