Retinal fibrovascular proliferation associated with Nocardia subretinal abscess.

PURPOSE: To report the development of extensive fibrovascular proliferation in association with Nocardia subretinal abscess. METHOD: Case report. RESULTS: Extensive retinal neovascularization with tractional retinal detachment developed soon after ocular involvement in a 61-year-old patient with systemic nocardiosis. Fundus fluorescein angiography showed extensive area of capillary nonperfusion and severe leakage from the neovascular complex. The Nocardia subretinal abscess responded to systemic antibiotics, and the retinal neovascularization and tractional retinal detachment stabilized after 3 months. CONCLUSIONS: Retinal ischemia and severe retinal neovascularization may complicate intraocular nocardiosis. The authors propose secondary retinal vasculitis as a contributing factor towards the development of retinal ischemia in this setting.

Relationship between napping and melatonin in the blind.

Daytime sleepiness is a common complaint in blind subjects. Abnormally timed melatonin has been invoked as a possible cause of both daytime sleepiness and nighttime awakening. In free-running blind individuals, there is an opportunity to assess the relationship between endogenous melatonin rhythms and subjective sleepiness and naps. The aim of this study was to characterize melatonin rhythms and simultaneously to evaluate subjective napping. A total of 15 subjects with no conscious light perception (NPL) were studied for 1 month. Prior to the study, sleep disorders were assessed using the Pittsburgh Sleep Quality Index. Cosinor and regression analysis revealed that 9 of the 15 NPL subjects had free-running 6-sulphatoxymelatonin (aMT6s) rhythms (period [tau] range = 24.34 to 24.79 h), 3 were entrained with an abnormal phase, and 3 were normally entrained. Most of the subjects (13 of 15) had daytime naps; the 2 individuals who did not made conscious efforts not to do so. Subjects with abnormal aMT6s rhythms had more naps of a longer duration than did those with normal rhythms. Free-running nap rhythms occurred only in subjects with free-running aMT6s rhythms. The 2 abnormally entrained subjects who napped did so at times that coincided with high levels of aMT6s (mean aMT6s acrophase [phi] +/- SD = 14.30 +/- 1.08 h, 20.30 +/- 0.62 h; mean nap time +/- SD = 14.01 +/- 3.60 h, 18.23 +/- 3.20 h, respectively). Regardless of aMT6s rhythm abnormality, significantly more naps occurred with a 4-h period before and after the estimated aMT6s acrophase. In 4 free-running subjects, aMT6s acrophase (phi) passed through an entire 24-h period. When aMT6s was in a normal phase position (24:00 to 06:00 h), night-sleep duration tended to increase with a significant reduction in the number and duration of naps. Sleep onset and offset times tended to advance and delay as the aMT6s rhythms advanced and delayed. Our results show a striking relationship between the timing of daytime production of melatonin and the timing of daytime naps. This suggests that abnormally timed endogenous melatonin may induce sleepiness in blind subjects.

Relationship between melatonin rhythms and visual loss in the blind.

Melatonin rhythms were assessed in 49 registered blind individuals by measurement of the urinary metabolite of melatonin, 6-sulfatoxymelatonin (aMT6s). Subjects had different causes of visual loss and were classified as having light perception or better (LP; n = 19) or having no perception of light (NPL; n = 30). Subjects collected four-hourly urine samples (eight-hourly overnight) for 48 h at weekly intervals for 3-5 weeks. The majority of LP subjects (14 of 19) had normally entrained aMT6s rhythms (mean acrophase range, 2.4-6.2 h), 4 were abnormally entrained to 24 h (mean acrophase range, 8.9-1.0 h), and 1 was unclassified. Conversely, most NPL subjects had abnormal rhythms (23 of 30), the incidence of which was greater in uni- and bilaterally enucleated subjects. The majority of NPL subjects (17 of 30) had free-running aMT6s rhythms period range, 24.13-24.79 h), 5 were abnormally entrained to 24 h (acrophase range, 7.2-20.6 h), and 1 was unclassified. Output (micrograms of aMT6s per 24 h) and amplitude (micrograms per h) of aMT6s production did not vary between LP and NPL subjects (mean 24-h output +/- SD, 12.7 +/- 7.5 and 9.4 +/- 6.4 micrograms aMT6s/24 h, respectively; mean amplitude +/- SD, 0.6 +/- 0.4 and 0.5 +/- 0.3 microgram/h, respectively). These results indicate that a higher proportion of NPL subjects have abnormal melatonin rhythms compared to those with LP.

Subretinal "napkin-ring" membrane in proliferative vitreoretinopathy.

A "napkin-ring" subretinal membrane is an unusual expression of subretinal proliferation associated with retinal detachment. An 80-year-old man with a total funnel-shaped retinal detachment underwent pars plana vitrectomy, 360 degrees relaxing retinotomy, excision of a subretinal napkin-ring membrane, and silicone oil injection. Histopathologic examination of the removed napkin-ring subretinal membrane revealed the presence of retinal pigment epithelium (RPE) as the major source of cells within the membrane. Myofibroblasts were the most common cellular constituents; the total number of these cells may have correlated with the degree of clinical contraction, causing a funnel-shaped retinal detachment. Arch Ophthalmol. 2000;118:1287-1289

Intraocular hemorrhages associated with endoscopic spinal surgery.

PURPOSE: To report the occurrence of intraocular hemorrhages in association with endoscopic spinal surgery. METHODS: Case report. RESULTS: A 40-year-old patient noted severe visual loss in both eyes after epidural endoscopy, epidurography, and endoscopic adhesiolysis. Ophthalmic examination showed a best-corrected visual acuity of RE: 20/800, and LE: counting fingers, and extensive subhyaloid, retinal, and subretinal hemorrhages in both eyes. The hemorrhages resolved over a period of 8 weeks and the best-corrected visual acuity improved to 20/40 in both eyes after 4 months. CONCLUSION: A syndrome of visual loss and intraocular hemorrhages after an endoscopic spinal procedure is studied.

Ophthalmologic features of thallium poisoning.

Thallium intoxication is characterized by the development of painful peripheral neuropathy, alopecia, mental disorders, and in severe cases, respiratory failure and death. Toxic optic neuropathy is also a feature. Ophthalmologic features of thallium poisoning include optic neuropathy, blepharoptosis, lens opacities, and ophthalmoplegia. A 44-year-old man with criminal sublethal thallium poisoning was examined one month after he was seen in the neurology department with classic systemic features. He was found to have diminished contrast sensitivity, a tritan defect in color vision, and a relative cecocentral scotoma before he developed optic atrophy.

Idiopathic giant retinal tears in identical twins.

PURPOSE: To report idiopathic unilateral giant retinal tears with retinal detachment in identical twins that occurred 2 weeks apart. METHODS: Case reports. RESULTS: In both patients, giant retinal tear and retinal detachment was treated with pars plana vitrectomy, placement of encircling scleral buckle, fluid-perfluorocarbon exchange, endolaser treatment, perfluorocarbon-air exchange, and 16% perfluoropropane injection. One year after retinal detachment surgery, cataract developed in both postoperative eyes. Phacoemulsification with posterior chamber intraocular lens implantation was performed on both eyes. Three and a half years after retinal surgery, corrected visual acuity in both treated eyes was 20/20, and retinal reattachment was successful. CONCLUSIONS: To our knowledge, this is the first report of idiopathic giant retinal tears in identical twins and raises the issue of genetic influences in the pathogenesis of this disease.

Superficial temporal artery biopsy diagnostic for lung carcinoma.

PURPOSE: To report a unique finding of metastatic tumor cells in the lumen of a superficial temporal artery biopsy specimen in a patient with severe visual loss and optic neuropathy. METHODS: Case report. RESULTS: A 69-year-old man presented with anorexia, pancranial headaches, and acute unilateral visual loss. Ophthalmic examination showed a visual acuity of no light perception and an amaurotic pupil in the left eye. Fundus examination was normal. A superficial temporal artery biopsy, performed for presumed arteritic posterior ischemic optic neuropathy, demonstrated intraluminal cells with irregular nuclei and prominent nucleoli suggestive of metastatic malignancy. Further systemic evaluation uncovered a poorly differentiated adenocarcinoma of the lung with intravascular infiltration and multiple distant metastases. CONCLUSION: Extensive systemic intravascular tumor embolization may be associated with optic neuropathy.

Purtscher-like retinopathy associated with pancreatic adenocarcinoma.

PURPOSE: To investigate a case of Purtscher-like retinopathy that occurred in association with pancreatic adenocarcinoma. METHOD: Case report. RESULTS: A 63-year-old woman presented with multiple gray patches in the central vision of both eyes. Visual acuity was 20/20 in both eyes. Funduscopy showed large peripapillary yellow-white patches within the superficial retina and small superficial retinal hemorrhages in both eyes. The patient subsequently had abdominal pain. Computed tomography of the abdomen demonstrated a large pancreatic mass with extension into the liver. Histologic examination of a percutaneous needle biopsy specimen showed mucinous pancreatic adenocarcinoma. CONCLUSION: Pancreatic adenocarcinoma should be added to the list of systemic diseases that can be associated with Purtscher-like retinopathy.

Emerging ciprofloxacin-resistant Pseudomonas aeruginosa.

PURPOSE: To report a clinical series of ciprofloxacin-resistant ocular isolates of Pseudomonas aeruginosa from a tertiary care ophthalmic center. METHODS: Review of in vitro sensitivities of all ocular isolates of P. aeruginosa be tween July 1991 and September 1998. In vitro resistance was defined as a minimum inhibitory concentration of 4 or more microg per ml. RESULTS: Nine of 423 ocular isolates of P. aeruginosa showed in vitro resistance to ciprofloxacin. From 1991 to 1994, 0.44% (1/227) of ocular isolates were resistant to ciprofloxacin, whereas from 1995 to 1998, 4.1% (8/ 196) of ocular isolates showed in vitro resistance (P = .014). CONCLUSIONS: Ciprofloxacin-resistant P. aeruginosa has been identified in recent clinical ocular specimens. Ciprofloxacin resistance among ocular isolates of P. aeruginosa is a local and worldwide concern.

Effect of potent antiretroviral therapy on recurrent cytomegalovirus retinitis treated with the ganciclovir implant.

PURPOSE: To determine the effect of highly active antiretroviral therapy on cytomegalovirus (CMV) retinitis treated with ganciclovir implants. METHODS: A retrospective cohort study was performed of 15 patients with recurrent CMV retinitis treated with the ganciclovir implant and highly active antiretroviral therapy (cases) and 38 patients with recurrent retinitis treated with ganciclovir implants before availability of improved antiretroviral therapy (controls). Progression was defined as occurrence of new lesions in the treated eye or advancement of the retinitis border by more than 750 microm. RESULTS: Cases and controls were statistically similar in age, ethnicity, and duration of acquired immunodeficiency syndrome (AIDS). Controls had received intravenous ganciclovir for 9.5 +/- 9.5 months vs 3.5 +/- 4.6 months in cases (P = .003). The mean (+/- SE) time to progression of retinitis after implantation of the device was 26.7 +/- 2.4 months (95% confidence interval, 22.1 to 31.3) in the cases receiving highly active antiretroviral therapy vs 6.2 +/- 0.9 months (95% confidence interval, 4.5 to 7.9) in the controls (P = .001). Multivariate analysis, adjusted for preoperative variables, confirmed a significantly prolonged time to progression in patients receiving highly active antiretroviral therapy (P = .0003). The odds ratio for progression in the cases vs controls was 0.034 (95% confidence interval, 0.003 to 0.350). Cases had higher CD4+ T-lymphocyte counts (P = .004) and longer survival (P < .001) than controls. CONCLUSION: Highly active antiretroviral therapy is associated with improved outcomes in patients with AIDS and recurrent CMV retinitis treated with the ganciclovir implant.

Intraoperative echographic localization of iodine-125 episcleral plaque for brachytherapy of choroidal melanoma.

PURPOSE: To report intraoperative echographic localization of iodine-125 episcleral plaque for brachytherapy of choroidal melanoma. METHODS: In a retrospective study, 117 eyes with medium-sized choroidal melanoma in 117 patients not participating in the Collaborative Ocular Melanoma Study underwent iodine-125 episcleral plaque radiotherapy with intraoperative echographic verification of plaque placement between January 1992 and December 1998 at the Bascom Palmer Eye Institute. RESULTS: After initial plaque placement using standard localization techniques, intraoperative echography demonstrated satisfactory tumor-plaque apposition in 76% of eyes (89 of 117). In the 28 eyes (28 of 117, 24%) that required repositioning of the plaque, the extent of misplacement was less than 1 mm in 10 eyes, 1.1 to 3.0 mm in six eyes, and greater than 3 mm in eight eyes. Two eyes had tilting of the plaque, and in two additional eyes, although the plaque covered all tumor margins, the centration was considered suboptimal. Repositioning was necessary in 1 eye with an anteriorly located tumor (1 of 13, 7.7%) and in 20 eyes with peripapillary or posterior pole tumors (20 of 67, 26.3%). Anteriorly located tumors required plaque repositioning significantly less frequently than did posteriorly located tumors (P = .041). Misalignment involved one tumor margin in 23 eyes and two margins in five eyes. The most commonly misaligned margins were the lateral (35%) and posterior margins (26%). In no case was an anterior marginal misalignment documented. At a mean follow-up of 37 months, no tumor-related death or metastatic disease was noted. Two of the 117 patients (1.7%) had local tumor recurrence and underwent enucleation. CONCLUSIONS: Intraoperative echography is an effective adjunct for localization and confirmation of tumor-plaque relationship. This technique facilitates the identification and correction of suboptimal plaque placement at the time of surgery, potentially minimizing treatment failures.

Disturbance of sleep in blindness.

PURPOSE: To determine the prevalence and severity of sleep disturbance in blind subjects and its relation to the form and duration of visual loss. METHODS: Of 403 blind subjects (visual acuity of less than 20/200 or a visual field of less than 5 degrees) recruited for the study, 15 were excluded because of affective disorder as identified by Montgomery Asberg Depression Scale. The remaining 388 subjects and a comparison group of 44 normally sighted individuals underwent an interview, and the Pittsburgh Sleep Quality Index questionnaire was administered. Sleep disturbance was classified as mild, moderate, or severe. RESULTS: Disturbance of sleep was recorded in 189 (48.7%) of the blind subjects. The prevalence was higher and the sleep disturbance was more severe in those with no perception of light than in those with light perception or better visual acuity. In the comparison group, four (9.1%) had mild sleep disturbance only. The differences between blind subjects and normally sighted individuals were highly significant (P < .001). The most common sleep-related problem among the blind subjects was interrupted sleep, followed by increased sleep latency, short sleep duration, and daytime naps. Among the blind subjects, no correlation was found between the extent of sleep disturbance and the duration and pattern of visual loss. CONCLUSIONS: Blind subjects who retain light perception, as well as those with total loss of vision, have a high frequency of sleep disturbance, although disorder is more common and more severe in subjects with no light perception. Management of the sleep disturbance may improve the quality of life in the visually handicapped.

Intraocular lens implants and risk of endophthalmitis.

AIM: To investigate the possible association between the use of three piece foldable silicone polypropylene (SPP) intraocular lenses (IOLs) and an increased risk of postoperative endophthalmitis. METHODS: A retrospective analysis was conducted of all cases of postoperative endophthalmitis following phacoemulsification surgery in a single unit over a 3 year period. The incidence of postoperative endophthalmitis in eyes with SPP IOLs was compared with the incidence in eyes with single piece polymethylmethacrylate (PMMA) IOLs. RESULTS: 772 cataract extractions by phacoemulsification were performed. One (0.16%) of the 622 patients with PMMA IOLs developed endophthalmitis. Excluding one patient who had aplastic anaemia, five (3.33%) of 150 patients with SPP IOLs developed endophthalmitis. The relative risk for postoperative endophthalmitis associated with the use of the SPP IOL compared with the PMMA IOL was 20.1 (p = 0.015). CONCLUSION: This study adds further evidence to the concept that SPP IOLs can be a significant risk factor in the development of postoperative endophthamitis.

Hardness and ultrasonic characteristics of the human crystalline lens.

PURPOSE: To evaluate the relationship between hardness of the human crystalline lens and its acoustic characteristics. SETTING: St. George's Hospital Medical School, University of London, London, United Kingdom. METHODS: Cataractous lenses from patients who had extracapsular cataract surgery were studied for hardness and ultrasonic characteristics. Lens hardness was assessed with an automated guillotine. Ultrasound velocity and attenuation were measured with a scanning acoustic macroscope using the pulse transmission reflection method. RESULTS: Thirty-seven lenses from 37 patients (mean age 75.5 years) were evaluated. Lens hardness was associated with ultrasound attenuation (r = 0.65, P <.0001) and attenuation frequency gradient (r = 0.67, P <.0001). The correlation of hardness with mean ultrasound velocity was not significant (r = 0.22, P =.2). CONCLUSIONS: The attenuation of ultrasound waves by the human crystalline lens correlated with its hardness. Ultrasonography can be used to evaluate lens hardness.

Dellen causing disappearance of Vogt's limbal girdle (II): A compressive phenomenon?

The cornea remains clear and avascular partly as a result of the compactness of the stromal lamellae. Loosening of these lamellae promotes loss of corneal transparency and peripheral vascularisation. Conversely, increased compactness of corneal tissue may possibly result in resorption of certain peripheral opacities. We report a case in which increased corneal compactness, produced by dellen formation, resulted in the disappearance of a type II Vogt's limbal girdle.

Effect of flurbiprofen on acetylcholine-induced pupillary contraction.

Preoperative treatment with topical nonsteroidal anti-inflammatory agents such as flurbiprofen (Ocufen) is used to maintain pupil dilation during cataract surgery. Flurbiprofen maintains pupil dilatation by inhibiting release of prostaglandins and other modulators of surgical miosis. Some reports suggest that these agents may reduce the miotic effect of intra-operative acetylcholine (Miochol). It is hard to explain this effect unless there is a pharmacological interaction between the two drugs. This study aimed to investigate the possibility of a direct interface by flurbiprofen with the action of acetylcholine on the pupil sphincter. Iris tissue of seven cadaver eyes were isolated and maintained in an organ bath containing Kreb's solution. Pupil contraction force induced by acetylcholine was measured in the presence and absence of flurbiprofen. Acetylcholine produced a mean pupillary contraction force of 52.4 x 10(-3) N. When it was added to the organ bath in the presence of flurbiprofen the mean contraction force was 50.5 x 10(-3) N (paired t-test P = 0.68). This study does not find any evidence to suggest that flurbiprofen reduces the pupil sphincter contraction that is induced by acetylcholine. It is likely that the apparent reduction in miosis is due to factors other than the mechanism of action of acetylcholine on the sphincter pupillae.

Visual function during acute hypoglycaemia.

Hypoglycaemia symptoms are of particular interest in view of the importance of hypoglycaemia unawareness. Visual symptoms arising during acute hypoglycaemia may be the result of metabolic disturbances in the visual pathways within the central nervous system or impairment of the refractive apparatus of the eye and binocular function. This study investigated the effect of hypoglycaemia upon visual acuity, binocular interaction and contrast sensitivity. Various aspects of visual function were examined in ten normal subjects before, during and after acute insulin-induced hypoglycaemia. A simultaneous study of hypoglycaemic symptoms enabled us to relate the objective findings to the symptoms as reported by the subjects. Snellen visual acuity, fusion and stereopsis were not affected by hypoglycaemia. Five subjects noted visual disturbance. Eight developed significant impairment of contrast sensitivity, which closely matched the lowered blood glucose concentration. These observations suggest that hypoglycaemic visual symptoms are due to neuroglycopenia of central visual pathways rather than changes within the refractive apparatus or abnormality of binocular function. Although these symptoms are not a constant feature of the hypoglycaemic state, subtle impairment of visual function occurs in most cases. Contrast sensitivity testing can be useful for assessment of fine changes in visual function.

Systemic conditions in the Emergency Eye Clinic.

PURPOSE: A systemic disease may be diagnosed for the first time in patients who present to the eye department with ophthalmological manifestations. This study documents the pattern of systemic disorders which were encountered in an emergency eye clinic for the first time. SUBJECTS AND METHOD: Over a period of six months details of all patients who had a previously unknown systemic condition diagnosed in the Emergency Eye Clinic were recorded. Patients were seen in this clinic upon referral from other practitioners. All patients, with the exception of those with minor ophthalmic problems, were screened for hypertension and glycosuria. The patients were subsequently referred to their general practitioner or the appropriate hospital specialist for further management. RESULTS: During this period 1025 new patients visited the emergency eye clinic. Previously undiagnosed systemic disease was present in 86 patients (8.4%). The commonest disorders were neurological 35 (41%), cardiovascular 17 (20%), glycosuria 13 (15%) and respiratory 5 (6%). Visual disturbance and pain were the most frequent ocular presentation. In 54 patients (62.8%) the ocular condition was a direct manifestation of the systemic condition and in 32 patients (37.2%) the systemic disease was a coincidental finding. CONCLUSIONS: Awareness of ophthalmological manifestations of systemic disorders helps in the early diagnosis of these conditions and reduces the resulting morbidity and possibly mortality. This study illustrates the hidden role of the emergency eye clinic in identifying patients with an underlying systemic condition.

Combined lensectomy, vitrectomy and scleral fixation of intraocular lens implant after closed-globe injury.

PURPOSE: To describe our experience in the surgical management of cataracts in patients with complications of closed-globe injury using pars plana lensectomy (PPL), pars plana vitrectomy (PPV), and scleral fixation of posterior chamber intraocular lens (PCIOL). METHODS: We retrospectively reviewed charts of all patients with closed-globe injury who underwent PPL, PPV and scleral fixation of PCIOL at our institution between January 1991 and July 1997. We identified 28 eyes; because of less than 2 weeks follow-up, 4 eyes were excluded from the current study. All eyes had lens subluxation/dislocation and visually significant cataract. Additional indications for surgery included secondary glaucoma (10 eyes), vitreous hemorrhage (3 eyes) and retinal detachment (1 eye). RESULTS: The postoperative follow-up interval ranged from 6 to 61 months (mean 18.5 months). Preoperative visual acuity (VA) ranged from 20/60 to hand motion and was 20/100 or better in 6 eyes (25%). Postoperatively, 19 eyes (79%) improved to 20/100 or better. Five eyes had subsequent surgery for the following indications: retinal detachment (2 eyes), poorly controlled glaucoma (2 eyes), and epiretinal membrane formation (1 eye). CONCLUSIONS: In patients undergoing PPL, PPV and scleral fixation of PCIOL for cataract after a closed-globe injury, a substantial visual improvement occurred in a majority of the involved eyes.