Ivan R. Schwab

Bartonella henselae neuroretinitis in cat scratch disease : Diagnosis, management, and sequelae

OBJECTIVE This study aimed to report the long-term outcomes of patients treated with an antibiotic drug combination for Bartonella henselae neuroretinitis. DESIGN The study design was a retrospective case series. PARTICIPANTS Seven consecutive patients with neuroretinitis and cat scratch disease participated. INTERVENTIONS Patients underwent medical and ophthalmic evaluations. Blood cultures were obtained, and B. henselae antibody titers were measured. Tuberculosis, Lyme, toxoplasmosis, syphilis, and sarcoidosis were excluded. Patients received oral doxycycline 100 mg and rifampin 300 mg twice daily for 4 to 6 weeks and were observed for an average of 16 months (range, 10-24 months). Formal electrophysiologic testing was performed in three patients after resolution of neuroretinitis. MAIN OUTCOME MEASURES The changes in ocular inflammation and visual function associated with treatment were recorded. Follow-up examinations and electrophysiologic testing documented sequelae. RESULTS Patients presented following cat exposure with fever, malaise, and blurred vision. Decreased visual acuity (ranging from 20/40 to counting fingers) frequently was associated with dyschromatopsia and afferent pupillary defects. Ophthalmoscopic analysis showed signs of neuroretinitis, including nerve fiber layer hemorrhages, cotton-wool spots, multiple discrete lesions in the deep retina, and stellate macular exudates. B. henselae infection was confirmed with positive blood cultures or elevated immunofluorescent antibody titers or both. Therapy appeared to promote resolution of neuroretinitis, restoration of visual acuity, and clearance of bacteremia. After 1 to 2 years, two eyes had residual disc pallor, afferent pupillary defects, retinal pigmentary changes, and mildly decreased visual acuity. Electrophysiologic studies showed that when compared to the fellow eye, affected eyes had subnormal contrast sensitivity, abnormal color vision, and abnormal visually evoked potentials. Conversely, electroretinograms were normal in all subjects. CONCLUSIONS B. henselae is a cause of neuroretinitis in cat scratch disease. Compared to historic cases, doxycycline and rifampin appeared to shorten the course of disease and hasten visual recovery. Long-term prognosis is good, but some individuals may acquire a mild postinfectious optic neuropathy.

Boston type 1 keratoprosthesis: the university of california davis experience.

Purpose: To compare the University of California Davis experience using the Boston keratoprosthesis with the Boston Keratoprosthesis Study Groups initial report. Design: Retrospective chart review. Participants: We analyzed 30 eyes of 28 patients who previously underwent Boston type 1 keratoprosthesis surgery at our institution between 2004 and 2008. Methods: Preoperative, intraoperative, and postoperative parameters were collected and analyzed. Main Outcome Measures: Visual acuity and keratoprosthesis stability. Results: Preoperative diagnoses were failed graft (26 eyes, 87%), chemical injury (3 eyes, 10%), and Stevens-Johnson syndrome (1 eye, 3%). Twenty eyes (66%) had preoperative glaucoma. Preoperative best-corrected visual acuity ranged from 20/150 to light perception and was <20/200 in 83% of eyes. At an average follow-up of 19 months (range, 1-48; SD, 13.8; and median, 13), postoperative vision improved to ≥20/200 in 77% of eyes. Among eyes at least 1 year after the operation (16 eyes), vision was ≥20/200 in 75% of eyes and ≥20/40 in 25% of eyes. At an average follow-up of 19 months, retention of the initial keratoprosthesis was 83.3%. Conclusions: The Boston type 1 keratoprosthesis is a viable option after multiple keratoplasty failures or in conditions with a poor prognosis for primary keratoplasty. Patients with autoimmune disease are at higher risk for complications. The University of California Davis experience seems equivalent to the initial report of the Boston Keratoprosthesis Study Group. With longer follow-up, additional surgical procedures may be required but good anatomic and functional outcomes can be maintained.

The science of pterygia

Pterygium is an ocular surface disease of humans attributed to chronic ultraviolet-B exposure. Clinically, the condition involves invasive centripetal growth with associated inflammation and neovascularisation. Previous clinical studies focused primarily on the clinical characteristics and surgical management of pterygia and, because of this, the pathogenesis of pterygia remains incompletely understood. However, considerable progress in this area has been achieved, providing additional insight into this complex disease. This recent evidence implicates antiapoptotic mechanisms, immunological mechanisms, cytokines, growth factors, extracellular matrix modulators, genetic factors, viral infections and other possible causative factors. Limited investigation regarding differences in pathogenesis of primary and recurrent pterygia has been performed. We summarise many of these recent discoveries concerning the pathogenesis of pterygia and describe reported differences between primary and recurrent pterygia.

A fibrin-based bioengineered ocular surface with human corneal epithelial stem cells

Purpose. The purpose of the investigation was to prepare a bioengineered ocular surface tissue replacement consisting of (presumed) human corneal epithelial stem cells in a cross-linked fibrin gel for potential transplant. Methods. Presumed human epithelial stem cells were harvested, isolated, and cultivated as previously described from adult donor corneas obtained from a tissue and organ bank. The cultured corneal epithelial stem cells were suspended in a fibronectin/fibrin gel cross-linked by factor XIII. Plasma components were derived from a fibrinogen-rich cryoprecipitate of human plasma. Suspended cells proliferated in the fibrin gel, giving rise to colonies that eventually coalesced to near confluence over the 15 days of cultivation. The gels were sectioned and immunostained for keratin 3 (AE5) and keratin 19. Results. The fibrin gel product with corneal stem cells was easily manageable and maneuverable. Addition of the protease inhibitor aprotinin to the incubation medium prevented gel degradation; once it was removed, gels disintegrated within 24 hours. All of the cells cultivated in the fibrin gel stained positively for keratin 3 (AE5), indicating differentiation along the corneal epithelium lineage. Cells located in the center of the colonies were keratin 19–positive, suggesting a more primitive cell type. Growth kinetics were documented. Conclusions. A bioengineered ocular surface with a combination of presumed corneal epithelial stem cells in a cross-linked fibrin gel represents a potential improvement in current attempts to create a transportable, pliable, and stable tissue replacement. Since both the cells and the plasma components of the fibrin gel are of human origin, this technique provides the potential for a totally autologous bioengineered replacement tissue.

Foreshortening of the Inferior Conjunctival Fornix Associated with Chronic Glaucoma Medications

The authors designed a device to measure the depth of the inferior conjunctival fornix at the slit lamp using topical anesthesia. The fornices of 179 glaucoma patients receiving topical medications for glaucoma and 420 control subjects who had no history of ocular disease were measured. These measurements were age-stratified by decade. A significant foreshortening of the inferior conjunctival fornix was found with aging (P less than 0.01). Patients in their sixth through ninth decades using miotics for 3 years or longer and patients using nonmiotic agents for 3 years or longer exhibited significant foreshortening of the inferior fornix when compared with age-stratified (by decade) control subjects (P less than 0.01). These observations suggest that increasing age and topical medications for glaucoma, or the preservatives, used for 3 years or longer, are independently associated with conjunctival shrinkage.

Silk fibroin in ocular tissue reconstruction

The silk structural protein fibroin displays potential for use in tissue engineering. We present here our opinion of its value as a biomaterial for reconstructing tissues of clinical significance within the human eye. We review the strengths and weaknesses of using fibroin in those parts of the eye that we believe are most amenable to cellular reconstruction, namely the corneoscleral limbus, corneal stroma, corneal endothelium and outer blood-retinal barrier (Ruyschs complex). In these areas we find that by employing the range of manufacturing products afforded by fibroin, relevant structural assemblies can be made for cells expanded ex vivo. Significant questions now need to be answered concerning the effect of this biomaterial on the phenotype of key cell types and the biocompatibility of fibroin within the eye. We conclude that fibroins strength, structural versatility and potential for modification, combined with the relative simplicity of associated manufacturing processes, make fibroin a worthy candidate for further exploration.

Reconstruction of the Periocular Mucous Membrane by Autologous Conjunctival Transplantation

We have extended the concept of autologous conjunctival transplantation for corneal resurfacing as recommended by Thoft to reconstruction in 14 patients with unilateral abnormalities of the bulbar and palpebral conjunctiva caused by alkali burns (2), irradiation (2), neoplasms (3), degenerative diseases (5), trauma (1), and developmental anomalies (1). Large, free conjunctival grafts from bulbar and forniceal donor sites were used. No complications have been noted at the recipient or donor sites. Grafts of normal conjunctiva provided intact basement membrane, goblet cells, and epithelium that help restore normal ocular and lid surfaces. The use of free conjunctival grafts provides significant advantage over the use of buccal mucous membrane grafts. The techniques and results of our experience with free conjunctival grafts in 14 patients are discussed.

Multifocal choroiditis in patients with familial juvenile systemic granulomatosis

PURPOSE To document clinical features of uveitis in patients with familial juvenile systemic granulomatosis. DESIGN Retrospective chart review. METHODS Ophthalmologic examination, medical history, and clinical course in 16 patients from eight families examined at six academic medical centers. RESULTS Of the 16 patients, 15 had evidence of panuveitis with multifocal choroiditis. One patient had only an anterior uveitis. Ischemic optic neuropathy, presumably due to a small vessel vasculopathy, and retinal vasculopathy each occurred in one patient. Ocular complications were common, including cataracts in 11, glaucoma in six, band keratopathy in six, cystoid macular edema in six, and optic disk edema in six. All 16 patients had polyarthritis, and at least nine had skin rash. Often patients were misdiagnosed initially as having either juvenile rheumatoid arthritis or sarcoidosis. CONCLUSIONS Familial juvenile systemic granulomatosis is an uncommon genetic disease characterized by polyarthritis and uveitis. Panuveitis and multifocal choroiditis often may be present. Patients with a diagnosis of juvenile rheumatoid arthritis but having a family history of the disease and multifocal choroiditis should be suspected of having familial juvenile systemic granulomatosis.

Pterygium and Associated Ocular Surface Squamous Neoplasia

OBJECTIVE To measure the rate of histopathologically identified ocular surface squamous neoplasia (OSSN) in pterygium specimens. METHODS All pterygium specimens collected from consecutive patients between April 8, 2003, and February 6, 2008, were submitted for histopathologic examination, and the rate of OSSN was calculated. RESULTS The rate of OSSN was 9.8% (52 of 533) insequential pterygium specimens. CONCLUSIONS This rate of unsuspected OSSN suggests that all specimens of pterygium should be submitted for histopathologic examination and that patients in whom OSSN is noted should be examined at more frequent intervals so any clinical OSSN that develops can be identified at an early stage.

Social economic development in the prevention of global blindness

AIMS To assess the relation between a countrys economic developmental status and its prevalence of blindness. METHODS Available epidemiological data on worldwide visual loss and its causes compiled by the World Health Organization were reviewed. Findings were compared with economic development data from the involved countries and regions. Analysis was completed in view of the socioeconomic status of each country and region. RESULTS Analysis of the global distribution of blindness indicates a trend of higher prevalence existing in developing countries with lower per capita income. Preventable causes of blindness (that is, cataract, trachoma) are also more prevalent in these countries. CONCLUSIONS Because economic development is shown to be a factor in blindness, programmes for blindness prevention should not be the only route to the elimination of unnecessary blindness throughout the world. Concomitant economic development is also necessary to reduce and eventually eradicate much of the preventable and avoidable causes of blindness.