Retinal Photocoagulation for Proliferative Sickle Cell Retinopathy: A Prospective Clinical Trial with New Sea Fan Classification

Purpose

To compare the clinical outcome of stage III proliferative sickle cell retinopathy (PSR) treated by peripheral retinal scatter photocoagulation to natural course disease.

Methods

Long-term follow-up of 101 patients enrolled in a prospective trial of photocoagulation for PSR has been completed. Among 202 eyes of 101 patients enrolled at the University Eye Clinic of Créteil, 73 eyes showed a stage III PSR, which the authors further divided into five new grades (A, B, C, D, E) considering size, hemorrhage, fibrosis, and visible vessels. Grading was based on a three-mirror fundus examination, 360° color photographs, and fluorescein angiography. Mean follow-up was 4 years.

Results

Thirty-eight treated eyes and 35 untreated eyes were included in this study. The evolution was not statistically significant between treated and untreated groups concerning flat sea fan p<1 MPS disc area (grade A) or elevated sea fan with partial fibrosis (grade C). Progression and regression were compared between the two groups for grade B, resulting statistically significant (pp<0.05). Nine complications (13%) were observed, which only occurred in untreated patients with elevated sea fan and hemorrhage (grade B) or complete fibrosed sea fan with well defined vessels (grade E) (pp<0.05).

Conclusions

These data suggest that patients with grade A or C new sea fan classification should not be initially treated but observed.

Progression of pregnancy-dependent mouse mammary tumors after long dormancy periods. Involvement of Wnt pathway activation

Mouse mammary tumor virus (LA) induces pregnancy-dependent mammary tumors that progress toward autonomy. Here we show that in virgin females, pregnancy-dependent tumor transplants are able to remain dormant for up to 300 days. During that period, these tumors synthesize DNA, express high levels of estrogen and progesterone receptors (ER+PR+) and are able to resume growth after hormone stimulation. Surprisingly, in a subsequent transplant generation, all these tumors are fully able to grow in virgin females, they express low levels of ER and PR (ER-PR-) and have a monoclonal origin; i.e., show all of the features we have described previously in pregnancy-independent tumors. Histologically, mouse mammary tumor virus (LA)-induced tumors are morphologically similar to genetically engineered mouse (GEM) mammary tumors that overexpress genes belonging to the Wnt pathway. Interestingly, in the virus-induced neoplasias, pregnancy-independent passages arising after a dormant phase usually display a lower level of glandular differentiation together with epithelial cell trans-differentiation, a specific feature associated to Wnt pathway activation. In addition, dormancy can lead to the specific selection of Int2/Fgf3 mutated and overexpressing cells. Therefore, our results indicate that during hormone-dependent tumor dormancy, relevant changes in cell population occur, allowing rapid progression after changes in the animal internal milieu.

Usefulness of systematic ophthalmologic investigations in neurofibromatosis 1: a cross-sectional study of 211 patients

PURPOSE

To evaluate the usefulness of ophthalmologic examination for diagnosis and for detection of complications in adult patients with neurofibromatosis 1.

METHODS

PATIENTS with at least one criterion of neurofibromatosis 1 (excluding ophthalmologic criteria) seen at a referral centre had a systematic ophthalmologic examination including best-corrected visual acuity, slit-lamp examination and dilated funduscopy. The ophthalmologist was unaware of all other anamnestic data.

RESULTS

PATIENTS

211 patients with NF1 were included (mean age: 32 +/- 14 yr.). Ophthalmologic examination in neurofibromatosis 1 patients: Lisch nodules (n = 185) (87.7%); choroidal hamartomas (n = 61) (29%); enlarged corneal nerves (n = 1); 3 plexiform neurofibromas (n = 3); symptomatic optic pathway gliomas (n = 5). Diagnostic contribution of presence of Lisch nodules: 6 (3%) of 211 patients. Detection of complications: none.

CONCLUSIONS

In adult patients with neurofibromatosis 1, the contribution of ophthalmologic examination to diagnosis and to the detection of complications is low. Ophthalmologic examination should be performed in patients for whom questioning and clinical examination failed to give evidence of NF1 or to determine the NF subtypes.

[Severe thyroid ophthalmopathy related to interferon alpha therapy]

The authors report a case of a 49-year-old patient presenting with dysthyroid ophthalmopathy, who was treated with interferon alpha for chronic hepatitis C. Proptosis appeared 3 months after treatment onset and many complications occurred over more than 1 year. The extreme severity seen in this case is infrequent. After a summary of other ocular damage linked to interferon, the authors suggest that every interferon treatment include a check-up before beginning therapy and regular biological and ophthalmological monitoring.

[Choroidal neovascularization as a complication following laser treatment of central serous chorioretinopathy]

We report the case of a 39-year old man who presented with central serous chorioretinopathy. Two months after diagnosis, argon laser photocoagulation was performed. One month later, the patient noticed distortion and a reduction in vision revealing a subretinal neovascularization above the fovea next to the laser scar. The patient underwent surgical extraction of the neovascular membrane and recovered a visual acuity of 20/30. This case report shows a complication of laser treatment of central serous chorioretinopathy and underlines the diagnostic difficulties of this disease and its treatment modalities. The surgical excision, the first reported in this etiology, led to good visual recovery, as is usually observed in young patients operated on for neovascular membrane.

Choreic movements and MRI abnormalities in the subthalamic nuclei reversible after administration of coenzyme Q10 and multiple vitamins in a patient with bilateral optic neuropathy

A 37-year-old man developed choreic movements of the limbs over a few months. His medical history included bilateral visual loss detected at the age of 9 and worsening at age 20. Visual field testing showed a central scotoma. Fundus examination showed atrophy of the optic disks and narrowing of vessels. The diagnosis of Leber hereditary optic neuropathy (LHON) was considered. There was no family history of visual loss or movement disorders. Blood lactate:pyruvate ratio was moderately elevated. Skeletal muscle biopsy was normal. Magnetic resonance imaging showed bilateral hypointense lesions on T1-weighted sequences in the subthalamic nuclei and in the lateral part of the substantia nigra. Linear hyperlucencies in the pyramidal tract facing the lateral part of the ruber nuclei were also demonstrated on T2-weighted sequences. Nine LHON-associated mutations were ruled out by RFLP analysis. Treatment with 250 mg coenzyme Q10 per day and multiple vitamins was initiated. Gradual recovery in movement disorders occurred over 1 year. Lactate to pyruvate ratio normalized. No change of visual function was observed. On magnetic resonance imaging performed 3 years later, lesions of the subthalamic nuclei almost completely disappeared. We think the patient might have an unusual, genetically uncharacterized mitochondrial disorder, combining optic neuropathy and chorea.

Photorefractive keratectomy in 176 eyes: one year follow-up

Beginning in March 1992, 176 eyes from 176 patients underwent photorefractive keratectomy with the Summit Technology Eximed UV200LA. This study was designed to evaluate the efficacy of this method.

[Surgery for moderate or mild myopia]

After a long period of hesitation and reluctance, surgery of moderate to mild myopia (1 to 6 dioptries) is currently practiced by specialists in refractive surgery. At present, two ambulatory techniques are in competition: radial keratotomy, a truly surgical procedure that is more than 10 years' old, and the much more recent photorefractive keratectomy performed with an excimer laser beam, which is still under evaluation but has a very promising future. The goal of these two techniques is to correct myopia by flattening the cornea. The degree of correction obtained depends on several variables (some of which can be mastered), which explains why the results are not fully predictable. However, the overall results are satisfactory, provided the indications have been strictly selected. Per- and postoperatory complications are extremely rare. The main risk is early under-correction (particularly when the initial myopia is pronounced) or late over correction, mainly observed with radial keratotomy. Visual rehabilitation is much slower with the laser technique than after radial keratotomy. The two techniques are applied to patients aged from 20 to 40 years who have stable myopia, do not tolerate contact lenses and need an excellent sight for their professional or sporting activities.

Eight-year follow-up of central serous chorioretinopathy with and without laser treatment

A long-term retrospective study was conducted on two groups of patients affected with typical central serous chorioretinopathy (CSCR). One group was not treated and the other was treated by direct argon laser photocoagulation. CSCR shows a long-term good prognosis of visual acuity. The visual acuity of laser-treated eyes improves significantly (P less than or equal to 0.05), particularly in single focus cases (P less than or equal to 0.01). Unfortunately, these results cannot be statistically compared to the natural course of the non-treated patients because of the initial inhomogeneity of the two groups. Laser treatment did not produce any long-term complications. The recurrence rate in treated and untreated eyes was similar.

Sjögren-like syndrome after drug-induced toxic epidermal necrolysis

7 of 9 patients recovering from a drug-induced toxic epidermal necrolysis (TEN) which they had had 2 months to 4 years before had xerostomia, or keratoconjunctivitis sicca, or both. 5 patients had symptoms; 2 had severe visual impairment. In 5 cases there was lymphocytic infiltration of small salivary glands; in 2 patients this was identical to that of Sjögren syndrome. None of the patients had antinuclear antibody. TEN may occur during acute graft-versus-host disease (GVHD) and these observations are reminiscent of the sicca syndromes reported during chronic GVHD. They suggest that autoimmune mechanisms may be involved in drug-induced TEN and that Sjögren syndrome may occur as the result of a drug reaction.

Birdshot retinochoroidopathy and subretinal new vessels

Decrease of visual acuity in birdshot retinochoroidopathy is due either to optic atrophy or to 3 types of macular involvement: cystoid macular oedema, geographic atrophy, or macular serous detachment. We describe 3 cases of juxtapapillary subretinal neovascularisation occurring in long-standing birdshot retinochoroidopathy. The mechanism of the formation of the new vessels is discussed.

A hypereosinophilic syndrome with retinal arteritis and tuberculosis

A 35-year-old man was initially seen with a decrease in visual acuity, renal insufficiency, and elevation of the eosinophil count in the blood. The ocular syndrome was caused by extensive arterial occlusions of the retina. The subsequent apparition of cardiac, pulmonary, and neurologic signs fulfilled the criteria for the diagnosis of hypereosinophilic syndrome (HES). Most symptoms, including ocular, were temporarily but notably improved by hydroxyurea. The patient died after two years. An autopsy showed an endomyocardial fibrosis and disclosed destruction of the left kidney by an active tuberculosis. A pathogenic relationship between the infectious disease and the HES is envisaged.