INDOLENT, NONPROGRESSIVE, MULTIFOCAL CHOROIDAL LESIONS: A Presumed Benign Choroidal Lymphoid Disease.

PURPOSE: In 2012, four patients with multiple asymptomatic, indolent, unilateral, choroidal lesions were described. We suspected benign-behaving lymphocytes infiltrating the choroid. This article expands the number of patients and duration of follow-up and speculates further on the etiology. Although histopathologic confirmation of these lesions is still unknown, the natural course of these patients is excellent and should be distinguished from aggressive choroidal lymphoma. METHODS: To qualify for the study, the patients had to meet the following criteria: 1) Patients collected had asymptomatic choroidal infiltrates as demonstrated in the figures; 2) absence of vitreous cells; 3) no evidence of concomitant systemic malignancy; 4) no systemic inflammatory diseases, including sarcoidosis; 5) no birdshot chorioretinopathy; 6) no conjunctival or orbital lesions; and 7) advanced multimodal imaging and clinical follow-up were performed. RESULTS: There were 11 eyes of 11 patients seen. Follow-up ranged from 4 months to 12 years and 1 month (mean 50.2 months; median 24 months). Systemic workup was unrevealing. No patients in this cohort developed systemic, conjunctival, orbital, or vitreoretinal lymphoma or inflammatory disease. No patients developed symptoms or vision loss. CONCLUSION: This entity is an indolent choroidal infiltrative disease. It resembles some cases of choroidal lymphoma and may represent an indolent lymphocytic infiltrate.

Indolent nonprogressive multifocal choroidal lesions.

PURPOSE: We present a case series of four patients with unilateral, nonprogressive, yellow or white choroidal lesions of unknown etiology. METHODS: Four healthy patients were referred to an academic medical retina practice for unusual fundus findings in one eye only. Both eyes of all four patients underwent clinical examination and retinal imaging, including fluorescein angiography, indocyanine green imaging, and optical coherence tomography. The outcome of this series was based on the clinical course of these patients and the features of the retinal images. RESULTS: The differential diagnosis based on the clinical appearances for these unknown cases includes birdshot chorioretinopathy, lymphoma or reactive lymphoid hyperplasia, metastases, orbital and intraocular pseudotumor, and bacterial or fungal infection. Extensive workups for these clinical entities including HLA-A29, angiotensin-converting enzyme level and computed tomography of the chest, liver function testing, magnetic resonance imaging of the brain, and orbital ultrasound have remained negative. CONCLUSION: Clinical and imaging characteristics for the four patients include absence of intraocular inflammation, late staining of lesions on fluorescein angiography, and hypofluorescence of lesions on indocyanine green. Lesions were not visible in the retina or retinal pigment epithelium using time domain optical coherence tomography. However, enhanced depth imaging spectral-domain optical coherence tomography imaging available for one patient suggests that these lesions are localized to the choroid; further interpretation of this advanced imaging technique will likely prove useful in the future. The patients' clinical course has remained nonprogressive with no changes over a prolonged period of observation. These cases could represent atypical manifestations of known retinal disease diagnoses or variations of a new chorioretinal disease process.

Atypical presentations of multiple evanescent white dot syndrome without white dots: a case series.

PURPOSE: To describe three unusual clinical cases of patients who were diagnosed with multiple evanescent white dot syndrome at the onset of their disease but lacked the characteristic white dots on clinical examination, autofluorescence, and angiographic testing at any time during their follow-up. METHODS: Three eyes of three patients with clinical symptoms of multiple evanescent white dot syndrome seen at an academic clinical practice were included. Retinal imaging, including fluorescein angiography, indocyanine green imaging, fundus autofluorescence, and optical coherence tomography, was used to further characterize and describe the clinical findings. RESULTS: All three patients presented with classic multiple evanescent white dot syndrome complaints. All patients demonstrated classic foveal granularity and mild disk swelling and/or peripapillary whitening. No characteristic hyperfluorescent lesions were seen on fluorescein angiography, and indocyanine green imaging did not demonstrate typical patterns of hypofluorescence and/or leakage. Optical coherence tomography documented focal disruption or loss of the inner segment/outer segment photoreceptor line in all cases. CONCLUSION: Our case series demonstrates another atypical presentation of multiple evanescent white dot syndrome that has not been described previously: foveal involvement at the onset of the disease without white spots.

Pharmacologic therapy of pseudophakic cystoid macular edema: 2010 update.

PURPOSE: To review the current management and pharmacologic treatment of pseudophakic cystoid macular edema. METHODS: Systematic review of currently accepted treatment modalities for pseudophakic cystoid macular edema. Main outcome measures include visual acuity and retinal thickness measurement by optical coherence tomography. RESULTS: Optical coherence tomography is used to diagnose and monitor response to therapy. New topical nonsteroidal antiinflammatory drugs have been approved by the Food and Drug Administration for ophthalmic use, and some show promise in the treatment of pseudophakic cystoid macular edema. Other areas of clinical research include the use of anti-vascular endothelial growth factor agents and the addition of intravitreal routes of administration (e.g., corticosteroids, nonsteroidal antiinflammatory drugs, and anti-vascular endothelial growth factor agents). Surgical therapeutic options include Nd:YAG laser for anterior vitreolysis and pars plana vitrectomy for chronic refractory cases. CONCLUSION: Surprisingly, few changes have occurred in recent years in the treatment of pseudophakic cystoid macular edema. Placebo-controlled, double-masked, randomized, clinical trials are largely lacking.

Wooden intraorbital foreign body injuries: clinical characteristics and outcomes of 23 patients.

PURPOSE: To describe the clinical characteristics, interventions, and visual outcomes of orbital injuries associated with wooden foreign bodies. METHODS: A retrospective case review of orbital injuries managed at Wills Eye Institute and Massachusetts Eye and Ear Infirmary was conducted between 1992 and 2006. RESULTS: The clinical course and management for a total of 23 intraorbital wooden foreign body injuries were reviewed. The distribution of wood included pencil (39%), tree branch/plant matter (35%), and other treated wood (26%). About half of the subjects (52%) presented with preoperative vision between 20/20 and 20/40. Almost all [corrected] of the subjects with preoperative vision between 20/20 to 20/40 retained vision in that range postoperatively (92%). [corrected] Time from injury to presentation was highly variable, ranging from 24 hours to 17 months (mean, 62 days; median, 3 days). Forty-three percent of subjects presented within 24 hours of injury. The site of foreign body found within the orbit was superior (26%; n = 6), medial 30% (n = 7), inferior (26%, n = 6), posterior (9%; n = 2), and lateral (4%; n = 1). Preliminary radiographic interpretation for foreign body was definite in 61% (n = 14), possible in 22% (n = 5), and absent in 13% (n = 3). CONCLUSIONS: Young men are at particularly high risk for wood intraorbital foreign body. There was a relatively equal distribution of wood type. The time from injury to presentation was variable, ranging from <1 day to over a year. Almost half of the subjects presented within 24 hours of injury. In patients with a known site of penetration, almost half occurred in the conjunctiva, notably without presence of eyelid laceration, emphasizing the need to check the conjunctiva and fornices closely. Preliminary radiographic readings often miss or are inconclusive in detecting the foreign body. The shape, location, serial examinations, and particularly the use of quantitative CT are extremely helpful in distinguishing retained wood foreign body from other low-density signals of air or fat.

Glaucoma screening in a high-risk population.

PURPOSE: To evaluate a screening protocol for detection of individuals with a higher risk of chronic open angle glaucoma for which a complete glaucoma evaluation is indicated. PATIENTS AND METHODS: African Americans over 40 years of age in New Haven, CT. In the screening phase, volunteers filled out a questionnaire and underwent measurements of visual acuity, intraocular pressure (IOP) with a Tono-Pen and visual field with Frequency Doubling Technology. Participants were categorized into "glaucoma likely" or "unlikely," but all were encouraged to follow up with a free complete glaucoma exam, which included applanation tonometry, pachymetry, visual fields with a Humphrey Visual Field Analyzer, gonioscopy, and fundoscopy. Based on the latter exam, patients were categorized into "glaucoma likely" (suspects and confirmed glaucoma) or "unlikely" groups. RESULTS: One hundred eighty-four subjects completed both phases of the study and 76 of 93 patients (82%) who were classified as "glaucoma likely" in the final exam, were also classified as "glaucoma likely" in the screening. Adjusted analysis revealed family history of glaucoma in first degree relatives and screening IOP > 21 mm Hg to have statistically significant associations with the final impression of "glaucoma likely." A combination of these findings gave an overall sensitivity of 81.7% with a specificity of 55%. CONCLUSIONS: In the study population, the combination of an IOP > 21 mm Hg and history of glaucoma in a first degree relative allowed the identification of a significant percentage of individuals with a higher risk of chronic open angle glaucoma, for which a complete glaucoma examination is indicated.