Iris Nevus (Cogan-Reese) Syndrome Presenting with Zonular Dehiscence during Cataract Extraction

The aim of this study was to report a novel presentation of Cogan-Reese syndrome presenting with zonular dehiscence during cataract extraction with intraocular lens placement. A 49-year-old woman presented with worsening vision over 2 years. The examination was significant for bilateral pupil miosis, visually significant cataracts, and unilateral glaucoma. No iris nodules or corneal endothelial disease was observed through slit-lamp examination and specular microscopy bilaterally. Cataract extraction on the left eye was complicated by significant zonular dehiscence. An iris sample taken during the procedure demonstrated histopathologic findings consistent with an iris nodule composed of melanocytic nevoid cells. Cogan-Reese, or iris nevus syndrome, is a subset of iridocorneal endothelial syndrome that usually presents with iridic stromal matting and stromal loss, nodule formation, and secondary unilateral angle-closure glaucoma. Here, we describe a presentation of Cogan-Reese syndrome that presented with pupillary miosis and glaucoma preoperatively, and zonular dehiscence during cataract extraction with no underlying corneal pathology.

Total Tear IgE Levels Correlate with Allergenic and Irritating Environmental Exposures in Individuals with Dry Eye

Dry eye (DE) and allergic conjunctivitis may present similarly, and it remains unclear whether some individuals have an underlying allergic component to their DE. To better understand this relationship, we performed a cross-sectional study in 75 individuals with DE symptoms and/or signs. Immunoglobulin E (IgE) levels in tear samples were quantified and home environmental exposures assessed via standardized survey. Tears were collected by Schirmer strip, and total tear IgE levels were quantified using enzyme-linked immunosorbent assay (ELISA). Data were analyzed using descriptive statistics and linear and logistic regressions. The main outcome measures were total tear IgE levels and their association with environmental exposures. The mean age of the subjects was 66.2 ± 7.8 years. Sixty-two individuals had dry eye symptoms (Dry Eye Questionnaire-5 ≥ 6), and 75 had one or more signs of DE. Detectable total tear IgE levels were observed in 76% of subjects, and 17.3% had high levels (>1 ng/mL). Individuals with exposure to pet(s) (odds ratio (OR) 11.5, p = 0.002) and smoke (OR 38.6, p = 0.008) at home were more likely to have high IgE levels compared to those not exposed. Individuals with tears collected during spring or summer were 3.9 times (p = 0.028) more likely to have high IgE compared to those sampled at other times of year. Subjects born in the US were 3.45 times (p = 0.010) more likely to have high IgE compared to individuals born outside the US. To conclude, a majority of individuals with DE symptoms and/or signs had detectable IgE levels in their tears. High tear IgE levels were correlated with allergy season and exposures in the home linked with allergy.

Sudden-onset Blindness from a Spontaneous Carotid-cavernous Fistula with Secondary Central Retinal Artery Occlusion and Posterior Ischemic Optic Neuropathy

Our case describes a patient diagnosed with a carotid-cavernous fistula (CCF) secondary to a spontaneously ruptured cavernous carotid aneurysm, presenting with sudden vision loss, and a concomitant central retinal artery occlusion as visualized by a cherry-red spot in the macula and posterior ischemic optic neuropathy. Computed tomography of the brain and orbits showed mild hydrocephalus, orbital fat haziness, and proptosis with concern for fluid in the basal cisterns. Cerebral angiography confirmed the suspected diagnosis of CCF. After angiography, a Magnetic resonance imaging of the brain demonstrated abnormal diffusion restriction in the posterior right optic nerve confirmed on the apparent diffusion coefficient map, consistent with ischemia of the optic nerve in this location. Two weeks after discharge, outpatient fundus photography showed resolution of her cherry-red spot, and optical coherence tomography showed thinning of the entire retinal nerve fiber layer as compared to the contralateral eye. In CCFs, congestive symptoms of proptosis, pain, and even central retinal vein occlusion findings are frequently described. However, our patient's no light perception vision and imaging findings suggest associated central retinal artery occlusion and ischemic optic neuropathy. These findings underscore the multitude of serious visual effects of high flow CCFs.

INTRAVENOUS IMMUNOGLOBULIN IN THE TREATMENT OF JUVENILE RETINITIS PIGMENTOSA-ASSOCIATED CYSTOID MACULAR EDEMA AND UVEITIS

PURPOSE

To evaluate the efficacy of intravenous immunoglobulin in the treatment of cystoid macular edema and uveitis caused by juvenile retinitis pigmentosa in a woman interested in planning a pregnancy.

METHODS

Descriptive case report. A 25-year-old woman with retinitis pigmentosa presented with decreased visual acuity, interested in a second opinion.

RESULTS

Intravenous immunoglobulin therapy was begun at 2-week intervals. Visual acuity improved from 20/100 to 20/70 by 6 weeks, where it stabilized for the remaining year. Serial optical coherence tomography imaging revealed marked improvement in cystoid macular edema after 2 treatments of intravenous immunoglobulin at 2 weeks of follow-up, with complete resolution noted at 4 months, a finding that persisted at 1 year of follow-up.

CONCLUSION

Our findings support the use of intravenous immunoglobulin as a therapeutic option for the resolution of cystoid macular edema and management of uveitis secondary to juvenile retinitis pigmentosa.

Meibomian Gland Disease: The Role of Gland Dysfunction in Dry Eye Disease

TOPIC

To discuss the pathology, causes, and ocular surface impact of meibomian gland disease (MGD), as well as its relationship to dry eye.

CLINICAL RELEVANCE

MGD is a common disorder with various contributing mechanisms and clinical manifestations. Understanding MGD pathophysiology and its relationship to dry eye is important in order to optimize diagnosis and treatment algorithms.

METHODS

A review of current literature was performed to discern MGD in terms of pathophysiology, risk factors, and ocular surface impact, and the relationship to dry eye.

RESULTS

Meibomian gland obstruction and meibocyte depletion are important components of MGD. Many pathologies can disrupt function of meibomian glands, ranging from congenital to acquired causes. Once gland disruption occurs, the quality and quantity of meibum is altered, with a negative impact on the ocular surface. Increased tear evaporation, tear hyperosmolarity, increased ocular surface staining, increased inflammation, symptomatic irritation of the eyelid and globes, as well as decreased visual acuity have all been observed.

CONCLUSION

MGD leads to changes in meibum quality and quantity that can cause evaporative dry eye and ocular surface disruption, leading to dry eye symptoms in some individuals.

The impact of conjunctivochalasis on dry eye symptoms and signs

PURPOSE

The purpose of this project was to study the relationship between conjunctivochalasis (Cch) and ocular signs and symptoms of dry eye.

METHODS

Ninety-six patients with normal eyelid and corneal anatomy were prospectively recruited from a Veterans Administration hospital over 12 months. Symptoms (via the dry eye questionnaire 5 [DEQ5]) and signs of dry eye were assessed along with quality of life implications. Statistical analyses comparing the above metrics among the three groups included χ(2), analysis of variance, and linear regression tests.

RESULTS

Participants were classified into three groups: nasal conjunctivochalasis (NCch; n = 31); nonnasal conjunctivochalasis (non-NCch; n = 41); and no conjunctivochalasis (no-Cch; n = 24). Patients with NCch had more dry eye symptoms than those with non-NCch (DEQ5: NCch = 13.8 ± 5.0, non-NCch = 10.2 ± 5.0, no-Cch = 11.6 ± 5.8; P = 0.014), and more ocular pain than those with Non-NCch and no-Cch (numerical rating scale [NRS]: NCch = 4.5 ± 3.0, non-NCch = 2.3 ± 2.8, no-Cch = 3.3 ± 2.6; P = 0.008). They also had worse dry eye signs compared to those with no-Cch measured by Schirmer score with anesthesia (NCch = 14.5 ± 6.9, non-NCch = 16.8 ± 8.2, no-Cch = 19.9 ± 6.4; P = 0.039); meibomian gland dropout (NCch 1.8 ± 0.9, non-NCch = 1.4 ± 1.0, no-Cch = 1.0 ± 1.0; P = 0.020); and eyelid vascularity (NCch = 0.84 ± 0.8, non-NCch = 0.74 ± 0.7, no-Cch = 0.33 ± 0.6; P = 0.019). Moreover, those with NCch more frequently reported that dry eye symptoms moderately to severely impacted their quality of life (NCch = 87%, non-NCch = 51%, no-Cch = 58%; P = 0.005).

CONCLUSIONS

The presence of NCch associates with dry eye symptoms, abnormal tear parameters, and impacts quality of life compared with non-NCch and no-Cch. Based on these data, it is important for clinicians to look for Cch in patients with symptoms of dry eye.

Intrastromal Corneal Ring Segment Explantation in Patients With Keratoconus: Causes, Technique, and Outcomes

PURPOSE

To assess the causes for intrastromal corneal ring segment (Intacs; Addition Technology Inc., Lombard, IL) explantation in patients with keratoconus, and technique for explantation, long-term outcomes, and secondary procedures to correct visual acuity.

METHODS

Ten eyes of 8 patients with a history of Intacs explantation between 2004 and 2012 were included in a retrospective study performed at the Bascom Palmer Eye Institute, Miami, Florida. Causes of Intacs removal, surgical technique, preoperative and postoperative corneal examination, and uncorrected and corrected distance visual acuity were documented. Additionally, corneal topography (Tomey, Nagoya, Japan) parameters such as average keratometry and corneal cylinder were assessed.

RESULTS

Although the segments were well positioned, the most common cause of Intacs removal was worsening visual acuity (80%). There was no statistically significant difference between pre-Intacs placement, post-Intacs placement, and post-Intacs removal in uncorrected and corrected distance visual acuity, average keratometry, or corneal cylinder, except between 1-year post-Intacs placement corrected distance visual acuity (0.57 logMAR [20/75 Snellen]) and 1-month post-Intacs removal corrected distance visual acuity (0.25 logMAR [20/36 Snellen], P =.03). Four patients underwent penetrating keratoplasty after Intacs removal with good visual outcomes.

CONCLUSION

This study demonstrates the visual and structural outcomes that returned to near baseline after Intacs explantation in keratoconic eyes.

Human Tear Serotonin Levels Correlate with Symptoms and Signs of Dry Eye

PURPOSE

Serotonin, a neurotransmitter known to be involved in nociceptor sensitization, is present in human tears. The purpose of this study was to correlate tear serotonin levels, as a marker of nociceptor sensitization, to facets of dry eye (DE), including symptoms and signs.

DESIGN

Cross-sectional study.

PARTICIPANTS

A total of 62 patients with normal eyelid and corneal anatomy were prospectively recruited from a Veterans Administration Ophthalmology Clinic over 11 months.

METHODS

Dry eye symptoms (Ocular Surface Disease Index [OSDI]), signs (tear break-up time [TBUT], corneal staining, and Schirmer's score), and clinical descriptors of neuropathic ocular pain (NOP) (sensitivity to light or sensitivity to wind) were assessed. For tear analysis, each patient's tears were collected after instilling 50 μl of sterile saline to the lower cul-de-sac of each eye and using capillary action microcaps to collect the ocular wash. Tear serotonin levels were measured using enzyme-linked immunosorbent assay.

MAIN OUTCOME MEASURES

Correlations between tear serotonin concentrations and DE symptoms and signs.

RESULTS

The mean age of the population was 61±14 years, and 84% (n = 52) of the patients were male. Serotonin concentrations negatively correlated with Schirmer's scores (r = -0.28; P = 0.02) but did not correlate with other DE parameters, such as OSDI scores, sensitivity to light or wind, TBUT, and staining. According to our hypothesis, we divided patients into groups based on both DE symptoms and aqueous tear production; serotonin concentrations were significantly higher in DE group 1 (OSDI ≥6 and Schirmer's <8) compared with both DE group 2 (OSDI ≥6 and Schirmer's ≥8) and controls (OSDI <6 and Schirmer's ≥8). Patients in DE group 2 more frequently reported sensitivity to light (64%) and wind (67%) compared with DE group 1 (40% and 60%, respectively) and controls (8% and 17%, respectively).

CONCLUSIONS

Patients with DE symptoms and aqueous tear deficiency had higher tear serotonin levels compared with those with DE symptoms but normal tear production and those without DE symptoms.