Category: Cases

Herpes Zoster Ophthalmicus in Africa

In EnglishHerpes zoster ophthalmicus involves V1 cranial nerve (n.ophthalmicus). Here are three examples of herpes zoster in 2 young men and one 7yo girl. Both men are HIV-positive (this must be an AIDS-stage). HZO is definitely second quickest germ to penetrate and destroy the cornea. Pseudomonas has no chance in comparison to those two. HIV is certainly a boost for the fulminant clinic.

in Russian / по-русскиГерпес зостер c вовлечением первой ветви из моей африканской практики. Случай у двух взрослых мужчин и у девочки 7 лет (активный у мужчин, и в исходе у девочки). Herpes zoster ophthalmicus – наверное второй по скорости разъедания роговицы после гонококковой инфекции. Синегнойная палочка определённо нервно курит в сторонке. Мужчины были однозначно ВИЧ-положительны, а это, как известно, означает стадию СПИД. И это конечно одна из основных причин для такой яркой и драматической клинической картины.

Advanced herpes zoster ophthalmicus with corneal melt and lens/uvea prolapse. HIV positive patient.

Advanced herpes zoster ophthalmicus with corneal melt and lens/uvea prolapse. HIV positive patient.

Advanced herpes zoster ophthalmicus with resultant corneal leucoma in 7yo girl.

Advanced herpes zoster ophthalmicus with resultant corneal leucoma in 7yo girl.

Advanced herpes zoster ophthalmicus with corneal melt and iris prolapse. HIV positive patient.

Advanced herpes zoster ophthalmicus with corneal melt and iris prolapse. HIV positive patient. Failed conjunctival flap adherence depicted.

Anterior chamber and iris granuloma in newly diagnosed HIV+ kid

This was a case of Mai 2016. Eleven y.o. boy came to our outpatient department with the father complaining of “growth” in one of boy’s eyes, that was allegedly present already for 2 weeks. Visual acuity 6/9 and there were no pains except photophobia.  On examination – solid feathery cream-colored mass in the AC, adherant to the iris. Yellowish behind. No anterior chamber cells, no flare, absolutely quiet eye. Upon the HIV-test she was confirmed newly positive.

presumed aspergillosis iris-AC granuloma

presumed aspergillosis iris-AC granuloma

She was started on steroid and cycloplegic topical eye drops and NSAID tablets, and in 5 days the exudate was gone. But the iris cyst remained in place. There was no vitreous or retinal involvement, and the IOP was OK.

presumed aspergillosis iris-AC granuloma after tx, note torn posterior synechiae

presumed aspergillosis iris-AC granuloma after tx: UBM-scan

Differential diagnosis: intraocular medulloepithelioma (must be congenital, but looks similar, although originating mostly from the angle or ciliary body, not the iris), intraocular lymphoma (looks simmilar, but much more scary!), tuberculoma, leproma, nonpigment melanoma or primary iris tumors, toxoplasmosis gumma, metastases in the iris (lungs, intestine, kidneys), fungi!

Other useful resources  to review iris cysts:

eyewiki.aao.org/Iris_Cysts
bjo.bmj.com/content/59/5/276.full.pdf
https://www.archivesofpathology.org/doi/pdf/10.5858/arpa.2010-0669-RS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3872564/

Literature search at that time in 2016 showed one paper from 2009 by Jain V with a similar case, Aspergillus iris granuloma: a case report with review of literature, claiming that to 2009 only three cases of aspergillosis of the anterior segment of the eye had been ever published. Here is a picture of their case:

Jain V, Aspergillus iris granuloma: a case report with review of literature. 2009

Our patient was left on the same topical treatment further in attempt to conquer the cyst and lost to follow-up. Unfortunately or fortunately, no iris-biopsy was performed that time, and therefore I had no microbiological evidence of fungi. One must also consider, that no natamycin was readily available topically in Western Province of Zambia that time, and in most of the times one must rely on antifungal activity of povidone-iodine eye drops (which are good and readily available hand made, by the way). One must strongly consider the lungs screening (CXR or CT) in immunocompromised patients, to exclude the primary source of hematogenous dissemination to
the brain or meninges. The immune status must be supported of course (f.e. HAART).

I thank my peer-colleagues from Terra-Ophthalmica for the kind help with the differential diagnosis and additional ideas for this case.

Peculiar golden eyelid papilloma

Golden upper eyelid papilloma

Golden upper eyelid papilloma

Stereo-pair image of Golden upper eyelid papilloma

Stereo-pair image of Golden upper eyelid papilloma

In EnglishA case of October 2016. A peculiar outlook of the upper eyelid papilloma in a 10yo girl. It was then immediately excised under topical anesthesia via shaving.

 

in Russian / по-русски Золотая плоскоклеточная папиллома верхнего века. Девочка 10 лет. Лечение: прямое иссечение лезвием у основания под подкожной анестезией (обработка области повидон-йодом, пол кубика или кубик лидокаина под кожу в этой области, лезвие бритвы или хирургический нож №15, кожный пинцет, стерильная марля для купирования небольшого кровотечения, в повязке нужды нет; выполняется в процедурном кабинете).
Был вынужден сделать фото, т.к. обидно удалять такое не сфотографировав.

Yet another periorbital dermoid cyst

periorbital dermoid cyst in 2yo boy

periorbital dermoid cyst in 2yo boy

In EnglishA case of November 2016. A medium sized clinically suspected and otherwise not disturbing the 2yo kid periorbital dermoid cyst. The management: observation, surgery later in course of his life to avoid the unnecessary general anesthesia risks. Dermoid cyst growth relatively slow and does not lead to disturbance of vision. Surgery is mainly indicated due to aesthetic reasons. Spontaneous cyst rupture with consequent aseptic periorbital inflammation is very rare and cannot serve alone as an indication to the surgery in earlier age. Equally rare is the bony erosion or intraorbital/intracranial extension of periorbital dermoid cyst (https://www.ncbi.nlm.nih.gov/pubmed/28089745). The older the age and the larger the cyst, – the bigger is the chance of spontaneous rupture and inflammation (https://www.ncbi.nlm.nih.gov/pubmed/27429223, https://www.ncbi.nlm.nih.gov/pubmed/31520721). However, the smaller the cyst, the bigger is the change for intraoperative rupture (https://www.ncbi.nlm.nih.gov/pubmed/28089745). Imaging in younger age is not indicated for laterally located inconspicious dermoid cysts (https://www.ncbi.nlm.nih.gov/pubmed/22337456 and https://www.ncbi.nlm.nih.gov/pubmed/28089745).

in Russian / по-русскиСлучай ноября 2016 г. Окологлазничная дермоидная киста у ребёнка около 2х лет. Не причиняет неудобств, не влияет на зрение и на развитие зрения, не имеет глазничных симптомов и признаков распространения в орбиту. На момент осмотра операция показана не была. Операция показана позднее, в идеале – до возраста, когда её выполнение возможно без общей анестезии. Единственным настоящим показанием является эстетические переживания ребёнка и родителей. Спонтанные разрывы дермоидной кисты, вовлечение орбиты или полости черепа, эрозия примыкающей кости – описанные редкие осложнения. Чем старше ребёнок и чем больше киста – тем больше риск на спонтанный разрыв. Тем не менее, чем меньше дермоидная киста – тем выше риски на интраоперационный разрыв.  Ссылки см. выше. Интересно отметить, что при отсутствии глазничных сипмтомов – КТ орбиты не показано.