Lynn E. Harman

Cystoid macular edema associated with latanoprost in aphakic and pseudophakic eyes

PURPOSE To describe four patients who developed cystoid macular edema shortly after onset of treatment with latanoprost. METHOD Retrospective review of medical records of patients with open-angle glaucoma who developed cystoid macular edema shortly after starting latanoprost. RESULTS The use of topical latanoprost was temporally related to the development of cystoid macular edema in four patients (six eyes; two aphakic eyes and four pseudophakic eyes). Cystoid macular edema resolved in all patients after latanoprost was discontinued. CONCLUSIONS Cystoid macular edema is a potential complication of latanoprost therapy. Further observations are needed to determine if the risk of cystoid macular edema is limited to or greatest in patients who are pseudophakic or aphakic.

Fingolimod (FTY720) as an Acute Rescue Therapy for Intraocular Inflammatory Disease

OBJECTIVES To compare the inflammatory reaction associated with the insertion of silicone and polypropylene endplates and endplates made of a new biocompatible polymer, Vivathane, in the rabbit subconjunctival space. METHODS Similar-sized endplates made of 3 different biomaterials were sutured to the sclera in the superotemporal quadrant of the rabbit eye. Thirty eyes of 15 albino New Zealand rabbits were randomly assigned to the 3 groups. Conjunctival vascular hyperemia was graded in a masked fashion among groups. At the end of 3 weeks, the enucleated eyes were examined histologically and using scanning electron microscopy. RESULTS Polypropylene and Vivathane were associated with significantly more inflammation in clinical observations and based on histological grading. Silicone was associated with the least amount of inflammation. Three polypropylene and 1 Vivathane plate were extruded between the second and third week. CONCLUSIONS Silicone is the most inert of the 3 materials tested. Inflammation associated with biomaterials may contribute to the failure of the glaucoma drainage devices. CLINICAL RELEVANCE Bleb inflammation may be related to the biomaterial being used as the endplate. Endplates should be handled carefully during surgery to avoid creating rough spots.

Wegener's Granulomatosis

Clinical manifestations of Wegeners granulomatosis are nonspecific and indistinguishable from a variety of neoplastic, infectious, and inflammatory diseases. Ophthalmic disease is the presenting feature in nearly one sixth of patients with Wegeners granulomatosis and will ultimately develop in a majority. The discovery of antineutrophil cytoplasmic antibodies, particularly antiproteinase-3, has changed the clinical approach to evaluating patients suspected of having Wegeners granulomatosis. These antibodies are distinguished from other related autoantibodies because they produce a coarse granular pattern of cytoplasmic staining on indirect immunofluorescence with ethanol-fixed neutrophils. Treatment of Wegeners granulomatosis with oral cyclophosphamide and corticosteroids has decreased morbidity and improved survival, but side effects from long-term immunosuppressive therapy are common and sometimes serious. The effectiveness of trimethoprim-sulfamethoxazole in decreasing the number and severity of recurrences of Wegeners granulomatosis is being investigated. It remains to be determined if wide use of trimethoprim-sulfamethoxazole in limited Wegeners granulomatosis could further improve the quality of life for some patients.

Ocular Pseudoexfoliation and Cardiovascular Disease: A National Cross-Section Comparison Study

Background: Pseudoexfoliation is a systemic disorder characterized by the deposition of extracellular matrix material. The microfibrillar material that gives rise to the condition is visible clinically in the anterior segment of the eye, and is also found in other tissues, including blood vessels, skin, gallbladder, kidneys, lungs, and heart. Aims: The present study aims to determine whether ocular pseudoexfoliation is associated with selected cardiovascular diseases. Materials and Methods: A cross-section comparison study was conducted with the help of the Veterans Health Administration databases, using the International Classification of Diseases, Ninth revision, Clinical Modification for pseudoexfoliation of lens capsule and pseudoexfoliation glaucoma. Selected cardiovascular diseases and risk factors for cardiovascular disease were identified using the appropriate medical codes. Patients with primary open-angle glaucoma, chronic sinusitis, and benign prostatic hyperplasia served as the comparison groups. A logistic regression model was used to control for age, gender, race, and major cardiovascular risk factors. Results: There were 6,046 case patients with pseudoexfoliation; approximately half were diagnosed with pseudoexfoliation glaucoma. Various stages of ischemic heart disease, cardiomyopathy, and aortic aneurysm were significantly associated with ocular pseudoexfoliation, after controlling for age, gender, race, and major cardiovascular risk factors. Associations, in general, were less demonstrable relative to the primary open-angle glaucoma comparison group. Conclusion: Associations of ocular pseudoexfoliation with cardiovascular diseases were generally fewer and less pronounced when compared to patients with primary open-angle glaucoma. These results add to the results of earlier studies, which suggest that open-angle glaucoma itself might be a risk factor for certain cardiovascular disorders.

The Reliability of Clinical Methods in Ophthalmology

The reliability of clinical methods is often taken for granted. There is considerable evidence, however, that variability of clinical measurements, interpretations, and judgements are greater than commonly thought. Inconsistency of clinical methods has profound and widespread implications in clinical practice. The inferential capacity of measurements depends on accuracy and reproducibility. Appropriate medical decisions cannot be reached without accurate and reliable data. This review will examine the conceptual relationship of reliability, accuracy, and validity. The role of observer reliability in ophthalmic test measurements and interpretations will be addressed in the context of three case reports.

Posterior vitreous detachment : How to approach sudden-onset floaters and flashing lights

PREVIEW Acute posterior vitreous detachment (PVD) is the most common cause of unilateral floaters and flashing lights. These visual experiences are frightening to the patient, and they are usually accompanied by few, and often subtle, physical findings on eye examination. Patients with symptomatic PVD are at risk for retinal detachment and vision loss. In this article, the authors discuss the evaluation and management of unilateral floaters and flashing lights.

Substance use disorder and the risk of open-angle glaucoma.

PurposeTo test the hypothesis that cocaine use (abuse and/or dependency) is associated with open-angle glaucoma. MethodsA case-control study. Potential case patients were identified from the Veterans Health Administration national clinical database using International Classification of Disease, Version 9, Clinical Modification for open-angle glaucoma for fiscal year 2009. Inclusion criteria included consecutive prescriptions for 1 or more topical antiglaucoma medications. Cocaine exposure was identified through International Classification of Disease, Version 9, Clinical Modification codes. The odds of cocaine exposure were compared with the overall outpatient population of national Veterans Health Administration beneficiaries and adjusted for age and other illicit drug use. A nested case-control study was conducted to examine the confounding influence of race. ResultsAge-adjusted odds ratios of cocaine exposure among patients with glaucoma were statistically significant for both men [3.52 (95% confidence interval, CI: 3.21-3.86)] and women [1.87 (95% CI: 1.79-1.96)], and did not change significantly when analyzed according to drug-dependency status. Subset analysis adjusted for age, other illicit drugs, and race remained significant for men [1.45 (95% CI: 1.27-1.66)], but not women. Persons with substance use disorder and glaucoma were nearly 18 years younger than glaucoma patients without a drug exposure history. ConclusionsThis pilot study suggests the use of cocaine and possibly other illicit drugs are predictive of glaucoma. Should the association of substance use disorder (cocaine or cocaine/poly-drug abuse) and open-angle glaucoma be verified, it represents a potentially modifiable risk factor for vision loss.

Autoimmune disease: Conceptual history and contributions of ocular immunology

Medical historians identify the mid-20th century as the time when the scientific and medical communities acknowledged the existence of autoimmune disease. Several conditions including sympathetic ophthalmia and endophthalmitis phacoanaphylactica, however, were proposed as autoimmune disorders much earlier. During the first half of the century, autoimmune disease was viewed as biologically implausible. Paul Ehrlich coined the term horror autotoxicus to emphasize that autoimmunity would contradict natures aversion to self-injury. The discoveries of allergy and anaphylaxis were the first clues that the immune system was capable of self-harm. A major obstacle to comprehending the pathogenesis of autoimmunity was how the immune system distinguishes foreign from self, a process eventually understood in the context of immune tolerance. Investigators of sympathetic ophthalmia and endophthalmitis phacoanaphylactica were positioned to invalidate horror autotoxicus but lacked sufficiently convincing experimental and clinical evidence to accomplish the task. Seminal studies of chronic thyroiditis and a series of clinical laboratory breakthroughs led to the general acceptance of autoimmune disease in the 1950s. The travails encountered by ophthalmic investigators offer insights into the how medical ideas take shape. We review the contributions of ocular immunology to the conceptual development of autoimmune disease and explore the reasons why the concept caught on slowly.

Pathology of the Vitreous

The vitreous is a watery, loose connective tissue whose properties are appropriately suited to serve as optical medium, mechanical buffer, and interface to the neurosensory retina. The seemingly simple, water-rich composition of the vitreous belies its physiological complexity. At times referred to as vitreous humor or vitreous body, this clear medium is rarely the site of primary disease but is susceptible to a variety of injuries and degenerations that can adversely affect vision directly or through interactions with adjacent tissues.

Retinoblastoma: Although treatment outcomes for retinoblastoma have improved, patients with a germline gene mutation carry a high risk for second cancers.

BackgroundRetinoblastoma is the most common intraocular malignancy of infants and children. With early diagnosis and treatment, survival is greater than 90%; however, patients with a germline retin...