Vitreomacular interface abnormalities in type 2 macular telangiectasia (MacTel)

PURPOSE

To describe the different types of vitreomacular interface abnormalities (VMIA) seen on optical coherence tomography (OCT) in type 2 macular telangiectasia (MacTel) and explain the possible reasons for its development.

METHODS

In this retrospective cross-sectional study, type 2 MacTel eyes with macular volumetric OCT imaging protocol were included to identify different types of VMIA such as abnormal PVD, vitreomacular traction (VMT), ERM, and lamellar and full-thickness macular hole. The VMIA findings were then correlated with different MacTel disease stages and visual acuity.

RESULTS

One thousand forty-three OCTs of 332 type 2 MacTel eyes from 169 patients at different visits were examined. VMIA was detected in 709 (68%) of those OCT scans in 216 (65%) eyes. There were 273 (39%), 31 (4%), 89 (13%), 7 (1%), and 381 (54%) OCT scans with vitreomacular adhesion, VMT, ERM, and inner and outer lamellar macular holes discovered respectively. VMIA eyes had a high frequency of abnormal PVD (p = 0.001) and retinal pigment clumps (RPCs) [p = 0.032]. Eyes with abnormal PVD (p = 0.034) and RPC (p = 0.000) had a higher rate of ERM development. RPC was linked to an increased risk of developing ERM (odd ratio 2.472; 95% CI 1.488-4.052). RPC and ERM contributed significantly to poor visual acuity (0.661 ± 0.416, 20/92).

CONCLUSION

OCT reveals a high frequency of VMIA in advanced type 2 MacTel eyes. RPC could be responsible for the development of anomalous PVD, as well as subsequent VMIAs and ERM. Additional work is required to examine the long-term changes and surgical outcomes of these eyes.

Right-angled vessel characteristics in different stages of type 2 macular telangiectasia (MacTel)

PURPOSE

To study right-angled vessels (RAV) in disease progression and macular neovascularization in type 2 macular telangiectasia (MacTel) eyes.

METHODS

This retrospective image analysis study examined type 2 MacTel patients' multicolour® and OCT imaging records from January 2015 to March 2023. Age, gender, laterality, visual acuity, systemic disease, and follow-up duration were recorded. RAV characteristics were assessed using OCT and multicolour® images. This study examined RAV characteristics and type 2 MacTel disease stage.

RESULTS

In total, 270 eyes of 146 patients (97 females, 66%) with a mean age of 60.77 ± 9.34 years were studied. 153 (57%) eyes showed RAV. The non-proliferative stage of type 2 MacTel had either no RAV or a normal-calibre right-angled vein, while the proliferative stage had a right-angled artery and a dilated or normal-calibre RAV [p < 0.001]. RAV characteristics differed at the final follow-up (p < 0.001). 11 eyes transitioned from non-proliferative to proliferative after a median period of 26 months (range: 5-96 months). RAV characteristics changed from a normal calibre right-angled vein at presentation to a normal calibre vein and artery in 6 (55%) eyes and to a dilated vein and artery in 5 (45%) eyes respectively.

CONCLUSION

RAV characteristics may indicate type 2 MacTel stages. A right-angled artery in type 2 MacTel may indicate proliferative disease.

Epiretinal membrane formation and optic disc vascularisation in type 2A macular telangiectasia (MacTel)

PURPOSE

To describe a rare clinical finding of epiretinal membrane (ERM) and abnormal optic disc vascularisation in type 2A macular telangiectasia (MacTel).

CASE DESCRIPTION

A 52-year-old asymptomatic healthy male was examined in the retina clinic. In both eyes, corrected visual acuity was 20/20, N6. Anterior segment examination and intraocular pressure were both normal in both eyes.

RESULTS

The right eye's dilated fundus examination revealed loss of retinal transparency and superficial intraretinal crystals. A thick ERM extending from the optic disc to the macula obscured the details of the underlying perifoveal region in the left eye fundus. The diagnosis of bilateral type 2 MacTel was confirmed by confocal blue reflectance imaging, fluorescein angiography (FA), and macular optical coherence tomography (OCT). The left eye macular OCT scan also revealed a thick ERM without causing significant retinal traction. Furthermore, FA of the left eye revealed early hyperfluorescence with intense late leakage at the inferior aspect of the optic disc, giving the impression of abnormal optic disc vascularisation. No other cause for the disc vascularisation could be identified. OCT scan through the area with the optic disc leakage revealed a tuft of irregular hyperreflective tissue lying over the ERM. OCT angiography imaging confirmed the vascularity within the tuft of hyperreflective tissue over the ERM. Over a two-year period, no changes in clinical or imaging features were observed.

CONCLUSION

In type 2A MacTel eyes, ERM formation and abnormal disc vascularisation are uncommon findings. More histopathologic research is needed to characterise these membranes.

Comparison of pigment epithelium detachment composition indices between neovascular age-related macular degeneration and polypoidal choroidal vasculopathy

PURPOSE

To compare changes in the fibrous component of pigment epithelium detachment composition indices (PEDCI-F) in neovascular age-related macular degeneration (n-AMD) and polypoidal choroidal vasculopathy (PCV) over 12 months.

METHODS

This was a retrospective chart review of treatment-naïve n-AMD and PCV eyes treated with anti-vascular endothelial growth factor (anti-VEGF) agents. Optical coherence tomography (OCT) images were recorded at baseline and at 3, 6, and 12 months. OCT images were processed by filtering followed by pigment epithelium detachment (PED) segmentation and analysis of PED lesion heterogeneity based on the composition (PEDCI-F).

RESULTS

A total of 74 eyes with n-AMD (36) and PCV (38) were included. Overall, PEDCI-F increased minimally in both n-AMD and PCV groups (both p > 0.05). The majority, i.e., 58.3% and 60.5%, of n-AMD and PCV eyes, respectively, showed an increase in PEDCI-F at 12 months. An increase in PEDCI-F was associated with improved BCVA logMAR (n-AMD, r = -0.79; p < 0.001 and PCV, r = - 0.06; p = 0.74) and the need for fewer anti-VEGF injections (n-AMD, r = - 0.53; p < 0.001 and PCV, r = - 0.09; p = 0.58).

CONCLUSION

PEDCI-F increases in the majority of eyes with n-AMD and PCV through 12 months following treatment with anti-VEGF injections. This group had better visual acuity compared to the other subset with reduction in PEDCI-F requiring more anti-VEGF injections and worse visual acuity, possibly due to fibrovascular PED (FVPED) collapse and atrophy or a relative increase in other PEDCI constituents at 12 months.

Abnormal retinal vessel filling in central retinal artery occlusion

CLINICAL RELEVANCE

Central retinal artery occlusion (CRAO) is an ophthalmic emergency with a poor prognosis. Several initial CRAO presentation factors can influence the final visual outcome. Fluorescein angiography filling of retinal vessels in CRAO has not been studied in great detail.

BACKGROUND

The aim of this paper is to study the aberrant filling of the retinal vessels on fluorescein angiography in patients with CRAO and understand its clinical relevance.

METHODS

Cases of CRAO diagnosed between June 2017 and May 2022 and who had undergone a fundus fluorescein angiography were included. Comparisons were made between the cases with and without aberrant filling of the retinal vessel.

RESULTS

Twenty-two eyes of 22 patients (14 males and 8 females) with CRAO underwent fluorescein angiography. Ages of the patients ranged from 18 to 73 years, while time interval between development of acute onset vision problems and presentation to the retinal clinic ranged from a minimum of 1 day to a maximum of 30 days. Snellen visual acuity at presentation ranged from perception of light (PL +) to 6/6. On fluorescein angiography, aberrant flow of the fluorescein dye into the retinal vein was observed in four of the 22 (18%) eyes with CRAO. All these cases showed a patient's temporal cilioretinal artery. The cases with aberrant filling of the retinal vessels showed a better presenting visual acuity (6/6-6/60), lesser severity of inner retinal damage and a better final visual acuity (6/6-6/60) compared to CRAO cases without aberrant filling.

CONCLUSION

Aberrant filling of the retinal vein can be seen on fluorescein angiography in eyes with CRAO and a patent temporal cilioretinal artery. Such eyes with aberrant retinal vessel filling have a better visual prognosis.

A rare case of hyperpigmented torpedo maculopathy

PURPOSE

To describe a rare presentation of torpedo maculopathy (TM).

CASE DESCRIPTION

A 25-year-old male was examined in the retina clinic for a macular scar in the left eye. His visual acuity was 20/20, N6 in both eyes and no past history of ocular trauma or any medical or ocular history. The anterior segment was quiet and intraocular pressure was normal.

RESULTS

The patient's left eye on 78D slit lamp biomicroscopy revealed a flat, diffusely hyperpigmented fusiform torpedo-like lesion with sharp margins and surrounding hypopigmentation located predominantly temporal to the fovea, with its tip pointing towards it and just crossing the vertical foveal midline. Dilated fundus examination with binocular indirect ophthalmoscopy revealed no peripheral chorioretinal lesions or vitritis in both eyes. OCT scan through the lesion revealed gross damage to the outer retinal layers, as well as thickening of the retinal pigment epithelium and underlying shadowing, as well as a hyporeflective subretinal cleft involving the lesion. OCT also revealed outer retinal layer damage with an intact retinal pigment epithelium through the lesion's hypopigmented margins. Fundus autofluorescence image revealed a globally hypoautofluorescent lesion in the left eye, with surrounding patchy hyperautofluoroscent areas. Based on the patient history, clinical and imaging findings, other differential diagnoses such as atypical congenital hypertrophy of retinal pigment epithelium (RPE), choroidal nevus, RPE hamartoma, trauma and inflammatory conditions were ruled out. The diagnosis of TM was confirmed based on the typical lesion shape and location.

CONCLUSION

A torpedo lesion with diffuse hyperpigmentation is an unusually rare presentation.

Timing of ocular examination and retinal imaging for the diagnosis of type 2 macular telangiectasia (MacTel)

PURPOSE

To report a case demonstrating the relevance of ocular examination and retinal imaging timing in type 2 macular telangiectasia (MacTel).

CASE DESCRIPTION

A 55-year-old-female complained of blurring of vision in the left eye for the last 6 months. Corrected visual acuity was 20/20, N6 and 20/30, N8 in the right and left eye respectively. Anterior segment examination was normal in both eyes. Her both eyes' fundus was seen initially by the general ophthalmologist and was subsequently referred to the retinal specialist.

RESULTS

Dilated fundus examination of the right eye appeared normal while the left eye showed no specific retinal pathology except for a dull foveal reflex. Retinal imaging with optical coherence tomography and confocal blue reflectance (CBR) imaging were not conclusive of any specific clinical diagnosis. A fluorescein angiography and repeat CBR imaging was done on the following day which now clearly showed the features of type 2 MacTel.

CONCLUSION

Specific clinical and imaging features in type 2 MacTel are observed better in the absence of light exposure. Retinal imaging with CBR should not be performed immediately after dilated retinal examination in a suspected case of type 2 MacTel.

Evolution of demarcation line after pneumatic retinopexy-a case report

BACKGROUND

Demarcation line in a rhegmatogenous retinal detachment (RD) is a classic finding noted in chronic cases. In this case report, we describe a case of evolution of post-operative demarcation line after pneumatic retinopexy (PnR) in a subtotal rhegmatogenous RD.

CASE DESCRIPTION

A 31-year-old male diagnosed with acute, subtotal, macula-off rhegmatogenous RD in the left eye of 15-day duration underwent PnR on the same day. His presenting visual acuity was 6/48 in the left eye. Transconjunctival cryopexy was performed to the retinal break at the same sitting and 0.5 cc of 100% perfluoroproprane (C3F8) gas was injected in the vitreous cavity and right lateral position was advised to the patient.

RESULT

A pigmentary demarcation line was noted extending the nasal part of the macula along the most dependent part of the detachment on the immediate post-operative day and was more obviously visible on the 2nd and then on the 11th post-operative day. The visual acuity at the last follow-up visit improved to 6/18. Successful reattachment of the retina was noted on the last follow-up visit.

CONCLUSION

Post-operative demarcation lines after RD surgery could develop due to subretinal migration of pigments and along the most-dependent part depending upon post-operative positioning of the patient. Careful post-operative positioning, particularly in macula splitting RDs could be important to avoid pigment accumulation along the foveal area.

Congenital versus acquired optic disc pit maculopathy: An OCT based study

PURPOSE

The purpose of this study is to describe and compare the demographic, ocular, and imaging characteristics of a cohort of patients with congenital and acquired optic disc pit maculopathy (ODPM).

METHODS

This retrospective case series included patients diagnosed with ODPM between June 2017 and April 2023. These patients' baseline demographics, ocular characteristics, and optical coherence tomography (OCT) imaging characteristics and follow up changes were analyzed.

RESULTS

A total of 14 eyes with ODPM were identified (9 congenital and 5 acquired). Eyes with congenital ODP developed maculopathy at a younger age, presented commonly with visual symptoms, and exhibited an obvious pit at the temporal foveal margin as well as a high cup: disc ratio (p < 0.05). Primary open-angle glaucoma was identified in all five eyes with acquired ODPM. On OCT, eyes with acquired ODPM lacked the characteristic nerve fibre layer schisis, outer retinal layer hole, and foveal serous macular detachment (p < 0.05) unlike congenital ODPM. At the final follow-up visit, two cases from the congenital ODPM group and one case from the acquired ODPM group displayed complete resolution of maculopathy. The two cases of congenital ODPM were treated with pars plana vitrectomy and laser barrage to the optic disc margin, while the solitary case of acquired ODPM was treated with trabeculectomy surgery alone.

CONCLUSION

Clinical examination and baseline OCT imaging reveal distinct differences between congenital and acquired ODPM eyes. These characteristics may help with accurate diagnosis and treatment planning for these two distinct clinical entities.

Real-world practice patterns of eplerenone use for central serous chorioretinopathy

PURPOSE

To report eplerenone use by retina specialists worldwide for central serous chorioretinopathy (CSCR).

METHODS

A self-reporting questionnaire was distributed to retina specialists worldwide to gather clinicians' perspectives on CSCR cases treated, eplerenone dosage and duration, reasons to use it, and side effects.

RESULTS

The survey included 241 retina specialists (122 Indian and 119 international) with an average experience of 15.69 ± 9.59 years. Oral eplerenone was used to treat CSCR by 149 (62%) participants. Only 6% (n = 9) had easy access to verteporfin dye and photodynamic therapy. 30 (20%) of the 149 respondents changed their treatment with eplerenone after VICI trial results. Eplerenone was prescribed mostly for chronic CSCR (n = 86, 58%), regardless of involvement laterality. 62% (n = 92) had fewer than 25% CSCR cases treated with eplerenone. 85 (57%) respondents used eplerenone only when other treatments failed, while 36 (24%) used it as first-line treatment. 73 (49%) respondents, prescribed eplerenone at a 50 mg daily dose and 137 (92%) retina specialists used eplerenone for 0-3 months. The drug's efficacy dissatisfied 21 (14%) study participants. 124 (83%) study participants did not encounter any ocular or systemic side effects with eplerenone use. Eplerenone related kidney and electrolyte issues were noted by 11 (7%) study participants.

CONCLUSION

The treatment of CSCR varies around the world and is primarily influenced by the photodynamic therapy availability and the findings of VICI trial. Despite the limited benefit of eplerenone reported by the VICI trial, it is still used as evidenced by real-world experience.

TRIAL REGISTRATION NUMBER

Not applicable.

Central posterior hyaloid fibrosis: evolution and outcomes

PURPOSE

To report contributory factors and clinical outcomes of central posterior hyaloid fibrosis (CPHF) associated with neovascular age-related macular degeneration (nAMD).

METHODS

In this retrospective, single-center study, patients with CPHF and nAMD were included. Demographic and imaging characteristics, as well as the anatomical and functional outcomes, of these patients were analysed.

RESULTS

We identified 530 eyes in 273 patients with chronic predominantly scarred macular neovascularisation (MNV), and 32 eyes in 29 patients revealed CPHF, representing a prevalence of 6%. Patients had a mean age of 72.76 years. Before and during the development of CPHF, Type 2 MNV was observed in all eyes. At the time of MNV diagnosis, mean logMAR visual acuity was 1.308 ± 0.559 (20/407). The average time to develop CPHF was 27.3 months since the diagnosis of MNV. At the time of CPHF identification, the mean logMAR visual acuity was 1.498 ± 0.374 (20/630). RPE tear was observed in 6% (n = 2) of CPHF eyes. The average number of intravitreal anti-VEGF injections administered prior to the diagnosis of CPHF was 2.4 and after the onset of CPHF was 0.9. The final visual acuity was not significantly different at the final follow-up visit [1.304 ± 0.42 (20/402); p = 0.646].

CONCLUSION

Rarely observed in eyes with predominantly scarred subfoveal type 2 MNVs and extensive subretinal fibrosis, CPHF is associated with poor visual outcomes. Its presence could possibly suggest a profibrotic effect of MNV on the posterior hyaloid.

TRIAL REGISTRATION NUMBER

Not applicable.

Ocular blood vessel arrangement in choroidal coloboma

OBJECTIVE

To describe the ocular blood vessel arrangement in choroidal coloboma eyes.

METHODS

In this retrospective, observational cross-sectional study, fundus images from 69 coloboma eyes of 45 patients were classified as per Ida Mann's classification. The arrangement and distribution of retinal, choroidal, and episcleral vessels, as well as vortex veins, were observed in non-colobomatous, colobomatous, and extra-colobomatous regions.

RESULTS

Seventy-eight colobomas were identified. There were 12 type 1, 13 type 2, 10 type 3, 13 type 4, 11 type 5, 4 type 6 and 15 type 7 colobomas respectively. In most cases of type 1 and 2 colobomas, origin of retinal blood vessels could not be determined. In colobomas type 3-7, retinal blood vessels originated either from the optic disc centre or, rarely, from the optic disc or coloboma margin. Eyes with large and deep type 1, 2, 3 and 7 colobomas showed prominent choroidal vessels in the non-colobomatous region and around the coloboma. Small choroidal colobomas lacked prominent choroidal vessels. Similarly, prominent extraocular episcleral vessels within the coloboma bed were observed in eyes with colobomas of types 1, 2, 3 and 7. Vortex veins were visible in 70% of coloboma eyes. They were more commonly seen with small focal colobomas and less frequently with large deep colobomas.

CONCLUSION

Coloboma eyes have variations in the arrangement and distribution of ocular blood vessels. The position, size, and antero-posterior extent of the choroidal coloboma are the primary determinants of how these blood vessels are arranged. Future research would benefit from additional imaging with indocyanine green angiography.

Onion ring sign on spectral domain optical coherence tomography in diabetic macular edema: Its evolution and outcomes

PURPOSE

To report evolution and outcomes of hyperreflective crystalline deposit (HCD) on optical coherence tomography (OCT) in diabetic maculopathy (DM).

METHODS

Patients with DM showing HCD on OCT for the first time between June 2017 and May 2021 were included in the study. Demographic, ophthalmic and OCT features were documented and analysed. Factors leading to the development of HCD and its effect on the functional outcome were analysed and described in this study.

RESULTS

Sixty cases of HCD were identified in 45 (males -33; females - 12) patients for the first-time during the defined study period. Mean age of the eligible patients was 61.53 ± 8.19 years. Average duration of diabetes was 13.82 ± 7.38 years. Mean visual acuity of these patients was 0.902 ± 0.438 logMAR units (Snellen equivalent = 20/160). Patients with HCD showed subretinal hard exudates, were on anti-cholesterol medications (n = 36, 80%) and showed reduced visual acuity (20/160) if the HCD involved the fovea. The median time taken for the development of HCD was 28 months. Mean follow-up duration of the study was 26.19 ± 27.98 months. Persistence of HCD in all cases (n = 42, 100%) was noted at the last follow-up visit.

CONCLUSION

Horizontal, single or multi-layered HCDs on OCT in DM represent intraretinal or subretinal cholesterol crystal precipitates evolving from the hard exudates identical to the "onion ring sign" seen in neovascular AMD. HCDs or CCs depict deranged lipid metabolism, chronic vascular leakage and can lead to substantial visual impairment if the fovea gets involved.

Aberrant filling of the retinal vein on fluorescein angiography in branch and hemi-central retinal artery occlusion

OBJECTIVE

To study aberrant filling of the retinal vessels on fluorescein angiography (FA) images in patients with branch (BRAO) or hemi-central retinal artery occlusions (hemi-CRAO) and correlate with associated changes on optical coherence tomography (OCT).

METHODS

Cases of acute BRAO or hemi-CRAO having FA and OCT images at presentation between June 2017 to May 2022 were included. Comparisons were made between the cases with and without aberrant filling of the retinal vessel.

RESULTS

Thirty-nine eyes of 39 patients with acute retinal artery occlusions underwent FA and OCT imaging. Seven of the ten cases with either BRAO or hemi-CRAO showed aberrant filling of the retinal vein on FA. No case with CRAO showed aberrant filling on FA. The cases with aberrant filling showed a better presenting visual acuity and lesser severity of retinal ischemia on OCT. Shunts between the retinal artery in the unaffected region and the retinal vein in the affected segment was seen in two eyes. The remaining five eyes showed no arteriovenous anastomosis. Cases with aberrant filling had a better visual function even at the last visit.

CONCLUSION

Aberrant retinal vein filling across the horizontal median raphe in the affected region in BRAO or hemi-CRAO eyes had less severity of retinal ischemia and better presenting and final visual acuities. Reduced perfusion in retinal capillaries with altered retinal vascular anatomy or arteriovenous shunts could be probable reasons for the development of this FA finding. Presence of aberrant filling of the retinal vein could indicate better final visual prognosis.

Baseline demographic, clinical and multimodal imaging features of young patients with type 2 macular telangiectasia

PURPOSE

Macular telangiectasia (MacTel) type 2 is observed in patients in their 5th-8th decades of life. The clinical and imaging findings in younger patients is unknown in larger cohorts. The study purpose is to report prevalence, baseline clinical and spectral domain optical coherence tomography (SDOCT) findings in young MacTel patients below 40 years.

METHODS

This hospital-based, multicentre, retrospective, cross-sectional study included patients between 2011 and 2023. Retinal photographs from multiple imaging techniques were evaluated to diagnose and stage type 2 MacTel and describe their SDOCT findings. Imaging characteristics were correlated with clinical stages and visual acuity.

RESULTS

Among all MacTel patients seen in hospital, prevalence of young MacTel cases less than age 40 was 1.77% (32/1806; 62 eyes). Youngest participant was 34 years, while mean age was 38.44 ± 1.795 years. Sixteen patients (50%) were diabetics. Perifoveal greying (n = 56, 90%) and perifoveal hyperreflective middle retinal layers (n = 47, 76%) were the most prevalent clinical and SDOCT imaging finding respectively. Less than 10% (n = 6) eyes had proliferative disease. Presence of retinal pigment clumps (RPC) (7% vs. 67%; p = 0.002) coincided with proliferative MacTel. Poor vision was associated with presence of outer retinal layer SDOCT findings like outward bending of inner retinal layers (p = 0.047), RPC (p = 0.007), subfoveal neurosensory detachment (p = 0.048) and subretinal neovascular membrane (p = 0.001).

CONCLUSION

Type 2 MacTel before age 40 is rare, common in women and diabetics, and affects vision in advanced stage. Disease symmetry, comparison with older cases, and longitudinal SDOCT changes in such patients require further study.

Evaluation of baseline optic disc pit and optic disc coloboma maculopathy features by spectral domain optical coherence tomography

PURPOSE

The aim of this study is to describe and compare the baseline demographic, ocular, and imaging characteristics of a cohort of patients with optic disc pit (ODP) or optic disc coloboma (ODC) maculopathy.

METHODS

This retrospective study included patients diagnosed with ODP or ODC on clinical examination between June 2017 and December 2022. These patients' baseline demographics, ocular characteristics, and optical coherence tomography (OCT) imaging characteristics were analyzed.

RESULTS

Fundus examination revealed 11 eyes of 11 patients with ODP and 14 eyes of 9 patients with ODC, respectively. On OCT, maculopathy was observed more frequently in ODP (n = 10) than in ODC (n = 4) [p = 0.004] cases. Eyes with ODP were more likely to exhibit retinoschisis and/or serous macular detachment [SMD] (n = 7, 70%), communication of the retinoschisis with the optic disc (p = 0.015), whereas the SMD did not communicate with the optic disc (p = 0.005), and significant outer retinal layer thinning (p = 0.015). In contrast, eyes with ODC exhibited only SMD (p = 0.005) and no retinoschisis on the non-colobomatous retina. SMD in ODC communicated with the margin of the optic disc. In both clinical entities, hyperreflective foci were observed in the SMD.

CONCLUSION

In summary, baseline maculopathy characteristics on OCT, including its type, location, and relationship to the optic disc, are among the most distinguishing characteristics between an ODP and an ODC.

TRIAL REGISTRATION NUMBER

Not applicable.

Mid-phase pinpoint hyperfluorescent spots on fundus fluorescein angiography in acute central retinal artery occlusion - a novel imaging finding

PURPOSE

To describe the development and outcome of mid-phase pinpoint hyperfluorescent spots (MPHS) on fundus fluorescein angiography (FFA) in acute (< 7-day symptom onset) central retinal artery occlusion (CRAO) patients.

METHODS

This retrospective study included acute CRAO patients who underwent multimodal imaging utilizing optical coherence tomography (OCT) and FFA between June 2017 and January 2023. The correlation of FFA images with the OCT images in various stages and severity of CRAO were studied.

RESULTS

Twenty-three FFA studies on 23 patients with acute CRAO were included. In 11 (48%) cases, an important finding noted on FFA was the presence of single or multiple MPHS with adjacent minimal late vascular leakage. Of these 11 cases, eight (73%) were males and median age was 41 years (inter quartile range: 33-55 years). Visual acuity ranged from 'light perception' to 6/18, and these patients presented anytime on the same day to seven days after symptom onset. On OCT, three eyes had severe CRAO, seven eyes had moderate CRAO, and one eye had mild CRAO. MPHS were primarily observed at the posterior pole and more frequently observed in moderate CRAO severity. During follow-up, the MPHS and retinal vessel staining on FFA disappeared as the CRAO showed signs of resolution.

CONCLUSION

MPHS at the posterior pole on FFA in acute CRAO patients could indicate a more severe occlusion and poor visual outcomes, even after treatment. This finding is most likely caused by red blood cell aggregation or rouleaux formation.

TRIAL REGISTRATION NUMBER

Not applicable.

Retinal OCT findings in acute central retinal artery occlusion of varying severity at different disease stages - a retrospective, observational study

PURPOSE

To study the optical coherence tomography (OCT) changes in eyes with acute central retinal artery occlusion (CRAO) of different severity and at different disease stages.

METHODS

The study included acute CRAO cases of < 7 days duration, imaged on OCT at various time points. Based on the OCT findings at presentation, cases were classified into three severity groups: mild, moderate, and severe. OCT scans were evaluated and classified into four-time intervals based on symptom duration.

RESULTS

There were 39 eyes from 38 patients with acute CRAO who underwent 96 OCT scans. At presentation, the study had 11, 16, and 12 cases of mild, moderate, and severe CRAO, respectively. Middle retinal layer opacification was more common in mild CRAO cases, which caused inner retinal layer thinning over time. Moderate CRAO cases had total inner retinal layer opacification, which resulted in retinal thinning over time. Prominent middle limiting membrane (p-MLM) sign was seen in mild and moderate CRAO eyes while were not visualised in severe CRAO. This sign gradually faded out over time. Other OCT findings in higher grades of CRAO included inner retinal fluid, neurosensory detachment, internal limiting membrane detachment, hyperreflective foci, and posterior vitreous opacities. Regardless of the CRAO grade, the final end-point seen was inner retinal layer thinning over time.

CONCLUSION

OCT in CRAO is a useful for determining the severity of retinal ischemia, disease stage, tissue damage mechanism, and final visual outcome. More prospective studies analysing a larger number of cases at fixed time points will be required in the future.

TRIAL REGISTRATION

Trial Registration Number: Not applicable.

Ocular surface changes following vitreoretinal procedures

Dry eye disease (DED) can lead to ocular discomfort as well as visual disturbances. Older adults are more likely to develop DED. They are also more likely to develop retinal diseases such as diabetic retinopathy and age-related macular degeneration, which may require vitreoretinal surgeries, lasers, and intravitreal injections. Posterior segment surgery may cause or worsen existing dry eye symptoms, albeit temporarily. Despite good anatomic and functional outcomes, ocular surface dysfunction can have a significant impact on the quality of life, lowering a patient's satisfaction with the retinal treatment. Preexisting DED, intraoperative tissue handling, and postoperative treatment may all contribute to the severity of ocular surface dysfunction. In this article, we have reviewed all relevant studies on the development of ocular surface changes and DED, as well as the impact of vitreoretinal surgeries and procedures on the ocular surface.

REal-world treatment outcomes after delayed intRavitreal therapy in center-involving diabetic macular edema - RETORT study

PURPOSE

To compare real-life data on delayed intravitreal treatment of diabetic macular edema (DME) patients to early treatment.

METHODS

In this single-centre, retrospective, interventional, comparative study, DME patients were divided into two groups based on when they received treatment: Group 1 - received treatment within 24 weeks and Group 2 - at or after 24 weeks from the time of treatment advice. Visual acuity and central subfield thickness (CSFT) changes were compared at various time points. Reasons for delaying treatment were noted.

RESULTS

The study included 109 (Group 1-94; Group 2-15) eyes. When treatment was advised, demographic profile, diabetes duration, glucose control and VA between two groups were comparable. At this point, CSFT was higher in Group 1 than in Group 2 (p = 0.036). At injection time, Group 2 had better VA and lower CSFT than Group 1 (p < 0.05). Group 2's VA (53.4 ± 12.67) was significantly lower than Group 1's (57.38 ± 20.01) after 1-year treatment. At 1-year, CSFT decreased in Group 1 and increased in Group 2. Group 1 had mean improvement of + 7.6 letters and Group 2 had a decline of -6.9 letters. Group 2 required more intravitreal anti-VEGF (median - 3; IQR: 2-4), steroid injections (median - 4; IQR: 2-4) and focal laser sessions (median - 4; IQR: 2-4).

CONCLUSION

Late-treated DME eyes needed more injections and focal laser sessions than early treated eyes. Adherence to early treatment of DME in real-life will help prevent long-term vision loss.

Amino Acid Tracer PET MRI in Glioma Management: What a Neuroradiologist Needs to Know

PET with amino acid tracers provides additional insight beyond MR imaging into the biology of gliomas that can be used for initial diagnosis, delineation of tumor margins, planning of surgical and radiation therapy, assessment of residual tumor, and evaluation of posttreatment response. Hybrid PET MR imaging allows the simultaneous acquisition of various PET and MR imaging parameters in a single investigation with reduced scanning time and improved anatomic localization. This review aimed to provide neuroradiologists with a concise overview of the various amino acid tracers and a practical understanding of the clinical applications of amino acid PET MR imaging in glioma management. Future perspectives in newer advances, novel radiotracers, radiomics, and cost-effectiveness are also outlined.

Long-term effects of combined brilliant blue G and xenon light induced retinal toxicity following macular hole repair surgery

BACKGROUND

The purpose of this study was to look at the long-term effects of retinal phototoxicity after macular hole repair surgery using xenon endolight illumination and Brilliant blue G (BBG) dye.

CASE PRESENTATION

An elderly man in his late seventies underwent para plana vitrectomy with BBG dye to repair an idiopathic full-thickness macular hole (MH) in his right eye. Prior to macular hole surgery, his visual acuity in the right eye was 6/60, N24 at the time of presentation. The MH closed with type 1 closure immediately after surgery, but there was extensive damage to the outer retinal layers and retinal pigment epithelium (RPE) at the macula, resulting in a reduction in visual acuity to 2/60. We presumed that the combination of BBG and xenon light, is the probable reason of retinotoxicity in the current patient. There was a progressive increase in the area of retinal and RPE layer damage and choroidal thinning over a 4-year period.

CONCLUSION

Due to combined BBG-induced dye and endoilluminator toxicity, a rare case of continuously progressing RPE layer damage with choroidal thinning over a long follow-up interval was described. Such long-term effects of BBG and endolight induced retinotoxicity have not been reported in the literature, to the best of our knowledge.

Post-vitrectomy delayed retinal breaks in proliferative diabetic retinopathy

PURPOSE

To report a series of cases of post-operative new secondary retinal breaks following vitrectomy for proliferative diabetic retinopathy (PDR).

METHODS

This retrospective case series included data of patients diagnosed with post-operative retinal breaks following uneventful vitrectomy surgery for PDR from January 2018 to December 2021.

RESULTS

New post-vitrectomy retinal breaks in PDR were seen in 7% of eyes (n = 10/148 eyes; 10 patients). Age of study patients ranged from 45 to 69 years and there were 8 males. Vitreous surgery was performed for vitreous hemorrhage in six eyes, macular tractional retinal detachment in three eyes and epiretinal membrane in one eye. Tractional fibrovascular proliferation near the retinal break prior to its development was noted either pre- or intra-operatively in 8 eyes. Mean time interval between the vitreous surgery and secondary retinal break development was 6.4 months. Residual fibrous tissue post-surgery adjacent to the break was noted in 4 cases. Sclerosed retinal vessel was noted in 4 eyes and associated inner retinal thinning or schisis in 5 eyes. No retinal detachment was noted in any case. Prophylactic barrage was done in 4 eyes. Last follow-up interval ranged from 4 to 53 months and visual acuity ranged from 6/6 to 6/60. No subretinal fluid, traction or break enlargement was noted at the last visit.

CONCLUSION

Delayed post-operative retinal breaks following vitrectomy are uncommon in PDR eyes. Careful preoperative evaluation of the retinal proliferations, intraoperative dissection of the membranes and regular post-operative reviews are vital in anticipating the development of delayed post-vitrectomy retinal breaks. Observation could be the management strategy for these breaks.

Tamoxifen retinopathy and macular telangiectasia: A comparative case series

PURPOSE

To report a case series of tamoxifen retinopathy (TR) with and without type 2 macular telangiectasia (MacTel) and compare their clinical and imaging findings.

METHODS

Retrospective comparative study. Female patients with tamoxifen use or with clinical diagnosis of type 2 MacTel were divided into 4 groups: Group A-tamoxifen use without retinopathy; Group B-tamoxifen use with retinopathy; Group C-type 2 MacTel with tamoxifen use and Group D-type 2 MacTel without tamoxifen use. Clinical and image analysis was conducted.

RESULTS

There were 6 patients (11 eyes) in group A, 8 (13 eyes) patients in Group B, 2 patients (4 eyes) in Group C and 8 patients (14 eyes) in Group D respectively. TR patients were young, showed retinal crystals, perifoveal greying and no retinal pigment clumps (RPC) on examination. Foveal contour irregularity (n = 13, 100%) and outer retinal layer damage (n = 11, 85%) were common OCT findings seen in TR. In group C, all eyes showed 360° middle retinal layer (MRL) hyperreflectivity (100% vs 86%) and presence of outer retinal hyporeflective cavitation (100% vs 43%) on OCT compared to patients in group D. Abnormal autofluoroscence, detection and leakage from the telangiectatic vessels on fluorescein and OCT angiography was seen in type 2 MacTel disease.

CONCLUSION

Patients with TR showed retinal crystals and outer retinal hyporeflective foveal cavitation on OCT. Patients with type 2 MacTel having with tamoxifen intake showed hyporeflective outer retinal foveal cavitation and 360° perifoveal MRL hyperreflectivity on OCT. RPC was observed exclusively in the type 2 MacTel group.

Choroidal Melanocytic Hamartoma

We report on a case series that revealed flat, choroidal lesions on optical coherence tomography (OCT) and on enface MultiColor® (MCI) imaging of the fundus but were not noticeable on clinical examination or conventional color fundus images. This observational study included 12 eyes from 11 patients who had distinct, orange-colored lesions on MCI. Retinal imaging was conducted using conventional color fundus photography and OCT. On the color fundus images and the blue and green reflectance channels of MCI, each of the lesions was difficult to distinguish. On the infrared channel, the lesion was identified as bright white in color and bright orange on the multicolor image. The lesion was identified on OCT as a flat, homogeneous hyperreflective lesion involving the choroid, with an intact overlying retinal pigment epithelium and retinal layers. A comparison of the clinical and imaging features with other known entities led to the conclusion that the lesion was a distinct clinical entity. The presence of melanin in the lesion was confirmed based on the retinal imaging findings and the light absorption properties of melanin. As a result, the lesion was named as 'choroidal melanocytic hamartoma'. A longer follow-up is required to confirm the benign nature of this clinical entity.

Is Type 2 Macular Telangiectasia a Bilateral and Symmetrical Disease Entity?

Purpose

To study the inter-eye asymmetry in cases diagnosed with type 2 macular telangiectasia (MacTel).

Methods

Herein, type 2 MacTel cases were staged as per Gass and Blodi classification with multiple imaging techniques. Based on disease stage symmetry, two groups identified. Group 1: Symmetrical stage and Group 2: Asymmetrical stage MacTel disease. Prevalence, demography, and clinical features of MacTel cases showing inter-eye asymmetry were analyzed.

Results

Two hundred and eighty eyes of 140 patients diagnosed clinically with type 2 MacTel (84-Group 1 and 56-Group 2) were evaluated. Eighty-nine (64%) were female, and the median age of the entire cohort was 62.5 years (inter-quartile range: 57.0-68.75). MacTel disease with asymmetric stage was seen in 56 (40%) of the 140 patients. At presentation, a two-stage difference was noted in 46% (n = 26) of the patients with asymmetrical MacTel disease. A 10% conversion from symmetrical to asymmetrical disease stage was noted at the final visit. Of the 280 eyes evaluated for type 2 MacTel disease, 12 (4%) eyes showed no findings suggestive of MacTel on clinical examination and fluorescein angiography, optical coherence tomography (OCT), and OCT angiography when available and were labeled as unilateral type 2 MacTel disease.

Conclusions

Type 2 MacTel can show inter-eye disease stage asymmetry. Unilateral type 2 MacTel disease is a distinct stage in MacTel which would need further evaluation and consideration while staging.

Lincoff's Rule Is Not Followed in Pediatric Rhegmatogenous Retinal Detachments

PURPOSE

To validate Lincoff's rules (LRs) in cases of rhegmatogenous retinal detachment (RRD) in the pediatric age group and to identify factors in cases LR was not followed.

METHOD

This was a retrospective study where 98 pediatric patients with RRD were identified through surgery records. Forty case sheets with complete record of ocular examination and surgical findings were analyzed. Visible or suspected preoperative retinal break identified using the LR and actual intraoperative retinal break noted was recorded. Validity of LR was tested and analysed.

RESULT

The median age of the study participants was 11 years ranging from 5 to 18 years. There were 35 (88%) boys and 5 (12%) girls in the study. Myopia was noted in 13 (33%) eyes and in 21 (53%) eyes, there was a history of preexisting ocular trauma. Moderate degree of agreement with a Cohen's kappa 0.41 was noted with regards to LR validity in pediatric RRD. LR was validated in non-myopic eyes (p = 0.022), inferior RD (p < 0.001), and those with anteriorly located retinal breaks (p < 0.001). Other attributes such as history of trauma (p = 0.08), lens status (p = 0.489), macula sparing RRD (p = 0.882), and chronicity of RRD (p = 0.612) did not have a statistically significant association with validity of LR. Multivariate logistic regression analysis identified the presence of anterior retinal break (p = 0.011) and presence of inferior RD (p = 0.022) as the two most important attributes in a RD for agreement of LR.

CONCLUSION

LRs fail to accurately identify the exact location of the retinal break due to its posterior location and absence of posterior vitreous detachment in most cases with pediatric RRDs.

Reactivation of juvenile idiopathic arthritis associated uveitis with posterior segment manifestations following anti-SARS-CoV-2 vaccination

Background/purpose

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in the pediatric population and anterior uveitis is its commonest extra-articular manifestation. Typically the uveitis presents as chronic anterior uveitis and there is limited literature of the posterior segment manifestations of the disease. Similar to other vaccines, anti-SARS-CoV-2 vaccination that began as an urgent measure to control the spread of the SARS-CoV-2 pandemic has not been without adverse events. We are reporting a 19-year-old Asian Indian female who was diagnosed and treated for JIA associated anterior uveitis that was unilateral and was under anti-inflammatory control but showed worsening of uveitis with posterior segment inflammation in both eyes following anti-SARS-CoV-2 vaccination.

Case report

A 19-year-old Asian Indian female with a history of juvenile idiopathic arthritis on treatment with methotrexate, presented with right eye chronic anterior uveitis with peripheral subclinical retinal vasculitis and macular edema which was brought under control following administration of adalimumab. She was inflammation free for 6 months until she received anti-SARS-CoV-2 vaccination and developed new onset floaters in both eyes that were initially noted after the first dose and increased after the second dose. Clinical examination revealed presence of keratic precipitates and grade 1+ anterior chamber inflammation along with vitiritis in both eyes. Fundus fluorescein angiography revealed angiographically active retinal vasculitis without the presence of macular edema in both eyes. This was managed with a short course of topical difluprednate and continuation of systemic immunosuppressive therapy with adalimumab and methotrexate.

Conclusion

JIA associated uveitis results from an autoimmune process which can be controlled with timely immunosuppressive treatment. It is important to be aware of the potential risk of flare up of uveitis with posterior segment manifestations following anti- SARS-CoV-2 vaccination.

Factors associated with recurrent stroke and recanalization in patients presenting with isolated symptomatic carotid occlusion

Background and purpose

Patients with symptomatic internal carotid artery (ICA) occlusion constitute a small proportion of stroke/transient ischaemic attack patients who are at increased risk of early stroke recurrence and poor outcome. The optimal medical treatment for patients with symptomatic ICA occlusion who are ineligible for thrombolysis or thrombectomy is unknown.

Methods

Consecutive patients presenting at a single center with newly diagnosed symptomatic ICA occlusion (not involving the circle of Willis) were retrospectively reviewed. Those treated with intravenous thrombolysis or intra‐arterial thrombolysis/thrombectomy were excluded. Patients were divided into two groups based on whether they experienced recurrent in‐hospital stroke.

Results

The selected study population (n = 33) represented a small (20.4%) proportion of all newly symptomatic carotid occlusions, who nevertheless had an elevated risk of recurrent stroke during admission (24.2%). Of the variables examined (age, gender, admission National Institutes of Health Stroke Scale score, vascular risk factors, atrial fibrillation, prior stroke/transient ischaemic attack and anticoagulation within 48 h of presentation), only anticoagulation was significantly associated with a lower risk of in‐hospital recurrent stroke. Anticoagulated patients showed a decreased incidence of stroke recurrence within the first week (6.7% vs. 38.9%, P = 0.032) and fewer strokes or deaths at 1 month (13.3% vs. 47.1%, P = 0.040). Hemorrhagic transformation was not observed in any patient. On follow‐up imaging, ICA recanalization was significantly more frequent in anticoagulated patients (46.2% vs. 9.1%, P = 0.047).

Conclusion

Patients with newly diagnosed symptomatic ICA occlusion (not involving the circle of Willis) represent a small but high risk subgroup of patients with carotid occlusion. Early anticoagulation was associated with fewer recurrent strokes and increased ICA recanalization. Larger scale prospective studies may be justified.

Percentage signal recovery derived from MR dynamic susceptibility contrast imaging is useful to differentiate common enhancing malignant lesions of the brain

BACKGROUND AND PURPOSE

Differentiation of enhancing malignant lesions on conventional MR imaging can be difficult and various newer imaging techniques have been suggested. Our aim was to evaluate the role of PSR obtained from DSC perfusion measurements in differentiating lymphoma, GBM, and metastases. The effectiveness of PSR was compared with that of rCBV. We hypothesized that the newly defined parameter of PSR is more sensitive and specific in differentiating these lesions.

MATERIALS AND METHODS

This retrospective study included 66 patients (39 men and 27 women; age range: 27-82 years) with a pathologically proved diagnosis of primary CNS lymphoma, GBM, or metastases (22 patients in each group). Mean PSR, min PSR, max PSR, and rCBV were calculated. The classification accuracy of these parameters was investigated by using ROC.

RESULTS

Mean PSR was high (113.15 ± 41.59) in lymphoma, intermediate in GBM (78.22 ± 14.27), and low in metastases (53.46 ± 12.87) with a P value < .000. F values obtained from 1-way ANOVA analysis for mean, min, and max PSR ratios were 29.9, 39.4, and 23.4, respectively, which were better than those of rCBV (11.1) in differentiating the 3 groups. Max PSR yielded the best ROC characteristics with an A(z) of 0.934 (95% CI, 0.877-0.99) in differentiating lymphoma from metastases and GBM. The A(z) for mean and min PSR of 0.938 (95% CI, 0.0.884-0.990) and 0.938 (95% CI, 0.884-0.991), respectively, was better than rCBV (A(z), 0.534; 95% CI, 0.391-0.676) in the differentiation of metastases from GBM and lymphoma (P ≤ .0001).

CONCLUSIONS

PSR appears to be a parameter that helps in differentiating intracerebral malignant lesions such as GBM, metastases, and lymphoma.

Post-marketing surveillance of buprenorphine

PURPOSE

This study was undertaken to evaluate the adverse consequences of recently introduced higher strength (0.4 and 2.0 mg per tablet) buprenorphine in Indian market. Buprenorphine, a partial opiate agonist and antagonist, is an emerging alternative to methadone as an agent for long-term treatment of opiate dependence.

METHODS

The current investigation was conducted through a multi-centric post-marketing surveillance (PMS) study using a structured performa from patients receiving buprenorphine as routine therapy from de-addiction centres. Evaluation included subjective and objective assessments and recording of adverse events.

RESULTS

Of the 5551 observations from ten centres, common subjective symptoms were generalised weakness (48.9%), sense of high (euphoria) (44.5%), muscle aches (39.5%) and relief from pain (37.2%). About 5% observations recorded systolic hypertension. Among 55 subjects where laboratory tests were conducted, 12 showed raised levels of AST ad 9 had elevated ALT. Twelve adverse events reported included seizure, epistaxis, panic attacks, constipation and dyspnoea. Significant relation was seen between duration of use and time since last dose, and total number of subjective symptoms reported.

CONCLUSIONS

Majority of the adverse effects could be understood as either effects related to intoxication or withdrawal from agonists.

Traumatic transverse fracture of sacrum with cauda equina injury--a case report and review of literature

Fractures of the sacrum are rare and generally associated with fracture of the pelvis. Transverse fractures of the sacrum are even less frequent and neurological deficit may accompany these fractures. A case of transverse fracture sacrum with cauda equina injury treated by sacral laminectomy and root decompression, is reported.

Clinicopathological correlation in 50 cases of erythroderma

Fifty cases of erythroderma were studied clinically and histopathologically. Clinically 11 were of eczemas, 12 of psoriasis, 14 were drug-induced, 11 of idiopathic group and 1 each of pemphigus foliaceus (PF) and cogenital bullous ichthyosiform erythroderma (CBIE). Histopathologically 10 cases of psoriasis, 1 of PF and 1 of CBIE showed specific histopathology and therefore clinical histopathological correlation was possible only in 12 (24%) cases. Exact differentiation in erythroderma due to eczemas, drugs or idiopathic was not possible histopathologically.