One year of intravitreal injections of steroids.

PURPOSE: Chronic macular oedema sometimes does not respond to classic treatment such as laserphotocoagulation, periocular and systemic steroids or carbonic anhydrase inhibitors. High dose intravitreal injection of steroids can be a valuable alternative in these patients. METHODS: Sixty-four eyes of 51 patients with chronic macular oedema, refractory to conventional treatments, received an intravitreal injection of 4 mg Kenacort (triamcinolone acetonide). At postoperative controls (1 day, 1 month, 3 months, 6 months, 1 year), the visual acuity, intraocular pressure, central retinal thickness on OCT II were analyzed retrospectively. RESULTS: In the diabetic group, but also in cases of chronic uveitis, retinal vein thrombosis, birdshot chorioretinopathy, Irvine Gass syndrome, cellophane maculopathy and age-related macular degeneration with classic subfoveolar neovascular membrane, dramatic decrease of the oedema was observed on funduscopy and OCT. A statistically significant reduction of mean central foveal thickness of 61% at 1 week and 49% at 3 months post-injection was demonstrated on OCT. Considerable gain in visual acuity was noted. The highest benefit in post-operative visual acuity was achieved after 3 months and averaged a gain of +3.55 Snellen lines (n=39). In 17% of eyes a rise in intraocular pressure was noted. Unfortunately we had one case of endophthalmitis in a poorly regulated diabetic woman. Six eyes were retreated because of recurrence of macular oedema. CONCLUSION: Intravitreal injection of steroids can dramatically help in some cases of chronic macular oedema, not reacting to classic treatment. The injection should be performed under sterile conditions since endophthalmitis is a potential risk. The most frequent complication seems to be a rise in intraocular pressure in cortisone responders.

Scopolamine intoxications.

Pure scopolamine intoxications are extremely rare. We treated a series of severe intoxications exclusively caused by scopolamine and due to the intentional mixing of pure scopolamine into drinks. The clinical course and therapy are reported. On the basis of our experience and a survey of literature, we found physostigmine to be an excellent antidote. The symptomatology of the patients confirms that scopolamine has a dose-related stimulant effect on the central nervous system.

Ocular non-Hodgkin's lymphoma: a clinical study of nine cases.

BACKGROUND: Primary oculocerebral large cell malignant non-Hodgkin's lymphoma, formerly called ocular reticulum cell sarcoma, runs a uniformly fatal course. Once the central nervous system (CNS) is involved, survival without treatment is very limited. Although treatment does not substantially improve the long term survival, it provides short term improvement in these patients. METHODS: The charts of all patients with ocular involvement of non-Hodgkin's lymphoma followed during the period 1984-93 were reviewed. The diagnosis of non-Hodgkin's lymphoma was made by different diagnostic approaches: CNS biopsy, anterior chamber tap, vitrectomy, haematology, and necropsy. RESULTS: Eight patients had oculocerebral large cell and one had small cell non-Hodgkin's lymphoma. Five patients with pure ocular localisation had initially received steroid treatment for intermediate uveitis. First diagnosis was made on CNS biopsy in three, anterior chamber tap in one, vitreous aspirate in three, haematology in one, and necropsy in one case. CONCLUSION: Ocular non-Hodgkin's lymphoma is a difficult diagnosis. Vitrectomy allows cytological diagnosis in most but not all cases. When no treatment is given, patients survive for only a few weeks once the CNS is involved. Although the disease is eventually fatal, treatment by means of radiotherapy, steroid administration, and vitrectomy can allow these patients to lead a normal professional and social life during the years between recurrences.

Actinobacillus (formerly Pasteurella) ureae meningitis and bacteraemia: report of a case and review of the literature.

A 26-year-old man addicted to alcohol was admitted to hospital with headache and rhinorrhoea. Investigation revealed Pasteurella ureae meningitis and bacteraemia. A course of intravenous cefotaxime and penicillin G, followed by surgical correction of a nasocranial fistula, led to full recovery. Fourteen cases of serious extrarespiratory infections due to P. ureae are briefly reviewed.

Paraneoplastic Sjögren's syndrome.

A patient with primary Sjögren's syndrome preceding an oat cell carcinoma of the lung, is presented. Arguments to support a possible relationship between these two disorders are discussed.

Treatment of hepatitis B virus-related polyarteritis nodosa: two case reports and a review of the literature.

A substantial number of cases of polyarteritis nodosa (PAN) are related to hepatitis B virus (HBV) infection. Different treatment strategies are reported in the literature. The aim of this study was to review 15 years of literature (1988-2002) to determine the optimal treatment for HBV-related PAN at present, and to discuss the indications and mechanism of action of corticosteroids in HBV-related PAN, as many physicians are reluctant to use these in the presence of HBV infection. The first patient stopped his initial treatment, relapsed and died of cerebral infarction. The second case illustrates the favorable outcome with the standard treatment: corticosteroids, lamivudine and plasma exchanges. If adequate follow-up is possible, antiviral agents as well as corticosteroids are indicated in HBV-related PAN. Corticosteroids diminish inflammation and corticosteroid withdrawal induces an alanine aminotransferase (ALT) rebound in patients with a low baseline ALT level. Antiviral agents are essential, as they reduce the production of HBV antigens and help to achieve hepatitis B early antigen (HBeAg) seroconversion. Plasma exchanges reduce the level of circulating immune complexes and are included in the treatment protocol of all recent studies. However, their effect has not been evaluated in controlled trials. We concluded that if adequate follow-up is possible, antiviral agents as well as corticosteroids are indicated in HBV-related PAN.

Intranasal caffeine and amphetamine causing stroke.

A 37 year-old man with an ischaemic stroke after the nasal use of amphetamine and caffeine is reported. Transient arterial hypertension due to these agents may have been the mediator of the stroke. Mitral annular calcification was the only other abnormality found, and was thought not to play an important role in this patient. There was no evidence of a primary or secondary hypercoagulable state. Stroke due to nasal use of these agents appears not to have been previously reported (Medline literature search 1983-1993).

Drug-induced spongiform leucoencephalopathy, a case report with review of the literature.

A nineteen year-old girl developed rhabdomyolysis and central pyrexia after the ingestion of multiple drugs: amphetamines, benzodiazepines, methadone, ethanol, and cocaine. On admission, the patient was deeply comatose and during the hospitalisation asymmetrical spastic quadriparesis was noted. Brain biopsy was diagnostic of spongiform leucoencephalopathy. A review of the literature concerning drug-induced spongiform encephalopathy revealed a large amount of heroin-induced cases. The role of cocaine, however, is less well described. After prolonged hospitalisation, our patient improved clinically and radiologically and could be transferred to a rehabilitation center.

Filum terminale ependymoma revealed by acute cauda equina compression syndrome following intratumoral and spinal subarachnoid hemorrhage in a patient on oral anticoagulants.

A 65 year-old woman with a filum terminale ependymoma is reported, presenting with acute cauda equina compression syndrome due to intratumoural and subsequent spinal subarachnoid hemorrhage (SAH) following therapy with oral anticoagulants. Few cases of spinal ependymoma have been reported with an acute cauda equina compression syndrome as the initial and only symptom, and the unique feature of our patient's anticoagulant status has only been described once in this setting. Although intratumoural hemorrhage is very well known since the myxopapillary variant is unique to the cauda equina and consists of loose connective tissue and numerous small blood vessels that are prone to bleeding, spinal SAH is seldom seen and the different hypotheses about the pathophysiological mechanisms that might promote bleeding still remain unresolved and will be discussed in this paper, as well as the special clinical features of spinal SAH and some diagnostic and therapeutic implications. A review of the literature (Medline search 1983-1993) revealed only 13 cases, including ours, of spinal SAH due to cauda equina ependymoma, and the results of this review together with our findings are described in this paper.

Post-traumatic endophthalmitis.

In a group of 615 cases of perforating trauma, 25 cases (4%) of proven endophthalmitis were seen. The percentage of Bacillus infections was unusually high compared to other types of endophthalmitis (3.8% for the whole group, 31% for the group with intraocular foreign bodies). Bacillus cases have a very poor outcome and in fact the overall functional results in the post-traumatic endophthalmitis group were poorer than in other categories.

Methicillin resistance of bacteria isolated from vitreous fluid from patients undergoing vitrectomy.

PURPOSE: The aim of this study was to compare the resistance patterns of bacteria in vitreous fluid from patients undergoing vitrectomy for diagnostic reasons, with bacteria of other nosocomial infections. METHODS: Vitreous fluid samples (n=144) were obtained from 133 patients undergoing vitrectomy for endophthalmitis, and 11 for uveitis as suspected endophthalmitis. They were Gram stained and cultured. Antibiotic susceptibility tests were run on all isolates. RESULTS: Gram stains were positive in 45/144 cases (31%), among which 38/45 (84%) were confirmed by a positive culture. Cultures were positive in 74/144 patients (51%) with mainly coagulase-negative staphylococci (n = 44) and Staphylococcus aureus (n = 13). In 133 patients endophthalmitis occurred after lens implantation (80 cases) and in 53 cases there was another origin (e.g. corneal transplantation, endogenous). In 26/80 post-lens implantation infections, culture remained negative; 32 infections occurred with coagulase-negative staphylococci, 10 with Staphylococcus aureus, 9 with streptococci and 3 with gram-negative bacteria. For endophthalmitis, ophthalmologists in our institution give an intraocular injection of vanccmycin and ceftazidim after vitrectomy. Among the 44 isolates of coagulase-negative staphylococci, 12 (27%) were resistant to methicillin. This is in contrast to other hospital-related coagulase-negative staphylococcus infections in general, and the resistance rate is 75% in our hospital. Only 2/13 Staphylococcus aureus isolates were methicillin-resistant. CONCLUSIONS: We conclude that isolates of coagulase-negative staphylococci from vitreous fluid are less resistant to methicillin than those isolated in other nosocomial infections.

Persistent hyperplastic primary vitreous.

Case report of a pars plana surgery for persistent hyperplastic primary vitreous (PHPV) with a clear lens. This situation enabled us to show the important features of PHPV: the initial small but clear lens, the fibrovascular membrane giving rise to the leukokoria, the elongated processi ciliares visible in the pupil and a patent A. hyaloidea, feeding the retrolental fibrovascular membrane. The surgery includes removal of the lens, the fibrovascular membrane and the endocoagulation of the feeding vessel in order to interrupt the natural cause of PHPV leading to blindness. After the surgery the baby is adapted with a soft contact lens and an occlusion treatment is started.

[Retinal detachment following blunt trauma]. / Le décollement de rétine dans les traumatismes non-perforants.

In the first part of this study a description of the different types of ocular trauma is given. This is followed by the pathogeny of retinal detachment after blunt trauma. Then the specific characteristics of the tears and other signs of non-perforation traumatic retinal detachment are discussed. Finally a description is given of the operative technique used in those cases.

Non-diabetic and non-oculotraumatic vitreous haemorrhage treated by pars plana vitrectomy.

BACKGROUND: Until the advent of pars plana vitrectomy, no efficient treatment for non-resorbing vitreous haemorrhage was at hand. Especially if the cause of the vitreous haemorrhage was not known, such as in most cases of non-diabetic and non-oculotraumatic vitreous haemorrhage, a lot of time often was lost by waiting for the resorption, because of the lack of any effective treatment modality. METHODS: All the cases (126) of non-diabetic and non-oculotraumatic vitreous haemorrhage treated with a pars plana vitrectomy for non-resorbing vitreous bleeding during a 15-year period were studied. Both the aetiology of the haemorrhage as well as the functional results have been tabulated. Except for the cases with a retinal detachment or a suspected retinal tear that were operated on immediately, 6 months were waited upon for spontaneous clearing. RESULTS: One third of these haemorrhages was due to vascular lesions (32.5%), one third to "rhegmatogenous" disordes [retinal tears with (25.5%) or without (8%) retinal detachment and one third to a group of various diseases (13.5%)]. In this last group Terson syndrome (5.5%), age-related macular degeneration (13.5%) and presumed posterior vitreous detachment (12%) were most numerous. Functional results mainly depend upon the underlying cause of the vitreous haemorrhage. Visual acuity ranged from 20/40-20/20 in 100% of cases of Terson syndrome and posterior vitreous detachment, 80% of retinal tears, 27% of vascular disorders and 25% of retinal detachments. Vision below 20/400 was obtained in 76% of age-related macular degenerations, 51% of vascular lesions, 50% of retinal detachments and 10% of retinal tears. CONCLUSION: Non-oculotraumatic and non-diabetic vitreous haemorrhages can be caused by a wide variety of diseases. If there is no tendency to spontaneous clearing a pars plana vitrectomy can be helpful by restoring visual function and by allowing treatment of the underlying disease in some cases. Most indications for vitrectomy are not urgent and one can wait for spontaneous clearing of the vitreous for about 6 months but with respect to retinal tears with or without retinal detachment no time should be lost. In these cases the vitrectomy should be done at once.

Metastatic uveal melanoma: diagnosis and treatment. A literature review.

In the past three decades many efforts were done to improve the visual prognosis of patients with uveal melanoma. However, mortality has remained unchanged. The systemic prognosis depends on the size and other characteristics of the lesion. It is not affected by the choice of local treatment. This suggests dissemination at an early stage. The failure to improve survival is caused by difficulties in early detection of metastases and the limited susceptibility of these metastases to systemic therapies.

The value of medical imaging techniques in the diagnosis of extra-ocular extension of malign melanoma of the choroid: a case report.

The major goal in the evaluation of posterior uveal tumours is to determine whether an intra-ocular malignancy is present and whether intervention is necessary. Small uveal pigmented tumours can safely be managed by observation until growth is documented. However, extensive evaluation for each suspicious lesion is necessary in order not to miss any signs of malignancy. A case is presented of a 41 year old male patient with orbital pain as initial symptom of a choroidal melanoma. Fluorescein-angiography revealed signs of double circulation. Abnormal choroidal vessels inside the tumour showed up clearly on indocyanine-green angiography. By ultrasonography we were able to detect scleral perforation and extra-scleral extension. Computed tomography confirmed the extra-scleral extension. As there were no signs of metastasis, an orbital exenteration with sparing of the eyelids was performed. Histopathology is compared with the results of clinical investigation.

Chorioretinal biopsy in the diagnosis of intraocular lymphoma: a case report.

A patient with non-Hodgkin lymphoma with low grade malignancy complained of gradual visual loss. Symmetric multiple deep retinal yellow dots were disseminated in both fundi. The patient developed progressive papilledema associated with further decreasing visual acuity. Other signs of uveitis were absent. A chorioretinal biopsy confirmed the intraocular lymphomatous involvement. Cerebrospinal fluid revealed abnormal lymphocytes and local Ig-M production thus proving the lymphomatous meningeal involvement.

Clinicopathologic correlation in a case of metastatic uveal tumor.

A clinicopathologic correlation is reported of an ocular metastasis from an unknown primary tumor. The tumor appeared initially confined to the choroid. The diagnosis of metastatic adenocarcinoma was obtained by choroidal biopsy. The metastasis was uncontrollable with teleradiotherapy. Six months later the anterior segment also appeared infiltrated and the eye was enucleated.

Choroidal biopsy in the diagnosis of a suspect intraocular lesions.

A thirty-eight year-old man, treated medically since 1985 for a chronic pancreatitis, showed a choroidal infiltrate in the superior mid periphery of the left fundus. A thorough systemic examination could not reveal an underlying cause. The differential diagnosis of the lesion included metastasis, intraocular lymphoma and sarcoidosis. Two months later the lesion had increased both on fundoscopy and echography and was accompanied by a serous macular detachment. A choroidal biopsy showed a moderately well differentiated mucinous adenocarcinoma. The primary site could not be determined. The mucinous character is rather suggestive for a gastrointestinal origin. Gastro intestinal choroidal metastases, and more specifically the pancreatic ones, are however rare.

Malignant melanomas of the choroid and ruthenium applicators.

Fourty patients with a malignant melanoma of the choroid were treated with ruthenium applicators. Depending on the height of the tumour, the patients were divided into 3 groups. In the first group with a tumour height superior to 6 mm the results were poor as well from a functional point of view as considering tumour regression. In a second group with a tumour height between 5 and 6 mm the results were favourable concerning tumour regression, but only in 50% of the cases did the eye remain functional. The results in the third group with a tumour height between 2 and 5 mm were satisfactory. Tumour regression was obtained in 96% of the eyes; 86% of the eyes remained functional. Tumour related death (7.5%) was not correlated with initial height of the tumour at the time of diagnosis.