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Oxacillin-resistant Staphylococcus aureus endophthalmitis after ganciclovir intraocular implant.

PURPOSE: To describe a patient who developed oxacillin-resistant Staphylococcus aureus endophthalmitis after insertion of a ganciclovir intraocular implant. METHOD: Case report. RESULTS: A 42-year-old man with acquired immunodeficiency syndrome (AIDS) and a history of cytomegalovirus retinitis was admitted with right-sided eye pain and decreased visual acuity 10 days after receiving a second ganciclovir intraocular implant in the right eye. A therapeutic vitrectomy, right eye, was performed on the day of admission. A vitreal tap produced frank pus and white, fluffy debris. Cultures of the vitreal fluid grew oxacillin-resistant S aureus, sensitive only to vancomycin, rifampin, and trimethoprim/sulfamethoxazole. The patient was successfully treated with removal of both ganciclovir implants in the right eye and a 4-week course of vancomycin and rifampin. However, the infection left the patient blind in the infected eye. CONCLUSION: Bacterial endophthalmitis is an infrequent but serious complication of the ganciclovir intraocular implant.

AIDS-Related Opportunistic Infections↗

Vitreoperfusion. A new approach to ocular ischemia.

No satisfactory treatment is available to supply the metabolic needs of the retina in vascular occlusion. Consequently, necrosis occurs. We devised vitreoperfusion, a technique of perfusing the vitreous cavity after vitrectomy-lensectomy with selected fluids containing glucose and oxygen. We tested whether vitreoperfusion could protect the retina from severe combined retinal and choroidal ischemia. An intraocular pressure of 170 mm Hg was induced in each eye of nine cats for up to four hours, and simultaneously one eye of each cat underwent vitreoperfusion. After one week, histopathologic examination revealed retinal atrophy and dissolution in untreated eyes but not in eyes treated with vitreoperfusion. To our knowledge, such severe ischemia has never been treated successfully before. Vitreoperfusion is a potential treatment modality in various forms of ocular ischemia. Additional studies are warranted to refine the technique and determine any clinical applicability.

Animals↗

Pupil size after extracapsular cataract extraction and posterior chamber lens implantation: a prospective randomized trial of epinephrine and acetylcholine.

The effects of using epinephrine in the irrigating fluid and intracameral acetylcholine were studied by measuring changes in pupil size in the 48 hours following extracapsular cataract extraction and intraocular lens implantation in 39 eyes. Epinephrine reduced peroperative pupil constriction, but its effect was insignificant thereafter. The pupil constriction following acetylcholine was maximal at 2 hours and was still significant at 4 hours, but pupils redilated by 6 hours. Neither drug had any effect after this time. The edge of most lens implants was visible at 6 hours, after which pupils steadily constricted.

Acetylcholine↗

Treatment of intraocular retinoblastoma with carboplatin and etoposide chemotherapy.

PURPOSE: Management of intraocular retinoblastoma was initiated with 2-drug chemotherapy in an effort to improve the rate of vision preservation and ocular salvage and to avoid or delay the use of external beam radiation treatment. METHODS: Six patients with intraocular retinoblastoma (five bilateral; one unilateral, 1 month old) received 6 to 7 monthly cycles of intravenously administered carboplatin and etoposide (VP-16) as primary treatment. No eyes were enucleated primarily. Twelve of the 33 discrete tumors in the 11 study eyes received prophylactic supplemental treatment with cryotherapy or laser hyperthermia. Response was documented with frequent eye examinations with the patient under general anesthesia and with repeated fundus photography. RESULTS: All eight larger tumors (> 10-mm diameter) underwent dramatic regression after treatment with chemotherapy alone, and six of these tumors ultimately became fully calcific. One larger tumor and two smaller tumors showed post-treatment growth, each within 2 months after completion of chemotherapy. Six larger tumors were observed without growth or further treatment for 7 to 21 months after completion of chemotherapy. Subretinal fluid resorbed completely in four of four eyes with extensive retinal detachment, and vitreous seeding diminished considerably in four of four eyes. In five eyes, intraocular disease recurrence at a distance from any initially observed tumor eventually required treatment with external beam radiation (three eyes) or enucleation (three eyes). Eight of 11 involved eyes were salvaged, including 5 of 8 with larger tumors and 4 of 4 with vitreous seeding; 4 retained eyes received no radiation exposure, including 3 with larger tumors and 1 with vitreous seeding. Good vision was preserved in six eyes, two of which were markedly improved after occlusion therapy for amblyopia. There was no extraocular disease recurrence and no serious harm from treatment during observation ranging from 12 to 40 months after diagnosis. CONCLUSION: Chemotherapy with carboplatin and etoposide shows promise as initial treatment for intraocular retinoblastoma. Further study is indicated to define its proper role in the management of this disease.

Antineoplastic Agents↗

Fuchs heterochromic cyclitis: rubella virus antibodies and genome in aqueous humor.

PURPOSE: To characterize the polyspecific intraocular antibody synthesis in aqueous humor of patients with chronic inflammatory diseases of the eye and to detect the causative antigen in Fuchs heterochromic cyclitis (FHC). DESIGN: Retrospective case-control study. METHODS: Intraocular antibody synthesis is detected in aqueous humor with the Antibody Index [AI] (improved Goldmann-Witmer Index) and quantified as specific antibody fraction, F(s) (intraocular specific antibody concentration in percent of intraocular total immunoglobulin G in aqueous humor). Virus detection is by nested polymerase chain reaction. RESULTS: Fifty-two eyes of 52 patients with clinically defined FHC (aged 16-73 years) had an intraocular synthesis of rubella antibodies (AI > or =1.5). The rubella genome was detected in 5 (18%) of 28 aqueous humor samples investigated, or in 5 (56%) of 9 patients aged <40 years. Oligoclonal IgG was synthesized in 34 (87%) of 39 eyes. Unaffected fellow eyes (n = 3) or cerebrospinal fluid (n = 2) were normal. In FHC the median rubella AI = 20.6 (total range 1.5-309) was seven times higher than in multiple sclerosis (MS) patients (n = 15) with uveitis intermedia or periphlebitis retinae. In MS the intraocular rubella antibody synthesis (frequency 73%) is part of a polyspecific immune response (increased measles AI in 80%, varicella zoster virus AI in 47%, herpes simplex virus AI in 23%). The median rubella-F(s) = 2.6% in FHC (range = 0.14%-45.9%) was approximately 40 times higher than in MS, consistent with a virus-driven antibody response in FHC. Noninflammatory controls (50 senile cataracts) had neither an intraocular rubella antibody synthesis (normal AI < or =1.4) nor rubella antigen in aqueous humor. The rubella AI was normal in all patients with an intraocular toxoplasmosis (n = 24), anterior uveitis (n = 27), herpes simplex virus iritis (n = 25), and varicella zoster virus iritis (n = 14). CONCLUSIONS: Fuchs heterochromic cyclitis is a rubella virus-driven disease with persistence of the virus preferentially detected in the younger patients. The proposed laboratory supported diagnosis of FHC is based on the increased rubella Antibody Index. The virus etiology gives a rationale for omitting the ineffective corticosteroid therapy of FHC.

Adolescent↗

Epikeratophakia for control of pediatric bullous keratopathy.

A child who had had a congenital cataract phacoemulsified at age four months became contact lens intolerant, and at age two years had an implantation of a Worst metal-looped iris-clip intraocular lens. He developed painful pseudophakic bullous keratopathy three years later. Since the child remained with dense deprivation amblyopia and contact lens intolerance, when the IOL was removed an epikeratophakia graft was applied. The bullous keratopathy resolved and the patient has remained asymptomatic for 22 postoperative months. The proposed mechanism for relief of the bullous keratopathy is to increase tissue thickness and resistance, thus reducing fluid volume transferred to the subepithelial space.

Cataract↗

Ciliochoroidal detachment.

Ciliochoroidal detachments occur under a variety of pathological circumstances and are most commonly noted following intraocular surgery where hypotony is combined with postoperative inflammation. Although the condition is easily recognized, the pathophysiologic mechanisms involved are not well understood. In this review, the pathophysiologic mechanisms are summarized, with special emphasis on fluid dynamics within the suprachoroidal space. The clinical features, etiology and treatment of ciliochoroidal detachments are also reviewed.

Animals↗

[Intraocular complications following Custodis-Lincoff operation].

This investigation is based on 262 cases of retinal detachment treated with episcleral silastic sponge implants and cryopexy. Anatomical restoration of the retina after one operation or more was successful in 89 percent. Drainage of subretinal fluid was carried out in 52 percent of the cases. Supplementary light-coagulation 3 or 4 weeks after the operation was applied in 43 cases (17 percent) in order to seal off retinal holes on the buckle due to inadequate chorioretinal adhesion following cryopexy. Insufficient adhesion was directly related to the retinal elevation in the area of the tear. Chorioretinal haemorrhages in the group without release of subretinal fluid were caused by the following factors: Repeated cryo-application in the same place, application of the probe on the open part of the tear instead of around the tear, sponge-fixation in the immediate area to vortex veins, pressure exerted by the sponge on choroidal and retinal vessels, particularly in persons of advanced age. Local haze of the vitreous corresponding to the location of the cryp-application was directly related to the number of applications and the position of the tear. Vitreous haze was more frequent where the hole was situated towards the ciliary body. Pigment migration was observed in 9 percent of the cases. It should be noted that this complication was also encountered preoperatively in a group amounting to 4 percent of the total number of cases after padding of the eyes and absorption of subretinal fluid. Such cases should be distinguished from those of postoperative occurrence of pigment migration. Detachment of the choroid happened more often in the group in which subretinal fluid was released. In this group expulsive haemorrhage also occurred, which, apart from the choroidal detachment, resulted, immediately upon drainage of subretinal fluid, in high intracular pressure. Macular puckering was noticed in 5 cases (2,7 percent). In 4 out of the 5 cases with this complication, the tear was located towards the posterior pole and sponge fixation was radial.

Choroid↗

A new intraocular aspiration probe with bipolar cautery and reflux capabilities.

The design of the Mentor Wet-Field eraser (Mentor O & O Inc, Norwell, Mass) has been modified so as to include fluid aspiration and reflux capabilities. This 20-gauge disposable probe minimizes instrument exchange through sclerotomy ports and provides sensitive control over reflux action by minimizing the dead-space volume over which reflux occurs. Safer manipulation of detached retina, membranes, and clots is therefore achieved.

Cautery↗

Mechanisms of immune privilege in the eye and hair follicle.

It has been recognized for over a century that the eye is endowed with remarkable properties that permit the long-term survival of foreign tumor and tissue grafts that are normally rejected at extraocular sites. This ocular immune privilege was originally attributed to a putative sequestration of antigens in the eye as a result of the conspicuous absence of intraocular lymphatic drainage channels. In the last 30 years, a sizeable body of information indicates that ocular immune privilege is a product of multiple anatomical, physiological, and immunoregulatory processes. Ocular tissues and fluids express a wide variety of anti-inflammatory and immunosuppressive molecules, including CD95L (FasL), transforming growth factor-beta, macrophage migration inhibitory factor, alpha-melanocyte-stimulating hormone, calcitonin gene-related peptide, somatostatin, and complement regulatory proteins. Moreover, antigens entering the anterior chamber of the eye evoke a unique form of immune deviation that culminates in the antigen-specific suppression of TH1 immune responses. Finally, the intraocular milieu contains both cell membrane and soluble factors that inhibit both the adaptive and innate immune systems. The hair follicle is also recognized for its immune privilege. Like the anterior chamber of the eye, it produces anti-inflammatory and immunosuppressive cytokines, such as transforming growth factor-beta and adrenocorticotrophic hormone. The cells of the hair follicle display limited expression of class Ia MHC molecules and, like cells that line the anterior chamber of the eye, are protected against CD8+ cytotoxic T lymphocyte attack. Gaining a better understanding of the immune privilege of the hair follicle may provide insights into the regulation and pathogenesis of immune-mediated diseases of the skin.

Animals↗

Catastrophic acute retinal necrosis syndrome associated with diffuse orbital cellulitis: a case report.

BACKGROUND: To report a case of severe acute retinal necrosis syndrome (ARN) associated with initial features of orbital cellulitis. METHODS: A 49-year-old immunocompetent woman presented with unilateral painful orbital inflammation associated with deep visual loss due to ARN. Polymerase chain reaction (PCR) for detection of viral DNA was applied to ocular fluids. Immunohistochemistry for detection of viral antigens and histopathologic studies were performed on orbital biopsy specimens. RESULTS: HSV-2 DNA was detected by PCR in ocular fluids. Orbital biopsy disclosed non-specific inflammation without viral replication. Orbital inflammation resolved rapidly after the initiation of antiviral drugs, whereas intraocular inflammation worsened. Final ophthalmic examination disclosed no light perception due to optic atrophy. CONCLUSION: ARN and cellulitis may be associated. Consequently, ARN should be investigated in all patients with orbital inflammation, in order to initiate immediately an appropriate antiviral strategy.

Antibodies, Viral↗

Lectin affinity and PAGE analysis of soluble axonally transported glycoconjugates in the rat visual system.

Recent reports of the transsynaptic transfer of wheat germ agglutinin (WGA) in several systems are consistent with the hypothesis that WGA binds to endogenous glycoproteins(s) which undergo transsynaptic transfer. Such molecules might be involved in trophic interactions between neurons. Since these hypothetical glycoproteins must be soluble proteins (it is unlikely that integral membrane proteins are exchanged between neurons) this preliminary study of the soluble, axonally transported glycoconjugates of the visual system was undertaken. Soluble, tritium-labeled macromolecules which accumulated in the rat lateral geniculate nucleus (LGN) and visual cortex after intraocular injections of tritiated fucose were studied by lectin affinity chromatography and polyacrylamide gel electrophoresis (PAGE). After correction for hematogenously or cerebrospinal fluid transported label, 9.6% of the radioactivity in the LGN and 17.9% of the radioactivity in the visual cortex was found in the soluble fraction of a phosphate-buffered saline homogenate. In the LGN, 31.3% of the axonally transported soluble label was bound by concanavalin-A (Con-A) agarose. The corresponding figure in the visual cortex was 25.7%. Most (greater than 90%) of the label which did not bind Con-A was soluble in 10% trichloroacetic acid (TCA). Eighty-eight percent of the label which bound Con-A was precipitated by 10% TCA. On 7.5% polyacrylamide SDS reducing gels, the Con-A bound material from either the LGN or the visual cortex migrated as a single peak near the origin of the gel (apparent molecular weight greater than 300,000 Da).(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

Adrenomedullin in the eye.

Adrenomedullin (AM) is a multifunctional regulatory peptide that is produced and secreted by various types of cells. We showed the presence of high concentrations of adrenomedullin-immunoreactivity in the vitreous fluid, and the levels were elevated in patients with proliferative vitreoretinopathy. Furthermore, adrenomedullin mRNA expression levels were elevated in the tissues of intraocular tumors and orbital tumors. Adrenomedullin is produced and secreted by cultured human retinal pigment epithelial (RPE) cells. Inflammatory cytokines and hypoxia are strong stimulators for the adrenomedullin expression in retinal pigment epithelial cells. Adrenomedullin stimulated the proliferation of retinal pigment epithelial cells both under normoxia and hypoxia. Dexamethasone (DEX) increased the adrenomedullin expression in two cultured cell lines of human retinal pigment epithelial cells; ARPE-19 cells and D407 cells, while it had no noticeable effects on the cytokine-induced adrenomedullin expression. These findings suggest that adrenomedullin is involved in the pathophysiology of inflammatory and neoplastic eye diseases as an autocrine or paracrine growth stimulator. The findings on glucocorticoid-induced AM expression raise the possibility that it may be related to the pathogenesis of some eye diseases, such as central serous chorioretinopathy and multifocal posterior pigment epitheliopathy, which are frequently seen in patients treated with high doses of glucocorticoids.

Adrenomedullin↗

Structural aspects of isozyme selectivity in the binding of inhibitors to carbonic anhydrases II and IV.

Carbonic anhydrase inhibitors are effective in lowering intraocular pressure, the primary indication of glaucoma. Human carbonic anhydrase II, and possibly carbonic anhydrase IV (CAII and CAIV, respectively), help regulate fluid secretion into the anterior chamber of the eye. Because inhibitors currently formulated as drugs to treat glaucoma were designed to target CAII, an understanding of the structural basis of CAII-CAIV discrimination by inhibitors would be useful for probing the role of each isozyme in the etiology of the disease. Here, we report the X-ray crystal structures of three novel thieno[3,2-e]-1,2-thiazine-6-sulfonamides complexed with CAII and the computationally predicted structures of the same compounds complexed with CAIV. All three compounds bind with similar affinity to CAII, but they bind with up to 100-fold lower affinities to CAIV. Comparisons of experimentally determined structures of CAII-inhibitor complexes and computationally predicted structures of CAIV-inhibitor complexes allow us to rationalize these affinity trends and outline molecular features that may contribute to high-affinity inhibitor binding to CAIV. This study demonstrates how experimental structure determination methods and computational structure prediction methods can be used together to answer questions that cannot be answered by either method alone.

Carbonic Anhydrase II↗

Hypertropia following insertion of inferiorly sited double-plate Molteno tubes.

The use of double-plate Molteno tubes is well established in the management of intractable glaucoma, particularly in eyes that may have had previous surgical procedures, often involving the superior conjunctiva with subsequent subconjunctival scarring. As it is frequently the case that the area of least scarring is inferiorly, we have sited the tubes there but have found that, although this usually provides good control of intraocular pressure, successful drainage of aqueous has been associated with the development of hypertropia due to upward displacement of the globe by fluid encapsulated around the plates. We report a retrospective study of 16 eyes undergoing inferiorly sited double-plate Molteno tubes, in which 9 eyes developed significant hypertropia at a mean time after insertion of 3.5 months. Mean degree of hypertropia was 9.8 prism dioptres. The management of this complication is discussed.

Adolescent↗

[Risk factors for surgical failures in rhegmatogenous retinal detachment].

BACKGROUND: The evaluation of further risc factors predesposing failure in retinal detachment surgery than those already known to be associated with PVR was the goal of this retrospective study. PATIENTS AND METHODS: The data from 130 cases with unilateral rhegmatogenous retinal detachment treated initially with buckling procedures, were retrospectively reviewed to investigate pre-, intra- and postoperative factors which may predispose anatomical failure in retinal detachment surgery. None of the selected consecutively operated eyes had risk factors, which have already been associated with an unfavourable outcome, such as the presence of preoperative macular holes, PVR or assumed PVR-inducing factors, such as ocular trauma, giant retinal tears, vitreous hemorrhage, previous vitrectomy, cryopexy and laser photocoagulation. RESULTS: The anatomic success rate after scleral buckling procedures was 78.5% and the overall success rate after multiple surgery including vitrectomy increased to 94.6%. 102 (78.5%) cases, treated with a maximum of two scleral buclking operations were statistically compared to the 28 cases which needed further vitreoretinal surgery. The statistical analysis revealed as preoperative risk factors for failure in rhegmatogenous retinal detachment surgery 1) retinal detachment exceeding two retinal quadrants (p < 0.05) and 2) size of the retinal tear larger than 60 degrees (p < 0.05), whereas postoperative risk factors were 1) presence of subretinal hemorrhage (p < 0.01) and 2) persistent subretinal fluid at least two days after surgery (p < 0.01). Eyes with preoperative visual acuity less than 0.1, pseudophacic eyes with posterior chamber intraocular lenses and eyes with severe intraoperative hypotony also showed a tendency to unfavourable outcome, but without a statistically significant level. CONCLUSIONS: Possible ways of interfering in the retinal reattachment process and the clinical importance of these evaluated factors are discussed. They should be taken in consideration for the prognosis of the postoperative anatomical result and treatment modalities if further surgery is required.

Adult↗