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The etiologies of facial pain are innumerable, thus facial pain misdiagnosis and resultant mismanagement is common. Numb chin syndrome presents with hypoesthesia and/or anesthesia in the dermatomal distribution of the inferior alveolar or the mental nerve. In this case report, we will discuss a case of intractable facial pain in a 57-year-old male with a history of esophageal adenocarcinoma who was initially misdiagnosed and treated as trigeminal neuralgia. During clinical examination, the loss of sensation in the inferior alveolar nerve distribution was identified and led to the diagnosis of mandibular metastasis. The details of the clinical presentation will be discussed in the context of accurate identification and diagnosis. Focal radiation to the metastatic location along with sphenopalatine ganglion radiofrequency ablation and medication management provided significant pain relief. This case report provides additional information to the current medical knowledge and it enhances the clinical vigilance of the clinicians when they encounter similar cases. We concluded that patients with a history of neoplasms who present with atypical symptoms of facial pain should undergo further investigation with advanced imaging. Targeted treatment based on an accurate diagnosis is the foundation of pain management.

A 47-year-old man presented at the Ophthalmology Department of Saku City Asama General Hospital complaining of hyperemia and pain after industrial sodium hydroxide (approx. 40% concentration) had entered his left eye. With an epithelial defect of the bulbar and palpebral conjunctiva, ischemia of the inferior third of the limbal conjunctiva, a total corneal epithelial defect and mild corneal stromal opacity, the damage was determined as Roper-Hall grade III. 2% rebamipide ophthalmic suspension, which is used for dry eye disease, was administered 4 times a day followed by conventional treatment for serious alkali injury. The corneal epithelial defect was resolved, and there were no side effects. The effectiveness of 2% rebamipide ophthalmic suspension in both the repair and improvement of the damage in the conjunctival and corneal epithelia, and its anti-inflammatory effect suggest that it may be an effective treatment not only for dry eye disease but also for alkali ocular damage.

We report 2 cases illustrating the use of a new technique to manage vitreous loss during phacoemulsification, which we have termed ‘trimanual’ anterior vitrectomy. In each case, after recognizing posterior capsule tear, the remaining nuclear pieces were removed with low-parameter phacoemulsification. The remaining cortical material was then removed using bimanual irrigation and aspiration handpieces while the assistant surgeon inserted the vitrectomy probe through a separate 1-mm limbal incision. The vitrectomy probe was held below the plane of the posterior capsule tear, used to cut the vitreous and to provide a mechanical blockade to potentially descending lens material. While this technique involves the potentially awkward simultaneous use of 3 intraocular instruments, we believe that there are several advantages over standard bimanual anterior vitrectomy. © 2014 S. Karger AG, Basel

Two female patients with histories of cancer who showed cryptogenic organizing pneumonia (COP) complications and bilateral anterior uveitis with hypopyon were examined. Both patients had suffered from COP and received intermitted systemic corticosteroid administration (SCA). The first patient, a 65-year-old woman with a history of breast cancer, showed bilateral uveitis with hypopyon. The topical corticosteroid treatment was ineffective. After SCA for the treatment of COP was started, the hypopyon gradually dissipated. Upon termination of SCA, uveitis relapses were controlled by renewed SCA. The other patient, a 69-year-old woman with a history of ovarian cancer, showed bilateral anterior uveitis with hypopyon. Her intraocular outcome did not improve by the topical corticosteroid administration, but SCA that was applied to treat COP led to remission of uveitis. Imaging examinations, biochemical analysis, symptoms or HLA-B27 antigen screenings in either patient did not explain the development of uveitis. Bilateral anterior uveitis is commonly related to autoimmune disease or systemic syndrome. We report two cases with COP that developed bilateral anterior uveitis with hypopyon resistant to topical administration but responsive to systemic administration of corticosteroid. These findings suggest that COP can be associated with the etiology of anterior uveitis.

We present the case of an 86-year-old woman who developed a blowout fracture after Descemet's stripping automated endothelial keratoplasty (DSAEK). Sixteen months after DSAEK, she suffered a blow to her left eye caused by a fall. Computed tomography confirmed the presence of a blowout fracture of the inferior wall of the left orbit with soft tissue prolapsing into the orbit. The patient complained of no abnormal symptoms, and her operated cornea was intact and clear. There was no abnormal finding in both the anterior and posterior segments. This case highlights that the DSAEK technique provides adequate tectonic stability of the globe throughout the traumatic event in contrast to penetrating keratoplasty, which can lead to devastating vision damage after trauma.

Purpose: To report the case of a patient with unilateral idiopathic macular telangiectasia (IMT) associated with type 3 neovascularization. Methods: Observational case report. Results: We describe a case of an 85-year-old woman who presented at our department with a gradual vision loss in her left eye (LE). Her best-corrected visual acuity (BCVA) was 20/200 in the LE. Fundus examination showed 2 small hemorrhages located nasally to the LE fovea, as well as lipid exudates. Fluorescein angiography revealed early hyperfluorescence corresponding to the dilated capillaries. Spectral-domain optical coherence tomography (SD-OCT) showed several microaneurysms within the inner retinal layers. Late indocyanine green angiography revealed a focal hyperfluorescence corresponding to a type 3 neovascularization. No signs of IMT or type 3 neovascularization were detected in the right eye. Based on these findings, the patient was diagnosed with type 1 IMT and coincident type 3 neovascularization. The LE was treated with intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections. Twenty-four months later, SD-OCT revealed regression of the exudative signs, and LE BCVA improved to 20/100. Conclusion: We describe the case of an unusual association between older-onset IMT and type 3 neovascularization, and subsequent regression by anti-VEGF injections. We propose a new IMT subtype called type 1C for this association. Further research must be done in order to establish the pathophysiologic mechanism and likelihood of this association.

A 38-year-old Japanese male was referred to our hospital with abnormal chest X-ray results and severe Coombs-positive hemolytic anemia. He was diagnosed with a stage IV, WHO type A thymoma and was treated with oral prednisolone (1 mg/kg/day) and subsequent chemotherapy. After chemotherapy, the patient underwent surgical resection of the thymoma. Hemolysis rapidly disappeared and did not return after the discontinuation of oral corticosteroids. Corticosteroid therapy may be preferable to chemotherapy or thymoma surgical resection in the management of autoimmune hemolytic anemia with thymoma.

Interval appendectomy (IA) for appendiceal abscesses is useful for avoiding extended surgery and preventing postoperative complications. However, IA has problems in that it takes time before an abscess is reduced in size in some cases and in that elective surgery may result in a delay in treatment in patients with a malignant tumor of the appendix. In order to rule out malignancy, we performed colonoscopy on three patients with an appendiceal abscess that did not decrease in size 5 or more days after IA. After malignancy had been ruled out by examination of the area of the appendiceal orifice, the appendiceal orifice was compressed with a colonoscope, and a catheter was inserted through the orifice. Then, drainage of pus was observed from the appendiceal orifice into the cecal lumen. Computed tomography performed 3 days after colonoscopy revealed a marked reduction in abscess size in all patients. No endoscopy-related complication was noted. Colonoscopy in patients with an appendiceal abscess may not only differentiate malignant tumors, but also accelerate reduction in abscess size.

Ureteric strictures can be caused by traumatic pelvic surgery, urolithiasis and instrumentation. There are various treatment options for ureteric stricture, including laparoscopic ureteric reimplantation. A 56-year-old female with a history of chronic left pelviureteric junction obstruction presented with urosepsis secondary to right-sided urolithiasis. The patient had a left nephrectomy and developed right-sided ureteric stricture following repeated ureteroscopy to manage her stone disease. The treatment with ureteric stenting was unsuccessful. Here we present a case on the feasibility of laparoscopic reimplantation for ureteric stricture in a solitary kidney to preserve renal function and avoid further ureteroscopy or nephrostomies.

A 55-year-old male recently diagnosed with stage IV lung adenocarcinoma presented with altered mental status approximately 1 week after the completion of 14 fractions of whole-brain radiotherapy (WBRT) for brain metastases. On admission, he was somnolent but oriented and without focal neurological deficits. Brain imaging revealed marked regression of his brain metastases. Laboratory values were only significant for hyponatremia with urine hyperosmolality consistent with syndrome of inappropriate antidiuretic hormone secretion. The patient developed seizures 3 days after admission, at which time cerebrospinal fluid was significant for positive herpes simplex virus (HSV)-1 PCR but with a negative cell count, and acyclovir was started for HSV encephalitis (HSE). After 3 weeks of acyclovir 10 mg/dl i.v. 3 times per day, he had significant neurological recovery and was discharged. Although HSE is a relatively rare condition, it is the most common cause of sporadic encephalitis in Western countries. Since the pathogenesis is believed to be due to the reactivation of latent HSV, it is possible that patients who are immunosuppressed are at higher risk for HSE. In addition, patients who are immunosuppressed or immunocompromised often present atypically, which may delay time to diagnosis and treatment, thus significantly worsening prognosis. This case report intends to raise awareness of this severe condition in the context of patients who have received WBRT and immunosuppressive therapy. In addition, important considerations of diagnosis and treatment of HSE in this patient population are discussed.

We report an atypical presentation of Antiphospholipid syndrome (APS) with concomitant subhyaloid hemorrhage, engorged and tortuous retinal veins, intraretinal hemorrhages, and cotton wool spots in a 38-year-old female. Medical treatment was preferred to any invasive treatment. The subhyaloid hemorrhage resolved spontaneously and the patient recovered a visual acuity of 20/20 in her right eye 3 months after the initial episode. A prompt diagnosis of this condition is fundamental to consider a systemic treatment to avoid any further thrombosis.

Zenker's diverticulum (ZD), also known as cricopharyngeal, pharyngoesophageal or hypopharyngeal diverticulum, is a rare condition characterized by an acquired outpouching of the mucosal and submucosal layers originating from the pharyngoesophageal junction. This false and pulsion diverticulum occurs dorsally at the pharyngoesophageal wall between the inferior pharyngeal constrictor and the cricopharyngeus muscle. The pathophysiology of ZD involves altered compliance of the cricopharyngeus muscle and raised intrabolus pressure. Decreased compliance of the upper esophageal sphincter and failure to open completely for effective bolus clearance both lead to an increase in the hypopharyngeal pressure gradient. Different open surgical techniques and transoral endoscopic approaches have been described for the management of ZD, although there is no consensus about the best option. We report the case of a 61-year-old patient with a 7-year history of dysphagia and odynophagia for solid food, which after 2 months progressed to dysphagia for liquids and after 4 months to regurgitation 2-6 h after meals. The patient experienced a 12-kg weight loss. Diagnosis was established by esophagogram, which showed a diverticulum through the posterior pharyngeal wall, suggestive of a ZD. Esophagogastroduodenoscopy showed a pouch with erythematous mucosa. Under general anesthesia, diverticulectomy and myotomy were performed. After an uneventful recovery and adequate oral intake, the patient remains free of symptoms at 4 months of follow-up.

We report the case of a 29-year-old female patient who presented with an acute onset of anisocoria, blurred vision, nausea and severe left-sided headache. There was no history of trauma, drug abuse, or instillation of topical mydriatic compounds. The ocular history was negative for similar events. On presentation, her visual acuity was 0.2 in the left and 1.0 in the right eye with a +2.5 dpt sph. correction. Slit-lamp examination demonstrated a shallow anterior chamber as well as the presence of iris nodules in both eyes. These nodules were identified as Lisch nodules as the patient referred to the previous diagnosis as being neurofibromatosis type 1. A third nerve palsy was considered, but a brain MRI showed normal results. Her ocular motility was normal, but the left pupil was mydriatic and poorly reacting to light, with an associated raised intraocular pressure (IOP) of 38 mm Hg. An examination of the fellow eye was normal, with the IOP measuring 18 mm Hg. Gonioscopy of the right eye showed a narrow angle. On further anamnestic investigation, the patient revealed that the pain and the blurred vision begun in the morning while she was helping her mother in the garden. Finally, after showing the patient a picture of Datura flowers, which she recognized immediately, we made the unusual diagnosis of angle closure glaucoma by Datura, a well-known toxic plant with mydriatic properties. The patient was successfully treated with systemic acetazolamide and topical pilocarpine.

We present a case of radiation-associated angiosarcoma. A 67-year-old Thai woman was diagnosed with endometrium carcinoma stage IC and was treated with surgery and radiations. Ten years later, she presented with a gradually enlarging mass on the pubic area, in the shape of a pair of panties. Skin biopsy of lesions confirmed angiosarcoma. The diagnosis was radiation-associated angiosarcoma. She was treated with chemotherapy due to unresectable tumour. The chemotherapy was started with paclitaxel 70 mg/m2 every 2 weeks. After completing the fifth cycle of paclitaxel, the lesion was markedly decreased in size and the symptoms previously described were also completely resolved.

Sump syndrome is a rare long-term complication of side-to-side choledochoduodenostomy (CDD), a common surgical procedure in patients with biliary tract disease in the era before endoscopic retrograde cholangiopancreatography (ERCP). Frequently only pneumobilia, serving as sign for functioning biliary-enteric anastomosis, is reminiscent of the former surgery. We present the case of an 81-year-old patient with sump syndrome who presented with clinical signs of ascending cholangitis, decades after the initial CDD procedure. Finally the detailed medical history that was taken very thoroughly in combination with the presence of pneumobilia led to the suspicion of sump syndrome. Sump syndrome was diagnosed by ERCP, and after endoscopic debris extraction and antibiotic treatment the patient recovered quickly. In the ERCP era little is known about CDD and its long-term complications, especially by young colleagues and trainees. Therefore this report provides an excellent opportunity to refresh the knowledge and raise awareness for this syndrome.

We report a case of primary undifferentiated bladder carcinoma, which revealed a remarkable response to methotrexate, vinblastine, adriamycin, and cisplatin (MVAC) therapy. A 46-year-old Japanese woman presented at the hospital with the chief complaints of gross hematuria and pain during urination. Cystoscopy revealed a large smooth-surfaced tumor in the urinary bladder. The histopathological diagnosis was undifferentiated carcinoma. The patient then received 3 courses of MVAC over a 3-month period. Hydronephrosis disappeared after the first course, and the tumor shrank rapidly. After completion of the third MVAC course, radical cystectomy and ileal conduit surgery were performed. After 7 years, the patient has still had no recurrences or metastases. We retrospectively review the relative efficacy of the two popular chemotherapeutic regimens in the management of muscle-invasive bladder cancer in patients who had had radical cystectomy.