[Survey on blood thinning therapy in patients with age-related macular degeneration]

BACKGROUND

Patients with age-related macular degeneration (AMD) often receive concomitant systemic blood thinning medications. These are known to increase the risk of severe hemorrhage also in connection with AMD, which can lead to extensive subretinal hemorrhaging.

OBJECTIVE

The purpose of this study was to investigate the proportion of patients with AMD and concomitant blood thinning treatment, including the type and reason for blood thinning treatment.

METHODS

This survey was prospectively conducted at the University Eye Hospital, Bonn, Germany. Volunteers were recruited during retinal consultations and the consultations for intravitreal injections (IVOM).

RESULTS

The questionnaire was completed by 178 patients. The mean age was 81.7 years (58-100) and 101 patients (57.7%) were undergoing blood thinning treatment. The majority of patients were taking antiplatelet agents (n = 59; 58.4%), especially ASA (n = 55; 54.5%). Direct oral anticoagulants (DOAC) were taken by 33 patients (32.7%), including most frequently apixaban (17.8%). Vitamin K antagonists (VKA) was taken by 4 patients (4%). The most common reason for blood thinning treatment was atrial fibrillation (n = 32, 31.7%), followed by stent implantation (n = 20, 19.8%) and stroke (n = 12, 11.9%) but 13 patients (12.9%) did not know why they were undergoing blood thinning treatment. No clear indications for the use of blood thinners were found in 31 patients (30.7%).

CONCLUSION

A large proportion of patients with AMD undergo blood thinning treatment; however, not every patient has a clear indication. Due to the increased risk of bleeding, the use of blood thinners should be critically evaluated in close cooperation with primary care physicians and cardiologists.

Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: A Case Series and Systematic Review

This study describes three unilateral cases of hemorrhagic occlusive retinal vasculitis (HORV) after cataract surgery and a review of the literature until February 2022, including 21 articles reporting HORV cases. Altogether, 61 eyes (41 patients) were included. Twenty patients had bilateral and 21 patients had unilateral HORV. Prophylactic vancomycin was given to all patients. Additional vancomycin use was associated with the worst outcome. The mean time to HORV was 9 days post-cataract surgery. In bilateral cases, the median time between surgeries was 7 days. Visual acuity was < 20/400 in 48%, with no light perception in 20%. Neovascular glaucoma developed in 43%. Central macular thickening or hyperreflectivity of the inner retinal layers on optical coherence tomography was associated with worse outcomes. Corticosteroid treatment, early panretinal laser photocoagulation, or anti-vascular endothelial growth factor therapy, and prophylaxis alternative to vancomycin is recommended. [Ophthalmic Surg Lasers Imaging Retina 2022;53:702-712.].

Development of subretinal hemorrhage after treatment discontinuation for neovascular age-related macular degeneration and polypoidal choroidal vasculopathy

PURPOSE

To investigate the incidence, risk factors, and their influence on visual outcomes of subretinal hemorrhage (SRH) in patients with neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy(PCV) who discontinue treatment.

METHODS

This retrospective study included 148 patients with nAMD and PCV who discontinued treatment. The development of a 3-disc area or greater extent of SRH after treatment discontinuation was identified. Visual acuity at the final visit was compared between patients with and those without SRH. Factors associated with SRH were then analyzed.

RESULTS

During the mean 56.8 ± 18.2 months of follow-up, treatment was discontinued at a mean 24.1 ± 16.3 months after diagnosis. SRH developed in 24 (16.2%) patients at a mean 21.5 ± 17.6 months after treatment discontinuation. The visual acuity at the final follow-up was significantly worse in patients with SRH than in those without SRH (P < 0.001). There was a significant difference in the incidence of SRH among the different types of macular neovascularization (MNV) (P = 0.024). In particular, the incidence of type 3 MNV was relatively high (36.0%).

CONCLUSIONS

The development of SRH may lead to very poor visual prognosis in patients who discontinue treatment. The high risk of SRH in type 3 MNV suggests the need for caution when choosing treatment discontinuation in cases of type 3 MNV.

HEMORRHAGIC OCCLUSIVE RETINAL VASCULITIS AFTER INTRACAMERAL VANCOMYCIN USE IN CATARACT SURGERY AFTER INTRAVENOUS EXPOSURE

PURPOSE

To report a case of hemorrhagic occlusive retinal vasculitis after cataract surgery.

METHODS

A 74-year-old woman presented with blurry vision and distorted vision, which started 2 days after an uncomplicated cataract surgery in the left eye. Intracameral vancomycin was injected during the case. The patient reported being treated with systemic vancomycin in the past.

RESULTS

The visual acuity was 20/80 in the left eye. She had trace cells in the anterior chamber with no hypopyon and intraocular lens implant within the capsular bag in the left eye. Dilated fundus examination revealed no vitritis, There were large patches of peripheral retinal hemorrhages and retinal ischemia. The patient was diagnosed with hemorrhagic occlusive retinal vasculitis likely secondary to hypersensitivity reaction to intracameral vancomycin. The patient was started on oral prednisone, and the topical difluprednate course was escalated. Within 3 weeks, vision improved to 20/30 in the left eye. She underwent pan retinal photocoagulation targeting the ischemic areas in the periphery.

CONCLUSION

The patient had previous exposure to systemic vancomycin, which may have sensitized her immune system. Later on, the hypersensitivity reaction took place after exposure to intracameral vancomycin during cataract surgery. Our hemorrhagic occlusive retinal vasculitis case had a favorable visual outcome, and recognition of this entity will ensure that vancomycin will not be used for infection prophylaxis in the fellow eye at the time of cataract surgery.

Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: A Clinical-Pathophysiological Analysis

PURPOSE

To derive novel insights into the pathophysiology of vancomycin-related hemorrhagic occlusive retinal vasculopathy (HORV) through a careful clinicopathologic correlation.

METHODS

We retrospectively reviewed the clinical and pathologic course of 2 consecutive patients who developed HORV. The clinical history, multimodal imaging, ultrasound biomicroscopy (UBM), and intraoperative and histologic findings are reported.

RESULTS

Both patients presented with decreased vision and eye pain within 1 week following otherwise uncomplicated cataract extraction and were diagnosed with HORV after endophthalmitis was ruled out. Both patients presented with significant ocular discomfort that progressively worsened, and both experienced a dismal visual outcome despite early aggressive medical and surgical therapy. One patient requested enucleation for a blind and painful eye. Upon histologic examination of this eye, the iris and ciliary body appeared to be infarcted with separation of the iris and ciliary epithelia from their adjacent stromal components. These findings were corroborated by UBM of the second patient. Histologic examination of the posterior segment demonstrated severe hemorrhagic necrosis of the neurosensory retina and an occlusive nonarteritic vasculopathy of the retina and choroid. The choroid was thickened by prominent nongranulomatous chronic inflammation accompanied by a glomeruloid proliferation of small vessels. The inflammatory infiltrate was almost exclusively confined to the choroid and consisted of predominantly T cells. There was conspicuous absence of inflammatory cells in the retina and no histologic evidence of leukocytoclastic vasculitis.

CONCLUSIONS

HORV is a rare condition that can lead to profound vision loss. Significant ocular pain can be a presenting sign of HORV in cases with severe iris and ciliary body ischemia. Although it has been suggested that HORV is a form of leukocytoclastic retinal vasculitis, the histologic findings herein indicate that the pathophysiology is more complex. It is grounded in a necrotizing retinal vasculopathy in the absence of retinal vasculitis, chronic nongranulomatous choroiditis, and an unusual glomeruloid proliferation of endothelial cells in the choroid and elsewhere in the eye.

Regorafenib-induced retinal and gastrointestinal hemorrhage in a metastatic colorectal cancer patient with liver dysfunction: A case report

RATIONALE

Regorafenib is effective for metastatic colorectal cancer but its toxicity such as hemorrhage should be considered. The safety of regorafenib for the patient with the liver disease is not known.

PATIENT CONCERNS

Seventy-one-year old man of colon cancer had myodesopsia and blood stool after 14 days from the initiation of regorafenib administration with 50% dose reduction due to liver dysfunction.

DIAGNOSES

Fundus examination revealed hemorrhage of the retinal vein.

INTERVENTIONS

Regorafenib treatment was discontinued and observational therapy was pursued.

OUTCOMES

Retinal and gastrointestinal hemorrhage resolved in 1 week.

LESSONS

Retinal hemorrhage should be considered as the differential diagnosis of myodesopsia in the patient treated by regorafenib. Safety and pharmacokinetic of continuous regorafenib administration for patients with liver dysfunction remains to be clarified.

HEMORRHAGIC OCCLUSIVE RETINAL VASCULITIS AND NONHEMORRHAGIC VASCULITIS AFTER UNCOMPLICATED CATARACT SURGERY WITH INTRACAMERAL VANCOMYCIN

PURPOSE

To describe two cases of vasculitis: one hemorrhagic and one nonhemorrhagic after uncomplicated cataract surgery with intracameral vancomycin.

METHODS

Retrospective case series.

RESULTS

A 74-year-old female and a 54-year-old female developed severe visual loss within 2 weeks of uncomplicated cataract surgery with intracameral vancomycin. The first patient developed a fulminant hemorrhagic vasculitis, whereas the second patient developed a less severe nonhemorrhagic vasculitis. Partial visual recovery and prevention of neovascular glaucoma was achieved using a combination of topical, oral, and intravitreal corticosteroids, along with intravitreal antivascular endothelial growth factor agents in the first patient and a combination of topical and oral corticosteroids alone in the second patient.

CONCLUSION

Hemorrhagic occlusive retinal vasculitis and nonhemorrhagic vasculitis after uncomplicated cataract surgery with intracameral vancomycin have been rarely reported. Early recognition and treatment may prevent devastating visual outcomes.

Bilateral subinternal limiting membrane hemorrhage in benzene toxicity

PURPOSE

To report the clinical and spectral domain optical coherence tomography findings in a patient with bilateral central vision loss and a history of exposure to polyamides.

METHODS

The clinical presentation of the patient was documented with color fundus photographs and spectral domain optical coherence tomography. The patient was a 20-year-old male factory worker with no medical history who was initially admitted for workup of hematologic malignancy due to petechiae and fevers.

RESULTS

Optical coherence tomography revealed bilateral hemorrhages in the subinternal limiting membrane space resembling Valsalva retinopathy. Complete blood count revealed pancytopenia and marked thrombocytopenia.

CONCLUSION

Heavy exposure to benzene, a byproduct of the polyamide-curing process, is known to cause aplastic anemia. Accompanying thrombocytopenia may increase the risk of spontaneous subinternal limiting membrane hemorrhage.

Retinal neovascularization and hemorrhage associated with the use of imatinib (Gleevec(®)) in a patient being treated for gastrointestinal stromal tumor (GIST)

BACKGROUND

Gastrointestinal stromal tumor (GIST) is a mesenchymal malignancy of the gastrointestinal tract. Imatinib mesylate (Gleevec(®), ST1571, Novartis Pharmaceuticals, Basel, Switzerland) is a selective inhibitor of break point cluster-Ableson (BCR-ABL), c-Kit, and platelet-derived growth factor receptor alpha (PDGFRα) tyrosine kinases. Imatinib has been approved in the U.S. for the treatment of Philadelphia-chromosome positive chronic myeloid leukemia, KIT (CD117)-positive unresectable and metastatic malignant GIST and adjuvant treatment of adult patients following resection. Ocular side effects are commonly reported with Gleevec(®), the most common being periorbital edema and epiphora.

CASE REPORT

Here we present the case of a 62-year-old male with a history of GIST in the jejunum who was started with imatinib mesylate at 400 milligrams daily. Seven months into his therapy, he reported blurry vision. He was evaluated by an ophthalmologist, and was ultimately found to have retinal hemorrhage and neovascularization. His dose was reduced by 50% to 200 milligrams daily with an almost complete resolution of symptoms within several weeks. No recurrence of symptoms or signs was noticed at 6 months follow-up.

DISCUSSION

This patient's Naranjo scale was calculated to be 7, indicating a probable adverse drug reaction. Our patient's symptoms significantly improved with a dose reduction of imatinib, and this hints that there was a dose-dependent effect. The World Health Organization has categorized retinal hemorrhage as an unlikely side-effect of therapy, and to our knowledge this has never been reported before in a patient receiving imatinib mesylate for GIST treatment. Neovascularization also has not been previously reported in patients receiving this medication. It is important to identify less common ocular toxicity in patients receiving imatinib.

[Pegylated interferon and ribavirin associated retinopathy in patients with hepatitis C]

CASE REPORT

We describe two patients with chronic hepatitis C, treated with pegylated interferon and ribavirin, who developed multiple cotton-wool spots in the retina of both eyes. The ocular findings were identified as pegylated interferon associated retinopathy, and in one case spontaneously resolved and in the other after the treatment was withdrawn.

DISCUSSION

Interferon is an immunomodulating cytokine used as a first line treatment of hepatitis C. Numerous adverse effects have been reported, but ocular ones are less known. We believe that periodic ophthalmological examinations during this treatment are required in order to detect these complications, which can be serious.

Fenethylline as a possible etiology for retinal vein occlusion

We are report 3 cases of hemorrhagic central retina vein occlusion following continuous use of fenethylline hydrochloride. The hemorrhage, the edema and the engorged veins showed marked improvement after discontinuing the drug and laser supplement in one case.

The retinal tolerance to bevacizumab in co-application with a recombinant tissue plasminogen activator

AIM

To investigate the retinal toxicity of bevacizumab in co-application with a commercially available recombinant tissue plasminogen activator (rt-PA), and to facilitate a new therapeutic concept in the treatment of massive subretinal haemorrhage caused by neovascular age-related macular degeneration (AMD).

METHODS

Isolated bovine retinas were perfused with an oxygen-preincubated nutrient solution. The electroretinogram (ERG) was recorded as a transretinal potential using Ag/AgCl electrodes. Bevacizumab (0.25 mg/ml) and rt-PA (20 microg/ml) were added to the nutrient solution for 45 min. Thereafter, the retina was reperfused for 60 min with normal nutrient solution. Similarly, the effects of rt-PA (20 microg/ml, 60 microg/ml and 200 mug/ml) on the a- and b-wave amplitudes were investigated. The percentages of a- and b-wave reduction during application and at washout were calculated.

RESULTS

During application of bevacizumab (0.25 mg/ml) in co-application with 20 microg/ml (rt-PA), the ERG amplitudes remained stable. The concentrations of rt-PA alone (20 microg/ml and 60 microg/ml) did not induce significant reduction of the b-wave amplitude. In addition, 20 microg/ml rt-PA did not alter the a-wave amplitude. However, 60 microg/ml rt-PA caused a slight but significant reduction of the a-wave amplitude. A full recovery was detected for both concentrations during the washout. At the highest tested concentration of 200 microg/ml rt-PA, a significant reduction of the a- and b-wave amplitudes was provoked during the exposure. The reduction of ERG amplitudes remained irreversible during the washout.

CONCLUSION

The present study suggests that a subretinal injection of 20 microg/ml rt-PA in co-application with bevacizumab (0.25 mg/ml) for the treatment of massive subretinal haemorrhage seems possible. This is a safety study. Therefore, we did not test the clinical effectiveness of this combined treatment.

Large submacular hemorrhage following PDT with verteporfin in patients with occult CNVM secondary to age-related macular degeneration

A review of the charts for all patients who developed large submacular hemorrhages following photodynamic therapy for choroidal neovascular membranes secondary to age-related macular degeneration yielded three patients who met the criteria for a large submacular hemorrhage. All three patients were treated for exudative age-related macular degeneration and were taking warfarin for chronic anticoagulation. Before photodynamic therapy, the international normalized ratio ranged from 1.2 to 1.6. All three patients had received at least one previous verteporfin treatment in the study eye. All three hemorrhages were not noted immediately after photodynamic therapy and were documented within 1 to 2 weeks following the procedure. Patients with age-related macular degeneration who are receiving warfarin therapy and undergoing repeat verteporfin treatments appear to be at risk for submacular hemorrhages.

[Submacular hemorrhage following photodynamic therapy in the treatment of choroidal neovascularization]

PURPOSE

To describe the incidence, clinical features and evolution of submacular hemorrhage (SMH) occurring after photodynamic therapy (PDT) with verteporfin in the treatment of choroidal neovascularization (CNV).

METHODS

A retrospective analysis of the patients treated with PDT in our hospital between July 2002 and May 2005 was undertaken.

RESULTS

8 out of 504 eyes treated with PDT (1.58%) developed SMH; 4 of them (0.79%) required surgical attack. The incidence of SMH for every application of PDT was 0.65% (8/1221). The underlying disorder defined was age-related macular degeneration (AMD) in 7 cases (87.5%), and high myopia in one case (12.5%). Regarding the type of lesion, 5 were occult (62.5%; p=0.01), 1 predominantly classic, 1 minimally classic, and the last one was not classified. The average final visual acuity (VA) was 0.057, with 25% of patients having a VA >or= 0.1. Patients lost 4 Snellen lines on average.

CONCLUSIONS

SMH after PDT was an event of unknown etiology and low frequency. The incidence in our series (1.58%) was comparable with that described in the world literature (0.24-9.0%). The greatest incidence of AMD was in the occult group with no classic type of CNV, suggesting a possible higher risk for SMH in this type of lesion. It is mandatory to inform patients of the possibility of this complication, which can compromise the visual result of the PDT, and sometimes require surgery. The low risk of SMH related to the PDT justifies its application when it is indicated.

[Damage to retinal vasculature]

The use of interferon increased these last years. Cotton wool-spots, retinal hemorrhages, and microaneurysms are common manifestations of interferon retinopathy. The frequency of this retinopathy is underestimated as it is often asymptomatic. Screening and a multidisciplinary approach are therefore recommended.

Trombose de veia central da retina em paciente usuária de interferon e ribavirina: relato de caso

Interferon and ribavirin are medications widely used in the treatment of some systemic diseases, mainly hepatitis C. Ribavirin when associated with interferon increases the rate of success of this treatment. There are about 170 million patients with chronic hepatitis C in the world, many in use of these medications. The classic associated retinopathy is described as cotton wool exudates and hemorrhages. Since the first reports, several different ocular disturbances were described in association with interferon. The present case shows a patient whose right eye presented with central retinal vein occlusion and whose left eye presented the typical findings of hemorrhages; prompt resolution after the medications were discontinued.

Risk factors for retinopathy associated with interferon α-2b and ribavirin combination therapy in patients with chronic hepatitis C

AIM: To elucidate the frequency and risk factors for retinopathy in patients with chronic hepatitis C who are treated by interferon-ribavirin combination therapy.

METHODS: We prospectively analyzed 73 patients with histologically confirmed chronic hepatitis C, who underwent combination therapy for 24 wk. Optic fundi were examined before, and 2, 4, 12 and 24 wk after the start of combination therapy.

RESULTS: Fourteen patients (19%) developed retinopathy, which was initially diagnosed by the appearance of a cotton wool spot in 12 patients. Retinal hemorrhage was observed in 5 patients. No patient complained of visual disturbance. Retinopathy disappeared in 9 patients (64%) despite the continuation of combination therapy. However, retinopathy persisted in 5 patients with retinal hemorrhage. A comparison of the clinical background between the groups with and without retinopathy showed no significant differences in age, gender, viral genotype, RNA level, white blood cell count, platelet count, prothrombin time, complications by diabetes mellitus or hypertension, or pretreatment arteriosclerotic changes in the optic fundi. However, multiple logistic regression analysis revealed that complication by hypertension was observed with a high frequency in the group with retinopathy (P = 0.004, OR = 245.918, 95% CI = 5.6-10786.2).

CONCLUSION: Retinopathy associated with combination therapy of interferon α-2b and ribavirin tends to develop in patients with hypertension.

[Retinopathy during interferon treatment in combination with ribavirin for chronic hepatitis C]

PURPOSE

To observe the retinopathy of the patients who received interferon/ribavirin for treatment of chronic hepatitis C.

METHODS

We observed 6 patients(5 males and 1 female) who received interferon/ribavirin for treatment of chronic hepatitis C. Visual acuity tests and detailed fundus examinations were performed monthly during 6 months of interferon/ribavirin therapy.

RESULTS

All patients developed soft retinal exudate and 5 developed retinal blot hemorrhage. None of the patients exhibited visual impairment or subjective symptoms during the treatment period, and the retinopathy disappeared or decreased in all patients. All of the patients in this study developed interferon retinopathy while undergoing interferon/ribavirin combination therapy.

CONCLUSION

Because the combination of ribavirin with interferon may increase the incidence of interferon retinopathy, and cases of severe retinal complications have also been reported, careful fundus examinations should be performed during combination therapy, just as they are performed during conventional interferon therapy.

Retinal toxicity during pegylated alpha-interferon therapy for chronic hepatitis C: a multifocal electroretinogram investigation

BACKGROUND

Ocular side-effects in the form of retinal ischaemia and haemorrhages have been reported in patients undergoing standard alpha-interferon therapy.

AIM

To assess the ocular impact of therapy with sustained release pegylated alpha-2a interferon (Pegasys) for chronic hepatitis C.

METHODS

Ten patients receiving Pegasys and ribavirin and 10 healthy volunteers were recruited. Patients underwent full ophthalmic investigations and multifocal electroretinogram testing at baseline, at regular intervals during treatment and post-treatment. The multifocal electroretinogram maps retinal function. Responses were compared with sequential recordings from healthy volunteers.

RESULTS

All patients had normal clinical ophthalmic investigations at baseline. During therapy a single patient experienced central visual disturbance lasting 24 h with no prolonged ill effect. No other patient was aware of any change in vision. Fundal abnormalities appeared in five patients during treatment. The multifocal electroretinogram showed reductions in retinal function in five patients. Nine of 10 patients exhibited abnormalities on at least one multifocal electroretinogram or fundoscopic investigation.

CONCLUSIONS

Subclinical retinal toxicity during anti-viral therapy with pegylated alpha-interferon and ribavirin was frequent in this study and it suggests that patients should be warned of this risk and monitored during therapy.

Is screening for interferon retinopathy in hepatitis C justified?

BACKGROUND/AIM

In the treatment of hepatitis C, the National Institute for Clinical Excellence advocates use of a combination of interferon alfa and ribavirin for selected patients. Retinopathy is a well recognised side effect of interferon therapy and is characterised by retinal haemorrhages, cotton wool spots, and macular oedema. The aim of this study was to document the incidence and natural history of the retinopathy in patients treated with a long acting (pegylated) interferon and ribavirin for hepatitis C and to assess the need to screen for retinal complications.

METHODS

All patients started on treatment from September 2002 to August 2003 were invited to participate in the study. The past medical and ocular history, visual symptoms, and the results of a full ophthalmological assessment performed 3 months after starting treatment were noted. Any patient with retinal changes was followed up at 3 month intervals until the changes resolved.

RESULTS

Of the 25 patients examined, four had evidence of retinopathy including deep retinal haemorrhage and cotton wool spots. Two of the patients were diabetic and one hypertensive. None had any visual symptoms and in all four the retinopathy resolved while the patients completed their course of treatment.

CONCLUSIONS

The incidence of retinopathy with pegylated interferon is low. The retinal complications resolve while treatment is continued and are asymptomatic. This study does not support routine screening for retinopathy in patients treated with pegylated interferon and ribavirin for hepatitis C.

Safety and efficacy of dispase and plasmin in pharmacologic vitreolysis

PURPOSE

To evaluate the safety and efficacy of dispase and plasmin when inducing posterior vitreous detachment (PVD) by intravitreous injection in rabbit eyes.

METHODS

Forty-eight young pigmented rabbits were randomized into six groups. Groups 1 and 5 received 0.025 U dispase in test eyes; group 2, 0.1 U dispase; groups 3 and 6, 1 U plasmin; and group 4, 4 U plasmin. All groups received PBS in control eyes. Groups 5 and 6 were euthanatized 15 minutes after surgery for ocular histologic examination. The remaining groups (groups 1-4) received indirect ophthalmoscope and biomicroscopy 15 and 30 minutes; 1, 2, and 8 hours; and 1, 3, and 7 days after surgery. Ultrasonography and electroretinogram were performed 1 hour and 1 and 7 days after surgery. The eyes then were examined by scanning and transmission electron microscopy.

RESULTS

Partial or complete PVDs were observed in the eyes that received dispase and plasmin, confirmed by the results of scanning electron microscopy. Light microscopy showed inflammation in both dispase- and plasmin-treated eyes of groups 5 and 6. However, whereas in plasmin-treated eyes the ERG and cell ultrastructure showed no significant changes, in dispase-treated eyes, the amplitudes of ERG showed a significant reduction from baseline and ultrastructural damage to the retina was detected by transmission electron microscopy. Cell damage, preretinal hemorrhage, and cataract were also observed in these eyes. No changes were observed in the control eyes.

CONCLUSIONS

Intravitreal injection of dispase at 0.025 U or more can induce PVD, but it is not safe. Plasmin (1-4 U) is safer, except for the potential risk of inducing intraocular inflammation.

Ocular expression of vascular cell adhesion molecule (VCAM-1) in 2-butoxyethanol-induced hemolysis and thrombosis in female rats

We demonstrated previously that exposure of rats to 2-butoxyethanol (BE) was associated with morphological changes in red blood cells, hemolytic anemia, and disseminated thrombosis and infarction in different organs including the eyes. In order to elucidate the mechanism of thrombosis formation, we examined in this study the histology and immunohistochemical expression of vascular cell adhesion molecule-1 (VCAM-1), endothelial intercellular adhesion molecule-1 (ICAM-1), and P-selectin in the eyes of the female F344 rat exposed to 2, 3, or 4 daily doses of BE/250 mg/kg body weight. In this BE hemolysis and thrombosis model, positive VCAM-1 expression occurred only in eyes of rats exposed to 3 and 4 doses and was localized in the iris (epithelium lining the posterior surface, anterior mesenchymal epithelium), ciliary processes (lining epithelium, stromal cells), and retina (hypertrophic retinal pigment epithelium). Only weak immunolabeling was seen in eyes exposed to 2 doses. The appearance of VCAM-1 immunostaining correlated with the development of thrombosis located in the same structures. No change in ICAM-1 or P-selectin expression was seen. This immunolabeling distribution suggests that VCAM-1 functions in the pathogenesis of BE-related thrombosis by promoting adhesion of erythrocytes to the endothelium.

Subfoveal hemorrhage after verteporfin photodynamic therapy in treatment of choroidal neovascularization

BACKGROUND

To identify the frequency of new subfoveal hemorrhage and its impact on visual acuity 2 weeks following verteporfin photodynamic therapy (PDT) in the treatment of predominantly classic subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD).

METHODS

Retrospective, noncomparative, consecutive, interventional case series. At a tertiary retinal referral center, 104 eyes of 97 consecutive patients with predominantly classic subfoveal CNV were treated by PDT. Morphological outcomes include new subfoveal hemorrhage assessed on the photo review (pretreatment, 2 and 12 weeks after PDT). Visual acuity outcomes include moderate (3-5 ETDRS lines) and severe (6 and more ETDRS lines) loss of visual acuity at 2 weeks after PDT.

RESULTS

In this study, 104 eyes of 97 patients were analyzed. CNV in all eyes was secondary to AMD. New subfoveal hemorrhage was found in 22% (23/104) of the eyes 2 weeks following PDT. 17.4% (4/23) of the eyes with new subfoveal hemorrhage had moderate or severe loss of visual acuity. In such eyes the 12-week examination revealed considerable resorption of the new subfoveal hemorrhage with some improvement of visual acuity.

CONCLUSIONS

In 3.8% of the eyes that underwent PDT for predominantly classic subfoveal CNV secondary to AMD, new subfoveal hemorrhage may result in moderate or severe loss of visual acuity within 2 weeks. In all eyes with new subfoveal hemorrhage, considerable resorption of the hemorrhage and some improvement of the visual acuity were seen at 12 weeks. Candidates for PDT should be informed about the low risk of this complication.

Acute bilateral vitreo-retinal hemorrhages following oxygen-ozone therapy for lumbar disk herniation

PURPOSE

To describe a case of acute bilateral intraocular hemorrhages occurring after injection of oxygen-ozone (O(2)O(3)) mixture.

DESIGN

Observational case report.

METHODS

A 45-year-old woman complained about acute bilateral visual loss after intradiscal and periganglionic injection of gas mixture (O(2)O(3)) for lumbar disk herniation. Detailed ophthalmologic examination; magnetic resonance imaging (MRI) of brain and spinal cord; and neodymium:yttrium-aluminum-garnet (Nd:YAG) laser membranotomy in the left eye was performed.

RESULTS

Ophthalmoscopy revealed a premacular hemorrhage involving the left macula. In the right eye multiple, flat, retinal hemorrhages around the optic disk and the posterior pole were observed. The MRI scan for intracranial hemorrhage was unremarkable. Drainage of the left premacular hemorrhage by pulsed Nd:YAG laser was obtained a few weeks later.

CONCLUSIONS

Retinal hemorrhages seem to be an uncommon but significant complication of intradiscal O(2)O(3) infiltration, and we suggest that it should be carefully considered when recommending this procedure.

Photodynamic therapy with verteporfin for polypoidal choroidal vasculopathy of the macula

PURPOSE

Indications for photodynamic therapy (PDT) have increased from age-related macular degeneration with choroidal neovascularization (CNV), containing more than 50% of the classic component, to occult CNV, myopic CNV and CNV due to ocular histoplasmosis syndrome. In the present study, the effect of PDT with verteporfin was examined in polypoidal choroidal vasculopathy (PCV) of the macula.

METHODS

PDT was performed in 9 eyes with PCV of the macula. Fundus examination, fluorescein angiography, and indocyanine green angiography were performed before PDT and 3 months after PDT in all eyes. Optical coherence tomography was performed in 6 eyes.

RESULTS

After the initial PDT, visual acuity was stabilized or improved in 8 eyes (89%), polypoid elements were obliterated in 7 eyes (78%), and vascular nets were reduced in 8 eyes (89%). Of 6 eyes that received optical coherence tomography, pigment epithelium detachment was reduced or disappeared in all eyes except 1, which developed a disciform scar. An additional PDT was performed in 4 eyes to decrease vascular leakage. During the follow-up period of 3-18 months, no reactivation of PCV was observed.

CONCLUSION

PDT offers an effective way of treating PCV of the macula, by obliterating polypoid elements of the PCV. However, long-term follow-up is needed.

Large submacular hemorrhages after verteporfin therapy

PURPOSE

To report the occurrence of large submacular hemorrhages after photodynamic therapy with verteporfin in age-related macular degeneration patients with subfoveal choroidal neovascularization (CNV) composed of occult with no classic CNV in whom the hemorrhage precluded determining if additional therapy should be given within 3 months after initiation of treatment.

DESIGN

Retrospective, noncomparative case series.

METHODS

The records of all age-related macular degeneration patients who received verteporfin therapy for subfoveal lesions composed of occult with no classic CNV between February and July 2001 at The Wilmer Eye Institute were reviewed. Subjects who reported either having undergone a procedure to remove intraocular blood before a month 3 follow-up visit, or who had submacular hemorrhage at the month 3 visit that was severe enough to preclude determining if additional verteporfin therapy should be given were identified.

RESULTS

Fifty-five eyes of 52 patients were reviewed. Five eyes (9% [95% confidence interval, 1.4%-16.6%]) developed submacular hemorrhage that precluded determining if additional verteporfin therapy should be given. Visual acuity 3 months after documentation of the hemorrhage decreased a median of 8.5 lines compared with pretreatment acuity.

CONCLUSIONS

Even in the absence of acute severe visual acuity decrease, submacular hemorrhage after verteporfin therapy can be associated with severe vision loss and preclude determining if additional therapy should be given.

Survenue d’hémorragies rétiniennes lors du traitement de l’onchocercose par l’ivermectine chez une patiente co-infectée par la loase

A case of retinal hemorrhages with special features and degradation of the general condition is reported in a 27-year-old female patient, following the ingestion of ivermectin for the treatment of onchocerciasis. The patient was infested by both Onchocerca volvulus and Loa loa. A bilateral peripheral temporal location of the retinal lesions was observed. The role of L. loa microfilarial load in the occurrence of the retinal lesions as well as the transient character of the lesions are discussed, based on the clinical observation and with reference to the literature. The authors call for setting up a rapid therapeutic system to take care of serious adverse reactions following treatment with ivermectin in areas with a high prevalence of L. loa infestation.

Unilateral uveitis induced by a nonionic iodinated contrast agent

PURPOSE

To report recurrent unilateral uveitis after computed tomography (CT) enhanced by the contrast agent iopamidol.

DESIGN

Observational case report.

METHODS

A 44-year-old man with a history of mixed-cellularity Hodgkin lymphoma, Stage I B (axillar, infraclavicular, subpectoral lymphomas) was under remission after chemotherapy and radiotherapy. The contrast-enhanced CT scans performed every 3 months were within hours followed by a marked unilateral anterior uveitis, vitritis, and retinal bleedings. Symptoms resolved with topical corticosteroid treatment within a week.

RESULTS

We observed recurrent unilateral uveitis after intravenously application of 150 ml of iopamidol for contrast-enhanced CT scans in a patient with lymphoma in remission.

CONCLUSIONS

Iopamidol may induce uveitis under certain circumstances. We suggest a coincidence of immunologic mechanisms with predisposing discrete vascular radiation damage.

Intravitreal injection of dispase causes retinal hemorrhages in rabbit and human eyes

PURPOSE

To check the effects of intravitreally injected dispase in the vitreo-retinal region.

METHODS

Dispase, 0.05 to 2.5 units dissolved in 100 microl of phosphate-buffered saline, was injected into the midvitreous of rabbits which were killed from 15 to 120 min afterwards. The enzyme was also injected into four human eyes of patients with orbital tumors 15 min before enucleation during orbital exenteration surgery. The eyes were examined in vivo as well as by light and electron microscopy.

RESULTS

Hemorrhages were detected by fundus observations and confirmed by microscopical analysis in nearly all rabbits and in half of the human eyes. The red blood cells were observed in the vitreous and retina. Breaches in the inner limiting membrane were visualized in human eyes and ruptures of small blood vessels in rabbit eyes. In spite of that, vitreous detachment was not verified. In fact, the cortical-vitreous collagen-fibril network was conspicuous on scanning electron micrographs.

CONCLUSIONS

Retinal hemorrhages were evident as early as 11 min after injection. It is suggested that this enzyme degraded selectively basement membrane components without affecting other proteins involved in the vitreous-retinal junction.

Retinal hemorrhage after photodynamic therapy in patients with subfoveal choroidal neovascularization caused by age-related macular degeneration

PURPOSE

To report the frequency and the evolution of the extensive retinal hemorrhages that can appear within 48 h after the application of photodynamic therapy.

METHODS

Two hundred and fifteen individual eyes of 194 consecutive patients with subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration who underwent photodynamic treatment were included in the study. The visual acuity was measured before and after treatment. Color and red-free photographs were taken. Fluorescein angiography and optical coherence tomography (OCT) were also performed in order to describe the macular hemorrhages.

RESULTS

Four out of 215 eyes developed macular hemorrhage within 48 h after the photodynamic therapy. Before treatment one of the four patients had classic CNV, one predominantly classic and two patients occult CNV without any classic component. In all four cases, the hemorrhage after photodynamic therapy (PDT) was extensive, it extended beyond the arcades and it was not absorbed during the follow-up period, which ranged from 11 to 21 months. The greatest linear dimension of the hemorrhage was extremely high (>12,000 microm).

CONCLUSION

Extensive macular hemorrhage was observed in 1.86% of the studied cases. The hemorrhage was not related to the type of the CNV lesion before treatment. The size and the appearance of hemorrhage within 48 h after treatment support the view that the hemorrhage is a direct consequence of the photodynamic therapy and not related to the natural course of the disease.

Retinal and choroidal vascular occlusion after posterior sub-tenon triamcinolone injection

PURPOSE

To report a case of retinal and choroidal vascular occlusion occurring as a complication after posterior sub-Tenon triamcinolone injection for treatment of uveitic cystoid macular edema.

DESIGN

Interventional case report.

METHODS

Retrospective study. A 32-year-old woman with uveitis and cystoid macular edema underwent a right posterior sub-Tenon injection of triamcinolone (40 mg/ml, 1 ml total) through a superotemporal approach after topical anesthesia. After the procedure, the patient experienced severe eye pain, orbital ecchymosis, and globe proptosis consistent with retrobulbar hemorrhage.

RESULTS

Dilated fundus examination of the right eye (OD) demonstrated multiple intraretinal hemorrhages with particulate white emboli occluding the retinal and choroidal vessels. Visual acuity was no light perception. Ocular massage and hypotensive therapy was initiated for an intraocular pressure of 50 mm Hg. Canthotomy and cantholysis were performed. A total of 39 months post-incident, her visual acuity improved to 20/100.

CONCLUSION

Posterior sub-Tenon triamcinolone injection can rarely result in retinal and choroidal occlusion. Immediate intervention may preserve limited visual acuity.

Retinopathy in chronic hepatitis C patients during interferon treatment with ribavirin

AIM

To assess the ocular effect of interferon alfa 2b prescribed with ribavirin in patients undergoing therapy for chronic hepatitis C.

METHODS

19 patients with chronic hepatitis C who satisfied the follow up criteria were assessed for ocular complications using slit lamp biomicroscopy and indirect ophthalmoscopy before, during, and after the treatment at regular intervals.

RESULTS

8/19 patients, while on treatment, developed an asymptomatic retinopathy. Among these 3/8 were relapsers and 5/9 were non-responders to interferon monotherapy. All retinal changes faded, often while the patients continued the therapy. There was no significant association in occurrence of retinopathy with haematological and/or biochemical changes.

CONCLUSION

Retinopathy was more common in interferon monotherapy non-responders than relapsers when treated with interferon alfa 2b with the addition of ribavirin. The changes were transient, disappearing while the patients were still being treated.

Progressive renal failure and blindness due to retinal hemorrhage after interferon therapy for hepatitis C virus-associated membranoproliferative glomerulonephritis

We treated a 67-year-old Japanese woman with membranoproliferative glomerulonephritis (MPGN) and chronic active hepatitis associated with hepatitis C virus (HCV) infection. Treatment commenced with a daily dose of 6 MU IFN alpha-2b for 2 weeks, which was changed to three times weekly thereafter. After 2 weeks, HCV RNA in the serum was undetectable and there was a concomitant reduction in proteinuria. Treatment with IFN alpha-2b was discontinued because of severe headache and fever. Five weeks after the discontinuation of IFN alpha-2b, the patient experienced the sudden onset of visual loss due to retinal hemorrhage. Subsequently, proteinuria and renal function progressively deteriorated though HCV RNA was undetectable. This case exemplifies the need for careful monitoring of renal function and retinal lesions not only in patients receiving IFN but also in those following the discontinuation of IFN treatment.

Toxicity of the photosensitizer NPe6 following intravitreal injection

BACKGROUND AND OBJECTIVE

To determine the retinal toxicity of mono-L-aspartyl chlorin e6 (NPe6) following intravitreal injection.

METHODS

Twelve Dutch-belted rabbits divided into 5 experimental groups (n=2 each) were injected intravitreally with 6.25, 12.5, 25, 50, or 100 microg of NPe6; one control group (n=2) was injected with intravitreal normal saline. One eye in each rabbit was sutured shut to test the effect of light exposure. Fundus photography and electroretinograms were performed before treatment and 2 days, 1 week, and 2 weeks after injection. Animals were euthanized and the eyes enucleated for histopathologic analysis.

RESULTS

After 1 week, 4 uncovered eyes given 50 and 100 microg had central retinal vein occlusion and varying degrees of retinal hemorrhage. RPE proliferation was seen in the covered eyes given 50 or 100 microg. Electroretinograms revealed absent retinal response at 100 microg and mild toxicity at 50 microg, but no change from normal at doses of < or = 25 microg of NPe6.

CONCLUSIONS

Intravitreal doses of < or = 25 microg NPe6 caused little or no apparent toxicity; however, toxicity was significant at doses of 50 microg and 100 microg.

[Side effects of sildenafil: findings from two years practical experience]

Sildenafil has been registered for the treatment of erectile dysfunction since 1998. World wide a large number of patients were reported, dying of acute heart disease after using sildenafil. Therefore the patient instruction text was adapted. Simultaneous use of sildenafil and nitrates is contraindicated because of serious decrease of the blood pressure. The use of sildenafil can lead to physical stress in patients with a history of heart disease and a treadmill test assessment is advisable. In two years 38 adverse reactions were seen in 25 Dutch patients. The Dutch reports (three cardiovascular deaths since the introduction) also show the dilemmas in the assessment of the safety of sildenafil: is it the underlying disease or is it the drug that causes death? Further research into the adverse reactions has to be done, therefore reporting suspected side effects of sildenafil is important.