Ophthalmology @ Point of Care

To evaluate the outcomes of deep anterior lamellar keratoplasty (DALK) followed by phacoemulsification and toric intraocular lens (IOL) implantation for the treatment of concomitant stromal disease and cataract.

In this retrospective non-comparative interventional case series, ten eyes affected by stromal disease and cataract underwent DALK followed by phacoemulsification with toric IOL implantation after a minimum period of 5 months from complete suture removal. In each case, topographic astigmatism, refraction, visual acuity, and endothelial cell density were recorded before DALK and 1, 6, and 12 months after cataract surgery. In addition, IOL rotation was evaluated using anterior segment optical coherence tomography.

Big-bubble DALK was performed in all eyes but one that received manual dissection. Topographic astigmatism averaged 5.6 ± 2.2 diopters (D) after suture removal; refractive astigmatism decreased to 0.55 ± 0.61 D as early as one month after cataract surgery and did not change substantially throughout the follow-up period. In all patients, one month after phacoemulsification uncorrected and best spectacle-corrected visual acuity were, respectively, ≥20/40 and ≥20/25 with a residual spherical equivalent of 0.00 ± 0.84 D. At the latest follow-up visit, in all cases the IOL rotation was ≤5 degrees from the intended position and the endothelial cell loss within 8.5%. No complications were recorded.

DALK followed by phacoemulsification with toric IOL implantation optimizes visual and refractive outcomes in patients with concomitant stromal disease and cataract. In comparison with a combined procedure, the sequential approach offers better predictability of the postoperative refraction in the absence of an increased risk of complications.

To report a case of Purtscher-like retinopathy associated with travel at high altitude.

Case report.

A 67-year-old man presented 2 weeks after acute vision loss in his left eye that occurred while he was hiking in the mountains of South America. Funduscopic examination revealed multiple cotton-wool spots and discrete areas of retinal whitening. Fluorescein angiography demonstrated areas of choroidal fluorescence blocked by retinal whitening, delayed arteriovenous transit time, and late capillary leakage. Spectral-domain optical coherence tomography showed hyperreflectivity in the inner plexiform, inner nuclear, and outer plexiform layers localized to the areas of retinal whitening. These findings were believed to be most consistent with Purtscher flecken, and the patient was diagnosed with Purtscher-like retinopathy.

Purtscher-like retinopathy may be linked to travel at high altitude through retinal vessel dilation and constriction leading to retinal vasospasm and precapillary arteriole occlusion. This proposed mechanism of pathogenesis suggests that Purtscher-like retinopathy may represent a partial central retinal artery occlusion.

To report the first case of a one-eyed child with micro-cornea, coloboma of iris and acute hydrops without any other disorder of the cornea or systemic disease.

Intracameral injection of perfluoro propane (C3F8) gas was performed under general anaesthesia.

Resolution of the hydrops was observed at 1st week of follow-up, which was confirmed by anterior segment optical coherence tomography. Patient was subsequently lost to follow-up.

Intracameral injection of perfluoro propane gas is an effective way to quickly resolve acute hydrops. In this specific case, the patient presented with micro-cornea and no other corneal abnormalities.

To raise awareness of ophthalmologists that toxoplasmosis should be considered in the differential diagnosis of multifocal or diffuse necrotizing retinitis in nonimmunosuppressed elderly patients.

Interventional case report with serial color fundus photographs, indocyanine green angiography, fluorescein angiography, optical coherence tomography, and chorioretinal biopsy histology.

A 77-year-old, nonimmunosuppressed man developed extensive multifocal retinochoroiditis with scattered focal hemorrhages and significant vitreous haze. This case posed a significant diagnostic challenge mimicking viral retinitis. Vitreous polymerase chain reaction and chorioretinal biopsy confirmed the diagnosis of toxoplasma retinochoroiditis.

As demonstrated in this case, toxoplasmosis should be considered as a cause of multifocal and/or diffuse necrotizing retinitis in elderly patients even in the absence of obvious systemic immunosuppression.

To investigate the influence of at least 12 hours of fasting followed by acute water ingestion on macular choroidal thickness in eyes of healthy subjects.

Prospective case series study including healthy volunteers from April 1, 2015 to May 31, 2015. Macular choroidal thickness was measured on enhanced depth imaging optical coherence tomography (EDI-OCT) and on swept-source (SS)-OCT after 12 hours of fasting, and 60 minutes after acute water ingestion (750 mL in 5 minutes).

A total of 52 eyes of 26 healthy volunteers were included in this study. The mean age for participants was 32 years old. After 12 hours of fasting, the mean (±SD) subfoveal choroidal thickness was 335.43 (±104.82) μm on EDI-OCT and 286.16 (±80.32) μm on SS-OCT. The mean (±SD) subfoveal choroidal thickness after acute water intake was 352.32 (±120.36) μm and 290.5 (±85.86) μm, respectively. There was no significant difference between the mean subfoveal thickness at baseline and 60 minutes after acute water ingestion for any of the choroidal imaging techniques (p = 0.1386 for EDI-OCT and p = 0.0659 for SS-OCT).

These results suggest that choroidal circulation can physiologically quickly adapt to systemic vascular changes in healthy eyes. Choroidal thickness did not depend upon the hydration status for the subjects participating in this study.

To describe an innovative imaging technique of color editing and 3D volume rendering of optical coherence tomography-angiography (OCT-A) images.

Each vascular layer acquired by OCT-A (AngioVue, Optovue) is colored and edited with the GNU Image Manipulation Program. Then a 3D volume rendering of the assessed retinal area is possible, using Adobe After Effect software (Adobe Systems).

The combined color editing and 3D volume rendering of optical coherence tomography angiography images allow the creation of a short movie displaying the 3D image from chosen angles.

Image editing and 3D volume rendering is a rather simple technique, which, besides its aesthetic prerequisites, also facilitates simultaneous, distinct visualization of the segmented retinal layers.

To describe a new technique to split rock-hard nuclei using an ultrasonic chopper (Ultrachopper) and a prechopper, in order to perform a modified small incision manual cataract extraction.

The Ultrachopper device, which is compatible with modern phacoemulsification systems, is used to facilitate the division of very hard nuclei in a straightforward manner using a manual prechopper, and the two fragments are extracted using Kansas forceps.

In rock-hard nuclei, this technique is very effective to divide and extract the fragments. The risk of complications related to phacoemulsification on these very challenging cases is avoided.

This modified small incision manual cataract extraction technique, assisted with an ultrasonic chopper (Ultrachopper) and a prechopper, is a very good alternative in rock-hard nuclei.

To report a case of Descemet membrane endothelial keratoplasty (DMEK) performed with phacoemulsification and intraocular lens implantation (triple procedure) for coexisting keratoconus (KC), Fuchs endothelial dystrophy (FED), and visually significant cataract.

One eye of one patient with moderate and stable KC, FED, and visually significant cataract was treated with combined DMEK and phacoemulsification with intraocular lens implantation (triple procedure). Visual acuity and corneal reflectivity/densitometry, thickness, and topographic measurements were recorded and compared to their preoperative values. At all postoperative time points, the endothelial graft was found to be completely attached. By 3 months postoperatively, the patient's best spectacle corrected vision had improved from 20/50 (0.4) to 20/25 (0.8) where it remained stable. No intra- or postoperative complications were experienced.

DMEK may be an effective alternative to penetrating keratoplasty in eyes with coexisting stable KC and FED.

To compare pro re nata (PRN) and bimonthly intravitreal aflibercept injection protocols in the treatment of neovascular age-related macular degeneration (nAMD).

This was a retrospective, observational, comparative study in 2 centers. All study patients presented with newly diagnosed nAMD and were treated as follows after an induction of 3 consecutive monthly loading doses: the bimonthly group was retreated every 2 months and followed up every 4 months while the PRN group was retreated in case of subretinal exudation or visual acuity decrease and followed up every month. A comprehensive ophthalmic examination was performed at each study visit.

At 1 year, 34 eyes were analyzed. The 19 patients in the bimonthly group had a mean visual acuity improvement of +8.5 Early Treatment Diabetic Retinopathy Study (ETDRS) letters whereas stabilization was observed in the PRN group (-0.47 ETDRS letters; p = 0.027). All patients in the bimonthly group had 4 follow-up visits and 7.5 injections whereas the mean number of follow-up visits in the PRN group (15 patients) was 7.8 with 7.6 injections.

Our study suggests that a fixed bimonthly aflibercept retreatment protocol may provide better visual results than a PRN protocol.

This study describes the imaging of avascular serous pigment epithelial detachment (PED) in age-related macular degeneration (AMD) patients using confocal scanning laser ophthalmoscopy and spectral-domain optical coherence tomography (SD-OCT).

A total of 18 patients with avascular serous PED underwent assessment of best-corrected visual acuity, infrared (IR) reflectance, fundus autofluorescence (FAF), fluorescein angiography (FA), indocyanine green angiography (ICGA), and SD-OCT evaluation at baseline and at last follow-up visit. The imaging of avascular PED was compared with vascularized PED.

A total of 23 eyes with 15.5 ± 6.4 months’ follow-up were included. Imaging revealed 3 features associated with avascular serous PED. A reticular pattern, highly reflective (IR), and hyperautofluorescent matching with a reticular area of decreased fluorescence (FA and ICGA) was constantly observed (23/23 eyes). This reticular pattern correlated on SD-OCT with dense hypereflective deposits beneath and within the sensory retina. This reticular pattern was observed in only 2/19 eyes with vascular serous PED (p<0.05). A sharp border of increased IR reflectance, matching with a halo of reduced fluorescence on both FAF and late FA frames, was observed in 23/23 eyes. This sharp border appeared as a sharp hypofluorescent border on late ICGA frames, and as an abrupt elevation of the retinal pigment epithelium on SD-OCT. Hyporeflective fluid beneath the foveal depression was observed in 17/23 (74%) eyes. Only 1/23 eyes developed choroidal neovascularization during the follow-up.

Integrated imaging shows peculiar features of avascular PED and possibly contributes to distinguishing this clinical identity from neovascular AMD.

To evaluate the performance of various tests with automated and subjective evaluation for primary diagnostics of glaucoma in a normal clinical setting.

Subjects referred because of suspicion of glaucoma were recruited. All subjects had full ophthalmologic evaluation with stereophotography of the optic nerve head (ONH), red-free retinal nerve fiber layer (RNFL) photography, scanning laser polarimetry (SLP), optical coherence tomography (OCT), and standard automated perimetry (SAP). Analysis of all results was made jointly by 5 glaucoma specialists, with a consensus for each eye as healthy, glaucomatous, or glaucoma suspect. Results from each method were evaluated against this consensus, followed by a subjective evaluation of each method by a glaucoma specialist, comparing this with automated classification by the devices.

Of the 101 subjects and 202 eyes examined, 23 eyes were by consensus glaucomatous, and 23 were glaucoma suspect. Sensitivity was best with ONH photos and worst with SAP, while SLP had a better sensitivity but poorer specificity than did RNFL photographs and OCT. Subjective evaluation of SLP, OCT, and SAP data gave better sensitivity and specificity than did classification by numeric values from the devices only, with OCT performing better in automatic classification than did SLP or SAP.

None of the current methods is superior to others in diagnosing glaucoma, and the accuracy of automated tests was better when subjectively evaluated by an experienced ophthalmologist. Diagnosis of glaucoma should be based on a combination of test results interpreted by a clinician.

We report the case of monolateral corneal endotheliitis, which occurred following systemic West Nile virus (WNV) infection.

A 56-year-old male patient with right eye (RE) endotheliitis, diffuse arthralgias, and diagnosis of previous WNV systemic infection underwent a measurement of best spectacle corrected visual acuity (BSCVA), full ophthalmic examination, biomicroscopy, and in vivo scanning laser confocal microscopy (IVCM), before and after topical immunomodulatory treatment. In addition, a polymerase chain reaction test on aqueous humor was performed to test for WNV RNA sequences.

Photophobia was reported at presentation. A mild corneal haze was noted at the slit lamp exam. BSCVA in RE was 0.1 LogMar, corneal thickness was 667 micron, and confocal microscopy showed stromal folds. No WNV RNA sequences were detected in the aqueous humor. The cytomegalovirus and herpes virus were not tested as the patient refused additional procedures.

One month after topical corticosteroid application in the RE, the patient reported significant improvement in photophobia, BSCVA improved to −0.1 LogMar, and corneal thickness was reduced to 540 microns. In addition, IVCM showed a disappearance of stromal folds.

A presumptive diagnosis of WNV-associated endotheliitis was formulated. Improvement following topical corticosteroid treatment suggests an immune-based pathophysiology.

During retinal angiography a fluorescein-induced allergic reaction is rare but possible.

We report a single retrospective clinical case.

During retinal angiography on a 75-year-old man, an unexpected allergic reaction to fluorescein (FL) dye occurred. At the beginning of the exam, we erroneously took some filtered shots of the patient's face. We noticed that the pictures of the patient's skin using the FL and indocyanine green filters revealed dye accumulation before the clinical appearance of hives.

Taking filtered shots of a patient's face could be an original method to promptly detect and easily document allergic hives, by simply using an angiographic device.

To report the association of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome with bilateral papilledema and bilateral choroidal neovascularization (CNV) in a 61-year-old man and to compare our findings with data from a review of the literature.

Diagnosis of POEMS syndrome was based on paraproteinemia immunoglobulin A lambda associated with progressive sensorimotor peripheral neuropathy and increased serum vascular endothelial growth factor (VEGF) levels. Shortly later, loss of vision of the left eye (LE) was noted and bilateral papilledema was observed with peripapillary hemorrhages and papillomacular subretinal fluid. Lenalidomide 25 mg daily and weekly dexamethasone 20 mg were administered and the patient was followed up closely. The systemic complaints initially were controlled and peripheral neuropathy improved. Regression of the papilledema and hemorrhages was observed as well as regression of the papillomacular edema in the LE. However, after a few months, the systemic VEGF levels increased, and an active CNV was diagnosed in the LE. Melphalan and prednisone were administered systemically, and the CNV was treated with bevacizumab intravitreal injections and these treatments proved to be effective.

Optic disc edema is reported frequently in POEMS syndrome but complication with CNV is rare, this being the second reported case.

Ghost drusen (GD) are pyramidal or dome-shaped retinal pigment epithelium elevations observed in some geographic atrophy (GA) areas in the context of age-related macular degeneration (AMD). The purpose was to investigate the first morphologic features preceding GD on spectral-domain optical coherence tomography (SD-OCT) on patients with GA associated with AMD.

A retrospective observational study was performed on a series of patients with GA that had at least 3 years of follow-up. Using the follow-up tool of SD-OCT, we tracked the initial lesions that could lead to GD.

Among 442 patients with GA, 37 had well defined GD (8%). We included the 17/37 patients (31 eyes) with at least 3 years of follow-up for analysis, which led to a total of 582 counted GD. Most GD were already present at the first visit, and remained stable. However, on 13 of the 582 analyzed GD (2.2%), soft drusen were shown as the initial lesion, which progressively turned into GD.

GD were observed in less than 10% of eyes with GA. None of the ghost drusen turned into another shaped lesion, suggesting that GD is a possible final stage of evolution. In a few cases, large drusen were shown as the primary lesion that progressed into GD.

To report a case of central serous chorioretinopathy (CSC) associated with a retinal pigment epithelium detachment in a myopic patient with marked pachychoroid.

Case report of a 37-year-old male patient with relatively high myopia (-5.00D in OD/-5.75D in OS), unilateral CSC, and bilateral retinal pigment epithelial detachments, pachychoroid, and choroidal hyperaemia. Standard ophthalmological examination and multimodal imaging, including fundus photography, fundus autofluorescence, spectral-domain and enhanced depth optical coherence tomography, and indocyanine green angiography were performed.

Findings characteristic for the spectrum of CSC/pachychoroid pigment epitheliopathy can be observed in patients with relatively high myopia. Based on the outcome of complete ophthalmological examination, this clinical picture can be discerned from other diseases, which is important for the optimal therapeutic approach.

To evaluate the outcome of surgical options in the management of Thiel-Behnke corneal dystrophy (TBCD). This is a retrospective case report.

A 52-year-old female with TBCD with a visual acuity of 0.50 LogMAR in both eyes underwent deep anterior lamellar keratoplasty (DALK) in her left eye (LE) and, 8 months later, phototherapeutic keratectomy (PTK) in her right eye (RE). Postoperatively, the presence of recurrence, uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), central corneal thickness (CCT), and spherical equivalent (SE) were assessed. Spectralis domain anterior segment optical coherence tomography was also performed to evaluate corneal morphology and reflectivity.

At 1 year, the LogMAR UCVA and BCVA were +0.80 and +0.24, respectively, in the LE and +0.70 and +0.24 in the RE, respectively. CCT and SE were 741 microns (μm) and +4.25 diopters (D) in the LE, respectively, and 339 μm and +6.00 D in the RE, respectively. The cornea was clear in the LE. There was early recurrence of the TBCD and corneal haze in the RE.

The visual outcome of both DALK and PTK were similar for TBCD. No episodes of rejection or recurrence of dystrophy were noted in the eye that underwent DALK. However, postoperative hyperopic shift, persistent haze, and early recurrence were noted after PTK.

To describe a novel technique of tube placement in the anterior chamber.

In this technique, the extra cut piece of the tube is used to provide a hinge/fulcrum such that the main tube entering the anterior chamber would be angulated posteriorly away from the cornea.

The tube entering the anterior chamber is angulated posteriorly.

Using a fulcrum beneath the tube would assist in posterior positioning of the tube and prevent long-term tube endothelial touch.