Iridociliary Body Metastasis of Atypical Carcinoid: Case Management with Intravitreal Anti-Vascular Endothelial Growth Factor Injections.

We report a rare case involving a 52-year-old female diagnosed with an atypical bronchial carcinoid tumor with metastases to the mediastinum, hilar lymph nodes, breast, and pancreas. In additional, the patient had metastases to the iris and ciliary body, resulting in progressive vision loss in her left eye. Treatment was successful by intravitreal injections of anti-vascular endothelial growth factor.

Phacoemulsification, Intraocular Lens Implantation, Goniosynechialysis, and Pseudo-Pupilloplasty for Refractory Acute Primary Angle Closure with Atonic Dilated Pupil.

Objective To evaluate the efficacy and safety of prompt phacoemulsification, intraocular lens implantation, visco-goniosynechialysis, combined with pseudo-pupilloplasty for refractory acute primary angle closure (APAC) with atonic dilated pupil and to describe a feasible method of pupilloplasty. Methods A consecutive series of refractory APAC patients who had atonic dilated pupil and undergone prompt phacoemulsification combined with pseudo-pupilloplasty at our center were retrospectively analyzed. Pseudo-pupilloplasty referred to a method of pupilloplasty which included 4.5-mm capsulorhexis, postoperative opacification of anterior capsule residue, and ultimate pseudo-pupil formation. Preoperative and postoperative measurements included intraocular pressure (IOP), best corrected visual acuity (BCVA), and anterior chamber depth (ACD). Intraoperative and postoperative complications were documented. The process of pseudo-pupil formation was also observed. Results A total of 20 eyes of 19 APAC patients were followed up for 19.7 ± 9.8 months. IOP was lowered from preoperative 44.0 ± 9.8 mmHg to 15.5 ± 2.6 mmHg at final visit (t=11.945, P< 0.001). ACD was deepened from preoperative 1.77 ± 0.21 mm to 3.40 ± 0.20 mm at final visit (t=-27.711, P< 0.001). Twelve of 20 eyes had residual angle synechiae, whereas only 3 eyes needed anti-glaucoma medications. No severe complication was observed. All eyes had pseudo-pupil gradually formed within 3 months, accompanied with the gradual improvement of BCVA from preoperative 1.18 ± 0.55 to 0.58 ± 0.22, 0.26 ± 0.09, 0.11 ± 0.09, and 0.11 ± 0.09 at postoperative day 1, month 1, month 3, and last visit. Conclusions Prompt phacoemulsification-goniosynechialysis is effective and safe for refractory APAC with atonic dilated pupil. Pseudo-pupilloplasty is a feasible procedure for pupil reconstruction.

A Case of Refractory Childhood Glaucoma Secondary to Weill-Marchesani Syndrome: Management with Combined CO2 Laser-Assisted Sclerectomy Surgery and Trabeculectomy.

A 2-year-old girl was diagnosed as Weill-Marchesani syndrome with typical systemic features of short stature, short and stubby hands and feet, language disorders and mental retardation. He developed bilateral angle closure glaucoma, ectopia lentis and suffered visual loss from the ocular features of Weill-Marchesani syndrome. The child was successfully treated by combined CO2 laser-assisted sclerectomy surgery and trabeculectomy.

[Application of Ultrasound Biomicroscopy in Longterm Follow-up Post Modified CO2 Laser-assisted Sclerectomy Surgery].

Objective To observe the role of ultrasound biomicroscopy(UBM)in two-year post-operative follow-up for primary open-angle glaucoma patients with modified CO2 laser-assisted sclerectomy surgery(CLASS).Methods This was a case series study.A combination of modified CLASS and preoperative laser iris management was administered to 28 eyes.Visual acuity,intraocular pressure(IOP),and slit-lamp examinations,visual field testing,and gonioscopy were carried out at baseline and until 24 months postoperatively.UBM examination was performed at 1,3,12 and 24 months postoperatively.Results Compared with the mean preoperative IOP [(30.61±10.59)mmHg],the IOP at each time point after operation was significantly lowered [(15.15±5.87),(12.56±3.24),(13.15±2.73),(13.75±2.55)and(13.75±2.46)mmHg at 1,3,6,12 and 24 months,respectively;all P<0.001].Complete success rates and qualified success rates at 12 months and 24 months were 60.71%,89.29% and 53.57%,85.71%,respectively.UBM images can present "dolphin head sign" after successful CLASS.The thickness of trabeculo-Descemet's window was(0.13±0.03)mm,which had no significant correlation with postoperative IOP at 12(r=-0.278,P=0.144)and 24 months(r=0.026,P=0.895).UBM examination revealed a severe scleral lake diminution(a change > 50%)in 1 eye(3.57%)at 12 months and 3 eyes(10.71%)at 24 months.There was no statistical significance detected between the size of the scleral lake and IOP after CLASS.Non-founctional blebs were found in 16 eyes(57.14%)at 12 months and 25 eyes(89.28%)at 24 months.Two eyes(7.14%)demonstrated severe peripheral anterior synechiae at 24 months,requiring surgical intervention.Conclusions UBM can effectively observe the morphology of the scleral lake,anterior chamber angle and filtering blebs in post-operative follow-up after modified CLASS,and give early warning of complications.It plays an important role in ensuring the success of CLASS.

Comparison of aqueous humor levels of PlGF and VEGF in proliferative diabetic retinopathy before and after intravitreal conbercept injection.

AIMS: The aim of this paper is to observe the change of aqueous humor levels of placenta growth factor (PlGF) and vascular endothelial growth factor (VEGF) in proliferative diabetic retinopathy (PDR) patients before and one week after intravitreal conbercept injection. METHODS: A prospective case series study was conducted in 24 active PDR patients (24 eyes). All the patients had received 0.5 mg of intravitreal conbercept followed by vitrectomy one week later. The aqueous humor was collected before conbercept injection and at the beginning of vitrectomy. RESULTS: Before conbercept injection, the aqueous humor median levels of VEGF-A, VEGF-B and PlGF were457.0pg/mL(IQRfrom392.9to860.6pg/mL), 43.6pg/mL(IQRfrom33.6to81.6pg/mL), 37.5pg/mL(IQRfrom25.0to53.6pg/mL), respectively. One week after conbercept injection, the aqueous humor levels of VEGF-A, VEGF-B and PiGF decreased significantly. The aqueous humor VEGF-A levels in PDR patients with fibrovascular membranes were lower than those without them. There was positive correlation between aqueous humor VEGF-B and PiGF levels (P = 0.007). No significant correlation was found between VEGF-A and PiGF levels. No ocular and systemic adverse events were observed. CONCLUSIONS: The aqueous humor levels of PlGF was correlated with VEGF-B, and levels of VEGF-A, VEGF-B, and PlGF decreased after intravitreal conbercept injection in active PDR patients.

Bilateral Choroidal Occlusion in Antiphospholipid Syndrome Associated with Systemic Lupus Erythematosus.

This article reports a rare case of bilateral choroidal occlusion that occurred in a 24-year-old woman with antiphospholipid syndrome (APS) associated with systemic lupus erythematosus (SLE). This young lady concurred with aorta ventralis thrombosis and bilateral iliac artery occlusion when presented, and experienced a rapid deterioration of vision. She also has a history of recurrent miscarriage. Corticosteroid, immunosuppression and anticoagulation therapy were administered. Patients with APS associated with SLE are at risk for thrombotic phenomena, which may affect the ocular vessels of all sizes, including choroidal vessel. Our case alerts ophthalmologists and rheumatologists that bilateral choroidal occlusion may indeed be developed in patients with APS associated with SLE, and is a potential cause of visual morbidity.

[Peripapillary choroidal thickness in primary open angle glaucoma and normal subjects measured by enhanced depth imaging optical coherence tomography].

OBJECTIVE: To compare peripapillary choroidal thickness (CT) between primary open angle glaucoma (POAG) and normal subjects using enhanced depth imaging optical coherence tomography (EDI-OCT). METHODS: This research was a cross-sectional study. A 360-degree 3.4 mm diameter peripapillary circle scan was performed for retinal nerve fiber layer (RNFL) assessment by EDI-OCT in one eye of 40 POAG patients and 41 age- and sex-matched normal subjects. The observer used the manual segmentation function to delineate the posterior edge of the retinal pigment epithelium and the sclerochoroidal interface. The RNFL thickness algorithm function was used to automatically generate the CT in corresponding sectors. The intra- and inter-observer reproducibility was evaluated by intraclass correlation coefficient (ICC). Repeated measures ANOVA and LSD-t test were used to analyze differences in CT by peripapillary location. A Pearson correlation was calculated for variation in CT relative to age and RNFL. Spearman rank correlation was calculated to test the strength of the relationship between global mean RNFL and visual field mean deviation (MD) and between CT and MD. Independent-samples t-test was conducted to compare mean RNFL and CT between POAG and normal subjects. RESULTS: The intra- and interobserver ICC values ranged from 0.993 to 0.999 and 0.993 to 0.998 respectively. In both groups, the CT showed a negative correlation with age at each peripapillary location (r = -0.509 to -0.608, -0.549 to -0.668; P = 0.000 to 0.001) but no significant correlation with RNFL for any location (r = -0.186 to 0.273, -0.090 to 0.132; P = 0.092 to 0.869). The peripapillary CT was thickest superotemporally and superonasal, then nasally and temporally, and was thinnest inferotemporally and inferonasal (P = 0.000 to 0.036). Compared to normal subjects, eyes with POAG had significantly thinner RNFL at all locations (t = 6.975 to 16.087, P = 0.000), but CT measurements did not differ between groups for any location (t = -0.474 to 0.367, P = 0.637 to 0.978). In POAG patients, the global mean RNFL (rs = -0.511, P = 0.001) but not CT (rs = -0.285, P = 0.079) was found to significantly correlate with visual field MD. CONCLUSIONS: The peripapillary CT in POAG neither differ from that in normal subjects nor correlate with RNFL and visual field index, which does not support using it as a clinical parameter in glaucoma diagnosis or management.

[Expression of Nogo-A, NgR mRNA and protein in the retina of rats with chronic elevated intraocular pressure].

OBJECTIVE: To investigate the expression of Nogo-A and its receptor NgR mRNA and protein in the retina of rats with chronic elevated intraocular pressure (IOP). METHODS: Experimental study. Rat chronic ocular hypertension (OHT) was induced by obstructing episcleral veins and temporal limber veins. The retinal tissues were collected at day 3, 7, 14 and 28 after the IOP elevated in rats. Each group includes 16 rats and one group served as normal control. Expression of Nogo-A and NgR mRNA was detected by reverse transcription polymerase chain reaction (RT-PCR), while the protein levels of Nogo-A and NgR were expressed by the western blot in rat retinal tissues in different groups. Expression of Nogo-A, NgR mRNA and protein were analysed by one way analysis of variance (ANOV) and multiple comparison ANOV. RESULTS: IOP in rat OHT group was significantly increased after day 3 lasting for 28 day. Compared with control group, the level of Nogo-A mRNA and protein in rat chronic OHT groups were significantly (mRNA: F = 7.464, protein: F = 5.677; P < 0.01) increased at day 7, 14, and 28 (mRNA: 0.661 ± 0.065 vs 0.831 ± 0.055, 0.813 ± 0.063, 0.844 ± 0.077, protein: 1.284 ± 0.043 vs 1.359 ± 0.033, 1.381 ± 0.063, 1.361 ± 0.044), respectively. There is a tendency of increase of Nogo-A mRNA expression at day 3 but did not reach statistical significance. However, the level of NgR in the retina in rats with the chronic OHT was not significantly (mRNA:F = 0.598, protein:F = 0.460; P > 0.01) changed compared with normal group. CONCLUSION: The increased expression of Nogo-A in retina of rat OHT indicates that Nogo-A may play a primary role in obstructing regeneration of optic nerve, which is mediated by other receptors and elements rather than NgR.

[Analysis of fundus fluorescein angiography, indocyanine green angiography and choroidal thickness in central serous chorioretinopathy].

OBJECTIVE: To evaluate the characteristics of choroidal thickness changes and abnormalities in choroidal circulation in cases of central serous chorioretinopathy (CSC). METHODS: This was a case control study, we measured the bilateral choroidal thickness in 21 patients with unilateral CSC and 24 eyes of 24 age- and sex-matched normal subjects using enhanced depth imaging optical coherence tomography (EDI-OCT). The choroid was measured from the posterior edge of the retinal pigment epithelium (RPE) to the choroid-scleral junction at 500 µm intervals of a horizontal section from 3 mm temporal to the fovea to 3 mm nasal to the fovea. Paired-samples t-test was conducted to compare mean choroidal thicknesses between symptomatic eyes and fellow eyes of patients. The datum between patients and normal subjects were analyzed by independent-samples t-test. Fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA) were performed and the digital images were analyzed in CSC patients. RESULTS: The 21 CSC patients had a mean age of 45.6 years, and 12 patients (57.1%) were male. The choroid in symptomatic eyes was thickest beneath the fovea (519.0 ± 102.5) µm. It was significantly thicker than that in the fellow eyes (439.3 ± 94.1) µm (t = 4.171, P < 0.05). Choroidal thickness in both groups was significantly greater than that in the eyes of age- and sex-matched normal subjects (332.0 ± 67.3) µm (t = 7.125, 4.441; P < 0.05). Choroidal thickness at each of the other 12 points showed a similar tendency (t = 2.544 to 3.819, 4.799 to 7.816, 2.487 to 5.236; P < 0.05). ICGA showed a choroidal filling delay (100%), vessels dilation (90.5%), and focal choroidal hyperfluorescence (100%) surrounding leakage from the RPE in symptomatic eyes. Pigment epithelium detachment with abnormal choroidal circulation was observed in 6 fellow eyes. In 4 symptomatic eyes and 11 fellow eyes, ICGA revealed choroidal hyperfluorescence but FFA showed normal appearance. CONCLUSIONS: CSC seems to be a bilateral eye disease with choroidal focal ischemia followed by vessels congestion and hyperpermeability. EDI OCT is a useful tool for monitoring choroidal thickness changes caused by choroidal vascular hyperpermeability.

[Novel exploration of emergency treatment for ueitic acute angle closure glacuma].

OBJECTIVE: To explore the effects of anterior chamber paracentesis plus pupillary block relief under slit-lamp microscope for the emergency treatment of uveitic acute angle closure glaucoma (ACG). METHODS: In early stage, 14 uveitc acute ACG patients received anterior chamber paracentesis plus pupillary block relief while another 10 uveitc acute ACG patients underwent laser peripheral iridectomy (LPI). The intraocular pressure (IOP), degree of Tyndall, degree of pupillary block and severe adverse events were recorded at each observation timepoint. RESULTS: The IOP values for the paracentesis plus pupillary block relief group were (9.2 ± 2.1) mm Hg, (12.4 ± 3.7) mm Hg and (14.1 ± 2.6) mm Hg at 1, 48 h and 10 d vs (24.5 ± 7.1) mm Hg, (22.2 ± 8.6) mm Hg and (19.3 ± 9.3) mm Hg respectively for the LPI group. The inflammatory reaction of anterior chamber was more relieved in the paracentesis plus pupillary block relief group at Day 10. Pupillary block was observed in 1(1/14) patient from the paracentesis plus pupillary block relief group and 6 (6/10) patients from the LPI group at Day 10. Mild hemorrhage at pupillary margin was observed in 2 cases from the paracentesis plus pupillary block relief group. Both were self-absorbed within 10 days. CONCLUSION: Anterior chamber paracentesis plus pupillary block relief under slit-lamp microscope is the safe and effective emergency treatment for uveitic acute ACG. And it may offer a basis for further therapy.

Factors related to prognosis of refractory glaucoma with diode laser transscleral cyclophotocoagulation treatment.

OBJECTIVE: To evaluate the predictive factors of refractory glaucoma treated with diode laser transscleral cyclophotocoagulation (TSCP) in a midterm observation. METHODS: Fifty-four consecutive patients (54 eyes) with refractory glaucoma were enrolled and underwent TSCP (power of 1.5-2.0 W, exposure time of 2 seconds and 20-50 applications). Patients were regularly followed up for 12 months. Intraocular pressure (IOP) was measured before TSCP treatment and at each follow-up visit. Patients were divided into the sensitive and insensitive groups according to the effect of a single treatment of TSCP on IOP. The success rate was defined as the percentage of eyes achieving an IOP between 5 and 21 mm Hg following TSCP therapy at their final follow up visit. Difference of age between the sensitive and insensitive groups was evaluated with independent-samples T test and that of gender distribution of two groups was evaluated with Fisher's exact test. The success rate of different types of glaucoma to TSCP was calculated. RESULTS: A total of 32 patients were sensitive to TSCP (sensitive group) and 22 patients were insensitive to TSCP (insensitive group). The success rates of female (77.8%, 14/18) and cases being over 50 years (71.4%, 20/28) were higher than those of male (50.0%, 18/36) and ones being under 50 years (46.2%, 12/26) (all P>0.05). The age of the sensitive and insensitive groups was 56.0+/-15.5 and 46.4+/-15.4 years, respectively (P=0.029). The age (P=0.029) and gender distribution (P=0.046) of the two groups had significant difference. The success rate of neovascular glaucoma, primary angle-closure glaucoma, primary open angle glaucoma, traumatic glaucoma, uveitic glaucoma, and secondary glaucoma after silicone oil injection to TSCP was 57.1%, 100.0%, 50.0%, 20.0%, 81.8%, and 0%, respectively. CONCLUSION: Age, gender, and type of glaucoma appear to be associated with effect of TSCP on IOP control.

[Effects of central corneal thickness and corneal curvature on measurement of intraocular pressure with Goldmann applanation tonometer and non-contact tonometer].

OBJECTIVE: To investigate the effects of central corneal thickness (CCT) and corneal curvature (CC) on intraocular pressure (IOP) measurements by the Goldmann applanation tonometer (GAT) and the non-contact tonometer (NCT). METHODS: One hundred and twenty patients were recruited from the clinic of Peking Union Medical College Hospital. The CCT was measured by ultrasound pachymetry and the mean radius of CC by using Canon PK-5 refractometer. The IOP of each eye was measured by both GAT and NCT. Linear regression was used to compare the measurements of GAT and NCT; multi regression was used to analyze the relationships between CCT, CC and the measurements of GAT and NCT. Bland-Altman method was used to compare the effect of NCT and GAT on the IOP measurements. RESULTS: The results of the right eyes were reported in this paper. The mean and standard deviation of IOP measured by GAT and NCT was (18.4 + or - 4.0) mm Hg (1 mm Hg = 0.133 kPa) and (17.0 + or - 4.6) mm Hg, respectively, the difference was statistically significant (r = 0.835, P = 0.000). IOP measured using GAT increased by 0.039 mm Hg per microm increase in CCT. IOP measured using NCT increased by 0.064 mm Hg per microm increase in CCT. For an increase of 1 mm of mean corneal curvature there was decrease in IOP of 2.648 mm Hg measured by the GAT and of 3.190 mm Hg measured by the NCT. Compared to the GAT, NCT underestimated at low IOP level and overestimated at higher IOP level. CONCLUSIONS: The IOP measurement obtained with both GAT and NCT varied with CCT and CC. CCT affected IOP measurements by NCT more than that by GAT.

[Long-term outcomes of laser peripheral iridectomy for primary angle closure glaucoma].

OBJECTIVE: To explore the long-term efficacy and safety of laser peripheral iridectomy for primary angle closure glaucoma (PACG). METHODS: It was a retrospective case series study. Data were collected from those patients who received laser peripheral iridectomy (LPI) for acute or chronic PACG from April 1992 through October 2002 at the Peking Union Medical College Hospital. Only patients who were followed for at least 5 years were included in this study. The control of intraocular pressure (IOP), visual acuity and managements after LPI were analyzed. All of the studied eyes were re-classified into three categories according to the status of anterior chamber angle, optic nerve head and visual field before LPI: primary angle closure suspect (PACS), primary angle closure (PAC) and primary angle closure glaucoma (PACG). Satisfactory control of IOP was defined as the IOP was less than 21 mm Hg (1 mm Hg = 0.133 kPa) without any medications after LPI. No satisfactory control of IOP was defined as the IOP was greater than 21 mm Hg after LPI, yet could be controlled below 21 mm Hg by anti-glaucoma medications. A failure in IOP control was defined as an acute attack of angle closure developed or filtering surgery was required to control IOP after LPI. Chi-square analysis was used for comparison of IOP control in different groups. RESULTS: One hundred and thirty one patients (251 eyes) with PACG were eligible for this study. The mean follow-up period was (9.2 +/- 3.7) years. Of the 251 eyes, 18 eyes (7.2%) were identified as PACS, 98 eyes (39.0%) PAC, 129 eyes (51.4%) PACG, and 6 eyes (2.4%) could not be classified owing to the lack of the information on the optic nerve head and visual field before LPI. The rates of satisfactory control of IOP were 27.1% in all eyes, and 88.9% (16/18), 38.8% (38/98) and 10.9% (14/129) in PACS, PAC and PACG eyes respectively. The rates of no satisfactory control of IOP were 59.8% in all eyes, and 5.6% (1/18), 48.0% (47/98) and 75.2% (97/129) in PACS, PAC and PACG eyes respectively. The rates of failure in IOP control were 13.1% in all eyes, and 5.6% (1/18), 13.3% (13/98) and 14.0% (18/129) in PACS, PAC, PACG eyes respectively. The difference in IOP control between PACS, PAC and PACG eyes was statistically significant (chi(2) = 59.08, P = 0.000). Only 8 eyes had an acute attack of angle closure after LPI. No long-term complications after LPI were observed in all eyes. CONCLUSIONS: The IOP control after LPI in PACG eyes is not so good as expected. However, most of PACG eyes after LPI are free of acute attack of angle closure. PACG eyes should be given close and regular follow-up in a long-term to monitor the IOP control and the progression of PACG after LPI.