Vinod Lakhanpal

Deferoxamine (Desferal®)-induced Toxic Retinal Pigmentary Degeneration and Presumed Optic Neuropathy

Eight patients (16 eyes) developed ocular toxicity while undergoing intravenous deferoxamine mesylate (Desferal) chelation therapy for transfusional hemosiderosis. Presenting symptoms included decreased visual acuity, color vision abnormalities, and night blindness. Six patients presented as presumed retrobulbar optic neuropathy demonstrating central scotomas and color vision abnormalities. The remaining two patients presented with pigmentary changes confined either to the macula or equator. Following cessation of therapy, vision improved in all but four eyes, which did not attain their pretreatment visual acuity. Optic neuropathy resolved in all cases. However, follow-up revealed development of retinal pigmentary degeneration in seven patients, involving the macula in six and the equatorial retina in one. Fluorescein angiography and electrophysiological tests suggested toxicity at the level of retinal pigment epithelium and photoreceptors.

Anterior Chamber Tube Shunt to an Encircling Band in the Treatment of Neovascular Glaucoma and other Refractory Glaucomas: A Long-term Study

Long-term follow-up results of the anterior chamber tube shunt to an encircling band (ACTSEB) procedure are reported. Thirty eyes of 28 patients with neovascular glaucoma (Group I) and five eyes with non-neovascular refractory glaucoma (Group II) underwent this procedure. In Group I, the average preoperative intraocular pressure (IOP) was 57.1 mmHg. After surgery and average followup of 25 months 96% of eyes had a successful outcome with an average IOP of 15.8 mmHg (P less than 0.001). In Group II, despite multiple glaucoma surgical procedures, the average preoperative IOP was 54 mmHg. After surgery and average followup of 20 months 80% of eyes had a successful outcome with an average IOP of 19.8 mmHg (P less than 0.01). Revisions in our surgical technique utilizing a small entry with a 25-gauge needle into the anterior chamber and use of Healon resulted in a fully formed anterior chamber by two days. Clinical and experimental evidence is presented which suggest that aqueous filters through the tube to a reservoir around the encircling band.

Clindamycin in the Treatment of Toxoplasmic Retinochoroiditis

We treated 26 patients with acute toxoplasmic retinochoroiditis with clindamycin between 1974 and 1982. Four patients were treated with clindamycin alone and 17 with clindamycin and prednisolone. Five patients received clindamycin and prednisolone, sulfadiazine, pyrimethamine, or cryocoagulation, or a combination of these. All patients with the acute disease had the characteristic foci and a positive titer on the Sabin-Feldman dye test of at least 1:16. Other causes of retinochoroiditis were excluded. All but two patients, who developed diarrhea after two weeks, received clindamycin for a minimum of three weeks. All patients improved after two weeks of treatment, but two patients with lesions larger than 2 disk diameters required an additional six weeks of treatment to heal completely. During follow-up periods ranging from 18 months to seven years (mean, three years) there have been only two recurrences (7.7%). Complications with clindamycin treatment were limited to gastrointestinal upsets, diarrhea, and skin rash. There were no cases of pseudomembranous colitis, the most serious reported complication of clindamycin use.

Intraoperative Massive Suprachoroidal Hemorrhage during Pars Plana Vitrectomy

Seven eyes (7 patients) developed massive suprachoroidal hemorrhage (MSCH) during pars plana vitrectomy (PPV) for complicated retinal detachments. The MSCH developed late in the procedure following PPV, air fluid exchange, endolaser, cryopexy, and scleral buckling in five of seven eyes. In two eyes, mild hemorrhagic choroidal detachments noted intraoperatively progressed to MSCH within 72 hours postoperatively. Diagnosis of MSCH was confirmed by echography and CT scan. Multiple scleral buckling surgeries, high myopia, aphakia, and intraocular inflammation were the main risk factors. Placement of a broad posterior scleral buckle with intraoperative hypotony and cryopexy were important precipitating factors. Visual results were poor, with six of seven eyes showing no light perception. The mean follow-up time was 12.8 months. Once acute MSCH is recognized intraoperatively, surgical decompression at that time should be avoided as MSCH itself may tamponade the choroidal bleed. Details of prevention and management are discussed.

Laser treatment of macular holes.

Macular holes have not been treated with the laser because of the rarity of subsequent total retinal detachment (RD). The authors attempted to clear the subretinal fluid of the halo by laser coagulation of the rim of the hole. Eighteen eyes with visual acuity of 20/200 or less were treated with a laser and followed for a mean of 34.8 months. Ten eyes (55.6%) improved three to eight lines, five eyes (27.8%) remained the same, and the vision of three (16.6%) deteriorated three to five lines. The best visual results noted in three eyes (20/400-20/70, 20/200-20/80, and 20/200-20/60) correlated with the least late loss of pigment epithelium and pigment migration.

Prospective Clinical, Study of Radial Keratotomy

A prospective clinical study of radial keratotomy was conducted at the University of Maryland. Results of surgery on 33 eyes of 19 patients with a minimum follow-up of seven months and a mean of 13.8 months are reported. There were eight patients (15 eyes) who needed adequate unaided visual acuity for occupational purposes. Preoperative visual acuity was 20/400 in 79% of eyes. Postoperative visual acuity was 20/50 or better in 48% of cases. However, in patients with preoperative refractive errors of 5 diopters or less, postoperative visual acuity was 20/50 or better in 84% of cases. Average decrease in myopia was 2.5 diopters. Decrease in myopia following radial keratotomy did not correlate with corneal curvature or whether 8 or 16 incision technique was used. However, there was a very significant (P = 0.001) difference in postoperative visual acuity of patients with refractive error of 5 diopters or less, as compared to those with greater than 5 diopters of myopia. Complications included corneal scarring, vascularization, and glare. No microperforation or endothelial cell loss was observed.

Transient Myopia and Accommodative Paresis Following Retinal Cryotherapy and Panretinal Photocoagulation

Loss of accommodation, transient myopia, or both, were complications following retinal cryotherapy in two eyes and after panretinal photocoagulation in six eyes (seven patients). A 17-year-old young man had these refractive difficulties one week after cryotherapy for retinal holes. His accommodative amplitude measured 1.0 D in the treated eye and 8.0 D in the untreated eye. One week later he received cryotherapy to the previously untreated eye, reducing that accommodative amplitude to 2.5 D. Accommodative paresis and transient myopia resolved without treatment within five weeks. Six other patients (six eyes, seven episodes) with an average age of 33 years demonstrated accommodative loss (40% to 92% decrease, average decrease 64%), transient myopia, or both, after panretinal photocoagulation for proliferative diabetic retinopathy. All patients recovered without treatment within six weeks (average, 22 days). All young patients should be made aware of this transient, but troublesome complication before treatment.

Crohn's disease complicated by idiopathic central serous chorioretinopathy with bullous retinal detachment.

SummaryA case of idiopathic central serous chorioretinopathy with bullous retinal detachment occurring in a patient with Crohns disease is described. This rare eye condition (36 reported cases in the worlds literature) has previously been seen in association with ulcerative colitis, and its occurrence in a patient with Crohns disease suggests that it may represent another ophthalmologic complication of inflammatory bowel disease.

Abnormal dark adaptation in adult patients with protein-energy malnutrition: Correction by protein-energy repletion

Abstract Markedly abnormal dark adaptation was observed in three patients with treated pancreatic insufficiency and one patient with histologically inactive alcoholic cirrhosis despite normal serum vitamin A (>40 μg/dl) and zinc levels (>70 μg/dl). Intrinsic retinal disease was excluded by extensive ophthalmological examinations in each case. Abnormal dark adaptation was associated with protein-energy malnutrition in all patients. In two patients, dietary protein repletion without supplemental vitamin A or zinc led to a rise in serum albumin and serum vitamin A transport proteins, and correction of the dark adaptation abnormality. No change was observed in total serum vitamin A and serum zinc levels after protein repletion for six weeks. These observations may indicate impaired peripheral utilization of retinol in chronically ill patients with protein-energy malnutrition.

Pseudophakic and aphakic retinal detachment mimicking cystoid macular edema

Seventeen eyes of patients who were being followed by their ophthalmologists for aphakic (8 eyes) or pseudophakic (9 eyes) cystoid macular edema (CME) were examined on referral. All eyes showed retinal detachment (RD), and eight eyes had CME with RD. Most RDs were inferior and shallow. Proliferative vitreoretinopathy (PVR) was noted in 15 eyes (88.2%). There was history of vitreous loss during the last intraocular surgery in 88.2% eyes. Visual acuity ranged from 20/40 to hand movements. Fundus view was hazy in most eyes, and indirect ophthalmoscopy was most useful in detecting RD. Retinal reattachment with scleral buckling and/or vitrectomy was achieved in 16 eyes (94.1%). Postoperative visual recovery was jeopardized due to longstanding macular detachment of greater than 1 month in 11 eyes (64.7%). Eight eyes (47%) achieved 20/50 vision whereas 25% did not improve to better than 20/400. Factors leading to failure in making the correct diagnosis and their prevention are discussed.