Roy D. Brod

Central serous chorioretinopathy in women

BACKGROUND Central serous chorioretinopathy is a disorder that typically affects young and middle-aged men. Although extensive information is available pertaining to the clinical features of central serous chorioretinopathy in men, little is known about this condition in women. MATERIALS AND METHODS The authors reviewed the medical records and photographic files of women who received a diagnosis of central serous chorioretinopathy. The women were divided into three groups for data analysis: idiopathic, exogenous corticosteroid use, and pregnancy. RESULTS Fifty-one women with active central serous chorioretinopathy were evaluated. These findings in women with idiopathic serous chorioretinopathy were similar to those described in men, with the exception that women tend to be older at the time of onset. Central serous chorioretinopathy in women taking exogenous corticosteroids more likely was characterized by bilateral involvement and subretinal fibrin. Central serous chorioretinopathy in pregnant women typically developed in the third trimester and resolved spontaneously within 1-2 months after delivery. CONCLUSION Idiopathic central serous chorioretinopathy is similar in women and men, with the exception that women tend to be more older at the time of onset. The finding of exogenous corticosteroid use in a significant number of women in our study provides further support that cortisol may play a role in the development of central serous chorioretinopathy. The mechanism by which cortisol influences the development of central serous chorioretinopathy is unclear.

Endogenous Candida Endophthalmitis Management without Intravenous Amphotericin B

Eight consecutive cases of culture-proven endogenous Candida endophthalmitis (ECE) were managed between 1980 and 1988. All patients were treated with vitrectomy and injection of intravitreal amphotericin B. Blood cultures were negative in all patients, although Candida albicans was cultured from a foot ulcer in one patient. No systemic therapy was used in three patients, three patients received oral ketoconazole, and two patients received oral flucytosine postoperatively. Intravenous amphotericin B was not used because of lack of evidence of disseminated candidiasis and the systemic toxicity associated with its use. The ECE responded favorably to treatment in all cases. Final vision was better in patients with a shorter interval between onset of symptoms and initiation of antifungal therapy. Posttreatment visual acuities were: four eyes greater than or equal to 20/50, two eyes at 20/80 to 20/200, and two eyes less than 5/200. This series showed that ECE without evidence of disseminated disease can be treated successfully with vitrectomy and intravitreal amphotericin B.

Management options for retinal detachment in the presence of a posteriorly dislocated intraocular lens

Six consecutive cases of retinal detachment occurring in the presence of a posteriorly dislocated intraocular lens were managed between 1978 and 1988. In three cases, a standard scleral buckling procedure was performed with successful retinal reattachment, leaving the dislocated implant in the inferior formed vitreous. In two cases, the implant was removed through the pars plana at the time of pars plana vitrectomy, fluid/gas exchange, and scleral buckling procedure. In the remaining case, the intraocular lens was repositioned with scleral fixation sutures after pars plana vitrectomy, fluid/gas exchange, and scleral buckling. All cases acheived and maintained retinal reattachment with visual improvement. Recommendations for management are discussed.

An extension of the Early Treatment Diabetic Retinopathy Study (ETDRS) system for grading of diabetic macular edema in the Astemizole Retinopathy Trial.

Purpose: To compare the effects of astemizole, an antihistamine, versus placebo on the 1-year course of diabetic macular edema (DME) and to illustrate use of a modified ETDRS system for grading areas of retinal thickening and hard exudates that may be useful in clinical trials of treatments for this disorder. Methods: Between June 1994 and September 1997, at 2 clinics, 63 patients who had, in at least one eye (the study eye), DME that had not previously been treated with macular photocoagulation, and for which photocoagulation was not currently recommended by the investigator, were enrolled and randomly assigned to astemizole or placebo. Fifty-four of the 63 patients (86%, 26 in Clinic 1 and 28 in Clinic 2) completed 1 year of followup and had adequate 7-field stereoscopic film-based color fundus photographs of the study eye at the baseline and 1-year visits. DME was > 0.33 disc diameters (DD) from the center of the macula in 48% of study eyes and involved the center in 13%. Photographs were graded using the ETDRS protocol modified to allow estimates of areas of retinal thickening (RT) and hard exudate (HE) to be made on continuous scales in disc area (DA) units. Principal outcome measures were mean change in the square root of RT area (the average diameter of the area in DD), mean change in area of HE, and change in the degree to which RT involved or threatened the center of the macula. Results: At baseline, RT area in the 54 study eyes ranged from 0.09 to 4.0 DA (median 1.1). At the 1-year visit the square root of RT area (RTdd) had decreased by ≥ 0.3 DD in 10 eyes, increased by ≥ 0.3 DD in 19 and was about the same in 25. Mean change at 1 year was +0.09 DD (SD 0.57) for astemizole versus +0.19 DD (SD 0.48) for placebo, for a difference of −0.10 DD (95% CI −0.38, +0.19; p = 0.51). Adjustments for baseline and time-dependent risk factors did not change this result appreciably, although there was a trend towards a difference in favor of astemizole in the subgroup of patients with more severe retinopathy. Other morphologic outcomes paralleled change in RTdd. Change in RTdd did vary by clinic: −0.03 DD in Clinic 2, versus + 0.32 DD in Clinic 1, for a difference of −0.35 DD (95% CI −0.62, −0.07; p = 0.014). Clinic 1 is a tertiary retinal referral center in Pennsylvania and Clinic 2 a retinal clinic closely affiliated with a large diabetes clinic in Copenhagen. The unexpected clinic difference in outcome provided an opportunity for further analyses using the modified ETDRS system. In comparison to Clinic 1, Clinic 2 patients were more often male, were younger at diagnosis of diabetes, and had less severe retinopathy and better visual acuity, but these differences did not appear to explain the trend for lesser increase in RTdd. Conclusion: No effect of astemizole was found, but the confidence interval for the principal outcome, mean change in RTdd, included both a modest beneficial effect and a small harmful effect. This outcome measure did demonstrate a small difference in outcome by clinic, which could not be explained by baseline characteristics but may reflect differences in access to and/or continuity of care or other unmeasured differences associated with different referral patterns. Although optical coherence tomography may supplant photography as a measure of central RT, photographic assessments of change in RT and HE areas analyzed with the methods described herein may be useful outcomes in trials assessing treatment of early stages of DME. Application of these methods to other data sets is needed to confirm this conclusion.

Current management of endophthalmitis

Infectious endophthalmitis is classified by the events leading to the infection and by the timing of the clinical diagnosis. The broad categories include postoperative endophthalmitis (acute-onset, chronic or delayedonset, conjunctival filtering-bleb associated), posttraumatic endophthalmitis, and endogenous endophthalmitis (Table 1). Rare causes include cases associated with microbial keratitis, suture removal, or intravitreal injections. These categories are important in predicting the causative organisms and guiding therapeutic decisions before microbiologic confirmation of the clinical diagnosis.

Choroidal Nonperfusion in Giant Cell Arteritis

A 68-year-old man had visual loss secondary to isolated choroidal nonperfusion as a clinical manifestation of giant cell arteritis. Ophthalmoscopy disclosed scattered yellow-white lesions at the level of the retinal pigment epithelium in the posterior pole of the right eye. Intravenous fluorescein angiography demonstrated marked delay in choroidal filling of the macula in the right eye. There was no ophthalmoscopic or angiographic evidence of anterior ischemic optic neuropathy or central retinal artery occlusion. After approximately 72 hours of intravenous corticosteroid therapy, the patients visual acuity improved and repeat intravenous fluorescein angiography showed normal choroidal circulation. Isolated choroidal ischemia is a potential cause of reversible visual loss in patients with giant cell arteritis.

Unusual retinal and renal vascular lesions in the Klippel-Trenaunay-Weber syndrome.

Ocular fundus abnormalities associated with the Klippel-Trenaunay-Weber syndrome are uncommon and include retinal vascular tortuosity and diffuse choroidal hemangioma. A case involving a young girl with Klippel-Trenaunay-Weber syndrome who had unusual bilateral, exudative, outer retinal vascular masses involving the peripheral fundus in one eye and the foveal area in the other eye is reported. Kidney biopsy for renal insufficiency disclosed abnormal excess mesangial tissue. The fundus lesions appear to represent vascular tumors of the retina that differ clinically from previously reported retinal vascular tumors and Coats disease. The simultaneous retinal and renal involvement suggest that Klippel-Trenaunay-Weber syndrome may be associated with more widespread vascular malformations than previously realized.

The Site of Operating Microscope Light-Induced Injury on the Human Retina

We determined the site of the focal illumination from the Zeiss OPMI-6 operating microscope on the retina of the phakic and aphakic human cadaver eye by directly observing the illuminating element image on the posterior scleral surface of the globe. With the eye straight ahead and the operating microscope level, the focal oval area of retinal illumination was located superior to the foveola in both the phakic and aphakic eye. Tilting the operating microscope 10 degrees toward the surgeon displaced the entire illuminating element image 0.50 mm below the foveola in the phakic eye and 0.25 mm below the foveola in the aphakic eye. Rotating the eye inferiorly 10 degrees displaced the entire illuminating element image 1.0 mm below the foveola in the phakic eye and 1.25 mm below the foveola in the aphakic eye. Centering the field of view superiorly (viewing the superior limbus) paradoxically displaced the illuminating element image inferiorly, resulting in central foveal illumination. Foveal light exposure was avoided in most eye positions by tilting the microscope at least 10 degrees toward the surgeon.

Endophthalmitis: Current approaches to diagnosis and therapy

Early recognition and prompt management are important in reducing visual loss from infectious endophthalmitis. Increased awareness of the predisposing factors for postoperative endophthalmitis have led to more widespread use of preventive measures during anterior segment surgery. The use of less toxic intraocular antibiotics may reduce retinal damage and routine administration of intravitreal corticosteroids will reduce the tissue destruction produced by the intraocular inflammatory response. The use of vitrectomy in endophthalmitis management is being studied in a randomized, prospective study. Newer, less toxic, systemic antifungal medications which can be used alone or in conjunction with local ocular therapy for fungal endophthalmitis are available. Current diagnostic and management approaches are reviewed.

Gentamicin and other antibiotic toxicitiy.

Antibiotics have the potential to cause significant ocular toxicity when they gain access to the inside of the eye. The aminoglycosides, in particular gentamicin, are the most toxic of the antibiotics commonly used in ophthalmology. Extreme caution should be used when administering a periocular injection of aminoglycoside for treatment or prophylaxis of infection. Intraocular injection of aminoglycoside for gram-negative coverage in endophthalmitis management has been replaced in most cases by ceftazidime. Ceftazidime provides excellent coverage against gram-negative bacteria with less potential for retinal toxicity at therapeutic dosages. Experimental and clinical studies have shown that intraocular vancomycin is safe and effective treatment against gram-positive organisms causing endophthalmitis. A combination of ceftazidime and vancomycin provides broad-spectrum coverage for virtually all bacteria causing endophthalmitis and is the current intraocular treatment of choice.