Retinal Whitening Research Articles

Retinal Artery Occlusion after Fat Injection Laryngoplasty

A 72-year-old man presented with significantly decreased vision in his left eye for 10 days. He had received radiation therapy to the left submandibular gland adenoid cystic carcinoma, and undergone autologous fat injection laryngoplasty for vocal cord paralysis. Visual acuity was 20/50 in the left eye. Fundus showed multiple, dispersed, refractile retinal arteriolar fat emboli with retinal whitening over the left the paramacular region (Fig A). Fluorescein angiography revealed filling defects in multiple branch retinal arteries consistent with the diagnosis of branch retinal artery occlusions (Fig B and C).

Use of ultra-wide field retinal imaging and optical coherence tomography angiography in the diagnosis of incomplete Susac syndrome.

To describe clinical findings through ultra-wide field (UWF) images and optical coherence tomography angiography (OCT-A), in Susac's syndrome (SS). SS patients were retrospectively analyzed in a single center. Clinical features, ultra-wide-field retinographies (UWF-PR), UWF fluorescein angiographies (UWF-FA), and optical coherence tomography angiography & en face (OCT-A/EF) were reviewed. Twelve eyes from six patients with a mean follow-up of 35.66 months ± SD 36.88 were included. UWF-PR showed areas of retinal whitening and cotton-wool spots in all the eyes after acute attack. Segmentary mid peripheral arteriolitis could be observed in five eyes by UWF-FA in acute and convalescent stages. OCT-A revealed capillary density changes in all of the affected eyes. During the acute phase there was a well-preserved superficial capillary network, while deep retinal plexus showed a lower density in the affected areas. OCT-A/EF revealed deep retinal plexus drop-out and surrounding edematous retina in acute attacks, becoming atrophic over time. Conversely, superficial plexus was much less affected. Perifoveal reperfusion was seen in seven eyes after the acute attack. UWF-PR/FA and OCT-A/EF might be helpful to stablish an early diagnosis and to monitor SS progression.

Purtscher’s retinopathy: a case report

Purtscher’s retinopathy is a rare haemorrhagic and vaso-occlusive vasculopathy following severe head trauma associated with sudden blindness. Here we report a case of 28 years old male pre­sented to out-patient department with history of sudden and painless loss of vision in his right eye for two days. He gave history of head injury following bike accident. At the time of presentation his best corrected visual acuity was 1/60 in the right eye and 6/6 in the left eye. On examina­tion, anterior segments of both eyes were normal. On fundus examination, right eye revealed retinal whitening in the peripapillary region (Purtscher’s flecken), an intraretinal hemorrhage and signs of macular edema whereas left eye was unremarkable. Findings were suggestive of right eye purtscher’s retinopathy. Optical coherence tomography and fundus fluorescence angiography was done to support the diagnosis. Purtscher’s retinopathy should not be neglected because it is associated with different systemic disease. Its pathophysiology remains unclear and there is no definite treatment but meticulous management is urgent to prevent from severe complications.

PURTSCHER’S RETINOPATHY: A CASE REPORT

Purtscher’s retinopathy is a rare haemorrhagic and vaso-occlusive vasculopathy following severe head trauma associated with sudden blindness. Here we report a case of 28 years old male pre­sented to out-patient department with history of sudden and painless loss of vision in his right eye for two days. He gave history of head injury following bike accident. At the time of presentation his best corrected visual acuity was 1/60 in the right eye and 6/6 in the left eye. On examina­tion, anterior segments of both eyes were normal. On fundus examination, right eye revealed retinal whitening in the peripapillary region (Purtscher’s flecken), an intraretinal hemorrhage and signs of macular edema whereas left eye was unremarkable. Findings were suggestive of right eye purtscher’s retinopathy. Optical coherence tomography and fundus fluorescence angiography was done to support the diagnosis. Purtscher’s retinopathy should not be neglected because it is associated with different systemic disease. Its pathophysiology remains unclear and there is no definite treatment but meticulous management is urgent to prevent from severe complications.

BRANCH RETINAL ARTERY OCCLUSION WITH PARACENTRAL ACUTE MIDDLE MACULOPATHY PRESUMABLY RELATED TO HEAVY CANNABIS USE

To report a case of branch retinal artery occlusion associated with paracentral acute middle maculopathy on spectral-domain optical coherence tomography presumably related to heavy cannabis consumption. Retrospective case report. Spectral-domain optical coherence tomography, fluorescein angiography, and optical coherence tomography angiography were performed. A 21-year-old healthy man described the acute onset of superior visual field loss in his right eye. He admitted smoking approximately 15 g daily of cannabis for several weeks during COVID-19 confinement. Ophthalmoscopic examination of the right eye showed inferotemporal retinal whitening. Spectral-domain optical coherence tomography illustrated evidence of the ischemic cascade with diffuse hyperreflectivity of the inner and middle retinal layers within the central region of the retinal infarct and paracentral acute middle maculopathy at the border of the infarct. Optical coherence tomography angiography demonstrated predominant flow signal loss at the level of the deep retinal capillary plexus. Fluorescein angiography and complete systemic workup were unremarkable. Branch retinal artery occlusion and paracentral acute middle maculopathy may be related to heavy cannabis use as the result of transient arterial vasospasm.

Purtscher’s-Like Retinopathy Following Acute Pancreatitis

Background: Purtscher’s retinopathy is a rare condition that results from trauma to the head, neck or thorax. Purtscher’s-like retinopathy is similar in appearance to Purtscher’s retinopathy but occurs in association to various systemic conditions, including acute pancreatitis. Both are a result of occlusion of precapillary arterioles by small and intermediate sized emboli and present with retinal whitening and intraretinal hemorrhages throughout the posterior pole. Other findings may include optic nerve edema, macular edema, macular ischemia and serous macular detachment. Patients are often symptomatic for reduced vision and visual field loss. Case Report: A 23-year-old African American male presented with reduced vision in both eyes following hospitalization for the treatment of acute pancreatitis secondary to alcohol abuse. Fundus examination revealed extensive peripapillary retinal whitening in both eyes with a few intraretinal hemorrhages. Optical coherence tomography of the macula revealed a serous detachment in both eyes. Improvement in visual acuity and partial resolution of the macular subretinal fluid was observed upon follow up. Conclusion: Purtscher’s and Purtscher’s-like retinopathy are thought to be self-limiting conditions that resolve without ocular treatment. Following resolution of the acute retinal findings, patients can be left with visual acuity and/or visual field loss. While there is currently no accepted treatment for the retinopathy itself, it is important to treat the associated systemic condition. CE Notification: This article is available as a COPE accredited CE course. You may take this course for 1-hour credit. Read the article and take the qualifying test to earn your credit. Click here to Enroll (https://www.crojournal.com/purtschers-like-retinopathy-following-acute-pancreatitis) Please check COPE course expiry date prior to enrollment. The COPE course test must be taken before the course expiry date.

Toxoplasmosis chorioretinitis mimicking acute retinal necrosis associated with local corticosteroid

BackgroundThe cases discussed highlight the atypical presentation and diagnostic dilemmas of toxoplasmosis with fulminant retinal necrosis and the potentially devastating visual outcomes of toxoplasma chorioretinitis following local corticosteroid exposure.Case presentationWe report a series of three patients who presented with toxoplasmosis mimicking severe acute retinal necrosis. Patients were between 59 and 77 years old and had been exposed to local corticosteroids preceding our evaluation. All patients demonstrated diffuse retinal whitening with severe vision loss on presentation. Polymerase chain reaction testing (PCR) was diagnostic in two patients, and histopathologic examination of a vitrectomy specimen was diagnostic in one patient. All cases of retinitis resolved with anti-parasitic medication; however, visual acuity failed to improve in all patients due to disease severity and presentation.ConclusionsLocal corticosteroid injection may trigger or exacerbate toxoplasmosis chorioretinitis, leading to fulminant retinal necrosis and severe vision loss. Toxoplasma chorioretinitis should be considered in the differential diagnosis of patients presenting with clinical features of acute retinal necrosis, particularly following local corticosteroid injection regardless of their baseline systemic immune status. Diagnostic vitrectomy may be helpful in patients in whom PCR testing is negative and ocular toxoplasmosis is suspected.

Prevalence of Retinal Emboli and Acute Retinal Artery Occlusion in Acute Ischemic Stroke

ObjectiveIn population-based studies asymptomatic retinal emboli occur in .32%-2.9% of people. Retinal artery occlusion (RAO) may occur concurrently with cerebral stroke but the frequency is unknown. No study has examined how commonly retinal emboli occur in the acute stroke population. We aimed to assess the prevalence of retinal emboli and RAO at the time of carotid territory ischemic stroke. MethodsPatients were enrolled prospectively after onset of symptoms consistent with the diagnosis of carotid territory ischemic stroke. Every participant underwent pharmacologic dilation of both pupils and bedside funduscopic examination. Emboli were classified as cholesterol, calcific, platelet/fibrin, or other and categorized by the side of occurrence. Stroke was classified as atheroembolic, cardioembolic, embolic stroke of undetermined source, lacunar, or other. Acute RAO was diagnosed by direct visualization of ischemic retinal whitening. ResultsSixty-five patients were enrolled with a mean age of 59.2 years; 23 were female (35.4%). Eleven of 65 subjects (16.9%) had retinal emboli visible on funduscopy; all were cholesterol emboli except a single platelet/fibrin embolus in a patient with atheroembolic source. Six patients (9%) had acute RAO and no RAO was seen in the lacunar or undetermined source subgroups. ConclusionsRetinal emboli occurred more than 10 times more frequently in the acute stroke patient than in large population-based studies. RAOs also occurred concurrently with ischemic stroke. Although emboli were seen in patients with atheroembolic and cardioembolic sources, all patients with carotid disease had emboli in the ipsilateral eye. Future studies are required to determine if the presence of retinal emboli or RAO may help elucidate an etiology in patients suffering from embolic stroke of undetermined source.

Clinical Features of Combined Central Retinal Artery and Vein Occlusion.

Purpose To describe the clinical features of combined central retinal artery and vein occlusion (CCRAVO). Methods This retrospective study included 33 admitted patients (33 eyes) who had CCRAVO. Clinical data, such as age, gender, best-corrected visual acuity (BCVA), intraocular pressure (IOP), findings on fundus color photography and fundus fluorescein angiography (FFA), and information about follow-up, were collected and analyzed. Results The age of the patients with CCRAVO ranged from 22 to 78 years, with a mean of 48.8 ± 14.1 years. At presentation, BCVA of the involved eyes ranged from no light perception (NLP) to 20/20. In addition, 45.5% (15/33) of the eyes had BCVA of finger counting (FC) or below, whereas 12.1% (4/33) had BCVA of 20/60 or above. The IOP was lower in the involved eyes than in the fellow eyes (15.0 ± 3.0 mmHg vs. 16.4 ± 2.3 mmHg, p=0.03). Ophthalmoscopic examination showed changes in both central retinal artery occlusion (CRAO) and central retinal vein occlusion (CRVO), including retinal hemorrhage, retinal ischemic whitening, optic disc hyperemia and/or edema, venous dilation and tortuosity, cotton wool spot (CWS), and Roth's spot. FFA showed prolonged arm-to-retina time (ART) and retinal arteriovenous passage time (RAP) (17.1 ± 4.9 s and 12.1 ± 8.8 s, respectively). Capillary nonperfusion (CNP) was seen in 21 eyes (63.6%), and in 14 (42.2%) of these, CNP was larger than 10 disc areas. At 2 to 3 weeks after presentation, BCVA improved in 23 eyes (71.9%) and further deteriorated in 5 eyes (15.6%). Retinal ischemic whitening improved in more than half of the eyes, whereas retinal hemorrhage increased in nearly half of the eyes. Follow-up ranged from 6 to 56 months. Seven patients were lost to follow-up. At final follow-up, six eyes had a visual acuity of 20/60 or greater, but 6 eyes had FC or worse. Four eyes developed neovascularization on follow-up. Conclusion CCRAVO is a sight-threatening entity. Manifestations of CRAO and CRVO can be seen simultaneously in the early stage of disease, and CRVO may play a more important role in the development of CCRAVO.

1372 A Rare Case of Purtscher's Retinopathy in the Setting of Acute Alcoholic Pancreatitis

INTRODUCTION: Purtscher's retinopathy (PUR) is a rare condition first described in 1910. Occlusive microvasculopathy is characterized by sudden visual loss with multiple areas of retinal whitening in the posterior pole. Associated with acute pancreatitis, connective tissue disorders, renal failure, childbirth, bone marrow transplantation. Proteases like trypsin activate the complement system cascade causing coagulation and leukoembolization of the retinal precapillary arterioles. The emboli lodge in the arterioles producing the clinical appearance of PUR with impaired visual acuity and visual field loss. We present a case of a young female with repeat acute pancreatitis who developed sudden visual changes seconday to PUR. CASE DESCRIPTION/METHODS: 28 yo F with PMH of Etoh abuse, gastritis, Mallory-Weiss tear and prior admissions for pancreatitis presented to ED with emesis and abdominal pain for one day. Exam revealed a diffusely tender abdomen. Labs included lipase (939 U/L) (aspartate aminotransferase = 351 U/L, alanine aminotransferase = 179 U/L, alkaline phosphatase = 133 U/L) and hyperbilirubinemia (1.8 mg/dL). Abdominal U/S showed peripancreatic edema correlating acute pancreatitis along with hepatomegaly and steatosis. On day 1 of admission pt complained of visual disturbances upon awakening. Acute visual changes included blurriness, flashes and floaters which completely resolved by the evening. Bedside ophthalmologic exam revealed multiple cotton wool spots bilaterally. Ophthalmology evaluation revealed macular edema and neurosensory detachment of the macula bilaterally secondary to PUR. Visual field testing showed loss of central field bilaterally with preserved peripheral vision. Acuity was 20/200 bilaterally and received intraocular steroid injections with weekly follow up. Exam at 8 weeks demonstrated improvement to visual acuity to 20/40 bilaterally. DISCUSSION: Purtscher Flecken are variable, polyglonal regions of retinal whitening with a clear zone and are pathognomonic. The treatment for the ocular complications of PuR have not been proven and prognosis depends on the areas of the retina that are affected. Isolated case reports have shown rapid improvement in vision with high dose IV steroids. Steroids help preserve the neuronal membrane and suppress granulocyte aggregation caused by complement activation. Patient's complaining of changes in vision following an episode of acute pancreatitis should undergo eye examination in order to rule out Purtscher-like retinopathy.

Ophthalmic features of HIV associated cryptococcal meningitis in Malawian Adults: an observational study

Background: Cryptococcal meningitis (CM) is the commonest neurological complication in patients with advanced HIV. Visual disturbance is a frequent presenting symptom. Papilloedema is commonly reported but other ophthalmic findings are not well described. Methods: We performed an observational study comparing severely immunocompromised HIV-infected patients with and without CM to determine the nature and prevalence of retinal pathology attributable to CM. 70 adult patients were enrolled in Blantyre Malawi, 35 with CM and 35 HIV-infected patients without CM. Results: 79% (19/24) of CM patients examined on day one had evidence of retinal abnormalities compared to 17% (6/35) of HIV-infected controls (p <0.001). In the CM group, retinal whitening was the commonest abnormality (50%), followed by optic disc swelling (29%), haemorrhage (25%) and vascular abnormalities (7%). Retinal whitening was the only abnormality observed in the comparator group (17%). In CM, there was no significant difference between those with and without retinal abnormalities in fungal burden (13,550 cfu/ml vs. 9,150 cfu/ml; p = 0.65), CD4 count (28 cells/µl vs. 76 cells/µl; p = 0.79) or CSF opening pressure (21cm H20 vs. 27cm H20; p = 0.5). There was no association between presence/absence of retinal abnormalities and death (40% 10-week mortality vs. 26%; p = 0.6). Conclusions: Whether the presence of CM retinopathy could be used as a marker of disease severity warrants further investigation. The observed ophthalmic findings provide a descriptive framework for CM retinopathy to be utilised in future CM studies. Trial registration: ISRCTN (ISRCTN45035509) 19/06/2012.

CYTOMEGALOVIRUS RETINITIS WITH BELATACEPT IMMUNOSUPPRESSION

To report two cases of cytomegalovirus (CMV) retinitis in renal transplant patients after conversion to belatacept immunosuppression. Case report. Case A was a 41-year-old African American man with no ocular history, chronic hepatitis B infection on entecavir, status-post living relative renal transplant for end-stage renal disease secondary to IgA nephropathy presented with a chief complaint of "blurry vision" in his right eye. Fundoscopic examination of the right eye revealed perivascular retinitis of the superior arcade extending temporally and a lesion nasal to the optic disk. The patient was diagnosed with CMV retinitis with macular involvement. Case B was a 52-year-old woman with an ocular history significant for bilateral vein occlusions treated with laser, and a medical history of hypertension, hyperlipidemia, and end-stage renal disease secondary to hypoplastic kidney status-post deceased donor renal transplant presented with one week of blurred vision in the right eye. Fundoscopic examination of the right eye revealed macular star configuration of exudates, as well as subretinal fibrosis temporal to the macula. Fundoscopic examination of the left eye showed Grade 4 vitreous haze and multiple areas of retinal whitening and hemorrhage, consistent with CMV retinitis infection. The patient was diagnosed with bilateral CMV retinitis, with macular involvement in the right eye. Renal transplant patients converted to belatacept immunosuppression may be at an increased risk for herpes virus infection, and thus herpes virus retinitis. Although the degree of risk remains uncharacterized, patients on belatacept therapy who are at the high risk of CMV infection (i.e., donor-positive/recipient-negative patients) should be counseled on the presenting signs and symptoms of CMV retinitis. In these cases, clinicians should also consider regular monitoring of serum CMV titers or continuation of antiviral prophylaxis.

Cilioretinal Artery Occlusion Associated With Optic Disc Edema

Purpose: This work investigates the clinical features of cilioretinal artery occlusion (CLRAO) in the setting of optic disc edema. Methods: A retrospective chart review of 3 patients with concomitant CLRAO and optic disc edema was performed. All patients underwent multimodal imaging and systemic workup. Results: The patients were female, had a median age of 32 years, and were otherwise healthy. Presenting visual acuities were hand motion, 20/1000, and 20/70. One patient had optic nerve enhancement on magnetic resonance imaging. Systemic workups were noncontributory. All patients had ischemic retinal whitening and inner-retinal thinning in the cilioretinal artery (CLRA) distribution. Fluorescein angiography showed no signs of capillary nonperfusion, vascular inflammation, or frank vein occlusion. One patient was lost to follow-up and 2 were treated with high-dose corticosteroids with improvement in visual acuity. Conclusions: CLRAO can be associated with optic disc edema in the absence of outright central retinal vein occlusion, giant-cell arteritis, or known systemic disease.

Atteintes rétiniennes du neuro-paludisme ou « rétinopathie paludique » à Yaoundé

Contribute to the improvement of diagnostic and prognostic approaches to treating children with neuro-malaria in Yaoundé. A prospective and analytical study carried out in 2hospitals of Yaoundé from October 2015to March 2016. All patients aged 3months to 15years hospitalized for neuro-malaria in one of the 2hospitals benefited from a fundus examination. The variables studied were: age, sex, Glasgow or Blantyre score, fundus examination and parasitaemia. For statistical analysis, we used the software R 3.3.0, Chi2, exact of Fisher or Kolmogorov-Smirnov tests with a significance P<5%. Out of the 178children hospitalized during the study period, 44had neuro-malaria (24.71%) and 26 (46diseased eyes) among them presented retinal lesions at a frequency of 14.60%. The mean age was 5.54±3.49years with a sex ratio of 1.09. The under 5-years-old were the most affected with 31 (70.45%) cases. The fundus lesions of 26 (59.09%) were retinal hemorrhages in 24 (54.54%), retinal whitening and vessel discoloration in 8 (18.18%) respectively. Papillary edema was associated in 4 (9.09%). Macular involvement was noted in 9cases. These lesions were correlated with age, depth of coma, duration, and clinical course. The rate of parasitaemia did not affect their occurrence. Retinal lesions are frequent and serious during neuro-malaria in our environment, especially in children under five. They must therefore be an emphasis in the systematic exam to rule it out for a better prognostic evaluation and a fast and adequate multidisciplinary management.

Schisis of the Retinal Nerve Fiber Layer in Epiretinal Membranes

To describe schisis of the retinal nerve fiber layer (sRNFL) associated with epiretinal membranes (ERMs) seen on spectral-domain optical coherence tomography (OCT) prior to vitreoretinal surgery. Areas of sRNFL (size and location) were noted during preoperative planning. Spectral-domain OCT scans were obtained to study the inner retinal morphology postoperatively. Retrospective observational consecutive case series. Pre- and postoperative spectral-domain OCT and en face images of 41 eyes with ERMs that had undergone vitrectomy by a single surgeon were analyzed to record the presence of sRNFL. The extent of sRNFL was classified as focal or diffuse. Other characteristics such as involvement of the papillomacular bundle and areas of fibrillary protrusion of sRNFL above the internal limiting membrane (ILM) were documented. Color fundus photographs were reviewed to correlate with the spectral-domain OCT images. Mean patient age and length of follow-up were 69.3 years (range 52-82 years) and 6.8months (range 0.25-21months), respectively. Mean preoperative and postoperative central thicknesses were 477μm and 387μm, respectively (P < .0001). sRNFL was observed in 51.2% (21/41 eyes), and was classified as diffuse (>1 disc diameter) in 90.5% (19/21 eyes). Protrusion of sRNFL through the ILM was present in 76.2% (16/21 eyes) and occurred in areas of dehiscence of the adjacent ILM. sRNFL was best visualized on spectral-domain OCT and en face imaging at the vitreoretinal interface and sometimes correlated with areas of retinal whitening. sRNFL resolved in all cases postoperatively. sRNFL was a relatively common occurrence in ERMs, correlated frequently with areas of dehisced ILM intraoperatively, and resolved postoperatively in all cases.

Ocular findings in patients with novel A/H1N1 infection: an observational cross-sectional study

Background: The systemic findings of novel A (H1N1) influenza have been well documented but data on ocular lesions is scarce. We report the systemic and ophthalmoscopic findings of 14 patients with proven H1N1 infection. Methods: An observational non-interventional retrospective study. During a period of nine years, 14 patients (six female and eight males), were referred for an ophthalmic evaluation. All patients underwent a detailed systemic and ocular evaluation. Results: Three patients (21.4 %) showed ocular lesions in the form of a unilateral intraretinal hemorrhage. Of these, one patient (7.1%) had a large disc hemorrhage and an area of retinal whitening, consistent with ischemia in the macular area. Conclusions: Physicians dealing with H1N1 infection should be aware of these findings and may include an ocular evaluation as part of their protocol.

Ophthalmic features of HIV associated cryptococcal meningitis in Malawian Adults: an observational study

Background: Cryptococcal meningitis (CM) is the commonest neurological complication in patients with advanced HIV. Visual disturbance is a frequent presenting symptom. Papilloedema is commonly reported but other ophthalmic findings are not well described. Methods: We performed an observational study comparing severely immunocompromised HIV-infected patients with and without CM to determine the nature and prevalence of retinal pathology attributable to CM. 70 adult patients were enrolled in Blantyre Malawi, 35 with CM and 35 HIV-infected patients without CM. Results: 79% (19/24) of CM patients examined on day one had evidence of retinal abnormalities compared to 17% (6/35) of HIV-infected controls (p &lt;0.001). In the CM group, retinal whitening was the commonest abnormality (50%), followed by optic disc swelling (29%), haemorrhage (25%) and vascular abnormalities (7%). Retinal whitening was the only abnormality observed in the comparator group (17%). In CM, there was no significant difference between those with and without retinal abnormalities in fungal burden (13,550 cfu/ml vs. 9,150 cfu/ml; p = 0.65), CD4 count (28 cells/µl vs. 76 cells/µl; p = 0.79) or CSF opening pressure (21cm H20 vs. 27cm H20; p = 0.5). There was no association between presence/absence of retinal abnormalities and death (40% 10-week mortality vs. 26%; p = 0.6). Conclusions: Whether the presence of CM retinopathy could be used as a marker of disease severity warrants further investigation. The observed ophthalmic findings provide a descriptive framework for CM retinopathy to be utilised in future CM studies. Trial registration: ISRCTN (ISRCTN45035509) 19/06/2012.

Combined central retinal vein, central retinal artery and cilioretinal artery occlusion with ischemic macular hole secondary to severe orbital cellulitis after black fly bite.

Background: Orbital cellulitis is an infection of the ocular adnexal and orbital tissues behind the orbital septum. The complications are poor prognosis. This paper is to describe some severe rare complications of orbital cellulitis.Case presentation: A case of 32-year-old female presented with acute severe progressive orbital cellulitis on the right eye after a black fly (Simuliidae spp.) bite. Orbital imaging with computed tomography and magnetic resonance imaging showed eyelid abscess with orbital abscess formation and superior ophthalmic vein thrombosis. She was promptly treated with intravenous vancomycin, piperacillin and had surgical procedures to release orbital pressure including lateral canthotomy, lateral cantholysis, and eyelid with orbital abscess drainage. Pus collection culture was positive for Staphylococcus aureus. Even though she responded well to antibiotics treatment, progression involved severe orbital inflammation with marked increased orbital pressure, and her visual acuity was such that she had no light perception. Combined central retinal vein, central retinal artery and cilioretinal artery occlusion were identified. Fundus examination showed retinal whitening at the posterior pole and a few scattered flame-shaped retinal hemorrhages. The cilioretinal artery presented with perivascular retinal whitening. A fundus fluorescein angiogram revealed cilioretinal and retinal artery filling delay and also delayed arteriovenous transit time. She also developed an ischemic macular hole after a week of treatment. We demonstrate an optical coherence tomography image showing the intact posterior hyaloid membrane that represents no traction on the macula to support the ischemic cause.Conclusion: Multiple retinal vascular occlusion and ischemic macular hole could be an early complication of severe orbital cellulitis from increased orbital pressure; therefore, close monitoring of visual acuity with IOP, and prompt treatment when indicated might reduce the risk of consequent blindness.

Purtscher Retinopathy and Fat Embolism Syndrome

Purtscher retinopathy and fat embolism syndrome are chorioretinopathies occurred after indirect ocular trauma. These diseases look like similar conditions but there are important differences which are help to differential diagnosis. In general, trauma is responsible from these diseases; but crush trauma play role in Purtscher retinopathy, while bone fracture play role in fat embolism syndrome. Retinal whitening is dominant funduscopic finding in these diseases; but whitening is wide and centrally in Purtscher retinopathy, while it is smaller and located more peripherally in fat embolism syndrome. These clinical findings associated with Purtscher retinopathy and fat embolism syndrome, resolve spontaneously in weeks or months but permanent visual loss can be seen in survivors. In this manuscript, we aimed to give general information about emergence and clinical course and differentiation of Purtscher retinopathy and fat embolism syndrome.

Postoperative Hemorrhagic Occlusive Retinal Vasculitis Associated with Intravitreal Injection of Vancomycin

PURPOSE: To present a case of hemorrhagic occlusive retinal vasculitis (HORV) associated with intravitreal injection of vancomycin after pars plana vitrectomy (PPV).METHODS: Single case report.RESULTS: A 67-year-old woman presented with best corrected visual acuity (BCVA) of 20/400 in left eye. For clinical suspicion of chronic endophthalmitis, empirical treatment was initiated with vancomycin and ceftazidime without clinical improvement. The patient was submitted to pars plana vitrectomy. During surgery rhegmatogenous retinal detachment was observed and treated. At the end of surgery, intravitreal vancomycin was injected. After 18 days BCVA was counting fingers and fundus examination showed diffuse retinal vascular sheathing, intraretinal hemorrhages and ischemic macular whitening. The clinical diagnosis was compatible with HORV secondary to retinal toxicity due to intraocular vancomycin.CONCLUSIONS: This case illustrates the importance of including intravitreal vancomycin during PPV surgery on the list of potential causes when investigating a case of suspected hemorrhagic occlusive retinal vasculitis.