Restoration of vision by combined experimental antithymocyte therapy, and orbital radiation with high-dose steroids for severe, acute, steroid-refractory, congestive thyroid orbitopathy.

PURPOSE: We report diagnostic and therapeutic dilemmas in the difficult case of compressive optic neuropathy with severe visual acuity and visual field loss with subsequent visual recovery in both eyes, in a patient with Graves' orbitopathy (GO) by a combination of experimental antithymocyte therapy, orbital radiotherapy with high-dose steroids. METHODS: A 72-year-old man presented with severe vision loss in both eyes. The visual symptoms had appeared over a year before the GO diagnosis. He was initially misdiagnosed with neuroborreliosis and optic neuritis based on brain and orbital magnetic resonance imaging. There was no exophthalmos. The ophthalmological examination included visual acuity, visual field, tonometry in primary and upgaze eye position, optical coherence tomography (OCT), pattern electroretinogram (PERG), pattern, and flash visual evoked potentials (PVEP and FVEP). The patient received experimental therapy with ATG, followed by high-dose of intravenous steroids and orbital radiotherapy. RESULTS: Delayed VEP peaks became shorter after treatment. After systemic and local therapy lowering of intraocular pressure was achieved. Abnormal PERG has been found three months before ganglion cells atrophy was detected in OCT. Visual acuity and visual field improvement occurred in both eyes after therapy, despite partial left optic nerve atrophy. The patient regained full decimal visual acuity (1.0 right from as poor as 0.3  to 1.0 in the right eye and from hand movements to 0.9 in the left. Severe visual field loss with advanced absolute scotomata has improved to slight relative scotomata. The duration of follow-up time after the treatment was 4 months. CONCLUSIONS: Intensive treatment of steroid-resistant Graves' orbitopathy (GO) may prevent total optic nerve atrophy. Despite severely advanced optic neuropathy, this report emphasizes the necessity of therapy even with nearly complete visual function loss hence there is always a possibility to regain full visual acuity and visual field. Patients with tense orbital septum may not present with significant exophthalmos, thus delaying the correct diagnosis of orbitopathy. A supporting sign of GO was the difference in intraocular pressure in the primary and upgaze eye positions. Electrophysiological examinations are helpful in the diagnosis and monitoring of GO therapy. To our knowledge, this is the first report of this kind presenting visual function restoration and structural recovery in a patient with advanced optic neuropathy in GO.

Diagnostic methods in ocular argyrosis: case report.

PURPOSE: The aim of this report is to present a case of a patient, metal foundry worker, who had been exposed to industrial silver salts for over 20 years. It is well established that chronic exposure to silver compounds can cause accumulation of silver deposits in various tissues. This condition is referred to as argyrosis or argyria, whereas changes related to eye tissues are defined as ocular argyrosis. METHODS: A complete eye examination, corneal confocal microscopy, kinetic and static visual field test, posterior segment optical coherent tomography, pattern visual evoked potentials (PVEP), flash visual evoked potentials, multifocal electroretinogram, pattern electroretinogram (PERG), full-field electroretinography (FERG) and electrooculogram were all performed. RESULTS: Eye examination revealed decreased visual acuity, corneal deposits and drusenoid changes within the macula. Although electrophysiology tests did not show changes in the function of retinal pigment epithelium, they revealed abnormal function of photoreceptors in the central and peripheral retina. PERG abnormalities and delayed latency of P100 wave in PVEP confirmed impaired function of the inner layers of the retina in the macular region. CONCLUSIONS: Corneal confocal microscopy and electrophysiological tests may help confirm the diagnosis of ocular argyrosis.

Determination of Serum Ceruloplasmin Concentration in Patients with Primary Open Angle Glaucoma with Cataract and Patients with Cataract Only: A Pilot Study.

BACKGROUND The aim of this article was to describe the role of ceruloplasmin and to report preliminary results of ceruloplasmin concentrations in patients with primary open-angle glaucoma (POAG) with cataract and in patients with only cataract. Glaucoma, a neurodegenerative disease, is a heterogeneous group of conditions characterized by loss of retinal ganglion cells (RGC), their axons, progressive optic nerve damage, and visual field deterioration. MATERIAL AND METHODS The POAG group included 30 patients and the cataract group included 25 patients. RESULTS Ceruloplasmin plays an essential role in iron metabolism and inactivating free radicals. In the presented pilot study, serum ceruloplasmin level was lower in the POAG group in comparison to the group with only cataract. CONCLUSIONS In treating persistent inflammation in the course of glaucoma, antiglaucoma drugs may increase the permeability of the blood-ocular barrier, which may be connected with the lower concentration of serum ceruloplasmin in the glaucoma patients group.

Antithymocyte Globulin as Second-Line Therapy in Graves Orbitopathy-Preliminary Results From a Prospective Single-Center Study.

Objective: Management of Graves' orbitopathy remains a challenge. Our previous case report has shown promising results for rabbit antithymocyte globulin (rATG) in the treatment of Graves' orbitopathy. Design: We present the response of 7 individuals with active moderate-to-severe steroid-resistant Graves' orbitopathy to rATG, representing preliminary results from a prospective single-center study. Methods: rATG was administered intravenously at a dose of 0.8-1.0 mg/kg daily (cumulative dose of 150-200 mg). The primary outcome measures at weeks 24 and 48 were ≥2-point reduction in Clinical Activity Score from baseline, a proptosis response, a diplopia response, and improvement of distant best-corrected visual acuity and mean retinal sensitivity. Key secondary outcomes included stabilization of ganglion cell complex thickness, a decrease of retinal nerve fiber layer in OCT, and a reduction in CD4/CD8 ratio and TRAb at 48 weeks. Results: An improvement in clinical activity score was observed in all patients, with disease inactivation in 3 cases. Proptosis reduction equal to or greater than 2 mm was noted for 8 of 10 eyes. Diplopia improved in three of 6 patients. There was an improvement in best-corrected visual acuity (from 0.69 to 0.78) and mean retinal sensitivity (from 20.8 to 23.5 dB). In addition, there was a long-lasting improvement in CD4/CD8 ratio in 6 patients. Two patients experienced adverse events (influenza and serum sickness). Conclusion: rATG therapy offers a long-lasting improvement in moderate-to-severe steroid-resistant Graves' orbitopathy with improvement in functional vision (reduction of diplopia, improvement of visual acuity, retinal sensitivity, and VEP pattern). The therapy is well-tolerated. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT05199103.

The impact of exposure on the magnitude of astigmatism formed within the precorneal tear film over the central optical zone of the cornea in ocular surface disease.

PURPOSE: To estimate the astigmatic power and axis of the tear film over the central optical zone of the cornea by vector analysis of topographic data, in ocular surface disease (OSD) and controls, during blink suppression. METHODS: Video-keratoscopic images were captured on opening the eyes after a single blink 5, 10 & 15 s later during blink suppression in OSD patients (mixed aetiology, group 1 age 20 - 50 years, n = 12, group 2 > 50 years, n = 38) and controls (group 3, n = 19). The SimK and axis values were used to calculate the astigmatism (power and axis) that formed in the precorneal tear film during each period. Data were aggregated into 3 periods; T0-T5 (between 0 & 5 s after the blink), T5-T10 (5 & 10 s later, T10-T15 (between 10 & 15 s later). RESULTS: Mean (± SD, 95%CI) astigmatic power (DC) formed in the tear film over each period was respectively : Group 1, -0.81 DC (0.99, -1.44 to -0.17), -2.65 DC(1.36, -3.52 to -1.79), -1.37 DC (2.15, -2.73 to -0.01). Group 2, -0.33 DC (0.38, -0.45 to -0.20), -0.57 DC (0.97, -0.91 to -0.24) -0.96 DC (2.10, -1.68 to -0.24), Group 3, -0.57 DC (0.55 -0.76 to -0.38), -0.56 DC (0.57, -0.76 to -0.37), -0.31 DC (0.44, -0.46 to -0.16). Changes were significant in groups 1 (p = 0.013) & 3 (p = 0.033) but not in 2 (p = 0.078). Intergroup differences were significant at all periods (p < 0.05). Significant correlations were detected following vector analysis, e.g Group2 between the astigmatism formed during T5-T10 (y) and ocular surface astigmatism at 5 s was y = 0.281x - 0.834 (r = 0.328, n = 38, p < 0.05). In all three groups apparent changes in the axes of astigmatism were not significant (p > 0.05). CONCLUSIONS: Changes in the precorneal tear film after blinking are predominately astigmatic indicating that changes in the central region of the tear film following the natural blink are quasi-orthogonal.

Long-term remission of steroid-resistant Graves' orbitopathy after administration of anti-thymocyte globulin.

Not required for Clinical Vignette.

The efficacy of microperimetry and contrast sensitivity test in the diagnosis of optic chiasm compression due to pituitary adenomas.

INTRODUCTION: The aim of the study was to determine which microperimetry and contrast sensitivity test parameters would prove the most valuable during diagnosing optic chiasm compression due to pituitary adenomas. MATERIAL AND METHODS: A control group comprised healthy individuals (Group 1). Patients with pituitary macroadenoma were divided into two groups: Group 2 - absent optic chiasm compression; and Group 3 - present optic chiasm compression detected on contrastenhanced magnetic resonance imaging (MRI). Each group comprised 20 patients (40 eyes), i.e. a total of 60 patients (120 eyes) were examined. A complete ocular examination, intraocular pressure, microperimetry, contrast sensitivity test, kinetic Goldmann visual field, and static Octopus visual field test were performed. RESULTS: Group 1 and 2 variables showed no statistically significant differences with respect to the mean sensitivity (MS) and mean defect (MD) in microperimetry. After dividing the microperimetry area into quadrants, a difference was shown in the mean sensitivity of the lower-nasal quadrant (MS LN) and mean defect of the lower-nasal quadrant (MD LN) between those groups. Receiver operating characteristic (ROC) curves analysis revealed that the microperimetry parameter - MS LN as well as row D and E contrast sensitivity test could be highly specific in the assessment of early damage of the optic nerve in patients suffering from pituitary adenoma. CONCLUSIONS: Microperimetry and contrast sensitivity test are non-invasive diagnostic investigations adjunctive to MRI, which facilitate detection of early chiasmal compression caused by pituitary adenomas.