Retinopathy as a Prognostic Marker in Cerebral Malaria

OBJECTIVE

To study the association between fundal changes (malarial retinopathy) and mortality in children with cerebral malaria.

METHODS

50 consecutive children (mean age 8.4 y, 23 males) with cerebral malaria (acute febrile encephalopathy and either peripheral smear or Rapid diagnostic test positive for malaria) were evaluated by a single ophthalmologist for any changes of retinopathy. Children were managed as per standard guidelines for treatment of cerebral malaria.

RESULTS

P. vivax infection was seen in one child, P. falciparum infection in 42 children, and a mixed infection in 7. Retinopathy was present in 48% of the children. 13 children died during hospital stay. The mean interval from admission to fundus examination was 11.6 (4.64) h. Presence of any retinopathy (P=0.02), and either of papilledema (P=0.02), hemorrhages (P=0.005) or vessel changes (P=0.01), were associated with a significantly higher risk of death.

CONCLUSION

Malarial retinopathy is significantly associated with mortality in children with cerebral malaria. It may be used for both prognostication, and triaging for optimum utilization of intensive care facilities in these children.

Long-term survival of a patient with small cell lung cancer associated with cancer-associated retinopathy

Cancer-associated retinopathy (CAR) is a rare paraneoplastic disorder that is frequently found in patients with small cell lung cancer (SCLC); it is caused by autoantibody to the 23-kDa photoreceptor protein, recoverin. We report a 9-year survivor of SCLC after concurrent chemoradiotherapy. His anti-recoverin antibody remains positive. Long-term survival without SCLC recurrence might be related to an autoimmunity mechanism that causes CAR due to the presence of anti-recoverin antibody cross-reacting with retinal cells and tumor cells. The current literature review was conducted to evaluate the impact on overall survival according to anti-recoverin antibody status.

Retinal vessel diameter and cardiovascular mortality: pooled data analysis from two older populations

AIMS

The retinal microvasculature may reflect pre-clinical changes in the cerebral and coronary microcirculations. We assessed whether smaller retinal arterioles and larger venules predicted coronary heart disease (CHD)- and stroke-mortality.

METHODS AND RESULTS

We pooled data from the Beaver Dam Eye Study (n = 4926, aged 43-86) and the Blue Mountains Eye Study (n = 3654, aged 49-97). Retinal vessel diameters were measured from digitized retinal photographs. Change point models were used to assess and document the existence of threshold effects. We defined smaller arterioles as diameters within the narrowest quintile and larger venules as diameters within the widest quintile, with other quintiles as the reference. Of 8550 participants, 7494 (88%) with complete data were included, of whom 653 died from CHD and 299 from stroke over 10-12 years follow-up. After multivariable adjustment, each standard deviation (SD) increase in arteriolar diameter, or SD decrease in venular diameter, was not found to be significantly associated with either CHD-mortality or stroke-mortality. However, smaller arterioles [hazard ratio (HR) 1.34, 95% confidence interval (CI) 1.11-1.62] and larger venules (HR 1.24, CI 1.02-1.52), predicted increased risk of CHD-mortality. These associations were mainly evident among persons aged 43-69 (smaller arterioles: HR 1.70, CI 1.27-2.28; larger venules: HR 1.41, CI 1.06-1.89). Smaller arterioles (HR 1.64, CI 1.00-2.67) and larger venules (HR 1.53, CI 0.94-2.47) were also associated with an increased risk of stroke-mortality among persons aged 43-69.

CONCLUSION

Retinal vessel diameter may predict risk of CHD and stroke deaths in middle-aged persons.

Retinal arteriolar narrowing and left ventricular remodeling: the multi-ethnic study of atherosclerosis

OBJECTIVES

This study sought to examine the relationships of retinal vascular signs with left ventricular (LV) mass, volume, and concentric remodeling.

BACKGROUND

Microvascular disease, reflected as retinopathy lesions, has been shown to predict clinical congestive heart failure. Whether these retinal vascular changes are related to early structural alterations and remodeling of the heart in asymptomatic individuals is unknown.

METHODS

A cross-sectional, population-based study of 4,593 participants ages 45 to 85 years, free of clinical cardiovascular disease. Retinal vascular calibers and retinopathy were graded from retinal photographs according to standardized protocols. The LV mass and volume were measured from cardiac magnetic resonance imaging. Extent of LV concentric remodeling was determined by the ratio of LV mass to end-diastolic volume (M/V ratio).

RESULTS

After controlling for age, gender, race, center, past and current systolic blood pressure, body mass index, smoking, antihypertensive medications, diabetes, diabetes duration, glycosylated hemoglobin, lipid profile, and C-reactive protein, narrower retinal arteriolar caliber was associated with concentric (highest quintile of M/V ratio) remodeling (odds ratio [OR] 2.06, 95% confidence interval 1.57 to 2.70). This association was seen in men and women, and was present even in those without diabetes, without hypertension, and without significant coronary calcification. In multivariate analysis, the presence of retinopathy (OR 1.31, 95% confidence interval 1.08 to 1.61) was also associated with concentric remodeling.

CONCLUSIONS

Narrower retinal arteriolar caliber is associated with LV concentric remodeling independent of traditional risk factors and coronary atherosclerotic burden, supporting the hypothesis that microvascular disease may contribute to cardiac remodeling.

Prevalence and Associations of Enhanced Retinal Arteriolar Light Reflex

PURPOSE

To assess the prevalence, associated risk factors and prognosis (mortality) of the enhanced retinal arteriolar light reflex sign in an older Australian population.

DESIGN

Population-based cross-sectional study.

PARTICIPANTS

Three thousand six hundred fifty-four participants (82.4% response) ages >/=49 years from Australia's Blue Mountains region.

METHODS

Retinal photographs of participants were graded for presence and severity of the enhanced arteriolar light reflex sign by comparison with standard photographs. Associations with systemic factors (subject-specific) and ocular variables (eye-specific) were assessed by logistic regression. Mortality data were obtained using the Australian National Death Index. Hazard ratios were calculated using Cox regression.

MAIN OUTCOME MEASURES

Prevalence of enhanced arteriolar light reflex and associations with demographic variables (age, gender), blood pressure, blood parameters, health risk behaviors, cataract, retinal vessel wall signs, retinopathy, and 10-year incident mortality.

RESULTS

The enhanced arteriolar light reflex sign was found in 1053 participants (31.7%, including 28.8% graded as mild and 2.9% as marked). Prevalence decreased with age (36.0%, 37.7%, 28.0%, and 18.8% for age groups < 60, 60-69, 70-79 and > or = 80 years, respectively, P(trend)<0.0001); odds ratio (OR) 0.78; and 95% confidence interval (CI) 0.72 to 0.85 per decade. Persons with cataract were less likely to have mildly enhanced light reflex (OR, 0.74; CI 0.64-0.87). After multivariate adjustment, mildly enhanced light reflex was significantly associated with serum glucose (OR 1.11 per SD increase), total cholesterol (OR 1.11), low-density lipoprotein (OR 1.55), triglycerides (OR 1.11), platelets (OR 0.89), and body mass index (OR 1.12). Markedly enhanced light reflex was significantly associated with mean arterial blood pressure (OR 1.24), heavy alcohol consumption (OR 2.66, > or = 40 grams alcohol per day), and serum glucose (OR 1.16). Strong associations were demonstrated between presence of mildly enhanced light reflex and either arteriovenous nicking (OR 3.12) or retinopathy (OR 1.96). There was no association between mildly or markedly enhanced light reflex and either all-cause or vascular mortality.

CONCLUSIONS

In this older population, the enhanced retinal arteriolar light reflex sign was a relatively common finding. Although some associations of this sign with vascular risk factors were found, only a marked level of enhanced light reflex was correlated with elevated blood pressure, but not with poor survival.

[Fundus hypertonicus Okulare Veranderungen bei systemischen Erkrankungen]

Cardiovascular disease is one of the major causes of mortality and morbidity in the western world. However, 30% of men and 15% of women were not aware of their elevated blood pressure. Hypertension has been defined as a multiply exceeded threshold value set by the WHO. With increasing blood pressure, mortality increases significantly. Studies have shown an increasing risk of stroke or cardiovascular disease in this patient group. The ophthalmologist plays an important role in the assessment and classification of vascular abnormalities. Typical parenchymal and vascular changes are helpful in arriving at a proper diagnosis, as well as providing a means of risk assessment and potentially helping to identify patients at risk.

Orbital irradiation for Graves' ophthalmopathy: Is it safe? A long-term follow-up study

PURPOSE

We evaluated the frequency of long-term complications of orbital irradiation (radiation-induced tumors, cataract, and retinopathy) in comparison with glucocorticoids.

DESIGN

We conducted a follow-up study in a cohort of 245 Graves' ophthalmopathy patients who had been treated with retrobulbar irradiation (20 Gy in 2 weeks) and/or oral glucocorticoids between 1982 and 1993 in our institution. Irradiated patients were compared with nonirradiated patients.

METHODS

Data on mortality and cause of death were obtained. Living patients were invited to participate in a follow-up study. Possible retinopathy was assessed in a masked fashion and defined as the presence of > or =1 hemorrhages and/or microaneurysms on red-free retina photographs. If >5 lesions were present, patients were categorized as suffering from definite retinopathy. Cataract was assessed using the Lens Opacity Classification System II score.

MAIN OUTCOME MEASURES

Mortality, prevalence of retinopathy, prevalence of cataract, and type of cataract.

RESULTS

Thirty-seven of the 245 patients had died, none of them from an intracranial tumor. Mortality was similar in the irradiated (27/159 [17%]) and nonirradiated patients (10/86 [12%]; P = 0.264). One hundred fifty-seven of the 208 living patients (75%) consented to participate in a follow-up ophthalmologic investigation; the mean follow-up time (+/- standard deviation) was 11+/-3 years. Possible retinopathy was present in 15% of patients, 22 of the irradiated and 1 of the nonirradiated patients (P = 0.002). In 5 patients (all had been irradiated), definite retinopathy (i.e., >5 retinal lesions) was present. Of these, 3 had diabetes mellitus, and 1 had hypertension. Diabetes was associated with both possible (P = 0.029) and definite (P = 0.005) retinopathy, with a relative risk of 21 (95% confidence interval, 3-179). The prevalence and severity of cataract were similar in the radiotherapy group (29%) and the glucocorticoid group (34%); it should be noted that 88 of 104 of the irradiated patients were also treated with oral glucocorticoids.

CONCLUSION

The data suggest that orbital irradiation for Graves' ophthalmopathy is a safe treatment modality, except possibly for diabetic patients.

[Retinal diseases with primary pulmonary hypertension]

BACKGROUND

Primary pulmonary hypertension (PPH) is a rare but fatal disease that results in right heart failure from idiopathic occlusion of the pulmonary arteries. Patients develop stagnation of venous pressure. PPH occurs most commonly in young and middle-aged women and the mean survival time from onset of symptoms is 2-3 years. The aetiology of PPH is unknown, although familial occurrence of the disease suggests a genetic predisposition. Pulmonary transplantation is reserved for patients who fail medical therapy. Pathophysiologically, PPH is a functional and structural alteration of the pulmonary blood vessels.

METHODS

The authors retrospectively reviewed the clinical records of three patients (mean age 34 years) diagnosed with PPH and retinal diseases.

RESULTS

All three patients developed central retinal vein occlusion (CRVO). One patient developed a neovascular glaucoma and on the other eye a serous retinal detachment with uveal effusion. A few months after the central vein obstruction was diagnosed two patients died as a result of PPH.

CONCLUSIONS

The elevated venous pressure found in PPH is responsible for decreased choroidal perfusion and reduced venous blood outflow from the eye. This would explain the clinical findings of serous retinal detachment and central retinal vein occlusion in these patients.

Retinal findings predictive of outcome in cerebral malaria

The pathogenesis of cerebral malaria is poorly understood. Direct and indirect ophthalmoscope examinations of 141 Malawian children with strictly defined cerebral malaria revealed 2 distinct and prognostically significant findings: papilloedema and extramacular retinal oedema. The relative risk of death in patients with papilloedema was 6.7 times that in patients without papilloedema. Extramacular retinal oedema was associated with a 2.9 fold increase in the relative risk of dying. The mortality rate in patients with neither of these signs was only 1.3% compared to an overall mortality rate of 9.2%. The clinical and laboratory features associated with each of these ophthalmological findings were different, suggesting that there may be at least 2 different pathogenetic processes in patients with cerebral malaria.

Prognostic importance of retinopathy in acute leukemia

This prospective study evaluates the relationship, between the fundus findings in leukemic retinopathy and the survival in patients with newly diagnosed acute leukemia. Fifty-four newly diagnosed consecutive patients with acute leukemia were included in this study. The patients were examined within few days of initial admission and diagnosis. Leukemic retinopathy was detected in 19 (35%) patients. The observation period ranged from 434 days to 1220 days (mean +/- SD 880 +/- 225) for those patients who survived. Despite similar chemotherapy compared to those without retinopathy (332.4 +/- 99.6 and 76 vs. 640.7 +/- 106 and 192 days respectively) although survival did not differ significantly (p = 0.073). Patients with cotton-wool spots had lower mean and median survival times than did those without such lesions (168.8 +/- 70.9 and 27 vs. 609.4 +/- 91.4 and 289 days respectively) and survival differed significantly (p = 0.04). The presence of cotton-wool spots and age > or = 40 years were the major adverse prognostic factors for survival in multivariate analysis. Cotton-wool spots had a more significant adverse prognostic effect than age > or = 40 years (hazard function coefficients: 1.0708 for cotton-wool spots vs 0.0355 for age > or = 40 years). The relative odds of dying among patients with cotton-wool spots were about 8 times higher than that for those without this feature, and about 7 times higher in patients aged > or = 40 years than that for patients aged < 20 years. Our findings suggest that the presence of leukemic retinopathy in general, and cotton-wool spots, in particular is a poor prognostic sign for survival in acute leukemia.

The association of central retinal artery occlusion and extracranial carotid artery disease

To determine the incidence of associated carotid artery disease and the effect of carotid endarterectomy on subsequent neurologic sequelae, a retrospective study of 66 patients with central retinal artery occlusion (CRAO) was undertaken. Ipsilateral extracranial carotid artery disease was present in 23 of 33 patients (70%) who had carotid arteriography. Sixteen patients had carotid endarterectomy following their CRAO (Group I) and 50 did not (Group II). Seven of the 40 patients available for follow-up in Group II had a subsequent stroke (mean follow-up: 54 months). Of the seven Group II patients shown to have associated carotid disease (Group IIs), three (43%) had a subsequent stroke during follow-up (mean: 28.3 months) compared to zero in Group I (p = 0.033; mean follow-up: 18.7 months). Because of the strong association between CRAO and ipsilateral carotid artery disease and because of the significantly higher incidence of subsequent ipsilateral stroke in CRAO patients with carotid disease who did not undergo endarterectomy, thorough evaluation of the carotid arteries followed by carotid endarterectomy, if indicated, is warranted in CRAO patients who have no other obvious etiology for the occlusion.

Retinopathy as an independent indicator of all-causes mortality

The association between retinopathy and mortality in hypertensive patients is well established. At the same level of blood pressure the prognosis gets worse with increasing seriousness of retinopathy. To assess the prognostic value of retinopathy for all-causes mortality, we studied the data from a general health survey of 1583 men and 1508 women after 15 and 25 years of follow up. Among the men a clear association was found in the first 15 years. Among the women a weaker association was found only after 25 years of follow-up. This association was independent of hypertension or other cardiovascular risk indicators, such as obesity, serum cholesterol, smoking or proteinuria.

[Life expectancy of patients with circulatory disorders of the posterior eyeball segment]

Based on the method of person-years, the morality rate of 155 patients with circulatory disorders was calculated and compared with the death rate of an age-matched general population. No excess mortality was found among 53 patients with central retinal vein occlusion and among 58 patients with ischemic optic neuropathy. On the other hand, 44 patients with central retinal or branch artery occlusion showed a statistically significant increased mortality rate. Patients with arterial circulatory disorders were subdivided into hypertensives and normotensives; an increased mortality rate was seen only among patients with hypertension but not among patients with normal blood pressure. Hypertension is one of the main cardiovascular risk factors. The increased mortality risk among our patients with hypertension may be indicative of a progressive atherosclerosis.