Presentation of Infectious Keratitis to ED during COVID-19 Lockdown.

OBJECTIVES: To compare presentation of infectious keratitis during COVID-19 lockdown with previous years, assess relative severity, and compare outcomes between COVID-19 and pre-COVID-19 era groups. METHODS: Acute presentations of infectious keratitis during a strict government-mandated COVID-19 lockdown period were analysed retrospectively (March-May 2020). Data were compared with the same periods in 2018-2019. The clinical notes of patients undergoing corneal scrapes were reviewed, and data were collected on treatment, culture growth, surgical interventions, visual outcomes, admission rates, and risk factors. RESULTS: There were 37% fewer presentations of infectious keratitis to the ED in 2020 (N = 29, 47, and 45, respectively). Risk factor profiles and microbial data were similar across all periods. Admission rates and use of fortified antibiotics were lower in 2020. COVID-19 era cases recovered less vision (LogMAR 0.26, 0.67, and 0.45, respectively; p = 0.04) and were more likely to require surgical intervention (10%, 4%, and 2%, respectively; OR 3.4 (CI 0.7-17.9, p = 0.1)). CONCLUSION: A concerning fall in presentations of infectious keratitis to ED during the pandemic lockdown was observed. Though societal behaviour changed during the lockdown, our data suggest it is unlikely that the incidence of infectious keratitis fell significantly. It is unclear how and where these patients were treated. We postulate that lower levels of visual recovery and higher rates of surgical intervention may have been caused by delays in accessing care. To minimise avoidable ocular morbidity as COVID-19 resurges, we must communicate clearly with patients and health professionals on how to access available emergency eye care services.

Secukinumab-Associated Crystalline Corneal Deposition.

PURPOSE: To describe the first reported case of corneal crystalline deposition associated with the monoclonal antibody secukinumab (Cosentyx; Novartis, Basel, Switzerland) and the subsequent follow-up of the case. METHODS: Case report. RESULTS: An 18-year-old man was referred for a corneal opinion 1 year after commencing secukinumab monoclonal antibody therapy for ankylosing spondylitis. Crystalline corneal deposits were identified at a routine optometrist appointment. The same optometrist had documented normal anterior segment examination 2 years earlier. On examination, anterior stromal refractile crystals were visible in both corneas extending out to the limbus. The patient's best-corrected distance visual acuity was 20/20 bilaterally, and he was asymptomatic. Family history and systemic workup for other causes of crystal deposition were negative. By a process of elimination of other etiologies, we concluded that the monoclonal antibody secukinumab was responsible for the deposition. At the 1-year point of treatment with secukinumab, the patient remains asymptomatic and is still undergoing therapy. CONCLUSIONS: To the best of the authors' knowledge, this is the first report of corneal crystal deposition attributed to secukinumab. The number of monoclonal antibodies in use across multiple medical disciplines is increasing, and corneal specialists may see this presentation more frequently in the future. These drugs provide critical disease-modifying treatment to patients with debilitating systemic pathology. It is important that we understand the natural history of their side effects to allow their full utilization.

Successful reconstruction of an ocular defect resulting from granulomatosis with polyangiitis, following treatment with rituximab.

PURPOSE: To report a unique case of orbital inflammatory disease which was ultimately diagnosed as granulomatosis with polyangitis (GPA) and thus successfully treated. OBSERVATION: A 47 year-old man presented with a rapidly progressive necrotic soft tissue mass within the medial antero-superior aspect of the right eyelid and orbit. He also had transient retinal vasculitis in the left. Serology, histology and imaging were atypical of, but consistent with, GPA. He was thus successfully treated with intravenous rituximab followed by reconstruction of the medial eyelid. CONCLUSION AND IMPORTANCE: A high index of suspicion of GPA is required in orbital inflammatory disease, especially when typical diagnostic findings are absent.

Molecular phylogenetics and morphological reappraisal of the Platanthera clade (Orchidaceae: Orchidinae) prompts expansion of the generic limits of Galearis and Platanthera.

BACKGROUND AND AIMS: The Platanthera clade dominates the North American orchid flora and is well represented in eastern Asia. It has also generated some classic studies of speciation in Platanthera sections Platanthera and Limnorchis. However, it has proved rich in taxonomic controversy and near-monotypic genera. The clade is reviewed via a new molecular phylogenetic analysis and those results are combined with brief reconsideration of morphology in the group, aiming to rationalize the species into a smaller number of larger monophyletic genera and sections. METHODS: Nuclear ribosomal internal transcribed spacer (ITS) sequences were obtained from 86 accessions of 35 named taxa, supplemented from GenBank with five accessions encompassing a further two named taxa. KEY RESULTS: Using Pseudorchis as outgroup, and scoring indels, the data matrix generated 30 most-parsimonious trees that differed in the placement of two major groups plus two closely related species. Several other internal nodes also attracted only indifferent statistical support. Nonetheless, by combining implicit assessment of morphological divergence with explicit assessment of molecular divergence (when available), nine former genera can be rationalized into four revised genera by sinking the monotypic Amerorchis, together with Aceratorchis and Chondradenia (neither yet sequenced), into Galearis, and by amalgamating Piperia, Diphylax and the monotypic Tsaiorchis into the former Platanthera section Platanthera. After further species sampling, this section will require sub-division into at least three sections. The present nomenclatural adjustments prompt five new combinations. CONCLUSIONS: Resolution of major groups should facilitate future species-level research on the Platanthera clade. Recent evidence suggests that ITS sequence divergence characterizes most species other than the P. bifolia group. The floral differences that distinguished Piperia, Diphylax and Tsaiorchis from Platanthera, and Aceratorchis and Chondradenia from Galearis, reflect various forms of heterochrony (notably paedomorphosis); this affected both the perianth and the gynostemium, and may have proved adaptive in montane habitats. Floral reduction was combined with lateral expansion of the root tubers in Piperia and Diphylax (including Tsaiorchis), whereas root tubers were minimized in the putative (but currently poorly supported) Neolindleya-Galearis clade. Allopolyploidy and/or autogamy strongly influenced speciation in Platanthera section Limnorchis and perhaps also Neolindleya. Reproductive biology remains an important driver of evolution in the clade, though plant-pollinator specificity and distinctness of the species boundaries have often been exaggerated.

Orbital roof fractures: management of ophthalmic complications.

PURPOSE: To review the clinical features and management of patients with orbital roof fractures. METHODS: Non-comparative, retrospective case review of 21 patients presenting with orbital roof fractures. RESULTS: The orbital roof fractures in our series resulted from motor vehicle accidents, blunt trauma, head injuries, and penetrating orbital injuries. Associated orbital and ocular injuries included other ipsilateral orbital fractures (16 cases), traumatic optic neuropathy (3 cases), ptosis (2 cases), perforating eye injuries (2 cases), intraorbital foreign bodies (2 cases), and oculomotor nerve palsy (1 case). Six patients required surgical intervention for ophthalmic sequelae, which included motility problems (4 cases), lagophthalmos (1 case), and a retained intraorbital foreign body with a cerebrospinal fluid leak (one case). The outcome of surgery was favorable in all cases, with complete resolution of symptoms in five of six patients. CONCLUSIONS: Orbital and ocular injuries are common in association with orbital roof fractures. A multidisciplinary approach to management is required because facial and cerebral injuries are also common. Most patients can be managed conservatively. The specific ophthalmic indications for surgical intervention are limited, but the outcome in these cases is gratifying.

Clinical features and management of intraorbital foreign bodies.

PURPOSE: To review the clinical features and management of patients with intraorbital foreign bodies. DESIGN: Noncomparative interventional case series. PATIENTS AND METHOD: Forty patients seen at two regional orbital surgery departments with intraorbital foreign bodies were reviewed. MAIN OUTCOME MEASURES: Visual acuity, surgical interventions, and complications. RESULTS: Seventy-three percent of patients were younger than 30 years old. There were 22 metallic, inorganic; 5 nonmetallic, inorganic; and 13 organic intraorbital foreign bodies (IOrbFb) in this series. Thirty patients were seen at the time of injury, and 10 patients were seen in a delayed setting with orbital complications. Thirty-four patients had surgical removal of their IOrbFb either because of complications or easy surgical access. Six patients had no surgery because of posteriorly located inorganic foreign bodies. Thirteen patients had resultant blind eyes; 12 of these were blind from the initial trauma. CONCLUSIONS: Loss of vision in conjunction with IOrbFbs is usually a result of the initial trauma. All patients should have antibiotic therapy because of the high incidence of secondary orbital infections. Computed tomography is the best initial mode of imaging. Surgical removal is indicated for all organic IOrbFbs. Inorganic IOrbFbs should be removed if causing complications or if located anteriorly after discussion of potential surgical complications with the patient. Posteriorly located inorganic IOrbFbs should be left alone, unless they are causing significant orbital complications.