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Purpose To describe a case of bilateral cystoid macular edema in a patient with long-standing Tramadol hydrochloride use. Methods Observational case report. Results and discussion: A 73-year-old female patient was referred for progressive, bilateral decreased visual acuity. The patient was phakic with a best-corrected visual acuity (BCVA) at presentation was 20/50 on the right eye (RE) and 20/64 on the left eye (LE). The patient had a history of low back pain and had been on Tramadol hydrochloride 200 mg/day for 16 years. Bilateral cystoid macular edema (CME) was confirmed by means of multimodal imaging, including OCT angiography. Tramadol intake was progressively reduced over one month and then completely interrupted. At three months follow-up, the cystoid macular edema had completely resolved and BCVA improved in both eyes. Conclusion CME may be associated with longstanding treatment with Tramadol hydrochloride. Tramadol hydrochloride associated CME is described, as well as its resolution on Tramadol cessation.

An 8-year-old boy with no significant medical history or family history presented with 1–2 weeks of decreased visual acuity and blurry vision. The patient denied any headaches, vomiting, dizziness, seizures or weakness. Physical examination was significant for poorly reactive pupils, constricted

Purpose To describe the presentation, microbiology, management, and prognosis of eyes with endophthalmitis following Boston keratoprosthesis (KPro) implantation. Methods Retrospective case series with history, diagnostics, management, and outcomes data in endophthalmitis following KPro implantation presenting to a tertiary center between 2009 and 2020. Results Of 137 KPro-implanted eyes, 7 eyes of 7 patients (5%) developed endophthalmitis. On presentation, 6 (86%) reported decreased visual acuity (VA), and only 1 (14%) reported pain. Peripheral corneal ulcers were present in 2 eyes (29%). Seidel testing was negative in all cases. Six eyes (86%) had retroprosthetic membranes. One (14%) underwent initial pars plana vitrectomy (PPV) with mechanical vitreous biopsy, whereas 6 (86%) received a needle vitreous tap-half of which were dry. Organisms were isolated following vitreous tap in 2 eyes: Streptococcus intermedius and Mycobacterium abscessus. Mean VA pre-endophthalmitis, at presentation, and at 6 months were 20/267, 20/5944, and 20/734, respectively. VA improved 9.08 ± 11.78 ETDRS lines from presentation to 6 months. Six-month VA was correlated with pre-endophthalmitis VA (r=0.92, p=0.003) but not presenting VA (p=0.838). Conclusion Visual acuity at 6 months is correlated with pre-endophthalmitis VA, not presenting VA. Endophthalmitis should be considered in the differential diagnosis of painless intraocular inflammation any time after KPro implantation, even if Seidel negative.

Background The Indiana University Student Outreach Clinic (IUSOC) Eye Clinic is a monthly student-run eye clinic that provides free visual screening to the Near East Side community of Indianapolis, IN, USA. Screening includes assessments of visual acuity, intraocular pressure, peripheral visual fields, refraction, and non-mydriatic fundus photography. Methods This is a retrospective chart review of 875 patients seen at the IUSOC Eye Clinic from October 2013 to February 2020. Data on demographics, insurance coverage, ocular history, physical examination, suspected diagnosis, referral status, and glasses provided were collected and analyzed. Results 875 patients were seen at the IUSOC Eye Clinic from October 2013 to February 2020. 39.2% of the patients seen at the clinic reported being uninsured. 61.4% of patients were found to have visual acuity of 20/40 or worse, while 51.3% of patients were found to have a near visual acuity of 20/40 or worse. 20.3% of patients were referred to the local county hospital for further evaluation by an ophthalmologist, 14.4% of patients received free glasses prescriptions, and 27.9% of patients received free reading glasses. Common reasons for referral for further ophthalmology evaluation included glaucoma, decreased visual acuity, and diabetic retinopathy. An estimated value of services provided over the seven years of the clinic was 1271 relative value units. Conclusion The IUSOC Eye Clinic fills an important role in advancing ocular health and preventing irreversible blindness in an underserved Indianapolis community. Additionally, the clinic demonstrates an educational model for involving medical student volunteers.

Summary Corneal haze represents subepithelial corneal fibrosis, a manifestation of a pathological healing process. It occurs as a result of an epithelial-stromal lesion involving a break in the epithelial barrier. It is an inflammatory response that involves the migration, multiplication and differentiation of keratocytes into mature myofibroblasts, causing loss of corneal transparency. Although it is a transient phenomenon, this complication is feared following refractive photokeratectomy (PRK), because it can cause alterations in the quality of vision, refractive regression and decreased visual acuity. The severity of these symptoms is correlated with the severity of the corneal haze, which can be assessed clinically or by objective means such as corneal densitometry measurement. The frequency and severity of corneal haze increase with the depth of photoablation in PRK and are therefore increased during the treatment of severe ametropia. Considering that no consensus exists, the application of mitomycin C (MMC) intraoperatively and topical corticosteroids postoperatively are conventionally used to inhibit collagen synthesis, sometimes in combination with various protocols depending on the center or surgeon. This review of the literature reports the current knowledge on corneal haze, in order to better understand it and optimise its prevention in the context of a decreased MMC supply, which has occurred in the past and could recur in the future.

Purpose To describe a patient with newly developed paracentral acute middle maculopathy after uncomplicated epiretinal membrane removal. Methods Retrospective chart review. Results A 74-year-old white man underwent uncomplicated vitrectomy and epiretinal membrane removal in his left eye. One week later, the patient complained of a small paracentral visual field deficit and decreased visual acuity. Spectral domain optical coherence tomography revealed a characteristic hyperreflective band-like lesion at the level of the inner nuclear layer, consistent with paracentral acute middle maculopathy. The patient was closely followed and endorsed subjective improvement of his paracentral visual deficit at 3 months postoperatively. Conclusion Paracentral acute middle maculopathy, although rare, may be encountered after epiretinal membrane removal.

International audience; Purpose: To investigate cone density in the asymptomatic fellow eye of patients with unilateral central serous chorioretinopathy (CSCR). Methods: Seventeen asymptomatic fellow eyes of patients with unilateral CSCR and 17 eyes of aged-matched and gender-matched healthy controls underwent adaptive optics ophthalmoscopy. Cone density and spacing were assessed at the fovea. Clinical and multimodal imaging findings were also recorded. Results: In the CSCR group, the patient mean age was 48.9 ± 9.8 years. The mean (±SD) subfoveal choroidal thickness was 417.8 ± 125.2 mm. The foveal external limiting membrane and ellipsoid zone were intact in all patients. Adaptive optics fundus imaging showed a significant decrease in cone density at 2°of eccentricity nasal and temporal to the fovea in asymptomatic fellow eyes of patients with unilateral CSCR compared with controls (P = 0.001 and P = 0.027, respectively). No statistically significant difference in cone density was found at 4°of eccentricity nasal and temporal to the fovea between both groups. Conclusion: Asymptomatic fellow eyes of patients with unilateral CSCR showed a reduced density of foveal cones in the absence of a decreased visual acuity and photoreceptor line disruption on optical coherence tomography. These results suggest that the photoreceptors could be damaged independently of the occurrence of a serous retinal detachment.

Mujer de 55 años que acudió por cefalea súbita intensa, ptosis palpebral izquierda asociada a disminución de la agudeza visual a predominio del ojo izquierdo; además, los exámenes de laboratorio evidenciaron hiponatremia más hipopituitarismo. La resonancia magnética cerebral mostró un adenoma pituitario con gran componente necrótico que posteriormente fue confirmado en el estudio anatomo patológico. Se concluyó en una apoplejía hipofisaria como forma de presentación de un adenoma hipofisario sin diagnóstico previo, con buena evolución de los síntomas visuales después de la cirugía. A 55-year-old woman who attended for sudden intense headache, left palpebral ptosis associated with decreased visual acuity to predominance of the left eye; in addition, laboratory tests showed hyponatremia plus hypopituitarism. The cerebral magnetic resonance showed a pituitary adenoma with a large necrotic component that was later confirmed in the pathological study. It was concluded in a pituitary apoplexy as a form of presentation of a pituitary adenoma without prior diagnosis, with good evolution of visual symptoms after surgery.

To assess the efficacy of a treat-and-extend strategy with intravitreal ranibizumab for radiation-related macular edema. Forty eyes with radiation-induced macular edema and decreased visual acuity were enrolled in the phase IIb, prospective clinical trial and randomized into 3 cohorts: (A) monthly ranibizumab, (B) monthly ranibizumab with targeted retinal photocoagulation (TRP), or (C) as-needed ranibizumab and TRP. In year 2, all subjects entered a treat-and-extend protocol for ranibizumab. The primary outcome measure was mean change in early treatment diabetic retinopathy study (ETDRS) best-corrected visual acuity (BCVA) from baseline. Through year 1, the mean change in ETDRS BCVA was significantly different between the three cohorts (p

Purpose To investigate the choroidal thickness (CT) and choroidal area (CA) in patients with unilateral commotio retinae of the macula using spectral domain optical coherence tomography with enhanced-depth imaging. Methods This is a retrospective review of 16 eyes of 8 consecutive patients with unilateral macular commotio retinae within 7 days of blunt ocular trauma that underwent optical coherence tomography with enhanced-depth imaging seen at our institution. The contralateral, nontraumatized eye served as the control group. All patients underwent spectral domain optical coherence tomography imaging with enhanced-depth imaging protocol. Using the electronic caliper within the Zeiss optical coherence tomography review software, CT was measured from the outer portion of the retinal pigment epithelium band to the inner surface of the sclera. The central horizontal and vertical rasters were averaged to calculate the final CT measurement of each eye. The final CA reading of each eye was obtained by averaging the central 1,500 μm of subfoveal CA using the same rasters. The researchers compared the CT, CA, and best-corrected visual acuity in traumatized eyes with macular commotio with their fellow nontraumatized control eyes. Results Traumatized eyes with macular commotio retinae had greater subfoveal CT and CA (P = 0.0027, P = 0.0279) compared with the normal fellow eye. An increase in CT and CA in the subfoveal area in the presence of commotio retinae was associated with worse visual acuity (P = 0.0180). Conclusion Subfoveal CT and CA were greater in eyes with commotio retinae when compared with normal fellow eyes. Increased CT and CA in macular commotio retinae were associated with decreased visual acuity.

Herein, we report the longitudinal observation of a case with reopening of the macular hole associated with a lamellar macular hole-associated epiretinal proliferation (LHEP) followed by spontaneous closure in patients with stage 2 idiopathic macular hole. A 64-year-old woman was referred for the decreased visual acuity (VA) and acute anorthopia in the right eye. Funduscopy and optical coherence tomography (OCT) showed stage 2 full-thickness macular hole without posterior vitreous detachment (PVD) and operculum formation. Her best-corrected visual acuity (BCVA) was 20/32. One month later, the diameter of the macular hole was getting small and VA improved. Six months later, the macular hole was treated spontaneously with the attached hyaloid membrane to the macula by OCT and the BCVA improved to 20/20. Fourteen months after the first visit, the BCVA decreased to 20/50 and the patient was diagnosed with stage 4 macular hole with complete PVD. OCT showed full-thickness macular hole with a LHEP in the right eye. After 25G-gauge vitrectomy with the peeling of internal limiting membrane (ILM) and LHEP, the macular hole was closed and BCVA finally improved to 20/25. Spontaneous macular hole closure without PVD may rarely occur in patients with LHEP. The surgical removal of ILM and LHEP may contribute to the successful macular hole closure after vitrectomy.

Purpose To investigate genetics, electrophysiology, and clinical course of KCNV2-associated retinopathy in a cohort of children and adults. Study design This was a multicenter international clinical cohort study. Methods Review of clinical notes and molecular genetic testing. Full-field electroretinography (ERG) recordings, incorporating the international standards, were reviewed and quantified and compared with age and recordings from control subjects. Results In total, 230 disease-associated alleles were identified from 117 patients, corresponding to 75 different KCNV2 variants, with 28 being novel. The mean age of onset was 3.9 years old. All patients were symptomatic before 12 years of age (range, 0-11 years). Decreased visual acuity was present in all patients, and 4 other symptoms were common: reduced color vision (78.6%), photophobia (53.5%), nyctalopia (43.6%), and nystagmus (38.6%). After a mean follow-up of 8.4 years, the mean best-corrected visual acuity (BCVA ± SD) decreased from 0.81 ± 0.27 to 0.90 ± 0.31 logarithm of minimal angle of resolution. Full-field ERGs showed pathognomonic waveform features. Quantitative assessment revealed a wide range of ERG amplitudes and peak times, with a mean rate of age-associated reduction indistinguishable from the control group. Mean amplitude reductions for the dark-adapted 0.01 ERG, dark-adapted 10 ERG a-wave, and LA 3.0 30 Hz and LA3 ERG b-waves were 55%, 21%, 48%, and 74%, respectively compared with control values. Peak times showed stability across 6 decades. Conclusion In KCNV2-associated retinopathy, full-field ERGs are diagnostic and consistent with largely stable peripheral retinal dysfunction. Report 1 highlights the severity of the clinical phenotype and established a large cohort of patients, emphasizing the unmet need for trials of novel therapeutics., Highlights • The current study established the largest and most characterized cohort of molecularly confirmed patients with KCNV2-associated retinopathy. • Report 1 highlights the genetic background, evidence of electroretinography stability over a broad age range, and the severe phenotype of the disease.

Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory disorder of the central nervous system (CNS) known for its predilection for the spinal cord, the optic nerves, and the brainstem. However, headache and more specifically idiopathic intracranial hypertension (IIH) is an unusual presentation of the disease. Here, we present a 40-year-old female, who initially presented in our department of neurology with refractory headache, blurry vision, and diplopia. She had an undiagnosed episode of headache, blurred vision, scotomas, and decreased visual acuity in her right eye, 6 months earlier. The actual ophthalmologic assessment revealed a decreased visual acuity in both eyes, optic atrophy in the right eye, and papilledema in the left one. The lumbar puncture showed a raised opening pressure of 30 cm H2O. Venous brain MR, cerebrospinal fluid examination, and other laboratory investigations were normal. Optic neuritis was discovered on visual evoked potential. The patient was treated with intravenous steroids and acetazolamide with a good outcome. One year later, she appeared with longitudinally extensive myelitis. The patient tested positive for anti-NMO antibodies which finally led to the diagnosis of NMOSD. Through this case, we highlight the importance of suspecting optic neuritis in patients having a headache and visual impairment and we suggest performing an exhaustive ophthalmologic examination to investigate effectively the eyes and the optic nerves.

Background Epiretinal membrane (ERM) is a disease that affects the vitreoretinal interface and causes metamorphopsia, anorthopia, and decreased visual acuity. In this study, ERM patients who underwent internal limiting membrane (ILM) peeling were classified as those with glaucoma (Group G) and a control group (Group C). Changes in ganglion cell complex (GCC) thickness were compared between these groups to investigate whether such changes had an effect on progression of glaucoma from structural change. Methods This was a retrospective, observational study that included 27 eyes of 27 patients. Group C included 22 eyes, and Group G included 5 eyes. Patients underwent ILM peeling, and cataract surgery was combined with vitrectomy for 16 phakic eyes; 2 phakic eyes and 9 aphakic eyes were treated only with vitrectomy. GCC thickness was measured preoperatively and at 2 weeks and 1, 3, and 6 months postoperatively, and these values and the rates of thinning were compared between the two groups. Results The mean age of patients was 66.7±12.8 years (range 30-84 years). There was no significant difference between groups in the thickness of the GCC or its rate of thinning after ILM peeling. Conclusions The present results suggest that this procedure does not cause structural exacerbation of glaucoma in glaucoma patients. Although further studies of the functional effects of ILM peeling are required, the present results suggest that there is no significant difference between the two groups.

We describe the electroretinographic findings of a case of primary intraocular lymphoma (PIOL) wherein the patient received intravitreal injections of methotrexate (ivMTX). A 62-year-old man developed blurred vision and complained of decreased visual acuity (VA) in his right eye. Fundus examination showed vitreous opacity and multiple subretinal yellowish lesions. Optical coherence tomography (OCT) revealed subretinal and intraretinal infiltrations. The full-field electroretinogram (ffERG) showed subnormal combined rod-cone response and multifocal electroretinogram (mfERG) recorded using skin electrodes showed severe attenuation of the response compared with the other eye. Pars prana vitrectomy, phacoemulsification, and lens implantation were performed to remove the opacity, and vitreous biopsy revealed a high ratio of interleukin 10–6 (76.0). There was no systemic malignant lesion, and the patient was diagnosed with PIOL. Treatment with ivMTX (400 μg/0.1 mL) was started. One month later, the intraretinal infiltration had disappeared, and mfERG revealed recovery of the response density from the central area. Two months later, OCT showed recovery of the foveal ellipsoid and interdigitation zones, and VA recovered to 20/17; mfERG showed maintenance of macular function. However, the amplitude of a- and b-waves in the ffERG gradually decreased. Macular function recovered, but there was also a decrease in total retinal function. mfERG and ffERG recorded using skin electrodes were useful in monitoring macular and entire retinal function with repeated examinations and showed recovery and maintenance of macular function in a case of PIOL treated with ivMTX.

Purpose To study the association between television-watching in the earlier years of life and subsequent parents’ concerns about decreased visual acuity in their elementary school-aged child. Study design Population-based longitudinal cohort. Methods Television-watching and its daily duration, as the main exposure, and parents’ concerns for their child’s decreased visual acuity during the school years, as the main outcome, were picked up from yearly questionnaires performed for the Longitudinal Survey of Newborns in the Twenty-First Century involving all babies born in Japan during either of two periods: between January 10 and 17, 2001 or between July 10 and 17, 2001 (N = 47,015). Results Television-/video-watching as the main form of play of children at the ages of 1.5 years and 2.5 years was significantly associated with parents’ concerns for their child’s decreased visual acuity raised once or more in six surveys conducted between the ages of 7 and 12 years (odds ratio, 1.1 and 1.09; 95% CI 1.05–1.15 and 1.04–1.14, respectively). The association remained significant after adjustment for confounding variables, including child’s sex, preterm birth, multiple birth, mother’s age at delivery, mother’s and father’s education, and residential area. Longer daily duration of television-watching at 2.5 years was significantly associated with concerns for the child’s decreased visual acuity between the ages of 7 and 12 years, but not at the ages of 3.5, 4.5, and 5.5 years. The association remained significant in a sensitivity analysis of 28,820 children who participated in all six surveys. Conclusions Longer daily exposure to television in children in the earlier years of life was associated with parents’ subsequent concerns about decreased visual acuity in their elementary school-aged child.

Purpose The effectiveness and safety of surgery for spheno‐orbital meningiomas remains subject of debate, as studies often describe different surgical approaches and reconstruction techniques with very heterogeneous outcomes. We aimed to systematically summarize and analyse the literature on spheno‐orbital meningiomas regarding presenting symptoms, surgical techniques, outcomes and complications. Methods Studies were retrieved from eight databases. Original articles were included if in ≥5 patients presenting symptoms, surgical treatment and outcomes were described. Fixed‐ and random‐effects meta‐analysis was performed to estimate weighted percentages with 95%CIs of presenting symptoms, outcomes and complications. Results Thirty‐eight articles were included describing 1486 patients. Proptosis was the most common presenting symptom (84%; 95%CI 76–91%), followed by unilateral visual acuity deficits (46%; 95%CI 40–51%) and visual field deficits (31%; 95%CI 20–43%). In 35/38 studies (92%), a pterional craniotomy was used. Decompression of the optic canal (82%) and the superior orbital fissure (66%) was most often performed, and usually dural (47%) and bony defects (76%) were reconstructed. In almost all patients, visual acuity (91%; 95%CI 86–96%), visual fields (87%; 95%CI 70–99%) and proptosis (96%; 95%CI 90–100%) improved. Furthermore, surgery showed improvement in 96% (95%CI 78–100%) for both diplopia and ophthalmoplegia. The most common surgical complications were hypesthesia (19%; 95%CI 10–30%), ptosis and diplopia (both 17%; 95%CI, respectively, 10–26% and 5–33%) and ophthalmoplegia (16%; 95%CI 10–24). Conclusion Patients with spheno‐orbital meningioma usually present with proptosis or unilateral decreased visual acuity. Surgery shows to be effective in improving visual acuity and visual field deficits with mostly minor and well‐tolerated complications.

Background: The purpose of this paper was to report a case of bilateral lens capsule rupture in a patient with previously undiagnosed Alport’s syndrome. Case presentation: A 12-years-old child was referred to our hospital for cataract extraction secondary to decreased visual acuity in the right eye two years after lensectomy and posterior chamber intraocular lens implant in the left eye secondary to assumed traumatic cataract. Slit-lamp examination showed a ruptured anterior capsule in the right eye with lens matter in the anterior chamber. Clinically the patient was anemic and deaf; he was referred for pediatric evaluation and was diagnosed with Alport’s syndrome and end-stage renal disease. Once the patient’s hypertension was controlled, a lensectomy and posterior chamber intraocular lens implant was performed. Results: Lensectomy and posterior chamber intraocular lens implant removed the cataract and allowed the restoration of visual acuity. Conclusions: Ophthalmologists may be the first to consider the diagnosis of Alport’s syndrome based on lens changes. Uncontrolled Blood pressure can delay surgery, during which time intraocular pressure (IOP) should be monitored closely. Results of lensectomies with foldable IOL implantation are successful. To our knowledge, this is the second report of a case of bilateral lens capsule rupture in a patient with previously undiagnosed Alport’s syndrome.

We report a case of cyclodialysis with decreased visual acuity after microhook trabeculotomy (mTLO) successfully treated by vitreous surgery. A 41-year-old man had been medically treated for primary open-angle glaucoma in both eyes. He was scheduled to undergo mTLO due to progression of visual field impairment and unstable intraocular pressure in his right eye. His preoperative best-corrected visual acuity (BCVA) was 0.4 OD, and the intraocular pressure was unstable, ranging from 12 to 27 mm Hg. On the day after the operation, a shallow anterior chamber developed, and a low intraocular pressure occurred. His visual acuity continued to decrease, and cyclodialysis was confirmed by ultrasonic biomicroscopy. No improvement was obtained with medical treatment, and his BCVA dropped to 0.08 OD, while his intraocular pressure remained at 2–3 mm Hg. Three months later, a second surgery was performed by combining cataract surgery with intraocular lens implantation, vitrectomy, cryopexy for the pars plana of the ciliary body, and 20% SF6 gas tamponade. Two weeks after the reoperation, the intraocular pressure had been normalized to 12 mm Hg, and the BCVA had returned to 0.3. We successfully treated cyclodialysis as a complication after mTLO by vitreous surgery that led to the recovery of the visual acuity and intraocular pressure.

Purpose To analyze morphologic and functional changes after inverted internal limiting membrane-flap technique for optic disk pit maculopathy using optical coherence tomography, multifocal electroretinography, and microperimetry. Methods One case report. Results A 30-year-old woman presented us with decreased visual acuity (20/63) in the left eye because of retinoschisis and serous macular detachment associated with optic disk pit. Optical coherence tomography did not localize the source of intraretinal and subretinal fluid. A partial flattening of serous detachment after vitrectomy with internal limiting membrane peeling, inverted internal limiting membrane-flap technique, and gas tamponade was reported. Visual acuity and multifocal electroretinography improved while retinal sensitivity decreased at microperimetry during 3 months of follow-up. Conclusion Optical coherence tomography is helpful to assess the effectiveness of surgical maneuvers to treat optic disk pit maculopathy. Multifocal electroretinography and microperimetry might offer additional tools for follow-up analysis of retinal function after surgery.

Objective: Posterior capsular opacification (PCO) is a postoperative complication causing decreased visual acuity. This study aims to study the efficacy of Nd: YAG laser capsulotomy in posterior capsular opacification following cataract surgery by analyzing the visual outcome. Material and Methods: A prospective study included a sample size of 50 eyes of 37 patients with Posterior capsular opacification following uneventful cataract surgery with significantly decreased visual acuity. Detailed anterior and posterior segment examination was done, best-corrected visual acuity (BCVA) was recorded along with measurement of IOP. Posterior capsulotomy was performed using Nd: YAG laser (Neodymium: Yttrium-aluminum–garnet) and patients were followed up. Visual acuity was assessed and complications if any were recorded. Results: It was noted that 74% of the patients at the end of 1st week and 78% of the patients at the end of 1st and 3rd month had significant visual improvement following Nd: YAG laser capsulotomy. There was a statistically significant difference in Post Nd: YAG laser BCVA on follow up with P-value

A 41-year-old woman has come to our attention complaining of decreased visual acuity and monocular diplopia associated with upper and lower limb hypoesthesia. Malabsorption syndrome with vitamin A and E deficiency developed after a bariatric biliopancreatic diversion. The clinical ophthalmological signs and symptoms improved after oral vitamin supplementation therapy. The past medical history is essential in the case of a patient complaining of visual symptoms compatible with vitamin deficiency in order to detect the cause and to start a prompt therapy to avoid irreversible neurological and visual sequelae. The clinical features of our case closely resemble other cases described in the literature of patients affected by vitamin A and E deficiency secondary to malabsorption syndrome.

BACKGROUND: Spontaneous vitreous hemorrhage is uncommon in the general population. Of cases, 1020% are idiopathic or due to occult causes and a majority of the remainder are associated with diabetic disease. The evaluation and disposition of an aviator has not been reported previously. This case will document the work-up and safe return to flight of a patient.CASE REPORT: A 33-yr-old male MH-60R pilot presented with acute blurred vision in the left eye and eye pain which began at his desk. His review of systems was otherwise negative. His medical history was noncontributory. On initial examination his vital signs and external ocular exam were normal. He was immediately referred to the optometry clinic, where a dilated funduscopic examination (DFE) with scleral depression demonstrated a large floater OS composed of streaks of blood and tobacco dust. His DFE was otherwise normal with no retinal tears or vitreous detachments. On repeated DFEs, his intraoccular pressures remained normal and his hemorrhage resorbed without decreased visual acuity or field deficits. A hematologic work-up was negative. After 4 mo of observation, the patient was returned to flight status without further recurrence.DISCUSSION: No known associations exist between aeronautical duties and spontaneous vitreous hemorrhages. The stressors aviators are subjected to, such as high vibrations and increased g forces, may make them more likely to suffer intraocular microvascular damage that could lead to retinal detachment, vitreous detachment, and bleeding. Further reports are needed to determine the risks of recurrence in aviators and their differences from typical spontaneous vitreous hemorrhage patients.Wallace SA. Spontaneous vitreous hemorrhage in a naval aviator. Aerosp Med Hum Perform. 2020; 91(11):904907.

Introduction: The most common cause of vision loss in cases of Retinal vein occlusion (RVO) is due to macular edema. This study was conducted to examine the effect of intravitreal bevacizumab (IVB) in the treatment of macular edema secondary to RVO. Materials and methods: The authors conducted a retrospective study of 94 eyes (N) of 92 patients with macular edema associated with decreased visual acuity secondary to RVO who were treated with IVB. Patients received IVB at baseline, 1 month and 2 months. At each follow up patients were evaluated and re-injected if necessary. Results: The mean age of the patients was 56.6 ±11.51 years. The average number of injections per eye was 2.1 ± 0.87. The baseline median central macular thickness (CMT) and best-corrected visual acuity (BCVA) in LogMAR was 465.00μm (Min 254μm, Max 1218μm) and 1.00 (Min 0.30, Max 2.28), respectively. The median CMT at one month following first, second and third dose of IVB was 258μm (N=94, Z= -7.64, p

Neuroleukemia is a severe complication of hemoblastosises characterized by infiltration of blast cells of the meninges, the substance of the brain, cranial and peripheral nerves.The purpose. To analyze the clinical manifestations of leukemia with optic nerve damage in leukemia and malignant lymphomas.Patients and Methods. From January 2016 to January 2020, one center-based non-randomized prospective study was conducted on patients with leukemia and non-Hodgkin’s lymphomas who were treated in the hematology department of MONIKI and made complaints about reduced vision. 26 patients were examined, 4 of them were diagnosed neuroleukosis with leukemic infiltration of the optic nerves: three women aged 41, 44, 46 years and a man aged 50 years.Results. All patients had one common ophthalmological symptom — decreased visual acuity. Complaints of reduced vision in one patient appeared at the onset of the disease, in other patients-during a relapse. The picture of the eye’s fundus in all patients was identical: the optic disk had blurred borders, and elevated above the retina. In the first days, the vascular funnel was viewed, then closed by infiltration. A dense white infiltrate of the peripapillary retina spread over the entire macular area. The retinal veins were sharply dilated of uneven caliber. Along the course of the vessels, there were a large number of different sizes and shapes of hemorrhages. Various types of neuroleukemia with lesion of the optic nerve were described: a combination of focal lesions of the brain and the optic nerve, isolated damage to the optic nerve with blast cytosis in the cerebrospinal fluid (CSF), isolated damage to the intraocular part of the optic nerve without changing the cerebrospinal fluid. In three patients the diagnosis of neuroleukemia exhibited on the basis of changes according to magnetic resonance imaging (MRI) and/or the number of blast cells in punctate liquorologic research. In the fourth patient, in the absence of changes in the liquor and MRI, the diagnosis of leukemic infiltration of the optic nerve was confirmed by data from a cytological examination of a punctate from the peripapillary retina. After the beginning of antitumor treatment, the significant improvement visual acuity and decrease in leukemic infiltrate of the optic disc and retina of the affected eye was noted in all patients.Discussion. Damage of the optic nerve can develop both at the onset of the disease, and relapses of leukemia or aggressive non-Hodgkin’s lymphomas. Leukemic infiltration evolves in all parts of the optic nerve, but more often affects its intraocular portion. The damage to the intraocular part is characterized by the presence of a dense infiltrate both in the area of the papilla and the peripapillary retina.Conclusion. Leukemic infiltration of the optic nerve is manifested by a significant decrease in visual acuity. Careful attention to complaints of reduced vision in patients with leukemia can help to recognize the development of the disease’s debut or its progression. Timely antitumor treatment leads to an improvement in visual acuity and, consequently, an improvement in the quality of life of patients.

The case is reported of a 59-year-old woman, who reported decreased visual acuity (VA) in the left eye (LE). On examination, a corrected VA of finger count/ 30cm was observed in LE. Corneal oedema and folds in the Descemet's membrane were observed using the slit lamp. Anterior synechiae, iris atrophy, and corectopia were also found. Iridocorneal endothelial syndrome (ICE) was diagnosed. The treatment option was a combination of cataract surgery and automated endothelial keratoplasty with Descemet's membrane dissection (DSAEK). There were no complications during the operation, with a successful anatomical and functional recovery, with a VA of 0,8 being observed after one year. This result supports the efficacy of DSAEK in ICE syndrome, encouraging more studies to be carried out that should also support its efficacy in this syndrome.

Introduction: Schnyder corneal dystrophy (SCD) is a rare, autosomal dominant, anterior stromal dystrophy described as progressive bilateral corneal opacification due to abnormal accumulation of cholesterol and phospholipids in the cornea. The clinical signs can change as the patient ages. SCD with different presentations may actually be misdiagnosed. Early diagnosis would help to rule out other potentially sight threatening or treatable conditions like infectious keratitis or drug toxicity. Case: We present a case of a 34-year-old Syrian male patient, came to our clinic for bilateral decreased visual acuity for 5 years. His visual acuity was 0.15 in both eyes. Slitlamp examination revealed corneal arcus or disk-like lesion and polychromatic crystalline depositions in both eyes in subepithelial and the anterior 1/3 of the stroma. The mild onset of arcus lipoides was also seen. Central corneal thickness results were 507 μm in the right eye and 503 μm in the left eye. A diagnosis of Schnyder corneal dystrophy was thought based on clinical presentation and coexistence dyslipidemia of the patient. Conclusion: Ophthalmologists should keep in mind SCD and its associated systemic findings that need to be evaluated and managed properly.

To characterize tomographic patterns and quantify corneal higher-order aberrations (HOAs) in eyes with corneal scar due to phlyctenular keratitis. Retrospective consecutive case series. This study included 51 eyes of 38 patients (24 women; 14 men) with corneal scar due to phlyctenular keratitis. HOAs of the total cornea, and of the anterior and posterior surfaces were measured using anterior segment optical coherence tomography (AS-OCT). Corneal tomographic patterns were classified into five types: increased regular astigmatism, ectasia, asymmetric, flattening and minimal change patterns. The correlation between corneal HOAs and visual acuity was evaluated. Mean months from onset was 50.7 ± 74.7 and mean number of recurrences 2.1 ± 1.1 (1–5). Mean logarithm of the minimal angle of resolution (logMAR) was 0.19 ± 0.31. AS-OCT showed ectasia pattern in 16 eyes (31.4%), asymmetric pattern in 12 eyes (23.5%), increased regular astigmatism pattern in 9 eyes (17.6%), flattening pattern in 3 eyes (5.9%) and minimal change pattern in 11 eyes (21.6%). HOAs of the total cornea were 0.57 ± 0.44 μm and 1.16 ± 0.77 μm within a 4-mm and 6-mm diameter, significantly larger than in normal controls (P

Background: Proliferative diabetic retinopathy (PDR) is the most advanced stage of DR. It significantly increases the risk for progressive vision loss, and without intervention, approximately one half of eyes ultimately experience severe vision loss. Although PRP is the gold standard treatment of PDR by reducing moderate visual loss by 50% in treatment groups, it also caused significant macular edema, which is recognized as the most common cause of decreased visual acuity in diabetic eyes. Optical Coherent Tomography (OCT) helps us studying these macular edema and its characteristics. Objective: To investigate the changes in macular thickness and morphology after panretinal photocoagulation (PRP) in eyes with proliferative diabetic retinopathy (PDR) and without clinically significant macular edema. Patients and Methods: This study enrolled 20 eyes of 15 patients with early proliferative diabetic retinopathy (PDR) without any clinically significant macular edema. Panretinal photocoagulation was applied 3 sessions, one week apart. Fundus fluorescein angiography and OCT were carried out for all patients before PRP. Baseline and post PRP visual acuity and central foveal thickness were evaluated after 3 months. Results: The mean patient age was 59.00±9.93 years (range, 33-72 years). Fifteen of the 20 eyes (75%) had stable or improved vision, while 5 eyes (25%) had worsened by 3 months following PRP. Mean preoperative vision was 0.50±0.1 decimal fraction, and although worsened at 3 months 0.48±0.15 decimal fraction, this was statistically insignificant (P = 0.453). Mean pre- PRP central foveal thickness was 253.05 ± 18.53 μm (ranging from 227 – 281μ), increased significantly to 281.45 ± 28.71 μm (ranging from 240 – 344μ) at 3 months’ follow-up (P˂ 0.001). Three months after PRP, 15 eyes developed complications. The most common abnormality was cystoid edema seen in 6 eyes (30%), followed by diffuse macular edema in 4 eyes (20%), posterior vitreous detachment (PVD) in 2 eyes (10%), neuro sensory detachment in two eyes (10%), and epiretinal membrane (ERM) in one eye (5%). Conclusion: Panretinal photocoagulation is safe, effective in treating and preserving vision in proliferative diabetic retinopathy (PDR), although causing temporary drop in vision and changes in macular morphology/thickness.

A 39-year-old man presented to the ophthalmology emergency room complaining of decreased visual acuity and metamorphopsia on his left eye after undergoing Nd:YAG facial hair epilation without wearing proper eye protection. Fluorescein angiography showed a foveal staining initially, with an increase in foveal leakage over late phases. On optical coherence tomography, a subfoveal retinal pigment epithelial detachment with associated subretinal fluid and no signs of choroidal neovascularization or cystoid macular edema was observed. Observation with monthly follow-ups was adopted. By the fourth month, the subretinal fluid had already disappeared and visual acuity had returned to 20/20. Over one-year follow-up, the retinal pigment epithelial detachment experienced a decrease in its size. Conservative management may be a valid option in assessing accidental foveal photocoagulation when choroidal neovascularization or cystoid macular edema is absent. The use of wavelength specific goggles is mandatory for the patient and the aesthetician operating the cosmetic laser, especially when operating on the face or around the eyes. Abbreviations: Nd:YAG = neodymium-doped yttrium aluminium garnet, OCT = optical coherence tomography, PED = pigment epithelial detachment, CME = cystoid macular edema.

Purpose To determine outcomes after photodynamic therapy (PDT) for choroidal metastasis. Design Retrospective interventional case series. Participants Forty-three patients with 40 eyes harboring 58 choroidal metastases. Methods Treatment with standard fluence PDT using verteporfin. Main Outcome Measures Tumor control and visual outcomes. Results The primary cancer originated in the lung (n = 17 [39%]), breast (n = 16 [37%]), kidney (n = 3 [8%]), thyroid (n = 2 [6%]), and other sites (n = 5 [10%]). The mean patient age at entry was 61 years. Ocular symptoms included decreased visual acuity (n = 23 [53%]), visual field defect (n = 2 [5%]), floaters (n = 7 [16%]), flashes (n = 3 [7%]), and asymptomatic (n = 8 [19%]). The median entering visual acuity (Snellen equivalent) was 20/40. The median tumor diameter was 5.0 mm, and median thickness by ultrasonography was 2.0 mm. The median distance to the optic disc was 3.0 mm, and that to the foveola was 2.0 mm. Of the 43 patients, 35 maintained follow-up (40 eyes, 45 tumors), and PDT achieved tumor control with 1 session (n = 32 tumors [71%]) or 2 sessions (n = 3 tumors [7%]) and failed to achieve regression (n = 10 tumors [22%]). The 10 metastases for which treatment failed were managed further with plaque radiotherapy (n = 3), proton beam radiotherapy (n = 1), external beam radiotherapy (n = 1), systemic chemotherapy (n = 4), and observation (patient preference; n = 1). A comparison of clinical features for tumor control (PDT alone vs. PDT plus additional therapy) revealed those controlled with PDT alone were more likely to be adenocarcinoma (73% vs. 30%; P = 0.02) and those eyes were more like to achieve final visual acuity of 20/20 to 20/40 (66% vs. 30%; P = 0.03), with better median final Snellen visual acuity (20/30 vs. 20/70; not significant). Primary cancer site or ocular tumor features (size, location, color, shape, related subretinal fluid) did not impact tumor control. In the entire group of 40 eyes, visual acuity improved or remained stable in 28 (70%) and decreased in 12 (30%), related to subfoveal scar, persistent subretinal fluid, reactive exudation, radiation maculopathy, and brain metastasis. At last follow-up (mean, 20 months), of the entering 43 patients, 9 (21%) were alive and 34 (79%) had died of systemic metastasis. Conclusions Photodynamic therapy with verteporfin is an effective outpatient method for small to medium choroidal metastatic tumors, providing tumor control in 78% of eyes and visual outcome of 20/20 to 20/40 in 66% of eyes.

Purpose: To report the case of a patient with adrenocorticotropic hormone (ACTH)-producing pituitary adenoma who developed a mental disorder after initial surgery that kept him from undergoing scheduled follow-up visits and who ultimately had a giant recurrent tumor that resulted in blindness. Case Report: A 37-year-old male presented with the primary complaint of decreased visual acuity (VA) in both eyes and visual field defects. Visual field examination revealed bitemporal hemianopia. Magnetic resonance imaging (MRI) showed a pituitary tumor of approximately 4 cm in diameter extending from the intrasellar region to the sphenoid sinus and the suprasellar region. Transnasal transsphenoidal surgery was performed. Immunostaining of tumor tissue collected intraoperatively showed ACTH-positive cells, thus leading to the diagnosis of ACTH-producing pituitary adenoma. Postoperatively, the patient reportedly developed mental disorder that possibly interfered with scheduled appointments or continuous follow-up visits for many years, so we had no postoperative data about the vision/visual filed. Seven years later, he presented with markedly decreased VA (i.e., no light perception) in both eyes. Fundus examination showed bilateral marked optic disc atrophy. MRI showed a larger than 8-cm diameter giant recurrent pituitary adenoma in the suprasellar region, for which craniotomy was performed for partial tumor resection. Preoperatively, his blood cortisol level was low, and the lesion was deemed a nonfunctioning pituitary adenoma. Postoperatively, no significant complications occurred, yet his VA was no light perception OD and light perception OS. Conclusions: Clinicians should be aware that patients with ACTH-producing pituitary adenomas may develop a mental disorder following surgery and possibly be unable to undergo scheduled follow-up, thus illustrating the importance of establishing an adequate patient follow-up system.

Purpose To determine if there is a benefit to adjuvant corneal crosslinking (CXL) and to compare natamycin versus amphotericin B for filamentous fungal keratitis. Design Outcome-masked, 2×2 factorial design, randomized controlled clinical trial. Participants Consecutive patients presenting with moderate vision loss from a smear-positive fungal ulcer at Aravind Eye Hospital, Madurai, India. Methods Study eyes were randomized to 1 of 4 treatment combinations using an adaptive randomization protocol. The treatment arms included (1) topical natamycin 5% alone, (2) topical natamycin 5% plus CXL, (3) topical amphotericin B 0.15% alone, and (4) topical amphotericin 0.15% plus CXL. Main Outcome Measures The primary outcome of the trial was microbiological cure at 24 hours on repeat culture. Secondary outcomes included best spectacle-corrected visual acuity (BSCVA) at 3 weeks and 3 months, percentage of study participants with epithelial healing at 3 days, 3 weeks, and 3 months, infiltrate or scar size at 3 weeks and 3 months, 3-day smear and culture, and adverse events. Results Those randomized to CXL regardless of medication (topical natamycin or amphotericin) had 1.32-fold increased odds of 24-hour culture positivity, although this was not statistically significant (95% confidence interval [CI], 0.57–3.06; P = 0.51). We were also unable to find a difference in 24-hour culture positivity between those randomized to amphotericin and those randomized to natamycin when evaluating as a group regardless of whether or not they received CXL (coefficient 1.10; 95% CI, 0.47–2.54; P = 0.84). The BSCVA was approximately 0.22 logarithm of the minimum angle of resolution (logMAR) (2.2 Snellen lines) worse on average at 3 weeks among those receiving CXL regardless of medication (95% CI, −0.04 to 0.40; P = 0.04) and 0.32 logMAR (3.2 Snellen lines) worse visual acuity at 3 months after controlling for baseline visual acuity (95% CI, 0.03–0.54; P = 0.02). There was no difference in infiltrate or scar size, percentage of epithelialized or adverse events when comparing CXL with no CXL or the 2 topical medications. Conclusions There appears to be no benefit of adjuvant CXL in the primary treatment of moderate filamentous fungal ulcers, and it may result in decreased visual acuity.

Purpose To report the 5-year outcomes of the first reported case of bilateral Descemet stripping only (DSO) for Fuchs endothelial corneal dystrophy (FECD) at our center. Visual, biomicroscopic, and confocal microscopic findings are described. Methods A retrospective case report. Results A 55-year-old woman with bilateral FECD was referred with decreased visual acuity and blurred vision that interrupted activities of daily living. She underwent sequential 4-mm DSO procedures 6 months apart, with early postoperative results previously reported. Subjective visual symptoms, visual acuity, and corneal edema were analyzed at 1 month, 3 months, 6 months, 12 months, 2 years, 3 years, and 5 years postoperatively. Best corrected visual acuity of 0.0 (logarithm of the minimum angle of resolution) and corneal clearance were achieved in the third month after the procedure. These results have remained stable in the 5-year follow-up period. Conclusions Early postoperative results from DSO surgery are encouraging, but questions remain regarding its longevity. Publication of longer-term outcomes such as this is necessary to establish the validity of this procedure as an intervention for FECD.

Fundal abnormalities, including preretinal and retinal changes, are a rare finding in patients with the autosomal recessive lysosomal storage disorder Gaucher disease, most often described in patients with the chronic neuronopathic form (type 3). We evaluated whether these ophthalmological findings correlated with other manifestations of type 3 Gaucher disease. Reviewing the records of 40 patients with type 3 Gaucher disease, we identified five with white vitreous opacities and reviewed their clinical course in depth. Each of the patients described decreased visual acuity and "floaters" obstructing their vision. The development and/or progression of these fluffy-appearing white opacities in each patient were tracked longitudinally in the context of their neurological and other clinical findings. It was noted that all five patients shared genotype p.L483P/p.L483P (L444P/L444P) and had significant neurological, oculomotor and bone involvement and two had undergone splenectomy. Enzyme replacement therapy with recombinant glucocerebrosidase did not prevent the development or progression of these ocular opacities. Since preretinal findings, in addition to other neuro-ophthalmological findings, can be a feature of Gaucher disease, it is recommended that patients be monitored by regular eye examinations.

Pachymeningeal en plaque tuberculoma is a rare manifestation of tuberculosis and has a poor prognosis if not diagnosed early and treated adequately. The aim of the present paper is to collect the reported clinical and radiological signs in the literature and compare it with a personal observation to evaluate the possibility of a presumptive diagnosis. A 4-year-old boy presented at the pediatric emergency department with 7 days history of severe headache, vomiting blurred vision and had one partial seizure. His neurologic examination was notable for decreased visual acuity with bilateral papilledema and intact extra-ocular muscles. His neck was rigid. Neuroimaging revealed a multifocal dural-based mass on the fronto-parietal convexity with dense heterogeneous contrast enhancement and hydrocephalus. He has undergone a Ventriculoperitoneal shunt and surgical excision of the mass the next day. Outcome was favorable with antituberculosis therapy and corticosteroids. The clinical presentation and outcome were similar to the reported cases in the literature.

Purpose To report 3 cases of unilateral neuroretinitis associated with the chikungunya fever (CHIKV). Methods Retrospective noncomparative case series. Results Three female patients with similar complains of blurry vision and decreased visual acuity that started several weeks after experiencing symptoms of the CHIKV. All patients had decreased best-corrected visual acuity and distortion on the Amsler grid in the affected eye. Evidence of unilateral optic nerve swelling and macular exudates was noted in all patients. No pharmacologic therapy was given. At 2-month follow-up evaluation, all patients had regained at least 3 lines in the Snellen chart, and subretinal fluid and optic nerve swelling had resolved. Conclusion Unilateral neuroretinitis can present as a late-onset manifestation of CHIKV. Three patients with diagnosis of CHIKV developed unilateral neuroretinitis weeks after the acute viral syndrome, suggesting a possible immunological etiology for this manifestation. To our knowledge, this is the first case series of CHIKV leading to neuroretinitis in the Western World.

Introduction First responders and those who work with organophosphate (OP) compounds can experience ocular symptoms similar to those caused by exposure to low levels of nerve agents. This study was designed to examine the efficacy of a safe, clinically available, simulant that reproduces ocular symptoms associated with low-level OP exposure. Among these ocular symptoms are a constriction of the pupils (miosis), decreased visual acuity, and changes in accommodation. Materials and Methods Volunteers aged 18–40 were assigned to groups receiving either a two-drop or three-drop dose of FDA approved 2% pilocarpine ophthalmic solution. Baseline visual performance measurements were taken before eye drop instillation and a timer was started following the first drop of pilocarpine. Once eye drops were administered, visual performance including distant and near vision, pupil size, and accommodation were measured every 5 minutes for 2 hours. Results Both groups experienced significant miosis in excess of 90 minutes. Visual acuity was significantly reduced because of accommodative changes. The three-drop group experienced longer lasting combined effects when compared to the two-drop group. Conclusions 2% pilocarpine ophthalmic solution can safely simulate major ocular symptoms of OP exposure for behavioral research studies for at least 60 minutes.

Assessing the papillomacular nerve fiber bundle (PMB) can identify glaucoma patients with decreased visual acuity. In this study, we explore efficient methods for evaluating PMB thickness in glaucoma patients, based on swept source-optical coherence tomography (SS-OCT).This study included 347 eyes of 205 open-angle glaucoma (OAG) patients. Patients were excluded if they had best-corrected decimal visual acuity0.3, axial length28 mm, non-glaucoma ocular disease, or systemic disease affecting the visual field. We obtained vertical 12.0 × 9.0 mm 3D volume scans covering both the macular and optic disc regions with SS-OCT (DRI OCT Triton, Topcon), and measured the thickness of the PMB, as well as average macular retinal nerve fiber layer thickness (mRNFLT) and macular ganglion cell complex thickness (mGCCT) in the macular map and temporal-quadrant circumpapillary RNFL thickness (tcpRNFLT). We also measured central-strip RNFLT (csRNFLT) and GCC (csGCCT) in a 1.5 × 6.6 mm area of the scan centered between the fovea and optic nerve head. CsRNFLT and csGCCT were divided lengthwise into three 1.5 × 2.2 mm sections. We then calculated Spearman's rank correlation coefficient between these OCT measurements and visual acuity. Logistic regression analysis was used to find the cutoff value for the OCT measurements to predict logMAR0.The correlation coefficients with logMAR were 0.38 for mRNFLT, 0.44 for mGCCT, 0.37 for middle csRNFLT, 0.50 for middle csGCCT, and 0.33 for tcpRNFLT (allWe found strong associations between OCT parameters in the PMB, especially middle csGCCT, and visual acuity in patients with OAG. The thickness of the PMB may therefore be valuable information for glaucoma care and may help prevent visual acuity disturbance.

Neurorretinitis as a manifestation of cat scratch disease occurs in 1-2 % of patients with Bartonella Henselae eye disease. Ocular manifestations tend to follow systemic ones, although they can appear in their absence. The presence of star-shaped macular exudate is characteristic and suggestive of this infection. We report a case of a 14-year-old healthy boy, with 15 days of decreased visual acuity, who was admitted for suspected left optic neuritis with papilledema. Ophthalmological examination revealed the characteristic "macular star" that led to the diagnosis of infection by Bartonella Henselae, later confirmed by positive serology.

Purpose The purpose of this article is to describe a severe side effect presentation of a bilateral cataract after treatment with intense focused ultrasound (IFUS) and subsequent uneventful cataract surgery. Observations A 43-year-old woman presented to the emergency room with decreased visual acuity several hours after undergoing an eyelid-tightening procedure using IFUS. The patient's vision was decreased (R>L), a result of an acute cataract, which had an unusual appearance and consistency. Several weeks later, visual acuity had decreased further in the right eye to 20/400 and the patient underwent uneventful laser-assisted cataract surgery with intraocular lens implantation, which resulted in full visual recovery. Conclusions and importance This case emphasizes the need for particular attention to possible side effects resulting from periocular IFUS, including severe ocular impact requiring surgical intervention.

Background We report here a case of a healthy 23-year-old female patient who was assessed at the gynecology emergency department for genital ulcers, fever, and blurred vision. After suspicion of herpes simplex virus-2 lesions, the diagnosis of Behçet’s disease was made. We report this case with the aim of including Behçet’s disease in the differential diagnosis of genital ulcers, and emphasize the emergency of the vision loss that can be irreversible. Case presentation A healthy 23-year-old European female patient was assessed by gynecology in the emergency department for genital lesions associated with fever and blurred vision. At first, these lesions were suspected to be primary herpes simplex virus-2 infection One day later, she experienced decreased visual acuity in both eyes. After 4 days of worsening genital ulcers and persistent blurred vision, the patient was referred to the ophthalmology department. Fundoscopic examination showed retinal hemorrhages that were consistent with the first presentation of Behçet’s disease. Conclusions This case demonstrates that genital ulcers can be the very initial symptom of this ophthalmologic emergency. The differential diagnosis of genital ulcers is challenging. Behçet’s disease should be included, especially when associated with systemic or ocular manifestations, and should be considered an emergency for the gynecologist to prevent long-term vision loss.

OBJECTIVE To describe the clinical features and outcomes of patients who underwent transorbital debulking of sphenoid wing meningioma. METHODS Patients with a diagnosis of sphenoid wing meningioma who underwent transorbital debulking were included in this series. Preoperative and postoperative symptoms and examination findings, including best corrected visual acuity (BCVA) and proptosis were extracted from patient charts. All imaging studies, records of additional surgical and medical management, and complications of surgery were collated. RESULTS Eight patients were included. The most common symptoms at presentation were blurred vision (6/8) and proptosis (6/8). The most common clinical findings at presentation were decreased visual acuity and proptosis. Mean BCVA preoperatively was 0.93 in logMAR units and mean relative proptosis preoperatively was 4.88 mm. All patients underwent orbitotomy with or without bone flap with decompression of hyperostotic bone and subtotal resection of soft tissue mass. Mean follow-up time was 14 months. Five of eight patients experienced postoperative improvement in BCVA, for mean change of 0.32. All patients demonstrated reduction in proptosis postoperatively with a mean reduction of 3.63 mm. CONCLUSIONS Sphenoid wing meningioma can present with decreased visual acuity and/or proptosis. It is possible to address both of these problems in selected patients with transorbital debulking, an approach that avoids the aesthetic and functional consequences of craniotomy. The aim of this technique is not surgical cure, but rather improvement in vision and disfigurement.

Ocular toxoplasmosis frequently presents as necrotizing retinochoroiditis and, less often, as peripapillary chorioretinitis and/or papillitis. The progression from papillitis to peripapillary retinochoroiditis has been rarely described. We report the case of a 52-year-old patient living in southern Brazil, who developed papillitis in the right eye and was treated with systemic corticosteroids (prednisone 0.6 mg/kg/day and pulse therapy with methylprednisolone 15 mg/kg/day, for 3 days). After 14 days, the patient developed peripapillary retinochoroiditis with vitritis and decreased visual acuity (20/60), and was immediately initiated on the classic oral treatment for toxoplasmosis, consisting of pyrimethamine (50 mg/day), sulfadiazine (4 g/day), folinic acid (15 mg every 3 days) and prednisone (0.6 mg/kg/day). The visual acuity of the right eye normalized after treatment (20/20), which lasted approximately 70 days, but scotomas were detected on visual field examination, especially in the lower nasal quadrant. Although two studies mentioned this presentation, our report emphasizes the possible manifestation of ocular toxoplasmosis as papillitis in the initial phase, with progression to peripapillary retinochoroiditis and permanent visual field defects, which justifies early treatment for toxoplasmosis in suspected cases, especially in endemic regions.

Background Children's vision screening children commonly uses optotype-based visual acuity or instrument-based methods measuring amblyogenic risk factors (ARFs). Objective To compare the performance of the Spot Vision Screener (SVS) (PediaVision, Welch Allyn, NY) and a nurse-administered visual acuity screen (NVAS) in identifying ARFs and decreased visual acuity. Methods A prospective, cross-sectional population-based study of preschool children in South-East Queensland, Australia. Eligible participants had both forms of screening by trained community nurses. All children with an abnormal result by either method as well as a cohort of randomly selected children who passed both assessments were assessed at a tertiary paediatric ophthalmology clinic. Results Over a 10 month period, 2237 children (mean age; 64.4 ± 4.0 months) were screened from 38 schools. 6.4% of children failed SVS and 8.3% failed NVAS (with 3.8% overlap, failing both). The positive predictive value (PPV) in identifying either ARFs and/or reduced VA for the SVS and NVAS was 70.4% (95% Confidence Interval (CI): 61.6%-78.2%) and 60.5% (95% CI: 52.6%-67.9%) respectively. Highest PPV to detect either ARFs and/or reduced VA was achieved by a 'hybrid' method by combining failed NVAS and failed SVS: 91.0% (95% CI: 82.4 to 96.3) but this would risk children with sight impairment being missed in the community. Conclusion To our knowledge, this is the first population-based study providing detailed comparative measures of diagnostic accuracy for NVAS and SVS in preschool children. One in ten preschool children failed one or both screens. A number of children who required ophthalmic intervention were missed if only one screening method was utilized.

Owing to its rapid development, short-term and long-term effects of the COVID-19 vaccine are still not well understood. This case report highlights bilateral corneal endothelial graft rejection after administration of the Pfizer COVID-19 vaccine. A 73-year-old woman with bilateral Descemet stripping endothelial keratoplasty presented with bilateral decreased visual acuity, ocular pain, and photophobia after her second dose of the Pfizer-BioNTech COVID-19 vaccine. Two weeks after vaccine administration, the uncorrected visual acuity was 20/70 and 20/40. Central corneal thickness as measured by ultrasound was 809 and 825 µm and by Scheimfplug imaging was 788 and 751 µm at the pupil center. Slit-lamp biomicroscopy revealed quiet conjunctiva and sclera but was significant for thickened corneas with Descemet folds in both eyes. The patient was instructed to use prednisolone acetate 1% every 1 to 2 hours with Muro ointment at bedtime.

We investigated the postoperative visual outcomes and morphological changes of the internal limiting membrane (ILM) flap, in patients who underwent the temporal inverted ILM flap technique for macular hole (MH). Between August 2018 and February 2020, 22 eyes of 22 patients with idiopathic or myopic MH who underwent vitrectomy with ILM flap were included in this study and followed-up for more than 6 months. Postoperative MH status, comparison of best-corrected visual acuity (BCVA) before and 6 months after surgery, changes in the ILM flap area at 1 and 6 months postoperatively, and the factors related to changes in ILM flap size, were analyzed. MH closure was achieved in all of the patients. The BCVA at 6 months postoperatively (0.18 ± 0.15) was significantly better than the preoperative BCVA of 0.63 ± 0.37 (P t test). The area of the ILM flap decreased significantly from 3.25 ± 1.27 mm2 at 1 month to 3.13 ± 1.23 mm2 at 6 months (P = 0.024, Wilcoxon signed-rank test). Two eyes showed an ILM flap contraction of more than 20%, and one eye required reoperation due to an increase in metamorphopsia and decreased visual acuity. Among age, sex, ILM flap area at 1 month, preoperative BCVA, and axial length, ILM flap contraction was correlated with patient age and ILM flap area. Although vitrectomy with the inverted ILM flap technique confers a good visual outcome, the ILM flap may contract in younger patients.

Objective To compare the indications, surgical techniques and outcomes for revision orbital decompression surgery for thyroid eye disease in open, endoscopic, and combined open and endoscopic approaches. Methods A retrospective review of all revision orbital decompression procedures for thyroid eye disease from a single large academic institution over a 17-year period (01/01/2004–01/01/2021) was performed. Patient demographics, as well as indications and types of surgery were reviewed. Outcome measures included changes in proptosis, intraocular pressure, visual acuity and diplopia. Results Thirty procedures were performed on 21 patients. There was a median of 9.4 months between primary orbital decompression and revision decompression surgery. There were 6 bilateral procedures, and 2 of these patients underwent additional revision surgeries due to decreased visual acuity with concern for persistent orbital apex compression or sight-threatening ocular surface exposure in the setting of proptosis. Twenty-five procedures were performed as open surgeries with 5 endoscopic/combined cases. Combined Ophthalmology/Otolaryngology surgery via combined open/endoscopic approaches was favoured for persistent orbital apex disease. Visual acuity remained preserved in all patients. The overall median reduction in proptosis was 2 mm and intraocular pressure change was 1 mmHg regardless of surgical approach. The overall rate of new onset diplopia after surgery was 15%. These patients had open approaches. All endoscopic/combined approach patients had pre-existing diplopia. There were no statistically significant differences between the open and endoscopic/combined groups in regard to change in visual acuity, reduction in proptosis or intraocular pressure. Conclusion Revision orbital decompression is an uncommon procedure indicated for those patients with progressive symptoms despite previous surgery and intensive medical management. Both endoscopic and non-endoscopic techniques offer favourable outcomes with respect to visual acuity, decrease in intraocular pressure, and improvement in proptosis and overall lead to a low incidence of new onset diplopia. Level of evidence Level IV.

Background The effect of subretinal fluid (SRF) in uveitic cystoid macular edema (CME) is not fully understood. This study evaluates the quantitative effect of SRF and intraretinal thickness on visual acuity in eyes with uveitic CME. We separately measured SRF and intraretinal area on Optical Coherence Tomography (OCT) to determine the associations of each component with visual acuity and response to treatment. Main text Medical records were reviewed of patients with CME presenting to the University of Colorado uveitis clinic from January 2012 to May 2019. All available OCTs were reviewed to classify eyes as either having only CME or CME with SRF. Intraretinal area was manually measured using Image J along the central 1-mm section of B-scan OCT spanning from the internal limiting membrane to the outer most portion of the outer retina including both cysts and retinal tissue. SRF cross-sectional area was measured spanning from the outermost portion of the outer retina to retinal pigment epithelium. Response to treatment was assessed one to four months after presentation. Eyes with CME secondary to structural or non-inflammatory causes were excluded. Forty-seven (50.5%) eyes had CME alone and 46 (49.5%) eyes had SRF with CME. Measured SRF cross-sectional area was not associated (p = 0.21) with LogMAR at presentation. Conversely, intraretinal area was strongly correlated with visual acuity in eyes with SRF (p p p p = 0.001). Similarly, logMAR improved in both groups (p = 0.008 for SRF eyes and p = 0.005 for non-SRF eyes), but the change was more prominent in the SRF group (p = 0.06). Conclusions There was no direct association observed between the amount of SRF and visual acuity. In contrast, increased intraretinal area was significantly associated with decreased visual acuity. This relationship between intraretinal thickening and visual acuity may explain differences observed in response to treatment between SRF and non-SRF eyes, with a larger decrease in the intraretinal cross-sectional area in SRF eyes associated with a greater improvement in logMAR visual acuity.

A 76-year-old man presented with 1 day history of eyelid swelling and decreased vision on the left side. History reveals nose blowing the night prior to the occurrence of the symptoms. Initial examination of the left eye showed decreased visual acuity, increased intraocular pressure, and limited ocular motility with presence of air bubbles under the bulbar conjunctiva. Imaging studies showed medial orbital wall fracture with severe emphysema. The patient was observed for a week and no active surgical intervention was performed. Thereafter, spontaneous resolution of symptoms was observed. Eyelid swelling, dramatic improvement in visual acuity, intraocular pressure, and extraocular movements were noted.