Talc emboli and retinal neovascularization in a drug abuser

A 38-year-old male drug abuser had multiple emboli in the retinal circulation of the posterior pole of both eyes. He showed widespread peripheral retinal capillary nonperfusion and neovascular proliferation at the junction of perfused and nonperfused retina. The emboli were considered to be talc particles from the intravenous administration of suspensions of oral medications. The presumed mechanism of development of neovascularization in this case was the filtering out of the particles by the retinal vasculature with vaso-occlusion, ischemia and subsequent retinal neovascularization.

Cryotherapy of proliferative sickle retinopathy, II: triple freeze-thaw cycle

Complete closure of retinal neovascularisation due to proliferative sickle cell retinopathy was achieved in 28 'sea fans' (areas of neovascularisation) in 9 eyes of 9 patients by means of a triple freeze-thaw technique. However, 2 eyes developed subsequent rhegmatogenous retinal detachments, presumably related to vitreous traction on necrotic retina. We therefore recommend photocoagulation as the best treatment of proliferative sickle cell retinopathy. If opacities in the media prevent photocoagulation, a single freeze-thaw cycle is preferable.

Staphyloma: a complication of surgery for hyphema

Anterior staphylomas developed in two young patients as a postoperative complication of hyphema extractions through corneoscleral sections. The patients, aged five and nine years, underwent evacuation of the hyphemas after rebleeding caused medically unmanageable intraocular pressure elevations. Postoperatively, both patients received corticosteroids and had elevation of intraocular pressure. To repair the staphyloma, a scleral overlay patch graft was performed in one patient, but the intraocular pressure remained elevated and the staphyloma gradually recurred. Enucleation of the eye was eventually required. Resection of the staphylomatous area with lensectomy and complete vitrectomy was performed in the second patient. After four years of follow-up this patient continues to do well.

Peptostreptococcal endophthalmitis with a relapsing course

A posttraumatic exogenous endophthalmitis developed that was due to Peptostreptococcus. This Gram-positive anaerobe was isolated in pure culture from vitreous. The endophthalmitis showed a bacteriologic and clinical relapse despite conventional routes of antimicrobial treatment. A second clinical relapse occurred despite apparent vitreal sterilization with intravitreal antibiotics. The response to vitrectomy was impressive, and postoperatively the patient's visual acuity improved to 20/20.

Amelanotic small flat lesions of the choroid

On routine examination, three patients demonstrated yellow-white lesions in the posterior third of the fundus. These lesions have a subtle but unique appearance. They are in the choroid and have definite borders, minimal or no elevation, a lack of secondary changes in the overlying pigment epithelium or neuroepithelium, and no pigment within the lesion or at its borders. Ophthalmoscopic and fluorescein angiographic data permit discussion of the differential diagnosis of these lesions. They may represent amelanotic nevi of the choroid.

The disc sign in sickling hemoglobinopathies

The disc sign is the presence of dark red spots on the optic disc of patients with a sickling hemoglobinopathy. The dark spots appear to be plugs of deoxygenated erythrocytes in small surface disc vessels. The occlusions, which are transient and do not produce clinically detectable visual impairment, were seen most often in patients with homozygous sickle cell anemia and may be the result of clogging of small vessels by irreversibly sickled erythrocytes.

Therapy of scleritis with cytotoxic agents

Four patients with severe anterior scleritis that had not responded to conventional therapy were treated with cytotoxic immunosuppressive alkylating agents alone (one case) or in combination with prednisone (three cases). Two of the patients had Wegener's granulomatosis, one pyoderma gangrenosum, and one rheumatoid vasculitis. All patients responded well to this therapy with a decrease in inflammation and a healing of the sclera. Other systemic manifestations of the underlying diseases often responded well also.

Carotid artery disease and glaucoma

Five patients with evidence of severe bilateral carotid artery disease and increased intraocular pressure have been followed up for 3 to 12 years without the development of glaucomatous disc or field changes. Although it is frequently stated that glaucoma patients with low systemic or ophthalmic artery blood pressures show rapid progression of their eye disease, our patients show that this is not necessarily true. Other more important and largely unknown susceptibility factors determine the occurrence of glaucoma in patients with raised intraocular pressure.

Systemic hypotension and glaucomatous changes

We undertook a prospective study to determine the frequency of development of glaucomatous disk or field changes in a series of patients who had survived at least one episode of shock with poor peripheral tissue perfusion. In 18 patients with 26 distinct episodes of shock we were unable to demonstrate any glaucomatous disk or field changes.

An unusual presentation of Best's disease

We diagnosed an unusual case of Best's disease in a patient with multiple geographic macular and extramacular lesions. Initial confusion in the diagnosis arose because of a past history of intravenous drug abuse by the patient. The electro-oculogram was helpful in establishing the correct diagnosis.

Leber's congenital amaurosis

An early stage of Leber's congenital amaurosis, characterized by white spots or lines in the fundus, occurred in two children. Light microscopic examination of eyes obtained from one child, a 16-month-old Japanese girl, revealed subretinal deposits corresponding to the white spots and lines in the fundus deposits. Light and electron microscopic examination of the eye showed distinctive changes in the outer retinal layers and choroid, while the inner retinal layers were nearly normal. Characteristic early lesions of congenital amaurosis appeared to be produced by deposits consisting of loose outer segments and apical processes of the pigmental epithelial cell and macrophages. Undifferentiation in the nuclei of the photoreceptor cell, the inner segment, the pigment epithelial cell, and the choriocapillaris were likely characteristics of the early changes of congenital amaurosis.

Active giant cell arteritis with cerebral involvement. Findings following four years of corticosteroid therapy

A patient had continued active giant cell arteritis proved on biopsy four years after the initial diagnosis of temporal arteritis. The patient had had erythrocyte sedimentation rates within the normal range and had been receiving corticosteroids without interruption for four years. Central nervous system symptoms occurred three and four years after the initial diagnosis.

Pathways of the eye's response to topical nitrogen mustard

We studied the effect of prior corneal herpes simplex infection with its resultant corneal hypesthesia on the irritative response of the rabbit eye to topical nitrogen mustard. Both the miosis and the breakdown of the blood-aqueous barrier that follow the application of topical nitrogen mustard were diminished in eyes infected three weeks previously with herpes simplex virus. Nonspecific corneal scarring did not affect the response. This suggests again that an axon reflex requiring intact sensory innervation mediates the response to nitrogen mustard. Pretreatment of normal (noninfected) rabbits with systemic H1 and H2 antihistamines, topical scopolamine hydrobromide, or topical and systemic corticosteroids was ineffective in blocking the miosis or increased protein in the aqueous humor following topical nitrogen mustard.

Occlusive retinal arteriolitis with neovascularization

A 34-year-old white woman who had used oral contraceptives for six years showed an occlusive bilateral retinal arteriolitis that resulted in a branch arteriolar occlusion in the right eye and retinal neovascularization. Three years later, we observed active arteriolitis in the left eye with successive occlusion of several branch arterioles. The disease has shown spontaneous remissions and exacerbations. An extensive medical evaluation revealed only old pulmonary granulomatous disease and an elevated sedimentation rate in association with exacerbations of the arteriolitis.

Diagnostic features of the Favre-Goldmann syndrome

Extensive retinal vascular disease was noted in three patients from two families with Favre-Goldmann syndrome. In addition to classical features they had pronounced leakage from some retinal vessels. Vessels were either opaque ('sclerotic') or non-perfused. Cystoid macular oedema was a contributing cause of decreased vision. Two of the three patients showed a discrepancy on electroretinography between single-flash photopic amplitudes and flicker fusion frequency. This may be characteristic of Favre-Goldmann syndrome.

Ischemia of ciliary arterial circulation from ocular compression

Two patients developed unilateral central retinal artery and posterior ciliary artery occlusions related to ocular compression during general anesthesia. One patient had evidence of extensive choroidal ischemia with diffuse hypopigmentation, pigmentary mottling of the posterior pole, and disc edema. Electroretinography showed diminution of the A and B waves. The other patient showed patchy choroidal ischemia with subsequent development of wedge-shaped areas of pigmentary atrophy and mottling in the midperiphery. Iridocyclitis and prolonged hypotony were also present. Retinal and posterior ciliary artery occlusion (perhaps at the level of the ophthalmic artery) can occur as a result of ocular compression by a face mask or an improperly positioned headrest. Systemic hypotension is a factor in many cases. Proper positioning of the head on an adequate headrest and avoidance of ocular compression will prevent the occurrence of retinal and choroidal occlusion during general anesthesia.

Comma-shaped venular segments of conjunctiva in chronic granulocytic leukemia

Isolated comma or corkscrew-shaped venular segments in the conjunctiva have been felt to be diagnostic of sickle cell disease. External eye examination of a 34-year-old black man with a two-year history of chronic granulocytic leukemia revealed multiple small and medium-sized isolated conjunctival venular segments. Laboratory findings at the time of examination included a white blood cell count of 132,000/mm3 with 87% eosinophils, a hematocrit reading of 30%, and hemoglobin AA. Since whole blood hyperviscosity can be present in chronic granulocytic leukemia as well as sickle cell disease, this may account for the similarly of the conjunctival changes.

Peripheral retinal microaneurysms in chronic leukemia

Of 25 patients with chronic leukemia, there was clinical evidence of peripheral retinal microaneurysm formation in two of eight patients with chronic lymphocytic leukemia and six of 17 patients with chronic myelogenous leukemia. There was no proliferative retinopathy in any of the 25 patients. An elevated leukocyte count seemed necessary for microaneurysm formation in leukemia, although some patients with elevated counts had no microaneurysms. The prolonged leukocytosis of chronic leukemia can produce peripheral capillary dropout, vascular stagnation, microaneurysm formation, and, rarely, peripheral proliferative retinopathy similar to sickle cell disease.

Pathways for the response of the eye to injury

The role of a neural pathway in the disruption of the blood-aqueous barrier of the rabbit after two irritating stimuli, topical nitrogen mustard, and paracentesis, was studied. Retrobulbar anesthesia or section of the ophthalmic division of the trigeminal nerve decreased the breakdown of the blood-aqueous barrier, as measured by protein in the aqueous humor, after topical nitrogen mustard. Sensory denervation, accomplished with retrobulbar alcohol, virtually prevented the protein rise in the aqueous humor. Disruption of the blood-aqueous barrier after paracentesis, however, was not affected by retrobulbar anesthesia or alcohol denervation. Therefore, the increased protein in the aqueous humor after an irritative stimulus appears to be mediated by at least two pathways. The response to a stimulus such as nitrogen mustard depends on sensory innervation and is not mediated by prostaglandins to any important degree. The response to paracentesis does not require sensory innervation and appears to be mediated, at least in part, by prostaglandins.

Ocular clinical findings and basement membrane changes in Goodpasture's syndrome

Goodpasture's syndrome is a rapidly progressive disease characterized by the onset of pulmonary hemorrhage with glomerulonephritis, leading to pulmonary and renal failure. The hallmark of this disease is linear deposition of antibasement membrane IgG in the basement membranes of the kidney and lung. In two cases of nonrhegmatogenous retinal detachment in patients with Goodpasture's syndrome, the first patient demonstrated multiple ischemic areas in the choroid on fluorescein angiography. Histopathologic and immunologic studies of the eyes in the second patient demonstrated macular edema and elevation of the retina in association with choroidal infarction and linear deposition of IgG in Burch's membrane and the basement membranes of the choroidal vessels.

IgA associated lymphoplasmacytic tumor involving the conjunctiva, eyelid, and orbit

A 65-year-old white man had an unusual disseminated lymphoid tumor that first appeared in the subconjunctival tissues of the right eye. The tumor later appeared in the skin, lymph nodes, and left upper eyelid and orbit. A monoclonal serum IgA spike was present although the urine did not contain Bence Jones proteins. The cells of the tumor appeared to be plasmacytoid lymphocytes. Prominent intranuclear inclusions, or Dutcher bodies, were present. Throughtout the 11-year history, the patient has been treated only with local excision and radiation.