Favourable outcome in a patient with penetrating intraocular BB pellet injury.

Intraocular BB pellet injuries are a devastating form of ocular trauma with a poor prognosis. The penetration of the eye by the pellet causes a marked disruption of the intraocular contents that in most cases leads to enucleation. We describe a 15-year-old boy who suffered a penetrating intraocular BB pellet injury to his right eye and underwent primary repair of the injury followed by secondary vitrectomy and prophylactic panretinal photocoagulation. The postoperative management was complicated by a retinal detachment; however, this responded to a scleral buckling procedure. Eighteen months after the injury the acuity in the affected eye was 20/30 with a contact lens. To our knowledge this is the first case in which useful vision has been recovered in this type of injury.

Initial identification of antinuclear-antibody-negative systemic lupus erythematosus on ophthalmic examination: a case report, with a discussion of the ocular significance of anticardiolipin (antiphospholipid) antibodies.

A 21-year-old man presented with an acute life-threatening illness that was diagnosed and treated as thrombotic thrombocytopenic purpura. The patient survived and during his recovery noted that his central vision was markedly impaired in both eyes. An ophthalmologic examination showed inflammatory and ischemic changes in the retinal vasculature consistent with a diagnosis of systemic lupus erythematosus (SLE). Review of the patient's clinical and laboratory findings did in fact support a diagnosis of SLE that was negative for antinuclear antibody but positive for anticardiolipin antibody. The authors discuss the importance of an ophthalmic examination in patients with SLE-like syndromes and the significance of positivity for anticardiolipin antibody and other antiphospholipid antibodies in patients with thrombosis in the eye or elsewhere.

Cerebral ischemic events associated with endocarditis, retinal vascular disease, and lupus anticoagulant.

PURPOSE: A group of young patients presenting with cerebral ischemic events, endocardial lesions, and lupus anticoagulant is described in order to highlight the common clinical laboratory features. PATIENTS AND METHODS: Fourteen consecutive patients (10 females, age range 17 to 53 years [mean 38 years]) at onset of symptoms of cerebral ischemia who had evidence of the lupus anticoagulant syndrome and were being followed prospectively are reviewed. All patients had abnormal phospholipid-dependent coagulation test results, and most had anticardiolipin antibody at the time of presentation. Three of 14 had four or more American Rheumatism Association criteria for definite systemic lupus erythematosus and the remaining patients were considered to have primary lupus anticoagulant syndrome. RESULTS: The common features among these patients included at least one cerebral ischemic event at presentation (stroke or transient ischemic attack), or recurrent episodes suggesting cerebral ischemia (amaurosis fugax, recurrent severe migraine headaches), livedo reticularis, endocardial valvular lesions noted on echocardiography (11 mitral, two aortic valve) that were often associated with discrete vegetations, retinal vascular lesions, and computed tomographic/magnetic resonance imaging scanning or angiographic evidence of multiple cerebral infarction. Venous thromboembolic events were uncommon (three of 14). Common laboratory studies included thrombocytopenia (10 of 14), positive direct Coombs' test result (11 of 14), and hypocomplementemia (11 of 14). Follow-up after initial treatment with either salicylates or anticoagulant therapy (warfarin) for up to 10 years indicated that while many patients had recurrent symptoms suggesting cerebral ischemia, major stroke syndromes did not recur nor new episodes emerge. CONCLUSION: The combination of multiple cerebral ischemic lesions and endocardial lesions, including valvular vegetations, suggests that these cerebral ischemic events represent cerebral emboli, and that these cerebral embolic events originate from vegetative lesions on the mitral or, less commonly, aortic valve, in association with lupus anticoagulant.

Successful treatment of the ocular ischemic syndrome with panretinal photocoagulation and cerebrovascular surgery.

The ocular ischemic syndrome is a manifestation of chronic vascular insufficiency. The natural history is for progressive visual loss. The authors describe 12 patients (13 eyes) who presented with at least one asymmetric ocular finding, including midperipheral dot and blot hemorrhages (hypoperfusion retinopathy) (in 8), iris neovascularization (in 7), neovascular glaucoma (in 3) and vitreous hemorrhage (in 1). Cerebral angiography revealed stenosis or occlusion of the ipsilateral carotid artery in all cases. The treatment was panretinal photocoagulation (in four cases), cerebrovascular surgery (in three) or both (in six). All but one patient showed stabilization of visual acuity (20/60 or better in nine cases) and regression of proliferative retinopathy and of iris neovascularization. The results underline the importance of early recognition and treatment of the ocular ischemic syndrome.

Continuous subcutaneous insulin infusion in adults: glycemic advantage is predicted by venous plasma C-peptide concentrations.

Continuous subcutaneous insulin infusion (CSII) has been compared with conventional insulin injection treatment (CIT) supplemented by self-monitoring of capillary blood glucose (SMBG) in 18 nonobese adults with insulin-dependent diabetes mellitus (IDDM). Mean daily insulin dosage and rates of hypoglycemia were similar during CSII (duration of treatment 36 +/- 2 wk mean +/- SE) and CIT (31 +/- 1.6 wk). On the basis of fasting C-peptide concentrations and postintravenous glucagon increments of less than 0.1 pmol/ml, subjects were classified C-peptide negative (CP NEG) (N = 11), or C-peptide positive (CP POS) (N = 7). Relative to CIT, CP NEG subjects on CSII had significant decreases in premeal/bedtime and postmeal plasma glucose concentrations and glycosylated hemoglobin (percent of total). CP POS patients during each of CSII and CIT showed glycemic responses equivalent to those of CP NEG patients on CSII. In neither group could results be explained on the basis of improved beta cell function. Thus, therapeutic advantage of CSII was not apparent in IDDM adults retaining significant C-peptide activity.

Comparison of stereofundus photographs in patients with insulin-dependent diabetes during conventional insulin treatment or continuous subcutaneous insulin infusion.

Sixty-five patients with mild to moderate nonproliferative diabetic retinopathy who enrolled in a prospective controlled clinical trial had stereofundus photographs assessed for change over an 8-mo period. The entire study group showed a worsening of retinopathy with time (P less than 0.001). The worsening was greater in the pump-treated group (15/32) than in the conventionally treated group (9/33). The significance of this difference ranged from P = 0.67, if changes in mean retinopathy level for each patient were compared, to P = 0.177 if a grading system keyed to the worse eye was compared. The difference in rates of change between treatment groups was found to be related to the baseline mean retinopathy level (P = 0.031), but less significantly so if baseline retinopathy keyed to the worse eye was used as a covariate (P = 0.08). Worsening occurred more frequently in those patients starting with the lower retinopathy levels. Progression was associated with the appearance of retinal infarcts (cotton-wool spots, soft exudates) and/or intraretinal microvascular abnormalities, with the pump patients showing a significant increase in these individual retinal lesions compared with the conventionally treated patients over 8 mo (P less than 0.025).

Diabetic dense premacular hemorrhage. A possible indication for prompt vitrectomy.

A review was undertaken of nine eyes of nine patients who suffered tightly bound dense premacular hemorrhage as a complication of proliferative diabetic retinopathy. Patients who did not receive vitrectomy within four weeks of the onset of the hemorrhage all progressed to late macular traction and visual acuity no better than 6/30. Of the five patients who received vitrectomy within four weeks of the onset of the hemorrhage, none developed significant late macular traction and all achieved visual acuity of 6/12 or better. It is possible that the tightly bound dense premacular hemorrhage represents an indication for vitrectomy within one month of its onset.

Pars plana vitrectomy for the complications of diabetic retinopathy: a report on 131 cases.

The results of primary vitrectomy for the complications of proliferative diabetic retinopathy were explored in 131 eyes of 105 patients. A minimum of 6 months' follow-up was obtained. The primary indications for surgery were persistent vitreous hemorrhage (in 66% of the eyes) and progressive tractional macular detachment (in 31%). Technical (surgical) success (clearing of the ocular media or relief of macular traction, or both) was achieved by the time of the last examination in 69% of the eyes; it was achieved in 70% of those with persistent vitreous hemorrhage and in 68% of those with tractional macular detachment. Visual improvement was observed in 55% of all the eyes.

Ocular involvement in thrombotic thrombocytopenic purpura: the angiographic and histopathological features.

We report two cases of thrombotic thrombocytopenic purpura (TTP). The first case illustrates the clinical findings and fluorescein angiographic features of this disease, notably the serous macular detachments and focal areas of choriocapillaris occlusion. The second case demonstrates a more severe case of TTP, with neurologic complications that led to death; histopathological examination of the eyes showed serous retinal detachments and choriocapillaris occlusion, with electron microscopic evidence of intravascular fibrin-platelet thrombi.

Clinically stationary choroidal melanoma with extraocular extension.

A malignant melanoma of the choroid was observed for three years because of an erroneous diagnosis of disciform macular degeneration. No lateral or vertical growth was noted during the observation period, but significant extrascieral extension was discovered at the time of radioactive phosphorus uptake test and enucleation.

Ultrasonography and 32P test in the diagnosis of choroidal melanoma with massive vitreous hemorrhage.

A malignant melanoma of the choroid presented with a massive vitreous hemorrhage which prevented any view of the posterior pole. The diagnosis was confirmed by the results of a radioactive phosphorus test and ultrasonography. In eyes with opaque media, these tests will ofter prevent delays in diagnosis.

Retinoblastoma simulating Coats' disease: a clinicopathologic report.

A case report of a male infant with leukocoria and a clinical picture of Coats' disease is presented. The correct diagnosis was suggested by contact B-scan ultrasonography, which demonstrated an exophytic mass with calcification compatible with retinoblastoma. The value of this technique in the differential diagnosis of retinoblastoma is discussed.

Intraocular wooden foreign body clinically resembling a pearl cyst.

Five years after injuring his right eye with a wooden arrow, an 11-year-old boy had an iris lesion resembling a pearl cyst. Surgery demonstrated an intraocular wooden foreign body. Wooden foreign bodies are uncommon but may be surprisingly well tolerated if uncontaminated. A differential diagnosis of iris mass lesions in the posttraumatic eye is provided.

The diagnosis of uveal malignant melanomas in eyes with opaque media.

Of 358 eyes enucleated between 1962 and 1975, and found to contain posterior uveal melanomas, 31 had opaque media (8.6%). Eighteen of these patients with opaque media were seen between 1962 and 1971, before the use of combined ultrasonography and the radioactive phosphorus uptake (32P) test. Melanoma was unsuspected at enucleation in one third of these patients and there was often a long delay in diagnosis. Of the 13 patients seen between 1971 and 1975, after the initiation of combined ultrasonography and 32P) test, there was no delay in diagnosis becuase a melanoma pattern was recognized immediately with ultrasonography and confirmed with a positive 32P test. During the latter part of this study, 19 patients with opaque media had a "melanoma pattern" with ultrasonography. The 32P test was positive in 12 cases and a melanoma was confirmed histologically in every instance. The 32P test was negative in seven cases and all were documented on follow-up to have benign lesions, such as subretinal hemorrhages.

Fluorescein angiographic findings in familial exudative vitreoretinopathy.

We describe the fluorescein angiograms in four cases of familial exudative vitreoretinopathy. The vascular nature of the temporal retinal masses is confirmed. Primary abnormalities within the peripheral retinal circulation are demonstrated. We stress the similarity between familial exudative vitreoretinopathy and retrolental fibroplasia.