Upside down words as initial clinical presentation of an underlying acute ischemic stroke

@#We report a diabetic patient who was diagnosed with an acute stroke who presented with a 3-day history of difficulty of reading, described as the words were turned upside down, as if the words were inverted horizontally with associated right homonymous hemianopia and multiple higher cortical function deficits (alexia without agraphia, achromatopsia, prosopagnosia). He has poorly controlled diabetes and hypertension. Cranial magnetic resonance imaging (MRI) revealed an acute infarct on the left posterior cerebral artery territory. The patient was managed as an acute ischemic stroke and follow up after 6 months revealed improvement of the visual field cut but with persistence of the higher cortical function deficits. To the best of our knowledge, we report the first rare occurrence reversal of vision metamorphopsia described as inverted words as the sole initial presentation of an underlying stroke.

Effects of vitrectomy and macular epiretinal membrane dissection combined with or without internal limiting membrane peeling on choroid thickness, vision and metamorphopsia in patients with idiopathic macular epiretinal membrane / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To analyze the effects of vitrectomy and macular epiretinal membrane dissection combined with or without internal limiting membrane(ILM)peeling on choroid thickness, vision and metamorphopsia in patients with idiopathic macular epiretinal membrane(IMEM).<p>METHODS: Totally 88 patients(88 eyes)with IMEM admitted to the hospital were selected between January 2016 and January 2020. They were divided into group A and group B by random number table method with 44 eyes in each group. Patients in group A were treated with vitrectomy and macular epiretinal membrane dissection combined with ILM peeling, while patients in group B were treated with vitrectomy and macular epiretinal membrane dissection. The choroid thickness, vision, metamorphopsia, central macular thickness(CMT), ellipsoid zone(EZ)continuity were compared between the two groups.<p>RESULTS: Compared with preoperative, the sub-foveal choroidal thickness(SFCT), choroidal thickness 1 000μm from nasal side central of fovea(NFCT)and choroidal thickness 1 000μm from temporal side central of fovea(TFCT)were significantly reduced in the two groups at 3mo and 6mo after operation(<i>P</i><0.05), but there was no statistically significant difference between the groups(<i>P</i>>0.5). Compared with preoperative, the best corrected visual acuity(BCVA)LogMAR was reduced, while mean sensitivity(MS)was increased in the two groups. The number of scotoma points(SP)increased in group A and decreased in group B. Group A had significantly lower MS and higher SP than group B at 1mo, 3mo, and 6mo after operation(<i>P</i><0.05). Compared with preoperative, the M scores(Angle of view when horizontal and vertical variability begins to disappear)and average M scores of the two groups were significantly reduced at 3mo and 6mo after operation, without statistically significant differences between the groups(<i>P</i>>0.05). Compared with preoperative, CMT was significantly reduced in the two groups at 1, 3 and 6mo after operation. The ratio of EZ continuity in group A at 1mo after operation was significantly lower than that before operation. The CMT of group A was larger than that of group B at 3mo and 6mo after operation(<i>P</i><0.05). No statistically significant differences were found in the ratio of EZ continuity and the incidence of complications between the groups(<i>P</i>>0.05).<p>CONCLUSION: Vitrectomy and macular epiretinal membrane dissection combined with or without ILM peeling both can improve vision and metamorphopsia in patients with IMEM, with similar effects on choroid thickness and safety. However, combined use of ILM peeling will lower MS and increase SP as well as CMT. Therefore, it has no significant advantages in the treatment of patients with IMEM.

Influencing factors of visual function in patients with idiopathic macular epiretinal membrane after internal limiting membrane peeling / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To explore the risk factors that affect visual function recovery in patients with idiopathic macular epiretinal membrane(IMEM)undergoing internal limiting membrane peeling(ILMP).<p>METHODS: This study retrospectively reviewed 118 patients(118 eyes)with IMEM who underwent ILMP in the hospital between January 2016 and April 2020. The patients were followed up for 6mo after surgery to evaluate curative effect. Changes in visual acuity before surgery and at 1, 3 and 6mo after surgery, metamorphopsia degree, mean central foveal thickness and volume of macular area were observed. The correlation of mean central foveal thickness and volume of macular area before and after surgery with postoperative visual acuity and metamorphopsia scores was analyzed. The risk factors for poor visual function recovery after surgery were evaluated.<p>RESULTS: In this study, 96 eyes obtained good visual function recovery, and the improvement rate was 81.4%. At 1, 3 and 6mo after surgery, visual acuity was significantly improved(<i>P</i><0.05), metamorphopsia score in horizontal direction, mean central foveal thickness and volume of macular area were significantly reduced(<i>P</i><0.05). The mean central foveal thickness and volume of macular area before surgery and at 6mo after surgery were negatively correlated with visual acuity at 6mo after surgery(<i>P</i><0.05), but positively correlated with metamorphopsia score in horizontal direction(<i>P</i><0.05). The course of IMEM, preoperative corrected visual acuity, preoperative horizontal or vertical metamorphopsia, and preoperative macular edema were influencing factors of visual function recovery after surgery(all <i>P</i><0.05). Poor preoperative corrected visual acuity(<i>OR</i>=3.062), horizontal metamorphopsia(<i>OR</i>=2.438)and preoperative macular edema(<i>OR</i>=2.000)were risk factors for poor visual function recovery.<p>CONCLUSION: The curative of ILMP is effect on IMEM, which can effectively improve visual acuity of operative eyes and reduce metamorphopsia. The longer the course of disease, the worse the preoperative corrected visual acuity, and the more severe the preoperative metamorphopsia, the worse the visual function recovery in patients with preoperative macular edema after ILMP.

Analysis of factors of metamorphopsia after vitrectomy for rhegmatogenous retinal detachment / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To identify factors associated with metamorphopsia in patients with rhegmatogenous retinal detachment(RRD)who underwent primary vitrectomy(PPV). <p>METHODS:This retrospective study included 94 patients(94 eyes)who underwent 23G PPV for repair of RRD between January, 2017 and January, 2019. Each patient were examined both eyes preoperatively and postoperatively(at 1, 6, 12mo and last visits). At each time-point, patients received a complete ophthalmological examination, including best corrected visual acuity(BCVA), intraocular pressure, slit-lamp biomicroscopy, optical coherence tomography(OCT), and M-chart examination.<p>RESULTS: One month after surgery, metamorphopsia occurred in 53%(<i>n</i>=50), the mean M value was 0.68±0.28. The metamorphopsia rate differed significantly between macula-off and macula-on RRD(<i>P</i><0.01). There was significant difference in M-chart among the different time(<i>F</i>=26.442, <i>P</i><0.01). Univariate analysis demonstrated that the macula status, location of retinal breaks, and disrupted EZ was a risk factor that was significantly associated with metamorphopsia. In multivariate analysis, macula-involving retinal detachment(<i>OR</i>=9.020, 95% <i>CI</i>:1.808-45.011, <i>P</i>=0.007)and disrupted EZ(<i>OR</i>=10.570, 95% <i>CI</i>:2.909-38.400, <i>P</i><0.01)was a significant predictors of metamorphopsia.<p>CONCLUSION: The metamorphopsia was improved after anatomically successful RRD surgery. Macular involvement retinal detachment and disrupted EZ were more likely to develop metamorphopsia.

Central serous chorioretinopathy risk factors in the mid-Euphrates region, Iraq

Central serous chorioretinopathy (CSC) is an ophthalmic disorder that often affects young male patients under psychological stres and is clinically characterized by blurring of vision, metamorphopsia, a visual abnormality in which normally straight lines appears curved, and micropsia, a visual abnormality in which objects appear smaller than normal. The annual incidence of the condition is not well recognized in our country. The objective of this cross-sectional study was to highlight the incidence rate of CSC in our community and to make an insight on possible associated risk factors. This cross-sectional study included 92 patients with vissual impairment that has been proved due to central serous chorioretinoplathy (CRC). The sample included 68 males and 24 females. The sample of CRC was all the available patients visiting ophthalmology unit at Al-Diwaniyah teaching hospital and at the ophthalmology unit at Medical Committee Instituion, both these health centers lie at Al-Diwaniyah province, mid-Euphrates region, Iraq. A rough estimation of the annual incidence of CRC in this mid-Euphrates region of Iraq was 3.5 per 100.000. Mean age of patients was 43.02 ± 4.71 years, and the disease was 2.83 times more common in males. The main possible risk factors are psychosocial stress and steroid therapy. CRC is common in our community, and the main possible risk factors are psychosocial stress, and steroid use and these associations need to be validated in a large longitudinal study or at least a case-control study

Effect of vitrectomy combined with macular epiretinal membrane peeling on visual acuity and metamorphopsia in IMEM patients / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM: To study the effect of vitrectomy combined with macular epiretinal membrane peeling on visual acuity, central macular thickness(CMT)and metamorphopsia degree in patients with idiopathic macular epiretinal membrane(IMEM).<p>METHODS: Totally 31 cases(31 eyes)of patients with IMEM were treated with vitrectomy combined with macular epiretinal membrane peeling, and the best corrected visual acuity(BCVA), CMT, ellipsoid zone(IS/OS)connectivity and macular morphology were examined before and after operation. The treatment effect was assessed, and the relationship between BCVA, macular structure and morphology before and after operation was studied. All the factors that might affect the surgical outcomes were analyzed.<p>RESULTS: The mean BCVA and CMT were 0.59±0.14 and 429.35±86.17μm respectively before operation, and were decreased to 0.38±0.09 and 304.87±62.54μm at 6mo after operation(<i>P</i><0.05). The metamorphopsia degree after operation was gradually decreased, and the metamorphopsia degree at 1, 3 and 6mo after operation was lower than before operation(<i>P</i><0.008). At 1mo after operation, the IS/OS connectivity ratios were 65%, and there was no significant difference compared with that before operation with 52%(<i>P</i>>0.008). The ratio of IS/OS connectivity was 81% and 90% at 3mo and 6mo after operation, and the difference was statistically significant compared with that before operation(<i>P</i><0.008). There was significant difference in the macular morphology at different time after operation(<i>P</i><0.008). The proportions of patients with normal macular morphology at 1, 3 and 6mo after operation were 26%, 52% and 77% respectively, and the differences were statistically significant compared with before operation(<i>P</i><0.008). Pearson or Spearman correlation analysis showed postoperative BCVA in IMEM patients was positively correlated with preoperative BCVA and postoperative CMT(<i>P</i><0.05), but that was negatively correlated with preoperative macular morphology, preoperative and postoperative IS/OS connectivity and postoperative macular morphology(<i>P</i><0.05).<p>CONCLUSION: Vitrectomy combined with macular epiretinal membrane peeling can significantly reduce the CMT of patients with IMEM, and improve the IS/OS connectivity and macular morphology, so as to improve the visual acuity and reduce the metamorphopsia degree.

Metamorphopsia change and influence factors before and after idiopathic epiretinal membrane surgery / 中华实验眼科杂志

Objective To investigate the changes of metamorphopsia between before and after surgery in the patients with idiopathic epiretinal membrane and its influence factors.Methods A series cases observitional study included 39 eyes of 39 patients with idiopathic epiretinal membrane.Follow-up was carried out at 1 week before surgery and 3,6 months after surgery respectively.M-chart was used to quantify the severity of metamorphopsia (M-score).EDTRS visual chart was used to quantify best corrected visual acuity (BCVA) (converted to LogMAR).Central subfield thickness (CST),central foveal volumn (CV),cube average thickness (CAT),central foveal thichness (CFT),ganglion cell layer (GCL) thickness,inner nuclear layer (INL) thickness,outer nuclear layer (ONL) and outer plexiform layer (OPL) thickness,the integrity of external limiting membrane,ellipsoid zone and interdigitation zone were analyzed by using spectral domain-optical coherence tomography (OCT).This study protocol was approved by Ethic Committee of Beijing Tongren Hospital (No.TRECKY-012).Written informed consent was obtained from each subject before surgery.Results Mean M-score was significantly decreased from 0.8 (0.3,1.1) before surgery to 0.5 (0.2,0.8) at 3 months after surgery,with a significant difference between the two time points (Z=-2.013,P=0.044).Mean M-score was 0.6(0.2,0.8) at 6 months after surgery,which was not significantly different in comparison with before surgery and 3 months after surgery (Z =-1.873,P =0.061;Z =-0.288,P =0.773).Compared with before surgery,the horizontal M-score was significantly decreased 3 months and 6 months after surgery (Z =-2.329,P =0.020;Z =-2.858,P =0.004).No significant difference was found in vertical M-score among before surgery and 3,6 months after surgery (all at P＞0.05).The BCVA was improved from 0.40 (0.30,0.66) before surgery to 0.20 (0.06,0.42) 3 months after surgery and declined to 0.30 (0.10,0.52) at 6 months after surgery,and significant differences were obtained between 3 months after surgery and before surgery or 6 months after surgery (Z =-4.087,P＜0.001;Z =-2.235,P =0.025).Compared with before surgery,the BCVA in cataract combined with vitrectomy operative group was significantly improved in 3 months and 6 months after surgery (Z=-2.613,P=0.009;Z=-2.466,P=0.014) and the BCVA in only vitrectomy group was significantly improved at 3 months after surgery but decreased 6 months after surgery,showing significant differences between 3 months after surgery and before surgery or 6 months after surgery (Z =-3.104,P =0.002;Z =-3.464,P =0.001).Preoperative M-score was positively correlated with preoperative BCVA,preoperative CST or preoperative CFT (rs =0.384,P =0.016;rs =0.585,P＜0.001;rs =0.601,P＜0.001).No correlation was found between BCVA with GCL,INL or ONL + OPL thickness.Horizontal M-score was positively correlated with CST,postoperative CV and postoperative CAT (rs=0.322,P=0.045;rs=0.340,P=0.034;rs =0.336,P=0.036),and no correlation was found between horizontal M-score and BCVA,CFT,GCL thickness,INL thickness,ONL+OPL thickness in 6 months after surgery.The vertical M-score and mean M-score were not correlated with OCT parameters in 6 months after surgery.The mean M-score was positively correlated with preoperative mean M-score,preoperative CST,preoperative CV,preoperative CAT in 6 months after surgery (rs =0.589,P＜0.001;rs =0.330,P =0.040;rs =0.404,P =0.011;rs =0.410,P =0.009).In addition,and no significant correlation between mean M-score and preoperative BCVA,CFT,GCL thickness,INL thickness,ONL+OPL thickness.Multivariate stepwise linear regression showed that preoperative M-score was a predictor of postoperative M-values (adjusted R2 =0.211,P =0.002).Conclusions Most metamorphopsia can be alleviated after idiopathic epiretinal membrane surgery.The residue metamorphopsia after surgery probably is correlated with preoperative metamorphopsia and CFT.

Prosopometamorphopsia in Acute Ischemic Stroke

No abstract available.

Reproliferation of Idiopathic Epiretinal Membrane after Spontaneous Separation

PURPOSE: To report the reproliferation of membrane after a spontaneous separation in a patient with idiopathic epiretinal membrane (ERM). CASE SUMMARY: A 62-year-old woman complained of metamorphopsia in the left eye. Her vision without correction was 0.8. On fundus examination, the epiretinal membrane was covering the fovea with posterior vitreous detachment. Optical coherence tomography (OCT) showed the ERM and thickened macula. Retinal break, intraocular inflammatory disease, and retinal vascular disease were not noted. We diagnosed her with idiopathic ERM and followed up regularly. At month 7, a partial separation of the membrane from the retinal surface was noted. At month 12, complete spontaneous separation of the ERM from the macula except that in the temporal area was accompanied by improvement of vision to 1.0. OCT, showing recovery of the fovea contour. However, her corrected vision decreased to 0.7 at month 17, and the ERM was again observed to cover the macula. Thickening of the ERM progressed further, and her corrected vision decreased to 0.5 at month 21. CONCLUSIONS: Spontaneous separation of membrane is a rare phenomenon in idiopathic ERM. Reproliferation of membrane can develop and induce visual impairment. Therefore, regular examination is recommended in patients with spontaneous separation of membrane.

Morphision: A method for subjective evaluation of metamorphopsia in patients with unilateral macular pathology (i.e., full thickness macular hole and epiretinal membrane).

Background: Lack of clinical tests to quantify spatial components of distortion in patients with full thickness macular holes (FTMH) and epiretinal membranes (ERM). Aim: To develop a test for subjective evaluation of visual distortion in the central visual field around fixation in patients with unilateral FTMH or ERM. Settings and Design: Prospective case‑control study carried out at tertiary referral center. Materials and Methods: Twenty‑five patients with unilateral macular disease (13 macular epiretinal membranes, 12 full‑thickness macular holes), and nine controls (without ocular pathology) underwent ophthalmological examination with logMAR ETDRS visual acuity, near vision and contrast sensitivity assessed. Macular optical coherence tomography and metamorphopsia assessment using Morphision test was also carried out. This test consists of a set of modified Amsler charts for detection, identification, and subjective quantification of visual distortion in the central visual field around fixation. Morphision test content and construct validity, and reliability (test‑retest method) were evaluated. Sixteen patients completed an unstructured survey on test performance and preference. Results: Every patient with unilateral FTMH or ERM identified a particular chart using Morphision test (content validity). None of the normal subjects without symptoms of metamorphopsia identified any distortion (construct validity). Test‑retest showed a 100% consistency for frequency and 67% for amplitude. The mean amplitude difference between measurements was 0.02 degrees (SD = 0.038). The coefficient of repeatability was 0.075. There was a correlation between Morphision amplitude score and visual acuity and contrast sensitivity, individually. Conclusions: Morphision test allowed detection and subjective quantification of metamorphopsia in the clinical setting in our patients with unilateral macular epiretinal membranes and full thickness macular holes.

Assessment of metamorphopsia in patients with central serous chorioretinopathy.

Background: To evaluate the presence and extent of metamorphopsia using M-CHARTS™ (Inami Co., Tokyo, Japan) in patients with central serous chorioretinopathy (CSC). Design: Retrospective consecutive medical record review in a university hospital. Materials and Methods: We examined 33 eyes of 33 consecutive CSC patients using M-CHARTS, which yields scores reflecting the severity of metamorphopsia. The condition was considered present when an M-CHARTS score was 0.3 or over. In all patients, optical coherence tomography (OCT) was performed, best-corrected visual acuity (BCVA) was assessed, and M-CHARTS scores were calculated at the first and the 1- and 3-month follow-up visits. The correlation between M-CHARTS scores and BCVA values was determined. We also sought to define relationships between the level of metamorphopsia and specific OCT findings. Results: Of 33 CSC patients, 15 showed symptoms of metamorphopsia, and all 15 had M-CHARTS scores of over 0.3. However, no correlation was evident between BCVA values and the extent of metamorphopsia as determined using M-CHARTS. In metamorphopsia patients, the incidence of focal retinal pigment epithelial detachment was notably greater than in the non-metamorphopsia group (P = 0.03). Conclusion: M-CHARTS is valuable for monitoring subjective symptom improvement during the clinical course of CSC. M-CHARTS serves as a useful adjunct to OCT.

Dengue Fever Presenting as Bilateral Dengue Maculopathy

Dengue fever is a common pyrexial-viral infection in the Asian region and the incidence is increasing yearly. There are various ocular manifestations of dengue fever such as maculopathy, retinal hemorrhages, retinal lesions and vasculitis. Reduction in visual acuity and other visual disturbances such as metamorphopsia is the most common presentation of dengue-associated maculopathy. We report an interesting case of a young lady with bilateral maculopathy secondary to dengue fever who was managed conservatively with dramatic visual improvements. This case highlights the possibility of bilateral and simultaneous ocular involvements in patients infected with dengue fever. Both ophthalmologists and physicians need to be aware of ocular complications following dengue fever and advice patients regarding the symptoms.

The two-minute approach to monocular diplopia

Objective: To describe a quick and simple diagnostic approach to monocular diplopia. Background: Diplopia is a common visual complain in casualty departments, general practice clinics, neurologic clinics as well as ophthalmic clinics. Monocular diplopia, however, is uncommon. Many well established clinical examination methods are available to address diplopia. Some require special equipments which are not easily available or unfamiliar outside of ophthalmic clinic. We describe a simple two-minute diagnostic approach to monocular diplopia. Conclusion: Basic knowledge and understanding of simple clinical examination techniques enhances diagnostic skill and allow proper localization of underlying disorders.

An Analysis of Metamorphopsia Using Preferential Hyperacuity Perimeter Following Macular-off RRD Surgical Repair

PURPOSE: To determine the efficacy of using the preferential hyperacuity perimeter (PHP) for the analysis of metamorphopsia following macular-off rhegmatogenous retinal detachment (RRD) surgical repair. METHODS: PHP examination was performed in those who complained of metamorphopsia after successful surgical reattachment of RRD. The subjective symptoms were evaluated based on a scale, ranging from 0 to 10, and were compared with the results of PHP examination. Patients age, duration of retinal detachment, pre and post-operative visual acuity, postoperative presence of subretinal fluid (SRF), surgical methods, presence of epiretinal membrane, and time from operation to PHP test were analyzed to find the correlation with the PHP results. RESULTS: Of the 19 eyes included in this study, nine eyes were found to have a hyperacuity defect upon PHP examination. In this group, the subjective level of metamorphopsia was significantly worse (p<0.01), the age was significantly higher (p=0.02), and SRF persisted in the macula more frequently at two months postoperatively (p=0.04), as compared to those without the defect. There were no significant differences in the other factors. CONCLUSIONS: Subjectively severe metamorphopsia after surgery for RRD could be confirmed objectively using PHP. In the case of older patients and persistent submacular fluid, metamorphopsia would develop more frequently due to displacement of the photoreceptors in the process of reattachment.

Correlation of OCT and Preferential Hyperacuity Perimeter in Exudative Age-related Macular Degeneration

PURPOSE: Preferential hyperacuity perimeter (PHP) is a device that measures metamorphopsia in the central 14 degrees of the macular visual field which is presented by hyperacuity defect. We elucidated a hyperacuity defect lesion of PHP in exudative age-related macular degeneration (AMD) by Optical coherence tomography (OCT). METHODS: Nineteen eyes of 18 patients with exudative AMD diagnosed by fundus examination and fluorescein angiography (FA) underwent PHP. We then elucidated any hyperacuity defect lesion of PHP by fundus photography, FA and OCT. For a control, 20 eyes of 10 age-matched persons who had no ophthalmological abnormality underwent PHP and OCT to determine if hyperacuity defect would appear. RESULTS: Hyperacuity defect lesion appeared in 18 eyes (95%) of AMD patients. There was good locational correlation between the hyperacuity defect lesions and lesions in the fudoscopic examination in 16 eyes of 18, but there was a counterpart relation at the superior-inferior and left-right in 2 eyes. Hyperacuity defect lesion in PHP was of smooth or irregular elevation of the retinal pigment epithelium (RPE) in OCT. In the control, hyperacuity defect lesion appeared in 1 eye (5%) and it was normal in OCT. CONCLUSIONS: PHP showed a highly positive rate in detecting AMD-related lesion. The hyperacuity defects that are noted by the PHP are produced from elevation of the RPE.