Binasal visual field defects from simultaneous bilateral retinal infarctions in sickle cell disease

Binasal Field Defect in Non-arteritic Anterior Ischemic Optic Neuropathy

Non-arteritic anterior ischemic optic neuropathy (NAION) is the most common cause of optic neuropathy in older adults and is usually associated with an altitudinal visual field defect. Binasal hemianopia is a rare visual field presentation, and most causes are due to ocular pathology instead of brain pathology. It is an infrequent finding in NAION. We report a rare presentation of binasal hemianopia visual field defect in a patient with NAION. This a case of an elderly lady with underlying uncontrolled type 2 diabetes mellitus, hypertension, and dyslipidemia who presented with a sudden onset of painless blurring of vision in the left eye. She had a similar episode of blurred vision involving the other eye two years ago. Her visual acuity was reduced in both eyes. Humphrey visual field showed a binasal field defect. Fundoscopy showed mild hyperemic optic disc swelling in the left eye and a pale disc in the right eye. The CT scan and MRI were normal. She was co-managed with the medical team to control her systemic risk factors. Although NAION is the most common cause of optic neuropathy in older adults, binasal hemianopia is a rare visual field presentation in NAION. The history and assessment from this case add important information toward diagnosing NAION.

Retinal and choroidal thickness in pediatric patients with sickle cell disease: a cross-sectional cohort study

BACKGROUND

To measure the retinal/choroidal thicknesses in the macular area of asymptomatic pediatric patients with sickle cell disease (SCD).

METHODS

This cross-sectional cohort study included 40 children (79 eyes) with SCD and 19 control patients (36 eyes). All subjects underwent spectral-domain optical coherence tomography (SD-OCT) with enhanced-depth imaging OCT. Generalized Estimating Equations (GEE) were applied to compare the outcomes between groups. P ≤ 0.05 was considered significant.

RESULTS

The choroidal thickness in the macular area in the study subfields was significantly thinner in the SCD eyes compared with control eyes (subfoveal subfield and temporal parafoveal subfield, p < 0.0001; nasal parafoveal subfield, p < 0.0001 temporal perifoveal subfield, p < 0.0001; and nasal perifoveal subfield, p < 0.0001). The variations in the retinal thickness were not significant.

CONCLUSION

EDI-OCT showed that the macular choroidal thickness is thinner in asymptomatic pediatric patients with SCD.

Binasal Visual Field Defects Due to Sickle Cell Maculopathy

ABSTRACT

A 26-year-old African American man with sickle cell disease noticed blurry vision in both eyes after a recent complicated hospital admission for sickle cell crisis. Anterior and posterior segment examination of each eye was normal, but visual field testing revealed binasal scotomas. Optical coherence tomography of the macula demonstrated severe thinning of the temporal inner retina, suggesting previous bilateral occlusions of terminal retinal arterioles involving the temporal macula, an uncommon complication of sickle cell disease. This case is a reminder that retinal pathology should always be considered as a potential cause of unexplained visual field defects and highlights the role of macular OCT in evaluation of these patients.

Sickle cell retinopathy. A focused review

PURPOSE

To provide a focused review of sickle cell retinopathy in the light of recent advances in the pathogenesis, multimodal retinal imaging, management of the condition, and migration trends, which may lead to increased prevalence of the condition in the Western world.

METHODS

Non-systematic focused literature review.

RESULTS

Sickle retinopathy results from aggregation of abnormal hemoglobin in the red blood cells in the retinal microcirculation, leading to reduced deformability of the red blood cells, stagnant blood flow in the retinal precapillary arterioles, thrombosis, and ischemia. This may be precipitated by hypoxia, acidosis, and hyperosmolarity. Sickle retinopathy may result in sight threatening complications, such as paracentral middle maculopathy or sequelae of proliferative retinopathy, such as vitreous hemorrhage and retinal detachment. New imaging modalities, such as wide-field imaging and optical coherence tomography angiography, have revealed the microstructural features of sickle retinopathy, enabling earlier diagnosis. The vascular growth factor ANGPTL-4 has recently been identified as a potential mediator of progression to proliferative retinopathy and may represent a possible therapeutic target. Laser therapy should be considered for proliferative retinopathy in order to prevent visual loss; however, the evidence is not very strong. With recent development of wide-field imaging, targeted laser to ischemic retina may prove to be beneficial. Exact control of intraoperative intraocular pressure, including valved trocar vitrectomy systems, may improve the outcomes of vitreoretinal surgery for complications, such as vitreous hemorrhage and retinal detachment. Stem cell transplantation and gene therapy are potentially curative treatments, which may prevent retinopathy.

CONCLUSIONS

There is lack of evidence regarding the optimal management of sickle retinopathy. Further study is needed to determine if recent progress in the understanding of the pathophysiology and diagnosis of sickle retinopathy may translate into improved management and outcome.

Sickle cell retinopathy: improving care with a multidisciplinary approach

Sickle cell retinopathy (SCR) is the most representative ophthalmologic complication of sickle cell disease (SCD), a hemoglobinopathy affecting both adults and children. SCR presents a wide spectrum of manifestations and may even lead to irreversible vision loss if not properly diagnosed and treated at the earliest. Over the past decade, multidisciplinary research developments have focused upon systemic, genetic, and ocular risk factors of SCR, enabling the clinician to better diagnose and manage these patients. In addition, newer imaging and testing modalities, such as spectral domain-optical coherence tomography angiography, have resulted in the detection of subclinical retinopathy related to SCD. Innovative therapy includes intravitreal injection of an anti-vascular endothelial growth factor (eg, Lucentis^® [ranibizumab] or Eylea^® [aflibercept]) which appears comparatively safe and efficient, and may be combined with laser photocoagulation (LPC) for proliferative SCR. The effect of LPC alone does not significantly lead to the regression of advanced SCR, although it helps in avoiding hemorrhage and sight loss. This comprehensive article is based on 10-years retrospective (2007–2017) studies. It aims to present advances and recommendations in SCR theranostics while pointing out the requirement of combinatorial approaches for better management of SCR patients. To reach this goal, we identified and analyzed randomized original and review articles, clinical trials, non-randomized intervention studies, and observational studies using specified keywords in various databases (eg, Medline, Embase, Cochrane, ClinicalTrials.gov).

Asymptomatic atrophy of the temporal median raphe of the retina associated with cerebral vasculopathy in homozygous sickle cell disease

A 13-year-old girl with homozygous sickle cell disease was referred for vision loss in her left eye of 1 year's duration. Clinical findings were consistent with a past retinal arterial occlusion. In the asymptomatic right eye, spectral domain optical coherence tomography showed a severe atrophy of the inner retinal layers of the temporal median raphe; a significant internal carotid stenosis was also present. We hypothesize that specific atrophy of the retinal temporal median raphe resulted from chronic ischemia. The inner layers of the retina are vascularized by terminal vessels and the median raphe can therefore be regarded as a junction territory; its atrophy may represent an ocular equivalent of a silent border zone cerebral infarct.

Central macular splaying and outer retinal thinning in asymptomatic sickle cell patients by spectral-domain optical coherence tomography

PURPOSE

To investigate the prevalence and degree of macular thinning on optical coherence tomography (SDOCT) in African-American female patients with asymptomatic sickle cell disease.

DESIGN

Prospective comparative case series.

METHODS

Twenty-one sickle cell patients (42 eyes) without other systemic or ocular diseases and 18 healthy control patients (33 eyes) underwent SD-OCT. Images were manually segmented to measure inner retinal thickness (IRT) and outer retinal thickness (ORT). Central macular (central 1 mm), parafoveal (0.5-1.5 mm eccentricity), and perifoveal (1.5-3 mm eccentricity) thickness measurements were obtained in sickle cell patients and age/gender/race-matched healthy control subjects.

RESULTS

Central macular total thickness (CMT) in sickle cell patients was 220 ± 3 μm (mean ± SEM), which was significantly lower (P < .05) than controls (228 ± 3 μm). Parafoveal regions had thickness measurements of 314 ± 5 μm (nasal) and 304 ± 2 μm (temporal), which were significantly lower than controls (327 ± 2 μm and 311 ± 2 μm nasally and temporally, respectively) (P < .03, P < .043). There was also no significant difference in IRT in central macula, parafoveal, and perifoveal regions. Central macular ORT was 175 ± 2 μm vs 185 ± 1 μm in controls (P < .0002). ORT in temporal parafoveal and perifoveal regions was 142 ± 2 μm and 120 ± 1 μm, respectively, vs 150 ± 1 μm and 122 ± 1 μm in controls (P < .001 and P = .16, respectively).

CONCLUSIONS

Manual segmentation of SD-OCT images revealed significant total retinal thinning in the central macula and splaying in asymptomatic sickle cell patients. Retinal thinning was predominately in outer retinal layers in central macula and parafoveal regions.