Assessment of optic nerve cup-to-disk ratio changes in patients receiving multiple intravitreal injections of antivascular endothelial growth factor agents.

PURPOSE: To assess whether the transient intraocular pressure rise, frequent intraocular pressure fluctuations, or antivascular endothelial growth factor (VEGF) effects of repeated intravitreal injection of anti-VEGF agents can lead to changes in the optic nerve vertical cup-to-disk ratio (C/D). METHODS: Patients with a known history of glaucoma and those receiving triamcinolone acetonide were excluded from the study. Fundus photographs were cropped to optic disk images only, which were then randomized and independently graded by two glaucoma specialists. In patients who received treatments in only one eye, the fellow eye was used as a control. RESULTS: Twenty-three eyes of 21 patients met inclusion criteria. The mean change in C/D was -0.012 (95% confidence interval [CI], -0.053 to 0.029) for the treated group and -0.006 (95% CI, -0.106 to 0.095) for the control group, with no statistically significant difference (P = 0.90). The mean change in C/D for eyes receiving < or =5 injections (n = 9) was 0.003 (95% CI, -0.089 to 0.095) in the treated group and 0.054 (95% CI, -0.033 to 0.142) in the control group, with no statistically significant difference (P = 0.33). In eyes receiving >5 injections (n = 14), the mean change in C/D was -0.021 (95% CI, -0.095 to 0.052) in the treated group and -0.057 (95% CI, -0.231 to 0.116) in the control group, with no statistically significant difference (P = 0.70). CONCLUSION: There was no statistically significant change in the vertical C/D of optic nerves in patients receiving multiple intravitreal injections of anti-VEGF agents, regardless of whether they received fewer or more than five total injections. This suggests that the short-term intraocular pressure rise and frequent intraocular pressure fluctuation, as well as the anti-VEGF properties of these drugs, do not adversely change the optic nerve C/D. Additional prospective studies are warranted to confirm these conclusions.

Cataract secondary to electrical shock from a Taser gun.

A 35-year-old man presented with traumatic iritis, angle-recession glaucoma, and a retinal dialysis secondary to blunt trauma from a Taser gun in the right eye and a unique electrical cataract in the left eye. Taser guns, which can also function as stun guns, can lead to electrical cataract formation. Given the increasing use of Taser guns by law enforcement and citizens, blunt mechanical and electrical sequelae of Taser gun injuries should be recognized.

Choroidal neovascularization associated with West Nile virus chorioretinitis.

A case of late-onset choroidal neovascularization in a patient with a history of West Nile virus chorioretinitis is described. An 86-year-old man with a history of diabetes mellitus developed bilateral West Nile virus chorioretinitis in 2001, after which his vision improved to baseline. Approximately 5 years later, the patient was found to have choroidal neovascularization in his left eye, for which he received an intravitreal injection of bevacizumab. After one injection, there was good anatomical response. Choroidal neovascularization may be a late-onset complication of West Nile virus chorioretinitis, and bevacizumab may be a good therapeutic option.

Change in head posture and character of nystagmus in a patient with neurological upbeat nystagmus.

PURPOSE: To report a case of a patient with chin-up head posture and presumed congenital toxoplasmosis chorioretinal scars, who had a change in the character of the nystagmus and therefore the head posture following treatment for a neurological upbeat nystagmus. CASE REPORT: A 5 month old female presented with a chin up head posture and upbeat nystagmus. Magnetic resonance imaging of the brain revealed an arachnoid cyst in the area of the pineal gland. Nine months after cyst-peritoneal shunt surgery, the upbeat nystagmus was dampened but change in character to a rotary nystagmus worse on the left gaze. The patient had assumed a left face turn, shifting the null point from the vertical to the horizontal plane. The left face turn was successfully corrected at age eight years with a Kestenbaum procedure. CONCLUSION: This case emphasizes the possibility of having two distinct types of nystagmus associated with two etiologies. In this case, an acquired upbeat nystagmus secondary to an arachnoid cyst, and a congenital left rotary nystagmus from the chorioretinal scars. Furthermore, there can be a change in head position and character of nystagmus after treating the cause of the central motility disorder, thereby affecting the choice and timing of surgical intervention to correct the head positioning.

Mucous membrane pemphigoid in a patient with chronic lymphocytic leukemia.

PURPOSE: To describe a case of mucous membrane pemphigoid (MMP) with ocular manifestations in a patient subsequently diagnosed with B-cell chronic lymphocytic leukemia (CLL). METHODS: Case report and literature review. RESULTS: A 64-year-old man presented with redness and irritation of both eyes. The patient also had blistering lesions on the roof of his mouth, trunk, and buttocks as well as bilateral conjunctival ulceration and symblepharon formation. A complete blood count performed before initiating treatment of presumed mucous membrane pemphigoid revealed a markedly increased white blood cell count (83,920) with a predominance of lymphocytes. Hematologic evaluation including immunophenotyping flow cytometry resulted in the diagnosis of B-cell chronic lymphocytic leukemia. Cyclophosphamide treatment improved his MMP and decreased the white blood cell count. CONCLUSIONS: Mucous membrane pemphigoid has been reported in association with a variety of nonhematologic malignancies. This case suggests that mucous membrane pemphigoid may also occur in B-cell CLL and supports the concept that autoantibodies play a role in the pathogenesis of this cicatricial conjunctival disease.

Congenital simple hamartoma of the retinal pigment epithelium.

Congenital simple hamartoma of the retinal pigment epithelium (CSHRPE) is a rare tumor speculated to arise from the retinal pigment epithelium (RPE). A case of CSHRPE is presented herein along with the related literature. A healthy 20-year-old Middle-Eastern man was evaluated for an asymptomatic retinal lesion found on routine examination of his left eye. Fluorescein angiogram, spectral domain optical coherence tomography, and A and B scan ultrasonography confirmed the suspected clinical diagnosis. For the first time high-definition OCT images are shown, which have an RPE origin for this tumor.

Effects of music therapy on intravitreal injections: a randomized clinical trial.

PURPOSE: To investigate the effects of music therapy on anxiety, perceived pain, and satisfaction in patients undergoing intravitreal injections in the outpatient setting. METHODS: This is a randomized clinical trial. Seventy-three patients were recruited from the retina clinic at 1 institution and randomized into a music therapy (n=37) or control (n=36) group. Prior to injection, patients completed the state portion of the Spielberger State Trait Anxiety Inventory (STAI-S). The music therapy group listened to classical music through computer speakers while waiting for and during the injection. The control group underwent the injection in the same setting without music. Afterward, all patients completed another STAI-S and a satisfaction and pain questionnaire. The main outcome measures were objective anxiety derived from STAI-S scores and subjective pain and anxiety from the post procedure questionnaire. RESULTS: The music therapy group had a greater decrease in anxiety than the control group (P=0.0480). Overall, 73% of all patients requested music for future injections (P=0.0001). The music therapy group (84%) requested music in future injections more frequently than the control group (61%) (P=0.0377). Both groups reported similar levels of pain (P=0.5879). CONCLUSIONS: Classical music before and during intravitreal injections decreases anxiety in patients without decreasing pain. Most patients desire to have music during future injections. Music therapy is a low-cost, easy, safe intervention that reduces anxiety during intravitreal injections in the outpatient setting.

High-altitude retinopathy and optical coherence tomography findings.

PURPOSE: To report the case and OCT findings of a case of high altitude retinopathy (HAR). METHODS: Case report and review of literature. RESULTS: HAR is part of the clinical syndrome of high altitude illness, which includes acute mountain sickness and high altitude cerebral edema. A patient presented with decreased vision and HAR after ascending to an elevation of 24,757 feet. Associated optical coherence tomography findings and review of the literature are presented. CONCLUSIONS: HAR is an important entity to recognize, as it is associated with life-threatening high-altitude cerebral edema.

Treatment of serpiginous choroiditis with intravitreous fluocinolone acetonide implant.

PURPOSE: To describe a case in which a fluocinolone acetonide implant was used in a patient with serpiginous choroiditis. DESIGN: Case report. RESULTS: A 57-year-old woman with active serpiginous choroiditis threatening the fovea of her right eye received one intravitreous triamcinolone acetonide injection, leading to immediate disease control. An intravitreous fluocinolone acetonide implant was placed, and resulted in ongoing control of the disease as of her 14 months postoperative follow-up. CONCLUSIONS: Intravitreous fluocinolone acetonide implant should be recognized as a potential treatment option for serpiginous choroiditis.

Nocardia asteroides necrotizing scleritis associated with subtenon triamcinolone acetonide injection.

PURPOSE: To report a case of Nocardia asteroides infection after subtenon triamcinolone acetonide injection. DESIGN: Case report. RESULTS: An 80-year old female received a subtenon triamcinolone acetonide injection for postcataract surgery cystoid macular edema. Shortly after, the patient developed a chronic red eye that progressed to a fulminant necrotizing scleritis. Eventual scleral biopsy revealed Nocardia asteroides infection, which improved after 5 months of systemic antibiotic therapy. CONCLUSIONS: Subtenon triamcinolone acetonide injection should be recognized as a cause of serious infectious scleritis.