Emergency Treatment of Ocular Trauma.

Injuries to the eye and its adnexa are common in head and neck trauma centers. An ophthalmologist experienced in ocular traumatology is not always available. Therefore, every emergency physician should be familiar with the basic evaluation, triage, and management of ocular trauma. Above all, the identification of a need for immediate treatment should be implemented in the algorithm of an emergency room, especially in a head and neck trauma center, to reduce the risk of a devastating loss of vision. This article formulates the different types of ocular trauma and their required first-line therapy.

Role of human cytomegalovirus genotype polymorphisms in AIDS patients with cytomegalovirus retinitis.

Although several host factors have been identified to influence the course of HCMV infection, it still remains unclear why in AIDS patients without highly active antiretroviral therapy human cytomegalovirus (HCMV) retinitis is one of the most common opportunistic infections, whereas in other immunosuppressed individuals it has a low incidence. It was suggested that HCMV glycoprotein B strains may be suitable as marker for virulence and HCMV retinitis. Moreover, UL144 ORF, a member of the TNF-α receptor superfamily, may play a crucial role in innate defences and adaptive immune response of HCMV infection. Furthermore, sequence analyses of HCMV genes UL128, UL130, and UL131A as major determinants of virus entry and replication in epithelial and other cell types were performed. To evaluate the association of sequence variability of depicted viral genes with HCMV retinitis and in vitro growth properties in retinal pigment epithelial cells (RPE) and human foreskin fibroblasts (HFF), we compared 14 HCMV isolates obtained from vitreous fluid and urine of AIDS patients with clinically proven HCMV retinitis. Isolates were analyzed by PCR cycle sequencing and phylogenetic analysis. In addition, sequences of HCMV strains AF1, U8, U11, VR1814, and its cell culture adapted derivates were included. Sequence analysis of gB yielded three genetic subtypes (gB type 1 (5 isolates), gB type 2 (12 isolates), and gB type 3 (5 Isolates)), whereas sequence analysis of UL144 showed a greater diversity (7 isolates type 1A, 2 isolates type 1C, 7 isolates type 2, and 3 isolates type 3). In contrast, the UL128, UL130, and UL131A genes of all low-passage isolates were highly conserved and showed no preferential clustering. Moreover, in HFF and RPE cells, all of our HCMV isolates replicated efficiently independently of their genetic subtype. In conclusion, beside a possible link between the gB subtype 2 and HCMV retinitis, our study found no direct evidence for a connection between UL144/UL128/UL130/UL131A genotypes and the incidence of HCMV retinitis in AIDS patients.

Reactivation of toxoplasma retinochoroiditis under atovaquone therapy in an immunocompetent patient.

PURPOSE: To report a case of toxoplasma retinochoroiditis reactivation in an immunocompetent patient under atovaquone therapy. METHODS: Case report. RESULTS: A healthy woman with a history of bilateral toxoplasma retinochoroiditis since childhood presented with a reactivation of toxoplasma retinochoroiditis. Because earlier treatment regimens had either produced intolerable side effects and/or were deemed ineffective for the prevention of reactivation, the patient was started on atovaquone suspension (750 mg three times a day). After initial regression of the lesion and still under atovaquone therapy, the patient presented again five weeks later with worsened best-corrected visual acuity. Examination showed that the lesion had expanded again and more cells were present in the vitreous. CONCLUSIONS: To our knowledge, this is the first report of a reactivation of toxoplasma retinochoroiditis in an immunocompetent patient under atovaquone therapy, possibly indicating tachyzoite resistance to atovaquone.

Increased replication of human cytomegalovirus in retinal pigment epithelial cells by valproic acid depends on histone deacetylase inhibition.

PURPOSE: Human cytomegalovirus (HCMV) replication depends on different cellular pathways, including histone acetylation and extracellular-signal regulated kinases 1 and 2 (Erk 1/2). In the present study, the influence of therapeutic valproic acid (VPA) concentrations was investigated on HCMV replication in retinal pigment epithelial (RPE) cells. METHODS: HCMV antigen expression and replication were detected by immunostaining, real-time RT-PCR, and determination of virus titers. Histone acetylation and Erk 1/2 phosphorylation were detected by Western blot. RESULTS: Pretreatment with VPA < or =1 mM enhanced HCMV antigen expression and replication by up to ninefold. In addition to histone deacetylase (HDAC) inhibition, VPA stimulated Erk 1/2 phosphorylation in RPE cells. Investigation of six VPA derivatives revealed that S-2-pentyl-4-pentynoic acid was the only derivative that induced histone hyperacetylation, indicating HDAC inhibition, in the observed concentrations < or =1 mM and that increased HCMV antigen expression. Other derivatives did not enhance HCMV replication in the tested concentrations, although some were found to induce Erk 1/2 phosphorylation. The mitogen-activated protein kinase kinase (MEK) inhibitor PD98059 inhibited VPA-induced Erk 1/2 phosphorylation but did not affect VPA-induced increased HCMV replication. In addition, the structurally nonrelated HDACI trichostatin A enhanced HCMV replication but did not affect Erk 1/2 phosphorylation in RPE cells. CONCLUSIONS: The data demonstrate that VPA stimulates HCMV replication by HDAC inhibition independent of Erk 1/2 phosphorylation in therapeutic concentrations in RPE cells. Therefore, patients at risk of HCMV retinitis who are treated with VPA or other HDAC inhibitors should be carefully monitored.

The human eye (retina): a site of persistent HCMV infection?

BACKGROUND: Human cytomegalovirus (HCMV) retinitis frequently occurs in severely naturally and iatrogenically immunocompromised patients. It has been shown that the immune-privileged retina is a major site of HCMV infection in AIDS patients. It is conceivable either that during the immunosuppression HCMV infection reactivates in various other organs viremically affecting the retina or that HCMV persisting in the retina may locally reactivate and result in HCMV retinitis. METHODS: As there is still controversy about the sites of HCMV latency and persistence we investigated 75 eyes of HIV-seronegative patients undergoing enucleation due to a variety of malignant and non-viral benign ophthalmic disorders for the retinal presence of HCMV antigen and DNA. RESULTS: None of the analyzed patients had symptoms of HCMV retinitis. Immunohistologic staining as well as Taq Man DNA PCR analysis showed all samples to be free of HCMV. CONCLUSIONS: Our data suggest that the human eye is rather unlikely to be a site of productive or latent HCMV persistence.

[Telemedicine in Ophthalmology: A Useful Tool in Store-and-Forward Counselling?]. / Telemedizin in der Augenheilkunde: Ein Hilfsmittel in der konsiliarischen Mitbeurteilung?

Side by side with the progress in computers and imaging, telemedicine has already been used successfully in a large number of specialties of medicine. But high-quality images are not always suitable for transfer via modem because of their file size. The present experimental study was conducted to determine the effects of image compression by the JPEG algorithm on image quality and on the reliability of diagnosis after compression. Digital photographs of the retina were taken and the JPEG compressed images assessed by an experienced ophthalmologist. The present study showed a high reliability of diagnosis and a good agreement between the observations taken at the patient and at the computer. For this reason, JPEG image compression algorithm is suitable for reducing image size for producing high-quality images manageable for transmitting via modem in a store-and-forward teleophthalmological system.

[Intravitreal injection of rt-PA and gas in the management of minor submacular haemorrhages secondary to age-related macular degeneration]. / Intravitreale Gabe von rt-PA und Gas zur Behandlung kleinflächiger subfovealer Blutungen bei altersbezogener Makuladegeneration.

BACKGROUND: Subfoveal haemorrhage is a serious complication of choroidal neovascularization in age-related macular degeneration (ARMD). Recent studies have demonstrated that intravitreal injections of the fibrinolytic agent recombinant tissue plasminogen activator (rt-PA) and expansile gas may be effective in displacing submacular blood and facilitating visual improvement. However, in most of these studies, this technique has been used for the management of major haemorrhages. The purpose of our study was to investigate the efficacy of treating minor subfoveal haemorrhages with intravitreal rt-PA and pneumatic displacement. PATIENTS AND METHODS: In a prospective study, 25 consecutive eyes of 25 patients with recent ( 14 days showed a comparable outcome (p = 0.017). There were no side effects or complications. CONCLUSIONS: Our findings suggest that intravitreous injections of rt-PA and sulfur hexafluoride are of value for an improved and accelerated visual recovery in ARMD patients with minor subfoveal haemorrhages. Duration of haemorrhage

Rheopheresis for age-related macular degeneration: a novel indication for therapeutic apheresis in ophthalmology.

Age-related macular degeneration (AMD) is the leading cause of visual impairment and blindness in the elderly. Successful therapy is not yet available for the majority of patients, especially not for patients with dry AMD. AMD at cellular and molecular levels is at least in part a microcirculatory disorder of the retina. Rheopheresis is a safe and effective modality of therapeutic apheresis to treat microcirculatory disorders and represents a novel treatment option for patients with dry AMD. Elimination of a defined spectrum of high molecular weight proteins from human plasma including pathophysiologically relevant risk factors for AMD such as fibrinogen, cholesterol, von Willebrand factor, and alpha 2-macroglobulin results in the reduction of blood and plasma viscosity as well as erythrocyte and thrombocyte aggregation. Pulses of lowering blood and plasma viscosity performed as a series of Rheopheresis treatments lead to rapid changes of blood flow, subsequently inducing sustained improvement of microcirculation and recovery of retinal function. Two controlled randomized clinical trials demonstrated the safety and efficacy of Rheopheresis for the treatment of AMD patients, especially for those with the dry form. Recently the interim analysis of the sham-controlled, double blind, randomized multicenter Multicenter Investigation of Rheopheresis for AMD (MIRA-I) trial confirmed these results. The framework of completed and still ongoing controlled clinical trials in combination with postcertification studies including the RheoNet registry represents a comprehensive quality management approach for this novel interdisciplinary therapy for AMD. The development and continuous update of guidelines for the precise indication of Rheopheresis for AMD follows the requirements of evidence-based medicine.