Optic disc and choroidal metastases secondary to breast cancer: A case report.

AIM: To report an uncommon case of optic disc and multiple choroidal metastases secondary to breast cancer, assessed with swept source optical coherence tomography (SS-OCT), fluorescein (FA), and infracyanine (ICGA) angiographies. METHODS: Observational case report. CASE PRESENTATION: A 40-year-old woman with history of left breast carcinoma presented with blurred vision in her right eye (RE). Her visual acuity was 1/20 in the RE and 10/10 in the left eye. Fundus examination of the RE showed a large yellowish elevation of the posterior pole and a particular whitish nodular papillary cluster protruding from the optic disc into the vitreous. Infrared imaging enhanced the papillary nodular infiltrates. Characteristic findings of choroidal metastasis were noted within the macular lesion on SS-OCT and ICGA. SS-OCT showed specific "lumpy bumpy" irregularity of the anterior surface of the choroid and elevated hyperreflective nodular lesions of the optic disc associated to peripapillary subretinal fluid. The papillary lesions appeared as a bunch of hypofluorescent dots on both FA and ICGA, and ultra-wide field FA was helpful clearly delimiting the large macular lesion. Besides, comprehensive imaging and especially ICGA could detect two asymptomatic choroidal metastases in a systematic assessment of the fellow eye. CONCLUSION: Optic disc metastases are extremely rare. Their diagnosis can be easily done on fundus examination when presenting with characteristic whitish cluster nodular infiltrates of the optic disc. However multimodal imaging remains very useful for the assessment of the local extension of the lesion and for diagnosing associated asymptomatic choroidal lesions gone unnoticed at the fundus examination.

Multimodal imaging of bilateral immunogammopathy maculopathy associated to Waldenström's macroglobulinemia.

AIM: Our aim is to report a case with bilateral Waldenström's macroglobulinemia (WM) associated maculopathy, assessed with multimodal imaging including swept source optical coherence tomography (SS-OCT) and OCT-Angiography (OCT-A). METHODS: Observational case report. CASE PRESENTATION: A 61-year-old diabetic woman with history of treated WM currently in remission, presented with progressive bilateral visual loss. Best-corrected visual acuity was 20/100 in the right eye (RE) and 20/200 in the left eye (LE). Fundus examination showed bilateral microaneurysms and retinal punctuate hemorrhages and a large macular serous detachment in the LE. There was no retinal ischemia on FA nor macular dye leakage. SS-OCT showed a significant schisis-like intraretinal fluid accumulation in the RE and a large prominent macular detachment with significant subretinal fluid accumulation in the LE. Retinal and choriocapillaris vascular densities were normal on OCT-A. CONCLUSION: Our case illustrated characteristic multimodal imaging findings in WM associated maculopathy such as schisis-like intraretinal fluid accumulation and angiographically silent serous macular detachment. OCT-A could non-invasively analyze macular vascular densities layer-by-layer, without noticing any vascular anomaly.

Case Report: Swept-source Optical Coherence Tomography and Angiography Findings in Lipemia Retinalis.

SIGNIFICANCE: Lipemia retinalis is a very rare ocular manifestation of severe hypertriglyceridemia. It is usually symptomatic and regresses after normalization of triglycerides levels. Early recognition is important to prevent ocular and life-threatening complications. PURPOSE: This study aimed to report a case of marked lipemia retinalis secondary to type V hypertriglyceridemia assessed with swept-source optical coherence tomography (OCT) and OCT angiography (OCT-A), with follow-up after dietary lipid restriction. METHODS: Observational case report of lipemia retinal findings on color fundus photography, swept-source OCT and OCT-A, initially and after triglycerides lowering. CASE REPORT: A 32-year-old pregnant patient with gestational diabetes and a history of hypertriglyceridemia was referred for diabetic retinopathy screening. Fundus examination revealed bilateral milky-white discoloration of retinal vessels with a "salmon-colored" retina. Swept-source OCT and OCT-A revealed extremely hyperreflective and dilated retinal vessels and multiple high-flow retinal hyperreflective dots, corresponding to dilated retinal capillaries. Choroidal vessels were enlarged and engorged, and choriocapillaris layer appeared thickened and hyperreflective with dilated and tortuous capillaries. Serum triglycerides were very high (70.02 mmol/L). After 21 days of very-low-fat diet, it was lowered to 15 mmol/L. We noted a normalization of the clinical, structural, and vascular findings. However, peripheral retinal vessels remained hyperreflective, despite their clinical normalization. CONCLUSIONS: Swept-source OCT and OCT-A were beneficial in assessing lipemia retinalis noninvasively and monitoring choroidal and retinal vascular changes. Lipemia retinalis signs regressed initially in the posterior pole, choroidal anomalies were first to resolve, and clinical normalization preceded tomographic resolution.

Valsalva retinopathy occurring after general anesthesia.

PURPOSE: To report a case of patient who presented with valsalva retinopathy after genral anesthesia for the treatment of ruptured intracranial aneurysm. OBSERVATION: A forty year-old man presented, after a general anesthesia for treatment of a ruptured intracranial aneurysm, with a severe decrease of the visual acuity in the left eye. Ophthalmic examination, performed one month after surgery showed a retrohyaloid macular hemorhage. After failure of laser Nd-YAG hyaloidotomy, vitrectomy allowed drainage of the hematoma with good visual outcome. CONCLUSION: Valsalva retinopathy is a rare complication that can occur after genral anesthesia. Vitrectomy may be needed if Nd-Yag laser hyaloidotomy fails.

Association of carotido-cavernous fistula and controlateral optic neuropathy secondary to cranial trauma.

PURPOSE: to report a case of a woman who had a severe cranial trauma complicated by two ophalmologic potentially cecitating complications: right carotido-cavernous fistula and left traumatic optic neuropathy. OBSERVATION: A 56 years-old woman, without any medical history, referred, one month after fall from a height of 3 meters, for right exophthalmos. Ophthalmic examination of the right eye completed by retinal angiography suspected carotid-cavernous fistula which was confirmed by angio-MRI. In the left eye, the visual acuity was decreased to no light perception and fundus examination showed optic nerve head palor secondary to traumatic optic neuropathy. Arterial embolization was performed and allowed closing of the fistula. CONCLUSION: Optic neuropathy and carotido-cavernous fistula are two severe complications that can occur simultaneously in the same patient. The prognosis of the optic neuropathy may be compromised, and the treatment of carotido-cavernous fistula benefited from progress in interventional neuro-radiology.

Ophthalmic artery occlusion with total ophtalmoplegia and anisocoria revealing cavernous sinus thrombosis.

AIM: To describe a case of ophthalmic artery occlusion associated with anisocoria and revealing a cavernous sinus thrombosis due to sinusitis. OBSERVATION:   A 48-year-old man with a history of diabetes presented acutely with loss of vision and proptosis in the left eye. Ophthalmologic examination concluded in a left ophthalmic artery occlusion with anisocoria and total ophthalmoplgia. Cardiac assessment was normal. Magnetic resonance imaging (MRI) revealed left ophthalmic artery and internal carotid occlusions, left cavernous and transverse sinus thrombosis and sphenoid sinusitis. The patient underwent extensive haematological and medical assessment to search for embolic sources and disease causing thrombophilia. The patient recovered from the thrombosis episode, but sustained permanent blindness. CONCLUSION: Ophthalmic manifestations may be the only signs revealing cavernous sinus thrombosis which must be usually suspected. Visual prognostic was very poor.

Characteristics of Astigmatism in a Population of Tunisian School-Children.

PURPOSE: To evaluate the characteristics of astigmatism in a cross-sectional study of schoolchildren in Tunisia. MATERIALS AND METHODS: A random cluster design was used to recruit children from primary schools across urban and rural settings in Tunisia, from 2008 to 2010. A total of 6192 students aged 6-14-years old were enrolled. All students whose uncorrected visual acuity was worse than 20/20 underwent a complete ophthalmic examination. Astigmatism was defined as the cylinder power of 0.75 diopter (D) or greater. RESULTS: The prevalence of astigmatism was 6.67%. Mean cylinder power was - 1.89 ± 0.79D. The prevalence of astigmatism increased statistically significantly with age (P = 0.032). The prevalence of astigmatism was not significantly related to gender (P = 0.051). Of those with cylinder, 63.6%, 17.8%, and 18.6% schoolchildren had with with-the-rule, against-the-rule, and oblique astigmatism, respectively. ATR astigmatism was significantly higher in males (P = 0.033). There was no significant association between the student's area of residence and astigmatism (P = 0.059). CONCLUSION: Comparisons with other studies show that the prevalence of astigmatism in Tunisia is higher than in some countries. The prevalence of astigmatism increased with age but not gender. The majority of schoolchildren had with-the-rule astigmatism.

Herpes zoster ophthalmicus associated with abducens palsy.

The extraocular muscle palsies associated with herpes zoster ophthalmicus (HZO) are transient, self-limiting conditions, usually seen in elderly patients. There are different treatment recommendations for paralytic complications, but prognosis has generally reported to be favorable. A 75-year-old male patient presented with diplopia. Clinical history revealed left facial vesicular eruptions and pain treated by oral aciclovir 1 week following symptom onset. On examination, we observed cicatricial lesions with crusts involving left hemiface, a limitation in abduction of the left eye, and a superficial punctuate keratitis (SPK) with decreased visual acuity (4/10). Examination of the right eye was unremarkable. Hess screen test confirmed left six nerve palsy.

[Epidemiologic study of hyperopia in schoolchildren in Tunisia]. / Profit épidémiologique de l'hypermétropie en milieu scolaire primaire en Tunise: à propos de 6192 enfants.

AIM: To study the epidemiological profile and the degree of severity of hyperopia in Tunisia primary school and to assess its effect on school performance. METHODS: A cross-sectional, descriptive survey was conducted among 6-14 aged Tunisian children attending primary urban and rural schools. A total of 6192 children were selected using stratified random cluster sampling. Cycloplegic refractive error was measured among all children with uncorrected visual acuity less than 9/10 or signs of astheniopia. Hyperopia was defined as spherical equivalent (SE) 2.0 diopters (D). We have also searched a possible relation between degree of severity of hyperopia and school performance. RESULTS: The prevalence of hyperopia was 2.61%. The spherical equivalent mean was + 3.73 ± 0.94 D. The mean age was 9.67 ± 0.44 years. This prevalence was 2.77% in boys and 2.47% in girls. 3.13% of students were living in urban areas and 1.42% in rural areas. The hyperopia rate decreased significantly with age (p = 0.021), but it was not significantly related to gender (p=0.54). The difference in the prevalence of hyperopia between urban and rural areas was not statistically significant (p = 0.067). There was no significant association between the degree of severity of hyperopia and school performance (p=0.41). CONCLUSION: In our study, the prevalence of hyperopia among schoolage children in Tunisia was 2.61%.The identification of this refractive error and its correction as soon as possible would ensure these children better visual comfort and a better education.

Choroidal thickness measurement in highly myopic eyes using SD-OCT.

BACKGROUND AND OBJECTIVE: To measure macular choroidal thickness (CT) using spectral-domain optical coherence tomography (OCT) and to investigate the correlation between CT and age, degree of myopia, and history of macular choroidal neovascularization (CNV). PATIENTS AND METHODS: A cross-sectional study included 187 highly myopic eyes of 187 patients examined between January and December 2010. The choroid was imaged with spectral-domain OCT by changing the reference position from the vitreous to the choroid. CT was measured from the outer border of the hyperreflective line corresponding to the retinal pigment epithelium to the inner scleral border. RESULTS: The mean age was 47.21 ± 14.24 years, the mean spherical equivalent refractive error was -13.66 ± 5.77, and the mean subfoveal CT was 100.71 ± 59.98 µm. CT was correlated negatively with age (P < 10(-3)) and refractive error (P < 10(-3)). Forty-two eyes had a history of CNV, the mean CT was 55.45 ± 24.46 µm, and this was significantly thinner than in eyes without CNV (P < 10(-3)). CONCLUSION: In highly myopic eyes, the choroid is thin and undergoes further attenuation with age and increasing myopia. In addition, these findings suggest that the choroid may play a role in the pathogenesis of CNV.

Intravitreal injection of triamcinolone combined with bevacizumab for choroidal neovascularization associated with large retinal pigment epithelial detachment in age-related macular degeneration.

PURPOSE: To discuss the effect and outcome of a combined intravitreal triamcinolone acetonide (IVTA) injection with intravitreal bevacizumab (IVB) in treating choroidal neovascularization (CNV) associated with large retinal pigment epithelial detachment (PED) in age-related macular degeneration (AMD). DESIGN: Prospective, consecutive, observational case series. METHODS: Seven eyes (five patients) with CNV associated with large PED in AMD were treated by IVTA (4 mg/ 0.1 ml), followed by a IVB (1.25 mg/0.05 ml) 1 week later. Patients were evaluated for best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) at baseline, at 1 week and every 6 weeks. Fluorescein angiography (FA) and indocyanine green angiography (ICG) were performed at baseline and every 3 months afterwards. Indications for retreatment by combined injection were defined as persistent PED with subretinal and/or intraretinal fluid on OCT. Patients with flattening of the PED and activity leakage demonstrated by OCT underwent subsequent IVB. RESULTS: The mean duration of follow-up was 11 months (range 9-14 months). BCVA at baseline averaged 20/125, and 20/80 at the end of follow-up. FA showed no leakage from the lesion in four eyes at the end of follow-up, and three eyes showed a decrease in leakage. Average central foveal thickness was (CFT) 325.7 microns at baseline and 209.2 microns at the end. The average size of the PED was 2.34 disk diameters (range 1.33-3.25) at baseline, and the PED disappeared in four eyes, while it decreased in size at the end in the remaining three. The subretinal fluid disappeared in all patients at the end. The combined treatment (IVTA with IVB 1 week later) was repeated in four eyes, and the number of IVB after combined injection ranged from one to three. No RPE tear appeared during follow-up. Two eyes developed glaucoma controlled by topical medication. There were no other ocular or systemic complications CONCLUSION: Combined IVB and IVTA therapy seems to be an effective and safe procedure to treat CNV associated with large PED in AMD.

Optical Coherence Tomographic Findings in Berlin's Edema.

PURPOSE: To describe optical coherence tomography (OCT) findings in a patient with Berlin's edema following blunt ocular trauma. CASE REPORT: A 26-year-old man presented with acute loss of vision in his left eye following blunt trauma. He underwent a complete ophthalmologic examination and OCT. Fundus examination revealed abnormal yellow discoloration in the macula. OCT disclosed thickening of outer retinal structures and increased reflectivity in the area of photoreceptor outer segments with preservation of inner retinal architecture. Re-examination was conducted one month later at the time which OCT changes resolved leading to a surprisingly normal appearance. CONCLUSION: OCT can be a useful tool in the diagnosis and follow-up of eyes with Berlin's edema and may reveal ultrastructural macular changes.

[Severe infectious keratitis in renal transplant patient: a case report]. / Kératite infectieuse sévère chez un greffé du rein: à propos d'une observation.

Keratitis occurring in renal transplant patients are often severe, with difficult management. We describe the case of a renal transplant patient, 44 year-old man, with history of recurrent herpetic keratitis, which developed an impending corneal perforation. Conjunctival smear showed the presence of amoebic cysts. Anti-amoebic treatment was undertaken in addition with oral aciclovir, and a therapeutic penetrating keratoplasty was performed. An ulceration of the graft occurred within five months. Ocular samples showed the presence of Candida albicans. Despite aggressive antifungal therapy, he required a second therapeutic penetrating keratoplasty for graft perforation. One month later, we noted a recurrence of the ulcer with corneal thinning which evolved to perforation.

[Orbital cellulitis and endophthalmitis after cataract surgery]. / Cellulite orbitaire avec endophtalmie après chirurgie de cataracte.

Orbital cellulitis with endophthalmitis is an extremely uncommon complication following ocular surgery. We report the case of 38 year-old man who developed orbital cellulitis and endophthalmitis after extracapsular extraction and posterior chamber implant placement for cataract secondary to radiotherapy. Phacoextraction was performed under general anaesthesia and was uneventful. Three days postoperatively, the patient was examined for a reduced visual acuity and lid swelling in the operated eye. Ocular examination has shown signs of endophthalmitis and orbital cellulitis, which was confirmed by a computed tomographic scan. Bacteriology cultures were positive for a Streptococcus pneumoniae. The ocular infection evolved towards phthisis bulbi with no light perception 45 days after surgery. Enucleation with orbital implant was performed.

[Retinal detachment due to macular hole: therapeutic problems]. / Décollement de rétine par trou maculaire: problèmes thérapeutiques.

UNLABELLED: To compare the success rate and the visual improvement of different surgical techniques for treating 21 retinal detachments due to macular hole in highly myopic eyes. METHODS: Twelve patients were treated by gas tamponade alone, 5 patients underwent vitrectomy with gas tamponade, 4 patients underwent vitrectomy with epiretinal membrane pealing and gas or oil silicone tamponade. RESULTS: Fifty eight % of patients were successfully treated after gas tamponade alone, and 75% after vitrectomy, epiretinal membrane pealing and gas or silicone oil tamponade. After retreatment in 7 patients, the final reattachment rate was 80%. Visual acuity was inchanged in 12 cases, improved to 1/20-1/10 in 8 case and reached 3/10 in 1 case. CONCLUSION: A therapeutic scheme is suggested according to the type of retinal detachment, macular vitreoretinal traction and pigment epithelium and chorioretinal degeneration condition.