Incidence of hydroxychloroquine retinopathy in 1,207 patients in a large multicenter outpatient practice.

OBJECTIVE: To define the true risk of hydroxychloroquine (HCQ) retinal toxicity by studying the largest single group yet evaluated. METHODS: Retrospective chart review of all patients in the Kaiser Permanente Medical Care Program, Southern California Region, who had HCQ prescriptions filled from 1991 through 1993 (1,556 patients in 11 medical centers). Of 1,207 charts of patients who took HCQ and had documented ophthalmologic examinations, initial screening identified 21 charts (1.7%) that indicated possible HCQ toxicity. RESULTS: We identified 1 patient with definite toxicity (1 of 1,207; 0.08%) and 5 other patients with indeterminate but probable toxicity (5 of 1,207; 0.4%). The incidence of definite HCQ retinal toxicity in patients treated with HCQ at <6.5 mg/kg/day was 0. CONCLUSION: In HCQ-treated patients whose renal function is normal, routine ophthalmic screening is not indicated if the daily dosage is <6.5 mg/kg. In patients whose daily dosage is >6.5 mg/kg or who have taken HCQ continuously for > 10 years, annual screening may be appropriate.

Laser injury to multiple retinal foci.

A 21-year-old man received an accidental laser injury to three separate foci of the retina of his right eye from a Q-switched Nd:YAG laser target designator emitting at 1,064 nm, operating at 10 Hz, with a pulse duration of 20 ns. The nominal output of this device was 50 mJ, and the diameter of the output beam was approximately 4 cm. The extent of injury consisted of retinal necrosis, subretinal hemorrhage, vitreous hemorrhage, and striate retinopathy. The initial visual acuity was 20/400, but quickly recovered to 20/30. One year following injury the visual acuity was 20/40. Mature chorioretinal scars were apparent. A preretinal membrane was evident with marked wrinkling effect on the macular area of the retina.

Retinal toxicity secondary to intraocular gentamicin injection.

The authors present five cases of severe retinal ischemia associated with gentamicin injection. In three of the cases massive doses of gentamicin were erroneously injected into the eye; in two of the cases the authors presume that gentamicin toxicity occurred. The sequence of clinical findings was similar in all five cases. The prominent findings included early superficial and intraretinal hemorrhages, opaque and edematous retina, cotton-wool infarcts, arteriolar narrowing, and venous beading. Fluorescein angiography revealed severe retinal vascular nonperfusion. Chronic findings included rubeosis irides, neovascular glaucoma, retinal pigmentary degeneration, and optic atrophy. Of the documented cases of massive intraocular gentamicin injection, two patients had no light perception (NLP) vision and one had bare light perception. Of the two cases of presumed gentamicin toxicity, one had 20/400 vision and one had count fingers vision. Strict precautions are necessary to prevent the catastrophic events resulting from inadvertent gentamicin injection; such precautions should include precise labeling of all injectable solutions on the surgical field, waiting to draw up injectable antibiotics until the time they are needed, and drawing up injectable antibiotics under direct physician observation. All intravitreal injections should be performed slowly, in the anterior vitreous, with the needle bevel up.

Levobunolol compared with timolol for the long-term control of elevated intraocular pressure.

Levobunolol hydrochloride (0.5% and 1%) and timolol maleate (0.5%) are being compared in an ongoing, double-masked, randomized study of 141 patients with ocular hypertension or chronic open-angle glaucoma. Baseline intraocular pressure (IOP) in the three treatment groups ranged from 26 to 27 mm Hg. During the first 15 months of the study, the two drugs have not proved to be significantly different in ocular hypotensive efficacy, with overall mean IOP decreases of 6.8 to 7.6 mm Hg. In addition, the two concentrations of levobunolol have been equally effective in controlling IOP. Neither drug has been associated with any significant ocular side effects. Both drugs have produced significant decreases (five to ten beats per minute) in mean heart rate. The effect on mean blood pressure has been less pronounced: overall decreases have been less than 4 mm Hg for both systolic and diastolic blood pressure. The results of this ongoing study suggest that levobunolol is as effective and as safe as timolol for the long-term control of IOP.

The inflammatory role of endotoxin in rabbit gram-negative bacterial endophthalmitis.

The authors used the limulus lysate assays to measure the amount of gram-negative endotoxin produced in two rabbits with experimentally induced gram-negative (Escherichia coli) endophthalmitis. A similar amount of purified enodotoxin was injected into the eyes of 14 rabbits to determine the rate of clearance of endotoxin from the rabbit eyes. Endotoxin was found in clinically inflammatory quantities 2 weeks after injection. Results of pathologic examination showed that endotoxin incites severe inflammatory responses in the eye, affecting the ciliary body, vitreous, choroid, retina, and optic nerve. These results suggest that the limulus lysate assay may be useful for detecting early gram-negative endophthalmitis, and that in such cases, early emergency vitrectomy may be needed to remove the inflammation-inciting endotoxin and preserve useful vision.

Exposed scleral buckle: a case report in an eleven-year course.

One patient with an exposed scleral buckling element in the left eye was initially followed conservatively. Soon after exposure, he developed a retinal detachment in the fellow eye, resulting in loss of useful vision. Because of concern over possible redetachment and loss of vision in the remaining eye, the patient has been followed with the exposed element for more than 11 years. Treatment has consisted solely of prophylactic topical antibiotics.

Interaction of apomorphine and amantadine with ethanol in men.

Male moderate drinkers (n = 12) drank ethanol (0.8 g/kg) and then ingested one of the following: apomorphine (5 mg), amantadine (200 mg), or placebo. Subjects were tested on a battery of physiological and behavioral measures using a double-blind, within-subjects, crossover design. Postethanol ingestion of apomorphine significantly increased ethanol's effect on 3 out of the 8 measures employed (divided attention, objective and subjective inebriation ratings) without significantly altering blood ethanol concentrations or the rate of blood ethanol decline. There was no indication that apomorphine antagonized ethanol's effects. In contrast to reports indicating that amantadine antagonized ethanol depression in rodents, amantadine did not significantly alter the degree of ethanol intoxication in humans. The increase in intoxication induced by apomorphine supports suggestions that dopaminergic systems may be involved in mediating ethanol intoxication and that the sobering effect of catecholamine-augmenting drugs results from noradrenergic, rather than combined noradrenergic and dopaminergic, stimulation. Further studies are necessary to elucidate the role of pre- and postsynaptic dopaminergic receptors in mediating these effects.

Diabetic traction detachment.

One hundred thirty-six of 124 patients with diabetic traction detachment (TD) were observed for an average of 4.6 years (range, 3.0 to 9.4 years) with no surgical intervention. Visual acuity was maintained or improved in 51 of these eyes; 71 continued to be 20/200 or better. Diabetic TDs remained stable for long periods, those of more severe grade being more stable. At final examination, 60% (81/136) were graded at the same anatomic level (36/136) or an improved level (45/136). Spontaneous reattachment occurred in 20% (27/136); 78% (21/27) of these eyes had small detachments (TD1). The status of the vitreous and the vitreoretinal adhesion determined both the degree of detachment and the incidence of spontaneous reattachment.

Reversal of ethanol intoxication in humans: an assessment of the efficacy of L-dopa, aminophylline, and ephedrine.

The effect of postethanol treatment with L-Dopa, aminophylline and/or ephedrine was investigated. In one experiment, healthy, male, moderate drinkers ingested ethanol (0.8 g/kg) and then either L-Dopa (1.5 g), or placebo. In a second experiment, subjects ingested ethanol followed by aminophylline (200 mg), ephedrine (50 mg), aminophylline (200 mg) plus ephedrine (50 mg), or placebo. Double-blind, within-subjects, crossover designs were employed. Treatment with L-Dopa significantly reduced ethanol's effect on the electroencephalogram, motor coordination, and divided attention performance (t-test for paired data). Treatment with aminophylline and/or ephedrine also significantly reduced ethanol's effects on the electroencephalogram and motor coordination. The ethanol-antagonism may result from central noradrenergic stimulation.

Acute pulmonary edema following head injury: two case reports.

An acute episode of pulmonary edema may occur in association with head injury. This is due to the elevation of systemic blood pressure, to maintain cerebral circulation in the presence of increasing intracranial pressure (ICP). In these instances, the pulmonary edema arises as a pathophysiologic, neurohemodynamic response to the intracranial disease. This response has been produced experimentally, and 2 case reports described this problem clinically. If such patients with increased ICP could be treated immediately with antihypertensive drugs, pulmonary edema might be prevented and the high mortality rate decreased.

Reversal of ethanol intoxications in humans: an assessment of the efficacy of propranolol.

The effect of post-ethanol ingestion of a single dose of propranolol on acute intoxication was studied in 13 healthy male volunteers. A within subjects, double-blind, crossover design was employed. Each subject participated in two experimental sessions. In each session, subjects took a battery of tests under three conditions: Sober, Alcohol (0.8 g/kg) and Alcohol (1.1 g/kg) + Pill, in that order. The pill contained propranolol (40 mg) in one session and placebo in the other. Ethanol significantly reduced motor coordination, memory and divided attention performance and altered mood scores. Propranolol significantly increased ethanol's effects on divided attention, inebriation ratings and the electroencephalogram without significantly altering blood alcohol concentrations. There was no indication that propranolol antagonized any of ethanol's effects. These results agree with studies indicating that ethanol's effects are increased by a reduction in the functional capacity of central catecholamine systems. It is suggested that central catecholamine-stimulating drugs may reverse some of ethanol's effects.