[Central serous chorioretinopathy as a complication of epitheliopathy under treatment with glucocorticoids]

CASE REPORT

We present cases of two patients who were examined in our department with the diagnosis of epitheliopathy following treatment with oral and topical glucocorticoids. They were referred because of loss of visual acuity. The ophthalmic examination established the diagnosis of central serous chorioretinopathy and it was decided to stop treatment with glucocorticoids.

DISCUSSION

The pathogenesis of the central serous chorioretinopathy is still imprecisely known, but it has been related to several situations characterized by exposure to high levels of endogenous or exogenous glucocorticoids. Both of these cases provide more evidence of the potential association between corticosteroids and the acute manifestations of central serous chorioretinopathy.

Optical coherence tomography: its clinical use for the diagnosis, pathogenesis, and management of macular conditions

BACKGROUND

Optical coherence tomography (OCT) is a noninvasive, noncontact transpupillary imaging technology that can image retinal structures in vive with a resolution of up to 10 microns. Anatomic layers within the retina can be differentiated and retinal thickness measured. The objective is to demonstrate clinical viability and useful interpretation of macular images derived from a commercially available OCT instrument.

METHODS

A Stratus OCT (Zeiss-Humphrey, Dublin, California) imaging system was used to evaluate several pathological presentations of the macula in selected patients. Conditions illustrated in this case series were macular holes, epiretinal membranes, macular edema, idiopathic central serous choroidopathy, detachments of pigment epithelium and sensory retina, choroidal neovascular membranes, and retinal vascular occlusions.

CONCLUSIONS

Acquired OCT images achieved structural information regarding anatomical characteristics of the conditions scanned. A cross-sectional resolution of 10 microns was accomplished, which is 10 times greater than current ultrasound. OCT provides important information that may be critical in the diagnosis and management of some ocular conditions. Its high-resolution scans may contribute to the better understanding of disease pathogenesis, as well as assistance in or confirmation of a diagnosis. This imaging technology provides important information beyond what can be seen on clinical examination, and offers a useful adjunct to other diagnostic imaging tools such as fundus photography, fluorescein angiography, and indocyanine green angiography.

Critical Flicker Frequency as a Potential Vision Technique in the Presence of Cataracts

PURPOSE

Potential vision testing attempts to predict the visual outcome that might be expected as a result of a cataract operation. This report details the clinical utility of critical flicker frequency (CFF) as a potential vision test (PVT).

METHODS

CFF thresholds were determined in 31 subjects with age-related idiopathic cataract and no other eye disease, 19 subjects with macular disease (MD) and clear ocular media, and 24 age-matched control subjects. In addition, the CFF technique was administered before cataract surgery in 52 patients and compared with the information provided by presurgical case history and ocular examination alone (ophthalmological judgment [OJ]) and results from two commonly used PVTs (the retroilluminated pinhole and the potential acuity meter).

RESULTS

CFF thresholds obtained in the nonsurgical cataract group were unrelated to cataract severity and were similar to those in the control group. In contrast, CFF scores were significantly related to visual acuity (VA) in the MD group. In the pre- and postsurgical studies, OJ predicted postoperative VA very well in patients with moderate cataract and normal fundi and better than all the PVTs. OJ performed less well in patients with comorbid eye disease and dense cataracts, when information from the PVTs would probably have been useful. CFF provided the most accurate predictions of postoperative VA in the small sample of patients with dense cataracts.

CONCLUSIONS

CFF was unaffected by cataract, yet sensitive to MD, and provided useful information about the postoperative visual outcome beyond that obtained through history and ocular examination in patients with dense cataracts.

Ophthalmic manifestations of multiple myeloma

PURPOSE

To describe ophthalmic manifestations in a series of patients with multiple myeloma (MM) and review the literature.

DESIGN

Retrospective case series.

METHODS

Review of all cases with ophthalmic manifestations of MM seen at the Department of Ophthalmology, Royal Adelaide Hospital, between 1987 and 2002.

RESULTS

Of all patients with MM who were managed at the Royal Adelaide Hospital in the study period, only 8 were referred to the Ophthalmology Department with ophthalmic manifestations. Five males and 3 females with a mean age of 61.25 years (range 42-78) who exhibited ophthalmic manifestations were studied. Six patients (75%) had known MM at the time of their ophthalmic evaluation. Four patients (50%) had neuro-ophthalmic symptoms resulting in diplopia or visual disturbances. Three patients (37.5%) presented with orbital involvement and 1 (12.5%) with hyperviscosity retinopathy. Five patients (62.5%) died within 2 months of their ophthalmic presentation.

CONCLUSION

Ophthalmic manifestations of MM are uncommon and diverse. They may appear at the initial presentation of the disease or occur late in the disease process. Awareness of the possible manifestations may lead to an earlier diagnosis and have a positive influence on the disease course.

Nuclear factor-kappa B p65 in NMDA-induced retinal neurotoxicity

Transcription factors of the nuclear factor-kappa B (NF-kappaB)/Rel family may be involved in neuronal cell death or survival. We examined the role of NF-kappaB p65 in N-methyl-D-aspartate (NMDA)-induced neurotoxicity in the rat retina. Western blot analysis showed that elevated levels of retinal NF-kappaB p65 protein at days 1 and 5 after intravitreal NMDA injection. Immunohistochemistry localized increased NF-kappaB p65 immunoreactivity in the ganglion cell layer (GCL) and the inner nuclear layer (INL) after NMDA injection especially in retinal ganglion cells (RGCs), displaced amacrine cells, and amacrine cells. Concomitant with the early increase in NF-kappaB p65 protein levels, there was an increase in NF-kappaB DNA binding activity after NMDA injection as shown by electrophoretic mobility shift assay (EMSA). These increases in NF-kappaB p65 protein levels and NF-kappaB DNA binding activity were totally abolished by simultaneous injection of NF-kappaB p65 antisense oligodeoxynucleotide (AS ODN). A partial but significant protective effect on the inner retina was noted when the AS ODN was given together with NMDA as shown by morphological analysis, morphometry of cells in the GCL and morphometry of inner plexiform layer thickness as well as quantitative real-time PCR of Thy-1 mRNA levels. These results suggest that activated NF-kappaB p65 may participate in NMDA-induced retinal neuronal cell death and that inhibition of NF-kappaB activation such as the use of AS ODN may be a viable neuroprotective strategy for protective RGCs and other inner retinal neurons.

Endogenous endophthalmitis with subretinal abscess after dental procedures

Endogenous endophthalmitis with subretinal abscess is an extremely uncommon complication following dental procedures. An unsuspected source of infection or misdiagnosis of the condition as iridocyclitis may result in inadequate or delayed treatment leading to severe visual impairment. A high index of suspicion is required for accurate diagnosis and prompt treatment. A 49-year-old man was found to have endophthalmitis in his right eye after treatment of gingival abscess. Ophthalmoscopic examination revealed multiple septic emboli and a 4-disc diameter sized subretinal abscess in his retina. No other infectious origin could be found on systemic work-up. Cultures from blood, urine, aqueous and vitreous were all negative. Pars plana vitrectomy was performed 8 days after the initial presentation because of deterioration of visual acuity to finger counting despite intravitreal and systemic antibiotics administration. Visual acuity recovered to 20/25 one month postoperatively and the retina remained attached during follow-up for 1 year. Ophthalmologists should be aware of the possibility of transient septicemia-induced endophthalmitis and subretinal abscess after dental procedures. Prompt intervention with systemic and intravitreal antibiotics combined with pars plana vitrectomy can achieve successful visual and anatomic outcome.

Comparison of laser beam intensity profiles produced by photodynamic therapy (PDT) and transpupillary thermotherapy (TTT) lasers

BACKGROUND AND OBJECTIVES

For photodynamic therapy (PDT) or transpupillary thermotherapy (TTT) lasers, long irradiation time (typically 1 minute or longer) is used and a large area of retina is treated. Consequently, the power stability but also the light distribution within the laser beam plays a major role. This study aimed to evaluate beam intensity profiles produced by several PDT and TTT lasers.

STUDY DESIGN/MATERIALS AND METHODS

A beam profile analyzer (Cohu 4812 camera connected to a LPA-300PC, Spiricon, Logan, UT) was used to compare the beam profiles of PDT lasers: OPAL (Lumenis, USA); ACTIVIS (Quantel Medical, France), VISULAS (Zeiss, Germany). Spots of 2, 3, 4, and 5 mm were tested with each laser. Similarly, TTT lasers: OCULIGHT SLx (Iridex, CA) and IRIDIS trade mark (Quantel Medical, France) were evaluated with 2 and 3 mm spot diameter and power ranging from 200 to 1,000 mW.

RESULTS

PDT lasers: OPAL had a "top hat" and homogeneous profile whatever the spot size. Numerous micro-spikes and micro-nadirs of power were observed with the ACTIVIS and the VISULAS. TTT lasers: for the IRIDIS the beam shape was rather gaussian, but the homogeneity was reduced by micro-spikes of power. With the OCULIGHT Slx the beam shape was rather top hat and only few micro-spikes or micro-nadirs of power could be disclosed.

DISCUSSION

The literature tends to prove that the shape and homogeneity of the beam profile could play a role on the efficacy of the treatment.

CONCLUSION

Since PDT and TTT lasers display different beam profiles, this parameter should be carefully evaluated when performing clinical evaluations of PDT or TTT treatments.

Bilateral Coats' disease with unusual presentation--a case report

Coats' disease is a well-known ocular disorder, characterized by idiopathic retinal telangiectasia, retinal exudation and retinal detachment. We report on a boy who first presented at the age of 2 years with Coats' disease and secondary neovascular glaucoma. The differential diagnosis with retinoblastoma could not be made clinically or with the help of imaging studies, such as ultrasonography or computed tomography scanning (CT-scan). The right eye was consequently enucleated for diagnostic and therapeutical purposes. Histopathologic examination confirmed the diagnosis of Coats' disease. Five years later the same boy consulted again with profound visual loss in his only functional left eye. Fundoscopy revealed lesions typical for Coats' disease. Coats' disease can present in very different ways and bilateral disease is possible, even after several years.

Hypertensive retinopathy signs as risk indicators of cardiovascular morbidity and mortality

Hypertensive retinopathy has long been regarded as a risk indicator for systemic morbidity and mortality. New population-based studies show that hypertensive retinopathy signs are strongly associated with blood pressure, but inconsistently associated with cholesterol and other risk factors of atherosclerosis. Mild hypertensive retinopathy signs, such as generalized and focal retinal arteriolar narrowing and arteriovenous nicking, are weakly associated with systemic vascular diseases. Moderate hypertensive retinopathy signs, such as isolated microaneurysms, haemorrhages and cotton-wool spots, are strongly associated with subclinical cerebrovascular disease and predict incident clinical stroke, congestive heart failure and cardiovascular mortality, independent of blood pressure and other traditional risk factors. These data support the concept that an assessment of retinal vascular changes may provide further information for vascular risk stratification in persons with hypertension.

The foveal photoreceptor layer and visual acuity loss in central serous chorioretinopathy

PURPOSE

To describe changes of the foveal photoreceptor layer using optical coherence tomography (OCT) in central serous chorioretinopathy (CSC) and evaluate the correlation with visual acuity (VA) loss.

DESIGN

Observational case series.

METHODS

We studied 28 eyes with acute or chronic CSC using high-resolution OCT. The tomographic findings of the detached foveal photoreceptor layer were compared with VA. Sixteen eyes also were evaluated after foveal reattachment.

RESULTS

The outer photoreceptor layer (OPL) in the detached fovea was preserved in 14 eyes, of which 13 had symptoms for <1 year and atrophic in 14 eyes with symptoms for >1 year. The preserved OPL had an even profile in 7 eyes and a granulated profile in 7 eyes. Mean VA was 0.19 logMAR with a preserved OPL and 0.72 logMAR with an atrophic OPL (P <.001). Cases seen after the detachment resolved included 6 eyes with preserved even OPL, 5 eyes with preserved granulated OPL, and 5 eyes with atrophic OPL. Mean final VA was 0.06 logMAR in eyes with preserved OPL and 0.90 logMAR in eyes with atrophic OPL (P <.001). The VA improved in 73% of eyes with preserved OPL and no eyes with atrophic OPL (P = .025). The VA recovered completely in 83% of eyes with preserved even OPL and no eyes with preserved granulated OPL (P = .015).

CONCLUSION

High-resolution OCT demonstrates changes in the foveal photoreceptor layer in CSC that highly correlate with VA loss and may predict visual recovery after macular reattachment.

Recombinant AAV-mediated gene transfer to the retina: gene therapy perspectives

Retinal degenerative diseases such as retinal macular degeneration and retinitis pigmentosa constitute a broad group of diseases that all share one critical feature, the progressive apoptotic loss of cells in the retina. There is currently no effective treatment available by which the course of these disorders can be modified, and visual dysfunction often progresses to total blindness. Gene therapy represents an attractive approach to treating retinal degeneration because the eye is easily accessible and allows local application of therapeutic vectors with reduced risk of systemic effects. Furthermore, transgene expression within the retina and effects of treatments may be monitored by a variety of noninvasive examinations. An increasing number of strategies for molecular treatment of retinal disease rely on recombinant adeno-associated virus (rAAV) as a therapeutic gene delivery vector. Before rAAV-mediated gene therapy for retinal degeneration becomes a reality, there are a number of important requirements that include: (1) evaluation of different rAAV serotypes, (2) screening of vectors in large animals in order to ensure that they mediate safe and long-term gene expression, (3) appropriate regulation of therapeutic gene expression, (4) evaluation of vectors carrying a therapeutic gene in relevant animal models, (5) identification of suitable patients, and finally (6) manufacture of clinical grade vector. All these steps towards gene therapy are still being explored. Outcomes of these studies will be discussed in the order in which they occur, from vector studies to preclinical assessment of the therapeutic potential of rAAV in animal models of retinal degeneration.

Silicone oil concentrates fibrogenic growth factors in the retro-oil fluid

AIM

To determine whether silicone oil concentrates protein and growth factors in the retro-oil fluid.

METHODS

A laboratory analysis of intraocular fluid and vitreous specimens obtained from patients undergoing removal of silicone oil, revision vitrectomy, or primary vitrectomy for macular hole, proliferative vitreoretinopathy (PVR), or retinal detachment. Patients were prospectively recruited from routine vitreoretinal operating lists. Vitreous cavity fluid and vitreous samples were analysed for the presence of transforming growth factor beta (TGF-beta2), basic fibroblast growth factor (bFGF), interleukin 6 (IL-6), and total protein using either commercially available enzyme linked immunosorbent assays (ELISA) or protein assay kits.

RESULTS

The median levels of bFGF, IL-6, and protein in the retro-oil fluid were raised (p<0.05) compared to all the other vitreous and vitreous cavity fluid samples. bFGF, IL-6, and protein levels were raised in PVR vitreous compared to non-PVR vitreous. TGF-beta2 levels were not significantly raised in retro-oil fluid or in PVR vitreous.

CONCLUSIONS

The concentration of fibrogenic (bFGF) and inflammatory (IL-6) growth factors and protein is raised in retro-silicone oil fluid. This may contribute to the process of retro-oil perisilicone proliferation and subsequent fibrocellular membrane formation.

Pathologies rétiniennes d’origine héréditaire et DMLA : nouvelles perspectives thérapeutiques

This article summarizes our current knowledge on two types of retinal diseases: hereditary retinal degeneration and wet aged-related macular degeneration. Our understanding of retinal physiopathology in hereditary retinal degeneration and the successful experimental therapeutic results on animal models call for a new approach to these patients to prepare future clinical trials. Longitudinal follow-up of the functional alteration rhythm based on international standards and by expert centers is an essential prerequisite to including these patients in future clinical trials. Creating international databases that include data on follow-up using electrophysiological, psychophysical and morphological analyses would require standards defining how each of these procedures should be carried out. Furthermore, the relevance and value of the various examinations would then be evaluated in a longitudinal manner. The repeated use of these procedures in the various centers would bring to light any limitations these techniques may have for use in prospective studies. Continuous re-evaluation of these investigative techniques will therefore be necessary, a crucial factor in the preparation of multicenter clinical studies. The inclusion of patients phenotyped at different centers would require that certification procedures be set up for these centers. A great leap forward, clinical trials on new antiangiogenic approaches for the treatment of neovascular AMD are currently underway. The reasons for the switch between the neovascular and atrophic forms of AMD are as yet unknown, but these new approaches are based on the events that occur sequentially during the angiogenic response.

[Bilateral traumatic retinopathy associated to whiplash injury]

CASE REPORT

A 20-year old female complained of a paracentral scotoma after having suffered a whiplash injury. Eye fundus examination and fluorescein angiography suggested the diagnosis of traumatic retinopathy.

DISCUSSION

There is not a clear explanation to justify the development of traumatic retinopathy after an indirect ocular trauma. Some authors favour a mixed mechanism, mechanic and vascular, to explain these alterations. We consider that a vascular aetiology is the most possible explanation for the development of traumatic retinopathy.

Acute commotio retinae determined by cross-sectional optical coherence tomography

PURPOSE

To demonstrate the cross-sectional anatomy in acute commotio retinae.

METHODS

A 27-year-old male with unilateral decreased vision after acute blunt ocular trauma, was examined by optical coherence tomography (OCT).

RESULTS

Visual acuity was 20/20 OD and 20/50 OS. Fundus examination OS demonstrated a mild edema in the papillomacular and foveal area. OCT confirmed a separation of the neurosensory retina and the retinal pigment epithelium (RPE). The thickness of the retina was normal and the contour of the foveola intact. The uncommon hyperreflective band at the outer retina may present the traumatic disruption of photoreceptors.

CONCLUSIONS

In vivo investigations by OCT confirmed previous histological studies, a commotio retinae consists a disruption and fragmentation at the level of the foveal photoreceptor segments and RPE.

Retinal periphlebitis resembling frosted branch angiitis with nonperfused central retinal vein occlusion

PURPOSE

To report the unusual association between severe retinal periphlebitis resembling frosted branch angiitis and nonperfused central retinal vein occlusion (CRVO).

METHODS

Observational case reports.

RESULTS

Patient 1 was a 28-year-old man who presented with extensive sheathing involving all retinal veins in one eye followed by nonperfused CRVO. Twenty-seven months after initial presentation, he developed perfused CRVO in the other eye followed by periphlebitis that progressed into nonperfused CRVO. Patient 2 was a 47-year-old man who presented with unilateral severe retinal periphlebitis associated with nonperfused CRVO. Despite systemic administration of corticosteroid therapy, rubeosis iridis developed in both patients and neovascular glaucoma developed in Patient 1 despite full panretinal photocoagulation. Extensive systemic workup and coagulation studies were unremarkable except for the presence of antiphospholipid antibodies in both patients and elevated plasma homocysteine level in Patient 2.

CONCLUSIONS

Severe retinal periphlebitis complicated by nonperfused CRVO is associated with poor visual outcome despite appropriate medical and surgical treatment.

The white dot syndromes

PURPOSE

To review the distinctive and shared features of the white dot syndromes, highlighting the clinical findings, diagnostic test results, proposed etiologies, treatments, and prognosis.

DESIGN

Review.

METHODS

Review of the literature.

RESULTS

Common white dot syndromes are reviewed, including acute posterior multifocal placoid pigment epitheliopathy, birdshot chorioretinopathy, diffuse unilateral subacute neuroretinitis, multiple evanescent white dot syndrome, multifocal choroiditis with panuveitis, serpiginous choroiditis, and acute zonal occult outer retinopathy.

CONCLUSIONS

The white dot syndromes are a group of disorders characterized by multiple whitish-yellow inflammatory lesions located at the level of the outer retina, retinal pigment epithelium, and choroid. For clinicians and researchers alike, they present significant diagnostic and therapeutic challenges.

Posterior segment manifestations of HIV/AIDS

The ocular posterior segment manifestations of AIDS may be divided into four categories: retinal vasculopathy, unusual malignancies, neuro-ophthalmologic abnormalities, and opportunistic infections. Microvasculopathy is the most common manifestation. Opportunistic infections, particularly cytomegalovirus retinitis and progressive outer retinal necrosis, are the most likely to result in visual loss due to infection or subsequent retinal detachment. Diagnosis and treatment are guided by the particular conditions and immune status of the patient.