Asymmetry indicates more severe and active disease in Graves' orbitopathy: results from a prospective cross-sectional multicentre study.

PURPOSE: Patients with Graves' orbitopathy can present with asymmetric disease. The aim of this study was to identify clinical characteristics that distinguish asymmetric from unilateral and symmetric Graves' orbitopathy. METHODS: This was a multi-centre study of new referrals to 13 European Group on Graves' Orbitopathy (EUGOGO) tertiary centres. New patients presenting over a 4 month period with a diagnosis of Graves' orbitopathy were included. Patient demographics were collected and a clinical examination was performed based on a previously published protocol. Patients were categorized as having asymmetric, symmetric, and unilateral Graves' orbitopathy. The distribution of clinical characteristics among the three groups was documented. RESULTS: The asymmetric group (n = 83), was older than the symmetric (n = 157) group [mean age 50.9 years (SD 13.9) vs 45.8 (SD 13.5), p = 0.019], had a lower female to male ratio than the symmetric and unilateral (n = 29) groups (1.6 vs 5.0 vs 8.7, p < 0.001), had more active disease than the symmetric and unilateral groups [mean linical Activity Score 3.0 (SD 1.6) vs 1.7 (SD 1.7), p < 0.001 vs 1.3 (SD 1.4), p < 0.001] and significantly more severe disease than the symmetric and unilateral groups, as measured by the Total Eye Score [mean 8.8 (SD 6.6) vs 5.3 (SD 4.4), p < 0.001, vs 2.7 (SD 2.1), p < 0.001]. CONCLUSION: Older age, lower female to male ratio, more severe, and more active disease cluster around asymmetric Graves' orbitopathy. Asymmetry appears to be a marker of more severe and more active disease than other presentations. This simple clinical parameter present at first presentation to tertiary centres may be valuable to clinicians who manage such patients.

Does early response to intravenous glucocorticoids predict the final outcome in patients with moderate-to-severe and active Graves' orbitopathy?

PURPOSE: Intravenous glucocorticoids (ivGCs) given as 12-weekly infusions are the first-line treatment for moderate-to-severe and active Graves' orbitopathy (GO), but they are not always effective. In this study, we evaluated whether response at 6 weeks correlated with outcomes at 12 (end of intervention) and 24 (follow-up) weeks, particularly in patients initially unresponsive. METHODS: Our database (Bartalena et al. J Clin Endocrinol Metab 97:4454-4463, 10), comprising 159 patients given three different cumulative doses of methylprednisolone (2.25, 4.98, 7.47 g) was analyzed, pooling data for analyses. Responses at 6 weeks were compared with those at 12 and 24 weeks using three outcomes: overall ophthalmic involvement [composite index (CI)]; quality of life (QoL); Clinical Activity Score (CAS). Responses were classified as "Improved", "Unchanged", "Deteriorated", compared to baseline. RESULTS: Deteriorated patients at 6 weeks for CI (n = 8) remained in the same category at 12 weeks and 7/8 at 24 weeks. Improved patients at 6 weeks for CI (n = 51) remained in the same category in 63% and 53% of cases at 12 and 24 weeks, respectively. Unchanged patients at 6 weeks (n = 100) eventually improved in 28% of cases (CI), 58% (CAS), 32% (QoL). There was no glucocorticoid dose-dependent difference in the influence of early response on later outcomes. CONCLUSIONS: Patients who deteriorate at 6 weeks after ivGCs are unlikely to benefit from continuing ivGCs. Patients unresponsive at 6 weeks still have a significant possibility of improvement later. Accordingly, they may continue ivGC treatment, or, alternatively, possibly stop ivGCs and be switched to a second-line treatment.

Pituitary apoplexy during pregnancy: a rare, but dangerous headache.

Pituitary apoplexy is a rare endocrine emergency that occurs in a small number of patients with a pituitary tumor. It is a clinical syndrome characterized by the sudden onset of headache, nausea, vomiting, visual impairment, and decreased consciousness, caused by hemorrhage and/or infarction of the pituitary gland. Pituitary apoplexy has very rarely been described during pregnancy, when it is potentially life-threatening to both the mother and the fetus, if unrecognized. Only a few cases have been published to date. The review of the existing literature underlines that pituitary apoplexy, although rare, should be borne in mind when a pregnant woman presents with severe headache and visual defects of sudden onset. After initial management, which includes intravenous glucocorticoid therapy, fluid and electrolyte replacement, the final selection of medical or surgical treatment should result from a multidisciplinary approach involving expert specialists, keeping into account both severity of clinical presentation and gestational week.

Prevalence and natural history of Graves' orbitopathy in a large series of patients with newly diagnosed graves' hyperthyroidism seen at a single center.

BACKGROUND: The prevalence and natural history of Graves' orbitopathy (GO) are poorly documented. METHODS: A large series of 346 patients with newly diagnosed and recent onset Graves' hyperthyroidism seen at a single (nontertiary referral) center over an 8-year period were enrolled in an observational prospective study and evaluated for GO activity and severity according to the EUGOGO (European Group on Graves' Orbitopathy) criteria. After excluding patients immediately treated for moderate-to-severe GO, patients undergoing total thyroidectomy or radioactive iodine treatment, and patients lost to follow-up, 237 patients were submitted to antithyroid drug (ATD) treatment, with ocular evaluation at 6, 12, and 18 months. RESULTS: Among the whole cohort, at presentation 255 (73.7%) had no ocular involvement, 70 (20.2%) had mild and inactive GO, 20 (5.8%) had moderate-to-severe and active GO, and 1 (0.3%) had sight-threatening GO with dysthyroid optic neuropathy. Of the 237 patients who completed the 18-month follow-up during or after ATD treatment, 194 (81.9%) had no GO at baseline. Progression to moderate-to-severe GO occurred in 5 (2.6%) of these patients. Of the 43 (18.1%) patients with mild and inactive GO at baseline, 1 (2.4%) progressed to moderate-to-severe GO, and 25 (58.1%) experienced complete remission. CONCLUSIONS: Most patients with newly diagnosed Graves' disease have no ocular involvement. Moderate-to-severe and active GO or sight-threatening GO are rare at presentation and rarely develop during ATD treatment. Most patients (>80%) with no GO at baseline do not develop GO after an 18-month follow-up period. Remission of mild GO occurs in the majority of cases.

Efficacy and safety of three different cumulative doses of intravenous methylprednisolone for moderate to severe and active Graves' orbitopathy.

BACKGROUND: Optimal doses of i.v. glucocorticoids for Graves' orbitopathy (GO) are undefined. METHODS: We carried out a multicenter, randomized, double-blind trial to determine efficacy and safety of three doses of i.v. methylprednisolone in 159 patients with moderate to severe and active GO. Patients were randomized to receive a cumulative dose of 2.25, 4.98, or 7.47 g in 12 weekly infusions. Efficacy was evaluated objectively at 12 wk by blinded ophthalmologists and subjectively by blinded patients (using a GO specific quality of life questionnaire). Adverse events were recorded at each visit. RESULTS: Overall ophthalmic improvement was more common using 7.47 g (52%) than 4.98 g (35%; P = 0.03) or 2.25 g (28%; P = 0.01). Compared with lower doses, the high-dose regimen led to the most improvement in objective measurement of ocular motility and in the Clinical Activity Score. The Clinical Activity Score decreased in all groups and to the least extent with 2.25 g. Quality of life improved most in the 7.47-g group, although not reaching statistical significance. No significant differences occurred in exophthalmos, palpebral aperture, soft tissue changes, and subjective diplopia score. Dysthyroid optic neuropathy developed in several patients in all groups. Because of this, differences among the three groups were no longer apparent at the exploratory 24-wk visit. Major adverse events were slightly more frequent using the highest dose but occurred also using the lowest dose. Among patients whose GO improved at 12 wk, 33% in the 7.47-group, 21% in the 4.98-group, and 40% in the 2.25-group had relapsing orbitopathy after glucocorticoid withdrawal at the exploratory 24-wk visit. CONCLUSIONS: The 7.47-g dose provides short-term advantages over lower doses. However, this benefit is transient and associated with slightly greater toxicity. The use of a cumulative dose of 7.47 g of methylprednisolone provides short-term advantage over lower doses. This may suggest that an intermediate-dose regimen be used in most cases and the high-dose regimen be reserved to most severe cases of GO.

Herpes simplex virus type 2 acute retinal necrosis in an immunocompetent patient.

PURPOSE: To report a case of acute retinal necrosis caused by herpes simplex virus 2 in an otherwise healthy patient. CASE REPORT: A 45-year-old man presented with one month's history of decreased vision in the right eye. He had previously received a course of intravenous gancyclovir because of a clinical suspicion of cytomegalovirus retinitis. The patient's ocular history was remarkable for a similar episode in the left eye thirty years earlier, resulting in important visual impairment. System and laboratory investigations were unremarkable. Ocular examination showed severe anterior granulomatous uveitis, vitreous haze, areas of necrosis and retinal exudates. The anterior chamber tap disclosed the presence of HSV type 2, and oral steroids and acyclovir were instituted. Two weeks after the patient had been discharged, a retinal detachment occurred in the right eye, necessitating surgical repair. The presence of HSV type 2 was confirmed in the vitreous. Visual acuity recovered completely after surgery and the patient was placed on a maintenance dose of oral acyclovir. CONCLUSIONS: HSV type 2 is a rare cause of acute retinal necrosis in healthy patients. Bilateral involvement can occur in the fellow eye, even with a long delay. Acute retinal necrosis is a severe ocular inflammatory syndrome associated with a very poor visual outcome. It is caused by VZV, HSV type 1 and, less commonly, by HSV type 2. The disease can affect healthy patients and cause bilateral involvement in the fellow eye, even with a long delay.

Correlation between optical coherence tomography data and biomicroscopic interpretation of idiopathic macular hole.

PURPOSE: This study was designed to assess the new clinical information given by optical coherence tomography in patients with idiopathic macular hole. METHODS: Sixty-one consecutive eyes of 47 patients with idiopathic macular hole at different stages of development were studied clinically. Patients with myopia, epiretinal macular membrane, and any other ocular disease were excluded. Best-refracted visual acuity and biomicroscopic fundus examination with macular contact lens were performed. Optical coherence tomography was performed through a dilated pupil. The optical coherence tomography findings were correlated with the Gass biomicroscopic classification of idiopathic macular hole. RESULTS: Optical coherence tomography provided different or additional information in 22 of 24 eyes (91.7%) biomicroscopically classified in stages 1-A and stage 1-B, according to the Gass macular hole classification, and in seven of 37 eyes (18.9%) biomicroscopically classified in stages 2, 3, and 4. The main difference from Gass biomicroscopic classification was a macular pseudocyst instead of a foveolar detachment in the first stages. The main additional optical coherence tomography observation, not detected biomicroscopically, was the presence of retinal tissue on the bottom of the macular hole. Optical coherence tomography may be particularly useful in evaluation of early stages in development of idiopathic macular hole. CONCLUSIONS: Compared with classic biomicroscopical observation, optical coherence tomography frequently gives different or additional information on idiopathic macular hole, especially in its early stages. Correct diagnosis and surgical indication of idiopathic macular hole may benefit from optical coherence tomography imaging.

Florid diabetic retinopathy (FDR): a long-term follow-up study.

PURPOSE: To evaluate efficacy of laser photocoagulation and pars-plana vitrectomy in patients with FDR. METHODS: Eighty-eight patients (155 eyes) with FDR were retrospectively evaluated (mean age 27 +/- 6.0 years; proportion of females 66%; insulin-dependent diabetes 100%; mean duration of diabetes 16.5 +/- 5.8 years; poor metabolic control 83%). The eyes were divided in two groups: group I: 136 eyes amenable to laser photocoagulation and, when necessary, to vitrectomy afterwards (45/136); group II: 19 eyes subjected directly to vitrectomy. RESULTS: In group I (mean follow-up 54.2 +/- 38.7 months) the initial visual acuity (IVA) was 0.61 +/- 0.30 and the final visual acuity (FVA) was 0.47 +/- 0.34; in the 45 vitrectomized eyes IVA was 0.15 +/- 0.24 and FVA was 0.19 +/- 0.25. FDR regressed in 75% and worsened in 25% of the cases. In group II (mean follow-up 46.4 +/- 36.3 months) IVA was 0.1 +/- 0.14 and FVA 0.14 +/- 0.22. FDR regressed in 32% and worsened in 68% of cases. CONCLUSIONS: FDR remains a cause of severe visual impairment in diabetics. Patients at risk of FDR are young females with long-standing, poorly controlled insulin-dependent diabetes. Panretinal laser photocoagulation prior to vitrectomy is beneficial; information on this severe form of retinopathy is essential to ensure prompt diagnosis and improve its unfavorable clinical course.

Optical coherence tomography in idiopathic epiretinal macular membrane surgery.

PURPOSE: To evaluate the usefulness of Optical Coherence Tomography (OCT) images for surgical indication, intraoperative management and postoperative outcome of patients with idiopathic epiretinal macular membrane (IEMM). METHODS: 28 selected eyes underwent surgery for removal of IEMM. The patients' mean age was 57.3 years. The macular region and the IEMMs were studied before and after surgery using OCT, slit-lamp biomicroscopy and fundus photography. The mean postoperative follow-up was 6.2 months (range 1.3-14). RESULTS: Preoperatively, in 12 of the 28 eyes (42.9%) only the OCT images revealed IEMM partially separated from the macula, with tractional focal point(s) of attachment to the macular region. In the other 16 eyes (57.1%) in which IEMMs were totally adherent to the macular region, the membranes were barely visible by OCT in 13 eyes and not visible in three. Intraoperatively, the surgeon was guided in the peeling procedures. A significant correlation (p < 0.001) was found between visual acuity and macular thickness before surgery and at the end of the postoperative follow-up. CONCLUSIONS: OCT images provide very useful information for the surgical indication, intraoperative management and postoperative outcome of patients with IEMM.

Ultrasound biomicroscopic evaluation of ciliochoroidal effusion after laser treatment.

We evaluated ciliochoroidal effusion (CE) by ultrasound biomicroscopy (UBM) following diode endophotocoagulation at the end of the vitreoretinal surgery. The aim of our study was to assess any differences in the CE morphology following diode endophotocoagulation or transpupillary krypton photocoagulation, and to demonstrate the influence of diabetes and intravitreal surgery on CE formation. Sixty-six consecutive patients were divided in to four groups. Twenty-nine patients with proliferative retinopathy underwent transpupillary krypton photocoagulation; 11 diabetic patients underwent vitreoretinal surgery and diode endophotocoagulation; 18 nondiabetics underwent vitreoretinal surgery and diode endophotocoagulation; 8 consecutive nondiabetic patients were the control group and underwent vitreoretinal surgery, without laser treatment. UBM was performed in the four groups before and after laser treatment, if performed. We determined, by UBM, not only the presence, but also the thickness of CE. CE was present in all the patients treated by laser, diabetics and nondiabetics, and its thickness was not correlated with the number of laser spots (p = 0.28). CE was seen ultrasonically in all the patients undergoing transpupillary photocoagulation or endophotocoagulation, regardless of diabetes and surgical trauma.

Peribulbar anesthesia with either 0.75% ropivacaine or a 2% lidocaine and 0.5% bupivacaine mixture for vitreoretinal surgery: a double-blinded study.

UNLABELLED: No study has evaluated the efficacy of ropivacaine in peribulbar block for ophthalmic surgery. The purpose of this prospective, randomized, double-blinded study was to compare ropivacaine and a lidocaine-bupivacaine mixture in peribulbar anesthesia. Sixty ASA physical status I or II patients scheduled for elective vitreoretinal surgery were randomized to receive a peribulbar block with 8 mL of either 0.75% ropivacaine (ropivacaine group, n = 30) or a 1:1 mixture of 2% plain lidocaine and 0.5% plain bupivacaine (lido-bupivacaine group, n = 30). Time required for onset of surgical anesthesia, quality of postoperative analgesia, incidence of side effects, and analgesic consumption were recorded. Surgical block was achieved after 8 +/- 5 min in the lido-bupivacaine group and after 10 +/- 5 min in the ropivacaine group (P = 0.23). A 3-mL supplemental injection 15 min after block placement was required in 6 patients in the lido-bupivacaine group (20%) and in 10 patients in the ropivacaine group (33%) due to inadequate motor block (P = 0.38). On Postoperative Day 1, 26 patients in the ropivacaine group (87%) reported no pain at the verbal rating score, compared with 18 patients in the lido-bupivacaine group (60%) (P = 0.005). We conclude that 0.75% ropivacaine may be a suitable choice when performing peribulbar anesthesia for vitreoretinal surgery. IMPLICATIONS: Quick onset of block with prolonged postoperative analgesia is an important goal in regional anesthesia for ophthalmic surgery. Evaluating clinical properties of 0.75% ropivacaine and a 1:1 mixture of 2% lidocaine and 0.5% bupivacaine for peribulbar anesthesia, we demonstrated that ropivacaine has an onset similar to that of the lidocaine-bupivacaine mixture and provides a better quality of postoperative analgesia.

[Telemedicine in vitreoretinal surgery]. / Telemedicina u vitreoretinalnoj hirurgiji.

The authors present one-year experience of the multimedia role in ophthalmology with particularly review on example in vitreoretinal surgery. It has been shown goal of the project, methodology, evaluation of one-year work results and possibility of project's expansion.

Methods for the determination of organochlorine pesticide residues in human serum.

The effectiveness of solid-phase extraction with Florisil for the determination of 12 organochlorine pesticide residues from human serum was examined. Recoveries greater than 84% and coefficients of variation better than 19% were obtained. Others methods, such as column partition and matrix solid-phase dispersion, were compared. The better method provides quantification limits ranging from 1.08 microg/l for gamma-HCH and 37.5 microg/l for p,p'-DDT when capillary gas-liquid chromatography with electron-capture detection is used for the final determination.

Axial length and refraction in retinal vein occlusions.

To assess whether axial length and refraction are risk factors for retinal vein occlusion, we measured these parameters in 88 consecutive patients with unilateral branch retinal vein occlusion (BRVO), in 58 consecutive patients with unilateral central retinal vein occlusion (CRVO) and in 50 patients selected as a control group. Patients and controls were free or affected by systemic or local predisposing factors. We compared eyes with CRVO with control eyes, eyes with BRVO with control eyes, and eyes with CRVO with eyes with BRVO. Comparing CRVO eyes and controls, none of the investigated variables was shown to be significant. From the analysis of BRVO eyes versus controls, it resulted that refraction was the only variable which played the role of an independent prognostic factor. When comparing BRVO eyes with CRVO eyes, we found that age was slightly related to the development of BRVO. In conclusion, faulty refraction appeared to be a risk factor for the development of BRVO. We did not find any influence of axial length on the occlusion of retinal veins.

Myofasciocutaneous expansion in the tegumentary rehabilitation of the amputation stump.

In post-traumatic amputations, in particular in leg amputations, the presence of an unstable scar or of ulcerous areas that are difficult to heal in the site of the amputation stump constitutes a repair problem that is not easily solved. In this specific field of reconstruction skin expansion has earned significant agreement, and is even considered to be a safe and reliable method for the surgical rehabilitation of the amputation stump, allowing us to obtain high-quality tegumentary covering, with no excessive thickness, that adapts well to the prosthesis and to the underlying skeleton, and that is characterized by good sensitivity of protection. Tegumentary amplification may, in some cases, also become myocutaneous, allowing us to obtain more tissue thickness for protection in patients submitted to chronic loading that lasts longer and in those with thin teguments, in which traditional expansion could determine excessive narrowing of the tegumentary covering, following atrophy caused by compression of the subcutaneous adipose tissue.

Interaction between infrared radiation and vitreous substitutes.

OBJECTIVE: To characterize the interaction between midintrared radiation of cutting lasers used or proposed for vitreoretinal surgery and fluid vitreous substitutes commonly used in vitreoretinal surgery. METHODS: Optical transmittance of vitreous substitutes was measured with a double-beam spectrophotometer. Measurements were performed in a wide spectral range of infrared radiation, including the 2120-nm wavelength of the holmium-YAG laser and the water absorption peaks at 1440, 1930, and 2940 nm. RESULTS: The wavelengths considered have a penetration depth varying from 410 to 1 microns in Ringer's solution, balanced salt citrate-buffered solution, balanced salt bicarbonated-buffered solution, hyaluronate sodium, and hydroxypropyl methylcellulose ophthalmic solution, from 2000 to 13 mm in perfluorocarbon liquid, and from 52 to 2.5 mm in silicone and fluorosilicone oils. CONCLUSIONS: Midinfrared optical radiation exhibits dramatic differences of penetration depth in different vitreous substitutes. High-absorbing liquids should be used mainly with contact laser procedures and could provide a shield for remote structures. Low-absorption vitreous substitutes allow noncontact laser surgical procedures, but they also may cause direct optical damage to remote tissues. The knowledge of wavelength transmittance of vitreous substitutes is necessary to evaluate and optimize the efficacy and safety of cutting laser sources.

OCT images and surgery of juvenile Macular retinoschisis.

We describe three cases of X-linked juvenile retinoschisis confined to the posterior pole of the eye, one of which surgically treated. In the first two cases, in vivo optical coherence tomography (OCT) had revealed a cleavage plane in both nerve fiber and outer retinal layers. In the two similar operated eyes of the third case, postoperative OCT had revealed the disappearance of macular schisis in the eye with good recovery of visual function after surgery. On the contrary, it had revealed a persistent splitting of the retina in the other eye, not clinically visible, which explained the poor recovery of visual function after surgery. In cases with progressive worsening of macular involvement in X-linked juvenile retinoschisis, highly accurate surgery may be considered, and the pre- and postsurgical OCT monitor of these patients is indicated.