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Meng PP, Lin CJ, Hsia NY, Lai CT, Bair H, Lin JM, Tsai YY. MULTIMODAL IMAGING OF ACUTE MULTIFOCAL HEMORRHAGIC RETINAL VASCULITIS: A CASE REPORT. Retin Cases Brief Rep 2023; 17:65-69. [PMID: 33290296 DOI: 10.1097/icb.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PURPOSE To report a case of acute multifocal hemorrhagic retinal vasculitis and demonstrate the multimodal imaging. METHODS Interventional case report. RESULTS A 54-year-old woman without significant past medical history complained of redness and blurred vision in both eyes. Her visual acuity was counting fingers and 20/60. Mild conjunctival injection, anterior chamber cells, and vitreous haze were noted. Fundus showed multifocal intraretinal hemorrhages. Fluorescein angiography revealed vasculitic process with intraretinal hemorrhage blocking defects and retinal ischemic changes in both eyes. Anterior chamber tap fluid polymerase chain reaction for varicella zoster virus, herpes simplex virus I/II, cytomegalovirus, and Epstein-Barr virus was unremarkable. Rheumatology was consulted and systemic vasculitis was ruled out. Her vision improved to 20/50 and 20/20 after pulse methylprednisolone therapy, oral methotrexate, and prednisolone treatment. CONCLUSION Acute multifocal hemorrhagic retinal vasculitis can occur in an immunocompetent patient. Multimodal Imaging is useful in the diagnosis and follow-up. Patients could benefit from early and aggressive immunosuppressive therapy.
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Affiliation(s)
- Ping-Ping Meng
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chun-Ju Lin
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Optometry, Asia University, Taichung, Taiwan; and
| | - Ning-Yi Hsia
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chun-Ting Lai
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Henry Bair
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan
- Stanford University School of Medicine, Stanford, California
| | - Jane-Ming Lin
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Yi-Yu Tsai
- Department of Ophthalmology, China Medical University Hospital, China Medical University, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Optometry, Asia University, Taichung, Taiwan; and
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Arterial sheathing in Leber hereditary optic neuropathy. Am J Ophthalmol Case Rep 2022; 26:101431. [PMID: 35243167 PMCID: PMC8881369 DOI: 10.1016/j.ajoc.2022.101431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 02/10/2022] [Accepted: 02/14/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Presentation of a case of Leber hereditary optic neuropathy (LHON) with arterial sheathing eleven years after initial loss of vision. Observations A 46-year-old female was referred for re-evaluation of Leber hereditary optic neuropathy. She first noticed rapid painless loss of vision eleven years prior. Fundus imaging performed at that time did not demonstrate arterial sheathing. Genetic testing revealed the presence of the LHON 11778 G-A mitochondrial mutation. Laboratory values were within normal limits save for angiotensin-converting enzyme elevated to 69 U/L. Eleven years later, visual acuity was count fingers at 12 feet with complete loss of color vision. Funduscopic examination of the optic nerve revealed bilateral pallor, sheathing of the retinal arteries, diffuse vessel narrowing, and tortuous retinal vessels. Conclusions and Importance We present a case of LHON that demonstrates retinal arterial sheathing and possibly broadens the spectrum of LHON fundus findings. Fundus examination of patients with Leber hereditary optic neuropathy may reveal arterial sheathing. Arterial sheathing may appear in the chronic phase of Leber hereditary optic neuropathy. There are previous published cases of vascular sheathing in Leber hereditary optic neuropathy.
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Diagnostic and Therapeutic Challenge. Retina 2021; 41:1570-1576. [PMID: 32332425 DOI: 10.1097/iae.0000000000002820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Baumal CR, Spaide RF, Vajzovic L, Freund KB, Walter SD, John V, Rich R, Chaudhry N, Lakhanpal RR, Oellers PR, Leveque TK, Rutledge BK, Chittum M, Bacci T, Enriquez AB, Sund NJ, Subong ENP, Albini TA. Retinal Vasculitis and Intraocular Inflammation after Intravitreal Injection of Brolucizumab. Ophthalmology 2020; 127:1345-1359. [PMID: 32344075 DOI: 10.1016/j.ophtha.2020.04.017] [Citation(s) in RCA: 182] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To evaluate features and outcomes of eyes with retinal vasculitis and intraocular inflammation (IOI) after intravitreal injection (IVI) of brolucizumab 6 mg/0.05 ml for treatment of neovascular age-related macular degeneration. DESIGN Retrospective case series. PARTICIPANTS Fifteen eyes from 12 patients identified from 10 United States centers. METHODS Review of patient demographics, ophthalmologic examination results, and retinal imaging findings. MAIN OUTCOME MEASURES Baseline and follow-up visual acuity (VA), prior anti-vascular endothelial growth factor (VEGF) injections, clinical presentation, retinal findings, fluorescein angiography results, and treatment strategies. RESULTS The number of previous anti-VEGF IVIs ranged between 2 and 80 in the affected eye before switching to brolucizumab. Retinal vasculitis and IOI were diagnosed at a mean of 30 days after brolucizumab IVI. Mean VA before brolucizumab IVI was 0.426 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, 20/53) and VA at diagnosis of retinal vasculitis was 0.981 logMAR (Snellen equivalent, 20/191; range, 20/25-20/1600; P = 0.008). All affected eyes showed IOI with variable combinations of focal or elongated segmental sheathing and discontinuity of small and large retinal arteries, sclerotic arteries, regions of vascular nonperfusion, cotton-wool spots, Kyrieleis plaques, irregular venous caliber with dilated and sclerotic segments, perivenular hemorrhages, and foci of phlebitis. Fluorescein angiography revealed delayed retinal arterial filling, retinal vascular nonperfusion, and variable dye leakage from affected vessels and the optic nerve. Systemic evaluation for embolic causes was unrevealing in 2 patients, and 3 patients showed negative laboratory assessment for uveitis. Treatment consisted of various combinations of corticosteroids (systemic, intravitreal, and topical), and 2 eyes underwent vitrectomy without improvement in vision. After a mean follow-up of 25 days, mean VA was 0.833 logMAR (Snellen equivalent, 20/136), which was reduced compared with baseline (P = 0.033). CONCLUSIONS Retinal vasculitis and IOI after brolucizumab IVI are characterized by variable occlusion of large or small retinal arteries, or both, and perivenular abnormalities. It may span from peripheral vasculitis to occlusion of large retinal arteries around the optic nerve or macula with severe vision loss. A high index of suspicion is required because vitreous cells may obscure visualization of retinal details.
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Affiliation(s)
- Caroline R Baumal
- Tufts University School of Medicine, New England Eye Center, Boston, Massachusetts.
| | - Richard F Spaide
- Vitreous, Retina, Macula Consultants of New York, New York, New York
| | | | - K Bailey Freund
- Vitreous, Retina, Macula Consultants of New York, New York, New York; Department of Ophthalmology, New York University, New York, New York
| | | | - Vishak John
- Vistar Eye Center, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Ryan Rich
- Retina Consultants of Southern Colorado PC, Colorado Springs, Colorado
| | - Nauman Chaudhry
- Department of Ophthalmology, Yale University School of Medicine, New Have, Connecticut
| | - Rohit R Lakhanpal
- The Retina Care Center, LLC, Associated Retinal Consultants, LLC, Union, New Jersey
| | - Patrick R Oellers
- Retina-Vitreous Surgeons of Central New York, PC, Liverpool, New York
| | - Thellea K Leveque
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | - Bryan K Rutledge
- Retina-Vitreous Surgeons of Central New York, PC, Liverpool, New York
| | - Mark Chittum
- Retina Consultants of Southern Colorado PC, Colorado Springs, Colorado
| | - Tommaso Bacci
- Vitreous, Retina, Macula Consultants of New York, New York, New York
| | - Ana Bety Enriquez
- Tufts University School of Medicine, New England Eye Center, Boston, Massachusetts
| | - Newman J Sund
- The Retina Care Center, LLC, Associated Retinal Consultants, LLC, Union, New Jersey
| | | | - Thomas A Albini
- Bascom Palmer Eye Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
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Ghannam MY, Naseemuddin M, Weiser P, Mason JO. Acute multifocal hemorrhagic retinal vasculitis in a child: a case report. BMC Ophthalmol 2016; 16:181. [PMID: 27756269 PMCID: PMC5069860 DOI: 10.1186/s12886-016-0360-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/11/2016] [Indexed: 01/21/2023] Open
Abstract
Background Acute Multifocal Hemorrhagic Retinal Vasculitis (AMHRV) is a rare disease with unknown incidence that presents with abrupt onset of visual loss associated with retinal vasculitis, retinal hemorrhage, non-confluent posterior retinal infiltrates, vitreous cellular inflammation and papillitis in, otherwise, healthy adult individuals. The reported treatment options for Acute Multifocal Hemorrhagic Retinal Vasculitis are oral corticosteroids, intravitreal ganciclovir and laser photocoagulation or vitrectomy. We report a child with Acute Multifocal Hemorrhagic Retinal Vasculitis who was treated with aggressive immunosuppressive therapy resulting in a favorable visual outcome. Case presentation A retrospective case report of a 10-year-old African American girl who developed unilateral Acute Multifocal Hemorrhagic Retinal Vasculitis, which later on progressed bilaterally. We conducted a review of the clinical, laboratory and photographic records to evaluate her functional and anatomic outcome after aggressive immunosuppressive treatment. During the first 4 months of treatment of OD with intravitreal ganciclovir, intravitreal dexamethasone and systemic prednisone, the change in vision in OD improved from light perception (LP) to counting fingers (CF). During the next 18 months of aggressive systemic treatment of OD and the newly affected left eye (OS), the change in vision improved from CF in OD and CF in OS to 20/200 in OD and 20/80 in OS. Management during the 18-month interval included rituximab infusions, cyclophosphamide/methylprednisolone infusions, prednisone and mycophenolate. Conclusions This is the first reported case of Acute Multifocal Hemorrhagic Retinal Vasculitis occurring in a child. Ophthalmologists should be aware of the need to treat severe Acute Multifocal Hemorrhagic Retinal Vasculitis with aggressive immunosuppressive agents in collaboration with rheumatologists to obtain the best possible visual outcome.
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Affiliation(s)
- Malik Y Ghannam
- AN-Najah University Teaching Hospital, Asira, Nablus, West Bank, Palestine.
| | | | - Peter Weiser
- University of Alabama (UAB), Birmingham, AL, USA.,Clinical Immunology and Rheumatology, University of Alabama (UAB), Birmingham, AL, USA
| | - John O Mason
- University of Alabama (UAB), Birmingham, AL, USA
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Witkin AJ, Shah AR, Engstrom RE, Kron-Gray MM, Baumal CR, Johnson MW, Witkin DI, Leung J, Albini TA, Moshfeghi AA, Batlle IR, Sobrin L, Eliott D. Postoperative Hemorrhagic Occlusive Retinal Vasculitis. Ophthalmology 2015; 122:1438-51. [DOI: 10.1016/j.ophtha.2015.03.016] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 03/07/2015] [Accepted: 03/11/2015] [Indexed: 11/30/2022] Open
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Abstract
The diagnosis of Behçet disease is clinical and based on the presence of characteristic ocular and systemic inflammatory manifestations. Patients may present with anterior, posterior, or panuveitis in one or both eyes. The differential diagnosis includes a variety of infectious and noninfectious causes of acute nongranulomatous anterior uveitis, intermediate uveitis, occlusive retinal vasculitis, focal or multifocal retinitis, and necrotizing retinitis. A course characterized by sudden onset with improvement followed by recurrence of inflammatory signs is most typical for Behçet uveitis.
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Affiliation(s)
- Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University , Istanbul , Turkey
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Abstract
Retinal vasculitis is a sight-threatening intraocular inflammation affecting the retinal vessels. It may occur as an isolated ocular condition, as a manifestation of infectious or neoplastic disorders, or in association with a systemic inflammatory disease. The search for an underlying etiology should be approached in a multidisciplinary fashion based on a thorough history, review of systems, physical examination, and laboratory evaluation. Discrimination between infectious and noninfectious etiologies of retinal vasculitis is important because their treatment is different. This review is based on recently published articles on retinal vasculitis and deals with its clinical diagnosis, its link with systemic diseases, and its laboratory investigation.
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Affiliation(s)
- Ahmed M Abu El-Asrar
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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Proliferative Retinopathies. Ophthalmology 2009. [DOI: 10.1016/b978-0-323-04332-8.00097-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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10
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Bronner G, Shah S, Bhagat N, Zarbin M. Acute idiopathic multifocal hemorrhagic retinal vasculitis with transient profound visual loss. Retin Cases Brief Rep 2008; 2:178-80. [PMID: 25389836 DOI: 10.1097/icb.0b013e318033a288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute idiopathic multifocal hemorrhagic retinal vasculitis is a rare entity. The diagnosis is based on typical fundus findings following exclusion of other more common conditions with similar features. The authors present a case that outlines their approach to diagnosis and management of a patient with simultaneous bilateral presentation. METHOD Retrospective case report. RESULTS This diagnosis often carries a poor prognosis. However, the reported patient did well, with an improvement in vision from light perception in the right eye and hand motions in the left eye at presentation to 20/60 in the right eye and 20/25 in the left eye at 24-month follow-up. Management included intravitreal ganciclovir, oral corticosteroids, panretinal photocoagulation in both eyes, and vitrectomy in one eye. CONCLUSION Patients with acute idiopathic multifocal hemorrhagic choroiditis can exhibit delayed and substantial visual improvement despite initial profound visual loss. The authors discuss this case and review the current understanding of the diagnosis and management of this disease.
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Affiliation(s)
- Guri Bronner
- From the Institute of Ophthalmology and Visual Science, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark
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Kolacny D, Stalmans P, Wouters C, Van Ranst M, Casteels I. Bilateral acute retinal necrosis in a 12-year-old girl. J AAPOS 2005; 9:599-601. [PMID: 16414533 DOI: 10.1016/j.jaapos.2005.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2005] [Accepted: 07/25/2005] [Indexed: 11/29/2022]
Abstract
Acute retinal necrosis (ARN) is a severe ocular syndrome consisting of a moderate-to-severe anterior uveitis, vasculitis, and vaso-occlusive retinal necrosis. It can occur in healthy individuals at any age, but reports of this condition in children are rare.
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Affiliation(s)
- D Kolacny
- Department of Ophthalmology, University Hospitals Leuven, Leuven, Belgium
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12
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Ozdek S, Gürelik G, Hasanreisoglu B, Fu AD, Harrison S, Godley B. Diagnostic and therapeutic challenges. Retina 2004; 24:602-9. [PMID: 15300082 DOI: 10.1097/00006982-200408000-00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Sengül Ozdek
- Opthalmology Department, Gazi University School of Medicine, Ankara, Turkey
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Abstract
Eales disease, first described by Henry Eales in 1880, remains an enigma. The disease, observed more commonly in the Indian subcontinent than in the rest of the world, occurs in young healthy adult males, initially presenting as retinal periphlebitis and later as retinal ischemia that may lead to vascular alterations and neovascularization. Recurrent vitreous hemorrhage with or without retinal detachment is the common sequelae. In recent years, immunological, molecular biological, and biochemical studies have indicated the role of human leukocyte antigen, retinal autoimmunity, mycobacterium tuberculosis genome, and free radical mediated damage in the etiopathogenesis of this disease. However, its etiology appears to be multifactorial. The management depends on the stage of the disease and consists of medical treatment with oral corticosteroids in the active inflammatory stage and laser photocoagulation in the advanced retinal ischemia and neovascularization stages. The results of vitreoretinal surgery have been found to be satisfactory in case of vitreous hemorrhage with or without retinal detachment.
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Abstract
Neovascularization is an infrequent but serious complication of uveitis. The retina and optic disk appear to be affected most often, although new blood vessels may arise from the iris, ciliary body, and choroid as well. Although neovascularization can usually be identified on careful clinical examination, some patients may require fluorescein angiography or UBM. Numerous neovascular growth and inhibitory factors have been identified experimentally. Clinically, however, uveitic neovascularization appears to be determined most directly by the severity of the inflammation and the presence of retinal nonperfusion. Virtually all patients with uveitic neovascularization deserve a trial of local or systemic corticosteroids. Laser photocoagulation can be considered in those patients who fail to respond to corticosteroid therapy, but only when retinal nonperfusion has been demonstrated on fluorescein angiography. Surgical excision of newly formed vessels is reserved for selected patients with CNV and uveitis, but should only be considered when corticosteroids and focal photocoagulation are ineffective or are otherwise contraindicated.
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Affiliation(s)
- I C Kuo
- Francis I. Proctor Foundation, UCSF, Medical Center 94143, USA
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Jampol LM, Ebroon DA, Goldbaum MH. Peripheral proliferative retinopathies: an update on angiogenesis, etiologies and management. Surv Ophthalmol 1994; 38:519-40. [PMID: 8066542 DOI: 10.1016/0039-6257(94)90146-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- L M Jampol
- Department of Ophthalmology, Northwestern University Medical School, Chicago, Illinois
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Abstract
The acute retinal necrosis (ARN) syndrome represents a specific pattern of clinical presentation for certain herpes virus infections in the posterior segment of the eye. The classically described triad of the ARN syndrome consists of (1) an arteritis and phlebitis of the retinal and choroidal vasculature, (2) a confluent, necrotizing retinitis that preferentially affects the peripheral retina, and (3) a moderate to severe vitritis. Anterior segment inflammation, optic neuritis, and late retinal detachment are also common features of this disorder. Definitive evidence now implicates at least two members of the herpes virus family; varicella zoster virus and herpes simplex virus as causative agents. This paper summarizes the clinical presentation, as well as the currently recommended treatment regimen for the ARN syndrome, highlighting recent advances that have resulted in a significant improvement in the visual prognosis for affected patients.
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Affiliation(s)
- J S Duker
- Eye Research Institute, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston
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Woon HW, Graham EM. Bilateral visual loss with eosinophilic infiltration in the bone marrow and the retina. Int Ophthalmol 1990; 14:405-11. [PMID: 2249920 DOI: 10.1007/bf00163567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A young patient is described who presented with sudden visual loss in the left eye quickly followed by proliferative retinopathy with retinal detachment and thrombotic glaucoma. He developed similar initial symptoms in the right eye but has now made a complete recovery in that eye on systemic steroids, oral acyclovir, cyclosporin A and colchicine. Pathological examination of the left eye revealed inflammation in the ciliary body, retina and choroid with prominent eosinophils. The nature of the initial insult and the possible role of the eosinophils are discussed.
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Affiliation(s)
- H W Woon
- Medical Eye Unit, St. Thomas' Hospital, London, England
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