Intra-operative use of indocyanine green (ICG) angiography and lymphography has been reported as a valuable adjunct during microsurgical subinguinal varicocelectomy (MSV).1 The development of a video microsurgery platform and fluorescence imaging technology further facilitates identification of testicular arteries and lymphatics. We report the intra-operative imaging of two patients who underwent varicocele repair for grade 3 left varicoceles in February and March 2021 using the new platform.

The operations were performed under three-dimensional (3D) optical magnification images on the television monitors using the video microsurgery platform with VITOM® 3D system (KARL STORZ SE, Tuttlingen, Germany) as previously described.2 A pack of 25 mg ICG (Diagnogreen; Daiichi Sankyo Co, Tokyo, Japan) was dissolved in 10 mL water. Identification of testicular arteries was assisted by ICG angiography with intravenous injection of 2 mL (5 mg) ICG solution. After preservation of the testicular arteries, the differentiation between lymphatics and small veins was facilitated by ICG lymphography performed following intra-parenchymal testicular injection of 0.5 mL (1.25 mg) ICG solution followed by gentle testicular massage.3 The setting of ICG fluorescence imaging consisted of an IMAGE1 S™ 4U RUBINA™ with 4K 3D monitor system (KARL STORZ SE, Tuttlingen, Germany) and a HOPKINS™ Straight Forward Telescope 0° (10-mm diameter/20-cm length) [KARL STORZ SE, Tuttlingen, Germany]. We demonstrate intra-operative ICG angiography of patient 1, a 35-year-old man with primary infertility and oligoasthenoteratozoospermia. The testicular artery appeared green on the overlay image mode with clear simultaneous visualisation of white light microscopy images in the background (Fig 1a and b). In addition to the testicular artery, the small (<1 mm) cremasteric artery could also be identified in the monochromatic mode that further enhanced the contrast (Fig 1c). After successful preservation of the testicular arteries in patient 2, a 28-year-old man with left scrotal pain, two probable lymphatics were identified under white light microscopy (Fig 2a). The strong green colouration seen in the overlay mode after ICG injection unambiguously confirmed the successful preservation of lymphatics in MSV (Fig 2b).

Microsurgical subinguinal varicocelectomy is the standard for varicocele repair with excellent surgical outcomes reported.4 Nonetheless identification of testicular arteries and lymphatics under white light microscopy alone is operator-dependent and remains challenging for novice surgeons. Several adjuncts have been introduced to facilitate artery- and lymphatic-sparing procedures during MSV. One such adjunct is ICG fluorescence imaging.1 In our opinion, the new overlay mode provided by the latest platform is particularly useful for MSV. Without the need to switch between different modes, the combined regular white light image and near-infrared/ICG data allow accurate localisation of even the smallest vessel without ambiguity (Fig 3). Moreover, the display of ICG signal alone in white on a black background in the monochromatic mode maximises contrast and further improves identification of target vessels (Fig 3). We believe the advances of this surgical platform and imaging technology play a role in enhancing patient safety by increasing the success of arterial and lymphatic preservation in MSV.

Concept or design: CL Cho.
Acquisition of data: All authors.
Analysis or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

The authors have disclosed no conflict of interest.

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Patients were treated in accordance with the Declaration of Helsinki. Patients provided written informed consent for the procedures, and verbal consent for publication.

1. Cho CL. Is there any role for indocyanine green angiography in testicular artery preservation during microsurgical subinguinal varicocelectomy? In: Esteves SC, Cho CL, Majzoub A, Agarwal A, editors. Varicocele and Male Infertility: a Complete Guide. Switzerland AG: Springer Nature; 2019: 603-14. Crossref

2. Cho CL, Chu RW. Use of video microsurgery platform in microsurgical subinguinal varicocelectomy with indocyanine green angiography. Surg Prac 2019;23:20-4. Crossref

3. Cho CL, Chiu PK, Chu RW. Preliminary experience with indocyanine green lymphography during microsurgical subinguinal varicocelectomy. Surg Prac 2021;25:207-10. Crossref

4. Zini A. Varicocelectomy: microsurgical subinguinal technique is the treatment of choice. Can Urol Assoc J 2007;1:273-6.

In July 2019, a 54-year-old woman with type 2 diabetes mellitus and suboptimal drug compliance with metformin and gliclazide presented to the emergency department complaining of abdominal pain, progressive weakness, and confusion. Her body temperature was 39.1°C and blood tests revealed serum glucose 29.1 mmol/L; haemoglobin A1c 10.4%; serum glucose 29.1 mmol/L; haemoglobin A1c 10.4%; C-reactive protein 224.3 mg/L; and white cell count 11.9 × 10⁹/L with 92.8% segmented neutrophils; and serum creatinine 437.4 mmol/L. Computed tomography scan of the abdomen and pelvis without contrast revealed a cystic gas-producing liver lesion and diffuse intramural gas dissecting the urinary bladder wall with extension to the left kidney (Fig). A diagnosis was made of acute emphysematous cystitis complicated by liver abscess.

Percutaneous drainage of the liver abscess was performed under ultrasound guidance. Klebsiella pneumoniae, sensitive to meropenem, was cultured from the urine and drained pus. The patient was transferred to the intensive care unit and treated with resuscitation, glycaemic control, and broad-spectrum antibiotics with intravenous meropenem. Meropenem was continued for the initial 7 days and then changed to ceftazidime plus amikacin according to susceptibility testing results. Her symptoms subsided and blood parameters improved gradually. She made an uneventful recovery and was discharged from the hospital on day 20.

Emphysematous cystitis is an uncommon type of infection characterised by gas collections within the bladder wall and lumen. It is usually caused by gas-producing pathogens such as Escherichia coli and Klebsiella pneumoniae.1 Predisposing factors are diabetes, female sex, obstructive uropathy and possibly immunosuppression. Gas is believed to be produced by fermentation of albumin or glucose by the infecting organisms. Emphysematous cystitis combined with liver abscess is rare. The mechanisms of emphysematous cystitis are not well understood. Some reports emphasise that pathogenesis may be related to hematogenous transmission from the liver abscess.2 3 Immunosuppression related to poorly controlled diabetes is another contributing factor.

Clinical presentation of emphysematous cystitis varies. Our patient presented with systemic manifestations of septic shock and severe upper abdominal pain secondary to the liver abscess. She reported no lower urinary tract symptoms. Computed tomography is the best diagnostic modality with its high sensitivity when assessing the extent of gas patterns. Appropriate antibiotic therapy, correction of the underlying disorder, and adequate drainage is the recommended treatment.

Concept or design: Both authors.
Acquisition of data: L Zeng.
Analysis or interpretation of data: L Zeng.
Drafting of the manuscript: L Zeng.
Critical revision of the manuscript for important intellectual content: Q Wang.

Both authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

The authors declared no potential conflicts of interest.

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This study was approved by the Hospital of Chengdu University of Traditional Chinese Medicine Research Ethics Committee. Informed consent was obtained from the patient.

1. Amano M, Shimizu T. Emphysematous cystitis: a review of the literature. Intern Med 2014;53:79-82. Crossref

2. Lai CC. Concomitant emphysematous cystitis and liver abscess. Korean J Intern Med 2018;33:839-40. Crossref

3. Su YC, Chen CC. Emphysematous cystitis complicating Klebsiella pneumoniae liver abscess. Am J Emerg Med 2006,24:256-7.Crossref

We first performed 10-core transperineal prostate biopsy at our institution in 2018. After having acquired the technique and experience, we developed a biopsy protocol that could be modified according to prostate size (Fig): 10 cores for prostate size <30 cc, 16 cores for prostate size 30 to 50 cc, and 20 cores for prostate size >50 cc.

We currently take a 24-core prostate biopsy (Fig d), irrespective of prostate size, to further improve the detection of prostate cancer. There is no gold standard protocol for total number of cores required in any patient; it is dictated by hospital policy, availability of resources, and the experience of the urologist.

This video demonstrates systematic transperineal prostate biopsy.

The instruments used during the procedure comprised an ultrasound machine with long side-fire sensor probe, a bed with two leg supports to facilitate lithotomy position, one disposable biopsy gun, two needles for local anaesthesia, two metal trocars, and eight specimen bottles.

Before the procedure and in the absence of any contraindication, patients are prescribed a single dose per oral 1 g Augmentin and 500 mg ciprofloxacin. One tube of per rectal 4.5 oz Fleet Enema is administered as bowel preparation. Local anaesthetic (EMLA) cream is applied to the patient’s perineum 1 hour before the procedure.

Step 1: the perineum is disinfected with chlorhexidine.

Step 2: 10 mL of 1% lidocaine is injected through each side of the perineum into the periprostatic plane as local anaesthesia, at an angle of 45° and 15 mm away from the anus as shown.

It is vital to maintain the needle parallel to the ultrasound probe to ensure continued visualisation of the needle.

Step 3: a 14-gauge metal trocar is inserted through the right side of the perineum under ultrasound guidance.

Step 4: anterior sector prostate biopsies are taken by tilting an 18-gauge disposable biopsy gun downwards.

It is important not to hit the urethra during the procedure.

Step 5: basal sector prostate biopsies are taken.

Step 6: central sector prostate biopsies are taken.

Step 7: posterior sector prostate biopsies are taken.

Step 8: Left lobe prostate biopsies are also taken using a technique similar to that for the right lobe.

Final step: After removing the metal trocars, haemostasis is achieved by compression. A transparent adhesive film dressing is sprayed over the two puncture sites.

No post-procedure antibiotic is required.

All authors contributed to the concept or design of the study, acquisition of the data, analysis or interpretation of the data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

The authors have no conflicts of interest to disclose.

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

This study was approved by the Joint Chinese University of Hong Kong–New Territories East Cluster Clinical Research Ethics Committee (Ref CREC 2018.323). The patient provided written informed consent.

A 68-year-old Chinese man presented with proptosis, epiphora and discomfort in the right eye associated with impaired visual acuity. Contrast computed tomography scan revealed a 3.3 cm × 2.1 cm heterogeneously enhancing mass at the superotemporal aspect of the right orbit with displacement of the lateral rectus muscle (Fig 1). A pigmented tumour with dense adhesions to the surrounding structures was found in orbitotomy with leakage of the pigmented content upon surgical exploration. The lesion was excised as much as possible. Detailed clinical examination showed no evidence of intraocular melanoma, conjunctival or eyelid melanoma, or melanoma anywhere else. Systemic examination and whole-body positron emission tomography-computed tomography scan were unremarkable. The patient was alive with no evidence of disease at 9-month follow-up.

The tumour was a solid, dark brownish multinodular mass covered by fat and skeletal muscle, comprising lobulated sheets of epithelioid and spindly melanocytes with vesicular chromatin, prominent nucleoli, and variable amounts of melanin pigment (Figs 2, 3, and 4). The mitotic count was 1 per 10 HPFs. The neoplastic melanocytes were positive for S100 and SOX10 but negative for BRAF. BRCA1-associated protein 1 immunostaining was intact. Sanger sequencing revealed a GNA11 Q209L mutation. No mutation was found in GNAQ, NRAS, KRAS, BRAF or KIT.

Ocular melanoma most frequently involves the uveal tract (choroid, ciliary body, and iris) and the conjunctiva, where melanocytes are normally present. According to The Cancer Genome Atlas uveal melanoma project, mutually exclusive mutations in GNAQ, GNA11, CYSLTR2 and PLCB4 are the tumour-initiating mutations whereas BAP1, EIF1AX and SF3B1/SRSF2 mutations are associated with prognosis in uveal melanoma.1 In contrast, conjunctival melanoma typically exhibits BRAF, NRAS and NF1 mutations of the MAPK pathway with UV-induced C→T mutation signature.2 Orbital soft tissue melanoma is uncommon with >90% representing secondary tumours as a result of contiguous spread or metastasis from uveal, conjunctival, cutaneous or sinonasal melanomas.3 Primary orbital melanoma is exceedingly rare and has been postulated to arise in embryological remnants of melanocytes arrested in the region since a substantial proportion of cases are associated with blue nevus, orbital melanocytosis or oculodermal melanocytosis (nevus of Ota). Alternatively, it may arise from isolated melanocytes found in the optic nerve sheath, orbital fat, extraocular muscles or orbital periosteum. The majority of patients are white Europeans in their fourth to fifth decade. Histologically, it comprises epithelioid, spindle or mixed populations of neoplastic melanocytes that are frequently pigmented but with a lesser degree of nuclear pleomorphism than their cutaneous and mucosal counterparts. The prognosis is generally poor but a small proportion of patients survive long term. The most frequent site of metastasis is the liver.3 4 The clinicopathological features of primary orbital melanoma are very similar to those of uveal melanoma. The findings of GNAQ, SF3B1, EIF1AX mutations5 and GNA11 mutation in this case provide further evidence that primary orbital melanoma has a close pathogenic relationship with uveal melanoma.

All authors contributed to the concept or design of the study, acquisition of the data, analysis or interpretation of the data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

As an adviser of the journal, HKL Yuen was not involved in the peer review process. Other authors have disclosed no conflicts of interest.

This case was presented as a poster at the Annual Scientific Meeting of The College of Ophthalmologists of Hong Kong and Hong Kong Ophthalmological Society on 14 to 15 December 2019.

This pictorial medicine paper received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors.

The patient was treated in accordance with the tenets of the Declaration of Helsinki. Informed consent was obtained from the patient.

References

1. Bakhoum MF, Esmaeli B. Molecular characteristics of uveal melanoma: insights from the Cancer Genome Atlas (TCGA) Project. Cancers (Basel) 2019;11:1061.Crossref

2. Swaminathan SS, Field MG, Sant D, et al. molecular characteristics of conjunctival melanoma using whole-exome sequencing. JAMA Ophthalmol 2017;135:1434-7. Crossref

3. Rose AM, Luthert PJ, Jayasena CN, Verity DH, Rose GE. Primary orbital melanoma: presentation, treatment, and long-term outcomes for 13 patients. Front Oncol 2017;7:316. Crossref

4. Shields JA, Shields CL. Orbital malignant melanoma: the 2002 Sean B Murphy lecture. Ophthalmic Plast Reconstr Surg 2003;19:262-9. Crossref

5. Rose AM, Luo R, Radia UK, et al. Detection of mutations in SF3B1, EIF1AX and GNAQ in primary orbital melanoma by candidate gene analysis. BMC Cancer 2018;18:1262. Crossref

A 65-year-old Chinese woman was referred to the ophthalmology clinic complaining of grittiness in both eyes for 1 month. She had been diagnosed with stage IV metastatic pulmonary adenocarcinoma with positive mutation in epidermal growth factor receptor (EGFR) gene (L858R) and had been prescribed erlotinib 4 months previously as palliative treatment (Table).

Physical examination revealed bilateral long thick curly eyelashes (Figs 1 and 2) affecting all four eyelids. A papulopustular rash over the periocular region was also evident. The patient denied use of topical prostaglandin analogue for either medical or cosmetic use. A diagnosis was made of drug-induced trichomegaly. Corneal punctate epithelial erosion as a result of the misdirected lashes was treated symptomatically with regular epilation and topical lubricants.

Upon follow-up, gradual partial reversal of trichomegaly was evident at 6 weeks after erlotinib cessation. There was also improvement of the periorbital papulopustular rash. The reversal of trichomegaly after EGFR inhibitor cessation is not well documented in the literature. This case illustrates the presentation and partial resolution of drug-induced trichomegaly.

Eyelash trichomegaly is a rare condition characterised by increase in length, thickness, pigmentation, and curling of the eyelashes. The eyelash follicle, just as the scalp hair follicle, undergoes the cycle of anagen, catagen, and telogen phase. The anagen phase of eyelashes (ie, the growth phase) typically spans 8 weeks in Asian patients and occurs in 18% of eyelashes at any given time.1

Drug-induced trichomegaly is the most common form of trichomegaly to present in a general ophthalmology setting. Prostaglandin analogues such as latanoprost and bimatoprost, although commonly used as antiglaucomatous drugs, are well known for their side-effect of eyelash trichomegaly. The effect is due to up-regulation of prostaglandin E2, D2 receptor expressed in hair follicles.2

The occurrence of EGFR inhibitor–induced trichomegaly is seen less often but is not uncommon in the ophthalmology setting. It has been postulated that EGFR inhibitors inactivate the nuclear factor of activated T-cells. This leads to activation of stem cell bulge and suprabulbar region of the eyelash hair follicles.3 In a typical course, trichomegaly develops between the second and fifth month of EGFR inhibitor treatment.4 An Asian study reported that 2% of patients prescribed EGFR inhibitor treatment had trichomegaly.5 The EGFR inhibitor is also well known to cause a series of cutaneous adverse effects known as the PRIDE syndrome (papulopustules and/or paronychia, regulatory abnormalities of hair growth, itching, and dryness).6 In this case, the patient exhibited PRIDE syndrome affecting the periocular skin as demonstrated in Figures 1 and 2.

Trichomegaly is a benign condition, but long misdirected lashes may lead to corneal punctate epithelial erosion and corneal abrasion. Frequent trimming, epilation, and topical lubricants serve as first-line treatment. Electro-epilation or cryoablation directed at the affected hair follicles may be considered in instances of recurrent misdirected lashes with corneal complications such as infective corneal ulcer.

This case highlights the clinical course of EGFR inhibitor–induced trichomegaly upon cessation of drug therapy, which is not well documented in the literature. Partial reversal of trichomegaly was achieved after stopping erlotinib for 6 weeks. It is evident that the time required for trichomegaly resolution follows the typical eyelash follicle cycle.

All authors contributed to the design, acquisition of data, analysis of data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

As an adviser of the journal, HKL Yuen was not involved in the peer review process. Other authors have disclosed no conflicts of interest.

This pictorial medicine received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

The patient was treated in accordance with the Declaration of Helsinki. The patient provided written informed consent for the treatment/procedures, and consent for publication.

1. Na JI, Kwon OS, Kim BJ, et al. Ethnic characteristics of eyelashes: a comparative analysis in Asian and Caucasian females. Br J Dermatol 2006;155:1170-6. Crossref

2. Colombe L, Michelet JF, Bernard BA. Prostanoid receptors in anagen human hair follicles. Exp Dermatol 2008;17:63- 72. Crossref

3. Dalal A, Sharma S, Kumar A, Sharma N. Eyelash trichomegaly: a rare presenting feature of systemic lupus erythematosus. Int J Trichology 2017;9:79-81. Crossref

4. Jeon SH, Ryu JS, Choi GS, et al. Erlotinib induced trichomegaly of the eyelashes. Tuberc Respir Dis (Seoul) 2013;74:37-40. Crossref

5. Chanprapaph K, Pongcharoen P, Vachiramon V. Cutaneous adverse events of epidermal growth factor receptor inhibitors: A retrospective review of 99 cases. Indian J Dermatol Venereol Leprol 2015;81:547. Crossref

6. Lacouture ME, Lai SE. The PRIDE (Papulopustules and/or paronychia, Regulatory abnormalities of hair growth, Itching, and Dryness due to Epidermal growth factor receptor inhibitors) syndrome. Br J Dermatol 2006;155:852-4. Crossref