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Cyclic Macular Edema
VOL. 95, NO. 3
CORRESPONDENCE
nuorescein corresponding to the areas of serous retinal detachments in the late phase in both eyes. Vogt-Koyanagi-Harada syndrome asso ciated with shallow anterior chamber was diagnosed and a drop of 1% atropine sulfate was instilled in each eye and treatment with betamethasone tablets (5 mg/day) was instituted. On July 9, anterior chamber depth, measured with a pachymeter, was R.E.: 1.7 mm and L . E . : 1.6 mm. Intraocular pressure by applanation tonometry was 20 mm Hg in both eyes and, therefore, treatment with timolol ophthalmic solution was dis continued. That same day, cycloscopy with mini mum scierai identation 2 showed edematously swollen ciliary processes (Figure, left). On July 10 when the patient was admitted to our hospital, anterior cham ber depth was R.E.: 2.8 mm and L.E.: 2.6 mm. Intraocular pressure by applana tion tonometry was R.E.: 19 mm Hg and L.E.: 15 mm Hg. On July 15, anterior chamber depth was R.E.: 3.2 mm and L.E.: 3.1 mm. Intraocular pressure was R.E.: 20 mm Hg and L.E.: 11 mm Hg. On July 19, anterior chamber depth was 3.2 mm in both eyes, and the intraocular pressure was R.E.: 13 mm Hg and L.E.: 14 mm Hg. Gonioscopy disclosed a completely open angle in each eye. Although visual acuity did not improve, ophthalmoscopy disclosed decreased serous retinal de tachments in both eyes. By cycloscopy with maximum scierai indentation, per formed through mydriatic pupils, the cili ary processes were slightly edematous but smaller than they were on July 9, especially at their tips (Figure, right). Laboratory tests and a physical examina tion showed a moderate sensorineural hearing loss in the left ear but no other abnormalities. Although this patient had a protracted course, by Nov. 1, his visual acuity was 20/20 without correction in
403
both eyes and the anterior chambers were deep and clear. Intraocular pres sure was R.E.: 17 mm Hg and L.E.: 18 mm Hg. Both eyes appeared diffusely red by ophthalmoscopy. REFERENCES
1. Kimura, R., Sakai, M., and Okabe, H.: Tran sient shallow anterior chamber as initial symptom in Harada's syndrome. Arch. Ophthalmol. 99:1604, 1981. 2. Mizuno, K., Kimura, R., and Muroi, S.: Cy closcopy of angle-closure glaucoma. Albrecht von Graefes Arch. Klin. Exp. Ophthalmol. 204:247, 1977.
CORRESPONDENCE
Correspondence concerning recent articles or other material published in THE JOURNAL should be submitted within six weeks of publi cation. This correspondence must be typed and prepared in the same way as Letters to THE JOURNAL.
Every effort will be made to resolve contro versies between the correspondents and the authors of the article before formal publica tion.
Cyclic Macular E d e m a EDITOR:
The excellent article, "Cyclic macular edema" (Am. J. Ophthalmol. 94:664, Nov. 1982), by P. Sternberg, Jr., F. Fitzke, and D. Finkelstein documented nicely a concern to diabetic patients. Some of our diabetic patients tell us that their vision is worse in the morning and better at the end of the day. All of these patients show some macular edema. For the last five or six years I have suggested that each patient put four-inch blocks of wood under the legs at the head of his bed to keep his head in a slightly elevated position during the night. This tends to reduce the amount of macular edema and to maintain vision
404
AMERICAN JOURNAL OF OPHTHALMOLOGY
at a generally better level. This can be documented by fluorescein angiography. H O W A R D SCHATZ,
San Francisco,
M.D.
California
Removing Air Bubbles From Gonioscopic Solution EDITOR:
In his letter, "Removing air bubbles from gonioscopic solution" (Am. J. Ophthalmol. 94:817, Dec. 1982), L. J. Gi rard noted that he used a shaking tech nique. I keep air bubbles out of my gonioscopic solution by leaving the bot tle in the rack upside down. M I C H A E L L. STEINER,
Rocky Mount, North
M.D.
Carolina
Caution Advised When Managing Diabetic Retinopathy by Continuous Subcutaneous Insulin Infusion EDITOR:
In their letter, "The effect of continu ous subcutaneous insulin infusion treat ment on proliferative diabetic retinopa thy" (Am. J. Ophthalmol. 94:685, Nov. 1982), T. Segato, E. Midena, S. Piermarocchi, G. Crepaldi, and A. Tiengo Segato reported that regression of neovascularization occurred in two patients after blood glucose levels had been con trolled for nine months by continuous subcutaneous insulin infusion. Good control was achieved without concomi tant photocoagulation and was associat ed with regression of cotton-wool spots, reduction of leakage on the fluorescein angiogram, and normalization of vein size. In three other patients who under went photocoagulation as well there were no retinal changes during the nine-month period. These findings differed from those re ported by us and by others. Our col leagues and we managed 12 patients (nine proliferative and 15 preprolifer-
MARCH, 1983
ative eyes) by continuous subcutaneous insulin infusion for periods of four to 19 months. 1 Six of the eyes with prolifera tive retinopathy also received photoco agulation. Of the 24 eyes, 20 deteriorat ed (initiation or further development of new vessels). Tamborlane and associ ates 2 also found no instances of regres sion in 11 eyes with background reti nopathy and in 13 with proliferative retinopathy. A prospective randomized study of the effect of continuous subcu taneous insulin infusion on background retinopathy suggested a possible wors ening of retinopathy in the patients who had the best-controlled blood glucose level (T. Lauritzen, K. Frost-Larsen, H. W. Larsen, and T. Deckert, unpub lished data). In our patients deteriora tion was so marked that possible detri mental effects such as reduced perfusion of ischemie retina or stimulation of growth mediating factors were ques tioned. Although we believe that good control of blood glucose levels is worth striving for in order to reduce microvascular dis ease, we do not recommend the applica tion of continuous subcutaneous insulin infusion alone as a treatment for prolif erative retinopathy. Photocoagulation, which is known to be effective, is the treatment of choice in such cases. We would also advise close observations of all retinopathy patients managed by continuous subcutaneous insulin infu sion until the effect of markedly im proved blood glucose levels is better understood. PAUL LARSON, E V A M. KOHNER,
London,
M.D. M.D.
England
REFERENCES 1. Lawson, P. M., Champion, M. C , Canny, C , Kingsley, R., White, M. C , Dupre, J., and Kohner, E. M.: Continuous subcutaneous insulin infusion (CSII) does not prevent progression of proliferative and preproliferative retinopathy. Br. J. Ophthalmol. 66:762, 1982.
CORRESPONDENCE
nuorescein corresponding to the areas of serous retinal detachments in the late phase in both eyes. Vogt-Koyanagi-Harada syndrome asso ciated with shallow anterior chamber was diagnosed and a drop of 1% atropine sulfate was instilled in each eye and treatment with betamethasone tablets (5 mg/day) was instituted. On July 9, anterior chamber depth, measured with a pachymeter, was R.E.: 1.7 mm and L . E . : 1.6 mm. Intraocular pressure by applanation tonometry was 20 mm Hg in both eyes and, therefore, treatment with timolol ophthalmic solution was dis continued. That same day, cycloscopy with mini mum scierai identation 2 showed edematously swollen ciliary processes (Figure, left). On July 10 when the patient was admitted to our hospital, anterior cham ber depth was R.E.: 2.8 mm and L.E.: 2.6 mm. Intraocular pressure by applana tion tonometry was R.E.: 19 mm Hg and L.E.: 15 mm Hg. On July 15, anterior chamber depth was R.E.: 3.2 mm and L.E.: 3.1 mm. Intraocular pressure was R.E.: 20 mm Hg and L.E.: 11 mm Hg. On July 19, anterior chamber depth was 3.2 mm in both eyes, and the intraocular pressure was R.E.: 13 mm Hg and L.E.: 14 mm Hg. Gonioscopy disclosed a completely open angle in each eye. Although visual acuity did not improve, ophthalmoscopy disclosed decreased serous retinal de tachments in both eyes. By cycloscopy with maximum scierai indentation, per formed through mydriatic pupils, the cili ary processes were slightly edematous but smaller than they were on July 9, especially at their tips (Figure, right). Laboratory tests and a physical examina tion showed a moderate sensorineural hearing loss in the left ear but no other abnormalities. Although this patient had a protracted course, by Nov. 1, his visual acuity was 20/20 without correction in
403
both eyes and the anterior chambers were deep and clear. Intraocular pres sure was R.E.: 17 mm Hg and L.E.: 18 mm Hg. Both eyes appeared diffusely red by ophthalmoscopy. REFERENCES
1. Kimura, R., Sakai, M., and Okabe, H.: Tran sient shallow anterior chamber as initial symptom in Harada's syndrome. Arch. Ophthalmol. 99:1604, 1981. 2. Mizuno, K., Kimura, R., and Muroi, S.: Cy closcopy of angle-closure glaucoma. Albrecht von Graefes Arch. Klin. Exp. Ophthalmol. 204:247, 1977.
CORRESPONDENCE
Correspondence concerning recent articles or other material published in THE JOURNAL should be submitted within six weeks of publi cation. This correspondence must be typed and prepared in the same way as Letters to THE JOURNAL.
Every effort will be made to resolve contro versies between the correspondents and the authors of the article before formal publica tion.
Cyclic Macular E d e m a EDITOR:
The excellent article, "Cyclic macular edema" (Am. J. Ophthalmol. 94:664, Nov. 1982), by P. Sternberg, Jr., F. Fitzke, and D. Finkelstein documented nicely a concern to diabetic patients. Some of our diabetic patients tell us that their vision is worse in the morning and better at the end of the day. All of these patients show some macular edema. For the last five or six years I have suggested that each patient put four-inch blocks of wood under the legs at the head of his bed to keep his head in a slightly elevated position during the night. This tends to reduce the amount of macular edema and to maintain vision
404
AMERICAN JOURNAL OF OPHTHALMOLOGY
at a generally better level. This can be documented by fluorescein angiography. H O W A R D SCHATZ,
San Francisco,
M.D.
California
Removing Air Bubbles From Gonioscopic Solution EDITOR:
In his letter, "Removing air bubbles from gonioscopic solution" (Am. J. Ophthalmol. 94:817, Dec. 1982), L. J. Gi rard noted that he used a shaking tech nique. I keep air bubbles out of my gonioscopic solution by leaving the bot tle in the rack upside down. M I C H A E L L. STEINER,
Rocky Mount, North
M.D.
Carolina
Caution Advised When Managing Diabetic Retinopathy by Continuous Subcutaneous Insulin Infusion EDITOR:
In their letter, "The effect of continu ous subcutaneous insulin infusion treat ment on proliferative diabetic retinopa thy" (Am. J. Ophthalmol. 94:685, Nov. 1982), T. Segato, E. Midena, S. Piermarocchi, G. Crepaldi, and A. Tiengo Segato reported that regression of neovascularization occurred in two patients after blood glucose levels had been con trolled for nine months by continuous subcutaneous insulin infusion. Good control was achieved without concomi tant photocoagulation and was associat ed with regression of cotton-wool spots, reduction of leakage on the fluorescein angiogram, and normalization of vein size. In three other patients who under went photocoagulation as well there were no retinal changes during the nine-month period. These findings differed from those re ported by us and by others. Our col leagues and we managed 12 patients (nine proliferative and 15 preprolifer-
MARCH, 1983
ative eyes) by continuous subcutaneous insulin infusion for periods of four to 19 months. 1 Six of the eyes with prolifera tive retinopathy also received photoco agulation. Of the 24 eyes, 20 deteriorat ed (initiation or further development of new vessels). Tamborlane and associ ates 2 also found no instances of regres sion in 11 eyes with background reti nopathy and in 13 with proliferative retinopathy. A prospective randomized study of the effect of continuous subcu taneous insulin infusion on background retinopathy suggested a possible wors ening of retinopathy in the patients who had the best-controlled blood glucose level (T. Lauritzen, K. Frost-Larsen, H. W. Larsen, and T. Deckert, unpub lished data). In our patients deteriora tion was so marked that possible detri mental effects such as reduced perfusion of ischemie retina or stimulation of growth mediating factors were ques tioned. Although we believe that good control of blood glucose levels is worth striving for in order to reduce microvascular dis ease, we do not recommend the applica tion of continuous subcutaneous insulin infusion alone as a treatment for prolif erative retinopathy. Photocoagulation, which is known to be effective, is the treatment of choice in such cases. We would also advise close observations of all retinopathy patients managed by continuous subcutaneous insulin infu sion until the effect of markedly im proved blood glucose levels is better understood. PAUL LARSON, E V A M. KOHNER,
London,
M.D. M.D.
England
REFERENCES 1. Lawson, P. M., Champion, M. C , Canny, C , Kingsley, R., White, M. C , Dupre, J., and Kohner, E. M.: Continuous subcutaneous insulin infusion (CSII) does not prevent progression of proliferative and preproliferative retinopathy. Br. J. Ophthalmol. 66:762, 1982.