BILATERAL DIFFUSE UVEAL MELANOCYTIC PROLIFERATION MISTAKEN FOR NIVOLUMAB-INDUCED VOGT-KOYANAGI-HARADA DISEASE-LIKE SYNDROME

BACKGROUND/PURPOSE

To describe a case of bilateral diffuse uveal melanocytic proliferation (BDUMP) that was mistaken for nivolumab-induced Vogt-Koyanagi-Harada disease-like syndrome.

METHODS

We present the case of a 58-year-old white man with metastatic renal clear cell carcinoma for which he was palliatively treated with IV nivolumab immunotherapy. The patient developed subacute onset of blurry vision and gray spots in the visual fields of both eyes, macular subretinal fluid, thickening of the retinal pigment epithelium, and swollen optic nerve heads. Differential diagnosis included nivolumab-induced Vogt-Koyanagi-Harada disease-like syndrome, and the patient was initially treated with steroids, which gave no improvement. Investigation showed the development of dark-gray patches in the peripheral retina of both eyes and cataract, which prompted reevaluation of the diagnosis, deeming BDUMP most likely. The patient was successfully treated with plasmapheresis.

RESULTS

The initial presentation of the case was incorrectly diagnosed as nivolumab-induced Vogt-Koyanagi-Harada disease-like syndrome. On repeat studies of the patients' symptoms and imaging, we concluded we had missed signs of BDUMP.

CONCLUSION

The diagnosis BDUMP was missed in the first evaluation. We present this case to discuss the similarities and differences between this disease and nivolumab-induced Vogt-Koyanagi-Harada disease-like syndrome. More importantly, we want to highlight that reevaluation of the diagnosis on worsening of a disease was key in this unusual case.

Uveal effusion induced by topical travoprost in a patient with Sturge-Weber-Krabbe syndrome

PURPOSE

To report a case of uveal effusion with subtotal exudative retinal detachment induced by topical administration of travoprost.

CASE REPORT

A 20-year-old woman with a medical history of right-sided Sturge-Weber-Krabbe syndrome and bilateral aphakia secondary to congenital cataract extraction was referred to our department for retinal detachment associated with uveal effusion of the right eye. The ocular manifestations of Sturge-Weber-Krabbe syndrome in her right eye were glaucoma and diffuse choroidal hemangioma. Antiglaucomatous medications using topical travoprost 0.004%/timolol 0.5% (fixed combination) had been begun 1 week before. An adverse effect of travoprost was suspected and the drug was discontinued. Three weeks later, a fundus examination showed total disappearance of the uveal effusion.

CONCLUSIONS

Interaction of the effects of topical prostaglandin analogs (blood-aqueous barrier disruption, enhancement of uveoscleral outflow) with both the diffuse choroidal hemangioma and the elevated episcleral venous pressure may lead to uveal effusion in Sturge-Weber-Krabbe syndrome. In spite of their efficiency, prostaglandin F2 analogs (latanoprost, travoprost and bimatoprost) should be used with caution in Sturge-Weber-Krabbe syndrome and particularly in cases of proved diffuse choroidal hemangioma.

Escitalopram-induced uveal effusions and bilateral angle closure glaucoma

PURPOSE

To report the onset of bilateral angle closure glaucoma resulting from ciliochoroidal effusions noted after taking escitalopram.

DESIGN

Case report.

METHODS

A 41-year-old woman with a medical history of depression was placed on escitalopram and presented with acute bilateral angle closure glaucoma. A medical history and ophthalmic examination (including slit-lamp photography and high-frequency ultrasonography) were performed at the time of diagnosis and at resolution of her symptoms.

RESULTS

High-frequency ultrasonography revealed bilateral choroidal effusions with ciliary body detachments and angle closure. Attempts to reduce intraocular pressure with topical ocular antihypertensive drugs and subsequent laser peripheral iridotomy were unsuccessful. Over the course of four days, the use of topical cycloplegics, corticosteroids, and discontinuation of escitalopram resulted in normalization of intraocular pressures, deepening of anterior chamber depths, and resolution of her uveal effusions.

CONCLUSIONS

The use of escitalopram resulted in uveal effusions, angle rotation, and acute bilateral angle closure glaucoma. Discontinuation of escitalopram and corticosteroid therapy resulted in normalization of the patient's eyes.

Ultrastructural changes in rabbit ciliary body after extraocular mitomycin C

PURPOSE

To study the ultrastructural changes in ciliary body epithelium of the rabbit eye after subconjunctival injections of mitomycin C.

METHODS

One eye of six New Zealand white rabbits was given a subconjunctival injection at the 12-o'clock position with 0.005, 0.02, 0.08, 0.1, 0.12, or 0.16 mg mitomycin C. The fellow eye was given a subconjunctival injection of balanced salt solution. Two weeks after treatment, the eyes were enucleated, and the ciliary body was exposed and submerged in fresh 4% paraformaldehyde/2% glutaraldehyde in 0.1 M phosphate buffer, pH 7.4, at 4 degrees C. Electron microscopy of the ciliary body was performed at two sites: the injection site (12-o'clock position) and 180 degrees away (6-o'clock position).

RESULTS

At dosages of 0.1 mg and higher, ciliary body epithelial cells beneath the injection site were thinned. There were vacuoles and expansion of intracellular and intercellular spaces. Plasma membrane infoldings were disrupted, and the apical membrane was thinned. Mitochondria and nuclei were normal. Ciliary body epithelium at 6-o'clock position showed only mild architectural distortion of the plasma membrane infoldings. Eyes that received lower doses of mitomycin C (0.005 mg, 0.02 mg, and 0.08 mg) and balanced salt solution showed normal ciliary body epithelium at the injection site and 180 degrees away.

CONCLUSIONS

Subconjunctival injection of mitomycin C in the rabbit produces dose-dependent localized ultrastructural changes of the ciliary body epithelium.

An animal model for cidofovir (HPMPC) toxicity: intraocular pressure and histopathologic effects

Intravitreal cidofovir has been shown to be a long acting and highly efficacious treatment for CMV retinitis; however decrease in IOP is an adverse effect. We wanted to determine the effect of cidofovir on intraocular pressure (IOP) in the guinea pig, and rabbit eye to develop an animal model of cidofovir induced ocular hypotony and to study the histopathology of this toxicity. Twenty-eight guinea pig eyes were injected with cidofovir yielding final intravitreal concentrations of 25, 200, 625 and 2000 micrograms ml-1. Eighteen eyes of pigmented rabbits were injected with cidofovir yielding final intravitreal concentrations of 625 and 2000 micrograms ml-1. A carefully calibrated low volume displacement manometer system using a micro-transducer was used to determine the IOP measurements in the guinea pig and rabbit eyes. Histology was evaluated using light and electron microscopy. Injection of 6.25 micrograms of cidofovir intravitreally (vitreous concentration of 25 micrograms ml-1) is the highest non-toxic dose in the guinea pig; the IOP was unchanged at two and four weeks after injection with this dose; histologically the eyes were normal. A single injection of 50 micrograms of cidofovir intravitreally (vitreous concentration of 200 micrograms ml-1) caused a long lasting (9.3 mmHg) decrease in IOP (approximately 50% of baseline). At this dose there were only mild and variable histologic changes in the ciliary body and the retina. Higher doses of 156.25 micrograms and 500 micrograms of cidofovir (vitreous concentrations of 625, and 2000 micrograms ml-1, respectively) caused moderate to severe ciliary body and retinal changes. In rabbit eyes there was a mild but statistically insignificant pressure drop with doses of 875 micrograms cidofovir intravitreally (vitreous concentration of 625 micrograms ml-1); retina was within normal limits after injection with this dose, there were mild changes in the ciliary body. There was a total destruction of ciliary body and loss of nonpigmented epithelial cells with injections of 2800 micrograms of cidofovir intravitreally (vitreous concentration of 2000 micrograms ml-1): retina was relatively well preserved. The guinea pig eye shows similar reduction in IOP and ciliary body changes as are seen in the human eye after intravitreal cidofovir and also appears to have a similar dose-response curve. However, the reduction of IOP caused by cidofovir occurs in the guinea pig eye at a concentration 40 times higher than was observed in the human eye.

Drug-induced transient myopia and angle-closure glaucoma associated with supraciliary choroidal effusion

PURPOSE

We investigated the mechanism of drug-induced transient myopia, anterior chamber shallowing, and secondary angle-closure glaucoma in a young woman.

METHODS

Ultrasound biomicroscopy was performed and the effects of cycloplegic eyedrops and unilateral laser iridotomy were evaluated.

RESULTS

Cycloplegic eyedrops and unilateral laser iridotomy had no effect. Ultrasound biomicroscopy identified the presence of a supraciliary choroidal effusion that caused forward displacement of the lens-iris diaphragm, resulting in increased myopia, anterior chamber shallowing, and angle-closure glaucoma. Discontinuance of trimethoprim and sulfamethoxazole combination led to the complete resolution of the condition.

CONCLUSIONS

Idiosyncratic drug reactions may produce a supraciliary choroidal effusion, resulting in myopia and secondary angle-closure glaucoma from the induced forward shift in the position of the crystalline lens and ciliary body.

Drug-induced ciliary body oedema: a new theory

Drug-induced oedema of the ciliary body is rare, and occurs predominantly following exposure to sulphonamides. In a 31-year-old patient in her 37th week of pregnancy, we observed reversible myopia of -4.75 dioptres following the ingestion of chlorthalidone. In a second case report we describe, in a 61-year-old patient suffering from aspirin-sensitive asthma, recurrent ciliary body oedema with a marked spastic component which was triggered by the medications acetazolamide, dipivefrine and pilocarpine. We explain oedema of the ciliary body on the basis of the eicosanoids. We believe that the oedema is caused mainly by prostaglandins and that leucotrienes are predominantly responsible for the spastic component. We postulate a drug-induced elevation in eicosanoid concentrations, as well as certain interrelationships between ciliary body oedema and aspirin-sensitive asthma.

Transdermal scopolamine cycloplegia in juvenile diabetes

We report a case of transdermal scopolamine-induced cycloplegia in a 15-year-old diabetic girl. Transdermal scopolamine disks are widely used and neurologists should be ready to discern their possible side-effects.

Retinal and choroidal vascular occlusion secondary to corticosteroid embolisation

We report a case of visual loss following intranasal injection of triamcinolone acetonide and phenylephrine hydrochloride in a 22-year-old female with chronic sinusitis. Clinical examination and fluorescein angiography revealed vascular occlusions which involved multiple small branches of both the choroidal and retinal circulations. The mechanism of such a complication probably involves inadvertent intra-arterial injection into the anterior or the posterior ethmoidal artery, with retrograde flow into the opthalmic arterial system. Precautions can be taken to avoid such complications.

Six cases of central serous choroidopathy induced by systemic corticosteroid therapy

We report 6 cases of central serous choroidopathy (including pigment epithelial detachment in one case) which appeared in the course of systemic corticosteroid administration conducted to cure concurrent general diseases, and in one patient with a steroid-releasing pituitary adenoma. The majority of cases arose within about one month following the administration of more than 200 mg of prednisolon. It is postulated that corticosteroids operate as a kind of stress intervening in the hypophysis-adrenal system, leading eventually to the development of central serous choroidopathy.

Central serous chorioretinopathy complicating systemic corticosteroid treatment

Central serous chorioretinopathy developed in 2 cases of retrobulbar neuritis during systemic treatment with corticosteroids. Fluorescein angiography confirmed leakage surrounded by central serous detachment of the retina. In one case the central serous chorioretinopathy recurred 3 times during 3 separate courses of treatment. Spontaneous recovery accompanied a reduction in steroid treatment to a low level. It is suggested that high dosage corticosteroids may damage the posterior blood-ocular barrier.

Tapetal changes in beagle dogs. I. Ocular changes after oral administration of a beta-adrenergic blocking agent--SCH 19927

SCH 19927 [R,R)-(-)-2-Hydroxy-5-[1-hydroxy-2-[(1-methyl -3-phenylpropyl)amino]ethyl]benzamide hydrochloride) is a beta-adrenergic blocking agent which has vasodilating properties. In a subchronic oral toxicity study in beagle dogs, SCH 19927 was given by gavage at doses of 30, 60, and 90 mg/kg. Lesions were observed at weeks 13 and 19 in the tapetum lucidum, a light reflecting structure of the eye. The lesions consisted of focal to multifocal areas of discoloration of the tapetal portion of the ocular fundus, pigmentation in the tapetal area, and, in one dog, subretinal edema resulting in a focal retinal detachment. Light and electron microscopic examination of the ocular lesions demonstrated tapetal cell degeneration and necrosis with macrophages, lymphocytes, and occasional plasma cells in the tapetum and adjacent choroid. Local cellular infiltrates within the retina internal to the pigmented epithelium were observed in one dog (60 mg/kg) which was demonstrated to have focal retinal edema during the study. In a repeat study the lesion again occurred in tapetal beagle dogs but not in atapetal beagle dogs (90 mg/kg) or cynomolgous monkeys (360 mg/kg). The lesion had not occurred in a previous subchronic study in albino rats. These results demonstrated that the tapetum lucidum was a target organ of toxicity for SCH 19927 and indicated that the finding was without observable toxicological significance in animals, including man, whose eyes do not have this structure.

Tapetal changes in beagle dogs. II. Ocular changes after intravenous administration of a macrolide antibiotic--rosaramicin

Two studies were conducted to assess the toxicity of rosaramicin (a macrolide antibiotic) when given intravenously for 30 consecutive days to beagle dogs with and without a tapetum lucidum (a light reflecting structure within the choroid of the eye). In the initial study, groups of three tapetal dogs/sex were given 20, 40, or 80 mg of rosaramicin/kg, twice daily. Ophthalmoscopic examination during Week 4 revealed dose-related, bilateral ocular changes characterized by a brown-tan discoloration and general pallor or loss of reflectivity of the normally blue-purple or yellow-green, highly reflective tapetum lucidum. These findings were restricted to the tapetal fundus; recovery occurred between Weeks 4 and 10 of the postdose period. To further investigate these changes, a second study was conducted in which groups of three tapetal dogs were given rosaramicin or erythromycin lactobionate (comparative macrolide antibiotic) at 80 mg/kg, twice daily. A third group of atapetal dogs was given 80 mg of rosaramicin/kg, twice daily. A similar change was observed in tapetal dogs given 80 mg of rosaramicin/kg, twice daily, in the follow-up study, but not in the other two groups. No other compound-related changes were observed in either study. The ocular changes observed in dogs given rosaramicin were reversible and structure-specific, occurring only in animals possessing a tapetum lucidum.

Histopathological and laboratory assessment of visual dysfunction

The currently available methods of assessing ocular toxicity are discussed. Manifestations of ocular toxicity are best described clinically; histopathological examination of the eye is beset with problems of preparing the eye for morphological examinations. Electron microscopy is essential to look for chemically induced side effects at the cellular level. Mechanisms of ocular toxicity are poorly understood, and the limitation of animal studies in predicting side effects in man must be appreciated.

Experimental model of gyrate atrophy in animals

Intravitreal injection of L-ornithine hydrochloride in physiologic saline solution caused marked edema specifically in the pigment epithelium of Sprague-Dawley strain albino and Evans black hooded rats and rhesus and cynomologus monkeys. Swelling of the pigment epithelial cells, which was most prominent four hours after the injection, disappeared by 24 hours. However, many pigment epithelial cells gradually degenerated resulting in patches of denuded areas. The photoreceptor cells overlying the damaged pigment epithelium degenerated secondarily.

Experimental ciliochoroidal detachment. Effect on intraocular pressure and aqueous humor flow

Ciliochoroidal detachments were produced in rhesus monkeys by injecting glutathione bicarbonate Ringer's solution, autologous serum, or silicone oil into the anterior suprachoroidal space. Silicone oil detachments, like sham operations, caused a transient 2 mm Hg reduction in intraocular pressure. Detachments with glutathione bicarbonate Ringer's solution or serum caused a 6 mm Hg reduction in intraocular pressure, which normalized in three weeks. Aqueous humor flow in serum-detached eyes was normal, indicating that the hypotonia does not result from reduced aqueous humor formation. Blood was present in Schlemm's canal in most eyes with hypotonia, which suggests that hypotonia is not the result of enhanced conventional aqueous humor outflow. Therefore, it is postulated that hypotonia might result from enhanced aqueous humor outflow from the anterior chamber into the suprachoroidal space and out of the eye through the emissarial channels of the sclera (uveoscleral outflow).

Progressive chorioretinopathy after receiving thioridazine

A distinctive appearance of the ocular fundus as a late complication of high doses of orally administered thioridazine hydrochloride (Mellaril) is described. Discrete nummular areas of loss of retinal pigment epithelium (RPE) extended from the posterior pole to the midperiphery. Fluorescein angiography demonstrated loss of choriocapillaris in these zones. Atrophy of the remaining RPE was progressive, with advancement of the edges of the atrophic zones and breakdown of bridges of RPE separating them. Atrophy occurred after discontinuation of the drug and advanced without further exposure to it. Dark adaptation, the electroretinogram, and the electro-oculogram were abnormal in the late stages. Central visual acuity remained relatively good.

Mydriasis from Datura wrightii

A 4-year-old girl had painless, uniocular mydriasis after picking flowers. Pharmacologic testing with 1% pilocarpine confirmed the probability that an atropine-like agent had been instilled in the affected eye. The flowers were identified as Datura wrightii and contained scopolamine, hyoscyamine, and atropine on thin-layer chromatography.

[Plexiglas (PMMA) in the anterior chamber. An experimental study on biological compatibility]

For six months the anterior chambers of rabbits were examined at regular intervals with the slit-lamp photograph. The reactions of iris, aqueous, and cornea were observed after implanting one PMMA-disc (0.25 mm thickness and 1.5 mm diameter) through a lancet incision. At the place where the disc touched the iris one could see during the half year period hyperaemia iridis, ciliary injection, atrophia iridis, and foreign-substance-granuloma of the iris with partial adhesion of the iris wrinkles. The cause for these reactions is a toxin in the PMMA. Mechanical irritation and plastic alteration could be excluded by the experimental method.

Miotic drugs: a review of ocular, visual, and systemic complications

Cholinergic drugs and anticholinesterases have caused ocular complications including cataracts, iris cysts, retinal detachment, iritis, increased intraocular tension, allergic and toxic reactions, and hypermia. The visual complications include accommodative spasm; myopia and reduced visual acuity; changes in vision sensitivity, dark adaptation, and visual fields; and discomfort. The systemic complications are those common to cholinergic drugs and anticholinesterases. This review is intended as a ready reference to the drugs that cause such effects and source material.

[Persistent iridoplegia and filamentary keratitis complications following cataract extraction (author's transl)]

In a series of 3,222 cataract operations where enzymatic zonulolysis with Alphachymotrypsin was employed, the authors describe two complications which are thought to be due to the effects of the enzyme. They are the persistent iridoplegia in 18 cases (0.05) and the filamentary keratitis in 34 patients (1.05%). The clinical picture of an acute enzymatic intraocular pressure increase and the appearance of a persistent iridoplegia are discussed. Furthermore, these complications are brought together in tables and associated with other which are also thought to be caused by Chymotrypsin.