Retrobulbar hemorrhage and prasugrelRetrobulbar hemorrhage (RBH) is the accumulation of blood in the orbit behind the globe. Although some hemorrhages are minor and do not result in significant mass effect, an RBH is an ophthalmologic emergency requiring immediate surgical intervention. An RBH manifests as acute ipsilateral orbital pain and proptosis and can be variably associated with loss of vision, ophthalmoplegia, subconjunctival hemorrhage, and increased intraocular and intraorbital pressure. 1 Most cases of RBH are traumatic or postsurgical, but some occur spontaneously in patients with bleeding diatheses. Another etiology for RBH is retrobulbar anesthesia injection. 1 The use of antiplatelet therapy has not been considered to be a significant risk factor for RBH 1,2 ; yet newer, more potent antiplatelet agents may carry significantly more risk for RBH. We report a case of RBH causing blindness in a patient taking aspirin and prasugrel. To our knowledge, this is the first such case reported in the English-language ophthalmic literature.
DISCUSSIONRBH is a potentially visually devastating complication of retrobulbar anesthesia. Although older literature
A 23-month-old man was referred for a history of painless, progressive proptosis and motility deficits of the right eye (right eye) for 1 year. There was no history of trauma or malignancy. The patient had an unremarkable birth, medical, and family history. On ocular examination, he had fix and follow vision in both eyes (both eyes) without a relative afferent pupillary defect. External examination revealed axial proptosis in the right eye. Anterior segment and dilated fundus examination, including the optic nerves, were normal in both eyes. Intraocular pressure was 16 mm Hg in the right eye and 18 mm Hg in the left eye (left eye). Ocular motility in the right eye was moderately restricted in all fields of gaze, but full in the left eye with orthophoric alignment in a primary position. FIG. 1. Serial neuroimaging at 3-year follow-up show stable enlarged muscles in the right orbit. Initial presenting MRI T1weighted coronal and axial (A, B) demonstrate enhancement of enlarged extraocular muscles, but are hypointense on T2weighted images (C) suggestive of fibromatosis. D-F. Follow-up imaging at 3 years show minimal interval change and stability in the disease.
The aim of this study was to describe a case of herpes simplex virus (HSV) and varicella-zoster virus (VZV) corneal coinfection in a patient with systemic immunosuppression.Methods: A 77-year-old White man who was recently administered pembrolizumab present with reduction in visual acuity in his left eye from 20/25 to 20/50. There was a known history of ocular HSV keratitis. Slit-lamp examination showed superficial dendritic lesions suggestive of VZV.Results: Viral polymerase chain reaction testing was positive for both HSV and VZV, confirming clinical diagnosis of VZV keratitis in the setting of recurrent HSV keratitis. The infection responded to treatment with topical trifluridine. Two months later, he had another episode of keratitis based on his symptoms reported through telephone encounter which resolved with trifluridine. Unfortunately, the patient committed suicide 4 months after onset.Conclusions: This is the first case of keratitis with HSV and VZV co-infection likely related to systemic immunosuppression. Clinicians should have a high suspicion for viral co-infections in the setting of systemic immunosuppression.
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