INTRAVITREAL DEXAMETHASONE FOR THE TREATMENT OF MACULAR EDEMA SECONDARY TO HYDROXYCHLOROQUINE TOXICITY.

PURPOSE: Cystoid macular edema is a vision-threatening complication infrequently associated with hydroxychloroquine retinal toxicity. There are limited data on the best treatment for this pathology. METHODS: A retrospective case series is presented. RESULTS: In this series, we present three cases of cystoid macular edema in patients with diagnosed hydroxychloroquine maculopathy successfully treated with intravitreal dexamethasone implantation. CONCLUSION: Minimal literature has been published regarding the best management of cystoid macular edema related to hydroxychloroquine toxicity. Our case series suggests a possible new agent in the treatment of this rare occurrence.

Prevalence of Retinal Diseases and Associated Risk Factors in an African Population From Mwanza, Tanzania.

BACKGROUND AND OBJECTIVE: To determine the prevalence of retinal disease among a population in Mwanza, Tanzania, and to identify relevant risk factors for retinal disorders in this cohort. PATIENTS AND METHODS: A cross-sectional population-based study was conducted in Mwanza, Tanzania, among patients older than 18 years. Participants completed a demographics survey and underwent an ophthalmic examination that included fundus photography. RESULTS: Complete data were available for 1,007 (93.8%) of the 1,073 persons examined. The prevalence of vitreoretinal disorders was 22.8% (230/1,007). The leading retinal diseases were age-related macular degeneration (7.0%), hypertensive retinopathy (4.5%), and macular scars (2.7%). CONCLUSION: This study is the first population-based study of retinal disease in Mwanza. The findings reveal a considerable burden of retinal disease in this region, suggesting a need for trained local ophthalmic personnel and resources. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:S17-S25.].

Ocular ultrasound versus MRI in the detection of extrascleral extension in a patient with choroidal melanoma.

BACKGROUND: To describe the superiority of ocular ultrasound in the diagnostic management of extrascleral extension in choroidal melanoma. CASE PRESENTATION: We present a case of a 94-year-old male with choroidal melanoma of the right eye imaged with MRI and ocular ultrasound to aid in the detection of extrascleral extension. CONCLUSIONS: With advancement in technology and new imaging modalities emerging, it can become difficult to determine the best diagnostic approach for patients. We believe that ocular ultrasound remains the superior imaging modality in detection of extrascleral extension in choroidal melanoma.

Three presentations of CNS disease in patients with intraocular retinoblastoma at a tertiary medical center in the United States.

BACKGROUND: Patients with intraocular retinoblastoma who present with central nervous (CNS) disease at diagnosis is very rare in developed countries. METHODS: Herein, we report a review of patients with intraocular retinoblastoma diagnosed with concurrent CNS disease in the United States between January 2011 and June 2013. RESULTS: Three patients were identified in this review. The first case is a 2-year old male who presented with unilateral Group E retinoblastoma, optic nerve infiltration to the orbital apex, and a suprasellar mass. The second case is a 5-month old female with bilateral retinoblastoma, who had no optic nerve invasion, but demonstrated a temporal lobe lesion that was biopsy-proven to be metastatic retinoblastoma. The third case is a 10-month old girl with bilateral retinoblastoma who presented with a sellar mass and no evidence of optic nerve invasion in the enucleated Group E eye. CONCLUSIONS: Although rare in developed countries, patients with intraocular retinoblastoma can present with a spectrum of CNS findings at the time of diagnosis. Magnetic resonance imaging of the brain and orbits is a critical component of the staging evaluation.

Rabbit model of ocular indirect photodynamic therapy using a retinoblastoma xenograft.

PURPOSE: The goal of this project was to demonstrate the feasibility of coupling the indirect ophthalmoscope laser delivery system with the 690 nm wavelength diode laser used to perform photodynamic therapy (PDT) in the treatment of retinoblastoma. METHODS: For phase 1, a total of six pigmented rabbits were treated with the indirect laser delivery system. The laser source was provided by the Lumenis Opal 690 nm laser unit, delivered through a 810 nm Indirect ophthalmoscope headpiece and a hand-held 28-diopter indirect lens (1.0 mm spot size). Four rabbits received intravenous verteporfin at doses of 0.43 or 0.86 mg/kg, and two rabbits did not receive verteporfin (controls). A second phase of the study involved eight rabbits using a retinoblastoma xenograft to determine the effect of indirect PDT on subretinal tumors. RESULTS: For phase 1, a total of 20 laser treatments were performed in the right eyes of six rabbits. Laser power levels ranged between 40 and 150 mW/cm2 and treatment duration ranged between 1 and 3 min. In the four rabbits that received verteporfin, focal retinal scars were noted at 40 mW/cm2 and higher power levels. In the two control rabbits that did not receive verteporfin, thermal burns were confirmed at 75 mW/cm2 and higher power levels. Histopathology showed focal retino-choroidal scars at the site of PDT treatment, without evidence of generalized ocular damage. Using the retinoblastoma xenograft, the indirect PDT system was shown to cause areas of tumor necrosis on histopathology. CONCLUSIONS: The results of this pre-clinical study suggest verteporfin may be activated in the rabbit retina with the indirect delivery system and the 690 nm laser unit (i.e., Indirect PDT). Using verteporfin, treatment effects were observed at 40-50 mW/cm2 in the rabbit retina, while photocoagulation was achieved at 75 mW/cm2 and higher power levels. Fundoscopic and histopathologic examination of treated areas showed circumscribed areas of retinal damage and a lack of generalized ocular toxicity, suggesting that this modality may represent a safe and localized method for treating intraocular retinoblastoma.

Endothelial Keratoplasty Safety-Basket Suture for Management of Difficult Cases.

PURPOSE: To describe a novel technique of a safety-basket for management of Descemet stripping automated endothelial keratoplasty in eyes with defects of the lens-iris diaphragm, postvitrectomized eyes, eyes with previous glaucoma tube-shunt or trabeculectomy, or when the patient cannot lie supine. METHODS: The safety-basket suture is placed after the endothelial graft has been positioned under air and all wounds have been closed. Double-armed 10-0 polypropylene suture on a curved needle is passed under the graft in a single-running fashion, a modification of the Masket technique used as a safety suture in the management of malpositioned intraocular lenses. Care is taken not to touch the graft with the needle or suture. The suture can be left in place and removed at the slit-lamp postoperatively with continued use of topical antibiotics while the safety-basket is left in place. RESULTS: The technique was used successfully for 35 high-risk cases with good success with no cases of postoperative infection. CONCLUSIONS: Endothelial keratoplasty safety-basket sutures, when used in high-risk Descemet stripping automated endothelial keratoplasty patients with abnormal anterior segment anatomy can provide support to maintain the graft in a central position and thus allow for easier rebubbling, should it detach in the early postoperative course.

Retrospective Review of Ocular Point-of-Care Ultrasound for Detection of Retinal Detachment.

INTRODUCTION: Retinal detachment is an ocular emergency that commonly presents to the emergency department (ED). Ophthalmologists are able to accurately make this diagnosis with a dilated fundoscopic exam, scleral depression or ophthalmic ultrasound when a view to the retina is obstructed. Emergency physicians (EPs) are not trained to examine the peripheral retina, and thus ophthalmic ultrasound can be used to aid in diagnosis. We assessed the accuracy of ocular point-of-care ultrasound (POCUS) in diagnosing retinal detachment. METHODS: We retrospectively reviewed charts of ED patients with suspected retinal detachment who underwent ocular POCUS between July 2012 and May 2015. Charts were reviewed for patients presenting to the ED with ocular complaints and clinical concern for retinal detachment. We compared ocular POCUS performed by EPs against the criterion reference of the consulting ophthalmologist's diagnosis. RESULTS: We enrolled a total of 109 patients. Of the 34 patients diagnosed with retinal detachment by the ophthalmologists, 31 were correctly identified as having retinal detachment by the EP using ocular POCUS. Of the 75 patients who did not have retinal detachment, 72 were ruled out by ocular POCUS by the EP. This resulted in a POCUS sensitivity of 91% (95% CI [76-98]) and specificity of 96% (95% CI [89-99]). CONCLUSION: This retrospective study suggests that ocular POCUS performed by EPs can aid in the diagnosis of retinal detachment in ED.

Case report: imaging and treatment of ophthalmic manifestations in oculodentodigital dysplasia.

BACKGROUND: Diagnostic and surgical management of severe chronic angle- closure glaucoma secondary to ciliary body cysts can be difficult to manage in a patient with oculodentodigital dysplasia. CASE PRESENTATION: A 6-year old girl with oculodentodigital dysplasia, with progressive chronic angle- closure glaucoma secondary to ciliary body cysts presented to our clinic. The initial examination revealed counting fingers vision in the left eye. Intraocular pressure (IOP), as assessed by tonopen, was 31 mm Hg. Ultrasound biomicroscopy revealed ciliary body cysts in the left eye, and gonioscopy confirmed chronic angle closure. A tube shunt was placed to control the elevated IOP. A year after her tube shunt placement in the left eye, ultrasound biomiscropy was performed on her right eye and showed no ciliary body cysts. Gonioscopy in the right eye revealed an open angle to the ciliary body band. Subsequent serial gonioscopy every 3 months showed gradual narrowing of the right eye angle and finally three-and-a-half years after tube placement of the left eye, her right eye IOP became uncontrolled with medications alone and a tube shunt was similarly placed in the right eye. Intraoperative ultrasound biomicroscopy performed at the time of the right eye tube shunt revealed extensive ciliary body cysts in the right eye. Her IOP in both eyes have been well controlled since the placement of tube shunts. CONCLUSIONS: This is one of the first reported cases of severe chronic angle- closure glaucoma secondary to ciliary body cysts in a patient with oculodentodigital dysplasia. We believe that early screening for ciliary body cysts is important in patients with oculodentodigital dysplasia.

Ultrasound diagnosis of malaria: examination of the spleen, liver, and optic nerve sheath diameter.

BACKGROUND: Over 90% of all cases of malaria worldwide occur in Africa. Current methods of diagnosis are time and labor intensive, and could lead to delayed treatment. METHODS: In this study we investigated the effectiveness of measurements of spleen, liver, and optic nerve sheath diameter (ONSD) in identifying patients with malaria or severe malaria through the use of hand-held ultrasound devices. We recruited 40 adult patients with malaria and 16 adult control subjects at two hospitals in Mwanza, Tanzania. Ultrasonographic diagnosis was compared with rapid antigen diagnostic test and peripheral blood smear as the gold standards. An receiver operating characteristic curve test was performed to determine the most optimal diagnostic threshold for malaria and severe malaria, using each of the measurements for liver size, spleen size, and ONSD. The thresholds were determined to be >12 cm for spleen length and >15.1 cm for liver length, whereas ONSD was not significant in this study. RESULTS: The sensitivities for malaria diagnosis were 66.7% and 58.3% for liver and spleen length respectively, suggesting that these measurements may not be suitable for identifying patients with severe malaria. However, the high specificity of 90.9% for spleen length and the acceptable specificity of 75.0% for liver length suggest that these measurements can be used as a method to eliminate false-positive diagnoses (i.e. patients who do not have severe malaria but are classified as having it by a test with a high sensitivity), giving a high positive predictive value. CONCLUSIONS: We report a high specificity for spleen size and a moderate specificity for liver size in the ultrasonographic diagnosis of severe malaria. Thus when paired with a highly sensitive method of malaria diagnosis, ultrasonographic measurement of spleen and liver size is promising as part of a diagnostic algorithm for malaria. It could be used to stratify risk in patients diagnosed with malaria and assist in their triage. If no sensitive tests are available, ultrasound might be useful to suggest malaria as a cause of a patient's constellation of clinical symptoms.

Orbital Recurrence following Aggressive Laser Treatment for Recurrent Retinoblastoma.

PURPOSE: To report a case of a 29-month-old male with familial, bilateral retinoblastoma with orbital recurrence following aggressive laser treatment. METHODS: This is a retrospective case report of a single patient. RESULTS: A 3-week-old male was diagnosed with familial, bilateral retinoblastoma (group D OD, group A OS), and treated with 6 cycles of systemic chemotherapy and laser treatment. The patient exhibited full regression of tumors in both eyes. Two years after diagnosis, a small tumor recurrence within the macular laser scar of the right eye was discovered. The tumor recurrence was treated with argon and diode laser over 6 months. The tumor recurrence completely resolved following the laser treatments. Ten weeks after the last laser treatment, MRI revealed a large intraconal orbital mass, contiguous with the sclera of the right eye. Orbital biopsy and systemic work-up confirmed the diagnosis of retinoblastoma with no other metastatic foci. B-scan ultrasonography showed thinning of the sclera at the site of recurrence. CONCLUSION: This is an unusual orbital recurrence after successful treatment of intraocular disease with aggressive laser therapy. Clinicians should be aware of the rare possibility of orbital recurrence following chemoreduction with local consolidation even when fundus examinations are normal.

Ultrasound diagnosis of malaria: examination of the spleen, liver, and optic nerve sheath diameter / 世界急诊医学杂志（英文）

@#BACKGROUND: Over 90％ of all cases of malaria worldwide occur in Africa. Current methods of diagnosis are time and labor intensive, and could lead to delayed treatment. METHODS: In this study we investigated the effectiveness of measurements of spleen, liver, and optic nerve sheath diameter (ONSD) in identifying patients with malaria or severe malaria through the use of hand-held ultrasound devices. We recruited 40 adult patients with malaria and 16 adult control subjects at two hospitals in Mwanza, Tanzania. Ultrasonographic diagnosis was compared with rapid antigen diagnostic test and peripheral blood smear as the gold standards. An receiver operating characteristic curve test was performed to determine the most optimal diagnostic threshold for malaria and severe malaria, using each of the measurements for liver size, spleen size, and ONSD. The thresholds were determined to be >12 cm for spleen length and >15.1 cm for liver length, whereas ONSD was not significant in this study. RESULTS: The sensitivities for malaria diagnosis were 66.7％ and 58.3％ for liver and spleen length respectively, suggesting that these measurements may not be suitable for identifying patients with severe malaria. However, the high specificity of 90.9％ for spleen length and the acceptable specificity of 75.0％ for liver length suggest that these measurements can be used as a method to eliminate false-positive diagnoses (i.e. patients who do not have severe malaria but are classified as having it by a test with a high sensitivity), giving a high positive predictive value. CONCLUSIONS: We report a high specificity for spleen size and a moderate specificity for liver size in the ultrasonographic diagnosis of severe malaria. Thus when paired with a highly sensitive method of malaria diagnosis, ultrasonographic measurement of spleen and liver size is promising as part of a diagnostic algorithm for malaria. It could be used to stratify risk in patients diagnosed with malaria and assist in their triage. If no sensitive tests are available, ultrasound might be useful to suggest malaria as a cause of a patient's constellation of clinical symptoms.

An evolutionarily conserved program of B-cell development and activation in zebrafish.

Teleost fish are among the most ancient vertebrates possessing an adaptive immune system with B and T lymphocytes that produce memory responses to pathogens. Most bony fish, however, have only 2 types of B lymphocytes, in contrast to the 4 types available to mammals. To better understand the evolution of adaptive immunity, we generated transgenic zebrafish in which the major immunoglobulin M (IgM(+)) B-cell subset expresses green fluorescence protein (GFP) (IgM1:eGFP). We discovered that the earliest IgM(+) B cells appear between the dorsal aorta and posterior cardinal vein and also in the kidney around 20 days postfertilization. We also examined B-cell ontogeny in adult IgM1:eGFP;rag2:DsRed animals, where we defined pro-B, pre-B, and immature/mature B cells in the adult kidney. Sites of B-cell development that shift between the embryo and adult have previously been described in birds and mammals. Our results suggest that this developmental shift occurs in all jawed vertebrates. Finally, we used IgM1:eGFP and cd45DsRed;blimp1:eGFP zebrafish to characterize plasma B cells and investigate B-cell function. The IgM1:eGFP reporter fish are the first nonmammalian B-cell reporter animals to be described. They will be important for further investigation of immune cell evolution and development and host-pathogen interactions in zebrafish.