Biomedical subjects
Publications and source records attributed to C M Greven.
Immunocompromised patients are known to be at risk for varicella-zoster virus reactivation, often in atypical manners. We describe a 30-year-old man with simultaneous involvement of the retina, optic chiasm, and optic nerve with varicella-zoster virus who had a bitemporal visual field defect.
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OBJECTIVE: To determine prognostic factors and visual outcomes in patients with intraocular foreign bodies (IOFBs). DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Fifty-nine consecutive patients undergoing removal of an IOFB with a minimum of 6 months of follow-up. INTERVENTION: Surgical removal of the IOFB and repair of associated ocular trauma. MAIN OUTCOME MEASURES: Final best corrected visual acuity was the main outcome measured. Ocular findings at presentation were compared with final visual acuity to determine prognostic factors for visual outcome. RESULTS: Final best corrected visual acuity of 20/40 or more was obtained in 42 patients (71%) and ambulatory vision (>5/200) was achieved in 50 patients (85%). Presenting visual acuity was predictive of final visual outcome (P < 0.01). Prognostic factors for a better visual outcome (P < 0.05) included better presenting visual acuity and hammering metal on metal as the mechanism of injury. Prognostic factors for a poor outcome (P < 0.05) included poor presenting visual acuity, the presence of an afferent pupillary defect, and vitreous hemorrhage. CONCLUSIONS: Final visual outcomes were excellent in 71% of patients. Presenting visual acuity was the strongest predictor of final visual outcome in this series. Additional predictive factors included the mechanism of injury, the presence of an afferent pupillary defect, and vitreous hemorrhage.
PURPOSE: To report presenting characteristics as well as anatomic and visual results in asymptomatic clinical rhegmatogenous retinal detachment repaired by scleral buckling. METHODS: Review of 28 eyes of 27 patients with an asymptomatic clinical retinal detachment-defined as a rhegmatogenous retinal detachment with subretinal fluid extending more than 2 disk diameters posterior to the equator-which were repaired by scleral buckling from January 1989 through December 1996 with follow-up of 6 months or longer. RESULTS: With a single scleral buckling procedure, anatomic reattachment of the retina occurred in all eyes; one eye redetached 14 months after the initial surgery secondary to a new retinal break and was successfully reattached. All eyes had best-corrected presenting and final visual acuity of 20/50 or better. Final best-corrected Snellen visual acuity was within 1 line of best-corrected presenting visual acuity in 82% of eyes; three eyes improved more than 1 line of Snellen visual acuity and two eyes lost more than 1 line. CONCLUSION: Anatomic and visual results in asymptomatic clinical rhegmatogenous retinal detachment after scleral buckling surgery are excellent. Strong consideration should be given to repair of these detachments.
OBJECTIVE: To test the hypothesis that pretreatment fluorescein angiography (FA) is not necessary for effective laser treatment of patients with clinically significant diabetic macular edema (CSME). DESIGN: Prospective, randomized, controlled treatment simulation. PARTICIPANTS: Six fellowship trained retina specialists. INTERVENTION: The authors compared the ability of four retina specialists (observers) to plan laser treatment with and without the use of FA. One hundred consecutive cases of CSME were selected, each case consisting of a stereo pair of color photographs and a corresponding fluorescein angiogram. These cases were first read by two retina specialists who reached consensus on a treatment plan for each case (standard map). Each of the 4 observers reviewed 50 of these cases on 2 occasions and plotted 2 sets of treatment maps, 1 set created with and 1 without the aid of FA. Each observer's 100 treatment maps were graded for accuracy by comparing them to the corresponding standard maps. The role of FA in improving the accuracy of treatment maps was evaluated using logistic regression analysis to control for different observers, different cases, and different posterior pole characteristics. MAIN OUTCOME MEASURES: Accuracy was defined as the proportion of standard treatment correctly treated by the observer. RESULTS: For the observers as a group, the use of FA improved treatment planning accuracy from 49% to 54.5% (P = 0.02); however, there was significant interobserver variation in performance (P < 0.001). Treatment planning accuracy without and with FA was as follows: observer 1, 40.8% and 40.2%; observer 2, 49.8% and 72%; observer 3, 56.1% and 59.5%; and observer 4, 49.2% and 46.4%. CONCLUSION: The use of FA improves the accuracy of treatment planning for CSME. The authors' study supports the use of FA in laser treatment of patients with CSME.
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PURPOSE: To report the natural history of macular pseudoholes with regard to ophthalmoscopic appearance and visual acuity. METHODS: Thirty-six eyes of 34 patients with macular pseudoholes who were followed up for 1 year or longer were retrospectively evaluated to compare the initial ophthalmoscopic appearance and visual acuity with the most recent follow-up appearance and visual acuity. RESULTS: Mean visual acuity at initial examination was 20/32 (median, 20/30); mean follow-up visual acuity was 20/32 (median, 20/30). Fourteen eyes (39%) had identical initial and final visual acuities, and 30 eyes (83%) had final visual acuity within 2 lines on the visual acuity chart from their initial examination. Four eyes had improved visual acuity of more than 2 lines, and two eyes lost more than 2 lines of visual acuity. Thirty-one eyes had adequate initial and follow-up photographs allowing comparison of macular appearance. Twenty-three (74%) of the 31 eyes showed a definitive change in macular appearance. CONCLUSIONS: Visual acuity in patients with macular pseudoholes tended to remain stable. However, the macular appearance changed in 74% of eyes.
PURPOSE: To present the clinicopathologic features of the eyes of a patient with age-related macular degeneration (ARMD): the right eye was treated for well-defined extrafoveal choroidal neovascularization (CNV), and the left eye had an untreated disciform scar. METHODS: The patient was studied ophthalmoscopically and by fluorescein angiography at the time of presentation and on follow-up examinations up to 54 days after laser treatment, when he died. The posterior portions of both eyes (obtained postmortem), including the macula and optic nerve head, were sectioned serially for light microscopy. Tissue sections from both eyes were removed from glass slides and studied by transmission electron microscopy. RESULTS: Histopathologic study of the right eye disclosed a thin layer of basal laminar deposit throughout the posterior pole. Two defects in Bruch's membrane without CNV were present within the area of laser photocoagulation located superior to the fovea. No CNV was present in the scar. Eleven areas of early CNV were present in the posterior pole. Histopathologic study of the left eye showed a prominent basal laminar deposit throughout the posterior pole. A 2.6 x 2.7 mm disciform scar was present that was located mostly in the subretinal space. Four sources of CNV were present. CONCLUSIONS: The clinicopathologic features of a treated eye with well-defined extrafoveal CNV, and the fellow eye with a disciform scar, both associated with ARMD, are presented. Although laser treatment obliterated a choroidal neovascular membrane, 11 additional areas of early, subclinical CNV were present.
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PURPOSE: To describe a patient with peripheral retinal neovascularization and vascular occlusion associated with activated protein C resistance. METHODS: Case report. A 63-year-old woman was examined for acute loss of vision in both eyes. She was noted to have macular edema in both eyes as well as a macular branch vein occlusion in the right eye and a central retinal vein occlusion in the left eye. Peripheral retinal neovascularization was present in both eyes. RESULT: Extensive systemic evaluation disclosed a heterozygous state for the factor V Leiden indicating activated protein C resistance. CONCLUSION: Activated protein C resistance may be associated with peripheral retinal neovascularization.
Retinal arterial occlusions occur secondary to a multitude of mechanisms. The evaluation and workup of a patient with a retinal arterial occlusion depends on many factors, including the age and the systemic health status of the patient. Retinal arterial occlusions in the young typically occur by somewhat different mechanisms than do arterial occlusions in older adults. This article reviews the recent literature related to the etiology and diagnostic evaluation of retinal arterial occlusions in young people as well as potential new managements.
PURPOSE: To determine the cause, associated factors, visual results, and systemic morbidity in patients less than 40 years old with retinal arterial occlusions. METHODS: We studied 27 eyes with nontraumatic retinal arterial occlusions in 21 patients less than 40 years old (range, 22 to 38 years; mean, 28 years). RESULTS: Of the 21 patients, branch retinal artery (arteriolar) occlusion occurred in 15 (71%), central retinal artery occlusion occurred in five (24%), and cilioretinal artery occlusion occurred in one (5%). Retinal artery occlusions were bilateral in six patients (29%) and occurred in 14 women (67%). Emboli were identifiable in seven patients (33%). Cardiac valvular disease was the most commonly recognized etiologic agent and was present in four patients (19%). Various associated factors leading to a hypercoagulable state or embolic condition were identified in 19 patients (91%). CONCLUSION: Retinal arterial occlusions in young adults occur via multiple mechanisms. Systemic evaluation allows detection of a risk factor for retinal arterial occlusive disease in most patients.
BACKGROUND: A syndrome consisting of rapidly progressive outer retinitis in patients with suppressed immune systems has been described. The etiologic agent appears to be a member of the herpes virus family. METHODS: A 41-year-old man with acquired immune deficiency syndrome (AIDS) developed bilateral outer retinitis and choroiditis, which progressed despite antiviral treatment. A transscleral eye wall biopsy specimen and whole globe were submitted for microbiologic and histologic study. RESULTS: Polymerase chain reaction of a transscleral eye wall biopsy specimen and of the enucleated specimen determined the etiologic agent to be varicella zoster virus (VZV). Histologic studies demonstrated intranuclear inclusions consistent with viral particles in choroidal cells. CONCLUSION: Our study revealed intranuclear inclusions in choroidal cells, a previously undocumented finding in progressive outer retinal necrosis. Polymerase chain reaction was very useful in identifying the causative agent.
The objective of this study was to report the occurrence of reactivation ocular toxoplasmosis in bone marrow transplant (BMT) recipients and to propose guidelines for identification and chemoprophylaxis of high-risk patients. The study design was a series of cases from the tertiary care university hospital which has an active BMT program. The patients were two recipients of autologous BMTs with past histories of toxoplasma retinochoroiditis who developed symptomatic reactivation of ocular toxoplasmosis as documented by formal opthalmologic examination in the early post-transplant period. Opthalmoscopic examinations in the two patients with non-Hodgkin's lymphoma who received autologous transplants and then developed decreased visual acuity in the first week after transplant revealed recurrent retinochoroiditis adjacent to old toxoplasma lesions. Pre-transplant eye examinations in both patients had demonstrated only inactive chorioretinal scars. Therapy with sulfadiazine, pyrimethamine and prednisone ultimately led to resolution of retinitis in both patients. BMT recipients who are seropositive for antibody to T. gondii and have findings consistent with previous toxoplasma retinochoroiditis on pre-transplant ophthalmologic examination appear to be at risk for reactivation of ocular toxoplasmosis in the early post-transplant period and may warrant preventive chemoprophylaxis for toxoplasmosis.
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A 75-year-old man presented with a diffuse necrotizing retinitis in his left eye. Although his condition was initially diagnosed as acute retinal necrosis syndrome, the serologic test results were interpreted as indicating recurrent toxoplasmosis retinitis. Cytopathologic examination of the vitreous following pars plana vitrectomy for repair of a retinal detachment revealed Toxoplasma organisms. The observation of Toxoplasma gondii in the vitreous specimen confirmed our clinical diagnosis and helped guide treatment of the patient.
PURPOSE: Intraocular infection caused by Candida species can have devastating visual consequences. With the emergence of Candida as a major nosocomial pathogen, the authors investigated the prevalence of ocular lesions in patients with candidemia and evaluated risk factors for eye involvement. METHODS: This study is a prospective, multicentered, observational design. One hundred eighteen patients with candidemia were evaluated by the infectious disease service and received indirect ophthalmologic examination within 72 hours of a reported positive blood culture. Ocular findings were classified on the basis of objective, pre-determined criteria. Candida chorioretinitis was defined as the presence of focal, white, infiltrative chorioretinal lesions without vitreal involvement. Candida endophthalmitis was defined as chorioretinitis with extension into the vitreous or intravitreal "fluff balls." RESULTS: In contrast to previous studies of patients with candidemia citing prevalence rates of endophthalmitis approaching 40%, no patients were shown to have endophthalmitis. Candida chorioretinitis was seen in 9% of the patients, all of whom received antifungal agents. The observation that chorioretinitis never progressed to endophthalmitis suggests that systemic antifungal agents provided adequate ocular therapy. Risk factors for Candida chorioretinitis include fungemia with Candida albicans (versus nonalbicans species), multiple positive blood cultures, visual symptoms, and immunosuppression. Twenty percent of patients had nonspecific ocular lesions not directly related to infection. CONCLUSION: Patients with candidemia who have the risk factors noted above warrant formal ophthalmologic examination.