Poor Visual Outcomes in Syphilitic Uveitis Associated with Methamphetamine Use: A Case Series.

PURPOSE: This study aimed to investigate the potential link between methamphetamine use and infectious syphilitic uveitis through a retrospective chart review of four patients with both conditions. METHODS: A retrospective chart review was conducted on four patients with a prior history of methamphetamine use and presented with vision loss at an emergency room or clinic that was ultimately diagnosed as syphilitic uveitis. RESULTS: The average age of the four patients was 41.5 ± 9.8 years old, and each presented with symptoms of blurry vision after an average of 3 weeks. Clinical and serologic examinations revealed variable severity of syphilitic uveitis in each patient, and a confirmed history of methamphetamine use was found on a review of social history. Each patient had worsening visual outcomes after the initial presentation and diagnosis. CONCLUSION: Syphilitic uveitis is a challenging diagnosis due to its similarity with other ocular pathologies. This case series highlights the importance of maintaining a high level of suspicion for syphilis in patients with a history of methamphetamine use and uveitis to enable rapid treatment and prevent visual decline. The poor visual outcomes observed in these four patients underscore the significance of identifying and treating syphilitic uveitis promptly in this population and the barriers to treatment completion.

Suspected Neratinib Macular Toxicity Presenting As Macular Telangiectasia Type II.

The purpose of this case report is to present the first case of neratinib maculopathy. We describe the initial presentation, baseline characteristics, imaging findings, and outcomes. The case report is accompanied by a thorough literature review including possible mechanisms of tyrosine kinase inhibitor (TKI) maculopathy. Neratinib is a novel TKI that is commonly used in the treatment of breast-associated malignancies. Neratinib toxicity presents similarly to macular telangiectasia type II but differs with the fine granular hypofluorescent areas spanning the limit of the posterior pole and vascular arcades as well as the nasal aspect of the optic nerve.  We report a case of suspected macular toxicity secondary to neratinib. Concomitant use of neratinib in conjunction with docetaxel and other chemotherapeutics with known retinal side effects should alert clinicians of an increase in the risk of macular toxicity. Albeit commonly reported ocular side effects of TKIs, maculopathy is a rare and potentially overlooked side effect. Patients that have planned chemotherapy should undergo a baseline retinal examination.

A Case of Frosted Branch Angiitis in the Age of Polymerase Chain Reaction: Diagnostic and Therapeutic Considerations.

To describe a unique case highlighting the limitations and caveats of multiplex polymerase chain reaction (mPCR) in the diagnosis of posterior infectious uveitis, specifically frosted branch angiitis (FBA), we present a case of FBA in which multiple diagnostic modalities, including mPCR, are inconclusive. A thorough literature review was carried out to discuss the validity of mPCR in the setting of posterior infectious uveitis, the theoretical effect of sample dilution, and to explore a management strategy in these difficult cases. It is known that mPCR has high sensitivity and specificity, with a low false negative rate. However, the rate of false negatives appears to increase in cases of FBA, and when samples are diluted. In such cases we suggest empiric treatment be initiated and targeted towards microorganisms most likely to be implicated based on exam and history.

Successful Use of Intravitreal Bevacizumab and Methotrexate in a Case of Neovascularization of the Iris and Pseudohypopyon Secondary to Recurrent Diffuse Large B-Cell Lymphoma.

In this case report, we aim to describe a rare case of recurrent diffuse large B-cell lymphoma (DLBCL) reportedly in remission presenting with primary anterior segment findings and use of intravitreal bevacizumab and methotrexate to treat the sequelae. The patient presented with hypopyon and neovascularization of the iris (NVI). Anterior chamber studies including flow cytometry and imaging revealed DLBCL recurrence with central nervous system (CNS) involvement. Over one month, he was treated with one intravitreal injection of bevacizumab, repeat injections of methotrexate, and systemic therapies with the resolution of ocular symptoms but persistent systemic disease. This case highlights the utility of anterior chamber paracentesis in diagnosis and intravitreal bevacizumab and methotrexate in the treatment for anterior segment manifestations of intraocular lymphoma (IOL).

Baseline retinal thickness measurements with a novel integrated imaging system (concurrent optical coherence tomography and fundus photography) positively correlates with spectralis optical coherence tomography.

BACKGROUND: Traditionally fundus photographs and optical coherence tomography (OCT) are obtained separately during evaluation of retinal pathology. We describe a novel integrated imaging system (Monaco, Optos) that records both OCT as well as fundus photography concurrently. The present study aims to measure retinal thickness and compare it to OCT obtained with traditional spectral domain OCT in subjects without known retinal disease to establish normative data for clinical use. METHODS: In this cross sectional study, fundus photographs and OCT was obtained concurrently in 34 eyes in healthy patients without any known retinal disease with integrated imaging system. OCT with spectralis was also obtained at the same visit for comparison. All subjects underwent a complete ophthalmologic exam to ensure the absence of ocular pathology. OCT was performed by the same operator. Central subfield thickness (CST), central point thickness (CPT), and retinal thickness in nine central subfields were measured with both 1 instruments. Fundus photographs were obtained. Students t-test was used to determine statistical significance. RESULTS: The mean CST as measured with MIIS-SD OCT and Spectralis OCT was 300.53±22.81 µm and 265.18±17.33 µm (P<0.001) respectively. The Pearson's correlation coefficient, r value was 0.5285, P<0.0013. The mean CPT as measured with MIIS-SD OCT and Spectralis OCT was 268.55±20.70 and 230.67±17.75 µm (P<0.001) respectively. The r-value was 0.5697, P<0.0004. The mean difference between retinal thicknesses was 44.88 µm (range, 21-91 µm) in the eight ETDRS subfields, with r value 0.53, P<0.05, ranging from 0.51 to 0.60. Concurrently obtained ultrawide angle fundus photographs revealed (200°) clear media, normal disc, normal vasculature and normal periphery in all patients with excellent resolution. CONCLUSIONS: Retinal thickness measurements strongly correlated with those obtained by Spectralis. An increased measurement in thickness of 35.35 µm was noted in the central fovea. In addition, wide-angle fundus photography was successfully obtained in all subjects. Integrated system provides quality fundus photographs as well as OCT, obviates the need for two separate instruments and likely improves the clinic flow.

Successful Management of Complex Rhegmatogenous Retinal Detachment in Congenital Glaucoma.

 Retinal detachment in congenital glaucoma is rare and often associated with a poor prognosis. In this report, we describe ocular manifestations of congenital glaucoma, pre- and post-operative ophthalmic findings, and overall anatomic and functional outcomes after successful rhegmatogenous retinal detachment repair along with a review of the literature. Rhegmatogenous retinal detachment in a 45-year-old monocular patient with congenital glaucoma was successfully repaired with small gauge pars plana vitrectomy, intra-operative perfluorocarbon use and 1,000 centistoke silicone oil tamponade. Best-corrected visual acuity improved from CF to 20/70; however, the post-operative course was complicated by hypotony-associated maculopathy after removal of silicone oil. Five thousand centistoke silicone oil was reinfused with good anatomic and functional outcomes. The functional outcome may ultimately be limited by pre-existing amblyopia and other ocular comorbidities.

Allergic fungal sinusitis masquerading as cavernous sinus thrombosis.

Allergic fungal sinusitis (AFS), a noninvasive form of fungal sinusitis, is rarely seen in immunocompetent patients. Involvement of sphenoid sinus can result in proptosis and loss of vision. We report AFS masquerading as posterior cavernous sinus syndrome. A 59-year-old African-American man presented with right complete ptosis with ophthalmoplegia. After an initial work-up and imaging studies, patient underwent endonasal sphenoid surgery, which revealed characteristic 'allergic fungal mucin'. Cavernous sinus syndrome is a rare presenting clinical feature of allergic fungal sinusitis. Ophthalmologists should be aware of this rare presentation of relatively common otorhinological disease for timely referral and appropriate management.

Ultra wide field angiography documented peripheral retinal eovascularization as cause of vitreous hemorrhage after scleral buckle surgery.

We describe an unusual case of ultra wide fluorescein angiography (UWFA) documented peripheral retinal neovascularization (NVE) with delayed vitreous hemorrhage after placement of an encircling scleral buckle (a common procedure for repair of retinal detachment). Anterior segment ischemia is a rare complication after scleral buckle surgery for the treatment of retinal detachment and results from altered choroidal flow through the impingement of the anterior and long posterior ciliary arteries. UWFA performed for the evaluation of vitreous hemorrhage confirmed ischemia anterior to the scleral buckle and consequential NVE. This case represents the utility of UWFA in evaluating and managing this exceptionally rare complication associated with a common procedure in the field of vitreoretinal surgery.

Pazopanib Selectively Inhibits Choroidal Vascular Endothelial Cell Proliferation and Promotes Apoptosis.

Exudative age related macular degeneration (AMD) is related to active choroidal neovascularization (CNV) and formation of disciform scars. Vascular endothelial growth factor (VEGF) mediated choroidal vascular endothelial cell (CVECs) proliferation is characteristic of CNV. Intravitreal injections of bevacizumab, ranibizumab and aflibercept (anti-VEGF monoclonal antibodies) are used to treat exudative AMD. Pazopanib, a tyrosine kinase inhibitor, inhibits neovascularization through blockade of intracellular tyrosine kinase VEGF receptor and platelet-derived growth factor receptor. In this in vitro investigation, we evaluated the inhibitory consequences of escalating doses of pazopanib on proliferation of VEGF-enriched CVECs to establish a safe dosage range. VEGF (50 ng/mL) enriched CVECs were treated with escalating doses of pazopanib (10, 50,100 and 250 µM). Cell proliferation rates (WST-1 assay), cell viability (trypan blue exclusion assay), and reactive oxygen species (ROS) levels were measured at 48 hours (h), 72h and 1 week. Intracellular caspase 3 levels and morphological changes were recorded. VEGF enriched CVECs showed a significant decrease in cell proliferation rates after one week of treatment with increasing doses of pazopanib (10, 50,100 and 250 µM) treatment i.e. 87.8%, 43.0%, 38.1% and 9.3% compared to controls (p<0.001). Similarly, trypan blue exclusion assay revealed a decrease in cell viability as 81.8%, 81.0%, 53.4% and 8.7%, respectively (p<0.05). Further, pazopanib actively inhibited proliferation of VEGF-enriched CVECs, with 1.32, 1.92, 1.92 and 4.1-fold increase (p<0.01) in intracellular caspase 3 levels. VEGF-enriched CVECs treated with escalating doses of pazopanib decreased cell viability and increased caspase 3 levels in a time and dose dependent manner.

Towards a medical aesthetic and its performative nature.

Beyond the techniques and instruments it employs, medicine has an intrinsic value that enables it to be interpretative, dramatic, and above all, real. In this essay, the aesthetic that emerges through the medical examination is thoroughly discussed. The piece deconstructs the qualities of the medical examination in a manner that facilitates medical practice to be perceived as an art form. The signifiers found in a medical diagnosis and its aesthetic consequences are reviewed. The nature of the diagnosis positions medical practice as a dramatic art.