CHOROIDAL AND RETINAL ABNORMALITIES IN CUSHING SYNDROME: Correlation with the Cortisol Level

PURPOSE

To investigate the structure and blood flow of the retina and choroid in Cushing syndrome and their relationship with cortisol levels.

METHODS

A consecutive series of patients with Cushing syndrome with adrenocortical carcinoma were included in this study. Cortisol levels gradually returned to normal after adrenalectomy. Optical coherence tomography and optical coherence tomography angiography were used to assess patients with Cushing syndrome before and after the surgery for retina and choroid. Correlation analysis was performed between cortisol level and fundus changes.

RESULTS

Compared with normal cortisol levels, patients with Cushing syndrome had significantly lower central macular thickness with increased cortisol level (220.82 ± 16.59 µ m and 223.68 ± 15.78 µ m, P = 0.019). However, the central choroidal thickness was higher with increased cortisol level (255.18 ± 105.89 µ m and 205.94 ± 87.04 µ m, P < 0.001). The choriocapillaris flow area was higher with increased cortisol level (2.05 ± 0.14 mm 2 and 2.00 ± 0.13 mm 2 , P = 0.02). The change of choriocapillaris flow area was correlated with the score of Huaxi Emotional-distress Index and 24-hour urine-free cortisol (24h-UFC).

CONCLUSION

The increased cortisol level was correlated with lesser central macular thickness and thicker central choroidal thickness. The decrease of choriocapillaris flow area was correlated with 24h-UFC, indicating the effect of increased cortisol level on choroidal vessels.

DESCRIBING THE LOCATION AND MORPHOLOGY OF THE DOTS IN WHITE DOT FOVEA USING ADAPTIVE OPTICS

PURPOSE

To characterize the white dots in white dot fovea, an entity chiefly described in Japan, using adaptive optics imaging and propose a hypothesis regarding their origin.

METHOD

The patient underwent comprehensive ophthalmic examination, including color and green monochromatic fundus photography, fluorescein angiography, spectral-domain optical coherence tomography, and adaptive optics imaging.

RESULTS

An asymptomatic 66-year-old Korean woman presented with bilateral white, glistening deposits in a ring pattern around the fovea of both eyes. The dots were highly reflective on green monochromatic images, were not visible on fluorescein angiography, and appeared hyperreflective in the inner retina using spectral-domain optical coherence tomography. Adaptive optics showed polygonal granules ranging from 1 to 10 μ m in size. The patient denied any systemic disorder or the use of any medications related to crystalline retinopathy. The patient had lived in Japan for 35 years before just moving to the United States.

CONCLUSION

The location, small size, and polygonal shape of the dots in white dot fovea are suggestive of intraretinal deposition of crystals, and not cells on the surface of the fovea as has been previously proposed. Carotenoid deposition related to dietary habits is a plausible cause because of the similarity to other retinopathies associated to these compounds.

Posterior segment manifestations of Takayasu arteritis: A narrative review

Ocular symptoms can be the presenting manifestation of Takayasu arteritis (TA) or could be indicative of disease reactivation. A review of published literature related to posterior segment manifestations of TA by using the keywords "Takayasu arteritis," "ophthalmic manifestations," "retina," "retinopathy," "ocular," "optic nerve," and "optic neuropathy" was performed. In total, 62 case reports and 12 case series were included. The majority of the articles were from Asia (n = 47, 64%). Females outnumbered males in the ratio of 7:1. The mean age of patients was 33 years (range: 8-78 years, SD: 13.5 years). In 58% (n = 41 out of 71) cases, ocular symptoms were the presenting manifestation of the underlying disease. Hypotensive retinopathy was found in 70% of eyes, and hypertensive retinopathy was found in 27%. The mean presenting visual acuity (VA) was +1.03 logMAR (range: -0.12 to 3, SD: 1.07), and at the final follow-up was +1.02 logMAR (range: -0.12 to 3, SD 1.17). VA improved in 34% (n = 29/86), remained stable in 45% (39/86), and worsened in 21% (18/86). The mean follow-up was 9 months (range: 0.5-204, SD: 16 months).

Multicolor imaging: Current clinical applications

Multicolor (MC) imaging is an innovative pseudocolor fundus imaging modality based on confocal scanning laser ophthalmoscopy. It effectively scans the retina at different depths to create a composite image. The green reflectance image depicts the middle retinal while blue reflectance image provides images of the retinal surface. The infrared reflectance image depicts retinal structures at the level of outer retina and choroid. We systematically analyze published case reports, case series, and original articles on MC imaging where it has helped in discovering additional clinical features of retinal diseases not readily apparent on conventional color fundus photography and played a role in monitoring the response to treatment.

SUBTENON'S VANCOMYCIN INJECTION FOR SUBRETINAL ABSCESS SECONDARY TO METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS ENDOGENOUS ENDOPHTHALMITIS: A CASE REPORT AND LITERATURE REVIEW

PURPOSE

To report the use of a subtenon's vancomycin injection for the treatment of subretinal abscess secondary to methicillin-resistant Staphylococcus aureus endogenous endophthalmitis.

METHODS

A 17-year-old man developed endogenous endophthalmitis with subretinal abscess in his right eye secondary to methicillin-resistant Staphylococcus aureus bacteremia from axillary necrotizing fasciitis. Despite prompt treatment with IV vancomycin and an intravitreal vancomycin injection, the patient displayed minimal improvement. The patient was subsequently treated with a subtenon's vancomycin injection. The injection technique is described in detail, as well as a review of the treatment options available for bacterial subretinal abscesses.

RESULTS

On presentation, examination revealed minimal vitritis and a large yellow subretinal abscess superotemporally extending close to the macula with subretinal fluid inferotemporally involving the macula. Four days postintravitreal vancomycin injection, the abscess remained stable and the patient developed an exudative detachment temporally. Vancomycin was injected superotemporally in the subtenon's space with no complications during the procedure or during his postoperative recovery. At seven days postinjection, the subretinal abscess and exudative retinal detachment resolved completely with necrosis at the area of previous abscess.

CONCLUSION

We present the first successful case of subtenon's vancomycin injection for the treatment of bacterial subretinal abscess. Our case demonstrates that subtenon's injection of antibiotics is a safe and effective nonsurgical management option for bacterial subretinal abscesses.

Peripapillary fluid: Obvious and not so obvious!

Intraretinal or subretinal fluid in the peripapillary area can be clinically visualized in conditions such as peripapillary choroidal neovascularization, optic disc pit maculopathy, and optic nerve head tumors and granulomas. Optical coherence tomography (OCT) helps to visualize peripapillary fluid in many other chorioretinal conditions such as peripapillary pachychoroid syndrome, posterior uveitis, central retinal vein occlusion, malignant hypertension, hypotonic maculopathy as well as neuro-ophthalmological conditions such as glaucoma, microcystic macular edema and disc edema due papilledema, non-arteritic anterior ischemic optic neuropathy, neuroretinitis, and diabetic papillopathy. Often, the differential diagnosis of peripapillary fluid is a bit tricky and may lead to misdiagnosis and improper management. We describe a diagnostic algorithm for peripapillary fluid on OCT and outline the salient features and management of these conditions.

Subretinal hyperreflective material in retinal and chorioretinal disorders: A comprehensive review

Subretinal hyperreflective material (SHRM) is a common and remarkable optical coherence tomography (OCT) biomarker whose importance is emerging in several retinal and chorioretinal diseases, including age-related macular degeneration, central serous chorioretinopathy, polypoidal choroidal vasculopathy, pathologic myopia, posterior uveitis, vitelliform lesions and macular dystrophies, and rarer disorders. Multimodal imaging, also thanks to the introduction of OCT angiography, allowed a deeper characterisation of SHRM components and its morphological changes after treatment, suggesting its usefulness in clinical practice. We discuss and summarize the nature, multimodal imaging characteristics, and prognostic and predictive significance of SHRM in the different retinal and choroidal disorders in which it has been described.

NOVEL RETINAL FINDINGS IN A PATIENT WITH AUTOSOMAL RECESSIVE CUTIS LAXA TYPE 2A

PURPOSE

To report a case of autosomal recessive cutis laxa type 2A with novel retinal findings.

METHODS

Case report.

RESULTS

A 22-year-old female patient presented with a long-standing history of reduced visual acuity in her right eye. She has generalized redundant skin, downslanting of palpebral fissures, and long philtrum. Ophthalmic examination showed ptosis in her right eye and visual acuity of 20/2000 in the right eye and 20/30p in the left eye. Funduscopic examination showed a round macular scar lesion in the right eye macula and a chorioretinal scar superonasally in the left eye. Multimodal imaging showed macular atrophy in the right eye with speckled hypoautofluorescence of the described lesions. Genetic testing showed a homozygous splice acceptor variant of the ATP6V0A2 gene.

CONCLUSION

The natural history of the presented pigmentary lesions is not known, and further follow-up is needed to assess any progressive nature. Our case adds to the variability of ophthalmic manifestations reported in autosomal recessive cutis laxa type 2A and, therefore, to the importance of regular ophthalmic surveillance in patients with cutis laxa.

ANATOMICAL AND FUNCTIONAL OUTCOMES OF BEVACIZUMAB TREATMENT IN PEDIATRIC AUTOSOMAL RECESSIVE BESTROPHINOPATHY

PURPOSE

The purpose of this study was to report functional and anatomical outcomes of anti-VEGF treatment in eyes with autosomal recessive bestrophinopathy (ARB) presenting in the first decade of life.

METHODS

The study included case series of four eyes from two siblings with compound heterozygous mutations in the BEST1 gene who were treated with eight monthly intravitreal bevacizumab injections. Response to treatment was analyzed using color fundus photography, fundus autofluorescence, optical coherence tomography, OCT angiography, and microperimetry.

RESULTS

Patient 1 (male, age 9 years) had visual acuity of 20/20 in the right eye and 20/50 in the left eye. Patient 2 (female, age 10 years) had visual acuity of 20/25 in the right eye and 20/20 in the left eye. All eyes had multifocal subretinal deposition of lipofuscin and subretinal fluid, and three eyes had choroidal neovascularization (CNV). Lipofuscin material reabsorbed in 2 of 4 eyes, the CNV regressed in 3 of 3 eyes, a bacillary detachment resolved in 1 of 1 eye, but the subretinal fluid did not change. Functional improvement in visual acuity was noted, but MP showed scattered areas of reduced retinal sensitivity. No ocular or systemic side effects were detected.

CONCLUSION

Anti-VEGF treatment of choroidal neovascularization in eyes with ARB resulted in anatomical changes that were only clinically significant in the eye with decreased visual acuity. The hyporeflective subretinal material remained unchanged suggesting a nonexudative cause. These findings provide new insights into the management of ARB, especially in pediatric subjects with CNV.

RAPID ONSET HYDROXYCHLOROQUINE TOXICITY

PURPOSE

Hydroxychloroquine (HCQ) can cause irreversible damage to the retina, especially when taken over longer periods. The American Academy of Ophthalmology recommends a regimen for dosing, screening, and monitoring of patients treated with HCQ. We present an unusual case of a rapid development of severe HCQ-associated retinopathy already after 2 years after commencing HCQ treatment.

METHODS

Observational case report. Clinical examination, optical coherence tomography, fundus autofluorescence imaging, perimetry, and full-field and multifocal electroretinography were performed. Ancillary tests included neoplastic and paraneoplastic work-up, vitamin levels, and whole-exome sequencing, to rule out other potential causes of a panretinal degeneration.

RESULTS

We report on a 58-year-old woman with rheumatoid arthritis, treated initially with 200 mg HCQ daily for 1 year (daily dose 3.6 mg/kg), then 400 mg daily for 1 year (daily dose 7.2 mg/kg), and a cumulative dose of 216 g. Her medical history was otherwise unremarkable. No family history for inherited retinal conditions. She was referred due to a rapid and sudden progressive and severe concentric visual field constriction, 2 years after commencing HCQ treatment.

CONCLUSION

This case of a rapid-onset, severe panretinal degeneration shortly after start of HCQ treatment suggests underlying mechanisms and risk factors for HCQ toxicity in addition to those previously reported and a potential need for supplementary screening tests to prevent HCQ toxicity. American Academy of Ophthalmology dosing guidelines of 5 mg/kg should be strictly adhered to in patients receiving HCQ therapy.

PARACENTRAL ACUTE MIDDLE MACULOPATHY IN GIANT CELL ARTERITIS

PURPOSE

To describe a representative case and review the literature on paracentral acute middle maculopathy (PAMM) and giant cell arteritis (GCA).

METHODS

A review of the English-language ophthalmic literature was performed using the search terms of PAMM, giant cell arteritis, and temporal arteritis.

RESULTS

A 72-year-old woman with PAMM as the presenting ophthalmic manifestation of GCA was described with a review of the prior cases from the literature. It was found that there were 26 cases of PAMM in GCA. In 19 of 26 cases, PAMM was associated with no other fundus abnormalities and was only seen on multimodal imaging including optical coherence tomography.

CONCLUSION

PAMM can cause acute paracentral visual loss, and GCA should be suspected in all cases of PAMM of the elderly patients, even when isolated and not associated with constitutional symptoms of GCA.

Vitreomacular interface abnormalities in type 2 macular telangiectasia (MacTel)

PURPOSE

To describe the different types of vitreomacular interface abnormalities (VMIA) seen on optical coherence tomography (OCT) in type 2 macular telangiectasia (MacTel) and explain the possible reasons for its development.

METHODS

In this retrospective cross-sectional study, type 2 MacTel eyes with macular volumetric OCT imaging protocol were included to identify different types of VMIA such as abnormal PVD, vitreomacular traction (VMT), ERM, and lamellar and full-thickness macular hole. The VMIA findings were then correlated with different MacTel disease stages and visual acuity.

RESULTS

One thousand forty-three OCTs of 332 type 2 MacTel eyes from 169 patients at different visits were examined. VMIA was detected in 709 (68%) of those OCT scans in 216 (65%) eyes. There were 273 (39%), 31 (4%), 89 (13%), 7 (1%), and 381 (54%) OCT scans with vitreomacular adhesion, VMT, ERM, and inner and outer lamellar macular holes discovered respectively. VMIA eyes had a high frequency of abnormal PVD (p = 0.001) and retinal pigment clumps (RPCs) [p = 0.032]. Eyes with abnormal PVD (p = 0.034) and RPC (p = 0.000) had a higher rate of ERM development. RPC was linked to an increased risk of developing ERM (odd ratio 2.472; 95% CI 1.488-4.052). RPC and ERM contributed significantly to poor visual acuity (0.661 ± 0.416, 20/92).

CONCLUSION

OCT reveals a high frequency of VMIA in advanced type 2 MacTel eyes. RPC could be responsible for the development of anomalous PVD, as well as subsequent VMIAs and ERM. Additional work is required to examine the long-term changes and surgical outcomes of these eyes.

PARACENTRAL ACUTE MIDDLE MACULOPATHY ASSOCIATED WITH EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS

PURPOSE

To present a case of paracentral acute middle maculopathy (PAMM) associated with transient loss of vision from eosinophilic granulomatosis with polyangiitis (EGPA)-associated ischemic vasculitis.

METHODS

Case report and review of the literature.

RESULTS

A 52-year-old man presented with recurrent episodes of amaurosis of the right eye. A diagnosis of EGPA was established with the combination of late-onset asthma, peripheral eosinophilia, patchy parenchymal consolidation, and diffuse pansinusitis. Fundus examination displayed cotton wool spots in the right eye. Optical coherence tomography (OCT) of the macula showed features of paracentral focal inner nuclear layer/outer plexiform layer hyperreflectivity consistent with PAMM. He was treated with corticosteroids and cyclophosphamide. At 2 months following the treatment, his EGPA was in remission; the patient reported no recurrence of visual symptoms. Dilated fundoscopy revealed resolution of the cotton wool spots. A repeat OCT of the macula showed resolution of PAMM.

CONCLUSION

This case supports sublethal hypoxia of the middle retinal layers as the underlying mechanism for PAMM. Ophthalmologists should be cognizant to look for PAMM on OCT in patients presenting with transient visual loss and be aware of EGPA-associated ischemic vasculitis as a rare cause of amaurosis.

INDOCYANINE GREEN ANGIOGRAPHY-GUIDED PHOTOCOAGULATION OF LARGE MICROVASCULAR ABNORMALITIES ("TELCAPS") IN A PATIENT WITH PERSISTENT MACULA EDEMA IN THE CONTEXT OF RADIATION RETINOPATHY

PURPOSE

The purpose of this report is to describe a patient with radiation retinopathy who responded to indocyanine green angiography (ICGA)-guided photocoagulation as treatment for persistent macula edema secondary to TelCaps, a newly defined type of large microvascular abnormality.

METHODS

Retrospective case report.

RESULTS

A 40-year-old man with a history of bilateral retinoblastoma and right enucleation presented with decreased vision in the left eye secondary to macula edema. Examination revealed radiation retinopathy with a cluster of ICGA-avid large microaneurysms temporal to the macula. The patient did not respond to treatment with intravitreal bevacizumab or triamcinolone. Complete resolution of macula edema was demonstrated after two rounds of ICGA-guided focal photocoagulation to the aforementioned microaneurysm cluster. No subsequent or adjunctive intravitreal injections of anti-VEGF were required, and there was no recurrence of the TelCaps lesions at follow-up to eight years.

CONCLUSION

TelCaps are large microvascular abnormalities with high affinity for ICG. These lesions may not have been recognized because of difficulties in their detection on routine examination and with investigations including ocular coherence tomography angiogram and fluorescein angiogram. Early evidence supports their role in macula edema that is not responsive to intravitreal injections of anti-VEGF. ICGA-guided photocoagulation of TelCaps lesions can result in resolution of macula edema. To our knowledge, this is the first reported case of TelCaps secondary to radiation retinopathy.

RP2-Associated X-linked Retinopathy: Clinical Findings, Molecular Genetics, and Natural History in a Large Cohort of Female Carriers

PURPOSE

RP2-associated retinopathy typically causes severe early onset retinitis pigmentosa (RP) in affected males. However, there is a scarcity of reports describing the clinical phenotype of female carriers. We tested the hypothesis that RP2 variants manifest in female carriers with a range of functional and anatomic characteristics.

DESIGN

Retrospective case series.

METHODS

Females with disease-causing variants in RP2 were identified from investigation of pedigrees affected by RP2 retinopathy. All case notes and results of molecular genetic testing, retinal imaging (fundus autofluorescence imaging, optical coherence tomography (OCT)), and electrophysiology were reviewed.

RESULTS

Forty pedigrees were investigated. Twenty-nine pedigrees had obligate carriers or molecularly confirmed female members with recorded relevant history and/or examination. For 8 pedigrees, data were available only from history, with patients reporting affected female relatives with RP in 4 cases and unaffected female relatives in the other 4 cases. Twenty-seven females from 21 pedigrees were examined by a retinal genetics specialist. Twenty-three patients (85%) reported no complaints and had normal vision and 4 patients had RP-associated complaints (15%). Eight patients had normal fundus examination (30%), 10 had a tapetal-like reflex (TLR; 37%), 5 had scattered peripheral pigmentation (19%), and the 4 symptomatic patients had fundus findings compatible with RP (15%). All asymptomatic patients with normal fundus, TLR, or asymptomatic pigmentary changes had a continuous ellipsoid zone on OCT when available. The electroretinograms revealed mild to severe photoreceptor dysfunction in 9 of 11 subjects, often asymmetrical, including 5 with pattern electroretinogram evidence of symmetrical (n = 4) or unilateral (n = 1 subject) macular dysfunction.

CONCLUSIONS

Most carriers were asymptomatic, exhibiting subclinical characteristics such as TLR and pigmentary changes. However, female carriers of RP2 variants can manifest RP. Family history of affected females with RP does not exclude X-linked disease. The phenotypic spectrum as described herein has prognostic and counselling implications for RP2 carriers and patients.

TOWARD AN IMAGING-CENTRIC DEFINITION OF NONPARANEOPLASTIC AUTOIMMUNE RETINOPATHY

PURPOSE

To explore characteristic imaging features of nonparaneoplastic autoimmune retinopathy (npAIR) to augment diagnostic criteria.

METHODS

This is a retrospective cohort study of patients with npAIR evaluated at the Emory Eye Center between 2013 and 2019. Multimodal fundus images were evaluated to characterize the evolution of the disease.

RESULTS

Twenty-one eyes of 12 patients were classified as having npAIR. Five patients (42%) were female, with median (range) age of 59 years (45-85 years). Median baseline visual acuity was 20/30 (20/20 to hand motions). Disease was asymmetric in 11 patients (92%). Common imaging findings included absence of bone spicules (86% of affected eyes), presence of attenuated vessels (86%), and speckled hypoautofluorescence in perimacular and perivenular regions. Three eyes were noted to present early with subtle splotchy fundus autofluorescence abnormality, ultimately developing characteristic speckled perimacular hypoautofluorescence. On optical coherence tomography, 18 eyes (86%) had loss of outer retinal bands with relative foveal sparing and a tapered transition zone.

CONCLUSION

Many eyes with npAIR exhibit a subacute, asymmetric, generalized photoreceptor degeneration featuring outer retinal atrophy with relative foveal sparing, retinal vascular attenuation, absence of bone spicules, and speckled hypoautofluorescence often in a perimacular and perivenular distribution. Findings of this study augment diagnostic criteria to improve specificity and accessibility of testing for npAIR.

Sensitivity and specificity of SS-OCT for detecting macular pathologies vs SD-OCT

PURPOSE

To evaluate the sensitivity and specificity of swept-source optical coherence tomography (SS-OCT) biometer compared with the gold standard spectral-domain optical coherence tomography (SD-OCT) for detecting macular pathology in patients with cataract.

SETTING

Eye Centers of Tennessee, Crossville, TN.

DESIGN

Prospective, cross-sectional, observational, examiner-masked.

METHODS

The study included 132 participants aged 50 years and older, who underwent precataract surgery work-up. All participants underwent fixation check retinal scans using SS-OCT biometer (IOLMaster 700) as well as full macular scans using Cirrus SD-OCT. 3 independent masked examiners evaluated the scans if they were normal or had a suspected pathology. Different measures of diagnostic accuracy were calculated for 3 examiners.

RESULTS

True positive rate (sensitivity) ranged from 71.1% (32/45) to 79.2% (42/53), and false negative rate was between 20.8% (11/53) and 28.9% (13/45) for the 3 examiners. True negative rate (specificity) ranged from 86.8% (59/68) to 94.1% (64/68), and false positive rate was between 5.9 (4/68) and 13.2% (9/68). The fitted receiver operating characteristic area ranged from 0.83 to 0.95.

CONCLUSIONS

Using retinal SS-OCT biometer scans as a replacement of the dedicated macular SD-OCT for screening or diagnosing macular health would not be appropriate because of its low sensitivity. SS-OCT biometer may potentially fail to identify approximately one-fourth of patients who actually have the disease. Therefore, the final decision on macular health should be based on the gold standard SD-OCT scans. When full macular SD-OCT scans are not accessible, the limited retinal scan information from SS-OCT biometer may still provide useful insights into the macular health.

Clinical, electrophysiologic and serologic evidence of cancer associated retinopathy preceding a diagnosis of breast cancer

We report the case of a woman in her 50s who presented headaches, blurred vision, diplopia and loss of peripheral vision. She was treated for normal tension glaucoma based on optic nerve cupping prior to the development of diplopia. Records demonstrated visual field constriction over 4 months despite well-controlled intraocular pressures. Examination revealed decreased visual acuity and visual field constriction. The multifocal electroretinogram was abnormal. After a thorough review of her medical and family history, a concern for cancer-associated retinopathy developed. Blood samples were positive for antiretinal antibodies against 23 kDA and 46 kDA proteins. Cancer screening was recommended as the aetiology for retinopathy was unknown and revealed a left breast lump. Following lumpectomy with adjuvant chemoradiation, her visual acuity normalised and visual field defects completely resolved. This case serves to provide an example that distant systemic symptoms may be a manifestation of the underlying malignancy and the importance of clinical suspicion with prompt evaluation.

Diagnosis of retinal damage using Resnet rescaling and support vector machine (Resnet-RS-SVM): a case study from an Indian hospital

PURPOSE

This study aims to address the challenge of identifying retinal damage in medical applications through a computer-aided diagnosis (CAD) approach. Data was collected from four prominent eye hospitals in India for analysis and model development.

METHODS

Data was collected from Silchar Medical College and Hospital (SMCH), Aravind Eye Hospital (Tamil Nadu), LV Prasad Eye Hospital (Hyderabad), and Medanta (Gurugram). A modified version of the ResNet-101 architecture, named ResNet-RS, was utilized for retinal damage identification. In this modified architecture, the last layer's softmax function was replaced with a support vector machine (SVM). The resulting model, termed ResNet-RS-SVM, was trained and evaluated on each hospital's dataset individually and collectively.

RESULTS

The proposed ResNet-RS-SVM model achieved high accuracies across the datasets from the different hospitals: 99.17% for Aravind, 98.53% for LV Prasad, 98.33% for Medanta, and 100% for SMCH. When considering all hospitals collectively, the model attained an accuracy of 97.19%.

CONCLUSION

The findings demonstrate the effectiveness of the ResNet-RS-SVM model in accurately identifying retinal damage in diverse datasets collected from multiple eye hospitals in India. This approach presents a promising advancement in computer-aided diagnosis for improving the detection and management of retinal diseases.

Trends in the Prevalence of Common Retinal and Optic Nerve Diseases in China: An Artificial Intelligence Based National Screening

Purpose

Retinal and optic nerve diseases have become the primary cause of irreversible vision loss and blindness. However, there is still a lack of thorough evaluation regarding their prevalence in China.

Methods

This artificial intelligence-based national screening study applied a previously developed deep learning algorithm, named the Retinal Artificial Intelligence Diagnosis System (RAIDS). De-identified personal medical records from January 2019 to December 2021 were extracted from 65 examination centers in 19 provinces of China. Crude prevalence and age-sex-adjusted prevalence were calculated by mapping to the standard population in the seventh national census.

Results

In 2021, adjusted referral possible glaucoma (63.29, 95% confidence interval [CI] = 57.12-68.90 cases per 1000), epiretinal macular membrane (21.84, 95% CI = 15.64-29.22), age-related macular degeneration (13.93, 95% CI = 11.09-17.17), and diabetic retinopathy (11.33, 95% CI = 8.89-13.77) ranked the highest among 10 diseases. Female participants had significantly higher adjusted prevalence of pathologic myopia, yet a lower adjusted prevalence of diabetic retinopathy, referral possible glaucoma, and hypertensive retinopathy than male participants. From 2019 to 2021, the adjusted prevalence of retinal vein occlusion (0.99, 95% CI = 0.73-1.26 to 1.88, 95% CI = 1.42-2.44), macular hole (0.59, 95% CI = 0.41-0.82 to 1.12, 95% CI = 0.76-1.51), and hypertensive retinopathy (0.53, 95% CI = 0.40-0.67 to 0.77, 95% CI = 0.60-0.95) significantly increased. The prevalence of diabetic retinopathy in participants under 50 years old significant increased.

Conclusions

Retinal and optic nerve diseases are an important public health concern in China. Further well-conceived epidemiological studies are required to validate the observed increased prevalence of diabetic retinopathy, hypertensive retinopathy, retinal vein occlusion, and macular hole nationwide.

Translational Relevance

This artificial intelligence system can be a potential tool to monitor the prevalence of major retinal and optic nerve diseases over a wide geographic area.

Whole genome sequencing for inherited retinal diseases in the Korean National Project of Bio Big Data

PURPOSE

This study aimed to analyze the genetic results of inherited retinal diseases (IRDs) and evaluate the diagnostic usefulness of whole genome sequencing (WGS) in the Korean National Project of Bio Big Data.

METHODS

As part of the Korean National Project of Bio Big Data, WGS was performed on 32 individuals with IRDs with no identified pathogenic variants through whole or targeted exome sequencing.

RESULTS

Individuals with retinitis pigmentosa (n = 23), cone dystrophy (n = 2), cone-rod dystrophy (n = 2), familial exudative vitreoretinopathy (n = 2), pigmented paravenous chorioretinal atrophy (n = 1), North Carolina macular dystrophy (n = 1), and bull's-eye macular dystrophy (n = 1) were included. WGS revealed genetic mutations in the IQCB1, PRPF31, USH2A, and GUCY2D genes in five cases (15.6%). Two large structural variations and an intronic variant were newly detected in three cases. Two individuals had biallelic missense mutations that were not identified in previous exome sequencing.

CONCLUSION

With WGS, the causative variants in 15.6% of unsolved IRDs from the Korean National Project of Bio Big Data were identified. Further research with a larger cohort might unveil the diagnostic usefulness of WGS in IRDs and other diseases.

A proposal for an updated staging system for LCHADD retinopathy

OBJECTIVE

To develop an updated staging system for long-chain 3-hydroxyacyl coenzyme A dehydrogenase deficiency (LCHADD) chorioretinopathy based on contemporary multimodal imaging and electrophysiology.

METHODS

We evaluated forty cases of patients with genetically confirmed LCHADD or trifunctional protein deficiency (TFPD) enrolled in a prospective natural history study. Wide-field fundus photographs, fundus autofluorescence (FAF), optical coherence tomography (OCT), and full-field electroretinogram (ffERG) were reviewed and graded for severity.

RESULTS

Two independent experts first graded fundus photos and electrophysiology to classify the stage of chorioretinopathy based upon an existing published system. With newer imaging modalities and improved electrophysiology, many patients did not fit cleanly into a single traditional staging group. Therefore, we developed a novel staging system that better delineated the progression of LCHADD retinopathy. We maintained the four previous delineated stages but created substages A and B in stages 2 to 3 to achieve better differentiation.

DISCUSSION

Previous staging systems of LCHADD chorioretinopathy relied on only on the assessment of standard 30 to 45-degree fundus photographs, visual acuity, fluorescein angiography (FA), and ffERG. Advances in recordings of ffERG and multimodal imaging with wider fields of view, allow better assessment of retinal changes. Following these advanced assessments, seven patients did not fit neatly into the original classification system and were therefore recategorized under the new proposed system.

CONCLUSION

The new proposed staging system improves the classification of LCHADD chorioretinopathy, with the potential to lead to a deeper understanding of the disease's progression and serve as a more reliable reference point for future therapeutic research.

Exploring Patient Demographics and Presence of Retinal Vascular Disease in Paracentral Acute Middle Maculopathy

PURPOSE

To investigate the sociodemographic profile, the association with retinal vascular diseases (RVD) and systemic comorbidities, and visual outcomes of patients with paracentral acute middle maculopathy (PAMM) in a large, ethnically diverse single-center cohort.

DESIGN

Retrospective cohort study.

METHODS

Electronic health record query for all patients presenting with PAMM at Moorfields Eye Hospital, London, was completed. Detailed demographic, clinical, and systemic information were collected and analyzed.

RESULTS

A total of 78 eyes of 78 patients with confirmed PAMM were included in the study. Forty patients (51.3%) presented with no RVD, 20 patients (25.6%) with retinal vein occlusion (RVO), 16 patients (20.5%) with retinal artery occlusion (RAO), and 2 patients (2.6%) with concomitant RAO and RVO. Patients with PAMM+RAO were older than those with RVO (P = .02) and more likely to have a history of major adverse cardiovascular events (MACE) (P = .01), with a significantly worse presenting best corrected visual acuity (BCVA) (20/50) compared to patients with RVO (P = .02) and no RVD (P < .001). Individuals with isolated PAMM had a significantly higher prevalence of previous MACE (P = .04) and sickle cell disease (SCD) (P = .04) compared to those with RVO. At the last follow-up, 64 patients (85.3%) had a good BCVA (>20/32).

CONCLUSIONS

The significant association of PAMM with RVD supports the hypothesis of an ischemic etiology. Individuals with isolated PAMM had a higher prevalence of MACE and SCD. Thus, it is important to prompt immediate referral for a comprehensive systemic evaluation. Across the whole cohort, PAMM was associated with good BCVA improvement during follow-up, indicating a good visual prognosis.

Gender differences in retinal diseases: A review

Gender medicine is a medical specialty that addresses gender differences in health and disease. Traditionally, medical research and clinical practice have often been focused on male subjects and patients. As a result, gender differences in medicine have been overlooked. Gender medicine considers the biological, psychological, and social differences between the genders and how these differences affect the development, diagnosis, treatment, and prevention of disease. For ophthalmological diseases epidemiological differences are known. However, there are not yet any gender-based ophthalmic treatment approaches for women and men. This review provides an overview of gender differences in retinal diseases. It is intended to make ophthalmologists, especially retinologists, more sensitive to the topic of gender medicine. The goal is to enhance comprehension of these aspects by highlighting fundamental gender differences. Integrating gender medicine into ophthalmological practice helps promote personalized and gender-responsive health care and makes medical research more accurate and relevant to the entire population.

The Use of the RETeval Portable Electroretinography Device for Low-Cost Screening: A Mini-Review

Electroretinography (ERG) provides crucial insights into retinal function and the integrity of the visual pathways. However, ERG assessments classically require a complicated technical background with costly equipment. In addition, the placement of corneal or conjunctival electrodes is not always tolerated by the patients, which restricts the measurement for pediatric evaluations. In this short review, we give an overview of the use of the RETeval portable ERG device (LKC Technologies, Inc., Gaithersburg, MD, USA), a modern portable ERG device that can facilitate screening for diseases involving the retina and the optic nerve. We also review its potential to provide ocular biomarkers in systemic pathologies, such as Alzheimer's disease and central nervous system alterations, within the framework of oculomics.

Electrodiagnostic Biomarkers in Paraneoplastic Retinopathy

OBJECTIVE

Paraneoplastic retinopathy (PNR) is a rapid-onset photoreceptor and post-photoreceptor dysfunction triggered by a cross-reaction between antigens expressed by the underlying tumour and retinal proteins. The present study aims to determine the electrodiagnostic biomarkers that support the diagnosis of PNR and evaluate the effect of treatment.

METHODS

A retrospective observational case-controlled study including 25 patients with suspected PNR, of which 11 patients were diagnosed with PNR. The presence of PNR was confirmed based on clinical examination, supported by colour fundus photography, fundus autofluorescence imaging, optical coherence tomography, fluorescein angiography, retinal vessel oximetry, colour test, full-field electroretinogram (ffERG), on-/off ERG, S-cone ERG, and multifocal ERG (mfERG). The relationships between the clinical symptomatology and the effect of therapy were evaluated.

RESULTS

All PNR patients (Nr: 11) presented with subjective symptoms of newly reported central vision or visual field deterioration. Posterior segment findings showed a severe patchy-like retinal atrophy, attenuation of the retinal vessels, and a waxy optic disc. Optical coherence tomography revealed a discontinued ISe line, and multiple hyperreflective foci. Retinal vessel oxygen saturation was increased. Multifocal ERG revealed reduced central and paracentral responses and ffERG severely attenuated scotopic-, photopic-, on-/off- and S-cone responses. The colour vision test revealed a tritan-tetartan-weakness. Two of the PNR patients underwent rituximab therapy with no further progression and even recovery of electrodiagnostic responses.In 1 nPNR (non-paraneoplastic retinopathy) patient (total Nr: 14) pseudoxanthoma elasticum-related retinopathy was the reason for impaired vision. In 3 of 13 patients with bronchopulmonary cancer a MEK- and FGFR-inhibitor- drug toxicity was the reason for the visual deterioration.

CONCLUSION

Careful investigation for signs of central and/or peripheral visual field deterioration must be performed in the presence of history of a co-existing malignancy. The possibility of PNR should be taken into account. The electrodiagnostic biomarkers, suggested in this study, may help to promptly recognise PNR and also to evaluate the effect of implemented therapy.

Chorioretinal Findings in a Patient with New-Onset Systemic Lupus Erythematosus and Antiphospholipid Syndrome after Stillbirth Associated with Pre eclampsia

PURPOSE

To describe chorioretinal findings in a patient with new-onset systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) after a stillbirth associated with preeclampsia.

STUDY DESIGN

Case report.

RESULTS

We report a patient with new-onset SLE and APS after pregnancy, who had a history of preeclampsia and intrauterine death that presented with bilateral visual loss after a seizure. Clinical findings of a unilateral vaso-occlusive retinopathy and choroidopathy associated with intraocular inflammation, serous retinal detachment, and vasculitis are presented, which responded well to immunosuppressive therapy.

CONCLUSION

New-onset systemic lupus erythematosus (SLE) during or after pregnancy could occur, especially when complicated with preeclampsia, making it difficult to diagnose accurately. Pregnancy-induced hypertension retinopathy and choroidopathy, as well as chorioretinal manifestations of SLE and APS, can share similar ocular manifestations that can overlap and coexist in the same patient, and it is important to recognize them for an adequate management and follow-up.

Artificial Intelligence (AI) for Early Diagnosis of Retinal Diseases

Artificial intelligence (AI) has emerged as a transformative tool in the field of ophthalmology, revolutionizing disease diagnosis and management. This paper provides a comprehensive overview of AI applications in various retinal diseases, highlighting its potential to enhance screening efficiency, facilitate early diagnosis, and improve patient outcomes. Herein, we elucidate the fundamental concepts of AI, including machine learning (ML) and deep learning (DL), and their application in ophthalmology, underscoring the significance of AI-driven solutions in addressing the complexity and variability of retinal diseases. Furthermore, we delve into the specific applications of AI in retinal diseases such as diabetic retinopathy (DR), age-related macular degeneration (AMD), Macular Neovascularization, retinopathy of prematurity (ROP), retinal vein occlusion (RVO), hypertensive retinopathy (HR), Retinitis Pigmentosa, Stargardt disease, best vitelliform macular dystrophy, and sickle cell retinopathy. We focus on the current landscape of AI technologies, including various AI models, their performance metrics, and clinical implications. Furthermore, we aim to address challenges and pitfalls associated with the integration of AI in clinical practice, including the "black box phenomenon", biases in data representation, and limitations in comprehensive patient assessment. In conclusion, this review emphasizes the collaborative role of AI alongside healthcare professionals, advocating for a synergistic approach to healthcare delivery. It highlights the importance of leveraging AI to augment, rather than replace, human expertise, thereby maximizing its potential to revolutionize healthcare delivery, mitigate healthcare disparities, and improve patient outcomes in the evolving landscape of medicine.

Long-term outcomes of anti-vascular endothelial growth factor therapy with and without posterior scleral reinforcement on myopic maculopathy in myopic choroidal neovascularization eyes

BACKGROUND

Anti-vascular endothelial growth factor (anti-VEGF) therapy is used for myopic choroidal neovascularization (mCNV). Patchy chorioretinal atrophy (pCRA) enlargement has been reported in mCNV cases associated with vision loss. Our aim was to compare the long-term effectiveness of anti-VEGF therapy alone versus anti-VEGF followed by posterior scleral reinforcement (PSR) in controlling myopic maculopathy in mCNV eyes.

METHODS

We performed a retrospective review of the medical records of 95 high myopia patients (refractive error ≥ 6.00 diopters, axial length ≥ 26.0 mm) with mCNV. Patients were treated with anti-VEGF alone (group A) or anti-VEGF followed by PSR (group B). The following data were collected: refractive error, best corrected visual acuity (BCVA), ophthalmic fundus examination, ocular coherence tomography and ocular biometry at 12 and 24 months pre- and postoperatively. The primary outcomes were changes in pCRA and BCVA.

RESULTS

In 26 eyes of 24 patients, the mean pCRA size significantly increased from baseline (0.88 ± 1.69 mm2) to 12 months (1.57 ± 2.32 mm2, t = 3.249, P = 0.003) and 24 months (2.17 ± 2.79 mm2, t = 3.965, P = 0.001) postoperatively. The increase in perilesional pCRA in group B (n = 12) was 98.2% and 94.2% smaller than that in group A (n = 14) at 12 and 24 months (Beta 0.57 [95% CI 0.01, 191 1.13], P = 0.048). In group B, 7 eyes (58.3%) gained more than 2 lines of BCVA compared with only 4 eyes (28.6%) in group A at 24 months.

CONCLUSION

Anti-VEGF therapy followed by PSR achieved better outcomes than anti-VEGF therapy alone in controlling the development of myopic maculopathy in mCNV and may constitute a better treatment option by securing a better long-term VA outcome.

Patient experiences and perceived value of genetic testing in inherited retinal diseases: a cross-sectional survey

This study evaluated patient experiences with genetic testing for inherited retinal diseases (IRDs) and the association between underlying knowledge, testing outcomes, and the perceived value of the results. An online survey was distributed to adults with IRDs and parents/guardians of dependents with IRDs who had had genetic testing. Data included details of genetic testing, pre- and post- test perceptions, Decision Regret Scale, perceived value of results, and knowledge of gene therapy. Of 135 responses (85% from adults with IRDs), genetic testing was primarily conducted at no charge through public hospitals (49%) or in a research setting (30%). Key motivations for genetic testing were to confirm IRD diagnosis and to contribute towards research. Those who had received a genetic diagnosis (odds ratio: 6.71; p < 0.001) and those self-reported to have good knowledge of gene therapy (odds ratio: 2.69; p = 0.018) were more likely to have gained confidence in managing their clinical care. For over 80% of respondents, knowing the causative gene empowered them to learn more about their IRD and explore opportunities regarding clinical trials. Key genetic counselling information needs include resources for family communications, structured information provision, and ongoing genetic support, particularly in the context of emerging ocular therapies, to enhance consistency in information uptake.

Purtscher-like retinopathy following carotid angioplasty and stenting in the treatment of severe carotid stenosis

We present a case of Purtscher-like retinopathy (PLR) following carotid angioplasty and stenting (CAS). A 56-year-old man with a history of severe stenosis of the left carotid artery and treated by CAS refers acute and painless visual loss on the left eye (OS) 48 h after the procedure. Funduscopic examination showed cotton wool spots and intraretinal hemorrhages confined to the peripapillary and posterior pole of the OS. The optical coherence tomography (OCT) showed retinal thickening and hyperintense lesions in the inner nuclear layer retina.

Crystalline Retinopathy Following Intravitreal Clindamycin

This case report describes a 74-year-old woman who developed a crystalline retinopathy following intravitreal injection of clindamycin. The patient presented with ocular toxoplasmosis in the left eye but was allergic to sulfa medications, so she was treated with intravitreal clindamycin. Subsequently, fine refractile yellow-white crystals were observed on examination of the left macula. Optical coherence tomography localized the crystals to the posterior hyaloid. Intravitreal clindamycin should be considered in the differential diagnosis of crystalline retinopathy. [Ophthalmic Surg Lasers Imaging Retina 2024;55:168-170.].

MICROVASCULATURE ALTERATIONS OF PERIPAPILLARY RETINA AND MACULA IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS WITHOUT OCULAR INVOLVEMENT BY OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY

PURPOSE

To evaluate microvasculature alterations of the peripapillary retina and macula and to assess whether the changes can detect preclinical retinopathy in systemic lupus erythematosus patients.

METHODS

Cross-sectional study of 32 systemic lupus erythematosus patients without retinopathy and 22 normal controls. Optical coherence tomography angiography was used to measure the microvasculature of the peripapillary retina and macula. Vessel densities (VD, %) and fractal dimensions of superficial capillary plexus (SCP) and deep capillary plexus were calculated.

RESULTS

Compared with controls, macular vessel densities of the whole image SCP (macular vessel density of SCP-wi) and macular vessel density of inferior SCP (macular vessel density of SCP-i) were significantly reduced in systemic lupus erythematosus patients ( P < 0.05). The peripapillary vessel densities (peripapillary vessel density [pVD]) of a 2.5-mm circle of SCP (pVD of SCP Φ2.5 ), pVD of SCP Φ3.5 , and pVD of inferior region of the inner circle of SCP (pVD of SCP-ii) were significantly reduced in patients treated with hydroxychloroquine >5 years. Macular vessel density of SCP-wi declined with age (β = -0.12; P < 0.01) and pVD of SCP-ii declined with hydroxychloroquine cumulative dose (β = -0.01; P < 0.01). Macular vessel density of SCP-i had the best discrimination power of 0.77 ( P < 0.01).

CONCLUSION

Systemic lupus erythematosus patients without ocular involvement had microvasculature alterations that were particularly evident in the SCP. Peripapillary retina microvasculature may be reduced in patients with longer hydroxychloroquine treatment.

FIVE-YEAR FOLLOW-UP OF A SPONTANEOUSLY PROGRESSIVE RETINAL RACEMOSE HEMANGIOMA

PURPOSE

To report the progression of a patient with retinal racemose hemangioma after 5 years of follow-up.

METHODS

Observational case report.

RESULTS

A 14-year-old girl was diagnosed with an isolated retinal racemose hemangioma with retinal arteriovenous malformation in the posterior pole of the left eye fundus. At the fifth year of follow-up, a spontaneous enlargement of the previously normal vessel was found above the original lesion. The patient's vision remained stable, and no complication was observed.

CONCLUSION

Retinal racemose hemangioma was once considered stable and nonprogressive, but progression and expansion of the lesion may also occur, so long-term follow-up is necessary.

ATYPICAL FOVEAL AND PARAFOVEAL ABNORMALITIES IN SICKLE CELL DISEASE

PURPOSE

The primary aim was to describe the patterns of paramacular involvement, not yet reported but that optical coherence tomography angiography can now detect in patients with sickle cell disease. The secondary aim was to search arguments concerning the physiopathogeny of paramacular involvement.

METHODS

This institutional cohort retrospective study was conducted in a Referral Center for Ophthalmological Rare Diseases. Follow-up included an ophthalmologic examination with optical coherent tomography and optical coherent tomography angiography.

RESULTS

One hundred and thirty-two patients with SCD were included. Typical sickle cell maculopathy was observed in temporal area in 84 eyes (40.0%) of SS patients and eight eyes (14.8%) of SC patients ( P < 0.001). Enlargement of the foveal avascular zone was observed in 10 eyes of eight SS patients. Two atypical parafoveal abnormalities were found in SS patients only. The first one consisted of macular thinning with normal vascularization in 15 eyes of 11 patients. The second atypical maculopathy was large areas of loss of vascularization without retinal thinning 10 eyes of six patients. Multivariate analysis did not show a statistically significant relation between the peripheral sickle retinopathy stage and the different type of sickle cell maculopathy ( P = 0.21).

CONCLUSION

Those atypical sickle cell maculopathy may correspond to early forms preceding a typical sickle cell disease maculopathy (SCDM). This would point toward several physiopathogenic mechanisms. The first one included the existence of ischemia that can be related to anemia. Presence of retinal thinning without vascular involvement point out to a neurogenic mechanism.

Fundus imaging features of congenital rubella retinopathy

PURPOSE

To evaluate the clinical characteristics of congenital rubella retinopathy (CRR) with modern fundus imaging.

METHODS

Single-center case series. Eleven patients (2005-2020) at the Emory Eye Center with known or presumed CRR. Trained image readers reviewed fundus imaging (color fundus photography, widefield pseudocolor imaging, near-infrared reflectance imaging, autofluorescence imaging, and spectral-domain optical coherence tomography) for pre-specified features suggestive of CRR.

RESULTS

Eleven patients with confirmed (63.6%) or presumed (36.3%) CRR were identified. All were female with median (range) age of 53 (35-67) years. Six (54.5%) were born during the 1964-1965 United States rubella epidemic. All had congenital hearing loss. Two (18.2%) had a congenital heart defect. Eleven (50.0%) eyes had salt-and-pepper retinal pigmentary changes. Twenty-two eyes (100.0%) had irregularly distributed regions of speckled hypoautofluorescence. One eye (4.5%) had a presumed macular neovascularization.

CONCLUSION

Modern fundus imaging demonstrates characteristic features of CRR, even when pigmentary changes are not readily apparent on examination. Widefield autofluorescence findings of irregularly distributed speckled hypoautofluorescence are particularly revealing. This series of newly diagnosed adults with CRR may represent the milder end of the phenotypic spectrum of this condition, highlighting imaging findings that may aid in diagnostically challenging cases of CRR.

RECURRENCE OF ACUTE RETINOPATHY IN PSEUDOXANTHOMA ELASTICUM

PURPOSE

To report a case of recurrent acute retinopathy associated with pseudoxanthoma elasticum and to propose a reappraisal of this entity based on multimodal imaging analysis.

METHODS

Retrospective case report. High-resolution optical coherence tomography (high-res OCT), ultra-widefield imaging, and widefield swept-source OCT angiography and en face OCT were performed.

RESULTS

A man in his 40s diagnosed with pseudoxanthoma elasticum and angioid streaks presented with two distinct episodes of acute retinopathy in his right eye during a one-year follow-up period. Acute retinopathy was characterized by rapid vision loss. High-res OCT showed multifocal hyperreflective lesions splitting the retinal pigment epithelium/Bruch membrane complex and associated with focal choroidal thickening. After the first episode, OCT angiography confirmed the development of macular neovascularization at the site of a previous inflammatory lesion. During the second episode, multimodal images showed findings consistent with epiphenomenon multiple evanescent white dot syndrome (EpiMEWDS). On en face widefield OCT, acute retinopathy was characterized by multiple hyperreflective spots scattered at the posterior pole.

CONCLUSION

Recurrence of acute retinopathy can be observed in patients with pseudoxanthoma elasticum and angioid streaks. Multimodal imaging shows that some lesions of pseudoxanthoma elasticum-associated acute retinopathy closely resemble those of punctate inner choroidopathy/idiopathic multifocal choroiditis.

PARACENTRAL ACUTE MIDDLE MACULOPATHY WITH SICKLE CELL TRAIT

PURPOSE

To report a case of paracentral acute middle maculopathy in a pediatric patient with sickle cell trait.

METHODS

The patient was evaluated with a comprehensive ophthalmic examination, optical coherence tomography, optical coherence tomography angiography, and fluorescein angiography.

RESULTS

Acute loss of vision occurred immediately after an uneventful scleral buckling procedure for retinal detachment in a 16-year-old female patient. Retinal imaging studies confirmed the occurrence of paracentral acute middle maculopathy, an ischemic condition characterized by infarction of the inner nuclear layer of the retina caused by hypoperfusion of the intermediate and deep capillary plexuses. Laboratory evaluation was only remarkable for sickle cell trait. Over a course of 3 months after the loss of vision, visual acuity improved from 20/1,000 to 20/20, and optical coherence tomography lesion resolved to a parafoveal area of inner and middle retinal layer thinning. Paracentral scotoma corresponding to the atrophic area persisted.

CONCLUSION

Dehydration because of the presurgical nil-per-os status and transient increase in intraocular pressure during the buckling surgery may have predisposed this patient with sickle cell trait to a sickling event that caused localized ischemia in the middle retina's end-capillaries. Avoiding long nil-per-os status, being mindful of transient intraocular pressure elevation during scleral buckling procedures, and presurgical hemoglobin electrophoresis in at-risk populations are recommended to prevent sickling attacks during retinal surgeries in individuals with sickle cell trait.

Nationwide Usage of Pentosan Polysulfate and Practice Patterns of Pentosan Polysulfate Maculopathy Screening in South Korea

OBJECTIVE

To investigate the nationwide use of pentosan polysulfate (PPS) and screening practices for PPS maculopathy (PPM), with a focus on the timing and modalities used.

DESIGN

Population-based cohort study.

PARTICIPANTS

For evaluation of nationwide usage, 133 762 individuals who received PPS prescriptions between 2012 and 2021 were included. To investigate practice patterns, 55 487 individuals (referred to as overall users) who initiated PPS therapy between 2018 and 2020 were identified using the Health Insurance Review and Assessment database. After excluding patients with ophthalmic diseases before PPS administration, 34 857 PPS users without prior ophthalmic diseases were identified.

METHODS

Ophthalmic examinations performed after initiating PPS therapy were categorized as baseline and subsequent monitoring examinations. The timing and modalities employed for these examinations were analyzed. The annual trends in PPS utilization and maculopathy screening were evaluated by assessing the number of PPS users and determining the proportion of patients receiving retinal/macular examinations among these users.

MAIN OUTCOME MEASURES

Performance of baseline and subsequent monitoring examinations and timing and modalities used for screening.

RESULTS

The number of PPS users dramatically increased annually over the study period from 5494 in 2012 to 40 451 in 2021. However, the majority of PPS users did not undergo baseline or subsequent monitoring examinations for PPM. Only 27.2% and 12.4% of PPS users without prior ophthalmic disease underwent baseline and monitoring examinations, respectively. Funduscopy/fundus photography was the most commonly utilized, whereas OCT and fundus autofluorescence (FAF) were performed in only 45.2% and 5.3% of the PPS users without prior ophthalmic diseases for monitoring, respectively. The performance of the screening examinations differed significantly across the 3 different daily dose and duration groups (all P < 0.05).

CONCLUSIONS

This study highlights the lack of performance of baseline and monitoring examinations for maculopathy in most patients taking PPS in South Korea. The limited use of OCT and FAF suggests potential insensitivity in detecting PPM. These findings emphasize the need for improvements in screening practices, including increased awareness and referrals to ophthalmologists, utilization of more sensitive modalities, and regular monitoring to enable early detection of PPM.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.