Choroideremia presenting as vision loss secondary to choroidal neovascularization

BACKGROUND

Choroidal neovascularization (CNV) is a rare complication of choroideremia that occurs secondary to relative atrophy of the retinal pigment epithelium and eventual rupture of Bruch's membrane. The ideal management of CNV in choroideremia is unclear.

MATERIALS AND METHODS

Case report.

OBSERVATIONS

A 14-year-old male with no known ocular history presented to the eye emergency department complaining of a central scotoma in the right eye for 4 days. He had no past medical history and family history was unremarkable for known ocular disease. Visual acuity was 20/70 in the right eye and 20/30 in the left eye. Posterior segment exam revealed chorioretinal atrophy extending from the outer macula to the midperiphery in both eyes. There was CNV with associated subretinal hemorrhage in the right eye. Optical coherence tomography demonstrated the presence of CNV with subretinal fluid in the right eye and parafoveal outer retinal atrophy in both eyes. Genetic testing revealed a hemizygous exon 2 deletion on the CHM gene, pathogenic for choroideremia. The patient received a total of 3 injections 4 weeks apart followed by 1 injection 6 weeks later with resolution of the subretinal hemorrhage and reduction in CNV size with improvement in visual acuity to 20/20 at last follow-up exam.

CONCLUSIONS AND IMPORTANCE

Choroidal neovascularization is a rare cause of central vision loss in patients with choroideremia. In this report, we demonstrate a good functional and anatomic response to intravitreal bevacizumab in a 14-year-old patient with undiagnosed choroideremia who presented with CNV-induced central vision loss.

Patients With Dragged Optic Disc Vessels and Retinal Folds: Clinical Features, Multimodal Imaging, and Histopathology

BACKGROUND AND OBJECTIVE

To describe the multimodal imaging and histopathological features of patients with dragged optic disc vessels (DODV).

PATIENTS AND METHODS

This is a retrospective, observational analysis using multimodal imaging of eyes with DODV in patients with retinal vascular diseases including familial exudative vitreoretinopathy, inflammatory disease, and others. In addition, two additional enucleated eyes with DODV underwent histopathological analysis.

RESULTS

Of the 13 patients, eight were girls and five were boys. Mean age was 5 years (ranging from 4 months to 10 years old). Of the 15 eyes, 12 (80%) demonstrated temporal dragging and three (20%) had nasal dragging. Retinal vascular abnormalities were present in 11 of the fellow eyes. Multimodal imaging demonstrated features of DODV including direction of traction, outer retinal thickening, increased flow, and other features. Only two (13.3%) eyes required surgical intervention. Mean follow-up was 14 (range 3 to 30 months) months. At last follow-up all eyes remained stable. Last visual acuity ranged from 20/100 to counting fingers. As well, two enucleated globes of adults with retinopathy of prematurity underwent histopathologic evaluation, showing optic nerve fibers that extended from the optic nerve into the DODV.

CONCLUSIONS

DODV is a sign of various late-stage retinal vascular diseases, associated with poor visual function. Multimodal imaging and histopathology can assist in understanding the disease pathology. [Ophthalmic Surg Lasers Imaging Retina 2023;54:634-642.].

Outcomes in Patients with Suprachoroidal Hemorrhage After Anterior Segment Surgery

Objective

The purpose of the current study is to report outcomes of suprachoroidal hemorrhage (SCH) after anterior segment surgery at a single institution, and to identify clinical features associated with visual prognosis.

Methods and Analysis

Retrospective consecutive case series of patients with SCH occurring after anterior segment surgery.

Results

The study includes 112 eyes of 112 patients between 2014 and 2020. There were 76 cases of non-appositional SCH versus 36 cases of appositional SCH. The mean presenting visual acuity for patients with non-appositional versus appositional SCH was 2.03 logMAR (SD 0.78) versus 2.39 logMAR (SD 0.43), respectively. Visual acuity outcomes generally remained poor at last follow-up: 64 (58%) patients had a visual acuity (VA) of ≤ 20/200, including 19 (17%) with light perception (LP), and 11 (10%) with no light perception (NLP). Regarding management of non-appositional versus appositional SCH, observation was selected in 46 (61%) vs 12 (33%), delayed drainage in 14 (18%) vs 15 (42%), delayed pars plana vitrectomy in 16 (21%) vs 13 (36%), and VA at last follow-up was 1.2 versus 1.86 logMAR (p=0.002). In patients that were observed, both appositional SCH (p=0.01) and duration of apposition (p=0.04) were correlated with worse outcome.

Conclusion

Appositional SCH was associated with poorer visual outcomes compared to non-appositional SCH. Observation remains a reasonable management strategy for non-appositional SCH.

Diagnosis and management of iatrogenic trochar-induced cyclodialysis cleft with intraoperative gonioscopy and argon endolaser

Purpose

To report a case of iatrogenic vitrectomy trochar-induced cyclodialysis cleft successfully treated with intraoperative argon endolaser.

Observations

A 68-year-old Caucasian male with a history of high myopia underwent pars plana vitrectomy to clear symptomatic vitreous opacities but developed early postoperative hypotony that was recalcitrant to medical management for the first 6 postoperative months. Intraoperative gonioscopy demonstrated a cyclodialysis cleft and argon endolaser was applied to close the cleft.

Conclusions and Importance

Endolaser is an effective treatment for cyclodialysis clefts and intraoperative gonioscopy allows direct visualization of the cleft in a controlled operating room setting. Placement of vitrectomy ports should be done with care in high myopes to avoid accidental piercing of the ciliary body and inducing a cyclodialysis cleft.

Comparison Between Graders in Detection of Diabetic Neovascularization With Swept Source Optical Coherence Tomography Angiography and Fluorescein Angiography

PURPOSE

We compared the ability of ophthalmologists to identify neovascularization (NV) in patients with proliferative diabetic retinopathy using swept-source optical coherence tomography angiography (SS-OCTA) and fluorescein angiography (FA).

DESIGN

Retrospective study comparing diagnostic instruments.

METHODS

Eyes with proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy and a high suspicion of NV based on clinical examination were imaged using SS-OCTA and FA at the same visit. Two separate grading sets consisting of scrambled, anonymized SS-OCTA and FA images were created. The ground truth for presence of NV was established by consensus of 2 graders with OCTA experience who did not participate in the subsequent assessment of NV in this study. The 2 anonymized image sets were graded for presence or absence of NV by 12 other graders that included 2 residents, 6 vitreoretinal fellows, and 4 vitreoretinal attending physicians. The percentage of correct grading of NV using SS-OCTA and FA was assessed for each grader and across grader training levels.

RESULTS

Forty-seven eyes from 24 patients were included in this study. Overall, the mean percentage of correct NV grading was 87.8% using SS-OCTA with B-scans and 86.2% using FA (P = .92). Assessing each grader individually, there was no statistically significant asymmetry in correct grading using SS-OCTA and FA.

CONCLUSIONS

Ophthalmologists across training levels were able to identify diabetic NV with equal accuracy using SS-OCTA and FA. Based on these results, SS-OCTA may be an appropriate standalone modality for diagnosing diabetic NV.

Ocular trauma secondary to exercise resistance bands during the COVID-19 pandemic

Objective

To characterize injuries caused by exercise resistance bands.

Method

Single-site retrospective case series of patients presenting to the Bascom Palmer Eye Institute emergency room with ocular injuries secondary to exercise resistance bands from March through September 2020.

Results

Eleven patients (9 males, 2 females, 14 eyes) were reviewed. Eight patients had a unilateral injury (3 right eyes, 5 left eyes) while 3 had bilateral injuries. Iritis was the most common presentation, seen in all 11 patients, followed by hyphema (9 patients, 82%), and vitreous hemorrhage (4 patients, 36%). Among affected eyes, the mean presenting visual acuity was approximately 20/100, improving to 20/40 on the last follow up (p = 0.06). However, 4 eyes (33%) had vision ≤20/60 at last follow up.

Conclusions

Exercise resistance bands can cause a wide spectrum of ocular injuries, some leading to long-term vision loss. As such, we recommend that patients strongly consider using eye protection goggles or glasses while using resistance bands for exercise.

Peripheral combined hamartoma of the retina and retinal pigment epithelium with remote peripapillary choroidal neovascular membrane

Purpose

To describe the first reported case of combined hamartoma of the retina and retinal pigment epithelium (CHRRPE) associated with a remote choroidal neovascular membrane (CNVM).

Observations

A 19-month-old girl with a normal prenatal and infantile history presented with esotropia of the left eye. Fundus examination demonstrated a large, elevated, charcoal-colored lesion in the nasal equatorial retina. There was dragging of the nasal retinal vessels and a retinal fold, presumed to have resulted from nasal traction from the lesion. There was also subretinal hemorrhage in the peripapillary macula. Multimodal imaging demonstrated a peripapillary choroidal neovascular membrane (CNVM) underlying the retinal fold. There was no leakage within the tumor or secondary retinal neovascularization. Examination of the fellow eye was unremarkable. The patient was diagnosed with peripheral CHRRPE with associated peripapillary CNVM. She was treated with serial intravitreal bevacizumab to the affected eye which resulted in a reduction in leakage from the CNVM and resolution of the subretinal hemorrhage. The CHRRPE remained stable on follow-up.

Conclusions

Peripheral CHRRPE can rarely be associated with a remote CNVM.

Social media in ophthalmology: An analysis of use in the professional sphere

To characterize how ophthalmologists are using social media in their practice. A survey regarding ophthalmologists’ personal and professional use of social media was distributed online through a university alumni listserv. Data collection occurred over 4 weeks from January to February 2020. In total, 808 ophthalmologists opened the survey email, and 160 responded (19.8%). Of 160 respondents, 115 (71.9%) participated in social media for personal use. Professional use of social media was noted by 63 (39.4%) respondents. Age >40 years old correlated with less personal ( X2 = 5.06, p = 0.025) but not professional use ( p = 0.065). Private practice was associated with more use of social media professionally compared to those in an academic or Veteran’s Affairs hospital ( X2 = 6.58, p = 0.037). A majority of respondents (58.7%) were neutral regarding the effect of social media on their practice. The present survey showed that nearly 40% of respondents are involved in social media in a professional context. Private practice correlated with increased use of social media professionally, but providers were most commonly neutral regarding the impact of social media on their practice. This finding suggests further avenues of research including how providers using social media professionally are defining and assessing successful use.

A Characterization of Ophthalmology Residency Program Social Media Presence and Activity

Objective To determine the presence and activity of ophthalmology departments associated with residency programs on social media platforms and the use of these social media platforms by residency applicants.

Design Cross-sectional online assessment of ophthalmology training program departments' presence and activity on Facebook, Twitter, and Instagram.

Participants A total of 120 accredited ophthalmology residency training programs and 498 ophthalmology residency applicants.

Methods Each department was evaluated by (1) searching for social media links on the department's Web site, (2) searching for the department on Facebook, Twitter, and Instagram, and (3) searching on Google. A simultaneous survey was conducted to assess social media platform use of 2019 to 2020 ophthalmology residency application cycle candidates.

Main Outcomes The presence of ophthalmology departments on Facebook, Twitter, and Instagram, as well as the total number of followers and posts during January 2020.

Results Of 120 programs evaluated, 45 programs (37.5%) had a Facebook page, 29 (24.3%) were on Twitter, and 22 (18.3%) had an Instagram page. Among top 20 Doximity-ranked ophthalmology programs, 80% had at least one social media page on Facebook, Twitter, or Instagram compared with 33% among the remainder of programs (chi-square test = 15.2, p < 0.001). Top 20 programs also had more followers compared with others on Facebook (4,363 vs. 696, respectively, p < 0.0001) and Twitter (3,673 vs. 355, respectively, p = 0.007) but not on Instagram (1,156 vs. 1,687, respectively, p = 0.71). Among 498 residency applicants to Bascom Palmer Eye Institute from the 2019 to 2020 cycle, 159 (31.9%) responded to a survey regarding their use of social media during the application process. In total, 54 (34%) responded that they used social media to evaluate residency programs.

Conclusion Departments of top 20 ophthalmology residency had both a greater presence and following on social media compared with other departments. While Facebook was the most used platform by ophthalmology departments, applicants most commonly used Instagram. As applicants come to use these social media resources more frequently, ophthalmology residency programs may increasingly benefit from maintaining an active social media page.

Chronic, Recurrent Bacterial Endophthalmitis Caused by Achromobacter xylosoxidans: Clinical Features and Management

A 79-year-old man presented to a tertiary referral center from the Dominican Republic with an opaque corneal graft and a diagnosis of chronic, recurrent culture-positive Achromobacter xylosoxidans endophthalmitis of the left eye. The patient had a history of penetrating keratoplasty for Fuchs' dystrophy and had undergone multiple intraocular surgeries including pars plana vitrectomy and anterior chamber wash out for the diagnosis and management of chronic endophthalmitis. After being referred, the patient underwent a third PKP, removal of his intraocular lens (IOL), capsulectomy, and injection of intravitreal antibiotics. All surgical specimens demonstrated the growth of A. xylosoxidans. Five months after surgery, the graft remained clear without evidence of infection and best-corrected visual acuity was 20/350.

Asymmetric retinopathy of prematurity in presumed fungal endophthalmitis

Purpose

To report a case of asymmetric retinopathy of prematurity (ROP) in a neonate with endophthalmitis.

Observations

A 25-week old female was born by caesarean section due to preeclampsia. The patient required supplemental oxygen after birth. The neonatal period was complicated by sepsis secondary to necrotizing enterocolitis with intestinal perforation. The patient subsequently developed endophthalmitis in the right eye. A fungal ball was seen overlying the termination of a persistent hyaloid artery. The patient also had ROP, identified at 31 weeks postconceptional age, which progressed asymmetrically and demonstrated greater severity in the eye affected by endophthalmitis. The endophthalmitis resolved with intravitreal antifungal treatment and systemic therapy. The right eye was also treated with intravitreal bevacizumab, demonstrating regression of ROP severity on follow up.

Conclusions and Importance

The present case describes the first reported case of asymmetric ROP associated with endophthalmitis. The more severe ROP occurred in the eye with endophthalmitis suggesting that, outside of systemic factors, the local ocular inflammatory environment is important in determining the progression of ROP. Additionally, the fungal ball present in the eye affected by endophthalmitis was seen at the termination of the hyaloid artery, suggesting the hyaloid artery as the route of entry of the fungus into the vitreous.