Pneumatic displacement of submacular haemorrhage.

PURPOSE: To evaluate the outcomes of pneumatic displacement of submacular hemorrhage secondary to choroidal neovascular membrane (CNV) (n = 9) and retinal arterial macroaneurysm (RAM) (n = 3). METHODS: This is a retrospective case series study of 12 eyes from 12 patients in Aberdeen Royal Infirmary, Aberdeen, UK. The mean duration of visual loss was 10.8 ± 4.11 days. All cases received intravitreal injection of expansile gas within 24 h of presentation (C3F8 in 11 cases and SF6 in one case) and postured face down for five days. Anterior chamber paracentesis was done right after gas injection. Intravitreal anti-VEGF was injected at the same time in cases with CNV. Further anti-VEGF injections were done in CNV cases as needed afterwards. Cases were followed up for 6 months. RESULTS: The submacular hemorrhage was successfully displaced from underneath the fovea in all but one case. The bleeding disappeared totally in 44% of cases and was inferiorly displaced in 56%. VA improvement at 6 months was statistically significantly higher than baseline VA. All cases but 2 (one because of subfoveal fibrosis and one because of late presentation) experienced improved VA. The mean VA improved from 1.37 ± 0.18 logMAR at baseline to 0.83 ± 0.26 logMAR at 6 months. No complication related to the procedure was reported. CONCLUSION: Pneumatic displacement of submacular hemorrhage appears to be a safe and effective technique to treat the condition. It is an easy procedure that can be done in outpatient setting. Further studies are needed to validate our results.

A Rare Case of Eccrine Porocarcinoma of the Eyelid.

BACKGROUND: To report a rare case of eyelid eccrine porocarcinoma and compare this to previous documented cases in the literature. MAIN OBSERVATIONS: We report a case of an 86-year-old man who presented with three months' history of irritation in the right eye, who was found to have an irregular nodule on lower eyelid, which was later diagnosed as eccrine porocarcinoma (EPC). The lesion was excised and the defect repaired with Hughes flap. A computerized tomography (CT) scan of the head, neck, and chest showed no metastasis and no lymphadenopathy. There was no evidence of recurrence after 18 months of follow-up. CONCLUSION: To date, there have been only six cases of eyelid EPC reported in the literature. EPC has significant risk of recurrence and metastases after local excision. It is therefore important to consider it in the differential diagnosis of malignant eyelid tumour. A histological diagnosis should prompt wide margin excision, assessment of the patient for regional lymph node involvement, and imaging for metastatic disease.

Treatment of diffuse subretinal fibrosis uveitis with rituximab.

Diffuse subretinal fibrosis uveitis (DUS) syndrome is a rare form of granulomatous multifocal choroiditis (MFC) characterised by enlarging areas of subretinal fibrosis (SRF) which coalesce with subsequent macular involvement and visual loss. First described by Palestine, DUS carries a poor visual prognosis despite use of high-dose corticosteroids and systemic immunosuppression. We report two cases of bilateral DUS successfully treated with rituximab. We believe given the B-cell predominance in the underlying pathogenesis of the disease, rituximab should be considered first line in the management of this potentially devastating disease.

Concentric macular rings sign in patients with foveal hypoplasia.

IMPORTANCE: We describe a sign that can be used as a rapid and noninvasive adjunct to aid in the diagnosis of foveal hypoplasia. OBJECTIVE: To describe a concentric macular rings sign found on infrared reflectance (IRR) images in patients with foveal hypoplasia. DESIGN, SETTING, AND PATIENTS: We studied 13 patients with foveal hypoplasia (7 with ocular albinism [OA], 5 with oculocutaneous albinism [OCA], and 1 with aniridia) at a tertiary ophthalmology center with access to electrodiagnostic services from February 18, 2009, through April 9, 2013. MAIN OUTCOMES AND MEASURES: All patients and an age-matched control participant underwent a complete clinical examination, electroretinography (full field and pattern), visual evoked potentials, fundus autofluorescence IRR, and optical coherence tomography (OCT). One patient with OA and the control participant also underwent scanning laser polarimetry with variable corneal compensation (GDx VCC). RESULTS: Thirteen patients (6 girls and 7 boys), with a mean age of 5.8 years (range, 3-11 years), were included in the study. Seven patients were diagnosed as having OA and had minimal clinical signs (fine nystagmus in 2 patients and subtle iris transillumination in 5 patients). Five patients with OCA and 1 with aniridia were also included. In 12 patients, OA and OCA were confirmed with 5-channel visual evoked potentials (optic nerve misrouting). Whenever OCT was performed, foveal hypoplasia was indicated by the lack of foveal dip. The macula lacked the foveal attenuation normally seen with fundus autofluorescence, and a concentric macular rings reflex was seen with IRR in all 13 patients and with GDx VCC in 1 patient. A normal bowtie reflex was seen with IRR and GDx VCC in the age-matched control participant. CONCLUSIONS AND RELEVANCE: Our findings suggest that concentric macular rings seen on IRR or GDx VCC can occur in patients with foveal hypoplasia and can therefore aid in the diagnosis, especially in patients with minimal clinical signs (mild OA) or in cases in which OCT cannot be performed (young patients or patients with high-amplitude nystagmus).

Imaging of adult ocular and orbital pathology--a pictorial review.

Orbital pathology often presents a diagnostic challenge to the reporting radiologist. The aetiology is protean, and clinical input is therefore often necessary to narrow the differential diagnosis. With this manuscript, we provide a pictorial review of adult ocular and orbital pathology.

Retained Descemet's membrane following penetrating keratoplasty for Fuchs' endothelial dystrophy: a case report of a post-operative complication.

PURPOSE: To report a case of retained Descemet's membrane following penetrating keratoplasty in a patient suffering from Fuchs' endothelial corneal dystrophy. The use of confocal microscopy, histopathological tissue analysis, and treatment options are discussed. METHODS: Case report of an 85-year-old man with a past ophthalmic history of atrophic macular degeneration, underwent a penetrating keratoplasty for Fuchs' endothelial corneal dystrophy. Postoperative review revealed a retained retrocorneal membrane within the anterior chamber. Further surgery was performed to excise the membrane, with a subjective and objective postoperative improvement in visual acuity and without subsequent complications of the corneal graft. RESULTS: Histopathological assessment confirmed the clinical suspicion of a retained Descemet's membrane, marrying with the initial histology from the corneal button excised during the penetrating keratoplasty, which showed only a very thin Descemet's layer. CONCLUSION: Retention of the Descemet's membrane following penetrating keratoplasty is a rare but potential complication of this surgery, particularly in cases of Fuchs' endothelial corneal dystrophy due to the thickened and abnormal histological nature of the endothelium and high index of suspicion is required.

Are patients attending the smoking cessation clinic aware of the association between eye disease and smoking?

It is well established that smoking is related to cardiovascular, respiratory, ophthalmological, and other diseases. Over the years, anti-smoking campaigns have concentrated on heart and lung disease and overall mortality to motivate smokers to stop smoking. The aim of our questionnaire study is to assess the motivation for attending a smoking cessation clinic in a local district hospital in the Highlands, and the level of awareness of the association between smoking and eye disease.

Management of inflammatory choroidal neovascularization (CNV) secondary to punctate inner choroidopathy in a young female of childbearing age with intra-vitreal ranibizumab and half-fluence photodynamic therapy (PDT) - a holistic approach.

Choroidal neovascularization (CNV) may occur in up to 40% of patients with punctate inner choroidopathy (PIC). We report a case of a young woman of childbearing age treated successfully for an inflammatory choroidal neovascular membrane (CNV) secondary to PIC with a combination of intravitreal ranibizumab and photodynamic therapy (PDT).

Leber's hereditary optic neuropathy precipitated by tadalafil use for erectile dysfunction.

Leber's hereditary optic neuropathy (LHON) is an inherited condition leading to bilateral centrocaecal scotoma. Phosphodiesterase type-5 (PDE5) inhibitors such as tadalafil are widely used for male erectile dysfunction. We present a case of a middle-aged male whose LHON presented acutely following tadalafil use. It is postulated that this is due to alteration in the optic nerve head perfusion.

Immediate loss of vision due to retinal pigment epithelial tear after anti-angiogenesis treatment of pigment epithelial detachment.

Intravitreal injection of ranibizumab, an antivascular endothelial growth factor (VEGF) drug, is currently the primary treatment for wet age-related macular degeneration (AMD) in the UK. Use of ranibizumab for the treatment of isolated pigment epithelial detachments (PEDs) without the presence of an occult choroidal neovascular membrane has not been studied in a randomized controlled fashion and is strictly off-label. One possible complication of intravitreal injection of the drug is retinal pigment epithelial (RPE) tear. To date, the etiology of RPE tear associated with intravitreal injection is unknown; it could be attributed to rapid contraction of the neovascular membrane by fibrosis, perhaps triggered by the drug. We report a case of an RPE tear occurring less than a minute after intravitreal injection of ranibizumab for a fibrovascular PED. To our knowledge, this is the first report of such a case.

Visual and optical coherence tomography outcomes of intravitreal bevacizumab and ranibizumab in inflammatory choroidal neovascularization secondary to punctate inner choroidopathy.

PURPOSE: Choroidal neovascular membranes (CNV) are the major cause of visual loss in punctate inner choroidopathy (PIC), an idiopathic inflammatory condition predominantly affecting young, myopic women. We present a case series of 9 patients with CNV associated with PIC, treated with intravitreal anti-vascular endothelial growth factor agents. METHODS: This is a retrospective case series of 9 patients treated with either intravitreal bevacizumab or ranibizumab for inflammatory CNV secondary to PIC. Initial and posttreatment converted logMAR visual acuity, fundus fluorescein angiograms (FFA), optical coherence tomography (OCT), previous and concurrent treatments, and side effects were recorded. Informed consent for treatment was obtained from each patient. RESULTS: Nine patients (8 female, 1 male) with an average age of 34.4 years were treated for an average of 14.9 months. Six patients were treated with bevacizumab, and 3 with ranibizumab, with a mean of 2.34 injections per year. The mean visual acuity gain for the whole group of 9 patients was 0.26 converted logMAR units (Wilcoxon signed-rank test, p<0.015). Eight patients remained stable or had visual improvement at final follow-up, with a mean gain of 0.36 converted logMAR units. Only one patient's vision deteriorated (loss of 0.48 converted logMAR units). Concomitant short courses of oral corticosteroid were used in 3 of the 9 patients. CONCLUSIONS: Over a 1-year period, bevacizumab and ranibizumab can be safely and successfully used to treat inflammatory CNV secondary to PIC, avoiding the need for systemic immunosuppression in the majority of patients.

Systemic cyclosporin A in severe atopic keratoconjunctivitis.

PURPOSE: Severe atopic keratoconjunctivitis (AKC) is associated with atopic dermatitis and is often refractory to topical treatment and potentially blinding. Because T lymphocytes are central in the pathogenesis of these diseases, systemic cyclosporin A (CSA) should treat both dermatologic and ocular manifestations. We describe the successful treatment of 8 patients with severe AKC, resistant to conventional management, with systemic CSA. METHODS: This was a retrospective observational case series. The notes of patients with severe AKC were reviewed, where the disease did not respond to topical or other systemic treatment, and was treated with systemic CSA. Response to such treatment was observed and reported in 8 patients. RESULTS: Cyclosporin A was effective as a steroid-sparing agent. Systemic corticosteroids were stopped in half of the patients. Dosage varied between 50 mg and 300 mg daily (in divided doses), and duration of treatment varied between 5 months and 7 years. Papillary blepharoconjunctivitis and punctuate keratopathy completely resolved a few weeks after CSA therapy. Corneal ulcers resolved after 5 to 10 weeks of treatment. Coexistent eczema or dermatitis was brought under control with systemic immunosuppression, and flare-ups were not present during the duration of treatment. There was remission of AKC in all 8 patients with increase in visual acuity and low incidence of side effects. CONCLUSIONS: Cyclosporin A is effective in the treatment of atopic dermatitis and keratoconjunctivitis. Our case series potentiates previous smaller case series that systemic CSA can be used effectively and safely in cases that are resistant to conventional treatment to preserve vision.

Rosella parrot exposure as a cause of bird fancier's lung.

A case of a 30-year-old man who presented with a 2-month history of progressively worsening dyspnoea, cough, and reduced exercise tolerance is discussed. A chest x-ray and computerized tomography of the chest suggested interstitial lung disease, which was confirmed on histology of an open lung biopsy. Careful questioning revealed that the patient had sustained close exposure to a rosella parrot acquired as a pet 9 months prior to presentation, which led to the diagnosis of bird fancier's lung. The case, investigations, and outcome are presented. This is followed by a discussion on extrinsic allergic alveolitis with particular emphasis on the importance of a complete social and environmental history in patients presenting with similar respiratory symptoms.