Malignant Epiretinal Membrane After Proton Beam Radiation of Ciliary Body Melanoma

Purpose: To report the development of malignant epiretinal membrane after radiation of ciliary body melanoma.Case report: A 65-year-old woman was referred for evaluation of a ciliary body tumor in her right eye. On examination, a pigmented ciliary body tumor, displacing the iris anteriorly, was visible superotemporally and ultrasound biomicroscopy revealed a large solid ciliary body tumor. She was diagnosed with ciliary body melanoma and treated with proton beam radiation. Over the following 29 months, the treated tumor regressed but optical coherence tomography (OCT) showed the development of a dense epiretinal membrane. Enucleation was performed and histopathological examination showed viable melanoma cells in the vitreous cavity with sheet-like growth of viable spindle melanoma cells on the epiretinal surface. Conclusion: The development of a pigmented epiretinal membrane in eyes with uveal melanoma should raise the possibility of a malignant epiretinal membrane

Neurophthalmological conditions mimicking glaucomatous optic neuropathy: analysis of the most common causes of misdiagnosis

Background: To analyze the most common neurophthalmological conditions that may mimic glaucomatous optic neuropathy and to determine which most often lead to misdiagnosis when evaluated by a glaucoma specialist. Methods: We reviewed the charts of consecutive patients with optic neuropathies caused by neurophthalmological conditions screened in a single Eye Clinic within a period of 24 months. Within these enrolled patients, we selected the eyes whose fundoscopic appearance could resemble glaucoma based in pre-defined criteria (vertical cup-to-disc ratio >= 0.6, asymmetry of the cup-to-disc ratio >= 0.2 between eyes, presence of localized retinal nerve fiber layer and/or neuroretinal rim defects, and disc haemorrhages). Then, color fundus photographs and Humphrey Visual Field tests (HVF) of these eyes were mixed with tests from 21 consecutive glaucomatous patients (42 eyes with normal tension glaucoma). These images were mixed randomly and a masked glaucoma specialist was asked to distinguish if each set of exams was from a patient with glaucoma or with a neurophthalmologic condition. Results: Among the 101 eyes (68 patients) enrolled with neurophthalmological diseases, 16 (15.8%) were classified as conditions that could mimic glaucoma. The most common diagnoses were ischemic optic neuropathy (25%), compressive optic neuropathy (18.7%) and hereditary optic neuropathy (18.7%). Based on the analysis of fundus photographs and HVF tests, 25% of these were misdiagnosed as glaucoma (two ischemic optic neuropathies and two congenital optic disc anomalies). Conversely, 11.9% of the glaucomatous neuropathies were misdiagnosed as neurophthalmological disorders. Overall, the glaucoma specialist correctly diagnosed 84.5% of the eyes. Conclusions: Some neurophthalmological disorders can mimic glaucoma. In our study, isquemic and compressive optic neuropathies were the ones that most often did so. Almost one quarter of the eyes were misdiagnosed when evaluated by a glaucoma specialist, which can lead to inadequate management and influence the prognosis of these patients.Univ Fed Sao Paulo, Dept Ophthalmol, Sao Paulo, BrazilHosp Med Olhos, Glaucoma Unit, Sao Paulo, BrazilUniv Sao Paulo, Dept Ophthalmol, Sao Paulo, BrazilMayo Clin, Dept Ophthalmol, 4500 San Pablo Rd, Jacksonville, FL 32224 USAUniv Fed Sao Paulo, Dept Ophthalmol, Sao Paulo, BrazilWeb of Scienc

Cyclodialysis Cleft and Hypotony Following Combined Phacoemulsification and Excisional Goniotomy with the Kahook Dual Blade

A 69-year-old woman with bilateral primary open-angle glaucoma who underwent cataract extraction with intraocular lens implantation and excisional goniotomy with the Kahook Dual Blade (KDB; New World Medical, Rancho Cucamonga, CA, USA) in both eyes one year prior was referred for evaluation of significant visual acuity loss and pain in the left eye. On initial examination, intraocular pressure in the left eye was 3 mmHg and slit lamp examination revealed normal anterior chamber depth. Gonioscopy revealed a cyclodialysis cleft that was confirmed by anterior segment optical coherence tomography. Prominent chorioretinal folds suggestive of long-standing hypotony maculopathy were observed during fundoscopic examination. The cyclodialysis cleft, thought to be created inadvertently during the KDB goniotomy, resolved after three sessions of argon laser photocoagulation and the patient’s symptoms and visual acuity partially improved

Analysis of neuroretinal rim distribution and vascular pattern in eyes with presumed large physiological cupping: a comparative study

Background: To investigate possible differences in neuroretinal rim distribution, vascular pattern, and peripapillary region appearance between eyes with presumed large physiological optic disc cupping (pLPC) and eyes with minimal optic disc excavation.Methods: We prospectively enrolled consecutive subjects with pLPC and individuals with minimal excavation (optic disc excavation within normal limits; control group). All eyes had normal visual fields and untreated intraocular pressure (IOP) = 0.6 and >= 30 months of follow-up with no evidence of glaucomatous neuropathy. for controls, VCDR was limited to <= 0.5. We compared ocular signs and characteristics related to the neuroretinal rim distribution, vascular pattern, peripapillary region appearance and disc size between groups. Whenever both eyes were eligible, one was randomly selected for analysis.Results: A total of 74 patients (mean age, 45.6 +/- 14.9 years) with pLPC and 45 controls (mean age, 44.8 +/- 11.6 years) were enrolled (p = 0.76). Median disc size and VCDR was significantly larger in eyes with pLPC compared to controls (p < 0.01). the proportion of eyes with violation of the ISNT rule, laminar dot sign, nasal shifting of the central vessels, nasal excavation and baring of circumlinear vessel was significantly greater in the eyes with pLPC compared to controls (p < 0.01). There were no significant differences regarding the proportions of eyes with peripapillary atrophy between groups (p < 0.09). Finally, disc size was significantly associated with VCDR (r(2) = 0.47, p < 0.01), with an increase of 0.21 in VCDR for each 1 mm(2) in disc area.Conclusion: Compared to normal controls, eyes with pLPC may present a higher proportion of optic nerve head findings frequently observed in glaucomatous eyes. This seems to be explained in part by the larger discs found in these eyes. We believe care should be taken while classifying them as glaucomatous or not based solely on these characteristics.Universidade Federal de São Paulo, Dept Ophthalmol, BR-04021001 São Paulo, BrazilHosp Med Olhos, Glaucoma Unit, BR-06018180 Osasco, SP, BrazilMayo Clin, Dept Ophthalmol, Jacksonville, FL 32224 USAUniversidade Federal de São Paulo, Dept Ophthalmol, BR-04021001 São Paulo, BrazilWeb of Scienc

Eyes with Large Disc Cupping and Normal Intraocular Pressure: Using Optical Coherence Tomography to Discriminate Those With and Without Glaucoma

We evaluated the ability of spectral-domain optic coherence tomography (SD-OCT) to differentiate large physiological optic disc cupping (LPC) from glaucomatous cupping in eyes with intraocular pressure (IOP) within the normal range.  We prospectively enrolled patients with glaucoma or presumed LPC. Participants  had optic discs with confirmed or suspected glaucomatous damage (defined as a vertical cup-to-disc ratio≥0.6), and all eyes had known untreated IOP&lt;21 mmHg. For glaucomatous eyes, a reproducible glaucomatous visual field (VF) defect was required. LPC eyes required normal VF and no evidence of progressive glaucomatous neuropathy (follow-up≥30 months). Peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell complex (GCC) thicknesses were obtained using SD-OCT. For all studied parameters of pRNFL and GCC thicknesses, eyes with glaucoma (n=36) had significantly thinner values compared to eyes with LPC (n=71; P&lt;0.05 for all comparisons). In addition, pRNFL parameters had sensitivity of 66.7% and specificity of 83.1%, and GCC parameters had sensitivity of 61.2% and specificity of 81.7%. The combination of the two analyses increased the sensitivity to 80.6%. In conclusion, while evaluating patients with large optic disc cupping and IOP in the statistically normal range, SD-OCT had only limited diagnostic ability to differentiate those with and without glaucoma. Although the diagnostic ability of the pRNFL and the GCC scans were similar, these parameters yielded an increase in sensitivity when combined, suggesting that both parameters could be considered simultaneously in these cases

Mecanismos de fechamento angular sem bloqueio pupilar: análise de prevalência e resultados terapêuticos

Purpose: To assess the prevalence and treatment outcomes of angle-closure mechanisms other than pupillary block in a population of Brazilian patients.Methods: A retrospective chart review was conducted to evaluate patients who had undergone laser peripheral iridotomy (LPI) due to occludable angles at a single institution between July 2009 and April 2012. An occludable angle was defined as an eye in which the posterior trabecular meshwork was not visible for >= 180 degrees on dark-room gonioscopy. Key exclusion criteria were any form of secondary glaucoma and the presence of >90 degrees of peripheral anterior synechiae. Collected data were age, race, gender, angle-closure mechanism (based on indentation goniocopy and ultrasound biomicroscopy), intraocular pressure (IOP), number of antiglaucoma medications and subsequent management during follow-up. If both eyes were eligible, the right eye was arbitrarily selected for analysis.Results: A total of 196 eyes of 196 consecutive patients (mean age 58.3 +/- 11.6 years) who underwent LPI were included. in most of the patients [86% (169 patients; 133 women and 36 men]), LPI sucessfully opened the angle. Mean IOP was reduced from 18.3 +/- 6.4 mmHg to 15.4 +/- 4.5 mmHg after LPI (p<0.01). Among the 27 patients with persistent occludable angles, the most common underlying mechanisms were plateau iris (56%) and lens-induced component (34%). Most of these patients (85%) were treated with argon laser peripheral iridoplasty (ALPI); approximately 90% showed non-occludable angles following the laser procedure (mean IOP reduction of 18.9%), with no significant differences between patients with plateau iris and lens-induced components (p=0.34; mean follow-up of 11.4 +/- 3.6 months).Conclusions: Our findings suggest that, in this population of Brazilian patients, several eyes with angle closure were not completely treated with LPI. in the present large case series involving middle-age patients, plateau iris was the leading cause of persistent angle closure and was effectively treated with ALPI. A detailed eye examination with indentation gonioscopy should always be performed after LPI to rule out persistent angle closure due to non-pupillary block mechanisms.Hosp Med Olhos, Glaucoma Unit, Osasco, SP, BrazilUniversidade Federal de São Paulo, São Paulo, BrazilMayo Clin, Jacksonville, FL 32224 USAUniversidade Federal de São Paulo, São Paulo, BrazilWeb of Scienc

Role of CYP1B1, MYOC, OPTN and OPTC genes in adult-onset primary open-angle glaucoma: predominance of CYP1B1 mutations in Indian patients

Mutations in the CYP1B1, MYOC, OPTN, and WDR36 genes result in glaucoma. Given its expression in the optic nerve, it is likely a mutation in the OPTC gene is also involved in initiating glaucoma. This study was designed to evaluate the involvement of the CYP1B1, MYOC, OPTN, and OPTC genes in the etiology of adult-onset primary open-angle glaucoma (POAG) found in 251 Indian patients