Sequential Observation of Fundus Changes in Patients with Long Standing Membranoproliferative Glomerulonephritis Type II (MPGN type II)

Specific fundus changes have been reported in patients with membranoproliferative glomerulonephritis type II (MPGN type II). We studied the clinical course of this retinopathy in four patients who all had a long follow-up with several fundus examinations. Sequential observation was indicative of a slow progression of the retinopathy. Most eyes maintained in the chronic stages a nearly normal visual acuity, and a full visual field despite the existence of marked drusen and atrophic changes. The prognosis however must be somewhat guarded, since choroidal neovascularization developed in three eyes and caused bilateral severe visual loss in one patient.

Bilateral Optic Neuropathy Associated with the Crest Variant of Scleroderma

We report a case of bilateral optic neuropathy associated with the CREST syndrome, a variant of scleroderma. Immunosuppressive therapy achieved significant improvement of the visual symptoms for two years. The pathophysiological mechanisms underlying this unique association remain unclear.

[Diabetic retinopathy in Lubumbashi]

PURPOSE

To evaluate the frequency of diabetic retinopathy in Lubumbashi (Democratic Republic of Congo).

METHODS

Descriptive survey including 369 diabetic patients examined in our department of Ophthalmology of Lubumbashi from May 2006 to March 2008. Rates of glycaemia and blood pressure were noted. All the patients had a complete ophthalmological examination including visual acuity measurement, anterior biomicroscopy, intraocular pressure and fundus examination after pupil dilation.

RESULTS

At the time of ocular examination, the mean age of diabetic patients was 57 years (range 16 to 85) with a sex ratio of 1.2 males for 1 female. The frequency of type 1 diabetic patients was 28% and of type 2, 72%. High blood pressure was found in 42% of the patients. The frequency of diabetic patients (all forms included) was 13% and diabetes-induced blindness was 0.27%. In our study, the frequency of diabetic retinopathy increased with the patient's age and the duration of the diabetes. Diabetic retinopathy was more frequently found in adults. We did not find correlation between the level of glycaemia and the incidence of diabetic retinopathy.

CONCLUSION

From our epidemiological study, diabetic retinopathy is a concern for adult public health. It requires organized screening and early treatment to prevent blindness of those diabetic patients.

Acute visual field constriction in optic disc drusen: report of an unusual case

We describe a case of an acute symptomatic and non-progressive visual field constriction in one eye of a 19-year-old female with optic disc drusen. The fellow eye showed slowly progressive visual field defects. A limited or retrolaminar infarction of the optic nerve head seems a plausible cause of the acute visual field loss. The slow progression in the fellow eye is most probably due to mechanical compression by the drusen. The case is documented with Humphrey perimetry during a follow-up of 11 years and with Color Doppler Imaging (CDI) of the optic nerve.

[Treatment of age-related macular degeneration with intravitreous injections of bevacizumab (Avastin): short-term results]

PURPOSE

To analyse short term visual outcomes and macular morphologic changes associated with intravitreal injection of bevacizumab (Avastin) therapy for subfoveal choroidal neovascularization (CNV) in age-related macular degeneration (AMD) METHOD: Retrospective study of 59 eyes. Each included eye received 3 intravitreal injections of 1.25 mg bevacizumab at 4 to 6-week intervals. Mean follow-up was 5.5 months (range 3 to 9). Best-corrected visual acuity, ophthalmoscopic examination, optic coherence tomography and fluorescein or green indocyanin angiography were performed before and routinely after the treatment.

RESULTS

A total of 160 injections were performed with a mean value of 2.7 (1-6) per eye. Visual acuity improved at least two lines in 17% (10 eyes), worsened at least two lines in 14% (8 eyes) and was stabilized in 69% (41 eyes). Among that last group of 41 eyes, a significative reduction of macular thickness was observed in more than 39% (12 eyes) and a subjective improvement with less metamorphopsia and better visual comfort was noticed in 24% (10 eyes). No intraocular or systemic adverse effects were observed except a self-limited iritis in two cases.

CONCLUSION

Intravitreal bevacizumab therapy resulted in visual and morphologic improvements in a significant number of cases of advanced AMD with CNV. Randomized studies and longer follow-up are needed to confirm these preliminary results.

[Trauma and imputability]

The imputability of a bodily damage to a traumatism and the bond of causality are at the basis of the mission of the medical expert in the procedure that leads to indemnification in reparation of a suffered prejudice. The aim of this paper is to enumerate the bases on which the expert grounds to prove the imputability and the bond of causality. He will also insist on the final role of the jurist who, grounding his opinion on the elements of the expert appraisement, will establish the causality and hence the responsibility and the level of reparation.

[Diffuse retinal epitheliopathy: study of 30 eyes]

Retrospective study of 17 patients (30 eyes) with diffuse retinal epitheliopathy followed for at least 5 years. The study is based on clinical data, ophthalmoscopic findings and fluorescein angiograms. The patients (16 men and 1 woman) are all caucasian with a mean age of 43 years. The disease is bilateral in 13 patients. We report an association with systemic corticosteroid treatment after kidney transplantation in 10 cases. Nine patients have arterial hypertension. Two patients are diabetic and 2 present high level of psychological stress. After a mean follow-up of 12 years, a loss of vision of at least 3 lines is noted in 17 eyes. The decrease in vision is related to an enlargement of the pigment epithelium atrophy to the fovea (15 eyes) or with permanent retrofoveolar serous detachment (2 eyes).

Successful photodynamic therapy combined with laser photocoagulation in three eyes with classic subfoveal choroidal neovascularisation affecting two patients with multifocal choroiditis: case reports

Multifocal choroiditis (MC) is an idiopathic choroidal inflammatory disease affecting young subjects. Secondary choroidal--and often central--neovascularisation is a frequent complication leading to a poor visual prognosis. Photodynamic therapy (PDT) has now proven to be successful to treat classic subfoveal choroidal neovascularisation in age-related macular degeneration and in pathologic myopia. We describe the treatment applied to classic choroidal neovascularisation in two young women with MC, two eyes with subfoveal neovascular membrane and one eye in which new vessels encroach the foveal avascular zone. PDT has been useful in the three reported eyes, with stable or improved visual acuity. In two of them, it even made the membrane retract and become extrafoveal, allowing a secondary treatment using conventional laser.

[Advantages of digital indocyanine green angiography for diagnosing choroidal tumors]

Indocyanine green angiography (ICG) is a well-known ancillary test for evaluation of choroidal tumors. The authors review the different images seen in choroidal nevus, melanoma, metastasis, hemangioma, osteoma, and vortex vein varix. ICG appears to be useful for the diagnosis of non pigmented choroidal tumors. In addition, ICG provides good information on the limits of pigmented tumors, particularly for the follow-up of a growing tumor and the choice of treatment.

[Ocular manifestations of cancer]

Cancer may affect the eye and orbit as a direct result of metastatic neoplastic infiltration, compression, or circulating antibodies involving paraneoplastic retinal degeneration. A metastatic tumor to the uvea is the most common form of an intraocular metastatic process. The choroid is the most common site for uveal metastasis; metastases to the ciliary body, iris, retina, optic disk, and vitreous are rare. Approximately one-third of patients have no history of primary cancer at the time of ocular diagnosis. Breast and lung carcinomas for women and lung and gastrointestinal carcinomas for men most commonly metastasize to the eye and orbit. The short-term prognosis for vision is usually good after an individualized therapeutic approach (chemotherapy, hormonal therapy, external beam radiotherapy, or plaque radiotherapy), but the systemic prognosis is poor. The visual paraneoplastic syndromes encompass several distinct clinical and pathological entities including carcinoma-associated retinopathy (CAR), melanoma-associated retinopathy (MAR), and bilateral diffuse melanocytic uveal proliferation (BDUMP). The CAR syndrome affects photoreceptors, MAR is thought to affect bipolar cell function, and BDUMP targets the uveal tract. Identification of circulating antibodies against retinal proteins (recovering, 23-kDa retinal protein; 46-kDa and 60-kDa retinal proteins) serves to recognize the paraneoplastic nature of the patient's symptoms, which frequently develop before the cancer is diagnosed. Anecdotal therapeutic responses are described after systemic steroids, immunoglobulin injection, and plasmapheresis. Recognition of their visual symptoms and ocular findings should alert the ophthalmologist to the possibility of cancer and systemic evaluation should be pursued.

[Herpetic retinal necrosis]

Update on herpetic retinal necrosis, including cytomegalovirus retinitis.

Multiple arterial ectasias in patients with sarcoidosis and uveitis

PURPOSE

To describe and evaluate the cause of a clinical entity characterized by bilateral intraocular inflammation, multiple arterial ectasias including beading, macroaneurysms, comma-like ectasias and kinking, with vasculitis, staining of the optic disk and multiple peripheral round punched-out hypopigmented chorioretinal scars in elderly patients. The formation and the course of the arterial ectasias is analyzed.

METHODS

Seven patients with this syndrome were evaluated by clinical examination, fluorescein angiography, and systemic investigations.

RESULTS

Three of the seven patients had a biopsy characteristic of sarcoidosis, two others showed positive bronchoalveolar lavage, as well as other analyses and tests suggesting sarcoidosis, and two showed other findings suggestive of sarcoidosis. The patients were all over 60 years of age and had arterial hypertension. In two patients, an arterial ectasia developed at the site of previous focal inflammation. The macroaneurysms either remained unchanged, became comma-like ectasias, arterial kinks, or completely vanished.

CONCLUSION

Elderly patients with multiple arterial ectasias, uveitis, disk staining, and peripheral chorioretinitis should be thoroughly investigated for sarcoidosis. We suggest that sarcoidosis may cause some degree of arteritis, which may weaken the arterial wall, with resulting ectasia. Arterial hypertension may play a role in the formation of the ectasias by increasing the pressure on the arterial wall weakened by inflammation.

Late-onset renal failure in Senior-Loken syndrome

We report on four patients, from three different families, with Senior-Loken syndrome (SLS). They were unusual in that they reached end-stage renal failure (ESRF) only during the fifth or sixth decade. SLS is an autosomal-recessive disorder defined by the association of nephronophthisis and retinal dystrophy. Affected individuals invariably progress to ESRF, usually before the age of 20 years. The diagnosis was based on typical clinical presentation and characteristic renal histology, that is, a picture of chronic interstitial nephritis with pronounced thickening and multilayering of tubular basement membranes. Deterioration of renal function was slow, leading to ESRF between the ages of 42 and 56 years. Retinal dystrophy, already symptomatic during childhood in two patients, led to severe visual impairment in all. In contrast with four cases of SLS recently reported in very young patients, the NPH1 gene (the main gene responsible for nephronophthisis) was not deleted in our two tested patients. We conclude that SLS should be considered in adults who suffer from both chronic interstitial nephropathy and retinal degeneration. Whether the SLS is a variant of nephronophthisis and whether early- and late-onset renal failure in SLS is accounted for by genetic or allelic heterogeneity remain to be determined.

Polypoidal choroidal vasculopathy in Caucasians

PURPOSE

To study the prevalence of polypoidal choroidal vasculopathy (PCV) in Caucasian patients with occult choroidal neovascularization (CNV); to study the clinical spectrum of PCV in Caucasians and the outcome after laser photocoagulation of such lesions.

METHODS

(1) A consecutive series of 374 eyes of Caucasian patients at least 58 years old, presenting occult CNV, presumed to have age-related macular degeneration (AMD) on fluorescein angiography (FA) were further characterized by indocyanine green angiography (ICGA) to determine the frequency of PCV. (2) The funduscopic, FA and ICGA findings in a cohort of 36 Caucasian patients with PCV were analyzed. (3) The outcome after laser photocoagulation was studied in 14 PCV eyes with a minimum follow-up of 6 months.

RESULTS

(1) Fourteen of 374 eyes (4%) presenting occult CNV in patients at least 58 years old were diagnosed as PCV by means of ICG-A. (2) A polypoidal lesion was found in the macula in 22 of 45 PCV eyes, in the peripapillary area in 16 of 45, under the temporal vascular arcade in 6 of 45 and in the midperiphery in 6 of 45. Large or soft drusen were observed in 15 of 45 eyes with PCV. (3) Regression of fundus signs without persisting polyps 6 months after laser photocoagulation was obtained in 5 of 5 treated peripapillary lesions but in only 5 of 9 treated macular or arcade lesions.

CONCLUSION

Polypoidal choroidal vasculopathy is not rare in Caucasian patients presenting with occult choroidal neovascularization. The fundus abnormalities seen in such eyes overlap with the typical manifestations of AMD. Whereas the prognosis after photocoagulation of peripapillary polypoidal lesions appears to be relatively good, it is more guarded for macular or arcade lesions.

[Etiologies of intermediate, posterior, and panuveitis: a review of 201 cases]

The authors conducted a retrospective analysis of 201 patients with intermediate, posterior or panuveitis to determine the most frequent etiologies and collect some epidemiological data. A specific diagnosis was made in 70% of the cases: 35% were of infectious origin, 23% were associated with a systemic disease and 24% had a specific ocular condition. The most common entities included toxoplasmosis (24%), sarcoidosis (7.5%) and Behçet disease (5.5%). Birdshot retinochoroidopathy was the most frequent specific ocular disease (3.5%). The findings of this study are compared with those previously published in the literature.

Bilateral granulomatous panuveitis as initial presentation of diffuse systemic T cell lymphoma

A high-grade diffuse T cell lymphoma, initially simulating bilateral panuveitis, was diagnosed by analysis of a vitreous biopsy specimen and a breast tumor in a 57-year-old woman. It responded favorably to aggressive chemotherapy before it relapsed in leukemic transformation. This case emphasizes the misleading initial symptoms of primary intraocular lymphoma and the role of immunophenotyping in the diagnosis and classification of lymphoproliferative ocular disorders. The presentation and management of uveal lymphoid neoplasia are discussed.

[Retinal occlusive vasculopathy and primary anti-phospholipid syndrome: when to evoke it?]

A severe case of retinal vascular occlusion in a 31 year old white female is reported. Its origin is attributed to the primary antiphospholipid syndrome. The diagnostic criteria and the treatment of the primary antiphospholipid syndrome are revised and discussed. When the etiology of a retinal vascular occlusion is not assessed by the initial work-up, especially if the initial presentation consists of a severe occlusive disease, antiphospholipid antibodies should be checked.

[Radiotherapy treatment of subfoveal retinal neovascularization related to age]

Thirty-three patients who underwent low dose of radiation therapy for subfoveal choroidal membranes were studied after a mean follow-up of 16 months. The evaluated parameters were the visual outcome and the choroidal neovascularization evolution. In this study, the efficacy of low-dose radiation delivered to the macular region as an alternative treatment in subfoveal membrane was limited.

[Recurrent corneal erosions: new manifestation of juvenile alport syndrome]

A history of recurrent corneal erosion (RCE) in 3 brothers with juvenile X-linked Alport's syndrome (AS), whereas their 2 brothers without AS were unaffected, suggested a possible association between AS and RCE. A survey, among 39 patients with AS, revealed that 6 of them had suffered from RCE, supporting the association of the two conditions. RCE has to be considered as an additional ocular manifestation of AS, with a prevalence of 15 to 21%.

Recurrent corneal erosion associated with Alport's syndrome. Rapid communication

Ocular defects associated with Alport syndrome (AS) include anterior lenticonus and retinal flecks. We report on recurrent corneal erosion (RCE) as another ocular manifestation of the disease. Three brothers with AS reported a history of spontaneous attacks of RCE (2 episodes over 1 to 3 years in 2 of them and about 60 episodes in one brother over the last 10 years) characterized by acute ocular pain, lacrimation and photophobia lasting two to five days. The absence of RCE in the two other non-affected brothers from the same kindred suggested an association between AS and RCE, and prompted us to assess its prevalence. Forty-one patients with AS and renal failure and 67 control transplanted patients (with another original nephropathy) were evaluated. Seven AS patients had a history of RCE (first manifested between the ages of 12 and 21) versus only one control patient (P = 0.003). In conclusion, a history of RCE is found in about 20% of patients with AS and renal failure. RCE is likely to result from an inherent structural weakness of the corneal epithelial basement membrane (containing type IV collagen). A history of RCE should be sought when evaluating a patient for AS. Ophthalmologists should also be aware of this association, when confronted with a patient suffering from non-traumatic RCE.

Diffuse retinal pigment epitheliopathy complicating systemic corticosteroid treatment

AIMS/BACKGROUND

This study was undertaken to confirm the association between diffuse retinal pigment epitheliopathy (DRPE) and systemic corticosteroid therapy. This finding can be of help in determining an aetiological factor in DRPE and associated diseases. Corticosteroids may contribute to the development of leakage in the presence of a retinal pigment epitheliopathy or central serous chorioretinopathy.

METHODS

Cases of DRPE were collected from the files of members of the European Fluorescein Angiography Club. There were 34 who developed their ophthalmic symptoms while being treated with corticosteroids.

RESULTS

DRPE developed in 34 patients from 10 European eye clinics during systemic treatment with corticosteroids. Thirteen patients were treated with corticosteroids after allotransplantation, 21 other patients developed ocular symptoms while treated with steroids for serious systemic disorders. Symptoms occurred in some patients when the daily corticosteroid dosage was elevated, and the visual complaints ameliorated or even disappeared sometimes on discontinuation of the corticosteroid therapy.

CONCLUSION

Corticosteroids can damage the retinal pigment epithelial barrier and predispose a patient to serous retinal detachment, whereas psychological stress may play a role in the development of central serous chorioretinopathy. A decrease of the daily corticosteroid dosage may help to diminish the visual symptoms.

Fundus changes in membranoproliferative glomerulonephritis type II. A fluorescein angiographic study of 23 patients

A total of 23 patients aged between 11 and 64 years who had biopsy-proven membranoproliferative glomerulonephritis type II (dense deposit disease) were studied using fluorescein angiography of the retina. With the exception of two adolescents, all patients exhibited small subretinal nodules that were similar to basal laminar drusen. Subjects with a long history of renal disease displayed more numerous and larger nodules as well as atrophic changes. Four subjects presented with subretinal neovascular membranes.

Purtscher-like retinopathy after retrobulbar anesthesia

A Purtscher-like retinopathy occurred in a 41-year-old woman who underwent the excision of a pterygium after a retrobulbar injection of 3 ml of lidocaine HCl. Visual acuity increased from 20/200 on the first postoperative day to 20/25, 12 weeks later. The exudates and the hemorrhages progressively disappeared. However, a relative, localized, paracentral scotoma and an afferent pupil defect still persist. The pathophysiology of this Purtscher-like retinopathy is discussed.

Retinal and choroidal vaso-occlusive disease in systemic lupus erythematosus associated with antiphospholipid antibodies

Three patients with systemic lupus erythematosus (SLE) associated with anti-phospholipid antibodies are reported. All three had severe vaso-occlusive disease: the first had an unilateral vaso-occlusive retinopathy, the second an unilateral central retinal venous obstruction, and the third a bilateral ischemic choroidopathy. The association of these occlusive ocular vascular diseases with the presence of the lupus anticoagulant and other associated factors in SLE is discussed.