Ocular tuberculosis presenting with a conjunctival granuloma.

An 18-year-old female patient was referred with complaints of tearing and redness in the left eye for 3 months after a mild ocular trauma with a turkey feather. She was treated with topical antibiotics and corticosteroids with no improvement. Slit-lamp examination of the left eye showed a vascularized lesion with a polypoidal appearance due to multiple contiguous micronodules on the temporal and inferior bulbar conjunctiva. Results of the anterior and posterior segment examination were unremarkable in both eyes. A biopsy specimen of the conjunctival mass showed multiple tuberculoid granulomas composed of epithelioid histiocytes with associated Langhan's type multinucleate giant cells and a necrotic nodule surrounded by histiocytes and giant cells. The Mantoux test was positive with induration of 15mm. The patient was prescribed antituberculosis therapy. Three months after treatment initiation, the conjunctival lesions had resolved. Mycobacterium tuberculosis should be considered in cases of unilateral chronic recalcitrant conjunctivitis. Biopsy of a conjunctival mass is of utmost importance to establish a definite diagnosis.

IRVAN syndrome: A retrospective review of 9 cases from Tunisia.

PURPOSE: To describe clinical features, relevant imaging findings, disease course, and response to treatment in 9 patients (18 eyes) with idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome. METHODS: Retrospective review of the charts of nine patients (18 eyes) diagnosed with IRVAN syndrome at Fattouma Bourguiba University Hospital, Monastir, Tunisia, from January 1, 2011 to January 1, 2022. RESULTS: Nine patients were included with bilateral involvement in all cases. Mean initial best-corrected visual acuity (VA) was 20/32 (range, 20/1600-20/20). Clinical findings at presentation included vitreous cells (10 eyes, 55.6%), peripapillary exudates (12 eyes, 66.7%), partial or complete macular star (11 eyes, 61.1%), and vascular sheathing (11 eyes, 61.1%). Fluorescein angiography showed arteriolar aneurysms (18 eyes, 100%), areas of peripheral capillary non-perfusion (16 eyes, 88.9%), and retinal neovascularization (6 eyes, 33.3%). Optical coherence tomography showed macular edema in 5 eyes (27.8%). Optical coherence tomography angiography of the optic disc demonstrated papillary aneurysms in 4 eyes of 2 patients. Indocyanine green angiography showed retinal arteriolar aneurysmal dilatations in 4 eyes of 2 patients. Ten eyes (55.6%) had stage 2 disease, 6 eyes (33.3%) had stage 3, and 2 eyes (11.1%) had stage 1. Treatment modalities included peripheral photocoagulation (16 eyes, 88.9%), intravitreal bevacizumab (4 eyes, 22.2%), and intravitreal triamcinolone acetonide (1 eye, 5.6%). Mean final best-corrected VA was 20/32 (range, 20/600-20/20). Ocular complications included vitreous hemorrhage in 3 eyes (16.7%), branch retinal artery occlusion in 2 eyes (11.1%) and submacular fibrosis in 3 eyes (16.7%). CONCLUSION: IRVAN syndrome should be highly suspected in patients with peripapillary exudates associated with vascular sheathing and vitreous cells. Multimodal imaging confirms the diagnosis by showing retinal macroaneurysms. Early treatment of macular edema and/or peripheral retinal non-perfusion is mandatory to improve prognosis.

[Idiopathic orbital inflammatory syndrome: Report of 24 cases]. / Syndrome d'inflammation orbitaire idiopathique : à propos de 24 cas.

BACKGROUND: Idiopathic orbital inflammatory syndrome (IOIS) is an inflammatory condition of unknown etiology. The inflammation may affect all the structures within the orbit (anterior, diffuse, apical, myositic, dacryoadenitis) and corresponds to uniquely orbital inflammation without an identifiable local cause or systemic disease. The goal of this study is to describe the clinical and radiographic characteristics of IOIS and discuss the role of orbital biopsy in this condition. PATIENTS AND METHODS: This is a retrospective review of the charts of 24 patients diagnosed with IOIS at Fattouma Bourguiba hospital, Monastir, Tunisia, from January 2007 to December 2015. This study included all patients with IOIS and a minimum follow-up of six months. All patients had a complete ophthalmological examination and orbital and head CT scan and/or MRI. A work-up was performed in all cases to rule out local causes and systemic disease. Only 11 patients underwent biopsy. The diagnosis of the clinical entity IOIS was made according to the Rootman criteria. Oral steroids were the first line therapy. A bolus of intravenous methylprednisolone was administered first in vision-threatening cases. Response to treatment was defined as disappearance of signs and symptoms of IOIS. RESULTS: Orbital pain was the most common symptom (62.5%), followed by proptosis and decreased vision (37.5% each). Best-corrected visual acuity (BCVA) was greater than 5/10 in 70.7% of patients. Lacrimal gland enlargement was observed in 3 patients. Oculomotor disorders were present in 70% of cases and 20.8% of patients had compressive optic neuropathy. Orbital imaging showed, in most cases, oculomotor muscle inflammation (87.5%) involving particularly the superior rectus muscle (54.2%) and inflammation of orbital fat (66.7%). Fifty percent had myositic inflammation. Biopsy was performed in 11 patients, showing nonspecific inflammation (n=10) and the sclerosing form (n=1). A total of 83.3% of patients received oral corticosteroids for a mean duration of 5.5 months. CONCLUSION: IOIS is a diagnosis of exclusion, based on history, clinical course, response to steroid therapy, laboratory tests, or even biopsy in selected cases. Orbital imaging provides valuable clues for diagnosis of IOIS and for identification of affected structures. Prolonged steroid therapy is necessary as IOIS classically responds to steroids; nevertheless, partial recovery or relapses often occur.

The hematopoietic growth factor "erythropoietin" enhances the therapeutic effect of mesenchymal stem cells in Alzheimer's disease.

Alzheimer's disease is a neurodegenerative disorder clinically characterized by cognitive dysfunction and by deposition of amyloid plaques, neurofibrillary tangles in the brain. The study investigated the therapeutic effect of combined mesenchymal stem cells and erythropoietin on Alzheimer's disease. Five groups of mice were used: control group, Alzheimer's disease was induced in four groups by a single intraperitoneal injection of 0.8 mg kg(-1) lipopolysaccharide and divided as follows: Alzheimer's disease group, mesenchymal stem cells treated group by injecting mesenchymal stem cells into the tail vein (2 x 10(6) cells), erythropoietin treated group (40 microg kg(-1) b.wt.) injected intraperitoneally 3 times/week for 5 weeks and mesenchymal stem cells and erythropoietin treated group. Locomotor activity and memory were tested using open field and Y-maze. Histological, histochemical, immunohistochemical studies, morphometric measurements were examined in brain sections of all groups. Choline transferase activity, brain derived neurotrophic factor expression and mitochondrial swellings were assessed in cerebral specimens. Lipopolysaccharide decreased locomotor activity, memory, choline transferase activity and brain derived neurotrophic factor. It increased mitochondrial swelling, apoptotic index and amyloid deposition. Combined mesenchymal stem cells and erythropoietin markedly improved all these parameters. This study proved the effective role of mesenchymal stem cells in relieving Alzheimer's disease symptoms and manifestations; it highlighted the important role of erythropoietin in the treatment of Alzheimer's disease.

A clinical and magnetic resonance spectroscopy study of a brain tumor in a patient with segmental neurofibromatosis.

INTRODUCTION: Segmental neurofibromatosis 1 (segmental NF-1) is a rare genodermatosis caused by somatic mutations in the NF-1 gene. It consists of localized characteristic skin lesions. A serial study using magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) of a brain tumor in a 16-year-old patient with segmental NF-1 is reported. CASE REPORT: A 16-year-old boy with congenital dorsal scoliosis and segmental NF-1 was evaluated for bilateral optic atrophy. Neurological examination showed an isolated tetra pyramidal syndrome. The cerebral MRI showed a bilateral brain lesion involving the basal ganglia, optic pathways, temporal lobes, and the midbrain. Serial MRSs showed a decreased N-acetylaspartate (NAA)/creatine ratio and increased choline/creatine ratio. An increase in the myoinositol (MYO)/creatine ratio and the presence of a lipid/lactate peak were also recorded. A neuroimaging follow-up with MRI and MRS performed 2 years later showed similar findings. COMMENTS AND CONCLUSION: We describe an MRS study of a brain tumor in a patient with segmental NF-1 for the first time. The MRS study showed similar findings, described earlier in rare studies of patients with the classic form of NF-1. MRS is a noninvasive technique for detecting the presence of tumor tissue in the brain through its metabolic activity. MRS plays an important role in clinical studies and it can be used to differentiate malignant and nonmalignant brain lesions from normal brain tissue.

[Intravitreal injection of triamcinolone acetonide for the treatment of macular edema]. / Traitement des oedèmes maculaires par injection intravitréenne d'acétonide de triamcinolone.

PURPOSE: To study the efficacy and safety of intravitreal injection of triamcinolone acetonide for the treatment of macular edema (ME). METHODS: Thirty-five eyes of 33 patients with ME were studied. The causes of ME included diabetes (24 eyes), postoperative ME (four eyes), intraocular inflammation (three eyes), retinal vein occlusion (three eyes), and Coats disease (one eye). All patients underwent a complete ophthalmic examination and fluorescein angiography before and after treatment. Treatment consisted of a single intravitreal injection of 2 or 4 mg of triamcinolone acetonide under subconjunctival anaesthesia. Mean follow-up time was 4 months (range, 1-10 months). RESULTS: Mean visual acuity before treatment was 20/200 (range, 20/400-20/70). Visual acuity improved by one line or more on the Snellen visual acuity chart in seven eyes (20%) and remained unchanged in nine eyes (25.7%). In the 19 remaining eyes, visual acuity improved slightly and remained less than 20/200. ME diminished or resolved completely in 32 eyes (91%). This improvement was seen in all eyes with diabetic ME, pseudophakic ME, or inflammatory ME. ME recurred in three eyes 3 months after injection of triamcinolone and in one eye 9 months after injection of triamcinolone. In one diabetic patient, retinal neovascularization associated with ME resolved as a consequence of intravitreal triamcinolone injection. Reversible ocular hypertension occurred in ten eyes (28.6%). No case of endophthalmitis was seen. CONCLUSION: Intravitreal injection of triamcinolone acetonide is an effective treatment of ME. Its best indications seem to be diabetic, pseudophakic and inflammatory ME. Randomized clinical trials are warranted to assess long-term efficacy and safety of this treatment modality of ME.

[Choroid metastases revealing pulmonary adenocarcioma resolved with chemotherapy]. / Métastases choroïdiennes révélatrices d'un adénocarcinome bronchique et involuant sous chimiothérapie.

Lung cancer is the leading cause of choroidal metastasis in men, but choroidal metastasis is rarely inaugural. With the advent of new generations of chemotherapy molecules non-small-cell lung cancer (NSCLC) has become more chemosensitive. Choroidal metastasis may respond to chemotherapy. We report a case of a 52-year-old men who developed choroidal metastasis revealing pulmonary adenocarcinoma confirmed by the bronchial biopsy. Systemic chemotherapy using gemcitabine-cisplatin led to total involution of the choroidal metastasis with improvement of the visual acuity in one eye and stabilization in the other. Systematic search for lung cancer is required in patients presenting choroidal metastasis. If compatible with the patient's general status, histologically-adapted chemotherapy must be instituted. This approach can avoid the use of radiotherapy and therefore deterioration of visual acuity after radiation.

[Compressive optic neuropathy caused by fibrous dysplasia]. / Neuropathie optique compressive secondaire à une dysplasie fibreuse.

We report a case of compressive optic neuropathy caused by fibrous dysplasia in a 28-year-old woman. The patient had no significant medical history. Her best-corrected visual acuity was 20/20 in the right eye and 20/400 in the left eye. There was an afferent pupillary defect in the left eye. Slit-lamp examination was unremarkable. Funduscopy showed a normal optic disc bilaterally and congenital hypertrophy of the retinal pigment epithelium in the right eye. Systemic evaluation disclosed facial asymmetry and mucocutaneous lentiginosis involving the face and the limbs. Goldmann visual field testing showed a cecocentral scotoma in the left eye. Imaging studies demonstrated extensive changes of craniofacial fibrous dysplasia involving the sphenoid bone, with compression of the left optic nerve by a cystic structure. Results of gastrointestinal fibroscopy were unremarkable. The patient was given systemic steroids. After 4 days of treatment, her visual acuity had improved to 20/40, with resolution of the afferent pupillary defect and visual field improvement. Debulking of the tumor was recommended, but the patient declined the procedure. She has remained stable over 13 months of follow-up. Compressive optic neuropathy should be considered as a leading cause of visual loss in patients with craniofacial fibrous dysplasia. Early diagnosis, close follow-up, and appropriate management are mandatory to improve or maintain the visual function in such patients.

[Association of spheno-orbital dysplasia with plexiform neuroma in von Recklinghausen's neurofibromatosis]. / Association d'une dysplasie sphéno-orbitaire à un névrome plexiforme au cours d'une neurofibromatose de Von Recklinghausen.

We report a case of plexiform neurofibroma of the upper eyelid associated with spheno-orbital dysplasia in a 18-year-old woman with von Recklinghausen neurofibromatosis. Visual acuity was 20/40 in the right eye and 20/20 in the left. Plexiform neurofibroma involving the right upper eyelid was associated with mild ptosis and ipsilateral facial hypertrophy. Biomicroscopic examination showed lisch nodules. Funduscopic examination, visual field and neurologic examinations were normal. Café au lait spots involved the trunk with neck plexiform neurofibroma. Computed tomography disclosed spheno-orbital dysplasia. The patient's status remained unchanged at 6 months follow-up. Cranial features of von Recklinghausen neurofibromatosis are found in 3 to 7% of patients. In patients with plexiform neurofibroma of the eyelid the ophthalmologist should look for associated spheno-orbital dysplasia.

Retinal venous macroaneurysm associated with premacular hemorrhage.

To report an unusual association of a retinal venous macroaneurysm with premacular hemorrhage in a 50-year-old man, using a case report method. The patient exhibited a dense premacular hemorrhage in the left eye. Fluorescein angiography demonstrated that the source of bleeding was an isolated retinal venous macroaneurysm. The anterior surface of the hematoma was opened with an argon green laser, resulting in rapid clearing of the premacular hemorrhage and improvement in vision. Treatment of the retina surrounding the macroaneurysm to prevent recurrence of bleeding was ineffective to achieve occlusion of the lesion. No recurrent hemorrhage occurred during the observation period. Retinal venous macroaneurysm, a quite rare condition, may be complicated by premacular hemorrhage. Argon green laser may be useful in treating such hemorrhage. Hemorrhagic detachment of the internal limiting membrane or subhyaloid hemorrhage in the macula may occur after retinal vessel rupture with physical exertion (Valsalva retinopathy) or in retinal vascular diseases, such as proliferative diabetic retinopathy, and retinal arterial macroaneurysm. Arterial macroaneurysms are a common, well-described retinal vascular disorder. In contrast to retinal arterial macroaneurysms, retinal venous macroaneurysms are quite rare. In this article we describe a patient who presented with premacular hemorrhage that was caused by a retinal venous macroaneurysm. The hematoma and the macroaneurysm were treated with argon green laser.

Sectorial choroidal ischemia associated with ipsilateral lacrimal gland tumor.

PURPOSE: To report the association of sectorial choroidal ischemia with ipsilateral tumor of the lacrimal gland. METHODS: Case report. In a 62-year-old man, a complete ophthalmologic examination, including fluorescein angiography and computed tomographic scans of the orbit, was performed. The patient underwent an en bloc excisional biopsy of the tumor. RESULTS: Fluorescein angiography of the left eye showed extensive sectorial choroidal ischemia superotemporal to the optic disk with macular involvement and associated chorioretinal folds. The patient was found to have a benign mixed tumor of the left lacrimal gland. CONCLUSION: The tumor of the lacrimal gland may have compressed choroidal vessels and short posterior ciliary arteries with subsequent sectorial choroidal ischemia.

Endocrine involvement in minor (non-H-2) graft versus host reaction in mice: dissociated effect on corticosterone and aldosterone plasma levels.

The graft vs. host reaction (GVHR) induced across a non-H-2 histocompatibility antigen barrier was shown to be a multiorgan disease with a strict time-dependent pattern of functional alterations. The present study was undertaken to examine the effects of the GVHR on corticosterone, aldosterone, corticotropin (ACTH), Na+, and K+ plasma concentrations in mice. GVHR was induced in irradiated (DBA/2 X B10.D2)F1 mice by transplantation of B10.D2 hemopoietic cells. Controls were untreated F1 mice and irradiated syngeneic (F1) cell-grafted F1 mice. Nonimmunological stimuli transiently increased ACTH and corticosterone plasma levels during the first 5 days, although the early ACTH peak was markedly reduced in GVHR mice. Circulating corticosterone levels returned to normal values thereafter in controls. ACTH returned to basal levels in all mice, even in GVHR mice in spite of their persistent high corticosteronism. The enhancing effect of GVHR on plasma aldosterone concentrations was delayed until day 30 after the cell graft. Results suggest 1) a dissociated effect of GVHR on mineralocorticoid and glucocorticoid metabolism and 2) either an alteration of adrenal sensitivity to ACTH in GVHR mice or a possible mimicking of some neuroendocrine activities by the lymphocytes responsible for the onset of the disease.

Endocrine involvement in minor (non-H-2) graft-versus-host reaction in mice. Early and primary thyroid failure.

A minor (non-H-2) graft-vs.-host reaction (GVHR) was induced in adult irradiated (DBA/2 X B10.D2)F1 mice by hematopoietic parental B10.D2 cell grafts. Syngeneic (F1) cell transplantation was performed as control. In one set of experiments T4 plasma level (enzyme linked immunosorbent assay) was systematically followed up in individual GVHR and control mice. Compared to the control, GVHR triggered off a significant and sustained decrease of T4 plasma level. In another set of experiments, TSH plasma levels (RIA) were measured in killed animals. GVHR induced an early elevation of plasma TSH. In a third set of experiments, mice undergoing GVHR received daily injections of L-T4 (0.03, 0.15, or 0.3 microgram/mouse). Compared to the control (saline injected) GVHR mice, T4 supply did not improve GVHR state. No positive effect of the high dose and rather a negative effect of both lower doses especially on glucose plasma concentration, were observed. All these data suggest that thyroid gland is primarily and very early involved in the onset of the GVH disease.