Sympathetic ophthalmia associated with pars plana vitrectomy without antecedent penetrating trauma

PURPOSE

To evaluate, describe, and categorize the clinical presentation, clinical course, histopathology, and response to therapy in patients without a history of penetrating ocular trauma who developed sympathetic ophthalmia following pars plana vitrectomy.

METHODS

The records of patients without a history of trauma who underwent pars plana vitrectomy and developed sympathetic ophthalmia were retrospectively reviewed. Cases were analyzed with respect to clinical presentation, fluorescein angiographic findings, anatomic and visual outcomes, histopathology, and response to therapy.

RESULTS

Eight eyes were identified. The median age at presentation was 55 years, with a range of 14 to 62 years. The time from vitrectomy to diagnosis of sympathetic ophthalmia ranged from 2 months to greater than 2 years, with a median of 7 months. Six of eight patients (75%) presented with anterior chamber reaction. All eight patients presented with a vitreous inflammatory response. The optic nerve was inflamed clinically or angiographically in four of eight cases (50%). Small yellow-white sub-retinal pigment epithelial deposits were present in four of eight cases (50%). Two eyes had lesions characterized as multifocal choroiditis. One eye had larger yellow placoid-like lesions. One eye presented with vitritis but no retinal lesions. Subretinal choroidal neovascularization was noted in the inciting eye of one patient. Vision improved in the sympathizing eye with immunosuppressive therapy in five of eight cases (62.5%).

CONCLUSIONS

Sympathetic ophthalmia can be seen following pars plana vitrectomy in patients without penetrating injuries or a history of trauma. Indeed, it may be seen after successful vitrectomy for retinal detachment. Diverse clinical presentations are possible, and persistent or atypical uveitis following vitrectomy should alert the surgeon to the development of sympathetic ophthalmia.

Retinal findings in melanoma-associated retinopathy

PURPOSE

To report unusual fundus findings in two cases of melanoma-associated retinopathy.

METHODS

Observational case reports. The histories of two patients with melanoma-associated retinopathy were reviewed. Sera from both patients were examined for antibodies against retinal bipolar cells. Immunofluorescence was performed on cryostat sections of unfixed normal human retinas. Sera and IgG from both patients were tested against a known melanoma-associated retinopathy patient as well as a control subject.

RESULTS

Our patients had metastatic, cutaneous melanoma and a clinical syndrome consistent with melanoma-associated retinopathy. Both patients had serum antibodies that were reactive against retinal bipolar cells. They had unusual fundus changes not previously described in association with melanoma-associated retinopathy. One patient also developed vitiligo.

CONCLUSION

Patients with metastatic cutaneous melanoma and melanoma-associated retinopathy may present unusual fundus lesions that may be caused by autoimmunity which is part of the clinical picture of melanoma-associated retinopathy or metastatic melanoma.

Variations in the presentation of primary intraocular lymphoma: case reports and a review

Primary intraocular lymphoma is a distinct subset of primary non-Hodgkin's lymphoma of the central nervous system (CNS). Diagnosis can be difficult and is often delayed, as the clinical presentation can mimic a number of other ocular conditions. This report describes four different presentations of intraocular lymphoma and focuses on its modes of clinical presentation. Primary intraocular lymphoma can present with a wide variety of manifestations frequently mimicking diffuse uveitis that is refractory to corticosteroids. Subretinal pigment epithelium tumors may be seen. However, other presentations may include multiple deep white dots in the retina secondary to tumor infiltration; retinal infiltration, causing a necrotizing retinitis; or infiltration of the retinal vasculature, causing arterial or venous obstruction. Finally, optic nerve invasion may be seen. CNS lymphoma develops in the majority of patients before, in conjunction with, or after the development of eye disease. Intraocular lymphoma often has a fatal outcome, but recognition of its modes of presentation facilitates early diagnosis and treatment that may improve prognosis.

Differentiation between presumed ocular histoplasmosis syndrome and multifocal choroiditis with panuveitis based on morphology of photographed fundus lesions and fluorescein angiography

OBJECTIVE

To evaluate whether inactive cases of presumed ocular histoplasmosis syndrome (POHS) and multifocal choroiditis with panuveitis (MFC) can be differentiated from each other by their appearance on fundus photography and fluorescein angiography.

METHODS

Two masked observers classified 50 patients' photographs (27 with fluorescein angiograms) as POHS, MFC, or "indeterminate." Twenty-five patients had known POHS and 25 had known MFC. Statistical analysis was performed to assess agreement and interrater reliability.

RESULTS

Observer A classified 33 patients and was indeterminate on 17. Of the 33, he was correct on 26 (79% crude accuracy; kappa = 0.560; 95% confidence interval [CI], 0.286-0.834). Observer B classified 40 patients and was indeterminate on 10. Of the 40, he was correct on 33 (82% crude accuracy; kappa = 0.650; 95% CI, 0.422-0.878). Both observers ventured a diagnosis on 28 common patients. Of these, they selected the same diagnosis on 26 (93% crude agreement). When the 2 observers' diagnoses were compared and indeterminate patients were factored in, the kappa value was 0.408 (95% CI, 0.215-0.601). When the indeterminate patients are excluded, the kappa agreement increased to 0.825 (95% CI, 0.592-1). When pictures only were available, observer A and observer B kappa values against the gold standard were 0.625 (95% CI, 0.270-0.980) and 0.588 (95% CI, 0.235-0.940), respectively. The pictures-only kappa values for observer A vs observer B were 0.582 (95% CI, 0.316-0.848) with indeterminate patients factored in and 1.0 (95% CI, 1.0-1.0) when indeterminate patients were excluded. Pictures and fluorescein angiogram kappa values were 0.493 (95% CI, 0.076-0.909) for observer A and 0.706 (95% CI, 0.413-0.999) for observer B against the gold standard. For observer A vs observer B, the kappa value was 0.261 (95% CI, -0.002 to 0.524) with indeterminate patients factored in and 0.567 (95% CI, 0.032-1) excluding indeterminate patients. Sensitivity for all cases for observer A was 60% (+/-13%) for POHS and 94% (+/-6%) for MFC. For observer B, the sensitivity for all cases was 70% (+/-10%) for POHS and 95% (+/-5%) for MFC.

CONCLUSIONS

Given adequate funduscopic information, the experienced observer can often accurately distinguish between POHS and MFC without the need for ancillary testing. Angiography in addition to fundus photography does not appear to increase diagnostic ability. There appears to be a higher sensitivity for MFC than for POHS.

Relentless placoid chorioretinitis: A new entity or an unusual variant of serpiginous chorioretinitis?

OBJECTIVE

To characterize an unusual clinical entity resembling acute posterior multifocal placoid pigment epitheliopathy (APMPPE) and serpiginous choroiditis but with an atypical clinical course.

PATIENTS

We describe 6 patients, aged 17 through 51 years, exhibiting this unusual entity who were seen at 6 different centers from 1984 to 1997.

RESULTS

The acute retinal lesions in this series were similar to those of APMPPE or serpiginous choroiditis, both clinically and on fluorescein and indocyanine green angiography. However, the clinical course, number of lesions, and location of these lesions were atypical. These patients had evidence of numerous posterior and peripheral retinal lesions predating or occurring simultaneously with macular involvement. Older, healing pigmented lesions were often accompanied by the appearance of new active white placoid lesions. Additionally, these cases all demonstrated prolonged periods of activity resulting in the appearance of more than 50 and sometimes hundreds of lesions scattered throughout the fundus. Growth of subacute lesions and the appearance of new lesions continued for 5 to 24 months after initial examination, and relapses were common.

CONCLUSIONS

This entity has clinical features similar to APMPPE and serpiginous choroiditis but has a prolonged progressive clinical course and widespread distribution of lesions. It may represent a variant of serpiginous choroiditis or may be a new entity. We call it relentless placoid chorioretinitis. Arch Ophthalmol. 2000;118:931-938

Progressive optic nerve cupping and neural rim decrease in a patient with bilateral autosomal dominant optic nerve colobomas

PURPOSE

To document progressive optic nerve cupping and neural rim decrease in a patient with normal intraocular pressures and bilateral autosomal dominant optic nerve colobomas.

METHODS

The ophthalmology records, stereoscopic fundus photographs, and visual fields of a 27-year-old woman with familial (autosomal dominant) optic nerve colobomas were reviewed. The appearance of the optic nerves was documented over a 13-year period (1985 to 1998).

RESULTS

Despite repeatedly normal intraocular pressures, the patient showed progressive optic nerve cupping and neural rim decrease in both eyes. Visual field testing was available over a 5-year period (1993 to 1998) and was abnormal, but no progression was seen.

CONCLUSIONS

This case of progressive cupping and neural rim decrease in a patient with autosomal dominant optic nerve coloboma in both eyes may provide insight into the optic nerve cupping associated with normal tension glaucoma. Careful follow-up of patients with optic disk colobomas or patients is indicated to detect possible optic nerve changes or field loss.

Pigmented adenoma mimicking a juxtapapillary melanoma. A 20-year follow-up

A 52-year-old white woman was first diagnosed with a tumor of the right optic nerve in 1972. She remained asymptomatic until 1992, when she had a seizure on the left side of her body from a frontoparietal glioblastoma multiforme. Ophthalmic examination revealed enlargement of the eye tumor. This case provides clinical documentation spanning 20 years of a growing, pigmented tumor of the optic nerve head shown histopathologically to be a retinal pigment epithelial adenoma.

Idiopathic polypoidal choroidal vasculopathy of the macula

OBJECTIVE

The authors evaluated the clinical, fluorescein, and indocyanine green (ICG) angiographic characteristics of the macular variant of idiopathic polypoidal choroidal vasculopathy (IPCV).

DESIGN

Observational case series.

PARTICIPANTS

The records, photographs, and fluorescein and ICG angiograms of eight eyes of seven patients with IPCV lesions confined to the macula were reviewed.

MAIN OUTCOME MEASURES

The visual acuity, fundus examination, fluorescein and ICG angiographic characteristics, and clinical course were compared.

RESULTS

All patients demonstrated polypoidal lesions arising from macular choroidal vessels on ICG angiography. One patient had bilateral lesions. These lesions appeared hyperfluorescent in the early phases of both fluorescein and ICG angiography. Late-phase leakage was seen in cases associated with subretinal fluid or exudate. None of these patients demonstrated polypoidal lesions arising from the peripapillary choroidal circulation or peripapillary choroidal neovascularization. Three eyes with polypoidal lesions that were associated with subretinal fluid and exudates were treated with photocoagulation. Five eyes were not treated. Final visual acuity ranged from 20/20 to hand motions. Severe visual loss was associated with vitreous and subretinal hemorrhage, but this resolved without permanent severe visual loss in several cases.

CONCLUSIONS

In the macular variant of IPCV, ICG and fluorescein angiography demonstrate characteristic macular polypoidal lesions without evidence of peripapillary lesions. The vascular origin of these polypoidal lesions appears to be the macular choroidal circulation. This is distinguished from classic IPCV, in which lesions appear to arise from the peripapillary choroidal circulation. Visual prognosis appears to be good, with most patients retaining visual acuity of 20/80 or better. If subretinal fluid or exudates reduce visual acuity, photocoagulation should be considered.

Drug-induced uveitis

Uveitis has been reported in association with a variety of topical, intraocular, periocular, and systemic medications. To establish causality of adverse events by drugs, in 1981, Naranjo and associates proposed seven criteria, which are related to the frequency and documentation of the event; circumstances of occurrence, recovery, and recurrence; and coexistence of other factors or medications. Rarely does a drug meet all seven criteria. The authors review reports of drug-associated uveitis, applying the seven criteria and examining possible mechanisms. Only systemically administered biphosphonates and, perhaps, topical metipranolol meet all seven criteria. Systemic sulfonamides, rifabutin, and topical glucocorticoids fulfill at least five criteria.

Results of peripheral laser photocoagulation in pars planitis

PURPOSE

To determine the effect of peripheral retinal laser photocoagulation (PLP) on visual acuity, intraocular inflammation, and other ocular findings, including retinal neovascularization in eyes with pars planitis.

METHODS

A retrospective chart review of eyes with pars planitis that had undergone PLP.

RESULTS

Twenty-two eyes in 17 patients with pars planitis had undergone treatment with PLP at 2 centers. The mean age at the time of treatment was 19.3 years. Following treatment, mean follow-up was 16.3 months (range, 6 to 37 months). Mean visual acuity was 20/60 preoperatively and 20/50 postoperatively. This level of improvement was not statistically significant (P > .10), but there was a statistically significant decrease in the use of corticosteroids between the preoperative examination and the last postoperative examination (86% versus 27%, P < .05). There was also a statistically significant decrease in vitritis at the last follow-up (P = .0008) and a decrease in neovascularization of the vitreous base (P = .03) and in clinically apparent cystoid macular edema (P = .02). Epiretinal membranes were noted in 23% of eyes preoperatively and in 45% of eyes postoperatively. Only one of these epiretinal membranes was considered to be visually significant. One eye developed a tonic dilated pupil, which slowly improved.

CONCLUSIONS

Although the long-term natural history of clinical findings in pars planitis is not well documented, PLP appears to decrease the need for corticosteroids while stabilizing visual acuity. It also appears to decrease vitreous inflammation. PLP has few complications and should be considered in patients with pars planitis who are unresponsive or have adverse reactions to corticosteroids.

Unifocal helioid choroiditis

OBJECTIVE

To report a previously undescribed clinical entity involving an unusual inflammatory lesion of the choroid.

PATIENTS

Six young, healthy patients experienced acute unilateral visual loss secondary to unifocal choroiditis in the macula.

RESULTS

All patients exhibited a solitary, elevated, yellow-white active focus of choroiditis with overlying subretinal fluid and in some cases subretinal hemorrhaging. The lesions were approximately 1 disc diameter in size and, on follow-up, showed minimal growth, then gradual resolution of the subretinal fluid. No other signs of ocular inflammation were noted, except in 1 patient who had anterior chamber and vitreous inflammation. In the 3 patients with prolonged follow-up, elevated white plaquelike lesions persisted with little change over time. Relapses were seen, and some permanent visual loss occurred in 1 of the 3 patients. Systemic evaluations revealed no definitive etiology.

CONCLUSIONS

To our knowledge, these patients exhibit an undescribed clinical entity, separable from previously established choroidal disorders. The cause of the lesions remains uncertain. We call this entity "unifocal helioid choroiditis."

Management of varicella zoster virus retinitis in AIDS

AIMS/BACKGROUND

Varicella zoster virus retinitis (VZVR) in patients with AIDS, also called progressive outer retinal necrosis (PORN), is a necrotising viral retinitis which has resulted in blindness in most patients. The purposes of this study were to investigate the clinical course and visual outcome, and to determine if the choice of a systemic antiviral therapy affected the final visual outcome in patients with VZVR and AIDS.

METHODS

A review of the clinical records of 20 patients with VZVR from six centres was performed. Analysis of the clinical characteristics at presentation was performed. Kruskall-Wallis non-parametric one way analysis of variance (KWAOV) of the final visual acuities of patients treated with acyclovir, ganciclovir, foscarnet, or a combination of foscarnet and ganciclovir was carried out.

RESULTS

Median follow up was 6 months (range 1.3-26 months). On presentation, 14 of 20 patients (70%) had bilateral disease, and 75% (15 of 20 patients) had previous or concurrent extraocular manifestations of VZV infection. Median initial and final visual acuities were 20/40 and hand movements, respectively. Of 39 eyes involved, 19 eyes (49%) were no light perception at last follow up; 27 eyes (69%) developed rhegmatogenous retinal detachments. Patients treated with combination ganciclovir and foscarnet therapy or ganciclovir alone had significantly better final visual acuity than those treated with either acyclovir or foscarnet (KWAOV: p = 0.0051).

CONCLUSIONS

This study represents the second largest series, the longest follow up, and the first analysis of visual outcomes based on medical therapy for AIDS patients with VZVR. Aggressive medical treatment with appropriate systemic antivirals may improve long term visual outcome in patients with VZVR. Acyclovir appears to be relatively ineffective in treating this disease.

Choroidal neovascularization secondary to Candida albicans chorioretinitis

PURPOSE

To study the clinical histories and courses of six patients with choroidal neovascularization secondary to endogenous Candida albicans chorioretinitis.

METHODS

The medical records, fundus photographs, and fluorescein angiograms of six patients who developed C. albicans chorioretinitis secondary to candidemia and who subsequently developed choroidal neovascularization in one or both eyes were reviewed.

RESULTS

The six patients ranged in age from 18 to 79 years. Four were women and two men; all but one showed evidence of bilateral chorioretinal scarring secondary to C. albicans chorioretinitis. All patients had been treated successfully with systemic antifungal therapy (amphotericin B). Two weeks to two years after the chorioretinitis, choroidal neovascularization developed in one eye (four cases) or both eyes (two cases). The neovascularization on initial examination was subfoveal in four eyes, extrafoveal in three eyes, and juxtafoveal in one eye. Laser photocoagulation was used in four of the eight involved eyes. In these cases, the active choroidal neovascularization was brought under control. In one eye, the patient had submacular surgery for excision of the choroidal neovascular membrane. Final visual acuities ranged from 20/20 to 20/200 in treated eyes and from 20/50 to 20/400 in untreated eyes.

CONCLUSION

Choroidal neovascularization is a potential cause of late visual loss in patients who have had C. albicans sepsis and endogenous C. albicans chorioretinitis. Eyes that have chorioretinal scarring from C. albicans chorioretinitis should be watched for the development of choroidal neovascularization. Laser photocoagulation or perhaps surgical excision of the neovascular complex may be of benefit in selected cases.

New concepts of regulation of retinal vessel tone

OBJECTIVE

To review the mechanisms of local regulation of the vascular tone of the retinal and choroidal circulations.

DESIGN

Literature review.

RESULTS

The vascular endothelial cell may produce nitric oxide, endothelins, prostaglandins, and renin-angiotension products in response to chemical stimuli such as acetylcholine and bradykinin, to changes in blood pressure and vessel wall stress, to changes in local oxygen levels, and to other local stimuli. These substances are among the most potent vasoconstrictors and vasodilators known. Preliminary investigations suggest a potential role for these substances in endothelial autoregulation of the retinal and choroidal vasculatures.

CONCLUSION

Hormonal products of the vascular endothelium may provide the final common pathway for vessel autoregulation in response to varying physiologic stress in many vascular beds, including the retina and choroid. Pharmacologic modulation of this process may provide treatment modalities for diseases such as hypertensive and diabetic retinopathies.

Intraocular lymphoma presenting as retinal vasculitis

We describe two unusual young patients with intraocular lymphoma who presented clinically with "retinal vasculitis." Brain biopsy specimens in both showed an angiocentric pattern of lymphocytic infiltration. Immunohistochemical studies were positive for T-cell markers. Both the retinal and the brain blood vessels were thus a preferential site of appearance of the malignant T-cells. Both cases responded favorably to aggressive chemotherapy with long-term survival. In the world's literature, there are 57 cases of intraocular lymphoma in which cell surface-marker studies were performed; of these, 53% proved to be B-cell lymphomas and 21% to be T-cell lymphomas. As more cases of intraocular lymphoma are studied with cell-typing and as our histochemical techniques improve, a correlation between the systemic and ocular findings and the cell type may be revealed.

Cytomegalovirus retinitis

Cytomegalovirus retinitis is the most common ocular opportunistic infection in patients infected with human immunodeficiency virus and remains a significant cause of visual loss in patients with the acquired immunodeficiency syndrome. Drugs are now available to treat this condition and recent advances in delivery techniques offer promising alternatives to traditional methods.

Peripheral proliferative retinopathies: an update on angiogenesis, etiologies and management

Many clinical entities may be associated with the development of peripheral retinal neovascularization. In this paper, we review the mechanisms of normal and abnormal angiogenesis in the retina. Specific disease entities associated with peripheral proliferative retinopathies are discussed. These include vascular disease with ischemia, inflammatory diseases with possible ischemia and a variety of miscellaneous causes, including hereditary diseases and tumors. Basic principles for the clinical evaluation of patients with retinal neovascularization are described. Finally, the treatments for retinal neovascularization, including cryopexy and local and panretinal photocoagulation are reviewed, and techniques and possible mechanisms of the beneficial results of treatment are described.

Cavernous hemangioma of the optic nerve

BACKGROUND

Cavernous hemangioma of the retina and optic disc is a rare lesion that was first defined as a distinct entity by Gass in 1971. It is usually easily recognized by its characteristic appearance of saccular "grape-like" lesions. On fluorescein angiography, plasma-erythrocyte separation is seen.

METHODS

Two patients with cavernous hemangioma of the optic nerve were examined over a period of 5 to 10 years.

RESULTS

Although these tumors are usually considered to be static and not capable of growth, these two cases of cavernous hemangioma of the optic nerve showed documented growth. One case required vitrectomy for vitreous hemorrhage.

CONCLUSION

Cavernous hemangioma of the optic disc can grow and can cause vitreous hemorrhage severe enough to require vitrectomy.

Chronic recurrent multiple evanescent white dot syndrome

PURPOSE

Multiple evanescent white dot syndrome (MEWDS) is usually unilateral, self-limited, and monophasic. The purpose of this study was to demonstrate that a chronic recurring form of the disease exists.

METHODS

Three patients with otherwise typical MEWDS were observed for 4 to 5 years. Their ocular histories and physical findings were recorded.

RESULTS

Multiple recurrences (5-7) involving both eyes were noted in each of the three patients. Classic clinical findings were seen, including granularity to the macula, white dots, and optic disc changes. Despite these recurrences, the patients still retained visual acuity of 20/20 in each eye.

CONCLUSION

A chronic recurrent form of MEWDS exists. The cause of MEWDS remains unknown, and it is unclear why these patients demonstrated this atypical clinical course.

Retinal periphlebitis in patients with acquired immunodeficiency syndrome with cytomegalovirus retinitis mimics acute frosted retinal periphlebitis

Acute frosted retinal periphlebitis is an inflammatory condition of unknown origin characterized by marked perivenular infiltration in otherwise healthy patients. We encountered seven patients with acquired immunodeficiency syndrome who exhibited visual loss associated with an unusual diffuse retinal periphlebitis very similar in appearance to acute frosted retinal periphlebitis. Each patient developed a thick inflammatory infiltrate surrounding the retinal venules, creating a frosted appearance. Two cases were bilateral. All patients had areas of more typical cytomegalovirus retinitis in their involved eye(s). Five of six patients treated with ganciclovir sodium showed improvement not only of the cytomegalovirus retinitis but also of the periphlebitis. Although we do not have histopathologic evidence that cytomegalovirus was the cause of these cases of periphlebitis, we believe that periphlebitis may be a previously unrecognized finding of cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome. So far, there is no evidence implicating cytomegalovirus as the cause of acute frosted retinal periphlebitis in healthy patients.

Complications of glaucoma surgery. Ocular decompression retinopathy

In seven eyes of four patients, retinal hemorrhages were observed following trabeculectomy under both local and general anesthesia. The hemorrhages were diffuse, both deep and superficial, and many had white centers when first observed. Two patients were young healthy male myopes undergoing primary trabeculectomy. The third patient was a young man with chronic uveitis. The fourth patient was an elderly man with primary open angle glaucoma who had an acute rise in intraocular pressure following cataract extraction. Intraocular pressure and visual results appeared unaffected by the hemorrhages. Retinal hemorrhages associated with ocular decompression appear to be relatively benign.

Primary malignant melanoma of the optic nerve simulating a melanocytoma

Primary malignant melanoma of the optic nerve head is an extremely rare tumor. We describe a patient with a pigmented optic nerve lesion that simulated a growing melanocytoma. The pigmented tumor slowly infiltrated the optic nerve causing disc edema, retinal venous congestion, progressive visual field loss, and eventually, loss of central acuity. Following enucleation of the eye, and later resections of the optic nerve to the chiasm, histopathologic examination of the optic nerve, disc, and peripapillary region demonstrated a primary malignant melanoma of the optic nerve without choroidal involvement. Involvement of the optic nerve extended 26 mm beyond the lamina cribrosa. Malignant melanoma of the optic nerve is a real entity and may clinically simulate a melanocytoma.

Choroidal neovascularization associated with choroidal hemangiomas

Two patients with choroidal hemangiomas developed choroidal neovascularization. One patient with Sturge-Weber syndrome, a unilateral diffuse choroidal hemangioma, and a serous detachment of the macula was treated with yellow dye laser photocoagulation in a grid pattern to the tumor before glaucoma filtration surgery. Four years after successful laser treatment, the patient developed subfoveal choroidal neovascularization in an area of treatment. A second patient with a circumscribed choroidal hemangioma developed spontaneous subfoveal choroidal neovascularization 12 years after initial diagnosis of the hemangioma. The development of choroidal neovascularization associated with choroidal hemangiomas represents a potential cause of poor visual outcome in these patients.

Ocular findings of incontinentia pigmenti in a male infant with Klinefelter syndrome

A male infant with Klinefelter karyotype (47, XXY) manifested both the typical dermatologic findings of the X-linked dominant disorder incontinentia pigmenti (Bloch-Sulzberger syndrome) and ocular findings including retinal pigmentary changes, peripheral retinal avascularity, and preretinal fibrovascular proliferation. To our knowledge, this is the first reported case of incontinentia pigmenti with this specific abnormal genotype manifesting ocular findings.

Improvement in visual acuity in chronic aphakic and pseudophakic cystoid macular edema after treatment with topical 0.5% ketorolac tromethamine

Ketorolac tromethamine 0.5% ophthalmic solution treatment was compared to placebo treatment in 120 patients with chronic aphakic or pseudophakic cystoid macular edema (six-month or more duration of distance visual acuity of 20/40 or less and angiographic evidence of cystoid changes) during a four- to five-month double-masked, multicenter study in which patients were randomly assigned. A statistically significant improvement in distance visual acuity (two lines or more) was observed in the ketorolac-treated group as compared to the placebo-treated group after 30 days (P = .038), 60 days (P = .017), and 90 days (P = .008) of treatment. This improvement in visual acuity remained statistically significant one month after cessation of treatment (P = .001). Nine ketorolac-treated patients and two placebo-treated patients demonstrated a decrease in visual acuity one month after treatment was discontinued. Seven of the nine ketorolac-treated patients experienced an improvement in visual acuity after retreatment as compared to none of the placebo-treated patients. This study offers evidence for a more optimistic outlook in the medical treatment of chronic aphakic and pseudophakic cystoid macular edema.

Blind spot enlargement as a manifestation of multifocal choroiditis

Enlargement of the blind spot without optic disc edema has been reported in patients with no other ocular findings (acute idiopathic blind spot enlargement) and in patients with multiple evanescent white dot syndrome. We describe three patients with multifocal choroiditis who developed acute symptomatic enlargement of the blind spot. All three patients were young women in excellent health. During the course of the blind spot enlargement, the appearance of the optic nerve remained normal. We demonstrate that acute enlargement of the blind spot without disc edema occurs in patients with multifocal choroiditis. This enlargement is likely due to peripapillary retinal dysfunction. We speculate on the association of multifocal choroiditis with acute idiopathic blind spot enlargement and multiple evanescent white dot syndrome.

Unilateral acute idiopathic maculopathy

This is a report of nine patients who experienced sudden, severe, unilateral central vision loss following a flulike illness. Each patient had an exudative detachment of the macula. All patients experienced a spontaneous resolution of the acute macular manifestations with near-complete recovery of vision. A characteristic "bull's-eye" appearance in the macula persisted. The acute manifestations of the disorder did not recur in any of the patients during the period of follow-up. The constellation of findings was suggestive of an inflammatory disease of the retinal pigment epithelium, but a specific causative agent could not be identified. The acute clinical and angiographic features, the natural course, and the residual pigment epithelial derangement were not consistent with any previously described disorder.

Unilateral frosted branch angiitis

We examined two patients with monocular frosted branch angiitis. The patients were young and healthy; they rapidly developed severe visual loss with thick, white sheathing of the retinal veins and responded promptly to systemic corticosteroids. The fluorescein angiograms showed late leakage from the retinal veins, without evidence of stasis or occlusion. Frosted branch angiitis can be either a unilateral or a bilateral condition. We believe the potential for visual loss and the prompt response to systemic corticosteroids make early, accurate diagnosis and institution of therapy desirable.

A randomized clinical trial of feeder vessel photocoagulation of sickle cell retinopathy. A long-term follow-up

Long-term follow-up of patients enrolled in a randomized prospective trial of feeder vessel photocoagulation for proliferative sickle retinopathy has been completed. Of the 44 patients enrolled in Chicago, nearly a decade follow-up has been achieved on 29 patients (45 eyes). There were 20 control untreated eyes and 25 argon laser-treated eyes. Prolonged loss of visual acuity was rare in both groups. Argon laser photocoagulation has had a sustained effect on reducing the incidence of vitreous hemorrhage and visual loss from vitreous hemorrhage. Nine (45%) of 20 control eyes had vitreous hemorrhage, and it was recurrent in six (66%) of these nine eyes. A single episode was the only hemorrhagic event in the treated eyes. The laser-induced complications of choroidal neovascularization or retinal detachment were not associated with long-term visual sequelae. New sea fan evolution in 47% of study eyes suggests that these patients require long-term surveillance.

Idiopathic sclerochoroidal calcification

Idiopathic sclerochoroidal calcification is a disorder that is often overlooked, occurring at the level of the posterior sclera and choroid in older patients. Clinically, it may be confused with choroidal osteoma, choroidal metastasis, amelanotic choroidal nevus, or choroiditis. The authors present seven cases of this unusual entity. The patients ranged in age from 58 to 80 years. In all cases, the yellow lesions were clinically estimated to be at the level of the choroid and sclera, and they were usually located superior to the superotemporal retinal vascular arcade. Systemic investigation of calcium and phosphate metabolism was normal in all patients. The classic clinical manifestations and differentiation of this unusual entity from other similar fundus lesions is discussed.

An update on techniques of photocoagulation treatment of proliferative sickle cell retinopathy

Proliferative sickle cell retinopathy (PSR) can lead to visual loss from vitreous haemorrhage and traction or rhegmatogenous retinal detachment. We review two techniques of photocoagulation for PSR, feeder vessel photocoagulation and scatter photocoagulation. A prospective randomised trial of feeder vessel photocoagulation for PSR demonstrated that the incidence of vitreous haemorrhage and visual loss was diminished in eyes which were treated. Since this technique of treatment is difficult and can be associated with choroidal neovascularisation and retinal tears, scatter photocoagulation has also been tested. A prospective randomised trial of scatter photocoagulation for PSR demonstrated a decreased incidence of vitreous haemorrhage and visual loss in treated eyes compared to untreated eyes. No complications of scatter treatment were noted. We presently recommend local scatter photocoagulation to areas of PSR. In unreliable patients, we recommend 360 degrees of peripheral circumferential treatment as otherwise new seafans will develop. If scatter photocoagulation does not result in sufficient regression of the neovascularisation and vision threatening complications such as vitreous haemorrhage continue, feeder vessel treatment can be used to supplement the scatter treatment.

A randomized clinical trial of scatter photocoagulation of proliferative sickle cell retinopathy

A randomized prospective clinical trial of argon laser scatter photocoagulation therapy for proliferative sickle cell retinopathy was performed on 116 patients (174 eyes) in Kingston, Jamaica. Ninety-nine eyes were treated with scatter photocoagulation and 75 eyes served as controls. The average length of follow-up was 42 months for the control eyes and 47 months for the treated eyes. Prolonged loss of visual acuity was statistically significantly reduced in the treated eyes. The incidence of vitreous hemorrhage was also significantly reduced in the treated eyes after controlling for the previously defined risk factors of vitreous hemorrhage and extent of proliferative sickle cell retinopathy at entry into the study. There were no complications associated with argon laser scatter photocoagulation. Scatter photocoagulation of proliferative sickle cell retinopathy is currently the most effective and safe way to treat patients with sea fan neovascularization.