The pathophysiology of cigarette smoking and age-related macular degeneration

Age-related macular degeneration (AMD) is the most common form of visual impairment, in people over 65, in the Western world. AMD is a multifactorial disease with genetic and environmental factors influencing disease progression. Cigarette smoking is the most significant environmental influence with an estimated increase in risk of 2- to 4-fold. Smoke-induced damage in AMD is mediated through direct oxidation, depletion of antioxidant protection, immune system activation and atherosclerotic vascular changes. Moreover, cigarette smoke induces angiogenesis promoting choroidal neovascularisation and progression to neovascular AMD. Further investigation into the effects of cigarette smoke through in vitro and in vivo experimentation will provide a greater insight into the pathogenesis of age-related macular degeneration.

Nd:YAG laser hyaloidotomy for valsalva pre-macular haemorrhage

AIM

To report a case of successful drainage of a large pre-macular haemorrhage using laser photo-disruption of the posterior hyaloid membrane.

MATERIALS AND METHODS

A case report.

RESULTS

A 47-year-old man presented acutely to our emergency department complaining of a 24-h history of sudden onset, painless and persistent loss of vision in his left eye. Immediately before noticing this loss of vision, he had been vomiting violently from excessive alcohol intake. The left visual acuity was counting fingers. Dilated fundoscopy of the left eye revealed a large pre-macular haemorrhage which was 14 disc diametres in size. Clotting investigations were normal. A diagnosis of valsalva retinopathy was made and the patient elected to receive a prompt neodymium-doped yttrium aluminium garnet (Nd:YAG) laser posterior hyaloidotomy as an outpatient. At 1 week follow-up, the haemorrhage had drained completely into the vitreous space revealing a healthy macula and the visual acuity had improved to 6/12 unaided. At 6-month follow-up the left visual acuity stabilised at 6/9 unaided.

CONCLUSION

Nd:YAG laser posterior hyaloidotomy is a useful outpatient procedure for successful clearance of large pre-macular haemorrhages that offers patients rapid recovery of visual acuity and the avoidance of more invasive intraocular surgery.

Growth factors and protein kinase C inhibitors as novel therapies for the medical management diabetic retinopathy

Diabetic retinopathy is a leading cause of acquired visual loss. Current treatment modalities are not effective in all cases and may have side effects. Investigation of the biochemical basis of diabetic retinopathy suggests that future treatments may reverse or halt the progression of diabetic retinopathy, or actually prevent the development of diabetic retinopathy. Pharmacological manipulation of protein kinase C and various growth factors may form the basis of future treatments for diabetic retinopathy.

The effect of arteriovenous sheathotomy on cystoid macular oedema secondary to branch retinal vein occlusion

BACKGROUND

Arteriovenous (AV) sheathotomy, a potential treatment for branch retinal vein occlusion (BVO), surgically separates retinal vessels at an AV crossing. Relief of the aetiological obstruction, with resolution of cystoid macular oedema (CMO), may result in improved visual acuity.

METHODS

A retrospective review of consecutive cases of AV sheathotomy for BVO was undertaken. Eyes were categorised as having resolution (group 1), reduction (group 2), or persistence (group 3) of CMO. Intergroup comparisons were made with regard to preoperative, intraoperative, and postoperative parameters. Preoperative and postoperative visual acuities were compared within each group.

RESULTS

Of the 27 eyes identified, eight (29.6%) had resolution, 14 (51.8%) had reduction, and five (18.6%) had persistence of CMO. Median preoperative visual acuity was similar in all groups (1.0, 1.0, 1.3, respectively; p = 0.29). Overall median follow up was 12.0 months (Q1 = 12.0, Q2 = 22.5). Eyes in group 1 had significantly better median postoperative visual acuity than eyes in groups 2 and 3 (0.6, 1.0, 2.0 respectively; p = 0.01). A significantly higher proportion of eyes in group 1 had visual acuity improvement compared with eyes in the other groups (87.5% v 35.7% and 20.0%; p = 0.03). Median postoperative visual acuity was significantly better than median preoperative visual acuity in group 1 eyes only (p = 0.02). A higher percentage of group 1 eyes had evidence of postoperative retinal perfusion (83.0% v 21.43% and 40.0%; p = 0.16). Postoperative retinal detachment occurred in three eyes (11.1%).

CONCLUSION

Complete resolution of CMO after AV sheathotomy occurred in one third of patients, and postoperative vision improved significantly in this group. However, in the majority of cases, despite an improvement in CMO, there was no improvement in vision after AV sheathotomy.

Systemic considerations in the management of diabetic retinopathy

PURPOSE

To highlight the systemic factors which affect onset and/or progression of diabetic retinopathy (DR) and to emphasize the role and responsibilities of ophthalmologists and other eye care providers to ensure that appropriate systemic medical evaluation of the patient with diabetes is being pursued.

DESIGN

Literature review of publications relevant to diabetic retinopathy, blood glucose control, diabetes mellitus type, hypertension, renal disease, elevated serum lipids, exercise, pregnancy, anticoagulation, thrombolysis, smoking, anemia and antioxidant ingestion.

FINDINGS

Intensive blood glucose control and control of systemic hypertension reduce the risk of new onset DR and slow the progression of existing DR. Severe DR may be an indicator of renal disease while severe renal disease and its treatment can affect the progression of DR. Elevated serum lipids are associated with macular exudate and moderate visual loss. Certain types of excessive exercise in patients with advanced stages of retinopathy may aggravate vitreous hemorrhage. During pregnancy, DR should be monitored closely as transient progression of DR can occur. Therapeutic anticoagulation and thrombolysis are not contraindicated at any stage of DR. Anemia can result in progression of DR, smoking in general should be discouraged, and the role of antioxidant therapy requires further study.

CONCLUSIONS

Blindness from diabetic retinopathy is now largely preventable with timely detection and appropriate interventional therapy. Routine, repetitive, lifelong, expert clinical retinal examination is essential for the fundamental ophthalmic care of the patient with diabetes. However, diabetes mellitus is a systemic disease and thus optimal ophthalmic care must include diligent evaluation and treatment of concomitant systemic disorders that influence the development, progression and ultimate outcome of diabetic retinopathy. Optimization of these systemic considerations through an intensive, multi-disciplinary, healthcare team-based approach will maximize the ophthalmic and general health of these patients. Ophthalmologists and other eye care providers are critical members of this team with unique responsibilities to ensure that appropriate systemic medical evaluation is being pursued.

Pilomatrix carcinoma of the eyelid

PURPOSE

To report a case of a recurring mass with an unusual origin on the eyelid of a 34-year-old man.

METHOD

Case report.

RESULT

Histology demonstrated that the mass was a pilomatrix carcinoma.

CONCLUSION

An atypical mass with unusual symptoms or signs needs definitive treatment and diagnostic confirmation with histology.

Conjunctival 'MALToma' with systemic recurrence

We report the recurrence of a localized conjunctival lymphoma arising in mucosal-associated lymphoid tissue (MALToma) in the psoas muscle, 18 months after initial treatment with radiotherapy. Findings from systemic investigations demonstrated MALToma recurrences in the psoas muscle and the stomach. Ocular adnexal MALTomas typically manifest as localized tumors, which respond well to radiotherapy, but a proportion may recur in typical MALT sites. To our knowledge, this is the first report of a recurrence in the psoas muscle, and the clinical implication is that all patients with ocular adnexal lymphomas need to be followed up for an indefinite period.