Torpedo maculopathy: A case series - insights into basic pathology.

Torpedo maculopathy is a benign retinal disorder whose pathophysiological origins are currently poorly understood. A number of theories have been postulated, with stable developmental anomalies of the retinal pigment epithelium taking the forefront. Four clinical cases are outlined of patients with macular torpedo lesions, with differing clinical presentation. In all four cases, this reveals very thin retinal pigment epithelium and outer retina associated with the lesion. In a single case, the oldest patient of the group, there is the additional finding of subretinal and intraretinal fluid accumulation. The contrast between this case and the other cases suggests that while initially this benign pathology might start with structurally normal retina with no fluid accumulation, dysgenetic changes in the retinal pigment epithelium might lead to secondary accumulation of fluid over time. Whether indeed this disorder might be progressive in nature, or whether in fact it is a static, non-progressive developmental abnormality as formerly thought, requires further elucidation.

Treatment of submacular hemorrhage with tissue plasminogen activator and pneumatic displacement in age-related macular degeneration.

PURPOSE: To evaluate visual and anatomic outcomes following pars plana vitrectomy and intravitreal or subretinal tissue plasminogen activator for submacular hemorrhage in patients with age-related macular degeneration. METHODS: This was a retrospective study on patients with a minimum follow-up of 12 months undertaken at a tertiary referral center. Data collected include demographic details, visual and optical coherence tomography changes, surgical details, and complications. Surgical results were compared with patients who were age and lesion size matched and treated with anti-vascular endothelial growth factor injections alone. RESULTS: There were 36 patients in surgical and 18 patients in control group. Patients in surgical arm had pars plana vitrectomy, intravitreal tissue plasminogen activator with air 24 (67%), 6 (16%) with C3F8 gas, 1 (3%) with SF6 gas, 4 (11%) subretinal tissue plasminogen activator with air, and 1 (3%) with C2F6 as post-operative tamponade. Mean LogMAR in tissue plasminogen activator group at baseline was 1.56, and it was improved at all time points 1.06 at 1 month (p < 0.05), 0.91 at 6 months (p < 0.05), and 1.07 at 1 year (p < 0.05). Mean best corrected visual acuity in control group at baseline was 1.22LogMAR with no significant improvement at any time points: 1 month (1.27), 6 months (1.35), and 12 months (1.36). Complications included retinal detachment 5%, vitreous hemorrhage 7.5%, and cataract 19%. CONCLUSION: Pars plana vitrectomy with intravitreal (or subretinal) tissue plasminogen activator and pneumatic displacement can offer better outcome in comparison to anti-vascular endothelial growth factor alone in patients with submacular hemorrhage secondary to age-related macular degeneration.

Rate of Postoperative Autofluorescent Macular Shift with Expanding Gas Bubble Tamponade and No Prone Posture Ambulatory Care in Patients with Macula-Involved Retinal Detachment.

PURPOSE: Chronically distorted vision is an important adverse outcome in patients with otherwise successfully treated macula-involved retinal detachment (RD). Symptomatic distortion is associated with macular vessel shift on fundus autofluorescence (FAF) imaging. Immediate prone posture has to date been the only mechanism adopted to reduce postoperative FAF shift. The aim of this study was to establish the rates of primary anatomical success and (FAF) macular shift in 67 eyes with macula-involved RD and superior breaks treated with vitrectomy, retinopexy, 0.7-1 mL 100% gas tamponade, and no prone posture. METHODS: Single-center, retrospective series. RESULTS: Rates of primary anatomical success and fundus autofluorescent imaging macular shift were 89 and 26%, respectively. CONCLUSION: Vitrectomy with a 0.7-1 mL expanding gas bubble tamponade and no prone posture were associated with an acceptable rate of primary anatomical success. We found the lowest yet reported rate of FAF shift in patients with macula-involved RD. If confirmed, this simple technique modification could improve the visual outcome of RD surgery whilst facilitating postoperative ambulatory care.

Acute retinal detachment induced by the Valsalva manoeuvre in morning glory disc anomaly.

We present a case in which a large, bullous, predominantly inferior, serous retinal detachment developed acutely after the Valsalva manoeuvre (from a coughing fit) in an eye with morning glory disc anomaly. We postulate that a rapid alteration in intracranial pressure was transmitted through the cavitary disc defect. This allowed a sudden influx of cerebrospinal fluid and/or liquefied vitreous into the subretinal space. This previously unreported case provides important evidence for the role of intracranial pressure fluctuations in the pathogenesis of macular schisis and neurosensory detachment secondary to optic disc cavitations.

The Effect of Multispot Laser Panretinal Photocoagulation on Retinal Sensitivity and Driving Eligibility in Patients With Diabetic Retinopathy.

IMPORTANCE: Panretinal photocoagulation (PRP) for proliferative diabetic retinopathy (PDR) may lead to peripheral field loss that prevents driving. Anti-vascular endothelial growth factor agents are proposed as treatments for PDR that spare peripheral vision. If multispot lasers cause less visual field loss, continuing to perform PRP may be justified. OBJECTIVE: To assess the effect of bilateral multispot laser PRP on retinal sensitivity and driving visual fields in PDR. DESIGN, SETTING, AND PARTICIPANTS: This prospective nonrandomized interventional cohort analysis performed at a tertiary referral center included 43 laser-naive patients with PDR that required bilateral PRP. Participants were recruited from June 27, 2012, to October 14, 2013. At baseline and 6-month follow-up, patients underwent detailed static and kinetic perimetry, microperimetry, optical coherence tomography, wide-field color fundus photography, and fluorescein angiography. Quantitative change in retinal sensitivity was assessed by comparing the mean global retinal sensitivity before and after laser treatment and by comparing the modeled hill of vision by deriving a volumetric measure. Final follow-up was completed on May 21, 2014. INTERVENTIONS: Multispot laser treatment was applied using standard parameters, until neovascularization regressed or complete retinal coverage was achieved. MAIN OUTCOMES AND MEASURES: Participants who passed the Esterman binocular visual field test for driving in the United Kingdom (at least 120° horizontal field with no significant defects within the central 20°) and full-field and macular retinal sensitivity. RESULTS: Of the 43 patients (17 men; 26 women; mean [SD] age, 46.6 [13.3] years), 38 (88%) completed the study. Before treatment, 41 of 43 patients (95%) passed the Esterman visual field test for driving; after completion of laser treatment, 35 of 38 patients (92%) passed. The mean (SD) change in retinal sensitivity on static perimetry was -1.4 (3.7) (95% CI, -2.7 to -0.1) dB OD and -2.4 (2.9) (95% CI, -3.4 to -1.4) dB OS. Mean (SD) 4° macular sensitivity decreased by 3.0 (5.2) dB OD and 2.6 (5.4) dB OS. CONCLUSIONS AND RELEVANCE: This prospective study investigating the effects of multispot laser PRP on retinal sensitivity demonstrates a high likelihood of retaining eligibility to drive based on adequate visual field. A mild loss of retinal sensitivity was detected at 6 months after completion of laser treatment. Further change to visual fields may have occurred with longer follow-up. This study provides information that might be used to counsel patients requiring PRP and informs the debate regarding the role of anti-vascular endothelial growth factor therapy in patients with PDR who might otherwise receive laser treatment.

Progressive outer retinal necrosis: manifestation of human immunodeficiency virus infection.

We present the case of a 54-year-old man who developed progressive outer retinal necrosis (PORN) as an initial manifestation of HIV infection without any significant risk factors for infection with HIV. PORN is usually found as a manifestation of known AIDS late in the disease. Our patient presented with transient visual loss followed by decrease in visual acuity and facial rash. Subsequent investigation revealed anterior chamber tap positive for varicella zoster virus (VZV), as well as HIV positivity, with an initial CD4 count of 48 cells/µL. Systemic and intravitreal antivirals against VZV, and highly active antiretroviral therapy against HIV were started, which halted further progression of retinal necrosis. This case highlights the importance of suspecting PORN where there is a rapidly progressive retinitis, and also testing the patient for HIV, so appropriate treatment can be started.