Granuloma piogénico tras blanqueamiento ocular cosmético / Pyogenic granuloma after cosmetic eye whitening

CASO CLÍNICO: Varón caucásico de 46 años con antecedente de hiperemia conjuntival crónica que acude a nuestra clínica 5 años después de realizar el procedimiento quirúrgico de blanqueamiento ocular cosmético. En la exploración observamos granuloma piógeno en el ojo derecho, además de uveítis anterior no granulomatosa aguda y escleritis necrosante en ambos ojos. RESULTADO: Se realizó una evaluación clínica con exclusión de enfermedades sistémicas completas. El granuloma piógeno se trató con resección quirúrgica y la uveítis anterior y escleritis necrosante se trataron con éxito con corticoesteroides sistémicos y metotrexato. CONCLUSIÓN: El blanqueamiento ocular cosmético quirúrgico podría tener como complicación el granuloma piógeno además de la escleritis necrosante y la uveítis anterior no granulomatosa y presentarse 5 años después del procedimiento. La resección quirúrgica es un tratamiento exitoso para esta presentación de granuloma piógeno

CLINICAL CASE: A 46-year-old caucasian male with a history of chronic conjunctival hyperemia, presented at our clinic 5 years after he underwent the surgical procedure of cosmetic eye whitening. On examination we observed pyogenic granuloma in the right eye; besides acute nongranulomatous anterior uveitis and necrotizing scleritis in both eyes. RESULT: Complete clinical evaluation and full work-up exclusion of systemic diseases was done. The pyogenic granuloma was treated with surgical resection, as well as anterior uveitis and necrotizing scleritis were successfully treated with systemic corticoesteroids and methotrexate. CONCLUSION: The surgical cosmetic eye whitening could have as complication the pyogenic granuloma in addition to necrotizing scleritis and nongranulomatous anterior uveitis; and be present 5 years after the procedure. The surgical resection is a successful treatment for this presentation of pyogenic granuloma

Pyogenic granuloma after cosmetic eye whitening. / Granuloma piogénico tras blanqueamiento ocular cosmético.

CLINICAL CASE: A 46-year-old caucasian male with a history of chronic conjunctival hyperemia, presented at our clinic 5 years after he underwent the surgical procedure of cosmetic eye whitening. On examination we observed pyogenic granuloma in the right eye; besides acute nongranulomatous anterior uveitis and necrotizing scleritis in both eyes. RESULT: Complete clinical evaluation and full work-up exclusion of systemic diseases was done. The pyogenic granuloma was treated with surgical resection, as well as anterior uveitis and necrotizing scleritis were successfully treated with systemic corticoesteroids and methotrexate. CONCLUSION: The surgical cosmetic eye whitening could have as complication the pyogenic granuloma in addition to necrotizing scleritis and nongranulomatous anterior uveitis; and be present 5 years after the procedure. The surgical resection is a successful treatment for this presentation of pyogenic granuloma.

Dexamethasone intravitreal implant: an effective adjunctive treatment for recalcitrant noninfectious uveitis.

PURPOSE: To describe our experience in treating recalcitrant and severe cases of noninfectious posterior uveitis with the 0.7-mg dexamethasone intravitreal implant as adjunctive anti-inflammatory treatment. PROCEDURES: Retrospective study. Twelve patients (8 females; 4 males; 14 affected eyes, 15 implants) with severe recalcitrant uveitis were treated. Patients had an inadequate control of uveitis despite different immunosuppressants and periocular corticosteroid therapy. Primary outcome measures evaluated were: decrease in uveitis activity, improvement in visual acuity, reduction of macular thickness, and occurrence of adverse events. RESULTS: Uveitis activity decreased in all patients after the implant. The mean follow-up time from injection was 9 months. Best-corrected visual acuity improved from 20/80 to 20/40 at the end of follow-up. The mean retinal thickness improved from 496 to 226 µm. Adverse events encountered were: 3 eyes with intraocular pressure elevation, 1 vitreous hemorrhage and 1 subconjunctival hemorrhage. Three patients reduced the daily systemic corticosteroid dosage after treatment. CONCLUSIONS: The 0.7-mg dexamethasone intravitreal implant appears to be a novel and promising adjunctive treatment for patients with severe posterior noninfectious uveitis recalcitrant to different immunosuppressive agents.

Anti-CD 20 monoclonal antibody (rituximab) treatment for inflammatory ocular diseases.

Rituximab is a monoclonal antibody directed against the CD20 antigen expressed on B cells and widely used in the treatment of non-Hodgkin's lymphoma and rheumatoid arthritis. There is a growing amount of literature which suggests that rituximab may be useful for inflammatory ocular diseases and intraocular lymphoma. Few cases have been reported on treatment of refractory scleritis, peripherative ulcerative keratitis, uveitis and ocular surface inflammatory disorders. Rituximab may be effective in the treatment of ocular inflammatory diseases in particular the most aggressive, recalcitrant and sight-threatening forms of inflammation such as uveitis associated to juvenile idiopathic arthritis. We review the literature covering the use of Rituximab in these conditions and report our results on the efficacy of Rituximab in the treatment of 8 children with very severe and long-standing uveitis who failed to respond to one or more TNF blockers. Our patients showed improvement in activity of uveitis, reduction of concomitant corticosteroids and immunosuppressants after a mean follow-up time of 14.87 months on rituximab. No serious adverse events were encountered in our treated patients. Although further studies are needed for assessing the efficacy of rituximab and the exact dosing regimen, rituximab may be considered as a treatment alternative in patients with the most aggressive forms of inflammatory ocular diseases who fail to respond to conventional and anti-TNF immunosuppressive agents.

Gamma knife radiosurgery for uveal melanoma: 12 years of experience.

AIM: To present our treatment protocol and evaluate the results of Gamma knife radiosurgery (GKR) in treating patients with uveal melanoma. METHODS: Seventy-eight consecutive patients with uveal melanoma underwent stereotactic radiosurgery (radiation dose 30-50 Gy) with a Leksell Gamma-Knife at the San Raffaele University Hospital, Milan, Italy between 1994 and 2006. The main outcome measures evaluated were: survival rate, local tumour control, eye retention rate, visual acuity and treatment-related complications. RESULTS: Survival rate was 88.8% at 3 years and 81.9% at 5 years. Local tumour control was achieved in 91.0% of patients. The median tumour thickness reduction after treatment was 1.96 mm (p<0.0001) (-32.1%). The eye retention rate was 89.7%. A significant relative reduction of visual acuity was observed during follow-up. The most frequent treatment-related complications were: exudative retinopathy (33.3%), neovascular glaucoma (18.7%), radiogenic retinopathy (13.5%) and vitreous haemorrhages (10.4%). CONCLUSION: GKR can be considered an alternative to enucleation for the treatment of choroidal melanomas.

Effective treatment with topical cyclosporine of a child with steroid-dependent interstitial keratitis.

PURPOSE: To report a case of steroid-dependent idiopathic interstitial keratitis in a child successfullytreated with topical cyclosporine 2% drops. METHODS: Case report. RESULTS: The authors describe a case of a 6-year-old boy with a history of recurrent idiopathic bilateral interstitial keratitis. The patient had recurrent episodes of corneal inflammation that became more frequent and severe during the follow-up, and caused severe corneal opacities and visual loss. Long-term treatment with topical corticosteroid was required to avoid corneal scarring that eventually caused secondary elevation of intraocular pressure. Topical cyclosporine 2% was therefore introduced as a steroid sparing agent totreat the keratitis. The treatment was continued for 1 year and the patient achieved a complete remission of corneal inflammation with resolution of corneal scarring and normalization of intraocular pressure. CONCLUSIONS: In this child with recurrent episodes of interstitial keratitis, topical cyclosporine 2% has been shown to be a safe and effective alternative for treating corneal inflammation.

Immune recovery uveitis and human leukocyte antigen typing: a report on four patients.

PURPOSE: To report the typing of human leukocyte antigen (HLA) in four human immunodeficiency virus-positive (HIV) patients with immune recovery uveitis (IRU). METHODS: The medical history of four consecutive patients who presented at the Ocular Immunology and Uveitis Service (University Hospital San Raffaele, Milan, Italy) with definite diagnosis of IRU is reported. The HLA typing was tested in all patients. RESULTS: All patients presented the clinical and ophthalmological characteristics of IRU. The HLA typing analysis showed the presence of HLA B 8-18 in all patients. CONCLUSIONS: The data obtained from these patients indicate the presence of the same HLA typing (B 8-18). The clinical relevance of such association needs to be further evaluated.

Immune recovery uveitis in an iatrogenically immunosuppressed patient.

PURPOSE: To report a case of immune recovery uveitis (IRU) in an iatrogenically immunosuppressed human immunodeficiency virus (HIV)-negative patient. METHODS: Interventional case report. One patient was diagnosed with cytomegalovirus retinitis in the left eye while receiving immunosuppressive treatment following renal transplantation. The retinitis resolved completely with systemic ganciclovir. Further reduction of immunosuppressive treatment, causing a rapid increase in CD4-T lymphocyte count, was associated in the same eye with the occurrence of IRU consisting of anterior uveitis, vitritis, and macular edema. RESULTS: Visual acuity at IRU presentation onset was 20/200 in the left eye. After 6 weeks of follow-up, the uveitis resolved with topical and periocular steroid treatment. Visual acuity restored to 20/40. CONCLUSIONS: IRU can occur in iatrogenically immunosuppressed HIV-negative patients.

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.

Clinical evaluation of twice-daily emedastine 0.05% eye drops (Emadine eye drops) versus levocabastine 0.05% eye drops in patients with allergic conjunctivitis.

PURPOSE: The efficacy and safety of emedastine 0.05% eye drops (Emadine; Alcon Laboratories, Inc, Fort Worth, Texas), a new H(1) antagonist, were studied in comparison to levocabastine 0.05% eye drops (Livostin; Janssen-Cilag N V, Berchem, Belgium) during a twice-daily treatment schedule for 6 weeks in adult and pediatric patients with seasonal allergic conjunctivitis. METHODS: In a prospective, multicenter, randomized, double-masked, parallel group study, 222 patients with allergic conjunctivitis were randomized (221 received treatment) to either emedastine or levocabastine, instilled twice daily for 6 weeks. Patient diaries were completed four times daily (before the morning and evening instillations, at noon, and in the afternoon), and clinical examinations were conducted at regular intervals. Primary efficacy variables of ocular redness and itching and secondary efficacy variables of chemosis, eyelid swelling, patient diary data, and physician's global assessment were analyzed. RESULTS: Both emedastine and levocabastine produced a statistically significant (P =.0001) reduction in itching and redness within 5 minutes of the first instillation. All signs and symptoms improved progressively over the 6-week treatment period. After 7 days of use, and throughout the remainder of the study, emedastine was statistically superior to levocabastine (P <.006) in preventing and alleviating the signs and symptoms (itching, redness, chemosis, and eyelid swelling) of allergic conjunctivitis. CONCLUSIONS: Emedastine 0.05% eye drops administered twice daily are more efficacious than levocabastine 0.05% eye drops in the prevention and treatment of the signs and symptoms of allergic conjunctivitis in adults and children of 4 years and above. Both emedastine 0.05% eye drops and levocabastine 0.05% eye drops were well tolerated.

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.

A disposable needle for frontalis suspension surgery in congenital ptosis.

In six patients affected by congenital ptosis, a disposable epidural anesthesia needle was used instead of a Wright needle for frontalis suspension surgery. For each of the patients in this study, the use of a disposable needle permitted smaller supra-brow area incisions with a minimal scar. The needle also created a smaller breach in the plane of levator aponeurosis and preaponeurotic fat, causing less tissue edema and bleeding than with a Wright needle.

Glucose metabolism and pathological findings in uveal melanoma: preliminary results.

The aims of this study were to assess the sensitivity of positron emission tomography (PET) using [18F]fluorodeoxyglucose (18F-FDG) in the detection of uveal melanoma, and to establish the relationship between pre-operative 18F-FDG uptake and a number of pathological features of uveal melanoma. Twenty consecutive patients with a clinical diagnosis of uveal melanoma were enrolled in the study. 18F-FDG uptake was assessed in all subjects and the following parameters were assessed in 11 enucleated subjects: the mitotic index, the MIB-1 proliferating cell index, number of epithelioid cells, largest tumour diameter, tumoral necrosis and inflammatory infiltration. Tumours with a diameter less than 7.5 mm were not detected by PET, possibly because of limited spatial resolution, and only 7 of 12 tumours with a diameter greater than 7.5 mm were detected. With tumours greater than 7.5 mm in diameter, PET and 18F-FDG allow two subgroups to be distinguished: those with high and those with low glucose consumption. Apart from tumour size, 18F-FDG uptake was not related to the pathological features examined. We hypothesize that 18F-FDG uptake may be related to the ratio of viable to non-viable cells, or to the hypoxic cell fraction within the tumour.

Quantitative comparison of direct antibody labeling and tumor pretargeting in uveal melanoma.

UNLABELLED: SPECT radioimmunoscintigraphy with 99mTc-labeled anti-melanoma monoclonal antibodies (MAbs) 225.28S is being used to detect uveal melanoma. Recently, pretargeting methods have been described to reduce background activity and perform imaging in a shorter time interval. METHODS: We compared the three-step pretargeting method with conventional radioimmunoscintigraphy in 15 patients with a clinical and laboratory diagnosis of uveal lesion. High-resolution SPECT radioimmunoscintigraphy was performed in all patients with directly labeled MAbs and, 1 wk later, with the three-step pretargeting technique. Eleven patients underwent eye enucleation and specimens of uveal melanoma were available for histology, whereas four patients underwent conservative therapy. The percent injected dose (%ID) delivered to the tumor and the tumor-to-background ratio were calculated. RESULTS: In all three-step radioimmunoscintigraphy studies, there was a reduction of nonspecific nasopharyngeal background. The three-step radioimmunoscintigraphy tumor-to-nontumor ratio was 3.1 +/- 1.3 versus 1.5 +/- 0.5 of conventional radioimmunoscintigraphy, while the percent injected dose on the tumor was similar for the two methods (4.4 +/- 3.0 versus 3.8 +/- 2.8) x 10(-3). CONCLUSION: Improved SPECT imaging with the three-step radioimmunoscintigraphy results from reduced background and from higher counting statistics due to reduction of time interval between radiotracer administration and imaging, whereas the absolute amount of tracer delivered to the tumor by the two methods is comparable.

Indocyanine green and fluorescein angiography of surgically excised macular choroidal neovascularizations: correlations with histopathologic and ultrastructural findings.

BACKGROUND: Informations are expected from the histopathological study of surgically excised choroidal neovascular membranes (CNMs), particularly in relation to the angiographic aspects of vascular architecture. METHODS: Fluorescein and indocyanine green (ICG) angiograms were studied together with the histopathological features of 12 surgically excised subfoveal CNMs in eyes affected by age-related macular degeneration (ARMD). RESULTS: Instead of the early and delayed diffuse hyperfluorescence secondary to CNMs observed on fluorescein angiography (seven were well defined, five scar evolved), ICG revealed (a) very early hypofluorescence of the membrane bulk over the fluorescence of the outer choroidal vascular bed and (b) late hyperfluorescence gradually increasing and partially defining the border of membranes. CNMs with well-defined hyperfluorescent aspects were characterized by fibrovascular bulk lined on one side by retinal pigment epithelium. Fibrosis reaction predominated over the vascular components in scar-evolved membranes. CONCLUSIONS: Fluorescein and ICG angiographic differences in the appearance of CNMs could depend on (a) the morphological structure and size of the CNM (b) its location within the chorioretinal layers and (c) different molecular characteristics of the dyes used.

Immunoscintigraphy with three step monoclonal pretargeting technique in diagnosis of uveal melanoma: preliminary results.

Several problems still limit the full use of the diagnostic potential of immunoscintigraphy (IS) with technetium-99m labelled monoclonal antibodies (MoAbs) 225-28S directed to high molecular weight melanoma associated antigen (HMW-MAA). The principal problem is the unfavourable ratio of tumour to non-tumour activity (T/nT), due to the poor tumour uptake and the high aspecific uptake of the tissue surrounding the tumour. Recently, it was demonstrated that using the tumour pretargeting technique based on the injection of monoclonal antibody and the avidin/biotin system (three step immunoscintigraphy), an improvement in the T/nT ratio can be obtained in patients with carcinoembryonic antigen secreting tumours. The aim of this study was to compare the diagnostic sensitivity of traditional immunoscintigraphy with that of three step immunoscintigraphy in seven patients with uveal melanoma. All the patients underwent immunoscintigraphy with MoAb 225.28S radiolabelled with technetium-99m, and a three step immunoscintigraphy 1 week later. No patients demonstrated immediate toxic effects after receiving the reagents, no matter which of the two methods was used. The traditional immunoscintigraphy had a diagnostic sensitivity of 71.4%, diagnosing five out of seven melanomas tested. The three step study detected all the melanomas examined (7/7) with a diagnostic sensitivity of 100% and showed a drastic reduction in background. The preliminary results confirm the feasibility of visualising the uveal melanoma and show that the three step immunoscintigraphy is more diagnostically sensitive than traditional immunoscintigraphy, particularly in small lesions.

MRI, antibody-guided scintigraphy, and glucose metabolism in uveal melanoma.

To evaluate the usefulness of structural and biochemical imaging techniques for the diagnosis of uveal melanoma, 12 patients with choroidal melanoma were examined. Magnetic resonance imaging was used in 11 of 12 patients, as one had a metal prosthesis. All the subjects underwent single photon planar scintigraphy (SPPS) and single photon emission computed tomography (SPECT) using the 99mTc-labeled F(ab')2 of the anti-melanoma monoclonal antibody 225.28S ([99mTc]MoAb) and positron emission tomography (PET) using [18F]fluorodeoxyglucose ([18F]FDG). Magnetic resonance identified 6 of 11 melanotic lesions (definite melanomas) and 4 of 11 hypomelanotic lesions (probable melanomas), whereas in one case it was inconclusive. [99mTc]MoAb uptake was observed in 5 of 12 lesions using SPPS and 8 of 12 lesions using SPECT. [18F]FDG uptake was observed in 3 of 12 lesions by PET. These results demonstrate that both MR and radioimmunoscintigraphy are sensitive techniques for the diagnosis of choroidal melanomas and suggest that the detection of melanomas by MR, SPPS, and SPECT is largely dependent upon their size. The validity of these conclusions was verified in four subjects in whom the diagnosis was based on MR and/or SPECT findings only and confirmed by histology. The finding that only some of the uveal melanomas of larger size are visualized based on [18F]FDG uptake suggests that melanomas can have either high or low glucose consumption.

Clinical variability in keratometry, ultrasound biometry measurements, and emmetropic intraocular lens power calculation.

We calculated inter-examiner and intra-examiner variability in keratometry and ultrasound biometry when performed by two different examiners. The potential effect on intraocular lens power calculation was also considered. Intra-examiner variability was statistically and clinically significant for axial measurements, particularly in eyes with axial length greater than 24 mm. Thus, variability in biometric examination affected the emmetropic intraocular lens power, especially in myopic eyes.

Preoperative astigmatic influence on the predictability of intraocular lens power calculation.

The preoperative and postoperative influence of different parameters on the predictability of formulas used for intraocular lens (IOL) power calculation (axial length, corneal dioptric power, IOL malposition, postoperative astigmatism) has been shown by various authors. In this study, we evaluated the preoperative astigmatic influence on the prediction of postoperative refraction in eyes operated on for cataract with IOL implantation. Three hundred and fifty-nine eyes were evaluated after cataract surgery and IOL implantation. We calculated predictive errors of both the Binkhorst and SRK formulas for each eye. Based on the outcome of the predictive errors we divided the eyes into six groups: three of high and three of low predictability. Preoperative astigmatism in these groups was statistically compared (using the Student's t-test). The preoperative astigmatism was always higher in the group with low predictability than in the group with high predictability (P less than .05).