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Purpose To present an atypical case of acute posterior multifocal placoid pigment epitheliopathy in a 15 year old treated with immunosuppressive therapy. Methods Interventional case report. Results On initial presentation, the vision was 20/200 in the right eye and 20/300 in the left eye. The posterior poles of both eyes showed numerous creamy-white placoid lesions. Fundus autofluorescence demonstrated hypoautofluorescence lesions with hyperautofluorescence rims, while fluorescein angiography showed early blockage followed by late staining. These findings were consistent with a diagnosis of acute posterior multifocal placoid pigment epitheliopathy. Optical coherence tomography demonstrated outer retinal disruptions and thinning. Due to the severity of his disease, the patient was treated first with oral prednisone and later transitioned to mycophenolate mofetil by 2 months. His poor vision persisted beyond a 5-month follow-up visit despite fading of the lesions and reconstitution of the outer retinal layers and thickness on optical coherence tomography. By 8 months of follow-up, the visual acuity returned to 20/20 bilaterally without any further recurrences. Conclusion Although most patients with acute posterior multifocal placoid pigment epitheliopathy have a relatively short course and recover vision quickly, the use of steroids and immunosuppression may be of benefit for those patients with severe and prolonged visual loss.

BACKGROUND AND OBJECTIVE To determine the prophylactic and therapeutic value of a single subthreshold 810-nanometer laser treatment in patients with high risk drusen as a manifestation of dry age-related macular degeneration in both eyes. PATIENTS AND METHODS The Prophylactic Treatment of Age-related Macular Degeneration study enrolled 1,278 eyes of 639 participants who were 50 years or older with at least 5 drusen 63 µm or more in diameter in each eye. Treatment consisted of the placement of an annular grid of 48 extrafoveal, subthreshold 810-nm diode laser applications centered at but sparing the foveola in one eye of each participant, with the fellow eye serving as a control. Development of choroidal neovascularization and change in best-corrected visual acuity were compared between treated and untreated eyes. RESULTS Subthreshold laser treatment did not decrease the incidence of choroidal neovascularization in treated versus untreated eyes. A modest visual acuity benefit in treated eyes was found at 24 months (1.5 letter difference; P = .04) and in the treated eyes of participants with a baseline visual acuity between 20/32 and 20/63 (4.0 letter difference; P = .0034). However, this treatment effect was not sustained at 3 years. CONCLUSION A single subthreshold 810-nanometer laser treatment to eyes of participants with bilateral high risk drusen is not an effective prophylactic strategy against choroidal neovascularization. [Ophthalmic Surg Lasers Imaging 2009;40:530-538.] AUTHORS From the UPMC Eye Center (TRF, PMB), University of Pittsburgh, Pittsburgh, Pennsylvania; the Shiley Eye Center (WRF), University of California–San Diego, La Jolla, California; and the W. K. Kellogg Eye Center (DCM), University of Michigan, Ann Arbor, Michigan. Accepted for publication December 19, 2008. Supported by Iridex Corporation, Mountain View, California, and the sources listed under the individual center descriptions found at the end of the article; the Eye and Ear Foundation of Pittsburgh, Pittsburgh, Pennsylvania; Research to Prevent Blindness, Inc., New York, New York; and unrestricted funds from several participating centers. Presented in part at the annual meeting of the American Academy of Ophthalmology, October 15-18, 2005, Chicago, Illinois, and the annual meeting of the Association for Research in Vision and Ophthalmology, April 30-May 4, 2006, Ft. Lauderdale, Florida. The authors thank photographic readers Cheryl Hiner, Columbia, MD, Rosemary J. Brothers, Madison, WI, and Linda Huang, MD, and Maria Palaiou, MS, Pittsburgh, PA; the Data and Safety Monitoring Committee voting members Donald J. D’Amico, MD, Mark W. Johnson, MD, J. Richard Landis, PhD, and nonvoting ex-officio member, Dr. Musch; and Giorgio Dorin for his contribution to the manuscript. The authors have no financial or proprietary interest in the materials presented herein. Address correspondence to Thomas R. Friberg, MS, MD, UPMC Eye Center, 203 Lothrop Street, Suite 824, Pittsburgh, PA 15213. doi: 10.3928/15428877-20091030-01

We attempted to determine the efficacy of perilimbal anesthesia with Monitored Anesthesia Care (intravenous sedation with monitoring of the patients' vital signs by anesthesia) in patients undergoing pars plana vitrectomy. We selected 15 patients who were screened for any physical condition that would preclude them from lying supine and motionless for the duration of the surgery. Patients with complicated vitreoretinal abnormalities and patients who required reoperations were excluded. The patients ranged in age from 55 to 79 years and included three with nonclearing vitreous hemorrhage, seven with macular hole, three with macular pucker, one with proliferative diabetic retinopathy, and one with endophthalmitis. Total operating time ranged from 45 to 135 minutes (mean, 102.3 +/- 22.0 minutes). No complaints of discomfort were reported. All operations were completed without additional anesthetic. Our findings demonstrate that pars plana vitrectomy using perilimbal anesthesia with monitored anesthesia care is effective in selected patients. This form of anesthesia administration eliminates the risks of inadvertent globe perforation associated with retrobulbar and perilimbal anesthesia and the risks of general anesthesia.

Background: Intravitreal administration of ganciclovir has been used to treat cytomegalovirus (CMV) retinitis in patients with acquired immune deficiency syndrome (AIDS) who are unable to tolerate systemic antiviral therapy. Although retinal toxicity from intravitreal ganciclovir has been observed in animal experiments, to our knowledge, retinal toxicity from intravitreal ganciclovir has not been reported in humans. Methods: A case of inadvertent intravitreous injection of a high dose of ganciclovir (40 mg/ 0.1 ml) for CMV retinitis in a patient with AIDS is presented. Results: Despite immediate intervention with vitreous surgery, permanent retinal damage and visual loss developed. Clinical observations and photographic documentation are provided. Conclusion: Retinal toxicity can occur from a high-dose intravitreal ganciclovir injection. This toxicity may result from the high alkaline nature of this preparation, from osmotic damage, or from a direct effect of the concentrated ganciclovir.

PURPOSE: To report a case of caterpillar setae embedded in the corneal stroma and inferotemporal retina with minimal inflammation. DESIGN: Observational case report. METHODS: A 4-year-old boy developed a red eye after playing with a caterpillar. He was placed on topical tobramycin/dexamethasone and referred for evaluation of embedded setae in his conjunctiva, cornea, iris, and retina. Examination revealed no iridocyclitis or vitritis. RESULTS: Because of the lack of intraocular inflammatory response, no invasive intervention was conducted to remove or destroy the setae and he was tapered off the tobramycin/dexamethasone. At 4-month follow-up he remained asymptomatic with the setae still present in both his cornea and retina. In addition, vitreous membranes had formed in the immediate vicinity of the intraretinal setae. CONCLUSION: Intraretinal and corneal setae can be embedded with minimal inflammation and can be tolerated without need for surgical intervention.

PURPOSE: To report a case of ocular myasthenia associated with administration of nitrofurantoin. METHODS: Case report and review of the literature. RESULTS: While taking nitrofurantoin after urinary tract surgery, a 10-year-old female developed diplopia and ptosis. Sleep test confirmed ocular myasthenia. Signs and symptoms resolved after discontinuation of the drug. CONCLUSION: Ocular myasthenia may be associated with nitrofurantoin administration.

Background Cytomegalovirus retinitis and cryptococcal choroiditis are opportunistic infections in patients with acquired immune deficiency syndrome. These infections are associated with a retinal vasculitis and vascular attenuation. Methods We present a case of retinal vascular nonperfusion and retinal neovascularization in a patient with acquired immune deficiency syndrome. Results Retinal vascular nonperfusion and retinal neovascularization were confirmed by fluorescein angiography. Conclusions This is the first reported case of retinal neovascularization in a patient with acquired immune deficiency syndrome, ocular cytomegalovirus retinitis, and cryptococcal infection.

We report a case of unilateral cataract with a posterior located central opacity greater than 3 mm in diameter, which resolved without surgical intervention in an otherwise healthy child.

Purpose/Methods Acute syphilitic posterior placoid chorioretinitis causes visual loss in patients with secondary syphilis. The condition is characterized by vitreitis and large, yellow placoid lesions in the macula. We examined a patient with syphilis who had a serous retinal detachment and an exudative fluid meniscus (pseudohypopyon). Results/Conclusions Visual recovery and complete resolution of the chorioretinal lesion occurred after intravenous penicillin therapy. Secondary syphilis should be considered in the differential diagnosis of any patient with a macular pseudohypopyon.

Objective: Iridocyclitis has been identified as a dosage-dependent side effect in patients with the acquired immunodeficiency syndrome (AIDS) who are treated for Mycobacterium avium complex (MAC) infection with systemic rifabutin. We reviewed cases of acute hypopyon uveitis occurring in patients with AIDS to establish whether there was an association. Design: Retrospective case series. Setting: Outpatient clinic and inpatient hospital-based ophthalmology referral practice and infectious disease specialty service. Patients: Seven patients with AIDS, aged 10 to 40 years, presenting with acute unilateral hypopyon mimicking infectious endophthalmitis. Main Outcome Measures: Findings from complete ophthalmological evaluation and ancillary laboratory testing. Results: At the time of presentation, all seven patients were receiving treatment for MAC infection with rifabutin (dosage range, 300 to 600 mg/d) and clarithromycin. Results of microbiological investigations in five patients were negative. Iridocyclitis became bilateral in all seven patients, and hypopyon developed in the contralateral eye in five of seven patients. Hypopyon resolved rapidly with intensive topical corticosteroid therapy. Residual inflammation responded to topical corticosteroids with or without reduction of the rifabutin dosage. Conclusions: Concomitant use of rifabutin, clarithromycin, and fluconazole may precipitate hypopyon uveitis in patients with AIDS being treated for MAC infection.

Purpose: A technique that uses the El-Mofty/Schepens diathermy tip (MIRA, Inc.) to effect drainage of subretinal fluid during scleral buckling surgery is described. The efficacy of this drainage technique and its complication rate in a series of consecutive patients is discussed. Methods: The study included all of the scleral buckling procedures performed at the Retina Service for retinal detachments in which this technique was used. The El-Mofty/Schepens diathermy tip was first used to cauterize the choroid at the drainage site at low power, thus rendering it avascular, and then at higher power, to cause vaporization of the choroid, and allow spontaneous drainage of subretinal fluid. The success rate and all intraoperative and postoperative complications were recorded. Results: This technique achieved successful spontaneous drainage in 53 (82.8%) of 64 consecutive cases. Complications that are occasionally associated with the drainage of subretinal fluid, including iatrogenic retinal holes, choroidal hemorrhage, and retinal incarceration in the sclerotomy site, were not seen in any of the cases. Conclusion: This method provides a simple and safe technique for the drainage of subretinal fluid that obviates the need to directly perforate the choroid.

We have studied the specificity of ultraviolet (u.v.) mutagenesis in single-stranded DNA phage by analyzing u.v.-induced forward mutations in the lac insert of M13mp2 hybrid phage. Sequence analysis of 114 lac mutants derived from u.v.-irradiated phage grown in u.v.-irradiated cells showed that ultraviolet induces mainly single-nucleotide substitutions and deletions in progeny phage DNA. A total of 74% of the single-base substitution mutations occurred at sites of adjacent pyrimidines in the single-stranded DNA, with both T → C and C → T transitions predominating in the u.v. spectrum. Single-nucleotide deletion mutations occurred preferentially in tracts of repeated pyrimidine nucleotides. Tandem, double-base substitutions did not represent a major class of u.v.-induced mutations, but nearly 10% of mutant clones contained multiple, non-tandem nucleotide changes.

The insulin receptor and its regulation by insulin was studied in U-937 monocytes, a human cell line with properties similar to those of normal peripheraf blood monocytes. Treatment of this cell with insulin for 8–16 h produced an overall loss in the insulin receptor, i.e., a loss of receptors from the cell surface and internal pools. In contrast, short-term insulin treatment (15–30 min) caused a reduction in cell surface receptors but an increase in the internal receptors, as judged by pronase treatment at 4°C to distinguish receptor location. After the removal of insulin and pronase, the internalized receptors were rapidly reinserted back into the cell surface after warming to 37°C. Further studies showed an insulin-mediated increase in fluid-phase pinocytosis as measured by horseradish peroxidase (HRP) uptake. The amount of HRP accumulation and the time course for this stimulation were similar to those for receptor internalization. These features plus other results suggest that the insulin-stimulated internalization of insulin receptors may require an acceleration in the rate of pinocytic vesicle formation.