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PURPOSE: To determine the ocular complications in school-age children and adolescents surviving at least 1 year following allogeneic bone marrow transplantation. DESIGN: Retrospective cohort study. METHODS: In this institutional study, 162 patients (7-18 years old) met our inclusion criteria with a mean age of 13.4 years at bone marrow transplantation. Follow-up ranged from 13 months to 12 years (mean 4 years; median 3.2 years). Patient charts were screened for cataract formation, dry eye, and other anterior and posterior segment diseases. RESULTS: Cataract formation was noted in 57 patients. Univariate analysis showed that fractionated total body irradiation, race, and use of cytarabine significantly increased the incidence of cataract formation (P < 0.05). Multivariate analysis of significant variables showed that total body irradiation was a risk factor for cataract formation. Of the 57 patients (97 eyes) who developed cataracts after bone marrow transplantation, 4 patients (6 eyes) required cataract surgery. After surgery, all patients had visual acuities of 20/20 to 20/25. Of the 162 patients, 51 developed dry eyes. Univariate analysis showed that age at transplantation; steroid use, chronic graft-versus-host disease; use of fludarabine, melphalan, and thiotepa; and receiving no pre-transplantation conditioning regimen prior to bone marrow transplant significantly increased the risk of dry eye syndrome (P < 0.05). In multivariate analysis, chronic graft-versus-host disease was a significant risk factor for dry eye syndrome. CONCLUSIONS: Due to the high incidence of cataract formation and dry eye disease in this population, this study proposes these patients be screened using examinations by a pediatric or general ophthalmologist at least every year.
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Trasplante de Médula Ósea/efectos adversos , Oftalmopatías/etiología , Adolescente , Segmento Anterior del Ojo/patología , Catarata/diagnóstico , Catarata/etiología , Niño , Síndromes de Ojo Seco/diagnóstico , Síndromes de Ojo Seco/etiología , Femenino , Estudios de Seguimiento , Enfermedad Injerto contra Huésped/etiología , Enfermedades Hematológicas/terapia , Humanos , Masculino , Segmento Posterior del Ojo/patología , Estudios Retrospectivos , Factores de Riesgo , Trasplante Homólogo , Agudeza Visual , Irradiación Corporal Total/efectos adversosRESUMEN
PURPOSE: To investigate ocular complications associated with bone marrow transplant and associated continued maintenance therapy in a preschool population. METHODS: The medical records of patients <7 years of age were reviewed retrospectively. Patient charts were screened for cataract formation, dry eye, and other anterior and posterior segment disease. RESULTS: Of 270 cases reviewed, 91 met inclusion criteria. Mean age at diagnosis was 3.17 years. Average follow-up was 5.8 years (range, 1.9 months-14.1 years). Of the 91, 37 patients developed cataracts (35 bilaterally) over a 14-year period. Cumulative incidence corrected for competing event (death before cataract) for the study population was found to be 58.4% after 14 years. Univariate analysis for cataract formation showed statistical significance for total body irradiation dose, age at diagnosis, race, donor type (related vs unrelated), product type, diagnosis type, survival status, calcineurin inhibitor use, and bisulfan, cytarabine, and thiotepa use. Multivariate analysis for competing event (death), showed that total body irradiation dose was not statistically significant; however, when studied in a binary logistic regression model, total body irradiation dose was statistically significant. Notably, steroid use and presence of graft-versus-host disease did not show statistical significance for cataract development. No other ocular complication was found in sufficient quantities to allow statistical analyses. CONCLUSIONS: Due to the high incidence of cataract formation in this population, especially those enduring a treatment regimen with total body irradiation, we propose screening examinations by a pediatric or general ophthalmologist at least annually. We also urge a low threshold for treatment of dry eye syndrome.
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Trasplante de Médula Ósea/efectos adversos , Oftalmopatías/epidemiología , Segmento Anterior del Ojo/patología , Antineoplásicos/uso terapéutico , Terapia Conductista , Catarata/diagnóstico , Catarata/epidemiología , Catarata/etiología , Niño , Preescolar , Síndromes de Ojo Seco/diagnóstico , Síndromes de Ojo Seco/epidemiología , Síndromes de Ojo Seco/etiología , Oftalmopatías/diagnóstico , Oftalmopatías/etiología , Femenino , Estudios de Seguimiento , Enfermedad Injerto contra Huésped , Humanos , Incidencia , Lactante , Masculino , Neoplasias/terapia , Examen Físico , Segmento Posterior del Ojo/patología , Estudios Retrospectivos , Factores de Riesgo , Trasplante Homólogo , Irradiación Corporal TotalAsunto(s)
Azatioprina/administración & dosificación , Enfermedades de la Coroides , Ciclofosfamida/administración & dosificación , Metilprednisolona/administración & dosificación , Enfermedad Mixta del Tejido Conjuntivo , Arteria Retiniana/diagnóstico por imagen , Vasculitis Retiniana , Vena Retiniana/diagnóstico por imagen , Adolescente , Anticuerpos Antinucleares/sangre , Enfermedades de la Coroides/diagnóstico , Enfermedades de la Coroides/etiología , Enfermedades de la Coroides/terapia , Técnicas de Diagnóstico Oftalmológico , Femenino , Humanos , Inmunosupresores/administración & dosificación , Angiografía por Resonancia Magnética/métodos , Enfermedad Mixta del Tejido Conjuntivo/sangre , Enfermedad Mixta del Tejido Conjuntivo/diagnóstico , Enfermedad Mixta del Tejido Conjuntivo/tratamiento farmacológico , Enfermedad Mixta del Tejido Conjuntivo/fisiopatología , Vasculitis Retiniana/diagnóstico , Vasculitis Retiniana/etiología , Vasculitis Retiniana/fisiopatología , Vasculitis Retiniana/terapia , Resultado del Tratamiento , Agudeza VisualRESUMEN
BACKGROUND: Pleurostomophora richardsiae (formerly Phialophora richardsiae) is a dematiaceous fungus that is an uncommon cause of ocular infection. Herein, we present a case of endogenous endophthalmitis associated with disseminated P. richardsiae infection. FINDINGS: This is a descriptive case report with a brief review of literature. A 43-year-old male admitted to the hospital following an acute cerebellar hemorrhage was found to have a swollen and tender wrist. The patient was afebrile with leukocytosis. Visual acuity was hand motion in the right eye and 20/20 in the left. Right eye examination noted anterior chamber cells and flare, vitreous haze and multiple large, and fluffy retinal infiltrates. Diagnostic vitrectomy revealed a mixed inflammatory cell infiltrate with numerous fungal elements. Blood cultures were negative, multiple transesophageal echocardiography studies revealed no vegetations, and synovial fluid aspiration of the wrist and biopsy of the radius were unremarkable. The patient was treated with intravitreal cefazolin, vancomycin, and amphotericin B, topical ciprofloxacin and natamycin, and intravenous amphotericin B and voriconazole. Visual acuity in the right eye declined to light perception, and examination revealed increasing anterior and posterior chamber inflammation. The patient died several weeks after presentation due to a massive intracranial hemorrhage. Fungal culture results from the vitrectomy were received post mortem and were positive for P. richardsiae. CONCLUSIONS: P. richardsiae endophthalmitis is rare, and outcomes are typically poor. Infections typically occur following traumatic skin inoculation; however, a long refractory period may occur before symptoms develop. Early diagnosis and combination antimicrobial therapy are essential to optimize visual outcomes.
RESUMEN
Dry eye disease is a well-known late complication of radiation therapy and is often difficult to treat. We evaluated the usefulness of cyclosporine 0.05% ophthalmic emulsion for the treatment of radiation-associated dry eye in children. Eleven children received cyclosporine 0.05% emulsion twice daily after failure of conventional therapy. After 6 months, dry eye manifestations improved in three children (27.3%). The remaining eight children showed no improvement with cyclosporine 0.05% ophthalmic emulsion. These results suggest that twice-daily cyclosporine 0.05% ophthalmic emulsion has limited use in children with refractory radiation-associated chronic dry eye.
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Ciclosporina/administración & dosificación , Síndromes de Ojo Seco/tratamiento farmacológico , Neoplasias del Ojo/radioterapia , Inmunosupresores/administración & dosificación , Radioterapia/efectos adversos , Niño , Preescolar , Síndromes de Ojo Seco/etiología , Emulsiones , Femenino , Humanos , Masculino , Soluciones Oftálmicas , Estudios RetrospectivosRESUMEN
BACKGROUND: Little information exists regarding pediatric contrast-enhanced US. OBJECTIVE: To assess the safety and feasibility of contrast-enhanced US of pediatric abdominal and pelvic tumors. MATERIALS AND METHODS: This prospective study included eight boys and five girls (mean age, 10.8 years) with abdominal or pelvic tumors. Cohorts of three subjects underwent US with perflutren contrast agent at escalating dose levels. Neurological and funduscopic examination, electrocardiography and continuous pulse oximetry were performed before and after contrast administration. Three radiologists independently scored six imaging parameters on pre- and postcontrast sonography. Inter-reviewer agreement was measured by the Kappa statistic. RESULTS: No neurological, retinal, electrocardiographical or pulse oximetry changes were attributable to the contrast agent. Two subjects reported minor, transient symptoms. Postcontrast US parameter scores improved slightly in 8 of 12 subjects. Postcontrast ultrasound inter-reviewer agreement improved slightly for detection of tumor margins (precontrast = 0.20, postcontrast = 0.26), local tumor invasion (precontrast = -0.01, postcontrast = 0.10) and adenopathy (precontrast = 0.35, postcontrast = 0.44). CONCLUSIONS: Although our sample size is small, perflutren contrast agents appear to be safe and well tolerated in children. Contrast-enhanced sonography of pediatric abdominal and pelvic tumors is feasible, but larger studies are needed to define their safety and efficacy in children.
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Neoplasias Abdominales/diagnóstico por imagen , Fluorocarburos , Neoplasias Pélvicas/diagnóstico por imagen , Ultrasonografía/métodos , Niño , Medios de Contraste/efectos adversos , Estudios de Factibilidad , Femenino , Fluorocarburos/efectos adversos , Humanos , Masculino , Proyectos Piloto , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: In 1994, Tennessee converted its Medicaid program to a managed care system--TennCare. Graduate medical education (GME) funding by TennCare was linked to several workforce goals that included increasing the number of residents training in primary care and increasing the number of primary care physicians practicing in underserved areas of Tennessee. OBJECTIVES: To determine the effects of the TennCare GME plan on GME and the physician workforce of Tennessee. DESIGN, SETTING, AND PARTICIPANTS: Bureau of TennCare GME data from 1996-2004 and American Medical Association Physician Masterfile data through 2003. MEASUREMENTS: Changes in filled residency positions and number of stipend supplements awarded after implementation of the TennCare GME plan. Changes in physician workforce characteristics between a 5-year period before and after implementation of TennCare. RESULTS: Filled primary care residency positions increased from 839 (45.2%) in 1996 to 906 (47.9%) in 2000, but declined to 862 (43.5%) by 2004. Eleven of 133 available primary care stipend supplements were awarded through 2004. The percentage of physicians remaining in Tennessee after completion of residency decreased from 46.2% before TennCare to 42.4% (P = .087) after implementation of TennCare. U.S. medical graduates remaining in state declined by 5.8% (P = .019). CONCLUSIONS: The major goals of the TennCare GME plan have not been achieved. Overall, physician retention has decreased and the number of U.S. medical graduates remaining in state has declined. State policymakers should consider other methods to increase the number of residents training in primary care and ultimately practicing in underserved areas of Tennessee.
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Educación de Postgrado en Medicina/tendencias , Internado y Residencia/tendencias , Selección de Profesión , Educación de Postgrado en Medicina/economía , Humanos , Internado y Residencia/economía , Programas Controlados de Atención en Salud/economía , Programas Controlados de Atención en Salud/tendencias , Atención Primaria de Salud/economía , Atención Primaria de Salud/tendencias , TennesseeRESUMEN
PURPOSE: To describe a patient with conjunctival posttransplantation lymphoproliferative disorder (PTLD). DESIGN: Interventional case report. METHODS: A 8-year-old boy, three months status post bone marrow transplantation with bilateral enlarged gelatinous bulbar conjunctiva was examined. Biopsy of the bulbar conjunctiva was performed. RESULTS: Conjunctival biopsy revealed a polymorphous infiltrate of lymphoid cells with large atypical immunoblastic lymphoma cells, plasmacytoid lymphocytes, and plasma cells. B-cell markers CD20 and CD79a were positive. Plasma cells exhibited restriction for kappa immunoglobulin light chain and were positive for CD79a. Most cells were positive for Epstein-Barr virus (EBV) encoded ribonucleic acid. EBV-related polymorphic PTLD was diagnosed and treated with discontinuation of cyclosporine, reduction in prednisone dosage and administration of EBV-specific cytotoxic T lymphocytes. The conjunctival lesions resolved during the next five weeks. CONCLUSIONS: Posttransplantation lymphoproliferative disorder rarely involves the ocular structures with most cases presenting as a masquerade syndrome. This case illustrates that PTLD can involve the conjunctiva and further expands the clinical spectrum of ocular PTLD.
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Trasplante de Médula Ósea/efectos adversos , Enfermedades de la Conjuntiva/etiología , Infecciones por Virus de Epstein-Barr/etiología , Infecciones Virales del Ojo/etiología , Trastornos Linfoproliferativos/etiología , Biomarcadores/metabolismo , Niño , Enfermedades de la Conjuntiva/diagnóstico , Enfermedades de la Conjuntiva/metabolismo , Ciclosporina/administración & dosificación , ADN Viral/sangre , Infecciones por Virus de Epstein-Barr/diagnóstico , Infecciones por Virus de Epstein-Barr/metabolismo , Infecciones Virales del Ojo/diagnóstico , Infecciones Virales del Ojo/metabolismo , Humanos , Técnicas para Inmunoenzimas , Hibridación in Situ , Trastornos Linfoproliferativos/diagnóstico , Trastornos Linfoproliferativos/metabolismo , Masculino , Prednisona/administración & dosificación , Linfocitos T Citotóxicos/inmunología , Síndrome de Wiskott-Aldrich/cirugíaRESUMEN
PURPOSE: To report the cases of six patients with primary sclerosing cholangitis and uveitis. DESIGN: Retrospective observational case series. METHODS: Two index cases were identified from the Uveitis Clinic of the Casey Eye Institute, Oregon Health and Science University and another from the Portland area. Additional cases were identified through a web-based survey of members of the American Uveitis Society. RESULTS: Three males and three females were identified. Five of six patients were diagnosed with uveitis prior to primary sclerosing cholangitis. Four had unilateral eye involvement. Five had insidious onset. All had persistent duration. Clinical course was chronic for three, recurrent for two, and chronic-recurrent in one. Vitreous inflammation was prominent in five. CONCLUSIONS: Although the number of patients who were studied is limited, there appears to be an association between primary sclerosing cholangitis and uveitis. Further studies are required to confirm such an association.
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Colangitis Esclerosante/complicaciones , Uveítis/complicaciones , Adulto , Colangitis Esclerosante/diagnóstico , Enfermedad Crónica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Estudios Retrospectivos , Uveítis/diagnósticoRESUMEN
Inadvertent perforation of the sclera is a well-known complication of strabismus surgery. Scleral perforation may lead to retinal detachment, intraocular hemorrhage, cataract, hyphema, glaucoma, endophthalmitis, and phthisis bulbi. However, endophthalmitis following strabismus surgery is extremely rare, with an estimated incidence of 1:3500 to 1:185,000. We describe a case of Staphylococcus epidermidis endophthalmitis in an adult following strabismus surgery treated successfully with intravitreal antibiotics and corticosteroids.
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Endoftalmitis/microbiología , Infecciones Bacterianas del Ojo/microbiología , Complicaciones Intraoperatorias , Infecciones Estafilocócicas/microbiología , Staphylococcus epidermidis/aislamiento & purificación , Estrabismo/cirugía , Infección de la Herida Quirúrgica/microbiología , Anciano , Antibacterianos , Quimioterapia Combinada/uso terapéutico , Endoftalmitis/diagnóstico , Endoftalmitis/tratamiento farmacológico , Infecciones Bacterianas del Ojo/diagnóstico , Infecciones Bacterianas del Ojo/tratamiento farmacológico , Humanos , Masculino , Músculos Oculomotores/cirugía , Esclerótica/lesiones , Infecciones Estafilocócicas/diagnóstico , Infecciones Estafilocócicas/tratamiento farmacológico , Infección de la Herida Quirúrgica/diagnóstico , Infección de la Herida Quirúrgica/tratamiento farmacológico , Cuerpo Vítreo/microbiologíaAsunto(s)
Antihipertensivos/efectos adversos , Conjuntivitis Alérgica/inducido químicamente , Prednisolona/análogos & derivados , Quinoxalinas/efectos adversos , Uveítis Anterior/inducido químicamente , Administración Tópica , Anciano , Anciano de 80 o más Años , Antihipertensivos/administración & dosificación , Tartrato de Brimonidina , Conjuntivitis Alérgica/tratamiento farmacológico , Femenino , Glaucoma/tratamiento farmacológico , Glucocorticoides/uso terapéutico , Humanos , Presión Intraocular/efectos de los fármacos , Masculino , Soluciones Oftálmicas , Prednisolona/uso terapéutico , Quinoxalinas/administración & dosificación , Uveítis Anterior/tratamiento farmacológicoRESUMEN
Retinal vasculitis represents a group of diseases characterized by inflammation affecting the retinal vasculature. It is an uncommon disorder that may occur as an isolated disease or more commonly in association with other ocular diseases or a variety of systemic diseases. With a wide variety of disease associations, a search for an underlying etiology should be undertaken based on a meticulous history, review of systems, and physical examination. The laboratory evaluation of patients with retinal vasculitis is an essential component of the work-up to facilitate detection of any underlying disease or to establish a limited differential diagnosis. The management of infectious causes of retinal vasculitis consists of antimicrobial therapy while noninfectious retinal vasculitis is managed with corticosteroids and/or immunosuppressive agents. Because retinal vasculitis is an uncommon disease, there are only a limited number of publications over the past year related to this topic.
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Vasculitis Retiniana/diagnóstico , Vasculitis Retiniana/terapia , Oftalmopatías/complicaciones , Oftalmopatías/diagnóstico , Angiografía con Fluoresceína , Humanos , Inmunosupresores/uso terapéutico , Infecciones/complicaciones , Infecciones/diagnóstico , Procedimientos Quirúrgicos Oftalmológicos , Vasculitis Retiniana/complicaciones , Vasculitis Retiniana/etiologíaRESUMEN
PURPOSE: To document clinical features of uveitis in patients with familial juvenile systemic granulomatosis. DESIGN: Retrospective chart review. METHODS: Ophthalmologic examination, medical history, and clinical course in 16 patients from eight families examined at six academic medical centers. RESULTS: Of the 16 patients, 15 had evidence of panuveitis with multifocal choroiditis. One patient had only an anterior uveitis. Ischemic optic neuropathy, presumably due to a small vessel vasculopathy, and retinal vasculopathy each occurred in one patient. Ocular complications were common, including cataracts in 11, glaucoma in six, band keratopathy in six, cystoid macular edema in six, and optic disk edema in six. All 16 patients had polyarthritis, and at least nine had skin rash. Often patients were misdiagnosed initially as having either juvenile rheumatoid arthritis or sarcoidosis. CONCLUSIONS: Familial juvenile systemic granulomatosis is an uncommon genetic disease characterized by polyarthritis and uveitis. Panuveitis and multifocal choroiditis often may be present. Patients with a diagnosis of juvenile rheumatoid arthritis but having a family history of the disease and multifocal choroiditis should be suspected of having familial juvenile systemic granulomatosis.