Racemose hemangioma presenting as a vitreous hemorrhage: case report / Hemangioma racemoso apresentando-se como hemorragia vítrea: relato de caso

ABSTRACT This report describes a case of retinal racemose hemangioma that first presented as a vitreous hemorrhage. The authors present the case of a 47-year-old woman with a sudden 5-day painless visual loss in her left eye. At the first visit, the best-correct visual acuities were 20/20 in the right eye and hand motions in the left eyes. Ultrasonography showed an attached retina and a massive vitreous hemorrhage. Pars plana vitrectomy was performed and a dilatation of large vessels was detected bulging from the optic disc. The best-correct visual acuities on day 30 postoperatively was 20/25 in the left eye. Fundus angiography and spectral-domain optical coherence tomography angiography showed anomalous arteriovenous communications with no intervening capillaries. The diagnosis was racemose hemangioma, an arteriovenous malformation of group 2 retina based on the Archer classification.

RESUMO Este relato descreve um caso de hemangioma racemoso da retina que se apresentou inicialmente como hemorragia vítrea. Os autores apresentam o caso de uma mulher de 47 anos com perda visual súbita e indolor 5 dias antes no olho esquerdo. Na primeira visita, a melhor acuidade visual corrigida foi de 20/20 no olho direito e movimentos das mãos no olho esquerdo. A ultrassonografia mostrou uma retina aderida e uma hemorragia vítrea maciça. Foi realizada vitrectomia pars plana, sendo detectada proliferação de grandes vasos salientes do disco óptico. A acuidade visual no dia 30 de pós-operatório foi de 20/25 no olho esquerdo. A angiografia de retina e a angiotomografia de coerência óptica de domínio espectral mostraram comunicações arteriovenosas anômalas sem capilares intermediários. O diagnóstico foi hemangioma racemoso, uma malformação arteriovenosa da retina do grupo 2 com base na classificação de Archer.

Um cirurgião sob o olhar de Deus

Objetivo A síndrome de Terson (ST), também conhecida como hemorragia vítrea, é relatada em pacientes com hemorragia subaracnóide causada por um aneurisma rompido. Este estudo tem como objetivo avaliar a presença de hemorragia ocular nesses pacientes, buscando identificar aqueles que poderiam se beneficiar do tratamento específico para a recuperação do déficit visual. Métodos Estudo prospectivo de 53 pacientes com hemorragia subaracnóide espontânea (SSAH) por aneurisma rompido. Os pacientes foram avaliados quanto à hemorragia vítrea por fundoscopia indireta com 6 a 12 meses de seguimento. Resultados A idade dos pacientes variou de 17 a 79 anos (média de 45,9 ± 11,7); 39 pacientes eram do sexo feminino (73%) e 14 do sexo masculino (27%). Seis pacientes (11%) apresentaram ST e 83,3% apresentaram perda transitória de consciência durante a ictus. Conclusões Uma avaliação oftalmológica deve ser realizada rotineiramente em pacientes com hemorragia subaracnóide, especialmente naqueles com pior grau neurológico. Além disso, o prognóstico foi ruim em pacientes com ST.

Terson Syndrome: Assessment of 53 Patients with Subarachnoid Hemorrhage by a Ruptured Aneurysm

Objective Terson syndrome (TS), also known as vitreous hemorrhage, is reported in patients with subarachnoid hemorrhage caused by a ruptured aneurysm. This study aims to evaluate the presence of ocular hemorrhage in such patients, trying to identify those who could benefit from the specific treatment for visual deficit recovery. Methods Prospective study of 53 patients with spontaneous subarachnoid hemorrhage (SSAH) due to ruptured aneurysm. The patients were evaluated for vitreous hemorrhage through indirect fundoscopy with 6 to 12 months of follow-up. Results The ages of the patients ranged from 17 to 79 years-old (mean age, 45.9 11.7); 39 patients were female (73%) and 14 were male (27%). Six patients (11%) presented TS, and 83.3% had a transient loss of consciousness during ictus. Conclusions An ophthalmologic evaluation must be routinely performed in subarachnoid hemorrhage patients, especially in those with worse neurological grade. Moreover, prognosis was bad in TS patients.

Perdas visuais agudas: uma revisão dos últimos 10 anos de causas não infecciosas e não maculares / Acute visual loss: a review from the last 10 years of non-infectious and non-macular causes

Objetivo: o conhecimento das principais causas de perda visual aguda possibilita o diagnóstico precoce do paciente, o que favorece o tratamento mais rápido e eficaz, a fim de preservar a acuidade visual. Neste artigo de revisão, as principais causas não infeciosas e não oriundas da mácula são abordadas, a fim de buscar e revisar os tópicos mais pertinentes sobre cada tema, como as manifestações clínicas e os tratamentos mais utilizados. Métodos: trata-se de uma revisão de literatura, com 30 artigos selecionados e revisados da plataforma MEDLINE. Resultados: as causas de perda visual aguda discutidas são cinco. Primeiro, as por baixa acuidade visual, súbita, unilateral, sem dor e sem hiperemia: hemorragia vítrea, descolamento de retina, oclusão vascular de retina e neuropatia óptica isquêmica anterior. Posteriormente, por baixa acuidade visual, súbita, unilateral, com dor e sem hiperemia: neurite óptica. Por meio deste estudo, alguns fatores de risco podem ser evidenciados e os principais tratamentos destacados. Conclusão: o diagnóstico precoce das perdas visuais agudas deve ser realizado, com os exames físicos adequados, como a fundoscopia e os exames complementares necessários solicitados. Além disso, o encaminhamento ao oftalmologista é de extrema importância para minimizar sequelas e evitar complicações.

Objective: The knowledge of the main causes of acute visual loss enables the early diagnosis of the patient, which favors faster and more effective treatment in order to preserve visual acuity. In this review article, the main non-infectious causes not originating from the macula are addressed in order to search and review the most relevant topics on each theme, such as the clinical manifestations and the most used treatments. Methods: This is a literature review with 30 articles selected and reviewed from the MEDLINE platform. Results: Five causes of acute visual loss are discussed. First, those for sudden, unilateral, without pain, and without hyperemia low visual acuity are reviewed: vitreous hemorrhage, retinal detachment, retinal vascular occlusion, and anterior ischemic optic neuropathy. Subsequently, one due to low visual acuity, sudden, unilateral, with pain and without hyperemia is evaluated: optic neuritis. Through this study, some risk factors and main treatments can be highlighted. Conclusion: The early diagnosis of acute visual loss should be performed with appropriate physical exams, such as fundoscopy and the necessary complementary exams. In addition, referral to an ophthalmologist is extremely important to minimize sequelae and avoid complications.

Antithrombotic Medication and the Risk of Vitreous Hemorrhage in Atrial Fibrillation: Korean National Health Insurance Service National Cohort

PURPOSE: Antithrombotic therapy could be related with nuisance bleeding. This study investigated whether vitreous hemorrhage (VH) is associated with specific types of antithrombotic medication in patients with atrial fibrillation (AF). MATERIALS AND METHODS: In the Korean National Health Insurance Service National Sample Cohort, we identified 9352 antiplatelet/anticoagulant-treated AF patients. The occurrence of VH was compared between warfarin (n=1493) and a propensity score (PS)-matched antiplatelet group (n=1493) and between warfarin (n=1493) and a PS-matched warfarin+antiplatelet group (n=1493). RESULTS: The outcomes of VH were lower in the warfarin than in the matched antiplatelet (1.45 vs. 3.72 events/1000 patient-years) and matched warfarin+antiplatelet groups (1.45 vs. 6.87 events/1000 patient-years). Compared with warfarin, the risk of VH increased with antiplatelet [adjusted hazard ratio (aHR) 3.90; 95% confidence interval (CI) 1.22–12.4, p=0.022] and warfarin+antiplatelet agents (aHR 4.39, 95% CI 1.74–11.2, p=0.002). Compared with warfarin only, warfarin+antiplatelet agents increased the risk of VH in patients ≥65 years, regardless of gender and hypertension. The risk of VH was significantly higher with dual antiplatelet therapy (aHR: 5.02, 95% CI: 1.56–16.2, p=0.007) or in dual (aHR: 5.02, 95% CI: 1.74–14.5, p=0.003) or triple therapy using warfarin and antiplatelet agents than with warfarin monotherapy (aHR: 6.12, 95% CI: 1.76–21.3, p=0.004). CONCLUSION: Dual antiplatelet or triple therapy increased the risk of VH significantly, compared to warfarin monotherapy. Considering the low efficacy of preventing ischemic stroke and high risk of bleeding, dual or triple therapy using warfarin and antiplatelet agents should be avoided to prevent VH in AF patients.

Dipeptidyl Peptidase-4 Inhibitors versus Other Antidiabetic Drugs Added to Metformin Monotherapy in Diabetic Retinopathy Progression: A Real World-Based Cohort Study

BACKGROUND: To investigate the effects of dipeptidyl peptidase-4 inhibitor (DPP4i) as add-on medications to metformin on progression of diabetic retinopathy (DR) in patients with type 2 diabetes mellitus, compared with sulfonylurea (SU) or thiazolidinedione (TZD). METHODS: We identified 4,447 patients with DPP4i, 6,136 with SU, and 617 with TZD in addition to metformin therapy from the database of Korean National Health Insurance Service between January 2013 and December 2015. Cox proportional hazards regression models were used to calculate hazard ratios (HRs) for DR progression. The progression of DR was defined by the procedure code of panretinal photocoagulation, intravitreal injection or vitrectomy; or the addition of diagnostic code of vitreous hemorrhage, retinal detachment, or neovascular glaucoma. RESULTS: The age and sex-adjusted HR of DR progression was 0.74 for DPP4i add-on group compared with SU add-on group (95% confidence interval [CI], 0.62 to 0.89). This lower risk of DR progression remained significant after additional adjustments for comorbidities, duration of metformin therapy, intravitreal injections and calendar index year (HR, 0.80; 95% CI, 0.66 to 0.97). CONCLUSION: This population-based cohort study showed that the use of DPP4i as add-on therapy to metformin did not increase the risk of DR progression compared to SU.

Diabetic Nephropathy in Type 2 Diabetic Retinopathy Requiring Panretinal Photocoagulation

PURPOSE: To investigate the risk factors of diabetic nephropathy in patients with diabetic retinopathy requiring panretinal photocoagulation (PRP) and the visual prognosis. METHODS: A retrospective review of electronic medical records was conducted at Seoul St. Mary's Hospital, comprising 103 patients with type 2 diabetes mellitus and diabetic retinopathy who underwent PRP from 1996 to 2005. Patients with type 1 diabetes mellitus, non-diabetic renal disease, non-diabetic retinal disease, visually significant ocular disease, high-risk proliferative diabetic retinopathy, and advanced diabetic retinopathy were excluded. The patients were divided into three groups: no nephropathy (group 1, n = 45), microalbuminuria (group 2, n = 16), and advanced nephropathy (group 3, n = 42). Duration of diagnosis of retinopathy and nephropathy, glycosylated hemoglobin, visual acuity, complications, and treatment history were investigated. RESULTS: The mean glycosylated hemoglobin of group 3 (8.4 ± 1.2) was higher than that of group 1 (7.7 ± 1.0) or group 2 (7.7 ± 1.0) (p = 0.04). Mean interval from PRP to diagnosis of nephropathy was 8.8 ± 6.0 years in group 2 and 8.7 ± 4.9 years in group 3. The significant decrease in visual acuity in group 3 (28 eyes, 35.9%) was significantly higher than that in group 1 (15 eyes, 18.1%, p = 0.01) or group 2 (6 eyes, 20.7%, p = 0.03). Only vitreous hemorrhage showed a significantly higher incidence in groups 2 and 3 than in group 1 (p = 0.02). Multivariate regression analysis revealed that female sex and lower glycosylated hemoglobin were significantly associated with a protective effect on development of nephropathy. CONCLUSIONS: In the clinical setting, many patients with PRP-requiring diabetic retinopathy develop nephropathy an average of 8 to 9 years after PRP. Male sex and higher glycosylated hemoglobin could be risk factors of nephropathy.

Bilateral Rhegmatogenous Retinal Detachments after Systemic Pazopanib Treatment

PURPOSE: A case of bilateral rhegmatogenous retinal detachment is reported after pazopanib treatment of a patient with breast angiosarcoma. CASE SUMMARY: A 53-year-old female presented with bleeding in a right breast mass prior to an emergency room visit. She was diagnosed with metastatic breast angiosarcoma after a breast mass biopsy. She was treated with paclitaxel and radiation therapy. Systemic pazopanib treatment was added to treat lung metastasis. After 3 weeks, she felt sudden floaters in her right eye. In her fundus examination, there was vitreous hemorrhage, but no retinal detachment was noted. Five weeks later, she visited the clinic for a bilateral temporal visual field defect. A fundus examination showed bilateral retinal detachments with superonasal retinal tears. Both the patient and her family did not want surgery for her systemic condition because of her terminal cancer. CONCLUSIONS: Retinal detachment has been reported as a rare complication after systemic pazopanib treatment, but there has been no previous report in the Republic of Korea, therefore this is the first case of bilateral retinal detachments after systemic pazopanib treatment.

Choroidal Effusion after Consecutive General Anesthesia

PURPOSE: To report a case of extensive choroidal effusion following the Valsalva maneuver under consecutive general anesthesia. CASE SUMMARY: A 41-year-old man who underwent panretinal photocoagulation with proliferative diabetic retinopathy had pars plana vitrectomy and endolaser photocoagulation under general anesthesia due to vitreous hemorrhage. Urology cooperated as the patient had hematuria; the day after the operation, he was transferred to the urology department. Two days after vitrectomy, the patient had an urgent transurethral bladder tumor resection under general anesthesia with suspicion of bladder tumor. At 6 days postoperatively, extensive choroidal effusion was observed from 8 to 10 o'clock on fundus examination and ultrasonography. On day 23 after urological surgery, the choroidal effusion had disappeared without treatment. CONCLUSIONS: Consecutive general anesthesia requires caution, as it is not only burdensome to the body as a whole but may also cause choroidal effusion in the eye.

The Effects of Long-term Hemodialysis on Visual Acuity and Central Macular Thickness in Diabetic Retinopathy Patients

PURPOSE: To investigate the changes of visual acuity and central macular thickness (CMT) in patients with diabetic retinopathy (DR) receiving long-term hemodialysis (HD). METHODS: From January 1, 2008, to December 31, 2018, the medical records of patients who were diagnosed with DR receiving HD three times a week for ≥18 months due to chronic kidney disease (CKD) were analyzed. Among them, patients diagnosed with DR 6 months before the start of HD were included. Patients with vitreous hemorrhage (VH) affecting visual acuity (VA), other retinal diseases, and cataract surgery after HD were excluded. The VA and CMT before HD and at 1, 3, 6, 12, and 18 months after HD were analyzed. RESULTS: Of the 222 eyes of 111 patients who were diagnosed with DR and received HD for CKD due to diabetes, 174 eyes with DR diagnosed after starting HD were excluded. Ten eyes with VH before starting HD, two eyes with epiretinal membrane, and four eyes with cataract surgery after starting HD were also excluded. Thirty-two eyes of 18 patients were included. The mean age of the patients was 53.71 ± 9.25 years. Twenty-four males and eight female patients were included in the study. The mean logMAR VA improved significantly from 0.36 ± 0.28 before starting HD to 0.26 ± 0.27 at 18 months after starting HD (p = 0.002). The mean CMT was significantly decreased from 307.12 ± 89.52 µm before starting HD to 279.71 ± 61.75 µm at 12 months after starting HD (p = 0.02). CONCLUSIONS: In patients with DR who underwent long-term HD, CMT decreased and VA improved, when compared with these parameters before HD.

Maculopatia hipotônica pós ciclodiálise traumática por arma de fogo / Hypotonic maculopathy post traumatic cyclodialysis with firearms

Resumo Um traumatismo ocular contuso pode gerar uma vasta gama de lesões intraoculares que são dependentes da quantidade de energia que o objeto transfere ao olho durante o impacto. As lesões da íris, malha trabecular e corpo ciliar podem repercutir na drenagem do humor aquoso. A ocorrência de uma ciclodiálise caracterizada pelo descolamento do corpo ciliar da parede escleral, criando uma comunicação entre a câmara anterior e o espaço supracoroidiano, pode provocar importante redução da pressão intraocular. Esta diminuição pressórica é a responsável pela ocorrência da maculopatia hipotônica que pode cursar com diminuição irreversível da acuidade visual. Não existe consenso na literatura sobre o tratamento das ciclodiálises. Neste relato, descrevemos um caso de ciclodiálise traumática pós impacto com projétil de arma de fogo tratada com aplicação de laser de argônio.

Abstract Blunt eye trauma can generate a wide range of intraocular lesions that are dependent on the amount of energy the object transfers to the eye during the impact. Lesions of the iris, trabecular meshwork and ciliary body may influence aqueous humor drainage. The cyclodialysis which is characterized by the detachment of ciliary body from the scleral wall, creating a communication between the anterior chamber to supracoroid space, can cause a several reduction of intraocular pressure. This pressure decrease is responsible for the occurrence of hypotonic maculopathy which may induce a severe impact on visual acuity. There is no consensus in the literature about cyclodialysis treatment. In this report, we describe a case of traumatic cyclodialysis after impact with a firearm projectile treated with argon laser photocoagulation.

Vitreous Hemorrhage after Aneurismal Rupture: Terson Syndrome

Introduction Terson syndrome is described as an intraocular hemorrhage consequent to a spontaneous subarachnoid hemorrhage (SSAH). In the present article, we describe cases of patients who underwent neurosurgical treatment of ruptured cerebral aneurysmat our institution over a period of one year, and who were diagnosed with Terson syndrome. Methods The present study included patients with a diagnosis of SSAH by rupture of a cerebral aneurysm who underwent treatment in our neurosurgical service from December 2009 to December 2010. The patients were followed-up for a minimum of 20 months.We have also performed a literature review and compared the data with those available in the current literature. Results The present study included 34 patients, 18 (53%) of which underwent endovascular treatment, and 16 (47%) who underwent microsurgical clipping. In the sample, the mortality was 14.7% (5 patients), the same percentage of patients who were diagnosed with Terson Syndrome, which is an incidence of 14.7%. Regarding the ophthalmologic evaluation, all patients had vitreous hemorrhage detected by an ultrasound examination, which was unilateral in only two patients. Visual acuity improved in all patients, being incomplete in only one of them. Conclusion Terson syndrome is relatively common and is associated with higher mortality. With the existence of an effective treatment, it should be investigated in all patients with SSAH.

Medical Litigations Associated with Cataract Surgery in Korea

BACKGROUND: To analyze the results of court rulings about medical litigations related to cataract surgery in Korea. METHODS: We collected 50 anonymized judgements regarding cataract surgery between 2000 and 2016 and analyzed the reasons for the medical litigations, the court rulings, the reasons for compensation, and the amount claimed and finally awarded. RESULTS: Forty-eight litigations (96%) resulted from errors in treatment, and the reasons were as follows: endophthalmitis, dissatisfaction of visual outcome or ocular discomfort, bullous keratopathy or corneal opacity, retinal detachment, glaucoma or vitreous hemorrhage due to the progression of an underlying diabetic retinopathy, and others in order. Two litigations (4%) arose due to errors in diagnosis. Among the 50 final cases, 21 litigations (42%) were decided in favor of the plaintiff, and 29 litigations (58%) were decided against the plaintiff and dismissed. Ten cases awarded damages to the plaintiffs because of a violation of duty of care, and 11 cases awarded damages due to a violation of informed consent. When comparing cases with errors in diagnosis to cases with errors in treatment, there was no significant difference in the relative risk of a defendant's verdict (P = 0.503). The total amount of awarded damages was KRW 439,124,496 (USD 399,204), and the average amount was KRW 20,910,690 (USD 19,010). CONCLUSION: Nearly half of the cases were decided in favor of the plaintiff due to the violation of informed consent. This study's results will be helpful in understanding the results of medical litigations regarding cataract surgery and reducing future lawsuits.

Clinical Outcomes of Combined Vitrectomy and Intrascleral Fixation of New Intraocular Lenses in In-the-bag Dislocations

PURPOSE: To investigate the clinical outcomes of combined vitrectomy and intrascleral fixation of a new posterior chamber intraocular lens (PC IOL) as a treatment for IOL dislocation. METHODS: We conducted a retrospective interventional study at our medical facility from January 2015 to January 2017. Posteriorly dislocated IOLs were removed with pars plana vitrectomy. Two intrascleral tunnels, 2.0 mm in length, were created 1.5 mm to the limbus at 6 and 12 o'clock positions. Both haptics of new foldable acrylic 3-piece IOLs were inserted into the tunnel until the IOL was secured in a central position. We analyzed the preexisting ocular condition, visual acuity (VA), and refractive error preoperatively and postoperatively, and recorded postoperative complications. RESULTS: Forty-nine patients (50 eyes) were enrolled in the study. The mean follow-up period was 12.8 ± 6.6 months. A best-corrected VA of 6/12 or better was achieved in 43 eyes (86%). The mean VA significantly improved from 0.32 logarithm of the minimum angle of resolution (logMAR) at baseline to 0.18 logMAR at last follow-up (p = 0.03). The refractive status after intrascleral fixation of the PC IOL revealed a mean hyperopic shift of +1.09 ± 1.28 diopters from the predicted spherical equivalent. Postoperative vitreous hemorrhages occurred in six cases and were cleared without visual compromise. Cystoid macular edema was well-controlled by topical nonsteroidal anti-inflammatory drugs (NSAID) medications in two cases. In two cases, IOL dislocation recurred and required re-operation. There were no serious adverse events of suture-related complications, retinal detachment, corneal compromise, or endophthalmitis in any of the patients. CONCLUSIONS: Our data revealed that use of combined vitrectomy and intrascleral fixation of PC IOLs is a safe and efficient technique to correct IOL dislocation. We observed good visual outcomes with only minor complications.

A novel mutation in XLRS1 gene in X-linked juvenile retinoschisis

X-linked juvenile retinoschisis (XLRS) is characterized by the progressive loss of visual acuity and vitreous hemorrhage. XLRS is caused by a mutation of retinoschisin 1 (RS1) gene at Xp22.13. In the current report, a 2-year-old Korean patient with XLRS was described. The germline deletion of exon 1 was identified in the RS1 gene. Considering X-linked inheritance pattern, validation of a carrier state of a patient's mother is important for the genetic counseling of other family members and for the future reproductive plan. To confirm the carrier state of his mother, the multiplex ligation-dependent probe amplification analysis was done using peripheral leukocytes and found the heterozygous deletion of exon 1 in his mother.

Retinal changes in solid organ and bone marrow transplantation patients / Alterações retinianas em pacientes de um programa de transplante de órgãos sólidos e de medula óssea

ABSTRACT Objective To evaluate retinal changes in patients who underwent solid organ or bone marrow transplantation. Methods A retrospective analysis of medical records of patients evaluated from February 2009 to December 2016. All patients included underwent funduscopy. Clinical and demographic data regarding transplantation and ophthalmological changes were collected. Results A total of 126 patients were analyzed; of these, 108 underwent transplantation and 18 were in the waiting list. Transplantation modalities were heart, lung, kidney, liver, pancreas, combined pancreas and kidney and bone marrow transplantation. The main pre-transplantation comorbidities were diabetes and arterial hypertension. Of the 108 transplanted patients, 82 (76%) had retinal changes. All patients who underwent pancreas or combined pancreas and kidney transplantation had diabetic retinopathy. The main retinal changes found were diabetic retinopathy, hypertensive retinopathy, retinal vascular occlusions, chorioretinal infections and central serous chorioretinopathy. Conclusion Retinal changes were either related to preexisting conditions, mainly diabetic retinopathy, or developed postoperatively as a complication of the surgical procedure, or as an infection related to the immunosuppressive status, or due to drug toxicity. These patients may present with complex ophthalmological changes and should be carefully evaluated prior to surgery and further followed by an ophthalmologist skilled in the management of diabetic retinopathy and posterior pole infections.

RESUMO Objetivo Analisar as alterações retinianas de pacientes submetidos a transplantes de órgãos sólidos ou de medula óssea. Métodos Análise de prontuário dos pacientes avaliados no período de fevereiro de 2009 a dezembro de 2016. Todos os pacientes incluídos foram submetidos à avaliação fundoscópica. Foram coletados dados demográficos e clínicos, referentes ao transplante e às alterações oftalmológicas encontradas. Resultados Foram avaliados 126 pacientes, sendo 108 submetidos a transplantes e 18 que aguardavam o procedimento. Foram avaliados pacientes submetidos a transplantes de coração, pulmão, rim, fígado, pâncreas, pâncreas-rim e medula óssea. As principais comorbidades pré-transplante foram diabetes e hipertensão arterial. Dos 108 pacientes transplantados, 82 (76%) apresentaram alterações retinianas. Todos os pacientes submetidos ao transplante de pâncreas ou pâncreas-rim apresentaram alterações retinianas relacionadas ao diabetes. As principais alterações retinianas detectadas foram retinopatia diabética, retinopatia hipertensiva, oclusões vasculares retinianas, infecções coriorretinianas e coriorretinopatia serosa central. Conclusão As alterações retinianas estavam relacionadas a doenças preexistentes, principalmente à retinopatia diabética, ou surgiram após o transplante, como complicação do procedimento cirúrgico, ou como complicação infecciosa associada à imunossupressão, ou ainda por toxicidade medicamentosa. Tais pacientes podem apresentar alterações oculares complexas, devendo ser submetidos à avaliação retiniana pré-operatória cuidadosa e ao acompanhamento pós-operatório por oftalmologista especializado no manejo da retinopatia diabética e de doenças infecciosas do segmento posterior ocular

Retinoic Acid Syndrome and Pseudotumor Cerebri in Patients with Acute Promyelocytic Leukemia

PURPOSE: To report cases of a retinal, preretinal and vitreous hemorrhage due to retinoic acid syndrome and a papilledema caused by increased intracranial pressure in patients with acute promyelocytic leukemia treated with all-trans retinoic acid (ATRA). CASE SUMMARY: (Case 1) A 48-year-old female visited our clinic with headache, dyspnea, and visual disturbance during ATRA medications for acute promyelocytic leukemia. Her visual acuity of both eyes was hand motion, and fundus examination revealed extensive retinal, preretinal, and vitreous hemorrhage. The laboratory test showed leukocytosis and computed tomography of brain and chest revealed subarachnoid hemorrhage and pulmonary alveolar hemorrhage. She was diagnosed with retinoic acid syndrome and was treated with vitrectomy in both eyes. (Case 2) A 17-year-old male, who had been treated with ATRA for acute promyelocytic leukemia, had headache and visual disturbance. His best-corrected visual acuity was 1.0 in both eyes, but the fundus examination showed papilledema and retinal hemorrhage in both eyes. Goldmann visual field examination revealed an enlarged blind spot in both eyes. He was diagnosed with papilledema caused by ATRA induced increased intracranial pressure, and was observed. CONCLUSIONS: Patients with acute promyelocytic leukemia treated with ATRA may have retinoic acid syndrome and increased intracranial pressure that could result in retinal hemorrhage, vitreous hemorrhage, and papilledema.

A Case of Rapid Progression to Proliferative Diabetic Retinopathy Associated with Generalized Edema

PURPOSE: We report a case of rapid progression to proliferative diabetic after generalized edema occurrence in a non proliferative diabetic retinopathy patient. CASE SUMMARY: A 48-year-old man visited our hospital with both eyes visual disturbance which occurred 1 week ago. He was diagnosed with moderate non proliferative diabetic retinopathy 5 months ago and there was no significant interval change 3 weeks ago. Date of visit, diffuse macular edema and neovascularization were observed in both eyes. Accompanying visual disturbance, he had generalized edema and 10 kg of weight gain. We thought it was not common diabetic macular edema, we held ophthalmic treatment such as an intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection and requested medical treatment to the department of nephrology. Diagnosed with aggravation of left ventricle heart failure and diabetic nephropathy, he took diuretics and low salt diet for 10 days. After 10 days, his visual acuity improved and macular edema disappeared. Since then, he received intravitreal anti-VEGF injection and panretinal photocoagulation for proliferative diabetic retinopathy treatment. Nevertheless, he underwent pars plana vitrectomy due to vitreous hemorrhage in right eye. CONCLUSIONS: We experienced a case of sudden diffuse macular edema and progression to proliferative diabetic retinopathy associated with generalized edema. We suggest that it is necessary to consider systemic changes in diabetic retinopathy.

Ruptured Retinal Arterial Macroaneurysm after Panretinal Photocoagulation for Diabetic Retinopathy

PURPOSE: To report a case of deterioration of a retinal arterial macroaneurysm after panretinal photocoagulation (PRP) for diabetic retinopathy. CASE SUMMARY: A 70-year-old woman visited our clinic for evaluation of diabetic retinopathy. Fundus examination and fluorescein angiography showed severe non-proliferative diabetic retinopathy and PRP was planned for the patient. In addition, the patient was found to have a retinal arterial macroaneurysm on the superotemporal area of the retina on her right eye. However, the lesion was small and was located far from the macula, causing no symptoms; thus we decided to observe the patient over a period of time. Two months after PRP, the patient revisited the clinic complaining of acute visual loss. Fundus examination showed vitreous and retinal hemorrhage and optical coherence tomography revealed subretinal fluid in the corresponding area. This was considered to be due to aggravation of the pre-existing macroaneurysm. Intravitreal Bevacizumab injection, C₃F₈ gas injection, and pars plana vitrectomy were performed. After absorption of the hemorrhage, barrier photocoagulation was performed around the retinal macroanerysm. The visual acuity improved and the retina remained stable through the most recent follow-up. CONCLUSIONS: We experienced the rupture of a preexisting retinal arterial macroaneurysm in an asymptomatic patient after panretinal photocoagulation. PRP in diabetic patients could aggravate retinal arterial macroaneurysms. Therefore, it is necessary to carefully examine the patient for retinal macroaneurysms when planning a PRP for diabetic retinopathy.

Two Cases of Serous Retinal Detachment Following Vitrectomy in Patients with Proliferative Diabetic Retinopathy

PURPOSE: In the present study, 2 cases of serous retinal detachment in patients diagnosed with proliferative diabetic retinopathy after pars plana vitrectomy are reported. CASE SUMMARY: (Case 1) A 38-year-old female diagnosed with high-risk proliferative diabetic retinopathy underwent pars plana vitrectomy and cataract surgery due to intravitreal hemorrhage. One day after the operation, fundus photograph and optical coherence tomography (OCT) revealed serous retinal detachment. After ensuring that no retinal hole was present based on fundus examination, the patient was diagnosed with serous retinal detachment and antimicrobial and steroid eye drops were applied. After 1 week, subretinal fluid disappeared. (Case 2) A 63-year-old male diagnosed with proliferative diabetic retinopathy underwent pars plana vitrectomy due to right vitreous hemorrhage. On postoperative day 1, focal subretinal fluid under the macula was observed using OCT. Intravitreal triamcinolone injection was performed during surgery and steroid eye drops were applied. Subretinal fluid collection was absorbed 5 days postoperatively. CONCLUSIONS: Two cases of serous retinal detachment that occurred postoperatively in patients with diabetic retinopathy are reported. Serous retinal detachment was resolved after several days without specific management.