A study of initial therapy for glaucoma in southern India: India Glaucoma Outcomes and Treatment (INGOT) Study.

PURPOSE: To compare initial glaucoma therapy with medications and trabeculectomy in southern India. METHODS: Patients aged ≥ 30 years newly diagnosed with glaucoma were randomized to trabeculectomy with 5-fluorouracil or medical therapy. Subjects with best-corrected vision <6/18 due to cataract underwent phacoemulsification (phaco/intraocular lens, IOL). Intraocular pressure (IOP), vision and visual function were assessed at 12 months. RESULTS: Patients assigned to medications and surgery received the expected therapy in 86% (172/199) and 64% (126/199) of cases, respectively. Forty patients (20%) assigned to surgery refused any treatment and 33 (17%) received medications. Among 199 patients randomized to medications, 52 (26.1%) underwent phaco/IOL, as did 89/199 (43.7%) of patients randomized to trabeculectomy. Baseline parameters of the two groups did not differ, nor did 1-year follow-up rates (medication 65%, trabeculectomy 58%, P = 0.15). Final IOP was lower with randomization to trabeculectomy (16.3 ± 5.1 mmHg) than medication (18.8 ± 6.7 mmHg, P < 0.0001). In regression models, randomization to trabeculectomy (P < 0.0001) was associated with lower IOP, and simultaneous trabeculectomy and cataract surgery was associated with higher IOP (P = 0.008) than trabeculectomy alone. Subjects receiving Phaco/IOL had significantly better final acuity (P < 0.0001) and visual function (P = 0.035), despite concurrent glaucoma treatment. Final visual acuity was worse in those receiving trabeculectomy in addition to cataract surgery, but this was of borderline significance (P = 0.06). CONCLUSIONS: Trabeculectomy lowered IOP significantly more than medical treatment, but with slightly greater loss of visual acuity. Combined phaco/IOL and trabeculectomy improved visual acuity with substantial IOP lowering.

Stem Cell Transplantation for Retinal Degenerations

Within the last few years, several reports have revealed that cell transplantation can be an effective way to replace lost neurons in the central nervous system (CNS) of patients affected with neurodegenerative diseases. Concerning the retina, the concept that newborn photoreceptors can integrate the retina and restore some visual functions was univocally demonstrated recently in the mouse eye (MacLaren et al. 2006) and remains to be achieved in human. These results pave the way to a standard approach in regenerative medicine aiming to replace lost photoreceptors. With the discovery of stem cells a great hope has appeared towards elaborating protocols to generate adequate cells to restore visual function in different retinal degeneration processes. Retinal stem cells (RSCs) are good candidates to repair the retina and are present throughout the retina development, including adulthood. However, neonatal mouse RSCs derived from the radial glia population have a different potential to proliferate and differentiate in comparison to adult RSCs. Moreover, we observed that adult mouse RSCs, depending on the culture conditions, have a marked tendency to transform, whereas neonatal RSCs show subtle chromosome abnormalities only after extensive expansion. These characteristics should help to identify the optimal cell source and culture conditions for cell transplantation studies. These results will be discussed in light of other studies using RSCs as well as embryonic stem cells. Another important factor to consider is the host environment, which plays a crucial role for cell integration and which was poorly studied in the normal and the diseased retina. Nonetheless, important results were recently generated to reconsider cell transplantation strategy. Perspectives to enhance cell integration by manipulating the environment will also be presented.

Novel molecular mechanisms of neuronal and vascular protection in experimental glaucoma

Le glaucome est la deuxième cause de cécité irréversible dans le monde. La perte de vision qui se produit lors du glaucome s’explique par une dégénérescence du nerf optique et une mort progressive et sélective des cellules ganglionnaires de la rétine (CRG). L'hypertension oculaire est un facteur de risque majeur dans le glaucome, mais des défauts du champ visuel continuent à se développer chez un contingent de patients malgré l'administration de médicaments qui abaissent la pression intraoculaire (PIO). Par conséquent, bien que la PIO représente le seul facteur de risque modifiable dans le développement du glaucome, son contrôle ne suffit pas à protéger les CRGs et préserver la fonction visuelle chez de nombreux patients. Dans ce contexte, j'ai avancé l'hypothèse centrale voulant que les stratégies de traitement du glaucome visant à promouvoir la protection structurale et fonctionnelle des CRGs doivent agir sur les mécanismes moléculaires qui conduisent à la mort des ces neurones. Dans la première partie de ma thèse, j'ai caractérisé l'effet neuroprotecteur de la galantamine, un inhibiteur de l'acétylcholinestérase qui est utilisé cliniquement dans le traitement de la maladie d'Alzheimer. Cette étude s’est basée sur l'hypothèse que la galantamine, en modulant l'activité du récepteur de l'acétylcholine, puisse améliorer la survie des CRGs lors du glaucome. Nous avons utilisé un modèle expérimental bien caractérisé d'hypertension oculaire induite par l’administration d'une solution saline hypertonique dans une veine épisclérale de rats Brown Norway. Les résultats de cette étude (Almasieh et al. Cell Death and Disease, 2010) ont démontré que l'administration quotidienne de galantamine améliore de manière significative la survie des corps cellulaires et des axones CRGs. La protection structurelle des CRGs s’accompagne d’une préservation remarquable de la fonction visuelle, évaluée par l'enregistrement des potentiels évoqués visuels (PEV) dans le collicule supérieur, la cible principale des CRGs chez le rongeur. Une autre constatation intéressante de cette étude est la perte substantielle de capillaires rétiniens et la réduction du débit sanguin associé à la perte des CRGs dans le glaucome expérimental. Il est très intéressant que la galantamine ait également favorisé la protection de la microvascularisation et amélioré le débit sanguin rétinien des animaux glaucomateux (Almasieh et al. en préparation). J'ai notamment démontré que les neuro-et vasoprotections médiées par la galantamine se produisent par iv l'activation des récepteurs muscariniques de l'acétylcholine. Dans la deuxième partie de ma thèse, j'ai étudié le rôle du stress oxydatif ainsi que l'utilisation de composés réducteurs pour tester l'hypothèse que le blocage d'une augmentation de superoxyde puisse retarder la mort des CRG lors du glaucome expérimental. J'ai profité d'un composé novateur, un antioxydant à base de phosphineborane (PB1), pour tester sur son effet neuroprotecteur et examiner son mécanisme d'action dans le glaucome expérimental. Les données démontrent que l'administration intraoculaire de PB1 entraîne une protection significative des corps cellulaire et axones des CRGs. Les voies moléculaires conduisant à la survie neuronale médiée par PB1 ont été explorées en déterminant la cascade de signalisation apoptotique en cause. Les résultats démontrent que la survie des CRGs médiée par PB1 ne dépend pas d’une inhibition de signalisation de protéines kinases activées par le stress, y compris ASK1, JNK ou p38. Par contre, PB1 induit une augmentation marquée des niveaux rétiniens de BDNF et une activation en aval de la voie de survie des ERK1 / 2 (Almasieh et al. Journal of Neurochemistry, 2011). En conclusion, les résultats présentés dans cette thèse contribuent à une meilleure compréhension des mécanismes pathologiques qui conduisent à la perte de CRGs dans le glaucome et pourraient fournir des pistes pour la conception de nouvelles stratégies neuroprotectrices et vasoprotectrices pour le traitement et la gestion de cette maladie.

Effects of mercury intoxication on the response of horizontal cells of the retina of thraira fish (Hoplias malabaricus)

Methyl mercury (MeHg) is highly neurotoxic, affecting visual function in addition to other central nervous system functions. The effect of mercury intoxication on the amplitude of horizontal cell responses to light was studied in the retina of the fish Hoplias malabaricus. Intracellular responses were recorded from horizontal cells of fish previously intoxicated with MeHg by intraperitoneal injection (IP group) or by trophic exposure (T group). Only one retina per fish was used. The doses of MeHg chloride administered to the IP group were 0.01, 0.05, 0.1, 1.0, 2.0, and 6.0 mg/kg. The amplitudes of the horizontal cell responses were lower than control in individuals exposed to 0.01 (N = 4 retinas), 0.05 (N = 2 retinas) and 0.1 mg/kg (N = 1 retina), whereas no responses were recorded in the 1.0, 2.0, and 6.0 mg/kg groups. T group individuals were fed young specimens of Astyanax sp previously injected with MeHg corresponding to 0.75 (N = 1 retina), 0.075 (N = 8 retinas) or 0.0075 (N = 4 retinas) mg/kg fish body weight. After 14 doses, one every 5 days, the amplitude of the horizontal cell response was higher than control in individuals exposed to 0.075 and 0.0075 mg/kg, and lower in individuals exposed to 0.75 mg/kg. We conclude that intoxication with MeHg affects the electrophysiological response of the horizontal cells in the retina, either reducing or increasing its amplitude compared to control, and that these effects are related to the dose and/or to the mode of administration.

A visão através dos contrastes

O primeiro estágio de processamento da informação do estímulo visual consiste na contagem de fótons pelas células fotorreceptoras. Nos estágios pós-receptorais a informação de intensidade absoluta do estímulo é transformada em comparações de informações provindas de áreas adjacentes da retina e momentos sucessivos. Essa métrica implementada pelo sistema visual para quantificar o estímulo é chamada de contraste - contraste espacial ou simultâneo e contraste temporal ou sucessivo. A presença de contraste é essencial para a geração de percepção visual consciente no domínio do espaço e do tempo e em três dimensões ortogonais de cores - branca e preta; azul e amarela; verde e vermelha. Uma curva em forma de sinodelimita os limiares de detecção de contraste em função da frequência especial ou temporal do estímulo. Ela é chamada função de sensibilidade ao contraste e é afetada por uma série de fatores ópticos e neurais. Neurônios de diferentes classes contribuem para regiões diferentes da função de sensibilidade ao contraste e suas atividades representam as ações de vias de processamento visual que se estendem da retina ao córtex visual. Investigações básicas e clínicas têm dado suporte à importância do estudo da sensibilidade ao contraste espacial de luminância (branco e preta) como uma ferramenta indicadora da função visual em sujeitos normais e afetados por disfunções neuro-oftalmológicas.

Color vision loss in patients treated with chloroquine

Pacientes que fazem uso de cloroquina ou hidróxi-cloroquina, drogas que são freqüentemente administradas para o tratamento de artrite reumatóide, lúpus eritrematoso ou malária, podem sofrer alterações na visão de cores e na sensibilidade de contraste. O presente estudo avaliou a função visual destes pacientes em um estudo conjunto da Universidade de São Paulo (USP), em São Paulo, e da Universidade Federal do Pará (UFPA), em Belém. Trinta e dois pacientes usuários de cloroquina sem alterações no exame de fundo de olho foram avaliados em São Paulo (n=10, 38 a 71 anos, média=55,8 anos) e em Belém (n=22, 20 a 67 anos, média=40 anos). A dose acumulada de cloroquina prescrita foi de 45 a 430 g (média=213 g; dp=152 g) para o grupo de São Paulo, e de 36 a 540 g (média=174 g; dp=183 g) para o grupo de Belém. Os testes foram realizados monocularmente com o estado refracional corrigido. A discriminação de cor foi avaliada utilizando o Teste de Cor de Cambridge (CCT): o limiar de discriminação de cor foi mensurado primeiro nos eixos protano, deutano e tritano, e em seqüência, três elipses de MacAdam foram determinadas. A visão de cores dos pacientes também foi avaliada com testes de arranjo de cores: o teste de 100 matizes de Farnsworth-Munsell (FM100), o D15 de Farnsworth-Munsell, e o teste Lanthony Dessaturado (D15d). A sensibilidade de contraste foi também medida com grades senoidais preto-e-brancas em 22 pacientes. Os resultados foram comparados com controles sem patologias oftalmológicasou neuro-oftalomológicas. 24 pacientes apresentaram discromatopsia adquirida, com perdas seletivas (11 pessoas) ou difusas (13 pessoas). Embora as perdas estivessem presentes no FM100, não houve correlação entre o escore de erro do FM100 e a área elíptica medida pelo CCT. Além disso, três pacientes que tiveram escores normais no FM100 falharam para alcançar limiares normais no CCT. O teste de Lanthony foi menos sensível do que os outros dois testes, tal que falhou em indicar perda em cerca de metade dos pacientes afetados, e o D15 foi o teste menos sensível, deixando de indicar déficits em 9 de 10 pacientes. A sensibilidade de contraste esteve dentro dos valores normais para pacientes submetidos a este teste. A extensão das perdas na discriminação de cores foi positivamente correlacionada com a dose acumulada. O CCT é recomendado para o acompanhamento destes pacientes, pois forneceu dados quantitativos que podem ser diretamente interpretados no espaço cromático da CIE (Commission Internationelle d'Éclairage).

Life quality assessment of patients after phacoemulsification or extracapsular cataract extraction

Métodos: O trabalho foi realizado no Serviço de Oftalmologia do Hospital Universitário Bettina Ferro de Souza, Belém, Pará, Brasil. O desenho experimental consistiu em séries de casos comparados. O estudo incluiu 60 indivíduos com catarata. Metade dos pacientes foi submetida à extração de catarata extracapsular convencional (ECEE) e a outra metade à extração de catarata por facoemulsificação (PHACO). Os pacientes foram entrevistados usando-se o questionário Visual Function 14 (VF-14) para determinar a qualidade de vida antes e 30 dias depois da cirurgia. Os resultados do exame oftalmológico foram registrados no arquivo de cada paciente e disponibilizados ao longo do trabalho. Foram usados análise de variância simples e comparação post-hoc com teste de Tukey e teste dos sinais para a análise estatística dos resultados. Resultados: O índice de satisfação médio VF-14 foi 38,0 e 89,4 antes e após a cirurgia, respectivamente, para o grupo ECEE, sendo 47,0 e 94,1 para o grupo PHACO. A melhora na qualidade de vida após a cirurgia foi significativa em ambos os grupos de pacientes (p<0,0001), tendo sido semelhante em ambos os grupos. Conclusão: A melhora observada na qualidade de vida avaliada foi significativa e diretamente relacionada à satisfação dos pacientes com os resultados da cirurgia, a qual também foi significativa (p<0,0001). A satisfação e a qualidade de vida são fatores individuais. Consequentemente, as respostas dos pacientes relativas à melhoria em cada atividade são subjetivas e dependem unicamente da percepção individual.

Losses of immunoreactive parvalbumin amacrine and immunoreactive alphaprotein kinase C bipolar cells caused by methylmercury chloride intoxication in the retina of the tropical fish Hoplias malabaricus

To quantify the effects of methylmercury (MeHg) on amacrine and on ON-bipolar cells in the retina, experiments were performed in MeHg-exposed groups of adult trahiras (Hoplias malabaricus) at two dose levels (2 and 6 µg/g, ip). The retinas of test and control groups were processed by mouse anti-parvalbumin and rabbit anti-_aprotein kinase C (_aPKC) immunocytochemistry. Morphology and soma location in the inner nuclear layer were used to identify immunoreactive parvalbumin (PV-IR) and _aPKC (_aPKC-IR) in wholemount preparations. Cell density, topography and isodensity maps were estimated using confocal images. PV-IR was detected in amacrine cells in the inner nuclear layer and in displaced amacrine cells from the ganglion cell layer, and _aPKC-IR was detected in ON-bipolar cells. The MeHg-treated group (6 µg/g) showed significant reduction of the ON-bipolar _aPKC-IR cell density (mean density = 1306 ± 393 cells/mm²) compared to control (1886 ± 892 cells/mm²; P < 0.001). The mean densities found for amacrine PV-IR cells in MeHg-treated retinas were 1040 ± 56 cells/mm² (2 µg/g) and 845 ± 82 cells/mm² (6 µg/g), also lower than control (1312 ± 31 cells/mm²; P < 0.05), differently from the data observed in displaced PV-IR amacrine cells. These results show that MeHg changed the PV-IR amacrine cell density in a dose-dependent way, and reduced the density of _aKC-IR bipolar cells at the dose of 6 µg/g. Further studies are needed to identify the physiological impact of these findings on visual function.

Effects of age and optical blur on real depth stereoacuity

Stereoscopic depth perception utilizes the disparity cues between the images that fall on the retinae of the two eyes. The purpose of this study was to determine what role aging and optical blur play in stereoscopic disparity sensitivity for real depth stimuli. Forty-six volunteers were tested ranging in age from 15 to 60 years. Crossed and uncrossed disparity thresholds were measured using white light under conditions of best optical correction. The uncrossed disparity thresholds were also measured with optical blur (from +1.0D to +5.0D added to the best correction). Stereothresholds were measured using the Frisby Stereo Test, which utilizes a four-alternative forced-choice staircase procedure. The threshold disparities measured for young adults were frequently lower than 10 arcsec, a value considerably lower than the clinical estimates commonly obtained using Random Dot Stereograms (20 arcsec) or Titmus Fly Test (40 arcsec) tests. Contrary to previous reports, disparity thresholds increased between the ages of 31 and 45 years. This finding should be taken into account in clinical evaluation of visual function of older patients. Optical blur degrades visual acuity and stereoacuity similarly under white-light conditions, indicating that both functions are affected proportionally by optical defocus.

Electrophysiological evidence for impairment of contrast sensitivity in mercury vapor occupational intoxication

Contrast sensitivity (CS) was evaluated in 41 former workers from a lamp manufacturing plant who were on disability retirement due to exposure to mercury and 14 age-matched controls. The CS was measured monocularly using the sweep visual evoked potential (sVEP) paradigm at 6 spatial frequencies (0.2, 0.8, 2.0, 4.0, 15.0, and 30 cpd). Statistical difference (p < 0.05) was found between the controls and the patient right and left eyes for 2.0 and 4.0 cpd. According the results in those spatial frequencies the eyes were classified in best and worst. Statistical differences were found between the controls and the best eyes for 2.0 and 4.0 cpd and for 0.8, 2.0, and 4.0 cpd for their worst eyes. No correlation was found between CS results and the time of exposure (mean 8.9 yr +/- 4.1), time away from the mercury source (mean = 6.0 yr +/- 3.9), urinary mercury level at the time of work (mean = 40.6 mu g/g +/-36.3) or with the mercury level at the CS measurement time (mean = 1.6 mu g/g +/-1.1). We show the first evidence of a permanent impairment in CS measured objectively with the sVEP. Our data complement the previous psychophysical works reporting a diffuse impairment in the CS function showing a CS reduction in the low to middle spatial frequencies. In conclusion, non-reversible CS impairment was found in occupational exposure to mercury vapor. We suggest that CS measurement should be included in studies of the mercury effects of occupational exposure. (C) 2007 Elsevier Inc. All rights reserved.

Contrast Sensitivity Mediated by Inferred Magno- and Parvocellular Pathways in Type 2 Diabetics with and without Nonproliferative Retinopathy

PURPOSE. To evaluate achromatic contrast sensitivity (CS) with magnocellular-(M) and parvocellular-(P) probing stimuli in type 2 diabetics, with (DR) or without (NDR) nonproliferative retinopathy. METHODS. Inferred M-and P-dominated responses were assessed with a modified version of the steady-/pulsed-pedestal paradigm (SP/PP) applied in 26 NDR (11 male; mean age, 55 +/- 9 years; disease duration, 5 +/- 4 years); 19 DR (6 male; mean age, 58 +/- 7 years; disease duration = 9 +/- 6 years); and 18 controls (CTRL; 12 male; mean age, 55 +/- 10 years). Thresholds were measured with pedestals at 7, 12, and 19 cd/m(2), and increment durations of 17 and 133 ms. The thresholds from the two stimulus durations were used to estimate critical durations (Tc) for each data set. RESULTS. Both DR and NDR patients had significant reduction in CS in both SP and PP paradigms in relation to CTRL (Kruskal-Wallis, P < 0.01). Patients` critical duration estimates for either paradigm were not significantly different from CTRL. CONCLUSIONS. The significant reduction of CS in both paradigms is consistent with losses of CS in both M and P pathways. The CS losses were not accompanied by losses in temporal processing speed in either diabetic group. Significant CS loss in the group without retinopathy reinforces the notion that neural changes associated with the cellular and functional visual loss may play an important role in the etiology of diabetic visual impairment. In addition, the results show that the SP/PP paradigm provides an additional tool for detection and characterization of the early functional damage due to diabetes. (Invest Ophthalmol Vis Sci. 2011; 52:1151-1155) DOI:10.1167/iovs.09-3705

Elektrophysiologische Untersuchungen am experimentellen Autoimmun-Glaukom-Modell

Das Glaukom ist eine der führenden Erblindungsursachen weltweit. Trotzdem ist die Pathogenese, die zur Degeneration der retinalen Ganglienzellen führt, bisher nicht verstanden. In den letzten Jahren ergaben sich verschiedene Hinweise auf die Beteiligung einer immunologischen Komponente. Thema dieser Arbeit waren elektrophysiologische Untersuchungen, im Sinne von visuell evozierten Potentialen, am Tiermodell des Experimentellen Autoimmun Glaukoms und die Etablierung dieses Modells. Das Modell basiert auf einer Immunisierung von Lewisratten mit Pertussistoxin, inkompletten Freunds Adjuvant und potentiellen Antigenen, die zu einer Immunreaktion und einem Verlust von retinalen Ganglienzellen führen sollen. Zur Etablierung des Experimentellen Autoimmun Glaukom Modells wurde eine fünfwöchige Studie mit vier Gruppen durchgeführt. Als Antigene wurden Glia fibrilläres saures Protein (n= 10) und Myelin basisches Protein (n=10) verwendet, die beide in Studien zu Serum- und Kammerwasseranalysen bei Glaukompatienten eine Abweichung zur Kontrollgruppe gezeigt hatten. Außerdem wurde eine Gruppe mit selbst hergestelltem Sehnerv-Homogenat (n=12) immunisiert. Eine Gruppe erhielt keine Immunisierung und diente als Kontrolle (n=10). Zur Überprüfung der Effekte des Modells dienten verschiedene Untersuchungsmethoden, wie die Augeninnendruckmessung und die Untersuchung der Fundi. Des Weiteren wurden transiente und stationäre visuell evozierte Potentiale abgeleitet und die Latenzen, Amplituden und die Marker S (Steigung) und TR (Temporale Antworten) verglichen. Außerdem erfolgte nach Tötung der Tiere die Entnahme der Gehirne und Augen. Die Gehirne wurden nach Paraffineinbettung geschnitten, mit Luxol Fast Blue und Kresylviolett gefärbt und hinsichtlich etwaiger Entmarkungsherde oder anderer Pathologien unter dem Mikroskop bewertet. Der Verlauf des intraokulären Drucks zeigte sowohl zwischen den Gruppen als auch zwischen den verschiedenen Zeitpunkten keine signifikanten Unterschiede. Er bewegte sich im physiologischen Bereich mit durchschnittlich circa 12 mmHg. Die Funduskopien lieferten zu keinem Zeitpunkt krankhafte Veränderungen. Auch die visuell evozierten Potentiale lieferten zwischen den Gruppen keine signifikanten Unterschiede, sondern belegten normale visuelle Funktion bei allen Tieren. Die Auswertung der histologischen Untersuchung der Hirnschnitte zeigte keine Entmarkungsherde. Die erzielten Ergebnisse dieser Arbeit legen nahe, dass der retinale Ganglienzellverlust beim Experimentellen Autoimmun Glaukom Modell ohne eine Augeninnendruckerhöhung stattfindet. Die Fundusuntersuchung und die visuell evozierten Potentiale, wie in diesem Versuchsaufbau durchgeführt, scheinen nicht sensibel genug zu sein, diese Verluste nachzuweisen. In weiteren Arbeiten sollten andere Methoden zum Nachweis der retinalen Ganglienzellverluste erprobt werden. Neben elektrophysiologischen Methoden bieten sich für das weitere Vorgehen besonders immunhistologische Methoden an. Außerdem sollten die Mechanismen erforscht werden durch die es nach der Immunisierung zur Apoptose von retinalen Ganglienzellen kommt und welche Antikörper dazuführen können. Des Weiteren ist von Interesse, ob und wie eine zelluläre Komponente an der Pathogenese des Experimentellen Autoimmun Glaukoms beteiligt ist.

Stem cell-based therapeutic applications in retinal degenerative diseases

Retinal degenerative diseases that target photoreceptors or the adjacent retinal pigment epithelium (RPE) affect millions of people worldwide. Retinal degeneration (RD) is found in many different forms of retinal diseases including retinitis pigmentosa (RP), age-related macular degeneration (AMD), diabetic retinopathy, cataracts, and glaucoma. Effective treatment for retinal degeneration has been widely investigated. Gene-replacement therapy has been shown to improve visual function in inherited retinal disease. However, this treatment was less effective with advanced disease. Stem cell-based therapy is being pursued as a potential alternative approach in the treatment of retinal degenerative diseases. In this review, we will focus on stem cell-based therapies in the pipeline and summarize progress in treatment of retinal degenerative disease.

Retinitis and optic neuritis in a child with chickenpox: case report and review of literature

In immunocompetent individuals, necrotizing retinopathy is a rare complication of chickenpox. Herein, we report on a 3-year-old immunocompetent boy who developed retinitis and optic neuritis 3 days after the onset of chickenpox and compare the findings to published cases. Since macula and optic nerve were affected, visual acuity remained poor. An early diagnosis and treatment of ocular manifestations in chickenpox is imperative for the preservation of a residual visual function and prevention of blinding secondary complications.

Adjuvant or radical fractionated stereotactic radiotherapy for patients with pituitary functional and nonfunctional macroadenoma

Purpose To evaluate the efficacy and toxicity of stereotactic fractionated radiotherapy (SFRT) for patients with pituitary macroadenoma (PMA). Methods and Materials Between March 2000 and March 2009, 27 patients (male to female ratio, 1.25) with PMA underwent SFRT (median dose, 50.4 Gy). Mean age of the patients was 56.5 years (range, 20.3 - 77.4). In all but one patient, SFRT was administered for salvage treatment after surgical resection (transphenoidal resection in 23, transphenoidal resection followed by craniotomy in 2 and multiple transphenoidal resections in another patient). In 10 (37%) patients, the PMAs were functional (3 ACTH-secreting, 3 prolactinomas, 2 growth hormone-secreting and 2 multiple hormone-secretion). Three (11.1%) and 9 (33.3%) patients had PMA abutting and compressing the optic chiasm, respectively. Mean tumor volume was 2.9 ± 4.6 cm3. Eighteen (66.7%) patients had hypopituitarism prior to SFRT. The mean follow-up period after SFRT was 72.4 ± 37.2 months. Results Tumor size decreased for 6 (22.2%) patients and remained unchanged for 19 (70.4%) other patients. Two (7.4%) patients had tumor growth inside the prescribed treatment volume. The estimated 5-year tumor growth control was 95.5% after SFRT. Biochemical remission occurred in 3 (30%) patients with functional PMA. Two patients with normal anterior pituitary function before SFRT developed new deficits 25 and 65 months after treatment. The 5-year survival without new anterior pituitary deficit was thus 95.8%. Five patients with visual field defect had improved visual function and 1 patient with no visual defect prior to SFRT, but an optic chiasm abutting tumor, had a decline in visual function. The estimated 5-year vision and pituitary function preservation rates were 93.2% and 95.8%, respectively. Conclusions SFRT is a safe and effective treatment for patients with PMA, although longer follow-up is needed to evaluate long-term outcomes. In this study, approximately 1 patient with visual field defect out of two had an improved visual function.