UNUSUAL CAUSE OF BRANCH RETINAL ARTERY OCCLUSION: POLYCYTHEMIA IN A TRANSGENDER MAN FROM UNREGULATED TESTOSTERONE USE.

PURPOSE: We report a transgender patient with branch retinal artery occlusion who had secondary polycythemia from unregulated testosterone injections and review the literature on the mechanisms of supraphysiologic and standard doses of testosterone causing a hypercoagulable state. METHODS: Case report. RESULTS: A 45-year-old Chinese transgender man with no medical history presented with a 1-week history of a scotoma in his left eye vision. Ophthalmologic examination revealed retinal pallor and edema along the superotemporal arteriole in the left eye. Optical coherence tomography showed increased thickness of the inner retinal layers of the superotemporal retina. Fluorescein angiography demonstrated an arm-retina time of 1 minute and 43 seconds, with no vascular sheathing and capillary fallout. A diagnosis of left superotemporal branch retinal artery occlusion was made. Initial blood tests revealed a hemoglobin level of 19.3 g/dL (11.8-14.6 g/dL), hematocrit of 62% (34.3-43.0%), and erythrocytes of 6.56 × 1012/L (3.7-4.8 × 1012/L). He revealed later that he had been on weekly testosterone injections (testosterone enanthate 250-mg depot injection) since 2011. He was also exposed to a moderately high altitude, when his symptoms occurred, raising the possibility of worsening hypercoagulability resulting in his thrombotic event. CONCLUSION: To the best of our knowledge, this is the first documented case of a trans man who developed branch retinal artery occlusion after self-administering supraphysiological doses of testosterone. In a young patient with no history of cardiovascular risk factors who develops retinal arterial occlusion, other causes such as hypercoagulable syndromes must be excluded. This case warns of the dangers of unregulated testosterone use, especially at supraphysiologic doses, and the risks of thrombotic events from secondary polycythemia.

Analysis and Outcomes of Cataract Surgery in Patients with Acquired Immunodeficiency Syndrome.

PURPOSE: To investigate the surgical outcomes, complications and postoperative progression in HIV patients undergoing cataract surgery in a teaching hospital. METHODS: A retrospective cohort study of patients with HIV/AIDS who had cataract surgery from January 2000 until December 2011 at a tertiary referral multidisciplinary hospital in Singapore. RESULTS: We identified 44 eyes from 29 patients. Preoperatively, 41.3% had no ophthalmic manifestations of HIV/AIDS, while 16 eyes had quiescent cytomegalovirus retinitis (CMVR). Postoperatively, 1 eye developed new CMVR, while 1 eye had reactivation of previous CMVR. Of eyes with new or previous CMVR, 1 eye developed rhegmatogenous retinal detachment (RD) postoperatively. Only 3 eyes had prolonged postoperative inflammation. There were no cases of endophthalmitis or cystoid macular edema. Postoperative improvement of at least two Snellen lines was achieved in 86.6% of eyes. CONCLUSIONS: Cataract surgery in HIV patients is generally safe, regardless of CD4 count, but their general and ocular health should be optimized preoperatively.

Dataset of aqueous humor cytokine profile in HIV patients with Cytomegalovirus (CMV) retinitis.

The data shows the aqueous humor cytokine profiling results acquired in a small cohort of 17 HIV patients clinically diagnosed with Cytomegalovirus retinitis using the FlexMAP 3D (Luminex®) platform using the Milliplex Human Cytokine® kit. Aqueous humor samples were collected from these patients at different time points (pre-treatment and at 4-weekly intervals through the 12-week course of intravitreal ganciclovir treatment) and 41 cytokine levels were analyzed at each time point. CMV DNA viral load was assessed in 8 patients at different time points throughout the course of ganciclovir treatment. The data described herein is related to the research article entitled "Aqueous humor immune factors and cytomegalovirus (CMV) levels in CMV retinitis through treatment - The CRIGSS study" (Iyer et al., 2016) [1]. Cytokine levels against the different time points which indicate the response to the given treatment and against the CMV viral load were analyzed.

Aqueous humor immune factors and cytomegalovirus (CMV) levels in CMV retinitis through treatment - The CRIGSS study.

PURPOSE: This study aims to perform comprehensive longitudinal immune factor analysis of aqueous humor in relation to the aqueous CMV viral load and systemic CD4 counts during treatment of patients with co-infection of HIV and CMVR. METHODS: Aqueous humor samples were collected from 17 HIV-positive patients with CMVR scheduled to undergo weekly intravitreal ganciclovir therapy as part of the prospective CMV Retinitis Intravitreal Ganciclovir Singapore Study (CRIGSS) over the course of 1year. Full data across all the 4 time points was obtained and analyzed for CMV DNA viral load, 41 cytokine and chemokine factors using real-time PCR with the FlexMAP 3D (Luminex®) platform and assessed using the Milliplex Human Cytokine® kit. RESULTS: The following immune factors (Spearman correlation coefficient r value in parenthesis, p<0.05) showed strong correlation with CMV DNA load in the aqueous - MCP-1 (0.80, IFN-g (0.83), IP-10 (0.82), IL-8 (0.81), fractalkine (0.73), RANTES (0.68) - while the following showed moderate correlation - PDGF-AA (0.58), Flt-3L (0.59) and G-CSF (0.53). Only PDGF-AA revealed a statistically significant negative correlation with serum CD4 levels (r=-0.74). CONCLUSION: Immune factors that correlate with intraocular CMV DNA load are identified. They are indicative of a Th1 and monocyte-macrophage mediated response, and exhibit a decreasing trend longitudinally through the course of treatment. These factors may be an important new consideration in individualizing the treatment of patients with CMVR.

Ophthalmic complications of dengue.

We report 13 cases of ophthalmic complications resulting from dengue infection in Singapore. We performed a retrospective analysis of a series of 13 patients with dengue fever who had visual impairment. Investigations included Humphrey automated visual field analyzer, Amsler charting, fundus fluorescein angiography, and optical coherence tomography. Twenty-two eyes of 13 patients were affected. The mean age of patients was 31.7 years. Visual acuity varied from 20/25 to counting fingers only. Twelve patients (92.3%) noted central vision impairment. Onset of visual impairment coincided with the nadir of serum thrombocytopenia. Ophthalmologic findings include macular edema and blot hemorrhages (10), cotton wool spots (1), retinal vasculitis (4), exudative retinal detachment (2), and anterior uveitis (1). All patients recovered visual acuity to 20/30 or better with residual central scotoma by 12 weeks. These new complications suggest a widening spectrum of ophthalmic complications in dengue infection.

Corneal honeybee sting.

BACKGROUND: We report the complications and management of a retained bee sting injury to the cornea. The case highlights the acute and chronic management of an uncommon injury and its pathogenesis. METHODS: A 67-year-old man was attacked by a swarm of bees and was referred for severe chemosis on the right eye. A retained corneal bee stinger (ovipositor) was seen but removal was only partially successful. He subsequently developed a large corneal epithelial defect, anterior uveitis, intractable glaucoma, traumatic cataract, toxic optic neuropathy, and corneal scarring. We reviewed the literature on corneal bee sting injuries and their complications. RESULTS: Inflammation was controlled with topical steroids and the patient underwent a combined phacoemulsification and trabeculectomy with mitomycin-C for uncontrolled glaucoma. However, optic neuropathy did not resolve. INTERPRETATION: Corneal bee sting injuries are uncommon but can result in severe sight-threatening complications such as toxic optic neuropathy. Early recognition of the possible complications and appropriate treatment may help to prevent permanent loss of vision. Removal of a retained corneal bee stinger remains controversial.

Recurrent Enterococcus faecalis endophthalmitis after phacoemulsification.

We present the first reported case of late recurrence of postoperative Enterococcus faecalis endophthalmitis after cataract surgery in a 45-year-old diabetic man. Culture-positive E faecalis endophthalmitis was diagnosed 2 days after uneventful phacoemulsification. Early vitrectomy with intravitreal and subconjunctival vancomycin and amikacin and topical vancomycin resulted in apparently complete clinical resolution after 4 months and a best corrected visual acuity of 20/25. Recurrent endophthalmitis with hypopyon occurred 7 months postoperatively and resolved with intravitreal vancomycin and topical prednisolone acetate 1%. However, the patient had a similar relapse at 9 months that resulted in deterioration of visual acuity to no light perception despite a repeat vitrectomy, intraocular lens explantation, capsular bag removal, and intravitreal antibiotics. The late recurrences could have been the result of persistent sequestration of the organism in the capsular bag.