Frosted branch angiitis in an octogenarian with infective endocarditis.

PURPOSE: To present the difficulties in diagnosing frosted branch angiitis (FBA) in an elderly person, and to present the likely immunogenic association of FBA with alpha-hemolytic streptococci. METHODS: Thorough review of the medical records of an 80-year-old white man diagnosed with FBA. Patient consent was obtained before the writing of this article. RESULTS: Our patient presented with 1 week of decreasing vision and floaters in his right eye and 3 days of floaters in his left eye. Significant medical history included a prosthetic mitral valve. Notable features on examination were bilateral retinal vascular sheathing, with retinal edema and hemorrhage. Preliminary investigations-including a transoesophageal echocardiogram-did not reveal intraocular or systemic infection, autoimmune disease, or underlying malignancy. Idiopathic FBA was unlikely given that the majority of cases had been documented in middle-aged Japanese populations. Thus, we chose to treat our patient empirically for common causes of retinal vasculitis such as viral retinitis. Interestingly, 2 weeks after the diagnosis of FBA, our patient became febrile. He was subsequently diagnosed with infective endocarditis and commenced on intravenous vancomycin (penicillin allergy). Review of his transoesophageal echocardiogram found an oscillating lesion that had been initially missed. Therefore, it is likely that our patient had blood culture-negative endocarditis at the time of presentation. This was further supported by the regression of his ocular disease with intravenous vancomycin. CONCLUSION: We hypothesize that our patient developed FBA as an immunogenic response to Streptococcus viridans and Streptococcus oralis infection. Previous associations between streptococci and FBA have been made. Notably, beta-hemolytic streptococcal antigens are known to cross-react with retinal antigens. However, the implicated pathogens in our patient were alpha-hemolytic. Alpha-hemolytic streptococcal endophthalmitis has been linked to frosted branch response before, but it has never been associated with FBA through an immunogenic pathway. Therefore, it is important to note that idiopathic FBA can be associated with infective endocarditis and alpha-hemolytic streptococcal infections. Furthermore, FBA in elderly patients needs thorough evaluation to rule out systemic causes.

Comparison of polyhexamethylene biguanide and chlorhexidine as monotherapy agents in the treatment of Acanthamoeba keratitis.

PURPOSE: To compare the therapeutic outcomes of polyhexamethylene biguanide (PHMB) and chlorhexidine for Acanthamoeba keratitis. DESIGN: Prospective, double-masked, randomized comparative study. METHODS: Fifty-six eyes of 55 patients with Acanthamoeba keratitis were randomized to receiving PHMB 0.02% or chlorhexidine 0.02%. Diagnosis was made based on positive culture results (cornea or contact lens case) or on clinical grounds. The primary outcome measure was treatment failure defined as failure to induce a favorable clinical response within two weeks. Secondary outcomes were: 1) recovery of visual acuity (VA), 2) the degree of corneal scarring posttreatment, or 3) the need for penetrating keratoplasty. RESULTS: Fifty-one eyes completed the study. Twenty-three eyes received PHMB and 28 received chlorhexidine. Ninety-eight percent were contact lens wearers. Eighteen (78%) PHMB patients were treatment successes compared with 24 (85.7%) chlorhexidine patients (P = .71). Diagnosis was confirmed by positive corneal culture results in 26 cases (51%). Diagnosis was made within 28 days in 29 cases (56.9%), between one and two months in 13 cases (25.5%), and after more than two months in eight cases (15.7%). Improvement in VA was seen in 13 eyes (56.5%) receiving PHMB vs 20 eyes (71.4%) receiving chlorhexidine. Mild one-quadrant corneal scarring was seen in 43.5% of eyes receiving PHMB and 71.4% of eyes receiving chlorhexidine, whereas moderate corneal scarring in two or three quadrants was seen in 21.7% of eyes receiving PHMB and in 10.7% of eyes receiving chlorhexidine. Five eyes worsened while receiving PHMB vs four eyes worsening while receiving chlorhexidine. Penetrating keratoplasty was required in three eyes from PHMB group and in two eyes from chlorhexidine group. CONCLUSIONS: Outcomes were similar when using PHMB and chlorhexidine as monotherapy agents in treating Acanthamoeba keratitis.

Development of a questionnaire to assess subjective vision score in myopes seeking refractive surgery.

PURPOSE: To assess vision in patients with myopia and myopic astigmatism before and after refractive surgery. METHODS: A prospective controlled study of visual quality amongst myopes and astigmatic myopes. Focus groups, ophthalmic surgeons, and questionnaire experts devised a Subjective Vision Questionnaire (SVQ), modified after a pilot trial. Participants were administered the SVQ before clinical evaluation. Items answered by over 95%, with factor loadings > 0.55 were included. Test-retest reliability was assessed by repeat testing. Factor analysis identified groups of questions measuring particular dimensions of data. RESULTS: Sixty-seven items were answered by 128 patients and reduced to 24 items in a final questionnaire. Factor analysis identified six types of questions within the questionnaire, the most important of which was related to driving. CONCLUSION: The simplicity, low cost, and psychometric properties of the Subjective Vision Questionnaire support its use clinically and in research.

Fluorescein angiographic monitoring of corneal vascularization in lipid keratopathy.

The use of digital fluorescein corneal angiography to assist argon laser photocoagulation is reported. Photocoagulation was performed on the vascular supply of lipid keratopathy in the left eye of a 44-year-old woman.