Case Report: Self-Resolved Macular Edema Secondary to Congenital Retinal Macrovessels

PurposeTo report a case of macular edema secondary to congenital retinal macrovessels (CRMs), which resolved spontaneously without any treatment.ObservationsA 39-year-old female presented with blurry vision of the right eye for one day. Fundus examination revealed a branch of artery and vein of the inferior retinal arcade crossing the horizontal raphe. Optical coherence tomography (OCT) through the fovea showed cystoid macular edema in the outer plexiform layer. However, no leakage of the vessels was noticed by fundus fluorescein angiography (FFA). Observation was recommended with close follow-up. Two weeks later, the patient returned with good visual acuity, and the macular edema was resolved spontaneously.ConclusionsMacular edema is a possible complication of CRM by increasing retinal capillary hydrostatic pressure. Treatment is not necessary for this kind of macular edema if no leakage of the vessels is noticed on FFA.

Fundus Examination in Pediatric Patients Using Indirect Ophthalmoscopy

The goal of this chapter is to provide the clinician with an understanding of binocular indirect ophthalmoscopy (BIO) and helpful clinical techniques for success in examining the fundus of the pediatric patient, including scleral depression. The challenging technique to examine the premature infant at risk for retinopathy of prematurity will be explained in detail, including the standard classification of the disease with photos depicting the different location and stages of disease. BIO with the addition of scleral indentation helps the clinician diagnose and locate lesions that may otherwise go undetected, such as retinal holes, tears, or vitreoretinal adhesions. Complete examination of the fundus of a child is no less important than of any other patient who seeks eye care but often requires efficiency and precision (as well as many human arms). Time is a rate limiting aspect when examining children so preparation and experience will lead to success.

Fundus Examination in Pediatric Patients

There are a number of different pieces of equipment and techniques available for examination of the fundus of a pediatric patient. Two of these tools are handheld devices, the direct ophthalmoscope and PanOpticTM ophthalmoscope. Both of these devices allow for examination of the posterior pole of the eye. This chapter will discuss the indications, advantages, and disadvantages of both of these pieces of equipment in addition to how to use the equipment to examine the posterior segment of a pediatric patient.

Idiopathic intracranial hypertension leading to bilateral optic atrophy in a patient with recent COVID-19 infection: a case report

Neurologic complications are common in patients hospitalised with COVID-19 infection. Most common complications are myalgias, headaches, encephalopathy and dizziness. Uncommon complications are stroke, motor and sensory deficits, seizures, ataxia and movement disorders. Multiple neuro-ophthalmological manifestations have also been reported in association with COVID-19. These complications may be the result of a range of pathophysiological mechanisms like hypoxic neuronal injury during active COVID-19 infection, RAS dysfunction, immune dysfunction and direct injury by the virus etc throughout the course of the disease. Here we reported a case of neuro-ophthalmic complication of Idiopathic intracranial hypertension (IIH) followed by bilateral optic atrophy in a middle-aged man with recent COVID-19 infection. He presented to the emergency with complaints of headache, dizziness and sudden painless bilateral diminution of vision for 3 days. His fundus examination was suggestive of bilateral papilledema, his MRI brain was normal and opening pressure of CSF was raised on lumbar puncture. His MRV was normal, there was no evidence of CSVT. He was started on steroids and acetazolamide. His headache improved but there was no improvement in visual acuity. Repeat fundus showed pale disc and MRI orbit was suggestive of bilateral optic atrophy.

Bilateral Diffuse Uveal Melanocytic Proliferation in a Woman with Metastatic Scalp Squamous Cell Carcinoma Treated with Cemiplimab

Bilateral diffuse uveal melanocytic proliferation (BDUMP) is a rare paraneoplastic intraocular syndrome that causes progressive visual loss in patients driven by an IgG factor associated with an underlying malignancy. The IgG factor – cultured melanocyte elongation and proliferation – was found in the IgG fraction of the serum of BDUMP patients. It has been shown to be involved in melanocytic proliferation. In this case report, we describe the first case of BDUMP related to metastatic cutaneous squamous cell carcinoma (cSCC) of the scalp. A 61-year-old woman complained of decreased vision in both of her eyes, while being treated with cemiplimab (an anti-PD-1 therapy) for metastatic cSCC. Fundus examination showed hypopigmented lesions in a leopard pattern and pigmentary clumps in both eyes. Further imaging confirmed the diagnosis of BDUMP. The patient was successfully treated with plasmapheresis. During follow-up, cataract progressed in both eyes, and she underwent cataract surgery with visual acuity improvement to 20/20. BDUMP is a challenging diagnosis especially in patients treated with anti-PD-1 immunotherapy as it can be confused with drug-related effects. It is crucial to distinguish between the cases in order to allow the appropriate treatment which includes continuation of systemic anti-PD-1 for the underlying malignancy and plasmapheresis therapy for BDUMP.

A case of subretinal hemorrhage due to choroidal tear in right eye following blunt trauma in a 35 years old female

A 35-year-old Asian Indian female presented to our institute with a history of fall on road and accidental hit by stone over her right eyebrow, grossly no anterior segment abnormality was noted. On dilated fundus examination, a superotemporal choroidal tear was noted which led to choroidal hemorrhage. Patient was managed conservatively by giving oral steroids and tablet vitamin C. After 2 months of treatment there was complete resolution of the lesion with a final best corrected visual acuity of 6/6.

Correlation between Ultra-Wide-Field Retinal Imaging Findings and Vascular Supra-Aortic Changes in Takayasu Arteritis

(1) Background: Takayasu arteritis (TA) is a chronic inflammatory large-vessel vasculitis. Ultra-wide-field imaging allows describing the retinal lesions in these patients and correlating them with vascular supra-aortic stenosis. (2) Methods: In total, 54 eyes of 27 patients diagnosed with TA were included, and a complete ophthalmological examination was performed, including UWF color fundus photography (UWF-CFP), fluorescein angiography (UWF-FA), and computed tomography angiography measuring supra-aortic stenosis. Eleven patients underwent Doppler ultrasound imaging assessing the blood flow velocity (BFV) in the central retinal artery (CRA). (3) Results: Microaneurysms were detected in 18.5% of eyes on fundus examination, in 24.4% of eyes on UWF-CFP, and in 94.4% of eyes on UWF-FA. The number of microaneurysms significantly correlated with the presence of an ipsilateral supra-aortic stenosis (p = 0.026), the presence of hypertension (p = 0.0011), and the duration of the disease (p = 0.007). The number of microaneurysms per eye negatively correlated with the BFV in the CRA (r = −0.61; p = 0.003). (4) Conclusions: UWF-FA improved the assessment of TA-associated retinal findings. The significant correlation between the number of microaneurysms and the BFV in the CRA gives new insight to our understanding of Takayasu retinopathy. The total number of microaneurysms could be used as an interesting prognostic factor for TA.

Mitochondrial Mutations in Ethambutol-Induced Optic Neuropathy

Background: Ethambutol-induced optic neuropathy (EON) is a well-recognized ocular complication in patients who take ethambutol as a tuberculosis treatment. The aim of the current study was to investigate the presence of mitochondrial mutations, including OPA1 and Leber’s hereditary optic neuropathy (LHON)-mitochondrial DNA (mtDNA), in patients with EON and to determine their effect on clinical features of these patients.Methods: All 47 patients underwent clinical evaluations, including best-corrected visual acuity, fundus examination, and color fundus photography; 37 patients were then followed up over time. Molecular screening methods, including PCR-based sequencing of the OPA1 gene and LHON-mtDNA mutations, together with targeted exome sequencing, were used to detect mutations.Results: We detected 15 OPA1 mutations in 18 patients and two LHON-mtDNA mutations in four patients, for an overall mutation detection rate of 46.8%. The mean presentation age was significantly younger in the patients with the mitochondrial mutations (27.5 years) than in those without mutations (48 years). Fundus examination revealed a greater prevalence of optic disc hyperemia in the patients with mutations (70.5%) than without mutations (48%). Half of the patients with mutations and 91% of the patients without mutations had improved vision. After adjusting for confounders, the logistic regression revealed that the patients with optic disc pallor on the first visit (p = 0.004) or the patients with the mitochondrial mutations (p < 0.001) had a poorer vision prognosis.Conclusion: Our results indicated that carriers with OPA1 mutations might be more vulnerable for the toxicity of EMB to develop EON.

Comparison of conventional and wide field direct ophthalmoscopy on medical students’ self-confidence for fundus examination: a 1-year follow-up

Background Fundus examination is an easy, quick and effective way to diagnose sight- and life-threatening diseases. However, medical students and physicians report lack of proficiency and self-confidence in perform fundoscopy. The aim of this study was to compare students’ self-confidence in fundus examination, using two different direct ophthalmoscopes, 1 month and 1 year after practical training. Methods In this prospective cohort, medical students (MS) of the same class were divided in small groups for PanOptic (PO) or conventional (CO) direct ophthalmoscope training. The intervention group encompassed MS of the 4th -year (class of 2019), and the control group encompassed MS of year behind (class of 2020). A questionnaire to measure self-confidence in fundoscopy technique assessing optic nerve, cup-to-disc ratio and macula was translated and validated to Portuguese, and applied 1-month and 1-year after practical training. Results One-hundred and sixty-seven MS were enrolled (35 PO group, 38 CO group, and 94 control group). PO group had a significantly higher overall self-confidence comparing either control or CO groups, respectively (3.57 ± 0.65 vs. 2.97 ± 1.03 vs. 2.46 ± 0.87, p < 0.01) as well as in evaluate cup-to-disc ratio (3.09 ± 0.75 vs. 2.32 ± 0.87 vs. 1.46 ± 0.81, p < 0.01), optic disc margins (3.26 ± 0.85 vs. 2.71 ± 0.96 vs. 2.01 ± 0.97, p < 0.01) and macula (3.43 ± 1.12 vs. 2.89 ± 1.08 vs. 2.02 ± 0.89, p < 0.01) 1-month after practical training. One-year after intervention, CO group showed a significantly higher score compared to PO group in overall self-confidence (3.31 ± 0.69 vs. 3.18 ± 0.73, p = 0.03) and in optic disc margins assessing (3.16 ± 0.85 vs. 2.95 ± 0.78, p = 0.03), but not significant in the evaluation of cup-to-disc ratio (2.78 ± 0.97 vs. 2.68 ± 0.94, p = 0.08), and macula (3.34 ± 0.79 vs. 3.27 ± 0.98, p = 0.07). Conclusions Students were more confident in use PO as an instrument to perform direct ophthalmoscopy immediately after practical training, but confidence level of CO was higher compared to PO one year after practical training. These findings would help medical schools decide which ophthalmoscope to choose to teach fundus examination.

INTRAOPERATIVE BREAKAGE OF A REUSED 25 GAUGE ILM PEELING FÓRCEPS

A 59 years male presented with painless diminution of vision in right eye for 4 months. His vision was 20/100 in right eye and 20/30 in left eye. Fundus examination revealed epiretinal membrane in right eye with central macular thickness of 747 μm for which he underwent 25 guage pars plana vitrectomy. Intraoperatively after internal limiting membrane peeling, during removal of the pieces of the membrane from the forceps with the endoilluminator pipe, accidentally one blade from the tip of ILM peeling forceps broke. In this report, we describe first case of inadvertent intraoperative fracture of 25- gauge Grieshaber DSP End-Grasping ILM forceps in a case of ERM who underwent vitrectomy and removal of ERM with successful removal of fractured tip of ILM forceps.