CYTOMEGALOVIRUS RETINITIS AFTER AN INTRAVITREAL DEXAMETHASONE IMPLANT IN AN IMMUNOCOMPETENT PATIENT.

PURPOSE: To present the case of a 71-year-old woman who developed cytomegalovirus retinitis after the administration of an intravitreal dexamethasone implant in an immunocompetent patient. METHODS: Retrospective case report. PATIENTS: Single patient with a diagnosis of cytomegalovirus retinitis associated with the intravitreal dexamethasone implant. RESULTS: The patient developed cytomegalovirus retinitis three months after an intravitreal injection of a dexamethasone implant for macular edema. The patient had no history of poor immune function and was not taking immunosuppressive medications. CONCLUSION: Cytomegalovirus retinitis has been associated with local steroid therapy. This has been described in both immunocompromised and immunocompetent patients. The intravitreal dexamethasone implant may cause local immunosuppression and result in cytomegalovirus retinitis in immunocompetent patients.

Treatment of Ipilimumab-Induced Vogt-Koyanagi-Harada Syndrome With Oral Dexamethasone.

The author presents a retrospective case report of a 54-year-old male with ipilimumab (Yervoy; Bristol-Myers Squibb, New York City, NY)-induced Vogt-Koyanagi-Harada Disease (VKH), which consisted of uveitis, optic neuritis, and choroiditis that was successfully treated with oral dexamethasone. The patient demonstrated resolution of uveitis, optic neuritis, and choroiditis 1 month following initiation of oral dexamethasone. Ipilimumab is a recently approved therapy for malignant melanoma. Reports have identified that VKH disease is a potential side effect of the medication. Oral dexamethasone is a safe and effective treatment for this side effect of the medication. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:928-931.].

Primary Vitreoretinal Lymphoma: Management of Isolated Ocular Disease.

BACKGROUND: The prognosis for patients with primary vitreoretinal is dismal. The close association of primary vitreoretinal lymphoma with primary central nervous system lymphoma is responsible for high rates of mortality. Traditional treatments consist of systemic chemotherapy and whole-brain radiotherapy. The optimal approach for the treatment of isolated primary vitreoretinal lymphoma is unclear. METHODS: A review of the relevant medical and scientific literature was performed, focusing on the clinical features of primary vitreoretinal lymphoma and the progress made in the management of isolated ocular disease. RESULTS: Ocular treatment options for primary vitreoretinal lymphoma have recently expanded with the addition of intravitreal chemotherapeutic agents and localized radiation. Based on several retrospective reports, a general shift has been made toward local therapy (eg, orbital radiotherapy, intravitreal chemotherapy) for ocular disease. No prospective, randomized clinical trials yet exist to guide therapy. CONCLUSIONS: Optimal treatment regimens for isolated primary vitreoretinal lymphoma continue to evolve. Further investigations into novel therapies and protocols are needed to decrease recurrence rates, reduce or prevent central nervous system involvement, and improve rates of overall survival.

Polycystic Ovary Syndrome and Central Serous Chorioretinopathy.

The authors report a case series of five women with the diagnosis of polycystic ovary syndrome (PCOS) (n = 4) or a first-degree relative with PCOS (n = 1) who presented with central serous chorioretinopathy (CSR). This report is the first to correlate PCOS and CSR on clinical presentation. Patients with PCOS often exhibit physical evidence of elevated androgens, such as testosterone, which recently has been linked to CSR. The authors suggest that women with CSR be investigated for PCOS if indicated clinically. In addition, further studies should investigate the relationship between the two disorders.

Machines and cutters: Constellation®.

The Alcon Constellation® provides state-of-the-art technology for vitrectomy surgery. Its innovative features include utilization of high-speed and small-gauge vitrectomy systems, surgeon-controlled duty cycle, fine intraocular pressure control, and integrated laser and intraocular gas mixing capabilities. The goal of vitrectomy surgery is the safe and efficient removal of vitreous while avoiding iatrogenic retinal tears or iatrogenic incarceration of retinal tissue. This requires the removal of vitreous in a controlled manner while maintaining safe levels of intraocular pressure. The Alcon Constellation contains improvements in technology that allow a surgeon to consistently accomplish these goals.

Central serous chorioretinopathy in patients receiving exogenous testosterone therapy.

PURPOSE: To report an association between central serous chorioretinopathy (CSCR) and exogenous testosterone therapy. METHODS: This is a retrospective case series from two institutions. Patients who presented with fluorescein angiography and optical coherence tomography findings consistent with CSCR were included. All patients were concurrently being treated with exogenous testosterone therapy and lacked other known risk factors for CSCR. RESULTS: Nine patients presented with CSCR after beginning exogenous testosterone therapy. Two patients stopped therapy with resolution of symptoms and subretinal fluid. CONCLUSION: Exogenous testosterone may be an independent risk factor for the development of CSCR.

Characteristics of intraretinal deposits in acute central serous chorioretinopathy.

PURPOSE: To describe the temporal and spatial characteristics of intraretinal deposits in patients with acute central serous chorioretinopathy (CSC) using spectral domain optical coherence tomography (OCT). MATERIALS AND METHODS: We retrospectively reviewed the medical records of all patients that presented with acute CSC to Weill Cornell Medical College from January 2012 to May 2013. Acute CSC was defined as a diagnosis of CSC within 4 months of the onset of symptoms. Only one eye per patient was included in the study. Each patient was imaged with spectral domain OCT at the initial office visit. The decision to reimage these patients was made by the treating physician. RESULTS: A total of 25 patients (25 eyes; 17 men and eight nonpregnant women) were included in this review. Seven of 25 patients (28%) demonstrated intraretinal deposits within the outer plexiform layer during the initial OCT, with deposits appearing as early as the same day as the onset of symptoms. A total of 25 of 25 patients (100%) demonstrated intraretinal deposits in the outer nuclear layer upon initial (76%) or follow-up OCT, as early as 2 days after the onset of symptoms. A total of 24 of 25 patients (96%) demonstrated deposits in the external limiting membrane upon a follow-up OCT, as early as 7 days from symptoms appearing. A total of 24 of 25 patients (96%) developed intraretinal deposits in the inner segment/outer segment layer upon follow-up OCT, appearing as early as 14 days after symptom onset. At the time of resolution of subretinal fluid, 20 of 25 patients (80%) demonstrated intraretinal deposits. CONCLUSION: Intraretinal deposits are present in the outer retinal layers in patients with acute CSC, with the deposits appearing progressively deeper within the retina as the condition evolves. Upon resolution of subretinal fluid, the deposits slowly resolve.

Isolated foveal hypoplasia without nystagmus.

We report the case of a 23-year-old healthy Caucasian male with isolated foveal hypoplasia without nystagmus. Clinical examination and spectral-domain optical coherence tomography demonstrated the bilateral absence of a foveal depression and the patient was diagnosed with isolated foveal hypoplasia. This is a rare condition which is probably under-diagnosed since it can exist without nystagmus and low vision.

Spectrum of ocular manifestations in CLN2-associated batten (Jansky-Bielschowsky) disease correlate with advancing age and deteriorating neurological function.

BACKGROUND: Late infantile neuronal ceroid lipofuscinosis (LINCL), one form of Batten's disease is a progressive neurodegenerative disorder resulting from a CLN2 gene mutation. The spectrum of ophthalmic manifestations of LINCL and the relationship with neurological function has not been previously described. METHODS: Patients underwent ophthalmic evaluations, including anterior segment and dilated exams, optical coherence tomography, fluorescein and indocyanine green angiography. Patients were also assessed with the LINCL Neurological Severity Scale. Ophthalmic findings were categorized into one of five severity scores, and the association of the extent of ocular disease with neurological function was assessed. RESULTS: Fifty eyes of 25 patients were included. The mean age at the time of exam was 4.9 years (range 2.5 to 8.1). The mean ophthalmic severity score was 2.6 (range 1 to 5). The mean neurological severity score was 6.1 (range 2 to 11). Significantly more severe ophthalmic manifestations were observed among older patients (p<0.005) and patients with more severe neurological findings (p<0.03). A direct correlation was found between the Ophthalmic Severity Scale and the Weill Cornell Neurological Scale (p<0.002). A direct association was also found between age and the ophthalmic manifestations (p<0.0002), with older children having more severe ophthalmic manifestations. CONCLUSIONS: Ophthalmic manifestations of LINCL correlate closely with the degree of neurological function and the age of the patient. The newly established LINCL Ophthalmic Scale may serve as an objective marker of LINCL severity and disease progression, and may be valuable in the evaluation of novel therapeutic strategies for LINCL, including gene therapy.

The impact of color Doppler ultrasound on treatment patterns of epididymitis in a university-based healthcare system.

INTRODUCTION AND OBJECTIVES: Evaluate the impact of scrotal color Doppler ultrasound (CDUS) on epididymitis treatment patterns in a university-based institution. MATERIALS AND METHODS: From 1 January 1999 to 30 July 2005, 870 patients from a single institution were diagnosed with epididymitis. A total of 480 men met the inclusion criteria for acute epididymitis. Scrotal ultrasound was included as a part of the diagnostic evaluation in 42.7% of men. Ultrasound reports were available for review in 187 cases. Information regarding patient demographics, diagnostic evaluation, and treatment was reviewed. RESULTS: Ultrasound findings consistent with epididymitis were identified in 69.3% of men. The four most commonly reported irregularities were scrotal wall thickening (84.2%), abnormal epididymal echotexture (74%), increased epididymal vascularity (72.9%), and an enlarged epididymis (71.5%). Scrotal ultrasound was performed in 67% men under age 20 compared to 36% men between ages 30 and 69. Patients presenting to the Emergency Department underwent sonographic evaluation 57% of the time versus 17.2% men presenting to primary care physicians (P < 0.001). Ninety-five per cent (194/204) of patients who underwent CDUS were treated with antibiotics compared to 96% (263/275) of those who did not receive an ultrasound (P = 0.78). CONCLUSIONS: CDUS can be helpful in patients with a potential diagnosis of testicular torsion, however, the use of CDUS as a diagnostic adjunct in the evaluation of epididymitis is of limited value. Treatment patterns and antibiotic usage were not significantly altered by ultrasound findings at this institution.

Comparison of ultra-widefield fluorescein angiography with the Heidelberg Spectralis(®) noncontact ultra-widefield module versus the Optos(®) Optomap(®).

PURPOSE: To compare ultra-widefield fluorescein angiography imaging using the Optos(®) Optomap(®) and the Heidelberg Spectralis(®) noncontact ultra-widefield module. METHODS: Five patients (ten eyes) underwent ultra-widefield fluorescein angiography using the Optos(®) panoramic P200Tx imaging system and the noncontact ultra-widefield module in the Heidelberg Spectralis(®) HRA+OCT system. The images were obtained as a single, nonsteered shot centered on the macula. The area of imaged retina was outlined and quantified using Adobe(®) Photoshop(®) C5 software. The total area and area within each of four visualized quadrants was calculated and compared between the two imaging modalities. Three masked reviewers also evaluated each quadrant per eye (40 total quadrants) to determine which modality imaged the retinal vasculature most peripherally. RESULTS: Optos(®) imaging captured a total retinal area averaging 151,362 pixels, ranging from 116,998 to 205,833 pixels, while the area captured using the Heidelberg Spectralis(®) was 101,786 pixels, ranging from 73,424 to 116,319 (P = 0.0002). The average area per individual quadrant imaged by Optos(®) versus the Heidelberg Spectralis(®) superiorly was 32,373 vs 32,789 pixels, respectively (P = 0.91), inferiorly was 24,665 vs 26,117 pixels, respectively (P = 0.71), temporally was 47,948 vs 20,645 pixels, respectively (P = 0.0001), and nasally was 46,374 vs 22,234 pixels, respectively (P = 0.0001). The Heidelberg Spectralis(®) was able to image the superior and inferior retinal vasculature to a more distal point than was the Optos(®), in nine of ten eyes (18 of 20 quadrants). The Optos(®) was able to image the nasal and temporal retinal vasculature to a more distal point than was the Heidelberg Spectralis(®), in ten of ten eyes (20 of 20 quadrants). CONCLUSION: The ultra-widefield fluorescein angiography obtained with the Optos(®) and Heidelberg Spectralis(®) ultra-widefield imaging systems are both excellent modalities that provide views of the peripheral retina. On a single nonsteered image, the Optos(®) Optomap(®) covered a significantly larger total retinal surface area, with greater image variability, than did the Heidelberg Spectralis(®) ultra-widefield module. The Optos(®) captured an appreciably wider view of the retina temporally and nasally, albeit with peripheral distortion, while the ultra-widefield Heidelberg Spectralis(®) module was able to image the superior and inferior retinal vasculature more peripherally. The clinical significance of these findings as well as the area imaged on steered montaged images remains to be determined.

Wide-field imaging of the retina.

The retinal periphery is the site of pathology in several eye diseases. Imaging of the peripheral retina offers a way to diagnose, monitor, and evaluate responses to the treatment of these conditions. Traditional fundus cameras have offered a 30- to 50-degree field of view. Recent technology has advanced to provide up to a 200-degree field of view. The utility of this technology in clinical practice continues to be investigated; wide-field color photography, autofluorescence imaging, and fluorescein angiography have been used for imaging peripheral retinal disease. Due to the limitations of this imaging technology and the lack of normative data, however, the clinical role of wide-field imaging remains controversial.

Oral anticoagulation and the risk of vitreous hemorrhage and retinal tears in eyes with acute posterior vitreous detachment.

PURPOSE: To determine if oral anticoagulation alters the association between vitreous hemorrhage (VH) and retinal tears in eyes with acute, posterior vitreous detachment (PVD). METHODS: In this retrospective chart review, the complete records of consecutive patients with spontaneous, symptomatic acute PVD from a single referral-based practice were reviewed. The use of oral anticoagulants, the presence of a VH, and the presence of a retinal tear or detachment were recorded. RESULTS: A total of 336 consecutive eligible patients (336 eyes) were included in the final analysis. Vitreous hemorrhage occurred in 118 (35%) eyes; in 43% of patients taking aspirin, clopidogrel, or warfarin versus 31% not taking these medications (P = 0.03). Retinal tears occurred in 46% of patients with VH versus 27% of patients without VH (P = 0.0007). Retinal tears occurred in 39% of patients with VH taking aspirin, clopidogrel, or warfarin compared with 52% of patients not taking these medications. (P = 0.20) A decreased proportion of patients with acute PVD taking one or more of the oral anticoagulant medications studied, regardless of the presence of VH, were diagnosed with a retinal tear (P = 0.0017) or retinal detachment (P = 0.0001). CONCLUSION: Retinal tears are commonly found (46%) in the eyes of patients who present with symptoms and signs of acute PVD and VH. Patients taking aspirin, clopidogrel, or warfarin who develop an acute PVD are more likely to present with VH. No statistically significant association was demonstrated between the use of oral anticoagulants in patients with acute PVD and VH and the presence of retinal tears or retinal detachment.

Bilateral maculopathy associated with Pierre Robin sequence.

Pierre Robin sequence has been associated with a number of ocular complications, including myopia, strabismus, Möbius syndrome, nasolacrimal duct obstruction, glaucoma, cataract, microphthalmos, coloboma of choroid, and retinal detachment. We report a 10-day-old boy who presented with micrognathia, glossoptosis, and cleft palate as well as multiple congenital anomalies. Ophthalmic examination was notable for bilateral maculopathy, with focal areas of retinal and retinal pigment epithelial atrophy. The association of Pierre Robin sequence and maculopathy has been reported only twice previously.

Peripheral autofluorescence findings in age-related macular degeneration.

PURPOSE: To describe the peripheral autofluorescent findings in patients with age-related macular degeneration (AMD) using ultrawide-field imaging. METHODS: We retrospectively reviewed the ultra-wide-field autofluorescent images of all patients diagnosed with AMD or macular drusen at the Department of Ophthalmology of Weill Cornell Medical College from July 2010 to September 2011. Peripheral autofluorescent phenotypes included normal autofluorescence, focal pinpoint hyperfluorescence, granular fluorescent changes, patchy hypofluorescence, and reticular hypofluorescence. RESULTS: One hundred and ten consecutive patients (220 eyes) with a diagnosis of AMD or macular drusen were imaged using ultra-wide-field autofluorescent technology during the study period. Eighty-three patients (157 eyes) were included in the final analysis. Peripheral autofluorescent abnormalities were present in 63.6% of eyes with AMD versus 35.7% of control eyes (p=0.049). Granular fluorescent changes (p=0.0001) and patchy hypofluorescence (p=0.0015) were more common in eyes with advanced AMD than in eyes with early AMD or control eyes. Granular fluorescent changes were also more common in eyes with choroidal neovascularization (p=0.026) or geographic atrophy (p=0.0001). Patchy hypofluorescence (0.0001) was more common in eyes with geographic atrophy. CONCLUSIONS: Peripheral autofluorescent abnormalities are common in eyes with AMD. The peripheral findings in eyes with AMD may represent different phenotypes, which may indicate different environmental or genetic factors in the development of AMD. Characterizing the different peripheral phenotypes may have implications for diagnosis and treatment of AMD subtypes.

Emergency department eye care in Florida: a study of principal payer sources 2005 through 2009.

OBJECTIVE: To describe trends in health insurance coverage for emergency department (ED) eye care in Florida from January 1, 2005, through December 31, 2009. METHODS: The Florida Agency for Health Care Administration ED data sets for ED outpatient visits and ED admissions for eye care were analyzed for type of insurance coverage and stratified according to age younger than 18 years and 18 years or older. Negative binomial regression models were used to measure the percentage of change in payer distribution for each 1-year increase in calendar year. RESULTS: During the 5-year study period, commercial insurance was the most frequent payer of ED outpatient services (31.1%), followed by self-pay (26.2%) and Medicaid (22.0%). For persons younger than 18 years, Medicaid and self-payment made up 67.7% of principal payers. For outpatient ED visits, the percentage of change in Medicaid increased 5.9% for each calendar year (P < .001) and commercial coverage declined 4.5% (P < .001 ). The proportion of Florida residents receiving Medicaid during the study period was less than the national average. CONCLUSIONS: A substantial proportion of ED eye care in Florida is reimbursed through Medicaid or is paid for out of pocket. How the Patient Protection and Affordable Care Act of 2010 and the national economic recovery will affect safety-net institutions such as EDs and hospital staff is speculative, but the effect could be substantial.

Optical coherence tomography predicts visual outcome in macula-involving rhegmatogenous retinal detachment.

PURPOSE: Visual recovery after rhegmatogenous retinal detachment (RRD) repair depends upon various anatomical factors. We investigated spectral-domain optical coherence tomography (SD-OCT) abnormalities, pre- and postoperatively, in patients with nontraumatic RRD and correlated these findings with visual outcome. METHODS: The medical records of all patients presenting to Weill Cornell Medical College with nontraumatic macula-involving RRD from August 2010 to September 2011 were retrospectively reviewed in this single-center, consecutive case series. All patients underwent pre- and postoperative visual acuity (VA) testing, slit-lamp biomicroscopy, and dilated fundus examination. Spectral domain optical coherence tomography was obtained preoperatively in twelve patients and postoperatively in ten patients. RESULTS: Twelve patients (12 eyes) were included in the final analysis. Preoperative optical coherence tomography revealed that the inner segment/outer segment (IS/OS) junction was disrupted in 10/12 eyes (83%), the external limiting membrane (ELM) was disrupted in 9/12 (75%) eyes, cystoid macular edema (CME) was present in 10/12 (83%) eyes, an epiretinal membrane (ERM) was present in 2/12 eyes (17%) and outer retinal corrugation was present in 7/12 (58%) eyes. In postoperative imaging of 10 eyes, the IS/OS junction was disrupted in 4/10 (40%), the ELM was disrupted in 3/10 (30%) eyes, CME was present in 2/10 (20%), and an ERM in 1/10 (10%). All retinas were attached postoperatively. Outer retinal corrugation was the most predictive of worse preoperative (P = 0.0016) and 1-month postoperative visual acuity (P = 0.05). CONCLUSION: Preoperative SD-OCT demonstrating outer retinal corrugation in macula involving RRD predicts poor visual acuity outcome in nontraumatic RRD. Such findings may have implications for the urgency for these eyes to undergo surgical repair.

Kyrieleis plaques associated with acute retinal necrosis from herpes simplex virus type 2.

PURPOSE: To present the case of a 19-year-old woman with acute retinal necrosis syndrome due to herpes simplex virus type 2, who developed segmental periarterial (Kyrieleis) plaques six and one half weeks into her clinical course. METHODS: Retrospective case report. PATIENTS: Single patient with the diagnosis of acute retinal necrosis syndrome. RESULTS: The patient's vitreous biopsy was positive by polymerase chain reaction for herpes simplex virus type 2. DISCUSSION: Kyrieleis plaques have been found in the setting of toxoplasmosis, tuberculosis, syphilis, rickettsial disease, herpes zoster virus, intraocular lymphoma, and idiopathic branch retinal artery occlusions. The differential diagnosis for these periarterial plaques should also include herpes simplex virus type 2.

Acute retinal necrosis associated optic neuropathy.

Acute retinal necrosis (ARN) syndrome is characterized by severe intraocular inflammation, occlusive vasculopathy and peripheral retinal necrosis. Vision threatening complications of this syndrome include retinal detachment, macular oedema and ischaemia and optic neuropathy. Optic nerve involvement may be the presenting sign of ARN and this condition should be included in the differential diagnosis of acute papillitis. Several mechanisms may lead to ARN associated optic neuropathy including vasculitis, optic nerve ischaemia and direct optic nerve invasion by the herpes virus. We review optic nerve involvement during ARN and present its incidence, pathogenesis, differential diagnosis and treatment.