Ronni M. Lieberman

Treatment of Retinal Detachments in Patients with the Acquired Immune Deficiency Syndrome

Thirty-nine eyes from 31 patients with retinal detachment due to cytomegalovirus (CMV) retinitis were treated by either laser photocoagulation (22 eyes), scleral buckle (9 eyes), pars plana vitrectomy (5 eyes), or no therapy (3 eyes). The success rates for photocoagulation (77.2%), scleral buckle (77.7%), and vitrectomy (with gas or oil, 80%) were similar. The median survival time was 95 days (range, of 7 to 280 days). The extent of detachment, the presence of active disease in either the periphery or the posterior pole, and overall health served to determine what type of therapy was best suited for each patient. Although silicone oil appears to be best for patients with a total retinal detachment and active disease, this small series suggests that conservative modes of therapy such as laser photocoagulation and scleral buckles can be used successfully to treat these patients if there is an absence of active retinitis.

An Evidence-Based Meta-analysis of Vascular Endothelial Growth Factor Inhibition in Pediatric Retinal Diseases: Part 1. Retinopathy of Prematurity

Recently there has been interest in the novel, off-label use of anti-vascular endothelial growth factor (anti-VEGF) agents for various stages of retinopathy of prematurity (ROP). The authors report on the quality and depth of new evidence published from 2009 to 2011 concerning the treatment of retinopathy of prematurity (ROP) with bevacizumab (Avastin; Genentech Inc., South San Francisco, CA) as either primary or adjunctive treatment for ROP. There is significant variability in the evidence, quality, and design of the studies available in the literature. There has been a trend in the scientific literature of the past 2 years toward larger, multi-center, randomized studies investigating the role of bevacizumab in the treatment of ROP. More recent evidence suggests that monotherapy with intravitreal bevacizumab may be a viable first-line treatment for select cases of zone I ROP and possibly for posterior zone II disease. Adjunctive treatment with bevacizumab may enhance outcomes in patients treated with laser photocoagulation or pars plana vitrectomy. However, there are significant concerns regarding its long-term safety profile. Further prospective studies are warranted to more fully determine the role of anti-VEGF therapy in this disease.

Chronic retinal necrosis: cytomegalovirus necrotizing retinitis associated with panretinal vasculopathy in non-HIV patients.

Purpose: To characterize a unique cytomegalovirus (CMV)-associated retinopathy in patients with limited immune dysfunction. Methods: Retrospective observational case series. CMV was confirmed as the pathogenic agent via polymerase chain reaction analysis of aqueous or vitreous humor samples or via immunohistochemical analysis of retinal biopsy specimens. Results: Five non-HIV patients with granular necrotizing retinitis, vitritis, and severe occlusive vasculopathy were identified. Patient histories all suggested a basis for limited immune dysfunction including advanced age (n = 4), diabetes mellitus (n = 4), and noncytotoxic immunotherapy (n = 3). Diagnosis of CMV retinitis was delayed in all cases and patients received either no antiviral therapy (n = 2) or incorrect antiviral therapy (n = 3) for presumed herpes simplex/varicella zoster-related acute retinal necrosis. Retinitis subsequently regressed in all cases with introduction of systemic ganciclovir/valganciclovir (n = 5) and/or intravitreal foscarnet (n = 2). Four of five patients developed neovascularization because of extensive retinal ischemia. Conclusion: The clinical expression of CMV-associated retinopathy is strongly related to immune status. In patients with limited immune dysfunction, a mixed clinical picture of intraocular inflammation with panretinal occlusive vasculopathy, more characteristic of acute retinal necrosis, and peripheral slowly progressive granular retinitis, more characteristic of classic CMV retinitis, is observed. Recognition of this atypical clinical presentation, which the authors term chronic retinal necrosis, should prompt molecular testing for CMV to determine the appropriate antiviral therapy. Consideration should also be given to prophylactic panretinal photocoagulation in such eyes, given the high risk of neovascular complications.

Bilateral Central Serous Chorioretinopathy Caused by Intranasal Corticosteroids: A Case Report and Review of the Literature

The relationship between systemic corticosteroids and central serous chorioretinopathy (CSCR) has been well established; however, there also appears to be an association with intranasal corticosteroids. A search of the English literature revealed only three reported cases of CSCR linked to intranasal corticosteroid use, and in each, clinical improvement was observed after cessation of the steroid agent. We present an additional case of bilateral CSCR resulting from intranasal corticosteroid use and review the literature regarding this uncommon side effect. Otolaryngologists, as frequent prescribers of these medications, should be aware of their myriad side effects, including ophthalmologic conditions such as CSCR.

Hypertensive crisis with massive retinal and choroidal infarction

A 30-year-old female with no prior ophthalmic complaints presented with a 1-week history of bilateral gradual painless vision loss. Her blood pressure was 225/115 mmHg (Hypertensive crisis is defined as a systolic reading of 180 mm Hg or higher or a diastolic reading of 110 mm Hg or higher). Past medical history included chronic renal failure from IgA nephropathy requiring hemodialysis for the past 8 years. She had a history of noncompliance with her dialysis which led to multiple hospital admissions, where she was found to be in hypertensive crisis but never reported visual complaints. Visual acuity was hand motion in the right eye and counting fingers in the left eye. Slit lamp examination was unremarkable in both eyes. Funduscopic examination revealed disc swelling, diffuse retinal hemorrhages, and sclerotic and attenuated vessels with sheathing in both eyes (Fig. 1). Optical coherence tomography revealed massive intraretinal thickening with loss of layered retinal architecture (Fig. 2). Fluorescein angiography revealed neovascularization of the disc, complete loss of retinal capillaries,

Immune Reconstitution Uveitis Complicated by Vitreoretinal Traction and Formation of a Retinal Tear

The authors report a case of immune reconstitution uveitis induced by cytomegalovirus retinitis with subsequent development of vitreoretinal traction and a resultant retinal tear.