Radgonde Amer

Spectral domain optical coherence tomography findings in patients with acute syphilitic posterior placoid chorioretinopathy.

Purpose: To describe the appearance of acute syphilitic posterior placoid chorioretinitis, a rare ocular manifestation of syphilis, on spectral domain optical coherence tomography (SD OCT) both before and after treatment. Methods: Ophthalmic examination and imaging studies of 30 eyes of 19 confirmed cases were analyzed both at the time of presentation and at each follow-up visit. Patients with SD OCT and fluorescein angiography at the time of presentation, and at least three documented follow-up visits after initiation of therapy, were included in the study. Standard treatment of neurosyphilis was given to each patient, including 4 million units of penicillin G administered intravenously every 4 hours for 14 days. Results: Fundus examination and imaging studies were consistent with previous reports and confirmed the diagnosis of acute syphilitic posterior placoid chorioretinitis. In 13 eyes (43.3%), baseline SD OCT scans were performed within 1 to 2 days of presentation and revealed a small amount of subretinal fluid, disruption of the inner segment/outer segment junction, and hyperreflective thickening of the retinal pigment epithelium (RPE). All 30 eyes were again scanned between Days 7 and 9 after presentation and revealed loss of the inner segment/outer segment and OS/RPE bands, and irregular hyperreflectivity of the RPE with prominent nodular elevations but without subretinal fluid. Early disruption of the external limiting membrane and punctate choroidal hyperreflectivity were seen in 1 of the 30 eyes (3.3%) and 14 of the 30 eyes (46.6%), respectively. Vision improved and the outer retinal abnormalities normalized in 28 of the 30 eyes (93.3%) after the treatment of neurosyphilis. The external limiting membrane, inner segment/outer segment band, and/or linear outer segment/RPE junction remained substantially abnormal despite treatment in 2 eyes left with 20/200 vision. Conclusion: Patients with acute syphilitic posterior placoid chorioretinitis show characteristic outer retinal abnormalities on SD OCT imaging, including disruption of the inner segment/outer segment band, nodular thickening of the RPE with loss of the linear outer segment/RPE junction, and, in some cases, loss of the external limiting membrane, accumulation of subretinal fluid, and punctate hyperreflectivity in the choroid. Vision improved and these abnormalities reversed after treatment of neurosyphilis in most of the patients. Persistently, poor vision despite treatment was associated with long-term loss or disruption of outer retinal anatomy on SD OCT.

Punctate Inner Choroidopathy

Punctate inner choroidopathy (PIC) is a relatively uncommon inflammatory multifocal chorioretinopathy that affects predominantly young myopic women. It is characterized by the presence of multiple, small, well-defined, yellow-white fundus lesions frequently limited to the posterior pole in the absence of flare and inflammatory cells in the anterior chamber or vitreous cavity. Most patients with PIC do not require treatment, as the disease does not often threaten vision; however, when subfoveal choroidal neovascular membrane (CNV) ensues, patients usually lose sight rapidly, requiring immediate care. Treatment modalities that have been used to manage patients with PIC and subfoveal CNV include systemic and local steroids, other immunosuppressant agents, laser photocoagulation, photodynamic therapy, submacular surgery and, most recently, anti-vascular endothelial growth factor therapy. To date, however, there is no clear consensus on the effective therapy. Further research into this area, as well as on the cause and possible predisposing factors for PIC, is warranted.

Treatment options in the management of choroidal metastases.

We performed a retrospective study of 40 consecutive patients (50 eyes) treated for choroidal metastases of solid systemic malignancies in order to evaluate treatment results. Patients received either systemic or local therapy or a combination of both. The most common primary tumor was breast carcinoma (62.5%). Systemic chemotherapy alone was used in 13.3% of eyes, local therapy alone in 44.4%, and a combination of both in 42.2% of eyes. Local treatment modalities included brachytherapy, external beam irradiation, and laser photocoagulation. Complete regression of the choroidal metastases was seen in 57.8% of eyes, partial regression in 15.6 and no response in 4.4%; 22.2% were not available for re-evaluation. We have concluded that the treatment modality in patients with metastatic ocular disease should be individually tailored. When ocular metastases are concurrent with widespread metastatic disease, systemic chemotherapy alone or in combination with local therapy is reasonable. In patients manifesting metastases in the eyes alone, local therapy modalities may be safe, allowing conservation of visual functions with minimal systemic morbidity.

Bevacizumab for choroidal neovascularization related to inflammatory diseases.

Purpose:The purpose of this study was to report our experience with intravitreal bevacizumab for inflammation-related choroidal neovascularization in two tertiary centers. Methods:This study was a retrospective analysis of patients with choroidal neovascularization related to inflammatory diseases, treated with intravitreal bevacizumab injections (1.25 mg/0.05 mL). Results:Ten eyes of 10 patients (range, 14-78 years; mean age, 44 years) with underlying uveitis were treated with intravitreal bevacizumab for inflammation-related choroidal neovascularization from 2006 to 2008. Mean follow-up time was 13 ± 8 months, and the mean number of injections was 2.7 ± 2. Resolved leakage on fluorescein angiography and resolution of subretinal fluid on optical coherence tomography occurred in all patients, with improvement in visual acuity in 9 of 10 eyes and no change in visual acuity in 1 of 10 eyes. Seven patients received additional treatment based on the underlying condition. Mean macular thickness on optical coherence tomography decreased from 394 ± 116 μm to 254 ± 52 μm (P < 0.01). Mean visual acuity improved from 0.87 ± 0.74 logarithm of the minimum angle of resolution to 0.38 ± 0.63 (P = 0.005). Seven patients reached a visual acuity of 0.2 logarithm of the minimum angle of resolution (Snellen 6/9) or better. Conclusion:Intravitreal bevacizumab is an effective treatment for choroidal neovascularization related to inflammatory diseases when inflammation is controlled.

Retinal artery occlusion due to Bartonella henselae infection: a case series.

To report a case series of six patients suffering from branch retinal artery occlusion due to Bartonella henselae infection, in order to raise awareness to this etiology in the differential diagnosis of retinal artery occlusion.

Usher syndrome associated with Fuchs’ heterochromic uveitis

BackgroundThe purpose of this study is to report two new cases of Usher syndrome associated with Fuchs’ heterochromic uveitis (FHU), to confirm our previous observation of the association between FHU and retinitis pigmentosa (RP), and to evaluate if FHU is particularly associated with Usher syndrome.MethodsRetrospective medical record review of all new RP cases at Hadassah Medical Center between the years 2000 and 2007, review of our previously published data, and a meta-analysis of published relevant articles in peer reviewed journals.ResultsDuring the time frame of the study we diagnosed 58 new cases of RP, of whom one male and one female had the typical findings of FHU, and both had Usher syndrome type II. The difference in the occurrence of FHU between the 616 controls and the patients with RP was significant (p = 0.0073, Fishers exact test). In our combined data, FHU occurred only in two types of RP; RP simplex with an incidence of 0.57%, and Usher syndrome with an incidence of 13.5%. This difference between the incidence of FHU in patients with Usher syndrome and other types of RP was significant (p < 0.0001, Fishers exact test). Adding up these two cases with what is already published in the literature makes up a total of 17 RP patients with coexisting FHU.ConclusionsThis study confirms the association between FHU and RP; and a particularly stronger association with Usher syndrome type II. Although infectious agents seem to play a role, the cause for this significant correlation is still unclear.

Paradoxical response in ocular bartonellosis

IntroductionCat scratch disease is an infectious disease caused by thebacteria Bartonella henselae [1] and is transmitted by catscratches or exposure to cat saliva. The spectrum of itsocular manifestations includes Parinauds oculoglandularsyndrome, iritis, vitritis, neuroretinitis, panuveitis, retinitisappearing as small white intraretinal infiltrates, and choroi-dal white lesions [1, 2]. B. henselae is reported to be themost common cause of neuroretinitis; typically character-ized by optic disk edema in association with a partial orcomplete macular star. The majority of infected patientspresenting with neuroretinitis reported in the literature aretreated with antibiotics. In some cases steroids were added.However several reports showed that even patients who didnot receive treatment had an excellent visual outcome [1].We describe here a paradoxical response to treatment in ayoung female presenting with bilateral neuroretinitis andinflammatory optic disk lesions.Case reportA 19-year-old healthy female presented with an abruptdeterioration of left eye vision of 1-day duration. For10 days prior to presentation, she was suffering from drycough; 5 days later she had intermittent fever up to 41°Cwith shaking chills. There was a history of contact with acat, but she denied being scratched. On admission, physicaland neurologic examinations were unremarkable. Ophthal-mologic assessment disclosed visual acuity of 4/4 in theright eye and 4/60 in the left eye. She had normal anteriorsegments and intraocular pressures. A left afferent pupillarydefect was noted. Funduscopy of the right eye showed asmall white optic disk lesion in its temporal aspect with adeep retinal white lesion along the superonasal arcade(Fig. 1). The left optic disk had blurred margins with biggerwhite lesions in its nasal and temporal aspects with anassociated localized vitreous opacity on its surface (Fig. 1).There was marked macular edema and two deep retinalwhite lesions along the superotemporal arcade and infer-onasal to the optic disk. Optical coherence tomography(OCT) revealed intraretinal fluid in the right papillomacularbundle and left exudative macular detachment (Fig. 2).Visual field examination showed right nasal step andsuperonasal arcuate defect while there was enlargement ofthe left blind spot with nasal step (Fig. 3). Work-uprevealed mild anemia with hemoglobin of 11.7 g% andleukocytosis of 14,800 (lymphocytes, 31%). Kidney andliver functions were within normal limits except for aslightly elevated lactate dehydrogenase at 768 (normalrange, 300–620 u/l). She had elevated erythrocyte sedi-mentation rate (ESR) (90 mm/h) and C-reactive protein(5.3 mg%; normal range, less than 1). Chest X-ray did notreveal any pathological findings, and CT scan and MRI ofthe head and brain showed mild thickening of the opticnerves bilaterally and hyperintense foci in the flairsequences in the intraocular aspects of the optic nerves,respectively. Cerebrospinal fluid cytology was normal.Serological tests were negative for HIV, syphilis, Brucella,Coxiella burnetti, toxoplasma, and toxocara. Serologicaltests for B. henselae revealed positive IgM titer at 75 units

Carcinoembryonic Antigen Cell Adhesion Molecule-1 (CEACAM1) in Posterior Uveal Melanoma: Correlation with Clinical and Histological Survival Markers

PURPOSE Carcinoembryonic antigen cell adhesion molecule (CEACAM)-1 is a multi-functional protein, with strong predictive value for poor prognosis when found in primary cutaneous melanoma lesions. In this study, the expression of CEACAM1 in uveal melanoma was correlated with clinicopathologic parameters. METHODS CEACAM1 expression was immunohistochemically evaluated in 79 primary uveal melanomas and 21 liver metastases of patients who were treated at the Hadassah-Hebrew University Medical Center between the years 1986 and 2006. The findings were correlated with location, cell type, extracellular matrix patterns, tumor size, and metastatic disease. RESULTS CEACAM1 was expressed in 45% of the primary tumors compared with 81% of the metastases (Fishers exact test, P = 0.003). There was no significant association between CEACAM1 and location of the primary tumors. Histologically, CEACAM1 was associated with epithelioid-type tumors (69.6%), but not with spindle-type tumors (25.0%) (Cramers V = 0.354; P = 0.019). Also it was significantly associated with network extracellular matrix pattern (73.3%), but not with silent pattern (11.8%) (Cramers V = 0.510; P = 0.004). CEACAM1-positive tumors were not statistically different in size from CEACAM1-negative tumors. The higher frequency of CEACAM1 in patients who ultimately developed metastases (58.8% vs. 41.7%) was not statistically significant (likelihood ratio χ(2) = 2.069; P = 0.1503). CONCLUSIONS This report describes CEACAM1 expression in uveal melanoma. Correlation with poor prognostic factors such as epithelioid cell type and networks of extracellular matrix pattern was found, but definitive prognostic conclusions still cannot be deduced. Additional validation studies on the use of CEACAM1 expression as a prognostic marker are warranted.

Traumatic Displacement of the Globe Into the Paranasal Sinuses: Case Report and Guidelines for Treatment

Orbital wall fractures are a common outcome of facial trauma. Most are a complex type of fracture involving the orbito-zygomatic complex and/or naso-orbito-ethmoidal (NOE) complex. Blowout fractures are orbital fractures that do not involve the orbital rim. The mechanism of these fractures was described by Smith and Regan 50 years ago in a cadaveric study in which they were able to induce orbital floor fractures through a sudden elevation of intraorbital pressure. In this type of fracture, orbital contents may partially collapse into the maxillary sinus (since the orbital floor is most commonly involved). This fracture also alters orbital volume, causing orbital enlargement in most cases. These phenomena result in globe displacement, clinically observed as enophthalmus or dystopia. In some cases, orbital contents are trapped within the fracture, limiting ocular movements (mostly upper gaze) due to muscle entrapment. Both of these situations necessitate surgical intervention. Prolapse of the globe into the adjacent paranasal sinuses is extremely rare, with few cases reported in the literature. It mostly involves the maxillary sinus, but prolapse of the globe into the ethmoid cells also has been reported. In this report, we first describe the management of a patient with traumatic globe displacement into the maxillary sinus, with its functional and anatomic sequelae. We then present guidelines for managing globe displacement that we developed based on this experience and a thorough search and review of previous reports of similar trauma in the English literature. We retrospectively analyzed the medical files of the patient reported herein with regard to the mechanism of trauma, diagnosis, imaging, treatment, and outcome. We compared these data with that of previously reported cases found by an electronic search of the English literature (Medline), using the terms “traumatic prolapsed globe” and “traumatic dislocated globe,” over a 40-year period.

Posterior scleritis: an ominous sign of occult Takayasu’s arteritis

Takayasu’s arteritis is a rare chronic obliterative vasculitis affecting the aorta and its major branches. Epidemiologically it is found mainly in females of reproductive age and is more prevalent in Asian and Latin American countries. Although the pathogenesis has not been entirely elucidated, Takayasu’s arteritis (TA) is considered to be a T-cell mediated granulomatous vasculitis.1 We herein report the case of a patient who presented with posterior scleritis that proved to be the only clinical manifestation of a fatal case of TA. A 26-year-old healthy male Caucasian patient was referred to the Department of Ophthalmology of Aberdeen Royal Infirmary because of blurred vision, painful red eyes and photophobia. For 20 months prior to presentation he was treated with intermittent topical steroids and NSAIDS because of bilateral refractory steroid-dependent episcleritis. On examination visual acuity was 6/6 OD and 6/24 OS. Pupils were poorly reactive to light and no afferent pupillary defect was detected. He had significant episcleral injection bilaterally, but no signs of anterior uveitis were seen. Fundoscopy revealed a swollen right optic disc with choroidal folds in the posterior poles of both eyes (fig 1). B-scan echography revealed significant diffuse scleral thickening around the optic nerve extending to the extraocular muscle insertions with widening of Tenon’s space. The patient was thus diagnosed to have posterior …