Isolated optic nerve oedema as unusual presentation of electric injury.

A 45-year-old man with no significant medical history presented following an electric current injury (380 V). He developed multiple systemic injuries including third degree burns and after 1 week of hospitalisation he reported unilateral visual changes. Examination suggested the presence of optic nerve oedema without evidence of haemorrhage, exudate or vessel abnormality. This was considered to be related to the electric shock. A trial of corticosteroids was considered. He was followed up to 5 months in clinic and was noted to have developed unilateral optic atrophy and no other systemic manifestations. Initial and 5 months follow-up optic nerve colour photograph and optical coherence topography were documented. The present case highlights the fact that electric current injury can present with only a unilateral ischaemic optic neuropathy, the need for early diagnosis for timely treatment and the controversial role of corticosteroids.

Papillary conjunctivitis associated with Kikuchi disease.

PURPOSE: To describe a case of papillary conjunctivitis associated with Kikuchi-Fujimoto disease (KFD). METHODS: Case report. RESULTS: A 35-year-old black man developed bilateral eye redness before developing high fevers and cervical lymphadenopathy. Mediastinoscopy confirmed the diagnosis of KFD. The eye redness resolved on a regimen of prednisone 60 mg daily and recurred after corticosteroids were discontinued. The patient was found to have bilateral papillary conjunctivitis that resolved with topical prednisolone acetate. CONCLUSIONS: Papillary conjunctivitis may be associated with KFD.

Comparison of antimetabolite drugs as corticosteroid-sparing therapy for noninfectious ocular inflammation.

PURPOSE: To compare the relative effectiveness and side effect profiles of antimetabolite drugs in the treatment of noninfectious ocular inflammation. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 257 patients with inflammatory eye disease seen in a single-center, academic practice and treated with an antimetabolite as a first-line immunosuppressive agent from 1984 to 2006. METHODS: Data recorded included demographics, antimetabolite and prednisone doses, use of other immunosuppressive drugs, response to therapy, and side effects associated with drug use. MAIN OUTCOME MEASURES: Ability to control ocular inflammation and to taper prednisone to

Smoking as a risk factor for cystoid macular edema complicating intermediate uveitis.

PURPOSE: To describe risk factors for the presence of cystoid macular edema (CME) among patients presenting with intermediate uveitis. DESIGN: Cross-sectional study. SETTINGS: Single-center, academic practice. STUDY POPULATION: Two hundred and eight patients with intermediate uveitis evaluated from July 1, 1984 through September 30, 2006. PROCEDURES: Clinical and demographic data were entered retrospectively into a database and analyzed. OUTCOME MEASURES: Presence of CME at presentation to our clinic; risk factors for presenting with CME. RESULTS: Of the 208 patients, 74% had bilateral intermediate uveitis, yielding 363 affected eyes. Eighty-nine patients (43%) had CME in at least one eye at the time of presentation to our clinic. After controlling for potentially confounding variables including demographics, duration of disease, active intraocular inflammation, history of diabetes mellitus or hypertension, and presence of epiretinal membrane, actively smoking at presentation was associated with a four-fold increased risk of CME at presentation vs never smoking (odds ratio (OR), 3.90; 95% confidence interval (CI), 1.43, 10.66; P = .008). Former smoking also appeared to increase the risk of CME at presentation in the multivariate analysis, but the result was of borderline statistical significance (OR, 1.97; 95% CI, 0.99, 3.94; P = .055). After adjusting for confounding, there was a 4% increased risk of CME at presentation for each cigarette smoked per day (OR, 1.04; 95% CI, 1.01, 1.7; P = .005). CONCLUSIONS: CME was a common structural ocular complication observed in our cohort. Current smoking was associated with a dose-dependent increased risk of having CME at the time of presentation to our clinic.

Loss of visual field among patients with birdshot chorioretinopathy.

PURPOSE: To describe the prevalence and incidence of loss of visual field among patients with birdshot chorioretinopathy (BSCR) and to describe the effect of therapy on such field loss in these patients. DESIGN: Retrospective cohort study. SETTING: Single-center, academic practice. STUDY POPULATION: Fifty-five patients with BSCR evaluated from January 1984 through July 2006. PROCEDURES: Demographic, clinical, and visual field data were collected retrospectively. OUTCOME MEASURES: Visual field loss is defined as an abnormal visual field score on Goldmann perimetry within six months of presentation and during follow-up; rate of visual field loss is defined as the number of degrees lost per year. RESULTS: Forty-eight eyes of 24 patients had Goldmann visual fields performed within six months of presentation and of these eyes, 75% and 56% had abnormal field scores for the I-4 and IV-4 isopters, respectively. Of the 28 eyes of 14 patients that received immunosuppressive drug therapy during the follow-up period, the rate of visual field "loss" prior to treatment was 107 degrees/year (95% confidence interval [CI]: 65, 148 degrees/year) and 56 degrees/year (95% CI: 5, 109 degrees/year) for the I-4 and IV-4 isopters, respectively. The rate of "gain" after institution of immunosuppressive drug therapy was 53 degrees/year (95% CI: 10 degrees lost/year, 98 degrees gained/year) and 30 degrees/year (95% CI: 20 degrees lost/year, 81 degrees gained/year) for each isopter. CONCLUSIONS: Visual field loss was common among our patients with BSCR. Usage of immunosuppressive drug therapy may reverse some of the visual field loss while therapy is employed.

Multifocal choroiditis with panuveitis incidence of ocular complications and of loss of visual acuity.

PURPOSE: To estimate the incidences of ocular complications and vision loss in patients with multifocal choroiditis with panuveitis (MFCPU) and to describe the association between therapy and the incidences thereof. DESIGN: Retrospective cohort study. PARTICIPANTS: Sixty-six patients (122 eyes) with MFCPU evaluated from January 1984 through June 2005 at a single-center academic practice. METHODS: Demographic and clinical information on patients diagnosed with MFCPU was collected and entered into a computerized database for statistical analyses. MAIN OUTCOME MEASURES: Development of ocular complications, including choroidal neovascularization, epiretinal membrane, and cystoid macular edema (CME), and loss of visual acuity (VA) to 20/50 or worse and to 20/200 or worse. RESULTS: Among affected eyes of patients with MFCPU, frequencies of VAs of 20/50 or worse and of 20/200 or worse at presentation were 55% and 38%, respectively. Choroidal neovascularization was observed in 22% of affected eyes at presentation and was the leading cause of poor VA at presentation. The incidence rates of vision loss to 20/50 or worse and to 20/200 or worse were 0.19/eye-year (EY) and 0.12/EY in affected eyes and 0.07/person-year (PY) and 0.04/PY in better-seeing eyes. Choroidal neovascularization was the most common cause of incident vision loss, with approximately 45% of incident vision loss attributed to new-onset or recurrent choroidal neovascularization. Presence of epiretinal membrane and CME also was associated with the development of vision loss during follow-up. When taken in combination, the incidence of any posterior pole complication was 0.13/EY in affected eyes. Use of immunosuppressive drug therapy (but not low-dose corticosteroid therapy) was associated with an 83% reduction in the risk of posterior pole complications (P = 0.004) and with a 92% reduction in the risk of 20/200 or worse VA in affected eyes (P = 0.05). Of the 6 eyes with recurrent choroidal neovascularization, only one recurrence was observed, in a patient receiving immunosuppressive drug therapy. CONCLUSIONS: Treatment with immunosuppressive drugs may improve VA outcomes among patients with MFCPU by reducing the risk of sight-threatening posterior pole complications, including new-onset choroidal neovascularization and recurrent choroidal neovascularization among eyes with existing choroidal neovascularization.

Role of intravitreal triamcinolone acetonide in the treatment of postoperative endophthalmitis.

PURPOSE: To report the use of commercially available triamcinolone acetonide as adjunct treatment for acute-onset endophthalmitis after intraocular procedures. METHODS: Charts of 14 patients who received intravitreal triamcinolone in combination with intravitreal antibiotics for treatment of acute endophthalmitis were reviewed. Patients were included if they presented with pain, vision loss, and severe anterior chamber reaction or hypopyon. Visual acuities, intraocular pressures, anterior chamber reaction, and view of fundus details were recorded at baseline, 1 day, 1 week, 1 month, and 3 months to 5 months. RESULTS: Culture-positive results were found for 57% (8/14) of patients. Isolated species included Staphylococcus epidermidis, viridans streptococcus, group D Streptococcus (nonenterococcus), Propionibacterium acnes, and diphtheroid bacilli. Visual acuities improved an average of 7.5 Snellen lines. Preendophthalmitis level visual acuities were recovered in 78.6% patients (11/14), with 64% (9/14) of patients achieving visual acuity of 20/40 or better regardless of presenting vision. Resolution of anterior chamber reaction and view of fundus details were consistent with visual acuities. CONCLUSIONS: Intravitreal triamcinolone combined with intravitreal antibiotics appears to have a safety profile similar to current modalities with a favorable effect on visual recovery and function in the setting of acute postoperative endophthalmitis.

Vitreous penetration of topical moxifloxacin and gatifloxacin in humans.

PURPOSE: To determine the vitreous penetration of the new fourth-generation topical fluoroquinolones moxifloxacin 0.5% and gatifloxacin 0.3%. METHODS: A prospective randomized clinical trial comprising 12 eyes of 12 patients scheduled for pars plana vitrectomy between August 2003 and September 2003 was performed in a clinical practice. The patients were randomly assigned to receive topical moxifloxacin 0.5% (n = 6) or gatifloxacin 0.3% (n = 6). One half the patients in each antibiotic group received 1 drop every 15 minutes for a total of 3 doses starting 1 hour before surgery, and the other one half self-administered the antibiotic drop 4 times daily for 3 days before surgery and at 7 am on the day of surgery. Undiluted vitreous samples were obtained and analyzed using high-performance liquid chromatography. RESULTS: Either moxifloxacin 0.5% or gatifloxacin 0.3% was detected in the vitreous in all 12 patients in the study. There was no significant difference between the mean vitreous concentration of moxifloxacin 0.5% given over 1 hour preoperatively (0.012 +/- 0.011 microg/mL) and that given in the 3-day regimen (0.011 +/- 0.008 microg/mL) (P = 0.93). There was also no significant difference between the mean vitreous concentration of gatifloxacin 0.3% given over 1 hour preoperatively (0.001 +/- 0.0003 microg/mL) and that given over 3 days (0.008 +/- 0.006 microg/mL) (P = 0.11). Vitreous concentrations of moxifloxacin 0.5% and gatifloxacin 0.3% in each eye were all lower than the 90% minimum inhibitory concentration for the commonest bacterial isolates causing endophthalmitis. With both dosing regimens, the mean vitreous concentration of moxifloxacin 0.5% was higher than that of gatifloxacin 0.3% administered at the same regimen, but this was not statistically significant. CONCLUSION: Both topical moxifloxacin 0.5% and gatifloxacin 0.3% penetrated the vitreous in the uninflamed eye, but the vitreous concentrations attained were all lower than the 90% minimum inhibitory concentration for the commonest bacterial pathogens causing acute postoperative endophthalmitis.

Birdshot retinochoroidopathy: ocular complications and visual impairment.

PURPOSE: To describe the incidence of vision loss and of ocular complications attributable to birdshot retinochoroidopathy and to describe the association between therapy and the incidence thereof. DESIGN: Retrospective cohort study. SETTING: Single-center, academic practice. STUDY POPULATION: Forty patients with birdshot retinochoroidopathy were evaluated from January 1984 through March 2004. OBSERVATION PROCEDURE: Demographic and clinical information on patients diagnosed with birdshot retinochoroidopathy was collected. MAIN OUTCOME MEASURES: Visual acuity and visual field loss; ocular complications including cystoid macular edema (CME). RESULTS: In affected eyes, the frequencies of vision loss to 20/50 or worse and to 20/200 or worse and of CME at presentation were 33%, 13%, and 20%, respectively. Patients who presented with a duration of disease of > or = 30 months had higher frequencies of visual impairment to 20/50 or worse (68% vs 32%; P = .004) and to 20/200 or worse (32% vs 9%; P = .01), and had a higher frequency of CME (38% vs 14%; P = .02) than patients who presented with a duration of disease <30 months. The incidence rates on follow-up for vision loss to 20/50 or worse and to 20/200 or worse were 13% and 4% per eye-year (EY), respectively. The incidence of CME was 10%/EY. Use of immunosuppressive drug therapy was associated with a reduced risk of developing CME (relative risk = 0.17; 95% confidence interval: 0.05, 0.64; P = .009). CONCLUSIONS: Birdshot retinochoroidopathy is a progressive disease with the potential for visual impairment. Patients who present at a later date after the onset of disease were more likely to have vision impairment and CME. Use of long-term immunosuppressive therapy may reduce the risk of CME.

Sympathetic ophthalmia after a hyphema due to nonpenetrating trauma.

PURPOSE: To report a case of sympathetic ophthalmia occurring after nonpenetrating ocular trauma. METHODS: Interventional case report. RESULTS: An 18-year-old white male presented with sympathetic ophthalmia four weeks after a hyphema from a nonpenetrating bungee cord injury. Vision was 20/20; there were keratic precipitates, anterior chamber cells, vitritis, and discrete yellow deep choroidal lesions consistent with Dalen-Fuch's nodules OU. The uveitis was treated with topical, oral, and periocular corticosteroids and the oral immunosuppressives cyclosporine and mycophenolate mofetil. Vision remained 20/20 OU for the first year of follow-up; vision OD then deteriorated to 20/50 over the next year with the formation of a posterior subcapsular cataract OD. CONCLUSION: Sympathetic ophthalmia may result from nonpenetrating ocular trauma. Ophthalmologists should be aware of this as prompt intervention is warranted.

Spermatic cord leiomyosarcoma metastatic to the orbit.

PURPOSE: To report a case of spermatic cord leiomyosarcoma metastatic to the orbit. DESIGN: Case report. METHODS: A 78-year-old man presented with progressive redness, proptosis, and decreasing vision of the left eye of 3 weeks' duration. Computed tomography revealed an intraconal mass (1.5 x 2 cm) inferior to and displacing the left optic nerve. RESULTS: A left lateral orbitotomy was performed, and a well-demarcated mass was removed from the surrounding tissue. A follow-up computed tomography of the chest and abdomen was consistent with metastatic disease to the lungs and liver. CONCLUSIONS: Spermatic cord leiomyosarcoma is a rare cause of metastatic lesions to the orbit.

Intraocular concentration and pharmacokinetics of triamcinolone acetonide after a single intravitreal injection.

PURPOSE: To describe the pharmacokinetics occurring after the direct injection of triamcinolone acetonide into the vitreous humor of humans. DESIGN: Interventional case series. PARTICIPANTS: Five patients who received a single 4-mg intravitreal injection of triamcinolone acetonide. METHODS: An aqueous humor sample was obtained from 5 eyes via an anterior chamber paracentesis at days 1, 3, 10, 17, and 31 after injection. At each visit, visual acuity and intraocular pressure were measured and indirect ophthalmoscopy was performed. A fluorescein angiogram was carried out at day 10. Concentrations were determined using high performance liquid chromatography; pharmacokinetic analysis was carried out using PK Analyst, an iterative, nonlinear, weighted, least-squares regression program. MAIN OUTCOME MEASURES: Intraocular concentrations of triamcinolone were measured and population pharmacokinetic parameters were calculated. RESULTS: Pharmacokinetic data followed a two-compartment model. Peak aqueous humor concentrations ranged from 2151 to 7202 ng/ml, half-lives from 76 to 635 hours, and the integral of the area under the concentration-time curve (AUC(0-t)) from 231 to 1911 ng/h per milliliter. After a single intravitreal injection of triamcinolone, the mean elimination half-life was 18.6 days in nonvitrectomized patients. The half-life in a patient who had undergone a vitrectomy was shorter at 3.2 days. CONCLUSIONS: There was considerable intrasubject variation among peak concentration, AUC(0-t) values, and elimination half-lives. After intravitreal injection, measurable concentrations of triamcinolone would be expected to last for approximately 3 months (93 +/- 28 days) in the absence of a vitrectomy. Because triamcinolone pharmacokinetics were characterized only in elderly patients with macular edema, the results cannot be extrapolated to other patient populations.

Clinical relevance of reverse transcriptase-polymerase chain reaction for the detection of axillary lymph node metastases in breast cancer.

BACKGROUND: The mammary sentinel lymph node procedure can increase the detection of axillary metastases by 45% compared with standard axillary dissection. Some investigators have reported that reverse transcriptase-polymerase chain reaction (RT-PCR) increases metastasis detection even more, but it is uncertain whether a positive RT-PCR test in the face of a negative histological evaluation is clinically meaningful. METHODS: RT-PCR for epithelial glycoprotein 2 and cytokeratin 19 was performed on sentinel and pooled nonsentinel axillary lymph nodes from 108 women with clinical stage I or II breast cancer who were followed up for a median of 40 months. RESULTS: Axillary metastases were detected on standard tissue sections in 26% and by RT-PCR in 30%. Results for the two tests were concordant for 80% of the cases. RT-PCR upstaged 16%. Tumors from women whose lymph nodes were positive only by RT-PCR were phenotypically similar to those from women with no metastases detected by any method. Moreover, 4-year actuarial distant disease-free survival was 100% for women with metastases detected by RT-PCR only, as compared with 74% for those with metastases detected by routine histology (P =.03) and 93% for those with no metastases detected by either method (P =.04). CONCLUSIONS: Analysis of sentinel lymph nodes by RT-PCR for epithelial glycoprotein 2 and cytokeratin 19 is unlikely to provide clinically useful information.

Cause and prognosis of nontraumatic sixth nerve palsies in young adults.

OBJECTIVE: To review the causes and prognosis of sixth nerve palsies in patients who are 20 to 50 years of age. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: All patients aged 20 to 50 years with a nontraumatic sixth nerve palsy seen in a neuro-ophthalmic practice from 1994 to 2000. INTERVENTION: Diagnostic testing to determine the cause of the palsy and surgical intervention to correct persistent stable strabismus. MAIN OUTCOME MEASURES: Cause of the palsy. The patients' clinical courses were reviewed. RESULTS: The most common cause for a sixth nerve palsy in this age group was a central nervous system (CNS) mass lesion, although the most common cause for an isolated sixth nerve palsy in this age group was multiple sclerosis. Patients with a CNS mass lesion responsible for their palsy had the highest rate of nonresolution requiring strabismus surgery. CONCLUSIONS: Sixth nerve palsies are unusual in young adults, but in the practice of author (GBK) most are secondary to CNS mass lesions and, when isolated, multiple sclerosis. Deferring neuroimaging or other appropriate investigations presuming a microvascular cause for the palsy in this age group is not recommended.

Adjuvant chemotherapy with doxorubicin and cyclophosphamide in women with rapidly proliferating node-negative breast cancer.

This prospective clinical trial was designed to assess the impact of adjuvant chemotherapy in women with rapidly proliferating node-negative breast cancer. This group has been predicted to have a 5-year disease-free survival (DFS) of 70% without adjuvant chemotherapy. In this study, 449 women with rapidly proliferating breast cancer (91% measured by S-phase fraction and 9% by histochemistry) received adjuvant chemotherapy with doxorubicin/cyclophosphamide (AC) plus tamoxifen for estrogen receptor-positive or progesterone receptor-positive cancer. The 5-year DFS was 90% (+/- 2%) and the 5-year overall survival was 94% (+/- 1%). At a median follow-up of 62 months, the strategy of administering 6 cycles of AC to women with T2 N0 cancer and 3 cycles in those with smaller T1 N0 cancers appeared to eliminate tumor size as a potential prognostic factor. Adjuvant chemotherapy with AC appears effective in reducing recurrence rates for women with rapidly proliferating node-negative breast cancer.

Conservative surgery and radiation therapy for macroscopically multiple ipsilateral invasive breast cancers.

BACKGROUND: The presence of macroscopically multiple ipsilateral invasive breast cancer (MMIIBC) has been considered a contraindication for breast conservation. Early series reported high rates of local recurrence. A treatment regimen was developed to accommodate patient requests for breast conservation in MMIIBC. METHODS: We reviewed medical records of the 15 MMIIBC patients who underwent partial mastectomy followed by radiation between 1989 and 1997. All patients had 2 or more separate macroscopic tumors greater than 2 mm in diameter. After tumor excision, all specimens were evaluated; the protocol required surgical margins of at least 2 mm. RESULTS: As of June 2000 (median follow-up 76 months), 14 patients (93%) were alive without evidence of disease. One patient died of systemic disease without local recurrence. CONCLUSIONS: In selected cases, the combination of breast conservative surgery and radiation therapy with systemic therapy results in acceptable local-regional control. Patients who present with MMIIBC with clear surgical margins should be considered for breast conservation.

Loss of heterozygosity in benign breast epithelium in relation to breast cancer risk.

The multistage model of breast carcinogenesis suggests that errors in DNA replication and repair generate diversity in the breast epithelium (the mutator phenotype), resulting in selection and expansion of premalignant clones with an acquired survival advantage. We measured loss of heterozygosity (LOH) in breast epithelial cells obtained by random fine-needle aspiration (FNA) biopsy from 30 asymptomatic women whose risk of breast cancer had been defined by the Gail model. Polymorphic microsatellite markers were selected on the basis of their relevance to breast cancer. Breast epithelium of 11 (37%) of 30 women had normal cytology, and that of 19 (63%) had proliferative cytology (eight with atypia and 11 without atypia). LOH was detected in two women with normal cytology and in 14 women (seven with atypia and seven without atypia) with proliferative cytology (P =.007). The frequency of LOH was associated with the cytological diagnosis, as well. The mean proportion (range) of informative markers demonstrating LOH was 0.02 (0-0.20) for the 11 women with normal cytology, as compared with 0.15 (0-0.50) for the 19 women with proliferative cytology (P =.02). Mean lifetime risk for developing breast cancer, as calculated by the Gail model, was 16.7% for women with no LOH compared with 22.9% for women with any LOH (P =.05). These observations support a multistage model of breast carcinogenesis where the initiating events are those that result in genomic instability. Accurate individualized breast cancer risk assessment may be possible based on molecular analysis of breast epithelial cells obtained by random FNA.

Gorham disease of the orbit.

PURPOSE: To report a case of Gorham disease, also known as vanishing bone disease, of the orbit. DESIGN: Interventional case report. METHODS: A 43-year-old Caucasian woman developed a depression in her left temple, pulsation in her left upper eyelid and temple, and bulging of the left upper eyelid and headache. Computerized tomography revealed a lytic lesion in the roof of the left orbit. RESULTS: Intraoperative examination of the lesion revealed a bony defect in the left orbital roof. Surgical intervention resulted in improvement of her symptoms, and pathology failed to reveal evidence of malignancy or other benign neoplastic process. CONCLUSION: Gorham disease should be considered in the differential diagnosis of lytic bony lesions of the orbit.

Validating the performance of the mammary sentinel lymph node team.

BACKGROUND AND OBJECTIVES: The mammary sentinel lymph node (SLN) procedure has the potential to improve the accuracy and lower the morbidity of axillary staging in breast cancer patients, but results are closely linked to experience and can vary widely between institutions. Standardized performance measures need to be established in order to optimize the transition to SLN biopsy only. METHODS: Performance data were prospectively collected for the first 156 mammary SLN procedures performed by three surgeons in our institution. RESULTS: Seventy-five cases were required to achieve an SLN visualization rate of > 80% on preoperative lymphoscintigraphy. The SLN visualization rate was 90% for the last 52 cases. Two surgeons required 25 cases before consistently achieving a > or = 90% SLN identification rate in the operating room and one required 15 cases. The metastasis detection rate increased from 22% for the first 52 cases to 31% for the last 52 cases. The false negative rate for the procedure was 5%. CONCLUSIONS: The following performance criteria and benchmarks are suggested for validating the performance of the SLN team: (1) SLN visualization rate on preoperative lymphoscintigraphy > or = 80%, (2) SLN identification rate in the operating room > or = 90%, (3) False negative rate for the procedure 5%. Thirty procedures per surgeon were sufficient to achieve these benchmarks in our group.