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.

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.

Long-term follow-up of acute retinal necrosis with retinal detachment secondary to herpes simplex virus type 2 with a successful visual outcome

A man in his early 20s presented with acute loss of vision in his only eye, the left eye (OS), and was on oral steroids. He had lost vision in his right eye during his childhood and the cause was unknown. There was no history of trauma. Best-corrected visual acuity (BCVA) in OS was 20/100 and in the right eye was hand movements. OS showed non-granulomatous keratic precipitates on the cornea, anterior chamber flare 1+ and cell 1+, early cataract, vitreous haze and cells 2+ with nasal retinal detachment and superior full thickness retinitis. He underwent pars plana vitrectomy with intravitreal ganciclovir and barrage laser away from the necrotic retina. PCR for herpes simplex virus 2 was positive from the aqueous and vitreous sample. He was started on oral valacyclovir 1 g three times a day and continued on tapering dose of oral steroids. BCVA in OS at 6-month follow-up was 20/25.

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.

Recommendations for management of peripheral retinal degenerations

Some degenerations involving the peripheral retina can result in a rhegmatogenous retinal detachment. Currently, there are no clear guidelines for retinal screening and/or management of these peripheral retinal degenerations in patients with or without recent onset posterior vitreous detachment or in those prior to refractive surgery or intraocular procedures. This article aims to provide a set of recommendations for the screening and management of peripheral retinal degenerations based on a common consensus obtained from an expert panel of retinal specialists.

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.

Serial ERG monitoring of response to therapy in vitamin A deficiency related night blindness

Two male patients with known systemic disorders who presented with complaints of nyctalopia underwent a complete ophthalmic examination including electrophysiological evaluation and serum vitamin A (retinol) levels. A significant vitamin A deficiency was detected, supplementation started and repeat electroretinogram (ERG) testing was carried out to monitor the timeline of recovery. Restoration of rod and generalised cone function was rapid within the first week of receiving treatment and near normal recovery was seen after 1 month of supplementation. Serial monitoring of ERG changes in vitamin A deficiency (VAD) associated night blindness plays an important role to demonstrate functional recovery post-treatment. The different effects of VAD on rod and cone function, and their rate of recovery, may reflect differences in the visual cycle between the two photoreceptors. We report the serial ERG changes in VAD related night blindness secondary to intestinal lipofuscinosis and liver cirrhosis in two patients.

Central Corneal Thickness and Intraocular Pressure of Adult Nigerians: An Assessment of Zaria Community

BACKGROUND

Glaucoma is the commonest cause of irreversible blindness globally and intraocular pressure is the only known risk factor that can be therapeutically manipulated to change the course of the disease.1 Central corneal thickness (CCT) is known to affect the accuracy of intraocular pressure (IOP) measurements by applanation tonometry.2 A thicker cornea requires greater force to flatten and, conversely, a thinner cornea is more easily flattened. Data on this important parameter is scanty in northern Nigeria. The aim and objective of this study was to determine the mean CCT and IOP and relate CCT to Age and IOP.

STUDY DESIGN

It was a cross sectional study of the right eyes of two hundred and two suitable consecutive participants in an eye screening camp. Their IOP was measured using Perkins Applanation Tonometer and the CCT was assessed using an ultrasound Pachymeter (Sonomed Pac Scan 300AP+).These were done for both eyes at the same sitting by the same examiner. The data was analysed using Analyse-it for Excel soft ware.

RESULTS

There were 50 males and 152 females. M:F 1:3 and age range was 18-80 years with mean of 46.2 years ± 15 years. The mean CCT was 526.90mm ±SD 35.3.The mean in those who have glaucoma/glaucoma suspects was 523.10mm ±SD 41.3.The mean IOP was 16.8 ± 5.1mmHg. Age/CCT Pearson's correlation: r = -0.20 t= -3.97 p <0.0001. The CCT/IOP Pearson's correlation r=0.16, p=0.0206.T Conclusion: The mean CCT of 526.90mm for non-glaucomatous eyes in this study is thinner than but comparable to similar population of African Americans (528.50mm) and black population of Barbados Eye Study(529.80mm) .Similarly those of Egyptians(530.10mm) and Sudanese (530.20µm) were thicker. The value for white population of Barbados Eye Study was the thickest (545.20mm).There was a negative correlation between Age and CCT but a positive correlation between CCT and IOP.

Combined hepatocellular and cystadenocarcinoma presenting as a giant cyst of the liver--a case report

Primary cystic lesions of the liver are very rare. Most of the solid tumours are hepatocellular carcinomas (HCC) with a smaller number being cholangiocarcinomas. The association of HCC with other primary liver malignancies is also extremely rare. This case report is about a 27 year old male patient who presented with a giant cystic lesion of the left liver. A CT scan showed a cystic lesion with internal septations and a thrombus in the main portal vein. The patient underwent an extended left hepatectomy and a portal venotomy with removal of the thrombus. Coexistent hepatocellular and cystadenocarcinoma were reported on histopathological examination. The patient was put on 5-FU postoperatively. He is doing well 11 months after surgery.