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Invasive fungal sinusitis is a rare and potentially fatal infection that tends to occur in immunocompromised hosts. Presented is the case of a 33-year-old immunocompetent male with several months of recurrent facial and nasal pain refractory to several antibacterial courses before a diagnosis of invasive Aspergillus sinusitis was made. The patient’s symptoms and infection were successfully treated with a combination of surgical debridement and voriconazole. The authors review the epidemiology, risk factors, diagnosis, and treatment of invasive fungal sinusitis due to Aspergillus.

Background: The objective of this trial was to demonstrate the clinical efficacy and safety of topical cocaine as part of the effort to gain regulatory approval from the United States Food and Drug Administration. Methods: This phase III, randomized, prospective, double‐blind, multicenter, single‐dose, placebo‐ and dose‐controlled, parallel‐group study aimed to evaluate the safety and efficacy of topical intranasal cocaine (RX0041‐002). A total of 925 subjects were screened and a total of 648 subjects were randomized: 95 to placebo; 275 to 4% RX0041‐002; and 278 to 8% RX0041‐002. Efficacy was assessed with subjective pain intensity scores using the visual numeric rating scale and objectively using the von Frey filament test. Adverse events (AEs), vital signs, Holter monitoring, nasal irritation on visual examination, and smell assessment were recorded. The placebo and experimental groups were compared using a two‐tailed Fisher's exact test. Results: Topical 4% and 8% cocaine achieved significant subject analgesia, the primary efficacy endpoint. Both doses were safe and well‐tolerated, with a safety profile similar to placebo. In the 4% and 8% groups, headache (1.5% and 2.5%, respectively), epistaxis (0.7% and 1.1%), and anxiety (0.7% and 0%) were the only AEs reported by >1 subject. No cardiovascular AEs, serious AEs, or deaths occurred. A higher percentage of subjects in the 4% and 8% groups compared with the placebo group had a modest increase in either systolic or diastolic blood pressure. Conclusion: Topical 4% and 8% cocaine is an effective anesthetic that can be safely administered for nasal procedures. [ABSTRACT FROM AUTHOR]

Background: Topical cocaine is currently available for local anesthesia of the upper airway mucous membranes. Objective: The objective of this study was to define the safety and efficacy of topical intranasal cocaine for a subsequent phase II clinical trial. Methods: This study was a single-dose, single-center, and open-label study of the plasma and urinary pharmacokinetics (PK) of 4% topical cocaine and its major metabolites, benzoylecgonine (BE) and ecgonine methyl ester (EME), in 30 healthy subjects. Subjects received the topical solution on cotton pledgets containing 4 mL of 4% topical cocaine applied for 20 minutes, which was equivalent to 160 mg of cocaine hydrochloride. Results: A total of 30 subjects (14 males and 16 females) were enrolled, treated, and provided PK data for analysis. Mean plasma concentrations of cocaine rose rapidly during the intranasal exposure period, with peak levels (Cmax, 37.0 ± 17.3 ng/mL) observed at the time of pledget removal (Tmax, 0.43 ± 0.34 h). Mean plasma concentrations then fell rapidly and monoexponentially for the remainder of the study, with a mean half-life (t1/2) of 1.04 ± 0.35 hours. Following a 20-minute topical intranasal exposure to a 160 mg dose of cocaine 4% solution, the mean 0 to 12 hours recoveries of cocaine, BE, and EME were 117 ± 67 μg, 816 ± 440 μg, and 275 ± 113 μg, respectively. Plotting urinary recovery by collection interval showed that urinary excretion of cocaine closely followed the time course of plasma cocaine. Conclusions: Cocaine was rapidly but incompletely absorbed and then rapidly eliminated. Only 4% of the administered cocaine dose appeared to be absorbed in this study. Cocaine appeared in the urine with a time course similar to that in plasma. [ABSTRACT FROM AUTHOR]

Choroidal osteoma is an unusual form of intraocular calcification seen in otherwise healthy eyes. It is a benign idiopathic osseous tumor of the choroid, typically seen in young females. Choroidal neovascular membrane (CNVM) is a complication seen in one-third of these patients and carries a poor visual outcome. We report a case of a 25-year-old hyperthyroid female with choroidal osteoma and subfoveal CNVM in her left eye which was successfully treated using low-fluence photodynamic therapy (PDT) with verteporfin followed by a single injection of intravitreal ranibizumab.

This is a rare case of persistent Horner′s syndrome following epidural anesthesia and Caesarean section. A 33-year-old female presented with persistent ptosis and miosis following epidural anesthesia and Caesarian section several months prior. Magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) of head, neck, and chest were unremarkable. Medline search using terms Horner′s, epidural, spinal anesthesia, delivery, childbirth, Caesarian, and pregnancy identified 31 articles describing Horner′s syndrome in obstetric epidural anesthesia, of which 11 were following Caesarean section. The increased incidence of Horner′s syndrome in the setting of epidural anesthesia in pregnancy may be related to epidural venous engorgement and cephalic spread of the local anaesthetic, with disruption in the oculosympathetic pathway. It is important to include recent epidural anesthesia within the differential diagnosis of acute Horner′s syndrome in a postpartum female. Rarely, the ptosis may be permanent and require surgical intervention.

Anterior megalophthalmos, a rare hereditary disorder, is macrocornea (horizontal corneal diameter more than 13 mm) in association with enlarged lens-iris diaphragm and ciliary ring. One of the major challenging issues in the cataract surgery of these patients is preventing intraocular lens (IOL) malposition, because of probable large capsular bag. Several approaches have been selected by previous surgeons, such as, custom-made anterior chamber IOLs. In this study, we show a normal capsular bag diameter despite ciliary ring enlargement, with application of ultrasound biomicroscopy (UMB). We suggest that in cases of anterior megalophthalmos without phacodonesis, UBM could measure the actual size of the capsular bag and obviate the need for further procedures.

Anterior segment infiltration in acute myeloid leukemia (AML) presenting as hypopyon uveitis is very rare. We report this case as an uncommon presentation in a patient on remission after bone marrow transplant for AML. In addition to the hypopyon, the patient presented with "red eye" caused by ocular surface disease due to concurrent graft-versus-host disease and glaucoma. The classical manifestations of masquerade syndrome due to AML were altered by concurrent pathologies. Media opacities further confounded the differential diagnosis. We highlight the investigations used to arrive at a definitive diagnosis. In uveitis, there is a need to maintain a high index of clinical suspicion, as early diagnosis in ocular malignancy can save sight and life.

A 55-year-old woman, with history of cataract surgery 1 year back, presented with features of ocular inflammation for last 3 months. She had no history of any other intraocular surgery. On examination, anterior segment showed frothy material in the inferior angle with moderate anterior chamber reaction (cells+/flare+) and sulcus intraocular lens with large posterior capsule rent. Fundoscopy showed multiple, small to medium-sized transparent bubbles of perfluorocarbon liquid (PFCL) with membranes in the vitreous cavity. Ultrasonography confirmed the presence of PFCL in the vitreous cavity. Pars plana vitrectomy with anterior chamber wash was done which led to good visual recovery. To conclude, retained PFCL can cause late onset fibrinous inflammation after a quiescent period but surgical intervention may lead to good visual outcome.

We report a rare case of keratoconus with granular dystrophy with a follow-up of two decades, documenting the sequential presentation of two diseases confirmed by histology and genetic studies. A 13-year-old boy was diagnosed in 1988 with keratoconus in both eyes (BE) based on slit-lamp biomicroscopy findings of corneal ectasia in BE accompanied by Fleischer′s ring, Vogt′s striae, a small, old, healed hydrops. The left eye (LE) had central corneal thinning and scar in the central area involving the mid and posterior stroma secondary to healed hydrops. Penetrating keratoplasty (PKP) was advised. The boy was lost to follow-up till 1991 and presented with white, dot-like opacities in the central cornea in the RE only, suggestive of granular corneal dystrophy. Similar findings of white, dot-like opacities were noted in the LE in 1995 and the patient subsequently underwent PKP in BE. Histopathology of corneal buttons confirmed the presence of patchy, crystal-like orange deposits, which stained bright red with Masson′s trichrome. Mutational analysis of the TGFBI gene in patient′s DNA revealed a heterozygous mutation corresponding to a change in Arg555Trp in the keratoepithelin protein. Granular dystrophy recurred after 8 years in the RE.

Rationale. There is evidence from research in animals and humans that the γ-aminobutyric acid B receptor subtype (GABA[sub B]) agonist baclofen may have promise as a pharmacotherapy for cocaine addiction. Objectives. In the present study, the ability of baclofen to modify the reinforcing, subject-rated and cardiovascular effects of intranasal cocaine in humans was determined. Methods. Non-treatment-seeking volunteers (n=7) with recent histories of cocaine use were recruited to participate in this placebo-controlled, double-blind study. Baclofen (0, 10, 20 and 30 mg) was administered orally, followed approximately 1.5 h later by intranasal cocaine (4 mg [placebo] and 45 mg). Subject-rated and cardiovascular measures were taken prior to baclofen administration and then at regular intervals after cocaine was administered. The reinforcing effects of cocaine and cocaine–baclofen combinations were assessed using the Multiple-Choice Procedure. Results. Intranasal cocaine significantly increased the crossover point on the Multiple-Choice Procedure relative to placebo, suggesting that this cocaine dose functioned as a reinforcer. This dose of intranasal cocaine also produced increases in subject-rated effects typical of psychostimulants and elevated cardiovascular measures. The time course for the effects of cocaine was consistent with its pharmacokinetic profile following intranasal administration; increases in subject-rated and cardiovascular effects were observed almost immediately following administration and peaked at approximately 30 min. Pretreatment with baclofen had no significant effect alone, nor in combination with cocaine, on any outcome. Conclusions. These data demonstrated that acute administration of three clinically relevant baclofen doses did not influence the acute behavioral effects of intranasal cocaine in humans. [ABSTRACT FROM AUTHOR]

Cocaine is used to produce a euphoric effect by abusers, who may be unaware of the devastating systemic and ocular side effects of this drug. We describe the first known case of cilioretinal artery occlusion after intranasal cocaine abuse.