Dematiaceous fungal endophthalmitis: report of a case and review of the literature.

BACKGROUND: Pleurostomophora richardsiae (formerly Phialophora richardsiae) is a dematiaceous fungus that is an uncommon cause of ocular infection. Herein, we present a case of endogenous endophthalmitis associated with disseminated P. richardsiae infection. FINDINGS: This is a descriptive case report with a brief review of literature. A 43-year-old male admitted to the hospital following an acute cerebellar hemorrhage was found to have a swollen and tender wrist. The patient was afebrile with leukocytosis. Visual acuity was hand motion in the right eye and 20/20 in the left. Right eye examination noted anterior chamber cells and flare, vitreous haze and multiple large, and fluffy retinal infiltrates. Diagnostic vitrectomy revealed a mixed inflammatory cell infiltrate with numerous fungal elements. Blood cultures were negative, multiple transesophageal echocardiography studies revealed no vegetations, and synovial fluid aspiration of the wrist and biopsy of the radius were unremarkable. The patient was treated with intravitreal cefazolin, vancomycin, and amphotericin B, topical ciprofloxacin and natamycin, and intravenous amphotericin B and voriconazole. Visual acuity in the right eye declined to light perception, and examination revealed increasing anterior and posterior chamber inflammation. The patient died several weeks after presentation due to a massive intracranial hemorrhage. Fungal culture results from the vitrectomy were received post mortem and were positive for P. richardsiae. CONCLUSIONS: P. richardsiae endophthalmitis is rare, and outcomes are typically poor. Infections typically occur following traumatic skin inoculation; however, a long refractory period may occur before symptoms develop. Early diagnosis and combination antimicrobial therapy are essential to optimize visual outcomes.

A histological analysis of the Müllerectomy: redefining its mechanism in ptosis repair.

BACKGROUND: The goals of this study were to determine whether the surgical target amount of Müller's muscle removed is consistent with the histological amount obtained, to assess the clinical outcome of ptosis repair based on these amounts, and to evaluate the role of the levator aponeurosis in the procedure. METHODS: The Müllerectomy procedure was performed on eight eyelids of four cadavers and eight eyelids of seven patients (six unilateral, one bilateral). Histologically, the dimensions of the Müller and levator muscles were measured in the specimens removed. If present, the elastic fiber network of the levator aponeurosis was noted. Ptosis measurements were analyzed according to the target amount of resection and histologic amount obtained. RESULTS: The median percentage of Müller's muscle histologically measured compared with the target tissue resection obtained was 23.25 percent (0 to 37.5 percent, n = 8) in cadavers, compared with 31.13 percent (2.8 to 58.8 percent) in patient specimens. Levator aponeurosis was identified in all cadaver specimens (n = 8) and all patient specimens (n = 8). Elastin stain identified the elastic fiber network of the levator aponeurosis. There was no statistically significant difference between amount of resection and presence of the Müller or levator muscle in cadaver (p > 0.05) or patient specimens (p > 0.05). CONCLUSIONS: There is a consistent presence of levator aponeurosis that may play a role in ptosis repair via aponeurosis advancement and resection using a modified internal Müllerectomy approach. Using the authors' surgical technique, there is no correlation of the histologically measured amount of Müller's muscle to the postoperative marginal reflex distance-1 change in the operative eyelid. The levator aponeurosis may play a greater role in ptosis repair using an internal Müllerectomy approach than previously thought.

Uterine papillary serous carcinoma metastatic to the choroid.

PURPOSE: To report an unusual case of choroidal metastasis from uterine papillary serous carcinoma presenting as a choroidal hemorrhage. METHODS: A 70-year-old woman with a history of Stage IV endometrial cancer presented with sudden loss of vision and pain behind the right eye. Clinical examination revealed a choroidal hemorrhage with retinal detachment. The clinical findings, results of imaging studies, and pathologic findings are described. RESULTS: The patient underwent drainage of the choroidal hemorrhage but developed a painful, blind eye resulting from secondary glaucoma that was refractory to maximal medical therapy. Examination of the drained choroidal fluid showed no malignant cells. The patient elected for enucleation of the affected eye, and histopathologic analysis was consistent with uterine papillary serous carcinoma metastatic to the choroid. The patient tolerated the procedure well. However, she entered hospice shortly after surgery to receive palliative care for her metastatic disease. CONCLUSION: Rare cases of uterine cancer metastasizing to the uvea have been reported. To our knowledge, this is the first case of uterine papillary serous carcinoma with uveal metastasis. Metastatic disease involving the uvea should be considered in the differential diagnosis for a patient presenting with pain and sudden loss of vision, particularly when the patient has a known primary malignancy. Histopathology and cytology can assist in identifying a uveal mass as metastatic.

Management of congenital nonpigmented iris cyst.

PURPOSE: Previously reported clinical outcomes after treatment of congenital iris cysts have been poor, complicated by cyst recurrence and vision loss. Our purpose was to evaluate the outcomes of surgical excision and microdiathermy of congenital iris cysts. DESIGN: Interventional retrospective case series. METHODS: Four patients (3 children, 1 adult) were treated for a congenital iris cyst based on history and clinical presentation. After cyst excision with caution to avoid cyst rupture, the base of the cyst was treated with microdiathermy. MAIN OUTCOME MEASURE: Presence or absence of a residual cyst after surgical intervention. RESULTS: In all 4 patients, histopathological findings confirmed the diagnosis of a congenital iris cyst. Follow-up periods ranged from 1.4 to 6.2 years (mean +/- standard deviation, 4+/-2). Vision loss did not occur in any of the treated eyes. No cyst recurrence was noted after initial surgical treatment. CONCLUSION: A modern microsurgical technique with adjunctive use of microdiathermy provides improved outcomes in the surgical management of congenital iris cysts. We believe that microdiathermy applied to the base of the cyst removes residual epithelial tissue that accounted for the recurrences documented in previous reports.

Bacillary angiomatosis with cytomegaloviral and mycobacterial infections of the palpebral conjunctiva in a patient with AIDS.

We report the clinical and histopathologic findings of bacillary angiomatosis involving the palpebral conjunctiva with concomitant infection by cytomegalovirus and Mycobacterium species in a patient with acquired immune deficiency syndrome. After debulking, the conjunctival tissue was studied with the use of light and electron microscopy; stains for bacteria, acid-fast bacilli, and Bartonella species; and immunohistochemical studies for cytomegalovirus and herpes simplex virus. We observed the typical histopathologic findings of bacillary angiomatosis, the presence of bacilli stained by the Steiner and Steiner method, and the electron microscopic demonstration of bacilli consistent with Bartonella species. Immunohistochemistry confirmed infection with cytomegalovirus, which had been suggested by characteristic cytologic abnormalities. Acid-fast bacilli were also found in the excised tissue. Patients with bacillary angiomatosis of the conjunctiva may have infections with multiple additional microorganisms.

Traumatic evulsion of the globe.

PURPOSE: To report the clinical and pathologic findings in 3 cases of traumatic evulsion of the globe, during which the optic nerve and its sheath were disrupted at different locations and to varying extents. METHODS: Case series (3 patients). RESULTS: We describe the clinical, gross, and microscopic pathologic findings in 3 globes that were traumatically evulsed from their orbits. The optic nerves and sheaths were disrupted at 2 different locations and in 2 distinct combinations. Two of these variations in discontinuity of the nerve and/or its sheath were unique. In 1 case, the eye and optic nerve sheath were evulsed without the nerve; in another case, the nerve and sheath were pulled from the posterior sclera at the lamina cribrosa. CONCLUSIONS: Traumatic evulsion of the globe may cause the optic nerve and its sheath to be disrupted at varying distances from the eye and may involve the optic nerve and its sheath together or separately. To the best of our knowledge, no cases have been reported in which orbital trauma caused the globe and optic nerve sheath to be removed together, leaving the nerve behind, or in which disruption of the optic nerve at the lamina cribrosa resulted in a complete posterior scleral defect. Three theories are proposed to explain possible mechanisms leading to optic nerve disruption during traumatic evulsion of the globe.