Kathleen M. Stoessel

Incidence and rate of disappearance of retinal hemorrhage in newborns

OBJECTIVE To determine the prevalance, associated biometric factors, and rate of disappearance of neonatal retinal hemorrhage. DESIGN Cross-sectional and natural history study. METHODS Healthy newborns (n = 149) at an urban hospital were examined using indirect ophthalmoscopy within 30 hours of birth. Newborns with retinal hemorrhage were reexamined biweekly until hemorrhage resolved. MAIN OUTCOME MEASURES Neonatal and maternal biometric factors, and incidence and rate of resolution of retinal hemorrhage. RESULTS Intraretinal hemorrhage was present in 34% of newborns and varied from a single dot hemorrhage in one eye to bilateral widespread hemorrhages, occasionally with white centers. The incidence of hemorrhage was higher for vacuum-assisted (75%) than for spontaneous vaginal deliveries (33%) and was least for infants delivered by cesarean section (7%). The mean maternal age was greater for infants with retinal hemorrhage. By 2 weeks after birth, retinal hemorrhage resolved in 86% of eyes, and at 4 weeks no intraretinal hemorrhage was detected, although a single subretinal hemorrhage persisted until 6 weeks after birth. CONCLUSIONS Intraretinal hemorrhages are common in the immediate postnatal period and resolve by 1 month of age. Retinal hemorrhage in infants older than 1 month should heighten suspicion that the hemorrhage is associated with factors other than birth.

Varicella zoster virus retrobulbar optic neuritis preceding retinitis in patients with acquired immune deficiency syndrome

OBJECTIVE This study aimed to describe a recently recognized and rare presentation of varicella zoster virus (VZV) retrobulbar optic neuritis preceding retinitis in patients with acquired immune deficiency syndrome and to identify factors that may relate to improved visual outcome. METHODS Diagnosis, treatment, and clinical course are described for three eyes of two patients with this viral infection. RESULTS Patients had decreased vision, headache, and recent zoster dermatitis. Varicella zoster virus retrobulbar optic neuritis was diagnosed on the bases of clinical, laboratory, and electrophysiologic examination results. Profound vision loss and peripheral retinitis ensued despite intravenous antiviral treatment. Combination intravenous and intravitreous antiviral injections were administered with dramatic visual recovery. CONCLUSIONS Varicella zoster virus retrobulbar optic neuritis should be considered in immunocompromised patients with visual loss. Early diagnosis and aggressive combination therapy via systemic and intravitreous routes may enable return of useful vision.

Pars Planitis and Autoimmune Endotheliopathy

A migrating endothelial rejection line is the clinical criterion of specific immune reaction in corneal allotransplantation. This line when seen in otherwise intact corneas has been presumed to be an autoimmune endotheliopathy. We have recorded corneal changes similar to autoimmune endotheliopathy in four of ten patients with the diagnosis of pars planitis. These observations suggest that pars planitis may be an autoimmune process directed against the vitreous humor.

Choroidal Neovascularization Associated with West Nile Virus Chorioretinitis

A case of late-onset choroidal neovascularization in a patient with a history of West Nile virus chorioretinitis is described. An 86-year-old man with a history of diabetes mellitus developed bilateral West Nile virus chorioretinitis in 2001, after which his vision improved to baseline. Approximately 5 years later, the patient was found to have choroidal neovascularization in his left eye, for which he received an intravitreal injection of bevacizumab. After one injection, there was good anatomical response. Choroidal neovascularization may be a late-onset complication of West Nile virus chorioretinitis, and bevacizumab may be a good therapeutic option.

Dinitrochlorobenzene Immunotherapy of Recurrent Squamous Papilloma of the Conjunctiva

Dinitrochlorobenzene (DNCB) immunotherapy of a recurrent conjunctival papilloma was employed successfully in a 24-year-old man. Previous attempts at electrocautery, surgical excision, and cryosurgery met without success. The tumor response to DNCB therapy resulted in total eradication of the tumor and represents a more successful modality than previous treatments. Poor patient compliance, variable patient immune mechanisms, and tumor size may influence the variable patient immune mechanisms, and tumor size may influence the fate and type of response to DNCb immunotherapy. DNCB therapy should be considered in the treatment of conjunctival papillomas refractory to conventional modes of therapy.

Assessment of visual-field changes before and after focal photocoagulation for clinically significant diabetic macular edema

Visual fields were compared before and after focal photocoagulation for eyes with nonproliferative diabetic retinopathy and clinically significant diabetic macular edema. A total of 8 eyes was tested before treatment and 6-8 weeks after treatment using static automated visual fields (Octopus). The visual-field indices, mean defect (MD) and corrected loss variance, were employed as measures of retinal sensitivity. Our results show that focal photocoagulation (CLV) generally depressed sensitivity (increased MD) in the treated central 10 degrees field, whereas in the untreated control region (10-30 degrees) sensitivity generally remained stable. However, the whole-field indices indicated that overall the fields remained stable following focal photocoagulation treatment. These results suggest that although focal treatment produces local absolute visual-field defects, the effects are small relative to the global indices.

An analysis of the effect of intravitreal blood on visual acuity.

We investigated the effect of diffuse hemorrhage on Snellen visual acuity in a model of vitreous hemorrhage in phakic and aphakic eyes. Two cylindrical test chambers with optical paths of 17 mm and 23 mm were constructed to simulate the effect of vitreous hemorrhage in phakic and aphakic eyes. The visual acuity was measured in two subjects in a double-masked fashion for 17 dilutions of whole blood between 1/100 and 1/12,800. The visual acuity decreased approximately linearly between the 1/800 and 1/4,800 dilutions of blood. The visual acuity was 20/20 in all dilutions of blood higher than 1/4,800. The visual acuity was reduced to hand motions or worse with 12.5 microliter of blood in the 5-ml test chamber under all test conditions. The visual acuity was 20/20 in all tests with 1.04 microliter of blood in the test chamber. The visual acuity decreased from 20/20 to hand motions with only a twelve-fold change in concentration of blood in the test chamber.

Paracentral acute middle maculopathy: precursor to macular thinning in sickle cell retinopathy

We present a case of paracentral acute middle maculopathy (PAMM) in a patient with sickle cell disease (SCD). Though gradual capillary loss may contribute to pathophysiology of sickle cell retinopathy as well, our case suggests that PAMM may be the precursor lesion to macular thinning commonly observed in patients with SCD. In addition, fluorescein angiography may be unable to detect these acute vascular events occurring at the deep capillary plexus.

Pathogenesis and Surgical Management of Common Geriatric Ophthalmic Disorders

Visual loss is a leading cause of morbidity in elderly patients in industrialized and developing countries. Decreased visual acuity interferes with activities such as reading, driving, walking without assistance, and numerous daily tasks that allow employment and independent living. It has been estimated that in the United States 10% of persons over the age of 75 years have a visual disability, and 2.2% over age 65 years are legally blind (defined as acuity of 20/200 or worse in the better eye or visual field constriction to less than 20 degrees).1–4 Many cases of legal blindness are preventable with early detection and treatment.5,6