Antiphospholipid syndrome in a patient with sarcoidosis: a case report.

We report the case of a 72-year-old female with sarcoidosis who developed a central retinal artery occlusion in her left eye in association with persistently high titers of IgG anti-cardiolipin antibodies. Only two previous cases of antiphospholipid antibody syndrome in association with sarcoidosis have been reported. Our patient's vision stabilized on anti-coagulant therapy along with concomitant treatment of sarcoidosis-related uveitis with methotrexate.

Closure of chronic macular holes using passive aspiration to the edges of the macular hole.

Full-thickness macular holes are characterized by central dehiscence of neurosensory tissue and a reduction in visual acuity. According to Gass (1) and then Johnson and Gass, (2) full-thickness macular holes are caused by progressive vitreous cortex condensation, resulting in tangential traction with centrifugal displacement of photoreceptor elements at the fovea.

Intravitreal clindamycin and dexamethasone for toxoplasmic retinochoroiditis.

BACKGROUND AND OBJECTIVE: To present a new method for the management of toxoplasmic retinochoroiditis (TRC). METHODS: The patients were females ranging in age from 10 to 61 years (average 26.5). Four eyes of 4 patients were treated with intravitreal injections of 1.0 mg clindamycin in 0.1 mL and 1.0 mg of dexamethasone in 0.1 mL. The injections were given under general or peribulbar anesthesia. Three patients continued one systemic drug. Follow-up ranged from 11 to 26 months (mean 17.5). RESULTS: A favorable response was noted in each eye within two weeks after the intravitreal injections. All patients required 2 to 4 intravitreal injections in the affected eye for the control of TRC. Visual acuity improved in each eye. The disc and macula were preserved in all eyes. Recurrence was noted in one case, which responded to a repeated intravitreal injection of clindamycin and dexamethasone. CONCLUSIONS: Intravitreal injections of clindamycin and dexamethasone are well tolerated and may offer an additional strategy to treat TRC in patients who are unable to afford or tolerate systemic therapy, or whose disease progresses despite systemic therapy.

Acute optic neuropathy and transverse myelopathy in patients with antiphospholipid antibody syndrome: favorable outcome after treatment with anticoagulants and glucocorticoids.

We describe two patients with established antiphospholipid syndrome, who during periods of subtherapeutic anticoagulation, developed acute optic neuropathy and transverse myelopathy. Treatment with optimal anticoagulation and high dose glucocorticoids was followed by resolution of the neurologic deficits.

Surgical chorioretinal venous anastomosis for ischemic central retinal vein occlusion.

BACKGROUND AND PURPOSE: To report results of a pilot study to create chorioretinal venous anastomosis (CRVA) in eyes with ischemic central retinal vein occlusion (CRVO) via a pars plana approach. PATIENTS AND METHODS: Five eyes of 5 patients with ischemic CRVO underwent surgical CRVA. Following pars plana vitrectomy, the posterior hyaloid face was removed, and slit-like incisions were made with a microvitreoretinal blade adjacent to a major retinal vein in each quadrant. Small pieces of 50 Mersilene sutures (Ethicon, Somerville, NJ) were positioned over the vein and inserted into these incisions to promote vascularization. Panretinal photocoagulation was applied. RESULTS: A functional CRVA site was noted at 10 of 16 attempted sites (4 sites in 1 patient could not be evaluated because of cataract). Minor fibrous proliferation was noted at CRVA sites in all eyes. Optic atrophy developed in 3 eyes. Visual acuity improved in 3 eyes, remained unchanged in 1, and deteriorated in 1 eye after a mean follow up of 13.4 months (range 8-20 months). CONCLUSION: Surgically induced CRVA may improve the prognosis in some eyes with ischemic CRVO.

Use of a macular buckle in the treatment of exudative age-related macular degeneration.

BACKGROUND AND OBJECTIVE: To evaluate a macular buckle for exudative choroidal neovascularization secondary to age-related macular degeneration (ARMD). PATIENTS AND METHODS: Forty-two eyes with choroidal neovascular membranes (CNVM) secondary to ARMD underwent surgical placement of a macular buckle. A Gore-Tex strip (2.0-2.5 mm wide) was button-holed through a 5 mm diameter silicone sponge (9 mm long) and placed behind the macula underneath the CNVM by the same surgeon (Dr Peyman) in all cases. Follow-up ranged from 7-76 months (mean, 20.9 months). RESULTS: Of 12 eyes with classic subfoveal CNVM: 4 (33%) gained 2 or more lines of Snellen visual acuity; 3 (25%) gained 1 line, remained the same, or lost 1 line; and 5 (42%) lost 2 or more lines (range + 6 to - 6 lines). Of 22 eyes with ill-defined subfoveal CNVM: 12 (54%) gained 1 line, remained the same, or lost 1 line; and 10 (46%) lost 2 or more lines (range + 1 to - 8 lines). Eight eyes with ill-defined juxtafoveal CNVM had the following visual acuity outcomes: 5 eyes (62%) maintained the same level of Snellen visual acuity (gained 1, 0, or lost 1 line); and 3 (38%) got worse (lost 2 or more lines of Snellen visual acuity, range + 1 to - 6 lines). Ten eyes (24%) bled subretinally during the follow-up period (average 11.5 months, range 14 days to 27 months), all outside the area of indentation of the macular buckle. CONCLUSIONS: The macular buckle treatment for exudative subretinal choroidal neovascular membranes in ARMD stabilized visual decline and displaced significant subfoveal hemorrhage.

Intravitreal tPA and SF6 promote clearing of premacular subhyaloid hemorrhages in shaken and battered baby syndrome.

BACKGROUND AND OBJECTIVE: Child abuse is a serious problem in many cultures. The ocular signs of shaken baby include intraretinal, subretinal, and preretinal hemorrhages. The hemorrhages may be unilateral or bilateral and are seen in 50% to 80% of patients. Previous treatment was limited to observation or vitrectomy, but some observed eyes develop amblyopia, and pediatric vitrectomy has many complications. PATIENTS: We report 4 eyes in 2 children with shaken baby syndrome in whom we administered intravitreal tissue plasminogen activator (tPA) in an attempt to resolve preretinal hemorrhages earlier than observation alone without the complications of vitrectomy. The tPA dose ranged from 12.5-25 microg per injection. Eyes were injected once weekly for 3 consecutive weeks. Each time 0.25 cc of sulfur hexafluoride gas was also injected. RESULTS: Within 1 week following the last tPA administration, complete resolution of the preretinal hemorrhage was seen. There were no associated ophthalmic complications. CONCLUSION: Intravitreal tPA with an expansive gas is an alternative method to observation or vitrectomy for resolution of preretinal hemorrhages in battered babies and may allow faster resolution of hemorrhages without the complications of vitrectomy.

Retinal toxicity of intravitreous octreotide in the rabbit.

OBJECTIVE: To evaluate the ocular toxicity of intravitreous octreotide. DESIGN: New Zealand white rabbits weighing approximately 2 kg were given 5 mg (group 1, two eyes), 2 mg (group 2, four eyes), 1 mg (group 3, four eyes), 0.5 mg (group 4, two eyes), 0.3 mg (group 5, two eyes) or 0.1 mg (group 7, two eyes) of octreotide acetate, two doses of 0.3 mg 1 week apart (group 6, four eyes) or 0.1 mL of balanced salt solution (group 8 [control group], two eyes). OUTCOME MEASURES: Findings on clinical examination and electroretinography, performed before and 10 days after injection, and on light microscopy. RESULTS: Cataracts developed in groups 1 and 2. No clinical changes were found in groups 3 to 8. Electroretinography showed various degrees of decrease in the b-wave amplitude in groups 1 and 2; the results were normal in groups 3 to 8. Histologic examination showed macrophage and monocyte infiltration in the vitreous and retina in group 1. No histologic change was seen in the eyes in groups 2 to 8. CONCLUSIONS: Octreotide injected intravitreally is safe at dosages of 1 mg or less.

Trauma-induced Acinetobacter lwoffi endophthalmitis with multi-organism recurrence: strategies with intravitreal treatment.

Endophthalmitis and its treatment are challenging, controversial subjects. We report here a patient whose recurrent endophthalmitis required several modes of treatment.

Effect of a somatostatin analog (octreotide acetate) on the growth of retinal pigment epithelial cells in culture.

PURPOSE: Proliferative vitreoretinopathy is a serious complication of retinal detachment surgery in which retinal pigment epithelial cells abnormally proliferate within the vitreous cavity and under the retinal surface. Octreotide acetate, a somatostatin analog, has been shown to inhibit the cellular proliferation of a variety of cell types. The aim of this study was to investigate the effect of octreotide acetate on the growth of rabbit retinal pigment epithelial cells in culture. METHODS: Retinal pigment epithelial cells were isolated from rabbits and maintained in culture. Cells were exposed to standard media or media supplemented with octreotide acetate 10(-4) M to 10(-12) M for five days. Each concentration of octreotide acetate was tested in quadruplicate. RESULTS: Exposure of rabbit retinal pigment epithelial cells to octreotide acetate significantly inhibited proliferation with a peak effect at 10(-8) M. The effect of octreotide is biphasic with higher and lower concentrations having less effect than 10(-8) M. CONCLUSIONS: This study suggests that octreotide acetate may be useful in the treatment of proliferative vitreoretinopathy; however, the optimum therapeutic dose range for this drug may be narrow.

Ischemic optic neuropathy and high-level anticardiolipin antibodies in primary Sjögren's syndrome.

A 39-year-old woman with recurrent severe anterior ischemic optic neuropathy in the setting of Sjögren's syndrome was found to have high-titer IgM anticardiolipin antibodies (aCL) that were enhanced by the phospholipid-binding glycoprotein beta 2GP1. The recognition of IgM aCL-associated vasculopathy as a possible etiologic factor in the optic neuropathy in Sjögren's syndrome may be relevant in deciding appropriate therapy.

Branch retinal artery occlusion (BRAO) combined with branch retinal vein occlusion (BRVO) and optic disc neovascularization associated with HIV and CMV retinitis.

Two vaso-occlusive events, branch retinal artery occlusion (BRAO) and branch retinal vein occlusion (BRVO), were observed in the retina of an HIV-infected patient with cytomegalovirus (CMV) retinitis who developed neovascularization of the disc (NVD). Although BRVO and reversible NVD have been reported in association with CMV retinitis, we have seen no reports of concomitant BRAO. CMV damages endothelial cells and causes an occlusive vasculitis. In HIV-infected individuals, damaged endothelial cells and rheologic problems result in increased blood viscosity. HIV infection has also been associated systemically with elevated levels of cytokines, including tumor necrosis factor alpha (TNF-alpha). In vitro, TNF-alpha exerts effects that decrease fibrinolytic potential; this activity in the circulation of a patient with AIDS may lead to vascular occlusive events. In the patient reported here, the retinal changes were not reversed by induction therapy with ganciclovir and the NVD did not regress.

Perfluorooctylbromide (PFOB) as a vitreous substitute in non-human primates.

We evaluated the toxicity of perfluorooctylbromide in the primate eye as a short-term postoperative vitreous substitute. Four eyes of 4 African green monkeys underwent complete vitrectomy and vitreous replacement with 1.5-2.0 ml of PFOB. One additional animal received BSS as a control vitreous substitute in one eye. Animals were examined twice weekly for clarity and consistency of the vitreous replacement substance. Anterior segment and lenses remained clear in all eyes, although in the immediate postoperative period one eye became inflamed and had a culture-negative vitritis. The other eyes showed a minimal anticipated postoperative vitreous inflammation. Emulsification of the PFOB began within 3 days of injection and progressed up to 3 weeks, precluding fundus examination and fluorescein angiography after 2 weeks. Eyes were enucleated and light microscopy performed at 2 days, 10 days, 33 days, and 45 days. No toxic effects to the retinal cells were detectable by histological examination, but perivasculitis of retinal vessels was noted at 45 days. Indirect examination was normal up to 10 days; thereafter, the fundus view was obscured by the emulsified PFOB. Because of cellular migration into the vitreous cavity and retinal perivasculitis, observed histologically, PFOB seems most suitable for intraoperative rather than postoperative use.

Effects of scleral reinforcement on the elongation of growing cat eyes.

OBJECTIVE: We investigated the effect of scleral reinforcement on ocular elongation in the rapidly growing eyes of juvenile cats. METHODS: Bands made from donor sclera or expanded polytetrafluoroethylene were used to reinforce one eye of each animal; contralateral eyes underwent sham surgery. RESULTS: During 5 months of follow-up, normal intraocular pressures implied normal functioning of angle structures. A-scan on the central axis showed no difference in globe lengths. Direct physical measurements of the posterior aspect of the globe at enucleation revealed significant decreases in off-center lengthening where reinforcement was present compared with unreinforced areas in the same eyes and in the contralateral unbanded eyes. Venous beading in fundus photographs of three eyes suggested impairment of venous outflow. CONCLUSIONS: Scleral reinforcement appears to control expansion of the growing cat eye to a limited extent, but the effects on vision and retinal perfusion require further investigation.

Early and early disseminated phases of Lyme disease in the rhesus monkey: a model for infection in humans.

We demonstrate that Borrelia burgdorferi infection in the rhesus monkey mimics the early and early disseminated phases of human Lyme disease. Clinical, bacteriological, immunological, and pathological signs of infection were investigated during 13 weeks after inoculation of the spirochete. Three animals were given B. burgdorferi (strain JD1) by needle inoculations, six animals were exposed to the bite of B. burgdorferi-infected Ixodes dammini ticks, and three animals were uninfected controls. B. burgdorferi could be recovered from all animals that were given the spirochete. Bacteria were detectable until week 6 postinoculation (p.i.) in blood, until week 8 p.i. in skin biopsies, and at 10 weeks p.i. in the conjunctiva of one of two animals which developed conjunctivitis. Erythema migrans (EM) appeared in one of the three animals infected by needle inoculation and in five of the six animals infected by ticks. Deep dermal perivascular lymphocytic infiltrations (characteristic of human EM) were observed in all animals showing EM clinically. Both EM and conjunctivitis were documented concomitantly with the presence of the spirochete. Lethargy, splenomegaly, and cerebrospinal fluid pleocytosis were also noted in some animals, but the direct connection of these signs with the infection was not shown. The appearance rate of immunoglobulin M and immunoglobulin G antibodies to B. burgdorferi, as well as the antigen spectra recognized, were remarkably similar to those seen in humans. Serum antibodies from infected animals were able to kill B. burgdorferi in vitro in the presence of rhesus complement. The rhesus monkey model appears to be useful for the investigation of the immunology and pathogenesis of Lyme disease and for the development of immunoprophylactic, diagnostic, and chemotherapeutic protocols.