Presumed retinal lead poisoning: a case report.

PURPOSE: To describe a case of presumed retinal lead poisoning. METHODS: Clinical examination, optical coherence tomography, fundus autofluorescence, fluorescein angiography, and electroretinography were used to study a 42-year-old male with the complaint of bilateral reduced vision following systemic lead poisoning. RESULTS: The fundus examination showed venous tortuosity, as well as macular atrophy, and pigmentary changes in his both eyes. Optical coherence tomography revealed retinal thinning, outer retinal and retinal pigment epithelium atrophy, as well as foveal schitic changes. Blue autofluorescence showed moderately hypoautofluorescence in peripapillary area of both eyes. Fluorescein angiogram showed a leopard-like pattern of hypo- and hyperfluorescence in the posterior pole. Electroretinogram showed a moderate reduction in photopic and scotopic responses. CONCLUSIONS: The most probable diagnosis of this case is early onset retinal lead poisoning.

Early macular and peripapillary vasculature dropout in active thyroid eye disease.

PURPOSE: To compare macular and peripapillary vasculatures in active thyroid eye disease (TED), not active not compressive (NANC) TED, and control eyes. METHODS: Twenty-one eyes of 12 active TED patients, 77 eyes of 43 NANC patients, and 65 eyes of 35 healthy normal subjects were recruited in this observational study. The participants underwent optical coherence tomography (OCT) and OCT angiography (OCT-A) of the peripapillary and macular areas. Macular ganglion cell complex (GCC) was measured in addition to peripapillary and macula superficial and deep vasculatures. RESULTS: Linear mixed models accounting for inter-eye correlation showed that whole macular and parafoveal superficial vessel densities were significantly lower in the active TED with values of 50.6 ± 4.3% and 52.7 ± 4.8%, respectively, compared with control group values of 53.7 ± 3.0% and 56.3 ± 3.2% (P = 0.03, P < 0.001, respectively). In contrast, only the nasal sector of parafoveal vasculature value was significantly lower in the NANC TED than in control eyes (P = 0.03) and in the active group than in the NANC group (P < 0.001). Similarly, the average peripapillary vessel density was lower in the active TED than in the NANC and control groups. No significant differences were observed in GCC thickness among active, NANC, and control groups. Whole superficial macular and parafoveal vessel densities were significantly correlated with visual field MD (r = 0.32, r = 0.30, respectively, both P < 0.001). CONCLUSIONS: OCT-A findings of lower peripapillary and macular vessel density values in the active TED eyes show subclinical retinal and optic nerve involvement.

A case report of pediatric-onset MS associated uveitis.

BACKGROUND: To report a case of Pediatric-onset MS associated uveitis managed with local and systemic medications. CASE PRESENTATION: An 11-year-old boy who was diagnosed with Pediatric-onset MS (POMS) with the first presentation of left optic neuritis in another center, was referred to our clinic with the complaint of non-improved vision in the left eye despite receiving IV 5gr methylprednisolone. After the ophthalmologic examinations, the patient was diagnosed as bilateral POMS-associated intermediate uveitis, and local treatment with corticosteroid was administered to both eyes. He was continued on systemic therapy such as Rituximab and five sessions of plasmapheresis. After four months, the patient's vision improved from FC at 50cm to 9/10 in the left eye. The intensity of intraocular inflammation decreased in both eyes. In fluorescein angiography findings, the optic disc, as well as vascular leakage, subsided bilaterally. CONCLUSION: Despite its rarity, POMS-associated uveitis presents a considerable challenge that necessitates the collaborative efforts of neurologists and ophthalmologists to achieve the most effective treatment outcomes.

Langerhans Cell Histiocytosis of the Uvea with a Ciliochoroidal Mass: A Case Report of Management with Systemic Therapy.

Background: This study is aimed at exploring a case of choroidal Langerhans cell histiocytosis (LCH) successfully treated with systemic corticosteroid and immunosuppressant. Case presentation. A 24-year-old man with known multisystem LCH developed loss of vision, ocular pain, conjunctival injection, panuveitis, and a ciliochoroidal mass. After receiving an intravenous methylprednisolone pulse, oral high-dose corticosteroids, and methotrexate, the mass resolved quickly and completely without flare-ups during 6 months of follow-up. Conclusions: Intraocular involvement of LCH is rare and can present with or without a history of multisystemic disease. The diagnosis is challenging, and the standard treatment is not established. Systemic anti-inflammatory and immunosuppressive therapy could be an effective treatment, as the LCH itself contains an essential element of inflammation and the symptoms may be mainly inflammatory.

Tamoxifen retinopathy.

Tamoxifen (TAM) is a selective estrogen receptor modulator that is used in the treatment of breast cancer. As there are estrogen receptors in the retina, retinal pigment epithelium, and choroid, these tissues may also be affected by TAM. We describe the reported effects of TAM on the retina and choroid. Medical databases were searched using relevant keywords and the results were extracted and pooled. The incidence of retinal/choroidal toxicity ranged from 0.9% to 12%. There was a wide range for the time of exposure before the development of TAM retinopathy (3 weeks to 13 years). While functional measurements may be appropriate for assessment of TAM retinopathy, they have not been effective for screening patients. There is no generally accepted screening modality, but serial funduscopy and optical coherence tomography imaging seem to be the most reasonable approach for detecting early TAM-induced retinal toxicity.

Bacillary Layer Detachment in Diabetic Retinopathy: A Case Report.

To our knowledge, this is the first report to describe bacillary layer detachment (BLD) in a patient with diabetic retinopathy treated with anti-vascular endothelial growth factor. We present the case of a 55-year-old diabetic female who was referred to our hospital complaining of decreased vision in her left eye for 2 weeks. Fundus examination of both eyes was compatible with diabetic retinopathy. Spectral-domain optical coherence tomography of the left eye showed a large dome-shaped cystic space with marginal septa, splitting the myoid zone, consistent with the BLD phenotype. A single dose of intravitreal bevacizumab injection was administered. After 4 weeks, BCVA was improved significantly with complete resolution of BLD. Underlying choroidal ischemia in patients with different vascular disorders like diabetes mellitus may lead to photoreceptor stress and BLD. This study adds to the growing literature, which describes BLD as a marker of fluid accumulation in relation to several macular diseases.

Cataract surgery in patients with retinitis pigmentosa: systematic review.

Retinitis pigmentosa (RP) is an inherited bilateral retinal degenerative disease with an incidence of 1 in 4000 people. RP affects more than 1 million individuals worldwide. Although night blindness and restricted visual field are the most typical symptoms of these individuals, generalized vision loss due to cataracts can be expected in the latter stages of the disease. It has been demonstrated that posterior subcapsular cataract is the most prevalent cataract in younger individuals with RP, as opposed to age-related cataracts. Although most ophthalmologists may have a negative view of cataract surgery in patients with RP, it appears that it can play an important role in the visual restoration of patients with RP. However, there are concerns about performing cataract surgery for patients with RP. Herein, a systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses on databases of MEDLINE and Scopus.

Microvascular and structural analysis of the retina and choroid in heart failure patients with reduced ejection fraction.

This cross-sectional study was designed to assess alterations of choroidal and retinal microvasculature in patients with Heart Failure with Reduced Ejection Fraction (HFrEF) and compare them with a normal age and sex-matched population. Fifty-two eyes of 26 patients with HFrEF (left ventricular ejection fraction [LVEF] < 40%) and 64 eyes of 32 healthy individuals were considered as the patient and the control groups, respectively. We found no statistically significant differences in age-adjusted mean central macular thickness (CMT), superficial or deep retinal capillary plexus vascular densities, and choriocapillaris flow (CC flow) density between the HFrEF group and the normal controls, with the exception of the parafoveal mean superficial capillary plexus vascular density (P = 0.023), which remained statistically significant after adjusting for age (P = 0.034). The patients with HFrEF had a significantly lower subfoveal choroidal thickness (SFCT) than the normal subjects (264 ± 82 vs 313 ± 72; P = 0.009), and the difference was still statistically significant after age adjustment (P = 0.026). Although choroidal vascularity index (CVI) was lower in the HFrEF group than in the control group, the difference was not statistically significant before and after age adjustment (73.45 ± 6.67 vs 75.77 ± 5.92; P = 0.118 and P = 0.096, respectively). In conclusion, in patients with HFrEF, we observed a reduction in parafoveal retinal VD in the superficial capillary plexus, as well as SFCT, but no significant change in CVI, CMT, or CC flow density.

Pachychoroid neovasculopathy can mimic wet type age-related macular degeneration.

PURPOSE: to determine the percentage of patients with pachychoroid neovasculopathy (PNV) among patients who have been misdiagnosed and treated with wet age-related macular degeneration (AMD). METHODS: In this retrospective cross-sectional study, patients over 55 years old, who were diagnosed with wet AMD, were re-evaluated. All patients were recalled for examination and imaging. Patients with PNV were differentiated form wet AMD based on inclusion and exclusion criteria. RESULTS: Overall, 120 patients (137 eyes) were recorded with wet AMD in the clinic. Finally, after complete re-evaluation, 94 (106 eyes) and 26 patients (31 eyes) were assigned to the AMD and the PNV group, respectively. Thus, a total of 20% of patients with primary mistake diagnosis of wet AMD, actually had PNV. The mean sub field choroidal thickness (SFCT) in the AMD and PNV groups was 173.8 ± 69 µm and 342 ± 27 µm, respectively. Drusen and pachydrusen were found in 69.9% and 24% of the cases with AMD and PNV, respectively (P = 0.001). The average number of intravitreal injections of anti-VEGF (vascular endothelial growth factor) required in the AMD and PNV groups was about 5 and 3, respectively, which was statistically significant (P-value 0.02). CONCLUSION: This study revealed that about a one-fifth of wet AMD patients are actually pachychoroid neovasculopathy. These patients were younger and had thicker SFCT, and developed less subretinal scarring. Thus, the disorder must be considered as an important differential diagnosis of AMD-CNV.

Management of primary choroidal lymphoma presenting as extensive serous retinal detachment and salmon patch of bulbar conjunctiva: a case report.

BACKGROUND: We describe the outcome of ultra-low-dose radiotherapy plus intravitreal methotrexate and rituximab injections for a patient with primary choroidal lymphoma who presented with nodular conjunctival salmon patches and extensive serous retinal detachment. CASE PRESENTATION: A 34-year-old Iranian man presented with a nodular patch of bulbar conjunctiva in the right eye, and 1+ vitritis. A nearly complete shallow serous retinal detachment, retinal folds, and multifocal yellow choroidal infiltrates were seen during a fundus examination of the right eye. Enhanced depth imaging optical coherence tomography revealed macular retinal folds and an uneven, undulating, "seasick" appearance of the choroidal surface with choriocapillaris compression, intraretinal and subretinal fluid, and clusters of optically dense material at the outer retinal level. An incisional biopsy of the conjunctival lesion confirmed the diagnosis of primary choroidal lymphoma with epibulbar involvement. The patient was treated with ultra-low-dose "boom-boom" radiation (4 Gy delivered in two fractions over two consecutive days) as well as intravitreal methotrexate and rituximab injections. After a year, the lesions had completely disappeared, with no adverse effects or recurrence. CONCLUSION: Ultra-low-dose (boom-boom) radiotherapy combined with intravitreal chemotherapy and/or immunotherapy may be an effective treatment for primary choroidal lymphoma with anterior epibulbar extension and diffuse subretinal fluid with favorable response and minimal side effects.

Non-cystic macular thickening on optical coherence tomography as an alternative to fluorescein angiography for predicting retinal vascular leakage in early stages of uveitis.

To evaluate the relationship between non-cystic thickening of the macula on optical coherence tomography (OCT) and retinal vascular leakage on fluorescein angiogram (FA) in patients with uveitis. A cross-sectional study of patients seen in the uveitis clinic. Patients with any degree of inflammatory cells in the anterior vitreous were included, provided that no macular cyst or subretinal fluid or macular atrophy was observed in OCT. The correlation between OCT features and best corrected visual acuity (BCVA), the degree of inflammation, and FA findings were examined. The severity of vascular leakage in FA was graded for optic nerve, macula and posterior and peripheral leakage. We used generalized estimation equation to assess the associations between macular thickness and volume with angiographic scores. A total of 43 patients (100 exam data) met inclusion criteria. There was a significant relationship between OCT parameters (central macular thickness, 3 mm and 6 mm perifoveal macular thickness as well as total and central macular volume) with angiographic scores (macular, optic disc, posterior and peripheral vascular leakage score) (all P values < 0.0001). The correlation between the 6 mm perifoveal thickness and peripheral vascular leakage score (R = 0.76; P < 0.001) was stronger than the correlation of CMT with this angiographic score (R = 0.69; P < 0.001). Non-cystic thickening of the macula on OCT, especially in perifoveal area, is a reliable predictor of the presence of retinal vascular leakage in patients with uveitis.

Effect of Smoking on Retinal Thickness and Vascular Density in Thyroid Eye Disease.

PURPOSE: To evaluate the effect of smoking on retinal thickness and macular and peripapillary vascular density in thyroid eye disease (TED). METHODS: In this cross-sectional study, subjects diagnosed with TED were analyzed in three groups: smokers, passive smokers, and non-smokers. Ganglion cell complex thickness, total retinal thickness, macular superficial vascular plexus densities, deep vascular plexus densities, optic nerve head, and radial peripapillary capillary density were measured in each group. RESULTS: Twenty-two eyes (21.6%) of active smokers, 11 eyes (10.8%) of passive smokers, and 69 eyes (67.6%) of non-smokers constitute the study subjects. Twenty-one eyes (12.6%) had active status (clinical activity score ≥3), 77 eyes (46.1%) were neither active nor compressive, four eyes (2.4%) of two patients constituted the compressive group. Age and disease activity adjusted analysis was performed. Ganglion cell complex thickness of smokers was significantly higher than non-smokers in the inferior hemi-parafoveal sector (p = 0.04). Active smokers had significantly higher (p < 0.01) retinal thickness in all sectors compared to non-smokers, except the foveal sector. Smokers had lower superficial vessel density in the superior parafoveal sector compared to non-smokers (p = 0.04). Considering deep vessel densities between smokers and non-smokers, no significant difference was observed. Radial peripapillary capillary densities (significant difference was observed in the whole image and infranasal peripapillary sector), Macular vascular densities (significant difference was observed in parafoveal sectors), and optic nerve head (not reaching statistical significance level in any sectors) were highest in passive smokers. CONCLUSIONS: Smoking is associated with increased total retinal thickness. Macular vascular densities were not different between smokers and non-smokers in TED.

Infectious keratitis: trends in microbiological and antibiotic sensitivity patterns.

OBJECTIVES: To report the spectrum and trends of isolated microorganisms and their antibiotic susceptibility profile in patients with infectious keratitis in a 6-year period at a referral centre in Tehran. METHODS: The microbiology records of all corneal scrapings with a diagnosis of infectious keratitis were reviewed. RESULTS: A total of 6282 corneal scrapings were performed during the study period, of which 2479 (39.5%) samples were culture positive. Pseudomonas aeruginosa was found to be the most common causative agent in patients with keratitis, although Streptococcus pneumonia was the most prevalently isolated microorganism in patients older than 50 years. Fusarium sp. was the most common responsible pathogen in patients with fungal keratitis. The prevalence of bacterial keratitis due to gram positive microorganisms increased over time, however the number of Pseudomonas keratitis decreased in the second half of the study. Gram negative organisms showed a good sensitivity to levofloxacin, however, 34.1% of S. aureus isolates and 29.7% of coagulase negative staphylococci were resistant to this antibiotic. The odds of ciprofloxacin and levofloxacin resistance increased 1.25 and 1.15 for each 1-year increase in culture date, respectively (P < 0.001, P = 0.004). CONCLUSIONS: We documented an increasing trend in the percentage of gram positive bacteria. Levofloxacin monotherapy might still be a good option in patients with gram negative bacterial keratitis, however owing to increasing resistance of staphylococci to fluoroquinolones, a regimen consisting of a combination of fortified antibiotics may be more effective in staphylococcal keratitis.

A Solitary Choroidal Mass with Spontaneous Resolution.

BACKGROUND: To report an atypical case of a transient choroidal mass lesion with spontaneous resolution. Case Presentation. A solitary choroidal mass with an overlying neurosensory retinal detachment was seen in an otherwise healthy 31-year-old female. General physical examinations and serum chemistry were unremarkable. The patient had spontaneous resolution two weeks after initial examination without treatment. CONCLUSIONS: Inflammatory choroidal masses may be self-limited, but complete diagnostic measures must always be performed in these patients to distinguish between important causes such as tuberculosis, sarcoidosis, and tumors.