DIRECTIONAL OPTICAL COHERENCE TOMOGRAPHY IMAGING OF MACULAR PATHOLOGY.

PURPOSE: To survey the impact of directional reflectivity on structures within optical coherence tomography images in retinal pathology. METHODS: Sets of commercial optical coherence tomography images taken from multiple pupil positions were analyzed. These directional optical coherence tomography sets revealed directionally reflective structures within the retina. After ensuring sufficient image quality, resulting hybrid and composite images were characterized by assessing the Henle fiber layer, outer nuclear layer, ellipsoid zone, and interdigitation zone. Additionally, hybrid images were reviewed for novel directionally reflective pathological features. RESULTS: Cross-sectional directional optical coherence tomography image sets were obtained in 75 eyes of 58 patients having a broad range of retinal pathologies. All cases showed improved visualization of the outer nuclear layer/Henle fiber layer interface, and outer nuclear layer thinning was, therefore, more apparent in several cases. The ellipsoid zone and interdigitation zone also demonstrated attenuation where a geometric impact of underlying pathology affected their orientation. Misdirected photoreceptors were also noted as a consistent direction-dependent change in ellipsoid zone reflectivity between regions of normal and absent ellipsoid zone. CONCLUSION: Directional optical coherence tomography enhances the understanding of retinal anatomy and pathology. This optical contrast yields more accurate identification of retinal structures and possible imaging biomarkers for photoreceptor-related pathology.

CLINICAL AND STRUCTURAL IMPACT OF SUBMACULAR FLUID AFTER PNEUMATIC RETINOPEXY REPAIR FOR RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: To assess the impact of submacular fluid (SMF) after pneumatic retinopexy for primary rhegmatogenous retinal detachment repair. METHODS: Retrospective review of consecutive patients treated with pneumatic retinopexy for primary rhegmatogenous retinal detachment repair. 387 eyes (374 patients) were included, of which 166 underwent optical coherence tomography imaging after successful pneumatic retinopexy. Foveal-centered optical coherence tomography scans were reviewed. RESULTS: SMF occurred in 59 eyes (35.5%) and was associated with macular detachment ( P ≤ 0.001) and phakic lens status ( P = 0.007). Submacular fluid resolved over an average of 9.39 months and was associated with worse preprocedure best-corrected visual acuity and delayed visual recovery. The mean final best-corrected visual acuity was 0.277 logarithm of the minimum angle of resolution (20/40) in eyes with SMF and 0.162 logarithm of the minimum angle of resolution (20/30) in those without SMF ( P < 0.001). Submacular fluid was associated with discontinuity of the interdigitation zone ( P = 0.003), ellipsoid zone ( P = 0.005), and external limiting membrane ( P ≤ 0.001) after SMF resolution. Ellipsoid zone discontinuity was associated with worse visual prognosis ( P = 0.009). CONCLUSION: Trace SMF detected by optical coherence tomography is common after successful pneumatic retinopexy and resulted in delayed visual recovery and increased rates of outer retinal discontinuity after SMF resorption, although the final difference in best-corrected visual acuity in those with and without SMF was minimal.

Developmental Dysplasia of the Hip: An Audit of the Ultrasound Screening Programme.

Aims Developmental dysplasia of the hip (DDH) is an important cause of disability in children and young adults. Early diagnosis and treatment can help avoid more invasive interventions and long-term morbidity. This study examines the ultrasound screening programme conducted in University Hospital Waterford (UHW), and the outcomes for infants with DDH in the Southeast of Ireland. Methods We conducted an audit of all the DDH screening ultrasounds performed in UHW in the year 2020, a total of 992 infants. Data included referral and ultrasound times, screening results, interventions, and outcomes. Results Of those screened, 255 (26%) were referred to the Orthopaedic clinic, with a significant female majority of nearly 3:1. At the time of writing, only two infants were ultimately referred for further management of persistent DDH, the rest being successfully treated by less invasive interventions such as harnessing and bracing. There were no babies scanned within the recommended 6 weeks who later presented with a dislocated hip or required tertiary referral for DDH management. Conclusion The ultrasound screening programme in UHW is shown to be successful in the prompt diagnosis and early treatment of DDH. This plays a significant role in avoiding the lifelong disabling outcomes of untreated DDH, and the invasive surgical procedures required in the management of late-stage disease.

Incidence of acute complications of herpes zoster among immunocompetent adults in England: a matched cohort study using routine health data.

BACKGROUND: Herpes zoster can cause rare but serious complications; the frequency of these complications has not been well described. OBJECTIVES: To quantify the risks of acute non-postherpetic neuralgia (PHN) zoster complications, to inform vaccination policy. METHODS: We conducted a cohort study among unvaccinated immunocompetent adults with incident zoster, and age-, sex- and practice-matched control adults without zoster, using routinely collected health data from the UK Clinical Practice Research Datalink (years 2001 to 2018). Crude attributable risks of complications were estimated as the difference between Kaplan-Meier-estimated 3-month cumulative incidences in patients with zoster vs. controls. We used Cox models to obtain hazard ratios for our primary outcomes in patients with and without zoster. Primary outcomes were ocular, neurological, cutaneous, visceral and zoster-specific complications. We also assessed whether antivirals during acute zoster protected against the complications. RESULTS: In total 178 964 incident cases of zoster and 1 799 380 controls were included. The absolute risks of zoster-specific complications within 3 months of zoster diagnosis were 0·37% [95% confidence interval (CI) 0·34-0·39] for Ramsay Hunt syndrome, 0·01% (95% CI 0·0-0·01) for disseminated zoster, 0·04% (95% CI 0·03-0·05) for zoster death and 0·97% (95% CI 0·92-1·00) for zoster hospitalization. For other complications, attributable risks were 0·48% (95% CI 0·44-0·51) for neurological complications, 1·33% (95% CI 1·28-1·39) for ocular complications, 0·29% (95% CI 0·26-0·32) for cutaneous complications and 0·78% (95% CI 0·73-0·84) for visceral complications. Attributable risks were higher among patients > 50 years old. Patients with zoster had raised risks of all primary outcomes relative to controls. Antiviral prescription was associated with reduced risk of neurological complications (hazard ratio 0·61, 95% CI 0·53-0·70). CONCLUSIONS: Non-PHN complications of zoster were relatively common, which may affect cost-effectiveness calculations for zoster vaccination. Clinicians should be aware that zoster can lead to various complications, besides PHN.

FINGERPRINT SIGN OF THE HENLE FIBER LAYER.

PURPOSE: To describe the appearance of concentric, fingerprint-like waves within the Henle fiber layer (HFL) using en face optical coherence tomography in patients with tractional pathologies of the retina. METHODS: Retrospective analysis of six eyes of six patients imaged by optical coherence tomography with volumetric slabs positioned at the level of the HFL. RESULTS: Optical coherence tomography data from six patients with tractional vitreoretinal pathology were reviewed. Concentric, fingerprint-like microwaves were visualized through en face optical coherence tomography in all six study eyes at the level of the HFL. This finding resembled the finding of HFL waves previously noted histopathologically from force exerted on this layer. CONCLUSION: In retinal pathologies in which specific physical forces act on the retina, volumetric optical coherence tomography may permit visualization of en face concentric, fingerprint-like hyperreflective rings within the HFL. This "fingerprint sign" may represent a biomechanical consequence of traction on the retina and allow clinical decision making based on improved recognition of the existence of such traction.

Phylogeny, Macroevolutionary Trends and Historical Biogeography of Sloths: Insights From a Bayesian Morphological Clock Analysis.

Sloths, like other xenarthrans, are an extremely interesting group of mammals that, after a long history of evolution and diversification in South America, became established on islands in the Caribbean and later reached North America during the Great American Biotic Interchange. In all three regions, they were part of the impressive Pleistocene megafauna. Most taxa became extinct and only two small, distantly related tree-dwelling genera survived. Here, we incorporate several recently described genera of sloths into an assembled morphological data supermatrix and apply Bayesian inference, using phylogenetic and morphological clock methods, to 64 sloth genera. Thus, we investigate the evolution of the group in terms of the timing of divergence of different lineages and their diversity, morphological disparity and biogeographical history. The phylogeny obtained supports the existence of the commonly recognized clades for the group. Our results provide divergence time estimates for the major clades within Folivora that could not be dated with molecular methods. Lineage diversity shows an early increase, reaching a peak in the Early Miocene followed by a major drop at the end of the Santacrucian (Early Miocene). A second peak in the Late Miocene was also followed by a major drop at the end of the Huayquerian (Late Miocene). Both events show differential impact at the family level. After that, a slight Plio-Pleistocene decline was observed before the marked drop with the extinction at the end of the Pleistocene. Phenotypic evolutionary rates were high during the early history of the clade, mainly associated with Mylodontidae, but rapidly decreased to lower values around 25 Ma, whereas Megalonychidae had lower rates at the beginning followed by a steady increase, peaking during the Late Miocene and the Pliocene. Morphological disparity showed a similar trend, with an early increase, followed by a slowly increasing phase through the Late Oligocene and Early Miocene, and ending with another increase beginning at the middle of the Miocene. Biogeographic analysis showed southern South America as the most probable area of origin of the clade and the main region in which the early diversification events took place. Both Megatheriinae and Nothrotheriinae basal nodes were strongly correlated with Andean uplift events, whereas the early history of Mylodontidae is closely associated with southern South America and also shows an early occupation of the northern regions. Within Megalonychidae, our results show Choloepus as a descendant of an island dispersing ancestor and a probable re-ingression to South America by a clade that originated in Central or North America.

Health inequalities in timely antenatal care: audit of pre- and post-referral delays in antenatal bookings in London 2015-16.

BACKGROUND: Antenatal booking has potential to reduce infant and maternal health inequalities; yet, those most in need are least likely to access timely care. This audit describes late referral and antenatal booking across London in 2015-16, according to maternal characteristics. METHODS: Referral < 8 weeks' gestation, booking < 2 weeks after referral and booking < 10 weeks' gestation were audited against maternal and referral characteristics. RESULTS: Of 122 275 antenatal bookings, 27.1% were before 10 weeks' gestation and 72.8% by 12 + 6 weeks. Characteristics associated with late booking were living in more deprived areas, age < 20 years, higher parity, Black or Minority ethnicity (particularly Bangladeshi or Black African), birth in Somalia, Jewish religion, first language other than English, unemployment of self or partner, lack of social support, or single parent families. Women living in more deprived areas, with first language other than English, of Jewish religion, Black and Minority ethnicity or who were unemployed, waited longer from referral to booking, despite later referral. CONCLUSIONS: Post-referral delays can compound late referral for some women, exacerbating health inequalities, but should be amenable to provider interventions. Different patterns of pre- and post-referral delay suggest that a tailored approach is needed to address inequalities in access to antenatal care.

Species-specific responses of Late Quaternary megafauna to climate and humans.

Despite decades of research, the roles of climate and humans in driving the dramatic extinctions of large-bodied mammals during the Late Quaternary period remain contentious. Here we use ancient DNA, species distribution models and the human fossil record to elucidate how climate and humans shaped the demographic history of woolly rhinoceros, woolly mammoth, wild horse, reindeer, bison and musk ox. We show that climate has been a major driver of population change over the past 50,000 years. However, each species responds differently to the effects of climatic shifts, habitat redistribution and human encroachment. Although climate change alone can explain the extinction of some species, such as Eurasian musk ox and woolly rhinoceros, a combination of climatic and anthropogenic effects appears to be responsible for the extinction of others, including Eurasian steppe bison and wild horse. We find no genetic signature or any distinctive range dynamics distinguishing extinct from surviving species, emphasizing the challenges associated with predicting future responses of extant mammals to climate and human-mediated habitat change.

American mastodon extirpation in the Arctic and Subarctic predates human colonization and terminal Pleistocene climate change.

Existing radiocarbon ((14)C) dates on American mastodon (Mammut americanum) fossils from eastern Beringia (Alaska and Yukon) have been interpreted as evidence they inhabited the Arctic and Subarctic during Pleistocene full-glacial times (∼ 18,000 (14)C years B.P.). However, this chronology is inconsistent with inferred habitat preferences of mastodons and correlative paleoecological evidence. To establish a last appearance date (LAD) for M. americanum regionally, we obtained 53 new (14)C dates on 36 fossils, including specimens with previously published dates. Using collagen ultrafiltration and single amino acid (hydroxyproline) methods, these specimens consistently date to beyond or near the ∼ 50,000 y B.P. limit of (14)C dating. Some erroneously "young" (14)C dates are due to contamination by exogenous carbon from natural sources and conservation treatments used in museums. We suggest mastodons inhabited the high latitudes only during warm intervals, particularly the Last Interglacial [Marine Isotope Stage (MIS) 5] when boreal forests existed regionally. Our (14)C dataset suggests that mastodons were extirpated from eastern Beringia during the MIS 4 glacial interval (∼ 75,000 y ago), following the ecological shift from boreal forest to steppe tundra. Mastodons thereafter became restricted to areas south of the continental ice sheets, where they suffered complete extinction ∼ 10,000 (14)C years B.P. Mastodons were already absent from eastern Beringia several tens of millennia before the first humans crossed the Bering Isthmus or the onset of climate changes during the terminal Pleistocene. Local extirpations of mastodons and other megafaunal populations in eastern Beringia were asynchrononous and independent of their final extinction south of the continental ice sheets.

New estimates of the burden of acute community-acquired infections among older people with diabetes mellitus: a retrospective cohort study using linked electronic health records.

AIM: To describe the incidence of acute community-acquired infections (lower respiratory tract infections, urinary tract infections and sepsis) among the UK population aged ≥65 years with diabetes mellitus, and all-cause 28-day hospital admission rates and mortality. METHODS: We used electronic primary care records from the Clinical Practice Research Datalink, linked to death certificates and Hospital Episode Statistics admission data, to conduct a retrospective cohort study from 1997 to 2011. RESULTS: Among the 218 805 older people with diabetes there was a high burden of community-acquired infection, lower respiratory tract infections having the highest incidence (crude rate: 152.7/1000 person-years) followed by urinary tract infections (crude rates 51.4 and 147.9/1000 person-years for men and women, respectively). The incidence of all infections increased over time, which appeared to be driven by the population's changing age structure. Most patients diagnosed with pneumonia and sepsis were hospitalized on the same day (77.8 and 75.1%, respectively). For lower respiratory tract infections and urinary tract infections, a large proportion of 28-day hospitalizations were after the day of diagnosis (39.1 and 44.3%, respectively), and a notable proportion of patients (7.1 and 5.1%, respectively) were admitted for a cardiovascular condition. In the 4 weeks after onset, all-cause mortality was 32.1% for pneumonia (3115/9697), 31.7% for sepsis (780/2461), 4.1% for lower respiratory tract infections (5685/139 301) and 1.6% for urinary tract infections (1472/91 574). CONCLUSIONS: The present large cohort study provides up-to-date detailed infection incidence estimates among older people with diabetes in the community, with variation by age, sex and region and over time. This should be of use for patient communication of risk and future healthcare planning.

Sensitivity of fluid detection in patients with neovascular amd using spectral domain optical coherence tomography high-definition line scans.

PURPOSE: To determine the sensitivity of the Cirrus high-definition (HD) 5-line raster scans for detecting retinal fluid in neovascular age-related macular degeneration when using the spectral domain optical coherence tomography macular cubes as a gold standard. METHODS: Patients were retrospectively identified from their initial follow-up visit after being newly diagnosed with neovascular age-related macular degeneration in at least one eye. Patients were imaged with Cirrus spectral domain optical coherence tomography using the 512 × 128 macular cube scan and HD 5-line raster scan settings. Patients with other diseases that cause subretinal or intraretinal fluid, or who had an epiretinal membrane causing macular traction were excluded from the analysis. We recorded the presence or absence of subretinal or intraretinal fluid in the macular cube and on the HD 5-line raster scans. RESULTS: Seventy-nine patients met the study requirements. Of the 63 patients who had fluid present on the macular cube, 1 did not seem to have fluid on the HD 5-line raster scans. Taking the macular cube as a gold standard, the sensitivity of the HD 5-line raster scans for detecting retinal fluid in this cohort was 98.4%. CONCLUSION: The Cirrus HD 5-line raster scans have a high sensitivity for detecting fluid in the macular cube in patients with neovascular age-related macular degeneration.

En face spectral domain optical coherence tomography analysis of lamellar macular holes.

PURPOSE: To analyze the anatomical characteristics of lamellar macular holes using cross-sectional and en face spectral domain optical coherence tomography. METHODS: Forty-two lamellar macular holes were retrospectively identified for analysis. The location, cross-sectional length, and area of lamellar holes were measured using B-scans and en face imaging. The presence of photoreceptor inner segment/outer segment disruption and the presence or absence of epiretinal membrane formation were recorded. RESULTS: Forty-two lamellar macular holes were identified. Intraretinal splitting occurred within the outer plexiform layer in 97.6% of eyes. The area of intraretinal splitting in lamellar holes did not correlate with visual acuity. Eyes with inner segment/outer segment disruption had significantly worse mean logMAR visual acuity (0.363 ± 0.169; Snellen = 20/46) than in eyes without inner segment/outer segment disruption (0.203 ± 0.124; Snellen = 20/32) (analysis of variance, P = 0.004). Epiretinal membrane was present in 34 of 42 eyes (81.0%). CONCLUSION: En face imaging allowed for consistent detection and quantification of intraretinal splitting within the outer plexiform layer in patients with lamellar macular holes, supporting the notion that an area of anatomical weakness exists within Henle's fiber layer, presumably at the synaptic connection of these fibers within the outer plexiform layer. However, the en face area of intraretinal splitting did not correlate with visual acuity, disruption of the inner segment/outer segment junction was associated with significantly worse visual acuity in patients with lamellar macular holes.

Multifocal Vitelliform Paravascular Retinopathy (MVPR): A New Disorder in the Vitelliform Spectrum.

PURPOSE: To describe a new retinal phenotype characterized by bilateral, multifocal, subretinal vitelliform lesions along the vascular arcades that we refer to as multifocal vitelliform paravascular retinopathy (MVPR). DESIGN: Observational case series. METHODS: Multimodal retinal imaging including color fundus photography, fundus autofluorescence and cross sectional and en-face optical coherence tomography was performed to evaluate and characterize the lesions of MVPR. RESULTS: Thirteen asymptomatic patients aged 10 to 78 [mean 49±24, 49% under 50] were evaluated for bilateral retinal lesions. Initial visual acuity was 20/30 or better in 22 (85%) eyes. Of the 20 eyes with follow-up, 14 (70%) exhibited visual acuity 20/30 or better at final follow-up. Multifocal small round yellow lesions with distinct borders were identified along the vascular arcades in all patients. The vitelliform lesions were brightly hyperautofluorescent and consisted of focal areas of subretinal hyperreflective material on optical coherence tomography (OCT) that in some cases evolved to hyporeflective spaces (or retinal pigment epithelium atrophy) with associated hypoautofluorescence. When performed, electroretinography (ERG) and electrooculography (EOG) testing were normal and genetic testing was negative for variants in BEST1 and other genes associated with vitelliform retinopathies. CONCLUSIONS: MVPR may represent a novel entity of vitelliform disorders with a distinct clinical presentation and phenotype and generally favorable prognosis.

Emerging concepts in the management of acute retinal necrosis.

Acute retinal necrosis (ARN), also known as Kirisawa-type uveitis, is an uncommon condition caused by infection of the retina by one of the herpes family of viruses, most typically varicella zoster virus or herpes simplex virus and less commonly cytomegalovirus. Clinical diagnosis can be challenging and is often aided by PCR-based analysis of ocular fluids. Treatment typically involves extended use of one or more antiviral agents. Long term retinal detachment risk is high. We review the literature on ARN and present an approach to the diagnosis and management of this serious condition.

FULL-THICKNESS MACULAR HOLE FORMATION FOLLOWING PANRETINAL PHOTOCOAGULATION FOR PROLIFERATIVE DIABETIC RETINOPATHY.

PURPOSE: To report two patients who developed full-thickness macular holes following panretinal photocoagulation for proliferative diabetic retinopathy. METHODS: Case series. RESULTS: Case 1 was a 58-year-old woman with Type 1 diabetes mellitus and proliferative diabetic retinopathy and Case 2, a 72-year-old man with Type 2 diabetes mellitus and proliferative diabetic retinopathy. Before panretinal photocoagulation, each patient had an epiretinal membrane and an irregular foveal contour noted on optical coherence tomography. At 2 months follow-up, each patient showed foveal floor thinning and Case 2 also had a lamellar macular hole. At 6 months follow-up, each patient had a full-thickness macular hole. Each were successfully repaired with vitrectomy, membrane peeling, and gas tamponade. CONCLUSION: The relationship between hole formation and previous panretinal photocoagulation in the patients reported here is unclear and possibly coincidental.

A 66-year-old woman with two weeks of distorted vision in the left eye.

PURPOSE: To report a case of concurrent melanoma metastasis to the orbit and MEK inhibitor-associated retinopathy. METHODS: Case report of a 66-year-old female patient undergoing mutation targeted MEK-inhibitor treatment for metastatic melanoma with retinal manifestations. RESULTS: After initiating MEK-inhibitor therapy our patient presented with bilateral blurred vision. Clinical examination and OCT imaging revealed multifocal bilateral serous retinal detachments consistent with MEKAR. Extrafoveal subretinal fluid foci resolved after discontinuation of MEK-inhibitor therapy, but her foveal lesions persisted for over 18 months. Years after her initial evaluation for MEKAR, our patient developed metamorphopsia in the left eye resulting from chorioretinal folds secondary to intraconal orbital metastasis. MRI revealed additional intracerebral and lung metastases, and the patient expired in 2 months. CONCLUSION: We report a case of prolonged MEKAR with concomitant orbital metastasis from melanoma. Multimodal imaging in conjunction with history and clinical features allows for disease identification and monitoring.

PURTSCHER-LIKE RETINOPATHY IN A PATIENT WITH MILK-ALKALI SYNDROME AND PANCREATITIS.

PURPOSE: To report a case of Purtscher-like retinopathy in a patient with milk-alkali syndrome and pancreatitis. METHODS: Case report and review of the literature. RESULTS: A 46-year-old woman presented with decreased vision following discharge from the intensive care unit, where she had been admitted for milk-alkali syndrome secondary to long-term calcium supplementation and over-the-counter antacid use, and pancreatitis. Dilated examination showed ischemic retinal whitening and retinal hemorrhages in the posterior pole bilaterally consistent with Purtscher-like retinopathy. Over three months, the retinopathy resolved and her vision improved. CONCLUSION: Milk-alkali syndrome is the clinical triad of hypercalcemia, renal failure, and metabolic alkalosis and occurs secondary to the consumption of large amounts of calcium and alkali. The hypercalcemia associated with milk-alkali syndrome may cause pancreatitis, which can lead to Purtscher-like retinopathy.

NIVOLUMAB-INDUCED HARADA-LIKE UVEITIS WITH BACILLARY DETACHMENT MIMICKING CHOROIDAL METASTASIS.

PURPOSE: To describe a patient with metastatic clear cell renal cell carcinoma in remission on maintenance nivolumab therapy who developed late-onset ocular toxicity manifesting as creamy chorioretinal lesions with exudative retinal detachment concerning for choroidal metastasis. METHOD: Case report. Main outcome measures include ophthalmoscopic examination, fundus photography, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, spectral domain optical coherence tomography, and B-scan ultrasonography. RESULTS: A 49-year-old woman with a medical history of metastatic clear cell renal cell carcinoma in remission for two years after immunotherapy with four cycles of ipilimumab and nivolumab followed by maintenance nivolumab infusions developed lesions concerning for choroidal metastases in her right eye. Optical coherence tomography of the lesions revealed a bacillary layer detachment containing possible fibrinous exudate organized into layers and underlying choroidal thickening with chorioretinal folds. Later, choroidal thickening and chorioretinal folds also occurred in the left eye. Given that pan imaging detected no metastasis and the posterior segment abnormalities resolved after cessation of nivolumab and treatment with systemic corticosteroids, the patient was diagnosed with nivolumab-induced Vogt-Koyanagi-Harada-like uveitis. CONCLUSION: This case expands on the clinical spectrum of nivolumab-induced Vogt-Koyanagi-Harada-like uveitis, a condition that can also present with bacillary layer detachment mimicking an early choroidal metastasis, manifest asymmetrically in each eye, and develop after long-standing treatment.

BARTONELLA HENSELAE -ASSOCIATED OPTIC NEUROPATHY PRESENTING AS A CENTRAL SCOTOMA IN THE ABSENCE OF OVERT PAPILLITIS: A MULTIMODAL IMAGING STUDY.

BACKGROUND/PURPOSE: The purpose of this report was to describe the use of multimodal imaging to establish the diagnosis of Bartonella henselae -associated optic neuropathy in a patient who presented with a central scotoma without overt evidence of optic nerve involvement. METHODS: This was a case report. Main outcome measures included clinical, optical coherence tomography, and fluorescein angiography findings. OBSERVATIONS: A 72-year-old woman presented with a 3-day history of central scotoma in the left eye. Her examination was remarkable for faint exudation in the nasal macula of the left eye but was otherwise normal for her age. Spectral domain optical coherence tomography of the macula revealed mild thickening of the papillomacular bundle with scattered small cystoid spaces and several intraretinal exudates, none of which were visible clinically. Fluorescein angiography revealed localized leakage of the inferotemporal optic disc. When prompted, the patient recalled being scratched multiple times by her two pet kittens. Serial testing showed rising anti- B. henselae ( B. henselae ) immunoglobulin G antibody titers to 1:1,280, confirming the suspected diagnosis of B. henselae -associated optic neuropathy. CONCLUSION: Bartonella -associated optic nerve involvement can occur without overt evidence of optic disc swelling. Multimodal imaging can be used to suggest the diagnosis and support appropriate serologic testing.