Fetal pleural effusion, a nonspecific accumulation of fluid in the pleural space, is an uncommon anomaly which can be associated with aneuploidy and a range of other structural malformations or genetic syndromes. Spontaneous resolution is not rare and confers a good prognosis. Perinatal outcome is better for those fetuses without hydrops than those presenting with hydrops. A detailed review of the literature indicates that, for fetuses with persistent effusions, in utero intervention (repeated thoracocentesis, intrauterine shunting and pleurodesis) may improve the chances of survival.

Fetal pleural effusion.

New treatment of early fetal chylothorax.

The progress of a fetal severe pleural effusion at mid-trimester is extremely poor. We encountered a fetus that developed a severe left pleural effusion at 21 weeks of gestation. The pleural effusion was removed by thoracocentesis at 22 weeks. Cytology revealed abundant lymphocytes, suggesting chylothorax. However, a reaccumulation of pleural effusion with hydrops was subsequently noted, and a thoracoamniotic shunt with double-basket catheters was installed at 23 weeks. The pleural effusion decreased after 24 weeks and completely disappeared at 26 weeks. At 40 weeks of gestation, a female infant was born by vaginal delivery, with no evidence of pleural effusion. We would like to stress that thoracoamniotic shunt with double-basket catheters in the second trimester is effective for pleural effusion with hydrops.

Thoracoamniotic shunting with double-basket catheters for fetal chylothorax in the second trimester.

PURPOSE
This study aimed to investigate the effects of commercial tattoo inks used in corneal tattooing on conjunctival microbiota.


METHOD
This prospective case control study consisted of 125 participants divided in the following three groups: 35 patients with corneal tattoos, 40 patients with corneal leukoma, and 50 healthy subjects. Corneal tattooing was performed in all the cases in this study using a tattoo pen machine and commercial tattoo ink. A total of 500 cultures were taken from 250 eyes of 125 individuals on chocolate and sheep blood agar. Bacteriological samples were taken from the inferior eyelid conjunctiva using a sterile cotton swab. Without any contact elsewhere, the swabs were smeared on bedside chocolate agars and 5% sheep blood agar.


RESULTS
In tattooed eyes, bacterial growth was detected in 42.9% of the chocolate and sheep blood agar samples. In other healthy eyes of patients with corneal tattoos, 54.5% bacterial growth on chocolate agar and 57.1% on sheep blood agar were detected. No statistical difference was detected in the conjunctival microbiota of chocolate and sheep blood agar (p = 0.254, p = 0.134, respectively) in the tattooed eyes compared to the other eye of the individual. No statistically significant difference was found in terms of bacterial growth in tattooed, leukoma, or healthy eyes on chocolate and sheep blood agar (p = 0.408, p = 0.349). The growth rate of Staphylococcus epidermidis decreased by 33.3% (from 12 to 8) on chocolate agar in 35 tattooed eyes, and it decreased by 28.5% (from 14 to 10) on sheep blood agar, while gram-negative bacteria Brevundimonas diminuta, Acinetobacter lwofii, and Psychrobacter faecalis were detected in three patients.


CONCLUSION
Corneal tattooing using commercial dye does not affect conjunctival microbiota. In the past 3 years, 120 patients have been tattooed with commercial tattoo ink in Istanbul Medeniyet University Göztepe Training and Research Hospital. No complications related to infection were found in the 3-year follow-up. The gram-negative bacteria detected in the healthy control group and tattooed eyes were bacteria found on normal skin or in the respiratory tract. Although some gram-negative bacteria do not cause infection, careful eye examination, follow-up, and culture are required in suspicious cases.

Does corneal tattooing affect the conjunctival microbial flora?

This fetus had ascites disproportionate to hydrops, with peritoneal calcification and dense bowel loop adhesions, which were suggestive of meconium peritonitis. Literature search revealed reports of 25 cases of meconium peritonitis with nonimmune hydrops fetalis to date. Of these cases, the cause of peritonitis with hydrops could be elucidated in only nine cases. Of these, six cases had parvovirus B19 infection, one case each had maternal cytomegalovirus and hepatitis B infection and one case was associated with chorioangioma of placenta. The etiology of hydrops is not known in other cases. In our case, the mother was negative for HbsAg, IgM antibodies for cytomegalovirus and had negative PCR for parvovirus B19. In addition to hydrops and meconium peritonitis, this fetus had ambiguous external genitalia with female internal genitalia, female karyotype, anal atresia and unilateral renal agenesis. These associated findings suggested the possibility of URSM sequence in the fetus. We could not demonstrate the presence of fistula owing to dense bowel adhesions. URSM sequence is thought to arise due to incomplete division of the primitive cloaca and lack of breakdown of the cloacal membrane. Deficiency of mesoderm in the caudal region of the embryo has been suggested as the basic cause for URSM sequence. The unusual finding in this case was the presence of a normal anus. Sudheer et al. have reported a similar case with URSM sequence associated with a normal anal opening (Sudheer and D’Souza, 2001). We propose that in this case the intestinal obstruction owing to high anal atresia must have led to leakage of meconium into the peritoneal cavity leading to meconium peritonitis, fetal hydrops with ascites, adhesion of bowel loops and peritoneal calcification. Although intestinal obstruction is known to cause meconium peritonitis and URSM sequence is usually associated with intestinal obstruction, there are no reports in literature of these two features occurring together. This is the first report of a case of URSM sequence presenting as nonimmune hydrops fetalis. This may have implications in management of cases with nonimmune hydrops fetalis.

Prenatal therapy for primary fetal hydrothorax in a dichorionic twin pregnancy.

We present a case of dichorionic diamniotic twin pregnancy in which one of the fetuses was found to have a major pleural effusion at 15 weeks of gestation. A single-needle pleural fluid aspiration was performed at 15 and 16 weeks, but the fluid reaccumulated quickly after each procedure and at 16 weeks, the fetus was found to become progressively hydropic. A shunt was then successfully inserted at 17 weeks, which is the earliest gestation reported so far in the literature for such a procedure to treat isolated hydrothorax. Because we felt that the fetus would be too small for a classical double-pigtail pleuroamniotic shunt, we used a multilength double-pigtail bladder stent (Harrison drain; Cook; Spencer; Indiana; USA) via a 13-gauge echo tip trocar. This shunt could be used for both singleton and twin pregnancies presenting with fetal pleural effusion from as early as 16 to 17 weeks to prevent the development of fetal hydrops and polyhydramnios and subsequent premature delivery. Treatment at this stage of gestation would also minimize the risk of lung hypoplasia, which is the main clinical issue when shunts are inserted after 24 weeks.

Successful early in utero management of fetal hydrothorax in a twin pregnancy.

Postoperative endophthalmitis caused by Rothia mucilaginosa, a gram-positive, coagulase-negative Micrococcaceae of the oropharyngeal flora, is rare and all previously reported intraocular implant-related cases have resulted in evisceration. R. mucilaginosa endophthalmitis has also not been described with any glaucoma implant device. Here, the authors report a case of subacute R. mucilaginosa endophthalmitis after phacoemulsification with implantation of an intraocular lens and the iStent inject (Glaukos). The infection was managed with intravitreal antibiotic injections, pars plana vitrectomy, and intraocular lens and iStent explantations. This was followed by a second pars plana vitrectomy and silicone oil tamponade for a tractional retinal detachment. Nine months after the initial presentation, vision in the affected eye was partially preserved, and the globe remained intact. R. mucilaginosa infections are associated with grave outcomes due to biofilm formation on infected implants, and as such, removal of infected implants is advised.

Rothia Mucilaginosa Endophthalmitis Associated With iStent Inject Implantation.

ABSTRACT Transient visual obscurations (TVOs) represent brief ischaemic events of the optic nerve. These most commonly occur in the setting of raised intracranial pressure or more localised aetiologies within the orbit that result in decreased perfusion pressure. Transient vision loss has rarely been associated with pituitary tumours or optic chiasm compression, but details are lacking. We describe classic TVOs that completely resolved following resection of a pituitary macroadenoma causing chiasmal compression with a relatively normal eye examination. Clinicians should consider neuro-imaging in patients with TVOs and a normal evaluation.

Transient Visual Obscurations Without Papilloedema as the Heralding Symptom of Chiasmal Compression

Lacrimal sac squamous cell carcinoma is a rare but life-threatening disease that is often a delayed diagnosis secondary to difficulty in differentiating from other causes of dacrocystitis and acquired nasolacrimal duct obstruction. Chronic inflammation, including that of an underlying autoimmune disease, prior instrumentation, and poor wound healing, may be risk factors in the development to lacrimal sac squamous cell carcinoma. The authors present the first case of lacrimal sac squamous cell carcinoma associated with antineutrophil cytoplasmic antibody-associated vasculitis and immunoglobulin G4 positivity. Rather than an overlap syndrome between antineutrophil cytoplasmic antibody-associated vasculitis and immunoglobulin G4-related disease, high immunoglobulin G4 positivity may be considered an inflammatory marker of disease severity in the setting of antineutrophil cytoplasmic antibody-associated vasculitis and underlying malignancy. Inflammation-mediated tumorangiogenesis should be considered in the development of malignancy and red flags of chronic uncontrolled inflammation should warrant a lower threshold for further workup.

Antineutrophil Cytoplasmic Antibody-Associated Vasculitis With Immunoglobulin G4 Involvement in Lacrimal Sac Squamous Cell Carcinoma.

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Papers

Successful early in utero management of fetal hydrothorax in a twin pregnancy.

Rothia Mucilaginosa Endophthalmitis Associated With iStent Inject Implantation.

Transient Visual Obscurations Without Papilloedema as the Heralding Symptom of Chiasmal Compression

Antineutrophil Cytoplasmic Antibody-Associated Vasculitis With Immunoglobulin G4 Involvement in Lacrimal Sac Squamous Cell Carcinoma.