Pharmacotherapy of borderline states.

Our current state of knowledge regarding the pharmacologic management of BDs is at an early point in its evolution, exceeded only marginally by our ability to define the nosologic boundaries of these disorders. As the boundaries become better defined, especially those shared with the AD spectrum, and concurrently there is an effort to define nosologic subgroups based on differential drug treatment response, we gradually will be able to prospectively make better prescribing decisions and thereby reduce the trial-and-error aspect, with its potential for further sensitizing this population who already deal poorly with inconstancy.

Chronic ocular ischemia and neovascular glaucoma: a result of extracranial carotid artery disease.

Severe occlusive disease of the carotid artery may produce a rare syndrome of chronic ocular ischemia. Prolonged retinal hypoxia is associated with characteristic funduscopic changes and neovascularization of the iris, with subsequent obstruction of aqueous humor resorption. A case of neovascular glaucoma as a result of severe bilateral carotid occlusive disease and the pathophysiology involved are discussed. Definitive treatment consisted of carotid endarterectomy and aggressive control of intraocular pressure, including operative placement of a drainage implant in the anterior chamber of the eye. Seizure activity and an exacerbation of glaucoma developed after successful revascularization, exemplifying the derangements in cerebral and ocular function that may result from chronic hypoperfusion.

Vascular hypotension and bradycardia following intraocular injection of acetylcholine during cataract surgery.

Two patients, an 80-year-old woman and a 70-year-old man, experienced profound systemic hypotension and bradycardia following intraocular acetylcholine administration during cataract surgery. When we compared these two cases with three previously published reports of similar occurrences, we found no common factors other than age that might have predisposed these patients to such complications. All five patients were in relatively good health and each received different combinations of premedication. This reaction occurred in two patients given local anesthesia, two given local anesthesia with intravenous sedation, and one given general anesthesia. Although a cause-and-effect relationship has not been proven, the suggestive temporal sequence of events indicated that all patients undergoing cataract surgery in which the use of intraocular acetylcholine is contemplated should be monitored by an anesthesiologist.

Convergence amplitude insufficiency.

There is a frequently overlooked group of patients, usually under 20 years of age, with typical symptoms of convergence insufficiency and diminished convergence amplitudes, but with normal near point of convergence. We studied ten cases of this type, which we call convergence amplitude insufficiency. The diagnosis in such patients will not be missed if convergence amplitudes are measured on every patient complaining of asthenopic symptoms during close work.

Simulated blowout fracture of the orbit.

A case of probable traumatic simulated Brown's syndrome, in which there was a false positive orbital tomogram, is presented. To our knowledge, this combination of findings has not been previously reported. The deceptive clinical signs combined with the false positive radiologic data led to the erroneous diagnosis of blowout fracture of the orbital floor and to a subsequent negative surgical exploration. Surgeons should be aware that these two infrequent findings may occur together. When there is any doubt about the diagnosis of blowout fracture of the orbital floor with muscle entrapment, conservative management may be indicated.

Cavernous sinus syndrome caused by rhabdomyosarcoma.

A 16-year-old boy was found to have a cavernous sinus syndrome secondary to rhabdomyosarcoma originating in the masseter muscle. Radiologic studies showed evidence of dissemination to the cavernous sinus without involvement of the skull base or its foramina. Despite aggressive therapy with transient improvement of his ocular palsy, the patient died within 16 months after the onset of his illness. Neuro-ophthalmic complications often develop as a result of direct extension from rhabdomyosarcoma originating in the head and neck region. However, to the best of our knowledge, this is the first report of a cavernous sinus syndrome caused by metastasis from rhabdomyosarcoma.

Response of a choroidal metastasis to multiple-drug chemotherapy.

A choroidal metastasis from a primary breast carcinoma in a 32-year-old woman underwent clinically complete regression during a course of five-drug combined chemotherapy for widespread metastases. The need for radiation therapy to the eye was thus obviated.

An eyelid tumor caused by a migrated hard contact lens.

An enlarging eyelid mass was removed and found to be a fibrocollagenous tumor surrounding a hard contact lens which had apparently migrated from the upper fornix, where it had been lost. A review of the literature revealed that formation of such a tumor around a migrated contact lens is unusual but that migration of hard contact lenses through the conjunctiva of the upper fornix is not as rare as is generally believed.

Long-term course of chloroquine retinopathy after cessation of medication.

Seven patients with chloroquine retinopathy were examined ten years after their therapy with chloroquine or hydroxychloroquine, or both, had been discontinued and an additional five patients with chloroquine retinopathy were similarly examined from two to eight years after their therapy had been discontinued. Visual acuity, visual fields, and ophthalmoscopic examinations were compared to those performed at the time therapy was discontinued. These long-term observations confirmed the previously published observations based on short-term studies that chloroquine retinopathy tends to remain stable after therapy is discontinued, although a few patients in the early stages of retinopathy may show regression and occasionally a patient with a more advanced stage of the disease may show progression.

Low-dose neuroleptic regimens in the treatment of borderline patients.

The use of pharmacologic agents in treating patients described as borderline generally has been accorded an insignificant, or at best, minor, role. We discuss this observation and review the literature that has dealt with this aspect of treatment. Diagnostic criteria are presented that appear to define a specific population of borderline patients who have been observed to be responsive to low doses of neuroleptic drugs. Five case histories of patients with conditions diagnosed and treated in this manner are presented, followed by a discussion of the implications of this approach in terms of clarifying the nosologic issues that have arisen around the "borderline" concept.