Cat scratch disease: posterior segment manifestations.

OBJECTIVE: To evaluate the posterior segment findings seen in ocular cat scratch disease. DESIGN: Retrospective case series. PARTICIPANTS: There were 24 patients (35 eyes) with choroidal, retinal, or optic disc manifestations of Bartonella infection evaluated at the authors' institutions over a 6-year period. MAIN OUTCOME MEASURES: Clinical and photographic records were reviewed for evidence of disc edema, macular star, foci of retinitis or choroiditis, choroidal masses, optic nerve masses, vascular-occlusive events, or other findings. RESULTS: Discrete white retinal or choroidal lesions, 50 to 3000 microm in diameter, were the most common posterior segment findings in this series of patients (83% of eyes, 83% of patients). Optic disc swelling was the second most common finding (46% of eyes, 63% of patients) followed by a macular star (43% of eyes, 63% of patients). Vascular-occlusive events were also seen (14% of eyes, 21% of patients), and the site of occlusion was found to be intimately associated with the aforementioned retinal lesions. Final visual acuity was 20/25 or better in 26 (74%) of 35 eyes and was similar in both treated and untreated patients. CONCLUSION: Isolated foci of retinitis or choroiditis were the most common ocular manifestation of cat scratch disease in the authors' patient population, but an array of posterior segment findings may occur.

Diagnosis of reactive lymphoid hyperplasia by chorioretinal biopsy.

We treated a patient with reactive lymphoid hyperplasia in whom the diagnosis was made by chorioretinal biopsy. Histopathologic examination and culture of the biopsied specimen allowed us to rule out a neoplastic or infectious process. The biopsy result allowed us to treat him with systemic corticosteroid alone, thus avoiding the potential harmful side effects of other medications, including antituberculous drugs. There were no surgical or postoperative complications. This study confirms the usefulness of chorioretinal biopsy for establishing a diagnosis and formulating a rational treatment plan.

Accidental skin punctures during ophthalmic surgery.

PURPOSE: Accidental skin puncture carries the risk of both hepatitis B and human immunodeficiency virus transmission. There have been studies of the incidence of these skin punctures in general surgery, but no study has focused on ophthalmic surgery. METHOD: All incident reports of skin punctures in the Bascom Palmer Eye Institute operating rooms from January 1990 through November 1991 were reviewed retrospectively. The incidence of skin puncture also was studied propsectively from December 1991 through May 1992. During the prospective phase, the healthcare worker was asked to complete an anonymous form regarding the instrument involved, whether it was clean or contaminated, the persons involved, and whether the room lights were on or off. RESULTS: There were 37 such occurrences in 14,878 operations (0.25%) during the retrospective study and 12 in 4246 operations (0.28%) in the prospective period. In only one case was the instrument contaminated by contact with a patient known to have positive serology for the human immunodeficiency virus. There were no documented seroconversions of healthcare personnel for either hepatitis B or human immunodeficiency virus. In 63% of these occurrences, the penetrating instrument was known to be definitely contaminated with the patient's blood. Only one person was handling the instrument 84% of the time. CONCLUSION: The low but present danger to ophthalmic personnel during surgical procedures justifies precautions to decrease the occurrence of skin punctures.

Choroidal neovascularization associated with choroidal nevi.

OBJECTIVE: We undertook a retrospective study of all choroidal nevi with overlying neovascularization seen at Bascom Palmer Eye Institute, Miami, Fla, to determine long-term effects on vision and whether the presence of neovascularization represented increased malignant potential of the lesion. DESIGN: A computer search of patients with a coded diagnosis of both a choroidal nevus and choroidal neovascularization was performed. Cases in which the neovascularization was directly overlying the nevus were used for the study. RESULTS: The records of 23 patients followed up for a mean of 6.5 years were reviewed for visual acuity, effect of treatment, and change in the size of the choroidal lesion. Fifteen of the 23 patients had a final visual acuity in the affected eye of 20/200 or better. Five of six patients treated with laser had visual improvement of 2 or more lines. Only one of these lesions showed any growth, and this was after 17 years of no growth. CONCLUSIONS: Choroidal neovascularization associated with choroidal nevi can have profound effects on vision. Laser treatment, when indicated, is effective and may be safely performed. The clinical course of these lesions, to date, does not indicate any clinically significant malignant transformation.

Oral therapy in diffuse unilateral subacute neuroretinitis.

Diffuse unilateral subacute neuroretinitis is an endemic disease associated with severe visual loss in the southeastern and midwestern United States and the Caribbean. It is caused by a single nematode that may wander in the subretinal space for many months or years. Until recently, the only effective treatment has involved the difficult and time-consuming biomicroscopic detection of the worm followed by photocoagulation. This report describes the use of oral thiabendazole in four patients with presumed diffuse, unilateral, subacute neuroretinitis. Serial fundus photography was used to detect evidence of early destruction of the worm.

Histopathology of rejected orthotopic corneal grafts in the rat.

We have used an orthotopic graft model in the rat to study the histologic characteristics of corneal allograft rejection. Unrejected allogeneic grafts could not be distinguished from clear syngeneic grafts. Although donor Langerhans cells are necessary for the development of delayed-type hypersensitivity (DTH), the histopathological characteristics of rejecting corneal allografts in immunologically naive hosts were identical regardless of the presence or absence of donor Langerhans cells. By contrast, preimmunization had a dramatic effect on the histology of graft rejection. Untreated allografts placed onto pre-immunized recipients underwent a marked cellular necrosis accompanied by minimal inflammation that easily distinguished these grafts from the previous groups. These results suggest that neither the presence nor absence of DTH responsiveness correlates with the histopathological events that accompany corneal graft rejection. However, preimmunization leads to a different histologic pattern of rejection that is characterized by an intense cellular necrosis.

Presentation of the H-Y antigen on Langerhans' cell-negative corneal grafts downregulates the cytotoxic T cell response and converts responder strain mice into phenotypic nonresponders.

We have used the murine cornea is an allograft model to investigate the relative roles of graft-derived IA+ APC (Langerhans' cells) and host-derived APC during the induction of CTL responses to H-Y. The natural exclusion of LC from the immunizing corneal graft led to a specific state of unresponsiveness to H-Y in responder strain mice, while inclusion of LC resulted in responsiveness. Failure to respond to H-Y could not be attributed to the absence of H-Y or IA antigen expression on the surface of LC-deficient grafts but instead, appeared to be due to active suppression of the T helper cell response during in vivo priming. Reprocessing of the H-Y antigen by host APC did not occur after immunization with H-Y presented on H-2-incompatible grafts unless presented initially by graft-derived LC. H-2 as well as some non-H-2 alloantigens were presented to the host without a requirement for donor-derived LC. Thus there appear to be differential requirements for the processing and presentation of alloantigens.