Ocular choristomas

Choristomas are congenital lesions representing normal tissue(s) in an abnormal location. They are the most common epibulbar and orbital tumors in children. Epibulbar choristomas affect the cornea, limbus or subconjunctival space, and range in appearance from a small, flat lesion to a large mass filling most of the epibulbar region. Astigmatism is often present. Choristomas may be associated with coloboma, Goldenhar syndrome or epidermal nevus syndromes; those associated with the latter are often bilateral and extensive. Choristomas are occasionally familial. Surgery may be indicated to improve vision or cosmesis, or to impede growth. Although choristomas most commonly involve the epibulbar area, they can affect many areas of the eye and orbit, and often affect more than one area.

Foveal avascular zone in diabetes mellitus

The foveal avascular zone was measured angiographically in 144 subjects with diabetic retinopathy and 27 control subjects. Statistical significance was defined as P < 0.01. Quantitatively, the foveal avascular zone was significantly smaller in control eyes (median = 0.405 mm2) than in eyes with diabetic retinopathy, and smaller in eyes with background diabetic retinopathy (BDR; median = 0.737 mm2) than in eyes with proliferative diabetic retinopathy (PDR; median = 0.866 mm2) and preproliferative diabetic retinopathy (PPDR; median = 1.001 mm2). Qualitatively, the contour of the foveal avascular zone in diabetic retinopathy was irregular (29.2% of eyes with diabetic retinopathy vs 3.7% of control eyes) with scattered round microaneurysms. Diabetic retinopathy is characterized by an irregular, large foveal avascular zone with scattered microaneurysms.

Congenital dacryocele. A collaborative review

Fifty-four cases of congenital dacryocele from several medical centers were reviewed retrospectively. There was strong female preponderance (73%) and unilateral involvement (88%). Lacrimal sac contents could be expressed by local massage through the puncta in 21% of cases. Probing and irrigation were done under general (27.8%) or local (55.6%) anesthesia, while in other cases (16.7%), the cyst resolved before intervention. Recurrence of the dacryocele occurred in 10 patients (22%) after probing. Nasal cysts were visualized in six cases. Marsupialization of nasal cysts was necessary in four cases. In one center, after conservative therapy, 80% of cysts resolved spontaneously and 20% developed dacryocystitis. Surgical intervention is indicated in cases of dacryocystitis, cellulitis, breathing difficulty from large nasal cysts, recurrent dacryocele, and lack of its resolution after a short trial of digital massage.

Histopathology of commotio retinae

The pathogenesis of commotio retinae in animal models has included extracellular edema, intracellular edema, and photoreceptor outer segment disruption. Histopathologic findings obtained within 24 hours of blunt trauma in a human eye with clinically-observed commotio retinae revealed photoreceptor outer segment disruption and damage to the retinal pigment epithelium. The major site of injury in commotio retinae seems to be at the level of the photoreceptor outer segment-retinal pigment epithelium junction.

Ocular findings in the facioauriculovertebral sequence (Goldenhar-Gorlin syndrome)

We reviewed the ocular findings in 57 consecutive patients with the facioauriculovertebral sequence (Goldenhar-Gorlin syndrome). Epibulbar choristomas were detected in 18 cases (32%), a much lower occurrence than reported previously. Various motility disorders (11 cases, 19%), blepharoptosis or narrow palpebral fissures (seven cases, 12%), eyelid colobomas (six cases, 11%), and lacrimal drainage system anomalies (six cases, 11%) were more frequent than previously noted. These ocular findings were more common in the patients with epibulbar choristomas. Of the various features of the Goldenhar-Gorlin syndrome (skin tags, microtia, hemifacial microsomia, and vertebral anomalies), only skin tags correlated positively with the laterality of epibulbar choristomas. Preauricular and facial tags represent choristomas, explaining their association with epibulbar choristomas and the laterality they share.

Ethmoid sinus osteoma presenting as epiphora and orbital cellulitis: case report and literature review

Paranasal sinus osteoma is a slow-growing, benign, encapsulated bony tumor that may be commonly asymptomatic, being detected incidentally in 1% of plain sinus radiographs or in 3% of sinus computerized tomographic scans. In a patient presenting with orbital cellulitis and epiphora, computed tomography disclosed a large osteoma of the ethmoid sinus. Excision of the osteoma allowed recovery of vision, return of extraocular muscle function, and resolution of choroidal folds. Proptosis, diplopia, and visual loss are other frequent presenting signs of paranasal osteomas. Epidemiology, diagnosis, treatment, and pathologic findings in paranasal sinus osteoma are reviewed.

Ziv-aflibercept in macular disease

BACKGROUND/AIMS

Aflibercept is an approved therapy for neovascular age-related macular degeneration (AMD) and diabetic macular oedema (DME). In vitro and in vivo studies did not detect toxicity to the retinal pigment epithelium cells using the approved cancer protein, ziv-aflibercept. Our purpose is to determine if ziv-aflibercept can be used in AMD and DME without ocular toxicity, to test the stability of ziv-aflibercept, and to do a cost analysis.

METHODS

Prospectively, consecutive patients with AMD or DME and poor vision underwent one intravitreal injection of 0.05 mL of fresh filtered ziv-aflibercept (1.25 mg). Monitoring of best-corrected visual acuity, intraocular inflammation, cataract progression, and retinal structure by spectral domain optical coherence tomography was done at 1 day and 1 week after injection. Ziv-aflibercept activity over 4 weeks was measured by capturing vascular endothelial growth factor by ELISA.

RESULTS

There were no signs of retinal toxicity, intraocular inflammation or change in lens status in four eyes with AMD and two eyes with DME. Visual acuity improved (p=0.05) and central foveal thickness decreased in all patients (p=0.05). Ziv-aflibercept had no loss of anti-VEGF activity when kept at 4°C in polycarbonate syringes over 4 weeks. Similar to bevacizumab, compounded ziv-aflibercept would yield a tremendous saving compared with aflibercept or ranibizumab.

CONCLUSIONS

Off-label use of ziv-aflibercept improves visual acuity without ocular toxicity and may offer a cheaper alternative to the same molecule aflibercept.

TRIAL REGISTRATION NUMBER

NCT02173873.

Intravitreal bevacizumab in inflammatory ocular neovascularization

PURPOSE

To assess the role of bevacizumab in inflammatory ocular neovascularization.

DESIGN

Retrospective, multicenter, consecutive case series of inflammatory ocular neovascularization.

METHODS

Patients with inflammatory ocular neovascularization of varying causes for whom standard therapy failed were treated with intravitreal injection of bevacizumab. Main outcome measures included improvement of best-corrected visual acuity (BCVA) expressed in logarithm of minimum angle of resolution units, response of inflammatory ocular neovascularization by funduscopy and angiography, and decrease in central foveal thickness as measured by optical coherence tomography at the three-month follow-up.

RESULTS

At the three-month follow-up, 84 eyes of 79 patients had been treated with a mean of 1.3 injections (range, one to three). Thirty-four eyes showed juxtafoveal choroidal neovascularization (CNV), 34 eyes showed subfoveal CNV, eight eyes showed peripapillary CNV, and 11 eyes showed neovascularization of the disc (NVD) or neovascularization elsewhere (NVE). BCVA improved 2.4 lines from 0.68 (6/28 or 20/94) to 0.44 (6/17 or 20/55) (P < .001). BCVA improved by one to three lines in 34.5% of the eyes, by four to six lines in 16.7% of the eyes, and by more than six lines in 14.2% of the eyes. Function was unchanged in 23.8% of the eyes. BCVA worsened in 10.7% (zero to three lines in 7.1%, more than four lines in 3.6%). Central foveal thickness decreased from baseline 346 to 252 microm (P < .001). For CNV, 32 eyes (43.2%) had complete regression after the injection, 27 (36.5%) had partial regression, five (6.8%) had no response, and 10 eyes (13.5%) were not evaluated by the contributors. For NVD or NVE, seven eyes (63.6%) had complete regression of new vessels and four eyes (36.4%) had partial regression after the injection.

CONCLUSIONS

Intravitreal bevacizumab led to short-term significant visual improvement and regression of inflammatory ocular neovascularization in a wide variety of inflammatory ocular diseases.

Optic disk size in ischemic optic neuropathy

We measured the horizontal diameter, vertical diameter, and area of the optic disk in fellow eyes of patients with unilateral nonarteritic ischemic optic neuropathy and in control eyes without ocular disease. The fellow eyes of patients with anterior ischemic optic neuropathy had a smaller horizontal than vertical disk diameter (P less than .05), a difference not present in controls. Both the horizontal disk diameter and the disk area were significantly smaller in fellow eyes of patients with anterior ischemic optic neuropathy than in controls (P less than .05). There was no statistical difference in the vertical disk diameters between the two groups. Our findings suggest that a small disk area along with a horizontal shortening of the scleral canal can lead to crowding of optic nerve fibers, predisposing to a circulatory compromise of the optic nerve head in non-arteritic anterior ischemic optic neuropathy.

Central trochlear palsy

Historically, the trochlear (IV) nerve has been "neglected" by neurologists and ophthalmologists. However, the reported incidence of trochlear palsy in two large series has more than doubled in the past two decades, indicating increasing awareness of this nerve. Trauma is the most common cause of trochlear palsy, as the trochlear nerve is anatomically more vulnerable to trauma than the other ocular motor nerves. Trochlear palsy can also be caused by vascular and inflammatory diseases, congenital factors, toxic substances and tumors. Diplopia secondary to vertical and horizontal deviation is the most common presentation. The trochlear nerve has a relatively high recovery rate after the underlying cause of injury has been corrected. In this article, the anatomy and physiology of the trochlear nerve are described, and the various etiologies, methods of diagnosis and differential diagnosis of trochlear palsy are reviewed.

Ocular findings in aplastic anemia

OBJECTIVE

To analyze the ocular findings in aplastic anemia.

DESIGN

Eighteen patients with aplastic anemia were examined.

RESULTS

Ocular findings included cotton wool spots (38%), nerve fiber layer or preretinal hemorrhages (67%), vitreous hemorrhages (13%), a picture resembling central retinal vein occlusion (13%) and optic disk edema (6%). Preretinal hemorrhages were the presenting sign of aplastic anemia in 2 patients (13%).

CONCLUSIONS

A blood profile is needed in patients with unexplained retinal hemorrhages. Patients with aplastic anemia need to avoid ocular massage and Valsalva maneuvers to decrease ocular morbidity.

Metastatic eyelid disease

The authors conducted a clinicopathologic study of 31 patients with metastatic disease to the eyelid at the Armed Forces Institute of Pathology. Metastasis was found predominantly in women (female/male = 4:1). The mean age was 69 years (range, 3-92). The most common primary sites were breast (35%), skin (16%), and gastrointestinal and urogenital tracts (each 10%). Aside from breast carcinoma, there was no sex predilection for the extramammary malignancies to metastasize to the eyelids. Metastasis was suspected in only 32% of the cases. Most common misdiagnoses were chalazion, cyst, granuloma, and xanthoma. The lid lesions were detected before the primary focus in 45% of the cases. The authors conclude that metastatic disease should be considered in the differential diagnosis of eyelid lesions.

Ocular pathology in congenital heart disease

PURPOSE

To describe the ocular findings in subjects with congenital heart disease (CHD).

METHODS

In a prospective study, the same observer examined 240 consecutive patients with CHD admitted to the medical centre. Two independent geneticists performed identification of syndromes.

RESULTS

The commonest anatomic cardiac anomalies were ventricular or atrial septal defects (62), tetralogy of Fallot (39), pulmonary stenosis (25), and transposition of the great arteries (24). The heart lesions were divided physiologically into volume overload (90), cyanotic (87), and obstructive (63). In all, 105 syndromic subjects included the velocardiofacial syndrome (18), Down's syndrome (17), CHARGE association (6), DiGeorge syndrome (5), Williams syndrome (3), Edwards syndrome (3), Noonan syndrome (3), VACTERL association (2), and Patau syndrome (trisomy 13) (2). The paediatric team recognized 51 patients as syndromic. Two independent geneticists recognized additional 54 patients as syndromic. Positive eye findings were present in 55% (132) and included retinal vascular tortuosity (46), optic disc hypoplasia (30), trichomegaly (15), congenital ptosis (12), strabismus (11), retinal haemorrhages (8), prominent eyes (7), and congenital cataract (6). There was a strong correlation between the retinal vascular tortuosity and both a low haematocrit (P=0.000) and a low arterial oxygen saturation (P=0.002).

CONCLUSIONS

Patients with CHD are at a high risk for ocular pathology and need screening for various ocular abnormalities.

Long-term visual outcomes of intravitreal bevacizumab in inflammatory ocular neovascularization

PURPOSE

To assess the long-term role of bevacizumab (Avastin; Genentech Inc, South San Francisco, California, USA) in inflammatory ocular neovascularization.

DESIGN

Retrospective multicenter consecutive case series of inflammatory ocular neovascularization.

METHODS

settings: Multicenter institutional and private practices.

STUDY POPULATION

Patients with inflammatory ocular neovascularization in one or both eyes of varying etiologies who failed standard therapy. intervention: Intravitreal injection of bevacizumab.

MAIN OUTCOME MEASURES

Improvement of best-corrected visual acuity (BCVA) expressed as logarithm of minimal angle of resolution (logMAR), and decrease in central foveal thickness as measured by optical coherence tomography at 6, 12, 18, and 24 months of follow-up.

RESULTS

Mean logMAR BCVA (central foveal thickness) following intravitreal bevacizumab was as follows: baseline, 0.65 (6/27 or 20/90) (338 microm; 99 eyes of 96 patients); 6 months, 0.42 (6/16 or 20/53) (239 microm; 2.0 injections; 81 eyes); 12 months, 0.39 (6/15 or 20/49) (241 microm; 2.3 injections; 95 eyes); 18 months, 0.40 (6/15 or 20/50) (261 microm; 3.0 injections; 46 eyes); and 24 months, 0.34 (6/13 or 20/44) (265 microm; 3.6 injections; 27 eyes). Paired comparisons revealed significant visual improvement at 6 months of 2.4 lines (P = .000), at 12 months of 2.5 lines (P = .000), at 18 months of 2.5 lines (P = .001), and at 24 months of 2.2 lines (P = .013). Paired comparisons revealed significant central foveal flattening at 6 months of 78 microm (P = .000), at 12 months of 85 microm (P = .000), at 18 months of 90 microm (P = .003), and at 24 months of 77 microm (P = .022). Three eyes developed submacular fibrosis and 1 eye submacular hemorrhage.

CONCLUSION

Intravitreal bevacizumab led in the long-term to significant mean visual improvement of > or =2.2 lines and significant foveal flattening in a wide variety of inflammatory ocular diseases without major complications.

Racial variation of optic disc size

The optic disc size was measured in 125 volunteers without ocular disease. The horizontal disc diameter and the disc area were significantly smaller in whites and Hispanics than in non-American Indians, Orientals and blacks, and smaller in females than in males. There was no correlation between disc size and age. Future studies analyzing optic disc morphometry need to account for the influence of sex and race.

Ocular complications of arteriovenous communications of the retina

Primary arteriovenous communications of the retina (AVCR) are usually considered to be stable retinal lesions. Complications were documented in seven cases of AVCR, including intraretinal macular hemorrhage, central and peripheral retinal vein occlusions, neovascular glaucoma, and vitreous hemorrhage. To explain these developments, a hypothesis is presented that AVCR are associated with localized decreased retinal arterial pressure, increased retinal venous pressure, increased turbulence of blood flow, and decreased perfusion of adjacent retinal tissues.

National survey of blindness and low vision in Lebanon

AIMS

To survey level of blindness and low vision in Lebanon.

METHODS

A population survey was undertaken in 10,148 individuals to measure the prevalence and identify the causes of blindness in Lebanon.

RESULTS

The prevalence of blindness was 0.6% and that of low vision 3.9%. The major causes of blindness were cataract (41.3%) and uncorrected large refractive error (12.6%).

CONCLUSION

Most causes of blindness in Lebanon can be controlled by various educational and medical programmes.

Retinal vascular events after intravitreal bevacizumab

PURPOSE

To record retinal vascular events following intravitreal bevacizumab injection.

METHODS

Collaborative multi-centre retrospective case series.

RESULTS

Eight patients were documented to have central retinal artery occlusion (four patients), branch retinal artery occlusion, capillary occlusion, central retinal vein occlusion and branch retinal vein occlusion (one patient each) within 0-55 days (median 2 weeks) of intravitreal bevacizumab. All patients had several ocular and systemic risk factors for retinal vascular events: elevated intraocular pressure on discharge (four patients), pre-existent glaucoma (one patient), pre-existent ischaemic retinal vascular disorder (four patients), systemic hypertension (five patients), diabetes mellitus (three patients), coronary artery disease (four patients), carotid disease (three patients), smoking (two patients) and migraine (one patient).

CONCLUSION

The retinal vascular events may be associated with the underlying ocular disease under treatment or with the underlying systemic disease, may be related to an increased intraocular pressure post-injection constraining further an already poor retinal perfusion, the vasoconstrictor effect of bevacizumab, or a combination of all three.

Macular serpiginous choroiditis

The authors describe in seven eyes of four patients a form of serpiginous choroiditis beginning in the macula without initial peripapillary activity. Eyes with macular serpiginous choroiditis often had a poor visual prognosis and sometimes developed subretinal neovascularization. Fluorescein angiography of the acute lesions showed hypofluorescence; some cases were thus initially diagnosed as having choroidal ischemia. Fluorescein angiography in one eye, however, suggested that at least some of the hypofluorescence seen acutely in eyes with serpiginous choroiditis is secondary to blocked fluorescence from "opaque" retinal pigment epithelium.

Five-decade profile of women in leadership positions at ophthalmic publications

OBJECTIVE

To evaluate the balance between the sexes of published ophthalmic material at the editorial, reviewer, and author levels.

DESIGN

Cross-sectional study of 3 journals, American Journal of Ophthalmology, Archives of Ophthalmology, and Ophthalmology, for 1969, 1979, 1989, 1999, and 2009. The data were compared with ophthalmologist-in-training and physician profile in major contributing states from North America and Europe during the same period.

RESULTS

Of the 3 major ophthalmology journals, none had a female editor-in-chief. For all journals, the proportion of editorial board members who were women increased from 3.3% in 1969 to 18.8% in 2009. For all journals and all years, women composed a higher proportion of first authors (29.2% in 2009) compared with senior authors (22.9% in 2009), reviewers (18.9% in 2009), or assistant editors (12.5% in 2009). There was an abrupt shift toward women after 1989 in first authorship in Ophthalmology (1969, 4.6%; 1979, 5.4%; 1989, 12.3%; and 1999, 20.2%), Archives of Ophthalmology (1969, 6.6%; 1979, 5.1%; 1989, 15.6%; and 1999, 28.6%), and American Journal of Ophthalmology (1969, 5.6%; 1979, 4.2%; 1989, 9.2%; and 1999, 23.9%). There was also an abrupt increase in female senior authorship for American Journal of Ophthalmology after 1989 (1979, 8.5%; 1989, 8.1%; and 1999, 18.3%). The increase in female first authorship during the 5 decades was parallel with the increase in US female physicians.

CONCLUSIONS

Women ophthalmologists are authoring publications in increasing numbers that match their prevalence in the academic and overall workforce. However, all editors are men. This discrepancy relates to the relatively younger generation of female ophthalmologists or selection bias, a subject that requires further investigation.

Clinicopathological findings in a growing optic nerve melanocytoma

We present an unusual case of a melanocytoma of the optic disc that showed documented progressive growth over a period of six years. It reached the largest size of any reported optic nerve melanocytoma and the eye was enucleated because of the possibility of malignant degeneration. Optic nerve melanocytomas are locally invasive but are not known to undergo transformation into malignant melanoma. Follow-up should remain the primary approach in the management of patients with optic nerve melanocytomas, as previously advocated by Zimmerman.

Three-year visual and anatomic results of administrating intravitreal bevacizumab in inflammatory ocular neovascularization

OBJECTIVE

To assess the 3-year visual outcome of intravitreal bevacizumab in inflammatory ocular neovascularization.

DESIGN

Experimental study.

METHODS

Retrospective multicenter consecutive case series in 81 patients with inflammatory ocular neovascularization refractory to standard therapy and treated with intravitreal bevacizumab. The outcome measures included improvement of best corrected visual acuity expressed as logarithm of minimum angle of resolution (logMAR) and paired comparison decrease in central foveal thickness by optical coherence tomography.

RESULTS

Mean best corrected visual acuity improved from baseline 0.699 (6/30 or 20/101) (SD 0.434) to 0.426 (6/16 or 20/53) (SD 0.428) (n = 81; p < 0.001), a gain of 2.7 lines (median 3 injections; 81 eyes; 81 patients). Paired comparisons revealed significant central foveal flattening at 3 years of 97.9 μm (n = 51; p < 0.001). In a subgroup analysis, visual improvement was significant for ocular histoplasmosis (p = 0.026); multifocal choroiditis (p = 0.05); serpiginous choroiditis (p = 0.028); ocular toxoplasmosis (p = 0.042); and punctate inner choroidopathy (p = 0.015). In a subgroup analysis, foveal flattening was significant for ocular histoplasmosis (p = 0.004); multifocal choroiditis (p = 0.007); serpiginous choroiditis (p = 0.011); and punctate inner choroidopathy (p = 0.001). Of the group, 5 eyes developed submacular fibrosis, 1 eye retinal pigment epithelial tear, and 1 eye macular ischemia in the context of vasculitis.

CONCLUSION

At 3 years, intravitreal bevacizumab sustained significant visual improvement of 2.7 lines and significant foveal flattening of 98 μm in a wide variety of inflammatory ocular diseases without major complications after a median of 3 injections.

Long-term follow-up in Bietti crystalline dystrophy

PURPOSE

To present a long-term follow-up of Bietti crystalline dystrophy.

METHODS

Two brothers are presented including the clinical findings, fluorescein angiography, electrophysiology (electroretinography [ERG], electrooculography [EOG], adaptometry), optical coherence tomography (OCT), and transmission electron microscopy of bulbar conjunctiva and peripheral blood lymphocytes. The clinical findings were documented over a period of 25 years in one brother and 5 years in the other.

RESULTS

The most striking features were deposits in the retina that were formed de novo with old ones replaced by choroidal atrophy in advanced stage of the disease. The light rise (EOG), rod- and cone-driven responses (ERG), and visual fields were affected progressively during the course. These changes of the retinal pigment epithelium and choriocapillaris were observed in the second decade and worsened gradually. OCT demonstrated preferential crystal accumulation in the inner retina. Cytoplasmic lipid crystalline inclusions were found in lymphocytes and conjunctival fibroblasts by transmission electron microscopy.

CONCLUSIONS

Bietti crystalline retinopathy is a progressive retinal disease characterized by retinal crystals gradually replaced by atrophy of the retinal pigment epithelium and gradual constriction of visual fields.

Ocular findings in the velo-cardio-facial syndrome

Velo-cardio-facial syndrome is a common genetic syndrome of cleft palate, learning disability, heart disease, and abnormal facial appearance. Ocular findings include retinal vascular tortuosity, posterior embryotoxon, narrow palpebral fissures, suborbital discoloration, small optic nerves, iris nodules, and cataracts. Retinal vascular tortuosity was found to be associated intrinsically with the syndrome and not secondary to the heart disease. The ocular and systemic findings suggest a primary developmental anomaly of neural crest derivatives in the pathogenesis of the syndrome.