Quraish Ghadiali

CENTRAL SEROUS CHORIORETINOPATHY TREATED WITH MINERALOCORTICOID ANTAGONISTS: A ONE-YEAR PILOT STUDY.

Purpose: To assess the treatment response to mineralocorticoid antagonists in a pilot study of patients diagnosed with central serous chorioretinopathy using multimodal imaging. Methods: This retrospective observational case series included 23 eyes of 14 patients with central serous chorioretinopathy treated by a single physician (L.A.Y.) with either spironolactone, eplerenone, or both consecutively over a 12-month period. Choroidal thickness, central macular thickness, and best-corrected visual acuity were measured and compared with baseline values. Twelve eyes of 11 patients demonstrated subretinal fluid before or during the initiated treatment course. Subretinal fluid was measured and compared with baseline values in this subgroup. Results: In all eyes (n = 23), best-corrected visual acuity improved at 12 months of treatment; however, central macular thickness and choroidal thickness showed no improvement. In the subgroup with subretinal fluid (n = 12), subretinal fluid was significantly decreased at 6 months and 12 months of treatment; however, central macular thickness, choroidal thickness, and best-corrected visual acuity showed no significant change. Conclusion: Mineralocorticoid antagonists may improve best-corrected visual acuity and decrease subretinal fluid in patients with central serous chorioretinopathy, but do not affect the choroidal or macular thickness. This pilot study demonstrates that mineralocorticoid receptor antagonists may be effective in treating central serous chorioretinopathy but warrants consideration for future research within a randomized clinical trial.

Optical Coherence Tomography Angiography Of Chorioretinal Lesions Due To Idiopathic Multifocal Choroiditis

Purpose: To evaluate the spectrum of macular chorioretinal lesions occurring in idiopathic multifocal choroiditis using optical coherence tomography angiography (OCTA) to evaluate those showing neovascular flow. Methods: This was a descriptive, retrospective study of 18 eyes of 14 patients with multifocal choroiditis. Macular lesions were characterized as subretinal pigment epithelium, subretinal, or mixed and evaluated during active and presumed inactive states of multifocal choroiditis. Correlations between structural optical coherence tomography and OCTA were performed. In select cases, correlations between OCTA, fluorescein angiography, and fundus autofluorescence were evaluated. In 5 eyes, quantitative measurements of neovascular lesions were compared at baseline and following intravitreal anti–vascular endothelial growth factor therapy. Results: Mean patient age was 48 years (SD: 13.8; 86% women). Optical coherence tomography angiography flow signatures consistent with neovascularization were identified in 83% of eyes, including in 0% of subretinal pigment epithelium, 91% of subretinal, and 100% of mixed lesions. Lesions that did not demonstrate definitive signs of fluorescein angiography leakage were frequently found to have neovascularization using OCTA. There was no change in quantitative measurements of neovascular lesions after anti–vascular endothelial growth factor therapy (all tested variables P > 0.05). Conclusion: Optical coherence tomography angiography may be a useful imaging modality for understanding the pathophysiology of multifocal choroiditis and monitoring its clinical course.

Aflibercept: a review of its use in the treatment of choroidal neovascularization due to age-related macular degeneration.

Choroidal neovascularization (CNV) due to age-related macular degeneration (AMD) is an important cause of visual morbidity globally. Modern treatment strategies for neovascular AMD achieve regression of CNV by suppressing the activity of key growth factors that mediate angiogenesis. Vascular endothelial growth factor (VEGF) has been the major target of neovascular AMD therapy for almost two decades, and there have been several intravitreally-administered agents that have enabled anatomical restitution and improvement in visual function with continual dosing. Aflibercept (EYLEA®), initially named VEGF Trap-eye, is the most recent anti-VEGF agent to be granted US Food and Drug Administration approval for the treatment of neovascular AMD. Biologic advantages of aflibercept include its greater binding affinity for VEGF, a longer intravitreal half-life relative to other anti-VEGF agents, and the capacity to antagonize growth factors other than VEGF. This paper provides an up-to-date summary of the molecular mechanisms mediating CNV. The structural, pharmacodynamic, and pharmacokinetic advantages of aflibercept are also reviewed to rationalize the utility of this agent for treating CNV. Results of landmark clinical investigations, including VIEW 1 and 2 trials, and other important studies are then summarized and used to illustrate the efficacy of aflibercept for managing treatment-naïve CNV, recalcitrant CNV, and CNV due to polypoidal choroidal vasculopathy. Safety profile, patient tolerability, and quality of life measures related to aflibercept are also provided. The evidence provided in this paper suggests aflibercept to be a promising agent that can be used to reduce the treatment burden of neovascular AMD.

UNUSUAL POSTERIOR VARIX OF A VORTEX VEIN AMPULLA.

Purpose: We describe a patient with an unusually posterior varix of a vortex vein ampulla. Methods: Case report. Results: An unusually posterior varix of a vortex vein ampulla mimicking a choroidal neoplasm was identified. The diagnosis was obscured by the presence of overlying drusen. Through a combination of indocyanine green angiography and enhanced depth imaging optical coherence tomography, the varix was identified as an engorged vascular process correlating to ophthalmoscopic and tomographic examination. Collapse of the varix after direct digital pressure on the globe was observed on enhanced depth imaging optical coherence tomography further confirming our diagnosis. Conclusion: Varices of vortex vein ampullas may be incorrectly diagnosed as choroidal neoplasms. Using a combination of multimodal imaging and dynamic maneuvering, varices can be correctly identified.

bartonella Henselae Neuroretinitis Associated With Central Retinal Vein Occlusion, Choroidal Ischemia, And Ischemic Optic Neuropathy

PURPOSE We describe a healthy 37-year-old man with Bartonella henselae (B. henselae) neuroretinitis with concurrent central retinal vein occlusion and ischemic optic neuropathy resulting in optic atrophy and choroidal ischemia. METHODS Case report. RESULTS A 37-year-old man presented with unilateral decreased vision and a fundus examination consistent with neuroretinitis. Further imaging review supported a concurrent diagnosis of central retinal vein occlusion. Although initially negative, repeat serological testing for B. henselae infection was positive. Multimodal imaging displayed severe outer retinal disruption, ischemic optic neuropathy, and choroidal ischemia. The patient demonstrated near complete resolution of fundus findings and restoration of outer retinal architecture. Residual findings included optic disk pallor and ischemic choroidopathy. DISCUSSION B. henselae neuroretinitis may be associated with concurrent retinal vascular occlusive disease and ischemic optic neuropathy. Central retinal vein occlusion and choroidal ischemia leading to optic nerve atrophy are additional sequelae further expanding the clinical spectrum of this entity.

Unilateral Ocular Manifestations of Vogt–Koyanagi–Harada Disease

ABSTRACT Purpose: To describe a case of unilateral Vogt–Koyanagi–Harada (VKH) disease and associated multimodal imaging. Methods: Retrospective case report. Results: A 50-year-old Hispanic male presented with three days of painless decreased vision in his left eye, headache, and decreased hearing. His visual acuity was 20/20 in the right eye and counting fingers in the left eye. Examination of his right eye was unremarkable. Funduscopic examination of his left eye revealed multiple serous retinal detachments. Fluorescein angiography demonstrated late multifocal pinpoint hyperfluorescence in his left eye and a diagnosis of VKH disease was made. He was treated with oral prednisone. Serial re-examination demonstrated resolution of the serous retinal detachments and a taper of his oral prednisone was initiated with improvement of his visual acuity to 20/25. Conclusions: Our patient had imaging and a clinical course that was consistent with VKH disease. This unilateral presentation may represent a clinical variant of VKH disease.

Pars Plana Vitrectomy and Pars Plana Lensectomy for Retained Lens Fragments

While cataract extraction surgery has become increasingly safe and efficient, retained lens material or a “dropped nucleus” continues to be one of the more common complications, typically as a result of posterior capsule compromise or zonular dehiscence. An attempt to remove posteriorly dislocated lens material by the anterior segment surgeon is often attempted via an anterior vitrectomy, but may result in anterior vitreous traction leading to retinal tears and possibly detachment. While small cortical lens fragments may be well tolerated and eventually absorbed, persistent retained lens material places the eye at risk for elevated intraocular pressure, chronic inflammation predisposing to cystoid macular edema and corneal edema, and retinal detachment. Although some authorities advocate for prompt lens removal, the definitive timing to posterior segment intervention is not universally agreed upon. Depending on the hardness of the lens, its removal may be achieved with the vitrectomy handpiece alone or in combination with Fragmatome phacoemulsification. Surgical outcomes are typically favorable with the majority of patients retaining 20/40 vision or better (Pars plana vitrectomy for the management of retained lens material after cataract surgery. Am J Ophthalmol 144(3):364–370, 2007).

Scleral Buckling for Rhegmatogenous Retinal Detachment

The principle of rhegmatogenous retinal detachment (RRD) repair is rooted in the concept of closing the retinal break(s) and relieving the vitreous traction on the flap(s). However, the methods by which to repair a RRD vary considerably. While scleral buckles were formerly the mainstay of treatment, small-gauge instrumentation has made pars plana vitrectomy the preferred technique for a majority of retina specialists. Nevertheless, scleral buckle surgery either alone or in combination with pars plana vitrectomy is an essential component of retinal detachment repair and should be in the arsenal of all vitreoretinal surgeons. The principle of accurate identification and localization of retinal breaks is as pertinent to scleral buckling today as it was when first emphasized by Jules Gonin in 1921. Precisely identifying areas of retinal pathology is critical for choosing the appropriate buckling element. Consequently, meticulous preoperative and intraoperative examinations are essential to maximizing surgical success. Silicone rubber is the preferred material used for scleral buckle explants, either in the form of compressible sponges or solid elements. Compared to other materials, silicone rubber has been found to be biologically inactive, chemically inert, and is less prone to bacterial infection (Michels retinal detachment, St. Louis, 1997). Scleral buckles may be applied in a segmental (either circumferential or radial) or encircling fashion. The latter may be used as a solitary treatment or in combination with pars plana vitrectomy repair.

An Assessment of Vitreous Degeneration in Eyes with Vitreomacular Traction and Macular Holes

Purpose. To compare the stages of vitreous degeneration in patients with vitreomacular traction (VMT) and macular holes (MH). Methods. A retrospective study was performed analyzing stages of vitreous degeneration of eyes with VMT or MH using swept-source optical coherence tomography (SS-OCT) and spectral-domain optical coherence tomography (SD-OCT). An analogous review was performed on a control group of eyes with contralateral posterior vitreous detachments. Thirty-four eyes with VMT/MH and 39 control eyes were reviewed. Results. Twenty-seven VMT/MH eyes and 31 control eyes were included. Eyes with VMT/MH demonstrated significantly earlier stages of vitreous degeneration when compared to the control group (p = 0.048) despite significantly greater age (p = 0.032). Conclusions. Vitreoretinal interface disease is more often associated with a formed vitreous and an intact premacular bursa. This is contrary to previous assumptions implicating degeneration of vitreous as a precipitating factor of interface disease when in conjunction with abnormal vitreomacular separation.

CONTRALATERAL ANESTHESIA IN TWO PATIENTS AFTER RETROBULBAR BLOCK

Purpose: To report a case series of two patients with contralateral anesthesia after retrobulbar block. Methods: Retrospective review of two cases and review of the literature. Results: Two patients of one practitioner received contralateral anesthesia after retrobulbar block for posterior segment surgery. Patient 1 suffered from transient contralateral akinesia, whereas Patient 2 experienced transient contralateral amaurosis. Conclusion: Posterior spread of anesthetics is a rare but potentially serious complication of retrobulbar anesthesia caused by spread of anesthetics along the optic nerve sheath. Modification of injection technique can decrease the risk of this complication.