Intraretinal Hemorrhages Research Articles

HEMORRHAGIC UNILATERAL RETINOPATHY

To evaluate the possible etiologies of a hemorrhagic unilateral retinopathy in healthy patients. Retrospective case series and review of the literature. All patients underwent a detailed ophthalmologic evaluation and analyses of their medical histories. Eleven eyes of 10 patients with unexplained unilateral, predominantly deep, intraretinal hemorrhages were identified. All patients were women. Mean age of the subjects was 48.4 years (range, 25-83 years). The main complaint at presentation was sudden visual loss, with visual acuity ranging from 20/20 to hand motion. The mean follow-up was 17 months, and the 9 eyes with follow-up showed spontaneous resolution of the hemorrhages and marked improvement of vision. There was no history of Valsalva maneuver or strenuous exercise. The patients were healthy at presentation and during follow-ups as long as 84 months. This series depicts the characteristics of a possible new entity with a review of the differential diagnosis. The visual outcome was excellent.

The course of retinal vasculitis

AimsTo determine if characteristics of retinal vasculitis correlate with ocular complications, or the response to different lines of treatment.Materials and methodsWe performed a computerised database analysis of 56 patients evaluated...

English

AIM: To report a case of bilateral intra-retinal macular hemorrhage in a young female. CASE REPORT: A 25 year old healthy female, with no history of prior ocular complaints presented to the Regional Institute of Ophthalmology Medical College Amritsar with the complaint of sudden bilateral painless blurring of vision since 24 hours. On examination, visual acuity was 6/36 partial in OD and 6/60 partial in OS. Near vision was 6/12 partial OU. Fundoscopy disclosed bilateral maculopathic hemorrhage confirmed with OCT. Investigations for the common causes such as drug induced anemia, blood dyscrasias, diabetes, hypertension, vasculitides and valsalva retinopathy were carried out. A platelet count of 1,00,000 was the only significant finding. All other results were normal. On the basis of clinical suspicion and low platelet count, Dengue Serology was advised which was positive. Ruling out other causes, a diagnosis of Dengue Maculopathy causing bilateral intraretinal hemorrhage was formed. Patient was kept under observation, and showed drastic improvement. CONCLUSIONS: In literature, bilateral intra-retinal macular hemorrhage alone is a rare finding. Apart from the more common causes, dengue fever should be kept in mind. Dengue associated maculopathy most commonly presents as blurring of vision with macular hemorrhage or macular edema. Hence in endemic areas, a high index of suspicion and thorough ocular examination is mandatory in dengue suspects.

Fundus autofluorescence in blunt ocular trauma.

To describe the findings of fundus autofluorescence (FAF) imaging in patients with blunt ocular trauma. In this non-interventional retrospective study, we reviewed medical records and imaging examination results. The data analyzed included gender, age, laterality, trauma etiology, time between trauma and imaging, visual acuity, changes in the retinal periphery, fundus examination results, and FAF imaging findings. FAF imaging was performed using a Topcon TRC-50DX Retinal Camera (Tokyo, Japan). Eight eyes from 8 patients were studied. The mean age was 27.6 years (range, 19-43 years). Men (n=7) were more frequently affected by blunt ocular trauma than women (n=1). Physical aggression was the most common trauma etiology (n=3), followed by accidents with fireworks (n=2). Other causes were car accidents (n=1), occupational trauma caused by a grinder (n=1), or being hit by a stone (n=1). Visual acuity ranged from 20/80 to light perception. Traumatic pigment epitheliopathy (TPE) was identified in 5 cases, choroidal rupture in 3 cases, subretinal hemorrhage in 3 cases, and Purtscher’s retinopathy in 1 case. Hypoautofluorescence was observed in cases of choroidal rupture, recent subretinal hemorrhage, and intraretinal hemorrhage, and in two cases of TPE. Hyperautofluorescence was observed in cases of old subretinal hemorrhage and at the edge of the lesion in two cases of choroidal rupture. Mild hyperautofluorescence was observed in the posterior pole in Purtscher’s retinopathy. Three cases of TPE exhibited hypoautofluorescence with diffuse hyperautofluorescent areas. FAF imaging is a non-invasive method for assessing changes in the posterior segment of the eye resulting from blunt ocular trauma. Furthermore, this technique provides valuable information. We described the findings of FAF imaging in cases of TPE, choroidal rupture, subretinal hemorrhage, and Purtscher’s retinopathy.

Increased choroidal thickness in patient with high-altitude retinopathy

We report a case of high-altitude retinopathy with increased choroidal thickness detected by spectral-domain optical coherence tomography (SD-OCT). A 36-year-old Japanese man developed an acute vision decrease in his left eye after he had trekked at an altitude of 4600 m in Tibet for 1 week. His visual acuity was 20/20 OD and 20/200 OS with refractive errors of − 0.25 diopters (D) OD and − 0.50 D OS 3 weeks after the onset of the visual decrease. Funduscopic examinations revealed multiple intraretinal hemorrhages bilaterally and a macular hemorrhage in the left eye. SD-OCT showed that the thickness of choroidal layer at the fovea was 530 μm OD and 490 μm OS which is thicker than that in normal subjects of approximately 300 μm. We suggest that the increase in the retinal blood flow under hypoxic conditions may be associated with an increase in the choroidal blood flow resulting in an increase in choroidal thickness.

Retinal Pigment Epithelial Detachment With Disgorgement in Age-Related Macular Degeneration Observed With OCT

This report describes a rare appearance of retinal pigment epithelial changes in a 71-year-old woman with known long-standing, non-exudative age-related macular degeneration. She presented with visual distortion in her right eye and was found to have a retinal pigment epithelial detachment (RPED) on optical coherence tomography (OCT). Over the following 8 years, sequential OCT imaging revealed an appearance and progression of a break in the existing RPED, disgorgement of material from within the RPED, and appearance of hyper-reflective spots within the inner retinal layers, suggesting pigment epithelial cell migration. Visual acuity remained stable over this period. The RPED resolved spontaneously without treatment. The patient later developed new intraretinal hemorrhage, which was treated with intravitreal bevacizumab.

Shaken Adult Syndrome

To establish that the intracranial and ophthalmologic findings present in victims of abusive head trauma can also be seen in shaken adults. We report 2 cases of shaken adults with intracranial and ophthalmologic findings that resulted from repetitive acceleration-deceleration injury. These findings included intracranial hemorrhages, hemorrhages involving the optic nerve sheath, intraretinal and subretinal hemorrhages, and macular folds. The intracranial and ophthalmologic findings that are characteristic of abusive head trauma--subdural hemorrhages, optic nerve sheath hemorrhages, and retinal hemorrhages--are generally thought to be limited to young children and infants. Adults may also be victims of shaking abuse, and an ophthalmic examination may be beneficial when shaking is suspected.

Spontaneous Resolution of Macular Edema in Leber’s Miliary Aneurysms

The natural history of Leber's miliary aneurysms is described. A patient with Leber's miliary aneurysm presented with count fingers visual acuity due to significant lipid exudates, intraretinal hemorrhages, and macular edema. Over the next 3 months, the macular edema resolved spontaneously and the visual acuity improved to 20/20. The dramatic improvement in both macular edema and visual acuity highlights the importance of conservative management before pursuing more invasive treatments.

A Degenerative Retinal Process in HIV-Associated Non-Infectious Retinopathy

HIV retinopathy is the most common non-infectious complication in the eyes of HIV-positive individuals. Oncotic lesions in the retinal nerve fiber layer, referred to as cotton wool spots (CWS), and intraretinal (IR) hemorrhages are frequently observed but are not unique to this pathology. HIV-positive patients have impaired color vision and contrast sensitivity, which worsens with age. Evidence of inner–retinal lesions and damage have been documented ophthalmoscopically, however their long term structural effect has not been investigated. It has been hypothesized that they may be partially responsible for loss of visual function and visual field. In this study we utilized clinical data, retinal imaging and transcriptomics approaches to comprehensively interrogate non-infectious HIV retinopathy. The methods employed encompassed clinical examinations, fundus photography, indirect ophthalmoscopy, Farmsworth-Munsell 100 hue discrimination testing and Illumina BeadChip analyses. Here we show that changes in the outer retina, specifically in the retinal pigment epithelium (RPE) and photoreceptor outer segments (POS) contribute to vision changes in non-infectious HIV retinopathy. We find that in HIV-positive retinae there is an induction of rhodopsin and other transcripts (including PDE6A, PDE6B, PDE6G, CNGA1, CNGB1, CRX, NRL) involved in visual transduction, as well as structural components of the rod photoreceptors (ABCA4 and ROM1). This is consistent with an increased rate of renewal of rod outer segments induced via increased phagocytosis by HIV-infected RPE previously reported in culture. Cone-specific transcripts (OPN1SW, OPN1LW, PDE6C, PDE6H and GRK7) are uniformly downregulated in HIV positive retina, likely due to a partial loss of cone photoreceptors. Active cotton wool spots and intraretinal hemorrhages (IRH) may not affect photoreceptors directly and the interaction of photoreceptors with the aging RPE may be the key to the progressive vision changes in HIV-positive patients.

Managing IBD Outside the Gut: Ocular Manifestations

Extraintestinal manifestations are common in inflammatory bowel disease (IBD), being reported in over 25% of patients. Ocular complications of IBD occur in around 10% of cases, but may precede systemic symptoms and are usually nonspecific. Complications of therapy, such as cataracts or glaucoma from steroid use or keratoconjunctivitis sicca related to 5-aminosalicylic acid medications, may also involve the eyes. The pathogenesis remains unclear, but factors such as the extent of intestinal disease, disease activity, and the presence of associated arthritis have been associated with ocular involvement. Conjunctivitis, episcleritis, scleritis and uveitis are by far the most common ophthalmic complications of IBD. However, posterior uveitis, intraretinal hemorrhages, vasculitis, choroiditis, optic neuropathy, and vaso-occlusive phenomena may also occur. The most frequent severe ocular manifestation is anterior uveitis (more common in women). It usually presents as a mild anterior nongranulomatous uveitis (60% of the cases). The inflammation in the eye and the inflammation in the gut are rarely correlated. Patients with uveitis, scleritis, and other anterior segment inflammation usually respond to steroids (topical, periocular or systemic). If the inflammation is resistant to steroids, or if appreciable steroid adverse effects are encountered, systemic immunosuppressive treatment should be considered; this is more likely in HLA-B27-positive patients with uveitis. Evaluation of the eye should be a routine component in the care of patients with IBD.

The Retinal Disease Screening Study: Retrospective Comparison of Nonmydriatic Fundus Photography and Three-Dimensional Optical Coherence Tomography for Detection of Retinal Irregularities

To determine the sensitivity of three-dimensional optical coherence tomography (3D-OCT) versus single field nonmydriatic fundus photography (FP) for detection of a variety of retinal abnormalities. Images from consecutive patients in a retina clinic undergoing simultaneous 3D-OCT (512 × 128) and single, foveal nonmydriatic 45° color fundus imaging with 3D-OCT-1000 in a 4 month-period were retrospectively collected. Findings from each modality were graded independently by two graders as present, questionable, or absent. Irregularities were separated into three categories for intermodality comparisons: epiretinal, retinal/subretinal, and RPE/choroidal irregularities. The approximate location of findings in relation to the 3D-OCT field was noted as in field and out of field. Findings from both modalities were combined to form the gold standard for comparison for each modality. Five hundred and one sets of 3D-OCT scans and fundus images of 395 eyes of 223 patients were found in the study period, of which, 474 unique visits were included. Ninety-six percent of the scans had abnormal findings. Twenty-six fundus images (5.5%) were ungradable. 3D-OCT identified some abnormality in 25/26 (96.2%) of the ungradable fundus images. For overall detection of a variety of retinal irregularities or irregularity of each category (epiretinal, intraretinal, or RPE/choroidal irregularity), 3D-OCT was found to be more sensitive than that of nonmydriatic color fundus images. When single specific feature was speculated, 3D-OCT demonstrated various detection abilities: higher than FP for abnormal retinal thickness (or intraretinal hyporeflective features); similar as FP for RPE atrophy; however, lower for pigment migration (or intraretinal hemorrhage). In this study, sensitivities of 3D-OCT were higher than nonmydriatic fundus images for overall detection of retinal abnormalities or irregularities in each category. 3D-OCT demonstrated good ability to detect most features; however, with limitation to intraretinal hemorrhage and pigment migration. It is likely that OCT will be added to photography screening for chorioretinal diseases in the near future.

Ophthalmologische Veränderungen im Rahmen der Erstdiagnose einer HIV-Infektion

Acquired immunodeficiency syndrome (AIDS) caused by the human immunodeficiency virus (HIV), is one of the most important infectious causes of death in the twentieth and twenty-first centuries. Ocular manifestations can appear in particular when the CD4 cell count is low. This article presents a case report of a 38-year-old homosexual man in whom HIV microangiopathy retinopathy syndrome (MAPS) was found during the assessment of the initial HIV diagnosis. Typical findings in MAPS are conjunctival and retinal vessel abnormalities, cotton wool spots as well as intraretinal hemorrhages. Loss of vision is a rare complication but MAPS shows an impairment of the immune status and is also associated with a higher mortality.

Purtscher-like retinopathy associated with dermatomyositis

BackgroundTo report a rare case of bilateral Purtscher-like retinopathy in a Chinese female patient with dermatomyositis.Case presentationAn 18-year-old woman with lower extremity muscle weakness was admitted due to decreased vision of both eyes for two weeks. Ophthalmic examination revealed violaceous eruption on eyelids with swelling. Ocular fundus examination revealed multiple cotton wool spots and Purtscher flecken, and intra-retinal haemorrhages with pseudo-cherry red spot. The erythrocyte sedimentation rate, C-reactive protein, lactate dehydrogenase and creatine kinase was measured and found to be increased. A diagnosis of Purtscher-like retinopathy associated with dermatomyositis was made and the patient was treated with corticosteroids.ConclusionAlthough dermatomyositis is a rare cause of Purtscher-like retinopathy, it is important to keep in mind that systemic associations such as dermatomyositis should be ruled out in such patients.

Roth spots as the primary presentation of a metastatic solid malignancy

### Learning Point for Clinicians This case report highlights a novel presentation of a common disease, specifically a solid malignancy presenting as blurred vision due to Roth spots. It would be interesting to physicians from a variety of medicine specialities as it links oncology with a well-known, but nonetheless, intriguing ophthalmologic finding. A 58-year-old man with hyperlipidemia and alcohol dependence presented with a 2-day history of visual blurring, seeing flashes of light and pain in his eyes associated with headaches. The patient had bi-temporal region tenderness and hepatomegaly, but no fever or murmurs. Digital retinal imaging revealed bilateral intra-retinal hemorrhages and Roth spots (Figure 1a). The patient was anemic, with a hemoglobin of 91 g/l, had leukocytosis with white blood cell count of 17.2 × 109/l (neutrophils 13.2 × 109/l, lymphocytes 2.6 × …

Solid-appearing retinal cysts in diabetic macular edema: a novel optical coherence tomography finding.

To describe a novel finding of solid-appearing retinal cysts in patients with diabetic macular edema. Case series of four patients with diabetic retinopathy discovered to have solid-appearing retinal cysts on spectral-domain optical coherence tomography. These cases demonstrate the presence of inner retinal hyporeflective cysts filled with an isoreflective substance on spectral-domain optical coherence tomography. These solid-appearing cysts arise from previously fluid-filled cysts and are not found in relation to intraretinal hemorrhage. Treatment with intravitreal anti-vascular endothelial growth factor agents did not seem to directly alter their natural course. The authors report solid-appearing retinal cysts as a new optical coherence tomography finding in four patients with diabetic macular edema. The exact composition of this isoreflective material is unknown. The authors hypothesize that fibrin or other inflammatory by-products fill these spaces.

Retinal arterial macroaneurysms

Retinal arterial macroaneurysms are acquired saccular or fusiform dilatations of the large arterioles of the retina, usually within the first three orders of bifurcation. They are associated with systemic vascular conditions such as hypertension and arteriosclerotic disease occurring most commonly in elderly women. The primary reported symptom is a sudden loss of vision due to haemorrhage or oedema affecting the macula. Most of macroaneurysms regress without treatment and without causing decreased visual acuity. Poor visual outcome may occur secondary to foveal exudates and subfoveal haemorrhage.

Fundus Autofluorescence and Colour Fundus Imaging Compared During Telemedicine Screening in Patients with Diabetes

We investigated the use of fundus autofluorescence (FAF) imaging in screening the eyes of patients with diabetes. Images were obtained from 50 patients with type 2 diabetes undergoing telemedicine screening with colour fundus imaging. The colour and FAF images were obtained with a 15.1 megapixel non-mydriatic retinal camera. Colour and FAF images were compared for pathology seen in nonproliferative and proliferative diabetic retinopathy (NPDR and PDR, respectively). A qualitative assessment was made of the ease of detecting early retinopathy changes and the extent of existing retinopathy. The mean age of the patients was 47 years, most were male (82%) and most were African American (68%). Their mean visual acuity was 20/45 and their mean intraocular pressure was 14.3 mm Hg. Thirty-eight eyes (76%) did not show any diabetic retinopathy changes on colour or FAF imaging. Seven patients (14%) met the criteria for NPDR and five (10%) for severe NPDR or PDR. The most common findings were microaneurysms, hard exudates and intra-retinal haemorrhages (IRH) (n = 6 for each). IRH, microaneurysms and chorioretinal scars were more easily visible on FAF images. Hard exudates, pre-retinal haemorrhage and fibrosis, macular oedema and Hollenhorst plaque were easier to identify on colour photographs. The value of FAF imaging as a complementary technique to colour fundus imaging in detecting diabetic retinopathy during ocular screening warrants further investigation.

Diabetic retinopathy.

This paper describes the importance of diabetic retinopathy in the loss of visual function. We exposed the most important risk factors, such as diabetes duration, poor metabolic control, pregnancy, puberty, hypertension, poor control of blood lipids, renal disease, and sleep apnea syndrome. We describe the pathogenesis of the disease, small retinal vessel microangiopathies which produce extravasation, edema and ischemia phenomena. We put special emphasis on the vascular endothelial growth factor (VEGF) and its pathogenic importance. They are also described the main clinical symptoms as microaneurysms, intraretinal hemorrhages, hard and soft exudates, intraretinal microvascular abnormalities (IRMA), venous disorders, formation of new vessels and diabetic macular edema (the latter being the most common cause of vision loss). Finally we describe the latest diagnostic techniques and eye treatment, with special emphasis on obesity surgery importance as more important preventive factor to eliminate the predisposing and precipitating disease symptoms.

Accelerated ischemic vascular retinopathy after intravitreally injected bevacizumab for central retinal vein occlusion in elderly patients

Background:Ischemic changes in the retinal circulation are an uncommon but severe adverse vascular reaction to intravitreal bevacizumab (Avastin®, Genentech, San Francisco, CA, USA/Roche, Basel, Switzerland) for central retinal vein occlusion (CRVO). In the two cases reported here, ischemic changes in the retina vasculature following intravitreal bevacizumab for CRVO were observed with the aim of describing the clinical and angiographic features of these changes.Methods:Two elderly patients with recent-onset CRVO received one off-label intravitreal injection of bevacizumab 0.05 mL/1.25 mg.Results:In Case 1, the patient’s pre-treatment visual acuity was 20/400. At 3 weeks post injection, the patient could count fingers at a distance of 1 ft (30 cm) and fluorescein angiography showed reduction in intraretinal hemorrhages and areas of retinal non-perfusion. However, at 6 weeks these were markedly increased compared with those seen in the photograph taken 3 weeks after treatment. In Case 2, the patient’s pre-treatment visual acuity was 20/200. At 1 month post injection, vision had decreased to 20/400 and fluorescein angiography showed severe macular ischemia with a remarkable capillary dropout throughout the macula.Conclusion:Ischemic retinal injury may be an uncommon but severe adverse vascular reaction to intravitreal bevacizumab for CRVO. Although progression of retinal ischemia in CRVO could be observed shortly after intravitreal bevacizumab, whether this is a drug- or procedure-related effect or part of the natural history of the condition remains uncertain.

Manifestations oculaires au cours de l’endocardite bactérienne subaigüe

Introduction : Subacute Bacterial Endocarditis (SBE) is a flammable bacterial infection of the endocardium and usually builds on a pre-existing heart disease. Ocular events are a particularly rare complication that occurs in a child. Case study : a 10 year old patient having a history of recurrent tonsillitis and hospitalized in pediatric for kidney failure, shows a decrease in visual acuity reduced to finger counting at 1 meter. Ophthalmologic examination revealed papilledema, premacular hemorrhage, Roth spots and several intraretinal hemorrhages in both eyes and the presence of a segmental vasculitis in the left eye. Under etiological assessement, a transthoracic echocardiography was performed retaining the diagnosis of infective endocarditis. Blood culture isolated viridans streptococci. The patient received appropriate systemic antibiotics. Two months later, the evolution was marked by the recovery of visual acuity to 10/10 and net regression both papilledema as hemorrhagic lesions. Discussion : Although rheumatic fever has become an exceptional condition in developed countries, it may still be a rheumatic valve that is grafted sepsis. In infective endocarditis, several ophthalmologic manifestations have been described in the literature. They result for most of infectious emboli in the retinal vessels and in some cases may reveal endocarditis. Conclusion : Besides vital prognosis engaged in bacterial endocarditis, visual functional prognosis may also be threatened by serious eye damage. Thus, an eye examination is essential in patients with infective endocarditis.