Quantitative evaluation of metamorphopsia with M-CHARTS™ and evaluation of retinal morphologic changes by optical coherence tomography before and after pars plana vitrectomy in patients with idiopathic epiretinal membrane

PURPOSE

We aimed to quantitatively evaluate metamorphopsia pre- and postoperatively in patients with idiopathic epiretinal membrane(iERM) using M-CHARTS™ and to evaluate the relationship between morphological changes in retinal layers on optical coherence tomography (OCT) and metamorphopsia scores.

MATERIALS AND METHODS

This prospective study included 42 patients followed in Akdeniz University Hospital Ophthalmology Clinic diagnosed with iERM by fundus examination and OCT between 2020-2022. Detailed ophthalmologic findings, visual acuities, metamorphopsia scores, and OCT parameters of all patients were recorded. The relationship between pre- and postoperative visual acuity, metamorphopsia scores and OCT parameters was investigated. Changes in OCT parameters were compared by evaluating patients with stable or increasing metamorphopsia scores as one group (group1) and patients with decreasing metamorphopsia scores as the other group (group 2).

RESULTS

In "group 2", preoperative Ganglion Cell Layer+Inner Plexiform Layer (Central) (GCL+IPL (C)) was significantly (P: 0.028) higher than in "group 1".

CONCLUSION

A statistically significant preoperative thickness difference in the OCT parameters of the GCL+IPL (C) layer was associated with the quantitative metamorphopsia complaints of the patients. The thickness of the preoperative GCL+IPL (C) layer can be considered an important indicator of symptoms of metamorphopsia determining functional success after surgery.

Comparative Evaluation of Visual Outcomes in Combined Cataract and Vitrectomy for Idiopathic Epiretinal Membrane with an Advanced or Conventional Intraocular Lens

INTRODUCTION

The aim of this study was to investigate the efficacy of new monofocal intraocular lens (IOL) in comparison with conventional monofocal IOL in patients undergoing combined cataract and vitrectomy surgery for epiretinal membrane (ERM).

METHODS

This prospective non-randomized comparative study included 65 eyes of 65 patients who underwent combined cataract and vitrectomy for ERM with implantation of advanced monofocal IOL (Eyhance ICB00, 33 patients) and standard monofocal IOL (Tecnis ZCB00, 32 patients). Monocular visual acuities were measured 6 months post-operatively, including corrected and uncorrected distance visual acuity (CDVA, UCDVA), uncorrected intermediate visual acuity (UCIVA), and uncorrected near visual acuity (UCNVA). Furthermore, contrast sensitivity and metamorphopsia were measured.

RESULTS

There was no significant difference between two groups regarding operation time, post-operative CDVA, UCDVA, UCNVA, and spherical equivalent (p > 0.05). Monocular UCIVA was significantly higher in the Eyhance IOL group than in the Tecnis IOL group (p = 0.005). The photopic and mesopic contrast sensitivities were comparable between each group for any spatial frequency (p > 0.05). The correlation coefficients from correlations between retinal wrinkling ratio and M score did not differ significantly between groups (p = 0.877), and the degree of metamorphopsia was not significantly related to the type of IOL (p = 0.969).

CONCLUSIONS

In combined cataract and vitrectomy for ERM, Eyhance IOL provided significant better visual performance at intermediate distance than standard monofocal IOL without compromising operation time, distance vision, contrast sensitivity, and evaluating metamorphopsia. Eyhance IOL can be a useful option for both surgeons and patients.

Quantitative Analyses of Retinal Traction Force and Metamorphopsia in Lamellar Macular Hole and Related Diseases

Purpose

To investigate the involvement of retinal traction in the pathogenesis of lamellar macular hole (LMH) and related diseases based on OCT-based consensus definition.

Design

Retrospective, observational study.

Participants

Seventy-two eyes with LMH, epiretinal membrane foveoschisis (ERM-FS), or macular pseudohole (MPH).

Methods

To quantitatively evaluate the involvement and strength of retinal traction in their pathogenesis, retinal folds were visualized with en face OCT imaging, and the maximum depth of the parafoveal retinal folds (MDRF) was measured. Metamorphopsia was quantified by measuring the minimum visual angle of dotted lines needed to cause it to disappear using M-CHARTS (Inami).

Main Outcome Measures

Maximum depth of retinal folds and M-CHARTS scores.

Results

Of the 72 eyes, 26 were classified as having LMH, 25 as having ERM-FS, and 21 as having MPH. Parafoveal retinal folds were observed in 7 (26.9%) eyes with LMH, 25 (100%) with ERM-FS, and 21 (100%) with MPH. The MDRF (7.5 ± 17.6 μm) was significantly smaller in LMH than in ERM-FS (86.3 ± 31.4 μm) and MPH (74.5 ± 24.6 μm) (both P < 0.001), whereas no significant difference in MDRF between MPH and ERM-FS was observed (P = 0.43). A significant positive correlation between MDRF and M-CHARTS scores was observed in ERM-FS and MPH (P = 0.008 and 0.040, respectively) but not in LMH (P = 0.073).

Conclusions

Retinal traction was significantly weaker in the LMH group than in the ERM-FS and MPH groups. The MDRF was significantly associated with the degree of metamorphopsia in the ERM-FS and MPH groups. These results provide insights into the diseases' pathophysiology and treatment strategy.

Binocular metamorphopsia in patients with branch retinal vein occlusion: a multi-center study

PURPOSE

The pathology of branch retinal vein occlusion (BRVO), a retinal circulatory disease, is related to monocular metamorphopsia-related vision impairment of the affected eyes, but the association of binocular metamorphopsia in such patients is unclear. This study aimed to examine the frequency of binocular metamorphopsia and its association with the clinical characteristics of patients with BRVO.

METHODS

A total of 87 patients who were treated for BRVO-associated macular edema (ME) were included in this study. At baseline and 1 and 3 months after the initiation of anti-vascular endothelial growth factor (VEGF) treatment, we quantified metamorphopsia in the affected eyes and binocular metamorphopsia using the M-CHARTS^® diagnostic tool.

RESULTS

At baseline, 53 and 7 patients had metamorphopsia in the affected eyes and binocular metamorphopsia, respectively. Although the visual acuity improved significantly after the initiation of anti-VEGF treatment, the mean M-CHARTS score in the affected eyes did not change from the baseline score. At 3 months, 9 patients showed binocular metamorphopsia; it was significantly associated with metamorphopsia in the affected eyes with a 95% confidence interval of 0.021-0.122 (β = 0.306, p = 0.006).

CONCLUSION

Metamorphopsia in the affected eyes can cause binocular metamorphopsia in patients with BRVO-ME.

[Disorders of the visual system following vitreoretinal and macular surgery]

The visual system is highly complex. Monocular or binocular disorders can develop, for example during tractive alterations of the macula, such as in epimacular membranes, and result in symptoms, such as double vision, aniseikonia or metamorphopsia. These symptoms are also observed following vitreomacular or vitreoretinal surgery, especially after treatment of large retinal detachment involving the macular area using pars plana vitrectomy or scleral buckle surgery but also as a result of vitreomacular interventions, such as membrane peeling in epimacular gliosis. Some patients have preoperatively existing latent conditions, which are not explicitly addressed during routine preoperative diagnostics. For patients and surgeons it is worth noting that these troublesome symptoms are often manifested in patients with good restoration of best corrected visual acuity following vitreomacular surgery. In such cases, patients tend to be dissatisfied with the surgical result despite good visual acuity. Treatment of postoperative metamorphopsia, aniseikonia and double vision is often difficult. In clinical studies, the maximum depth of tractive retinal folds has been described as a reliable morphological biomarker for the occurrence of metamorphopsia in epimacular gliosis. As metamorphopsia tends to postoperatively resolve slowly and even persist in ca. 30% of cases, this biomarker can have an impact on preoperative consulting and postoperative monitoring. Persistent binocular discomfort is often treatable by exact refraction correction and by applying a vertical and, if necessary, a horizontal prism. This often requires patience on the part of both the patient and the physician but is mostly successful due to fusion and adaptability.

Choroidal macrovessel and persistent metamorphopsia after epiretinal membrane surgery

We report the case of a 59-year-old man with decreased visual acuity and metamorphopsia in both eyes in the context of bilateral epiretinal membrane (ERM) who underwent retinovitreal surgery (chromovitrectomy plus peeling of internal limiting membrane). He recovered visual acuity in his left eye. However, the visual results of his right eye were not satisfactory, with persistence of metamorphopsia in that eye. The multimodal imaging study that included color and red filter retinographies, enhanced depth imaging optical coherence tomography (EDI-OCT), fluorescein angiography (FA), indocyanine green angiography (ICGA), OCT angiography (OCTA) and OCT en face, were useful to diagnose a choroidal macrovessel. This ran from the fovea to the temporal macula. EDI-OCT revealed that the choroidal macrovessel generated a foveal deformation of both the ellipsoid zone (EZ) and the retinal pigment epithelium (RPE). This paper discusses whether structural changes in the fovea generated by the choroidal macrovessel are related to persistent metamorfopsia in the affected eye.

Symptomatic idiopathic bilateral multifocal retinal pigment epithelial detachments

Purpose

To report a rare case of idiopathic bilateral serous retinal pigment epithelial detachments.

Observations

We present a case of a 43-year-old female patient with metamorphopsia with the presence of innumerable bilateral serous retinal pigment epithelial detachments. Detailed ocular and systemic clinical work-up revealed no underlying disease.

Conclusions

/Importance: Idiopathic multiple serous retinal pigment epithelial detachments are an extremely rare condition, that has been observed as an incidental clinical finding in asymptomatic patients. Multimodal imaging and detailed systemic work up are essential to rule out an underlying disease. Initial symptoms, as in our case, are uncommon and usually occur only in patients with complications such as choroidal neovascularization or hemorrhages. Therefore, regular follow ups are recommended to early detect and treat possible complications.

•

Idiopathic multiple serous retinal pigment epithelial detachments (PEDs) are an extremely rare condition.

•

Multimodal imaging is essential to confirm the serous nature of the PEDs and to rule out presence of an underlying disease.

•

Regular follow ups are recommended to early detect and treat possible complications.

Comparison of surgical outcomes after removal of epiretinal membrane associated with retinal break and idiopathic epiretinal membrane

PURPOSE

To compare the surgical outcomes of epiretinal membranes (ERMs) associated with retinal break and idiopathic ERMs.

METHODS

This retrospective study included patients with an idiopathic ERM or an ERM associated with retinal break, who were followed up for ≥ 6 months after ERM removal. The postoperative functional and anatomical outcomes were compared between the groups.

RESULTS

A total of 160 and 38 eyes (198 patients) were in the idiopathic and retinal break groups, respectively. There was no significant difference in the baseline anatomical and functional parameters between the groups. At 6 months after surgery and at the final follow-up, best-corrected visual acuity, central foveal thickness, and ectopic inner foveal layer improved significantly in both groups, but there was no significant difference between the groups. In latter 49.0% of patients, tests for metamorphopsia and aniseikonia were performed. There was a significant improvement in the scores of metamorphopsia (0.40 ± 0.38 to 0.27 ± 0.28; p < 0.001) and aniseikonia (6.07 ± 4.46 to 4.11 ± 3.52; p < 0.001) in the idiopathic group at 6 months after surgery, but not in the retinal break group. The idiopathic group had significantly greater circularity of ERM extent compared to the retinal break group (p = 0.025).

CONCLUSION

Visual and anatomical improvements after removal of ERMs associated with retinal break and idiopathic ERMs were comparable. However, metamorphopsia and aniseikonia improved only after removal of idiopathic ERMs.

[Subretinal air injection for treatment of retinal folds after retinal detachment surgery]

Hintergrund

Faltenbildungen der Netzhaut stellen ein Problem v. a. nach Vitrektomie oder Buckelchirurgie mit Gaseingabe dar. Liegen diese Falten im Makulabereich, wirkt sich das meist erheblich auf das Sehvermögen des Patienten aus. Im Folgenden wird eine Behandlungstechnik solcher Falten beschrieben.

Methode

In einem Zeitraum von Januar 2017 bis Juni 2020 wurden 6 Patienten mit der im Folgenden beschriebenen Behandlungstechnik operiert. Es erfolgte die erneute Abhebung der Netzhaut mittels Balanced Salt Solution (BSS), gefolgt von einer subretinalen Eingabe gefilterter Luft. Das Ausstreichen der Falte erfolgte mithilfe von Perfluorcarbon (PFC). Eine postoperative Drainage der subretinalen Luft und Flüssigkeit erfolgte nicht, die Spontanresorption wurde abgewartet.

Ergebnisse

Bei keinem Patienten kam es zu einer Visusverschlechterung nach erneuter Netzhautabhebung. Eine Verbesserung der Sehschärfe zeigte sich bei 4 von 6 Fällen. Eine Verminderung der Metamorphopsien konnte bei 5 von 6 Patienten erreicht werden, 2 Patienten gaben an, die Metamorphopsien gar nicht mehr wahrzunehmen. Nur 1 Patient berichtete über einen gleichbleibend verzerrten Seheindruck trotz anatomisch glatter zentraler Netzhaut.

Schlussfolgerung

Bei kritischer Indikationsstellung stellt unsere Behandlungstechnik eine sichere und erfolgreiche Vorgehensweise zur Behandlung von Netzhautfalten im Bereich der Makula nach Ablatiooperation dar.

MacuFix® versus Amsler grid for metamorphopsia categorization for macular diseases

Purpose

Macular diseases often lead to metamorphopsia, which is traditionally tested using the Amsler grid. This study evaluates a novel method for assessing metamorphopsia, based on the software AMD-A Metamorphopsia Detector, application MacuFix®.

Methods

In this observational study, the usability of a new smartphone-based testing method to assess metamorphopsia was evaluated in 45 patients experiencing metamorphopsia in at least one eye using the questionnaire “System Usability Score (SUS).” Additionally, the diagnostic adherence of self-monitoring with the Amsler grid was compared to self-monitoring with the novel software MacuFix®.

Results

The average score of the SUS questionnaire in this study was 76.7 ± 15.5, corresponding to the “good” score on the grading scale. The average interval between two home administered tests was significantly shorter (6 days) when the application was used as compared to using the Amsler grid (19 days). The odds ratio of the frequency of patients using the application to the patients using the home test was 4.

Conclusion

MacuFix® application can help in effective home monitoring of macular function as high user satisfaction and increased testing frequency was observed in its use in patients with macular diseases.

Infectious causes of Alice in Wonderland syndrome

Alice-in-Wonderland syndrome (AIWS) is a perceptual disorder embracing a spectrum of self-experienced paroxysmal body image illusions including most commonly distortions of shape (metamorphopsia), size (macropsia or micropsia), distance (pelopsia or teleopsia), movement, and color among other visual and somesthetic distortions. Depersonalization, derealization, and auditory hallucinations have also been described. Recent reports suggest that infectious diseases are the predominant etiology for AIWS, especially among children. This article reviews current understanding regarding the association between infection and development of AIWS.

Correlation between tangential distortion of the outer retinal layer and metamorphopsia in patients with epiretinal membrane

PURPOSE

To evaluate tangential morphological changes in the outer retina and assess their correlation with the degree of metamorphopsia in patients with idiopathic epiretinal membrane (ERM).

METHODS

This retrospective study included patients with idiopathic ERM who underwent vitrectomy between January 2018 and December 2019. We evaluated the preoperative examination results. Using cross-sectional spectral-domain optical coherence tomography (OCT) images along the horizontal/vertical meridian through the fovea, we defined a new parameter, tangential displacement (TD), as the tangential component of the position vector of the distorted outer nuclear layer caused by ERM. Visual function measurements included M-CHARTS results (vertical/horizontal metamorphopsia score [MV/MH]) and best-corrected visual acuity (BCVA). The correlations among the OCT parameters including TD and central foveal thickness (CFT) with visual function measurements were determined.

RESULTS

Overall, 78 eyes of 76 patients (49 females; mean age, 67.9 [± standard deviation, 7.5 years]) were included. The mean horizontal TD was 24.0 ± 73.9 μm, which was significantly different from 0 (p = 0.005). The mean vertical TD was 6.0 ± 76.2 μm, which was not significantly different from 0. The absolute value of horizontal TD was significantly correlated with MV (r = 0.513, p < 0.01) and MH (r = 0.423, p < 0.01). The absolute value of vertical TD was also significantly correlated with MV (r = 0.274, p = 0.02) and MH (r = 0.413, p < 0.01). However, neither value was significantly correlated with BCVA. Multiple regression analysis showed that the horizontal absolute TD was an independent factor associated with both MV (β = 0.635, p < 0.001) and MH (β = 0.259, p = 0.048).

CONCLUSION

We found that ERM tended to distort the outer retinal layer toward the temporal side of the fovea. The tangential distortion of this layer was associated with the degree of metamorphopsia, suggesting that misalignment of parafoveal photoreceptors causes metamorphopsia in patients with ERM.

Correlations among metamorphopsia test scores, optical coherence tomography findings and multifocal electroretinogram responses in epiretinal membrane patients

PURPOSE

To quantify metamorphopsia with a novel objective method in patients with epiretinal membrane (ERM) and to compare the relationships among metamorphopsia scores, spectral-domain optical coherence tomography (OCT) findings, and multifocal electroretinogram (mfERG) results.

METHODS

This study included 52 eyes of 52 patients with idiopathic ERM who underwent comprehensive ophthalmologic examinations, including measurement of best-corrected visual acuity (BCVA), OCT, and mfERG. The degree of metamorphopsia was quantified using MonPack One® (Metrovision, Perenchies, France). On the topographic map of the early treatment diabetic retinopathy (ETDRS) grid, retinal thickness in the central, superior, inferior, nasal, and temporal subfields were measured, and metamorphopsia scores for each corresponding subfield were also obtained. The amplitudes and implicit times of mERG were elicited from each subfield. Then, the correlations among metamorphopsia scores, OCT findings, and mfERG responses were analyzed.

RESULTS

The mean age of the patients was 65.3 ± 18.5 y, and the average metamorphopsia score of the individual subfields was 2.03 ± 1.18. Initial BCVA was 0.50 ± 0.12 logMAR, but there was no significant correlation between metamorphopsia scores and BCVA. The metamorphopsia scores from the central subfields showed significant correlations with central retinal thickness (CRT) (p = 0.001). The mean metamorphopsia scores in the central subfield showed a significant relationship with the mean N1 and P1 amplitudes (p = 0.001, p = 0.048, respectively), while no relationship was observed between metamorphopsia scores and mfERG amplitudes in other subfields.

CONCLUSIONS

The degree of metamorphopsia in patients with ERM could be objectively quantified in each subfield using a novel metamorphopsia test. The metamorphopsia scores were significantly correlated with retinal thickness, especially at the central subfields, and the scores in the central subfields were significantly correlated with the N1 and P1 amplitudes of mfERG. Thus, the metamorphopsia test can be a useful method to evaluate metamorphopsia symptoms for patients with ERM.

Effects of cataract surgery in Japanese patients with neovascular age-related macular degeneration

Purpose

To investigate the effects of cataract surgery in Japanese patients with neovascular age-related macular degeneration (nAMD).

Methods

The primary endpoint in this prospective, observational study was patient satisfaction at 6 months after cataract surgery in patients with nAMD. Secondary endpoints comprised changes in best-corrected visual acuity (BCVA), M-chart score, central retinal thickness (CRT), AMD status, and number of AMD treatments. All examinations were performed before surgery, and at 1, 3, and 6 months postoperatively.

Results

Fifty patients (52 eyes) were included in this study (32 men; mean age, 76.1 ± 7.1 years). Thirty-nine patients (75.0%) reported satisfaction with cataract surgery. BCVA significantly improved at all postoperative timepoints (all p < 0.0001), whereas differences in M-chart scores were not statistically significant. The number of eyes with BCVA ≤ 0.3 logarithm of the minimum angle of resolution (logMAR) increased from 21 to 38; however, CRT did not change. The number of AMD treatments did not change during follow-up. All questionnaire scores showed postoperative improvement. Univariate and multivariate analyses revealed that final BCVA ≤ 0.3 logMAR was significantly associated with patient satisfaction.

Conclusion

Cataract surgery significantly improved vision in Japanese patients with nAMD, without affecting AMD status. Patients were satisfied with cataract surgery, especially with respect to improvement of distance vision.

Multimodal imaging of an idiopathic florid vascularised epiretinal membrane: Course, treatment, and outcome

Idiopathic vascular epiretinal membrane is an extremely rare entity and the pathogenesis and clinical course is not clearly understood. A 53-year-old hypertensive female patient presented with complaints of altered vision in the right eye. On examination, her vision was 20/30 and fundoscopy showed a vascularized epiretinal membrane (ERM), which was confirmed on spectral-domain optical coherence tomography. No primary cause was found after investigations. The symptoms and ERM showed slow progression over the next three years with a visual acuity of 20/60. She underwent surgery for removal of the ERM, which was subjected to histopathological evaluation. This is a unique case of a florid proliferative vascularisation of an ERM in the absence of any identifiable cause, which had a good visual outcome following surgery.

Numerous retinal pigment epithelial elevations and drusen associated with unusual dilated choroidal vessels seen at choriocapillaris level in macular area

Purpose

To report the ocular findings in a patient with extensive diffuse elevations of the retinal pigment epithelium (RPE) and drusen associated with dilated choroidal vessels.

Observations

The eye of a 72-year-old woman with numerous drusen and dilated choroidal vessels in the macular and surrounding areas of the right eye was studied. Her visual acuity was 20/16 in this eye and she was asymptomatic although the Amsler grid testing showed mild metamorphopsia. Indocyanine green angiography showed dilated choroidal vessels that collected blood from their branches in the macular and surrounding areas and flowed out of the eye at the entry site of a short posterior ciliary artery. A large choroidal vein ran from the nasal quadrants toward the superotemporal quadrant. Optical coherent tomography (OCT) showed two types of RPE elevations over an extensive area: one was a relatively steep dome-shaped RPE elevation, and the other was a flatter placoid-shaped RPE detachment. Detailed examinations including OCT angiography showed that the dome-shaped RPE elevation coincided with the course of the dilated choroidal vessels which were seen at the level of the choriocapillaris. The visual acuity and the ocular findings remained stable during the 2.5-year follow-up period, and this condition did not require any treatments.

Conclusions and importance

We conclude that the dilated choroidal vessels are most likely parts of the posterior ciliary venous system, and they function as a posterior route of choroidal outflow. Because such eyes might be diagnosed and treated as age-related macular degeneration based on the presence of drusen, RPE detachments, and abnormal vessels beneath the RPE, knowledge of these observations in a functionally normal eye is important to avoid unnecessary treatments.

Evaluation of pre- and post-surgery reading ability in patients with epiretinal membrane: a prospective observational study

Background

This study aimed to investigate the pre- and post-surgery reading ability in patients with idiopathic epiretinal membrane (ERM) to evaluate whether measurement of reading performance is a helpful test in addition to visual acuity (VA) as an assessment measure.

Methods

This prospective observational study involved 42 eyes of 40 patients with idiopathic ERM. Best-corrected visual acuity (BCVA), reading ability, and metamorphopsia score were evaluated at baseline and at 3, 6, and 12 months post-surgery. As the outcome measure, the reading ability of each patient (i.e., overall performance) was examined with MNREAD-J, the Japanese version of the MNREAD reading acuity (RA) charts, to determine RA, critical print size (CPS), and maximum reading speed (MRS). Generally, a difference of 0.2 logMAR or more is considered a significant change in BCVA. Thus, as a subgroup analysis, we additionally evaluated the BCVA and reading ability of the patients with a BCVA difference of 0.1 logMAR or less between at baseline and at 12 months post-surgery.

Results

Relative to their values at baseline, the subjects exhibited significantly improved BCVA, RA, and CPS throughout the post-surgery examination period (P < 0.001) and significantly improved MRS at 12 months post-surgery (P = 0.04). No significant change in the vertical metamorphopsia score was observed throughout the post-surgery follow-up period. However, and compared to the value at baseline, significant improvements in the horizontal metamorphopsia score were observed at 3, 6 (P < 0.05), and 12 months (P < 0.001) post-surgery. In the subgroup analysis of the 23 eyes that exhibited a BCVA improvement of 0.1 logMAR or less, the median BCVA did not change, but the median RA and CPS improved by 0.2 logMAR.

Conclusions

Our findings showed that the surgical removal of ERM improves reading ability, even when the BCVA score does not improve. The measurement of reading performance appears to be a helpful test in addition to VA as a measure for assessing the surgical removal of ERM.

Dreamy State, Delusions, Audiovisual Hallucinations, and Metamorphopsia in a Lesional Lateral Temporal Lobe Epilepsy Followed by Ipsilateral Hippocampal Sclerosis

We report a 65-year-old man who was diagnosed with focal status epilepticus generating a dreamy state, delusions with anxiety, complex audiovisual hallucinations, elementary auditory hallucinations, and metamorphopsia with a growing large lateral temporal lobe lesion. After administrating anti-seizure drugs, all the symptoms disappeared, and brain magnetic resonance imaging revealed ipsilateral hippocampal sclerosis. To the best of our knowledge, this is the first report to present all the symptoms in one epilepsy case. On the basis of semiology, electroencephalography, and brain magnetic resonance imaging, we speculated that epileptic activities that have originated from the lateral lesion might have propagated to the ipsilateral mesial temporal lobe, causing hippocampal sclerosis.

[Bilateral multifocal pigment epithelial detachments associated with inhaled corticosteroids]

A 37-year-old male patient presented with metamorphopsia and unilateral visual impairment with the presence of hundreds of bilateral avascular retinal pigment epithelial detachments (PEDs). The patient suffered from allergic bronchial asthma which was treated with inhaled corticosteroids. Cessation of corticosteroid treatment resulted in flattening of larger PEDs and subsequent transition to atrophic areas over time while smaller PEDs persisted and spread peripherally over an observation period of 14½ years.

Prospective study of vitrectomy for epiretinal membranes in patients with good best-corrected visual acuity

Background

To evaluate the efficacy of epiretinal membrane removal in patients with good best-corrected visual acuity (BCVA) for improving visual function and quality of life (QOL).

Methods

This prospective case study compared 37 subjects with preoperative BCVA ≦ 0.046 logMAR (Good group) to 35 patients with 0.10–0.52 logMAR (Moderate group) at 3 and 6 months. Linear mixed-effect models were used for statistical analysis. The primary outcome was the horizontal metamorphopsia score (MH) at 6 months postoperatively (post-6 M), while secondary outcomes were postoperative BCVA, vertical metamorphopsia score (MV), aniseikonia, stereopsis and central foveal thickness. In the Good group, QOL was assessed using the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) at 6 and 12 months.

Results

MH was significantly improved at post-3 M and post-6 M in the both groups but there were no significant differences between the two groups. MV showed no improvement at the final observation in either group. LogMAR BCVA was significantly improved at post-6 M in the Good group, which had significantly better vision than the Moderate group. Preoperative vertical and horizontal aniseikonia scores remained unchanged in the Good group at post-6 M but worsened in the Moderate group. The NEI VFQ-25 score improved in the Good group, reflecting improved general health, general vision, and mental health.

Conclusions

Early epiretinal surgery for patients with BCVA ≦ 0.046 logMAR was effective for improvement of HM, BCVA, and QOL and prevented worsening of aniseikonia.

Trial registration

UMIN000021220. Registered 10 September 2015.

UMIN Clinical Trials Registry.

Correlation between metamorphopsia and disorganization of the retinal inner layers in eyes with diabetic macular edema

PURPOSE

To investigate factors associated with the severity of metamorphopsia secondary to diabetic macular edema (ME) by evaluating optical coherence tomography (OCT) parameters including disorganization of the retinal inner layers (DRIL).

METHODS

We retrospectively reviewed medical records of 37 eyes of 37 consecutive patients with diabetic ME or resolved diabetic ME, who underwent spectral-domain OCT examination and metamorphopsia assessment with M-CHARTS on the same day between November 2017 and March 2018. Age, sex, visual acuity, lens status, treatment history, and factors analyzed on OCT examination including DRIL length were evaluated in association with M-CHARTS scores.

RESULTS

Metamorphopsia was detected in 20 eyes (54%). The patients with metamorphopsia were relatively older than those without it (P = 0.060), and DRIL length was relatively longer in eyes with metamorphopsia (P = 0.065), while visual acuity was significantly better in eyes without metamorphopsia (P = 0.048). In correlation analyses to the severity of metamorphopsia, the DRIL length was the only OCT parameter associated with the M-CHARTS score (P = 0.035), while age, visual acuity, and ME were not significantly associated with the severity of metamorphopsia (P = 0.051, 0.060, and 0.344, respectively).

CONCLUSION

The DRIL length was significantly associated with the severity of metamorphopsia secondary to diabetic ME. The inner retinal layer plays a key role in the development of metamorphopsia in eyes with diabetic ME. Metamorphopsia should be carefully considered when treating diabetic ME since its severity has been found to be independent of visual acuity and ME status.

Functional and morphological results of treatment of macula-on and macula-off rhegmatogenous retinal detachment with pars plana vitrectomy and sulfur hexafluoride gas tamponade

BACKGROUND

To examine morphological and functional results after pars plana vitrectomy (PPV) with sulfur hexafluoride (SF6) gas tamponade due to macula-on and macula-off rhegmatogenous retinal detachment (RRD) during 6 months of the follow-up.

METHODS

The study included 62 eyes that underwent successful PPV with SF6 tamponade with macula-on (34 eyes) and macula-off (28 eyes) RRD preoperatively. The best-corrected visual acuity (BCVA), Amsler test, M-charts, optical coherence tomography (OCT) and microperimetry were performed at 1, 3 and 6 months postoperatively.

RESULTS

Results of the Amsler test were abnormal postoperatively in 54% of the patients in the group with macula-off and in 32% of the patients with macula-on RRD. Horizontal M-charts improved significantly from 0.33 to 0.2, vertical M-charts- from 0.29 to 0.17 during 6 months of the follow-up. There was a significant increase in the central retinal thickness (CRT) and average thickness (AT) between follow-up examinations only in the macula-off group. 29 of 62 eyes (47%) after surgery (equally with macula-on and macula-off RRD) showed morphological changes in OCT in the macular region, as epiretinal membrane, macular edema, subretinal fluid or alterations of the outer layers of the retina. The average threshold in microperimetry increased significantly within both groups during the follow-up.

CONCLUSION

Both horizontal and vertical M-charts scores, as were as microperimetry sensitivity improved significantly during the 6 months of the follow-up both in macula-on and macula-off group. Although PPV with SF6 gas tamponade was successful, almost half of eyes revealed anatomical changes in the macular region in OCT both with macula-on and macula-off group.

TRIAL REGISTRATION

Current Controlled Trials NCT03902795 registered on 03/04/2019. Retrospectively registered.

Assessment of the deformation of the outer nuclear layer in the Epiretinal membrane using spectral-domain optical coherence tomography

Background

We aimed to investigate the deformation of the outer nuclear layer using optical coherence tomography in patients with epiretinal membrane (ERM) and its relationship with metamorphopsia.

Methods

Thirty-nine eyes from 39 patients with ERM were included in the study. Patients with the subtypes of pseudo macula hole and lamellar hole were excluded. Twenty-one fellow eyes without macular disease were included as normal controls. Forty-nine B-scan images were obtained in the range of 20 degrees around the macula using SD-OCT. The outer nuclear layer (ONL) was evaluated as a three-dimensional image (3D-ONL) reconstructed using the distance between the ONL and retinal pigment epithelium (RPE) line. The deformation of the ONL was figured at the reference plane and evaluation plane (ONL-B). The characteristic parameters of the ONL-B were defined as circularity, area ratio, and axis ratio. The correlations between these parameters and visual acuity and MCHART score ratio (MH/MV) were then evaluated.

Results

ONL height was significantly higher in ERM patients than in normal controls (54.1 ± 5.3 μm and 84.1 ± 12.9 μm, respectively; P < 0.001). In ERM patients, the MV score was 0.53 ± 0.50, the MH score was 0.71 ± 0.61, and the distance from the RPE line to the ONL-B was 153.5 ± 13.5 μm. The axis of the ONL-B in normal controls and ERM patients was − 6.25 ± 21.8 and − 1.28 ± 29.1, respectively, which indicates that the ONL is horizontally long in both normal individuals and ERM patients. The circularity and area ratio were significantly smaller in ERM patients than in normal controls. In all ERM patients, MH/MV had a significant correlation with axis (r = − 0.29, p = 0.034), circularity (r = − 0.28, p = 0.044), and area ratio (r = − 0.47, p = 0.001). Moreover, we found that the correlation was more significant if the subjects had an axis of the ONL within ±10 degrees (n = 16); the correlations of MH/MV with axis (r = − 0.29, p = 0.034), circularity (r = − 0.53, p = 0.021), and area ratio were more significant (r = − 0.78, P < 0.0001).

Conclusion

The ONL is horizontally long in normal individuals and ERM patients. The direction of metamorphopsia is correlated with the direction of ONL deformation.

Alice in Wonderland syndrome: a novel neurological presentation of Zika virus infection

Zika virus (ZIKV) is a flavivirus endemic in Africa and Southern Asian countries, which has recently emerged in unprecedented epidemic proportions around the world. Although ZIKV infection is often asymptomatic or distinguished by non-specific influenza-like symptoms, an increase in its pathogenicity and biological behavior has been the hallmark of the current pandemic. Increasing evidence suggests that neurotropic strains of ZIKV have evolved from less pathogenic strains of the virus. Neurological manifestations of ZIKV infection include a spectrum of congenital and non-congenital clinical entities, however visual somatosensory perceptual disorders have not been recorded to date. Herein, we report a case of a 15-year-old female who presented with a constellation of perceptual symptoms (metamorphopsia, telopsia, and pelopsia) following acute ZIKV infection. Although such symptoms may have originated from direct viral injury, a post-ZIKV autoimmune reaction to previously unexposed neuronal surface antigens or through molecular mimicry cannot be excluded. The development of Alice in Wonderland syndrome in our patient highlights the ever-increasing expanding spectrum of neurological symptoms associated to ZIKV infection.

Recurrence rate and need for reoperation after surgery with or without internal limiting membrane removal for the treatment of the epiretinal membrane

Purpose

To compare the recurrence rate and need for reoperation after epiretinal membrane surgery with and without removal of the internal limiting membrane.

Methods

In this retrospective study, 125 patients operated for epiretinal membrane removal were evaluated, with a minimum 6-month follow-up. Removal of the epiretinal membrane (ERM) was performed in 78 patients, while 47 had removal of the epiretinal membrane associated with internal limiting membrane peeling (ERM + ILM).

Results

The mean age in the ERM group was 65.8 years old, ranging from 41 to 80 years old. In the ERM + ILM group, the mean age was 67.2 years old, ranging from 52 to 82 years old. The mean preoperative visual acuity in the ERM group was 20/80p, and in the ERM + ILM group, it was 20/80. The mean postoperative visual acuity in both groups was 20/30. The mean preoperative macular thickness in the ERM group was 467 µm ranging from 281 to 663 µm; in the ERM + ILM group, the preoperative macular thickness was 497 µm, ranging from 172 to 798 µm. After surgery, a reduction in macular thickness was observed in both groups. In the ERM group, the mean macular thickness reduction was 361 ± 101. µm, whereas in the ERM + ILM group, it was 367 ± 75.2 µm. Twenty-two patients presented with a recurrence of epiretinal membrane, of which 16 (20.5%) were from the ERM group and 6 (12.8%) were from the ERM + ILM group (p = 0.39); one patient (2%) was retreated in the ERM + ILM group, whereas 5 patients (6%) where retreated in the ERM group.

Conclusion

We postulate that ILM peeling for the treatment of epiretinal membrane is not a relevant factor either for visual recovery or macular thickness reduction, but it may reduce the recurrence and reoperation rate.

P300-based acuity estimation in imitated amblyopia

PURPOSE

A frequent approach to estimating visual acuity objectively is the recording of visual evoked potentials (VEPs) to patterns of different coarseness. This, however, overestimates acuity in patients with fragmented and distorted vision such as in amblyopia. This is likely due to VEP-based techniques using checkerboard or grating stimuli. We hypothesized that no overestimation would occur when the event-related potential P300 in response to optotype stimuli is used for acuity estimation.

METHODS

In 29 visually normal participants, we recorded P300 responses to Landolt C optotypes of different sizes. Vision was artificially degraded by placing a patterned polymethyl methacrylate pane in front of the monitor, which resulted in fragmentation and distortion of the stimulus. As control, a frosted pane was used. Both panes were adjusted to yield the same reduction of acuity in a standard subjective acuity test. A difference of less than 0.1 log MAR was defined as criterion to judge the outcomes of the objective tests as equivalent for both types of artificial visual impairment.

RESULTS

The average difference of P300-based objective acuity estimates between types of visual degradation was significantly smaller than 0.1 log MAR, indicating that the performance of the objective acuity test was equivalent for both types of visual degradation.

CONCLUSION

Our data suggest that P300-based objective acuity testing with optotype stimuli is more akin to standard psychophysical acuity testing and thus a suitable approach in cases of visual impairment where VEP-based methods fail to yield reliable results.

[Juvenile idiopathic epiretinal membrane]

Idiopathic epiretinal membrane (iERM) is very rare in adolescent patients. The pathogenesis remains unclear although the role of hyalocytes is of major importance. The clinical features in young patients are different from those in older patients. We describe a case of iERM in a 15-year-old girl who presented with metamorphopsia of the right eye. This case report presents the basis for the decision for surgical treatment as well as the clinical features at follow-up examination 9 months after surgery.

Two-year results of metamorphopsia, visual acuity, and optical coherence tomographic parameters after epiretinal membrane surgery

PURPOSE

To determine the 2-year results of metamorphopsia, visual acuity, and optical coherence tomographic (OCT) parameters after epiretinal membrane (ERM) removal, and to evaluate the correlations among them.

METHODS

We studied 75 eyes of 75 patients with an ERM who underwent vitrectomy and membrane peeling. The best-corrected visual acuity (BCVA), metamorphopsia scores, and OCT parameters were measured at the baseline, and 1, 3, 6, 9, 12, 18, and 24 months postoperatively. M-CHARTS were used to quantify the degree of metamorphopsia.

RESULTS

The mean BCVA, degree of metamorphopsia, and all of the OCT parameters except the photoreceptor outer segment (PROS) length improved significantly from that at the baseline at 24 months (P < 0.001). However, they were not significantly different from those at 12 months. The better BCVA at 24 months was correlated with the longer PROS length at the baseline (P < 0.01). The degree of metamorphopsia at 24 months was significantly correlated with that at baseline (P < 0.01).

CONCLUSIONS

A postoperative follow-up period of 12 months may be sufficient to assess the improvements induced by the ERM surgery. The preoperative PROS length was the prognostic factor for the postoperative BCVA. The preoperative degree of metamorphopsia was the prognostic factor for the postoperative degree of metamorphopsia, suggesting that surgery for ERM should be performed before development of severe metamorphopsia.

[Central scotoma after viral prodrome]

CASE REPORT

A 29-year-old female patient presented with a unilateral deterioration of visual acuity, metamorphopsia and a paracentral scotoma. The patient had suffered from a viral rhinitis 1 week prior to the ophthalmological symptoms.

DIAGNOSTICS

Fundoscopy revealed parafoveal changes in the retinal pigment epithelium and spectral-domain optical coherence tomography (SD-OCT) disclosed corresponding hyperreflective, subretinal changes with disruption of Bruch's membrane and the outer limiting membrane. In the course of the disease there was a spontaneous regression of these changes. Visual acuity improved and the central scotoma resolved. The patient showed the typical history and clinical findings of unilateral acute idiopathic maculopathy.

CONCLUSION

The most probable explanation for the patient's symptoms is an immunologically triggered adverse reaction due to a previous viral rhinitis, with participation of the retina and retinal pigment epithelium. As a rule the disease has a spontaneous and favorable course.

Metamorphopsia before and after full-thickness macular hole surgery

PURPOSE

We quantified the degree and dynamics of metamorphopsia changes in patients subjected to full-thickness macular hole surgery.

MATERIAL/METHODS

This prospective interventional case series included 10 eyes of 10 patients with full-thickness macular hole (mean age 66.2±6.0 years). The patients underwent a complete ophthalmological examination including SD-OCT. The severity of metamorphopsia (expressed as M-score) was evaluated with M-CHARTS. 20-gauge pars plana vitrectomy with trypan blue staining, internal limiting membrane peeling and 20% sulphur hexafluoride tamponade was performed. Time course of metamorphopsia changes and their relation to best corrected visual acuity (BCVA) and OCT parameters were assessed.

RESULTS

Significant but not total M-score decrease was observed one month postoperatively (0.72±0.44 vs. 0.50±0.36, z=-2.207, p=0.0353, power=0.26, pre- vs. post-op), with subsequent stabilization (0.41±0.41 three months and 0.37±0.44 six months post-op). The differences between M-score one month, three months and six months postoperatively were not significant. Baseline M-score correlated significantly with postoperative values at three follow-ups (rho=0.853, 0.715, 0.847; p<0.05 for all; power=0.94, 0.58, 0.79). Baseline M-score did not correlate with macular hole dimensions (including basis p=0.154, minimal diameter p=0.051 or height of the border p=0.700). No correlation between M-score and the following parameters was found either pre- or postoperatively: BCVA, central foveal thickness, central subfield macular thickness and central subfield macular volume.

CONCLUSIONS

In patients with successfully operated full-thickness macular hole, M-score decreased as early as one month postoperatively and was stable afterwards. The baseline M-score was a prognostic factor for the postoperative M-score. M-score turned out to be independent from BCVA and macular hole dimensions.

A retrospective study of a single practice use of ocriplasmin in the treatment of vitreomacular traction

PURPOSE

To evaluate success with intravitreal injection of ocriplasmin in releasing symptomatic vitreomacular traction (VMT).

METHODS

A retrospective review of consecutive series of patients in a single vitreoretinal practice. Patients with symptomatic distortion and loss of vision secondary to VMT were included in the study. Patients received a single injection of ocriplasmin (JETREA®) and were followed-up after 1 month with optical coherence tomography.

RESULTS

Eight patients (8 eyes) were included (2 males and 6 females) in the study. Five of 8 eyes (62.5%) experienced complete release of the VMT; one of 8 eyes (12.5%) had partial release of VMT and two of 8 eyes (25%) did not have release of VMT. The two patients with no release of their VMT had the same vision. Of the 5 patients with complete release of VMT, 3 patients had a one line worsening of their vision, 1 had a 4 line improvement of vision, and 1 stayed the same. The patient with only partial release of their VMT had a 1 line worsening of vision.

CONCLUSIONS

Intravitreal ocriplasmin is a promising treatment option for vitreomacular traction syndrome in symptomatic patients.

[Alice in Wonderland syndrome]

CASE REPORT

A case of Alice in Wonderland syndrome is described as the only sign of Epstein-Barr virus infection.

DISCUSSION

Epstein-Barr virus infection may include visual symptoms as the first or only signs of disease. All patients presenting with a clinical picture consistent with the Alice in Wonderland syndrome should undergo serological testing for Epstein-Barr virus infection.

Multimodal Sensory Distortions in Postpartum Exacerbation of Schizophrenia

BACKGROUND

Sensory distortions of body image commonly occur during migraine, seizures, nondominant cortical infarcts and hallucinogen abuse.

METHODS

We report the case of a 30-year-old woman with paranoid schizophrenia presenting with postpartum onset multimodal sensory distortions in the absence of any neurological disorders or substance use.

RESULTS

Her symptoms involved persistent facial/body metamorphopsia (distorted images) and vocal paracousis (distorted voices), in the absence of visual hallucinations, illusions or agnosia. Neuropsychological assessments revealed deficits on visual processing tasks. Neuroimaging, electroencephalography and ophthalmological evaluation revealed no abnormalities. The multimodal sensory distortions responded to antipsychotic treatment, paralleling improvement in other schizophrenia psychopathology, over a period of one month.

CONCLUSIONS

Prominent and persistent multimodal sensory distortions like metamorphopsia and paracousis in the presence of psychotic symptoms warrant a detailed neurological and general medical work-up. These symptoms presenting in the absence of neurological or substance use disorders may be a component of schizophrenia.

Ranibizumab for idiopathic epiretinal membranes: A retrospective case series

PURPOSE

To study the effect of intravitreal ranibizumab on idiopathic epiretinal membranes (ERMs).

METHODS

A retrospective cohort study on a consecutive series of ranibizumab intravitreal injections for epiretinal membranes was performed. Four cases were identified by reviewing a claims database linked to electronic medical records. All patients received a total of three 0.05 mg/0.05 ml ranibizumab intravitreal injections at a monthly interval. The primary outcome measure was the final best-corrected visual acuity (BCVA) at the end of the injection series, and the final central macular thickness (CMT).

RESULTS

All four patients completed 3 months follow-up after the last ranibizumab injection. The mean baseline CMT was 509 microns (SD = 111). A trend was noticed for reduction in CMT (Δ = 41 microns) P = 0.08. Three patients improved by one line in their BCVA. The remaining patient maintained the same BCVA. No complications were noted.

CONCLUSION

In this study, intravitreal injection of ranibizumab marginally reduced retinal thickness in four patients with minimal improvement in visual acuity. No safety concerns were noticed. Further basic science and clinical studies may be warranted to assess the role of vascular endothelial growth factor and the effect of ranibizumab on idiopathic epiretinal membranes.