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Patient: Female, 44 Final Diagnosis: Optic neuritis Symptoms: Unilateral vision loss Medication: — Clinical Procedure: Fundoscopic examination Specialty: Ophthalmology Objective: Rare disease Background: Systemic lupus erythematosus (SLE) causes sight-threatening, ophthalmologic problems that are frequently challenging to manage. Optic neuropathy is a rare ophthalmological complication of SLE that can progress to total bilateral vision loss if not identified and treated rapidly. We describe a patient with SLE who presented with an acute, painless unilateral optic neuropathy who subsequently experienced partial recovery of vision when treated with high-dose intravenous corticosteroids. Case Report: A 44-year-old female with known SLE presented with 4 days of painless, complete, and gradual vision loss in the right eye. Initial ophthalmologic examination revealed no light perception, afferent pupil defect, 4+ optic disc swelling, and 1+ venous tortuosity of the right eye. No hemorrhage or exudates were noted. Diagnostic workup revealed a lupus flare with elevated inflammatory markers including elevated anti-nuclear antibody, anti-ds-DNA antibody, anti-Sm antibody, and anti-phospholipid IgG antibody. The diagnosis of optic neuropathy was clinically established, and the patient was treated with high-dose intravenous corticosteroids. Her vision improved, and she was transitioned to oral corticosteroids with eventual significant improvement in her vision. Conclusions: Optic neuropathy is a rare and devastating ophthalmologic complication of SLE. The diagnosis can be made by linking key clinical findings on ophthalmologic examination with positive serological studies. If treated rapidly with immunosuppressive therapy, the vision loss can be reversed, and permanent blindness avoided. Although this rare complication is generally bilateral in nature, clinician must also be aware of unilateral disease and treat patients accordingly.

Background Cytomegalovirus retinitis is an infectious sight-threatening condition that usually occurs in immunosuppressed individuals, but rare cases of Cytomegalovirus retinitis have been reported in immunocompetent patients. Findings A 68-year-old woman without any history of systemic diseases referred to the emergency ward of Farabi eye hospital with a two-week history of decreased vision in her left eye. Fundoscopy of the left eye revealed mild venous tortuosity, hemorrhagic retinitis within the macula, and papillitis. The right eye had a history of Cytomegalovirus retinitis 2 years ago that complicated with rhegmatogenous retinal detachment. Immunologic evaluations were normal without any sign of immunosuppressive conditions. She was treated with intravenous ganciclovir for 2 weeks, intravitreal ganciclovir (twice weekly) for 1 week, and also daily oral valganciclovir as maintenance therapy for 6 months resulted in resolving of retinitis patches and improving her best-visual acuity from hand motions to 20/100. Forty-five days after stopping maintenance therapy recurrence occurred. So we started the treatment again to stabilize the patient. She is currently maintained on valganciclovir 900 mg daily without recurrence for 9 months. Conclusions Cytomegalovirus retinitis can recur in the same or contralateral eye of immunocompetent patients, especially without prophylactic medication.

Introduction: Certain changes occur in high altitude which can be organic, motor or functional. This study was conducted to find out ocular morbidity at high altitude in Nepal. Methods: A cross sectional study was conducted at four different places at altitudes of 2710 m (Jomsom), 2900 m (Kagbeni), 3500 m (Jharkot) and 3800 m (Muktinath) of Mustang district of Nepal using convenient sampling method. A total of 222 subjects (444 eyes) were included. They were examined for vascular engorgement and tortuosity, arteriovenous ratio changes, retinal hemorrhages, cataract, pterygium, color vision and intraocular pressure. The motor changes like esodeviation and exodeviation were studied. Results: Of the total 222 participants, 164 (77.5%) were more than 40 years of age and 58 (22.5%) were less than 40 years. The male to female ratio was 1:1.1. The duration of stay at high altitude was >10 years in 96.6%, >15 years 88.3% and >20 years 83.8%. The prevalence of cataract was 19.8% and pseudophakia 17.1%. Other organic changes like venous engorgement, arterio-venous ratio changes and venous tortuosity was also found at high altitude. There was no significant change in intraocular pressure at high altitude. Esodeviation was present in 14%. The prevalence of pterygium was present in 39.6%. Similarly, the prevalence of red green color vision deficiency was 45.1%. Conclusion: Cataract, pterygium, red green color vision deficiency, esodeviation, venous engorgement and venous tortuosity were found to be prevalent at high altitude of Nepal.

We present a case of a previously healthy 52-year-old woman with acute onset of scotomas in both eyes. It was associated with headache and vomiting for the past 1 week after a cold. The best-corrected visual acuity was 20/20 in both eyes. The examination of bilateral fundus revealed a venous tortuosity and mild dilatation in the posterior pole, with pre- and intraretinal hemorrhages. However, vasculatures were normally straight in the mid-peripheral and peripheral retina of both eyes. Hemorrhages showed complete resolution without treatment. There was no change in the appearance and shape of the vasculature. Ophthalmologists should be aware of congenital venous tortuosity as a possible cause of retinal hemorrhages.

This funduscopic image shows right eye optic disc swelling, retinal haemorrhage, and venous tortuosity (arrows), all suggestive of central retinal vein occlusion; and a lack of retinal perfusion over …

Purpose. To evaluate the capacity of OCT angiography (OCTA) for detecting infraclinical lesions in parafoveal capillaries in diabetic patients without diabetic retinopathy (DR). Methods. This prospective observational cross-sectional case-control study analyzed the superficial and deep capillary plexuses (SCP and DCP) on macular OCTA scans (3 × 3 mm) centered on the fovea. We compared 22 diabetic patients (34 eyes included) without DR diagnosis on color fundus photographs, with 22 age- and gender-matched nondiabetic controls (40 eyes included). Qualitative analysis concerned morphological ischemic capillary alterations. Quantitative analysis measured foveal avascular zone (FAZ) size, parafoveal capillary density, and enlargement coefficient of FAZ between SCP and DCP. Results. Neither the qualitative nor quantitative parameters were significantly different between both groups. No microaneurysms or venous tortuosity was observed in any of the analyzed images. On the SCP, the mean FAZ area was 0.322 ± 0.125 mm2 in diabetic patients and 0.285 ± 0.150 mm2 in controls, P=0.31. On the DCP, the mean FAZ area was 0.444 ± 0.153 mm2 in cases and 0.398 ± 0.138 mm2 in controls, P=0.20. Conclusion. OCTA did not detect infraclinical qualitative or quantitative differences in parafoveal capillaries of diabetic patients without DR in comparison with nondiabetic controls.

Purpose To evaluate the change in visual acuity and retinal appearance in patients after early initiation of intravitreal bevacizumab treatment for central retinal vein occlusion (CRVO). Design Retrospective, interventional case series. Methods Patients with CRVO of fewer than three months' duration receiving intravitreal bevacizumab as primary treatment were evaluated. Patients received an intravitreal 1.25 mg (0.05 ml) bevacizumab injection. Changes in visual acuity, central macular thickness, venous tortuosity and diameter, and optic disk edema were noted. Results Six eyes of five consecutive patients with CRVO treated with intravitreal bevacizumab injection were reviewed retrospectively. The patients did not have other ocular conditions that could have compromised visual acuity. The mean baseline visual acuity was 20/428 (logarithm of the minimum angle of resolution [logMAR] units, 1.33). The mean follow-up period was 12 months (range, seven to 15 months), and the number of bevacizumab injections ranged from four to 10. The patients showed a statistically significant decrease in optic nerve head swelling, venous tortuosity, and venous diameter, with the largest proportion of change occurring within one month of the first bevacizumab injection. The mean visual acuity at last follow-up was 20/53 (logMAR units, 0.42; P = .035, as compared with baseline). In no patient did collateral vessels at the optic nerve head develop. Conclusions The patients experienced a dramatic improvement in the visual acuity and clinical fundus appearance, without collateral vessel formation. These findings are difficult to explain with current theories of the pathophysiologic features of CRVO. These findings also suggest early initiation of anti–vascular endothelial growth factor (VEGF) treatment should be studied in a larger trial for CRVO.

To the Editor. —In their article, Hupp et al 1 reviewed their experience with retrobulbar optic nerve decompression in a variety of clinical settings. The longest follow-up period in their series was nine years. In their review of the literature, they referred to a case of pseudotumor cerebri in which we reported successful reversal of visual loss following bilateral optic nerve decompression. 2 We are now able to provide follow-up information 13 years later. Although the patient was an extremely poor complier in terms of medications and weight reduction and despite persistently raised intracranial pressure, she had visual acuities of 20/25 OU with full kinetic visual fields when last seen, in April 1986. Both discs were flat and pink with very mild blurring of the nasal margins and some residual venous tortuosity. This excellent long-term result confirms our belief that optic nerve decompression is valuable in protecting visual function in