Unilateral hypertensive choroidopathy as a sole manifestation in malignant hypertension: optical coherence tomography angiography findings-case report.

BACKGROUND: We present a case of hypertensive choroidopathy due to malignant hypertension with exudative retinal detachment as a sole finding. We use OCT- angiography for initial diagnosis and report findings from extensive follow up. CASE PRESENTATION: A 51-year-old female with no past medical history, presented to our clinic with painless loss of vision in her left eye. Fundus examination revealed only exudative retinal detachment in her left eye that was confirmed with Optical Coherence Tomography. Fluorescein angiography showed hyperfluorescent spots with leakage in late phases. OCTA manifested a focal dark area in the choriocapillaris slab corresponding to flow signal voids, signifying regions of non-perfusion. Her blood pressure was 220/120 mmHG. Complete blood work -up failed to reveal any other possible etiology. During follow-up period of 9 months blood pressure normalized, patient regained visual function and choriocapillaris perfusion was completely restored. DISCUSSIONS AND CONCLUSIONS: Hypertensive choroidopathy with exudative retinal detachment can be the only sign of malignant hypertension and no pre-existing history of a systemic disease is required in order to become apparent. OCTA reveals areas of non-perfusion at choriocapillaris level, proving that it is an essential tool in the diagnosis and follow up of patients with hypertensive choroidopathy. Finally, we propose that early diagnosis prevents permanent damage of the RPE and leads to complete choroidal remodeling and better visual outcomes.

Long-Term Outcomes following Intravitreal Ranibizumab for Choroidal Neovascularization Related to Nd:YAG Laser Macular Injury: A Case Report.

Choroidal neovascularization (CNV) secondary to Nd:YAG laser macular injury consists of a rare condition without standardized treatment. Herein, we present the long-term outcomes of a case with a spontaneous closure of a laser-associated macular hole that was followed by late-onset CNV and was successfully treated with intravitreal ranibizumab. A 32-year-old man suffered a macula injury in his right eye after accidental exposure to an 800-nm wave length Nd:YAG laser pulse. Ophthalmological examination demonstrated deterioration in visual acuity along with parafoveal and post-hyaloid hemorrhage. After 1 month, fundoscopy indicated the formation of a full-thickness macular hole. A close observation revealed spontaneous closure of the hole and visual improvement within the next month. One and a half year later, the patient presented with sudden visual distortion, while optical coherence tomography and fluorescein angiography disclosed the development of CNV. The patient was successfully treated with a single intravitreal injection of ranibizumab. The patient's condition has remained stable during an 8-year follow-up period. In conclusion, laser-induced macular injury consists of an increasingly remarkable condition that may have a profound impact on visual outcomes. Our case provides insight into the potential mechanisms of Nd:YAG laser injury and its complications, indicating that CNV may occur even in the long term, while anti-vascular endothelial growth factor may help maintain stable anatomic and functional outcomes.

A Novel Modified Surgical Approach for FIL SSF Lens.

This study aimed to describe a novel modified surgical technique for FIL SSF lens (Rome, Italy: Soleko) implantation. A retrospective study of FIL SSF lens implantation on six eyes of six patients with subluxated or dislocated intraocular lens (IOL). Standard pars plana vitrectomy (PPV) was performed in all patients. The subluxated or dislocated IOL was removed from a 2.4 corneal incision. From the same incision, the folded FIL SSF lens was inserted. Then lens plugs were extremized through a 23G scleral incision inside two 4 mm pockets that were created at the beginning of the operation. In two cases one pocket had to be converted into a triagonal-shaped scleral flap. All scleral pockets were sutured with 7.0 Vicryl suture and the conjunctiva with 7.0 Vicryl. In the follow-up period of six months, the lens is centered and not tilted. The refractive outcome is within the expectations. Visual acuity is improved in all patients. No haptic exposure and no other complications were noted in all cases. FIL SSF lens is a good option for treating aphakia. This modified implantation technique is safe, fast, and easy. It is also versatile, combining the advantages of both previously described techniques, as it gives the option of flap conversion if needed. Larger studies and prospective comparative studies can highlight the best and more appropriate technique.

A Corneal Perforation Related to Beauveria Bassiana and Post-Penetrating Keratoplasty Management Discussion.

Fungal keratitis is an infection that is insidious and frequently misdiagnosed. Those with chronic eye surface conditions, contact lenses, systemic immunosuppression, and diabetes have been the most frequently affected with fungal keratitis. An 84-year-old male patient with a history of bilateral penetrating keratoplasty (PK) for keratoconus presented with pain and decreased visual acuity on his left eye. A corneal perforation was found, which was treated immediately with a full-thickness corneal transplant. The specimen was sent for bacterial and fungal cultures. Topical corticosteroids were prescribed postoperatively. Beauveria bassiana was isolated from the corneal scrapings. The postoperative treatment was modified by reducing the dose of corticosteroid and adding topical natamycin together with systemic posaconazole. No recurrence occurred in the transplant four months postoperatively under topical dexamethasone 0.1% b.i.d.  This is the first case of keratitis and perforation in a previously transplanted cornea. Due to the rarity of the infection, there are no clear guidelines for postoperative prophylaxis in B. bassiana infection. Either the continuation of corticosteroids or the switch to another immunosuppressive therapy and selecting the appropriate antifungal regimen posed a significant therapeutic dilemma.

Progressive External Ophthalmoplegia Diagnosed in the Glaucoma Clinic: The Importance of a Complete Clinical Examination.

PURPOSE: To present a case of chronic progressive external ophthalmoplegia (CPEO) diagnosis in the setting of a busy glaucoma clinic. MATERIALS AND METHODS: Case report. RESULTS: A 70-year-old-female presented to our glaucoma clinic concerned on her glaucoma status. She was previously followed-up elsewhere. Her past ophthalmic history included a diagnosis of normal tension glaucoma 10 years earlier for which she was on topical anti-glaucoma medication. On inspection, symmetrical ptosis was noted and when she was asked about her family history, she reported that 4 members of her family had "problems with moving their eyes" as she also had from a young age. Her best corrected visual acuity was 20/100 in her right eye (RE) and 20/80 in her left eye (LE). Optic discs had normal margins with peripapillary atrophy and cup/disc ratio was 0.7 RE and 0.8 LE. Intraocular pressure was 10mmHg bilaterally. Ocular motility examination revealed severe restriction in all directions of gaze. She had mild alternating exotropia but she did not report any diplopia. Based on her family history, bilateral ptosis, ophthalmoplegia and reported symptoms, the diagnosis of CPEO was made. CONCLUSION: In the setting of a busy subspecialty clinic, it is common for clinicians to focus on a specific pathology and overlook additional signs and symptoms that represent a second often unrelated condition. Our case highlights the importance of a thorough assessment including history taking (general, ophthalmic and family), good documentation of symptoms and an adequate clinical examination.

Traumatic Aniridia and Aphakia Management with Iris Reconstruction Lens Using Gore-Tex Sutures, an Ab-Externo Approach.

BACKGROUND A safer and more delicate approach is required for the management of a post-traumatic aphakia and subtotal aniridia. CASE REPORT A 55-year-old man was referred to our clinic with symptoms of decreased vision (hand motion) and photophobia in his right eye. This patient had previously undergone pars plana vitrectomy (PPV) for the management of blunt ocular trauma in the same eye. He was being treated with topical antihypertensives, due to silicone oil-induced glaucoma. On presentation, the best corrected visual acuity (BCVA) in his right eye was 20/40 and the intraocular pressure (IOP) in the same eye was 20 mmHg. Slit lamp examination of his right eye showed aphakia, aniridia, and some silicone oil droplets (fish eggs) following silicone oil extraction. His corneal endothelium and thickness were within normal limits. Dilated fundoscopic examination of the right eye revealed that the retina was attached with no signs of proliferative vitreoretinopathy (PVR). An artificial iris intraocular lens (IOL) was implanted, along with 4-point scleral fixation in conjunction with Gore-Tex sutures. After 6 months, the BCVA in his right eye was 20/40 and he had no symptoms of photophobia. The IOP in that eye was 15 mmHg while on treatment with dorzolamide-timolol eye drops. No suture-related or other serious complications were observed. The patient expressed satisfaction with the functional and cosmetic results. CONCLUSIONS Modern vitrectomy combined with an artificial iris IOL and scleral fixation with Gore-Tex sutures in eyes lacking an iris and lens can provide long-term anatomic and functional restoration. Intraoperative IOP fluctuations and extra corneal damage can be avoided by lens preparation with the sutures using a small incision ab-externo approach.

The Effect of Eplerenone in Chronic Central Serous Chorioretinopathy Refractory to Photodynamic Therapy.

Purpose: To evaluate the efficacy and safety of oral eplerenone in cases of central serous chorioretinopathy (CSCR) refractory to photodynamic therapy (PDT). Methods: 19 patients with chronic CSCR and persistent subretinal fluid (SRF) were treated with oral eplerenone for 6 months, starting at a dose of 25 mg/day for 4 weeks and then 50 mg/day for 5 months. All patients underwent visual acuity measurement and optical coherence tomography (OCT), while fluorescein angiography was also performed at baseline, before treatment. Resolution of SRF, changes in retinal thickness and BCVA changes at month 6 and 12 post-treatment initiation were assessed. In addition, creatinine and electrolyte test was done on each patient every month for potential complications. Results: Two out of 19 cases were excluded, since one presented with hyperkaliemia 15 days after eplerenone intake and one with skin rash one day after the treatment initiation. At month 12, 88.2% of patients exhibited visual acuity improvement and 76.4% SRF resolution, while in 11.8% of patients SRF remained stable. Conclusions: This study has shown that eplerenone is safe and effective in cases of chronic CSCR, refractory to previous PDT.

Late onset corneal haze after corneal cross-linking for progressive keratoconus.

PURPOSE: To present the case of a patient that underwent corneal crosslinking for progressive keratoconus and 18 months later revealed clinically significant corneal stromal haze. OBSERVATIONS: A 20-year-old male presented with progressive visual loss OU for the past few years. His corrected distance visual acuity (CDVA) OD was 20/30 (-2.75 -1.75 @55) and OS 20/30 (-0.50 -1.75@110). Corneal topography revealed keratoconus OU and the patient underwent corneal crosslinking according to the Dresden Protocol. The postoperative regimen included combined tobramycin and dexamethasone qid along with lubrication until epithelium healed and then fluorometholone qid with weekly tapering. At 3 months postoperatively, his topography was stable and his corrected distance visual acuity (CDVA) was 20/25 OU. On slit lamp examination, only clinically insignificant stromal haze was observed. At 18 months postoperatively, the patient reported vision deterioration. On examination his CDVA was 20/25 in right eye, and 20/40 in his left eye. Deep stromal haze was revealed in his central cornea, more dense in his left eye. Corneal topography was stable and the CDVA loss was attributed to the notable deep stromal haze. The patient was treated with dexamethasone qid with biweekly tapering. 18 months after corneal crosslinking, the patient demonstrated clinically significant stromal haze, most prominent OS. He was treated with dexamethasone qid. One month later his CDVA OS gradually improved to 20/25, and stromal haze was still noted but less dense. CONCLUSIONS AND IMPORTANCE: Late-onset deep corneal haze is a possible complication of corneal crosslinking in keratoconic patients.