Comprehensive ophthalmology update最新文献

Intravitreal pharmacotherapies have been used with increasing frequency in the treatment of retinal disease. Indications for their use include choroidal neovascular membranes, diabetic macular edema, ischemic neovascularization, inflammatory and infectious processes, and neoplasia. Complications of intravitreal therapies include cataract formation, glaucoma, and endophthalmitis. Recent developments of pharmacologic agents administered intravitreally and the new applications of systemic medications in retinal disease present the practitioner with expanded treatment options. Current and emerging data will help guide therapy in order to maximize the benefits and limit the systemic and ocular complications of these new treatment options.

Sulfonamide medications can cause an idiosyncratic reaction, resulting in acute transient myopia and acute angle-closure glaucoma. The risk of an adverse reaction to a sulfonamide is approximately 3%, and the exact mechanism of the myopia and angle-closure glaucoma remains controversial. Typical clinical presentation includes bilateral involvement with blurring of vision that generally occurs over minutes to hours, nausea or vomiting, red eye, and headache. Examination may show conjunctival injection, corneal edema, anterior chamber inflammation, and flat or shallow anterior chamber. Diagnosis is based on clinical suspicion, although an ultrasound biomicroscopy may be helpful in diagnosing swelling of the ciliary body. Topiramate, a sulfa derivative, is used for the treatment of migraines or seizures. The side effects include acute myopia and angle-closure glaucoma. Treatment of this condition is primarily supportive along with discontinuation of the medication; topical miotics and peripheral iridectomy are not helpful. If intraocular pressure remains uncontrolled, additional therapies, such as topical intraocular pressure-lowering medications, high-dose steroids, and trabeculectomy, may need to be considered.

Since the advent of pay for performance in medicine, there has been an intense debate about its efficacy and enforceability. This article examines some philosophical and psychological aspects of pay for performance. The very concept of pay for performance is inimical to the Hippocratic oath; it operates in direct conflict with powerful ideals such as altruism and concern for community. These ideals traditionally serve as powerful motivators for physicians. Physicians have just begun to incorporate and enhance the autonomy model. This is designed to help patients and physicians make decisions leading to positive outcomes. Pay for performance threatens to reintroduce an incurable power imbalance between patients and clinicians. Research from the corporate world suggests that hardwiring the thought processes of pay for performance into health-care delivery may lead to a culture of hyper-productivity. This can lead to addictive behavior and ethical abuse.

Proliferative diabetic retinopathy is characterized by neovascularization originating from the retina and/or optic disk in patients with diabetes mellitus. The role of vascular endothelial growth factor appears to be central in the pathogenesis of proliferative diabetic retinopathy. Advanced glycation end products are important in the development of vitreous abnormalities in proliferative diabetic retinopathy. The majority of the neovascular membranes are adherent to the posterior vitreous cortex. When the posterior hyaloid exerts traction, the edges of the neovascular complex are pulled forward, resulting in vitreous hemorrhage. Tractional and/or rhegmatogenous retinal detachments can occur. The Diabetic Retinopathy Study demonstrated the ability of panretinal photocoagulation to reduce the rate of severe visual loss by 50% for eyes with high-risk characteristics, defined as neovascularization originating from the optic disk > 1/3 disk diameter, any neovascularization originating from the optic disk with hemorrhage, and neovascularization originating from the retina with vitreous hemorrhage. The Early Treatment Diabetic Retinopathy Study showed that patients with type II diabetes mellitus who were older than 40 with severe nonproliferative diabetic retinopathy (defined as hemorrhages in four quadrants, venous beading in two quadrants, or intraretinal microvascular abnormalities in one quadrant) also benefited from early panretinal photocoagulation. The Diabetic Retinopathy Vitrectomy Study showed that early vitrectomy (within 6 months of onset of vitreous hemorrhage) was associated with better results in type I diabetes mellitus patients only. The goals of vitreous surgery are to remove the vitreous, including the posterior hyaloid, and to relieve traction from fibrovascular tissue. Delamination and segmentation techniques have been used in the excision of fibrovascular growth on the internal limiting membrane and extending into the vitreous. Panretinal photocoagulation is an integral component of vitrectomy for proliferative diabetic retinopathy. Anti-vascular endothelial growth factor agents may be used in addition to laser as an adjunct to reduce the risk of neovascularization. Vitrectomy surgery may have intraoperative and postoperative complications, including cataract, anterior hyaloidal fibrovascular proliferation, fibrovascular ingrowth, retinal detachment, and recurrent vitreous hemorrhage. Visual potential depends on the preoperative and postoperative status of the macula, as well as on retinal perfusion and the health of the optic nerve. With the improvement in instruments, techniques, and drugs, the results of vitrectomy in proliferative diabetic retinopathy are improving.

The white dot syndromes are a heterogeneous group of rare inflammatory disorders affecting the retina, the retinal pigment epithelium, and the choroid. Not all of these diseases actually cause white dots, but they all have unique lesions in the fundus. We describe acute posterior multifocal placoid pigment epitheliopathy, serpiginous choroiditis, birdshot chorioretinopathy, multifocal choroiditis with panuveitis, diffuse subretinal fibrosis syndrome, punctate inner choroidopathy, multiple evanescent white dot syndrome, and diffuse unilateral subacute neuroretinitis as the white dot syndromes in this review. Some of these conditions share an association with systemic infectious diseases. In addition, treatment of these diseases is similar. Some can be treated with immunosuppressive therapy. Other treatment options include laser photocoagulation, topical or systemic steroid therapy, photodynamic therapy, and, most recently, anti-vascular endothelial growth factor agents. The new development in treatment may alter the visual prognosis of the patients, leading to a better outcome in visual acuity.

Adamantiades-Behcet disease is a relapsing systemic vasculitis that may involve the eyes, skin, and almost all other organ systems. The comprehensive ophthalmologist plays a key role by not only making the diagnosis but also by monitoring inflammatory status to guide systemic therapy. If left untreated, the disease has a high likelihood of causing blindness and death. Adamantiades-Behcet disease with retinal involvement is now considered an absolute indication for systemic immunomodulatory therapy. The diagnostic signs, potential complications, and treatment modalities currently available for ocular Adamantiades-Behcet disease are reviewed.

Intermittent exotropia is the most common form of divergent strabismus. Treatment is indicated with increasing tropia phase to preserve or restore binocular function and restore/reconstruct normal ocular alignment. While medical treatment is sometimes helpful for temporary relief, surgical therapy is the preferred definitive treatment modality by most pediatric ophthalmologists and strabismologists. Congenital exotropia is rare and is associated with a high incidence of amblyopia. The treatment of choice in this condition is also surgical. Sensory exotropia is most often acquired after monocular visual loss. The preferred treatment is surgical recession/resection on the impaired eye. Convergence insufficiency is usually not diagnosed until the teenage years or later, and it is best approached nonsurgically with convergence exercises. In this article, we review the current literature and practice on the diagnosis and management of exotropia with emphasis on intermittent exotropia.