[Punctate Inner Choroidopathy]

Punctate Inner Choroidopathy (PIC) is a rare idiopathic ocular inflammatory disease. It occurs mostly in young, myopic, otherwise healthy women. Symptoms of the disease include acute vision decrease associated with central and paracentral scotoma. In 80% of cases PIC occur bilaterally. We report the case of a woman at the age of twenty-five, who was treated for PIC. Due to the finding of active inflammatory deposit in the retina of the left eye and low visual acuity was recommended corticosteroid therapy with a good therapeutic effect.

KEY WORDS

Punctate Inner Choroidopathy (PIC), white dot syndromes.

Aflibercept (Eylea) and diabetic macular oedema. A first-choice VEGF inhibitor in case of marked visual loss

Overall, VEGF inhibitors administered by intravitreal injection have a similar harm-benefit balance. However, a publicly funded trial has shown that aflibercept is more effective than ranibizumab and bevacizumab in patients with marked loss of visual acuity.

Rapid improvement in visual loss with cabergoline treatment in a giant prolactinoma case: 5 years survey

Giant prolactinoma is a rare subset of macroadenomas. Limited studies demonstrated which therapy could be successfully used in the first-line therapy of giant prolactinoma. We presented a case with a 54 × 40 × 40 mm pituitary adenoma and optic chiasmatic compression with left sphenoid sinus invasion. The tumor caused a loss of visual field of the right side. Cabergoline treatment was started with dose of 1.5 mg/week. Fifteen days later, the clinical visual acuity examination showed a significant improvement in the patient with visual field defect. After the five years follow-up magnetic resonance imagining showed reduction of the adenoma size (17 × 12 mm) was significant. Our findings suggest that, cabergoline can be used as a first-line therapy in giant prolactinomas because tumoral shrinkage without a surgical procedure and rapid improvement in visual field defect is achieved with this medical treatment.

Behçet disease: visual prognosis and factors influencing the development of visual loss

PURPOSE

To assess the visual prognosis of patients with ocular Behçet disease and to determine factors predictive of visual loss and severe visual loss.

DESIGN

Retrospective case series.

METHODS

One hundred seventy-five eyes of 107 patients diagnosed with ocular Behçet disease were included. The main outcome measures were visual loss (best-corrected visual acuity, worse than 20/40) and severe visual loss (best-corrected visual acuity, 20/200 or worse).

RESULTS

The mean duration of follow-up was 6.5 years. Presenting visual acuity was worse than 20/40 in 50% of eyes and 20/200 or worse in 21% of eyes; approximately one third of this was reversible with treatment. The most common cause of irreversible severe visual loss was ischemic maculopathy. At 10 years, there was a 39% risk of visual loss and a 24% risk of severe visual loss, the latter figure being reduced to 13% if patients with irreversible visual loss at presentation were excluded. After controlling for potentially confounding variables, male sex, unilateral disease, and left eye involvement all were statistically significant risk factors for severe visual loss at 5 and 10 years. Patients who were treated with biologic agents were less likely to have severe visual loss in either eye at both 5 and 10 years.

CONCLUSIONS

Many patients with ocular Behçet disease still have irreversible visual loss at presentation. However, the visual prognosis is otherwise improved, with a 10-year risk of severe visual loss of 13% in this cohort. The use of biologic agents is associated with a lower risk of severe visual loss at 5 and 10 years.

Acute painless monocular visual loss due to central retinal artery occlusion in a patient with Churg–Strauss vasculitis

Ocular involvement in Churg-Strauss syndrome (CSS) is infrequent. We describe a case of a 50-year-old woman, with blood eosinophilia, involvement of the respiratory tract, skin, and peripheral nervous system, fulfilling the American College of Rheumatology criteria for CSS, who presented with left foot drop followed by left acute painless visual loss. Central retinal artery occlusion was diagnosed by fundoscopic findings (retinal whitening with a cherry-red spot). CSS was confirmed by sural nerve biopsy. Despite treatment with high-dose corticosteroids, cyclophosphamide, and anticoagulant therapy, visual acuity was not substantially improved. Acute blindness in CSS has been rarely described. Even more rarely, central retinal artery occlusion has been found to be the underlying cause of this infrequent clinical manifestation in CSS.

Octreotide: a therapeutic option for idiopathic intracranial hypertension

PURPOSE

To study the effects of octreotide, a somatostatin analogue, in patients with Idiopathic Intracranial Hypertension (IIH).

METHODS

We performed a prospective, open-label study of the effect of Octreotide on 26 patients with symptoms and signs of IIH, investigated by brain MRI and lumbar puncture. Octreotide was administered subcutaneously, at an initial dose of 0.3 mg/day; and was gradually increased until headache was relieved (upper-dose limit: 1 mg/day). Treatment with octreotide at 1 mg/day was administered for a maximum of six to eight months and afterwards the dose was gradually tapered. Patients were followed prospectively every month for three years. CSF opening pressure was measured before the treatment was started and again in the first follow-up examination, on month one. In all follow-up visits the presence of papilledema was evaluated by fundoscopy; visual fields and visual acuity were also examined.

RESULTS

Overall 24/26 patients improved significantly (92%). Headache was relieved within days (1-10, median 7 days). Papilledema subsided in all 24 patients, in up to two months (35 to 68, median 45 days). Visual disturbances, initially presenting in 20 of our patients, improved in 18 (90%). The mean reduction in CSF pressure after treatment was 20.72A+/-10.7 cmH2O (range 2 to 48). Patients were followed for three years after cessation of treatment. No recurrence of papilledema, or any other symptoms, has been observed.

CONCLUSIONS

Octreotide resulted in a significant and sustained improvement of IIH in our patients. These results suggest that it may be an effective alternative to existing treatments for IIH.

Natalizumab reduces visual loss in patients with relapsing multiple sclerosis

OBJECTIVE

To examine the effects of natalizumab on low-contrast letter acuity as a prespecified tertiary endpoint in two randomized clinical trials and to evaluate the usefulness of low-contrast letter acuity testing as a candidate test of visual function in multiple sclerosis (MS).

METHODS

AFFIRM and SENTINEL were randomized, double-blind, placebo-controlled, multicenter, phase 3 clinical trials of natalizumab in relapsing MS. Natalizumab was evaluated as monotherapy in AFFIRM and as add-on to interferon beta-1a in SENTINEL. Vision testing was performed at 100% contrast (visual acuity) and low-contrast (2.5% and 1.25%).

RESULTS

The risk of clinically significant visual loss (predefined as a two-line worsening of acuity sustained over 12 weeks) at the lowest contrast level (1.25%) was reduced in the natalizumab treatment arms by 35% in AFFIRM (hazard ratio = 0.65; 95% CI: 0.47 to 0.90; p = 0.008) and by 28% in SENTINEL (hazard ratio = 0.72; 95% CI: 0.54 to 0.98; p = 0.038, Cox proportional hazards models). Mean changes in vision scores from baseline were also significantly different, reflecting worsening in non-natalizumab groups.

CONCLUSIONS

Natalizumab reduces visual loss in patients with relapsing multiple sclerosis. Low-contrast acuity testing has the capacity to demonstrate treatment effects and is a strong candidate for assessment of visual outcomes in future multiple sclerosis trials.

Successful use of recombinant activated factor VII in the treatment of vitreous haemorrhage: a report of seven cases

Vitreous haemorrhage poses a serious threat to vision if untreated. Therapeutic options remain scarce and surgical intervention to resolve persistent bleeding is associated with risks that may further compromise vision. We report the use of recombinant activated factor VII (rFVIIa) in seven patients (six men, one woman; age, 30-65 years) with vitreous haemorrhage and severe reduction in visual acuity caused by trauma (n = 4) or proliferative diabetic retinopathy (n = 3). Initial doses ranged from 60 to 140 microg/kg; most patients received maintenance therapy with 20-60 microg/kg for at least 3 days. One patient received rFVIIa treatment for only 24 h and suffered a re-bleed, controlled successfully with further rFVIIa therapy. Five patients responded well to rFVIIa treatment, with reduced symptoms and improvements in visual acuity. Late presentation several days after trauma or symptom onset may have contributed to poor outcomes in the two patients who failed to respond to rFVIIa therapy. No adverse events were observed. An initial dose of rFVIIa 60-140 microg/kg, followed by 20-60 microg/kg repeated at 8-h intervals for 3-5 days, appears to be an effective therapeutic option for vitreous haemorrhage. However, further studies of rFVIIa use in this indication are warranted.

Noninfectious Hypopion after Intravitreal Triamcinolone Acetonide Injection for Central Retinal Vein Occlusion: A Case Report

Although it is rare, infectious endophthalmitis is a severe ocular complication resulting from intravitreal injection of triamcinolone acetonide (TA). Therefore, care must be taken by ophthalmologists to differentiate between what is infectious and noninfectious endophthalmitis. We report on a 62-year-old woman who received an intravitreal injection of TA for treatment of central retinal vein occlusion. One day after the injection, a hypopion (a white-yellowish deposit) was noted in the inferior anterior chamber. The patient complained that her vision had deteriorated, but there was no pain, eyelid edema, increased conjunctival injection or corneal edema. The hypopion gradually diminished and by the fifth postoperative day, resolved completely without the administration of intravitreal or systemic antibiotic therapy.

Do complaints of amaurosis fugax and blurred vision after transcatheter device closure of atrial septal defect indicate microemboli to retinal vessels?

Atrial septal defect (ASD) is a common diagnosis in adults undergoing surgical repair. The aim of the study was to determine if ocular symptoms following treatment are due to microemboli. The study group included 20 adult patients (9 men, 11 women, mean age 57.2 years) with ASD who had undergone successful closure with the Amplatzer occluder. Patients were treated with aspirin or warfarin during the 6 months after the procedure. All were evaluated neurologically and an ocular medical history was obtained. Ocular examination included the 120-point Humphery visual field. Transcranial Doppler (TCD) was performed to monitor the middle cerebral artery. Two patients complained of amaurosis fugax at 1 and 3 months after the procedure, and two patients complained of blurred vision at 3 and 4 months after the procedure. TCD performed within 24 h of the complaints revealed no abnormalities. In all patients, the neurological and ocular examinations, including the visual field test, were normal. In conclusion, microembolic events do not appear to be the cause of the ocular complaints in patients with ASD treated with Amplatzer occluder. Further studies in larger samples are needed to confirm these results.

[Choroidal neovascularization followed in a patient with "Multiple Evanescent White Dot Syndrome" (MEWDS) -- a case report]

BACKGROUND

Since the description of the "multiple evanescent white dot syndrome" (MEWDS) by Jampol et al, choroiditis has been in the focus of interest. But the classical type of MEWDS was an exceptional case in clinical routine.

CASE REPORT

A 48-year-old female presented to our hospital with a sudden unilateral visual acuity decrease and an extension of the blind spot. Ophthalmoscopy and fluorescein angiography revealed typical multiple grey-white chorioretinal patches of the same stage with lesion areas of about 100 - 200 microm compatible with the diagnose of MEWDS. Although visual acuity increased continuously the patient developed a classical choroidal neovascularization within 4 weeks. She was treated with PDT and visual acuity as well as the ophthalmoscopic diagnosis remained stable.

CONCLUSION

In spite of visual improvement in MEWDS, regular control is recommended. In addition we propose to consider the diagnosis of MEWDS if an enlargement of the blind spot and CNV without lesions of the retinal pigment epithelium are diagnosed.

Bilateral severe visual loss in brucellosis

PURPOSE

To report a case of brucellosis with bilateral permanent loss of vision.

METHODS

Case report.

RESULTS

Bilateral loss of vision developed within two weeks in a young adult with positive Brucella antibodies. There was optic disc swelling with optic neuropathy and serous retinal detachment in both eyes. The patient had chronic active brucellosis confirmed by serum antibody titers (1/640).

CONCLUSION

This case shows that optic neuropathy may result in severe visual loss in patients with brucellosis.

Corticosteroid Treatment for Melanoma-Associated Retinopathy

BACKGROUND

Visual disturbance in the course of melanoma is rare. Specific localized metastases and drug toxic effects are frequently the cause. Recognition of a retinopathy raises several questions when the diagnosis of melanoma-associated retinopathy (MAR) can be confirmed. Descriptions of such patients in dermatologic literature are rare and deserve attention because therapeutic decisions are mandatory.

OBSERVATIONS

A 70-year-old woman had a first melanoma in 1985 and a second primary melanoma in 1994. Axillary lymph node involvement occurred in November 2000, leading to surgery and chemotherapy. In December 2001, she had sudden bilateral visual loss, with shimmering blobs of color and flickering photopsias. Computed tomography and cerebral magnetic resonance imaging ruled out localized tumor on the eyes or optic nerves or evolution of disease. Ophthalmologic examination revealed a bilateral posterior uveitis, with hyalitis and progressive destruction of retinal pigment. The electrophysiologic data confirmed the diagnosis of MAR. Symptoms improved after systemic corticosteroid therapy, with no relapse after tapering doses despite worsening of melanoma.

CONCLUSIONS

As a rare paraneoplastic visual syndrome possibly leading to blindness, MAR is characterized by bipolar cell involvement without photoreceptor cell impairment. Also, MAR is linked to the presence of autoantibodies directed against melanoma antigens that cross-react with the rod bipolar cells of the retina. Corticosteroid therapy is rarely beneficial. Our case of MAR is noteworthy because it involved a woman, was associated with an uveitis, and improved with corticosteroid therapy.

Retinal Vasculitis and Cystoid Macular Edema after Body Tattooing: a Case Report

BACKGROUND

To report a case of retinal vasculitis occurring after the placement of permanent tattoos.

HISTORY AND SIGNS

A 21-year-old male was referred to our department with impairment of visual acuity. Permanent tattoos covered the head, body, arms and legs. The patient was examined with ophthalmoscopy, fluorescein angiography, indocyanine green angiography and optical coherence tomography. Systemic medical and laboratory work-up were performed in order to exclude an infectious agent or an inflammatory disease. He had no history of intravenous drug abuse.

THERAPY AND OUTCOME

Our patient presented severe posterior uveitis associated with retinal vasculitis and cystoid macular edema. Laboratory tests ruled out all diseases causing vasculitis. HIV and B, C hepatitis tests were negative. Cystoid macular edema and vasculitis were resolved after immunosuppressive therapy.

CONCLUSIONS

This is the first description of a retinal vasculitis associated with cystoid macular edema in a completely healthy individual after the placement of permanent tattoos. A phagocytosis of tattoo pigments leading to their lysis is described in the literature as a mechanism causing vasculitis.

Ginkgoextrakt bei eingeschranktem Sehvermogen - Behandlung mit dem Spezialextrakt EGb 761R bei Beeintrachtigung aufgrund seniler trockener Makuladegeneration*

The therapeutic efficacy of Ginkgo special extract Egb 761 was investigated in a controlled, double-blind trial involving 99 patients with impaired vision due to senile, dry macular degeneration. The primary objective target variable was the change in the corrected visual acuity of the more severely impaired eye at baseline, during a six months treatment period with either 240 mg/die (group I = 50 patients) or 60 mg/die (group II = 49 patients) Egb 761. Marked improvement of the study participants' vision was observed in both treatment groups already after four weeks, with more pronounced improvements in group I (acuity increases by 0.13 in group I vs. 0.10 in group II after 24 weeks). The fraction of patients with improvement of visual acuity > or = 0.2 was nearly twice as large in the group treated with 240 mg/die Egb 761 as in patients receiving the lower dosage (p = 0.08). Subjective health impairments, if present, could be improved during treatment as well. The investigator rated a favorable tolerability for both dosages of Egb 761. In conclusion, the results demonstrate the therapeutic efficacy of Egb 761 in patients with senile, dry macular degeneration, with obvious benefits in every-day life.

Lung cancer, proptosis, and decreased vision

A 48-year-old man presented to the emergency department with a 3-day history of decreased vision in a painful proptotic right eye. The patient was being treated with chemotherapy and radiation for non-small cell lung carcinoma. Examination showed visual acuity of hand motions, decreased motility, and an afferent pupillary defect on the right, consistent with an orbital apex syndrome. Neuroimaging revealed "dirty" orbital fat and no paranasal sinus disease. Orbital biopsy initially showed only fibrosis; however, on subsequent biopsies, nonseptate hyphae later identified as mucormycosis was recovered. The patient survived with exenteration and systemic amphotericin B.

Lagophthalmos in a multibacillary population under multidrug therapy in the People's Republic of China

Lagophthalmos may be the most common potentially blinding ocular condition in leprosy. The magnitude of the problem among multibacillary patients has not been determined. We sought to ascertain the magnitude of lagophthalmos in a multibacillary leprosy patient population under multidrug therapy (MDT) (both newly diagnosed and with a prior history of dapsone monotherapy) in China and assess factors associated with its presence. In a survey of 640 multibacillary patients 3.8% of the newly diagnosed patients and 10.2% of the patients with prior dapsone monotherapy had lagophthalmos. Corneal disease and vision loss were common in both groups. Poor compliance with MDT, duration between onset and diagnosis, and duration on dapsone monotherapy were associated with the presence of lagophthalmos. Our findings suggest that there may be a threshold at which MDT must be maintained to prevent lagophthalmos. Early leprosy diagnosis and treatment would also lessen the incidence of lagophthalmos in these patients. The high proportion of lagophthalmos patients with corneal disease suggests that there has been inadequate eye care for these patients.

Increased visual impairment after exercise (Uhthoff's phenomenon) in multiple sclerosis: therapeutic possibilities

The Uhthoff symptom, a transient impairment of visual function after exercise, is demonstrated in 2 multiple sclerosis patients. Following exercise, impairment of visual function, as documented most clearly by the testing of contrast sensitivity, was less obvious after body surface cooling and after treatment with orally administered 4-aminopyridine. It is hypothesized that both treatment modalities improve the nerve conduction safety factor and thereby prevent the occurrence of a conduction block, which is believed to be the mechanism underlying the Uhthoff symptom.