Plaque brachytherapy is a well-accepted modality to manage selected cases of ocular melanoma. Although this modality provides validated oncologic and quality of life benefits, severe complications and adverse events can occur. This article reviews complications and adverse events of plaque brachytherapy, including scleral necrosis, strabismus, cataract, glaucoma, and retinopathies as well as management of these conditions. For practicing oncologists and ophthalmologists, these complications are important to understand, identify, and treat. Additionally, an understanding of common complications of brachytherapy should influence the decision of pursuing it as a treatment option.

Diagnosing culture-proven endophthalmitis is complicated by the insufficient yield of intraocular samples and the variety of etiologies which mimic true endophthalmitis. In cases of impending vision loss where vitreous biopsy cannot provide a definitive diagnosis, transvitreal retinochoroidal biopsy can be an effective next step. Our case is a 48-year-old male with B-cell acute lymphoblastic leukemia that presented with counting fingers vision, redness, and tearing of the left eye. Exam showed cell and flare with hypopyon as well as dense vitritis. The patient underwent diagnostic pars plana vitrectomy and vitreous culture was negative at the time. Flow cytometry demonstrated no malignant cells. However, the patient's vision and mental status continued to clinically decline despite being started on intravitreal and systemic antibiotic and antifungal therapy. Neuroimaging revealed rim-enhancing brain lesions. Transvitreal retinochoroidal biopsy was performed in an elevated area of the retina. The biopsy helped rule out malignancy and showed acute-angle, septate, branching hyphae characteristic of Aspergillus fumigatus. Ultimately, the vitreous biopsy, cultures, and a biopsy from the left frontal lobe brain abscess all confirmed this diagnosis as well. Transvitreal retinochoroidal biopsy can play a role in the diagnosis of a case of posterior uveitis and can be particularly effective in diagnosing a fungal endophthalmitis.

High frequency percussive ventilation (HFPV) is a method of ventilation that delivers biphasic percussive microvolumes in a time-cycled, pressure limited fashion. The goal is to increase recruitment of alveoli burdened by secretions or atelectasis to improve gas exchange for those failing conventional ventilation. HFPV has been utilized in the acute inhalation injury population; however, its use has spread to the medical community as a rescue method in acute respiratory distress (ARDS) patients. CASE PRESENTATION:A 24-year-old male with a past medial history of type 2 diabetes, obstructive sleep apnea, and obesity presented to the Emergency Department for worsening epigastric pain, nausea, and vomiting. He was ill appearing with diffuse abdominal pain, guarding, and rebound. Pertinent labs included a lipase of 3,600 U/L and triglycerides of 1,700 mg/dL. Computed tomography (CT) of the abdomen and pelvis revealed severe pancreatic edema with a non-enhancing pancreatic tail concerning for necrosis. He was admitted to the Intensive Care Unit and started on crystalloid infusion and continuous insulin. He developed progressive tachypnea and ultimately required intubation for severe hypoxemia. He further decompensated with worsening fevers and hypotension, requiring initiation of broad-spectrum antibiotics and vasopressors. Despite the insulin infusion, the patient's triglycerides increased to 9,500 mg/dL and he was started on therapeutic plasma exchange. Echocardiogram did not reveal evidence of left ventricular dysfunction. Chest x-ray showed worsening bilateral pulmonary infiltrates suggestive of ARDS. Despite a lung-protective, volume-controlled method of ventilation, the patient continued to exhibit high plateau and driving pressures. Given his significantly distended abdomen and high bladder pressures, he was unable to tolerate prone positioning. PaO2/FiO2 ratio (P/F ratio) was as low as 91. Subsequently he underwent cannulation for veno-venous extracorporeal membrane oxygenation (VV-ECMO). His secretion burden remained high and CT chest revealed dense atelectasis. He was then switched to HFPV for better secretion management and improvement in oxygenation. After 48 hours of HFPV, he had significant improvement in his atelectasis on CT chest and P/F ratio. After eight days, he was decannulated from VV-ECMO and later extubated. DISCUSSION: Our patient experienced known severe complications from hypertriglyceride-induced pancreatitis. His ARDS improved robustly with HFPV with VV-ECMO support. In centers with experience with this type of ventilation, it can be a powerful tool for patients suffering from inhalation injury, high-secretion pneumonias, and ARDS.CONCLUSIONS: Though HFPV does not have a dense volume of data supporting its use in ARDS, in the appropriately selected patient it can provide a safe and efficient way of improving lung recruitment, gas exchange, and potentially outcomes.

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