Subjective Visual Improvement Research Articles

Long‐term response to idebenone treatment in a patient with advanced Leber hereditary optic neuropathy

Aims/Purpose: To present a case with advanced LHON and its response to 2‐year‐treatment with idebenone, which was prescribed 13 years after the onset of the disease.Methods: A 40‐year‐old Caucasian male patient with a history of bilateral painless visual loss since the age of 28 was examined at our Ophthalmology department. His brother had also suffered similar visual loss. At presentation ETDRS best corrected visual acuity (BCVA) was counting fingers (CF) in both eyes (BE). Fundoscopy revealed pale optic discs bilaterally. Visual fields (30‐2) showed central scotomas in BE. During OCT/OCTA imaging of the optic disc RNFL and GCC thickness were decreased bilaterally. In electrophysiological assessment with flash visual evoked potentials a reduction in amplitude was recorded in BE but with normal latency. Full‐field ERG was within normal limits in BE. At the genetic test, a mitochondrial point mutation m. 3460 G>A at MT‐ND1 gene was detected, which was compatible with LHON. The patient was prescribed 300 mg idebenone per os three times/day for 24 months. Follow‐up visits were scheduled at 6, 12, 18 and 24 months.Results: At 6‐ and 12‐month follow‐up visits visual acuity, fundoscopic findings and OCT‐RNFL imaging remained unchanged. However, the patient reported subjective visual improvement bilaterally, with greater improvement in the visual field of the left eye. At 18 months following initiation of treatment an improvement of the visual field was documented in BE. No change of the GCC thickness was noted. At 2‐year follow‐up his condition remained improved.Conclusions: Delayed treatment with idebenone in advanced LHON can lead to subjective visual improvement. Moreover, an improvement in visual fields can also be documented even after 18 to 24 months of the initiation of the treatment.

Nd:YAG Laser Capsulotomy: Efficacy and Outcomes Performed by Optometrists.

An increasing number of optometrists are performing Nd:YAG laser capsulotomy procedures; however, there is limited published information on the outcomes of these procedures. This study aimed to assess the efficacy and safety of capsulotomy procedures performed by optometrists. Subjects diagnosed with posterior capsule opacification causing reduced vision and subjective visual complaints were recruited for this study. A baseline examination was performed to ensure that the subjects met all the necessary criteria. The procedure was performed by a licensed doctor of optometry at six different clinics, and each subject was monitored for visual outcome and any potential complications. Subjects' Snellen visual acuity improved from an average of 20/40 to 20/23 ( P < .001) with no complications of increased intraocular pressure, inflammation, visually significant lens pitting, macular edema, or retinal detachment. Of 78 subjects who responded to a post-procedure survey, 77 (99%) reported subjective improvement in vision after capsulotomy. Based on the outcomes of this study, YAG laser capsulotomies are effective treatments to improve patient vision that can be safely and effectively performed by optometrists.

Fulminant Idiopathic Intracranial Hypertension Refractory to Treatment Associated to SARS-CoV-2: A Case Report (P14-4.004)

<h3>Objective:</h3> NA <h3>Background:</h3> Idiopathic Intracranial Hypertension (IIH) is characterized by increased intracranial pressure, which most frequently occurs in childbearing-age obese women. Scarce reports of COVID-19 infection associated IIH exist and have only described this in women and children. “Fulminant IIH” is defined as intracranial hypertension without secondary cause, with severe vision loss within 4 weeks of onset, and progressive vision loss over days. A 36-year-old man with obesity came to the Ophthalmology clinic for evaluation of vision loss and headache, the patient tested positive for SARS-CoV-2 one month before this. He was identified to have bilateral grade V papilledema, confirmed with optical coherence tomography (OCT), and admitted to Neurology for IIH management. The patient was started intravenous therapy with high-dose steroids and acetazolamide without relief of headache or vision improvement (20/100). Lumbar puncture was performed, revealing an opening pressure of ≥55 cm H20. The MRI only showed findings of increased intracranial hypertension, and the MRV ruled out thrombosis. The lack of improvement in his headaches and vision loss ultimately required ventriculoperitoneal shunt placement. The patient had immediate subjective visual improvement after this, with unchanged visual acuity. On follow-up 4 weeks later, the patient continued to have headaches and the opening pressure was 30 cm H20. Lumboperitoneal shunt was placed. Both optic nerves became completely atrophic. Despite finally reaching an opening pressure of 15 cm H20, headaches did not resolve, and the patient currently only perceives light. <h3>Design/Methods:</h3> NA <h3>Results:</h3> NA <h3>Conclusions:</h3> This case represents, to our best knowledge, the first description of fulminant IIH associated with SARS-CoV-2. The previous reports described mild to moderate cases in women and children with response to treatment. This occurred to an adult male who despite receiving promptly treatment, had a poor response. Further studies are needed to determine if atypical clinical phenotypes are associated with refractory forms. <b>Disclosure:</b> Dr. Murguia Fuentes has nothing to disclose. Mr. Murguia Fuentes has nothing to disclose. Dr. Adamu has nothing to disclose. Dr. Carvajal- Gonzalez has nothing to disclose. Dr. Arvas has nothing to disclose.

Vortex keratopathy after photorefractive keratectomy in a patient on long-term clozapine treatment

Background: Vortex keratopathy is a corneal entity characterized by corneal deposits at the level of the basal epithelium in the form of a whorl-like pattern in the interpalpebral portions of the cornea. Medications such as amiodarone, chloroquine, hydroxychloroquine, indomethacin, phenothiazines, ibuprofen, and naproxen bind to the cellular lipids of the basal epithelial layer of the cornea, producing a characteristic whorl pattern. Here, we report a case of bilateral central vortex keratopathy with slight vision impairment 3 weeks after uneventful photorefractive keratectomy (PRK) in a woman on long-term clozapine treatment.&#x0D; Case Presentation: A 42-year-old woman presented to the outpatient clinic for refractive surgery for the correction of bilateral moderate myopia. Her best-corrected distance visual acuity was 20 / 20 in both eyes. She had been on antipsychotic clozapine tablets 400 mg / day for the past 6 years to manage a psychiatric disorder. On detailed preoperative slit-lamp examination, her corneas were clear, with perilimbal conjunctival pigmentations. Other ocular examination results were unremarkable. At the 3-week follow-up after an uneventful PRK, her uncorrected distance visual acuity was 20 / 25 in the right eye and 20 / 20 in the left eye, with complaints of slightly unclear vision in both eyes. Slit-lamp examination revealed bilateral corneal subepithelial deposits in a whorl-like pattern reminiscent of vortex keratopathy. The deposits were restricted to the epithelial and subepithelial regions and did not extend to the stroma without evident stromal haze. Dilated fundus examination results were normal bilaterally. Despite excellent refractive outcomes and visual acuity in both eyes, she was dissatisfied and complained of unclear vision. She was administered with lubricating eye drops and placed on regular follow-ups. At the 4-month follow-up, the vortex lines were cleared centrally, and she reported improvement in vision. Anterior-segment optical coherence tomography of the cornea revealed no epithelial deposits in the central part of the cornea and residual deposits in the temporal peripheral cornea, indicating clearing of the deposits from the central cornea and explaining the subjective improvement in vision. Her final best-corrected distance visual acuity was 20/20 in both eyes with an unremarkable ocular examination.&#x0D; Conclusions: Our case indicates a potential causal relationship between long-term clozapine treatment and development of temporary, visually significant vortex keratopathy after uneventful PRK. Further large-scale studies are required to verify the causal relationship between the long-term clozapine administration and the development of vortex keratopathy following surface ablation photorefractive procedures.

The use of rigid gas permeable contact lens in managing severe anisometropia caused by monocular aphakia following retinal reattachment surgery and high myopia in a 13 year old girl: a case report

Anisometropia if not treated accordingly may cause other issues especially in developing pediatric eyes. This case is a 13 year old female presented with chief complaint of headache and double vision upon wearing prescribed spectacles. Patient had history of high myopia on both eye, amblyopia and spontaneous rhegmatogenous retinal detachment on the left eye. Retinal reattachment and lensectomy surgery were conducted to correct the problem. The surgery was performed without intra ocular lens (IOL) implantation, which left her left eye become high hyperope due to aphakia. Patient was treated with RGP CLs. Final best visual acuity with EDTRS chart was 6/48 on both eyes. Patient reported subjective visual improvement, no headache or double vision.

Carotid Endarterectomy Restores Decreased Vision Due to Chronic Ocular Ischemia

A prospective, observational, single-center study was performed from March 2015 to September 2018. In 41 patients (75% symptomatic), who had undergone carotid artery endarterectomy (CEA), ocular blood flow, as measured by laser speckle flowgraphy, had significantly increased on the operated side but not on the nonoperated side. More than one half of the patients reported subjective visual improvement on the operated side. CEA can successfully reverse visual dysfunction caused by chronic ocular ischemia resulting from carotid artery stenosis by increasing ocular blood flow.

Carotid endarterectomy restores decreased vision due to chronic ocular ischemia.

The therapeutic effect of carotid endarterectomy (CEA) on visual disturbance caused by chronic ocular ischemia due to carotid artery stenosis has not been validated. This prospective observational study aims to investigate whether CEA is associated with an increase in ocular blood flow (OBF) and postoperative visual improvement. In total, 41 patients with carotid artery stenosis treated by CEA between March 2015 and September 2018 were enrolled in this study. OBF was evaluated by laser speckle flowgraphy, which can measure the mean blur ratio (MBR) which is well correlated to the absolute retinal blood flow. Visual acuity was assessed before and after CEA by subjective improvement and objective visual assessment using CSV-1000, an instrument used to test contrast sensitivity. OBF increased after CEA on the operated side (mean MBR 33.5 vs 38.2, p < 0.001) but not on the non-operated side (mean MBR 37.8 vs 37.5, p = 0.50). After CEA, 23 patients (56.1%) reported subjective visual improvement on the operated side. The mean CSV-1000 score among the patients with increased OBF after CEA (5.44 vs 5.88, p = 0.04) but not among those without increased OBF (5.48 vs 5.95, p = 0.09). The mean CSV-1000 scores increased significantly after CEA in 18 patients with decreased vision and decreased OBF (4.51 vs 5.37, p < 0.001), but not in the 23 patients without those (6.19 vs 6.31, p = 0.6). CEA may successfully reverse visual dysfunction caused by chronic ocular ischemia due to carotid artery stenosis by increasing OBF.

Gabapentin and memantine increases randomness of oscillatory waveform in ocular palatal tremor.

Syndrome of oculopalatal tremor (OPT) causes pendular nystagmus of the eyes and its disabling consequence on the visual system. Classic pharmacotherapeutic studies revealed reduction in the eye velocity of the oscillatory waveforms. Subjective improvement in vision, however, remains out of proportionately low. Elegant models depicting quasi-sinusoidal coarse oscillations of the eyes highlighted two distinct oscillators; one at the inferior olive causing primary 2Hz oscillations, while the second, independent oscillator, at the cerebellum adding the randomness to the waveform. Here we examined whether pharmacotherapy affects the randomness of the oscillatory waveform. Horizontal, vertical, and torsional angular eye positions were measured independently from both eyes as six subjects with OPT directed gaze toward a straight-ahead target. The measurements were performed before administration of alpha-2-delta calcium channel blocker (gabapentin) or NMDA receptor antagonist (memantine) and after the subjects were treated with each of these drugs for at least 8days. Amplitude and velocity of eye oscillations were reduced by gabapentin and memantine, but there was an increase in the waveform randomness. We found that the increase in randomness was proportionate to the amount of reduction in the waveform velocity or amplitude. Hierarchical clustering revealed distinct patterns of oscillatory waveforms, with each subject belonging to a specific cluster group. The pharmacotherapy changed the waveform clustering pattern of the waveform in each subject. We conclude that in addition to incomplete resolution of the oscillation intensity, increased randomness could be one of the reasons why there is not enough clinical difference in the patients' visual quality.

P14.126 radiation-induced optic neuropathy

Abstract BACKGROUND Optic neuropathy is an inflammation of the optic nerve leading to a rapidly progressive visual loss. Most frequent etiologies are multiple sclerosis, vasculitides, and infections. In the context of tumorous pathology, optic neuropathy can occur due to meningeal infiltration, tumoral compression, or antitumor therapeutics (radiation therapy, some targeted cancer therapies, and checkpoint inhibitors). In the current study, we examine radiation-induced optic neuropathy (RION), which is the most frequent among optic neuropathies caused by antitumor therapeutics. MATERIAL AND METHODS We present the cases of 3 patients who experienced RION. For each patient, we collected data on age, type of tumor, date and modalities of radiation-therapy, starting date of visual loss, ophthalmologic description, MRI images, treatment, and clinical and radiological evolution. RESULTS The three patients were aged 57 to 68 years old at the time of NORI. They had irradiation between 2013 and 2018. Two patients had proton therapy and one had whole brain irradiation. The visual loss occurred between seven and twelve months after the end of radiation therapy. In all patients the symptoms were bilateral and the loss of vision was rapidly worsened until culminating in almost total blindness. The MRI abnormalities were consistent with retrobulbar optic neuritis. The visual loss remained severe despite the treatment administered. High dose steroids had no clinical effect. Bevacizumab enabled a discrete subjective visual improvement in one patient, but a worsening of visual loss in another. Hyperbaric oxygen therapy had no clinical effect but was undertaken three months after the starting date of visual loss which is probably too late for efficiency. Interestingly one patient was treated with an anti-IL6 antibody (tocilizumab). It was administered in order to avoid fibrosis formation, which is the ultimate condition of the inflammatory process. The rationale is that radiation-induced opening of the bood-brain-barrier and destruction of endothelial and glial cells lead to reparation process through microglia activation. In-vitro studies showed an increased secretion of IL-6 (and other pro-inflammatory cytokines) by the activated microglia. Our patient could not experience benefit from tocilizumab, but the treatment was administered four months after the starting date of visual loss and fibrosis was probably already formed. CONCLUSION These cases are consistent with existing literature. The risk is mostly due to the total dose and dose per fraction of the irradiation and the prognosis is very poor with no efficient treatment at the present time. Anti-IL6 antibody could be an interesting treatment if administered at an early stage, but a future prospective clinical trial would be needed to clinically validate this hypothesis.

Photodynamic Therapy for Circumscribed Choroidal Haemangioma in a Scottish Cohort

Purpose: The aim of this study was to evaluate the safety and efficacy of photodynamic therapy (PDT) with verteporfin as a treatment for circumscribed choroidal haemangioma (CCH). Procedures: This is a retrospective cohort study of all treatment-naïve patients undergoing PDT with verteporfin for CCH in a single centre between April 1, 2007, and September 30, 2016. Best corrected visual acuity (BCVA; using ETDRS letter score), optical coherence tomography (OCT) measurements and a subjective measurement of visual function were recorded before treatment, at 3-month follow-up and at each annual follow-up. Results: Seventeen Caucasian patients with CCH received PDT, with a re-treatment rate of 23.5% (n = 4). Mean (±SD) follow-up was 36.5 (±32.6) months (range 2–106). Mean (±SD) pre-PDT BCVA was 58.5 (±15.5) letters, with a mean improvement from baseline of 8.2 letters at 3 months, of 13.8 letters at 1 year, of 21.1 letters at 2 years and of 19.5 letters at 3 years of follow-up. Subjective visual improvement was noted in 67% at 3 months, in 93% at 1 year, in 86% at 2 years and in 100% at 3 years of follow-up. OCT demonstrated no intraretinal/subretinal fluid in 63% at 3 months, in 77% at 1 year, in 86% at 2 years and in 100% at 3 years of follow-up. No complications of PDT were noted during the study. Conclusions: PDT is a safe and effective treatment for CCH which results in both structural and functional improvements, and these findings are particularly applicable to patients of Caucasian ethnicity. OCT provides a useful and readily available option to monitor CCH disease activity and its response to PDT.

Cataract surgery in patients with late-onset retinal degeneration

To review the outcomes in a series of patients with long anterior lens zonular fibers associated with late-onset retinal degeneration who had phacoemulsification cataract surgery. Newcastle Eye Centre, Newcastle upon Tyne, United Kingdom. Retrospective case series. Inclusion criteria were patients with genetically confirmedlate-onset retinal degeneration requiring cataract surgery. Perioperative data relating to surgery were collected. In addition, the corrected distance visual acuity (CDVA) and retinal imaging data were recorded. Selected lens capsules were examined using immunohistochemistry or scanning electron microscopy (SEM). Eleven eyes of 7 patients were included. The long anterior lens zonular fibers made capsulorhexis challenging; however, it was completed safely in all cases. There were no intraoperative or postoperative issues with lens stability. The CDVA improved postoperatively in those cases with intact foveal photoreceptors and retinal pigment epithelium. Over the longer term, the CDVA slowly declined because of progressive atrophy of the macula. Most patients noticed a subjective improvement in vision, even those with advanced disease at baseline. Immunohistochemistry showed that the C1QTNF5 protein was expressed within the lens capsule epithelial cells, although SEM of the long anterior lens zonular fibers showed them to be smaller in diameter than normal anterior lens zonular fibers and to be composed of a helix of fibers. In this small series of patients with late-onset retinal degeneration, cataract surgery was successfully performed without long-term complications involving intraocular lens stability. The objective improvement in CDVA seemed to be limited to patients with good foveal photoreceptor architecture.

INDUCTION OF MACULAR DETACHMENT FOR THE TREATMENT OF PERSISTENT OR RECURRENT IDIOPATHIC MACULAR HOLES.

To analyze the efficacy of induced macular detachment for the treatment of persistent or recurrent idiopathic macular holes after treatment with one or more standard pars plana vitrectomies (PPVs) with internal limiting membrane peeling. This study is a retrospective consecutive case series of 10 patients who underwent a PPV with subretinal balanced salt solution injection from 2011 to 2014 to treat persistent or recurrent idiopathic macular holes. All patients had previously undergone PPV with internal limiting membrane peeling. Visual acuity, ocular examination findings, and optical coherence tomographic images were reviewed preoperatively and postoperatively to assess the anatomical and visual outcomes of this procedure. Nine of the 10 patients who underwent the procedure had closure of their macular holes postoperatively (90%) and remained closed 6 months postoperatively. Most patients reported a subjective visual improvement. A mean objective visual improvement of 16 letters (Early Treatment Diabetic Retinopathy Study, 0.324 logMAR) was seen between preoperative and 6-month postoperative assessments of all patients (pre = 1.490, post = 1.166; P = 0.022). Subgroup analysis of patients with successful closure revealed 20 letters of improvement (0.398 logMAR) in visual acuity (pre = 1.491, post = 1.093; P = 0.004). There were no intraoperative or postoperative complications. In eyes with persistent or recurrent idiopathic macular holes after standard PPV with internal limiting membrane peeling, repeat PPV with subretinal balanced salt solution injection to create a macular detachment may be a viable surgical treatment option. Our results show improved anatomical and visual outcomes postoperatively that compare favorably to other case series describing various surgical treatments for these challenging cases.

Migrated Intracranial Falling Bullet, Crossed Midline Twice in a Conscious Patient

Our reported case is a 40-years-old male with history of penetrating head injury by a falling bullet, crossed midline twice (at time of injury and during spontaneous migration). The patient of our report was conscious at presentation and showed moderate visual field defect. Although reported morbidity and mortality is high in such injuries, our patient survived with less morbidity and a subjective visual improvement after surgical removal of the bullet

Indication for cataract surgery. Do we have evidence of who will benefit from surgery? A systematic review and meta-analysis.

The need for cataract surgery is expected to rise dramatically in the future due to the increasing proportion of elderly citizens and increasing demands for optimum visual function. The aim of this study was to provide an evidence‐based recommendation for the indication of cataract surgery based on which group of patients are most likely to benefit from surgery. A systematic literature search was performed in the MEDLINE, CINAHL, EMBASE and COCHRANE LIBRARY databases. Studies evaluating the outcome after cataract surgery according to preoperative visual acuity and visual complaints were included in a meta‐analysis. We identified eight observational studies comparing outcome after cataract surgery in patients with poor (<20/40) and fair (>20/40) preoperative visual acuity. We could not find any studies that compared outcome after cataract surgery in patients with few or many preoperative visual complaints. A meta‐analysis showed that the outcome of cataract surgery, evaluated as objective and subjective visual improvement, was independent on preoperative visual acuity. There is a lack of scientific evidence to guide the clinician in deciding which patients are most likely to benefit from surgery. To overcome this shortage of evidence, many systems have been developed internationally to prioritize patients on waiting lists for cataract surgery, but the Swedish NIKE (Nationell Indikationsmodell för Katarakt Ekstraktion) is the only system where an association to the preoperative scoring of a patient has been related to outcome of cataract surgery. We advise that clinicians are inspired by the NIKE system when they decide which patients to operate to ensure that surgery is only offered to patients who are expected to benefit from cataract surgery.

Initial clinical results of a new telescopic IOL implanted in patients with dry age-related macular degeneration.

To evaluate the safety and efficacy of the iol-AMD technology (London Eye Hospital Pharma, London, UK), which includes two injectable, hydrophobic acrylic intraocular lenses (IOLs) in a pilot study of patients diagnosed as having cataract and dry age-related macular degeneration. The cataract surgery and IOL implantation were performed after a preoperative evaluation using the iolAMD simulator in eyes with bilateral intermediate dry age-related macular degeneration. Outcomes were intraoperative and postoperative complications, subjective and objective visual acuity improvement, visual field changes, and postoperative diplopia. Three eyes of 2 patients were evaluated. The surgeries were uneventful. All eyes gained monocular reading vision at the 1-week postoperative visit. One patient with monocular implantation recognized diplopia for distance vision. Preoperative corrected distance visual acuity ranged from 20/800 to 20/125 and corrected near visual acuity was 20/800 or less. Two months after surgery, corrected distance and near visual acuities increased to levels between 20/40 and 20/25 (uncorrected distance visual acuity was 20/60 to 20/32; uncorrected near visual acuity was 20/200 to 20/25). These early results showed that the iolAMD simulator is a promising technology improving near and distance visual acuity in eyes with intermediate dry macular degeneration. The prismatic IOL effect did not lead to diplopia when implanted bilaterally. The surgery was safely performed.

Temporally coherent superresolution of textured video via dynamic texture synthesis.

This paper addresses the problem of hallucinating the missing high-resolution (HR) details of a low-resolution (LR) video while maintaining the temporal coherence of the reconstructed HR details using dynamic texture synthesis (DTS). Most existing multiframe-based video superresolution (SR) methods suffer from the problem of limited reconstructed visual quality due to inaccurate subpixel motion estimation between frames in an LR video. To achieve high-quality reconstruction of HR details for an LR video, we propose a texture-synthesis (TS)-based video SR method, in which a novel DTS scheme is proposed to render the reconstructed HR details in a temporally coherent way, which effectively addresses the temporal incoherence problem caused by traditional TS-based image SR methods. To further reduce the complexity of the proposed method, our method only performs the TS-based SR on a set of key frames, while the HR details of the remaining nonkey frames are simply predicted using the bidirectional overlapped block motion compensation. After all frames are upscaled, the proposed DTS-SR is applied to maintain the temporal coherence in the HR video. Experimental results demonstrate that the proposed method achieves significant subjective and objective visual quality improvement over state-of-the-art video SR methods.

Acute-Onset Altitudinal Visual Field Defect Caused by Optic Canal Meningioma

Dear Editor, Altitudinal visual field defect (VFD), which involves the loss of visual sensation in the horizontal half of the visual field, is caused mainly by anterior ischemic optic neuropathy (AION),1,2,3 or rarely by compressive neuropathy due to a tumor or aneurysm.4,5 However, acute-onset inferior altitudinal VFD is a hallmark of AION.1,2,3 We observed a patient with a rapidly developed inferior altitudinal VFD due to a small meningioma inside the optic canal, which was almost undetectable in standard imaging studies. A 65-year-old man with hypertension and hyperlipidemia complained of blurred vision persisting over several days. He denied having headache, diplopia, or ocular pain. He had a history of medullary infarction and was taking aspirin, antihypertensive medication, and a statin. With the exception of the old infarction, there were no abnormal findings on axial T2-weighted MRI scans obtained 10 months previously (Supplementary Fig. 1 in the online-only Data Supplement). An ophthalmologic examination revealed decreased visual acuity in the left eye (10/20) compared to the right (16/20). Humphrey perimetry revealed an inferior altitudinal VFD in the left eye, which was more severe on the nasal side than on the temporal side (Fig. 1A). There was no evidence of relative afferent pupillary defects, ptosis, proptosis, or disc swelling, or pallor on funduscopy. Ocular movement, intraocular pressures, and slit-lamp and optical coherence tomography findings were normal. The acute onset and painless monocular visual loss raised a suspicion of AION, leading to a focus on evaluating the patient's vascular etiology. However, there were no abnormal findings on MR angiography (Supplementary Fig. 1 in the online-only Data Supplement). A follow-up visual field test performed 3 weeks later revealed an aggravated altitudinal VFD, especially on the inferior temporal side (Fig. 1A). High-spatial-resolution (2-mm slice thickness) MRI with gadolinium enhancement of the orbit was performed to exclude compressive neuropathy mimicking AION. The results revealed a 1.2-cm meningioma on the posterior part of the left optic canal causing medial displacement and downward compression of the optic nerve (Fig. 1B and C). The patient underwent a frontotemporal craniotomy and resection of the meningioma. The tumor originated from the left side tuberculum sellar and extended into the optic canal. Although he reported a subjective improvement in vision immediately after surgery, the VFD was aggravated on the superior side just before surgery (Fig. 1A). Four months after resection of the tumor, his vision had partially recovered (Fig. 1A). Fig. 1 Serial Humphrey perimetries and high-resolution MRI of compressive optic neuropathy with a monocular inferior altitudinal visual field defect (VFD). A: Initial Humphrey perimetry shows an inferior altitudinal VFD in the left eye that is more severe on ... The main mechanism underlying the visual disturbance in compressive optic neuropathy is secondary disruption of the axoplasmic flow and demyelination of the optic nerve.6 Therefore, the onset of VFD usually progresses slowly. Since the optic nerve delivers visual information received from each of the retinal quadrants to the optic chiasm, the VFD can present in various patterns according to the initial direction of optic nerve compression. In this case the VFD started at the inferonasal area and extended to the inferotemporal area, which can be explained by a medial downward displacement of the optic nerve due to compression from the meningioma (Fig. 1D). The VFD was rapid and severe due to the meningioma being located on the optic canal and the diagnosis delay. Another possible mechanism is ischemia caused by vascular compression. Ischemic symptoms usually present as posterior ischemic optic neuropathy (PION) with compression of the collateral branches from the ophthalmic artery in the optic canal.7 However, ischemia is unlikely to be the main mechanism in this case for two reasons: 1) an altitudinal VFD is relatively rare in PION7 and 2) in this case the VFD worsened according to the direction of nerve compression and improved following surgical resection. Other features associated with compressive optic neuropathy were absent in this case, which may be due to the smallness of the tumor. Optic nerve meningioma arising within the optic canal is rare.8 These tumors are usually extremely small despite causing significant visual disturbance and can easily be overlooked on routine MRI. Furthermore, they may not have any orbital signs, and may present with a normal-appearing optic disc.8 Therefore, it is necessary to consider compressive optic neuropathy when a patient presents with an altitudinal VFD, even in the absence of other symptoms.

Manuel′s asteroid disruption technique

A seventy-year-old male presented with dense asteroid hyalosis in both eyes. He had undergone cataract extraction in one eye 3 years ago, and the other eye had immature cataract. Both the autorefractor and dilated streak retinoscopy did not give readings and subjective visual improvement could not be achieved. Immediately following YAG posterior capsulotomy and anterior vitreous asteroid disruption, the vision improved to 20/20 with recordable auto refractor and streak retinoscopy values. Our initial experience indicates that the treatment is simple, safe and effective but needs controlled and prospective studies to confirm its long-term safety.

A Case of Nonparaneoplastic Autoimmune Retinopathy

Purpose: To report a case of nonparaneoplastic autoimmune retinopathy diagnosed using serum anti-retinal autoantibodies. Case summary: A 60-year-old female complained of progressive visual loss in both eyes over 3 months. Her best corrected visual acuity was hand motion in the right eye, 0.9 (decimal) in the left eye, and no definite abnormal findings were identified on fundus examinations. Automated visual field test revealed severely depressed visual fields in both eyes. Standard full-field electroretinogram (ERG) revealed nearly extinguished scotopic b-waves and spectral-domain optical coherence tomography (SD-OCT) showed subtle obscuration and interruption of the inner segment/outer segment (IS/OS) junction of the photoreceptors. Using Western blotting with human retinal proteins and the patient’s serum, we diagnosed nonparaneoplastic autoimmune retinopathy and performed posterior subtenon steroid injection in the right eye, systemic corticosteroids, and oral mycophenolate mofetil. Full-field ERG after treatment showed slightly increased amplitude but there was no subjective visual improvement. OCT after treatment did not reveal significant changes in the photoreceptor layer. Conclusions: This is the first reported case of nonparaneoplastic autoimmune retinopathy in Korea diagnosed using Western blotting with anti-retinal autoantibodies. Autoimmune retinopathy should be considered in patients with visual field and ERG impairment without definite fundus abnormalities. J Korean Ophthalmol Soc 2015;56(7):1134-1140

Response to aflibercept as secondary therapy in patients with persistent retinal edema due to central retinal vein occlusion initially treated with bevacizumab or ranibizumab.

Recent advances have given practitioners options for the treatment of macular edema secondary to central retinal vein occlusion. These options include steroid injections and implants as well as anti-vascular endothelial growth factor medications. However, there is little in the medical literature to guide secondary therapy when an initial treatment strategy is insufficient. The authors present encouraging results from the treatment of six consecutive cases of central retinal vein occlusion treated with aflibercept as a secondary therapy for macular edema refractory to repeated intravitreal bevacizumab or ranibizumab injections. A retrospective review of six consecutive cases of central retinal vein occlusion with persistent macular edema despite regular anti-vascular endothelial growth factor injections that were transitioned to aflibercept was conducted. Optical coherence tomography and visual acuity data were examined. All six eyes from the six patients included showed either complete or near complete resolution of macular edema with one or two injections of aflibercept. The improvement in edema was accompanied by lasting modest visual gains in three of the six patients and in subjective visual improvement in four of the six patients. The six eyes in this series all responded favorably to aflibercept as a secondary therapy. Although the sample size is too small to draw definitive conclusions, the results are encouraging.