choroidal neovascular (CNV) membrane in the left eye (OS) for 2 weeks. Best-corrected visual acuity was 20/20 in both eyes. The anterior segment was quiet. Some yellowish-gray lesions were also present in the right eye.Fluorescein angiography (FA) showed early hypofluorescence and late hyperfluorescence due to staining at the level of the lesions. Acute lesions on indocyanine green (ICG) angiography were hypofluorescent. Both revealed a CNV membrane in the OS. (Figures 1 and 2).Sarcoidosis, tuberculosis, and presumed ocular histoplasmosis syndrome were excluded. Blood analysis excluded other infectious and inflammatory causes.The patient received three intravitreal (IVT) injections of ranibizumab in the OS spaced 1 month apart. The CNV membrane disappeared, but 2 months later it reappeared and vision decreased to 20/80. Three additional injections were administered whereby vision stabilized at 20/63. FA was repeated. No leakage was present. However, the ICG showed small hypofluorescent spots within 3 DD of the lesion that suggested inflammatory activity in the choroid. (Figure 3).We performed an IVT injection of 400 mg methotrexate (MTX) in 0.1 ml. Vision improved to 20/25 over 3 months. The vision remained stable with no flare up for over 20 months.
CommentCNV occurs in up to one third of patients with MFC. Numerous therapies have been proposed, including thermal laser, subretinal surgery, PDT, local and systemic corticosteroids, anti-VEGF therapy, and immunosuppressive agents. 1 IVT MTX, used as chemotherapy, is effective in inducing a clinical remission of intraocular tumor in primary central nervous system lymphoma. 2 MTX has also been used in unilateral intermediate or posterior uveitis, and cystoid macular edema. 3 Its antiinflammatory effect is well known, but it can also decrease VEGF. 4 For instance, Byun et al 5 used topical and subconjunctival MTX for corneal neovascularization with good results. We achieved improved vision and no CNV membrane recurrence by administering IVT MTX. The absence of recurrence can be due to MTX's dual mechanism of action: anti-inflammatory and anti-angiogenic. MTX should be considered as a treatment option for CNV membrane especially in cases with an inflammatory etiology.
Conflict of interestThe authors declare no conflict of interest.
Serum Adenosine deaminase (ADA) activity in normal healthy control subjects increases upto 30 years, remains steady between 31-60 years of age and shows a steep increase in the age group of 61-70 years. This was compared with serum aspartate transaminase (AST) and alanine transaminase (ALT) activity which also showed a gradual increase upto 40 years of age and decreased thereafter. The activities of serum ADA, AST and ALT increased in patients with hepatitis of all age groups compared to their respective controls. The degree of increase in the activities of the above enzymes in hepatitis, decreased with age. The present study also shows that while studying serum ADA activity in hepatitis for diagnostic purposes, the value obtained in a particular age group should be compared with normal range of values for the respective age group only.
Midbrain hemorrhage causing isolated fourth nerve palsy is extremely rare. Idiopathic, traumatic and congenital abnormalities are the most common causes of fourth nerve palsy. We report acute isolated fourth nerve palsy in an 18-year-old lady due to a midbrain hemorrhage probably due to a midbrain cavernoma. The case highlights the need for neuroimaging in selected cases of isolated trochlear nerve palsy.
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