Multiple iridociliary cysts: One entity with various clinical presentations.

Purpose: Iris cysts have a wide range of clinical manifestations ranging from totally asymptomatic to full-blown glaucoma. The aim of this report is to present three patients with multiple bilateral iridociliary cysts. Each one of them had a different stage of glaucoma and required individualized management. Observations: All three patients presented to our clinic. Patient 1 was a 25-year old female with no symptoms and normal intraocular pressure (IOP), Patient 2 a 20-year old female with cup-disk asymmetry and nocturnal IOP spikes and Patient 3 a 69-year old male with chronic angle closure, uncontrolled IOP on maximum medical therapy and optic nerve cupping. During clinical evaluation, gonioscopic findings raised the suspicion of possible multiple bilateral iridocilary cysts, which were then verified with ultrasound biomicroscopy in all patients. Each case was managed differently; Patient 1 was opted for observation, Patient 2 was started on prostaglandin analogue and Patient 3 underwent trabeculectomy with Mitomycin-C. Conclusions and Importance: Although iris cysts represent a relatively rare entity, patients with this anomaly can be encountered in our everyday clinical practice. They may be totally asymptomatic, where observation alone suffices, or at the other end of the spectrum, they may present with full-blown glaucoma, requiring traditional glaucoma surgeries. Considering the wide variety of clinical manifestations and that management may differ depending on the diagnosis, it is highly important for clinicians to carry out a careful examination, especially in patients with narrow angle. In cases of high suspicion for iris cysts, ancillary testing, such as Ultrasound Biomicroscopy, should be performed for the definite diagnosis as well as for the exclusion of malignancies.

Glioma-associated radiation retinopathy treated successfully with aflibercept.

Radiation retinopathy is a chronic, progressive retinal microangiopathy which can occur with variable latency after retina exposure to ionizing radiation used for cancer treatment. It can occur secondary to treatment of nasopharyngeal tumors, as well as intraocular tumors, such as uveal melanoma and retinoblastoma. Several treatment modalities have been reported including intravitreal corticosteroids, intravitreal anti-VEGFs and argon laser photocoagulation. Our purpose is to present a case report of bilateral radiation retinopathy with macular edema in one eye that was revealed 6 years after glioma therapy and treated successfully by using monotherapy of aflibercept. A 59-year-old male patient presented with gradually deteriorating visual acuity in his left eye for the past 12 months. Best corrected visual acuity in his right eye was 20/25 and in his left eye 20/100. Fundoscopy and fluorescein angiography revealed severe non-proliferative retinopathy in his right eye and proliferative retinopathy in his left eye with macular edema. Following complete work-up and due to his past medical history, he was diagnosed with radiation retinopathy. The patient received 6 intravitreal injections of aflibercept in a period of 9 months in order to treat macular edema and radiation retinopathy. According to the literature, there is minimal experience using aflibercept monotherapy to successfully treat macular edema due to radiation retinopathy. In addition, radiotherapy for glioma is a rather rare cause of radiation retinopathy compared to other more common causes, such as nasopharyngeal tumors, meningiomas, and uveal melanomas.

An unusual optic disc neovascularization in a case of intermediate uveitis associated with multiple sclerosis.

PURPOSE: To report a case of intermediate uveitis associated with multiple sclerosis (MS) presenting with a complex of an unusual optic disc neovascularization which was treated successfully. METHODS: Interventional case report. Best-corrected visual acuity measurements (BCVA), slitlamp examination, fundus biomicroscopy, and fluorescein angiography (FFA) were performed at baseline examination and during the follow-up period. The patient underwent one injection of intravitreal bevacizumab combined with systemic steroids and panretinal photocoagulation. RESULTS: A 28-year-old man presented with decreased vision in the right eye (RE) (BCVA 20/40). Compete examination showed a large new vessels complex on the optic disc of the RE protruding into the vitreous, ischemic vasculitis, and snowbanking inferiorly. Similar findings but less severe were found in the left eye (LE) with mild vitritis. The RE had also mild, diffuse vitreous hemorrhage. All tests were normal including blood tests, Mantoux, and chest X-ray except brain magnetic resonance imaging which showed three demyelinating lesions. Neurologic evaluation was unremarkable for the first year. The clinical appearance was consistent with intermediate uveitis associated with MS. The patient underwent one injection of intravitreal bevacizumab combined with systemic steroids and panretinal photocoagulation. After 6 months BCVA increased to 20/20 and the neovascular complex became fibrous in RE. The patient, 2 years after treatment, remains stable. CONCLUSIONS: Intermediate uveitis may precede the diagnosis of MS. Intravitreal bevacizumab combined with systemic steroids and panretinal photocoagulation proved successful in the management of this case.

Prevalence of diplopia related to cataract surgery among cases of diplopia.

PURPOSE: To evaluate the prevalence of diplopia in Greece after cataract surgery among diplopia cases. METHODS: The authors retrospectively reviewed the medical records of 571 patients with diplopia over an 8-year period in order to evaluate the prevalence of diplopia related to cataract surgery. The surgical and anesthetic records were also reviewed. All patients had full orthoptic assessment including prisms with cover test in all gaze positions. The chi-square and cross-tabulation statistical tests were used for statistical analysis. RESULTS: Thirty-nine cases (6.8%) were having persistent diplopia related to cataract surgery. Type of anesthesia was peribulbar. Hyaluronidase was not used. Thirteen patients were men and 26 were women. Left eyes were involved in 22 cases (56.4%), right in 17 cases (43.6%). Mean age was 72.5 years. Patients were divided into four groups. Group 1 consisted of 29 patients related to surgical trauma due to anesthesia. Group 2 consisted of 7 patients related to pre-existing disorders. Group 3 consisted of 2 patients related to aniseikonia or anisometropia. Group 4 with 1 patient related to macular pathology. Vertical diplopia was mostly noted (28 cases). Twenty-nine patients were corrected with prisms, 9 needed strabismus surgery, and 1 needed both surgery and prisms. CONCLUSIONS: Cataract surgery is not a common cause of persistent diplopia. However, this report highlights that prevalence of diplopia related to cataract is high among cases of diplopia in general, with diplopia being mostly vertical (p=0.001), affecting females (p=0.006), and being more common in left eyes, although results did not reach statistical significance (p=0.133).

Vascular shunt of the optic disc resembling neovascularization in a diabetic patient with optic disc drusen.

PURPOSE: To report an insulin-dependent diabetic patient who was referred by the diabetic screening clinic as having proliferative diabetic retinopathy who was found to have bilateral optic disc drusen with optociliary shunt resembling neovascularization on the disc. METHODS: Complete ocular evaluation including a fluorescein angiography was performed. RESULTS: Fundus examination showed signs of mild nonproliferative diabetic retinopathy in the right eye and the presence of well-defined optic disc drusen in both eyes with a peculiar vascular abnormality resembling neovascularization on the right disc. The central retinal vein pulsation was normal on digital examination. Autofluorescence confirmed the presence of the optic disc drusen in both eyes. Fluorescein angiography showed no leakage from the optociliary shunt. The vascular abnormality has remained stable for 2 years. CONCLUSIONS: This case highlights the correlation of optic disc drusen and optociliary shunts which in diabetic patients can be misdiagnosed as neovascularization.

Photodynamic therapy in retinal angiomatous proliferation stage I.

PURPOSE: To report a case of photodynamic therapy (PDT) treatment in an 85-year-old patient with retinal angiomatous proliferation (RAP) stage I. METHODS: According to Treatment of Age-Related Macular Degeneration with Photodynamic Therapy and Verteporfin in Photodynamic Therapy study guidelines, two sessions of PDT with verteporfin were performed, which was activated by a diode laser light at 690 nm. RESULTS: The left eye was treated with PDT because of RAP stage I. Even in the early stage of RAP, PDT treatment did not alter the natural course of the disease. In particular, the lesion evolved towards stage III, being initially in stage I, with the final result of development of retinal pigment epithelial (RPE) tear after the second session of PDT treatment. CONCLUSIONS; Even in the early stage of RAP, PDT treatment did not alter the natural course of the disease, with the final result of RPE tear after the second session of PDT treatment.

Photodynamic therapy with verteporfin of choroidal neovascularization in angioid streaks: conventional versus early retreatment.

PURPOSE: To evaluate the effectiveness of conventional photodynamic therapy with verteporfin (PDT) in a series of patients with macular choroidal neovascularization (CNV) due to angioid streaks and to compare it to the effectiveness of early PDT retreatment. METHODS: This is a retrospective study of 24 eyes (22 consecutive patients) with subfoveal or juxtafoveal CNV secondary to angioid streaks treated with PDT from September 2000 through February 2003 and that completed at least the first year of follow-up. Until August 2001, retreatments were performed according to the conventional protocol for PDT every 3 months (Group 1, consisting of 11 eyes of 9 patients). After August 2001 (13 more eyes of 13 new patients), retreatments were performed earlier (every 8 weeks) when indicated (Group 2). The follow-up time ranged from 30 to 42 months and from 12 to 30 months in Groups 1 and 2. RESULTS: At the end of the follow-up, final best-corrected visual acuity decreased in 21 (87.5%), stabilized in 2 (8.3%), and improved in 1 (4.2%) of the total 24 eyes. In all, 19 of the 24 eyes (79.2%) had a final best-corrected visual acuity equal to or less than 20/400. There were not any statistically significant differences in final visual acuity between the two groups. CONCLUSIONS: In this large series of patients with macular CNV secondary to angioid streaks, the functional and the anatomic results of PDT were not satisfactory, even when retreatments were performed earlier than the conventional time of 3 months.

Diffuse retinal pigment epitheliopathy: treatment with laser photocoagulation.

PURPOSE: To evaluate the effectiveness of laser treatment in eyes with diffuse retinal pigment epitheliopathy (DRPE). METHODS: The authors retrospectively reviewed the medical records of 56 consecutive patients (78 eyes) with DRPE. All eyes were treated with digital fluorescein angiography guided argon green laser photocoagulation, direct on the focal retinal pigment epithelium (RPE) leaks and in a grid pattern to the RPE decompensation areas. A processed digital red-free fundus image including all the important traces on it was used as a guide to the laser treatment. The follow-up period ranged from 6 months to 7 years. RESULTS: At the end of the follow-up time, 70 (89.7%) eyes showed anatomic improvement with complete or partial resolution of the macular exudative lesions. Visual acuity of less than 20/40 was noted in 60 eyes (76.9%) preoperatively compared with 46 eyes (59.0%) finally (p=0.0252). The visual acuity was improved in 19 eyes (24.4%), stabilized in 51 (65.4%), and reduced in only 8 eyes (10.2%). CONCLUSIONS: In this series of patients with DRPE, the results of laser treatment were uniformly satisfactory producing a gradual resolution of the macular exudative lesions and an improvement or stabilization of the visual acuity.

Polypoidal choroidal vasculopathy associated with Doyne's familial choroiditis: treatment with thermal laser.

PURPOSE: To report the unusual occurrence of polypoidal choroidal vasculopathy (PCV) in a patient with Doyne's familial honeycomb choroiditis (DFHC) and its course after laser treatment. DESIGN: Interventional case report. METHODS: Indocyanine green (ICG) angiography guided laser was performed on active polypoidal lesions. RESULTS: A 45-year-old man with a 15-year history of bilateral DFCH and a scarred macular choroidal neovascularization in the right eye (RE) was referred to us with exudative maculopathy in the left eye (LE). His best-corrected visual acuity (BCVA) was 20/800 in the RE and 20/40 in the LE. ICG angiography revealed a picture that was characteristic for PCV in both eyes. ICG guided argon green laser was performed on the active parapapillary and perifoveal polypoidal lesions of the LE. Eight months after the laser photocoagulation treatment, the macular exudative lesions had subsided and the BCVA improved to 20/20. The favorable anatomic and functional results have remained stable over 3 years. CONCLUSIONS: This is, to our knowledge, the first case of a PCV that occurred secondary to DFHC.

Polypoidal choroidal vasculopathy and exudative age-related macular degeneration in Greek population.

PURPOSE: To study the prevalence, the clinical features, and the visual prognosis without treatment of polypoidal choroidal vasculopathy (PCV) in a large series of Greek patients presenting with exudative maculopathy. METHODS: The medical records, photographs,as well as fluorescein and indocyanine green(ICG) angiograms of a series of 268 consecutive elderly white Greek patients, who were originally diagnosed as having exudative age-related macular degeneration (AMD) were reviewed retrospectively. RESULTS: In all, 22 of the 268 (8.2%) patients initially suspected of having AMD were ultimately diagnosed with PCV. In 15 of the 22(68.2%) patients with PCV, the polypoidal lesions were located in the peripapillary area. Large soft drusen were present in only two fellow eyes of the 10 (20%) patients with unilateral PCV compared with 120 fellow eyes of the 148 (81.1%) patients with unilateral AMD. At the last examination, 11 of the 22(50%) patients with PCV and 120 of the 246(48.8%) patients with AMD presented a visual acuity of less than 6/60 in at least one eye due to scar formation in the macula. CONCLUSIONS: PCV is not an infrequent disease in Greece. A measurable number of Greek patients with findings suggestive of exudative AMD will instead have PCV. ICG angiography is important in differentiating between these two clinical entities. In Greeks, polypoidal lesions are predominantly peripapillary and are not usually associated with macular drusen in the fellow eye. PCV and exudative AMD do not differ significantly in terms of their natural course and visual prognosis in Greek patients.

Polypoidal choroidal vasculopathy associated with Doynes familial choroiditis: treatment with thermal laser.

PURPOSE: To report the unusual occurrence of polypoidal choroidal vasculopathy (PCV) in a patient with Doynes familial honeycomb choroiditis (DFHC) and its course after laser treatment. DESIGN: Interventional case report. METHODS: Indocyanine green (ICG) angiography guided laser was performed on active polypoidal lesions. RESULTS: A 45-year-old man with a 15-year history of bilateral DFCH and a scarred macular choroidal neovascularization in the right eye (RE) was referred to us with exudative maculopathy in the left eye (LE). His best-corrected visual acuity (BCVA) was 20/800 in the RE and 20/40 in the LE. ICG angiography revealed a picture that was characteristic for PCV in both eyes. ICG guided argon green laser was performed on the active parapapillary and perifoveal polypoidal lesions of the LE. Eight months after the laser photocoagulation treatment, the macular exudative lesions had subsided and the BCVA improved to 20/20. The favorable anatomic and functional results have remained stable over 3 years. CONCLUSIONS: This is, to our knowledge, the first case of a PCV that occurred secondary to DFHC. (Eur J Ophthalmol 2004; 14: 264-8).

Lacquer crack formation after photodynamic therapy.

PURPOSE: To report the occurrence of a lacquer crack after photodynamic therapy (PDT) of choroidal neovascularization (CNV) in a patient with pathologic myopia. METHODS: PDT was performed with verteporfin, which was activated by a diode laser light at 690 nm. RESULTS: The left eye of a 42-year-old woman was treated with PDT because of juxtafoveal CNV caused by pathologic myopia. No lacquer crack was present in the macula on either fluorescein or indocyanine green angiography before treatment. The CNV subsided after treatment. However, a large lacquer crack underlying a subretinal hemorrhage was formatted in the macula of the treated eye soon after PDT. CONCLUSIONS: Although the chorioretinal damage produced by PDT is minimal, it is enough to create, directly or indirectly, the basis for the formation of a lacquer crack in an eye with pathologic myopia.

Induced electrophysiological isolation of the myocardium prevents ventricular fibrillation.

STUDY OBJECTIVE: to investigate whether an encircling procedure without ventriculotomy, not involving the endocardium, may have a protective effect against ventricular fibrillation (VF), by achieving a physiological rather than anatomic entrenchment. DESIGN: the occurrence of VF was tested by DC application within an area entrenched by a circular "dotted" line formed by LASER (Nd-Yag) point by point applications. The result was compared with that from similar DC applications before the successful LASER entrenchment or beyond the restricted area. SUBJECTS: 16 anaesthetized mongrel dogs, weights 14-20 kg were used. MEASUREMENTS AND RESULTS: VF occurred 13/118 times by applying DC within the entrenched area and 86/114 times by applying the current outside this area or before the intervention (P less than 0.0005). The pacing threshold was significantly (P less than 0.001) increased within the circumscribed area (4.625 +/- 5.335 vs 0.859 +/- 0.947 mA). The maximal rate at which the ventricles could be driven by pacing at double threshold intensity was not significantly altered by the encircling procedure. Histological examination showed crater-like epicardial destruction with necrosis, loss of myocardial striation, haemorrhage, and polymorphonuclear infiltration, extending about 0.5 cm from the necrotic tissue. The subendocardial area was spared showing only hyperaemia, while the endocardium was intact. CONCLUSIONS: Encircling a small area by LASER point by point applications prevents the occurrence of VF when DC is applied within the restricted area, while permitting the conduction of paced beats. The size of the encircled area necessary to this effect is of importance, possibly reflecting the critical mass needed for the occurrence and maintenance of VF.