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Vitreous Hemorrhage and Sleep Apnea
LETTERS TO THE JOURNAL
Vitreous Hemorrhage and Sleep Apnea
with good results, but the patient continues to have minor bleeding in the right eye. The patient's wife described his loud snoring and apnea attacks, which had occurred since he was 30 years old, but which have gotten worse during the last few years. She had noted a periodic worsening of symptoms that coincided with retinal bleeding. Ambulatory monitoring of the breathing pattern with a solid state recorder suggested a sleep-apnea syndrome. During a six-month period four recordings were done. The results varied from being normal to showing obstructed breathing during 60% of the night. Change in blood pressure occurs during spells of sleep apnea, but the hypoxia itself seems to be a more plausible explanation as an etiologic link between sleep apnea and vitreous hemorrhage. In a study of 72 diabetic patients with vitreous hemorrhage, Anderson! found that only one of six hemorrhages was associated with activity more strenous than walking. This suggests that variations in blood pressure are unlikely to be a major etiologic factor in vitreous hemorrhage. The oxygen consumption in the retina is increased in darkness," and in both a normal and diabetic population studies have shown that breathing of pure oxygen leads to a reduction in retinal blood flow. 4 The possible increased blood flow in the retina during apneic spells may contribute to the disruption of the altered diabetic retinal vessels. We suggest that screening for sleep apnea
Ingimundur Gislason, M.D., and Helgi Kristbjarnarson, M.D. University Eye Clinic, St. Joseph's Hospital (I.G.); Department of Psychiatry, Landspitalinn (The National Hospital) (H.K.), Reykjavik.
Inquiries to Ingimundur Cislason, M.D., St. Joseph's Hospital, 15-101 Reykjavik, Iceland.
The increased occurrence of vitreous hemorrhage in diabetics has been noted during sleep. Hypoglycemia and increased venous pressure have been suggested as possible etiologic factors.' We studied a case of repeated vitreoretinal hemorrhages occurring at the time of sleep apnea attacks. Diabetes had been diagnosed in a 42-year-old man at the age of 10 years. It has been well controlled on insulin treatment. Four years ago proliferative retinopathy was found in the left eye and one year ago in the right eye. During this time the patient has had more than 20 moderate to major episodes of vitreous hemorrhages, all occurring during sleep. The patient, who is a cabinet maker, sustained two eye injuries at work after his vision began to deteriorate. In both instances there was a moderate contusion in each eye with a hyphema in the anterior chamber but no signs of new bleeding into the vitreous body. The patient was treated with argon laser panphotocoagulation in both eyes and subtotal vitrectomy in the left eye
THE JOURNAL welcomes letters that describe unusual clinical or pathologic findings, experimental results, and new instruments or techniques. The title and the names of all authors appear in the Table of Contents and are retrievable through the Index Medicus and other standard indexing services. Letters must not duplicate data previously published or submitted for publication. Each letter must be accompanied by a signed disclosure statement and copyright transfer agreement published in each issue of THE JOURNAL. Letters must be typewritten, double-spaced, on 8112 x l1-inch bond paper with 1 1/2-inch margins on all four sides. (See Instructions to Authors.) They should not exceed 500 words of text. A maximum of two black-and-white figures may be used; they should be cropped to a width of 3 inches (one column). Color figures cannot be used. References should be limited to five. Letters may be referred to outside editorial referees for evaluation or may be reviewed by members of the Editorial Board. All letters are published promptly after acceptance. Authors do not receive galley proofs but if the editorial changes are extensive, the corrected typescript is submitted to them for approval. These instructions markedly limit the opportunity for an extended discussion or review. Therefore, THE JOURNAL does not publish correspondence concerning previously published letters.
796
Vol. 102, No.6
Letters to the Journal
may be indicated in cases of repeated vitreous hemorrhages.
References 1. Tasman, W.: Diabetic vitreous hemorrhage and its relationship to hypoglycemia. Mod. Probl. Opthalmol. 20:413, 1979. 2. Anderson, B.: Activity and diabetic vitreous hemorrhages. Opthalmology. 87:173, 1980. 3. Stefansson, E., Wollbarsht, M. L., and Landers, M. B., III.: In vivo O2 consumption in rhesus monkeys in light and dark. Exp. Eye Res. 37:251, 1983. 4. Grunwald, J. E., Riva, C. E., Petrig, B. L., Sinclair, S. H., and Brucker, A. J.: Effect of pure Oj-breathing on retinal blood flow in normals and in patients with background diabetic retinopathy. Eye Res. 3: 239, 1984.
Fluorescein-Conjugated Lectin Identification of a Case of Human Keratomycosis Jeffrey B. Robin, M.D., Steven Nielson, B.S., and Melvin D. Trousdale, Ph.D. Estelle Doheny Eye Foundation, University of Southern California Department of Ophthalmology. This study was supported in part by Core Center Grant EYO-3040 from the National Institutes of Health to the Estelle Doheny Eye Foundation. Inquiries to Jeffrey B. Robin, M.D., 1355 San Pablo Los Angeles, CA 90033.
si..
The diagnosis of mycotic ocular infections is frequently challenging. Cultures may take as long as two weeks to disclose fungal growth. Additionally, the stains commonly used to identify fungi on smears require prolonged processing times. Other, more rapid stains (such as potassium hydroxide) are frequently difficult to interpret. Accurate diagnosis of mycotic infections, therefore, is commonly prolonged, resulting in delays in the institution of appropriate therapy. Recently, fluorescein-conjugated lectins have been shown to identify rapidly and consistently the presence of fungi in smears taken either from fungal cultures or from ocular mycoses in experimental animals." Additionally, using multiple fluorescein-conjugated lectins, specific binding and staining patterns have been
797
established for a variety of fungi. In addition to aiding fungal visualization, these staining patterns may facilitate species identification. We report herein a case of human keratomycosis in which the infecting organism was rapidly visualized and identified using fluoresceinconjugated lectins. The patient, a 30-year-old woman, came to our institution because of a two-month history of irritation and redness involving the left eye. She had also noted for one week a "white dot" overlying her pupil. The patient had a history of traumatic corneal abrasion involving the left eye approximately six months previously. During the two-month course of her symptoms treatment included a variety of antibiotic ointments, corticosteroid eyedrops, and patching. The remainder of her ocular and medical histories were unremarkable. On examination, corrected visual acuities were R.E.: 20/20 and L.E.: 1/200. Biomicroscopic examination of the left eye showed marked injection of the bulbar and palpebral conjunctiva, as well as a 3 x 5-mm dense white infiltrate that involved the mid and anterior coreal stroma (Fig. 1). Immediately overlying this infiltrate was a dense white plaque that was elevated slightly off the corneal epithelial surface. The stroma surrounding the dense infiltrate was moderately edematous. The anterior chamber had a 10% hypopyon and there were several fine posterior synechiae scattered around the pupillary border. Corneal sensation was intact bilaterally and symmetrical. Results of the remainder of the ocular examination were unremarkable.
Fig. 1 (Robin, Nielson, and Trousdale). Densely opaque, white stromal infiltrate located in inferocentral cornea. Note the associated hypopyon (arrows) (x 16).
Vitreous Hemorrhage and Sleep Apnea
with good results, but the patient continues to have minor bleeding in the right eye. The patient's wife described his loud snoring and apnea attacks, which had occurred since he was 30 years old, but which have gotten worse during the last few years. She had noted a periodic worsening of symptoms that coincided with retinal bleeding. Ambulatory monitoring of the breathing pattern with a solid state recorder suggested a sleep-apnea syndrome. During a six-month period four recordings were done. The results varied from being normal to showing obstructed breathing during 60% of the night. Change in blood pressure occurs during spells of sleep apnea, but the hypoxia itself seems to be a more plausible explanation as an etiologic link between sleep apnea and vitreous hemorrhage. In a study of 72 diabetic patients with vitreous hemorrhage, Anderson! found that only one of six hemorrhages was associated with activity more strenous than walking. This suggests that variations in blood pressure are unlikely to be a major etiologic factor in vitreous hemorrhage. The oxygen consumption in the retina is increased in darkness," and in both a normal and diabetic population studies have shown that breathing of pure oxygen leads to a reduction in retinal blood flow. 4 The possible increased blood flow in the retina during apneic spells may contribute to the disruption of the altered diabetic retinal vessels. We suggest that screening for sleep apnea
Ingimundur Gislason, M.D., and Helgi Kristbjarnarson, M.D. University Eye Clinic, St. Joseph's Hospital (I.G.); Department of Psychiatry, Landspitalinn (The National Hospital) (H.K.), Reykjavik.
Inquiries to Ingimundur Cislason, M.D., St. Joseph's Hospital, 15-101 Reykjavik, Iceland.
The increased occurrence of vitreous hemorrhage in diabetics has been noted during sleep. Hypoglycemia and increased venous pressure have been suggested as possible etiologic factors.' We studied a case of repeated vitreoretinal hemorrhages occurring at the time of sleep apnea attacks. Diabetes had been diagnosed in a 42-year-old man at the age of 10 years. It has been well controlled on insulin treatment. Four years ago proliferative retinopathy was found in the left eye and one year ago in the right eye. During this time the patient has had more than 20 moderate to major episodes of vitreous hemorrhages, all occurring during sleep. The patient, who is a cabinet maker, sustained two eye injuries at work after his vision began to deteriorate. In both instances there was a moderate contusion in each eye with a hyphema in the anterior chamber but no signs of new bleeding into the vitreous body. The patient was treated with argon laser panphotocoagulation in both eyes and subtotal vitrectomy in the left eye
THE JOURNAL welcomes letters that describe unusual clinical or pathologic findings, experimental results, and new instruments or techniques. The title and the names of all authors appear in the Table of Contents and are retrievable through the Index Medicus and other standard indexing services. Letters must not duplicate data previously published or submitted for publication. Each letter must be accompanied by a signed disclosure statement and copyright transfer agreement published in each issue of THE JOURNAL. Letters must be typewritten, double-spaced, on 8112 x l1-inch bond paper with 1 1/2-inch margins on all four sides. (See Instructions to Authors.) They should not exceed 500 words of text. A maximum of two black-and-white figures may be used; they should be cropped to a width of 3 inches (one column). Color figures cannot be used. References should be limited to five. Letters may be referred to outside editorial referees for evaluation or may be reviewed by members of the Editorial Board. All letters are published promptly after acceptance. Authors do not receive galley proofs but if the editorial changes are extensive, the corrected typescript is submitted to them for approval. These instructions markedly limit the opportunity for an extended discussion or review. Therefore, THE JOURNAL does not publish correspondence concerning previously published letters.
796
Vol. 102, No.6
Letters to the Journal
may be indicated in cases of repeated vitreous hemorrhages.
References 1. Tasman, W.: Diabetic vitreous hemorrhage and its relationship to hypoglycemia. Mod. Probl. Opthalmol. 20:413, 1979. 2. Anderson, B.: Activity and diabetic vitreous hemorrhages. Opthalmology. 87:173, 1980. 3. Stefansson, E., Wollbarsht, M. L., and Landers, M. B., III.: In vivo O2 consumption in rhesus monkeys in light and dark. Exp. Eye Res. 37:251, 1983. 4. Grunwald, J. E., Riva, C. E., Petrig, B. L., Sinclair, S. H., and Brucker, A. J.: Effect of pure Oj-breathing on retinal blood flow in normals and in patients with background diabetic retinopathy. Eye Res. 3: 239, 1984.
Fluorescein-Conjugated Lectin Identification of a Case of Human Keratomycosis Jeffrey B. Robin, M.D., Steven Nielson, B.S., and Melvin D. Trousdale, Ph.D. Estelle Doheny Eye Foundation, University of Southern California Department of Ophthalmology. This study was supported in part by Core Center Grant EYO-3040 from the National Institutes of Health to the Estelle Doheny Eye Foundation. Inquiries to Jeffrey B. Robin, M.D., 1355 San Pablo Los Angeles, CA 90033.
si..
The diagnosis of mycotic ocular infections is frequently challenging. Cultures may take as long as two weeks to disclose fungal growth. Additionally, the stains commonly used to identify fungi on smears require prolonged processing times. Other, more rapid stains (such as potassium hydroxide) are frequently difficult to interpret. Accurate diagnosis of mycotic infections, therefore, is commonly prolonged, resulting in delays in the institution of appropriate therapy. Recently, fluorescein-conjugated lectins have been shown to identify rapidly and consistently the presence of fungi in smears taken either from fungal cultures or from ocular mycoses in experimental animals." Additionally, using multiple fluorescein-conjugated lectins, specific binding and staining patterns have been
797
established for a variety of fungi. In addition to aiding fungal visualization, these staining patterns may facilitate species identification. We report herein a case of human keratomycosis in which the infecting organism was rapidly visualized and identified using fluoresceinconjugated lectins. The patient, a 30-year-old woman, came to our institution because of a two-month history of irritation and redness involving the left eye. She had also noted for one week a "white dot" overlying her pupil. The patient had a history of traumatic corneal abrasion involving the left eye approximately six months previously. During the two-month course of her symptoms treatment included a variety of antibiotic ointments, corticosteroid eyedrops, and patching. The remainder of her ocular and medical histories were unremarkable. On examination, corrected visual acuities were R.E.: 20/20 and L.E.: 1/200. Biomicroscopic examination of the left eye showed marked injection of the bulbar and palpebral conjunctiva, as well as a 3 x 5-mm dense white infiltrate that involved the mid and anterior coreal stroma (Fig. 1). Immediately overlying this infiltrate was a dense white plaque that was elevated slightly off the corneal epithelial surface. The stroma surrounding the dense infiltrate was moderately edematous. The anterior chamber had a 10% hypopyon and there were several fine posterior synechiae scattered around the pupillary border. Corneal sensation was intact bilaterally and symmetrical. Results of the remainder of the ocular examination were unremarkable.
Fig. 1 (Robin, Nielson, and Trousdale). Densely opaque, white stromal infiltrate located in inferocentral cornea. Note the associated hypopyon (arrows) (x 16).