Faculty Bibliography

BACKGROUND: There are currently no standardized treatment guidelines for endogenous bacterial endophthalmitis. We report the long-term outcomes of early intravitreal treatment of endogenous bacterial endophthalmitis, defined as intravitreal and systemic antibiotics administered within 24 h of diagnosis, with conservative use of pars plana vitrectomy. DESIGN: Interventional retrospective case series. PARTICIPANTS: Consecutive patients treated for culture-proven endogenous bacterial endophthalmitis between 2001 and 2008 at the Weill Cornell Medical Center. METHODS: The clinical records of 18 eyes from 13 patients were reviewed. MAIN OUTCOME MEASURES: Visual acuity. RESULTS: Mean age at presentation was 61 (25-85) years. All patients had underlying medical conditions. Extraocular infectious foci were identified in nine (69%) patients, with endocarditis being the most common. Gram-positive organisms were identified in 12 (92%) patients, including five with methicillin-resistant Staphylococcus aureus. No cases were misdiagnosed. Final visual acuities of better than 6/120 and counting fingers were achieved in 6 (55%) and 7 (64%) of 11 eyes, respectively. Longer time between onset of ocular symptoms and intravitreal antibiotic injection correlated with worse visual outcomes (P < 0.05) and was associated with mortality (P < 0.05). Mortality was also associated with methicillin-resistant S. aureus infection (P < 0.05). Of those with follow up longer than 1 year, retinal detachment developed in 3 of 10 eyes (30%) after the acute infection, and cataract developed in 6 of 9 (67%) phakic eyes. Mean follow up was 146 (4-313) weeks. CONCLUSIONS: Intravitreal antibiotics for endogenous bacterial endophthalmitis administered within 24 h to supplement immediate systemic antibiotics may provide a relatively favourable visual prognosis.

PURPOSE: This case report describes combined central retinal veincilioretinal artery occlusion in a 16-year-old healthy girl. To our knowledge, our patient is the youngest described so for in the MEDLINE literature. METHODS: The patient underwent a full history, physical examination, and extensive laboratory studies to determine the potential risk factors leading to her vascular occlusion. RESULTS: Her family history was significant for multiple miscarriages and early cerebrovascular events. Laboratory testing revealed a compound heterozygous mutation (C677T and A1298C) in the methylenetetrahydrofolate reductase (MTHFR) gene and an elevated factor VIII level. As a result of her ocular occlusive event, abnormal hypercoagulable findings, and family history, the hematologist treated her with folate and warfarin. She has had no further ocular or systemic thrombotic events to date. CONCLUSION: The combination of the compound heterozygous C677TA1298C MTHFR mutation and an elevated factor VIII level may lead to an increased thrombotic tendency and may have resulted in combined central retinal veincilioretinal artery occlusion in an otherwise healthy 16-year-old girl.

AIM: To describe the appearance of the non-exudative forms of age related macular degeneration (AMD) as imaged by ultrahigh resolution optical coherence tomography (UHR-OCT). METHODS: A UHR-OCT ophthalmic imaging system, which utilises a femtosecond laser light source capable of approximately 3 mum axial resolution, was employed to obtain retinal cross sectional images of patients with non-exudative AMD. Observational studies of the resulting retinal images were performed. RESULTS: 52 eyes of 42 patients with the clinical diagnosis of non-exudative AMD were imaged using the UHR-OCT system. 47 of the 52 (90%) eyes had the clinical diagnosis of drusen and/or retinal pigment epithelial (RPE) changes. In these patients, three patterns of drusen were apparent on UHR-OCT: (1) distinct RPE excrescences, (2) a saw toothed pattern of the RPE, and (3) nodular drusen. On UHR-OCT, three eyes (6%) with a clinical diagnosis of non-exudative AMD had evidence of fluid under the retina or RPE. Two of these three patients had findings suspicious for subclinical choroidal neovascularisation on UHR-OCT. CONCLUSION: With the increased resolution of UHR-OCT compared to standard OCT, the involvement of the outer retinal layers are more clearly defined. UHR-OCT may allow for the detection of early exudative changes not visible clinically or by angiography.

BACKGROUND: Uterus didelphys with obstructed hemivagina and ipsilateral renal agenesis usually presents after menarche with progressive abdominal pain during menses secondary to hematocolpos. We describe a case with the unique presentation of rectal pain and constipation. CASE: A 13-year-old girl presented to the emergency department complaining of lower abdominal and rectal pain and constipation of two weeks' duration. Pelvic ultrasound, physical examination and laparoscopic findings established a diagnosis of hematometracolpos secondary to uterus didelphys with unilateral imperforate hemivagina. An incision in the vaginal septum allowed drainage of the hematocolpos, providing relief of the patient's symptoms. CONCLUSION: Uterus didelphys with unilateral imperforate hemivagina and ipsilateral renal agenesis may present with apparent gastrointestinal symptoms. With increased awareness of this problem, timely diagnosis may be achieved

The early endosome is the first vacuolar compartment along the endocytic pathway. It is the site of internalization and initial processing of amyloid precursor protein (APP) and apolipoprotein E (ApoE), two proteins of etiological importance in Alzheimer's disease, and a putative site of beta-amyloid peptide (Abeta) formation. Here, we identify early endosomes in human pyramidal neurons, using specific compartmental markers and morphometry, and show that in Alzheimer's disease individual endosomes display up to 32-fold larger volumes than the normal average. Endosomal enlargement contributed to an average 2.5-fold larger total endosomal volume per neuron, implying a marked increase in endocytic activity. Endosomal alterations were evident in most pyramidal neurons in Alzheimer brain, detectable at early stages of the disease but absent in several other neurodegenerative disorders examined. In addition, mature and proenzyme forms of the proteases cathepsin B and cathepsin D, a candidate APP secretase, were identified in most early endosomes in Alzheimer brains but were detectable in only a minor proportion of endosomes in normal brain. Expression of the cation-dependent 46 kDa mannose 6-phosphate receptor was elevated in pyramidal neurons of Alzheimer brains, which could be a possible basis for the altered cathepsin trafficking pattern. Enhanced endocytic activity, coupled with increased trafficking to endosomes of proteases, which may have the ability under pathological conditions to generate Abeta, constitutes a potential mechanism by which beta-amyloidogenesis may become accelerated in sporadic AD and also be subject to influences by ApoE