International Journal of Retina and Vitreous

Aneurysmal type 1 neovascularization (AT1) is a term recently introduced to better describe the aneurysmal dilatation that may arise from neovascular lesions, more commonly known as polypoidal choroidal vasculopathy. The proposed term, AT1, includes an expanded clinical spectrum of aneurysmal (polypoidal) lesions observed in both different ethnicities and associated with varied clinical phenotypes. A 61-year-old woman of European descent was referred for a new, asymptomatic retinal hemorrhage found on routine examination. Ophthalmoscopy revealed cuticular drusen in both eyes best appreciated on fundus autofluorescence, and a hemorrhagic retinal pigment epithelium detachment above the superior arcade in the right eye. In the fellow eye, a reddish appearing pigment epithelial detachment was noted nasal to the optic nerve. Indocyanine green angiography showed findings of AT1 in both eyes. Optical coherence tomography angiography showed intrinsic flow signal within the aneurysmal lesions. Eyes with cuticular drusen may develop AT1 which, to our knowledge, has not been described. This is an important observation because the documented coexistence of AT1 in the setting of a variant of age-related macular degeneration lends supports to this new understanding of AT1 as a growth pattern of neovascular tissue proliferating between the RPE and Bruch membrane, rather than as a distinct disease entity.

To describe the development and outcome of mid-phase pinpoint hyperfluorescent spots (MPHS) on fundus fluorescein angiography (FFA) in acute (< 7-day symptom onset) central retinal artery occlusion (CRAO) patients. This retrospective study included acute CRAO patients who underwent multimodal imaging utilizing optical coherence tomography (OCT) and FFA between June 2017 and January 2023. The correlation of FFA images with the OCT images in various stages and severity of CRAO were studied. Twenty-three FFA studies on 23 patients with acute CRAO were included. In 11 (48%) cases, an important finding noted on FFA was the presence of single or multiple MPHS with adjacent minimal late vascular leakage. Of these 11 cases, eight (73%) were males and median age was 41 years (inter quartile range: 33–55 years). Visual acuity ranged from ‘light perception’ to 6/18, and these patients presented anytime on the same day to seven days after symptom onset. On OCT, three eyes had severe CRAO, seven eyes had moderate CRAO, and one eye had mild CRAO. MPHS were primarily observed at the posterior pole and more frequently observed in moderate CRAO severity. During follow-up, the MPHS and retinal vessel staining on FFA disappeared as the CRAO showed signs of resolution. MPHS at the posterior pole on FFA in acute CRAO patients could indicate a more severe occlusion and poor visual outcomes, even after treatment. This finding is most likely caused by red blood cell aggregation or rouleaux formation. Not applicable.

Cryoglobulinemia, the presence of serum cryoglobulins which are immunoglobulins or complement components that precipitate at temperatures below 37 °C, commonly present with cutaneous manifestations initially, but are more rarely associated with ocular manifestations. To our knowledge, we report the first case of a patient presenting with sequential central retinal artery occlusion (CRAO) associated with cryoglobulinemia. A 69-year-old female with a history of indolent B-cell lymphoma associated cryoglobulinemia, treated hepatitis B infection and CRAO in the left eye presented with acute vision loss and diffuse retinal whitening with a cherry red spot in her right eye, suggestive of sequential CRAO. Laboratory studies revealed a cryocrit of 55% (normal  < 1%), elevated titres of cryoglobulin IgG at 1.98 g/L and cryoglobulin IgM at 3.78 g/L (normal  < 0.3 g/L)9, and elevated kappa free light chain at 283.5 mg/L (normal  < 0.06 g/L). Such elevated tires of cryoglobulins in the context of the patient’s CRAO raised suspicion of cryoglobulinemia associated CRAO. The patient was promptly referred to rheumatology and oncology and was admitted for treatment including intravenous methylprednisone, rituximab and bendamustine chemotherapy. We report a patient with a complex medical history presenting with significant vision loss due to a sequential CRAO likely associated with cryoglobulinemia. Although a direct relationship between cryoglobulinemia and CRAO cannot be confirmed in this case, it highlights the importance of considering cryoglobulinemia in high-risk patients with prior history of hematological malignancy or chronic hepatitis infection.

Mục đích của nghiên cứu hiện tại là báo cáo các kết quả giải phẫu và chức năng của việc ghép màng ối người ngoài chỉ định như một can thiệp chính để sửa chữa các lỗ hoàng điểm lớn đến khổng lồ và trong các ca phẫu thuật lại khi việc bóc màng nội giới hạn rộng không thành công. Đã tiến hành đánh giá hồ sơ bệnh án theo phương pháp hồi cứu tại năm trung tâm khác nhau để xác định tất cả các trường hợp đã trải qua việc ghép màng ối người ngoài chỉ định nhằm điều trị các lỗ hoàng điểm lớn hoặc thất bại (MH). Dữ liệu thu thập bao gồm tuổi, giới tính, các chẩn đoán kèm theo khác, thời gian có triệu chứng, tình trạng thấu kính, số lần phẫu thuật trước đó, kích thước lỗ hoàng điểm (đường kính tối thiểu và đường kính cơ bản), thời gian theo dõi sau phẫu thuật trung bình (tháng), và thị lực tốt nhất đã chỉnh sửa (BCVA) trước và sau phẫu thuật. Các chỉ số kết quả chính là tỷ lệ đóng lỗ hoàng điểm và BCVA cuối cùng (theo logMAR). Phép thử Wilcoxon hạng không tham số được sử dụng vì dữ liệu không phân phối bình thường, giá trị P < 0.05 được coi là có ý nghĩa thống kê. Mười chín mắt của 19 bệnh nhân đã được xác định và đưa vào nghiên cứu. Tuổi trung bình là 66.21 ± 14.96 năm và chủ yếu là nữ (84%). Tất cả các mắt đã đóng MH thành công với một can thiệp duy nhất mà không có tái phát trong thời gian theo dõi trung bình là 9 ± 3.87 tháng. BCVA trung vị trong logMAR trước phẫu thuật là 1.30 ± 0.44 (0.80–2.0), tương đương khoảng 20/400 trên bảng Snellen và BCVA trung vị sau phẫu thuật trong logMAR là 1.0 ± 0.72 (0.4–3.0), tương đương khoảng 20/200 (p < 0.0001) với độ trung vị cải thiện thị lực ba dòng. Việc sử dụng ghép màng ối người dường như là một phương pháp khả thi và hiệu quả cho việc điều trị các lỗ hoàng điểm lớn và dai dẳng. Tuy nhiên, cần có thêm các nghiên cứu lớn hơn có kiểm soát tiềm năng để xác nhận các kết quả ban đầu của chúng tôi về kỹ thuật phẫu thuật mới này.

Việc quan sát trong quá trình thắt sclera truyền thống thường được thực hiện qua phương pháp thăm khám gián tiếp. Những tiến bộ gần đây đã áp dụng kính hiển vi phẫu thuật và hệ thống chiếu sáng nội soi dựa trên ống thông 25 gauge, còn được gọi là hệ thống đèn Chandelier. Báo cáo này trình bày một phương pháp cải tiến sử dụng một ống dẫn ánh sáng có bảo vệ 25 hoặc 27 gauge cùng với nền tảng kỹ thuật số ba chiều Ngenuity. Một ống dẫn ánh sáng Alcon tiêu chuẩn đã được điều chỉnh bằng cách thêm một lớp bảo vệ silicon để chỉ lộ ra 5 mm ở đầu ống dẫn sáng. Lớp bảo vệ được tạo thành từ silicone đã được mở ra để giữ cho các đầu của băng quấn thường sử dụng (ví dụ: 70, 270). Ống dẫn ánh sáng có bảo vệ này sau đó được chèn vào ống thông như một sự thay thế cho hệ thống đèn Chandelier. Đây là một báo cáo kỹ thuật về một kỹ thuật quan sát phẫu thuật sử dụng nền tảng quan sát kỹ thuật số ba chiều với ống dẫn sáng vi phẫu cầm tay đã được điều chỉnh. Việc sử dụng ống dẫn ánh sáng có bảo vệ để quan sát trong quá trình thắt sclera nguyên phát là một kỹ thuật hứa hẹn, hiệu quả và hiệu suất cao. Màn hình kỹ thuật số ba chiều cho phép tạo ra tác động giáo dục tốt hơn và cải thiện giao tiếp phẫu thuật với các học viên và thành viên phụ trợ của nhóm phẫu thuật.

To analyse morphologic features of the choroid in Non-pathological myopic eyes using spectral-domain (SD) optical coherence tomography (OCT). Retrospective analysis of enhanced depth SD-OCT images of Non-pathological myopic eyes in comparison with age-matched healthy controls was performed. Choroidal thickness (CT) and large choroidal vessel thickness (LCVT) were measured at the fovea, 750 µm nasally from fovea (N750) and 750 µm temporally (T750) from fovea. Medium choroidal vessel thickness (MCVT) was calculated by subtracting LCVT from CT. Choriocapillaris was encompassed by MCVT, given its reduced thickness. Linear regression analysis evaluated the relationship between age and axial with CT, LCVT and MCVT. The study group comprised 42 eyes of 31 patients (mean age 46.13 ± 15.63; 15 females). Control group included 57 eyes of 34 patients (mean age of 42.3 ± 15.29; 24 females). Mean axial length in myopic eyes and control group was 26.57 ± 1.27 and 23.59 ± 0.99 mm respectively. Myopic eyes showed significant thinning of MCVT and CT at all locations (p < 0.0001) compared to controls, unlike LCVT (p > 0.05). With each decade, thinning of up to 37 µm in CT was noted along with thinning of LCVT (up to 22.6 µm) and MCVT (up to 25 µm). Each mm increase in axial length caused 38.2 µm thinning of choroid along with LCVT (<10 µm), however, MCVT showed more notable thinning (>30 µm). Significant thinning of MCVT was noted in non-pathological myopic eyes in comparison to healthy subjects. It appears that MCVT has stronger relationship with age and axial length.

Multiple surgical techniques exist for the repair of rhegmatogenous retinal detachments (RRD). Suprachoroidal buckling (SCB), consisting of injecting viscoelastic material in the suprachoroidal space to allow chorioretinal apposition, has been recently described in the repair of RRD. The aim of this study is to report the complications of SCB and to propose measures to decrease their incidence during the learning curve. A total of 26 eyes of 26 patients who underwent a SCB procedure for the management of RRD secondary to a single or multiple retinal breaks were enrolled. Patients were operated between January 2014 and March 2017 at two academic institutions. Patient and retinal detachment characteristics were obtained from the charts. Surgical videos were reviewed for every case and intraoperative complications were recorded. Complications observed postoperatively were obtained from the charts. Sixteen eyes (62%) underwent SCB alone, 5 eyes (19%) underwent additional gas tamponade and 5 eyes (19%) had combined pars plana vitrectomy. The most common complication was hemorrhage (6 cases, 23%). There were no cases of ischemic choroidal changes or hyperpigmentation at the edge of the dome. All six complications occurred in phakic patients who had inferior RRD with retinal breaks in the inferior quadrants. Isolated subretinal hemorrhage occurred in 4 patients and isolated suprachoroidal hemorrhage in 1 patient, and those did not affect final visual outcome. Extensive combined subretinal and suprachoroidal hemorrhage occurred in one case, and was complicated by phthisis bulbi. Re-detachment occurred in 4/6 (67%) of patients, and 5/6 (83%) of patients required a secondary procedure. Three out of 6 patients (50%) had at least 2 lines of visual acuity improvement. SCB performed for RRD can be associated with hemorrhagic complications. The hemorrhages are usually self-limited but may occasionally result in severe visual compromise when involving the suprachoroidal space. Specific surgical measures need to be undertaken in order to decrease the likelihood of complications and further studies are needed to assess the safety and efficacy of this technique.

Macular holes in children are generally associated with trauma. We report the first case of an idiopathic full thickness macular hole in a 10-year-old girl. 23-gauge transconjunctival pars plana vitrectomy, induction of a posterior vitreous detachment, ILM blue-assisted internal limiting membrane peel, fluid–air exchange and air-26% sulfur hexafluoride (SF6) exchange was performed with subsequent macular hole closure. This is the first reported case of an idiopathic full thickness macular hole in a child. Treatment with pars plana vitrectomy with peeling of the ILM resulted in significant anatomic and functional improvement.

Vitamin A deficiency is rare in the United States and can be missed in patients with malabsorption syndromes without a high dose of suspicion. Ocular complications of hypovitaminosis A include xerosis and nyctalopia, and to a lesser extent reduction in visual acuity and color vision. Outer retinal changes, as seen on spectral domain optic coherence tomography (SD-OCT), in patients with vitamin A deficiency have previously not been documented. We present two cases with symptoms of severe nyctalopia who were subsequently diagnosed with severe Vitamin A deficiency and their unique findings on SD-OCT of outer nuclear layer diffuse thinning with irregular appearance of the interdigitating zone and the ellipsoid zone as well as normalization after vitamin A supplementation. Outer nuclear layer thinning and disruption of the outer retinal bands on SD-OCT are reversible with correction of vitamin A deficiency. Improvement in visual acuity, color vision, and nyctalopia are possible with early diagnosis and appropriate treatment.

To describe the epidemiological traits, clinical characteristics, diagnostic procedures, therapeutic interventions and evolution in a large series of patients with diagnosis of Eales’ disease. A clinical retrospective review of patients with Eales’ disease, evaluated and treated between April 2009 and April 2018, with a 1-year minimum follow-up. Thirty patients (59 eyes), were included. Age, sex, laboratory results (CBC, glycemia, protein electrophoresis, ACE levels) immunological profile and a Quantiferon-TB Gold Plus test were recorded. The patients were divided into groups according to their evolution, medical or surgical treatment, and visual outcomes. Seventeen male patients and 13 female patients were included, and their ages ranged from 14 to 35 years. The Quantiferon-TB Gold Plus test was positive in 25 patients. Twenty-eight patients had unilateral vitreous hemorrhage, 10 of whom presented with vasculitis and non-perfusion areas in the contralateral eye, 9 presented contralateral peripheral neovascularization and 9 had contralateral fibrovascular proliferation. The remaining 2 patients presented with a rhegmatogenous retinal detachment. In 6 patients, conservative treatment with intravitreal anti-VEGF injections and photocoagulation was performed after the hemorrhage cleared. Twenty-two patients, required vitrectomy, with good visual outcomes. Macular edema was found in 16 eyes, which responded to periocular and/or systemic corticosteroid therapy, except for 9 eyes that required intravitreal bevacizumab, with complete resolution in 7 eyes and partial resolution in 2 eyes. Eales’ disease is a pathology of significant prevalence in our country. The distribution according to sex, tends to be equivalent. The etiology, even when it is not specifically determined, according to laboratory tests, confirms the probable immunologic response in the presence of Mycobacterium tuberculosis antigens. This is still a diagnosis of exclusion, and therefore, it is advisable to perform a complete laboratory work-up in each case. Timely application of laser and other medical treatments, help to avoid progression to more advanced stages and their complications. The surgical treatment of vitrectomy for vitreous hemorrhage, and/or tractional vitreous detachment yields good primary anatomical and functional outcomes. Secondary macular edema responds to periocular and intravitreal corticosteroids, and in refractory cases, the use of anti-VEGF therapy leads to an effective resolution.