Ocular findings following trauma from paintball sports.

PURPOSE: To raise awareness of potential significant ocular damage and visual loss secondary to paintballs in those not wearing ocular protection and to report high incidence of chorioretinitis sclopetaria from paintball contusion. METHODS: We reviewed cases of eye injury presenting to a single institution from 2000 to 2005. Those cases in which the injury was attributed to paintballs were identified and evaluated to determine ocular findings and visual prognosis. RESULTS: Ocular paintball injuries occurred in eight male subjects and one female subject (nine eyes) with an average age of 16 years (range, 11-26). None had ocular protection at the time of ocular injury. On initial examination, vitreous haemorrhage was present in six eyes (67%), maculopathy, hyphema, cataract, and commotio retinae were each present in four eyes (44%). Two eyes suffered retinal detachment and one eye an optic nerve avulsion. Chorioretinitis sclopetaria occurred in four eyes (44%). The final visual acuity was > or =20/40 in three eyes, 20/50 to 20/150 in two eyes, and < or =20/200 in four eyes. CONCLUSION: Injuries owing to paintballs can result in severe ocular damage and visual loss. Increased awareness and need for proper ocular protection should be emphasized by ophthalmologists. Chorioretinitis sclopetaria occurs with a high frequency and its presence should be recognized, as its management is different from retinal tear or detachment.

Ciliary body naevus.

PURPOSE: To describe clinical, ultrasound biomicroscopy (UBM), and histopathologic characteristics of benign melanocytic tumors of the ciliary body. DESIGN: Consecutive case series. METHODS: Six patients with a pigmented ciliary body tumour underwent complete ophthalmic examination and UBM, with histopathologic examination carried out on three cases. RESULTS: Six patients presented with a pigmented iridociliary mass, with central displacement of iris root. UBM revealed a stromal mass arising in pars plicata and/or pars plana in all six with a cyst in three cases (intrinsic=1 and extrinsic=2). Iridocyclectomy was performed because of documented growth in three cases, and all three cases proved to be ciliary body spindle-cell naevus. The other three patients have remained stable. CONCLUSIONS: On clinical basis and with available ancillary studies, ciliary body naevi cannot be reliably differentiated from ciliary body melanocytoma and ciliary body melanoma. Even with clinically documented growth, the lesions may prove to be ciliary body naevi.

Management of subretinal macular haemorrhage by direct administration of tissue plasminogen activator.

BACKGROUND/AIMS: Recent studies on the treatment of acute subretinal macular haemorrhage have shown that the volume of the clot and the time to evacuation have strong prognostic factors for visual outcome. A novel technique for surgical evacuation of these lesions involves direct injection of tissue plasminogen activator (t-PA) into the haematoma using pars plana vitrectomy. The aim of this study was to evaluate the clinical outcomes of this recently described procedure. METHODS: 17 consecutive patients with subretinal macular haemorrhages caused by age related macular degeneration were enrolled. Patient demographics, acuities, and fluorescein angiograms were obtained for all evaluations. All patients underwent complete three port pars plana vitrectomy to enable direct cannulation of the subretinal space and injection of 48 mug of t-PA, partial fluid-air exchange, 1 hour face up supine positioning postoperatively, followed by upright positioning overnight. RESULTS: 88% of patients within the study had stabilisation or improvement of visual acuity. Nine patients had total clearing of the macular haemorrhage and eight patients had subtotal clearing. Two patients had recurrence of the haemorrhage after the procedure and one patient underwent repair for retinal detachment. Occult lesions demonstrated similar outcomes to classic or predominately classic lesions. Nine patients required no therapy after the study to treat subfoveal neovascularisation. CONCLUSIONS: This study represents one of the largest case series to date showing that direct injection of subretinal t-PA with air-fluid exchange only and no intraoperative clot lysis period can have favourable results.

Photodynamic therapy of circumscribed choroidal haemangioma.

AIM: To evaluate efficacy of verteporfin ocular photodynamic therapy (PDT) in treatment of 10 patients with a symptomatic circumscribed choroidal haemangioma. DESIGN: Prospective non-randomised, interventional case series and critical review of previously published studies. METHODS: 10 consecutive patients (seven primary, two failed transpupillary thermotherapy (TTT), and one failed external beam radiotherapy) with symptomatic circumscribed choroidal haemangioma were treated using verteporfin 6 mg/m2 given as an intravenous infusion over 10 minutes. Diode laser (690 nm) with an intensity of 600 mW/cm2 for 83 seconds (50 J/cm2) was applied 5 minutes after completion of infusion. Single or multiple partially overlapping spots were applied based on the tumour basal dimensions. Periodic follow up with ophthalmoscopy, ultrasonography, and angiographic studies was performed. RESULTS: All 10 patients showed evidence of regression with flattening of tumour, resolution of subretinal fluid, and reduction of choroidal vasculature on angiograms. The visual acuity either improved or remained stable in eight (80%) patients. Visual loss due to delayed choroidal atrophy was seen in two patients. CONCLUSIONS: Although verteporfin PDT is an effective treatment for management of symptomatic circumscribed choroidal haemangioma, delayed treatment related effects can lead to visual loss.

The effect of arteriovenous sheathotomy on cystoid macular oedema secondary to branch retinal vein occlusion.

BACKGROUND: Arteriovenous (AV) sheathotomy, a potential treatment for branch retinal vein occlusion (BVO), surgically separates retinal vessels at an AV crossing. Relief of the aetiological obstruction, with resolution of cystoid macular oedema (CMO), may result in improved visual acuity. METHODS: A retrospective review of consecutive cases of AV sheathotomy for BVO was undertaken. Eyes were categorised as having resolution (group 1), reduction (group 2), or persistence (group 3) of CMO. Intergroup comparisons were made with regard to preoperative, intraoperative, and postoperative parameters. Preoperative and postoperative visual acuities were compared within each group. RESULTS: Of the 27 eyes identified, eight (29.6%) had resolution, 14 (51.8%) had reduction, and five (18.6%) had persistence of CMO. Median preoperative visual acuity was similar in all groups (1.0, 1.0, 1.3, respectively; p = 0.29). Overall median follow up was 12.0 months (Q1 = 12.0, Q2 = 22.5). Eyes in group 1 had significantly better median postoperative visual acuity than eyes in groups 2 and 3 (0.6, 1.0, 2.0 respectively; p = 0.01). A significantly higher proportion of eyes in group 1 had visual acuity improvement compared with eyes in the other groups (87.5% v 35.7% and 20.0%; p = 0.03). Median postoperative visual acuity was significantly better than median preoperative visual acuity in group 1 eyes only (p = 0.02). A higher percentage of group 1 eyes had evidence of postoperative retinal perfusion (83.0% v 21.43% and 40.0%; p = 0.16). Postoperative retinal detachment occurred in three eyes (11.1%). CONCLUSION: Complete resolution of CMO after AV sheathotomy occurred in one third of patients, and postoperative vision improved significantly in this group. However, in the majority of cases, despite an improvement in CMO, there was no improvement in vision after AV sheathotomy.

Splice site mutation in the peripherin/RDS gene associated with pattern dystrophy of the retina.

PURPOSE: To report the phenotype and genotype of a splice site mutation at intron 2 of the peripherin/RDS gene in four half-siblings with pattern dystrophy of the retina. DESIGN: Experimental study. METHODS: In four siblings with a common mother and three separate fathers, complete ophthalmic examination, pedigree, electrophysiologic testing, and fluorescein angiography studies were obtained. Genomic DNA from serum lymphocytes was isolated and used as a template for primers specific for the cone homeobox gene (CRX), rhodopsin (RHO), and peripherin/RDS genes to conduct single stranded conformational analysis and cycle sequencing. RESULTS: The pedigree of four affected siblings suggested probable autosomal dominance transmission of pattern dystrophy. In the four siblings, best corrected visual acuity ranged from 20/20 to 20/80 by Snellen chart. Clinical findings included discrete, localized degenerative changes of the macular retinal pigment epithelium in all patients, with subclassification foveal. One patient exhibited pigment clumping within the atrophic areas. Another patient exhibited yellow flecks diffusely in the macula. Fluorescein angiographic findings included central hypofluorescence with a surrounding rim of hyperfluorescence that corresponded to the observed fundus lesions and window defects. There was a range of electroretinography (ERG) and electrooculography (EOG) findings. One patient demonstrated both cone and rod dysfunction on ERG testing and another demonstrated decreased rod function. EOG testing was normal in two patients and mildly diminished in one patient. DNA sequencing identified a point mutation in intron 2 of the peripherin/RDS gene, consisting of an A to T change at 1068+3, present in all four affected patients. CONCLUSIONS: Four siblings with pattern dystrophy of the retina presented a splice site mutation in the peripherin/RDS gene.

Macular traction detachment and diabetic macular edema associated with posterior hyaloidal traction.

PURPOSE: To review the clinical, photographic, fluorescein angiographic, and optical coherence tomographic findings in patients with the diabetic macular traction and edema (DMTE) associated with posterior hyaloidal traction (PHT). METHODS: We performed a prospective review of nine eyes of nine patients with diabetic macular edema (DME) and PHT on clinical examination. The patients had a comprehensive ophthalmic history and examination, color photographs, fluorescein angiography, and optical coherence tomography (OCT). RESULTS: All patients had diabetic retinopathy and DME. Of the nine eyes, eight patients had previous focal or grid photocoagulation. All nine eyes had a thickened, taut, glistening posterior hyaloid on clinical biomicroscopic examination with no posterior vitreous separation. Fluorescein angiography was performed on seven eyes, and all had early hyperfluorescence with deep, diffuse, late leakage in the macular area consistent with DMTE associated with PHT. Optical coherence tomography scans of the macular region revealed retinal thickening in all eyes with a mean retinal thickness of 556.9 +/- 114.7 microns. In addition, eight of the nine eyes had a shallow macular traction detachment associated with PHT. CONCLUSION: Eyes with DME associated with PHT may have a shallow, subclinical, macular detachment. Optical coherence tomography may be useful in evaluating patients with DME to see if a macular detachment is present.

Ciliary body endophotocoagulation during pars plana vitrectomy for pediatric patients with vitreoretinal disorders and glaucoma.

PURPOSE: To investigate the efficacy of ciliary body endophotocoagulation during pars plana vitrectomy in eyes of pediatric patients with medically uncontrolled glaucoma. METHOD: We compared preoperative and postoperative intraocular pressure and visual acuity in five eyes of five patients aged between 10 months and 14.5 years who had 180 degrees of ciliary body endophotocoagulation with pars plana vitrectomy. RESULTS: Preoperative intraocular pressure on medical therapy for glaucoma ranged from 30 to 55 mm Hg (median, 35 mm Hg). Postoperative follow-up ranged from 12 to 24 months, with a median of 16 months. Postoperative intraocular pressure on medical therapy ranged from 12 to 35 mm Hg (median, 25 mm Hg) at 6 weeks, from 12 to 33 mm Hg (median, 29 mm Hg) at 6 months, and from 12 to 29 mm Hg (median, 27 mm Hg) at 12 months. Twelve months after surgery, mean intraocular pressure reduction of 20 mm Hg was statistically significant (P = .020). CONCLUSION: Ciliary body endophotocoagulation during pars plana vitrectomy may be an effective treatment for pediatric patients with simultaneous uncontrolled glaucoma and vitreoretinal disorders.

Diagnosis of digestive deaths.

Diagnosis of deaths due to digestive disorders can be a difficult task. It is helpful if the carcass can be viewed for condition, position, and location before being moved from the pen in which it was found. A complete necropsy is absolutely necessary even though postmortem decomposition may be advanced. All thoracic and abdominal organs must be examined for gross lesions. If one believes that the central nervous system was involved, the brain should be removed and examined. Checking the ruminal pH is important. If indicated, samples should be obtained and submitted to a diagnostic laboratory. Salient lesions include congestion of the anterior portion of the carcass, especially the cervical muscles and tissues adjacent to the esophagus and trachea, paleness of the posterior portion of the carcass, edema between the muscle groups of the hindquarters, scrotal, or mammary area, and a lack of other gross lesions. Many cases have congestion and(or) edema in the submucosa of the dorsal portion of the trachea extending from the thoracic inlet cranially. One must list the cause of death as unknown or undetermined when it is not apparent.

The use of the polymerase chain reaction to map CD4+ T cell epitopes.

CD4+ T cells recognize processed exogenous antigen in the form of peptides bound to syngeneic major histocompatibility complex class II molecules on antigen-presenting cells. We have developed a novel and convenient method to synthesize and map CD4+ T cell epitopes of cloned antigens using polymerase chain reaction (PCR)-directed construction of genes expressing recombinant protein fragments. Unique restriction sites incorporated into the PCR primers were employed for the unidirectional cloning of gene fragments into a bacterial expression vector that can be induced to high-level expression. The bacterial lysate could be used directly in T cell proliferation assays. Overlapping recombinant fragments spanning the entire protein were generated and tested. The length of the sequence containing the epitope was further reduced by utilizing PCR to generate 3' truncations. Finally, a small number of overlapping peptides spanning a sequence of 39 amino acids were synthesized to identify a thirteen-amino acid peptide epitope within chicken transferrin that stimulates the T helper cell clone D10.G4.1. PCR-directed construction of fragments of antigen allows for optimal design of strategies for the mapping and analysis of CD4+ T cell epitopes.

Molecular mapping of Osp-A mediated immunity against Borrelia burgdorferi, the agent of Lyme disease.

It is paradoxical that although antibodies to the outer surface protein (Osp) A of Borrelia burgdorferi protect mice against infection and that immunization of uninfected mice with Osp-A is protective, antibodies to Osp-A induced early in natural infection of mice are not curative. A region recognized by a neutralizing mAb is also recognized by sera from chronically infected or immunized mice but is not bound by sera from mice infected for 15 days. Infection in mice, despite the presence of early Osp-A antibody, may therefore be explained in part by the lack of response to this epitope. Sera from infected humans recognizes this region, although in this case the immune response to Osp-A occurs only late in infection. Nonetheless, the fact that both human sera and sera from mice immunized with Osp-A bind a conformationally dependent epitope that localizes to the same region tentatively suggests that humans are able to respond to a protective epitope and that an Osp-A-based vaccine may elicit protective immunity in humans.