Bilateral macular holes resulting from septic embolization

ATYPICAL MACULAR HOLES

PURPOSE

To study the etiology, clinical features, management options, and visual prognosis in various types of atypical macular holes (MHs).

METHODS

A review of the literature was performed, which focused on the etiopathogenesis of atypical or secondary MHs, their differentiating clinical features, management strategies, and varied clinical outcomes. Idiopathic or age-related, myopic, and traumatic MHs were excluded.

RESULTS

Atypical or secondary MHs arise out of concurrent ocular pathologies (dystrophy, degeneration, or infections) and laser/surgery. The contributing factors may be similar to those responsible for idiopathic or typical MHs, i.e., tangential or anteroposterior vitreofoveal traction or cystoid degeneration. The management is either observation or treatment of the underlying cause. The prognosis depends on the background pathology, duration of disease, and baseline visual acuity governed by the size of MH and morphologic health of underlying RPE and photoreceptors. The closer the morphology of atypical MH is to that of an idiopathic MH, the better the surgical outcome is.

CONCLUSION

With the advancements in retinal imaging, atypical MHs are now more frequently recognized. With increasing understanding of the underlying disease processes, and improvement in investigations and surgical treatment, management of atypical MHs may improve in the future.

Macular hole formation secondary to bacterial septic embolism demonstrated by serial spectral-domain optical coherence tomography imaging

PURPOSE

To describe a case of macular hole (MH) formation secondary to bacterial septic embolism and demonstrate the changing thereof using serial spectral-domain optical coherence tomography (SD-OCT) images.

METHODS

A single case report.

RESULTS

A 69-year-old woman who had been diagnosed with Klebsiella pneumonia septicemia was referred for decreased vision in her left eye. Impending MH was detected by SD-OCT and retinitis with multiple retinal hemorrhages by funduscopy. One week after the initial visit, a full-thickness MH had formed, and 13 weeks after the initial visit, we were able to close the MH following vitrectomy and gas tamponade. The MH was formed by retinal thinning due to outer retinal disruption without vitreomacular traction.

CONCLUSION

Metastatic retinal septic embolism and consequent outer retinal disruption can cause MH. Ophthalmologists must be aware of the possibility of MH in cases of retinal metastatic bacterial septic embolism, especially if the lesion infiltrates the fovea.

Bilateral foveal cysts secondary to Streptococcus constellatus endocarditis

Infective endocarditis can be acute or subacute, depending on the virulence of the causative organism. It can also cause loss of vision by a variety of mechanisms, ranging from embolic retinal artery occlusion to endogenous endophthalmitis. We illustrate the first report of foveal cyst formation secondary to infective endocarditis. A 53-year-old man presented to his general practitioner with a variety of constitutional symptoms, but initial laboratory and imaging investigations revealed only mild normocytic anaemia, and he was discharged from further medical care. Four weeks later he developed bilateral visual loss associated with whitish lesions of the superficial retina at both foveae. These later developed into foveal cysts with disruption of the photoreceptor inner segment-outer segment junction and persistent poor visual acuity of 6/60 OU. No retinal haemorrhages or Roth spots were noted. Only after he presented with visual loss did further investigations reveal the underlying diagnosis of streptococcal endocarditis. Ophthalmologists assessing retinal pathology which presents in association with undiagnosed constitutional symptoms are advised to refer such patients promptly for thorough medical investigation, including blood culture and echocardiography where appropriate.

Macular hole surgery in 2000

Patient selection and surgical experience have increased the closure rates for idiopathic macular holes to more than 90%. The best surgical results are obtained in patients with acute idiopathic macular holes. Biologic adjuvants are not as useful as they were once thought to be. Internal limiting membrane peeling and endolaser are useful for failed macular holes, reopened macular holes, and chronic macular holes. Internal limiting membrane peeling may not be necessary for acute idiopathic macular holes, provided a complete posterior vitreous detachment is created. Silicone oil tamponade should be considered in patients who have positioning problems or air travel plans. Humidifying the infusion air may reduce postoperative visual field defects. Every patient with a macular hole should be given the opportunity to improve his or her vision with macular hole surgery.

A prospective search for ocular lesions in hospitalized patients with significant bacteremia

The purpose of this study was to determine the prevalence, risk factors, and prognostic value of ocular lesions in unselected patients with bacteremia. A total of 202 bacteremic patients, 101 nonbacteremic septic patients, and 90 nonseptic control patients were compared in a prospective, controlled, observational study. Ocular lesions related to bacteremia were found in 12% of the bacteremic group, 5% of the septic group, and 2% of the control group. Ocular lesions were significantly more frequent in the bacteremic patients than in the control patients (P=.007). The severity of the clinical condition and the presence of fungemia predict independently a higher risk of ocular lesions. Mortality rates among bacteremic patients with and without ocular lesions were, respectively, 32% and 8% (P<.01; OR, 3.99). The asymptomatic nature of most ocular lesions in patients with bloodstream infections and the impossibility of amelioration in most cases lead us to recommend ophthalmologic examination for bacteremic patients only when prognostic information is needed.

Macular hole

A macular hole is a full-thickness defect of retinal tissue involving the anatomic fovea, thereby affecting central visual acuity. Macular holes have been associated with myriad ocular conditions and originally were described in the setting of trauma. The pathogenesis of idiopathic, age-related macular holes remains unclear despite a litany of theories. Recently, Gass has described an updated biomicroscopic classification of macular holes and postulated that tangential vitreous traction may play a role. Cellular components surrounding the rim of macular holes may also contribute tangential traction forces and elevate the rim. Pseudomacular holes may be mistaken for macular hole lesions, despite careful clinical examination. Careful biomicroscopic examination with a contact lens and use of the Watzke and laser aiming beam tests help to ensure accurate diagnosis. Newer imaging technology, such as optical coherence tomography, helps distinguish true macular holes from pseudoholes and may provide additional insight into the pathogenesis of this condition. Surgical management with or without pharmacosurgical adjuncts can improve vision in select cases. The most common surgical complication is progressive lens opacification in phakic patients.