CHANGES IN SCLERAL THICKNESS IN THE ACUTE PHASE OF VOGT-KOYANAGI-HARADA DISEASE.

PURPOSE: To evaluate changes in scleral thickness in Vogt-Koyanagi-Harada (VKH) disease. METHODS: This study included 34 eyes of 17 treatment-naïve patients with acute-phase VKH disease. Scleral thickness and the presence of ciliochoroidal effusion were examined using anterior segment optical coherence tomography at baseline and 1 week, 2 weeks, and 12 weeks after the start of corticosteroid treatment. Scleral thickness was measured 6 mm posterior to the scleral spur in four directions. RESULTS: Twenty-eight eyes (82.4%) initially had ciliochoroidal effusion, but this rapidly decreased to nine eyes (26.5%) after 1 week. The sclera with ciliochoroidal effusion became thinner from baseline to 1 week at the superior (400.2 ± 46.9-353.5 ± 47.9 µm), temporal (428.4 ± 53.6-387.8 ± 56.1 µm), inferior (451.5 ± 71.0-400.5 ± 50.5 µm), and nasal (452.4 ± 78.0-407.6 ± 62.9 µm) points (P < 0.01 for all), and no further changes were observed. The sclera without ciliochoroidal effusion remained unchanged. CONCLUSION: In VKH disease, eyes with ciliochoroidal effusion exhibited the maximum scleral thickness during the acute phase. This thickening responded rapidly to treatment and became thinner within 1 week. Inflammation in VKH disease may affect not only the choroid but also the sclera.

Radius-Maumenee syndrome-associated glaucoma, a therapeutic challenge: A case report.

INTRODUCTION: Radius-Maumenee syndrome is a rare cause of open-angle glaucoma, secondary to elevated episcleral venous pressure (EVP) without any orbital or systemic abnormalities. CASE PRESENTATION: We present a case of a male patient in his mid-sixties, who presented with bilateral dilated episcleral vessels, bilateral glaucoma, chorioretinal folds in both maculae and choroidal effusion in his left eye. Our case highlights the differentials that should be considered and the systematic investigations that should be performed. We describe the clinical, optical coherence tomography and angiography findings of this patient and propose a potential pathophysiological mechanism leading to the propensity for perioperative complications. CONCLUSION: Radius-Maumenee syndrome should be a diagnosis of exclusion. Secondary glaucoma can remain refractory to medical treatment and filtering surgery carries the risk intra-operative or post-operative uveal effusions.

Concurrent ciliary body detachment in patients presenting with serous choroidal detachment following glaucoma surgery.

PURPOSE: To examine the rate of ciliary body detachment in patients with choroidal detachment following glaucoma surgery and its effect on the clinical course, management, and prognosis. METHODS: A prospective observational case-series study. Patients with choroidal detachment following glaucoma surgery in 2018-2019 were included. All underwent complete ophthalmological examination and ultrasound biomicroscopy for evaluation of the presence and extent of ciliary body detachment. Follow-up examinations including ultrasound biomicroscopy scans were performed at 1 week, 1 month, 3 months, and 6 months. RESULTS: Eight patients (8 eyes) were enrolled, 4 male and 4 female, of mean age 72 years (range 60-83). Five patients underwent trabeculectomy with mitomycin C (0.02%), which was combined with phacoemulsification cataract extraction in one; two underwent Ahmed glaucoma valve implantations, and one underwent ab-interno Xen45 gel stent implantation with mitomycin C (0.02%). The mean intraocular pressure was 26.0 ± 7.65 mmHg preoperatively, dropping to 6.9 ± 2.64 mmHg on first postoperative day one. Mean time from surgery to diagnosis of choroidal detachment was 11.6 ± 5.73 days. Ciliary body detachment was identified by ultrasound biomicroscopy in all patients, ranging between one and four quadrants. All patients were treated with topical steroids and cycloplegics; three (37.5%) received oral steroids. No surgical intervention for the choroidal or ciliary body detachments was indicated. CONCLUSIONS: In this real-world prospective study, concurrent ciliary body detachment was identified in all patients who presented with choroidal detachment following glaucoma surgery. This observation may deepen our understanding of the mechanism underlying the hypotony that is often seen after glaucoma surgery.

Sildenafil-induced bilateral ciliochoroidal effusion syndrome: Case report.

PURPOSE: To report a case of bilateral ciliochoroidal effusion syndrome associated with sildenafil use. CASE REPORT: A 41-year-old male presented with a five-day history of bilateral blurred vision, elevated intraocular pressure, and myopic shift. Ultrasound biomicroscopy radial scans showed closed angles and 360 degrees of ciliochoroidal effusion in both eyes. Anterior segment coherence tomography angiography showed bilateral shallow anterior chamber. Further questioning revealed that the patient had taken sildenafil several times just a few days before symptoms appeared. Since then, the patient stopped dosing sildenafil. After treatment of anti-inflammation and shifting the lens-iris diaphragm posteriorly, the patient's visual acuity improved and intraocular pressure decreased. Follow-up ultrasound biomicroscopy and anterior segment coherence tomography angiography revealed resolution of ciliochoroidal effusion and increase of anterior chamber depth in both eyes. CONCLUSIONS: The patient demonstrated a rare case of sildenafil-induced bilateral ciliochoroidal effusion syndrome. This case report shows that sildenafil should be added to the possible causative agents of ciliochoroidal effusion syndrome.

The Effect of Steroid Intervention before Vitrectomy for Rhegmatogenous Retinal Detachment Associated with Choroidal Detachment: A Meta-Analysis and Systematic Review.

PURPOSE: This meta-analysis discusses the effectiveness of steroid intervention before vitrectomy in patients with rhegmatogenous retinal detachment associated with choroidal detachment. METHODS: We searched PubMed, MEDLINE, EMBASE, and the Cochrane Library for randomized controlled trials and observational studies published until August 2023. We included studies involving: patients with rhegmatogenous retinal detachment associated with choroidal detachment with proliferative vitreoretinopathy; an experimental group that was not administered steroids and a control group that was administered steroids; and assessment of visual acuity, retinal reattachment rate, and complications. The heterogeneity, publication bias, and sensitivity analysis were performed to ensure the statistical power and reliability of the analysis. RESULTS: Two randomized controlled trials and four case-control studies involving 490 eyes were included in the meta-analysis. There were no significant differences in the primary and final retinal reattachment rates after surgery between the steroid and non-steroid groups (primary retinal reattachment rate: odds ratio = 1.01, 95% confidence interval = 0.63-1.63, p = .41; final retinal reattachment rate: odds ratio = 0.82, 95% confidence interval = 0.43-1.59, p = .33). There was no statistically significant difference in postoperative visual acuity improvement between the two groups (odds ratio = 1.19, confidence interval = 0.63-2.25, p = .69). In addition, subgroup analyses of different types of steroids showed that systemic and local administration of steroids had similar results for retinal reattachment rate and visual acuity improvement. CONCLUSION: Patients with rhegmatogenous retinal detachment associated with choroidal detachment who did not receive preoperative steroids achieved the same effect as patients with rhegmatogenous retinal detachment associated with choroidal detachment who did receive preoperative steroids in terms of retinal reattachment rate and visual acuity. It is recommended that patients with rhegmatogenous retinal detachment associated with choroidal detachment undergo surgery as promptly as possible.

Bilateral Choroidal Detachments Associated with Perinuclear Anti-Neutrophil Cytoplasmic Antibodies (P-ANCA) - Associated Vasculitis.

PURPOSE: To report an uncommon, isolated presentation of bilateral choroidal detachments in a patient diagnosed with P-ANCA-associated vasculitis and to highlight the importance of an inflammatory work-up in such cases. METHODS: Case report. RESULTS: A 70-year-old male with a past medical history of autoimmune hepatitis presented with a sudden decrease in vision in both eyes. Over the course of the previous decade, he had experienced recurrent attacks of episcleritis, which were successfully managed with topical corticosteroid eye drops. The patient was diagnosed with bilateral detachments without accompanying scleritis or intraocular inflammation. Inflammatory markers revealed high P-ANCA and anti-MPO levels, confirming the diagnosis of P-ANCA-associated vasculitis. Treatment with systemic rituximab and corticosteroids led to the resolution of the choroidal detachment in both eyes. A 40-month follow-up confirmed the sustained resolution of the detachments. CONCLUSION: Choroidal detachment without other extraocular/intraocular inflammation can be associated with P-ANCA-associated vasculitis, a previously under-reported link. It is important to consider an inflammatory work-up for patients presenting with choroidal detachment to rule out conditions like P-ANCA-associated vasculitis.

Spontaneous resolution of long-standing choroidal effusion after glaucoma drainage implant surgery without significant visual deterioration : a case report.

BACKGROUND: Choroidal effusion is a common complication of glaucoma surgery. Although most cases of choroidal effusions resolve spontaneously with observation or medical management alone as intraocular pressure normalizes, surgical drainage might be needed in severe or persistent cases. Herein, we report a case of spontaneous resolution of long-standing severe choroidal effusion after Ahmed glaucoma valve implantation. CASE PRESENTATION: An 85-year-old man with uncontrolled primary open-angle glaucoma and medical history of chronic kidney disease underwent uneventful Ahmed glaucoma valve implantation. On postoperative day 8, transient hypotony occurred, and large 360° peripheral choroidal detachments developed. Although the intraocular pressure increased to normal levels on postoperative day 15, choroidal effusion did not resolve. Fundus examination over 8 months showed that the large choroidal effusion persisted despite a well-controlled intraocular pressure. Laboratory test performed at preoperatively and follow-up period revealed persistently elevated potassium and creatinine levels. On postoperative 9 months, the lesion resolved spontaneously without any surgical intervention. We found that the patient's creatinine level was normalized, pre-existing hyperkalemia was corrected, and accordingly his general condition was improved. CONCLUSIONS: Considering the underlying medical condition may be helpful in patients with persistent choroidal effusion of an unclear etiology following glaucoma filtering surgery.

Appositional Choroidal Detachment Following XEN45 Gel Stent Requiring Surgical Drainage.

An 82-year-old man with severe primary open-angle glaucoma on maximal medical therapy underwent an ab externo closed conjunctival Xen45 device insertion with mitomycin C. The surgery was uncomplicated, with a first postoperative day intraocular pressure of 4 mm Hg and visual acuity of 20/40 OD. Ten days later, the patient presented with an intraocular pressure of 5 mm Hg and a visual acuity of counting fingers at 5 feet. Examination showed Seidel negative bleb, shallow anterior chamber, and large nonappositional choroidal detachments. Medical therapy with steroids and cycloplegia was initiated. One week later, the serous choroidal detachments became appositional, and Xen explantation and surgical drainage of the choroidal detachment was performed. Postoperatively, the vision improved to 20/60. Significant choroidal detachments can occur after XEN45 implantation requiring surgical intervention.

Unilateral Idiopathic Choroidal Effusion in a Patient Who Takes Sulfonamides.

Purpose: To report a challenging case of unilateral choroidal effusion.Methods: A case report about patient who presented with unilateral choroidal effusion and who was taking sulfonamides. Patient has been under care of a multidisciplinary team of uveitis consultant, ocular oncology consultant, and systemic oncology consultant. A comprehensive workup was done (blood tests, Spectralis OCT, FFA, chest X-rays, MRI, PETCT).Results: Baseline visual acuity on the affected (right) eye was 6/12. Patient is amblyopic and hypermetropic on that eye. Blood test results were negative on syphilis, tuberculosis, or sarcoidosis. MRI showed no mass lesions. PETCT scan showed no signs of malignant process out of the eye. Suprachoroidal drainage was done and analysis of the drainaged fluid showed no presence of malignant cells. Overall workup period patient's vision was stable.Conclusion: Definite diagnosis of unilateral choroidal effusion was done. A comprehensive workup is needed to exclude potential malignant process.

Acute angle-closure glaucoma with choroidal effusion revealing a hantavirus infection: Description of ultrasound biomicroscopy imagery and optical coherence tomography Visante.

PURPOSE: To report a case of bilateral angle-closure associated with systemic hantavirus infection. MATERIALS AND METHODS: A 32-year-old Caucasian man was referred with blurred vision, fever, cough, dyspnea and thrombocytopenia. Ophthalmologic examination revealed myopic shift, elevated intraocular pressure (30 mmHg right eye and 24 mmHg left eye), corneal edema, iridocorneal angle closure and shallow anterior chamber. Ciliochoroidal effusion was detected on anterior segment optical coherence tomography and ultrasound biomicroscopy. Serologic test and polymerase chain reaction confirmed the diagnosis of hantavirus infection and the serotype Puumala. On the sixth day after he started topical anti-glaucoma and cycloplegic medications, the anterior chamber and iridocorneal angles were normalized with disappearance of ciliochoroidal effusion. CONCLUSION: Puumala hantavirus infection is an exceptional cause of acute bilateral angle-closure combined with ciliochoroidal effusion.

Choroidal Detachment following an Intravitreal Injection in a Patient with Vogt-Koyanagi- Harada Disease.

Purpose: To report a unique case of choroidal detachment following an intravitreal injection in a patient with Vogt-Koyanagi-Harada (VKH) disease.Methods: A 33-year-old male, a known case of chronic VKH disease for 9 years developed an inflammatory choroidal neovascular membrane (CNVM) in the right eye. Following an intravitreal ranibizumab injection, he reported loss of vision 2 days later. Clinical examination revealed hypotony with annular serous choroidal detachment.Results: Following an intensive systemic corticosteroid therapy, there was a complete resolution of choroidal detachment and restoration of visual acuity at 1 week of follow up. The subretinal fluid and cystic spaces due toCNVM also resolved completely.Conclusion: This is the first report of a patient with VKH disease developing choroidal detachment following an uncomplicated intravitreal injection of ranibizumab for an inflammatory CNVM.

A Retrospective Case Series of Uveal Effusion Syndrome.

PURPOSE: This study aimed to describe the clinical findings and management of eyes affected by uveal effusion syndrome. METHODS: We retrospectively evaluated the charts of 13 eyes of 8 consecutive patients diagnosed with uveal effusion syndrome attending the Ophthalmology Unit of the University Hospitals Leuven, Belgium, between 2007 and 2018. The presenting features, investigations, management, and outcomes were analyzed for each case. RESULTS: Cataract surgery was the predisposing factor for uveal effusion in 6 eyes, 2 bilateral uveal effusions (4 eyes) were considered to be medication-induced, and in 3 eyes, the uveal effusion was described as idiopathic. Fundus examination of 5 of 13 eyes showed bullous choroidal detachment, treated with pars plana vitrectomy with superotemporal sclerectomy or transscleral punction. Fundoscopy showed uveal effusion without serous retinal detachment in 3 eyes. Serous retinal detachment accompanied by uveal swelling was observed in 3 eyes and the 2 remaining eyes presented with uveal swelling only. The 8 nonbullous choroidal detachments were treated in a conservative way. A rapid resolution of subretinal fluid and uveal effusion was observed in all cases. CONCLUSIONS: A conservative approach with acetazolamide treatment or just observation was used in our case series in choroidal detachment without substantial visual loss if, over time, slow improvement was documented. However, further studies are needed to verify the effectiveness of the reported therapy.

Pembrolizumab-related Bilateral Ocular Hypotony, Uveitis, Cataracts, Exudative Retinal, and Choroidal Detachments: An Unusual Success Story.

Here, we report the presentation and management of a rare case of sight-threatening bilateral panuveitis with secondary chronic hypotony, subcapsular cataracts, exudative retinal detachments, and choroidal detachments, following initiation of pembrolizumab immunotherapy for metastatic melanoma. An 82-year-old white woman presented with painful, blurry vision 3 days after initiation of pembrolizumab immunotherapy. She had developed a marked panuveitis causing secondary hypotony. The fundal view was entirely limited by acutely dense cataracts and small, uveitic pupils unresponsive to topical dilation. Urgent cataract surgery with intravitreal dexamethasone implant (Ozurdex) was completed successfully and allowed a fundal examination. This revealed bilateral, symmetrical, inferior exudative retinal detachments, and choroidal detachments secondary to chronic hypotony. After 3 months of observation and cessation of oral steroids, the panuveitis remains quiescent, hypotony persists, and the choroidal and retinal detachments are showing progressive self-resolution. The current best-corrected visual acuity is 6/24 OU. She remains under close monitoring. The immune checkpoint inhibitor, pembrolizumab, has been reported to cause sight-threatening adverse effects. We report a rare case of profound bilateral complications treated successfully with oral and intravitreal steroids. To the authors' knowledge, this has not previously been reported in the literature. Ophthalmologists and oncologists should be aware of the ocular effects of pembrolizumab and be able to identify various complications early. Here, cataract surgery with a steroid implant has been an effective sight-saving intervention. The promising visual outcome makes this an unusual success story.

A Case of Delayed-onset Hemorrhagic Choroidal Detachment After PreserFlo Microshunt Implantation in a Glaucoma Patient Under Anticoagulant Therapy.

PURPOSE: To describe a case of delayed-onset hemorrhagic choroidal detachment (HCD) in a patient affected by primary open-angle glaucoma (POAG) undergone PreserFlo Microshunt implantation. CASE REPORT DESCRIPTION: A 76-year-old patient with POAG, under treatment with Dabigatran (a novel oral anticoagulant), underwent an uncomplicated PreserFlo Microshunt implantation in the left eye. In the first postoperative day, intraocular pressure (IOP) was 6 mm Hg, conjunctival bleb was diffuse, anterior chamber (AC) deep, and device correctly positioned. Twelve days after surgery, the patient had emergency access complaining severe ocular pain and sudden vision loss. Ophthalmological evaluation revealed shallow AC and an IOP of 50 mm Hg. The fundus examination revealed almost kissing HCD. OUTCOME: Immediate topical treatment with atropine, aqueous humor suppressants, and corticosteroids was started. Because of high IOP, ocular pain, and the presence of almost kissing HCD, surgical drainage of suprachoroidal hemorrhage and removal of PreserFlo Microshunt were performed. An improvement of the clinical condition was observed in the following postoperative days, with partial resolution of the HCD and a decrease of the IOP. On the third postoperative day, there was a worsening of the HCD, with a reduction of the AC depth and IOP elevation. HCD was drained through the previously performed sclerotomies, associated with pars-plana vitrectomy and silicone-oil tamponade. HCD completely resolved during the following 6 weeks, with IOP reduction and partial improvement of visual acuity. CONCLUSION: Great attention must be taken in patients with glaucoma under treatment with a novel oral anticoagulant, also when planning PreserFlo Microshunt implantation.

Prospective cohort study of risk factors for choroidal detachment after trabeculectomy.

PURPOSE: To investigate risk factors for choroidal detachment after trabeculectomy. METHODS: We prospectively evaluated 97 patients with open-angle glaucoma who underwent primary trabeculectomy to investigate risk factors for choroidal detachment after trabeculectomy. The primary outcome measure was risk factors for the occurrence and severity of choroidal detachment after trabeculectomy. Choroidal detachment severity was quantified as the number of fundus quadrants with choroidal detachment. RESULTS: Sixteen patients (16.5%) had choroidal detachment. Mean period between surgery and occurrence of choroidal detachment was 7.9 ± 5.7 days. Mean intraocular pressure (IOP) on the first day of choroidal detachment was 6.1 ± 3.0 mm Hg. Multivariable analyses revealed that the exfoliation glaucoma, greater ΔIOP between preoperative and lowest postoperative IOPs, and thicker cornea were associated with choroidal detachment (P = 0.022, P = 0.002, and P = 0.013, respectively). These factors were also associated with the severity of choroidal detachment (exfoliation glaucoma; P = 0.013, greater ΔIOP; P < 0.001, and thicker cornea; P = 0.006). CONCLUSIONS: Exfoliation glaucoma, more IOP reduction, and thicker cornea are associated with the occurrence and severity of choroidal detachment after trabeculectomy.

Familial Nanophthalmos Presenting with Spontaneous Uveal Effusion Syndrome.

Purpose: To report two unique cases of spontaneous uveal effusion syndrome (UES) from the same family.Methods: The patients included father (54 years old) and a daughter (23 years old). The father presented 7 years ago with bilateral exudative retinal detachment, nanophthalmic eyes (axial length 16.11 mm and 16.43 mm in right and left eyes, respectively) with hypermetropia, and a thickened sclera on MRI. The daughter presented with left eye peripheral exudative annular retinal detachment with bilateral nanophthalmos (axial length 20.7 mm and 20.33 mm, in right and left eyes, respectively), with MRI showing ciliochoroidal detachment, suprachoroidal effusion and mild thickening of the sclera in left eye.Results: The father underwent subscleral sclerectomy in the left eye that led to resolution of submacular fluid. Scleral biopsy confirmed the deposition of glycosaminoglycans on Alcian blue stain. The daughter was kept under observation, because of absence of any macular subretinal fluid, and counselled about the familial nature of the disease and possible need for future intervention.Conclusion: This is the first report of familial nanophthalmos presenting with spontaneous UES.