Occlusive retinal vasculitis in a patient with West Nile virus

Background: West Nile virus (WNV) was first identified in the United States in 1999. In addition to a spectrum of systemic manifestations, several ocular conditions secondary to the virus have been reported, including chorioretinitis, uveitis and optic neuritis. Age and diabetes mellitus (DM) have been reported to be associated risk factors for the more severe forms of the systemic disease. Only seven cases of occlusive retinal vasculitis have been reported in patients with WNV infection. Case history: A 60‐year‐old Asian male presented with complaints of decreased vision in his left eye. He had been hospitalised approximately seven weeks earlier with meningo‐encephalitis secondary to presumed WNV infection, at which time he was also diagnosed with DM. The visual loss coincided with the manifestation of systemic WNV infection. Old peripheral chorioretinal lesions without active inflammation in both eyes were consistent with WNV infection. In addition, retinal haemorrhage and cotton wool spots were noted in the posterior pole of both eyes with severe macular ischaemia in the left eye. Conclusion: Occlusive retinal vasculitis is an uncommon ocular manifestation of WNV, which should be suspected in patients with meningitis or encephalitis who reside in endemic areas with ocular findings of the disease.     

Towards Gaining the Best Information About Vision to Assist the Recovery of a Patient with Stroke

Abstract

Aim: The aim of this paper is to report on the development and evaluation of a tool, to be used by any healthcare practitioner, to screen for the presence of eye issues and problems in patients who have been diagnosed to have had a stroke. Practitioners caring for patients with stroke often detect stroke-related vision defects but miss pre-existing eye diseases, the need for glasses, and reduced acuity. In stroke units where orthoptists are employed the detection of eye conditions is high (83%) . The availability of orthoptists to work in stroke units is limited, so affected patients are likely to have undetected vision-based problems that may decrease the responsiveness to rehabilitation or prevent adaptations being made that can assist the patient with tasks.

Research design: A retrospective study using patient data collected from 100 patient case histories.

Methodology: The tool is a single page, tick-box checklist. It has 3 sections, each with actions to be implemented as required. The sections are:

a. questions about ocular history and symptoms

b. observation of ocular conditions (red eye, ptosis)

c. tests requiring responses that could be affected by vision defects (ability to fix and follow)

The tool was tested against 100 case histories of patients admitted to hospital following a stroke, comparing the ocular information noted by nonorthoptic healthcare practitioners and information from the orthoptic assessment.

Results: Of the 498 ocular conditions found by the orthoptic assessment, the tool identified 309 (62%). Nonorthoptic healthcare practitioners identified 85 (17%) ocular conditions.

Conclusion: In the absence of orthoptic services, the tool has the capacity to enable improved detection of vision conditions resulting in improved management as well as enhancing the response for rehabilitation.

The study has at all times followed the principles as outlined in the Declaration of Helsinki.     

Development of Vitreoretinal Lymphoma in a Patient with Sarcoid Uveitis

ABSTRACT

Purpose

The purpose of this article is to report the first case of primary vitreoretinal lymphoma in a patient with sarcoid uveitis.     

Bilateral Retrobulbar Neuritis Due to Varicella Zoster Preceding Retinal Necrosis in a Patient with AIDS

Objective: The purpose of this study is to describe a case report of varicella zoster (VZV) infection presenting as bilateral retrobulbar neuritis affecting optic tracts, chiasm, and bilateral optic nerves preceding bilateral progressive outer retinal necrosis in a single patient with AIDS.

Methods:The clinical course of a single patient with confirmed VZV infection will be described including presentation, diagnosis, and treatment.

Results:The affected patient presented with acute, bilateral vision loss, and headache. The patient’s history was devoid of past, concurrent, or subsequent development of herpes zoster dermatitis. The patient lacked signs of meningeal irritation or infection. Diagnosis of VZV arachnoiditis and retrobulbar optic neuritis were confirmed by radiological and CSF examination and preceded the clinical identification of retinal involvement. Despite early, aggressive treatment with intravenous antiviral and steroids, as well as intravitreal antiviral therapy, complete bilateral visual loss resulted.

Conclusion: Varicella zoster continues to present uniquely in patients with acquired immune deficiency syndrome. Absence of retinal involvement doesn’t rule out retrobulbar visual pathways involvement by VZV. The astute clinician should be aware of this presentation and suspect the involvement of varicella zoster in immunocompromised patients presenting with retrobulbar optic neuritis and meningeal involvement with normal fundus exam.     

Subretinal Abscess Due to Nocardia farcinica Resistant to Trimethoprim- Sulfamethoxazole in a Patient with Systemic Lupus Erythematosus

Purpose: To report a case of subretinal abscess due to Nocardia farcinica resistant to trimethoprim-sulfamethoxazole in a patient with systemic lupus erythematosus on immunosuppressive therapy. Design: Observational case report. Methods: We retrospectively studied the medical record of a patient with nocardiosis. Results: The microorganism disseminated from the lungs (pneumonia) to the eye and brain. The ocular lesion appeared to be a yellowish, lobulated subretinal abscess with irregular surface and superficial retinal hemorrhages. As it was not responding to empiric therapy for nocardia, pars plana vitrectomy and aspiration of the subretinal material was performed to confirm the etiology. Conclusion: In an immunocompromised patient with pulmonary involvement and a subretinal abscess with a characteristic aspect, one should consider nocardia as a possible etiology taking into account its possible antibiotic resistances.     

Rituximab for Remission Induction in a Patient with Relapsing Necrotizing Scleritis Associated with Limited Wegener's Granulomatosis

Purpose: The authors report a case of necrotizing scleritis associated with Wegener's granulomatosis (WG), which was treated with rituximab for relapsing disease. Method: Observational case report. Results: A 32-year-old male patient presented with necrotizing scleritis in his left eye. The patient was diagnosed as having limited WG. Cyclophosphamide was begun. Under maintenance treatment with azathioprine two relapses of scleritis occurred. Since a high cumulative dose of cyclophosphamide (22.5 g) was utilized initially, two intravenous infusions of rituximab 1 g was given. Complete resolution of scleritis occurred. Conclusions: Rituximab may be effective to induce remission in patients with scleritis due to WG.     

联合应用磁共振弥散张量成像及质子密度加权成像对青光眼患者中枢神经系统视路的初步研究

[目的]使用磁共振成像观察伴双侧视野缺损的青光眼患者眼外中枢神经系统视路的改变.[方法]前瞻性研究.35名受检者纳入研究.其中,经眼科检查确诊伴双侧视野缺损的原发性慢性闭角型青光眼患者7例;伴双侧视野缺损的原发性开角型青光眼患者12例;正常对照者16人.采用GE SignaHD1.5T超导磁共振扫描仪及头部8通道相控阵头线圈进行扫描;应用弥散张量成像技术测量视路白质纤维束的部分各向异性(FA)及平均扩散系数(DCavg),并行纤维跟踪技术重建白质纤维束;应用冠状位质子密度加权成像技术测量外侧膝状体体积.由两位技术娴熟的神经放射学医生手工描绘感兴趣区,测量双侧视神经、视交叉、双侧视束、双侧视放射的平均FA值、平均DCavg值及双侧外侧膝状体体积.使用SPSS13.0软件进行统计学分析.[结果]不同组间双侧视神经、视交叉、双侧视束、双侧视放射比较,平均FA值差异有统计学意义(F=25.985,20.626,12.262,22.399,21.708,24.994,22.774;P＜0.05),而平均DCavg值差异无统计学意义(F=2.097,2.178,0.530,0.983,0.608,0.866,1.504;P＞0.05);不同组间外侧膝状体体积比较,差异有统计学意义(F=18.631,17.274;P＜0.05).[结论]青光眼患者存在眼外中枢神经系统视路的变性.     

Recovery of Visual Field Defect via Corpus Callosum in a Patient with Cerebral Infarct

Recovery mechanism of visual field defect in stroke patients has not been clearly elucidated. In this study, we report on a patient with a cerebral infarct who showed recovery of visual field defect via the corpus callosum, using diffusion tensor tractography (DTT) for optic radiation (OR). A 57-year-old male patient underwent conservative management for a cerebral infarct in the subcortical white matter of the right temporal lobe. Left homonymous hemianopsia was detected on the 2-week Humphrey visual field test. However, the patient showed improvement of hemianopsia with time; consequently, a left lower peripheral visual defect with the resolution of the upper and medial portions of the initial left hemianopia was observed on the 11-month Humphrey visual field test. Both 2-week and 11-month DTTs for the right OR showed a discontinuation between the right lateral geniculate nucleus (LGN) and the right OR. On 2-week DTT, the left OR was connected to the transcallosal fibres, and on 11-month DTT, these transcallosal fibres were elongated to the right primary visual cortex via the right posterior OR. The visual field defect in this patient appears to have recovered by the neural pathway originating from the left OR and terminating in the primary visual cortex via the transcallosal fibres and right distal OR. We believe that the results of this study may suggest one of the mechanisms for recovery of visual field defect following injury of OR in stroke patients.     

Rapid seroconversion to Treponema pallidum and HIV positivity in a patient with retinal vasculitis

A patient with idiopathic retinal vasculitis was found to have rapid conversion of serological tests for Treponema pallidum and HIV. The diagnosis was confirmed by Venereal Disease Research Laboratory (VDRL) testing and dark ground illumination for T. pallidum, and enzyme-linked immunosorbent assay (ELISA) and Western blot assay tests for HIV. Following treatment with intravenous penicillin, the fundus lesions resolved and visual acuity recovered from inaccurate light projection to 6/24 in the right eye and from counting fingers close to face to 2/60 in the left eye. Serological tests for T. pallidum in patients with concurrent HIV infection may be unpredictable. Hence, it is important to repeat these tests even in the early treatment phase of patients with retinal vasculitis who have shown initial seronegativity. This enables earlier diagnosis and initiation of specific treatment.     

Response of choroidal thickness to aerobic exercise in subjects with primary open-angle glaucoma

目的:研究原发性开角型青光眼患者有氧运动前后脉络膜厚度的变化.方法:研究选取17例正常受试者(对照组)及17例原发性开角型青光眼患者(试验组)进行有氧运动(慢跑),运动前后依次记录脉络膜厚度(ChT),眼压(IOP)及平均动脉压数值(MAP).结果:1)运动后对照组及试验组ChT及IOP均出现显著性降低,其中,试验组运动后ChT及IOP降低幅度更为显著.2)运动后对照组及试验组MAP均出现显著性升高,而对照组MAP升高幅度更为明显.3)受试者工作曲线分析提示:对照组与试验组运动前后ChT变化量及IOP变化量曲线下面积分别为0.75及0.281.结论:有氧运动所诱导的交感神经活性升高可能是运动后ChT及IOP降低,MAP升高的主要原因.而POAG患者自主神经功能紊乱是导致运动后ChT,IOP及MAP与正常人存在不同反应性的主要因素.     

Use of Dermal Filler to Improve Exposure Keratopathy in a Patient with Restrictive Dermopathy

ABSTRACT

A 26-year-old female with “Progeria-like” phenotype presented with bilateral lagophthalmos and exposure keratopathy. Given the paucity of available skin to harvest, in conjunction with co-morbidities, standard surgery in the form of conventional skin grafting was contraindicated. We highlight the role of dermal fillers in such situations to reduce upper lid sulcus hollowing and increase weight of the upper lid in order to reduce lagophthalmos.     

Photodynamic Therapy Combined with Intravitreal Bevacizumab in a Patient with Choroidal Neovascularization Secondary to Choroidal Osteoma

Choroidal osteoma is a benign ossified tumor that is found predominantly in healthy young women during their second and third decades of life. The lesions are white-to-cream or orange in color, are located in the peripapillary and macular areas, and are unilateral in most patients. The symptoms of choroidal osteoma include decreased visual acuity and metamorphopsia or scotoma corresponding to the location of the osteoma, but some patients have no symptoms. Prognosis of vision varies according to tumor location, retinal pigment epithelial and sensory retinal degeneration, subretinal fluid and hemorrhage, and development of a subretinal neovascular membrane.     

Bilateral Optic Nerve Involvement Combined with Unilateral Facial Palsy in a Patient with Acute Myeloid Leukaemia: A Case Report

Central nervous system (CNS) involvement, including optic nerve involvement, in a patient with acute myeloid leukaemia (AML) is an extremely rare condition. We report a case of bilateral optic nerve involvement combined with unilateral facial palsy in a patient with AML who achieved complete remission following allogenic peripheral blood stem cell transplantation as a young patient. After further evaluation, the patient was diagnosed with a recurrence of AML with CNS involvement. The presentation of multiple types of CNS involvement in AML may be suspicious evidence of AML recurrence.     

Ocular Toxocariasis Presenting as Leukocoria in a Patient with Low ELISA Titer to Toxocara canis

A 4-year-old white female presented with leukocoria of the right eye. White punctate lesions were observed posterior to the retrolental membrane, which suggested retinoblastoma to some examiners. A full history, physical examination, ultrasonography, and CT scan failed to rule the diagnosis of retinoblastoma in or out. A serum ELISA titer was 1:4, which was considered nondiagnostic. Examination of the enucleated eye revealed a midsegment of the second stage larva of Toxocara canis. The strengths and weaknesses of various diagnostic modalities used to differentiate leukocoria caused by retinoblastoma and T canis are discussed.     

Neuroretinitis Secondary to Bartonella Henselae in a Patient with Myelinated Retinal Nerve Fibers: Diagnostic Dilemmas and Treatment

Purpose: To report an unusual case of Bartonella henselae neuroretinitis (BHNR) in a patient with myelinated retinal nerve fibers (MRNFs).

Methods: A 56-year-old male presented for a consultation, because of a decrease in visual acuity from his right eye. Onset was unclear and the patient was not sure if this was a new symptom.

Results: Fundoscopy revealed MRNF without any other clinical findings. After 2 weeks, the patient returned complaining of further visual acuity decrease. Fundoscopy disclosed macular star formation. The patient was treated with azithromycin. The visual acuity deteriorated to 20/400 and we added systemic corticosteroids with slight improvement of the visual fields but minimal visual gain to 20/160. Serology test results were positive for BH (IgG titers>1/256).

Conclusions: Co-existence of BHNR and MRNF can create diagnostic dilemmas. The presence of myelinated nerve sheath in combination with the expected swelling in neuroretinitis may have caused an irreversible mechanical nerve damage.     

Activated protein C resistance in patients with central retinal vein occlusion in comparison to patients with a history of deep-vein thrombosis and a healthy control group

Background: The recently described “APC resistance” caused by a mutant form of factor V (factor V Leiden) is the most frequent cause of hereditary thrombosis. This study was carried out to investigate the association between activated protein C resistance and central retinal vein occlusion (CRVO). We evaluated the prevalence of APC resistance in patients with CRVO, patients with a history of deep-vein thrombosis, and a healthy control group. Patients and methods: We examined 107 patients with CRVO, 112 patients with deep-vein thrombosis and 70 healthy individuals. The test performed was a modified APC-resistance assay using factor V-deficient plasma. Results: We identified APC resistance in 5.6 % of patients with CRVO and in 5.7 % of the control group. All carriers were heterozygous. In the deep-vein thrombosis group 23.2 % tested positive for APC resistance. Four patients were homozygous and 22 were heterozygous carriers. Conclusion: These results indicate that APC resistance has no major role in the pathogenesis of CRVO. Routine testing for the presence of factor V Leiden mutant in CRVO is not necessary.

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Hintergrund: Der am h?ufigsten vorkommende genetische Defekt innerhalb der Gerinnungskaskade ist eine Faktor-V-Mutation, die eine Inaktivierung von Faktor Va durch aktiviertes Protein C (APC) verhindert. Diese Mutation ist die h?ufigste Ursache für tiefe Thrombosen im Bein- und Beckenvenensystem. Um die Bedeutung der APC-Resistenz bei Zentralvenenverschlu? (ZVV) zu untersuchen, wurden Patienten mit ZVV mit Patienten mit tiefen Bein- und Beckenvenenthrombosen und einer gesunden Kontrollgruppe verglichen. Patienten und Methode: Wir untersuchten 107 Patienten mit fluoreszenzangiographisch gesichertem ZVV. Zum Vergleich wurde bei 112 Patienten mit Becken- und Beinvenenthrombosen sowie einer gesunden Kontrollgruppe von 70 Personen die APC-Resistenz unter Verwendung von Faktor-V-Mangelplasma bestimmt. Ergebnisse: Sechs von 107 Patienten mit ZVV zeigten eine heterozygote APC-Resistenz. Das entspricht 5,6 % im Vergleich zu gefundenen 5,7 % in der Kontrollgruppe. Bei den Patienten mit tiefen Becken- und Beinvenenthrombosen fanden wir in 23,2 % eine APC-Resistenz. 4 Patienten waren homozygot und 22 Patienten heterozygot. Schlu?folgerung: Die APC-Resistenz wird als Mitursache für die Entwicklung eines ZVV diskutiert. In unserer Studie ist die APC-Resistenz bei Patienten mit ZVV im Vergleich zum gesunden Kontrollkollektiv nicht erh?ht und stellt somit keinen Risikofaktor dar.

     

Patients with AMD and a large absolute central scotoma can be trained successfully to use eccentric viewing,as demonstrated in a scanning laser ophthalmoscope

Twenty patients with age-related macular degeneration, an absolute central scotoma and a mean visual acuity of 0.04 (20/475) were studied. A scanning laser ophthalmoscope (SLO) was used for microperimetry and determination of preferred retinal locus, often located to the left of the retinal lesion (corresponding to a location to the left of the visual field scotoma), which is considered unfavorable for reading. All 20 patients were trained to use a new and more favorable retinal locus for reading, above (or occasionally below) the retinal lesion (corresponding to a location below or above the visual field scotoma), first by reading scrolled text under simultaneous fixation monitoring and instruction in the SLO and then by reading printed text, using high magnification (mean 14.3x). For the 18 patients who learned to use eccentric viewing, reading speed with adequate magnification prior to training was 9.0+/-5.8 words/min. With training (mean 5.2 hours), it increased significantly (p<0.001) to 68.3+/-19.4 words per min. Training of eccentric reading has thus proved to be very successful.     

Prediction of response to treatment in patients with scleritis using a standardised scoring system

Scleritis is a severe chronic inflammation of the eye wall. High-dose corticosteroids and other immunosuppressive drugs are often required to control the inflammatory process. With the development of new and potentially more effective treatment modalities for scleritis has emerged the need for an accurate and reproducible system for quantifying the severity of scleritis and evaluating the response of individual patients to treatment.
We have developed a quantitative scoring system, based on common clinical signs of scleritis, and evaluated it in 24 patients with scleritis. Our results indicate that this system is simple, rapid, reproducible and useful in grading the severity of scleritis and in predicting the response of patients to systemic immunosuppressive therapy.     

Neuropeptide Y system in the retina: From localization to function

The retina is a highly complex structure where several types of cells communicate through countless different molecules to codify visual information. Each type of cells plays unique roles in the retina, presenting a singular expression of neurotransmitters. Some neurotransmitter systems in the retina are well understood, while others need to be better explored to unravel the intricate signaling system involved. Neuropeptide Y (NPY), a 36 amino acid peptide, is one of the most common peptide neurotransmitter in the CNS and a highly conserved peptide among species. We review the localization of NPY and NPY receptors (mainly NPY Y₁, Y₂, Y₄ and Y₅) in retinal cells. Common features of the expression of NPY and NPY receptors in mammalian and non-mammalian species indicate universal roles of this system in the retina. In the present review, we highlight the putative roles of NPY receptor activation in the retina, discussing, in particular, their involvement in retinal development, neurotransmitter release modulation, neuroprotection, microglia and Muller cells function, retinal pigmented epithelium changes, retinal endothelial physiology and proliferation of retinal progenitor cells. Further studies are needed to confirm that targeting the NPY system might be a potential therapeutic strategy for retinal degenerative diseases.