Mark C. Kuperwaser

Relapsing Acute Myeloid Leukemia Manifesting as Hypopyon Uveitis

PURPOSE Although acute lymphoblastic leukemia may masquerade as hypopyon uveitis, acute myeloid leukemia has only rarely been reported to cause this complication, and ocular relapse generally has been associated with evidence of malignant cells at other sites. We studied a patient with acute myeloid leukemia whose only sign of relapse was bilateral anterior uveitis with pseudohypopyon that was refractory to topical and systemic corticosteroids. METHODS A 26-year-old woman with acute myeloid leukemia in remission, who had bilateral anterior uveitis and increased intraocular pressure at initial examination, was studied clinically. Blood films, bone marrow smears, and preparations were examined by using immunoperoxidase staining. RESULTS Although there was no evidence of leukemia in the blood or bone marrow samples, the cells obtained from the anterior chamber showed myeloblastic leukemic cells with morphologic characteristics similar to those present in the original bone marrow biopsy obtained 14 months previously. Irradiation and chemotherapy were used to kill the malignant cells in the eye and central nervous system. The persisting glaucoma resolved after anterior chamber washout of necrotic tumor cells. CONCLUSIONS Unusual features of uveitis in this patient indicated that she had a masquerade syndrome, despite normal results of bone marrow and blood film tests. Aspiration of intraocular cellular infiltrate for cytopathologic examination was required to obtain the correct diagnosis and enable treatment to commence without delay.

Comparison of Combined Cataract and Glaucoma Surgery Using Planned Extracapsular and Phacoemulsification Techniques

BACKGROUND AND OBJECTIVE The surgical management of coexisting cataract and glaucoma is a common problem for the ophthalmologist. PATIENTS AND METHODS We evaluated intraocular pressure (IOP) reduction and bleb formation in combined cataract and filtration surgery, comparing planned extracapsular cataract extraction (ECCE) and phacoemulsification approaches coupled with similar trabeculectomy techniques. Seventy-two eyes with primary open-angle or pseudoexfoliation glaucoma underwent combined cataract and filtration surgery. Thirty-five eyes underwent planned ECCE, intraocular lens (IOL) implantation, and trabeculectomy, and 37 eyes underwent phacoemulsification, IOL implantation and trabeculectomy. Minimum follow-up for both groups was 1 year with a mean of 16 months. RESULTS The mean IOP reduction for phacoemulsification/trabeculectomy eyes (5.0 +/- 4.3 mm Hg) was significantly lower than the mean IOP reduction for ECCE/trabeculectomy eyes (2.9 +/- 4.1 mm Hg; P < 0.03). There was no significant difference between the groups in terms of visual acuity improvement or glaucoma medication reduction. CONCLUSION Combined cataract and filtration surgery using phacoemulsification is associated with greater IOP reduction than combined surgery using ECCE.

Surgical outcomes after epiretinal membrane peeling combined with cataract surgery

Objective To compare functional and anatomical outcomes after idiopathic epiretinal membrane (ERM) peeling combined with phacoemulsification and intraocular lens implantation versus ERM peeling alone. Methods A retrospective, non-randomised comparative case series study was conducted of 81 eyes from 79 patients who underwent ERM peeling at the Beth Israel Deaconess Medical Center between 2001 and 2010. Eyes that underwent combined surgery for ERM and cataracts (group 1) were compared with those that had ERM peeling alone (group 2) with respect to best-corrected visual acuity at 6 months and 1 year after surgery, postoperative central macular thickness (CMT) as measured on optical coherence tomography, and rates of complications, including elevated intraocular pressure (IOP), ERM recurrence and need for reoperation. Results Mean logMAR visual acuity improved significantly in both groups at 6 months (p<0.001) and 1 year (p<0.001) after surgery. There was no statistical difference between the two groups in visual acuity improvement at 6 months (p=0.108) or 1 year (p=0.094). Mean CMT of both groups also significantly decreased after surgery (p=0.002), with no statistical difference in CMT reduction between the two groups, but a trend toward less CMT reduction in group 1 (p=0.061). The rates of complications, including IOP elevation, ERM recurrence and frequency of reoperation, were similar in the two groups, with non-statistical trends toward greater ERM recurrence (p=0.084) and need for reoperation (p=0.096) in those that had combined surgery. Conclusions Combined surgery for ERMs and cataracts may potentially be as effective as membrane peeling alone with respect to visual and anatomical outcomes. Further studies are necessary to determine if there may be greater ERM recurrence or need for reoperation after combined surgery.

Ocular Blast Injuries in Mass-Casualty Incidents: The Marathon Bombing in Boston, Massachusetts, and the Fertilizer Plant Explosion in West, Texas

PURPOSE To report the ocular injuries sustained by survivors of the April 15, 2013, Boston Marathon bombing and the April 17, 2013, fertilizer plant explosion in West, Texas. DESIGN Multicenter, cross-sectional, retrospective, comparative case series. PARTICIPANTS Seventy-two eyes of 36 patients treated at 12 institutions were included in the study. METHODS Ocular and systemic trauma data were collected from medical records. MAIN OUTCOME MEASURES Types and severity of ocular and systemic trauma and associations with mechanisms of injury. RESULTS In the Boston cohort, 164 of 264 casualties were transported to level 1 trauma centers, and 22 (13.4%) required ophthalmology consultations. In the West cohort, 218 of 263 total casualties were transported to participating centers, of which 14 (6.4%) required ophthalmology consultations. Boston had significantly shorter mean distances to treating facilities (1.6 miles vs. 53.6 miles; P = 0.004). Overall, rigid eye shields were more likely not to have been provided than to have been provided on the scene (P<0.001). Isolated upper body and facial wounds were more common in West largely because of shattered windows (75.0% vs. 13.6%; P = 0.001), resulting in more open-globe injuries (42.9% vs. 4.5%; P = 0.008). Patients in Boston sustained more lower extremity injuries because of the ground-level bomb. Overall, 27.8% of consultations were called from emergency rooms, whereas the rest occurred afterward. Challenges in logistics and communications were identified. CONCLUSIONS Ocular injuries are common and potentially blinding in mass-casualty incidents. Systemic and ocular polytrauma is the rule in terrorism, whereas isolated ocular injuries are more common in other calamities. Key lessons learned included educating the public to stay away from windows during disasters, promoting use of rigid eye shields by first responders, the importance of reliable communications, deepening the ophthalmology call algorithm, the significance of visual incapacitation resulting from loss of spectacles, improving the rate of early detection of ocular injuries in emergency departments, and integrating ophthalmology services into trauma teams as well as maintaining a voice in hospital-wide and community-based disaster planning.

Care of Older Adults: Role of Primary Care Physicians in the Treatment of Cataracts and Macular Degeneration.

This article aims to facilitate optimal management of cataracts and age‐related macular degeneration (AMD) by providing information on indications, risk factors, referral guidelines, and treatments and to describe techniques to maximize quality of life (QOL) for people with irreversible vision loss. A review of PubMed and other online databases was performed for peer‐reviewed English‐language articles from 1980 through August 2012 on visual impairment in elderly adults. Search terms included vision loss, visual impairment, blind, low vision, QOL combined with age‐related, elderly, and aging. Articles were selected that discussed vision loss in elderly adults, effects of vision impairment on QOL, and care strategies to manage vision loss in older adults. The ability of primary care physicians (PCPs) to identify early signs of cataracts and AMD in individuals at risk of vision loss is critical to early diagnosis and management of these common age‐related eye diseases. PCPs can help preserve vision by issuing aptly timed referrals and encouraging behavioral modifications that reduce risk factors. With knowledge of referral guidelines for soliciting low‐vision rehabilitation services, visual aids, and community support resources, PCPs can considerably increase the QOL of individuals with uncorrectable vision loss. By offering appropriately timed referrals, promoting behavioral modifications, and allocating low‐vision care resources, PCPs may play a critical role in preserving visual health and enhancing the QOL for the elderly population.

IS LINEAR ANALYSIS SUFFICIENT TO REVEAL ABNORMALITIES OF THE VISUAL SYSTEM UNDER DICHOPTIC STIMULATION CONDITIONS

Measurement of evoked potentials with low signal-to-noise ratios usually is carried out with conventional signal averaging. For visual evoked potentials repetitive stimuli are used, with timing intervals of the order of one-half to one second. Thus the first few hundred milliseconds of the averaged response can be viewed as the visual system’s impulse response to a single stimulus. Because of the anatomic intermixing of the nerve transmission pathways from the two eyes, this type of measurement has to be carried out testing one eye at a time (monocular test condition). Some use has been made of steady-state VER testing, using fixed rate repetitive stimuli (e.g., flash stimuli a t 30 Hz). In such cases it is possible to stimulate each eye independently by using two sets of stimuli at slightly different frequencies.’ Thus the system is being tested under steady-state conditions with two fixed but different frequencies. While this does allow some degree of resolution of the steady-state responses from the two eyes, a more general approach to obtaining dichoptic VER measurements would be to stimulate each eye separately using independent stimuli covering a range of frequencies. Provided that the timing of the two sets of stimuli is randomized, then cross-correlation analysis allows the recovery of VER responses representing the impulse-response of the visual system to each of the two sets of noiselike stimuli. It is of interest to ask whether linear cross-correlation analysis of such dichoptically induced VERs demonstrates the same type of behavior of the visual system as observed under conditions of monocular stimulation, and whether the dichoptic test results suggest the existence of a significant degree of cross-coupling between the two visual pathways. For some years now we have been applying cross-correlation techniques to the measurement of VERs (and ERGS) in human subjects.’X3 For VER measurements either flash stimuli or video presentations of alternating checkerboards have been used. Regardless of the type of stimulus used the timing of the stimulus occurrenceflash or pattern-alternation-is controlled by a pseudorandom binary sequence, so that the intervals between stimuli vary in a statistically definable manner. The use of two independent pseudorandom binary sequences to control two separate stimulus presentations permits “true” dichoptic stimulation of the two eyes! With this test arrangement the subject views two similar but independently driven displays-one for each eye. The amplified occipital signal, measured from a single pair of midline electrodes, then is cross-correlated with each of two independent reference waveforms, corresponding to the two independent pseudorandom binary sequences used to control the stimuli. The two cross-correlation VERs obtained in this manner from the occipital signal represent the first.-order responses of the visual system to the stimuli presented to each eye. Using a “true” dichoptic stimulation system, we can investigate differences in the

Advantages of a Cross-Correlation Technique for ERG Measurement in Children

The measurement of ERGs of infants and children suspected of having retinal dysfunction can present some significant practical problems. Often the degree of cooperation is less than ideal, the stimulus actually reaching the retina may vary, and the level of background electrical activity can mask small responses. Single flash ERGs often are not adequate in such circumstances, and usually it is advantageous to use some form of noise reduction. Conventional averaging techniques can be used, but one disadvantage is the time required to average a significant number of responses. The use of rapid, pseudorandomly timed stimuli and a cross-correlation signal recovery procedure offers some theoretical and practical advantages. Usually a better defined response (with a higher signal-to-noise ratio) can be obtained in a relatively short time, sometimes in a few seconds. In addition, the pseudorandomly timed flash stimuli inherently contain a wide range of frequencies, so that in effect the frequency response of the outer layers of the retina is being measured. Some clinical examples will be described to illustrate the practical application of this procedure for measuring the cone and rod ERGs of young patients.