Clinical Practice Update: Management of Infectious Endophthalmitis After Intravitreal Anti-VEGF Injection.

Although infectious endophthalmitis after intravitreal antivascular endothelial growth factor injections is rare, it is the most feared and potentially devastating complication of this procedure. There is no high-level evidence to provide definitive guidance on the management of endophthalmitis occurring after intravitreal injection (IVI). This clinical practice update reviews the published literature regarding post-IVI endophthalmitis and highlights areas in which further research is needed to better guide its management.

Spontaneous Closure of a Macular Hole in Macular Telangiectasia Type 2.

Purpose: Spontaneous closure of a macular hole in macular telangiectasia type 2 (MacTel) with vision improvement is described. Methods: A case report is presented. Results: A 71-year-old man presented with a 1-week history of distorted vision in his left eye. Left visual acuity (LVA) was 20/80. Optical coherence tomography showed an almost full-thickness left macular hole with an intact internal limiting membrane drape. Small inner retinal cavitations were present at the right macula; multimodal imaging confirmed MacTel. Managed conservatively, at 5 months the patient's LVA had improved to 20/60, the defect was no longer full thickness, and the external limiting membrane had reconstituted. At the right macula, the inner cavitations grew and outer cavitations developed, but the external limiting membrane remained intact. At 32 months, right VA was 20/20 and LVA was 20/40. Conclusions: This case of MacTel with spontaneous closure of a macular hole was associated with an overlying internal limiting membrane drape.

Presumed choroidal metastasis from soft tissue myoepithelial carcinoma.

PURPOSE: To report a case of presumed choroidal metastasis from soft tissue myoepithelial carcinoma and highlight challenges in its diagnosis. OBSERVATIONS: A 52-year-old man was referred with a two-week history of photopsia in his left eye. His background medical history included known soft tissue myoepithelial carcinoma metastatic to his bone, lung, liver and chest wall. A large, raised, yellow choroidal lesion was identified nasal to and abutting the optic disc. This lesion demonstrated growth 1 month after presentation. The patient died with widespread metastatic disease 5 months after initial presentation. CONCLUSION AND IMPORTANCE: Soft tissue myoepithelial carcinoma can rarely metastasise to the choroid and present as a rapidly-growing, yellow, echodense tumour with serous retinal detachment. MRI brain can assist in tumour evaluation and monitoring progression, while immunoperoxidase stains and molecular testing can assist with diagnosis. The condition has an aggressive natural history and poor prognosis.

Topical antibiotics and intravitreal injections.

There is increasing evidence that topical antibiotics, given before and/or after intravitreal injections, are ineffective in preventing endophthalmitis and are possibly harmful. In addition to the lack of efficacy and increased development of resistant organisms, the use of topical antibiotics adds significantly to the cost of delivering intravitreal therapy. Despite this, in many countries, it is still common practice to use pre- and/or postinjection topical antibiotics. This review outlines the general principles of effective antibiotic prophylaxis, and the evidence regarding topical antibiotic use as a prophylactic measure for endophthalmitis following intravitreal injections. A key distinguishing feature of intravitreal injections from most other invasive procedures is the fact that they are often repeated on multiple occasions to the same eye. Given the lack of evidence to support topical antibiotics as an effective method of prophylaxis for postinjection endophthalmitis, it appears that more widespread education of ophthalmologists is required to avoid continued inappropriate use. Revision of drug labels in some jurisdictions, and amendment of local/professional society guidelines, may be required to assist in achieving this goal. Emphasis should be placed on antisepsis and aseptic technique, which are the major proven methods of endophthalmitis prevention, rather than antibiotics.

TATTOO-ASSOCIATED UVEITIS WITH CHOROIDAL GRANULOMA: A RARE PRESENTATION OF SYSTEMIC SARCOIDOSIS.

PURPOSE: The authors report a rare case of systemic sarcoidosis manifesting as bilateral granulomatous panuveitis and multiple tattoo granulomas. METHODS: Case report. RESULTS: A 30-year-old man presented with headaches, ocular pain, photophobia, and blurred vision. He was found to have significant skin inflammation, predominantly involving areas of tattoos. Fundoscopic examination revealed bilateral granulomatous panuveitis with small focal choroidal lesions. Skin biopsy demonstrated granulomatous inflammation of the dermis with tattoo pigment evident in numerous histiocytes. He was diagnosed with systemic sarcoidosis. CONCLUSION: The authors report another rare case of tattoo-associated uveitis, in which inflammation is limited to tattooed skin and the uvea. This uncommon presentation may prove informative in elucidating the pathogenesis of systemic sarcoidosis.

Aqueous Chlorhexidine for Intravitreal Injection Antisepsis: A Case Series and Review of the Literature.

PURPOSE: To determine the incidence of endophthalmitis in a large clinical series using aqueous chlorhexidine for antisepsis before intravitreal injection and to review the ophthalmic literature regarding chlorhexidine efficacy and safety. DESIGN: Multicenter retrospective case series. PARTICIPANTS: All patients receiving intravitreal injections from 7 retinal specialists. METHODS: An audit of intravitreal injections performed by retinal specialists who exclusively used aqueous chlorhexidine 0.05% or 0.1% for prophylaxis of infective endophthalmitis was undertaken. The incidence of endophthalmitis was determined from August 1, 2011, to February 28, 2015. A literature review was performed to critically appraise the ocular safety and efficacy of aqueous chlorhexidine. MAIN OUTCOME MEASURES: Incidence of endophthalmitis after intravitreal injections. RESULTS: A total of 40 535 intravitreal injections were performed by 7 retinal specialists across 3 centers. Chlorhexidine was well tolerated, and only 1 patient with a suspected allergic reaction was noted. Three cases of endophthalmitis were identified with 1 culture-positive case. The 0.0074% (1 in 13 512) per-injection rate of endophthalmitis in this series compares favorably with previous series in which povidone-iodine has been used. CONCLUSIONS: Aqueous chlorhexidine was associated with a low rate of postinjection endophthalmitis and was well tolerated by patients.

Endophthalmitis following intravitreal anti-vascular endothelial growth factor (VEGF) injection: a comprehensive review.

The purpose of this review is to report and summarize previously reported studies and assess many of the individual steps of the intravitreal injection procedure's possible effect on the prevention of endophthalmitis. The pooled endophthalmitis rate from 20 large retrospective case series of anti-VEGF injections was 144/510,396 (0.028%; 1/3,544). Injections may be performed in an office-based location or in an operating room (OR) and low rates of endophthalmitis can be achieved in either location with careful attention to asepsis. Pre- or post-injection topical antibiotics have not been shown to be effective, and could select for more virulent microorganisms. Povidone-iodine prior to injection is accepted as the gold-standard antiseptic agent, but aqueous chlorhexidine may be an alternative. Antisepsis before and after gel or subconjunctival anesthetic is suggested. The preponderance of Streptococcal infections after intravitreal injection is discussed, including the possible role of aerosolization, which can be minimized by using face masks or maintaining silence. As with other invasive procedures in medicine, the use of sterile gloves, following adequate hand antisepsis, may be considered. Control of the eyelashes and lid margin is required to avoid contamination of the needle, but this can be achieved with or without a speculum. Techniques to minimize vitreous reflux have not been shown to reduce the risk of endophthalmitis. Same day bilateral injections should be performed as two separate procedures, preferably using drug from different lots, especially when using compounded drugs.

Central retinal artery occlusion after phacoemulsification.

PURPOSE: To report 2 cases of central retinal artery occlusion (CRAO) that occurred within 24 hours of routine phacoemulsification cataract surgery using peribulbar anesthesia. METHODS: Case 1: An otherwise well 76-year-old woman with right pseudoexfoliation syndrome and bilateral open angle glaucoma presented with right visual acuity of counting fingers on the first postoperative day after cataract surgery. The CRAO was noted on fundoscopy. Emergency measures to reduce intraocular pressure (IOP) and hyperbaric oxygen treatment were performed. Case 2: A 59-year-old man with a history of non-Hodgkin's lymphoma, hypertension, hyperlipidemia, and ischemic stroke was similarly diagnosed with CRAO on the first postoperative day, with left visual acuity of counting fingers. RESULTS: The final visual acuity remained at counting fingers in both cases. CONCLUSION: Central retinal artery occlusion after routine cataract surgery is unusual. We review the literature on CRAO after routine intraocular procedures and propose three hypotheses regarding the potential mechanisms involved. A vasoconstrictive effect of the anesthetic agent on the central retinal artery, a rise in lOPs after anesthesia administration resulting in closure of the central retinal artery, and a mechanical effect of the volume of anesthetic on the central retinal artery are considered as plausible mechanisms, with a mechanical effect being the favored hypothesis.

Postoperative Mycobacterium abscessus nodular conjunctivitis.

Non-tuberculous or 'atypical' mycobacteria are unusual causes of ocular or periocular infection. We report a case of postoperative Mycobacterium abscessus infection of the conjunctiva. A 71-year-old gentleman developed nodular conjunctival injection and irritation 6 weeks after cataract surgery. After failure of topical therapy with antibiotics, steroids and lubricants, a biopsy was taken. Histological examination revealed non-caseating granulomas within which were clusters of acid-fast bacilli, subsequently identified as M. abscessus. The patient received a total of 16 weeks of oral antimycobacterial treatment and the conjunctivitis completely resolved. A suspected recurrence was successfully treated with topical ciprofloxacin and at final follow up 15 months later there was no evidence of infection. To the best of our knowledge this is the first report of non-tuberculous mycobacterial infection of the conjunctiva occurring after cataract surgery.

Pars plana vitrectomy for the management of retained lens material after cataract surgery.

PURPOSE: To evaluate the management and outcomes of patients undergoing pars plana vitrectomy (PPV) for retained lens material after cataract surgery; and to evaluate risk factors for poor visual outcome, retinal detachment, raised intraocular pressure (IOP), and cystoid macular edema (CME). DESIGN: Retrospective interventional consecutive case series. METHODS: setting: Institutional and Clinical practice. study population: Patients with retained lens material after cataract surgery who underwent vitrectomy at Sydney Eye Hospital between July 1, 1998 and October 31, 2003. intervention: Standard three-port PPV/lensectomy. main outcome measures: Final best-corrected visual acuity (BCVA), retinal detachment, raised IOP, and CME. RESULTS: A total of 223 eyes of 223 patients were included, with a mean follow-up of 20.5 months after vitrectomy. Final BCVA was 6/12 or better in 159 patients (71.3%). Retinal detachment occurred in 20 patients (9%), with 11 diagnosed before or during vitrectomy, and nine occurring after vitrectomy. Ten patients (5.0%) developed raised IOP and 42 (23.2%) developed CME. Poor final visual acuity was associated with retinal detachment (P = .0026), and with poor visual acuity at presentation (P = .030). There was a significant association between retinal detachment and a long interval (>30 days) between cataract surgery and vitrectomy (P = .00047) and between retinal detachment and younger age (P = .0070). CONCLUSIONS: Visual acuity results in this study compared favorably with previously published reports. Although the overall rate of retinal detachment was low, it was significantly higher in those with a delayed interval between cataract surgery and vitrectomy, and was significantly associated with a poorer visual outcome.

Euphorbia lactea sap keratouveitis: case report and review of the literature.

PURPOSE: To describe a case of Euphorbia lactea sap keratouveitis and to review all reported cases of ocular toxicity caused by Euphorbia species. METHODS: Case report and review of literature. RESULTS: A 79-year-old woman presented 34 hours after she felt some sap of an E. lactea plant spray into her right eye. Visual acuity was counting fingers at 1 m. Examination revealed ciliary injection, 90% corneal epithelial defect, marked stromal edema with Descemet folds, and anterior-chamber flare with a 1-mm hypopyon. There was no vitreitis, and funduscopy was unremarkable. No foreign body was seen on B scan ultrasound or computed tomography scan of the orbits. Corneal scraping excluded bacterial and herpetic keratitis. Intensive topical antibiotic therapy was started with cephalothin 5% and gentamicin 0.9%, and the pupil was dilated with atropine. Topical steroids were started once the epithelial defect had healed. Examination 11 weeks after the injury revealed minimal subepithelial corneal haze and marked improvement in visual acuity. CONCLUSIONS: To the best of our knowledge, this is only the third reported case of E. lactea sap keratouveitis. The clinical course of E. lactea sap keratouveitis is compared with that reported for other Euphorbia species.

Papillary endothelial hyperplasia of the orbit: report of a case highlighting a pitfall on fine needle aspiration biopsy.

BACKGROUND: Papillary endothelial hyperplasia (PEH) is an unusual form of thrombus organization that occurs predominantly in the extremities, including the head and neck. However, it is rare in the orbit/ocular region. Although the histologic features of PEH have been well described, the cytologic diagnosis remains difficult. CASE: A 63-year-old man presented with a left intraorbital mass that was increasing in size and associated with paresthesia and a recent history of excision of squamous cell carcinomas (SCC) from his left cheek. Fine needle aspiration biopsy (FNAB) yielded very limited material, predominantly blood. However, 1 Papanicolaou-stained slide showed groups of atypical cells with scanty but dense cytoplasm and large, hyperchromatic nuclei with prominent nucleoli. SCC was favored, and excision was performed. Histology showed PEH within an assumed cystic lymphangioma, associated with inflammatory and fibrotic change in the compressed supraorbital nerve. CONCLUSION: To our knowledge this is the third report on the cytology of PEH and the first report of FNAB in PEH of the orbit. The case was also unusual as it was the second metachronous PEH in the patient.

Orbital leiomyoma: a case report with clinical, radiological and pathological correlation.

Orbital leiomyoma is a benign tumour of smooth muscle origin that can be clinically, radiologically and histopathologically difficult to diagnose due to the rarity of leiomyomas in this location. A 74-year-old woman presented with a 2-month history of painless proptosis. Computed tomography and magnetic resonance imaging studies revealed a well-circumscribed intraconal lesion separate from the optic nerve, and not eroding adjacent bone. A right lateral orbitotomy via a lid crease incision was performed to remove the firm lobulated lesion. Postoperatively there was an obvious decrease in proptosis. Microscopically the lesion was a well-circumscribed tumour composed of spindle cells. There were no light microscopic features to suggest malignancy, and immunohistochemistry was used to confirm the diagnosis of leiomyoma. Leiomyoma is a tumour that is rarely found in the orbit most likely due to the paucity of smooth muscle in this location. The differential diagnosis is wide, and the role of radiology, histology and immunohistochemistry in the diagnosis of leiomyoma is discussed. Surgical excision in this case excluded malignancy, provided a definitive diagnosis of a rare entity and resulted in marked clinical improvement.

Unrecognised ventriculitis/meningitis presenting as hydrocephalus in infancy.

Infantile hydrocephalus due to unrecognized neonatal-onset meningitis/ventriculitis, was studied retrospectively using 1991-1998 chart review. Seventy two patients with hydrocephalus were reviewed. Thirteen infants had hydrocephalus associated with active meningitis/ventriculitis which had remained unrecognized. Active meningitis/ventriculitis was confirmed by the finding of an abnormal lumbar and ventricular CSF with or without positive culture. All had perinatal risk factors and 10/13 had been given antibiotics in the postnatal period. 6/13 infants appeared to be well. The most common presentation was increasing head size. All lumbar and ventricular CSFs were abnormal and 10/13 had positive cultures as well. Imaging revealed hydrocephalus in all. The infants were treated with antibiotics for a mean of 32.8 days before VP shunting. 7/11 were severely disabled. Unrecognized active meningitis/ventriculitis is an important cause of infantile hydrocephalus.