Macular dual retinitis with Herpes simplex and Cytomegalovirus following periocular corticosteroid in a patient of Pemphigus Vulgaris.

BACKGROUND: Cytomegalovirus (CMV) retinitis may occur in non-HIV individuals following systemic immunosuppressive treatment or periocular corticosteroid administration. However, simultaneous multiple viral retinitis is rare in HIV-negative individuals. We report a case of dual viral retinitis in a non-HIV female on systemic immunosuppressive for pemphigus vulgaris who was administered a periocular corticosteroid injection. METHOD: A 32-year-old female on double immunosuppressive therapy (prednisolone and cyclophosphamide) for pemphigus vulgaris, presented with gradual painless diminution of vision in the right eye for one month. She was initially diagnosed to have possible autoimmune neuroretinitis by the referring ophthalmologist and received a single injection of posterior subtenon triamcinolone acetonide for the same. Her vision however deteriorated further and she received an intravitreal ganciclovir injection with a revised diagnosis of CMV retinitis. Due to suboptimal response she was referred to us. Aqueous Polymerase chain reaction (PCR) revealed dual positivity for CMV and Herpes simplex virus. She was successfully managed with intravitreal ganciclovir injections, systemic acyclovir and tapering of systemic immunosuppressive drugs. RESULT: The retinitis lesions resolved gradually leaving behind a pale optic disc and foveal atrophy at 12 weeks follow-up. CONCLUSION: Infective etiology must be ruled out in immunosuppressed patients before considering periocular corticosteroids. Dual viral involvement, although rare, may cause fulminant retinitis in predisposed individuals. High index of suspicion and PCR from ocular fluids should be performed at the earliest in patients with atypical or poorly responding retinitis lesions.

Optical coherence tomography angiography-guided diagnosis of a traumatic choroidal rupture-associated choroidal neovasular membrane and its management with intravitreal ranibizumab.

A 25-year-old female presented with sudden onset diminution of vision in the right eye (oculus dextrus [OD]) following blunt trauma after a sports injury. Ocular examination revealed best-corrected visual acuity (BCVA) of 20/30 in OD and fundus revealed commotio retinae, localized preretinal bleed, and a large choroidal rupture (CR). She was managed conservatively at that moment. Three months following trauma, she returned with further deterioration of BCVA (20/80) in OD. Optical coherence tomography angiogram (OCTA) confirmed the presence of choroidal neovascular membrane (CNVM). She was treated with single intravitreal ranibizumab injection. Repeat OCTA after 6 weeks showed the regression of CNVM. Her BCVA improved to 20/30 at 6 months of follow-up. In the index report, we present a unique OCTA guided the diagnosis of posttraumatic CR-associated CNVM and its successful management with single intravitreal ranibizumab.

Cobalt blue light unit filter - A smartphone attachment for blue light photography.

PURPOSE: The aim of this study was to carry out blue light photography of fluorescein-stained corneas using a novel smartphone attachment. METHODS: A smartphone attachment known as the cobalt blue light unit (C-BLU) was developed. It can filter out all wavelengths of light except the blue light emerging from the flashlight of a smartphone. A pilot study was carried out wherein the images captured with the C-BLU system were compared with slit-lamp photographs of the same patients. This setup was then used to photo document fluorescein-stained corneas in various clinical settings assembled at point-of-care. RESULTS: Many pathologies of the fluorescein-stained cornea were captured using the C-BLU filter. It was used effectively in various settings (remote eye camps, intensive care units (ICU), pediatric group, corneal trauma triaging, etc.). C-BLU was assembled and used by optometrists and ophthalmology residents. The images captured were used for documenting, assisting in the treatment, and also for telecommunication of the patients' findings. CONCLUSION: C-BLU is a low-cost pocket-size filter which is easy to use with a modern smartphone without any technical expertise needed to obtain a clear image of fluorescein-stained pathological corneas.

Case Report: Foveolitis as an Indicator of Underlying Undiagnosed Dengue Fever.

We describe a case of dengue fever-associated foveolitis that presented initially to the ophthalmologists with complaints of unilateral diminution of vision. A 30-year-old Indian woman had presented with sudden onset diminution of vision in the left eye (LE) for the past 2 days. It was also associated with low-grade fever and myalgia, which started few days before visual deterioration. Fundus showed few retinal hemorrhages and tiny subretinal yellowish lesions at the fovea in the LE. Optical coherence tomography and fluorescein angiography were indicative of foveolitis. Amsler charting showed a central scotoma in the LE. She was treated with oral steroids along with supportive treatments. A near-complete anatomical and functional recovery was noted. Our case depicts the significance of awareness of the ophthalmic complications of dengue fever among both ophthalmologists and physicians, and also highlights the key clinical and multimodal imaging findings in a case of dengue foveolitis.

Alport syndrome with bilateral simultaneous anterior and posterior lenticonus with severe temporal macular thinning.

Alport syndrome (AS) is a hereditary disease with various modes of inheritance, X-linked being the the most common. Anterior lenticonus is the characteristic abnormality along with perimacular and peripheral fleck retinopathy. Our two cases of AS had simultaneous anterior and posterior lenticonus with severe temporal macular thinning on optical coherence tomography with no specific renal symptomatology and were diagnosed as AS without any invasive renal biopsy. First patient was a 19-year-old man who presented with compound myopia due to bilateral anterior and posterior lenticonus with perimacular fleck retinopathy and lozenge sign and bilateral moderate sensorineural hearing loss (SNHL). Second patient was a 24-year-old man who presented with difficulty in vision due to bilateral anterior and posterior lenticonus with bilateral severe SNHL. Our cases emphasise the crucial role of an ophthalmologist in diagnosing AS before the onset of renal symptoms and prompting further nephrological work-up in the patient or the carrier.

Rapidly reversing bilateral macular edema associated with fluid overload in a young type 1 diabetic.

We report a case of sudden onset bilateral diminution of vision in a young lady with type 1 diabetes. She was administered intravenous fluids for correction of diabetic ketoacidosis (DKA) prior to onset of her ocular symptoms. Dramatic resolution of macular edema was noted within a very short period after correction of fluid input-output ratio. Visual acuity was restored to baseline after 3 days without any active ocular intervention.

Chronic Discharging Sinus of Upper Lid Due to the Missed Wooden Foreign Body.

BACKGROUND: Foreign bodies of the orbit can have a diverse range of clinical presentations, which may be perplexing to the most Ophthalmologists. Wooden foreign bodies can remain quiescent for a long time, before presenting with various complications. We report a case of Post-traumatic chronic non-healing discharging sinus in the left upper lid, which on exploration revealed the presence of the missed wooden foreign body. CASE: A 48-year-old male, presented to Ophthalmic OPD with a complaint of discharge from the left upper eyelid for 18 months. The patient had a history of minor trauma to the left upper eyelid while collecting wood in the forest, 18 months back. The patient was misdiagnosed on previous examinations elsewhere. The diagnosis of retained wooden foreign body was made at our center and surgical exploration was done to remove the same. OBSERVATION: On clinical examination, there was a 2-3mm long sinus in the left upper eyelid with purulent discharge and granulation tissue. Surrounding skin showed hyperpigmentation and excoriation. CT scan orbit was inconclusive. MRI orbit revealed a peripherally enhancing extraconal/conal collection in the left orbit with a central hypo intense structure suggestive of a foreign body. Surgical exploration of the wound was done and a small wooden foreign body measuring 9mm was removed with excision of the sinus tract. CONCLUSION: A history of trauma followed by chronic discharging sinus should evoke suspicion of a retained foreign body. Prompt imaging, followed by surgical exploration should be done to prevent misdiagnosis and inappropriate management.