A case of successful treatment of a rare retinal disease presented by interferon-induced retinopathy.

OBJECTIVE: Aim: To showcase a rare retinal lesion and the results of contemporary diagnostic and treatment of interferon-induced retinopathy. PATIENTS AND METHODS: Materials and Methods: We describe a case of a 36-year-old patient with interferon-induced retinopathy, with hepatitis C, that received prolonged interferon treatment. Clinical signs, examination and combined laser and pharmacologic treatment were showcased in the study. RESULTS: Results: As a result of pharmacologic and laser treatment, the patient's visual acuity increased from 0.1 to 1.0 through the duration of 3 months after treatment. The patients` condition remained stable under dynamic observation. CONCLUSION: Conclusions: Because interferon-induced retinopathy is a rare occurrence in routine ophthalmologic practice, combined laser therapy can be used for treatment of preretinal hemorrhage, which leads to improvement of visual functions and stabilization of the retinal processes. This case is an addition to the few described cases of interferon-induced retinopathy.

Nd:YAG Laser Hyaloidotomy: A Therapeutic Approach for Valsalva Premacular Hemorrhage.

Subhyaloid hemorrhage, characterized by localized vitreoretinal detachment due to blood accumulation, often results in sudden vision loss, especially in the macular area. This case report highlights a 23-year-old female presenting with exercise-related Valsalva retinopathy leading to premacular subhyaloid hemorrhage. The patient underwent neodymium-doped yttrium aluminum garnet (Nd:YAG) laser hyaloidotomy, a non-invasive procedure, leading to rapid blood drainage and visual recovery. The patient's initial visual acuity was severely impaired, with a significant premacular hemorrhage obscuring the macula. A week later, due to the expanding hemorrhage, Nd:YAG laser hyaloidotomy was performed, demonstrating successful blood dispersion and restoration of vision. Follow-up revealed significant improvement with demarcation of the previous hemorrhage and no evidence of new findings. The case emphasizes the importance of prompt intervention and considers alternative treatments for premacular subhyaloid hemorrhage. While associated with ocular pathologies, such as macular holes and retinal detachment, Nd:YAG laser hyaloidotomy remains a safe and effective outpatient procedure for managing premacular subhyaloid hemorrhage, avoiding the risks of more invasive surgical interventions. The presented case highlights the significance of tailored interventions based on patient history, minimizing the need for invasive procedures and their associated risks.

Evaluation of the efficacy and safety of pars plana vitrectomy with irido-zonulo-hyaloidotomy for malignant glaucoma.

PURPOSE: To assess the efficacy and safety of pars plana vitrectomy with irido-zonulo-hyaloidotomy (IZH) for fluid misdirection syndrome (FMS) in pseudophakic eyes. METHODS: This was a retrospective case series study of patients treated with pars plana vitrectomy with IZH for FMS between February 2017 and March 2020. Complete success was defined as central anterior chamber (AC) deepening with an intraocular pressure (IOP) of 21mmHg or less (on 2 consecutive visits at least 1 week apart) without topical or systemic glaucoma medications. Qualified success was defined as central AC deepening with an IOP of 21mmHg or less (on 2 consecutive visits at least 1 week apart) with topical or systemic glaucoma medications. RESULTS: Twelve eyes of 12 patients with a diagnosis of FMS were included. The mean age of the population was 73.6±15.4 years [39-90] with a majority of women (58.3%). Prior surgeries at the time of FMS diagnosis were trabeculectomy (4 eyes) and non-perforating deep sclerectomy (2 eyes). At presentation, mean IOP was 38.2±9.8mmHg, which decreased to 17.9±7.7mmHg (P<0.0001) at final follow-up (mean follow-up of 4.9±4.3 months). Complete success was achieved in 6 eyes (50%) and qualified success in 10 eyes (83%), with two eyes failing treatment. There was no statistical significant relationship between demographic data and clinical success (P > 0.05). CONCLUSION: Pars plana vitrectomy combined with IZH appears to be a safe and effective technique for the treatment of FMS in pseudophakic patients.

Outcomes of Medical and Surgical Management in Aqueous Misdirection Syndrome.

Purpose: To report the outcomes of medical and surgical management in patients diagnosed with aqueous misdirection syndrome (AMS). Patients and Methods: A retrospective chart review of all cases diagnosed with AMS at a single tertiary care eye center during the period from 2014 to 2021. Outcome measures were anatomical success (deepening of the anterior chamber (AC)), functional success (improvement in visual acuity), and treatment success (control of intraocular pressure (IOP)). Results: A total of 26 eyes with AMS from 24 patients were included. The patients were followed for a mean duration of 24 ± 18 months. Although some patients initially responded to medical and laser therapy, all but one (3.8%) eventually required surgery during the first 3 months after presentation. The mean duration from presentation until surgery was 45.9 ± 45.8 days (range: 2-119 days). The majority of cases (69.2%) were managed by pars plana vitrectomy. At the last follow-up visit, anatomical success was achieved in 20 (76%) eyes, 15 (57%) eyes had a final visual acuity that was either similar to or better than baseline, and successful control of IOP was achieved in 17 (65%) eyes. Univariate analysis revealed that a history of trabeculectomy as a cause of AMS was a risk factor for treatment failure (OR, 7.8; 95% CI, 1.16-52.35; P, 0.02). Conclusion: Our findings indicate that medical and laser management of AMS provide temporary control, and almost all patients eventually require surgery within the first 3 months. A history of trabeculectomy was found to be a risk factor for treatment failure.

Spontaneous resolution of parafoveal macular hole post YAG hyaloidotomy in a case of Valsalva retinopathy.

PURPOSE: To report a rare case of spontaneous resolution of parafoveal macular hole post YAG hyaloidotomy in case of Valsalva retinopathy. METHODS: Case Report. RESULTS: A 29-year-old female presenting with sudden diminution of vision in her left eye (LE) for two months following a bout of vomiting was diagnosed with pre-macular haemorrhage. Patient was planned for YAG hyaloidotomy on the same day followed by propped up positioning. On follow up haemorrhage was seen to be cleared around macula with corresponding improvement of visual acuity. Patient was found to have developed a parafoveal hole post procedure which spontaneously healed without any intervention. Visual acuity was subsequently improved with resolution of macular hole as seen on fundus imaging and Optical coherence tomography (OCT). CONCLUSION: Pre-macular haemorrhage is quite common phenomenon in Valsalva retinopathy cases and YAG hyaloidotomy is an established surgical modality for management of the same in literature with good clinical outcomes. However, formation of macular hole is not very common but described in literature post procedure. It is a rare phenomenon to have spontaneous resolution of macular hole. Hence, observation can be an option for managing such cases.

A case of bilateral pseudophakic malignant glaucoma treated with a new variant of irido-zonulo-hyaloid-vitrectomy.

Purpose: To describe a case of bilateral pseudophakic malignant glaucoma treated with a new variant of irido-zonulo-hyaloid-vitrectomy. Observations: A patient who developed refractory bilateral pseudophakic malignant glaucoma underwent an irido-zonulo-hyaloid-vitrectomy via the anterior chamber in both eyes, one 2-months apart from the other. The procedure involved the use of an 18 Gauge needle to perform a straight vertical irido-zonulo-hyaloidotomy and a 25 Gauge vitreous cutter to complete the vitrectomy. The intraocular pressure was recorded on day 1, day 7, day 14, then monthly until 6 months postoperatively, whereas an ultrasound biomicroscopy of the anterior chamber was performed on day 1 and 6 months after the operation. The malignant glaucoma resolved in both eyes with no intra- nor post-operative complications. At 6 months from the surgeries none of the eyes developed recurrences. Conclusions: The new variant of irido-zonulo-hyaloid-vitrectomy we propose for the management of refractory pseudophakic malignant glaucoma resulted to be a safe and effective technique.

Postcoital visual loss due to valsalva retinopathy: A case report.

Valsalva retinopathy is a rare pathology presenting as a sudden and painless loss of vision affecting young subjects with no medical history. It is the result of an increase of intraocular venous pressure, leading to retrohyaloid haemorrhage. We describe here the clinical presentation of a retrohyaloid hemorrhage resulting from a valsalva mechanism following a sexual activity, in a 28-year-old patient treated by Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser hyaloidotomy with a visual recovery of 20/20 on 3 weeks follow-up. Valsalva retinopathy is a rare and an easy-to-diagnose pathology that is safely handled by Nd:YAG laser hyaloidotomy for a quick visual acuity recovery.

Successful Management of Malignant Glaucoma With Irido-Zonulo-Hyaloidotomy and Complete Pars Plana Vitrectomy.

Successful irido-zonulo-hyaloidotomy in combination with complete pars plana vitrectomy in malignant glaucoma may lead to better intraocular pressure (IOP) control and a promising visual outcome. We report a case of an 81-year-old woman who presented with a ten-day history of right eye redness and blurring of vision associated with throbbing pain. An ocular examination revealed right-eye visual acuity (VA) of 6/60. The cornea was oedematous with a shallow anterior chamber (AC) and a grade 0 (Shaffer's grading) by gonioscopy. The intraocular pressure at presentation was 52 mmHg. The optic disc was pink, with a cup-disc ratio of 0.3. Complete pars plana vitrectomy with irido-zonulo-hyaloidotomy was performed in view of poorly controlled intraocular pressure despite aggressive medical therapies, laser treatment, and the Chandler procedure. Postoperatively, the IOP was maintained at mid-teens without intraocular pressure-lowering agents. The visual acuity improved to 6/9. The early decision for irido-zonulo-hyaloidotomy with complete pars plana vitrectomy leads to resolution of malignant glaucoma with a lower relapse risk.

Role of Neodymium Double Frequency Laser Posterior Hyaloidotomy in Delayed Presentation of Sub-hyaloid Haemorrhage.

Laser hyaloidotomy with Nd: YAG or green argon laser is a non-invasive, out-patient procedure in which the posterior hyaloid face is punctured and the opening enables the drainage of sub-hyaloid haemorrhage into the vitreous. The blood is absorbed gradually and vision is improved within days with gradual clearance of the macular area. Researchers recommend laser treatment in recent haemorrhages (<2 weeks) while for delayed cases invasive surgeries are advised. We report a case of delayed presentation of sub-hyaloid haemorrhage (>3 weeks) treated successfully with laser hyaloidotomy.

Aqueous misdirection after Nd:YAG goniopuncture in deep sclerectomy treated with Nd:YAG irido-zonulo-hyaloidotomy.

BACKGROUND: To report a case of aqueous misdirection after goniopuncture in deep sclerectomy treated with Nd:YAG laser irido-zonulo-hyaloidotomy. CASE PRESENTATION: About 72 years old patient with pseudoexfoliation glaucoma who underwent deep sclerectomy, developed aqueous misdirection after Nd:YAG laser goniopuncture. Medical management failed and subsequent peripheral Yag laser iridotomy to expose the zonules coupled with laser zonulo-hyaloidotomy was done and an instant gush of aqueous and vitreous substance prolapse through the iridotomy was noticed. Later, the anterior chamber was deep and the pressure was controlled. CONCLUSIONS: Aqueous misdirection can occur after Nd:YAG laser goniopuncture. Nd:YAG laser irido-zonulo-hyaloidotomy can be effective in breaking the attack.

Clinical variations and therapeutic challenges in the management of symptomatic retinal artery macroaneurysm: a tertiary center experience.

PURPOSE: To find out clinical characteristics, therapeutic options, and visual outcome in symptomatic retinal artery macroaneurysm (RAMA) patients. METHOD: Newly diagnosed cases of symptomatic RAMA from January 2015 to December 2019 were included. Fifteen eyes of 15 patients with mean age 62.46 years ± 14.89 (SD) fulfilled the inclusion criteria. RESULT: Hypertension was present in 66.6% of the patients, and the commonest site was superotemporal (12 eyes, 80%). The most commonly employed treatment was Nd: Yag laser hyaloidotomy in 4 eyes (26.6%). Other treatments were intravitreal bevacizumab in 3 eyes (20%), focal laser with intravitreal bevacizumab in 3 eyes (20%), PPV with focal laser (13.3%) in 2, focal laser only in one (6.6%), PPV with focal and intravitreal bevacizumab in one (6.6%). The mean best-corrected visual acuity (BCVA) at baseline was 1.35 ± 0.84 LogMAR, which improved to 0.39 ± 0.53 LogMAR at the last follow-up. Presenting VA 0.77 (±0.40) improved to 0.20 (±0.17) p value (0.180) in intravitreal bevacizumab only group, 1.29 (±0.35) to 0.75 (±0.15) p value 0.66 in Nd: Yag laser group, 2.67 (±0.58) to 0.46 (±0.28) p value 0.019 in PPV group and did not improve in combined anti-VEGF and focal laser group due to dense hard exudates at the fovea in one and persistent cystoid macular edema in another case. CONCLUSION: With regard to its presentation, which can vary tremendously, there are no approved guidelines for its treatment. The present study reinforces the need for a treatment guideline development. Customization of treatment should be considered depending on the clinical presentation of each case.

Clinical efficacy of inferior peripheral irido-capsulo-hyaloidotomy for pseudophakic malignant glaucoma.

PURPOSE: The present research aimed to investigate the effects of Inferior peripheral irido-capsulo-hyaloidotomy for the management of pseudophakic malignant glaucoma. METHOD: Ten pseudophakic eyes with aqueous misdirection were diagnosed between September 2017 and December 2018 (10 eyes of 8 patients), which were included in the prospective consecutive case series study. Seven eyes underwent Inferior laser peripheral irido-capsulo-hyaloidotomy, and three eyes underwent pars plana vitrectomy, zonulo-capsulo-hyaloidectomy, and inferior iridectomy. RESULTS: Eight eyes (80%) had angle-closure glaucoma. The mean duration of the follow-up was 12.25 ± 3.05 months (ranging from 10-18 months). The patients had a mean age of 69.25 ± 6 years. The IOP at the onset of malignant glaucoma was found to be 33.8 ± 5.5 mmHg, which was reduced to 13.9 ± 2.7 mmHg at the final visit (P value = 0.002). The reduction in the number ± SD of anti-glaucoma medications (3.3 ± 0.48 to 1.4 ± 0.51) and improvement in mean ± SD LogMAR visual acuity (1.2 ± 0.06 to 0.61 ± 0.26) between the onset and final visit were significant (p = 0.004 and P = 0.005, respectively). All the patients responded to Inferior peripheral irido-capsulo-hyaloidotomy (with YAG laser or with the surgical procedure), which led to a significant reduction in intraocular pressure (IOP) and deepening of the anterior chamber. CONCLUSION: The success rate of peripheral irido-capsulo-hyaloidotomy with laser or surgical procedure in the inferior quadrant was high regarding pseudophakic malignant glaucoma patients. The establishment of a patent inferior communication between the vitreous cavity and the anterior chamber was the main component in the treatment of pseudophakic malignant glaucoma patients.

Valsalva retinopathy: Long-term results and management strategies.

PURPOSE: To investigate the long-term results and efficacy of the treatment modalities for preretinal hemorrhage due to valsalva retinopathy. METHODS: Retrospective review was conducted on 24 eyes of 24 patients with valsalva retinopathy who were treated between 2004 and 2019. These patients were treated with Nd:YAG laser, argon laser and vitrectomy or were only observed. Nd:YAG laser hyaloidotomy was performed in 10 eyes, argon laser was applied to two of those following failed Nd:YAG laser, and vitrectomy was performed in one eye. A conservative approach was adopted in 13 eyes. RESULTS: There were 15 females and nine males with mean age of 41.08 ± 12.72 (21-65) years. Mean follow-up period was 42.83 ± 23.78 (range: 12-116) months. Patients with hemorrhage size smaller than or equal to 4-disc diameter were observed for spontaneous resorption and achieved 20/20 visual acuity within 6 months. Visual acuity of all patients treated with Nd:YAG and/or argon laser, increased within the first week after the treatment. Vitrectomy was performed in only one patient with hemorrhage located away from macula. The good visual outcomes were achieved in all treatment modalities. CONCLUSIONS: Observation, Nd:YAG laser and argon laser seem to be safe and effective approaches for eyes with valsalva retinopathy. The size, volume and duration of hemorrhage are the most crucial factors for treatment choice, success and complications.

Treatment outcomes and efficacy of pars plana vitrectomy-hyaloidotomy-zonulectomy-iridotomy in malignant glaucoma.

AIM: To study the treatment outcomes and efficacy of pars plana vitrectomy-hyaloidotomy-zonulectomy-iridotomy in malignant glaucoma. METHOD: A retrospective case series study of patients treated for malignant glaucoma between 2005 and 2017. The treatment included medical management as first-line in the form of cycloplegic with anti-glaucoma medications (AGM) or pars plana vitrectomy-hyaloidotomy-zonulectomy-iridotomy as second-line therapy. The resolution was defined as 'deepening of central anterior chamber' with intraocular pressure of ⩽ 21 mm Hg (minimum on two consecutive visits 1 week apart) with or without topical anti-glaucoma medications in the absence (complete success) or presence (qualified success) of systemic medications. RESULTS: Twenty-three eyes of 22 patients were included. At the time of diagnosis of malignant glaucoma preceding surgeries were cataract surgery (13 eyes) and trabeculectomy (4 eyes). One eye each had phacotrabeculectomy, Yag capsulotomy and optical keratoplasty. Eighteen eyes were pseudophakic and two eyes were phakic. At presentation, mean intraocular pressure was 26.25 ± 14.78 mmHg which was decreased to 15.90 ± 8.12 mmHg (p < 0.0001) at final follow-up (median follow-up was 15.50 months). Fifteen (75%) eyes had complete success, 3 (15%) eyes had qualified success and 2 (10%) eyes had treatment failure. Of 15 eyes that had achieved complete success, 3 eyes had undergone medical management and 12 eyes undergone second-line procedure. There was no significant difference in visual acuity or number of anti-glaucoma medication at presentation and final follow-up (p > 0.05). CONCLUSIONS: Though malignant glaucoma is highly refractory to treatment, appropriate management in the form of medical or vitrectomy-hyaloidotomy-zonulectomy-iridotomy could achieve 90% success in this series.

TREATMENT OPTIONS FOR PREMACULAR AND SUB-INTERNAL LIMITING MEMBRANE HEMORRHAGE.

INTRODUCTION: Premacular hemorrhage (PH) and sub-internal limiting membrane hemorrhage (sub-ILM-H) are among the causes of sudden deterioration of central visual acuity. Anatomical and functional outcomes of different therapeutic options were evaluated retrospectively. METHODS: The study included three eyes of three patients (2 females and 1 male). Location of the hemorrhage was determined by spectral domain optical coherence tomography. Subhyaloid premacular location of the hemorrhage was proven in one eye of each woman and sub-ILM location of the hemorrhage in one eye of the male. The baseline best corrected visual acuity (BCVA) was 0.63 in the eyes of the females and 0.16 in the eye of the male. Conservative treatment option was chosen in case of juxtafoveolar PH in the eye of the female patient on anticoagulant warfarin therapy. The female patient with PH secondary to proliferative diabetic retinopathy (PDR) underwent Nd: YAG laser hyaloidotomy. The male patient with unexplained cause of the sub- ILM-H underwent 25-Gauge vitrectomy with ILM peeling and subsequent ultrastructural morphometric and histopathological examination of the ILM. RESULTS: Both BCVA and retinal finding improvement were achieved in all patients. Final BCVA was 0.8 in the eye of the female patient with PDR and 1.0 in rest of the eyes of the other patients. No complications were recorded at follow-up visits. Histopathological and morphometric examination demonstrated variable ILM thickness (2.70 ±1.58 μm) and proved presence of fibroblasts and macrophages with hemosiderin deposits on the retinal side of ILM. CONCLUSION: The choice of the treatment option of PH and sub-ILM-H depends on input parameters such as the initial BCVA, the extent and the location of the hemorrhage, as well as the overall health of the patient. Nd: YAG laser hyaloidotomy is an effective method for rapid recovery of visual functions. Surgical ILM peeling and aspiration of the underlying hemorrhage result in the removal of breakdown products of hemoglobin and minimization of the risk of secondary epiretinal membranes development.

Management of Pseudophakic Malignant Glaucoma in Sunset Syndrome: A Case Report and Literature Review.

To present an interesting case of pseudophakic malignant glaucoma in sunset syndrome, which potentially points to a correlation between a posterior chamber intraocular lens (PCIOL) subluxation and development of aqueous misdirection. Furthermore, we underlined the effectiveness of YAG-laser hyaloidotomy as a first line treatment for malignant glaucoma. This is a case report and literature review. A 76-year-old male with primary open angle glaucoma (POAG) with a history of left monocular diplopia due to inferior dislocation of the PCIOL (sunset syndrome), presented with a sudden onset of pain in the left eye and decreased visual acuity with corrected distance visual acuity (CDVA) of 20/60, seven years after an uneventful left phacoemulsification. The anterior chamber (AC) was shallow, the intraocular pressure (IOP) elevated and the PCIOL extruded in AC. Aqueous misdirection was diagnosed and treated with YAG laser hyaloidotomy. A gush of fluid emerged with simultaneous deepening of the AC and the IOP dropped immediately to 24 mmHg and later to 9 mmHg. A prophylactic YAG peripheral iridotomy was also performed. An IOL exchange surgery with anterior chamber IOL placement was performed a few days later resulting in a final CDVA of 20/30. We argue that postoperative subluxation of a PC IOL is likely to be an initiating event for aqueous misdirection.

Recurrent pre-retinal haemorrhages associated with coagulation factor VII deficiency. / Hemorragias prerretinianas de repetición asociadas a déficit del factor VII de la coagulación.

The case concerns a 20 year-old woman with a sudden visual loss in her left eye. In the fundus examination, a focal pre-retinal haemorrhage was observed in the superior temporal vascular branch with accompanying vitreous haemorrhage. There was a favourable spontaneous outcome. Eighteen months later, she presented with a new visual loss in the same eye, showing a sub-hyaloid pre-macular haemorrhage that was satisfactorily drained by hyaloidotomy using a Nd-YAG laser. The patient had also presented with an upper digestive tract haemorrhage and menorrhagia. A haemostasis study was performed that showed a coagulation factor VII deficiency. This is a very uncommon disorder that has not been previously described in association with the appearance of pre-retinal haemorrhages.

Nd:YAG laser therapy for non-resolving premacular subhyaloid hemorrhage in Saudi patients.

PURPOSE: To report anatomical and visual outcomes of Nd:YAG laser posterior hyaloidotomy (NYPH) in Saudi patients affected by Premacular subhyaloid haemorrhage (PMSHH). METHODS: 8 eyes from 8 patients (7 males and one female) were treated with NYPH when no spontaneous resolution of PMSHH was noticed. The cause of PMSHH was proliferative diabetic retinopathy (PDR) in 3 cases, Central retinal vein occlusion (CRVO) in 2 cases, Valsalva retinopathy in 2 cases, and laser pointer injury in one case. The YAG laser was delivered using a Q switched mode and 3 mirrors contact lens. One attempt of laser delivery was enough in 6 cases and 2 cases needed 2 attempts. The laser power needed ranged between 2 and 4 mJ. RESULTS: Anatomical success was achieved in all cases. The mean LogMAR VA improved from 1.5 before treatment to 0.3 post-treatment. The difference is statistically significant (p = 0.012). No complications related to Nd:YAG laser therapy was reported in any of the study cases until the last follow up. CONCLUSION: To our knowledge, this is the first study to report the outcomes of NYPH for non-resolving PMSHH in Saudi cases. In this small cases series, the procedure seems to be safe, effective, simple, cheap, and non-invasive treatment modality for this disorder that is conducted in the outpatient setting. We think it should be considered as a first option for cases of SHH covering the fovea due to various aetiologies.