Avni V. Patel

Unilateral Eye Findings: A Rare Herald of Acute Leukemia

Background/Aim: Unilateral choroidal infiltration as the initial manifestation of leukemic relapse in adults is rare, particularly after an extended period of remission. This report describes this unique ophthalmic presentation, highlights the associated diagnostic challenges, and reviews the literature. Methods: Two cases are described and an extensive literature review was conducted. Results: A 59-year-old male with acute lymphoid leukemia, in remission for 18 months, presented with unilateral scleritis, exudative retinal detachment, and choroidal thickening. A 57-year-old male with a history of acute myeloid leukemia, in remission for 4 years, presented with unilateral choroidal thickening leading to secondary angle closure. In both cases, there was a significant lag from the onset of eye symptoms to establishing a systemic diagnosis of acute leukemia, leading to a delay in definitive systemic treatment, despite a high suspicion of disease based on ophthalmic findings. Conclusions: These two cases illustrate the fundus findings consistent with leukemic choroidal infiltration that can represent the first sign of relapsed leukemia. The successful treatment of these patients hinges on collaboration between ophthalmologists and oncologists to optimize patient outcomes, highlighting the need for both groups to be aware of this rare ophthalmic presentation.

Finding the Optimal Treatment Plan for Exudative AMD: A review of Current Anti-VEGF Dosing Regimens.

Age-related macular degeneration (AMD) is the leading cause of severe central visual acuity loss in people over 50 years of age in the United States. Approximately 1.75 million North Americans are estimated to have AMD and an estimated 200,000 new cases of exudative (also referred to as neovascular or wet) AMD develop each year. This number will increase to almost 3 million by 2020. Macular degeneration is a complex spectrum of normal age-related changes including reduced photoreceptor density, ultrastructural changes in the pigment epithelium, formation of lipofuscin granules, accumulation of basal laminar lipid-rich deposits, and progressive changes in the choriocapillaris. These changes may cause disturbances in Bruch’s membrane allowing vessels originating from the choriocapillaris to form a new and abnormal fibrovascular complex. This fibrovascular complex or choroidal neovascularization (CNV) is the hallmark of exudative AMD. It is well-established that vascular endothelial growth factor (VEGF) plays a major role in the neovascular or exudative form of AMD by aiding in the induction of angiogenesis and enhancing vascular permeability. Consequently, intravitreal injections with medications targeting VEGF have become the standard of care for exudative AMD. Currently there are several anti-VEGF drugs that are used in the treatment of exudative AMD: pegaptanib (Macugen), bevacizumab (Avastin), ranibizumab (Lucentis), and VEGF Trap (Eylea). Pegaptanib, or Macugen, was the first VEGF inhibitor approved for use in macular degeneration. It is a modified oligonucleotide that binds

Orbital Branch of the Infraorbital Artery: Further Characterization of an Important Surgical Landmark

Abstract The orbital branch of the infraorbital artery, a key vascular structure that is not universally noted in orbital textbooks and atlases, is clinically significant, since injury to it can result in perioperative hemorrhage. We conducted a cadaver dissection to document its presence, measure its location, and evaluate it histopathologically. It was present in 8 of 9 orbits and was a mean distance of 16.6 mm (range 10–23) from the inferior orbital rim. In half of the specimens, there were 2 separate structures seen. Histopathology confirmed these structures to be neurovascular bundles.

Emerging Infectious Uveitis: Aspergillus and Other Fungi

Intraocular fungal infection is a rare, but potentially devastating, ocular condition. Aspergillus and other fungal pathogens reach the eye either endogenously via hematogenous spread or exogenously through trauma or surgery. Aspergillus is the second most common cause of fungal endophthalmitis, after Candida, causing a necrotizing chorioretinitis or endophthalmitis via hematogenous spread usually from the lungs. Aspergillus and other fungi covered in this chapter are commonly present in the environment; however risk factors such as immunocompromise and ocular trauma make patients susceptible to infection with these organisms. While intraocular infection with Aspergillus and the other fungi covered in this chapter is rare, prompt diagnosis and treatment is important in reducing ocular morbidity.

Occult Perforating Globe Injury Caused by Intraocular Foreign Body.

Intraocular foreign bodies (IOFBs) may be associated with occult exit wounds. The authors present a case of a man who sustained a zipper-tooth IOFB through the cornea from a car tire explosion. CT showed an IOFB within the vitreous cavity, but the IOFB was not identified during vitrectomy. Extension of the peritomy revealed an exit wound with the foreign body lodged in the extraocular space. This case demonstrates that IOFBs can rest within the vitreous cavity after creating an exit wound, but may escape detection by being driven back out of the globe during vitrectomy due to the pressurized eye. Coexistent ocular surface and intraocular pathology often limit intraoperative visualization, but a perforating through-and-through injury should be suspected if the IOFB cannot be identified during vitrectomy. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:1162-1163.].

Idiopathic Orbital Inflammation Presenting with Bilateral Panuveitis.

Idiopathic orbital inflammation or orbital pseudotumor is rare in the pediatric population and may present with ocular findings not normally seen in the adult population. The authors report the case of a 14-year-old boy with idiopathic orbital inflammation who presented with bilateral panuveitis to highlight the features that make this diagnosis more difficult in the pediatric population.

Toxoplasmic Retinitis: To Treat or Not to Treat and With What Drug?

Ocular toxoplasmosis represents a major cause of infectious uveitis and the most common cause of posterior uveitis in the world. This infection is due to Toxoplasma gondii, an intracellular protozoan, and the most common presentation of disease is toxoplasmic retinitis. Epidemiological studies suggest that around 23% of the world has been infected with this protozoan at some point in their life and that around 10% of this population has had at least 1 episode of retinitis. The typical appearance of active toxoplasmic retinitis includes a unilateral, solitary area of retinitis often adjacent to a pigmented chorioretinal scar with overlying moderate to severe vitritis. Despite a relative preponderance of cases, there remains controversy regarding the diagnosis and many aspects of treatment for this all too common disease. Diagnosis is often made from the common clinical presentation but there remains debate regarding the utility and reliability of formal diagnostic testing. This paper addresses the controversies surrounding treatment of toxoplasmic retinitis and focuses on understanding why the majority of cases are treated and how classic therapy (pyrimethamine, sulfadiazine, and prednisone) became the standard to compare all other therapies. It is important to establish a standard of care for any common disease. However, it is important that this treatment is well established and thoroughly supported by the literature. There are >30 publications in the literature addressing treatment outcomes of active toxoplasmic retinitis in a prospective or retrospective study manner. Much of the remaining literature on toxoplasmic retinitis management is case-series based and does not directly compare treat-