Late-onset necrotizing scleritis due to pigmented mycetoma (dematiaceous fungi) in 2 cases.

PURPOSE: To describe the atypical presentation of fungal infection and necrotizing scleritis, the potential role of histopathology in the diagnosis, and surgical excision in the management. METHODS: Retrospective interventional case series. RESULTS: Two patients presented with a pigmented conjunctival mass, one resembling necrotizing scleritis with uveal prolapse and the other resembling a pigmented ocular surface tumor, both after excision of nasal pterygium, 12 and 50 years previously, respectively. The pigmented lesion was 2 × 1.5 mm in each case, both situated on the bulbar surface 2 mm from the nasal limbus. After surgical excision, each lesion histopathologically displayed fungal filaments (pigmented dematiaceous fungi). CONCLUSIONS: Pigmented mycetoma (dematiaceous fungi) can simulate uveal tissue prolapse, pigmented foreign body, or pigmented epibulbar tumors, particularly melanoma. Surgical excision of the entire lesion is effective for management.

Incidence of ocular complications in patients with multibacillary leprosy after completion of a 2 year course of multidrug therapy.

AIM: To evaluate the incidence of and risk factors for ocular complications in multibacillary (MB) leprosy patients following completion of 2 year, fixed duration, multidrug therapy (MDT). METHODS: Biannual eye examinations were conducted prospectively on a cohort of MB patients who had completed MDT and followed up for 5 years. The incidence of ocular pathology was calculated as the number of events per person year of event free follow up of patients who did not have the specific finding before completion of MDT. RESULTS: 278 patients had one or more follow up visits after completion of MDT. The incidence of lagophthalmos was 0.24%/patient year (95% CI 0.10% to 0.37%); corneal opacity, 5.35%/patient year (95% CI 4.27% to 6.70%); uveal involvement, 3.78%/patient year (95% CI 2.96% to 4.83%); and cataract that reduced vision to 6/18 or less, 2.4%/patient year (95% CI 1.77% to 3.26%). Overall, 5.65%/patient year (95% CI 4.51% to 7.09%) developed leprosy related ocular disease and 3.86%/patient year (95% CI 3.00% to 4.95%) developed leprosy related, potentially blinding ocular pathology during the period following MDT. Age and other disability also predicted incident eye disease. CONCLUSIONS: Every year, approximately 5.6% of patients with MB who have completed MDT can be expected to develop new ocular complications of leprosy, which often (3.9%) are potentially vision threatening. Because many of these complications cannot be detected without slit lamp examination, periodic monitoring, particularly of older patients and those with other disability, is recommended, in order to detect and treat ocular complications satisfactorily.

Post traumatic polymicrobial endophthalmitis, including Neisseria subflava.

DESIGN: To report the second known case of post-traumatic endophthalmitis caused by Neisseria subflava. DESIGN: Interventional case report. METHODS: A two-year-old child with post-traumatic corneal laceration and uveal prolapse required medical and surgical therapy for endophthalmitis caused by multiple organisms including N. subflava. RESULTS: After aggressive therapy, patient had a favorable outcome without vision compromise. CONCLUSIONS: As there is still not a standard protocol for therapy for post-traumatic endopthalmitis, we recommend the use of broad-spectrum antibiotics via intravitreal, intravenous, and topical routes. Consideration of typical and unusual bacteria that have been reported to cause endopthalmitis, as well as the source of injury, should guide antibiotic choice.

Ocular histopathology of Ehrlichial infections in the dog.

Histologic examination of eyes and brains of 27 dogs experimentally infected with either Ehrlichia canis, E. ewingii, E. chaffeensis, or human granulocytic ehrlichia (HGE) was conducted in the course of several experiments, the primary objectives of which were to investigate the susceptibility of the domestic dog to infection with various ehrlichial species and to assess the ability of ixodid tick species to acquire and transmit those infections. Uveitis and meningitis occurred in each of the dogs infected with E. canis but was not observed in dogs infected with the other Ehrlichia species. The inflammatory infiltrate was predominantly lymphocytic, monocytic, and plasmacytic; granulocytes were notably few. Ocular inflammation was most common and most intense in the ciliary body, becoming less intense in the choroid, iris, and retina, respectively. Meningitis was often accompanied by mild neuroparenchymal vascular cuffing and gliosis. The meningeal inflammatory cell infiltrate included a prominent monocyte population. Ocular and meningeal lesions were present in all E. canis-infected dogs from 22 through 200 days postexposure. Neither ocular nor brain lesions were observed with any of the other ehrlichial infections.

Retinal detachment due to breaks in pars plicata of ciliary body after endogenous fungal endophthalmitis.

An eye with retinal detachment due to breaks in the nonpigmented epithelium in the pars plicata of the ciliary body was reported in a patient who had been infected by endogenous Candida endophthalmitis about 3 years previously. He had no history of ocular trauma or atopic dermatitis, and had undergone extracapsular cataract extraction because of secondary cataract following the endophthalmitis. Three months later, the breaks were detected in his right eye, distributed extensively between the 3:30 and 11:45 o'clock meridians in the pars plicata. The posterior edges of these breaks were pulled to the contracted posterior capsule by zonular fibers. Posterior capsulectomy, vitrectomy, encircling and scleral buckling were performed and resulted in the reattachment of the retina. It was suggested that the ciliary body which had been damaged by endophthalmitis played a role in the development of these breaks.

Miliary retinitis in coccidioidomycosis.

We studied the pathologic features of a rare case of coccidioidomycosis retinitis in a 12-year-old girl. At autopsy there were multiple small lesions throughout the vital organs. Ocular lesions were restricted to the posterior part of the fundus. Step-level serial sectioning including the optic axes of both eyes showed 29 discrete retinal and 22 choroidal granulomas. Topographic analysis demonstrated random distribution of lesions throughout the fundus. Retinal granulomas were centered within layers served by the retinal circulation. Choroidal lesions most often involved the middle vascular layer and in only two areas focally disrupted Bruch's membrane. The pigment epithelium was intact. Retinal granulomas were not topographically associated with choroidal lesions.

Prevalence of chorioretinal scars associated with coccidioidomycosis.

A retrospective study was conducted to determine the prevalence and spectrum of chorioretinal involvement among individuals with previously documented systemic coccidioidomycosis. Fifty-four subjects were given a modified ocular examination, and their medical records were abstracted for clinical classification of the disease and its correlation with ocular findings. Five of 54 subjects with documented past infection with Coccidioides immitis had characteristic inactive peripheral chorioretinal scars. No relationship between the presence of scars and the extent of disease was evident; typical scars were found in patients who had experienced mild respiratory tract infection as well as in more extensively disseminated disease. We conclude that dissemination of C immitis to the eye can occur during benign pulmonary coccidioidomycosis as well as with more severe systemic disease, and the prevalence of chorioretinal lesions is more common than isolated case reports would indicate.

Strain specificity of clinical isolates of herpes simplex virus.

Herpes simplex virus (HSV) produces a wide variety of ocular disease in man. Although host factors are important in determining this variation, it is possible that the different clinical patterns of herpetic ocular disease may be attributed at least partially to the differing biological behavior of specific strains of HSV. To test this theory, we compared the anterior segment disease produced by infecting rabbit corneas with seven different strains of HSV. We found that these seven different strains produced different patterns of ocular disease in the rabbit eye. This also may occur in humans, and we hope to define the biological differences that cause one strain to produce disease more severe than that produced by another strain.

The association of viruses with urveal melanoma.

Electron microscopic examination of 57 ocular melanomas (54 human, two feline and one canine) revealed the presence of viral particles in six specimens. Herpesviruses particles were observed in one human specimen and were passed in human fibroblasts (WI-38), where they gave rise to intranuclear inclusions. A-type oncornavirus particles (oncogenic RNA virus) were observed in a second case, both in cells of tumor directly removed from an enucleated eye as well as in cells grown in tissue culture. In three human specimens and one feline specimen, togavirus particles were observed. Rubella is a member of this group, and the possibility that the presence of togavirus in these tumors is the result of latent ocular infection by rubella virus is raised. Herpes virus and RNA tumor viruses are widely considered as having a possible etiologic role for certain human cancers. The observation of togavirus is unexpected, as this virus has not been previously implicated in human or animal tumors. Injection of an RNA tumor virus (Gardner strain feline sarcoma virus) into the anterior chamber of newborn kittens resulted in the development of iris and ciliary body melanomas, many of which showed invasion and, in one instance, metastasis. This is the first animal model of a viral-induced uveal melanoma, and the histology and ultrastructure are described. These results emphasize the need for the continued investigation of the role of these viruses in uveal melanoma.

Ocular cryptococcosis.

We studied ocular cryptococcosis in a 59-year-old man who had received extensive chemotherapy for abdominal malignant lymphoma. Mucinous lesions containing abundant cryptococci, but no inflammatory cells, formed in the posterior choroid of the eye. Electron microscopy revealed that mucin, a filamentous substance, coated the encapsulated organisms. Except for a few degenerating ones in histiocytes, most cryptococci appeared in the extracellular space.

Congenital syphilis of the eye with lens involvement.

Pathological examination of a girl with congenital syphilis revealed a focal granulomatous reaction involving the anterior uvea and lens. Krajian's (silver) stain exhibited spiral forms that were morphologically compatible with Treponema pallidum within the lens cortex. These findings have been rarely reported in early congenital lues.

Herpes simplex uveitis in immune rabbits. Priming effect of nonherpetic uveitis.

Systemic immunization of rabbits with herpes simplex virus (HSV) had two opposite effects on the outcome of subsequent efforts to produce primary HSV uveitis, the difference depending on whether or not the rabbits had had nonherpetic uveitis before the HSV challenge. In normal eyes, systemic immunization with HSV provided complete protection against the production of primary uveitis by an intraocular injection of HSV; but in eyes that had had a bout of experimentally induced nonherpetic uveitis before the challenge, the same systemic immunization was not protective. In these eyes, an immune-mediated uveal inflammation developed. Nonherpetic uveitis had apparently "primed" the eyes of the HSV-immune rabbits for subsequent immune-mediated HSV uveitis.