David H. Fischer

Ocular toxoplasmosis in patients with the acquired immunodeficiency syndrome

In seven of eight cases of presumed ocular toxoplasmosis in patients with AIDS, the diagnosis was supported by a reduction or resolution of intraocular inflammation and healing of necrotic retinal lesions after initiation of antiparasitic drug therapy including one or more of the following medications: pyrimethamine, sulfadiazine, clindamycin, tetracycline, or spiramycin. In two cases the diagnosis was confirmed histologically. The cases differed clinically and histopathologically from those in immunocompetent patients. There was no evidence that disease originated in preexisting retinochoroidal scars. Lesions frequently were bilateral and multifocal. Vitreous inflammatory reaction was a common clinical finding, but histopathologic examination demonstrated scant retinal inflammation in areas of necrosis. Ocular toxoplasmosis in these patients with AIDS probably resulted from newly acquired infection or dissemination of organisms from nonocular sites of disease. Infections became clinically inactive with drug therapy in all treated patients, but reactivation and progression of disease occurred when therapy was stopped in two of three patients. Severe retinal necrosis led to retinal tears or detachment in three cases. Ocular lesions were the first manifestation of Toxoplasma gondii infection in four of five patients with evidence of multisystem infection.

Inadvertent Globe Perforation during Retrobulbar and Peribulbar Anesthesia: Patient Characteristics, Surgical Management, and Visual Outcome

The authors report a series of 20 eyes from 20 patients in whom inadvertent perforation of the globe occurred during local anesthesia for ocular surgery. Perforation resulted from retrobulbar anesthesia in 18 eyes and from peribulbar anesthesia in 2 eyes. Nine (45%) of 20 eyes had an axial length greater than or equal to 26.00 mm. Combining this figure with axial length data for the general population and estimates for the risk of globe perforation during local anesthesia yields an approximate incidence of perforation in eyes with axial length greater than or equal to 26.00 mm of 1 in 140 injections. Proliferative vitreoretinopathy (PVR) developed in 8 of the 20 eyes (40%) in this series. Overall, 15 (75%) of the 20 eyes were successfully repaired, and, in five eyes (25%), the final visual acuity was 20/70 or better.

Cotton-wool spots

A series of 24 consecutive patients presenting with a fundus picture characterized by a predominance of cottonwool spots, or a single cotton-wool spot, is reported. Excluded were patients with known diabetes mellitus. Etiologic conditions found included previously undiagnosed diabetes mellitus in five patients, systemic hypertension in five patients, cardiac valvular disease in two patients, radiation retinopathy in two patients, and severe carotid artery obstruction in two patients. Dermatomyositis, systemic lupus erythematosus, polyarteritis nodosa, leukemia, AIDS, Purtschers retinopathy, metastatic carcinoma, intravenous drug abuse, partial central retinal artery obstruction, and giant cell arteritis were each found in one patient. In only one patient did a systemic workup fail to reveal an underlying cause. The presence of even one cotton-wool spot in an otherwise normal fundus necessitates an investigation to ascertain systemic etiologic factors. RETINA 5:206-214, 1985

Retinal pigment epithelial tears after intravitreal bevacizumab injection for exudative age-related macular degeneration

Purpose:  To determine the incidence of and the risk factors for the development of retinal pigment epithelial (RPE) tears after intravitreal bevacizumab (Avastin) injection for the treatment of exudative age‐related macular degeneration (AMD).

Repair of Retinitis-related Retinal Detachments With Silicone Oil in Patients With Acquired Immunodeficiency Syndrome

To provide prompt visual rehabilitation and to reduce the need for repeated operations, we performed vitrectomy with silicone oil tamponade in 16 consecutive eyes with retinal detachments related to cytomegalovirus retinitis and acute retinal necrosis in 13 patients with acquired immunodeficiency syndrome. In all 16 eyes (100%), retinas were reattached with one operation. Preservation of ambulatory vision was achieved in six of eight eyes (75%; mean follow-up, 14.6 weeks). No patient with hand motion visual acuity or worse preoperatively recovered ambulatory vision. Visual acuity recovery was limited by optic nerve disease in five eyes (31%). Silicone oil-related side effects did not adversely affect visual outcome in any eye. Six patients (46%) have since died (mean, 4.4 months postoperatively). These data indicated that successful surgical repair of these detachments can be consistently achieved with this approach. The prognosis for ambulatory vision is strongly related to preoperative visual acuity.

Detection of cytokine mRNA production in infiltrating cells in proliferative vitreoretinopathy using reverse transcription polymerase chain reaction

AIMS To determine whether the infiltrating cells in the vitreous and subretinal fluid of patients with proliferative vitreoretinopathy (PVR) express messenger RNA for various cytokines found in this condition. METHODS The presence of mRNA coding for HPRT, IL-6, IL-1β, IL-8, and TNFα was investigated in 20 vitreous and subretinal fluid (SRF) samples from patients with PVR by reverse transcriptase polymerase chain reaction (RT-PCR). 16 samples from patients with retinal detachment and macular holes were used as controls. RESULTS HPRT was detected in all samples of PVR and in 11 (69%) control cases. Patients with PVR demonstrated mRNA for the cytokines tested more often than controls. The difference was statistically significant. CONCLUSION The presence of mRNA encoding for IL-6, IL-1β, IL-8, and TNFα is significantly detected by RT-PCR in vitreous and SRF samples of patients with PVR, indicating local production of these cytokines by vitreous and SRF cells.

Infantile endogenous Candida endophthalmitis presenting as a cataract

The most common pathogen to cause endogenous endophthalmitis is the fungus Candida albicans. Most cases involve adults who are either immunosuppressed or have a history of repeated or prolonged extracorporeal access to their circulatory system. Endogenous Candida endophthalmitis can occur in infants as well, particularly when prematurity, broad spectrum antibiotic therapy, or prior surgery are present as predisposing factors. We report the clinical and histopathological findings of an infant who developed a unilateral, sectoral lens opacity four months after undergoing treatment for disseminated candidiasis. The diagnosis of localized intralenticular fungal abscess with associated endophthalmitis was made via histopathologic examination of the aspirated lens material. Treatment with systemic antifungal agents successfully preserved the eye. In addition, we review and summarize the previously reported cases of Candida endophthalmitis in patients under one year of age.

Management of Sympathetic Ophthalmia with the Fluocinolone Acetonide Implant

OBJECTIVE We examined whether implantation of the fluocinolone acetonide (Retisert) implant achieved control of inflammation and a reduced need for oral corticosteroids or immunosuppressives in patients with sympathetic ophthalmia (SO). DESIGN Retrospective, noncomparative case series. PARTICIPANTS Eight patients with active SO. METHODS The results of fluocinolone acetonide implantation in 8 patients with active SO were studied with a follow-up period of 6 months to 2 years. MAIN OUTCOME MEASURES Presence or absence of intraocular inflammation, visual acuity, intraocular pressure, need for further surgery, and the need for additional use of oral or locally injected corticosteroids and/or immunosuppressives. RESULTS All patients demonstrated a significant reduction in the systemic medication required to maintain control of inflammation. Two patients had recurrent inflammatory episodes requiring the resumption of an oral immunosuppressive. Vision improved or was stabilized in all 8 patients. CONCLUSIONS The fluocinolone acetonide implant provides inflammatory control and reduces the dependence on systemic immunosuppression in patients with SO.

Propionibacterium acnes Endophthalmitis after Intracapsular Cataract Extraction

The authors report a case of Propionibacterium acnes endophthalmitis after intracapsular cataract extraction with implantation of an anterior chamber intraocular lens. The patients chronic inflammation persisted for 5 years after cataract surgery despite treatment with pars plana vitrectomy, intraocular lens removal, topical and oral steroids, and topical fortified antibiotics. Fluctuations in the inflammation were paralleled by changes in the size and appearance of a white plaque on the posterior corneal surface. Anterior chamber tap cultures were positive for P. acnes after 8 days of incubation under anaerobic conditions. The inflammation was not controlled until the posterior corneal plaque, which was the presumed nidus of the chronic infection, was removed and the patient was treated with intravitreal and oral antibiotics.

Intrathecal chemotherapy for recurrent central nervous system intraocular lymphoma

PURPOSE To report the use of intrathecal chemotherapy for two patients with recurrent central nervous system (CNS) intraocular lymphoma. DESIGN Two interventional case reports. PARTICIPANTS The clinical course of two patients with documented recurrent CNS intraocular lymphoma were retrospectively reviewed. INTERVENTION Both patients had previously undergone external beam radiation therapy to the orbit and brain, as well as systemic methotrexate (MTX) and intrathecal cytarabine (Ara-C), for primary CNS intraocular lymphoma. Both patients developed recurrent CNS intraocular lymphoma and treatment involved intrathecal MTX and Ara-C delivered by means of an Ommaya reservoir. MAIN OUTCOME MEASURE Survival and resolution of intraocular lymphoma. RESULTS Complete remission of the CNS intraocular lymphoma was seen in both patients. Both patients maintain reading visual acuity in at least one eye. Both patients remain disease free with lymphoma in remission for greater than 5 years after initial diagnosis. CONCLUSIONS Intrathecal chemotherapy for recurrent CNS intraocular lymphoma seems to be effective in preserving vision and possibly increasing survival.