Suprachoroidal and vitreous haemorrhage as a presenting feature of metastatic melanoma.

A man in his 70s presented with right ocular pain, vision loss and temporal headache 4 days after undergoing laser peripheral iridotomy. The patient had lost 10 lbs over the preceding 6 weeks and had a medical history significant for a previously excised melanoma of the left arm. During the course of investigations, the patient was referred to oncology for workup, ultimately leading to a diagnosis of metastatic melanoma. Visceral metastases were identified in the lungs, right anterior fourth rib, left femoral distal diaphysis and medial side of the right globe. The patient decompensated and died shortly after his first radiotherapy treatment.This is the first published report of suprachoroidal haemorrhage secondary to metastasis from suspected cutaneous melanoma. The case highlights the importance of considering malignancy on the differential diagnosis for a suprachoroidal haemorrhage of unknown aetiology and involving oncology early for workup and treatment.

SURGICAL TREATMENT OF VITREORETINAL COMPLICATIONS DURING DISSEMINATED INTRAVASCULAR COAGULATION SECONDARY TO MENINGOCOCCEMIA.

PURPOSE: To report a case of the surgical management of vitreoretinal complications during disseminated intravascular coagulation secondary to meningococcemia. METHODS: A case report. RESULTS: A 25-year-old man presented with loss of vision due to retinal and vitreous hemorrhages during disseminated intravascular coagulation secondary to meningococcemia. Examination revealed the visual acuity to be counting fingers in the right eye and light perception in the left eye. Bilateral vitreous hemorrhages were found on fundus examination. A dome-shaped lesion overlying the macula consistent with a subinternal limiting membrane hemorrhage was seen on optical coherence tomography. Bilateral vitrectomy was performed. Multiple subinternal limiting membrane hemorrhages were evident in the posterior pole. A membrane forceps was used to peel the internal limiting membrane and remove the fibrin under it. The internal limiting membrane and vitreous samples were sent for anatomopathological examination confirming our hypothesis. The peripheral retina revealed bilateral multiple ischemic areas, and argon laser photocoagulation was performed on it. Both eyes were filled with silicone oil. Eight months after surgery, his vision improved to 70 and 65 on the early diabetic retinopathy study scale in the right and left eyes, respectively. CONCLUSION: Published cases of retinal and vitreous hemorrhages during disseminated intravascular coagulation secondary to meningococcemia are few. There is no specific and codified management of these ocular complications. This case is the first reporting positive visual recovery after surgical treatment. Surgical procedure seems to be effective to treat multiple vitreoretinal hemorrhages secondary to meningococcemia.

Risk factors for breakthrough vitreous hemorrhage after intravitreal tissue plasminogen activator and gas injection for submacular hemorrhage associated with age related macular degeneration.

PURPOSE: We investigated risk factors for breakthrough vitreous hemorrhage (VH) after an intravitreal tissue plasminogen activator (tPA) and gas injection in patients with submacular hemorrhage (SMH) associated with age-related macular degeneration (AMD). METHODS: The medical records of patients diagnosed with SMH associated with AMD who received an intravitreal tPA (50 µg/0.05 mL) and perfluoropropane gas (0.3 mL) injection were reviewed retrospectively. We analyzed the associations of breakthrough VH with age, sex, best-corrected visual acuity, intraocular pressure, AMD subtype, accompanying sub-retinal pigment epithelium (RPE) hemorrhage, history of cataract surgery, history of hypertension and diabetes mellitus, history of drinking and smoking, and history of antiplatelet or anticoagulant medication. We also examined the relationships between various parameters, including the area ratio of the SMH to the optic disc (AHD) and the height of the SMH obtained from optical coherence tomography. RESULTS: In total, 52 eyes from 52 patients were enrolled in this study; 16 eyes (30%) showed breakthrough VH. The proportions of patients with a current smoking history were 75.0% in the VH group and 22.2% in the non-VH group (p = 0.010). Other factors did not differ significantly between the two groups. The proportion of cases with accompanying sub-RPE hemorrhage was 50.0% and 58.3% in the VH and non-VH groups, respectively (p = 0.763). The AHD (p = 0.001) and SMH height (p < 0.001) were significantly greater in the VH group. In a receiver operating characteristic curve analysis, the cut-off values of AHD and SMH height were 20.1 and 1208 µm, respectively. According to logistic regression analysis, when the AHD and SMH height were greater than the individual cut-off values, the odds ratio of VH increased by 10.286 fold (95% confidence interval [CI], 2.452-43.148; p = 0.001) and 75.400 fold (95% CI, 7.991-711.441; p < 0.001), respectively, with respect to their respective reference groups (less than the cut-off value). Among the significant factors associated with VH occurrence, including current smoking, AHD, and SMH height, only current smoking and SMH height were found to be significant in multiple regression analysis (p = 0.040, 0.016). CONCLUSIONS: The incidence of breakthrough VH was significantly higher in those with current smoking status and for SMH with a larger AHD and greater height. The height of the SMH was more predictable of the possibility of VH than AHD.

NOVEL PRERETINAL HAIR PIN-LIKE VESSEL IN RETINAL ASTROCYTIC HAMARTOMA WITH VITREOUS HEMORRHAGE.

BACKGROUD/PURPOSE: To report a case of retinal astrocytic hamartoma with vitreous hemorrhage and a hair pin-like vessel adhering to a posterior vitreous membrane. A 33-year-old man with a retinal astrocytic hamartoma presented with vitreous hemorrhage 5 times. METHODS: Multimodal imaging, including fundus photography, fluorescein angiography, optical coherence tomography, and B-mode ultrasonography. RESULTS: Multimodal imaging demonstrated a novel hair pin-like vessel that adhered to the posterior vitreous membrane. CONCLUSION: Some cases of retinal astrocytic hamartoma with vitreous hemorrhage may be related to structure abnormalities of tumor vessels.

Atypical acute retinal necrosis accompanied by Terson's syndrome: a case report.

BACKGROUND: Acute retinal necrosis (ARN) has characterized by panuveitis, vitritis, severe vaso-occlusive vasculitis, and diffuse necrotizing retinitis. There are no case reports on atypical ARN combined with Terson's syndrome. Herein, we report a case of ARN with atypical clinical features combined with Terson's syndrome that we successfully treated by intravitreal ganciclovir injection. CASE PRESENTATION: A 64-year-old man visited our eye clinic with a complaint of decreased visual acuity in his right eye. At the initial visit, his best corrected visual acuity was 20/125 in the right eye. Slit-lamp examination demonstrated mild hyperemia, keratic precipitates, and anterior chamber inflammatory reaction. Fundus examination revealed multiple diffuse white-yellowish infiltrations in the peripheral retina combined with dot hemorrhages. Ultra-wide-field fluorescence angiography showed obstructive arteritis with peripheral non-perfusion and leakage from the retinal vessels. As a result of the PCR analysis, varicella zoster virus DNA was identified in the aqueous humor. Under the diagnosis with VZV-mediated ARN, we started with intravenous acyclovir and oral prednisolone. After 3 days of the above treatment, the anterior chamber inflammation and vitreous opacity were increased. On fundus examination, multiple whitish infiltrations were increased. In addition, newly developed vitreous and peripapillary hemorrhages were detected. On the T2 brain magnetic resonance imaging (MRI) demonstrated a sub-acute or old hemorrhagic infarction in the right occipital lobe, and contrast-enhancing lesions in the right basal ganglia. The spinal tapping was performed in the department of neurology in our hospital at the time when the patient complained of headache, and intracranial pressure was 31 mmHg. Under the diagnosis of ARN with Terson's syndrome, we started intravitreal ganciclovir (2 mg/0.5 ml) injections. After 5 intravitreal ganciclovir injections over a period of 8 months, the diffuse whitish infiltrating retinal lesions combined with dot hemorrhage were decreased. The vitreous and peripapillary hemorrhage was significantly reduced. There was no recurrence in the patient's right eye, in which his visual acuity had improved to 20/60. CONCLUSIONS: In the event of a poor response to traditional treatment such as intravenous acyclovir, intravitreal ganciclovir may have a role as an adjunctive therapy in patients of VZV associated ARN combined with Terson's syndrome.

Tumor parameters predict the risk of side effects after ruthenium-106 plaque brachytherapy of uveal melanomas.

BACKGROUND: To report on radiation-related side effects and complications after ruthenium-106 plaque brachytherapy of uveal melanomas. METHODS: Medical records of 143 eyes with uveal melanoma, treated by ruthenium-106 brachytherapy between 1997 and 2012 at a single center, were analyzed. We evaluated the occurrence of radiation-related side effects on the anterior and posterior segment of the eye. The influence of patient, tumor and treatment parameters on outcome was analyzed by multivariate time to event analysis considering competing risks. RESULTS: The median overall follow-up was 37.9 months. After treatment, the estimated risk at 12, 24 and 48 months for developing anterior segment complications was 25.3%, 37.5% and 50.3% for cataract formation and 5.4%, 6.4% and 8.1% for secondary glaucoma, respectively. The estimated risk for the occurrence of posterior segment complications 12, 24 and 48 months after treatment was 3.1%, 6.7% and 18.3% for radiation retinopathy, 18.3%, 27.1% and 42.6% for radiation maculopathy and 16.5%, 21.0% and 32.8% for radiation neuropathy, respectively. The risk of an increase in retinal detachment after treatment was 14.7%, 14.7% and 17.4% at 12, 24 and 48 months, respectively. The risk of vitreous hemorrhage occurring after treatment was 6.2%, 8.1% and 12.7%, and the risk of tumor vasculopathy was 15.4%, 17.4% and 19.0%. Scleral necrosis was observed in one patient. CONCLUSION: Radiation-related side effects and complications are common among patients treated with ruthenium brachytherapy for uveal melanoma. However, the risk for those largely depends on individual tumor parameters. Before treatment, patients should be informed of their specific risks to develop various side effects. Patient information before treatment should cover not only general information about the treatment and possible complications and side effects but should also give details on the specific risks of the patient in her individual situation. This also includes elucidating the patient's individual resources and expectations and her willingness for long-term regular follow-up examinations and secondary adjunct treatments.

Histopathologic Analysis of the Posterior Segment for Terson's Syndrome: The GioBiopsy Technique.

The purpose of this study was to report on a case of Terson's syndrome (TS) using a novel instrument and technique to harvest posterior pole pathology from a postmortem eye. A modified ocular clamp was used to remove the posterior pole from the postmortem enucleated eye. Gross photographs were taken and an ocular sample of the posterior pole was sent to The New York Eye and Ear Pathology Laboratory. TS was identified from gross pathology and histologic examinations. The case history was consistent with that diagnosis. The authors concluded that high-quality gross and histopathologic examination of the posterior pole can be obtained with this novel instrument and technique. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:170-174.].

POLYPOIDAL CHOROIDAL VASCULOPATHY: A CLINICOPATHOLOGIC STUDY.

PURPOSE: To present a unique case of polypoidal choroidal vasculopathy presenting as a blind, painful eye with a suspected intraocular mass, and to correlate clinical findings with histopathologic studies. METHODS: Clinical case report and literature review. RESULTS: A 58-year-old Vietnamese man presented with a blind, painful eye with concern for an intraocular mass. B-scan ultrasonography showed massive intraocular hemorrhage and could not rule out a tumor. The patient underwent enucleation and the histopathologic findings were consistent with polypoidal choroidal vasculopathy. CONCLUSION: Polypoidal choroidal vasculopathy can present with dense vitreous hemorrhage and may masquerade as an intraocular mass. It can progress rapidly and lead to profound, irreversible vision loss. A diagnosis of polypoidal choroidal vasculopathy should be considered in patients of African or East Asian origin presenting with vitreous hemorrhage.

The role of ILM peeling in vitreous surgery for proliferative diabetic retinopathy complications.

BACKGROUND AND OBJECTIVE: To evaluate the influence of pars plana vitrectomy (PPV) with or without internal limiting membrane (ILM) peeling on spectral-domain optical coherence tomography (SD-OCT) in vitreous hemorrhage and tractional retinal detachment as a complication of diabetic retinopathy. PATIENTS AND METHODS: Retrospective study of PPV in patients with diabetic retinopathy complications. Group A (53 patients) had PPV with ILM peeling, and group B (59 patients) had PPV without ILM peeling. SD-OCT imaging and fluorescein angiography were performed postoperatively. RESULTS: Preoperative visual acuity was 0.04 and final postoperative visual acuity was 0.27 in both groups (23.4 months in group A, 60 months in group B). Postoperative central retinal thickness was 193 µm (group A) and 258.6 µm (group B). Epiretinal membranes were observed less frequently in group A than in group B (24% vs 49%). Repeated surgeries were performed in 38 cases in group A and in 51 cases in group B. CONCLUSION: Fewer cases of epiretinal membranes and macular edema are observed postoperatively with ILM peeling. Visual acuity is similar in both groups, but additional surgeries are fewer with ILM peeling.

Intravitreal bevacizumab (Avastin) and panretinal photocoagulation in the treatment of high-risk proliferative diabetic retinopathy.

PURPOSE: To report the short-term efficacy and safety of intravitreal bevacizumab (Avastin) injection with panretinal laser photocoagulation (PRP) in patients with high-risk proliferative diabetic retinopathy (PDR) according to the Early Treatment Diabetic Retinopathy Study criteria. METHODS: A prospective, interventional case series study was conducted in 17 patients (20 eyes) with high-risk PDR, who were treated with intravitreal bevacizumab (2.5 mg) followed by PRP when the peripheral vitreous became clear or 2 weeks after injection. Patients underwent complete ophthalmic evaluation, including Snellen visual acuity and fluorescein angiography at baseline, 1, 3, and 6 months after bevacizumab injection. Main outcome measures included the serial changes in visual acuity, vitreous clear-up time, and neovascularization on the disc (NVD) regression time. RESULTS: All patients had obvious reduction in angiographic leakage and involution of retinal neovascularization (NV) at the 1- and 3-month follow-up. The mean follow-up time was 7.5 months. The vitreous hemorrhage (VH) showed a partial resolution as early as 1 week, and complete regression at 3 months. The mean vitreous clear-up time after intravitreal Avastin was 8.5±2.2 weeks. The mean time interval from intravitreal Avastin to NVD regression was 10.8±3.4 weeks. Mean logarithm of the minimum angle resolution visual acuity improved from 1.03 at baseline to 0.36 at 1-month, 0.38 at 3-month, and 0.48 at the 6-month follow-up (P<0.01). Three eyes (18%) required vitrectomy surgery during follow-up. The indication for vitrectomy was dense, persistent VH in 2 eyes, and focal tractional retinal detachment (TRD) in 1 eye. Recurrent retinal NV with minor preretinal hemorrhage was observed in 6 eyes (30%) 3 months after the first injection, and resolved after repeated bevacizumab injections. Patients received an average of 1.4 injections (range: 1-2). Seven eyes (35%) underwent 2 injections. One eye (5%) had ocular complication of PDR progression to TRD. No systemic adverse events were observed following injections. CONCLUSIONS: Short-term results suggest combined intravitreal bevacizumab and PRP achieved rapid clearance of VH, regression of retinal NV, and visual improvement in the treatment of high-risk PDR. Long-term study is warranted to assess the long-term efficacy and safety.

[Histological findings in bilateral asymmetrical vasoproliferative retinal tumor]. / Histologie bei bilateral asymmetrischem vasoproliferativem Tumor der Retina.

We present a case of a bilateral vasoproliferative tumor of the retina in a young man. The first symptom was visual impairment due to vitreous hemorrhage. The right eye showed small tumors which were successfully treated by repeated cryocoagulation, photocoagulation and bevazicumab injection. The tumor in the left eye was larger and eventually led to a painful secondary glaucoma. After enucleation, this tumor was examined histologically and immunohistochemically. The clinical and histological differential diagnoses and therapeutic options are discussed.

Intravitreous VEGF-A in eyes with massive vitreous hemorrhage.

PURPOSE/BACKGROUND: Although vascular endothelial growth factor (VEGF) is abundant in serum, the intraocular concentration of VEGF in eyes with massive vitreous hemorrhage (VH) is not well-known. The present study was conducted to elucidate the effects of a massive VH on intravitreous VEGF concentration. METHODS: Vitreous samples were obtained during vitrectomy: 12 samples from eyes with epiretinal membrane without diabetic retinopathy (DR), and nine samples from massive VH with no DR, such as age-related macular degeneration, rhegmatogenous VH, Terson's syndrome and macro-aneurysm rupture. Twelve samples were obtained from proliferative DR. VEGF was measured with an enzyme-linked immunosorbent assay (ELISA). Samples incubated with or without heparin were also examined for the release of VEGF binding to the vitreous body. The localization of VEGF and type II collagen in the vitreous was evaluated from immunohistochemistry. RESULTS: The concentration of VEGF was significantly higher in eyes with proliferative DR (821 ± 949 pg/ml) than in non-DR with massive VH (2.75 ± 7.5 pg/ml, P < 0.01, chi-square test) or non-DR with no VH (less than detectable level, P < 0.01, chi-square test) There was no statistically significant difference between eyes with massive VH and non-diabetic eyes without VH. Treatment with heparin did not significantly affect the concentration of vitreous VEGF. VEGF was localized mainly in the clot from the results of an immunohistochemical analysis. CONCLUSIONS: Even with a massive VH, diffusible VEGF does not increase significantly in the liquid phase and is principally present in a clot. VH alone should not be an indication for vitrectomy from the point of view of VEGF-related pathology.

Anatomical and functional outcomes in contusion injuries of posterior segment.

PURPOSE: To evaluate the clinical features, and anatomical and visual outcomes in patients with closed-globe contusion injury involving the posterior segment. METHODS: Retrospective review of posterior segment contusion injuries admitted to our tertiary referral center. RESULTS: In all, 115 patients (115 eyes) with complete data were reviewed. Surgery had been performed in 79 (69%) patients. The mean follow-up period was 6 months (range, 2-34 months). Retinal detachment, in 31% of eyes, was the most frequently encountered posterior segment pathology. The presence of retinal detachment was associated with poor visual outcome (<20/100), (P<0.001). Coexisting (five patients, 4%) and postoperative proliferative vitreoretinopathy (PVR) (two patients, 2%) was the main cause of failure in these cases. A significant positive correlation was obtained between initial and final visual acuity levels in both the medical treatment group and the surgical treatment group (P<0.05). The presenting visual acuity of <20/400 was associated with poor visual outcome (P<0.05 for both groups). Poor visual outcome in 13 patients with successful repair of retinal detachment was due to the macular lesions and the optic atrophy. CONCLUSION: Retinal detachment was the most frequently encountered posterior segment pathology subsequent to closed-globe contusion injuries. In addition to macular scarring and optic nerve damage, development of PVR has prognostic significance in these eyes.

Intra-ocular expression of vascular endothelial growth factor (VEGF) and pigment epithelial-derived factor (PEDF) in a case of Eales' disease by immunohistochemical analysis: a case report.

We report a immunohistochemical study of expression of VEGF and PEDF in Eales' disease. An enucleated eye from a patient with Eales' disease and an age and sex-matched donor eyeball were subjected to immunohistochemical and histopathological analysis to study the expression of VEGF and PEDF in the retinal region. Strong positive anti-VEGF immunostaining was found around the vessel walls in the retina in the eyeball from the Eales' disease patient compared with the donor control, from which it was almost absent. PEDF staining was detected in the normal donor eyeball retinal layers surrounding the blood vessels, and the photoreceptor and ganglion cell layer, whereas in the eyeball from Eales' disease patient PEDF staining was restricted to the surrounding blood vessels. The strong expression of VEGF in eyes with Eales' disease as opposed to weak expression of PEDF indicates the propensity of the disease to show neovascularization and recurrent hemorrhages.

A case of accidental macular injury by Nd: YAG laser and subsequent 6 year follow-up.

Here, we report the case of a patient who sustained Nd: YAG laser macular injury with subsequent 6 year follow-up evaluation. A 23-year-old female was accidentally exposed to a Q-switched Nd: YAG laser without protective goggles. Upon initial evaluation, the best-corrected visual acuity of her affected eye was 20/100 OD. Fundoscopic examination revealed a macular laser burn and vitreous hemorrhage. Corticosteroids, in the form of 60 mg prednisolone, were administered orally with a 10 mg per week taper. Nineteen days following exposure, fundoscopic examination revealed a distinct epiretinal membrane which resolved within six months. The best-corrected visual acuity of the affected eye remained 20/100 OD. This clinical course is similar to those of previously reported cases including vitreous hemorrhage and subsequent epiretinal membrane formation. However, visual acuity did not recover despite spontaneous regression of the epiretinal membrane and at 6 year follow-up, there was neither choroidal neovascularization nor macular hole formation.

[Proliferative diabetic retinopathy inauguring gestational diabetes]. / Une rétinopathie diabétique proliférante inaugurant un diabète gestationnel.

INTRODUCTION: Diabetic retinopathy is one of the diabetic microangiopathy complications generally occurring after insulin-dependent diabetes has evolved for a few years. OBSERVATION: We report a 24-year-old pregnant woman with severe proliferative diabetic retinopathy discovered at the time of the gestational diabetes diagnosis. Argon laser photocoagulation of retinal ischemic territories was initiated. The disease progressed to vitreous haemorrhage in the right eye. DISCUSSION: Proliferative diabetic retinopathy is exceptionally present at the time of the gestational diabetes. We did not find any similar case in the literature. CONCLUSION: Fundus examination seems necessary at the onset of gestational diabetes. It can prevent blindness in young women.

Histopathologic characteristics of choroidal melanoma in eyes enucleated after iodine 125 brachytherapy in the collaborative ocular melanoma study.

OBJECTIVE: To describe the histopathologic findings in eyes with uveal melanoma that had secondary enucleation after failed brachytherapy plaque treatment. METHODS: Histopathologic findings in eyes that had secondary enucleation after plaque radiation therapy in the Collaborative Ocular Melanoma Study (COMS) were reported on a standardized data form. The findings were compared with eyes that had primary enucleation for uveal melanoma. RESULTS: Seventy-five eyes that had secondary enucleation were studied. Compared with primary enucleations, tumors in the irradiated eyes had lower mitotic activity, a smaller proportion of histologically intact tumor, more inflammation, more fibrosis, and more vascular damage within the tumor. In addition, compared with primary enucleations, eyes previously irradiated had a higher frequency of retinal invasion by the tumor and greater damage to the retinal vasculature, consistent with radiation retinopathy; neovascularization of the iris; and vitreous hemorrhage. Tumor growth or extrascleral extension was confirmed histopathologically in 25 of 42 eyes (60%) enucleated because of a reported failure of local control. CONCLUSIONS: Eyes with secondary enucleation after brachytherapy differ histopathologically from eyes with primary enucleation for uveal melanoma. These histopathologic differences may be due to the effects of radiation, tissue conditions related to plaque failure, and, in some cases, tumor growth. In 40% of eyes enucleated because of suspected failure of local control, increased tumor size could not be histologically confirmed.