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Retinopathy of Prematurity-Like Fundus and Persistent Hyperplastic Primary Vitreous Associated with Maternal Cocaine Use
Vol. 103, No. 5
Letters to the Journal
sites of 5.0 units each, placed above each eye brow. The patient improved both subjectively and objectively, and showed no signs of de creased responsiveness to or complication of therapy (14 months of follow-up). Type A botulinum toxin injection proved a safe and efficacious treatment for the tempo rary relief of visually incapacitating apraxia of eyelid opening, when injected into the frontalis muscle of our affected patient. The neuroanatomic basis of apraxia of eyelid opening and the pathophysiologic explanation of this patient's success are still unknown. Previous reports of treatment failure in this condition with levodopa and 5-hydroxytrytophan 5 lead us to con sider further clinical trials.
References 1. Lepore, F. E., and Duvoisin, R. C : "Apraxia" of eyelid opening. An involuntary levator inhibition. Neurology 35:423, 1985. 2. Liepmann, H.: Das krankheitsbild der apraxie ("Motorischen Asymbolie"). Berlin, S. Karger, 1900. 3. Scott, A. B., Kennedy, R. A., and Stubbs, H. A.: Botulinum A toxin injection as a treatment for blepharospasm. Arch. Ophthalmol. 103:347, 1985. 4. Kuo, I., Drachman, D. B., and Price, D. L.: Botulinum toxin. Mechanism of presynaptic block ade. Science 193:1256, 1976. 5. Tokigucki, S., Natsukawa, M., Kawase, Y., Hayashi, H., and Tsukada, Y.: Pure akinesia with apraxia of lid-opening. Rinsho Shinkeigaku 18:192, 1978.
719
healthy, full-term infant with typical persistent hyperplastic primary vitreous in one eye and retinopathy of prematurity-like changes in the other eye, born to a mother whose pregnancy was complicated by regular cocaine use during the entire nine months of her pregnancy. A 3,360-g infant boy was born at 40 weeks of gestation by normal vaginal delivery to a 39year-old woman. The apgar score was 8, and the infant required no supplemental oxygen therapy. At 10 weeks of age, the child was examined for apparent microphthalmos of the right eye. A presumptive diagnosis of persistent hyper plastic primary vitreous was made. At 12 weeks of age, the child underwent an examination under anesthesia that disclosed a microphthalmic right globe with a corneal diameter of 9.0 mm. Ophthalmoscopic examination disclosed a fibrovascular stalk extending from the optic nerve head to the posterior surface of the lens. A computed tomographic scan (Fig. 1) con firmed the diagnosis of persistent hyperplastic primary vitreous and failed to show any calcifi cation suggestive of a retinoblastoma. Exami nation of the patient's left eye showed a normal corneal diameter of 10.5 mm, and a normal anterior segment. Ophthalmoscopic examina tion, however, showed changes suggestive of retinopathy of prematurity (Fig. 2). The periph eral retina was avascular for 360 degrees and was associated with a shallow temporal ridge. There were a few new vessels growing over the ridge at the 5:00 o'clock position. Additionally, there was a circumferential vitreous condensa tion more posterior to this in an area of vascu-
Retinopathy of Prematurity-Like Fundus and Persistent Hyperplastic Primary Vitreous Associated With Maternal Cocaine Use Michael P. Teske, M.D., and Michael T. Trese, M.D. Kresge Eye Institute. Inquires to Michael T. Trese, M.D., Kresge Ei/e Institute, 3994 John R, Detroit, MI 48201. Recent reports of cocaine use by women dur ing pregnancy have disclosed an increased inci dence of spontaneous abortions, abruptio pla centae, impairment of neonatal interactive and state organization abilities, 1 and perinatal cere bral infarction. 2 We examined an otherwise
Fig. 1 (Teske and Trese). Orbital computed tomog raphy demonstrating microphthalmia and fibrovas cular stalk connecting the optic nerve to the posterior lens surface typical of persistent hyperplastic pri mary vitreous. Left globe appears normal.
720
May, 1987
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 2 (Teske and Trese). Left eye, Shallow equato rial ridge extending from the 12:00 to 6:00 o'clock position with new vessels extending over the ridge at the 5:30 position. A circumferential vitreous opacification is present posterior to the ridge. There is 360 degrees of peripheral retinal avascularization and the ora serrata was flattened for 360 degrees. larized retina, suggestive of an old ridge. The ora serrata was flattened for 360 degrees. There was no dragging or tortuosity of the retinal vessels and the optic nerve head and macula appeared normal. The mother states that she smoked "crack" cocaine on a regular basis for the entire term of her pregnancy. Other maternal drug use in cluded an occasional marijuana cigarette, three to four drinks of alcohol per week, and approxi mately one pack per day of tobacco cigarettes. Her pregnancy was otherwise uncomplicated. Both parents have, subsequently, had full oph thalmic examinations, which failed to show any evidence of familial exudative vitreoretinopathy. Changes similar to those of retinopathy of prematurity may occasionally be seen in fullterm infants who have had no supplemental oxygen therapy. Many of these may represent sporadic cases of familial exudative vitreoretinopathy. Cocaine acts as a central nervous system stimulant. Peripherally, it blocks the reuptake of norepinephrine at the nerve terminals, re sulting in subsequent vasoconstriction, tachy cardia, and an acute rise in blood pressure. 3 Placental vasoconstriction may occur, which
results in decreased blood flow to the fetus. 4 Thus, regular cocaine use during pregnancy may subject the immature fetal retina to peri ods of hypoxia that are then followed by peri ods of "relative hyperoxia," resulting in vaso constriction of the developing retinal vessels. The findings in this case of typical persistent hyperplastic primary vitreous in one eye and the changes similar to those of retinopathy of prematurity in the other eye are most probably a coincidental association. Posterior hyperplas tic primary vitreous is typically unilateral and unassociated with other ocular or systemic ab normalities. The bilateral cases of persistent hyperplastic primary vitreous are frequently associated with other systemic abnormalities or chromosomal anomalies such as trisomy 13. 5 Our patient showed no systemic or neurologic abnormalities, and it is unlikely that maternal cocaine use and unilateral persistent hyper plastic primary vitreous are related.
References 1. Chasnoff, I. J., Burns, W. J., Schnoll, S. H., and Burns, K. A.: Cocaine use in pregnancy. N. Engl. J. Med. 313:666, 1985. 2. Chasnoff, I. ]., Bussey, M. E., Savich, R., and Stack, C. M.: Perinatal cerebral infarction and mater nal cocaine use. J. Pediatr. 108:456, 1986. 3. Ritchie, J. M., and Greene, N. M.: Local anes thesia. In Gilman, A. G., Goodman, L. S., and Gilman, A. (eds.): The Pharmacological Basis of Therapeutics, 6th ed. New York, Macmillan, 1980, pp. 300-320. 4. Sherman, W. T., and Gautieri, R. F.: Effect of certain drugs on perfused human placenta. X. Nor epinephrine release by bradykinin. J. Pharmacol. Sci. 61:878, 1972. 5. Haddad, R., Font, R. L., and Reeser, F.: Persis tent hyperplastic primary vitreous. A clinicopathologic study of 62 cases and review of the literature. Surv. Ophthalmol. 23:123, 1978.
Staphylococcus epidermidis Endophthalmitis After Pneumatic Retinopexy Claus Eckardt, M . D . Department of Ophthalmology, University of Kiel. Inquiries to Claus Eckardt, M.D., Department of Ophthalmology, University of Kiel, Hegewischstr. 2, D-2300 Kiel, West Germany. The injection of gases into the vitreous cavity
Letters to the Journal
sites of 5.0 units each, placed above each eye brow. The patient improved both subjectively and objectively, and showed no signs of de creased responsiveness to or complication of therapy (14 months of follow-up). Type A botulinum toxin injection proved a safe and efficacious treatment for the tempo rary relief of visually incapacitating apraxia of eyelid opening, when injected into the frontalis muscle of our affected patient. The neuroanatomic basis of apraxia of eyelid opening and the pathophysiologic explanation of this patient's success are still unknown. Previous reports of treatment failure in this condition with levodopa and 5-hydroxytrytophan 5 lead us to con sider further clinical trials.
References 1. Lepore, F. E., and Duvoisin, R. C : "Apraxia" of eyelid opening. An involuntary levator inhibition. Neurology 35:423, 1985. 2. Liepmann, H.: Das krankheitsbild der apraxie ("Motorischen Asymbolie"). Berlin, S. Karger, 1900. 3. Scott, A. B., Kennedy, R. A., and Stubbs, H. A.: Botulinum A toxin injection as a treatment for blepharospasm. Arch. Ophthalmol. 103:347, 1985. 4. Kuo, I., Drachman, D. B., and Price, D. L.: Botulinum toxin. Mechanism of presynaptic block ade. Science 193:1256, 1976. 5. Tokigucki, S., Natsukawa, M., Kawase, Y., Hayashi, H., and Tsukada, Y.: Pure akinesia with apraxia of lid-opening. Rinsho Shinkeigaku 18:192, 1978.
719
healthy, full-term infant with typical persistent hyperplastic primary vitreous in one eye and retinopathy of prematurity-like changes in the other eye, born to a mother whose pregnancy was complicated by regular cocaine use during the entire nine months of her pregnancy. A 3,360-g infant boy was born at 40 weeks of gestation by normal vaginal delivery to a 39year-old woman. The apgar score was 8, and the infant required no supplemental oxygen therapy. At 10 weeks of age, the child was examined for apparent microphthalmos of the right eye. A presumptive diagnosis of persistent hyper plastic primary vitreous was made. At 12 weeks of age, the child underwent an examination under anesthesia that disclosed a microphthalmic right globe with a corneal diameter of 9.0 mm. Ophthalmoscopic examination disclosed a fibrovascular stalk extending from the optic nerve head to the posterior surface of the lens. A computed tomographic scan (Fig. 1) con firmed the diagnosis of persistent hyperplastic primary vitreous and failed to show any calcifi cation suggestive of a retinoblastoma. Exami nation of the patient's left eye showed a normal corneal diameter of 10.5 mm, and a normal anterior segment. Ophthalmoscopic examina tion, however, showed changes suggestive of retinopathy of prematurity (Fig. 2). The periph eral retina was avascular for 360 degrees and was associated with a shallow temporal ridge. There were a few new vessels growing over the ridge at the 5:00 o'clock position. Additionally, there was a circumferential vitreous condensa tion more posterior to this in an area of vascu-
Retinopathy of Prematurity-Like Fundus and Persistent Hyperplastic Primary Vitreous Associated With Maternal Cocaine Use Michael P. Teske, M.D., and Michael T. Trese, M.D. Kresge Eye Institute. Inquires to Michael T. Trese, M.D., Kresge Ei/e Institute, 3994 John R, Detroit, MI 48201. Recent reports of cocaine use by women dur ing pregnancy have disclosed an increased inci dence of spontaneous abortions, abruptio pla centae, impairment of neonatal interactive and state organization abilities, 1 and perinatal cere bral infarction. 2 We examined an otherwise
Fig. 1 (Teske and Trese). Orbital computed tomog raphy demonstrating microphthalmia and fibrovas cular stalk connecting the optic nerve to the posterior lens surface typical of persistent hyperplastic pri mary vitreous. Left globe appears normal.
720
May, 1987
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 2 (Teske and Trese). Left eye, Shallow equato rial ridge extending from the 12:00 to 6:00 o'clock position with new vessels extending over the ridge at the 5:30 position. A circumferential vitreous opacification is present posterior to the ridge. There is 360 degrees of peripheral retinal avascularization and the ora serrata was flattened for 360 degrees. larized retina, suggestive of an old ridge. The ora serrata was flattened for 360 degrees. There was no dragging or tortuosity of the retinal vessels and the optic nerve head and macula appeared normal. The mother states that she smoked "crack" cocaine on a regular basis for the entire term of her pregnancy. Other maternal drug use in cluded an occasional marijuana cigarette, three to four drinks of alcohol per week, and approxi mately one pack per day of tobacco cigarettes. Her pregnancy was otherwise uncomplicated. Both parents have, subsequently, had full oph thalmic examinations, which failed to show any evidence of familial exudative vitreoretinopathy. Changes similar to those of retinopathy of prematurity may occasionally be seen in fullterm infants who have had no supplemental oxygen therapy. Many of these may represent sporadic cases of familial exudative vitreoretinopathy. Cocaine acts as a central nervous system stimulant. Peripherally, it blocks the reuptake of norepinephrine at the nerve terminals, re sulting in subsequent vasoconstriction, tachy cardia, and an acute rise in blood pressure. 3 Placental vasoconstriction may occur, which
results in decreased blood flow to the fetus. 4 Thus, regular cocaine use during pregnancy may subject the immature fetal retina to peri ods of hypoxia that are then followed by peri ods of "relative hyperoxia," resulting in vaso constriction of the developing retinal vessels. The findings in this case of typical persistent hyperplastic primary vitreous in one eye and the changes similar to those of retinopathy of prematurity in the other eye are most probably a coincidental association. Posterior hyperplas tic primary vitreous is typically unilateral and unassociated with other ocular or systemic ab normalities. The bilateral cases of persistent hyperplastic primary vitreous are frequently associated with other systemic abnormalities or chromosomal anomalies such as trisomy 13. 5 Our patient showed no systemic or neurologic abnormalities, and it is unlikely that maternal cocaine use and unilateral persistent hyper plastic primary vitreous are related.
References 1. Chasnoff, I. J., Burns, W. J., Schnoll, S. H., and Burns, K. A.: Cocaine use in pregnancy. N. Engl. J. Med. 313:666, 1985. 2. Chasnoff, I. ]., Bussey, M. E., Savich, R., and Stack, C. M.: Perinatal cerebral infarction and mater nal cocaine use. J. Pediatr. 108:456, 1986. 3. Ritchie, J. M., and Greene, N. M.: Local anes thesia. In Gilman, A. G., Goodman, L. S., and Gilman, A. (eds.): The Pharmacological Basis of Therapeutics, 6th ed. New York, Macmillan, 1980, pp. 300-320. 4. Sherman, W. T., and Gautieri, R. F.: Effect of certain drugs on perfused human placenta. X. Nor epinephrine release by bradykinin. J. Pharmacol. Sci. 61:878, 1972. 5. Haddad, R., Font, R. L., and Reeser, F.: Persis tent hyperplastic primary vitreous. A clinicopathologic study of 62 cases and review of the literature. Surv. Ophthalmol. 23:123, 1978.
Staphylococcus epidermidis Endophthalmitis After Pneumatic Retinopexy Claus Eckardt, M . D . Department of Ophthalmology, University of Kiel. Inquiries to Claus Eckardt, M.D., Department of Ophthalmology, University of Kiel, Hegewischstr. 2, D-2300 Kiel, West Germany. The injection of gases into the vitreous cavity