Occlusion of the central retinal artery in Plasmodium falciparum malaria.

A 40-year-old woman presented with sudden painless diminution of vision in left eye. The best corrected visual acuity was 20/20 in the right eye and 20/400 in the left eye. The vision loss occurred 3 days after the onset of fever with chills and rigour. Rapid diagnostic test and peripheral blood smear examination revealed Plasmodium falciparum malaria. The left eye fundus showed a pale disc with marked attenuation of arterioles. A detailed systemic evaluation including cardiovascular, haematological and angiographic assessments was performed which did not reveal any abnormality. A diagnosis of central retinal artery occlusion (CRAO) associated with uncomplicated P. falciparum malaria was made. In this communication, we report that acute loss of vision in a patient with P. falciparum malaria, CRAO needs to be ruled out.

A Novel clinical sign in Intraocular Tuberculosis: Active chorioretinitis within chorioretinal atrophy.

PURPOSE: To report a novel clinical sign in patients with intraocular tuberculosis. The current study is an observational consecutive case series of patients diagnosed with intraocular tuberculosis managed at a tertiary eye care centre from June 1, 2012 to December 31, 2015. OBSERVATIONS: The diagnosis of intraocular tuberculosis was made in 6 patients based on ocular features suggestive of tuberculosis along with a positive tuberculin skin testing and chest X-ray consistent with tuberculosis. All patients presented with decreased visual acuity ranging from 20/25 to 20/400, anterior chamber reaction, vitritis, multifocal choroiditis and vasculitis. All patients had an area of active chorioretinitis within the zone of pre-existing chorioretinal atrophy, apart from various other signs suggestive of intraocular inflammation. All patients were started on anti-tubercular therapy for a period of 9 months alone or in combination with oral corticosteroids tapered over 3-4 months. A prompt response to the treatment with resolution of chorioretinitis within the chorioretinal atrophy occurred in all patients. In addition, there was resolution of vitritis and improvement in the visual acuity ranging from 20/20 to 20/40 at last follow-up. CONCLUSIONS AND IMPORTANCE: Active chorioretinitis within an area of chorioretinal atrophy is a novel clinical sign that may indicate intraocular tuberculosis.

A novel clinical sign in macular telangiectasia type 2.

The objective of the study is to report, and propose a hypothesis for, a novel clinical sign in patients with macular telangiectasia type 2. Nine consecutive patients with macular telangiectasia and visible parafoveal graying were examined. The parafoveal graying decreased in intensity with continuous light exposure from an indirect ophthalmoscope. After dark adaptation for 15 minutes, the intensity of parafoveal graying increased again. This phenomenon appears to be a novel and global sign in patients with macular telangiectasia type 2. It could be a possible photochemical reaction occurring due to the release of chromophores from the abnormal Müller cells.

An outbreak of Ralstonia pickettii endophthalmitis following intravitreal methotrexate injection.

PURPOSE: To report an outbreak of endophthalmitis in three eyes of two patients following intravitreal methotrexate, caused by Ralstonia pickettii. DESIGN: Retrospective, noncomparative, consecutive case series. METHODS: Medical records and microbiology results of two patients who presented with acute endophthalmitis following intravitreal methotrexate injection in November 2013 were reviewed. RESULTS: Following intravitreal injections, the patients experienced pain and decrease in vision in the affected eye within 24 hours of receiving intravitreal methotrexate injection. The presenting visual acuity in case 1 was 20/50 in the left eye. The presenting visual acuity in case 2 was hand motions in the right eye and counting fingers at 1 m in the left eye. Both the patients received methotrexate prepared in the same manufacturing facility. Both the patients underwent vitreous biopsy and intravitreal injection of vancomycin 1 mg/0.1 mL, amikacin 400 µg/0.1 mL, and dexamethasone 400 µg/0.1 mL. Microbiology cultures from vitreous, and used and unused vials of methotrexate from the same batch grew R. pickettii. After 8 months of follow-up, both the patients had visual acuity 20/60 or better. CONCLUSION: R. pickettii can be rarely associated with outbreak of endophthalmitis. Timely intervention can be associated with good visual outcome in such patients.

Coexisting choroidal neovascularization and active retinochoroiditis-an uncommon presentation of ocular toxoplasmosis.

BACKGROUND: Choroidal neovascularization during the active stage of Toxoplasma retinochoroiditis is an uncommon clinical presentation. The authors retrospectively reviewed medical charts of patients with coexisting choroidal neovascular membrane and active Toxoplasma retinochoroiditis. FINDINGS: Three patients presented with coexisting choroidal neovascular membrane and active Toxoplasma retinochoroiditis. All lesions had adjacent subretinal hemorrhage. The diagnosis was confirmed based on clinical presentation, fundus fluorescein angiography (FFA), and optical coherence tomography (OCT) findings. The patients were managed with a combination of treatments including intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF), oral anti-Toxoplasma treatment, and oral corticosteroids. In all patients, the retinitis lesion resolved in 6 weeks and the coexisting choroidal neovascular membrane resolved over 6 to 12 weeks. CONCLUSIONS: Recurrences in Toxoplasma retinochoroiditis are common as satellite lesions adjacent to an old atrophic scar. Coexisting choroidal neovascularization with active Toxoplasma retinochoroiditis is an important presentation and should be suspected in the presence subretinal hemorrhage and managed with a combination of anti-Toxoplasma treatment and intravitreal anti-VEGF.

Clinical experience in treatment of diffuse unilateral subretinal neuroretinitis.

PURPOSE: To describe the clinical features, management, and outcomes of patients with diffuse unilateral subacute neuroretinitis (DUSN). METHODS: A noncomparative, consecutive analysis of case series from two tertiary care campuses of LV Prasad Eye Institute, India, between January 2011 and April 2014 was performed. Medical records of the patients presenting with DUSN (early or late stage) were reviewed. RESULTS: The current study included 13 patients. The majority (10/13, 76.92%) of the patients were aged 20 years or less. All patients had unilateral eye involvement. Visual acuity at presentation was 20/200 or worse in 9/13 (69.23%) patients. A delay in diagnosis occurred in 6/13 patients, and initial diagnosis in these patients included retinitis pigmentosa (4 patients) and posterior uveitis (2 patients). Clinical features included early presentation (prominent vitritis, localized retinitis, and vasculitis) in 7/13 (53.85%) patients and late presentation (attenuation of vessels, retinal pigment epithelium atrophic changes, and optic atrophy) in 6/13 (46.15%) patients. Worm could not be identified in any of the cases. All the patients received laser photocoagulation of retina and oral albendazole treatment for a period of 30 days. With treatment, visual acuity improved in seven patients (six early stage, one late stage) and remained unchanged in six patients. Mean follow-up period was 8.69 months (range, 1-21 months). The mean central foveal thickness in the affected eye, done by optical coherence tomography, during the late stage of the disease was 188.20±40 µm (range, 111-242 µm), which was significantly thinner than the fellow eye, 238.70±36.90 µm (range, 186-319 µm), P=0.008. CONCLUSION: DUSN is a serious vision threatening disease, which may progress to profound vision loss in the later stage of the disease. Visualization of subretinal worm is usually not possible. Treatment with high-dose albendazole therapy and laser photocoagulation may alter the blood-retinal barrier and may be useful in achieving visual recovery.

The role of intravitreal trimethoprim/sulfamethoxazole in the treatment of toxoplasma retinochoroiditis.

The authors evaluate the role of intravitreal trimethoprim/sulfamethoxazole in the treatment of toxoplasma retinochoroiditis (TRC) in four patients. Intravitreal injection of trimethoprim/sulfamethoxazole 1.28 mg/0.08 mL with dexamethasone 400 µg/0.1 mL was injected weekly or biweekly. After the initiation of treatment, a reduction in intraocular inflammation was observed clinically and on optical coherence tomography within 1 week. Three patients regained visual acuity of 20/20, and one patient improved to 20/40 with residual macular scarring. No evidence of retinal toxicity was noted on full-field electroretinogram. Intravitreal trimethoprim/sulfamethoxazole and dexamethasone combination may be an alternative treatment strategy in patients with TRC.

Filamentous fungal endophthalmitis: results of combination therapy with intravitreal amphotericin B and voriconazole.

PURPOSE: To report outcomes of exogenous fungal endophthalmitis treated with combination of intravitreal antifungal agents. DESIGN: Retrospective, non-randomized, interventional, consecutive case series. METHODS: Twelve eyes of twelve consecutive cases of filamentous fungal endophthalmitis were treated with a combination of intravitreal amphotericin-B and intravitreal voriconazole (AmB-Vo Regime) along with pars plana vitrectomy at a single center. Clinical characteristics, microbiology results, treatment strategy, visual, and anatomical outcomes were analyzed. RESULTS: Ten cases out of the twelve were postoperative endophthalmitis of which nine were part of a post cataract surgery cluster. The remaining included endophthalmitis following keratitis post pterygium excision (1) and following open globe injury (2). The most common fungus was Aspergillus terreus, which was isolated in 8/12, followed by A. flavus in 2/12 and Fusarium solani in 1/12. The presenting visual acuity ranged from light perception (LP) to counting fingers. The visual acuity at final follow-up was 20/400 or better in 7/12 eyes (58.33%) and 20/60 in 2/12 eyes (range 20/60 to LP). All eyes with corneal involvement had final visual acuity 20/400 or worse. Globe salvage was achieved in all cases. CONCLUSION: Combining intravitreal amphotericin-B and voriconazole could be a novel treatment strategy in the management of endophthalmitis caused by filamentous fungus. Eyes with corneal involvement had poor visual outcome either with or without therapeutic penetrating keratoplasty.

Intravitreal triamcinolone acetonide as an adjuvant in the management of acute retinal necrosis.

OBJECTIVE: To determine the role of intravitreal triamcinolone acetonide (IVTA) as an adjuvant in the management of acute retinal necrosis (ARN). DESIGN: Interventional case series. PARTICIPANTS: Four eyes of 4 patients diagnosed with ARN were studied. METHODS: This pilot case series included 4 patients who presented with clinical features suggestive of ARN. IVTA was injected 1 to 2 weeks after initiation of antiviral therapy and concurrent usage of oral corticosteroids. The disease course and clinical outcome were observed. The patients received additional treatment depending on the sequelae of ARN. RESULTS: Signs of reduction in vitritis and resolution of retinitis were observed as early as 1 week after IVTA was administered. In all 4 patients, inflammation promptly resolved with no untoward effects like raised intraocular pressure or worsening of the retinitis. A final visual acuity of 20/40 or better was achieved in 3 of 4 patients after appropriate treatment of ARN-related complications. CONCLUSIONS: Intravitreal triamcinolone under antiviral cover could be a useful adjunct to systemic steroids in the treatment of ARN.

Myocardial infarction increases progressive visual field defects in well treated early primary open angle glaucoma--a prospective case control study.

The purpose of the study was to evaluate the progression of glaucomatous field damage in patients with stable primary open angle glaucoma after an attack of myocardial infarction. In this case control study, 62 open angle glaucoma patients were selected and regularly followed up. Among 62 patients, 9 had an attack of myocardial infarction. The intra-ocular pressure and visual field progression of both the groups (myocardial infarction versus no myocardial infarction) were analysed. Three (33.3%) out of 9 patients who had suffered from myocardial infarction showed progressive visual field loss whereas only 9 (16.9%) out of 53 patients who did not suffer from myocardial infarction, showed progressive field changes. Both the groups had stable target intra-ocular pressure between 14 and 16 mm Hg. Myocardial infarction may adversely influence the progression of primary open angle glaucoma which is suspected to result from ischaemia induced neuronal loss and only control of intraocular pressure is not the only solution. We have to look for other drugs that prevents ischaemia induced neuronal damage.