Prominent Optic Disc Featured in Inherited Retinopathy

Background We investigated the relationship between prominent optic disc (POD) and inherited retinal dystrophy (IRD). Patients and Methods A cross-sectional consecutive study was performed in 10 children and 11 adults of 7 non-related families. We performed clinical phenotyping, including a detailed examination, fundus autofluorescence, and colour fundus and OCT imaging. Genetic testing was subsequently performed for all family members presenting retinal pathology. Results In 4 members of a 3-generation family, hyperfluorescent deposits on the surface of POD were related to a p.(L224M) heterozygous mutation in BEST1. In the second family, one member presented deposits located on the surface on hyperaemic OD and a compound p.(R141H);(A195V) mutation in BEST1. In the third family, POD was observed in father and child with early onset cone-rod dystrophy and a novel autosomal recessive p.(W31*) homozygous mutation in ABCA4. In the fourth family, POD with "mulberry-like" deposits and attenuated vessels were observed in a 7-year old girl, with a mutation in USH1A, and with early onset rod-cone dystrophy, associated with hearing loss. In the fifth family, blurry OD with tortuous vessels was observed in 4 consanguineous female carriers and a hemizygous boy with a p.(R200H) mutation in the X-linked retinoschisis RS1. In the sixth family, a mother and her son were both affected with POD and attenuated peripapillary vessels, and presented with a p.(Y836C) heterozygous mutation in TOPORS, thus confirming autosomal dominant RP. In the seventh family, in 3 family members with POD, compound p.(L541P;A1038 V);(G1961E) mutations in ABCA4 confirmed the diagnosis of Stargardt disease. Conclusions A variety of OD findings are found in a genetically heterogeneous group of IRDs. In the presence of POD, an inherited progressive photoreceptor disease should be ruled out.

The association between retinal nerve fibre layer thickness and N-acetyl aspartate levels in multiple sclerosis brain normal-appearing white matter: a longitudinal study using magnetic resonance spectroscopy and optical coherence tomography

BACKGROUND AND PURPOSE

N-acetyl aspartate (NAA) assessed using proton magnetic resonance spectroscopy (¹ H MRS) has a high pathological specificity for axonal density. Retinal nerve fibre layer thickness (RNFLT) measured by using optical coherence tomography is increasingly used as a surrogate marker of neurodegeneration in multiple sclerosis (MS). Our aim was to investigate the relation between RNFLT and NAA/creatine in brain normal-appearing white matter (NAWM), their dynamics over time and the association with clinical outcome measures in relapsing MS. T2 WM lesions served as control tissue.

METHODS

Forty-three MS patients underwent standardized neurological examination including the Expanded Disability Status Scale (EDSS), Multiple Sclerosis Functional Composite (MSFC) score, optical coherence tomography and magnetic resonance imaging including ¹ H MRS at baseline and after 1 year.

RESULTS

At baseline, NAA/creatine level was lower in T2 WM lesions than in NAWM (1.64 ± 0.16 vs. 1.88 ± 0.24, P < 0.001). Lowest levels were found in secondary progressive MS (SPMS). Mean RNFLT was higher in clinically isolated syndrome than in the combined group of relapsing-remitting MS and SPMS (99.8 ± 12.3 μm vs. 92.4 ± 12.8 μm, P = 0.038). In all patients, mean RNFLT decreased by 1.4% during follow-up. At baseline, MSFC z-scores correlated with NAA/creatine levels both in NAWM (r = 0.42; P = 0.008) and T2 WM lesions (r = 0.52, P = 0.004). NAWM NAA/creatine variation correlated with the RNFLT change over 1 year (ρ = 0.43, P = 0.046).

CONCLUSIONS

N-acetyl aspartate/creatine level reduction correlated with RNFLT thinning over 1 year in an EDSS stable MS cohort suggesting that these techniques might be sensitive to detect subclinical disease progression.

[The role of chronic or transient hypoxia on the retinal nerve fiber layers]

BACKGROUND

In a clinical study, the role of chronic hypoxia in patients with chronic obstructive pulmonary disease or the role of transient hypoxia in patients with obstructive sleep apnea syndrome were examined for the peripapillary retinal nerve fiber layers.

PATIENTS AND METHODS

10 patients with chronic obstructive pulmonary disease GOLD stages 3 or 4 (4 men and 6 women, age 47 to 71 years, mean 60.6 years) and 10 patients with obstructive sleep apnea syndrome with an apnea-hypopnea index of 15 or more (8 men and 2 women, age 39 to 76 years, mean 60.7 years) were included in the study. The thickness of the retinal nerve fiber layers was measured with an optical coherence tomography.

RESULTS

In the group with chronic obstructive pulmonary disease and in the group with obstructive sleep apnea syndrome, the measurements of the retinal nerve fiber layers were in normal range.

CONCLUSIONS

By using optical coherence tomography, no lesions to the retinal nerve fiber layers were detectable in patients with chronic or transient hypoxia. The findings of the study could be limited by the too short duration of the disease and/or to the too small number of patients.

[Disease perception in patients with wet age-related macular degeneration]

BACKGROUND

The disease perception of the patients treated with intravitreal injections of anti-vascular endothelial growth factor due to wet age-related macular degeneration was investigated.

PATIENTS AND METHODS

177 questionnaires focusing on the development of the perceived visual acuity and the quality of life were evaluated. The subgroup 1 included 125 patients (70.6%) with a unilateral wet age-related macular degeneration. The subgroup 2 included 52 patients (29.4%) with a bilateral wet age-related macular degeneration.

RESULTS

Patients would almost always recommend the therapy to a friend (97.2%). The critical remarks are related to the uncertain course of the disease (22.8%) and the uncertain duration of the treatment (19%). There was a discrepancy between the measured visual outcome and the perceived one in 5.6% in the subgroup 1, and in 38.5% in the subgroup 2. This difference was statistically significant (chi-square test with p<0.01).

CONCLUSIONS

The treatment of wet age-related macular degeneration with intravitreal injections of anti-vascular endothelial growth factor is judged positively. Binocular affected patients have a higher disease perception and therefore a poorer self-assessment of their visual acuity and their quality of life compared with monocular affected patients.

Retinal vessel oxygen saturation in patients suffering from inherited diseases of the retina

PURPOSE

The aim of this study was to evaluate the oxygen saturation in patients with inherited diseases of the retina.

METHODS

Fundus oximetry images were taken using a retinal vessel analyser (IMEDOS Systems UG, Jena, Germany). Retinal vessel oximetry was performed in 53 eyes of 27 patients suffering from inherited retinal diseases and compared to 22 eyes of 11 healthy controls. The oxygen saturation in all four major retinal arterioles (A-SO2) and venules (V-SO2) were measured and their difference (A-V SO2) was calculated. The data were compared within groups and to controls.

RESULTS

Based on V-SO2 values, the rod-cone dystrophy group (66.46%; SD, ± 5.09) could well be differentiated from controls 54.02% (SD, ± 3.04), from cone-rod dystrophies 57.56% (SD, ± 5.66), as well as from inherited maculopathies 58.42% (SD, ± 4.74). The mean A-SO2 in the rod-cone dystrophy group was increased to 98.96% (SD, ± 6.06, p<0.014), while in the cone-rod group and in the maculopathy group it was 92.75% (SD, ± 3.75), respectively 94.44% (SD ± 4.85), closer to the normal values (92.68%; SD, ± 3.53, p>0.05). The A-V SO2 difference, as an indirect indicator for retinal oxygen use, was reduced in the rod-cone patients, however only when the controls were taken into account (p=0.01).

CONCLUSION

This is to our knowledge the first study which proposes the retinal vessel oximetry to be a sensitive measure for differentiating rod-cone dystrophy patients not only from controls, but also from patients with other inherited retinal dystrophies.

[Dexamethason implant in the treatment of macular edema in retinal vein occlusion and intraocular inflammatory disease]

BACKGROUND

The efficacy of a single dose of Ozurdex® was evaluated over a 6-month period in eyes with macular edema due to retinal vein occlusion and intraocular inflammatory disease.

HISTORY AND SIGNS

20 eyes of 20 consecutive patients with macular edema received a single injection of Ozurdex® (intravitreal dexamethasone implant 0.7 mg). Patients with branch retinal vein occlusion (n = 11), central retinal vein occlusion (n = 6), non-infectious posterior uveitis (n = 1) and Irvine-Gass Syndrome (n = 2) were included. In 10 patients Ozurdex® was used as the first treatment, 10 patients had undergone previous treatments for macular edema. The mean duration from the symptoms to the initiation of the treatment was 14.2 (1-60) months. The follow-up measurements were performed 1, 3 and 6 months after treatment. The main interest of the study was the visual and structural development over the duration of 6 months after a single dose of Ozurdex® with outcome measures including changes in best-corrected visual acuity and central retinal thickness.

THERAPY AND OUTCOME

At baseline, the mean best-corrected visual acuity of all patients was 50 (± 16) ETDRS letters and the mean central retinal thickness was 632 (± 168.3) microns. Mean follow-up time was 3.4 (± 1.5) months and 7 patients dropped out during the follow-up period (4 patients after 3 months, additional 3 patients after 6 months). One month after treatment, 14 out of 20 patients (70%) showed a complete regression of macular edema, and in 6 cases (30%) it was partially recurrent. The mean best-corrected visual acuity improved to 56 (± 20.8) ETDRS. Central retinal thickness showed a mean decrease to 278 (± 84.9) microns. 6 months after treatment, recurrence was observed in 9 cases out of the remaining 13 patients (69.2%). In 3 cases, macular edema persisted (23.1%) and in one case (7.7%) the macula remained dry. The mean best-corrected visual acuity was 55 (± 13.9) ETDRS letters. The mean central retinal thickness decreased to 603 (± 174.6) microns.

CONCLUSIONS

Ozurdex® showed a good effect in the treatment of macular edema one month after its application, namely a temporary decrease in central retinal thickness and a corresponding increase in best-corrected visual acuity. 6 months after treatment, the recurrence rate was high, and only one person with a branch retinal vein occlusion remained relapse-free over the entire follow-up. Based on our data, the patients should be checked at the latest after 3 months and then monthly in order to detect relapse in time and to initiate another treatment if needed.

[Bevacizumab and Ranibizumab for macular edema due to retinal vein occlusions]

BACKGROUND

The effect of Bevacizumab (BE) (Avastin®) or Ranibizumab (RA) (Lucentis®) on the visual acuity (VA) and on the central foveal thickness (CFT) was evaluated in macular edema due to retinal vein occlusion.

PATIENTS AND METHODS

Eyes with a macular edema due to a central retinal vein occlusion or to a branch retinal vein occlusion were considered if at least 3 intravitreal injections of Bevacizumab (1.25 mg) or Ranibizumab (0.5 mg) had been performed. The visual acuity with ETDRS and the central foveal thickness with spectral optical coherence tomography (OCT) were measured. The 3-months follow-up and, if further injections were necessary, the 6-months follow-up were evaluated.

RESULTS

After 3 months a significant improvement of the visual acuity was measured in both groups (p < 0.001) while during the same period the mean central foveal thickness diminished significantly (p < 0.001). At the 3-months follow-up there were no significant differences between the two groups for the mean visual acuity and for the mean central foveal thickness. The treatment was continued in 36 eyes and the visual acuity and the central foveal thickness were compared between the 3-months and the 6-months follow-up. No further improvements of the visual acuity or of the central foveal thickness were measured in both groups. A relapse of the macular edema was diagnosed in 30 eyes without a significant difference in the Bevacizumab group compared to the Ranibizumab group.

CONCLUSION

Intravitreal injections of Bevacizumab and Ranibizumab improved the visual acuity and the central foveal thickness in macular edema due to retinal vein occlusion at 3 months. A further improvement was not measured if the treatment was prolonged to 6 months. There were no significant differences measured between Bevacizumab and Ranibizumab. The ratio of relapses is important to note.

[Heavy tamponade in complicated inferior retinal detachment]

BACKGROUND

Retinal detachment with inferior proliferative vitreoretinopathy is a difficult to treat problem. The aim of our study was to assess the safety and efficacy of Densiron in the clinical management of complicated retinal detachment.

HISTORY AND SIGNS

6 eyes of 6 consecutive patients presenting with a retinal detachment with inferior proliferative vitreoretinopathy grade 3 were treated with pars plana vitrectomy and injection of Densiron. The mean age of the patients was 61 years. 3 patients had a previous unsuccessful vitreoretinal surgery and 3 patients had Densiron as a first procedure. The extent of detachment was at least 2 or more quadrants with macular involvement in 3 cases. Preoperatively the mean visual acuity was 29.2 letters with ETDRS.

THERAPY AND OUTCOME

Densiron was removed after an average of 58 days. 5 patients achieved retinal re-attachment without further tamponade, and 1 patient after additional injection of conventional silicon oil. 4 - 6 weeks after removal of Densiron the mean visual acuity was 50.2 letters with ETDRS. The most common complication was an elevated intraocular pressure during endotamponade, which resolved following removal of the agent.

CONCLUSIONS

Densiron improves inferior tamponade, and in clinical practice may be considered to increase the anatomic success rate in selected cases of complicated retinal detachment with inferior proliferative vitreoretinopathy.

The treatment of choroidal neovascularizations in age-related macular degeneration using either Avastin or Lucentis

BACKGROUND

Either Avastin or Lucentis was used in our clinic to treat choroidal neovascularizations in age-related macular degeneration. The number of injections necessary for drying the macular findings was especially assessed.

PATIENTS AND METHODS

From April 2006 to August 2008 324 eyes were treated with Avastin, and from January 2007 to August 2008 348 eyes were treated with Lucentis. The intravitreal injections with Avastin (1.25 mg in 0.05 mL) were performed every six weeks, and with Lucentis (0.05 mg in 0.05 mL) every four weeks until the macular findings were considered to be dry. Fluorescein angiography and optical coherence tomography were used for the diagnosis and for the checks which were carried out every twelve weeks. The visual acuity was measured with an ETDRS chart.

RESULTS

The treatment with Avastin is completed in 319 eyes with an average improvement of the visual acuity of 5.1 letters after 3.3 injections, and with Lucentis in 226 eyes with an average improvement of the visual acuity of 6.4 letters after 3.4 injections (p = 0.24; one way ANOVA).

CONCLUSION

Both of the drugs allow the drying of the macular findings in the great majority of the cases after a short time and lead to a quite similar improvement of the visual acuity. A definitive stabilization of the disease after stopping the treatment is not foreseeable.

Pars plana vitrectomy with 25-gauge instruments in the treatment of idiopathic epiretinal membranes

BACKGROUND

The sutureless pars plana vitrectomy (ppv) using a 25-gauge instrumentation is a minimally invasive technique which is mainly performed for procedures that do not require extensive vitreous dissection. In a consecutive case series with retrospective collection of data, the advantages and the risks of this technique are discussed in comparison with the conventional 20-gauge ppv for patients with idiopathic epiretinal membranes.

PATIENTS AND METHODS

Between July 2003 and November 2004, 64 consecutive patients (26 men, 38 women, mean age: 72 years) were treated with a 20-gauge ppv, and between December 2004 and January 2006, 75 consecutive patients (42 men, 33 women, mean age: 70.4 years) were treated with a 25-gauge ppv. The patients were classified into three groups: ppv combined with phacoemulsification (group 1), ppv in pseudophakic eyes (group 2), or ppv without phacoemulsification (group 3). There were postoperative controls after at least 1, 30 and 180 days.

RESULTS

The visual acuity improves quicker in the groups 1 and 2 of the 25-gauge ppv compared with the 20-gauge ppv due to less postoperative inflammation and to the practical absence of postoperative astigmatism. In the group 3, after using either a 25-gauge or a 20 gauge ppv, the development of a postoperative cataract restrained the improvement of the visual acuity. The following postoperative complications were noticed using the 25-gauge ppv: transitory hypotonia with an eye pressure < 5 mmHg (9 cases) and with attendant choroidal detachment (3 cases), macular oedema (1 case), and endophthalmitis (1 case); using the 20-gauge ppv: transitory hypertonia (9 cases), macular oedema (2 cases), and retinal detachment (3 cases).

CONCLUSIONS

The sutureless 25-gauge ppv is advantageous for a quick postoperative recovery of the visual acuity, and may be well combined with cataract surgery. Nevertheless, this technique involves risks and its further evaluation, especially in comparison using a 23-gauge ppv, is indicated.

Uveal effusion syndrome

BACKGROUND

The idiopathic uveal effusion syndrome is characterized by a spontaneous serous detachment of the choroid and ciliary body. Pathophysiology is related to a relative scleral impermeability to protein. A possible complication is the development of a serous retinal detachment.

HISTORY AND SIGNS

We present a 65-year-old male, mild hyperopic patient with a peripheral circular choroidal tumour OD, and macular retinal folds OU. Visual acuity was OD 0.5 due to an additional cataract and OS 1.0. Ocular inflammation was not present. Extensive medical, serological and immunological investigations were normal. On MRI a thicker sclera compatible with the diagnosis was measured.

THERAPY AND OUTCOME

Twelve months after the first presentation the patient has no complaints and the ocular findings are stable so that a therapy was not necessary up to now.

CONCLUSIONS

Uveal effusion syndrome is a rare disease which belongs to the differential diagnosis of choroidal tumour with serous retinal detachment. The correct diagnosis is important as sclerectomy or sclerotomy may be an effective treatment.

[Visual improvement of an amblyopic eye in an adult patient after visual loss in the non-amblyopic eye]

BACKGROUND

The sensitive period for a successful amblyopia treatment is limited to the age of 11 to 13 years.

HISTORY AND SIGNS

We present a 60-year-old patient with complete visual loss on his dominant eye after retinal arterial occlusion. The fellow eye had a known severe amblyopia with a corrected visual acuity of 0.1.

THERAPY AND OUTCOME

After retinoscopy the patient received a full correction for his amblyopic eye and the vision increased to 0.25. After three months follow-up visual acuity was 0.5 for single optotypes.

CONCLUSIONS

Even in adulthood a attempt at full correction of an amblyopic eye after loss of vision in the dominant eye should be performed for optimising the quality of life.

Photodynamic Therapy in the Treatment of Chronic Central Serous Chorioretinopathy

BACKGROUND

Central serous chorioretinopathy (CSC) is usually a benign disorder which resolves spontaneously, and requires no treatment. Nevertheless, in cases of chronic or recurrent detachment of the neurosensory retina a durable decrease of the visual acuity may be measured due to lesion of the photoreceptors. To avoid this evolution we performed a pilot study to assess the effect of photodynamic therapy (PDT) in patients with CSC without clinical normalization 6 months after the begin of the symptoms.

PATIENTS AND METHODS

We report on 14 eyes in 13 patients presenting a chronic CSC without leaking point accessible for focal laser photocoagulation. The diagnosis was confirmed by fluorescein angiography (FA), and optical coherence tomography (OCT). PDT with verteporfin was performed according to the protocol used for treating choroidal neovascularization in age-related macular degeneration.

RESULTS

One month after PDT, leakage on FA and detachment of the neurosensory retina on OCT had disappeared, and visual acuity had improved in all patients.

CONCLUSIONS

The mechanism of action of PDT in chronic CSC is still hypothetical. PDT should decrease the passage of fluid towards the retina by affecting the choroidal blood flow, and allow a better resorption of the subretinal fluid. PDT could be an alternative to treat patients with chronic CSC.

[Photodynamic therapy for choroidal neovascularizations in age-related macular degeneration]

La dégénérescence maculaire liée à l'âge (DMLA) est une altération qui touche le centre de la rétine. En fonction de la sévérité de la pathologie, une absence de symptôme ou des troubles plus ou moins importants de la vision sont constatés. Dans les pays occidentaux, la forme néovasculaire de DMLA est la cause principale de perte irréversible d'acuité visuelle chez les personnes de plus de 65 ans. Cette forme correspond à la prolifération de vaisseaux choroïdiens sous la partie centrale de la rétine. De nombreux traitements visant à éradiquer spécifiquement les vaisseaux choroïdiens pathologiques ont été envisagés. A l'heure actuelle, la thérapie photodynamique (TPD) demeure le traitement de choix pour la forme néovasculaire de DMLA. Ce traitement retarde la progression de la maladie mais ne permet que rarement une amélioration de l'acuité visuelle. L'association de substances antiangiogéniques à la TPD pour tenter d'en améliorer l'efficacité est en cours d'évaluation.

Simultaneous Fluorescein and Indocyanine Green Angiography for Exudative Macular Degeneration

BACKGROUND

The present study investigates how often a simultaneous fluorescein and indocyanine green (ICG) angiography had therapeutic consequences and if it is useful as a clinical routine diagnostic tool.

PATIENTS AND METHODS

502 consecutive simultaneous angiographies in eyes with exudative macular degeneration were retrospectively studied.

RESULTS

A classic extra- or juxtafoveolar choroidal neovascularisation (CNV) was found in 3.5 % of the eyes. A subfoveal predominantly classic CNV was present in 19 % of the angiographies. ICG angiography showed a vascular network in 3 % of the eyes with occult CNV in fluorescein angiography. A neovascularisation supplied by retinal vessels (retinal angiomatous proliferation) was found in 9 % and a polypoidal choroidal vasculopathy (PCV) in 6 %. Other plaques or hot spots were visible in 4 %. In 11 eyes with progressive exudation from PCV and threatening of the fovea, laser treatment was successfully performed.

CONCLUSIONS

Combined angiography identifies treatable PCV. Advantages of a combined procedure (easier logistics, no missing of treatable cases) and arguments for a two step procedure with ICG angiography only in selected cases (lower costs, lower rate of adverse reactions) must be weighed against each other.

Fundus-Quiz 2004

Six cases with characteristic fundus pathologies are presented and discussed using multiple choice questions.

Asymmetry of the Optokinetic Nystagmus in Lesion of the Central Nervous System

BACKGROUND

Unilateral lesions of the central nervous system (CNS) may be associated with a reduction of the optokinetic nystagmus (OKN) slow component in the direction of the lesion. The aim of our study was to assess the role played in these cases by the direct injury of the OKN pathways and/or by a possible associated visual field defect.

METHODS AND PATIENTS

Monocular OKN was elicited with black and white stripes moving temporally-to-nasally (TN) or nasally-to-temporally (NT) at velocities of 15, 30, 45 and 60 degrees /s. Patients with cortical or chiasmal lesions associated with visual field defects were investigated. OKN was considered asymmetrical if the gain difference between TN and NT stimulation was not within 2 standard deviations of an age-matched control group (n = 86).

RESULTS

We examined 12 patients with cortical lesions and 4 patients with chiasmal lesions. Asymmetric OKN gain was measured in 7 patients with cortical lesions associated with a visual field defect, and in 2 patients with chiasmal compression and bitemporal hemianopia. In 2 patients with isolated occipital lesions, OKN asymmetry was explained by the associated visual field defect.

CONCLUSION

The interpretation of OKN asymmetry in patients with CNS lesions should not only consider a direct lesion of the OKN pathways but also a sensory deficit due to a visual field defect.

Look and Stare Optokinetic Nystagmus in Healthy Subjects and in Patients with No Measurable Binocularity. A Prospective Study

BACKGROUND

The aim of our study was to assess the difference between look and stare optokinetic nystagmus (OKN) in healthy subjects and in patients with early onset strabismus and no measurable binocularity.

METHODS AND PATIENTS

OKN was elicited monocularly with black and white stripes moving horizontally or vertically at 15, 30, 45 and 60 degrees /s. Subjects were instructed either to follow individual stripes across the screen (look OKN) or to fixate stripes in the centre of the screen (stare OKN). We examined 20 healthy subjects (mean age 29 years; range 21 - 39), and 10 patients with no measurable binocularity (mean age 12.7 years; range 5 - 37). OKN gain was measured with photo-oculography.

RESULTS

In both groups and at stimulation with the higher velocities gains for look OKN were significantly better than for stare OKN, and gains with horizontal stimuli were significantly better than with vertical stimuli (p < 0.05). In the group with no measurable binocularity horizontal look and stare OKN answers were significantly better for temporal-to-nasal stimulation than for nasal-to-temporal stimulation (p < 0.05).

CONCLUSIONS

The performance of look or stare OKN influences the gain in healthy subjects and in patients with no measurable binocularity. Data about both modes of OKN stimulation are helpful to better interpret OKN responses especially in subjects with poor cooperation.

Age related change of optokinetic nystagmus in healthy subjects: a study from infancy to senescence

BACKGROUND

Optokinetic nystagmus (OKN) gain is asymmetrical between temporal to nasal (TN) and nasal to temporal (NT) stimulation in infancy and decreases at older ages. The age at which OKN gain becomes symmetrical and decreases is debated. The aim was to investigate OKN over the whole lifespan in a large sample of healthy subjects.

METHODS

In a prospective, cross sectional study OKN was tested monocularly using TN and NT small field stimulation. Stimulation velocity was 15 degrees /s and 30 degrees /s for children aged under 1 year (n = 97), and 15 degrees /s, 30 degrees /s, 45 degrees /s, and 60 degrees /s for older subjects (1-9 years, n = 66; 10-89 years, n = 86). Gain was measured using infrared oculography.

RESULTS

Significant OKN gain asymmetry in favour of TN versus NT stimulation was found during the first 5 months of life (p<0.05). Only at 11 months of age was OKN symmetrical in 100% of the subjects. The percentage of children with symmetrical OKN decreased with increasing stimulus velocity. OKN gain increased in the second and third years (p<0.05 for 15 degrees /s), remained stable until 50 years of age, and showed a small but significant decrease afterwards for the tested velocities (between 6% and 18%, p<0.05).

CONCLUSIONS

Infrared oculography is an accurate method to assess OKN, especially in children. Knowledge about change of OKN in healthy subjects could be helpful to interpret OKN in patients with abnormal binocular vision or lesions of the central nervous system.

Role of the stimulus size in the generation of optokinetic nystagmus in normals and in patients with retinitis pigmentosa

BACKGROUND

To find out the smallest stimulus size still able to elicit optokinetic nystagmus (OKN). To discuss the differences in the generation of OKN between normals and patients with tunnel vision.

METHODS AND PATIENTS

OKN was elicited monocularly with black and white stripes of 2 degrees moving on a screen temporally-to-nasally or nasally-to-temporally at velocities of 15, 30, 45, and 60 degrees /s. In healthy subjects (n = 10) the size of the stimulus was gradually increased from minimal 8 degrees x 0.5 degrees to maximal 48 degrees x 10 degrees. OKN was elicited in retinitis pigmentosa (RP) patients (n = 2) with visual field reduced to the central 10 degrees. OKN gain was measured using infrared oculography. OKN response was considered as normal if it was within 2 standard deviations of the mean OKN of age-matched control groups (n = 29).

RESULTS

In healthy subjects the size of the stimulus necessary to elicit normal OKN gain was smaller at low velocity of 15 degrees /s (16 degrees x 1 degrees ) than at higher velocities of 30, 45, and 60 degrees /s (16 degrees - 24 degrees x 3 degrees ). Normal OKN gain was measured in the RP patients only at the low velocity of 15 degrees /s.

CONCLUSIONS

Small stimuli are sufficient in normals to elicit good OKN answers. Therefore, poor OKN gain in RP patients may not be explained by their tunnel vision only. We postulate that in these patients the reduction of gain is due to a multifactorial decrease of their visual perception related to disorders of the visual field, the visual acuity, and the contrast sensitivity.

Fundus-Quiz 2003

6 cases with pathognomonic fundus pathologies are presented and discussed using multiple-choice questions.

Endoscopic Laser Coagulation of the Ciliary Processes in Patients with Severe Chronic Glaucoma

BACKGROUND

To investigate the effect of endoscopic laser coagulation on the ciliary processes in order to control intraocular pressure (IOP) in patients with severe chronic glaucoma.

PATIENTS AND METHODS

6 eyes (5 pseudophakic, 1 phakic) of 5 patients (mean age 60 years, range 46 - 70) were treated. Glaucoma was related to previous detachment surgery (patients 1), panuveitis (patient 2), iris dystrophy (patient 3), or neovascularization (patient 4: central venous occlusion; patient 5: proliferative diabetic retinopathy). Preoperatively, all patients had not responded to intensive glaucomatous topical and systemic treatment (mean 4.2 drugs, range 3 - 5). Trabeculectomy has been unsuccessfully performed in patients 2 and 3. After pars plana vitrectomy, the ciliary processes were coagulated under endoscopic view over 180 - 270 degrees using endolaser (argon green with spots of 300 - 500 mW for 0.4 - 0.5 s). Patient 5 was treated in both eyes.

RESULTS

The mean preoperative IOP was 39 mm Hg (range 32 - 47). The mean postoperative follow-up was 339 days (range 125 - 485). The postoperative IOP was over 1 year under 21 mm Hg in patient 1 with one topical drug, and in patients 2 and 3 without any further treatment. Patient 4 needed trabeculectomy and one topical drug to control IOP. The IOP was not controlled in patient 5 with the shortest follow-up despite additional topical treatment. No serious treatment-related complication was noted.

CONCLUSIONS

Endoscopic laser coagulation allows a precise destruction of the ciliary processes, and permits a better control of IOP in certain cases of severe chronic glaucoma. Further investigations are necessary to better evaluate this therapy.

A 5-year follow-up study for distance visual acuity after low dose radiation on subfoveal choroidal neovascularization in age-related macular degeneration

In a prospective study with a 5-year follow-up, we assessed the effect of a single series of low-dose radiation on the distance visual acuity in eyes with angiographically confirmed subfoveal choroidal neovascularization (CNV) in age-related macular degeneration (ARMD). The posterior pole of 12 eyes was treated with 5 Gy (4 x 1.25 Gy), and 34 eyes treated with 8 Gy (4 x 2 Gy). The best corrected distance visual acuity was measured at the time of treatment, and annually thereafter for 5 years. The study obtained complete follow-up for 11 patients in the 5-Gy group (nine classic, two occult CNVs), and 29 patients in the 8-Gy group (12 classic, 17 occult CNVs). At baseline, the mean distance visual acuity of the treated eyes was 0.16 (20/125) in the 5-Gy group, and 0.2 (20/100) in the 8-Gy group. Five years later, an average loss of 3.2 lines was present in the 5-Gy group, and 4 lines in the 8-Gy group. After 5 years, an average loss of 2 lines was found in a control group consisting of 18 second eyes with low stage dry ARMD, with a mean distance visual acuity of 0.5 (20/40) at baseline. Statistical analyses with Wilcoxon and Mann-Whitney U-tests showed that a single series of low dose radiation with either 5 Gy or 8 Gy was not able to stabilize the distance visual acuity of eyes with subfoveal CNV in ARMD during a 5-year follow-up.

Cocaine abuse, generalized myasthenia, complete external ophthalmoplegia, and pseudotonic pupil

We present the case of a 29-year-old woman with generalized myasthenia. Myasthenia with complete external ophthalmoplegia was unmasked by cocaine abuse. It was associated with changes of the pupillary motility, including light-near dissociation and positive 0.1% pilocarpine test. Treatment with acetylcholinesterase inhibitors improved the patient's condition rapidly, and led to complete normalization of extraocular movements and pupillary function. To our knowledge, this is the fourth case of cocaine-related myasthenia, and the first case of myasthenia with pseudotonic pupil.

Optokinetic nystagmus in patients with central scotomas in age related macular degeneration

BACKGROUND

Reports on the impact of a loss in the central field of vision on optokinetic nystagmus (OKN) are varied. A study was therefore undertaken to reassess the role of the central retina in the generation of OKN in a large group of patients with age related macular degeneration.

METHODS

Four groups of 20 patients were examined: a control group without scotoma and three groups with absolute central scotomas measuring 1 degrees--10 degrees, 11 degrees--20 degrees, and 21 degrees--30 degrees. OKN was elicited with black and white stripes moving nasally to temporally or temporally to nasally on a screen subtending 54 degrees x 41 degrees at four velocities (15, 30, 45, and 60 degrees /s). OKN gain was measured using infrared oculography.

RESULTS

There was no significant difference in OKN gain between the control group and those with scotomas of 1 degrees--10 degrees and 11 degrees--20 degrees. A significant difference in OKN gain was found between the group with scotomas of 21 degrees--30 degrees and all other groups at stimulus velocities of 30, 45, and 60 degrees/s (p<0.05). OKN gain significantly diminished with increasing stimulus velocity (p<0.05). No statistically significant difference was found in OKN gain between stimuli moving temporally to nasally and nasally to temporally.

CONCLUSION

Abnormalities of OKN gain were noted only in patients with large scotomas. An intact macula is therefore not necessary for the generation of OKN.

Periodic alternating nystagmus in two children with a similar, unusual phenotype

The report describes two unrelated male children, aged 6 and 8 years, respectively, with congenital periodic alternating nystagmus, congenital strabismus, microcephaly with cortical and cerebellar hypoplasia, mental retardation, low stature, and bat ears. Karyotypes were normal. Neuropediatric and ophthalmologic examinations, radiologic imaging of the brain, and laboratory analyses were performed to exclude other causes of periodic alternating nystagmus, such as ataxia-telangiectasia, acquired disease of the caudal brainstem or the cerebellum, albinism, or loss of vision resulting from cataract or vitreous hemorrhage. The similar morphologic and clinical features of both patients raise the possibility that they have an identical syndrome.

Indocyanine green versus fluorescein angiography in the differential diagnosis of arteritic and nonarteritic anterior ischemic optic neuropathy

PURPOSE

We evaluated in a prospective study the usefulness of indocyanine green (ICG) versus fluorescein angiography in the differential diagnosis between arteritic and nonarteritic anterior ischemic optic neuropathy (AION).

METHODS

Simultaneous ICG and fluorescein angiography was performed on 22 eyes with AION. Appearance of both dyes in the choroid and in the retina, laminar flow, venous filling, and complete filling of the choroid were measured independently. Massive delayed choroidal filling corresponding to occluded posterior ciliary arteries was especially assessed, as it is almost always diagnostic of arteritic AION. We considered the choroidal filling as massive delayed if it was still incomplete after the venous filling.

RESULTS

We diagnosed 5 arteritic AIONs, confirmed by biopsy, and 17 nonarteritic AIONs. In both types of angiography, 3 of 5 patients with arteritic AION showed massive delayed complete choroidal filling times (44.2, 45.8, and 70 seconds), and patients with nonarteritic AION had normal complete choroidal filling times. Dye appearance at the different angiographic times was similar for fluorescein and ICG angiography (P = 0.95-0.96).

CONCLUSION

Fluorescein angiography alone is sufficient to reveal massive delayed choroidal filling time in arteritic AION. For our purpose, ICG angiography provides no additional information.

Low dose radiation for subfoveal choroidal neovascularization in age-related macular degeneration. A pilot study: radiotherapy for age-related macular degeneration

The aim of our pilot study was to test the effect of low dose radiation on classic and occult subfoveal choroidal neovascularization (CNV) in age-related macular degeneration (AMD). The posterior pole of the afflicted eye of 12 patients was irradiated with 5 Gray (Gy), and that of 34 patients with 8 Gy. The radiotherapy was done by a linear accelerator (6 MV X-rays) during 4 consecutive days with daily doses of 1.25 Gy and 2 Gy respectively. At the time of treatment, and 6 weeks, 6 months and 1 year after, a simultaneous fluorescein and ICG angiography of both eyes were carried out, and the distance visual acuity was measured. In none of the cases were we able to note a reduction in the subfoveal membrane's size. With regards to the visual acuity, the evolution was slightly better than the spontaneous courses described in existing literature. Further prospective randomized studies with higher dose radiation are necessary in order to determine the significance of radiotherapy in the treatment of this pathology.

A case of Erdheim-Chester disease with orbital involvement

The Erdheim-Chester disease is a rare idiopathic, systemic, histiocytic disorder. To our knowledge, ocular involvement has been reported in only 16 cases. We describe a 55-year-old man who had symmetrical exophthalmos and several skin nodules on the arms and trunk. A magnetic resonance imaging scan confirmed the presence of bilateral, intraconal, retrobulbar tumors. An examination of the histopathologic features of orbital and skin biopsy specimens revealed xanthogranulomatous infiltrate with Touton giant cells. Further systemic investigations showed bone and retroperitoneal involvement. Three years later, multiple eyelid xanthelasmas developed in the patient. These findings are consistent with the diagnosis of the Erdheim-Chester disease. The patient's condition is stable under therapy with low-dose corticosteroids. His survival is longer than usually described in the literature.

[Low dosage radiotherapy of subfoveal neovascularizations in age related macular degeneration. Results after 6 weeks and 6 months]

AIM OF THE STUDY

The aim of this pilot study is to test the effect of low dose radiation on classic and occult subfoveal neovascular membranes (SNVM) in age-related macular degeneration.

METHODS AND PATIENTS

From November 1993 through to May 1995 the macula of the affected eye was irradiated with 5 Gy for 12 patients and with 8 Gy for 34 patients. The radiotherapy was done ambulatorily by a linear accelerator 6 MeV during 4 consecutive days with daily 1.25 Gy and 2 Gy respectively. A "half beam technic" was used to protect the lens. Before the treatment, 6 weeks and 6 months later different parameters of the visual acuity were measured and a simultaneous Fluo- and ICG-angiography was done.

RESULTS

In the 5 Gy group, all the planned controls were done for 11 patients. 9 membranes were classic and 2 occult. After 6 months the vision in the distance remained the same in 7 cases, was better in 2 cases and worse in 2 cases. The size of the membrane increased in 10 cases and remained unchanged in 1 case. In the 8 Gy group, all the planned controls were done for 29 patients. 12 membranes were classic and 17 occult. The vision in the distance remained the same in 17 cases, was better in 4 cases and worse in 8 cases. The size of the membrane increased in 12 cases and there was no change in 17 cases.

DISCUSSION AND CONCLUSION

Exact comparisons between the 5 Gy and 8 Gy group are not possible because of the different composition of these groups. In no case were we able to note a reduction of the size of the membrane. Concerning the visual acuity, our results are better than the spontaneous evolutions described in the literature. Meanwhile, affirmations about possible stabilisation of the visual acuity are too early. A further study which is being done in our hospital may possibly bring new information.

Elevation deficit caused by accessory extraocular muscle

PURPOSE

To report an elevation deficit, which was caused by an accessory extraocular muscle, in a 6-year-old boy.

METHODS

Computed tomography and magnetic resonance imaging were used to confirm an accessory, fusiform, well-defined, solid structure in the retrobulbar space.

RESULTS

A supernumerary intraconal muscle was detected between the annulus of Zinn and the posterior part of the left globe.

CONCLUSION

This rare anomaly may represent an atavistic retractor bulbi muscle.

[Low dosage radiotherapy of subfoveal neovascularization in age-related macular degeneration. Preliminary results]

AIM OF THE STUDY

The aim of this study is to test the effect of low dose radiation on the subfoveal neovascular membranes (SNVM) and to analyse visual acuity in age-related macular degeneration.

METHODS AND PATIENTS

From November 1993 through to August 1994, 10 patients, on the one hand, were given a dose of 5 Gy followed by controls 6 weeks and 6 months later. On the other hand, 21 patients were treated with a dose of 8 Gy and were subjected to controls 6 weeks later. Before the radiotherapy and during the control sessions, all patients were required to be measured for different parameters of visual acuity and to receive a simultaneous fluorescein and indocyanine green angiography. The radiotherapy was done by a linear accelerator 6 MeV and through a lateral port 3 x 4 cm in half beam technic.

RESULTS

In the 5 Gy group, no changes in the parameters for visual acuity were noted in most cases after 6 months. In 9 of the cases, the membranes had increased in size and in 1 case, they had remained unchanged. In the 8 Gy group, no changes in the visual acuity or in the membrane size were diagnosed. Of all the patients treated, only one refused the angiography control.

DISCUSSION AND CONCLUSIONS

Given the low dose used and the period of observation, the visual acuity of all patients remained stable. The size of the membranes increased in most cases for those 5 Gy patients and in this respect, no changes at all were noted in the 8 Gy patients. In order to better evaluate the potential of radiotherapy, this study must be pursued and coupled with further studies analysing the effect of different doses on patients.