ACUTE RETINAL PIGMENT EPITHELIITIS: ASSOCIATION WITH ACUTE COXSACKIE A VIRUS INFECTION.

PURPOSE: The purpose of this study was to describe the occurrence of acute retinal pigment epitheliitis in association with serologic evidence of acute Coxsackie A virus infection. METHODS: This study is a case report. RESULTS: A 37-year-old man noted an acute onset of paracentral scotomas in his right eye correlating with stippled retinal pigment epithelial pigment alterations with whitish halos surrounding the fovea. Spectral domain optical coherence tomography revealed scattered distinct retinal pigment epithelial elevations in the paracentral macular region arranged in an annular fashion, with associated alterations in the interdigitation and ellipsoid zone layers anterior to the retinal pigment epithelial, characteristic of acute retinal pigment E. Suspicion of acute Coxsackie A virus in the patient because of the presence of simultaneous viral exanthematous illness in the patient's 1-year-old son prompted serologic testing for Coxsackie virus. Titers showed strongly positive IgM ("early") antibody for several Coxsackievirus A serotypes, including A16 (most commonly associated with hand-foot-mouth disease). Spontaneous regression of the anatomical and clinical findings occurred over the next month, with complete resolution noted 16 months later. CONCLUSION: This is the first documented case of acute retinal pigment epitheliitis associated with evidence of acute Coxsackie A virus infection. Corroboration with serology in future cases would add to evidence that acute retinal pigment epitheliitis is part of the apparently expanding spectrum of recognized "Coxsackie retinopathies."

PNEUMATIC COMPACTION TREATMENT OF ACUTE SUBFOVEAL HEMORRHAGE AFTER BLUNT TRAUMA IN A PATIENT WITH ANGIOID STREAKS ASSOCIATED WITH PSEUDOXANTHOMA ELASTICUM.

PURPOSE: To report a case of photoreceptor restitution and vision improvement with pneumatic compaction treatment of acute subfoveal hemorrhage in a patient with angioid streaks associated with pseudoxanthoma elasticum, observed by sequential fundus photography, spectral domain optical coherence tomography, and fundus autofluorescence. METHODS: Findings on initial and sequential clinical examinations, fundus autofluorescence, and spectral domain optical coherence tomography are presented, before and after pneumatic compaction, demonstrating the course of compaction and resolution of subfoveal hemorrhage and status of the foveal ellipsoid zone and external limiting membrane. Sequential improvements in oxygen and nutrient diffusion are calculated using Fick's law of diffusion. Findings are compared with previous reports regarding the natural history of similar patients. RESULTS: Rapid compaction of subfoveal hemorrhage occurred, resulting in an 89% improvement in oxygen diffusion in 15 days. No centrifugal movement of subfoveal hemorrhage occurred, potentially minimizing photoreceptor-shearing injury. Ultimately, resorption of all hemorrhage occurred with reestablishment of the foveal ellipsoid zone and external limiting membrane and minimal juxtafoveal subretinal fibrosis; best-corrected visual acuity improved to 20/40: an advantage over natural history based on published reports. CONCLUSION: Pneumatic compaction in patients with acute subfoveal hemorrhage secondary to angioid streaks associated with pseudoxanthoma elasticum compacts subfoveal hemorrhage, therefore improving oxygen and nutrient diffusion. This potentially spares foveal photoreceptors of ischemic and shearing injury, theoretically reducing subfoveal fibrosis and improving vision prognosis in these patients.

Mycobacterium chimaera chorioretinitis as a biomarker of systemic disease activity following nosocomial acquisition during cardiopulmonary bypass.

Objectives: To understand the role of ophthalmoscopic examination (dilated retina examination and widefield fundus photography) in the diagnosis and management of nosocomial acquisition of Mycobacterium chimaera following open heart surgery with cardiopulmonary bypass utilizing a heater-cooler unit, an entity that is associated with >50% mortality during the worldwide outbreak that has occurred since 2013.Methods: Case report with review of previous cases.Results: Signature Mycobacterium chimaera chorioretinal lesions can be used as a diagnostic sign and a biomarker for assessment of treatment efficacy.Conclusions: Ophthalmologic examination can play a key role in diagnosis and management of systemic Mycobacterium chimaera following cardiopulmonary bypass; such examinations may yield earlier diagnosis, diminishing mortality rates.

SERIAL "EN FACE" OPTICAL COHERENCE TOMOGRAPHY IMAGING OF SLOWLY RESORBING SUBRETINAL FLUID AFTER PNEUMATIC RETINOPEXY.

PURPOSE: To describe the use and utility of serial "en face" C-scan optical coherence tomography in following the postoperative subretinal fluid status in a patient after pneumatic retinopexy treatment of a rhegmatogenous retinal detachment. METHOD: Case study. RESULTS: Serial "en face" optical coherence tomography imaging enhanced postoperative follow-up of persistent subretinal fluid, demonstrating its spontaneous disappearance over time. CONCLUSION: Previous studies showed that subretinal fluid persists in a large proportion of patients after rhegmatogenous retinal detachment repair (especially in those with a chronic component). "En face" optical coherence tomography imaging is a valuable tool for demonstrating postoperative fluid status and aids in the ability of the practitioner to evaluate for spontaneous disappearance of fluid with time.

Current intravitreal pharmacologic therapies for diabetic macular edema.

INTRODUCTION: Diabetic retinopathy is the leading cause of vision loss in working-age adults; it is a highly prevalent cause of vision loss overall and has a potent impact on the quality of life in those with diabetes mellitus and public health in general. Diabetic macular edema (DME) is the most common cause of vision loss from diabetic retinopathy. In patients with diabetes mellitus, chronic hyperglycemia leads to activation of the inflammatory cascade and retinal capillary damage that result in microaneurysm formation in the retina. In addition to the possibility of associated ischemia, microaneurysms are hyperpermeable; the resultant loss of the blood-retinal barrier leads to vision loss if consequent edema involves the center of the fovea. The standard of DME therapy for >25 years was focal laser photocoagulation applied to or near the microaneurysms. However, results from clinical trials of intravitreal vascular endothelial growth factor (VEGF) blockers and corticosteroids for the treatment of DME have led to a dramatic paradigm shift away from laser therapy to primary treatment with these pharmacologic agents. METHODS: Medline literature search of approaches for treating DME. RESULTS: Intravitreal pharmacologic treatments with anti-VEGF agents and corticosteroids have recently been shown to be superior to laser treatment of DME. CONCLUSION: The existence of pharmacologic treatment of DME, shown to be superior to laser monotherapy, has created a seismic change in the approach of treatment of these patients. This review provides a summary of the therapies and the rationale regarding the current pharmacologic therapy of DME.

Rhegmatogenous retinal detachment.

Patients often present after trauma with symptoms of vision loss or loss of a field of vision from a rhegmatogenous retinal detachment (RRD). This study aims to equip the health care provider with knowledge on the recognition, evaluation, and management of RRD to improve communication between the patient and consultant. The article highlights the symptoms, signs (including ophthalmoscopic findings), and pathogenesis of RRD. Causes and presentations of RRD are considered. Treatment paradigms are discussed and surgical options for treatment of RRDs are reviewed, including pneumatic retinopexy, pars plana vitrectomy, and scleral buckle surgery.

Intravitreal bevacizumab and triamcinolone acetonide combination therapy for exudative neovascular age-related macular degeneration: short-term optical coherence tomography results.

PURPOSE: The aim of this study to describe the short-term anatomical results after an intravitreal injection of bevacizumab and triamcinolone acetonide in patients with foveal edema and/or subfoveal fluid associated with neovascularization (NV) due to age-related macular degeneration (AMD). METHODS: A retrospective, noncomparative case series was conducted in patients with foveal edema and/or subfoveal fluid associated with NV due to AMD during a 3-month period. Patients were treated with intravitreal injections of bevacizumab (1.25 mg/0.05 mL) and followed immediately with triamcinolone acetonide (2 mg/ 0.05 mL) in separate syringes. Ophthalmoscopic examination with optical coherence tomography analysis of foveal edema and subfoveal fluid volume was performed at baseline and follow-up visits. RESULTS: There were 30 consecutive eyes of 27 patients who received a short-term follow-up between 1 and 8 weeks after injection. Foveal thickness and subfoveal fluid volume were each statistically significantly reduced in the short term (paired Student t test; P < 0.01). No complications of intraocular pressure greater than 30 mmHg, endophthalmitis, retinal detachment, or vitreous hemorrhage developed. CONCLUSIONS: Reduction of foveal edema and subfoveal fluid in patients with NV due to AMD suggests that combination treatment with intravitreal bevacizumab and triamcinolone merits further investigation.

Retinal vascular disease in hypertension. Risk factor modification optimizes vision outcomes.

In a previous article (July 2004, page 57), Dr Colucciello reviewed nonproliferative and proliferative diabetic retinopathy. In this article, he discusses retinal vascular disease associated with hypertension, which is especially likely to occur in persons with vasculopathic risk factors. Retinal vein occlusion, retinal arterial macroaneurysm, retinal artery occlusion, and carotid artery disease are predictive of progressive systemic vascular disease. Modification of risk factors and prompt identification of retinal vascular disease optimize vision outcomes and preserve quality of life.

Diabetic retinopathy. Control of systemic factors preserves vision.

Diabetic retinopathy, a retinal microangiopathy, is the leading cause of blindness for persons aged 20 to 65 years in the United States. Routine screening and early treatment are cost-effective and have been shown to help preserve sight. Primary care physicians play a key role in treatment of systemic factors that lead to poor outcomes and referral to an ophthalmologist or a retinal specialist for screening and local treatment. This article, the first of two on retinal vascular disease, provides a review of nonproliferative and proliferative diabetic retinopathy. The second article, which will appear in an upcoming issue of POSTGRADUATE MEDICINE, discusses retinal vascular disease in hypertension.