Case report of severe acute anterior chamber inflammation leading to formation of hypopyon following corneal instillation of cyanoacrylate adhesive

Dr Christopher Go1, Dr Philomena McNamara1, A.Prof Nitin Verma1

1Royal Hobart Hospital, Hobart, Australia

 

Cyanoacrylate has been used in the management of corneal perforations since 1968. Cyanoacrylate’s side effects are well documented in animal experiments and clinical case reports including instillation into the anterior chamber. We report a case of severe acute anterior chamber inflammation with hypopyon formation following corneal instillation of cyanoacrylate. To our knowledge, this is the first reported case of hypopyon formation resulting from cyanoacrylate toxicity in the literature.

A 48 year old male was referred by a private ophthalmologist for a left 0.2mm paracentral perforation with a 5 year history of bilateral peripheral ulcerative keratitis of unknown cause. He has been treated with long-term QID topical fluorometholone acetate and ofloxacin for over 1 year and has a resultant white cataract. He also has significant atopy from hyper-IgE managed by the dermatologist with mycophenalate and is on patanol to minimise exacerbation of PUK. This patient was managed with cyanoacrylate via a syringe in emergency with bandage contact lens and hourly topical antibiotics. 36 hours later, he was found to have a 1mm hypopyon with 4+ AC activity. This resolved gradually over 1 week and there was no growth on both his vitreous and AC tap.

Given the negative taps, the authors believe this was a reactive response to cyanoacrylate from either; inadvertent entry into the anterior chamber from the application technique, or a severe inflammatory response given the patient’s significant atopic profile. This case report reminds clinicians of the synthetic non-biodegradable nature and toxicity profile of cyanoacrylate and the importance to follow the recommended patch technique by Vote to maximises superficial application only. Also, clinicians should consider the biodegradable fibrin glue if there is a significant history of atopy.


Biography

Philomena McNamara is a PGY 3 unaccredited ophthalmology registrar Royal Hobart Hospital. She completed her internship and residency at the Wollongong Hospital after studying medicine at the University of Sydney.

 

Case series of subretinal lenticular material

Dr Christopher Go1, Dr Samantha Bobba1, Dr Jay Chandra1

1Westmead Hospital, Sydney, Australia

 

Subretinal lenticular material is a rare clinical condition. To date, there have been eight reported cases; two from blunt trauma and the other 6 from different surgical techniques including couching, lensectomy, phacoemulsification and vitrectomy. This case series reports two unusual cases of subretinal lenticular material. To our knowledge, there is no report of subretinal intraocular lens in the literature.

Case One describes a 27 year old male referred for query left subluxed intraocular lens after cataract surgery. The operation was “difficult but uncomplicated”. The patient underwent a lens repositioning day one post-operatively with reason not documented. On examination, a dislocated capsular complex noted with no evidence of the IOL. Examination was made difficult due to obscuration from the displaced capsule. B scan demonstrated a retinal detachment and a planned vitrectomy was performed. Intraoperatively, a submacula IOL was found after introduction of heavy liquid and removed with intraocular forceps. The patient subsequently underwent subsequent operation including a sutured IOL with good outcome (6/12).

Case Two is a 74 year old male referred following right cataract surgery complicated by posterior capsule tear (PCT) and dropped nucleus. On examination, he had a 180 degree circumferential giant tear with radial extension to the optic disc, and RPE burn beneath the radial extension. There were several dislocated lens fragments, mostly in the vitreous cavity but one had migrated sub-retinally which was initially mistaken as a choroidal detachment. This was later removed when the heavy liquid was replaced with silicone oil. Whilst the retina remained flat, his best corrected VA post-operatively was poor (6/120).

Vigorous vitreous manipulation following PCT is considered the likely pathogenesis for subretinal nucleus, which is consistent with Case Two. However, a PCT was not observed in Case One, and the mechanism is still unknown. It may be related to lens repositioning or an undetected pre-operative giant retinal tear. The authors also question whether the IOL could be left subretinally if removal was difficult as two of the reported subretinal cases were left behind with good visual outcome. This case series demonstrates how imperative it is to undergo an extensive dilated examination prior to cataract surgery and be mindful of the risks of surgical revision.


Biography

Chris is a second year registrar training in the Sydney Eye Hospital Network currently rotating at Royal Hobart Hospital.

Prospective, consecutive study utilising confocal and light microscopy of deposition of Ophthalmic Viscoelastic Device in the anterior cornea.

Mr Brendon W. H. Lee1,2, Dr Jeremy Tan2, Dr Fiona Lau2,3, Dr Michelle Hui4, Dr Jenny Norman1,6, Dr  Christopher  Douglas7, Dr Ashish Agar1,2, Professor Minas Coroneo1,2, Associate Professor Ian Francis1,2,5

1Faculty of Medicine, University Of New South Wales, Sydney, Australia,
2Department of Ophthalmology, Prince of Wales Hospital, Sydney, Australia,
3St George and Sutherland Clinical School, Sydney, Australia,
4Royal Prince Alfred Hospital, Sydney, Australia,
5Chatswood Private Hospital, Sydney, Australia,
6Electron Microscope Unit, University of New South Wales, Sydney, Australia,
7Histopath Specialist Pathologists, Sydney, Australia

 

Purpose: To evaluate the incidence and significance of Deposition of Ophthalmic Viscoelastic Device in the Corneal Subepithelium (DOCS) at the sideport region following phacoemulsification cataract surgery (phaco).

Methods: Prospective, consecutive case series of 212 eyes that underwent phaco by a single ophthalmic surgeon. The presence and number of small transparent globules seen on slit lamp, presumed to be Ophthalmic Viscoelastic Device (OVD) deposition in the sideport region of the corneal subepithelium, was recorded at one day, one week, and one month postoperatively. A sample of loose epithelium containing the globules, near the sideport region, was removed and examined using microscopy (light, confocal, electron) and mass spectrometry. Other parameters measured included: age, gender, cataract nuclear sclerosis grade, intraoperative and postoperative complications, duration of surgery, and preoperative and postoperative corrected distance visual acuity (CDVA) at one day, one week, and one month. All patients received followup for at least one month postoperatively. The data were analysed using SPSS (version 21) statistical software.

Results: Confocal and light microscopy confirmed the transparent globular material in the corneal subepithelium to be OVD. DOCS was present at or near the sideport incision site, with significantly more DOCS observed at one week (27.5%) and one month (15.2%) after surgery than at day one (6.2%) postoperatively (p<0.001). There was a positive correlation between DOCS and duration of surgery (r=0.148, p=0.032).  At one month postoperatively, 96.2% of the cohort achieved CDVA of at least 6/6.

Conclusion: The ophthalmological literature has not previously recorded DOCS. This study documents the incidence, slit lamp examination, confocal and light microscopic appearance, of DOCS at the sideport region following phaco. Furthermore, at one month followup, 15.2% of cases had residual DOCS at the sideport region. There appeared to be no detrimental effects either on surgical or visual outcomes in these patients. Thus, DOCS may represent a benign entity, whose diagnosis may be recognised by its unique appearance. The presence of DOCS should indicate to a clinician new to the patient that cataract surgery has been performed using OVD, and that the prognosis has likely not been adversely affected.


Biography

Brendon Lee is a fifth-year medical student at the University of New South Wales currently undertaking research with Prof Coroneo and A/Prof Francis. He has previously presented work at RANZCO and ARVO. He wishes to continue broadening his knowledge of ophthalmology by taking an elective later this year.

Corneal Case Presentations

Dr George Smith1

1Tasmanian Eye Clinics, Glenorchy, Australia

 

A series of 4 short case presentations to illustrate the importance of the cornea in community private practice: Two cases of intra ocular lens choice dilemmas in the presence of abnormal corneal topography. A case of post operative astigmatism control with the aid of the LenSx laser and ORA system and a case of perseverance in endothelial corneal transplantation.

 


Biography

Consultant Ophthalmologist and Anterior Segment Specialist has worked with Tasmanian Eye Clinics for over 3 years. Previous experience working in Sydney, Melbourne and in the UK.

Efficacy and dynamics of self-targeting CRISPR/Cas constructs in the retina

Li F, Hung SS, Wang S, Lim JK, Wang JH, Tu L, Daniszewski M, Lo C, Wong RC, Pébay A, King AE, Bui BV, Liu GS, Hewitt AW.

Delivery of CRISPR/Cas proteins remains one of the major remaining impediments to the widespread application of in vivo gene editing and the anticipatory cures of monogenic retinal diseases.  We recently reported the utility of viral mediated CRISPR/Cas gene editing in the retina; however, with such a viral delivery system, active exogenous endonucleases will be maintained in the retina for an extended period. Consequently, CRISPR/Cas genotoxicity is a significant consideration in clinical applications. To address this issue, we have rationally designed a self-destructing “kamikaze” CRISPR/Cas system that disrupts the CRISPR/Cas enzyme itself after active protein expressed. Four different guide RNAs (sgRNAs) were designed to target Streptococcus pyogenes Cas9 (SpCas) and after in situ validation, selected sgRNAs were cloned into the pX552-YFP-sgRNA plasmid to generate yellow fluorescent protein (YFP) targeting “kamikaze-CRISPR/Cas” vector (pX552-YFP sgRNA-SpCas9 sgRNA). The editing efficacy our “YFP targeting kamikaze-CRISPR/Cas” constructs were further validated in vitro in YFP expressed HEK293 cells by Western blot and FACS analysis. Constructs were packaged into an adeno-associated virus 2 (AAV2) vector and administered intravitreally in the Thy1-YFP transgenic mouse and the expression of spCas9 as well as number of YFP fluorescent cells in the retinas were evaluated at 8 weeks after injection. AAV2-mediated LacZ or single YFP targeting SpCas9 sgRNAs were used as controls. Marked reduction of SpCas9 protein concentration (90% at day 2) as well as YFP expression (~66% to 80% at day 10) was found following transfection of our YFP targeting kamikaze-CRISPR/Cas vector in YFP-expressing HEK293 cells compared to the LacZ targeting CRISPR/Cas control. AAV2-mediated in vivo delivery of this construct significantly reduced the number of YFP fluorescent cells (~86% reduction) in the inner retina of Thy1-YFP transgenic mice. Moreover, a significantly decrease of spCas9 mRNA was also detected in AAV2-mediated YFP targeting kamikaze-CRISPR/Cas infected retina over relative to those treated with YFP targeting CRISPR/Cas alone. CRISPR/Cas genotoxicity is a significant consideration in future clinical applications. Our work has demonstrated that a “self-destructing/kamikaze” CRISPR/Cas can be used as a safe and robust tool for refined gene editing in the retina.

 

Thrombosed varix of the superior ophthalmic vein causing unilateral proptosis

Dr Chinh Nguyen1, A/Prof  Nitin Verma1

1Royal Hobart Hospital , Hobart, Australia

78 year-old female presented with proptosis, lid chemosis and diplopia on the right eye. The patient never had a history of head trauma or any other significant trauma. Magnetic resonance imaging angiography showed a thrombosed varix of the superior ophthalmic vein, with no evidence of dural arteriovenous fistula or vascular malformation. Digital subtraction angiography (DSA) was performed one week following the initial presentation, and in the mean time the patient was admitted for observation without anticoagulation. DSA found the thrombosed varix to have re-vascularised on its own at day seven of admission. All symptoms subsided after 2 weeks of the intial presentation. This case study demonstrated that an isolated thrombosed varix of an ophthalmic vein may resolve on it’s own, without the need for anticoagulation or surgery.

To Be or not to TB…

Dr William Yates1, Professor  Peter McCluskey2, Doctor  Tani Brown1

1Sydney Eye Hospital, Sydney, Australia,

2Save Sight Institute , Sydney, Australia

 

23y.o student referred in by optometrist with left eye inferior vein occlusion.
Reduced vision over the prior 2-3 weeks.
On examination had a left interior branch vein occlusion with neovascularisation. Evidence of occlusive retinitis on both examination and imaging.
Referred to the uveitis clinic for investigation and management.
Required investigation for causes of occlusive retinitis.
Treatment commenced for both BRVO including anti-VEGF as panretinal photocoagulation, and “presumed TB”.

(Please note the clinical history and findings with subsequent management will be explored further during the presentation)


Biography:

Will is a currently a resident at Sydney Eye Hospital with particular interest in the eye manifestations of systemic diseases. He had conducted research with the Uveitis Service at both Sydney Eye Hospital and the Ocular Inflammatory Group at UNSW

Ocular Experience from Manchester – the Syphilis Capital of Europe

Dr Jane Wells1,3,4, Dr Claire Wood2, Dr Ashish Sukthankar2, Prof Nicholas Jones1,3

1Manchester Royal Eye Hospital, Manchester, United Kingdom,

2Manchester Royal Infirmary, Manchester, United Kingdom,

3The University of Manchester, Manchester, United Kingdom,

4The Canberra Hospital, Canberra, Australia

 

The British Medical Journal named Manchester the “Syphilis Capital of Europe” back in 2004. To date, the population of Manchester continues to be over-represented in the incidence and prevalence of syphilis, including syphilitic uveitis, compared with the UK population.

This presentation summarises statistical and clinical findings from a retrospective observational case series of patients presenting with ocular syphilis to the tertiary referral subspecialist Uveitis Service at Manchester Royal Eye Hospital between 2002 & 2016.


Biography:

Dr Wells is the Uveitis and Medical Retina Specialist at The Canberra Hospital and Senior Lecturer in Ophthalmology at Flinders University in Adelaide.  Her subspecialty training includes a combined Teaching and Uveitis Fellowship at Flinders Medical Centre in Adelaide and a Senior Clinical Fellowship in Uveitis and Medical Retina at Manchester Royal Eye Hospital.

Iritis- Kids vs Adults

Dr Stephen Hing1

1Park Road Eye, Hurstville, Australia

A case of iritis in a child will be presented to highlight the differences between adult and childhood iritis.


Biography:

Senior staff specialist at the Sydney Children’s Hospitals Westmead Campus