Retrospective analysis of 58 children with retinoblastoma”

We performed a retrospective analysis of 58 children with retinoblastoma seen at the University of Illinois at Chicago between 1960 and 1982. Our findings showed an almost equal distribution by sex, a predominance (69%) of white patients, and a common presenting symptom (70%) of leukocoria, with (22%) or without (48%) strabismus. Unilateral involvement was noted in 35 patients (60%). Of the 23 (40%) bilaterally affected children, 19 had simultaneous involvement at the time of diagnosis. All bilateral and 90% of the unilateral cases were diagnosed before age five years. Family history was positive for retinoblastoma in five bilateral and one unilateral case. At the time of diagnosis, 35 patients had stage V disease (Reese-Ellsworth classification, Table 1). Depending on the stage of disease treatment included enucleation, radiation, and chemotherapy. Mortality was 25% from 1960 to 1974, and zero thereafter.

Developmental abnormalities in the Nuc1 rat retina: a spontaneous mutation that affects neuronal and vascular remodeling and retinal function

The retina serves as an excellent model in which to study vertebrate CNS development. We have discovered a spontaneous mutation in the Sprague-Dawley rat that results in a novel and unusual ocular phenotype, including retinal abnormalities, that we have named Nuc1. We have previously shown that the Nuc1 mutation appears to suppress programmed cell death in the developing retina. Here we report that maturation of both the retinal neurons and the retinal vessels is abnormal in Nuc1 homozygous rats. The developmental changes in the retinal neurons and vasculature are correlated with regard to degree of abnormality. As Nuc1 homozygotes mature, focal retinal detachment begins at approximately 3 months after birth, and near total traction retinal detachment, associated with pre-retinal fibrosis and neovascularization, is evident by 18 months. Electroretinographic studies at 2.5 months of age indicate that functional retinal degeneration precedes retinal detachment. The functional abnormality is most evident in rods and the inner retina, and is present in homozygous but not heterozygous mutants. Immunocytochemical studies of rod and cone photoreceptors indicate abnormalities in rod, but not cone, photoreceptors in Nuc1 homozygotes, consistent with the electroretinographic findings. In Nuc1 animals, the Muller cells are activated. Although such activation may result from inflammation, Muller cells in Nuc1 may be reacting to a neuronal influence. It appears that the Nuc1 mutation plays a regulatory role in both developing and maturing ocular tissues. The Nuc1 mutation may also serve as an important genetic tool to explore the relationships that may exist among gliosis, normal neuronal development, and normal vascular development and how abnormalities in these associations lead to common retinal diseases.

Choroidal infarction, anterior ischemic optic neuropathy, and central retinal artery occlusion from polyarteritis nodosa

PURPOSE

Ocular ischemia from polyarteritis nodosa (PAN) is rare. The authors present a case of multifocal ocular infarction from PAN.

METHODS AND RESULTS

A 70-year-old woman developed hand and foot numbness followed by intermittent blurred vision and binocular horizontal diplopia. Two weeks later, she suddenly lost vision in the right eye from a central retinal artery occlusion and then developed a left anterior ischemic optic neuropathy and bilateral triangular choroidal abnormalities consistent with infarction. Her erythrocyte sedimentation rate and C-reactive protein were elevated. Although giant cell arteritis was suspected, a multiple mononeuropathy was demonstrated by electromyogram and nerve conduction velocity studies. Biopsy specimens from her sural nerve and biceps muscle showed a necrotizing vasculitis with fibrinoid necrosis, consistent with PAN.

CONCLUSIONS

Polyarteritis nodosa can produce ischemia of a variety of ocular structures, including the retina, choroid, and optic nerve. In our patient, all three structures were affected. To our knowledge, this is the first reported case of the triangular sign of Amalric in PAN.

Redefining papillorenal syndrome: an underdiagnosed cause of ocular and renal morbidity

PURPOSE

To report ocular and renal findings specific to the inheritable entity called papillorenal (also known as renal-coloboma) syndrome and relate these to a common cause.

DESIGN

Observational case series and genetic study.

PARTICIPANTS

Two unrelated probands presenting with absent central retinal vessels and 11 available family members.

TESTING

Doppler ultrasonographic imaging of the optic nerves and kidneys, fluorescein angiography, and genetic testing for PAX2 mutations were performed. In selected cases, indocyanine green angiography, scanning laser ophthalmoscope perimetry, Retinal Thickness Analyzer measurements, visual evoked potentials, and magnetic resonance imaging were also performed.

MAIN OUTCOME MEASURES

Better defined characteristics of the papillorenal syndrome.

RESULTS

Numerous cilioretinal vessels were present with rudimentary or absent central retinal vessels. Superonasal visual field defects, typical for papillorenal syndrome, corresponded to inferotemporal areas of anomalous retinal and choroidal perfusion and hypoplastic retina. Renal hypoplasia was discovered in two affected members of one family (with previously unsuspected renal failure in one case), and recurrent pyelonephritis was discovered in four affected members of the other family. No PAX2 mutations were detected.

CONCLUSIONS

In the papillorenal syndrome, the hereditary absence of central retinal vessels may be missed, leading to confusion with isolated coloboma, low-tension glaucoma, and morning glory anomaly. Greater awareness of this syndrome will avoid unneeded glaucoma therapy, allow earlier recognition of renal diseases, and allow genetic counseling. We propose that the papillorenal syndrome is a primary dysgenesis that causes vascular abnormalities predominantly affecting the eye, kidney, and urinary tract, leading to hypoplasia of these structures. The absence of defects in the PAX2 gene in these families suggests that mutations in other genes may also be responsible for this syndrome.

Transscleral diode laser retinopexy in retinal detachment surgery: results of a multicenter trial

PURPOSE

To evaluate the safety and efficacy of transscleral diode laser for retinopexy in rhegmatogenous retinal detachment surgery in a multicenter trial.

METHODS

Seventy-two patients with primary rhegmatogenous retinal detachments were enrolled. No patient with chronic detachment, a retinal break greater than 90 degrees, history of uveitis or infectious retinopathy, or proliferative vitreoretinopathy was enrolled.

RESULTS

Information from follow-up of 6 months or longer was available on 65 eyes. Retinas were attached at 6 months with a single operation in 58 (89%) of these eyes. Complications included apparent pinpoint breaks in Bruch's membrane in 15 eyes, scleral-thermal effect in 14 eyes, and limited hemorrhage, which was intraretinal in 10 eyes and extended into the vitreous in 3 eyes. In one case, hemorrhage was judged perhaps to have contributed to initial surgical failure. The other complications had no known adverse effects. Complications were significantly associated with the physician's experience in using transscleral laser retinopexy.

CONCLUSIONS

In this multicenter study, transscleral diode laser retinopexy served as a safe and effective means of creating chorioretinal adhesion during retinal reattachment surgery. Minor complications were minimized by increasing experience with the technique.

Sickle cell disease presenting with extensive peri-macular arteriolar occlusions in a nine-year-old boy

PURPOSE

To report a dramatic occlusive event of the macula surrounding the foveal avascular zone, causing severe and permanent loss of vision in a child with sickle cell disease.

METHODS

Case report. A nine-year-old boy with SS hemoglobinopathy and oculocutaneous albinism developed acute unilateral loss of vision.

RESULTS

Ophthalmoscopy revealed a pale, milky white, thickened retinal lesion centered on the fovea in the right eye as well as foveal hypoplasia in the left eye. The presence of macular malformation associated with oculocutaneous albinism precluded formation of a cherry-red spot. Fluorescein angiography of the right eye demonstrated extensive occlusions of the arterioles surrounding the foveal avascular zone. The presence of occlusions surrounding the fovea from multiple directions suggested the possibility of central retinal artery occlusion with migration of microemboli downstream.

CONCLUSION

The patient, the youngest case reported, developed an irreversible macular infarction that was not improved by an exchange erythrocyte transfusion. He was placed on a long-term monthly transfusion protocol to protect his unaffected eye.

Traumatic hyphema in children: risk factors for complications

OBJECTIVE

To identify risk factors associated with higher rates of ocular complications in children with traumatic hyphema.

METHODS

Consecutive inpatient records from July 1990 through December 1997 were retrospectively reviewed for all children (aged < or = 18 years) who were admitted to the Wilmer Ophthalmological Institute, Baltimore, Md, within 48 hours of a closed-globe injury leading to hyphema. Data obtained included age, sex, race, sickle cell status, initial and final visual acuities, hyphema size and intraocular pressure at presentation, the occurrence of a secondary hemorrhage, subsequent intraocular pressure elevations, and therapeutic interventions.

RESULTS

Forty children fulfilled the inclusion criteria: 20 African American, 1 Asian American, and 19 white. Five of the 20 African American children had sickle cell trait, and 1 had sickle cell anemia. The rate of secondary hemorrhage was statistically higher in the African American population (P =.05), but no statistical difference existed between the rate of secondary hemorrhage in patients with and without sickle cell hemoglobinopathy. Sickle cell hemoglobinopathy was associated with a higher intraocular pressure at presentation (P =.03) and during inpatient follow-up (P =.02).

CONCLUSIONS

In the setting of traumatic hyphema, African American children appear to be at greater risk for developing a secondary hemorrhage. In our patients, sickle cell hemoglobinopathy increased the risk of intraocular pressure elevation, but did not seem to increase the risk of rebleeding beyond that associated with race. Larger studies are needed to validate these observations.

Central retinal vein occlusion: report of two familial cases

The authors report a 46-year-old father and 17-year-old son who each presented with unilateral central retinal vein occlusion (CRVO) and bilateral abnormalities of retinal vascular perfusion. The son presented with a nonperfused CRVO in the left eye, developed traction-rhegmatogenous retinal detachment treated with vitreous surgery, and developed prolonged arteriovenous filling in the retina of the fellow eye. The father presented with progressive CRVO in the right eye, developed choroido-vitreal neovascularization following laser treatment to create a chorioretinal anastomosis, underwent vitrectomy for retinal detachment and vitreous hemorrhage in that eye, and developed prolonged arm-eye and retinal arteriovenous circulation times in the fellow eye. An extensive evaluation (including hematological studies and imaging of the major vessels of the neck) failed to reveal a predisposing cause in either patient although echocardiography disclosed a mitral valve thrombus in the father. After institution of coumadin therapy, the circulatory parameters in the fellow eye of each patient improved.

Central retinal vein occlusion: review of management

Central retinal vein occlusion is usually a disease of the elderly and is often associated with systemic vascular disease, e.g., hypertension, diabetes mellitus, arteriosclerotic vascular disease. Younger patients, especially those less than 45 years of age, with retinal vein occlusion should be evaluated carefully for the possibility of an underlying thrombotic tendency. The authors describe the ocular manifestations, pathogenesis, associated conditions, patient evaluation, and treatment of patients with central retinal vein occlusion.

Prevention and control of epidemic keratoconjunctivitis in a teaching eye institute

PURPOSE

To determine if an ongoing infection control program is associated with a reduction in rates of nosocomial outbreaks of epidemic keratoconjunctivitis (EKC) and outbreak morbidity from nosocomial EKC in a large teaching eye institute.

METHODS

The number of nosocomial EKC outbreaks, the number of affected patients, and the total number of patient visits were collected for each year between 1984 and 1997. An infection control program was implemented in 1992. The program included specified methods of patient screening and isolation, handwashing, instrument disinfection, medication distribution, and furlough of infected employees. The program included two levels of intensity of infection control measures, for non-outbreak and outbreak conditions. We compared rates per 100,000 patient visits of nosocomial outbreaks of EKC and affected patients for the 6-year period after the program was implemented, 1992-1997, with corresponding rates for 1984-1991.

RESULTS

One, to three nosocomial outbreaks of EKC occurred annually in the period 1984-1991. After the implementation of the infection control program, no nosocomial outbreaks occurred in three of six years studied. In the pre-infection control years 1984-1991, there were 3.89 outbreaks and 54.09 affected patients per 100,000 visits, respectively. For the post-infection control years 1992-1997, the corresponding rates were 0.54 outbreaks and 5.66 affected patients per 100,000 patient visits. Rates for both outbreaks and affected patients were significantly lower for the post-implementation period (p < 0.005 and p < 0.0005, respectively).

CONCLUSIONS

An ongoing infection control program was associated with decreased rates of nosocomial EKC outbreaks and outbreak morbidity from nosocomial EKC in our institute. Although several reports have described infection control measures that terminated individual outbreaks of nosocomial EKC, this study demonstrates that an ongoing infection control program may preemptively reduce nosocomial EKC outbreaks.

Macular vasculopathy and its evolution in incontinentia pigmenti

PURPOSE

To describe macular vasculopathy in incontinentia pigmenti.

METHODS

Twelve baby girls with incontinentia pigmenti were evaluated under general anesthesia by fluorescein angiography of the macula. Nine eyes of nine patients had sufficient detail to allow evaluation of capillary changes. Angiography was initiated as early as three months of age, and was repeated in seven eyes at 3-12 month intervals. Changes in capillary patterns were identified.

RESULTS

Irregularly enlarged or distorted foveal avascular zones were noted in all nine maculas. Sparseness of the perifoveolar capillary bed was a characteristic finding. Sequential macular angiography demonstrated nonprogressive (stable) capillary closure in two eyes; progressive closure was noted in another macula; progressive closure plus addition or reopening of macular capillaries occurred in three eyes; and central retinal artery occlusion, with cherry red spot formation, was observed in one eye at 12 days of age. In addition, progressive tractional detachment of the macula, associated with bleeding pre-retinal neovascularization, occurred in two of these eyes, and progressive macular neovascularization also occurred in one eye.

CONCLUSIONS

Macular ischemia is characteristic of incontinentia pigmenti and is often progressive. It is the initiating event of a typical vasculopathy, characterized by capillary remodelling and, occasionally, by neovascularization and tractional detachment of the retina.

Optical cross-sectional imaging of the macula with the retinal thickness analyzer in X-linked retinoschisis

OBJECTIVE

To assess the morphologic characteristics of the foveal abnormality in juvenile X-linked retinoschisis using the scanning retinal thickness analyzer (RTA). This characteristic foveal abnormality is present in 83% to 100% of patients with X-linked retinoschisis and has not been demonstrated histopathologically.

METHODS

The RTA is a noncontact imaging device. The RTA scans an obliquely oriented slit laser beam across the macula to obtain a series of optical cross sections, which are digitized.

PARTICIPANTS

The RTA was used to examine 7 eyes of 5 patients with X-linked retinoschisis.

RESULTS

The RTA demonstrated foveal schisis in all eyes examined. In 2 eyes of 2 patients, a single schisis cavity, with an inner leaf in a dome-shaped configuration, was present. In 4 eyes of 3 patients, a single schisis cavity containing fine strands was present. Some of these strands partially, and others completely, bridged the cavity. In 1 eye of 1 patient, 2 separate schisis cavities with bridging strands were present in the fovea.

CONCLUSIONS

Scanning RTA is a noninvasive imaging modality capable of producing optical cross sections that demonstrate the extent and structural details of the foveal schisis in X-linked retinoschisis. Scanning RTA seems to be effective in the detection, characterization, and quantification of foveal schisis.

Indocyanine green angiography patterns of zones of relative decreased choroidal blood flow in patients with exudative age-related macular degeneration

BACKGROUND AND OBJECTIVE

To investigate the incidence and patterns of posterior zones of relative decreased choroidal blood flow in patients with exudative age-related macular degeneration.

PATIENTS AND METHODS

Digital indocyanine green (ICG) angiograms from 100 patients with exudative age-related macular degeneration were reviewed for the presence of posterior zones of relative decreased choroidal blood flow. The patterns of these zones and their location relative to the choroidal neovascular process were noted.

RESULTS

Ninety-five percent of the angiograms displayed the presence of either a complete or an incomplete zone of relative choroidal hypoperfusion. The zone was most apparent in the early frames of the angiogram. Five different patterns of relative decreased choroidal blood flow were identified: horizontal (32%), vertical (14%), bipartite (9%), tripartite (31%), and quadripartite (9%). The choroidal neovascular process was located within or at the edge of the zone of relative choroidal hypoperfusion in all cases.

CONCLUSION

Most cases of choroidal neovascularization localize to areas of relative choroidal dye nonfilling on ICG angiography. These patterns of choroidal nonfilling may have implications in the pathogenesis and management of choroidal neovascular membranes in age-related macular degeneration.

Macular vasculopathy and its evolution in incontinentia pigmenti

PURPOSE

To describe macular vasculopathy in incontinentia pigmenti.

METHODS

Twelve baby girls with incontinentia pigmenti were examined under general anesthesia by fluorescein angiography of the macula. Nine eyes of 9 patients had sufficient detail to allow evaluation of capillary changes. Angiography was initiated as early as 3 months of age and was repeated in 7 eyes at 3- to 12-month intervals. Changes in capillary patterns were identified.

RESULTS

Irregularly enlarged or distorted foveal avascular zones were noted in all 9 maculas. Sparseness of the perifoveolar capillary bed was a characteristic finding. Sequential macular angiography demonstrated non-progressive (stable) capillary closure in 2 eyes; progressive closure in another macula; progressive closure plus addition or reopening of macular capillaries in 3 eyes; and central retinal artery occlusion, with cherry-red spot formation, in 1 eye at 12 days of age. In addition, progressive tractional detachment of the macula occurred in 2 of these eyes, and progressive macular neovascularization occurred in 1 eye.

CONCLUSIONS

Macular ischemia is characteristic of incontinentia pigmenti and is often progressive. It is the initiating event of a typical vasculopathy, characterized by capillary remodelling and, occasionally, by neovascularization and tractional detachment of the retina.

Laser-induced chorioretinal venous anastomosis for nonischemic central or branch retinal vein occlusion

OBJECTIVE

To establish a communication between an obstructed retinal vein and the choroid by means of laser in eyes with nonischemic central or branch vein occlusion.

METHODS

Retrospective review identified eyes with nonischemic central or branch vein occlusion, and with decreasing or persistently decreased visual acuity of 20/100 or worse for 4 months or more before treatment, that received 1 or more sessions of laser photocoagulation to create a chorioretinal anastomosis.

RESULTS

Of 24 eyes with central vein occlusion, an anastomosis formed in 9 (38%) within 2 months after treatment, with visual improvement of 6 or more lines in 2 (8%) of 24 eyes, 1 to 3 lines in 5 (21%), and no improvement in 2 (8%). Of 6 eyes with branch vein occlusion, an anastomosis formed in 3 (50%) within 2 months after treatment, with visual improvement of 1 to 3 lines in 2 (33%) of 6 and no improvement in 1 (16%). No permanent, vision-limiting complications occurred during a mean follow-up of 13 months after the first treatment session or 8 months after the last session.

CONCLUSIONS

Laser photocoagulation of a retinal vein and Bruch's membrane may create a chorioretinal anastomosis in some eyes with a nonischemic vein occlusion. Progression to an ischemic status may possibly be prevented with successful anastomosis formation. Marked visual improvement may occur. Treatment techniques to create reliably an anastomosis with subsequent visual improvement, while minimizing potential complications, continue to evolve.

Serial optical sectioning of macular holes at different stages of development

OBJECTIVE

This study aimed to examine the characteristics of intraretinal changes associated with macular holes and epiretinal membranes by scanning retinal thickness analysis.

STUDY DESIGN

The study design was a nonconsecutive case series.

PATIENTS

Fifty-six eyes of patients who had either a suspected or clinically diagnosed macular hole or epiretinal membrane were recruited.

INTERVENTIONS

A commercial prototype of the scanning retinal thickness analyzer (RTA) was used. It projected a laser slit beam onto the retina and scanned it, in 200 or 400 msec, across a 2- x 2-mm area, yielding multiple optical cross sections that were recorded digitally.

RESULTS

Epiretinal membranes were detected, and sites of attachment could be identified. Full-thickness holes corresponded to intraretinal cavities in which the inner retinal surface was broken, usually at the center. The majority of eyes with full-thickness macular holes showed increased retinal thickness surrounding the hole. The so-called "cuff of subretinal fluid," however, often was not present by retinal thickness analysis, despite clinical diagnosis to the contrary, even though retinal thickness analysis is capable of detecting such fluid. In 20 (42%) of 47 eyes diagnosed or suspected of having macular holes, scanning retinal thickness analysis showed findings different from those reported by retinal specialists.

CONCLUSIONS

Examination of macular holes with the scanning RTA provides useful information in the diagnosis of macular holes in addition to that obtained through conventional techniques. The findings support the idea that many macular holes develop in association with intraretinal cystic changes. The precise chronology of the events remains to be determined.

Feasibility of laser-targeted photoocclusion of the choriocapillary layer in rats

PURPOSE

A new method, laser-targeted photoocclusion, was developed to occlude choroidal neovascularization while minimizing damage to the overlying retina. The ability to occlude normal choriocapillary layer in rats was evaluated as a first test of the feasibility of treating choroidal neovascularization with this method.

METHOD

A photosensitive agent, aluminum phthalocyanine tetrasulfonate, encapsulated in heat-sensitive liposomes, was administered intravenously along with carboxyfluorescein liposomes. A low-power argon laser (retinal power density of 5.7 W/cm2) locally released a photosensitizer bolus, monitored by the simultaneous release of carboxyfluorescein. A diode laser (operating at 675 nm with a retinal power density of 0.27 W/cm2) activated the photosensitizer with its release.

RESULTS

Vessels in the choriocapillary layer were occluded at day 3 after laser treatment and remained unchanged during the 30-day follow-up. Larger choroidal vessels and retinal capillaries remained perfused. Control experiments excluded possible effects of heat or activation of free photosensitizer. Pilot histologic studies showed no damage to the retinal pigment epithelium.

CONCLUSIONS

Laser-targeted photoocclusion caused selective occlusion of normal choriocapillaries while sparing overlying retinal pigment epithelium and retinal vessels. The method has potential as a treatment of choroidal neovascularization that may minimize iatrogenic loss of vision.

Histopathologic features of neovascularization in sickle cell retinopathy

PURPOSE

To examine the histopathologic and morphometric features of neovascular lesions in human proliferative sickle cell retinopathy.

METHODS

Postmortem ocular tissue was obtained from three subjects (aged 20, 28, and 40 years) with SS hemoglobinopathy and prepared for adenosine diphosphatase flat-embedding. Morphometric analysis was performed before serial sectioning.

RESULTS

Numerous active and autoinfarcted lesions were found that represented virtually all stages in the life cycle of preretinal neovascularization. These formations ranged from single small loops extending from arteries and veins along the retinal surface to the typical complex, elevated sea fan formations. Sea fans developed at hairpin loops and at arteriovenous crossings. There was an average of 5.6 connections between sea fans and retinal vessels; of these, 45% were arteriolar, 52.5% were venular, and 2.6% were at the capillary level. Six of eight sea fans were located at arteriovenous crossings. Autoinfarction appeared to occur initially within the sea fan capillaries. The average height of sea fans was 123 microns above the retinal surface.

CONCLUSIONS

Preretinal neovascularization in sickle cell retinopathy can arise from both the arterial and venous sides of the retinal vasculature and can assume a variety of morphologic configurations. Multiple feeding arterioles and draining venules are common, and autoinfarction appears to occur initially at the preretinal capillary level rather than at feeding arterioles. Arteriovenous crossings may be a preferential site for sea fan development.

Application of rapid scanning retinal thickness analysis in retinal diseases

PURPOSE

The authors have further developed their method of retinal thickness analysis to rapidly generate multiple optical cross sections of the retina and provide thickness maps at the posterior pole. The potential use of this method was evaluated in a number of macular disorders.

METHODS

A commercial prototype of the scanning retinal thickness analyzer was used to examine patients with a variety of macular diseases. A laser slit beam was projected on the retina and scanned across a 2- X 2-mm retinal area in 200 to 400 msec. The images of the intersection of the laser slit beam with the retina were recorded digitally and used for visualization of disease. Nine scans were combined, and an operator-free algorithm generated a three-dimensional thickness map at the posterior pole.

RESULTS

Cysts could be visualized in macular edema associated with diabetes mellitus and with retinal vein occlusion. The retinal thickness map quantitated the location, extent, and height of the edema. In serous detachment, the extent and the height of the retinal pigment epithelial elevation could be documented. In cases of suspected macular holes and pseudoholes, the diagnosis was considered more reliable than with conventional biomicroscopy. The extent of epiretinal membranes, the sites of adherence, and associated intraretinal cystic changes were identified. In glaucoma, the anatomic course of localized loss of neuronal retinal tissue could be traced.

CONCLUSIONS

Scanning retinal thickness analysis provided multiple optical cross sections of the retina and yielded information useful in the diagnosis and monitoring of macular diseases. The three-dimensional thickness map provided quantitative information that may be useful for clinical management.

Multicenter trial of transscleral diode laser retinopexy in retinal detachment surgery

PURPOSE

To evaluate the safety and efficacy of transscleral diode laser for retinopexy in rhegmatogenous retinal detachment surgery in a multicenter trial.

DESIGN

67 patients with primary rhegmatogenous retinal detachment underwent scleral buckling surgery, using transscleral diode laser for retinopexy, at five study centers.

STUDY PARTICIPANTS

72 patients with primary rhegmatogenous retinal detachments were enrolled. No patient with chronic detachment, a retinal break greater than 90 degrees, history of uveitis or infectious retinopathy, or proliferative vitreoretinopathy was enrolled. Five eyes were excluded because they required additional nonprotocol treatment at the time of surgery (vitrectomy or supplementary cryotherapy due to probe malfunction).

MAIN OUTCOME MEASURES

Retinal reattachment at six months after one operation. Secondary measures: visual acuity and complications, including choroidal, retinal, and vitreous hemorrhage, inflammation, and scleral damage.

RESULTS

Six months or greater follow-up information was available on 65 eyes. Retinas were attached at 6 months with a single operation in 58 (89%) of these eyes. Complications included apparent pinpoint breaks in Bruch is membrane in 15 eyes, scleral thermal effect in 14 eyes, and limited hemorrhage, which was intraretinal in 10 eyes, and extended into the vitreous in 3 eyes. In one case, hemorrhage was judged to have contributed possibly to initial surgical failure. The other complications had no known adverse effects. Complications were significantly associated with the physicians experience with transscleral laser retinopexy.

CONCLUSION

In this multicenter series, transscleral diode laser retinopexy served as a safe and effective means of creating chorioretinal adhesion during retinal reattachment surgery. Minor complications were minimized by increasing experience with the technique.

Noninvasive visualization of blood flow in the choriocapillaris of the rat

PURPOSE

The rat has been used to generate models of various eye diseases. However, methods to study the choriocapillaris noninvasively have been inadequate in this species. Laser-targeted angiography was applied to generate local, repetitive angiograms of the choriocapillaris in the rat and to assess the similarity between the choriocapillaris of the rat and that of the subhuman primate.

METHODS

Carboxyfluorescein was encapsulated in heat-sensitive liposomes and injected intravenously in rats. The liposome contents were then released locally in the choroid by the application of a short, noncoagulating heat pulse provided by an argon laser. Videoangiograms of the downstream spread of the bolus of dye were generated with excitation illumination provided by another output from the argon laser.

RESULTS

Laser-targeted angiography demonstrated that the bolus of dye perfused the choriocapillaris. Clusters of choriocapillaris lobules were observed and appeared similar to those described in the primate. Dynamic filling and emptying patterns also were similar to those of the primate. Lobules were filled by a central arteriole and drained by a venous annulus.

CONCLUSIONS

This study demonstrates the feasibility of noninvasively studying the choriocapillaris of the living rat using the technique of laser-targeted angiography. It demonstrates as well the similarity between the rat and the primate choriocapillaris, thus indicating that the rat is an acceptable and convenient model for the study of physiological and pathologic changes in the choroidal vasculature.

Clinicopathologic correlation of argon laser photocoagulation of retinal angiomas in a patient with von Hippel-Lindau disease followed for more than 20 years

PURPOSE

The authors review the histopathologic findings in the eyes of a patient with multiple retinal angiomas and von Hippel-Lindau disease, who underwent treatment with argon laser photocoagulation with follow-up of more than 20 years.

METHODS

The patient was studied ophthalmoscopically and by fluorescein angiography before and after argon laser photocoagulation of retinal angiomas. The eyes were obtained postmortem, and the central portion of the right eye, including the macula and optic nerve head, was sectioned serially for light microscopy. The pupil-optic nerve segment of the left eye was step-sectioned serially for light microscopy.

RESULTS

Histopathologic study of the right eye disclosed mild cystoid macular edema and focal areas of exudation in the midperiphery possibly secondary to irradiation of the head. A 1.5 x 0.3-mm area of residual angioma was present in the nasal peripapillary retina. Superotemporally, four chorioretinal scars were present in one photocoagulated area. These scars were composed of dense fibrous tissue with vascularization and variable retinal pigment epithelium hyperplasia. Large, nonangiomatous vessels within each of the scars were continuous with other retinal vessels. Inferotemporally, two chorioretinal scars were present in one photocoagulated area. Histopathologically, these scars were similar to the superotemporal scars, except that no patent retinal vessels traversed the inferotemporal scars. Neovascularization of the retina was associated with one superotemporal and one inferotemporal scar. No residual angiomatous tissue was present in the supero- or inferotemporal areas. Histopathologic examination of the left eye disclosed extensive vitreous organization and periretinal fibrovascular proliferation, extensive gliosis of the retina, and a 4.5 x 2-mm schisis cavity filled with fibrinous exudate. Three angiomas with variable fibrosis were present in the left eye.

CONCLUSION

Despite a poor clinical course in one eye treated with xenon arc photocoagulation, trans-scleral diathermy, and argon laser photocoagulation, a patient with von Hippel-Lindau disease and multiple retinal angiomas retained good vision in the other eye after successful treatment with argon laser photocoagulation with follow-up of more than 20 years. The amount of regression of angiomatous tissue after photocoagulation varied from lesion to lesion (complete in some; minimal in others). The authors conclude that argon laser photocoagulation of early lesions is effective in ablating smaller ( < or = 3-disc diameter) retinal angiomas.

Intracranial assessment of incontinentia pigmenti using magnetic resonance imaging, angiography, and spectroscopic imaging

OBJECTIVE

To evaluate patients with incontinentia pigmenti for evidence of cerebrovascular disease using magnetic resonance imaging techniques.

DESIGN

A prospective case series of seven patients (four of whom were related) with incontinentia pigmenti using magnetic resonance imaging, magnetic resonance angiography, and multislice proton (1H) magnetic resonance spectroscopic imaging.

SETTING

The Johns Hopkins Medical Institutions, Baltimore, Md, a tertiary, referred care center.

PATIENTS

Seven patients with a diagnosis of incontinentia pigmenti.

RESULTS

Five of the seven patients had abnormal magnetic resonance imaging consistent with small-vessel occlusions. Of these five patients, four had normal magnetic resonance angiography and spectroscopic imaging, and one patient had reduced middle cerebral artery flow on magnetic resonance angiography and increased lactate level in the cerebrospinal fluid on spectroscopic imaging. The remaining two patients had normal magnetic resonance imaging and spectroscopic imaging. Of these two patients, one had normal magnetic resonance angiography and the other had a right supraclinoid internal carotid aneurysm. There was substantial concordance between clinical (ophthalmic/neurologic) and imaging abnormalities.

CONCLUSIONS

The central nervous system changes in patients with incontinentia pigmenti may represent the result of small-vessel occlusive phenomena in the brain. These central nervous system findings may share a common pathophysiologic state with the vascular occlusive disease seen in the retinas of these patients. The changes in the retinal vasculature may serve as a potential marker for central nervous system disease. Physicians should be aware of the systemic and debilitating nature of incontinentia pigmenti.

Diagnostic pars plana vitrectomy report of a 21-year retrospective study

PURPOSE

To review the experience of diagnostic pars plana vitrectomies (PPV).

METHODS

The authors reviewed 405 consecutive diagnostic PPV's performed between November 1973 and October 1994.

RESULTS

Diagnostic vitrectomy was performed in 215 (53%) of 405 eyes for suspected endophthalmitis. Of those 215 cases, acute inflammation was confirmed in 62 (28.8%), 60 (27.9%) had microbial organisms present and 36 (16.7%) were culture-positive. Microbial organisms were observed microscopically in 31 (20%) of 156 patients suspected of postoperative endophthalmitis. Of those 31 cases, 23 (74%) were gram-positive, eleven (37%) of 30 eyes had organisms associated with glaucoma filtering procedures and 20 (16%) of 126 eyes had organisms with non-filtering procedures. The pooled percentage of eyes that developed postoperative endophthalmitis as a complication during the period July 1990 thru June 1994 is 5 (0.046%) out of a heterogeneous group of 10,898 cases operated on at the Wilmer Eye Institute for cataract, glaucoma, corneal transplant, pars plana vitrectomy and retinal detachment. Bacteria were identified microscopically in 6 (18%) of 34 post-traumatic cases. Microbial organisms were identified in 23 (92%) of 25 cases with an endogenous infection. Patients with endogenous infections had the most fungal infections, and the majority were in males. Neoplasms were diagnosed in 58 (14%) of the 405 cases. The most common neoplasm was ocular lymphoma 42 (72%), 69% of which were in females. Only 42 (48.3%) of 87 patients clinically suspected of having ocular lymphoma, actually had ocular lymphoma. Those negative for lymphoma were significantly older (67.4 +/- 10 years) compared to those with lymphoma (60.4 +/- 14 years) (P = 0.01).

CONCLUSION

Diagnostic PPV has proved to be valuable in confirming and establishing various clinical diagnoses.

Ophthalmology

It is estimated that 49% to 74% of cases of contact lens-associated ulcerative keratitis could be prevented by eliminating overnight wear. Heavy alcohol consumption appears to be associated with all types of cataracts. Cigarette smokers have a nearly threefold greater risk of developing age-related macular degeneration than nonsmokers.

The blinding mechanisms of incontinentia pigmenti

The ocular and cerebral abnormalities associated with incontinentia pigmenti, an X-linked dominant disease with characteristic cutaneous features, are far worse than the name would indicate. Although some patients have normal vision, total blindness or permanent visual deficiency may occur. Retinal vascular abnormalities, involving the periphery as well as the macula, appear to represent the primary disease process in the eye. Retinal detachment may then ensue, due to mechanisms that seem analogous to those of retinopathy of prematurity. Optic nerve atrophy and occipital lobe infarction are additional causes of severe visual dysfunction in some patients. For the first time, neonatal infarction of the macula is documented in this disease. The purpose of this report is to describe the visually disabling ocular and cerebral manifestations in five selected cases of incontinentia pigmenti.

Detection of cellular adhesion molecules in inflamed human corneas

PURPOSE

The expression of cellular adhesion molecules in 31 penetrating keratoplasty specimens from a broad range of corneal inflammatory diseases was studied using monoclonal antibodies and an immunoperoxidase technique.

METHODS

Corneas were divided into noninflamed, mild to moderately inflamed, and severely inflamed groups based on histologic findings. The panel of adhesion molecules studied included HLA-ABC, HLA-DR, CD3, LFA-1, MAC-1, ICAM-1, PECAM-1, VCAM-1, and E-selectin-1.

RESULTS

The adhesion molecules ICAM-1, HLA-DR, PECAM-1, CD3, VCAM-1, LFA-1, and MAC-1 were selectively expressed in areas of corneal inflammation. In general, HLA-DR and intercellular adhesion molecule ICAM-1 were co-expressed in similar regions. PECAM-1 was restricted to zones of marked inflammation and vascularization. E-selectin-1 was detected only in the stroma of a graft melt in a patient with active ocular cicatricial pemphigoid, and may reflect a primary regulatory dysfunction in this disorder. The ICAM-1 ligand was, in general, more diffusely distributed than its receptor LFA-1, a beta-2 integrin found on leukocyte cell membranes. The localization of the integrin MAC-1, present on macrophages, neutrophils, and some lymphocytes, did not always parallel the staining pattern of ICAM-1, suggesting promiscuity in its binding to other ligands besides ICAM-1.

CONCLUSIONS

Adhesion molecules are detected readily at sites of corneal inflammation and may play a critical role in facilitating the recruitment of immune regulatory cells to these areas. Future efforts to block or modulate the expression of intercellular adhesion molecules may provide new therapeutic options in the treatment of corneal inflammatory diseases.

Identification of a nonsense mutation at codon 128 of the Norrie's disease gene in a male infant

OBJECTIVE

Norrie's disease (ND) is a rare X-linked hereditary disorder characterized by congenital blindness. A putative gene for ND has been isolated and mapped to Xp11.3. Four point mutations in this gene have been identified recently in patients with ND, thus providing strong evidence that this gene is associated with the disease. We report a new mutation.

DESIGN

Clinical findings from the proband were correlated with results from DNA analysis. The proband's DNA was compared with that from his mother, an unaffected brother, and four unrelated normal males.

PATIENT

The proband was a male infant referred for ocular evaluation at 3 months of age.

INTERVENTIONS

The patient was evaluated with a general ocular examination at 4 months of age, a computed tomographic scan at 8 months of age, and then periodic follow-up examinations over the next 7 years. Blood samples were also collected from the proband, his family, and four unrelated normal males. DNA was extracted, amplified using polymerase chain reactions, and then cloned and sequenced.

RESULTS/CONCLUSIONS

We identified a new mutation at codon 128 of the ND gene, a dinucleotide GC-to-AA substitution that changed the normal codon for cysteine, TGC, to TAA, which is a stop codon. Thus, this patient lacks the last six amino acids of the carboxyl terminus of the ND protein. The normal ND protein has 11 cysteines in conserved positions that are proposed to be functionally significant. The mutation at codon 128 occurs at the 10th cysteine and might be expected to alter the function of the ND protein. Since the phenotype of this patient is similar to those of other patients with point mutations in the ND gene, this mutation is likely to be the molecular basis of the phenotype.

Retinal and other manifestations of incontinentia pigmenti (Bloch-Sulzberger syndrome)

BACKGROUND

One of the largest series of patients with incontinentia pigmenti who have undergone detailed ophthalmologic examination is reported here, including previously unrecognized findings with visually disabling consequences.

METHODS

Thirteen females with incontinentia pigmenti from eight unrelated families were evaluated. The diagnosis of incontinentia pigmenti had been established previously by a referring pediatrician or dermatologist in 12 patients and by the authors in one other patient on the basis of retinal findings and history of characteristic skin manifestations.

RESULTS

Abnormalities of the eye, central nervous system, skeleton, teeth, and hair develop in a majority of patients. The authors describe the evolution of retinal vascular abnormalities, and, for the first time, document foveal hypoplasia (in 4 of their 13 patients). The authors also provide the first report of a child with a normal brain shown on computed tomographic scan at 3 days old, which evolved to devastating cerebral ischemia, edema, and cortical blindness beginning at 6 days old.

CONCLUSIONS

Incontinentia pigmenti should be included in the differential diagnosis of patients with peripheral retinal vascular nonperfusion, preretinal neovascularization, infantile retinal detachment, or foveal hypoplasia, particularly if there is evidence of characteristic dermatologic or other systemic manifestations. In infants with incontinentia pigmenti, retinal vascular anomalies are best detected by examination under anesthesia using fluorescein angiography.

Dual-perspective analysis of vascular formations in sickle cell retinopathy

OBJECTIVE

To examine the sickle cell retina in dual perspective (vascular patterns en bloc and structure in serial sections) to gain new insights into sickle cell retinopathy.

METHODS

We analyzed the retinas of two patients with sickle cell disease (a 54-year-old patient with hemoglobin SC, heterozygous for the S and C mutation in the beta chain of the globin gene, and a 20-month-old patient with sickle cell anemia [SS], homozygous for the S mutation) using the previously described adenosine diphosphatase flat-embedding technique.

RESULTS

The dual-perspective analysis afforded by our technique revealed that the primary site of occlusions was located at the precapillary level. An unusual neovascular formation, the hairpin loop, was observed in both patients' retinas and appeared to result from recanalization of the wall of an occluded vessel. Many autoinfarcted pre-retinal neovascular formations were observed in the older SC patient. Two patent preretinal formations were studied in detail and their evolution appeared to be influenced by mechanical factors. The vessels appeared to have been extruded from the retina, perhaps owing to hydrostatic pressure secondary to downstream occlusions. Small pigmented lesions consisting of retinal pigment epithelial cells ensheathing channels that resembled autoinfarcted vessels were found in the eye of the SC patient.

CONCLUSIONS

This study illustrates unusual morphological features of intraretinal and preretinal neovascularization and of chorioretinal lesions in sickle cell retinopathy and suggests alternative mechanisms for their formation.

Pilot trial of transscleral diode laser retinopexy in retinal detachment surgery

OBJECTIVE

To evaluate the safety and efficacy of the transscleral diode laser for retinopexy in rhegmatogenous retinal detachments.

DESIGN

Ten consecutive patients with primary rhegmatogenous retinal detachments underwent scleral buckling surgery, using the transscleral diode laser for retinopexy. Patients were followed up for at least 6 months.

STUDY PARTICIPANTS

Ten patients with primary rhegmatogenous retinal detachments were enrolled. Patients with chronic detachments, a retinal break greater than 90 degrees, history of uveitis or infectious retinopathy, or proliferative vitreoretinopathy were excluded.

MAIN OUTCOME MEASURE

Retinal reattachment. Secondary measures: visual acuity and complications, including choroidal, retinal, and vitreous hemorrhage, inflammation, and scleral damage.

RESULTS

By 6 months, nine of 10 retinas were successfully repaired following only one operation. The retina of the 10th patient redetached at 6 1/2 weeks owing to proliferative vitreoretinopathy. Following a vitrectomy and retinal reattachment procedure, the retina of the 10th patient has remained attached for 1 year. No significant complications were encountered with the laser retinopexy, although small presumed breaks in Bruch's membrane occurred in three eyes and a moderate scleral thermal effect occurred in two. Visual results in the postoperative course were comparable to those achieved previously with cryotherapy.

CONCLUSION

In this pilot series, transscleral diode laser retinopexy served as a safe and effective means of obtaining chorioretinal adhesion in retinal detachment surgery.

Elevated intraocular pressure, pigment dispersion and dark hypopyon in endogenous endophthalmitis from Listeria monocytogenes

Listeria monocytogenes endophthalmitis occurred in an immunologically competent patient with no identifiable extraocular septic focus. The patient presented with a dark hypopyon and markedly elevated intraocular pressure, and the diagnosis was established by culture and histopathologic examination of ocular fluid. Four of the fourteen reported cases of Listeria monocytogenes endophthalmitis also presented with a dark hypopyon, and all cases had markedly elevated intraocular pressure. The presence of a dark hypopyon and elevated intraocular pressure may indicate endogenous intraocular infection with Listeria monocytogenes, even in an apparently healthy host.

Choroidal neovascularization associated with choroidal hemangiomas

Two patients with choroidal hemangiomas developed choroidal neovascularization. One patient with Sturge-Weber syndrome, a unilateral diffuse choroidal hemangioma, and a serous detachment of the macula was treated with yellow dye laser photocoagulation in a grid pattern to the tumor before glaucoma filtration surgery. Four years after successful laser treatment, the patient developed subfoveal choroidal neovascularization in an area of treatment. A second patient with a circumscribed choroidal hemangioma developed spontaneous subfoveal choroidal neovascularization 12 years after initial diagnosis of the hemangioma. The development of choroidal neovascularization associated with choroidal hemangiomas represents a potential cause of poor visual outcome in these patients.

A randomized clinical trial of feeder vessel photocoagulation of sickle cell retinopathy. A long-term follow-up

Long-term follow-up of patients enrolled in a randomized prospective trial of feeder vessel photocoagulation for proliferative sickle retinopathy has been completed. Of the 44 patients enrolled in Chicago, nearly a decade follow-up has been achieved on 29 patients (45 eyes). There were 20 control untreated eyes and 25 argon laser-treated eyes. Prolonged loss of visual acuity was rare in both groups. Argon laser photocoagulation has had a sustained effect on reducing the incidence of vitreous hemorrhage and visual loss from vitreous hemorrhage. Nine (45%) of 20 control eyes had vitreous hemorrhage, and it was recurrent in six (66%) of these nine eyes. A single episode was the only hemorrhagic event in the treated eyes. The laser-induced complications of choroidal neovascularization or retinal detachment were not associated with long-term visual sequelae. New sea fan evolution in 47% of study eyes suggests that these patients require long-term surveillance.

Aminocaproic acid versus prednisone for the treatment of traumatic hyphema. A randomized clinical trial

One hundred twelve patients who sustained hyphema after blunt trauma were enrolled in a double-blind randomized clinical trial to determine the relative efficacies of aminocaproic acid (Amicar) and systemic prednisone for reducing the rate of secondary hemorrhage. Fifty-six patients received an oral dosage of 50 mg/kg of aminocaproic acid every 4 hours for 5 days, up to a maximum of 30 g daily, and 56 patients received an oral dosage of 40 mg of prednisone daily (adjusted for weight) in two divided doses. Placebo pills and liquids were given to each patient to mask the treatment schedules. There were no statistically significant differences between the patient populations for any demographic or clinical characteristic (e.g., visual acuity, intraocular pressure [IOP], initial hyphema size) measured in the study. Blacks comprised 53% of the study population, and the mean age of the patients was 23.5 years. Four patients in each of the treatment groups experienced a secondary hemorrhage; the rebleed rate was 7.1% in each group.

Intraocular tissue plasminogen activator in a rabbit model of traumatic hyphema

Tissue plasminogen activator was used to evaluate the clearance of traumatic hyphema in a rabbit model. A neodymium-YAG laser was used to disrupt iris vessels, creating a traumatic hyphema. Tissue plasminogen activator (1800 IU/0.1 mL) was injected into the anterior chamber 24 hours after creation of the hyphema. Two control groups (one receiving balanced salt solution and one receiving no treatment) were used for comparison. A multivariate analysis of covariance indicated that the greatest difference in hyphema clearance between the groups occurred at days 3, 4, and 5. Five days after tissue plasminogen activator treatment, the mean size of the clot remaining in the anterior chamber was 27% of that of the original hyphema. In control eyes, almost 60% of the original clot remained at day 5. Treatment of animals with tissue plasminogen activator doses of 5000 IU and 10,000 IU produced a substantial increase in repeated bleeding episodes in our rabbit model. We concluded that although the use of tissue plasminogen activator in our rabbit model of traumatic hyphema significantly improved clearance of blood from the anterior chamber, the remaining clot was of such size that the clinical benefit was questionable.