CHOROIDAL NEOVASCULARIZATION AND CHORIORETINAL ATROPHY IN A PATIENT WITH MELANOMA-ASSOCIATED RETINOPATHY AFTER IPILIMUMAB/NIVOLUMAB COMBINATION THERAPY.

PURPOSE: To describe a case of choroidal neovascularization (CNV) and chorioretinal scarring in a patient with melanoma-associated retinopathy after ipilimumab/nivolumab combination immune therapy for malignant melanoma. METHODS: Retrospective case report with fundus photography, fluorescein angiography, optical coherence tomography, and electroretinography. RESULTS: A 65-year-old woman presented with symptoms of photopsia and visual field loss. She had previously undergone ipilimumab/nivolumab combination chemotherapy treatment for malignant melanoma 14 months earlier coinciding with the onset of her visual symptoms. Fundus photography showed bilateral atrophic chorioretinal lesions and peripheral retinal pigment epithelial changes. Fluorescein angiography revealed retinovascular leakage in both eyes with CNV in the right eye. Optical coherence tomography showed a pigment epithelial detachment with subretinal fluid and subretinal hyperreflective material consistent with occult CNV. Visual field testing showed generalized visual field loss in both eyes. Bloodwork discovered an elevated angiotensin-converting enzyme. Electroretinography revealed abnormal peripheral rod and cone function with impairment of the photoreceptor and inner nuclear layer. Serum Western blot was positive for 60 kDa antiretinal autoantibody. After a single bevacizumab injection in the right eye, CNV resolved and visual acuity improved from 20/50 before the injection to 20/25 3 months after the injection. Visual acuity in the left eye deteriorated for months to counting fingers but then improved to 20/100 on follow-up examinations. CONCLUSION: Ipilimumab and nivolumab have been associated with immune-related ocular adverse effects. We report a case of combination therapy presenting with chorioretinal scarring and subsequent CNV in a patient with melanoma-associated retinopathy, a rare yet important adverse effect.

BILATERAL CHOROIDAL DETACHMENTS SECONDARY TO IPILIMUMAB AND PEMBROLIZUMAB USE.

PURPOSE: To report the occurrence of bilateral choroidal detachments due to the use of ipilimumab and pembrolizumab immunochemotherapeutics to treat widely metastatic cutaneous melanoma and to raise awareness about this potentially vision-threatening adverse drug event. METHODS: A 77 year-old man presented with acute onset, painless, and bilateral blurry vision. He had started ipilimumab and pembrolizumab 2 weeks prior for Stage IV metastatic cutaneous melanoma. RESULTS: Clinical examination revealed bilateral choroidal detachments. After discussion with the patient's medical oncologist, the patient discontinued both medications and began oral prednisone to expedite visual recovery. The choroidal detachments subsequently resolved, and visual acuity improved 2 weeks later. CONCLUSION: Ipilimumab and pembrolizumab have been reported both in monotherapy and in combination to cause a wide variety of ophthalmic adverse events. This is the first report of choroidal detachments as a complication.

Disseminated Tubercular Granulomas Associated with the Use of Azathioprine.

Purpose: To describe a case of multiple disseminated choroidal tuberculomas in a patient of early-phase Vogt-Koyanagi- Harada (VKH) disease being treated with Azathioprine.Methods: A retrospective chart review.Results: A 55-year-old female, a diagnosed case of VKH disease, was being treated with oral steroids and Azathioprine. During one of her follow-up visit, she was detected with multiple subretinal granulomas with surrounding fluid in both eyes. Fundus fluorescein angiography (FFA), Indocyanine green angiography (ICGA) and Optical Coherence Tomography (OCT) favored the presence of choroidal granulomas and Positron emission Tomography (PET) scan revealed lesions in spleen as well. She was started on anti-tubercular therapy along with oral steroids. She responded very well to treatment and her choroidal granulomas resolved in follow-up.Conclusion: Disseminated tubercular granulomas can rarely occur with the use of oral Azathioprine and poses caution for its use in cases requiring long-term immunosuppressants.

[Tyrosine kinase inhibitor-associated choroidopathy]. / Tyrosinkinaseinhibitor-assoziierte Choroidopathie.

A 66-year-old male patient presented to the ophthalmology department with bilateral blurred vision, which had persisted for 1 week. Due to a pulmonary melanoma metastasis, the patient received a combination treatment with dabrafenib and trametinib. At the first presentation visual acuity was 1.2 on the right and 1.0 on the left. A normotensive intraocular pressure was measured in both eyes. Fundoscopy showed bilateral white, areolar alterations in the choroid and choroid folds and in the left eye a bullous choroidal detachment. Bilateral neurosensory detachment and subretinal fluid were found in optical coherence tomography (OCT). After reduction of the local treatment for pressure reduction and under local and systemic anti-inflammatory treatment, the choroidal swelling was progressive, the visual acuity dropped to 0.5 in the right and to 0.1 in the left eye. A significant regression of the findings occurred only after pausing the treatment with trametinib. Visual acuity rose to 1.0 (left) and 0.8 (right). The OCT showed a dry macula on the right and a small amount of residual subretinal fluid in the left eye.

Effect of acute and chronic aldosterone exposure on the retinal pigment epithelium-choroid complex in rodents.

Preclinical and clinical evidences show that aldosterone and/or mineralocorticoid receptor (MR) over-activation by glucocorticoids can be deleterious to the retina and to the retinal pigment epithelium (RPE)-choroid complex. However, the exact molecular mechanisms driving these effects remain poorly understood and pathological consequences of chronic exposure of the retina and RPE/choroid to aldosterone have not been completely explored. We aimed to decipher the transcriptomic regulation in the RPE-choroid complex in rats in response to acute intraocular aldosterone injection and to explore the consequences of systemic chronic aldosterone exposure on the morphology and the gene regulation in RPE/choroid in mice. High dose of aldosterone (100 nM) was intravitreously injected in Lewis rat eyes in order to yield an aldosterone dose able to induce a molecular response at the apical side of the RPE-choroid complex. The posterior segment morphology was evaluated in vivo using optical coherence tomography (OCT) before and 24 h after aldosterone injection. Rat RPE-choroid complexes were used for RNA sequencing and analysis. Uninephrectomy/aldosterone/salt (NAS) model was created in wild-type C57BL/6 mice. After 6 weeks, histology of mouse posterior segments were observed ex vivo. Gene expression in the RPE-choroid complex was analyzed using quantitative PCR. Acute intravitreous injection of aldosterone induced posterior segment inflammation observed on OCT. RNA sequencing of rat RPE-choroid complexes revealed up-regulation of pathways involved in inflammation, oxidative stress and RNA procession, and down-regulation of genes involved in synaptic activity, muscle contraction, cytoskeleton, cell junction and transporters. Chronic aldosterone/salt exposure in NAS model induces retinal edema, choroidal vasodilation and RPE cell dysfunction and migration. Quantitative PCR showed deregulation of genes involved in inflammatory response, oxidative stress, particularly the NOX pathway, angiogenesis and cell contractility. Both rodent models share some common phenotypes and molecular regulations in the RPE-choroid complex that could contribute to pachychoroid epitheliopathy in humans. The difference in inflammatory status relies on different intraocular or systemic route of aldosterone administration and on the different doses of aldosterone exposed to the RPE-choroid complex.

Atypical Presentation of Choroidal Folds: Steroid-induced Central Serous Chorioretinopathy-like Maculopathy

This article reports a case of choroidal folds and central serous chorioretinopathy-like maculopathy induced by corticosteroid treatment. The patient was a 70-year-old woman who presented with decreased visual acuity in the right eye. She had a history of rheumatoid arthritis and was prescribed 20 mg leflunomide and 16 mg corticosteroid daily. Fundoscopy indicated bilateral macular edema and the presence of choroidal folds. Retinal imaging supported choroidal folds and central serous chorioretinopathy-like maculopathy. Corticosteroid therapy was discontinued, and the patient was followed up. Complete regression of the maculopathy was observed at 8-month follow-up examination.

ACUTE MYOPIA WITH ELEVATION OF INTRAOCULAR TENSION AS AN ADVERSE SIDE EFFECT OF ANTIDEPRESSANT MEDICATION.

CASE-REPORT: The author presents case report of acute induced myopia with mild intraocular pressure elevation by young patient using trazodone. The presentation is completed with the documentation of anterior chamber depth and angle changes by using and after discontinuation of trazodone. CONCLUSION: Acute transient myopia may be rare side effect of systemic used drugs in predisposed patients. Early and correct diagnosis is very important, because induced myopia may be accompanied by acute angle-closure glaucoma or supraciliary choroidal effusion. The only correct treatment in this case is discontinuation of the drug. Key words: acute angle-closure glaucoma, acute myopia, antidepressants, side effects, trazodone.

Indapamide-induced bilateral choroidal effusion in pseudophakic patient.

We describe a case of indapamide-induced bilateral choroidal effusion, first time reported in pseudophakic patient, associated with no change in visual acuity and stable refraction.A 70-year-old man was referred for ophthalmic assessment, with binasal visual field defect for 2 days. He had been started on treatment with indapamide 3 weeks earlier. His ophthalmic history included bilateral cataract surgery and intraocular lens implant. Fundal examination revealed bilateral choroidal effusions; B-scan ultrasonography was used to measure the extent of the choroidal detachment and the anterior chamber depth. Discontinuation of indapamide resulted in spontaneous resolution of choroidal effusion after 3 days. Our case is the first in the literature that describes bilateral choroidal effusion induced by indapamide in a pseudophakic patient. The lack of myopic shift likely resulted in a later presentation, enhancing the theory that lens thickening and/or accommodative spasm may play a crucial role in pathophysiology.

CEFALIUM-INDUCED BILATERAL TRANSIENT MYOPIA, RETINAL FOLDS, AND FOCAL CHOROIDAL DELAY.

PURPOSE: To describe a case of acute bilateral transient myopia, retinal folds, and island of choroidal delay associated with oral administration of Cefalium, a medication commonly prescribed in Brazil for migraine that combines acetaminophen 500 mg, caffeine 40 mg, dihydroergotamine mesylate 1 mg, and metoclopramide hydrochloride 10 mg. METHODS: A 21-year-old woman with bilateral blurred vision 1 day after the use of Cefalium. The main outcomes measures were BCVA, ocular fundus, ocular coherence tomography, and angiography findings. RESULTS: The patient developed bilateral myopia, retinal folds, and focus choroidal delay 1 day after the administration of oral cefalium. Ocular fundus examination and ocular coherence tomography revealed retinal folds in the internal surface of the retina. Angiography showed focus areas of hypofluorescence in both eyes. Seven days after Cefalium was suspended, all clinical symptoms had resolved, with full recovery from the abnormal findings on ocular fundus, ocular coherence tomography, and angiography. CONCLUSION: This is the first report that identified and described bilateral transient myopia, retinal folds, and focus choroidal delay secondary the use of Cefalium.

Asymptomatic choroidal tubercle in a patient with Crohn's disease on adalimumab treatment. / Tubérculo coroideo asintomático en un paciente con enfermedad de Crohn en tratamiento con adalimumab.

INTRODUCTION: Adalimumab, an anti-tumour necrosis factor alpha therapy for active Crohn's disease (CD), is associated with increased risks of tuberculosis infection. CASE REPORT: The case is presented of a 48 year-old male with active CD on treatment with adalimumab. After three months, he developed a miliary pulmonary tuberculosis infection, with a solitary non-reactive choroidal tubercle temporal-superior to the optic disc being found in an ophthalmological study. Fluorescein angiography showed late hyperfluorescence in a staining pattern. Optic coherence tomography showed a flat mass without serous retinal detachment. The choroidal tubercle slowly regressed with antituberculosis therapy. DISCUSSION: Choroidal tubercles with no vitreo-retinal symptomatology can be present in patients with CD and on treatment with adalimumab.

Bilateral acute angle closure glaucoma and myopic shift by topiramate-induced ciliochoroidal effusion: case report and literature review.

PURPOSE: To report two cases of ciliochoroidal effusion after the usage of topiramate. CASES: Two middle-aged women experienced sudden onset of acute glaucoma and acquired myopia after taking topiramate. Ultrasound biomicroscopy demonstrated bilateral ciliochoroidal effusion and angle closure. The A-scan ultrasonography revealed shallow anterior chamber and thick lens. After the treatment and drug withdrawal, intraocular pressure, refractive status and angle anatomy returned to normal and there was resolution of ciliochoroidal effusion. During the clinical course, the anterior chamber depth (ACD) increased from 2.02 to 3.30 mm (1.28 mm of changes) OD and from 1.94 to 3.36 mm (1.42 mm of changes) OS. The lens thickness (LT) became thinner from 4.53 to 4.31 mm (0.22 mm of changes) OD and from 4.59 to 4.30 mm (0.29 mm of changes) OS in the first case. In the second case, the ACD increased from 2.33 to 3.07 mm (0.74 mm of changes) OD and from 2.30 to 3.05 mm (0.75 mm of changes) OS. The LT became thinner from 4.42 to 4.27 mm (0.15 mm of changes) OD and from 4.38 to 4.26 mm (0.12 mm of changes) OS. The forward displacement of the lens-iris diaphragm contributed more to the shallowness of the anterior chamber than the thickening of the lens itself (only accounting for 20%). CONCLUSION: Topiramate-induced bilateral acute angle closure glaucoma and myopic shift was due to ciliochoroidal effusion which resulted in thicker lens and shallow anterior chamber. The later was mainly due to anterior displacement of the lens-iris diaphragm.

[Case report on choroidal effusion after oral acetazolamide administration: an unusual manifestation of a well-known idiosyncratic effect?] / Acetazolamid orális alkalmazása mellett jelentkezo chorioidealeválás két esete: ismert idioszinkráziás hatás szokatlan megjelenési formája?

Sulpha drugs are widely employed in medicine for various diseases and disorders. During the last several decades, numerous papers had been published on supra ciliary and posterior choroidal effusion likely presenting as an idiosyncratic effect of these drugs especially of acetazolamide. In each publication, the effusion was associated with either an acute angle-closure glaucoma or transitory myopia or both of these as leading symptoms. In the current publication, authors report on two cases where the acetazolamide-induced choroidal effusion was an accidental finding without either a myopic shift in refraction or an acute elevation in intraocular pressure. To our best knowledge, ours is the first report in the literature describing this unusual, "silent" form of a sulpha drug-induced choroidal effusion. Since the choroidal involvement may vary in size and location, and is not necessarily associated with acute glaucoma and myopia, one can assume that a considerable amount of acetazolamide-related ocular side-effects will not be discovered. The above case report aims to draw the attention of other specialities to the need for ophthalmic examination for their patients taking sulpha drugs with acute visual deterioration. Orv Hetil. 2017; 158(50): 1998-2002.

Pachychoroid Pigment Epitheliopathy Associated With Tamoxifen.

Pachychoroid pigment epitheliopathy (PPE) is considered to be a forme fruste of central serous chorioretinopathy. Tamoxifen (Soltamax; Midatech Pharma, Raleigh, NC) has an anti-estrogenic effect on cytoplasmic estrogen receptors. Serum total testosterone, cortisol, and cortisone levels increase during tamoxifen therapy. Tamoxifen may cause hormone disturbance leading to the development of disorders in the pachychoroid spectrum. The authors present two cases of PPE associated with tamoxifen therapy. A 65-year-old woman (Patient 1) and a 52-year-old woman (Patient 2) had a recent history of tamoxifen therapy. PPE lesions were seen in both eyes of Patient 1 and in the right eye of Patient 2. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:838-842.].