Thomas P. Ward

Homocysteine: A Risk Factor for Retinal Venous Occlusive Disease

PURPOSE Recent studies have shown a relationship between elevated levels of homocysteine and vascular disease including cerebrovascular accidents and myocardial infarctions. We evaluated patients with a recent retinal vein occlusion to determine if there was an associated elevation of homocysteine. DESIGN Age and gender matched case-controlled study. PARTICIPANTS Twenty patients with retinal venous occlusive disease within the previous 6-month period and 40 control patients without retinal venous occlusive disease were enrolled in the study. METHODS Twenty patients with a history of retinal vein occlusion underwent laboratory testing to determine serum homocysteine levels. In addition, a health survey was completed and several laboratory tests relating to vascular disease including cholesterol were checked. Two control groups were selected. The first group included patients with diabetes and no history of retinal vascular occlusive disease. The second control group included nondiabetic patients who also had no prior history of retinal vascular occlusive disease. MAIN OUTCOME MEASURES The main parameter measured in this study is fasting homocysteine. RESULTS Fifteen of 20 patients (75%) with retinal vein occlusion disease had an elevated fasting serum homocysteine level, whereas only 5 of 40 control patients (13%) had an abnormal homocysteine level (P < 0.0005). CONCLUSIONS Patients with retinal venous occlusive disease have higher levels of homocysteine, which may serve as a modifiable risk factor.

Ocular injuries from paintball pellets.

OBJECTIVE To evaluate the ocular effects of blunt trauma due to injury from a paintball pellet. DESIGN Noncomparative case series. PARTICIPANTS Thirteen patients who suffered ocular injury from paintballs are described. The patients presented to six different civilian and military emergency departments in tertiary care medical centers. INTERVENTION Patients were treated for the ocular injury. MAIN OUTCOME MEASURES Patients were evaluated for initial and final visual acuity. The reason for persistent loss of vision was delineated. RESULTS There were 12 males and 1 female with an average age of 21 years (range, 12-33 years). Eleven of the 13 had no ocular protection at the time of the ocular injury. On initial examination, nine patients had a hyphema, nine had a vitreous hemorrhage, six had a retinal tear or detachment, three had corneal or corneal-scleral ruptures, and one had traumatic optic neuropathy. The final visual acuity was 20/40 or better in two patients, 20/50 to 20/150 in three patients, and 20/200 or worse in eight patients. CONCLUSION Injuries due to paintball pellets can result in severe ocular damage and significant loss of vision. Eyecare professionals should be aware of the risks of this sport and must strongly advise participants to wear adequate protection when involved in this activity.

Outcome of sulcus fixation of dislocated posterior chamber intraocular lenses using temporary externalization of the haptics33

OBJECTIVE This study evaluated the visual outcome and complications of repositioning and sulcus fixation of a dislocated posterior chamber intraocular lens (PC IOL) using a technique in which the haptics of the IOL are temporarily externalized for suture placement. DESIGN Retrospective, noncomparative case series. PARTICIPANTS Seventy-eight patients with a dislocated PC IOL. INTERVENTION All patients underwent surgery to fixate the PC IOL using this technique. MAIN OUTCOME MEASURES Patients were evaluated for visual acuity, refractive error, and surgical complications associated with the procedure. RESULTS The average visual acuity before surgery was 20/205 (range, 20/20 to light perception), with a median refractive error of -1.00 diopters (D; range, -7.25-+15.00 D). After surgery, the average visual acuity improved to 20/72 (range, 20/20 to no light perception), with a median refractive error of -0.75 D (range, -5.50-+3.50 D). Patients were observed for a median of 15.5 months (range, 6-57 months). Twenty patients had postoperative cystoid macular edema (26%), 7 patients had an epiretinal membrane (ERM) (9%), and 5 patients had a retinal detachment (6%). Eight patients (10%) experienced iris capture of the sutured IOL, and in three patients (4%) the PC IOL dislocated again after surgery. CONCLUSIONS This technique is an effective method for securing a dislocated PC IOL.

Eye injuries in a terrorist bombing: Dhahran, Saudi Arabia, June 25, 1996.

OBJECTIVE We report the experience of our institution in the evaluation and care of multiple simultaneous ocular trauma patients after a terrorist bomb attack on a United States military base in Saudi Arabia. DESIGN Retrospective, noncomparative small case series. PARTICIPANTS Three patients who received severe ocular injuries after a terrorist bombing. INTERVENTION All patients underwent surgical repair of the injuries that were inflicted as a result of the terrorist bombing. MAIN OUTCOME MEASURES Baseline ocular characteristics, intraoperative findings, surgical procedures, and final (3 years after injury) anatomic and visual outcomes were noted. RESULTS Glass fragments caused by the blast were the mechanism of all the ocular injuries in these patients. All patients had primary repair of the injuries done in Saudi Arabia and were sent to our institution for tertiary care. Three of the four eyes injured had stable or improved visual acuity and one eye was enucleated. Two patients had no serious injury other than the globe trauma. One patient had extensive eyelid trauma and required serial procedures to allow fitting of a prosthesis. CONCLUSIONS Blast-injury patients are at risk for open globe injury as a result of glass fragments. The types of injury that can occur from terrorist blasts can be extensive and involve all the tissues of the eye, the ocular adnexa, and the orbit.

Treatment of Nocardia asteroides Keratitis with Polyhexamethylene Biguanide

PURPOSE Polyhexamethylene biguanide (PHMB) is a polymeric biguanide disinfectant that has been used previously in the treatment of Acanthamoeba keratitis. The authors report the first case of Nocardia asteroides keratitis treated successfully with PHMB. Further studies documenting the efficacy of PHMB against N. asteroides in vitro also are presented. METHODS A soft contact lens wearer presented with an infectious keratitis. Cultures from the cornea grew N. asteroides. The infection resolved with the treatment with PHMB 0.02%. Serial dilutions of PHMB were performed against N. asteroides in culture. RESULTS In vitro dilution studies determined that the minimal inhibitory concentration for PHMB against the tested isolate of N. asteroides was 0.01%. This is a concentration that has been shown to be well tolerated by the cornea in vivo. CONCLUSIONS Polyhexamethylene biguanide is effective against both Acanthamoeba and Nocardia and may have a wider range of usefulness than that currently recognized. Further testing, both in vitro and in vivo, is required.

Novel corneal phenotype in a patient with alport syndrome.

Purpose: To report the clinical and histopathologic findings of an unusual keratopathy, which may represent a new corneal dystrophy in a patient with Alport syndrome (ATS). Methods: A 59-year-old woman with longstanding diagnosis of autosomal recessive ATS was evaluated for progressively decreasing vision in the left eye. She had anterior lenticonus and cataract and central corneal stromal opacification with significant thinning and flattening bilaterally. She underwent penetrating keratoplasty and cataract extraction with posterior chamber intraocular lens implantation. We describe the light microscopic and ultrastructural findings from the cornea. Results: Histopathology of the corneal button revealed marked stromal thinning with decreased keratocytes. The endothelial cells were attenuated and focally lost. Immunohistochemical stains for cytokeratin were positive, findings consistent with posterior polymorphous dystrophy (PPMD). Transmission electron microscopy showed necrosis and a marked loss of keratocytes. Multilayering of the endothelium was consistent with PPMD, but mature desmosomes and microvilli were absent. In vivo confocal microscopy on the fellow eye showed linear hyporeflective bands at the level of Descemets membrane consistent with PPMD. In addition, there were fine linear changes in the deep stroma and diffuse hyperreflectivity of the mid and superficial stroma with lack of identifiable keratocytes throughout. Conclusions: We believe this to be the first reported case to demonstrate some histopathologic features of PPMD in ATS. However, the clinical, histopathologic, and ultrastructural characteristics are not typical of PPMD. This may represent a new phenotypic expression of PPMD or may be a distinct clinicopathologic dystrophy associated with ATS.

Evaluation of digital fundus images as a diagnostic method for surveillance of diabetic retinopathy.

OBJECTIVE The goal was to evaluate a digital imaging system for diagnosing and grading diabetic retinopathy (DR) and cystoid macular edema (CME). METHODS A single 45 degrees, nonmydriatic, digital color photograph was taken of 231 eyes of 120 patients with diabetes mellitus. The images were graded for DR and CME by a remote ophthalmologist, and the results were compared with dilated ophthalmoscopy performed by a retina specialist. RESULTS For DR, the level of agreement between digital image review and ophthalmoscopy was moderate (kappa = 0.44). The sensitivity and specificity of digital image review were 0.60 and 1.00, respectively. For CME, the level of agreement was moderate (kappa = 0.60). The sensitivity and specificity of digital image review were 0.60 and 0.99, respectively. CONCLUSION A single 45 degrees, nonmydriatic, digital image is not reliable as the sole modality for DR screening. However, with modifications, it may be useful where access to an experienced ophthalmologist is limited.

Acyclovir Use and Survival Among Human Immunodeficiency Virus-Infected Patients with CD4 Cell Counts of <500/mm3

To examine the relationship between acyclovir use and survival in AIDS, we performed a retrospective analysis of data collected through an observational cohort of the 17-site Community Program for Clinical Research on AIDS (CPCRA), under the sponsorship of the National Institute of Allergy and Infectious Diseases. Data were analyzed regarding 2,368 patients with CD4+ lymphocyte counts of < 500/mm3, and 7,836 follow-up visits were conducted from September 1990 to July 1994. Factors associated with use of acyclovir were studied by stratified analysis of variance and Mantel-Haenzel chi 2 tests. The association between acyclovir and survival was studied with use of the proportional hazards regression model. Individuals reporting acyclovir use were more likely to be white, male, and homosexual; to have a history of herpes simplex and zoster; and to have lower CD4+ T cell counts than those who did not. After adjustments for differences in baseline factors, acyclovir use was not associated with prolonged survival.

Blast injury-associated optic disc pit maculopathy.

Congenital pits of the optic nerve head are anomalies of embryogenesis due to neuroectodermal fold remnants or aplasia of Bergmeister’s papilla.1 The defect allows the vitreous to pass spontaneously into the subretinal and inner nuclear layers of the retina, resulting in serous retinal detachment with macular cyst formation.2 Alternatively, a direct communication between the optic pit and subarachnoid space may exist, leading to cerebrospinal fluid (CSF) accumulation in the subretinal space as well as passage of intraocular contents into the CSF.3 A recent case report noted a symptomatic optic pit 3 months after a blunt ocular injury,4 and another case report noted an association between optic pit maculopathy and subsequent …

Ocular Diseases and Nonbattle Injuries Seen at a Tertiary Care Medical Center during the Global War on Terrorism

We retrospectively reviewed the records of 107 U.S. military personnel referred to the Walter Reed Army Medical Center ophthalmology service with eye diseases and nonbattle injuries diagnosed during Operation Enduring Freedom and Operation Iraqi Freedom. Ocular diseases and nonbattle injuries ranged from minor to vision-threatening, represented a broad variety of conditions, and required the expertise of a number of ophthalmic subspecialists. The most common diagnoses were uveitis (13.1%), retinal detachment (11.2%), infectious keratitis (4.7%), and choroidal neovascularization (4.7%). Eighty-four patients (78.5%) met Army retention standards and were returned to duty. Twenty patients (18.7%) were referred to a medical evaluation board, seven (6.5%) of whom failed to meet retention standards for eye and vision; the retention status of three patients (2.8%) remains to be determined.