Combined 50- and 20-MHz frequency ultrasound imaging in intermediate uveitis.

PURPOSE: To evaluate the information provided by multifrequency ultrasound examination in patients with intermediate uveitis. DESIGN: Prospective observational case series. METHOD: High-resolution ultrasonography with 50- and 20-MHz frequency immersion probes was performed in seven eyes of five young patients with clinical diagnosis of intermediate uveitis. RESULTS: Exudative material over the inferior pars plana and peripheral retina (snowbank) was found in all eyes with 50- and 20-MHz probe, although resolution of the latter was poorer. The 50-MHz imaging was superior for visualization of angle structures and details of pars planitis; the anterior vitreous involvement and cyclitic bands were better shown with the 20-MHz probe, which could also evidence cystoid macular edema. CONCLUSIONS: Ultrasound examination with both 50- and 20-MHz frequency probes can detect the typical snowbank in intermediate uveitis and be useful in eyes with small pupil, dense vitreitis, or both, especially before pars plana vitrectomy or cataract surgery.

Ultrasound biomicroscopy in traumatic aniridia 2 years after phacoemulsification.

A 45-year-old man with retinitis pigmentosa experienced total aniridia in the left eye due to direct blunt trauma 2 years after uneventful bilateral phacoemulsification via a 3.5 mm clear corneal incision. Ultrasound biomicroscopy (UBM) of the left eye revealed no missing or stretched zonular fibers extending from the ciliary body to the anterior capsule, a few iris root remnants, a normal ciliary body, an in-the-bag acrylic intraocular lens, and Descemet's membrane dehiscence at the corneal tunnel through which the iris extruded. The eye recovered 20/25 visual acuity after 1 week. Transient hyphema and a rise in intraocular pressure were recorded. This is the first report of traumatic aniridia 2 years after phacoemulsification with UBM evidence of undamaged zonular apparatus. A UBM examination may be clinically helpful, especially when blood prevents accurate slitlamp examination of the anterior segment.

Extranodal Rosai-Dorfman disease: involvement of eye, nose and trachea.

Rosai-Dorfman disease (RDD) is a rare non-neoplastic histiocytic proliferative disorder characterized by painless lymphadenopathy. Extranodal lesions frequently occur in the head and neck regions. We report the clinical and histological features of extranodal RDD in a 43-year-old man with a previously unreported combination of multiple gross anterior epibulbar nodules in the right eye, submucosal masses of nasal septum and trachea, and no lymphadenopathy during the 12-year follow-up. The patient underwent ophthalmological, otolaryngological and systemic evaluation; gallium 67 scintigraphy; bronchoscopy; ophthalmic ultrasound; head and neck CT scan; biopsies of epibulbar, nasal and tracheal tissues; and septoplasty. Histological specimens showed lymphocytophagocytosis and positive immunoperoxidase staining for S100 protein in foamy histiocytes; both features were typical for RDD. No response to topical or systemic steroids or to radiation therapy was recorded. Removal of nasal septum masses resolved nasal obstruction. The diagnosis of RDD requires histological and, in challenging cases, immunohistological specimens and is difficult--especially with pure extranodal localizations as in our case. RDD should be suspected in cases of subconjunctival mass and/or submucosal nasal and tracheal swellings not responding to systemic steroids.

Coats' Disease: Very Long-Term Outcome After Early Stage Conventional Treatment.

PURPOSE: To report on the outcome of conventional therapy in patients with Coats' disease. METHODS: Retrospective analysis of the charts of thirteen patients with Coats' disease. RESULTS: Mean age of 9 male (70%) and 4 female (30%) patients was 17.7 (range, 5-33) years; one female had bilateral disease. Eleven eyes with retinal telangiectasia and exudation were treated with argon laser photocoagulation alone or photocoagulation associated with cryotherapy; the mean follow up was 32.5 (range,17-41) years. In four eyes without foveal involvement (stage 2a) the mean presenting visual acuity (VA) remained at 0.8 or improved, whereas poor VA in seven stage 2b eyes deteriorated minimally over time. In one and two of the three eyes with total retinal detachment, phthisis or neovascular glaucoma ensued. CONCLUSION: About three decades after conventional treatment of Coats' disease stage 2a, treated eyes maintained good VA, and stage 2b eyes did not progress to advanced stages.

High-resolution ultrasonography in central serous chorioretinopathy.

PURPOSE: To investigate the use of high-resolution ultrasonography for detecting choroidal layer abnormalities in eyes with central serous chorioretinopathy (CSC). DESIGN: Prospective observational case series. METHOD: Optical coherence tomography (OCT) and high-resolution ultrasonography with a 20-MHz immersion probe were performed bilaterally in 10 patients, of whom 5 were affected by unilateral active CSC and 5 by unilateral cystoid macular edema (CME). Ten age-matched control subjects were also investigated. RESULTS: Both OCT and high-resolution ultrasonography showed a macular elevation in eyes with CSC and CME. High-resolution ultrasonography has shown evidence of a nonechogenic linear band under the retinal pigment epithelium in patients affected by CSC. This could be found in neither patients with CME or in control subjects. CONCLUSION: High-resolution ultrasonography can detect a nonechogenic space consistent with hyperpermeability of choroidal capillaries in eyes with active CSC. Shadowing by an altered retinal pigment epithelium cannot be ruled out, however.

Bilateral optic neuropathy and intraretinal deposits after pars plana vitrectomy in amyloidosis.

Pathological examination of material from a nonextensive pars plana vitrectomy (PPV) in the right eye provided a diagnosis of nonfamilial amyloidosis in a 68-year-old woman, who presented with bilateral glass wool-like vitreous opacities. Genetic testing revealed a Tyr114Cys mutation in the transthyretin gene. Six months after PPV, perimetry showed intense constriction with a temporal island and central scotoma in the right eye. An extensive PPV was performed in the left eye. Spectral domain optical coherence tomography evidenced bilateral epimacular amyloid deposits and unreported reflective spots within the inner retina. One year later, visual acuity had decreased to 20/400 in the left eye, with mild vitreous opacity, pale cupped optic disc and inferior altitudinal field defect. Bilateral diurnal intraocular pressure, transiently increased after PPV, never exceeded 16 mmHg with medication. Our patient presented optic nerve blood supply impairment, due to amyloidosis, which caused optic atrophy. Epiretinal and intraretinal deposit detection could aid in diagnosing patients with suspected amyloidosis.

Retained intravitreal lens fragments after phacoemulsification: complications and visual outcome in vitrectomized and nonvitrectomized eyes.

PURPOSE: To evaluate the ocular complications and visual outcomes in vitrectomized and nonvitrectomized eyes with retained lens fragments after phacoemulsification. SETTING: Department of Neurological, Psychiatric, and Ophthalmological Sciences, University of Padua, Padua, Italy. METHODS: This prospective nonrandomized study comprised 36 consecutive patients with retained intravitreal lens fragments after phacoemulsification. Eighteen eyes had a pars plana vitrectomy (Group 1), and 18 eyes (Group 2) were treated with medication only. Intraocular pressure (IOP), intraocular inflammation, cystoid macular edema (CME), and best corrected visual acuity (BCVA) were evaluated 1, 3, and 6 months postoperatively. RESULTS: Ophthalmoscopy and B-scan echography showed that the lens fragments were significantly larger in Group 1 than in Group 2 (P < .03). An uncontrollable IOP rise and inflammation prompted an early vitrectomy in 11 eyes in Group 1. At the 6-month follow-up, the IOP with medications was acceptable in 2 and 5 eyes in Group 1 and Group 2, respectively. Intraocular inflammation was no longer detectable 1 month after vitrectomy but persisted during the entire follow-up in Group 2. At 3 months, 5 eyes in Group 1 and 13 in Group 2 had CME and at 5 months, 3 eyes and 1 eye, respectively, had CME. The difference between groups was significant at both follow-ups (P < .05). Three retinal detachments, 1 before and 2 after vitrectomy, occurred in Group 1. The mean BCVA in Group 1 was better than in Group 2 during the entire follow-up; however, the difference was significant at 3 months only (P < .5). At 6 months, 94.4% in Group 1 and 83.2% in Group 2 had a BCVA of 20/50 or better and 66.6% and 55.5%, respectively, attained at least 20/30. CONCLUSIONS: Intraocular inflammation, increased IOP, and CME were major complications in nonvitrectomized eyes after phacoemulsification; retinal detachment occurred in 2 vitrectomized eyes. In eyes with intravitreal lens fragments after phacoemulsification, vitrectomy can yield faster visual rehabilitation and better quality of vision. Conservative management is feasible at the price of long-term intraocular inflammation and slower restoration of comparable visual function.

Skin and eye: uncommon sites of distant metastasis from tongue base squamous cell carcinoma.

The frequency of non-lymphatic distant metastases from primary head and neck squamous cell carcinoma (SCC) appears to be higher than previously presumed. The general conditions of the affected patients, who usually also present with locoregional recurrences, are so impaired as to limit the use of available methods for diagnosing the distant spread of head and neck SCC. The incidence reported in autopsy studies is approximately three to four times higher than that in clinical studies. Lung metastases from head and neck SCC are most common, followed by metastases to bone and liver. Metastases to the skin are unusual. Secondary ocular localizations of head and neck SCC are exceedingly rare. We report the first case of synchronous intraocular (involving the choroid and vitreous body) and cutaneous metastases from a recurrent tongue base SCC in a 64-year-old woman who had undergone radiotherapy, bilateral neck dissection and chemotherapy. Cytological evaluation of vitreous aspirate and histological diagnosis of the skin lesion were performed < 1 month before the patient's death. Skin metastases occur in 1-4% of patients with diagnosed head and neck SCC and are usually associated with advanced or recurrent disease. To the best of our knowledge, fewer than 10 cases of ocular metastases from head and neck SCC have been reported. The average survival time after diagnosis of ocular or skin metastases from head and neck SCC is 7 months. Treatment for eye and skin metastases is palliative and rarely alters patient outcome.

Long-term echographic surveillance of elevated choroidal nevi.

PURPOSE: To report the outcomes of choroidal nevi monitoring and to compare the detection of ultrasonographic hollowness, a risk factor of malignant transformation, from a B-scan with results from an A-scan examination. DESIGN: Retrospective cohort study. METHODS: Standardized A- and B-scan echography and ophthalmoscopy in 358 consecutive patients with median age 69 years and baseline choroidal nevus higher or lower than 1.5 mm in 51 (14%) and 307 (86%) eyes, respectively. RESULTS: No growth or change in echographic or ophthalmoscopic features were found in 307 nevi with a median elevation of 0.9 mm (range, 0.7 to 1.5 mm) and a median follow-up of 6 years (range, 4 to 9 years). After 2 to 6 years, decreased internal reflectivity on standardized A-scan and ultrasonographic hollowness on B-scan were detected in 7 (18%) of 38 initially highly reflective choroidal nevi (thickness, 1.98 ± 0.37 mm); 2 (5%) nevi grew into melanoma 15 years after the first observation. Of 13 choroidal nevi (thickness, 2.75 ± 0.66 mm), with initial atypical medium to high reflectivity on standardized A-scan (100%) and hollowness on B-scan (85%), 6 (46%) were plaqued 6 to 15 months later because of the presence of multiple risk factors. CONCLUSIONS: No changes in thickness or echographic features of choroidal nevi elevated up to 1.5 mm were recorded during the follow-up period. In initially typical choroidal nevi higher than 1.5 mm, strong agreement was detected between decreased reflectivity on standardized A-scan and ultrasonographic hollowness on B-scan found after up to 15 years of stability. The vast majority of choroidal nevi with initial atypical standardized A-scan features showed ultrasonographic hollowness.

Intracorneal blood removal six weeks after canaloplasty.

In a 71-year-old patient with bilateral open-angle glaucoma, intracorneal blood was found after a canaloplasty procedure in the right eye. Six weeks after surgery on ultrasound biomicroscopy examination, liquified blood and blood clots could be observed nasally in the deep corneal stroma close to the Descemet's membrane. The intracorneal blood was washed out with balanced saline solution following deep corneal incision and lamellar dissection. Descemet's membrane was reattached with air injection into the anterior chamber. Two months later, visual acuity improved to 20/50, intraocular pressure was 16 mm Hg without medication and confocal microscopy showed deep stromal folds and limited endothelial cell loss. Viscoelastic entering the cornea at Schwalbe's line and reflux of blood from the collector channels to Schlemm's canal can account for corneal hematoma. Even six weeks after canaloplasty, successful blood removal could be fulfilled without rupturing the Descemet's membrane.

Ultrasound biomicroscopy examination of anterior uveal tumors: information on location and size only?

The aim of the study was to assess whether ultrasound biomicroscopy (UBM) examination of anterior uveal tumors could help in tissue differentiation. Five anterior uveal tumors in five patients underwent UBM (Paradigm P45, 50 MHz) examination prior to fine needle aspiration (FNA) of the lesion; two melanomas, one nevus, one metastatic carcinoma, and one bilateral iris lymphoma were cytologically diagnosed. Only UBM information was obtained from four small non-growing lesions consistent with iris nevi. Four ciliary body pigmented tumors elevated by 4 to 6 mm were examined both with UBM and immersion standardized echography (Cinescan S, Quantel Medical). UBM showed high reflective iris subsurface in all iris nevi. Of the FNA verified iridociliary pigmented tumors, the iris pigment epithelium was found to be indistinct in iridociliary melanoma only. Iridociliary melanoma, nevus and metastatic carcinoma showed angle invasion and similar acoustic pattern and reflectivity on UBM examination. Multiple iris masses were imaged in lymphoma and metastatic carcinoma. Two ciliary body low to medium reflective and two ciliary body high reflective tumors on standardized echography, consistent with ciliary body melanoma and melanocytoma, were plaqued or observed for four and thirteen years; UBM was informative for superficial margins and angle invasion only. In conclusion, UBM was very useful for location and size of small anterior uveal tumors, but could not help in tissue differentiation of iridociliary tumors. Multiple iris lesions were found in iridociliary lymphoma or metastatic carcinoma only. Standardized echography allowed for tissue differentiation in at least 4-mm thick ciliary body pigmented

Ultrasound biomicroscopy after canaloplasty: clinical study with two different units.

Canaloplasty is a recent non penetrating glaucoma surgical procedure where Schlemm's canal is dilated and trabecular meshwork distended by tensioning polypropylene suture. The aim of this study was to visualize the iridocorneal angle after the canaloplasty procedure by means of two different ultrasound biomicroscopy (UBM) units. Ten eyes of nine patients with primary open angle glaucoma (average age 62 years) underwent canaloplasty (six eyes) or canaloplasty combined with phacoemulsification and in-the-bag intraocular lens implantation (4 eyes). Both 50 MHz (Paradigm P45) and 80 MHz (i-UltraSound) systems were used. All procedures were performed by the same surgeon. UBM examination was performed 3 to 12 (mean 7 +/- 3.1) months after surgery. No, mild and good trabecular meshwork distension by suture tensioning was graded as 0, 1 and 2 according to the higher resolution 80 MHz images. Both ultrasound systems could show intrascleral lake and trabecular meshwork distension, which was graded as 0, 1 and 2 in 10%, 30% and 60% of eyes, respectively. Schlemm's canal could be imaged with the 80 MHz transducer only. The overall qualified success of canaloplasty (80%) was apparently correlated with suture tensioning (r=0.64). In our experience, after canaloplasty the 80 MHz but also 50 MHz technology can show trabecular meshwork distension. A greater number of eyes are needed to assess the correlation between intraocular pressure decrease and suture tensioning.

Reduced endothelial progenitor cells and brachial artery flow-mediated dilation as evidence of endothelial dysfunction in ocular hypertension and primary open-angle glaucoma.

PURPOSE: This study aimed to assess vascular endothelial function in patients with ocular hypertension (OHT) or primary open-angle glaucoma (POAG) by measuring: (a) endothelium-dependent flow-mediated vasodilation (FMD) of the brachial artery, and (b) circulating endothelial progenitor cells, which are believed to support the integrity of the vascular endothelium. METHODS: We enrolled 25 patients with OHT, 23 with POAG and 26 control subjects, all of whom were aged < 65 years and had no medical history of cardiovascular disease or cardiovascular risk factors. All subjects underwent a complete ophthalmological examination, biochemistry study, assessment of cardiovascular parameters, brachial artery ultrasound assessment of endothelium-dependent FMD, generic circulating progenitor cell (CPC) and circulating endothelial progenitor cell (EPC) count with the use of flow cytometry. RESULTS: Flow-mediated vasodilation values differed significantly in OHT (4.5 +/- 1.1%; p = 0.021) and POAG (4.0 +/- 0.9%; p = 0.003) patients compared with controls (7.7 +/- 0.8%). The CD34(+) KDR(+) EPC count was markedly lower in OHT (28.0 +/- 5.0; p < 0.001) and POAG (24.3 +/- 3.4; p < 0.001) patients compared with controls (73.1 +/- 8.1). Neither FMD not EPCs differed significantly between OHT and POAG patients. No significant differences in CPC count or cardiovascular parameters were found among OHT or POAG patients and controls. The levels of CD34(+) KDR(+) EPCs were directly correlated (p = 0.043) with FMD, and inversely correlated (p = 0.032) with baseline intraocular pressure in OHT and POAG patients. CONCLUSIONS: Both OHT and POAG patients without cardiovascular risk factors have previously unreported severely reduced circulating EPCs and reduced FMD, both of which are indicators of endothelial dysfunction and increased risk of cardiovascular events.

Choroidal vascular changes after transpupillary thermotherapy for choroidal melanoma.

OBJECTIVE: To evaluate choroidal vascular alterations after transpupillary thermotherapy used as the sole treatment for choroidal melanoma. DESIGN: Prospective noncomparative interventional case series. PARTICIPANTS: Forty-five eyes of 45 patients affected by malignant choroidal melanoma treated with transpupillary thermotherapy alone with more than 1 year of follow-up. INTERVENTION: Transpupillary thermotherapy was performed through a panfunduscopic contact lens using an 810-nm diode laser. MAIN OUTCOME MEASURES: Dynamic/static fluorescein and indocyanine green angiography were performed at scheduled intervals (24 hours, at 3-month intervals during the first year, and every 6 months thereafter) after transpupillary thermotherapy. Visual acuity, clinical evaluation, fundus photographs, and ultrasonographic examination were also performed. RESULTS: The mean follow-up was 30.5 months (range, 12-54 months). Changes in the choroidal circulation were always confined within the treatment margins (except in one case) and characterized by occlusion of choriocapillaris (100%), patent medium and/or large choroidal vessels (76%), retinochoroidal anastomosis (11%), and progressive choroidal vascular remodeling (42%). Forty-one cases (91%) showed persistent clinical regression, and four cases (9%) recurred; recurrent cases showed retinochoroidal anastomosis. CONCLUSIONS: Transpupillary thermotherapy is suggested as a new single therapeutic modality in the treatment of selected choroidal melanomas, but more precise eligibility criteria and longer follow-up are mandatory. Patent choroidal circulation, choroidal vascular remodeling, and anastomosis after transpupillary thermotherapy might be helpful to detect recurrent tumors.