BILATERAL ENDOGENOUS ENDOPHTHALMITIS FROM STREPTOCOCCUS PNEUMONIAE.

PURPOSE: To report a case of bilateral endogenous endophthalmitis from Streptococcus pneumoniae with devastating sequelae. METHODS: Interventional case report. RESULTS: A 56-year-old man presented with acute bilateral blurred vision and floaters with fever and hemodynamic instability. Previously, he was diagnosed with acute otitis externa and reported manually extracting several of his own teeth. He underwent a vitreous tap and intravitreal antibiotic injections. Blood and vitreous cultures were positive for S. pneumoniae. The patient later developed life-threatening medical sequelae. His final visual acuity was no light perception in the right eye and 20/25 in the left eye. CONCLUSION: Diagnosing endogenous endophthalmitis early is essential to initiating a systemic evaluation for potentially life-threatening medical conditions, including sepsis, endocarditis, and osteomyelitis. A high degree of suspicion, expeditious treatment, and interdisciplinary collaboration are essential to maximizing patient outcomes.

Crystalline lens dislocation secondary to bacterial endogenous endophthalmitis.

PURPOSE: To present an unusual case of endogenous endophthalmitis secondary to Group A streptococcus (GAS) that resulted in dislocation of the crystalline lens. OBSERVATIONS: An immunocompetent 51-year-old man presented to the emergency room (ER) with upper respiratory infection (URI) symptoms and painful right eye. He was diagnosed with URI and viral conjunctivitis and discharged on oral azithromycin and polytrim eyedrops. He returned to the ER 30 h later with sepsis and findings consistent with endophthalmitis, including light perception only vision. Ophthalmology was consulted at this time and an emergent vitreous tap and injection was performed. Both blood and vitreous cultures grew an atypical non-hemolytic variant of GAS (Streptococcus pyogenes). The primary source of infection was presumed to be secondary to pharyngitis or cutaneous dissemination. Final vision in the affected eye was no light perception, likely from a combination of anterior segment scarring, posterior segment damage, and hypotony. Interestingly, head computed tomography (CT) at the initial ER presentation showed normal lens position, but repeat CT at re-presentation revealed posterior dislocation of the lens. CONCLUSIONS AND IMPORTANCE: Endophthalmitis secondary to GAS has been sparsely reported in the literature, and this case highlights a unique clinical presentation. We suspect that this atypical non-hemolytic strain may have evaded detection on initial pharyngeal cultures. Additionally, we hypothesize that GAS-mediated protease release resulted in breakdown of the zonular fibers and subsequent lens dislocation. Ophthalmologists should be aware of GAS and its devastating intraocular manifestations.

CRYSTALLINE RETINOPATHY FROM HYPEROXALURIA: LONG-TERM FOLLOW-UP.

PURPOSE: To report long-term follow-up in a patient with retinal oxalosis from primary hyperoxaluria. METHODS: Retrospective chart review was performed for this patient. PATIENTS: A 6-year-old girl that presented to our clinic before and after combined kidney/liver transplant. RESULTS: Optical coherence tomography and fundus findings consistent with oxalate crystal deposition. CONCLUSION: Progressive macular changes, including atrophy and fibrosis can occur in crystalline retinopathy, secondary to hyperoxaluria, after combined hepatorenal transplant.

A standardized grading system for scleritis.

OBJECTIVE: This study evaluated the performance of a standardized grading system for scleritis using standard digital photographs. DESIGN: Cross-sectional interobserver agreement study. PARTICIPANTS: Photo archives from the National Eye Institute. METHODS: Three uveitis specialists from 3 different centers graded 79 randomly arranged images of the sclera with various degrees of inflammation. Grading was done using standard screen resolution (1024×768 pixels) on a 0 to 4+ scale in 2 sessions: (1) without using reference photographs and (2) with reference to a set of standard photographs (proposed grading system). The graders were masked to the order of images, and the order of images was randomized. Interobserver agreement in grading the severity of inflammation with and without the use of grading system was evaluated. MAIN OUTCOME MEASURES: Interobserver agreement. RESULTS: The proposed grading system for assessing activity in scleritis demonstrated a good interobserver agreement. Interobserver agreement (pooled κ) was poor (0.289) without photographic guidance and improved substantially when the "grading system" with standardized photographs was used (κ = 0.603). CONCLUSIONS: This system of standardized images for scleritis grading provides significantly more consistent grading of scleral inflammation in this study and has clear applications in clinical settings and clinical research.

A case of rapid progression and vision loss in a patient with primary intraocular lymphoma.

PURPOSE: To describe an atypical case of primary intraocular lymphoma (PIOL) with rapid progression leading to vision loss and death. METHODS: A 71-year-old woman with a history of PIOL presented with a sudden decline in vision. MRI, CSF cytology, and ocular examination 2 months prior were unremarkable. RESULTS: Repeat MRI of the brain and orbits at this time revealed a 0.8 x 2.4-cm lesion of the left choroid plexus. LP revealed rare atypical B cells. The patient rapidly deteriorated and died a month later. CONCLUSION: Recognition of the potential for rapid progression and mortality in patients with PIOL is essential.

Infliximab for the treatment of active scleritis.

OBJECTIVE: This study aimed to evaluate the possible safety and effectiveness of infliximab in patients with active scleritis. STUDY DESIGN: Prospective, nonrandomized, open-label pilot study (Protocol No. 04-EI-0065). PARTICIPANTS: Five patients with active anterior scleritis. METHODS: This single-centre, pilot study of infliximab for the treatment of active anterior scleritis was conducted at the National Eye Institute, National Institutes of Health, between 2003 and 2007. Scleritis patients with active disease who had used at least 1 conventional immunosuppressive agent in the past were included. Primary outcome was a 2-step decrease in scleral inflammation within 14 weeks. Patients received infliximab (5 mg/kg) at baseline, at weeks 2 and 6, and every 4 weeks through week 30, after which the infusion interval was increased (week 36, 48). RESULTS: All patients met the primary outcome by achieving quiescence of their active scleritis by week 14 with no additional immunosuppressives. However, after 14 weeks 1 patient developed new-onset intraocular inflammation that did not respond to reinduction and was terminated from the study. Side effects attributable to infliximab included ear infection with transient decreased hearing, urinary tract infection, lower respiratory tract infection, and facial rash in 1 patient and urinary tract infection, diarrhea, upper respiratory tract infection, nasal congestion and headache, mouth sores, head tremor, and occasional numbness and tingling in extremities in another patient, all of which resolved spontaneously or with appropriate treatment. CONCLUSIONS: Infliximab may be considered as a viable option in treating patients with active scleritis; however, patients should be monitored closely for potentially serious side effects.

Lingual force detection system.

The tongue is an organ of great significance in the processes of both swallowing and speech. Any disorder of the tongue's function (dysphagia, lateral sclerosis), with regard especially to the forces it produces, can drastically impair an individual by leaving them unable to swallow or talk. Up to this point, few systems have been created to quantitatively measure tongue force. Here we describe development of a new device that measures and outputs tongue force and endurance at six strategically positioned points in the mouth. Two mouth guards were fitted with six (three per guard) thin, highly sensitive sensors that independently output tongue force at each location. To ensure proper sensor readings, that is, reliable contact between the tongue and the sensor, each sensor was placed between a hard backing plate of stainless steel and a pliable puck constructed from silicone rubber. Forces were output to a computer using National Instruments' ELVIS system and a novel user friendly interface created using NI's LabVIEW. The proposed system can be utilized as a first step in diagnosis and treatment planning for speech rehabilitation and therapy. In future studies, collected data will be compared with control data (obtained previously from healthy volunteers) to diagnose potential tongue weakness and pinpoint its location in the mouth (whether unilateral or diffuse).

High resolution contrast ultrasound and NADH fluorescence imaging of myocardial perfusion in excised rat hearts.

Simultaneous imaging of myocardial flow and hypoxia could be vital for identifying acute ischemic mechanisms that may trigger an arrhythmia. We have studied the distribution of flow and hypoxia in excised locally ischemic rat hearts using simultaneous contrast ultrasound imaging and beta-nicotinamide adenine dinucleotide (NADH) fluorescence imaging. Local ischemia was induced by controlling flow within a major coronary artery. Intra-myocardial flow was imaged using contrast high-resolution ultrasound (linear probe; 13-6 MHz). An ultrasound contrast agent (UCA) was used to highlight the ischemic border. We observed distinct borders between two perfusion beds. UCA images showed high contrast borders of flow. The progression of UCA through the tissue was clearly visible. Intramyocardial regions of flow overlap could be identified by superimposing images of UCA from two perfusion zones. Borders between hypoxic and normoxic tissue were clearly revealed by increased NADH fluorescence. Hypoxic borders were oriented along borders of flow. In summary, simultaneous ultrasound and NADH imaging of excised hearts from small animals provide high fidelity images for characterizing the distribution of flow and hypoxic tissue during acute localized ischemia.