Recurrent intrascleral cyst after strabismus surgery

BACKGROUND

Intrascleral epithelial inclusion cysts have been described after ocular trauma, scleral buckling and strabismus surgery. They are usually small, asymptomatic and located anteriorly.

CASE REPORT

The clinical history of a 9-year-old girl who developed a huge epi- and retrobulbar intrascleral cyst in both the upper and the lower nasal quadrants after multiple strabismus operations is described.

RESULTS

Surgical resection of the cyst wall was twice unsuccessful. Drainage of the cyst, followed by the injection of tetracycline (30 mg/ml) in the cyst site, led to complete recovery.

CONCLUSION

Recurrent posteriorly located intrascleral cyst can occur after strabismus surgery. Therapy consisting of drainage combined with intrascleral administration of tetracycline solution (30 mg/ml) to induce sclerodesis appeared to be effective during a 2-year follow-up period.

Autosomal dominant central areolar choroidal dystrophy caused by a mutation in codon 142 in the peripherin/RDS gene

PURPOSE

Because several macular dystrophies are caused by mutations in the peripherin/RDS gene, we examined autosomal dominant and sporadic cases of central areolar choroidal dystrophy for mutations in the peripherin/RDS gene.

METHODS

DNA sequence analysis of the peripherin/RDS gene was performed in four sporadic cases and in ten affected and nine unaffected individuals from seven families with autosomal dominant central areolar choroidal dystrophy.

RESULTS

An Arg-142-Trp mutation in the peripherin/RDS gene was found in ten affected family members in seven families. Among these, a 69-year-old man with the Arg-142-Trp mutation, who was unaffected six years before blood sample analysis, showed a parafoveal area of chorioretinal atrophy. The 65-year-old sister of this family had the Arg-142-Trp mutation with no macular abnormalities, but she might still develop central areolar choroidal dystrophy at an older age. No mutation was found in the four sporadic cases.

CONCLUSION

Autosomal dominant central areolar choroidal dystrophy, studied in seven families, is caused by an Arg-142-Trp mutation in the peripherin/RDS gene.

Butterfly-shaped pigment dystrophy of the fovea associated with subretinal neovascularization

BACKGROUND

The association of butterfly-shaped pigment dystrophy of the fovea, an uncommon inherited macular disease, with subretinal neovascularization has rarely been reported in the literature.

CASE REPORT

We describe the clinical history of a patient affected with butterfly-shaped pigment dystrophy of the fovea, myopia, and optic nerve head dysplasia. She was followed up for 23 years. During the course of the disease, bilateral subretinal neovascularization in the macular area occurred. Fluorescein angiography confirmed the diagnosis. Recently, indocyanine green (CG) videoangiography was also performed. Because of the bilateral subfoveal localization no laser treatment was advised.

DISCUSSION

Usually, good visual acuity is maintained in this uncommon inherited macular disease. However, acute visual loss can be caused by the ingrowth of subretinal new vessels. Therefore, if visual acuity decreases or metamorphopsia develops in these patients, careful biomicroscopic examination and fluorescein/ICG angiography is advisable.

The development of central areolar choroidal dystrophy

BACKGROUND

Central areolar choroidal dystrophy (CACD) is a hereditary macular disorder of which the development is poorly understood.

METHODS

One hundred and eight members of seven families with CACD underwent ophthalmological examination. If macular alterations were found or suspected, the patients underwent fluorescein angiography, electroretinography (ERG), electrooculography (EOG) and tests of colour vision and visual field. CACD was divided into four stages: I, slight parafoveal changes of the pigment epithelium (RPE); II, RPE mottling encircling the fovea; III, additional atrophy of the choriocapillaris without central involvement; IV, as stage III with central involvement.

RESULTS

In 60 eyes of 30 patients, 8 with stage I, 12 with stage II, 18 with stage III and 22 with stage IV CACD were found. The photopic ERG was subnormal in about half of the cases with stage II-IV. Colour vision tests revealed diminished red sensitivity and pseudoprotanomaly in stages I and II and combined red-green and blue-yellow defect in stages III and IV. Parafoveal reduced sensitivity (stages I and II) and parafoveal and foveal reduced sensitivity (stages III and IV) were found in the visual field tests.

CONCLUSION

We describe and expand the stages of development of CACD. Early recognition of patients may have a great influence on their subsequent life.

Visual acuity and scar size in eyes with age-related subfoveal choroidal neovascular lesions, 30 months after radiation therapy

PURPOSE

In a study to determine the effectiveness of ionizing radiation on the deterioration of visual acuity (VA) due to choroidal neovascularisation (CNV) the affected eyes of 10 patients were treated with a total dose of 24 Gy (6 Gy fractions). A special lens-sparing technique was used to avoid cataract development. During 30 months of follow-up the visual acuity (VA) and scar size (SS) of the treated eyes and fellow eyes of all 10 patients were evaluated.

RESULTS

After 30 months of follow-up 5 eyes showed a stable VA and fluorescein angiogram (FA) appearance. Concerning 4 out of 5 eyes with progressive disease, the 4 eyes treated with radiation therapy had better VA and smaller SS as compared with the untreated fellow eyes with exudative AMD.

CONCLUSIONS

The results suggest that 24 Gy either stabilizes or delays the deleterious effects of CNV on the visual acuity. Until now no late side effects have been observed.

Circumscribed choroidal hemangioma diagnosed by ultrasonography. A retrospective analysis of 40 cases

Circumscribed choroidal hemangioma (CCH), a relatively rare benign tumor, can cause differential diagnostic problems by its atypical appearance at the time of presentation. Ancillary test such as fluorescein angiography, indocyanin green angiography, ultrasonography, computer tomography (CT), magnetic resonance imaging (MRI) bring not always additional information and their results are not always pathognomic. We retrospectively reviewed the clinical records of 40 patients with the ultrasonographical diagnosis of CCH compiled in the last 20 years. Ultrasonography appeared to be uniform in its lesion characteristics and reliable in the diagnosis. During the mean follow-up time of 7.4 years there were no clinical or posttherapeutical developments that made a correction of the diagnosis necessary.

Vitreous haemorrhage and other ocular complications of a persistent hyaloid artery

PURPOSE

To report ocular complications of a persistent hyaloid artery.

METHODS

We studied eight patients with persistent hyaloid artery.

RESULTS

Seven patients showed strabismus and very low visual acuity (< or = 0.12) of one eye. Despite correction of refractive errors, cataract surgery and occlusion therapy for amblyopia, visual acuity had not improved in these cases. Four patients showed nystagmus. Four had progression of unilateral cataract. In two cases, a 24-year-old women and a 4-months-old boy, a vitreous haemorrhage had occurred due to rupture of a hyaloid artery, in the woman's case probably due to a spontaneous posterior vitreous detachment.

CONCLUSION

A persistent hyaloid artery may be associated with strabismus, cataract, amblyopia and nystagmus. Despite amblyopia treatment, the prognosis of visual acuity of the involved eye is unfavourable. A persistent hyaloid artery may cause vitreous haemorrhage.

A spider hits the eye

To determine the necessary medical care and permanent ocular damage of a particular type of preventable ocular trauma, an observational study of 22 patients referred to the University Hospital Nijmegen (1983-1993) with eye injuries caused by the accidental release of tightened elastic straps of the so-called "spider' design was performed. Although the traumatized eyes of the 22 patients could be saved from blindness by extensive medical and surgical treatment in the majority of cases, 13 patients (59%) had residual permanent visual impairment (visual acuity < or =6/10, or aphakia) at the end of the follow-up period. Three of them had lost the perception of light in the involved eye; one painful blind eye had to be removed. It is concluded that elastic straps with free-end metal hooks should not be used to secure luggage because of the potential risk of irreversible damage to the eye.

[Results of photorefractive keratectomy using the excimer laser in the treatment of myopia; 1-year follow-up]

OBJECTIVE

Evaluation of the first excimer laser treatments of myopia.

DESIGN

Descriptive.

SETTING

Excimer Laser Centrum, Department of Ophthalmology, University of Nijmegen, Nijmegen, the Netherlands.

METHOD

312 patients underwent spherical excimer laser treatment to correct myopia of 1.2 up to 10 diopters between February 1992 and October 1993. 245 patients completed a follow-up of one year or more; 36 retreatments were carried out. Group I (treatment 1.2 to 6 D) numbered 174 patients, group II (6.1-10 D) 71 patients.

RESULTS

After a follow-up period of one year or just before retreatment 79% of group I and 48% of group II achieved a refractive correction within 1 D of the attempted correction. Visual acuity without correction was 0.5 or more in 94% of group I and in 76% of group II. Less than one percent (n = 1) of group I and 6% (n = 4) of group II lost more than one line of best corrected visual acuity. Retreatment could correct 50% of those eyes that did not achieve a refraction within 1 D of attempted correction. Loss of visual acuity was corrected by retreatment in 5 of 6 cases of group I and in 7 of 11 cases of group II.

CONCLUSION

Based on a one-year follow-up, refractive surgery with the excimer laser appears to correct myopia between 1 and 10 D effectively. Predictability is diminishing on correcting higher amounts of refractive error. Thorough information of the patients regarding the results to be expected will prevent disappointment.

Full-thickness macular holes treated with vitrectomy and tissue glue

In the surgical treatment of full-thickness macular holes good results have been published with the combination of vitrectomy, gas and application of Transforming Growth Factor beta 2. Other authors report a 73% success rate in closing a full-thickness macular hole after vitrectomy and gas tamponade alone. We used, in addition to vitrectomy and gas tamponade, a tissue glue to stimulate adhesion of the elevated cuff of neurosensory retina surrounding a full-thickness macular hole and to close to hole itself. A total of 15 eyes of 13 patients (3 men, 10 women), with stage 3 and 4 macular holes were operated. All of the 13 uncomplicated cases showed complete closure of the macular hole. In one case (8%) the visual acuity decreased one line in spite of a funduscopically closed hole, and in two cases (16%) visual acuity remained the same despite closure. Increased visual acuity was seen in ten cases (76%), eight of which improved more than two lines.

Radiation therapy for age-related subfoveal choroidal neovascular membranes. A pilot study

In this pilot study the effect of radiation therapy on subfoveal CNV membranes associated with age-related macular degeneration was evaluated. Four groups of 10 patients were treated with external beam radiotherapy (16 MV photons) on an area of 1 cm2 (macular region) using a lens-sparing technique and total dose of 8 to 24 Gy. The first group received 8 Gy in a single fraction. In this group only 30% had a stable visual acuity and a stable FA after 18 months follow-up. In 50% of patients in group 2 (12 Gy) and 40% of patients in group 3 (18 Gy) the visual acuity and FA appearance remained stable after 18 months of follow-up. In the last group (24 Gy) 80% of patients had a stable visual acuity and FA appearance after 12 months follow-up. Comparison of these findings with the natural history data of subfoveal age-related CNV, suggests a beneficial effect of radiation therapy with a total dose of 12 Gy or more on the progression of CNV membranes.

Radiation therapy for subfoveal choroidal neovascular membranes in age-related macular degeneration. A pilot study

BACKGROUND

The natural course of the visual acuity of age-related subfoveal choroidal neovascularisation (CNV) membranes is poor. Laser photocoagulation of subfoveal CNV is recommended if the patient is willing to accept a large decrease in visual acuity immediately after treatment. A large proportion of patients with subfoveal CNV do not meet the Macular Photocoagulation Study Group (MPS) guidelines for laser photocoagulation. The fact that so few patients meet these criteria makes further research into new treatment techniques warranted. Ionising radiation may prevent the proliferation of endothelial cells of newly formed subretinal capillaries and may induce obliteration of the aberrant new vessels.

METHODS

In this study, the effect of radiation therapy on subfoveal CNV membranes was evaluated. Four groups of ten patients were treated with external beam radiotherapy (16-MV photons) on an area of 1 cm2 (macular region) using a lens-sparing technique and total doses of 8-24 Gy. The first group received 8 Gy in one fraction. The second, third and fourth groups received 12 Gy in 2 fractions, 18 Gy in three fractions and 24 Gy in four fractions respectively. The studied parameters included best-corrected visual acuity and membrane size and leakage on the fluorescein angiogram. We included 17 occult and 23 classic CNV membranes as defined by the MPS, with a duration of less than 5 weeks at presentation. Complete ophthalmic examination including fluorescein angiography was performed before and 3, 12 and 18 months after radiation treatment. We analysed the angiogram using a standard overprojection sheet. The results concerning the visual acuity and fluorescein angiography (FA) were compared with the extensively published, natural course data.

RESULTS

The first group (including three cases of occult CNV) received 8 Gy in a single fraction. In this group only four of ten patients had stable visual acuity and stable FA appearance after 21 months follow-up. The visual acuity and FA remained stable after 13.6 months follow-up in seven of the patients in group 2 (12 Gy in two fractions, four occult CNV). The third group (18 Gy in three fractions, seven occult CNV) contained six patients with stable visual acuity, although two of them had CNV deterioration on the FA (11.1 months follow-up). In the last group (24 Gy in four fractions, three occult CNV), with a short follow-up of 5.6 months, eight patients had stable visual acuity and FA appearance. We did not note any regression of the CNV membrane on the angiogram. The visual acuity in groups 2, 3 and 4 decreased to 0.1 or worse in only three cases, three cases and one case respectively after at least 6 months follow-up.

CONCLUSION

Comparison of these findings with the natural history data of subfoveal age-related CNV suggests a beneficial effect of radiation therapy with a total dose of 12 Gy or more on the progression of CNV. To date no negative side effects have been observed.

Echographic classification of intraocular tumours. A 15-year retrospective analysis

The data on echographic routine diagnosis of intraocular tumours (prominence equal to, or larger than 2 mm) during the years 1976-1990 in the authors' department, were analyzed by multivariate statistical methods, using the final diagnosis either from pathology after enucleation or from the confirmed clinical diagnosis. The material consisted of melanomas (n = 325), metastases (n = 44), haemangiomas (n = 19) and other intraocular tumours (n = 16). The best set of echographic parameters in descending order of significance was: reflectivity (A-mode), choroidal excavation (B-mode), shape (B-mode), and regularity (A/B mode). Echographic differentiation by computer analysis of data on the three main kinds of tumours (melanoma/metastasis/haemangioma) separate from all the remaining tumours was expressed by the correct fraction: melanoma 89%, metastasis 80% and haemangioma 97%. The clinical echographic classification for these cases was 89%, 93% and 99.5%, respectively. The simultaneous differentiation between the three classes was found to yield a correct fraction of 85% by computer statistics and 95% by routine echography. The results of the present study might be used for prospective classification through the use of the parameter 'knowledge base' contained in the statistical classification procedure.

Clinical application of digital indocyanine green videoangiography in senile macular degeneration

Digital indocyanine green videoangiography (ICGV) was done in 34 eyes of 24 patients with aging macular degeneration (AMD), including drusen, either alone (6 eyes) or in association with other AMD changes (9 eyes), geographic atrophy of the retinal pigment epithelium (2 eyes), well-defined choroidal neovascularization (CNV; 3 eyes), occult CNV (12 eyes) and recurrent CNV (11 eyes). Of the 11 eyes with soft drusen, 10 showed abnormal fluorescence in the late ICGV picture. ICGV of the 4 eyes with hard drusen showed no abnormality. The geographic atrophy of the retinal pigment epithelium and choriocapillaris remained hypofluorescent with sharply demarcated boundaries throughout the study. ICGV confirmed the presence of CNV in all 3 eyes with well-defined CNV and in 11 of the 12 eyes with occult CNV. Additionally, all but 1 eye with primary occult CNV and 6 of the 8 eyes with recurrent occult CNV could be reclassified in this study as having well-defined CNV. Overall, ICGV yielded additional information in 17 of the 20 eyes with primary and recurrent occult CNV. Its clinical importance for the evaluation of early stages of AMD has still to be confirmed by future investigations. ICGV is recommended as a diagnostic examination in eyes with CNV poorly defined by fluorescein angiography.

Localization of the gene for dominant cystoid macular dystrophy on chromosome 7p

In a family with autosomal dominant cystoid macular dystrophy (DCMD) linkage was detected with the dinucleotide marker D7S435 on the short arm of chromosome 7. With markers flanking D7S435, the DCMD locus could be assigned to the interval D7S493-D7S526 at 7p15-p21, which spans approximately 20 cM. Three-point linkage yielded a maximal lod score of 9.46 and location score of 43.5 and suggested that DCMD is 5,5 cM proximal to D7S493. Recently, a retinitis pigmentosa (RP7) locus has been mapped in roughly the same area of chromosome 7. Genetic data of both studies described below, allow a region of overlap between the location of the DCMD and the RP7 gene between D7S435 and D7S526. Both genes being one and the same will further substantiate the close relationship between macular degeneration and retinitis pigmentosa.

[Treatment of central serous choroidopathy with the beta receptor blocker metoprolol (preliminary results)]

Numerous theories have been proposed to explain the origin of central serous choroidopathy (CSC). However, it has been shown recently that there is a close relationship between CSC and type A-behaviour pattern (TABP) which is characterized by high adrenergic activity in the body. It is interesting to note that one of our patients who had chronic central serous choroidopathy, and metoprolol treatment for hypertension during one year, developed a recurrence of CSC three weeks after cessation of metoprolol treatment. This was one of the reasons to start this treatment modality for CSC. In this study, we present 6 cases of CSC in which the diagnosis was established by ophthalmoscopy and fluorescein angiography. In these patients, we proposed to analyse the relationship between CSC and a high adrenergic activity by the use of a selective beta-blocker (metoprolol; 50 mg tablets, twice daily). In two of the six cases, laser photocoagulation was also performed prior to commencement of the metoprolol treatment. Visual acuity improved in two patients, stayed at 1.0 in three patients and stabilized on the pretreatment level (0.8) in one patient (case-5). However, the symptoms (metamorphopsia and micropsia) and the signs (serous retinal detachment and angiographic hyperfluorescence) decreased or disappeared in all patients after treatment. Also visual complaints in all patients improved subjectively. No recurrences were noted during the metoprolol treatment in any of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperhomocysteinemia in retinal artery and retinal vein occlusion

In 19 patients who had retinal vein occlusion or retinal artery occlusion before the age of 50 years, the incidence of hyperhomocysteinemia, as observed in heterozygosity for homocystinuria, was studied by the performance of a standardized, oral methionine-loading test. In four of the 19 patients (21%), two with retinal artery occlusion and two with central retinal vein occlusion, the after-load peak levels of homocysteine exceeded the mean level, established in normal control subjects, by more than two standard deviations and were as well within the ranges established in obligate heterozygotes for homocystinuria. Because the frequency of heterozygosity for homocystinuria in the normal population is one in 70 (1.4%) at the most, we conclude that hyperhomocysteinemia predisposes to the development of premature retinal artery and retinal vein occlusion (P < .01; chi 2 test).

Familial congenital grouped pigmentation of the retina

Congenital grouped pigmentation of the retina is an uncommon disorder characterized by a grouping together of round to oval spots of pigment in one or more quadrants of the retina, except for the macula. Detection is usually coincidental during routine ocular examination. We examined a mother and daughter with bilateral grouped pigmentation of the retina. Visual acuity, visual fields, and results of electrophysiologic examination were normal. Autosomal dominant inheritance with variable expression was likely.

Congenital arteriovenous communications and the development of two types of leaking retinal macroaneurysms

We treated a patient with a rare combination of congenital arteriovenous communications and the development of leaking macroaneurysms of different types. Initially, leaking macroaneurysms developed in the shunt area of the arteriovenous communication; later, a preexistent fusiform macroaneurysm in the afferent arteriole of the congenital communication started leaking. Because exudates and fluid from the leaking macroaneurysms reached the fovea, laser treatment was performed to obliterate the macroaneurysms. We assume that after obliteration of the macroaneurysms with laser in the shunt area, the increase of hydrostatic pressure on the thin wall of the fusiform aneurysm of the afferent artery led to its leaking. We saw no signs of vascular occlusion after laser treatment.

Fluorescein angiographic findings and results of laser treatment in circumscribed choroidal hemangioma

We studied retrospectively 12 eyes with a solitary choroidal hemangioma in 12 patients over a period of 13 years. A peculiar, even hyperfluorescence of the tumor within the retinal venous phases occurred in all 12 cases. In all but four patients, laser therapy was performed to reduce subretinal fluid and partially destroy the tumor. Two of the three eyes without extensive retinal detachment or cystoid macular edema at the initial visit regained a final vision of 20/30 or better. The remaining 5 patients with the two major complications had a final vision of 20/80 or worse due to degenerative retinal changes. We believe that laser treatment is definitely advisable in the early stages of a circumscribed choroidal hemangioma.

Early findings in central areolar choroidal dystrophy

We examined 69 members of two caucasian families with an autosomal dominant form of central areolar choroidal dystrophy using ophthalmoscopy and fundus photography. In five members who had a good visual acuity macular lesions were found. In three of them retinal function tests were performed, which turned out to be normal. These 5 patients underwent fluorescein angiography. Early symptoms of central areolar choroidal dystrophy are small parafoveal hyperfluorescent areas due to retinal pigmentepithelium loss and areas of pigment mottling in the macula. Until now the early lesions of central areolar choroidal dystrophy in patients with a good visual acuity in both eyes have not been described clearly.

[Treatment of choroidal neovascularization in degenerative myopia]

Choroidal neovascularization is quite frequent in degenerative myopia. If the neovascularization is near the center, a krypton laser photocoagulation can be effected. If they reach the center, no photocoagulation should be effected. We report here our results in the treatment by krypton laser and describe a simple technic for the determination of the exact position of the foveola, that can be displaced in degenerative myopia.