Nancy Kunjukunju

Antioxidant Drug Therapy Approaches for Neuroprotection in Chronic Diseases of the Retina

The molecular pathways contributing to visual signal transduction in the retina generate a high energy demand that has functional and structural consequences such as vascularization and high metabolic rates contributing to oxidative stress. Multiple signaling cascades are involved to actively regulate the redox state of the retina. Age-related processes increase the oxidative load, resulting in chronically elevated levels of oxidative stress and reactive oxygen species, which in the retina ultimately result in pathologies such as glaucoma or age-related macular degeneration, as well as the neuropathic complications of diabetes in the eye. Specifically, oxidative stress results in deleterious changes to the retina through dysregulation of its intracellular physiology, ultimately leading to neurodegenerative and potentially also vascular dysfunction. Herein we will review the evidence for oxidative stress-induced contributions to each of the three major ocular pathologies, glaucoma, age-related macular degeneration, and diabetic retinopathy. The premise for neuroprotective strategies for these ocular disorders will be discussed in the context of recent clinical and preclinical research pursuing novel therapy development approaches.

Spontaneous choroidal hemorrhage in a patient on dabigatran etexilate (Pradaxa).

PURPOSE To report the first known case of spontaneous choroidals in association with a patient on dabigatran etexilate. METHODS Observational case report. RESULTS An 82-year-old man on 150 mg dabigatran etexilate by mouth twice a day for atrial fibrillation developed spontaneous choroidal hemorrhage in his left eye. No other causes were found after careful history and examination. CONCLUSION Dabigatran is a popular new alternative to warfarin that has no blood monitoring or reversal agent. Physicians should be aware of this new medication and its possible hemorrhagic complications.

Clinical application of optical coherence tomography in combination with functional diagnostics: advantages and limitations for diagnosis and assessment of therapy outcome in central serous chorioretinopathy

Purpose While identifying functional and structural parameters of the retina in central serous chorioretinopathy (CSCR) patients, this study investigated how an optical coherence tomography (OCT)-based diagnosis can be significantly supplemented with functional diagnostic tools and to what degree the determination of disease severity and therapy outcome can benefit from diagnostics complementary to OCT. Methods CSCR patients were evaluated prospectively with microperimetry (MP) and spectral domain optical coherence tomography (SD-OCT) to determine retinal sensitivity function and retinal thickness as outcome measures along with measures of visual acuity (VA). Patients received clinical care that involved focal laser photocoagulation or pharmacotherapy targeting inflammation and neovascularization. Results Correlation of clinical parameters with a focus on functional parameters, VA, and mean retinal sensitivity, as well as on the structural parameter mean retinal thickness, showed that functional measures were similar in diagnostic power. A moderate correlation was found between OCT data and the standard functional assessment of VA; however, a strong correlation between OCT and MP data showed that diagnostic measures cannot always be used interchangeably, but that complementary use is of higher clinical value. Conclusion The study indicates that integrating SD-OCT with MP provides a more complete diagnosis with high clinical relevance for complex, difficult to quantify diseases such as CSCR.

nampt/PBeF/visfatin serum levels: a new biomarker for retinal blood vessel occlusions

The main objective of the study was to quantify serum levels of nicotinamide phosphoribosyltransferase (Nampt/pre-B-Cell colony-enhancing factor 1/visfatin) in subjects with a history of retinal vascular occlusions (RVOs), disease conditions characterized by pronounced ischemia, and metabolic energy deficits. A case–control study of 18 subjects with a history of RVO as well as six healthy volunteers is presented. Serum Nampt levels were quantified using a commercially available enzyme-linked immunosorbent assay kit. Serum Nampt levels were 79% lower in patients with a history of RVO compared with that in healthy volunteers (P<0.05). There was no statistically significant difference among the types of RVOs, specifically branch retinal vein occlusions (n=7), central retinal vein occlusions (n=5), hemiretinal vein occlusions (n=3), and central retinal artery occlusions (n=3; P=0.69). Further studies are needed to establish the temporal kinetics of Nampt expression and to determine whether Nampt may represent a novel biomarker to identify at-risk populations, or whether it is a druggable target with the potential to ameliorate the long-term complications associated with the condition, ie, macular edema, macular ischemia, neovascularization, and permanent loss of vision.

Recombinant tissue plasminogen activator in the treatment of suprachoroidal hemorrhage.

Background: Suprachoroidal hemorrhages are a vision-threatening complication, and poor visual outcome is correlated with increasing hemorrhage complexity. The recommended time of surgical drainage is 10–14 days after the hemorrhage begins to liquefy. We describe a case in which recombinant tissue plasminogen activator (r-tPA), alteplase, is injected within the suprachoroidal space before surgery to assist in the drainage of an organized clot prior to liquefaction. This is a report of a technique in which r-tPA is used in the intrachoroidal space to target the organized clot of suprachoroidal hemorrhage prior to drainage. Case report: A 62-year-old male presented 12 days after retinal detachment repair with sudden ocular pain and vision loss after a Valsalva maneuver. Vision was light perception only, and intraocular pressure was 43 mmHg. Diagnosed with hyphema and suprachoroidal hemorrhage, the patient underwent surgery the following day. An injection of r-tPA 100 μg was given intracamerally, and an additional dose of r-tPA 100 μg was injected into the suprachoroidal space prior to surgery. Liquified by r-tPA, the clot was expressed through the sclerotomies. Best corrected vision in the eye eight months after the drainage procedure was 20/40. Conclusion: To the author’s knowledge, this is the first reported case in which r-tPA was successfully injected in the suprachoroidal space to liquefy and drain a suprachoroidal hemorrhage prior to natural dissolution.

A rare case of odontogenic parainfectious intraorbital optic neuritis with the absence of clinical manifestation of orbital cellulitis.

PURPOSE To report the case of a 67-year-old male patient with odontogenic maxillary sinusitis who presented with unilateral parainfectious intraorbital optic neuritis without clinical signs and symptoms suggestive of orbital cellulitis. Despite the absence of clinical signs, taking a thorough history and obtaining the appropriate neuroimaging study raised the suspicion for an infectious etiology as the cause of optic neuropathy and stopped the continuation of corticosteroid treatment. METHODS Retrospective case report. RESULTS The only abnormal findings in the ophthalmic examination were acute decrease visual acuity, inferior visual field loss, and the presence of a relative afferent pupillary defect. A gadolinium contrast-enhanced magnetic resonance imaging scan showed ill-defined diffuse enhancement of the left intraorbital optic nerve and sheath with mild perineural fat stranding and enlargement of the inferior rectus muscle. There was also complete opacification of the ipsilateral maxillary sinus with peripheral enhancement, suggestive of a sinus abscess. CONCLUSION Prompt arrival to the diagnosis led to expedient implementation of treatment comprising of broad-spectrum intravenous antibiotics and maxillary sinus irrigation by otolaryngology ultimately resulted in restoring the patients vision back to baseline with complete resolution of the relative afferent pupillary defect.

Macular infarction secondary to Staphylococcus epidermidis infection.

PURPOSE To describe a patient with macular infarction caused by Staphylococcus epidermidis-induced endophthalmitis. METHODS Case report. RESULTS An 88-year-old woman was referred to our clinic for endophthalmitis after cataract extraction. She was diagnosed to have an S. epidermidis infection. Her vision dropped from 20/50 to hand motions. During the course of her infection, she developed multiple multifocal branch retinal artery occlusions associated with absolute capillary nonperfusion centrally and was diagnosed with macular infarction. CONCLUSION Although most commonly associated with aminoglycoside toxicity, macular infarction can occur after endophthalmitis treatment without the use of aminoglycosides.

Exudative retinal detachment and angle closure glaucoma as the presenting signs of primary pulmonary hypertension.

BACKGROUND Primary pulmonary arterial hypertension is a rare systemic condition that may present with distinct ocular findings. PURPOSE To report a patient whose ophthalmic manifestations led to a diagnosis of pulmonary arterial hypertension. RESULTS A 58-year-old woman presented with bilateral serous detachments, angle closure, dilated episcleral blood vessels, subretinal drusenoid-like deposits, and intraretinal hemorrhages. She was diagnosed with pulmonary arterial hypertension. Her ocular findings resolved once her underlying systemic disorder had been treated. CONCLUSION To our knowledge, this is the first reported case in which an ophthalmic evaluation led to the diagnosis of pulmonary arterial hypertension.