CYTOMEGALOVIRUS RETINITIS AFTER AN INTRAVITREAL DEXAMETHASONE IMPLANT IN AN IMMUNOCOMPETENT PATIENT.

PURPOSE: To present the case of a 71-year-old woman who developed cytomegalovirus retinitis after the administration of an intravitreal dexamethasone implant in an immunocompetent patient. METHODS: Retrospective case report. PATIENTS: Single patient with a diagnosis of cytomegalovirus retinitis associated with the intravitreal dexamethasone implant. RESULTS: The patient developed cytomegalovirus retinitis three months after an intravitreal injection of a dexamethasone implant for macular edema. The patient had no history of poor immune function and was not taking immunosuppressive medications. CONCLUSION: Cytomegalovirus retinitis has been associated with local steroid therapy. This has been described in both immunocompromised and immunocompetent patients. The intravitreal dexamethasone implant may cause local immunosuppression and result in cytomegalovirus retinitis in immunocompetent patients.

The histopathologic effects of transpupillary thermotherapy in human eyes.

OBJECTIVE: To determine the histopathologic effects of transpupillary thermotherapy (TTT) on the normal human retina. DESIGN: Prospective, noncomparative small case series. PARTICIPANTS: Three patients with eyes scheduled for enucleation because of the presence of a malignant intraocular tumor. INTERVENTION: Application of TTT to the posterior pole by using an 810-nm laser and the following laser parameters: 2-mm spot size, 60-second duration, and power settings of 430, 530, and 630 mW (low, medium, and high doses, respectively). Two or three TTT treatments at varying dose levels were performed in each eye. The eyes were then enucleated within 7 days of TTT, and light microscopy of serial sections was performed. MAIN OUTCOME MEASURES: Light microscopic histopathologic changes of the neurosensory retina, retinal pigment epithelium (RPE), and choroid in the areas of treatment compared with adjacent normal (control) tissue. Visual acuity, fundus appearance by slit-lamp biomicroscopy, and symptoms of pain, burning, or visual change were recorded before and after each TTT application. The degree of fundus pigmentation was also noted. RESULTS: Eight treatment spots from three eyes were analyzed. The first eye was judged to have a lightly pigmented fundus, and no histopathologic alterations were seen on light microscopy at any of the three dose levels. The second eye had a more pigmented fundus. This eye had minimal outer retinal changes in the area corresponding to the low-dose treatment, more prominent changes in the outer and middle layers in the medium-dose treatment area, and full-thickness retinal alterations, along with changes in the RPE and choroid, where the high dose was applied. The third eye was found to have an unexpected extension of pigmented choroidal melanoma under the fovea, and full-thickness retinal changes were observed in this area after a medium-dose application. No histopathologic changes were seen at the low dose in this eye. CONCLUSIONS: TTT applications resulted in a spectrum of histopathologic effects of the retina that are related to both energy level and fundus pigmentation. Mild or no changes were observed in most low- or medium-dose applications. More extensive retinal damage occurred with applications that used energy levels higher than what have been used in the clinical setting or when the fundus was more heavily pigmented.

A comparison of laser photocoagulation with cryotherapy for threshold retinopathy of prematurity at 10 years: part 1. Visual function and structural outcome.

OBJECTIVE: To assess visual and structural outcomes after laser photocoagulation and transscleral cryotherapy for threshold retinopathy of prematurity (ROP) after 10 years. DESIGN: Extended follow-up of a randomized controlled clinical trial. PARTICIPANTS: One hundred eighteen eyes from 66 patients were randomly assigned to receive either cryotherapy or laser photocoagulation for threshold ROP. Forty-four eyes from 25 patients were examined for 10-year follow-up evaluations. INTERVENTION: Early Treatment of Diabetic Retinopathy Study (ETDRS) visual acuity, slit-lamp, and fundus examination; fundus photography; and B-scans (eyes with retinal detachments) were performed. Patients' histories were taken to elicit past amblyopia therapy. Based on fundus photographs, independent observers graded the degree of retinal dragging as none, mild, moderate, or severe. MAIN AND SECONDARY OUTCOME MEASURES: Best-corrected ETDRS visual acuity (BCVA). The degree of dragging was determined clinically and photographically. In addition, the presence of strabismus or amblyopia and/or any history of treatment for amblyopia were noted accordingly. RESULTS: Eyes treated with laser had a mean BCVA of 20/66 (Snellen equivalent), whereas cryotherapy-treated eyes had a mean BCVA of 20/182 (Snellen equivalent) (P = 0.015, n = 42). Compared with eyes treated with cryotherapy, eyes treated with laser photocoagulation were 5.2 times more likely to have a 20/50 or better BCVA (95% confidence interval, 1.37-19.8, n = 42). Eyes treated with cryotherapy were 7.2 times (95% confidence interval, 1.54-33.6, n = 33) more likely to develop retinal dragging compared with laser treatment. By linear regression analysis, ETDRS visual acuity was inversely proportionate to the degree of retinal dragging in both laser (r = -0.637, P = 0.006) and cryotherapy (r = -0.517, P = 0.040) treated eyes. Among the 21 patients with favorable outcomes in both eyes, 13 had strabismus (62%) and 6 had received amblyopia therapy (29%). Ptosis, loss of cilia, and cortical cataract were among probable treatment-related complications that were noted in this study. CONCLUSIONS: Overall, laser-treated eyes had better structural and functional outcome compared with eyes treated with cryotherapy.

A comparison of laser photocoagulation with cryotherapy for threshold retinopathy of prematurity at 10 years: part 2. Refractive outcome.

OBJECTIVE: To compare the refractive outcome of eyes treated with cryotherapy for threshold retinopathy of prematurity (ROP) with eyes treated with laser photocoagulation. DESIGN: Extended follow-up of a randomized controlled clinical trial. PARTICIPANTS: One hundred eighteen eyes from 66 patients were randomly assigned to receive either cryotherapy or laser photocoagulation for threshold ROP. Twenty-five patients (44 eyes treated) were available for follow-up examination 10 years later. INTERVENTION: Cycloplegic autorefraction or retinoscopy was performed. Immersion ultrasound biometry (A-scan) was also performed, and an autokeratometer was used for keratometry. If an A-scan could not be tolerated or the patient was not cooperative, a B-scan through-the-lid biometry was performed. Corneal thickness was measured using optical coherence tomography. MAIN AND SECONDARY OUTCOME MEASURES: Refractive error. In addition, anterior chamber depth, lens thickness, and axial length were measured. Central corneal thickness measurements and keratometric readings were also obtained. RESULT: Eyes treated with cryotherapy were significantly more myopic than those treated with laser photocoagulation. When comparing patients with bilateral treatment, the mean spherical equivalent (SE) of eyes treated with laser was -4.48 diopters (D) compared with a mean SE of -7.65 D for eyes treated with cryotherapy (n = 15 pairs of eyes, P = 0.019). Cryotherapy-treated eyes had a mean axial length of 21.7 mm versus 22.9 mm for laser-treated eyes (P = 0.024, n = 12 pairs of eyes). The anterior chamber depth and lens thickness averaged 2.86 mm and 4.33 mm, respectively, in the cryotherapy-treated eyes compared with 3.42 mm and 3.95 mm in the laser-treated eyes (P < 0.001, n = 12 pairs for both measurements). There were no statistical differences in anterior corneal curvature and central corneal thickness between the two treatment modalities. Crystalline lens power bore the strongest correlation to refractive outcomes in both laser-treated (r = 0.885, P < 0.001) and cryotherapy-treated eyes (r = 0.591, P = 0.026). Although keratometric readings were higher than normal values in these eyes, there was no correlation to the degree of myopia. CONCLUSIONS: Laser-treated eyes were significantly less myopic than cyrotherapy-treated eyes. Lens power seemed to be the predominant factor contributing to the excess myopia.

Cataract surgery in patients with retinal disease.

Retinal disease and cataracts frequently are associated with one another. Cataract formation can occur following pars plana vitrectomy and pneumatic retinopexy. Conversely, cataract surgery may exacerbate existing retinal disease, such as diabetic retinopathy, macular degeneration, and uveitis. Finally, cataract surgery can lead to retinal disease de novo, such as cystoid macular edema. A review of the medical literature was performed for all articles published between August 1st, 2000 and July 31st, 2001 on the topic of cataract surgery in patients with retinal disease. The authors selected ten articles that were most relevant to the practicing ophthalmologist for inclusion in this review. Topics of interest included age related macular degeneration, retinal detachment, macular hole, diabetic retinopathy, uveitis, and cystoid macular edema.