Iodine-125 Brachytherapy for Uveal Melanoma: A Systematic Review of Radiation Dose

AIM

To investigate whether lower radiation doses may yield similar outcome measures to those from the COMS trial.

METHODS

A literature review of English language articles was performed using the PubMed database of the U.S. National Library of Medicine and the Cochrane Central Register of Controlled Trials using the following keywords: uveal melanoma, choroidal melanoma, primary uveal malignant melanoma, iodine-125 brachytherapy, local recurrence, local treatment failure, and local tumor control. The relationships between study local recurrence rate and median dosage were tested by linear regression, with each study weighted by the number of patients included.

RESULTS

Fifteen retrospective and prospective studies were selected for systematic review (2,662 patients). Ranges of reported mean or median radiation dose to tumor apex were 62.5-104.0 Gy. Local recurrence rates ranged from 0 to 24%. A 1.0-Gy increase in the average study dose was associated with a 0.14% decrease in local recurrence rate, which was not statistically significant (p value 0.336).

CONCLUSION

The gold standard empirically derived 85.0-Gy radiation dose for the treatment of uveal melanoma could be tested in a randomized study.

Differentiating Veins From Arteries on Optical Coherence Tomography Angiography by Identifying Deep Capillary Plexus Vortices

PURPOSE

To introduce a simple method for differentiating retinal veins from arteries on optical coherence tomography angiography (OCTA).

DESIGN

Cross-sectional pilot study.

METHODS

Four default en face slabs including color depth encoded, grayscale full-thickness retina, superficial plexus, and deep capillary plexus (DCP) from nine 3×3-mm and nine 6×6-mm OCTA scans were exported and aligned. Nine ophthalmologists with minimum OCTA experience from 2 eye institutions were instructed to classify labeled vessels as arteries or veins in 3 stages. Classification was performed based on graders' own assessment at stage 1. Graders were taught that a capillary-free zone was an anatomic feature of arteries at stage 2 and were trained to identify veins originating from vortices within the DCP at stage 3. Grading accuracy was analyzed and correlated with grading time and graders' years in practice.

RESULTS

Overall grading accuracy in stages 1, 2, and 3 was (50.4% ± 17.0%), (75.4% ± 6.0%), and (94.7% ± 2.6%), respectively. Grading accuracy for 3×3-mm scans in stages 1, 2, and 3 was (49.9% ± 16.3%), (79.2% ± 9.6%), and (96.9% ± 3.1%), respectively. Accuracy for 6×6-mm scans in stages 1, 2, and 3 was (51.4% ± 20.8%), (72.3% ± 7.9%), and (93.2% ± 3.3%), respectively. Grading performance improved significantly at each stage (all P < .001). No significant correlation was found between accuracy and time spent grading or between accuracy and years in practice (r = -0.164 to 0.617, all P ≥ .077).

CONCLUSIONS

We describe a simple method for accurately distinguishing retinal arteries from veins on OCTA, which incorporates the use of vortices in the DCP to identify venous origin.

Outcomes of Pars Plana Vitrectomy Alone versus Combined Scleral Buckling plus Pars Plana Vitrectomy for Primary Retinal Detachment

PURPOSE

We compared the outcomes of primary uncomplicated rhegmatogenous retinal detachment (RRD) repair using pars plana vitrectomy (PPV) alone versus combined scleral buckling plus PPV (SB+PPV).

DESIGN

Retrospective, observational study.

PARTICIPANTS

Patients with primary RRD who underwent PPV or SB+PPV from June 1, 2014, through December 31, 2017.

METHODS

We performed a single-institution, retrospective, observational study of 488 consecutive patients with primary RRD repaired via PPV alone or SB+PPV and gas tamponade. We excluded patients younger than 18 years and those with advanced proliferative vitreoretinopathy, giant retinal tear, trauma, or secondary forms of RRD. We performed logistic regression and Cox proportional hazard regression analyses to identify potential risk factors associated with a retinal redetachment.

MAIN OUTCOME MEASURES

Single-operation anatomic success (SOAS), defined as adequate retinal reattachment achieved with only 1 procedure.

RESULTS

The mean follow-up interval was 14.3 months. Single-operation anatomic success and final anatomic success were achieved in 425 eyes (87.1%) and 487 eyes (99.8%), respectively. Single-operation anatomic success was achieved in 90 of 111 eyes (81.1%) with PPV alone compared with 345 of 374 eyes (92.2%) with SB+PPV (P = 0.0010). Scleral buckling plus PPV showed greater SOAS than PPV alone in phakic eyes (P < 0.0001), but not in eyes with a posterior chamber intraocular lens (PCIOL). Retinal redetachments occurred on average at 1.5 and 9 months after the initial surgery. Significant best-corrected visual acuity improvement was associated with SOAS (P < 0.0001).

CONCLUSIONS

Scleral buckling plus PPV resulted in greater SOAS outcomes than PPV alone for primary RRD repair. Phakic eyes achieved greater surgical success with SB+PPV, whereas eyes with a PCIOL achieved similar results with both methods. Most retinal redetachments occurred within the initial postoperative 3-month period. Single-operation anatomic success was associated with statistically significant visual improvement.

Opacification of Akreos Hydrophilic Acrylic Lens After Retinal Detachment Repair with Silicone Oil Tamponade: A Case Report

We report localized opacification of a sclera-fixated Akreos^® hydrophilic acrylic intraocular lens after successful repair of rhegmatogenous retinal detachment with silicone oil tamponade in a nondiabetic patient. No intraoperative lens opacification during air-fluid exchange or lens dislocation was encountered. Granular opacities within the optic were noted at 5 months after surgery, and did not relent to scrubbing with a vitrector during oil removal. Akreos lens opacification under silicone oil is not well documented in the literature. Surgeons must be aware of this potential complication, which is known to occur with various types of hydrophilic acrylic lenses after exposure to air or gas.

Bilateral radiation therapy followed by methotrexate-based chemotherapy for primary vitreoretinal lymphoma

Primary vitreoretinal lymphoma (PVRL) is a subset of primary CNS lymphoma that presents as isolated ocular disease without brain involvement. Although ocular radiotherapy (RT) is an effective treatment for PVRL, the optimal treatment is uncertain. PVRL may later involve the brain in 56%-85% of patients. We report on 12 PVRL patients treated with a combination of bilateral RT and a systemic chemotherapy (CT) regimen containing high-dose methotrexate (M). Ten received RT (30-40 Gy) followed by CT, one received RT, and one was treated with intravitreal M; all achieved a complete response (CR). Three patients had tumor recurrence in the brain and received CT and one patient relapsed in the eye with a second recurrence in the brain. Three patients achieved CR-2 remain alive and one died of dementia. One died from recurrent CNS disease. With a median follow of 68 months (range, 17-154 months), median progression-free and overall survival have not been reached. Bilateral RT followed by M-based CT is an effective treatment for reducing CNS progression and prolonging survival.

Animal models of radiation retinopathy - From teletherapy to brachytherapy

Radiation retinopathy is a serious vision-impairing complication of radiation therapy used to treat ocular tumors. Characterized by retinal vasculopathy and subsequent retinal damage, the first sign of radiation retinopathy is the preferential loss of vascular endothelial cells. Ensuing ischemia leads to retinal degradation and late stage neovascularization. Despite the established disease progression, the pathophysiology and cellular mechanisms contributing to radiation retinopathy remain unclear. Clinical experience and basic research for other retinal vasculopathies, such as diabetic retinopathy and retinopathy of prematurity, can inform our understanding of radiation retinopathy; however, the literature investigating the fundamental mechanisms in radiation retinopathy is limited. Treatment trials have shown modest success but, ultimately, fail to address the cellular events that initiate radiation retinopathy. Animal models of radiation retinopathy could provide means to identify effective therapies. Here, we review the literature for all animal models of radiation retinopathy, summarize anatomical highlights pertaining to animal models, identify additional physiological factors to consider when investigating radiation retinopathy, and explore the use of clinically relevant tests for studying in vivo models of radiation retinopathy. We encourage further investigation into the mechanistic characterization of radiation retinopathy in the hope of discovering novel treatments.

Episcleral brachytherapy for retinoblastoma

BACKGROUND/AIMS

To report visual outcomes, survival outcomes and complications following episcleral brachytherapy (EB) for retinoblastoma.

METHODS

Retrospective review of retinoblastoma cases treated with EB in a single institution. Survival outcomes were analysed using the Kaplan-Meier method.

RESULTS

Eleven tumours of 11 eyes were treated with either iodine-125 or ruthenium-106 EB with a mean apical dose of 44 Gy. The tumours were classified as group B in 5 (46%), C in 3 (27%) or D in 3 (27%) eyes, respectively. Mean follow-up time was 75.4 months. EB served as primary treatment in 3 eyes (27%) and secondary treatment in 8 eyes (73%). Final visual acuity was better than 20/200 in 70% of cases. Globe preservation was achieved in 9 (82%) eyes. Local recurrence occurred in 18% of cases at a mean onset of 17.4 months after EB. Two group D tumours that recurred after secondary EB underwent enucleation. Mean onset of radiation retinopathy was 17.4 months following EB. No metastatic or fatal events were recorded. Kaplan-Meier analysis showed recurrence-free survival and ocular survival of 80% and overall survival of 100% at 5 years after EB.

CONCLUSION

EB is an effective primary or secondary treatment modality for selected retinoblastoma eyes (groups B and C). Advanced group D tumours may represent a risk factor for local recurrence. Visually significant complications such as radiation retinopathy should be anticipated.

Intravitreal rituximab for the treatment of a secondary intraocular relapse of a large B-cell lymphoma

PURPOSE

To report a rare case of secondary intraocular lymphoma treated with intravitreal rituximab, following pars plana vitrectomy.

OBSERVATIONS

A 74-year-old female with history of parotid gland large B-cell lymphoma presented bilateral intraocular recurrence 10 years after the onset of the primary malignancy. Systemic work-up including PET/CT Scan, bone marrow biopsy, brain MRI and CSF analysis were unremarkable, and the patient declined to undergo systemic chemotherapy. Vision loss in her left eye was severe due to significant sub-retinal pigment epithelium (RPE) infiltration involving the macula; this eye was treated with external beam radiation therapy. On the right eye, the relapse manifested with vitreous involvement and fovea-sparing multifocal, sub-RPE infiltration for which the patient received monthly intravitreal rituximab injections, following pars plana vitrectomy. Through the course of therapy, the patient achieved good local control and maintained 20/20 visual acuity on her right eye. Brain magnetic resonance imaging (MRI) surveillance, every 3 months, was performed and revealed a cerebellar recurrence 24 months into the course of therapy.

CONCLUSIONS AND IMPORTANCE

Our case illustrates how intravitreal immunotherapy with rituximab may provide local control of CD-20 positive secondary intraocular lymphoma; particularly in cases where systemic therapy is not amenable. In our case, a prior vitrectomy, did not appear to interfere with the therapeutic effect of intravitreal rituximab. Close quarterly surveillance with Brain MRI may help disclose central nervous system recurrences in such cases.

Expression of hypothalamic neurohormones and their receptors in the human eye

Extrapituitary roles for hypothalamic neurohormones have recently become apparent and clinically relevant, based on the use of synthetic peptide analogs for the treatment of multiple conditions including cancers, pulmonary edema and myocardial infarction. In the eye, it has been suggested that some of these hormones and their receptors may be present in the ciliary body, iris, trabecular meshwork and retina, but their physiological role has yet to be elucidated. Our study intends to comprehensively demonstrate the expression of some hypothalamic neuroendocrine hormones and their receptors within different retinal and extraretinal structures of the human eye. Immunofluorescence, Western blot analysis, and RT-PCR were used to evaluate the qualitative and quantitative expression of Luteinizing Hormone Releasing Hormone (LHRH), Growth Hormone Releasing Hormone (GHRH), Thyrotropin Releasing Hormone (TRH), Gastrin Releasing Peptide (GRP) and Somatostatin as well as their respective receptors (LHRH-R, GHRH-R, TRH-R, GRP-R, SST-R1) in cadaveric human eye tissue and in paraffinized human eye tissue sections. The hypothalamic hormones LHRH, GHRH, TRH, GRP and Somatostatin and their respective receptors (LHRH-R, GHRH-R, TRH-R, GRPR/BB2 and SST-R1), were expressed in the conjunctiva, cornea, trabecular meshwork, ciliary body, lens, retina, and optic nerve.

Multifocal Primary Uveal Melanoma: Clinical and Molecular Characteristics

We report two patients who developed a second distinct choroidal melanoma in the same eye following successful regression of their first choroidal melanoma after iodine-125 plaque brachytherapy. Neither patient demonstrated ocular melanocytosis, local tumor recurrence, or vitreous seeding. One patient had the second tumor arising from a previously documented choroidal nevus, and after undergoing enucleation, there was no detectable connection between the tumors on histopathologic examination. Germline BAP1 mutation was absent in both cases. Multifocal primary uveal melanoma is a rare entity in which the second tumor may occur either de novo or from a malignant transformation of a choroidal nevus. Known risk factors include ocular melanocytosis or germline BAP1 mutation. Additional underlying mechanisms have yet to be elucidated.

Ophthalmic Manifestations of Hodgkin Lymphoma: A Review

Background

Hodgkin lymphoma (HL) is a hematopoietic neoplasm characterized by cancerous Reed-Sternberg cells. In contrast to ophthalmic manifestations by non-HL that are well recognized, there is paucity of the literature as it relates to ophthalmic manifestation by HL. We performed a comprehensive review of published studies (case reports and small case series) to characterize the ophthalmic manifestations of HL.

Summary

Thirty patients were identified with ophthalmic manifestation of HL. Thirteen (43%) were male, and 14 (46%) were female (in 3 cases, sex was not specified). The median age at ophthalmic presentation was 27 years. Diagnosis of HL was made after ophthalmic manifestation in 10 (33%) cases, whereas 11 (36%) cases had a prior diagnosis of HL. Ophthalmic manifestations can be classified into 3 main groups; direct infiltration, inflammatory reaction, and paraneoplastic process. Seven cases had infiltration of the optic nerve. Uveal inflammatory reaction was reported in 21 cases. The presence of intraocular Reed-Sternberg cells had been confirmed in 1 case with granulomatous uveitis. Conjunctival and corneal reaction was seen in 3 cases. HL was in stage 2 or higher, with only 1 case with stage 1A (12 cases HL stage not specified). Seven cases (22%) died of HD, all were diagnosed with advanced lymphoma, and none was treated with chemotherapy.

Key Message

Ocular involvement in HL is extremely rare. A few cases of histopathologically confirmed optic nerve/tract infiltration are within the spectrum of CNS involvement by HL. Inflammatory uveitis is the most common ophthalmic association of HL. In the presence of prior known diagnosis of HL, restaging should be considered to exclude recurrence. Toxicity or adverse reaction to drugs used to treat HL may also contribute to ophthalmic involvement.

Linear nevus sebaceous syndrome presenting as circumscribed choroidal hemangioma

A 4-year-old female with a unilateral circumscribed choroidal hemangioma and secondary total exudative retinal detachment. A nasal skin scar-like lesion incised to confirm a histopathologic diagnosis of linear nevus sebaceous. Further imaging disclosed asymmetry of the lateral ventricle frontal horns, suggestive of the diagnosis of linear nevus sebaceous syndrome. The choroidal hemangioma was treated with I-125 episcleral brachytherapy (apical dose of 45 Gy). At 6 months post-radiation, the tumor showed regression with total resolution of exudative retinal detachment.

Conjunctival Melanoma Angiotropic Microsatellitosis: A Mechanism of Local Extravascular Migratory Metastasis

Purpose

To report a case of local metastasis of conjunctival melanoma, which may occur via extravascular migratory metastasis (EVMM), and discuss its clinical relevance in conjunctival melanoma tumor staging and possible management implications.

Methods

Retrospective chart review of a single clinical case with clinicopathologic correlation.

Results

A 65-year-old male referred due to local recurrence of conjunctival melanoma at the caruncle was successfully treated after two excisional procedures with negative sentinel lymph node biopsies. Forty-eight months after initial presentation, the patient developed a nodular lesion representing local recurrence in the ipsilateral upper tarsal conjunctiva, distant from the primary tumor site. Histopathology showed nodules in the substantia propria in the absence of primary acquired melanosis. The tumor cells were found along the extravascular surface without intralymphatic or intravascular tumor cells consistent with local metastasis. One possible mechanism is angiotropic microsatellitosis leading to local EVMM. Additional neck CT imaging showed no lymphadenopathy.

Conclusion

EVMM via angiotropic microsatellitosis is another possible mechanism of noncontiguous local recurrence of conjunctival melanoma. Angiotropic microsatellitosis may represent a high-risk finding possibly related to increased melanoma-related mortality.

Histopathologic Patterns of Recurrent Choroidal Melanoma Following I-125 Plaque Brachytherapy

Purpose

Histologic correlation of clinical patterns of recurrent choroidal melanoma following I-125 plaque brachytherapy was performed to identify pathologic mechanisms of recurrence.

Methods

We reviewed 7 cases of recurrent choroidal melanoma following I-125 plaque brachytherapy managed with enucleation. Clinical characteristics included tumor dimensions, radiation dose, time to local recurrence, and clinical pattern of recurrence. Histopathology (hematoxylin and eosin and periodic acid - Schiff) and immunohistochemistry (Ki-67, CD-163, HMB45, and SOX10) were performed.

Results

Mean follow-up time and time to local recurrence were 42 and 21 months after brachytherapy, respectively. Tumor recurrences were described clinically as marginal in 43%, diffuse in 29%, and extraocular extension (EOE) in 29%. Eighty-six percent were classified as mixed cell type and 14% were epithelioid type. Tumor zonation (histologic demarcation between zones of recurrent and nonrecurrent tumor cells by immunohistochemistry) was present in marginal and EOE cases (n = 6) and absent in the diffuse cases (n = 2). Ki-67 proliferative index was higher in marginal and EOE recurrences, while diffuse cases showed uniform -Ki-67 staining. CD-163 staining was found to be greater in nonrecurrent tumor. HMB45 correlated with SOX10 with a greater staining in recurrent tumor.

Conclusion

Our observations provide a correlation between histopathologic and clinical patterns of local recurrence of choroidal melanoma after brachytherapy.

Choroidal calcifications in two cases of aplasia cutis congenita and oculoectodermal syndrome

PURPOSE

To describe choroidal calcifications as an ophthalmic feature in aplasia cutis congenita (ACC) with oculoectodermal syndrome (OES).

OBSERVATIONS

Two cases of ACC/OES with characteristic echographic evidence of choroidal calcifications are described.

CONCLUSIONS AND IMPORTANCE

The ophthalmic manifestations of ACC/OES may be expanded to include choroidal calcifications. The presence of a choroidal calcification with B-scan ultrasound in a case suspicious for ACC/OES may facilitate a more timely diagnosis and inform future follow-up regimens to monitor ophthalmic and systemic manifestations of this disease.

Primary hepatic carcinoid tumor metastasizing to eyelid: A case report

Purpose

We report a rare case of a metastatic carcinoid tumor to the right lower lid masquerading as a chalazion.

Observations

A 78-year-old Hispanic woman who presented with a 3-month history of a non-resolving chalazion on the right lower lid despite aggressive medical treatment. The patient had a history of noninfectious anterior uveitis and primary hepatic carcinoid tumor that was incidentally diagnosed during the initial uveitis work-up. The right lower eyelid lesion was biopsied and histological and immunopathological analysis revealed a well differentiated neuroendocrine tumor consistent with a carcinoid tumor.

Conclusionand Importance

Neuroendocrine tumors should be considered as part of the differential diagnosis of focal, vascularized eyelid masses. To the authors best knowledge this is the first reported case of primary hepatic carcinoid tumor with metastasis to the eyelids. We also highlight the importance of pursuing a histopathologic diagnosis, in the setting of a non-resolving or recurrent chalazion.

Penile Filler Injection Leading to Silicone Embolism Syndrome and Paracentral Acute Middle Maculopathy

A 31-year-old male with acute blurred vision and respiratory distress occurring three days after a penile filler injection was found to have outer plexiform layer hyperreflectivity on optical coherence tomography (OCT), consistent with paracentral acute middle maculopathy (PAMM). He was diagnosed with diffuse bilateral pneumonitis and silicone embolism syndrome requiring inpatient management. Following systemic stabilization, his vision and OCT findings improved. PAMM may be associated with silicone embolism syndrome in the presence of acute central scotomas and minimal retinal findings. Penile filler injections could contribute to retinal vaso-occlusion via an embolic process. PAMM may be self-limited and result in functional vision. [Ophthalmic Surg Lasers Imaging Retina 2022;53:635-638.].

A novel rat contact lens model for Fusarium keratitis

PURPOSE

The aim of this study was to develop and characterize a new contact lens-associated fungal keratitis rat model and to assess the ability of non-invasive spectral-domain optical coherence tomography (SD-OCT) to detect pathological changes in vivo in fungal keratitis.

METHODS

We used SD-OCT to image and measure the cornea of Sprague Dawley rats. Fusarium infection was initiated in the rat eye by fitting Fusarium solani-soaked contact lenses on the experimental eye, while the control animals received contact lenses soaked in sterile saline. The fungal infection was monitored with periodic slit-lamp examination and in vivo SD-OCT imaging of the rat eye, and confirmed by histology, counting of viable fungi in the infected rat cornea, and PCR with specific primers for Fusarium sp.

RESULTS

We imaged and measured the rat cornea with SD-OCT. Custom-made contact lenses were developed based on the OCT measurements. Incubation of contact lenses in a F. solani suspension resulted in biofilm formation. We induced contact lens-associated Fusarium keratitis by fitting the rat eyes for 4 h with the Fusarium-contaminated contact lenses. The SD-OCT images of the cornea correlated well with the slit-lamp and histopathological results and clearly defined clinical signs of infection, namely, increased corneal thickening, loss of epithelial continuity, hyper-reflective areas representing infiltrates, and endothelial plaques characteristic of fungal infection. Moreover, in three cases, SD-OCT detected the infection without any clear findings on slit-lamp examination. Infection was confirmed with histological fungal staining, PCR, and microbiological culture positivity.

CONCLUSIONS

We developed a highly reproducible rat contact lens model and successfully induced contact lens-associated Fusarium keratitis in this model. The clinical presentation of contact lens-associated Fusarium keratitis in the rat model is similar to the human condition. SD-OCT is a valuable tool that non-invasively revealed characteristic signs of the fungal infection and could provide sensitive, objective monitoring in fungal keratitis.

Intraocular inflammation secondary to intravitreal brolucizumab treated successfully with Sub-Tenon triamcinolone: A case report

Purpose

Observations

Conclusions and Importance

Nd:YAG Laser Hyaloidotomy: A Therapeutic Approach for Valsalva Premacular Hemorrhage

Subhyaloid hemorrhage, characterized by localized vitreoretinal detachment due to blood accumulation, often results in sudden vision loss, especially in the macular area. This case report highlights a 23-year-old female presenting with exercise-related Valsalva retinopathy leading to premacular subhyaloid hemorrhage. The patient underwent neodymium-doped yttrium aluminum garnet (Nd:YAG) laser hyaloidotomy, a non-invasive procedure, leading to rapid blood drainage and visual recovery. The patient's initial visual acuity was severely impaired, with a significant premacular hemorrhage obscuring the macula. A week later, due to the expanding hemorrhage, Nd:YAG laser hyaloidotomy was performed, demonstrating successful blood dispersion and restoration of vision. Follow-up revealed significant improvement with demarcation of the previous hemorrhage and no evidence of new findings. The case emphasizes the importance of prompt intervention and considers alternative treatments for premacular subhyaloid hemorrhage. While associated with ocular pathologies, such as macular holes and retinal detachment, Nd:YAG laser hyaloidotomy remains a safe and effective outpatient procedure for managing premacular subhyaloid hemorrhage, avoiding the risks of more invasive surgical interventions. The presented case highlights the significance of tailored interventions based on patient history, minimizing the need for invasive procedures and their associated risks.

External Compressive Ischemic Orbitopathy: A Rising Clinical Entity

PURPOSE

Saturday night retinopathy, the term coined by Jayam et al . in 1974, is a rare condition in which external compression of the orbit during a drug and alcohol stupor causes a unilateral orbitopathy with ophthalmoplegia and ischemic retinopathy. This condition has been increasingly reported in the last decade, correlating with an increasing burden of substance use. This condition mirrors a similar entity typically reported in patients following spinal surgery, where a headrest supporting the patient's face compresses the orbit. The current authors combine these 2 entities, entitled external compressive ischemic orbitopathy, and present a comprehensive literature review describing this entity.

METHODS

A systematic review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All related publications of vision loss in the setting of orbital compression were reviewed. Data collected included patient demographics, precipitating circumstances of vision loss, presenting ocular symptoms, outcomes, and ancillary imaging.

RESULTS

In total 31 articles were selected for inclusion, yielding 46 patients. A total of 10 patients suffered orbitopathy in the setting of a drug stupor, and 36 following prone-positioned surgery. However, 79% of patients presented with visual acuity of light perception or worse. Also, 86% of patients presented with ophthalmoplegia, 92% with proptosis and orbital edema, and 86% with varying degrees of retinal ischemia. When compared with iatrogenic cases, self-induced stuporous cases demonstrated worse presenting visual acuity, ophthalmoplegia, retinal and choroidal filling, and worse final outcomes.

CONCLUSION

External compressive ischemic orbitopathy is a severe vision-threatening condition that has been increasingly reported in the last decade.

Superficial and Deep Capillary Plexus Nonperfusion in Nonaccidental Injury on OCTA

A 5-year-old Caucasian male with a history nonaccidental injury (NAI) at age 1 presented with new onset no light perception in the left eye due to a closed funnel retinal detachment. The right eye showed optic nerve pallor, peripheral vascular attenuation, and leakage. Optical coherence tomography angiography (OCTA) revealed significant parafoveal attenuation of the superficial vascular plexus, intermediate capillary plexus, and the deep capillary plexus. This correlated with inner and middle retinal layer thinning temporal to the fovea and preservation of the ellipsoid zone. The peripapillary vascular plexus was preserved. Laser photocoagulation was performed to the nonperfused peripheral retina and intravitreal bevacizumab was injected. OCTA may be used in patients with NAI to characterize macular ischemia changes. Attenuation of the superficial, intermediate, and deep capillary plexuses in our patient may represent chronic ischemic retinal changes that arise from traumatic injury to the vitreoretinal interface and inner retina in NAI.