Retinal Whitening Research Articles

Cytomegalovirus chronic retinal necrosis with ganciclovir resistance: a case report.

Cytomegalovirus (CMV) chronic retinal necrosis (CRN) is a rare viral retinal infection that occurs in mildly immunocompromised people. It shares some features with both acute retinal necrosis and CMV retinitis. It is typically treated with combination intravitreal and systemic ganciclovir. We discuss the management of a case of CMV CRN with ganciclovir resistance. An 80-year-old female presented with one month of blurry vision in the left eye. She was being treated with abatacept, methotrexate, and prednisone for rheumatoid arthritis. Examination revealed anterior chamber and vitreous cell along with peripheral retinal whitening. Fluorescein angiogram showed diffuse retinal non-perfusion. Aqueous fluid PCR testing returned positive for CMV. The retinitis was initially controlled with oral and intravitreal ganciclovir, but then recurred and progressed despite these therapies. Ganciclovir resistance was suspected and the patient was switched to intravitreal foscarnet injections, along with oral letermovir and leflunomide, which lead to resolution of the retinitis. The patient has now continued with letermovir and leflunomide for approximately 2.5 years without reactivation of the retinitis or need for further intravitreal anti-viral injections and with adequate control of her rheumatoid arthritis. The incidence of CMV CRN may increase in the future as the use of non-cytotoxic immunosuppressive therapies that result in relatively mild immunosuppression also increases. Treatment with ganciclovir is effective but frequently leads to resistance, as in our case. In this situation, combination therapy with letermovir and leflunomide, particularly in the setting of rheumatoid arthritis where leflunomide can also have an anti-inflammatory effect, can be considered.

Spectrum of retinal microvascular ischemia in patients with COVID-19 based on multimodal imaging

PurposeTo describe and evaluate the multimodal imaging findings in retinal microvascular ischemia associated with COVID-19 infection. MethodsPatients with COVID-19 associated retinal microvascular ischemia and visiting the outpatient Department of Ophthalmology, Shanghai General Hospital from December 2022, to February 2023, were documented and their multimodal images were retrospectively reviewed. Retinal microvascular ischemia was defined as the presence of isolated or multiple focal retinal whitening(s) on color fundus images. Patients with retinal vessel occlusion or retinopathies secondary to systematic disorders diagnosed before infection were excluded. ResultsA total of 32 eyes from 21 patients were included, 24 (75.00 %) eyes with multiple retinal whitenings, while 8 (25.00 %) eyes with isolated lesions. When divided by the types of ischemia, 9 (28.13 %) eyes had only inner retinal involvement (known as cotton wool spot, CWS), 4 (12.50 %) eyes had only middle retinal involvement (known as paracentral acute middle maculopathy, PAMM), and 19 (59.38 %) eyes had both. In addition, 4 (12.50 %) eyes had coincident angular sign of Henle fiber layer hyperreflectivity (ASHH). Patients with hypertension tended to have multiple lesions rather than isolated lesion of retinal microvascular ischemia (P = 0.008). Transient uncontrolled high blood pressure or acute kidney injury was simultaneously detected in some cases. ConclusionsOcular manifestation of COVID-19 associated microvascular ischemia can be variable, including CWS, PAMM and ASHH. Multimodal fundus imaging technologies are useful tools to reveal involved retinal layers, extent, and severity. Moreover, ocular manifestations may serve as a window of COVID-19 related microcirculation in other systems throughout the body.

Central Retinal Artery Occlusion Following Intralesional Triamcinolone Injection for IgG4-related Orbital Disease.

The risk of blindness associated with periocular and facial injections is well documented. Previous cases describing vision loss following a recent periocular or facial injection have emphasized the importance of facial "danger zones." To date, the literature suggests that nearly half of all cases of central retinal artery occlusion in the setting of a recent periocular or facial injection involve an injection in or around the nose. Here, the authors report the second known case of central retinal artery occlusion following a triamcinolone injection to the lacrimal gland. A 30-year-old female with a diagnosis of IgG4-related disease underwent lacrimal gland debulking with an intralesional steroid injection. She noted OD vision loss immediately after surgery, with posterior segment examination demonstrating retinal whitening with a cherry-red spot and intra-arterial yellow-white plaques. This case serves as a reminder to clinicians regarding the risk of iatrogenic embolism following triamcinolone injections around the face with special attention drawn to the lacrimal gland.

Differences in macular thickness associated with peripheral retinal vessel whitening in diabetic patients

This study aimed to determine the difference in macular thickness among patients with diabetes mellitus (DM) with and without peripheral retinal vessel whitening (PRVW). PRVW was defined by retinal vessel whitening outside the standard seven ETDRS fields. Subjects were divided into DM with PRVW, DM without PRVW, and normal age-matched controls. Optical coherence tomography scans were divided into total, inner, and outer retinal layer thicknesses and were compared in the macula's central, inner, and outer rings. Forty-seven eyes were included: DM with PRVW = 15, DM without PRVW = 16, and Controls = 16. Overall, the mean retinal thickness in patients with DM with PRVW was lower than in patients with DM without PRVW and controls. In the inner macula, DM patients with PRVW showed a significantly lower mean inner superior, nasal, inferior, and temporal macula compared to DM patients without PRVW (p = 0.014, 0.008, 0.005, < 0.001, respectively). DM patients with PRVW also showed a significantly lower mean outer superior, nasal, inferior, and temporal macula than controls (p = 0.005, 0.005, 0.016, 0.025, respectively). This study demonstrates that PRVW in DM patients may be associated with global structural changes to the macular region, promoting a decrease in inner and outer retinal thickness. Further studies should investigate the functional correlation with PRVW in DM patients in order to better understand its potential implications in diabetic patients.

Eye stroke protocol in in the emergency department

BackgroundVisual outcomes of acute central and branch retinal artery occlusions (CRAO/BRAO) are poor and acute treatment options are limited by delayed diagnosis. In the hyper-acute setting, the ocular fundus may appear “normal”, making recognition challenging, but is facilitated by retinal optical coherence tomography (OCT), which is seldom available in emergency departments (ED). We evaluated the use of non-mydriatic ocular fundus photographs (NMFP) combined with OCT to facilitate ultra-rapid remote diagnosis and stroke alert for patients with acute vision loss presenting to the ED. MethodsProspective evaluation of all CRAO/BRAO between 06/06/2023-06/06/2024 who had NMFP-OCT in our general ED affiliated with a stroke center. ResultsOver 1 year, 22 patients were diagnosed with CRAO, 4 with BRAO. Five patients presented within 4.5 hours of vision loss onset, 6 within 4.5 to ≤12 hours and 15 within >12 to 24 hours. On average, NMFP-OCT was performed within 141 minutes of presentation to the ED (range 27- 422 minutes). Diagnosis of acute RAO was made remotely with NMFP-OCT within 4.5 hours in 4 patients, 2 of whom received intravenous thrombolysis. Of the 9 patients with NMFP-OCT within 12 hours of symptom onset, 5 patients had subtle retinal whitening on color fundus photograph, but all had OCT inner retinal hyper-reflectivity/edema. ConclusionImplementation of NMFP-OCT in a general ED enables rapid remote diagnosis of CRAO/BRAO and facilitates initiation of an eye stroke protocol in acute patients. OCT complements color fundus photography and provides greater diagnostic accuracy in hyperacute cases with near-normal appearing ocular fundi.

Combined Central Retinal Artery and Vein Occlusion-like Manifestations with Aplastic Anemia: Unveiling Pathophysiological Insights

Purpose: To report the association of a combined central artery and vein occlusion (CCRAVO)-like pattern with aplastic anemia and discuss the pathophysiology associated with ophthalmologic examinations. Methods: We report a female patient with aplastic anemia who presented with retinal hemorrhage, blurred optic disc margins, retinal whitening, peripapillary subretinal fluid, and venous engorgement. The authors described the evolution of ophthalmologic lesions in correlation with improvements in systemic conditions. Results: We discuss and correlate the ophthalmological findings of this patient (optic disc edema, vascular engorgement, subretinal fluid, among others) with the pathophysiology of Aplastic Anemia based on current literature. Conclusion: These findings provide a better understanding of the pathophysiology of this rare disease. In certain cases, ophthalmologic symptoms can be the first presentation, underscoring the importance of reporting ocular findings for the recognition of this disease, which entails significant systemic involvement.

Central retinal artery occlusion after intravitreal brolucizumab injection for treatment-naïve neovascular age-related macular degeneration; a case report

BackgroundTo report a case of central retinal artery occlusion (CRAO) after intravitreal injection of brolucizumab for a treatment-naïve neovascular age-related macular degeneration (nAMD) patient without comorbid cardiovascular disease history.Case presentationA 79-year-old Asian male without a cardiovascular disease history such as diabetes or hypertension underwent three times of monthly consecutive intravitreal brolucizumab injections for treatment of progressed nAMD in his left eye. Two days after the third injection, the patient presented with acute painless visual loss. Typical retinal whitening with a cherry red spot was observed on the fundus photograph, and retinal swelling with hyper-reflectivity was also identified on the optical coherence tomography (OCT) scan. On the fundus fluorescein angiography, arm-to-retina time and arteriovenous transit time were remarkedly delayed, but clinical findings suggesting an intraocular inflammation (IOI) were not observed. Therefore, CRAO was diagnosed, and anterior chamber paracentesis was administrated immediately. However, there had been no improvement in visual acuity during the follow-up period of three months, despite prolonged oral steroid and anti-platelet agent medication.ConclusionsIn rare cases, patients without cardiovascular comorbidities can develop CRAO after intravitreal brolucizumab injection without gross evidence of IOI. Therefore, CRAO should always be in consideration and careful observation is required after intravitreal brolucizumab injection for nAMD patients with old age, even if the patient does not have any other cardiovascular disease history.

OUTCOMES OF INFECTIOUS PANUVEITIS ASSOCIATED WITH SIMULTANEOUS MULTI-POSITIVE OCULAR FLUID POLYMERASE CHAIN REACTION.

To evaluate features of infectious panuveitis associated with multiple pathogens detected by ocular fluid sampling. Single-center, retrospective, consecutive case series of patients with aqueous/vitreous polymerase chain reaction testing with >1 positive result in a single sample from 2001 to 2021. Of 1,588 polymerase chain reaction samples, 28 (1.76%) were positive for two pathogens. Most common pathogens were cytomegalovirus (n = 16, 57.1%) and Epstein-Barr virus (n = 13, 46.4%), followed by varicella zoster virus (n = 8, 28.6%), Toxoplasma gondii (n = 6, 21.4%), herpes simplex virus 2 (n = 6, 21.4%), herpes simplex virus 1 (n = 6, 21.4%), and Toxocara (n = 1, 3.6%). Mean initial and final visual acuity (logarithm of the minimum angle of resolution) were 1.3 ± 0.9 (Snellen ∼20/400) and 1.3 ± 1.1 (Snellen ∼20/400), respectively. Cytomegalovirus-positive eyes (n = 16, 61.5%) had a mean final visual acuity of 0.94 ± 1.1 (Snellen ∼20/175), whereas cytomegalovirus-negative eyes (n = 10, 38%) had a final visual acuity of 1.82 ± 1.0 (Snellen ∼20/1,320) ( P < 0.05). Main clinical features included intraocular inflammation (100%), retinal whitening (84.6%), immunosuppression (65.4%), retinal hemorrhage (38.5%), and retinal detachment (34.6%). Cytomegalovirus or Epstein-Barr virus were common unique pathogens identified in multi-PCR-positive samples. Most patients with co-infection were immunosuppressed with a high rate of retinal detachment and poor final visual acuity. Cytomegalovirus-positive eyes had better visual outcomes compared with cytomegalovirus-negative eyes.

The great escape- preserved cilioretinal artery with transient central retinal artery occlusion following snake bite

A 24-year female sustained a snake bite on the lateral side of the left ankle, followed by localized pain and blurring of vision in right eye. Her best corrected visual acuity was 20/20 in the both eyes. Relative afferent pupillary defect was noted in right eye. Fundus examination of right eye showed clear media, normal optic disc and retinal whitening with sparing of small area on macula, temporal to disc with small cilioretinal artery, suggestive of central retinal artery occlusion (CRAO) with presence of cilioretinal artery sparing. Ophthalmic manifestations following a snake bite are uncommon and can arise through diverse mechanism such as hematotoxicity from the snake bite, resulting in CRAO. Although CRAO following snake bite has been reported, we present a very rare case of snake bite induced transient CRAO with presence of spared cilioretinal artery.

Internal limiting membrane separation and posterior vitreous hyperreflective dots: novel OCT findings in Purtscher-like retinopathy

BackgroundPurtscher or Purtscher-like retinopathy is diagnosed by retinal hemorrhages and areas of retinal whitening on fundus examination, as well as a reduction in visual acuity due to microvascular occlusion of the precapillary retinal arterioles. We describe novel optical coherence tomography (OCT) findings of internal limiting membrane (ILM) separation and posterior hyperreflective dots in a case of Purtscher-like retinopathy in this report.MethodsA 33-year-old man with acute pancreatitis and alcohol-induced liver disease presented to the retina department complaining of four days of painless vision loss in both eyes. Both eyes’ anterior segment examination and intraocular pressure were normal. Dilated fundus examination of both eyes revealed confluent areas of retinal whitening, hemorrhages, and cotton-wool spots over the posterior pole, indicating Purtscher-like retinopathy. OCT scans through the macula revealed dense inner retinal reflectivity, thickening, and loss of retinal layer stratification, as well as outer retinal layer shadowing and islands of ILM separation, posterior vitreous hyperreflective dots, and minimal subfoveal fluid, all of which corresponded to areas of retinal whitening on fundus photographs. The patient was given a brief course of systemic steroids.ResultsOn the tenth day after the presentation, visual acuity in the right eye had improved to 6/18 and finger counting at 1 m in the left eye. The retinal findings had faded. The retina had reverted to its normal thickness on the OCT scans, with minimal hyperreflectivity remaining. The ILM separation and posterior vitreous hyperreflective dots were no longer present.ConclusionFollowing Purtscher or Purtscher-like retinopathy, we believe inflammation could play a major role in the development of these two novel OCT findings. This case offers an additional perspective on the underlying mechanisms responsible for the retinal manifestations observed in Purtscher or Purtscher-like retinopathy.

When Retinal Vasculitis Wears a Mask: Unveiling Retinal Vasculitis Presented as Branch Retinal Vein Occlusion in a Young Male Patient

Introduction : Retinal vasculitis can present with a range of clinical features. Correct diagnosis and prompt treatment are essential to prevent permanent visual loss. We describe a case of retinal vasculitis with branch retinal vein occlusion (BRVO) as initial diagnosis, which is a rare manifestation in a young individual without any vascular risk factors.&#x0D; Case Illustration : A 24-year-old male was referred to our center with a sudden onset of blurry vision of his left eye. He was previously diagnosed with BRVO. The patient denied having any chronic diseases, fever, or sore throat. Visual acuity was 6/18 on the left eye and 6/6 on the right eye, respectively. The anterior segment showed no abnormalities. However, fundus examination revealed prominent retinal sheathing, retinal whitening at the inferior quadrant, and macular star. Systemic diseases, such as Bechet disease, sarcoidosis, and systemic lupus erythematosus were excluded by ancillary tests. One month after the initial examination, the patient reported worsening of vision. Funduscopic examination revealed preretinal hemorrhages and macular star. The patient then received intravitreal injection of anti-vascular endothelial growth factor (VEGF), which helped to resolve the hemorrhage and improve vision.&#x0D; Discussion : Further investigations, such as fundus fluorescein angiogram, may aid in the diagnosis and management of this condition. Anti-VEGF therapy may be a useful treatment option for retinal vasculitis-associated hemorrhages.&#x0D; Conclusion : Our case highlights the importance of considering retinal vasculitis as a differential diagnosis in young patients presenting with BRVO, even in the absence of traditional risk factors.

Diagnosis of primary vitreoretinal lymphoma masquerading infectious retinitis by retinal biopsy

PurposeTo report a case of primary vitreoretinal lymphoma masquerading as infectious retinitis that was diagnosed via a retinal biopsy.ObservationsA 72-year-old female patient was referred to our ophthalmology clinic for evaluation of retinitis and vasculitis in the right eye (OD). On examination, best-corrected visual acuities (BCVAs) were hand motions OD and 20/20 in the left eye (OS). Fundus examination revealed optic disc edema and diffuse retinal whitening superior to the superotemporal arcade OD. Given the high suspicion of infectious retinitis, the patient was treated with intravitreal foscarnet, systemic acyclovir, and oral prednisone and underwent a comprehensive uveitis workup, which was unremarkable for viral and autoimmune entities. Given the patient’s history of diffuse large B cell lymphoma with cutaneous involvement, vitreoretinal lymphoma was suspected, prompting pars plana vitrectomy with a retinal biopsy. Biopsy and immunohistochemistry results were consistent with B-cell lymphoma, and the patient was treated with high-dose methotrexate and rituximab. At 5-month follow-up, BCVAs were hand motions OD and 20/30 OS, and fundus examination demonstrated disc edema with resolution of retinal whitening OD. She responded well to the treatment with regression of vitreoretinal lymphoma on examination and is being monitored closely for lymphoma recurrence.Conclusions and importanceAlthough uncommon, patients with vitreoretinal lymphoma may masquerade as infectious retinitis, and vitreoretinal lymphoma should be suspected when refractory to antiviral therapy and in the setting of a negative workup for viral etiologies. Vitrectomy with retinal biopsy may be considered to aid the diagnosis of vitreoretinal lymphoma although careful consideration of the risks and benefits is warranted.

Pattern of Clinical and Laboratory Presentation of Cerebral Malaria among Children in Nigeria.

Cerebral malaria (CM) is the most lethal form of severe malaria with high case fatality rates. Overtime, there is an inherent risk in changing pattern of presentation of CM which, if the diagnosis is missed due to these changing factors, may portend a poor outcome. Variations in the pattern of clinic-laboratory presentations also make generalization difficult. This study was, therefore, set out to report the pattern of clinical and laboratory presentation of CM. This was a cross-sectional study among children aged 6 months to 14 years admitted with a diagnosis of CM as defined by the World Health Organization criteria. A pretested pro forma was filled, and detailed neurological examination and laboratory (biochemical, microbiology, and hematology) investigations were done. P <5% was considered statistically significant. Sixty-four children were recruited with a mean age of 34.9 ± 24.9 months and a male-to-female ratio of 1.9:1. There were 87.5% of under-five children. Fever (96.9%) was the major presenting feature closely followed by convulsions (92.2%). Convulsions were mainly generalized (94.9%) and multiple (76.5%). Profound coma (Blantyre coma score of 0) was present in 12.5% of cases, and the leading features on examination were fever (84.4%) and pallor (75.0%). Retinal vessel whitening (48.4%) was the most common funduscopic abnormality. Metabolic acidosis (47.9%), severe anemia (14.1%), hyperglycemia (17.2%), and hypoglycemia (7.8%) were seen among the children. Few (1.6%) had hyperparasitemia and bacteremia (3.2%). Early recognition of the clinical presentation and prompt management may improve the outcome of cerebral malaria.

Purtscher-like retinopathy and paracentral acute middle maculopathy following breast filler injection

BackgroundTo report a rare case of pulmonary and ocular complications with visual loss due to bilateral Purtscher-like retinopathy and paracentral acute middle maculopathy (PAMM) following a hyaluronic acid (HA) filler injection to the breast. Systemic and visual recovery was attained following corticosteroid therapy.Case presentationA 27-year-old lady presented with painless blurring of vision in both eyes for 2 weeks following hyaluronic acid breast filler injections by a non-medical practitioner. She was initially admitted to the medical ward for diffuse alveolar haemorrhage and altered sensorium. The presenting visual acuity was counting fingers in both eyes. Bilateral dilated fundus examination showed hyperaemic discs, concentric rim of retinal whitening around macula with patches of polygonal-shaped retinal whitening, generalised cotton-wool spots, tortuous veins, and flame-shaped haemorrhages. Spectral-domain optical coherence tomography (SD-OCT) macula revealed hyper-reflective bands at the inner nuclear layer (INL). Fluorescein angiography demonstrated hot discs, delayed arm-to-retina time, arterial filling, and arterio-venous transit time with staining of the vessels at the posterior pole. She was managed with a tapering dose of systemic corticosteroids. The visual acuity improved to 6/12 over 8 weeks with significant anatomical and functional improvement. Dilated fundus examination showed resolution of initial funduscopy findings. The hyper-reflective bands on the OCT had resolved with subsequent thinning of the INL and disorganisation of retinal inner layers.ConclusionFiller injections are in increasing demand and are frequently being performed by non-medical practitioners. Visual loss from non-facial HA fillers is rare. Inadvertent entry of HA into a blood vessel may potentially cause systemic and sight-threatening ocular complications. Good anatomical knowledge and proper injection technique are vital in preventing this unfortunate sequela. There are limited reports on successful visual recovery following various treatment approaches and we hope this case provides valuable insights.

Central retinal artery occlusion without cherry-red spots

BackgroundCherry-red spots are a very important sign for the clinical diagnosis of central retinal artery occlusion (CRAO). We retrospectively summarized the clinical manifestations of CRAO and analysed the causes and characteristics of CRAO without cherry-red spots. In this study, we explored a diagnostic method for CRAO without cherry red spots.MethodsSeventy patients (70 eyes) with CRAO were examined retrospectively. Corrected distance visual acuity, fundus photos, FA and OCT images were collected at the first outpatient visit. The causes of CRAO without cherry-red spots were analysed through fundus photos. The incidence of increased hyperreflectivity of the inner retina, central macular thickness (CMT) and arteriovenous transit time in patients with and without cherry-red spots were compared.ResultsFundus examination showed posterior retinal whitening in 57 cases (81.43%) and cherry-red spots in 39 cases (55.71%). Thirty-one patients presented at the first outpatient visit without cherry-red spots. The reasons for the absence of cherry-red spots included leopard fundus (32.26%), retinal vein occlusion (25.81%), no obvious inner retinal coagulative necrosis (19.35%), ciliary retinal artery sparing (12.90%), high macular oedema (9.68%) and cherry-red spot enlargement (3.23%). OCT revealed increased hyperreflectivity of the inner retina in 67 CRAO patients (95.71%). All 3 patients without increased hyperreflectivity of the inner retina did not present with cherry-red spots at the first visit. The median CMT in patients without cherry-red spots was 166.00 μm, while the median MCT in patients with cherry-red spots was 180.00 μm; there was no significant difference between these two groups (P = 0.467). FA showed delayed arteriovenous transit time > 23 s in 20 patients (28.57%), > 15 s in 43 patients (61.43%) and no delay in 27 patients (30.77%). The median arteriovenous transit time in patients without cherry-red spots was 19.00 s, while it was 18.00 s in patients with cherry-red spots; there was no significant difference between these two groups (P = 0.727).ConclusionsThere are multiple factors that could cause the absence of cherry-red spots in CRAO. The use of OCT to observe increased hyperreflectivity of the inner retina is the most effective imaging method for the early diagnosis of CRAO without cherry-red spots.

Unilateral Purtscher’s retinopathy – A rare case report

With retinal whitening (Purtscher’s flecken) and intraretinal hemorrhages, Purtscher’s retinopathy was initially reported as a symptom of sudden loss of vision following head trauma in 1910. A 28-year-old male patient presented with a history of sudden painless decrease of vision in his left eye (LE) for 1 week. He gave a history of head-and-neck injury following a road traffic accident. Unaided distance visual acuity was 20/20 in the right eye (RE) and 20/40 in the LE which improved up to 20/25 on pinhole at the time of presentation. On examination, the anterior segment was within normal limits. Fundus photo and ocular coherence tomography (OCT) showed normal in the RE; however, LE showed multiple white patches around the optic disc with flamed-shaped hemorrhages on the fundus photo and macular edema with discontinuity in the inner and outer retinal layer on OCT. The patient received oral steroids as treatment, and after 1 month of follow-up, had recovered to 20/20 visual acuity.

Peripheral retinal vessel whitening in patients with diabetes mellitus

This study aimed to identify retinal vessel whitening outside the standard Early Treatment Diabetic Retinopathy Study (ETDRS) fields and to correlate the findings with vision and severity of diabetic retinopathy. Patients with diabetes mellitus who were seen in the retinal clinic to assess diabetic retinopathy status were included. Retinal vessel whitening was identified using ultra-widefield imaging. Four hundred and forty-five eyes of 260 patients were included. Thirty-five eyes in 24 patients (7.9%) were noted to have peripheral retinal vessel whitening. Thirty-one eyes with peripheral retinal vessel whitening did not have vessel whitening within the standard 7 ETDRS fields (p < 0.001). The proportion of whitening increased as DR severity increased, from 4.0% for patients with no DR (OR 0.249) to 33.3% for those with severe NPDR and PDR (OR 6.430 and 7.232, respectively). In addition, patients with peripheral retinal vessel whitening had worse visual acuity (logMAR = 0.34) compared to those without (logMAR = 0.15) (p < 0.001). In conclusion, we found an association between peripheral retinal vessel whitening in diabetic patients which correlated with diabetic retinopathy severity. Additionally, we found an association between vessel whitening and reduced vision, suggesting that vessel whitening identified using ultra-widefield imaging may be a prognostic indicator of vision in diabetic retinopathy.

Chorioretinitis sclopetaria and orbital emphysema caused by a high-velocity liquid missile.

To highlight a case of chorioretinitis sclopetaria, with concomitant macular hole formation and orbital emphysema, caused by a commercial-grade pressure washer. A 19-year-old male presented to the emergency department with a left eye injury, incurred after being sprayed with a commercial-grade pressure washer. He endorsed ipsilateral blurred vision, pain, and linear floaters. Left eye visual acuity was 20/40. Dilated fundus exam showed inferior vitreous hemorrhage, retinal whitening, and pre-, intra-, and sub-retinal hemorrhages, consistent with chorioretinitis sclopetaria. Optical coherence tomography revealed a full-thickness macular hole. Computed tomography scan of the orbits showed subcutaneous and post-septal orbital emphysema. Two months following injury, vitreous and retinal hemorrhages and macular hole resolved. Five months following injury, visual acuity improved to 20/20. Chorioretinitis sclopetaria is defined as a full-thickness chorioretinal disruption resulting from a high-velocity projectile passing adjacent to or into the orbit without penetrating the globe. Chorioretinal deformation and ocular comorbidities are influenced by the velocity of the missile and its spatial relationship to the orbit. While this pattern of injury is typically associated with indirect trauma to the globe by a BB or a bullet, this is the first report of chorioretinitis sclopetaria precipitated by a high-velocity liquid missile.

Purtscher-like Retinopathy in a Patient with Acute Pancreatitis: A Case Report and Literature Review

Purtscher-like retinopathy is a rare chorioretinopathy associated with a non-traumatic inciting event including acute pancreatitis, renal failure, long-bone injury, chest compression, connective tissue diseases and hematologic disorders. We present the case of a 33-year-old woman with abdominal pain and visual changes that was diagnosed with acute pancreatitis. Fundoscopic examination revealed bilateral diffuse flame hemorrhages and retinal whitening (Purtscher flecken), which were diagnostic of Purtscher-like retinopathy secondary to acute pancreatitis. The patient improved without intravenous or intravitreal corticosteroid administration. Follow up at 5 and 8 months revealed improved vision, complete resolution of the retinal pathology with residual inner retinal thickening on ocular coherence tomography (OCT), consistent with sustained retinal damage. Given that Purtscher-like retinopathy is associated with higher morbidity and mortality rates in patients with acute pancreatitis, high suspicion of this pathology and a thorough clinical assessment are imperative. Since half of the patients suffer life-long visual changes, further research is required for the development of efficacious treatment options.

Preventive Inflammation Management with Steroids before Retreatment with Anti-VEGF after Severe Inflammation due to Brolucizumab.

We report two successful cases of treatment by steroids after severe inflammation due to an intravitreal injection (IVI) of brolucizumab and their retreatment with another type of anti-vascular endothelial growth factor (VEGF), with steroid treatments to prevent severe inflammatory recurrence in patients with exudative age-related macular degeneration (AMD). CLINICAL CASES, CASE 1: An 88-year-old woman with exudative AMD in her left eye who had persistent subretinal fluid despite receiving an IVI, including ranibizumab and, subsequently, aflibercept. A switch to brolucizumab was decided. Two weeks after the third dose, she had a visual loss decreasing from 20/40 to counting fingers at 50 cm. Fundus examination revealed retinal whitening and perivenous sheathing. Fluoresceine angiography confirmed retinal arterial occlusion. Differential diagnoses were ruled out. She was treated with intravenous methylprednisolone and prednisolone eye drops. Three months after the treatment, visual acuity improved to 20/80 with no intraocular inflammation but subretinal fluid recurred. IVI of ranibizumab was rescheduled with preventive treatment by oral and local prednisolone without any inflammation recurrence. CASE 2: An 80-year-old man with exudative AMD in his right eye who had persistent subretinal fluid despite an IVI of aflibercept. Switching him to brolucizumab was decided. Two months after the third dose, he had blurred vision with no pain. Visual acuity decreased from 20/20 to 20/25. Examination showed 1+ anterior chamber cells and hyalitis. We confirmed the diagnosis of anterior uveitis with hyalitis. Differential diagnoses were ruled out. Treatment by prednisolone eye drops was initiated every 30 minutes for 1 day with a gradual decrease for 6 weeks. One week later, visual acuity improved to 20/20 with no inflammation. Three weeks later, subretinal fluid due to AMD increased. The patient was retreated by aflibercept with prednisolone eye drops, 48 hours before and after the IVI, with no recurrence of inflammation. Brolucizumab is one of the latest FDA-approved anti-VEGF agents for wet AMD. Since its wider use, few cases of severe ocular inflammation have been reported in post-marketing analysis. Because wet AMD recurrences should be expected after intraocular inflammation, insight is needed into treatment tolerance in cases that received further IVI retreatment. Our cases demonstrate that an IVI reinjection with a different anti-VEGF drug for exudative AMD recurrence can be safely reperformed. The use of local steroids could be effective in preventing recurrence of ocular inflammation after severe intraocular inflammation due to brolucizumab.