Bilateral acute macular neuroretinopathy associated with COVID-19 infection presenting with central scotoma.

Purpose: To report a case of bilateral acute macular neuroretinopathy (AMN) associated with COVID-19 infection presenting with central scotoma. Observation: A 26-year-old female presented with a chief complaint of bilateral central scotomas for the last seven days. She had a history of fever over the past ten days, and RT-PCR test for COVID-19 was positive on the second day of fever. She had been vaccinated against COVID-19 eight months prior. Her best corrected visual acuity was 6/6 in both eyes on the Snellen chart. Dilated fundus evaluation revealed subtle bilateral perifoveal grey macular lesions. Optical coherence tomography (OCT) demonstrated focal hyperreflectivity at the level of the outer nuclear and plexiform layer consistent with bilateral AMN. Near-infrared reflectance (NIR) and red-free (RF) imaging showed large, confluent hyporeflective lesions in the right eye and discrete petaloid lesions with apices pointing toward the fovea in the left eye. OCT angiography (OCTA) revealed decreased flow signal at the level of the deep capillary plexus (DCP) and choriocapillaris (CC) in both eyes. Automated visual field testing (Humprey Field Analyzer (HFA) 24-2) revealed bilateral central scotoma with depression of adjacent points. After two weeks, the patient had depressed visual fields on HFA 10-2. At two months of final follow-up, OCT macula, NIR and RF images revealed resolving AMN lesions in both eyes. OCTA showed an increase in perfusion at the level of the DCP. There was a decrease in scotoma density on HFA 10-2, suggestive of resolving AMN. Conclusion and importance: AMN with central scotoma as presenting feature of COVID-19 is rare. Fundus findings may be very subtle in AMN, but NIR and RF imaging delineate the lesions well. OCT, NIR imaging, OCTA and HFA 10-2 can be used to assess the clinical course of AMN.

Incomplete homonymous hemianopsia progressing to junctional scotoma due to a large internal carotid artery aneurysm: A case report.

Visual field disorders caused by cerebral aneurysms are diverse, nonspecific, and vary in their degree of compression. They should be distinguished from those caused by other common diseases, such as glaucoma.

Peripapillary Versus Macular Thinning to Detect Progression According to Initial Visual Field Loss Location in Normal-Tension Glaucoma.

PURPOSE: To investigate the predictive capabilities of peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell-inner plexiform layer (mGCIPL) thinning to detect visual field (VF) progression in normal-tension glaucoma patients with an initial parafoveal scotoma (IPFS) or nasal step (INS). DESIGN: Retrospective cohort study. METHODS: 185 early-stage glaucoma eyes, followed for 10 years, were retrospectively stratified into IPFS and INS groups. Progressive pRNFL and mGCIPL thinning were assessed using spectral-domain optical coherence tomography and VF progression using both event- or trend-based analysis. Kaplan-Meier survival analysis compared VF survival in each VF phenotype with or without progressive pRNFL and mGCIPL thinning. Cox proportional regression analysis identified VF progression factors. RESULTS: VF progression was detected in 42 IPFS (n=86) and 47 INS (n=99) eyes. Among VF progressors, pRNFL thinning was significantly faster in INS group compared to IPFS group (P < 0.01), while mGCIPL thinning was similar (P = 0.16). At five years, eyes with progressive mGCIPL thinning showed significantly lower VF survival in both VF phenotypes (all P < 0.05). Progressive pRNFL thinning showed significantly lower VF survival only in INS eyes (P = 0.015). Cox multivariate regression revealed that mGCIPL thinning predicted subsequent VF progression in IPFS eyes, while mGCIPL and pRNFL thinning had significant associations with VF progression in INS eyes. CONCLUSIONS: mGCIPL outperforms pRNFL at early follow-up in detecting VF progression in IPFS eyes but not INS eyes. Appropriate selection of structural parameters (mGCIPL vs pRNFL) maximizes early VF progression detection according to initial VF defect location.

Outcome of Visual Function after Removal of Tuberculum Sellae Meningioma Presenting with Scotoma at the Lower Visual Field Center.

Tuberculum sellae meningiomas commonly present as bitemporal hemianopia and loss of visual acuity due to optic nerve compression. Two female patients (48 and 58 years old) presented with a small scotoma at the lower visual field center due to tuberculum sellae meningioma (25 and 10 mm, respectively). Despite the fact that their visual field defect was not very large, daily activities, including walking or reading were hindered. By the total removal of the tumors in both patients, the scotoma was cured and daily activities recovered. When patients exhibit visual deficits, especially in the lower center fields, surgical removal should be considered even if the tumors are small and visual deficits are limited because improvement of both vision and daily activities can be achieved.

Ocular Autoimmune Systemic Inflammatory Infectious Study (OASIS) - Report 6: Dengue Uveitis at a Tertiary Eye Institution in Singapore.

OBJECTIVES: To identify the characteristics, treatment, and visual outcomes of dengue uveitis at a tertiary eye care centre in Singapore. METHODS: Retrospective case record review of all consecutive dengue uveitis patients (2004 to 2015) from the Ocular Autoimmune Systemic Inflammatory and Infectious Study (OASIS) database. RESULTS: Fifty-four patients were identified from the OASIS database. The most common ocular symptom was blurring of vision (n = 41, 75.9%), followed by floaters (n = 9, 17.0%), scotoma (n = 5, 9.3%), and metamorphopsia (n = 3, 5.7%). Scotoma based on history, Amsler grid, and perimetry accounted for 27 (50%) patients. Majority presented with either a posterior uveitis or retinal vasculitis (n = 51, 94.4%). Treatments ranged from close observation for spontaneous improvement, to the use of high-dose corticosteroids. CONCLUSIONS: Dengue uveitis may present with a spectrum of disease manifestations including posterior uveitis, vasculitis, and macula edema. Scotoma is significant and may be found on history taking, Amsler charting, and perimetry.

Central Visual Field Testing in Early Glaucoma: A Report by the American Academy of Ophthalmology.

PURPOSE: To evaluate the current published literature on the utility of the 10-2 visual field (VF) testing strategy for the evaluation and management of early glaucoma, defined here as mean deviation (MD) better than -6 decibels (dB). METHODS: A search of the peer-reviewed literature was last conducted in June 2023 in the PubMed database. Abstracts of 986 articles were examined to exclude reviews and non-English-language articles. After inclusion and exclusion criteria were applied, 26 articles were selected, and the panel methodologist rated them for strength of evidence. Thirteen articles were rated level I, and 8 articles were rated level II. The 5 level III articles were excluded. Data from the 21 included articles were abstracted and reviewed. RESULTS: The central 12 locations on the 24-2 VF test grid lie within the central 10 degrees covered by the 10-2 VF test. In early glaucoma, defects detected within the central 10 degrees generally agree between the 2 tests. Defects within the central 10 degrees of the 24-2 VF test can predict defects on the 10-2 VF test, although the 24-2 may miss defects detected on the 10-2 VF test. In addition, results from the 10-2 VF test show better association with findings from OCT scans of the macular ganglion cell complex. Modifications of the 24-2 test that include extra test locations within the central 10 degrees improve detection of central defects found on 10-2 VF testing. CONCLUSIONS: Evidence to date does not support routine testing using 10-2 VF for patients with early glaucoma. However, early 10-2 VF testing may provide sufficient additional information for some patients, particularly those with a repeatable defect within the central 12 locations of the standard 24-2 VF test or who have inner retinal layer thinning on OCT scans of the macula. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Saccadic re-referencing training with gaze-contingent FRL-'fixation': Effects of scotoma type and size adaptation.

Foveal vision loss makes the fovea as saccadic reference point maladaptive. Training programs have been proposed that shift the saccadic reference point from the fovea to an extrafoveal location, just outside the area of vision loss. We used a visual search task to train normal-sighted participants to fixate target items with a predetermined 'forced retinal location' (FRL) adjacent to a simulated central scotoma. We found that training was comparatively successful for scotomata that had either a sharp or blurry demarcation from the background. Completing the task with sharp-edged scotoma resulted in overall higher training gains. Training with blurry-edged scotoma, however, yielded overall better results when scotoma size was increased after training and participants needed to adapt to a more eccentric FRL, as may be necessary in patients with progressive degenerative eye diseases.

Anatomic and refractional correlations in earliest glaucomatous visual field defects / Correlações anatômicas e refracionais nos defeitos de campo visual em glaucoma inicial

ABSTRACT Purpose: In glaucoma, initial visual field scotomas can be peripheral or central, whereas central scotomas are more severe and can disrupt daily activities. Individual anatomical features may influence the distribution of retinal nerve fibers and the starting site of visual field defects in glaucoma. In this study, we aimed to correlate myopia and hyperopia or anatomical variation of the disk-fovea angle with initial central or peripheral lesions in the visual field. Methods: This cross-sectional study included patients with primary open-angle glaucoma divided into a group of isolated central or peripheral scotomas in the visual field with MD > or equal to -6 dB, correlating with the degree of ametropia and anatomical variations, such as the disk-fovea angle. Results: We included 52 patients with glaucoma. Of 20 myopic patients, 6 (30%) had central scotomas, and 14 (70%) had peripheral scotomas. Of 32 hyperopic patients, 12 (37.5%) had central scotomas, and 20 (63.5%) had peripheral scotomas. Regarding the disk-fovea angle, 25 eyes had the disk-fovea angle of < -7°, with 9 (36%) eyes presenting with central scotoma, and 27 eyes presented with the disk-fovea angle of > -7°, with 9 (33.3%) eyes presenting with a central scotoma. Conclusion: This study showed an association between ametropia and scotomas on the perimetry in patients with glaucoma. Patients had a higher incidence of peripheral scotomas, but hyperopic patients had a greater number of central scotomas than myopic patients, and myopic patients had more peripheral scotomas than hyperopic patients. The disk-fovea angle was not correlated with scotomas in initial glaucoma.

RESUMO Objetivos: No glaucoma, os escotomas iniciais no campo visual podem ser periféricos ou centrais. Os escotomas centrais são mais graves e podem atrapalhar as atividades diárias. As características anatômicas individuais podem influenciar a distribuição das fibras nervosas da retina e o local inicial dos defeitos do campo visual no glaucoma. Nesse estudo buscamos correlacionar a miopia e a hipermetropia ou a variação anatômica do ângulo disco-fóvea com lesões iniciais centrais ou periféricos no campo visual. Métodos: Este foi um estudo transversal incluindo pacientes com glaucoma primário de ângulo aberto divididos em grupo de escotomas isolados central ou periférico no campo visual com MD > ou igual a -6 dB, correlacionando com o grau de ametropia e variações anatômicas como o ângulo disco fóvea. Resultados: Incluímos 52 pacientes com glaucoma. Dos 20 míopes, 6 (30%) apresentaram escotoma central e 14 (70%) escotoma periférico) e 32 olhos hipermetrópicos com 12 (37,5%) escotomas centrais e 20 (63,5%) escotomas periféricos. Sobre o ângulo disco fóvea, 25 olhos tiveram ângulo disco fóvea menor que -7º com 9 (36%) olhos apresentando escotoma central e 27 olhos com ângulo disco fóvea maior que -7º com 9 (33,3%) olhos apresentando escotoma central. Conclusão: Este estudo mostrou associação da ametropia e os escotomas na perimetria em pacientes com glaucoma. Pacientes apresentaram maior incidência de escotomas periféricos, porém hipermétropes apresentaram maior quantidade de escotoma central que os míopes e os míopes mais escotomas periféricos que os hipermetropes. O ângulo disco fóvea não foi correlacionado com escotomas na perimetria no glaucoma inicial.

Paracentral acute middle maculopathy in systemic sclerosis and subsequent branch retinal artery occlusion.

Purpose: We report a case of systemic sclerosis-associated paracentral acute middle maculopathy (PAMM) in a young woman who subsequently developed branch retinal artery occlusion. Observations: A 22-year-old woman presented with a paracentral scotoma. Optical coherence tomography (OCT) revealed bilateral paracentral acute middle maculopathy. Upon systemic examination, she was diagnosed with systemic sclerosis (SSc). She subsequently developed branch retinal artery occlusion despite vasodilator medications. After the prescription of aspirin, she did not experience a new event for one year. Conclusion and importance: This case illustrates that SSc may affect the retinal vascular system and vision and cause PAMM. The optimal prophylaxis for patients with recurrent retinal events should be investigated in future studies.

Ophthalmic complications during the dengue epidemic in Reunion Island in 2020: a case series and review of the literature.

INTRODUCTION: Dengue is an arboviral disease transmitted by the dengue virus, whose vectors are Aedes aegypti and Aedes albopictus. The acute phase with its cohort of well-known symptoms is usually spontaneously favorable. Since 2020 in Reunion Island, a new symptom has appeared: the ocular damage of dengue fever, which has already been described in South Asia and South-East Asia. We therefore decided to describe the clinical, biological, ophthalmological, therapeutic, and outcomes of patients with ocular manifestations during dengue fever in Reunion Island in 2020. PATIENTS AND METHODS: This was a retrospective observational study. Patients were included from January 2020 to August 2020 and then reassessed by teleconsultation 1 year later. The patients were identified from the French public health surveillance network by all ophthalmologists on the island. Medical data were collected directly from medical records. RESULTS: Twenty-eight patients were included. The mean age was 41.9 years. Ocular involvement occurred approximately 9.2 days after the onset of dengue symptoms. The main symptoms were scotoma (71.4%) and sudden decrease of visual acuity (39.2%). Eighteen patients (64.2%) had macular involvement. Fourteen patients were treated with oral or intravenous corticosteroids. Twenty-two (78.5%) patients were evaluated by telephone one year later. Scotoma and decreased visual acuity persisted in 15 patients. Thirteen patients (59%) were bothered by night driving, 32% of patients had reading difficulties and 27% of patients became sensitive to prolonged exposure to screens. CONCLUSION: Ocular complications of dengue require early and collegial management to limit the risk of long-term sequelae. Further studies on the characteristics and complications of dengue fever are needed to better understand this disease.

Inner retinal cystoid changes immediately following laser peripheral iridotomy.

Purpose: To outline the patient course of a rare complication that occurred during routine laser peripheral iridotomy. Observation: A patient developed symptomatic foveal cystoid changes with a central scotoma immediately following laser peripheral iridotomy. Successful treatment included topical anti-inflammatory therapy with complete resolution of cystoid changes and the central scotoma. Conclusions and importance: Laser peripheral iridotomy is a commonly performed procedure by comprehensive ophthalmologists and therefor it is important to document even the rarest side effects that can occur. Inner retinal changes can occur but overall, this patient did well with conservative therapy.

Effects of Stimulus Luminance, Stimulus Color and Intra-Stimulus Color Contrast on Visual Field Mapping in Neurologically Impaired Adults Using Flicker Pupil Perimetry.

Purpose: We improve pupillary responses and diagnostic performance of flicker pupil perimetry through alterations in global and local color contrast and luminance contrast in adult patients suffering from visual field defects due to cerebral visual impairment (CVI). Methods: Two experiments were conducted on patients with CVI (Experiment 1: 19 subjects, age M and SD 57.9 ± 14.0; Experiment 2: 16 subjects, age M and SD 57.3 ± 14.7) suffering from absolute homonymous visual field (VF) defects. We altered global color contrast (stimuli consisted of white, yellow, cyan and yellow-equiluminant-to-cyan colored wedges) in Experiment 1, and we manipulated luminance and local color contrast with bright and dark yellow and multicolor wedges in a 2-by-2 design in Experiment 2. Stimuli consecutively flickered across 44 stimulus locations within the inner 60 degrees of the VF and were offset to a contrasting (opponency colored) dark background. Pupil perimetry results were compared to standard automated perimetry (SAP) to assess diagnostic accuracy. Results: A bright stimulus with global color contrast using yellow (p= 0.009) or white (p= 0.006) evoked strongest pupillary responses as opposed to stimuli containing local color contrast and lower brightness. Diagnostic accuracy, however, was similar across global color contrast conditions in Experiment 1 (p= 0.27) and decreased when local color contrast and less luminance contrast was introduced in Experiment 2 (p= 0.02). The bright yellow condition resulted in highest performance (AUC M = 0.85 ± 0.10, Mdn = 0.85). Conclusion: Pupillary responses and pupil perimetry's diagnostic accuracy both benefit from high luminance contrast and global but not local color contrast.

Optic Disc Morphology and Paracentral Scotoma in Patients with Open-Angle Glaucoma and Myopia.

This study's aim was to investigate the association between optic disc morphology and the occurrence of paracentral scotoma in eyes with open-angle glaucoma (OAG) and myopia. Two-hundred and eleven myopic eyes with OAG were classified into three groups according to the location of visual field (VF) defect (99 paracentral scotoma, 65 peripheral scotoma, and 47 no VF defect). Optic disc morphology was assessed based on the tilt ratio and eccentricity of the central retinal vessel trunk (CRVT). Clinical characteristics of the three groups were compared, and factors affecting the occurrence of paracentral scotoma were determined. Eyes with paracentral scotoma had a higher tilt ratio than the other groups (ps ≤ 0.04). Multiple linear regression showed that a nasal location of CRVT (p < 0.001), longer axial length (p = 0.001), and lower VF mean deviation (p = 0.021) were significantly associated with higher tilt ratio. In logistic regression analysis, tilt ratio was the only factor that was significantly associated with the occurrence of paracentral scotoma (odds ratio = 7.12, p = 0.032). In conclusion, the optic disc tilt ratio increased with nasal shift of CRVT, longer axial length, and lower VF mean deviation. Higher optic disc tilt was significantly associated with the occurrence of paracentral scotoma in eyes with OAG and myopia.

TRAUMA-RELATED ACUTE MACULAR NEURORETINOPATHY. A CASE REPORT.

AIMS: To introduce a case report and review the literature on trauma-related acute macular neuroretinopathy as an unusual etiology of acute macular neuroretinopathy. MATERIAL AND METHODS: A 24-year-old man presented with unilateral paracentral scotoma following non-ocular trauma in a car accident. The relative afferent pupillary defect was negative and the best corrected visual acuities of both eyes were 10/10 (by the Snellen chart scale). RESULTS: Retinoscopy revealed a reduced foveal reflex, along with a small pre-retinal hemorrhage over the mid-pathway of the supranasal arteriole. OCT images showed an obvious ellipsoid zone (EZ) layer disruption in the macula of the left eye. The infrared fundus photograph of the same eye revealed a distinct hyporeflective area involving the macula. On fundus angiography, no macular vascular lesion was detected. The scotoma persisted after 3 months follow-up. CONCLUSION: Non-ocular trauma including head or chest trauma without direct ocular injury accounts for most cases of trauma-related acute macular neuroretinopathy. It is important to distinguish this entity, given that there are also unremarkable findings in the retinal examination of these patients. Indeed, proper clinical suspicion leads to further suitable investigations and impedes other extraordinary images, which are the basic rules in the management of traumatic patients suffering multiple injuries and incurring medical expenses.

[Simple fundus perimetry with the slit lamp]. / Einfache Fundusperimetrie mit der Spaltlampe.

This article describes a method for direct fundus perimetry with the slit lamp through a highly refractive converging lens (+ 90 D). For this purpose an intermediate position within the existing diaphragm system was chosen to form a double half circle light mark. In the clinical practice quick results can be achieved with little stress especially for patients suffering from hemianopia. The method described could be much more refined by purposeful changes in the diaphragm system of the slit lamp.

Coincident Acute Macular Neuroretinopathy and Paracentral Acute Middle Maculopathy in COVID-19.

An ophthalmology consultation was requested for a 29-year-old woman complaining of visual field defects. The patient had presented to the emergency department with cough and high fever one day earlier. Chest computed tomography demonstrated pneumonia and two severe acute respiratory syndrome coronavirus 2 polymerase chain reaction tests were positive. The patient had undergone renal transplantation 11 years ago due to glomerulonephritis. Best-corrected visual acuity (BCVA) was 20/40 in the right eye and 20/30 in the left eye. Fluorescein angiography showed macular hypoperfusion, and optical coherence tomography (OCT) showed hyperreflectivity in the inner nuclear, outer plexiform, and outer nuclear layers, as well as discontinuity of the ellipsoid zone. Perimetry confirmed bilateral central scotoma. Levels of D-dimer and fibrinogen were 0.86 g/mL and 435.6 g/mL, respectively. The patient was diagnosed as having concurrent acute macular neuroretinopathy and paracentral acute middle maculopathy and was given low-molecular-weight heparin treatment for one month. Her BCVA improved to 20/20 in both eyes, and regression was observed in the retinal findings, hyperreflectivity and ellipsoid zone disruption on OCT, and scotoma in perimetry. Inflammation, thrombosis, and glial involvement may play a role in the pathogenesis of retinal microvascular impairment in COVID-19.

Retinopatía asociada a melanoma. Reporte de caso y revisión de literatura / Melanoma associated retinopathy. Case report and literature review

Introducción: La retinopatía asociada a melanoma (RAM) es un desafío para el equipo tratante de pacientes oncológicos debido a la inespecificidad del cuadro clínico y a la dificultad de realizar exámenes que ofrezcan un diagnóstico. Métodos: Paciente 55 años, sexo femenino con diagnóstico de melanoma, consulta por escotoma central asociado a síntomas visuales positivos. Resultados: Examen oftalmológico dentro de rangos normales. Electrorretinograma (ERG) estándar muestra respuesta máxima electronegativa en ambos ojos, sugerente de RAM. Discusión: El reconocimiento temprano de RAM mediante ERG tiene importancia diagnóstica, permitiendo iniciar tratamiento temprano y reducir el riesgo irreversible de daño a la retina.

Introduction: Melanoma-associated retinopathy (MAR) is a challenge for the oncology team due to the non-specific clinical presentation and the associated difficulty of performing indicative tests for diagnosis. Methods: A 55-year-old female patient initially diagnosed with melanoma consults due to vision with central scotoma associated with positive visual symptoms. Results: Ophthalmological examination within normal ranges. Standard electroretinogram (ERG) shows the maximum electronegative response in both eyes, suggesting MAR. Discussion: The early recognition of MAR by ERG has diagnostic importance because it would allow a possible early treatment and could reduce the risk of irreversible retina damage.