NIVOLUMAB-INDUCED HARADA-LIKE UVEITIS WITH BACILLARY DETACHMENT MIMICKING CHOROIDAL METASTASIS.

PURPOSE: To describe a patient with metastatic clear cell renal cell carcinoma in remission on maintenance nivolumab therapy who developed late-onset ocular toxicity manifesting as creamy chorioretinal lesions with exudative retinal detachment concerning for choroidal metastasis. METHOD: Case report. Main outcome measures include ophthalmoscopic examination, fundus photography, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, spectral domain optical coherence tomography, and B-scan ultrasonography. RESULTS: A 49-year-old woman with a medical history of metastatic clear cell renal cell carcinoma in remission for two years after immunotherapy with four cycles of ipilimumab and nivolumab followed by maintenance nivolumab infusions developed lesions concerning for choroidal metastases in her right eye. Optical coherence tomography of the lesions revealed a bacillary layer detachment containing possible fibrinous exudate organized into layers and underlying choroidal thickening with chorioretinal folds. Later, choroidal thickening and chorioretinal folds also occurred in the left eye. Given that pan imaging detected no metastasis and the posterior segment abnormalities resolved after cessation of nivolumab and treatment with systemic corticosteroids, the patient was diagnosed with nivolumab-induced Vogt-Koyanagi-Harada-like uveitis. CONCLUSION: This case expands on the clinical spectrum of nivolumab-induced Vogt-Koyanagi-Harada-like uveitis, a condition that can also present with bacillary layer detachment mimicking an early choroidal metastasis, manifest asymmetrically in each eye, and develop after long-standing treatment.

A 48-YEAR-OLD CAUCASIAN MAN WITH UNILATERAL "SMUDGE" IN INFERIOR VISUAL FIELD.

PURPOSE: To report an increasingly prevalent fundoscopic manifestation of syphilitic uveitis. METHODS: Case report of a patient with acute retinal necrosis secondary to syphilis. RESULTS: A 48-year-old man presented with decreased vision, anterior segment inflammation, and a wedge-shaped retinal lesion in the superior periphery, with a diaphanous leading edge extending down toward the superior arcade. The patient was HIV+ and poorly compliant with therapy. The top three differential diagnoses were herpetic necrotizing retinitis, syphilis, and lymphoma. An extensive lab workup was positive for syphilis. The patient was treated with IV penicillin G and demonstrated improvement in visual acuity and examination. CONCLUSION: There have been an increasing number of reports of syphilis patients, especially in the population of men who have sex with men, who present with fundus findings similar to acute retinal necrosis. These findings include a characteristic ground glass, translucent appearance of unifocal or multifocal lesions, primarily affecting the inner retina and sometimes associated with co-localizing occlusive vasculitis. Treatment with IV penicillin G is warranted and has demonstrated good visual recovery.

CLINICAL AND STRUCTURAL IMPACT OF SUBMACULAR FLUID AFTER PNEUMATIC RETINOPEXY REPAIR FOR RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: To assess the impact of submacular fluid (SMF) after pneumatic retinopexy for primary rhegmatogenous retinal detachment repair. METHODS: Retrospective review of consecutive patients treated with pneumatic retinopexy for primary rhegmatogenous retinal detachment repair. 387 eyes (374 patients) were included, of which 166 underwent optical coherence tomography imaging after successful pneumatic retinopexy. Foveal-centered optical coherence tomography scans were reviewed. RESULTS: SMF occurred in 59 eyes (35.5%) and was associated with macular detachment ( P ≤ 0.001) and phakic lens status ( P = 0.007). Submacular fluid resolved over an average of 9.39 months and was associated with worse preprocedure best-corrected visual acuity and delayed visual recovery. The mean final best-corrected visual acuity was 0.277 logarithm of the minimum angle of resolution (20/40) in eyes with SMF and 0.162 logarithm of the minimum angle of resolution (20/30) in those without SMF ( P < 0.001). Submacular fluid was associated with discontinuity of the interdigitation zone ( P = 0.003), ellipsoid zone ( P = 0.005), and external limiting membrane ( P ≤ 0.001) after SMF resolution. Ellipsoid zone discontinuity was associated with worse visual prognosis ( P = 0.009). CONCLUSION: Trace SMF detected by optical coherence tomography is common after successful pneumatic retinopexy and resulted in delayed visual recovery and increased rates of outer retinal discontinuity after SMF resorption, although the final difference in best-corrected visual acuity in those with and without SMF was minimal.

Multimodal imaging of soccer ball-related ocular posterior segment injuries.

PURPOSE: To investigate the clinical and anatomic characteristics of soccer ball-induced posterior segment injuries in the era of modern multi-modal imaging. METHODS: Retrospective case series of patients with soccer ball injury and diagnostic imaging from 2007 to 2020 at a single vitreoretinal practice. RESULTS: Eight patients met inclusion criteria. Fundus photographs (FP) and optical coherence tomography (OCT) were obtained in eight patients, fundus autofluorescence (FAF) in five patients, fluorescein angiography (FA) in three patients, and en-face OCT and OCT-Angiography (OCT-A) were obtained in two patients each. FA and FAF identified traumatic pigment epitheliopathy secondary to commotio. Increased hypo-autofluorescence was associated with shallow, peripheral retinal detachment on FAF. OCT of the macula displayed outer retinal changes associated with commotio, and offered insight into the acute and subacute changes of traumatic macular hole formation. A patient displayed foveal hyper-reflectivity in the shape of an hourglass with retinal cyst at the level of the external limiting membrane (ELM) as seen on OCT and En-face OCT. A patient with commotio involving the macula lacked microvascular changes on OCT-A. CONCLUSION: OCT, FA, and FAF imaging may aid in the work-up and management of the soccer ball-related posterior segment injuries.

Optic disc edema with peripapillary serous retinal detachment as the presenting sign of necrotizing herpetic retinitis.

PURPOSE: To describe an atypical case of necrotizing herpetic retinitis (NHR) that presented initially with mild anterior uveitis, optic disc swelling, and peripapillary serous retinal detachment (SRD). OBSERVATIONS: A 48-year-old Asian Indian man presented with blurred central vision and pain in his left eye. Examination revealed mild anterior chamber inflammation, optic disc swelling, and a peripapillary SRD in the affected eye. Multimodal imaging, including widefield fluorescein angiography, showed optic disc leakage and confirmed the presence of a peripapillary SRD, but was otherwise unremarkable with no evidence of retinitis. The patient was diagnosed with presumed Vogt-Koyanagi-Harada disease and was treated with systemic corticosteroids. While there was objective visual improvement initially, the patient subsequently noted peripheral vision loss and was found to have peripheral necrotizing retinitis and occlusive retinal vasculitis in affected eye. Polymerase chain reaction-based testing of aqueous humor detected varicella zoster virus DNA, confirming the diagnosis of NHR. CONCLUSION AND IMPORTANCE: Optic disc edema and peripapillary SRD may precede the development of overt retinitis in some patients with NHR.

OCULAR INJURIES ASSOCIATED WITH ELASTIC EXERCISE BANDS.

PURPOSE: To discuss the mechanism of injury and characterize the clinical features of ocular trauma associated with elastic cord exercise equipment band injuries in a consecutive series of patients seen at a single vitreoretinal surgery practice. METHODS: We performed a retrospective review of all patients who were treated for blunt trauma from 2013 to 2020 at a single vitreoretinal practice. RESULTS: Thirteen eyes from 11 patients met the inclusion criteria of possessing ocular trauma secondary to recoil from exercise bands. Presenting visual acuity ranged from 20/16 to HM (median: 20/32). The most frequently observed anterior segment pathologies were traumatic iritis (54%) and angle recession (31%). The most common posterior segment findings were vitreous hemorrhage (54%) and peripheral commotio retinae (54%). Three eyes (23%) required surgical intervention. Follow-up intervals ranged from 0 to 10 months (median: 1.75 months). Visual acuity at last examination ranged from 20/13 to 20/400 (median: 20/40). CONCLUSION: A wide spectrum of serious ocular injuries requiring medical and surgical intervention can result from this form of blunt ocular trauma. The frequency of this event would be decreased by the use of sports goggles and careful inspection of equipment for wear and over use.

Vitreoretinal lymphoma following primary testicular lymphoma: Report of two cases and review of the literature.

PURPOSE: To report two cases of vitreoretinal lymphoma that developed following primary testicular lymphoma and review the literature. OBSERVATIONS: Two men, one age 66 and the other age 77, both with a history of diffuse large B-cell testicular lymphoma, diagnosed one and three years previously, respectively, presented with vitritis and yellow-white subretinal infiltrates. Diagnostic vitrectomy in both cases revealed diffuse large B-cell lymphoma. Systemic work up in both cases showed no evidence of disease relapse elsewhere. Each were treated with intravitreal methotrexate injections. CONCLUSIONS: Vitreoretinal lymphoma can occur following primary testicular lymphoma, and may mimic primary vitreoretinal lymphoma. Monitoring of patients with a history of testicular lymphoma with regular dilated fundus examinations should be considered.

Directional Reflectivity of the Ellipsoid Zone in Dry Age-Related Macular Degeneration.

BACKGROUND AND OBJECTIVE: Ellipsoid zone (EZ) reflectivity on optical coherence tomography (OCT) is affected by the orientation of the scanning beam. The authors sought to determine how directional reflectivity changes in dry age-related macular degeneration (AMD). PATIENTS AND METHODS: Retrospective image analysis included 17 control and 20 dry AMD subjects. Directional OCT (D-OCT) was performed using multiple displaced pupil entrance positions. EZ pixel values and apparent incidence angles were measured. RESULTS: EZ reflectivity decreased in off-axis scans in controls (P < .001), AMD areas between drusen (P < .001), and AMD areas overlying drusen (P < .001). The magnitude of decrement in EZ reflectivity was significantly higher when incidence angles exceeded 10° in controls than in AMD areas between drusen (P = .024). CONCLUSION: EZ reflectivity in dry AMD may vary by incident angle of light less than in controls, possibly indicating alteration of photoreceptor orientation or integrity. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:145-152.].

PARACENTRAL ACUTE MIDDLE MACULOPATHY ASSOCIATED WITH IDIOPATHIC INTRACRANIAL HYPERTENSION.

PURPOSE: Paracentral acute middle maculopathy (PAMM) is a recently identified clinical entity with numerous retinal vascular and systemic associations. To our knowledge, this is the first reported case of PAMM associated with idiopathic intracranial hypertension. METHODS: A case is presented with multimodal imaging. RESULTS: A patient with idiopathic intracranial hypertension is found to have the characteristic clinical, spectral domain optical coherence tomography, and OCT angiography findings associated with PAMM. CONCLUSION: Paracentral acute middle maculopathy is believed to arise from a microvascular insult to the retinal deep capillary plexus. We add a previously undescribed association with idiopathic intracranial hypertension to the list of etiologies that can cause PAMM.

Cardiopulmonary Resuscitation Retinopathy in an Adult.

A man developed vision loss and bilateral subhyaloid, outer plexiform, and subretinal hemorrhages after 2 minutes of chest compressions. Several potential mechanisms, including venous transmission of pressure and elevated intracranial pressure (ICP), could explain these findings.

FINGERPRINT SIGN OF THE HENLE FIBER LAYER.

PURPOSE: To describe the appearance of concentric, fingerprint-like waves within the Henle fiber layer (HFL) using en face optical coherence tomography in patients with tractional pathologies of the retina. METHODS: Retrospective analysis of six eyes of six patients imaged by optical coherence tomography with volumetric slabs positioned at the level of the HFL. RESULTS: Optical coherence tomography data from six patients with tractional vitreoretinal pathology were reviewed. Concentric, fingerprint-like microwaves were visualized through en face optical coherence tomography in all six study eyes at the level of the HFL. This finding resembled the finding of HFL waves previously noted histopathologically from force exerted on this layer. CONCLUSION: In retinal pathologies in which specific physical forces act on the retina, volumetric optical coherence tomography may permit visualization of en face concentric, fingerprint-like hyperreflective rings within the HFL. This "fingerprint sign" may represent a biomechanical consequence of traction on the retina and allow clinical decision making based on improved recognition of the existence of such traction.

RETINAL ARTERIOVENOUS MALFORMATION.

PURPOSE: To describe a case of an isolated Group 3 retinal arteriovenous malformation (AVM). METHODS: Observational case report. RESULTS: A 15-year-old girl with no significant medical history presented with no light perception vision in her right eye and gradually decreasing vision in her left eye over several years. She was found to have a large AVM in the posterior pole of the right eye with associated perivascular sheathing in the periphery. Her left eye seemed totally unremarkable. Neuroimaging revealed no intracranial or intraorbital abnormalities. A diagnosis of isolated Group 3 retinal AVM was made. CONCLUSION: Retinal AVMs are congenital, nonhereditary, and sporadic vascular anomalies that develop in the posterior pole. A number of patients with this finding can have coexisting AVMs in the brain, mandible, skin, or orbit, which comprises the Wyburn-Mason syndrome. Because of these systemic associations, neuroimaging should always be considered when a retinal AVM is seen. Severe vision loss can occur from these AVMs secondary to a number of ocular complications, including central retinal vein occlusions.

Rhegmatogenous Retinal Detachment in Patients with Acute Syphilitic Panuveitis.

PURPOSE: To describe the clinical characteristics and surgical management of rhegmatogenous retinal detachment (RD) in patients with acute syphilitic panuveitis. METHODS: Retrospective case series and comprehensive literature review. RESULTS: Including present and previously reported cases, we identified 11 eyes in 8 patients with acute syphilitic panuveitis that developed a rhegmatogenous RD. Seven of 11 eyes (63.6%) were repaired with a combined scleral buckling, vitrectomy, and endolaser photocoagulation surgery; 1 eye (9.1%) was repaired with scleral buckling only; and 2 eyes (18.2%) with vitrectomy only. Cryotherapy was used to treat a giant retinal tear in 1 eye (9.1%). Four eyes (36.4%) redetached and 3 underwent a second vitrectomy surgery. CONCLUSIONS: Although uncommon, rhegmatogenous RD can occur in patients with moderate to severe acute syphilitic panuveitis. We believe scleral buckling, vitrectomy, endolaser photocoagulation, and silicone oil tamponade give the best chance for successful retinal reattachment.

Choroidal metastases 34 years after remission of breast cancer.

PURPOSE: To report a case of choroidal metastases from breast carcinoma occurring after a remission period of 34 years. METHODS: Case report and literature review. RESULTS: A 77-year-old woman who presented with blurry vision was found to have choroidal metastatic lesions in both her eyes. She had a remote history of breast cancer (status post mastectomy) 34 years ago. A metastatic workup was performed that revealed the presence of widespread metastatic lesions in the lungs, liver, and bones. CONCLUSION: Although the median time period for the detection of choroidal metastases is 3 years after the diagnosis of the primary malignancy, choroidal metastases can present till 34 years later as in our case (the longest time interval reported in the literature).

Spectral domain optical coherence tomography findings in eyes with acute ischaemic retinal whitening.

Acute retinal ischaemia presents in various forms depending on the type and location of the associated vascular occlusion. Cotton wool spots have been considered one manifestation of ischaemia and represent swelling in the nerve fibre layer. However, clinical retinal whitening also occurs in areas not affected by cotton wool spots, and has distinguishing spectral domain optical coherence tomography (SD-OCT) features. We present SD-OCT findings of hyper-reflectivity and thickening in four eyes with representative retinal arterial or retinal venous occlusions, specifically branch retinal artery occlusion, central retinal vein occlusion, Purtscher-like retinopathy and ophthalmic artery occlusion. The spectrum of retinal ischaemia from various causes was found to manifest in inner nuclear layer hyper-reflectivity and thickening on SD-OCT. En Face OCT imaging further characterises the topographical distribution of ischaemia, and reveals patterns which provide insight into the pathological processes involved.

Central serous chorioretinopathy after trabeculectomy in a patient with microphthalmos and congenital rubella syndrome.

PURPOSE: To describe a case of central serous chorioretinopathy after trabeculectomy surgery in an eye with microphthalmos in the setting of congenital rubella syndrome. METHODS: A Case report with color fundus photographs, fluorescein angiography, and spectral domain optical coherence tomography. RESULTS: A 46-year-old African American man, with a history of congenital heart disease and bilateral hearing loss, developed persistent vision loss in the left eye after trabeculectomy surgery. Ocular examination revealed bilateral salt-and-pepper retinopathy and a serous detachment in the macula of the left eye. Fluorescein angiography showed an early "smoke-stack" pattern of hyperfluorescence with progressive filling of the subretinal space consistent with central serous chorioretinopathy. Spectral domain optical coherence tomography documented both size and extent of the serous retinal detachment and showed several pigment epithelial detachments. B-scan ultrasonography confirmed the serous retinal detachment on the left but showed no evidence of posterior eye wall thickening or of retrobulbar fluid. An A-scan revealed an axial length of 21.8 mm on the right and 19.7 mm on left eye, confirming microphthalmos and supporting the suspected diagnosis of congenital rubella syndrome. CONCLUSION: Although uncommon, central serous chorioretinopathy can occur in anatomically small eyes after trabeculectomy surgery.

Purtscher-like retinopathy after prostate surgery.

PURPOSE: To describe a case of Purtscher-like retinopathy after uncomplicated radical prostatectomy. METHODS: Observational case report. RESULTS: Purtscher retinopathy is named after the Austrian ophthalmologist Othmar Purtscher (1852-1927) who first fully described the syndrome of "traumatic retinal angiopathy" in 1912 as patches of retinal whitening, retinal hemorrhages, and disk edema after compression injury to the head. Since that time, similar findings, often called Purtscher-like retinopathy, have been described in association with a number of conditions, including, among others, acute pancreatitis, chest compression injury, childbirth, and fat embolism syndrome, after long-bone fracture or surgery. CONCLUSION: The occurrence of Purtscher-like changes after nonorthopedic surgery seems, however, to be rare. The authors describe a single case of Purtscher-like retinopathy after uncomplicated radical prostatectomy.

Chronic exogenous exophiala dermatitidis endophthalmitis.

PURPOSE: To describe a case of chronic exogenous Exophiala dermatitidis endophthalmitis. METHODS: Retrospective chart review and case report. RESULTS: A 60-year-old man with history of chronic herpes zoster keratitis complicated by secondary fungal keratitis treated with penetrating keratoplasty presented with a white cataract, chronic anterior uveitis, and counting fingers vision in the left eye. Combined cataract extraction and diagnostic vitrectomy revealed positive cultures and polymerase chain reaction-based testing for E. dermatitidis-the same organism responsible for the keratitis. The patient was treated with multiple oral, intravenous, and intravitreal antifungal agents. Ultimately, the corneal infection recurred and the patient elected to undergo enucleation. Filamentous fungi consistent with E. dermatitidis infection were identified in the cornea of the enucleation specimen. CONCLUSION: Although rare, Exophiala species can cause exogenous endophthalmitis. Chronic endophthalmitis should be suspected in patients who develop persistent intraocular inflammation after infectious keratitis.