Minoxidil induced central serous Chorioretinopathy treated with oral Eplerenone - a case report.

BACKGROUND: Minoxidil solution has routinely been used for decades for the treatment of androgenic alopecia. Central serous chorioretinopathy (CSCR) is a rare side-effect noted following prolonged topical minoxidil therapy for androgenic alopecia. In this report, we describe a case of a 41-year-old young man who developed CSCR following prolonged therapy with topical Minoxidil solution and was treated with oral eplerenone. CASE PRESENTATION: A 41-year-old male presented to the retina clinic with complaints of seeing a black spot, blurred vision and metamorphopsia involving the right eye for the past 4 months. He was on treatment for androgenic alopecia with topical 5% Minoxidil application on scalp two times a day. He noticed the symptoms 8 months after starting the treatment and had stopped the medication since the past 2 months. On examination, best-corrected visual acuity was 20/20 in both eyes. Fundoscopic examination of the right eye with +78D lens on slit lamp revealed the presence of subretinal fluid and few focal spots of retinal pigment epithelial alterations. Optical coherence tomography scan evaluation showed the presence of subretinal fluid (SRF) and pachychoroid supporting the diagnosis of CSCR. Indocyanine green angiography revealed dilated hyperpermeable choroidal vasculature on the nasal side of the fovea in the early and later phases of the angiogram. The patient was diagnosed with CSCR as a possible consequence of the topical minoxidil solution. Patient was asked to avoid future use of Minoxidil and was started on oral eplerenone therapy 50 mg/day for 4 consecutive weeks. One month later, there was complete resolution of his symptoms and SRF. At the final follow-up visit, 2 months after starting the therapy, there was no recurrence of SRF. CONCLUSION: CSCR is a rare side-effect noted following prolonged topical minoxidil therapy for androgenic alopecia. While we found oral eplerenone to be safe and effective, further studies would be required before it can be routinely used in the population.

Intrachoroidal cavitation in myopic eyes.

PURPOSE: To determine the incidence and characteristics of intrachoroidal cavitation (ICC) in the eyes with high myopia. METHODS: In this retrospective, non-interventional, comparative study, we analysed the case records of 108 eyes with and without pathological myopia (PM). PM was defined as having a refractive error (spherical equivalent) of ≥ - 6.0 D or axial length ≥ 26 mm. The presence of other features like posterior vitreous detachment, myopic traction maculopathy, posterior staphyloma, focal/patchy chorioretinal atrophy (CRA), choroidal neovascularisation and retinoschisis was looked for on OCT. The association of these features with ICC was analysed using statistical tests. RESULTS: In this study, 38 out of 68 eyes with PM and 4 out of 40 eyes with non-PM showed the bowing of the posterior sclera and the presence of ICC. On statistical analysis with Chi-square test and multiple variable linear regression analysis tests, it was identified that the presence of focal/patchy CRA (p = 0.005) and intrascleral vessels (p = 0.018) in and around the cavitation was important features noted in eyes with ICC. The OCT features of macular and peripapillary ICC were similar. The transudation of fluid from the dilated intrascleral vessels in and around the ICC could be one other mechanism responsible for the development of ICC. CONCLUSION: ICC is seen in 55.8% of highly myopic eyes with the presence of focal CRA or myopic conus and/or presence of intrascleral vessels near the cavitation. These findings suggest that patchy atrophy affects the scleral contour within posterior staphyloma beyond the funduscopically identified patchy atrophy by ICC. The presence of intrascleral vessels could also contribute to the ICC development. Eyes with patchy CRA or myopic conus needs to be checked on further follow-up visits for the development of macular or peripapillary ICC.

Differences in the multicolour imaging features between the superficial and deep vascular occlusions.

Purpose To describe the multicolour imaging (MI) findings in superficial and deep vascular plexus occlusions. METHODS: In this retrospective observational study, patients diagnosed with central retinal artery and branch retinal artery occlusion, cotton-wool spot, paracentral acute middle maculopathy and acute macular neuroretinopathy between January 2018 and June 2019 were included. Colour fundus photograph, optical coherence tomography and MI of these patients were analysed. RESULTS: A total of 41 eyes of 40 patients were included in this study. In eyes with central retinal artery occlusion, MI showed white areas in the retina with orange foveal centre. In eyes with branch retinal artery occlusion, MI showed white area along the affected retinal quadrant without an orange foveal centre. In pure superficial vascular plexus occlusions as in cotton-wool spots, the lesion was identified on MI as a white lesion. On MI, paracentral acute middle maculopathy showed parafoveal white areas with orange foveal centre while acute macular neuroretinopathy on MI parafoveal greyish-white areas with normal foveal centre. CONCLUSION: En-face images using MI technology can provide yet another way to identify the level of retinal vasculature involvement which complements the existing gold standard of optical coherence tomography imaging.

Structural and Functional Outcomes of Surgery for Lamellar Macular Holes with or without Epimacular Proliferations.

PURPOSE: To compare the clinical, optical coherence tomography (OCT) features, and surgical outcomes of lamellar macular hole (LMH) depending on the presence of epimacular membrane proliferation (EMPF). METHODS: This retrospective chart review included 112 eyes with LMH. The patients were divided into two groups depending on the presence of EMPF. Group 1 had LMH without EMPF and Group 2 had LMH with EMPF. The best-corrected visual acuity was recorded and OCT scans were obtained. RESULTS: Lamellar macular hole without and with EMPF was noted in 62 (55%) and 50 (45%) eyes, respectively. The presence of EMPF was associated with lower presenting visual acuity (P = 0.049), wider LMH size at the largest diameter on the horizontal scan (P = 0.001), thinner residual retinal tissue (P = < 0.0001), and larger IS-OS defects (P = < 0.0001) as compared to the non-EMPF group. Of the 112 eyes, 18 eyes underwent surgery for LMH. Seven eyes had EMPF and the remaining eleven did not have EMPF. The average follow-up time for patients post-surgery and under observation was 16.8 and 24.1 weeks, respectively. A significant improvement in visual acuity was noted in the operated eyes with no EMPF as compared to the eyes with EMPF (P = 0.008). Worsening visual acuity (P = 0.021) was noted in eyes with LMH associated with EMPF which did not undergo surgery. Eyes with LMH and no EMPF, which were not operated on showed a minimal negative change in visual acuity. CONCLUSION: LMH with EMPF showed a higher association with accompanying ellipsoid zone disruption. Better anatomical and functional outcomes were achieved in those eyes that underwent surgery for LMH with no presence of EMPF and ellipsoid zone defect.

Association Between Sleep Apnea Risk Score and Retinal Microvasculature Using Optical Coherence Tomography Angiography.

PURPOSE: To investigate the retinal vessel changes at peripapillary and parafoveal regions using optical coherence tomography angiography in patients with varying obstructive sleep apnea syndrome (OSAS) risk, identified by the STOP-BANG questionnaire. DESIGN: Prospective, hospital-based cross-sectional study. METHODS: Participants were divided into 3 groups based on the OSAS risk score. Flow areas and vessel densities were calculated at peripapillary and parafoveal regions using optical coherence tomography angiography. Microvasculature changes between the 3 groups and correlation between OSAS risk score and vascular changes were calculated. RESULTS: Six hundred and six eyes of 303 patients were included in groups 1 (n = 96), 2 (n = 135), and 3 (n = 72). In patients with high OSAS risk, an increase in flow areas (P = .011) and vessel densities (P = .002) in superficial capillary plexus was noted. In contrast, flow areas (P = .003) and vessel densities (P < .000) in deep capillary plexus were reduced. Positive correlation was noted between sleep scores and vessel densities in superficial capillary plexus (P = .04). Negative correlation was noted between sleep scores and flow areas (P = .003) and vessel densities (P ≤ .001) in deep capillary plexus. CONCLUSION: The sleep apnea questionnaire is an easy method of identifying the disease severity stage, but polysomnography still remains the definitive gold standard. Optical coherence tomography angiography shows some associations with disease severity, but it cannot be used unambiguously to distinguish the severity of sleep apnea.

Torpedo Retinopathy.

PURPOSE: Torpedo lesions in the retina are rare. This study aimed to investigate torpedo-shaped lesions in the retina in an adult population and to determine the spectrum and features of the disease. METHODS: The review of a database for clinical diagnosis identified nine patients who were diagnosed with torpedo-shaped lesions in the retina between June 2017 and February 2019. Fundus photography and optical coherence tomography (OCT) imaging were used to analyze the cases. Multicolor imaging was also performed. RESULTS: Nine patients with torpedo-shaped lesions in the fundus were identified. Fundus images revealed that the lesion involved the macula in six eyes; in the remaining three eyes, the lesion was present outside the macula. OCT identified six patients with type 1 torpedo lesions, one with type 2, and two with type 3. On multicolor imaging, the lesion was visualized as a region of increased reflectance in blue, green, and infrared light in all eyes, with notably increased infrared reflectance in eyes with focal choroidal excavation. Choroidal neovascular membrane was evident in one patient on OCT angiography. CONCLUSION: Torpedo lesions in the retina can occur away from the macula and exhibit features similar to those of torpedo maculopathy. As such, the authors propose a change in the nomenclature for torpedo lesions in the retina from "torpedo maculopathy" to "torpedo retinopathy."

Combined brilliant blue G and xenon light induced outer retinal layer damage following macular hole surgery.

We report a case of combined brilliant blue G and endoilluminator retinal toxicity in a patient who has undergone macular hole surgery. The patient developed extensive degeneration of the retinal pigment epithelium as early as 1 week following surgery that eventually lead to poor visual outcome. We look into the pathogenesis of BBG and endoilluminator causing retinal toxicity and also suggest measures to avoid this irreversible retinal damage.

Retinal structural and vascular changes in posterior microphthalmos.

BACKGROUND: Posterior microphthalmos (PM) is a rare developmental disorder characterised by high hyperopia, short axial length, presence of retinal papillomacular fold and relatively normal anterior segment findings. The study objective is to describe the retinal structural and vascular changes in eyes with PM with spectral domain optical coherence tomography, optical coherence tomography angiography and multicolour imaging. METHODS: In this retrospective, comparative case series, 10 eyes of five patients with PM as cases and 10 eyes of five age- and sex-matched controls were included. Structural changes, namely inner and outer retinal layer thicknesses, were measured using optical coherence tomography. Multicolour imaging findings were noted. Perifoveal vascular changes with qualitative and quantitative assessments were analysed using optical coherence tomography angiography. RESULTS: The foveal dip was absent in all 10 eyes (100 per cent) with PM. There was an elevated retinal papillomacular fold in six eyes (60 per cent) and intraretinal cystoid spaces in two eyes (20 per cent) with PM. The inner retinal layers were thicker in PM. On multicolour imaging, foveal avascular zone and retinal wrinkles were identified in eyes with retinal papillomacular fold in blue and green reflectance images. Perifoveal vascular changes in optical coherence tomography angiography included foveal area size reduction in superficial and deep vascular networks. The foveal capillary vessel densities were higher in PM compared to the controls in both superficial (46.3 ± 3.7 per cent; p = 0.000) and deep (54.7 ± 3.5 per cent; p = 0.000) capillary plexuses. Flow areas in superficial (p = 0.693) and deep (p = 0.088) capillary plexuses were not statistically relevant. CONCLUSION: The study suggests that in PM, retinal foreshortening occurs in one meridian leading to secondary changes such as loss of foveal dip, posterior bowing of the outer layers of the eye, thickening of the inner retina and ultimately, retinal papillomacular fold formation. The findings of the study need further validation in a larger series of patients with PM.

Relevance of Multicolor Imaging in Type 2 Macular Telangiectasia.

PURPOSE: To report the imaging characteristics of various clinical features in idiopathic macular telangiectasia (MacTel 2) on multicolor imaging (MCI) and compare its accuracy vis-à-vis color fundus photograph (CFP) and fluorescein angiography (FA). METHODS: In this retrospective observational study, 54 eyes of 27 patients with MacTel 2 were included after institutional review board approval. Multimodal imaging with CFP, optical coherence tomography (OCT), MCI, and FA was done. Images were analyzed to identify and describe the clinical findings in MacTel 2. Sensitivity, specificity, and positive and negative predictive values were computed for the various imaging modalities in MacTel 2. RESULTS: In this study, the MCI identified all the different clinical features of MacTel 2 in 100% of cases. The confocal blue reflectance (BR) image was more sensitive than CFP (100% vs. 96.3%) in identifying the loss of retinal transparency in MacTel 2. For other clinical features such as right-angled vessels, superficial retinal crystals, and retinal pigment epithelial hyperplasia/plaques, the sensitivity of BR, and green reflectance (GR) image, was comparable to that of CFP. Confocal infrared reflectance (IR) images showed poor sensitivity in identifying the non-proliferative features in MacTel 2 (P < 0.001). Loss of retinal transparency was not picked up on IR image. Other features such as right-angled vessels, superficial retinal crystals, and pigment plaques were seen in 20%, 4.6%, and 26.3% of cases, respectively. However, confocal IR images were superior to FA (100% vs. 47%) and CFP (100% vs. 15%) in identifying the extent and location of subretinal neovascular membrane. The confocal BR and GR images were unable to identify the choroidal neovascular membrane (P < 0.001). CONCLUSION: MCI is a useful and non-invasive imaging modality to identify the clinical features in MacTel 2. MCI can be used as a complementary imaging tool to CFP, FA, and OCT.

Multicolour imaging in central serous chorioretinopathy.

BACKGROUND: Multicolour imaging (MI) is a novel, non-invasive retinal imaging technology. Its sensitivity for detecting the clinical features in central serous chorioretinopathy (CSCR) has not been previously described. The aim of this study is to evaluate the accuracy of MI compared to fluorescein angiography and colour fundus photography in CSCR, and to describe the imaging features of MI. METHODS: In this retrospective study at a tertiary referral centre, 63 consecutive eyes with CSCR (both acute and chronic) were included after obtaining permission from the institutional review board. Multimodal imaging with colour fundus photography, optical coherence tomography, MI and fluorescein angiography/indocyanine green angiography and near-infrared and blue wavelength autofluorescence was analysed to identify the clinical findings in CSCR. Sensitivity and specificity values were computed for the different clinical features for each imaging modality. RESULTS: On comparison with fluorescein angiography, MI was found to be more effective in identifying the extent of subretinal fluid (78 per cent versus 13 per cent). MI was equally capable in identifying pigment epithelium detachment (100 per cent versus 100 per cent) and retinal pigment epithelial changes (100 per cent versus 100 per cent). Focal leaks were identified in 84 per cent and 97 per cent of eyes using MI and fluorescein angiography imaging, respectively. The sensitivity of MI in identifying focal retinal pigment epithelial leaks was higher compared to near-infrared autofluorescence (84 per cent versus 34 per cent) and blue wavelength autofluorescence (84 per cent versus 18 per cent) imaging. CONCLUSION: MI is a useful, non-invasive imaging modality for detecting clinical features in CSCR. In the future, MI has the potential to substitute for fluorescein angiography and colour fundus photography as the imaging modality of choice.

Oral Eplerenone Versus Observation in the Management of Acute Central Serous Chorioretinopathy: A Prospective, Randomized Comparative Study.

In this prospective, interventional case-control study, 58 patients with unilateral acute central serous chorioretinopathy (CSCR) were recruited. Patients ≥ 18 years age, presenting with first episodes of acute CSCR, were included. Acute CSCR was defined by the presence of subretinal fluid (SRF) and symptoms for <12 weeks duration with no clinical or imaging features of chronicity. Patients were alternately divided into treatment (Table Eplerenone 50 mg/day for minimum 1 month) and observation groups. Vision, SRF height and subfoveal choroidal thickness (SFCT) were checked at 1-, 2- and 3-months in both eyes of each group. Each group had 29 eyes. Mean age was 40.4 ± 7.1 and 43.3 ± 8.34 years in treatment and observation group, respectively. Mean symptom duration was 6.46 ± 1.45 and 5.87 ± 2.09 weeks, respectively. Vision improvement to 6/6 was seen in 92%, 100% and 100% cases in treatment group and 74%, 86% and 100% in control group at each visit, respectively. Complete SRF resolution in the treatment group was noted in 45%, 55% and 62% cases at each respective monthly visit. In the observation group, complete SRF resolution was noted in 10%, 21% and 31% at 1-, 2- and 3-month visits, respectively. SRF (p < 0.001) and SFCT (p < 0.001) reduction was noted in the affected eye of both groups. SFCT was reduced in the fellow eye after treatment (p = 0.005) compared to the observation group (p = 0.276). In conclusion, oral eplerenone achieves faster SRF resolution and vision improvement in acute CSCR. Additionally, it shows beneficial effects on the fellow eye.

Variability in Imaging Findings in Choroidal Nevus Using Multicolor Imaging Vis-à-vis Color Fundus Photography.

PURPOSE: To describe the multicolor imaging (MCI) features in a series of patients diagnosed with a choroidal nevus and compare it vis-à-vis color fundus photography (CFP) in identifying the lesion. METHODS: In this retrospective, descriptive case series at a tertiary referral center in South India, all patients diagnosed with the choroidal nevus underwent CFP, optical coherence tomography, MCI, and infrared reflectance (IR) imaging. RESULTS: In this study, we found that on MCI, the choroidal nevus could be identified in only six of the 12 eyes. The lesions were seen as an area of hyperreflectance on IR image and orange-colored lesion on multicolor image. In one eye, there was a mixed pattern of hyper and hyporeflectance on IR imaging. The remaining five eyes with choroidal nevus lesions were not identified on MCI. CONCLUSION: The variable features of the choroidal nevus on MCI are most likely due to the variable melanin content within the nevus cells. Further studies are needed to validate these findings.

Retinal cafe-au-lait macules: A rare retinal finding in a patient with neurofibromatosis type 1.

We report the retinal and choroidal manifestations using multimodal imaging in a patient with Neurofibromatosis type 1 (NF-1). In this report, we describe the occurrence of a new retinal finding which we label as retinal café-au-lait macules. Also, we describe the superiority of multicolour imaging in comparison to colour fundus photography for identifying the retinal manifestations in NF-1.