Severe Anterior Chamber Reaction Research Articles

Outbreak of toxic anterior segment syndrome following vitreoretinal surgery - A retrospective analysis.

Toxic anterior segment syndrome (TASS) is an uncommon complication of vitreoretinal surgery and is characterized by severe anterior chamber reaction, hypopyon, and limbus-to-limbus corneal edema. Twenty-nine vitreoretinal surgeries were performed, of which 14 developed TASS in the early postoperative period. The operative records were reviewed retrospectively. The median age of patients was 49.07 ± 16.75 years and 14.28% of them were female. Also, 71.42% were operated in the left eye and 42.8% were pseudophakic. Recurrent retinal detachment, secondary scleral-fixating intraocular lens (SFIOL), and silicone oil removal (SOR) were the most common procedures. Severe anterior chamber reaction was seen in 14 patients, circumcorneal congestion in eight, corneal edema in 11 (78.6%), hypopyon in 13 (92.8%), and severe fibrin membrane in two patients. We describe the largest series of TASS following uneventful vitreoretinal surgery. Balanced salt solution was the instigating agent in this series. A prompt and thorough investigation is critical in obviating recurrences.

Abiotrophia defectiva Endophthalmitis Post-Keratoplasty – A Case Report and Literature Review

ABSTRACT Purpose To report the first case of acute Abiotrophia defectiva endophthalmitis post-keratoplasty and review the current literature. Methods A 47-year-old male, post-keratoplasty, presented with vision loss and severe anterior chamber reaction. Diagnostic investigations included vitreous cultures and molecular analysis. Results Abiotrophia defectiva was identified. Despite aggressive treatment, visual acuity remained low. We reviewed a total of 14 post-procedural cases of A. defectiva endophthalmitis, focusing on antibiotic and steroidal treatment regimens and long-term prognosis. Conclusion We emphasize aggressive treatment of external disease prior to intraocular surgery. In cases of A. defectiva endophthalmitis, we advocate judicious use of steroids.

Five-Year Outcomes of Single Trabecular Microbypass Stent (iStent®) Implantation with Phacoemulsification in Korean Patients.

This study reports the long-term intraocular pressure (IOP)-lowering efficacy and safety of a singletrabecular microbypass stent(iStent®; Glaukos Corp., San Clemente, CA, USA) for medically controlled open-angleglaucoma in Korean patients. This retrospective observational study included 42 eyes of 35 patients with primary open-angle glaucoma (POAG). All subjects underwent single first-generation iStent® implantation with phacoemulsification by a single surgeon with 5years follow-up. The primary outcomes were changes in IOP and the number of antiglaucoma medications compared to the preoperative values. The secondary outcome was the proportion of eyes with IOP ≤ 18mmHg without medication, ≤ 15mmHg without medication, and ≤ 18mmHg with or without medication. Adverse events and need for secondary glaucoma surgery were also recorded. The mean IOP decreased from 15.8 ± 2.8 to 13.8 ± 1.7mmHg and the mean number of medications was reduced from 2.24 ± 1.18 to 0.83 ± 1.12, respectively, at year5. At 3 and 5years, 80.6% and 78.6% of eyes, respectively, were receiving fewer medications than preoperative numbers. In contrast, only 50% of eyes on four preoperative medications showed medication reductions at 5years. At years3 and 5, 61.3% and 53.5% of eyes achieved IOP ≤ 18mmHg without medication, whereas 90.3% and 89.3% of eyes achieved ≤ 18mmHg regardless of medication use, respectively. Four eyes required additional glaucoma surgery (two Ahmed glaucoma valve implantations, one trabeculectomy, and one XEN45 Gel Stent implantation), and all were receiving four preoperative antiglaucoma medications. Transient IOP elevation (14.3%) was the most common complication, followed by five hyphema, one stent obstruction, one stent malposition, and one severe anterior chamber reaction. This study demonstrated a good safety profile and sustained IOP reduction after the implantation of a single trabecular microbypass stent (iStent®) with phacoemulsification in Korean patients. The majority of subjects with POAG showed a relatively good response; however, eyes receiving a higher number of medications preoperatively (especially four medications) had difficulty achieving a low target IOP.

Endogenous endophthalmitis in post-COVID-19 patients: a case report.

Two patients who were hospitalized and received treatment for COVID-19 pneumonia with remdesivir and systemic steroids presented with decreased vision. The first case had a severe anterior chamber reaction with a hypopyon and dense exudates in the vitreous. The second case had cells and flare in the anterior chamber and exudates in the vitreous. They were diagnosed with EE and underwent a diagnostic vitreous tap followed by pars plana vitrectomy and intravitreal antibiotic and steroid. The culture of vitreous fluid was negative for any bacteria and fungus in both cases. However, the first case demonstrated Escherichia coli in urine culture. The follow-up visual acuity was no perception of light and only perception of light in the first and second case, respectively. Severe COVID-19 patients who are hospitalized, receive systemic steroid and have associated comorbidities like diabetes mellitus are at high risk of EE. Delay in diagnosis and appropriate treatment in these patients leads to poor visual outcome.

Clinical features of early-onset pediatric traumatic glaucoma and predictive factors for the need of early glaucoma surgery.

To assess the clinical presentation of pediatric patients having early traumatic glaucoma and to analyze early predictors for the need of filtration surgery. Patients with early traumatic glaucoma after close globe injury (CGI) from January 2014 to December 2020 were retrospectively reviewed. Clinical features, treatment provided (medical and surgical), and visual outcomes were documented. Patients were divided into two groups based on the management required: group A- trabeculectomy and group B- medication + minor surgery. A total of 85 patients were studied after applying the necessary inclusion and exclusion criteria. Out of these, 46 underwent trabeculectomy for the control of intraocular pressure (IOP) and the remaining 39 were managed with antiglaucoma medications. Significant male predominance of 9.6:1 was observed. Patients presented to the hospital after a mean duration of 8.5 days posttrauma. Wooden objects were most commonly responsible for trauma. Mean best corrected visual acuity at presentation was 1.91 log of minimum angle of resolution (logMAR). Mean IOP at presentation was 40 mmHg. The common anterior segment finding were severe anterior chamber (AC) reaction (63.5%), followed by angle recession (56.4%). Severe AC reaction (P = 0.0001) and corneal microcystic edema (P = 0.04) were significant predictive factors for early need of trabeculectomy. Need of trabeculectomy was higher in patients with severe AC reaction and corneal microcystic edema. The threshold to perform trabeculectomy should be lower, as glaucoma is often relentless, severe, and may result in irreversible vision loss.

Distinguishing infectious endophthalmitis from noninfectious inflammation – Cataract surgery and intravitreal injection

AbstractWith both cataract surgery and intravitreal injections, there is a risk of infectious or non‐infectious intraocular inflammation. The ability to differentiate between the two types of inflammatory reaction is important as the delay in treatment in the former case or unnecessary treatment in the latter case can have consequences.Infectious endophthalmitis is usually associated with pain, hypopyon, severe anterior chamber reaction, hyperemia and significant vision loss, while symptoms associated with sterile endophthalmitis are often less severe. Nevertheless, although rarely, non‐infectious intraocular inflammation can be potentially vision‐threatening after phacoemulsification cataract surgery or intravitreal injection. Since it may be easily mistaken for infectious endophthalmitis, a clear understanding of this pathology is essential. If the ophthalmologist is not sure about the sterile origin of the inflammation, this complication must be treated as an acute endophthalmitis because of the severe visual outcome of this intraocular infection without antibiotic therapy. The aetiology of sterile endophthalmitis remains uncertain and a multifactorial origin must be considered. We will provide further insight into the mechanisms, causative factors and clinical differences among various types of inflammation, with the goal that clinicians can reduce the risk of these events in the future.

Intracameral Recombinant Tissue Plasminogen Activator (rtPA) as the Primary Treatment for Secondary Pupillary Block

Alteplase is a recombinant form of human tissue plasminogen activator (tPA) that converts plasminogen to plasmin essential for fibrinolysis. It is commonly used to treat embolic or thrombotic disorders such as ischemic stroke. Despite its rarity use in ophthalmology, we are reporting the effectiveness of recombinant tissue plasminogen activator (rtPA) in treating an eye with secondary pupillary block as a consequence of severe endophthalmitis. A patient presented with acute endophthalmitis after a complicated cataract extraction. Examination showed severe anterior chamber reaction leading to seclusion pupillae, iris bombe and presence of iridocorneal touch 360-degree. Following intracameral alteplase 2.5 microgram in 0.1 ml given, iris bombe was observed to resolve completely onehour later. Anterior chamber was also significantly deeper and slightly larger pupil compared to before rtPA injection. Due to clearer view of anterior segment, pars planar vitrectomy and extraction of intraocular lens could be performed with significant visual improvement after surgery. Our findings suggest that usage of rtPA, which is alteplase, was effective in treating secondary pupillary block due to intense anterior segment inflammation in endophthalmitis cases. Thus it is useful in replacing the conventional use of laser peripheral iridotomy in treating pupillary block, as the latter potentially aggravates the pre-existing inflammatory condition.

Intracameral r-tPA for the management of severe fibrinous reactions in TASS after cataract surgery.

To describe the use of intracameral recombinant tissue plasminogen activator (r-tPA) in the treatment of severe fibrinous reactions in toxic anterior segment syndrome (TASS) after cataract surgery. A case series of 59 eyes of 59 patients with severe fibrinous anterior chamber reaction following cataract surgery who received intracameral r-tPA (25 µg/0.1 ml). The main outcome measures after intracameral r-tPA were the incidence of complete fibrinolysis, time of maximal effect, visual acuity, and complications. Severe fibrinous reactions appeared 11.5 ± 5.3 days after cataract surgery. Fibrinolysis was observed 2.33 ± 2.70 days after rtPA use and 36 eyes (61%) exhibited resolution of the fibrin by the end of the first day following injection (p < 0.001). Transient corneal edema observed at 1-day after injection was the only complication reported during the injection of r-tPA or at follow-up. Eight eyes (13.6%) required a second r-tPA injection. Best-corrected visual acuity improved from 0.88 ± 0.67 logMAR units before rtPA injection to 0.48 ± 0.49 logMAR units at 1-month (p < 0.001). The application of r-tPA was a quick and efficacious therapeutic approach for the management of severe fibrinous reactions in TASS after cataract surgery. In a clinical setting, intracameral r-tPA may be useful when rapid visual recovery is needed.

Herpes simplex virus stromal keratitis and endotheliitis after femtosecond laser–assisted cataract surgery and astigmatic keratotomy

Two weeks after uneventful femtosecond laser–assisted cataract surgery (FLACS) with laser astigmatic keratotomy (AK) in the right eye, a 72-year-old woman developed a corneal ulcer and infiltrate in the superonasal AK incision, with severe anterior chamber reaction. She was initially treated for bacterial followed by fungal keratitis, without resolution. She was referred to our university corneal service for consultation. Based on clinical presentation and slitlamp examination, the patient was diagnosed with herpes simplex virus keratitis (HSK). The patient was administered topical steroid eyedrops and systemic antiviral therapy, with full resolution of the keratitis. To the authors’ knowledge, this is the first reported case of herpes simplex virus stromal keratitis and endotheliitis after FLACS combined with AK. This report postulates about possible etiologic factors for activation of HSK after femtosecond laser treatment and proposes preventative actions.

Cyclodestructive procedures for refractory glaucoma.

Cyclodestructive procedures for refractory glaucoma.

Clinical features, risk factors and progresses on treatment of recurrent Vogt-Koyanagi-Harada disease

Vogt-Koyanagi-Harada disease(VKH) is a bilateral, granulomatous panuveitis associated with central nervous system, auditory, and integumentary manifestations. Clinically, VKH usually responds well to early aggressive glucocorticosteroid treatment and may be cured without any clinically significant sequelae. Some patients, however, may enter the chronic recurrent phase, which may result in marked loss of vision due to complications such as complicated cataract, secondary glaucoma and maculopathy. Recurrent VKH is mainly characterized by anterior uveitis associated with thickening of the choroid. Initial poor visual acuity, severe anterior chamber reaction, choroidal folds,rapid tapering of systemic corticosteroids or inadequate duration of treatment, and development of extraocular manifestations may be risk factors of disease recurrence. Prolonged glucocorticosteroid treatment has been suggested as effective strategy for recurrence of VKH. The positive effects of other immunosuppressive agents and biologic agents on treatment of chronic recurrent and refractory VKH have been gradually recognized by the uveitis community. (Chin J Ophthalmol, 2017, 53: 317-320).

More Than a Masquerade Syndrome: Atypical Presentations of Vitreoretinal Lymphomas

Purpose: To present a population of patients sharing atypical manifestations of vitreoretinal lymphoma (VRL).Methods: Institutional case series in a single tertiary center. Patients with cytologically proven VRL, referred between November 2009 and May 2010, were retrospectively reviewed. Diagnosis of VRL was based on cytology of vitreous samples, immunohistochemistry, and molecular biology. Patients with confirmed VRL and clinical features different from the typical manifestations were included. Demographical and clinical characteristics of these patients were studied.Results: Twelve cases of VRL were diagnosed. Four cases (2M/2F) were considered atypical (A-VRL) in their presentations. Mean age for typical lymphoma (T-VRL) was 71.9 years (range: 62–87 years); mean age for A-VRL was 54 years (range: 50–59 years).Conclusions: Diagnosis of VRL is challenging and diagnostic delay is frequent. The authors describe a series of patients sharing common characteristics, such as a younger age (p = 0.05), severe anterior chamber reaction, mild or no vitritis, and possible fulminant evolution.

Acute Anterior Uveitis Following Intravitreal Injection of Bevacizumab

To report five cases of iritis after intravitreal injection of bevacizumab. The clinical charts of patients who received intravitreal injections of bevacizumab or ranibizumab from January 2009 to September 2011 by one physician were retrospectively reviewed. A total of 1,097 injections of bevacizumab and 571 of ranibizumab were administered. Five patients developed acute anterior uveitis and presented with severe pain, photophobia, conjunctival injection, and anterior chamber reaction 2 to 24 hours after intravitreal injection of bevacizumab. All five patients were treated with topical corticosteroids with rapid resolution of the inflammation. Although uncommon, acute iritis is a complication of intravitreal injection of bevacizumab.

Postcataract Endophthalmitis due to Mycobacterium tuberculosis

Purpose: To report a case of endophthalmitis caused by Mycobacterium tuberculosis (MTB). Design: Descriptive case report.Methods: Review of patient records.Results: A 77-year-old female patient presented with postoperative endophthalmitis. Anterior segment examination revealed a severe anterior chamber and vitreous reaction. She underwent an anterior chamber tap followed by a vitrectomy, which were both positive for MTB via polymerase chain reaction. There was no radiological evidence of systemic disease. She responded well to antibiotics and antitubercular therapy for a final visual acuity of 6/9 at 1-month follow-up.Conclusions: Mycobacterium tuberculosis may be an etiologic agent for postoperative endophthalmitis.

Severe Anterior Chamber Reaction in two Post-Cataract Surgery Cases Due to Inadvertent Substitution of Tobrex for Tobradex

Severe Anterior Chamber Reaction in two Post-Cataract Surgery Cases Due to Inadvertent Substitution of Tobrex for Tobradex

Management of bilateral idiopathic healed sclerokeratouveitis with ciliary and intercalary staphyloma with complicated cataract and secondary glaucoma

Dear Editor, We read the article by Parihar et al.[1] and agree with their conclusions and would like to share the course of a uveitic glaucoma with intercalary staphyloma which was managed well with phacoaspiration, posterior chamber intraocular lens (PCIOL), and Ahmed glaucoma valve (AGV) implantation. Uveitic glaucoma is challenging due to the early onset and the numerous mechanisms of pathogenesis including steroid-induced intraocular pressure (IOP) elevation.[2] Medical and surgical interventions though initially successful eventually fail due to fibrosis.[34] A 32-year-old lady with recurrent episodes of pain and redness in both eyes (BE) for 3 years was referred to our center with uncontrolled high IOP in left eye. She was on topical timolol maleate 0.5%, brimonidine tartrate 0.15%, and dorzolamide 2% twice daily in BE since 6 months and complained of progressive diminution of vision, dark coloration of the sclera, and white opacities on the cornea for 1 year. There was not any history of ocular injury, fever, joint pain, skin lesions, or any other systemic illness. On examination, vision in the right and left eye was 1/60 and 20/200, respectively. Both eyes had vascularized maculoleucomatous corneal opacities, normal anterior chamber depth, annular posterior synechiae, patent peripheral iridectomies, and cataract. She also had bilateral ciliary and intercalary staphyloma more in the right than the left eye. Tonopen reading in the right and left eye was 20 mmHg and 40 mmHg, respectively. Fundus and gonioscopy examination was not possible due to media opacities [Fig. 1].Figure 1: Both eyes showing healed sclerokeratouveitis with complicated cataractB-scan of BE was anechoic. Complete blood counts, ESR, rheumatoid factor, cANCA (antinuclear cytoplasmic antibody), PANCA, antinuclear antibody, HLAB27, chest X-ray, and X-ray of sacroiliac joints were also normal. We diagnosed this patient as bilateral idiopathic healed sclerokeratouveitis with ciliary and intercalary staphyloma with complicated cataract and secondary glaucoma. We planned phacoaspiration with PCIOL and AGV implantation as a single-stage procedure in the left eye under cover of oral prednisolone (1 mg/kg) tapered in 4 weeks. The plate of AGV was placed in the superotemporal quadrant and the tube was covered with the cadaveric scleral graft. Fixing the AGV tube and plate was an extremely uphill task due to thinness of sclera. Using iris retraction hooks, temporal phacoaspiration was performed and a multipiece acrylic foldable PCIOL was implanted in the bag. On the first postoperative day, left eye IOP was 17 mmHg and vision was 20/200. However, on the second day, there were a severe anterior chamber reaction, an exudative membrane over the IOL and iridectomy with an IOP of 22 mmHg and vision of finger counting at 1 m. We performed YAG membranectomy and pigment sweeping of the IOL on the fifth postoperative day. By the seventh day the IOP was 14 mmHg and vision improved to 20/63 and has remained in the lower teens in 2-year follow-up [Figs. 2 and 3].Figure 2: Postoperative appearance at 3 monthsFigure 3: Cadaveric scleral graft covering the tube of the Ahmed glaucoma valveWe would like to conclude that glaucoma drainage device implantation is an appropriate primary surgical procedure in patients with refractory glaucoma with intercalary staphyloma and can be safely combined with phacoaspiration with PCIOL implantation.

Endogenous Aeromonas Hydrophila Endophthalmitis in an Immunocompromised Patient

PurposeTo report a case of endogenous endophthalmitis due to Aeromonas hydrophila in a patient with distal common bile duct carcinoma and biliary sepsis.MethodsA 72-year-old woman with distal common bile duct carcinoma, obstructive jaundice, diabetes mellitus, and hypertension had a 1-day history of blurred vision, redness, and eye discharges in the right eye. An ophthalmic examination showed no light perception vision, increased intraocular pressure, severe corneal edema, severe anterior chamber reaction, exudative membranes on the anterior lens surface, and severe vitreal reaction. There was no ocular history of trauma, infection, or surgery in either eye.ResultsUnder the impression of endogenous bacterial endophthalmitis, immediate intraocular cultures and intravitreal antibiotic injections were performed, but the anterior chamber reaction, and the ultrasonogram findings were deteriorated. Evisceration was undertakened because of extrusion of the intraocular contents, and Aeromonas hydrophila was isolated by intraocular culture.ConclusionsEndogenous endophthalmitis due to Aeromonas hydrophila is rare, but has a rapid clinical course and a poor prognosis, despite of prompt diagnosis and management.

ROLE OF INTRAVITREAL TRIAMCINOLONE ACETONIDE IN THE TREATMENT OF POSTOPERATIVE ENDOPHTHALMITIS

To report the use of commercially available triamcinolone acetonide as adjunct treatment for acute-onset endophthalmitis after intraocular procedures. Charts of 14 patients who received intravitreal triamcinolone in combination with intravitreal antibiotics for treatment of acute endophthalmitis were reviewed. Patients were included if they presented with pain, vision loss, and severe anterior chamber reaction or hypopyon. Visual acuities, intraocular pressures, anterior chamber reaction, and view of fundus details were recorded at baseline, 1 day, 1 week, 1 month, and 3 months to 5 months. Culture-positive results were found for 57% (8/14) of patients. Isolated species included Staphylococcus epidermidis, viridans streptococcus, group D Streptococcus (nonenterococcus), Propionibacterium acnes, and diphtheroid bacilli. Visual acuities improved an average of 7.5 Snellen lines. Preendophthalmitis level visual acuities were recovered in 78.6% patients (11/14), with 64% (9/14) of patients achieving visual acuity of 20/40 or better regardless of presenting vision. Resolution of anterior chamber reaction and view of fundus details were consistent with visual acuities. Intravitreal triamcinolone combined with intravitreal antibiotics appears to have a safety profile similar to current modalities with a favorable effect on visual recovery and function in the setting of acute postoperative endophthalmitis.

The Effect of Latanoprost, Bimatoprost, and Travoprost on Intraocular Pressure After Cataract Surgery

The aim of this study was to evaluate the effect of preoperative topical latanoprost, bimatoprost, and travoprost administration on postoperative intraocular pressure (IOP) after phacoemulsification and posterior chamber intraocular lens (PC IOL) implantation. This prospective, randomized, double-masked study included 120 eyes of 120 consecutive, normotensive, uncomplicated cataract patients having phacoemulsification surgery with PC IOL implantation. They were randomized into 1 of 4 treatment groups, each of which had 30 patients. Two (2) h before the surgery, the patients received 0.005% latanoprost (Group 1), 0.004% bimatoprost (Group 2), 0.03% travoprost (Group 3), or placebo (Group 4, artificial tears). IOP was measured at preoperative, 4, 8, and 24 h postoperative with a Goldmann applanation tonometer. The anterior chamber was examined postoperatively 24 h for levels of cell and flare using slit-lamp biomicroscopy. The preoperative mean IOP was not statistically significant different among the four groups. In Groups 1 and 3, the mean IOP at 4, 8 and 24 h were significantly lower than the control (Group 4; P < 0.05). However, in Group 2, there was no significant difference in IOP during the study period, compared to the control (Group 4; P > 0.05). In addition, the mean postoperative IOP at 24 h in Groups 1 and 3 were significantly lower than the preoperative IOP (P < 0.05). No severe anterior chamber reaction was observed in any group. Our findings show that a single-dose topical of latanoprost and travoprost can prevent early postoperative IOP elevation after phacoemulsification surgery without any sideeffects.

Rhodococcus ruber as a Cause of Keratitis

To report a case of suppurative keratitis caused by Rhodococcus ruber in a healthy 31-year-old male patient. Ocular examination of the patient revealed a central corneal epithelial defect following trauma, with severe anterior chamber reaction hypopyon. Corneal scrapings were performed from the base of the ulcer and were subjected to routine microbiologic investigation including direct microscopic techniques (Gram stain and 10% KOH), and culture was done on blood agar and potato dextrose agar. Biochemical analysis and antibiotic sensitivity testing were done on the isolate, and additional confirmation was done by DNA sequencing. The isolate was identified as Rhodococcus ruber, an uncommon cause of suppurative keratitis. The isolate was found to be sensitive to augmentin, erythromycin, co-trimoxazole, tobramycin, amikacin, ciprofloxacin, ofloxacin, and sulfamethoxazole. We present a case of Rhodococcus ruber, which was successfully treated. Even if the clinical picture of ulcer is nonspecific, the need of a routine microbiologic examination and sequencing proves to be confirmatory in cases of suppurative keratitis, where the causative organisms are varied in nature.