BILATERAL CHOROIDAL METASTASIS WITH CONCURRENT UNILATERAL RHEGMATOGENOUS RETINAL DETACHMENT IN A PATIENT WITH STAGE IV BREAST CANCER.

PURPOSE: To describe an unusual case of bilateral choroidal metastasis with simultaneous rhegmatogenous retinal detachment in the right eye. METHODS: Case Report. PATIENT: A 65-year-old woman with Stage IV breast cancer and gradual deterioration of vision in the right eye. RESULTS: Dilated fundus examination of the right eye revealed a large solitary choroidal mass with exudative retinal detachment and with an incidental discovery of a lower peripheral break with subretinal fluid, and the left eye revealed multiple choroidal masses. The diagnosis of bilateral CM was confirmed using optical coherence tomography. Pars plana vitrectomy with silicone oil injection was performed for the right eye followed by external beam radiotherapy to both choroids, which resulted in anatomical and visual success for 6 months. CONCLUSION: Prompt ophthalmologic evaluation is a must in patients with advanced breast or lung malignancy with recent blurring of vision. External beam radiotherapy is a safe, available, relatively cheap, and effective means for managing CM. Choroidal metastasis with a concurrent vision-threatening pathology requiring intraocular surgery represents a dilemma, and the risks and benefits should be weighed carefully with proper counseling of the patient.

Bacillary layer detachment with malignant choroidal tumors: a case series.

PURPOSE: To study the incidence and characteristics of bacillary layer detachment (BALAD) occurring with the two most common choroidal malignancies, choroidal metastasis and choroidal melanoma. METHODS: A retrospective multicentric record analysis. Eyes with a diagnosis of choroidal melanoma or choroidal metastasis that had good-quality fundus photography and spectral domain optical coherence tomography (OCT) scans of the macular and tumor regions allowing for delineation of the retinal layers were included for analysis. Qualitative image evaluation was done by two independent graders for the presence, location, and OCT features of BALAD, as well as any associated intraretinal or subretinal fluid. Demographic and clinical data were also retrieved. RESULTS: Of the 11 eyes with choroidal metastasis and 7 eyes with choroidal melanoma that were included in the final analysis, 6 (54.5%) and 1 (14.3%) had BALAD, respectively. The BALAD co-localized with the subretinal fluid in all cases and with the intraretinal fluid in 1/3 cases (33.3%), was foveal in location in 3 eyes (42.9%), was overlying the tumor in 6 eyes (85.7%), and varied in number and size. Reflectivity within the BALAD was consistently higher than the vitreous and adjacent subretinal fluid, and discernable suspended hyperreflective particles were noted in 5 eyes (71.4%). CONCLUSION: BALAD is relatively common with choroidal metastasis. The OCT features described supplement our recognition of this new entity.

Clinical and multimodal imaging characteristics of eyes with Vogt-Koyanagi-Harada disease: An Egyptian experience.

BACKGROUND: Vogt-Koyanagi-Harada (VKH) disease is a vision-threatening inflammatory disorder that is challenging in diagnosis and management. METHODS: Retrospective, record-based analysis of 54 eyes belonging to 27 adult patients that fulfilled the revised diagnostic criteria for VKH between January 2018 and January 2021. Demographic, clinical, and imaging data on presentation and during follow-up visits were collected for each patient. Available imaging studies included B-scan ultrasonography (B-scan US), spectral domain optical coherence tomography (OCT), fundus fluorescein angiography (FFA), and OCT angiography (OCT-A). RESULTS: The female-to-male ratio was 2.38:1. Nineteen patients (70.37%) presented during an initial attack, while eight patients (29.63%) presented during recurrence. The most commonly presenting sign in the posterior segment was exudative retinal detachment (44 eyes, 81.48%). B-scan US was utilized in 4 eyes (7.41%), OCT was utilized in 48 eyes (88.89%) with the most common finding being subretinal fluid (43 eyes, 89.58%), FFA was performed in 39 eyes (72.22%) with the most common finding being punctate hyperfluorescence and late dye pooling (33 eyes, 84.62%), and OCT-A was performed in 30 eyes (55.56%), in which choriocapillaris flow deficit that correlated with disease activity was detectable in 25 eyes (83.33%). Improved visual acuity was noted in 85% of the eyes that were followed up. CONCLUSION: Early diagnosis and treatment of VKH result in favorable visual outcome. Multimodal imaging, with the recent addition of OCT-A, provides complementary data that could serve in diagnosis and monitoring.

Methanol Intoxication Presenting With Bilateral Optic Neuritis and Paracentral Acute Middle Maculopathy.

A 52-year-old male presented nine days following accidental methanol ingestion with a drop of vision in both eyes. A complete ophthalmic assessment was performed, with a referral to a neurologist for multidisciplinary management. On ophthalmological evaluation, visual acuity was hand motion (HM) bilaterally with swollen optic discs. Macular optical coherence tomography (OCT) showed a picture consistent with paracentral acute middle maculopathy (PAMM) in both eyes, and brain magnetic resonance imaging showed ischemic insults. Slight visual improvement was detected following steroid and antiplatelet therapy. At two months of follow-up, bilateral optic atrophy ensued. Special attention must be given to the macular assessment and not just the optic nerve when considering a case of methanol toxicity, as methanol intoxication can lead to ischemic manifestations.

Autosomal Recessive Bestrophinopathy Presenting With a Macular Hole Retinal Detachment.

Purpose: To report a case of autosomal recessive bestrophinopathy (ARB) that presented with macular hole retinal detachment (MHRD). Methods: A case report. Results: A 31-year-old male patient presented with rapid deterioration of vision in the left eye. On fundus examination, bilateral retinal deposits in both eyes, which were brightly hyperautofluorescent, and an MHRD in the left eye could be detected. An electrooculogram demonstrated absent light rise with abnormal Arden's ratio in both eyes. The patient was offered surgery for the MHRD but refused due to the guarded visual prognosis. Follow up of the patient after one year revealed progression of the retinal detachment. Genetic testing revealed a novel, homozygous missense mutation in the BEST1 gene, confirming the diagnosis of ARB. Conclusion: ARB can present with an MHRD. Counseling patients with inherited retinal dystrophies about the visual prognosis following surgical intervention is important.

Navigated perilesional transcranial magnetic stimulation can improve post-stroke visual field defect: A double-blind sham-controlled study.

BACKGROUND: Visual field defects (VFD) usually do not show improvement beyond 12 weeks from their onset. It has been shown that repetitive presentation of a stimulus to areas of residual vision in cases of visual field defect can improve vision. The counterpart of these areas in the brain are the partially damaged brain regions at the perilesional areas where plasticity can be enhanced. OBJECTIVE: We aimed to study the effect of navigated repetitive transcranial magnetic stimulation (rTMS) applied to perilesional areas on the recovery of patients with cortical VFD. METHODS: Thirty-two patients with cortical VFD secondary to stroke of more than 3 months duration received 16 sessions of either active or sham high frequency navigated perilesional rTMS. Automated perimetry and visual functioning questionnaire (VFQ-25) were performed at baseline and after completion of the sessions. RESULTS: The active group showed significant improvement after intervention, compared to the sham group, in both mean deviation (MD), visual field index (VFI) and in the VFQ-25 scores. CONCLUSIONS: Navigated rTMS is a new treatment option for post-stroke VFD as it can selectively stimulate areas of residual vision around the infarcted tissue, improving the threshold of visual stimulus detection which could be used alone or in combination with existing therapies.

Experience with Intravitreal Ranibizumab as an Adjunct to Ablation Therapy in Eyes with Exudative Coats' Disease.

BACKGROUND: Coats' disease is a rare entity with retinal vascular telangiectasia that can progress to exudative retinal detachment, neovascular glaucoma, and a blind painful eye requiring enucleation. Despite recent therapeutic advances decreasing the need for enucleation, no consensus exists about the optimum management of exudative Coats' disease. The use of intravitreal anti-vascular endothelial growth factor agents as an adjunct to ablation therapy has been shown to achieve favorable outcomes, but some reports suggest an increased incidence of vitreoretinal (VR) fibrosis and tractional retinal detachment (TRD). METHODS: We retrospectively reviewed records of patients presenting with exudative Coats' disease (stages 2 and 3) from April 2016 till November 2020. Extracted data included clinical and radiological assessment, stage (Shields' classification), interventions, and follow-up. RESULTS: Sixteen eyes were included in the final analysis, of which 4 (25%) were stage 2 and 12 (75%) were stage 3. All eyes underwent intravitreal ranibizumab injection combined with ablation therapy, 14 (87.5%) underwent cryotherapy, 4 (25%) underwent laser ablation, 3 (18.75%) underwent external subretinal fluid drainage, and 3 (18.75%) underwent buckle or vitrectomy surgery. After a median follow-up of 16 months, 11 eyes (68.75%) had complete resolution, 4 (25%) had incomplete resolution, and only one (6.25%) progressed but did not require enucleation. Three eyes (18.75%) developed VR fibrosis, but none progressed to TRD. CONCLUSION: Combining intravitreal ranibizumab injection with ablation therapy is effective in managing exudative Coats' disease. External drainage should be preserved for when ablation therapy is not feasible. Future prospective trials with pre-defined outcomes are required.

Autologous Retinal Transplantation for Primary and Refractory Macular Holes and Macular Hole Retinal Detachments: The Global Consortium.

PURPOSE: To report the anatomic and functional outcomes of autologous retinal transplantation (ART). DESIGN: Multicenter, retrospective, interventional, consecutive case series. PARTICIPANTS: One hundred thirty eyes of 130 patients undergoing ART for the repair of primary and refractory macular holes (MHs), as well as combined MH-rhegmatogenous retinal detachment (MH-RRD), between January 2017 and December 2019. METHODS: All patients underwent pars plana vitrectomy and ART, with surgeon modification of intraoperative variables. A large array of preoperative, intraoperative, and postoperative data was collected. Two masked reviewers graded OCT images. Multivariate statistical analysis and subgroup analysis were performed. MAIN OUTCOME MEASURES: Macular hole closure rate, visual acuity (VA), external limiting membrane and ellipsoid zone (EZ) band integrity, and alignment of neurosensory layers (ANL) on OCT. RESULTS: One hundred thirty ART surgeries were performed by 33 vitreoretinal surgeons worldwide. Patient demographics were: mean age of 63 ± 6.3 years, 58% female, 41% White, 23% Black, 19% Asian, and 17% Latino. Preoperative VA was 1.37 ± 0.12 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, approximately 20/500), which improved significantly to 1.05 ± 0.09 logMAR (Snellen equivalent, approximately 20/225; P < 0.001) after surgery (mean follow-up, 8.6 ± 0.8 months). Autologous retinal transplantation was performed for primary MH repair in 27% of patients (n = 35), for refractory MH in 58% of patients (n = 76; mean number of previous surgeries, 1.6 ± 0.2), and for MH-RRD in 15% of patients (n = 19). Mean maximum MH diameter was 1470 ± 160 µm, mean minimum diameter was 840 ± 94 µm, and mean axial length was 24.6 ± 3.2 mm. Overall, 89% of MHs closed (78.5% complete; 10% small eccentric defect), with a 95% closure rate in MH-RRD (68.4% complete; 26.3% small eccentric defect). Visual acuity improved by at least 3 lines in 43% of eyes and by at least 5 lines in 29% of eyes. Reconstitution of the EZ (P = 0.02) and ANL (P = 0.01) on OCT were associated with better final VA. Five cases of ART graft dislocation (3.8%), 5 cases of postoperative retinal detachment (3.8%), and 1 case of endophthalmitis (0.77%) occurred. CONCLUSIONS: In this global experience, patients undergoing ART for large primary and refractory MHs and MH-RRDs achieved good anatomic and functional outcomes, with low complication rates despite complex surgical pathologic features.