Vascular co-option in lung cancer metastatic to the eye after treatment with bevacizumab

Abstract Background Chemotherapy with bevacizumab alters the angiogenic environment, and therefore, the growth and spread of metastases. We present a patient with metastatic lung adenocarcinoma to the eye with findings suggestive of retinal vascular co-option. Methods Case report. Results A 57-year-old male, receiving systemic bevacizumab for metastatic lung adenocarcinoma, presented with vitreous opacities and clumped deposits adherent to the retinal vessels. No choroidal metastases were present. Diagnostic vitrectomy yielded cellular evidence of adenocarcinoma, with thyroid transcription factor-1 staining confirming a lung primary. Conclusion The perivascular growth of small foci of metastatic vitreous cells suggests vascular co-option from the native retinal circulation. Similar modification of metastatic disease by bevacizumab has been observed in animal models and selected human cases

Chorioretinitis: A diagnostic clue to West Nile neuroinvasive disease

The use of ancillary ophthalmic imaging can aid in the timely and accurate diagnosis of West Nile neuroinvasive disease in the presence of chorioretinal involvement

Ocular Biopsy, Diagnostic Vitrectomy

Invasive diagnostic procedures are appropriate in cases of uveitis in which the diagnosis is uncertain, and the differential diagnosis includes significant disorders, such as sight-threatening infections or neoplasia. Small and large case series document the diagnostic utility of biopsy of the vitreous, retina, or choroid in selected cases. Vitreous biopsy has reported overall diagnostic yields from a low of 30 % to a high of 82 %. For lymphoma, the diagnostic yield ranges from 10 to 64 %. Several small case series have included retinal biopsy for diagnosis of viral retinitis, sometimes incidental to retinal detachment repair

Effect of Visual Feedback on the Eye Position Stability of Patients with AMD

The sources of the reduced fixation stability exhibited by patients with central vision loss in the light are relatively well understood, but we have no information on how they control eye position in complete darkness, in the absence of visual error signals. We therefore explored the effect of visual feedback on eye position stability by testing patients with age-related macular degeneration (AMD) and controls with normal vision in the light and in complete darkness. Nine patients (ages 67 to 92 years) and 16 controls (ages 16 to 74 years) were tested binocularly in the light and in complete darkness while remembering the location of a now invisible target. Binocular eye position was recorded with a video-based eye tracker. Results show that eye position stability both in the light and in the dark is worse for patients than for controls and that, for the two groups, eye position stability in the dark is, on average, 5.9 times worse than in the light. Large instability of fixation in patients with AMD was found even in absolute darkness when the scotoma cannot impair vision. These data reflect permanent changes in the oculomotor reference of patients with AMD

An update on the cause and treatment of scleritis

To review new clinically relevant data regarding the cause and treatment of scleritis that has been identified over the past 36 months. A recently described T-helper cell population, known as Th-17, has been implicated in scleritis. Large-scale, retrospective reviews of standard corticosteroid-sparing systemic therapies, published in the last few years, have demonstrated only moderate efficacy for any particular immunomodulatory agent, whereas new data have confirmed excellent efficacy and tolerability to subconjunctival corticosteroids. Improved understanding of the immunopathophysiology of scleritis offers hope for future molecule-specific drug design. Data continue to support the use of local steroids as a reasonable therapeutic option for nonnecrotizing, noninfectious anterior scleritis

Internal drainage for chronic macula-involving serous retinal detachment in idiopathic central serous chorioretinopathy

Conventional treatment of idiopathic central serous chorioretinopathy (ICSC) consists of argon laser, photodynamic therapy, or observation. However, in cases of atypical bullous ICSC with exudative detachment preventing any laser therapy, a surgical approach with external drainage of fluid has been performed. We present a case of ICSC with persistent macula involving exudative retinal detachment without evidence of uveitis that responded favorably to internal drainage by vitrectomy along with a scleral buckle placement. Our case, treated with internal drainage, also demonstrated successful long-term reattachment of the serous retinal detachment without any additional complications from the surgery

Image Stabilization in Central Vision Loss: The Horizontal Vestibulo-Ocular Reflex

For patients with central vision loss and controls with normal vision, we examined the horizontal vestibulo-ocular reflex (VOR) in complete darkness and in the light when enhanced by vision (VVOR). We expected that the visual-vestibular interaction during VVOR would produce an asymmetry in the gain due to the location of the preferred retinal locus (PRL) of the patients. In the dark, we hypothesized that the VOR would not be affected by the loss of central vision. Nine patients (ages 67 to 92 years) and 17 controls (ages 16 to 81 years) were tested in 10-s active VVOR and VOR procedures at a constant frequency of 0.5 Hz while their eyes and head movements were recorded with a video-based binocular eye tracker. We computed the gain by analyzing the eye and head peak velocities produced during the intervals between saccades. In the light and in darkness, a significant proportion of patients showed larger leftward than rightward peak velocities, consistent with a PRL to the left of the scotoma. No asymmetries were found for the controls. These data support the notion that, after central vision loss, the preferred retinal locus (PRL) in eccentric vision becomes the centre of visual direction, even in the dark

Evaluation of the reactive T-cell infiltrate in uveitis and intraocular lymphoma with flow cytometry of vitreous fluid (an American Ophthalmological Society thesis)

To describe the reactive T-cell infiltrate in uveitis and intraocular lymphoma using flow cytometry of clinical intraocular specimens acquired during diagnostic pars plana vitrectomy. This was a retrospective review of diagnostic vitreous specimens (1992-2011) obtained at a university-based, tertiary care center. Seventy-eight patients with uveitis or lymphoma undergoing pars plana vitrectomy were selected for intraocular testing based on clinical diagnostic uncertainty. Pars plana vitrectomy with flow cytometry, gene rearrangement studies, and cytology was performed. T-cell infiltrates were found in all diagnostic categories with limited power to discriminate between uveitis and T-lymphocyte reactive infiltrates in response to intraocular lymphoma. Statistically significant differences by two-sample test of means between group means were found between 35 uveitis and 35 B-cell lymphoma cases for T-cell markers CD2, 3, 4, 5, and 7, but not for CD8. The CD4:CD8 ratio had a higher mean value in the uveitis group (P=.0113), and 8 T-cell lymphomas had a statistically greater number of CD3+ lymphocytes compared to uveitis (P=.0199) by two-sample test of means. Likelihood ratios were highest for CD2, CD5, CD7, CD4:CD8 ratio, CD20, and CD22. Discrimination between uveitis and lymphoma based on cell identification by flow cytometry was limited because of the prevalence of T lymphocytes in all diagnostic categories, emphasizing the importance of a reactive T-cell infiltrate in B-cell lymphomas, which may impede diagnosis. Flow cytometry may allow identification of more cases of T-cell lymphoma than reported when it is combined with gene rearrangement and cytology

Unassisted Scleral Depression During Vitrectomy Surgery: Two Simple, Cost-Effective Techniques

The ability to visualize and work in the region of the vitreous base during vitrectomy surgery is important. However, this usually requires the use of a surgical assistant for scleral depression or expensive chandelier systems requiring extra incisions. The authors describe two alternative simple, cost-effective techniques to independently and simultaneously view and cut (or apply laser) in this difficult anatomical region. Light-pipe assisted scleral depression using a standard light pipe and ring depressor indentation while maintaining two intraocular instruments are described. The described techniques are simple, cost-effective, safe, suitable for phakic and pseudo-phakic patients, and allow the surgeon to operate independently with maximum control

HLA-DR, DQ class II DNA typing in pediatric panuveitis and tubulointerstitial nephritis and uveitis

To describe chorioretinal lesions in pediatric uveitis that are associated strongly with the HLA-DR, DQ class II type associated with tubulointerstitial nephritis and uveitis (TINU). Retrospective, observational case series. University-based clinic. Fifteen consecutive patients with onset of bilateral panuveitis at less than 16 years of age who were seen between September 2004 and October 2012 and 6 pediatric patients with confirmed TINU. HLA-DR, DQ class II DNA typing. Detection of the HLA-DRB1*01 and HLA-DQB1*05 risk alleles for TINU. Fourteen (93%) of the 15 patients with otherwise unexplained pediatric panuveitis typed HLA-DRB1*01-HLA-DQB1*05. Eleven (73.3%) of 15 patients had bilateral sharply demarcated, usually inferior, 200- to 300-μm spots of chorioretinal atrophy, and 4 (27.7%) of 15 patients had bilateral clusters of 500- to 750-μm poorly defined orange choroidal lesions without overlying atrophy of the retinal pigment epithelium. None had interstitial nephritis. Four of the 6 definite TINU cases had class II typing and TINU risk alleles; all 6 had bilateral panuveitis. The frequency of risk alleles was statistically higher in those with pediatric panuveitis than in the North American population and in nonpanuveitis pediatric uveitis patients assumed to have the North American HLA distribution (P < .0001, Fischer exact test). Positive likelihood ratios were 9.92 to 5.18, depending on assumptions regarding pretest probability of disease. Recognition of characteristic chorioretinal lesions in otherwise unexplained pediatric panuveitis, supported by selective HLA class II DNA typing, is useful in narrowing diagnostic possibilities and directing further evaluations. Panuveitis is underappreciated as a manifestation of TINU