[Isovolumic hemodilution in the management of the acute phase of central retinal vein occlusion: a pilot study]. / Effet de l'hémodilution isovolémique dans le traitement de la phase aiguë des occlusions de la veine centrale de la rétine: une étude pilote.

INTRODUCTION: Cases series and randomized studies support the use of isovolumic hemodilution at the acute phase of the central retinal vein occlusion (CRVO). However, a recent meta-analysis showed the difficulty of interpreting the long-term effect of isovolumic hemodilution because of the late complications and the concomitant use of other treatments. We present here a pilot case-series study aiming to demonstrate the effect of isovolumic hemodilution at the acute phase of the disease, before any other treatment was applied. PATIENTS AND METHOD: Twenty-two consecutive cases of CRVO were prospectively treated with isovolumic hemodilution within 15 days of disease onset (substitution of 10 ml/kg of blood by a macromolecular solution (Voluven), aiming at a hematocrit of 35%). The treatment was performed in ambulatory conditions after excluding common contraindications (cardiac, respiratory and renal insufficiency, angina pectoris, history of heart attack or stroke during the last 6 months). The patients were followed prospectively with respect to visual acuity, fluorescein angiography and visual acuity at one week, one month, three months and twelve months. RESULTS: Visual acuity improved of at least one ETDRS line (5 letters) in 59% of the patients one week after the treatment. Improvement in the haemodynamic was observed in all these cases on fluorescein angiography. The vision remained stable at 1 month and 3 months before any other treatment was applied. After the 3rd month, additional intravitreous injection of triamcinolone was applied in 32% of eyes for persistent macular edema. At 12 months after hemodilution, visual acuity improved in 64% of cases and only 5% of the eyes converted into an ischemic CRVO. DISCUSSION: Isovolumic hemodilution at the acute phase of the CRVO is followed by an improvement in both vision and angiographic characteristics in more than 60% of our patients and the conversion into an ischemic form was limited to 5% of eyes. Further randomized studies are needed to evaluate the specific effect of hemodilution in the long term.

The value of the ophthalmological independent medical examination: analysis of 344 cases.

AIM: The aim of the study was to assess the value of the ophthalmological independent medical examination (IME) for detecting malingering, exaggerated or feigned symptoms, and incorrect causal relationship. DESIGN: Retrospective observational cohort study. METHODS: Consecutive examinees (n = 344) who underwent an IME by a single examiner between 1998 and 2005 in the setting of an ophthalmological group practice were included in the study. Diagnoses were made to at least a degree of medical certainty. Main outcome measures were frequency of exaggerated, feigned and non-causally related pathology and symptoms. RESULTS: In 172 claimants (50%), the symptoms and pathology claimed were fully substantiated. The other 172 claimants were found to have either exaggerated or totally feigned symptoms and/or symptoms and pathology misattributed (non-causally related to the claimed accident or incident). The most frequent feigned/exaggerated symptoms were visual loss (74%), ocular pain/discomfort (28%), visual field loss (19%), headaches (17%) and photophobia (13%). Visual field loss and the symptoms of ocular discomfort, headaches, dizziness and epiphora were more frequent in the feigning group (p<0.01). In contrast, complaints of swelling and deformity were more frequent (p = 0.001) among the examinees with real pathology. Review of the medical records provided helpful information in 163/172 cases in the feigning group. CONCLUSIONS: An ophthalmological IME is useful for detecting malingering, as well as symptoms and pathology not causally related to a claimed accident or injury or actually pre-existent to a claimed date. The advantages of an IME compared with relying on treating-doctor records, clues for diagnosing feigning and incorrect causal relationship, and guidelines for performing an ophthalmological IME are discussed.

Acute anticholinergic syndrome from Atropa belladonna mistaken for blueberries.

PURPOSE: To report the first case in the ophthalmic literature of acute anticholinergic syndrome after ingestion of Atropa belladonna mistaken for blueberries. METHODS: A 36-year-old woman presented to our ophthalmic emergency department with complaints of blurry vision, lightning flashes, disorientation, loss of balance, agitation, and anxiety for 24 hours. Ophthalmic examination revealed bilateral pupillary dilatation and paresis of accommodation. Additional symptoms of the anticholinergic syndrome were elicited on further questioning. RESULTS: Anticholinergic intoxication was suspected and the patient admitted to have eaten six "blueberries" found in the forest the previous day. The patient identified Atropa belladonna as the source of the berries she had eaten when shown photographs of the plant and its fruit. The recommendations of the Swiss Toxicological Information Centre were followed and physostigmine, the antidote for severe poisoning when 10 or more berries are ingested, was not administered. CONCLUSIONS: Accidental ingestion of Atropa belladonna berries may cause patients to first consult an ophthalmologist. It is important to recognize the anticholinergic syndrome caused by such intoxication in order to make a proper diagnosis, avoid unnecessary testing, and provide expedient appropriate treatment when required.

Bilateral multifocal retinal pigment epithelium detachments associated with systemic corticosteroids.

PURPOSE: To report an unusual case of central serous chorioretinopathy (CSC), presenting as bilateral and multifocal isolated serous retinal pigment epithelium detachments (RPEDs) following corticosteroid treatment. METHODS: An otherwise healthy 39-year-old man was evaluated for visual loss following blunt trauma of his right eye (RE). The patient underwent complete bilateral ophthalmologic examination, including optical coherence tomography and fluorescein (FA) and indocyanine green angiography (ICGA). RESULTS: At presentation, best-corrected visual acuity (BCVA) was 20/200 in the RE and 200/200 in the left eye (LE). Treatment included topical and oral corticosteroids. Three days later, the patient complained of metamorphopsia and further decrease in the VA of his RE. Fundus examination showed bilateral serous RPEDs. Optical coherence tomography, FA, and ICGA confirmed the diagnosis. Topical and oral corticosteroids were stopped and a follow-up examination 5 days later demonstrated marked resolution of the RPEDs in the RE. Five weeks later, RPEDs regressed in the RE while they persisted in the asymptomatic LE. Visual acuity in the RE further improved to 120/200. Nine months after the first visit, BCVA in the RE was 200/200. At that time, both eyes demonstrated retinal pigment epitheliopathy. CONCLUSIONS: Central serous chorioretinopathy is a known complication of corticosteroids. The classic variant of CSC consists of a shallow neuroretinal detachment located at the posterior pole of the fundus. Bilateral and multifocal isolated serous RPEDs represent an atypical form of CSC.

[Corneal findings in Fabry disease-related keratopathy using in vivo confocal microscopy]. / Evaluation d'une atteinte cornéenne dans le cadre d'une maladie de Fabry par microscopie confocale.

AIM: Description of corneal findings in Fabry disease-related keratopathy using in vivo confocal microscopy. OBSERVATION: A 65-year-old man presenting with a cerebral ischemic lesion was referred to our clinic for ophthalmologic evaluation with a suspicion of inaugural Fabry disease. Slit lamp biomicroscopy showed whorl-like lines in the inferior cornea of both eyes. In vivo confocal microscopy revealed the presence of numerous hyperreflective intracellular inclusions in the corneal epithelium and stroma. DISCUSSION: The whorl-like lines are related to deposition and accumulation of glycosphingolipids in the epithelial and stromal layers of the cornea. This case is also interesting for the late manifestation of Fabry disease, showing the variability in the expression of this condition. CONCLUSION: In vivo confocal microscopy may be an important tool in the follow-up of Fabry disease-related keratopathy, enabling us to monitor the effect of enzyme replacement therapy.

Autologous serum application in the treatment of Mooren's ulcer.

BACKGROUND: Mooren's ulcer is a peripheral corneal ulceration of presumed autoimmune aetiology. Its clinical course and eventual prognosis is variable and usually these ulcers respond poorly to conventional therapy. HISTORY AND SIGNS: A 67-year-old male was referred to our hospital for a painful, red and tearing left eye after receiving debris. Slit-lamp examination revealed a 3.2 x 2.1 mm peripheral corneal ulcer, a diffuse thinning of the lateral limbus (between 3 o'clock and 5 o'clock) and some endothelial precipitates. The conjunctiva was severely congested. In the anterior chamber, cells (++) and fibrin were found. THERAPY AND OUTCOME: We introduced an antibiotic, corticosteroid and cyclosporin therapy to treat the marginal corneal deficit caused by Mooren's ulcer. The patient did not respond to the initial treatment, but re-epithelialisation occurred and the corneal deficit improved after the introduction of autologous serum eye drops. CONCLUSION: Autologous serum seems to be an effective supplementary therapy in Mooren's ulcer.