Vision In Patients Research Articles

The Reliability of PCL/Anti-VEGF Electrospun Scaffolds to Support Limbal Stem Cells for Corneal Repair.

Since only few reported studies propose anti-vascular endothelial growth factor (anti-VEGF) delivery through electrospun scaffolds, this study greatly contributes to the potential prevention of patient's vision loss, as it explores electrospun polycaprolactone (PCL) coated with anti-VEGF for the blockage of abnormal cornea vascularization. In terms of physicochemical properties, the biological component increased the PCL scaffold fiber diameter (by ~24%) and pore area (by ~82%), while ut slightly reduced its total porosity as the anti-VEGF solution filled the voids of the microfibrous structure. The addition of the anti-VEGF increased the scaffold stiffness almost three-fold at both strains of 5 and 10%, as well as its biodegradation rate (~36% after 60 days) with a sustained release profile after Day 4 of phosphate buffered saline incubation. In terms of scaffold application function, the PCL/Anti-VEGF scaffold proved to be more favorable for the adhesion of cultured limbal stem cells (LSCs); this was confirmed by the SEM images, where the cells showed flat and elongated conformations. Further support of the LSC growth and proliferation was confirmed by the identified p63 and CK3 markers after cell staining. These results demonstrate the advantageous effect of the surface-adsorbed anti-VEGF to stop vision loss and help damaged corneal tissue repair.

Corneal Collagen Cross-Linking for Late Onset Progressive Keratoconus in Iridocorneal Endothelial Syndrome.

The aim of this study was to report the first case of successful use of corneal collagen cross-linking (CXL) to halt the progression of keratoconus in a patient with concurrent iridocorneal endothelial (ICE) syndrome. A 30-year-old White man was referred to our subspecialty corneal clinic for further investigation of right corectopia. The patient was asymptomatic and was otherwise fit. Slit-lamp examination revealed a right oval-shaped pupil decentered superiorly, a transillumination defect at the 5-o'clock position, minimal gutta-like changes in the corneal endothelium, and few inferior peripheral anterior synechiae. Dilated fundoscopy was normal in both eyes, with healthy optic discs, maculae, and peripheral retinae. Specular microscopy and slit-lamp findings suggested ICE syndrome. Subsequent investigation with corneal tomography showed progressive signs of inferior corneal ectasia with steepening, and thinning in the right eye, consistent with keratoconus. The left eye was unremarkable. Epithelium-off accelerated corneal CXL was performed in the affected eye. Early post-CXL follow-up (1 week) was unremarkable, and further follow-ups were arranged at 3, 6, 12, and 24 months, respectively. In subsequent reviews, the patient's vision and corneal tomography findings were stable. We describe the first case of corneal CXL for progressive keratoconus with ICE syndrome. co-existing keratoconus and ICE syndrome can occur, and corneal cross-linking was used successfully in this case to halt keratoconus progression. However, further studies will need to establish the impact of epithelium-off corneal cross-linking, especially in more severely affected eyes.

Inadvertent Globe Penetration and Subretinal injection of Botulinum Toxin in an Oculocutaneous Albinism Patient.

To present a case of localized retinal detachment and mild vitreous hemorrhage in a patient with oculocutaneous albinism following accidental intraocular injection of botulinum toxin A. Botulinum toxin A injection were administered to a 5-year old oculocutaneous albinism patient with esotropia, and resulted in an ocular penetration. Dilated fundus examination indicated a nasal retinal tear causing a mild vitreous hemorrhage and a localized retinal detachment. No treatment was required for the retinal detachment and we observed the patient at regular intervals. On Day 1, the detachment resolved spontaneously without sequelae. On follow up, scarring at the lesion site was detected at one month after the incidence and the patient's vision was stable. In this instance, Observation was sufficient for our patient with complete resolution of retinal detachment and no long-term complication. Botulinum toxin A did not appear toxic to intraocular tissues. However, intramuscular botulinum toxin A injection should be administered carefully. Oculocutaneous albinism did not seem to affect the final outcome in our case.

The Environmental and Social Risk Factors for Myopia in Children and Adolescents in Bangladesh

Background: The seriousness of myopia is still underappreciated by the general population. One in five occurrences of blindness may be traced back to uncorrected refractive error (The discrepancy between the patient's vision at presentation and their best-corrected vision). Objective: In this study our main goal is to evaluate the environmental and social risk factors for myopia in children and adolescents in Bangladesh. Method: This prospective cohort research conducted at a major medical center to investigate prenatal through adult risk factors for poor health and noncommunicable illnesses in young people. The study began in July 2020, and 100 people have been asked to participate in yearly follow-ups for two years. The majority of the people living there are from the Dhaka metropolitan area. Schools, daycares, community clinics, general practices, public health agencies, and collaborative research projects are just few of the places where participants are sought for recruitment. Results: During the study, 60% were in 11-18 years age group, 55% were male and 35% were in middle income group. 10% myopia had 3-10 years age group and 21% myopia in 11-18 years age group. 80% patients had everyday outdoor frequency, followed by 50% had 1-2 hours outdoor frequency, 60% had everyday near work frequency. There was a significant associations of myopia with low outdoor activity frequency, high near work duration and low near work frequency. Outdoor activity duration was not significantly associated with myopia. Conclusion: The results of our study indicate that regular sun exposure and limiting the amount of time spent in constant close work may help prevent the development of eye diseases. Furthermore, our cohort found that children of higher socioeconomic status were less likely to be myopic. Strategy development for myopia prevention in children of all ages should be prioritized in light of the massive economic burden imposed by the condition and the apparent ............

Animal model of subretinal fibrosis without active choroidal neovascularization

Subretinal fibrosis can occur during neovascular age-related macular degeneration (nAMD) and consequently provokes progressing deterioration of AMD patient's vision. Intravitreal anti–vascular endothelial growth factor (VEGF) injections decrease choroidal neovascularization (CNV), however, subretinal fibrosis remains principally unaffected. So far, no successful treatment nor established animal model for subretinal fibrosis exists. In order to investigate the impact of anti-fibrotic compounds on solely fibrosis, we refined a time-dependent animal model of subretinal fibrosis without active choroidal neovascularization (CNV). To induce CNV-related fibrosis, wild-type (WT) mice underwent laser photocoagulation of the retina with rupture of Bruch's membrane. The lesions volume was assessed with optical coherence tomography (OCT). CNV (Isolectin B4) and fibrosis (type 1 collagen) were separately quantified with confocal microscopy of choroidal whole-mounts at every time point post laser induction (day 7–49). In addition, OCT, autofluorescence and fluorescence angiography were carried out at designated timepoints (day 7, 14, 21, 28, 35, 42, 49) to monitor CNV and fibrosis transformation over time. From 21 to 49 days post laser lesion leakage in the fluorescence angiography decreased. Correspondingly, Isolectin B4 decreased in lesions of choroidal flat mounts and type 1 collagen increased. Fibrosis markers, namely vimentin, fibronectin, alpha-smooth muscle actin (α-SMA) and type 1 collagen were detected at different timepoints of tissue repair in choroids and retinas post laser. These results prove that the late phase of the CNV-related fibrosis model enables screening of anti-fibrotic compounds to accelerate the therapeutic advancement for the prevention, reduction, or inhibition of subretinal fibrosis.

Macular deep capillary nonperfusion in idiopathic retinal vasculitis, aneurysm, and neuroretinitis syndrome

Here, we report a rare case of a 47-year-old man presenting with idiopathic retinal vasculitis, aneurysm, and neuroretinitis (IRVAN) syndrome combined with primary open-angle glaucoma (POAG). He was treated with retinal photocoagulation combined with intraocular pressure (IOP)-lowering therapy. At the 1-year follow-up, the patient's vision had not decreased and the IOP was well controlled. The abnormality of this case is the nonperfusion of macular deep capillary. Many studies support that POAG has no effects on the ischemia of deep capillary plexus. This case suggests that ischemia in the deep capillary plexus should be considered in IRVAN syndrome.

An Atypical Case of GFAP Astrocytopathy

Objective To describe a case of anti-GFAP astrocytopathy with atypical features. Background Glial fibrillary acidic protein (GFAP) astrocytopathy is a steroid-responsive autoimmune meningoencephalitis that is commonly characterized by preceding viral illness followed by encephalopathy and papillitis without significant effect on visual acuity. We describe an atypical case of GFAP astrocytopathy presenting with profound vision loss and intracranial hypertension. Design/Methods Case Report Results 31 yo male with a history of hypertension developed flu-like symptoms for one week. Subsequently, he experienced blurry vision and presented to the hospital. He was found to be hypertensive with acute kidney injury. He was treated for hypertensive urgency and discharged. However, patient's vision continued to deteriorate and he developed non-threatening visual hallucinations. He was readmitted to the hospital. His eye exam revealed bilateral loss of visual acuity, retinal hemorrhages and severe papilledema. His laboratory work-up was notable for LP findings of lymphocytic pleocytosis, elevated protein and opening pressure of 54. He was started on acetazolamide and transferred to tertiary medical center. There, he developed encephalopathy with psychosis. An extensive infectious/ autoimmune/malignancy workup was completed. This included three repeat LPs showing persistent intracranial hypertension, lymphocytic pleocytosis, high protein and oligoclonal bands. He underwent imaging with CT chest/abdomen/pelvis, MRV and MRI head/orbits, which showed no evidence of malignancy, patent vasculature and pachymeningeal enhancement, respectively. His work-up was notable for positive IgG GFAP in CSF leading to diagnosis of GFAP astrocytopathy. He was treated with pulse dose IV steroids followed by slow steroid taper and concurrent PLEX therapy. Due to severity of case, he was later started on cyclophosphamide. For papilledema, he was continued on acetazolamide and underwent bilateral optic nerve sheath fenestration. Overall, his encephalopathy resolved but vision remained poor. Conclusions This case illustrates an unique manifestation of GFAP astrocytopathy including rapid visual loss, persistent intracranial hypertension and absence of characteristic MRI findings.

Ocular Lesions in Brucella Infection: A Review of the Literature.

Ocular lesions due to Brucella infection are uncommon and easily overlooked in clinical management, but must be differentiated from non-infectious eye diseases and treated promptly to protect the patient's vision. We reviewed the relevant literature and identified 47 patients with ocular complications of Brucella infection. Among them, 28 showed ocular neuropathy, 15 presented with uveitis, and four patients displayed other ocular symptoms. Ocular symptoms accompanying Brucella infection require prompt diagnosis and treatment. The main methods of diagnosis are intraocular fluid tests and blood tests. Early diagnosis and treatment with suitable antibiotics are central to protecting the patient's vision. Notably, in terms of mechanism of injury, Brucella infection is chronic and cannot be eliminated by phagocytes, and can cause damage to the eye by inducing autoimmune reactions, antigen-antibody complex production, release of endogenous and exogenous toxins, and bacterial production of septic thrombi in the tissues. In this review, we summarize the ocular symptoms, diagnosis, treatment and prognosis of Brucella infection, and discuss the mechanisms of Brucella in ocular lesions, providing a reference for the diagnosis and treatment of Brucella ocular lesions.

Spotlight on Targeted Chemotherapy in Retinoblastoma: Safety, Efficacy, and Patient Outcomes.

As the most common primary intraocular malignancy of childhood, retinoblastoma (RB) has had a complex journey in its management, following a course from enucleation as the first life-saving treatment to numerous globe-salvaging therapies during the last century. Currently, this potentially lethal disease has achieved high survival rates owing to multidisciplinary management and the introduction of neoadjuvant and multimodal chemotherapy. Therefore, the goal of treatment is shifting toward conserving the globe and vision as much as possible. Up until recently, many advanced cases of RB were enucleated primarily; however, targeted chemotherapy via the ophthalmic artery and management of intraocular seeding by local administration of chemotherapeutic agents have revolutionized the globe-conserving therapies. The added benefit of avoiding systemic complications of cytotoxic drugs resulted in these methods gaining popularity, and they are becoming a main part of care in many referral centers. Initially, there were some safety concerns regarding these approaches; however, increasing experience has shown that these modalities are relatively safe procedures and many complications can be averted by changing the choice of the drug and using some prophylactic measures. It is hoped that, in the near future, with advances in early diagnosis and patient-targeted molecular therapies, as well as gene-editing techniques, the patient's vision can be saved even in advanced RB.

Retinal arterial macroaneurysm rupture by Valsalva maneuver: a case report and literature review

BackgroundRetinal artery macroaneurysms (RAMs) are focal dilations of the large retinal arteries. Most RAMs are asymptomatic, however, when hemorrhage or exudation caused by a RAM involves the macula, patients can experience marked vision loss. This article reported a rare case of a ruptured RAM due to the Valsalva maneuver in an elderly female with constipation and offered a review of the relevant literature.Case presentationA 78-year-old woman with several risk factors presented with multi-level retinal hemorrhages following a Valsalva maneuver during constipation. Due to the poor coagulation and heavy bleeding in this case, the blood broke through the internal limiting membrane and drained "on its own" into the vitreous cavity. First, we observed the patient and controlled for her risk factors. After the blood was completely drained into the vitreous cavity, the root cause of the bleeding was found to be a RAM rupture. After laser photocoagulation, the patient's vision recovered significantly and remained stable for a long time despite the presence of an epiretinal membrane and a lamellar macular hole.ConclusionsThis is the first reported case of a RAM rupture by Valsalva maneuver during constipation. For multi-level hemorrhages caused by RAM, measures should be taken to drain out the sub-internal limiting membrane hemorrhage and simultaneously control for risk factors. After the RAM is exposed, laser photocoagulation can be performed.

Клинический случай акантамёбного кератита. Трудности диагностики и лечения

Acanthamoebic keratitis (AK) is a serious disease caused by the simplest acanthamoeba. Often it is associated with the wearing of contact lenses (CL) (80 –90 %). The article describes a clinical case of AK of both eyes associated with wearing soft contact lenses (MCL). The diagnosis was based on the patient's complaints, medical history and clinical presentation. Treatment was performed both topically and systemically and long-term follow-up on an outpatient basis. As a result, the active inflammatory process was stopped. Subsequently, in a calm period, the patient underwent through keratoplasty, reconstruction of the anterior chamber of the right eye. At the moment, the patient's vision allows him to lead a full life without any restrictions. Conclusions were drawn from this example: 1) determining the etiology of keratitis is extremely difficult; 2) CL users are obliged to know the risks and rules of wearing CL; 3) AK treatment is a long, difficult, not always successful and experimental process. The issue of patient routing and timely operative treatment under the compulsory health insurance system remains relevant. Keywords: аcantamoeba, acanthamoebic keratitis, clinical case, contact lenses, drug treatment

ODP288 A Cautionary Tale of Two Endocrine Emergencies- A Patient with Pituitary Macroadenoma Presenting with Acute Adrenal Crisis Leading to Pituitary Apoplexy

Abstract A 56 year old male with history significant for myasthenia gravis, non-functional pituitary macroadenoma and age related macular degeneration (ARMD), who presented to the hospital with 3 days of diplopia, nausea, vomiting, generalized weakness, and bitemporal headaches. Two months prior to presentation, he was diagnosed with an idiopathic disseminated rash for which he was treated with high dose steroids. Steroids were tapered rapidly and stopped abruptly 4 days ago. Initial presentation was significant for hypotension with BP of 95/64, hyponatremia [sodium 127(136 - 145 mmol/L)], chloride was 90 (98 - 107 mmol/L), potassium 5.9 (3.4 - 5.3 mmol/L) consistent with acute adrenal crisis. He was immediately initiated on high dose Solu-Cortef and intravenous fluids. Of historical significance was new visual field deficit which had occurred in the background of his existing ARMD. This raised the suspicion for pituitary apoplexy. MRI pituitary showed enlarging pituitary adenoma (2.1×2. 0×2.6 cm from 1.6×1.6×2.3 cm 5 months prior) with necrotic changes and internal signal complexity. Ophthalmology was consulted stat and on confirmation of new right optic neuropathy, urgent surgical decompression was performed via transnasal endoscopic resection of pituitary tumor by neurosurgical and ENT team. Further lab testing revealed secondary adrenal insufficiency and pan hypopituitarism. Patient's vision recovered remarkably well post operatively and he was initiated on thyroid hormone supplementation in addition to continuing steroids. He was discharged with recommendations to follow up with endocrinology outpatient for further management. Conclusion Pituitary apoplexy although well known can easily be missed clinically without a high degree of suspicion. While our patient presented with acute adrenal crisis leading to some of the presenting complaints, his new visual field deficits were unaccounted for. This case highlights the importance of a through history and examination to delineate between acute and chronic visual field symptoms especially in the background of pre-existing retinal diseases. Secondly, although the patient's adrenal insufficiency could be due to apoplexy, we hypothesize that it is more likely that it could have resulted due to abrupt discontinuation of high dose steroids leading to adrenal crisis. The fluctuation in BP in turn could have triggered an apoplectic event in an otherwise stable macroadenoma leading to two independent but interrelated endocrine emergencies. Presentation: No date and time listed

Advances in the treatment of intraocular malignancies: A literature review.

Intraocular malignant tumors including primary and metastatic tumors, are mainly found in Retina and uvea, and very few cases originate from the sclera and optic nerve. Intraocular tumors can endanger the patient's vision and even life, and proper treatment is vital. There have been several traditional treatments for intraocular tumors, such as radiotherapy, chemotherapy and surgery. In recent years, new methods have been developed in clinical applications including anti-VEGF and gene therapy. This paper aims to provide a timely review about recent progress in the treatment of intraocular malignant tumor.

Effect of anatomical differences and intraocular lens design on negative dysphotopsia.

To assess the effect of ocular anatomy and intraocular lens (IOL) design on negative dysphotopsia (ND). Department of Ophthalmology, Leiden University Medical Center, Leiden, the Netherlands. Ray-tracing study based on clinical data. Ray-tracing simulations were performed to assess the effect of anatomical differences and differences in IOL design on the peripheral retinal illumination. To that end, eye models that incorporate clinically measured anatomical differences between eyes of patients with ND and eyes of pseudophakic controls were created. The anatomical differences included pupil size, pupil centration, and iris tilt. The simulations were performed with different IOL designs, including a simple biconvex IOL design and a more complex clinical IOL design with a convex-concave anterior surface. Both IOL designs were analyzed using a clear edge and a frosted edge. As ND is generally considered to be caused by a discontinuity in peripheral retinal illumination, this illumination profile was determined for each eye model and the severity of the discontinuity was compared between eye models. The peripheral retinal illumination consistently showed a more severe discontinuity in illumination with ND-specific anatomy. This difference was the least pronounced, 8%, with the frosted edge clinical IOL and the most pronounced, 18%, with the clear edge biconvex IOL. These results show that small differences in the ocular anatomy or IOL design affect the peripheral retinal illumination. Therewith, they can increase the severity of ND by up to 18%.

Aqueous Humor Factors' Predictive Effects in Treating Refractor Macular Edema: An Overview.

The refractory macular edema (RME) seriously affects the patient's vision due to its repetition and ineffective drug response. RME is mainly related to the inflammatory pathway and angiogenesis pathway. At present, microglia activation and angiogenesis have also been widely focused on. With the promotion of the concept of precision diagnosis and treatment, intraocular fluid is becoming a popular evidence-based method. The detection and evaluation of aqueous humor factors can provide more accurate evidences and guidance for the treatment of RME. The purpose of this article is to review the treatment prediction and assessment progress of aqueous humor cytokines for the RME, giving evidence to provide a basis for expanding the diagnosis and treatment ideas of RME and guiding the development of personalized medical treatment.

Severe Macular Edema after Traumatic Head Injury: A Case of Whiplash Maculopathy.

Whiplash or "traumatic" maculopathy is associated with retinal concussion, typically following the rapid acceleration/deceleration experienced in motor vehicle collisions. It has rarely been discussed in the literature, likely given the spontaneous and relatively rapid nature with which the acute macular edema resolves. A focused clinical history around the trauma, as well as characteristics signs and structural features on retinal imaging, help to distinguish this condition from other sequelae of concussive retinal injury. We report a case of whiplash maculopathy following a blunt injury to the head, which presented with unilateral and substantial macular edema in the left eye. Case report. A 38 year old male presented with complaint of a central scotoma in his left eye following a blunt trauma to his head. Comprehensive ophthalmological evaluation and retinal imaging with optical coherence tomography (OCT) confirmed whiplash maculopathy, with acute macular edema in his left eye. Management with observation and close follow-up showed rapid improvement in his visual symptoms over the course of days, and improvements in the severity of macular edema. One month following his injury, macular edema had resolved with only mild irregularities, the patient's vision had improved and he was asymptomatic. When observing patients with significant macular edema following concussive head injury, whiplash maculopathy should be considered, regardless of the history of motor vehicle collision. The condition can present with significant asymmetry of disease. The diagnosis generally carries a good prognosis for vision; however, there are cases of persistent central visual disturbances.

Clinical Characteristics, Treatment, and Visual Prognosis in Pediatric Endophthalmitis: A 232-Case Retrospective Study.

In infective endophthalmitis, once the patient's vision is seriously damaged, the damage to children's vision is particularly serious. The main purpose of this study is to investigate the etiology, epidemiology, treatment, and visual prognosis of children's endophthalmitis and to conduct an in-depth analysis. Study Design. This study collected case data from the Beijing Tongren Hospital Capital Medical University in the period from January 1, 2002 to January 1, 2018. The basic conditions for inclusion in the collection range were patients who were less than or equal to 14 years old and had a history of infectious endophthalmitis. A retrospective study and analysis of etiology, epidemiology, treatment, and visual prognosis were performed. Kappa and Chi square test were used for statistical analysis. A total of 232 cases were collected, with an average age of 6.33 ± 2.89 years (range 8months to 14 years). The most common etiologies were ocular trauma (93.5%) and previous ocular surgery (5.2%). Overall, 81 samples were sent to the microbiology department for direct smear and culture, from which 21 organisms were isolated. 28 cases (39.5%) were culture-positive. The most organism was Gram-positive organisms. In treatment, the proportion of PPV use combined with silicone oil filling had increased gradually in three phases, while the other treatments were almost decreased or nearly similar. The final visual result is 22 (9.5) in 20/200 or better, 65 (28.0) in CF-20/200, 38 (16.4) in hand move (HM), 27 (11.6) in light perception (LP), 21 (9.1) in no light perception (NLP), and 59 (25.4) did not match (NM). Penetrating ocular trauma is the most common cause of infectious endophthalmitis in children. The detection rate of microorganisms is low and helpless for the treatment. In this study, it was found that despite the aggressive treatments such as antibacterial and vitrectomy, the ultimate improvement in vision was highly undesirable.

Dynamic Upper Eyelid Reconstruction for Total Periorbital Soft Tissue Loss.

Total eyelid defect comprises full-thickness loss of both upper and lower eyelids in a patient. It is a rare and devastating condition with serious implications related to vision, which mandates early and functional reconstruction when associated with intact globe. The primary goal is to give a stable coverage for orbital protection but at the same time provide a functional reconstruction of the defect, to allow for adequate mobility of the eyelids so that the patient's vision is restored to normal with minimal disability. When the defect is massive, and in the absence of loco-regional flaps, microvascular tissue transfer is needed. In this report we describe a radial-artery-based microvascular tissue transfer with a unique innovation utilizing the contralateral frontalis muscle to reconstruct a case of unilateral total upper and lower eyelid loss.

Cutaneous Vascular Compromise and Resolution of Skin Barrier Breakdown After Dermal Filler Occlusion-Implementation of Evidence-Based Recommendations Into Real-World Clinical Practice.

Vascular occlusions that threaten skin integrity, although not an emergency like those that threaten a patient's vision, is an urgent situation. Accurately interpreting physical examination findings is paramount. The use of high-dose, pulsed hyaluronidase is the mainstay of therapy; however, adjunctive measures that may optimize clearance of an occlusion and/or skin barrier repair such as the use of image guidance and hyperbaric oxygen should be considered. To provide a review of the literature on the treatment of vascular occlusions threatening skin barrier integrity and develop a step-wise treatment guide. The authors searched PubMed for peer-reviewed studies, consensus statements, case series, and case reports using a variety of keywords. Twenty-six articles focusing on vascular occlusions threatening the skin barrier were reviewed. The authors collectively agreed on treatments to reverse vascular occlusions and restore the skin barrier. The importance of high-dose, pulsed hyaluronidase was clear. Therapies that lacked evidence such as sodium thiosulfate were also revealed. A vascular occlusion that threatens skin integrity is an urgent matter which requires accurate interpretation of physical examination findings that will help guide intervention. High-dose, pulsed hyaluronidase along with adjunctive measures performed in a step-wise manner is key to an optimal outcome.

Retinitis due to Rickettsia infection

A 67-year-old woman with type 2 diabetes presented to our hospital with decreased left vision for 7 days. On examination, right visual acuity was 20/30, and left visual acuity was 20/50. Intraocular pressures were both normal. Anterior chambers were deep and uninflamed, with bilateral nuclear sclerotic cataracts. There was mild left vitritis, but none in the right eye. Right fundoscopy was normal. Left fundoscopy showed one-disc diameter of unifocal retinitis along the superior vascular arcade (figure A). Left fluorescein angiography revealed late staining in the area of retinitis. The patient was treated presumptively with anti-toxoplasmosis and anti-herpes therapy (oral pyrimethamine [100 mg for the first day then 50 mg daily] and oral sulfadiazine [1 g three times daily] for toxoplasmosis, and intravenous aciclovir [800 mg three times daily] for herpetic retinitis), while awaiting laboratory results. PCR testing of anterior chamber taps were negative for Herpes simplex virus and toxoplasmosis. Negative Treponema pallidum hemagglutination and venereal disease research laboratory test excluded syphilis. Negative QuantiFERON-TB Gold test and tuberculin skin test were negative, and eliminated tuberculosis as a possible cause. Serum angiotensin converting enzyme and lysozyme were normal, which made sarcoidosis an unlikely explanation for the clinical findings. The patient's vision worsened to 20/200 in the left eye. Fundoscopy showed ongoing retinitis with a new retinal haemorrhage and serous macular detachment. She subsequently disclosed having episodes of malaise, headache, myalgia, skin rash (figure B), and fever (maximum 39·5°C; unresponsive to amoxicillin 500 mg three times a day), following travel to rural Algeria. Serology for Rickettsia conorii showed an elevated IgG titer of 1024 g/L, but was negative for IgM. Anterior tap PCR and cutaneous biopsy were negative for Rickettsia. Fundoscopy improved markedly after 7 days of treatment with doxycycline (200 mg daily). After 2 months, visual acuity was 20/20 and the retinitis resolved fully. This case illustrates the importance of careful history taking, and maintaining an index of suspicion for Rickettsia in patients who have travelled to an endemic area and present with fever, skin rash, and retinitis.