Retinitis Proliferans Research Articles

Rapid, bloody, and blinding diabetic retinopathy

Rapid, bloody, and blinding diabetic retinopathy

A long-term follow-up of Eales’ disease

Purpose: To provide long-term follow-up information on Eales’ patients. Methods: Eales’ patients, who had been examined at varying periods between the years 1970 and 1991 with a minimum five-year follow-up, were included in the study. Results: A total of 130 patients were followed up for a minimum of five and a maximum of 26.5 years. The retinal lesions found during the first examination included vascular sheathing, disc and/or retinal neovascularization, vitreous hemorrhage, branch retinal vein occlusion, retinitis proliferans, and retinal detachment. Visual acuity improved in 37 (20%) of the 185 treated eyes, was maintained in 79 (43%), and worsened in 69 (37%). The complications were tractional detachment, cataract, rubeosis iridis, neovascular glaucoma, and phthisis bulbi. Conclusion: The most important elements in dealing with Eales’ disease are periodic follow-up, a good and adequate laser treatment, pars plana vitrectomy combined with procedures for nonclearing vitreous hemorrhage, and retinal vasoproliferative changes to stabilize the retinal lesions and maintain functional levels of vision.

EALES DISEASE: Medical, Laser, and Surgical Treatments

Eales disease is an idiopathic retinal vasculitis that affects predominantly young men. The major manifestations of Eales disease are the inflammation of retinal veins with or without arteritis papillitis anterior posterior uveitis or pars planitis. The prognosis usually depends on the degree of vitreous macular circulatory failure proliferative retinopathy. The involvement is mostly bilateral at the peripheral retina. The fundus lesions that can be observed vary among retinal neovascularization (fig.1) vascular sheathing (fig.2) retinal vitreous hemorrhage retinitis proliferans (fig.3) disc neovascularization (fig.4) branch central retinal vein occlusion tractional retinal etachment rubeosis iridis neovascular glaucoma. In addition to these lesions the engorged tortous retinal veins leakage from these veins macular retinal edema shunt vessels hypoxic areas microaneurysms (fig. 5) can be seen more easily with fluorescein angiography.

Visualization of retinal vasculitis in Eales' disease

Between 1970 and 1991 the authors examined 466 patients with Eales' disease. The mean age at diagnosis was 30, ranging between 14 and 55 years. The mean follow-up period was 43.5 months. At the initial examination, 356 cases were bilateral and 110 cases were unilateral (822 eyes). Vitreous hemorrhage was present in 257 of the 822 eyes. In the remaining 565 eyes, the major retinal lesions were retinal neovascularization (40.7%), vascular sheathing (20.7%), vascular sheathing and retinal hemorrhages (10.6%), retinitis proliferans (9.4%), disc neovascularization (9.0%), branch vein occlusion (3.2%), tractional retinal detachment (2.4%), central vein occlusion (1.8%), central vascular sheathing (1.1%), obliterated vessels (1.1%). Forty-nine out of the 110 initially unilateral cases eventually developed bilateral involvement after a mean period of 42 months. The percentage of eyes with a vision of 0.1 and better rose from 68.1% in the initial examination to 77.9% in the final examination. Fluorescein angiograms of the affected eyes show dye leakage with retinal staining, microaneurysms, capillary non-perfusion and neovascularization. Fundus changes are characteristic of Eales' disease. Unilateral cases should be closely followed because of the risk of involvement of the other eye. Fluorescein angiography is a requirement for early identification of vascular changes and for proper follow-up in Eales' disease.

Long-term follow-up of patients who underwent yttrium-90 pituitary implantation for treatment of proliferative diabetic retinopathy

Between 1960 and 1976 117 patients underwent pituitary implantation with yttrium-90 (90Y) for treatment of proliferative retinopathy at the Hammersmith Hospital, London. Mean age at operation was 35 +/- 11 years (mean +/- SD), and mean duration of diabetes 18.6 +/- 10.0 years. Mean insulin dosage prior to implant was 67.2 +/- 24 units, falling to 30.4 +/- 14.9 units post-implant. Thirty-two per cent of patients are still living, 60% are deceased and 8% are lost to follow-up. The 5-year survival rate was 82%. Of the causes of death, 21% died of infection, adrenal insufficiency or hypoglycaemia, 12% of renal failure, and 47% of myocardial or cerebral vascular disease. Ophthalmological follow-up was carried out on the 100 patients operated on between 1965 and 1976. The mean age of this group at implant was 35 +/- 10.5 years, and mean duration of diabetes 17.2 +/- 8.7 years. Visual acuity in the better eye at operation was 6/12 or better in 84% of patients, and this percentage remained similar at the time of the 5 and 10 year follow-up. Blindness (6/60 or worse) in both eyes was present in 12% of patients at the time of 5 and 10 year assessments. By 5 years new vessels on the disc had improved from a mean grading of 2.7 +/- 1.6 to 0.8 +/- 1.2 (p less than 0.001), and by 10 years there was no disc neovascularisation in any eye. There was a similar improvement in the grading of hard exudates, microaneurysms and haemorrhages, but there was an increase in fibrous retinitis proliferans.(ABSTRACT TRUNCATED AT 250 WORDS)

Pan-fundus photocoagulation (PRP)--prognostic aspects

Retinitis proliferans in the diabetic that can not be prevented by PRP can be attributed to insufficient treatment. Examination by means of fundus microscopy, stereochronoscopy of the macula, and computerized perimetry are of prognostic value. Increased PRP should be performed prior to any decision for vitrectomy.

Retinopathy in tropical pancreatic diabetes.

In a study of the retinopathy profile of 40 patients with tropical pancreatic diabetes, a form of secondary diabetes seen in tropical countries, diabetic retinopathy was detected in 13 patients. Ten patients had background retinopathy and three patients had proliferative retinopathy requiring laser photocoagulation. In two patients, fibrous retinitis proliferans was present. Three patients had evidence of diabetic maculopathy. To our knowledge, this is the first report of severe and sight-threatening retinopathy occurring with secondary diabetes. Retinopathy in these forms of diabetes has hitherto been considered to be rare or, if present, only of a mild background type.

Diabetic Choroidopathy: Light and Electron Microscopic Observations of Seven Cases

The choroid of seven young patients (ages 20–29 years), who had had diabetes mellitus for many years (14–23 years) was studied by light and electron microscopy. The eight enucleated eyes were blind and painful as a complication of diabetes mellitus. Histopathologically, the choriocapillaris and other small choroidal blood vessels disclosed marked basement membrane thickening of their walls. Periodic acid-Schiff-positive homogeneous acellular nodules were present and resembled those of diabetic glomerulosclerosis (Kimmelsteil-Wilson disease). Some choroidal arteries were arteriosclerotic. Choroidal compromise was suggested by luminal narrowing of the capillaries, capillary dropout, and focal scarring. Choroidal neovascularization with subretinal fibrovascular membranes occurred in two patients at the midperiphery and periphery, and resembled those of retinitis proliferans. Leakage of proteinaceous fluid into the choroidal stroma and beneath the focally detached pigment epithelium was suggested by the electron microscopic observations. Choroidal vasculopathy in diabetes mellitus is similar to much of what has been described in other tissues of the eye and body, and suggests an important role in the pathogenesis of diabetic retinopathy since the outer retinal layers are largely dependent on the choroid for their nutrition and oxygenation.

Diabetic Retinopathy and Pregnancy

CASSAR, J.; KOHNER, EVA M.; HAMILTON, A. M.; GORDON, H.; JOPLIN, G. F. Author Information

Diabetic Retinopathy and Pregnancy

Diabetic retinopathy was found to be present in 12 out of a group of 67 diabetic patients supervised by us during 92 pregnancies, and 3 further pregnant diabetics were referred to us because of retinopathy. The mean duration of diabetes was 13 years (range 3–25 years). Nine patients had minimal retinopathy, 2 had background retinopathy, and the remaining 4 proliferative retinopathy. The cases with minimal retinopathy showed no progression during pregnancy. In 1 patient with background retinopathy there was deterioration. Of the 4 patients with proliferative retinopathy 1 showed regression during the pregnancy, 2 showed advance and were treated with photocoagulation (these 2 patients now have normal vision), while the patient with extensive retinitis proliferans, with retinal detachment in both eyes and previous photocoagulation remained unchanged. The prognosis during pregnancy for patients with diabetic retinopathy is reasonable and has been improved by the advent of photocoagulation.

Diabetic retinopathy and pregnancy.

Diabetic retinopathy was found to be present in 12 out of a group of 67 diabetic patients supervised by us during 92 pregnancies, and 3 further pregnant diabetics were referred to us because of retinopathy. The mean duration of diabetes was 13 years (range 3--25 years). Nine patients had minimal retinopathy, 2 had background retinopathy, and the remaining 4 proliferative retinopathy. The cases with minimal retinopathy showed no progression during pregnancy. In 1 patient with background retinopathy there was deterioration. Of the 4 patients with proliferative retinopathy 1 showed regression during the pregnancy, 2 showed advance and were treated with photocoagulation (these 2 patients now have normal vision), while the patient with extensive retinitis proliferans, with retinal detachment in both eyes and previous photocoagulation remained unchanged. The prognosis during pregnancy for patients with diabetic retinopathy is reasonable and has been improved by the advent of photocoagulation.

Interstitial gamma irradiation by 198Au of the pituitary in diabetic retinopathy

Pituitary interstitial irradiation by stereotaxic implantation of a gamma pointemitter was performed in 110 patients with progressing diabetic retinopathy. Reduction of growth hormone secretion peaks was delayed, but was consistent and selective in all cases controlled by somatotropin stimulation test, while other pituitary secretions remianed unchanged in all but five cases. In 31 patients who had no associated photocoagulation, long-term postoperative assessment showed significant improvement of hemorrhages and intrarentinal new vessels with preservation of visual acuity. Preretinal vascular proliferation (except when treatable by photocoagulation), extensive retinitis proliferans, and macular deterioration are contraindications. This technique represents a new approach in the functional pituitary neurosurgical treatment of diabetic retinopathy and differs from all other procedures that result in a more or less complete hypophysectomy.

Ocular findings of elderly cases of homozygous sickle-cell disease in Jamaica.

The ocular fingings in 60 patients with homozygous sickle-cell disease over the age of 40 years have been described. Peripheral retinal vessel disease was common and appeared to increase with age. Retinitis proliferans was common among older patients in the group. Angioid streaks occurred in 13 (22 per cent) patients.

Ocular findings in children with sickle cell haemoglobin C disease in Jamaica.

The development of severe retinal vascular disease and retinitis proliferans in sickle cell haemoglobin C disease (SC disease) is well recognized (Welch and Goldberg, I966; Goldberg, 197I; Condon and Serjeant, I972a). In a recent survey in Jamaica, Condon and Serjeant (1972a) noted retinitis proliferans in 23 (33 per cent.) of seventy adults with SC disease. The changes were found in some patients as early as 15 years of age. The present study was designed to observe the pattern of retinal vessel pathology in children with SC disease before this age.

Non-oxygen induced retinitis proliferans and retinal detachment in full-term infants.

Non-oxygen induced retinitis proliferans and retinal detachment in full-term infants.

Placental glycogen metabolism in diabetes mellitus.

Carbohydrate metabolism may be markedly altered in the pregnant patient with diabetes mellitus. How such changes in maternal physiology affect the placenta, a tissue of fetal origin, has been studied by measuring glycogen synthetase, glycogen phosphorylase, and glycogen concentrations in fresh term placental tissue from eight normal women delivered vaginally, eight normal patients delivered by repeat cesarean section, and fifteen patients with diabetes mellitus. Placental weights were also determined. Placentas of normal patients, whether delivered vaginally or by cesarean section, were extremely similar in all parameters studied. In contrast, the glycogen concentration in placentas from diabetic patients was significantly elevated (p < .001) although glycogenesis appeared limited by decreased levels (p < .01) of synthetase I. Phosphorylase a activity was increased significantly (p < .025) in placental tissue of diabetic patients as was total phosphorylase (p < .05). Placental weight was decreased in patients with retini-tis proliferans. These placental enzyme differences noted between the normal and diabetic patient suggest that insulin may play an important role in controlling glycogen metabolism in the human placenta. In diabetes mellitus, increased glycogen concentrations of the placenta may be due to prolonged hyperglycemia throughout gestation and that the elevated term placental glycogen may be responsible for the observed suppressed synthetase I formation and the stimulated phosphorylase a activity found in the diabetic term placenta.

Diabetic retinopathy: new vessels arising from the optic disc. I. Grading system and natural history.

1. A grading method for new vessels arising from the optic disc is described. The grading system has been used to study the natural history of new vessels in forty-four eyes of thirty diabetic patients. 2. While some eyes showed considerable changes, the mean progression of new vessels in the entire group was slight and only reached one grade in four years. 3. The most striking feature of the study was the number of eyes which could not be fully assessed at different times during the follow-up period. Eyes became unassessable because of vitreous hemorrhage or retinitis proliferans. These increased from 18 per cent at six months to 66 per cent at four years. Both of these were more common when higher grading values of new vessels were reached. 4. The visual acuity deteriorated in twenty-five eyes. In nineteen of the eyes the deterioration was three lines or more; fifteen eyes became blind. The commonest cause for visual deterioration was vitreous hemorrhage.

Diabetic Retinopathy: New Vessels Arising from the Optic Disc: II. Response to Pituitary Ablation by Yttrium 90 Implant

The response of new vessels arising from the optic disc to pituitary ablation was studied in sixty-six eyes of forty-five patients over six months to four years. The response was related to the extent of pituitary ablation graded as complete, intermediate or slight from endocrine tests done three months post-implant. Following complete ablation there was a significant improvement in new vessels. A similar trend (but not significant values) was observed in partially ablated patients, while those with slight ablation showed no change. Retinitis proliferans deteriorated in all groups, but least in those with complete and most in those with slight ablation. The mean visual acuity in the completely ablated group did not change, while it deteriorated significantly in the slight ablation category. Patients under forty years of age at the time of the operation benefited more than those over forty. It is concluded that new vessels on the disc respond to complete and intermediate pituitary ablation, complete ablation being superior in its effectiveness.

Fluorescein Angiography in Eales' Disease

The cause of retinal vasculature periphlebitis is not known, but probably constitutes a local manifestation of a systemic or general­ ized disease; inflammatory, vascular, endo­ crine and hematologie disorders have been suggested as factors in its pathogenicity. Initially, vascular periphlebitis is charac­ terized by a slight localized peripheral edema of the retina which, at first, may involve only the small vascular branches of the pe­ riphery of the retina, but later spreads to in­ volvement of the larger veins. The next stage of the disease is characterized by new vessel formation and hemorrhage, mainly as the result of thrombosis and rupture of the affected retinal veins. These new vessels' are at first thin and capillary-like. Later, they increase to form bundles and plexuses of various shape under the posterior surface of the vitreous cavity. When these penetrate into the vitreous body, the result is retinitis proliferans, the final stage of the disease. In this stage, retinal detachment may occur sec­ ondary to the traction which is exercized by these pathologic elements.

Pituitary ablation, insulin dosage, and course of diabetic retinopathy

Vision and visual acuity have remained stable or improved during 7 to 93 months following hypophysectomy or stalk section in some 88 per cent of individuals with vision-threatening diabetic retinopathy. Preservation of vision and visual acuity was generally accompanied by decreases in or regression of neovascularization and massive hemorrhages; however, in three neovascularization and massive hemorrhages have persisted despite apparently complete pituitary ablation. Retinitis proliferans of the gliosis type did not disappear in any of the patients in whom this change was present pre-operatively. Failure to observe a post-operative reduction of insulin dosage did not mean that vision would not be benefited. The serum PBI and thyroidal I 131 uptake did decline, urinary 17-ketosteroids decreased, and other indices of hypopituitarism appeared following pituitary ablation in each of the patients in whom insulin dosage did not decrease. This suggests that failure to observe a lessened insulin requirement can be attributed to increased intensity of the diabetes or to more precise regulation. During maintenance on three grains of desiccated thyroid and 20 mgm of hydrocortisone daily, the serum PBI, plasma free 11 (OH) corticoids, and urinary Porter-Silber chromogens were largely or entirely within the pre-operative range. Urinary 17-ketosteroids were below the values recorded prior to pituitary surgery. Cyclic estrogen or estrogen-progestin therapy induced with-drawal bleeding in pre-menopausal women. In the males human chorionic gonadotropin or testosterone derivatives were almost uniformly without effect in reversing the post-operative decline or loss of potentia and sexual activity, but in some of them the latter was already decreased prior to surgery. Following pituitary surgery creatinine clearance decreased by 20 ml./min. in ten patients, remained unchanged in seven and increased in three out of a total of 20 patients. In those with normal blood pressure pre-operatively the readings generally remained unchanged, though persistent hypertension did develop later in four out of 23. Hypertension present prior to operation disappeared after surgery in only one out of six patients. To date we have no evidence that super-voltage X-ray irradiation of the pituitary (7,000 to 10,000 r) reduces pituitary function or affects the course of diabetic retinopathy.