Combined Endoscopic Cyclophotocoagulation and Phacoemulsification Versus Phacoemulsification Alone in the Glaucoma Treatment: A Systematic Review and Meta-Analysis.

The complete safety and efficacy of endoscopic cyclophotocoagulation (ECP) remain unclear in the literature and, to our knowledge, there are no current meta-analyses on phaco-ECP versus phacoemulsification alone to date. Thus, we conducted a systematic review and meta-analysis comparing these two strategies through studies, assessing the effectiveness and safety of outcomes in a population with glaucoma. The protocol for this systematic review was registered in the PROSPERO International Prospective Register of Systematic Reviews (CRD42023482376). We systematically searched PubMed, Embase, and Web of Science from inception to December 2023. A random-effects model was used for all analyses due to heterogeneity. Review Manager 5.3 (Cochrane Centre, The Cochrane Collaboration, Denmark) was used for statistical analysis. Finally, nine studies were included in this comprehensive review and a total of 5389 eyes were analyzed in our study. In comparison to the ECP and phacoemulsification group, those receiving phacoemulsification alone showed better results in best-corrected visual acuity (MD 0.09; CI 95% 0.03 to 0.16; I²=0%), but worse outcomes in intraocular pressure (IOP) (MD -1.49; 95% CI -2.29 to -0.68; I²=29%) and use medications (MD -0.75; 95% CI -0.94 to -0.56; I²=0%) in the last visit. Complication rates, both general and serious, were significantly different between the groups, indicating the potential impact of combined procedures on patient outcomes. Thus, combining ECP with phacoemulsification for glaucoma treatment showed sustained IOP reduction and decreased medication dependence. However, higher complication rates suggest careful consideration of risks. More extensive research with larger trials and longer follow-ups is needed to validate findings and address limitations, providing valuable insights into this treatment approach.

Effects of aflibercept and bevacizumab on cell viability, cell metabolism and inflammation in hypoxic human Müller cells.

Anti-VEGF (vascular endothelial growth factor) drugs such as aflibercept (AFL) and bevacizumab (BVZ) inhibit pathological neo-angiogenesis and vascular permeability in retinal vascular diseases. As cytokines and growth factors are produced by Müller glial cells under stressful and pathological conditions, we evaluated the in vitro effect of AFL (Eylea®, 0.5 mg/mL) and BVZ (Avastin®, 0.5 mg/mL) on cell viability/metabolism, and cytokine/growth factor production by Müller cells (MIO-M1) under cobalt chloride (CoCl2)-induced hypoxia after 24h, 48h and 72h. Cell viability/metabolism were analyzed by Trypan Blue and MTT assays and cytokine/growth factors in supernatants by Luminex xMAP-based multiplex bead-based immunoassay. Cell viability increased with AFL at 48h and 72h and decreased with BVZ or hypoxia at 24h. BVZ-treated cells showed lower cell viability than AFL at all exposure times. Cell metabolism increased with AFL but decreased with BVZ (72h) and hypoxia (48h and72h). As expected, AFL and BVZ decreased VEGF levels. AFL increased PDGF-BB, IL-6 and TNF-α (24h) and BVZ increased PDGF-BB (72h). Hypoxia reduced IL-1ß, -6, -8, TNF-α and PDGF-BB at 24h, and its suppressive effect was more prominent than AFL (EGF, PDGF-BB, IL-1ß, IL-6, IL-8, and TNF-α) and BVZ (PDGF-BB and IL-6) effects. Hypoxia increased bFGF levels at 48h and 72h, even when combined with anti-VEGFs. However, the stimulatory effect of BVZ predominated over hypoxia for IL-8 and TNF-α (24h), as well as for IL-1ß (72h). Thus, AFL and BVZ exhibit distinct exposure times effects on MIO-M1 cells viability, metabolism, and cytokines/growth factors. Hypoxia and BVZ decreased MIO-M1 cell viability/metabolism, whereas AFL likely induced gliosis. Hypoxia resulted in immunosuppression, and BVZ stimulated inflammation in hypoxic MIO-M1 cells. These findings highlight the complexity of the cellular response as well as the interplay between anti-VEGF treatments and the hypoxic microenvironment.

Optical coherence tomography detection of retinal neural loss in patients with tuberous sclerosis.

PURPOSE: Tuberous Sclerosis (TS) is a rare, multisystem genetic disease caused by mutations in the TSC1 and TSC2 genes, leading to abnormalities in cell differentiation and proliferation. This study aimed to evaluate the neural integrity of individuals with TS by using Optical Coherence Tomography (OCT) to examine the peripapillary retinal nerve fiber layer (RNFL) thickness and the macular thickness in patients with TS and to compare with healthy controls. METHODS: Peripapillary and macular OCT scans (Optopol Revo NX SD OCT) were performed on 41 eyes from 22 TS patients, divided into two groups based on the presence of retinal hamartomas, and compared to 20 eyes from a control group. The average peripapillary RNFL thickness was measured for each quadrant. The macular total thickness and ganglion cell layer (GCL) + inner plexiform layer (IPL) thickness were measured based on the Early Treatment Diabetic Retinopathy Study (ETDRS) map. All measurements were then compared between the groups and controls. RESULTS: The TS group showed significantly reduced RNFL thickness and macular thickness when compared to the control group. Specifically, patients with retinal hamartomas exhibited an even more pronounced thinning of both RNFL and macular thickness. CONCLUSIONS: These findings suggest that TS patients undergo significant changes in retinal neurodevelopment and experience axonal loss. This finding may have significant prognostic utility regarding central nervous system degeneration in TS, particularly among patients with retinal hamartomas. OCT may serve as a valuable tool for assessing axonal structural abnormalities in TS patients. TRIAL REGISTRATION NUMBER: Not applicable.

Surgical management of retinal detachment and macular holes secondary to ocular toxoplasmosis: a systematic review and meta-analysis.

BACKGROUND: Toxoplasma gondii causes ocular toxoplasmosis (OT), involving inflammation, scarring, and retinal complications. The OT complications were retinal detachment (RD), and retinal breakage (RB). Surgical interventions like scleral buckling (SB) and vitrectomy are common. Limited understanding exists of the safety and efficacy of surgical management of RD/RB secondary to OT. Another complication is toxoplasmosis-related macular holes (tMH), with sparse evidence on surgical outcomes. This meta-analysis aims to clarify clinical characteristics, and surgical results, and enhance understanding of RD, RB, and MH secondary to OT. METHODS: PubMed, Cochrane, Embase and Web of Science database were queried for retrospective studies, case series and case reports that provided information on RD, RB and MH associated with OT and reported the outcomes of: (1) Retinal reattachment of RD/RB and tMH closure; (2) Best-corrected visual acuity (BCVA) improvement; and (3) Complications. Heterogeneity was examined with I2 statistics. A random-effects model was used for outcomes with high heterogeneity. Statistical analysis was performed using the software R (version 4.2.3, R Foundation for Statistical Computing, Vienna, Austria). RESULTS: Fourteen final studies, comprising a total of 96 patients were analyzed, 81 with RD or RB and 15 with tMH. Overall, surgical management was associated with several advantages: a high rate of retinal reattachment of RD/RB of 97% (95% Confidence Interval [CI] 92-100%; I2 = 0%), retinal reattachment of just RD of 96% (95% CI 89-100%; I2 = 30%) and tMH closure 97% (95% CI 87-100; I2 = 12%). There were significant differences in BCVA after surgeries in studies of RD/RB (MD 0.60; 95% CI 0.35-0.65; I2 = 20%) and MH (MD 0.67; 95% CI 0.50-0.84; I2 = 0%). The overall complication rate associated with surgical procedures in RD/RB secondary to OT was confirmed to be 25%. CONCLUSIONS: The systematic review and meta-analysis showed that the treatment approaches currently in use are effective, with a remarkable rate of retinal reattachment of RD/RB, tMH closure, and substantial improvements in visual acuity. More randomized, long-term studies on disease and surgical factors can provide valuable insights into their impact on anatomical and visual outcomes.

Correlation between retinal sensitivity assessed by microperimetry and structural abnormalities on optical coherence tomography after successful epiretinal membrane surgery.

BACKGROUND: To verify the correlation between retinal sensitivity (RS) assessed by the microperimetry (MP) and optical coherence tomography (OCT) parameters measured in eyes submitted to pars-plana vitrectomy (PPV) for idiopathic epiretinal membrane (ERM) treatment. METHODS: 43 patients underwent PPV. Best-corrected visual acuity (BCVA) and OCT imaging were acquired preoperatively and 6 months after surgery. The RS values were recorded 6 months after the surgery. Total macular thickness (TMT) measurements and OCT-evaluated structural findings were also analyzed. The MP examination tested 44 points, with direct topographic correspondence with the OCT-ETDRS map. Correlations between BCVA, RS, and OCT parameters were assessed. RESULTS: TMT measurements in patients were significantly thicker preoperatively and reduced after surgery. All patients demonstrated BCVA improvements after surgery. The RS parameters after surgery were significantly lower in patients. For OCT structural analyses, patients with lower RS at the fovea correlated with the preexisting disorganization of retinal inner layers (DRIL). In addition, lower RS values were associated with DRIL, outer retinal changes (ORC), and intraretinal microcysts after surgery. CONCLUSIONS: The RS values after surgery were significantly lower when compared to controls. The DRIL presence before and after surgery, and microcysts and ORC after surgery were related to worse visual outcomes.

Retinoblastoma treatment in a Brazilian population. Presentation and long-term results.

INTRODUCTION: Retinoblastoma is a malignant tumor with a high cure potential when proper therapy is used. The purpose of this paper is to report the clinical features and outcomes of patients with retinoblastoma who were treated with a combination of local and systemic chemotherapy-based protocols. METHOD: We retrospectively studied patients treated with systemic chemotherapy plus local treatment between 2003 and 2015 with a follow-up ≥2 years. We correlated clinical and pathological characteristics with decimal visual acuity (VA) and death. RESULTS: Among 119 patients, 60% had unilateral disease (UNI), and 52% were male. The median presentation age was 19.5 months, 10% had a positive family history, and the most frequent sign was leukocoria (68.8%). Advanced disease was more frequent in eyes with UNI (98.4%) than in eyes with bilateral retinoblastoma (BIL: 55.3%). Enucleation was performed in 97% of UNI eyes and in 55.8% of BIL eyes. The overall globe salvage was 26.6%, 44.25% of BIL eyes. Bilateral enucleation was required in 5%. High-risk pathologic features occurred in 50% and 37% of eyes enucleated without and with neoadjuvant chemotherapy, respectively. High-risk features were related to the presence of goniosynechiae in the pathologic specimen and were more frequent in children younger than 10 months or older than 40 months. Extraocular disease was present in 5% of patients, and the death rate related to metastasis of the tumor was 8%. The final VA was ≥ 0.7 in 72.8% and ≥0.1 in 91% of BIL patients. CONCLUSIONS: Treatment of retinoblastoma with conservative systemic-based chemotherapy was associated with an excellent survival rate (92%). Albeit the low overall globe salvage rate, in BIL patients, approximately half the eyes were conserved, and a satisfactory functional visual result was achieved The evaluated protocol is an important treatment option, especially in developing countries.

Normative data for macular perimetry using the MP-3 microperimeter in healthy individuals / Dados normativos para perimetria macular usando o microperímetro MP-3 em indivíduos normais

ABSTRACT Purpose: Microperimetry has been used for several years as a form of visual function testing in patients with retinal diseases. Normal microperimetry values obtained with microperimeter MP-3 have not yet been fully published, and baseline values for topographic macular sensitivity and correlations with age and sex are needed to establish degrees of impairment. This study aimed to determine values for light sensitivity thresholds and fixation stability using the MP-3 in healthy individuals. Methods: Thirty-seven healthy volunteers (age, 28-68 years), underwent full-threshold microperimetry using a 4-2 (fast) staircase strategy with the standard Goldmann III stimulus size and 68 test points positioned identically to those in the Humphrey Field Analyzer 10-2 test grid. The fixation stability was simultaneously recorded during the microperimetry test. The relationship between global sensitivity and age was calculated using linear regression analysis. Results: Microperimetry was performed on 37 participants (74 eyes). The global mean sensitivity was 29.01 ± 1.44 (range, 26-31) dB. The mean central sensitivity at 2° measured by the MP-3 was 28.5 ± 1.77 dB in the right eye (OD) and 28.75 ± 1.98 dB in the left eye (OS). The total median fixation stability values within 2° and 4° were 80% and 96%, respectively. The linear regression analysis also revealed an age-related global sensitivity decline per year of -0.051 dB ± 0.018 (OD) and -0.078 dB ± 0.021 (OS). Conclusions: Microperimetry performed with the MP-3 allows for an automatic, accurate, and topography-specific examination of retinal sensitivity thresholds. The results of this study provide a normal and age-matched database of MP-3 microperimetry.

RESUMO Objetivos: A microperimetria tem sido usada há vários anos como uma forma de teste de função visual em pacientes com doenças da retina. Os valores normais de microperimetria obtidos com MP-3 ainda não foram totalmente publicados e os valores basais para sensibilidade macular topográfica e correlações com idade e sexo são necessários para estabelecer graus de comprometimento. O objetivo do trabalho é determinar valores para limiares de sensibilidade à luz e estabilidade de fixação usando o MP-3 em indivíduos normais. Métodos: Trinta e sete voluntários saudáveis (idade: 28-68 anos), submetidos à microperimetria de limiar total usando uma estratégia de escada 4-2 (rápida) com o tamanho de estímulo padrão Goldmann III e 68 pontos de teste posicionados de forma idêntica aos do Humphrey Field Analyzer 10-2 grade de teste. A estabilidade da fixação foi registrada simultaneamente durante o teste de microperimetria. A relação entre a sensibilidade global e a idade foi calculada por meio de análise de regressão linear. Resultados: A microperimetria foi realizada em 37 indivíduos (74 olhos). A sensibilidade média global foi de 29,01 ± 1,44 dB, intervalo: 26-31 dB. A mediana da sensibilidade central a 2° medida pelo MP-3 foi de 28,5 ± 1,77 dB (ER) e 28,75 ± 1,98 dB (OE). Os valores médios totais de estabilidade da fixação em 2° e 4° foram 80% e 96%, respectivamente. A análise de regressão linear também revelou um declínio de sensibilidade global relacionado à idade por ano de -0,051 dB ± 0,018 (ER) e -0,078 dB ± 0,021 (LE). Conclusões: A microperimetria realizada com o MP-3 permite um exame automático, preciso e específico da topografia dos limiares de sensibilidade da retina. Os resultados deste estudo fornecem um banco de dados normal e de idade correspondente da microperimetria MP-3.

A comparative study of visual outcome in patients with optic neuritis treated with five or seven days of intravenous corticosteroid treatment.

BACKGROUND: Optic neuritis (ON), a major cause of visual impairment in young adults, is generally associated with rapid visual recovery when treated with intravenous methylprednisolone treatment (IVMPT). However, the optimal duration of such treatment is unknown, ranging from three to seven days in clinical practice. We aimed to compare the visual recovery in patients treated with 5-day or 7-day duration IVMPT. METHODS: We performed a retrospective cohort study of consecutive patients with ON in São Paulo, Brazil, from 2016 to 2021. We compared the proportion of participants with visual impairment in 5-day and 7-day treatment schedules at discharge, at 1 month and between 6 and 12 months after the diagnosis of ON. The findings were adjusted to age, severity of the visual impairment, co-intervention with plasma exchange, time from symptom onset to IVMPT and the etiology of the ON to mitigate indication bias. RESULTS: We included 73 patients with ON treated with 5 or 7-day duration of 1 g/d intravenous methylprednisolone therapy. Visual impairment at 6-12 months in the 5-day or the 7-day treatment groups was similar (57% x 59%, p > 0.9, Odds Ratio 1.03 [95% CI 0.59-1.84]). The results were similar after adjusting for prognostic variables and when observed at different time points. CONCLUSION: Visual recovery is similar in patients treated with 5-day and 7-day duration treatments of 1 g/day intravenous methylprednisolone, suggesting a ceiling effect. Limiting the duration of the treatment can reduce hospital stay and costs, without interfering with clinical benefit.

Normative data for macular perimetry using the MP-3 microperimeter in healthy individuals.

PURPOSE: Microperimetry has been used for several years as a form of visual function testing in patients with retinal diseases. Normal microperimetry values obtained with microperimeter MP-3 have not yet been fully published, and baseline values for topographic macular sensitivity and correlations with age and sex are needed to establish degrees of impairment. This study aimed to determine values for light sensitivity thresholds and fixation stability using the MP-3 in healthy individuals. METHODS: Thirty-seven healthy volunteers (age, 28-68 years), underwent full-threshold microperimetry using a 4-2 (fast) staircase strategy with the standard Goldmann III stimulus size and 68 test points positioned identically to those in the Humphrey Field Analyzer 10-2 test grid. The fixation stability was simultaneously recorded during the microperimetry test. The relationship between global sensitivity and age was calculated using linear regression analysis. RESULTS: Microperimetry was performed on 37 participants (74 eyes). The global mean sensitivity was 29.01 ± 1.44 (range, 26-31) dB. The mean central sensitivity at 2° measured by the MP-3 was 28.5 ± 1.77 dB in the right eye (OD) and 28.75 ± 1.98 dB in the left eye (OS). The total median fixation stability values within 2° and 4° were 80% and 96%, respectively. The linear regression analysis also revealed an age-related global sensitivity decline per year of -0.051 dB ± 0.018 (OD) and -0.078 dB ± 0.021 (OS). CONCLUSIONS: Microperimetry performed with the MP-3 allows for an automatic, accurate, and topography-specific examination of retinal sensitivity thresholds. The results of this study provide a normal and age-matched database of MP-3 microperimetry.

Visual Hallucinations as a Major Manifestation of Posterior Reversible Encephalopathy Syndrome: Case Report and Literature Review.

We evaluated a 48-year-old woman who had visual hallucinations (VHs) as a major presenting sign of posterior reversible encephalopathy syndrome (PRES). Despite her mild loss of vision, she described various hallucinations after awakening from a comatose state days after a motorcycle collision. VHs are usually accompanied by more severe loss of vision, yet our case and literature review indicate that sudden onset of formed VHs should suggest a possible diagnosis of PRES in patients who have large fluctuations in blood pressure, renal failure, or autoimmune dysfunction, as well as in patients taking cytotoxic agents.

Severe bilateral visual loss as the first sign of IgA nephropathy / Perda visual bilateral grave como o primeiro sinal da nefropatia por IgA

ABSTRACT We describe a case of a 33-years-old woman who presents with severe acute bilateral visual loss secondary to massive exudative hypertensive maculopathy as the first sign of immunoglobulin A nephropathy. The patient's ophthalmic examination showed bilateral cotton-wool spots, flame-shaped retinal hemorrhages, diffuse narrow arterioles, optic disk edema, and exudative maculopathy. Systemic workup demonstrated a systolic and diastolic blood pressure of 240 mmHg and 160 mmHg, respectively, proteinuria, and hematuria, suggesting kidney disease as the causative condition. A kidney biopsy confirmed immunoglobulin A nephropathy. She was treated with systemic corticosteroids, antihypertensive drugs, and a single bilateral intravitreal injection of aflibercept. There was a prompt resolution of macular edema and vision improvement. Our case draws attention to the fact that severe bilateral visual loss can be the first sign of severe hypertension. Secondary causes, such as immunoglobulin A nephropathy, should be ruled out.

RESUMO Nosso objetivo é descrever uma paciente de 33 anos de idade, com perda visual bilateral grave por maculopatia hipertensiva exsudativa como o primeiro sinal da nefropatia por imunoglobulina A. A fundoscopia revelou a presença de manchas algodonosas, hemorragias em chama-de-vela, estreitamento arteriolar difuso, edema de disco óptico e maculopatia exsudativa bilateral. A pressão arterial sistólica foi de 240mmHg e a diastólica de 160 mmHg associado a proteinúria e hematúria, sugerindo a presença de doença renal. A biópsia renal confirmou a nefropatia por imunoglobulina A. A paciente foi tratada como corticoide sistêmico, drogas anti-hipertensivas e uma única dose intravítrea de Aflibercept em ambos os olhos. Houve rápida melhora do edema macular e da acuidade visual. Nosso caso chama a atenção para o fato de que a perda visual bilateral grave pode ser a primeira apresentação de uma doença hipertensiva sistêmica. Causas secundárias como a nefropatia por imunoglobulina A devem ser afastadas.

Retinal arterial macroaneurysms in patients recovered from COVID-19 / Macroaneurismas arteriais retinianos em pacientes recuperados da COVID-19

ABSTRACT This is a case series about retinal arterial macroaneurysms in three patients recovered from COVID-19. None of them had previous past ocular and systemic history. The first patient was a 47-year-old man, with best-corrected visual acuity of 20/20 in both eyes. He presented a cotton wool spot in the right eye and two peripheral exudative retinal arterial macroaneurysms in the left eye. Laser photocoagulation was performed and best-corrected visual acuity remained stable. The second one was a 62-year-old-woman with acute visual loss in the right eye (best-corrected visual acuity of 20/400). There was vitreous hemorrhage and a peripheral retinal arterial macroaneurysm in the right eye. Laser photocoagulation was performed and best-corrected visual acuity improved to 20/20. The third patient was a 54-year-old woman, with best-corrected visual acuity of 20/20 in the right eye and 20/600 in the left eye. Fundus examination showed multiple layer hemorrhage in the macular region and retinal arterial macroaneurysms in the superior temporal branch. The cases underwent fluorescein angiography, which confirmed the diagnosis of retinal arterial macroaneurysms.

RESUMO Esta é uma série de casos sobre macroaneurismas arteriais da retina em três pacientes recuperados da COVID-19. Nenhum tinha história ocular e sistêmica prévias. O primeiro era um homem de 47 anos, com melhor acuidade visual corrigida de 20/20 em ambos os olhos. Apresentava mancha algodonosa em olho direito e dois macroaneurismas arteriais da retina exsudativos periféricos em olho esquerdo. Foi realizada fotocoagulação a laser, e a melhor acuidade visual corrigida permaneceu estável. A segunda era uma mulher de 62 anos com perda visual aguda em olho direito (melhor acuidade visual corrigida de 20/400). Havia hemorragia vítrea e um macroaneurisma periférico em olho direito. O laser foi realizado, e a melhor acuidade visual corrigida melhorou para 20/20. A terceira paciente era uma mulher de 54 anos, com melhor acuidade visual corrigida 20/20 em olho direito e 20/600 olho esquerdo. A fundoscopia mostrou hemorragia em múltiplas camadas na região macular e um macroaneurisma arterial da retina no ramo temporal superior. Os casos foram submetidos à angiofluoresceinografia, que confirmou o diagnóstico de macroaneurismas arteriais da retina.

A standardized method to quantitatively analyze optical coherence tomography angiography images of the macular and peripapillary vessels.

BACKGROUND: Optical coherence tomography angiography (OCTA) is a relatively new non-invasive imaging technique to evaluate retinal vascular complexes. However, there is still a lack of standardization and reproducibility of its quantitative evaluation. Furthermore, manual analysis of a large amount of OCTA images makes the process laborious, with greater data variability, and risk of bias. Therefore, the aim of this study is to describe a fast and reproducible quantitative analysis of the foveal avascular zone (FAZ), macular superficial and deep vascular complexes (mSVC and mDVC, respectively), and peripapillary superficial vascular complex (pSVC) in OCTA images. METHODS: We survey models and methods used for studying retinal microvasculature, and software packages used to quantify microvascular networks. These programs have provided researchers with invaluable tools, but we estimate that they have collectively achieved low adoption rates, possibly due to complexity for unfamiliar researchers and nonstandard sets of quantification metrics. To address these existing limitations, we discuss opportunities to improve effectiveness, affordability, and reproducibility of microvascular network quantification with the development of an automated method to analyze the vessels and better serve the current and future needs of microvascular research. OCTA images of the macula (10°x10°, 15°x15°, or 20°x20° centered on the fovea) and peripapillary area (15 × 15º centered on optic nerve head) were exported from the device and processed using the open-source software Fiji. The mSVC, mDVC, and pSVC were automatically analyzed regarding vascular density in the total area and four sectors (superior, inferior, nasal, and temporal). We also analyzed the FAZ regarding its area, perimeter, and circularity in the SVC and DVC images. RESULTS: We developed an automated model and discussed a step by step method to analyze vessel density and FAZ of the macular SVC and DVC, acquired with OCTA using different fields of view. We also developed an automated analysis of the peripapillary SVC. CONCLUSION: Our developed automated analysis of macular and peripapillary OCTA images will allow a fast, reproducible, and precise quantification of SVC, DVC, and FAZ. It would also allow more accurate comparisons between different studies and streamlines the processing of images from multiple patients with a single command.

Severe bilateral visual loss as the first sign of IgA nephropathy.

We describe a case of a 33-years-old woman who presents with severe acute bilateral visual loss secondary to massive exudative hypertensive maculopathy as the first sign of immunoglobulin A nephropathy. The patient's ophthalmic examination showed bilateral cotton-wool spots, flame-shaped retinal hemorrhages, diffuse narrow arterioles, optic disk edema, and exudative maculopathy. Systemic workup demonstrated a systolic and diastolic blood pressure of 240 mmHg and 160 mmHg, respectively, proteinuria, and hematuria, suggesting kidney disease as the causative condition. A kidney biopsy confirmed immunoglobulin A nephropathy. She was treated with systemic corticosteroids, antihypertensive drugs, and a single bilateral intravitreal injection of aflibercept. There was a prompt resolution of macular edema and vision improvement. Our case draws attention to the fact that severe bilateral visual loss can be the first sign of severe hypertension. Secondary causes, such as immunoglobulin A nephropathy, should be ruled out.

Electroretinography reveals retinal dysfunction in Parkinson's disease despite normal high-resolution optical coherence tomography findings.

INTRODUCTION: Parkinson's disease (PD)-associated inner retinal abnormalities, particularly the retinal ganglion cells (RGC) layer, on optical coherence tomography (OCT) have recently gained importance as a biomarker of non-motor involvement of the disease but functional RGC evaluation using photopic negative response (PhNR) has not yet been determined. This study aims to compare structural and functional findings of the retina and optic nerve in PD with healthy controls (CT) including PhNR and OCT. METHODS: Forty-one eyes of 21 PD patients and 38 eyes of 19 CT underwent ophthalmic examination including visual contrast sensitivity test (CS), OCT, light-adapted full-field electroretinography (ffERG), and PhNR. OCT was used to measure the peripapillary retinal nerve fiber layer, the segmented macular layers, and the choroid. For functional parameters, CS, ffERG (oscillatory potentials, photopic response, 30 Hz-flicker), and PhNR waves were used. Measurements were compared using generalized estimating equation and significance was set at P ≤ 0.05. RESULTS: The PD group presented a significantly lower mono- and binocular CS, oscillatory potentials amplitude, b-wave amplitude on ffERG (152.3[45.4] vs 187.1[32.7]µV; P = 0.002), and PhNR amplitude (135.0[35.0] vs 156.3[34.1]µV; P = 0.025). There was no statistically significant difference in OCT measurements between groups. No correlation was found between statistically significant measurements and clinical data. CONCLUSIONS: Functional abnormalities on CS, ffERG, and PhNR can be detected in PD even when structural damages are not observed on OCT. PhNR represents a new potential biomarker in PD. Our findings indicate dysfunction of bipolar, amacrine, and retinal ganglion cells in PD, probably with a cellular dysfunction overcoming morphological damage.

Multiple attacks of transient monocular visual loss in a previously healthy man: a possible complication after COVID-19 vaccination?

BACKGROUND: The present case aims to describe a previously healthy man who presented multiple attacks of transient monocular visual loss after Pfizer-BioNTech COVID-19 vaccination and to discuss the possible mechanisms related to occurrence of this condition. CASE PRESENTATION: We report a case of multiple attacks of transient monocular visual loss in a previously healthy middle-aged man two weeks after Pfizer-BioNTech COVID-19 vaccination. TVL attacks were described as sudden and painless complete visual loss, lasting about one minute, followed by a full recovery. He presented several non-simultaneous attacks in both eyes, 16 in the right eye, and 2 in the left eye on the same day, fifteen days after receiving the second dose of the Pfizer-BioNTech COVID-19 vaccine. The brain's magnetic resonance angiography, echocardiogram, and doppler ultrasound imaging of the carotid and vertebral arteries were non-revealing. The complete blood exam revealed a slightly elevated C-reactive protein test. We assessed fundus examination during the transient visual loss attack and revealed diffuse vascular narrowing for both arterial and venous branches, notably in the emergence of the optic disc in right eye. In addition, the circumpapillary optical coherence tomography angiography (OCTA) vessel density map was reduced. Oral verapamil hydrochloride 60 mg twice daily was initiated, and the attacks of transient visual loss improved after two days. CONCLUSIONS: To date, and the best of our knowledge, this is the first case report of multiple transient monocular visual loss attacks due to retinal vasospasm in a previously healthy middle-aged man documented by fundus retinography and OCTA. We discuss in this article the possible association of retinal vasospasm and Pfizer-BioNTech COVID-19 vaccination, probably related to vaccine-induced inflammation.

Complete reversal of bilateral optic nerve infiltration from lymphoblastic leukemia using chemotherapy without adjuvant radiotherapy.

BACKGROUND: Leukemic involvement of the eyes is rare, therefore, treatment relies on previous case reports. The treatment of ocular complications poses additional difficulties, because the eye is considered as a pharmacological "sanctuary" for patients with acute lymphoblastic leukemia (ALL). Therefore, radiotherapy is the main therapeutic choice; however, it might lead to many important side effects. To the best of our knowledge, this is the first case report of a bilateral leukemic optic nerve infiltration that remitted with chemotherapy without adjuvant radiotherapy. CASE PRESENTATION: A 30-year-old female patient with previous history of remitted ALL presented with a one-week history of floaters in her right eye. Her ophthalmological exam showed remarkable optic disc swelling, in both eyes. She was diagnosed with ALL relapse presenting as a bilateral optic nerve leukemic infiltration. Local radiotherapy was planned for both eyes, however, due to efficient recovery with chemotherapy, it was cancelled. Allogenic bone marrow transplantation was subsequently performed. The patient is being followed up and ALL remitted. CONCLUSION: Leukemia relapse on central nervous system, despite rare, is a sign of poor prognosis and requires prompt treatment. Its occurrence on ocular tissues is even rarer. It is hypothesized that the blood-brain barrier limits the delivery of chemotherapeutic drugs to the eye and infiltration of the optic nerve by leukemic cells might prejudice the flow of cerebrospinal fluid between the cranial space and the optic disc.

Recurrent and Reversible, Bitemporal Field Defect from Presumed Chiasmitis in a Patient with Systemic Lupus Erythematosus.

Systemic lupus erythematosus (SLE) is a chronic, recurrent and remitting autoimmune disease affecting mostly women and presenting between late adolescence and the fourth decade of life. Ocular manifestations may occur in one-third of patients with SLE, with keratoconjunctivitis sicca as the most common and optic nerve and retina abnormalities as the most severe. Neuro-ophthalmological manifestations occur in approximately 1% of patients with SLE, usually in the form of optic neuropathy. The purpose of this paper is to describe a patient who developed recurrent optic chiasmitis as an uncommon sign of disease activity in SLE.

Prevalence of Focal Inner, Middle, and Combined Retinal Thinning in Diabetic Patients and Its Relationship With Systemic and Ocular Parameters.

Purpose: To determine the prevalence of focal inner, middle, and combined inner/middle retinal thinning (FIRT, FMRT, and FCRT, respectively) in different stages of diabetic retinopathy (DR) without diabetic macular edema and to assess the relationship between such findings with ocular and systemic parameters. Methods: This was a cross-sectional, comparative study comprising healthy participants and diabetic patients with different stages of DR. Forty-nine horizontal macular B-scans from the selected eye were obtained using spectral-domain optical coherence tomography (SD-OCT) and analyzed for the presence of FIRT, FMRT, or FCRT and any relationship with systemic and ocular parameters. Focal retinal thinning (FRT) was subjectively defined as any evidence of inner and/or middle retinal thinning. Results: A total of 190 participants (52 healthy participants and 138 diabetic patients) were included. A higher prevalence of FRT was observed in eyes with advanced DR versus healthy eyes and versus diabetic eyes with no DR or mild DR. FIRT and FCRT were significantly greater in eyes with proliferative DR treated with pan-retinal photocoagulation, and FMRT was significantly more common in eyes with severe nonproliferative DR. FRT was significantly more common in patients with coronary artery disease and was positively correlated with diabetes duration, serum creatinine, and glycosylated hemoglobin and negatively correlated with age, estimated glomerular filtration rate, and visual acuity. Conclusions: FRT occurs in all stages of DR and is increasingly prevalent with increasing severity of DR. Translational Relevance: OCT identification of FRT may provide a surrogate biomarker of retinal and systemic disease in diabetic patients.

Ocular motility changes after inferomedial wall and balanced medial plus lateral wall orbital decompression in Graves' orbitopathy: a randomized prospective comparative study.

OBJECTIVES: To compare the surgical outcomes of inferomedial wall orbital decompression (IM-OD) and balanced medial plus lateral wall orbital decompression (ML-OD) in patients with inactive Graves' orbitopathy (GO) with regard to exophthalmos reduction and ocular motility abnormalities. METHODS: Forty-two patients with inactive GO eligible for OD were randomly assigned to either the IM-OD or ML-OD groups. Pre and postoperative evaluations included Hertel exophthalmometry, sensory, and motor extraocular motility assessment, standardized photographs in the nine gaze positions, and computed tomography (CT) of the orbits. ClinicalTrials.gov: NCT03278964. RESULTS: Exophthalmometry reduction was statistically significant in both groups (p<0.001), but was greater in the ML-OD group (p=0.010). New-onset esotropia occurred in 11.1% and 23.5% of patients who underwent IM-OD and ML-OD, respectively, with no statistically significant difference in the frequency of pre and postoperative strabismus in either group. The mean increase in preoperative esotropia was 24±6.9 and 12±8.8 prism diopters in patients who underwent IM-OD and ML-OD, respectively. In the IM-OD group, abduction and elevation worsened at the first (p<0.05) and third (p<0.05) postoperative visits but were restored at 6 months. The versions did not change postoperatively with ML-OD. The preoperative CT-measured medial rectus muscle area predicted new-onset strabismus (p=0.023). Significant postoperative medial rectus muscle enlargement occurred in both groups (p<0.001). Restriction in elevation and abduction was significantly associated with enlarged inferior (p=0.007) and medial rectus muscle areas (p=0.002). CONCLUSIONS: IM-OD is as safe as ML-OD with regard to new-onset strabismus, and represents a good alternative for patients who do not require significant exophthalmos reduction. ML-OD offers greater exophthalmos reduction and smoother postoperative recovery. Patients with preoperative enlarged medial rectus muscle on CT are at risk for new-onset esotropia, and preoperative esotropia is likely to increase after OD.