Spontaneous hyphema from iris microhemangioma in Eisenmenger syndrome.

Purpose: We describe a patient with Eisenmenger syndrome and spontaneous hyphema from iris microhemangioma, two rare entities with a plausible pathophysiological connection. Observations: A 56-year-old Caucasian female with a background of cyanotic congenital heart disease complicated by Eisenmenger syndrome presented with non-traumatic hyphema and blurred vision. Multiple vascular tufts consistent with iris microhemangiomas were observed around the pupil margins bilaterally, with no iris or retinal neovascularization. In the affected eye, there was active bleeding from one lesion at 12 o'clock generating a macrohyphema. Additional findings included prominent episcleral injection and retinal venous tortuosity in both eyes. The active microhemorrhage and hyphema resolved with local medical management. Conclusions and importance: Chronic hypoxemia and erythrocytosis are known to induce dilation of the retinal and episcleral blood vessels in Eisenmenger syndrome. Corresponding dilation of iris stromal vessels may contribute to the formation and prominence of iris microhemangiomas.

A unique case of Paracentral Acute Middle Maculopathy with associated cystoid macular oedema post uncomplicated pterygium surgery.

PURPOSE: To present a unique and unusual case of Paracentral Acute Middle Maculopathy (PAMM) with associated cystoid macular oedema (CMO) following ocular surface surgery in a low risk patient. OBSERVATIONS: This observational case report describes the presentation of a single case of Paracentral Acute Middle Maculopathy following pterygium surgery. The patient harboured no risk factors and underwent uncomplicated pterygium surgery with no perioperative complications. Post-operatively the patient demonstrated marked visual acuity loss to count fingers only to the operated eye. Optical Coherence Tomography demonstrated hyper-reflective band-like lesions affecting the middle layers of the retina, pathognomonic for PAMM. Unusually, cystoid macular oedema was also evident. He was managed on topical and oral therapy, with limited visual recovery. CONCLUSIONS AND IMPORTANCE: We report a rare and unique case of PAMM with associated cystoid macular oedema occurring in a patient deemed low risk following pterygium surgery resulting in significant permanent visual loss. To our knowledge, this is the first reported incidence of PAMM following ocular surface surgery.

Central retinal vein occlusion secondary to severe iron-deficiency anaemia resulting from a plant-based diet and menorrhagia: a case presentation.

In this case presentation, we present a young vegan patient who developed a CRVO secondary to severe iron-deficiency anaemia (IDA) attributable to menstrual losses and limited iron intake. CRVO is a rare complication of IDA.With rising calls for sustainable diets and rising evidence for a plant-based diet, there has been a rise in popularity of such diet forms. While there are ocular benefits from this diet trend, the potential for nutritional deficiencies including iron needs to be monitored especially in susceptible individuals. Iron is essential for retina metabolism and function; however, excess iron contributes to disease states in the eye. Therefore, supplementation needs to be judicious.

Management of inflammatory choroidal neovascularization (CNV) secondary to punctate inner choroidopathy in a young female of childbearing age with intra-vitreal ranibizumab and half-fluence photodynamic therapy (PDT) - a holistic approach.

Choroidal neovascularization (CNV) may occur in up to 40% of patients with punctate inner choroidopathy (PIC). We report a case of a young woman of childbearing age treated successfully for an inflammatory choroidal neovascular membrane (CNV) secondary to PIC with a combination of intravitreal ranibizumab and photodynamic therapy (PDT).

Delayed dislocation of an injectable hydrophilic acrylic lens after Nd:YAG capsulotomy in anterior capsular contraction syndrome.

Posterior dislocation of IOLs has been reported following Nd:YAG laser for anterior capsule contraction in only 3 cases and these involved plate haptic silicone lenses; while the dislocation of IOLs into the vitreous cavity following posterior Nd:YAG laser capsulotomy have been reported in plate haptic silicone lenses and single piece hydrophilic acrylic (polymacon) lenses. We report a patient who suffered the delayed dislocation of an injectable hydrophilic acylic IOL (SlimFlex-m 123 IOL, PhysIOL, Liège, Belgium) following combined Nd:YAG laser anterior and posterior capsulotomy. We also explore the factors that may predispose to anterior capsular contraction syndrome and IOL dislocation.

Visual and optical coherence tomography outcomes of intravitreal bevacizumab and ranibizumab in inflammatory choroidal neovascularization secondary to punctate inner choroidopathy.

PURPOSE: Choroidal neovascular membranes (CNV) are the major cause of visual loss in punctate inner choroidopathy (PIC), an idiopathic inflammatory condition predominantly affecting young, myopic women. We present a case series of 9 patients with CNV associated with PIC, treated with intravitreal anti-vascular endothelial growth factor agents. METHODS: This is a retrospective case series of 9 patients treated with either intravitreal bevacizumab or ranibizumab for inflammatory CNV secondary to PIC. Initial and posttreatment converted logMAR visual acuity, fundus fluorescein angiograms (FFA), optical coherence tomography (OCT), previous and concurrent treatments, and side effects were recorded. Informed consent for treatment was obtained from each patient. RESULTS: Nine patients (8 female, 1 male) with an average age of 34.4 years were treated for an average of 14.9 months. Six patients were treated with bevacizumab, and 3 with ranibizumab, with a mean of 2.34 injections per year. The mean visual acuity gain for the whole group of 9 patients was 0.26 converted logMAR units (Wilcoxon signed-rank test, p<0.015). Eight patients remained stable or had visual improvement at final follow-up, with a mean gain of 0.36 converted logMAR units. Only one patient's vision deteriorated (loss of 0.48 converted logMAR units). Concomitant short courses of oral corticosteroid were used in 3 of the 9 patients. CONCLUSIONS: Over a 1-year period, bevacizumab and ranibizumab can be safely and successfully used to treat inflammatory CNV secondary to PIC, avoiding the need for systemic immunosuppression in the majority of patients.

Lens reabsorption following self-induced needling and subsequent intracapsular secondary intraocular lens placement.

We present the case of a young man who inadvertently penetrated his cornea and lens with a needle used for injecting heroin. Three years later, the lens had completely reabsorbed leaving a fibrosed capsular bag. We describe the surgical techniques used to insert a secondary intraocular lens into the capsular bag with excellent visual outcome.

Biologics in the treatment of uveitis.

PURPOSE OF REVIEW: This review summarizes the current evidence for biologic therapies in the treatment of uveitis. The review emphasizes published research in this field since 2005. RECENT FINDINGS: The anti-tumour necrosis factor-alpha infliximab and adalimumab have demonstrated significant efficacy in controlling uveitis associated with seronegative spondyloarthropathies and juvenile idiopathic arthritis; however, etanercept has failed to show a similar treatment effect in uveitis associated with these conditions. The majority of reports of biologic therapies in posterior uveitis have been uncontrolled trials, or retrospective studies, of uveitis resistant to immunosuppression. Encouragingly, successful control of such refractory intraocular inflammation has been consistently reported with infliximab and interferon alpha, particularly Behcet's disease-associated uveitis. A limited number of reports of anti-interleukin therapies, daclizumab and anakinra, have supported a role for these therapies in some types of uveitis. SUMMARY: Biologic therapies have increased the treatment options for sight-threatening uveitis. Despite experimental rationale, the lack of evidence from randomized controlled studies limits our understanding of when to commence therapy, which agent to choose and how long to continue treatment. Additionally, the high cost and potential side effects of all biologic agents have limited their current use to uveitis refractory to immunosuppression.

Epithelial downgrowth as a complication of toxic anterior segment syndrome.

We present a case of epithelial downgrowth that arose within 1 month of routine clear corneal phacoemulsification. The case was complicated by unexplained total corneal edema from the first postoperative day. Histological analysis following penetrating keratoplasty showed complete endothelial cell loss and an epithelial cyst on the internal surface of Descemet's membrane.

Age-related macular degeneration and recent developments: new hope for old eyes?

Age-related macular degeneration (AMD) is the commonest cause of blindness in the population over 60 years of age and accounts for over 50% of those registered blind in the UK. The incidence is increasing and as older generations live longer a growing number of patients will be affected in the future. Affected patients lose central vision, important in all aspects of everyday life. This review outlines risk factors for AMD, clinical features, treatment and management strategies for patients, families and physicians caring for those with AMD. Recent trials are included along with practical clinical advice. While there is no curative treatment at present, intervention can reduce the risk of developing AMD and limit disease progression if it occurs. These modalities are discussed here. As new discoveries in the field of genetics and novel therapies emerge, a brighter future seems certain for the ageing population.

Nonsteroidal drugs for the treatment of noninfectious posterior and intermediate uveitis.

PURPOSE OF REVIEW: This review summarizes current nonsteroidal drug therapies for noninfectious posterior and intermediate uveitis. RECENT FINDINGS: Continuing evidence shows that second-line agents including antimetabolites, T-cell inhibitors and alkylating agents, are effective in many patients, allowing reduction in steroid dose and preservation of visual function. There is an increased use of mycophenolate mofetil. Biologic therapies, including the antitumour necrosis factor-alpha agents and interferons, have demonstrated a high degree of efficacy in controlling uveitis refractory to immunosuppressants. SUMMARY: There are an increasing number of treatment options. As the vast majority of published studies in uveitis are case series or nonrandomized trials, there remains a lack of level 1 evidence to guide the choice and duration of therapy. Standard initial treatment for steroid-resistant disease is to add a single immunosuppressant to the regime, with additional agents being substituted or added as required. Combination of two immunosuppressants in addition to steroids may be indicated especially in chronic uveitis. High cost and limited long-term experience with biologic agents have restricted their use to uveitis refractory to immunosuppressants, but evidence suggests a potential therapeutic role earlier in Bechet's disease.