Prevalence and significance of retinopathy in subjects with type 1 diabetes of less than 5 years' duration screened for the diabetes control and complications trial

OBJECTIVE

The Diabetes Control and Complications Trial (DCCT) demonstrated the powerlul impact of glycemic control on the progression of diabetic retinopathy. A large number of individuals (2,771) underwent stereoscopic color photography and fluorescein angiography as part of screening for participation in the DCCT. A subgroup of those individuals screened participated in the DCCT and underwent evaluation of their retinal vasculature semiannually for 4-9 years. These data were evaluated to determine how the 2000 American Diabetes Association position statement would apply to the DCCT experience. Specifically, the position statement indicates that the first dilated eye examination should be performed after 3-5 years' duration of diabetes because vision-threatening retinopathy virtually never develops in patients with type 1 diabetes during that interval

RESEARCH DESIGN AND METHODS

We examined the experience of the DCCT in evaluating retinal photographs in 1,613 patients with type 1 diabetes of <5 years' duration and follow-up photographs every 6 months for 4-9 years in 855 members of that group.

RESULTS

Of 1,613 subjects with type 1 diabetes of <5 years' duration screened for the DCCT, 716 (44.4%) had stereo-color photographic evidence of diabetic retinopathy, and 6 had preproliferative or worse pathology. Fluorescein angiography revealed retinopathy in 158 of 713 subjects with no evidence of retinopathy on color photographs. Thus, 874 (54.2%) of the original 1,613 subjects had retinopathy at baseline. DCCT follow-up identified 341 additional individuals in whom retinopathy was developing before 5 years; 1,083 of 1,613 (67.1%) individuals screened for the DCCT had retinopathy before 5 years' duration of diabetes. Those with retinopathy before 5 years had more rapid three-step progression of vascular pathology than those with no retinopathy.

CONCLUSIONS

Dilated eye examinations and retinal photography should be included in the routine management of type 1 diabetes during the first 5 years to identify the individuals at greatest risk for vision-threatening problems.

Mycobacterium chelonae conjunctivitis and scleritis following vitrectomy

The atypical, or nontuberculous, mycobacteria are opportunistic pathogens that usually cause infection following accidental trauma or surgery. These organisms are ubiquitous in nature but have been found with increasing frequency in other environments that include medical offices and surgical suites. Management of atypical mycobacterial ocular infections can be difficult because in vitro antibiotic activity does not always correlate with in vivo efficacy and because normal immune defenses against mycobacteria may work too slowly to prevent irreversible damage to infected ocular tissues. This report describes a patient who developed a severe ocular infection due to Mycobacterium chelonae after vitrectomy. Despite eradication of the infection, the eye became blind and painful. Arch Ophthalmol. 2000;118:1125-1128

Microbiologic yields and complication rates of vitreous needle aspiration versus mechanized vitreous biopsy in the Endophthalmitis Vitrectomy Study

PURPOSE

To compare the microbiologic yields and complication rates associated with vitreous needle tap and vitreous biopsy in the Endophthalmitis Vitrectomy Study (EVS).

METHODS

Of 420 EVS patients with postoperative endophthalmitis, 201 received immediate vitreous tap or biopsy (without pars plana vitrectomy) by random assignment and 193 completed 9-12 months of follow-up. Vitreous specimens were obtained by biopsy with a 20-gauge vitrectomy cutting instrument or by needle tap with a 22-27-gauge needle. If resistance to aspiration by needle tap was noted, a vitreous biopsy was performed.

RESULTS

Of 201 patients undergoing tap or biopsy, 70 (35%) had needle tap, 127 (63%) had mechanized biopsy, and 4 (2%) had initial needle tap that was aborted to mechanized biopsy ("abort" eyes). Intraoperative hyphema occurred in 2 tap eyes (3%), 3 biopsy eyes (2%), and 0 (0%) abort eyes. Postoperative retinal detachment developed in 8 (11%) tap eyes, 10 (8%) biopsy eyes, and 0 (0%) abort eyes (not significant). Respective rates of culture and gram stain positivity were 69% and 42% in tap eyes and 66% and 41% in biopsy eyes (not significant). The rate of severe visual loss (final acuity <5/200) was significantly higher in tap eyes (16 eyes, 24%) compared with biopsy eyes (13 eyes, 11%) and abort eyes (0 eyes, 0%; P = 0.043). The difference was largely explained by the greater proportion of virulent organisms in the tap eyes compared with biopsy eyes. When visual acuity outcome was defined by other thresholds (20/40 and 20/100), the difference was not significant.

CONCLUSIONS

This study showed no significant differences between mechanized vitreous biopsy and needle tap with respect to microbiologic yield, operative complications, short-term (9-12 months) retinal detachment risk, or visual outcome. Choice of vitreous sampling procedure must depend on the clinical judgment of the surgeon.

Retinal and choroidal manifestations of cat-scratch disease

OBJECTIVE

The ability to diagnose cat-scratch disease (CSD) has been facilitated greatly by the recent isolation and characterization of Bartonella henselae (formerly genus Rochalimaea) and Afipia felis and by the subsequent development of specific enzyme-linked immunosorbent assay (ELISA) serologic tests. This study will help define the patterns of posterior segment ocular involvement in patients with confirmed CSD.

DESIGN

The study design is a retrospective case study and literature review.

PARTICIPANTS

Two consecutive patients with acute visual loss from retinal manifestations of CSD participated.

INTERVENTIONS

The diagnosis was confirmed by B. henselae ELISA testing. Patients underwent extensive medical and ophthalmic investigations to exclude other causes of retinal and choroidal disease. Ophthalmic investigation included fluorescein angiography and visual field testing. One patient received antibiotic therapy with cefotaxime, then with ciprofloxacin, and was treated with oral prednisone. The other patient was improving for several weeks before oral doxycycline was given.

MAIN OUTCOME MEASURES

The clinical syndromes observed were studied over time using visual acuity, visual field, and clinical findings. Data were collated with cases from the literature.

RESULTS

Unilateral neuroretinitis and an unusual macular retinitis developed in patient 1, as did bilateral small intraretinal white spots and a unilateral choroidal infiltrate that continued to develop while the patient received antibiotic treatment. Patient 2 had a branch arteriolar occlusion in relation to a perivascular retinal infiltrate and a few small, bilateral, intraretinal white spots. There was gradual resolution with visual improvement while the patient received the antibiotic treatment, although therapeutic efficacy could not be determined. Patient 1 also received oral corticosteroids. A detailed analysis of the literature placed these findings in context.

CONCLUSIONS

An unusual, well-defined retinal opacification with features of both multiple retinal arteriolar occlusions and a low-grade retinitis was described. Several features also may occur in posterior segment CSD, including neuroretinitis, a retinal white spot syndrome, and focal choroiditis.

Rapidly progressive herpetic retinal necrosis: a blinding disease characteristic of advanced AIDS

Eleven patients with rapidly progressive herpetic retinal necrosis (RPHRN) complicating AIDS were investigated retrospectively to study the disease spectrum, systemic involvement, and therapy. The mean CD4 cell count was 24/microL. There was a characteristic disease pattern with rapid progression, 82% bilaterality, relative resistance to intravenous antiviral therapy, and 70% retinal detachment. Varicella-zoster virus was the probable cause in 10 patients (detected by polymerase chain reaction in two eyes investigated), and herpes simplex virus was the probable cause in one. Cutaneous zoster occurred previously in 73% but was not concurrent. Seventy-three percent had central nervous system disease, possibly virus-related. RPHRN may be a local herpetic recrudescence in an immune-privileged site with transneural spread. Only four of 20 affected eyes retained useful vision. Poor ocular bioavailability, retinal ischemia, acquired drug resistance, and strain pathogenicity may underlie treatment failure. Acyclovir therapy appears relatively ineffective. Combined intravenous and intravitreal therapy with foscarnet and ganciclovir may be the best current management. Research advances are needed urgently.

Evaluation of microbiological diagnostic techniques in postoperative endophthalmitis in the Endophthalmitis Vitrectomy Study

OBJECTIVE

To analyze the data for cultures and Gram stains prospectively collected by protocol in the Endophthalmitis Vitrectomy Study.

DESIGN

Cultures of aqueous, undiluted vitreous, and (for patients who underwent vitrectomy) vitrectomy cassette fluid obtained from 420 patients were prepared on chocolate agar, in thioglycolate broth, and on Sabouraud dextrose agar; Gram stains of the aqueous and undiluted vitreous were made. Criteria were devised to distinguish true pathogens (confirmed positive cultures) from contaminants.

SETTING

Private and university-based retina-vitreous practices and corresponding microbiology laboratories.

RESULTS

Compared with the aqueous, undiluted vitreous produced a higher percentage of confirmed positive cultures and higher colony counts on chocolate agar and was more frequently the only source of a positive culture from the eye. Nevertheless, the aqueous and vitrectomy cassette fluid were the only source of a positive culture from the eye in 4.2% and 8.9% of eyes, respectively. The overall yields of chocolate agar and thioglycolate broth were similar. A positive Gram stain from the aqueous or undiluted vitreous was highly predictive of a positive culture from the eye, but a negative Gram stain had little predictive value for the culture result. The overall rate of laboratory-confirmed infection was not statistically significantly higher in the vitrectomy group than in the tap or biopsy group.

CONCLUSIONS

The vitreous was a richer source of positive cultures and high colony counts than was the aqueous, either because it is more supportive of bacterial growth or because a somewhat larger inoculum of the vitreous than of aqueous could be obtained. The result of Gram stain should not determine the choice of antibiotic drugs in the treatment of endophthalmitis. Vitrectomy, with culture of the vitrectomy cassette fluid, did not produce significantly more positive cultures than tap or biopsy material, and the procedure should not be performed to improve the microbiological yield.

Cytomegalovirus retinitis after initiation of highly active antiretroviral therapy

BACKGROUND

In previous natural history studies and clinical trials, AIDS-related cytomegalovirus (CMV) retinitis has occurred primarily in patients with absolute CD4 counts of 50 cells/microL or less (0.05 x 10(9)/L) at the time of diagnosis.

METHODS

We report five patients identified from our clinical practices who were diagnosed with CMV retinitis while their CD4 counts were above 195 cells/microL. We also analysed, based on CD4 counts, 76 AIDS patients with newly diagnosed CMV retinitis whose CD4 lymphocyte enumerations were done in laboratories that maintained certification in a common external quality control programme.

FINDINGS

5-24 weeks before retinitis was diagnosed, all five patients had had absolute CD4 lymphocyte counts of less than 85 cells/microL, and 4-7 weeks before diagnosis, all five patients had started taking highly active antiretroviral treatment (HAART) regimens. Only one (4%) of 27 patients enrolled in the trial between July, 1995, and February, 1996, had an absolute CD4 count of more than 50 cells/microL, and none of 27 had an absolute CD4 count of more than 100/microL on entry to the trial. However, from March, 1996 (when indinavir and ritonavir were approved by the FDA for marketing in the USA), to August, 1996, 14 (29%) of 49 patients had CD4 counts of more than 50/microL and seven (14%) of 49 had a CD4 count of more than 100 cells/microL on entry.

INTERPRETATION

These findings suggest that the early immunological effects of HAART may not provide sufficient protection to prevent CMV retinitis in patients who have very low CD4 counts when therapy is started. Clinicians should note that CMV retinitis may now occur in patients who have CD4 counts of more than 100 cells/microL.

Submacular neovascular membrane and focal granulomatous inflammation

BACKGROUND

Subretinal choroidal neovascular membranes in persons younger than 55 years old are commonly idiopathic or associated with the ocular histoplasmosis syndrome. There have been a few reports describing the histopathologic features of these membranes. Studies have shown that idiopathic membranes have the same morphologic features as membranes in age-related macular degeneration except for the absence of basal laminar deposits.

METHOD

The authors studied a clinicopathologic case of a macular lesion associated with two peripheral hypopigmented spots in a healthy 30-year-old woman.

RESULTS

The clinical and fluorescein angiographic findings in this patient were characteristic of submacular neovascular membranes, except that the edge of the lesion remained distinct in the late phase of the fluorescein angiogram. Results of histopathologic examination of the surgically excised membrane showed a well-circumscribed granuloma containing some eosinophils. Attenuated vascular spaces were present within the hard tubercle. Special stains for micro-organisms were negative. The patient had no evidence of a systemic inflammatory disease.

CONCLUSIONS

A visible edge despite intense staining in the late phases of a fluorescein angiogram may suggest the possibility of subretinal granulomatous inflammation in a lesion that otherwise appears like a neovascular membrane. The clinical distinction between this pattern of subretinal neovascularization and a typical idiopathic membrane may be important because subretinal granulomatous inflammation could respond to treatment with systemic corticosteroids.

Exogenous endophthalmitis initially treated without systemic antibiotics

PURPOSE

In 1987, the authors reported the successful eradication of infection in 16 patients with culture-proven acute exogenous bacterial endophthalmitis using intravitreal but no systemic antibiotics. They retrospectively reviewed additional consecutive cases since then to determine if the initial omission of systemic antibiotics remained reasonable.

METHODS

Twenty patients had culture-proven endophthalmitis. Four patients initially received systemic antibiotics for orbital cellulitis (2 patients), prevention of a possible scleral buckle infection (1 patient), and ascending cholangitis (1 patient). The remaining 16 patients were treated initially with intravitreal antibiotics only.

FINDINGS

Three of these additional 16 patients ultimately required systemic antibiotics for orbital cellulitis (1 patient), infectious scleritis (1 patient), and prevention of central nervous system infection with Neisseria meningitidis (1 patient). Only in one patient who had a neglected endophthalmitis and in whom an orbital cellulitis ultimately developed were we unable to clear the intraocular infection. In the overall series of 32 patients, cultures yielded staphylococcal species in 16 eyes, gram-positive bacilli in 3, streptococcal infection in 5, gram-negative cocci in 1, and gram-negative bacilli in 7. Half of the 14 specimens (1 aqueous and 13 vitreal) collected at the time of 16 reinjections in 13 eyes yielded organisms. Half (16/32) of the eyes attained visual acuity of 20/40 or better; 87.5% (28/32) attained visual acuity of 20/400 or better.

CONCLUSIONS

Therapy with intravitreal antibiotics without systemic antibiotics is reasonable, unless the infection has extended (or is at risk to extend) beyond the globe. Such evidence includes an elevated temperature or leukocyte count, corneal ring abscess, proptosis, loss of extraocular movements, scleral abscesses or infectious scleritis, and, perhaps, the presence of a scleral buckle.

Perforating ocular injuries caused by anesthesia personnel

Between February 1988 and May 1990, the authors treated 12 perforating ocular injuries caused by anesthetic injections around the eye. All 12 injections were performed by nonophthalmologists. Eleven were performed by anesthesiologists and one by a certified nurse anesthetist. Five were caused by blunt needles and seven by sharp needles. Two of the eyes had multiple posterior exit wounds. The five eyes that had sharp needle, single perforations (i.e., one entrance wound and one exit wound) were easily managed with cryopexy, laser, or observation. All five of these eyes have a visual acuity of 20/40 or better. Six vitrectomies were performed on the five patients with single perforations caused by blunt needles; three of these eyes have a visual acuity of counting fingers or worse. The two patients who had multiple posterior exit wounds required a total of four procedures. The visual acuity in these eyes is 20/400 and light perception. Anesthesia personnel should be well trained before attempting ocular anesthesia. The use of blunt needles does not prevent ocular penetration.

Cone electroretinograms and visual acuities of diabetic patients on sorbinil treatment

Photopic, 30-Hz, and foveal electroretinograms were measured in 19 diabetic patients in an experimental study of the effects of short-term Sorbinil (an aldose-reductase inhibitor) on retinal function. Patients were assigned in double-blind fashion to Sorbinil (250 mg/day) or placebo groups and were tested at the outset and after four weeks of therapy. Comparisons (t-test) between the Sorbinil and placebo groups failed to show significant effects of treatment on electroretinograms, although there was a significant correlation within the Sorbinil group between foveal recordings and red cell sorbitol at the end of treatment. Analysis showed that increased foveal electroretinograms were found in patients with low initial retinopathy but not in those with greater retinopathy. Eight patients continued Sorbinil treatment for one year. Again patients improving their foveal measurements had less initial retinopathy than those not improving. This difference was significant after one year of treatment but not at four weeks.

Chronic vitritis with macrophagic inclusions. A sequela of treated endophthalmitis due to a coryneform bacterium

A 75-year-old woman was treated successfully for endophthalmitis due to a coryneform bacterium contracted from a contaminated corneal graft. We were able to study the involved eye histologically when the patient died unexpectedly 5 1/2 weeks after treatment. The vitreous contained a moderate number of macrophages filled with PAS-positive particles. Ultrastructurally, the PAS-positive particles corresponded to degenerating bacterial cell walls. The striking resemblance of the macrophages in this case to macrophages in Whipple's disease is intriguing because Corynebacterium has been the most frequently implicated bacterial genus in the pathogenesis of Whipple's disease.

'Blow-outs' in the retinal pigment epithelium

A hole was detected in the epithelium of a retinal pigment epithelium (RPE) detachment in two patients. Leakage through the hole led to an elevation of the overlying neurosensory retina in each case. The resulting vision was 20/70 in one eye and 20/30 in the other. The defects in the RPE occurred in a setting different from that usually seen with tears in the pigment epithelium and had a different clinical appearance.

Exogenous bacterial endophthalmitis treated without systemic antibiotics

We treated 16 patients (16 eyes) with culture-proven exogenous bacterial endophthalmitis with intravitreal and subconjunctival antibiotics but without systemic antibiotics. After one to two sets of intravitreal injections, intraocular inflammation abated in all patients. After further surgery in four patients, all 16 eyes had clear media and attached retinas. Fifteen eyes attained a visual acuity of 20/400 or better; 12 eyes achieved 20/80 or better.

Bilateral melanocytic uveal tumors associated with systemic non-ocular malignancy. Malignant melanomas or benign paraneoplastic syndrome?

A 90-year-old woman developed bilateral diffuse melanocytic tumors of the uveal tract nearly 1 year before she died from an occult ovarian carcinoma. Although the syndrome of bilateral diffuse melanocytic tumors of the uvea and systemic carcinoma has been described, the uveal tumors in this patient were different in that they were indistinguishable histologically from mixed cell-type malignant melanoma. Although the relationship between the systemic malignancy and the uveal tumors is unclear, the cytologic features of the uveal tumors in this syndrome are probably more variable than originally thought.

Retinal infiltrates in six patients with an associated viral syndrome

This report documents the fundus findings in ten eyes of six patients who had retinal infiltrates develop during or shortly after a viral-like illness. The whitish infiltrates varied in size from 150 to 1700 micron. They occurred in both the posterior pole and periphery, and were located in the superficial as well as deep retinal layers. There was minimal or no vitritis. The infiltrates resolved over a period of months with and without chorioretinal scarring. The optic nerve was involved in two patients, causing a temporary decrease in acuity. However, the only eye left with visual acuity less than 20/40 had a paracentral macular lesion that scarred.

Retinal fold in macula following intraocular gas. An avoidable complication of retinal detachment surgery

Liquid vitreous was replaced with air during a scleral buckle for a superotemporal retinal detachment. After surgery, the patient was positioned so that air rolled over the detached retina from anterior to posterior, pressing a fishmouthed tear against the buckle that resulted in reattachment. After the air was absorbed, a large retinal fold was seen in the superotemporal macula along the former posterior margin of the detachment. If the patient had been positioned so that air rolled over the detached retina from posterior to anterior, the potentially visually destructive posterior retinal fold could have been avoided.

Diabetic rubeosis and panretinal photocoagulation

Iris fluorescein angiography was used to perform the first prospective, controlled, masked evaluation of the effect of panretinal photocoagulation on diabetic rubeosis. Eyes with rubeosis had iris fluorescein angiograms five to seven weeks apart. Eyes either had laser treatment immediately after the first angiogram or had no laser treatment between angiograms. The rubeosis was said to have improved if all three masked readers independently selected the angiogram performed last as having the less severe rubeosis. In eyes with severe rubeosis, only two of 11 (18%) spontaneously improved whereas 11 of 15 (73%) improved following laser therapy. In eyes with mild rubeosis, one of ten improved spontaneously and one of ten improved following laser therapy. Iris fluorescein angiography documented regression of severe but not mild rubeosis following panretinal photocoagulation.

Acute pressure elevation following panretinal photocoagulation

Intraocular pressure increased in 17 of 18 eyes treated for diabetic retinopathy with argon laser panretinal photocoagulation. All eyes had open anterior chamber angles before treatment. Fifteen eyes, continued to have open angles when first examined after treatment. The pressure elevation in these eyes averaged about 10 mm Hg, was detected soon after laser treatment, and persisted for several hours. Outflow facility usually was reduced. Three eyes had closed angles and elevated pressures when first examined after treatment. I addition, in five eyes that initially had open angles, angle closure developed later. Thus, the pressure elevation after extensive retinal photocoagulation usually begins with an open angle mechanism, but later may be due to angle closure as well. The reason for the pressure rise with an open angle is unknown.

Acute pressure elevation following panretinal photocoagulation

Intraocular pressure increased in 17 of 18 eyes treated for diabetic retinopathy with argon laser panretinal photocoagulation. All eyes had open anterior chamber angles before treatment. Fifteen eyes, continued to have open angles when first examined after treatment. The pressure elevation in these eyes averaged about 10 mm Hg, was detected soon after laser treatment, and persisted for several hours. Outflow facility usually was reduced. Three eyes had closed angles and elevated pressures when first examined after treatment. I addition, in five eyes that initially had open angles, angle closure developed later. Thus, the pressure elevation after extensive retinal photocoagulation usually begins with an open angle mechanism, but later may be due to angle closure as well. The reason for the pressure rise with an open angle is unknown.

Optic disc edema in juvenile-onset diabetes

The clinical and photographic records of patients with juvenile-onset diabetes and nonneurologic disc edema were reviewed to determine the natural history of the disease. Six female and two male patients, 14 to 40 years old, who had had diabetes for seven to 22 years had no visual complaints or mild blurring. All had 6/9 or better visual acuity and normal blood pressure. Visual fields were normal or showed an enlarged blind spot. The edematous discs had superficial, dilated, radially oriented, fluorescein-incontinent capillaries. Two patients had simultaneous neovascularization of the disc. Three received laser photocoagulation, and five received no therapy. In the seven followed up for six months or more, the edema resolved, resulting in 6/6 visual acuity. These findings suggest the edema resulted from a reversible vasculopathy that, due to few symptoms, may be more common than is presently appreciated.

The elimination of herpes simplex plaques by antibody and the emergence of resistant strains

Established type 1 HSV plaques were eliminated by antibody. Antibody had to remain in contact with infected cells for several days to have a maxi;mum effect. It did not prevent the production of viral induced antigens in a cell when applied after the cell was infected but did prevent the transmission of infection to contiguous cells. Strains which were resistant to elimination by antibody formed syncytia, did not grow to significantly higher titers than nonresistant strains, and were as easily neutralized by antiserum as nonresistant strains.