Conjunctival erosions associated with pemphigus vulgaris.

PURPOSE: Pemphigus vulgaris (PV) is an autoimmune blistering disease that affects mucous membranes and the skin. Most commonly, the disease begins in the oral cavity and spreads to other areas including the conjunctiva and eyelids. Ocular involvement is rare and likely underdiagnosed with a frequency that is underestimated. Ocular manifestations of systemic PV can imply severe disease and require a multidisciplinary approach. CASE REPORT: A 43-year-old black female presented with a chief complaint of pain with a white stringy discharge in the left eye for 2 weeks. On questioning, her health history revealed a 20-year systemic history of PV. Assessment of the anterior segment revealed diffuse conjunctival hyperemia with an area of bulbar conjunctival erosion. Based on the constellation of history, signs, and symptoms, ocular PV was diagnosed precipitating treatment for the ocular lesions and referral to the dermatologist for control of the underlying systemic condition. CONCLUSIONS: PV is an autoimmune disease of the pemphigus classification. It is characterized by the production of autoantibodies that attack intercellular substances. We review this unusual entity, its immunopathology, and treatment.

Highly active antiretroviral therapy-induced immune recovery in an HIV-positive patient with a history of herpes zoster ophthalmicus.

BACKGROUND: With the introduction of highly active antiretroviral therapy (HAART), the incidence of opportunistic infections in human immunodeficiency virus (HIV)-positive patients has dramatically decreased; however, clinicians should be made aware of the clinical presentation of immune recovery-mediated HAART-induced ocular inflammation. This case report discusses the correlation of HAART induction with immune recovery and ocular inflammation in an HIV-positive patient with a history of herpes zoster ophthalmicus (HZO). CASE REPORT: An HIV-positive man presented with a chief complaint of headache, severe facial pain, swollen eyelid, and light sensitivity in the right eye. The patient indicated the ocular discomfort was similar to his HZO outbreak treated successfully 3 months prior. He recently was initiated on HAART by his infectious disease specialist. The patient's diagnosis was immune recovery-mediated HAART-induced ocular inflammation associated with HZO. CONCLUSION: HAART has significantly reduced HIV-related morbidity and mortality, but new complications have emerged. Recognition of immune reconstitution inflammatory syndrome and the correlation with ocular inflammation is critical because treatment is based on protecting the patient against the effects of the inflammatory response without compromising antimicrobial or antiviral therapy.

Three presentations of monocular vision loss.

BACKGROUND: Carotid artery disease is estimated to affect 30% of persons older than 50. Risk factors include hypertension, cigarette smoking, hyperlipidemia and diabetes mellitus. Symptoms ascribed to carotid artery lesions with stenosis of the artery or plaque formation include monocular vision loss and transient ischemic attacks. Patients can present with transient monocular vision loss as their initial symptom. CASE REPORTS: Three patients from a geriatric clinic in Wilmington, Delaware presented with different complaints of vision loss with similar overall outcomes. Patient A was an 87-year-old woman who presented with dimming of vision on extreme left head turn. Dilated fundus examination found a retinal arterial emboli in the left eye (O.S.). Carotid duplex examination found 50% to 79% left internal carotid stenosis with no hemodynamic stenosis of the right internal carotid. Patient B was a 78-year-old woman who presented with a right superior altitudinal defect and transient vision loss in the right eye. Dilated fundus examination found retinal arterial emboli in the right eye (O.D.). Carotid duplex examination found 50% to 79% carotid stenosis in both the left and right internal carotids. Patient C was an 84-year-old man who complained of a superior altitudinal visual field defect O.D. Dilated fundus examination found a retinal arterial emboli O.D. Carotid duplex results showed calcified atherosclerotic plaques present at the level of the common carotid artery bifurcations bilaterally, with 50% to 70% narrowing of the right internal carotid artery with no significant narrowing of the left internal carotid artery. CONCLUSIONS: These 3 presentations show that in patients older than 50 who present with chief complaints of monocular vision loss, a differential diagnosis of carotid artery disease must be considered. Patients who exhibit retinal arterial emboli are at increased risk for stroke and vascular death. Appropriate measures for confirming a diagnosis include duplex ultrasound imaging, magnetic resonance angiography (MRA), and carotid angiography. Surgical techniques such as carotid angioplasty and carotid endarterectomy may be recommended.

Isolated retinal venous macroaneurysm.

BACKGROUND: Unlike retinal arterial macroaneurysms, retinal venous macroaneurysms are rare. Retrospective studies have previously described venous macroaneurysms predominantly in association with branch retinal vein obstruction. Only 2 cases of isolated retinal venous macroaneurysm without venous occlusion have been described in the literature. The patient being described in this case report has the third isolated nonocclusive venous macroaneurysm to be reported. CASE: A healthy 43-year-old white woman presented for a routine eye examination with no history of visual disturbance other than long-standing amblyopia in the left eye (O.S.). An isolated retinal venous macroaneurysm was found on the inferior temporal retinal vein just beyond the optic disc margin. All other retinal findings were normal. One-month and 6-month followup examinations showed the macroaneurysm unchanged. The etiology of the retinal venous macroaneurysm in this case is unknown. CONCLUSION: This patient has an isolated retinal venous macroaneurysm of unknown etiology. Based on the clinical profile of the patient, it is unlikely, although admittedly not impossible, for this to have resulted from a previous venous occlusive event. The identification and documentation of this extremely rare vascular phenomenon will help improve our understanding of its significance as well as any potential ocular sequela.