Early features in acute macular neuroretinopathy.

Acute macular neuroretinopathy (AMNR) is a rare disorder characterised by acute onset of unilateral or bilateral visual impairment associated with reddish-brown wedge-shaped outer macular lesions. It is more frequently reported in young females and though the pathophysiology remains unclear, factors reported in association with its onset include post-viral illness and vasoconstrictor use. We report a case of AMNR in an 18-year old female patient presenting with a 2-day history of acute painless blurring of central vision bilaterally, following 1 month of preceding flu-like illness. For 1 week prior to presentation, the patient had taken large doses of oral preparations containing phenylephrine hydrochloride. In addition to demonstrating characteristic optical coherence tomography findings seen in AMNR, we illustrate some rarely seen acute ophthalmoscopic features. Based on associations from this case, we add further insight into the pathophysiology of this condition which remains poorly understood.

Eyelid necrotizing fasciitis: what were the early signs?

BACKGROUND: Necrotizing fasciitis is a rare, life-threatening subcutaneous soft tissue infection that causes massive tissue destruction. OBJECTIVES: To illustrate the warning signs of this condition by reporting a rare case of eyelid necrotizing fasciitis. CASE REPORT: A previously healthy 22-year-old man presented with a preseptal eyelid infection that spread rapidly despite prompt treatment with several intravenous antibiotics. He developed the characteristic clinical and radiologic features of necrotizing fasciitis, and required surgical debridement to cure the infection. Histology confirmed the diagnosis. CONCLUSION: In this article, we suggest the indicators that may enable physicians to think of the development of necrotizing fasciitis in patients with infections of the skin and subcutis.

Bilateral foveal cysts secondary to Streptococcus constellatus endocarditis.

Infective endocarditis can be acute or subacute, depending on the virulence of the causative organism. It can also cause loss of vision by a variety of mechanisms, ranging from embolic retinal artery occlusion to endogenous endophthalmitis. We illustrate the first report of foveal cyst formation secondary to infective endocarditis. A 53-year-old man presented to his general practitioner with a variety of constitutional symptoms, but initial laboratory and imaging investigations revealed only mild normocytic anaemia, and he was discharged from further medical care. Four weeks later he developed bilateral visual loss associated with whitish lesions of the superficial retina at both foveae. These later developed into foveal cysts with disruption of the photoreceptor inner segment-outer segment junction and persistent poor visual acuity of 6/60 OU. No retinal haemorrhages or Roth spots were noted. Only after he presented with visual loss did further investigations reveal the underlying diagnosis of streptococcal endocarditis. Ophthalmologists assessing retinal pathology which presents in association with undiagnosed constitutional symptoms are advised to refer such patients promptly for thorough medical investigation, including blood culture and echocardiography where appropriate.

Hypothyroid cardiomyopathy due to hypopituitarism: a diagnostic dilemma.

A case of hypothyroid cardiomyopathy secondary to hypopituitarism posed a diagnostic challenge. This lesson describes the patient's presentation with simultaneous acute heart failure and neurological signs; the investigations and imaging findings which initially suggested myocardial infarction (MI) and/or infiltration; and the response to treatment, with biochemical, sonographic and clinical resolution of the cardiomyopathy following thyroxine replacement therapy. This lesson illustrates the cardiovascular sequelae of severe hypothyroidism, and physicians are reminded of the difficulties involved in investigating putative coronary events in hypothyroid patients, since hypothyroidism itself may mimic MI.

The pattern and distribution of retinal breaks in eyes with rhegmatogenous retinal detachment.

PURPOSE: To identify which presenting features of rhegmatogenous retinal detachment (RRD) suggest the presence of multiple retinal breaks and to ascertain relevant patterns in retinal break location. DESIGN: Observational single-center case series. METHODS: We collected data from 851 eyes undergoing surgery for RRD between January 2001 and September 2011. Data recorded included patient demographics; extent of RRD; and the size, location, and number of retinal breaks. Statistical regression was used to identify risk factors for the presence of multiple breaks and to analyze patterns in break location. RESULTS: Of 851 patients, 7 patients were excluded because of insufficient data. Of 844 patients analyzed, 60% were male. The mean age was 62 years. Three hundred twenty-eight eyes (38.9%) had solitary breaks, whereas 58.8% had breaks in more than 1 quadrant. The superotemporal (ST) quadrant was involved most frequently (582 eyes; 69%). The superonasal and inferotemporal quadrants were involved in 341 (40%) and 274 (32%) eyes, respectively. The inferonasal (IN) quadrant was involved the least frequently (144 eyes; 17%). Of 328 eyes with only 1 break, it was most likely to be in the ST quadrant (182 eyes; 55%) and least likely to be in the IN quadrant (19 eyes; 6%). The risk of having multiple breaks was highest for patients with inferior breaks. Eyes with an IN quadrant break were almost twice as likely to harbor further breaks compared with eyes with an ST quadrant break. Vitreous hemorrhage at presentation was associated with larger breaks. ST quadrant breaks were most likely to be detached (92%), whereas IN quadrant breaks were least likely to be detached (60%). CONCLUSIONS: The ST quadrant is the most likely location for retinal breaks, the most frequently involved quadrant in eyes with solitary breaks, and has the highest proportion of detached breaks. By contrast, the IN quadrant is the least likely location for a break, the least frequently involved quadrant in eyes with solitary breaks, and the most likely location for attached breaks. The presence of an inferior (especially IN quadrant) retinal break should raise suspicion that the eye harbors further breaks.

Hypertensive retinopathy in severely hypertensive children: demographic, clinical, and ophthalmoscopic findings from a 30-year British cohort.

PURPOSE: There is scarce data regarding the incidence and clinical features of hypertensive retinopathy in children. The authors studied a large British cohort of severely hypertensive children to ascertain who developed hypertensive retinopathy, the severity, and the visual prognosis. METHODS: A retrospective review was performed of children undergoing renal angiography for investigation of severe hypertension at a tertiary institution from 1980 to 2010. All relevant cardiovascular, radiologic, and ophthalmic information was collected from case notes of the children identified in the study period. The outcome measures were presenting blood pressure, presence/severity of hypertensive retinopathy, and visual outcome. RESULTS: Fifty-three severely hypertensive children were identified; 30 with renovascular disease (RVD+) and 23 without (RVD-). The majority had 'stage 2 hypertension.' There were no significant differences in age, gender, or blood pressure between RVD+ and RVD- children. Seven (18%) of the 39 children receiving ophthalmic assessment had hypertensive retinopathy, of whom 6 had severe disease (retinal hemorrhages, exudates, and optic disc edema). There was a trend toward a higher prevalence of hypertensive retinopathy in the RVD+ group (n = 5) but this was not statistically significant. Children with hypertensive retinopathy had higher blood pressure than those without (median: 216/158 vs 150/98 mm Hg, P < .001). CONCLUSIONS: This is the first study examining the incidence and characteristics of hypertensive retinopathy in British children with severe hypertension. The authors found an 18% incidence of hypertensive retinopathy, in some cases with permanent visual reduction.

Acquired melanosis of a conjunctival autograft following pterygium surgery.

Pterygium excision with conjunctival autografting is an established surgical treatment for symptomatic pterygia. Documented complications include wound dehiscence, Tenon's granuloma, inclusion cysts, graft oedema, and corneoscleral dellen. We illustrate a previously unreported complication of this technique. A 41 year old Sri Lankan man presented with selective hyperpigmentation of the conjunctival autograft approximately three months following pterygium excision. The possible biological mechanisms behind this complication are discussed.

"Swiss roll" amniotic membrane technique for the management of corneal perforations.

PURPOSE: To describe a novel technique for using amniotic membrane in the management of corneal perforations. METHODS: Interrupted 10-0 nylon sutures are passed across the perforation site. A roll of amniotic membrane is then placed across the row of preplaced sutures, and the sutures are tied to secure the membrane. An amniotic membrane patch is placed over the graft, which is then protected by a bandage contact lens. RESULTS: We illustrate the results of our 2 most recent patients. CONCLUSIONS: Amniotic membrane has been widely used in ocular surgery. We recommend the "Swiss roll" amniotic membrane graft technique in cases of severe corneal thinning or localized perforations.

Bilateral panuveitis following intravesical BCG immunotherapy for bladder carcinoma.

PURPOSE: To report a case of bilateral panuveitis following local treatment with Bacille Calmette-Guérin (BCG) immunotherapy for superficial bladder carcinoma. DESIGN: Case report and literature review. METHODS: A 70-year-old female presented with severe bilateral anterior chamber inflammation 5 days after intravesical BCG instillation. Despite topical steroids and mydriatics, inflammation worsened and bilateral optic nerve swelling developed. RESULTS: Oral corticosteroids settled the ocular inflammation, and optic nerve function recovered. A trial of steroid cessation caused rebound uveitis, so she remains on maintenance doses of oral corticosteroid. CONCLUSIONS: Ocular inflammations following BCG therapy for bladder cancer are rare, and little is known about the management of such cases. This is the first report of bilateral panuveitis with optic nerve edema following such treatment.