Correlation of changes in the mandible and retina/choroid vasculature of a rat model of BRONJ.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) causes bones of the mandible and maxilla to become necrotic and protrude into the oral cavity. Compromised blood supply to bone is also a feature of BRONJ. The design of this study was first to use our established technique of molar extraction and IV bisphosphonate injection to produce features of BRONJ in rats that mimic the human disease; second to confirm vascular changes in the mandible and eye using micro-CT of vascular casts, and image analysis of retina/choroid images; and third to show parallel bisphosphonate-induced changes in the structure and markers of the vasculature of the bone and eye. The results of this study show structural changes in the eye and mandible as well as biochemical changes including the up-regulation of VEGF in response to the bisphosphonate-associated ischemia. These changes are not associated with angiogenesis in either the eye or mandible as determined by reduced vascular complexity. These results suggest that observations of direct changes to the vasculature in the retina/choroid structures of the eye in patients taking bisphosphonates could serve as a window to the progression of debilitating changes occurring as a result of bisphosphonate therapy.

Neuro-ophthalmic manifestations of a complicated cholesteatoma.

BACKGROUND: A cholesteatoma, also known as an epithelioma, is a mass of soft tissue that results from the accumulation of keratin protein debris enclosed by a layer of stratified squamous epithelium. CASE REPORT: A patient with cholesteatoma surrounding both internal carotid arteries presented with cerebral ischemic symptoms expressed as visual and ocular symptoms. Because of its location, mass effect, and potential stenosis of the internal carotids, this slow-growing tumor is potentially sight threatening. Asymmetric cupping of the optic nerves associated with symptoms such as dizziness, diplopia, or facial pain should be worked up carefully. CONCLUSION: The primary care optometrist can play an important role in the diagnosis and continued management of a patient with a cholesteatoma, carefully monitoring early signs of progression or change. This case illustrates how an intracranial lesion, away from the eye, can impact a number of ocular and visual functions.

An unusual presentation of a lid varix.

BACKGROUND: A varix usually refers to any abnormally distended vein, artery, or lymphatic vessel. Although orbital varices are a common finding, isolated eyelid varices are rare. Orbital and lid varices may be associated with additional venous malformations elsewhere in the body. The varices can be induced by the Valsalva maneuver that leads to increased pressure on the jugular vein. Because of the passive nature of the venous system, varices can also be induced by prone posture or stooping. Patients with ophthalmic varices may present with proptosis or complain of visual disturbance. CASE: A 39-year-old Asian woman presented to our clinic for a comprehensive eye examination, with complaints of discomfort while lying down, bending, or crying. She experienced a sensation of fullness in the right upper eyelid that seemed to have worsened gradually over the prior 9 years since her last pregnancy. Lid examination found a firm, palpable, nontender mass present within the right superior nasal lid after stooping. When filled, the induced lid mass could be visualized by ultrasound scan. The mass resolved when the patient sat upright. CONCLUSION: Lid varices are rare and usually visually benign. Ligation of small sections of the varix, as appropriate, may achieve the desired cosmetic effect and improve patient comfort. The varix usually does not recur after removal. Venography is used to evaluate the extent and supply of the varix before surgery. Cavernous hemangioma, a similar presentation, should be differentiated as it carries significant visual morbidity. Careful differential diagnosis with magnetic resonance imaging and computed tomography is essential with a new-onset or spontaneous varix.

Phlyctenular keratoconjunctivitis in a patient with Staphylococcal blepharitis and ocular rosacea.

BACKGROUND: Phlyctenular keratoconjunctivitis is a type IV hypersensitivity reaction to an inciting agent. The presentation is usually bilateral. The diagnosis can be difficult, especially if compounded by an underlying skin disorder such as rosacea. The 2 types of phlyctenules are differentiated based on the location on the eye, i.e., conjunctival or corneal. CASE REPORT: A 22-year-old man presented with painful, bilateral, elevated vascularized corneal lesions. Ultimately, the diagnosis was bilateral phlyctenular keratoconjunctivitis secondary to concurrent posterior blepharitis and recurrent ocular rosacea. The patient was treated with topical steroids and followed up with until his lids and corneas stabilized. He was then maintained with oral doxycycline and cyclosporine ophthalmic emulsion 0.5%. Lid hygiene and maintenance is a key factor in the course of the disease. CONCLUSION: Phlyctenular keratoconjunctivitis usually responds well to topical steroids, but any inciting agents should be identified and treated. Complications include corneal scarring, thinning, and perforation. Staphylococcus aureus is a common culprit, and tuberculosis as a possible cause should also be considered.

Optic atrophy after sildenafil use.

BACKGROUND: It has been well-reported that phosphodiesterase-5 (PDE-5) inhibitors, originally investigated for their effect on smooth muscles and now used widely in treatment of erectile dysfunction, can cause mild transient visual disturbances because of their action on inhibiting enzymes involved in retinal transduction. Recently, these medications have been associated with the development of non-arteritic anterior ischemic optic neuropathy (NAAION) with attendant vision loss. CASE REPORT: An older male patient, previously examined and ocularly healthy, presented asymptomatically with an occult optic neuropathy, not characteristic of NAAION. Neuroimaging and serology failed to reveal any other underlying cause. The patient did, however, report the use of sildenafil during the interval between his previously normal examination and the observation of his optic neuropathy. CONCLUSIONS: This case details the development of an optic neuropathy with atrophy seemingly associated with the use of sildenafil, although no cause and effect could be conclusively found. This may indicate that medications used in the treatment of erectile dysfunction may be responsible for optic neuropathies other than NAAION.