Overview of Ocular Histoplasmosis Syndrome (OHS)

Overview of Ocular Histoplasmosis Syndrome (OHS) Dr Pradeep Venkatesh Histoplasmosis Amol D Kulkarni and Suresh R Chandra Introduction Histoplasmosis is a systemic disease caused by Histoplasma capsulatum.1 Introduction Histoplasmosis is a systemic disease caused by Histoplasma capsulatum.1 It produces intracellular granulomatous inflammation of many organs including eyes, lungs, liver, spleen, etc. Ocular histoplasmosis syndrome (OHS) is characterized by a triad of signs –of punched-out atrophic choroidal scars in the macula or periphery, peripapillary atrophy and choroidal neovascular membrane (CNVM).2 Etiology-Aetiology HistoplasmacapsulatumH. capsulatum, a dimorphic fungus, is presumed to play a causative role in the development of OHS.1 There are few reports of pathologic and molecular evidence supporting a the direct role for of H. capsulatum in the development of chorioretinal scars, ; however, no serologic confirmation of histoplasmosis infection has been reported.3,4 A haematogenous dissemination of the fungus results in choroidal invasion and subsequent scarring. Additionally, disseminated histoplasmosis presents with intraretinal infiltrates composed of histoplasma yeast cells that are easily demonstrable on histology. Extensive study of the affected individuals in Europe and the United States has revealed the presence of human leukocyte antigen (HLA)-DR15). 1: Please provide the full form of DR>.5 No full form; it indicates type of HLAThis HLA association suggests that immune reaction is likely to play a major role during the development of scarring and CNVM. H. capsulatum may induced local ized autoimmune reaction in the retina. However, an infection with this fungus is not an absolute requirement for the development of clinical OHS. Because of this lack of association, there has been a suggestion to rename this clinical syndrome as ‘multifocal choroidopathy’. Epidemiology OHS is most common in the Ohio and Mississippi River valleys of the United States, which are endemic for H. capsulatum.6 Up to 70% of the population living in the endemic areas reacts positively to the histoplasmin skin testing and 1.5% exhibits the typical fundus findings. 7It can be a blinding disease in its more severe manifestations. There is no gender predilection, although some reports show a higher prevalence in women. Pathobiology OHS belongs to the spectrum of autoimmune diseases triggered by an infectious organism, with H. capsulatum being one of several candidate pathogens. It is characterized by a chronic reaction to the immunogenic residua of the H. capsulatum, which acts as a nidus for inflammation. Light microscopy reveals mixed inflammatory cells in the choroidal lesions with the loss of overlying retinal pigment epithelium. There are adhesions between the outer retina and choroidal lesions. The genesis of CNVM in OHS is thought to be caused by the disruption of Bruch’s membrane at the site of atrophic scar. Systemic Featuresfeatures Mycilia Mycelia of Histoplasmosishistoplasmoses are inhaled and they transform to the yeast form shortly and infect lungs. They can produce caseation and enlargement of hilar nodes, which produce typical shadows on X-ray. About 90% of cases are benign and do not produce symptoms. In dDisseminated2: Kindly >OK histoplasmosis are is characterized by pyrexia, vomiting and enlargement of liver, spleen, and lymph glands. The Involvement involvement of skin, mouth, gastrointestinal tract and heart may also occur. Ocular Featuresfeatures The clinical findings in OHS include peripapillary atrophy, multiple punched punchedout white atrophic choroidal scars (histo spots), and a macular CNVM, accompanied by the complete absence of a cellular reaction in the anterior chamber or vitreous cavity [(Fig. 40.1(aA)].6 The histo spots are considered to be the earliest stage of the disease, and are usually asymptomatic [(Fig. 40.1 (Bb)]. CNVM will develop in fewer than 5% of individuals with histo spots. The Clinical clinical presentation of CNVM involves acute or insidious onset of painless progressive blurring of central vision and metamorphopsia. The Fundus fundus examination typically shows a yellow-green subretinal discolouration with accumulation of subretinal fluid. In advanced cases, there is subretinal fibrosis leading to disciform scar formation and that is associated with severe central visual loss. 9The exact time frame between the initial choroidal scarring and CNVAQ3: Please check if CNV stands for â€Å"choroidal neovascularization†and CNVM is choroidal neovascular membrane and should be replaced with CNVM>NO development is difficult to determine given that histo spots are asymptomatic. New histo spots may develop in more than 20% of individuals while they are under observation, ; however, only 3.8% progress to CNV. The precipitating factors promoting such progression are not known. Some studies implicate emotional stress and tension headaches as associated events. Diagnosis OHS is a clinical diagnosis and relies on the observation of characteristic fundus lesions in one or both eyes. Intravenous fluorescein angiography (FA) and optical coherence tomography (OCT) can assist in the evaluation of CNVM (Figs. 40.2 and 40.3). FA assists in identifying areas of CNVM and in planning photodynamic therapy. OCT is a useful tool for the detection and monitoring of treatment response. 10 Treatment The optimum treatment of subfoveal and juxtafoveal CNVM is the main focus in OHS. Histo spots are asymptomatic in most cases and require no treatment until a progression of the disease is detected.9-11 Corticosteroids Regimens of systemic corticosteroid therapy were widely used in early studies of ocular histoplasmosis. 12Few clinical studies have evaluated the role of subtenon’s and intraocular triamcinolone. The intravitreal steroids demonstrated favourable visual outcomes; however, they are associated with cataract formation or progression and increased intraocular pressure.13 Laser photocoagulation Laser Photocoagulation photocoagulation effectively inhibits the progression of OHS-related CNV. In randomized trials, the Macular Photocoagulation Study demonstrated that argon and krypton laser photocoagulation is effective in treating well-defined, classic extrafoveal, juxtafoveal, and peripapillary CNV lesions secondary to OHS.14, 15 Only 12% of treated individuals experienced significant disease progression, compared with 42% of the control patients. Surgical therapy The role of submacular surgery for the removal of CNV lesions was evaluated in a multicentere randomized clinical trial. 16The study data indicate that surgery may be beneficial to patients with visual acuity worse than 20/100, and subfoveal CNV. Photodynamic therapy Verteporfin in Ocular Histoplasmosis study enrolled 26 patients prospectively with subfoveal CNV and demonstrated an improvement of visual acuity from baseline as well as an absence of serious adverse events at in 2 years.17 Anti-vascular endothelial growth factor (VEGF) therapy Several intravitreal anti-vascular endothelial growth factor (VEGF) treatments are currently being pursued for the treatment of OHS-related CNV. Few retrospective studies have evaluated the role of intravitreal anti-VEGF therapy for CNV associated with OHS. One such study by Ehrlich et al. found that at least 50% of eyes with subfoveal or juxtafoveal CNV experienced ≠¥>=3 three lines of vision gain and 91.5% to –100% of patients had improved or had stable visual acuity (at 3-– to 12-month follow-up) after the intravitreal bevacizumab therapy. 18Similarly, the results concerning the therapeutic efficacy of ranibizumab are promising. Both treat-and-extend and pro re nata treatment strategies were effective. A study by Nielsen et al. demonstrated that many eyes require long-term anti-VEGF therapy to suppress the choroidal neovascular activity in OHS.19 Suggested reading Smith RE, Ganley JP. An epidemiologic study of presumed ocular histoplasmosis. Trans Am Acad Ophthalmol Otolaryngol 1971; 75:994–-1005. Gass JDM, Wilkinson CP. Follow-up study of presumed ocular histoplasmosis. Trans Am Acad Ophthalmol Otolaryngol 1972; 76:672–694. Hawkins BS, Alexander J, Schachat AP. Ocular histoplasmosis. In: Retina. Ryan, SJ, Schahchat, AP, editors. Retina. St. Louis, MO: , Mosby; 20014: Please check the author spelling>. Oliver A, Ciulla TA, Comer GM. New and classic insights into presumed ocular histoplasmosis syndrome and its treatment. Curr Opin Ophthalmol. 2005 Jun;16(3):160–165. Prasad AG, Van Gelder RN. Presumed ocular histoplasmosis syndrome. Curr Opin Ophthalmol. 2005 Dec;16(6):364–368. Macular Photocoagulation Study Group. Argon laser photocoagulation for ocular histoplasmosis: results of a randomized trial. Arch Ophthalmol 1983; 101:1347–1357. Macular Photocoagulation Study Group. Krypton laser photocoagulation for neovascular lesions of ocular histoplasmosis: results of a randomized clinical trial. Arch Ophthalmol 1987; 105:1499–-1507. Rosenfeld PJ, Saperstein DA, Bressler NM, et al. Photodynamic therapy with verteporfin in ocular histoplasmosis: uncontrolled, open-label 2-year study. Ophthalmology 2004; 111:1725–1733. Nielsen JS, Fick TA, Saggau DD, Barnes CH. Intravitreal anti-vascular endothelial growth factor therapy for choroidal neovascularization secondary to ocular histoplasmosis syndrome. Retina. 2012 Mar;32(3):468–472. Fig. ure 40.1 Fundus photographs of a patient with OHS showing peri-papillary atrophy and CNV with subretinal haemorrhage in the right eye (A) and macular histo spot in the left eye (B).Choroidal neovascularization Fig. ure 40.2 Early (A) and late (B) phase fluorescein photographs showing CNV with subretinal haemorrhage secondary to OHS. Fig. ure 40.3 OCT scan showing CNV with intraretinal fluid secondary to OHS.

From History to Modern Era Essay

The great virtue of this estimate of Zionism is that it seems to succeed in providing the modern movement with a long history of which it is the heir. Zionism is made to stand in an unending line of messianic stirrings and rebellions against an evil destiny which began right after the destruction of the Temple by the Romans, with the Bar Kokba revolt in the next century. This theory highlights the story of frequent â€Å"ascents† of small groups of pietists from the Diaspora to the Holy Land, occurring in every century of the medieval and pre- modern age, as expressions of a main theme — indeed, of the main theme — of â€Å"return,† which gave meaning to Jewish experience in the exile. The bond between the people and its land, which it never gave up hope of resettling, was thus never broken, and Zionism is, therefore, the consummation of Jewish history under the long-awaited propitious circumstances afforded by the age of liberalism and nationalism. Despite its neatness and appeal, this construction, which is chiefly identified with the name of the distinguished Israeli historian, Ben Zion Dinur, must be subjected to serious criticism. In the first place, it is really a kind of synthetic Zionist ideology presented as history. The assumption of being in the midst of an â€Å"end of days,† of a final resolution of the tension between the Jew and the world, is as yet unprovable. To date, even after the creation of the state of Israel, Zionism has neither failed nor succeeded. The position of the Jew is still unique in the world, and only those who are certain that their theories foretell the future can be convinced that, for example, the Diaspora will soon be dissolved. This may, indeed, be true, but an interpretation of the meaning of Zionism in Jewish history which boldly asserts that it must come to pass — as this theory does — is suspect of being doctrinaire. Much more could be said in detail about the implications of this theory that Zionism is Jewish messianism in process of realizing itself through this-worldly means. This description fits that stream of Zionist thought which remained orthodox in religious outlook, and therefore limited its tinkering with the classical messianic conception of the Jewish religion to the question of means; but this thesis pretends to apply to the main body of the movement, and, as such, it is artificial and evasive. What is being obscured is the crucial problem of modern Zionist ideology, the tension between the inherited messianic concept and the radically new meaning that Zionism, at its most modern, was proposing to give it. Zionism: Messianic Era Religious messianism had always imagined the Redemption as a confrontation between the Jew and God. The gentile played a variety of roles in this drama — as chastising rod in the divine hand, as the enemy to be discomfited, or, at very least, as the spectator to pay homage at the end of the play — but none of these parts are indispensable to the plot. In the cutting edge of Zionism, in its most revolutionary expression, the essential dialogue is now between the Jew and the nations of the earth. What marks modern Zionism as a fresh beginning in Jewish history is that its ultimate values derive from the general milieu. The Messiah is now identified with the dream of an age of individual liberty, national freedom, and economic and social justice — i. e. , with the progressive faith of the nineteenth century. This is the true Copernican revolution which modern Zionism announced — and it patently represents a fundamental change not merely in the concept of the means to the Redemption but in end values. Every aspect of Jewish messianism has been completely transmuted by this new absolute. So, classical Judaism had, for the most part, imagined that at some propitious moment an inner turning by the Chosen People would be the preamble to evoking the saving grace of God. Zionism, too, knows that the Jewish people must be remade in order to be redeemed — indeed, its sweeping and passionate demands lent themselves to being spoken in language reminiscent of the prophets — but it is supremely aware that its millennium is out of reach without the assent and co-operation of the dominant political powers.

Term Paper Help Articles for Dummies

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Essay The Future of Marriage in America - 9335 Words

http://marriage.rutgers.edu/Publications/SOOU/TEXTSOOU2007.htm The State of Our Unions The Social Health of Marriage in America 2007 Essay: The Future of Marriage in America David Popenoe  © Copyright 2007 Introduction In this year’s essay, David Popenoe argues that long-term trends point to the gradual weakening of marriage as the primary social institution of family life. More Americans today are living together, marrying at older ages or not at all, and rearing children in cohabiting or solo parent households. Overall, the U.S. trends are following the far-advanced trends toward nonmarriage in Northwestern European nations, albeit at a slower and more uneven pace. Popenoe attributes the weakening of marriage to a broad†¦show more content†¦Other possible reasons for the decreasing divorce rate are the rise of non-marital cohabitation and a decline in second and subsequent marriages. Divorcees, for example, have become more likely to cohabit rather than remarry, thus avoiding remarriages that have always had a disproportionately high risk of divorce. The Marriage Gap One surprising development of recent years is the growth of a marriage and divorce gap between differently educated segments of the population. People who have completed college (around a quarter of the population) tend to have significantly higher marriage and lower divorce rates compared to those with less education. Among those married in the early 1990s, for example, only 16.5 percent of college educated women were divorced within ten years, compared to 46 percent for high school dropouts. Indeed, most of the recent divorce rate decline has been among the college educated; for those with less than a high school education, the divorce rate actually has been rising. 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