Bacillary layer detachment with malignant choroidal tumors: a case series.

PURPOSE: To study the incidence and characteristics of bacillary layer detachment (BALAD) occurring with the two most common choroidal malignancies, choroidal metastasis and choroidal melanoma. METHODS: A retrospective multicentric record analysis. Eyes with a diagnosis of choroidal melanoma or choroidal metastasis that had good-quality fundus photography and spectral domain optical coherence tomography (OCT) scans of the macular and tumor regions allowing for delineation of the retinal layers were included for analysis. Qualitative image evaluation was done by two independent graders for the presence, location, and OCT features of BALAD, as well as any associated intraretinal or subretinal fluid. Demographic and clinical data were also retrieved. RESULTS: Of the 11 eyes with choroidal metastasis and 7 eyes with choroidal melanoma that were included in the final analysis, 6 (54.5%) and 1 (14.3%) had BALAD, respectively. The BALAD co-localized with the subretinal fluid in all cases and with the intraretinal fluid in 1/3 cases (33.3%), was foveal in location in 3 eyes (42.9%), was overlying the tumor in 6 eyes (85.7%), and varied in number and size. Reflectivity within the BALAD was consistently higher than the vitreous and adjacent subretinal fluid, and discernable suspended hyperreflective particles were noted in 5 eyes (71.4%). CONCLUSION: BALAD is relatively common with choroidal metastasis. The OCT features described supplement our recognition of this new entity.

Optical coherence tomography and electrophysiological analysis of proptotic eyes due to thyroid-associated ophthalmopathy.

PURPOSE: To study the degree of morphological and functional changes in thyroid-associated ophthalmology (TAO) patients using optical coherence tomography and electrophysiological studies and investigate their clinical correlation. METHODS: A cross-sectional study including 40 patients with TAO and a control group with age- and sex-matched healthy subjects. All subjects underwent a complete ophthalmological examination, proptosis evaluation, spectral domain optical coherence tomography, and electrophysiological tests (pattern and multifocal electroretinograms, and visual evoked potentials). RESULTS: On multiple regression analysis, the degree of proptosis and P50 amplitude were the most important predictors of central foveal thickness (CFT) (ß = - 0.56 and 0.39 and p = 0.03 and 0.01, respectively); while duration of the disease, and clinical activity score (CAS) were the most important predictors of average RNFL thickness (ß = 0.67 and - 0.81 and p = 0.004 and < 0.001, respectively). CONCLUSION: In the absence of fundus changes, macular thinning along with functional alterations noticed by pattern and multifocal electroretinogram could indicate presence of subclinical retinopathy in TAO cases.

Perfluorocarbon liquid-assisted vitreo-dissection in eyes with firmly adherent posterior hyaloid.

BACKGROUND: Induction of posterior vitreous detachment (PVD) is a critical step during pars plana vitrectomy. Multiple techniques and utilities have been proposed for assistance with this step with no consensus on the safest and most effective means, especially in eyes with firmly adherent posterior hyaloid. Viscodissection or the utilization of perfluorocarbon liquid (PFCL) can be used to dissect the posterior hyaloid and widely adherent epiretinal membranes. METHODS: A technique of PFCL dissection of the posterior hyaloid in eyes with abnormal adhesion of the posterior hyaloid. After core vitrectomy, breaking into the posterior hyaloid face is made via active aspiration and cutting or a sharp dissection. This is followed by active and slow injection of PFCL into the potential space between the posterior cortical vitreous and the neurosensory retina. A wave of PFCL propagates anteriorly causing "vitreo-dissection" of the peripheral cortical vitreous. RESULTS: The technique was effective and safe in 8 successive cases, 4 cases with vitreoretinal traction syndrome and 4 with diabetic tractional membranes. CONCLUSION: The technique can be considered in cases with abnormal firmly adherent posterior hyaloid when induction of PVD proves difficult.

Analysis of a two-year independent screening effort for retinopathy of prematurity in rural Egypt.

BACKGROUND: The third epidemic of retinopathy of prematurity (ROP) has majorly involved middle income countries in which tailored screening and local guidelines require development. The data regarding ROP prevalence and cutoff numbers for screening in Egypt are lacking. METHODS: Retrospective analysis of an independent screening effort spanning 2 years (February 2019 to February 2021) and involving 32 neonatal care units within Sharkia governorate, Egypt. Infants of gestational age (GA) ≤ 34 weeks and/or birth weight (BW) ≤ 2000 g were included, as well as those with unstable clinical course. Two eyecare centers located in Sharkia and Cairo governorates served as referral centers for any required interventions. RESULTS: Of the 276 screened infants, 133 (48.2%) had some form of ROP that was bilateral in 127 (95.5%) of them. Aggressive posterior ROP (AP-ROP) was detected in both eyes of 24 infants (8.7%). The median (IQR) GA of infants with ROP was 32 (30-34) weeks, and the median (IQR) BW was 1600 (1350-2000) g. Sixty-three infants (47.4%) required treatment. Of the total 84 eyes that primarily were treated, 73 (86.9%) received intravitreal ranibizumab, 8 (9.5%) underwent laser ablation therapy, and 3 eyes (3.6%) underwent surgery. Recurrence rate was 16.7% (14 eyes). Final outcome was favorable in 83 eyes (98.8%). Applying the American Academy criteria would have led to the missing of 36.8% of infants with ROP and 28.6% of those requiring treatment in our sample. CONCLUSION: The incidence of both ROP and AP-ROP in the Egyptian rural setting appears to be in the high end of global reported rates. Prevention measures should urgently be planned and implemented.

Financial and food security challenges of Egyptian women undergoing breast cancer treatment.

BACKGROUND: Breast cancer treatment is an established cause of financial toxicity, and associated costs may contribute to higher mortality and morbidity rates. In Egypt, breast cancer incidence and mortality rates are among the highest in the Middle East. Late-stage diagnosis is common, and disease occurs at an earlier age than in Europe and North America. Out-of-pocket payments are the primary means of financing healthcare in Egypt, and socioeconomic factors have been shown to significantly impact access to cancer screening and treatment. METHODS: An observational cross-sectional study was conducted among breast cancer patients at Ain Shams University Hospitals in Cairo from 2013 to 2015. RESULTS: One hundred women with breast cancer participated. There was a high need for financial assistance (66.0%) and patients with financial needs had great difficulty affording medications (80.0%). A number of patients had lost their jobs following diagnosis, with 32.7% employed prior to diagnosis and 15.3% afterwards. Nearly one-half of participants were classified as food insecure, and nearly one-third reported difficulty affording transportation costs. CONCLUSIONS: This is the first study to describe socioeconomic needs and financial impact among a cohort of Egyptian women undergoing breast cancer treatment. The findings highlight the financial impact of breast cancer treatment on a cohort of Egyptian breast cancer patients and the need for a multidisciplinary approach to help them access and mitigate the costs of treatment. Recommendations include implementing patient financial navigation services and producing printed materials to inform patients of resources to help mitigate the treatment's financial impact.

Embryologic and Fetal Development of the Human Eyelid.

PURPOSE: To review the recent data about eyelid morphogenesis, and outline a timeline for eyelid development from the very early stages during embryonic life till final maturation of the eyelid late in fetal life. METHODS: The authors extensively review major studies detailing human embryologic and fetal eyelid morphogenesis. These studies span almost a century and include some more recent cadaver studies. Numerous studies in the murine model have helped to better understand the molecular signals that govern eyelid embryogenesis. The authors summarize the current findings in molecular biology, and highlight the most significant studies in mice regarding the multiple and interacting signaling pathways involved in regulating normal eyelid morphogenesis. RESULTS: Eyelid morphogenesis involves a succession of subtle yet strictly regulated morphogenetic episodes of tissue folding, proliferation, contraction, and even migration, which may occur simultaneously or in succession. CONCLUSIONS: Understanding the extraordinary process of building eyelid tissue in embryonic life, and deciphering its underlying signaling machinery has far reaching clinical implications beyond understanding the developmental abnormalities involving the eyelids, and may pave the way for achieving scar-reducing therapies in adult mammalian wounds, or control the spread of malignancies.

Revisiting the Role of the Myofibroblast in Socket Surgery: An Immunohistochemical Study.

PURPOSE: To determine the impact of a single injection of various anti-inflammatory, antimitotic, and antiangiogenic agents on the cell count of myofibroblasts in an eviscerated socket. METHODS: One eye from 15 skeletally mature New Zealand white rabbits was eviscerated, and the rabbits were divided into 5 groups. Each group of 3 rabbits received a 0.1 ml subconjunctival injection of a different agent. Group I received bevacizumab 25 mg/ml, group II received triamcinolone 40 mg/ml, group III received 5-fluorouracil 50 mg/ml, group IV received mitomycin-C 0.4 mg/ml, while group V was the control group and received no injections. The animals were euthanized 19 days after evisceration and conjunctival samples were submitted for histopathological examination. Monoclonal α-smooth muscle actin antibody was applied, and the mean of 5 readings of the number of myofibroblasts was recorded in each slide. RESULTS: The mean count of myofibroblasts was highest for the control group and all groups achieved a statistically significant reduction in myofibroblast count compared with the control group. Sorting the means showed that Group IV (mitomycin-C) achieved the lowest mean value (p = 0.000006) followed by triamcinolone (p = 0.00048), while group I (bevacizumab) achieved the least reduction in myofibroblast count (p = 0.00148). CONCLUSION: Until newer antimyofibroblast medications and antibodies are commercially available, a single injection of mitomycin-C or triamcinolone during surgery achieves the highest mean reduction of myofibroblast count.

Congenital upper eyelid coloboma: embryologic, nomenclatorial, nosologic, etiologic, pathogenetic, epidemiologic, clinical, and management perspectives.

PURPOSE: To review the recent literature and describe the authors' experience with congenital upper eyelid coloboma. METHODS: In this review, we will summarize the embryologic and etiopathogenetic bases of congenital upper eyelid coloboma, and study the published clinical reports. We will also attempt to briefly shed some light on the rarer syndromic curiosities associated with upper eyelid coloboma. RESULTS: Congenital upper eyelid colobomas are one of the few nontraumatic oculoplastic emergencies that may occasionally present in the first few days of life with a corneal ulcer and may even present with impending perforation. They can present with or without corneopalpebral adhesions, may be isolated findings or a part of a larger spectrum of congenital anomalies as in the case of Fraser syndrome or Goldenhar syndrome, or could be associated with other rare curiosities that could challenge the clinician with a huge diagnostic dilemma. CONCLUSIONS: Existing literature dealing with congenital colobomas of the upper eyelid is fraught with nosologic problems, confusing etiologies, and overlapping clinical features. We attempted to clarify the salient clinical features, outline the management principles, and until a time in the not-so-distant future where advances in molecular genetic testing would help redefine the etiology and the diverse clinical spectrum of genetic diseases associated with upper eyelid colobomas, we propose a simplified classification scheme based on the relation of the coloboma to the cornea, the presence or absence of systemic features, and all the syndromic and nonsyndromic associations of congenital coloboma of the upper eyelid known today.

Autoimmune retinopathy associated with systemic autoimmune disease: a case series.

OBJECTIVE: To describe various presentations of autoimmune retinopathy (AIR) associated with systemic autoimmune diseases. DESIGN: Case series. PATIENTS AND METHODS: Four patients with systemic autoimmune disorders and AIR are described in this report. The clinical and multimodal imaging characteristics, systemic work-up, genetic testing results, management, and course of disease are detailed. RESULTS: The multimodal retinal features of 4 cases of AIR including the findings of fundus autofluorescence, optical coherence tomography, and electrophysiology necessary to document progressive photoreceptor loss are described. Each case of AIR was associated with a complicated autoimmune disorder. Case 1 was associated with chronic inflammatory demyelinating polyneuropathy and showed marked improvement with systemic steroid and intravenous immunoglobulin therapy. Case 2 was associated with rheumatoid arthritis, and the AIR condition progressed despite systemic immune therapy. Case 3 was associated with Lambert-Eaton myasthenic syndrome, and AIR developed 6 years later and stabilized with systemic immune therapy. Case 4 was associated with necrobiotic xanthogranuloma followed by AIR and was managed by systemic immune therapy. CONCLUSIONS: AIR in association with these systemic conditions is rarely reported. Our cases highlight the gaps in our current understanding of the definition, systemic associations, pathogenesis, and management of AIR and the importance of multimodal imaging and a multidisciplinary approach in managing patients with suspected AIR.

Prevalence and Distribution of Macular Fluid with Central Retinal Artery Occlusion and Anterior Ischemic Optic Neuropathy.

Purpose: To examine the prevalence and distribution of fluid within a cohort of eyes with acute central retinal artery occlusion (CRAO) and non-arteritic anterior ischemic optic neuropathy (AION) using optical coherence tomography (OCT). Methods: A retrospective analysis of patient records and OCT imaging. Patients presenting with acute CRAO or AION who had available macular OCT imaging and no co-morbidities known to cause macular fluid were included in the analysis. Baseline characteristics, visual acuity (VA), and fluid presence and distribution among the retinal layers were recorded. Results: In the 16 eyes with acute CRAO, fluid was noted in 5 eyes (31%), which was mainly subretinal (3 eyes) or intraretinal located within the outer retinal layers (3 eyes). Only one eye had inner retinal cysts. Of the 11 eyes with acute AION, fluid was present in 8 eyes (73%). Subretinal fluid was noted in 4 eyes and extended to the foveal area in 3 of them, and outer retinal versus inner retinal cysts were noted in 6 versus 3 eyes, respectively. None of the eyes showed hard exudate deposition. In the small subset of eyes with CRAO and macular fluid that were followed-up, VA improved, while in eyes with AION, VA remained stable. Conclusion: Macular fluid on OCT is not an uncommon feature of acute CRAO and AION and is mainly distributed within the outer retinal layers or subretinal space. Fluid is an understudied feature of retinal and optic nerve head infarction and may have a role in predicting neuronal damage extent and visual outcome.

Cystoid macular edema as a complication of central retinal artery occlusion.

Purpose: To describe the development of cystoid macular edema (CME) as a complication of central retinal artery occlusion (CRAO) in 2 cases. Observations: The first patient was a 51-year-old female who presented with acute loss of vision in the left eye. Multimodal retinal imaging revealed a CRAO with a perfused cilioretinal artery. CME acutely developed one week after presentation. Cystoid spaces predominantly involved the outer nuclear layer (ONL) on optical coherence tomography (OCT) and completely resolved in two weeks. The second case was a 50-year-old man who presented with acute vision loss in the right eye for 3 weeks. Multimodal retinal imaging illustrated an acute CRAO of the right eye. Four weeks later, visual acuity spontaneously improved to 20/20 and was maintained at 20/20 for more than 2 years. After 28 months, the patient returned with a recurrent drop of vision in the right eye. Cross sectional and en face OCT revealed CME in the right eye without leakage on FA. Cystoid spaces predominantly involved the inner nuclear layer (INL) and resolved with intravitreal anti-VEGF injection combined with carbonic anhydrase inhibitor (CAI) and steroid topical drop therapy. Conclusions and Importance: CME can rarely complicate both the acute and chronic phase of CRAO. In the acute phase, cystoid spaces were transient and confined to the ONL on OCT. While in the chronic phase, cystoid spaces were confined to the INL on OCT and angiographically silent on FA. Further studies are needed to identify the incidence, underlying pathophysiology and visual prognosis of CME in cases of CRAO.

Revisiting acute retinal pigment epitheliitis (Krill disease).

We reevaluate acute retinal pigment epitheliitis (ARPE) first described by Krill and Deutman in 1972, integrating a meticulous literature review with advanced multimodal imaging analyses. Our review included 98 eyes from 86 published cases diagnosed with ARPE. We scrutinized ARPE's clinical presentations, variability, and imaging characteristics, revealing that a large majority (90 %) of cases previously diagnosed as ARPE align more closely with other retinal disorders based on modern diagnostic criteria and imaging techniques. Only a small fraction (5 eyes) did not fit into any known categories, casting doubt on ARPE's distinct existence. This underscores the critical role of multimodal imaging in redefining our understanding of macular diseases and challenges the historical classification of ARPE as a unique clinical entity.

Visual outcomes and complications of combined versus sequential pars plana vitrectomy and phacoemulsification for epiretinal membrane.

BACKGROUND: Symptomatic epiretinal membrane (ERM) often requires surgical intervention via pars plana vitrectomy (PPV), for which cataract development is a common complication. There is insufficient data on the visual outcomes and complications of combined phacovitrectomy (COMB) in comparison to sequential PPV with deferred cataract surgery (SEQ) for ERM. METHODS: A retrospective dataset analysis of 8 National Health Service ophthalmology departments. The main outcome measures were postoperative visual acuity (VA), operative complications, postoperative cystoid macular oedema (CMO) and recurrent ERM. RESULTS: We included 898 and 299 eyes in the COMB and SEQ groups, respectively. Both procedures resulted in significantly better VA across all follow-up intervals (24 weeks). The proportion of eyes with Snellen VA of at least 20/40 at 12-24 weeks was comparable in both groups (47.8% [COMB] vs. 54.7% [SEQ], p = 0.4456). More eyes in the COMB group experienced posterior capsular rupture (2.9% vs. 0%, p = 0.0009) and iatrogenic retinal trauma (2.4% vs. 0%, p = 0.0023). However, regression analysis revealed that combined surgery did not predict either complication. There were no significant differences in the rates of CMO (6.5% [COMB] vs. 9% [SEQ], p = 0.1522) and recurrent ERM (2.1% [COMB] vs. 3.3% [SEQ], p = 0.2758) between both groups. CONCLUSION: Both combined and sequential procedures are comparably effective and safe means for managing eyes with ERM.

Pathogenesis of Central Serous Chorioretinopathy and the Link Between Choroidal Hyperpermeability and Retinal Pigment Epithelium Pump Reversal.

PURPOSE: To describe 6 cases of acute central serous chorioretinopathy (CSCR) and the response to laser treatment, focusing on the underlying pathogenic mechanism. METHODS: Multimodal imaging from 6 eyes of 6 patients with acute and recurrent CSCR were reviewed, including fundus autofluorescence (FAF), fluorescein angiography (FA), indocyanine green angiography (ICGA), and optical coherence tomography (OCT) at baseline and after laser therapy. RESULTS: In 3 of the 6 cases with acute CSCR, the hyporeflective lucency sign was identified with cross-sectional and en face OCT and co-localized with an intense active inkblot retinal pigment epithelium (RPE) leak on FA. The development of this sign was suggestive of active leakage into the subretinal space displacing overlying subretinal hyperreflective material (SHRM) and suggestive of a reversal of RPE pump function. All 6 cases were treated with focal laser to directly target the intense leakage points with remarkable resolution of the fluid due to destruction of the RPE cells mediating reversal of pump function. CONCLUSIONS: Unlike chronic CSCR in which degenerative changes of the RPE lead to oozing of fluid into the subretinal space, in acute forms of CSCR including bullous CSCR, there are focal leaks of the RPE that actively drive fluid into the subretinal space suggestive of RPE pump reversal. We propose that pachychoroid disease causes increased hydrostatic pressure and increased resistance to the RPE pump, thereby triggering a reversal in pump function. Understanding this concept can have therapeutic implications.

Retinal Ischemic Perivascular Lesions Are Associated With Myocardial Infarction in Patients With Coronary Artery Disease.

PURPOSE: To evaluate the association of retinal ischemic perivascular lesions (RIPLs) with myocardial infarction (MI) among patients diagnosed with coronary artery diseases (CAD). DESIGN: Retrospective cross-sectional study. METHODS: Consecutive patients (317 patients) with CAD who underwent macular spectral domain optical coherence tomography (SD-OCT) were captured. Patients with CAD who developed MI were compared to those without MI. SD-OCT were reviewed by 2 independent and masked graders for the presence of RIPLs. Medical records were reviewed. Multivariate logistic regression analysis was used to evaluate the relationship between RIPLs and MI including the following covariates age, gender, smoking status, hypertension, diabetes, dyslipidemia and body mass index. RESULTS: Of 317 patients with CAD for whom OCT scans were available to study, there were 54 (17%) with a history of MI. A higher prevalence of RIPLs was observed in the MI group compared to the non-MI group (59.3% vs 35.7%; P < .001). The presence of RIPLs was significantly associated with MI with an odds ratio of 3 (1.91-4.74; P < .001), after adjusting for age, gender, smoking status, hypertension, diabetes, dyslipidemia, and body mass index. CONCLUSIONS: The presence of RIPLs, detected with SD-OCT, is significantly associated with MI in patients with CAD. These findings underscore the potential clinical utility of incorporating RIPL evaluation in the medical management of CAD.

BILATERAL CHOROIDAL METASTASIS WITH CONCURRENT UNILATERAL RHEGMATOGENOUS RETINAL DETACHMENT IN A PATIENT WITH STAGE IV BREAST CANCER.

PURPOSE: To describe an unusual case of bilateral choroidal metastasis with simultaneous rhegmatogenous retinal detachment in the right eye. METHODS: Case Report. PATIENT: A 65-year-old woman with Stage IV breast cancer and gradual deterioration of vision in the right eye. RESULTS: Dilated fundus examination of the right eye revealed a large solitary choroidal mass with exudative retinal detachment and with an incidental discovery of a lower peripheral break with subretinal fluid, and the left eye revealed multiple choroidal masses. The diagnosis of bilateral CM was confirmed using optical coherence tomography. Pars plana vitrectomy with silicone oil injection was performed for the right eye followed by external beam radiotherapy to both choroids, which resulted in anatomical and visual success for 6 months. CONCLUSION: Prompt ophthalmologic evaluation is a must in patients with advanced breast or lung malignancy with recent blurring of vision. External beam radiotherapy is a safe, available, relatively cheap, and effective means for managing CM. Choroidal metastasis with a concurrent vision-threatening pathology requiring intraocular surgery represents a dilemma, and the risks and benefits should be weighed carefully with proper counseling of the patient.

Bilateral macular retinitis in patients with presumed rift valley fever from Sudan: A case series.

BACKGROUND: Epidemic retinitis occurs seasonally following febrile infections in endemic regions. Rift valley fever (RVF) is endemic to Sudan, with a recent outbreak starting in 2019. METHODS: Retrospective case series of 3 patients travelling from Sudan with post-febrile retinitis, and with a history and clinical picture suggestive of RVF retinitis. RESULTS: The three patients were adult males with underlying medical conditions and underwent fundus fluorescein angiography that confirmed bilateral retinitis and occlusive vasculitis involving the posterior pole. Optical coherence tomography showed distortion of the macular layers. Case 2 presented 1 month following febrile illness and had retinal thinning, with optical coherence tomography angiography showing marked reduction in vessel density. CONCLUSION: We present multimodal imaging data of three cases with presumed RVF retinitis from a recent outbreak in Sudan. The unavailability of standardized methods of testing for RVF, as is the case for most epidemic retinitis-causing pathogens, makes the diagnosis challenging.