Bryan K. Hong

Optical Coherence Tomography Angiography and En Face Optical Coherence Tomography Features of Paracentral Acute Middle Maculopathy

PURPOSE To characterize the optical coherence tomography (OCT) angiography, en face OCT, and microperimetry features of paracentral acute middle maculopathy in both the acute phase and after resolution, and to propose a classification of distinct subtypes of this entity. DESIGN Retrospective observational case series. METHODS Clinical histories, high-resolution digital color imaging, spectral-domain OCT images, fluorescein angiography, OCT angiography images, and en face OCT images of 16 patients with paracentral acute middle maculopathy were evaluated. Microperimetry was available in 6 patients. RESULTS The most common referring diagnoses were isolated branch retinal arterial occlusion (5/16), combined central retinal vein and cilioretinal artery occlusion (4/16), and isolated central retinal vein occlusion (4/16). All patients demonstrated hyperreflective plaque-like lesions at the level of the inner nuclear layer on spectral-domain OCT, with no fluorescein angiographic correlate. OCT angiography demonstrated variable areas of capillary dropout within the superficial and deep retinal capillary plexi in these areas. En face OCT highlighted confluent areas of middle retina hyperreflectivity corresponding to these lesions. Three distinct en face OCT patterns were observed: arteriolar, fern-like, and globular. Microperimetry demonstrated relative scotomas mapping to the area of middle retinal hyperreflectivity seen on en face OCT. CONCLUSIONS Paracentral acute middle maculopathy may be best evaluated with the use of en face OCT imaging, which corresponds to subjective and objective visual field defects. En face OCT appearance may be used to classify paracentral acute maculopathy into distinct subtypes.

Role of ultra-widefield fluorescein angiography in the management of uveitis

OBJECTIVE To discuss and illustrate the role of ultra-widefield fluorescein angiography (UWFFA) in the diagnosis and management of peripheral retinal vasculitis. DESIGN Retrospective case series. PARTICIPANTS Four consecutive patients in whom UWFFA showed far peripheral vasculitis were included. All patients were seen between May 2011 and May 2012 at the Doheny Eye Institute. METHODS Conventional fluorescein angiogram (FA) images or areas determined by the Early Treatment of Diabetic Retinopathy Study Group protocol for imaging the posterior pole and peripheral retina were superimposed on the UWFFA images. The ability to detect the extent and severity of vasculitis and vascular occlusion using both conventional FA and UWFFA was compared by 2 investigators, and any discrepancies were adjudicated by a third investigator. RESULTS In none of the cases was the full extent of vasculitis and capillary occlusion visible in the fields normally portrayed by conventional FA. In contrast, capillary nonperfusion and peripheral vasculitis were detectable by UWFFA in all cases. In 2 cases, the posterior extent of vasculitis could have been detected by conventional FA. CONCLUSIONS Detection and depiction of the extent and severity of peripheral vascular changes are enhanced with UWFFA, aiding in the management of vasculitis in the retinal periphery.

The utility of routine tuberculosis screening in county hospital patients with uveitis

Background/aim To evaluate the utility of tuberculosis (TB) screening in diagnosing ocular TB in uveitis patients in a government-funded hospital. Methods The charts of 142 consecutive patients seen during August 2011–July 2012 at the Los Angeles County Hospital uveitis clinic were reviewed for manifestation/laterality of uveitis, purified protein derivative (PPD) test results, interferon γ release assay, chest x-ray, birthplace, treatment history and diagnosis. ‘Presumed TB-uveitis’ was diagnosed when patients had positive TB screening and favourable response to anti-TB therapy, and definite ocular TB when Mycobacterium tuberculosis’ presence was demonstrated. Post-test probabilities were determined. Results TB screening was positive in 21.1%. Six patients were diagnosed with TB-related uveitis: one definite, four presumed and one systemic TB with uveitis. With regard to PPD positivity, being foreign-born was the only statistically significant factor with OR of 2.26 (95% CI 1.01 to 5.13; p<0.01) if born in Mexico and 4.90 (95% CI 1.74 to 13.83; p<0.01) if born in other foreign countries. The post-test probabilities of a positive PPD in a uveitis patient showed a 17.2% (overall) or 30.3% (foreign-born patients) chance of ocular TB. Conclusions PPD skin test plays an important role in the diagnosis of TB-associated uveitis in high-risk groups, such as immigrants from TB endemic regions.

Multimodal Imaging in Multiple Evanescent White Dot Syndrome

G.K.: Funding e NHMRC Clinical Research Postgraduate Scholarship and an Avant Doctor in Training Research Scholarship. K.P.B. and J.C.E.: Grants e Ophthalmic Research Institute Australia. Funded by a National Health and Medical Research Council (NHMRC) of Australia project (grant no. 595918), the National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, and UCL Institute of Ophthalmology. The sponsor or funding organization had no role in the design or conduct of this research. Author Contributions: Conception and design: Kaidonis, Burdon, Abhary, Petrovsky, Gleadle, Craig Data collection: Kaidonis, Burdon, Gillies, Abhary, Essex, Chang, Pal, Pefkianaki, Daniell, Lake, Petrovsky, Hewitt, Jenkins, Lamoureux, Gleadle, Craig Analysis and/or interpretation: Kaidonis, Burdon, Craig Obtained funding: Not applicable

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FEATURES OF BRANCH RETINAL VEIN OCCLUSION.

Purpose: Optical coherence tomography angiography (OCTA) is a novel technology that uses motion contrast instead of dye to generate angiographic images. Using several modalities of OCTA, the authors describe and compare changes observed in branch retinal vein occlusion. Methods: A case series of three patients with OCTA imaging. Results: Despite presenting at different time frames, the authors found common imaging findings consisting of vascular hypoperfusion, increased tortuosity, and telangiectasia in all their cases. Furthermore, macular edema and intraretinal fluid were noted on the en-face angiograms. The extent of vascular and structural alterations could clearly be delineated in superficial and deep retinal networks. However, fine capillary alterations were better appreciated on smaller-size scans. Conclusion: With the ability to noninvasively visualize vascular flow, OCTA could serve as a new diagnostic tool for current ophthalmic research and clinical practice. Such findings can help supplement other imaging modalities in establishing a diagnosis and monitoring disease progression over time. This would potentially be useful in regard to ischemic processes such as branch retinal vein occlusion and diseases affecting different layers of the retinal vasculature.

A 49-year-old man with unilateral, nontender left eyelid swelling

Brandon J. Wong, BA, Bryan K. Hong, MD, Daman Samrao, MD, Gene H. Kim, MD, and Narsing A. Rao, MD Author affiliations: aKeck School of Medicine, University of Southern California, Los Angeles, California; bDoheny Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California; cDepartment of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, California

Bilateral subinternal limiting membrane hemorrhage in benzene toxicity.

PURPOSE To report the clinical and spectral domain optical coherence tomography findings in a patient with bilateral central vision loss and a history of exposure to polyamides. METHODS The clinical presentation of the patient was documented with color fundus photographs and spectral domain optical coherence tomography. The patient was a 20-year-old male factory worker with no medical history who was initially admitted for workup of hematologic malignancy due to petechiae and fevers. RESULTS Optical coherence tomography revealed bilateral hemorrhages in the subinternal limiting membrane space resembling Valsalva retinopathy. Complete blood count revealed pancytopenia and marked thrombocytopenia. CONCLUSION Heavy exposure to benzene, a byproduct of the polyamide-curing process, is known to cause aplastic anemia. Accompanying thrombocytopenia may increase the risk of spontaneous subinternal limiting membrane hemorrhage.

Video Recording of Vitreous Tap and Intravitreal Antibiotic Injection From the Surgeon's Perspective.

Video Recording of Vitreous Tap and Intravitreal Antibiotic Injection From the Surgeon’s Perspective Head-mounted video recording devices have recently become available and are being used in medicine not only to help with patient care but also to serve as an educational tool. In contrast to traditional overhead recording systems used in ophthalmology, head-mounted recording systems such as Google Glass (Google Inc, Mountain View, CA) and GoPro (GoPro, San Mateo, CA) are lightweight, compact, and allow video capture of a procedure from a surgeon’s perspective; for example, Rahimy and Garg and Warrian et al recently described successful recording of scleral buckling. We describe our experience with the GoPro to record a vitreous tap and intravitreal antibiotic injection for a patient with post-cataract surgery endophthalmitis.

Intracameral injection of tissue plasminogen activator to treat severe postoperative fibrinous reaction in iridocorneal endothelial syndrome.

Iridocorneal endothelial (ICE) syndrome is a primary endothelial abnormality that can cause a spectrum of iris changes, corneal edema, and glaucoma. Glaucoma secondary to ICE is difficult to manage because of the inflammatory reaction and fibrosis it can cause. We present a case of postoperative fibrinous reaction following endoscopic cyclophotocoagulation in ICE that caused aqueous tube shunt occlusion and high intraocular pressure. The condition was successfully managed with tissue plasminogen activator.