Multifocal Toxoplasma Retinochoroiditis in a Nonimmunosuppressed Elderly Patient: Case Report and Brief Review of the Literature

Purpose To raise awareness of ophthalmologists that toxoplasmosis should be considered in the differential diagnosis of multifocal or diffuse necrotizing retinitis in nonimmunosuppressed elderly patients. Methods Interventional case report with serial color fundus photographs, indocyanine green angiography, fluorescein angiography, optical coherence tomography, and chorioretinal biopsy histology. Results A 77-year-old, nonimmunosuppressed man developed extensive multifocal retinochoroiditis with scattered focal hemorrhages and significant vitreous haze. This case posed a significant diagnostic challenge mimicking viral retinitis. Vitreous polymerase chain reaction and chorioretinal biopsy confirmed the diagnosis of toxoplasma retinochoroiditis. Conclusions As demonstrated in this case, toxoplasmosis should be considered as a cause of multifocal and/or diffuse necrotizing retinitis in elderly patients even in the absence of obvious systemic immunosuppression.

Origins of Ghost Drusen: A follow-up Analysis

Purpose Ghost drusen (GD) are pyramidal or dome-shaped retinal pigment epithelium elevations observed in some geographic atrophy (GA) areas in the context of age-related macular degeneration (AMD). The purpose was to investigate the first morphologic features preceding GD on spectral-domain optical coherence tomography (SD-OCT) on patients with GA associated with AMD. Methods A retrospective observational study was performed on a series of patients with GA that had at least 3 years of follow-up. Using the follow-up tool of SD-OCT, we tracked the initial lesions that could lead to GD. Results Among 442 patients with GA, 37 had well defined GD (8%). We included the 17/37 patients (31 eyes) with at least 3 years of follow-up for analysis, which led to a total of 582 counted GD. Most GD were already present at the first visit, and remained stable. However, on 13 of the 582 analyzed GD (2.2%), soft drusen were shown as the initial lesion, which progressively turned into GD. Conclusions GD were observed in less than 10% of eyes with GA. None of the ghost drusen turned into another shaped lesion, suggesting that GD is a possible final stage of evolution. In a few cases, large drusen were shown as the primary lesion that progressed into GD.

Diagnostic Accuracy of Glaucoma Tests in Everyday Practice

Purpose To evaluate the performance of various tests with automated and subjective evaluation for primary diagnostics of glaucoma in a normal clinical setting. Methods Subjects referred because of suspicion of glaucoma were recruited. All subjects had full ophthalmologic evaluation with stereophotography of the optic nerve head (ONH), red-free retinal nerve fiber layer (RNFL) photography, scanning laser polarimetry (SLP), optical coherence tomography (OCT), and standard automated perimetry (SAP). Analysis of all results was made jointly by 5 glaucoma specialists, with a consensus for each eye as healthy, glaucomatous, or glaucoma suspect. Results from each method were evaluated against this consensus, followed by a subjective evaluation of each method by a glaucoma specialist, comparing this with automated classification by the devices. Results Of the 101 subjects and 202 eyes examined, 23 eyes were by consensus glaucomatous, and 23 were glaucoma suspect. Sensitivity was best with ONH photos and worst with SAP, while SLP had a better sensitivity but poorer specificity than did RNFL photographs and OCT. Subjective evaluation of SLP, OCT, and SAP data gave better sensitivity and specificity than did classification by numeric values from the devices only, with OCT performing better in automatic classification than did SLP or SAP. Conclusions None of the current methods is superior to others in diagnosing glaucoma, and the accuracy of automated tests was better when subjectively evaluated by an experienced ophthalmologist. Diagnosis of glaucoma should be based on a combination of test results interpreted by a clinician.

Deep Anterior Lamellar Keratoplasty followed by Toric Lens Implantation for the Treatment of Concomitant Anterior Stromal Diseases and Cataract

Purpose To evaluate the outcomes of deep anterior lamellar keratoplasty (DALK) followed by phacoemulsification and toric intraocular lens (IOL) implantation for the treatment of concomitant stromal disease and cataract. Methods In this retrospective non-comparative interventional case series, ten eyes affected by stromal disease and cataract underwent DALK followed by phacoemulsification with toric IOL implantation after a minimum period of 5 months from complete suture removal. In each case, topographic astigmatism, refraction, visual acuity, and endothelial cell density were recorded before DALK and 1, 6, and 12 months after cataract surgery. In addition, IOL rotation was evaluated using anterior segment optical coherence tomography. Results Big-bubble DALK was performed in all eyes but one that received manual dissection. Topographic astigmatism averaged 5.6 ± 2.2 diopters (D) after suture removal; refractive astigmatism decreased to 0.55 ± 0.61 D as early as one month after cataract surgery and did not change substantially throughout the follow-up period. In all patients, one month after phacoemulsification uncorrected and best spectacle-corrected visual acuity were, respectively, ≥20/40 and ≥20/25 with a residual spherical equivalent of 0.00 ± 0.84 D. At the latest follow-up visit, in all cases the IOL rotation was ≤5 degrees from the intended position and the endothelial cell loss within 8.5%. No complications were recorded. Conclusions DALK followed by phacoemulsification with toric IOL implantation optimizes visual and refractive outcomes in patients with concomitant stromal disease and cataract. In comparison with a combined procedure, the sequential approach offers better predictability of the postoperative refraction in the absence of an increased risk of complications.

Peripapillary Choroidal Neovascularization as an Unusual Complication of POEMS Syndrome

Purpose To report the association of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome with bilateral papilledema and bilateral choroidal neovascularization (CNV) in a 61-year-old man and to compare our findings with data from a review of the literature. Case report Diagnosis of POEMS syndrome was based on paraproteinemia immunoglobulin A lambda associated with progressive sensorimotor peripheral neuropathy and increased serum vascular endothelial growth factor (VEGF) levels. Shortly later, loss of vision of the left eye (LE) was noted and bilateral papilledema was observed with peripapillary hemorrhages and papillomacular subretinal fluid. Lenalidomide 25 mg daily and weekly dexamethasone 20 mg were administered and the patient was followed up closely. The systemic complaints initially were controlled and peripheral neuropathy improved. Regression of the papilledema and hemorrhages was observed as well as regression of the papillomacular edema in the LE. However, after a few months, the systemic VEGF levels increased, and an active CNV was diagnosed in the LE. Melphalan and prednisone were administered systemically, and the CNV was treated with bevacizumab intravitreal injections and these treatments proved to be effective. Conclusions Optic disc edema is reported frequently in POEMS syndrome but complication with CNV is rare, this being the second reported case.

Central Serous Chorioretinopathy in a Myopic Patient with Pachychoroid

Introduction To report a case of central serous chorioretinopathy (CSC) associated with a retinal pigment epithelium detachment in a myopic patient with marked pachychoroid. Patient presentation Case report of a 37-year-old male patient with relatively high myopia (-5.00D in OD/-5.75D in OS), unilateral CSC, and bilateral retinal pigment epithelial detachments, pachychoroid, and choroidal hyperaemia. Standard ophthalmological examination and multimodal imaging, including fundus photography, fundus autofluorescence, spectral-domain and enhanced depth optical coherence tomography, and indocyanine green angiography were performed. Conclusions Findings characteristic for the spectrum of CSC/pachychoroid pigment epitheliopathy can be observed in patients with relatively high myopia. Based on the outcome of complete ophthalmological examination, this clinical picture can be discerned from other diseases, which is important for the optimal therapeutic approach.

Indocyanine Green and Fluorescein Filters Reveal Dye Staining before Clinical Development of Hives

Purpose During retinal angiography a fluorescein-induced allergic reaction is rare but possible. Methods We report a single retrospective clinical case. Results During retinal angiography on a 75-year-old man, an unexpected allergic reaction to fluorescein (FL) dye occurred. At the beginning of the exam, we erroneously took some filtered shots of the patient's face. We noticed that the pictures of the patient's skin using the FL and indocyanine green filters revealed dye accumulation before the clinical appearance of hives. Conclusions Taking filtered shots of a patient's face could be an original method to promptly detect and easily document allergic hives, by simply using an angiographic device.

Late Detachment after DALK in a Patient with Descemet Membrane Microperforation

We report a case of late detachment in a patient with Descemet membrane (DM) microperforation following a deep anterior lamellar keratoplasty (DALK). Late detachment of the DM in this case occurred 5 months after DALK because of the flattening pressure during the retinal exam with scleral depression. In patients with a history of microperforation during DALK, we suggest that the retinologist and patient avoid rubbing or applying pressure over the eye to minimize the risk of late detachment of the DM.