Acute syphilitic posterior placoid chorioretinitis as the presenting symptom of syphilis in an immunocompetent patient.

Purpose: To report the case of an immunocompetent 62-year old woman with acute syphilitic posterior placoid chorioretinitis. Observations: The patient presented with sudden, painless vision loss in the left eye (OS) four months after self-resolving decreased vision in the right eye (OD) which was incorrectly attributed to ischemic optic neuropathy. At the time of presentation, visual acuity (VA) was hand motion OS and 20/30 OD. The dilated fundus exam demonstrated a flat, yellow-white macular lesion, deep to the retinal vasculature with a temporal, curvilinear demarcation line OS and was unremarkable OD. Trace vitreous cells and veils OS were observed. Optical coherence tomography demonstrated loss of photoreceptor layers. Rapid plasma reagin and fluorescent treponemal antibody absorption were positive. The patient was treated with intravenous penicillin and prednisolone acetate drops with resolution of vitreous cells and return of VA. Conclusions and Importance: Acute syphilitic posterior placoid chorioretinitis can be the single presenting symptom in syphilis. It is imperative for ophthalmologists to consider this relatively uncommon manifestation of syphilis in the differential in immunocompetent patients presenting with unsuspecting histories and perplexing vision loss.

Anomalous Origin of the Right Coronary Artery From the Ascending Aorta Above the Left Sinus of Valsalva.

Congenital anomalous origin of the coronary arteries is a rare but well-described cause of myocardial ischemia and sudden cardiac death. Anomalous origin of the right coronary artery from the ascending aorta is an extraordinarily rare occurrence. We report a case of anomalous origin of the right coronary artery from the ascending aorta posteriorly above the left sinus of Valsalva found during coronary angiography for evaluation of newly diagnosed cardiomyopathy.

Chronic retinal detachment and neovascular glaucoma after intravitreal stem cell injection for Usher Syndrome.

A 42-year-old Hispanic female underwent intravitreal autologous adipose-tissue derived stem cell injection to her left eye in the Dominican Republic for treatment of retinitis pigmentosa associated with Usher Syndrome. Prior to intravitreal injection, the patient's best-corrected-visual-acuity (BCVA) was 1/200. The patient experienced decreased vision gradually over a 3-month period. The patient presented with no light perception (NLP) vision with a total funnel retinal detachment, as well as hyphema, iris neovascularization, and nearly 360 posterior synechiae of the iris to the lens capsule. The patient suffered from ocular pain with an intraocular pressure (IOP) of 37 mm Hg. Transcleral cyclophotocoagulation was performed. The IOP was 6 mm Hg six weeks after treatment and the patient was pain free.

Recurrence of Acute Macular Neuroretinopathy.

A 31-year-old female with a 2-month history of a central scotoma was diagnosed with acute macular neuroretinopathy (AMNR). Her symptoms resolved spontaneously, only to recur 2 years later with progressively worsening visual field deficits that did not improve with a trial of oral prednisone. The authors report a case of AMNR that is distinguished from other reports by its recurrence in the same eye after complete resolution of the first episode. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:962-968.].

A systematic review of shunt-related extraneural metastases of primary central nervous system tumors.

Extraneural metastasis (ENM) of primary central nervous system (CNS) tumors is an uncommon occurrence. Case reports and case series describe ENM after shunting, but this phenomenon has not been well characterized. In this review we aim to better understand the risk factors and clinical implications of ENM associated with shunting. A literature search of cases of ENM related to shunt placement in patients with primary CNS tumors reported through January 2018 was performed using PubMed and Google Scholar. We identified 106 cases of ENM of primary CNS tumors related to shunt placement. The three most common tumor histologies resulting in ENM were germinoma (24%), medulloblastoma (21%), and glioblastoma (11%). Of the patients with ENM, 48% had leptomeningeal spread and 37% had brain or spinal cord metastasis. Mean survival time from shunt placement was 13 months. Ventriculoatrial-shunted cases had higher rates of widespread metastasis and shorter average survival time from shunt placement (2 months) than the average of all types of shunts. Given the known association with ENM, careful consideration should be given to shunt placement in patients with primary CNS tumors, especially germinomas, medulloblastomas, and glioblastomas. Appropriate surveillance should be instituted after shunt placement, and leptomeningeal or neural metastasis should prompt the consideration of potential ENM. When considering distal shunt options, our review suggests that ventriculoatrial shunts should be avoided if possible. For truly obstructive pathologies, the risk of ENM is a further indication to consider other treatment options such as endoscopic third ventriculostomy rather than shunt placement.

Subepidermal Calcinosis in the Ocular Adnexa: A Systematic Review.

PURPOSE: To review the clinical and histopathologic findings associated with subepidermal calcinosis of the eyelids. METHODS: A systematic review of the literature on subepidermal calcinosis of the eyelids was performed. Cases included were idiopathic in nature and met the histologic criteria for subepidermal calcinosis with calcium deposits in the dermis of the skin. RESULTS: Twenty-one publications presenting 53 cases of subepidermal calcinosis involving the eyelids were published between 1970 and 2016. Males were affected more than females (67% vs. 33%), and 89% of patients were 21 years of age or younger. A total of 63% were non-Caucasian. Most cases involved a single lesion (82%), and lesions were most frequently located on the upper eyelid (63%). In 81% of cases, the lesion was less than 5 mm in diameter. When reported, the treatment of choice was complete surgical excision. CONCLUSIONS: Subepidermal calcinosis should be considered in the differential diagnosis of idiopathic lesions on the eyelid, particularly in young males with no history of systemic disease or laboratory abnormalities. These nodules usually present as painless, small, firm, mobile solitary cutaneous lesions with a predilection for the upper eyelid. Diagnosis is confirmed by histopathology, and treatment is with surgical excision.

A Rare Ocular Presentation of Metastatic Lung Cancer: Unilateral Anterior Chamber Angle, Bilateral Choroidal, and Multiple Intracranial Metastases.

A 64-year-old man who presented with photopsia was found to have elevated intraocular pressure in one eye and optic disc swelling in the other eye. He was initially diagnosed with neurocysticercosis and later metastatic lung adenocarcinoma. The purpose of this paper is to report a rare case of bilateral glare as the first sign of diffusely metastatic cancer and to raise clinical suspicion for systemic malignancy in the presence of multiple ocular manifestations.

Refractory open-angle glaucoma after neodymium-yttrium-aluminum-garnet laser lysis of vitreous floaters.

PURPOSE: To illustrate 3 cases of chronic open-angle glaucoma secondary to the neodymium-yttrium-aluminum-garnet (Nd:YAG) laser vitreolysis procedure for symptomatic vitreous floaters. DESIGN: Observational case series. METHODS: Location of the study was the Doheny Eye Institute. Three eyes of 2 patients who developed chronic open-angle glaucoma after Nd:YAG vitreolysis for symptomatic floaters presenting with very high intraocular pressure (IOP >40 mm Hg) were selected. The time from the laser treatment to the onset of elevated pressure ranges from 1 week to 8 months. There was no associated inflammation, steroid use, or other identifiable cause of chronic IOP elevation. RESULTS: All eyes were treated initially with glaucoma medication, followed by selective laser trabeculoplasty (SLT) and eventually glaucoma surgery (Trabectome) in 2 eyes for disease management. In all eyes, intraocular pressures were eventually stabilized within a normal pressure range from 18 to 38 months following Nd:YAG vitreolysis. At the latest follow-up post surgery, all eyes had intraocular pressures of 22 mm Hg or less with or without medications. CONCLUSIONS: Secondary open-angle glaucoma is a complication of Nd:YAG vitreolysis for symptomatic floaters that may present with an increase in intraocular pressure immediately, or many months after the surgery. Furthermore this complication may be permanent and require chronic medical therapy or glaucoma surgery.

Methyl-sulfonyl-methane (MSM)-induced acute angle closure.

PURPOSE: To report the first case of presumed bilateral acute angle closure (AAC) secondary to ingestion of the dietary supplement, methyl-sulfonyl-methane (MSM). PATIENT: A 35-year-old woman presented with bilateral AAC 1 week after starting multiple dietary supplements, one of which contained MSM. Ultrasound biomicroscopy demonstrated bilateral anterior rotation of the iris-lens diaphragm, ciliary body edema, and choroidal effusion. Four days after discontinuation of the supplements, her angle closure and uveal effusion resolved, and her best-corrected vision recovered to 20/20 bilaterally. DISCUSSION: Sulfa-based drugs have been reported to cause AAC, choroidal effusion, and ciliary body edema. In our patient, the coincidence of bilateral AAC with choroidal and ciliary body effusion that began 1 week after starting dietary supplements was suspicious for drug-induced AAC. The dietary supplement Basic Detox Nutrients contains MSM, the only constituent in the patient's medication list with a sulfonyl moiety. Given the similarities in chemical structure and clinical presentation, we postulate that MSM induces AAC in a manner similar to mechanisms previously described for other sulfa-based drugs. CONCLUSIONS: As MSM continues to be used and studied for its anti-inflammatory and antioxidative properties, investigators and marketers will need to be cognizant of its potential to cause AAC and provide proper warning to consumers.