Endogenous endophthalmitis caused by Escherichia coli.

Endophthalmitis is a rare complication of Escherichia coli-induced septicemia. Nine cases of endogenous endophthalmitis caused by E. coli have been reported previously, all except one in patients with diabetes. The most common primary site of infection is the urinary tract. The course of illness is rapidly progressive with a poor visual prognosis. Concurrent systemic morbidity, including body abscesses and endocarditis, is high. We report an additional case of endogenous endophthalmitis from E. coli in a diabetic woman. Enucleation was required despite aggressive topical and systemic treatment. The pertinent literature is reviewed.

Primary nonkeratinized epithelial ('conjunctival') orbital cysts.

The types of orbital cysts that are most familiar to ophthalmologists are epidermoid and dermoid cysts, both of which are lined by keratinized stratified squamous epithelium. We studied six patients who had orbital cysts lined by nonkeratinized epithelium that resembled normal conjunctiva. Compared with epidermoid and dermoid cysts, these primary nonkeratinized cysts tend to cause symptoms later in life, occur preferentially in the superonasal aspect of the orbit, and are less likely to be associated with underlying bony changes.

Strabismus caused by melanoma metastatic to an extraocular muscle.

Nonocular melanoma rarely metastasizes to the orbit. We report the case of a melanoma presumably arising from an axillary lymph node sinus that metastasized to the left medial rectus muscle causing proptosis, diplopia, and reduced saccadic velocity measurements. Clinical, radiographic, and histopathologic data are presented and discussed.

Atypical fibroxanthoma of the eyelid.

Atypical fibroxanthomas are tumors that arise in the skin, show strikingly atypical cytologic features, but usually follow a benign clinical course. The authors present a case of atypical fibroxanthoma involving the eyelid. Although early reports noted a favorable prognosis, these tumors can recur aggressively and metastasize. Therefore, complete excision is recommended for atypical fibroxanthomas around the eye.

Periocular malignant fibrous histiocytoma.

We present a case of periocular cutaneous malignant fibrohistiocytoma that invaded the orbit. Complete excision is recommended for atypical fibrohistiocytic tumors around the eye. Examination of specimen margins by frozen section should be undertaken with caution. It is recommended that frozen section evaluation be performed by a pathologist familiar with spindle cell neoplasm to ensure complete removal of this tumor.

The use of sodium hyaluronate as a biologic sleeve in strabismus surgery.

Strabismus surgery sometimes fails because of the mechanical restriction caused by the development of fibrous adhesions between the operated muscle and the surrounding tissues. Reoperation increases the frequency and severity of mechanical restriction significantly because of additional scar formation. Attempts to isolate the muscle from other tissues using gelatin sponges or Supramid plastic sleeves have been unsuccessful because of the body's reaction to these permanent foreign bodies. We used an ultra-pure fraction of sodium hyaluronate to study whether this nonantigenic, noninflammatory, viscoelastic substance could function as a temporary sleeve to prevent or reduce scarring and mechanical restriction following strabismus surgery. We resected the superior rectus muscle of 14 eyes from seven 5- to 7-pound white rabbits. In one eye, we instilled sodium hyaluronate 1% around the muscle. The other eye served as a control. The rabbits were killed at five, seven, ten, 14, 21, 28, and 42 days. Ante mortem length-tension measurements and post mortem histologic examinations of the operated muscles were performed in a blinded fashion. The results suggested, but did not definitely demonstrate, that sodium hyaluronate may reduce postoperative adhesions.

Minor trauma, disastrous results.

An 81-year-old-woman developed a right facial palsy and orbital cellulitis following an apparently innocuous puncture injury of the right lower eyelid. Generalized tetanus ensued which proved fatal despite aggressive treatment including use of tetanus immune globulin, wound debridement, and neuromuscular blockade with ventilatory assistance. Tetanus immunization status should be ascertained in all patients with potentially contaminated wounds in and around the eye. Cephalic tetanus, may be misleading initially because of the presence of cranial nerve palsies and the absence of classic signs such as trismus and risus sardonicus.

Large periocular keratoacanthoma: the case for definitive treatment.

Keratoacanthoma can usually be distinguished from squamous cell carcinoma. However, some tumors share certain characteristics of both lesions. There is a large group of actinic keratoacanthomas cytologically identical to squamous cell carcinomas. In locations other than the ocular adnexae, conservative therapy is often recommended for keratoacanthomas since these lesions tend to regress spontaneously. Two patients with large periocular keratoacanthomas illustrate some of the diagnostic and therapeutic dilemmas related to rapidly growing potentially malignant lesions about the eye. Extensive tissue destruction and possible recurrence following excision favor definitive surgical therapy in these cases.

Ocular manifestations of carotid artery atheroma.

Although carotid endarterectomy (CE) is recommended in appropriate patients with bifurcation atheroma for the prevention of stroke, these patients are also at risk for visual loss, either temporary or permanent. The presentations of patients undergoing 512 consecutive CEs were reviewed to determine the preoperative frequency and risks of ocular disturbances. Visual symptoms occurred in 131 patients (25%). Temporary, monocular blindness (amaurosis fugax, AF) was reported by 99 patients (19%). Concomitant neurologic symptoms were present in 33 (33%) of the patients with AF, and carotid artery stenoses of greater than 75% diameter were documented in 82 (83%) of these patients. No visual deficits were observed following operation. Permanent visual loss ranging from scotoma to complete blindness was documented in 32 patients (6.2%). The permanent deficits were due to retinal artery occlusions (RAO) in 20 patients (4%), ischemic optic neuropathy (ION) in eight patients (1.5%), and homonymous hemianopsia (HH) in four patients (0.7%). Visual loss occurred without any warning in 27 of these 32 cases (84%). The five cases with warning had multiple episodes of AF and then sustained RAO and blindness. Neurologic symptoms occurred concomitantly but not prior to visual symptoms in 7 of the 12 patients (58%) with ION and HH. Stenoses greater than 75% were present in 22 of 32 cases (69%) and in every case of ION. Operation had no effect on the visual deficit. Permanent visual loss occurred in a significant number of patients with carotid atheroma (6.2%). Warning in the form of visual prodroma is uncommon in these patients (16%).(ABSTRACT TRUNCATED AT 250 WORDS)

Corneal hematoma.

Two cases of corneal hematomas initially manifested as corneal blood staining, but were further complicated by the presence of persistent epithelial defects and stromal thinning. Both cases occurred following cataract surgery. Scanning electron and light microscopic examination in the second case demonstrated a loss of keratocytes, stromal collagen breakdown, and epithelial cell degeneration over the center of the hematoma. Large corneal hematomas may cause epithelial degeneration by functioning as barriers to nutrients and metabolic factors from the anterior chamber. Unlike corneal blood staining, conservative treatment is often insufficient therapy for corneal hematomas with associated persistent epithelial defects. Complications from epithelial defects, including corneal thinning, descemetocele, and perforation, may necessitate more aggressive treatment, even surgery. An epithelial defect overlying blood staining should suggest the presence of a corneal hematoma.

Malignant Merkel cell neoplasm of the eyelid.

Malignant Merkel cell neoplasms of the eyelid are most commonly found in elderly patients. They occur most frequently on the upper eyelid and are seen as large, nontender , red or violaceous masses with intact overlying skin. Differential diagnosis includes lymphoma and oat cell carcinoma. Conventional light microscopic features are usually distinctive, but tissue should be saved for electron microscopy and immunocytochemical studies, since the presence of dense-core neurosecretory granules and perinuclear microfilaments on electron microscopic examination and positive staining for neuron-specific enolase, are strongly suggestive of malignant Merkel cell neoplasm. Because of the diffuse infiltrative growth pattern and early lymphatic spread of this tumor, treatment requires careful examination of regional lymph nodes and wide surgical excision of the tumor with frozen-section control of margins.

Cyclic vertical deviation.

A 34-year-old Caucasian woman underwent craniofacial surgery for fronto-orbital fibrous dysplasia. She developed vertical diplopia for 10 months after surgery, which then disappeared for 1 month. The deviation returned with a circadian pattern, 24 hours of hypertropia and exotropia with diplopia alternating with 24 hours of straight eyes and fusion. Three months after the onset of this pattern, surgery was performed, resulting in straight eye position and fusion daily. The similarities to cyclic esotropia are discussed. The etiology of circadian strabismus remains unknown.

Uveal findings in patients with cutaneous melanoma.

A study Of the uveas of white patients with known cutaneous melanoma and white control subjects showed that patients with cutaneous melanoma had a significantly higher frequency of iris nevi (101 of 197 patients, 51%) than control subjects (58 of 147 subjects, 39%). The frequency of choroidal nevi was also higher in the group with cutaneous melanoma but the number (eight of 197 patients compared with two of 147 control subjects) involved was too small for statistical significance to be assessed. Patients with cutaneous melanoma, particularly women, had more skin nevi than did control subjects.

Histologic and ultrastructural characteristics of temporal arteritis. The value of the temporal artery biopsy.

Temporal artery biopsy is an easily performed procedure of low morbidity that produces valuable information in establishing a diagnosis and guiding therapy as well as providing tissue for further pathologic and immunologic research aimed at understanding and ultimately controlling this disease. The pathogenesis of temporal arteritis remains unresolved. In an effort to clarify this question, 19 temporal arteries demonstrating typical arteritic changes by light microscopy were also examined by transmission electron microscopy. At the light microscopic level, a granulomatous inflammation, often containing giant cells, was found in all layers of the vessel but most commonly concentrated within the internal or external border of the muscular media. The internal elastic lamina was usually fragmented and surrounded by inflammatory cells. Segmented subintimal fibromuscular hyperplasia and lymphocytic and plasma cell infiltration of the adventitia were nondiagnostic but suggestive findings commonly observed. Ultrastructural alterations were most striking in the muscular media. Degenerating smooth muscle cells with elongated mitochondria, dilated rough endoplasmic reticulum, and autophagic vacuoles containing electron-dense material were observed. Macrophages and giant cells contained degenerated smooth muscle cell basement membrane within phagocytic vacuoles, and macrophages were found within smooth muscle. Although frequently found in the vicinity of macrophages and giant cells, disrupted elastic lamina was not demonstrated in phagocytic cells.