A case report of fulminant endophthalmitis caused by Streptococcus dysgalactiae in a patient with traumatic corneal laceration.

BACKGROUND: To report a case of enucleation caused by Streptococcus dysgalactiae endophthalmitis after traumatic corneal laceration. CASE PRESENTATION: A 69-year-old man with history of retinal detachment treated with vitrectomy and subsequent cataract surgery presented with traumatic corneal laceration while cutting grass. Appropriate repair of corneal laceration and intravitreal antibiotics (vancomycin, ceftazidime) injection was performed. S. dysgalactiae which was sensitive to the conventional antibiotics (Ampicillin, Ceftriaxone, Levofloxacin, etc.) detected by aqueous culture. One day following primary closure, the patient developed a complete hypopyon and vitreous membranes. Despite vigorous systemic and intravitreal antibiotics administration with vitrectomy, endophthalmitis was not controlled and patient's ocular pain was increased. The vitreous culture was also positive for S. dysgalactiae. Finally, total enucleation was performed 9 days after trauma due to fulminant endophthalmitis with severe scleritis. CONCLUSION: Progression of traumatic endophthalmitis associated with S. dysgalactiae can be fulminant. Sufficient warning to patient about enucleation and intensive care is needed in the case of this infection.

Lenticular fungal infection caused by Aspergillus in a patient with traumatic corneal laceration: a case report.

BACKGROUND: To report a case of lenticular infection caused by Aspergillus, which was diagnosed 13 weeks after traumatic corneal laceration. CASE PRESENTATION: A 60-year-old woman presented with traumatic corneal laceration including anterior lens capsule rupture and traumatic cataract after being hit with a chestnut in the right eye. There were multiple injuries due to tiny thorns of the chestnut, including the conjunctiva, sclera, cornea, and anterior lens capsule. But no visible foreign body was detected by slit-lamp examination. Topical corticosteroid was prescribed to resolve the conjunctival inflammation induced by the thorns of chestnut, which could have caused persistent irritation. As conjunctival injection and edema being decreased during outpatient clinical follow-up, embedded conjunctival foreign body was detected and surgically removed (1st surgery). Approximately 10 weeks after the trauma, severe inflammation of the anterior segment accompanied with hypopyon developed suddenly and at the same time embedded scleral foreign body was revealed. After removal of scleral foreign body (2nd surgery), unspecified mold species was cultured from the scleral foreign body in SDA (Sabouraud dextrose agar) plate. Suspicious corneal foreign body was removed as 3rd surgery and phacoemulsification of traumatic cataract was planned as 4th surgery. Aspergillus was finally detected from removed anterior capsule and fibrotic membrane during the operation. Fungal infection resolved successfully after administration of topical (1% voriconazole and 5% natamycin) and systemic (fluconazole) antifungal agents and phacoemulsification of traumatic cataract. CONCLUSION: Chestnut thorns can damage multiple ocular tissues simultaneously. Lens capsular rupture could result in fungal inoculation and lead to delayed lenticular fungal infection with complicated cataract formation. In cases of ocular trauma due to organic substances such as thorns and branches, the possibility of fungal infection should be considered.

Changes of tear film lipid layer thickness by 3% diquafosol ophthalmic solutions in patients with dry eye syndrome.

AIM: To evaluate the quantitatively changes in lipid layer thickness (LLT) when 3% diquafosol eye drop is used for dry eye patients using the tear film interferometer. METHODS: A total 124 participants (32 males, 92 females; mean age, 28.9y) diagnosed with dry eye disease (DED) received topical instillation of 4 ophthalmic solutions in one eye: diquafosol, normal saline, 0.1% sodium hyaluronate and 0.3% gatifloxacin, in a masked manner. LLT was measured using an interferometer at baseline and 20min after the instillation of each ophthalmic solutions. RESULTS: Changes of LLT after instillation (nm, mean± standard error) were as follows: 12.6±2.0 for diquafosol (P<0.001), 1.2±2.2 for normal saline (P=0.301), 1.5±2.0 for hyaluronate (P=0.495), and 0.5±3.2 for gatifloxacin (P=0.884). CONCLUSION: Topical instillation of diquafosol increases tear film LLT in DED patients. Diquafosol 3% eye drop might be effective treatment option of evaporative DED with meibomian gland dysfunction.

Changes in Tear Volume after 3% Diquafosol Treatment in Patients with Dry Eye Syndrome: An Anterior Segment Spectral-domain Optical Coherence Tomography Study.

PURPOSE: To evaluate changes in the tear meniscus area and tear meniscus height over time in patients with dry eye syndrome, using anterior segment spectral-domain optical coherence tomography after the instillation of 3% diquafosol ophthalmic solution. METHODS: Sixty eyes from 30 patients with mild to moderate dry eye syndrome were included. Tear meniscus images acquired by anterior segment spectral-domain optical coherence tomography were analyzed using National Institutes of Health's image-analysis software (ImageJ 1.44p). Tear meniscus area and tear meniscus height were measured at baseline, 5 minutes, 10 minutes, and 30 minutes after instillation of a drop of diquafosol in one eye and normal saline in the other eye. Changes in ocular surface disease index score, tear film break-up time, corneal staining score by Oxford schema, and meibomian expressibility were also evaluated at baseline, and after 1 week and 1 month of a diquafosol daily regimen. RESULTS: Sixty eyes from 30 subjects (mean age, 29.3 years; 8 men and 22 women) were included. In eyes receiving diquafosol, tear volume was increased at 5 and 10 minutes compared with baseline. It was also higher than saline instilled eyes at 5, 10, and 30 minutes. Changes in tear volume with respect to baseline were not statistically different after the use of diquafosol for 1 month. Ocular surface disease index score, tear film break-up time, and Oxford cornea stain score were significantly improved after 1 week and 1 month of daily diquafosol instillation, but meibomian expressibility did not change. CONCLUSIONS: Topical diquafosol ophthalmic solution effectively increased tear volume for up to 30 minutes, compared to normal saline in patients with dry eye syndrome.

The anti-acetylcholine receptor antibody test in suspected ocular myasthenia gravis.

Aim. To estimate the clinical significance of anti-acetylcholine receptor antibody (anti-AChR-Ab) levels in suspected ocular myasthenia gravis. Methods. In total, 144 patients complaining of fluctuating diplopia and ptosis were evaluated for serum levels of anti-acetylcholine receptor antibody and their medical charts were retrospectively reviewed. Subjects were classified into three groups: variable diplopia only, ptosis only, and both variable diplopia and ptosis. We investigated serum anti-AChR-Ab titer levels and performed thyroid autoantibody tests. Results. Patients' chief complaints were diplopia (N = 103), ptosis (N = 12), and their concurrence (N = 29). Abnormal anti-AChR-Ab was observed in 21 of 144 patients (14.1%). Between the three groups, mean age, number of seropositive patients, and mean anti-AChR-Ab level were not significantly different (P = 0.224, 0.073, and 0.062, resp.). Overall, 27.5% of patients had abnormal thyroid autoantibodies. Conclusion. The sensitivity of anti-AChR-Ab was 14.1% in suspected ocular myasthenia gravis and seropositivity in myasthenia gravis patients showed a high correlation with the presence of thyroid autoantibodies.

Surgical outcomes of 23-gauge vitrectomy for the management of lens fragments dropped into the vitreous cavity during cataract surgery.

PURPOSE: To assess the clinical features and surgical outcomes of 23-Gauge (G) vitrectomy for lens fragments dropped into the vitreous during cataract surgery. METHODS: A retrospective, non-comparative, interventional case series at a single medical center. The medical records of 45 eyes from 45 consecutive patients who were referred to our hospital for surgical retrieval of phacoemulsification dropped lens fragments and who underwent 23-G vitrectomy were retrospectively reviewed. Data pertaining to patient demographics, pre- and post-operative Snellen visual acuity, and postoperative complications were recorded. Factors associated with dropped lens fragments were also examined. RESULTS: Mean patient age was 68.18 ± 11.47 years. The preoperative and postoperative mean logarithm of minimum angle of resolution (logMAR) visual acuity was 1.91 ± 0.59 (Snellen equivalent 0.06 ± 0.15) and 0.42 ± 0.51 (Snellen equivalent 0.54 ± 0.31), respectively. Forty-two eyes (93.3%) had dislocated lens fragments <50% of the total lens size. Two eyes (4.4%) had a large and hard lens nucleus, which necessitated the use of a 20-G fragmatome to efficiently and completely remove the lens material. At the final examination, 30 eyes (66.6%) had a visual acuity better than 20/40. Post-vitrectomy complications included elevated IOP for at least 3 months (n = 5 eyes, 11.1%), intraocular lens dislocation (n = 2 eyes, 4.4%), and cystoid macular edema (n = 1 eye, 2.2%). No cases of postoperative endophthalmitis or retinal detachment were observed. CONCLUSIONS: A 23-G vitrectomy is safe and efficient for the surgical management of dropped lens fragments following cataract surgery.

Cirrus high-definition optical coherence tomography versus spectral optical coherence tomography/scanning laser ophthalmoscopy in the diagnosis of glaucoma.

PURPOSE: This study was performed to compare the positive predictive value of peripapillary retinal nerve fiber layer (RNFL) thickness measurements obtained using Cirrus high-definition optical coherence tomography (Cirrus HD-OCT; Carl Zeiss Meditec, Dublin, CA) and spectral OCT/scanning laser ophthalmoscopy (SLO) (OPKO/OTI, Miami, FL) in the diagnosis of glaucoma. METHODS: A total of 50 eyes of 50 healthy subjects and 60 eyes of 60 subjects with glaucoma were included. All participants underwent RNFL thickness measurement using Cirrus HD-OCT and spectral OCT/SLO on the same day. Average, quadrant, clock-hour RNFL thicknesses, area under the receiver operating characteristic curve (AUC), and sensitivities at fixed specificities (80% and 95%) were calculated for comparison. RESULTS: RNFL thickness as measured by spectral OCT/SLO was greater than that measured using Cirrus HD-OCT (p < 0.001). For both the Cirrus HD-OCT and spectral OCT/SLO, the parameter with the largest AUC was average RNFL thickness (0.954 and 0.944, respectively). The AUCs of RNFL thickness for the discrimination of glaucoma did not differ significantly between the devices (p > 0.05), with the exception of RNFL thickness in the nasal area (nasal quadrant, clock-hour sectors 3 and 4); in these areas, spectral OCL/SLO yielded greater AUCs than Cirrus HD-OCT (p < 0.05). Sensitivities varied similarly to AUCs. CONCLUSIONS: RNFL thicknesses measures using Cirrus HD-OCT and spectral OCT/SLO were not interchangeable. The utility of RNFL thickness measurements in the diagnosis of glaucoma was similar for both the devices.

Characteristics of pupillo-accommodative functions according to time of onset, gender and age in tonic pupil.

AIM: To evaluate the characteristics of pupillo-accommodative functions in patients with idiopathic tonic pupil according to the time of onset, gender, and age. METHODS: Totally, 15 males and 19 females were divided into 2 groups depending on the time of disease onset: group I (onset <2 months, n=20) and group II (onset >2 months, n=14). A supersensivity test was conducted by applying diluted pilocarpine 0.125% to the eye and accommodative functions were evaluated using the near-point of accommodation (NPA) as the cutoff point, at which the patient experienced blurred vision. Pupil size and the ratio of decrease in the affected pupil after instillation of 0.125% pilocarpine were investigated. RESULTS: There was no significant difference between the 2 groups regarding the various pupillary reflex results, including data on the affected pupil size before and after 0.125% pilocarpine, anisocoria, and ratio of pupil decrease. No significant difference in NPA was found between the 2 groups. However, female patients were noted to have greater anisocoria and a faster constriction ratio than those of the male patients (P=0.02 and P=0.04). On subgroup analysis, female patients from group II had larger affected-pupil sizes before 0.125% pilocarpine instillation and longer NPAs than those of the male patients. CONCLUSION: No relationship was found between time of onset and dysfunction of pupillo-accommodative functions. Pupillo-accommodative functions and age were not related, except for the NPA.

Comparison of the outcome of silicone Ahmed glaucoma valve implantation with a surface area between 96 and 184 mm² in adult eyes.

PURPOSE: To compare the success rates, complications, and visual outcomes between silicone Ahmed glaucoma valve (AGV) implantation with 96 mm(2) (FP8) or 184 mm(2) (FP7) surface areas. METHODS: This study is a retrospective review of the records from 132 adult patients (134 eyes) that underwent silicone AGV implant surgery. Among them, the outcomes of 24 eyes from 24 patients with refractory glaucoma who underwent FP8 AGV implantation were compared with 76 eyes from 76 patients who underwent FP7 AGV implantation. Preoperative and postoperative data, including intraocular pressure (IOP), visual acuity, number of medications, and complications were compared between the 2 groups. RESULTS: There were no significant differences in baseline characteristics between the 2 groups (p > 0.05). The postoperative visual acuity of the patients in the FP8 group was better than that of the patients in the FP7 group in some early postoperative periods (p < 0.05); however, after 10 postoperative months, visual acuity was not significantly different through the 3-year follow-up period (p > 0.05). Postoperative IOP was not significantly different between the 2 groups (p > 0.05) except for IOP on postoperative day 1 (11.42 mmHg for the FP7 group and 7.42 mmHg for the FP8 group; p = 0.031). There was no statistical difference in success rates, final IOP, number of medications, or complication rates between the 2 groups (p > 0.05). CONCLUSIONS: The FP7 and FP8 AGV implants showed no difference in terms of vision preservation, IOP reduction, and number of glaucoma medications required.

Anti-vascular endothelial growth factor monotherapy in the treatment of submacular hemorrhage secondary to polypoidal choroidal vasculopathy.

PURPOSE: To evaluate the effect of intravitreal anti-vascular endothelial growth factor (VEGF) injections on submacular hemorrhage secondary to polypoidal choroidal vasculopathy. DESIGN: Retrospective, interventional case series. METHODS: Twenty-seven eyes from 27 polypoidal choroidal vasculopathy patients with submacular hemorrhage involving the fovea were included in the analyses. All patients were treated by anti-VEGF injection with an initial 3 loading injections by month, followed by an as-needed reinjection. Visual acuity, central macular thickness, submacular hemorrhage size, and the occurrence of vitreous hemorrhage were examined during a 12-month follow-up period. RESULTS: The mean number of injections administered over the course of 12 months was 3.59 ± 1.04. The size of submacular hemorrhages averaged 18.2 ± 13.8 mm². The mean logarithm of the minimal angle of resolution (logMAR) visual acuity at baseline was 1.02 ± 0.51 (Snellen equivalent, 20/204) and improved significantly to 0.76 ± 0.48 (Snellen equivalent, 20/115) at 12 months (P = .02). Mean central macular thickness decreased from 311.7 ± 124.5 µm at baseline to 246.8 ± 102.8 µm at 12 months (P = .01). At 12 months, visual acuity improved by 0.3 logMAR or more in 10 eyes (37%), stabilized (change between 0 and 0.3 logMAR) in 11 eyes (40.7%), and decreased by 0.3 logMAR or more in 6 eyes (22.2%). Three eyes (11.1%) were subjected to vitrectomy to clear a vitreous hemorrhage that occurred after anti-VEGF therapy. CONCLUSIONS: Intravitreal anti-VEGF injection monotherapy may be a valuable therapeutic option in treating eyes with submacular hemorrhage associated with polypoidal choroidal vasculopathy.

Fresnel prism on hess screen test.

A 65-year-old male patient complained of diplopia after a cataract surgery. He had esotropia of 18 prism diopters (PDs) at distant and near deviation, and therefore, we performed the Hess screen test to identify any abnormal eye movement. However, the indicator was found to be out of bounds, and therefore, the test could not be completed. Therefore, the test was subsequently performed with a 20 PD base-out Fresnel prism, and an abduction deficit was observed in the right eye, but not in the left eye. Therefore, we speculated that the patient had abducens nerve palsy in the right eye. The results obtained in the present study imply that performing the Hess screen test with the Fresnel prism may be very useful in diagnosing ambiguous abnormalities in patients with extraocular movement. The Hess screen test can be performed for patients with a strabismus of greater than 15 PD by using a Fresnel prism. Thus, a Fresnel prism may be useful for performing both the Hess screen test and Lancaster screen test.