Idiopathic polypoidal choroidal vasculopathy: a disease with diverse clinical spectrum and systemic associations.

PURPOSE: To report the clinical findings, angiographic results, clinical course, response to laser photocoagulation and systemic-associations in a group of patients with idiopathic polypoidal choroidal vasculopathy (IPCV). METHODS: All patients with IPCV attending the macular clinic underwent a complete ocular examination, and fluorescein and indocyanine green angiography. In addition, a systemic examination including blood pressure, full blood count, plasma viscosity and coagulation status of patients was carried out. RESULTS: We present a series of 5 patients (7 eyes) with clinical and angiographic evidence of IPCV with follow-up of 3-6 years. We report diverse demographic and clinical manifestations. One patient had polypoidal lesions found at the peripheral retina (anterior to equator) of both eyes. Three patients were treated with laser photocoagulation and achieved stable vision; 2 patients who had no laser treatment experienced deteriorated vision, one of whom had a vitrectomy. One patient was hypertensive, 2 patients were found to have raised plasma viscosity, and 1 patient had thrombocytopenia. CONCLUSIONS: The clinical spectrum of IPCV is wider than previously documented. It is a distinct clinical entity which should be differentiated from other forms of haemorrhagic and exudative maculopathy. The availability of indocyanine green angiography has allowed increased recognition of these cases. Early selective laser treatment on lesions affecting maculae-could stabilise the disease. Its association with systemic cardiovascular disease and blood disorder may predispose to the recurrence of haemorrhagic events in this entity.

Plasma VEGF and soluble VEGF receptor FLT-1 in proliferative retinopathy: relationship to endothelial dysfunction and laser treatment.

PURPOSE: To study plasma levels of vascular endothelial growth factor (VEGF, an index of angiogenesis), its soluble receptor (sFlt-1) and von Willebrand factor (vWf, an index of endothelial damage or dysfunction) in patients with proliferative retinopathy and corresponding changes in plasma levels after pan-retinal photocoagulation (PRP). METHODS: Eighteen patients (10 men; age, 57+/-16 years, mean +/- SD) with proliferative retinopathy secondary to diabetes (n = 13) and ischemic retinal vein occlusion (n = 5) with no previous PRP therapy were studied. Blood samples were obtained before and at 4 months after the last PRP session. Baseline (prelaser) plasma levels of VEGF, sFlt-1, and vWf (all by ELISA) were compared with levels in 16 diabetic patients with background retinopathy ("hospital controls"), and 18 healthy, age- and sex-matched "healthy controls." RESULTS: Patients with proliferative retinopathy had significantly raised plasma VEGF when compared with both control groups (P = 0.001). Patients with proliferative retinopathy and hospital controls had significantly raised plasma vWf levels when compared with healthy controls (P = 0.012). There was no difference in sFlt-1 levels between patients and controls (P = 0.162). After PRP, there was a significant reduction in plasma VEGF levels at 4 months' follow-up (P < 0.001), but no significant changes in plasma sFlt-1 or vWf levels. Patients with complete resolution of neovascularization had a trend toward lower median VEGF levels (80 versus 150 pg/ml, P = 0.062), but vWf levels (P = 0.50) and sFlt-1 (P = 0.479) were not statistically different. Baseline VEGF and sFlt-1 levels were significantly correlated (Spearman r = 0.505, P = 0.032) but after PRP at 4 months' follow-up, this was no longer significant (r = -0.269, P = 0.28). CONCLUSIONS: In this pilot study, patients with proliferative retinopathy demonstrate elevated peripheral markers of angiogenesis and endothelial dysfunction, suggesting a role for these processes in the pathogenesis of this condition. A fall in levels of VEGF after successful laser treatment may provide an opportunity for monitoring disease progression or relapse via a blood sample.

Polyarthropathy, orbital myositis and posterior scleritis: an unusual adverse reaction to influenza vaccine.

We report a patient who developed an acute symmetrical polyarthropathy, orbital myositis and posterior scleritis following inoculation with the 1993 Fluvirin (inactivated influenza vaccine: surface antigen) vaccine. We believe that this represents a hypersensitivity reaction to the vaccine as extensive investigations revealed no underlying infective, inflammatory or systemic cause. We review the current indications for vaccination against the influenza virus and the known adverse reactions to the vaccine.

Long-term follow-up of a single continuous adjustable suture in penetrating keratoplasty.

Penetrating keratoplasty was performed on 30 patients using a single adjustable continuous 10/0 nylon suture. Seventeen patients had astigmatism of 4.00 dioptre cylinders (DC) or more and were adjusted. The latest adjustment was at 32 weeks. Following adjustment there was a significant reduction in median post-keratoplasty astigmatism from 6.00 DC to 2.50 DC (p < 0.001). Thirteen patients, with astigmatism of 4.00 DC or less, were not adjusted. Median astigmatism for the non-adjusted group was 3.00 DC and for the entire group was 2.88 DC. Long-term refraction and suture status were monitored with time. Mean follow-up was 112 weeks (range 53-170 weeks). Over the study period the entire group showed significant 'long-term astigmatic drift' (LTAD), from 2.88 DC to 3.25 DC (median drift, 1.25 DC; range, 0.00-5.50 DC) (p < 0.001). Suture adjustment and suture removal showed no significant effect on LTAD. With suture removal between 32 and 84 weeks median LTAD was 1.50 DC. For suture removal after 84 weeks, median LTAD was also 1.50 DC, but the range of LTAD was 1.50 DC, compared with a larger range of 5.00 DC in the earlier suture removal group. The technique of single continuous adjustable sutures for penetrating keratoplasty is safe, effective in reducing astigmatism, but may need modification to further enhance long-term refractive stability.

Dye enhanced laser photocoagulation in the treatment of a peripapillary subretinal neovascular membrane.

A 45-year-old female with an elevated peripapillary subretinal neovascular membrane was treated with dye enhanced laser photocoagulation, using indocyanine green and the diode laser. Following treatment the membrane regressed, with flattening of the lesion. No side effects occurred and excellent visual acuity was maintained over a 12 month follow-up period.

Recurrent corneal erosion: clinical features.

The clinical features of a group of 30 patients with recalcitrant recurrent corneal erosions (i.e. those who failed to respond to conventional therapy) were evaluated. Associated ocular and facial abnormalities were documented. Meibomian gland dysfunction was present in all patients as manifest by dropout and inspissation of the meibomian glands, reduced tear film break-up time and debris in the tear film. Dropout of meibomian glands was present in 25 (83%) patients and was maximum in the medial half of the lid in 21 (84%) of these 25 patients. Tear film break-up time was reduced in all patients, being instant in 7 (23%), between 1 and 5 seconds in 22 (74%) and between 10 and 15 seconds in 1 (3%) patient. Superficial corneal abnormalities were present in 28 (93%) patients as manifest by maps, dots and fingerprints. Facial abnormalities such as telangiectasia, rhinophyma and acne rosacea were present in 22 (73%) patients. The findings of our study suggest an association between recalcitrant recurrent corneal erosions and meibomian gland dysfunction.

Oral tetracycline in the treatment of recurrent corneal erosions.

We report the results of a prospective, randomised controlled, 24 week trial to assess the efficacy of oral tetracycline and oral tetracycline with topical prednisolone in the treatment of recalcitrant recurrent corneal erosions, i.e. those which fail to respond to standard therapy. A total of 30 patients were randomly allocated to either standard treatment (group A), standard treatment and oral tetracycline (group B) or standard treatment, oral tetracycline and topical prednisolone (group C). Treatment groups B and C were instructed to perform daily lid hygiene. There was a significant reduction in the number of recurrent corneal erosions during the 24 week study period in group B (p = 0.04) and in group C (p = 0.0003) but not in group A (p = 0.66). There was a significant difference in the accelerated healing time of recurrent corneal microerosions between groups A and B (p = 0.001) and between groups A and C (p = 0.001). There was a significant improvement in the symptom scores during the study in treatment groups B and C (p = 0.005) but not in group A (p = 0.15). We conclude that lid hygiene and oral oxytetracycline 250 mg twice daily for 12 weeks with or without topical prednisolone for the first 7 days is beneficial in the management of recalcitrant recurrent corneal erosions.

Detection of varicella-zoster virus DNA in ocular samples from patients with uveitis but no cutaneous eruption.

Herpes zoster ophthalmicus is a well-recognised cause of intraocular inflammation, which may become recurrent or chronic after the acute phase has elapsed. Although it commonly presents with the typical rash, cases of ocular zoster with no cutaneous eruption have been well documented. We present two patients with unilateral anterior uveitis complicated by cataract, in whom molecular techniques based on the polymerase chain reaction detected varicella-zoster virus DNA in intraocular material obtained during cataract surgery. Neither patient gave a history of cutaneous eruption.

The management of post-keratoplasty astigmatism by post-operative adjustment of a single continuous suture.

Penetrating keratoplasty was performed in 39 consecutive patients. A 16 bite 10-0 nylon continuous suture was used. Post-operatively, the suture was adjusted to reduce astigmatism, as determined by refraction, keratoscopy and keratometry. Suture adjustment was performed if astigmatism was over 4 dioptres (D). The suture was tightened in the flatter meridian and loosened in the steeper meridian. Twenty-one patients had suture adjustment performed. Prior to adjustment, mean (+/- standard deviation) astigmatism measured 6.33 +/- 1.38 D. Following adjustment, mean astigmatism was significantly reduced to 2.69 +/- 1.14 D (p < 0.0001). The average final astigmatism for the entire group was 2.66 +/- 1.12 D. The use of a continuous adjustable suture in penetrating keratoplasty significantly reduced the post-operative astigmatism in a group of patients undergoing penetrating keratoplasty.

Ultrastructural findings in solar retinopathy.

This study documents the ultrastructural findings in a case of solar retinopathy, 6 days after sungazing. A malignant melanoma of the choroid was diagnosed in a 65-year-old man. On fundoscopy, the macula was normal. The patient agreed to stare at the sun prior to enucleation. A typical solar retinopathy developed, characterised by a small, reddish, sharply circumscribed depression in the foveal area. Structural examination of the fovea and parafovea revealed a spectrum of cone and rod outer segment changes including vesiculation and fragmentation of the photoreceptor lamellae and the presence of discrete 100-120 nm whorls within the disc membranes. Many photoreceptor cells, particularly the parafoveal rods, also demonstrated mitochondrial swelling and nuclear pyknosis. Scattered retinal pigment epithelial cells in the fovea and parafovea showed a degeneration characterised by loss of plasma membrane specialisations, swelling of the smooth endoplasmic reticulum and changes in the fine structure of the lipofuscin granules. The good visual prognosis in solar retinopathy was attributed to the resistance of the foveal cone cells to photochemical damage.