Search

Currently, the diagnosis of acute on chronic liver failure (ACLF) is clinical, and its early identification and proper management are essential for a better prognosis. The aim of this study was to identify histopathologic parameters by analyzing cirrhotic liver explants that could aid in the early recognition of this entity and to determine prognostic factors that would influence ACLF management.We performed a retrospective analysis of histopathologic material from liver explants from patients transplanted because of chronic hepatitis C virus infection from January 2007 to July 2017. Twenty-nine (n = 29) cases without hepatocellular carcinoma were selected. Histopathologic analysis included the Laennec classification, vascularization, and portal vein thrombosis.According to the diagnosis of ACLF, patients were divided in 2 groups: group ACLF (n = 10) and group no acute on chronic liver failure (NO-ACLF) (n = 19). Considering the whole series, mean age was 51 ± 11.48 years and prevalence of men was 58.62%. The mean Model of End-Stage Liver Disease (MELD) score at time of transplantation was significantly higher in the ACLF group than in the NO-ACLF group (35 ± 7 vs 22 ± 6, respectively, P .05) as was the mean total bilirubin (14.38 ± 13.31 vs 8.84 ± 10.46 mg/dl, respectively, P .05). Histopathologic analysis of explanted livers according to Laennec staging system of cirrhosis was as follows: 1. Group NO-ACLF: 1 case (5.25%) grade 3, 6 cases (31.58%) grade 4B, and 12 cases (63.16%) grade 4C; and 2. Group ACLF: 4 cases (40%) grade 4B and 6 cases (60%) grade 4C. Cholestasis was found in 1 patient in the NO-ACLF group (5%) and in 4 patients in the ACLF group (40%) (P = .03). We studied 30-day and 10-year survival respectively, which were 80% and 60% in the ACLF group and 83% and 70% in the NO-ACLF group (P = .794 and P = .657).In this preliminary approach, clinical and histologic findings contributed to the differential diagnosis of ACLF. The mean MELD score at time of liver transplantations, total bilirubin levels, and histologically evident cholestasis were significantly higher in patients with ACLF than in those without ACLF.

Background Oxymetazoline hydrochloride ophthalmic solution (0.1%) is a medication used to treat blepharoptosis. Patients who suffer from blepharoptosis have low-lying eyelids that can hinder their vision. Oxymetazoline hydrochloride ophthalmic solution (0.1%) is prescribed to patients to improve their vision by lifting the upper eyelids. Blepharospasm consists of involuntary, bilateral orbicularis oculi muscle movements that result in twitching and eyelid closure. Botulinum toxin is a treatment used to treat blepharospasm by preventing muscle contraction; but it is not always effective. Case presentation The effects of treatment with both oxymetazoline hydrochloride ophthalmic solution (0.1%) and botulinum toxin are assessed in three patients: (1) Patient A, a 58-year-old Filipina woman; (2) patient B, a 62-year-old Korean woman; and (3) patient C, A 57-year-old Vietnamese woman. All patients had been diagnosed with blepharoptosis as well as blepharospasm. Each patient was given an opportunity to complete an optional survey to assess not only the efficacy of oxymetazoline hydrochloride ophthalmic solution (0.1%) together with botulinum toxin but also their perceived stress during the past month. Conclusions Administering botulinum toxin for the treatment of blepharospasm in patients A and B yielded the expected results; adding oxymetazoline hydrochloride ophthalmic solution (0.1%), a medical treatment for ptosis, to the treatment regimen yielded an unexpected reduction of blepharospasm. We propose that botulinum toxin and oxymetazoline hydrochloride ophthalmic solution (0.1%) can have a synergistic effect on reducing blepharospasm when used concomitantly. We present three cases in which combined use of botulinum toxin with oxymetazoline hydrochloride ophthalmic solution (0.1%) reduced blepharospasm, and propose possible reasons for such effects. We also discuss previous literature in agreement with the results of our cases.

The Model for End-Stage Liver Disease (MELD) system reliably predicts mortality in cirrhotic patients. However, the etiology of liver disease and presence of portal vein thrombosis are not directly taken into account in MELD score. Its impact on the outcomes of patients on the waiting list is still unclear. The aim of this study was to investigate mortality and access to transplantation regarding etiology of liver disease and portal vein thrombosis (PVT).A total of 465 adult patients on the liver waiting list from August 2015 to August 2016 were followed up until August 2017. Patients were divided into groups according to the etiology of liver disease and presence of PVT.The most frequent etiologies were hepatitis C (26.88%), alcoholic cirrhosis (26.02%) and cryptogenic cirrhosis (10.75%). Death while on the waiting list occurred in 168 patients (36.1%) and was more frequent in nonalcoholic steatohepatitis (NASH, 65.4%) and alcoholic cirrhosis (41.3%). A total of 142 (30.5%) patients underwent transplantation and viral, autoimmune, and biliary diseases showed higher proportion of transplantation (36.3%, 53.8%, and 34%, respectively; P .01). Mean delta-MELD at the study endpoint was higher in patients with autoimmune hepatitis, biliary diseases, and NASH (8.3 ± 7.2, 8.3 ± 9.1, and 7.5 ± 9.1, respectively; P .01). A total 77 patients (16.7%) presented PVT. There was no significant difference in outcomes between patients with and without PVT.Patients with NASH and alcoholic liver disease had higher mortality while on the waiting list, whereas patients with viral and autoimmune hepatitis had higher transplantation rate. Outcomes were not influenced by PVT.

e21594Background: Malignant eyelid tumors are common, as the eyelids are exposed to environmental factors. The three most common malignant tumors are basal cell, squamous cell, and melanoma. The st...

Dengue virus (DENV) and Zika virus (ZIKV) are members of the Flaviviridae and are predominantly transmitted via mosquito bites. Both viruses are responsible for a growing number of infections in tropical and subtropical regions. DENV infection can cause lethargy with severe morbidity and dengue shock syndrome leading to death in some cases. ZIKV is now linked with Guillain-Barré syndrome and fetal malformations including microcephaly and developmental disorders (congenital Zika syndrome). The protective and pathogenic roles played by the immune response in these infections is unknown. Mucosal-associated invariant T (MAIT) cells are a population of innate T cells with potent anti-bacterial activity. MAIT cells have also been postulated to play a role in the immune response to viral infections. In this study, we evaluated MAIT cell frequency, phenotype, and function in samples from subjects with acute and convalescent DENV infection. We found that in acute DENV infection, MAIT cells had elevated co-expression of the activation markers CD38 and HLA-DR and had a poor IFNγ response following bacterial stimulation. Furthermore, we found that MAIT cells can produce IFNγ in response to in vitro infection with ZIKV. This MAIT cell response was independent of MR1, but dependent on IL-12 and IL-18. Our results suggest that MAIT cells may play an important role in the immune response to Flavivirus infections., Author summary Dengue virus (DENV) and Zika virus (ZIKV) are responsible for a growing number of infections in tropical and subtropical regions. DENV infection can cause dengue shock syndrome leading to death in some cases, while ZIKV is now linked with Guillain-Barré syndrome and congenital anomalies including microcephaly. The protective and pathogenic roles played by the immune response in these infection is unknown. Mucosal-associated invariant T (MAIT) cells are a population of innate T cells with potent anti-bacterial activity. MAIT cells have also been postulated to play a role in the immune response to viral infections. In this study, we found that MAIT cells are activated in acute DENV infection and in vitro following ZIKV infection. MAIT cell IFNγ response to ZIKV infection was TCR independent, but IL-12 and IL-18 dependent. IFNγ produced from MAIT cells could help limit viral replication. Further studies are needed to determine the protective or pathogenic role of MAIT cells in Flavivirus infections.

PURPOSE To investigate the clinical features, time to diagnosis, histopathology, treatment, and mortality rates of patients with sebaceous cell carcinoma. METHODS This was a retrospective, consecutive series of patients with sebaceous cell carcinoma at a tertiary referral medical center. Between January 1984 and January 2006, 31 patients with sebaceous cell carcinoma were evaluated at the Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics. The main outcome measures were clinical presentations, treatments, reconstructive procedures, and outcomes. RESULTS Thirty-one patients were diagnosed with sebaceous cell carcinoma of the ocular adnexa on histopathology. Twenty (65%) of the patients were women and 11 were men. The upper eyelid was involved in 18 patients, lower eyelid in 10, both upper and lower eyelids in 1, and caruncle in 2. Twenty-three patients had in situ disease, pagetoid disease, or both. Eight patients reported symptoms for

Objectives/Hypothesis: Diplopia remains a major potential complication of orbital decompression performed for thyroid eye disease. We sought to examine the effect of medial and lateral wall surgery with sparing of the orbital floor on the incidence of postoperative diplopia. Study Design: Retrospective review. Methods: A retrospective review was made of 63 consecutive medial and lateral orbital wall surgeries (40 patients) performed between December 1996 and May 2002 for orbital decompression of thyroid eye disease. Results: The average patient age was 50.9 years of age (age range, 14-83 y). The studied group was predominantly female (sex ratio, 36:4). Indications were compressive optic neuropathy (34), exposure keratopathy (25), and aesthetic concerns (4). The mean time since surgery was 31.5 months (range, 3-69 mo). The medial wall was approached by a transcaruncular (59) or endoscopic (4) technique. Two patients had fat removal. The average improvement in exophthalmos was 4.1 mm (range, 0-10 mm). The average palpebral fissure improvement was 2.0 mm (range, 0-7 mm). Two patients had cerebrospinal fluid leaks during excavation of the sphenoid bone. These were diagnosed and repaired primarily without complication. New-onset diplopia occurred in four patients. Two of these patients required strabismus surgery. Conclusion: A 10% new-onset diplopia rate compares favorably with other surgical series. Medial and lateral wall surgery only, sparing the floor, may reduce diplopia after surgery for orbital decompression in thyroid eye disease.

Purpose: To describe the systemic treatment of recurrent eosinophilic granuloma. Methods: Case report and review of Langerhans cell histiocytosis. Results: A 9-year-old boy had painful, right upper eyelid swelling. A computed tomography scan showed a right superolateral orbital mass with evidence of bony erosion. Frozen section evaluation was consistent with eosinophilic granuloma. Biopsy and curettage were performed. Systemic work-up was negative for extraorbital disease. Recurrence of the orbital mass 6 weeks after surgery was confirmed by magnetic resonance imaging (MRI). Four weeks after treatment with prednisone and vinblastine, MRI showed a marked decrease in the size of the orbital lesion. Additional treatment with 6-mercaptopurine and methotrexate was initiated, and MRI 6 months later showed complete resolution of the lesion. Conclusions: The treatment of recurrent eosinophilic granuloma is challenging. The goal is to effectively cure the lesion with minimal short-term and long-term side effects. Systemic steroids, vinca alkaloids, antimetabolites, and antifols are preferred because they have less toxicity and mutagenicity. Combination chemotherapy used in conjunction with treatment by a pediatric hematologist/oncologist appears to be an effective method of treating recurrent disease.

Objective To investigate clinical factors, causative organisms, treatments, and visual acuity and intraocular pressure outcomes associated with delayed-onset, bleb-associated endophthalmitis. Design Retrospective, noncomparative, consecutive case series. Participants All patients treated for bleb-associated endophthalmitis at Bascom Palmer Eye Institute between January 1, 1996, and July 1, 2001. All patients had prior glaucoma filtering surgery. Patients with inadvertent functioning blebs after cataract extraction were excluded. Main outcome measures Visual acuity outcomes and intraocular pressure control after endophthalmitis. Results An antifibrotic agent was used in 40 (82%) of the 49 eyes identified, including mitomycin-C in 33 (67%) and 5-fluorouracil (5-FU) in 7 (14%). The mean interval between the initial filtering surgery and endophthalmitis diagnosis was 5.0 years (range, 0.7–12.2 years). The mean follow-up time after treatment for endophthalmitis was 6.9 months (range, 1–60 months). As recorded in the medical record, potential risk factors and clinical features among the study population included history of bleb leak in 13 (27%) eyes, bleb manipulations in 15 (31%) (needling in 3 [6%], compression sutures in 2 [4%], laser suture lysis in 6 [12%], bleb revision in 5 [10%], and autologous blood injection in 2 [4%]), bleb defects in 6 (12%), inferior bleb location 6 (12%), and nasolacrimal duct obstruction in 1 (2%). The most common causative organisms were Streptococcus species in 15 eyes (31%) and Staphylococcus species in 11 eyes (22%). Final visual acuities in the vitrectomy group (n = 22) versus the initial tap group (n = 26) were as follows: ≥ 20/40 (5% versus 15%), 20/50 to 20/400 (32% versus 54%), and 21 mmHg) after treatment of endophthalmitis. Conclusions Streptococcus species and Staphylococcus species were the most common causative organisms in the current series of patients with delayed-onset bleb-associated endophthalmitis. Despite successful treatment of the infection, visual outcomes are generally poor.

OBJECTIVES/SPECIFIC AIMS: “Loss to follow up” is a common phenomenon and challenge in clinical medicine. Missed appointments are a well-documented source of waste in the health care system, and can lead to strained patient-physician relationships and inferior quality of care. Meningiomas are relatively common, benign tumors that arise from the dural coverings of the brain. Although complete surgical resection is considered curative, surgically excised meningiomas have a well-documented propensity to recur, necessitating continued imaging surveillance of postresection patients. A recent retrospective study at our institute demonstrated that 20% of postresection patients fail to return for follow up within a year of their surgery. Although social determinants of health have been associated with failure to follow up in this population, there has been no research identifying patient-reported barriers that result in loss to follow up in this patient population. The purpose of this study is to identify specific barriers that prevent patients from returning for surveillance. METHODS/STUDY POPULATION: We used an IRB approved, prospective brain tumor clinical database to identify patients who underwent surgical resection of intracranial meningioma at our institution between 2001 and 2013. “Loss to follow up” was defined as failure to attend follow-up appointments with neurosurgery, radiation oncology, or neuro-oncology within a year of the most recent assigned follow-up interval, as recorded in the electronic medical record. Structured interviews were conducted with patients who met study criteria and specific barriers to follow-up were elicited, transcribed, and coded. In 2 cases, a primary caregiver participated in all or portions of the interview with the patient. A general assessment of patient knowledge about meningioma and a screening for basic health literacy were also conducted. RESULTS/ANTICIPATED RESULTS: There were 80 patients in the brain tumor clinical database met chart review criteria for inclusion in the study. A total of 9 structured interviews were conducted; 1 interview was excluded from analysis for failure to meet study criteria. In total, 24 unique obstacles to follow up were recorded. These were stratified and grouped into 4 broad categories: 2 of 8 (25%) patients identified environmental factors, including distance to appointment and challenges with insurance coverage as barriers to follow up; 2 patients (25%) identified psychosocial factors, including poor communication with and distrust of their neurosurgeon as barriers to follow up; 2 (25%) patients identified health factors, including poor health and old age, as barriers to follow up; 6 patients identified healthcare systems factors as barriers to follow up, with 6 patients (75%) reporting seeing a non-specialist for follow up after surgery and 4 patients (50%) reporting not being told by their neurosurgeon that they would need continued follow up. Of those patients seen by non-specialists, only 1 reported any recent brain imaging by those providers. All patients had limited to no prior knowledge of meningiomas before their diagnosis. Four (50%) patients reported satisfaction with the level education about meningiomas they received from their physician. Of these patients, 3 (75%) correctly reported that meningiomas may recur following surgery. Of the patients who did not report satisfaction with physician counseling, 3 (75%) did not realize that meningiomas can recur. DISCUSSION/SIGNIFICANCE OF IMPACT: Healthcare system factors, including uncoordinated transition of postoperative care to non-neurosurgeons and uncertain postoperative surveillance schedules, represent that most common patient-identified barriers to follow up after meningioma resection. Improving transition of care from specialists to non-specialists, including designation of appropriate imaging surveillance schedules, as well as improving communication between specialists and patients about the need for continued follow up, represent clear points for intervention that could improve care for this patient population. In addition, consistent and clear counseling about meningioma and its disease course may reduce loss to follow up following meningioma resection. It is important to note, however, that the small sample size represents a significant limitation of the study.

Introduction: Hypereosinophilic syndrome (HES) is a rare hematologic disorder in which the eosinophils proliferate and infiltrate and damage multiple organs. Without treatment, the condition is fatal, usually due to cardiac dysfunction, particularly left ventricular dysfunction. Causes of reactive eosinophilia include allergic and hypersensitivity reactions, drug allergies, cytokine therapy (recombinant human interleukin), cutaneous disorders, connective tissue diseases, collagen vascular disorders, parasitic infections, immunodeficiency disorders, sarcoidosis, and neoplasms, such as Hodgkin's and non-Hodgkin's lymphoma (B- and T-cell), acute lymphoplastic leukemia, chronic myeloproliferative disorders. Jakafi is approved for myelodysplastic syndrome (MDS) and is effective in reducing splenomegaly. The medication is off-label for HES. This report demonstrates the successful treatment of HES with ruxolitinib. Methods: Case report Results: A 77 year-old Asian male presented with sudden onset pruritus. There was no history of drug allergy or scabies. Past medical history included hypertension, benign prostatic hypertrophy, and early glaucoma. He had shingles 3 times in his 50's on his thorax. Past surgical history included vasectomy, laser iridotomies, and pterygectomies. His medications included losartan, doxazosin and silodosin, amlodipine, carvedilol, and multi-vitamins. He was a retired pediatrician who was actively involved in gardening, carpentry, roller-blading, swimming, and walking his dogs. The patient first presented to his primary care physician, who offered a psychosomatic explanation for his symptoms. A CBC with a differential demonstrated elevated eosinophils of 36%. He was referred to an allergist, who started oral prednisone. There was some relief. He was given interferon. This resulted in fatigue and purple fingernails and no improvement in the pruritus, so interferon was discontinued. He was referred to a dermatologist who prescribed hydroxyzine and fluocinolone cream. This provided minimal relief. He saw a 2nd dermatologist who performed a skin biopsy, which was negative. The patient was referred to an oncologist. Bone marrow biopsy revealed a slight hypercellularity of 30-40% and increased eosinophilia of 16%. There was no evidence of leukemia, lymphoma, or MDS. Cytogenetic testing revealed the following: 46XY, del 9 (q13q22). Kappa/Lambda ratio was slightly elevated at 4.15. KIT mutation by PCR, T-cell clonality by PCR, and FISH panel were negative. Immunoglobulin testing revealed: IgA 140, IgG 1317, IgM 65, and IgE 358. The patient also saw an infectious disease specialist. HIV, ANA, serum tryptase, LDH, Vitamin B12,urine protein electrophoresis, parasitic work-up (trichinella, toxocara, strongyloides) was negative. Echocardiogram demonstrated an ejection fraction of 62%. The patient continued to have chronic pruritus with sleeplessness. In desperation, he attempted to discontinue his prostate medications in hopes that his condition was a simple allergy to medications, but this resulted in urinary retention with fever, sepsis, and anasarca, necessitating urgent antibiotic treatment. Although the patient was negative for the FIP1L1-PDGFRA mutation, a trial of imatinib (tyrosine kinase inhibitor) was given. Not surprisingly, there was no improvement in his symptoms or condition. The patient's symptoms worsened, so oral prednisone was increased from 20 to 80 mg. There was no improvement in his symptoms. Additional testing was obtained, revealing a JAK 2 kinase mutation. He was prescribed ruxolitinib 20 mg po bid. By the 3rd day, he could sleep a full night without pruritus. His prednisone was tapered; by one month, he had tapered off of his prednisone. He developed mild neutropenia, so ruxolinitib was decreased. He noted that when he missed even one dose of his ruxolitinib, the pruritus would recur. Most recent labs (4 years after initial presentation) revealed normal eosinophils of 2%. He had mild anemia and thrombocytosis, which were stable. Conclusions: This is the first case of HES treated with ruxolitinib. The patient had side effects from the standard treatments (prednisone, interferon, imatinib). Newer treatments should be available to patients who had documented HES to prevent delay in treatment and increased morbidity. Ruxolitinib is a potential treatment for HES who are intolerant of other treatments. Disclosures No relevant conflicts of interest to declare.

Antibodies produced by an individual without a known history of sensitization to the relevant antigen are called "natural" antibodies. Some natural antibodies, called xenoreactive antibodies, react with the cells of foreign species. Most xenoreactive antibodies in humans and higher primates bind to a nonreducing terminal galactose expressed by pigs and other lower mammals. Although human natural antibodies which bind to one or more of a variety of terminal alpha-galactosyl structures have been identified previously, the antigen recognized by anti-alpha-galactosyl antibodies on the cells of foreign species is thought to be exclusively Galalpha1-3Gal. Thus, anti-alpha-galactosyl antibodies which do not react with Galalpha1-3Gal are thought to be nonxenoreactive. Here, we identify natural antibodies in human serum which bind to Galalpha1-6Hexosepyrranosides but not Galalpha1-3Gal, indicating that these antibodies are not xenoreactive. Various lower mammals were found to have natural anti-Galalpha1-2Gal antibodies in their sera, suggesting that at least some anti-Galalpha1-2Gal antibodies might not be xenoreactive and indicating, surprisingly, that anti-alpha-galactosyl antibodies are much more phylogenetically disperse than previously known. Also surprising was the finding that some natural antibodies which bind to Galalpha1-3Gal in vitro do not bind to porcine xenografts. These studies show that naturally occurring anti-alpha-galactosyl antibodies in mammalian serum include antibodies with a greater variety of reactivities than previously thought, only some of which would bind to a porcine xenograft. Further, these studies show that the methods used to detect anti-alpha-galactosyl antibodies of relevance in xenotransplantation must be carefully evaluated to avoid detection of anti-alpha-galactosyl antibodies which would not bind to a porcine organ and which therefore are not involved in xenograft rejection.

Introduction Malignant glaucoma occurs when the intraocular pressure elevates in the setting of a shallow anterior chamber and patent iridectomy. We describe a case in which malignant glaucoma that was refractory to conventional treatment and complete vitrectomy was successfully managed by rerouting the glaucoma tubes into the pars plana. Case presentation A 47-year-old Latino man had a history of neovascular glaucoma and subsequent peripheral anterior synechiae. He was status post-two glaucoma drainage devices. He developed pupillary block. Laser iridotomy was performed without complications. He subsequently developed malignant glaucoma that was refractory to yttrium aluminum garnet capsulohyaloidotomy of the anterior hyaloid. He underwent pars plana vitrectomy with successful control of his intraocular pressure. After 2 weeks, the malignant glaucoma recurred. He underwent repositioning of the tubes into the pars plana with successful control of his intraocular pressure. Conclusion In rare cases of malignant glaucoma refractive to yttrium aluminum garnet hyaloidotomy and vitrectomy, placement of glaucoma drainage devices is a reasonable alternative.

Introduction: Necrotizing fasciitis is a rare but potentially fatal soft tissue infection. It involves rapidly progressive necrosis of fascia and subcutaneous fat often with necrosis of the overlying skin. Patients may have systemic toxicity, characterized by altered mental status, malaise, leukocytosis, fever, chills, and pain. It most commonly involves the trunk, extremities and perineum. It is often associated with minor trauma, surgery, diabetes mellitus, or intravenous drug abuse. Mortality rate range is 20-40%. Early diagnosis and aggressive treatment are essential for preventing tissue loss and increasing survival. When necrotizing fasciitis involves the orbit it can threaten vision, lead to cavernous sinus thrombosis and death. Reports indicate that outcomes are usually poor with unsightly scarring, visual impairment or the more serious problems mentioned above. We report our experience with two patients treated using Hyperbaric Oxygen (HBO) treatments as an adjunct in their management. Both had excellent clinical outcomes with preservation of vision and almost imperceptible cosmetic effects. Case presentation: Two patients with Group A Streptococcus periocular necrotizing fasciitis were referred to the first author for emergency medical management. Both patients were healthy females with no history of trauma who presented with rapid-onset periocular pain and edema. Antibiotics were started immediately followed by prompt surgical exploration and debridement and post-operative initiation hyperbaric oxygen treatments. Both patients had excellent outcomes results without loss of vision or complex oculoplastic intervention. Conclusion: Historically, periocular necrotizing fasciitis has had high complications rates. With prompt, aggressive treatment and adjunctive HBO therapy, our 2 patients achieved complete recovery with satisfactory cosmesis and only minimial cicatricial changes. We strongly recommend HBO be used as an adjunct in the management of periocular necrotizing fasciitis.

PURPOSE: To report atypical anterior optic neuropathy due to toxoplasmosis. METHODS: Interventional case report. A 33-year-old male presented with sudden painless loss of vision and floaters in the right eye. Examination demonstrated a best-corrected visual acuity of 20/200, optic nerve head edema, retinal hemorrhages, and vitreous opacities. RESULTS: Nine days later, a granuloma at the optic nerve head was apparent, and the patient was treated with pyrimethamine, sulfadiazine, folinic acid, and prednisone. Six weeks after initiating therapy, best-corrected visual acuity had improved to 20/25. CONCLUSION: Optic nerve involvement in toxoplasmosis is uncommon and, when it occurs, usually presents with a white inflammatory mass on the optic disk. The current case demonstrates the importance of including toxoplasmosis in the differential diagnosis of unilateral anterior optic neuropathy, even if a focal inflammatory mass is not apparent.

The purpose of this study was to review patients who developed ptosis after subtenon's steroid injection and to study the mechanism of steroid-induced ptosis in an animal model. Part 1. Twenty-two patients with uveitis who had received posterior subtenon's triamcinolone acetonide injections were retrospectively reviewed. Demographics, type of uveitis, type and number of surgeries, pre and postoperative marginal reflex distance (MRD1), and clinical outcomes were evaluated. Part 2. Study of rabbit levator muscle and aponeurosis histopathology after subtenon's triamcinolone injection was performed. Part 1. The average age was 44.6 years (range: 14 – 85 years) with a mean follow-up of 14 months. The most common causes of uveitis included uveitis after cataract extraction (five), pars planitis (three), multifocal choroiditis (three), and juvenile rheumatoid arthritis (three). The average time to documented onset of ptosis was 13.9 months (range: 0–49 months). In patients who received only one steroid injection, the average time to ptosis recorded was 2.7 months (range: 0–6 months). Seventeen patients underwent ptosis repair. Part 2. No ptosis was noted in the experimental and control groups. Histopathologic analysis of levator tissues revealed no significant difference in atrophy or degree of inflammation between experimental and control groups. Ptosis following subtenon's steroid injection ranged from mild to moderate and occurred a few months after steroid injection. Prior studies of muscles and periocular tissues exposed to corticosteroids demonstrated degenerative muscle changes; our studies revealed no histopathologic changes in the levator muscle or aponeurosis.

A 41-year-old woman was involved in a motor vehicle accident. On examination, the patient was intubated but responsive. Visual acuity was no light perception OU. Bilateral anterior globe subluxation was noted. The globes were intact. CT scans of the head and orbits revealed extensive facial fractures. The globes were gently reduced in the orbits. After surgery, the patient had not regained vision but was grateful that her eyes were intact and was coping with her vision loss. Prompt positioning of the eyes in the orbits and their subsequent preservation reduced the psychological stress associated with the patient's loss of vision.

To investigate clinical factors, causative organisms, treatments, and visual acuity and intraocular pressure outcomes associated with delayed-onset, bleb-associated endophthalmitis.Retrospective, noncomparative, consecutive case series.All patients treated for bleb-associated endophthalmitis at Bascom Palmer Eye Institute between January 1, 1996, and July 1, 2001. All patients had prior glaucoma filtering surgery. Patients with inadvertent functioning blebs after cataract extraction were excluded.Visual acuity outcomes and intraocular pressure control after endophthalmitis.An antifibrotic agent was used in 40 (82%) of the 49 eyes identified, including mitomycin-C in 33 (67%) and 5-fluorouracil (5-FU) in 7 (14%). The mean interval between the initial filtering surgery and endophthalmitis diagnosis was 5.0 years (range, 0.7-12.2 years). The mean follow-up time after treatment for endophthalmitis was 6.9 months (range, 1-60 months). As recorded in the medical record, potential risk factors and clinical features among the study population included history of bleb leak in 13 (27%) eyes, bleb manipulations in 15 (31%) (needling in 3 [6%], compression sutures in 2 [4%], laser suture lysis in 6 [12%], bleb revision in 5 [10%], and autologous blood injection in 2 [4%]), bleb defects in 6 (12%), inferior bleb location 6 (12%), and nasolacrimal duct obstruction in 1 (2%). The most common causative organisms were Streptococcus species in 15 eyes (31%) and Staphylococcus species in 11 eyes (22%). Final visual acuities in the vitrectomy group (n = 22) versus the initial tap group (n = 26) were as follows:or = 20/40 (5% versus 15%), 20/50 to 20/400 (32% versus 54%), and5/200 (64% versus 31%). Eleven (22%) patients eventually underwent enucleation or evisceration secondary to pain and/or poor vision (light perception to no light perception). In 4 (11%) of the 38 eyes not enucleated, intraocular pressures were poorly controlled at last follow-up (21 mmHg) after treatment of endophthalmitis.Streptococcus species and Staphylococcus species were the most common causative organisms in the current series of patients with delayed-onset bleb-associated endophthalmitis. Despite successful treatment of the infection, visual outcomes are generally poor.

The observation that strong amphiphilic alpha-helical potential exists in all proteins, including beta-sheet proteins, has given rise to the idea that alpha-helical intermediates may be critical to the folding paths of all proteins. Here we report that regions with amphiphilic alpha-helical potential in beta-sheet proteins are regularly spaced within the native structure of the proteins at an average interval of about 13 A. This regular spacing did not occur when the location of amphiphilic regions was randomly assigned (p = 0.0056), suggesting some degree of organization with respect to the native fold. However, in the native structure of various non-homologous proteins that contain the same fold, the location of the regions with amphiphilic alpha-helical potential was not conserved. Further, there was no apparent association of amphiphilic alpha-helical potential with any particular type of secondary structure, confirming that this potential is not involved in maintenance of native structure and suggesting that it may be associated with a highly adaptable process.

PURPOSE: To compare sensitivity of Pseudomonas aeruginosa corneal isolates to ofloxacin, ciprofloxacin, and trovafloxacin. METHODS: Sensitivities of P. aeruginosa corneal isolates to each antibiotic from the periods 1985 to 1987 (n = 32) and 1995 to 1999 (n = 85) were evaluated in vitro with E tests (AB Biodisk; Remel, Lenexa, Kansas). RESULTS: Overall, the percent of P. aeruginosa corneal isolates sensitive in vitro to ofloxacin (106/117, 90.6%) was significantly less than to ciprofloxacin (113/117, 96.6%, P = .016) and trovafloxacin (113/117, 96.6%, P = .016). We observed trends of decreasing sensitivity to ciprofloxacin and trovafloxacin, which were not statistically significant. Sensitivity to ofloxacin remained unchanged; however, sensitivity to ofloxacin was always less than sensitivity to ciprofloxacin and trovafloxacin. CONCLUSION: Although in vitro susceptibilities may not correlate with in vivo efficacy, our data suggest that ciprofloxacin and trovafloxacin are superior to ofloxacin in the treatment of P. aeruginosa keratitis.

Introduction Selective laser trabeculoplasty is a treatment option to lower intraocular pressure in patients with glaucoma. It has been proven to work in adults. We describe two pediatric patients with glaucoma who responded well to selective laser trabeculoplasty. Case presentations Two patients with pediatric glaucoma underwent selective laser trabeculoplasty. Patient 1 was a nine-year-old Iranian Asian girl with secondary aphakic glaucoma who was taking four glaucoma medications. She had a 50% decrease in intraocular pressure five weeks after selective laser trabeculoplasty. She was able to discontinue all four glaucoma drops after treatment. Patient 2 was a 13-year-old Filipino Caucasian boy who presented with early juvenile open-angle glaucoma and who was on no medications. He had a 40% drop in intraocular pressure four weeks after selective laser trabeculoplasty. Conclusion Selective laser trabeculoplasty can decrease intraocular pressure in pediatric patients with glaucoma, both as a primary and secondary therapy. This study demonstrates that selective laser trabeculoplasty is a good option for the treatment of glaucoma in the pediatric population.