Ponatinib Inducing a Panuveitis with Choroidal Effusions and Neurosensory Retinal Detachment in a Patient with Chronic Myeloid Leukaemia.

CASE SUMMARY: We present the case of a 50 year old male patient being treated for chronic myeloid leukemia by the tyrosine kinase inhibitor, Ponatinib. After 3 months of treatment, he developed a sight-threatening granulomatous panuveitis in both eyes, with choroidal effusions and neurosensory retinal detachments. Except for a positive interferon-gamma release assay suggesting previous Tuberculosis exposure, all uveitis investigations were normal. Discontinuation of the suspected causative drug led to resolution of signs and a consequent improvement in visual acuity. CONCLUSION: Ponatinib use may be associated with with a uveitic phenotype that is reminiscent of Harada's disease. We compare and contrast this rare ocular phenomenon with Vogt-Koyanagi-Harada syndrome and discuss a possible immunological basis.

High-resolution microscopy coil MR-Eye.

The eye is involved in several pathologies where precise identification of the underlying condition is essential for the optimal patient care. This preliminary report presents the potential of high-resolution microscopy coil magnetic resonance imaging (HR-MRI) to undertake this task being actively used in the clinical setting. We used a commercially available MRI scanner and a microscopy surface coil. Exquisite anatomic detail of the eye and orbit with depiction of previously unobserved structures and clear demonstration of the underlying pathology was achieved. This report supports the idea that orbital imaging can be revolutionized with the introduction of HR-MRI with broad clinical implications.

Contraceptive, cerebral vein thrombosis and choked discs.

PURPOSE: To raise awareness of the importance of prompt and appropriate imaging in patients presenting with signs and symptoms suggestive of idiopathic intracranial hypertension. METHODS: Case report with diagnostic tests and discussion of management options. RESULTS: A 15-year-old girl presenting with bilateral optic disc swelling was noted to have extensive thrombosis of intracerebral venous sinuses with the clot extending along the internal jugular vein as inferior as the root of the neck demonstrable on magnetic resonance venography. CONCLUSIONS: Ophthalmologists should be vigilant in obtaining appropriate imaging in cases of optic disc swelling.

Tuberculosis: an under-diagnosed aetiological agent in uveitis with an effective treatment.

PURPOSE: To highlight the diversity of clinical presentations with tubercular uveitis in a nonendemic setting, and discuss the diagnostic approach and an effective treatment. METHOD: Descriptive case series. RESULTS: A total of 12 cases of varied presentations of tubercular uveitis diagnosed over a period of 1 year of which six cases are described in detail. Presentations included choroidal tuberculomas, multifocal choroiditis, recurrent granulomatous uveitis, panuveitis with cystoid macular oedema, and serpiginous choroiditis. All cases had a chronic or recurrent course and responded very well to antitubercular treatment. Diagnosis was mainly assisted by positive tuberculin testing. CONCLUSION: A high index of suspicion helps diagnose ocular tuberculosis in areas of low prevalence of the disease. It forms part of the differential diagnosis of any chronic or recurrent uveitis, especially in an at-risk patient. Antitubercular treatment seems highly effective.

Prilocaine versus lignocaine for minor lid procedures.

PURPOSE: To determine whether prilocaine is a more comfortable local infiltration anaesthetic agent than the more widely used lignocaine for minor eyelid procedures. METHODS: A prospective randomised study was undertaken to compare the discomfort between local infiltration of plain 2% prilocaine versus its equivalent, plain 2% lignocaine. One hundred and twenty-five patients were recruited. Pain was assessed subjectively using a visual analogue pain score, graded from 0 to 10. RESULTS: The mean pain score for the prilocaine group was 1.82 compared with 3.19 for the lignocaine group. Using the Mann-Whitney U-test for significance, U = 1236.5; p < 0.001. CONCLUSION: Prilocaine is a more comfortable local infiltration anaesthetic agent than lignocaine when used for minor eyelid procedures.

What factors influence cataract waiting list time?

AIMS: To determine whether there were any specific factors that influenced waiting list time (WLT) for patients undergoing cataract surgery. METHODS: 70 preoperative cataract patients were interviewed by one of the authors using a questionnaire to score visual acuity, coexisting ocular pathology and disabilities, threat to independent living/employment, and perceived visual handicap for detailed, gross, and driving vision. Individuals were analysed separately according to whether it was their first or second cataract operation. RESULTS: The median WLT for first eye surgery was 9 months (n = 31) and 13 months for second eye surgery (n = 36). The WLT ranged from 2 to 25 months for first eyes and 0.25-18 months for second eyes. Where there was a perceived threat to independent living or employment the WLT was found to be significantly shorter than the median. A high overall score correlated with a shorter WLT. Surgical priority was also given to individuals with anisometropia >3 dioptres. CONCLUSION: This study has demonstrated that there are specific factors that influence clinicians when prioritising patients for cataract surgery.

Familial thrombophilia and retinal vein occlusion.

PURPOSE: To perform a pilot study on the prevalence of familial thrombophilia in all cases of retinal vein occlusion with no known risk factors. METHODS: Over the 1 year study period 71 patients presented with a new diagnosis of retinal vein occlusion (age 28-90 years). Fifty-five (77%) were excluded because of local predisposing factors. The remaining 16 (23%) had a full risk factor history taken and blood investigations of rheological factors and thrombophilia including tests for the factor V Leiden mutation, prothrombin G20210A allele and hyper-homocystinemia. RESULTS: Of those with no local predisposing factors, 3 patients had antiphospholipid antibodies, 3 had raised fibrinogen levels, 4 had hyper-homocystinemia and 1 was heterozygous for the Leiden mutation. Other lifestyle risk factors such as obesity, smoking and a positive family history of venous thrombosis were not uncommon. No patient had the prothrombin G20210A variant. CONCLUSIONS: It seems likely that several risk factors, both genetic and acquired, need to be present for thrombosis to occur. In investigating a new patient with a retinal vein occlusion one should test for hypertension, glaucoma and diabetes mellitus. Estimation of plasma viscosity and a full blood count are cheap investigations which may reveal neoplasia or vasculitis, and lipid levels should be estimated. In a young patient or one with an unexpected vein occlusion and a personal or family history of thrombosis, a hypercoagulable state may rarely be identified. This additional testing should include testing for antiphospholipid antibodies and a full thrombophilia screen including the factor V Leiden mutation, homocysteine and the prothrombin variant as part of a clinical trial. Until the role of these markers in thrombosis is better defined in relation to causation of retinal vein occlusion and treatment has been shown to improve outcome, we can not recommend them for routine testing. If a hereditary defect is found, referral should be made to a hematologist and consideration given to anticoagulation and screening of family members to prevent further thrombotic episodes. Retinal vein occlusions are multifactorial in origin except in rare cases.

Optic nerve breast metastasis mimicking meningioma.

PURPOSE: We report on an optic nerve breast metastasis masquerading initially as a central retinal vein occlusion and later as an optic nerve meningioma. METHODS: A 60-year-old female presented with a left central retinal vein occlusion (CRVO). She represented 7 months later with left upper ptosis, proptosis and painful rubeotic glaucoma Computed tomography (CT) and magnetic resonance imaging suggested an optic nerve meningioma. On referral to the regional orbital unit a mild left external ophthalmoplegia was noted and, in view of previous right mastectomy and chemotherapy 3 years earlier, the left optic nerve was biopsied simultaneously with left enucleation of her painful eye. RESULTS: Histopathology showed infiltration of the optic nerve and meningeal sheath spreading into the subretinal space and vitreous by malignant epithelial cells, consistent with breast origin. Further CT imaging and bone scans revealed no other metastases. Single field left orbit radiotherapy of 20 Gy was given in five fractions and Arimidex (Zeneca Pharmaceuticals, Cheshire, England) was commenced with the cessation of tamoxifen. The patient was also given an ocular prosthesis. Sadly, she lost vision in her other eye due to retrograde malignant invasion of her optic chiasm and died 6 weeks later. CONCLUSIONS: Orbital and choroidal metastases are relatively common but isolated optic nerve metastases are extremely rare. Progressive infiltration of the nerve is likely to enhance CRVO ischaemia and resultant rubeotic glaucoma. In the diagnosis of CRVO, proptosis or external ophthalmoplegia, the presence of pre-existing malignant disease should raise concerns, as delay in diagnosis may affect outcome, particularly if the metastases are sensitive to pharmacological therapy.