Eulogio Besada

Peripapillary schisis with serous detachment in advanced glaucoma.

Purpose. To describe features associated with the development and resolution of peripapillary retinoschisis with an underlying serous detachment in a patient with primary open angle glaucoma. This presentation occurred in the absence of an observed optic nerve coloboma, congenital, or acquired optic nerve head pit. Case Report. A patient with advanced glaucomatous optic nerve cupping developed a temporally localized peripapillary serous detachment in the right eye which spontaneously resolved. Results. Optical coherence tomography demonstrated an area of retinoschisis with underlying serous detachment contiguous with the temporal disc margin. Although fluorescein angiography was not performed and the presence of a peripapillary subretinal neovascular membrane could not be ruled out, an atypical coloboma, optic nerve head pit, or peripapillary subretinal neovascular membrane was not observed during biomicroscopy or scanning laser ophthalmoscopy. The retinoschisis and detachment resolved without intervention. Conclusion. Peripapillary retinoschisis with an underlying serous detachment may develop in subjects with advanced glaucoma. Although the occurrence of the findings in this case may be unrelated to glaucomatous optic neuropathy, the likelihood that a pathogenic mechanism linked to advanced glaucoma may be responsible for the development of peripapillary schisis and serous detachment should alternatively be taken into consideration. This case documents its spontaneous resolution without intervention.

Laser scanning confocal ophthalmoscopy and polarimetry of human immunodeficiency virus patients without retinopathy, under antiretroviral therapy.

Purpose. Confocal laser scanning ophthalmoscopy (HRT; Heidelberg retinal tomograph II) and scanning laser polarimetry (GDx-variable corneal compensator [VCC]) were used to investigate whether early indicators of retinal nerve fiber layer (RNFL) thickness loss could be observed in patients infected with the human immunodeficiency virus (HIV) that had no associated retinopathy or optic neuropathy and were concomitantly receiving antiretroviral medications. Methods. HRT and GDx-VCC parameters obtained from a group of 13 HIV-positive subjects (n = 26 eyes) on antiretroviral therapy examined with HRT, with a subgroup of six subjects (n = 12 eyes) examined with both HRT and GDx-VCC, were compared with those of a matched HIV-negative control cohort (13 subjects, n = 26 eyes) examined with HRT, with a subgroup of five subjects (n = 10 eyes) examined with both HRT and GDx-VCC. We employed generalized estimating equations for statistical analysis. Results. Reduced mean values for the HRT height variation contour (p < 0.045) and HRT mean RNFL thickness (p < 0.023) were observed in HIV-positive subjects controlling for age, sex, and race. A significantly reduced mean value corresponding to the GDx-VCC superior maximum (p < 0.014) and inferior maximum (p < 0.016) were also observed for the HIV-positive cohort analyzed controlling for age, sex, and race. Conclusion. HRT and GDx-VCC indicators of RNFL thickness appear to be significantly reduced in HIV-positive subjects without retinopathy or optic nerve disease using antiretroviral medication, suggesting RNFL loss occurs in this population of HIV-positive patients. The lack of correlation between CD4 counts, viral load, number of antiretroviral medications used, or years from diagnosis of HIV and RNFL thinning, suggests that possibly other factors associated with HIV infection may contribute to the apparent RNFL thickness loss.

Vitreal pathogenic role in optic pit foveolar retinoschisis and central serous chorioretinopathy

Purpose: To expand on current theories concerning the vitreal‐induced mechanism underlying the development of foveolar retinoschisis and macular sensory detachments associated with optic nerve head pits. To propose the notion that vitreal traction may contribute to the pathogenesis of serous detachments in central serous chorioretinopathy (CSC).

An uncommon presentation of Bartonella-associated neuroretinitis.

Background. This article documents a case of neuroretinitis initially presenting with ocular pain, 20/20 visual acuities, optic disc edema, and macular serous detachment without macular star formation in the absence of a history of exposure to pets or cats or symptoms suggestive of Bartonella infection. This initial clinical presentation appeared unilateral, but later became bilateral. Case Report. Physical and neuroophthalmologic consultation, neuroimaging studies, blood chemistry, and serologic analysis were requested. Positive serologic (IGG) titers to Bartonella henselae and Bartonella quintana were detected. Treatment was instituted initially with oral tetracycline (250 mg) qid and subsequently with doxycycline (100 mg) bid and prednisone (20 mg) qd. Conclusion. Bartonella infection may cause optic disc edema and serous detachment without macular star formation. This presentation may occur without the generally characteristic signs and symptoms of Bartonella-associated neuroretinitis. A bilateral involvement may follow an initial unilateral presentation during the affliction period of this disorder.

Choroiditis, pigment epithelial detachment, and cystoid macular edema as complications of poststreptococcal syndrome.

Purpose Two cases of poststreptococcal uveitis are presented. One patient developed nongranulomatous anterior uveitis (case 1). A second patient developed nongranulomatous anterior uveitis followed by granulomatous uveitis with concurrent choroiditis, retinal pigment epithelial detachment, and cystoid macular edema (case 2). Current concepts regarding the pathogenesis of poststreptococcal syndrome and its ocular sequelae are also discussed. Case Reports Case 1: A 31-year-old female patient presented with bilateral nongranulomatous uveitis after a recent onset of sore throat. A past diagnosis of rheumatic fever was revealed during acquisition of the patient’s history. Blood chemistry analysis indicated elevated anti-streptolysin O antibody titers as the only significant elevated result. Case 2: A 33-year-old female presented initially with bilateral nongranulomatous uveitis. A history of recurrent sore throat was reported. Blood chemistry analysis revealed elevated anti-streptolysin O antibody titers only. “Mutton fat” keratic precipitates eventually developed; however, the bilateral uveitis resolved after topical cycloplegic and corticosteroid treatment. An anterior granulomatous uveitis with concurrent choroiditis, retinal pigment epithelial detachment, and cystoid macular edema ensued during a recurrent episode. Blood chemistry analysis was unremarkable at that time. Conclusions. Anterior nongranulomatous/granulomatous and posterior uveitis should be considered clinical manifestations of poststreptococcal syndrome in patients with a clinical history and/or serological evidence indicating possible past streptococcal infection. A variation of host-genetic-predisposed immune response, the patient’s human leukocyte antigen haplotype, pathogen virulence, and/or deposition location of immune circulating complexes may give rise to the diverse spectrum of clinical ocular sequelae in poststreptococcal syndrome. Poststreptococcal uveitis may comprise a similar immunologic pathogenesis to that of acute rheumatic fever, acute glomerulonephritis, and other autoimmune diseases.

Bilateral disk edema with unilateral macular serous fluid secondary to neurocysticercosis

PURPOSE The purpose of this article is to document a case of neurocysticercosis that manifested clinically with bilateral disk edema and serous fluid accumulation in the macula of the left eye. We also describe the recovery of visual-field loss (O.D.) and diminution of bilateral disk edema following anti-helminthic treatment. CASE REPORT A 41-year-old woman reporting headaches came to us with bilateral disk edema and co-existing serous macular fluid in the left eye. RESULTS Magnetic resonance imaging (MRI) revealed the presence of large multi-septated cysts that exhibited peripheral enhancement, with minimal surrounding edema at the posterior left temporal lobe. Scattered punctate lesions, suggesting areas of calcification, were also observed within both temporal lobes. The optic chiasm appeared compressed. This presentation was considered characteristic of neurocysticercosis and the patient was prescribed a regimen of 200mg albendazole b.i.d. The patient responded well to the treatment, with progressive resolution of the bilateral disk edema and macular fluid. CONCLUSION Although rare, cases of cysticercosis and neurocysticercosis may still be encountered in industrialized nations, where the parasite has been almost eradicated. Ocular signs of disk edema and macular serous fluid secondary to neurocysticercosis may correspond to optic nerve, parenchymal, or extraparenchymal disease.

Pupillometry Study of Brimonidine Tartrate 0.2% and Apraclonidine 0.5%

This study investigated possible effects of brimonidine tartrate 0.2% and apraclonidine 0.5% on pupil diameter. Ten subjects between 20 and 40 years of age participated. A Colvard pupillometer (Oasis Medical) was used to measure pupil diameter. Baseline and serial measurements were obtained at 3 luminance levels (>6.4, <0.82–0.4, and <0.2–0.02 cd/m2) during a 4‐hour interval following instillation of 1 drop of brimonidine tartrate 0.2% or apraclonidine 0.5% in one eye versus a placebo in the contralateral eye. The measurements for each drug were obtained on different days. A nested random effects model controlling for subjects age, race, and sex was used for statistical analysis. A maximum reduction in pupil diameter was observed at 90 minutes from instillation (1.40 mm at >6.4 cd/m2, 1.69 mm at <0.82–0.4 cd/m2, and 1.55 mm at <0.2–0.02 cd/m2) for brimonidine tartrate 0.2%. At all time intervals and illumination levels, miosis (P < .01) occurred. Apraclonidine 0.5% did not produce a significant effect on pupil diameter. Brimonidine tartrate 0.2% produced a moderate miotic effect. No effect was observed for apraclonidine 0.5%. A predominant agonistic effect on α‐2 receptors of the iris dilator may explain this behavior.

Electrooculography and optical coherence tomography reveal late-onset Best disease.

Purpose Best vitelliform macular dystrophy, also known as Best disease, is a macular dystrophy characterized by bilateral yellowish egg yolk–like lesion(s) present within the maculae. It is a slowly progressive disease that usually presents at childhood. Best vitelliform macular dystrophy frequently proceeds through stages, beginning with a classic presentation described as vitelliform. A similar condition, known as adult-onset foveomacular vitelliform dystrophy, has been described among adult patients. Although the two maculopathies may look similar, they are considered two separate entities, because of the age of onset and overall clinical presentation. Case Report A 54-year-old man presented with gradual-onset blurred near vision in each eye. Previous records showed a history of unremarkable dilated fundus examinations for the past 8 years. Best-corrected distance acuities measured 20/20 OD and 20/20 OS. Amsler grid testing revealed a mild metamorphopsia OD and OS. Dilated fundoscopy revealed macular pseudohypopyon in each eye. In vivo imaging of the maculae was obtained with spectral-domain optical coherence tomography findings. Electrooculography findings were consistent with Best vitelliform macular dystrophy of atypical, late onset. Conclusions Best vitelliform macular dystrophy may vary in its presentation. Electrooculography and spectral-domain optical coherence tomography can aid in establishing the definitive diagnosis.

Unilateral granulomatous post-streptococcal uveitis with elevated tension.

Purpose. We document a presumptive case of unilateral post-streptococcal uveitis. The affected eye manifested a granulomatous anterior uveitis with elevated intra-ocular pressure (IOP) compared with the contra-lateral eye. This presentation was preceded by a recent streptococcal pharyngitis. Case Report. An asymptomatic, otherwise healthy 13-year-old black female presented with anterior chamber cells, mutton fat resembling keratic precipitates, and elevated IOP in the left eye relative to the right eye. The patient had been diagnosed with streptococcal pharyngitis approximately 1 week before her eye examination. A blood chemistry analysis, rheumatoid profile panel and antistreptolysin antibody titer were requested. The patient was prescribed predinisolone acetate 1% ophthalmic suspension in the left eye. Results. Anti-streptolysin antibody titers were significantly elevated (291 IU/ml). The patient responded favorably to topical ophthalmic steroid treatment with a reduction of IOP and inflammation. Conclusions. Unilateral, granulomatous anterior uveitis may be a variant manifestation of post-streptococcal uveitis. The IOP elevation in these cases may result secondary to concurrent trabeculitis.

Recurrent serous macular detachment after topical ocular hypotensive medication

We document the recurrence of a CSMD in a patient subsequent to the instillation of topical ocular hypotensive medications and its resolution on discontinuation of therapy. An independent cause or causes contributing to the development of CSMD other than the use of topical ocular hypotensive medications cannot be ruled out in this case, neither can it be considered dissociated from the use of these drugs. We recommend that patients with VTS, those with a history of CSMD or having developed recurrent episodes of CSMD requiring management with topical ocular hypotensive medications, be cautiously monitored for the possible occurrence or exacerbation of CSMD.