Acute Macular Neuroretinopathy Associated With COVID-19 Infection: Is Double Heterozygous Methylenetetrahydrofolate Reductase (MTHFR) Mutation an Underlying Risk Factor?

The goal of this report is to present a case of coronavirus disease 2019 (COVID-19)-associated acute macular neuroretinopathy (AMN) with an underlying MTHFR mutation. A 36-year-old male presented to the emergency department with a sudden-onset paracentral scotoma in his left eye. Although optical coherence tomography (OCT) was normal initially, four days later, it revealed a hyperreflective band in the outer plexiform layer with disruption of the ellipsoid zone/interdigitation zone. On infrared imaging and en-face OCT, wedge-shaped lesions were detected around the fovea with their tip oriented toward the fovea. OCT angiography, fundus autofluorescence, fundus fluorescein angiography, and visual fields were performed. The patient was positive for COVID-19 infection. The absence of medical history and the negative results of blood tests led to a diagnosis of AMN associated with COVID-19. Genetic testing for coagulation disorders was scheduled and revealed a heterozygous mutation for MTHFR C677T and A1298C. This is the first case of AMN in a patient with COVID-19 infection and a double heterozygous mutation of the MTHFR gene. Infection is the most commonly reported association of AMN, while MTHFR mutation may represent an additional underlying risk factor. Microthrombosis and small-vessel occlusion are thought to be involved in the pathophysiology of AMN, and patients should be tested for COVID-19 because it may be the first manifestation of the infection.

A Real-World, Multicenter, 6-Month Prospective Study in Greece of the Effectiveness and Safety of Ranibizumab in Patients with Age-Related Macular Degeneration Who Have Inadequately Responded to Aflibercept: The "ELEVATE" Study.

Purpose: Real-world evidence on short-term outcomes of ranibizumab in wet age-related macular degeneration (wAMD) following inadequate response to aflibercept is scarce. This study aimed to evaluate the functional and anatomic effects of switching to ranibizumab in cases of wAMD previously treated with aflibercept with inadequate response. Patients and Methods: Prospective, observational study performed in eight ophthalmology hospital/private clinics in Greece, enrolling consented patients with active wAMD, ≥50 years-old, who had initiated ranibizumab ≥28 days and <2 months after their last aflibercept injection. Data were collected at enrollment, and at 1, 3 and 6 months post-treatment onset (post-baseline). Results: Between September-2015 and November-2017, 103 eligible patients (56.3% females; mean age: 74.8±8.6 years) were consecutively enrolled. The age at AMD diagnosis in the study eye was 71.3±8.8 years. Aflibercept (median of 5 injections received over 11.3 months) had been discontinued for anatomical (in 69.9%) and/or functional (38.8%) reasons. At baseline (median: 24.3 months after wAMD diagnosis), choroidal neovascularization was occult in 69.1% of evaluable study eyes; 60.2% of the study eyes had pigment epithelial detachment (PED); 42.7% cysts; 21.4% fibrosis; 66.0% subretinal, and 59.2% intraretinal fluid. At 6 months post-baseline: a median of 3 ranibizumab injections (range: 1-6) had been received; the best-corrected visual acuity (BCVA)≥0 letter gain rate was 81.8%; the BCVA ≥15 letter gain rate was 17.0%; BCVA gain was 3.2 letters [mean increase: 3.2±10.0 letters; median: 0.0; p = 0.002]; PED greatest basal diameter (GBD; median: 1470.5 µm) also decreased (median decrease: 114.0 µm; p = 0.019). Baseline central retinal thickness (CRT; median: 312.0 µm) remained unchanged. One patient permanently discontinued ranibizumab due to adverse event occurrence, assessed as not causally related to ranibizumab. There were no ranibizumab-related adverse reactions. Conclusion: Six-month treatment with ranibizumab in aflibercept inadequate responders led to visual acuity and PED GBD improvements, with no statistically significant CRT change.

Long-term progression of myopic maculopathy in degenerative myopia as imaged by SD-OCT and IR imaging.

CLINICAL RELEVANCE: Clinicians can benefit from developing an understanding of the natural disease progression of myopic maculopathy in degenerative myopia using optical coherence tomography (OCT). BACKGROUND: The prevalence of high myopia is constantly increasing. In this work, infrared imaging and OCT is used to study the natural course of the disease. METHODS: This is a retrospective longitudinal study. Medical records of 72 patients with high myopia (< 6.00 D) and a minimum five-year follow-up period were analysed. Collected data on all enrolled patients included demographic characteristics and medical history, as well as recordings on best-corrected visual acuity, slitlamp examination, OCT, and fluorescein angiography in cases of suspected myopic choroidal neovascularisation. Images were independently marked by two graders. RESULTS: The mean age of patients was 54.6 ± 14.4 years (59.72% female) with baseline logMAR best-corrected visual acuity of 0.22 ± 0.28. At baseline examination, 70.83% of the study group showed signs of maculopathy and 62.5% diffuse or patchy atrophy. During follow-up, 22.2% of patients with any type of atrophy showed enlarged affected areas. Two patients with baseline lacquer cracks developed new lesions. There was a weak correlation between patient age and maculopathy progression (r = 0.233; p = 0.03). While central retinal thickness was not associated with maculopathy progression (p = 0.203), a moderate correlation was found between choroidal thickness and maculopathy progression (r = -0.516; p < 0.001). CONCLUSION: Lesion characteristics in myopic degeneration have been elucidated, taking advantage of the ongoing technological advances in retinal imaging. The understanding of disease patterns and progression is essential for appropriate management of patients, while discovering biomarkers which lead to choroidal neovascularisation development is of urgent importance to establish international diagnostic criteria and treatment protocols.

Retinal neurodegeneration, macular circulation and morphology of the foveal avascular zone in diabetic patients: quantitative cross-sectional study using OCT-A.

PURPOSE: Using OCT-A to investigate the association between neurodegeneration and vascular morphology in diabetic retinopathy (DR). METHODS: Cross-sectional study. One hundred and sixty-two patients were enrolled and following fundoscopy were assigned to two groups according to DR severity: 54 patients to the group of no clinical signs of DR (noDR) and 54 to the non-proliferative DR (NPDR) group. Fifty-four age-matched patients without known diabetes were recruited as the control group. Patients underwent full ophthalmic examination followed by OCT-A. Central retinal thickness (CRT), vessel density (VD) in the superficial and deep retinal layers and foveal avascular zone (FAZ) area were measured. Additionally, ganglion cell complex (GCC) layer thickness along with global loss volume (GLV) and focal loss volume (FLV) indices was measured. RESULTS: In total, 85 men with mean age of 51.93 ± 9.03 and 77 women with age of 50.14 ± 10.35 were examined. Mean diabetes duration was 4.62 ± 2.16 years in the noDR group and 11.34 ± 2.73 years in the NPDR group (p < 0.001). Superficial VD (sVD) and deep VD (dVD) were significantly different only between noDR and NPDR groups (p < 0.001 for both comparisons), but no statistically significant difference was observed between the controls and the DR groups. Global loss volume was significantly higher in the NPDR (4.38 ± 2.22) compared to the noDR group (3.24 ± 1.76; p < 0.03). Focal loss volume was significantly higher in both noDR (1.22 ± 1.03) and NPDR (2.09 ± 1.72) groups compared to controls (0.95 ± 0.83; p < 0.001 between noDR and NPDR and p = 0.02 between control and noDR groups). Significant associations were found between GLV and deep VD (p < 0.01, r = -0.48), FLV and superficial VD (p < 0.01, r = -0.42) and FLV with deep VD (p < 0.01, r = -0.64). CONCLUSION: In this study, we evaluated the impact of DR in both the vascular layers and neural components of the retina as expressed by FAZ, sVD, dVD and GCC thickness, FLV and GLV using OCT-A. We found that FLV was significantly higher in both noDR and NPDR groups indicating that in progressive DR stages FLV values might be increased, which might serve as an early index of neuronal damage in patients with diabetes even in the absence of overt DR signs.

Multimodal Imaging for the Assessment of Geographic Atrophy in Patients with "Foveal" and "No-Foveal" Sparing.

INTRODUCTION: The aim of the study was to evaluate the applicability of optical coherence tomography (OCT) angiography (OCTA) for measuring geographic atrophy (GA) areas in age-related macular degeneration (AMD) patients with "foveal" and "no-foveal" sparing disease and compare it to other imaging modalities. METHODS: A multimodal imaging protocol was applied, using infrared (IR) imaging, fundus autofluorescence (FAF), OCTA, and en-face OCT in 35 eyes of 23 AMD patients with GA. Patients were classified into 2 groups, with and without foveal sparing disease. GA area measurements for all imaging modalities were compared for each group separately. RESULTS: The measured GA area was estimated to be 6.68 ± 3.18 mm2 using IR; 6.99 ± 3.09 mm2 using FAF; 6.56 ± 3.11 mm2 using OCTA, and 6.65 ± 3.14 mm2 using en-face OCT. There was no statistically significant difference in the GA area between different modalities (p = 0.977). When separate analysis was conducted for patients with "foveal" and "no-foveal" sparing disease, although GA measurements in FAF imaging displayed higher numerical values than the other modalities, especially in patients with foveal sparing, no statistically significant difference in the GA area was found between the different imaging modalities in either group (p = 0.816 for foveal sparing; p = 0.992 for no-foveal sparing group). CONCLUSIONS: OCTA can be reliably used in the assessment of GA in AMD patients with and without foveal sparing disease. For both groups, measurements are comparable to IR, en-face OCT, and FAF, despite the fact that the latter recorded larger area of GA, mainly in the foveal sparing cases.

A Multicenter, Cross-Sectional Study of the Incidence of Major Macular Diseases That Cause Visual Impairment and Require Therapeutic Intervention in Greece: The ADVICE Study.

PURPOSE: This multicenter, epidemiological, cross-sectional study aimed to estimate the annual cumulative incidence of major macular diseases that cause visual impairment and require therapeutic intervention in the routine care of Greece. METHODS: The study was carried out between December 2012 and May 2015 in 20 ophthalmology clinics. Over a one-year recruitment period per study site, all treatment naïve adult patients newly diagnosed with wet age-related macular degeneration, visual impairment due to diabetic macular edema or macular edema secondary to retinal vein occlusion requiring therapeutic management and who had not been diagnosed or treated for the same disease in the past were enrolled after providing informed consent. Study data were collected during the single study visit. RESULTS: A total of 1532 incident cases were enrolled. The estimated annual cumulative incidence of wet age-related macular degeneration, diabetic macular edema and macular edema secondary to retinal vein occlusion requiring therapeutic management was 0.82 [95% confidence interval (CI): 0.76, 0.88; n=723], 0.63 (95% CI: 0.58, 0.69; n=559), and 0.29 (95% CI: 0.25, 0.32; n=250) per 10,000 cases, respectively. CONCLUSION: The study provides estimates of the incidence of major macular diseases causing visual impairment and requiring treatment in outpatient hospital settings in Greece, indicating a considerable socioeconomic burden to the healthcare system.

Segmentation errors and motion artifacts in OCT-A associated with epiretinal membranes.

OBJECTIVE: To explore segmentation errors, image quality, and motion-associated artifacts in eyes with idiopathic epiretinal membrane (ERM). METHODS: This is a prospective observational study. We included 39 eyes affected by ERM and 40 eyes from age-matched healthy subjects. Optical coherence tomography-angiography (OCT-A) was performed in both groups. Segmentation was automatically performed by intergraded software. Segmentation was regarded as inaccurate if either border deviated from the correct plane by more than 50 µm. Presence of motion artifacts (blink lines, displacement, stretch artifacts, quilting, vessel doubling) and image quality index were reported. RESULTS: Quality index score was 7.2 ± 0.9 for the ERM patients. Phakic eyes with ERM had quality index score of 7.71 ± 1.06, and pseudo-phakic eyes with ERM had a quality index score of 7.32 ± 0.85 (p = 0.22). Motion artifacts were 1.22 ± 0.7 in the study cohort. Segmentation was accurate in all healthy subjects (n = 40). Segmentation errors occurred in 64.1% of ERM patients. The inner plexiform layer was the segmentation boundary most prone to inaccurate segmentation, followed by the internal limiting membrane. Segmentation of retinal pigment epithelial layer was accurate in 96.7% of all cases. CONCLUSIONS: OCT-A image quality cannot be accurately reproduced in pathological conditions, such as in ERM patients, and is prone to motion artifacts and segmentation errors. Incorrect segmentation results in anatomically incorrect en-face OCT-A images and subsequently in false quantification measures.

Pre-operative intravitreal dexamethasone implant in patients with refractory diabetic macular edema undergoing cataract surgery.

To examine preoperative use of intravitreal dexamethasone implant in patients with refractory diabetic macular edema (DME) undergoing cataract surgery. Participants in this study were 17 patients with DME refractory to previous treatment with anti-vascular endothelial growth factor agents or dexamethasone implant, and co-existent cataract. All participants received intravitreal dexamethasone implant at baseline and underwent phacoemulsification within one month after its insertion. Best-corrected visual acuity (BCVA) and central subfield thickness (CST) changes between baseline, time of cataract surgery and postoperative months 1, 2 and 3 were evaluated. At month 1 after surgery, BCVA improved significantly from 42.3 ± 9.6 to 58.7 ± 11.9 letters compared to baseline (p < 0.001) and the improvement was sustained at month 2 and month 3 postoperatively. One month postoperatively, CST improved significantly compared to baseline (p < 0.001) and the improvement was sustained at month 2 (p < 0.001), while at month 3 CST started to increase, but remained significantly lower than baseline (p = 0.003). At month 3 postoperatively, 35.3% of patients presented recurrence of ME. Patients with refractory DME and cataract can safely undergo phacoemulsification when dexamethasone implant is inserted one month prior to surgery to ensure adequate control of postoperative inflammation and prevent deterioration of ME.

The Role of Disorganization of Retinal Inner Layers as Predictive Factor of Postoperative Outcome in Patients with Epiretinal Membrane.

PURPOSE: The purpose of this retrospective study was to evaluate the disorganization of the retinal inner layers (DRIL) as a potential predictive factor of postoperative visual outcome in patients with idiopathic epiretinal membrane (iERM), treated with pars plana vitrectomy (PPV). METHODS: Participants in the study were 46 consecutive patients diagnosed with iERM, who underwent PPV. Best corrected visual acuity (BCVA) measurement and spectral-domain optical coherence tomography (SD-OCT) were performed at baseline (preoperatively), and at months 3 and 6 postoperatively. DRIL and additional OCT parameters were assessed at 1-mm-wide foveal centered area. RESULTS: DRIL was observed in 47.8% of patients at baseline. There was statistically significant improvement in BCVA and central retinal thickness (CRT) between baseline and months 6 and 12 in all patients. There was a statistically significant difference in BCVA and CRT change between patients with and without DRIL at months 6 and 12 compared to baseline, showing that there was a correlation between change in BCVA or CRT and baseline DRIL. Ellipsoid zone and external limiting membrane were intact in 91.3 and 95.7%, respectively, not affecting our results. CONCLUSIONS: Baseline DRIL has been shown to be predictive of postoperative visual outcome in patients with iERM, treated with PPV.

Optical coherence tomography biomarkers as predictive factors for postoperative visual acuity in patients with epiretinal membrane treated with vitrectomy.

BACKGROUND: The purpose of this retrospective study was to evaluate potential predictive factors of postoperative visual outcome in patients with idiopathic epiretinal membrane (iERM), treated with pars plana vitrectomy (PPV). METHODS: Participants in the study were 46 patients diagnosed with iERM, who underwent PPV. Best-corrected visual acuity measurement and spectral domain-optical coherence tomography (OCT) were performed at baseline (preoperatively), and at months 6 and 12 postoperatively. Demographic characteristics and OCT parameters were assessed as potential predictive factors for postoperative visual outcome. RESULTS: Increasing age, retinal thickness, presence of disorganization of inner retinal layers, ellipsoid zone disruption, and presence of vitreomacular traction were found to be negatively associated with postoperative visual acuity. Gender, presence of subretinal fluid, cysts in the inner or outer nuclear layer, and hyperreflective foci were not found to affect visual acuity. There was statistically significant improvement in visual acuity and central retinal thickness between baseline and months 6 and 12 in the study sample. CONCLUSIONS: It is important to determine predictive factors for visual outcome, so as to inform patients about prognosis and help in the decision-making of patients' management.

Ranibizumab versus aflibercept for the treatment of vascularized pigment epithelium detachment due to age-related macular degeneration.

PURPOSE: To compare the efficacy and safety of two intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents, ranibizumab and aflibercept, for the treatment of vascularized pigment epithelium detachment (vPED) due to age-related macular degeneration (AMD) in a follow-up time of 12 months. METHODS: Participants in this study were 71 patients (71 eyes) with vPED due to AMD, who were treated with intravitreal 0.5 mg ranibizumab (n = 38) or 2.0 mg aflibercept (n = 33) and had at least 12-month follow-up. All patients underwent best-corrected visual acuity (BCVA) measurement and optical coherence tomography at baseline and at every visit. The PED height, the presence of subretinal fluid (SRF), intraretinal fluid and diffuse macular edema (DME) were recorded at each visit. RESULTS: There was a statistically significant difference in BCVA between the two groups at month 12 in favor of aflibercept. However, both agents were found to improve or stabilize BCVA in the majority of patients at the end of the follow-up. The change in PED height did not differ significantly between the two groups at the end of the follow-up with similar number of injections. At month 12, there was a significant improvement in SRF presence in both groups compared to baseline. CONCLUSIONS: Although aflibercept was found to be superior to ranibizumab regarding BCVA improvement, both agents showed anatomical effectiveness with significant reduction in PED height and SRF absorption in patients with vPED due to AMD.

Ranibizumab versus dexamethasone implant for central retinal vein occlusion: the RANIDEX study.

PURPOSE: To compare intravitreal ranibizumab and dexamethasone implant in patients with macular edema (ME) secondary to central retinal vein occlusion (CRVO). METHODS: Participants were 42 treatment naive patients with ME due to CRVO, who received either intravitreal 0.5 mg ranibizumab (n = 25) or intravitreal 0.7 mg dexamethasone implant (n = 17). The main outcomes included the mean change in best corrected visual acuity (BCVA) and central subfield thickness (CST) at month 12 compared to baseline in the two groups. RESULTS: At month 12, there was no statistically significant difference in BCVA and CST change between the two groups. However, there was recurrence in ME at month 5 in the dexamethasone group. CONCLUSIONS: Both ranibizumab and dexamethasone implant were found to be safe and effective at the 12-month follow-up in patients with ME secondary to CRVO. Since there was a recurrence in ME at month 5 in the dexamethasone group, we suggested that intravitreal injection of dexamethasone implant should be potentially administered sooner than 6 months.

Full-thickness macular hole formation following anti-VEGF injections for neovascular age-related macular degeneration.

PURPOSE: Macular hole (MH) is part of a group of age-related degenerative diseases characterized by pathology of vitreomacular interface. Similarly, neovascular age-related macular degeneration (nAMD) affects older patients and is a leading cause of irreversible visual loss. The purpose of this case series is to describe the development of full-thickness MH in patients with nAMD, following antivascular endothelial growth factor (anti-VEGF) treatment. METHODS: Participants in this case series were four patients with nAMD, who received anti-VEGF injections with variable therapeutic response to treatment. Patients were examined at baseline (when AMD was diagnosed) and monthly thereafter. The examination included visual acuity measurement, slit-lamp biomicroscopy, and optical coherence tomography. RESULTS: All patients were found to develop full-thickness MH within 1-4 months after the last anti-VEGF injection, even in the absence of pre-existing vitreomacular interface abnormalities in some cases. The median number of injections before the MH formation was 3. CONCLUSION: MH formation may represent an adverse effect of anti-VEGF treatment in patients with nAMD and could be also coexisting pathology with nAMD in older individuals.

Risk Factors for Central Serous Chorioretinopathy: Multivariate Approach in a Case-Control Study.

PURPOSE: The purpose of this prospective study was to investigate the potential risk factors associated independently with central serous retinopathy (CSR) in a Greek population, using multivariate approach. MATERIALS AND METHODS: Participants in the study were 183 consecutive patients diagnosed with CSR and 183 controls, matched for age. All participants underwent complete ophthalmological examination and information regarding their sociodemographic, clinical, medical and ophthalmological history were recorded, so as to assess potential risk factors for CSR. Univariate and multivariate analysis was performed. RESULTS: Univariate analysis showed that male sex, high educational status, high income, alcohol consumption, smoking, hypertension, coronary heart disease, obstructive sleep apnea, autoimmune disorders, H. pylori infection, type A personality and stress, steroid use, pregnancy and hyperopia were associated with CSR, while myopia was found to protect from CSR. In multivariate analysis, alcohol consumption, hypertension, coronary heart disease and autoimmune disorders lost their significance, while the remaining factors were all independently associated with CSR. CONCLUSIONS: It is important to take into account the various risk factors for CSR, so as to define vulnerable groups and to shed light into the pathogenesis of the disease.

Chronic Central Serous Chorioretinopathy-Like Maculopathy as Atypical Presentation of Chorioretinal Folds.

PURPOSE: The purpose of this case report was to present the clinical data and management of a 69-year-old female patient with chorioretinal folds who developed chronic central serous chorioretinopathy-like maculopathy. CASE PRESENTATION: A 69-year-old female patient presented with a recent-onset slight decrease in visual acuity in her left eye. Her past ocular history was clear. Regarding her medical history, she had only hypertension, treated with per os medications. The patient underwent a complete ophthalmological examination. At presentation, the visual acuity was 6/6 in the right eye and 6/7.5 in the left eye. Intraocular pressure was 16 mm Ηg in both eyes. On fundoscopy, chorioretinal folds were noticed in the left eye. Spectral-domain optical coherence tomography, fluorescein angiography, and indocyanine green angiography confirmed the diagnosis of chronic central serous chorioretinopathy-like maculopathy in the left eye, since other causes of chorioretinal folding were excluded. The right eye was normal. No treatment was given to the patient, and at the 6-month follow-up there was improvement in visual acuity, which was 6/6, and decreased subretinal fluid. CONCLUSIONS: Central serous chorioretinopathy-like maculopathy should be taken into account for the differential diagnosis of patients with chorioretinal folds.

Bilateral Hypertensive Retinopathy Complicated with Retinal Neovascularization: Panretinal Photocoagulation or Intravitreal Anti-VEGF Treatment?

PURPOSE: To present the case of a patient with bilateral hypertensive retinopathy complicated with retinal neovascularization who received anti-VEGF intravitreal injection in one eye and panretinal photocoagulation (PRP) in the fellow eye. METHODS: A 33-year-old male patient presented with gradual visual loss in both eyes for the last 5 months. At that time, he was examined by an ophthalmologist and occlusive retinopathy due to malignant systematic hypertension was diagnosed. He was put on antihypertensive treatment but no ophthalmic treatment was undertaken. At presentation, 5 months later, best-corrected visual acuity (BCVA) was 0.1 in the right eye (RE) and 0.9 in the left eye (LE). Fundus examination was compatible with hypertensive retinopathy complicated with retinal neovascularization. Fluorescein angiography (FFA) revealed macular ischemia mainly in the RE and large areas of peripheral retinal ischemia and neovascularization with vascular leakage in both eyes. The patient was treated with two anti-VEGF (ranibizumab) injections with 2 months interval in the RE and PRP laser in the LE. RESULTS: Follow-up examination after 12 months showed mild improvement in BCVA, and FFA documented regression of retinal neovascularization in both eyes. CONCLUSION: Hypertensive retinopathy can be rarely complicated with retinal neovascularization. Treatment with PRP can be undertaken. In our case, the use of an intravitreal anti-VEGF agent seemed to halt its progression satisfactorily.

Acute zonal occult outer retinopathy with atypical findings.

Background. To report a case of acute zonal occult outer retinopathy (AZOOR) with atypical electrophysiology findings. Case Presentation. A 23-year-old-female presented with visual acuity deterioration in her right eye accompanied by photopsia bilaterally. Corrected distance visual acuity at presentation was 20/50 in the right eye and 20/20 in the left eye. Fundus examination was unremarkable. Visual field (VF) testing revealed a large scotoma. Pattern and full-field electroretinograms (PERG and ERG) revealed macular involvement associated with generalized retinal dysfunction. Electrooculogram (EOG) light rise and the Arden ratio were within normal limits bilaterally. The patient was diagnosed with AZOOR due to clinical findings, visual field defect, and ERG findings. Conclusion. This is a case of AZOOR with characteristic VF defects and clinical symptoms presenting with atypical EOG findings.

Retinal arterial occlusive disease in a young patient with cat scratch disease.

PURPOSE: To report an unusual case of a branch retinal arterial occlusion and bilateral multifocal retinitis in a young woman with cat scratch disease. METHODS: A 23-year-old woman was referred to our clinic complaining of a sudden scotoma in the upper part of the visual field of her left eye. Fundoscopy revealed occlusion of an inferior temporal branch of the retinal artery in the left eye and bilateral multifocal retinitis, which was confirmed by fluorescein angiography. Subsequent indocyanine angiography did not reveal choroidal involvement. Laboratory analysis showed rising IgG titers for Bartonella henselae. RESULTS: Cat scratch disease was diagnosed, and a 4-week course of doxycycline was initiated. The patient responded well to the antibiotics. Both retinitis and arterial occlusion were resolved, the visual field was regained and the patient reported elimination of her symptoms. CONCLUSIONS: Cat scratch disease should be considered in the differential diagnosis in young patients with retinal occlusive disease.

Macular hole surgery with short-acting gas and short-duration face-down positioning.

PURPOSE: To report on the outcomes of vitrectomy and sulfur hexafluoride (SF(6)) gas tamponade for idiopathic macular holes with 2 days of face-down positioning. PATIENTS AND METHODS: This was a prospective, nonrandomized, observational sequential case-series study on 23 consecutive patients receiving macular hole surgery using 20% SF(6) and advised to stay in a face-down position for 2 days postoperatively (SF(6) group). These patients were compared to 23 consecutive patients who had previously undergone macular hole surgery, had received 14% C(3)F(8), and were advised to maintain a face-down position for 2 days (C(3)F(8) group). Patients in both groups underwent vitrectomy, internal limiting membrane peeling, and fluid gas exchange using either SF(6) or C(3)F(8.) Preoperative and postoperative data included best corrected visual acuity recorded in LogMAR units, slit-lamp biomicroscopy, and optical coherence tomography. RESULTS: At a 6-month follow-up, macular hole closure was noted in 23/23 eyes (100%) and in 22/23 eyes (96%) in the SF(6) and C(3)F(8) groups, respectively. The improvement in visual acuity (measured through Snellen acuity lines both preoperatively until 6 months postoperatively) was 4.08 ± 2.31 (95% confidence interval [CI]: 3.08-5.08) for the SF(6) group and 2.87 ± 2.30 (95% CI: 1.87-3.86) for the C(3)F(8) group; this difference was not statistically significant (P = 0.06). CONCLUSION: Vitrectomy with internal limiting membrane peeling and a short-acting gas tamponade using SF(6) with posture limitation for 2 days may give a high success rate in macular hole surgery.