Amaka Eneh

Predicting retinal tears in posterior vitreous detachment

OBJECTIVE The purpose of this study is to determine whether patients with acute posterior vitreous detachment (PVD) who develop delayed retinal tears within the first 6 weeks after initial presentation have predictive characteristics. DESIGN Prospective cohort study. PARTICIPANTS All patients presenting to the Hotel Dieu Hospital Emergency Eye Clinic between September 2008 and July 2009 diagnosed with acute PVD were offered enrollment. METHODS At the initial visit, patients were given the previously validated Queens University Posterior Vitreous Detachment Patient Diary to record their daily symptoms for 6 weeks. Two or 6 weeks later, patients were reexamined in detail, and their diaries were collected and analyzed. Exact logistic regression was used to establish characteristics predictive of delayed retinal tears. RESULTS In our study population of 99 patients, 2 developed delayed retinal tears. One had retinal hemorrhages and the other had a cloud-like floater at initial presentation. Vitreal or retinal hemorrhage, large number of floaters at initial presentation, and high floater frequency at initial presentation indicated a high risk of delayed retinal tear formation, yielding a median unbiased estimated odds ratio of 36.18 with p value 0.009. No other presenting risk factors or symptomatology followed daily over the first 6 weeks after acute PVD were predictive of delayed retinal tear formation. CONCLUSIONS PVD patients with retinal or vitreal hemorrhage, a significant number of floaters or a cloud like appearance to the floaters, or high floater frequency are at higher risk of developing delayed retinal tears.

Pediatric adenoid cystic carcinoma of the lacrimal gland treated with intra-arterial cytoreductive chemotherapy

Adenoid cystic carcinoma (ACC) of the lacrimal gland is the most common primary malignant tumor of the lacrimal gland. It typically affects patients in the fifth decade of life and presents with rapid progression of pain, ptosis, motility disturbances, and sensory deficits of less than 1 years duration. ACC is rare in children. Due to early, aggressive perineural and bony spread, there is a high risk of intracranial extension. Additionally, due to frequent hematogenous and lymphatic spread, there is a high rate of distant metastases even after treatment, which can occur late up to a decade or more. The currently accepted treatment for ACC is radical exenteration with orbitotomy and adjuvant chemotherapy and/or radiation therapy. Recently, intra-arterial cytoreductive chemotherapy (IACC) has been investigated as a neoadjuvant treatment modality. It has the advantage of increasing local concentration at the target tissue and decreasing systemic distribution. We report the first known pediatric case of ACC treated with IACC, followed by exenteration, radiation, and adjuvant intravenous chemotherapy. The patient was followed for 4 years, with no recurrence and no known complications.

Mönckeberg medial calcific sclerosis mimicking giant cell arteritis clinically.

Mönckeberg medial calcific sclerosis (MCS) is an uncommon finding in temporal arteries. We present a case of temporal artery medial ossification in a patient with suspected giant cell arteritis (GCA). An 85-year-old female presented with a 2-week history of left-sided scalp tenderness, jaw claudication, 1 new oral ulcer, and left-sided hearing loss. She denied vision changes, fever, or malaise, but reported a weight loss of 5.5 kg in the preceding 4 months. She was pseudophakic OD, and had previously been treated with intravitreal bevacizumab for neovascular age-related macular degeneration OS. Her comorbidities were osteoporosis, hypothyroidism, coronary artery disease, and osteoarthritis. She had recently been diagnosed with a primary lung neoplasm but declined further treatment. Her medications included risedronate, atenolol, rabeprazole, clomipramine, levothyroxine, iron, vitamins B12 and D, calcium, and Vitalux. Visual acuity was 6/7.5þ2 OD and 6/9þ2 OS. There was no afferent pupillary defect. Intraocular pressure was 14 mm Hg OU. Extraocular movements were full and she was orthotropic. Confrontation visual fields were normal. Ishihara colour plate scores were normal. Anterior segment examination was unremarkable. Her optic nerves appeared healthy. There were no cotton wool spots. Erythrocyte sedimentation rate was 23 mm/hour, C-reactive protein 1.0 mg/L, and platelet count 225 10/L. Despite the normal blood test results, the history was compelling enough to warrant initiation of 60 mg/day prednisone and temporal artery biopsy (TAB). Light microscopic examination of the biopsy specimen (27 mm) showed no evidence of active or healed arteritis. Instead, there were prominent areas of calcification with focal ossification including osteoclast-type giant cells (Figs. 1 and 2). The calcification was located in the tunica media and also present focally at the internal elastic lamina. The lumen was patent. These findings were consistent with a diagnosis of Mönckeberg MCS. The patient had received 60 mg/day prednisone for 10 days before the biopsy results. The dosage was tapered over 2 weeks and treatment discontinued. Her scalp tenderness, jaw claudication, and hearing loss all resolved and did not recur after the taper. MCS has been increasingly recognized in patients with end-stage renal disease, and it is associated with disturbances in serum calcium and phosphorous. It is possible that the supplemental calcium, vitamin D, and risedronate being taken for osteoporosis contributed to the arterial calcification in our patient. Vitamin D has been shown to induce MCS in an animal model.Al-Absi et al. described the case of a 50-year-old male on hemodialysis with symptoms of GCA (temporal headache, blurry vision, jaw claudication) who was found to have MCS

Visual function analysis in acute posterior vitreous detachment

OBJECTIVE To determine whether the visual function of patients with posterior vitreous detachment (PVD)changes between the initial visit and a 6-week follow-up visit, and to compare their visual function with that of patients with macular degeneration, cataract, glaucoma, low vision, cytomegalovirus (CMV) retinitis, or diabetic retinopathy and a reference population. DESIGN Prospective cohort study. PARTICIPANTS All patients presenting to the Hotel Dieu Hospital Emergency Eye Clinic between September 2008 and June 2009 who were diagnosed with acute PVD were offered enrollment in the study. METHODS Patients were administered the National Eye Institute Visual Function Questionnaire NEI VFQ-25 at two points in time. The composite scores from the initial and the 6-week visits were compared. The scores were also compared with established normative data and 6 ophthalmologic diagnoses. RESULTS The NEI VFQ-25 composite score for patients with acute PVD (n = 84) at baseline was 93.26 ± 5.59 (mean ± SD). After 6 weeks and a second ocular examination, there was no statistical difference in the composite score of 93.47 ± 6.20 (mean ± SD). (1-sided paired t-test, t = 0.57; P = 0.28). CONCLUSIONS The visual function of patients with acute PVD remains stable over the first 6 weeks after diagnosis. It is significantly higher than that of patients with 6 other ophthalmologic conditions but comparable to that of a normal population.

Practice patterns of Canadian vitreoretinal specialists in diabetic macular edema treatment

OBJECTIVE To establish the practice patterns of Canadian vitreoretinal (VR) specialists in the treatment of diabetic macular edema (DME). DESIGN A survey was mailed, faxed, e-mailed, and published online for access by all Canadian VR specialists. PARTICIPANTS All VR specialists identified from the Canadian Ophthalmology Society directory and the Canadian Retina and Vitreous Society directory. METHODS A 19-item survey investigating treatment of DME was mailed to all VR specialists. A reminder fax and e-mail was sent with the survey attached. In all correspondence, physicians were given information regarding an available online version of the survey. The survey data was descriptively analyzed with the Statistical Package for the Social Sciences. RESULTS With clinically significant macular edema (CSME) that is either away from the foveal avascular zone (FAZ) or diffuse, the most common first-line treatment option was macular photocoagulation 48 (78.8%) and 33 (54.1%), respectively. For microaneurysms within the FAZ, 33 (54.1%) of respondents chose intravitreal antivascular endothelial growth factor agents as their first-line treatment. In all, 51 respondents (83.6%) felt that vitrectomy played a role in the management of treatment-resistant CSME. Before utilizing intravitreal triamcinolone acetonide (IVT) injections, 34 (55.7%) of respondents did use a topical steroid trial to look for raised intraocular pressure whereas 16 (26.2%) of respondents did not use IVT injections at all. CONCLUSIONS This survey provides valuable practical information on how DME is currently being treated in Canada and may serve as a baseline to assess how these patterns evolve over time.