Raul N. G. Vianna

Early-stage diffuse unilateral subacute neuroretinitis: improvement of vision after photocoagulation of the worm

AbstractPurpose: To evaluate the visual outcome after direct laser photocoagulation of the worm in patients with early-stage diffuse unilateral subacute neuroretinitis (DUSN).Methods: We report on four patients with DUSN diagnosed in its early stage, in whom the worm was identified and destroyed by laser photocoagulation.Results: In all the four cases, resolution of the inflammatory multifocal lesions was achieved within 1 month of treatment. After that period and during follow-up (mean 11.5 months), visual acuity improved in three eyes and remained unchanged in one eye.Conclusion: The diagnosis of DUSN in its early stage followed by prompt location and destruction of the worm by photocoagulation may improve vision of affected patients.

Combined hamartoma of the retina and retinal pigment epithelium associated with neurofibromatosis type-1.

Background: Retinal tumors are occasionally seen in patients with neurofibromatosis type-1 (NF-1). These are usually astrocytic hamartomas or angiomas. Combined hamartoma of the retina and retinal pigment epithelium are tumors also described in NF-1, but this association has not been definitively established yet. Method: We report on a child with NF-1, who presented a combined hamartoma of the retina and retinal pigment epithelium in both eyes. Results: The diagnosis of bilateral combined hamartoma of the retina and retinal pigment epithelium in our patient was performed on the basis of the ophthalmoscopic appearance of the lesions. NF-1 was diagnosed following the current international clinical criterion, supplemented by neuroimaging findings. Conclusion: Despite the extreme rarity of this association, we believe that it is not coincidental, as the presence of a hamartomatous retinal lesion in a patient with a systemic hamartomatous neuroectodermic disease would be, at least, rational. Thus, NF-1 must be excluded in patients with combined hamartoma of the retina and retinal pigment epithelium.

Intravitreal injection of commercially available ketorolac tromethamine in eyes with diabetic macular edema refractory to laser photocoagulation.

Purpose: To evaluate the short-term effect of a single intravitreal injection of commercially available ketorolac tromethamine (KT) in eyes with diabetic macular edema refractory to laser photocoagulation. Methods: Prospective interventional case series. Twenty five patients with diabetic macular edema refractory to laser photocoagulation received a single intravitreal injection of commercially available KT (Toradol®), in a dose of 3000 µg. Examination included assessment of ETDRS-best corrected visual acuity (BCVA), measurement of intraocular pressure and high resolution imaging by optical coherence tomography, preoperatively and 7, 15, and 30 days postoperatively. Results: In the follow up visits at 7, 15 and 30 days, BCVA had improved five or more letters in 20% (95% confidence interval, 7.7–38.9%), 16% (95% confidence interval, 5.3–34.2%) and 28% (95% confidence interval, 13.2–47.7%) respectively. An improvement in macular thickness was also observed, although it has not been statistically significant. Conclusion: This pilot study showed that a single intravitreal injection of 3000 µg of commercial KT led to a short-term improvement of visual acuity in approximately 30% of eyes with diabetic macular edema refractory to laser photocoagulation.

Prevalence of refractive errors in students in Northeastern Brazil

PURPOSEnTo determine the prevalence of refractive errors in the public and private school system in the city of Natal, Northeastern Brazil.nnnMETHODSnRefractometry was performed on both eyes of 1,024 randomly selected students, enrolled in the 2001 school year and the data were evaluated by the SPSS Data Editor 10.0. Ametropia was divided into: 1- from 0.1 to 0.99 diopter (D); 2- 1.0 to 2.99 D; 3- 3.00 to 5.99 D and 4- 6D or greater. Astigmatism was regrouped in: I- with-the-rule (axis from 0 to 30 and 150 to 180 degrees), II- against-the-rule (axis between 60 and 120 degrees) and III- oblique (axis between > 30 and < 60 and >120 and <150 degrees). The age groups were categorized as follows, in: 1- 5 to 10 years, 2- 11 to 15 years, 3- 16 to 20 years, 4- over 21 years.nnnRESULTSnAmong refractive errors, hyperopia was the most common with 71%, followed by astigmatism (34%) and myopia (13.3%). Of the students with myopia and hyperopia, 48.5% and 34.1% had astigmatism, respectively. With respect to diopters, 58.1% of myopic students were in group 1, and 39% distributed between groups 2 and 3. Hyperopia were mostly found in group 1 (61.7%) as well as astigmatism (70.6%). The association of the astigmatism axes of both eyes showed 92.5% with axis with-the-rule in both eyes, while the percentage for those with axis against-the-rule was 82.1% and even lower for the oblique axis (50%).nnnCONCLUSIONnThe results found differed from those of most international studies, mainly from the Orient, which pointed to myopia as the most common refractive error, and corroborates the national ones, with the majority being hyperopia.

Cost considerations of the new fixed combinations for glaucoma medical therapy

Objective:u2002 To compare the costs of the new fixed combinations for glaucoma medical therapy.

Acquired Brown's syndrome secondary to Ahmed valve implant for neovascular glaucoma.

Clinical findings included anterior uveitis, episcleritis, raised intraocular pressure, macular oedema, pigment dispersion, and retinal detachment. Angiostrongylus cantonensis, a lung fluke of rodents, was first described by Chen in 1935 from the bronchial tree of Rattus norvegicus and R.rattus rattus, caught in Canton, China. It is a delicate filiform worm, and has a length of 16-25 mm and a maximum diameter of 0.260.36 mm; the female of the species is larger. The rodent is the definite host. It is thought that humans are infected by eating inadequately cooked intermediate hosts (slugs, snails, crabs), or vegetables contaminated by larvae. The most likely routes of entry into the orbit are between the optic nerve and sheath, through the cribriform plate, and into the anterior chamber through the limbus. It is difficult to know where our patient came into contact with the infected intermediate molluscum host. Although he is resident in the United Kingdom, he had recently visited South Africa. Medline search, however, revealed no previous reports of ocular Angiostrongyliasis from United Kingdom or South Africa.

Transpupillary thermotherapy in the treatment of circumscribed choroidal hemangiomas

Purpose: To evaluate the efficacy of transpupillary thermotherapy (TTT) for the treatment of serous retinal detachment secondary to circumscribed choroidal hemangiomas (CCH). Material and methods: Four eyes of four consecutive patients who presented decreased vision due to serous macular detachment secondary to CCH were enrolled in this study. After informed consent was obtained, the four eyes were treated with TTT. All the patients underwent pretreatment ocular examination, which included fluorescein angiography and ultrasonography. TTT was applied using a diode laser at 810 nm with a spot size of 4.3 mm. The diode laser was transmitted through a contact lens. The end-point of the treatment was a detectable light-gray appearance of the entire lesion. The patients were re-examined monthly during the first 6 months, and regularly thereafter. Results: Within 3 months of treatment all eyes had already demonstrated decreased exudation on clinical examination and on fluorescein angiography. Reduction in tumor prominence was observed in all eyes by A–B ultrasonography. Three patients showed an improvement in visual acuity (VA) over a period of 6 months. Case 2 from 20/60 to 20/25; case 3 from 20/400 to 20/50 and case 4 from 20/80 to 20/20. The VA in case 1 remained unchanged (counting fingers). No recurrences were observed within a mean follow-up of 14.5 months. Conclusions: TTT showed no deleterious side effects in treating serous macular detachment secondary to CCH, and must be regarded as a therapeutic alternative to manage selected cases.

Transpupillary Thermotherapy in the Treatment of Choroidal Metastasis from Breast Carcinoma

Background: Most patients who develop metastatic carcinoma to the choroid are managed by local radiation or chemotherapy. Since transpupillary thermotherapy (TTT) is currently gaining attention as an optional treatment for choroidal melanomas and hemangiomas, we sought to determine whether TTT is suitable for treatment of solitary choroidal metastasis at the posterior pole. Method: We report on a patient with decreased vision due to a serous macular detachment in a eye with a solitary choroidal metastasis from breast carcinoma, who was managed by TTT. Results: After two months of follow up, total re-absorption of the serous macular detachment was achieved and the patient recovered full visual acuity in the treated eye. The choroidal mass became atrophic and hyperpigmentation of the retinal pigment epithelium and retinal folds in the macular region were observed. After six months of TTT, the ocular picture remained unchanged. Conclusion: TTT can be considered an acceptable therapeutic option for solitary choroidal metastasis associated with serous retinal detachment.

Intravitreal pegaptanib reduces fluorescein leakage in idiopathic parafoveal telangiectasis

Idiopathic parafoveal telangiectasis (IPT) is a developmental retinal vascular abnormality associated with incompetence and ectasia of parafoveal capillaries.1 In some eyes with IPT, these incompetent vessels may leak and cause macular edema, which is the most common cause of visual loss in this entity.1 The pathogenesis of IPT is still unknown and no effective treatment has yet been introduced for this condition. Pegaptanib sodium is a selective RNA aptamer that inhibits vascular endothelial growth factor (VEGF), which is primarily responsible for pathologic ocular neovascularization and vascular permeability.2 Intravitreal pegaptanib was initially described in the treatment of subretinal neovascular membranes secondary to age-related macular degeneration, but recent papers have suggested that pegaptanib may provide therapeutic benefit for patients with diabetic macular edema and retinal vein occlusion.2–5 We report a case where intravitreal pegaptanib was injected in an attempt to improve vision in a patient with IPT and fluorescein leakage. A 61-year-old Caucasian woman with bilateral IPT developed fluorescein leakage in the left eye (Fig. 1A). Best-corrected visual acuity was 20/60 OD and 20/50 OS. An intravitreal injection of pegaptanib (0.3 mg/0.1 mL) OS was performed, and 1 month later the fluorescein angiography showed less hypofluorescence in the parafoveal area (Fig. 1B) than prior to the injection. However, visual acuity and optical coherence tomography (OCT) (Fig. 1B, inset) were unchanged. Although vision remained stable, 2 months later the OS fluorescein angiography had returned to its baseline characteristics. We decided to perform another intravitreal injection of pegaptanib OS and the patient agreed. Once more, 1 month later there was decreased hyperfluorescence in the parafoveal area. Nevertheless, vision remained 20/50 throughout the entire follow-up. The treatment of macular leakage from IPT has been suboptimal. Grid laser photocoagulation and intravitreal triamcinolone therapy neither improved nor stabilized long-term visual acuity.6 Recently, off-label use of intravitreal bevacizumab has been tried, with some benefit.7,8 Charbel Issa et al.7 reported an improvement of visual acuity in 3 out of 7 eyes in 6 patients with IPT and macular leakage who received 2 doses of intravitreal bevacizumab. Within 8 weeks, all patients showed a reduction in exten-

Walker-Warburg syndrome: report of two cases

The purpose of this study is to describe two infants that were diagnosed with Walker-Warburg syndrome (WWS), a rare form of congenital muscular dystrophy (CMD). They were studied in their clinical, laboratory, and neuroradiologic features. The index case had a brain magnetic resonance imaging (MRI) and the second patient had a head computerized tomography (CT). In addition, a literature review was performed to describe the main forms of CMD. The index case fulfilled all criteria for WWS. A brain MRI performed at age 4 months served to corroborate the clinical diagnosis, showing severe hydrocephalus, type II lissencephaly, cerebellar vermian aplasia, and a hypoplastic brain stem. The authors were able to establish a retrospective diagnosis of WWS in the index cases older sister, based upon her clinical picture and head CT report.