Bilateral central retinal vein occlusion as an initial manifestation of pseudotumor cerebri.

Pseudotumor cerebri, or benign intracranial hypertension, is known to produce visual symptoms. Central retinal vein occlusion has been linked with pseudotumor cerebri but rarely as an initial manifestation. We describe a 46-year-old patient--who was obese and mildly hypertensive with bilateral central retinal vein occlusions--who was subsequently diagnosed as having pseudotumor cerebri. In patients with simultaneous bilateral central retinal vein occlusions, unusual underlying systemic conditions such as pseudotumor cerebri should be considered in the diagnostic evaluation.

Central retinal vein occlusion associated with drusen of the optic disc.

A 43-year-old man had gradual visual changes OD. Funduscopic examination revealed central retinal vein occlusion OD. Complete ocular examination revealed bilateral drusen of the optic disc, confirmed by b-scan ultrasonography. Complete systemic evaluation showed no other etiology for the central retinal vein occlusion. Over a ten-year follow-up, in the absence of systemic disease or other local ocular anomalies, we concluded that central retinal vein occlusion can arise from external compression secondary to drusen of the optic disc.

The ocular ischemic syndrome. III. Visual prognosis and the effect of treatment.

The records of fifty-two consecutive patients with the ocular ischemic syndrome seen between 1978 and 1985 were reviewed with the purpose of investigating the visual prognosis and effects of treatment. On initial presentation, 43% of affected eyes had a visual acuity of 20/20-20/50, whereas 37% were counting fingers or worse. By the end of one year, only 24% remained in the 20/20-20/50 group, while 58% were counting fingers or worse. The presence of rubeosis iridis was an indicator of poor visual prognosis. Ninety-seven percent of eyes with rubeosis had vision of counting fingers or worse at the end of one year. We were unable to demonstrate convincingly that carotid endarterectomy and superficial temporal artery to middle cerebral artery bypass were of benefit in stabilizing or improving vision in persons with the ocular ischemic syndrome.

S-antigen. Identification of human T-cell lymphocyte proliferation sites.

Immune responses to normal retinal proteins, including S-antigen, have been demonstrated in patients with a variety of retinal disorders, as well as in those who have received panretinal laser photocoagulation. T-cell lymphocytes (T cells) have been implicated in the pathogenesis of several ocular inflammatory diseases of possible autoimmune etiology. We used synthetic peptides that correspond to the amino acid sequence of S-antigen in lymphocyte proliferation assays to identify specific sites in the molecule recognized by human T cells. Ten patients with type II diabetes were studied before and after initial panretinal laser photocoagulation for proliferative diabetic retinopathy. T-cell responses, expressed as a stimulation index, to S-antigen and peptides were negative in all patients before treatment. Three weeks after panretinal laser photocoagulation, eight of 10 assays were positive (stimulation index greater than 2; P less than .01) when lymphocytes were stimulated with peptide BSA(273-292); six of nine were positive (P less than .01) with peptide BSA(303-332); and six of six were positive (P less than .001) with peptide BSA(343-362). Our study identifies several specific sites in S-antigen that elicit human immune responses. The implications of these findings with regard to the pathogenesis and treatment of autoimmune uveitis are discussed.

Quadrantic venous-stasis retinopathy secondary to an embolic branch retinal artery obstruction.

Venous-stasis retinopathy is a term used to describe the posterior segment findings of the ocular ischemic syndrome. These include midperipheral blot retinal hemorrhages, dilated retinal veins, attenuated arterioles, peripheral retinal microaneurysms, macular edema, as well as retinal and optic disc neovascularization. The authors recently evaluated a 71-year-old woman who presented with an asymptomatic calcific embolus in her right infero-temporal branch retinal artery. Classic venous-stasis retinopathy that was limited to the territory of the obstructed arteriole was present concurrently. This case appears to demonstrate that chronic retinal hypoperfusion and resultant venous-stasis retinopathy can be produced by not only high-grade, fixed stenosis but also by embolic disease.

Choroidal neovascularization in an eye with a macular hole.

We report the case of a 68-year-old woman who initially presented with an idiopathic macular hole OD and atrophic macular degenerative changes and who subsequently developed subretinal neovascularization OU. The subretinal neovascularization evolved through the macular hole OD and decreased visual acuity to counts fingers, but the membrane was successfully treated OS with krypton laser photocoagulation and stabilization of visual acuity at 20/50 over the eight-year postoperative follow-up. This is the first report, to our knowledge, of a membrane developing through a macular hole. This may be a more common occurrence than reported due to obscuring of details from hemorrhage and exudate as part of the disciform process.

The early natural history of subfoveal neovascular membranes in eyes with age-related macular degeneration.

During the course of age-related macular degeneration, the visual prognosis is abruptly changed when the presence of a subretinal neovascular membrane (SRNVM) is established by intravenous fluorescein angiography (IVFA). Patients who have been alerted to this condition may notice distortion on the Amsler grid and report within days of the onset of symptoms. Unfortunately most patients either do not notice the early changes in central vision or incorrectly attribute these symptoms to the development of cataracts and defer proper retinal evaluation for several months. We reviewed our records to determine the natural history of those SRNVMs which on initial IVFA either originated or extended into the foveal portion of the macula. Our results clearly indicate that treatment must be undertaken early in the course of this disease to maintain useful visual function for as long as possible.

Progressive capillary nonperfusion in temporal branch retinal vein obstruction.

We studied 31 eyes with nonischemic temporal branch retinal vein obstruction (TBRVO) of six months' duration or less. Each eye had an initial and at least one follow-up fluorescein angiogram according to the clinical course. Five eyes had sufficient additional capillary nonperfusion by angiography to warrant reclassification into the ischemic category. This conversion to an ischemic TBRVO pattern was documented as early as one month and as late as 14 months (average 5.2 months) after initial evaluation. Males dominated the progressive group (P less than 0.005); age, sex, initial visual acuity, and associated medical and ocular conditions were not significantly different between progressive and nonprogressive eyes (P greater than 0.05). A nonischemic TBRVO may convert to an ischemic pattern, placing these eyes at increased risk for the subsequent development of neovascular complications.

Treatment of Eales' disease with scatter laser photocoagulation.

Eales' disease is an extremely uncommon vasoproliferative retinal disease predominantly affecting otherwise healthy young men. The etiology of this condition is unknown, but its progression and clinical appearance are similar to other vasoproliferative diseases of the retina such as diabetic and sickle cell retinopathies. These similarities make Eales' disease a good prospect for inclusion in a model pattern of retinal ischemic disease and suggest that treatment by panretinal photocoagulation should be effective in this condition. We had good results in treating eight eyes diagnosed as having Eales' disease with scattered laser photocoagulation.

Temporal branch retinal vein obstruction masquerading as a retinal arterial macroaneurysm: the Bonet sign.

We present the case report of a patient with a hemorrhage at an arteriovenous crossing which was erroneously interpreted as being an arterial macroaneurysm. Shortly thereafter, the typical appearance of a temporal branch retinal vein obstruction was evident indicating that the hemorrhage was an early sign of the venous obstruction. This sign (the Bonet sign) should alert the clinician to this disorder so that the correct diagnosis and recommendations for patient care can be undertaken.

Unilateral proliferative sickle retinopathy: a model for photocoagulation in the proliferative retinopathies.

We present a case report of a patient with unilateral proliferative sickle retinopathy who progressed to intractable vitreous hemorrhage, traction retinal detachment, and severe loss of vision after unsuccessful vitrectomy surgery. The patient's other eye had chronic uveitis resulting in widespread destruction of the retinal tissue, and subsequently the eye did not have any evidence of neovascularization. This observation is consistent with those seen in proliferative diabetic retinopathy where retinal damage from high myopia, trauma, or other cause typically protects that eye from the advanced stages of diabetic retinopathy. As in this case, the eye with long-standing uveitis did not have proliferative sickle retinopathy.

The ocular ischemic syndrome. II. Mortality and systemic morbidity.

The cases of 52 consecutive persons with ocular ischemic syndrome (ocular symptoms and signs attributable to severe carotid artery obstruction) were studied. Followup disclosed a five year mortality of 40%. In comparison, an age and sex matched control group from the Framingham study had a five year mortality of 11%. The leading cause of death was cardiac disease (63%), while stroke was second (19%). Other associated diseases included systemic arterial hypertension (73%), diabetes mellitus (56%) and peripheral vascular disease (19%).

An eye disorder caused by chronic cardiovascular disease.

Retinal vein occlusion is a serious ophthalmologic condition that requires prompt diagnosis and treatment to avoid permanent vision loss. With acute onset of central vein occlusion, vision loss is sudden, unilateral, and painless. Vision loss from branch vein occlusion is typically less severe. Many chronic medical conditions put the patient at high risk for this problem, among them hypertension, diabetes mellitus, arteriosclerosis, and other types of cardiovascular disease. Primary care practitioners, who ordinarily see many patients with such chronic illnesses, are in an excellent position to diagnose retinal vein occlusion and to participate in its management through opthalmologic referral.

Branch retinal-artery obstruction: a review of 201 eyes.

A study of 187 patients (201 eyes) with branch retinal-artery occlusion (BRAO) was done to determine the etiology, natural history, and treatment of this disorder. On follow-up, almost 90% of the patients had visual acuity of 20/40 or better. The rest had poor visual acuities initially. The patient population was divided into three groups according to treatment. Group I included 65 patients treated aggressively with mechanical and pharmaceutic measures to reduce intraocular pressure and with anti-platelet drugs. Group II was composed of 81 patients treated only with antiplatelet agents given chronically. Group III (41 patients) received no treatment and represented the control group. No statistically significant difference in visual outcome was found on comparison of these three groups of patients. In this study we observed that 98% of the BRAO cases involved the temporal arteries. Emboli were documented in 125 eyes (62%). Systemic hypertension was common (132 patients or 71%). Although BRAO appears to be a relatively benign disease, its association with severe systemic conditions and documented increase in patient mortality suggests the need for careful evaluation by ophthalmologists.

Quantification of progressive diabetic macular nonperfusion.

We used the IS-2000 Image Analyzer to estimate the extent of progressive diabetic macular nonperfusion in a patient by means of an automatic clustering algorithm applied to digitized fluorescein angiograms of the patient's macula taken over time. This method may provide an objective and reproducible quantification of progressive macular nonperfusion.

Central retinal-artery occlusion in proliferative sickle-cell retinopathy after retrobulbar injection.

Central retinal-artery obstruction (CRAO) is a devastating complication after retrobulbar anesthesia, a procedure which was previously recommended routinely to immobilize the eye and reduce discomfort during laser surgery. Recent developments in treatment technique, involving scatter laser applications given over several sessions with smaller spot sizes and shorter durations, have virtually eliminated the need for retrobulbar injections and the risks of retrobulbar hemorrhage, which can cause increased intraocular pressure and culminate in closure of the arterial circulation. We present the case of a patient with proliferative sickle retinopathy who sustained such a complication after direct photocoagulation treatment of sea-fans elsewhere and offer alternative treatment techniques which we have used for the past ten years that eliminate this hazard.

Dynamic amaurosis fugax secondary to compression of vertebral artery.

Transient unilateral loss of vision can be a manifestation of ipsilateral carotid disease; whereas transient visual impairment affecting both eyes simultaneously suggests vertebral basilar-artery insufficiency. We present such a case where the symptoms were related to head position. Congenital anomalies of the vertebral arteries were found on four-vessel cervical angiography.

Resolved incomplete central retinal-artery obstruction simulating ischemic optic neuropathy.

To our knowledge, this is the first reported case of an embolic three-fourths central retinal-artery obstruction with isolated sparing of the superior temporal branch artery. Multiple nonfoveolar-sparing cilioretinal arteries were also present. As a result of the unusual obstruction distribution, ischemic optic neuropathy was simulated after a five-month interval. Patients who are not seen acutely after a retinal-artery obstruction may be diagnosed and managed incorrectly if this variation from the usual condition is not recognized.

The ocular ischemic syndrome. Clinical, fluorescein angiographic and carotid angiographic features.

The records of 43 consecutive patients (51 eyes) with the ocular ischemic syndrome (ocular symptoms and signs attributable to severe carotid artery obstruction) were studied in a retrospective fashion. Men comprised 67% of the group and the mean age at presentation was 64.5 years. In the anterior segment, neovascularization of the iris was observed in 66% of eyes and iritis was noted in 18%. Posterior segment signs included narrowed retinal arteries and dilated, but not tortuous, retinal veins. Mid-peripheral retinal hemorrhages were seen in 80% of eyes, posterior segment neovascularization was observed in 37%, and a cherry red spot was noted in 12%. Fluorescein angiography commonly revealed delayed choroidal and retinal filling, while electroretinography generally demonstrated a reduction in the amplitude of both the a- and b-waves.