Faculty Bibliography

PURPOSE: Whipple's disease is a rare, chronic, and multiorgan bacterial disease that predominantly involves the gut and its lymphatic drainage in middle-aged Caucasian men but may involve the eye. It is often difficult to diagnose and treat. We report results of one more polymerase chain reaction (PCR) analysis-diagnosed ocular Whipple's disease (OWD) case and the care of three new patients with ocular inflammation caused by OWD. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Three patients. METHODS: Diagnostic PCR was performed on a vitreous sample, medical records of three patients with OWD were reviewed, and a literature review (1907 to present) located 74 OWD cases. Analysis of published OWD cases to seek out factors that contribute to earlier, definitive diagnosis and treatment of OWD is made. MAIN OUTCOME MEASURES: Response of ocular inflammation and vision to treatment. RESULTS: One of 3 new and 4 of 74 published OWD cases reviewed were diagnosed with PCR on vitreous samples and subsequently successfully treated with antibiotics without devastating central nervous system (CNS) sequelae. CONCLUSION: Diagnostic PCR on vitreous samples and recognition of key presenting symptoms in patients with OWD allows earlier definitive diagnosis, when the disease may be more amenable to antibiotic treatment, compared with 'late' CNS Whipple's disease in the cases reviewed

PURPOSE: To report three patients who developed central serous chorioretinopathy after epidural corticosteroid injection for treatment of back pain. DESIGN: Interventional case series. METHODS: Three men, aged 73, 52, and 73 years, presented with bilateral central serous chorioretinopathy after corticosteroid injection in the epidural space for treatment of back pain. In all three cases, we did not initially elicit the history of corticosteroid use. RESULTS: Two of the three patients, aged 52 and 73 years, had diffuse retinal pigment epitheliopathy and one, aged 73 years, had classic central serous chorioretinopathy. Two patients had a spontaneous resolution of the subretinal fluid in both eyes. One patient had laser photocoagulation in both eyes but continued to have diffuse leakage in one eye. CONCLUSIONS: A careful history to determine corticosteroid use, including possible intrajoint and epidural injection, should be performed in older people with serous detachment of the macula, particularly when bilateral

PURPOSE: To report the optical coherence tomographic characteristics of persistent bleb-like subretinal lesions after retinal reattachment surgery, including scleral buckling and cryopexy. METHODS: Case reports. RESULTS: In two eyes of two patients yellow to yellowish-orange bleb-like lesions were found in the posterior pole after retinal reattachment surgery. The common aspects of the surgery were scleral buckling procedures and cryopexy. There were subretinal precipitates in some of the lesions. The lesions showed no associated leakage during fluorescein or indocyanine green angiography. Optical coherence tomography demonstrated that the bleb-like lesions were tiny retinal detachments. CONCLUSION: Optical coherence tomography examination of bleb-like subretinal lesions showed that they were actually retinal detachments. Our patients and previously reported patients developed these lesions after scleral buckling and cryopexy. These lesions may represent persistent retinal detachment because of the presence of protein in the subretinal fluid

PURPOSE: To report on the frequency and clinical features of polypoidal choroidal vasculopathy (PCV) in a consecutive series of elderly Italian patients presenting with macular exudation. METHODS: The authors conducted a retrospective study on a series of 194 consecutive patients 50 years or older with newly diagnosed exudative maculopathy and the presumed diagnosis of age-related macular degeneration (ARMD). Color and/or red-free photographs and fluorescein and indocyanine green angiography were performed in all patients. RESULTS: Of the 194 patients, 19 (9.8%) were diagnosed with PCV. The remaining 175 (90.2%) patients had ARMD complicated by choroidal neovascularization. No age or sex differences were observed between the two groups. The disease was unilateral in 103 (58.9%) of 175 ARMD cases compared with 15 (78.9%) of 19 PCV cases (P = 0.09). Nine (47.3%) of 19 patients with PCV had an extramacular choroidal neovascularization, compared with only 5 (2.9%) of 175 patients with ARMD (P < 0.0001). Significant drusen were present in the fellow eyes of 66 (64.1%) of 103 unilateral cases in the ARMD group and in 4 (26.7%) of 15 patients with unilateral disease in the PCV group (P = 0.006). CONCLUSIONS: Polypoidal choroidal vasculopathy is not an uncommon disease in Italy and should be suspected in patients presenting with extramacular lesions and no large drusen in the fellow eye

OBJECTIVE: To evaluate whether inactive cases of presumed ocular histoplasmosis syndrome (POHS) and multifocal choroiditis with panuveitis (MFC) can be differentiated from each other by their appearance on fundus photography and fluorescein angiography. METHODS: Two masked observers classified 50 patients' photographs (27 with fluorescein angiograms) as POHS, MFC, or 'indeterminate.' Twenty-five patients had known POHS and 25 had known MFC. Statistical analysis was performed to assess agreement and interrater reliability. RESULTS: Observer A classified 33 patients and was indeterminate on 17. Of the 33, he was correct on 26 (79% crude accuracy; kappa = 0.560; 95% confidence interval [CI], 0.286-0.834). Observer B classified 40 patients and was indeterminate on 10. Of the 40, he was correct on 33 (82% crude accuracy; kappa = 0.650; 95% CI, 0.422-0.878). Both observers ventured a diagnosis on 28 common patients. Of these, they selected the same diagnosis on 26 (93% crude agreement). When the 2 observers' diagnoses were compared and indeterminate patients were factored in, the kappa value was 0.408 (95% CI, 0.215-0.601). When the indeterminate patients are excluded, the kappa agreement increased to 0.825 (95% CI, 0.592-1). When pictures only were available, observer A and observer B kappa values against the gold standard were 0.625 (95% CI, 0.270-0.980) and 0.588 (95% CI, 0.235-0.940), respectively. The pictures-only kappa values for observer A vs observer B were 0.582 (95% CI, 0.316-0.848) with indeterminate patients factored in and 1.0 (95% CI, 1.0-1.0) when indeterminate patients were excluded. Pictures and fluorescein angiogram kappa values were 0.493 (95% CI, 0.076-0.909) for observer A and 0.706 (95% CI, 0.413-0.999) for observer B against the gold standard. For observer A vs observer B, the kappa value was 0.261 (95% CI, -0.002 to 0.524) with indeterminate patients factored in and 0.567 (95% CI, 0.032-1) excluding indeterminate patients. Sensitivity for all cases for observer A was 60% (+/-13%) for POHS and 94% (+/-6%) for MFC. For observer B, the sensitivity for all cases was 70% (+/-10%) for POHS and 95% (+/-5%) for MFC. CONCLUSIONS: Given adequate funduscopic information, the experienced observer can often accurately distinguish between POHS and MFC without the need for ancillary testing. Angiography in addition to fundus photography does not appear to increase diagnostic ability. There appears to be a higher sensitivity for MFC than for POHS