Rubeosis iridis in retinoblastoma. Histologic findings and the possible role of vascular endothelial growth factor in its induction

PURPOSE: Iris neovascularization (rubeosis iridis) is a common finding in eyes harboring retinoblastoma. The purpose of the current study is to evaluate the histologic factors that may affect the development of rubeosis iridis in eyes with retinoblastoma and to examine whether vascular endothelial growth factor (VEGF), a hypoxia-induced angiogenic factor, is produced by hypoxic retinoblastoma and retinal cells in these eyes. MATERIALS AND METHODS: One hundred eighty-one enucleated eyes containing retinoblastoma were the source for the current study. Histologic slides were evaluated for the presence and degree of rubeosis iridis as well as for other histologic factors. Univariate and multivariate statistical analyses were performed to find a correlation between rubeosis iridis and the other histologic factors. Eight of the eyes underwent in situ hybridization with a specific VEGF mRNA probe to locate tumor and retinal cells that may produce this hypoxia-induced angiogenic factor. RESULTS: The amount of tumor necrosis as well as choroidal and optic nerve invasion was found to be one of the most important factors that correlated with the presence and degree of rubeosis iridis in the examined eyes. All eight eyes that underwent in situ hybridization analysis showed strong signals of VEGF mRNA in retinoblastoma cells around necrotic regions and in the outer nuclear layers in areas of detached retina. CONCLUSIONS: There exists an association between rubeosis iridis and histologic factors found in advanced stages of retinoblastoma, especially the amount of tumor necrosis. Vascular endothelial growth factor may well be an angiogenic factor that is secreted by the hypoxic retinoblastoma and retinal cells and, reaching the iris, causes (presumably in collaboration with other factors) rubeosis iridis.     

Extracapsular cataract extraction in diabetic eyes. The role of YAG laser capsulotomy

Cataract surgery may exacerbate preexisting diabetic retinopathy. Especially diabetics with active retinal neovascularisation are at high risk of rubeosis iridis after intracapsular cataract extraction. Thirty-five eyes previously treated with panretinal photocoagulation underwent extracapsular cataract extraction with posterior chamber lens implantation. Twenty-eight eyes with retinal neovascularisation required further Argon laser PRP after surgery. Fourteen eyes required YAG-laser capsulotomy. From the group of eyes without YAG-laser capsulotomy none developed neovascular glaucoma. From the YAG laser capsulotomy group six eyes developed rubeosis iridis and neovascular glaucoma. Our results indicate that eyes in which PRP has been performed, have an excellent prognosis after ECCE with posterior chamber lens implantation only if YAG Laser posterior capsulotomy is not performed.     

Effect of strength training on EMG of human skeletal muscle

An 8-year-old white girl with a history of vertigo, nausea, and vomiting developed a progressive hearing loss, bilateral retinal arteriolar narrowing in each eye, vasoproliferation, and subsequent intravitreal hemorrhage. An attempt at peripheral retinal ablation with cryotherapy in the left eye resulted in retinal detachment. Spontaneous retinal detachment occurred in the right eye and was successfully repaired. Repeated intermittent hemorrhages occurred despite intraocular diathermy. Three years after onset, visual acuity was R.E.: 6/21 (20/66) and L.E.: light perception. She remains totally deaf. A 20-year-old white woman developed severe bilateral sensorineural hearing loss with poorly functioning labyrinths, followed by midperipheral retinal arteriolar occlusions and vasoproliferation on the optic nerve head. Progressive retinal neovascularization was followed by rubeosis iridis and repeated episodes of intravitreal bleeding. Six years after onset, visula acuity was R.E.: hand motions, and L.E.: 6/3 (20/100). She remains totally deaf. Both patients were of normal gestation, development, and mentality, without evidence of other systemic disease. The cause of this disease was not found.     

Prevalence of diabetic ocular complications and systemic factors

The prevalence of diabetic ocular complications and the correlation between diabetic retinopathy and systemic factors were examined in 2,300 cases (4,600 eyes) with non-insulin-dependent diabetes mellitus. The prevalence of cataract was 66.7%, of retinopathy 37.0%, of refractive and accommodative change 6.2%, of glaucoma 1.9% (rubeotic glaucoma was 1.0%), of rubeosis iridis 1.5%, of iridocyclitis 0.8%, of extraocular muscle palsy 0.2%, and of ischemic optic neuropathy 0.1%. Duration of diabetes mellitus, HbA1C value, methods of diabetic control, age, diabetic nephropathy, diabetic neuropathy, hypertension, systolic blood pressure, diastolic blood pressure, and arteriosclerosis obliterans were related with diabetic retinopathy. We suggest that the management of diabetic patients needs sufficient attention in the cases with oral administration of medication, insulin therapy, and diabetic nephropathy.     

Cone b-wave implicit time as an early predictor of rubeosis in central retinal vein occlusion

PURPOSE: To investigate the predictive value of the cone b-wave implicit time in the 30-Hz flicker electroretinogram for rubeosis in the acute phase of central retinal vein occlusion. METHODS: In a prospective study, 25 patients (25 eyes) with a central retinal vein occlusion of less than 14 days' duration were examined with electroretinography and followed up for a minimum of 18 months. RESULTS: The cone b-wave implicit time in the eyes that developed rubeosis (n = 11) was more than 37.1 milliseconds and in the eyes that did not develop rubeosis (n = 14), less than 37 milliseconds (P < .00001). CONCLUSION: The cone b-wave implicit time in the 30-Hz flicker electroretinogram is a good predictor of rubeosis at an early stage in eyes with central retinal vein occlusion.     

Glaucoma after pars plana vitrectomy and silicone oil injection for complicated retinal detachments

OBJECTIVE: To determine the incidence and associations of glaucoma after pars plana vitrectomy (PPV) and silicone oil injection (SOI) for complicated retinal detachments and the response to treatment. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: A total of 150 eyes of 150 patients who had completed a minimum of 6 months of follow-up were included in this study. Analysis included clinical records of all consecutive cases of complicated retinal detachment that underwent PPV with SOI between July 1991 and February 1996. INTERVENTION: Surgical intervention for vitreoretinal pathology included standard three-port PPV and additional procedures as appropriate for the retinal pathology, and SOI. Procedures for the control of glaucoma were silicone oil removal (SOR), trabeculectomy with mitomycin C, cyclocryotherapy, semiconductor diode laser contact transscleral cyclophotocoagulation (TSCPC) and anterior chamber tube shunt to encircling band (ACTSEB). MAIN OUTCOME MEASURES: Presence of glaucoma (predefined as intraocular pressure [IOP] > or = 24 mmHg, which also was > or = 10 mmHg over the preoperative level, sustained for > or = 6 weeks) and the result of medical and surgical management were the main outcome measures. Demographic, preoperative, intraoperative, and postoperative parameters including the age of the patient, etiology of retinal detachment, refractive status, pre-existing glaucoma, aphakia, diabetes mellitus, presence of silicone oil (SO) in the anterior chamber, emulsification of SO, rubeosis iridis, and anatomic success were evaluated by univariate and multivariate logistic regression analyses to assess their predictive value in the causation of glaucoma and to determine factors prognosticating response to treatment. RESULTS: The main indications for PPV+SOI were proliferative vitreoretinopathy (57%; 85 of 150), proliferative diabetic retinopathy (15%; 23 of 150), and trauma (14%, 21 of 150). Glaucoma occurred in 60 eyes (40%) at 14 days median (range, 1 day-18 months). Elevation of IOP could be attributed directly to SO in 42 (70%) eyes. Glaucoma was controlled in 43 (72%) of 60 eyes on treatment (with medicines alone in 30%; SOR and medicines in 25%; trabeculectomy with mitomycin C/ACTSEB/cyclocryotherapy or TSCPC in 17%); 28% (17 of 60) remained refractory. Independent predictive factors for glaucoma on multivariate analysis were rubeosis iridis (odds ratio, 10.76), aphakia (odds ratio, 9.83), diabetes (odds ratio, 6.03), SO in anterior chamber (odds ratio, 4.74), and anatomic failure (negative risk factor; odds ratio, 0.11). Poor prognostic factors for the control of glaucoma were SO emulsification (odds ratio, 15.34) and diabetes (odds ratio, 6.03). CONCLUSION: Glaucoma is a frequent and often a refractory complication of PPV with SOI and has a multifactorial etiology. Aggressive medical and surgical management with SOR, trabeculectomy with mitomycin C, glaucoma shunts, and cyclodestructive procedures shows modest success in controlling IOP.     

Etiology and final clinical cause for 1000 enucleations. (A clinico-pathologic study) (author's transl)

From 1969-1974 1000 unselected enucleated globes have been examined histopathologically. 277 derive from the University Eye Hospital in Hamburg, 723 from various Eye Hospitals in northern and southern Germany. They originate from 589 men and 408 women, three times the sex was unknown. 86 globes had to be removed from children less than 15 years old. 6 groups of etiologies have been distinguished: trauma (308), histologically confirmed neoplastic disease (281), ocular manifestations of systemic diseases (diabetes mellitus, occlusions of central retinal vessels presumably following generalized vascular disease etc.: 128), "operative ocular disease" (164), primary inflammatory disease (71), miscellaneous (malformations, high myopia, pseudo-glioma and pseudo-melanoma: 48). The etiology "operative ocular disease" consists of 67 primary glaucomas (57 adults, 10 buphthalmus), 41 idiopathic cataracts (7 of these congenital) and 3 primary corneal dystrophies, as well as 53 cases of primary retinal detachment. Among the 281 neoplastic diseases, there are 238 primary intraocular malignant melanomas of the uvea, 18 retinoblastomas, 4 primary reticulumcellsarcomas of the retina, 2 choroidal nevi, 10 intraocular metastases and 9 orbital tumors. 16 enucleations among the 1000 enucleations have been performed for pseudo-gliomas (5 x Coats disease, 5 x persistent primary hyperplastic vitreous, 2 x retrolental fibroplasia, others 4 x). The manifestations of systemic disease are consisting of 68 central retinal vein-occlusions, 30 complications of diabetes mellitus and 10 central retinal artery occlusions as well as 20 other generalized diseases. A primary inflammatory disease led to enucleation 50 times due to an intraocular process, 5 times due to scleritis and 18 times as a consequence of keratitis (including 13 times herpes simplex). As the final clinical cause for enucleation the following categories have been elaborated: secondary glaucomas (416), clinical diagnosis of "tumor" (275), atrophy and phthisis bulbi (118), inflammation (112), acute trauma to 4 weeks after the accident (72), others (7). In conclusion the central role of rubeosis iridis leading to secondary angle closure glaucoma is emphasized. This process presents a challenge to ophthalmologic research. Finally the significance of early surgery for primary angle closure glaucomas and for complete restoration of the anterior chamber after trauma and any intraocular procedure is stressed.     

Occurrence of changes in the eye in diabetic retinopathy with significant myopia

The optic disc and retinal neovascularization are less prominent and less frequent in myopic eyes in patients suffering from diabetes mellitus. The exact mechanisms of this phenomenon are not well known, but there is some evidence that there is a reduced blood flow in myopic eyes which is associated with less damaged microcirculation in eyes of patients with diabetes mellitus. The aim of our study was to evaluate the correlation between myopic refractive error and degree of diabetic retinopathy. We conducted a retrospective study in a group of randomized patients, divided into the following groups according to their refractive error: emmetropia (30 eyes), myopia simplex (30 eyes) and high myopia, over -6.5 dsph (21 eyes). Among patients with high myopia, seven had monocular myopia. All patients suffered from non insulin dependent diabetes mellitus for more than ten years, and their average age was 52.37-3.48 years. We did not observe patients with rubeosis iridis and neovascular glaucoma or patients with myopia less than -2.0 dsph. Our results indicated that there was no significant difference in the appearance of fundus between the studied groups. In all patients the incidence rate of non proliferative and proliferative diabetic retinopathy was the same as well as the absence of retinopathy (Fisher's test). The only exception were the patients with monocular myopia over -13.o dsph who had no signs of diabetic retinopathy in myopic eye, while the other, emmetropic eye, showed various stages of retinopathy, from severe non proliferative to proliferative. Some of the risk factors which influence the incidence rate of ocular complications in diabetic patients are well known, as are duration of diabetes mellitus, blood sugar level, blood pressure, ocular pressure and eye perfusion. On the other hand, it is also known that amblyopia, optic atrophy, low blood pressure in central retinal artery and retinitis pigmentosa are ocular conditions which are not associated with proliferative diabetic retinopathy. It was also noticed that complications of diabetes in high myopic eyes are less prominent than in emmetropic eyes. This finding is in harmony with our results. Sultanov et al. observed diabetic changes in the retina in 40.9% of myopic refraction patients, 65.2% of emmetropia cases and 70.4% of hypermetropia cases. The severity of involvement was less in myopia than in other types of refraction. In medium severe myopia, no proliferative diabetic retinopathy was observed, and in high myopia (10 eyes) no diabetic involvement of the fundus oculi was found. In anisometropia diabetic symptoms on the myopic side were either absent or poorly manifest. The possible cause of such findings could be the changes in retinal perfusion in myopic eyes and eyes in patients with diabetes mellitus. In 1973 a lower blood flow was detected in the retina and the choroid, proportionally to the degree of myopia. In 1982, Perkins indicated that the circulation time and pulsation rate in the central retinal artery in myopic eyes were reduced proportionally to the degree of myopia. In cases with early diabetic retinopathy Coscas detected a lesser blood flow in retinal veins. On the other hand, it has been found that high blood pressure increases the risk of diabetic retinopathy. These data suggest that the reduced blood flow in high myopia is a protective factor regarding the occurrence of complications in diabetes. Anisometropia and amblyopia in cases with monocular myopia, which presents a particular group in our study, could be factors which also prevent the occurrence of proliferative diabetic retinopathy. Instead of conclusion, we would like to point out that pathophysiologic mechanisms of these phenomena are not discussed enough. It is, nevertheless, important to appropriately examine the fundus in patients with high myopia and diabetes mellitus, because if the complications appear, they may be disastrous and must be treated immediately.     

Microvascular injection studies in rubeosis iridis and neovascular glaucoma

Microvascular silicone injection, tissue clearing, and histologic examination were used to demonstrate the origin, distribution, and interconnections of newly formed iris and chamber angle blood vessels in four eyes with rubeosis iridis and neovascular glaucoma associated with diabetic retinopathy and central retinal vessel occlusion. The newly formed iris vessels that formed either a tight, evenly distributed (diabetic) or loose, irregularly distributed (central vessel occlusion) network in the iris originated from the normal iris arteries that were branches of either the major arterial circle or of the perforating branches of the anterior ciliary arteries, and drained into the normal iris and ciliary body veins and occasionally into the paralimbal episcleral veins. These newly formed iris vessels appeared to shunt intravascular fluid from arteries to veins. The newly formed anterior chamber angle vessels that formed tufts and arcades at the trabecular meshwork also originated from the roots of the iris arteries and the ciliary body arteries and connected with the peripheral neovascular iris network. In addition, the circumferentially running angle vessels that coursed within the trabecular meshwork branched into and coursed within a fibrosed Schlemm's canal and into two of its intrascleral collector channels. No open communication between these newly formed vessels and the Schlemm's canal-aqueous outflow system was seen.     

Characterization of the 12q13-15 amplicon in soft tissue tumors

Massive subretinal exudates as well as vitreal traction often induce complicated retinal detachments in patients with advanced Coats' disease. If left untreated, most patients experience secondary glaucoma by rubeosis and phthisis bulbi in addition to irreversible visual loss. We report on the surgical procedures used and results obtained in three patients aged between 21 and 28 years with combined exudative and traction-induced detachment. In all cases, extensive but unsuccessful retinal coagulation had been performed. The surgical intervention was done by application of an encircling buckle followed by vitrectomy and removal of preretinal membranes and subretinal lipid exudates via retinectomies. Particular attention was paid to the intensive endodiathermy of retinal teleangiectasies during surgery. Surgery was concluded by siliconeoil tamponade. Postoperatively, progressive resorption of remaining exudates and teleangiectatic vessels could be observed. All patients demonstrated stable functional and anatomic results at the last follow-up examination performed at 13 months to 6 years after surgery. A stabilization of the anatomic and functional situation can be achieved even in advanced cases of Coats'-induced traction retinal detachment by vitreoretinal surgery.     

Acute renal failure complicating nonfulminant hepatitis A

PURPOSE: To compare the orbital blood flow velocities of patients with long-standing ocular hypertension and patients with primary open-angle glaucoma. METHODS: Twenty patients with ocular hypertension were recruited from our clinic and underwent color Doppler imaging evaluation of their retrobulbar vessels. The blood flow velocities and resistance index of their central retinal artery, temporal short posterior ciliary artery, and ophthalmic artery were compared with those of 20 glaucoma patients individually matched for age and level of the highest untreated intraocular pressure ever recorded. RESULTS: Glaucoma patients had significantly lower peak systolic velocity and end-diastolic velocity than did patients with ocular hypertension in their central retinal artery (p < 0.001). No significant difference between the groups was observed in the other vessels studied. CONCLUSIONS: Glaucoma patients had lower blood flow velocity in the central retinal artery compared with that of ocular hypertension patients of similar age and level of untreated intraocular pressure. This might be important in the development of glaucomatous damage in those patients.     

Comparison of retinal breaks between patients with atopic dermatitis and mentally retarded patients with self-inflicted ocular injury]

We compared the distribution of retinal breaks in retinal detachment between patients with atopic dermatitis (AD) and mentally retarded patients who had self-inflicted ocular injury (MR). The cases of AD were 16 eyes in 14 patients (six males and eight females, ranging in age from 15 to 52 years, mean 24.5) and the cases of MR were 6 eyes in 5 patients (5 males, ranging in age from 14 to 25 years, mean 20.2). There was no corneoscleral laceration in either group. In the patients with AD, 14 (87.5%) of 16 eyes had retinal breaks at the vitreous base, and 21 (87.5%) of 24 retinal breaks in 16 eyes were at the vitreous base. In the patients with MR, five (83.3%) of 6 eyes had retinal breaks at the vitreous base and 6(66.7%) of 9 retinal breaks in 6 eyes were at the vitreous base. In both groups, ciliary epithelial breaks and peripheral retinal tears were frequently observed, suggesting that retinal detachment in AD has a pathophysiology similar to traumatic retinal detachment with repeated ocular contusion (self-inflicted injury).     

Combined pars plana vitrectomy, lens removal and intraocular lens implantation for complications of diabetic retinopathy. Surgical results in 120 cases

We performed combined vitrectomy, lens removal and posterior chamber intraocular lens implantation for proliferative diabetic retinopathy in 120 eyes of 101 patients. Follow-up periods ranged from 3 to 63 months, with a mean of 17 months. Three lens removal methods were used: extracapsular cataract extraction (14 eyes), phacoemulsification and aspiration (49 eyes), and pars plana phacoemulsification (57 eyes). Preoperative rubeosis iridis or neovascular glaucoma was found in 21 eyes. Gas or temporary silicone oil tamponade was employed in 32 eyes. Surgical results were good, and the postoperative vision was finger counts or below only in 13 eyes. Thus the combined surgery proved to have no serious problems. Our results indicate two important points. (1) It is best to chose either of the following two methods for the lens surgery: phacoemulsification with continuous circular capsulorhexis, self sealing sclerocorneal incision, and in-the-bag fixation of the posterior chamber lens, or pars plana phacoemulsification leaving the anterior capsule, rub off and aspirating the lens epithelial cells, continuous circular capsulorhexis, and posterior chamber lens implantation in front of the anterior capsule from a self-sealing sclerocorneal wound. (2) It is mandatory to do complete vitrectomy and cut out the vitreous gels incarcerated in the sclerotomy site.     

Retinal emboli in patients with mitral valve prolapse

Small fibrin-platelet emboli caused by prolapsed mitral valves may cause retinal occlusive disease with a wide range of ophthalmic manifestations, including amaurosis fugax in young people, retinal or choroidal arteriolar occlusion, and retinal neovascularization (atypical Eales' disease). Six patients with retinal occusive disease underwent extensive noninvasive cardiac and systemic tests and were found to have prolapsed mitral valves. Patients with unexplained ocular emboli should be examined by a cardiologist for possible mitral valve prolapse.     

Fluorescein angiography of the fundus after pars plana vitrectomy

In diabetic patients with massive vitreous hemorrhage, fluorescein angiography after pars plana vitrectomy demonstrated varying degrees of vascular involvement depending on the stage of the basic disease process. Arteriolar occlusions, capillary bed drop-out, microaneurysms, and neovascularization were common findings. We concluded that diabetic retinopathy continued its course behind the cloudy vitreous, sometimes leading to retinal ischemia and subsequent spontaneous involution, macular disease, or retinal detachment. In addition, some of these patients were also subject to nondiabetic diseases, such as senile macular degeneration, that could not be detected preoperatively, but that reduced visual acuity postoperatively. In the nondiabetic patients with vitreous hemorrhage, visual acuity after vitrectomy usually depended on the degree of coincident macular disease.     

Ocular arterial flow hemodynamics in patients with diabetes mellitus

The purpose of this study was to investigate ocular blood flow hemodynamics in patients with diabetes mellitus. We used color Doppler sonography, in 22 normal subjects and 52 patients with (n = 25) or without (n = 27) diabetic retinopathy, to determine blood flow velocities and the resistive index of the central retinal artery. The resistive index of the central retinal artery in patients with diabetic retinopathy (0.85 +/- 0.09) was significantly greater (P < 0.01) than that in normal subjects (0.72 +/- 0.08) and in patients without diabetic retinopathy (0.81 +/- 0.09). The resistive index of the central retinal artery in the patients without diabetic retinopathy was also significantly greater than that of normal subjects (P < 0.01). The resistive index of ocular arterial flow was increased in the patients with diabetes mellitus and further increased in the presence of retinopathy. Increased resistance in the peripheral ocular vascular bed contributes to diabetic retinopathy, and this change is present before the appearance of overt diabetic retinopathy.     

Retinal hypoxia in long-term diabetic cats

PURPOSE: To determine whether the retina is hypoxic in early stages of diabetic retinopathy in cats and to correlate intraretinal PO2 with fluorescein angiographic and histologic alterations. METHODS: Intraretinal PO2 was measured with microelectrodes in three cats with long-standing diabetes (>6 years) that had been followed with fluorescein angiographs every 6 months. Average PO2 in the inner vascularized half of the retina was compared with similar measurements in 21 control animals. Photoreceptor oxygen consumption was also compared. The retinal vascular endothelium of the diabetic animals was stained for ADPase activity in flatmounts, and transverse sections were used to visualize microscopic alterations in vascular structure. RESULTS: PO2 in the inner half of the retina was abnormally low in the diabetic cats, 7.7+/-5.2 mm Hg (35 penetrations in 3 cats) versus 16.4+/-9.3 mm Hg in normal cats (85 penetrations in 21 cats) (P < 0.001). Oxygenation was almost normal in some regions of the diabetic retinas, but little evidence of oxygen supply from the retinal circulation was observed in other regions. Inner retinal hypoxia was present in areas with no detectable capillary dropout in fluorescein angiograms or flatmounts. The worst changes histologically were microaneurysms, leukocyte and platelet plugging of aneurysms and venules, and degenerating endothelial cells in capillary walls. These histologic abnormalities were confined to small regions, some of which could be positively correlated with markedly abnormal PO2 profiles. Photoreceptor oxygen utilization was not affected in two diabetic cats, but was below normal in one animal in which choroidal PO2 was low. CONCLUSIONS: This is the first direct demonstration of retinal hypoxia in early diabetic retinopathy, before capillary dropout was evident clinically. Hypoxia was correlated with endothelial cell death, leukocyte plugging of vessels, and microaneurysms.     

Selective loss of vascular smooth muscle cells in the retinal microcirculation of diabetic dogs

This study was undertaken to further characterise the fine structural changes occurring in the retinal circulation in early diabetes. The eyes of eight alloxan/streptozotocin and three spontaneously diabetic dogs were examined by trypsin digest and electron microscopy after durations of diabetes of between 1 and 7 years. Basement membrane (BM) thickening in the retinal capillaries was the only obvious fine structural change identified during the first 3 years of diabetes and was established within 1 year of induction. Widespread pericyte loss was noted after 4 years of diabetes and was paralleled by loss of smooth muscle (SM) cells, in the retinal arterioles. SM cell loss was most obvious in the smaller arterioles of the central retina. No microaneurysms were noted in the experimental diabetic dogs with up to 5 years' duration of diabetes but were widespread in a spontaneously diabetic animal at 7 years. This study has shown that SM cell loss, a hitherto unrecognised feature of diabetic microangiopathy, accompanies pericyte loss in the retinal circulation of diabetic dogs.     

Toxoplasmic chorioretinitis complicated by retinal detachment

PURPOSE: To describe and analyse relationship between chorioretinal toxoplasmosis and retinal detachment. PATIENTS AND METHODS: Seven immunocompetent patients examined and treated between November 1992 and March 1996, with ocular toxoplasmic retinochoroiditis and retinal detachment. RESULTS: Of the 7 patients examined, 5 had active retinochoroiditis and 2 had typical inactive scars. Of the patients with active focus 3 had giant retinal tears, one had a posterior retinal tear and one had a retinal tear located at the edge of an atrophic scar. Of the patients with inactive lesions, one had tractional retinal detachment and the other presented with a complete retinal detachment, multiples tears and PVR. Five patients were treated by corticosteroid without antitoxoplasmic drug before they were referred. The seven patients underwent endo-ocular surgery with silicon oil or long actic gas tamponade. Three patients developed PVR and redetachment of the retina and two patients underwent further surgery. Good anatomical result was obtained in 6 patients. CONCLUSION: Retinal detachment associated with toxoplasmic retinochoroiditis is rare. However it represents a serious complication. Steroid administrated to salvage vision may then worsen the clinical course, these may be justified to reduce hypersensitivity to toxoplasma antigen, but they should be combined with an antimicrobial agent.     

Peripheral retinal hemorrhages: a literature review and report on thirty-three patients

BACKGROUND: Peripheral retinal hemorrhages are often asymptomatic and are detected during routine dilation. The incidence of peripheral retinal hemorrhages is unknown and there is a paucity of information on the subject available in the literature. METHODS: This article reports on 33 patients with peripheral retinal hemorrhage detected during routine fundus examination. The possible etiologies and pathophysiology of peripheral retinal hemorrhages are discussed and a management plan for the primary care clinician is presented. The ophthalmic literature was reviewed and reports of peripheral retinal hemorrhages were included. For each etiology, the ocular and systemic sequelae, symptoms, testing, treatment, and followup are delineated. RESULTS: Various proposed etiologies of peripheral retinal hemorrhages include senescence, systemic and retinal vascular disease, hematologic disorders, infectious disease, hypoxia, and mechanical and iatrogenic causes. CONCLUSION: Despite their asymptomatic nature, peripheral retinal hemorrhages have a variety of potential etiologies and risk factors. Causes associated with serious ocular or systemic complications must be identified so that appropriate treatment and followup can be instituted.