Fundoscopic Abnormalities Research Articles

Simple headache revealed a rare lymphoma: Waldenstrom macroglobulinemia with unique markers: a case report and review of the literature

BackgroundWaldenstrom macroglobulinemia (WM) is a rare lymphoma with an incidence rate of 3 per million people per year, with approximately 1000 to 1500 new cases diagnosed each year in the USA. It is primarily seen in Caucasian males with a median age of 70 years old. Patients are most often asymptomatic, but WM can manifest itself with constitutional symptoms such as lethargy, bleeding, organomegaly, and neurological or fundoscopic abnormalities. WM is characterized by immunoglobulin M (IgM) monoclonal gammopathy, lymphocytic infiltration of bone marrow, and normocytic anemia due to bone marrow replacement.Case presentationOur patient is a Hispanic 67-year-old female that presents with one month of intermittent band-like bilateral headache accompanied by dizziness, light-headedness, nausea, and blurred vision. A thorough diagnostic workup was performed, including serum protein electrophoresis (SPEP) with serum immunofixation (SIFE) showing an M spike and IgM kappa. Bone marrow biopsy was significant for lymphoplasmacytic infiltration with nodular B cells (CD19+, CD20+, CD22+). Computerized Tomography (CT) imaging showed splenomegaly in the patient. Treatment was provided for hyperviscosity syndrome with plasmapheresis twice. The patient reported improvement of her symptoms and was then scheduled for chemotherapy. Throughout 7 months, our patient received multiple cycles of bortezomib, dexamethasone, and rituximab. While her symptoms improved her psychiatric status got progressively worse.ConclusionIt is important not to neglect symptoms such as a headache, which may seem small, but could serve as a clue in the diagnosis of Waldenstrom's macroglobulinemia.

Utility of video-fundoscopy and prospects of portable stereo-photography of the ocular fundus in neurological patients

BackgroundProper evaluation of ocular fundi is an integral part of neurological examination. Unfortunately, neurology residents are increasingly uncomfortable performing fundoscopy and interpreting findings because of diminishing skills and lack of experience. This became more prominent during the COVID-19 pandemic as fundoscopy requires proximity to the patient.With the recent dramatic improvement of smartphone cameras, fundus photography using the PanOptic Ophthalmoscope (Welch Allyn, Skaneateles Falls, NY) with a smartphone adapter offered an alternative to direct fundoscopic examination. We present the first experience with our own design of a universal smartphone adapter.MethodsThis is a single-center case series, consecutive for a single user and certain presenting neurological symptoms, which is aimed to evaluate the feasibility and practicality of a new, universal PanOptic smartphone adapter. Presenting symptoms included headache, ocular symptoms, seizure, or encephalopathy. We used 3D modeling and printing techniques to create the adapter.We also developed a methodology of capturing stereoscopic images of the optic disc using a single smartphone camera, but the method was not systematically evaluated in this paper.ResultsHere we present our initial experience of fundus video/photography in patients, who presented with encephalopathy, headache, seizure, vision loss, and other ocular symptoms. Fundoscopic abnormalities were discovered in 11 out of 100 patients. Some were incidental findings and were unrelated to the presentation. In one case, fundoscopy played a critical role in establishing the correct diagnosis.ConclusionsOur custom-designed smartphone adapter allowed obtaining high-quality video and photo recordings using PanOptic Ophthalmoscope. The acquisition of high-quality photos enables a high-yield diagnostic tool and allows revisiting the image in the patient’s chart. Improvement of smartphone cameras opens vast horizons for stereo-fundoscopy and 3D reconstruction of the ocular fundus without using sophisticated and costly equipment. Microscopic eye movements allow taking snapshots of two side-by-side photos for 3D reconstruction and stereoscopic image viewing, which is the next level of optic disc assessment.

Demographic profile & correlation between retinal exudates and hematological parameters in leukemic patients

Background: Leukemia is frequently associated with fundoscopic abnormalities. However, no organized effort has been made for analyzing leukemic retinopathy in our country. This study was done to observe the demographic profile and correlation between fundoscopic findings of retinal exudates and hematological parameters in leukemic patients. Materials and Methods: The study was a hospital-based descriptive cross-sectional study among 50 leukemic patients in Medicine and Oncology departments of Bangladesh Medical College and Hospital (BMCH) from May, 2020 to October, 2020. Fundoscopic examination was done which was reviewed by an ophthalmologist. Collected data was analyzed statistically by using SPSS-17 (Chicago, Illinois). Results: Among 50 leukemic patients’, the fundal lesion was detected in 32 patients (64%), retinal exudates are rare. Only 3 patients (6%) had exudates while others (29 patients, 58%) have retinal hemorrhages. Exudates did not show any statistically significant relationship with types of leukemia (p value = 0.53). There was no statistically significant association between fundal exudates and high white cell count (p = 0.56) or low hemoglobin level (p = 0.11) or low platelet level (p = 0.11). Conclusion: This study has identified retinopathy occurring frequently in leukemic patients. Therefore, an adequate attention should be paid at fundoscopic evaluation while treating leukemic patients.

Risk factors and outcomes of patients with ocular involvement of candidemia.

BackgroundOcular involvement of candidemia can result in serious complications, including vision loss. This study investigated the risk factors for ocular involvement in patients with candidemia and the outcomes of treatment.MethodsEpisodes of candidemia in hospitalized adults who underwent ophthalmic examinations within 2 weeks of candidemia onset between January 2014 and May 2017 were retrospectively reviewed. Their demographic characteristics, antifungal treatments, and visual outcomes were evaluated.ResultsDuring the study period, 438 adults were diagnosed with candidemia, with 275 (62.8%) undergoing ophthalmic examinations within 2 weeks. Of these 275 patients, 59 (21.5%) had fundoscopic abnormalities suggestive of ocular involvement, including 51 with chorioretinitis and eight with Candida endophthalmitis. Eleven patients were symptomatic. Persistent candidemia (adjusted odd ratio [aOR], 2.55; 95% confidence interval [CI], 1.29–5.08; P = 0.01), neutropenia during the preceding 2 weeks (aOR, 2.92; 95% CI, 1.14–7.53; P = 0.03), and C. albicans infection (aOR, 2.15; 95% CI, 1.09–4.24; P = 0.03) were independently associated with ocular involvement. Among the 24 patients with neutropenia, 41.7% had ocular involvements at the initial examination. Ophthalmologic examination even before the neutrophil recovery was positive in one-third of neutropenic patients. Out of the 37 patients in whom ocular outcomes after 6 weeks were available, 35 patients showed favorable or stable fundoscopic findings. Two patients had decreased visual acuity despite the stable fundoscopic finding.ConclusionNeutropenia within two weeks of candidemia was a risk factor for ocular involvement. More than 80 percent of patients with ocular involvements were asymptomatic, emphasizing the importance of routine ophthalmic examinations. The median 6 weeks of systemic antifungal treatment resulted in favorable outcomes in 89.2% of patients.

Evaluation of Fundoscopic Abnormalities in Patients with Coronary Artery Disease

Objective: Coronary artery disease (CAD) is the leading cause of death in the world. There has been recent interest to microvasculature changes that are involved in systemic conditions associated with CAD. Retinal microvascular changes which can be easly detected noninvasively may be also a marker for cardiovascular diseases. Our aim in this study was to evaluate the relationship between the retinal findings and coronary artery disease by performing fundoscopic examination in patients diagnosed with CAD Methods: This study enrolled 100 patients (72 female, mean age: 59.3±7.1 years) diagnosed with CAD, along with 100 controls (75 female, mean age: 57.8±8.2 years) who were proved to have normal coronary arteries by coronary angiography. Bilateral fundoscopic examination was performed in all study population. Fundoscopic findings and risk factors for CAD were compared between the groups. Results: There was no significant difference between the groups in terms of clinical, demographical and laboratory characteristics of the patients. The prevalence of atherosclerotic changes was significantly higher in patients with CAD than controls (87 vs 58 %, p<0.001). Hypertensive retinopathy was observed more frequently in CAD group as compared to controls (95 vs 60 %, p<0.001). The prevalence of diabetic retinopathy, retinal vein occlusion, retinal collateral vessels, increased retinal tortuosity, Drusenoid bodies and Hollenhorst plaques were similar between the groups. Conclusion: The atherosclerotic and hypertensive retinal findings were more frequently observed in patients with coronary artery disease. Therefore, fundoscopic examination may be useful in the evaluation of such patients with coronary artery disease.

Avaliação oftalmológica em pacientes com AIDS e neurotoxoplasmose

To describe fundoscopic findings among patients with AIDS and active-phase neurotoxoplasmosis. A prospective study of case series type was developed, including 70 patients of both sexes and ages ranging from 20 to 63 years who were admitted to the wards of three public hospitals in the city of Recife, Pernambuco, Brazil, from January to October 2008, with diagnoses of AIDS and neurotoxoplasmosis determined according to the criteria of the Centers for Disease Control and Prevention (1992). The patients were characterized by a first episode of neurotoxoplasmosis (65; 92.9%) or recurrence (5; 7.1%), unawareness of having AIDS (23; 32.9%), mean T CD4+ count of 139.8 + or - 3.04 lymphocytes/mm(3) and mean viral load of 137,080 + or - 39,380 copies/ml. All patients underwent ophthalmological examination consisting of ocular inspection, gauging of visual acuity, investigation of ocular extrinsic muscle function and fundoscopy using a binocular indirect ophthalmoscope (model OHM 3.5 Eyetec) and external lens of 20 diopters (Volk). The findings consisted of retinal cotton-wool spot exudates (8.6%), slight diffuse arteriolar constriction (8.6%), retinochoroiditis scars characteristic of ocular toxoplasmosis (5.7%), atrophy of retinal pigment epithelium (2.9%), retinal detachment (2.9%), increased papillary excavation (1.4%), retinal peripheral degeneration (1,4%), macroaneurysm (1.4%), bilateral papilledema (1.4%) and vitreous-retinal traction (1.4%). Patients with AIDS and neurotoxoplasmosis may present fundoscopic abnormalities characteristic of ocular toxoplasmosis, either in active or in scar form, related to HIV or even to other opportunist or systemic diseases, which can be of great aid for integral treatment of patients by a multiprofessional team.

Meningoencefalitis tuberculosa en niños: Revisión de 35 casos en el Hospital Universitario San Vicente de Paúl en Medellín, Colombia. 1997-2004

OBJETIVO: documentar los rasgos clínicos y diagnósticos y explorar los factores asociados con la muerte de niños con meningoencefalitis tuberculosa (MT) en el Hospital Universitario San Vicente de Paúl, Medellín, Colombia. MÉTODO: revisión de las historias clínicas para obtener los datos demográficos, clínicos, de laboratorio, de tratamiento y de las complicaciones de 35 niños con tuberculosis del sistema nervioso central, entre julio de 1997 y julio de 2004. RESULTADOS: veinte de los 35 pacientes eran niños y 15 niñas. La edad promedio era 3.7 años; 30 (85.7%) estaban en el estadio III de la enfermedad y 5 (14.3%), en el estadio II. Se documentó un contacto sintomático respiratorio en 19 casos (54.3%). Diez y ocho pacientes (51.4%) estaban desnutridos. Hubo fiebre en 88.6%, vómito en 62.9%, alteración de la conciencia en 80% y convulsiones en 51.4%. La duración promedio de la sintomatología fue 10 días. Al examen físico se hallaron: signos meníngeos en 77%, trastorno de los movimientos en 31.4%, estupor o coma en 82.9%, hemiparesia en 60% y alteraciones en el fondo de ojo en 31.4%. En los 35 pacientes se encontró anormal el LCR. La tomografía reveló hidrocefalia en 88.7%, meningitis basal en 57.1%, infarto gangliobasal en 48.6% y tuberculomas en 11%. Se aisló M. tuberculosis en 11 pacientes (31.4%). La tasa global de mortalidad fue 17%. CONCLUSIONES: el contacto positivo en la casa, la duración de los síntomas mayor de 10 días, la hidrocefalia y los movimientos anormales sugieren fuertemente el diagnóstico de MT. La presencia de papiledema y el cultivo positivo para M. tuberculosis en el LCR se relacionan con la muerte.

Relation of left ventricular geometry and function to aortic root dilatation in patients with systemic hypertension and left ventricular hypertrophy (the LIFE study)

Echocardiographically detemined left ventricular (LV) hypertrophy is an independent predictor of increased cardiovascular morbidity and mortality in hypertensive patients. 1 Casale P.N Devereux R.B Milner M Zullo G Harshfeld G.A Pickering T.G Laragh J.H Value of echocardiographic assessment of left ventricular mass in predicting cardiovascular morbid events in hypertensive men. Ann Intern Med. 1986; 105: 173-178 Crossref PubMed Scopus (1034) Google Scholar , 2 Koren M.J Devereux R.B Casale P.N Savage D.D Laragh J.H Relation of left ventricular mass and geometry to morbidity and mortality in uncomplicated essential hypertension. Ann Intern Med. 1991; 114: 345-352 Crossref PubMed Scopus (2160) Google Scholar Recent reports have described associations between LV geometric adaptation and extracardiac target organ damage in essential hypertension, with hypertensive patients with concentric LV geometry having the most advanced fundoscopic abnormalities, the greatest renal dysfunction, 3 Shigematsu Y Hamada M Mukai M Matsuoka H Sumimoto T Hiwada K Clinical evidence for an association between left ventricular geometric adaptation and extracardiac target organ damage in essential hypertension. J Hypertens. 1995; 13: 155-160 Crossref PubMed Scopus (92) Google Scholar and the most severe abnormalities of carotid artery structure and function. 4 Roman M.J Pickering T.G Schwartz J.E Pini R Devereux R.B Relation of arterial structure and function to left ventricular geometric patterns in hypertensive adults. J Am Coll Cardiol. 1996; 28: 751-756 Abstract Full Text PDF PubMed Google Scholar , 5 Bella J.N Roman M.J Pini R Shwartz J.E Pickering T.G Devereux R.B Assessment of arterial compliance by carotid midwall strain-stress relation in hypertension. Hypertension. 1999; 33: 793-799 Crossref PubMed Scopus (13) Google Scholar However, although geometric and functional abnormalities of medium-sized capacitance arteries associated with LV hypertrophy have been identified in relatively mild, uncomplicated hypertension, 4 Roman M.J Pickering T.G Schwartz J.E Pini R Devereux R.B Relation of arterial structure and function to left ventricular geometric patterns in hypertensive adults. J Am Coll Cardiol. 1996; 28: 751-756 Abstract Full Text PDF PubMed Google Scholar , 5 Bella J.N Roman M.J Pini R Shwartz J.E Pickering T.G Devereux R.B Assessment of arterial compliance by carotid midwall strain-stress relation in hypertension. Hypertension. 1999; 33: 793-799 Crossref PubMed Scopus (13) Google Scholar relations of the size of the most proximal portion of the systemic arterial tree (the aortic root) to LV geometry and function have not been elucidated in patients with more severe hypertension. Therefore, the purpose of the present study was to identify the clinical and echocardiographic characteristics of hypertensive patients with aortic root dilatation and to examine the relation of cardiac geometry and function to aortic size in hypertensive participants enrolled in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) echocardiography substudy.

Is epistaxis evidence of end-organ damage in patients with hypertension?

To study the association between history of mild to severe epistaxis with different stages of hypertension and with other evidence of target organ damage in a sample of patients attending an outpatient hypertension clinic, controlling for potential confounding factors. A survey of adult patients with hypertension. A consecutive sample of 323 adults with hypertension was studied. The main outcome measures were history of adult epistaxis, high blood pressure, duration of hypertension, nasal abnormalities, and fundoscopic and electrocardiogram abnormalities. Ninety-four patients (29.1% of the whole sample) reported at least one episode of nosebleed after 18 years of age. Of these, 59 (62.8%) needed medical assistance to control at least one of the episodes. The history of epistaxis was not associated with blood pressure classified according to the World Health Organization/International Society of Hypertension paradigm or classified as severe or not severe. There was a trend of an association between history of epistaxis and duration of hypertension. The history of severe epistaxis (epistaxis that needed medical assistance) was not associated with blood pressure classified as severe or not severe and with duration of hypertension. More patients with left ventricular hypertrophy had a positive history of adult epistaxis. There was no association between history of epistaxis or history of severe epistaxis and fundoscopic abnormalities. Among the abnormalities detected at rhinoscopy, only the presence of enlarged septal vessels was associated with history of epistaxis. The presence of enlarged septal vessels was strongly and independently associated with history of epistaxis in the logistic regression model. Duration of hypertension and left ventricular hypertrophy showed a trend for an association with the history of epistaxis in the adult life. A definite association between blood pressure and history of adult epistaxis in hypertensive patients was not found. The evidence for an association of duration of hypertension and left ventricular hypertrophy with epistaxis suggests that epistaxis might be a consequence of long-lasting hypertension. The association between the presence of enlarged vessels at rhinoscopy with history of epistaxis in hypertensive patients is a novel observation that needs to be addressed in future observations.

Bilateral posterior scleritis

Purpose: To describe an unusual presentation of posterior scleritis in a healthy young patient. Method: We reviewed the medical record of 21 -year-old man for clinical presentation, course, and ancillary studies. Results: The healthy patient had a painless, bilateral posterior scleritis that presented with a combination of circumscribed fundus masses and exudative macular detachment. On fluorescein angiography, different hyperfluorescent patterns characterized the two manifestations of posterior scleritis. An ultrasound confirmed the scleral thickening. Fundoscopic abnormalities resolved with oral prednisone. Conclusion: Pain is not always present in this disease. A combination of exudative macular detachment and circumscribed fundus masses can be a form of presentation in posterior scleritis.

Vitreous fluorophotometry studies in retinitis pigmentosa.

Six patients with various genetic types of retinitis pigmentosa and ten carriers of the X-linked recessive type were studied by vitreous fluorophotometry. Kinetic vitreous fluorophotometry showed an alteration of the blood-retinal barrier (BRB) in patients with retinitis pigmentosa, even in those who had minimal fundoscopic abnormalities and only minor changes on the electroretinogram. Furthermore, an alteration of the BRB could be detected in the carriers of the X-linked recessive form of retinitis pigmentosa. In general, higher concentration of fluorescein in the vitreous correlated topographically with the extent of photoreceptor and retinal pigment epithelial disease, as well as with the presence of leakage from retinal capillaries.

The management of hypertensive emergencies.

SummaryMalignant hypertension and hypertensive crisis remain serious clinical situations necessitating vigourous emergency treatment.Each of the clinical pictures:— severe hypertension with encephalopathy and/or fundoscopic abnormalities,— acute lung edema and/or myocardial infarction,— dissecting aneurysm of the aorta,— renal failure,— eclampsia,— postoperative bleeding,asks for a different management.The use of one single drug for the treatment of all hypertensive emergencies is no longer tenable.Table 3 provides a guideline for the use of the different drugs in hypertensive emergencies.These data are derived from our own experience and from the current medical litterature (December 1980).