Intravitreal triple therapy with vancomycin, ceftazidime, and moxifloxacin for bacterial endophthalmitis: A Twelve-year experience

PURPOSE

Increasing rates of antibiotic resistance in endophthalmitis have been reported. This study examines outcomes of triple therapy with intravitreal vancomycin, ceftazidime, and moxifloxacin for endophthalmitis.

METHODS

Retrospective, consecutive series of all patients treated with abovementioned intravitreal antibiotics from January 2009 to June 2021. Percentages of eyes attaining greater than or equal to 20/200 and 20/50 Snellen visual acuities and adverse events were evaluated.

RESULTS

112 eyes met inclusion criteria. 63 of 112 eyes (56%) achieved a visual acuity of 20/200 during follow-up, with 39 (35%) returning to at least 20/50. In subgroup analysis, 23 of 24 (96%) eyes with post-cataract endophthalmitis obtained ≥ 20/200 acuity and 21 of 24 (88%) obtained ≥ 20/50 acuity during follow-up. There were no cases of macular infarction.

CONCLUSIONS

Intravitreal moxifloxacin (160 µg/0.1 mL) was well tolerated as an adjunct to vancomycin and ceftazidime for bacterial endophthalmitis. Use of this novel combination offers several theoretical advantages compared to standard therapy with two antibiotics, including expanded gram-negative coverage and potential synergy, and may be particularly valuable in geographies where the local antibiogram supports empiric use. Further study is merited to verify the safety and efficacy profile.

BILATERAL CHOROIDAL VASCULAR MALFORMATIONS IN HEREDITARY HEMORRHAGIC TELANGIECTASIA

PURPOSE

To describe a case of bilateral choroidal vascular malformations in a patient with hereditary hemorrhagic telangiectasia.

METHODS

Case report.

RESULTS

A 78-year-old man with hereditary hemorrhagic telangiectasia was incidentally noted to have focal, large deep choroidal vessels on optical coherence tomography with corresponding elevation of the overlying retina. Indocyanine green angiography revealed dilated, intensely fluorescent vessels in arterial phase emptying into massively dilated choroidal veins consistent with choroidal arteriovenous malformation.

CONCLUSION

This case presents multimodal imaging findings of choroidal arteriovenous malformations in hereditary hemorrhagic telangiectasia. Choroidal vascular malformations may represent an underrecognized clinical feature of this syndrome.

The Mydriatic Red Eye as the Initial Presentation of Syphilis

BACKGROUND

Syphilis is a sexually transmitted infection that has been increasing in prevalence since the early 2000s. Ocular involvement occurs in a minority of patients and must be in the differential diagnosis for patients who present with red eye and uveitis.

CASE REPORT

A 29-year-old woman presented to the emergency department with a painful, mydriatic red eye. Review of systems revealed a rash as well as a recent genital lesion and, on further questioning, she admitted to a history of intravenous drug use and high-risk sexual activity. Ophthalmology was consulted and the patient was diagnosed with bilateral uveitis. Serologic testing was positive for syphilis, and she was admitted and treated with intravenous penicillin, with resolution of her uveitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Red eye is a common ocular symptom in patients presenting to the emergency department. The differential diagnosis of the red eye is broad and can range from benign etiologies, such as conjunctivitis, to life- and sight-threatening conditions, such as endogenous endophthalmitis. Systemic diseases such as syphilis may present with primarily ocular symptoms, and ocular syphilis must be identified and managed appropriately to prevent devastating sequelae.

Anti-inflammatory Pharmacotherapy for the Prevention of Cystoid Macular Edema After Cataract Surgery

PURPOSE

To elucidate strategies for and controversies surrounding the use of anti-inflammatory medications after uneventful cataract surgery, with a focus on the prevention of irreversible vision loss due to cystoid macular edema (CME).

DESIGN

Perspective.

METHODS

Expert commentary on the management of inflammation after cataract surgery. Discussion includes combination therapy with corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs), dosing strategies, and emerging therapies.

RESULTS

While prescribing both NSAIDs and corticosteroids for cataract surgery is common, these classes have overlapping mechanisms. Combination therapy may speed visual recovery, but there remains little evidence for improved long-term visual outcomes from NSAIDs. The last 2 decades have seen increasing data on potential benefits of pretreatment with NSAIDs 1-3 days prior to cataract surgery. Simultaneously, newly approved "dropless" delivery systems hold promise, and clinical trials are ongoing to assess outcomes of such formulations.

CONCLUSIONS

Optimal pharmacologic treatment for inflammation after cataract surgery remains controversial. A consensus definition for clinically significant CME may facilitate the comparison of anti-inflammatory drugs. And there remains a need for well-designed trials examining both topical and extended-release drug-delivery systems to refine the treatment paradigm.

Iris anomalies and the incidence of ACTA2 mutation

BACKGROUND

Central cysts of the iris pigment epithelium, or iris flocculi, are frequently reported in the literature in association with thoracic aortic aneurysm and dissection due to smooth muscle alpha-actin 2 (ACTA2) mutations. Children with ACTA2 mutations may also present with congenital mydriasis. We report our experience regarding the frequency of ACTA2 mutation in children with the above iris anomalies.

METHODS

This is a retrospective, consecutive case series of all children presenting for iris flocculi or congenital mydriasis at a single tertiary centre from October 2012 to December 2016.

RESULTS

13 children with iris flocculi and 3 with congenital mydriasis presented during the study period. 10 children with iris flocculi completed genetic testing, and none were positive for ACTA2 mutation. All children with congenital mydriasis presented with a multisystem smooth muscle dysfunction syndrome; two of these three children tested positive for missense R179 ACTA2 mutations.

CONCLUSIONS

In this series, ACTA2 mutation or copy number variation was not detected in children presenting for iris flocculi, whereas congenital mydriasis was associated with R179 mutation in both cases that tested positive for ACTA2 mutation. The case of congenital mydriasis without typical cardiac features of the R179 ACTA2 phenotype or intracranial vasculopathy was negative for ACTA2 mutation. While all children presenting with these iris anomalies should be offered a genetic evaluation, incidence data should inform genetic counselling, particularly in the absence of a family history of aneurysm or sudden death, or systemic signs of smooth muscle dysfunction.

Superior ophthalmic vein thrombosis: A rare complication of Graves' orbitopathy

Superior ophthalmic vein thrombosis is a rare, life- and sight-threatening complication of both infectious and inflammatory orbital disease as well as hypercoagulable state. Only one case of superior ophthalmic vein thrombosis due to thyroid eye disease has been reported in the literature. This article describes the diagnosis and management of a case of superior ophthalmic vein thrombosis due to Graves' orbitopathy. Early diagnosis is critical to facilitate timely therapeutic intervention. Superior ophthalmic vein thrombosis should be considered in the differential diagnosis of acute on chronic proptosis in the setting of Graves' orbitopathy, and may represent and under-recognized and under-diagnosed clinical entity.

Management of frontal sinusitis-associated subperiosteal abscess in children less than 9 years of age

PURPOSE

To investigate practice patterns for cases of subperiosteal abscess (SPA) with concomitant frontal sinusitis to identify factors favorable to medical management in children <9 years of age.

METHODS

The medical records of all pediatric cases of orbital and periorbital cellulitis admitted at a tertiary care center from 1999-2014 were reviewed retrospectively. Cases were included if radiography demonstrated sinusitis-associated SPA in children <9 years of age. Cases of SPA with ipsilateral frontal sinusitis were compared to cases of SPA without ispilateral frontal sinus involvement.

RESULTS

A total of 21 cases with ipsilateral frontal sinusitis and 76 without were included. Patients with frontal sinusitis had a higher incidence of nonmedial SPA compared to those without frontal sinus involvement (6/21 vs 5/76, P = 0.01). Yet a majority of SPAs in the frontal sinusitis group were located medially (15/21 [71%]). All patients with superior or superomedial SPA underwent early surgical intervention. However, 14 of 15 patients (93%) in the frontal sinusitis cohort with medial SPAs were managed successfully with medical therapy alone.

CONCLUSIONS

Medical management of frontal sinusitis-associated SPA appears safe for select children <9 years of age with medial abscess. Although frontal sinusitis is cited as a criterion for surgical drainage of SPA, this criterion should be refined to frontal sinusitis with superiorly located abscesses.

Retinal metastasis from unknown primary: diagnosis, management, and clinicopathologic correlation

A 75-year-old man was incidentally found to have a yellow-white retinal lesion with scattered hemorrhages. He was empirically treated elsewhere for viral retinitis without resolution and later transferred to the Vanderbilt Eye Institute, where retinal biopsy with silicone oil tamponade showed retinal metastasis. He had no prior history of cancer, and multiple systemic imaging evaluations failed to identify a primary site. Histopathology and immunohistochemistry of the biopsy were consistent with non-small-cell lung carcinoma. Due to the radiation-attenuating properties of silicone oil, the patient underwent silicone oil removal prior to receiving external beam radiotherapy (EBRT). The retinal metastasis responded completely to EBRT, and at final follow-up, 18 months after initial presentation, no primary tumor has been identified.

SOX4 interacts with EZH2 and HDAC3 to suppress microRNA-31 in invasive esophageal cancer cells

BACKGROUND

Tumor metastasis is responsible for 90% of cancer-related deaths. Recently, a strong link between microRNA dysregulation and human cancers has been established. However, the molecular mechanisms through which microRNAs regulate metastasis and cancer progression remain unclear.

METHODS

We analyzed the reciprocal expression regulation of miR-31 and SOX4 in esophageal squamous and adenocarcinoma cell lines by qRT-PCR and Western blotting using overexpression and shRNA knock-down approaches. Furthermore, methylation studies were used to assess epigenetic regulation of expression. Functionally, we determined the cellular consequences using migration and invasion assays, as well as proliferation assays. Immunoprecipitation and ChIP were used to identify complex formation of SOX4 and co-repressor components.

RESULTS

Here, we report that SOX4 promotes esophageal tumor cell proliferation and invasion by silencing miR-31 via activation and stabilization of a co-repressor complex with EZH2 and HDAC3. We demonstrate that miR-31 is significantly decreased in invasive esophageal cancer cells, while upregulation of miR-31 inhibits growth, migration and invasion of esophageal adenocarcinoma (EAC) and squamous cell carcinoma (ESCC) cell lines. miR-31, in turn, targets SOX4 for degradation by directly binding to its 3'-UTR. Additionally, miR-31 regulates EZH2 and HDAC3 indirectly. SOX4, EZH2 and HDAC3 levels inversely correlate with miR-31 expression in ESCC cell lines. Ectopic expression of miR-31 in ESCC and EAC cell lines leads to down regulation of SOX4, EZH2 and HDAC3. Conversely, pharmacologic and genetic inhibition of SOX4 and EZH2 restore miR-31 expression. We show that SOX4, EZH2 and HDAC3 form a co-repressor complex that binds to the miR-31 promoter, repressing miR-31 through an epigenetic mark by H3K27me3 and by histone acetylation. Clinically, when compared to normal adjacent tissues, esophageal tumor samples show upregulation of SOX4, EZH2, and HDAC3, and EZH2 expression is significantly increased in metastatic ESCC tissues.

CONCLUSIONS

Thus, we identified a novel molecular mechanism by which the SOX4, EZH2 and miR-31 circuit promotes tumor progression and potential therapeutic targets for invasive esophageal carcinomas.

The regulation of cell-cell adhesion during epithelial-mesenchymal transition, motility and tumor progression

Adherens junctions (AJs) are essential for the maintenance of epithelial homeostasis and a key factor in the regulation of cell migration and tumor progression. AJs maintain cell-cell adhesion by linking transmembrane proteins to the actin cytoskeleton. Additionally, they participate in recruitment of signaling receptors and cytoplasmic proteins to the membrane. During cellular invasion or migration, AJs are dynamically regulated and their composition modified to initiate changes in signaling pathways and cytoskeleton organization involved in cellular motility. Loss of E-cadherin, a key component of AJs, is characteristic of epithelial-mesenchymal-transition (EMT) and is associated with tumor cell invasion. We will review recent findings describing novel mechanisms involved in E-cadherin transcription regulation, endocytosis of E-cadherin and signaling associated with loss of AJs as well as reorganization of the AJ during EMT.