Bilateral Macular Edema Research Articles

Optical coherence tomography angiography in retinitis pigmentosa

PurposeThe aim of this study is to describe macular vascular abnormalities in patients affected by retinitis pigmentosa using Optical coherence tomography angiography (OCT‐A).MethodsPatients with a clinical diagnosis of retinitis pigmentosa underwent 3 × 3 Swept Source OCT‐A scans using a Swept‐Source DRI OCT Triton (Topcon Corporation, Japan). Scans with artifacts were excluded. Retinal vascular supply was estimated at the level of the superficial (SCP) and deep (DCP) capillary plexus, choriocapillaris and choroid.ResultsSix patients (12 eyes) were included in this study. Five were females (83.33%) and the mean age was 28.66 years. Mean best corrected visual acuity was 0.5 ± 0.3 LogMAR. Two patients presented bilateral macular edema on Swept Source‐OCT and showed focal dislocations in the vascular network at the level of the DCP on the OCT‐A, corresponding to the serous intraretinal cysts displacing the vascular plexus and the neural tissue. Qualitative analysis of OCT‐A at the macular area revealed a reduction of vessel density in the SCP and DCP. The DCP and especially the temporal area are more affected. Three patients (50%) showed an enlarged foveal avascular zone at the DCP level.ConclusionsUsing OCT‐A, we have demonstrated reduction of vessel densities especially located in the DCP. This vascular depletion could be an early event in the disease, which eventually causes ischemia, tissue loss and affects the macular function. Morphological vascular evaluation in patients affected by retinitis pigmentosa allows better understanding the pathogenesis of this disease and can have direct therapeutic implications for the future practical management of retinal dystrophies.

Improvement of Diabetic Macular Edema in the Fellow Eye After Monocular Intravitreal Bevacizumab Injection

Introduction: Because of bilateral involvement in many cases with diabetic macular edema, Intravitreal bevacizumab injection perform in both eyes. There are some reports of therapeutic effects in the fellow eye after monocular injection of anti-vascular endothelial growth factors. In this study we describe a case of bilateral improvement of diabetic macular edema following unilateral intravitreal bevacizumab injection. Case Presentation: We report a patient with bilateral non-proliferative diabetic retinopathy and diabetic macular edema. Central macular thickness was 398µ in the right eye and 337µ in the left eye. Two months after intravitreal injection of 1.25mg bevacizumab in the right eye, significant improvement of diabetic macular edema was happened in both eyes including the left eye without intravitral injection. Central macular thickness was 245µ in the right eye and 250µ in the left eye. Conclusion: Unilateral injection of intravitreal bevacizumab may have therapeutic effects in the fellow untreated eye. Therefore; unilateral injection in bilateral cases may reduce the costs and complications of bilateral injection.

Characteristics of Macular Edema in Behcet Disease after Intravitreal Bevacizumab Injection.

Purpose:To investigate the effect of intravitreal bevacizumab (IVB) injection on macular edema (ME) secondary to Behcet's disease.Methods:This prospective case series included 15 patients with bilateral ME due to Behcet's disease. Intravitreal bevacizumab was injected into the more severely involved eye; the contralateral eye was evaluated as the control. Patients were followed up with comprehensive ocular examination, optical coherence tomography, and fluorescein angiography (FA) for a minimum of 6 months by a single ophthalmologist.Results:Patients with a mean age of 30.6 ± 7.4 years received a mean number of 3.3 IVB injections during the 6 months. The mean preinjection vision was 0.6 ± 0.3 and 0.4 ± 0.4 LogMAR in the case and control groups, respectively, with no significant improvement at 6 months. Mean central foveal thickness was 375.3 ± 132.1 and 307.2 ± 84.5 μm in the case and control groups, respectively, and these changed to 401 ± 199.9 (P = 0.65) and 307.7 ± 82.8 μm (P = 0.73) at month 6, respectively. A statistically nonsignificant improvement in ME was observed during the first 3 months in the case group. However, it did not persist up to month 6 on an as-needed basis. IVB injections caused a disproportionate decrease in the thickness of macular subfields. A reduction in disc leakage was observed on FA (P = 0.058). Logistic regression analysis revealed no statistically significant predictive factor for an improvement in visual acuity (VA) and a reduction in foveal thickness.Conclusion:During a 6-month period, IVB injections based on an as-needed protocol provided no statistically significant improvement in VA and ME.

Clinical Features and Course of Patients with Peripheral Exudative Hemorrhagic Chorioretinopathy.

Objectives:To evaluate the clinical characteristics of patients who were followed in our clinic with the diagnosis of peripheral exudative hemorrhagic chorioretinopathy (PEHC).Materials and Methods:Medical records of 12 patients who were diagnosed with PEHC in İstanbul University İstanbul Faculty of Medicine, Department of Ophthalmology between July 2006 and June 2014 were reviewed retrospectively.Results:This study included 21 eyes of 12 patients. Four (33.3%) of the patients were male and 8 (66.7%) were female and ages ranged between 73 and 89 years. Eight (66.7%) of the patients were referred to us with the diagnosis of choroidal mass. Unilateral involvement was found in 3 and bilateral involvement in 9 patients. Temporal quadrants were involved in all eyes. Fifteen eyes (71.4%) had subretinal hemorrhage and hemorrhagic/serous retinal pigment epithelial detachment, 11 (52.4%) had lipid exudation, 5 (23.8%) had chronic retinal pigment epithelium alterations, 2 (9.5%) had subretinal fibrosis and 1 (4.8%) had vitreous hemorrhage. PEHC lesions were accompanied by drusen in 11 eyes (52.4%), geographic atrophy in 2 eyes (9.5%), and choroidal neovascularization scar in 2 eyes (9.5%). Treatment was done in both eyes of a patient for lesions which threatened the macula, in a patient with bilateral macular edema and in a patient with vitreous hemorrhage. The remaining eyes were followed-up without any treatment because the lesions did not threaten the macula and they showed no progression during follow-up.Conclusion:PEHC is a degenerative disease of peripheral retina that is seen in older patients, and signs of age-related macular degeneration (AMD) may accompany this pathology. Especially in patients with AMD findings, the peripheral retina must be evaluated carefully for existing PEHC lesions.

Case Series Investigating the Efficacy and Safety of Bilateral Fluocinolone Acetonide (ILUVIEN(®)) in Patients with Diabetic Macular Edema: 10 Eyes with 12 Months Follow-up.

IntroductionThis short case series presents the results from 5 patients with bilateral chronic diabetic macular edema (DME), 12 months after they were initially treated with ILUVIEN® [0.2 μg/day fluocinolone acetonide (FAc)].MethodsTen eyes from five patients with pseudophakic lenses were investigated. Patients had bilateral, chronic DME and had received prior laser and anti-VEGF therapy. Visual and anatomic outcomes were investigated 12 months post-FAc implant in both eyes.ResultsAt baseline, central retinal thickness (CRT) was 645.3 ± 176.1 microns (mean ± standard deviation), intraocular pressure (IOP) was 13.7 ± 3.6 mmHg and visual acuity (VA) was 44.5 ± 18.6 Early Treatment Diabetic Retinopathy Study (ETDRS) letters. Mean CRT improved at 6 months (341.7 ± 169.7 microns) and 12 months (287.4 ± 103.1 microns) and there were concurrent improvements in VA (ETDRS letters were 56 ± 16 and 55 ± 16 at 6 and 12 months, respectively). Mean IOP was stable throughout and ≤21 mmHg. Left and right eyes were compared in the 5 patients by plotting changes in CFT, IOP and VA at 12 months, from baseline levels.ConclusionThis bilateral case series demonstrates the effectiveness of a sustained, controlled low dose of FAc in the management of bilateral DME over a 12-month period. The FAc implant has shown to work well in treatment of bilateral DME, although longer follow-up of these patients is still needed.FundingPublication charges were funded by Alimera Sciences Ltd.Electronic supplementary materialThe online version of this article (doi:10.1007/s40123-016-0049-3) contains supplementary material, which is available to authorized users.

Bilateral Macular Edema: A New Ocular Feature of Dandy–Walker Syndrome

ABSTRACTTo describe a case of bilateral cystoid macular edema in a patient with Dandy–Walker syndrome. An 18-year-old male was referred to our tertiary referral center for evaluation of his decreased visual acuity. Detailed ophthalmic examination and imaging revealed the presence of bilateral cystoid macular edema, which was successfully treated with intravitreal triamcinolone injections (2 mg in 0.05 ml). Recurrence of macular edema developed after a period of approximately four months. This is an unusual ophthalmic manifestation of Dandy–Walker syndrome. Cystoid macular edema should be included in the differential diagnosis of subjects with Dandy–Walker syndrome presenting with decreased vision. The pathogenetic mechanism for the development macular edema in this case is not clear. Intravitreal triamcinolone is an effective treatment, but edema was recurrent in our case. Other approaches (such as oral Acetazolamide or intravitreal Anti-VEGF) have to be considered as well.

Bilateral Simultaneous Central Retinal Vein Occlusion in a Patient with Waldenstrom's Macroglobulinemia

Purpose: The authors report a case of bilateral simultaneous central retinal vein occlusion caused by Waldenstrom’s macroglobulinemia. Case summary: A 65-year-old man presented to our department complaining of decreased visual acuity for the duration of about 6 months. On his initial visit, best-corrected visual acuity was 0.02 in the right eye and 0.06 in the left eye. Based on the findings of a funduscopic examination, the patient had bilateral diffuse retinal hemorrhages, dilated tortuous veins, and macular edema. He had experienced recurrent spontaneous epistaxis 6 months previously and had undergone treatments such as intravitreal bevacizumab injection and intravitreal dexamethasone implantation at another hospital. Laboratory tests at that hospital showed anemia and hyperproteinemia, for which he was referred to our hemato-oncology department. Bone marrow biopsy was consistent with Waldenstrom’s macroglobulinemia/lymphoplasmacytoid lymphoma, and he was treated with systemic chemotherapy. One year after the systemic chemotherapy, his best-corrected visual acuity was 0.15 in the right eye and 0.6 in the left eye. Funduscopy showed decreased bilateral retinal hemorrhages and macular edema. Conclusions: When simultaneous bilateral central retinal vein occlusion occurs in a patient with no other underlying disease such as hypertension or diabetes, it might be a sign of serum hyperviscosity, and there should be a very high level of suspicion for presence or progression of systemic disease. If such a disease is properly and timely diagnosed, effective early systemic evaluation and therapy can be administered, and it is important to have initial general treatment as well as ophthalmic treatment. J Korean Ophthalmol Soc 2016;57(6):1012-1017

The effect of intravitreal bevacizumab and ranibizumab on macular edema of the contralateral eye: A comparative study of two anti-VEGFs.

Purpose:To compare the effects of bevacizumab and ranibizumab on the visual function and macular thickness in the contralateral (untreated) eye of patients with bilateral diabetic macular edema (DME).Materials and Methods:Thirty-nine patients with bilateral DME, who had been treated with both bevacizumab and ranibizumab in the same eye, were considered retrospectively for this study. Recorded outcome measurements included the best-corrected visual acuity (BCVA) assessment with the Early Treatment Diabetic Retinopathy Study (ETDRS) chart and the central subfield macular thickness (CSMT) measurement of the contralateral, uninjected eye before and at 4 weeks after the injections.Results:The median BCVA of the uninjected eye was 50 ETDRS letters and the median CSMT was 459 μm preceding the bevacizumab injection whereas at the control appointment, 4 weeks after the injection, the median BCVA had increased to 52 letters (P = 0.098), and the median CSMT had decreased to 390 μm (P = 0.036). The mean interval between the bevacizumab and ranibizumab treatments was 4.79 ΁ 1.52 months. The measurements of the untreated eye after the ranibizumab treatment showed that the median BCVA decreased from 55 to 52 letters, and the median CSMT increased from 361 μm to 418 μm (P = 0.148 and P = 0.109, respectively).Conclusions:In contrast to ranibizumab, the intravitreal administration of bevacizumab resulted in a statistically significant decrease in macular thickness in the untreated eye in patients with bilateral DME.

Famous

A 62-year-old woman with multiple sclerosis experienced painless loss of vision in both eyes after starting fingolimod. Fundus examination revealed bilateral macular edema confirmed by optical coherence tomography. Fingolimod was discontinued, and a topical nonsteroidal inflammatory drug and corticosteroid were initiated. Within 2 months, vision returned to baseline with complete resolution of the macular edema.

RANIBIZUMAB MONOTHERAPY VERSUS COMBINED RANIBIZUMAB PLUS TRIAMCINOLONE FOR TREATING DIABETIC MACULAR EDEMA; EVALUATION AFTER SINGLE INJECTION

Anti vascular endothelial growth factor (Anti-VEGF) have been proved to be the main treatment for DME and also steroids showed a significant role in resolution of diabetic macular edema(DME). Based on concept of multifactorial causes of DME, this study proposed theoretically an adjuvant effects for steroids in combination with anti-VEGF for DME, the multifactorial complex pathogenetic mechanisms require a comprehensive approach. This study compares the outcome of monotherapy of intravitreal Ranibizumab injection in one eye versus combined therapy of Ranibizumab+Triamcinolone in other eye of the same patient. This study includes prospective consecutive interventional case series study. Patients with bilateral diabetic macular edema given Lucentis dose was 0.05 ml = 0.5 mg in on eye and Triamcinolone 0.05 ml = 2 mg in the other eye. Thirty patients with bilateral diabetic macular edema were enrolled in this study, all have perfused macula. The mean age at the start of the study was 54 years. The study has shown a promising results for the treating diabetic macular edema with combined therapy of Ranibizumab and Triamcinolone

Symmetry in early response to intravitreal ranibizumab in bilateral diabetic macular oedema.

To study the symmetry in response to bilateral diabetic macular oedema (DME) treated with bilateral intravitreal injections of ranibizumab (IVR). The charts of 36 eyes of 18 patients treated with a loading dose of three monthly IVR in both eyes were retrospectively reviewed. Favourable anatomical response was defined as a decrease by more than 10% in baseline central macular thickness (CMT), and favourable functional response was defined as an increase in visual acuity (VA) ≥5 letters. A symmetric response was defined as a similar anatomical and/or functional response in the first (FE) and second (SE) treated eyes. The VA improved significantly after ranibizumab treatment in both eyes (p<0.01). A statistically significant positive correlation was found for the functional response to ranibizumab between the FE and the SE (R(2) =0.26, p=0.03). The mean CMT decreased significantly in both eyes (p<0.01). A strong positive correlation was observed between the anatomical response to ranibizumab in the FE and the SE (R(2) =0.37, p=0.01). Symmetric favourable anatomical and functional responses were observed in 13 patients (72%). In two additional patients, an asymmetric functional response was observed despite a decrease in retinal thickness in both eyes. Symmetric anatomical and functional responses were observed in 72% of patients with DME after three initial IVR in each eye. This finding could be of clinical interest in the decision to treat the fellow eye, in a disease where a bilateral involvement is frequent.

Role of SD‐OCT in the follow‐up of a patient with macular edema associated with mucopoysaccharidosis type II (Hunter syndrome) undergoing idursulfase enzyme replacement therapy

PurposePurpose: Mucopolysaccharidosis (MPS) type II (Hunter syndrome) is a variable, progressive, multisystem disorder including severe airway obstruction, cardiomyopathy, skeletal deformities and neurological problems. It is an X‐linked recessive disease caused by deficiency of the lysosomal enzyme iduronate‐2‐sulphatase, leading to accumulation of glycosaminoglycans. Several ophthalmological disorders, including corneal opacities, glaucoma and retinal degeneration, have been previously reported. This is the first case of bilateral macular edema associated with MPS II. The patient underwent idursulfase enzyme replacement therapy with good response. We point out the utility of spectral domain optical coherence tomography (SD‐OCT) in the diagnosis and follow‐up of this condition.MethodsSD‐OCT, fundus autofluorescence and retinography were used in the diagnosis and follow‐up of the visual disorder.ResultsMacular edema was successfully managed with idursulfase enzyme replacement therapy stabilizing visual loss. Central macular thickness measured by SD‐OCT decreased significantly.ConclusionIdursulfase enzyme replacement therapy seems to be a good treatment option for macular edema associated with MPS II. Furthermore, SD‐OCT played a key role in the diagnosis and follow‐up of this condition.

Comparison of intravitreal bevacizumab and triamcinolone acetonide theraphies for diffuse diabetic macular edema.

To compare therapeutic effects of intravitreal triamcinolone acetonide (IVTA) versus intravitreal bevacizumab (IVB) injections for bilateral diffuse diabetic macular edema (DDME). Forty eyes of 20 patients with bilateral DDME participated in this study. For each patient, 4 mg/0.1 mL IVTA was injected to one eye and 2.5 mg/0.1 mL IVB was injected to the other eye. The effects of injection for diabetic macular edema (DME) were evaluated using best-corrected visual acuity (BCVA), central macular thickness (CMT) by optical coherence tomography (OCT) and intraocular pressure (IOP) by applanation tonometer. Patients underwent eye examinations, including BCVA, CMT, and IOP at pre-injection, 1, 4, 8, 12 and 24wk after injection. During the follow-up, second injections were performed to eyes which have CMT greater than 400 µm at 12wk for salvage therapy. BCVA (logarithm of the minimum angle of resolution) at pre-injection, 1, 4, 8, 12 and 24wk after injection was 0.71±0.19, 0.62±0.23, 0.63±0.12, 0.63±0.13, 0.63±0.14 and 0.61±0.24 in the IVTA group and 0.68±0.25, 0.61±0.22, 0.60±0.24, 0.62±0.25, 0.65±0.26 and 0.59±0.25 in the IVB group, respectively. CMT (µm) at pre-injection, 1, 4, 8, 12 and 24wk after injection was 544±125, 383±96, 335±87, 323±87, 333±92, 335±61 in the IVTA group and 514±100, 431±86, 428±107, 442±106, 478±112, 430±88 in the IVB group respectively. Reduction ratios of mean CMT were 29% at 1wk, 38% at 4wk, 40% at 8wk, 38% at 12wk, and 38% at 24wk in the IVTA group. Second IVTA injections were performed to the 6 eyes (30%) at 12wk. Reduction ratios of mean CMT were 16% at 1wk, 17% at 4wk, 14% at 8wk, 7% at 12wk, and 16% at 24wk in the IVB group. Second IVB injections were performed to the 15 eyes (75%) at 12wk. This study showed earlier and more frequent macular edema recurrences in the eyes treated with bevacizumab compared with the ones treated with triamcinolone acetonide. Triamcinolone acetonide was found to provide more efficient and long-standing effect in terms of reducing CMT compared with the bevacizumab.

Efficacy and tolerability of bilateral sustained-release dexamethasone intravitreal implants for the treatment of noninfectious posterior uveitis and macular edema secondary to retinal vein occlusion.

PurposeTo report our experience with bilateral placement of dexamethasone 0.7 mg (DEX) sustained-release intravitreal implant in the management of noninfectious posterior uveitis or macular edema secondary to retinal vein occlusion.MethodsA retrospective chart review of patients with bilateral noninfectious posterior uveitis and macular edema secondary to retinal vein occlusion who were treated with DEX intravitreal implant was performed. Ocular side effects such as intraocular pressure (IOP), cataract, and tolerability of bilateral injections was reviewed.ResultsTwenty-two eyes of eleven patients treated with a total of 32 DEX implants were included. Ten of eleven patients received bilateral implants due to active noninfectious uveitis while the other demonstrated macular edema in both eyes following separate central retinal vein occlusions. Among the patients with bilateral uveitis, the mean interval between DEX implant in the initial eye and the subsequent DEX in the fellow eye was 15.6 days (range 2–71 days). Seven of the ten patients received the second implant in the fellow eye within 8 days of the initial implantation. None of the patients had bilateral implantations on the same day. Seven eyes required reimplantation for recurrence of inflammation (mean interval between first and repeat implantation was 6.00±2.39 months). Following single or, in the case of the aforementioned seven eyes, repeat DEX implantation, all 20 uveitic eyes demonstrated clinical and/or angiographic evidence of decreased inflammation in the form of reduction in vitreous cells on slit lamp ophthalmoscopy, macular edema on ophthalmoscopy, or optical coherence tomography and/or disc and vascular leakage on fluorescein angiography. The mean follow-up for all eyes after initial implantation was 23.57 months (range 1–48 months). IOP was significantly higher (P=0.028) at 6 months (16.62 mmHg ±5.97) but not (P=0.82) at most recent follow-up (14.9±3.37 mmHg) when compared with baseline (14.68±3.02 mmHg). Four eyes (18.2%) required initiation of IOP-lowering medications. During the follow-up period, no eyes underwent filtration or cataract extraction. No serious ocular adverse effects were noted during the follow-up period.ConclusionIn patients with bilateral noninfectious posterior uveitis and macular edema secondary to vein occlusion, bilateral injection of DEX intravitreal implant was well tolerated and had an acceptable safety profile.

Repeated Intravitreal Bevacizumab Injections versus Single Combined Intravitreal Bevacizumab and Posterior Subtenon Triamcinolone Injections for Treatment of Diabetic Macular Edema

Aim: To compare efficacy of combined intravitreal bevacizumab and subtenon triamcinolone versus three intravitreal injections of bevacizumab at one month interval for reducing foveal thickness. Methods: Sixty eyes of 30 diabetic patients with bilateral diabetic macular edema were randomly enrolled in two groups, group A eyes treated with three intravitreal injections of Bevacizumab of 1 month apart, and group B eyes treated with a single intravitreal injection of Bevacizumab comb ined with a subtenon triamcinolone in the same operative session. Pre and postoperative clinical data were measured and followed up over 6 months. Results: Difference between pre - treatment and post - treatment clinical data for each parameter in the same gro up was highly statistically significant. However, on comparing results of post treatment BCVA, IOP and CMT in both groups, there was no statistically significant difference. Conclusion: Combination of subtenon triamcinolone and intravitreal bevacizumab i s a safe and effective choice to treat DME. Original Research Article

Arginine-Restricted Therapy Resistant Bilateral Macular Edema Associated with Gyrate Atrophy.

Introduction. Gyrate atrophy is a rare genetical metabolic disorder affecting vision. Here, we report a 9-year-old boy with gyrate atrophy associated with bilateral macular edema at the time of diagnosis and the effect of long term metabolic control on macular edema. Case Presentation. A 9-year-old boy presented with a complaint of low visual acuity (best corrected visual acuity: 20/80 in both eyes, refractive error: −12.00 D). Dilated fundus examination revealed multiple bilateral, sharply defined, and scalloped chorioretinal atrophy areas in the midperipheral and peripheral zone. Spectral-domain optical coherence tomography revealed bilateral cystoid macular edema in both eyes. Serum ornithine level was high (622 μmol/L). An arginine-restricted diet reduced serum ornithine level (55 μmol/L). However, visual findings including macular edema remained unchanged in 2 years of follow-up. Conclusion. Arginine-restricted diet did not improve macular edema in our patient with gyrate atrophy. A more comprehensive understanding of the underlying factors for macular edema will lead to the development of effective therapies.

Macular edema in Asian Indian premature infants with retinopathy of prematurity: Impact on visual acuity and refractive status after 1-year.

Purpose:To report the impact of transient, self-resolving, untreated “macular edema” detected on spectral domain optical coherence tomography in Asian Indian premature infants with retinopathy of prematurity (ROP) on visual acuity (VA) and refraction at 1-year of corrected age.Materials and Methods:Visual acuity and refraction of 11 infants with bilateral macular edema (Group A) was compared with gestational age-matched 16 infants with ROP without edema (Group B) and 17 preterms infants without ROP and without edema (Group C) at 3, 6, 9 and 12 months of corrected age using Teller Acuity Cards and cycloplegic retinoscopy. Sub-group analysis of the previously described pattern A and B macular edema was performed.Results:Visual acuity was lower in infants with macular edema compared with the other two control groups throughout the study period, but statistically significant only at 3 months. Visual improvement in these infants was highest between the 3rd and 6th month and plateaued by the end of the 1st year with acuity comparable to the other two groups. The edema cohort was more hyperopic compared to the other two groups between 3 and 12 months of age. Pattern A edema had worse VA compared to pattern B, although not statistically significant.Conclusion:Macular edema, although transient, caused reduced VA as early as 3 months of corrected age in Asian Indian premature infants weighing <2000 g at birth. The higher hyperopia in these infants is possibly due to visual disturbances caused at a critical time of fovealization. We hypothesize a recovery and feedback mechanism based on the principles of active emmetropization to explain our findings.

INTRAVITREAL RANIBIZUMAB FOR THE TREATMENT OF MACULAR EDEMA SECONDARY TO MALIGNANT HYPERTENSION

Our purpose is to report a clinical case of bilateral macular edema caused by malignant hypertension in a 35-year old male. Patient presented with bilateral low visual acuity, massive macular edema, retinal hemorrhages and papilledema. Soon after he was diagnosed with other target-organ lesions, on heart and kidneys. After months of controlled blood pressure, an increase in visual acuity and a small decrease of macular edema, we effectively treated the lower vision eye with two intravitreal ranibizumab 0,5 mg injections, improving anatomy and function on both eyes. Even though we only treated one eye with ranibizumab, the contralateral eye also improved visual acuity and central macular thickness. This probably happened due to systemic absorption of ranibizumab. To the best of our knowledge, this is the first report of ranibizumab use in macular edema due to malignant hypertension.

Double trouble: a patient with both HLA-B27 anterior uveitis and HLA-A29 birdshot chorioretinitis.

BackgroundBirdshot chorioretinitis (BSCR) is a rare ocular inflammatory disorder associated with HLA-A29 and characterized by bilateral choroidal lesions, vitritis, macular edema, and retinal vasculitis. Ocular inflammation associated with HLA-B27 is typically a recurrent, unilateral, acute anterior uveitis (AAU) that is frequently associated with ankylosing spondylitis (AS). To date, there are no reports of patients with both HLA-A29-positive BSCR and HLA-B27 AAU/AS in the English literature.FindingsA 50-year-old man with a history of bilateral anterior uveitis, vitritis, retinal vasculitis, and cream-colored depigmented oval choroidal lesions was found to be HLA-A29 and HLA-B27 positive. His lumbar spine and sacroiliac joint films revealed fusion of the spine, known as `bamboo spine' compatible with the diagnosis of ankylosing spondyloarthropathy. He had chronic ocular inflammation that was difficult to control with systemic steroids and immunomodulatory agents.ConclusionsThis is the only report of a patient with both HLA-A29-positive BSCR and HLA-B27-positive AS and associated anterior uveitis. The severity of his disease suggests that patients who test positive for both HLA-A29 and HLA-B27 carry a poor visual prognosis. Prompt diagnosis and treatment with local or systemic corticosteroids or steroid-sparing agents may control the disease.Electronic supplementary materialThe online version of this article (doi:10.1186/s12348-014-0028-6) contains supplementary material, which is available to authorized users.

Phaeochromocytoma revealed by a stellate neuroretinitis

A 28-year-old woman presented with bilateral progressive decrease in visual acuity for 1 month. She had a history of headache, palpitations, profuse sweating, and abdominal pain for 3 months. Visual acuity was 20/800 in both eyes. On funduscopy (fi gure A) we saw a prominent bilateral optic disc swelling (black arrowheads) with marked macular hard exudates in a star shape (white arrowheads). Several hyperpigmented lesions (Siegrist streaks; white arrows) were scattered in the temporal midperipheral retina, suggesting marked ischaemia over choroidal arteries. We also noted a mild and diff use arterial narrowing with some intraretinal haem orrhages. This presentation was consistent with a stellate neuroretinitis, which is defi ned by optic disc swelling and macular hard exudates in a star shape. Fluorescein angiography (fi gure B) showed, a bilateral papillary hyperfl uorescence (black arrowheads) with some areas of delayed choroidal fi lling (white arrows) and several well-defi ned hypofl uorescent lesions (Elschnig fl ecks; white arrowheads) suggestive of a hypertensive choroidopathy. Optical coherence tomography (fi gure C) revealed a bilateral mild macular oedema (white arrows) with many perimacular exudates (white arrowheads). Blood count, erythrocyte sedimentation rate, serum lysozyme concentration, serum angiotensin-converting enzyme concentration, and fasting glucose concentration showed no abnormal results. Serology for Bartonella, syphilis, Lyme disease, and leptospirosis, quantiferon gold for tuberculosis, and cerebral CT were all normal. The patient’s blood pressure was 240/130 mm Hg. Abdominal ultra sonography showed a right adrenal mass that was hyperechoic and highly vascularised, measuring 50 mm by 52 mm and displacing the kidney (fi gure D). An abdominopelvic CT scan showed a hypodense right adrenal lesion with areas of necrosis, no intratumoural calcifi cations, and measuring 60 mm in diameter. Urinary catecholamine concentrations were high (metanephrine 107·1 μmol/24 h; normetanephrine 17·22 μmol/24 h). Neck ultrasonography, calcitonin concentration, parathyroid hormone concentration, blood and urinary calcium concentration and phosphorus concentration were normal, discounting medullary thyroid carcinoma and primary hyperparathyroidism. We did a right laparoscopic adrenalectomy; pathological examination confi rmed Phaeochromocytoma. At 3-month follow-up, blood pressure was normal (100/80 mm Hg) and visual acuity was 20/63 (right eye) and 20/200 (left eye). In our patient, the ocular symptoms were related to the high blood pressure, with a subsequent breakdown of the blood–retinal barrier leading to stellate neuroretinitis (which is a grade 4 hypertensive retinopathy). Presentation with bilateral stellate neuroretinitis should lead to measurement of blood pressure. Additional presence of Menard’s triad (headache, palpitations, and sweating) should be recognised as suggestive of phaeochromocytoma.