Panayotis Zafirakis

Cytomegalovirus as a cause of anterior uveitis with sectoral iris atrophy

OBJECTIVE To report two cases of recurrent anterior uveitis with sectoral iris atrophy and ocular hypertension during attacks caused by cytomegalovirus (CMV). DESIGN Two observational case reports. PARTICIPANTS Two immunocompetent patients with a history of recurrent unilateral hypertensive anterior uveitis with sectoral iris atrophy were referred to us with the presumptive diagnosis of herpetic uveitis. MAIN OUTCOME MEASURES Comprehensive ophthalmic examination, aqueous humor polymerase chain reaction (PCR), and peripheral blood serologic studies were performed on both patients. RESULTS Examination of aqueous humor by PCR was positive for CMV and negative for herpesvirus. Serum IgG/IgM titers disclosed past CMV infection. Both patients responded well to antiviral therapy with ganciclovir. The final visual acuity level was 20/20 in both eyes of both patients. CONCLUSIONS CMV infection can produce recurrent attacks of anterior uveitis with clinical characteristics indistinguishable from those previously considered highly suggestive or even pathognomonic for herpetic infection. This observation has implications for the therapeutic management of such patients.

Corneal graft detachment without corneal edema after descemet stripping automated endothelial keratoplasty.

Purpose: To report the case of a patient who underwent Descemet stripping automated endothelial keratoplasty complicated by corneal graft detachment without corneal edema. Methods: Case report. Results: A 60-year-old man with bilateral decompensated endothelium 10 years after cataract extraction and anterior chamber intraocular lens implantation underwent combined anterior chamber intraocular lens explantation with iris-sutured posterior chamber intraocular lens implantation and Descemet stripping automated endothelial keratoplasty on the right eye. On the second postoperative day, the corneal graft was attached. Two weeks postoperatively, slit lamp examination revealed a double anterior chamber resulting from corneal graft detachment. The corneal graft was reattached by repositioning and injecting air. One week later, the corneal graft had detached again, creating a double anterior chamber. No corneal edema was present. Nine months postoperatively, the cornea remained clear, although a double anterior chamber was still evident as a result of the detached corneal graft. Conclusion: Despite post-Descemet stripping automated endothelial keratoplasty corneal graft detachment, the cornea remained without edema.

Medical treatment of macular edema in patients with uveitis.

Purpose: To determine the efficacy of medical treatment of cystoid macular edema (CME) in patients with uveitis. Methods: Retrospective study of 40 patients (57 eyes) with uveitis and CME. Inclusion criteria were presence of CME with minimal and no macular pathology, or vascular disease which could account for CME. Patients who had undergone intraocular surgery or had visual aucity (VA) of ≥20/40 were excluded. The diagnosis of CME was based on clinical and/or angiographic findings. Three treatment groups were defined: (1) transseptal injection of steroids (n=13 eyes); (2) systemic non steroidal anti-inflammatory drugs (NSAIDs) (n=11 eyes); both 1 and 2 (n=33 eyes). Results: Overall, 79% of eyes improved 3 or more lines of Snellen VA after treatment: 51% improved 4 or more lines. The average number of lines improved was 3.8 for eyes treated with transseptal injections of steroids, 2.9 for eyes treated with NSAIDs, and 4 for eyes treated with both. For all 3 treatment groups between 60–70% of eyes improving 2 or more lines reached best VA only after a minimum of 6 months of follow up. Conclusions: CME, a vision threatening complication of uveitis, respond fairly well to medical treatment; however, the best VA is achieved after several months. The improvement in VA did not differ markedly among the three treatment groups.

Human mast cell subtypes in conjunctiva of patients with atopic keratoconjunctivitis, ocular cicatricial pemphigoid and Stevens-Johnson syndrome

Purpose: Investigate mast cell (MC S ) subtypes in atopic keratoconjunctivitis (AKC), ocular cicatrical pemphigoid (OCP), and Stevens-Johnson Syndrome (SJS). Methods: MC S subtypes were determined by immunohistochemistry of conjunctiva (obtained from 34 patients – 9 AKC, 9 OCP, 9 SJS and 7 normal) using monoclonal antibodies directed against chymase (MC C ) and tryptase (MC T ). Double staining was used to distinguish MC S as positive for both chymase and tryptase (MC TC ). Results: The number of MC S was significantly increased in AKC, OCP and SJS patients, compared to normal subjects. MC C were especially high in AKC, and moderately high in OCP. MC T and MC TC were similar in each disease group. Conclusions: While the AKC findings were not surprising, the result in OCP and SJS suggests that MC S play an underappreciated role in the inflammatory process of these disorders. Disparate proportions of MC S subtypes in these diseases may imply differential functions of MC S in these disorders.

Herpes simplex virus type 2: a cause of acute retinal necrosis syndrome

PURPOSE: To describe a case of herpes simplex virus type 2 (HSV-2) acute retinal necrosis syndrome (ARN) in a 13-year-old immunocompetent girl. METHODS: Polymerase chain reaction (PCR), cultures, flow cytometry, and cytology were performed on the vitreous sample. RESULTS: Both PCR studies and vitreous cultures revealed HSV-2 as the cause of ARN. Flow cytometry showed CD4+, CD8+, and natural killer cells. The visual outcome of the patient was 20/200. CONCLUSION: Successful culture of HSV-2 from the vitreous specimen in a patient with ARN proved HSV-2 to be one of the causes of ARN. The successful culture of HSV-2 has not been previously reported.

Eosinophil activation in Wegener's granulomatosis: a harbinger of disease progression?

Purpose: To investigate the relation between eosinophil activation in tissue from patients with an active, limited form of Wegeners granulomatosis (WG) affecting the eye and subsequent systemic disease activity. Methods: Analysis of ocular specimens obtained from 10 patients was performed. Sections were probed with antibodies to assess the presence of major basic protein (MBP) and eosinophil cationic protein (ECP). Results: Four of the 10 specimens demonstrated the presence of MBP and ECP. WG progressed to the complete form in two of these patients, who received no or inadequate treatment. The other two, treated with cyclophosphamide for one year, did not progress to the complete form of WG during observation after therapy. Conclusions: Activated eosinophils in sclera or conjunctiva of patients with ocular limited WG may predict progression to complete WG.

Cystoid macular edema in a patient with acquired immunodeficiency syndrome and past ocular history of cytomegalovirus retinitis after initiation of protease inhibitors

Purpose: To describe a patient with acquired immunodeficiency syndrome (AIDS) who presented with cystoid macular edema (CME) which was not associated with active cytomegalovirus (CMV) retinitis or AIDS-related microvasculopathy. Method: A 32-year-old man with AIDS and a past ocular history of inactive CMV retinitis was placed on protease inhibitors when his CD4+ T lymphocyte counts dropped to 8 cells/mm3. Three months later, after his CD4+ T lymphocyte counts had increased to 196 cells/mm3 he complained of micropsia and metamorphopsia in his right eye of 1 week duration. The patient had a complete ocular examination including fluorescein angiography (FA). Results: Visual acuity (VA) was 7/10 OD. Fundus examination revealed CME and inactive CMV retinitis, and FA demonstrated CME and a hot disc. Two transseptal injections of corticosteroids were administered 2 weeks apart in the right eye as treatment of the CME. The patient reported gradual visual improvement and 6 weeks later, his VA was 10/10-2. CME had resolved clinically and angiographically. Conclusions: CME in our case is associated with inactive CMV retinitis and gradually increasing number of CD4+ T lymphocytes after initiation of treatment with protease inhibitors. It may be amenable to regional administration of corticosteroids without reactivation of retinitis.

Acute comitant esotropia after cataract surgery.

A 52-year-old woman developed comitant esotropia after cataract surgery. The ocular history was significant for accommodative esotropia; preoperatively, she manifested peripheral fusion with central suppression. Immediately postoperatively, the patient was diplopic with comitant esotropia and was treated with extraocular muscle surgery. The appearance of horizontal strabismus after cataract surgery in patients with a history of accommodative esotropia, especially those with subnormal binocularity, is a possible complication that should be discussed with the patient.