Bruce R. Saran

Familial primary pulmonary hypertension and associated ocular findings.

Background Familial primary pulmonary hypertension (PPH) is a rare, fatal, autosomal dominant disease that results in right heart failure from idiopathic obliteration of the pulmonary arteries. Patients develop stagnation of venous blood flow and elevated venous pressure. Methods The authors retrospectively reviewed the clinical records of three patients diagnosed with PPH that was confirmed on the basis of physical examination, chest X-ray, electrocardiogram, and echocardiogram. Cardiac catheterization excluded cardiac shunt and other secondary causes of pulmonary hypertension. Results Two patients presented with a clinical picture resembling venous stasis retinopathy, and one with bilateral choroidal detachments. Two patients had delayed choroidal filling on fluorescein angiography, which was confirmed in one patient with indocyanine green videoangiography. Conclusions Elevated venous pressure found in PPH is responsible for the delayed choroidal perfusion and the reduced venous blood outflow. This explains the clinical findings of venous stasis retinopathy and choroidal detachments seen in these patients.

Retinal toxicity of high dose intravitreal ganciclovir.

Background: Intravitreal administration of ganciclovir has been used to treat cytomegalovirus (CMV) retinitis in patients with acquired immune deficiency syndrome (AIDS) who are unable to tolerate systemic antiviral therapy. Although retinal toxicity from intravitreal ganciclovir has been observed in animal experiments, to our knowledge, retinal toxicity from intravitreal ganciclovir has not been reported in humans. Methods: A case of inadvertent intravitreous injection of a high dose of ganciclovir (40 mg/ 0.1 ml) for CMV retinitis in a patient with AIDS is presented. Results: Despite immediate intervention with vitreous surgery, permanent retinal damage and visual loss developed. Clinical observations and photographic documentation are provided. Conclusion: Retinal toxicity can occur from a high-dose intravitreal ganciclovir injection. This toxicity may result from the high alkaline nature of this preparation, from osmotic damage, or from a direct effect of the concentrated ganciclovir.

RETINAL VASCULAR NONPERFUSION AND RETINAL NEOVASCULARIZATION AS A CONSEQUENCE OF CYTOMEGALOVIRUS RETINITIS AND CRYPTOCOCCAL CHOROIDITIS

Background Cytomegalovirus retinitis and cryptococcal choroiditis are opportunistic infections in patients with acquired immune deficiency syndrome. These infections are associated with a retinal vasculitis and vascular attenuation. Methods We present a case of retinal vascular nonperfusion and retinal neovascularization in a patient with acquired immune deficiency syndrome. Results Retinal vascular nonperfusion and retinal neovascularization were confirmed by fluorescein angiography. Conclusions This is the first reported case of retinal neovascularization in a patient with acquired immune deficiency syndrome, ocular cytomegalovirus retinitis, and cryptococcal infection.

Macular Epiretinal Membrane Formation and Treated Retinal Breaks

PURPOSE We sought to determine the incidence of macular epiretinal membrane formation in eyes treated for retinal breaks after three different modalities of treatment: laser photocoagulation, cryotherapy, or both. METHODS We reviewed the charts of 262 consecutive patients with a diagnosis of retinal tears and included 205 patients who had more than six months of follow-up. RESULTS One hundred ninety-five patients were treated. One hundred seventy of these patients had retinal breaks in one eye and 25 patients had breaks in both eyes, for a total of 220 treated eyes. Cryopexy was applied in 125 eyes, laser retinopexy in 73 eyes, and both modalities in 22 eyes. Macular epiretinal membranes developed in a total of 26 eyes: 12 in the cryopexy group, ten in the laser-treated group, and four in the dual modality group. No statistically significant difference, at a level of P < or = .01, was seen in the rate of epiretinal membrane formation between the different treatment modalities. No statistically significant difference, at a level of P < or = .01, was seen in the rate of epiretinal membrane formation in the presence or absence of vitreous hemorrhage or in the type of precedent retinal break. CONCLUSIONS After treatment of retinal breaks with laser photocoagulation and cryotherapy, no statistically significant difference in the incidence of macular epiretinal membrane formation was demonstrated.

Intraocular caterpillar setae without subsequent vitritis or iridocyclitis.

PURPOSE To report a case of caterpillar setae embedded in the corneal stroma and inferotemporal retina with minimal inflammation. DESIGN Observational case report. METHODS A 4-year-old boy developed a red eye after playing with a caterpillar. He was placed on topical tobramycin/dexamethasone and referred for evaluation of embedded setae in his conjunctiva, cornea, iris, and retina. Examination revealed no iridocyclitis or vitritis. RESULTS Because of the lack of intraocular inflammatory response, no invasive intervention was conducted to remove or destroy the setae and he was tapered off the tobramycin/dexamethasone. At 4-month follow-up he remained asymptomatic with the setae still present in both his cornea and retina. In addition, vitreous membranes had formed in the immediate vicinity of the intraretinal setae. CONCLUSION Intraretinal and corneal setae can be embedded with minimal inflammation and can be tolerated without need for surgical intervention.

DRAINAGE OF SUBRETINAL FLUID IN RETINAL DETACHMENT SURGERY WITH THE EL-MOFTY INSULATED DIATHERMY ELECTRODE

Purpose: A technique that uses the El-Mofty/Schepens diathermy tip (MIRA, Inc.) to effect drainage of subretinal fluid during scleral buckling surgery is described. The efficacy of this drainage technique and its complication rate in a series of consecutive patients is discussed. Methods: The study included all of the scleral buckling procedures performed at the Retina Service for retinal detachments in which this technique was used. The El-Mofty/Schepens diathermy tip was first used to cauterize the choroid at the drainage site at low power, thus rendering it avascular, and then at higher power, to cause vaporization of the choroid, and allow spontaneous drainage of subretinal fluid. The success rate and all intraoperative and postoperative complications were recorded. Results: This technique achieved successful spontaneous drainage in 53 (82.8%) of 64 consecutive cases. Complications that are occasionally associated with the drainage of subretinal fluid, including iatrogenic retinal holes, choroidal hemorrhage, and retinal incarceration in the sclerotomy site, were not seen in any of the cases. Conclusion: This method provides a simple and safe technique for the drainage of subretinal fluid that obviates the need to directly perforate the choroid.

Macular Pseudohypopyon from Secondary Syphilis

PURPOSE/METHODS Acute syphilitic posterior placoid chorioretinitis causes visual loss in patients with secondary syphilis. The condition is characterized by vitreitis and large, yellow placoid lesions in the macula. We examined a patient with syphilis who had a serious retinal detachment and an exudative fluid meniscus (pseudohypopyon). RESULTS/CONCLUSIONS Visual recovery and complete resolution of the chorioretinal lesion occurred after intravenous penicillin therapy. Secondary syphilis should be considered in the differential diagnosis of any patient with a macular pseudohypopyon.

Ocular myasthenia and nitrofurantoin

PURPOSE To report a case of ocular myasthenia associated with administration of nitrofurantoin. METHODS Case report and review of the literature. RESULTS While taking nitrofurantoin after urinary tract surgery, a 10-year-old female developed diplopia and ptosis. Sleep test confirmed ocular myasthenia. Signs and symptoms resolved after discontinuation of the drug. CONCLUSION Ocular myasthenia may be associated with nitrofurantoin administration.