Vogt-Koyanagi-Harada Disease Following COVID-19 Infection.

A 29-year-old female presented to the emergency clinic with gradual visual disturbance in both eyes for 15 days duration, accompanied by bilateral tinnitus, and ocular pain that increased with ocular movements. One month prior to presentation, the patient had tested positive for severe acute respiratory syndrome coronavirus-2 but without complications. Visual acuity was 20/100 in the right eye and 20/300 in the left eye. Funduscopy demonstrated optic nerve swelling, radial nerve fiber striation disruption, and bilateral retinal folds. Optical coherence tomography showed serous (bacillary) retinal detachment and multifocal areas of hyper-reflective changes in the inner and outer plexiform layer with inner nuclear layer thickening and disruption of the interdigitation zone bilaterally. We present a case of incomplete Vogt-Koyanagi-Harada disease following COVID-19 infection.

Apolipoprotein AI-Derived Vitreous Amyloidosis: An Elusive Diagnosis.

A 56-year-old female presented with vitreous opacity with gradual visual disturbance in her right eye of 1-year duration. A Non-Hodgkin's lymphoma had been treated 15 years before. Presenting best-corrected visual acuity (BCVA) was 20/200 in her right eye and 20/25 in her left eye. Intraocular pressure was 18 mm Hg bilaterally. Slit-lamp examination revealed no abnormal findings in the anterior segment of both eyes, including the absence of cells and flare. Fundoscopic examination indicated hazy media with the typical glass-wool-like appearance in her right eye. B-scan ultrasound demonstrated that the vitreous was full of middle-echo spots, vitreous opacities, and posterior vitreous detachment occurred. The patient underwent vitreous biopsy and a standard 25-gauge pars plana vitrectomy (diagnostic and therapeutic). Intraoperatively, the eye was noted to have severe diffuse debris and very strong vitreoretinal adhesions. Cytospin smears prepared from the vitreous aspirate indicated amorphous acellular material that stained positively with Congo Red and showed apple green birefringence on polarized microscopy, consistent with the diagnosis of amyloidosis. A genetic evaluation of tongue tissue demonstrated apolipoprotein AI-derived amyloidosis. The BCVA was 20/25 OU at 3 months postoperatively.

Peritomy-sparing scleral buckle.

PURPOSE: To introduce a modified technique for encircling circumferential scleral buckling without peritomy thorough a small conjunctival opening for the repair of uncomplicated rhegmatogenous retinal detachment (RD). METHODS: This technique was performed in 10 eyes of 10 patients with primary rhegmatogenous RD who underwent encircling circumferential scleral buckling without peritomy. Transconjunctival traction sutures were placed in four rectus muscles. After transconjunctival location of the retinal break, a 5- to 6-mm radial conjunctival incision was performed in 4 quadrants without cutting the limbal conjunctiva-Tenon's capsule. A 240-silicone band in scleral belt loops was used for an encircling circumferential buckle. After drainage and cryopexy, SF6 was used for tamponade. The incision was closed via layered closure only ocassionally. RESULTS: Primary attachment success of 100% was achieved by single procedure. The intraoperative and postoperative complications observed included subconjunctival hemorrhage observed in 5 (50%) of eyes. These disappeared in the postoperative period. CONCLUSIONS: Minimal conjunctival incision in scleral buckle without peritomy can achieve excellent anatomical success in patients with rhegmatogenous RD without distorting ocular surface anatomy. This is the first description of technique preserving corneal limbus anatomy that could convert buckling surgery to more attractive option for retina surgeons.

Corrigendum: Optic neuropathy and congenital glaucoma associated with probable Zika virus infection in Venezuelan patients.

[This corrects the article DOI: 10.1099/jmmcr.0.005145.].

Optic neuropathy and congenital glaucoma associated with probable Zika virus infection in Venezuelan patients.

Introduction: Although the current Zika virus (ZIKV) epidemic is a major public health concern, most reports have focused on congenital ZIKV syndrome, its most devastating manifestation. Severe ocular complications associated with ZIKV infections and possible pathogenetic factors are rarely described. Here, we describe three Venezuelan patients who developed severe ocular manifestations following ZIKV infections. We also analyse their serological response to ZIKV and dengue virus (DENV). Case presentation: One adult with bilateral optic neuritis, a child of 4 years of age with retrobulbar neuritis [corrected]. and a newborn with bilateral congenital glaucoma had a recent history of an acute exanthematous infection consistent with ZIKV infection. The results of ELISA tests indicated that all patients were seropositive for ZIKV and four DENV serotypes. Conclusion: Patients with ZIKV infection can develop severe ocular complications. Anti-DENV antibodies from previous infections could play a role in the pathogenesis of these complications. Well-designed epidemiological studies are urgently needed to measure the risk of ZIKV ocular complications and confirm whether they are associated with the presence of anti-flaviviral antibodies.

Glaucomatous Optic Neuropathy Associated with Nocturnal Dip in Blood Pressure: Findings from the Maracaibo Aging Study.

PURPOSE: To determine which nocturnal blood pressure (BP) parameters (low levels or extreme dipper status) are associated with an increased risk of glaucomatous damage in Hispanics. DESIGN: Observational cross-sectional study. PARTICIPANTS: A subset (n = 93) of the participants from the Maracaibo Aging Study (MAS) who met the study eligibility criteria were included. These participants, who were at least 40 years of age, had measurements for optical tomography coherence, visual field (VF) tests, 24-hour BP, office BP, and intraocular pressure <22 mmHg. METHODS: Univariate and multivariate logistic regression analyses under the generalized estimating equations (GEE) framework were used to examine the relationships between glaucomatous damage and BP parameters, with particular attention to decreases in nocturnal BP. MAIN OUTCOME MEASURES: Glaucomatous optic neuropathy (GON) based on the presence of optic nerve damage and VF defects. RESULTS: The mean age was 61.9 years, and 87.1% were women. Of 185 eyes evaluated, 19 (26.5%) had signs of GON. Individuals with GON had significantly lower 24-hour and nighttime diastolic BP levels than those without. However, results of the multivariate GEE models indicated that the glaucomatous damage was not related to the average systolic or diastolic BP levels measured over 24 hours, daytime, or nighttime. In contrast, extreme decreases in nighttime systolic and diastolic BP (>20% compared with daytime BP) were significant risk factors for glaucomatous damage (odds ratio, 19.78 and 5.55, respectively). CONCLUSIONS: In this population, the link between nocturnal BP and GON is determined by extreme dipping effects rather than low nocturnal BP levels alone. Further studies considering extreme decreases in nocturnal BP in individuals at high risk of glaucoma are warranted.

ANTERIOR LENS CAPSULE IN THE MANAGEMENT OF CHRONIC FULL-THICKNESS MACULAR HOLE.

PURPOSE: To report the use of anterior lens capsule flap transplantation in two cases with chronic full-thickness macular hole (MH). METHODS: Case series. RESULTS: Two cases of chronic MH with a new treatment approach were reported. In the first case, a 66-year-old man presented with a chronic idiopathic MH in the left eye for 2 years. Presenting visual acuity was hand motion. The patient underwent phacoemulsification and vitrectomy with anterior lens capsule flap transplantation in the MH. At 5 months postoperatively, the visual acuity was 20/200 with MH closure. In the second case, a 68-year-old woman presented with decreased visual acuity for 2 years. Her visual acuity was hand motion in the right eye. The patient underwent phacoemulsification and vitrectomy with anterior lens capsule flap transplantation in the MH. Visual acuity improved to 20/400 with reduction in the MH diameter. Vision and MH diameter remained stable over 5 months postoperatively. CONCLUSION: Lens capsular flap transplantation is useful in closing chronic MH in the short term.

Phacoemulsification Outcomes with Different Illumination Techniques.

PURPOSE: To compare surgeon experience and the outcomes of phacoemulsification using 2 different illumination techniques for cataract extraction. METHODS: A prospective interventional case series was performed on 20 consecutive patients (20 eyes) with senile cataract who underwent phacoemulsification enhanced with a 23-G endoillumination probe. The main outcome measures were the surgeon's perception of depth of field and quality of visibility of intraocular structures, ease of performance of the surgical procedure, effectiveness, and complications related to the procedure. A surgeon-specific questionnaire was administered at the end of the procedure. RESULTS: Surgery was successfully performed in all patients without any complications. The surgeon indicated that lateral endoillumination markedly enhanced the details of the lens structures, mainly the posterior capsule visualization, better than the coaxial lighting with the surgical microscope. Lateral endoillumination created an enhanced 3D effect and improved the depth perception of lens intraoperatively. CONCLUSIONS: The lateral illumination technique with a 23-G endoilluminator probe placed in the anterior chamber through a paracentesis creates an enhanced 3D effect and improves depth perception of lens during phacoemulsification. These benefits increase the safety of the procedure.

Ophthalmic Manifestations of Congenital Zika Syndrome in Colombia and Venezuela.

Importance: The ocular manifestations and sequelae of Zika virus infection are not well known. Recently, the World Health Organization changed the declaration of Zika as a public health emergency and designated the viral outbreak and related microcephaly clusters as a long-term program of work. This change indicates the urgent need to evaluate and document ophthalmic manifestations in patients for timely management of this disease. In addition, confirmation whether the public health problem in Brazil extends to other regions in South America is needed. Objective: To report the ocular manifestations of congenital Zika syndrome with microcephaly in Colombia and Venezuela. Design, Setting, and Participants: This prospective case series included 43 patients from 2 ophthalmic centers in Colombia and Venezuela who underwent evaluation from October 1, 2015, through June 30, 2016, and were clinically diagnosed with congenital Zika syndrome. Twenty patients were Hispanic; 13, African; 8, white; and 2, Native American. Interventions: Ophthalmic and systemic evaluations and serologic testing were performed on all infants. Patients underwent external ocular examination and dilated ophthalmoscopy. Serologic testing ruled out toxoplasmosis, rubella, cytomegalovirus, syphilis, and human immunodeficiency virus. Main Outcomes and Measures: Ophthalmic manifestations of congenital Zika syndrome. Results: Of the 43 patients included in this series (28 female and 15 male), the mean (SD) age at examination was 2.1 (1.5) months. The mothers of all the children had no ophthalmic findings and did not report ocular symptoms during pregnancy. All patients had bilateral ophthalmic manifestations. Optic nerve findings included hypoplasia with the double-ring sign, pallor, and increased cup-disc ratio in 5 patients (11.6%). Macular abnormalities included mild to severe pigment mottling in 27 patients (63%) and lacunar maculopathy in 3 (6.9%). Chorioretinal scarring was present in 3 patients (7%). Eleven patients (26%) had a combination of lesions in the posterior pole. Five patients (12%) were diagnosed with congenital glaucoma, characterized by the clinical triad of epiphora, photophobia, and blepharospasm; increased intraocular pressure; corneal clouding at birth; and buphthalmos. These data reveal that 12% (95% CI, 5%-24%) of cases of congenital Zika with microcephaly had anterior segment abnormalities and 88% (95% CI, 76%-94%) had important macular and optic nerve abnormalities. The visual sequelae of these ophthalmic manifestations remain unknown. Conclusions and Relevance: Congenital Zika syndrome in the current study had severe ocular abnormalities, and all patients had bilateral involvement. Ocular findings were focal macular pigment mottling, chorioretinal atrophy with a predilection for the macular area, congenital glaucoma and optical nerve hypoplasia, and optic disc abnormalities. Ophthalmic examination is recommended in patients with congenital Zika syndrome.

INTRAVITREAL TRIAMCINOLONE IN SUSAC SYNDROME.

PURPOSE: To report the use of intravitreal triamcinolone for Susac Syndrome in one patient. METHODS: Case report. RESULTS: A 23-year-old woman presented with presented with sudden visual loss in the left eye with associated neurologic symptoms. Ophthalmic examination and fluorescein angiography showed multiple areas of branch retinal artery occlusion, bilaterally. Magnetic resonance imaging showed dot-like, diffusion-restricted lesions in the corpus callosum, and audiometry showed low-frequency sensory hearing loss, compatible with Susac Syndrome. The patient received a single intravitreal injection of triamcinolone (4 mg) in the left eye. One week later, before beginning systemic corticosteroids, all signs and symptoms resolved in the left eye only. CONCLUSION: In cases of delayed systemic corticosteroid therapy, intravitreal triamcinolone resolves the ocular manifestations of Susac Syndrome.

Pseudotumoral and Multiple Retinal Pigment Epithelium Proliferation in Vogt-Koyanagi-Harada Disease.

We report a case of pseudotumoral retinal pigment epithelium (RPE) proliferation in Vogt-Koyanagi-Harada (VKH) disease, in a 50-year-old female who presented with a juxtapapillary and peripheral subretinal hyperpigmented lesions in the left eye and "sunset glow fundus," hyperpigmented striae, and multiple atrophic chorioretinal spots in the periphery. The darkly pigmented exuberant larger subretinal mass extended to the periphery with associated subretinal fibrosis. This patient demonstrated the entire clinical presentation of VKH disease, which tends to course with a chronic, bilateral, granulomatous panuveitis and exudative retinal detachment associated with poliosis, vitiligo, alopecia, and central nervous system and auditory signs. Our case is unique for the presence of exuberant, pseudotumoral RPE proliferation at the juxtapapillary region and peripheral area. Although this complication has rarely been reported, a high index of suspicion is warranted for early diagnosis and avoids unnecessary treatments of a pseudotumor.

Surgical technique for transscleral fixation of a foldable posterior chamber intraocular lens.

The safety and efficacy of a modified technique for transscleral fixation of a foldable posterior chamber intraocular lens (IOL) for intracapsular aphakia (secondary IOL) or after complicated phacoemulsification was evaluated. All eyes had inadequate or no posterior capsular support. Follow-up was between 4 and 26 months (mean, 12 months). Uncorrected visual acuity improved (> 2 lines) in all patients. During follow-up, the IOL was correctly positioned in all cases. There were no major complications, such as endophthalmitis or suture erosion through the conjunctiva at the site of fixation. No patient required further surgical interventions. This modified technique of transscleral fixation of foldable posterior chamber IOL offers the advantages of a small incision and rapid visual rehabilitation, and minimizes the risk of intraoperative and postoperative complications.

Full-thickness macular hole after LASIK for the correction of myopia.

PURPOSE: To describe 19 patients (20 eyes) who developed a macular hole (MH) after undergoing bilateral LASIK for the correction of myopia. DESIGN: Noncomparative, interventional, retrospective, multicenter case series. PARTICIPANTS: Nineteen patients (20 eyes) who developed an MH after bilateral LASIK for the correction of myopia at 10 institutions in Venezuela, Colombia, Puerto Rico, Spain, and the United States. METHODS: Chart review. MAIN OUTCOME MEASURE: Macular hole development. RESULTS: The MH formed between 1 to 83 months after LASIK (mean, 12.1). In 60% of cases, the MH developed < or =6 months after LASIK, and in 30% of cases it developed > or =1 year after LASIK. Eighteen of 19 (94.7%) patients were female. Mean age was 46 years (range, 25-65). All eyes were myopic (range, -0.50 to -19.75 diopters [mean, -8.9]). Posterior vitreous detachment was not present before and was documented after LASIK in 55% of eyes. A vitrectomy closed the MH on the 14 eyes that underwent surgical management, with an improvement of final best-corrected visual acuity in 13 of 14 (92.8%) patients. Our 20 eyes with a full-thickness MH after LASIK reflect an incidence of approximately 0.02% (20/83938). CONCLUSION: An MH may infrequently develop after LASIK for the correction of myopia. Our study shows that vitreoretinal surgery can be successful in restoring vision for most myopic eyes with an MH after LASIK. Vitreoretinal interface changes may play a role in MH formation after LASIK for the correction of myopia.

Intraoperative peripheral anterior capsulotomy to prevent early postoperative capsular block syndrome.

We describe a new surgical technique, intraoperative peripheral anterior capsulotomy (IPAC), to prevent early postoperative capsular block syndrome (CBS). Eighty consecutive patients (80 eyes) had phacoemulsification and intraocular lens implantation with IPAC in the presence of a small (4.5 to 5.0 mm) anterior continuous curvilinear capsulorhexis (CCC). Patients were followed for a mean of 16 months (range 6 to 24 months), and none developed CBS or other complications. Our series suggests that IPAC may be an alternative to prevent CBS in high-risk eyes, including those with a small anterior CCC or ophthalmic viscosurgical device material trapped in the capsular bag. This surgical technique is safe, effective, inexpensive, and easy to perform.

Retinal detachment in myopic eyes after laser in situ keratomileusis.

PURPOSE: To report the characteristics and surgical outcomes of rhegmatogenous retinal detachments in myopic eyes after laser in situ keratomileusis (LASIK). METHODS: Clinical charts of patients that developed rhegmatogenous retinal detachment after LASIK were reviewed. Surgery to repair rhegmatogenous retinal detachment was performed in 31 eyes (mean follow-up of 14 months after vitreoretinal surgery). RESULTS: A total of 38,823 eyes underwent surgical correction of myopia from -0.75 to -29.00 D (mean -6.00 D). Thirty-three eyes (27 patients; frequency .08%) developed rhegmatogenous retinal detachment after LASIK; detachments occurred between 12 days and 60 months (mean 16.3 mo) after LASIK. Eyes that developed a rhegmatogenous retinal detachment had a mean -8.75 D before LASIK. Most rhegmatogenous retinal detachment and retinal breaks occurred in the temporal quadrants (71.1%). Final best spectacle-corrected visual acuity (BSCVA) of 20/40 or better was obtained in 38.7% of the 31 eyes (two patients refused surgery). Poor final visual acuity (20/200 or worse) occurred in 22.6% of eyes. Information regarding visual acuity after LASIK and before the development of rhegmatogenous retinal detachment was available in 24 eyes; 45.8% (11/24 eyes) lost two or more lines of visual acuity after vitreo-retinal surgery. Reasons for poor visual acuity included the development of proliferative vitreo-retinopathy (n=5), epiretinal membrane (n=1), chronicity of rhegmatogenous retinal detachment (n=1), new breaks (n=1), displaced corneal flap (n=1), and cataract. CONCLUSIONS: Rhegmatogenous retinal detachment after LASIK for myopia is a serious complication. Final visual acuity may be limited by myopic degeneration, amblyopia, or delayed surgical repair.

Topical anesthesia with sedation in phacoemulsification and intraocular lens implantation combined with 2-port pars plana vitrectomy in 105 consecutive cases.

BACKGROUND AND OBJECTIVE: To evaluate the efficacy of topical anesthesia as an alternative to peribulbar or retrobulbar anesthesia in phacoemulsification and intraocular lens implantation combined with our modified 2-port pars plana vitrectomy technique (phacovitrectomy). PATIENTS AND METHODS: Phacovitrectomy using topical anesthesia (4% lidocaine drops) was prospectively performed in 105 eyes with cataract and varied vitreoretinal pathology. In 75 eyes (71.4%), phacovitrectomy was combined with argon laser photocoagulation (endolaser). Preoperative and intraoperative sedation of varying degrees was necessary. Subjective pain and discomfort were graded from 1 (no pain or discomfort) to 4 (severe pain and discomfort). RESULTS: All patients had grade 1 pain and discomfort during most of the procedure. All patients had grade 2 (mild) pain and discomfort during pars plana sclerotomies, external bipolar cautery, and conjunctival closure. No patient required additional retrobulbar, peribulbar, or sub-Tenon's anesthesia. CONCLUSION: This technique avoids the risk of globe perforation, retrobulbar hemorrhage, and prolonged postoperative akinesia of the eye. With appropriate case selection, topical anesthesia is a safe and effective alternative to peribulbar or retrobulbar anesthesia in phacovitrectomy.