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.

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.

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.

Purtscher-like Retinopathy Associated with High Altitude Travel

Purpose To report a case of Purtscher-like retinopathy associated with travel at high altitude. Methods Case report. Results A 67-year-old man presented 2 weeks after acute vision loss in his left eye that occurred while he was hiking in the mountains of South America. Funduscopic examination revealed multiple cotton-wool spots and discrete areas of retinal whitening. Fluorescein angiography demonstrated areas of choroidal fluorescence blocked by retinal whitening, delayed arteriovenous transit time, and late capillary leakage. Spectral-domain optical coherence tomography showed hyperreflectivity in the inner plexiform, inner nuclear, and outer plexiform layers localized to the areas of retinal whitening. These findings were believed to be most consistent with Purtscher flecken, and the patient was diagnosed with Purtscher-like retinopathy. Conclusions Purtscher-like retinopathy may be linked to travel at high altitude through retinal vessel dilation and constriction leading to retinal vasospasm and precapillary arteriole occlusion. This proposed mechanism of pathogenesis suggests that Purtscher-like retinopathy may represent a partial central retinal artery occlusion.

Influence of Fasting followed by Acute Water Ingestion on Subfoveal Choroidal Thickness in Eyes of Healthy Subjects

Purpose To investigate the influence of at least 12 hours of fasting followed by acute water ingestion on macular choroidal thickness in eyes of healthy subjects. Methods Prospective case series study including healthy volunteers from April 1, 2015 to May 31, 2015. Macular choroidal thickness was measured on enhanced depth imaging optical coherence tomography (EDI-OCT) and on swept-source (SS)-OCT after 12 hours of fasting, and 60 minutes after acute water ingestion (750 mL in 5 minutes). Results A total of 52 eyes of 26 healthy volunteers were included in this study. The mean age for participants was 32 years old. After 12 hours of fasting, the mean (±SD) subfoveal choroidal thickness was 335.43 (±104.82) μm on EDI-OCT and 286.16 (±80.32) μm on SS-OCT. The mean (±SD) subfoveal choroidal thickness after acute water intake was 352.32 (±120.36) μm and 290.5 (±85.86) μm, respectively. There was no significant difference between the mean subfoveal thickness at baseline and 60 minutes after acute water ingestion for any of the choroidal imaging techniques (p = 0.1386 for EDI-OCT and p = 0.0659 for SS-OCT). Conclusions These results suggest that choroidal circulation can physiologically quickly adapt to systemic vascular changes in healthy eyes. Choroidal thickness did not depend upon the hydration status for the subjects participating in this study.