Superficial Retinal Hemorrhages Research Articles

Central Retinal Vein Occlusion as a Presenting Feature Caused by Hypertensive Crisis Secondary to IgA Nephropathy in a Previously Undiagnosed Young Patient

We present a case of Ischemic Central retinal vein occlusion (CRVO) caused by hypertension secondary to renal failure in IgA nephropathy. A 17 year old male came with chief complaints of sudden painless diminution of vision in RE since 15 days. On examination the Right eye showed multiple superficial retinal haemorrhages in all 4 quadrents with dilated veins and cystoid macular edema suggestive of CRVO and Left eye showed superficial flame shaped haemorrhage suggestive of grade 3 hypertensive changes.

Susac syndrome: A rare presentation

Susac syndrome is an autoimmune microangiopathy characterized by a triad of encephalopathy, sensori-neural hearing loss and varying degrees of branch retinal artery occlusion. A young male patient is described with features of focal neurological lesions and small superficial retinal haemorrhages and areas of retinal arteriolar endothelial inflammation appearing as Gass plaques. Susac syndrome presents with varying features involving brain, inner ear and retina. Fundus Fluorescein angiography should be performed in all patients with an unexplained encephalopathy to look for characteristic arteriolar wall changes.

Hypertensive Chorioretinopathy

A 54-year-old man was referred to the ophthalmology unit for blurring of vision in both eyes. On ophthalmic examination, his best-corrected visual acuity (BCVA) was 0.1 in the right eye and 0.7 in the left eye. Fundoscopy revealed disc swelling, cotton-wool spots, superficial retinal hemorrhages, and macular edema with hard exudates in both eyes. Optical coherence tomography (OCT) showed marked serous retinal detachment, involving the fovea, and cystic change of the inner retinal layer in both eyes. We diagnosed the condition as hypertensive retinopathy with marked serous retinal detachment caused by hypertensive choroidopathy. His blood pressure was 189/116 mmHg. There was no secondary cause of hypertension. Two months after resuming his regular medications, his BCVA improved to 0.6 in the right eye and 1.0 in the left eye, with regression of fundus changes, including serous retinal detachment. In malignant hypertension, both retinopathy and choroidopathy can occur, which can be detected on OCT.

Multimodal imaging characteristics in eyes with vitreoretinal lymphoma treated with intravitreal rituximab.

To characterize the imaging features in eyes with vitreoretinal lymphoma (VRL) using ultra-widefield fundus photography (UWF-FP), swept-source optical coherence tomography (SSOCT) and fundus autofluorescence (FAF) that are correlated to ongoing treatment with intravitreal Rituximab(IVR). Retrospective observational imaging-based study of 15 treatment-naive eyes with VRL treated with IVR. All patients with primary VRL underwent vitreous biopsy using 23/25G microincision vitrectomy system for confirmation of diagnosis. All eyes received monthly IVR (1mg/0.1mL) injections till disease remission. Baseline clinical characteristics, treatment details, outcomes, and sequential imaging features on UWF-FP, FAF, and SSOCT were analyzed. Baseline features and changes in UWF-FP, FAF patterns, and SSOCT features in response to treatment RESULTS: Clinically, patients presented with sub-RPE deposits (n = 15), superficial retinal hemorrhages (n = 2), 'giant' RPE (retinal pigment epithelium) holes (n = 2), and anterior segment reaction (n = 1). Eyes were treated with mean 5.7 IVR injections (median: 5; range 1-13) over a mean 7.2 ± 4.9months. During the course of treatment, two eyes developed superficial retinal hemorrhages with spontaneous resolution, 2 eyes developed CME, and 4 eyes developed characteristic 'leopard skin' pigmentation. Hyper-autofluorescence corresponding to areas of active lesions decreased with each treatment cycle and was finally replaced by hypo-autofluorescence. Serial OCTs showed regression of sub-RPE/subretinal deposits (n = 15), ellipsoid zone disruption (n = 9), and its resolution with treatment (n = 3), epiretinal membrane (ERM; n = 6), choroidal hyperreflective foci (HRF; n = 4), disorganization of retinal inner layers (DRIL; n = 3), RPE-rip (n = 2), cystoid macular edema (CME; n = 2), and hyperreflective lesions in the choroid (n = 1). Complete resolution was observed in all eyes with extensive hypo-AF. The central foveal thickness decreased from 237 ± 113μ to 182 ± 114μ (p = 0.1) and subfoveal choroidal thickness decreased from 258 ± 66μ to 220 ± 64μ (p = 0.12) at final follow-up. The mean baseline BCVA was logMAR 0.9 ± 0.9 that deteriorated to mean logMAR 1 ± 1 final visit (p = 0.7). The mean recurrence-free follow-up was 5.9 ± 5.1months CONCLUSION: Multimodal imaging provides novel insights into features of VRL, a better understanding of regression patterns, and prognostication of outcomes when treated with intravitreal rituximab. Larger, multicentric studies with longer follow-up will help unravel imaging biomarkers to understand these aspects better.

Central retinal vein occlusion caused by anomalous prepapillary venous loop

We present a case of prepapillary venous loop complicated by central retinal vein occlusion (CRVO). A 56-year-old female reported to us with blurring of vision in the right eye, noticed 8 days ago. Fundus examination in the right eye showed multiple superficial retinal hemorrhages in all the four quadrants with dilated veins and cystoid macular edema, suggestive of CRVO. Prepapillary venous loops were seen in both the eyes. In our case, both the eyes had an abnormal venous anatomy at the disc. On fundus fluorescein angiography, only the looped segment showed laminar flow in late phase in both the eyes. Hence, patients with an abnormal retinal venous anatomy should be treated with caution as they are considered to be at a high risk of retinal vein occlusion.

Risk factors of branch retinal vein occlusion (BRVO) a study at tertiary care centre

Introduction: Retinal vein occlusion is second most common retinal vascular disorder after diabetic retinopathy. BRVO caused due to occlusion of branch vein of retina with involvement of particular quadrant. On ophthalmoscopic examination patient will have retinal edema and or macular edema with superficial and deep retinal haemorrhages and venous dilatation within the affected sector. The most recognized risk factor for BRVO are age and systemic vascular disorders. Materials and Methods: Prospective observational study was done for the period of one year. Patients more than 30 years of age attending ophthalmology OPD found to have BRVO were evaluated for various risk factors after taking consent. History and thorough eye examination were carried out including fundus photography and fluorescein angiography. Results: In this study 38 patients of more than 30 years (32-75 years) found to have BRVO out of which 21 were male and 17 were female. 25 cases (65.78%) (p-value 0.0384) having hypertension, 8 case (21.05%) (p-value 0.135) having diabetes, 7 (18.42%) (p-value 0.04) were smokers, 13 (34.21%) (p-value 0.0008) were having altered lipid profile, 15 (65.22%) (p value < 0> Conclusion: With the help of modern instrument and technology branch retinal vein occlusion can be easily diagnosed and treated. It is a multi-factorial disease affect the eyes of an individual having hypertension with other risk factors like ageing, hyperlipidaemia, homocysteinemia etc. so beware of four H, higher age, hypertension, hyperlipidaemia, homocysteinemia. Keywords: BRVO, Diabetes mellitus, Hypertension, Homocysteinemia, Smoking

Atypical cytomegalovirus retinitis in an immunocompetent individual with diffuse large B-cell lymphoma posing a diagnostic enigma

Cytomegalovirus (CMV) retinitis is a vision-threatening condition seen with CD4+ count below 50/μL. In the presence of systemic lymphoma, CMV retinitis may pose a diagnostic dilemma due to similar clinical features with intraocular lymphoma. We, hereby, report a rare case of bilateral CMV retinitis in a patient with normal CD4+ counts and a past history of diffuse large B-cell lymphoma (DLBCL). A 51-year-old male presented with sudden-onset painless diminution of vision in the right eye (RE) for a 2-week duration. He had a past history of DLBCL and had been treated with chemotherapy. On examination, his best-corrected visual acuity was perception of light in RE and 20/20 in the left eye (LE). RE fundus examination showed yellowish-white deep retinal lesions with scanty superficial retinal hemorrhages and perivascular exudates. LE fundus examination showed only one focal area of yellowish-white deep retinal lesions along the inferotemporal arcade. A provisional diagnosis of bilateral intraocular lymphoma was made based on the past history of systemic lymphoma. RE vitreous tap was done, and intravitreal injection of methotrexate was given. Vitreous sample revealed CMV DNA on polymerase chain reaction but no evidence of malignant cells on cytology. CD4 count was 393 cells/μl. The patient was subsequently treated with intravenous ganciclovir and oral valganciclovir for bilateral CMV retinitis. This case report highlights the importance of vitreous sample analysis in patients of systemic lymphoma presenting with atypical retinal necrotic lesions to establish an accurate diagnosis and to differentiate between closely mimicking lesions of intraocular lymphoma and viral retinitis.

Isolated unilateral traumatic purtscher's retinopathy: An unusual presentation

This report describes a 55-year-old healthy male, who presented with defective vision, 2 days after a fall from height. Ophthalmoscopy showed multiple superficial retinal hemorrhages with cotton wool spots near the optic disc of the right eye. The left eye was normal. There was no evidence of focal neurological deficits, long bone fractures, or chest compression. With the history of trauma and characteristic retinal findings, a diagnosis of Purtscher's retinopathy was made. The patient was treated with tapering dose of systemic steroid. Visual acuity failed to regain with development of consecutive optic atrophy.

Multilayered optic disc hemorrhages in adolescents.

To describe the clinical characteristics of multilayered optic disc hemorrhages, which are defined as subretinal, superficial retinal, and subhyaloid or vitreous hemorrhages in adolescents. Case records of adolescents with acute multilayered optic disc hemorrhages were identified and evaluated retrospectively from 1994 to 2012. The appearance of the hemorrhages including the size, location, extension, and disc anatomy was recorded. Fluorescein angiography, visual field examination, and spectral-domain optical coherence tomography were performed in select cases. Nine boys and 7 girls were included, with a mean age of 15.0 ± 2.6 years. No precipitating factor, such as involuntary Valsalva maneuver, was identified in the majority of patients (93.75%). All eyes were myopic with an average refraction of -4.64 ± 1.88 diopters. Fifteen (93.75%) of the affected optic discs were crowded and tilted with small cups. Peripapillary subretinal hemorrhages were all crescent in shape and located at the nasal disc. Eight (50%) eyes had marked subretinal blood extension exceeding 1 disc diameter away from the disc edge. Superficial flame hemorrhages were predominantly located in the superotemporal part of the disc. Spectral-domain optical coherence tomography of the disc showed vitreopapillary traction and obvious subretinal hemorrhage with increased thickness. All multilayered optic disc hemorrhages resolved spontaneously. Multilayered optic disc hemorrhages in adolescents more commonly affect myopic eyes with crowded and tilted discs. The visual outcome is excellent.

An overlap of Coats and Eales diseases or a Coats variant?

To report an association between Coats and Eales diseases, an uncommon presentation. A 21-year-old male presented with gradual visual impairment of two years duration in his left eye. The slit-lamp examination of the affected eye revealed +2 vitreous cells. The other findings were peri-papillary fluid accumulation and extensive macular lipid exudate deposition. Small white vessels were coursing over the macula. The major veins were dilated and tortuous and massive sheathing of both arteries and veins was forming a common sheath. In the mid-periphery and periphery of the retina, discrete hard exudates, tiny superficial retinal hemorrhages and massive vascular sheathing were present. In the inferotemporal region, two intra-retinal macrocysts were located distal to the retinal vasculature. Fluorescein angiography (FA) of the left eye highlighted numerous aneurysmal dilatations throughout the posterior pole. Fluorescein angiography also showed para-foveal telangiectasia and tiny telangiectatic vessels on the optic disk that led to late staining of the macula and optic disk. Hyperfluorescent patches of deep choroiditis were present in the early phases. There was segmental but no diffuse staining of the retinal veins which showed massive sheathing on fundoscopy. In the periphery, segmental venous staining and choroidal leakage to a lesser extent were observed. In the infero-temporal quadrant, a clear-cut zone of non-perfusion and vascular abnormalities (micro-macro aneurysms, veno-venous shunts, venous beading) at the junction between the perfused and non-perfused zones were present. The findings were reminiscent of both Coats and Eales diseases. Though known as two distinct entities, both retinal pathologies may present in a single form.

Vascular changes in the retina in patients with chronic respiratory insufficiency.

Chronic respiratory insufficiency is a pathological state which occurs as a result of respiratory system inability to maintain normal gas exchange between the outside air and circulating blood. For the purposes of human organism's proper functioning, it is necessary that a certain amount of air in the lungs comes into contact with a certain amount of blood within a unit of time, so that an adequate hemoglobin oxygenation could be achieved. Then, hemoglobin from erythrocytes in the blood supply delivers oxygen to all the tissues and cells of the body including the eye. Direct impact of hypoxemia and hypercapnia on the wall of arterioles, venules and capillaries results in a severe vasodilatation along with the increased permeability of the walls causing clinically evident changes in the retina. The aim of this study was to determine the degree of ocular changes in retina with patients suffering from chronic respiratory insufficiency. A prospective study was conducted on 80 patients, 40 patients with respiratory failure and 40 patients with chronic obstructive pulmonary disease an and bronchial asthma (the control group). In all the patients direct and indirect ophthalmoscopy and fluoresceine angiography was performed. Clinically visible fundus and retina changes in patients suffering from chronic respiratory failure were categorized as mild (dilatation and retinal veins and arteries tortosion up to the mid-periphery), moderate (retinal hemorrhage) and severe (optic nerve edema, macular edema, superficial and deep retinal hemorrhages and venous occlusion). In the patients suffering from respiratory insufficiency the changes in retinal blood vessels were found [in 18 (45%) mild, in 13 (32.5%) moderate, and in 9 (22%) severe], while in the patients with chronic obstructive pulmonary disease and bronchial asthma (without respiratory insufficiency) no changes were recognized. The results of this study indicate the need for ophthalmologic examination in patients with chronic respiratory insufficiency. It is important to recognize, identify and quantify the changes on retinal blood vessels which are clinically significant. It is necessary to provide their monitoring and to prescribe proper therapeutic treatment in order to preserve visual functions.

Ocular Findings in Patients with Crimean-Congo Hemorrhagic Fever

To describe ocular findings of patients with Crimean-Congo hemorrhagic fever (CCHF). Prospective, interventional, consecutive case series. This study was conducted in Sivas, a city located in the central Anatolia, between July 1 and August 31, 2007. Confirmed CCHF patients were enrolled in the study and underwent ocular examination during hospitalization. Nineteen confirmed CCHF patients were included in this study. All patients were classified into 2 groups in terms of disease severity (severe vs nonsevere), according to the Swanepoel predictive criteria. Fourteen patients (73.7%) were classified as "nonsevere," and the remaining 5 patients (26.3%) were classified as "severe" in this study. One patient having severe disease died. Ocular findings were present in 14 patients (73.7%) and none of the patients presented any visual complaints. Ocular examination revealed that 7 patients (36.8%) had only bilateral multiple subconjunctival hemorrhage, and 2 patients (10.5%) (1 bilateral, 1 unilateral) had retinal hemorrhage. Five patients (26.3%) had subconjunctival hemorrhage and retinal hemorrhage. Follow-up examination 1 month later showed complete resorption of the subconjunctival hemorrhage and retinal hemorrhage. There was a statistically significant difference between patients with ocular findings and patients without ocular findings for prothrombin time (P = .011). There was no evidence of uveitis, retinal edema, sheathing of retinal vessels, or intravitreal hemorrhage in our patients. From the small sample study, CCHF caused a mild form of ocular disease. CCHF must be considered when subconjunctival or superficial retinal hemorrhages are seen in association with fever in endemic areas.

Retinal folds and retinoschisis in accidental and non-accidental head injury

To report the similarity of retinal findings in an infant who sustained an accidental head injury and an infant with non-accidental head trauma. Two male infants sustained head injuries with skull fractures. Case 1 was an accidental head injury and case 2 was a non-accidental head injury. On examination, in case 1, there were four superficial retinal haemorrhages in the right fundus. The left eye had a haemorrhagic optic disc oedema with extensive retinal haemorrhages, retinal folds, and schitic cavities within the retina at the posterior pole. In case 2, the right fundus had a single blot haemorrhage at the posterior pole. The left fundus revealed optic disc haemorrhage and oedema with extensive retinal haemorrhages. There was a haemorrhagic retinoschisis with a retinal fold. The two cases, one with accidental and the other with non-accidental injury, demonstrate very similar ophthalmic findings. This supports the argument that there may be no retinal signs seen exclusively in non-accidental head injury.

Behcet's disease

A 27-year-old man of Middle Eastern descent presented to the hospital after waking with severely reduced visual acuity in his left eye. Several months before presentation he had experienced an episode of reduced visual acuity in his right eye that had slowly resolved over several weeks. The patient had a history of long-standing recurrent oral–labial aphthae, intermittent painful swelling of his knees and ankles, low-grade fevers and night sweats. On examination, the patient was afebrile and had normal vital signs. An oral–labial aphtha was present (Fig. 1). His visual acuity was 6/60 in the left eye and 6/6 in the right. Funduscopy revealed disc edema and retinal vasculitis, shown by superficial retinal hemorrhages with pale centres (Fig. 2). Anterior uveitis was noted on examination with a slit lamp. The patient also had erythematous plantar maculae (Fig. 3), effusion in his right knee and scattered pseudofolliculitis. Fig. 1: Oral–labial aphtha. Fig. 2: Retinal hemorrhages with pale centres. Fig. 3: Erythematous plantar maculae. The results of blood counts and serum tests were normal. The C-reactive protein level was elevated at 123 (normal < 5) mg/L, as was the erythrocyte sedimentation rate at 35 (normal < 10) mm/h. Results of serologic tests, including those for collagen vascular diseases, were normal. Thoracic, lumbar and sacroiliac radiographs were unremarkable. Results of arthrocentesis were consistent with an inflammatory arthropathy. Results of an echocardiogram were normal. Fungal, viral (including HIV), bacterial and spirochete cultures were negative. Tuberculin purified protein derivative and pathergy skin testing also yielded negative results. The patient was positive for the HLA-B51 antigen. A skin biopsy revealed evidence of vasculopathy, including swelling of endothelial cells and perivascular inflammatory cell infiltrate (Fig. 4). Behcet's disease was diagnosed. Fig. 4: Endothelial cell swelling (black arrow) and perivascular inflammatory cell infiltrate (white arrows). The patient received no specific therapy for Behcet's disease, and after 4 weeks all symptoms had completely resolved.

New classification system-based visual outcome in Eales′ disease

A retrospective tertiary care center-based study was undertaken to evaluate the visual outcome in Eales' disease, based on a new classification system, for the first time. One hundred and fifty-nine consecutive cases of Eales' disease were included. All the eyes were staged according to the new classification: Stage 1: periphlebitis of small (1a) and large (1b) caliber vessels with superficial retinal hemorrhages; Stage 2a: capillary non-perfusion, 2b: neovascularization elsewhere/of the disc; Stage 3a: fibrovascular proliferation, 3b: vitreous hemorrhage; Stage 4a: traction/combined rhegmatogenous retinal detachment and 4b: rubeosis iridis, neovascular glaucoma, complicated cataract and optic atrophy. Visual acuity was graded as: Grade I 20/20 or better; Grade II 20/30 to 20/40; Grade III 20/60 to 20/120 and Grade IV 20/200 or worse. All the cases were managed by medical therapy, photocoagulation and/or vitreoretinal surgery. Visual acuity was converted into decimal scale, denoting 20/20=1 and 20/800=0.01. Paired t-test / Wilcoxon signed-rank tests were used for statistical analysis. Vitreous hemorrhage was the commonest presenting feature (49.32%). Cases with Stages 1 to 3 and 4a and 4b achieved final visual acuity ranging from 20/15 to 20/40; 20/80 to 20/400 and 20/200 to 20/400, respectively. Statistically significant improvement in visual acuities was observed in all the stages of the disease except Stages 1a and 4b. Significant improvement in visual acuities was observed in the majority of stages of Eales' disease following treatment. This study adds further to the little available evidences of treatment effects in literature and may have effect on patient care and health policy in Eales' disease.

Ocular manifestations of dengue fever in an East Indian epidemic

Background: The incidence and geographic distribution of dengue has increased dramatically in recent years. Previously, ocular findings in dengue fever were considered rare. We report a spectrum of ocular manifestations of this potentially fatal disease and its association with laboratory parameters. Methods: 134 patients hospitalized with a diagnosis of dengue fever during an epidemic were included. Systemic and ophthalmic examinations were completed on all patients. Results: The mean age was 31.3 years and 63.4% were males. All patients presented with fever. Six (4.5%) patients had retrobulbar pain and none of the patients presented with any visual complaints. Ocular findings were present in 54 (40.3%) patients. Subconjunctival haemorrhage was the commonest eye finding seen in 50 patients, of whom 84% had characteristic petechial type of haemorrhages. Fundus findings present in 10 (7.5%) patients included dilatation and tortuosity of vessels, superficial retinal haemorrhages, cotton-wool spots, and hard exudates; the macula, however, was spared in all patients. Only 6 of the patients with posterior segment involvement returned for follow-up examination and it was found that retinal changes had resolved without any specific treatment within 2 to 8 weeks time. Of all laboratory parameters evaluated, marked thrombocytopenia (platelet count <50000/µl_) emerged to be significantly associated with ocular haemorrhage. Interpretation: Multiple subconjunctival haemorrhages, especially petechial type, are a common manifestation of dengue infection. Dengue fever patients with marked thrombocytopenia are predisposed to spontaneous ocular haemorrhages.

Ocular manifestations of dengue fever in an East Indian epidemic

Background: The incidence and geographic distribution of dengue has increased dramatically in recent years. Previously, ocular findings in dengue fever were considered rare. We report a spectrum of ocular manifestations of this potentially fatal disease and its association with laboratory parameters. Methods: 134 patients hospitalized with a diagnosis of dengue fever during an epidemic were included. Systemic and ophthalmic examinations were completed on all patients. Results: The mean age was 31.3 years and 63.4% were males. All patients presented with fever. Six (4.5%) patients had retrobulbar pain and none of the patients presented with any visual complaints. Ocular findings were present in 54 (40.3%) patients. Subconjunctival haemorrhage was the commonest eye finding seen in 50 patients, of whom 84% had characteristic petechial type of haemorrhages. Fundus findings present in 10 (7.5%) patients included dilatation and tortuosity of vessels, superficial retinal haemorrhages, cotton-wool spots, and hard exudates; the macula, however, was spared in all patients. Only 6 of the patients with posterior segment involvement returned for follow-up examination and it was found that retinal changes had resolved without any specific treatment within 2 to 8 weeks time. Of all laboratory parameters evaluated, marked thrombocytopenia (platelet count <50000/µl_) emerged to be significantly associated with ocular haemorrhage. Interpretation: Multiple subconjunctival haemorrhages, especially petechial type, are a common manifestation of dengue infection. Dengue fever patients with marked thrombocytopenia are predisposed to spontaneous ocular haemorrhages.

Decreased Platelet Membrane Fluidity in Retinal Periphlebitis in Eales' Disease

Purpose: Oxidative damage to cellular membranes plays an important role in the pathobiology of tissue injury. Free radical-induced peroxidation of membrane lipid and protein is associated with alterations in cellular, morphological, biochemical, and physical dynamics, which are related to the mobility of lipid molecules. Retinal photoreceptors and platelets have been shown to be an easy target of oxidants because of their high proportion of polyunsaturated fatty acids. This study was undertaken, for the first time, to investigate membrane fluidity in the platelets of patients with Eales' disease. Methods: Assays of malonaldialdehyde levels and the enzymes superoxide dismutase and catalase and fluorescence polarization, for estimating membrane fluidity, were carried out on platelets from 20 patients with Eales' disease (stage 1 characterized by periphlebitis of small (1a) and large (1b) caliber vessels with superficial retinal hemorrhages) and 15 healthy controls. Results: A significant increase was observed in the malonaldialdehyde levels. A significant decrease in the activity of superoxide dismutase and catalase was also observed. Platelet fluorescence polarization was significantly higher in the patients, indicating decreased membrane fluidity compared to controls (p < 0.01). Conclusion: A decrease in platelet membrane fluidity occurs as a result of oxidative stress in retinal periphlebitis in Eales' disease. The decreased membrane fluidity suggests alterations in the physiological events, which may result in alterations in the functioning of retinal photoreceptors.

A new staging system for idiopathic retinal periphlebitis.

To develop and standardize a universally acceptable new staging system for idiopathic retinal periphlebitis (Eales disease). A new staging system was established and standardized based on standard terminology and features. Idiopathic retinal periphlebitis was classified as peripheral and central types. Peripheral disease consisted of four stages. Stage 1 is periphlebitis of small (1a) and large (1b) caliber vessels with superficial retinal hemorrhages. Stage 2a denotes capillary nonperfusion and 2b neovascularization elsewhere/of the disc. Stage 3a is classified as fibrovascular proliferation and 3b vitreous hemorrhage. Stage 4a is traction/combined rhegmatogenous retinal detachment whereas 4b is rubeosis iridis, neovascular glaucoma, complicated cataract, and optic atrophy. A total of 253 cases of idiopathic retinal periphlebitis (mean age, 24.7 +/- 4.7 years, all male) presenting at this tertiary care center were classified prospectively according to the new staging system, by two independent observers (interobserver correlation = 0.7). The new staging system was consistent, simple, and easy to recall. Peripheral and central types of idiopathic retinal periphlebitis were found in 94.07% and 5.93% of cases, respectively. The new staging system also defined the severity of the disease. Vitreous hemorrhage was found to be the commonest presenting feature (51.68%), whereas traction/combined rhegmatogenous detachment was found in 5.88% of cases. The new staging system is useful in classifying and assessing the severity of disease. Management strategy can also be defined according to the stage of the disease. It is designed to promote the use of standard assessment with applications to clinical management and research.

Retinal Lesions as Clues to Disseminated Bacterial and Candidal Infections

Invasive bacterial and candidal infections are known to involve the retina, but the natural history of the retinal lesions and the utility of ophthalmologic consultation in the critical care setting as a diagnostic tool are not well understood. We 1) performed weekly funduscopic examinations on 77 medical and surgical patients in intensive care units (ICUs), 2) analyzed results of serial ocular examinations in 180 non-neutropenic patients with candidemia, and 3) reviewed the English literature on the association of retinal lesions with disseminated bacterial or candidal infection (DBCI). We found that 15 (19%) of the ICU patients had retinal lesions consistent with DBCI. Of these 15, 1 had clearly sepsis-related retinal lesions, while 13 (87%) had 1 or more systemic disease that could have explained their retinal findings (6 diabetic retinopathy; 2 human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) retinopathy; 2 hypertensive retinopathy; 1 hemolytic uremic syndrome, and 1 leukemia). Multivariate analysis revealed that systemic disease (odds ratio 8.37, 95% confidence intervals: 3.24-21.56) independently correlated with the presence of retinal lesions while DBCI, trauma, hyperalimentation, and transfusion of blood products were not independently predictive in any analysis. Twenty of the 180 (15%) candidemic patients had retinal lesions. Two (1%) had classic 3-dimensional white lesions with vitreal extension, and 5 (2.7%) had chorioretinal lesions without vitreal haziness. Notably, 10% of patients had superficial retinal hemorrhages and/or cotton wool spots that could have been due to either candidemia or a systemic disease (diabetes, hypertension, renal failure, closed head trauma). Concurrent bacteremia occurred in 3 of the 27 patients with eye lesions. Retinal lesions resolved in a mean of 33 days. None of the patients had symptoms at the time of the retinal finding. We found 3 studies that prospectively assessed retinal lesions in bacteremic patients. The frequency of retinal lesions in these series varied from 12% to 26%, with the most common lesions being cotton wool spots followed by superficial retinal hemorrhages. White-centered hemorrhages were seen in about 15% +/- 2 of bacteremic patients. Five studies prospectively evaluated candidemic patients for Candida endophthalmitis. These studies observed rates from 0% to 78% for lesions consistent with candidal endophthalmitis. Most studies performed recently found that nonspecific lesions such as cotton wool spots or superficial retinal hemorrhages occurred with a frequency of 11% to 20%. The availability of less toxic antifungal agents, more frequent use of empirical therapy, and the trend to early treatment may be altering the frequency of this complication. Observation of a classic 3-dimensional retina-based vitreal inflammatory process is virtually diagnostic of endogenous endophthalmitis due to Candida spp., but such lesions are relatively uncommon. Conversely, nonspecific lesions that could be due to bacterial or candidal endophthalmitis (cotton wool spots, retinal hemorrhages, and Roth spots) are seen frequently. These lesions are most often due to an underlying systemic disease rather than an infection. Serial examinations provide the best evidence that a given lesion is due to an intercurrent infection. The current low rate of vitreal extension of retinal process appears to be due to the high rate of empirical or therapeutic use of antifungal agents in high-risk patient groups. Ophthalmoscopy should be performed in patients with known candidemia. However, ophthalmoscopic examination seems to have little value in assisting with the discovery of occult disseminated candidiasis or bacterial infection.