Microvascular Capillary Plexus Findings of Commotio Retinae on Optical Coherence Tomography Angiography

Optical coherence tomography (OCT) and histopathology features of commotio retinae (CR) have been established, but alterations of the microvascular macular capillary plexus on OCT angiography (OCTA) has not been previously studied. We present a 46-year-old man who sustained a tennis ball injury to the right eye with visual acuity reduction to 20/30 and grey-white deep macular discoloration, suggestive of CR. Spectral-domain OCT (SD-OCT) showed increased reflectivity and thickness of the ellipsoid zone (junction of photoreceptor inner and outer segments). OCTA revealed no apparent microvascular alterations (right versus left eye) in the foveal avascular zone superficial (0.42 vs. 0.43 mm2) and deep (0.45 vs. 0.44 mm2), superficial foveal capillary density (34.1 vs. 32.6%), and superficial parafoveal capillary density (55.2 vs. 52.2%). Deep macular capillary plexus and choriocapillaris were qualitatively comparable between the two eyes. At 2 months' follow-up, SD-OCT had normalized. CR is characterized by disruption of the ellipsoid zone without detectable alteration of the capillary plexuses.

Central cortical cleanup and zonular deficiency

BACKGROUND

Complete removal of the cortex has been advocated to prevent posterior capsular opacification but carries the risk of zonular dehiscence, hence there is a need for a safe maximal cortical cleanup technique in eyes with severe diffuse zonulopathy in subjects above age 90.

METHODS

We used bimanual central cortical cleaning by elevating central fibers and aspirating them toward the periphery. Peripheral cortical fibers were removed passively only when they became loose due to copious irrigation. A one-piece foldable implant was inserted without a capsular tension ring. Postoperative corticosteroid drops were used.

RESULTS

This technique was safely performed in a dozen eyes with severe pseudo-exfoliation or brunescent cataract with weak zonules. Posterior capsular rupture, iritis, vitreous loss, and lens subluxation were not observed. Moderate capsular phimosis occurred but with maintained central vision.

CONCLUSION

The dogma of "complete cortical cleanup" in severe zonulopathy needs to be revisited in favor of a clear visual axis with maximal preservation of the damaged zonules. This technique is ideal in patients above age 90 where posterior capsular opacification and late dislocation of intraocular lens-capsule bag complex are unlikely to occur until several years postoperatively.

Cataractogenesis after Repeat Laser in situ Keratomileusis

There has been the unsubstantiated clinical impression that laser refractive surgery accelerates cataract development along with solid experimental data about the cataractogenic effects of excimer laser treatment. We present the first documented case of significant cataract formation in a young myope after repeat excimer laser ablation necessitating phacoemulsification with a posterior chamber implant. Proposed explanations include focusing of the ablation wave on the posterior capsule (acoustic wave lens epithelial damage), photooxidative stress of the lens (ultraviolet and inflammatory oxidative stress), and corticosteroid-induced cataract (lens toxicity).

Ocular-systemic interrelationships in acquired immunodeficiency syndrome

We analysed the correlation between ophthalmic and systemic findings in 125 subjects with AIDS and 50 subjects with AIDS-related complex (ARC). Positive eye findings were defined as the presence of cotton-wool spots (CWS) or cytomegalovirus (CMV) retinitis. The presence of positive eye findings was significantly more frequent in AIDS than in ARC (P = 0.0001). Both lowest haematocrit and lowest T-helper cell count were significantly lower in AIDS than in ARC, and also lower in subjects with positive eye findings than in those with negative eye findings. No association was found between ocular findings and the following: risk factors for human immunodeficiency virus (HIV) transmission; positive titres for CMV, herpes simplex, Epstein-Barr virus (EBV), and toxoplasmosis; systemic infections; and intake of azidothymidine (AZT). Patients with AIDS and CWS were similar to patients with AIDS and CMV retinitis in viral serology, haematocrit, T-helper count, and survival. Positive eye findings, low haematocrit, and low T-helper count are poor prognostic signs for survival in AIDS.

Ocular sequelae of pneumatic drills

PURPOSE

To determine the ocular sequelae of rock-drilling.

METHODS

Nineteen rock-drillers and 20 age-, sex- and race-matched control subjects underwent ocular examination in a prospective manner.

RESULTS

Subepithelial corneal opacities were found in 12 drillers (63%) and none of the controls; pigmented trabecular meshwork was noted in 13 drillers (68%) and 1 control (5%); low-tension glaucoma was diagnosed in 1 driller (5%); vitreous liquefaction was present in 17 of 17 drillers (100%) examined by a retina specialist and 9 of 20 controls (45%).

CONCLUSIONS

The sequelae of drilling include corneal scars from projectile pieces of drilled stone as well as vibration-induced pigment deposition in the trabecular meshwork and vitreous liquefaction. Wearing of safety glasses is recommended.

Posterior Scleritis in Familial Mediterranean Fever

PURPOSE

Familial Mediterranean fever (FMF) is a monogenic autoinflammatory disease presenting as sporadic paroxysmal attacks of fever and abdominal pain. The inflammation of serosal spaces, joints, and skin is caused by the production of an abnormal protein called pyrin. Ocular pathology is scarce in FMF.

CASE REPORT

Herein we describe a case of FMF presenting with painful loss of vision in the left eye. Serous macular detachment assessed by OCT, leaky pinpoint subretinal foci temporal to the fovea examined by fluorescein angiography, scleral and choroidal thickening seen on ultrasonography, and a negative systemic workup for vasculitis established the diagnosis of FMF-related posterior scleritis. The posterior scleritis responded promptly to moderate-dose oral corticosteroids with return of vision to baseline and resolution of the subretinal fluid.

CONCLUSIONS

FMF rarely involves the posterior pole. Visual loss in FMF results from either posterior scleritis or posterior uveitis. A high degree of suspicion of posterior scleritis is warranted in female patients with known FMF presenting with cloudy serous macular detachment.

Association of epibulbar choristomas with linear cutaneous nevi. Review of the literature

The authors describe the association of epibulbar choristomas with linear cutaneous nevi of the epidermal and sebaceous variety in 24 cases reported in the literature. The choristomas are of the bilateral, extensive, multiple and complex type. The associated ocular and systemic findings include lid and uveal coloboma, lid choristoma, alopecia, convulsions and growth retardation.

Vitreous replacement by gas as a therapeutic modality in bacterial endophthalmitis

We investigated vitreous replacement by long-lasting gas in the management of severe Staphylococcus aureus endophthalmitis in 19 rabbits randomized for vitrectomy (9 animals) and for vitrectomy followed by replacement of the vitreous by a 20% perfluoropropane-80% air mixture (10 animals). Both groups received systemic antibiotics and achieved comparable intraocular antibiotic levels. Clinically and histopathologically, gas-filled eyes demonstrated less inflammation than did eyes without gas (P less than 0.01). Replacement of vitreous by gas offers an effective adjunct to vitrectomy by eliminating a culture medium, preventing vitreous abscess formation, enabling fundus visualization, and delaying the onset of retinal detachment.

A family with iridoschisis, narrow anterior chamber angle, and presenile cataract

Familial iridoschisis is a rare ocular disease and is probably transmitted as an autosomal dominant trait. The underlying abnormalities are not understood. Family members should be screened for this condition as well as for associated ocular abnormalities, namely presenile cataracts and narrow anterior chamber angle.

Long-term outcome of treat and extend intravitreal ziv-aflibercept therapy

Aim

To assess the 30-month outcome of treat and extend (TAE) intravitreal ziv-aflibercept therapy in eyes with macular diseases.

Methods

In this prospective study, consecutive subjects received intravitreal 0.05 mL ziv-aflibercept (1.25 mg) injections for various macular diseases. Outcome measures were best-corrected visual acuity (BCVA) (logarithm of the minimum angle of resolution) and central macular thickness (CMT) on spectral domain optical coherence tomography. Paired comparison was done using Wilcoxon signed-rank test calculator.

Results

Fifty-three eyes of 48 subjects (33 naïve eyes) received intravitreal ziv-aflibercept and were followed between 12 and 30 months following TAE included neovascular age-related macular degeneration (nAMD) (35 eyes) and diabetic macular oedema (DMO) (18 eyes). In eyes with nAMD, CMT decreased by 107.8 µm at the 30-month follow-up (p=0.012) with BCVA gain of 0.52 (p=0.001). In eyes with DMO, CMT decreased by 224.3 µm at the 30-month follow-up (p=0.027) with BCVA gain of 0.46 (p=0.042). Combining all disease categories, the mean number of injections was 9.2 at month 12, 2.5 between 12 and 18 months, 1.6 between 18 and 24 months and 1.0 between 24 and 30 months.

Conclusions

Using TAE regimen, intravitreal ziv-aflibercept appeared efficacious at managing retinal disease through month 30 using the TAE regimen.

Adult ocular toxocariasis mimicking ciliary body malignancy

Purpose. To discuss an unusual presentation of ocular toxocariasis. Methods. Case report. Results. A 40-year-old woman presented with decreased vision in the left eye with a long history of recurrent red eye from uveitis. Eosinophilia and positive ELISA titers for Toxocara canis favored the diagnosis of ocular toxocariasis. Over 3 months, an anterior scleral mass had a rapid growth raising the possibility of medulloepithelioma, which rarely can mimic uveitic syndromes. Surgical plan changed from local excision to enucleation. Histopathology demonstrated a large homogeneous mass of chronic inflammatory cells with inflammation of the overlying thinned out sclera, medial rectus insertion, and limbal cornea. The triad of peripheral granuloma, eosinophilia, and positive blood serology established the diagnosis of ocular toxocariasis. Conclusions. Ocular toxocariasis can mimic ocular malignancy such as medulloepithelioma in adults and rarely presents as an anterior scleral mass.

Regression of Inflamed Pterygia by Frequent High-Dose Intralesional Ziv-Aflibercept

PURPOSE

Intralesional single low-dose vascular endothelial growth factor antagonists have traditionally failed in causing regression of pterygia. The current pilot study investigates the role of high-dose repeated intralesional ziv-aflibercept in causing regression of inflamed or recurring pterygia.

METHODS

This prospective study from January 2015 to April 2017 consisted of using high dose of ziv-aflibercept between 0.1 mL (2.5 mg) and 0.3 mL (7.5 mg), depending on the pterygium size and the degree of inflammation. The injection was deep after tunneling the 30-gauge needle away from the injection site to avoid reflux. Reinjection was done at the first sign of recurrence of inflammation. The main outcome measure was regression of pterygial vessels by central retraction as documented by slit-lamp photography and anterior optical coherence tomography.

RESULTS

Four subjects, one with bilateral pterygia, were treated. Regression of new vessels and retraction of the leading edge of pterygial vessels occurred in all treated eyes (5 eyes) with dramatic visual gain in 1 eye from counting fingers to 6/9 (20/30). Numbers of injections were 9 (1 eye; 18 mo), 3 (2 eyes; 12 and 18 mo), and 1 (2 eyes; 2.5 and 7 mo).

CONCLUSIONS

Frequent high-dose intralesional ziv-aflibercept can lead to regression and/or retraction of inflamed pterygia in this pilot study.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov, NCT02486484.

Isolated amyloidosis of anterior uvea and trabecular meshwork

Amyloid deposition in the iris is rare, scanty and associated with systemic disease. We present a case of isolated localized heavy amyloid infiltration of the iris and describe a new hillock-pattern feature visualized using scanning electron microscopy.

Central areolar choroidal dystrophy in a family with pseudoachondroplastic spondyloepiphyseal dysplasia

The author reports the first association of central areolar choroidal dystrophy in three brothers with pseudoachondroplastic spondyloepiphyseal dysplasia. Both central areolar choroidal dystrophy and pseudoachondroplastic spondyloepiphyseal dysplasia represent heterogeneous disorders with autosomal dominant transmission. It is hypothesized that this association is a result of a new subtype involving both the skeletal system and the eye.

Comet-tailed drusen of the retinal pigment epithelium in angioid streaks

PURPOSE

To describe a fundus finding in angioid streaks, namely comet-tailed drusen of the retinal pigment epithelium.

METHODS

A review was carried out of fundus photographs in 110 cases of angioid streaks.

RESULTS

Five patients had comet-tailed drusen and the halo tail was radial and parallel to adjacent angioid streaks.

CONCLUSIONS

Comet-tailed drusen may represent zones of minor stress of the retinal pigment epithelium--Bruch's membrane complex compared with zones of major stress as in angioid streaks.

Fibrinogen-induced vitreous membranes

Fibrinogen was injected in the vitreous cavity of 29 rabbits with follow-up for 75 days. Vitreous membrane formation was detected by indirect ophthalmoscopy and confirmed by histopathological study. Membrane formation was significantly more common in the fibrinogen group than in the control group. Fifteen days after injection, the membranes decreased in size and gave place to vitreous liquefaction in the majority of eyes in the fibrinogen group. Histochemical stains for fibrinogen were positive in half of the vitreous membranes. Fibrinogen is thought to be transformed into a long fibrin polymer forming a matrix for surrounding cells to proliferate in the vitreous. An effective fibrinolytic system in the vitreous explains the ultimate resolution of most of the fibrinogen-induced membranes. Simple fibrinogen injections do not provide a good model for long-term vitreous band formation, yet they add more evidence to the role of fibrin in the pathogenesis of vitreoproliferative diseases. The spontaneous resolution of some proliferative vitreoretinopathies parallels the reversibility of most of the fibrinogen-induced vitreous membranes.

Autologous tenon plug and patch in phacoburn

This 75-year-old woman had phacomorphic angle closure, dense nuclear sclerosis, deep set eye, miotic pupil and tight corneal wound during phacoemulsification. Phacoemulsification wound burn was noted at the end of surgery. Tenon was harvested from the inferior conjunctiva, placed over the gape and anchored by two radial corneoscleral 10-0 nylon. Ten days later, anterior optical coherence tomography showed good wound apposition and sutures were removed with visual recovery to 20/25 (6/7.5) without astigmatism.

Hemorrhagic retinal macrocysts, simulating choroidal melanoma: a case report

INTRODUCTION

Hemorrhagic retinal macrocysts are extremely rare retinal lesions that can be mistaken for malignancy with subsequent enucleation. Such a case was diagnosed, by a retina specialist based on ultrasonography, as a choroidal melanoma with exudative retinal detachment and the patient was advised to have brachytherapy.

CASE PRESENTATION

A 15-year-old Caucasian boy suffered sudden visual loss in the left eye and exam revealed vitreous hemorrhage. Magnetic resonance imaging revealed the mass as hyperintense on T1-weighted images and isointense on T2-weighted images with no enhancement after gadolinium dye. Following scleral buckle, the hemorrhagic retinal macrocyst collapsed gradually over a period of 5 weeks. The patient recovered visual acuity of 6/7.5 at the 1-year follow up.

CONCLUSION

A hemorrhagic retinal macrocyst can be erroneously diagnosed as choroidal melanoma. Hints for the presence of retinal macrocysts include: egg shape; cyst wall configuration; no attachment to the choroid; and presence of retinal detachment.

Role of peripheral pan-retinal photocoagulation in diabetic macular edema treated with intravitreal ziv-aflibercept

PURPOSE

The aim of this study was to investigate the possibility of decreasing the number of intravitreal anti-VEGF by peripheral pan-retinal photocoagulation (PPRP) in managing diabetic macular edema (DME) in a subcategory of patients who cannot comply to strict anti-VEGF follow-up protocols.

MATERIALS AND METHODS

This is a pilot prospective study. Consecutive patients with naïve DME were offered the choice of treatment and extend intravitreal ziv-aflibercept if they showed willingness for good compliance or PPRP with modified pro re nata intravitreal injections.

RESULTS

Six eyes of 3 patients had PPRP versus 4 eyes of 4 patients had injections only. The number of anti-VEGF injections was markedly decreased when PPRP was administered from a mean number of injections of 16.8 (range 13-21; mean follow-up 24.3 months) to a mean number of 4.5 (range 0-8; mean follow-up 33.7 months). Mean initial central macular thickness (CMT) was 462.0 mm in the injection only group vs 457.3 mm in the PPRP group. Mean final CMT was 462.0 in the injection only group vs 350.0 in the PPRP group. Baseline and final mean logMAR (Snellen equivalent) best-corrected visual acuity was initially and finally 0.84 (20/137) and 0.60 (20/80) in the injection only group and 0.70 (20/100) and 0.69 (20/98) in the PPRP group, respectively. The monthly cost for the PPRP group was one-third of the monthly cost for the injection only group.

CONCLUSION

PPRP allowed for a decrease in the number of intravitreal anti-VEGF injections in selected DME patients (sick, difficult to ambulate, financial burden, and fear of injections).

A Case-Cohort Study of Exfoliation Risk Factors and Literature Review

The purpose of the study is to evaluate the risk factors associated with exfoliation in a case-cohort setting and literature review. This single-center, prospective, case-cohort study was carried out from January 2010 to April 2020 on patients operated for cataract surgery by a single surgeon in Lebanon. Forty-nine consecutive patients with exfoliation syndrome (XFS) and 62 consecutive control patients were identified and further investigated for selected systemic (diabetes mellitus, systemic hypertension, asthma, or atopy) and ocular variables (baseline vision, severity of nuclear sclerosis, glaucoma, eye rubbing, history of dry eye, or allergic eye disease). The mean baseline Snellen visual acuity was 20/283 in XFS versus 20/145 in control cases (P = 0.012). XFS also demonstrated significantly denser nuclear sclerosis than controls (P = 0.00958). By univariate analysis, allergic conjunctivitis (15 [30.6%] vs. 2 [3.2%]; P < 0.001), dry eye (20 [40.8%] vs. 13 [21.0%]; P = 0.0133), and habitual rubbing of the eyes (33 [67.3%] vs. 19 [30.6%]; P < 0.001) were associated with the presence of XFS. Habitual ocular rubbing was closely associated with allergic conjunctivitis (odds ratio [OR] = 13.0; 95% confidence interval [CI]: 2.8–58.8; P = 0.032). After multivariable analysis, the following variables showed significant results: glaucoma (OR = 34.5; 95% CI: 4.4–250; P = 0.010), duration of surgery (OR = 5.6; 95% CI 2.43–12.9; P < 0.001), and habitual ocular rubbing (OR = 4.42; 95% CI: 1.97–9.90; P = 0.029). This study shows a novel potential correlation between eye rubbing and XFS in a Lebanese cohort. Chronic eye rubbing induces or may exacerbate preexistent zonular damage in subjects with XFS, hence the need to better manage concurrent ocular surface disorder in these patients.