Uneventful phacoemulsification with implantation of a foldable, acrylic posterior chamber intraocular lens was performed in the right eye of a 73-year-old white man. Postoperatively, the patient developed a chronic, low-grade intraocular inflammation. Cultures from the aqueous specimen grew Actinomyces neuii, an unusual gram-positive bacillus. The low-grade intraocular inflammation persisted with intensive topical steroid-antibiotic medication and systemic antibiotics. A diagnostic, 3-port, pars plana vitrectomy was performed, and aqueous aspirate specimens were sent for culture and sensitivity and to look for abnormal cells. Intracameral antibiotics were not injected. The specimens were sterile to culture, and chronic inflammatory cells were reported on the vitreous specimen. On examination 6 months later, inflammation had not recurred and the best corrected visual acuity was 6/18.
Purpose To assess the safety of nurse-led services of intravitreal injection of dexamethasone implant. Methods An audit of intravitreal injection of dexamethasone implant service in our unit revealed a significant delay in the delivery of injection from the time a clinical decision was made. The limiting factors were an inadequate number of injectors and limited capacity. The constraint in capacity was addressed by moving the service from the theatre to the cleanroom in the outpatients setting. Two senior nurse practitioners in the existing pool of injectors, experienced in intravitreal anti-VEGF injection, were trained to deliver the intravitreal dexamethasone implant service. A safety audit was carried out after they had completed 1000 cases. Results The nurse practitioners administered 1006 injections from February 2017 to October 2019. There was no case of endophthalmitis (0%) or other visually significant complications like retinal detachment, vitreous haemorrhage, hypotony or iatrogenic cataract. One patient had incomplete scleral penetration of the implant, but this resolved without any sequelae. The waiting time to inject the implant nearly halved from 29.5 to 15 days in the nurse-led service. A patient satisfaction survey was overwhelmingly positive, with the majority advocating for the continuation of the nurse-led service. Conclusion The current cohort of experienced nurses providing anti-VEGF injections can be trained under supervision to inject the intravitreal dexamethasone implant (Ozurdex). This is safe, additionally effective in streamlining the service and reducing the waiting time for delivery of the steroid implant.
A 48-year-old woman with a positive BRCA1 gene mutation was diagnosed with stage 3b high-grade ovarian endometrioid carcinoma. She was treated with adjuvant carboplatin at a dose of 740 mg (AUC 6) in 3-weekly cycles. Five days after her fifth cycle of carboplatin, she awoke with new-onset blurred vision in her left eye. An ophthalmology review showed left-sided disc oedema with normal optic nerve function tests and 6/24 visual acuity. A CT scan of the head and orbits was performed which showed no evidence of metastasis or raised intracranial pressure. An autoimmune screen was performed which did not reveal any explanation for her visual symptoms. Fundus fluorescein angiography showed bilateral intense late disc leakage with no evidence of vasculitis. Her chemotherapy was stopped in view of a radiological and biochemical remission and her visual symptoms were monitored. She was also started on a tapering dose of prednisolone 40 mg daily. Five months after the initial review, she has developed left optic disc atrophy with 6/18 visual acuity, while the right eye remains asymptomatic. The diagnosis was felt to be that of carboplatin-induced unilateral disc oedema, a very rare side effect of this chemotherapy.
Chikungunya is a systemic viral disease transmitted to humans by infected mosquitoes in endemic areas of Africa, Asia and more recently in the Americas. Chikungunya infection produces a sudden onset of fever, joint pains and erythematous skin eruption. A plethora of ocular manifestations have been described ranging from a non-specific conjunctivitis to exudative retinal detachment. Ocular chikungunya seems to respond well to corticosteroid therapy, and outcomes are usually better if treated early. Our patient acquired this infection on a travel to Mexico jungle. This was confirmed by ReverseTranscriptase-PCR test once she returned to the UK. The peculiarity of the case is the inordinate delay of almost a year in the onset of eye symptoms, from acquiring the viral infection. The ocular inflammation responded to systemic corticosteroid therapy with a favourable visual outcome. She developed a recurrence many months later which again responded well to a course of oral steroids.
Ozurdex (Allergan, Irvine, California, USA) is a biodegradable sustained release intravitreal implant containing 0.7 mg dexamethasone in a solid polymer drug delivery system. In the UK, it is approved for use in patients with macular oedema secondary to retinal vein occlusion, diabetic maculopathy and non-infectious uveitis. Although the implant is meant to be injected into the vitreous cavity, it can be inadvertently injected into the crystalline lens. This can also migrate into the anterior chamber, under altered anatomical conditions of the anterior segment. We report a case of incompletely penetrated dexamethasone implant, in a patient undergoing treatment for macular oedema secondary to retinal vein occlusion. The partially penetrated implant was managed conservatively with a good outcome.
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