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Purpose: To report the surgical outcomes of antegrade balloon dacryocystoplasty combined with pushed-type monocanalicular intubation as a primary surgical treatment in patients with congenital nasolacrimal duct obstruction. Methods: A retrospective cohort study was conducted at National Cheng Kung University Hospital. The medical records of all patients with congenital nasolacrimal duct obstruction who underwent antegrade balloon dacryocystoplasty followed by pushed-type monocanalicular intubation as the primary surgical treatment from January 2018 to July 2020 were included. The monocanalicular tube was removed 1 to 2 weeks after intubation. Surgical success was defined as resolved epiphora 1 month after the tube was removed. Results: A total of 62 eyes of 48 patients were involved in this study. The mean age of the total population was 24.1 months (range: 12 to 66 months). The mean duration of the tube indwelling in the nasolacrimal duct was 9.5 days (range: 4 to 15 days). A total of 60 of the 62 eyes (96.77%) reported surgical success. Early tube loss occurred in 2 eyes (3.23%); however, epiphora was not reported afterward. No complications other than tube loss were recorded. There were no recurrences in patients who had undergone successful surgery observed up to July 2020. Conclusions: Antegrade balloon dacryocystoplasty with short-term pushed-type monocanalicular intubation as a primary surgical treatment for congenital nasolacrimal duct obstruction may have high potential with a high success rate and a low complication rate. [ J Pediatr Ophthalmol Strabismus . 2021;58(6):365–369.]

Purpose: Postoperative endophthalmitis caused by nontuberculous mycobacterium is a rare but devastating complication after intraocular surgery. However, optimal treatment strategies remain undetermined in view of its rarity. Methods: We investigated the cases of culture-proven postoperative Mycobacteroides abscessus subsp. abscessus endophthalmitis in southern Taiwan, focusing on clinical manifestations and microbiological study, and aimed to describe clinical staging and to propose a therapeutic modality for this disease. Results: Twelve cases, including two published cases, were treated in two medical centers in southern Taiwan between Aug. 2011 and Dec. 2016, and all ever received cataract surgery at one clinic. Their disease courses could be categorized into four distinct stages, i.e., the initial, quiescent, recurrent, and end stage, and some cases experienced 1–4 cycles of quiescent-recurrent stages. Although all eyes ended up with phthisis or were eviscerated, the affected eyes receiving pars plana vitrectomy (PPV) tended to become quiescent and survived longer than those without PPV (adjusted hazard ratio: 13.9, p

Objective To introduce the use of a CO2 laser for ablation of the orbicularis oculi muscle (OOM) in a modified Hotz procedure for correction of epiblepharon and to report its clinical outcome. Methods A retrospective consecutive study was conducted from August 2014 to January 2018. Patients who had undergone surgical correction for epiblepharon with the modified Hotz procedure and a CO2 laser ablation of OOM were included. The procedure includes a transverse subciliary incision with removal of a very small amount of skin using CO2 laser ablation. The ablation was carried out continuously on parts of the pretarsal portion and parts of the preseptal portion of the OOM inferior to the lower edge of the incised skin. Finally, the incised skin was closed and secured to the tarsus. The patients were followed for direct inspection of the wound, the direction of the lashes, and the status of the cornea. Results One hundred eyelids from 50 patients were enrolled. The average age was 6.4 years. The mean postoperative follow-up period was 14.3 months. In 90 eyelids (90.0%), the eyelashes were successfully outwardly everted. Undercorrections were noted in 10 eyelids (10.0%). To date, the cosmetic outcome was satisfactory in all cases without complications such as wound dehiscence, ectropion, and eyelid retraction. Conclusions A CO2 laser is a safe and effective alternative to the scalpel in the modified Hotz procedure to correct epiblepharon. Its advantages include limited skin excision, minimal bleeding during surgery, short operation time, and a satisfactory clinical outcome.

Lipemia retinalis is characterized by retinal blood vessels that are creamy white in color and is considered to be directly correlated to serum triglyceride levels. It is a rare retinal manifestation, with typical serum triglyceride levels above 2500 mg/dL required for its expression. We report two cases of lipemia retinalis with hypertriglyceridemia who presented with different retinal pictures during a 5-year follow-up. One showed a normalization of retinal vessels even though the serum triglyceride level was still far more than 2500 mg/dL (4660 mg/dL), but the other had persistent creamy white discoloration despite decreases in serum triglyceride level to below 2500 mg/dL (1031 mg/dL). This suggests that the absolute serum triglyceride level may not be the sole determinant of the typical retinal manifestation. In spite of this, early detection that leads to timely treatment will assist in prevention of severe ocular and systemic vascular complications.

Given the improvement in the instrument and techniques, novel surgical interventions emerged to avoid the osteotomy from the gold standard dacryocystorhinostomy (DCR) for treating primary acquired nasolacrimal duct obstruction (PANDO). This study’s aim is to compare the surgical outcomes of antegrade balloon dacryocystoplasty (DCP) with pushed monocanalicular intubation (MCI) to balloon DCP alone in patients with complete PANDO. Adult patients with complete PANDO receiving balloon DCP followed by pushed MCI or balloon DCP alone from December 2014 to May 2019 were retrospectively reviewed. A total of 37 eyes of 29 patients were treated with balloon DCP with pushed MCI for 1 month, whereas 35 eyes of 28 patients were treated with balloon DCP alone. The success rates at 1 month, 3 months, and 6 months after operation were 89.2%, 73.0%, and 70.2%, respectively, in balloon DCP with MCI group, and 62.9%, 62.9%, and 60.0%, respectively, in the balloon DCP alone group. The balloon DCP with pushed MCI group had a better success rate but only reached statistical significance at 1 month postoperatively (p < 0.01). Subgroup analysis was performed based on age. The success rate in those under 65 in the combined balloon DCP with MCI group was significantly higher than in balloon DCP alone group (72.7% vs. 9.1%, p = 0.004), whereas there was no significant difference between those aged at least 65 in the combined group and the balloon DCP alone group (69.2% vs. 83.3%, p = 0.2). Conclusively, there was no significant difference in the success rate between antegrade balloon DCP with and without pushed MCI in general. Nevertheless, the former procedure was associated with significantly higher surgical success rate than the latter in younger patients.

Purpose: To present a 5-year mortal case of Waldenström’s macroglobulinemia-related retinopathy and serous macular detachment. Case report: A 63-year-old man, with unremarkable medical history, presented with bilateral decreased vision for 2 months. Fundus examination revealed bilateral scattered retinal hemorrhages, exudates, venous tortuosity, and serous macular detachment. Hematologic and biochemistry profiles showed pancytopenia with blood smear demonstrating erythrocyte rouleaux formation. Hyperviscosity syndrome was suspected and later Waldenström’s macroglobulinemia was diagnosed by bone marrow biopsy and high concentration of serum IgM. Plasmapheresis and subsequent chemotherapy were arranged. In spite of resolution of most retinal abnormalities, his visual acuity still showed no improvement with a persistent bilateral macular detachment. The patient then died 5 years after the diagnosis of Waldenström’s macroglobulinemia. Conclusions: Long-term toxicity of IgM to the retinal pigment epithelium may impede the resolution of the persistent serous macular detachment, resulting in an inability of recovery in his vision. Therefore, early diagnosis and timely reduction of serum paraproteins by plasmapheresis and chemotherapy is critical for preventing permanent damages to patients’ health and vision.

We investigated the temporal changes in major eye injuries in Taiwan by reviewing the medical records of all patients with ocular trauma hospitalized at the National Cheng Kung University Hospital during 2002–2004 and 2012–2014. A total of 169 eyes (161 patients) during 2002–2004 and 121 eyes (120 patients) during 2012–2014 were enrolled (mean ± SD age: 41.9 ± 20.8 years in 2002–2004, and 51.8 ± 19.3 years in 2012–2014). Males accounted for ~75% of patients. The most frequent injury-causing object was metallic material (~24%), and blunt traumas were most frequently attributable to traffic accidents and falls. The most common locations of injuries for males and females were the workplace and home, respectively. Open-globe injuries occurred in ~70% of eyes, requiring primary repair, cataract extraction, and/or intraocular lens implantation. The frequencies of fall injury, lacrimal system laceration, lens injury, corneal/scleral foreign bodies, and use of intracameral antibiotics increased from 2002–2004 to 2012–2014, while those of closed-globe injury, vitreous haemorrhage, optic nerve injury, and medical treatment decreased. The final visual acuity remained poor (≤20/200) in >1/3 of injured eyes. Despite therapeutic advancements, major eye injuries still pose a high risk for poor visual outcome.

This study investigated the “real-world” use of ranibizumab for neovascular age-related macular degeneration (nAMD) in Taiwan and assessed the visual outcome. We reviewed the medical records at National Cheng Kung University Hospital, Taiwan, during 2012–2014 for 264 consecutive eyes of 229 patients with nAMD, who applied for ranibizumab covered by national health insurance. A total of 194 eyes (73.5%) in 179 patients (65.5% men; mean ± standard deviation age 69.4 ± 10.7 years) were pre-approved for treatment. Applications for treatment increased year by year, but approval rates decreased during this time. The major causes of rejection for funding were diseases mimicking nAMD, including macular pucker/epiretinal membrane, macular scarring, dry-type AMD, and possible polypoidal choroidal vasculopathy. After completion of three injections in 147 eyes, visual acuity significantly improved, gaining ≥1 line in 51.8% of eyes and stabilising in 38.3% of 141 eyes in which visual acuity was measured. The 114 eyes approved with only one application had a better visual outcome than the 27 eyes approved after the second or third applications. In conclusion, ranibizumab is effective for nAMD; however, approval after the second or third application for national health insurance cover is a less favourable predictor of visual outcome.

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(1) Background: Necrotizing fasciitis (NF) is an infection involving the superficial fascia and subcutaneous tissue. Endophthalmitis is an infection within the ocular ball. Herein we report a rare case of concurrent periorbital NF and endophthalmitis, caused by Pseudomonas aeruginosa (PA). We also conducted a literature review related to periorbital PA skin and soft-tissue infections. (2) Case presentation: A 62-year-old male had left upper eyelid swelling and redness; orbital cellulitis was diagnosed. During eyelid debridement, NF with the involvement of the upper Müller’s muscle and levator muscle was noted. The infection soon progressed to scleral ulcers and endophthalmitis. The eye developed phthisis bulbi, despite treatment with intravitreal antibiotics. (3) Conclusions: Immunocompromised individuals are more likely than immunocompetent hosts to be infected by PA. Although periorbital NF is uncommon due to the rich blood supply in the area, the possibility of PA infection should be considered in concurrent periorbital soft-tissue infection and endophthalmitis.

Receptor tyrosine kinases (RTKs) regulate many cellular processes, and Sprouty2 (Spry2) is known as an important regulator of RTK signaling pathways. Therefore, it is worth investigating the properties of Spry2 in more detail. In this study, we found that Spry2 is able to self-assemble into oligomers with a high-affinity KD value of approximately 16nM, as determined through BIAcore surface plasmon resonance analysis. The three-dimensional (3D) structure of Spry2 was resolved using an electron microscopy (EM) single-particle reconstruction approach, which revealed that Spry2 is donut-shaped with two lip-cover domains. Furthermore, the method of energy dispersive spectrum obtained through EM was analyzed to determine the elements carried by Spry2, and the results demonstrated that Spry2 is a silicon- and iron-containing protein. The silicon may contribute to the electroconductivity of Spry2, and this property exhibits a concentration-dependent feature. This study provides the first report of a silicon- and iron-containing protein, and its 3D structure may allow us (1) to study the potential mechanism through the signal transduction is controlled by switching the electronic transfer on or off and (2) to develop a new type of conductor or even semiconductor using biological or half-biological hybrid materials in the future.

Human infections caused by Weissella confusa are rarely reported. Ten patients with bacteraemia caused by W. confusa who were treated at a tertiary-care hospital in Taiwan during 1997–2007 were studied. All isolates were initially misidentified as various Lactobacillus and Leuconostoc species by two commercial automated identification methods, and were confirmed to be W. confusa by 16S rRNA sequencing analysis. MICs of these isolates for ten antimicrobial agents were determined by the agar dilution method. The characteristics of these patients included underlying malignancy (n = 4), presence of a central catheter (n = 6), surgery within the previous 3 months (n = 4) and concomitant polymicrobial bacteraemia (n = 5, 50%). Mortality was directly attributed to bacteraemia in two patients. All isolates exhibited high trimethoprim–sulphamethoxazole and ceftazidime MICs (≥128 mg/L) and were inhibited by linezolid, daptomycin, ceftobiprole and tigecycline at 4, 0.12, 2 and 0.12 mg/L, respectively. In conclusion, W. confusa should be included in the list of organisms causing bacteraemia in immunocompromised hosts. Novel antibiotics, including daptomycin, moxifloxacin, doripenem and tigecycline, exert good activity against W. confusa.

Information on the relatedness of isolates causing repeated meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia is limited. An observational study of 177 patients with MRSA bacteraemia, admitted to the emergency department of National Taiwan University Hospital, was conducted from January 2001 to June 2006. Among these patients, 28 had a previous episode of MRSA bacteraemia and 59 died during the index episode of bacteraemia. Until December 2007, among the 118 patients who survived the index episode (101 without previous bacteraemia and 17 with previous bacteraemia), 24 (20.3%) had repeated MRSA bacteraemia. The duration from discontinuation of antimicrobial therapy to repeat episodes was in the range 35–854 days (median 86 days). Eight patients (33.3%) died as a result of the second bacteraemic episode. Clinical characteristics associated with repeated bacteraemia included the diagnosis of infective endocarditis and active malignancy. Pulsed-field gel electrophoresis and multilocus sequence typing analysis were performed for 32 pairs of available isolates recovered from patients with repeated bacteraemia and revealed that 29 of them (90.6%) were genetically closely-related strains. The majority of patients with repeated MRSA bacteraemia had recurrent infections and a high mortality rate.

Purpose Paranasal sinusitis is widespread and can lead to orbital complications, blindness, and death. However, the correlation between ophthalmological findings and disease staging remains unclear. This study aimed to investigate the staging, acute ophthalmological manifestations, diagnosis, management, and outcomes of orbital complications of paranasal sinusitis during a 27-year period. Methods We retrospectively reviewed the medical records of all patients with orbital complications of paranasal sinusitis hospitalized at the National Cheng Kung University Hospital, a medical center in Taiwan during 1988–2015. Sex, age, symptoms, history, ophthalmological findings, laboratory and imaging findings, treatments, and outcomes were analyzed by staging. Results Eighty-three patients aged 9 days to 80 years had stage I (preseptal cellulitis, n = 39 patients), II (postseptal orbital cellulitis, n = 8), III (subperiosteal abscess, n = 16), IV (orbital abscess, n = 8), or V (intracranial involvement, n = 12) complications. Peak incidences occurred in patients aged 0–19 and 60–69 years. Chronic sinusitis and diabetes mellitus were common preexisting diseases. Extraocular movement limitation and proptosis predicted postseptal (stage II or more) involvement. The likelihood of elevated intraocular pressure increased with stage. Reduced visual acuity and presence of relative afferent pupillary defect indicated consideration of magnetic resonance imaging to investigate possible intracranial extension. Ipsilateral maxillary (81.7%) and ethmoidal (75.6%) sinuses were the most common sources of infection, and the most frequently implicated pathogens were coagulase-negative Staphylococcus spp. (25.3%) and Staphylococcus aureus (20.5%). All patients received intravenous antimicrobial therapy (multi-drug therapy in 88.0%), and 55.4% underwent surgery, most commonly endoscopic sinus surgery. One (1.2%) diabetic man with stage V complications died of fungal sinusitis with intracranial invasion. Five (6.0%) patients, all stage V, lost vision despite intensive treatment. The average length of hospital stay was 13.8 days (range 2–72 days), and significantly longer stays were associated with stages II–V as compared to stage I. Conclusions Orbital infection originating from paranasal sinusitis can cause vision loss and death due to intracranial extension. Acute ophthalmological findings predict staging and prognosis. Cooperative consultation between ophthalmologists, otorhinolaryngologists, and neurologists is essential. Urgent diagnostic studies and aggressive antimicrobial therapy are indicated, and surgery should be considered.

Three consecutive workers from the same foundry had Mycobacterium massiliense keratitis. The strains isolated from each patient were identical. This is the first report of a non-surgery-related outbreak of non-tuberculous mycobacterial ocular infection. An investigation revealed that injured cornea with exposure to aerosolized non-tuberculous mycobacteria might account for this outbreak.

The authors describe an 11-year-old boy developing bilateral acute anterior uveitis, papillitis in one eye, and neuroretinitis in the other eye after an upper respiratory tract infection of influenza A virus, possibly H1N1. Steroid pulse therapy resolved these conditions. The authors recommend alertness for visual blurring and ocular inflammation after influenza A infection.

Genitourinary infections caused by nontuberculous mycobacteria (NTM) are rarely reported. The medical records of all patients with genitourinary NTM infections treated at National Taiwan University Hospital from 1996–2008 were retrospectively reviewed. Fifteen patients were identified, of whom 10 (67%) were male. More than two-thirds of patients had underlying conditions, the most common of which was chronic renal disease. Only one patient had AIDS. Acid-fast smears of urine were negative in all patients. Eleven isolates were available for further confirmation by sequencing of the 16S rRNA gene. Mycobacterium avium complex was the most common (n = 5, 33%), followed by both Mycobacterium abscessus (n = 2; 13%) and Mycobacterium fortuitum (n = 2; 13%). Of the 12 patients receiving anti-NTM treatment, only four received adequate prescribed regimens and none died of NTM infections. Two patients died of refractory urosepsis before the urinary NTM infections were diagnosed. The clinical characteristics of the 15 patients were also compared with 43 previously reported patients with genitourinary tuberculosis. Patients with genitourinary NTM infections were more likely to report constitutional symptoms, seek medical help within 1 month after the onset of symptoms and develop leukocytosis. Patients with genitourinary tuberculosis were more likely to have ureteral strictures and abnormal chest radiographs associated with active or inactive tuberculosis. Although rare, genitourinary NTM infections pose a significant threat to life and should be considered in the differential diagnosis of genitourinary infections, especially when patients are unresponsive to conventional antibiotic treatment.