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A 30-year-old male presented with bilateral eye swelling and methicillin resistant staph aureous(MRSA) bacteremia from an outside hospital. His past medical history included poorly controlled type 1 diabetes mellitus, end stage renal disease on dialysis, heart failure with reduced ejection fraction, and bilateral below the knee amputations. With worsening bilateral periorbital swelling as well as concern for intracranial involvement/spread and for scleral melt on the left eye, the patient was taken for left eye enucleation with wound drainage/antibiotic irrigation. The entire globe was represented in the slide and it shows extensive intra-ocular, scleral and episcleral acute inflammation with multifocal abscess formation. MRSA orbital cellulitis is an aggressive disease and generally caused by external trauma or injury that seeds the gram-positive organism posterior to the orbital septum, although it can also be caused endogenously through systemic infection. Bilateral blindness from community-associated MRSA orbital cellulitis has also been seen in the literature. We present a histopathologic review of a case of MRSA panophthalmitis.

Non-organic visual loss (NOVL), defined as a decrease in visual acuity or field without an identifiable organic cause, can be challenging to diagnose, especially in patients whose NOVL is superimposed on some component of true organic pathology. Exposure to combat puts soldiers at risk of emotional distress and physical trauma, which can contribute to the development of NOVL with conversion disorder or malingering. This case series describes six patients with NOVL who sustained ocular or non-ocular injuries while serving in combat operations in Iraq and Afghanistan, and highlights diagnostic pearls and components of inter-disciplinary management in the unique military context.

Purpose: To investigate the Armed Forces Institute of Pathology (AFIP) experience with Ocular Leprosy. Methods: The AFIP data banks were screened for cases with diagnosis of ocular leprosy. Files and slides stained with Hematoxylin-eosin and acid-fast staining were reviewed by the Division of Ocular Pathology and by the Infectious Diseases Pathology Branch. Results: Twenty-five cases were found from 1951 to 1985 and there were 15 males and 7 females and in 3 cases the sex was not given. The disease process ran from 4 months to 50 years in this series. Three patients also had systemic mycobacterium tuberculosis infections. The clinical manifestations of leprosy did not correlate with the histopathological findings. Clinically, corneal manifestations were the most common clinical presentation in 15 cases with only one perforation, iridocyclitis following in 9 patients and eyelid abnormalities ranging from ectropion to trichiasis in 7 patients. Two patients at autopsy had lepromatous cells in the ciliary body as the only ocular manifestation. Conclusions: In summary, this paper represents a series of ocular leprosy cases from the AFIP which shows the severity of ocular involvement, the predilection of anterior segment involvement and a large number of histopathologic indeterminate cases. The current immigrant and refugee crisis warrants revisting this ancient disease in the differential diagnosis. Keywords: Mycobacterium tuberculosis, Armed forces institute of pathology, Cornea, Anterior segment, Histopathology, Autopsy

Background and Objective A smooth corneal surface prior to laser ablation is important in order to achieve a favorable refractive outcome. In this study, we compare PRK outcomes following two commonly used methods of epithelial debridement: Amoils epithelial scrubber (brush) versus 20% ethanol (alcohol). Study Design/Patients and Methods We reviewed records of patients who underwent wavefront-optimized PRK for myopia or myopic astigmatism between January 2008 and June 2010. Two treatment groups (brush vs. alcohol) were compared in terms of uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent (MRSE), corrected distance visual acuity (CDVA), and complications at postoperative months 1, 3, 6, and 12. Results One thousand five hundred ninety-three eyes of 804 patients underwent PRK during the study period: 828 brush-treated eyes and 765 alcohol-treated eyes. At 6 months postoperatively UDVA was ≥20/20 in 94.7% of brush-treated eyes versus 94.4% of alcohol-treated eyes (P = 0.907). At 1 month a higher percentage of brush-treated eyes maintained or gained one or more lines CDVA compared to alcohol-treated eyes (P = 0.007), but there were no other differences in UDVA, MRSE, or CDVA at any point postoperatively. At 1 month 75.4% of brush-treated eyes versus 70.4% of alcohol-treated eyes were free of complications (P = 0.032), and there were fewer brush-treated eyes with corneal haze (4.0% vs. 6.9%, P = 0.012) and dry eye (8.9% vs. 14.4%, P = 0.001). Although corneal haze was slightly more frequent in the alcohol group, most was trace and not significant. Conclusions Although alcohol-assisted PRK had more minor complications in the early postoperative period, including corneal haze and dry eye, results for both groups beyond 1 month were comparable. Lasers Surg. Med. 44: 475–481, 2012. © Wiley Periodicals, Inc.

Objective To analyze the clinical profiles, histopathologic features, and Mycobacterium tuberculosis polymerase chain reaction testing in patients with ocular tuberculosis. Design Retrospective case series. Participants Forty-two patients. Methods This retrospective study was approved by the Armed Forces Institute of Pathology (AFIP) Institutional Review Board. The AFIP data banks were screened for cases with diagnosis of ocular tuberculosis using key words such as mycobacterium; tuberculosis; and acid-fast bacilli. Files and slides stained with hematoxylin–eosin and acid-fast staining were reviewed by the Division of Ocular Pathology and by the Infectious Diseases and Parasitic Diseases Pathology Branches. When available; blocks and unstained slides were sent to the Doheny Eye Institute; Los Angeles; California; for quantitative polymerase chain reaction (qPCR) analysis to detect Mycobacterium tuberculosis-specific DNA. Main Outcome Measures Tuberculin skin test (TST) results, as well as the chest radiograph results, were recorded. When acid-fast bacilli were identified in tissue, their locations—ocular or extraocular sites—were recorded. Emphasis was placed on lymph node involvement and any systemic diseases. Results In the histopathologic specimens, microscopy revealed a paucity of organisms, and often there were only 1 or 2 organisms associated with or near a giant cell or near an area of necrosis. The qPCR analysis was performed on 6 biopsy specimens. These specimens showed necrotizing granulomatous inflammation from 6 different patients; 3 had positive qPCR results. In 2 of the 3 cases with positive qPCR results, acid-fast bacilli were not found in the tissue sections. In 17 patients, TST results were available; 10 had positive results (60%) and 7 had negative results (40%). Fourteen chest radiograph results were submitted, and 8 (57%) of 14 patients had normal chest films. Conclusions This study suggests that in dealing with those populations at increased risk of tuberculosis (e.g., immigrants from endemic areas and human immunodeficiency virus-infected patients) or patients receiving biologic therapy, the ophthalmologist should endeavor to entertain this diagnosis and to rely on the support of infectious disease specialists and pulmonologists to help solidify the diagnosis, because the current methods for the diagnosis have limited sensitivity. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Purpose The purpose of this study is to elicit the role of oral low-dose sirolimus as a corticosteriod-sparing agent for active uveitis. Methods A retrospective, interventional case series was performed by reviewing the clinical records of all patients treated with oral, low-dose sirolimus (1–4 mg daily) for severe uveitis. Data reviewed included symptomatic improvement, Snellen best-corrected visual acuity, corticosteroid requirement, sirolimus levels, intraocular inflammation, spectral-domain optical coherence tomography, and fluorescein angiogram. Primary outcome measures were determined by the ability to decrease the intraocular inflammation, corticosteroid requirement, and frequency of flares. Results Eight patients with varied diagnoses were treated with oral low-dose sirolimus for severe, chronic uveitis between 2008 and 2010. In four of the eight patients, there was an improvement of all primary outcome measures. While sirolimus monotherapy was successful in only one patient, a sirolimus/methotrexate combination was successful in three patients. Although there was a good initial response in three patients, treatment was a failure after serious side effects forced the cessation of sirolimus therapy. One patient was lost to follow-up. Conclusion Sirolimus may have a limited role in severe uveitis as an adjunct corticosteroid-sparing agent in combination with more standard immunosuppressive agents. Oral low-dose sirolimus appeared to be better tolerated than higher doses, but there were a significant number of adverse events, requiring therapy to be stopped.

Purpose: To determine graft survival and long-term visual outcome after penetrating keratoplasty (PK) for keratoconus in patients with Down syndrome. Methods: The records of all patients with Down syndrome who received PK by the same provider were reviewed. A retrospective analysis was performed to determine long-term graft survival, incidence of graft failure, and complication rate. Results: Twenty-one PKs were performed on 18 eyes of 13 patients with Down syndrome with keratoconus. Three repeat PKs were performed for secondary graft failure. All 18 eyes had clear grafts at the most recent examination. Follow-up ranged from 4 to 88 months, with a mean of 34.9 months. The average age of patients was 42 years, with a range of 20 to 63 years. Preoperative visual acuity ranged from 20/160 to count fingers. Postoperatively, visual acuity was objectively measurable in 12 eyes of 8 patients and ranged from 20/30 to 20/200, with a mean of 20/60. Broken sutures and difficulties with unsedated suture removal complicated postoperative care in some patients. Conclusion: Clear grafts and improvements in visual acuity can be obtained after PK in patients with Down syndrome, but consideration must be given to careful postoperative care by health care providers and home support personnel.

Purpose. To evaluate the use of ocular imaging to enhance management and diagnosis of war-related anterior segment ocular injuries.Methods. This study was a prospective observational case series from an ongoing IRB-approved combat ocular trauma tracking study. Subjects with anterior segment ocular injury were imaged, when possible, using anterior segment optical coherence tomography (AS-OCT), confocal microscopy (CM), and slit lamp biomicroscopy.Results. Images captured from participants with combat ocular trauma on different systems provided comprehensive and alternate views of anterior segment injury to investigators.Conclusion. In combat-related trauma of the anterior segment, adjunct image acquisition enhances slit lamp examination and enables real timeIn vivoobservation of the cornea facilitating injury characterization, progression, and management.

BACKGROUND AND OBJECTIVE: To examine the outcomes of vitrectomy in ocular trauma with opaque cornea. PATIENTS AND METHODS: This retrospective study included 17 eyes of 16 patients who underwent vitrectomy with temporary keratoprosthesis or endoscopy at Walter Reed Army Medical Center, Washington, DC, from March 2003 to October 2010. RESULTS: A temporary keratoprosthesis was used in 8 eyes (47%) and endoscopy in 9 eyes (53%). Overall, the number of eyes with visual acuity of 20/200 or better improved from 0 at baseline to 5 (29%) at 6 months. The number of eyes with retinal detachment also improved from 10 (59%) at baseline to 3 (18%) at 6 months. CONCLUSION: Vitrectomy may be safely performed in ocular trauma with opaque cornea using a temporary keratoprosthesis or endoscopy with comparable outcomes. Endoscopy allows earlier diagnosis and treatment of occult pathology and requires less time and fewer procedures to implement than the temporary keratoprosthesis.

Purpose To evaluate resident refractive surgery caseload and surgical outcomes in an academic medical center. Setting Walter Reed Army Medical Center, Washington, DC, USA. Design Comparative case study. Methods Keratorefractive procedures performed by residents at the Walter Reed Center for Refractive Surgery between 2002 and 2010 were reviewed. Outcomes of surgeries performed by the graduating classes of 2008 to 2010 were compared with those of cases performed by staff. The uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent, corrected distance visual acuity (CDVA), and complications were analyzed. Results Between 2002 and June 2010, residents performed 1566 procedures (1414 photorefractive keratectomy [PRK], 152 laser in situ keratomileusis), for a mean of 20.2 procedures from 2002 to 2004, 51.6 from 2005 to 2007, and 99.9 from 2008 to 2010. Outcomes analysis was performed on 333 resident eyes and 977 staff eyes treated between 2008 and June 2010. Six months postoperatively, 96.1% of resident-treated eyes and 94.6% of staff-treated eyes had a UDVA 20/20 or better (P=.312) and 61.3% and 64.3%, respectively, had a UDVA 20/15 or better (P=.324). The percentage of eyes within ±0.50 diopter of emmetropia at 6 months was 94.0% for residents and 91.1% for staff (P=.105). The postoperative CDVA was within 2 lines of preoperative baseline in all resident cases and 99.8% of staff cases (P=.999). Conclusions Resident experience grew steadily over the period studied. Overall safety and efficacy of resident-performed surgery, albeit mainly PRK based, matched that of fellowship-trained refractive surgeons. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

PURPOSE: To report the results of photorefractive keratectomy (PRK) in patients with pigment dispersion syndrome. METHODS: The pre- and postoperative records of patients with pigment dispersion syndrome who underwent PRK between January 2002 and March 2009 were reviewed. Data for analysis included gender, age, ablation depth, surgical complications, manifest refraction spherical equivalent, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), intraocular pressure (IOP), central corneal thickness (CCT), cup-to-disc (c/d) ratio, and postoperative complications. RESULTS: Thirty-seven eyes of 19 patients (17 men and 2 women) with a mean age of 37.5±6.9 years were included for review. At final follow-up, mean 404.1±119.5 days postoperative, UDVA was 20/15 or better in 67.6%, 20/20 or better in 91.9%, and 20/25 or better in 100% of eyes; 94.6% of eyes were within 0.50 diopters (D) and 100% were within 1.00 D of emmetropia. Corrected distance visual acuity was unchanged from preoperative in 73% and improved by one line in 27% of eyes. No eye lost 1 or more lines of CDVA. When corrected for change in CCT and curvature, mean postoperative IOP was elevated from baseline (16.7±3.8 mmHg) at 1 month (18.1±4.9 mmHg, P =.044) but unchanged at any other time postoperatively. Two (11%) of 19 patients were steroid responders, requiring a single topical agent until completing the course of steroids. No significant change was noted in mean c/d ratio from baseline (0.35±0.12) to final postoperative (0.35±0.13, P =.99). CONCLUSIONS: Although PRK in patients with pigment dispersion syndrome resulted in excellent UDVA, retention of CDVA, and low incidence of adverse effects 1 to 2 years after surgery, long-term safety and efficacy outcomes of PRK in this cohort remain speculative.

Cystoid macular edema (CME) is seen in 33% of patients with uveitis and requires local or systemic treatment for resolution.1 Standard systemic immunosuppressive medications can be associated with significant adverse effects.2–4 Management and prevention of the iatrogenic complications of immunosuppressive therapy accounts for most of the medical resources devoted to these individuals. Consequently, an effective treatment with a safer side effect profile is highly desirable. Efalizumab (Raptiva; Genentech Inc., San Francisco, CA) is a humanized form of a murine IgG1 antibody directed against CD11a, the α-subunit of lymphocyte function–associated antigen-1 (LFA-1).5 LFA-1 expression is increased in memory T-cells, and ICAM-1 is expressed on vascular endothelial cells at sites of inflammation in a variety of T-cell-mediated disorders, including uveitis.6 Both LFA-1 and intercellular adhesion molecule (ICAM)-1 are thought to play important roles in the pathogenesis of autoimmune disorders, and prior studies have shown that interference with adhesion molecule function, including CD11a, decreases histologic and clinical expression of endotoxin-induced uveitis.7,8 In vitro studies have shown that by binding to CD11a, efalizumab can inhibit T-cell activation, T-cell trafficking, and T-cell adhesion without depleting the T cells.9 Efalizumab was approved for use in moderate to severe plaque psoriasis in adults.10–12 Human NK cells have typically been identified as CD56+CD3− lymphocytes, with two subsets of human NK cells identified based on expression levels of cell surface CD56, CD56dim, and CD56bright.13–15 CD56bright regulatory NK cells have been proposed to play a regulatory role in immune responses based on their lower cytotoxic potential, higher secretion of downregulatory cytokines, and unique surface receptor expression profile.14,16–18 Previous studies have demonstrated that a low-dose infusion of recombinant human IL-2 selectively induces the CD56bright regulatory NK subset.19 Studies in the Laboratory of Immunology of the National Eye Institute and other work have revealed that infusion of daclizumab, a humanized IL-2R (CD25)-blocking antibody, also induces upregulation of this subset in both uveitis and multiple sclerosis.20,21 Patients with active uveitis had a significantly lower level of CD56bright regulatory NK cells in their peripheral blood compared with normal donors.20 The expansion of CD56bright cells correlates with decreased ocular and brain inflammation.20,21 Induced CD56bright regulatory NK cells have the ability to secrete large amounts of IL-10, whereas CD56dim NK cells do not, suggesting that the induction of the CD56bright regulatory NK cells may have a beneficial effect on the remission of active uveitis.20 This study was designed to evaluate the safety and potential efficacy of subcutaneous humanized anti-CD11a antibody treatments for macular edema associated with uveitis, while reducing or eliminating standard medications commensurate with the standard of care.

Uveitis is a manifestation of complex processes that can represent an infectious process or a dysfunction of the immune system that may have grave effects on the eye. Although infectious causes, once properly identified, may be successfully treated by addressing the inciting organism with recognized interventions, the immune-modulated chronic forms of uveitis often provide more complex challenges in management. Recent strides in understanding the inflammatory pathway and better bioengineering capabilities have resulted in some new modalities of treatment.

To identify factors associated with best-corrected visual acuity (BCVA) presentation and 2-year outcome in 479 intermediate, posterior, and panuveitic eyes.Cohort study using randomized controlled trial data.Multicenter Uveitis Steroid Treatment (MUST) Trial masked BCVA measurements at baseline and at 2 years follow-up used gold-standard methods. Twenty-three clinical centers documented characteristics per protocol, which were evaluated as potential predictive factors for baseline BCVA and 2-year change in BCVA.Baseline factors significantly associated with reduced BCVA included age ≥50 vs50 years; posterior vs intermediate uveitis; uveitis duration10 vs6 years; anterior chamber (AC) flaregrade 0; cataract; macular thickening; and exudative retinal detachment. Over 2 years, eyes better than 20/50 and 20/50 or worse at baseline improved, on average, by 1 letter (P = .52) and 10 letters (P.001), respectively. Both treatment groups and all sites of uveitis improved similarly. Factors associated with improved BCVA included resolution of active AC cells, resolution of macular thickening, and cataract surgery in an initially cataractous eye. Factors associated with worsening BCVA included longer duration of uveitis (6-10 or10 vs6 years), incident AC flare, cataract at both baseline and follow-up, pseudophakia at baseline, persistence or incidence of vitreous haze, and incidence of macular thickening.Intermediate, posterior, and panuveitis have a similarly favorable prognosis with both systemic and fluocinolone acetonide implant treatment. Eyes with more prolonged/severe inflammatory damage and/or inflammatory findings initially or during follow-up have a worse visual acuity prognosis. The results indicate the value of implementing best practices in managing inflammation.

Purpose To review the incidence, culture results, clinical course, management, and visual outcomes of infectious keratitis after photorefractive keratectomy (PRK) at 6 Army and Navy refractive surgery centers. Design Retrospective study. Participants Twelve thousand six hundred sixty-eight Navy and Army sailors and service members. Methods Army and Navy refractive surgery data banks were searched for cases of infectious keratitis. A retrospective chart review and query of the surgeons involved in the care of those patients thus identified provided data regarding preoperative preparation, perioperative medications, treatment, culture results, clinical course, and final visual acuity. Results Between January 1995 and May 2004, we performed a total of 25337 PRK procedures at the 6 institutions. Culture proven or clinically suspected infectious keratitis developed in 5 eyes of 5 patients. All patients received topical antibiotics perioperatively. All cases presented 2 to 7 days postoperatively. Cultures from 4 cases grew Staphylococcus , including 2 methicillin-resistant S. aureus (MRSA). One case of presumed infectious keratitis was culture negative. There were no reported cases of mycobacterial or fungal keratitis. In addition, we identified 26 eyes with corneal infiltrates in the first postoperative week that were felt to be sterile, and which resolved upon removal of the bandage contact lens and increasing antibiotic coverage. Conclusions Infectious keratitis is a rare but potentially vision-threatening complication after PRK. It is often caused by gram-positive organisms, including MRSA. Early diagnosis, appropriate laboratory testing, and aggressive antimicrobial therapy can result in good outcomes.

Purpose: To examine the causes, signs, and symptoms of anterior capsule contraction syndrome and the response to neodymium:YAG (Nd:YAG) anterior capsulotomy. Setting: Madigan Army Medical Center, Tacoma, Washington, USA. Methods: This retrospective review comprised 70 cases of phacoemulsification with foldable plate-haptic silicone intraocular lens (IOL) implantation. Patients who developed anterior capsule contraction postoperatively, defined as the anterior capsule being visible through an undilated pupil, had a radial anterior capsulotomy with an Nd:YAG laser. Variables analyzed were visual acuity, subjective complaints, associated inflammation, and IOL decentration. Results: Ten eyes of 9 patients (14%) developed anterior capsule contraction and had Nd:YAG laser radial anterior capsulotomy. Three of 9 patients reported decreased visual acuity and glare. Two other patients had chronic anterior_ chamber inflammation unresponsive to steroids after surgery that resolved after Nd:YAG anterior capsulotomy. Intraocular lens decentration was observed in 3 patients before the Nd:YAG capsulotomy. Posterior lens dislocation occurred in 1 patient after capsulotomy and required surgical lens exchange. Conclusion: One-piece foldable silicone IOLs may not provide enough peripheral capsule expansion.