Rare Association of Perivascular Granulomatous Lesions in a Patient with Acute Retinal Necrosis

Purpose

The aim of this study was to examine sequential changes in perivascular granulomatous lesions with acute retinal necrosis (ARN).

Methods

A healthy 46-year-old Japanese woman, who developed floaters and pain in her left eye, underwent optical coherence tomography (OCT), fluorescein angiography, and routine ophthalmological examinations. Treatment-associated changes in perivascular granulomatous lesions were monitored using spectral-domain (SD)-OCT.

Results

The patient had no previous ophthalmic history, and her general condition was good. A slit-lamp examination revealed keratic precipitates and aqueous cells (2+) in the left eye. A fundus examination showed yellow-white patches of necrotizing retinal lesions in the temporal upper area, retinal arteritis, retinal hemorrhage, and vitreous opacities. The patient was diagnosed with ARN according to diagnostic criteria. SD-OCT images confirmed high-intensity and uniform granulomatous deposits in the perivascular area and fovea. Systemic corticosteroids and antiviral therapy were initiated, resulting in the gradual resolution of granulomatous lesions. The patient continues to be followed untreated without evidence of recurrence, retinal detachment, or active inflammation.

Conclusions

This is the first report of perivascular granulomatous lesions in a patient with ARN. Our results showed that the formation of granulomas may be induced in the retina of ARN patients without fulminant inflammation.Key Words: Acute retinal necrosis, Optical coherence tomography, Granuloma     

Progressive Outer Retinal Necrosis and Immunosuppressive Therapy in Myasthenia Gravis

Introduction

Progressive outer retinal necrosis (PORN) is a rare but devastating infectious retinitis associated with varicella zoster virus (VZV) and responsible for severe visual loss.

Case Report

A 59-year-old man treated for generalized myasthenia with oral azathioprine and prednisone presented with severe unilateral necrotizing retinitis. Polymerase chain reaction of the aqueous and vitreous humors was diagnostic for VZV PORN.

Conclusion

VZV PORN is a severe potential ocular complication of immunosuppression, prompting urgent diagnosis and appropriate treatment.Key words: Retinitis, Progressive outer retinal necrosis, Varicella zoster retinitis     

Acute Retinal Necrosis in Childhood

Background

Acute retinal necrosis (ARN) is a viral syndrome consisting of uveitis/vitritis, occlusive vasculitis and peripheral necrosis. Few incidents are reported in children. The etiology is reactivated herpes simplex virus (HSV) or varicella-zoster virus (VZV). Treatment with acyclovir is often used. The administration of oral glucocorticosteroids is of unproven benefit. Prognosis is variable but poor.

Methods

Three weeks after contracting mild chickenpox, a healthy 4-year-old girl developed blurred vision in her right eye. Severely reduced visual acuity was noted, together with anterior uveitis, ‘mutton-fat’ precipitates and vitral flare. Retinal vasculitis with necrosis was present. Serology for toxoplasma, cytomegalovirus and HIV was negative, while HSV and VZV IgG antibodies were positive. She was treated with 30 mg/kg of intravenous methylprednisolone (3 days), 30 mg of oral prednisone (3 days), and tapering for 8 weeks. Intravenous acyclovir was given for 10 days, followed by oral acyclovir for 4 months. Aspirin (100 mg/day) was given for 4 months.

Results

At 12 months, the girl felt good. Her right eye acuity was 6/9, with an intraocular pressure of 17 mm Hg. The peripheral retina showed scarring but no detachment.

Conclusions

This is the first report of a once-daily high-dose methylprednisolone pulse therapy in one of the youngest known ARN cases. Pulsed steroid therapy was based on its known effectiveness in vasculitis, which is the main pathophysiology in ARN. There was no evidence of steroid-related viral over-replication. Our case achieved an excellent clinical and ophthalmic recovery in spite of the poor prognosis. The positive result of this case report provides a basis for further evaluation of high-dose steroid pulse therapy in ARN.Key words: Retinal necrosis, Children, Methylprednisolone     

Effect of aminoguanidine on caspase-3 expression in rat retina after ischemia-reperfusion injury

AIM: To investigate the effect of aminoguanidine(AG) on the expression of caspase-3 in rat retina after ischemia- reperfusion injury. METHODS: The rats were anesthetized with 30mg/kg sodium pentobarbital introperitoneal(ip) injections. After topical application of 10g/L dicaine,the anterior chamber was punctured with a 5-gauge needle connected to a bottle containing normal saline. Intraocular pressure was raised to 100 mmHg by elevating the saline container. The infusion needle was removed from the anterior chamber 60 minutes later. Reperfusion of the retinal vasculature was confirmed by fundus examination. AG 100mg/kg was ip injected in drug group. The rats were then euthanatized at 6, 24, and 72 hours after reperfusion, and their eyes were enucleated for immunohistochemistry. RESULTS: No specific staining was detected by using the caspase-3 antibody in the retina of control group. In ischemia group, the protein of caspase-3 was over-expressed at 6 hours and relieved at 24 hours and 72 hours, while with drug treatment, the expression of protein of caspase-3 was decreased at each time point. CONCLUSION: AG provides retinal protection against ischemia-reperfusion injury in rat retina, probably through an inducible NOS-dependent mechanism.     

Intraretinal Exudates in Coats' Disease as Demonstrated by Spectral-Domain OCT

Purpose

To describe the spectral-domain optical coherence tomography (SD-OCT) findings in a case of Coats'' disease, with emphasis on the intraretinal exudates.

Methods

Case report of a 4.5-year-old girl who presented with total exudative retinal detachment and organized exudates in a stellate configuration. SD-OCT was performed before and after treatment, which included surgical drainage of subretinal fluid and indirect laser application during the surgery.

Results

At presentation, the SD-OCT showed an elevation of the foveal contour, with thickening of the retina, many exudates and a large quantity of subretinal fluid. Two months after the surgical treatment, SD-OCT revealed a significant reduction in the amount of subretinal fluids, but with persistence of the exudates.

Conclusion

SD-OCT can be used as an important tool in order to describe the changes in each layer of the retina in Coats'' disease. Considering the histopathological findings in Coats'' disease, it is reasonable to assume that the exudates accumulate in the outer plexiform layer.Key words: Coats'' disease, Intraretinal exudates, Outer plexiform layer, Spectral-domain optical coherence tomography     

Macular edema formation and deterioration of retinal function after intravitreal bevacizumab injection for proliferative diabetic retinopathy

Purpose

To report a case of proliferative diabetic retinopathy (PDR) showing transient macular edema (ME) and deteriorated retinal function after intravitreal bevacizumab injection (IVB).

Methods and Results

A 53-year-old man received IVB (1.25 mg/0.05 ml) in both eyes for the treatment of PDR. There was no treatment-related complication. However, he complained of photopsia in both eyes 6 h after the injection. Slit-lamp examination revealed mild cellular infiltrations (1+) in the anterior chamber in both eyes. Optical coherence tomography showed ME formation in the left eye. Both full-field and multifocal electroretinography (ERG) revealed the deterioration of all parameters in both eyes compared with pretreatment. The inflammation in the anterior segment and ME disappeared 1 day after the injection. ERG parameters were improved 9 days after the injection, except for the N1 and P1 amplitude of multifocal ERG in the left eye.

Conclusion

We propose that patients who undergo IVB should be carefully informed and followed up for possible complications including temporal ME formation and retinal function deterioration.Key Words: Anti-vascular endothelial growth factor, Bevacizumab, Avastin, Multifocal electroretinography, Full-field electroretinography, Diabetic retinopathy, Optical coherence tomography, Macular edema     

Acute retinal necrosis in the United Kingdom: results of a prospective surveillance study

Background

To determine the incidence of acute retinal necrosis (ARN) in the United Kingdom and to describe the demographics, management, and visual outcome in these patients.

Methods

This was a prospective study carried out by the British Ophthalmological Surveillance Unit (BOSU) between September 2007 and October 2008. Initial and 6-month questionnaires were sent to UK ophthalmologists who reported cases of ARN via the monthly BOSU report card system.

Results

In all, 45 confirmed cases (52 eyes) of ARN were reported in the 14-month study period, giving a minimum incidence of 0.63 cases per million population per year. There were 20 females and 25 males. Age ranged from 10 to 94 years. Eight patients had a history of herpetic CNS disease. Aqueous sampling was carried out in 13 patients, vitreous in 27, and cerebrospinal fluid (CSF) in 4. Varicella-zoster virus followed by herpes simplex were the most common causative agents. Treatment in 76% of the cases was with intravenous antivirals; however, 24% received only oral antivirals. In all, 47% of patients had intravitreal antiviral therapy. Visual outcome at 6 months was <6/60 in 48% of the affected eyes.

Conclusion

The minimum incidence of ARN in the UK is 0.63 cases per million. Patients with a history of herpetic CNS disease should be warned to immediately report any visual symptoms. There is increased use of oral and intravitreal antivirals in initial treatment.     

Coincidence of Varicella-Zoster Virus Anterior Uveitis in a Patient with Chandler's Syndrome

Purpose

We report a patient who, based on the clinical manifestations, was originally diagnosed as having Chandler''s syndrome and later developed varicella-zoster virus (VZV) DNA-positive anterior uveitis.

Methods

The patient with Chandler''s syndrome who manifested anterior uveitis underwent a complete ophthalmologic examination. Polymerase chain reaction (PCR) was used to amplify the viral DNA in the aqueous humor to determine the cause of the intraocular inflammation.

Results

Slit-lamp biomicroscopy showed focal iris atrophy and peripheral anterior synechiae (PAS); specular microscopy of the corneal endothelium disclosed the hammered-silver appearance. Based on these clinical findings, we diagnosed this patient as having Chandler''s syndrome. During the follow-up period, however, the inflammatory cells suddenly appeared in the anterior chamber with formation of keratic precipitates and an increased intraocular pressure (IOP). VZV DNA was displayed in the aqueous humor by PCR. Based upon the diagnosis of VZV anterior uveitis, corticosteroids and acyclovir were given topically and systemically. The inflammation subsided with these medications; however, trabeculectomy was finally needed to control the IOP due to PAS progression.

Conclusion

The coincidence of VZV anterior uveitis with Chandler''s syndrome may constitute an implication for the possible viral etiology of iridocorneal endothelial syndrome.Key words: Chandler''s syndrome, Iridocorneal endothelial syndrome, Varicella-zoster virus, Anterior uveitis     

A Large Retinal Capillary Hemangioma in the Anterior Retina Treated with Photodynamic Therapy

Purpose

To report a case of a large anterior retinal capillary hemangioma (RCH) treated successfully with photodynamic therapy (PDT).

Methods

Case report.

Results

A 12-mm-large RCH located in the anterior retina, with vision-threatening exudative complications that had not responded to cryotherapy and repeated laser photocoagulations, was treated with PDT using verteporfin. Exudation regressed and tumor growth arrested after treatment.

Conclusion

PDT can be delivered effectively to a lesion in the anterior retina and should be included as an option for treating anteriorly located RCH when conventional cryotherapy and laser photocoagulation fail.Key words: Retinal capillary hemangioma, Photodynamic therapy, Subretinal fluid     

Efficacy and safety of a new surgical method to treat malignant glaucoma in pseudophakia

Purpose

To assess the efficacy and safety of a relatively new surgical method in pseudophakic malignant glaucoma patients.

Methods

This study is a retrospective, non-comparative, interventional case series. Ten eyes of nine pseudophakic malignant glaucoma patients with mean age of 63.3 years were analysed. All 10 eyes underwent a novel surgical technique, an anterior chamber capsulo-hyaloidectomy and anterior vitrectomy through the peripheral iridectomy. Main outcome measures were: reformation of the anterior chamber, intraocular pressure (IOP), best-corrected visual acuity (BCVA), and complications.

Results

All 10 eyes with pseudophakic malignant glaucoma were treated successfully by using a new surgical technique. All cases had a relief of aqueous misdirection with anterior chamber deepening during and after the surgery and post-operative intraocular pressure (IOP) normalization. No relapses have been observed so far. There were no complications during surgery and in the post-operative period.

Conclusion

The presented surgical technique seems to be safe and effective in all cases of malignant glaucoma in pseudophakia.     

Scanning beyond the limits of standard OCT with a Fourier domain optical coherence tomography integrated into a slit lamp: the SL SCAN-1

Purpose

With a new Fourier domain optical coherence tomography (FD OCT) device, SL SCAN-1 (Topcon Europe Medical BV, Capelle a/d IJssel, The Netherlands), integrated into a slit-lamp OCT, scans can be obtained through a handheld lens. The necessary adjustment of the reference arm is possible by fast Z-alignment. This study was performed to prove the capability of SL SCAN-1 to scan through a three-mirror contact lens, scanning the peripheral retina and anterior chamber angle.

Methods

Different representative pathologies of the peripheral retina and anterior chamber were simultaneously observed and scanned with the SL SCAN-1. The scans of peripheral retinal lesions were obtained both through a handheld lens and through a three-mirror contact lens. The anterior chamber angle was scanned directly with the SL SCAN-1 in anterior mode, and through the gonio-mirror of a three-mirror contact lens with the SL SCAN-1 in posterior mode.

Results

OCT scans could be obtained with the SL SCAN-1 of the peripheral retina through both, a common handheld lens and a three-mirror contact lens. The scans obtained through a three-mirror contact lens were of better quality, visualizing details of the different layers of the retina more clearly. The scans of the anterior chamber, obtained through the gonio-mirror of a three-mirror contact lens, visualized the open anterior chamber angle, with details of fine structures.

Conclusions

The SL SCAN-1 is a unique FD OCT system, which is able to scan not only the posterior pole and anterior segment but also the anterior chamber angle and the more peripheral retina. These four modalities combined into one device could make the SL SCAN-1 a very powerful aid in daily practice.     

Toxic Anterior Segment Syndrome following a Triple Descemet's Stripping Automated Endothelial Keratoplasty Procedure

Purpose

To present a unique case of a 58-year-old female with toxic anterior segment syndrome (TASS), following a triple procedure: Descemet''s stripping automated endothelial keratoplasty (DSAEK), phacoemulsification and posterior chamber intraocular lens implantation.

Methods

The patient was treated with topical dexamethasone sodium phosphate 0.1% and topical atropine sulfate 1%. Due to a slow improvement in her clinical status, oral prednisone 1 mg/kg/day was added.

Results

The anterior chamber reaction improved gradually, with tapering down of topical and oral treatment, until a complete resolution of the anterior chamber reaction was observed.

Conclusions

Taking into account the estimated volume of DSAEK triple procedures performed worldwide, we would expect an annual incidence of several TASS cases, following triple DSAEK procedures. However, we were unable to find any such previous reports in the literature. This fact raises questions regarding the cause of reduced TASS incidence following triple DSAEK procedures.Key words: Toxic anterior segment syndrome, Triple procedure, Descemet''s stripping automated endothelial keratoplasty     

Anterior Chamber Measurements by Pentacam and AS-OCT in Eyes With Normal Open Angles

Purpose

To assess the reproducibility and agreement of anterior chamber measurements between the Pentacam (PTC) and the Anterior segment optical coherence tomography (AOCT) in normal healthy eyes with open angle.

Methods

Prospective cross-sectional comparative case series. A total of 162 eyes of 81 healthy volunteers with normal open angle were included in this study. Anterior chamber angle (ACA) and anterior chamber depth (ACD) were measured with PTC and AOCT. Intra-observer variability and inter-methods agreement of both instruments for ACA and ACD were evaluated.

Results

Values of temporal and nasal ACA measured by two instruments were similar, and the results of ACD were also not significantly different between modalities (p>0.01). ACA and ACD measurements by PTC and AOCT showed good intra-observer and inter-method agreements (all >0.9).

Conclusions

PTC and AOCT are presumed to be very useful for the anterior chamber angle examination. They may provide good images and quantitative data about the angle structures including ACA and ACD.     

Evaluation of Anterior Segment Parameters in Obesity

Purpose

To investigate anterior segment parameters in obese patients in comparison to healthy individuals.

Methods

Thirty-four obese subjects and 34 age-sex-matched healthy subjects were enrolled in this prospective cross-sectional study. Ophthalmological examinations including intraocular pressure (IOP), central corneal thickness (CCT), anterior chamber depth (ACD), anterior chamber volume (ACV), anterior chamber angle (ACA), and axial length (AL) measurements were performed on each subject. Height and weight of all subjects were recorded and body mass index (BMI) was calculated.

Results

IOP was significantly higher in the obese group (p = 0.003). The mean ACD in obese subjects was significantly lower than that in control subjects (p = 0.036). AL, ACV, ACA and CCT were not significantly different between the groups. There was a positive correlation between BMI and IOP (r = 0.404, p < 0.001). ACD and ACA were negatively correlated with BMI.

Conclusions

IOP was significantly higher and ACD was significantly lower in obese subjects. AL, ACV, ACA and CCT were not significantly different between the groups. The impact of obesity on anterior chamber parameters should be further investigated.     

Expression of neuroglobin in ocular hypertension induced acute hypoxic-ischemic retinal injury in rats

AIM: To investigate the expression of neuroglobin (Ngb) in the retina of rats with ocular hypertension induced acute retinal hypoxic-ischemic injury. METHODS: Seventy Wistar rats were divided into 7 groups randomly. The experimental model was induced by elevation of intraocular pressure via anterior chamber canula insertion in the left eyes and the fellow eyes were preserved as normal controls. The retinal tissues were taken at 1, 5, 10, 15, 20, 30 and 60 minutes after hypoxic-ischemia injury. Protein was extracted, and then analyzed by Western-blot method. SPSS was used for statistical analysis. RESULTS: The time-depended expressions of Ngb were observed. The level of Ngb increased rapidly at 1 minute after ischemia and reached to the peak at 5 minutes, which had significant difference from that of control group (P<0.05). It kept in high level during 5-15 minutes (P<0.05), then decreased after 20 minutes till 60 minutes. There were no significant differences between experimental and control group in the latter period (P＞0.05). CONCLUSION: The expression of Ngb in retinal tissue increased rapidly after hypoxic-ischemic injury in rats, suggesting that Ngb may play an important role in the process of acute retinal hypoxic-ischemic injury.     

A Case of Delayed-Onset Propionibacterium acnes Endophthalmitis after Cataract Surgery with Implantation of a Preloaded Intraocular Lens

Purpose

To report a case of delayed-onset endophthalmitis after implantation of a preloaded intraocular lens (IOL) and examine the surgically removed IOL by scanning electron microscopy (SEM).

Case

A 77-year-old female underwent uneventful phacoemulsification and aspiration with preloaded silicone IOL implantation. Since intraocular inflammation unexpectedly worsened 1 month after the surgery, she was referred to our hospital. Her visual acuity was hand motion in the left eye. Hypopyon and fibrin formation were observed in the anterior chamber. A diagnosis of postoperative delayed-onset endophthalmitis was made, and vitrectomy with anterior chamber wash-out was performed. As intraocular inflammation remained unchanged postoperatively, an additional surgery with IOL removal was performed. We cultivated the surgically removed samples of aqueous humor and vitreous fluid under both aerobic and anaerobic conditions, performed 16S rDNA clone library analysis of these clinical samples, and examined the removed IOL by SEM.

Result

Inflammation subsided after the re-operation. Although cultures of aqueous and vitreous samples were negative, DNA of Propionibacterium acnes was detected in the aqueous humor. The SEM images showed that the rod bacteria and biofilm-like material formed on the tip of the IOL haptic.

Conclusion

Delayed-onset endophthalmitis may occur after uneventful implantation of a preloaded IOL. The SEM findings suggested that the tip of the preloaded IOL haptic might scratch bacteria which adhered to the tip of the injector nozzle when the IOL was inserted into the anterior chamber. In some cases with delayed-onset endophthalmitis, IOL removal is needed to eliminate the bacteria which adhere to the tip of the IOL haptic.Key Words: Endophthalmitis, Preloaded intraocular lens, Propionibacterium acnes, Scanning electron microscopy     

Laser peripheral iridotomy with iridoplasty in primary angle closure suspect: anterior chamber analysis by pentacam

Purpose

To compare conventional laser peripheral iridotomy (LPI) and LPI combined with laser peripheral iridoplasty in eyes with primary angle closure suspect (PACS) by assessment of anterior chamber dimensional changes using a Pentacam.

Methods

Forty-eight eyes of 24 subjects with bilateral PACS were recruited consecutively. Each eye was randomly allocated to treatment with conventional LPI, argon LPI only, or LPI plus iridoplasty, which consisted of simultaneous argon LPI and peripheral iridoplasty. Anterior chamber measurements were performed on each eye using a Pentacam, both before and after treatment. Mean anterior chamber depth (ACD), anterior chamber volume (ACV), and anterior chamber angle were measured, and topographic ACD analysis was performed. Results were compared between the two treatment groups.

Results

After treatment with either conventional LPI or LPI plus iridoplasty, the mean ACD and ACV increased significantly. Topographic ACD analysis revealed that the mid-to-peripheral ACD increase was significantly greater in the LPI plus iridoplasty group than in eyes treated with conventional LPI. Intraocular pressure changes and post-LPI complications did not differ between the groups.

Conclusions

Compared with conventional LPI, our study showed that LPI plus iridoplasty improved the mid-to-peripheral ACD increase. This procedure may have a role as an adjunct for reducing angle closure by simultaneously eliminating pupillary and non-pupillary block components.     

Trocar-assisted sutureless intrascleral posterior chamber foldable intra-ocular lens fixation

Purpose

We report a novel technique characterized by sutureless scleral fixation of three-pieces foldable intraocular lens (IOL) using 25-gauge transconjunctival sutureless vitrectomy (TSV) trocars in patients with insufficient posterior capsule support.

Materials and Methods

We performed this technique on the eight eyes of the seven patients. The scleral tunnels (STs) are prepared by insertion of the 25-gauge TSV microcannulas using the trocars, and anterior vitrectomy is performed through the clear corneal paracentesis with the aid of anterior chamber maintainer (ACM). Finally, the three-piece foldable IOL haptics are incarcerated into the prepared STs.

Results

The patients were followed up 5–8 months. None of the patients had complications such as postoperative endophthalmitis, glaucoma, IOL tilt or decentralization, and retinal detachment. Injection of a foldable IOL through a clear corneal small incision also contributes the less surgical-induced astigmatism.

Conclusion

The presented novel sutureless scleral IOL fixation technique may provide minimal trauma to the surrounding tissues, good IOL stabilization decreasing the incidence of IOL tilt along with shorter operation time, and postoperative quiet eye.     

Effect of air bubble on inflammation after cataract surgery in rabbit eyes

Purpose:

Intense inflammation after cataract surgery can cause cystoid macular edema, posterior synechia and posterior capsule opacification. This experimental study was performed to investigate the effect of air bubble on inflammation when given to anterior chamber of rabbit eyes after cataract surgery.

Materials and Methods:

30 eyes of 15 rabbits were enrolled in the study. One of the two eyes was in the study group and the other eye was in the control group. After surgery air bubble was given to the anterior chamber of the study group eye and balanced salt solution (BSS; Alcon) was left in the anterior chamber of control eye.

Results:

On the first, second, fourth and fifth days, anterior chamber inflammations of the eyes were examined by biomicroscopy. On the sixth day anterior chamber fluid samples were taken for evaluation of nitric oxide levels as an inflammation marker. When the two groups were compared, in the air bubble group there was statistically less inflammation was seen. (1, 2, 4. days P = 0,001, and 5. day P = 0,009).

Conclusions:

These results have shown that when air bubble is left in anterior chamber of rabbits’ eyes after cataract surgery, it reduced inflammation. We believe that, air bubble in the anterior chamber may be more beneficial in the cataract surgery of especially pediatric age group, uveitis patients and diabetics where we see higher inflammation. However, greater and long termed experimental and clinical studies are necessary for more accurate findings.     

A Case of Ampiginous Choroiditis

Purpose

Presentation of a case report of a unilateral ampiginous choroiditis.

Methods

This is an observational case report.

Results

A 70-year-old woman was referred to us with unilateral scattered chorioretinal lesions. The multifocal pattern of the lesions and the angiographic features led to the diagnosis of ampiginous choroiditis.

Conclusion

Ampiginous choroiditis is a primary inflammatory choriocapillaropathy with characteristics of both acute posterior multifocal placoid pigment epitheliopathy and serpiginous choroiditis.Key Words: Ampiginous choroiditis, Relentless placoid chorioretinitis, Primary inflammatory choriocapillaropathy