CAT SCRATCH DISEASE IMITATING A TOXOCARA GRANULOMA OF THE OPTIC DISK.

PURPOSE: The study reports an unusual presentation of a young female patient presenting with a granulomatous posterior pole mass and profound vision loss secondary to infection with Bartonella henselae. METHODS: A single case report in a child. RESULTS: An 8-year-old female presented with a recent history of flu-like illness associated with profound vision loss, panuveitis and leukocoria in the left eye. She was found to have a posterior granulomatous mass associated with an exudative retinal detachment presumed as a toxocara granuloma. Magnetic Resonance Imaging ruled out retinoblastoma. Lab work done was negative for toxocariasis and positive for Bartonella henselae titers. She was treated for Cat Scratch Disease (CSD) with steroids and azithromycin. With treatment, the inflammation and exudative retinal detachment resolved, however, the patient had no improvement in visual acuity. CONCLUSIONS: Young patients presenting with leukocoria need a full work up, which includes ruling out retinoblastoma. CSD can present as a granulomatous mass similar to toxocariasis, which can rarely lead to debilitating and irreversible vision loss.

High-Resolution Optical Coherence Tomography as an Adjunctive Tool in the Diagnosis of Corneal and Conjunctival Pathology.

PURPOSE: To evaluate the use of a commercially available, high-resolution, spectral-domain optical coherence tomography (HR-OCT) device in the diagnosis of corneal and conjunctival pathologies, with a focus on malignant lesions. METHODS: Eighty-two eyes of 71 patients were enrolled in this prospective case series, including 10 normal eyes, 21 with ocular surface squamous neoplasia (OSSN), 24 with a pterygium or pingueculum, 3 with lymphoma, 18 with pigmented conjunctival lesions (nevus, flat melanosis, or melanoma), and 6 with Salzmann nodular degeneration. Subjects were imaged using photography and HR-OCT (RTVue, Optovue, Fremont, CA). When clinically indicated, surgery was performed and histopathologic specimens were correlated with OCT images. RESULTS: HR-OCT was useful in differentiating among various lesions based on optical signs. Specifically, in OSSN, HR-OCT findings included epithelial thickening and hyper-reflectivity, whereas pterygia and pinguecula showed a subepithelial mass under thinner epithelium. In lymphoma, a hypo-reflective, homogenous subepithelial mass was observed. Differentiating between pigmented lesions with HR-OCT was more difficult, but certain characteristics could be identified. Eyes with nevi and melanoma both displayed intensely hyper-reflective basal epithelial layers and discrete subepithelial lesions, but could be differentiated by the presence of cysts in nevi and intense shadowing of sublesional tissue in most melanomas. CONCLUSION: We found that a commercially available HR-OCT was a useful noninvasive adjunctive tool in the diagnosis of ocular surface lesions.

Marsupialized fungal mycetoma masquerading as conjunctival melanoma.

PURPOSE: To report a case of a fungal mass misdiagnosed as a pigmented conjunctival melanoma. METHOD: Case report. RESULT: A 38-year-old woman was referred for a pigmented conjunctival lesion that was diagnosed as a melanoma. She had a history of a scleral buckle in that eye for retinal detachment 2 years before presentation. Slit-lamp examination revealed a pigmented mass from the 11- to 2-o'clock position. This was noted to be imbricated within the invagination of a conjunctival fold from the previous surgery. The mass was removed, cultured, and confirmed to be a fungal infection from Scytalidium sp. CONCLUSIONS: Scleral buckles can cause folds in the conjunctiva, which can be foci for fungal infection.

The use of Bowman's layer vertical topographic thickness map in the diagnosis of keratoconus.

PURPOSE: To evaluate the use of Bowman's layer (BL) vertical topographic thickness maps in diagnosing keratoconus (KC). DESIGN: Prospective, case control, interventional case series. PARTICIPANTS: A total of 42 eyes: 22 eyes of 15 normal subjects and 20 eyes of 15 patients with KC. INTERVENTION: Bowman's layer 2-dimensional 9-mm vertical topographic thickness maps were created using custom-made ultra high-resolution optical coherence tomography. MAIN OUTCOME MEASURES: Bowman's layer average and minimum thicknesses of the inferior half of the cornea, Bowman's ectasia index (BEI; defined as BL minimum thickness of the inferior half of the cornea divided by BL average thickness of the superior half of the cornea multiplied by 100), BEI-Max (defined as BL minimum thickness of the inferior half of the cornea divided by BL maximum thickness of the superior half of the cornea multiplied by 100), keratometric astigmatism (Ast-K) of patients with KC, and average keratometric (Avg-K) readings. RESULTS: In patients with KC, BL vertical thickness maps disclosed localized relative inferior thinning of the BL. Inferior BL average thickness (normal = 15±2, KC = 12±3 µm), inferior BL minimum thickness (normal = 13±2, KC = 7±3 µm), BEI (normal = 91±7, KC = 48±14), and BEI-Max (normal = 75±8; KC = 40±13) all showed highly significant differences in KC compared with normal subjects (P< 0.001). Receiver operating characteristic (ROC) curve analysis showed excellent predictive accuracy for BEI and BEI-Max with 100% sensitivity and specificity (area under the curve [AUC] of 1) with cutoff values of 80 and 60, respectively. The AUC of inferior BL average thickness and minimum thickness were 0.87 and 0.96 with a sensitivity of 80% and 93%, respectively, and a specificity of 93% and 93%, respectively. Inferior BL average thickness, inferior BL minimum thickness, BEI, and BEI-Max correlated highly to Ast-K (R = -0.72, -0.82, -0.84, and -0.82, respectively; P< 0.001) and to Avg-K (R = -0.62, P< 0.001; R = -0.59, P = 0.001; R = -0.60, P< 0.001; and R = -0.59, P = 0.001, respectively). CONCLUSIONS: Bowman's layer vertical topographic thickness maps of patients with KC disclose characteristic localized relative inferior thinning. Inferior BL average thickness, inferior BL minimum thickness, BEI, and BEI-Max are qualitative and quantitative indices for the diagnosis of KC that accurately correlate with the severity of KC. In our pilot study, BEI and BEI-Max showed excellent accuracy, sensitivity, and specificity in the diagnosis of KC.

Diagnostic performance of optical coherence tomography ganglion cell--inner plexiform layer thickness measurements in early glaucoma.

PURPOSE: To evaluate the glaucoma diagnostic performance of ganglion cell inner-plexiform layer (GCIPL) parameters used individually and in combination with retinal nerve fiber layer (RNFL) or optic nerve head (ONH) parameters measured with Cirrus HD-OCT (Carl Zeiss Meditec, Inc, Dublin, CA). DESIGN: Prospective cross-sectional study. PARTICIPANTS: Fifty patients with early perimetric glaucoma and 49 age-matched healthy subjects. METHODS: Three peripapillary RNFL and 3 macular GCIPL scans were obtained in 1 eye of each participant. A patient was considered glaucomatous if at least 2 of the 3 RNFL or GCIPL scans had the average or at least 1 sector measurement flagged at 1% to 5% or less than 1%. The diagnostic performance was determined for each GCIPL, RNFL, and ONH parameter as well as for binary or-logic and and-logic combinations of GCIPL with RNFL or ONH parameters. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR). RESULTS: Among GCIPL parameters, the minimum had the best diagnostic performance (sensitivity, 82.0%; specificity, 87.8%; PLR, 6.69; and NLR, 0.21). Inferior quadrant was the best RNFL parameter (sensitivity, 74%; specificity, 95.9%; PLR, 18.13; and NLR, 0.27), as was rim area (sensitivity, 68%; specificity, 98%; PLR, 33.3; and NLR, 0.33) among ONH parameters. The or-logic combination of minimum GCIPL and average RNFL provided the overall best diagnostic performance (sensitivity, 94%; specificity, 85.7%; PRL, 6.58; and NLR, 0.07) as compared with the best RNFL, best ONH, and best and-logic combination (minimum GCIPL and inferior quadrant RNFL; sensitivity, 64%; specificity, 100%; PLR, infinity; and NPR, 0.36). CONCLUSIONS: The binary or-logic combination of minimum GCIPL and average RNFL or rim area provides better diagnostic performances than those of and-logic combinations or best single GCIPL, RNFL, or ONH parameters. This finding may be clinically valuable for the diagnosis of early glaucoma.

Diagnostic specificities of retinal nerve fiber layer, optic nerve head, and macular ganglion cell-inner plexiform layer measurements in myopic eyes.

PURPOSE: To evaluate and compare the diagnostic specificities of peripapillary retinal nerve fiber layer (RNFL) thickness, macular ganglion cell-inner plexiform layer (GC-IPL) thickness, and optic nerve head (ONH) measurements in nonglaucomatous myopic individuals. METHODS: In a prospective, cross-sectional study, participants underwent a complete ophthalmic examination, a screening automated visual field test, and axial length measurement. The study eye then underwent optic nerve head and macular scanning using spectral-domain optical coherence tomography (OCT) instrumentation to determine RNFL thickness, GC-IPL thickness, and ONH measurements. False-positive rates for each of the OCT-derived parameters, using predefined criteria for an abnormal test, were calculated. Comparative analysis was performed using the McNemar test. RESULTS: Data from 43 eligible subjects were analyzed. The mean age was 30±6.8 years (range, 22 to 50 y) with an average axial length of 25.26±1.21 mm (range, 23.06 to 29.07 mm) and mean spherical equivalent of -4.50±1.93 D (range, -1.00 to -9.00 D). The false-positive rate was higher when using RNFL parameters compared with both ONH (47% vs. 7%, respectively; P<0.001) and GC-IPL (47% vs. 26%, respectively; P=0.049) parameters. The false-positive rate was higher when using GC-IPL parameters, compared with ONH parameters (26% vs. 7%, respectively; P=0.039). CONCLUSIONS: Caution should be exercised when relying on OCT-derived RNFL and GC-IPL thickness values to diagnose glaucoma in myopic individuals. OCT-derived ONH parameters perform better than RNFL and GC-IPL parameters and may increase diagnostic specificity in this population.

Topical chemotherapy for ocular surface squamous neoplasia.

PURPOSE OF REVIEW: Ocular surface squamous neoplasia (OSSN) is an umbrella term for a spectrum of epithelial dysplasias of the cornea, conjunctiva, and limbus. Treatment for OSSN has historically been surgery, but nonsurgical interventions have been increasingly adopted. Advantages of medical treatments include the ability to treat the entire ocular surface and prevention of surgical complications. RECENT FINDINGS: The primary medical treatments for OSSN include mitomycin C, 5-fluorouracil, and interferon α2b. Mitomycin C has been shown in studies to be highly effective but has short-term and long-term side-effects that may be intolerable. 5-Fluorouracil and interferon α2b have been found to be similar in efficacy to mitomycin, with interferon being extremely well tolerated in the majority of patients. Most recently, other chemotherapeutic agents have been tried for OSSN including antivascular endothelial growth factor agents and vitamin A. The data regarding these latter treatment strategies are still limited. SUMMARY: An understanding of the recent literature, with respect to the efficacy, advantages, and disadvantages of the various therapies for OSSN will allow us to tailor treatment to each patient.

Moxifloxacin and bilateral acute iris transillumination.

Recent publications have alerted clinicians to a syndrome of uveitic transilluminating iris depigmentation associated with systemic fluoroquinolones and other antibiotics. Bilateral acute iris transillumination, which is associated with loss of the iris pigment epithelium and results in iris transillumination, differs from the previously described bilateral acute depigmentation of the iris, which is associated with atrophy of the iris stroma without transillumination. We present a case of fluoroquinolone-associated uveitis with anterior segment optical coherence tomography imaging to highlight some observations about this syndrome. We interpret pharmacokinetic data to help explain why oral, but not topical, moxifloxacin may cause fluoroquinolone-associated uveitis.

Acute bilateral angle closure glaucoma induced by methazolamide.

PURPOSE: To report a case of bilateral acute myopia and angle closure glaucoma after ingestion of methazolamide. METHODS: An interventional case report of a 70-year-old male who developed bilateral, acute myopia and angle closure glaucoma after ingesting methazolamide tablets for the treatment of normal tension glaucoma. RESULTS: Bilateral anterior chamber shallowing associated with ciliary body edema, supraciliary effusions, and shallow posterior choroidal effusions were documented with slit-lamp photography and high-frequency ultrasonography. Near complete resolution of these signs after discontinuation of methazolamide were also documented. CONCLUSION: Methazolamide may be associated with secondary myopia and angle closure glaucoma. Discontinuation of methazolamide leads to resolution of this process, as documented by slit-lamp photography and high-frequency ultrasonography.

Effect of pupil dilation on macular choroidal thickness measured with spectral domain optical coherence tomography in normal and glaucomatous eyes.

To compare choroidal thickness before and after pupil dilation. Macular subfoveal, nasal, temporal and average choroidal thicknesses were measured in one eye of 17 healthy individuals and 40 glaucoma patients using enhanced depth imaging optical coherence tomography before and after pupil dilation. Comparisons were made between pre- and post-dilation measurements, and between normal and glaucomatous eyes. No statistically significant differences were found between pre- and post-dilation choroidal thickness measurements both in normal (p = 0.361 for subfoveal, 0.760 for nasal, 0.941 for temporal, 0.881 for average) and glaucomatous eyes (p = 0.687 for subfoveal, 0.340 for nasal, 0.913 for temporal, and 0.642 for average). After adjusting for age, the comparison between normal and glaucomatous eyes showed no significant differences in measurements both before (p = 0.701-0.907) and after pupil dilation (p = 0.757-0.988). Similar results were obtained for measurements unadjusted for age. Measurements obtained under the two conditions correlated well in normal (r = 0.92-0.97, p < 0.001) and in glaucomatous eyes (r = 0.84-0.98, p < 0.001). Bland-Altman analyses showed good agreements between them in both groups of eyes, with mean difference ranges of 0.43-2.86 and 0.39-3.08 µm between pre- and post-dilation measurements in normal and glaucomatous eyes, respectively. Subfoveal and average choroidal thickness decreased significantly by 2 µm/year. Each millimeter increase in axial length decreased subfoveal choroidal thickness by 16.5 µm and average thickness by 14.1 µm. Macular choroidal thicknesses measured before and after pupil dilation are comparable and may be used interchangeably without significant discrepancies both in normal and glaucomatous eyes.

Choroidal thickness in unilateral advanced glaucoma.

PURPOSE: To investigate whether choroidal thickness measured using optical coherence tomography (OCT) in eyes with advanced glaucoma differs from that of fellow eyes with no or mild glaucoma. METHODS: Thirty-six patients with advanced glaucoma in one eye and with no glaucoma or mild glaucoma in the fellow eye underwent macular scanning using enhanced depth imaging OCT. Average, subfoveal, nasal, and temporal choroidal thicknesses were compared between severely affected and fellow eyes after adjusting for axial length and intraocular pressure. RESULTS: There were no significant differences between choroidal thickness measurements in eyes with advanced glaucoma and those in fellow eyes (P = 0.78 to 0.99). Based on average and subfoveal choroidal thicknesses, the choroid of eyes with advanced glaucoma was thicker than that of fellow eyes in 2.8% and 2.8% of the patients, whereas the choroid of fellow eyes was thicker than that of eyes with advanced glaucoma in 5.6% and 8.3% of the patients (P = 0.55 and 0.30, respectively). Neither eye had a consistently thinner or thicker choroid. Stepwise multiple regression analysis also showed no differences between choroidal thicknesses of severely affected eyes and those of fellow eyes (all P > 0.05). Factors associated with a thinner choroid were aging (28.6 µm per decade, P < 0.001) and increasing axial length (21.4 µm/mm, P < 0.001). Visual field mean deviation did not correlate with choroidal thickness measurements. CONCLUSIONS: There was no significant change in choroidal thickness of eyes with advanced open-angle glaucoma compared to that of fellow eyes with no glaucoma or with mild glaucoma. A thinner choroid does not necessarily indicate the presence of glaucoma, nor is a thicker choroid necessarily a surrogate for the absence of glaucoma. These observations further suggest a lack of relationship between open-angle glaucoma and choroidal thickness.

Glaucoma diagnostic accuracy of ganglion cell-inner plexiform layer thickness: comparison with nerve fiber layer and optic nerve head.

PURPOSE: To determine the diagnostic performance of macular ganglion cell-inner plexiform layer (GCIPL) thickness measured with the Cirrus high-definition optical coherence tomography (HD-OCT) ganglion cell analysis (GCA) algorithm (Carl Zeiss Meditec, Dublin, CA) to discriminate normal eyes and eyes with early glaucoma and to compare it with that of peripapillary retinal nerve fiber layer (RNFL) thickness and optic nerve head (ONH) measurements. DESIGN: Evaluation of diagnostic test or technology. PARTICIPANTS: Fifty-eight patients with early glaucoma and 99 age-matched normal subjects. METHODS: Macular GCIPL and peripapillary RNFL thicknesses and ONH parameters were measured in each participant, and their diagnostic abilities were compared. MAIN OUTCOME MEASURES: Area under the curve (AUC) of the receiver operating characteristic. RESULTS: The GCIPL parameters with the best AUCs were the minimum (0.959), inferotemporal (0.956), average (0.935), superotemporal (0.919), and inferior sector (0.918). There were no significant differences between these AUCs and those of inferior quadrant (0.939), average (0.936), and superior quadrant RNFL (0.933); vertical cup-to-disc diameter ratio (0.962); cup-to-disc area ratio (0.933); and rim area (0.910), all P>0.05. CONCLUSIONS: The ability of macular GCIPL parameters to discriminate normal eyes and eyes with early glaucoma is high and comparable to that of the best peripapillary RNFL and ONH parameters. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Rates of abnormal retinal nerve fiber layer and ganglion cell layer OCT scans in healthy myopic eyes: Cirrus versus RTVue.

BACKGROUND AND OBJECTIVE: To compare rates of abnormal peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell layer scans acquired with Cirrus HD-OCT (Carl Zeiss Meditec, Inc., Dublin, CA) and RTVue-100 (Optovue Inc., Fremont, CA) in healthy myopic eyes. PATIENTS AND METHODS: Forty-one non-glaucomatous myopic eyes (41 individuals) were scanned with Cirrus to measure RNFL and ganglion cell-inner plexiform layer (GCIPL) and with RTVue to measure peripapillary RNFL and ganglion cell complex (GCC) thicknesses. Rates of abnormal scans were calculated and compared between devices. Inter-device agreement in falsely classifying scans as abnormal was also assessed. RESULTS: The rate of abnormal average and four-quadrant RNFL was 4.8% to 7.3% on Cirrus and 2.4% to 9.7% on RTVue (P > .05). The overall rate of abnormal scans was 19.2% on Cirrus and 29.3% on RTVue (P = .3). Rates of abnormal Cirrus average and segmental GCIPL (12.2% to 17%) were similar to those of RTVue average and segmental GCC (9.7% to 14.6%) (P > .05). The overall rate of abnormal GCIPL (36.6%) was higher than that of GCC (14.6%) (P = .023). The inter-device agreement was poor for average RNFL (κ = -0.09), very good for average ganglion cell (κ = 0.81), and fair for overall RNFL (κ = 0.35) and overall ganglion cell (κ = 0.34). CONCLUSION: The high rates of abnormal RNFL and ganglion cell layer scans on both devices call for caution, particularly when attempting to diagnose glaucoma in myopic eyes using these devices. The RNFL and ganglion cell layer analyses may not be interchangeable on either of these devices. These two devices are not interchangeable for classifying healthy myopic eyes based on RNFL or ganglion cell layer analysis.