Varicella Zoster Virus Necrotizing Retinitis in Two Patients with Idiopathic CD4 Lymphocytopenia.

PURPOSE: Progressive outer retinal necrosis (PORN) associated with varicella zoster virus (VZV) is usually diagnosed in HIV positive or immunosuppressed patients. We report two cases of immunocompetent patients with necrotizing viral retinitis found to have idiopathic CD4 lymphocytopenia. METHODS: Clinical presentation, examination, imaging, and laboratory testing of two patients with VZV retinitis are presented. RESULTS: An HIV negative patient with history of herpes zoster presented with rapid loss of vision and examination consistent with PORN. PCR testing confirmed VZV. Lymphocytopenia was noted with a CD4 count of 25/mm(3). A second HIV negative patient presented with blurred vision and lid swelling and was found to have peripheral VZV retinitis confirmed by PCR. Laboratory workup revealed lymphocytopenia with a CD4 count of 133/mm(3). CONCLUSIONS: VZV necrotizing retinitis classic for PORN can occur in HIV negative patients. Idiopathic CD4 lymphocytopenia should be considered healthy patients who develop ocular infections seen in the immunocompromised.

Retinal detachments after Boston Keratoprosthesis: incidence, predisposing factors, and visual outcomes.

PURPOSE: To determine the rates, predisposing factors, and visual outcomes of retinal detachment (RD) after Boston Keratoprosthesis (KPro) implantation. METHODS: In this noncomparative, interventional case series, the medical records of 170 patients (205 eyes) who underwent Boston type 1 and type 2 KPro implantation at the Massachusetts Eye and Ear Infirmary between April 1993 and June 2009 were retrospectively reviewed. Incidence and annual rates of RD were calculated, and the roles of possible predictive factors for RD after KPro were investigated. Main outcome measures were rates of and risk factors for RD, visual acuity after RD, and surgical outcomes after repair. RESULTS: Sterile vitritis and autoimmune systemic disease significantly predisposed patients to RD after KPro placement. Of patients who developed RD after implantation, 50% progressed to visual acuity of no light perception despite surgical repair. CONCLUSIONS: Inflammation plays a major role in RD development after KPro implantation. Patients with predisposing factors should be advised of the high rates of RD and comanaged with a vitreoretinal specialist.

Review of anti-VEGF therapy in proliferative diabetic retinopathy.

Proliferative diabetic retinopathy (PDR) is a visually significant complication of diabetes mellitus. Pan-retinal photocoagulation (PRP) remains the standard treatment of choice. However, adverse effects of and clinical barriers to PRP have led to exploration of alternative and adjunctive therapeutic strategies in the treatment of proliferative disease. Inhibition of ocular vascular endothelial growth factor (VEGF) has emerged as a promising treatment modality for PDR. This review summarizes results from published studies using intravitreal anti-VEGF agents singly and in combination with standard therapeutic regimens in the treatment of proliferative diabetic retinopathy.

Effect of trypan blue staining on the elastic modulus of anterior lens capsules of diabetic and nondiabetic patients.

PURPOSE: To determine whether trypan blue causes a significant difference in the biomechanical properties (stiffness) of diabetic and nondiabetic anterior lens capsules and to determine whether diabetes significantly alters the stiffness of anterior lens capsules. SETTING: Veterans Administration Boston Healthcare Center System, Jamaica Plain, Massachusetts, USA. METHODS: In this unmasked prospective randomized controlled experimental study, anterior lens capsules were obtained from diabetic and nondiabetic patients approved for cataract surgery. Four treatment groups were created: (1) capsules of nondiabetic patients without trypan blue; capsules of nondiabetic patients with trypan blue; (3) capsules of diabetic patients without trypan blue; (4) capsules of diabetic patients with trypan blue. Anterior lens capsule stiffness as a function of elastic (Young's) modulus (kilopascals) was measured with the Hysitron TriboIndenter. RESULTS: The use of trypan blue led to significantly stiffer anterior lens capsules (P= .036). Trypan blue had the greatest effect on the stiffness of diabetic lens capsules (P= .046). CONCLUSION: Trypan blue contributed to increased capsule stiffness during capsulorhexis, especially in diabetic patients.

A morphologic study of Fuchs dystrophy and bullous keratopathy.

PURPOSE: To describe the morphologic features of Fuchs corneal dystrophy and compare them with those of bullous keratopathy. METHODS: This was an observational case series. The study group consisted of 32 corneal buttons with a diagnosis of Fuchs dystrophy and the comparison group consisted of 22 corneal buttons with bullous keratopathy. Morphologic analysis was performed of corneal buttons from patients with the clinical diagnosis of Fuchs dystrophy or bullous keratopathy by light and electron microscopy. RESULTS: The main outcome measure was identification of degenerated keratocytes, granular material in and around keratocytes, and lipid keratopathy. The overall morphologic features of Fuchs dystrophy and bullous keratopathy are similar to those described in previous literature. A high proportion of keratocytes exhibited degenerative changes (78.9% in Fuchs dystrophy versus 50.5% in bullous keratopathy). Granular material was identified in and around variably degenerated keratocytes in all cases of Fuchs dystrophy and in 14 of 22 (64%) of the corneas with bullous keratopathy. The percentage of keratocytes with granular deposits was higher in Fuchs dystrophy corneas as compared with corneas with bullous keratopathy (51.7% versus 14.1%, P < 0.0005). Lipid keratopathy was a common occurrence in both Fuchs dystrophy and bullous keratopathy (23/32 [72%] versus 12/22 [55%]). CONCLUSIONS: Histopathologic changes in the corneal stroma and keratocytes occur in Fuchs dystrophy. Secondary lipid keratopathy ensues and may contribute to corneal haze. A higher proportion of keratocytes in Fuchs dystrophy have granular deposit than in bullous keratopathy. That a high proportion of keratocytes had degenerative changes in both Fuchs dystrophy and bullous keratopathy suggests that keratocytes may degenerate secondary to altered stromal microenvironment because of endothelial cell loss.

Periocular petrolatum.

PURPOSE: This report describes the clinical and histopathologic features and discusses the diagnostic difficulties and management of periocular deposition of petrolatum-based materials. METHODS: Excision of orbital and eyelid tissue, tissue processing, and histopathologic examination was performed in patients with deposition of petroleum-based products. Transmission electron microscopy was performed in 3 cases. RESULTS: Between 1983 and 2003, 11 patients were diagnosed with periocular petrolatum deposition, based on clinical history and the characteristic histopathologic features of polymorphic dropout spaces, and varied from a noninflammatory lesion (paraffinoma) to those with an associated granulomatous inflammatory reaction. CONCLUSIONS: The diagnosis of petrolatum deposition can be challenging due to the range of symptoms and variable delay in presentation. Petrolatum products should be avoided during surgery and used judiciously in the postoperative period. To avoid confusion with nonspecific cases of lipogranulomatous inflammation, the terms "ointment granuloma" or "orbital paraffinoma" should be used to refer to patients presenting with orbital/eyelid lesions caused by ointment use.