Combined pleural fluid cholesterol and total protein in differentiation of exudates and transudates.

Background. The management strategy to be adopted in pleural effusion depends on whether an effusion is a transudate or exudate. Objective. To evaluate the usefulness of pleural fluid cholesterol and/or total protein measurements for differentiating between exudates and transudates, and to compare it with Light’s criteria. Methods. In this prospective study 60 patients with pleural effusion were included. Pleural fluid total protein, lactate dehydrogenase (LDH) and cholesterol as well as serum total protein and LDH levels along with other investigations were studied. Clinical classification of transudate or exudate was done on the basis of aetiology. Results. Based on clinical signs and symptoms, chest radiograph, other investigations and response to treatment, 49 of these effusions were classified as exudates and 11 as transudates. Using pleural fluid cholesterol levels at a cut-off point of greater than 60 mg/dL and/or total protein at a cut-off point of greater than 3 g/dL for distinguishing transudates and exudates, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), were 100 percent. Using Light’s criteria for discriminating transudates and exudates, sensitivity, specificity, PPV and NPV were found to be 98%; 100%; 100% and 92%, respectively. The differences resulted from a mis-classification of one expected exudate as transudate by Light’s criteria. Conclusion. Pleural fluid cholesterol and total protein are simple, cost-effective, and useful parameters in distinguishing pleural transudates from exudates, with the advantage of requiring only two laboratory determinations and no simultaneous blood sample, compared to the use of Light’s criteria.

Full-thickness Sclerotomy for Uveal Effusion Syndrome

To report the surgical outcome of full-thickness sclerotomy in five cases of uveal effusion syndrome (UES). Full-thickness sclerotomy without sclerectomy was performed on five eyes of four patients with UES with or without nanophthalmos. In four of the eyes, exudative retinal detachment associated with UES resolved after the sclerotomy. The subretinal fluid in one eye, which had a normal axial length, was relieved after undergoing three sclerotomy procedures. Full-thickness sclerotomy without vortex vein decompression or sclerectomy is an effective surgical option for the management of significant UES.

Subretinal lipid exudation associated with untreated choroidal melanoma.

Subretinal lipid exudation in an untreated choroidal melanoma is very rare. It is seen following plaque radiotherapy in choroidal melanoma. There is only one case report of untreated choroidal melanoma with massive lipid exudation in a patient with metastatic hypernephroma. We report here a rare case of untreated choroidal melanoma with lipid exudation. Subretinal exudation that is rarely seen following plaque brachytherapy was noted at the borders of this untreated tumor. Lipid exudation partially resolved following brachytherapy.

Microalbuminuria and low hemoglobin as risk factors for the occurrence and increasing severity of diabetic retinopathy.

Aim: To assess the influence of urinary microalbuminuria and hemoglobin concentration on the occurrence and severity of diabetic retinopathy (DR), clinically significant macular edema (CSME) and hard exudate formation. Materials and Methods: In this prospective cross-sectional study carried out over a period of 2 years, type 2 diabetic patients seeking ocular evaluation for DR were assessed for presence and severity of DR, presence of hard exudates and CSME. Retinal findings were correlated to severity of microalbuminuria, hemoglobin concentration and other systemic risk factors using linear regression analysis. Results: Three hundred and six patients were included in the study. DR of any grade was seen in 132 (43%) patients, hard exudate formation in 93/306 (30.4%) patients, CSME in 50/306 (16.3%) patients and proliferative DR in 26/306 (8.5%) patients. Duration of diabetes (P <0.001), microalbuminuria (P <0.001) and low hemoglobin (P = 0.001) were found to be highly significant risk factors for the development and increasing severity of DR as well as for CSME and hard exudate formation. Conclusion: Microalbuminuria and low hemoglobin are strong predictors for DR, CSME and hard exudate formation in type 2 diabetics even after correcting for duration of diabetes and other systemic risk factors. Although not directly involved in the pathogenesis, microalbuminuria can help in identifying patients at risk for more severe diabetic eye disease. Microalbuminuria warrants intensive monitoring of both retinal and renal status. The hemoglobin levels should be monitored regularly in diabetic patients to detect and treat anemia, thereby reducing one risk factor for DR.

Acute-Onset Bilateral Myopia and Ciliochoroidal Effusion Induced by Hydrochlorothiazide

The authors experienced two cases of hydrochlorothiazide (HCTZ)-induced acute-onset bilateral myopia and shallowing of the anterior chambers. Two middle-aged women taking HCTZ, a sulfa derivative, visited our clinic complaining of acute bilateral visual deterioration. Both had good visual acuity without corrective lenses before taking HCTZ. A complete ophthalmologic examination revealed bilateral myopic shift, intraocular pressure elevation, shallowing of the anterior chambers, choroidal effusions, radiating retinal folds, and conjunctival chemosis. Approximately one week after HCTZ discontinuance, all ocular changes disappeared completely. Physicians should be aware of the adverse ocular effects of HCTZ and should manage patients accordingly.

Castleman's Disease Presenting with Uveal Effusion Syndrome

We report a rare case of multicentric Castleman's disease that presented with ophthalmic involvement, along with a review of the literature. A 63-year-old male presented with decreased visual acuity in both eyes. Both eyes had serous elevations of the retinas with shifting subretinal fluid and annular choroidal detachment. No retinal breaks were found. Laboratory tests revealed pancytopenia, hypergammaglobulinemia, and an increased erythrocyte sedimentation rate. Chest and abdominal computed tomographies showed multiple lymphadenopathies in the mediastinum, abdomen, and in both inguinal areas. Histological examination of the inguinal lymph node biopsy was consistent with Castleman's disease. After combination chemotherapy, the serous elevations of both retinas and the annular choroidal detachments of both eyes disappeared. Ophthalmic involvement in Castleman's disease is very rare, and to the authors' knowledge, this is the first report of ophthalmic involvement of Castlemans's disease in Korea.

Fibrinous anterior uveitis following laser in situ keratomileusis.

A 29-year-old woman who underwent laser in situ keratomileusis (LASIK) for myopic astigmatism in both eyes presented with severe pain, photophobia and decreased visual acuity in the left eye eight days after surgery. Examination revealed severe anterior uveitis with fibrinous exudates in the anterior chamber, flap edema and epithelial bullae. Laboratory investigations for uveitis were negative and the patient required systemic and intensive topical steroids with cycloplegics to control the inflammation. This case demonstrates that severe anterior uveitis may develop after LASIK and needs prompt and vigorous management for resolution.

Successful management of presumed Candida endogenous endophthalmitis with oral voriconazole.

Endogenous fungal endophthalmitis is most commonly caused by Candida species and usually occurs in patients with chronic diseases such as diabetes mellitus and renal insufficiency. Voriconazole, a broad-spectrum triazole antifungal agent, attains therapeutically significant concentrations in the vitreous cavity after systemic administration. We report, the successful management of presumed endogenous Candida endophthalmitis in a patient with multiple diseases and unstable systemic status with oral voriconazole. Though fungal endophthalmitis has been successfully treated with a combination of intravenous and intravitreal voriconazole, to the best of our knowledge this is the first report in ophthalmic literature (Medline Search) on the treatment of fungal endophthalmitis with only the oral route of administration of voriconazole.

Anterior chamber exudative mass due to Scedosporium apiospermum in an immunocompetent individual.

Endogenous intraocular infection of fungal etiology is extremely rare in an immunocompetent individual. Usually, an antecedent history of trauma, surgery, intravenous drug abuse or an immunocompromized state can be elicited. Scedosporium apiospermum is a known cause of keratomycosis after traumatic implantation and can cause fatal disseminated infection in immunocompromized patients. However, cases of S. apiospermum intraocular infection in immunocompetent individuals have been very rarely reported in literature. We report here a case of an anterior chamber exudative mass due to S. apiospermum in an immunocompetent individual which was managed successfully with anterior chamber wash and intravitreal injection of voriconazole.

Transudado o exudado? observaciones al proceso diagnóstico en derrames pleurales / Transudate or exudate? observations on the diagnostic process of pleural effusions

Los criterios de Light han tenido bajo rendimiento en manos de otros investigadores quienes han propuesto diversos indicadores. El mejor ha sido el uso combinado de colesterol y LDH pleurales: un colesterol sobre 45 mg/dl o una LDH sobre 88 porciento del límite superior normal del suero, identifican a los exudados con una sensibilidad de 99 porciento y una especificidad de 98 porciento exigiendo solo 2 mediciones en líquido pleural. Además, la tríada de Light se ha aplicado ampliamente sin la debida consideración a las diferencias de métodos de medición de LDH de los diferentes laboratorios, por lo que su punto de corte absoluto de 200 U/L en líquido pleural no es válido para todos. Con un límite superior normal para el suero (LSNS) de 300 U/L, el corte en 200 representa, para Light, 2/3 de este límite. Para otros laboratorios cuyo LSNS van de 225 a 460 U/L los puntos de cortes correctos deberían variar entre 150 y 307. Los trabajos de investigación e informes de laboratorio deben indicar su LSNS de manera que el punto de corte para LDH pleural se calcule como proporción de éste

Derrame pleural y colesterol: diferenciación entre exudados y trasudados / Pleural fluid and cholesterol: differentiation of transudates and exudates

En nuestro trabajo de tipo prospectivo fueron estudiados 44 pacientes con derrame pleural, admitidos en el Hospital Universitario de Caracas, entre los meses de Mayo y Octubre de 1989; el diagnóstico correcto de derrame pleural fue etablesido por examen físico, radiología convencional de tórax (PA, lateral, decúbito lateral), ultrasonido, toracocentesis y demás exámenes específicos, ejem.: biopsia pleural.Se obtuvo muestras del líquido pleural en todos los casos, mediante toracocentesis; siendo evaluados sólo los resultados de la primera toracocentesis. Los pacientes fueron ubicados en dos categorías diagnósticas: exudados y trasudados, previa consideración de criterios principales. El 44 pacientes estudiados, 21 hombres (47,72%) y 23 mujeres (52,27%), con edad comprendida entre 19 y 79 años (x=45,7), se obtuvieron los siguientes resultados: 1) Los pacientes con exudado (n = 29), mostraron: a)Contenido proteínico promedio del liquido pleural = 4,71 g/dl ñ 1,43 DE (rango 3,6-5,4); b) Relación proteica líquido pleural/plasma con x = 0,65 ñ 0,5 DE (rango 0,54-0,75); c) Contenido DHL en líquido pleural con x = 921,62 UI ñ 921,62 UI ñ 961 DE; d) Relación DHL en líquido pleural/DHL plasmática con x = 1,52 ñ 1,36 DE; e) Contenido de colesterol total en líquido pleural con x = 86,58 mg/dl ñ 35,15 DE (rango 71-90). n = 15, presentaron: a) Contenido proteico en líquido pleural con x = 2, 04 g/dl ñ 1,09 DE (rango 1,4-2,8); b) Relación proteica líquido pleural/plasma con x = 0,28 ñ 0,14 DE (rango 0,21-0,40); c) Contenido DHL en líquido pleural promedio, resultó = 213,46 UI ñ 131,8 DE; d) Relación DHL líquido pleural/DHL plasmática = 0,42 ñ 0,3 DE; e) Contenido de colesterol total en líquido pleural con x = 22,93 mg/dl ñ 14,2 DE. Conclusiones: Nuestros hallasgos indican que el nivel de colesterol total de 50 mg/dl el líquido pleural tomado como una linea divisoria, diferencia exudados de trasudados (50 mg/dl o más = EXUDADO y menos de 50 mg/dl = TRASUDADO) con una alta significancia estadística (p < 0,001); siendo una ayuda de simple realización, más efectiva y poco costosa, en comparación con las variantes habitualmente utilizadas (proteínas-DHL)