Combined intravitreal anti-VEGF and verteporfin photodynamic therapy for juxtafoveal and extrafoveal choroidal neovascularization as an alternative to laser photocoagulation.

PURPOSE: To evaluate anti-VEGF and photodynamic therapy (PDT) for juxtafoveal and extrafoveal choroidal neovascularization (CNV) due to age-related macular degeneration (ARMD), ocular histoplasmosis syndrome (OHS), and degenerative myopia. METHODS: A total of 10 eyes with juxtafoveal or extrafoveal choroidal neovascularization underwent intravitreal anti-VEGF therapy combined with verteporfin PDT (689 nm). Most treatments consisted of PDT every 12 weeks and either ranibizumab 0.5 mg every 4 weeks or bevacizumab 1.25 mg every 6 weeks, initiated concurrently. Retreatment criteria were persistent exudative signs on optical coherence tomography or fluorescein angiography. RESULTS: Presenting visual acuity (VA) ranged from 20/20 to 20/60 (mean log MAR+/-SD, 0.338+/-0.16 (20/44 equivalent)). After a mean follow-up of 17.5 months, it ranged from 20/15 to 20/40 (mean log MAR+/-SD, 0.150+/-0.14 (20/28 equivalent); P=0.027, paired t-test). Six eyes improved by > or = 2 lines and four remained within 2 lines of initial VA. Non-ARMD eyes required much fewer treatments than ARMD eyes. All five non-ARMD eyes and three of five ARMD eyes showed no CNV activity at least 5 months after last treatment. CONCLUSIONS: Anti-VEGF therapy and PDT can preserve good visual function and may be suited to some cases of nonfoveal CNV. ARMD eyes require longer courses of treatment than non-ARMD eyes.

Vitrectomy for large vitreous opacity in retinitis pigmentosa.

PURPOSE: To describe a patient with bilateral retinitis pigmentosa and visually disabling vitreous opacities, who benefited from vitrectomy in both eyes. METHODS: A 37-year-old man with retinitis pigmentosa and severely constricted visual fields developed a large, dense, vitreous floater and visual obscuration in the right eye. Subsequently, diffuse vitreous opacification and visual obscuration developed in the left eye. RESULTS: Bilateral pars plana vitrectomy relieved the patient's visual obscurations. Electron micrographs of the excised vitreous opacity from the left eye showed collagen fibrils and cellular debris. CONCLUSION: Visually significant vitreous opacities may develop as a complication of retinitis pigmentosa. The visual impact of such opacities may be magnified by its superimposition on limited visual fields. Vitrectomy may be of benefit in such cases.

Complications of pneumatic retinopexy.

Pneumatic retinopexy is a retinal reattachment procedure involving transconjunctival injection of gas into the vitreous cavity, combined with cryotherapy or laser retinopexy and followed by postoperative positioning. Although generally a safe procedure, it may be associated with certain adverse outcomes. These most commonly include misplaced gas injection, subretinal gas, vitreous hemorrhage, new retinal breaks, failure to reattach the retina, proliferative vitreoretinopathy, and delayed reabsorption of subretinal fluid. Less common problems include endophthalmitis, macular folds, angle-closure glaucoma, and macular hole. In most cases, complications are successfully managed, and a favorable outcome is achieved.

A combination light-pipe, soft-tipped suction, and infusion cannula instrument for macular translocation.

PURPOSE: To describe a combination light-pipe, soft-tipped suction needle, and infusion cannula instrument for use in macular translocation surgery. METHODS: Macular translocation surgery was performed in human cadaver and live rabbit eyes with a combination light-pipe, soft-tipped suction needle, and infusion cannula instrument. RESULTS: A combination light-pipe, soft-tipped suction needle, and infusion cannula can be used for macular translocation. This instrument is useful for relocating the retina after a 360 peripheral retinotomy is created. It can also be used for macular translocation with the scleral imbrication technique when superior movement of the fovea is required. When used in combination with another soft-tipped suction needle instrument, this surgical instrument allows precise bimanual placement of the retina with simultaneous infusion of liquid perfluorocarbon for fixating the macula to its new location. CONCLUSION: A combination light-pipe, soft-tipped suction needle, and infusion cannula instrument may be a useful tool for macular translocation surgery.

Combined pars plana lensectomy-vitrectomy with open-loop flexible anterior chamber intraocular lens (AC IOL) implantation for subluxated lenses.

OBJECTIVES: To review our experience with combined pars plana lensectomy-vitrectomy and open-loop flexible anterior chamber intraocular lens (AC IOL) implantation for managing subluxated crystalline lenses. METHODS: Retrospective review of 36 consecutive eyes (28 patients), all of which had subluxated crystalline lenses, managed by pars plana lensectomy-vitrectomy with insertion of an open-loop flexible AC IOL. The study was performed at the Medical College of Wisconsin, Milwaukee, over an 8-year period. RESULTS: An average preoperative visual acuity of 20/163 (range, 20/25 to hand motions) improved to 20/36 (range, 20/20 to 4/200) with surgery after a mean follow-up of 14 months (range, 1 to 59 months) (P < .001, Student's paired t test). Final visual acuity of 20/40 or better was achieved in 75% of eyes (27/36). Complications included cystoid macular edema (8% [3/36]), pupillary block (6% [2/36]), retinal detachment (3% [1/36]), hyphema (3% [1/36]), wound leak (3% [1/36]), and transient vitreous hemorrhage (3% [1/36]). No persistent ocular hypertension was seen, nor did angle abnormalities or corneal decompensation develop. CONCLUSIONS: Pars plana lensectomy-vitrectomy with AC IOL implantation appears to be an excellent technique for managing subluxated crystalline lenses. It is associated with a significant improvement in visual acuity (P < .001) and avoids many of the complications seen with extraction of a subluxated lens through a limbal wound. Additionally, use of an AC IOL offers a simplified alternative to placement of a ciliary sulcus sutured posterior chamber intraocular lens (PC IOL).

Acute dacryocystitis as a presenting sign of pediatric leukemia.

PURPOSE: To report acute dacryocystitis with preseptal cellulitis as the presenting sign of leukemia in a child. METHODS: Case report and literature review. RESULTS: During the initial evaluation of a 17-month-old child with epiphora, left lower eyelid swelling, and a tender left medial canthal mass, a complete blood cell count demonstrated pancytopenia. Bone marrow biopsy disclosed replacement of normal cellular architecture with a dense infiltrate of leukocyte blast forms. DNA analysis disclosed a translocation between chromosome 10 and 11, consistent with the diagnosis of nonlymphocytic leukemia. Although the adjacent lower eyelid cellulitis responded to intravenous antibiotics, lacrimal sac distention decreased only after chemotherapy was initiated. CONCLUSIONS: Dacryocystitis with preseptal cellulitis can be a presenting sign of leukemia. This blood malignancy should be considered in patients whose leukocyte counts do not correlate with their clinical presentation.

Suprachoroidal hemorrhage: outcome of surgical management according to hemorrhage severity.

OBJECTIVE: To report the visual and anatomic outcome after surgical drainage of suprachoroidal hemorrhage according to hemorrhage severity. DESIGN: A retrospective chart review. PARTICIPANTS: Forty-eight consecutive eyes undergoing surgical drainage of a suprachoroidal hemorrhage at The Medical College of Wisconsin were examined. INTERVENTION: Demographic and clinical data were abstracted from patients' medical records. Eyes were classified into four categories of increasing hemorrhage complexity: (1) nonappositional choroidal hemorrhage without vitreous or retinal incarceration in the wound (12 eyes); (2) centrally appositional choroidal hemorrhage without vitreous or retinal incarceration in the wound (17 eyes); (3) choroidal hemorrhage with associated vitreous incarceration in the wound (11 eyes); and (4) choroidal hemorrhage with associated retinal incarceration in the wound (8 eyes). MAIN OUTCOME MEASURES: Visual acuity, rate of persistent hypotony, and incidence of irreparable retinal detachment after surgical drainage for four classes of suprachoroidal hemorrhage were defined. RESULTS: Overall, 11 (23%) of 48 eyes had no light perception (NLP) vision develop, 9 (19%) of 48 eyes had persistent postsurgical hypotony (intraocular pressure < 6), and 21 (64%) of 33 eyes with retinal detachment enjoyed successful retinal reattachment surgery. A definite trend toward an increased rate of NLP vision (P < 0.02), persistent hypotony (P < 0.05), and irreparable retinal detachment (P = 0.11) was observed with increasing suprachoroidal hemorrhage complexity. Eyes with retinal incarceration, compared to eyes without retinal incarceration, had an increased rate of NLP vision (63% vs. 15%; P < 0.01), persistent postsurgical hypotony (50% vs. 13%; P < 0.05), and irreparable retinal detachment (50% vs. 20%; P = 0.07). CONCLUSIONS: Eyes requiring surgical drainage of a suprachoroidal hemorrhage have a guarded prognosis, with a poorer outcome associated with increasing hemorrhage complexity. A classification system incorporating choroidal apposition, and vitreous and retinal incarceration in the wound, provides a format for reporting and assessing the efficacy of management strategies in this condition.

Selective thrombolysis of central retinal artery occlusion without long-term systemic heparinization.

BACKGROUND: A central retinal artery occlusion is a potentially blinding retinal vascular event with no effective treatment regimen available. Recently, a few reports have described improved vision in eyes with central retinal artery occlusions after selective fibrinolytic therapy followed by long-term systemic anticoagulation. Acceptance of this treatment, however, has been hampered by a paucity of confirmatory reports and its potential for producing serious hemorrhagic complications. Our report independently confirms the beneficial effects of selective thrombolysis, even with the use of only short-term, post-procedure systemic heparinization. METHODS: A case report of selective fibrinolysis of an occluded central retinal artery using urokinase infusion into the ophthalmic artery followed with only 12 h of systemic heparinization is described. RESULTS: A 65-year-old man presenting with a central retinal artery occlusion of less than 4-h duration enjoyed an improvement of vision from counting-fingers acuity to 20/20 after selective fibrinolysis with urokinase and only 12 h of systemic heparinization. No hemorrhagic or thrombotic complications occurred. CONCLUSIONS: Selective thrombolysis with urokinase followed by short-term systemic heparinization can effectively treat a central retinal artery occlusion. Whereas the authors acknowledge that a single case does not prove that short-term heparinization is better than long-term heparinization, it does show that the latter is not always required.

Mycoplasma-like organism induced murine cardiac microvasculopathy. A transmission electron microscopic study.

Mycoplasma-Like Organisms [MLO] are intracellular cell wall deficient bacteria that cause ocular chronic vasculitis in man and chronic vascular disease in plants. Since MLO do not grow in culture, diagnosis of MLO-induced disease requires identification of the organisms by electron microscopy. Ultrastructurally, MLO appear as pleomorphic tubulo-spherical and filamentous organisms. In human ocular disease MLO have been detected in parasitised leucocytes and retinal pigment epithelial cells. We have previously reported the results of injecting MLO infected human vitreous into mouse eyelids. Two thirds of the mice developed chronic disease at the inoculation site, but, more importantly, the mice also developed lethal systemic MLO disease. Carditis with histologic features similar to those of various types of human carditis occurred in 18% of the mice. This report describes the ultrastructural features of the cardiac microvascular MLO disease in those 18 mice that died of carditis after inoculation with human MLO-infected vitreous. MLO were identified in leucocytes and endothelial cells of the murine vascular lesions. The vascular lesions were characterized by destruction of vessel walls as well as proliferation of endothelial cells. Electron dense deposits were seen in basement membranes and pericytial tissues. Similar features have been described in other bacterial vascular infections and in human idiopathic carditis. We suggest that MLO could be a cause of human cardiovascular disease and should be looked for in such cases.

Primary biliary cirrhosis in the mouse: induction by human mycoplasma-like organisms.

Human intraocular and orbital chronic inflammatory disease with autoimmune features has been reported to be caused by mycoplasma-like organisms (MLO). MLO are intracellular cell-wall deficient pathogenic bacteria, closely related to rickettsia, with a characteristic ultrastrural pleomorphic tubulo-spherical and filamentous appearance. No culture system has been developed for MLO and diagnosis of MLO disease is made by detecting these bacteria within infected cells using a transmission electron microscope. In human MLO ocular and orbital disease the organisms are found in parasitized leucocytes at the disease site. Inoculation of human MLO into mouse eyelids produces a high incidence of orbital and introcular disease. MLO disseminate to produce randomly distributed lethal systemic disease with infected leucocytes found in all disease sites and with similar histologic features in all disease sites. Microvasculitis is the initial lesion. Disease progression results in lysis of vascular and parenchymal structures, stromal lymphocytic infiltrates, granulomas, and fibrosis. This report describes the hepatic portal chronic progressive inflammatory disease in 11 of 100 of those mice versus 0 in 200 controls. MLO parasitized portal leucocytes are present in all 11 inflamed livers versus 0 in 5 control livers (P less than 0.05). The resemblance of the animal liver disease induced by MLO to human primary biliary cirrhosis and rifampin treatment of MLO disease are discussed.

Juvenile rheumatoid arthritis inflammatory eye disease. Parasitization of ocular leukocytes by mollicute-like organisms.

Patients with juvenile rheumatoid arthritis (JRA) commonly develop serious eye disease, particularly chronic uveitis. Most chronic uveitis is idiopathic. Mollicute-like organisms (MLO) were recently reported to be a common cause of chronic uveitis. MLO are pathogenic intracellular cell wall deficient bacteria. No culture system exists for MLO. Disease diagnosis is based on detection using a transmission electron microscope. Uveitis producing MLO are detectable within parasitized intraocular leukocytes. They appear as intracytoskeletal 0.005-0.01 micron diameter filaments and undulating pleomorphic 0.01-1.0 micron tubulospherical bodies. This report describes MLO parasitized lesional leukocytes in the inflammatory eye disease of 5 patients with JRA. Our results indicate that MLO caused the uveitis of these patients. The significance of these findings and rifampin treatment of MLO disease are discussed.

Crohn's disease uveitis. Parasitization of vitreous leukocytes by mollicute-like organisms.

Crohn's disease (CD) is an idiopathic chronic inflammatory gut disease with frequent extragut inflammatory manifestations in the eyes, orbit, lungs, joints, and skin. A bacterial cause of CD is suspected, but cultivation of a specific pathogen has not been forthcoming. Mollicute-like organisms (MLOs) were recently reported to cause human chronic ocular inflammatory disease. Inoculation of this MLO into mouse eyelids produced chronic progressive granulomatous ocular and orbital inflammatory disease. In addition, MLOs disseminated to produce similar disease in the gut, heart, and lungs. MLOs are noncultivable cell wall-deficient bacterial pathogens. Because they also pass bacteria-retaining 0.450-micron filters, they can be overlooked or confused with viruses. Because MLOs have a characteristic ultrastructural appearance, they can be identified in diseased cells with the use of a transmission electron microscope. MLOs parasitize and destroy leukocytes. They alter the nucleus, replace the cytoplasm, and destroy organelles. MLO-caused disease is treatable by certain antibiotics. This report describes MLO-parasitized vitreous lymphocytes, monocytes, and polymorphonuclear leukocytes from three patients with CD who had chronic uveitis. The results indicate that MLOs probably caused the uveitis of these patients with CD. The gut as the possible source of the MLO is suggested. Rifampin therapy of Crohn's and MLO-caused disease is discussed.

Mouse interstitial lung disease and pleuritis induction by human Mollicute-like organisms.

Mollicute-Like Organisms (MLO) are cell-wall deficient intracellular bacterial pathogens. As MLO are non-cultivable, detection is based on finding typical Mollicute bodies within the host cell using a transmission electron microscope. Extracellular Mollicutes cause disease by a variety of mechanisms. MLO cause disease by similar mechanisms, and in addition directly alter the host cell nucleus, replace the cytoplasm, and destroy the organelles. MLO parasitization of plant cells causes a well studied chronic vascular disease reversible by tetracycline antibiotics. Recently similar MLO were reported to cause human chronic ocular vasculitis. As it parasitizes, lyses, and destroys leucocytes, it has been termed Leucocytoclastic MLO. Inoculation of this MLO into mouse eyelids produced delayed onset chronic ocular and lethal cardiac vasculitis. All lesions demonstrated tissue lysis with leucocytic infiltrates and MLO parasitized leucocytes. MLO-caused human and mouse disease responds to Rifampin. This report describes the 40 interstitial lung disease lesions in 21 of 100 of those MLO inoculated mice vs 0 in 200 controls (P less than 0.05) and 27 pleuritis lesions in 17 mice vs 0 control mice (P less than 0.05). The lung and pleural disease were associated in 13 lesions and unassociated in 41 lesions. MLO parasitized leucocytes were found in both the lung and pleural lesions from six of six MLO inoculated mice versus none of six controls. As most human interstitial lung and pleural diseases are idiopathic and closely resemble this mouse disease, they may be induced by MLO and treatable by Rifampin.

Mouse lethal cardiovascular disease: induction by human leucocyte intracellular Mollicutes.

Plant pathologists have known for several years that intracellular Mollicutes (M), i.e. cell wall deficient bacteria, are plant vascular pathogens, but because those M are non-cultivatable, they can only be studied by Transmission Electron Microscopy (TEM). Only recently have similar M been shown to be human and animal pathogens. Those human ocular Vasculitis (V) and mouse chronic ocular and lethal systemic V producing M parasitize vitreous polymorphonuclear leucocytes, lymphocytes, and monocytes as 'viral-like' 0.005-0.010 micron elemental particles which grow within the leucocyte into 0.01-0.03 micron diameter tubules, 0.3-1.5 micron spherules, and distinctive 0.5-0.7 micron cocci with spore-like cell walls. This report describes the 48 arteriolar and capillary sized V, Aschoff nodules, valvulitis, and myocytolytic lesions in the heart and great vessels in 18 of 100 human vitreous VM containing eyelid inoculated mice versus 0 of 200 controls (P less than 0.05) plus VM within parasitized leucocytes in 15 of 15 of those lesions by TEM. The results indicate dissemination of VM from the eyelid to produce a significant incidence of distinctive multifocal VM directly induced cardiovascular micro-V lesions that probably contributed to their excessive mortality. Because several human idiopathic diseases develop similar cardiovascular lesions a TEM search for VM parasitized leucocytes in those human diseases seems justified.

Chronic intracellular leucocytoclastic bacterial vitritis. A transmission electron microscopic study of the monocytes.

Vitritis, the presence of leucocytes in the acellular ocular vitreous, often accompanies ocular vasculitis (V). Non-cultivatable intracellular mollicutes (M), i.e. cell wall deficient bacteria, readily identified by transmission electron microscopy (TEM), are well known plant vascular pathogens. Recently similar intracellular polymorphonuclear leucocytes (PMNL) and lymphocytes (L) parasitising/destroying and mouse ocular and lethal systemic V producing M-like bacteria were reported to be a common cause of human ocular V. In this TEM restudy of 8 human and 3 mouse VM induced chronic ocular V materials severe nuclear and cytoplasmic alterations associated with generalized cytoskeletal nuclear-anchoring 0.005-0.010 micron particles, 0.01-0.05 micron diameter branching filaments and tubules, and trilaminar membrane bound complex internal structure containing 0.1-1.9 micron spherules, all indistinguishable from VM, were observed within 1-3% of the monocytes in all 11 specimens. The results indicate that VM also parasitise and destroy both human and mouse monocytes. VM induced alterations in monocytes, PMNL, and L are compared, and the monocyte nuclear damage/Rifampin beneficial effect relationship in VM induced ocular V is discussed.