HEMORRHAGIC OCCLUSIVE RETINAL VASCULITIS AFTER INTRACAMERAL VANCOMYCIN USE IN CATARACT SURGERY AFTER INTRAVENOUS EXPOSURE.

PURPOSE: To report a case of hemorrhagic occlusive retinal vasculitis after cataract surgery. METHODS: A 74-year-old woman presented with blurry vision and distorted vision, which started 2 days after an uncomplicated cataract surgery in the left eye. Intracameral vancomycin was injected during the case. The patient reported being treated with systemic vancomycin in the past. RESULTS: The visual acuity was 20/80 in the left eye. She had trace cells in the anterior chamber with no hypopyon and intraocular lens implant within the capsular bag in the left eye. Dilated fundus examination revealed no vitritis, There were large patches of peripheral retinal hemorrhages and retinal ischemia. The patient was diagnosed with hemorrhagic occlusive retinal vasculitis likely secondary to hypersensitivity reaction to intracameral vancomycin. The patient was started on oral prednisone, and the topical difluprednate course was escalated. Within 3 weeks, vision improved to 20/30 in the left eye. She underwent pan retinal photocoagulation targeting the ischemic areas in the periphery. CONCLUSION: The patient had previous exposure to systemic vancomycin, which may have sensitized her immune system. Later on, the hypersensitivity reaction took place after exposure to intracameral vancomycin during cataract surgery. Our hemorrhagic occlusive retinal vasculitis case had a favorable visual outcome, and recognition of this entity will ensure that vancomycin will not be used for infection prophylaxis in the fellow eye at the time of cataract surgery.

Hemoglobin level and macular thinning in sickle cell disease.

Purpose: To study the relationship between complete blood count (CBC) indices over time, particularly serum hemoglobin (Hb) levels, and severity of macular thinning on spectral domain optical coherence tomography (SD-OCT) in patients with sickle cell disease (SCD). Methods: This is a single-center, retrospective analysis of 141 consecutive SCD patients over a 10-year period, of which 40 patients (79 eyes) had SD-OCT imaging of the macula and 29 (58 eyes, mean age 17.5 years) were eligible for the study. Investigators reviewed electronic medical records for documentation of retinopathy stage, disease genotype, CBC values, and SD-OCT imaging. SD-OCT parameters and CBC values were compared between different retinopathy stages and disease genotypes. Regression analyses were performed on SD-OCT parameters and CBC values. Results: Of the 58 eligible eyes (34HbSS, 18HbSC, 4HbSß +thal, 2HbS ßthal), 18 had PSR (proliferative sickle retinopathy), 14 had NPSR (nonproliferative sickle retinopathy), and 26 had NSR (no sickle retinopathy). Hb values were higher in SC group compared to SS group. Macular thickness in the temporal inner (Δ=26±33 um, p=0.01) and outer (Δ=21±30 um, p=0.02) subfields was higher in SC compared to SS group. Patients with SD-OCT thinning below the 5th percentile in the temporal outer subfields had lower recorded Hb nadirs (6.0±0.9) compared to those with thickness within the top 95th percentile (9.1±2.3). Regression analysis showed temporal macular thickness to be positively correlated with Hb values in the SS group. Conclusion: Macular thinning observed on SD-OCT in SCD patients with SS genotype may be related to the level of anemia in this population.

Paracentral acute middle maculopathy: precursor to macular thinning in sickle cell retinopathy.

We present a case of paracentral acute middle maculopathy (PAMM) in a patient with sickle cell disease (SCD). Though gradual capillary loss may contribute to pathophysiology of sickle cell retinopathy as well, our case suggests that PAMM may be the precursor lesion to macular thinning commonly observed in patients with SCD. In addition, fluorescein angiography may be unable to detect these acute vascular events occurring at the deep capillary plexus.

Characteristics and racial variations of polypoidal choroidal vasculopathy in tertiary centers in the United States and United Kingdom.

PURPOSE: To evaluate the characteristics and racial variations amongst patients with polypoidal choroidal vasculopathy (PCV) in the United States and the United Kingdom. METHODS: Fundus photos and indocyanine green angiography images were evaluated in a multicenter retrospective study to establish the diagnosis of PCV. Visual acuity (VA) was recorded in ETDRS letter count. RESULTS: Eighty eyes of 71 PCV patients (average age of 69.4 ± 10.4 years) were included in the analysis. Of the total 71 subjects, 46 (65%) were women, 33 (46.5%) were Blacks, 16 (22.5%) were Whites, 19 (26.8%) were Asians and 3 (4.2%) belonged to other races. The Black subgroup had vision gain of 3.5 letters. The White and Asian subgroups had vision loss of 13.1 and 3.5 letters, respectively. There was female predominance in Blacks (67%), Whites (69%), and Asians (58%). PCV was found to be a bilateral disease in 14 patients (20%). There was significant decrease of 7 letters with every decade increase in age (p = 0.005). Final VA was worse in males when compared to females (p = 0.042), and worse in Whites when compared to Blacks (p = 0.005). For every 10 letters worse in initial VA upon diagnosis with PCV, the final VA was worse by 6 letters (p < 0.001). The location of the polypoidal lesion within the macula was associated with significant decrease of 14 letters in BCVA (p = 0.02). The length of follow up was significantly associated with worse visual outcome (p = 0.012). Final VA had no significant correlation with the lens status, or the different treatment modalities. CONCLUSIONS: Based on our cohort from tertiary centers in the United States and United Kingdom, PCV is a bilateral disease in one-fifth of patients. It features a variable female predominance based on ethnicity. Increased age, worse vision upon initial presentation, longer follow up and macular location of the polyp were associated with worse visual outcome.

Asymmetric Deep Stromal Keratopathy in a Patient With Multiple Myeloma.

PURPOSE: To report a case of asymmetric deep stromal keratopathy in a patient with multiple myeloma. METHODS: Case report and literature review. RESULTS: An 85-year-old woman was found to have progressive visually significant left-sided deep stromal opacity in the setting of monoclonal gammopathy. Hematologic workup resulted in a diagnosis of IgG kappa multiple myeloma. Histopathology was significant for semicrystalline deposits in the posterior stroma. The patient's visual acuity improved to 20/50 7 months after penetrating keratoplasty. A similar deep stromal lesion appeared in the right eye 2 years after initial presentation. CONCLUSIONS: We present an unusual case of paraproteinemic keratopathy with a uniquely asymmetric presentation that resulted in a diagnosis of multiple myeloma.

BILATERAL DIFFUSE UVEAL MELANOCYTIC PROLIFERATION: A CASE REPORT.

PURPOSE: To report a case of bilateral diffuse uveal melanocytic proliferation (BDUMP) in the setting of metastatic ovarian cancer. METHODS: In this observational case report, a 59-year-old woman presented with bilateral worsening vision and photophobia. She had been diagnosed with metastatic ovarian cancer 5 years prior for which she received Tamoxifen. Ophthalmic examination was completed followed by fluorescein angiography and optical coherence tomography (Spectralis OCT; Heidelberg Engineering). RESULTS: The visual acuity was 20/150 in both eyes. Exam demonstrated an iris pigmented lesion in the right eye, bilateral nuclear sclerotic cataracts, multiple orange lesions in the fundus, elevated pigmented uveal melanocytic tumors with diffuse choroidal thickening and multifocal early hyperfluorescence of these lesions (giraffe-like pattern) on fluorescein angiography, and exudative retinal detachment on OCT. The patient was diagnosed with BDUMP in the setting of metastatic ovarian carcinoma. Further metastatic workup demonstrated enlarged lymphadenopathy in the right axilla and inguinal regions. The patient declined chemotherapy and was initiated on plasmapheresis. CONCLUSIONS: BDUMP is a peculiar paraneoplastic syndrome in the setting of metastatic ovarian cancer, where antigens from the retinal pigment epithelium, iris and choroidal melanocytes cross-react with ovarian tumor cell antibodies that are circulating in the serum. Plasmapheresis can decrease the concentrations of the antibodies, maintain reasonable functional vision and improve the quality of life.

Ocular Syphilis Presenting as Bilateral Acute Retinal Necrosis in an Immunocompetent Host.

Given the recent rise in reported cases of syphilis, clinicians must maintain a high index of suspicion for this great masquerader when evaluating patients with symptoms and signs of ocular inflammation. Ocular syphilis can present a diagnostic dilemma for ophthalmologists due to its myriad ofmanifestations. We report a case of ocular syphilis presenting as bilateral acute retinal necrosis (BARN) that we recently saw in Connecticut and review clinical signs, appropriate serum testing sequence, and specialized ophthalmic testing, as well as treatment of ocular syphilis.

Delayed bilateral fibrinous anterior chamber reaction following autologous bone marrow transplant and cataract surgery.

PURPOSE: Immune reconstitution uveitis (IRU) is a well-described phenomenon that by definition occurs in patients with AIDS who undergo highly active antiretroviral therapy resulting in a rebound inflammatory response to the presence of clinically latent cytomegalovirus (CMV). We hypothesize that similar phenomena may exist in other cohorts who undergo transient immunosuppression with rapid white blood cell count recovery. OBSERVATIONS: A patient developed rebound inflammation a few months after cataract surgery with intraocular lens placement characterized by photophobia, significant anterior chamber cell and fibrinous deposits. She had a history of multiple myeloma treated with chemotherapy and a recovery of white blood cell counts following autologous bone marrow transplant. She underwent a thorough work-up for infectious etiologies, as well as the presence of intraocular CMV, which were negative. Her vision and symptoms improved to baseline with the use of topical steroids and at one year her exam remained stable. CONCLUSIONS AND IMPORTANCE: With a negative work-up for infectious etiologies, and the timing and clinical presentation, the patient's inflammation was likely the result of rapid white blood cell count recovery following iatrogenic immunosuppression similar to the mechanism described for IRU.

Idiopathic retinal vasculitis, aneurysms and neuroretinitis case report.

PURPOSE: To report a case of idiopathic retinal vasculitis, aneurysms and neuroretinitis (IRVAN) in a young woman. OBSERVATIONS: A 21-year-old white female patient was referred to retina clinic with decreased vision in the left eye. On examination, best corrected visual acuity was 20/20 in the right eye and counting fingers in the left eye. Fundus examination revealed bilateral optic disc edema, peripapillary and macular exudates, retinal arterial aneurysms, and venous beading. In the left eye, there was a large focus of exudative material in the central macula. Examination of the peripheral retina was unremarkable, bilaterally. Fluorescein angiography demonstrated arterial aneurysms and venous beading in both eyes, with optic nerve activity and vascular sheathing noted on late frames in both eyes. In the left eye, there was a large central area of blockage corresponding to hard exudates surrounding a more central area of hyperfluorescence with leakage, representing retinal neovascularization. Review of systems and extensive laboratory workup were negative. The patient was diagnosed with IRVAN. She was observed, and her exam at 6-month follow-up revealed low grade inflammation for which the patient was started on oral prednisone. CONCLUSIONS AND IMPORTANCE: Management of IRVAN remains challenging because of its idiopathic nature and the lack of controlled clinical trials for such a rare entity. Bilateral involvement in IRVAN is variable and close follow up is crucial.

Pneumatic retinopexy for displaced macular laceration from intraocular foreign body.

PURPOSE: To report a case of macular laceration from intraocular foreign body (IOFB) treated with pneumatic retinopexy. OBSERVATIONS: A 74 year old man sustained penetrating injury to his left globe with retained metallic intraocular foreign body (IOFB). The patient underwent prompt pars plana vitrectomy, intravitreal antibiotics and removal of IOFB. The posterior point of impact left a displaced foveo-macular laceration which was recognized postoperatively and treated with pneumatic retinopexy for re-approximation of the foveal tissue. Optical coherence tomography confirmed acute traumatic laceration and edema, closure of the tissue and subsequent healing and adjacent retinal and retinal pigment epithelial atrophy. He regained visual acuity of 20/30. CONCLUSIONS AND IMPORTANCE: Traumatic macular lacerations can be treated with pneumatic retinopexy, after pars plana vitrectomy, with potentially good visual result.

Spectral domain optical coherence tomography findings in eyes with acute ischaemic retinal whitening.

Acute retinal ischaemia presents in various forms depending on the type and location of the associated vascular occlusion. Cotton wool spots have been considered one manifestation of ischaemia and represent swelling in the nerve fibre layer. However, clinical retinal whitening also occurs in areas not affected by cotton wool spots, and has distinguishing spectral domain optical coherence tomography (SD-OCT) features. We present SD-OCT findings of hyper-reflectivity and thickening in four eyes with representative retinal arterial or retinal venous occlusions, specifically branch retinal artery occlusion, central retinal vein occlusion, Purtscher-like retinopathy and ophthalmic artery occlusion. The spectrum of retinal ischaemia from various causes was found to manifest in inner nuclear layer hyper-reflectivity and thickening on SD-OCT. En Face OCT imaging further characterises the topographical distribution of ischaemia, and reveals patterns which provide insight into the pathological processes involved.

Spectral domain optical coherence tomography imaging of Purtscher-like retinopathy.

PURPOSE: To report spectral domain optical coherence tomography findings in a patient with Purtscher-like retinopathy. METHODS: Case report, image analysis, and literature review. RESULTS: A 71-year-old woman presented with decreased vision, cotton-wool spots, and a deep whitish polygonal lesion in her left eye, which was hyperreflective on spectral domain optical coherence tomography. She was diagnosed with Purtscher-like retinopathy and later was found to have metastatic pancreatic cancer. CONCLUSION: Purtscher-like retinopathy can occur secondary to malignant pancreatic cancer. Purtscher-flecken can be characterized by cross-sectional and en face spectral domain optical coherence tomography and represent deep capillary ischemia.

The army health hazard assessment program's medical cost-avoidance model.

BACKGROUND: The Logistics Management Institute initially developed a medical cost-avoidance model (MCAM) to estimate the costs associated with the failure to eliminate or control health hazards of army materiel systems during 1997. METHODS: Presented is an updated version of the MCAM that uses cost factors for individual health hazard categories. The earlier MCAM calculated army materiel acquisition-life cycle medical costs based on a single cost factor for all hazard categories. RESULTS: The Army's Health Hazard Assessment (HHA) Program, which uses the MCAM while assessing 18 types of health hazards commonly found in materiel undergoing the acquisition process, recognized the need to refine the MCAM to be hazard-type specific. These hazard types have unique cost factors and serve as the basis for the revised model. CONCLUSIONS: The revision will assist the HHA program in targeting health hazards that have the potential to affect soldier health and readiness.