A case of branch retinal artery occlusion postcataract surgery in an antiphospholipid syndrome patient

A 46-year-old female with preoperative vision 6/18 N18 (LogMar 0.5) in re and posterior subcapsular cataract underwent an uneventful phacoemulsification surgery under a peribulbar block. On the postoperative day 2, she complained of no visual gain in the operated eye. The reported vision was counting fingers close to the face. Through multimodal imaging (MMI), a diagnosis of branched retinal artery occlusion (BRAO) was made. A detailed consultation and history taking with the patient revealed a concealed history of four miscarriages in the past. A detailed systemic blood workup revealed antiphospholipid antibody (APLA) positive. BRAO postuneventful cataract surgery is a devasting outcome for the surgeon and patient undergoing surgery. The report focuses on the importance of taking detailed past medical history and usage of MMI early to rule out and diagnose unexpected scenarios. We suggest BRAO in our patient was a result of emboli formation, which is a common element in APLA-positive patients.

Hyperbaric Oxygen Therapy Combined with Immunosuppression for Acute Macular Neuroretinopathy in Systemic Lupus Erythematosus

PURPOSE

To describe the use of hyperbaric oxygen therapy (HBOT) in conjunction with immunosuppression for acute macular neuroretinopathy (AMN) in systemic lupus erythematosus (SLE).

METHODS

Two known cases of SLE presented to us with blurred vision and paracentral scotomas due to AMN. Both cases reported worsening of their conditions despite the initiation of high-dose steroid therapy. HBOT was added on as a treatment modality to address vaso-occlusive ischemic injury.

RESULTS

Both patients underwent a total of twelve cycles of HBOT. Functional and anatomical improvements were noted immediately after the initiation of therapy and were maintained over more than one year of follow-up. No significant retinal thinning was noted on optical coherence tomography on disease resolution, as has been noted previously. Visual field scotoma showed a complete resolution.

CONCLUSION

Our cases suggest that HBOT may have a role in aiding functional and anatomical recovery in AMN associated with SLE.

Polypoidal Choroidal Vasculopathy: An Update on Diagnosis and Treatment

Polypoidal choroidal vasculopathy (PCV) is a vascular disease of the choroid that leads to hemorrhagic and exudative macular degeneration. It may cause significant vision loss and thus affect the quality-of-life and psychological well-being. Non-invasive, non-ICGA-based OCT criteria have shown reliable results to plan adjunct photodynamic therapy (PDT) treatment, with the complete and consistent coverage of polypoidal lesions (PL) and branching neovascular network (BNN). The safety and efficacy of anti-vascular endothelial growth factor (anti-VEGF) monotherapy and its combination with verteporfin PDT have been established. However, treatment is still challenging due to frequent follow-ups, non-availability of PDT, and need for multiple anti-VEGF injection visits that increase the treatment burden and lead to patients being lost to follow-up. Effective treatments that prolong intervals between injections while maintaining vision and anatomical gains remain a critical unmet need. Longer acting molecules, like brolucizumab, have shown non-inferiority in BCVA gains and superior anatomical outcomes compared to other anti-VEGF agents. Newer therapies in the pipeline to enhance the efficacy and longevity of treatment include Faricimab and a port delivery system (PDS). This review summarizes the most recent diagnostic and treatment approaches in PCV to offer better treatment avenues.

Unilateral Purtscher-like retinopathy post-COVID-19

A 32-year-old male with no known systemic illness presented with unilateral Purtscher-like retinopathy in his left eye 2 weeks after recovering from a severe COVID-19 infection. Fundus examination revealed areas of intraretinal whitening and few cotton wool spots. Multimodal imaging findings were consistent with embolic occlusion of capillaries seen in Purtscher-like retinopathy. The case highlights the effect of virus-directed coagulation cascade activation leading to unilateral microvasculopathy in our patient. The case adds to the spectrum of COVID-19 retinopathy and presses that retina screening strategies should be established for patients suffering from or recovering from severe COVID-19 infection.

RETINAL PIGMENT EPITHELIAL IRREGULARITY AND ATROPHY AFTER INTERNAL MEMBRANE PEELING: A REPORT OF TWO CASES

PURPOSE

To report two cases of widespread retinal pigment epithelial clumping, irregularity, and atrophy after uncomplicated 25-gauge pars plana vitrectomy with brilliant blue-green-assisted internal limiting membrane peeling.

METHODS

Retrospective analysis of 2 eyes of 2 patients who underwent 25-gauge pars plana vitrectomy for macular diseases (macular hole with retinal detachment and vitreomacular traction) was performed. Surgical notes and video recordings were reviewed to determine the surgical procedures performed and the duration of the surgery. Multimodal imaging analysis, including fundus photography, fundus autofluorescence imaging, and optical coherence tomography were performed to determine the pathological changes in the postoperative period.

RESULTS

The mean age of the patients (all females) was 78 years. In all the patients, brilliant blue-green-assisted internal limiting membrane peeling was performed without any intraoperative complications. Four weeks after an uncomplicated surgery, the patients complained of progressive central visual disturbance and metamorphopsia. Retinal imaging demonstrated retinal pigment epithelial clumps and irregularity, which appeared as hyperautofluorescent on fundus autofluorescence, and widespread retinal pigment epithelial atrophy (hypoautofluorescent on fundus autofluorescence) in the posterior pole and peripapillary region, along with retinal and choroidal thinning.

CONCLUSION

In uncomplicated vitrectomy consisting of brilliant blue-green-assisted internal limiting membrane peeling, a remote risk of widespread retinal pigment epithelial damage exists even with the use of modern endoilluminators and relatively short surgical duration. Retinal phototoxicity seems to be the primary cause; however, dye-related cytotoxicity or a combination of both cannot be ruled out.

Retinal vasoocclusive spectrum following COVID-19

The coagulation abnormalities and thromboembolic complications of coronavirus 2 (SARS-CoV-2) are now a well-established fact. The hypercoagulable state, the tendency for thromboembolism, and a cytokine surge state have been the exclusive reasons for multiorgan failure and other morbidities that have been regularly reported in COVID-19 patients. Ocular involvement in patients with active disease and those who have recovered is uncommon but not rare. We report a case series of four patients with CRVO, BRVO, CRAO, and vitreous hemorrhage in patients with proven COVID-19 infection and no other systemic ailments. The case series also tries to correlate the elevated D-dimer values, which signify a plausible prothrombotic state with the vaso-occlusive phenomenon in the retina leading to significant visual morbidity.

Endogenous fungal endophthalmitis following intensive corticosteroid therapy in severe COVID-19 disease

Purpose:

To report endogenous fungal endophthalmitis, postrecovery from severe COVID-19 infection in otherwise immunocompetent individuals, treated with prolonged systemic steroids.

Methods:

Retrospective chart review of cases with confirmed and presumed fungal endogenous endophthalmitis, following severe COVID-19 disease, treated at two tertiary care referral eye institutes in North India.

Results:

Seven eyes of five cases of endogenous fungal endophthalmitis were studied. All cases had been hospitalized for severe COVID-19 pneumonia and had received systemic steroid therapy for an average duration of 42 ± 25.1 days (range 18–80 days). All the cases initially complained of floaters with blurred vision after an average of 6 days (range 1–14 days) following discharge from hospital. They had all been misdiagnosed as noninfectious uveitis by their primary ophthalmologists. All eyes underwent pars plana vitrectomy (PPV) with intravitreal antifungal therapy. Five of the seven eyes grew fungus as the causative organism (Candida sp. in four eyes, Aspergillus sp. in one eye). Postoperatively, all eyes showed control of the infection with a marked reduction in vitreous exudates and improvement in vision.

Conclusion:

Floaters and blurred vision developed in patients after they recovered from severe COVID-19 infection. They had received prolonged corticosteroid treatment for COVID-19 as well as for suspected noninfectious uveitis. We diagnosed and treated them for endogenous fungal endophthalmitis. All eyes showed anatomical and functional improvement after PPV with antifungal therapy. It is important for ophthalmologists and physicians to be aware of this as prompt treatment could control the infection and salvage vision.

Ultra-wide field retinal imaging: A wider clinical perspective

The peripheral retina is affected in a variety of retinal disorders. Traditional fundus cameras capture only a part of the fundus even when montaging techniques are used. Ultra-wide field imaging enables us to delve into the retinal periphery in greater detail. It not only facilitates assessing color images of the fundus, but also fluorescein angiography, indocyanine green angiography, fundus autofluorescence, and red and green free images. In this review, a literature search using the keywords "ultra-widefield imaging", "widefield imaging", and "peripheral retinal imaging" in English and non-English languages was done and the relevant articles were included. Ultra-wide field imaging has made new observations in the normal population as well as in eyes with retinal disorders including vascular diseases, degenerative diseases, uveitis, age-related macular degeneration, retinal and choroidal tumors and hereditary retinal dystrophies. This review aims to describe the utility of ultra-wide field imaging in various retinal disorders.

Recent advances in wide field and ultrawide field optical coherence tomography angiography in retinochoroidal pathologies

Introduction: With the advent of wide field (WF) and ultra-wide field (UWF) imaging in color fundus photography and fluorescein angiography (FA), the importance of an expanded field-of-view (FOV) has been illustrated for early detection of several chorioretinal disorders. The need to bring similar utility to optical coherence tomography angiography (OCTA) is imperative.Areas covered: For this review, we explored all research items with WF or UWF on Pubmed Central and Google Scholar. Software-based methods included algorithms for motion correction, artifact reduction, image pre-processing, post-processing and montage protocols while hardware methods included swept-source OCTA, faster scanning sources, hardware-based motion tracking and image registration, scanning sources with faster speeds and lower resolution. For various disorders such as diabetic retinopathy, uveitis, vascular disorders, among others, the increased FOV showed demonstrably increased detection rates and diagnostic yield.Expert opinion: Increased FOV in OCTA imaging is a meaningful and impactful step in ophthalmic imaging. Overcoming the hardware-based limitations can potentially yield higher FOV without loss of important details. In addition to improvements in the hardware and available equipment, better software tools and image processing algorithms may greatly enhance the utility of UWF OCTA in care of patients with various retinochoroidal diseases.

Tug of war: A bimanual technique for anterior circumferential proliferative vitreoretinopathy in recurrent retinal detachment

Purpose:

To describe a bimanual technique, “tug of war” for managing anterior circumferential proliferative vitreoretinopathy (PVR) in eyes with recurrent retinal detachment (RRD).

Methods:

We retrospectively analyzed outcomes from eyes with RRD that underwent reattachment surgery using this maneuver and had a minimum of 6 months follow-up. A chandelier light was inserted for endo-illumination and the circumferential anterior PVR was tackled with two 25-gauge forceps stretching circumferential tractional membranes in opposite direction (tug of war) till they snapped.

Results:

Eleven eyes of 11 patients with a mean age of 38.2 ± 19.7 years underwent surgery. All eyes had advanced PVR of Grade C A Type 4 (Circumferential). The median duration of RD from the time of first surgery was 6 months (interquartile range = 3–8 months). The tug of war maneuver was successful in relieving the anterior retinal traction leading to retinal reattachment in all eyes without the need for relaxing retinotomies or retinectomies. Small iatrogenic retina tears occurred at the time of tug of war maneuver in 3 (27%) eyes at the site of maximum traction. The mean best-corrected visual acuity (BCVA) improved from 1.87 ± 0.2 logarithm of minimum angle of resolution (logMAR) to 1.3 ± 0.4 logMAR at 6-months follow-up (P = 0.04).

Conclusion:

The 'tug of war' maneuver is useful for relieving circumferential anterior traction and reattaching the retina in eyes with RRD without having to resort to large relaxing retinotomies or retinectomies.

Inverted internal limiting membrane (ILM) flap technique for macular hole closure: patient selection and special considerations

This paper reviews the current status of the newer inverted internal limiting membrane flap technique for macular hole surgery. It gives an overview of the importance of patient selection and special considerations along with variations in technique. It discusses the pathophysiology and how the technique has been an important addition in the armamentarium of vitreoretinal surgeons to attain better anatomical as well as functional results in challenging situations.

Inverted flap technique for a large traumatic macular hole with choroidal rupture and subretinal hemorrhage

Large traumatic macular holes (TMHs) tend to be irregular and have a variable predictability. The inverted flap technique makes use of remnants of internal limiting membrane (ILM) at the periphery of the MH. The peeled-off ILM contains Müller cell fragments which can induce gliosis and help in closure of MH. We operated on a case of large TMH (~899 μ minimum linear diameter) with choroidal rupture and subretinal hemorrhage in a young female with the inverted flap technique of ILM peeling and observed successful closure of the MH. The excellent anatomical and surgical results achieved in our case seem to suggest this to be a safe and effective surgical manoeuvre for such cases.

Atypical retinal pigment epithelial defects with retained photoreceptor layers: a so far disregarded finding in age related macular degeneration

BACKGROUND

To report patients with age-related macular degeneration and atypical central retinal pigment epithelium (RPE) defects not attributable to geographic atrophy (GA) or RPE-tears with overlying preserved photoreceptor layers.

METHODS

Multimodal imaging case-series evaluating the course of atypical RPE- defects in patients with AMD using Color fundus images, Optical coherence tomography (OCT), OCT-Angiography, fundus autofluorescence (FAF) and fluorescein-angiography (FA).

RESULTS

Ten patients were identified. Three patients had a prior RPE-rip and were excluded. Seven patients with a mean follow-up period of 47 ± 38 months after the occurrence of the RPE-defect were included (age range 71-87 years). Mean distance Best corrected visual acuity (BCVA) at initial presentation was 0.36 ± 0.29logMAR and at last follow-up visit 0.51 ± 0.43logMAR. Patients presented with clinically apparent GA on funduscopy and FAF, but preserved photoreceptor layers on optical coherence tomography (OCT). On FA there was early hyperfluorescence and late pooling visible. Over time, migration of RPE/drusenoid material right above the Bruch's membrane with concomitant decrease of hypoautofluorescence was detectable in 4 cases. An enlargement of the RPE-defect was apparent in the remaining 3 cases. The majority (n = 4) showed a drusenoid pigment epithelium detachment (PED) preceding the lesion.

CONCLUSIONS

Beside GA and characteristic RPE-tears, another atypical form of RPE-defect with overlying preserved photoreceptor layers are found in AMD. This so far disregarded subgroup of patients present with reasonable visual function and long-term survival of photoreceptors layers. Repair mechanisms such as ingrowth of RPE/drusenoid material and persistent subretinal fluid (SRF), but also a RPE-independent visual cycle for cone photopigment within the neurosensory retina may contribute to their favorable course.

Spontaneous closure of a posttraumatic scleral fistula in an atypical choroidal coloboma

BACKGROUND

Scleral fistulas have been reported to occur in choroidal colobomas, and their repair has been described in the literature. Spontaneous closure of a posttraumatic fistula has not been reported.

PURPOSE

To describe the occurrence of posttraumatic scleral fistula formation and its spontaneous closure in an eye with an atypical choroidal coloboma.

METHODS

Interventional case report.

RESULTS

Spontaneous closure of the posttraumatic scleral fistula was noted at 1-month follow-up. This was documented clinically and confirmed by B-scan ultrasound.

CONCLUSION

Scleral fistula formation can occur at the base of a choroidal coloboma after blunt injury, and this can close spontaneously over a period of time.

Excyclotorsion in congenital fibrosis of extraocular muscles

The authors report marked bilateral excyclotorsion contributing to loss of binocularity and leading to ipsilateral head tilt in a patient with congenital fibrosis of the extraocular muscles type 1. Neuroimaging revealed bilateral hypoplastic superior recti and levator palpebrae superioris muscles. Postoperatively, head tilt was relieved and excyclotorsion was reduced. Assessment of torsion may influence surgical strategies and outcome in patients with congenital fibrosis of the extraocular muscles.

Peters plus syndrome

A 10-year-old boy, issue of unrelated parents presented with visual impairment, short stature and mental retardation. The presence of a Peters' anomaly, mental retardation, disproportionate short stature, skeletal abnormalities and distinctive facial features (broad forehead, telecanthus, cupid bow shaped upper lip) established the diagnosis of Peters' plus syndrome. Analysis of his genomic DNA revealed a homozygous deletion in the beta1,3-galactosyltransferase-like gene (B3GALTL), a recently identified gene.

Bilateral periorbital necrotizing fasciitis following exposure to Holi colors: a case report

Holi festival is celebrated in India traditionally by applying colors on one another. Various ocular adverse effects of these colors have been reported including conjunctivitis and corneal abrasion. We report a case of bilateral periorbital necrotizing fasciitis, following exposure to Holi colors. General physicians might encounter more such cases after exposure to Holi colors. In India, these colors are prepared on a small scale and lack any quality checks. Use of such toxic colors should be discouraged, and all doctors should caution people against using synthetic dyes. This case report highlights the need to put manufacturing of Holi colors under guidelines of the Food and Drug Cosmetic Act and the Bureau of Indian Standards.

Natural history of macular status in recent-onset branch retinal vein occlusion: an optical coherence tomography study

PURPOSE

To evaluate serially the course of structural changes in the macula in recent onset branch retinal vein occlusion (BRVO), using optical coherence tomography (OCT).

METHODS

Twenty eyes of patients at an institutional practice with recent onset BRVO were examined by OCT at presentation and at 3 and 6 months of onset of the occlusion. The macular thickness (MT) and the visual acuity were correlated with the macular perfusion status and analyzed statistically.

RESULTS

The mean MT at presentation, 3 and 6 months was 398.9 +/- 98.6 mm, 346.8 +/- 84.8 mm and 341.3 +/- 95.3 mm, respectively. Three distinct anatomical patterns of structural changes were appreciated on OCT-serous retinal detachment (SRD) only in 15%, cystoid macular edema (CME) only in 40%, and a combined form with both SRD and CME in 45%. At 6 months while the non-ischemic group showed an average percentage decline of 26.8% in thickness, the ischemic group showed an increase of 19.2% (P < 0.01). CME resolved in 10 of 13 perfused (non-ischemic) maculae, but persisted in all seven ischemic cases.

CONCLUSION

OCT delineates macular changes at a stage when fundus biomicroscopy and fluorescein angiography are not very informative. The anatomical cause for the increase in MT i.e., SRD and/or CME is also well delineated. Non-ischemic maculae show an early and more rapid decline in MT compared with ischemic occlusions. An increase in MT at 3 months on OCT in BRVO patients could be an indication of a possible ischemic course.

Bilateral incyclotorsion, absent facial nerve, and anotia: fellow travelers in Möbius sequence or oculoauriculovertebral spectrum?

We report a patient with bilateral incyclotorsion, asymmetric facial palsy, monocular depression deficiency, and unilateral Type 3 Duane syndrome, along with contralateral anotia and a midline cleft palate. A dysplastic middle ear cavity and unilateral absence of the facial nerve were noted on magnetic resonance imaging scanning. The differential diagnosis includes Möbius sequence, oculoauriculovertebral spectrum, and a congenital cranial dysinnervation disorder.

In vivo microscopy of Best's Vitelliform Macular Dystrophy: optical coherence tomography study of combined stage III and IV lesions

A 35-year-old man presented with decreased vision in both eyes. Fundus biomicroscopy of the right eye revealed a pseudohypopyon along with an area of hyperpigmentation and scarring at the macula (combined stage III and IVb Best's Vitelliform Macular Dystrophy [BVMD]). The left eye showed the presence of a pseudohypopyon along with macular atrophy (combined stage III and IVa). On optical coherence tomography both eyes had a neurosensory retinal detachment with an optically clear subretinal zone, an accumulation of material between neurosensory retina and the retinal pigment epithelium corresponding to the pseudohypopyon and subfoveal photoreceptor atrophy. We document on optical coherence tomography the transition of BVMD from stage III to IV (in the form of the combined stage). These new findings may be considered unique for this stage of BVMD, and would help in a further understanding of the disease as it passes through its various stages.

Familial calcific band-shaped keratopathy: Report of two new cases with early recurrence

We report two siblings with the rare entity of familial calcific band-shaped keratopathy (BSK). Detailed ophthalmic and systemic investigations failed to reveal any underlying causative pathology. Topical disodium ethylenediamine-tetraacetate (EDTA) was applied for 30 min to all four eyes. In addition the right eye of the younger sibling required a superficial keratectomy. An improvement in corneal clarity was seen in the immediate postoperative period in both siblings. Histopathology of the keratectomy specimen revealed linear extracellular sub-epithelial granular calcium deposits. However, an early recurrence was noted in all four eyes at four weeks postoperatively. We report the second instance in the English literature of this entity. Band-shaped keratopathy presenting without an obvious etiology merits a complete systemic and ophthalmic workup. Patients with familial idiopathic BSK could be cases with poor prognosis for treatment with EDTA due to an early recurrence of the disease.

Inverse hypopyon as the presenting feature of infectious scleritis in a case of tropical pyomyositis

CASE REPORT

A 25-year-old man presented with inverse hypopyon due to dense inflammatory exudation in the left eye. He was an ascetic with a history of long pilgrimages barefoot. Drainage of the pyogenic material with superficial exploration revealed localized scleral thinning at 2'o clock. Two days later, a thigh abscess was noted, which on ultrasonography showed hypoechoic areas with increased muscle mass suggestive of tropical pyomyositis. The culture from anterior chamber aspirate grew Staphylococcus aureus, as did 200 mL of pus drained from the thigh. His ocular condition improved significantly with high-dose systemic antibiotics.

COMMENTS

To our knowledge, this unusual presentation of infectious scleritis and coexistent pyomyositis has not been previously reported in the literature.

Chemo-paralysis for the removal of a live intraocular worm in ocular angiostrongyliasis

Angiostrongylus cantonensis is also called the rodent lung worm. It was first discovered in 1935 by Chen in Rattus rattus, in Canton, China. The rodent is the definitive host while infected mollusks, snails and crabs act as the intermediate hosts. Humans are infected by the 3rd stage larvae, either by eating undercooked intermediate hosts or by consuming vegetables.(1) It is a delicate nematode reported in Asia Pacific region most commonly in South-east Asia and has been reported from Taiwan, Thailand, Indonesia, Vietnam and Sri Lanka.(2) Anterior chamber angiostrogyliasis is extremely rare, and no previous case of ocular angiostrogyliasis from India could be found on Medline search. We report a new technique in the removal of the actively motile thread-like worm by paralysing it with intracameral preservative free lidocaine, which aids in the easy removal of the intact worm.

[Clinical aspects and therapy of acute poisoning by the drug combination melitracen-flupenthixol (Deanxit)]

From 1975 to 1982, the Austrian Poison Information Centre gave medical advice in forty cases of acute melitracenee-flupenthixol poisoning. The case reports were reviewed and analysed in retrospect. 13 patients who either had ingested less than 20 pills (n = 5) or who underwent early gastric lavage (n = 8) showed no symptoms. In 19 patients who had swallowed 20 to 60 (n = 11), 60 to 100 (n = 3) pills respectively, or an unknown dose (n = 5) atropine like symptoms predominated. Five patients developed atropine like and extrapyramidal symptoms. The number of pills taken by these patients ranged from 20 to 60 (n = 4) and in one up to 100. Extrapyramidal reactions were encountered as predominant symptoms in three patients one of which had taken 20, the other 60 and the third an unknown number of pills. Additionally, five patients were unconscious. 21 patients developed ECG changes, 19 of which showing sinus tachycardia. The remaining two patients who had ingested 600 to 1000 mg melitracen atrial premature beats or T-wave inversions were observed. All 40 patients recovered.