RWC Retina Rocks

West Nile virus uveitis Today’s case was submitted by Lisa Faia. - This 51YO female presented with a recent history of floaters in her left eye. There was no significant past ocular or medical history. Vision was 20/30 OS, and the right eye was normal. - Optos RG imaging shows clumps of vitreous floaters over the posterior pole, extending into the inferior periphery (image 1, top). A few retinal hemorrhages are noted in the temporal midperiphery and faint, small atrophic multifocal scars are seen inferotemporally. Fluorescein angiography (image 1, middle) better shows these multifocal scars with late staining. There is late optic nerve leakage and variable focal staining of the retinal vessels. OCT scanning shows mild cystoid edema (image 1, bottom). - We were concerned for possible herpes viral retinitis, and she was started on valtrex, had an anterior chamber tap and uveitis work up. The tap came back negative for herpes viruses. West Nile titers were ordered, and these came back positive for IgG (2.48) and low but detectable for IgM (0.10). Valtrex was stopped, and Durezol QID OS was started with a slow taper. - When she returned 6 weeks later, the vitreous was clear, and linear clumps of atrophic scars followed the retinal vessels (image 2). The scars were hyper-autofluorescent with small rims of increased autofluorescence. - The West Nile virus is an RNA virus acquired through the bite of a mosquito that fed on an infected bird. Although most infections are asymptomatic, about 20% will develop fever, weakness, headache, myalgia nausea and skin rash. Multifocal chorioretinitis with or without vitreous inflammation is the most common ocular finding, occurring in about 80% of cases. Acutely there are usually about 10-50 deep, 200-1000 micron yellow-white, scattered or radiating curvilinear clustered lesions which are relatively depigmented upon resolution. Treatment of the primary viral infection is supportive. See a great review on this topic by Garg and Jampol (Surv Ophthalmology 2005;50:3-13). - Go to www.retinarocks.org/cases for more West Nile cases. - [This case can be found on www.retinarocks.org in the Image Gallery, West Nile folder, West Nile UIB-] - Have an interesting case and want to help your peers learn something about the retina? Submit your images at www.retinarocks.org. - Retina Rocks and its charitable foundation, "Eye Reach" are supported in part by Optos (@optomap). Retina Rocks is the official image bank for the Retina World Congress (@RetinaWorldCongress). - #westnile #retina #optometry #ophthalmology #cool #odsonfacebook #adarshcharitablefoundation #UWF #optos #optomap #savingsightsavinglives #RetinaWorldCongress

When life gives you blurry vision and TB, just call it a unique perspective! Chronic ICSC with exudative retinal detachment and concomitant TB Today's Retina Foundation case of the week case was submitted by Anand Temkar (@dr.vitreous.humorous), Navneet Mehrotra (@drnavneetmehrotra) and Manish Nagpal (@drmanishnagpal). This 39YO male presented with 4 months of bilateral vision loss. He was diagnosed elsewhere with chronic idiopathic central serous chorioretinopathy (ICSC) and was placed on azathioprine and spironolactone 3 months earlier. There was no history of steroid use or injections. Vision was 20/120 OD and 20/200 OS. MultiColor imaging shows macular pigmentary changes that extend in a gutter inferiorly OD (image 2). Diffuse macular pigmentary changes are noted in his left eye that communicate with an inferior exudative retinal detachment (image 1). OCT scanning shows shallow subretinal fluid with hyperreflective shed outer segments, outer retinal hyperreflective foci and RPE detachments. Fluorescein angiography shows bilateral multifocal subretinal blot leakage (image 3). A broad area of ischemia is present overlying the inferior detachment OS. Mantoux skin testing (15x18mm) and QuantiFERON-TB Gold testing were positive. Chest CT showed fibrotic strands in right lung. He was referred for systemic antituberculosis treatment. A week later, his local ophthalmologist reported that this vision and retinal findings improved but he was then lost to followup. Our patient presented with severe bilateral idiopathic central serous chorioretinopathy (ISCS) with multifocal leaks in each eye and a secondary exudative detachment in his left eye. There are rare case reports of TB occurring in patients with ICSC, and these are likely coincidental findings (Khan et al, BMJ Case Rep 2017:bcr-2016-216471). Go to www.retinarocks.org/cases for more ICSC and TB cases. [This case can be found on www.retinarocks.org in the Image Gallery, ICSC HSR-20240628 folder, ICSC HSR-20240628] Have an interesting case and want to help your peers learn something about the retina? Submit your images at www.retinarocks.org. Keep reading 👇👇👇 Retina Rocks and its charitable foundation, "Eye Reach" are supported in part by Optos (@optomap) and Topcon Healthcare (@topconhealthcare). Retina Rocks is the image bank for the Retina World Congress (@RetinaWorldCongress). #icsc #exudativeretinaldetachment #tb #retina #optometry #ophthalmology #cool #odsonfacebook #adarshcharitablefoundation #UWF #optos #optomap #TopconHealthcare #savingsightsavinglives #RetinaWorldCongress

Subretinal drusenoid deposits Read this if you want to learn something! This 70YO female was referred for asymptomatic age-related macular degeneration (AMD). Vision was 20/30 OD and 20/25 OS. Triton color imaging of the right (image 1) and left (image 2) eyes shows symmetrical ribbon subretinal drusenoid deposits (SDD). On swept-source OCT, these lesions appear as hyperreflective material mostly between the RPE and ellipsoid zone (EZ). SDD are polymorphous light-gray interconnected accumulations located above the RPE. They are present in about one quarter of older adults with healthy maculas and in more than half of those with early to intermediate dry AMD. They can appear as an array of dots, interconnected reticular bands (as in our patient), or confluent lesions (Suzuki and Spaide, AJO 2014;157:1005-1012). The dot variant is associated with macular neovascularization (MNV) and the confluent with macular atrophy (Zhou et al, Ophthalmology 2016;123:1530-1540). Clinically they are often mistaken for conventional drusen and consist of similar, yet distinct lipid-rich material found in soft drusen. They are localized to rods, unlike typical soft drusen which are more central and cone based. As with drusen, SDD are dynamic and can grow, shrink, resolve, or even recur. Since they are located above the RPE, they are best visualized with blue or green illumination. On OCT they appear in 3 stages (Zweifel et al, Ophthalmology 2010;117:303-312) growing upwards from the RPE towards the external limiting membrane: stage 1 diffuse deposition of granular hyperreflective material between the RPE and the EZ, stage 2 material alters the EZ contour, and stage 3 conical appearance breaking through the EZ. Rod function seems to be preferentially affected, and there is an associated increased risk of delayed dark adaptation, macular atrophy and types 2 and 3 MNV. In fact, type 2 neovascularization in the setting of AMD occurs almost solely in eyes with subretinal drusenoid deposits. Keep reading In addition to large drusen and pigmentary abnormalities, SDD are the 3rd risk factor for progression to late AMD (Agron et al, Ophthalmology 2022;129:1107-1119). For recent review, see Wu et al, Progress Retinal Eye Research 2022;88;101017. Go to www.retinarocks.org/cases for more SDD cases. [This case can be found on www.retinarocks.org in Image Gallery, AMD 03 Subretinal drusenoid deposits (SDD) folder, AMD SDD ZWD-20210119] Have an interesting case and want to help your peers learn something about the retina? Submit your images at www.retinarocks.org. Retina Rocks and its charitable foundation, "Eye Reach" are supported in part by Optos (@optomap) and Topcon Healthcare (@topconhealthcare). Retina Rocks is image bank for the Retina World Congress (@RetinaWorldCongress). #subretinaldrusenoiddeposits #retina #optometry #ophthalmology #cool #odsonfacebook #adarshcharitablefoundation #UWF #optos #optomap #TopconHealthcare #savingsightsavinglives #RetinaWorldCongress

Ocular amyloidosis What exactly am I looking at? 🤔 Today’s case was submitted by Mariano Cotic (@dr.cotic), Natasha Gerschovsky (@natigerschovsky), Madeleine Saint Martin (@dra.saintmartin), Enzo Dilascio (@enzodilascio), Marcelo Zas (@zas.oftalmologo) and Pablo Chiaradia (@dr.chiaradia).                        This 65YO male presented with chronic bilateral vision loss. Vision was 20/200 OD and 20/100 OS. There was no past medical history. Optos color RG imaging of his right eye shows diffuse whitish, spider web-like fibrillar vitreous debris (image 1). In vivo corneal confocal microscopy reveals amyloid deposits. Similar findings were present in his left eye (not shown). Sequential therapeutic and diagnostic vitrectomy surgeries were performed on each eye. Vitreous and conjunctival biopsies were positive for amyloid deposits. Each fundus appeared normal postoperatively and vision improved to 20/20 OU. Despite the normal fundus appearance, OCT scanning shows residual vertical amyloid deposits resting on the foveal internal limiting membrane (image 2). Vitreous amyloidosis is a rare disorder where usually bilateral vitreous opacities appear as fine, fibrillar, and often whitish or translucent deposits which can reduce vision as the opaque amyloid material accumulates. OCT can reveal pathognomonic fine vertical needle-like hyperreflective deposits extending into the vitreous from the internal limiting membrane (Tasiopoulou et al, Ophthalmology Retina 2021;5:99-101). It is almost always related to mutant transthyretin (TTR), a plasma protein carrier of thyroxine and vitamin A, often associated with familial amyloid polyneuropathy (Venkatesh et al, Ophthalmology 2017;124:1014-1022). Systemic amyloidosis can also cause ocular manifestations including conjunctival, temporal artery, extraocular muscle, trabecular meshwork and cranial nerve deposition (Reynolds et al, Retina 2018;38:1371-1376). Our patient’s systemic workup was negative. Genetic testing for TTR was ordered and is pending. [This case can be found on www.retinarocks.org in the Image Gallery, Amyloidosis folder, Amyloidosis XLH-] Keep reading 👇👇👇 Have an interesting case and want to help your peers learn something about the retina? Submit your images at www.retinarocks.org. Retina Rocks and its charitable foundation, "Eye Reach" are supported in part by Optos (@optomap) and Topcon Healthcare (@topconhealthcare). Retina Rocks is the image bank for the Retina World Congress (@RetinaWorldCongress). #amyloidosis #retina #optometry #ophthalmology #cool #odsonfacebook #adarshcharitablefoundation #UWF #optos #optomap #TopconHealthcare #savingsightsavinglives #RetinaWorldCongress

Vitamin A deficiency retinopathy Read this if you want to become smarter Today’s case was submitted by Mattie Adams (@mattie_monroe_adams). This 70YO male presented with six months of vision loss. He has a history of severe Crohn’s disease. He has undergone 9 bowel surgeries resulting in short bowel syndrome being treated with total parenteral nutrition.  Vision was 20/50 OD and 20/40 OS. Triton color imaging shows numerous smaller subretinal yellow-white dots (image 1, top left). These dots are well-visualized on en face swept-source OCT through the outer retina (image 1, top right) and on the Optos green channel (image 2). OCT B scan shows outer retinal thinning and loss of the hyperreflective bands detail (image 1, bottom). There was a somewhat diffuse loss of the autofluorescent detail (image 3). Fasting serum vitamin A was severely low at 2.5 (normal 20-60), and he was started on parenteral vitamin A therapy. Vitamin A deficiency is rare in the United States and is sometimes related to malabsorption in chronic pancreatitis or inflammatory bowel disease. It leads to several well-documented ocular complications including nyctalopia, Bitot spots and xanthopsia. Outer nuclear layer thinning with disruption of the outer retinal bands can be visualized on OCT (Berkenstock et al, Int J Retin Vitr 2020;6:23). The outer retinal white dots colocalize to OCT outer retinal hyperreflective lesions (Aleman et al, Doc Ophthalmol 2013;127:239-243). Oral or intramuscular vitamin A replacement has been shown to reverse the retinal changes if initiated early enough. We are hoping that our patient’s vision and retinal findings will improve with continued treatment. Go to www.retinarocks.org/cases for more vitamin A deficiency cases. [This case can be found on www.retinarocks.org in the Image Gallery, Vitamin A deficiency folder, Vitamin A deficiency WVX-20240319] Have an interesting case and want to help your peers learn something about the retina? Submit your images at www.retinarocks.org. Retina Rocks and its charitable foundation, "Eye Reach" are supported in part by Optos (@optomap) and Topcon Healthcare (@topconhealthcare). Retina Rocks is the image bank for the Retina World Congress (@RetinaWorldCongress). #vitaminadeficiency #retina #optometry #ophthalmology #cool #odsonfacebook #adarshcharitablefoundation #UWF #optos #optomap #TopconHealthcare #savingsightsavinglives #RetinaWorldCongress

Exudative detachment from posterior retinal capillary hemangiomas Today’s Columbia University Irving Medical Center Department of Ophthalmology Edward S Harkness Eye Institute case of the week was submitted by Yuenpang Cheung (@joeyuenpangcheung) and Stephanie Choi (@stephschoice). - This 23YO female was noted by her optometrist in 2019 to have vision loss from a retinal lesion. At presentation vision was 20/400 in her left eye and 20/20 in the normal right eye. She was referred to an outside retina specialist who gave a single anti-VEGF injection and then referred her to Columbia University. Our initial examination on 8/16/22 revealed an inferior peripapillary retinal capillary hemangioma with surrounding exudation (image 1). OCT of the macula revealed mostly outer retinal fluid. The angioma was diffusely thickened and hyperreflective. On fundus autofluorescence (FAF), the angioma was hypo-FAF with a surrounding rim of hyper-FAF (image 2). Genetic testing for the VHL gene was negative and thus further systemic work-up of the brain and kidneys was deferred. She has undergone subsequent monthly anti-VEGF injections with resolving exudates. When last examined on 9/13/23, the lipid has decreased, but she continues to have persistent fluid and thickening on OCT (image 3). - Retinal capillary hemangiomas appear clinically as orange-red lesions, most commonly peripherally, associated with prominent dilated and tortuous paired feeding and draining vessels. They can also appear on or around the optic nerve lesions, either on the surface (endophytic) as in our patient, or buried within the substance of the nerve (exophytic). These lesions can cause severe vision loss or blindness from exudative retinal detachment and thus usually require aggressive treatment. Treatment options include thermal laser, photodynamic therapy, cryotherapy and anti-VEGF injections. Retinal capillary hemangioma is also a predominant feature of von Hippel-Lindau disease (VHL), an autosomal dominant condition caused by mutations in the VHL tumor suppressor gene. Patients develop benign and malignant tumors including central nervous hemangioblastoma, pheochromocytoma and renal cell carcinoma. Keep reading Go to www.retinarocks.org/cases for more retinal capillary hemangioma cases [This case can be found on www.retinarocks.org in the Image Gallery, Hemangioma retinal capillary folder, Hemangioma retinal capillary Hemangioma retinal capillary ORT] Have an interesting case and want to help your peers learn something about the retina? Submit your images at www.retinarocks.org. Retina Rocks and its charitable foundation, "Eye Reach" are supported in part by Optos (@optomap) & Topcon Healthcare (@topconhealthcare). Retina Rocks is image bank for the Retina World Congress (@RetinaWorldCongress). #retinalcapillaryhemangioma #retina #optometry #ophthalmology #cool #odsonfacebook #adarshcharitablefoundation #UWF #optos #optomap #TopconHealthcare #savingsightsavinglives #RetinaWorldCongress

Friday 10/4/24 Happy World Smile Day Today’s case was submitted by Pier Luigi Guerin (@pierguerin). This 70YO male with type 2 diabetes presented with these asymptomatic OCT findings that made our day. Vision was 20/25. World Smile Day is celebrated on the first Friday of October each year, a tradition that began in 1999. The day was created by Harvey Ball, the commercial artist who designed the iconic yellow smiley face. Ball was concerned that the over-commercialization of his symbol would dilute its original intent of spreading goodwill and cheer. To counteract this, he established World Smile Day to remind people of the power of a smile and to encourage acts of kindness around the world. The day is marked by various activities that promote smiling and kindness. People are encouraged to perform acts of kindness and to smile more, spreading positivity and happiness. The Harvey Ball World Smile Foundation, established after Ball’s passing in 2001, continues to sponsor the day and organize events. These events range from community activities to global initiatives, all aimed at creating smiles and fostering a spirit of generosity and joy. So, perform some random acts of kindness today and make the world a better place because you’re in it. Go to www.retinarocks.org/cases for more DME cases. [This case can be found on www.retinarocks.org in the Image Gallery, DR (Diabetic retinopathy) 03 DME folder, DR DME XZO-20220203] Have an interesting case and want to help your peers learn something about the retina? Submit your images at www.retinarocks.org. Retina Rocks and its charitable foundation, "Eye Reach" are supported in part by Optos (@optomap) and Topcon Healthcare (@topconhealthcare). Retina Rocks is the image bank for the Retina World Congress (@RetinaWorldCongress). #smileyface #harveyball #retina #optometry #ophthalmology #cool #odsonfacebook #adarshcharitablefoundation #UWF #optos #optomap #TopconHealthcare #savingsightsavinglives #RetinaWorldCongress

Thursday 10/3/24 Laser maculopathy from a 3D laser level This 46YO male presented with a several week history of unilateral vision loss. Vision was counting fingers in his right eye and 20/20 in his normal left eye. Optos color RGB imaging shows a mostly round foveal scar with a few dots of temporal blood (image 1, top). Triton swept-source OCT scanning shows the normal foveal architecture to be replaced by full-thickness, hyperreflective disorganized tissue (image 1, bottom). The RPE is thickened and somewhat elevated along the lesion’s edge (red arrow), with bare Bruch’s membrane more centrally (yellow arrow). Fluorescein angiography shows staining of the scar (image 2). Upon further questioning we found that the patient works as a contractor, and lost vision immediately following use of a laser leveler. He didn’t recall looking directly at the laser beam. He showed us the device, a WOKELINE WGR12L, which is used as a full room level laser device. A label on the back of the device defines it as a 520nm Class 2M laser with an output of less than 1 milliwatt (image 3). We found an image online of a similar device showing how this device projects a 3D green laser light in 2 vertical planes and a single horizontal plane to cover the floor, ceiling, and all walls simultaneously. A Class 2 laser device emits light in the visible 400-700 nm spectrum. It is presumed that the natural aversion response to the very bright light will be sufficient to prevent damaging exposure, although prolonged viewing may be dangerous. Although laser pointers, Class 2 or 3A devices, are supposed to have an out of under 5 milliwatts, real world findings reveal that the power output of many of these pointers often far exceeds what is displayed in their safety information. Laser pointer maculopathy is well reported in the literature (Bhavasar et al, Surv Ophthalmology 2021;66:231-360), although we are not aware of a prior case from a laser level device as in our patient. Go to www.retinarocks.org/cases for more laser maculopathy cases. Keep reading 👇👇👇 [This case can be found on www.retinarocks.org in the Image Gallery, Laser maculopathy folder, Laser maculopathy PVK-20240529] Have an interesting case and want to help your peers learn something about the retina? Submit your images at www.retinarocks.org. Retina Rocks and its charitable foundation, "Eye Reach" are supported in part by Optos (@optomap) and Topcon Healthcare (@topconhealthcare). Retina Rocks is the image bank for the Retina World Congress (@RetinaWorldCongress). #lasermaculopathy #retina #optometry #ophthalmology #cool #odsonfacebook #adarshcharitablefoundation #UWF #optos #optomap #TopconHealthcare #savingsightsavinglives #RetinaWorldCongress

Wednesday 10/2/24 PDR neovascularization with multimodal imaging Which image best shows the neovascularization? Today's case was submitted by Seif Anwar (@retina_seif). This 23YO male presented with bilateral proliferative diabetic retinopathy (PDR). Vision was 20/60 OD and 20/80 OS. Multimodal imaging of his left eye highlights an area of retinal neovascularization along the superotemporal arcade. Which modality do you feel best images the neovascularization? Or are they all complementary? MultiColor imaging shows the lacy active red vessels overlying the orange-red RPE and choroid. These vessels are better highlighted in the Blue-Reflectance image, since they appear black on a grey background. They profoundly leak on fluorescein angiography. En face OCT angiography (OCTA) beautifully shows the fine neovascular details. Finally, B-scan OCTA shows the neovascular vessels growing along the back surface of the partially detached posterior hyaloid (arrow). Go to www.retinarocks.org/cases for more PDR cases. [This case can be found on www.retinarocks.org in the Image Gallery, DR (Diabetic retinopathy) 08 PDR folder, DR PDR NVW-20230210] Have an interesting case and want to help your peers learn something about the retina? Submit your images at www.retinarocks.org. Retina Rocks and its charitable foundation, "Eye Reach" are supported in part by Optos (@optomap) and Topcon Healthcare (@topconhealthcare). Retina Rocks is the image bank for the Retina World Congress (@RetinaWorldCongress). #pdr #retinalneovascularization #retina #optometry #ophthalmology #cool #odsonfacebook #adarshcharitablefoundation #UWF #optos #optomap #TopconHealthcare #savingsightsavinglives #RetinaWorldCongress

Tuesday 10/1/24 Sporadic isolated retinal capillary hemangioma This healthy 42YO male was referred for an asymptomatic retinal lesion in his right eye. There was no family history for cancer or eye disease, although he had no knowledge about his birth father. Vision was 20/30 OD and 20/20 in his normal left eye. Optos color RGB imaging shows an active endophytic retinal capillary hemangioma (RCH) in the inferonasal midperiphery (image 1). The tumor is fed and drained by dilated and irregular vessels. The lesion profoundly leaks on fluorescein angiography (image 2). It measured about 2mm thick on B-scan ultrasonography (image 3). Genetic testing for the von Hippel-Lindau syndrome (VHL) gene was negative, as was MRI scanning of the brain, abdomen, and pelvis. Monthly intravitreal Avastin injections are planned to shrink the tumor, followed by thermal laser photocoagulation. RCAs are orange-red lesions associated with a prominent paired feeding and draining vessel and can cause severe vision loss or blindness from exudative retinal detachment. These benign vascular tumors need to be aggressively treated. Common treatment options include thermal laser, cryotherapy, and anti-VEGF injections. They are a predominant feature of VHL, an autosomal dominant condition caused by mutations in the VHL tumor suppressor gene. This prevents the degradation of hypoxia-inducible factor 1a (HIF-1a), which in turn causes production of numerous growth factors including VEGF (Kaelin, Drug Discoveries Today Disease Mechanisms 2005;2:225-231). Patients develop benign and malignant tumors including central nervous hemangioblastoma, pheochromocytoma and renal cell carcinoma. Sporadic RCHs in the absence of the VHL syndrome, are a rare occurrence (Singh et al, Ophthalmology 2001;108:1907-1911). The negative genetic testing fortunately ruled out VHL in our patient. Our patient’s lesion most likely resulted from a localized double-hit retinal VHL mutation. Go to www.retinarocks.org/cases for more hemangioma cases. [This case can be found on www.retinarocks.org in the Image Gallery, Hemangioma retinal capillary folder, Hemangioma retinal capillary PVO-20240501] Keep reading 👇👇👇 Have an interesting case and want to help your peers learn something about the retina? Submit your images at www.retinarocks.org. Retina Rocks and its charitable foundation, "Eye Reach" are supported in part by Optos (@optomap) and Topcon Healthcare (@topconhealthcare). Retina Rocks is the image bank for the Retina World Congress (@RetinaWorldCongress). #retinalcapillaryhemangioma #vhl #retina #optometry #ophthalmology #cool #odsonfacebook #adarshcharitablefoundation #UWF #optos #optomap #TopconHealthcare #savingsightsavinglives #RetinaWorldCongress