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Giant cell arteritis (GCA) is a medical and ophthalmological emergency due to risk of stroke and sudden irreversible loss of vision. Fast and accurate diagnosis is important to prevent complications and long-term high dose glucocorticoids toxicity. Temporal artery biopsy is gold standard for diagnosing GCA. However, temporal artery ultrasound is a fast and non-invasive procedure which may provide a supplement or an alternative to biopsy. This study assesses the diagnostic performance of ultrasound and biopsy in the diagnosis of GCA.Examination results of patients suspected of having GCA in the period from August 2018 to June 2019 were reviewed. Patients underwent clinical examination and blood tests. Within a few days of starting glucocorticoid treatment, temporal ultrasound and unilateral biopsy were performed. Experienced physicians established the final clinical diagnosis at 6-months follow-up.Seventy-eight patients underwent both ultrasound and biopsy. Thirty-five (45%) received the final clinical diagnosis of GCA. Compared with the final clinical diagnosis, biopsy had a sensitivity of 69% (51-83%) and a specificity of 100% (92-100%), and ultrasound a sensitivity of 63% (45-79%) and a specificity of 79% (64-94%). Area under the receiver operating characteristics curves were 0.84 and 0.71 for biopsy and ultrasound respectively (p = 0.048). False negative rate of ultrasound was 4 out of 78 (5%).Sensitivity of ultrasound is almost on par with that of biopsy although the overall diagnostic accuracy of ultrasound was slightly lower. We find that ultrasound is a reliable tool for first line diagnosis of GCA.

PURPOSE To assess retinal perfusion in eyes with unilateral ocular ischaemic syndrome (OIS) and to compare with control subjects. METHODS Retrospective case series. Linear blood flow velocities in macular vessels were estimated using motion-contrast fundus photography in eight patients with unilateral OIS (eight OIS eyes, seven fellow eyes) and 12 control subjects. The diagnosis of OIS was supported by carotid artery Doppler ultrasonography and pneumoplethysmographic measurement of ocular systolic perfusion pressure. RESULTS Macular arterial blood flow velocity (median, range) was 1.8 (1.4-2.7) mm/s in OIS eyes, 4.0 (2.9-5.3) mm/s in fellow eyes (p = 0.016) and 3.8 (2.3-5.1) mm/s in control eyes (p = 0.0004 and p = 0.67 versus OIS and fellow eyes, respectively). Macular venous blood flow velocity was 1.5 (1.0-2.1) mm/s in OIS eyes, 2.6 (2.0-2.9) mm/s in fellow eyes (p = 0.016) and 2.7 (1.8-3.5) mm/s in control eyes (p = 0.0007 and p = 0.64). Arterial velocities were below or equal to the lowest value observed in control subjects (≤2.3 mm/s) in seven of eight eyes with OIS. Visual acuity 0.7 or worse was found in two OIS eyes with arterial velocities below 1.7 mm/s and venous velocities below 1.3 mm/s and together with neovascular glaucoma or polycythemia vera (one eye each). CONCLUSION Motion-contrast imaging revealed markedly reduced macular perfusion velocities in OIS eyes compared with unaffected fellow eyes and healthy control eyes. The method appears to provide a clinically meaningful quantitative measure of macular hypoperfusion.

Introduction: Conjunctival neoplasms span from benign lesions to life-threatening malignancies. A wide range of treatment modalities has been developed, spanning from observation, simple ex...

Pemphigoid and pemphigus diseases as well as Stevens-Johnson syndrome present as vesiculobullous disorders of the skin and may additionally involve both the oral cavity and the ocular surface. Ocular involvement ranges from mild irritation and dry eye disease to chronic conjunctivitis, symblepharon, eyelid malposition, ocular surface scarring and severe visual loss. In addition to diagnostic assessments, ophthalmologists must treat the dry eye and meibomian gland dysfunction components of these diseases using a stepladder approach, including eyelid hygiene and lubricants. Topical anti-inflammatory therapy is used to treat acute inflammatory exacerbations of the ocular surface, but it cannot prevent scarring alone. Intralesional antimetabolite therapy can cause regression of conjunctival pathology in selected cases. Hence, patients with vesiculobullous disorders should be managed by a multidisciplinary team representing ophthalmology, dermatology, otolaryngology, oral medicine and pathology, internal medicine and intensive care. Systemic treatments including corticosteroids, azathioprine, cyclophosphamide, cyclosporine and mycophenolate mofetil help control inflammation. Intravenous immunoglobulins, plasmapheresis and targeted antibody therapy can be used in selected, severe and treatment-resistant cases. Local surgical management may include debridement of pseudomembranes, lysis of symblepharon, amniotic and mucous membrane grafting as well as reconstructive procedures. Prospective, multicentre, international studies are recommended to further support evidence-based practice.

Purpose To investigate changes in retinal metabolism, function, structure and morphology in relation to initiation of insulin pump therapy (continuous subcutaneous insulin infusion, CSII). Methods Visual acuity, retinopathy level, dark adaptation kinetics, retinal and subfoveal choroidal thickness, macular perfusion velocities, retinal vessel diameters and blood oxygen saturations were measured at baseline and after 1, 4, 16, 32 and 52 weeks in 31 patients with type 1 diabetes who started CSII and 20 patients who continued multiple daily insulin injections (MDI). Results One year of CSII reduced haemoglobin A1c (HbA1c) by 1.6% (17.8 mmol/mol) compared with 0.3% (3.1 mmol/mol) in the MDI group (p

The purpose of this experimental clinical study was to assess the effects of dark adaptation and acute changes in glycemia on retinal vessel diameters in men. The study included 14 patients (mean age 63 years, range 48–74 years) with type 2 diabetes mellitus and minimal or no diabetic retinopathy. Retinal vessel diameters were assessed using infrared photography before and after dark adaptation, first while fasting and then at peak hyperglycemia during an oral glucose tolerance test (OGTT). Dark adaptation was accompanied by retinal vasodilatation, both during fasting (mean glycemia 7.6 ± 1.7 mM) and postprandial hyperglycemia (15.7 ± 4.2 mM). When fasting, the increase in vein diameter during dark adaptation was 2.0% after 20 min (P=0.018) and 2.9% after 40 min (P=0.010). When subjects were hyperglycemic, the increase during dark adaptation was 2.8% for retinal vein diameters (P=0.027) and 2.0% for retinal artery diameters after 20 min (P=0.002) and 1.7% for retinal artery diameters after 40 min (P=0.022). For identical conditions of light/dark adaptation, retinal vessels were dilated when subjects were fasting compared to postprandial hyperglycemia. Thus, darkness and fasting were both associated with retinal vasodilation in this short-term experiment in patients with type 2 diabetes. Future studies should determine whether both the stimuli of vasodilation lead to retinal hyperperfusion, which would support that they may be involved in the aggravation of diabetic retinopathy.

Purpose To compare retinal vascular dynamics during acute hyperglycaemia in patients with type 2 diabetes and healthy volunteers. Methods Twenty-one patients with type 2 diabetes and 27 healthy controls were examined with fundus photographic measurement of retinal vessel diameters, retinal oximetry, macular perfusion velocities and optical coherence tomographic measurement of subfoveal choroidal thickness every 30 min during a 3-hr 75 g oral glucose tolerance test (OGTT). Patients paused antidiabetic therapy for 1 week prior to the OGTT. Results Plasma glucose (PG) and fluctuations in PG were larger in patients with diabetes (p

The purpose of the study was to characterize the long-term effect of insulin pump therapy (CSII) on electroretinography and dark adaptometry and to examine the influence of baseline glycaemic control on retinal function in patients with type 1 diabetes mellitus. This prospective observational extension study enrolled 13 patients out of 17 who completed a primary 1-year study of the effect of CSII on retinal function. Twelve patients were still on CSII at follow-up. The extension study included a single examination 3.5 years (range 3.0–4.0 years) after initiation of CSII of one study eye per patient. Procedures included full-field electroretinography (ERG), dark adaptometry, optical coherence tomography, and fundus photography. Mean ERG amplitudes 3.5 years after initiation of CSII were 15–43 % lower than at baseline (all p

Background Dark adaptation is an energy-requiring process in the outer retina nourished by the profusely perfused choroid. We hypothesized that variations in choroidal thickness might affect the rate of dark adaptation. Method Cross-sectional, observational study of 42 healthy university students (mean age 25 ± 2.0 years, 29 % men) who were examined using an abbreviated automated dark adaptometry protocol with a 2° diameter stimulus centered 5° above the point of fixation. The early, linear part of the rod-mediated dark adaptation curve was analyzed to extract the time required to reach a sensitivity of 5.0 × 10−3 cd/m2 (time to rod intercept) and the slope (rod adaptation rate). The choroid was imaged using enhanced-depth imaging spectral-domain optical coherence tomography (EDI-OCT). Results The time to the rod intercept was 7.3 ± 0.94 (range 5.1 - 10.2) min. Choroidal thickness 2.5° above the fovea was 348 ± 104 (range 153–534) μm. There was no significant correlation between any of the two measures of rod-mediated dark adaptation and choroidal thickness (time to rod intercept versus choroidal thickness 0.072 (CI95 -0.23 to 0.38) min/100 μm, P = 0.64, adjusted for age and sex). There was no association between the time-to–rod-intercept or the dark adaptation rate and axial length, refraction, gender or age. Conclusion Choroidal thickness, refraction and ocular axial length had no detectable effect on rod-mediated dark adaptation in healthy young subjects. Our results do not support that variations in dark adaptation can be attributed to variations in choroidal thickness. Electronic supplementary material The online version of this article (doi:10.1186/s12886-016-0273-6) contains supplementary material, which is available to authorized users.

Purpose To study the circulation in the retinal vessels in patients with blood dyscrasia due to myeloproliferative neoplasms using non-invasive retinal imaging. Methods Prospective consecutive case series of seven treatment-naive patients with chronic myeloid leukaemia (n = 2), polycythemia vera (n = 4), essential thrombocytosis (n = 1) examined before and after cytoreductive treatment. We investigated retinal circulation with motion-contrast imaging, retinal oximetry and spectral-domain optical coherence tomography. Results Retinal venous blood velocity increased by 8.14% (CI95 3.67% to 12.6%, p = 0.004) and retinal arterial oxygen saturation increased by 7.23% (CI95 2.9% to 11.6%, p = 0.010) at follow-up (mean 12 weeks, range 5–14 weeks) where complete haematological remission had been achieved by cytoreductive treatment. Abnormal optical coherence tomography reflectivity patterns were present at baseline in patients with chronic myeloid leukaemia and were replaced by normal patterns at follow-up. Retinopathy, in the form of cotton-wool spots and retinal haemorrhages, was found at presentation in the two patients with chronic myeloid leukaemia and in one patient with polycythemia vera. The retinopathy had resolved at follow-up in all patients. Conclusion With non-invasive retinal imaging, we were able to demonstrate increased retinal venous blood velocity, increased retinal arterial blood oxygenation and normalization of intravascular reflectivity patterns after successful treatment of myeloproliferative neoplasms. Larger prospective studies are needed to assess the prognostic value of these non-invasive imaging methods in predicting circulatory complications in myeloproliferative neoplasms.

Purpose To test the oxygen reactivity of a fundus photographic method of measuring macular perfusion velocity and to integrate macular perfusion velocities with measurements of retinal vessel diameters and blood oxygen saturation. Methods Sixteen eyes in 16 healthy volunteers were studied at two examination sessions using motion-contrast velocimetry and retinal oximetry with vessel diameter corrections. To test oxygen reactivity, participants were examined during normoxia, after 15 min of hyperoxia and finally after 45 min of normoxia. Repeatability was assessed by intraclass correlation coefficients (ICC) and limits of agreement. Results Fifteen minutes of hyperoxia was accompanied by mean reductions in arterial and venous perfusion velocities of 14% and 16%, respectively (p = 0.0080; p = 0.0019), constriction of major arteries and veins by 5.5% and 8.2%, respectively (p

Context: Thyroid dysfunction may have detrimental effects on patient outcomes. Few studies have assessed this issue in patients with secondary hypothyroidism. Objective: Our objective was to test the hypothesis that thyroid hormone status has an impact on cardiovascular risk factors in adult patients with hypopituitarism. Design and Setting: This was a retrospective observational study (1993–2012) at a tertiary referral university hospital. Patients: All GH-deficient patients starting GH replacement (1993–2009) with measured free T4 (fT4) (n = 208). Baseline fT4 defined patients as TSH-sufficient and TSH-deficient (further divided into tertiles according to baseline fT4; first tertile had lowest fT4). Main Outcome Measures: Anthropometric (body mass index [BMI], waist circumference, total fat (fat mass) and lean body mass [LBM]) and biochemical (lipids and fasting plasma glucose) data were collected at baseline and a median 4.1 years after commencement of GH. Results: At baseline, fT4 was negatively associated with BMI and waist circumference, but positively with high-density lipoprotein, independent of age, gender, and IGF-I (SD score). Only first-tertile TSH-deficient patients had higher BMI (P = .02), fat mass (P = .03), total cholesterol (P = .05), triglycerides (P < .01), and waist circumference (P = .01), and lower high-density lipoprotein cholesterol (P = .03) as compared with TSH-sufficient patients. At follow-up, IGF-I, LBM, and plasma glucose had increased in all subgroups (P < .01). The change in fT4 (ΔfT4) (follow-up − baseline) was negatively correlated to ΔBMI, ΔLBM, Δtotal cholesterol, and Δlow-density lipoprotein cholesterol (all P < .05, adjusted for ΔIGF-I and ΔGH and hydrocortisone dose). The negative correlation to Δtotal cholesterol and Δlow-density lipoprotein cholesterol persisted only in first-tertile TSH-deficient patients. Conclusion: This single-center study over a 20-year period has strengthened the importance of improved awareness of thyroid status and optimal thyroid replacement of hypopituitary patients to reduce cardiovascular risks in hypopituitary patients.

T his retrospective study analysed cases of branch retinal artery occlusion (BRAO) who had been examined by spectral-domain optical coherence tomography (SD-OCT) (Willerslev et al. 2014) to assess the characteristics of the intraluminal content of retinal arteries at the site of occlusion in BRAO. This case series included a selected group of 11 patients with BRAO seen at the Department of Ophthalmology at Glostrup Hospital between January 2010 and June 2013 and Copenhagen University Hospital Roskilde between September 2012 and August 2013, who presented with sudden painless visual loss and a visible retinal arterial plaque/embolus. All BRAOs were isolated (only one per eye) and located in a branch of a temporal vascular arcade artery and had an ophthalmoscopically visible plaque. All patients had undergone infrared 30 degree fundus photography and SD-OCT (Spectralis, Heidelberg Engineering, Heidelberg, Germany) at variable times during work-up. Scans are shown with brighter areas representing higher signal intensity at the conventional 2:1 height:width ratio (Sander et al. 2005). Fluorescein angiography, carotid artery Doppler ultrasonography and echocardiography were available in selected patients. In all cases, SD-OCT demonstrated endoluminal material at the site of arterial occlusion, the structure of which was divided into two distinctly different categories (exemplified in Fig. 1). A flake of highly reflective, yet transparent material, oriented with its edge towards the direction of flow and positioned in the middle of the artery was seen in three cases (Fig. 1). The reflectivity profile of the blood above and below the flake on SD-OCT and the fluorescein angiograms were normal, indicating that these emboli had little or no effect on blood flow. Amorphous or gritty endoluminal material was seen in 8 cases, all of which showed perfusion centrally, in what may have been a recanalized portion of the embolus, the remaining embolus material giving the appearance of a grossly thickened artery wall. All but one patient had risk factors for thromboembolic disease such as arterial hypertension and/or hyperlipidemia and their medication included antiplatelet drugs and/or statin. Antiplatelet drugs and statin were initiated in one patient after diagnosis of BRAO. None of the patients had known carotid atherosclerosis or stenosis before the incidence of BRAO. After clinical work-up, 6 of 11 cases were diagnosed with carotid atherosclerosis or stenosis but none with need for carotid artery surgical intervention. The cases presented here demonstrate that SD-OCT can visualize retinal artery emboli and demonstrate perfusion characteristics and embolus structure, from totally occluded artery segments over recanalized emboli to crystalline emboli. Only two case reports have previously been published on this subject (Shah et al. 2010; Oster et al. 2009). The non-invasive nature of SD-OCT and its ability to image most patients without pupil dilation offers advantages over fluorescein angiography when time is of the essence. Emboli with crystalline characteristics (flat, angular outline, highly reflective, transparent) may be taken to indicate that these were cholesterol flakes dislodged from an atheromatous arterial lesion. The other emboli appeared to take the shape of the arterial lumen, indicating that they were soft. Theoretically such emboli could have originated as thrombi from the atria of patients with atrial fibrillation or from peripheral veins in patients with a patent foramen ovale (Hayreh 2011). Six of 11 patients had carotid artery atherosclerosis which could be a potential source of emboli to the retinal circulation. In the presence of a retinal artery occlusion such a potential source of emboli should mandate consideration of therapeutic options aimed at preventing new embolism (Chang et al. 2012), such as the administration of statins and antiplatelet therapy. Recanalization seemed to be present in all 8 amorphus emboli. The intravascular reflectivity profile depends on the rate of blood flow (Willerslev et al. 2014) and could therefore be turbulent or abnormally high at a vascular stenosis produced by a retinal embolus. However, given the small diameter of the lumen of the observed stenoses, such details could not be resolved. An