Branch retinal artery occlusion and non-ischemic central retinal vein occlusion due to hyperhomocysteinemia in a 14-year-old child.

A 14-year-old girl presented with sudden, painless loss of vision in the left eye. Complete ophthalmologic examination including fluorescein angiography revealed an impending central vein occlusion and a branch retinal artery occlusion inferotemporally. One month later, there was a non-ischemic central retinal vein occlusion of the same eye. Systemic evaluation led to the diagnosis of hyperhomocysteinemia. This case report underscores the importance of excluding hyperhomocysteinemia in vascular occlusive disease.

Intra-observer and inter-observer reliability and reproducibility of slit-lamp-adapted optical coherence tomography for evaluation of anterior chamber depth and central corneal thickness.

BACKGROUND AND OBJECTIVE: To evaluate the intra-observer and inter-observer reproducibility of anterior chamber depth (ACD) and central corneal thickness (CCT) measurements taken by slit-lamp-adapted optical coherence tomography (SL-OCT) and to evaluate concordance of CCT and ACD values obtained by SL-OCT with gold standard devices. PATIENTS AND METHODS: Three images of each eye were taken by two different operators using SL-OCT. ACD and CCT values obtained by each operator were determined and compared to one another and to ultrasonic pachymetry (CCT) and axial OCT biometry (ACD) values obtained by a third, masked operator. Intra-observer and inter-operator reproducibility was assessed using the intraclass correlation coefficient (ICC). RESULTS: Forty-one eyes of healthy subjects were enrolled. Mean CCT was 0.556 +/- 0.020, 0.557 +/- 0.019, and 0.532 +/- 0.032 and mean ACD was 3.12 +/- 0.36, 3.13 +/- 0.38, and 3.50 +/- 0.44 for operators 1, 2, and 3, respectively (P < .001, for both CCT and ACD). Intra-operator reproducibility for CCT (ICC of 0.948 to 0.995) and ACD (ICC of 0.972 to 0.987) was excellent. CONCLUSION: SL-OCT provides highly reproducible measures for both CCT and ACD. SL-OCT yields higher values for CCT compared to ultrasonic pachymetry and lower values for ACD compared to axial OCT biometry. Caution should be taken when extrapolating these data into clinical practice until the differences between SL-OCT, axial OCT biometry, and ultrasonic pachymetry can be further elucidated.

Isolated lymphoma of the anterior visual pathway diagnosed by optic nerve biopsy.

A 72-year-old previously healthy man developed rapidly progressive visual loss, and brain imaging showed features suggestive of a malignant glioma of the anterior visual pathway. Biopsy of one optic nerve yielded a diagnosis of lymphoma. There was no evidence of an extracranial non-Hodgkin lymphoma, so the conclusion was that this represented a primary central nervous system lymphoma (PCNSL). PCNSL isolated to the optic chiasm has been described only once in an immunocompetent patient. Our patient is unusual in that the lymphoma involved the optic nerve, chiasm, and tract in an immunocompetent patient.

Clinical characteristics of Mooren's ulcer in South India.

AIM: To describe the clinical characteristics at presentation of a large cohort of patients with Mooren's ulcer in South India. METHODS: The medical records of patients with Mooren's ulcer examined in the cornea clinic at Aravind Eye Hospital Madurai, Tamil Nadu, India, over a 10-year period were reviewed in this retrospective observational case series. RESULTS: The cohort contained 242 eyes of 166 patients. All patients were from South India, and men outnumbered women by a ratio of 4.7:1. The median and mean ages at presentation were 65 and 61 years, respectively, with a range of 13-95 years. One eye was affected in 90 of 166 (54%) patients. Visual acuity in the affected eye at presentation ranged from 6/6 to light perception, and was 6/12 or better in 34 of 242 (14%) eyes, between 6/12 and 3/60 in 168 (69%) eyes, and worse than 3/60 in 40 (17%) eyes. Partial peripheral corneal ulceration was observed in 222 (92%) eyes, complete peripheral corneal ulceration was observed in 15 (6%) eyes and total corneal ulceration was observed in 5 (2%) eyes. For those 222 eyes with partial peripheral ulceration, 152 (68%) showed temporal involvement, 129 (58%) showed nasal involvement, 116 (52%) showed inferior involvement and 30 (14%) showed superior involvement. Perforation was observed in 26 (11%) eyes, and was more common in eyes with peripheral as compared with total ulceration (p<0.001). Identified risk factors in the cohort included evidence of prior corneal surgery (22%), corneal trauma (17%) and corneal infection (2%). CONCLUSIONS: Mooren's ulcer is a rare and potentially blinding eye condition observed not infrequently in the cornea clinic at Aravind Eye Hospital. Men are affected more often than women and may present with either unilateral or bilateral disease. Perforation is observed in approximately 1 in 10 affected eyes at presentation and occurs most often in the setting of peripheral ulceration. The occurrence of prior corneal surgery, trauma or infection in nearly one third of patients supports theories of exposure to corneal antigen in the pathogenesis of this disorder.

Hookworm infestation as a risk factor for Mooren's ulcer in South India.

OBJECTIVE: To investigate the association between Mooren's ulcer and intestinal hookworm infestation in South India. DESIGN: Prospective observational case-control study. PARTICIPANTS: Fifteen patients with Mooren's ulcer and 30 age- and gender-matched controls seen at Aravind Eye Hospital. METHODS: Stool samples from the Mooren's ulcer patients and controls were collected and analyzed for presence of hookworm infestation. MAIN OUTCOME MEASURE: Prevalence of hookworm infestation in Mooren's ulcer patients and controls. RESULTS: There was a statistically significant correlation between intestinal hookworm infestation and the occurrence of Mooren's ulcer (P = 0.009). Retrospective exploratory subgroup analyses suggested that the correlation between intestinal hookworm infestation and the occurrence of Mooren's ulcer in men (P<0.0001) was stronger than the correlation in women, with no statistically significant difference being observed in the prevalence of hookworm infestation between women with Mooren's ulcer and female control subjects (P>0.99). Similarly, when both the Mooren's ulcer and the control subject groups were analyzed retrospectively by age > 50 years or age < 50, subjects with an age over 50 demonstrated a stronger correlation between hookworm infestation and Mooren's ulcer than controls (P = 0.017), whereas there was no statistically significant difference in the prevalence of hookworm infection between Mooren's ulcer subjects and control subjects < or = 50 (P = 0.31). CONCLUSION: Intestinal hookworm infestation appears to be associated with the development of Mooren's ulcer in South India. Although the power of our retrospective exploratory subgroup analyses was limited by multiple testing and small sample sizes, these data suggest further that the correlation between intestinal hookworm infestation and the development of Mooren's ulcer may be greatest in male patients with more advanced age.

Assessment of a race-specific normative HRT-III database to differentiate glaucomatous from normal eyes.

PURPOSE: To determine if a new, normative, race-specific database enhances the ability of confocal scanning laser ophthalmoscopy to differentiate normal from glaucomatous eyes. METHODS: One eye of eligible normal and glaucoma patients was enrolled. All subjects underwent a complete ophthalmologic examination, standard achromatic perimetry (SITA-SAP, 24-2), and confocal scanning laser ophthalmoscopy [Heidelberg retinal tomograph (HRT-II)] within 1 month of enrollment. Racial groups were defined by self-report. Glaucoma was defined by the existence of reproducible SAP loss (pattern standard deviation <5% and/or Glaucoma Hemifield Test outside normal limits) on 2 consecutive fields. Normal subjects had 2 normal visual fields (pattern standard deviation >5% and Glaucoma Hemifield Test within 97% normal limits) and a normal clinical examination. HRT-II examinations were exported to the HRT-III software, which includes a large race-specific normative database consisting of 733 white and 215 black eyes. Moorfields regression analysis (MRA) for the most abnormal optic disc sector was compared between the HRT-II (MRA2) and the HRT-III software before (MRA3-B) and after (MRA3-A) adjustment for race. Sectors outside the 99.9% confidence interval limits ("outside normal limits") were determined to be abnormal. RESULTS: We enrolled 124 black (52 glaucoma, 72 normal) and 96 white (32 glaucoma, 64 normal) subjects. Mean age was 51+/-13 years and 50+/-16 years for blacks and whites, respectively (P = 0.45). Visual field mean deviation was -7.3+/-6.7 db for glaucomatous eyes and -0.4+/-1.1 db for normal eyes (P < 0.001). Sensitivity and specificity for the HRT-II was 71.9% and 95.3%, respectively, for white subjects and 50.0% and 98.6%, respectively, for black subjects. Using the expanded HRT-III database, analysis yielded a sensitivity of 81.3% and specificity of 93.8% for whites and a sensitivity of 71.2% and specificity of 86.1% for blacks. After an adjustment for black ethnicity was made in the HRT-III program, the sensitivity and specificity for blacks was 65.4% and 90.3%, respectively. CONCLUSIONS: A new, larger, race-specific HRT-III database increases sensitivity while maintaining specificity for whites and increases sensitivity but decreases specificity for blacks. New software and databases based on race require careful scrutiny before use in clinical practice.

Escitalopram-induced uveal effusions and bilateral angle closure glaucoma.

PURPOSE: To report the onset of bilateral angle closure glaucoma resulting from ciliochoroidal effusions noted after taking escitalopram. DESIGN: Case report. METHODS: A 41-year-old woman with a medical history of depression was placed on escitalopram and presented with acute bilateral angle closure glaucoma. A medical history and ophthalmic examination (including slit-lamp photography and high-frequency ultrasonography) were performed at the time of diagnosis and at resolution of her symptoms. RESULTS: High-frequency ultrasonography revealed bilateral choroidal effusions with ciliary body detachments and angle closure. Attempts to reduce intraocular pressure with topical ocular antihypertensive drugs and subsequent laser peripheral iridotomy were unsuccessful. Over the course of four days, the use of topical cycloplegics, corticosteroids, and discontinuation of escitalopram resulted in normalization of intraocular pressures, deepening of anterior chamber depths, and resolution of her uveal effusions. CONCLUSIONS: The use of escitalopram resulted in uveal effusions, angle rotation, and acute bilateral angle closure glaucoma. Discontinuation of escitalopram and corticosteroid therapy resulted in normalization of the patient's eyes.