UTILITY OF EN FACE OPTICAL COHERENCE TOMOGRAPHY IN INTRAOCULAR LYMPHOMA.

PURPOSE: To report the en face optical coherence tomography (OCT) features of intraocular lymphoma. METHODS: Retrospective, observational case report. RESULTS: A 59-year-old man, a known case of primary testicular carcinoma, complained of right eye blurred vision since 1 week. He had previously undergone systemic intravenous chemotherapy (R-CHOP regimen), orchiectomy, and external beam radiotherapy for the primary malignancy. His right eye vision was 20/30, 6/6 reduced Snellen. The right eye anterior segment examination was normal. Fundus examination showed vitreous cells 1+ and a large, bumpy, subretinal dull-yellow lesion sparing the fovea with multiple discrete yellow retinal lesions at the posterior pole. Magnetic resonance imaging of the brain was normal. Multimodal imaging was used to document the clinical features. On the en face OCT, multiple hyperreflective lesions were identified on the superficial, deep, and outer retinal slabs of the scan corresponding to the vertical hyperreflective lesions extending from the retinal nerve fiber layer to the retinal pigment epithelium. The subretinal pigment epithelium lesion can be well delineated in the choriocapillaris segment. He was treated with multiple injections of intravitreal methotrexate 400 µg/0.1 mL along with systemic chemotherapy in conjunction with the oncologist. At the 6-month follow-up, fundus lesions had regressed. In addition, resolution of the lesions was noted on the OCT and en face OCT scans. CONCLUSION: En face OCT imaging can be considered for monitoring the therapeutic efficacy after intravitreal chemotherapy in intraocular lymphoma.

Structural and Functional Outcomes of Surgery for Lamellar Macular Holes with or without Epimacular Proliferations.

PURPOSE: To compare the clinical, optical coherence tomography (OCT) features, and surgical outcomes of lamellar macular hole (LMH) depending on the presence of epimacular membrane proliferation (EMPF). METHODS: This retrospective chart review included 112 eyes with LMH. The patients were divided into two groups depending on the presence of EMPF. Group 1 had LMH without EMPF and Group 2 had LMH with EMPF. The best-corrected visual acuity was recorded and OCT scans were obtained. RESULTS: Lamellar macular hole without and with EMPF was noted in 62 (55%) and 50 (45%) eyes, respectively. The presence of EMPF was associated with lower presenting visual acuity (P = 0.049), wider LMH size at the largest diameter on the horizontal scan (P = 0.001), thinner residual retinal tissue (P = < 0.0001), and larger IS-OS defects (P = < 0.0001) as compared to the non-EMPF group. Of the 112 eyes, 18 eyes underwent surgery for LMH. Seven eyes had EMPF and the remaining eleven did not have EMPF. The average follow-up time for patients post-surgery and under observation was 16.8 and 24.1 weeks, respectively. A significant improvement in visual acuity was noted in the operated eyes with no EMPF as compared to the eyes with EMPF (P = 0.008). Worsening visual acuity (P = 0.021) was noted in eyes with LMH associated with EMPF which did not undergo surgery. Eyes with LMH and no EMPF, which were not operated on showed a minimal negative change in visual acuity. CONCLUSION: LMH with EMPF showed a higher association with accompanying ellipsoid zone disruption. Better anatomical and functional outcomes were achieved in those eyes that underwent surgery for LMH with no presence of EMPF and ellipsoid zone defect.

Bilateral idiopathic choroidal hyperpigmentation.

PURPOSE: To report a series of cases showing bilateral circumpapillary hyperpigmentation on routine fundus examination. METHODS: In this observational case series, three patients showing bilateral circumpapillary hyperpigmentation on routine fundus examination were included. Multimodal retinal imaging was done for these cases. RESULTS: Multimodal imaging of the lesion showed the hyper pigmentation to be confined to the choroid. The optical coherence tomography scans described the features through the hyperpigmented area, adjacent hypopigmented area and the normally pigmented area of the fundus as suggestive of choroidal hyper melanosis. Follow-up of these lesions over a period of 2-6 years showed no change in the vision or characteristics of the lesion. CONCLUSION: Bilateral circumpapillary hyperpigmentation needs to be considered as a differential for bilateral peripapillary pigmented lesions.

Bacillary layer detachment in acute nonpenetrating ocular trauma.

OBJECTIVE: To study the clinical and visual outcomes of patients presenting with bacillary layer detachment (BLD) on optical coherence tomography (OCT) in blunt ocular trauma. DESIGN: Retrospective observational study. PARTICIPANTS: Clinical fundus photographs and OCT scans with Spectralis machine were reviewed to identify patients with blunt ocular trauma showing BLD. METHODS: Patients were further analyzed for changes in their anatomic features such as subretinal hemorrhage, intrabacillary layer bleed. subretinal fibrosis and choroidal rupture and reattachment of BLD, and visual outcomes over subsequent follow-up visits. RESULTS: Of a total of 77 eyes with blunt ocular trauma, 6 (8%) eyes with BLD were identified. All patients were male with presenting visual acuity ranging from 6/9 to 2/60 (mean logMAR = 1.119; Snellen's equivalent = 20/263). The time interval between trauma and presentation ranged from 1 to 7 days. Subretinal hemorrhage and choroidal rupture were noted in all 6 eyes. On OCT, foveal involvement by the BLD was noted in 5 eyes. Intrabacillary layer hemorrhage was noted in all patients. Reattachment of the bacillary layer and visual acuity improvement were noted in all eyes at the final visit. The time interval for resolution of BLD ranged from 2 to 10 days. Visual acuity of 6/36 or less was secondary to subretinal fibrosis close to the fovea and subfoveal choroidal rupture. CONCLUSION: BLD in blunt ocular trauma is a rare finding, shows complete resolution, and appears not to influence visual or anatomic outcome.

SPONTANEOUS CLOSURE OF SECONDARY ECCENTRIC MACULAR HOLES FOLLOWING VITREORETINAL SURGERY.

PURPOSE: To report two cases of secondary eccentric macular holes that developed following vitrectomy and present their outcomes. METHODS: Retrospective, observational case report. CASE DESCRIPTION: A 69-year-old woman and a 57-year-old man developed secondary paracentral retinal hole following vitrectomy surgery for stage 4 macular hole and proliferative diabetic retinopathy respectively. In Case 1, the hole was left untreated, whereas in Case 2, laser photocoagulation was done around the paracentral retinal hole. In both cases, spontaneous closure of the paracentral retinal holes was noted 12 weeks and 3 weeks after presentation respectively. CONCLUSION: Secondary eccentric retinal holes are extremely rare following vitrectomy. The pathogenesis of macular holes in our cases is most consistent with contraction of the residual internal limiting membrane or preretinal fibrous tissue. Spontaneous closure of small eccentric retinal holes can occur as well which to the best of our knowledge has not yet been reported in literature.

Different types of macular telangiectasia in two eyes of a patient.

PURPOSE: To report a case of macular telangiectasia (MacTel) showing the features of type 3 disease in one eye and type 2 disease in the other eye. METHODS: Descriptive case report. CASE DESCRIPTION: A 50-year-old well-controlled diabetic man presented with complaints of distorted vision in the right eye for the past 1 year. His best-corrected visual acuity in both eyes was 20/20, N6. His anterior segment findings were normal. The right eye fundus showed an irregular perifoveal greying and a localised dark patch temporally inside the perifoveal region. Few microaneurysms were seen on clinical examination. No hard exudates were noted. The left eye fundus showed a few microaneurysms with minimal perifoveal greying temporally. Imaging with confocal blue reflectance, fluorescein and optical coherence tomography angiography confirmed the diagnosis of MacTel type 3 in the right eye and type 2A stage 2 in the left eye with mild non-proliferative diabetic retinopathy in both eyes. CONCLUSION: This case raises the possibility that type 3 disease could be a progressive non-proliferative form of a pre-existing type 2 MacTel disease.

The preproliferative stage in type 2 macular telangiectasia (MacTel type 2).

PURPOSE: To study clinical and imaging features of various stages of macular telangiectasia (MacTel type 2). METHODS: In this retrospective study, cases of MacTel type 2 with fluorescein angiography (FA), optical coherence tomography (OCT) and OCT-angiography (OCTA) imaging were included. Based on angiographic perifoveal fluorescence, two groups were formed: group 1: diffuse hyperfluoroscence and group 2: diffuse + focal hyperfluoroscence. Later, based on OCT features, group 2 was subdivided into group 2A: without SRNVM and group 2B: with SRNVM. Clinical, FA, OCT and OCTA features were analysed. Eyes showing conversion to the proliferative stage at final visit were noted. RESULTS: Ninety-four eyes of 48 patients were included. Group 1 (n = 28) showed diffuse perifoveal hyperfluoroscence, hyperreflective middle retinal layers, absent SRNVM (p = 0.006) on OCT and dilated perifoveal capillaries in deep capillary plexus (DCP) on OCTA. Group 2A (n = 40) showed diffuse + focal perifoveal hyperfluoroscence, hyperreflective middle retinal layers (p = 0.001), hyporeflective outer retina cavities (p = 0.021), absent SRNVM with dilated and bunching perifoveal capillaries (p = 0.004) in DCP. Group 2B (n = 26) showed late diffuse + focal perifoveal hyperfluoroscence, foveal contour irregularity (p = 0.002), retinal pigment clumps (p = 0.015) and SRNVM on OCT with bunching of capillaries in DCP and vessels in outer retina (p = 0.002). Five eyes showed conversion to group 2B at final visit. CONCLUSION: There exists a distinct disease stage called "preproliferative" MacTel type 2 showing clinical features of non-proliferative disease, diffuse + focal perifoveal hyperfluoroscence on FA, absent SRNVM on OCT and bunching perifoveal capillaries in DCP on OCTA. Its identification is important for suspecting proliferative disease, planning management and follow-up visit accordingly.

Indocyanine green angiography imaging findings in artery occlusions.

PURPOSE: To describe the multimodal imaging features including indocyanine green angiography (ICGA) in cases diagnosed clinically as central retinal artery occlusion (CRAO) at its different disease stages. METHODS: In this retrospective observational study, patients diagnosed clinically as CRAO or hemi-CRAO were included. All patients underwent multimodal imaging with optical coherence tomography (OCT), fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA) were studied. Analysis of ICGA images in different stages of artery occlusions and its correlation with accompanying FFA and OCT images was done. RESULTS: Eight such studies in five patients were available for analysis. The most important observation noted on ICGA was the presence of hypercyanescent spots seen during the acute stages of the disease in four of the five cases. The spots were accompanied by retinal vessel staining on FFA in the corresponding region. As the disease showed signs of resolution, the hypercyanescent spots on ICGA and retinal vessel staining on FFA disappeared. The hypercyanescent spots seen on the ICGA were noted due to the red blood cell aggregation or 'rouleaux' formation. In addition, choroidal perfusion abnormalities were noted on ICGA in all five cases in the acute stage. CONCLUSION: Choroidal perfusion changes can be identified in acute phase of retinal artery occlusion. Rouleaux formation in the retinal circulation occurs due to the slowing of the blood flow following artery occlusion. These are seen as hypercyanescent spots in the late phase on ICGA.

Choroidal and retinal thickness variations in anaemia and anaemic retinopathy.

Anemia is the most common hematological disorder noted in the people of the Indian subcontinent. Hemodynamic changes following anemia on the retina and choroid are not frequently studied. The aim of the study was to analyse the subfoveal retinal (CRT) and choroidal (SFCT) thickness changes in patients with anemia. In this retrospective, comparative study, patients who were diagnosed with primary anemia and had a fundus examination by a retinal specialist were included. Patients were divided into 3 groups: Group 1: Patients with anemic retinopathy; Group 2: Patients with anemia without retinopathy; Group 3: Normal healthy controls. One hundred and ninety-seven eyes of 197 subjects (group 1 - 38 eyes, group 2 - 90 eyes; group 3 - 69 eyes) met the inclusion criteria. Mean CRT was 269 ± 117µm, 258 ± 99.7µm and 201 ± 19.2µm and SFCT was 303 ± 68.4µm, 303 ± 50.1µm and 275 ± 38.9µm in groups 1, 2 and 3 respectively. Low haemoglobin corelated negatively with retinal (r = -0.362; p = <0.001) and choroidal (r = -0.294; p = <0.001) thickening and reduced visual acuity (r = -0.157; p = 0.03). In conclusion, patients with anemia have a thicker retina and choroid compared to normal healthy controls.

Functional relevance of macular telangiectasia (MacTel) area on multicolour imaging in type 2 MacTel.

PURPOSE: To analyse the correlation between area of macular telangiectasia (MacTel) involvement on multicolour (MC) imaging, disease stages and visual acuity in type 2 MacTel. METHODS: In this retrospective analysis of MC images, confirmed cases of type 2 MacTel were graded into different disease stages as per Gass and Blodi and Yannuzzi et al classification systems. The 'MacTel area' was calculated by marking the outer boundary of an area with abnormally increased reflectivity to confocal blue wavelength light. At every follow-up visit, best-corrected visual acuity, MacTel area and stage of disease on the MC image was documented. Analyses between disease stage, MacTel area and visual acuity was carried out. RESULTS: In total, 92 eyes of 49 patients were included in the study. The mean age was 59.6 ± 8.96 years. About 182 high-quality gradable MC images were available for analysis. There was a statistically significant difference in the visual acuity (p < 0.001) and area of involvement (p < 0.001) in the non-proliferative and proliferative type 2 MacTel groups. An increase in disease severity stage statistically correlated positively with Mactel area (r = 0.544; p < 0.001) and logMAR visual acuity (r = 0.329; p < 0.001). Over time, there was a significant increase in area of MacTel involvement (p = 0.012) with an associated decrease in the visual acuity (p = 0.023). CONCLUSION: The MacTel area measured on MC imaging showed a strong positive correlation with disease stage and a negative correlation with visual acuity. This could serve as a useful biomarker in clinical trials and understanding the natural history of the disease.

Acute Abducens Nerve Palsy Following the Second Dose of the AstraZeneca COVID-19 Vaccine.

The authors report the case of an otherwise healthy 65-year-old man who presented with an acute right abducens nerve palsy 3 days after receiving the second dose of the AstraZeneca coronavirus disease 2019 (COVID-19) vaccine. Abducens nerve palsies typically results from microvascular disease or compressive tumors, although they are known to arise following routine vaccinations. Given the lack of preexisting risk factors, normal computed tomography scan results, and the timing of the symptoms, the abducens nerve palsy was believed to be related to the vaccination. This report highlights the potential neurologic adverse effects associated with COVID-19 vaccines. [J Pediatr Ophthalmol Strabismus. 2021;58(6):e49-e50.].

Bacillary layer detachment on optical coherence tomography in exudative age-related macular degeneration.

PURPOSE: To report the bacillary layer detachment on optical coherence tomography in exudative age-related macular degeneration. METHODS: Retrospective, observational cases. CASE DESCRIPTIONS: Two cases of exudative age-related macular degeneration, one diagnosed as polypoidal choroidal vasculopathy following exudative age-related macular degeneration and other as wet age-related macular degeneration with choroidal neovascular membrane showed separation of myoid and ellipsoid zones of photoreceptor layer on optical coherence tomography. This is termed as BALAD. Other associated features noted were the presence of subretinal hyperreflective material, submacular hemorrhage and subretinal fluid. Both cases were treated with monthly intravitreal injections of Inj. Ranibizumab (0.5 mg/0.05 ml). Following 3 intravitreal injections at monthly intervals, reattachment of the bacillary layer detachment were noted in case 1 while the bacillary layer detachment persisted in case 2. CONCLUSION: Multimodal imaging using optical coherence tomography in these cases revealed the separation of the bacillary layer following exudative age-related macular degeneration; a finding which is not routinely described in literature.

Retinal artery occlusion as a probable idiosyncratic reaction to topical minoxidil: a case report.

BACKGROUND: Minoxidil hair formulation is commonly used for the treatment of male or female androgenic alopecia. This over-the-counter product is considered safe, but should be used with caution. Ocular side effects following topical minoxidil use are rarely reported. In this paper, we report a rare case of inferior hemiretinal artery occlusion possibly caused by topical 5% minoxidil treatment. CASE DESCRIPTION: A 21-year-old Asian Indian male presented to the retina clinic with sudden onset blurring of vision and superior visual field loss in the right eye since morning. He was diagnosed with androgenic alopecia and was on treatment with topical 5% minoxidil spray twice a day for the last 3 years. On examination, his corrected distance visual acuity was 6/6, N6 in both eyes. Anterior segment examination and intraocular pressure in both eyes and left eye fundus were within normal limits. Right eye fundus examination showed features suggestive of inferior hemiretinal artery occlusion, which were confirmed on fluorescein angiography and optical coherence tomography. A detailed systemic evaluation and investigations (blood pressure, random blood sugar, hematological and coagulation profile, serum homocysteine level, Mantoux test, chest x-ray, cardiac two-dimensional echography, thyroid function test, and immunological profile) did not detect any abnormalities. The ocular condition and its visual prognosis were explained to the patient, and he was asked to review after 4 weeks. CONCLUSION: Though there is no definite cause-outcome relationship between topical minoxidil use and retinal artery occlusion development, this possibility should be kept in mind when observing retinal vascular occlusion cases with concurrent use of topical minoxidil.

Internal limiting membrane detachment in acute central retinal artery occlusion: a novel prognostic sign seen on OCT.

BACKGROUND: To present a series of acute central retinal artery occlusion (CRAO) cases showing internal limiting membrane detachment (ILMD) on optical coherence tomography (OCT) and to describe the possible etiopathogenesis and outcomes associated with it. METHODS: Demographic and OCT features of patients with acute CRAO were analysed retrospectively. OCT parameters noted were posterior vitreous opacities, ILMD, inner retinal layer stratification, hyperreflectivity and thickening, cystoid macular edema, neurosensory detachment. Eyes were grouped into Group (1) CRAO with ILMD; Group (2) CRAO with no ILMD. RESULTS: A total of 28 eyes of acute CRAO who had undergone OCT scans at the time of the acute episode were identified. Out of these, ILMD was noted in 5 eyes. The study findings suggested that cases of acute CRAO with ILMD are associated with poor presenting visual acuity and have more severe signs of retinal hypoperfusion on OCT, like inner retinal thickening, inner retinal hyperreflectivity and loss of inner retinal layer stratification. Patients with ILMD have poor final visual acuity and thinning and atrophy or necrosis of the inner retinal layers. CONCLUSION: ILMD can occur in acute CRAO due to total retinal artery occlusion and severe retinal hypoperfusion. The presence of ILMD on OCT can be considered a sign of poor prognosis in cases of acute CRAO. TRIAL REGISTRATION: Not applicable.

Rare presentation of choroidal neovascularisation in a case of congenital hypertrophy of retinal pigment epithelium.

A 22-year-old woman presented with a 2-week history of decreased vision, a central scotoma and metamorphopsia in her right eye. Her presenting visual acuity was 6/75 in the right eye and 6/6 in the left eye. Anterior segment examination was normal. Fundus examination of both eyes showed features of bilateral congenital hypertrophy of retinal pigment epithelium (CHRPE) lesions and choroidal neovascularisation (CNV) in the right eye. She was treated with intravitreal injection bevacizumab 1.25 mg/0.05 mL. One month later, there was regression of the CNV and subretinal fluid and her vision improved to 6/12. At the final follow-up visit, her vision was maintained at 6/9 with regression of CNV noted. To conclude, CNV is a rare association of CHRPE. It can lead to vision-threatening problem if it involves the macula and should be identified promptly and managed appropriately.

Multimodal imaging in a classic case of unilateral retinocytoma.

Retinoma or retinocytoma is a spontaneously arrested or spontaneously regressed variant of retinoblastoma. With the advent of the latest non-invasive imaging techniques, it is possible to evaluate the microstructural and microvascular changes associated with this tumour. Although there are a few reports which describe the imaging findings in retinocytoma, information regarding retinocytoma on the multicolour imaging is lacking. Here, we describe the multimodal imaging features in a patient with classic features of retinocytoma with special emphasis on its multicolour imaging features.

Conversion from type 2 to type 1 macular hole closure after surgery in high myopia.

We describe a case of spontaneous conversion from type 2 macular hole (MH) closure to type 1 closure following MH surgery in high myopia. A 42-year-old male patient with myopia was diagnosed with full-thickness MH and localised neurosensory detachment. His best-corrected vision in the right eye was 20/120, N18. He underwent pars plana vitrectomy with internal limiting membrane peeling and silicone oil tamponade. Nine days after surgery, optical coherence tomography (OCT) showed type 2 MH closure and presence of epiretinal tissue. At 6 weeks of follow-up, there was spontaneous conversion from type 2 to type 1 closure of MH with a thin epimacular tissue bridging across the fovea and vision improving to 20/80. At 3 months after surgery, silicon oil removal was done. OCT showed a closed type 1 MH and visual acuity of 20/80 at the final visit. Early spontaneous conversion in closure can occur over time, leading to better anatomical and visual outcomes.

COVID-19-associated central retinal vein occlusion treated with oral aspirin.

This is a case report of central retinal vein occlusion (CRVO) associated with COVID-19 treated with oral aspirin therapy. A 56-year-old woman reported decreased vision in her left eye. Her left eye vision was 6/18, N10. Anterior segment was within normal limits. Left eye fundus was suggestive of CRVO and macular oedema. Optical coherence tomography showed cystoid macular oedema and neurosensory detachment. Blood work-up revealed elevated D-dimer levels and erythrocyte sedimentation rate (ESR). She was started on treatment with low-dose aspirin 150 mg/day. After 1 month, her vision improved to 6/6, N6. Left eye fundus showed reduced retinal haemorrhages and complete resolution of macular oedema. Her repeat blood work-up showed reduced D-dimer and ESR levels. The patient was asked to be reviewed after 3 months. This case highlights that specific treatment for reducing the hypercoagulable state caused by COVID-19 with oral aspirin therapy can result in complete resolution of CRVO macular oedema.