OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY OF ACUTE MACULAR NEURORETINOPATHY REVEALS DEEP CAPILLARY ISCHEMIA.

PURPOSE: To present the multimodal retinal imaging findings, including optical coherence tomography (OCT) angiography, of an atypical case of acute macular neuroretinopathy (AMN). METHODS: The multimodal retinal imaging findings, including structural OCT and OCT angiography, of an atypical case of AMN are presented. RESULTS: A 23-year old woman, with a history of an unrelenting sinusitis treated with prednisone therapy and decongestants, presented with an acute scotoma of the right eye. Structural OCT illustrated an area of hyperreflectivity in the outer plexiform and outer nuclear layers nasal to the fovea, with associated disruption of the inner segment ellipsoid band consistent with AMN. At the 2-week follow-up visit, intraretinal fluid was noted with repeat OCT, with spontaneous resolution of the fluid at the 2-month follow-up visit. Optical coherence tomography angiography illustrated a flow void in the deep retinal capillary plexus associated with the AMN lesion. CONCLUSION: Atypical findings of AMN are presented in this case report including the presence and spontaneous resolution of intraretinal fluid. Although OCT angiography illustrated a flow deficit within the deep retinal capillary plexus, the cause of AMN remains elusive.

THE SPECTRUM OF AMALRIC TRIANGULAR CHOROIDAL INFARCTION.

PURPOSE: To describe the multimodal imaging findings, including optical coherence tomography angiography analysis, and spectrum of etiologies associated with Amalric triangular choroidal infarction. METHODS: This study is a multicenter, retrospective, observational case series review of the clinical and multimodal imaging findings for six patients with Amalric triangular choroidal infarction. RESULTS: Six patients (10 eyes) with Amalric triangular choroidal infarction were enrolled. Patients' ages ranged from 7 years to 90 years (mean 54 years, median 60 years). Wedge-shaped or triangular areas of choroidal ischemia were evident with fluorescein angiography in all patients and with indocyanine green angiography in one patient. Optical coherence tomography angiography demonstrated choriocapillaris flow reduction that colocalized with outer retinal structural abnormalities with en face optical coherence tomography and corresponded with the triangular zones of choroidal infarction identified with fluorescein angiography in one patient. Etiologies included giant cell arteritis in three cases: traumatic carotid dissection, traumatic retrobulbar hemorrhage, and malignant hypertension secondary to lupus-associated nephropathy. CONCLUSION: The Amalric triangular syndrome of choroidal infarction can occur as a result of a spectrum of etiologies, especially giant cell arteritis. Infarction is evident on traditional angiography in all cases. Optical coherence tomography angiography may provide a simple noninvasive tool to evaluate choroidal ischemia.

Optical Coherence Tomography Angiography of Deep Capillary Ischemia.

Paracentral acute middle maculopathy (PAMM) is defined by the spectral-domain optical coherence tomography (OCT) finding of paracentral hyper-reflective band-like lesions of the inner nuclear layer (INL) of the macula that progress to corresponding areas of severe INL thinning. En face analysis has enabled more detailed analyses and quantifications of these lesions and has provided insights into the pathogenesis of this abnormality. While there is a wealth of demographic and anatomical data indicating that these PAMM lesions are the result of an INL infarct, OCT angiography is the first modality to provide direct evidence. Several studies have recently shown that old PAMM lesions are indeed associated with ischemia of the deep capillary retinal plexus, while acute lesions may or may not show initial perfusion of the deep capillary retinal plexus.

Assessing Deep Retinal Capillary Ischemia in Paracentral Acute Middle Maculopathy by Optical Coherence Tomography Angiography.

PURPOSE: To assess microvascular blood flow of the deep retinal capillary plexus in eyes with paracentral acute middle maculopathy using optical coherence tomography (OCT) angiography. DESIGN: Retrospective, multicenter observational case series. METHODS: Clinical and multimodal imaging findings from 8 patients with paracentral acute middle maculopathy were reviewed and analyzed. OCT angiography scans were analyzed and processed, and vessel density was calculated. RESULTS: Eight patients (7 male, 1 female, aged 9-82 years) were included. OCT angiography was obtained at either the acute (4 cases) or old stage (4 cases). Scans of the deep capillary plexus showed preservation of perfusion in acute lesions and capillary attenuation in old cases. Cases of central retinal artery occlusion showed marked loss of the deep capillary plexus. The mean vessel density of the superficial capillary plexus in normal fellow eyes was 12.8 ± 1.8 mm(-1) vs 12.1 ± 1.9 mm(-1) in eyes with paracentral acute middle maculopathy (reduction -6.0%, P = .08). The mean vessel density of the deep capillary plexus in normal fellow eyes was 17.5 ± 1.4 mm(-1) vs 14.7 ± 3.5 mm(-1) in eyes with paracentral acute middle maculopathy (reduction -19.4%, P = .04). This significant difference was representative of the eyes with old lesions. CONCLUSION: Paracentral acute middle maculopathy lesions correspond to preservation of perfusion in focal acute lesions and to pruning of the plexus in old cases. Cases of central retinal artery occlusion demonstrate marked hypoperfusion of the deep capillary plexus. Our study further supports an ischemic pathogenesis of this retinal vasculopathy.

Cirrhosis-related coagulopathy resulting in disseminated intravascular coagulation and spontaneous orbital hemorrhages.

A 33-year-old patient presented to our Emergency Department (ED) with left-sided eyelid ecchymoses and edema. A CT scan of the orbits demonstrated a left retrobulbar hemorrhage, prompting an ophthalmology consultation. Upon examination, the patient reported worsening eye pain and decreasing vision in the left eye. Despite aggressive management with superior and inferior lateral canthotomy/cantholysis with placement of an orbital drain, visual loss occurred, and the patient ultimately expired from her systemic condition. Coagulopathy from liver disease resulting in systemic hemorrhage is commonly seen. Orbital hemorrhage in this setting requires emergent diagnosis and management to prevent irreversible compressive optic neuropathy.

Optic disc progression and rates of visual field change in treated glaucoma.

PURPOSE: To investigate the relationship between optic disc progression and rates of visual field (VF) change in patients with treated glaucoma. METHODS: Glaucoma patients with repeatable VF loss, ≥8 SITA-Standard 24-2 VF tests and good quality optic disc stereophotographs evaluated over a 10-year period were included. Optic disc photographs were reviewed for signs of glaucoma progression (neuroretinal rim change, widening of retinal nerve fibre layer defect, disc haemorrhage and enlargement of beta-zone parapapillary atrophy) by two glaucoma specialists masked to their temporal sequence. Disagreements were adjudicated by a third grader. VF progression was evaluated using automated pointwise linear regression (PLR) and defined as at least two adjacent test points progressing >1.0 dB/year at p < 0.01. VF progression outcomes were compared with photograph review results. RESULTS: Three-hundred and eighty nine eyes (389 patients; mean age 64.9 ± 13.0 years; mean baseline MD, -7.1 ± 5.1 dB) were included. Most patients had primary open angle glaucoma (54%). Eighty-two eyes (21%) had confirmed optic disc progression and 115 eyes (29%) met the VF PLR criteria. Eyes with documented optic disc progression had more rapid rates of VF change (-0.66 ± 0.7 versus -0.36 ± 0.7 dB/year, p < 0.01) and met the VF PLR endpoint more often (univariate OR = 1.85, p = 0.02; multivariate OR = 1.78, p = 0.03) than eyes without optic disc progression. There was moderate spatial consistency between the location of the optic disc progression and the hemifield with more rapid progression (81%, kappa = 0.40). CONCLUSIONS: Treated glaucomatous eyes with documented optic disc progression are at increased risk of diminished visual function over time and may require more aggressive therapy to prevent future vision loss. Among the indicators of structural progression, disc haemorrhage was the single most significant predictor for VF deterioration.

Cecocentral scotoma as the initial manifestation of subacute bacterial endocarditis.

INTRODUCTION: We report a case of a 67-year-old male who presented with a cecocentral scotoma caused by a septic embolus from subacute bacterial endocarditis (SBE). METHODS: A 67-year-old man presented with sudden, painless decreased vision in the left eye. A dilated fundoscopic exam, Humphrey visual field test, transthoracic echocardiogram, abdominal computed tomography (CT), and blood cultures were all performed. RESULTS: A dilated fundoscopic exam revealed temporal segmental optic disc pallor on the left, and Humphrey visual field testing demonstrated a dense left cecocentral scotoma. When the patient developed fever (103. 9°F) and palpitations, transthoracic echocardiogram revealed valvular vegetations, and contrast CT of the abdomen revealed an abscess in the dome of the liver likely due to an infectious thrombus. Blood cultures grew viridians group streptococci in three separate peripheral collections. CONCLUSION: This case illustrates that a sudden cecocentral scotoma may be the initial manifestation of SBE.