genesis of RPE tears. Retinal pigment epithelium tears must be included as a possible complication of angioid streaks.
Jennifer I. Lim, MD Sheridan Lam, MD Chicago, Ill This study was supported by core grant EY1792 and training grant EY7098 from the National Eye Institute, and an unrestricted research grant from Research to Prevent Blindness Inc, New York, NY. Reprint requests to The Johns Hopkins Hospital, The Wilmer Institute, 600 N Wolfe St, Maumenee Bldg, Baltimore, MD 21205 (Dr Lim).
Pathogenesis of tears of the retpigment epithelium. Br J Ophthalmol.
1. Gass JDM.
inal
1984;68:513-519. 2. Lim JI, Blair NP, Liu SJ. Retinal pigment epithelium tear in diabetic patient with exudative retinal detachment following panretinal photocoagulation and filtration surgery. Arch Ophthalmol. 1990;109:173-174. 3. Swanson DE, Kalina RE, Guzak SV. Tears of the retinal pigment epithelium: occurrence in retinal detachments and a chorioretinal scar. Retina. 1984;4:115-118. 4. Clarkson JG, Altman RD. Angioid streaks. Surv Ophthalmol. 1982;26:235-246.
Papilledema in a Patient Aplastic Anemia
With
Papilledema is an uncommon complication of severe anemia. Among patients with this
association, the anemia usual-
ly is related describe
sulting
deficiency. We with papilledema reidiopathic aplastic
to iron
child from
a
anemia.
Report of a Case. \p=m-\An8-year-old girl was admitted to the hospital with a 4-week history of easy bruising and exertion-related headaches. She had been in excellent health, and her only ocular problems were Fundus
photographs showing
Left, Right eye; right, left eye.
hyperopia and accommodative esotropia. Results of her general physical examination were remarkable for skin pallor, scattered bruises and petechiae, a grade 3 systolic murmur, and tachycardia. Blood pressure was normal. The patient was afebrile and had no neurologic deficits. Ophthalmologic examination revealed a visual acuity of 20/20 OU with full visual fields and normal color perception. The pupils reacted briskly to light exposure and there was no afferent pupillary defect. With spectacle correction, the patient's eyes were aligned. The range of eye movements
full. Fundus examination revealed pronounced optic disc swelling in both eyes associated with large flame-shaped and blot hemorrhages in a peripapillary distribution (Figure). The retinal veins were moderate¬ ly engorged and tortuous. The maculae were unremarkable. Laboratory studies disclosed pancytopenia, with a hemoglobin level of 42 g/L, white blood cell count of 1.6xl06/L, and platelet count of 1.0xl09/L. Results of a bone marrow biopsy revealed 5% to 10% cellularity and no malignant cells, consis¬ tent with severe aplasia. Results of com¬ puted tomography of the brain were normal. The patient received multiple blood and platelet transfusions and was treated with antithymocyte globulin. Improvement in hématologie parameters was evident within 3 months, and transfusions were no longer required after 5 months. Follow-up exami¬ nations revealed visual acuity of 20/20 OU, full visual fields, and resolution of disc was
swelling.
Comment. —Aplastic anemia is char¬ acterized by pancytopenia and hypoplastic or aplastic bone marrow. The term idiopathic is applied to cases that are not associated with toxic expo¬ sures, medications, radiation, or dis¬ eases capable of producing bone mar¬ row
suppression.
marked bilateral
The ocular manifestations of aplastic anemia include conjunctival pallor,
subconjunctival hemorrhage,
speculative. In our patient, the concurrence of bilateral acute optic disc swelling and
normal visual parameters indicated that the swelling represented papille¬ dema. Although previous reports have suggested that papilledema in patients with aplastic anemia may be secondary to intracranial hemorrhage, results of computed tomography in this case
optic disc swelling and multiple flame-shaped peripapillary hemorrhages.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/14/2015
cotton¬
wool spots, and both retinal and preretinal hemorrhage. Hyphema occurs rarely. The first report of optic disc swelling associated with aplastic ane¬ mia dates back to the original descrip¬ tion of the disease by Ehrlich in 1888. ' His patient was noted to have swelling of both optic nerves. In 1966, two fundus photographs of eyes with optic disc swelling appeared in a discussion of aplastic anemia by Massa et al,2 and a similar photograph is included in the 1974 review of ocular manifestations by Haye et al.3 More recently, Wang et al4 reported on the fundus findings in 120 cases of aplastic anemia. They observed unequivocal optic disc swell¬ ing in 10 patients, nine of whom had hemoglobin levels less than 40 g/L. Blurred disc margins were noted in an additional 34 patients. We are unaware of any reports in the English literature of optic disc swelling associated with idiopathic aplastic anemia. Further¬ more, the references cited above pro¬ vide no information about visual func¬ tion, and apart from Ehrlich's report, there is no indication as to whether disc swelling was unilateral or bilater¬ al. Consequently, the mechanisms of disc swelling in these cases remain
normal. In
addition, there were signs of meningitis. We believe that our patient had pseudotumor cerebri secondary to severe anemia. As is typical of such cases, the papilledema resolved with correction were
no
symptoms
Thiabendazole and 5-Hydroxythiabendazole Concentrations After Oral Administration*
or
of the anemia. Eileen R. Lilley, MD Carol S. Bruggers, MD Stephen C. Pollock, MD Durham, NC Reprint requests to Duke University Eye Cen-
ter, Box 3802, Durham, NC 27710 (Dr Pollock).
1. Ehrlich P. Ueber einen Fall von Anamie mit
uber regenerative Veranderungen des Knochenmarks. Charite-Ann. 1888;13:300-309. 2. Massa JM, de Vloo N, Jamotton L. Les manifestations oculaires des hemopathies. Bull Soc
Bemerkungen
Beige Ophtalmol. 1966;142:72-78. 3. Haye C, Bernard J, Dufier JL, Guyot-Sionnest M. Les manifestations ophtalmologiques de l'aplasie medullaire aigue idiopathique. Arch Oph-
talmol (Paris). 1974;34:793-799. 4. Wang XJ, Chang WM, Lee HL, Chang RF, Xu YZ. Fundus changes in 120 cases of aplastic anemia. Chung-Hua Yen Ko Tsa Chih. 1985;21: 344-346.
Ocular Penetration of Thiabendazole
Ocular Toxocara canis infection may cause decreased vision owing to direct retinal injury by the Toxocara organism or by secondary effects related to inflammation and scarring. Several treatment modalities for ocular toxocariasis have been advocated, including systemic antiparasitic medications, photocoagulation, and vitreous surgery. Although the T canis larva is sensitive to thiabendazole (Mintezol), as used in the treatment of visceral larva migrans, it is not known whether this drug crosses the blood-ocular barrier.1
Report of a Case.\p=m-\A7-year-old boy presented with painless loss of vision in the right eye, noted during routine visual screening. Visual acuity was 20/400 OD, 20/20 OS. Ophthalmic examination of the left eye showed it to be normal. Slit-lamp examination of the right eye revealed an uninflamed anterior segment and 1+ anterior vitreous cell. Funduscopic examination showed a large granuloma at the ora ser-
Control
Source Serum
Patient
(Background Fluorescence), mg/L
(90
min after 25
mg/kg),
mg/L
Thiabendazole 5-Hydroxythiabendazole Thiabendazole 5-Hydroxythiabendazole 0.17
0.03
7.0-9.4
9.3-12.3
Aqueous_0.32_0.23_0.59_0SÌ_ Vitreous *
Levels of
0.21
0.32
0.62
1.08
5-hydroxythiabendazole include sulfate and glucuronide conjugates of thiabendazole.
rata from the 6- to 9-o'clock meridian. Several vitreous snowballs were present adjacent to the granuloma. Vitreous bands ex¬ tended from the granuloma to the inferotemporal arcade. An epiretinal mem¬ brane was present in the macular area, causing moderate retinal distortion. History revealed that the patient had re¬ cently suffered a flulike illness. The patient admitted to pica and recent exposure to a litter of puppies. Laboratory tests showed an elevated white blood cell count of 14.6 X 10VL, with 0.10 eosinophils. Toxo¬ cara IgG enzyme-linked immunosorbent assay was positive at 1:128. A diagnosis of ocular toxocariasis was made. The patient underwent pars plana vitrectomy for epiretinal membrane removal. Ninety minutes prior to surgery, 500 mg (25 mg/kg) of thiabendazole was adminis¬ tered orally. Prior to infusion, a diagnostic vitrectomy was performed, with removal of approximately 2.5 mL of material. The vit¬ reous appeared clear and without heme. An anterior chamber paracentesis was then performed, with removal of 0.12 mL of aqueous. Venous blood was obtained and the serum separated by centrifugation. All samples were immediately frozen and stored at —70°C. Control samples of vitre¬ ous, aqueous, and serum were obtained in a similar manner during vitrectomy for a di¬ abetic traction retinal detachment.
Spectrophotofluorometric assays were performed by one of the authors (J.J.) for available thiabendazole and for the pri¬ mary inactive metabolites of thiabenda¬
zole: 5-hydroxythiabendazole as well as its sulfate and glucuronide conjugates (Table). Thiabendazole and metabolite assays have not been validated specifically for aqueous or vitreous. Therefore, these values can be interpreted only as reasonable estimates.
Comment.—These results are con¬ sistent with those of Arroyo and
Coming Next Month
.
.
Brown,2 who measured larvicidal con¬ centrations of thiabendazole in the cerebrospinal fluid several hours after oral administration of comparable doses of thiabendazole (23 mg/kg). The higher serum concentrations of thi¬ abendazole measured in our patient probably reflect sampling differences, as we obtained serum much sooner af¬ ter drug administration and, there¬ fore, closer to the peak level. Esti¬ mated concentrations of thiabenda¬ zole in vitreous specimens from our patient are within the range of in vitro antiparasitic activity for most helminths.3 We conclude that system¬ ically administered thiabendazole can enter the aqueous and vitreous of a minimally inflamed eye. These results suggest that systemically adminis¬ tered thiabendazole might be useful in the treatment of some intraocular par¬ asitic infections. Albert M. Maguire, MD Marco A. Zarbin, MD, PhD Thomas B. Connor, MD Baltimore, Md Josh Justin Rahway, NJ The authors have no proprietary interest in the sale or production of thiabendazole. 1. Sorr EM. Meandering ocular toxocariasis. Retina. 1984;4:90-96. 2. Arroyo JC, Brown A. Concentrations of thiabendazole and parasite-specific IgG in the cerebrospinal fluid of a patient with disseminated strongyloidiasis. J Infect Dis. 1987;156:520-523. 3. Andrews P, Haberkorn A, Thomas H. Antiparasitic drugs: mechanisms of action, pharmacokinetics, and in vivo and in vitro assays of drug activity. In: Lorian V, ed. Antibiotics in Laboratory Medicine. 2nd ed. Baltimore, Md: Williams &
Wilkins; 1986:282-345.
.
Beginning in January 1991, the Archives gets a fresh new look. We've redesigned the cover to give it a more contemporary, less cluttered appearance. An expanded table of contents will feature an improved format and larger, more readable type to make it easier to find major articles. Later in the year we will introduce further state-of-the-art electronic layout system.
graphic improvements
as we
convert to
a
Our goal is to continue to bring you the highest-quality, peer-reviewed scientific informa¬ tion while making it more attractive and easier to read. We hope you'll approve.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/14/2015
Jennifer I. Lim, MD Sheridan Lam, MD Chicago, Ill This study was supported by core grant EY1792 and training grant EY7098 from the National Eye Institute, and an unrestricted research grant from Research to Prevent Blindness Inc, New York, NY. Reprint requests to The Johns Hopkins Hospital, The Wilmer Institute, 600 N Wolfe St, Maumenee Bldg, Baltimore, MD 21205 (Dr Lim).
Pathogenesis of tears of the retpigment epithelium. Br J Ophthalmol.
1. Gass JDM.
inal
1984;68:513-519. 2. Lim JI, Blair NP, Liu SJ. Retinal pigment epithelium tear in diabetic patient with exudative retinal detachment following panretinal photocoagulation and filtration surgery. Arch Ophthalmol. 1990;109:173-174. 3. Swanson DE, Kalina RE, Guzak SV. Tears of the retinal pigment epithelium: occurrence in retinal detachments and a chorioretinal scar. Retina. 1984;4:115-118. 4. Clarkson JG, Altman RD. Angioid streaks. Surv Ophthalmol. 1982;26:235-246.
Papilledema in a Patient Aplastic Anemia
With
Papilledema is an uncommon complication of severe anemia. Among patients with this
association, the anemia usual-
ly is related describe
sulting
deficiency. We with papilledema reidiopathic aplastic
to iron
child from
a
anemia.
Report of a Case. \p=m-\An8-year-old girl was admitted to the hospital with a 4-week history of easy bruising and exertion-related headaches. She had been in excellent health, and her only ocular problems were Fundus
photographs showing
Left, Right eye; right, left eye.
hyperopia and accommodative esotropia. Results of her general physical examination were remarkable for skin pallor, scattered bruises and petechiae, a grade 3 systolic murmur, and tachycardia. Blood pressure was normal. The patient was afebrile and had no neurologic deficits. Ophthalmologic examination revealed a visual acuity of 20/20 OU with full visual fields and normal color perception. The pupils reacted briskly to light exposure and there was no afferent pupillary defect. With spectacle correction, the patient's eyes were aligned. The range of eye movements
full. Fundus examination revealed pronounced optic disc swelling in both eyes associated with large flame-shaped and blot hemorrhages in a peripapillary distribution (Figure). The retinal veins were moderate¬ ly engorged and tortuous. The maculae were unremarkable. Laboratory studies disclosed pancytopenia, with a hemoglobin level of 42 g/L, white blood cell count of 1.6xl06/L, and platelet count of 1.0xl09/L. Results of a bone marrow biopsy revealed 5% to 10% cellularity and no malignant cells, consis¬ tent with severe aplasia. Results of com¬ puted tomography of the brain were normal. The patient received multiple blood and platelet transfusions and was treated with antithymocyte globulin. Improvement in hématologie parameters was evident within 3 months, and transfusions were no longer required after 5 months. Follow-up exami¬ nations revealed visual acuity of 20/20 OU, full visual fields, and resolution of disc was
swelling.
Comment. —Aplastic anemia is char¬ acterized by pancytopenia and hypoplastic or aplastic bone marrow. The term idiopathic is applied to cases that are not associated with toxic expo¬ sures, medications, radiation, or dis¬ eases capable of producing bone mar¬ row
suppression.
marked bilateral
The ocular manifestations of aplastic anemia include conjunctival pallor,
subconjunctival hemorrhage,
speculative. In our patient, the concurrence of bilateral acute optic disc swelling and
normal visual parameters indicated that the swelling represented papille¬ dema. Although previous reports have suggested that papilledema in patients with aplastic anemia may be secondary to intracranial hemorrhage, results of computed tomography in this case
optic disc swelling and multiple flame-shaped peripapillary hemorrhages.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/14/2015
cotton¬
wool spots, and both retinal and preretinal hemorrhage. Hyphema occurs rarely. The first report of optic disc swelling associated with aplastic ane¬ mia dates back to the original descrip¬ tion of the disease by Ehrlich in 1888. ' His patient was noted to have swelling of both optic nerves. In 1966, two fundus photographs of eyes with optic disc swelling appeared in a discussion of aplastic anemia by Massa et al,2 and a similar photograph is included in the 1974 review of ocular manifestations by Haye et al.3 More recently, Wang et al4 reported on the fundus findings in 120 cases of aplastic anemia. They observed unequivocal optic disc swell¬ ing in 10 patients, nine of whom had hemoglobin levels less than 40 g/L. Blurred disc margins were noted in an additional 34 patients. We are unaware of any reports in the English literature of optic disc swelling associated with idiopathic aplastic anemia. Further¬ more, the references cited above pro¬ vide no information about visual func¬ tion, and apart from Ehrlich's report, there is no indication as to whether disc swelling was unilateral or bilater¬ al. Consequently, the mechanisms of disc swelling in these cases remain
normal. In
addition, there were signs of meningitis. We believe that our patient had pseudotumor cerebri secondary to severe anemia. As is typical of such cases, the papilledema resolved with correction were
no
symptoms
Thiabendazole and 5-Hydroxythiabendazole Concentrations After Oral Administration*
or
of the anemia. Eileen R. Lilley, MD Carol S. Bruggers, MD Stephen C. Pollock, MD Durham, NC Reprint requests to Duke University Eye Cen-
ter, Box 3802, Durham, NC 27710 (Dr Pollock).
1. Ehrlich P. Ueber einen Fall von Anamie mit
uber regenerative Veranderungen des Knochenmarks. Charite-Ann. 1888;13:300-309. 2. Massa JM, de Vloo N, Jamotton L. Les manifestations oculaires des hemopathies. Bull Soc
Bemerkungen
Beige Ophtalmol. 1966;142:72-78. 3. Haye C, Bernard J, Dufier JL, Guyot-Sionnest M. Les manifestations ophtalmologiques de l'aplasie medullaire aigue idiopathique. Arch Oph-
talmol (Paris). 1974;34:793-799. 4. Wang XJ, Chang WM, Lee HL, Chang RF, Xu YZ. Fundus changes in 120 cases of aplastic anemia. Chung-Hua Yen Ko Tsa Chih. 1985;21: 344-346.
Ocular Penetration of Thiabendazole
Ocular Toxocara canis infection may cause decreased vision owing to direct retinal injury by the Toxocara organism or by secondary effects related to inflammation and scarring. Several treatment modalities for ocular toxocariasis have been advocated, including systemic antiparasitic medications, photocoagulation, and vitreous surgery. Although the T canis larva is sensitive to thiabendazole (Mintezol), as used in the treatment of visceral larva migrans, it is not known whether this drug crosses the blood-ocular barrier.1
Report of a Case.\p=m-\A7-year-old boy presented with painless loss of vision in the right eye, noted during routine visual screening. Visual acuity was 20/400 OD, 20/20 OS. Ophthalmic examination of the left eye showed it to be normal. Slit-lamp examination of the right eye revealed an uninflamed anterior segment and 1+ anterior vitreous cell. Funduscopic examination showed a large granuloma at the ora ser-
Control
Source Serum
Patient
(Background Fluorescence), mg/L
(90
min after 25
mg/kg),
mg/L
Thiabendazole 5-Hydroxythiabendazole Thiabendazole 5-Hydroxythiabendazole 0.17
0.03
7.0-9.4
9.3-12.3
Aqueous_0.32_0.23_0.59_0SÌ_ Vitreous *
Levels of
0.21
0.32
0.62
1.08
5-hydroxythiabendazole include sulfate and glucuronide conjugates of thiabendazole.
rata from the 6- to 9-o'clock meridian. Several vitreous snowballs were present adjacent to the granuloma. Vitreous bands ex¬ tended from the granuloma to the inferotemporal arcade. An epiretinal mem¬ brane was present in the macular area, causing moderate retinal distortion. History revealed that the patient had re¬ cently suffered a flulike illness. The patient admitted to pica and recent exposure to a litter of puppies. Laboratory tests showed an elevated white blood cell count of 14.6 X 10VL, with 0.10 eosinophils. Toxo¬ cara IgG enzyme-linked immunosorbent assay was positive at 1:128. A diagnosis of ocular toxocariasis was made. The patient underwent pars plana vitrectomy for epiretinal membrane removal. Ninety minutes prior to surgery, 500 mg (25 mg/kg) of thiabendazole was adminis¬ tered orally. Prior to infusion, a diagnostic vitrectomy was performed, with removal of approximately 2.5 mL of material. The vit¬ reous appeared clear and without heme. An anterior chamber paracentesis was then performed, with removal of 0.12 mL of aqueous. Venous blood was obtained and the serum separated by centrifugation. All samples were immediately frozen and stored at —70°C. Control samples of vitre¬ ous, aqueous, and serum were obtained in a similar manner during vitrectomy for a di¬ abetic traction retinal detachment.
Spectrophotofluorometric assays were performed by one of the authors (J.J.) for available thiabendazole and for the pri¬ mary inactive metabolites of thiabenda¬
zole: 5-hydroxythiabendazole as well as its sulfate and glucuronide conjugates (Table). Thiabendazole and metabolite assays have not been validated specifically for aqueous or vitreous. Therefore, these values can be interpreted only as reasonable estimates.
Comment.—These results are con¬ sistent with those of Arroyo and
Coming Next Month
.
.
Brown,2 who measured larvicidal con¬ centrations of thiabendazole in the cerebrospinal fluid several hours after oral administration of comparable doses of thiabendazole (23 mg/kg). The higher serum concentrations of thi¬ abendazole measured in our patient probably reflect sampling differences, as we obtained serum much sooner af¬ ter drug administration and, there¬ fore, closer to the peak level. Esti¬ mated concentrations of thiabenda¬ zole in vitreous specimens from our patient are within the range of in vitro antiparasitic activity for most helminths.3 We conclude that system¬ ically administered thiabendazole can enter the aqueous and vitreous of a minimally inflamed eye. These results suggest that systemically adminis¬ tered thiabendazole might be useful in the treatment of some intraocular par¬ asitic infections. Albert M. Maguire, MD Marco A. Zarbin, MD, PhD Thomas B. Connor, MD Baltimore, Md Josh Justin Rahway, NJ The authors have no proprietary interest in the sale or production of thiabendazole. 1. Sorr EM. Meandering ocular toxocariasis. Retina. 1984;4:90-96. 2. Arroyo JC, Brown A. Concentrations of thiabendazole and parasite-specific IgG in the cerebrospinal fluid of a patient with disseminated strongyloidiasis. J Infect Dis. 1987;156:520-523. 3. Andrews P, Haberkorn A, Thomas H. Antiparasitic drugs: mechanisms of action, pharmacokinetics, and in vivo and in vitro assays of drug activity. In: Lorian V, ed. Antibiotics in Laboratory Medicine. 2nd ed. Baltimore, Md: Williams &
Wilkins; 1986:282-345.
.
Beginning in January 1991, the Archives gets a fresh new look. We've redesigned the cover to give it a more contemporary, less cluttered appearance. An expanded table of contents will feature an improved format and larger, more readable type to make it easier to find major articles. Later in the year we will introduce further state-of-the-art electronic layout system.
graphic improvements
as we
convert to
a
Our goal is to continue to bring you the highest-quality, peer-reviewed scientific informa¬ tion while making it more attractive and easier to read. We hope you'll approve.
Downloaded From: http://archopht.jamanetwork.com/ by a New York University User on 06/14/2015
