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colonized with Aspergillus species These may be found by incidental radiographic studies but may also present with significant hemoptysis The most effective therapy for symptomatic aspergilloma remains surgical resection Chronic necrotizing aspergillosis is a relatively rare disease seen in patients with some degree of immunocompromise and presents with a protracted course compared with the more common acute invasive form of the disease Fibrosis and cavity formation may be prominent and the response to antifungal therapy is not clear at present, although it would be reasonable to institute therapy targeting Aspergillus Surgical intervention may be necessary but complications are common Life-threatening invasive aspergillosis most commonly occurs in profoundly immunodeficient patients, particularly in patients following hematopoietic stem cell transplants and in those with prolonged, severe neutropenia Patients with very advanced HIV disease may also be at risk for invasive aspergillosis, particularly if they have other risk factors for the disease Pulmonary disease is most common, with patchy infiltration leading to a severe necrotizing pneumonia Invasive sinus disease also occurs There is often tissue infarction as the organism grows into blood vessels; clues to this are the development of pleuritic chest pain and elevation of serum LDH At any time, there may be hematogenous dissemination to the central nervous system, skin, and other organs Early diagnosis and reversal of any correctable immunosuppression are essential Blood cultures have very low yield In contrast to allergic aspergillosis, serologic tests have low sensitivities for invasive disease; detection of galactomannan by enzymelinked immunosorbent assay (ELISA) has been demonstrated to have acceptable sensitivity and specificity for the diagnosis of invasive disease, though multiple determinations should be done False-positive galactomannan tests have been reported in patients receiving -lactam antibiotics Isolation of Aspergillus from pulmonary secretions does not necessarily imply invasive disease, although its positive predictive value increases with more advanced immunosuppression Therefore, a definitive diagnosis requires demonstration of Aspergillus in tissue or culture from a sterile site Biopsy specimens may show branched septate hyphae but will not invariably grow the organism CT scan of the chest may show characteristics quite suggestive of invasive aspergillosis When severe invasive aspergillosis is considered clinically likely or is demonstrable by laboratory testing, rapid institution of voriconazole, high doses of amphotericin B, or caspofungin may be life-saving (see Additional Reading at the end of the chapter) Voriconazole has been shown to be more effective, improve survival, and be associated with fewer severe side effects than conventional amphotericin B when used as initial therapy in invasive aspergillosis The dosage of voriconazole is 6 mg/kg intravenously twice on the first day, followed by 4 mg/kg twice daily given either intravenously or by mouth Some experts believe that lipid preparations of amphotericin B should be used preferentially in this setting because they are better tolerated and can be given at higher doses Caspofungin acetate, an echinocandin antifungal, has been approved for the treatment of invasive aspergillosis in patients who are refractory to or intolerant of other treatments The drug is given as a 70 mg intravenous loading dose followed by 50 mg intravenously.

Contact lenses are used mostly for correction of refractive errors, for which they provide better optical correction than glasses, as well as for management of diseases of the cornea, conjunctiva, or lids The major types of lenses are rigid (gas-permeable) and soft Rigid lenses are more durable and easier to care for than soft lenses but are more difficult to tolerate Contact lens care includes cleaning and sterilization whenever the lenses are removed and removal of protein deposits as required Sterilization is usually by chemical methods For individuals developing reactions to preservatives in contact lens solutions, preservative-free systems are available All contact lenses can be inserted in the morning and removed at night Soft lenses are also available for extended wear Disposable soft lenses to avoid the necessity for lens cleaning and sterilization are available for daily or extended wear The major risk from contact lens wear is bacterial, amebic, or fungal corneal infection, potentially a blinding condition Such infections occur more commonly with soft lenses, particularly extended wear, for which there is an

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Various surgical techniques are available for the correction of refractive errors, particularly myopia Laser corneal refractive surgery reshapes the mid-portion (stroma) of the cornea with an excimer laser Laser assisted in situ keratomileusis (LASIK) and the surface ablation techniques epithelial LASIK (Epi-LASIK), laser epithelial keratomileusis (LASEK), and photorefractive keratectomy (PRK) each differ according to how access to the stroma is achieved LASIK is most commonly performed, because postoperative visual recovery is rapid and there is little postoperative discomfort, but it is contraindicated if the cornea is relatively thin Visual outcomes are impressive and many

intraoperative examination of excised tissue is particularly valuable in ensuring complete excision so that the risk of recurrence is reduced

Chan FM et al Treatment and outcomes of malignant melanoma of the eyelid: a review of 29 cases in Australia Ophthalmology 2007 Jan;114(1):187 92 [PMID: 17140665] Nemet AY et al Management of periocular basal and squamous cell carcinoma: a series of 485 cases Am J Ophthalmol 2006 Aug;142(2):293 7 [PMID: 16876511]

approximately sevenfold increase in risk of corneal ulceration compared with daily wear Contact lens wearers should be made aware of the risks they face and ways to minimize them, such as avoiding extended-wear soft lenses and maintaining meticulous lens hygiene, including not using tap water or saliva for lens cleaning Whenever there is ocular discomfort or redness, contact lenses should be removed Ophthalmologic care should be sought if symptoms persist

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