- Email: [email protected]
Endophthalmitis associated with retinal laser treatment in a trabeculectomized eye
Correspondence area (Fig. 1B) with choroidal effusion temporally. Intraoperatively, the tube of the Ahmed implant was severed 1–2 mm from the intact plate (Fig. 2) and its remaining portion was displaced anteriorly in the AC. The displaced tube and plate were explanted and pars plana vitrectomy, suturing of the residual scleral track, and implantation of a superotemporal Baerveldt GDI were performed. Spontaneous dislocation of an aqueous mini-express shunt, as well as traumatic migration of tube extender, have been reported.5,6 To our knowledge, this is the first reported case of tube dislodgement of a GDI following needling revision of an encapsulated bleb. Biomicroscopic detection of tube migration seen shortly following needling, together with the absence of any recent ocular trauma, makes an iatrogenic cause very plausible. Additionally, the severed tube found 1–2 mm from the plate margin directly below the encapsulated bleb supports our hypothesis. A manufacturer’s defect is usually not an isolated event and is very unlikely to be confined to only one site in the implant. In our case, SL-OCT assisted in the clinical diagnosis by showing the tube to be disconnected adjacent to the limbus. Hence, SL-OCT should be considered when evaluating similar cases. Although needling revision of an encapsulated bleb can be a useful alternative to adjunctive medical therapy or an additional surgical procedure, it often has poor success with the risk of complications. Manipulation while needling an encapsulated bleb should be performed far from the plate margin to avoid possible iatrogenic tube damage.
Endophthalmitis associated with retinal laser treatment in a trabeculectomized eye
A
48-year-old male with a history of diabetes presented with a spontaneous hyphema in the left eye and marked progression of his nonproliferative diabetic retinopathy in both eyes. His condition was diagnosed as chronic myelogenous leukemia, which had caused the hyphema and also exacerbated his retinopathy. The patient underwent chemotherapy, which controlled the leukemia, and the hyphema resolved. However, several months later bilateral neovascular glaucoma developed, which was treated with intravitreal bevacizumab, panretinal photocoagulation, and bilateral filtration surgery using mitomycin C. Subsequently, his eyes stabilized with vision of about 20/50 OD and 20/60 OS, good blebs, and intraocular pressure running in the mid teens. Two months after the filtration surgery, bilateral clinically significant diabetic macular edema developed. The patient underwent focal laser treatment in the left eye, and several days later the right eye was treated. The treatment was uneventful and was performed in the standard manner using a topical anaesthetic and a contact lens that had
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In conclusion, tube dislodgement should be added to the list of possible complications after needling revision, requiring prompt surgical intervention. REFERENCES 1. Minckler DS, Vedula SS, Li TJ, Mathew MC, Ayyala RS, Francis BA. Aqueous shunts for glaucoma. Cochrane Database Syst Rev 2006;2:CD004918. 2. Assaad MH, Baerveldt G, Rockwood EJ. Glaucoma drainage devices: pros and cons. Curr Opin Ophthalmol 1999;10: 147–53. 3. Freedman J, Chamnongvongse P. Supra-Tenon’s capsule placement of a single–plate Molteno implant. Br J Ophthalmol 2008;92:669–72. 4. Chen PP, Palmberg PF. Needling revision of glaucoma drainage device filtering blebs. Ophthalmology 1997;104:1004–10. 5. Sheets CW, Ramjattan TK, Smith MF, Doyle JW. Migration of glaucoma drainage device extender into anterior chamber after trauma. J Glaucoma 2006;15:559–61. 6. Teng CC, Radcliffe N, Huang JE, Farris E. Ex-PRESS glaucoma shunt dislocation into the anterior chamber. J Glaucoma 2008;17:687–9.
Pat-Michael Palmiero,*{ Siddhart Mehta,* Celso Tello,*{ Zaher Sbeity*{ *Einhorn Clinical Research Center, New York Eye and Ear Infirmary, New York, N.Y., and {New York Medical College, Valhalla, N.Y. Correspondence to Zaher Sbeity, MD: [email protected] Can J Ophthalmol 2010;45:181–2 doi:10.3129/i09-201
previously been soaked and cleaned with isopropyl alcohol. The evening after the laser surgery he noticed right ocular irritation, and by the next day he was complaining of significant pain and vision loss. His vision had dropped to light perception with active endophthalmitis and no view of the posterior segment. The bleb had been noted to be vascularized before and after laser therapy, but no leaking was noted on either occasion. The patient’s condition was treated with vitrectomy and intravitreal vancomycin, ceftazidime, and dexamethasone, as well as with topical fortified vancomycin and gentamicin. The vitreous fluid specimen was positive for Streptococcus oralis. Although the infection was controlled, there was an extensive tractional retinal detachment along with severe pain and loss of light perception, and the eye was ultimately enucleated. This is a case of severe endophthalmitis in a trabeculectomized eye after macular laser treatment. We are not aware of any reports like this in the literature (from a PubMed and MEDLINE search). Although this case does not prove causality between the laser and the bleb endophthalmitis, it is certainly suggestive given the temporal association. There are many factors that can influence the development of bleb-related endophthalmitis, including the use of
Correspondence antimetabolites, the position of the bleb, and the age of the patient.1–3 In this case, mitomycin C had been used, and the patient was functionally immunosuppressed given the history of diabetes and leukemia. We postulate that microtrauma to the filtering bleb caused by the contact lens ultimately allowed the ingress of bacteria. Ophthalmologists performing laser treatment should be aware of the presence of a filtering bleb and remind patients to seek medical attention immediately if there are any problems. It may also be reasonable to avoid touching the bleb with the contact lens, and to even consider performing laser surgery with an indirect noncontact lens if the bleb is very thin and fragile.4 REFERENCES 1. Ciulla TA, Beck AD, Topping TM, Baker AS. Blebitis, early endophthalmitis, and late endophthalmitis after glaucomafiltering surgery. Ophthalmology 1997;104:986–95.
La dengue, une nouvelle e´tiologie de paralysie oculomotrice
L
a dengue est une des plus communes arboviroses tropicales. Elle est transmise par la piquˆre des moustiques Aedes aegypti.1 La forme classique de la maladie associe un syndrome grippal a` une e´ruption maculopapuleuse et des manifestations he´morragiques. Re´cemment, quelques publications ont fait e´tat de complications oculaires de gravite´ diverse a` types d’he´morragies sous-conjonctivales et re´tiniennes, de nodules cotonneux, de maculopathies, de de´collement de re´tine exsudatif et ne´vrites optiques.2 Nous rapportons un cas de paralysie du nerf moteur oculaire externe (VI) secondaire a` une dengue. Un homme de 64 ans, sans ante´ce´dent me´dical, a presente´ en octobre 2007 pour une diplopie binoculaire horizontale de survenue brutale en rapport avec une paralysie de l’abduction de l’œil gauche. Ils s’y associat un syndrome grippal et des douleurs re´troorbitaires e´voluant depuis 7 jours. L’acuite´ visuelle e´tait de 20/20 aux deux yeux. L’examen des segments ante´rieur et poste´rieur e´tait normal, ainsi que la tension oculaire. Le test de HessLancaster confirmait la paralysie du nerf moteur oculaire externe gauche. L’angiographie a` la fluoresce´ine montrait une hyperfluorescence mouchete´e dans la re´gion susmaculaire de l’œil gauche, apparaissant de`s les temps pre´coces et attribue´e a` des alte´rations de l’e´pithe´lium pigmentaire (Fig. 1). Le reste de l’examen ge´ne´ral en particulier neurologique, cardiovasculaire et otorhinolaryngologique e´tait sans particularite´. L’imagerie par re´sonnance magne´tique ce´re´brale e´tait normale. Il existait une discre`te ane´mie et leucope´nie, ainsi qu’une thrombope´nie a` 50 000/mL. La se´rologie de la dengue e´tait fortement positive, a` la fois en Ig M (4,43 pour un seuil infe´rieur a` 0,9) et Ig G (supe´rieur a` 10 pour un seuil infe´rieur a` 1,8)
2. Lehman OJ, Bunce C, Matheson V, et al. Risk factors for development of post-trabeculectomy endophthalmitis. Br J Ophthalmol 2000;84:1349–53. 3. Greenfield DS, Suner IJ, Miller MP, Kangas TA, Palmberg PF, Flynn HW Jr. Endophthalmitis after filtering surgery with mitomycin. Arch Ophthalmol 1996;114:943–9. 4. Bates R, Wong D, Bloor P. Non-contact retinal photocoagulation using the Volk +90 dioptre lens. Eye 1988;2:409–11.
Lik Thai Lim,* William A. Argus,{ Johnathan D. Walker {
*Tennent Institute of Ophthalmology, Glasgow, U.K., {Fort Wayne, Ind., and {Indiana University School of Medicine, Fort Wayne, Ind. Correspondence to Lik Thai Lim, MB BCh, MRCSEd (Ophth): [email protected] Can J Ophthalmol 2010;45:182–3 doi:10.3129/i09-218
(ELISA Panbio par immunocapture). L’examen du liquide ce´phalorachidien ne montrait qu’une tre`s discre`te hyperprote´inorachie. Les e´tiologies classiques de paralysie oculomotrice ont e´te´ e´limine´es par les re´sultats des examens comple´mentaires. Un traitement symptomatique (parace´tamol et re´hydratation) a permis une rapide ame´lioration de l’e´tat ge´ne´ral. La symptomatologie oculomotrice avait comple`tement disparu en moins de 8 jours. L’e´limination dans notre cas des le´sions de nature ische´mique, he´morragique, compressive, tumorale, infectieuse ou inflammatoire, ainsi qu’une re´gression rapide de la symptomatologie et une se´rologie positive plaident fortement en faveur de la responsabilite´ de l’infection par le virus de la dengue. Comme les alte´rations de l’e´pithe´lium pigmentaire de la re´tine, la diplopie a e´te´ observe´e 1 semaine apre`s le de´but de la maladie.3 Le virus de la dengue est un virus neurotrope, capable de franchir la barrie`re he´mato-ence´phalique et de se re´pliquer dans le syste`me nerveux central.4 L’infection virale directe des cellules endothe´liales, dendritiques et des monocytes entraıˆnerait
Fig. 1—Angiographie a` la fluoresce´ ine de l’oeil gauche. Hyperfluorescence mouchete´e dans la re´gion sus-maculaire apparaissant de`s les temps pre´coces. CAN J OPHTHALMOL—VOL. 45, NO. 2, 2010
183
Endophthalmitis associated with retinal laser treatment in a trabeculectomized eye
A
48-year-old male with a history of diabetes presented with a spontaneous hyphema in the left eye and marked progression of his nonproliferative diabetic retinopathy in both eyes. His condition was diagnosed as chronic myelogenous leukemia, which had caused the hyphema and also exacerbated his retinopathy. The patient underwent chemotherapy, which controlled the leukemia, and the hyphema resolved. However, several months later bilateral neovascular glaucoma developed, which was treated with intravitreal bevacizumab, panretinal photocoagulation, and bilateral filtration surgery using mitomycin C. Subsequently, his eyes stabilized with vision of about 20/50 OD and 20/60 OS, good blebs, and intraocular pressure running in the mid teens. Two months after the filtration surgery, bilateral clinically significant diabetic macular edema developed. The patient underwent focal laser treatment in the left eye, and several days later the right eye was treated. The treatment was uneventful and was performed in the standard manner using a topical anaesthetic and a contact lens that had
182
CAN J OPHTHALMOL—VOL. 45, NO. 2, 2010
In conclusion, tube dislodgement should be added to the list of possible complications after needling revision, requiring prompt surgical intervention. REFERENCES 1. Minckler DS, Vedula SS, Li TJ, Mathew MC, Ayyala RS, Francis BA. Aqueous shunts for glaucoma. Cochrane Database Syst Rev 2006;2:CD004918. 2. Assaad MH, Baerveldt G, Rockwood EJ. Glaucoma drainage devices: pros and cons. Curr Opin Ophthalmol 1999;10: 147–53. 3. Freedman J, Chamnongvongse P. Supra-Tenon’s capsule placement of a single–plate Molteno implant. Br J Ophthalmol 2008;92:669–72. 4. Chen PP, Palmberg PF. Needling revision of glaucoma drainage device filtering blebs. Ophthalmology 1997;104:1004–10. 5. Sheets CW, Ramjattan TK, Smith MF, Doyle JW. Migration of glaucoma drainage device extender into anterior chamber after trauma. J Glaucoma 2006;15:559–61. 6. Teng CC, Radcliffe N, Huang JE, Farris E. Ex-PRESS glaucoma shunt dislocation into the anterior chamber. J Glaucoma 2008;17:687–9.
Pat-Michael Palmiero,*{ Siddhart Mehta,* Celso Tello,*{ Zaher Sbeity*{ *Einhorn Clinical Research Center, New York Eye and Ear Infirmary, New York, N.Y., and {New York Medical College, Valhalla, N.Y. Correspondence to Zaher Sbeity, MD: [email protected] Can J Ophthalmol 2010;45:181–2 doi:10.3129/i09-201
previously been soaked and cleaned with isopropyl alcohol. The evening after the laser surgery he noticed right ocular irritation, and by the next day he was complaining of significant pain and vision loss. His vision had dropped to light perception with active endophthalmitis and no view of the posterior segment. The bleb had been noted to be vascularized before and after laser therapy, but no leaking was noted on either occasion. The patient’s condition was treated with vitrectomy and intravitreal vancomycin, ceftazidime, and dexamethasone, as well as with topical fortified vancomycin and gentamicin. The vitreous fluid specimen was positive for Streptococcus oralis. Although the infection was controlled, there was an extensive tractional retinal detachment along with severe pain and loss of light perception, and the eye was ultimately enucleated. This is a case of severe endophthalmitis in a trabeculectomized eye after macular laser treatment. We are not aware of any reports like this in the literature (from a PubMed and MEDLINE search). Although this case does not prove causality between the laser and the bleb endophthalmitis, it is certainly suggestive given the temporal association. There are many factors that can influence the development of bleb-related endophthalmitis, including the use of
Correspondence antimetabolites, the position of the bleb, and the age of the patient.1–3 In this case, mitomycin C had been used, and the patient was functionally immunosuppressed given the history of diabetes and leukemia. We postulate that microtrauma to the filtering bleb caused by the contact lens ultimately allowed the ingress of bacteria. Ophthalmologists performing laser treatment should be aware of the presence of a filtering bleb and remind patients to seek medical attention immediately if there are any problems. It may also be reasonable to avoid touching the bleb with the contact lens, and to even consider performing laser surgery with an indirect noncontact lens if the bleb is very thin and fragile.4 REFERENCES 1. Ciulla TA, Beck AD, Topping TM, Baker AS. Blebitis, early endophthalmitis, and late endophthalmitis after glaucomafiltering surgery. Ophthalmology 1997;104:986–95.
La dengue, une nouvelle e´tiologie de paralysie oculomotrice
L
a dengue est une des plus communes arboviroses tropicales. Elle est transmise par la piquˆre des moustiques Aedes aegypti.1 La forme classique de la maladie associe un syndrome grippal a` une e´ruption maculopapuleuse et des manifestations he´morragiques. Re´cemment, quelques publications ont fait e´tat de complications oculaires de gravite´ diverse a` types d’he´morragies sous-conjonctivales et re´tiniennes, de nodules cotonneux, de maculopathies, de de´collement de re´tine exsudatif et ne´vrites optiques.2 Nous rapportons un cas de paralysie du nerf moteur oculaire externe (VI) secondaire a` une dengue. Un homme de 64 ans, sans ante´ce´dent me´dical, a presente´ en octobre 2007 pour une diplopie binoculaire horizontale de survenue brutale en rapport avec une paralysie de l’abduction de l’œil gauche. Ils s’y associat un syndrome grippal et des douleurs re´troorbitaires e´voluant depuis 7 jours. L’acuite´ visuelle e´tait de 20/20 aux deux yeux. L’examen des segments ante´rieur et poste´rieur e´tait normal, ainsi que la tension oculaire. Le test de HessLancaster confirmait la paralysie du nerf moteur oculaire externe gauche. L’angiographie a` la fluoresce´ine montrait une hyperfluorescence mouchete´e dans la re´gion susmaculaire de l’œil gauche, apparaissant de`s les temps pre´coces et attribue´e a` des alte´rations de l’e´pithe´lium pigmentaire (Fig. 1). Le reste de l’examen ge´ne´ral en particulier neurologique, cardiovasculaire et otorhinolaryngologique e´tait sans particularite´. L’imagerie par re´sonnance magne´tique ce´re´brale e´tait normale. Il existait une discre`te ane´mie et leucope´nie, ainsi qu’une thrombope´nie a` 50 000/mL. La se´rologie de la dengue e´tait fortement positive, a` la fois en Ig M (4,43 pour un seuil infe´rieur a` 0,9) et Ig G (supe´rieur a` 10 pour un seuil infe´rieur a` 1,8)
2. Lehman OJ, Bunce C, Matheson V, et al. Risk factors for development of post-trabeculectomy endophthalmitis. Br J Ophthalmol 2000;84:1349–53. 3. Greenfield DS, Suner IJ, Miller MP, Kangas TA, Palmberg PF, Flynn HW Jr. Endophthalmitis after filtering surgery with mitomycin. Arch Ophthalmol 1996;114:943–9. 4. Bates R, Wong D, Bloor P. Non-contact retinal photocoagulation using the Volk +90 dioptre lens. Eye 1988;2:409–11.
Lik Thai Lim,* William A. Argus,{ Johnathan D. Walker {
*Tennent Institute of Ophthalmology, Glasgow, U.K., {Fort Wayne, Ind., and {Indiana University School of Medicine, Fort Wayne, Ind. Correspondence to Lik Thai Lim, MB BCh, MRCSEd (Ophth): [email protected] Can J Ophthalmol 2010;45:182–3 doi:10.3129/i09-218
(ELISA Panbio par immunocapture). L’examen du liquide ce´phalorachidien ne montrait qu’une tre`s discre`te hyperprote´inorachie. Les e´tiologies classiques de paralysie oculomotrice ont e´te´ e´limine´es par les re´sultats des examens comple´mentaires. Un traitement symptomatique (parace´tamol et re´hydratation) a permis une rapide ame´lioration de l’e´tat ge´ne´ral. La symptomatologie oculomotrice avait comple`tement disparu en moins de 8 jours. L’e´limination dans notre cas des le´sions de nature ische´mique, he´morragique, compressive, tumorale, infectieuse ou inflammatoire, ainsi qu’une re´gression rapide de la symptomatologie et une se´rologie positive plaident fortement en faveur de la responsabilite´ de l’infection par le virus de la dengue. Comme les alte´rations de l’e´pithe´lium pigmentaire de la re´tine, la diplopie a e´te´ observe´e 1 semaine apre`s le de´but de la maladie.3 Le virus de la dengue est un virus neurotrope, capable de franchir la barrie`re he´mato-ence´phalique et de se re´pliquer dans le syste`me nerveux central.4 L’infection virale directe des cellules endothe´liales, dendritiques et des monocytes entraıˆnerait
Fig. 1—Angiographie a` la fluoresce´ ine de l’oeil gauche. Hyperfluorescence mouchete´e dans la re´gion sus-maculaire apparaissant de`s les temps pre´coces. CAN J OPHTHALMOL—VOL. 45, NO. 2, 2010
183