Recurrent Fevers and Neuro-ophthalmic Disorders in a Mathematical Genius.

Horner's syndrome coexisting with an ipsilateral fourth cranial nerve palsy is a rare occurrence and likely localises to pathology in the cavernous sinus. One such case may have occurred in the 18th century affecting the renowned mathematician Leonhard Euler. A review of his biographies, eulogies, and three finely detailed facial portraits suggest that these two neuro-ophthalmic conditions, along with visual loss and a decades-long intermittent febrile illness, may have been the result of an orbital cellulitis and septic cavernous sinus thrombosis, from an underlying chronic brucellosis infection.

A case of systemic sclerosis/lupus overlap syndrome presenting with bilateral cotton wool spots.

PURPOSE: Systemic sclerosis (SSc) is characterized by multi-system inflammation and fibrosis. Ophthalmologists must be aware of the uncommon ocular features of SSc to secure the diagnosis. OBSERVATIONS: Here we report the rare occurrence of bilateral cotton wool spots in an 86-year-old woman with SSc/lupus overlap syndrome presenting with a history of chronic obstructive pulmonary disease, gastroesophageal reflux disease, polymyalgia rheumatica, scalp tenderness, and right jaw pain on chewing. Fundoscopy showed diffuse bilateral cotton wool spots that prompted the diagnosis of SSc/lupus overlap syndrome. CONCLUSIONS: The confluence of patient symptoms was disguised as separate diseases, but the funduscopic finding of cotton wool spots in a patient without known risk factors prompted further investigation and the correct diagnosis. She was started on immunosuppressant therapy but unfortunately died four months later after developing right heart failure. IMPORTANCE: The differential diagnosis for bilateral cotton wool spots should include autoimmune processes such as SSc and systemic lupus erythematosus and may represent an early sign that can help direct treatment.

Microbiological Investigations of ReNu Plastic Bottles and the 2004 to 2006 ReNu With MoistureLoc-Related Worldwide Fusarium Keratitis Event.

PURPOSES: The purposes of this study were to determine whether the contact lens solution RevitaLens Ocutec (containing the antimicrobial agents alexidine and polyquaternium-1) would inhibit Fusarium organisms when heated in ReNu plastic bottles; whether alexidine would inhibit Fusarium organisms when heated in non-ReNu plastic bottles; and whether an alexidine-neutralizing compound leaches from heated ReNu bottles. METHODS: RevitaLens and an alexidine solution (0.00045%), previously stored in ReNu bottles at room temperature (RT) and 56°C, were incubated with 7 different Fusarium organisms. The alexidine solution was similarly stored in seven non-ReNu plastic bottles and incubated with these same organisms. To determine if an alexidine-neutralizing compound might be leaching from heated ReNu bottles, phosphate-buffered saline (PBS) was incubated at RT and 56°C in ReNu bottles, combined with alexidine, and then tested for anti-Fusarium capability. RESULTS: After being heated in ReNu bottles, RevitaLens retained its anti-Fusarium capability, whereas the alexidine solution did not. The alexidine solution heated in seven non-ReNu plastic bottles retained its anti-Fusarium capability. The alexidine solution retained its anti-Fusarium capability when incubated with a PBS solution that had been heated in ReNu bottles, indicating, microbiologically, that an alexidine-neutralizing compound did not leach from the heated ReNu bottle. CONCLUSIONS: Alexidine uniquely fails to inhibit Fusarium organisms when heated in a plastic ReNu bottle, but not in seven other plastic bottles, whereas the anti-Fusarium capability of RevitaLens (containing the antimicrobial agents alexidine and polyquaternium-1) is unaffected by heating in a ReNu bottle. There does not seem to be an alexidine-neutralizing compound leaching from heated ReNu bottles. An interaction between alexidine and its heated ReNu bottle may have been a critical factor in the worldwide ReNu with MoistureLoc-related Fusarium keratitis event of 2004 to 2006.

Canthaxanthin retinopathy with visual loss: a case report and review.

Canthaxanthin is a naturally occurring chemical, which is most commonly utilized as a colorant for food and dyes or a skin bronzing agent. Its most prevalent impact on human health is canthaxanthin retinopathy, which appears as birefringent, yellow to red crystals surrounding the macula. This occurs with increasing, dose-dependent exposure. Generally, patients remain asymptomatic and findings may only be evident on funduscopic examination. Cessation of canthaxanthin ingestion appears to reverse the retinopathy, but the time until crystal disappearance is variable. Despite a usually favorable outcome, long-standing visual changes may occur. We report a case of an 84-year-old woman with significant visual loss secondary to canthaxanthin retinopathy that ultimately improved upon cessation of the drug.

Oculocardiac reflex in a medial orbital wall fracture without clinically evident entrapment.

In this report, we describe a patient with a medial wall orbital fracture, who presented with vasovagal-like symptoms secondary to an oculocardiac reflex. This case is unusual because the patient had no other clinical evidence of muscle entrapment. A 15-year-old male presented with daily 5-10 min episodes of dizziness, light headedness, and nausea consistent with a vasovagal reaction. On examination, the patient had full extra ocular motility and was orthotropic in all fields of gaze. On computed tomography a comminuted medial orbital wall fracture was identified. The adjacent medial rectus muscle was in normal position, but was "rounded" relative to the contralateral side. The patient underwent fracture repair with immediate resolution of all symptoms. Symptoms related to a vasovagal response may occur with orbital fractures despite normal extra ocular motility. Presumably this relates to tension or pulling on an extra ocular muscle, which is not to a degree that alteration in function is appreciable clinically.

Pan-antimicrobial failure of alexidine as a contact lens disinfectant when heated in Bausch & Lomb plastic containers: implications for the worldwide Fusarium keratitis epidemic of 2004 to 2006.

OBJECTIVE: ReNu with MoistureLoc (ReNuML), containing the antimicrobial agent alexidine 0.00045%, was associated with the Fusarium keratitis epidemic of 2004 to 2006. Although a single-point source contamination was ruled out, only Fusarium organisms were reported during the outbreak. This study investigated whether the reported loss of antimicrobial effectiveness toward Fusarium of ReNuML after exposure to heat in high-density polyethylene (HDPE) plastic containers could also be demonstrated with other common fungal and bacterial agents of keratitis. METHODS: A buffered solution of alexidine 0.00045% was incubated in glass and ReNu HDPE plastic containers at room temperature (RT) and 56°C for 4 weeks, serially diluted, and tested for its ability to inhibit the growth of 20 bacterial isolates, 12 non-Fusarium fungal isolates, and 7 Fusarium isolates originally involved in the keratitis epidemic. RESULTS: A statistically significant loss of antimicrobial capability was seen with all fungi, all gram-positive bacteria, and all isolates of Klebsiella when alexidine 0.00045% was incubated at 56°C in ReNu HDPE containers compared with RT or glass incubation (P≤0.0001). CONCLUSIONS: Heating of an alexidine solution in ReNu HDPE plastic (but not glass) containers results in the same loss of anti-Fusarium activity as reported when testing the original ReNuML solution. This loss of inhibitory activity is not specific to Fusarium and occurs with other fungi and bacteria that cause keratitis. The reasons for the lack of reports of bacterial and/or non-Fusarium fungal keratitis during the original Fusarium keratitis epidemic remain unclear at this time.

Effects of time, temperature, and storage container on the growth of Fusarium species: implications for the worldwide Fusarium keratitis epidemic of 2004-2006.

OBJECTIVE: To demonstrate the effects of time, temperature, and container properties on the ability of ReNu with MoistureLoc (ReNuML; contains the antimicrobial agent alexidine) to inhibit growth of Fusarium species. METHODS: ReNu with MoistureLoc was stored in its Bausch & Lomb (Rochester, New York) plastic or similarly sized glass containers for 1 and 4 weeks at room temperature, 42°C, and 56°C, and then tested for its ability to inhibit growth of 7 Fusarium isolates. RESULTS: ReNu with MoistureLoc stored in glass containers for 1 or 4 weeks at all 3 temperatures demonstrated no significant fungistatic deterioration. However, ReNuML stored at 56°C in its Bausch & Lomb plastic container demonstrated a statistically significant fungistatic deterioration compared with room temperature storage in its original plastic container or with glass container storage at any temperature. CONCLUSION: When exposed to elevated storage temperature, it appears that an interaction between ReNuML and its Bausch & Lomb plastic container adversely affects the fungistatic properties of ReNuML, which could have contributed to the Fusarium keratitis epidemic of 2004 through 2006.

Temperature instability of ReNu With MoistureLoc: a new theory to explain the worldwide Fusarium keratitis epidemic of 2004-2006.

OBJECTIVE: To investigate the effect of storage temperature on the ability of contact lens solutions to inhibit growth of Fusarium species. A 2006 Food and Drug Administration inspection of Bausch & Lomb's Greenville, South Carolina, manufacturing site indicated that Bausch & Lomb failed to regulate storage and transport temperatures of their products. METHODS: Six contact lens solutions were studied: ReNu with MoistureLoc, ReNu MultiPlus, COMPLETE Moistureplus, AQuify, Clear Care, and OPTI-FREE RepleniSH. Two bottles of each solution were separately stored at room temperature and 60 degrees C for 4 weeks, serially diluted, and then tested for their ability to inhibit growth of 11 Fusarium isolates (7 of which were associated with the keratitis epidemic). RESULTS: ReNu with MoistureLoc demonstrated the greatest decline in efficacy after 60 degrees C storage. Clear Care and ReNu MultiPlus performed the best. Regarding the keratitis epidemic isolates only, the ReNu with MoistureLoc bottle stored at room temperature allowed growth in 27 of 84 combinations vs 67 of 84 combinations with the 60 degrees C-stored bottle. CONCLUSIONS: When exposed to prolonged temperature elevation, ReNu with MoistureLoc loses its in vitro fungistatic activity to a much greater extent than other products. Improper temperature control of ReNu with MoistureLoc may have contributed to the Fusarium keratitis epidemic of 2004-2006.

Evaluation of intraocular and orbital pressure in the management of orbital hemorrhage: an experimental model.

OBJECTIVE: To evaluate orbital pressure (OP), intraocular pressure (IOP), and the effectiveness of canthotomy, cantholysis, and septolysis using an experimental orbital hemorrhage model. METHODS: Expired whole blood was injected into the retrobulbar space of 10 human cadaver orbits. At 1-mL increments, OP, IOP, and globe position were documented. The mean (SD) time interval between the injections was 84 (36) seconds. Following injection of 22 mL, lateral canthotomy, cantholysis, and septolysis were performed. An additional 10 mL of blood was then injected. RESULTS: After injecting 22 mL of whole blood, mean (SD) OP and IOP were 68.4 (32.2) and 71.5 (19.1) mm Hg, respectively. The OP and IOP correlated closely throughout the experiment, with a mean (SD) difference of 11.4 (4.9) mm Hg (Pearson coefficient, 0.97). Following canthotomy, cantholysis, and septolysis, there was a mean (SD) decrease of 48.0 (27.2) mm Hg (70%) and 50.0 (18.1) mm Hg (59%) in OP and IOP, respectively. With additional injection of 10 mL of blood, OP and IOP increased rapidly. CONCLUSIONS: The IOP and OP rose in direct proportion to the volume of whole blood injected; OP lagged behind IOP by 11 mm Hg, and surgical release of the orbit reduced OP by 70%. This effect was short-lived in the setting of continued simulated hemorrhage.

Orbital giant cell angiofibroma recurring as a solitary fibrous tumor.

Giant cell angiofibroma has recently been hypothesized to be a clinicopathologic variant of solitary fibrous tumor. The authors report a case of an orbital giant cell angiofibroma that recurred as a solitary fibrous tumor 4 years later. The report strongly supports the hypothesis that giant cell angiofibroma and solitary fibrous tumor are related.

Temperature instability of ReNu with MoistureLoc: a new theory to explain the worldwide Fusarium keratitis epidemic of 2004-2006.

PURPOSE: A 2006 US Food and Drug Administration (FDA) inspection of Bausch & Lomb's (B&L's) Greenville, South Carolina, manufacturing site indicated that B&L failed to regulate storage and transport temperatures of their products. The present study investigated the effect of storage temperature on the ability of contact lens solutions to inhibit growth of Fusarium species. METHODS: SIX CONTACT LENS SOLUTIONS WERE STUDIED: ReNu with MoistureLoc (ReNu ML), ReNu MultiPlus, Complete Moistureplus, AQuify, Clear Care, and OPTI-FREE RepleniSH. Two bottles of each solution were separately stored at room temperature and 60 degrees C for 4 weeks, serially diluted, then tested for their ability to inhibit growth of 11 Fusarium isolates (7 of which were associated with the keratitis epidemic). RESULTS: ReNu ML demonstrated the greatest decline in efficacy after 60 degrees C storage. Clear Care and ReNu MultiPlus performed the best. Regarding the keratitis epidemic isolates only, the ReNu ML bottle stored at room temperature allowed growth in 27 of 84 combinations vs 67 of 84 combinations with the 60 degrees C stored bottle. CONCLUSIONS: When exposed to prolonged temperature elevation, ReNu ML loses its in vitro fungistatic activity to a much greater extent than other products. Improper temperature control of ReNu ML may have contributed to the Fusarium keratitis epidemic of 2004-2006.

KCC isoforms in a human lens epithelial cell line (B3) and lens tissue extracts.

We recently reported potassium-chloride cotransporter activity in human lens epithelial B3 (HLE-B3) cells. The purpose of the present study was to demonstrate in these cells as well as in human lens tissue the potassium-chloride cotransport (KCC) isoforms by reverse transcriptase-polymerase chain reaction (RT-PCR), Western blotting and immunofluorescence microscopy. Of the four KCC genes known to encode the respective proteins and their spliced variants, RT-PCR with both rat and human primers revealed the predicted cDNA fragments of KCC1, KCC3a, KCC3b, and KCC4 but not KCC2 in both HLE-B3 cells and in human lens tissue extracts from cataractous patients. Polyclonal rabbit (rb) anti-rat (rt) and anti-human (hm) antibodies against rtKCC1 and hmKCC3, respectively, and a commercially available rb-anti-mouse (ms) KCC4 antibody were used. Rb anti-rtKCC1-ECL3 [against epitopes within the large extracellular loop 3 (ECL3)] revealed a 150kDa band in HLE-B3 cells consistent with the known molecular weight of KCC1. Rb anti-hmKCC3-ECL3 yielded three bands of 150, 122 and 105kDa, evidence for the presence of KCC3a, KCC3b and possibly KCC3c isoforms. The 122 and 112kDa bands were also demonstrated by rb anti-hmKCC3-CTD [the C-terminal domain (CTD)]. Rb anti-msKCC4 antibody only showed a 100kDa band in HLE-B3 cells. In the human lens tissues, a 115kDa protein was detected with rb anti-rtKCC1-ECL3 and a 100kDa band with rb anti-msKCC4, however, no bands with rb anti-hmKCC3-ECL3 or rb anti-hmKCC3-CTD. Fluorescence microscopy revealed immunocytochemical cytoplasmic and membrane labeling of HLE-B3 cells with anti-KCC1, -KCC3 (laser confocal microscopy) and -KCC4 antibodies and a Cy3-tagged secondary antibody. Hence HLE-B3 cells expressed proteins of the KCC1, KCC3a, b, and KCC4 isoforms, whereas surgically removed cataractous lens tissue expressed only those of KCC1 and KCC4.

Sudden death from pituitary apoplexy in a patient presenting with an isolated sixth cranial nerve palsy.

A 68-year-old diabetic, hypertensive man presented with a left sixth cranial nerve palsy. MRI demonstrated an inhomogeneous sellar mass encroaching on the left cavernous sinus. Two days later, a left third cranial nerve palsy developed. Within 24 hours, the patient went into cardiac arrest and died. An autopsy showed hemorrhage within a pituitary macroadenoma ("pituitary apoplexy"). Pituitary apoplexy should be considered a cause of acute isolated sixth cranial nerve palsy and may represent a life-threatening emergency that can be averted with emergent hormonal replacement and hypophysectomy.