Patrick A. Coady

Spectral domain optical coherence tomography findings in eyes with acute ischaemic retinal whitening

Acute retinal ischaemia presents in various forms depending on the type and location of the associated vascular occlusion. Cotton wool spots have been considered one manifestation of ischaemia and represent swelling in the nerve fibre layer. However, clinical retinal whitening also occurs in areas not affected by cotton wool spots, and has distinguishing spectral domain optical coherence tomography (SD-OCT) features. We present SD-OCT findings of hyper-reflectivity and thickening in four eyes with representative retinal arterial or retinal venous occlusions, specifically branch retinal artery occlusion, central retinal vein occlusion, Purtscher-like retinopathy and ophthalmic artery occlusion. The spectrum of retinal ischaemia from various causes was found to manifest in inner nuclear layer hyper-reflectivity and thickening on SD-OCT. En Face OCT imaging further characterises the topographical distribution of ischaemia, and reveals patterns which provide insight into the pathological processes involved.

BILATERAL DIFFUSE UVEAL MELANOCYTIC PROLIFERATION: A CASE REPORT.

Purpose: To report a case of bilateral diffuse uveal melanocytic proliferation (BDUMP) in the setting of metastatic ovarian cancer. Methods: In this observational case report, a 59-year-old woman presented with bilateral worsening vision and photophobia. She had been diagnosed with metastatic ovarian cancer 5 years prior for which she received Tamoxifen. Ophthalmic examination was completed followed by fluorescein angiography and optical coherence tomography (Spectralis OCT; Heidelberg Engineering). Results: The visual acuity was 20/150 in both eyes. Exam demonstrated an iris pigmented lesion in the right eye, bilateral nuclear sclerotic cataracts, multiple orange lesions in the fundus, elevated pigmented uveal melanocytic tumors with diffuse choroidal thickening and multifocal early hyperfluorescence of these lesions (giraffe-like pattern) on fluorescein angiography, and exudative retinal detachment on OCT. The patient was diagnosed with BDUMP in the setting of metastatic ovarian carcinoma. Further metastatic workup demonstrated enlarged lymphadenopathy in the right axilla and inguinal regions. The patient declined chemotherapy and was initiated on plasmapheresis. Conclusions: BDUMP is a peculiar paraneoplastic syndrome in the setting of metastatic ovarian cancer, where antigens from the retinal pigment epithelium, iris and choroidal melanocytes cross-react with ovarian tumor cell antibodies that are circulating in the serum. Plasmapheresis can decrease the concentrations of the antibodies, maintain reasonable functional vision and improve the quality of life.

Paracentral acute middle maculopathy: precursor to macular thinning in sickle cell retinopathy

We present a case of paracentral acute middle maculopathy (PAMM) in a patient with sickle cell disease (SCD). Though gradual capillary loss may contribute to pathophysiology of sickle cell retinopathy as well, our case suggests that PAMM may be the precursor lesion to macular thinning commonly observed in patients with SCD. In addition, fluorescein angiography may be unable to detect these acute vascular events occurring at the deep capillary plexus.

Spectral domain optical coherence tomography imaging of Purtscher-like retinopathy.

PURPOSE To report spectral domain optical coherence tomography findings in a patient with Purtscher-like retinopathy. METHODS Case report, image analysis, and literature review. RESULTS A 71-year-old woman presented with decreased vision, cotton-wool spots, and a deep whitish polygonal lesion in her left eye, which was hyperreflective on spectral domain optical coherence tomography. She was diagnosed with Purtscher-like retinopathy and later was found to have metastatic pancreatic cancer. CONCLUSION Purtscher-like retinopathy can occur secondary to malignant pancreatic cancer. Purtscher-flecken can be characterized by cross-sectional and en face spectral domain optical coherence tomography and represent deep capillary ischemia.

Idiopathic retinal vasculitis, aneurysms and neuroretinitis case report

Purpose To report a case of idiopathic retinal vasculitis, aneurysms and neuroretinitis (IRVAN) in a young woman. Observations A 21-year-old white female patient was referred to retina clinic with decreased vision in the left eye. On examination, best corrected visual acuity was 20/20 in the right eye and counting fingers in the left eye. Fundus examination revealed bilateral optic disc edema, peripapillary and macular exudates, retinal arterial aneurysms, and venous beading. In the left eye, there was a large focus of exudative material in the central macula. Examination of the peripheral retina was unremarkable, bilaterally. Fluorescein angiography demonstrated arterial aneurysms and venous beading in both eyes, with optic nerve activity and vascular sheathing noted on late frames in both eyes. In the left eye, there was a large central area of blockage corresponding to hard exudates surrounding a more central area of hyperfluorescence with leakage, representing retinal neovascularization. Review of systems and extensive laboratory workup were negative. The patient was diagnosed with IRVAN. She was observed, and her exam at 6-month follow-up revealed low grade inflammation for which the patient was started on oral prednisone. Conclusions and Importance Management of IRVAN remains challenging because of its idiopathic nature and the lack of controlled clinical trials for such a rare entity. Bilateral involvement in IRVAN is variable and close follow up is crucial.

Asymmetric Deep Stromal Keratopathy in a Patient With Multiple Myeloma.

Purpose: To report a case of asymmetric deep stromal keratopathy in a patient with multiple myeloma. Methods: Case report and literature review. Results: An 85-year-old woman was found to have progressive visually significant left-sided deep stromal opacity in the setting of monoclonal gammopathy. Hematologic workup resulted in a diagnosis of IgG kappa multiple myeloma. Histopathology was significant for semicrystalline deposits in the posterior stroma. The patients visual acuity improved to 20/50 7 months after penetrating keratoplasty. A similar deep stromal lesion appeared in the right eye 2 years after initial presentation. Conclusions: We present an unusual case of paraproteinemic keratopathy with a uniquely asymmetric presentation that resulted in a diagnosis of multiple myeloma.

Pneumatic retinopexy for displaced macular laceration from intraocular foreign body

Purpose To report a case of macular laceration from intraocular foreign body (IOFB) treated with pneumatic retinopexy. Observations A 74 year old man sustained penetrating injury to his left globe with retained metallic intraocular foreign body (IOFB). The patient underwent prompt pars plana vitrectomy, intravitreal antibiotics and removal of IOFB. The posterior point of impact left a displaced foveo-macular laceration which was recognized postoperatively and treated with pneumatic retinopexy for re-approximation of the foveal tissue. Optical coherence tomography confirmed acute traumatic laceration and edema, closure of the tissue and subsequent healing and adjacent retinal and retinal pigment epithelial atrophy. He regained visual acuity of 20/30. Conclusions and importance Traumatic macular lacerations can be treated with pneumatic retinopexy, after pars plana vitrectomy, with potentially good visual result.

Delayed bilateral fibrinous anterior chamber reaction following autologous bone marrow transplant and cataract surgery

Purpose Immune reconstitution uveitis (IRU) is a well-described phenomenon that by definition occurs in patients with AIDS who undergo highly active antiretroviral therapy resulting in a rebound inflammatory response to the presence of clinically latent cytomegalovirus (CMV). We hypothesize that similar phenomena may exist in other cohorts who undergo transient immunosuppression with rapid white blood cell count recovery. Observations A patient developed rebound inflammation a few months after cataract surgery with intraocular lens placement characterized by photophobia, significant anterior chamber cell and fibrinous deposits. She had a history of multiple myeloma treated with chemotherapy and a recovery of white blood cell counts following autologous bone marrow transplant. She underwent a thorough work-up for infectious etiologies, as well as the presence of intraocular CMV, which were negative. Her vision and symptoms improved to baseline with the use of topical steroids and at one year her exam remained stable. Conclusions and Importance With a negative work-up for infectious etiologies, and the timing and clinical presentation, the patients inflammation was likely the result of rapid white blood cell count recovery following iatrogenic immunosuppression similar to the mechanism described for IRU.

Vitrectomy for Diabetic Macular Edema

Diabetic macular edema (DME) can often be a difficult disease to manage with a subset of patients not improving with existing treatments. As indicated in early studies, patients with hyaloid-retinal traction may benefit the most from vitrectomy for DME. However, some patients without evidence of hyaloid traction may also improve after vitrectomy. It is difficult to predict which patients will improve with surgery. In addition, as treatment options have evolved, the appropriate timing of vitrectomy for DME remains controversial. An improvement in imaging modalities and enhanced understanding of the pathophysiology of the disease may aid in the appropriate use of this treatment option.