SSRI-associated optic neuropathy.

PURPOSE: We report five cases of optic neuropathy (ON) identified over a 2-year period within an island population of 140 000. These cases display characteristics possibly related to long-term treatment with selective serotonin reuptake inhibitors (SSRIs). METHODS: Retrospective analysis of casenotes. Each case has been assessed using the Naranjo algorithm to indicate likelihood of adverse drug reaction (ADR). RESULTS: Clinical assessment and investigation confirmed ON in all cases with a vascular origin suspected. SSRI cessation may help protect the unaffected eye and in some cases recovery of vision seems possible. The Naranjo scores indicated possible ADR in four cases and probable ADR in one case. CONCLUSIONS: In 2004, ~7% of the UK adult population was receiving SSRI treatment for a range of 4.8-7.7 years. The most common ophthalmic side effect is acute glaucoma. Currently, there remain no reports of SSRI associated ON, although papilloedema has been reported. A potential mechanism for ischaemic optic neuropathy (ION) has been described in relation to raised serotonin levels. A single case of central retinal vein occlusion exists along with reports of deep vein thrombosis (DVT) and ischaemic stroke. We recommend a review of SSRI treatment in cases of acute ON.

The incidence and distribution of iatrogenic retinal tears in 20-gauge and 23-gauge vitrectomy.

PURPOSE: The development of 23-gauge vitrectomy surgery has many benefits including a reduction in surgical time and faster postoperative rehabilitation; however, some have suggested that the complication rate is higher. To assess this we compared the incidence and distribution of iatrogenic retinal tears in 20- and 23-gauge surgery. METHODS: Fifty consecutive 23-gauge and 50 consecutive 20-gauge vitrectomy cases were selected; eyes with a history of previous vitreoretinal surgery were excluded. All surgery was performed by two surgeons (JL and RN). Entry-site breaks (ESB) were defined as any new vitreoretinal abnormality occurring within 1 clock hour of an entry site for which treatment with cryotherapy was deemed necessary. Data were collected by retrospective case note review. Statistical analysis was carried out using Fisher's exact and χ(2)-tests. RESULTS: ESB occurred in 24% (12/50) of cases in the 20-gauge group compared with 8% (4/50) in the 23-gauge group (P = 0.03); 88% (14/16) occurred superiorly on the same side as the surgeons' dominant hand. Iatrogenic breaks recorded elsewhere indicated an increased incidence in the 20-gauge group (9/50 compared with 6/50 in 23-gauge) but this did not achieve significance; the most common position was at 6 o'clock. CONCLUSIONS: 23-Gauge vitrectomy is associated with significantly fewer ESB when compared with conventional 20-gauge vitrectomy. The incidence of other iatrogenic breaks did not appear to be significantly different between the two groups.

Use of pegaptanib for recurrent and non-clearing vitreous haemorrhage in proliferative diabetic retinopathy.

PURPOSE: Diabetes is the leading cause of blindness in the United Kingdom among people of working age. Many with proliferative diabetic retinopathy (PDR) go on to develop vitreous haemorrhage (VH). Those with recurrent or non-clearing VH require vitrectomy to restore vision. Pegaptanib is a vascular endothelial growth factor antagonist that disrupts the proliferative cascade and has been shown to precipitate regression of retinal neovascularisation. We assessed the effect of pre-operative intravitreal (IVT) pegaptanib on the timing, difficulty, and outcome of vitrectomy for recurrent VH in PDR. METHODS: Fourteen consecutive patients (15 eyes) were given a course of 1-3 IVT pegaptanib injections and vitrectomy was performed when indicated by the recurrence or persistence of VH, or progression of associated tractional retinal detachment (TRD). RESULTS: The range of patient follow-up was from 6 months to 2 years. All had no further VH for at least 4 weeks after IVT pegaptanib. Five eyes remained free from VH until the end of the study (8-25 months), thus obviating the need for vitrectomy. Two further cases avoided vitrectomy following further IVT pegaptanib. In the majority of patients with VH, IVT pegaptanib created a window for further laser and risk factor optimisation. Surgery was faster and less challenging, compared with conventional vitrectomy for recurrent VH due to PDR. CONCLUSIONS: IVT pegaptanib can be considered in diabetic patients with VH. Approximately one-third may avoid vitrectomy altogether. There are clear intra-operative advantages of using IVT pegaptanib pre-operatively. However, caution should be exercised where there is pre-existing TRD.

The effects of hypoxia on the ERG in paediatric cerebral malaria.

BACKGROUND/AIMS: Cerebral malaria (CM) is a disease of high mortality worldwide. It can be associated with malarial retinopathy (MR) resulting from impaired perfusion within the retinal microvasculature. Areas of capillary non-perfusion (CNP) appear white (retinal whitening) on ophthalmoloscopy. In this study, electrophysiological investigations were performed to investigate the physiological consequences of these hypoxic and ischaemic changes. METHODS: Children admitted with CM were assessed for inclusion in the study. Those with MR underwent further detailed fundus assessment to quantify retinal whitening and were then designated a severity score. Electrophysiological recordings were performed using a miniganzfeldt stimulator with calibration to the International Society for Clinical Electrophysiology of Visual (ISCEV) standards. ERG data were then analysed with respect to presence of MR and also graded disease severity. RESULTS: Thirty-one children were recruited with a diagnosis of CM, 20 had MR (group 1), and 11 had absent MR (group 2). Statistical analyses of these two groups showed a significant relationship between reduced single flash cone b wave amplitude (CBWA) and increased severity of retinal whitening/CNP (P<0.05). Cone and maximal response b : a wave ratios remained >1 in all subjects. CONCLUSION: Retinal whitening/CNP in MR is associated with significant changes in ERG cone b wave function. The relatively high b : a ratio is compatible with the high frequency of MR resolution without sequelae.

Submacular haemorrhages after intravitreal bevacizumab for large occult choroidal neovascularisation in age-related macular degeneration.

OBJECTIVE: To report the occurrence of submacular haemorrhages following intravitreal bevacizumab for occult choroidal neovascularisation (CNV) in age-related macular degeneration (AMD). METHODS: Retrospective chart review of 53 patients with occult CNV who had received intravitreal bevacizumab 1.25 mg. Analysis was done in three groups based on mean CNV lesion size: <10 mm(2) (n = 17), >/=10 to <15 mm(2) (n = 17) and >/=15 mm(2) (n = 18). ETDRS derived acuity, incidence of fresh macular haemorrhages and haemorrhage size (pre-existing or fresh) were documented and analysed. RESULTS: The median injection number was 1.0 (range: 1 to 3) with a minimum follow-up of 6 months (range: 4 to 12 months). The mean presenting size of occult lesions was 13.4 mm(2) (range: 3.0 to 30.3 mm(2)). Submacular fresh haemorrhages were seen in the absence of pre-existing haemorrhage in four out of 10 patients in the >/=15 mm(2) CNV size group (40%) but none in the remaining groups with CNV sizes <15 mm(2) (OR = 20.1, p = 0.01, 95% CI = 0.99 to 409.3). These haemorrhages developed at a median of 14 days. CONCLUSIONS: Submacular haemorrhages seem to be a significant adverse event following intravitreal bevacizumab in large occult choroidal neovascularisation and may affect visual outcomes. Prospective studies are required to establish the optimal dose of bevacizumab for larger lesion sizes or to identify the most appropriate anti-VEGF agent in large occult CNV with fibrovascular and serous PED lesions.

Outcome of ICG-assisted ILM peel in macular hole surgery.

PURPOSE: To investigate whether indocyanine green (ICG) staining of the internal limiting membrane (ILM) improves surgical outcome. METHODS: A total of 34 patients were identified who underwent macular hole surgery with ILM peeling augmented with ICG. These were matched retrospectively with 34 patients who underwent macular hole surgery without the use of ICG. Closure rates from primary and secondary procedures were compared, as were changes in Snellen and Logmar visual acuity. RESULTS: There was no significant difference between the two groups with reference to demographic features of age, sex, staging of the macular holes, and the proportion subsequently undergoing cataract surgery. The mean follow-up period was 7.7 months in the ICG group and 6.3 months in the non-ICG group. Closure rates from primary surgery were 91.2% in the ICG group and 73.5% in the non-ICG group (P = 0.056), whereas overall closure rates following further surgery were similar in both groups (94.1 and 91.2%, respectively). Logmar visual improvement above baseline was achieved in 53% of the non-ICG group compared to 82% of the ICG group (P = 0.01). Where primary hole closure occurred, there was no statistically significant difference in visual outcome between the two groups. CONCLUSION: ICG-assisted ILM peel in macular hole surgery is associated with a higher closure rate following a single surgical procedure. This difference was found to approach statistical significance (P = 0.056). Overall visual improvement was greater in the ICG group (P = 0.01); however, this reflected the higher closure rates. Visual outcomes between the two groups were comparable where primary hole closure occurred.

Long term effect on intraocular pressure of phacotrabeculectomy compared to trabeculectomy.

AIM: To compare the long term mean intraocular pressure (IOP) reduction after non-augmented single site phacotrabeculectomy with that after trabeculectomy and to determine the relation between preoperative IOP and IOP reduction. METHODS: A group of 44 consecutive patients with chronic open angle glaucoma who underwent phacotrabeculectomy were matched to a trabeculectomy control group and the results of surgery were compared. Linear regression analysis of preoperative IOP and IOP reduction was undertaken. RESULTS: The mean IOP reduction was significantly less in the phacotrabeculectomy group (6.7 (SD 2.1) mm Hg) than in the trabeculectomy group (11.0 (1.4) mm Hg) (p=0.0017). There was a significant difference in surgical success between the groups. The preoperative IOP was significantly related to the postoperative reduction in IOP in both groups (p<0.001). CONCLUSIONS: In elderly white patients with chronic open angle glaucoma, phacotrabeculectomy is not as effective as trabeculectomy in reducing IOP. In both procedures the magnitude of IOP reduction is proportional to the preoperative IOP.

Clinical-histopathological correlation of the abnormal retinal vessels in cerebral malaria.

BACKGROUND: Clinically abnormal retinal vessels unique to cerebral malaria have previously been shown to be associated with a poor outcome in African children. There have been no studies of the histopathological correlates of these vessels. DESIGN: This is a descriptive study of the clinical-histopathological correlates of the retinal vessels of 11 children who died with cerebral malaria. RESULTS: The retinal vessels in children with cerebral malaria contained many parasitized red blood cells; these cells tended to cluster at the periphery of vessels or, in the case of capillaries, to fill the vessel. Those with late-stage parasites had markedly reduced amounts of hemoglobin. The pattern of dehemoglobinization corresponds to the pattern of clinically abnormal vessels. CONCLUSIONS: The sequestration of late-stage parasitized red blood cells with reduced amounts of hemoglobin accounts for the unique white and pale orange retinal vessels seen in cerebral malaria. Clinical examination of these "marked" vessels offers a method to monitor a basic pathophysiological process of cerebral malaria in vivo. Arch Ophthalmol. 2000;118:924-928

Lymphangiectasia haemorrhagica conjunctivae.

PURPOSE: To re-describe a condition that has not been mentioned in the literature for more than four decades and to outline a new method of treatment of the pathology using an argon laser. METHODS: Nine patients were identified over a 2 year period who fitted a clinical picture consistent with the features of lymphangiectasia haemorrhagica. Three were treated for frequent recurrent haemorrhages with a newly developed technique using the argon laser and followed for up to 2 years. RESULTS: None of the three treated patients has had a recurrence of the condition to date. In the six untreated patients the condition resolved spontaneously after repeated attacks over between 8 months and 8 years. CONCLUSIONS: Lymphangiectasia haemorrhagica conjunctivae is probably more common than expected and may resolve spontaneously, but is readily amenable to treatment with the argon laser if attacks become frequent, uncomfortable or unsightly.