Identification and characteristics of SnRK genes and cold stress-induced expression profiles in Liriodendron chinense.

BACKGROUND: The sucrose non-fermenting 1 (SNF1)-related protein kinases (SnRKs) play a vivid role in regulating plant metabolism and stress response, providing a pathway for regulation between metabolism and stress signals. Conducting identification and stress response studies on SnRKs in plants contributes to the development of strategies for tree species that are more tolerant to stress conditions. RESULTS: In the present study, a total of 30 LcSnRKs were identified in Liriodendron chinense (L. chinense) genome, which was distributed across 15 chromosomes and 4 scaffolds. It could be divided into three subfamilies: SnRK1, SnRK2, and SnRK3 based on phylogenetic analysis and domain types. The LcSnRK of the three subfamilies shared the same Ser/Thr kinase structure in gene structure and motif composition, while the functional domains, except for the kinase domain, showed significant differences. A total of 13 collinear gene pairs were detected in L. chinense and Arabidopsis thaliana (A. thaliana), and 18 pairs were detected in L. chinense and rice, suggesting that the LcSnRK family genes may be evolutionarily more closely related to rice. Cis-regulation element analysis showed that LcSnRKs were LTR and TC-rich, which could respond to different environmental stresses. Furthermore, the expression patterns of LcSnRKs are different at different times under low-temperature stress. LcSnRK1s expression tended to be down-regulated under low-temperature stress. The expression of LcSnRK2s tended to be up-regulated under low-temperature stress. The expression trend of LcSnRK3s under low-temperature stress was mainly up-or down-regulated. CONCLUSION: The results of this study will provide valuable information for the functional identification of the LcSnRK gene in the future.

Damage-Associated Molecular Patterns (DAMPs) in Retinal Disorders.

Damage-associated molecular patterns (DAMPs) are endogenous danger molecules released from the extracellular and intracellular space of damaged tissue or dead cells. Recent evidence indicates that DAMPs are associated with the sterile inflammation caused by aging, increased ocular pressure, high glucose, oxidative stress, ischemia, mechanical trauma, stress, or environmental conditions, in retinal diseases. DAMPs activate the innate immune system, suggesting their role to be protective, but may promote pathological inflammation and angiogenesis in response to the chronic insult or injury. DAMPs are recognized by specialized innate immune receptors, such as receptors for advanced glycation end products (RAGE), toll-like receptors (TLRs) and the NOD-like receptor family (NLRs), and purine receptor 7 (P2X7), in systemic diseases. However, studies describing the role of DAMPs in retinal disorders are meager. Here, we extensively reviewed the role of DAMPs in retinal disorders, including endophthalmitis, uveitis, glaucoma, ocular cancer, ischemic retinopathies, diabetic retinopathy, age-related macular degeneration, rhegmatogenous retinal detachment, proliferative vitreoretinopathy, and inherited retinal disorders. Finally, we discussed DAMPs as biomarkers, therapeutic targets, and therapeutic agents for retinal disorders.

ICE-CBF-COR Signaling Cascade and Its Regulation in Plants Responding to Cold Stress.

Cold stress limits plant geographical distribution and influences plant growth, development, and yields. Plants as sessile organisms have evolved complex biochemical and physiological mechanisms to adapt to cold stress. These mechanisms are regulated by a series of transcription factors and proteins for efficient cold stress acclimation. It has been established that the ICE-CBF-COR signaling pathway in plants regulates how plants acclimatize to cold stress. Cold stress is perceived by receptor proteins, triggering signal transduction, and Inducer of CBF Expression (ICE) genes are activated and regulated, consequently upregulating the transcription and expression of the C-repeat Binding Factor (CBF) genes. The CBF protein binds to the C-repeat/Dehydration Responsive Element (CRT/DRE), a homeopathic element of the Cold Regulated genes (COR gene) promoter, activating their transcription. Transcriptional regulations and post-translational modifications regulate and modify these entities at different response levels by altering their expression or activities in the signaling cascade. These activities then lead to efficient cold stress tolerance. This paper contains a concise summary of the ICE-CBF-COR pathway elucidating on the cross interconnections with other repressors, inhibitors, and activators to induce cold stress acclimation in plants.

A highly efficient hybrid peptide ameliorates intestinal inflammation and mucosal barrier damage by neutralizing lipopolysaccharides and antagonizing the lipopolysaccharide-receptor interaction.

Intestinal inflammatory disorders, such as inflammatory bowel disease, are major contributors to mortality and morbidity in humans and animals worldwide. While some native peptides have great potential as therapeutic agents against intestinal inflammation, potential cytotoxicity, anti-inciting action, and suppression of anti-inflammatory activity may limit their development as anti-inflammatory agents. Peptide hybridization is an effective approach for the design and engineering of novel functional peptides because hybrid peptides combine the advantages and benefits of various native peptides. In the present study, a novel hybrid anti-inflammatory peptide that combines the active center of Cecropin A (C) and the core functional region of LL-37 (L) was designed [C-L peptide; C (1-8)-L (17-30)] through in silico analysis to reduce cytotoxicity and improve the anti-inflammatory activity of the parental peptides. The resulting C-L peptide exhibited lower cytotoxicity than either C or L peptides alone. C-L also exerted a protective effect against lipopolysaccharide (LPS)-induced inflammatory responses in RAW264.7 macrophages and in the intestines of a mouse model. The hybrid peptide exhibited increased anti-inflammatory activity compared to the parental peptides. C-L plays a role in protecting intestinal tissue from damage, LPS-induced weight loss, and leukocyte infiltration. In addition, C-L reduces the expression levels of tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), IL-1ß, and interferon-gamma (IFN-γ), as well as reduces cell apoptosis. It also reduced mucosal barrier damage caused by LPS. The anti-inflammatory effects of the hybrid peptide were mainly attributed to its LPS-neutralizing activity and antagonizing the activation of LPS-induced Toll-like receptor 4-myeloid differentiation factor 2 (TLR4/MD2). The peptide also affected the TLR4-(nuclear factor κB) signaling pathway, modulating the inflammatory response upon LPS stimulation. Collectively, these findings suggest that the newly designed peptide, C-L, could be developed into a novel anti-inflammatory agent for animals or humans.

Fundamentals of artificial intelligence for ophthalmologists.

PURPOSE OF REVIEW: As artificial intelligence continues to develop new applications in ophthalmic image recognition, we provide here an introduction for ophthalmologists and a primer on the mechanisms of deep learning systems. RECENT FINDINGS: Deep learning has lent itself to the automated interpretation of various retinal imaging modalities, including fundus photography and optical coherence tomography. Convolutional neural networks (CNN) represent the primary class of deep neural networks applied to these image analyses. These have been configured to aid in the detection of diabetes retinopathy, AMD, retinal detachment, glaucoma, and ROP, among other ocular disorders. Predictive models for retinal disease prognosis and treatment are also being validated. SUMMARY: Deep learning systems have begun to demonstrate a reliable level of diagnostic accuracy equal or better to human graders for narrow image recognition tasks. However, challenges regarding the use of deep learning systems in ophthalmology remain. These include trust of unsupervised learning systems and the limited ability to recognize broad ranges of disorders.

Survival Benefit of Maintained or Increased Body Mass Index in Patients Undergoing Extended-Hours Hemodialysis Without Dietary Restrictions.

OBJECTIVE: Low body mass index (BMI) is a potential risk factor for mortality in patients on maintenance hemodialysis. This suggests the usefulness of BMI as a prognostic factor and implies the importance of nutritional status, inflammation, and oxidative stress, all of which affect BMI. We aimed to evaluate BMI changes over time and the mortality risk in patients undergoing a novel combination therapy consisting of an extended-hours hemodialysis protocol without dietary restrictions, which enabled sufficient nutrition. DESIGN AND METHODS: This is a retrospective cohort study. Patients were divided into 2 groups based on BMI change (ΔBMI < 0, ΔBMI ≥ 0) between the 3rd and 12th month after transfer to the clinic. We studied the associations of BMI changes with all-cause mortality. Further subgroup analyses were performed using Cox models. We finally studied 187 patients who were receiving the combined therapy. The main outcome measure was all-cause mortality of the study group. RESULTS: The median (interquartile range) follow-up time was 4.9 (3.0-8.6) years. Overall, 138 patients were in the ΔBMI ≥ 0 group. As per unadjusted and adjusted Cox models, maintained or increased BMI during this period was associated with hazard ratios of 0.45 (confidence interval 0.23-0.87, P < .05) and 0.35 (confidence interval 0.17-0.75, P < .01) for all-cause mortality, respectively. In the same group, maintained or increased BMI was found to be significantly associated with decreased mortality in female, older, and nondiabetic patients. The data indicated that diabetic status could have a modifying effect on the association between variation in BMI and mortality (P = .006). CONCLUSIONS: Extended-hours hemodialysis without dietary restrictions led to a beneficial effect of maintenance or increase in BMI, especially in females, patients aged ≥65 years, and those without diabetic nephropathy, which could lead to prolonged survival.

Hepatitis-C Infection: Are we really committed to eliminate? Could it become the second Polio for Pakistan?

Pakistan's hepatitis C virus (HCV) burden is one of the highest in the world. Around eight million people live with HCV in Pakistan according to a National Hepatitis Survey. Most HCV-infected people are unaware of their infection status culminating in delayed diagnosis and treatment, progressing to end stage liver disease, cirrhosis, and hepatocellular carcinoma (HCC), thereby raising the disease load for a developing country with limited resources. Blood transfusions and injections with reused syringes lead to increased HCV rates in Pakistan. According to a survey viral infections like hepatitis C, hepatitis B and HIV were not screened in more than half of the blood transfusions done in Pakistan. Hepatitis C elimination requires financial support from the local government and private organizations, commitment from civil societies across the world and a dedicated political will. Without defining effective planning and strategy it is our fear that it could become the second Polio for Pakistan.

A Novel Peptide Ameliorates LPS-Induced Intestinal Inflammation and Mucosal Barrier Damage via Its Antioxidant and Antiendotoxin Effects.

Intestinal inflammation is an inflammatory disease resulting from immune dysregulation in the gut. It can increase the risk of enteric cancer, which is a common malignancy globally. As a new class of anti-inflammatory agents, native peptides have potential for use in the treatment of several intestinal inflammation conditions; however, their potential cytotoxicity and poor anti-inflammatory activity and stability have prevented their development. Hybridization has been proposed to overcome this problem. Thus, in this study, we designed a hybrid peptide (LL-37-TP5, LTP) by combing the active centre of LL-37 (13-36) with TP5. The half-life and cytotoxicity were tested in vitro, and the hybrid peptide showed a longer half-life and lower cytotoxicity than its parental peptides. We also detected the anti-inflammatory effects and mechanisms of LTP on Lipopolysaccharide (LPS)-induced intestinal inflammation in murine model. The results showed that LTP effectively prevented LPS-induced weight loss, impairment of intestinal tissues, leukocyte infiltration, and histological evidence of inflammation. Additionally, LTP decreased the levels of tumour necrosis factor-alpha, interferon-gamma, and interleukin-6; increased the expression of zonula occludens-1 and occludin; and reduced permeability in the jejunum of LPS-treated mice. Notably, LTP appeared to be more potent than the parental peptides LL-37 and TP5. The anti-inflammatory effects of LTP may be associated with the neutralization of LPS, inhibition of oxidative stress, and inhibition of the NF-κB signalling pathway. The findings of this study suggest that LTP might be an effective therapeutic agent for treating intestinal inflammation.

Development of a Highly Efficient Hybrid Peptide That Increases Immunomodulatory Activity Via the TLR4-Mediated Nuclear Factor-κB Signaling Pathway.

Immunity is a defensive response that fights disease by identifying and destroying harmful substances or microbiological toxins. Several factors, including work-related stress, pollution, and immunosuppressive agents, contribute to low immunity and poor health. Native peptides, a new class of immunoregulatory agents, have the potential for treating immunodeficiencies, malignancies, and infections. However, the potential cytotoxicity and low immunoregulatory activity and stability of native peptides have prevented their development. Therefore, we designed three hybrid peptides (LTAa, LTAb, and LTAc) by combining a characteristic fragment of LL-37 with an active Tα1 center that included Tα1 (17-24), Tα1 (20-25), and Tα1 (20-27). The best hybrid peptide (LTAa), according to molecule docking and in vitro experiments, had improved immunoregulatory activity and stability with minimal cytotoxicity. We investigated the immunoregulatory effects and mechanisms of LTAa using a cyclophosphamide-immunosuppressed murine model. LTAa effectively reversed immunosuppression by enhancing immune organ development, activating peritoneal macrophage phagocytosis, regulating T lymphocyte subsets, and increasing cytokine (tumor necrosis factor-alpha, interleukin-6, and interleukin-1ß) and immunoglobulin (IgA, IgG, and IgM) contents. The immunomodulatory effects of LTAa may be associated with binding to the TLR4/MD-2 complex and activation of the NF-κB signaling pathway. Therefore, LTAa could be an effective therapeutic agent for improving immune function.

Clinical impact of endocapillary proliferation according to the Oxford classification among adults with Henoch-Schönlein purpura nephritis: a multicenter retrospective cohort study.

BACKGROUND: Henoch-Schönlein purpura nephritis (HSPN) is a form of small vessel vasculitis associated with purpura and IgA deposition in the glomeruli. The International Study of Kidney Disease in Children (ISKDC) classification predicts renal prognosis in children with HSPN, but not in adults. Additionally, it is not well known whether the Oxford classification 2016 and/or the Japanese Histologic classification (JHC) are associated with renal outcome. Herein, we investigated the relationship between pathological characteristics and renal outcome among adult patients with HSPN. METHODS: A multicenter retrospective cohort study was conducted in adult patients with HSPN who underwent renal biopsy between 2004 and 2014. Two nephrologists classified each patient according to the Oxford classification 2016, JHC, and the ISKDC classification. Renal outcome was defined by a 30% decline in the eGFR and/or end-stage kidney disease. RESULTS: We enrolled 74 adult patients with HSPN (mean age, 47.8 ± 17.4 years; mean eGFR, 76.4 ± 25.8 ml/min/1.73 m2; median proteinuria, 1.40 [IQR: 0.70-2.38] g/day). During a mean follow-up period of 68.0 ± 33.0 months, fourteen patients (18.9%) reached the renal outcome, and all 14 had received immunosuppressive therapy. The log-rank test revealed that event-free renal survival was significantly shorter in patients with endocapillary proliferation (E1) according to the Oxford classification than in those with E0 (p = 0.0072). However, the JHC, ISKDC classification and other Oxford lesions could not demonstrate a significant difference in event-free renal survival. In a multivariate Cox model adjusted for clinical and pathological factors, age (HR, 1.57; 95% CI, 1.12-2.21) and E lesion (HR, 6.71; 95% CI, 1.06-42.7) were independent risk factors for renal outcome. CONCLUSIONS: Endocapillary proliferation is significantly associated with renal outcome in adult patients with HSPN, including those receiving immunosuppressive therapy. Other Oxford classification lesions, JHC, and ISKDC classification were not associated with renal outcome.

Expression, Purification, and Characterization of a Novel Hybrid Peptide with Potent Antibacterial Activity.

The hybrid peptide cecropin A (1⁻8)⁻LL37 (17⁻30) (C⁻L), derived from the sequence of cecropin A (C) and LL-37 (L), showed significantly increased antibacterial activity and minimized hemolytic activity than C and L alone. To obtain high-level production of C⁻L, the deoxyribonucleic acid sequence encoding C⁻L with preferred codons was cloned into pET-SUMO to construct a fusion expression vector, and overexpressed in Escherichia coli (E. coli) BL21 (DE3). The maximum fusion protein (92% purity) was obtained with the yield of 89.14 mg/L fermentation culture after purification with Ni-NTA Sepharose column. The hybrid C⁻L was cleaved from the fusion protein by SUMO-protease, and 17.54 mg/L pure active C⁻L was obtained. Furthermore, the purified C⁻L showed identical antibacterial and hemolytic activity to synthesized C⁻L. Stability analysis results exhibited that the activity of C⁻L changed little below 80 °C for 20 min, but when the temperature exceeded 80 °C, a significant decrease was observed. Varying the pH from 5.0 to 10.0 did not appear to influence the activity of C⁻L, however, pH below 4.0 decreased the antibacterial activity of C⁻L rapidly. Under the challenge of several proteases (pepsin, trypsin, and proteinase K), the functional activity of C⁻L was maintained over 50%. In summary, this study not only supplied an effective approach for high-level production of hybrid peptide C⁻L, but paved the way for its further exploration in controlling infectious diseases of farm animals or even humans.

Severe haemolysis and renal failure precipitated by hepatitis E virus in G6PD Deficient patient: A case report.

Hepatitis E virus is the etiological agent for Hepatitis E infection, which is congruent to Hepatitis A infection. The clinical spectrum of the disease range from asymptomatic self-limiting disease which requires no treatment to life threatening fulminant liver disease in pregnancy, G6PD deficient and post-liver transplant patients, which necessitate urgent treatment. Similarly we are reporting a case of a 28 year old male with no previous known comorbids, who presented in emergency department with low grade fever, yellow discolouration of eyes and upper abdominal pain for last 5-6 days. We affirmed the diagnosis of acute viral hepatitis E with G6PD deficiency. This case had a different prospect of HEV infection and its coexistence with G6PD deficiency, which lead to investigations, management and avoidance of complications of the disease.

Manifestation of hydatid cyst of liver with pancreatitis, cholangitis and jaundice: A case report.

Hydatid disease or echinococcosis, a systemic zoonosis is caused by Echinococcusgranulosus larvae. This is a common disease found all over the world, especially in the Mediterranean region. We report a 40 year old male with no known comorbids who came with complaints of fever with rigors and chills, right hypochondriac pain, and yellow discolouration of the sclera. A CT scan abdomen with endoscopic retrograde cholangiopancreatography (ERCP) gave a diagnosis of hydatid cyst of the liver with pancreatitis, cholangitis and jaundice due to involvement of the biliary tree and common bile duct ERCP was done and a stent was placed after which the patient was referred to general surgery department where the resection of cyst was performed under general anaesthesia. Pancreatitis was managed conservatively. We could not find any case reported in the literature, which showed manifestation of hydatid cyst of liver with pancreatitis, cholangitis and jaundice simultaneously, which made us report this case.

Aortoenteric fistula - A fatal cause of gastrointestinal bleeding. Can it be missed? - A case report.

Gastrointestinal (GI) bleeding, is the life threating presentation of many diseases in emergency room. Aortoenteric fistula (AEF) is one of the rare causes of GI bleeding that can be fatal if not diagnosed and treated promptly. We present a case of a86 years old hypertensive male with the history of fresh bleeding per rectum, dizziness, fatigability and palpitation for last 12 hours who came to the emergency room in January 2015 He was stabilized and resuscitated. On lab investigation and abdominal CT scan he was diagnosed as aortic aneurysm with AEF. The related pathology, diagnosis and management of the disorder has been discussed in this case report.

Safety of endoscopic N-Butyl-2 Cyanoacrylate injection for the treatment of bleeding gastric varices in children.

OBJECTIVE: To determine the safety and efficacy of N-butyl 2-cyanoacrylate in bleeding gastric varices in children. METHODS: This retrospective observational study was conducted in the Department of Gastroenterology and Pediatric Surgery in Liaquat National Hospital Karachi between January 2010 and January 2017. Gastric fundal varices were obliterated in pediatric population with single shot of N-butyl-2 Cyanoacrylate 0.50ml diluted with 0.50ml of Lipoidal with use of forward-viewing video endoscope with 22-gauge needle. The primary outcome was primary hemostasis, Secondary outcome was complications, re-bleeding and mortality. RESULTS: Thirty patients was included in the study, 18(60%) were male with mean age of 7.12± 2.9 years. Non cirrhotic portal hypertension was the most common etiology in 15 (50%) patients, followed by liver cirrhosis secondary to hepatitis B and D co-infection in 6(20%) patients. Primary hemostasis was achieved in 29 (96.7%), while 3(10%) patients developed re-bleeding after 48 hours, and hemostasis was achieved after second session of endoscopic obliteration. Abdominal pain and fever developed in 3(10%) patients which was managed conservatively. Mortality was observed in 1(3%) of cases due to sepsis after shunt surgery. CONCLUSION: Endoscopic fundal varix obliteration with N Butyl-2 cyanoacrylate was safe and effective in treatment of gastric variceal hemorrhage in children.

Retinal Hypercholesterolemia Triggers Cholesterol Accumulation and Esterification in Photoreceptor Cells.

The process of vision is impossible without the photoreceptor cells, which have a unique structure and specific maintenance of cholesterol. Herein we report on the previously unrecognized cholesterol-related pathway in the retina discovered during follow-up characterizations of Cyp27a1(-/-)Cyp46a1(-/-) mice. These animals have retinal hypercholesterolemia and convert excess retinal cholesterol into cholesterol esters, normally present in the retina in very small amounts. We established that in the Cyp27a1(-/-)Cyp46a1(-/-) retina, cholesterol esters are generated by and accumulate in the photoreceptor outer segments (OS), which is the retinal layer with the lowest cholesterol content. Mouse OS were also found to express the cholesterol-esterifying enzyme acyl-coenzyme A:cholesterol acyltransferase (ACAT1), but not lecithin-cholesterol acyltransferase (LCAT), and to differ from humans in retinal expression of ACAT1. Nevertheless, cholesterol esters were discovered to be abundant in human OS. We suggest a mechanism for cholesterol ester accumulation in the OS and that activity impairment of ACAT1 in humans may underlie the development of subretinal drusenoid deposits, a hallmark of age-related macular degeneration, which is a common blinding disease. We generated Cyp27a1(-/-)Cyp46a1(-/-)Acat1(-/-) mice, characterized their retina by different imaging modalities, and confirmed that unesterified cholesterol does accumulate in their OS and that there is photoreceptor apoptosis and OS degeneration in this line. Our results provide insights into the retinal response to local hypercholesterolemia and the retinal significance of cholesterol esterification, which could be cell-specific and both beneficial and detrimental for retinal structure and function.

The Japanese Histologic Classification and T-score in the Oxford Classification system could predict renal outcome in Japanese IgA nephropathy patients.

BACKGROUND: The Oxford Classification is utilized globally, but has not been fully validated. In this study, we conducted a comparative analysis between the Oxford Classification and Japanese Histologic Classification (JHC) to predict renal outcome in Japanese patients with IgA nephropathy (IgAN). METHODS: A retrospective cohort study including 86 adult IgAN patients was conducted. The Oxford Classification and the JHC were evaluated by 7 independent specialists. The JHC, MEST score in the Oxford Classification, and crescents were analyzed in association with renal outcome, defined as a 50% increase in serum creatinine. RESULTS: In multivariate analysis without the JHC, only the T score was significantly associated with renal outcome. While, a significant association was revealed only in the JHC on multivariate analysis with JHC. CONCLUSIONS: The JHC and T score in the Oxford Classification were associated with renal outcome among Japanese patients with IgAN. Superiority of the JHC as a predictive index should be validated with larger study population and cohort studies in different ethnicities.

Laser therapy versus observation for symptomatic retinal artery macroaneurysms.

PURPOSE: The optimal management approach to retinal arterial macroaneurysms (RAM) is unknown. This paper compares long-term outcomes in RAM treated with laser therapy versus observation. METHODS: This is an IRB-approved retrospective study of patients with symptomatic RAM. Charts of patients with a diagnosis of RAM causing symptomatic visual loss were reviewed. Patients with less than 6 months follow up, other confounding diagnoses, or additional therapy beyond thermal laser were excluded. Statistical analysis was done using χ(2) or Student's t test as appropriate. RESULTS: Forty-eight patients with RAM were identified and 27 were included in the study (13 treated, 14 observed). Mean visual acuity in the observation group improved from 20/120 to 20/96 (p = 0.53) compared to 20/280 to 20/54 (p = 0.0003) in the treated group. Subgroup analysis showed that visual acuity in primarily hemorrhagic lesions treated with laser therapy improved by 1.21 logMAR compared to a loss of 0.11 logMAR (p = 0.002) in those that were observed. In primarily exudative lesions, both treated and observed lesions showed an improvement of 0.32 logMAR. No patients in the treatment group had a final visual acuity below 20/200 compared to four in the observation group. CONCLUSION: Treatment with direct laser photocoagulation was associated in this study with greater improvement in visual acuity and may decrease the risk of severe visual loss especially in primarily hemorrhagic RAM lesions. Compared to observation alone.

Peripapillary serous detachment in multiple evanescent white dot syndrome.

BACKGROUND: To report the presence of transient peripapillary serous detachments in multiple evanescent white dot syndrome. METHODS: Retrospective case series. RESULTS: Four eyes of four patients diagnosed with multiple evanescent white dot syndrome presented with peripapillary serous detachments. Diagnosis was based on clinical presentation, fundus findings, and angiographic findings. All 4 were female with age ranges between 24 and 40 years and presented with photopsias, an enlarged scotoma contiguous with the blind spot, and chorioretinal white dots in the posterior pole with characteristic angiographic features. All of the serous detachments resolved or were greatly reduced concomitantly with the resolution of the patient's other clinical symptoms and fundus findings. CONCLUSION: The authors report peripapillary serous detachments as a previously unreported manifestation of multiple evanescent white dot syndrome. These seem to be self limited with concurrent resolution with the rest of the patient's symptoms.

Paraproteinemic maculopathy.

PURPOSE: Paraproteinemia relates to monoclonal gammopathy-producing pathologic antibodies with serous macular detachment being an uncommon ocular manifestation. We ascertained the clinical course of maculopathy in paraproteinemia and investigated the effect of various therapeutic methods on the resolution of subretinal deposits. DESIGN: Multicenter, retrospective, observational case series. PARTICIPANTS: The records of patients with paraproteinemia with optical coherence tomography (OCT) documentation of serous macular detachment were reviewed. METHODS: Data collection included coexisting morbidity, rheology data (immunoglobulin level, hematocrit, and blood viscosity), clinical examination results, and OCT findings. MAIN OUTCOME MEASURES: Best-corrected visual acuity (BCVA), height and basal area of the serous macular detachment, and systemic versus local therapies. RESULTS: A total of 33 cases were collected: 10 new and 23 previously reported in the literature. Diabetes was present in 7 patients, systemic hypertension in 9 patients, and anemia in 18. Mean initial immunoglobulin level was 6497 mg/dl, and mean serum viscosity was 5.5 centipoise (cP). Mean logarithm of the minimum angle of resolution initial vs. final BCVA was 0.55 (Snellen equivalent, 20/71) vs. 0.45 (20/56) in the right eye and 0.38 (20/48) vs. 0.50 (20/63) in the left eye. After mean follow-up of 7 months (range, 0-51 months). Systemic therapies included plasmapheresis (18), chemotherapy (30), blood transfusions (2), transplantation of progenitor hematopoietic cells (2), and oral rituximab (10). Immunoglobulin levels normalized in 8 patients and were unchanged in 1 after plasmapheresis, chemotherapy, or both. Ocular therapy in 8 patients included vitrectomy (1), laser photocoagulation (4), intravitreal bevacizumab (5), intravitreal triamcinolone (2), intravitreal dexamethasone implant (1), intravitreal rituximab (1), and sub-Tenon corticosteroid (1). The maculopathy resolved partially or completely in 17 patients and worsened or remained unchanged in 14 patients over median follow-up of 7 months. Maculopathy was unilateral in 9 cases and occurred at a lower initial immunoglobulin level in diabetics. There was a positive correlation between area of the detachment and serum viscosity. CONCLUSIONS: Paraproteinemic maculopathy can be unilateral. Decreasing the blood immunoglobulin level is the primary goal of therapy for paraproteinemic maculopathy, and this can be achieved by a systemic route. Coexisting diabetes facilitates leakage of immunoglobulins at lower levels than in nondiabetics.