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Concept: Dilated fundus examination

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A 77-year-old man presented to the ophthalmology clinic reporting three episodes of blurred vision in his right eye, each lasting approximately 5 minutes, during the past hour. A dilated fundus examination revealed a visible motile embolus, shown in a video.

Concepts: Retina, Eye, Visual perception, Ophthalmology, Optometry, Dilated fundus examination, Amaurosis fugax

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Abstract Purpose: To investigate the efficacy of intravitreal bevacizumab injection in patients with acute central serous chorioretinopathy (CSCR). Methods: Between 6 weeks and 3 months, 13 eyes of 22 patients with acute CSCR received an intravitreal bevacizumab injection (2 mg/0.08 mL), 9 eyes had no medical treatment as a control. At baseline and follow-up visits patients had best corrected visual acuity (BCVA), intraocular pressure assessment, dilated fundus examination, and spectral optical coherence tomography imaging. Outcome measures were the resolution of neurosensory detachment, improvement in visual acuity, and symptoms. Results: All patients showed prompt improvements of visual acuity and symptoms until the 3rd month and recovered from neurosensory detachment gradually following treatment in the study group. The vision of control subjects recovered later and the regression of serous retinal detachments were fairly slow. The mean BCVA improved from 0.39±0.16 at first visit (at baseline) to 0.73±0.17 at the 6th month in the study group; and, from 0.25±0.17 at first visit (at baseline) to 0.67±0.13 at the 6th month in the control group that was statistically significant (P=0.0001; P=0.0001, respectively). Mean retinal thickness for the study group was decreased from 414.38±102.79 at first visit (at baseline) to 256.46±84.77 at the 3rd month and 198.30±29.81 at the 6th month (P=0.0001, P=0.0001); and that for the control group was decreased from 510.33±80.59 at first visit (at baseline) to 336.33±127.83 at the 3rd month and 205.66±19.65 at the 6th month (P=0.004, P=0.0001, respectively). One of the patients in the control group revealed recurrence at the 6th month and the patient was given intravitreal injection of bevacizumab. Conclusion: Intravitreal bevacizumab injection for acute CSCR can lead to remarkable improvements of visual acuity within 3 months follow-up compared with controls. These results demonstrated that intravitreal bevacizumab injection may be a promising option for selected patients in the treatment of acute CSCR.

Concepts: Better, Statistics, Improve, Retina, Ophthalmology, Central serous retinopathy, Posterior vitreous detachment, Dilated fundus examination

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The ocular fundus examination is infrequently and poorly performed in clinical settings, placing patients at risk for missed and delayed diagnosis of vision- and life-threatening neurologic disease.

Concepts: Medicine, Eye, Fundus camera, Dilated fundus examination, Red-eye effect

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The present study was designed to compare the effect of indocyanine green (ICG)-enhanced laser (810 nm) thermocoagulation method and photodynamic therapy (PDT) on circumscribed choroidal hemangioma (CCH). A total of 36 patients (36 pair of eyes) diagnosed with CCH in the Ocular Fundus Disease Center of The Affiliated Hospital of Medical College of Ningbo University from June 2010 to January 2016 were selected and randomly divided into two groups. ICG-enhanced thermocoagulation was used to treat 18 patients (18 pair of eyes), and PDT was used to treat the remaining 18 patients (18 pair of eyes). The best corrected visual acuity of the affected eyes was observed before and after treatment, and changes in the tumor were observed through ocular fundus photochromes under the ophthalmoscope. The changes in tumor size and height were examined through B-scan ultrasonography. The changes in serous retinal fluid were examined by optical coherence tomography (OCT). A total of 36 patients were followed-up for 3, 7, 11 and 24 weeks after laser therapy with an average of 18 weeks. It was seen that the subretinal serous exudation disappeared in 36 patients through the fundus examination after treatment, and B-scan ultrasonography showed that the tumor size was reduced. Among 18 patients undergoing ICG-enhanced thermocoagulation treatment, the visual acuity of 72.2% of them was improved, while that of the remaining 27.8% was stable, and there were no patients with decreased visual acuity; the fundus observation showed that when tumor atrophy occurred, the tumor turned white accompanied with mild pigment disorders, but retinal and choroidal normal vessels were not damaged. Among 18 patients undergoing PDT treatment, the visual acuity of 44.4% was increased, that of 50% was stable, and that of 5.6% of the patients was decreased; through fundus observation, tumor atrophy scars and alignment, a large number of hyperplasia or pigment loss and partial vascular occlusion could be seen. The results indicated that in the treatment of CCH, ICG-enhanced laser (810 nm) thermocoagulation and PDT can lead to tumor atrophy and promote the absorption of exudation. However, the damage of ICG-enhanced laser thermocoagulation to normal fundus tissues is significantly smaller than that of PDT, and the former has higher safety.

Concepts: Retina, Eye, Visual acuity, Ophthalmology, Optical coherence tomography, Photodynamic therapy, Laser medicine, Dilated fundus examination

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An immunocompromised patient had positive blood cultures for Mycobacterium intracellulare and no identifiable organ seeding was started on treatment. One month later, the patient was clinically well with negative blood cultures but drug-induced myelotoxicity had developed. Ocular fundus examination at this time revealed bilateral choroidal granulomas which changed patient management.

Concepts: Immune system, Blood type, Dilated fundus examination, Mycobacterium intracellulare

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PurposeTo evaluate the sensitivity and specificity of a portable non-mydriatic fundus camera to diagnose vision-threatening diabetic retinopathy (VTDR).Patients and methodsA prospective, single-site, comparative instrument validation study was undertaken at the Aravind Eye Care System. Overall, 155 subjects with and without diabetes were recruited. Images from 275 eyes were obtained with the (1) non-mydriatic Smartscope, (2) mydriatic Smartscope, and (3) mydriatic table-top camera of the macular, nasal, and superotemporal fields. A retina specialist performed a dilated fundus examination (DFE), (reference standard). Two masked retina specialists graded the images. Sensitivity and specificity to detect VTDR with the undilated Smartscope was calculated compared to DFE.ResultsGraders 1 and 2 had a sensitivity of 93% (95% confidence interval (CI): 87-97%) and 88% (95% CI: 81-93%) and a specificity of 84% (95% CI: 77-89%) and 90% (95% CI: 84-94%), respectively, in diagnosing VTDR with the undilated Smartscope compared to DFE. Compared with the dilated Topcon images, graders 1 and 2 had sensitivity of 88% (95% CI: 81-93%) and 82% (95% CI: 73-88%) and specificity of 99% (95% CI: 96-100%) and 99% (95% CI: 95-100%).ConclusionsRemote graders had high sensitivity and specificity in diagnosing VTDR with undilated Smartscope images, suggesting utility where portability is a necessity.Eye advance online publication, 15 September 2017; doi:10.1038/eye.2017.199.

Concepts: Type I and type II errors, Sensitivity and specificity, Ophthalmology, Fundus camera, Dilated fundus examination

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We report a case of idiopathic paracentral acute middle maculopathy with typical optical imaging and clinical features. A 26-year-old Chinese policeman presented with a 20-day history of paracentral scotoma in the left eye after early wake-up and long-time working in front of computer the day before. He experienced sudden-onset strong flash in his left eye. Paracentral scotoma appeared in his left eye after 6hours of rest. The general history was negative. His best-corrected visual acuity was 20/20 OU. Anterior segment, dilated fundus examination, papillary evaluation and intraocular pressure were normal. Fuorescein angiography and blue light fundus autofluorescence showed no significant abnormality. In multicolor photography, the lesion was visible on the monochromic infrared/blue reflectance images and not clear in green reflectance. The 10-degree visual field examination revealed superior paracentral relative scotoma. Multifocal electroretinogram revealed reduced response in central area in the left eye. Spectral-domain optical coherence tomography showed that hyperreflective plaque was present at the IPL/INL/OPL level with hyperreflective point at the GCL. The plaque became thinner 3 months later and diminished 6 months later with obviously atrophied INL. In the 3 months follow-up, transverse scan revealed that there was a well-demarcated hypo-refractive lesion in IPL and hyper-refractive lesion in INL. OCTA revealed the deceased flow signal intensity of focal deep capillaries. En face OCT imaging of the left eye revealed a relative well-defined, hypo-refractive lesion and non-flow area localized at the level of the deep capillary plexus.

Concepts: Optics, Medical imaging, Retina, Visual system, Visual acuity, Ophthalmology, Optical coherence tomography, Dilated fundus examination

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The purpose of this study was to develop and validate a tool for the measurement of retinal oxygen saturation using a conventional fundus camera-based nonsimultaneous imaging technique. Retinal oximetry setup comprising a conventional Zeiss FF450IR fundus camera, dual wavelength band-pass filters of wavelengths 570 and 600 nm were used. Image analysis was performed using MATLAB R2013b. All the study participants underwent comprehensive eye examination, fundus examination, complete hemogram analysis, and evaluation of systemic hemodynamics. Fundus images were captured by a nonsimultaneous retinal oximetry. A total of 45 subjects were included in the analysis. Median age of the subjects was 21 years ranging from 19 to 34 years. The median retinal arteriolar and venular oxygen saturation was 94.7% and 55.8%. Comparison of retinal oxygen saturation between three visits showed no statistically significant difference for both arteriolar (p = 0.33)and venular oxygen saturation (p = 0.79). Intraclass correlation coefficients for test-retest, short-term, and day-to-day repeatability were 0.84, 0.90, and 0.86 for arteriolar oxygen saturation and 0.92, 0.98, and 0.98 for retinal venular oxygen saturation. Oxygen saturation in retinal arteriolar and venular blood vessels can be measured by nonsimultaneous image acquisition technique using a conventional fundus camera with good repeatability.

Concepts: Statistical significance, Pulse oximeter, Dilated fundus examination

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Behr syndrome is characterized by the association of early onset optic atrophy, cerebellar ataxia, pyramidal signs, peripheral neuropathy and mental retardation. Recently, some cases were reported to be caused by biallelic mutations in OPA1. We describe an 11-year-old girl (Pt1) and a 7-year-old boy (Pt2) with cognitive delay, ataxic gait and clinical signs suggestive of a peripheral neuropathy, with onset in early infancy. In Pt1 ocular fundus examination revealed optic disk pallor whereas Pt2 exhibited severe optic atrophy. In both children neuroimaging detected a progressive cerebellar involvement accompanied by basal ganglia hyperintensities and pathological peak levels of lactate. In both patients, muscle biopsy showed diffuse reduction of cytochrome c oxidase stain, some atrophic fibers and type II fiber grouping. Using a targeted resequencing panel in next generation sequencing, we identified the homozygous c.1180G>A/p.Ala394Thr mutation in Pt1 and the c.2779-2A>C mutation in compound heterozygosity with the c.2809C>T/p.Arg937Cys mutation in Pt2. All variants were novel and segregated in the healthy parents. Expression of OPA1 protein was significantly reduced in muscle tissues of both patients by Western blotting. We also observed in patients' fibroblasts a higher proportion of fragmented and intermediate mitochondria upon galactose treatment compared to controls, as already seen in other patients harboring mutations in OPA1. The presence of Leigh-like neuroimaging features is a novel finding in Behr syndrome and further adds to the complex genotype-phenotype correlations in OPA1-associated disorders.

Concepts: Brain, Mutation, Muscle, Basal ganglia, Ataxia, Cytochrome c, Compound heterozygosity, Dilated fundus examination

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Retinopathy of prematurity is a retinal vasoproliferative disease affecting extremely preterm infants exposed to high concentrations of oxygen therapy. Infants born before 32 post-menstrual weeks or with a birth weight of less than 1500g should systematically have a dilated fundus examination. The time of screening and schedule for follow-up are guided by the various risk factors. This disease results from immaturity of the peripheral retinal vessels at the time of premature birth. The classification of ROP depends on the anteroposterior extent of involvement (from center to periphery: zone I, II and III), its extension in 30° sectors (clock hours) and its stage (stage 1 to 5). “Plus” disease is defined as dilation and tortuosity of the retinal blood vessels in the posterior pole of the eye and represents a major risk factor for rapid unfavorable progression. A majority of patients will spontaneously recover, but patients with a high risk of progression will require treatment to prevent retinal detachment and blindness. The indications for treatment are threshold disease and type 1 pre-threshold disease. The current treatment of choice is peripheral retinal ablation with transpupillary laser, but ab externo cryotherapy may be used instead. Intravitreal injection of vascular endothelial growth factor inhibitors may be an attractive therapeutic option and is currently under investigation. After laser treatment, unfavorable outcomes occur in only 9 to 14 % of eyes, but at the price of peripheral retinal destruction. For all patients, whether treated or not, a regular fundus examination should be insured until complete retinal vascularization has occurred.

Concepts: Childbirth, Blood vessel, Retina, Eye, Ophthalmology, Preterm birth, Fundus, Dilated fundus examination