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We report a case of breast cancer with clinically significant retinal toxicity induced by 7 years’ Tamoxifen consumption in which patient’s visual acuity and paraclinical findings remarkably improved after drug discontinuation. A 49-year-old woman with a history of breast cancer and Tamoxifen consumption was referred to our clinic for evaluation and treatment of gradual and progressive decrease visual acuity of both eyes (more prominent in right eye). Funduscopy showed bilateral macular pigmentary changes, with diffused tiny yellow crystals and reduced macular tessellation. On spectral-domain optical coherence tomography (SD-OCT), there was retinal pigment epithelium (RPE) abnormality and ellipsoid zone discontinuity accompanied by retinal thinning and choroidal thickness that was more prominent in the right eye. One year after discontinuation of the drug, visual acuity was significantly improved and SD-OCT revealed some surprising recoveries in the photoreceptor layers especially in her right eye.

Background Retinopathy of prematurity is the leading cause of preterm infants’ blindness. The preferred method for the management of aggressive posterior ROP is the anti-vascular endothelial growth factor (anti-VEGF). However, systemic and ocular adverse effects of anti-VEGF drugs remain a concern. Case Presentation A case report of a preterm infant with a history of hypertension underwent intravitreal injection of aflibercept at the 50-week postmenstrual age because of aggressive posterior retinopathy of prematurity (ROP) in both eyes. Seven days after the intravitreal administration of aflibercept, he has a hypertension crisis and an ischemic stroke. Serial fundoscopies implied complete arrest of vascularization till seven months after receiving treatment. Conclusion We report a case of an infant, with a history of hypertension, had an ischemic stroke just one week after the intravitreal injection of aflibercept for aggressive posterior ROP. We can conclude that in cases of preterm infants with systemic comorbidities, like uncontrolled hypertension, that predispose patients to thromboembolic events, we should be cautious about the potential increase in the risk of thromboembolic events after administration of anti-vascular endothelial growth factor agents (anti-VEGF), especially those with a longer half-life, like aflibercept.

Purpose. To report on the efficacy of early pars plana vitrectomy (PPV), silicone oil (SO) tamponade, and intravitreal ganciclovir injection in the treatment of a case with progressive outer retinal necrosis (PORN). Case Presentation. A 33-year-old man with a history of shingles on the chest skin 2.5 months ago presented with progressive vision loss in both eyes over the past 20 days. Fundus examination revealed retinal necrosis with perivascular clearance. Human immunodeficiency virus (HIV) infection was confirmed by western blot analysis. Treatment with intravenous acyclovir and intravitreal ganciclovir injections was unable to stop the progression of retinitis. Along with highly active antiretroviral therapy, the patient underwent PPV with SO tamponade and intravitreal ganciclovir injection in both eyes. A few days after surgery, retinal lesions started to improve. Conclusion. Early PPV, SO tamponade, and intravitreal ganciclovir injection may be considered an effective intervention in PORN patients with an unfavorable response to medical treatment.

A 57-year-old shepherd was referred with a 2-week history of decreased visual acuity in both eyes. Optical coherence tomography (OCT) (Heidelberg Engineering GmbH, Heidelberg, Germany) revealed diffuse outer nuclear layer hyperreflectivity and indistinguishable external limiting membrane and ellipsoid zone. The patient announced to us that he took two 500 mg of closantel tablets (15.15 mg/kg) three days before the initiation of visual problems for sore throat as an antibiotic. Electroretinography displayed severely attenuated responses in both eyes. We decided to admit the patient with the presumed diagnosis of closantel retinal toxicity and treated him with intravenous methylprednisolone 1 g per day and intravenous erythropoietin 10000 IU twice a day, and reevaluation of the patient proved no change in his visual acuity on the third day of admission. Closantel is a veterinary drug with serious side effects in the human retina and central nervous system even in previously reported doses. Public awareness and appropriate drug labeling about its side effects could prevent accidental toxicity. OCT is a noninvasive and rapid diagnostic modality that should be done in suspected toxic retinopathy.

Background. The aim is to report an atypical presentation of ocular toxoplasmosis which led to the diagnosis of Acquired Immunodeficiency Syndrome (AIDS). Case Report. The 38-year-old woman was referred with metamorphopsia and reduced vision in the right eye over the past 3 weeks. Slit-lamp examination revealed granulomatous keratic precipitates (KPs), 2+ cells in the anterior chamber, and posterior synechiae. Fundus examination was remarkable for a white patch surrounding a scar, inferonasal to the optic disc with fibrous bands emanating from the lesion, and the retina around this region was detached with considerable extension towards the periphery, while no breaks could be appreciated. She mentioned anorexia and losing 10 kg in the past three months, and signs of anemia like paleness of face skin, bed nails, and bilateral angular cheilitis were observed on systemic evaluation. The results of the patient’s complete blood count revealed anemia and leukopenia and CD4 lymphocytes: 79 cells/μL. Enzyme-linked immunosorbent assays (ELISA) for HIV antibodies came back positive which was later confirmed with the Western blot test. Brain magnetic resonance imaging (MRI) showed multiple ring-enhancing lesions in both cerebral cortices. The patient underwent antitoxoplasmosis and anti-HIV treatment and serous retinal detachment completely resolved. Conclusion. This report highlights the fact that sometimes, the eyes are the site of the first presentation of a systemic life-threatening condition and emphasizes the role of ophthalmologists in such cases. In cases of atypical presentation, appropriate laboratory tests and CNS imaging should be requested. Systemic treatment with antitoxoplasmosis regimens and highly active antiretroviral therapy (HAART) is mandatory in AIDS patients with ocular toxoplasmosis.

PurposeTo demonstrate the value of “smoothness index” as a novel tool for quantitative analysis of iris surface findings in unilateral Fuchs’ uveitis (FU).MethodsIn this observational study, both phakic eyes from patients with the diagnosis of unilateral FU were enrolled. All eyes underwent a complete ophthalmic examination and anterior segment optical coherence tomography(AS-OCT). The images were extracted and exported to the ImageJ software for calculating the “smoothness index (SI)”. The SI was defined as ratio of length of the straight line connecting the most peripheral and the most central points of anterior iris surface to actual length of this boundary.ResultsForty eyes from 20 patients with unilateral FU were enrolled. Mean age of patients was 40±10 years. Mean overall SI was 0.876± 0.030 in eyes with FU that was significantly more than fellow control eyes (0.841± 0.041). (p=0.005) The mean temporal and nasal SI were 0.878± 0.035 and 0.874± 0.033 in eyes with FU, compared to 0.843± 0.041 and 0.838± 0.047 in control fellow eyes, respectively. (p = 0.008 and p = 0.009, respectively)ConclusionIris “smoothness index” is a novel index to quantitatively document diffuse smoothness of iris anterior surface in eyes with FU. This index may facilitate diagnosis of subtle iris atrophic changes in these eyes, especially when heterochromia is absent.

Hassan Khojasteh,1 Rasoul Amini Vishte,2 Ali Mirzajani,2 Elias Khalili Pour,1 Fatemeh Bazvand,1 Hamid Riazi-Esfahani,1 Masoud Mirghorbani,1 Bobeck S Modjtahedi3– 5 1Department of Ophthalmology, Farabi Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran; 2Department of Optometry, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran; 3Department of Ophthalmology, Southern California Permanente Medical Group, Baldwin Park, CA, USA; 4Department of Research and Evaluation, Southern California Permanente Medical Group, Pasadena, CA, USA; 5Eye Monitoring Center, Kaiser Permanente Southern California, Baldwin Park, CA, USACorrespondence: Hassan Khojasteh Email khojaste_hasan@yahoo.comPurpose: To evaluate changes in electroretinogram (ERG) response over the course of multiple sessions of panretinal photocoagulation (PRP) in patients with proliferative diabetic retinopathy (PRP).Methods: A prospective cohort study of 11 patients with PDR who required PRP was conducted. PRP was completed over three sessions. Each patient had five ERGs done: baseline, 1 week after each PRP session, and 6 weeks after the last session of PRP. Dark-adapted 0.01 ERG, Dark-adapted 3 ERG, Dark-adapted 10 ERG, Light- adapted 3 ERG, and Light-adapted 30 Hz flicker ERG were done. The mean change in a- and b-wave amplitudes as well as implicit times compared to baseline was analyzed.Results: A significant reduction in peak amplitudes of both a- and b-waves and delay in latencies were observed in all responses (p< 0.05). The absolute amplitude reduction and delay in latency were higher for scotopic b-waves (p< 0.05). The root mean square (RMS) of Dark-adapted 10.0 ERG (p< 0.05) and total mean amplitude changes of a- and b-waves (p< 0.001) were reduced after each laser session; however, the magnitude of change was not different between the first, second, or third sessions of PRP, and each session showed a similar deterioration rate of ERG parameters comparing to each other (p=0.4 for RMS and p=0.2 for total mean amplitude changes). In addition, the results indicated recovery of the amplitude and latency of ERG waves after 6 weeks from the final treatment (p< 0.001) although not to baseline levels.Conclusion: ERG findings following PRP show reduced retinal function after each session which partially recovers by 6 weeks after the completion of therapy. Clinicians should be mindful of these changes when planning the treatment course for patients with PDR.Keywords: diabetic retinopathy, electroretinogram, panretinal photocoagulation, laser