Seeing through thick and through thin: Retinal manifestations of thrombophilic and hyperviscosity syndromes

Bilateral Central Retinal Vein Occlusion Secondary to Leukostasis in the Setting of Diffuse Large-B Cell Lymphoma: Case Report

A woman in her 50's was diagnosed diffuse large B-cell lymphoma (DLBCL) after presenting to hospital in a critical condition, characterised by marked hyperleukocytosis (white cell count 290 x10⁹/L). She subsequently developed painless blurred vision bilaterally, and was diagnosed with bilateral central retinal vein occlusion secondary to leukostasis. She was managed with non-Hodgkin lymphoma R-CHOEP14 (rituximab, cyclophosphamide, doxorubicin, vincristine, etoposide, prednisolone) immunochemotherapy, with her ocular signs and symptoms improving following treatment. Optical coherence tomography and funduscopic examination demonstrated no evidence of intraocular lymphoma. Visual acuity returned to 6/6 in each eye with subsequent resolution of her symptoms. Repeat examination demonstrated stable appearance of her ocular disease.

The Spectrum of Ocular Manifestations in Patients with Waldenström's Macroglobulinemia

PURPOSE

To investigate the ocular manifestations in 91 Waldenström's macroglobulinemia (WM) patients.

METHODS

Retrospective, cross-sectional, observational analysis.

RESULTS

Ocular impairments, detected in 19 patients, included flame-shaped hemorrhages, venous sausaging, papilledema, macular detachments, or central retinal vein occlusion in 16 patients; paraproteinemic keratopathy in 2; and a CANOMAD syndrome in 1. Best-corrected visual acuity was ≥0.5 logMAR units in 11 of 38 eyes. Intraocular pressure was increased in seven eyes. Genetic analysis in seven patients showed a mutation in the MYD88 gene in six patients and a nonsense mutation in the CXCR4 gene in five patients. Plasmapheresis followed by chemotherapy with or without the addition of rituximab resulted in improvement or normalization of the ophthalmological findings in 15 patients.

CONCLUSION

The ocular manifestations of WM are protean and potentially sight threatening. Recent advances in genomic profiling and chemotherapy have remarkably improved the hematological and ophthalmological outcomes of these patients.

Heterozygous factor V Leiden mutation manifesting with combined central retinal vein occlusion, cilioretinal artery occlusion, branch retinal artery occlusion, and anterior ischaemic optic neuropathy: a case report

Background

Our purpose was to describe a patient who developed combined central retinal vein occlusion (CRVO), cilioretinal artery occlusion, branch retinal artery occlusion (BRAO), and anterior ischaemic optic neuropathy (AION) followed by CRVO in the second eye because of the heterozygous factor V Leiden (FVL) mutation.

Case presentation

A 39-year-old female with a history of recurrent pregnancy losses presented with acute blurred vision in the right eye (RE), with visual acuity limited to counting fingers. She was diagnosed with combined impending CRVO, cilioretinal artery occlusion, BRAO, and AION. The results of thrombophilia testing, not including the FVL mutation, were negative. Retinal atrophy with vascular attenuation and optic disc pallor developed after resolution of acute retinal findings. Nine months after initial presentation, the patient developed an impending CRVO in the left eye (LE), with a secondary progression to a complete CRVO causing a decrease in best corrected visual acuity (BCVA) to 20/40. The patient was determined to be heterozygous for the FVL mutation. She subsequently was treated with acenocoumarol. At the last follow-up visit, the BCVA was 20/400 in the RE and 20/20 in the LE, and there was a complete resolution of the acute CRVO findings in the LE.

Conclusion

Our case shows that the heterozygous FVL mutation may manifest with combined retinal vascular occlusion involving multiple sites in both eyes. Early recognition of such an inherited thrombophilic disorder is important because it implies the need for long-term anticoagulative therapy to reduce the patient’s risk of recurrent, sight-threatening and life-threatening thrombotic events.

Retinal vascular tortuosity: Mechanisms and measurements

Retinal vessel tortuosity has been used in the diagnosis and management of different clinical situations. Notwithstanding, basic concepts, standards and tools of measurement, reliable normative data and clinical applications have many gaps or points of divergence. In this review we discuss triggering causes of retinal vessel tortuosity and resources used to assess and quantify it, as well as current limitations.

Hyperviscosity Syndrome in Paraprotein Secreting Conditions Including Waldenstrom Macroglobulinemia

Hyperviscosity syndrome is a serious complication associated with high levels of paraproteins in patients with hematological malignancies. Therapeutic advances in disease control may reduce the incidence of hyperviscosity syndrome; however, management of acute cases requires an understanding of key symptoms and prompt treatment to mitigate serious consequences.

Ocular Manifestations in Patients with Philadelphia-Negative Myeloproliferative Neoplasms

The major complications of Philadelphia-negative (Ph-Negative) myeloproliferative neoplasms (MPNs) are thrombosis, haemorrhage and leukemic transformation. As systemic and haematological diseases, MPNs have the potential to affect many tissues and organs. Some complications lead to the diagnosis of MPNs, but other signs and symptoms are often misdiagnosed or neglected as a sign of MPN disease. Therefore, we reviewed the current literature to investigate and delineate the clinical manifestations seen in the eyes of Ph-negative MPN patients. We found that ocular manifestations are common among patients with MPNs. The most frequently described manifestations are due to the consequences of haematological abnormalities causing microvascular disturbances and hyperviscosity. More serious and vision-threatening complications as thrombotic events in the eyes have been repeatedly reported as well. These ocular symptoms may precede more serious extraocular complications. Accordingly, combined ophthalmological and haematological management have the potential to discover these diseases earlier and prevent morbidity and mortality in these patients. Furthermore, routine ophthalmological screening of all newly diagnosed MPN patients may be a preventive approach for early diagnosis and timely treatment of the ocular manifestations.

Guidelines for the Management of Retinal Vein Occlusion by the European Society of Retina Specialists (EURETINA)

The high prevalence of cardiovascular disease particularly in the elderly population is associated with retinal vascular disease. Retinal vein occlusions represent severe disturbances of the hypoxia-sensitive neurosensory retina. Acute and excessive leakage leads to the diagnostic hallmarks of retinal hemorrhage and edema with substantial retinal thickening. Advanced diagnostic tools such as OCT angiography allow to evaluate retinal ischemia and identify the risk for late complications and will soon reach clinical routine besides fluorescein angiography. Accordingly, the duration of non-perfusion is a crucial prognostic factor requiring timely therapeutic intervention. With immediate inhibition of vascular leakage, anti-VEGF substances excel as treatment of choice. Multiple clinical trials with optimal potential for functional benefit or a lesser regenerative spectrum have evaluated aflibercept, ranibizumab, and bevacizumab. As retinal vein occlusion is a chronic disease, long-term monitoring should be individualized to combine maintenance with practicability. While steroids may be considered in patients with systemic cardiovascular risk, surgery remains advisable only for very few patients. Destructive laser treatment is an option if reliable monitoring is not feasible. Ophthalmologists are also advised to perform a basic systemic workup to recognize systemic concomitants. The current edition of the EURETINA guidelines highlights the state-of-the-art recommendations based on the literature and expert opinions in retinal vein occlusion.

Can Rotational Thromboelastometry be a New Predictive Tool for Retinal Vein Occlusion Development?

PURPOSE

To evaluate clotting dynamics by a new tool called rotational tromboelastometry (ROTEM) in retinal vein occlusion.

MATERIALS AND METHODS

Thirty-six patients who were diagnosed with retinal vein occlusion and 43 age and sex matched healthy controls were included in this study. Diabetes and use of anticoagulant therapy were exclusion criteria. All study participants underwent detailed ophthalmologic and systemic medical examination, including blood pressure measurement, hemoglobin-hematocrit levels, platelet count, coagulation parameters including prothrombin time, activated partial thromboplastin time, fibrinogen levels, and D-dimer levels. Peripheral blood samples were collected and analyzed with ROTEM Coagulation Analyzer (Tem International, Munich, Germany).

RESULTS

The RVO patients and controls did not differ with respect to age, sex, hemoglobin, hematocrit, platelet numbers, prothrombin time, activated partial thromboplastin time, fibrinogen levels, D-dimer levels, and glucose levels. When extrinsic thromboelastometry results were analyzed, RVO patients showed a significantly decreased clotting time (76.5 ± 15.0 vs. 95.0 ± 21 s, respectively; p = 0.01) and clot formation time (83.3 ± 22 vs. 99.7 ± 24s; p = 0.01) as compared with healthy controls. Other ROTEM parameters did now show any difference between two groups.

CONCLUSION

Patients with retinal vein occlusion showed faster clotting time and shorter clotting formation time as compared with healthy controls. ROTEM detects the altered clotting dynamics and may be a useful tool to elucidate the disease pathophysiology. Further studies are needed to investigate if it can be used as a screening test for individuals who are under risk to develop RVO or as a first step test to evaluate hypercoagulable state in RVO.

Effective Approach to Classify and Segment Retinal Hemorrhage Using ANFIS and Particle Swarm Optimization

The main objective of this study is to progress the structure and segment the images from hemorrhage recognition in retinal fundus images in ostensible. The abnormal bleeding of blood vessels in the retina which is the membrane in the back of the eye is called retinal hemorrhage. The image folders are deliberated, and the filter technique is utilized to decrease the images specifically adaptive median filter in our suggested proposal. Gray level co-occurrence matrix (GLCM), grey level run length matrix (GLRLM) and Scale invariant feature transform (SIFT) feature skills are present after filtrating the feature withdrawal. After this, the organization technique is performed, specifically artificial neural network with fuzzy interface system (ANFIS) method; with the help of this organization, exaggerated and non-affected images are categorized. Affected hemorrhage images are transpired for segmentation procedure, and in this exertion, threshold optimization is measured with numerous optimization methods; on the basis of this, particle swarm optimization is accomplished in improved manner. Consequently, the segmented images are projected, and the sensitivity is great when associating with accurateness and specificity in the MATLAB platform.

Acute hyperviscosity: syndromes and management

Plasma hyperviscosity is a rare complication of both monoclonal and polyclonal disorders associated with elevation of immunoglobulins. Asymptomatic patients with an elevation in the serum viscosity do not require plasma exchange, and the majority will have other indications for therapeutic intervention. For patients with hemorrhagic or central nervous system manifestations, plasma exchange is the therapy of choice and is relatively safe. Viscosity measurements are not required to initiate therapy if the index of suspicion is high and the clinical presentation is typical. However, patients should have a sample sent for confirmation of the diagnosis. Whole-blood hyperviscosity is seen in patients with extreme elevation of the red cell and white cell count. Phlebotomy of patients with primary and secondary elevation of the red cell count is a well-established therapy.

Ocular posterior pole pathological modifications related to complicated pregnancy. A review

Ocular posterior pole modification are a pathological manifestation in complicated pregnancies, especially when pregnancy induced hypertension is present (PIH), as well as in preeclampsia (PE) or eclampsia. Nonetheless, as the pregnancy evolves, the possibility for an aggravated evolution with HELLP syndrome, disseminated intravascular coagulation, and idiopathic thrombocytopenic purpura may have an ocular manifestation that, mainly, implies a loss of visual field or acuity, that, left unattended, may constitute a permanent impairment. Pregestational conditions like pituitary adenoma or genetic pedigree for complement factor H gene (1q31.1) single nucleotide mutations could lead to central serous chorioretinopathy or retinal detachment with severe, ischemic, central cilioretinal artery or vein occlusion and optic nerve atrophy. Furthermore, although subtle in many cases, any new visual symptoms during pregnancy should constitute an alarming factor for obstetrical reevaluation and ophthalmological approach in order to preserve the mother's quality of life.

Cardiovascular Oncologic Emergencies

Oncologic emergencies can present either as a progression of a known cancer or as the initial presentation of a previously undiagnosed cancer. In most of these situations, a very high degree of suspicion is required to allow prompt assessment, diagnosis, and treatment. In this article, we review the presentation and management of cardiovascular oncologic emergencies from primary and metastatic tumors of the heart and complications such as pericardial tamponade, superior vena cava syndrome, and hyperviscosity syndrome. We have included the cardiovascular complications from radiation therapy, chemotherapeutic agents, and biologic agents used in modern cancer treatment.