Pneumatosis Cystoides Intestinalis Complicated during Chemotherapy for Pulmonary Nontuberculous Mycobacterial Disease

Background: Pneumatosis cystoides intestinalis (PCI) is a rare disease characterized by the presence of gas in the intestinal wall. Aim: We report two rare cases of PCI that are complicated during the chemotherapy for pulmonary nontuberculous mycobacterial (NTM) disease. Case Presentation: In this report, we described two cases (a 72-year-old woman and a 60-year-old woman) of PCI that appeared during the combined chemotherapy consisting of rifampicin, ethambutol and clarithromycin. Because there were few clinical symptoms and increased inflammatory responses, the diagnosis of PCI was delayed. However, there were fortunately no severe complications in both cases. Conclusion: Respiratory physicians should be aware of the potential development of PCI in patients during the chemotherapy for pulmonary NTM disease. It is important to detect PCI in the early stage through radiological examinations to avoid severe complications.

Gastrointestinal sarcoidosis associated with pneumatosis cystoides intestinalis

A 39-year-old male reported fevers,weight loss,watery loose stools,and decreased visual acuity in his right eye over the prior five years.He was pancytopenic,had an elevated American council on exercise level,total bilirubin,and alkaline phosphatase.Computed tomography revealed massive hepatosplenomegaly and emphysematous lung changes.Liver biopsy showed non caseating granulomas.The patient was diagnosed with extrapulmonary sarcoidosis and was treated with prednisone.The patient symptomatically improved but 5 mo later presented with abdominal pain caused by perforation of the cecum.He underwent a cecectomy and pathology revealed pneumatosis cystoides intestinalis.This represents the first reported association between pneumatosis cystoides intestinalis and sarcoidosis.The etiology of pneumatosis cystoides intestinalis in this case was likely multifactorial and involved both effects of the corticosteroids as well as the advanced nature of the gastrointestinal sarcoidosis.Furthermore this case has the unique features of emphysematous lung changes and pancytopenia which are uncommon with sarcoidosis.

Pneumatosis cystoides intestinalis associated with toxic epidermal necrolysis: A case report

Toxic epidermal necrolysis(TEN) is a severe adverse drug reaction, which is characterized by erythema, blisters, and/or erosions of the mucous membranes and skin, but intestinal involvement is rare. In contrast, pneumatosis cystoides intestinalis(PCI) is a rare condition associated with a wide variety of underlying diseases, but to date no patient has presented with PCI associated with TEN. A 55-year-old man was admitted to intensive care unit for treatment of TEN caused by phenobarbital. On day 8 after admission, he presented with progressive abdominal distention and hypotension. Computed tomography(CT) showed gas in the superior mesenteric vein and air filled cysts in the walls of the small intestine. He was suspected of having septic shock due to PCI. As there were no indications of bowel ischemia or necrosis, the patient was managed conservatively with antibiotics and oxygen therapy. On day 10 after admission, he was weaned off catecholamines, with CT on day 11 showing complete resolution of gas in the superior mesenteric vein and air filled cysts. To our knowledge, this article describes the first patient presenting with PCI associated with TEN.

Rare etiology of colonic intussusception involving an adult with emphysematous cystic enteropathy:A case report and review of literature

BACKGROUND Pneumatosis cystoides intestinalis(PCI),characterized by a collection of gas-filled cysts in the intestinal wall,is an uncommon but well-known condition in gastroenterology.Abdominal pain is the most frequent symptom associated with PCI.Intussusception represents a potential cause of recurrent abdominal pain or emergency presentation.However,the occurrence of colonic intussusception secondary to PCI is very unusual in adulthood.CASE SUMMARY A 52-year-old male,known with idiopathic PCI,presented seventeen months after initial diagnosis with a new right upper quadrant pain.A computed tomographyscan demonstrated a colonic intussusception at the hepatic flexure.PCI did not progress compared with initial investigation.The patient underwent an emergency right hemicolectomy.CONCLUSION Resection was recommended in this case because PCI proved to be persisting with no identified curable cause.Surgery allowed to address the underlying pathology,the potential relapse of intussusception,and the likely cause of recurrent abdominal pain,either invagination or PCI itself.

Combinative approach of transzonular triamcinolonemoxifloxacin and perioperative drops to minimize postoperative complications of cataract surgery

AIM: To investigate the effectiveness of combinationtherapy with transzonular triamcinolone-moxifloxacin andconventional perioperative drops in reducing postoperativecomplications of cataract surgery. METHODS: Electronic medical records of cataractsurgery patients (single surgeon) were reviewed fromJanuary 2018 to September 2021. The rate of postoperativecomplications including prolonged and/or recurrentpostoperative inflammation, endophthalmitis, cystoid macularedema (CME), and intraocular pressure (IOP) was comparedbetween the patients receiving combinative therapy andpatients receiving drops only. RESULTS: Totally 596 patients and 1057 eyes(Combinative-Therapy group 493 and Drop-Only group 564)were included in this study. Using combination therapyreduced the relative risk of postoperative inflammationby 26.9% (16.6% Combinative-Therapy vs 22.7% Drop-Only, P=0.013). The incidence of endophthalmitis was 0in Combinative-Therapy group vs 0.5% in Drop-Only group(relative risk reduction 100%), although not statisticallysignificant (P=0.10). The incidence of severe IOP spikeswas not significantly different between Combinative-Therapy (2.4%) and Drop-Only (1.6%) groups (P=0.33).The relative risk of postoperative CME was 51.4% less inthree months follow up visit in Combinative-Therapy group,although not statistically significant (P=0.07). The visualoutcome 1-month postop. (best corrected visual acuity) wassignificantly better in Combinative-Therapy (logMAR 0.10)compared to Drop-Only (logMAR 0.14) groups (P=0.02) whilethe baseline visual acuity was not significantly different. CONCLUSION: The combinative approach oftranszonular triamcinolone-moxifloxacin plus perioperativeeyedrops is an effective method to minimize postoperativeinflammation, with better visual outcomes. It couldpotentially reduce the risk of postoperative endophthalmitisand CME (near-significant P-values;larger studies couldanalyze better considering low incidence).

A systematic analysis of pneumatosis cystoids intestinalis

AIM:To increase the understanding,diagnosis and treatment of pneumatosis cystoides intestinalis(PCI)and to find the characteristics and potential cause of the disease in China.METHODS:We report here one case of PCI in a 70-year-old male patient who received a variety of treatment methods.Then,we systematically searched the PCI eligible literature published from an available Chinese database from May 2002 to May 2012,including CBM,CBMDisc,CMCC,VIP,Wanfang,and CNKI.The key words were pneumatosis cystoides intestinalis,pneumatosis,pneumatosis intestinalis,pneumatosis coli and mucosal gas.The patients' information,histories,therapies,courses,and outcomes were reviewed.RESULTS:The study group consisted of 239 PCI cases(male:female = 2.4:1)from 77 reported incidents.The mean age was 45.3 ± 15.6 years,and the median illness course was 6 mo.One hundred and sixty patients(66.9%)were in high altitude areas.In addition,43.5%(104/239)of the patients had potential PCI-related disease,and 16.3% had complications with intestinal obstruction and perforation.The most common symptom was abdominal pain(53.9%),followed by diarrhea(53.0%),distention(42.4%),nausea and vomiting(14.3%),bloody stool(12.9%),mucous stool(12.0%)and constipation(7.8%).Most multiple pneumocysts developed in the submucosa of the colon(69.9%).The efficacy of the treatments by combined modalities,surgery,endoscopic treatment,conservative approach,oxygen,and antibiotics were 100%,100%,100%,93.3%,68.3% and 26.3%,respectively.CONCLUSION:PCI can be safely managed by conservative treatments,presents more frequently in males,in the large bowel and submucosa,than in females,in the small intestine and subserosa.High altitude residence maybe associated with the PCI etiology.

Does massive intraabdominal free gas require surgical intervention?

We describe a rare case of an 81-year-old man who presented with severe epigastralgia. A chest radiograph showed massive free gas bilaterally in the diaphragmatic spaces. Computed tomography(CT) scan also showed massive free gas in the peritoneal cavity with portal venous gas. We used a wait-andsee approach and carefully considered surgery again when the time was appropriate. The patient received conservative therapy with fasting, an intravenous infusion of antibiotics, and nasogastric intubation. The patient soon recovered and was able to start eating meals 4 d after treatment; thus, surgical intervention was avoided. Thereafter, colonoscopy examination showed pneumatosis cystoides intestinalis in the ascending colon. On retrospective review, CT scan demonstrated sporadic air-filled cysts in the ascending colon. The present case taught us a lesson: the presence of massive intraabdominal free gas with portal venous gas does not necessarily require surgical intervention. Pneumatosis cystoides intestinalis should be considered as a potential causative factor of free gas with portal venous gas when making the differential diagnosis.

Concurrent removal of intravitreal lens fragments after phacoemulsification with pars plana vitrectomy prevents development of retinal detachment

AIM: To evaluate the outcomes of "concurrent vitrectomy" to retrieve dislocated lens fragment during phacoemulsification.METHODS: In a retrospective, observational case series, data of patients who underwent "concurrent" pars plana vitrectomy(PPV) for dislocated lens fragments between the period 2000 and 2008 were reviewed. Data collected included patient demographics, pre-operative visual acuity, intra-operative occurrence of retinal breaks, duration of follow up, post-operative intraocular pressure, final best-corrected visual acuity(BCVA),presence of cystoid macular edema(CME) and occurrence of rhegmatogenous retinal detachment(RRD).· RESULTS: A total of 58 eyes of 58 patients were included in the study. At 12 mo the mean postoperative BCVA was log MAR 0.17(20/30) with a range of log MAR0 to 0.69(20/20 to 20/100), with 96.6%(56/58) of patients showing post- operative improvement in visual acuity(P =0.005). None of the patients developed postoperative retinal detachment, endophthalmitis or non-resolving uveitis at 12 mo.CONCLUSION: Our study results suggest concurrent PPV for retained lens fragments after cataract surgery is beneficial and may decrease the risk of glaucoma and prevent development of RRD.

Evaluation of systemic risk factors in different optical coherence tomographic patterns of diabetic macular edema

AIM： To elucidate the relationship between systemic risk factors and different patterns of diabetic macular edema（DME） determined with optical coherence tomography（OCT）. METHODS： In this cross-sectional study, DME was classified by OCT as diffuse retinal thickness（DRT）, cystoid macular edema（CME） and serous retinal detachment（SRD） and the relationship between the systemic risk factors and DME patterns was evaluated. RESULTS： Of the 57 patients with DME, 21（36.8%） had DRT, 24（42.1%） had CME and 12（21.0%） had SRD. Microor macro-albuminuria was significantly higher in the DRT pattern（61.9%） compared with the SRD（50.0%） and CME patterns（25.0%; P=0.040）. Hemoglobin A1 c（Hb A1 c） level was significantly higher and patients were younger in the DRT pattern group（P=0.034, P=0.032）. Best corrected visual acuity was the worst and central macular thickness was the thickest in the CME pattern group. CONCLUSION： Micro-or macro-albuminuria may be more frequent and Hb A1 c level may be higher in patients with DRT. These patients are also seen to be younger than patients with non-DRT.

Insights into the pathogenesis of cystoid macular edema: leukostasis and related cytokines

Cystoid macular edema(CME) is the abnormal collection of intraretinal fluid in the macular region, especially in the inner nuclear and outer plexiform layers. CME leads to severe visual impairment in patients with various retinal diseases, such as diabetic retinopathy, retinal vascular occlusion, choroidal neovascularization, and uveitis. Although various retinal conditions lead to CME, a shared pathogenesis of CME is involved in these diseases. Accordingly, the pathogenesis of CME based on vasogenic mechanisms is first discussed in this review, including vascular hyperpermeability, leukostasis, and inflammation. We then describe cytotoxic mechanisms based on retinal Müller cell dysfunction. This comprehensive review will provide an understanding of the pathogenesis of CME for potential therapeutic strategies.

Comparison of topical nepafenac 0.1% with intravitreal dexamethasone implant for the treatment of Irvine-Gass syndrome

AIM: To compare safety and efficacy of intravitreal dexamethasone(IVD) implant with topical nepafenac(TN) 0.1% in previously untreated Irvine-Gass syndrome(IGS) in clinical practice. METHODS: This was a retrospective study of 62 eyes with IGS after phacoemulsification with posterior chamber intraocular lens(IOL) implantation. None of the patients used treatment before IVD or TN. Best-corrected visual acuity(BCVA) with Early Treatment Diabetic Retinopathy Study chart(ETDRS), slit-lamp, intraocular pressure(IOP) measurement, fundus examination, spectral-domain optical coherence tomography(OCT) and fundus florescein angiography were performed to all subjects at baseline, 1, 3 and 6 mo. RESULTS: The mean BCVA of the IVD group was 49.3±6.8, and the mean BCVA of the TN group was 32.9±7.3 ETDRS letters in post-treatment month 6. The mean central macular thickness(CRT) of IVD group was 266.6±53.5 μm and the mean CRT of TN group was 364.9±56.3 μm in posttreatment month 6. Baseline BCVA has correlation with final BCVA in TN group however there was no correlation between baseline BCVA and final BCVA in IVD group. CONCLUSION: IVD is found to be better than TN in controlling pseudophakic macular edema and improving visual acuity. IVD group also has significantly lower CRT however IOP is not significantly different between two groups in post-treatment month 6.

Comparative study of the efficacy and safety of bromfenac, nepafenac and diclofenac sodium for the prevention of cystoid macular edema after phacoemulsification

AIM： To compare the efficacy, tolerability and safety of bromfenac 0.09%, nepafenac 0.1% or diclofenac 0.1% for the prophylaxis of the cystoid macular edema（CME） after phacoemulsification. METHODS： Group sequential observational comparative study. After phacoemulsification, patients received two months for topical treatment of either diclofenac sodium, bromfenac or nepafenac. All patients received concomitant topical tobramycin 0.3% and topical prednisolone 1%. We measured CME using optical coherence tomography（OCT） central foveal thickness, macular thickness and total macular volume. RESULTS： We enrolled 243 patients from January to June 2015, and 35% received diclofenac, 32.9% bromfenac and 32.1% nepafenac. When we compared pre-operative to three weeks to two months, bromfenac was more effective in reducing foveal volume（21.3 and 35.4 mm3, respectively）, compared with the diclofenac（1.3 and 11.5 mm3, respectively）, and the nepafenac group, became more edematous 6.4 and 5.3, respectively. Totally 133 patients completed the post-surgical satisfaction questionnaire. Patients complained of eye stickiness in 13.8% whom we gave nepafenac, versus 10.3% whom we gave diclofenac sodium, and in 0 whom we gave bromfenac. CONCLUSION： Bromfenac is the best tolerated and is more effective than diclofenac and nepafenac in reducing CME after phacoemulsification.

Results of intravitreal dexamethasone implant 0.7 mg (Ozurdex^(█)) in non-infectious posterior uveitis

· AIM: To evaluate the safety and efficacy of dexamethasone implant in patients with non-infectious posterior uveitis with cystoid macular edema(CME).·METHODS: Retrospective analysis of patients reports with CME secondary to non-infectious uveitis treated with dexamethasone implant. Data included type of posterior uveitis, any systemic immunosuppressive therapy, Early Treatment Diabetic Retinopathy Study(ETDRS) best-corrected visual acuity(BCVA), central macular thickness(CMT) on optical coherence tomography(OCT) and signs of intraocular inflammation at baseline and then at 2wk postoperatively and monthly thereafter. Follow-up is up to 10 mo. Any per-operative and post-operative complications were recorded.·RESULTS: Six eyes of 4 patients with CME due to non-infectious posterior uveitis treated with dexamethasone implant. Diagnosis included idiopathic panuveitis, birdshot chorioretinopathy and idiopathic intermediate uveitis. At baseline mean ETDRS BCVA was63 letters and mean CMT 556 μm at 2wk postoperatively mean ETDRS BCVA improved to 70 letters and mean CMT decreased to 329 μm. All eyes showed clinical evidence of decreased inflammation. The duration of effect of the implant was 5 to 6mo and retreatment was required in 2 eyes. Two patients required antiglaucoma therapy for increased intraocular pressures.·CONCLUSION: In patients with non-infectious posterior uveitis dexamethasone implant can be a short-term effective treatment option for controlling intraocular inflammation.

Combined Descemet stripping automated endothelial keratoplasty and intravitreal dexamethasone implant for concomitant pseudophakic bullous keratopathy and cystoid macular edema

Dear Editor,Endothelial cell density decreases with age and in various ocular conditions,including corneal endotheliitis,uveitis,pseudoexfoliation syndrome,and birth injury(1)The reduction of endothelial cell density is exacerbated over time after intraocular surgery(1)Descemet stripping automated endothelial keratoplasty(DSAEK)is considered the primary procedure for patients with only endothelial dysfunction.

IOL repositioning using iris sutures: a safe and effective technique

This retrospective non-comparative consecutive case series study was conducted at Azienda Ospedaliera Universitaria Careggi, Florence, Italy and describes a useful intraocular lens(IOL) repositioning technique using iris sutures. In our study, 41 consecutive cases of posteriorly dislocated IOLs were surgically treated between January 2015 and May 2017. Six of the cases were post-traumatic luxations, and 20 patients had pseudoexfoliation syndrome. All the patients underwent pars plana vitrectomy and same IOL repositioning using iris sutures. The mean followup was 12.2 mo. The mean preoperative best corrected visual acuity(BCVA) was 0.10±0.15 logMAR, whereas the mean postoperative BCVA was 0.08±0.14 logMAR. The mean postoperative BCVA did not change significantly from the preoperative BCVA. The final mean spherical equivalent was-0.44±0.49 SD. Three lenses(7.31%) were found tilted during post-operative follow-up. Two eyes(4.87%) had postoperative cystoid macular edema. No eyes had endophthalmitis, hypotony, retinal or choroidal detachment. The iris fixation technique seems to be a safe and valid option for the management of dislocated IOLs.

Efficacy of topical dorzolamide 2% in diabetic cystoid macular edema

AIM:To study the effect of topical dorzolamide 2%on macular thickness reduction in diabetic cystoid macular edema(CME).METHODS:This was a prospective,non-randomized,open study including eyes with diabetic macular edema(DME).All eyes received topical dorzolamide 2%three times daily for one month.Changes in best-corrected visual acuity(BCVA),and central macular thickness(CMT)by optical coherence tomography were evaluated at 1 wk,1,and 3 mo post-treatment.RESULTS:Ninety-three eyes(84 patients)were included.Mean±SD(log MAR)BCVA improved significantly from 1.08±0.26 pretreatment to 0.66±0.24 at 1 mo and 0.87±0.26 at 3 mo post-treatment(P<0.001 both).The mean±SD CMT was significantly reduced from 535.27±97.4μm at baseline to 357.43±125.8μm at 1 mo and 376.23±114.5μm at 3 mo post-treatment(P<0.001 both).No significant ocular or systemic side effects were recorded.CONCLUSION:Topical dorzolamide 2%results in significant improvement of mean BCVA and reduction of mean CMT at 3 mo post-treatment.It can be used as an effective,affordable,and safe therapy for treatment of nonrefractory diabetic CME.

Effect of nepafenac 0.1% on retinal thickness after cataract surgery in patients without risk factors for cystoid macular edema

AIM:To evaluate the effect of topical preoperative nepafenac 0.1%treatment on postoperative macular edema using optical coherence tomography(OCT)after uncomplicated cataract surgery.METHODS:Ninety eyes of 90 patients without any risk factors were included in the study.The patients were assigned to three groups:group 1,treated with topical prednisolone acetate 1%;group 2,treated with topical nepafenac 0.1%in addition to prednisolone acetate(1%);and group 3,those who started receiving nepafenac 0.1%treatment 3 d prior to surgery and continued the treatment postoperatively in addition to prednisolone acetate(1%).Central retinal thickness(CRT)and macular volume values were recorded using OCT at weeks 3 and 6.RESULTS:The increases in macular volume in the central 1 mm area after 3 and 6 wk were significantly lower in patients who used prophylactic topical nepafenac preoperatively(group 3)compared with those in group 1(P=0.028 and 0.008,respectively).No significant differences in the increase in macular volume and CRT were noted between groups 2 and 3(P>0.05).In group 1,the increases in macular volume in the central 3 mm area at weeks 3 and 6 were significantly higher than that in group 2 and 3(3rd week,P=0.004;6th week,P=0.005).CONCLUSION:Nepafenac 0.1%treatment in addition to topical steroids after uncomplicated cataract surgery reduce the increase in macular volume in the early postoperative period.

Via pars plana anterior iris enclavation IOL fixation

AIM:To describe a via pars plana anterior iris enclavation intraocular lens(IOL)fixation techniqueMETHODS:A total of 35 consecutive aphakic vitrectomised patients(average age 71.12±10.12 y)underwent pars plana vitrectomy(PPV)and via pars plana anterior iris enclavation IOL fixation.RESULTS:The mean preoperative best corrected visual acuity(BCVA)was 0.11±0.14 log MAR,the mean postoperative BCVA was 0.07±0.11 log MAR.The preoperative mean spherical equivalent was 7.22±4.21 D.The final mean spherical equivalent was-0.25±0.15 D.No eyes had hypotony,retinal or choroidal detachment or endophthalmitis.CONCLUSION:This technique may be a safe and useful in the case of aphakia,and a prospective study would be useful to confirm this findings.

Foveal regeneration after resolution of cystoid macular edema without and with internal limiting membrane detachment:presumed role of glial cells for foveal structure stabilization

AIM: To document with spectral-domain optical coherence tomography the morphological regeneration of the fovea after resolution of cystoid macular edema(CME) without and with internal limiting membrane(ILM) detachment and to discuss the presumed role of the glial scaffold for foveal structure stabilization. METHODS: A retrospective case series of 38 eyes of 35 patients is described. Of these, 17 eyes of 16 patients displayed foveal regeneration after resolution of CME, and 6 eyes of 6 patients displayed CME with ILM detachment. Eleven eyes of 9 patients displayed other kinds of foveal and retinal disorders associated with ILM detachment. RESULTS: The pattern of edematous cyst distribution, with or without a large cyst in the foveola and preferred location of cysts in the inner nuclear layer or Henle fiber layer(HFL), may vary between different eyes with CME or in one eye during different CME episodes. Large cysts in the foveola may be associated with a tractional elevation of the inner foveal layers and the formation of a foveoschisis in the HFL. Edematous cysts are usually not formed in the ganglion cell layer. Eyes with CME and ILM detachment display a schisis between the detached ILM and nerve fiber layer(NFL) which is traversed by Müller cell trunks. ILM detachment was also found in single eyes with myopic traction maculopathy, macular pucker, full-thickness macular holes, outer lamellar holes, and glaucomatous parapapillary retinoschisis, and in 3 eyes with Müller cell sheen dystrophy(MCSD). As observed in eyes with MCSD, cellophane maculopathy, and macular pucker, respectively, fundus light reflections can be caused by different highly reflective membranes or layers: the thickened and tightened ILM which may or may not be detached from the NFL, the NFL, or idiopathic epiretinal membranes. In eyes with short single or multiple CME episodes, the central fovea regenerated either completely, which included the disappearance of irregularities of the photoreceptor layer lines and the reformation of a fovea externa, or with remaining irregularities of the photoreceptor layer lines. CONCLUSION: The examples of a complete regeneration of the foveal morphology after transient CME show that the fovea may withstand even large tractional deformations and has a conspicuous capacity of structural regeneration as long as no cell degeneration occurs. It is suggested that the regenerative capacity depends on the integrity of the threedimensional glial scaffold for foveal structure stabilization composed of Müller cell and astrocyte processes. The glial scaffold may also maintain the retinal structure after loss of most retinal neurons as in late-stage MCSD.

Postoperative Acute Bilateral Irvine-Gass Syndrome following Uncomplicated Phacoemulsification Surgery with Trifocal IOL—Two Case Reports

The case studies are about atypical bilateral, postoperative Cystoid Macular Edema (CME) in two patients who underwent bilateral uncomplicated pha- coemulsification surgery with a trifocal Intraocular Lens (IOL). In postoperative follow-up, both the cases presented with complaints of bilateral blurring of vision. Irvine-Gass syndrome has been diagnosed after evaluation of the retina by fundoscopy and OCT macula. Posterior subtenon steroid injection has been prescribed and given. Regular OCT examinations indicated substantial ede- ma improvement. Subsequent improvement in visual acuity was also noted in both cases. Cystoid macular edema can happen in any case irrespective of the quality of IOL. The visual outcome is satisfactorily responsive towards steroid medication.