Faculty Bibliography

PURPOSE: To describe the nature and evolution of acquired macular detachments in patients with immunogammopathies and to propose a mechanism for their development. DESIGN: Retrospective observational case series. METHODS: Three patients with multiple myeloma and 1 with light chain deposition disease were diagnosed with vitelliform macular detachments based on clinical examination, fundus autofluorescence, fluorescein angiography, and optical coherence tomography. These patients were followed over time and their clinical examinations and imaging studies were compared and contrasted. RESULTS: Three patients (5 eyes) with multiple myeloma and 1 patient (2 eyes) with light chain deposition disease presented with acquired macular yellowish subretinal deposits on funduscopic examination that corresponded to hyperautofluorescent lesions on fundus autofluorescence imaging and subretinal hyperreflective material on spectral-domain optical coherence tomography. One patient (2 eyes) had diffuse serous retinal detachments involving not only the macular region but also the midperiphery of the retina. These acquired macular vitelliform detachments were not associated with signs of hyperviscosity retinopathy in 5 eyes and resolved after successful treatment of the multiple myeloma in 6 eyes. CONCLUSION: Patients with an immunogammopathy such as multiple myeloma or light chain deposition disease may develop serous elevations of the macula that we classify as acquired vitelliform detachments using multimodal imaging. Appropriate evaluation including serum protein electrophoresis and hematology consultation should be considered in the management of patients with acquired vitelliform detachments of uncertain etiology.

The purpose of this paper is to report a series of macular holes that developed after demarcation laser photocoagulation for subclinical retinal detachments. This observational case series consists of three eyes from three patients seen between 2005 and 2012. Delayed idiopathic macular hole formation occurred following demarcation laser photocoagulation for subclinical retinal detachment. Demarcation laser photocoagulation of subclinical retinal detachments may predispose to macular hole formation.

A 51-year-old woman presented with acute myopic shift 3 years after uneventful cataract extraction in both eyes; recent medical history was remarkable for administration of intravenous meclizine 2 weeks prior to presentation. Examination of each eye revealed anterior chamber crowding and a posterior chamber intraocular lens (IOL) with distension of the capsular bag; clear fluid with a green hue was present between the IOL and the posterior capsule. We postulate a mechanism for the development of late-onset capsular bag distension syndrome. To our knowledge, no medication-induced incidences have been reported in the literature

PURPOSE: To describe the spectral-domain optical coherence tomography and fundus autofluorescence findings in a case of laser pointer-induced maculopathy. METHODS: Observational case report of a patient with bilateral decreased visual acuity after exposure to a handheld green laser pointer. RESULTS: A 15-year-old boy presented with decreased vision after exposure to a green laser pointer. Fundoscopy revealed gray and yellowish round spots in the foveal area of both eyes. Fundus autofluorescence imaging revealed subtle changes of the normal background macular autofluorescence of the right eye, with hyperautofluorescence dots in the fovea of the left eye. Spectral-domain optical coherence tomography showed a variety of changes of the outer retina and retinal pigment epithelium, with disruption of the external limiting membrane, the photoreceptor ellipsoid zone of the inner segments, and the interdigitation zone in the foveal region in both eyes. Six months after laser exposure, fundoscopic examination showed persistent alterations at the level of the retinal pigment epithelium in the fovea in both eyes. Fundus autofluorescence revealed mild but persistent changes of the normal autofluorescent macular background in both eyes. Spectral-domain optical coherence tomography showed partial resolution of the outer retinal disruption noted on his initial visit with persistent, small foveal photoreceptor defects in both eyes. CONCLUSION: Laser pointer maculopathy may disturb the outer retinal architecture in a manner evident on spectral-domain optical coherence tomography and fundus autofluorescence, resulting in decreased visual acuity. Proper warnings should accompany these devices and access to them by minors should be limited.

PURPOSE: To determine the cumulative incidence and annual incidence of intraocular hemorrhage (subretinal hemorrhage or vitreous hemorrhage) in patients with neovascular age-related macular degeneration (AMD) and association with daily antiplatelet or anticoagulant (AP/AC) medication usage (aspirin, clopidogrel, and warfarin), age, gender, hypertension, diabetes mellitus, or bilateral neovascular AMD. METHODS: Retrospective cross-sectional study in a tertiary university setting. Data on 195 eyes of 195 patients without previous intraocular hemorrhage examined over 73 months were reviewed. RESULTS: Ninety-six of 195 patients (49.2%) were taking daily AP/ACs. Of patients taking daily AP/AC agents, 63.5% had hemorrhage compared with 29.2% of patients not taking (odds ratio = 4.21; 95% confidence interval = 1.42-8.46; P < 0.001). The overall annual incidence of intraocular hemorrhage was 0.14% per year. Among patients taking daily AP/AC, the cumulative incidence (61 of 96, 63.5%) and annual incidence (0.10%) of concurrent intraocular hemorrhage were significantly greater compared with patients not taking them (29 of 99, 29.2% and 0.04%, respectively; P < 0.0001). Fourteen of 18 patients (77%) taking more than 1 daily AP/AC had occurrence of intraocular hemorrhage. Antiplatelet or anticoagulant usage was an independent risk factor for the development of intraocular hemorrhage. The use of any agent resulted in a significantly increased risk of developing intraocular hemorrhage. Additionally, presence of bilateral neovascular AMD was a significant association in those taking daily AP/ACs, whereas age was a significant association in those not taking daily AP/AC agents. CONCLUSION: All three daily AP/AC types were significantly associated with an increased risk of the development intraocular hemorrhage in patients with neovascular AMD, whereas gender, hypertension, and diabetes were not. Age was not significantly associated with hemorrhage in patients taking daily AP/AC agents, whereas the presence of bilateral neovascular AMD was significantly associated with hemorrhage. These findings indicate that the AP/AC use may predispose patients with neovascular AMD to intraocular hemorrhage more so than age and duration of disease alone. While the risk that discontinuing these medicines would pose to the patients' health may be too great to justify, ensuring that an appropriate medication dosage is maintained should be a priority within this patient population.

Toxoplasma gondii is the most frequent cause of chorioretinitis in immunocompetent patients. This paper highlights the case of a 15 years old girl, an immunocompetent patient, with an active chorioretinal focus in the LE and a chorioretinal scar in the RE. Serologically, the IgG antiToxoplasma titre is increased, but the IgM antibodies are negative. It is the bilateral character of the lesions and the serology found that make this case special.