OUTCOMES OF VITRECTOMY IN TERSON SYNDROME: A Multicenter Canadian Perspective.

PURPOSE: To characterize the presentation of Terson syndrome, the occurrence of a vitreous hemorrhage in association with intracranial hemorrhage, and report on the outcomes of vitrectomy at two major centers in Canada. METHODS: Retrospective chart review of consecutive patients with Terson syndrome undergoing vitrectomy by retina specialists over the last 10 years. Primary outcome was the change in best-corrected visual acuity (BCVA) at 3 months from baseline. Secondary outcomes included the association between baseline BCVA and final BCVA, and the association between final BCVA and timing of surgery (early vs. later than 90 days). RESULTS: A total of 14 eyes of 11 patients were included. The mean time between observation of intraocular hemorrhage and vitrectomy was 160 days. Baseline preoperative BCVA was logarithm of the minimum angle of resolution 1.57 ± 1.03 (Snellen 20/740), which improved to logarithm of the minimum angle of resolution 0.53 ± 0.82 (Snellen 20/70) at the final postoperative follow-up, P = 0.01. Baseline BCVA was not significantly correlated with final BCVA, Spearman's rho = 0.016, P = 0.957. Final BCVA did not significantly differ between those who had surgery before 90 days compared with after 90 days, P = 0.087. CONCLUSION: Vitrectomy is safe and effective and should be considered for nonclearing vitreal bleeding due to Terson syndrome. Ocular hemorrhaging in Terson syndrome can be observed conservatively for spontaneous improvement without the risk of reduced visual potential. Ophthalmic evaluation should be considered promptly after intracranial hemorrhage.

RETINAL LESION EVOLUTION IN SUSAC SYNDROME.

PURPOSE: To describe retinal lesion development in Susac syndrome during acute, postacute, and late phases of the disease. METHODS: Cross-sectional study of four patients with Susac syndrome and longitudinal short-interval case study of one additional patient. Retinal changes were analyzed with high-resolution spectral domain optical coherence tomography and retinal fluorescein angiography. RESULTS: Retinal Susac syndrome lesions comprise four different lesion sections, which can be distinguished in acute and postacute phases of the disease: a primary section at the site of branch retinal artery occlusion, which spans more layers than supplied by the affected vessel; hypoxic sections from superficial and deep capillary networks; and an axonal damage section with degenerating axons from perished ganglion cells in the main and hypoxic sections. In the later stages, main and hypoxic lesion sections can no longer be distinguished, and both show degeneration from outer plexiform to retinal nerve fiber layers. CONCLUSION: The dynamics of lesion development and morphologically distinct lesion sections suggest more complex mechanisms of lesion evolution beyond an isolated endothelial immune reaction and subsequent hypoxic tissue damage. The characteristic lesion morphology assists in differentiating the diagnosis of acute visual loss in neuroinflammatory disease. Specificity of the identified changes has to be determined in future studies also including patients with other retinal vascular diseases.

A case of isolated Susac occlusive retinal vasculitis.

Susac syndrome is characterized by encephalopathy, sensorineural hearing loss, and branch retinal artery occlusion. Additional ocular findings include arteriolar wall hyperfluorescence and Gass plaques. We present a 51-year-old Caucasian woman with ophthalmologic findings indicative of Susac syndrome in the setting of tinnitus and migraine with aura.

Acute zonal occult outer retinopathy in a patient with retinitis pigmentosa.

A 30-year-old woman with a phenotypic presentation of retinitis pigmentosa (RP) presented with a 5-day history of painless, acute vision loss in her right eye, with visual acuity dropping from 20/30 to hand motions. Optical coherence tomography of the right macula showed near-complete loss of the ellipsoid layer. Treatment with a prolonged course of oral prednisone resulted in a complete structural regeneration of the ellipsoid layer and improvement of visual acuity to 20/50, with eccentric fixation. Tests for infectious diseases, autoimmune disorders, and rare RP mimic syndromes (eg, Refsum disease) were negative. The patient has remained stable since. We favor a diagnosis of two separate pathologies and suggest a designation of acute zonal occult outer retinopathy (AZOOR) in RP for this previously unreported presentation.

Lid splinting eyelid retraction technique: a minimised sterile approach for intravitreal injections.

BACKGROUND/AIMS: To describe an alternative technique for avoiding contact with the lids and lashes, without the use of a lid speculum, during intravitreal anti-vascular endothelial growth factor injections. METHODS: Retrospective case series of all patients undergoing intravitreal injections of bevacizumab and ranibizumab, with the lid splinting retraction technique from January 2010 to December 2015. Injections performed by six vitreoretinal specialists were included. The key preinjection ocular surface preparation includes topical anaesthetic, 5% povidone-iodine and a subconjunctival injection of 2% lidocaine with epinephrine. A second instillation of 5% povidone-iodine is given and the intravitreal injection is then performed. No lid speculum is used. A search of the electronic medical records identified patients diagnosed with postinjection endophthalmitis and charts were reviewed to ensure inclusion criteria were met. The main outcome measure was incidence of postinjection endophthalmitis. RESULTS: A total of 78 009 consecutive intravitreal injections were performed, of which 22 207 were bevacizumab and 55 802 were ranibizumab. In this cohort of patients (n=6320), 12 cases of endophthalmitis developed, corresponding to a rate of 0.015%. CONCLUSIONS: The technique of eyelid retraction for intravitreal injection has a low rate of endophthalmitis, similar to the reported rates using a metal lid speculum. This is beneficial for both the physician and the patient as it minimises patient discomfort as well as the duration of the procedure. To our knowledge, this is one of the largest studies performed to date evaluating intravitreal injection-related endophthalmitis.

Effects of malicious ocular laser exposure in commercial airline pilots.

OBJECTIVE: Intentional malicious laser strikes on commercial pilots are committed by individuals who target a laser into airplane cockpits during takeoff and landing. Because laser exposure to pilots is a relatively new but growing occurrence, our study investigates the ocular effect of this laser exposure in pilots. DESIGN: Retrospective chart review by a single ophthalmologist. PARTICIPANTS: All commercial airline pilots (58 male, 3 female) who experienced a laser strike while flying between April 2012 and November 2014 who presented to our clinic were included. METHODS: A retrospective chart review was performed in a retinal specialist's practice. Ocular assessment was performed within 3 days of laser exposure. A complete ophthalmic evaluation was conducted, including Early Treatment Diabetic Retinopathy Study visual acuity, colour vision, visual fields, intraocular pressure, slit-lamp examination, dilated fundus examination, colour fundus photographs, and ocular coherence tomography. RESULTS: Sixty-four laser strike incidents involving commercial pilots were included. All pilots in the study experienced some degree of immediate ocular irritation or light sensitivity. No definite cases of ocular damage were attributed to laser strikes. No pilot had any functional ocular deficits. CONCLUSIONS: Our study revealed that laser strikes on aircraft did not result in permanent visual functional or structural deficits. However, laser strikes cause immediate visual effects, including glare, flash blindness, and ocular irritation that can interfere with a pilot's visual function. Given the widespread accessibility of high-power lasers and the rapid increase in incidents, laser strikes threaten to jeopardize aviation safety unless effective preventative measures are put in place.

Hyperbaric oxygen therapy in the treatment of orbital gas gangrene.

Clostridial gas gangrene (myonecrosis) is a rapidly progressive, life-threatening infection. The occurrence of clostridial gas gangrene in the orbit is uncommon. We present a case of gas gangrene in the orbit of a child, with Clostridium perfringens isolated from the wound. Our patient was successfully treated with extensive surgical débridement, anti-microbial therapy, and hyperbaric oxygen therapy. Hyperbaric oxygen is established as an adjuvant therapy of clostridial gas gangrene and has been shown to significantly reduce morbidity and mortality. To our knowledge, this is the first reported case of using hyperbaric oxygen therapy in the treatment of orbital gas gangrene.

Treatment of ocular metastasis with anti-VEGF: a literature review and case report.

PURPOSE: This is the first case report where 1.25mg intravitreal bevacizumab (IVB) correlated with choroidal mass resolution from metastatic breast cancer given concurrently with chemotherapy demonstrating, at best, disease stability in other organs. STUDY DESIGN: Case report. METHODS: Upon confirmation of choroidal, liver and bone metastasis from breast carcinoma, a 72-year-old female received four intravitreal bevacizumab 1.25mg injections based on the presence of subretinal and intraretinal fluid. Visual outcomes were analyzed by ophthalmologic evaluation, B-scan, fluorescein angiography, and optical coherence tomography. RESULTS: After 3 treatments of 1.25mg intravitreal bevacizumab, visual acuity improved from 20/125 OD to 20/30 OD. These results were maintained for 5 months, after which a 4th IVB injection was given to try to further improve visual outcomes. Following this, complete resolution of the mass was observed with remaining pigmentary changes and vision improved to 20/25 one month following this. IVB was administered concurrently to systemic chemotherapy that demonstrated at best disease stability in metastases in other organs. CONCLUSION: In this case 1.25mg intravitreal bevacizumab proved to be a safe, effective and relatively easy treatment for choroidal metastasis from breast cancer. An important benefit of intravitreal bevacizumab therapy for choroidal metastasis is the ease of administration and minimal time commitment required as compared to other therapies. Further studies should be conducted to confirm the appropriate dosing and long-term outcomes of intravitreal bevacizumab to treat choroidal metastasis.

Telemedicine approach to screening for severe retinopathy of prematurity: a pilot study.

PURPOSE: To evaluate the use of remote reading of digital retinal photographs in the diagnosis of severe (referral-warranted) retinopathy of prematurity (ROP) during longitudinal screening for ROP. STUDY DESIGN: Prospective, longitudinal cohort study. SUBJECTS: Forty-four consecutive premature infants at risk for ROP. METHODS: All infants were examined longitudinally, over a series of examinations, by indirect ophthalmoscopy (gold standard) and digital photography using the RetCam-120 Digital Retinal Camera (Massie Research Laboratories Inc., Dublin, CA) equipped with an ROP lens. Images were stored and read remotely by a masked reader. Referral-warranted ROP was defined as ROP in zone 1, the presence of plus disease or the presence of any stage 3 ROP. We determined whether and when referral-warranted ROP was diagnosed for each eye, of each infant, on each examination, during the course of each of the infant's screening. RESULTS: Severe (referral-warranted) ROP was diagnosed in 23 eyes by indirect ophthalmoscopy during their series of examinations. Digital photography had a sensitivity of 100% and a specificity of 96% in detecting referral-warranted ROP. The positive predictive value of digital photography was 92%, and the negative predictive value was 100%. In 87% of eyes, referral-warranted ROP was diagnosed by digital photography before or at the same time as indirect ophthalmoscopy. CONCLUSIONS: Longitudinal remote reading of digital photographs using the RetCam-120 system has excellent specificity and sensitivity in detecting referral-warranted ROP. This pilot study has shown that remote reading of digital photographs has promise for telemedicine strategies in ROP screening.