David C. Herman

Adverse Side Effects Associated With Latanoprost

PURPOSE To report three different adverse reactions after initiating treatment with latanoprost. METHOD Serial clinical examinations of three patients were performed. RESULTS Adverse reactions such as ocular hypotony and choroidal effusions, recurrent cystoid macular edema, and facial rash were noted to occur within 1 to 4 weeks after starting topical latanoprost for the treatment of primary open-angle glaucoma. CONCLUSION Clinicians should be alerted to these possible complications of topical latanoprost therapy.

Incidence and outcomes of uveitis in juvenile rheumatoid arthritis, a synthesis of the literature

BackgroundJuvenile rheumatoid arthritis (JRA) is the most common systemic cause of pediatric uveitis in Europe and North America. Uveitis is commonly perceived as a frequent sequela of JRA and JRA-associated uveitis is commonly considered to have a complicated course with frequent adverse visual outcomes.MethodsWe performed a systematic literature search for series of consecutive patients with JRA (as defined by the American College of Rheumatology criteria) reporting on the frequency of uveitis and/or complications of uveitis, published between January 1980 and December 2004. The main outcome measures were: the cumulative incidence of uveitis in JRA, the cumulative incidence of adverse visual outcome and that of complications in JRA-associated uveitis. Additionally, the influence of gender, presence of antinuclear antibody (ANA) and disease onset subtype to the likelihood of developing uveitis were examined.ResultsAnalysis of pooled data from the 26 eligible series suggested a cumulative incidence of uveitis in JRA of 8.3% [95% confidence intervals (CI), 7.5–9.1%]. The cumulative incidence of uveitis varied according to geographic location, being highest in Scandinavia, then the US, then Asia and lowest in India. JRA-associated uveitis was more common in pauciarticular than polyarticular onset patients [odds ratio (OR)=3.2, 95% CI, 2.33–4.36] and in ANA-positive than ANA-negative patients (OR=3.18, 95% CI, 2.22–4.54). Female gender was only a weak risk factor for the development of uveitis in JRA patients (OR=1.69, 95% CI 1.09–2.62) and was not statistically significant after considering disease onset subtypes. In JRA-associated uveitis the cumulative incidence of cumulative incidence of adverse outcome (visual acuity <20/40 OU) was 9.2% (95% CI: 4.7–15.8) of cataracts 20.5% (95% CI: 15.5–26.3), of glaucoma 18.9% (95% CI: 14.4–24.2) and of band keratopathy 15.7% (95% CI: 10.9–21.7).ConclusionThe cumulative incidence of uveitis in JRA varies according to geographic location, presence of ANA, type of JRA onset and gender. Uveitis, adverse visual outcome, and complications in JRA are less frequent than commonly accepted.

Increased corneal thickness in patients with ocular hypertension

BACKGROUND Central corneal thickness greater than 0.520 mm causes true intraocular pressure to be overestimated when the technique of applanation tonometry is used to measure intraocular pressure. OBJECTIVE To compare the corneal thickness measurements of patients enrolled in a study of ocular hypertension with those of age-matched control subjects with normal intraocular pressure. METHODS Central corneal pachymetry using an optical pachymeter was performed on each study subject (n = 55) at baseline and in an independent sample of control subjects. A 2 sample, 2-tailed T test was used to compare the 2 populations. RESULTS The patients with ocular hypertension had significantly higher mean corneal thickness measurements (mean +/- SD, 0.594 +/- 0.037 mm) than the control group (0.563 +/- 0.027 mm) (P<.001). CONCLUSION Corneal thickness may be a confounding factor in the measurement of intraocular pressure, and this may modify the risk for progression to glaucoma in patients with ocular hypertension.

Estimated incidence of open-angle glaucoma in Olmsted County, Minnesota

PURPOSE To determine the incidence rates of open-angle glaucoma (OAG) in Olmsted County, MINNESOTA: DESIGN Retrospective population-based estimate of incidence. PARTICIPANTS From the medical histories of 60,666 residents of Olmsted County, Minnesota, who had ocular diagnoses during the study period, 114 subjects with newly diagnosed OAG were identified. METHODS The database of the Rochester Epidemiology Project was used to identify all Olmsted County residents with a coded diagnosis of OAG, glaucoma suspect, or ocular hypertension during the period 1965 to 1980. Subjects newly diagnosed with and treated for OAG who also had documented clinical evidence of elevated intraocular pressure, optic nerve damage, and/or visual field loss consistent with glaucoma were included as incident cases. Population data for Olmsted County were drawn from United States Census data. Crude incidence data were adjusted to the age and gender distribution of the 1990 United States white population. MAIN OUTCOME MEASURES Estimated incidence rates of OAG. RESULTS The overall age- and gender-adjusted annual incidence rate of OAG in a predominantly Caucasian population is conservatively estimated to be 14.5 per 100,000 population. The rates increased with age from 1.6 in the fourth decade of life to 94.3 in the eighth decade. There was no significant difference in incidence by gender. The average annual rate of OAG in the last 2 years of the study was 27.7 compared with 12.3 before 1979. This difference is suggestive of the effect of the introduction of a new medical therapy (timolol) for OAG during the last 2 years. CONCLUSIONS The incidence rates of OAG increase markedly with advancing age, and screening efforts should be targeted at both men and women in the older age groups. The advent of new diagnostic and therapeutic modalities can have an effect on incidence rates.

Effects of glaucoma medications on corneal endothelium, keratocytes, and subbasal nerves among participants in the ocular hypertension treatment study

Purpose: To compare subbasal corneal nerve and keratocyte density and endothelial characteristics of ocular hypertensive patients treated with medications or observation. Methods: Participants in the Ocular Hypertensive Treatment Study (OHTS) randomized at Mayo Clinic to medication or observation were evaluated with specular microscopy annually for 6 years. Confocal microscopy was performed 78 to 108 months after enrollment. Subbasal nerve density was calculated by manual tracing and digital image analysis. Keratocyte density was determined by manual counting methods. Data were compared using a t test and a rank sum test. Results: After 6 years, corneal endothelial cell density, percent hexagonal cells, and coefficient of variation of cell area for the observation (n = 21) and medication groups (n = 26) were similar (2415 ± 300 vs. 2331 ± 239 cells/mm2; 63% ± 11% vs. 65% ± 10%; and 0.32 ± 0.07 vs. 0.30 ± 0.06, respectively). Of 38 participants undergoing confocal examination, the medication group (n = 19) had fewer nerves (3.8 ± 2.1 vs. 5.9 ± 2.0 nerves/frame; P = 0.02) and a lower nerve density (5643 ± 2861 vs. 9314 ± 3743 μm/mm2; P = 0.007) than the observation patients (n = 10). An additional 9 patients in the observation group, who began medication before confocal scanning, had intermediate nerve densities. Full-thickness keratocyte density was similar, with 22,257 ± 2419 and 23,430 ± 3285 cell/mm3 in the observation and medication groups, respectively. Conclusions: Chronic administration of glaucoma medications causes a decrease in the number and density of corneal subbasal nerve fiber bundles but does not affect keratocyte density or corneal endothelial characteristics.

Initial results of QuantiFERON-TB Gold testing in patients with uveitis

PurposeTo describe the use of the second-generation QuantiFERON-TB Gold (QFT-G) test in a series of patients in an ophthalmic practice.MethodsThe charts of all patients who had QFT-G tests ordered by Mayo Clinic ophthalmologists in the past 3 years were reviewed.ResultsA total of 27 QFT-G tests were ordered. Thirteen (48%) tests were negative, six (22%) were indeterminate, two (7%) tests were re-ordered after a lab accident or an improper cancellation, four (15%) were positive and represented infection, and two (7%) were positive but negative when re-tested. Of the four truly positive cases, three were treated for tuberculosis (TB): one had tuberculous iritis, one had retinal vasculitis and haemorrhage, and one had asymptomatic TB but was on immunosuppressive therapy. The fourth patient had previously been treated for latent infection.ConclusionsIn a series of selected patients with uveitis, the QFT-G test was able to detect TB infection in 15% of the patients, though it does not differentiate between active and latent TB infection. QFT-G should be considered in place of purified protein derivative testing in those with uveitis that have had prior BCG vaccination and in immunocompromised patients. Patients with a positive QFT-G, but who have little risk for TB infection and a negative systemic work-up, should be re-tested.

Optic Nerve Sheath Decompression for Visual Loss in Patients With Acquired Immunodeficiency Syndrome and Cryptococcal Meningitis With Papilledema

Visual dysfunction developing in association with acquired immunodeficiency syndrome (AIDS) can be multifactorial. Two patients with this syndrome and cryptococcal meningitis had papilledema and visual loss. Both were treated by optic nerve sheath fenestration. One patient had bilateral nonsimultaneous optic nerve sheath fenestrations; visual function improved in one eye. The other patient had bilateral visual improvement after a unilateral optic nerve sheath fenestration. Cryptococcal organisms were present in the dural sheath specimens of both patients despite ongoing therapy with antifungal medication. Postoperative orbital infectious complications did not occur. Autopsy examination of one patient showed that the sites of fenestration were patent. Medical treatment of cryptococcal meningitis associated with AIDS has a guarded prognosis. Optic nerve sheath fenestration offers a treatment alternative for papilledema and visual loss that occur with cryptococcal meningitis.

Validity of overall self-rated health as an outcome measure in small samples: A pilot study involving a case series

OBJECTIVE A single-item measure of overall self-rated health (SRH) commonly is used in population surveys, but has not been used in small pilot projects. The purpose of this study was to assess the validity of SRH in small samples. DESIGN We used data from a prospective, observational weight-loss project to compare change in SRH with change in body weight and physical activity (PA) (minutes) over 30 days (n = 34). Body mass index at baseline ranged from 25.5 to 50.4 (mean = 36.1, median = 34.6). SRH was self-assessed using the following question: How would you rate your health overall? Results An increase in weight was associated with a reduction in SRH (r = 0.37, P = 0.03). An increase in PA was associated with improved SRH (r = 0.39, P = 0.02). CONCLUSIONS A single-item SRH measure may be an efficient method for measuring programme outcomes, and may also be useful for comparing the relative effectiveness of different programmes in pilot projects and quality improvement studies.

Isolated metastasis to optic nerve from medulloblastoma

Isolated involvement of the optic nerve with metastatic tumor is uncommon. A 19-year-old man had a midline cerebellar medulloblastoma; a gross total removal was performed. He received postoperative radiation therapy to the whole brain, posterior fossa, and craniospinal axis. A progressive optic neuropathy developed 28 months later with radiologic evidence of an enlarged optic nerve. There was no evidence of metastatic disease elsewhere. An optic nerve biopsy showed metastatic medulloblastoma. An intramedullary metastasis developed 48 months after the primary diagnosis, and the patient died 5 months later.

Iris and anterior chamber involvement in acute lymphoblastic leukemia

The authors describe a 6-year-old child, with a history of acute lymphoblastic leukemia, who presented with leukemic infiltration of the anterior segment of one eye mimicking anterior uveitis. After tissue diagnosis, administration of radiation therapy to the affected eye resulted in dramatic improvement of the condition. Involvement of the iris and anterior chamber is a recognized but unusual manifestation of leukemia. In the absence of systemic relapse, local radiation therapy without chemotherapy is highly effective, although the prognosis in these patients may be guarded.