Acute Secondary Optic Neuropathy as a Complication of a Single Episode of Acutely Raised Intraocular Pressure: A Case Series.

PURPOSE: The purpose of this case series is to report development of acute secondary optic neuropathy due to optic nerve injury associated with single episode of acutely raised intraocular pressure (IOP) of varying etiologies. PATIENTS AND METHODS: Retrospective review of a series of 3 consecutive cases diagnosed at University hospitals of Coventry and Warwickshire and review of published literature. RESULTS: Three cases, respectively, with Posner Schlossman syndrome, acute idiopathic hypertensive anterior uveitis, and primary acute angle-closure initially presented with raised IOPs of 38 to 68 mm Hg. All cases were treated initially with medical management and the primary acute angle-closure case had subsequent Nd:YAG laser peripheral iridotomy. All 3 cases developed acute optic nerve injury with reduced vision, an afferent pupillary defect and optic disc swelling which subsequently persisted as optic neuropathy with sectoral optic atrophy and disc pallor. CONCLUSIONS: This rare cases series highlights the importance of increased awareness of the possibility of developing acute secondary optic neuropathy in patients with acutely raised IOP. On the basis of the acute clinical features, including disc edema with disc hemorrhages and an afferent pupillary defect the most likely pathophysiology of the resultant optic nerve injury is the acute impact of high IOP on optic nerve head perfusion. This appears similar to nonarteritic anterior oschemic optic neuropathy. Other systemic and local risk factors may also contribute. Appropriate timely management to reduce the acutely raised IOP are essential but may not be sufficient in preventing optic neuropathy due to changes at presentation.

Posner-Schlossman syndrome.

Posner-Schlossman syndrome, or glaucomatocyclitic crisis, is a unilateral ocular condition characterized by recurrent attacks of nongranulomatous anterior uveitis and raised intraocular pressure that can result in chronic secondary glaucoma. This relatively rare disease is most likely the result of recurrent cytomegalovirus infection and affects predominantly middle-aged males. Diagnosis is largely clinical, with aqueous and blood sampling aiding the identification of any underlying infectious cause. Successful disease management is often achieved by topical treatment, although systemic therapy and even surgical intervention may be required. We discuss our current understanding of Posner-Schlossman syndrome, from its pathophysiology through to recommended treatment options.

La isla mínima / The minimun island

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Recurrent iridocyclitis due to cotton fiber in anterior chamber.

BACKGROUND: Cotton is commonly used during ophthalmic surgical procedure. Cotton fibers may get attracted to the instruments due to electrostatic forces and become adhered to the surface. With the introduction of these instruments during the surgical procedure cotton fiber may get entry into the eye. In the literature they have been infrequently reported due to insignificant effect on the ocular structures. We present a case of recurrent iridocyclitis due to cotton fiber in the anterior chamber. Patient was relived of his symptoms after removal. CASE: A 78-year-old male presented with pain, redness and blurring of right eye vision since last six months. The patient had undergone phacoemulsification with implantation of hydrophilic intraocular lens (IOL) six years earlier. Postoperative follow up was uneventful from his records till last 6 months. Slit-lamp examination revealed a cotton fiber in the anterior chamber touching the endothelium. Keratic precipitates were seen on the endothelium. Removal of the cotton fiber resulted in subsidence of inflammation. CONCLUSION: We recommend use of plastic eye and trolley drapes, lint free instrument wipes and use of needle cap to support the globe during creation of side port while performing phacoemulsification instead of cotton buds to avoid entry of cotton fiber into the anterior chamber.

Revisión con aguja tras implante de válvula de Ahmed en la ciclitis heterocrómica de Fuchs / Needle revision after Ahmed valve implantation in the management of Fuch´s heterochromic cyclitis

La ciclitis heterocrómica de Fuchs es una uveítis crónica que puede ser asintomática por años o expresar solo la heterocromía antes que aparezca cualquier otro signo. El glaucoma se considera una de las complicaciones más difíciles de tratar, y requiere cirugía en múltiples ocasiones. Los dispositivos de drenaje están siendo cada vez más utilizados como alternativa de tratamiento quirúrgico en estos casos. Asiste a la consulta mádica una paciente de 36 años de edad, con antecedentes de uveítis crónica unilateral del ojo izquierdo asociado a catarata y glaucoma descompensado, a pesar del tratamiento médico. Se presenta con 50 VAR de visión y presión intraocular de 32 mmHg. Se realizó cirugía combinada: facoemulsificación e implante de válvula Ahmed modelo S2 con mitomicina C (0,2 mg/mL) durante cinco minutos. Se diagnostica ampolla de filtración encapsulada en la octava semana. Se realiza revisión con aguja y subconjuntival de 1 mg de bevacizumab (avastin) subtenoniano en área de la filtrante. La inyección se repite días alternos hasta completar tres dosis según protocolo institucional. Se logran cifras de presión intraocular de 17 mmHg y agudeza visual mejor corregida de 95 VAR a los 18 meses posoperatorios(AU)

Fuch´s heterochromic cyclitis is chronic uveitis that may be asymptomatic for years or may express heretochromia just before the onset of any other sign. Glaucoma is considered one of the most difficult complications to be treated and requires multiple surgeries. Drainage devices are increasingly used as a surgical treatment option in these cases. Here is the case of a 36 years-old woman with a history of unilateral chronic uveitis in her left eye associated to cataract and decompensate glaucoma despite the medical therapy. She presented with 50 VAR visual acuity and 32 mmHg intraocular pressure. She underwent combined surgery based on phacoemulsification and S2 model Ahmed valve implantation with mitomycin C (0,2 mg/mL) for 5 minutes. The diagnosis was encapsulated filtering bleb at the 8th week of operation. Subconjuctival needle revision with one mg of subtenial bevacizumab (avastin) in the bleb area was performed. Injection was administered every other day till completion of three doses according to the institutional protocol. Eighteen months after the surgery, the intraocular pressure was 17nnHg and the best corrected visual acuity reached 95 VAR best corrected visual acuity(AU)

[Endotoxin Is a Companent in Pathogenesis of Chronic Viral Diseases].

The level of endotoxin and indicators of activity of antiendotoxin immunity (antibody concentration to glycolipid Re-chemotype and general antigen of enterobacteria) were estimated in serum of 174 patients with persistent viral infections (viruses: herpes simplex, hepatitis C, human immunodeficiency). The presence of markers of systemic inflammatory response syndrome (interleukin IL-1ß) and acquired immunodeficiency (CD4+) in HIV-infected patients were also determined. Persistent viral infections are accompanied by endotoxin aggression intestinal origin (caused by them), which is able to induce the development of systemic inflammatory response syndrome. In HIV-infected patients with this syndrome is cyclical, when the phase of hyperactivity replaced immunodeficiency. Schematically, this process can be represented as the following sequence of events: HIV-mediated damage to the intestinal barrier--the development of endotoxin aggression--induction ofsystemic inflammatory response syndrome--the depletion of the immune system, which is transient and is related to the duration of activity of the virus replication cycle, i.e., with damage to enterocytes. Using antiendotoxin component (means of reducing levels of endotoxin in the blood) in the scheme of treatment of persistent viral infections can serve as an element of a successful prevention of complications.

Trabeculectomy ab interno (trabectome): yet another possibility in the treatment of uncontrolled glaucomatocyclitic crisis under systemic valganciclovir therapy?

PURPOSE: To assess the outcome of trabectome surgery in the treatment of glaucomatocyclitic crisis (Posner-Schlossman syndrome) in patients with uncontrolled intraocular pressure (IOP). PATIENTS/METHODS: Trabectome surgery was performed in seven patients with diagnosed glaucomatocyclitic crisis and uncontrolled IOP where cytomegalovirus DNA was verified by polymerase chain reaction in aqueous humour samples. All patients were treated with oral valganciclovir. After surgery the patients were followed-up for 12 months. RESULTS: Mean IOP before trabectome surgery was 40±10 mm Hg (range 33-58 mm Hg). The mean number of antiglaucoma medication prior to surgery was 3.1±0.4. By the end of the 12 months, IOP in all patients was reduced to normal level (13±1 mm Hg) and their antiglaucoma medication was decreased to 0.8±1.1. No recurring attack of glaucomatocyclitic crisis occurred. DISCUSSION: In addition to oral valganciclovir therapy, trabectome surgery seems to be a reliable and effective tool for the management of glaucomatocyclitic crisis with uncontrolled IOP.

Posner-Schlossman glaucomatocyclitic crisis.

In 1948, Posner and Schlossman first reported glaucomatocyclitic crisis, an uncommon form of glaucoma characterized by recurrent unilateral episodes of markedly elevated intraocular pressure (IOP) with mild idiopathic anterior chamber inflammation. The exact etiology of glaucomatocyclitic crisis is not clear. Although it is typically a self-limited condition, some cases with advanced optic nerve cupping and associated visual field loss have been reported. Diagnosis of Posner-Schlossman syndrome is difficult, and it may mimic a variety of ocular disorders. Treatment of this syndrome is directed towards controlling the inflammation and associated IOP elevation.

Iridoplastia con láser argón como tratamiento del iris plateau secundario a múltiples quistes del cuerpo ciliar: seguimiento a largo plazo con biomicroscopía ultrasónica / Argon laser iridoplasty as treatment of plateau-like iris configuration secondary to multiple ciliary body cysts: long-term follow-up by ultrasound biomicroscopy

Caso clínico: Varón de 37 años de edad diagnosticadode cierre angular secundario a quistes neuroepitelialesdel cuerpo ciliar. Se trató mediante iridoplastiaperiférica con láser argón y se realizó seguimientomediante biomicroscopía ultrasónica(BMU). Inicialmente se consiguió una resolucióndel cuadro, pero a los 6 meses los quistes y el cierreangular secundario reaparecieron.Discusión: La iridoplastia periférica con láserargón se ha propuesto como tratamiento en situacionesde bloqueo angular secundario a quistes neuroepitelialesdel cuerpo ciliar. Sin embargo, losquistes y, secundariamente el cierre angular, podríanrecidivar a largo plazo(AU)

Case report: We present a 37 year-old man withsecondary angle closure by neuroepithelial ciliarybody cysts. An argon laser peripherical iridoplastywas performed and ultrasound biomicroscopy(UBM) was employed to follow-up. Initially, thepatient had a favorable response to treatment, butsix months later the cysts and the secondary closedangle reappeared.Discussion: Argon laser peripheral iridoplasty hasbeen proposed as treatment of plateau-like iris configurationresulting from neuroepithelial ciliarybody cysts. However, the cysts and, the secondaryclosed angle could recur in a long-term(AU)

Aproximación diagnóstica a la ciclitis heterocrómica de Fuchs en ausencia de heterocromía / Fuchs´heterochronic cyclits without heterochromia: a diagnostic approach

Objetivo: Obtener pautas de diagnóstico de la ciclitis heterocrómica de Fuchs (CHF) en ausencia de heterocromía utilizando metodología bayesiana. Métodos: Se obtienen las probabilidades pre-test y post-test de que un determinado paciente sin heterocromía pero con otros síntomas característicos de la enfermedad, tales como nódulos iridianos, cataratas, glaucoma o vitritis anterior, tenga CHF. Para ello se utiliza el teorema de Bayes para la probabilidad condicionada. Los valores de la prevalencia de la CHF y de la frecuencia de presentación de los síntomas en la CHF y en el total de las uveitis anteriores se obtienen de los datos de la literatura publicada. Resultados: En ausencia de heterocromía, la combinación de nódulos iridianos junto con cataratas, vitritis o glaucoma, así como la asociación de estos tres últimos síntomas aún sin nódulos supone una probabilidad acumulada de más del 50% de tener la enfermedad. Conclusiones: La coincidencia en un paciente de varios síntomas indicativos aún en ausencia de heterocromía puede hacer que la CHF sea una opción diagnóstica probable

Objective: To obtain diagnostic guidelines of Fuchs’ heterochromic cyclitis (FHC) in the absence of heterochromia using Bayesian methods. Methods: The pre-test and post-test likelihood that a certain patient without heterochromia (but with other characteristic symptoms of the disease such as iris nodules, cataracts, glaucoma or vitritis) has FCH, was assessed by the Bayes’ theorem for conditioned likelihood. The prevalence values of FCH and the presentation rate of symptoms in FCH and in other forms of anterior uveitis were obtained from published literature data. Results: In the absence of heterochromia, the combination of iris nodules together with cataracts, vitritis or glaucoma, and the association of the last three symptoms in the absence of nodules, resulted in an accumulated likelihood of more than 50% of subjects having the disease. Conclusions: The coincidence in one patient of several indicative symptoms, even in the absence of heterochromia, may make FCH a likely diagnostic option

[Intestinal endotoxin in the pathogenesis of ocular inflammatory diseases and the antiendoxin constituent of its treatment].

Blood was studied in 119 patients with ocular inflammatory lesions: endophthalmitis (n = 10), iridocyclitis of viral (n = 47) and unknown (n = 62) genesis, by using the procedures developed by the authors to determine the integral values of the concentration of endotoxin in systemic blood flow and the activity of antiendotoxin immunity. Intestinal endotoxin aggression was found to be involved in the pathogenesis of ocular inflammatory diseases. The use of drugs and procedures, which could diminish the entry of intestinal endotoxin into the blood stream and intensify the processes of its binding and release from systemic blood circulation, substantially enhanced the efficiency of a therapeutic process.

Update on Fuchs' uveitis syndrome.

PURPOSE OF REVIEW: This update aims to summarize the current knowledge on Fuchs' uveitis syndrome and review publications in the last 10 years. Theories on the pathogenesis and etiology of Fuchs' uveitis syndrome are revisited and the management of cataract and glaucoma is updated to reflect recent surgical change. RECENT FINDINGS: Retrospective reviews have highlighted that patients with Fuchs' uveitis syndrome are often initially misdiagnosed. Studies comparing local inflammatory mediators and cell types have found differences in Fuchs' uveitis syndrome, but the differences in steroid response and degree of inflammation remain poorly understood. Local production of antibodies to rubella has been recently reported in the aqueous of all patients with Fuchs' uveitis syndrome and no controls. Excellent visual outcomes from phacoemulsification have been reported with reduced complications compared with extracapsular cataract extraction. SUMMARY: Although a single etiological agent and a sensitive laboratory test for the diagnosis of Fuchs' uveitis syndrome is alluring, the diagnosis of Fuchs' uveitis syndrome remains clinical, at least for now. Phacoemulsification has increased the safety of cataract extraction, and the use of intraocular lens is generally safe. The ideal lens material and design are not yet known, but silicone lenses may be best avoided. Glaucoma is often resistant to treatment and should actively be screened for in patients with Fuchs' uveitis syndrome. Medical and surgical treatment for reducing intraocular pressure should be especially aggressive in these patients. Vitrectomy appears to be safe in patients with visually significant vitreous opacification.

Fuchs' heterochromic cyclitis.

Fuchs' heterochromic cyclitis (FHC) is a chronic anterior segment inflammatory syndrome that accounts for 2 to 3% of all uveitis cases. The etiology is unknown, but Herpes simplex, ocular toxoplasmosis and rubella infection have been implicated in the pathogenesis of the disease. It occurs more commonly in the third and fourth decades of life with an equal gender distribution. Patients are usually asymptomatic but may present with floaters and blurry vision. There is a mild but persistent anterior chamber reaction with diffuse and characteristic white stellate keratic precipitates. Iris and trabecular meshwork show abnormal vessels that may sometimes lead to a hyphema. Synechia formation is uncommon. Heterochromia is considered an important feature and accounts for the name, but it is variable depending on the intensity of the anterior stromal atrophy, initial iris color and amount of pigment in the iris pigmented epithelium. Progression of the disease is associated with cataract formation and glaucoma. Anti-inflammatory treatment is not indicated for the low-grade anterior chamber reaction seen in Fuchs' patients. Occasionally, a short course of corticosteroids is indicated if a symptomatic exacerbation occurs. The long-term prognosis is good, and patients usually maintain a visual acuity of 20/40 or better.

Secondary glaucoma in patients with juvenile rheumatoid arthritis-associated iridocyclitis.

PURPOSE: The prevalence and management of glaucoma were evaluated in patients with juvenile rheumatoid arthritis (JRA)-associated iridocyclitis. METHODS: The records of 69 patients with JRA-associated iridocyclitis were reviewed. RESULTS: Twenty-nine (42%) of these patients had secondary glaucoma or ocular hypertension. Glaucoma was controlled with topical treatment in only 7 of the 41 affected eyes (17%); systemic carbonic anhydrase inhibitor therapy resulted in control of another 8 eyes. Surgery controlled all but one of the remainder. CONCLUSION: Glaucoma is a common complication of JRA-associated iridocyclitis. It results from prolonged, inadequately treated intraocular inflammation and in some instances, from steroid use. Medical and surgical therapy for the glaucoma associated with JRA-uveitis is challenging and incompletely effective. We suspect that a more aggressive approach to the treatment of JRA-associated uveitis, earlier in the course of the disease may reduce this vision robbing contribution to the process.

[Laser tyndallometry and monitoring of treatment in 20 children with juvenile uveitis]. / Laser-Tyndallometrie und Therapie-Monitoring bei juveniler Uveitis--eine retrospektive Untersuchung bei 20 Kindern.

BACKGROUND: Treatment of children with juvenile uveitis requires adequate control of inflammation while minimizing systemic or ocular side effects. The study was performed to evaluate the potential use of the laser flare-cell meter in monitoring and adjustment of therapy in juvenile uveitis. PATIENTS AND METHODS: Retrospectively, we monitored 20 children (11 girls and 9 boys) with an age range from 3 to 15 years presenting with juvenile iridocyclitis (10/20), intermediate (5/20) or posterior (5/20) uveitis. During the follow-up period (median 25.2 months, range: 2 to 83 months) multiple clinical controls were performed. We recorded clinical data, present therapy, and measurements using the laser flare-cell meter (Kowa FC-1000). RESULTS: Laser flare-cell meter measurements were easily obtained and highly reliable even in these young patients. During follow-up, 36 recurrences of intraocular inflammation were detected in 19 eyes. Relapses of inflammation as well as a response to treatment were seen at an early stage. Semiquantitative observations of cells and aqueous flare in the anterior chamber, or visual acuity of patients were less reliable in predicting recurrences. CONCLUSIONS: Laser tyndallometry offers a reliable, examiner-independent method to assess intraocular inflammation in children with juvenile uveitis and to adjust the necessary treatment.

Intravitreal gas injection for hypotony after cataract surgery.

PURPOSE: To evaluate the efficacy and safety of intravitreal perfluoropropane gas injection to treat hypotony after cataract surgery. SETTING: The ophthalmology department of a major tertiary medical center. METHODS: After uneventful cataract extraction, 5 patients with hypotony due to iridocyclitis, choroidal detachment, and serous retinal detachment were treated with an intravitreal injection of 1.0 cc of perfluoropropane gas. RESULTS: The hypotony, choroidal detachment, and exudative retinal detachment resolved in all 5 patients, and visual acuity improved. No complications were observed. CONCLUSION: Intravitreal gas injection can be used to treat hypotony after cataract surgery in selected patients.

Corneal stromal abscesses in the horse: a review of 24 cases.

The medical records of 24 horses with corneal stromal abscesses were reviewed. Twenty of the horses initially presented with a corneal ulcer, corneal opacity, or evidence of ocular pain. All of the horses were treated with topical antibiotics prior to referral. Most had also been treated with topical atropine sulphate and systemic flunixin meglumine. Ophthalmic examinations revealed focal, yellow-white corneal opacities, corneal vascularisation and evidence of iridocyclitis. Nine of the horses were treated primarily medically as the initial response to topical and systemic medication was rapid. Fifteen horses were treated both medically and surgically. Surgical treatment was undertaken when corneal rupture was imminent, the iridocyclitis was intractable or when there was minimal response to intensive medical therapy. The surgical procedure performed in most cases was a deep keratectomy with a conjunctival pedicle flap. Intraoperative specimens for cytology, culture, and/or histopathology contributed to the aetiological diagnosis in 5 of 8 cases in which preoperative cytology and cultures were nondiagnostic. All horses, excluding one that was enucleated at presentation for iris prolapse, had vision at discharge.