Muir-Torre Syndrome in a Middle-Aged Chinese Patient with Sebaceous Carcinoma of the Eyelid.

Muir-Torre syndrome is a rare, autosomal dominant condition characterized by the presence of a skin tumor of sebaceous differentiation and visceral malignancies. We reviewed the case of a 46-year-old Chinese man who had a bleeding mass over the right upper eyelid. He had a history of colon cancer and a family history satisfying the Amsterdam criteria for hereditary non-polyposis colorectal cancer syndrome with germline mutation in the MutS homolog-2 gene. The eyelid lesion was excised completely and submitted for histopathologic examination which showed sebaceous carcinoma. Frozen section and conjunctival map biopsy showed no residual malignancy or local metastasis. Post-operative positron-emission tomography with combined computed tomography did not reveal any residual or visceral malignancy. He had no recurrence in the 32-month follow-up period. We should consider Muir-Torre syndrome in patients with sebaceous carcinoma, especially in the presence of personal and/or family history of visceral malignancies.

Malignant eyelid tumors in Hong Kong 1997-2009.

PURPOSE: To determine the epidemiologic and clinical characteristics of patients with malignant eyelid tumors in Hong Kong. METHODS: A computerized retrieval system was used to identify all patients with histologically confirmed malignant eyelid tumors residing in Western Kowloon and the Southern New Territories, Hong Kong, during the 13-year period from 1997 to 2009. The patients' medical records were reviewed for clinical and demographic data. RESULTS: A total of 36 patients were identified; all were Chinese. The mean age at diagnosis was 73.4 ± 11.5 years. Women were more commonly affected. Each patient had 1 tumor. Tumors developed more commonly on the lower eyelid (n = 19; 52.8%) than on the upper eyelid (n = 11; 30.6%). The right eye was more often involved (n = 20; 55.6%). With regard to the type of tumor, 27 were basal cell carcinoma (BCC) (75%), 4 sebaceous gland carcinoma (11.1%), 2 squamous cell carcinoma (5.6%), 1 mucinous eccrine carcinoma (2.8%), 1 verrucous carcinoma (2.8%), and 1 metastatic carcinoma (2.8%). Most were treated by frozen section-guided excision and eyelid reconstruction. Recurrence occurred in 1 case only. Incidence was low until approximately 45 years of age, after which it rose sharply. The incidence continued to increase until above the age of 85 years. There was an overall increase in incidence from 0.6 per million in 1997 to 2.3 per million in 2009. CONCLUSION: Increasing incidence of malignant eyelid tumors was noticed in Hong Kong from 1997 to 2009, with BCC dominating the incidence trend. Recurrence after complete surgical excision was uncommon.

Acute renal failure after topical fortified gentamicin and vancomycin eyedrops.

PURPOSE: To report a case of acute renal failure after topical fortified gentamicin and vancomycin eyedrops in the treatment of endophthalmitis. METHODS: A 67-year-old lady with diabetes mellitus was treated for bleb-related endophthalmitis. After intravitreal antibiotics, she was given oral ciprofloxacin, fortified gentamicin, and vancomycin eyedrops. She developed acute renal failure a few days after therapy. Blood tests and ultrasound of the urinary system were performed to investigate for the cause of the renal failure. RESULTS: No apparent cause of renal failure could be identified in our patient. Autoimmune markers and ultrasound of the urinary system were unremarkable. Fortified gentamicin and vancomycin eyedrops were stopped on day 9 and 13, respectively. The renal function recovered dramatically. The gentamicin level was checked 2 days after it had been stopped, and the serum level was 0.34 mg/L. Renal function improved on supportive management without dialysis. Serum creatinine level completely normalized 2 months later. CONCLUSIONS: This is the first article that demonstrated a detectable level of serum gentamicin level after usage of topical eyedrops. This is also the first article demonstrating that nephrotoxicity of topical fortified gentamicin and vancomycin eyedrops was found. The acute renal failure in our patient recovered completely after cessation of the eyedrops.

Verrucous carcinoma: a rare tumor of the eyelid.

A 72-year-old gentleman presented with a left upper eyelid mass existing for several years but progressively increased in size over 2 weeks. Clinically the 1.5 × 1-cm firm, pigmented and sessile mass resembles a large wart. Excisional biopsy of the mass reveals a diagnosis of verrucous carcinoma. Verrucous carcinoma rarely occurs in the eyelid, and this is the first reported case of its occurrence in an Asian patient. As its appearance simulates that of a wart, it may be mistaken as the latter. Deep excisional biopsy is required in differentiating the two. Although being rare, ophthalmologists have to be aware of the diagnosis to avoid missing this potentially curable malignant lesion in patients presenting with eyelid tumors.

Successful treatment of Pseudallescheria boydii keratitis with topical natamycin as monotherapy.

PURPOSE: To report a case of Pseudallescheria boydii keratitis successfully treated with topical natamycin as monotherapy. METHODS: Interventional case report describing the clinical presentation, histopathologic findings, course, and treatment of a patient with P. boydii keratitis. RESULTS: A 50-year-old male electrician with a 4-day history of right eye pain and blurring of vision was referred. There was history of right eye injury while hammering and examining a hole in the ceiling. Examination showed a corneal abscess with overlying epithelial defect measuring 2 mm in diameter. Histopathologic investigation revealed septate hyaline cylindrical hyphae with acute angle branching and formation of oval to pyriform conidia truncated at the base, compatible with P. boydii. The patient was treated with topical natamycin 5%, which eradicated the infection, resulting in a final best-corrected visual acuity of 6/7.5. CONCLUSION: The fungus P. boydii can cause keratitis. The success rate for treatment was generally thought to be poor. Early detection and treatment is important in improving the outcome. This is believed to be the first reported case of P. boydii keratitis successfully treated with topical natamycin as monotherapy.

Clinical evaluation of the intraoperative refraction technique for intraocular lens power calculation.

OBJECTIVE: To evaluate clinically the intraoperative refraction technique for intraocular lens (IOL) power calculation using 2 existing formulas proposed by Ianchulev and Leccisotti and to derive alternative formulas for this technique. DESIGN: Comparative case series. PARTICIPANTS: One hundred eighty-two eyes from 182 patients with cataract. METHODS: Recruited patients were separated into a normal cornea group and a special group that included eyes with surgically altered corneas. Phacoemulsification was carried out for all cases. Intraoperative aphakic autorefraction using a portable autorefractor was performed. An IOL with power calculated before surgery then was implanted. In each eye, postoperative refraction was obtained. The IOL power that would have achieved emmetropia was calculated retrospectively. Aphakic autorefraction readings obtained during surgery were used to calculate the aphakic spherical equivalent (SE). The 2 formulas incorporating aphakic SE were applied to calculate the target IOL power. Comparison then was made to determine the accuracy of the formulas. MAIN OUTCOME MEASURES: A difference (referred to as IOL difference) was calculated by subtracting the adjusted emmetropic IOL power determined by postoperative refraction from the emmetropic IOL power calculated by the 2 formulas using intraoperative aphakic SE. RESULTS: One hundred forty-four patients were in the normal cornea group and 18 were in the special group. In the normal group, the Ianchulev formula showed a relatively accurate prediction for IOL power to achieve emmetropia over almost the full range of axial length except in extremely long eyes. The Leccisotti formula tended to overestimate IOL power and worked particularly poorly in short eyes. It worked best in long eyes. In the special group, neither of the 2 formulas was able to show superiority universally. Using data from the normal group, alternative formulas for IOL power calculation were derived. These new formulas then were validated on the special group that showed good estimation. CONCLUSIONS: The Ianchulev formula could be applied to most eyes, with the exception of those in highly myopic subjects. The Leccisotti formula showed good performance in myopic patients. For eyes falling into the special group, an alternative formula, correction factor, or both, may be required. The new formulas reported herein may be an option. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Calcification of a hydrophilic acrylic intraocular lens: clinicopathological report.

A 72-year-old man who had phacoemulsification with implantation of an Akreos Adapt Advanced Optics (AO) IOL in the left eye complained of blurring vision 4 months postoperatively. Multiple fine white granules were found within the IOL. Intraocular lens exchange was performed at 7 months, and the explanted IOL was sent for histopathological analysis. Diffuse fine white granules were seen within the explanted IOL material just beneath the surface; they were stained positive by alizarin red and the von Kossa method. Scanning electron microscopy confirmed the presence of calcium deposits in the IOL material. Blood and aqueous were drawn from the patient for biochemical analysis, and the results were normal. We believe this is the first clinicopathological report of calcification of the Akreos Adapt AO IOL.

Alignment artifacts in optical coherence tomography analyzed images.

PURPOSE: To compare retinal thickness and retinal height of the original scanned optical coherence tomography (OCT) images with those of the same images after automated retinal thickness analysis. DESIGN: Cross-sectional study. PARTICIPANTS: Thirty normal eyes, 20 eyes with neovascular age-related macular degeneration (AMD), 20 with central serous chorioretinopathy (CSC), 20 with macular holes, and 20 with non-AMD related macular edema from 110 subjects were selected randomly from an OCT database. One of the 6 macular scans in each eye was chosen randomly for analysis. METHODS: Two sets of OCT images--original images and analyzed images (after retinal thickness [single eye] analysis)--in each eye were exported for retinal thickness or retinal height measurement. Comparisons of retinal thickness or retinal height at selected locations were performed. MAIN OUTCOME MEASURES: Retinal thickness (defined as the distance between the anterior boundary of the retinal nerve fiber layer [RNFL] and posterior boundary of the photoreceptor layer) and retinal height (defined as the distance between the anterior boundary of the RNFL and baseline level of the anterior boundary of the retinal pigment epithelium [RPE]). Retinal height was measured when there was detachment of neurosensory retina or RPE. RESULTS: No significant difference in retinal thickness was observed between the original and the analyzed OCT images in normal eyes and in eyes with macular holes or non-AMD related macular edema. However, OCT-analyzed images demonstrated retinal thickness or retinal height measurements in eyes with CSC or neovascular AMD significantly lower than the corresponding measurements in the original images (all with Ps< or =0.001, Wilcoxon signed rank test). In the groups of neovascular AMD and CSC, Bland-Altman plots revealed mean differences of 124 mum (95% limits of agreement between -65.5 and 313.6) and 84.4 mum (95% limits of agreement between -178.0 and 346.8), respectively, between the original and analyzed retinal measurements. CONCLUSIONS: Retinal thickness and retinal height could be underestimated in patients with CSC or neovascular AMD after retinal thickness analysis in Stratus OCT when either automatic measurements or manual caliper-assisted measurements are performed on the analyzed images. We recommend exporting the original scanned OCT images for retinal thickness and retinal height measurement in patients with CSC or neovascular AMD.

Novel approach for anterior chamber angle analysis: anterior chamber angle detection with edge measurement and identification algorithm (ACADEMIA).

OBJECTIVE: To describe a novel approach to measuring anterior chamber angle dimensions and configurations. METHODS: Sixty-nine images were selected randomly from the ultrasound biomicroscopic image database to develop the algorithm. Thirty images were selected for further analyses. The value of each pixel of the 8-bit grayscale ultrasound biomicroscopic images was quantized into 0 (black) or 1 (white), and the edge points outlining the angle were detected and fitted with straight lines. The dimensions and profiles of anterior chamber angles were then measured. RESULTS: The algorithm failed to identify the edge points correctly in 8 (11.6%) of 69 images because of strong background noise. Three basic types of angle configuration were identified based on the derived angle profiles: constant, increasing, and decreasing, which corresponded to flat, bowed forward, and bowed backward iris contours, respectively. The angle measurements demonstrated high correlation with trabecular-iris angle and angle opening distance 500 (calculated as the distance from the corneal endothelium to the anterior iris surface perpendicular to a line drawn at 500 mum from the scleral spur). The strongest association was found between the averaged angle derived from the angle profile and the angle opening distance 500 (r = 0.91). CONCLUSION: The proposed algorithm has high correlations with angle opening distance and trabecular-iris angle with the added advantages of being fully automated, reproducible, and able to capture the characteristic angle configurations. However, good-quality ultrasound biomicroscopic images with high signal-to-noise ratio are required to identify the edge points correctly.

Treatment of cystic epithelial downgrowth with intralesional administration of mitomycin C.

PURPOSE: To report a case of postoperative cystic epithelial downgrowth treated with needle aspiration and intralesional administration of mitomycin C. METHODS: Case report. A 60-year-old woman with a history of right cataract surgery 7 years ago presented with decreased vision of 1/60. The reduced vision was diagnosed secondary to a large acquired cystic epithelial downgrowth on the surface of the iris occluding the pupil. RESULTS: The cystic epithelial downgrowth was treated with aspiration and intralesional administration of mitomycin C solution. There was no evidence of recurrence on follow-up 1 year after the procedure. CONCLUSIONS: Treatment of acquired cystic epithelial downgrowth with needle aspiration and intralesional administration of mitomycin C resulted in a satisfactory outcome without undertaking more extensive and invasive surgical treatments.

Visualization of anterior chamber angle dynamics using optical coherence tomography.

PURPOSE: To describe the technology of optical coherence tomography (OCT) in imaging the anterior chamber angles and its impact on understanding the pathophysiology of angle-closure glaucoma (ACG). DESIGN: Observational case series. PARTICIPANTS: Three subjects with, respectively, impending angle-closure attack, plateau iris syndrome, and phacomorphic glaucoma were recruited. METHODS: The anterior chamber angle in each patient was imaged with a commercially available OCT unit. The angle configurations were assessed and compared before and after laser peripheral iridotomy (LPI) and argon laser peripheral iridoplasty (ALPI). MAIN OUTCOME MEASURES: Visualization of the changes in the anterior chamber angle configurations and normalization of the intraocular pressure (IOP). RESULTS: A patient with impending angle-closure attack precipitated by a topical mydriatic agent was treated with LPI. Optical coherence tomography imaging of the anterior chamber angles was performed before and after the laser procedure. Conversion of anterior iris bowing and angle crowding to iris straightening and angle opening after LPI was demonstrated. Intraocular pressure became normalized with the change in angle configuration. The second patient presented with symptoms of intermittent angle-closure attacks and was initially diagnosed with primary ACG. Despite successful LPI, the angles remained occludable, and the IOP continued to be elevated. Optical coherence tomography was used to review the anterior chamber angle configuration and demonstrated a typical pattern compatible with the diagnosis of plateau iris syndrome. Subsequent ALPI converted the plateau configuration to open angle, with normalization of IOP and disappearance of symptoms. The third patient presented with an acute angle-closure attack and was diagnosed with phacomorphic glaucoma. Argon laser peripheral iridoplasty was performed successfully to open the angle, as evident by the OCT images, and the IOP was brought under control, together with relief of symptoms. CONCLUSIONS: The commercially available OCT unit can be practically employed for anterior chamber angle imaging. The different patterns of angle configurations are correlated with the underlying pathophysiology in different forms of ACG.