Development of full-thickness macular hole despite previous posterior vitreous detachment and vitrectomy for retinal detachment: two cases.

PURPOSE: To report the delayed development of idiopathic full-thickness macular hole in eyes with previously documented complete posterior vitreous detachment that were vitrectomized during surgery for rhegmatogenous retinal detachment. METHODS: Two interventional case reports with serial color fundus photographs and optical coherence tomography scans. RESULTS: Case 1: A 62-year-old man underwent vitrectomy, cryoretinopexy, and intraocular gas tamponade for rhegmatogenous retinal detachment associated with a complete posterior vitreous detachment. Three years later, he developed a full-thickness macular hole in the same eye. Peeling of the inner limiting membrane and gas tamponade resulted in complete closure of the macular hole with improvement in visual acuity. Case 2: A 70-year-old man presented with a macula-off inferior retinal detachment and counting fingers vision. Vitrectomy, cryoretinopexy to a single tear, and gas tamponade was successful and acuity improved to 6/9. He subsequently developed retinal redetachment associated with a new retinal tear and was treated by further vitrectomy and gas. He developed a full-thickness macular hole in the same eye 2 years later with acuity dropping to 1/60. CONCLUSIONS: Macular hole formation may occur in the context of vitrectomized eyes. These observations support the hypothesis that anteroposterior vitreomacular traction, while traditionally implicated, is not always essential for the development of macular holes.

Punctate inner choroidopathy-associated choroidal neovascular membranes during pregnancy.

UNLABELLED: PURPOSE AND MATERIALS: Punctate inner choroidopathy (PIC), first described by Watzke et al(1), is a disease in young women of child-bearing age. We present three cases of PIC-associated choroidal neovascular membrane (CNVM) occurring during pregnancy, and discuss associated investigative and treatment dilemmas. RESULTS: All three patients described showed evidence of recurrence of CNVM during their pregnancy. None underwent FFA but benefited from OCT monitoring. Different therapeutic strategies were adopted in each of our cases. Case 1, with a history of spontaneous CNVM regression, was managed conservatively. Cases 2 and 3 chose steroid treatment to their better-seeing eye. All cases remained stable postpartum. DISCUSSION: Management of PIC-related CNVM creates diagnostic and therapeutic challenges. The problem is exacerbated as the pathology is often sequentially bilateral and sight threatening. Owing to the rarity of such cases, there is a paucity of evidence on which to base the treatment strategies. A history of pregnancy should always be elicited before investigation with FFA, and women warned of the potential for disease exacerbation with limited therapeutic options during pregnancy. CONCLUSIONS: spontaneous resolution of CNVM is common in PIC, and should be borne in mind while treating pregnant women. Peri/intraocular steroid injection represents a reasonable option for sight-threatening CNVM in the better-seeing eye.

A prospective study of change in visual function in patients treated with pegylated interferon alpha for hepatitis C in the UK.

BACKGROUND: Hepatitis C virus and interferon treatment have been associated with retinopathy. Baseline and ongoing assessment by ophthalmologists have therefore been advocated in previous studies. Our experience suggests that the incidence is low, with no or negligible impact of pegylated interferon alpha on actual visual function. This study was conducted to determine whether ophthalmic assessment is necessary in such patients. METHODS: The study was a prospective case series of 52 patients (104 eyes). Visual acuity, contrast sensitivity, colour vision, visual field by perimetry and fundal assessment were measured at baseline and at 3 and 6 months post commencement of interferon alpha treatment. RESULTS: Forty-two men and ten women were followed. No patients reported any subjective visual symptoms. The mean changes in right and left logarithmic minimal angle resolution (LogMAR) visual acuity were negligible between baseline and 6 months (0.05 (SD 0.13) and 0.10 (SD 0.12), respectively). Mean changes in contrast sensitivity and colour vision were also negligible. Of all eyes monitored by serial perimetry for the full follow-up period and deemed to have reliable tests, none developed visual field defects. One patient appeared to develop nasal field defects within 3 months of commencing treatment but failed to attend for repeat testing. No patients developed optic disc changes or permanent fundal changes over the follow-up period. CONCLUSION: In contrast to previous studies in America and south-east Asia, our findings based on a UK cohort suggest that routine ophthalmic screening is not essential for patients with hepatitis C treated with pegylated interferon alpha who have no subjective visual complaints.

Patient consultation survey in an ophthalmic outpatient department.

INTRODUCTION: Consultation methods differ between medical practitioners depending on the individual setting. However, the central tenet to the doctor-patient relationship is the issue of confidentiality. This prospective survey highlights patient attitudes towards consultation methods in the setting of an ophthalmic outpatient department. METHOD: Questionnaires were completed by 100 consecutive patients, who had been seen by an ophthalmologist in a single room, which had a joint doctor-patient consultation occurring simultaneously. RESULTS: Each question of all 100 questionnaires was completed. 58% of patients were not concerned about sharing a consultation room with another patient or doctor. However, this did not equate to the 49% of patients who were indifferent to discussing issues in the joint consultation room. The most common factor was the general issue of confidentiality. DISCUSSION: Ensuring total patient confidentiality may be deemed more necessary for certain medical specialties than for others, as seen in the practice of separate medical records in genitourinary medicine, for instance. However, with regard to patient consultations, the same level of confidentiality should be afforded across all specialties, and such factors should be borne in mind when planning outpatient clinics.

Emergency management of corneal injuries.

UNLABELLED: Corneal injuries account for a significant proportion of the ophthalmic workload of most emergency departments. Although the vast majority of cases are relatively minor, accurate diagnosis and appropriate management are vital to prevent potentially sight-threatening sequelae. We present a survey of corneal injury cases at a general emergency department. INTRODUCTION: Corneal injuries are very common in both the adult and paediatric population and account for a significant proportion of the workload of most emergency departments. This survey assesses management of corneal injury cases at a general emergency department. MATERIALS AND METHODS: A retrospective case study was performed of 100 patients consecutively diagnosed with a corneal abrasion by slit lamp examination at the emergency department of the Chelsea and Westminster Hospital, London. Each case was assessed to determine documentation of set criteria including visual acuity (VA), treatment and grade of examiner. RESULTS: The commonest cause of injury was direct minor trauma (64% of cases) with contact lens related problems accounting for 12% of presentations. VA was documented correctly in 85 adult patients (90.4% of adults), incorrectly in 2 cases, and not documented at all in 7 adults (7.4%). VA was not recorded in paediatric cases. All cases were treated with topical chloramphenicol drops although frequency of treatment ranged from 2 to 5 times daily and duration of treatment ranged between 3 and 5 days and for 7 days. 6 cases (6%) were assessed by an emergency nurse practitioner and the remaining number were seen by a casualty officer. DISCUSSION: VA must be accurately documented in all adult cases and should be documented in children of school age. A pinhole test should be performed in cases where VA is below 6/9. For analgesia, the use of topical nonsteroidal anti-inflammatory drugs, lubricants and bandage contact lens should be considered. Emergency nurse practitioners and general practitioners are ideally placed to follow-up uncomplicated cases.

UK national survey of prophylactic YAG iridotomy.

PURPOSE: Acute angle-closure glaucoma is a common ophthalmic emergency and individuals with shallow anterior chambers and suspected narrow angles are increasingly referred to the hospital eye service for assessment. There appears to be variation in subsequent management, with no national consensus or college guidelines. This study ascertains the current use of prophylactic YAG iridotomy in patients with no known history of an acute angle-closure glaucoma attack, and also the methods used in patient selection. MATERIALS AND METHODS: Questionnaire-based survey mailed to 650 UK consultant ophthalmologists with a covering letter in 2003. RESULTS: A total of 546 questionnaires were returned. In all, 408 respondents (74.7%) confirmed they perform prophylactic YAG iridotomy and of these 347 (85.0%) use patient symptoms and 268 (65.6%) presenting IOP in patient selection, 394 (96.6%) perform gonioscopy and 97 (23.8%) use some form of provocative test first. A total of 135 (25.3%) stated they do not perform this procedure. CONCLUSION: This study reveals current national practice among UK ophthalmologists, with variations in the assessment of patients with narrow angles but a high uptake of prophylactic YAG iridotomy.

Stimulation or endothelin-1 secretion by human breast cancer cells through protein kinase A activation: a possible novel paracrine loop involving breast fibroblast-derived prostaglandin E2.

Breast cancer cells secrete endothelin-1 (ET-1), which may act as a paracrine mitogen in breast tumours. The paracrine factors and signal transduction pathways responsible for regulating ET-1 production in breast cancer are unknown. In this study we have examined the involvement of the protein kinase A (PKA) signalling pathway in the control of ET-1 secretion in the human breast cancer cell line MCF-7. Treatment of MCF-7 cells with various agents that activate protein kinase A (PKA) through increases in intracellular cAMP levels including forskolin, cholera toxin (ChT), the cAMP analogue 8-Br-cAMP, or the cAMP phosphodiesterase inhibitor, 3-isobutyl-1-methyl-xanthine (IBMX) all markedly increased ET-1 release. Prostaglandin E2 (PGE2) while stimulating cAMP production, but not inositol lipid hydrolysis also significantly stimulated ET-1 release. Activation of PKC by 2-O-tetradecanoyl phorbol 13-acetate (TPA) also stimulated ET-1 secretion in MCF-7 cells. The PKA inhibitor H-89 attenuated the ET-1 response to PGE2, forskolin and ChT, but not that due to the PKC agonist TPA. The possibility that human breast fibroblasts (HBFs) are a target for ET-1 action with regard to PGE2 production was also investigated, and revealed that while HBFs were unresponsive to ET-1 alone, pretreatment with the cytokine IL-beta greatly potentiated PGE2 release in response to ET-1. In conclusion our results show that activation of either the PKA or PKC signalling pathways in human breast cancer cells increases ET-1 secretion. We also found that HBFs release PGE2 after treatment with ET-1 and that PGE2 itself stimulates ET-1 production in MCF-7 cells. The implication of this potential novel paracrine loop may be significant in view of the high levels of PGE2 and ET-1 found in malignant breast tissues.