Everett Ai

A Sensitive and Specific Polymerase Chain Reaction-Based Assay for the Diagnosis of Cytomegalovirus Retinitis

PURPOSE To develop a sensitive and specific laboratory assay for the diagnosis of cytomegalovirus retinitis. METHOD We used a polymerase chain reaction-based assay for detection of cytomegalovirus DNA in vitreous samples. We attempted to detect cytomegalovirus DNA in 19 vitreous samples from patients with the acquired immunodeficiency syndrome (AIDS) who had untreated cytomegalovirus retinitis and in 40 vitreous samples from patients with AIDS who had been treated with systemic ganciclovir or foscarnet, or both. We also attempted to detect cytomegalovirus DNA in vitreous samples from 54 immunocompetent patients, including 32 with retinal detachment or macular hole, 11 with vitreous inflammation, and 11 with vitreous hemorrhage. Additionally, we attempted to detect cytomegalovirus DNA in 15 vitreous samples from patients with AIDS who had vitreoretinal inflammation not caused by cytomegalovirus. RESULTS Cytomegalovirus DNA was detected in 18 of 19 eyes with untreated cytomegalovirus retinitis. We detected cytomegalovirus DNA in 19 of 40 vitreous samples from patients with previously treated cytomegalovirus retinitis. Cytomegalovirus DNA was not detected in any of 69 patients who did not have a clinical diagnosis of cytomegalovirus retinitis. Thus, the assay had an estimated sensitivity of 95% in detecting untreated cytomegalovirus retinitis and a sensitivity of 48% in detecting cytomegalovirus retinitis that had been treated with systemic ganciclovir or foscarnet, or both. The assay did not give false-positive results in patients with vitreous hemorrhage or vitreous inflammation. Most important, the assay did not give false-positive results in AIDS patients with vitreous inflammation from causes other than cytomegalovirus retinitis. CONCLUSION We have developed a sensitive and specific diagnostic assay that will assist in the diagnosis of cytomegalovirus retinitis.

Diffuse Unilateral Subacute Neuroretinitis: Morphometric, Serologic, and Epidemiologic Support for Baylisascaris as a Causative Agent

PURPOSE Several nematodes have been postulated as etiologic agents in diffuse unilateral subacute neuroretinitis (DUSN), but the cause of this condition remains uncertain. The authors report the first case of DUSN from the western United States (northern California), along with morphometric, serologic, and epidemiologic evidence supporting Baylisascaris procyonis as its cause. METHODS One patient was examined and evaluated for disc edema and transient obscurations of vision. A diagnosis of DUSN was confirmed when a motile nematode was identified within the substance of the patients retina. Morphometric analysis of the nematode was done from projected fundus photographs. Serologic evidence of Baylisascaris infection was suggested by Western blot analysis. A necropsy was done on 12 raccoons from the area. They were examined for evidence of Baylisascaris infection, previously believed to be nonendemic in the region. RESULTS The intraocular nematode measured 1727 x 67 microns, most consistent with Baylisascaris. The patient had considerable exposure to raccoons, and was seropositive for B. procyonis infection on Western blot analysis. Necropsy evaluation showed B. procyonis infection in 8 of 12 raccoons examined from the area. CONCLUSIONS The morphometric, serologic, and epidemiologic findings in this case provide evidence that the raccoon ascarid, B. procyonis, is a cause of the large nematode variant of DUSN.

Intravitreal Bevacizumab For Previously Treated Choroidal Neovascularization From Age-related Macular Degeneration

Purpose: To report the optical coherence tomography (OCT) findings and visual results in a series of patients treated with intravitreal bevacizumab for choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD), and to determine if a difference in treatment effect exists between previously treated and treatment naïve patients. Methods: A retrospective review of all patients treated with intravitreal bevacizumab for CNV from AMD with visual acuity greater than or equal to 20/320 between September 2005 and February 2006 was performed. OCT data recorded included central macular thickness and the presence or absence of cystic intraretinal fluid, subretinal fluid, or pigment epithelial detachment at the time of the initial injection, at 1-week, 1-month, and 3-month intervals, as well as at the end of follow-up. Visual acuity measurements were recorded using Early Treatment Diabetic Retinopathy Study charts. Any ocular or systemic adverse events were recorded. Statistical analysis was performed to determine if OCT and visual acuity results were significant and to determine if a difference in outcomes existed between previously treated patients and treatment naïve patients. Results: Fifty-four eyes of 51 patients treated with intravitreal bevacizumab for CNV from AMD were identified. A total of 178 injections were performed. Mean number of days of follow-up was 138 with 91% of patients having at least 90 days of follow-up. Seventy percent of patients had undergone previous treatment for CNV. The mean number of intravitreal bevacizumab injections per eye was 3.3. Combined treatment with photodynamic therapy was provided in 20% of cases at the initial intravitreal injection. OCT data for all patients revealed an initial mean thickness of 362 &mgr;m, which was decreased at 1 week to 278 &mgr;m (P = 0.001), 235 &mgr;m at 1 month (P < 0.0001), 238 &mgr;m at 3 months (P = 0.0004), and 244 &mgr;m for the end of follow-up (P < 0.0001). Cystic retinal edema, subretinal fluid, and pigment epithelial detachment resolved in the majority of cases, but pigment epithelial detachment frequently took longer to resolve. Initial mean visual acuity was 20/125 (logMAR 0.8), and final mean visual acuity was 20/100 (logMAR 0.7) (P = 0.03). There was no difference in OCT or visual acuity outcomes (P = 0.62 and P = 0.28, respectively) between previously treated and treatment naïve patients. There was no difference in OCT or visual acuity outcomes (P = 0.67 and P = 0.21, respectively) between patients who received combination therapy and those who received monotherapy with intravitreal bevacizumab. No systemic or ocular adverse events were recorded. Conclusion: Intravitreal bevacizumab for CNV from AMD results in a rapid decrease in OCT-measured retinal thickness in a majority of cases. Visual acuity also improved in this series, suggesting a potential corresponding visual benefit. This series suggests that previously treated and treatment naïve patients have similar outcomes.

A multicenter study of Pneumocystis choroidopathy

We studied 21 patients with the acquired immunodeficiency syndrome and presumed Pneumocystic carinii choroidopathy. The lesions were characteristically yellow to pale yellow in color, appeared at the level of the choroid, and were found in the posterior pole. They varied in size from 300 to 3,000 microns, initially increasing in number before treatment and eventually resolving after systemic antimicrobial therapy. Of the 21 patients, 18 (86%) had received inhaled pentamidine as prophylaxis against Pneumocystis pneumonia. Visual acuity and visual field testing showed little evidence of retinal destruction. Survival after the diagnosis of the choroidopathy ranged from two to 36 weeks. Pneumocystic choroidopathy offers an easily accessible clue to disseminated Pneumocystis infection. When comparing drugs for Pneumocystis prophylaxis, careful ocular examination can provide one indicator of the relative efficacy of protection against extrapulmonary disease.

The natural history of pigment epithelial detachment associated with central serous chorioretinopathy.

Purpose: To determine the visual outcome of retinal pigment epithelial detachment (PED) associated with central serous chorioretinopathy (CSC), to further characterize the natural history of these lesions, and to provide a review of previous reports. Participants: Data for 340 consecutive patients with a diagnosis of CSC from January 2001 through December 2004 were retrospectively reviewed. Patients with CSC combined with angiographic evidence of PED were included in the study. Main Outcome Measures: Age, sex, use of corticosteroid medications, presenting visual acuity, and final visual acuity were recorded. Lesion characteristics including location, number of lesions, and laterality were recorded. Clinical outcome measures included resolution or persistence of the PED, progression to retinal pigmentary atrophy, or development of choroidal neovascularization. Fluorescein angiograms were obtained if available. Results: Thirty-four (9%) of 319 patients with angiographic evidence of CSC were diagnosed with PED over a mean follow-up of 49 months (range, 12–165 months; median, 36 months). Mean age of the patients was 47 years (range, 32–69 years; median, 48 years), most of whom were males (68%). Mean initial visual acuity was 20/32 (range, 20/13 to 20/400; median, 20/30). PEDs were commonly unilateral (88%), unifocal (76%), and extrafoveal (82%). Overall mean final visual acuity was 20/25 (range, 20/13 to 20/250; median, 20/25) for all patients. Mean visual acuity for the group of patients with subfoveal PED (18%) was 20/50 (range, 20/25 to 20/250; median, 20/50). Complete resolution of the PED occurred in 65% of patients, with resultant mean visual acuity of 20/25 (range, 20/13 to 20/250; median, 20/25). In this group, localized retinal pigment epithelial atrophy developed in 86%, with mean final visual acuity of 20/25 (range, 20/13 to 20/250; median, 20/25). Persistent PED was observed in 35% of patients, resulting in mean visual acuity of 20/25. There were no cases of choroidal neovascularization. Conclusions: CSC with associated retinal PED may be seen and generally has a good visual prognosis. The most frequent outcome is resolution with retinal pigment epithelial atrophy. Subfoveal PED occurs less commonly and may have a poorer visual prognosis.

Intravitreal triamcinolone acetonide treatment of macular edema associated with central retinal vein occlusion.

Purpose: To evaluate treatment of macular edema associated with central retinal vein occlusion (CRVO) using intravitreal triamcinolone acetonide. Methods: Retrospective review of data for 29 eyes of 29 patients with CRVO and macular edema treated with intravitreal triamcinolone acetonide. Initial visual acuity, intraocular pressure, and history of glaucoma were recorded. Final visual acuity, intraocular pressure, and adverse events were recorded during the treatment period. Results: Twenty-nine eyes were treated with intravitreal injection. The mean follow-up was 348 days. The median initial Early Treatment Diabetic Retinopathy Study visual acuity was 20/250 (median logMAR, 1.1). The median visual acuity 3 months after injection was 20/125 (median logMAR, 0.8). This difference was statistically significant. The median final visual acuity was 20/250 (median logMAR, 1.1). This difference in visual acuity was not statistically significant. Elevated intraocular pressure, excluding that related to neovascularization, occurred in 5 of 22 patients. Subgroup analysis revealed that patients who received multiple injections had better outcomes. Conclusion: Intravitreal triamcinolone acetonide may improve vision transiently but does not appear to result in a sustained visual acuity benefit for patients with macular edema associated with CRVO. Repeated injections may be necessary. The risk of glaucoma is significant, and additional study is required to further characterize this and other risks.

Massive spontaneous choroidal hemorrhage.

Purpose To describe the course, management, and prognosis of massive spontaneous choroidal hemorrhage. Methods The presenting visual acuity, ocular findings, duration to surgical intervention, and outcomes of five patients were retrospectively reviewed. Results Five eyes from four patients (median age, 80 years; range, 66–85 years) were studied. The patients were observed from 4 to 72 months (median, 33 months). Three patients were on anticoagulation therapy with warfarin; one patient had bilateral involvement with no history of anticoagulation therapy. Three patients were hypertensive, and three of the four had been diagnosed with age-related macular degeneration. Four eyes underwent choroidal drainage procedures, and one was observed. In all patients whose choroids were drained, the final vision was no light perception. Conclusions Massive spontaneous choroidal hemorrhage may be associated with hypertension, systemic anticoagulation, advanced age, and age-related macular degeneration. Final visual acuities are generally poor.

Anticoagulation with warfarin in vitreoretinal surgery.

Purpose: To describe the clinical course of patients undergoing vitreoretinal procedures while receiving systemic anticoagulation with warfarin. Methods: We reviewed patient demographics, ocular findings, and clinical courses for 25 patients receiving systemic anticoagulation with warfarin who subsequently underwent vitreoretinal surgery. Results: Patient ages ranged from 49 years to 81 years (median, 69 years). Indications for anticoagulation included atrial fibrillation, cerebrovascular disease, deep vein thrombosis, prosthetic heart valves, and hypercoagulable state. Follow-up ranged from 4 months to 36 months (median, 19.5 months). The international normalized ratio ranged from 1.5 to 3.1 (median, 2.0). Final vision after surgery ranged from 20/20 to 20/400 (median, 20/100). One patient who underwent scleral buckling and external drainage of subretinal fluid had an intraoperative subretinal hemorrhage associated with the drainage procedure. In all other patients, no intraoperative complications occurred. Conclusion: Cessation of therapy with warfarin may not be necessary in patients receiving anticoagulation who are undergoing vitreoretinal procedures. Successful visual and anatomical results may be achieved after vitreoretinal surgery for patients receiving anticoagulation with warfarin. The management of anticoagulation should occur in conjunction with the patient’s internist to allow a clear understanding of the potential systemic risks of cessation of warfarin treatment preoperatively.

Outpatient postoperative fluid-gas exchange after early failed vitrectomy surgery for macular hole.

BACKGROUND Vitrectomy surgery with fluid-gas exchange and prone positioning has been shown to close macular holes and improve vision. In those eyes that have failed surgery, repeat vitrectomy has been advocated. As an alternative, the authors performed an outpatient postoperative fluid-gas exchange on eyes when the macular hole failed to close after vitrectomy surgery. METHODS The authors reviewed all cases of failed vitrectomy surgery for macular holes that underwent a postoperative fluid-gas exchange. Eyes were considered to have failed initial surgery if a rim of subretinal fluid surrounded an open full-thickness macular hole. RESULTS Twenty-three consecutive eyes underwent outpatient fluid-gas exchange 1 week to 8 weeks after vitrectomy surgery. In 17 eyes (74%), fluid-gas exchange resulted in flattening and closure of the macular hole. In all 17 eyes, visual acuity improved 2 or more lines, with 8 (35%) of the 23 eyes achieving 20/50 or better visual acuity. CONCLUSIONS Postoperative fluid-gas exchange may achieve successful closure of macular holes and improve vision in eyes that have failed surgery for full-thickness macular holes and should be considered as a cost-effective alternative to repeat vitrectomy.

Progressive Zonal Outer Retinitis

We examined an immunocompetent patient with uniocular acute progressive outer retinitis. The retinitis was curvilinear in shape, showed progressive enlargement, and appeared to be altered by treatment with intravenous acyclovir. When regressed, the affected area of retina appeared atrophic and, at one-year follow-up, demonstrated intraretinal pigment migration with retinal pigment epithelial atrophy and atrophy of the choriocapillaris. Although visual acuity was unaffected, a dense scotoma was recorded on field testing. The response to acyclovir implicates the herpesvirus family, and acyclovir or another antiherpetic agent should be considered for such cases.