White-centred retinal haemorrhages (Roth spots)

Retinal hemorrhages and damages from tractional forces associated with infantile abusive head trauma evaluated by wide-field fundus photography

We evaluated the distribution and types of retinal hemorrhages (RHs) and other damages in eyes with abusive head trauma (AHT). This retrospective, consecutive case series of AHT and non-AHT conditions involved 54 children with AHT, 43 children with head bruises, and 49 children with blunt eye trauma, each of non-AHT supported by reliable witness accounts. RHs and other damage were evaluated using ophthalmoscopy and wide-field fundus photography. A variety of RH types and other damage were identified in the AHT group but not in the non-AHT group. RHs in AHT extended from the posterior pole to the far periphery in 77% of eyes and on/near the veins in 86% and arteries in 85%, most of which were in the far periphery. Retinoschisis, white-dot lesions, and retinal folds were seen even in the far periphery. RHs on/near the veins and arteries, retinoschisis, and retinal folds suggest a traumatic mechanism of the tractional force of the vitreous that is attached to the entire retinal surface. Identifying the distribution and arterio and venous origins of RHs is a key factor in determining the association with trauma. Thus, wide-field fundus photography is useful to record and evaluate the origin of the RHs and other retinal damage.

FROSTED BRANCH ANGIITIS ASSOCIATED WITH MIXED CONNECTIVE TISSUE DISEASE

PURPOSE

To present a case of frosted branch angiitis associated with an exacerbation of mixed connective tissue disease (MCTD).

METHODS

Single case report.

RESULTS

A 31-year-old woman presented with a flare of her long-standing MCTD after a change in her immunosuppressive medications. She developed blurred vision and floaters first in the left eye but eventually in both eyes. Fundoscopy showed patchy perivascular sheathing of tertiary branch venules surrounded by retinal hemorrhages characterized as frosted branch angiitis. The patient's MCTD symptoms and retinal vasculitis improved with continued immunosuppressive therapy. At 1-month follow-up, her visual acuity had improved to 20/20 bilaterally with complete resolution on fundoscopy.

CONCLUSION

To the authors' knowledge, this is the first report of frosted branch angiitis seen in association with MCTD. The improvement in the patient's visual acuity and fundoscopic findings in this case supports the role of immunosuppressive therapy to treat secondary frosted branch angiitis associated with an autoimmune condition such as MCTD. However, it is recommended that a comprehensive medical workup is performed to exclude an infective cause, particularly in immunocompromised patients.

Clinical aspects of malarial retinopathy: a critical review

This review will provide a better understanding of a set of signs known as malarial retinopathy. The discovery of this retinopathy in association with cerebral malaria is important because it best distinguishes patients with true cerebral malaria from those with coma due to other causes and incidental Plasmodium falciparum parasitemia. Identifying a comatose patient with malarial retinopathy increases the likelihood of an accurate severe or cerebral malaria diagnosis. As the World Health Organization does not specify that malarial retinopathy is one of the factors included in determining a cerebral malaria diagnosis, there are significant false-positive diagnoses of cerebral malaria. Once a cerebral malaria diagnosis is assigned, other possibilities and treatments are often excluded making an incorrect diagnosis of cerebral malaria potentially fatal. However, Plasmodium falciparum may also contribute to coma in some children with retinopathy-negative cerebral malaria, as this group is still not clinically well characterized, so all children with the WHO definition of cerebral malaria should be treated for severe malaria. Nevertheless, by raising awareness about malarial retinopathy, there could be a greater potential to accurately diagnose cerebral malaria and thus achieve more positive patient outcomes in the future. This literary review aims to raise awareness of the retinopathy by defining what it is to non-experts, explaining its pathology, clarifying the techniques needed to accurately diagnose malarial retinopathy, as well as the barriers that prevent clinicians from providing a proper diagnosis in malaria-endemic regions; and finally, discuss future directions to continue the study of malarial retinopathy.

Ophthalmic Manifestations as First Presenting Sign of Evans Syndrome

Purpose

This work reports a case of Evans syndrome first presenting with ophthalmic signs.

Methods

A 27-year-old previously healthy man presented with headaches and bilateral blurred vision for 2 weeks. The visual acuity was 20/30-1 and 20/60-2 in the right eye and left eye, respectively. A fundus examination revealed Roth spots, diffuse multilayer retinal hemorrhages in the macula and periphery, and tortuous vessels in both eyes. Optical coherence tomography showed a disrupted foveal contour from intraretinal fluid and hemorrhage in both eyes. Fluorescein angiography demonstrated dilated and tortuous vessels with scattered blocking defects from hemorrhages.

Results

A workup revealed warm hemolytic anemia with severe thrombocytopenia consistent with the diagnosis of Evans syndrome.

Conclusions

Evans syndrome is a rare blood dyscrasia that can first present as subacute vision loss and should be added to the differential of diffuse bilateral retinal hemorrhages spanning a multitude of retinal layers.

Roth-like Spot in an Adult With Vitamin B6 Deficiency and Nonepileptic Seizures

Purpose:

This work reports retinal findings in an adult patient with vitamin B6 deficiency.

Methods:

A case review of a single patient is presented.

Results:

A patient with a Roth-type retinal lesion and a history of nonepileptic seizures was found to have lymphocytic colitis. She was treated with pyridoxine, which resolved her seizures and the white-centered hemorrhage.

Conclusions:

Vitamin B6 deficiency should be considered in the differential diagnosis of patients presenting with white-centered hemorrhages and a history of nonepileptic seizures.

Multimodal imaging of valsalva petaloid maculopathy secondary to acute laryngospasm and endotracheal intubation

Purpose:

To report the multimodal imaging findings associated to Valsalva retinopathy following acute laryngospasm and endotracheal intubation.

Methods:

Case report and literature review.

Results:

Acute laryngospasm led to pulmonary edema which necessitated endotracheal intubation. Upon extubation the patient complained of bilateral scotomata due to Valsalva retinopathy. Multimodal imaging localizes the precise anatomic site of the intraocular hemorrhages. Petaloid hemorrhages are typical of Henle fiber layer involvement. All the hemorrhages spontaneously cleared without any sequelae.

Conclusion:

Patients with acute laryngospasm and endotracheal intubation may develop Valsalva retinopathy. Multimodal imaging localize the hemorrhages to the specific anatomic site which is important in determining the different management options.

[Ocular changes as a diagnostic tool for malaria]

BACKGROUND

According to the WHO Malaria Report 2019 a total of 229 million people fall ill with malaria each year and two thirds of deaths involve children under 5 years of age.

AIM

To review the fundus changes in the context of malaria and the importance of ophthalmoscopy in the diagnosis.

MATERIAL AND METHODS

Summary of changes in cerebral malaria visible on fundus examination, possible underlying pathomechanisms and the value of ophthalmoscopy in practice.

RESULTS

Retinal findings in malaria include white or gray staining of the retina (retinal whitening), color change of retinal vessels (orange or white staining), hemorrhages often with a white center, such as Roth's spot and papilledema.

DISCUSSION

The retinal changes in malaria are specific and may help to differentiate malaria from other causes of coma and fever. Smartphone-based fundus photography and artificial intelligence could support malaria diagnostics particularly in resource-poor regions.

Choroidal and retinal thickness variations in anaemia and anaemic retinopathy

Anemia is the most common hematological disorder noted in the people of the Indian subcontinent. Hemodynamic changes following anemia on the retina and choroid are not frequently studied. The aim of the study was to analyse the subfoveal retinal (CRT) and choroidal (SFCT) thickness changes in patients with anemia. In this retrospective, comparative study, patients who were diagnosed with primary anemia and had a fundus examination by a retinal specialist were included. Patients were divided into 3 groups: Group 1: Patients with anemic retinopathy; Group 2: Patients with anemia without retinopathy; Group 3: Normal healthy controls. One hundred and ninety-seven eyes of 197 subjects (group 1 - 38 eyes, group 2 - 90 eyes; group 3 - 69 eyes) met the inclusion criteria. Mean CRT was 269 ± 117µm, 258 ± 99.7µm and 201 ± 19.2µm and SFCT was 303 ± 68.4µm, 303 ± 50.1µm and 275 ± 38.9µm in groups 1, 2 and 3 respectively. Low haemoglobin corelated negatively with retinal (r = -0.362; p = <0.001) and choroidal (r = -0.294; p = <0.001) thickening and reduced visual acuity (r = -0.157; p = 0.03). In conclusion, patients with anemia have a thicker retina and choroid compared to normal healthy controls.

Hyperviscosity retinopathy as the initial presentation of aggressive multiple myeloma

Multiple myeloma (MM) is a hematologic malignancy resulting from the uncontrolled proliferation of neoplastic plasma cells and the excessive production of monoclonal immunoglobulins, both of which may lead to hyperviscosity retinopathy. Here, we present a 56-year-old male who had progressive painless loss of vision for 1 month. Ophthalmic examination revealed hyperviscosity retinopathy with bilateral central retinal vein occlusion-like appearance. Hematologic assessment revealed immunoglobulin A MM. Although the patient was treated with chemotherapy and autologous stem cell transplantation soon after referral, he did not survive due to the aggressive course of the disease. We highlight the importance of the ophthalmic presentation of MM. Early recognition and referral to an oncologist can lead to timely diagnosis and appropriate management.

Knowledge discovery using SPARQL property path: The case of disease data set

The Semantic Web allows knowledge discovery on graph-based data sets and facilitates answering complex queries that are extremely difficult to achieve using traditional database approaches. Intuitively, the Semantic Web query language (SPARQL) has a ‘property path’ feature that enables knowledge discovery in a knowledgebase using its reasoning engine. In this article, we utilise the property path of SPARQL and the other Semantic Web technologies to answer sophisticated queries posed over a disease data set. To this aim, we transform data from a disease web portal to a graph-based data set by designing an ontology, present a template to define the queries and provide a set of conjunctive queries on the data set. We illustrate how the reasoning engine of ‘property path’ feature of SPARQL can retrieve the results from the designed knowledgebase. The results of this study were verified by two domain experts as well as authors’ manual exploration on the disease web portal.

Peripheral ischaemic retinopathy and neovascularisation in a patient with subacute streptococcus mitis-induced bacterial endocarditis

Objective: To describe a patient with peripheral retinal ischaemia and neovascularisation who was diagnosed with streptococcus mitis-induced bacterial endocarditis. Methods: Retrospective analysis of case report. A 57-year-old man presented with a history of a rapidly progressive, bilateral, painless visual loss. He also suffered from pain in the neck and lower back and a weight loss of 10 kg. He underwent a full ophthalmologic work-up, laboratory investigations, and imaging of the spine. Results: BCVA was reduced to 20/40 in the right eye and 20/32 in the left eye. Fundoscopy showed rare intra-retinal haemorrhages including few Roth spots and cotton wool lesions. Fluorescein angiography demonstrated large areas of peripheral retinal ischaemia and neovascularisation. Imaging of the spine showed spondylodiscitis on several levels. Further imaging and blood cultures confirmed bacterial endocarditis of the mitral valve. Streptococcus mitis was subsequently identified as the causative organism. Conclusion: Peripheral retinal ischaemia and neovascularisation were previously unrecognised as a feature of infectious endocarditis. Therefore, their presence, apart from the classic Roth spots, should prompt the consideration of infectious endocarditis in the etiologic work-up.

Chronic myelocytic leukemic fundus lesion: A case report

The current study reports a case of a patient with a chronic myelocytic leukemic fundus lesion, initially diagnosed in the Department of Ophthalmology, Rizhao People's Hospital (Rizhao, China). A male, 23-years-of-age, presented with a dark shadow in the front of the right eye, accompanied with blurred vision for 3 days (visual acuity of right eye, 0.4; visual acuity of left eye, 0.6). In addition, the patient had experienced gingival bleeding for 2 years, and recurrent upper respiratory infections for 1 year. A fundus examination revealed mild binocular papillary edema, dilated and tortuous veins, and the retina exhibited large quantities of scattered and dark red bleeding spots. The bleeding spots had white spots in the center, which exhibited typical Roth spots, whilst routine blood examination, abdominal ultrasound, marrow biopsy and other laboratory tests confirmed the diagnosis of chronic myelogenous leukemia. Patients with leukemia typically present with initial symptoms that include fever, fatigue, anemia and hepatosplenomegaly, and a diagnosis as a result of eye-related symptoms is rare, rendering the present case unique.

Retinal and Optic Nerve Hemorrhages in the Newborn Infant: One-Year Results of the Newborn Eye Screen Test Study

PURPOSE

To report the birth prevalence, risk factors, characteristics, and location of fundus hemorrhages (FHs) of the retina and optic nerve present in newborns at birth.

DESIGN

Prospective cohort study at Stanford University School of Medicine.

PARTICIPANTS

All infants who were 37 weeks postmenstrual age or older and stable were eligible for screening. Infants with known or suspected infectious conjunctivitis were excluded.

METHODS

Infants born at Lucile Packard Children's Hospital (LPCH) from July 25, 2013, through July 25, 2014, were offered universal newborn screening via wide-angle digital retinal photography in the Newborn Eye Screen Test study. Maternal, obstetric, and neonatal factors were obtained from hospital records. The location, retinal layer, and laterality of FH were recorded by 1 pediatric vitreoretinal specialist.

MAIN OUTCOME MEASURES

Birth prevalence of FH. Secondary outcomes included rate of adverse events, risk factors for FH, hemorrhage characteristics, and adverse events.

RESULTS

The birth prevalence of FH in this study was 20.3% (41/202 infants). Ninety-five percent of FHs involved the periphery, 83% involved the macula, and 71% involved multiple layers of the retina. The fovea was involved in 15% of FH cases (birth prevalence, 3.0%). No cases of bilateral foveal hemorrhage were found. Fundus hemorrhages were more common in the left eye than the right. Fundus hemorrhages were most commonly optic nerve flame hemorrhages (48%) and white-centered retinal hemorrhages (30%). Retinal hemorrhages were found most frequently in all 4 quadrants (35%) and more often were multiple than solitary. Macular hemorrhages most often were intraretinal (40%). Among the risk factors examined in this study, vaginal delivery compared with cesarean section (odds ratio [OR], 9.34; 95% confidence interval [CI], 2.57-33.97) showed the greatest level of association with FH. Self-identified ethnicity as Hispanic or Latino showed a protective effect (OR, 0.43; 95% CI, 0.20-0.94). Other study factors were not significant.

CONCLUSIONS

Fundus hemorrhages are common among newborns. They often involve multiple areas and layers of the retina. Vaginal delivery was associated with a significantly increased risk of FH, whereas self-identified Hispanic or Latino ethnicity was protective against FH in this study. The long-term consequences of FH on visual development remain unknown.

Bilateral Macular Roth Spots as a Manifestation of Subacute Endocarditis

A 42-year-old man presented with a 2-day history of impaired vision in the right eye (OD). The best corrected visual acuity (BCVA) (LogMAR) was 1.1 for the right eye and 0.0 for the left eye (OS). Fundus examination revealed white-centered hemorrhages resembling Roth spots in both macular regions. The spectral-domain optical coherence tomography (SD-OCT) showed intraretinal pseudocysts and hyperreflective deposits in the areas corresponding to the Roth spots. Conducted blood tests revealed elevated D-dimer concentration, increased total number of neutrophils, high C-reactive protein concentration, and elevated erythrocyte sedimentation rate. Procalcitonin concentration, platelet count, and body temperature were within normal ranges. A blood culture was ordered and yielded Streptococcus mitis and intravenous antibiotics were started immediately. The patient started complaining of chest and left calf pain. The systemic examination revealed infective endocarditis accompanied by bicuspid aortic valve and paravalvular abscess formation. The patient underwent cardiac surgery with mechanical aortic valve implantation. After recovery, the patient's visual acuities improved fully. Control ophthalmic examination, including SD-OCT, showed no abnormalities.

A case of leukemic retinopathy mimicking common ischemic retinopathies

Reported case of leukemic retinopathy mimicking common ischemic retinopathies in a young adult where ophthalmic visit was the first step to the diagnosis of chronic myeloid leukemia. It highlights the importance of routine eye exams and that clinicians should suspect leukemia in an otherwise healthy patient presenting with ischemic retinopathy.

Roth Spots in Ocular Toxoplasmosis

PURPOSE

To report a case with unilateral preexisting ocular toxoplasmosis (OT) and newly occurred active retinochoroidal inflammation associated with white-centered retinal hemorrhages (Roth spots) in the healthy eye.

DESIGN

Case report.

METHODS

A 20 year-old man presented with a decrease of visual acuity in his right eye associated with 2+ cells in the anterior chamber. Ophthalmoscopy revealed an active retinochoroidal lesion on the upper nasal border of the optic disc associated with local hemorrhage and vitritis. The posterior pole presented white-centered flame-shaped retinal hemorrhages.

RESULTS

Toxoplasmosis serology showed an IgG titer >300IU/ml and a negative IgM titer. A complete blood count revealed no abnormalities; other serologies were negative. After 2 weeks of treatment with sulfadiazine, pyrimethamine, folinic acid and prednisone, although the peripapillary lesion was still active, the Roth spots disappeared.

CONCLUSION

OT may be one differential diagnosis of patients suffering Roth spots in association with retinochoroidal inflammation.

Visceral leishmaniasis with Roth spots

Visceral leishmaniasis (VL) is caused by the protozoan parasite Leishmania donovani and transmitted by the bite of infected sandfly Phlebotomus argentipes. The protozoa is obliged intracellularly and causes a wide spectrum of clinical syndromes: VL ('kala azar'), cutaneous leishmaniasis and mucocutaneous leishmaniasis (espundia). Kala azar is the most aggressive form and if untreated causes high mortality. Here, we describe a case of VL that presented to us with high-grade fever and found to have Roth spots that were resolved after 15 days of therapy.

Cerebral malaria in children: using the retina to study the brain

Cerebral malaria is a dangerous complication of Plasmodium falciparum infection, which takes a devastating toll on children in sub-Saharan Africa. Although autopsy studies have improved understanding of cerebral malaria pathology in fatal cases, information about in vivo neurovascular pathogenesis is scarce because brain tissue is inaccessible in life. Surrogate markers may provide insight into pathogenesis and thereby facilitate clinical studies with the ultimate aim of improving the treatment and prognosis of cerebral malaria. The retina is an attractive source of potential surrogate markers for paediatric cerebral malaria because, in this condition, the retina seems to sustain microvascular damage similar to that of the brain. In paediatric cerebral malaria a combination of retinal signs correlates, in fatal cases, with the severity of brain pathology, and has diagnostic and prognostic significance. Unlike the brain, the retina is accessible to high-resolution, non-invasive imaging. We aimed to determine the extent to which paediatric malarial retinopathy reflects cerebrovascular damage by reviewing the literature to compare retinal and cerebral manifestations of retinopathy-positive paediatric cerebral malaria. We then compared retina and brain in terms of anatomical and physiological features that could help to account for similarities and differences in vascular pathology. These comparisons address the question of whether it is biologically plausible to draw conclusions about unseen cerebral vascular pathogenesis from the visible retinal vasculature in retinopathy-positive paediatric cerebral malaria. Our work addresses an important cause of death and neurodisability in sub-Saharan Africa. We critically appraise evidence for associations between retina and brain neurovasculature in health and disease, and in the process we develop new hypotheses about why these vascular beds are susceptible to sequestration of parasitized erythrocytes.

High altitude retinal hemorrhages--an update

Retinal hemorrhages represent a common phenomenon in eyes of high altitude climbers. In this review, we present an update about this entity, with focus on its pathophysiology and practical implications. Due to their delayed appearance in the course of an expedition, retinal hemorrhages are not predictive when assessing the risk for life-threatening complications related to hypobaric hypoxia. Consequences for ocular health depend greatly on the extent and localization of retinal bleedings, but are generally mild and reversible in healthy eyes.

Central retinal artery occlusion due to infective endocarditis

We present a case of central retinal artery occlusion (CRAO) in a 59-year-old male suffering from infective endocarditis. The patient was receiving antibiotic treatment for the endocarditis for 5 days prior to the event and received conservative treatment for the CRAO without any improvement. A few days after the event, the patient underwent heart surgery with aortic and mitral valve replacement and eventually recovered without any other side-effects. CRAO is a rare but devastating embolic complication of infective endocarditis and can happen regardless of whether a patient is receiving systemic antibiotic treatment or not. These patients need close observation, because an immediate diagnosis and an urgent therapeutic procedure are mandatory, as the prognosis for vision is poor.

Anti-interleukin-6 receptor antibody therapy-induced retinopathy in a patient with rheumatoid arthritis

Tocilizumab, a humanized anti-human interleukin-6 (IL-6) receptor monoclonal antibody, is beneficial for treating autoimmune conditions such as rheumatoid arthritis (RA). The most common adverse event is upper respiratory tract infection; ocular side effects are rare. We describe a case of skin ulceration and bilateral retinopathy with multifocal cotton-wool spots and retinal hemorrhages in a patient with RA treated with tocilizumab. Tocilizumab administration increased the serum level of IL-6 without affecting the IL-8 levels. We could not exclude the possibility of blood coagulation or retinal vascular changes caused by tocilizumab. The current case highlights the need to consider that ocular adverse effects can develop in patients treated with tocilizumab.

Bilateral foveal cysts secondary to Streptococcus constellatus endocarditis

Infective endocarditis can be acute or subacute, depending on the virulence of the causative organism. It can also cause loss of vision by a variety of mechanisms, ranging from embolic retinal artery occlusion to endogenous endophthalmitis. We illustrate the first report of foveal cyst formation secondary to infective endocarditis. A 53-year-old man presented to his general practitioner with a variety of constitutional symptoms, but initial laboratory and imaging investigations revealed only mild normocytic anaemia, and he was discharged from further medical care. Four weeks later he developed bilateral visual loss associated with whitish lesions of the superficial retina at both foveae. These later developed into foveal cysts with disruption of the photoreceptor inner segment-outer segment junction and persistent poor visual acuity of 6/60 OU. No retinal haemorrhages or Roth spots were noted. Only after he presented with visual loss did further investigations reveal the underlying diagnosis of streptococcal endocarditis. Ophthalmologists assessing retinal pathology which presents in association with undiagnosed constitutional symptoms are advised to refer such patients promptly for thorough medical investigation, including blood culture and echocardiography where appropriate.

Autoimmune hemolytic anemia: mixed type-a case report

Mixed autoimmune haemolytic anemia (AIHA) is defined by the presence of both warm and cold auto antibodies. Diagnosis is based on detection of autoantibodies by monospecific direct antiglobulin test showing a pattern of IgG and complement C3d and presence of cold agglutinins. We report a rare case of primary mixed AIHA in a 12 year old girl who responded to corticosteroids.

Roth spots in pyridoxine dependent epilepsy

Pyridoxine dependent epilepsy (PDE) is a rare metabolic defect in the degradation of lysine. The authors report a patient with metabolic and DNA confirmed PDE, on the fifth day of life ophthalmoscopy showed bilateral multiple white centred retinal haemorrhages, so called Roth spots. Roth spots are non-specific haemorrhagic signs that occur in a variety of conditions of acute systemic insults in homeostasis - most often infections- which relate to retinal capillary damage and the ensuing reparative process. No biochemical or microbiological signs of infection were present in blood and liquor. MRI of the brain showed an abnormal diffusion signal with increased apparent diffusion coefficient and little blood around the tentorium. The knowledge of the pathogenesis of PDE is still limited. The presence of Roth spots is suggestive for a pathogenic mechanism of vasogenic damage in PDE.

Delayed appearance of high altitude retinal hemorrhages

BACKGROUND

Retinal hemorrhages have been described as a component of high altitude retinopathy (HAR) in association with altitude illness. In this prospective high altitude study, we aimed to gain new insights into the pathophysiology of HAR and explored whether HAR could be a valid early indicator of altitude illness.

METHODOLOGY/PRINCIPAL FINDINGS

28 mountaineers were randomly assigned to two ascent profiles during a research expedition to Mt. Muztagh Ata (7546 m/24,751 ft). Digital fundus photographs were taken prior to expedition at 490 m (1,607 ft), during expedition at 4497 m (14,750 ft = base camp), 5533 m (18,148 ft), 6265 m (20,549 ft), 6865 m (22,517 ft) and 4.5 months thereafter at 490 m. Number, size and time of occurrence of hemorrhages were recorded. Oxygen saturation (SpO₂) and hematocrit were also assessed. 79% of all climbers exhibited retinal hemorrhages during the expedition. Number and area of retinal bleeding increased moderately to medium altitudes (6265 m). Most retinal hemorrhages were detected after return to base camp from a high altitude. No post-expeditional ophthalmic sequelae were detected. Significant negative (SpO₂ Beta: -0.4, p<0.001) and positive (hematocrit Beta: 0.2, p = 0.002, time at altitude Beta: 0.33, p = 0.003) correlations with hemorrhages were found.

CONCLUSIONS/SIGNIFICANCE

When closely examined, a very large amount of climbers exhibit retinal hemorrhages during exposure to high altitudes. The incidence of retinal hemorrhages may be greater than previously appreciated as a definite time lag was observed between highest altitude reached and development of retinal bleeding. Retinal hemorrhages should not be considered warning signs of impending severe altitude illness due to their delayed appearance.

Metastatic endophthalmitis

Endophthalmitis carries a poor visual prognosis for patients and can be a potentially blinding condition that may result in loss of the eye. Early diagnosis and prompt treatment are imperative to save the eye. Delay in diagnosis affects visual prognosis and therefore doctors should be aware of the presenting features of endophthalmitis. Urgent ophthalmic referral is advised as soon as a diagnosis is suspected.

Clinical features remain important for the diagnosis of infective endocarditis in the modern era

BACKGROUND

Infective endocarditis (IE) can be difficult to diagnose, due to multiple (often non-specific) presenting features.

AIM

To assess the predictive accuracy of classical clinical features and blood investigations readily available at the time of presentation.

DESIGN

Cross-sectional analysis.

METHODS

We studied 29 IE cases and 79 controls (clinically suspicious contemporaneous cases where IE was subsequently excluded) from a hospital-based group of patients referred to a cardiac department with possible infective endocarditis. Patients were identified from the echocardiography database. Cases were defined by final diagnosis. Symptoms, signs, risk factors for IE and blood investigations were recorded from case notes and examined by univariate and multivariate analyses.

RESULTS

The sensitivity, specificity, and positive and negative predictive values of transthoracic echocardiography (TTE) for detection of IE in clinically suspected cases were 71%, 98%, 57% and 99%, respectively. Univariate analyses revealed a significant association between IE and several clinical features. Under multivariate analysis, previous heart valve surgery (OR 13.3, 90%CI 3.2-55.6), positive blood cultures (OR 17.2, 90%CI 4.9-58.8), signs of embolism (OR 11.4, 90%CI 3.0-43.5), a new, altered or changing murmur (OR 10.3, 90%CI 2.8-38.5) and splenomegaly (OR 18.2, 90%CI 3.6-90.9) were independent predictors for IE.

DISCUSSION

Clinical features at presentation continue to be important for the diagnosis of IE. Features such as positive blood cultures, signs of embolism and a changing heart murmur should be used to guide investigation and treatment of IE prior to echocardiography, or when TTE is negative.

Decompression Retinopathy after Trabeculectomy

PURPOSE

To present a case of a unilateral diffuse retinal hemorrhage in a 15-year-old girl, who underwent bilateral trabeculectomy for steroid induced glaucoma.

METHODS

Despite the maximally tolerable medical treatment, IOP in the right eye remained above 50 mmHg for four months, and was simultaneously elevated in the left eye. So we performed bilateral trabeculectomy.

RESULTS

On the first postoperative day, diffuse retinal hemorrhages were observed in the right eye; however, no retinal hemorrhage was found in the left eye. The hemorrhages resolved completely without consequences two months later.

CONCLUSIONS

In the case of high IOP for a long period, sudden lowering of IOP may acutely increase the blood flow and consequently rupture multiple retinal capillaries because of altered autoregulatory function. Special care is therefore needed to prevent an abrupt fall in IOP before, during, and after surgery, especially when IOP has been highly elevated for an extended period.